Aviation safety investigations & reports

Fuel data occurrence involving Bombardier Dash-8-315, VH TQE Tamworth Regional Airport, New South Wales, on 15 January 2021

Investigation number:
AO-2021-002
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final Report
[Download  PDF: 526KB]
 

What happened

In the evening on 15 January 2021, a QantasLink Bombardier Dash-8-315 aircraft, registered VH‑TQE, was being prepared for a scheduled passenger service from Tamworth to Sydney, New South Wales. There were two flight crew, two cabin crew and 29 passengers on board. During the pre‑flight preparations, the flight crew misread the aircraft’s fuel tank gauges and interpreted the total fuel on board to be about 340 kg more than the actual quantity.

The incorrect fuel figure was subsequently used to complete pre-flight documentation and data entry inputs, and the aircraft departed Tamworth with inaccurate load, take‑off and fuel management data. The error was not detected by the flight crew until the aircraft reached its cruise level, when it was corrected, and the flight continued without further incident.

What the ATSB found

The ATSB found that the captain and first officer were distracted by the circumstances associated with the Tamworth arrival and this probably influenced the inaccuracy of the initial fuel check. Having made the initial error, the flight crew formed an incorrect mental model of the aircraft fuel state that persisted throughout the pre-flight preparations. The crew identified the error when seeking out new fuel‑related information during the cruise procedural check.

What has been done as a result

Following this incident, QantasLink provided internal communications to flight crew on checklist usage and cross checking of data. QantasLink also intends using the incident as a case study in its human factors/non-technical skills training program.

Safety message

Data input error is one of the ATSB’s SafetyWatch priorities. Flight crews can guard against errors similar to those in this incident by applying effective threat and error management strategies that recognise when such threats may arise and put in place suitable actions to minimise error potential. These actions include the strict adherence to standard operating procedures, clear and concise communication and independent cross checks between pilots.

 

Download Final Report
[Download  PDF: 526KB]
 
 
 

The investigation

General details
Date: 15 January 2021   Investigation status: Completed  
Time: 1745 EDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Tamworth Regional Airport, New South Wales   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Loading related  
Release date: 30 September 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  
Anticipated completion: 3rd Quarter 2021    

Aircraft details

Aircraft details
Aircraft manufacturer Bombardier Inc  
Aircraft model DHC-8-315  
Aircraft registration VH-TQE  
Serial number 596  
Operator Eastern Australia Airlines (operating as QantasLink)  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Tamworth Regional Airport, New South Wales  
Destination Sydney Airport, New South Wales  
Last update 30 September 2021