Aviation safety investigations & reports

Engine power loss involving Piper Aircraft Inc. PA-36, VH-TVU, near Latrobe Valley Airport, Victoria, on 12 August 2019

Investigation number:
AO-2019-043
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 522KB]
 

What happened

On 12 August 2019, a Piper Aircraft Inc. PA-36-300, registered VH-TVU (TVU), departed Latrobe Regional Airport, Victoria, at 0830 Eastern Standard Time, on a ferry flight to Coffs Harbour, New South Wales. The aircraft had recently been sold and the new owner had arranged for the aircraft to be ferried to New Zealand. Shortly after take-off, the engine power reduced to below idle. Faced with limited options, the pilot conducted a forced landing into a paddock. During the approach, the aircraft struck power lines and subsequently contacted a fence and tree stumps during the landing. The pilot suffered minor injuries and the aircraft was substantially damaged.

What the ATSB found

The ATSB found that the engine power loss was probably the result of water‑contaminated fuel, and that the methods used to detect and remove the water before the flight were unreliable. An inspection of the fuel control unit also detected additional contamination that may have hindered fuel flow to the engine.

Finally, the aircraft was utilising the chemical hopper as a ferry fuel tank, contrary to the recommendation of the aircraft manufacturer, and no approved technical data could be provided on the installed fuel system.

Safety message

This accident highlights the danger of water‑contaminated fuel, a topic discussed in CASA Airworthiness Bulletin AWB 28-008. While this bulletin is related to aircraft using AVGAS or MOGAS, it is also relevant to the use of turbine fuel. It discusses the issue of water entering the fuel system through poor fitting, unapproved, incorrectly adjusted, or failed seals on the fuel caps or damaged/distorted tank filler necks.

When conducting fuel contamination checks, it is important that the check is positive and does not rely on sensory perceptions of colour and smell, as these can be deceptive. There are a number of ways this can be done:

  • place a small quantity of known fuel in container before taking the fuel sample
  • use a water-detecting paper or paste
  • check for cloudiness or other evidence of suspended water droplets, particularly in turbine fuel.

The accident also illustrates the importance of being mentally prepared for an emergency. In this case, the pilot had secured the seatbelts over their flying suit prior to take-off. The pilot had also conducted a pre-take-off brief, so was prepared to take immediate action when an engine power loss occurred. An article in Flight Safety Australia ‘Your one and only: mitigating the risk of engine failure in singles advises that:

Rather than passively waiting for power loss and falling back on trained responses, pilots must actively defend their aircraft against the consequences of engine failure. Know your aircraft and procedures. Fly as high as practical, keep your options open and have a clear plan rehearsed for engine failure during every sequence of flight.

Download final report
[Download  PDF: 522KB]
 
 
 

The investigation

General details
Date: 12 August 2019   Investigation status: Completed  
Time: 0825 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 2 km ENE Latrobe Valley Airport   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Engine failure or malfunction  
Release date: 25 November 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-36-300  
Aircraft registration VH-TVU  
Serial number 36-7760088  
Operator Fairglen Nominees  
Type of operation Aerial Work  
Sector Turboprop  
Damage to aircraft Substantial  
Departure point Latrobe Regional Airport, Victoria  
Destination Coffs Harbour, New South Wales  
Last update 30 November 2020