[Peetwo]

APOC: ATSB v TAIC & AAIB - 
First from today's latest flurry of Popinjay AAI activity...

Courtesy of today's Director Transport Safety, Stewie Godlike -   :

Fuel starvation incident highlights importance of proper fuel management



Two pilots experienced engine surging and declared a mayday after inadvertently exhausting the aircraft’s auxiliary tanks, an Australian Transport Safety Bureau investigation notes.

On 18 August 2022, an instructor and trainee instructor were operating a Cessna 310R during a training flight from Redcliffe Aerodrome, Queensland when the engines started surging alternatively.

The instructor declared a MAYDAY and began tracking for a forced landing at Sunshine Coast Airport, but during troubleshooting on descent, the crew switched from the auxiliary to the main fuel tanks, and the engine issues were rectified. The crew then conducted an uneventful landing.

An ATSB investigation found the auxiliary tanks had been exhausted, resulting in fuel starvation and engine surging.

“The pilots did not establish the amount of fuel on board prior to the flight, or manage the fuel state throughout the flight,” ATSB Director Transport Safety Dr Stuart Godley said.

“Both pilots were unaware of the fuel system configuration of the Cessna 310R, believing the aircraft was fitted with larger auxiliary tanks than was the case.”

The incident aircraft had a 140L usable fuel auxiliary tank capacity, but the instructor assumed it had the same 238L capacity as other Cessna 310 aircraft they had flown.

“The ATSB also found the operator had inconsistent and incomplete technical documentation for the aircraft, and the aircraft’s fuel selector plaques contained contradictory and incorrect information about the capacity of the auxiliary tanks, and in different units,” Mr Godley added.

Since the incident, the operator – Aircraft Australia – has implemented a new fuel log specific for the Cessna 310R.

Additionally, an internal memo has been distributed outlining the changes to the data sheet for the Cessna 310R to ensure all pilots and students are aware of the fuel configuration of the aircraft.

The operator has also requested fuel selector plaque replacements, to ensure the correct labels are installed.

Dr Godley welcomed the safety actions taken by the operator, but emphasised the incident’s relevance to all pilots.

“Accidents involving fuel mismanagement are an ongoing aviation safety concern, and are a reminder of the importance of monitoring fuel levels prior to, and during flight,” he said.

A selection of fuel management related incidents, and their safety lessons, have been previously published by the ATSB in the publication Avoidable Accidents No. 5.

Dr Godley also noted methods for cross-checking fuel on board before flight are published by the Civil Aviation Safety Authority in its Advisory Circular AC 91-13v1.1.

Read the ATSB’s report: AO-2022-040 Fuel starvation event involving Cessna 310, VH-JQK, near Sunshine Coast Airport, Queensland, on 18 August 2022

Publication Date 05/05/2023

Note that this 'Short' investigation didn't incorporate a prelim report, so once again relying on the ATSB notified difference to ICAO Annex 13 Ch 7 para 7.2: 

Detail of Differences: Australia will comply with the standard for the more complex accidents. However, for some less complex investigations Australia does not prepare a Preliminary Report.

 
However some kudos to the ATSB needs to be acknowledged for this investigation was completed to a final report inside of 9 months. Whether or not this investigation should have been continued to a final report and yet another concocted, 'attributable to' WOFTAM media report is another matter..?? 

Next I noted the following from the NZed TAIC Linkedin webpages:

Transport Accident Investigation Commission
853 followers
2w •

TAIC report: Safety issues for NZ CAA to resolve: requirements and technical standards for NVIS and helicopter air ambulance; crew resource management training and qualifications for non-pilots acting as crew members; guidelines for crew members assisting a pilot during #NVIS ops.

Misinterpretations by pilot of BK117-C1 helicopter during VFR flight using #nightvision goggles led to controlled flight into terrain (Southern Ocean sea). All 3 on board survived. #training #safety #nvg #airambulance

   
It would appear that the TAIC without 'fear nor favour' is quite prepared to take it up to the NZCAA...

However this post did cop some interesting criticism from a very qualified SME Mr Darren Straker:

Darren Straker
• 2nd

Expert: T/Pilot (CCAR/CS25), Aircraft Level Design, Certification/Development/Flight Test Safety/FltOps Audit/Accident Investigation
2w

This occurred on 22 April 2019? Its now April 2023, read the ICAO Annex 13 requirements for the production of Air Accident Reports 'within 12 months'.

Admittedly, there were logistical and distance constraints, however no analysis requires 4 years.
How does TAIC manage its responsibilities - let alone audit obligations - with a 4 year duration for an accident report?

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Gerard Robertson
2w

One did wonder.

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James H.

Still quicker than the ATSB

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Darren Straker

James H. At least the ASTB know what they're doing and they're accountable. 

4 Years to factor all of that accident safety information back to the CAA and the SMS systems in both organisations is pointless, in contradiction to the States ICAO SARP's, in conjunction with the CAA oversight for the SMS for these 'higher than normal risk' flights.

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Gerard Robertson

Darren Straker That was really my thinking, too. I would expect that prioritisation of accident investigations might be determined by likelihood of recurrence. Apparently not.

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Darren Straker

Gerard Robertson TAIC have priority over what they choose to investigate, up to a point. Annex 13 is clear on the risk assessments regarding serious incidents; accidents investigation should be mandatory.

Determining the 'likelihood of a reoccurrence': this was a CFIT over water with degraded visual conditions, this can happen anywhere in an operating environment such as NZ.

If the CAA SMS oversight system was functioning, the recommendations should be factored back into the system, to quote ICAO, ' to prevent a reoccurrence'.

A 4 year lapse is unacceptable nonsense and no-one in the MOT has a clue.

No complex accident investigation should take longer than 12 months, if the budget (NZ$+5 Million p.a.), the staffing levels, experience and capability are as required by the charter.

How many Chief Investigators has TAIC had in the previous 5 or 6 years? Quite a few. The question then is why?

 

Hmmm...maybe the TAIC has some similar operational issues to that of the ATSB but I do question whether the ATSB knows what it is doing and are accountable?? At least the TAIC are directly accountable to a Minister of the Crown: https://en.wikipedia.org/wiki/Transport_...Commission

It was established by Act of the Parliament of New Zealand (the Transport Accident Investigation Commission Act 1990) on 1 September 1990. TAIC's legislation, functions and powers were modelled on and share some similarities with the National Transportation Safety Board (USA) and the Transportation Safety Board (Canada). It is a standing Commission of Inquiry and an independent Crown entity, and reports to the Minister of Transport.

 

Finally I note the following Tweet by the UK AAIB:

AAIB @aaibgovuk · May 3

The AAIB has published a report into an incident involving a Pegasus Quik (G-CGRR) after it tipped over on landing at Harringe Court Farm, Ashford, Kent on 6 August 2022. Read the report https://gov.uk/government/news/aaib-repo...ugust-2022 #AviationSafety

Note that the AAIB had absolutely zero issue with investigating a non-fatal recreational ultralight accident which they completed inside of 9 months and saw no need (other than the Tweet) in using their limited resources in producing a pointless media blurb, rather they rely on their report to highlight the identified safety issues of the investigation...

MTF...P2