[Peetwo]

Groundhog day - Fuel exhaustion.

D’ya know – in  almost 50 years of flying – for real – I’ve never, ever heard of such a thing as the story above. I really, truthfully, have some problem actually believing it, particularly as the ATSB say it is so. There is a deep flaw in the logic from both industry and CASA on display here. Nothing in the rules – so pilots don’t do it – THINK about it.

Then let’s have a look at a normal, everyday situation; in terms of ‘logic’.

Bloggs is slated to fly today. A four hour ‘mission’ – charter, survey, medi-vac – whatever. Point is the total journey involves at least four hours ‘airborne’. The procedure is simplicity itself. Bloggs sits down, with pencil and paper and ‘nut’s-it-out’. Taxi, take-off, climb, cruise descent, approach, landing and taxi in. ALL totally calculable (ish). Armed with weather details, load and ‘other’ information – the flight and FUEL plan is structured.

Step 2 – Bloggs ambles out and CHECKS – the residual fuel of board – RFOB.

Step 3 – Bloggs decides that to stay legal – the maximum amount of fuel he can carry is X the job requires X +/- that amount. So the ‘flight plan’ is developed to suit the task. No problemo – unless fuel is not available; then a re-think is required…

Step 4 – Bloggs; as pilot in command (PIC) orders the fuel uplift.

Step 5 – Tanker turns up – fuel is loaded and A DOCKET IS ISSUED. This is SIGNED by the PIC. Bloggs wanted 500 litres – docket says 500 delivered; this plus the residual FOB should amount to the fuel required.

Step 6 – Bloggs (being conscientious) adds the fuel delivered to the RFOB and then – the big one – declares that he is ‘happy’. As in, he accepts command responsibility for the task.

This is a routine, daily occurrence. A cross check that there is sufficient fuel + reserves to complete the task – not only legally (which don’t signify) but SAFELY, which does.

The truly scary part is that because the regulations don’t say this must done – it’s not? Aw, FDS.

Well, bugger me. It would be a cold day in “K’s” workplace before I failed – dismally – to make sure required FOB equaled that already on board + uplift  = flight fuel required (+ reserves). WTD are they teaching these children?

The truly bad part is CASA are now required to ‘respond’. They will be obliged to spell out, in legal terms of strict liability – the things that every thinking airman should never need to be told about. Those that taught the pilot mentioned need to be tarred, feathered and run out of Dodge on a rail…………….FDS.

Are we now so completely dependent on; and, terrified of ‘the rules’ that we cannot, dare not  think for ourselves?   It seems to be so to me. Indeed it does.

“Yes, yes, a Jameson will chase that pint down very nicely; thank you."

What else can you do when lunacy rules. Cheers.

Spot on excellent post P7 -   

Ref SAN Presser:

Air Operator Certificate holders operating aircraft not greater than 5,700 kg
Fuel policy requirements

The current legislation does not require commercial operators of aircraft not greater than 5,700 kg maximum take-off weight (MTOW) to provide instructions and procedures for crosschecking the quantity of fuel on board before and/or during flight. This increases the risk that operators in this category will not implement effective fuel policies and training to prevent fuel exhaustion events.

What happened
On 17 July 2016, at about 1039 Central Standard Time, a McDonnell Douglas Corporation 369D helicopter, registered VH-PLY, experienced fuel exhaustion and a collision with terrain while performing powerline inspections 36 km north-west of Hawker, South Australia. There were three crew on board the helicopter. One pilot in the front left seat, one line-worker in the front right seat and one line-worker in the rear left seat. The three crew members were seriously injured and the helicopter was substantially damaged.

Why did it happen
The ATSB found that the pilot was mistakenly told by ground staff that the aircraft had been refuelled and through distraction, omitted a crosscheck of the fuel quantity before flight. The pilot’s monitoring of the fuel in-flight was based on anticipated endurance, which resulted in him not detecting a low fuel level. The ATSB also found the requirements for the development of fuel policy by operators were dispersed throughout the aviation legislation—14 legislative and three guidance material requirements were found—but they did not require the operator to publish procedures for determining fuel on board before and during flight for commercial operators of aircraft not greater than 5,700 kg MTOW.

Safety advisory notice
AO-2016-078-SAN-009: From 2003 to 2017, the ATSB has received 26 reports of fuel exhaustion events from Air Operator Certificate holders operating aircraft not greater than 5,700 kg MTOW. Two key contributing factors from these reports are pilots not crosschecking the fuel on board before and/or during flight. Aircraft greater than 5,700 kg MTOW are not represented in the ATSB fuel exhaustion reports. In accordance with CAO 20.2, operators of these aircraft are required to publish instructions and procedures in their operations manuals for the pilot in command to verify the fuel on board before flight. Additionally, CAAP 215-1(2) Appendix B includes guidelines for publishing operations manual procedures for inflight fuel management.

CASA 29/18 – Civil Aviation (Fuel Requirements) Instrument 2018, which contains proposed changes to the current fuel regulations and guidance material is scheduled to commence 8 November 2018. The ATSB considers that the implementation of these changes should address this safety issue.

Until the proposed changes to the current fuel regulations and guidance material are implemented, the ATSB advises Air Operator Certificate holders for aircraft not greater than 5,700 kg MTOW, to consider this safety issue and take action where appropriate.
Read more about this ATSB investigation: AO-2016-078.
 
Type:
Safety Advisory Notice
Investigation number:
AO-2016-078-SAN-009
Publication date:
2 August 2018
 
[img=110x0]https://www.atsb.gov.au/media/4097574/share.png[/img][img=111x0]https://www.atsb.gov.au/media/4097569/feedback.png[/img]

Last update 02 August 2018

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& from the SAN:

Proactive Action

Action organisation:
Civil Aviation Safety Authority
Action number:
NSA-008
Date:
02 August 2018
Action status:
Released

The Civil Aviation Safety Authority (CASA) has started project CD 1508OS, which was published on their website 20 January 2016. The project contains the proposed changes to Civil Aviation Regulation (CAR) 234, the issuance of a CAR 234 Legislative Instrument, and revised Civil Aviation Advisory Publication (CAAP) 234-1(2): Guidelines for aircraft fuel requirements, CAAP 215-1(2): Guide to the preparation of Operations Manuals, Volume 2, appendix B9: Fuel management, and the Air Operator’s Certificate (AOC) handbook Volume 2 – Flying Operations – Section 6: Fuel policy and related requirements. Once made into law, the amendments to the existing CAR 234 will commence on 8 November 2018.

A key outcome of the amendment is providing clarity about the regulatory requirements that apply to fuel by having those requirements set out in a legislative instrument. This overcomes difficulties with the previous arrangement, where requirements were set out in guidance material ‘called up’ by regulation, in that the requirements were often not readily recognised as having the force of law. CASA 29/18 – Civil Aviation (Fuel Requirements) Instrument 2018 sets out the legislative requirements that:

• specify the matters that must be referenced by the operator and the pilot in command in determining the quantity of usable fuel required for a flight
  
• specify the quantities required to commence a flight and also to continue a flight
  
• require that inflight fuel management be conducted, and
  
• specify the contingencies to which additional fuel calculation must be applied.
  

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To assist industry and CASA understanding of the changes to the fuel requirements in legislation, the amendment to guidance material CAAP 234-1(2) will be published. It will contain enhanced guidance on the generally applicable fuel related areas of the legislative instrument. CAAP 234-1(2) will differentiate between requirements and guidance.
 [/size]
ATSB response:
The ATSB has reviewed the draft project documents for CD 1508OS and considers that the implementation of the CAR 234 Legislative Instrument and CAAP 234-1(2), in conjunction with their requirements reflected in the AOC Handbook, should address the safety issue. The ATSB will continue to monitor the action by CASA. Until that time, the ATSB issues the following Safety Advisory Notice to AOC holders operating aircraft not greater than 5,700 kg.

What still gets me is how the hell it can take the ATSB 2+ years to get around to publishing this SAN. It also beggars belief that CASA, with the ATSB providing topcover, could honestly be promoting their timeline in the SAN as 'proactive action'. That is simply laughable at best and criminal negligence at worst. Besides the fact that the draft project (CD 1508OS) is still ongoing after 2.5 years, it should be remembered that this project is an adjunct of the original review of the CAR 234 legislative instrument  - i.e. Project OS 09/13 - Ref:  Project OS 09/13 - Fuel and Alternate requirements - which was originally approved in 2009: 

Project OS 09/13 - Fuel and Alternate requirements

Project approved. 21 Aug 2009

What makes it even worse is that project was finally approved after more than a decade of previous ATSB occurrence reports and safety recommendations that all pointed towards the need for urgent safety risk mitigation with review of CAR 234 and the rules surrounding mandatory fuel uptake. 

Disgusting -   I'll leave Ben Sandilands to posthumously comment on the issue, after all nothing has changed since (2015...err 1996):

ATSB forgets Pel-Air in study of fuel exhaustion accidents

Amnesia can now be again added to the failings of integrity and safety focus in ATSB reports on the repeated release today of  its study titled Starved and Exhausted: Fuel Management Aviation Accidents. It leaves out the fuel management related crash investigation of the century, the one in which a Pel-Air flight was ditched near […]
BEN SANDILANDS
 
FEB 09, 2015
 


APT ILLUSTRATION FROM TODAY'S BIZARRE ATSB RECYCLING OF OLD STUDY

Amnesia can now be again added to the failings of integrity and safety focus in ATSB reports on the repeated release today of  its study titled Starved and Exhausted: Fuel Management Aviation Accidents.
It leaves out the fuel management related crash investigation of the century, the one in which a Pel-Air flight was ditched near Norfolk Island in 2009.

But the notification of the study by the ATSB using Twitter is even stranger. It’s recycling the study it published according to the fly sheet in March 2013 and the web page the link to the download takes you was last edited in April 2014.

Among the illustrations in the study is the top of page photo of the retrieval of a Piper Cherokee Six that ditched while conducting inter-island charters between Mackay and the Whitsundays in April 2008.

So strange. If the ATSB can haul an entire Cherokee out of the Whitsunday waters, what really stopped it being sufficiently curious about the ditching the Pel-Air Westwind corporate jet from the water close to Norfolk Island to recover its flight data recorder?

What didn’t the ATSB want to know? Now, in 2015, we know that the ATSB and CASA variously withheld or dismissed serious findings about safety deficiencies in Pel-Air’s operations, owned by the generous Labor and Coalition political donor REX, who lavished completely unrelated and out of character gifts of money to both sides of politics in the same year that a discredited ATSB report into the crash was released.

The optics aren’t good. The ATSB re-releases a report that leaves out the most important fuel management accident in its history at the same time as it is trying to get away with conducting a new review of that Pel-Air rash report it insists is fault free.

This is pathetic.

    

MTF...P2