[Peetwo]

AO-2024-008 (Short) & AO-2023-020 (Defined) Final Reports completed?? - 

Courtesy of PJ's media minions and attributed to DTS Stewie Macleod:

Fuel management, unsecured cap risk highlighted in Aero Commander forced landing



[b]The pilot of an Aero Commander had to land the aircraft in a field after fuel siphoned overboard due to an incorrectly installed fuel cap, an ATSB investigation has concluded.[/b]

On 8 March 2024, the twin-engine Aero Commander 500-S was conducting a return freight flight from Bankstown to Parkes, with multiple stops each way.

Upon landing after the first sector of the day, the pilot found the aircraft’s fuel cap was off and secured only by a retention chain.

The pilot re-secured the cap, but found the cap off again after the second sector, after landing in Parkes.“For the two sectors from Bankstown to Parkes, the fuel cap had been incorrectly installed with the retention chain lodged in the fuel tank’s anti-siphon valve, resulting in the cap dislodging in flight, and fuel being siphoned overboard,” ATSB Director Transport Safety Stuart Macleod explained.

An inspection and rectification conducted at Parkes by a maintenance engineer fixed the issue.

“However, the pilot identified an unexplained discrepancy between expected fuel remaining and gauge quantity indication, but did not refuel to a known quantity, or amend the flight log,” Mr Macleod noted.

“This meant the aircraft left Parkes without enough fuel to complete the remaining sectors on its return trip back to Bankstown.

”After departing Parkes, the pilot likely did not monitor the fuel gauge, continued fuel calculations based on an incorrect fuel quantity, and did not refuel the aircraft to a known quantity when they landed at their final interim location, Bathurst.

Subsequently, shortly after take-off for the final sector to Bankstown, both engines lost power due to fuel exhaustion, and the pilot conducted a forced landing in a field. Fortunately, the aircraft was undamaged, and the pilot uninjured.

“A missing or unsecured fuel cap should be treated as an emergency, and if detected pilots should immediately divert to the nearest suitable aerodrome,” Mr Macleod said.

Since the incident, the operator, GAM Air, published a notice to pilots reinforcing fuel management procedures. It also commenced periodic auditing of pilot fuel calculations.

Additionally, in response to an ATSB finding that its Quick Turn Around – Pre-Start checklist did not include a fuel quantity check before start, the operator has announced the intention to discontinue using this specific checklist.

“Pre-flight fuel quantity checks should use at least two different verification methods to determine the amount of fuel on board,” Mr Macleod said.

“When using computed fuel on board and comparing against gauge readings, it is important that calculations are accurate. If any discrepancy is detected between the two methods, another method such as filling to a known quantity is required.”

Read the final report: Fuel exhaustion involving Aero Commander 500-S, VH-MEH, 6 km east of Bathurst Airport, New South Wales, on 8 March 2024 

Publication Date: 19/11/2024

Plus attributed to DTS Dr Godlike:

Saab 340 fire and smoke event highlights importance of aircraft configuration knowledge



An in-flight fire and smoke incident involving a Saab 340 freight aircraft over New South Wales last year highlights the importance of operators ensuring flight crews are aware of differences in aircraft configurations.

On 23 April 2023, the Saab 340A was being used for a non-revenue positioning flight from Wagga Wagga, New South Wales, to Charleville, Queensland with a captain and first officer on board. The aircraft was owned by Pel-Air and was being operated by flight crew from Pel-Air's sister company Regional Express (Rex).

While in cruise, the flight crew received a cargo smoke indication on the central warning panel, and fitted their oxygen masks and smoke goggles as a precaution.

A short time later, the cockpit filled with smoke.

“Commencing a diversion to Cobar, the first officer made a PAN-PAN call, and thick smoke filled the flight deck, preventing the crew from effectively seeing external visual references, or the aircraft’s flight instruments,” ATSB Director Transport Safety Dr Stuart Godley said.

While the crew was completing emergency checklists, there were warnings for avionics smoke, the cabin depressurised, and there was a right engine fire detection fail indication.

Fortunately, the crew was able to land at Cobar and evacuate the aircraft on the runway, uninjured.

Fire and Rescue personnel located a heat source at the air conditioning pack, and doused the area with water. An internal inspection later found fire damage in the area around the right recirculating fan.

An investigation by the ATSB determined the in-flight fire likely stemmed from the failure of the recirculating fan’s electronic box sub-assembly.

The investigation’s final report notes the aircraft had been operated by Rex as a passenger aircraft, before being modified to cargo configuration in 2009, for operation by Pel-Air.

“The Rex pilots usually operated passenger aircraft and were not familiar with the cargo-configuration of this aircraft, and Rex did not ensure its flight crews received training in the differences between passenger and freight-configured Saab 340 aircraft,” Dr Godley explained.

Further, it was identified both Pel-Air and Rex’s flight crew operating manuals did not include reference to the location and operation of the cross-valve handle, and the pilots were unable to locate it during the emergency checklist procedures, due to smoke.

Closing of the cross-valve was part of the checklist to address a cargo compartment smoke event, and the pilots were therefore unable to properly action this checklist, despite searching for more than a minute for the cross-valve handle.

The investigation also found the smoke curtain (to isolate the cargo area) was not in place for the flight, as is required for the cargo configuration of the Saab 340, and Saab’s pre-flight documentation for the cargo-configured 340 did not require crews to confirm that a smoke curtain was fitted.

The absence of a curtain, and the flight deck door being open, allowed smoke from the fire to enter the flight deck.
“The depressurisation occurred when the fire weakened the fuselage structure,” Dr Godley explained. 

“Fortunately, this depressurisation aided in the removal of enough smoke from the flight deck, to allow an unhindered approach into Cobar.”

Since the occurrence, Rex has amended its flight crew operating manual to require flight crews to verify the position of the cross-valve handle during pre-flight checks.

The operator has also updated training information delivered in their ground school to cover the cross-valve system for cargo-configured Saab 340 aircraft.

Pel-Air has also revised its flight crew operating manual, with a caution that the smoke barrier curtain must be installed whenever combustible material is carried.

Finally, Saab has revised its preparatory and walk-around pre-flight checklists to include the fitting of the smoke barrier curtain when carrying cargo in cargo-configured 340s.

“As this occurrence demonstrates, it is essential operators ensure flight crews are conversant with differences in aircraft configurations when required,” Dr Godley summarised.“Similarly, flight crew operating manuals must be relevant for the aircraft configuration, and manufacturer pre-flight checklists must cover the modifications fitted, so operators can write the appropriate documentation for flight crews.”

Read the final report: In-flight fire and cabin smoke involving Saab 340A, VH-KDK, 114 km east-north-east of Cobar, New South Wales, on 23 April 2023

Publication Date:
20/11/2024

MTF...P2