Fuel exhaustion involving a Piper PA-34-200T, VH-JOD, 2.5 km south of Jandakot Aerodrome, Western Australia, on 23 October 1996

Summary

The pilot reported he took a number of tourism industry passengers on a familiarisation flight over a proposed tourist route between Jandakot and Cervantes. He was on the return flight to Jandakot, with his second group of passengers on board, when he was forced to land the aircraft in a paddock due to fuel exhaustion.

The pilot had accumulated a lot of flying hours, predominately in helicopters, but had limited twin-engine, fixed-wing aircraft experience. He had recently completed an endorsement onto the aircraft type and had flown a total of 7 hours in the aircraft at the time of the forced landing. This included the 5 hours flown during the familiarisation flights.

On the evening prior to the occurrence, the pilot had filled the fuel tanks in preparation for the familiarisation flights. Before departing Jandakot on the first leg, he had drained 40 L out of the fuel tanks due to weight restrictions. He was not able to visually check the contents once he had drained the fuel and did not note the level before he started the drain. He paid little attention to the fuel gauges enroute as he normally monitored fuel contents by using fuel flow and elapsed time.

During the return flight, the pilot elected to land at Cunderdin to correct a fuel imbalance which had appeared after he added 200 litres of fuel at Cervantes. He used a bucket and hose to transfer fuel between tanks. He reported that he was not aware of how fuel could be cross fed between tanks whilst airborne.

The pilot became concerned about the state of the fuel contents enroute to Jandakot. He was convinced there was sufficient to continue to his destination, which was, by then, the closest airfield. The aircraft was less than 3 km south of Jandakot when the engines stopped.

Calculations indicate that a total of 620 L had been added to the aircraft before and during the flights. At the reported fuel flow of 94 L/hour a total flight time of 6 hours 35 minutes should have been available. The engines stopped after 5 hours, leaving 150 L unaccounted for. The pilot reported there had been recent instances of fuel theft from the Jandakot apron. As he had refuelled the aircraft the evening before the flights, he suspected the missing fuel had been stolen during the night.

Occurrence summary

Investigation number 199603493
Occurrence date 23/10/1996
Location 2.5 km south of Jandakot Aerodrome
State Western Australia
Report release date 20/11/1996
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-34-200T
Registration VH-JOD
Sector Piston
Departure point Hyden WA
Destination Jandakot WA
Damage Substantial

Birdstrike involving an Aero Commander 500-S, VH-KAV, 28 km south-east of Perth Aerodrome, Western Australia, on 24 October 1996

Summary

The aircraft was engaged in low-level survey operations over an area of trees in the hills to the east of Perth. The pilot saw a pair of wedge-tail eagles and, despite evasive action, hit one of them. The aircraft sustained some damage which did not prevent the pilot safely tracking to and landing at Jandakot.

The eagle had hit the left wing and caused compression of the leading edge outboard of the left engine.

Occurrence summary

Investigation number 199603492
Occurrence date 24/10/1996
Location 28 km south-east of Perth Aerodrome
State Western Australia
Report release date 31/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Birdstrike
Occurrence class Accident

Aircraft details

Manufacturer Aero Commander
Model 500-S
Registration VH-KAV
Sector Piston
Operation type Aerial Work
Departure point Jandakot WA
Destination Jandakot WA
Damage Substantial

ANSP info/procedural error involving a Boeing 737-376, VH-TAJ, 10 km south-east of Melbourne Aerodrome, Victoria, on 14 October 1996

Summary

FACTUAL INFORMATION

The crew of a B737, en route from Perth to Melbourne, requested an arrival on runway 34 after receiving the automatic terminal information service (ATIS) information 'W', which indicated that runway 27 was available for arrivals and runway 34 was available for departures. During the period between the crew receiving the ATIS and requesting runway 34, the aerodrome information changed. The latest ATIS information 'V', which the crew copied, indicated that Melbourne aerodrome was operating on runway 27 for departures and runway 16 for arrivals. The crew was advised that runway 34 was not available, due to the operations on runway 16, and was assigned a standard arrival route (STAR) clearance and runway 16. The crew did not hear the assigned runway because of radio interference and requested confirmation from the sector controller that the runway was 27. The sector controller replied that runway 27 was the assigned runway. The sector controller annotated runway 27 on the flight progress strip for the aircraft. The crews of subsequent aircraft were assigned runway 16 by the sector controller.

The crew of the B737 had not advised the sector controller of the code and receipt of the ATIS, nor had the controller verified that the crew had received the latest ATIS.

When the non-duty runway was assigned, the controller was required to annotate the "ops data" line of the aircraft's label on the radar display with the assigned runway. The "ops data" line for the B737 was not annotated with runway 27. Once the runway and the arrival clearance had been issued by the sector controller, there were no further checks to confirm the aircraft's arrival clearance or assigned runway.

The crew had previously requested track shortening and thought that the sector controller was actioning this request by assigning a runway which required fewer track miles to run to a landing. The crew transferred to approach control and continued to track in accordance with the cleared route. Overhead Essendon aerodrome, the crew continued to track eastwards for a left base to runway 27. The approach controller was expecting the B737 to turn left, to the north, for a left base to runway 16. The approach controller cancelled the standard arrival route and radar vectored the B737 for runway 16. As the B737 approached the centreline of runway 27, the crew requested from the controller the runway to which the aircraft was being radar vectored. The approach controller advised them that the vectors were for runway 16. The aircraft landed on runway 16. There was no breakdown of separation.

ANALYSIS

Initially, the sector controller issued the correct STAR and runway to the crew of the B737. However, when the crew queried the assigned runway, the controller replied with the incorrect runway and then annotated the flight progress strip with the wrongly assigned runway. The reason for the controller assigning the incorrect runway and not amending the "ops data" line of the label could not be determined.

The crew of the B737 did receive the latest ATIS but believed that the sector controller was providing them with their previously requested track shortening by assigning them runway 27. Consequently, they did not query the runway assignment with the Approach controller.

SIGNIFICANT FACTORS

1. The controller did not confirm that the crew of the B737 had received the latest ATIS.

2. The sector controller did not confirm the arrival runway, as indicated in the latest ATIS, when queried by the crew.

3. The sector controller did not amend the "ops data" line of the B737's label on the radar display with the assignment of the non-duty runway.

Occurrence summary

Investigation number 199603442
Occurrence date 14/10/1996
Location 10 km south-east of Melbourne Aerodrome
State Victoria
Report release date 11/06/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ANSP info/procedural error
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-376
Registration VH-TAJ
Sector Jet
Operation type Air Transport High Capacity
Departure point Perth WA
Destination Melbourne VIC
Damage Nil

Near collision involving a Piper PA-31-350, VH-OCF and Skyfox CA25N, VH-ZVC and Skyfox CA25N, VH-DLY, Maroochydore/Sunshine Coast Aerodrome, Queensland, on 9 October 1996

Summary

Two CA25 aircraft, VH-ZVC and VH-DLY, were operating in the circuit using runway 18. The pilots, both solo students, had been communicating with each other on the mandatory broadcast zone (MBZ) frequency. The pilot of ZVC had just turned final when DLY was turning base. The pilot of ZVC had reported base for a full stop landing. The pilot of DLY also reported base for a full stop landing. At no time did either pilot hear any other aircraft transmissions. As ZVC touched down the pilot became aware of a large twin engined aircraft approaching head on at high speed after it had landed on runway 36. The pilot of ZVC applied full power and went around passing over the top of the twin. The pilot of DLY was unaware of the presence of the twin and landed just as it was exiting the runway. As the twin engined aircraft VH-OCF taxied onto the apron the pilot apologised to the other pilots on the MBZ frequency.

The pilot of OCF said that he was flying on a scheduled service from Brisbane to Maroochydore. Whilst enroute he noticed the wind was from the north-east and planned his approach to land on runway 36. The pilot stated that during the descent he made a number of transmissions approaching the MBZ but heard no response. The Maroochydore MBZ has the same lateral dimensions as the control zone. He did not consider it unusual that there was no response, as frequently there is no other traffic, and if there is, he is usually advised by Brisbane Centre. After having cancelled SAR with Brisbane Centre, and when lined up on short final for runway 36, the pilot detected movement at the far end of the runway. He said a small dark object had risen from the ground which he initially thought was a bird, but he then realised it was a small aircraft. He then noticed another aircraft on final approach for runway 18 as he vacated runway 36. He then noticed that his VHF was selected to 124.8 mhz instead of the MBZ frequency 124.4 mhz.

Occurrence summary

Investigation number 199603419
Occurrence date 09/10/1996
Location Maroochydore/Sunshine Coast Aerodrome
State Queensland
Report release date 27/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Near collision
Occurrence class Incident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31-350
Registration VH-OCF
Sector Piston
Operation type Air Transport Low Capacity
Departure point Brisbane
Destination Maroochydore
Damage Nil

Aircraft details

Manufacturer Skyfox Aviation Ltd
Model CA25N
Registration VH-DLY
Sector Piston
Operation type Flying Training
Departure point Maroochydore
Destination Maroochydore
Damage Nil

Aircraft details

Manufacturer Skyfox Aviation Ltd
Model CA25N
Registration VH-ZVC
Sector Piston
Operation type Flying Training
Departure point Maroochydore
Destination Maroochydore
Damage Nil

Fuel exhaustion involving a Cessna 150G, VH-KPD, Forest Vale, 65 km north of Mitchell, Queensland, on 26 October 1996

Summary

The pilot had just bought the aircraft and was delivering it to his home. The previous owner had not flown the aircraft extensively and was unable to assist with performance and fuel information. As a result, the owner used the cruise performance information available in the pilot's handbook. This information showed an endurance of 7.9 hours and a range of 845 miles.

After refuelling to full tanks at Hughenden the pilot intended flying to Barcaldine and refuelling there. The turbulence enroute was considerable so the pilot elected to depart early the next morning to avoid the turbulence. He dipped the tanks and found that they were over half full. Since he considered that this would give him four hours of endurance he departed for Roma without refuelling. The ground speed obtained during the flight would have required a flight time of 223 minutes to Roma. While enroute, the engine failed due to fuel exhaustion. He conducted a forced landing on a road and obtained fuel to complete the flight.

The pilot later learned that the endurance figures quoted in the handbook were optimistic. He also found that the actual fuel used during flights was much higher than he had expected. By completing full flight plans he has been able to establish accurate fuel consumption figures for his aircraft.

After the landing the pilot attempted to activate the ELT using the remote control on the aircraft instrument panel. The unit did not operate because of a flat Lithium battery in the remote-control unit. After the battery was replaced, the unit was able to function correctly.

Occurrence summary

Investigation number 199603465
Occurrence date 26/10/1996
Location Forest Vale, 65 km north of Mitchell
State Queensland
Report release date 09/12/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel exhaustion
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 150G
Registration VH-KPD
Sector Piston
Operation type Private
Departure point Barcaldine QLD
Destination Roma QLD
Damage Nil

Wirestrike involving a Piper PA-25-235, VH-ALD, 16 km south of Ardlethan (ALA), New South Wales, on 23 October 1996

Summary

The Piper Pawnee aircraft was conducting spraying operations on a property. The landowner had provided a map of the treatment area, and the pilot had conducted an in-flight inspection. Spray runs were to be conducted at right angles to a powerline running along the boundary of the area to be treated, with the aircraft climbing over the powerline before carrying out a procedure turn and descending to commence another run.

The aircraft was fitted with a Global Positioning System (GPS) to provide track guidance to the pilot during the spray runs. The pilot reported that during the initial spray runs his attention was drawn to the GPS Marking System due to alignment errors. Following the procedure turn after the fifth spray run, the pilot reported he momentarily forgot about the presence of the powerline and descended into it. The landing gear snagged the wire, causing the aircraft to lose airspeed and strike the ground in an almost level attitude. The left wing and fuselage were damaged during the ensuing ground run. The pilot, who was wearing a full harness, was unhurt.  An Emergency Locator Transmitter (ELT) was not fitted to the aircraft.

Occurrence summary

Investigation number 199603414
Occurrence date 23/10/1996
Location 16 km south of Ardlethan (ALA)
State New South Wales
Report release date 21/01/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-25-235
Registration VH-ALD
Sector Piston
Operation type Aerial Work
Departure point Ardlethan NSW
Destination Ardlethan NSW
Damage Substantial

Fuel exhaustion involving a Cessna 182P, VH-LWM, 21 km east of Tarcutta, New South Wales, on 21 October 1996

Summary

The pilot had flown the aircraft from Porepunkah to Wangaratta where he added fuel. He then continued the flight as planned to Hoxton Park. On the evening before the return flight to Porepunkah the pilot travelled to Hoxton Park to check the aircraft. He used a dipstick to calculate the fuel remaining and estimated there was a total of 200 L, 90 L in the right fuel tank and 110 L in the left. He considered this was sufficient for the flight and declined the opportunity to add more fuel at that time.

The next morning the pilot completed a pre-flight inspection of the aircraft, including another check of the fuel quantity. He again estimated the fuel remaining to total 200 L. Approximately 90 minutes after departure, whilst the aircraft was cruising at 6,500 ft, the engine started to misfire, then experienced a complete loss of power. A forced landing was carried out following the pilot's unsuccessful attempt to restore power. The aircraft landed heavily and skidded along the ground for about 90 m, during which time the nose landing gear separated from the fuselage. The pilot and three passengers escaped without injury.

Weather conditions at 6,500 ft at the time of the accident were fine, with a temperature of 1 degree Celsius, and a dew point of minus 10 degrees Celsius.

An on-site examination of the aircraft indicated no evidence of an engine defect which may have contributed to the accident. No fuel was found in either fuel tank, and only a small quantity could be collected from the remaining fuel system. There was no evidence of fuel having vented or leaked from the fuel cells or the engine area, nor were there indications of excessive fuel consumption.

The recent flight history of the aircraft and relevant fuel purchases were examined. It was determined that there would most likely have been a total of about 100 lts remaining in the fuel cells when the pilot added a further 122 lts at Wangaratta. Using average fuel consumption figures for the aircraft type, and flight times obtained from the pilot, it was estimated that there had been insufficient fuel on board to complete the flight to Porepunkah.

When the pilot had refuelled at Wangaratta, he observed fuel bubbling up from each fuel inlet and assumed the fuel cells were full. He did not use a dipstick to confirm the quantity, nor did he look into the fuel inlets to observe the fuel levels after he removed the fuel nozzle from each inlet. There would have been about 222 L on board the aircraft when the pilot departed Wangaratta and not 303 L, as should have been the case if the fuel tanks had been filled to capacity. Subsequent observations of fuel quantity indications on the dipstick may have been influenced by this false assumption.

Occurrence summary

Investigation number 199603408
Occurrence date 21/10/1996
Location 21 km east of Tarcutta
State New South Wales
Report release date 24/12/1996
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 Cessna Aircraft Company
Model 182P
Registration VH-LWM
Sector Piston
Operation type Private
Departure point Hoxton Park, NSW
Destination Porepunkah, VIC
Damage Substantial

Animal strike involving a Cessna 182Q, VH-FMM, 45 km north-north-east of Helen Springs, Northern Territory, on 22 October 1996

Summary

The pilot was mustering cattle. He carried two observers in the aircraft. The weather was warm, windy, gusty and moderately turbulent. Hoping to turn the lead cattle towards a bore, he commenced a descent from about 140 ft above the ground while turning downwind. His intention was to level off at about 30 ft abeam the cattle. He planned to maintain an indicated airspeed of 75 to 80 kts with 20 degrees of flap. However, he was unable to arrest the rate of descent through 30 ft. He found himself too low to bank the aircraft successfully away from the cattle for fear of hitting a wing on the ground. With a left quartering tailwind, the aircraft drifted towards the herd. The pilot tried yawing the aircraft and pulling up to avoid the cattle, but the left main landing gear wheel struck a heifer across its back.

Despite tearing off the left main wheel, bending the landing gear leg aft, and killing the heifer, the aircraft remained airborne and eventually gained altitude. The pilot then smelt fuel, which was leaking from a fuel line, broken by the dislodged left landing gear leg. He declared an inflight emergency to flight service and to Helen Springs homestead. Homestead personnel quickly ran a grader over the airstrip to smooth it out and hopefully make it safer for the emergency landing. The pilot managed to land the aircraft without further damage.

The pilot probably encountered low windshear.

Occurrence summary

Investigation number 199603404
Occurrence date 22/10/1996
Location 45 km north-north-east of Helen Springs
State Northern Territory
Report release date 25/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Animal strike
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182Q
Registration VH-FMM
Sector Piston
Operation type Aerial Work
Departure point Bore 5 Helen Springs NT
Destination Bore 5 Helen Springs NT
Damage Substantial

Collision with terrain involving a Weatherly 620A, VH-WEA, 9 km south-south-east of Inverleigh, Victoria, on 17 October 1996

Summary

The pilot was involved in spraying operations, and this was his first take-off for the day. The strip was 700 m long, covered with 30 cm long grass and ran downhill to the east. There was no wind at ground level, so take-off was to the east. After liftoff, at an altitude of about 10 ft, the pilot experienced tail buffet and then sink. The aircraft then hit a fence and gate at the end of the strip which tore off a spray boom, tailwheel and main wheel. The pilot dumped the load and landed straight ahead.

After the accident the pilot and the company chief pilot made a closer assessment of the strip and surrounding terrain. That assessment indicated that the point from where the take-off run was commenced was probably shielded from a light westerly breeze (i.e. a tailwind) but once the aircraft got airborne closer to the eastern end of the strip, the westerly breeze was encountered. Although the strip was covered in long grass, it was evident from wheel marks that the aircraft had become airborne after a ground roll of between 450 and 500 m.

Occurrence summary

Investigation number 199603362
Occurrence date 17/10/1996
Location 9 km south-south-east of Inverleigh
State Victoria
Report release date 22/10/1996
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

Model 620A
Registration VH-WEA
Sector Piston
Operation type Aerial Work
Departure point Inverleigh Vic
Destination Inverleigh Vic
Damage Substantial

Forced/precautionary landing involving a Cessna 182E, VH-RHJ, 55 km north-east of Meekatharra Aerodrome, Western Australia, on 17 October 1996

Summary

The pilot reported that he was conducting sheep spotting operations at 500 ft above ground level when the engine suddenly lost power. He was forced to complete an emergency landing in rough terrain, damaging the aircraft in the process.

The pilot had refuelled the aircraft to full tanks and conducted a water drain test 45 minutes flying time prior to the power loss.

The carburettor was removed, tested and inspected. On the test bench, the carburettor flooded each time it was tested. The inspection disclosed some faults that probably led to the flooding. The float level had been incorrectly set, there was significant wear in the float attachment pin and the floats had been making contact with the carburettor body and the head of the needle valve had been repaired using silver solder. Additional tests also indicated that it was possible for the needle valve to jam in the closed position, starving the carburettor of fuel. The head of the needle valve was badly worn. This permitted it to become jammed in a corresponding wear mark on the carburettor body. Other faults, such as the use of locking wire instead of a split pin to secure the float pin and disintegration of the accelerator pump leather plunger were also evident.

An inspection of the aircraft logbooks indicated that the carburettor float level had been adjusted by a LAME 12 flying hours prior to the power loss. Float adjustment requires the carburettor to be opened. Some of the faults, which the inspection indicated had been present for a considerable time, should have been apparent during the adjustment. They were not corrected.

It is probably that the faults in the carburettor caused it to be starved of fuel or to flood and one of these situations led to the power loss.

Occurrence summary

Investigation number 199603387
Occurrence date 17/10/1996
Location 55 km north-east of Meekatharra Aerodrome
State Western Australia
Report release date 04/12/1996
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 Cessna Aircraft Company
Model 182E
Registration VH-RHJ
Sector Piston
Operation type Aerial Work
Departure point Mulgul Station WA
Destination Wonca Wol Station WA
Damage Substantial