ATSB....Is this another dud report? Power Loss at night in NT

[Jabawocky]

http://www.atsb.gov.au/media/4027718/ao2012092_final.pdf

Please correct me if I am wrong, but as I understand it, this aircraft had an engine failure, and the outcome was lucky and executed with some skill.

The report tells a story, but it fails to detail the one very serious reason that caused the incident.

We all read things hoping to take something away from it, when you read this there are some good reminders to keep in mind when flying at night in remote areas. But, there is something missing here.

The trusty Lycosaurus is a reliable animal, and we all recognise the greatest number of engine failures are usually a result of fuel being replaced with air! :eek:

So if my suspicions are correct, and I have good reason to think they are, this aircraft suffered from a loss of oil, due to not a leak, but consumption, perhaps not normal consumption but one at the extreme end of the "acceptable" range. The aircraft I believe had flown a lot of hours that day/night and nobody had replenished this one vital fluid. Perhaps not even at the beginning of the day? Who Knows? Nothing in the report about anything relating to this.

So if this suspicion is correct, why would the ATSB not pay any attention to the real cause of the failure. Poor Pilot/operator attention to detail.

The report makes not mention of the engine health, hours since OH/new, nothing of its maintenance records or daily uplift of oil in the recent past.

So, unless I am confusing this incident with something else, we have yet another very poor performance by the ATSB on a piston engine failure. Even if this flight is not the one I think it may be, the report is still very lacking in anything remotely like a report should be for an engine failure, and one typical of the entire GA fleet.

I am seriously thinking the Australian Government would get far better value for money, and spend less by closing CASA and ATSB (aviation related at least) and sub contract it all to the FAA/NTSB.

Yet another disgrace. Feel free to be critical of my thoughts and correct me if I am wrong about this incident.

For some reason this report "changed" location :hmm: http://www.atsb.gov.au/media/4019056/ao2012092_final.pdf here is the new one.

[blackhand]

So if my suspicions are correct, and I have good reason to think they are, this aircraft suffered from a loss of oil, Looking at the big hole in the crankcase it was a massive and instantaneous oil loss. the report says it was a big end cap bolt failure. You are looking for and finding fault where none exists

[Old Fella]

The report certainly is short on detail in terms of EHSO for the powerplant, or any other info. It does however clearly show the damage suffered by the engine as a result of the Bigend Bearing Cap bolt failure. There was a period of about 35 minutes between the first observation of lower than normal oil pressure and where it had dropped sufficiently to prompt the crew to make a precautionary landing. Another 5 minutes elapsed before the "Low Oil Pressure" light illuminated. No mention anywhere about higher oil temp, which one would reasonably expect to see, if falling oil quantity was the root cause of the falling oil pressure.

On the other hand if the bigend bearing cap bolt was gradually stretching, which would increase the bearing to crank clearance, one could expect the oil pressure to slowly fall as the clearance increased. The eventual failure of the bolt would cause a complete loss of oil pressure. The degree of damage certainly indicates a sudden and unanticipated mechanical failure.

As Jabawocky said, we all hope to learn from these reports. The only real lesson in this report is that the PAL system will not always work as advertised.

[Creampuff]

C’mon Jaba, safety is being enhanced all across the nation by the knowledge that:

- “the failure was a result of a No. 6 connecting rod, big end cap bolt failure”, and

- “responding to an adverse situation promptly can result in a positive outcome”.

My pre-flight checklist will now include “Check No. 6 connecting rod big end cap bolt” (using x-ray vision).

My emergency checklist will now include “Response: Prompt”, just under Douglas Adams’ invaluable advice “Panic: Don’t”.

BH: How does 1920 to 2000 – some 50 minutes – constitute ‘massive and instantaneous oil loss’?At about 1920 Central Standard Time (CST), when maintaining 7,500 ft above mean sea level (AMSL), the crew noticed that the engine oil pressure indication was slightly lower than normal.

The crew continued to monitor the oil pressure and, at about 1955, having noted the pressure dropping further, they began planning for a diversion to the Ti Tree aeroplane landing area (ALA). The instructor had flown into the ALA the previous week and reported using the pilot activated lighting (PAL) system without any issues. The crew relayed their intentions to air traffic control (ATC) via VH-XGN, a Cessna 310 cruising in the vicinity at a higher altitude.

At about 2000, the engine oil pressure light illuminated, necessitating an immediate landing.Bolding added.

The engine then began to ‘run rough and subsequently stopped’.

[blackhand]

BH: How does 1920 to 2000 – some 50 minutes – constitute ‘massive and instantaneous oil loss’? That would be because the oil level was OK, until the rod punched a hole through the case. Up till then the oil presure was decreasing as No. 6 journal clearance was increasing.

[Creampuff]

You may be correct.

If only the ATSB had put aside 10 minutes to ask and report on the pilot’s answers to the questions: What was the oil level when you dipped it? What was the oil temp indication during the period 1920 through to the decision to land? And, if an engine monitor was fitted to the aircraft: “What were the CHT and EGT indications during the period 1920 through to the decision to land? (The ATSB might even been able to download the lot (other than the oil level) from the engine monitor!)

Serious question, and purely hypothetically. Let’s say I take off in a fairly standard 6 cylinder, normally aspirated Lycoming or CMI engine, and with “just enough” oil, what are the symptoms and consequences as the oil falls below “just enough” and continues falling below the minimum (assuming we’ve enough fuel to keep flying until and beyond that point)?

[Jabawocky]

Come on guys... you are all better than this. Talk about Hook Line and Sinker.

Read my post again....read the report again.

Remember, I ampretty sure the reason for the oil pressure problem is known to several experts involved. Unless I have the wrong incited. But I am pretty sure I have not.

You are looking for and finding fault where none exists

No I am not. Where is the logical path that lead to that component failing. Was it a metallurgical fail? Was it lack of oil? If lack of oil pressure was it a pump failure? Was it an oil cooler leak....etc.

Think a bit further. Even If I am wrong about which Airvan had a failure like this and it was because it burned up all the oil in the sump, this report went nowhere near detailing what happened.

Old Fella
No mention anywhere about higher oil temp, which one would reasonably expect to see, if falling oil quantity was the root cause of the falling oil pressure.

Most of your post I can agree with, but this statement is an Old Wives Tale. This depends on a lot of things, and low oil level will not often show an increased temperature. It will eventually once the level gets really low start showing up as oil pressure issues.

blackhand
That would be because the oil level was OK, until the rod punched a hole through the case. Up till then the oil presure was decreasing as No. 6 journal clearance was increasing.

Or pehaps the more likely scenario of the oil pressure was fine until it started to drop due to insufficient oil, and then the oil pressure failed and a warning light said so. engine is still running but starved of oil. Then the big end bearing fails. After that of course the engine stops rotating, and thus no more bearings fail (even if they were about to) and given all the damage is at the top of the case, the oil remaining would still be in the sump.

But was there any??? :confused: I believe there was not and for a good reason. The ATSB have done nothing to give any credibility to this report, I doubt the engine went to a suitable engine shop, and the photo's supplied were clearly not taken with any forensic purpose in mind at all. If there were some, they did not publish them.

A joke of a report, even if my thought on the cause of the failure is very wrong.

[VH-XXX]

If nobody is hurt, they don't seem to care.

[blackhand]

Conrod bolts do not snap due to oil issues.
Its to do with manufacture or fitment.

Symptom of very low oil level
High oil temp
Prop hunting
You can think of more

[Back Pressure]

An aero engine blows up in flight, and the ATSB don't do any analysis whatsoever ? No safety implications at all ?

Why do a bloody investigation/report if the first place if they were going to come out with such garbage ?

[blackhand]

ATSB don't investigate everything



About this report Decisions regarding whether to
conduct an investigation, and the scope of an investigation, are based on many
factors, including the level of safety benefit likely to be obtained from an
investigation. For this occurrence, a limited-scope, fact-gathering
investigation was conducted in order to produce a short summary report, and
allow for greater industry awareness of potential safety issues and possible
safety actions.

[compressor stall]

Why is there the word "draft" at the footer of P1?

[Jabawocky]

It is meant to be a final report?

[Old Fella]

Jabba, Engines carry oil of sufficient quantity to not only lubricate the engine, but also to carry engine heat away via the oil cooler. I think my over fifty years in aviation, many hours as a Flight Engineer as well as a background in ground engineering in the engine trade taught me a fair bit. One of the lessons learned is that decreasing oil quantity leads to increased oil temperature which in turn leads to loss of oil pressure. No Old Wives Tale Jabba, just experience.

[Back Pressure]

blackhand, I am well aware that ATSB don't investigate every incident/accident, and I understand why, but in this case, we have an engine die in flight due to a failed big end cap bolt.

General questions:

Surely the ATSB would want to know why ? Did it fail due to overheat from lack of lubricant ? Or due to a manufacturing or material defect ? Wouldn't they examine all the end cap bolts from the engine to see if there may be a faulty batch ? Been heard of before (Lyco cranks). And if they actually did do this, then why was it not in the report ?

Another point: what "potential safety issues and possible safety actions" in this report are going to "allow for greater industry awareness" ? That you can land on a road in the outback ? :ugh: That the PAL at Ti Tree is cactus ?? A NOTAM is surely the more appropriate and effective way of doing that.

Who here would expect a pat on the back from the boss if you had written such an uninformative and irrelevant report of any topic, let alone one such as this ??

And yes, "Draft" at bottom of p1. Professional :mad: or what

Jaba, seems to be a final report. Nothing except my previous sentence to indicate otherwise.

[Jabawocky]

Jabba, Engines carry oil of sufficient quantity to not only lubricate the engine, but also to carry engine heat away via the oil cooler. I think my over fifty years in aviation, many hours as a Flight Engineer as well as a background in ground engineering in the engine trade taught me a fair bit. One of the lessons learned is that decreasing oil quantity leads to increased oil temperature which in turn leads to loss of oil pressure. No Old Wives Tale Jabba, just experience.

What you are saying is correct in that oil carries away heat, no argument whatsoever. However depending on where the temp sensor is, and a whole heap of things, in an aero engine this supposition of a considerable and noticeable long term temperature indication id false. We have data files to show this. Only a small rise (not enough to trigger an alarm) and not for very long and just prior to failure. So please understand this, you may see a temp rise worthy of not, but chances are it is highly unlikely. If you only see a significant indictation in 1 in 100 events, what are you going to teach people? ;)

Now back to this "work experience kid" report.

Back Pressure, yes indeed many more questions. I doubt this thread will uncover all of them.

I had a long discussion with my good friend and one of the few leading engine builders in Australia, and he once again was shocked and stunned. His ken eye within 2 minutes of reading the report focussed on the best technical evidence included. A phot showing that this is a narrow deck engine, not produced since 1975 or something like that. What was that doing in an Airvan? :=

How old was this engine, where did the parts come from and when was it assembled last?

Despite what blackhand has said, it is highly unlikely an faulty bolt, poorly torqued bolt or similar defect would have survived more than 20-50 hours, and the time it would take to go from beginning of failure to stopped in the sense of a bolt failure, would be far shorter than the time frame quoted. Without further evidence of the rest of the engine being inspected and photographed, the evidence so far does not add up at all.

So where did this engine come from? How did it become fitted to an Airvan, what was the real story of the oil status.

I am not the slight bit interested in persecution of the operator or anyone else. But there is much to be learned from when people almost died. The fact they did not is nothing short of very lucky. And to say that because nobody died it does not warrant the same level of investigation is criminal. Nobody died in the QF32 incident, why such a thorough report?

This is right up there with not recovering FDR/CVR's from the Westwind, the Mojave and Whyalla. I bet there are more buried away.

Be interesting to get another colleagues response to this. Standby for more!

[VH-XXX]

That ATSB picture is definitely not showing a first life factory fitted 540 from Gippy Aero that's for sure. They don't come in navy blue for starters.

[glen beard]

Not only is it not a factory engine,its an old style narrow deck 540 that was dis-continued years ago.(Look at the cyl hold-down nuts). one could only guess what history it had,but most probably out of old PA32-300 which used same engine.

Glen Beard

[Clearedtoreenter]

Well yes, one is certainly left with a feeling of 'is that it then? Engine just stopped due to a random failure of a bolt?'

Whether or not it is a bodgey old engine, (as seems possible) the public at least need to know how it got to be flying in that aircraft and it's overhaul history.

Surely it would not be too difficult to put that information together?

[prospector]

BH: How does 1920 to 2000 – some 50 minutes – constitute ‘massive and instantaneous oil loss’?

Maybe in the ten missing minutes funny things happened?

[Creampuff]

Whoops! You are correct - my maths was out by 10 minutes.:O

Still, I reckon 40 minutes still isn't 'instantaneous'.

[Lumps]

read the same report when it came out with a similar feeling of.... is that it? Mind you some NTSB reports give the same aftertaste - or maybe I'm reading the wrong versions.

[Old Akro]

Oil is a bit of a black art in Automotive circles, but even more so in Aviation. Recommended oil levels are rarely stated, simply sump capacity and minimum level. The sump capacity is determined by taking the minimum level, the endurance of the aircraft, the maximum permissible oil consumption of the engine and multiplying it out. There is no concern for clearance or windage losses or clearance to the crank. This is why so any aircraft spit oil out the breather at high levels and why most owners run the oil level more toward the minimum.

Engines will continue to run happily up to a point where the engine will suffer fluctuating oil pressure because the pump has trouble picking it up. The first casualty will probably be the top end ( valve gear) then the bearings due to heart stress. I suspect that an engine might happily run down to a coupe of litres.

I agree with an earlier post that running out of oil is more likely to be a ceased engine and large scale damage rather then dropping a big end cap and " putting a leg out of bed". Dropping a big end cap could have a number if causes, but I think they will all all into the general category of poor assembly.

I'm looking forward to reading the report now!

[Old Akro]

Has this report changed? I can't find the language that was complained of by the early posters.

I don't see much wrong with the report, other than it is so lightweight & scant on detail as to be useless.

The fist question that comes to mind is how many hours the aircraft & engine had on them. Was this engine straight out of rebuild? The numbers are written on the MR, I doubt that it would take the full resources of the ATSB to have found this out. Maybe a technique that I've used could be useful. You ring the guy up in the NT and ask him to fax you a copy. It's also probably more relevant than the PAL status of a private strip, yet they seemed to get excited about that.

The maintenance organisation is technically correct in that the engine failure was caused by the con rod cap failure. But anyone posessing more insight than the ATSB ( ie basically anyone) will ask why the con rod cap separated. Were the bolts intact, but missing? Were the bolts broken? Are there signs that the slipper bearings rotated? Are there signs of heat stress? Are the con rod cap bolts tight on the other 5? Are the main bearing cap bolts tight? Have the correct bolts been used? Do they all match, or has someone picked up bolts from the hangar floor?

One would hypothesise that the oil pressure was low at startup because the con rod cap was starting to get loose, making a larger gap for oil to flow out, thus dropping he pressure. This would have been accompanied by a change in engine sound. Did the pilots notice this? Did anyone ask?

This is an amateur report - its actually sub amateur standard. We deserve better from our statutory bodies.

The pilots did a pretty good job, but you'd probably like to be doing some sort of check ( in the interest of the safety of others) that there isn't a wider problem with engine parts or the shop that rebuilt the engine. Maybe I've missed something, but that's what I thought the ATSB was there for.

[Kharon]

There are only three pertinent things we can glean from this patronising, smug report. (a) The donkey quit, (b) the lights at the alternate didn't perform design function; and (c) the boys did a good job.

If you're operating a similar engine mark or model it may be handy to know why this donkey turned it's toes up. That's a fairly large hole in the thing and unless someone has developed armour piercing budgies, we can rule out bird strike.

So, we have not a scrap of useful report information, no crash comic to find the analysis in, and need to check the ATSB web site everyday to make sure that a safety recommendation has not been slipped in there.

There's probably enough engineering expertise here on Pprune to draft a report for the ATSB, maybe we should; just to show how to do it, 'cos they do seem to have forgotten how. :ugh:

[Sunfish]

So if oil pressure decreases measurably land immediately.

[halfmanhalfbiscuit]

Here is a link to a UK AAIB report for comparison of content, style and depth. I think it states preliminary too.

Air Accidents Investigation: Download PDF document (http://www.aaib.gov.uk/cms_resources/Gippsland%20GA8%20Airvan,%20G-CDYA%2006-11.pdf)


A previous detailed ATSB report on aircraft VH-WRT
http://www.atsb.gov.au/media/1537651/ao2008072.pdf

Just randomly selected from google search.

[Sarcs]

Come across several articles/blogs on the latest controversy on a proposed FAA AD for continental engines in the States, which IMO is particularly relevant to this thread for a number of reasons. But first a quote from the Avweb site: User Groups: Cylinder AD Proposal Risky, Costly (http://www.avweb.com/avwebflash/news/User-Groups-Cylinder-AD-Proposal-Risky-Costly220417-1.html)

AOPA and EAA responded this week to the FAA's proposed airworthiness directive (http://www.avweb.com/avwebflash/news/FAA-Proposes-Checks-For-Thousands-Of-GA-Engines220412-1.html) that would require thousands of GA aircraft owners to inspect and replace their ECi engine cylinders, saying the FAA's plan would impose a financial burden while also compromising safety. “Requiring the replacement of so many cylinders, in addition to repetitive inspections, goes well beyond the [NTSB] recommendations [PDF] (http://www.ntsb.gov/doclib/recletters/2012/A-12-007.pdf)," said Robert Hackman, AOPA's vice president of regulatory affairs. Hackman said (http://www.aopa.org/News-and-Video/All-News/2013/August/12/Cylinder-removal-AD-would-increase-costs-decrease-safety.aspx) he also is concerned that actual costs "could go well beyond the FAA’s estimate, and that the mass replacement of cylinders in the field would downgrade, rather than enhance safety." EAA noted (http://eaa.org/news/2013/2013-08-12_proposed-AD-demands-removal-of-thousands-of-ECI-titan-cylinders.asp) that the proposed AD does not cite either specific failure rates or a total number of failures for the ECi cylinders.
The AD "does not point to a single accident or injury caused by the failure of any ECi cylinder," EAA said. Both groups said they are working on a written response to the proposal. AOPA also encouraged members to post comments to the FAA docket (http://www.regulations.gov/#!searchResults;rpp=25;po=0;s=2013-19414;fp=true;ns=true), highlighting their operating experience with the cylinders. The FAA has set a deadline of October 11 for comments. EAA said it will insist on a comment period extension, "given the very high cost of the proposed AD, and the almost impossibility of finding enough cylinders to replace the ECi units if the AD were to become law."
So the only significant point of similarity between the US and Oz is possible regulator overkill on the proposed AD and no CBA (apparently) on the knock on effect of bringing in the AD...boy does that sound familiar??:ugh:

However that is where the similarities stop!

Firstly we have at least two reputable aviation associations, EAA and AOPA, who are not afraid to speak out about the potential ramifications of the FAA bringing in the proposed AD. Both of these organisations (amongst many others) are known to have significant political clout in the US and the FAA would ignore their concerns on the proposed AD at their peril.

Next we have a stark difference in the transport safety investigator's (ATSB with the thread incident and the NTSB SR) methodology and response to a significant safety issue. Here is part of the NTSB analysis and reason for issuing SR A-12-007 (http://www.ntsb.gov/doclib/recletters/2012/A-12-007.pdf) :
Reciprocating engine cylinder assemblies consist of two major parts, the cylinder barrel and the cylinder head. ECi cylinder heads are manufactured from an aluminum alloy casting, and house the intake and exhaust valves, with their respective seats, guides, and spark plugs. ECi cylinder barrels are typically manufactured from an alloy steel forging and have a smooth bore that houses the piston. The cylinder head and barrel are joined by heating the cylinder head to about 650° F then screwing it onto the cylinder barrel until specific surfaces make contact. As the cylinder head cools and shrinks onto the cylinder barrel, an interference fit is produced, locking the parts together at the threads and at an adjacent plain diameter, which is commonly referred to as a shrink band (shrink bands are features on the barrel and in the cylinder head; see figure 2). On new cylinder assemblies, the barrel mounting flange and cylinder mounting holes in the flange are machined after assembly to ensure the cylinder’s proper alignment on the engine case.

In most of the cases examined by the NTSB, the fatigue cracks in the cylinder heads initiated at the root of the thread that was engaged with the first (uppermost) thread on the cylinder barrels, as shown in figure 1 and indicated by the yellow line in figure 2. The fatigue cracks propagated outwards through the cylinder head wall to emerge between the third and fourth or the fourth and fifth cooling fin, depending on the engine model.

The fatigue cracks initiated at multiple locations, typically near the intake or exhaust valve side of the cylinder heads and, with engine use, propagated through the head thickness. Once the fatigue cracks propagated though the thickness of the cylinder wall, the cylinders lost compression, with a resulting reduction in or total loss of thrust. When the fatigue cracks reached a critical size, the cylinder heads fractured and separated at the fatigue location, with the lower portion remaining attached to the barrels, resulting in catastrophic engine failure.

Beginning in 2004, ECi and the FAA issued several bulletins and directives to address these fatigue failures. After 34 reported fatigue failures of ECi cylinders, the FAA issued AD 2004-08-10, effective May 2004, to require replacement of certain ECi cylinder assemblies on TCM model 520 and 550 series engines. The AD identified a manufacturing discrepancy that occurred between September 2002 and May 2003 (S/N 1044-7708), which resulted in an inadequate cylinder head wall thickness and an over-hardened condition that would reduce the fatigue strength of the aluminum cylinder head.

In August 2006, ECi issued Mandatory Service Bulletin (MSB) 06-2 instructing operators to perform repetitive inspections for leaks and cracks on cylinder assemblies between S/N 7709 and 33696 and to replace any discrepant cylinders. Affected assemblies were produced between September 2002 and November 2005 with inadequate cylinder head wall thickness on the exhaust side. At least 21 head separations have been reported for this group of cylinders, and the NTSB has investigated several of these, including those documented in NTSB case number ENG07SA033.

The fatigue initiated on the exhaust side of the cylinder head, between the 14th and 16th cooling fins, and propagated inwards toward the valve seat. The FAA issued Special Airworthiness Information Bulletin (SAIB) NE-07-09R1 in March 2007, detailing the importance of performing the inspections called for in ECi MSB 06-2, but did not require the inspections.
Get the picture?? {NB Feel free to read the entire SR}.

IMO this highlights more than anything else the significant importance of the long standing practice, by safety investigative agencies around the world, of issuing safety recommendations when a significant safety issue is brought to the attention of the investigators. Which, as we now know, is contrary to the current opinion/methodology adopted by ATSBeaker i.e. "a SR is definitely a last resort because we don't want to offend any directly interested parties"!:ugh: :ugh:

Hmm..perhaps this incident should be another that the TSB Canada do a comparitive difference in methodology and practice??:E

[Centaurus]

I think my over fifty years in aviation, many hours as a Flight Engineer as well as a background in ground engineering in the engine trade taught me a fair bit. One of the lessons learned is that decreasing oil quantity leads to increased oil temperature which in turn leads to loss of oil pressure. No Old Wives Tale Jabba, just experience.

Is that so? Well here is a bit more experience for you although this is a jet engine and not a piston. Thus the engine design makes a difference

On two occasions in 737-200 with Pratt & Whitney JT8D -17 engines I have seen severe loss of oil contents.

One at 31,000 ft in cruise due to an O-Ring problem and the other an incorrectly fitted oil filler cap. Oil levels fell from full to 10% full or 90% empty if you like. There was no rise in oil temperature and no loss of oil pressure. On my flight I shut down the engine as a precaution. The second occasion I was a passenger and the pilot elected not to shut it down and flew for a further three hours to destination. No Old Wives tale- just experience:ok:

[27/09]

I think my over fifty years in aviation, many hours as a Flight Engineer as well as a background in ground engineering in the engine trade taught me a fair bit. One of the lessons learned is that decreasing oil quantity leads to increased oil temperature which in turn leads to loss of oil pressure.

Logic says that less oil should mean higher oil temps as there oil passes through the engine more often and there fore has less time to lose heat and giving a reduction in pressure. On some engine installations no doubt this would happen every time. However I would suggest that this is not universally true today.

It could depend on whether or not it was a dry or wet sump system, how efficient the oil cooling system was and probably most importantly where the oil temp sensor is located.

In the case of the position of the temp sensor the oil temp may well be increasing but the sensor isn't measuring that increase. To give an example I had a car that once the water level had dropped a bit in the radiator the temperature sensor was no longer on contact with the water and was then only measuring the ambient temperature of the radiator.

Remember also many modern oils are multi grade and retain their viscosity over a wide range of temperatures so there may not be a noticeable change in oil pressure.

[Volumex]

While the vernatherm is functioning and the oil cooler has capacity, the oil temp will stay constant.

[Creampuff]

Ah, the history of GA writ large …

A million engines run for a billion hours, and still an argument starts about whether oil temperature will increase when oil is lost from an engine.

Doesn’t it depend on the kind of engine and lubrication system, the reason for the oil loss, the location and operation of the sensors driving the cockpit indications, the phase of the moon and the pilot’s star sign?

(PS: The ATSB report the subject of this thread was crap.)