Aviation occurrence briefs

Fuel contamination involving Diamond DA40, Port Pirie, SA, on 31 March 2018

Number:
AB-2018-048
Status: Completed
Investigation completed

Brief

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.

What happened

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),[1] instead of AVGAS[2] immediately prior to flight. The aircraft was recovered by road vehicle, to enable engine replacement.

Operator’s investigation

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.

Figure 1: Refuelling point at Port Pirie, SA

Figure 1: Refuelling point at Port Pirie, SA. Source: Operator

 

Source: Operator

Safety action

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.

Safety message

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.

 

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  1. AVTUR: Aviation turbine fuel, designed for use in aircraft gas turbine engines. Either straw coloured or colourless. Source: Chevron Products Company
  2. AVGAS: Aviation gasoline, designed for use in aircraft piston engines. Dyed green or blue for identification. Source: Chevron Products Company
General details
Date: 31 March 2018   Investigation status: Completed  
Time: 1545 CDT    
Location   (show map): Port Pirie Aerodrome    
State: South Australia    
Release Date: 03 September 2018   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Diamond Aircraft Industries  
Aircraft model DA40  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Last update 12 December 2018