Aviation safety investigations & reports

Engine failure and collision with terrain involving Robinson R44, VH-KJJ, 154 km south-west of Timber Creek, NT, on 14 June 2015

Investigation number:
AO-2015-062
Status: Completed
Investigation completed

Final Report

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What happened

On 14 June 2015, the pilot of a Robinson Helicopter Company R44 helicopter, registered VH-KJJ, was conducting cattle mustering operations at Waterloo Station, about 154 km south-west of Timber Creek, Northern Territory. After refuelling from drum fuel supply, the helicopter took off and, a short time later, experienced a loss of engine power at low altitude. The loss of engine power was a result of fuel starvation due to contaminants introduced into the helicopter’s fuel system during the drum refuelling. The loss of engine power required the pilot to conduct an autorotation and forced landing.

For reasons that could not be determined, the pilot was unable to satisfactorily reduce the rate of descent before the helicopter impacted the ground heavily. The pilot survived the impact but later succumbed to their injuries. The helicopter was destroyed.

What the ATSB found

The ATSB identified that the operator did not have adequate procedures to ensure fuel quality during drum refuelling.

The pilot was overdue for a helicopter flight review for low-level helicopter mustering operations. This potentially reduced the pilot’s familiarity and proficiency with managing engine failures and autorotations from low altitude. Had the pilot been able to satisfactorily reduce the rate of descent before touchdown, the impact forces would have been reduced.

The helicopter was likely ‘hot refuelled’, meaning that as a pilot only operation, the pilot had to exit the helicopter to refuel while it was operating. This increased the risk of loss of control of the helicopter as the flight controls were unmonitored.

What's been done as a result

The operator has informed the ATSB that they now test fuel supplies with water detection paste, and have restricted any aviation fuelling activities to be performed by authorised personnel.

In addition, an operator trial of a filter monitor-type filter highlighted that, although filter monitors increased the probability of detecting water contamination while refuelling, operators should assess the suitability and practicality of the available filter monitors for their operations.

Safety message

A number of defences are available to eliminate or significantly reduce the chance of using contaminated fuel from drum fuel supplies. These include:

  • application of appropriate aviation drum handling and storage methods
  • testing drum fuel supplies for contaminants prior to undertaking refuelling activities
  • use of filter monitors on drum hand pump supply lines
  • conducting fuel drains from aircraft after each refuel to ensure fuel quality.

In addition, the ATSB cautions pilots and operators to conduct hot refuelling in accordance with the aircraft flight manual and Civil Aviation Safety Authority regulations. Further, leaving the flight controls of an operating Robinson Helicopter Company R44 helicopter to conduct refuelling increases the risk of a loss of control.

Finally, this accident provides a timely reminder that the conduct of recurrent flight training allows pilots to practice and better respond to time critical emergencies such as those that occur from a low altitude.

Download final report
[Download  PDF: 3.16MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

Appendices

General details
Date: 14 June 2015   Investigation status: Completed  
Time: 1110 CST    
Location   (show map): 154 km south-west of Timber Creek   Investigation type: Occurrence Investigation  
State: Northern Territory   Occurrence type: Collision with terrain  
Release date: 17 November 2016   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Robinson Helicopter Co  
Aircraft model R44  
Aircraft registration VH-KJJ  
Serial number 1558  
Type of operation Private  
Sector Helicopter  
Damage to aircraft Destroyed  
Departure point Waterloo Station, NT  
Last update 14 November 2018