Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
On 31 March 2018, at 1545 Central Daylight-saving Time (CDT), a Diamond DA40 departed from runway 26 at Port Pirie, South Australia for navigation training purposes. The pilot was the only occupant.
During initial climb, between 100 ft and 400 ft, the engine commenced rough running combined with reduced performance and a high cylinder head temperature indication. A low level circuit was completed to enable an immediate return to Port Pirie, where the aircraft landed safely. An observer noted smoke emanating from the engine cowling during return taxi. An inspection found that the pilot had inadvertently fuelled the aircraft with Jet A-1 (AVTUR), instead of AVGAS immediately prior to flight. The aircraft was recovered by road vehicle, to enable engine replacement.
The operator found the student had undertaken one of three allocated briefing and monitoring sessions in refuelling operations, prior to assessment for competency, due to time constraints.
As a result of this occurrence, the operator has advised the ATSB that they are taking the following safety actions:
A reinforcement to their instructors of the importance in ensuring student competence in unassisted refuelling, after previous instruction and monitoring, prior to solo refuelling operations.
Pilots are reminded of the importance of checking fuel for the correct grade in addition to contaminants after refuelling operations are complete. The higher density of AVTUR in comparison to AVGAS, will cause it to settle to the bottom of fuel tanks, enabling distinction by colour and smell.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
|Date:||31 March 2018||Investigation status:||Completed|
|Location:||Port Pirie Aerodrome|
|Release Date:||03 September 2018||Occurrence category:||Serious Incident|
|Report status:||Final||Highest injury level:||None|
|Aircraft manufacturer||Diamond Aircraft Industries|
|Type of operation||Flying Training|
|Damage to aircraft||Nil|