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 21 April 2018, a Cessna 210M aircraft was conducting low-level survey operations to the south-east of Laverton Aerodrome, Western Australia. The pilot was the sole occupant on board.
After completing survey operations, the aircraft was returning to Laverton when, at about 1315 Western Standard Time (WST), the aircraft engine experienced power loss. Power was regained briefly, before the engine again experienced a loss of power. The pilot conducted procedures to identify the problem; including switching the fuel selector between tanks to rectify the rough running, but this did not improve the engine performance.
By this time, the aircraft altitude had reduced to tree top level, when the pilot prepared for a forced landing into the trees. The pilot activated the aircraft emergency location transmitter (ELT) and Spidertracks unit. The aircraft then contacted a number of trees before coming to a stop. A small fire started in the engine bay, which was extinguished. The aircraft received substantial damage to the left wing, empennage, firewall and survey stinger. The pilot was not injured.
The aircraft was fitted with auxiliary fuel tip tanks. The pilot commented that the normal fuel transfer procedure from the tip to the main tanks was changed, to lessen the effects of electrical interference to the survey equipment when running fuel transfer pumps. By focusing on the changed procedure, the pilot was distracted and did not ensure that all fuel had been transferred from the tips to the main tanks. This resulted in the starvation of fuel to the engine.
This occurrence is an example of what can happen when procedures are not followed. Pilots are reminded to follow published procedures when operating any aircraft system in accordance with the manufacturer’s recommendations.
Issue number 5 in the ATSB’s Avoidable Accident Series, Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents (AR-2011-112), provides more detail on these scenarios. This report is available from the ATSB website.
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:||21 April 2018||Investigation status:||Completed|
|Location:||37 km ESE of Laverton Aerodrome|
|Release Date:||25 July 2018||Occurrence category:||Accident|
|Aircraft manufacturer||Cessna Aircraft Company|
|Type of operation||Aerial Work|
|Damage to aircraft||Substantial|
|Departure point||Laverton Aerodrome, WA|