Fuel exhaustion involving a Gippsland Aeronautics Pty Ltd GA-200, VH-YPL, 40 km south-east of Jerramungup (ALA), Western Australia, on 20 October 1997

Summary

The aircraft was being used to spray crops approximately 600 m from the strip being used for take-offs and landings. The aircraft engine lost power during a spray run and the pilot elected to land straight ahead into the field of barley. After touchdown, the aircraft ground looped, causing some damage to the port wing trailing edge and aileron. The pilot noted after landing that the fuel transfer warning light was illuminated and he later found that there was only a small amount of fuel in the main fuel tanks.

The pilot reported that he had noted the aircraft's low fuel state before take-off but decided to fly until the fuel transfer warning light illuminated. The fuel transfer warning light illuminates when the fuel pressure at the inlet to the header tank falls below approximately 14 kpa for a sustained period, indicating that the mechanical fuel pump is not delivering fuel to the header tank or that the main fuel tanks have run dry. The pilot believed that he could return to the strip before fuel exhaustion caused the engine to fail.

With regard to the fuel transfer warning light, the aircraft flight manual states in part: "In the latter case, although the contents of the header tank has been declared "unuseable fuel" due to certification regulations, the remaining 12 litres of fuel in the header tank should in fact be available and sufficient for at least 12 minutes of further flight at normal power settings and aircraft attitudes". The aircraft was fitted with a Global Positioning System (GPS) tracking bar with a series of red lights to indicate lateral displacement from the desired flight path.

The GPS bar assists the pilot to correctly align the swath runs. The pilot reported that each of the GPS bar lights was similar in appearance to the fuel transfer warning light located in the coaming above the instrument panel. The fuel transfer warning light glowed a steady red when illuminated. The GPS bar was mounted in the accident aircraft such that it was directly in the pilot's line of sight, appearing just to the left of, and very near to, the fuel transfer warning light. The pilot reported that during the spray runs, he was concentrating on avoiding powerlines and was referring to the GPS bar.

He had not noticed the illumination of the fuel transfer warning light during the flight. The pilot noted after landing that the fuel transfer warning light was on; therefore, it had probably operated correctly. However, because the pilot's attention was drawn to avoiding powerlines as well as using the GPS bar, he failed to notice the illumination of the fuel transfer warning light during the flight. The proximity and similiarity of the GPS bar lights to the fuel transfer warning light probably contributed to the pilot not noticing the illumination of the fuel transfer warning light.

The pilot's decisions to rely on the fuel transfer warning light and to plan the use of the header tank fuel were probably encouraged by the aircraft's flight manual wording on unuseable fuel. The wording indicates that the unuseable fuel is useable.

SAFETY ACTION

The Bureau is considering the safety implications of the wording contained in the aircraft flight manual regarding the use of "unuseable" fuel from the header tank. Any safety action arising from the investigation of this matter will be forwarded to the relevant action agencies and will be published in the Bureau's Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199703511
Occurrence date 20/10/1997
Location 40 km south-east of Jerramungup (ALA)
State Western Australia
Report release date 09/06/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel exhaustion
Occurrence class Accident

Aircraft details

Manufacturer Gippsland Aeronautics Pty Ltd
Model GA-200
Registration VH-YPL
Sector Piston
Operation type Aerial Work
Departure point Jerramungup WA
Destination Jerramungup WA
Damage Substantial

Separation issue involving a Boeing 737-377, VH-CZP, 57 km west-south-west of Kalgoorlie VOR, Western Australia, on 23 October 1997

Summary

The aircraft departed two minutes apart from Kalgoorlie enroute to Perth. The first aircraft, BAe 146 VH-NJZ, was cleared by the sector air traffic controller to track via Southern Cross on planned route climbing to FL240. The route followed the 255 degree radial from the Kalgoorlie VOR. When the pilot of the second aircraft, Boeing 737 VH-CZP, contacted the sector controller for a clearance, he advised that the aircraft was avoiding weather and tracking the 240 degree radial from Kalgoorlie VOR. The sector controller subsequently cleared CZP to track via the Nalar Dulya route on climb to FL350.

The pilot of CZP was communicating with the pilot of NJZ on the flight service frequency to ensure separation was maintained between the aircraft during the weather avoidance. The FSO reported to the sector controller that the pilot of CZP advised that he was initially tracking outbound on the 257 degree radial from the Kalgoorlie VOR and was now paralleling track. When queried by the sector controller, the pilot of CZP advised that the aircraft was on approximately the 246 degree radial from the Kalgoorlie VOR and was leaving FL210 on climb. The controller instructed the pilot of CZP to maintain FL210, to which the pilot replied that the aircraft was leaving FL220 on descent to FL210. The pilot of NJZ was immediately queried by the sector controller about his altitude and he reported that his aircraft was leaving FL225 on climb.

The investigation revealed that it was unlikely that a breakdown in separation occurred because the pilots appeared aware of their relative positions and maintained separation. However, the sector controller took action to ensure procedural separation was maintained based upon the information available to him.

Occurrence summary

Investigation number 199703488
Occurrence date 23/10/1997
Location 57 km west-south-west of Kalgoorlie VOR
State Western Australia
Report release date 13/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZP
Sector Jet
Operation type Air Transport High Capacity
Departure point Kalgoorlie WA
Destination Perth WA
Damage Nil

Fuel exhaustion involving a Piper PA-31-350, VH-RDL, Cootamundra Aerodrome, New South Wales, on 19 October 1997

Summary

Piper Chieftain aircraft, VH-RDL, departed Boonoke (a property near Deniliquin) on a charter flight to Sydney in accordance with the Instrument Flight Rules, with a planned intermediate refuelling stop at Cootamundra. As the aircraft approached the Cootamundra circuit area the left engine began to surge. The pilot commenced a straight-in approach to the 10 grass runway, however the right engine also began to surge and lose power.

The aircraft was landed in a paddock, some 400 metres before the beginning of grass strip 10. During the ensuing ground roll the pilot was able to manoeuvre the aircraft over a shallow creek bed and a fence. The aircraft then passed through the aerodrome boundary fence before stopping on the runway. The nine passengers and pilot escaped without injury. The aircraft was substantially damaged.

During a subsequent examination of the aircraft it was determined that all useable fuel had been exhausted from both inboard tanks. The left outboard fuel tank contained 11 litres, while the right outboard tank contained 30 litres.

The Chieftain was one of a number of aircraft chartered to carry a large group of people to and from Boonoke during the weekend of 18-19 October. On the evening of 17 October, the operator briefed all pilots associated with the proposed charter on how the operation was to be conducted. During the briefing the operator said that he had arranged with fuel agents at Deniliquin and Cootamundra to provide fuel as required. Fuel purchases were to be placed on the operators account. Refreshments had also been arranged for passengers at Cootamundra while refuelling was taking place.

On the afternoon of 18 October VH-RDL was ferried from Bankstown to Sydney, having departed Bankstown with some 602 litres of fuel, comprised of full inboard tanks, and 100 litres in each of the two outboard tanks. After arriving at Sydney another pilot took command of the aircraft and flew nine passengers to Deniliquin. No fuel was added to the fuel tanks after the aircraft left Bankstown.

The following afternoon VH-RDL, which had remained at Deniliquin, was scheduled to take nine passengers from Boonoke to Sydney. A pilot who had flown another Chieftain, VH-XML, from Sydney to Deniliquin the previous evening, was tasked to carry out the return flight in VH-RDL. Prior to departing Deniliquin the pilot he said he carried out a Daily Inspection. His first action was to turn on the master switch and check the fuel contents indicators. He also opened both inboard tank caps to carry out a visual contents check. Although the tank interiors were in shadow he thought he could just see fuel, but he could not touch it. Based on his observations, and a comparison of the estimated fuel burn from Bankstown, he estimated the fuel remaining totalled 280 litres, whereas he had calculated he required 257 litres to fly to Cootamundra via Boonoke, including appropriate fuel reserves. The pilot also said that it was his understanding from the earlier briefing that each aircraft should carry sufficient fuel from Sydney to allow a return to Cootamundra via Boonoke before refuelling. He believed that it was preferable not to refuel at Deniliquin, although he felt that if he needed fuel it would not have been a problem obtaining it.

Another pilot reported that he spoke to the pilot of VH-RDL prior to the flight and suggested that the aircraft be refuelled prior to departing from Deniliquin, to eliminate the need to land en-route. However, the pilot of VH-RDL indicated he would refuel at Cootamundra, which would also provide for a passenger "comfort stop".

The aircraft was duly flown to Boonoke, to take on passengers, before departing for Cootamundra. After take-off the aircraft was climbed to its planned cruising altitude of 9,000 ft, drawing fuel from the inboard tanks. Once established in level flight the outboard tanks were selected and fuel was drawn from those tanks until commencing descent, some 16 minutes before the estimated time of arrival at Cootamundra. At about that point the pilot moved the fuel selectors to draw fuel from the inboard tanks. He said the outboard fuel contents gauges were indicating empty, and he had been monitoring the engine exhaust gas temperature gauges for initial indications of exhaustion of the outboard tanks. However, no indications were noticed before he reselected the inboard tanks, in accordance with a Flight Manual limitation to only use the outboard tanks in level flight. The pilot said he thought the inboard fuel tank contents were indicating between 1/4 and 1/2 full. At that stage he said he had no concerns about the amount of fuel remaining.

As the aircraft approached the Cootamundra circuit area the left engine began to surge. The pilot looked at the left fuel gauge and noted it was indicating below 1/4. He selected the left outboard tank and turned on the boost pump. The engine continued to surge briefly before operating normally. He then turned off the boost pump. At that point the aircraft was at an altitude of some 3,500-4,000 ft. Shortly after, the left engine again commenced to surge. The pilot said he again turned on the left boost pump and moved the fuel selector to run both engines from the right inboard tank via the fuel crossfeed.

With the aircraft still descending the pilot elected to carry out a straight-in approach to land on the 10 grass runway, joining final approach at an altitude of about 3,000 ft. Because the aircraft appeared to be high the landing gear was extended. However, both engines began to surge and lose power. Because the pilot was unsure if the aircraft could reach the runway threshold he elected to land short in an adjoining paddock, progressively extending flap prior to touchdown.

A subsequent investigation found that Chieftain, VH-XML, had carried out a similar flight to VH-RDL, from Sydney to Cootamundra, via Deniliquin and Boonoke. However, that aircraft had departed Sydney with full tanks, and was found to have used 551.17 litres upon arrival at Cootamundra. The useable capacity of both inboard and outboard tanks of the Chieftain totals 690 litres. The fuel remaining in VH-RDL after the accident was 41 litres. When compared to the fuel burn of VH-XML, the total fuel on board VH-RDL when it departed Sydney would have been about 590 litres.

The actual fuel carried in the aircraft on departure from Boonoke was probably about 190 litres, some 67 litres less than the minimum fuel required, including reserves.

Occurrence summary

Investigation number 199703415
Occurrence date 19/10/1997
Location Cootamundra Aerodrome
State New South Wales
Report release date 29/06/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel exhaustion
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31-350
Registration VH-RDL
Sector Piston
Operation type Charter
Departure point 'Boonoke' via Deniliquin NSW
Destination Cootamundra NSW
Damage Substantial

Wirestrike involving an Air Tractor AT-502B, VH-ODG, 11 km west-south-west of Kangaroo Flat, South Australia, on 17 October 1997

Summary

The pilot of the AT502 aircraft was pulling up on completion of the spray run when the propellor came into contact with a power line. The aircraft made and uneventful landing at the agricultural airstrip from which it was operating. Post flight inspection found that damage had been sustained by two blades of the propellor and the upper skin of the left wing.

Occurrence summary

Investigation number 199703423
Occurrence date 17/10/1997
Location 11 km west-south-west of Kangaroo Flat
State South Australia
Report release date 01/12/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident

Aircraft details

Manufacturer Air Tractor Inc
Model AT-502B
Registration VH-ODG
Sector Turboprop
Operation type Aerial Work
Departure point 5 NM WSW Kangaroo Flat SA
Destination 5 NM WSW Kangaroo Flat SA
Damage Substantial

Forced/precautionary landing involving a Robinson R22 Beta, VH-JKN, 165 km west-north-west of Newman Aerodrome, Western Australia, on 20 October 1997

Summary

The helicopter had just finished being used to survey cattle and was returning for a landing. The pilot reported that the engine governor was turned on and that during a steep turn downwind, he allowed the helicopter's airspeed to decrease to approximately 20 kts. As he lowered the helicopter's nose to accelerate downwind, the Low Rotor RPM warning horn sounded indicating that the main rotor RPM had decreased below 96%. The pilot reported that he immediately lowered the collective, fully opened the throttle and further lowered the helicopter's nose to recover airspeed. As the helicopter approached the ground, he selected a decelerative attitude, a manoeuvre that would normally recover some main rotor RPM. However, in this case, the main rotor RPM did not recover. When the helicopter had descended to approximately 3 ft AGL with an airspeed of approximately 55 kts, the pilot placed it in a sideways quick-stop manoeuvre. This was done to decrease the helicopter's air and ground speed before it contacted the ground. The pilot reported that he then levelled the helicopter before running it onto a sand ridge. Despite these actions, the Low Rotor RPM warning horn continued to sound throughout the descent and landing.

After sliding along the ground for approximately 20 ft, the helicopter somersaulted. After the dust had settled following the crash, the pilot reported that he checked the welfare of his passenger and then checked the engine. The pilot reported that the engine exhaust was cool enough to hold and that the rocker cover was only warm to touch.

Occurrence summary

Investigation number 199703441
Occurrence date 20/10/1997
Location 165 km west-north-west of Newman Aerodrome
State Western Australia
Report release date 21/11/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22 Beta
Registration VH-JKN
Sector Helicopter
Operation type Aerial Work
Departure point Talawana WA
Destination Talawana WA
Damage Destroyed

Loss of control involving a Robinson R22 Beta, VH-AOP, Hoxton Park Aerodrome, New South Wales, on 14 October 1997

Summary

The student helicopter pilot was conducting his second solo flight at Hoxton Park. The weather was fine, with almost no wind. Prior to commencing the solo phase, the student had completed a satisfactory dual circuit check.

As the instructor walked away from the helicopter, he heard a "thump'. As he turned around, he saw the helicopter had rolled onto its side, causing substantial damage to the rotor blades. The accident was consistent with 'dynamic rollover'. The student was not injured and was able to exit the helicopter.

As the student had commenced to lift off the helicopter had rapidly rolled to the right. Although he had expected there would be some rolling tendency, the rate of roll was greater than the student had anticipated, and he had been unable to prevent the rollover.

Occurrence summary

Investigation number 199703388
Occurrence date 14/10/1997
Location Hoxton Park Aerodrome
State New South Wales
Report release date 16/10/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22 Beta
Registration VH-AOP
Sector Helicopter
Operation type Flying Training
Departure point Hoxton Park NSW
Destination Hoxton Park NSW
Damage Substantial

Collision on ground involving a Grob G-115C2, VH-ZTN, Jandakot Aerodrome, Western Australia, on 14 October 1997

Summary

The aircraft had been parked in a recently opened grass parking bay. Whilst the aircraft was taxiing from the parking area onto a taxiway, the aircraft's left main landing gear wheel sank in soft sand on an unmarked irrigation outlet. The metal plate covering the outlet was not supported on one side. The wheel ran onto the unsupported side of the plate, causing it to flick up and puncture the underside of the wing and fuel tank. Exit routes from the parking area were not marked and the path taken by the pilot was not normally used.

Local Safety Action

The airport authorities are intending to clearly mark parking area entry and exit routes.

Occurrence summary

Investigation number 199703383
Occurrence date 14/10/1997
Location Jandakot Aerodrome
State Western Australia
Report release date 04/11/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Grob - Burkhart Flugzeugbau
Model G-115C2
Registration VH-ZTN
Sector Piston
Operation type Flying Training
Departure point Jandakot WA
Destination Jandakot WA
Damage Substantial

Partial power loss involving a Hughes Helicopters 269C, VH-MZR, Gamboola Station, 100 NM west of Mareeba, Queensland, on 10 October 1997

Summary

The pilot reported that when he was about 3 NM from the departure point he smelt smoke, and then saw smoke entering the cabin and trailing behind the aircraft. He immediately turned back towards a suitable landing site about 1 NM away, but the engine lost oil pressure and performance started to deteriorate. The pilot carried out an autorotational landing with partial power into a confined area, and on touchdown the vertical stabiliser and tail rotor blades struck an anthill. Subsequent inspection revealed a ruptured oil line as the cause of the smoke and loss of oil pressure. Structural damage was confined to the tail rotor blades, horizontal and vertical stabilisers, tail rotor transmission and drive shaft, and tail boom.

Occurrence summary

Investigation number 199703385
Occurrence date 10/10/1997
Location Gamboola Station, 100 NM west of Mareeba
State Queensland
Report release date 28/10/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Hughes Helicopters
Model 269C
Registration VH-MZR
Sector Helicopter
Operation type Aerial Work
Departure point Gamboola Station Qld
Destination 6 NM N Gamboola
Damage Substantial

Loss of control involving a Cessna 150L, VH-IEK, Marion Downs, Queensland, on 11 October 1997

Summary

The pilot reported that while he was conducting a turn above some cattle, the aircraft appeared to lose speed and altitude. The aircraft was about 75-100 ft AGL at the time. The pilot pushed the control column forward and applied full power. However, this had little effect, and it became obvious that the aircraft was going to strike the ground. The pilot said that just before impact, he pulled back on the control column. The pilot could not recall looking at the airspeed indicator during the final stages of the flight, and did not recall hearing the stall warning sound. However, he considered it likely that the aircraft stalled during the turn and that there was insufficient height above the ground for him to effect recovery to normal flight.

Occurrence summary

Investigation number 199703382
Occurrence date 11/10/1997
Location Marion Downs
State Queensland
Report release date 04/11/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Cessna Aircraft Company
Model 150L
Registration VH-IEK
Sector Piston
Operation type Aerial Work
Departure point Marion Downs Qld
Destination Marion Downs Qld
Damage Substantial

Collision with terrain involving a Robinson R22 HP, VH-KHI, Elizabeth Downs Station, Northern Territory, on 16 October 1997

Summary

The helicopter departed Mount Green in a northerly direction at approximately 1755 CST, for a survey of the locations of Army personnel in the area who were manning Rapier missile sites. The pilot said that while approaching one of the sites, he descended to approximately 100 ft AGL, and commenced a left-hand orbit while his passenger, an Army officer, was explaining the layout. When he was about halfway through the turn and maintaining approximately 60 knots with about 30 degrees angle of bank, the nose suddenly yawed to the left, and the helicopter descended rapidly in a nose low attitude. The helicopter impacted the ground, and slid backwards into a thicket of small trees 2 to 3 metres high.

One main rotor blade had sustained a spar fracture approximately 14 cms from the blade tip. Blade weight segments were installed in this region and could not be found after the accident. A section of the blade skin and honeycomb core extending over a distance of approximately 34 cms from the blade tip had also been lost. The nature of damage displayed by the blade was consistent with an impact between the blade leading edge and a solid rocky object, at a point approximately 20-25 cms from the blade tip, while the blade was rotating.

A series of unusual paint transfer markings along the upper surface of the leading edge of one main rotor blade was noted during examination. The paint was dark green in colour. Abrasive scores through some of these markings indicated that paint transfer associated with contact with some other material or component occurred prior to collision with the ground. It was established that the blade had struck a ground-to-air missile casing which was painted dark green. The stage in the accident sequence at which this occurred could not be determined.

Occurrence summary

Investigation number 199703381
Occurrence date 16/10/1997
Location Elizabeth Downs Station
State Northern Territory
Report release date 16/06/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22 HP
Registration VH-KHI
Sector Helicopter
Operation type Aerial Work
Departure point Mt Green NT
Destination Mt Green NT
Damage Substantial