Aviation safety investigations & reports

Fuel exhaustion and collision with terrain involving McDonnell Douglas Corporation 369, VH-PLY, 36 km NW Hawker, South Australia, on 17 July 2016

Investigation number:
AO-2016-078
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 17 July 2016, at about 1039 Central Standard Time, a McDonnell Douglas Corporation 369D helicopter, registered VH-PLY, experienced fuel exhaustion and a collision with terrain while performing powerline inspections 36 km north-west of Hawker, South Australia. There were three crew on board the helicopter. One pilot in the front left seat, one line-worker in the front right seat and one line-worker in the rear left seat. The three crew members were seriously injured and the helicopter was substantially damaged.

What the ATSB found

The ATSB found that ground staff mistakenly told the pilot that the aircraft had been refuelled and through distraction, omitted a crosscheck of the fuel quantity before flight. The pilot’s monitoring of the fuel in-flight was based on anticipated endurance, which resulted in him not detecting a low fuel level.

The helicopter was operating with an auxiliary fuel tank system, which did not include a fuel quantity indicator. The Civil Aviation Safety Authority and Design Approval Holder provided responses to the ATSB, which indicated that a misunderstanding likely occurred during the design review and approval process. This resulted in the auxiliary fuel tank system approval migrating from the restricted category to the normal category without a fuel quantity indicator.

The ATSB also found the requirements for the development of fuel policy by operators were dispersed throughout the aviation legislation—14 legislative and three guidance material requirements were found—but they did not require the operator to publish procedures for determining fuel on board before and during flight for commercial operators of aircraft less than 5,700 kg maximum take-off weight.

What's been done as a result

The operator immediately removed all auxiliary fuel tanks from their helicopter fleet and restricted their powerline patrols and inspection flights to main fuel tank fuel only. They developed a corrective actions plan, which included modifications to the auxiliary fuel tank system; permanent installation of a remote warning device; and amended their operations manual to include prescriptive fuel check instructions.

To provide clarity for fuel policy requirements for pilots and operators, in 2016 the Civil Aviation Safety Authority initiated a project to change the fuel regulations and guidance material. The Civil Aviation Amendment (fuel and oil requirements) Regulations 2018 are planned to be implemented in November 2018 as CASA 29/18 – Civil Aviation (Fuel Requirements) Instrument 2018.

The ATSB has issued a Safety Advisory Notice (AO‑2016‑078‑SAN-009) for Air Operator Certificate holders of aircraft not greater than 5,700 kg regarding fuel management.

Safety message

This accident highlights the importance of crosschecking fuel before flight and in-flight fuel monitoring by pilots to prevent fuel exhaustion accidents. It also highlights the potential consequences of distraction breaking the flow of ongoing activities. In this case, it resulted in the fuel quantity of the auxiliary fuel tank not being visually checked prior to flight. After recognising that a distraction has occurred, it is crucial that pilots re-establish situation awareness.

Operators of aircraft not greater than 5,700 kg maximum take-off weight are advised they can reduce their risk of a fuel exhaustion accident by providing published procedures and crew training for crosschecking fuel on board before and during flight.

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The occurrence

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issue

Go to AO-2016-078-SI-01 -

Air Operator Certificate holder fuel policy requirements

The current legislation does not require commercial operators of aircraft not greater than 5,700 kg maximum take-off weight to provide instructions and procedures for crosschecking the quantity of fuel on board before and/or during flight. This increases the risk that operators in this category will not implement effective fuel policies and training to prevent fuel exhaustion events.

Safety issue details
Issue number: AO-2016-078-SI-01
Who it affects: Air Operator Certificate holders
Status: Adequately addressed
General details
Date: 17 July 2016   Investigation status: Completed  
Time: 11:32 CST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Port Augusta E 107 km (Flinders Ranges)   Investigation phase: Final report: Dissemination  
State: South Australia   Occurrence type: Fuel exhaustion  
Release date: 02 August 2018   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer McDonnell Douglas Helicopter Company  
Aircraft model 369D  
Aircraft registration VH-PLY  
Serial number 110887D  
Type of operation Aerial Work  
Sector Helicopter  
Damage to aircraft Substantial  
Departure point Port Augusta, SA  
Last update 14 November 2018