Final ATSB report into Cessna 404 accident at Jandakot Airport
The ATSBs final report into the fatal aircraft accident at Jandakot on 11 August 2003 has determined that the aircrafts right engine lost power soon after takeoff when its engine driven fuel pump seized.
The Cessna 404 was being operated by one pilot and had five passengers who were to operate specialised equipment on the aircraft during maritime operations approximately 40 NM west of Jandakot. One passenger did not vacate the aircraft and was fatally injured. The pilot and the other four passengers sustained serious injuries as they vacated the aircraft. One of those passengers died from his injuries 85 days later.
In challenging circumstances, and with high-voltage powerlines crossing the aircrafts flight path 2,400 metres beyond the runway, the pilot turned the aircraft back to the aerodrome for an emergency landing. During the manoeuvring the pilot was unable to prevent the aircraft descending towards trees and scrub-type terrain, where it crashed and caught fire. Fuel from the ruptured wing tanks fed the fire.
A number of factors affect an aircraft's one-engine inoperative performance, including any variation from the airspeed to achieve the one-engine inoperative best rate of climb, control inputs made by the pilot to manage the situation and the effect of manoeuvring/turning the aircraft. One-engine inoperative climb performance significantly reduces during turns.
Jandakot did not have a dedicated aerodrome rescue and fire fighting service and the first local fire fighting unit arrived at the aerodromes emergency gate, about 1,500 m from the accident site about 12.5 minutes after being notified by the police. The Fire and Emergency Services Authority records showed that the first information from the accident site indicating that fire fighting was underway was received about six minutes later.
The investigation found that the engine-driven fuel pump failed when its spindle shaft and sleeve bearing seized. Although the auxiliary fuel pumps were being used during the takeoff, the low-pressure supplementary fuel was not sufficient to sustain engine operation at the take-off power setting.
A review of maintenance documentation revealed that a sleeve bearing replaced during the last overhaul of the engine driven fuel pump was not of the same material specification as the original bearing material. That material selection had the unintended consequence of increasing the likelihood of bearing seizure.
Following the occurrence, the operator modified other Cessna 404 aircraft in its fleet to incorporate a warning light to indicate low fuel pressure. The ATSB has previously issued safety recommendations to CASA regarding pilot training for engine-out operations, which are relevant to the circumstances of this accident.
Copies of the report ( Aviation Safety Investigation Report 200303579) can be downloaded from the website, or directly from the ATSB by telephoning (02) 6274 6590 or 1800 020 616.Media contact: 1800 020 616