Fuel starvation involving a Hiller Aviation UH-12E, VH-HIL, 30 km east of Taralga, New South Wales, on 13 March 1995

Summary

The pilot was positioning the helicopter for the first spray run.  As he lowered the collective lever and commenced a turn, he noticed that the rate of descent was higher than usual and that the dual tachometer needles had split. Realising that the engine had lost power, he performed an autorotative descent from less than 100 ft above ground level (agl).  During the touchdown on slightly sloping terrain, the right front skid tube broke, and the helicopter rolled on to its right side.

During the helicopter retrieval, the engineer estimated that he drained 4 to 5 litres of AVGAS from the helicopter's undamaged fuel tank.  The drained fuel was not accurately measured. The pilot's estimate of drained fuel was 6 to 8 litres.  No evidence was found of fuel having leaked onto the ground prior to or during the retrieval.  The engineer found no evidence of fuel leaks, blockages, water or significant foreign matter in the helicopter's fuel system.  His opinion was that the engine lost power due to fuel starvation.

The pilot cannot remember the fuel gauge reading immediately before the accident.  The failure occurred about 1.5 minutes after take-off from the loading base and 34 minutes flight time since the last refuel.

The pilot had refuelled approximately every 30 minutes of flight time during the previous four hours of spraying. 

After refuelling, he did not dip the tank to measure the fuel accurately. He advised that the last refuel consisted of 60 turns of a rotary hand pump.  He believed that every turn of the handle had pumped 0.8 litre into the fuel tank. In his opinion, the fuel gauge reading compared with the estimated amount of fuel pumped into the tank at each refuel.

A warning in the Hiller 12E flight manual states: - "Operating with fuel indicator in the yellow arc during sideward or rearward flight may result in loss of power", because the fuel tank pickup pipe may be exposed and cause the fuel pump to momentarily suck air in lieu of fuel.  The helicopter was not flying sideways or rearwards when engine power was lost.  The unusable fuel listed in the flight manual was only 1 litre for normal level flight.

The pilot thought that the engine did not stop completely during the descent but ran down to idle and that it idled very briefly after touchdown because he saw a small post-crash fire caused by the drift marker oil, a very light oil, dribbling into the exhaust.  Engineers were doubtful that the engine could have run on the ground with the helicopter steeply on its right side with the two carburettor float bowls side uppermost.

The pilot did not dispute that the helicopter appeared to have experienced fuel starvation.  However, he believed 48 litres of fuel were added at the last refuel before the accident. Since the helicopter had consistently used 60 to 62 litres per hour in recent times and because its tank was not empty at the commencement of the last refuel, in excess of 13 litres of AVGAS should have been in the fuel tank when the power loss occurred.

Several litres of AVGAS have not been accounted for.  No evidence was found to indicate that the drum refuelling pump was unserviceable.

It has not been possible to resolve discrepancies in fuel since the accident; nor has any fault been found with the aircraft which may have contributed to the accident.

Occurrence summary

Investigation number 199500734
Occurrence date 13/03/1995
Location 30 km east of Taralga
State New South Wales
Report release date 10/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Accident

Aircraft details

Manufacturer Hiller Aviation
Model UH-12E
Registration VH-HIL
Sector Helicopter
Operation type Aerial Work
Departure point Hanworth Station NSW
Destination Hanworth Station NSW
Damage Substantial

Collision on ground involving a de Havilland DH-104 Series 8, VH-DHQ, Essendon, Victoria, on 13 March 1995

Summary

The pneumatic system on this aircraft type operates the landing gear, flaps and brakes. The aircraft is equipped with a castering nosewheel and steering is achieved by differential braking. The pneumatic system normal operating pressure is 450 to 600 psi. The minimum pressure for engine start is 90 psi. Prior to engine start, the pilot noted that the pneumatic pressure was about 250 psi. He anticipated the pressure would increase to normal operating pressure after engine start.

The engines were started and the aircraft commenced taxiing. Shortly afterwards the pilot noted that pneumatic pressure had not increased to normal operating pressure as anticipated. At about this time he recalled that he had activated the pneumatic system drain valves during a ground inspection of the aircraft. He suspected that he may not have tightened the valves and that this could be the reason for lack of pneumatic pressure. He therefore decided to return to the parking area and investigate.

As there was still over 100 psi pressure, he considered it safe to taxy back to the hangar (bearing in mind that 90 psi is the minimum for start which infers that the brakes should work at that pressure). Approaching the hangar which involved taxiing on a downhill slope, he applied differential braking but there was no response. Realising that he would be unable to turn the aircraft he quickly shut the engines down. The aircraft rolled slowly towards a hangar where it collided with a scaffolding fence, incurring minor damage to the nose gear doors and skin areas of the nose and one wing.

During a post incident inspection, the pilot noted that the pneumatic system drain valves had not been properly tightened. This explained the reason for the lack of normal system pressure build up after engine start. However, the pilot said he believed there should still have been enough pressure for differential braking/steering. Accordingly, he would have a complete check made of the pneumatic system after the damage sustained in the incident had been repaired.

Occurrence summary

Investigation number 199500709
Occurrence date 13/03/1995
Location Essendon
State Victoria
Report release date 03/04/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer de Havilland Aircraft
Model DH-104 Series 8
Registration VH-DHQ
Sector Piston
Operation type Charter
Destination King Island TAS
Damage Minor

Wirestrike involving a Piper PA-28-181, VH-BRY, Torquay, Victoria, on 11 March 1995

Summary

Prior to departure the pilot rang the owner of the airstrip to get information on the strip and permission to land.  He was told that there were powerlines on approach to the 180 degree strip and the 090 degree strip.  He overflew the airfield on arrival and noted there was a light easterly breeze so decided to land on the 090 degree strip which has a published length of 910 metres in the AOPA directory.  The strip also has a displaced threshold which the pilot observed.

On final approach he noted that the strip seemed short.  The strip surface was grass, and the pilot thought it may have been wet.  He therefore slowed the aircraft and selected full flap while keeping power on, aiming to touch down as close as possible to the displaced threshold markings. Approaching the end of the strip the pilot believed he must have been past the powerline although he had not actually seen it.  He lowered the nose to touch down on the displaced threshold and at that point hit the powerline.  The aircraft then hit the ground heavily, sustaining substantial damage.

During the investigation the owner of the airstrip advised that the strip was 900 metres fence to fence.  Landing into the east there was 680 metres available due to the displaced threshold at the approach end.  After the accident the pilot said he noted that the powerline was in fact over the "turning area" at the approach end of the strip and the poles were some distance apart, remote from the final approach path.

The day after the accident the electricity supplier installed marker devices on the powerline.

Significant Factors

The following factors were considered relevant to the development of the accident:

  1. The pilot was warned about the presence of a powerline on the approach end of the strip he was using but did not ensure that he sighted it prior to making his landing approach.
  2. Although he had not sighted the powerline, on short final approach he made an assumption that he must have passed it and so lowered the nose to touch down as close as possible to the displaced threshold markers.
  3. The pilot "dragged the aircraft in with power" on a low final approach profile instead of flying a normal glidepath.
  4. The powerline was not fitted with any warning marker devices.

Occurrence summary

Investigation number 199500706
Occurrence date 11/03/1995
Location Torquay
State Victoria
Report release date 15/03/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28-181
Registration VH-BRY
Sector Piston
Operation type Private
Departure point Moorabbin VIC
Destination Torquay VIC
Damage Substantial

Operational non-compliance involving a Gulfstream III, N103GC and Saab SF-340B, VH-TCH, 60 km north of Canberra, New South Wales, on 3 March 1995

Summary

Due to crossing traffic at flight level 180 the pilot of N103GC was asked if the aircraft could reach flight level 190 by 25 miles from Canberra. The pilot said this could not be done and air traffic control told the pilot to maintain flight level 170.

During the climb the controller observed the mode C read out increase above flight level 170. The pilot was told to maintain flight level 170, but the level read out increased to flight level 176 before decreasing back to flight level 170. N103GC passed three to four miles behind the other aircraft, VH-TCH.

Significant Factors

The following factors were considered relevant to the development of the incident:

1. The pilot did not comply with the level restriction.

2. The precise reason for this happening was not determined.

Occurrence summary

Investigation number 199500702
Occurrence date 03/03/1995
Location 60 km north of Canberra
State New South Wales
Report release date 09/06/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer Gulfstream Aerospace Corp
Model Gulfstream III
Registration N103GC
Sector Jet
Operation type Charter
Departure point Canberra ACT
Destination Williamtown NSW
Damage Nil

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340B
Registration VH-TCH
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Wagga NSW
Damage Nil

Loss of control involving a Bellanca 8KCAB, VH-JIR, Canberra, Australian Capital Territory, on 9 March 1995

Summary

The pilot reported that he was giving another pilot instruction for the purpose of endorsement on type. A few seconds into the landing roll the left wing lifted, and the aircraft veered sharply left towards the runway edge. Both the instructor and the student applied opposite rudder resulting in the aircraft turning quickly right. This was followed by a series of sharp turns left and right down the runway until the aircraft eventually entered a ground loop to the left before coming to a halt.

Occurrence summary

Investigation number 199500682
Occurrence date 09/03/1995
Location Canberra
State Australian Capital Territory
Report release date 28/03/1995
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 Bellanca Aircraft Corp
Model 8KCAB
Registration VH-JIR
Sector Piston
Operation type Flying Training
Departure point Lake Bathurst NSW
Destination Canberra ACT
Damage Substantial

Depart/app/land wrong runway involving a Boeing 747-400, G-BNLG, Quarry, South Australia, on 11 March 1995

Summary

The aircraft was approaching Adelaide from Melbourne having received an airways clearance for descent to 3000ft, with a pilot's intercept of the runway 23 localizer.

Approximately 46km east of Adelaide the DME reading disappeared from the FMS CDU. The captain then selected the appropriate "FMS fix" page to reinsert the data which caused a "time out resynch" message to appear on the FMS CDU.

It was the crews first flight into Adelaide and a correct approach briefing had been given. Weather conditions were perfect, the wind calm with no cloud and unlimited visibility. The captain stated that due to the FMS problem, both he and the first officer, who was apparently hand flying the aircraft, had had a momentary lapse in monitoring the approach, and allowed the aircraft to pass through the localizer.

The first officer noticed the runways of an aerodrome immediately in front of them, notified Adelaide Approach that the aerodrome was in sight, and reacted instinctively by commencing a right turn for base leg to what he believed was runway 23, without descending below the cleared altitude of 3000ft.

The error was immediately recognised by the crew, at the same time Adelaide Approach advised "wrong aerodrome". The aircraft had been positioning for Parafield, a general aviation airport situated 20km north-east of Adelaide, and was then turned back onto the localizer for a landing on runway 23 at Adelaide.

The captain said that if weather conditions had been different he would not have spent time rectifying the DME fault, but would have completed the flight monitoring the navigation instruments to Adelaide via the 23 ILS. He is to submit an ASIR to his company on return to the United Kingdom, with a recommendation that Parafield and Edinburgh airports be highlighted on company operational documentation.

Occurrence summary

Investigation number 199500695
Occurrence date 11/03/1995
Location Quarry
State South Australia
Report release date 16/03/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Depart/app/land wrong runway
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-400
Registration G-BNLG
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic
Destination Adelaide SA
Damage Nil

Runway excursion involving a Piper PA-32R-301, VH-RMP, Aeropelican, New South Wales, on 10 March 1995

Summary

The pilot reported that as he entered the circuit area light rain was falling, associated with a light and variable wind from the southeast. He carried out a right circuit for a landing approach to runway 07, reducing speed to about 90 kts as the aircraft passed over the threshold. However, the aircraft floated before touching down about a quarter distance along the strip. The brakes were applied but were ineffective in slowing the aircraft. Concerned that he would overrun the strip and the highway beyond, the pilot deliberately ground looped the aircraft to the right. The left main and nose landing gears collapsed during the turn, before the aircraft came to rest against the perimeter fence.

The pilot subsequently learned that it had rained heavily prior to his arrival and thought his aircraft may have aquaplaned on the wet runway surface.

Occurrence summary

Investigation number 199500683
Occurrence date 10/03/1995
Location Aeropelican
State New South Wales
Report release date 06/12/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-32R-301
Registration VH-RMP
Sector Piston
Operation type Business
Departure point Coolangatta QLD
Destination Aeropelican NSW
Damage Substantial

Separation issue involving a Cessna 404, VH-TTZ and Unknown Glider, 25 km south of Ballarat, Victoria, on 25 February 1995

Summary

At the completion of a fire spotting exercise VH-TTZ was passing 9000 feet on descent in controlled airspace (CTA) when a glider was sighted at the same altitude.  Air traffic control had no knowledge of glider operations in the area, for which the lower level of CTA was 6,000 feet. The glider was not identified.

Investigation disclosed that a gliding competition was being conducted from Bacchus Marsh airfield and the glider was most probably one of those taking part. The competition task was a triangular cross-country flight departing from Bacchus Marsh, tracking southwest to Derrinallum, then north west to Buangor, then returning to Bacchus Marsh.

Bacchus March is situated under the 2,000 foot step of Melbourne CTA. On the day of the competition "Area Alpha", a specially released block of airspace over Bacchus Marsh with a 4,000 foot ceiling, gave pilots a higher start level over the airfield.  The south-eastern boundary of the 4,000 foot CTA step is located one mile to the west of the airfield. The competition track progressed under the 4,000, 6,000, 8,000 and 10,000 foot CTA steps.

Prior to take-off the pilots were briefed by the contest organiser who had arranged the task based on the weather forecast for the day, which indicated that thermals would go to 8,000 feet. The briefing covered task details, weather, safety and some airspace considerations. Pilots were not provided with airspace maps by the organiser, nor did the briefing involve airspace higher than 8,000 feet.

The weather for the day was much better than forecast with reports of some gliders taking part in the competition reaching 12,000 feet in thermals.

At the time of the airspace incursion the gliders were returning from the task. The incursion occurred south of Ballarat within the area of the 6,000 foot CTA step. Had the glider been observing the limitation and flying below the 6,000 foot CTA step, it would have been required to climb in thermals to have reached Bacchus Marsh. This would have slowed the glider's progress.

One aim of pilots in such competitions is to gain as much height as possible and, on the final glide, trade that height for speed to arrive over the airfield with just sufficient height to finish, conduct a circuit, and land. The pilot involved in the incursion would probably have been taking advantage of the strong conditions to maximise his competitive advantage and was either not aware of, or was not respecting, the airspace boundaries of the area in which he was flying.  Because of the smoke from the bushfire, it is doubtful that the glider pilots were able to achieve the visual navigation accuracy needed when flying close to CTA step boundaries.

Glider pilots do not receive training in airspace to the same extent as the pilots of powered aircraft. They also do not hold a licence issued by the Civil Aviation Authority (CAA) and consequently do not receive advice from the CAA in regard to availability of airspace maps and associated information.

The gliding fraternities' understanding and respect of airspace, and the quality of briefings, has been the subject of a previous accident report. (Ref 9303898 VH-AYB, GMN, Benalla 24 November 1993).

Significant Factors

The following factors were considered relevant to the development of the incident:

  1. Glider pilots taking part in the competition were inadequately briefed in regard to airspace requirements.
  2. Glider pilots do not receive formal training in airspace considerations.
  3. The pilot was either not aware of or was not respecting the airspace limitations.
  4. Smoke from a bushfire would have made visual identification of CTA step boundaries difficult.
  5. The glider was flown in controlled airspace without a clearance.

Safety Action

This ASOR is to be referred to the Gliding Federation of Australia to reinforce the need for increased awareness of these matters. (Ref SADN 950070).

Occurrence summary

Investigation number 199500681
Occurrence date 25/02/1995
Location 25 km south of Ballarat
State Victoria
Report release date 17/05/1995
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 Cessna Aircraft Company
Model 404
Registration VH-TTZ
Sector Piston
Operation type Charter
Departure point Essendon VIC
Destination Ballarat VIC
Damage Nil

Aircraft details

Manufacturer Unknown
Model Glider
Registration Unknown
Sector Other

Runway excursion involving a Piper PA-28-180, VH-CPM, Paramatee Station via Yunta, South Australia, on 28 February 1995

Summary

The pilot had undertaken a private flight from Port Pirie intending to land at a property. When he arrived in the general area, he saw an airstrip with a vehicle parked nearby and believing that he had arrived at his destination commenced an approach for landing.

After the aircraft had touched down the pilot realised the airstrip was not suitable for the operation but was committed to continue with the landing.

The aircraft over-ran the end of the airstrip with the left wing striking a tree causing damage to the wingtip and displacing the spar rearwards. The pilot being the only occupant was uninjured.

Occurrence summary

Investigation number 199500622
Occurrence date 28/02/1995
Location Paramatee Station via Yunta
State South Australia
Report release date 08/03/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28-180
Registration VH-CPM
Sector Piston
Operation type Private
Departure point Port Pirie SA
Destination Manunda Station SA
Damage Substantial

Forced/precautionary landing involving a Robinson R22 Beta, VH-LKS, West Alligator River, Northern Territory, on 7 March 1995

Summary

The helicopter was being operated on a wildlife survey flight, and while manoeuvring near a crocodile nest the pilot reported an apparent loss of engine power, with a subsequent decay in main rotor RPM. He attempted to regain rotor RPM by opening the throttle fully, applying right anti-torque pedal, increasing forward speed and reducing collective pitch as much as possible but was unable to arrest the descent. When ground impact became inevitable, he levelled the helicopter and applied up collective to cushion the impact, but the resulting heavy landing caused the landing gear skids to collapse and the main rotor blades to strike the ground. The engine was still running and stopped by the pilot.

A brief inspection of the helicopter was made at the accident site, but with some difficulty due to crocodiles in the area. A more detailed inspection was carried out after it was recovered to Darwin. No evidence was found to suggest that it was other than serviceable prior to impact.

The pilot stated that he had departed from Jabiru for the 58km flight with 32 litres of fuel on board the helicopter and was to refuel at a nearby airstrip for the return flight. Inspection revealed that the amount of fuel remaining in the tank at the time of the accident was 65-70 litres, and the helicopter's all up weight was estimated as being just below the allowable maximum.

The pilot later revised his statement to agree that there would have been about 65 litres of fuel on board at the time of the accident and suggested that he may have over-pitched the rotor system when distracted by outside events as he attempted to find a place to land near the crocodile nest.

Occurrence summary

Investigation number 199500659
Occurrence date 07/03/1995
Location West Alligator River
State Northern Territory
Report release date 06/04/1995
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-LKS
Sector Helicopter
Operation type Charter
Departure point Jabiru NT
Destination West Alligator River NT
Damage Substantial