VH-LBY Skippers C-441

[spinex]

Tried to post on the original thread, only to find it closed (??) Anyway the prelim report is out and shock horror, the obvious guess proved to be the correct one.
https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-019/

[Ixixly]

Don't be too quick to stick the boot in Spinex, yes it is Fuel Exhaustion, there is mention of water contamination and there is still no clearly identified reason why it happened, were the fuel gauges faulty perhaps? how significant a water contamination are we talking? Was the aircraft using more fuel than expected or shown? Still plenty of explanations as to what led to the Fuel Exhaustion situation so lets not stick in that boot too soon.

[junior.VH-LFA]

Don't be too quick to stick the boot in Spinex, yes it is Fuel Exhaustion, there is mention of water contamination and there is still no clearly identified reason why it happened, were the fuel gauges faulty perhaps? how significant a water contamination are we talking? Was the aircraft using more fuel than expected or shown? Still plenty of explanations as to what led to the Fuel Exhaustion situation so lets not stick in that boot too soon.

"The aircraft was refuelled and flown without incident to Broome Airport."

It seems pretty one way here.

I know nothing about the C441, does it have fuel quantity low master caution or warning annunciation?

[spinex]

Quite where the boot is involved in pointing out the blindingly obvious, I fail to see. It is however increasingly tempting to apply said size12s to the tails of those who persist in trying to whitewash a set of circumstances that would earn a newly minted PPL a well deserved raspberry, never mind a CPL with paying pax in the back.

[Bend alot]

Don't be too quick to stick the boot in Spinex, yes it is Fuel Exhaustion, there is mention of water contamination and there is still no clearly identified reason why it happened, were the fuel gauges faulty perhaps? how significant a water contamination are we talking? Was the aircraft using more fuel than expected or shown? Still plenty of explanations as to what led to the Fuel Exhaustion situation so lets not stick in that boot too soon.

Well the maintenance done on the side of road or actually on the road will be very interesting work sheets to read!

Time to call a Spade a Spade!

Or be willing to produce the test equipment and other required documents for the flight off the road.

Christ pilots can be insistent! the wheels were down! don't know how they folded back up!.


******* There is NO reasonable explanation that a engine surged and was shut down and then the other shutdown by itself soon after - other than lack of fuel. Being able to fly away soon after.

[Lead Balloon]

Ix: If there were explanations other than the usual, why would the pilot have been sacked by the operator? Wrongful dismissal claim would be a shoe in if the cause was a gauge or water or some other mechanical problem. And as has been pointed out on numerous occasions, the problem and the fix would be recorded in the maintenance docs.

Eddie Dean’s smoke and mirrors campaign has been exposed for what it was.

[Horatio Leafblower]

yes it is Fuel Exhaustion, there is mention of water contamination and there is still no clearly identified reason why it happened, were the fuel gauges faulty perhaps?

I don't want to sink the slipper into the poor hapless lad because the Gods will punish such hubris with a fuel exhaustion event of my own. Nonetheless, sources close to the investigation say there is a video of the aircraft taxiing out at FTZ or HLC with the LOW FUEL lights illuminated on the annunciator.
JET A1 is available at HLC and as they say in the classics, runway behind you... fuel on the ground... etc.

In other news, I believe a Territory operator has now gained a more-experienced-than-most Conquest driver and I am sure it's an error he'll never make again.

[Lead Balloon]

Well said, Horatio.

I think it was a bit rough that the PIC was sacked in the first place. Very bad mistake, but not one that he will make again. And everyone walked away unscathed.

If I were to say ‘there but for the grace of god’, no doubt the usual sky gods will claim perfection...

[Car RAMROD]

I think it was a bit rough that the PIC was sacked in the first place. Very bad mistake, but not one that he will make again. And everyone walked away unscathed.


That depends.

If the PIC knowingly took off without the required fuel to make the destination, and ignored potential warnings (refer the post about video and low fuel lights), id think sacking is warranted.

If the PIC had planned appropriately and believed that the gauges were correct, but an investigation finds out there were problems with the system (be it fuel system, maintenance system, or even the cultural system) and as a result he has run out, I don't think sacking is warranted.

Big difference. More information is needed. Until then bit hard to say whether sacking is or isn't warranted.

[red_dirt]

How come the rather vocal and adamant old mate allegedly working on a station next door that posted here saying there was no fuel uplifted isn't saying anything now??

[neville_nobody]

Nonetheless, sources close to the investigation say there is a video of the aircraft taxiing out at FTZ or HLC with the LOW FUEL lights illuminated on the annunciator.
JET A1 is available at HLC and as they say in the classics, runway behind you... fuel on the ground... etc.

But what if the fuel gauges showed more than enough fuel to fly to the destination? Which one do you believe?

From reading the prelim report this scenario is very possible.

[WingNut60]

How come the rather vocal and adamant old mate allegedly working on a station next door that posted here saying there was no fuel uplifted isn't saying anything now??

I was part of that conversation, but I didn't read it that way.
I think he was just saying that there was no fuel uploaded while he was there.
The guys at the site may also have told him that there was no fuel uploaded (as they might well do).

He sort of clarified the point when I asked about a station Toyota being able to get past the aircraft.

Why would a ringer off a station with a pocket full of money and heading for Broome wait around watching for more than a short period of time?
He'd have a new cowdie hat to buy and a barmaid to annoy.

[Lead Balloon]

But what if the fuel gauges showed more than enough fuel to fly to the destination? Which one do you believe?

From reading the prelim report this scenario is very possible.I would have thought that good airmanship says you believe the warning light until it’s proved that the gauges are overstating FOB. I’m not sure about the certification basis of the particular aircraft, but aren’t steam driven fuel guages only required to be accurate when indicating ‘empty’?

And you seem to have overlooked the fact that inaccurate gauges were not entered in the maintenance documentation then signed off as having been repaired, or the subject of an exemption or PUS granted by CASA at short notice, before departure.

(Eddie’s a ringer off a station? Surprisingly deep knowledge of aircraft maintenance for a ‘ringer’...)

[WingNut60]

(Eddie’s a ringer off a station? Surprisingly deep knowledge of aircraft maintenance for a ‘ringer’...)


Yeah, I know. But he's off a station and he's driving a Tojo so he has to be a ringer. My logic.

[Lead Balloon]

He said he was off a station and he said he was driving a Tojo. That’s not the same as him being off a station and driving a Tojo. Wild guess and pure speculation: Eddie drove a truck load of fuel from Broome to the aircraft...

[neville_nobody]

I would have thought that good airmanship says you believe the warning light until it’s proved that the gauges are overstating FOB.

100% agree. Not saying it is a good idea just saying that if someone had the fuel lights on it is possible that the gauges were indicating enough fuel. It is also quite possible that the gauges cross check against your fuel log too.

[WingNut60]

He said he was off a station and he said he was driving a Tojo. That’s not the same as him being off a station and driving a Tojo. Wild guess and pure speculation: Eddie drove a truck load of fuel from Broome to the aircraft...


In fact I was the one who said he was in a Tojo. Just part of my dig about him being a ringer.
What really confused me was the following statement:
It was on Sandfire Road, Great Northern H'way, heading to Roebuck Roadhouse when I saw it.
So was SSE of Sandfire and northish of Roebuck.

That makes no sense at all and had me wondering whether he'd been anywhere near the aircraft.

That location, if true, would have it in two pieces at least 200 km apart.

[Ethel the Aardvark]

Fuel exhaustion due excessive h2O contamination is the story I heard.

[Slippery_Pete]

I could believe a GA aircraft having one faulty fuel gauge, but two BOTH significantly overreading?

On water in the fuel, surely you can’t just have a double inflight shutdown due to contamination, and then top the tanks up from a drum and get going an hour or two later. Surely with enough contamination to stop both in flight, there’d have been a fairly rigorous maintenance procedure to get the tanks/lines/donks decontaminated and signed off.

[junior.VH-LFA]

Shutdown due to water contamination, fill it up and depart.

Bull****.

[Ixixly]

Quite where the boot is involved in pointing out the blindingly obvious, I fail to see. It is however increasingly tempting to apply said size12s to the tails of those who persist in trying to whitewash a set of circumstances that would earn a newly minted PPL a well deserved raspberry, never mind a CPL with paying pax in the back.

Why was he low on fuel to the point of Exhaustion? As I mentioned there could be a number of reasons that were NOT the Pilots fault. Personally I was not aware he had been let go by the company and can't remember reading that anywhere, if the case it does seem to point towards him being the source of the overall problem but without any actual facts I wouldn't be keen to stick the boot into anyone whilst there are other possbilities. As mentioned Spinex, all we know is that this was caused by Fuel Exhaustion but what we do NOT know is the events that lead to the Fuel Exhaustion, thusly putting the boot into the Crew as you seem to be doing is unwarranted at this point.

Bend Alot, it certainly seems like it was a matter of not having sufficient fuel on-board, but WHY was there insufficient fuel on board? Did the Pilot believe he had the right amount? Why did he believe so?

Lead Balloon, I don't recall seeing anything about the PIC being let go by the Operator, was that posted on the other thread or did you hear that from a source? If it was indeed a faulty Gauge that caused it then it's probably on a Maintenance Release somewhere that it has been fixed but would not have necessarily needed to be done before take off, just a dispensation sought to get it out of there to be fixed back at Broome.

Horatio, is that a video from a pax that was taken? Pretty damning if true, off that such a video didn't warrant mention in the Prelim report, seems to be a pretty glaring fact that is easily confirmed if it was presented, assuming it was presented before the report was released.

Personally, if this crew took off with a Low Fuel Light, especially from somewhere that had fuel available without any mitigating circumstances such as maintenance issues for example then sacking would be the least of their concerns and I would dare say warranted, I'd expect the same if I'd committed the same error, doesn't mean they don't deserve a second chance though, but that'll depend somewhat on how CASA decides to proceed when the investigation is completed.

Oh and Eddie did indeed clarify that he didn't see any fuel whilst he was passing by and chatted with the FO, which means there was plenty of time otherwise for fuel to have been uplifted and he was clear about that part when someone asked him.

[Lead Balloon]

So you’re taking what Eddie posted as gospel, despite the evident evasiveness and geographical oddities in what he posted?

If something was wrong with the aircraft so as to have misled the PIC as to FOB, that would have been mentioned in the ATSB report, would it not? If there was something wrong with the aircraft, there would have to been some maintenance investigation and documentation, would there not? Do you seriously believe that CASA would have issued the necessary paperwork to let the operator kick the tyres and light the fires after a forced landing where there was a suggestion of aircraft defects being causally connected with the forced landing?

You need to sharpen and apply Ockham’s Razor.

[Bend alot]

Why was he low on fuel to the point of Exhaustion? As I mentioned there could be a number of reasons that were NOT the Pilots fault. Personally I was not aware he had been let go by the company and can't remember reading that anywhere, if the case it does seem to point towards him being the source of the overall problem but without any actual facts I wouldn't be keen to stick the boot into anyone whilst there are other possbilities. As mentioned Spinex, all we know is that this was caused by Fuel Exhaustion but what we do NOT know is the events that lead to the Fuel Exhaustion, thusly putting the boot into the Crew as you seem to be doing is unwarranted at this point.

Bend Alot, it certainly seems like it was a matter of not having sufficient fuel on-board, but WHY was there insufficient fuel on board? Did the Pilot believe he had the right amount? Why did he believe so?

.

To the best of my knowledge (and it is rusty) RPT ops require some form of double check on the fuel on-board to confirm carried forward fuel amounts and not only rely on gauges.

Often this required (if dipping or other options not available) filling to full tank or tabs at regular intervals.

This dramatically reduces the compound error of fuel consumption vs gauge reading - don't forget L/H and R/H tanks and gauges are completely independent on the 441 as are the low fuel lights.

So it being an RPT Aircraft fuel records, flight plan and maintenance records should all point to the fuel on-board the pilot actually took command of that day (RPT is a very big paper trail).

Either the engine(s) were burning too much fuel that day for some reason or not enough fuel was added for the required flight.

Maybe he just forgot to retract the gear and flaps that day - but we would have seen a slow speed on the FW24.

[Capt Fathom]

I thought it was a charter flight?

[1a sound asleep]

I thought it was a charter flight?
Type of operation:Air Transport Low Capacity

If this has happened at somewhere like Virgin CASA would have grounded the airline

[cowl flaps]

How come the rather vocal and adamant old mate allegedly working on a station next door that posted here saying there was no fuel uplifted isn't saying anything now??

Because it appears old mate was full of ****.

[Ixixly]

So you’re taking what Eddie posted as gospel, despite the evident evasiveness and geographical oddities in what he posted?

If something was wrong with the aircraft so as to have misled the PIC as to FOB, that would have been mentioned in the ATSB report, would it not? If there was something wrong with the aircraft, there would have to been some maintenance investigation and documentation, would there not? Do you seriously believe that CASA would have issued the necessary paperwork to let the operator kick the tyres and light the fires after a forced landing where there was a suggestion of aircraft defects being causally connected with the forced landing?

You need to sharpen and apply Ockham’s Razor.



Not taking anything he said as Gospel, he's left it wide open to anything having happened before or after he was there which was by all appearances only a short time.

LB, you seem to have a lot of inside information here, you're suggesting you know that there was nothing entered into the Maintenance Release after the Forced Landing or that any sort of exemption was granted by CASA to fly it back out? You suggest that Good Airmanship says that if the Low Fuel Light is on you should believe it, which I agree with, and according to Horatio he possibly took off with those lights on which would be extremely poor Airmanship, the sort that CASA would likely have him grounded for right? Yet apparently he is already flying with someone else now, the fact that CASA have apparently not grounded him I think alludes to there being more to this whole event than just simply taking off without enough fuel. Also if was so cut and dry then why does the report mention that the ATSB are bothering to check the following:

information from the pilot
flight logs and fuel records
operational policy, procedures and practices applicable to fuel management including regulatory aspects
serviceability of the aircraft fuel system components
aircraft maintenance requirements and records
fuel tank contaminant detection processes
fuel quantity indication systems
other fuel exhaustion or starvation occurrences.

To be perfectly clear to everyone, I don't doubt at all that it was Fuel Exhaustion, that much is evident, my whole point is that we don't exactly what led to this Fuel Exhaustion Event, from the facts that I can see it appears an Aircraft took off, it suffered a Fuel Exhaustion Event, the Crew put it down on a Highway and it was then subsequently flown back out again and then examined by Engineers when back in Broome. There are suggestions of Low Fuel Lights being on from some video evidence, that nothing was entered into the Maintenance Release, no Exemptions were given to be able to fly it out but I don't know where that info comes from and have no idea how reliable it is so I'm going by the facts as I see them which still leave a bunch of possibilities and mitigating factors that say to me not to put the boot in to anyone yet.

Also, I'm not casting doubt on the info that LB and Horatio have, but once again, I don't know the source of their info and therefore am not relying on it to draw any conclusions as of yet.

[Lead Balloon]

So a low capacity RPT or charter aircraft carrying fare paying passengers is forced to land and the ATSB didn’t inquire into the aircraft’s serviceability?

I know the ATSB is busted, but I didn’t know it was that busted.

[megan]

sources close to the investigation say there is a video of the aircraft taxiing out at FTZ or HLC with the LOW FUEL lights illuminated on the annunciatorIt's 190 miles BRM - FTZ and schedule gives a block time of 50 minutes, BRM - HLC is 311 miles. Low fuel comes on at 150 to 250 pounds. The ABC report says the issue, whatever it was, was encountered after leaving HLC. I know don't believe what is reported in the media, but it's difficult, given the facts, that they would have taxiied FTZ for departure with the low fuel lights on. Max cruise power ISA at SL burns 401 lb/hr/engine TAS 243, 18K 306 lb/hr TAS 288, 35K 173 lb/hr TAS 268.

The ATSB mention of water is interesting, in as much could it have affected any of the five capacitance probes in each tank? My experience is that water will give an over reading on the gauge. Be an interesting report.

[Ixixly]

Lead Balloon, if they walked up, found an Aircraft devoid of fuel in the tanks with video evidence of it taxiing out with Low Fuel Lights on and being able to see that the fuel at the start of the day and fuel uplifted throughout didn't allow for the flight to be done safely, do you think they'd waste much more time looking through for more Maintenance defects? Not unless they've got an axe to grind I'd say. The fact that they specifically singled out the "Fuel Quantity Indication Systems" and not just the "aircraft maintenance requirements and records" says to me there's a bit more to it than just someone taking off without enough fuel and hoping for the best but that's just my opinion based on what I can see so far presented.

[Lead Balloon]

Well Ix, if it’s true the pilot was sacked but the fuel indication system was over-reading for reasons other than pilot error and the pilot had done proper calculations independent of the fuel gauge indications, the pilot is a shoe in for a wrongful dismissal claim.

The only time I believe my fuel gauges is when they read zero.

Water in the fuel has been mentioned as a possible cause of over-reading fuel gauges. I thought pilots did fuel drains to detect water in fuel. Is that not done or doable on a 441?

Maybe the “more to it” is that there was water that should have been but wasn’t discovered and calculations that should have been but weren’t done?

[Dempster]

A fuel drain in a conquest is like every other fuel drain in a GA aircraft. 3 drains per side and to be done after every refuel and first flight of the day. If the correct procedures were followed, I find it hard for the gauges to be over-reading due to water contamination.

[Bend alot]

Many aircraft have evidence of water based contamination.i
cton
Water often gets into fuel systems and creates corrosion. These corrosion deposits are often found in the bottom of fuel filter housings, lower corners of wet wing fuel panels and on fuel drains themselves.

What is extremely concerning is the aircraft seems to have departed the highway with no approval to do so. (open MR entry - Mayday called)

I would love to see the MR and what was and was not done.

WHO flew it out??? and under who's instruction???

More than one involved in this cover up I think!

[Cloudee]

Many aircraft have evidence of water based contamination.i
cton
Water often gets into fuel systems and creates corrosion. These corrosion deposits are often found in the bottom of fuel filter housings, lower corners of wet wing fuel panels and on fuel drains themselves.

What is extremely concerning is the aircraft seems to have departed the highway with no approval to do so. (open MR entry - Mayday called)

I would love to see the MR and what was and was not done.

WHO flew it out??? and under who's instruction???

More than one involved in this cover up I think!

Was there an open MR entry? It just ran out of fuel. Add fuel and it's good to go. The prelim report states it was refuelled, flown home and then examined by LAMEs with the involvement of ATSB and CASA. Presumably it was then the evidence of contamination was found in the fuel system. It'll be interesting to see if fuel contamination was a factor in this or just something peripheral discovered during the investigation.

[Desert Flower]

A fuel drain in a conquest is like every other fuel drain in a GA aircraft. 3 drains per side and to be done after every refuel and first flight of the day. If the correct procedures were followed, I find it hard for the gauges to be over-reading due to water contamination.

Can't remember ever seeing a fuel drain being done on a Conquest during my 20 years in the industry. Might have been if one was left sitting at the aerodrome overnight, but if so I didn't witness it. Certainly never done when a quick turnaround was required, which was most of the time.

DF.

[Bend alot]

Was there an open MR entry? It just ran out of fuel. Add fuel and it's good to go. The prelim report states it was refuelled, flown home and then examined by LAMEs with the involvement of ATSB and CASA. Presumably it was then the evidence of contamination was found in the fuel system. It'll be interesting to see if fuel contamination was a factor in this or just something peripheral discovered during the investigation.

An emergency declared and no MR entry! come on Mate

I doubt there is any reference to enter in the MR or work sheets that refers to "run out of fuel" land on road "Just refuel and go" ref CH 20 - standard dodgy opps.

[Ethel the Aardvark]

A few times I have seen pilots conduct a fuel drain, the plastic bottle is full of water and it is assumed to be full of fuel with no blob of water in the bottom, ( mainly GA piston types )
I would be surprised if it was lack of fuel considering the scrutiny after a brazilia was in a sticky situation with a fuel qty issue
Bend alot, how do you know it was not done by the book?

[Ixixly]

Bend Alot, have you seen the MR? Has anyone here seen the MR? Because a few people keep saying things about the MR but I highly doubt anyone here has seen it at all so perhaps unless you've ACTUALLY seen it then perhaps those people can stop acting like they know what was or was not written on it.

Lot of speculation here about things that I doubt anyone here actually has any first hand knowledge of such as whether they did or did not have any approval from CASA to do what they do when they flew it back out. I'm all for speculation but there's too many people in here acting like they've seen the MR or knew of every communication between the Operator and CASA that day.

[Ixixly]

Lead Balloon, if that was the case then sure, there would be grounds for coming at the operator, I have no first hand knowledge of the sacking that has been mentioned or the reasons behind it whatsoever and would love to hear from the person who originally told us about it what the reasons were behind it specifically, was this Pilot actually sacked or asked to leave? What was the conversation between this Pilot and Management? Did the Pilot say something during said conversation that got them subsequently sacked? Once again, someone has mentioned vaguely that the Pilot was fired but no particular reason why and we're left to assume it was specifically due to this incident but there could be a myriad of other reasons that went into it if that person even was sacked which, without any real official confirmation none of us seem to really know.

We've really gone into tin foil hat territory here with reading into a lot of things with very little facts and drawing big conclusions of them based on third hand knowledge that is so far unverifiable, so far as I can see the only real verified facts that have come out are contained in the ATSB report and that leaves open a bunch of possible avenues as to the whole "Who, What, Where, Why..." questions.

[Lead Balloon]

You’re the only one in tin foil territory.

I say again: You need to sharpen and use Ockham’s razor.

[Bend alot]

The pilot shut down the right engine and made a mayday call. Shortly after, the left engine lost power and the pilot conducted a forced landing without engine power on the Great Northern Highway

The aircraft was refuelled and flown without incident to Broome Airport. The aircraft was then examined by licenced aircraft maintenance engineers with the involvement of the ATSB and the Civil Aviation Safety Authority.

51A Reporting of defects in Australian aircraft: major defects

(1) This regulation applies to major defects:

(a) that have caused, or that could cause, a primary structural failure in an aircraft; or

(b) that have caused, or that could cause, a control system failure in an aircraft; or

(c) that have caused, or that could cause, an engine structural failure in an aircraft; or

(d) caused by, that have caused, or that could cause, fire in an aircraft.

(2) If a person connected with the operation of, or the carrying out of maintenance on, an Australian aircraft discovers a defect in the aircraft, being a defect of a kind to which this regulation applies, the person must report the defect to CASA immediately.

Penalty: 50 penalty units.

52A How must reports to Authority be made?

Examples of Major Defects

Listed below are some representative examples of major defects. The list is not exhaustive. If you have any doubt about whether a defect is a major defect, you can seek advice from the CASA SDR Unit by email [email protected] or phone 131 757:

(a) fires during flight, whether or not the related fire warning system operated correctly;

(b) false fire warning during flight;

(c) smoke, toxic or noxious fumes inside the aircraft;

(d) an engine exhaust system that causes damage during flight to the engine, adjacent structure, equipment or components;

(e) unscheduled engine shut-down;


**
So as per the ADSB report.

The aircraft was refuelled, flown then inspected by a LAME.

How did the major defect get cleared for the flight?

Either it was not written up or a pilot flew the aircraft out with a open entry on the MR. This would be a sack able offence.
Under no circumstances would CASA issue a Flight Permit without a LAME putting his name on the line that the aircraft is safe to fly. Remember it was 4:20 pm on a Friday and I doubt the pilots first call was to the CAsA office.

[Tankengine]

(E): The engine was scheduled for shutdown due lack of fuel, no mystery! ;)

[Ixixly]

Bend Alot, all well and good, how do you know it was an open Entry and that a LAME didn't go out with the fuel to sign it off? How do you know there was no Flight Permit thusly issued to get it off the highway and back to Broome? It didn't land and take off within a 15minute window, you think someone couldn't have gotten hold of CASA especially with the dang thing sitting on a Highway? You don't think CASA themselves would have been pretty quick to call up themselves? I've had to call a Pan Pan before and CASA had already called up my Chief Pilot to let him know about it before my wheels touched the ground again about 20mins after making the call.

Pretty sure with an Aircraft sitting on a Highway that CASA would have been very keen to make sure there was an appropriate response and a LAME and others getting out there ASAP to figure out what state it was in, whether everyone was safe and then what would be required to get it off said Highway right smart, LAME gets out there, determines whatever the issue was, signs it off and being fine for the short flight back to Broome, CASA are called and give the ok and away it goes. Nowhere in the report does it state it was flown with an open MR entry nor whether it was checked before that or not, you're assuming from that fact that they didn't specify that a LAME went out at that time to refuel it that therefore none did.

[Bend alot]

Bend Alot, all well and good, how do you know it was an open Entry and that a LAME didn't go out with the fuel to sign it off? How do you know there was no Flight Permit thusly issued to get it off the highway and back to Broome? It didn't land and take off within a 15minute window, you think someone couldn't have gotten hold of CASA especially with the dang thing sitting on a Highway? You don't think CASA themselves would have been pretty quick to call up themselves? I've had to call a Pan Pan before and CASA had already called up my Chief Pilot to let him know about it before my wheels touched the ground again about 20mins after making the call.

Pretty sure with an Aircraft sitting on a Highway that CASA would have been very keen to make sure there was an appropriate response and a LAME and others getting out there ASAP to figure out what state it was in, whether everyone was safe and then what would be required to get it off said Highway right smart, LAME gets out there, determines whatever the issue was, signs it off and being fine for the short flight back to Broome, CASA are called and give the ok and away it goes. Nowhere in the report does it state it was flown with an open MR entry nor whether it was checked before that or not, you're assuming from that fact that they didn't specify that a LAME went out at that time to refuel it that therefore none did.

CAsA would not give a rats about any inconvenience to traffic hold ups on the remote road.

The ATSB would have included in their report to date of any maintenance carried out to determine airworthiness and such findings (such as they did with water based contamination) prior to and after refuel. They have not and if you suggest they have not seen the MR or asked if the aircraft was inspected prior to that flight, then you don't know how these investigations happen.

Mention in the report would have mentioned a flight under a Permit issued by CAsA or a delegate - it was not.

No I don't think CAsA would have been pretty quick to call them up, it takes some time for rumours to hit CAsA and who would have been contacted Perth or Darwin? - well not Darwin or it would still be on the road! Perth traffic is wonderful, do a u turn when you get to your driveway and go back to the office. A Special Flight Permit is not a 5 minute job and it requires specific information current hours as parked on the road, serial numbers of airframe, engines and props details of what happened and from memory even a copy of the MR. The SFP is then required to be attached to the MR and its details written on the MR. The SFP requires what needs to be done prior to flight and a LAME to say the aircraft is safe for flight.

Now the problem is what is required to be done for such an event? I don't have a C441 manual in front of me but I do have them (may not be current). But there is no reference in the Manufactures Approved Data for inspections required for "running out of fuel" that I recall.

So that makes it very hard to sign off an entry that should have been put in the MR by a LAME.

Are the airframe fuel pumps to be changed/inspected/overhauled?
Does the aircraft need to be fully fuelled to inspect for leaks?
Does the fuel system need to be bleed?

I have had aircraft run out of fuel before and the insistence of there being enough fuel for the flights has required massive maintenance inspections and tests (said aircraft suffered damage to fuel tanks so quantity could not be physically checked).

CAsA would also be waiting to hear of ATSB intentions before any consideration of issue of a SFP.

Any info on the CAsA branch attendance at the Broome inspection and the date of the inspection?

[Bend alot]

It's 190 miles BRM - FTZ and schedule gives a block time of 50 minutes, BRM - HLC is 311 miles. Low fuel comes on at 150 to 250 pounds. The ABC report says the issue, whatever it was, was encountered after leaving HLC. I know don't believe what is reported in the media, but it's difficult, given the facts, that they would have taxiied FTZ for departure with the low fuel lights on. Max cruise power ISA at SL burns 401 lb/hr/engine TAS 243, 18K 306 lb/hr TAS 288, 35K 173 lb/hr TAS 268.

The ATSB mention of water is interesting, in as much could it have affected any of the five capacitance probes in each tank? My experience is that water will give an over reading on the gauge. Be an interesting report.

Total fuel burn is much less if you shut one down - say top of climb!

[Ixixly]

You don't think that CASA would have been alerted to a Mayday call being made? Really? This isn't a rumour reaching them, it's ATC receiving a Mayday call from a LCPRT IFR Aircraft that was well within range of ATC, that'd get to them pretty bloody quick I'd dare say!

The SFP can easily be fast tracked depending on the situation and all those details are sitting in an office waiting to be gathered and can be done pretty promptly when a fire is lit under the ass of a Maintenance Organisation who are worried if it's something they did that caused it. They don't take a while to issue an SFP because it takes a certain amount of time to grow on a tree they issue it when it comes up next in the Queue and that queue is dictated by CASA and I've seen dispensations handed out by them pretty quickly when the right person is called for far less reasons in the past. The incident happened at 4.20, so they would have likely still been in the office as well. How often is the CASA office in Broome manned as well I wonder?

You'd also think that the ATSB would be pretty quick to include if an Aircraft had been illegally flown out without the SFP as well wouldn't you? They equally have that fact to hand, if you think they should mention if it was flown out with an SFP then it's equally as likely they'd mention if it didn't have one as required.

As I said Bend Alot, you're making a lot of assumptions and they're to fit the narrative you've already decided upon.

[Lead Balloon]

So walk us through the scenario that has the aircraft do a forced landing then fly out soon after, Ix.

Mine is the aircraft ran out of fuel because of one or both of: (1) fuel indications overreading because of water that should have been but wasn’t detected on a pre-flight inspection, and; (2) failure to properly calculate FOB and fuel needed for the trip.

In this scenario, the aircraft is rendered serviceable by removing the water, if any, from the system and putting fuel in the tanks. No SFP or PUS required. Bad mistake by the PIC. Poor reflection on the CP and C&T system. No tin foil hat required either.

[Bend alot]

You don't think that CASA would have been alerted to a Mayday call being made? Really? This isn't a rumour reaching them, it's ATC receiving a Mayday call from a LCPRT IFR Aircraft that was well within range of ATC, that'd get to them pretty bloody quick I'd dare say!

** Correct particularly if no injury - ATSB most likely contacted. Ever called a CAsA office at 4:21pm on a Friday?

The SFP can easily be fast tracked depending on the situation and all those details are sitting in an office waiting to be gathered and can be done pretty promptly when a fire is lit under the ass of a Maintenance Organisation who are worried if it's something they did that caused it.

** BS on that - there is no fast tracking of a SFP that info can be gathered and updated and then forwarded on, but it takes time and is always checked to confirm ones head is not being put on a block - I always spend much time confirming before passing on info in such cases.

They don't take a while to issue an SFP because it takes a certain amount of time to grow on a tree they issue it when it comes up next in the Queue and that queue is dictated by CASA and I've seen dispensations handed out by them pretty quickly when the right person is called for far less reasons in the past.

** BS again CAsA have policy to follow and will not deviate from it at risk of in house penalties - rules are rules and CAsA will follow them to be 100% non accountable.

The incident happened at 4.20, so they would have likely still been in the office as well. How often is the CASA office in Broome manned as well I wonder?

**They are out the door at 4:21pm - exactly what manned office in Broome it is Darwin that covers Broome and they are not often there.

You'd also think that the ATSB would be pretty quick to include if an Aircraft had been illegally flown out without the SFP as well wouldn't you?

** No ATSB do not assign blame or get involved in CAsA responsibilities such as illegal flight if it is not directly related to the incident flight.

They equally have that fact to hand, if you think they should mention if it was flown out with an SFP then it's equally as likely they'd mention if it didn't have one as required.

** As above this is not an area of control or concern of ATSB but that of CAsA.

As I said Bend Alot, you're making a lot of assumptions and they're to fit the narrative you've already decided upon.

No I just have had to work with the ATSB and CAsA and applied for and cleared SFP's on many occasions and know the legal requirements and CAsA requirements on the issue of SFP's. With area specific knowledge of CAsA in both areas that could be investigating (Perth and Darwin).

So no mention of my comment on no way to sign the defect off with in relation to approved data! or will a nice CAsA female AWI just give you a SFP if you ask nicely? with no cause provable for running out of gas?

[Ixixly]

What if the Gauges were wrong Lead Balloon? They believed that had more fuel than they really had and didn't realise they were wrong till the noise stopped, would also explain why they'd be tempted to push on even with low fuel lows as apparently they did. Silly idea mind you as the Low Fuel Lights should have been good reason to stop and really check it out first but there's any number of organisational or environmental pressures that could lead them to pushing on and hoping the Gauges were right but the Low Fuel Lights were wrong? What if there was a butt load of water onboard for some reason? Fuel Exhaustion is a lack of usable fuel, not dry tanks, there could have been a significant amount of water in there somehow that caused whatever was in the tanks to no longer be "Usable Fuel". How about some sort of fuel leak that was fairly minor but not spotted meant they expected to land with min fuel but ended up not, or maybe the engines were burning way more than expected in conjunction with some fault gauges? There's a heap of possibilities and most of them would require the tanks to be drained and likely run through with fuel allowing them to take off with a known quantity of fuel to make the very short hop to Broome quite safely if they were only 39km away. Most of these should have been covered by good paperwork that would tell them the fuel figures didn't add up right to what the Gauges said but once again, plenty of Human Factor reasons that could explain them either ignoring the paperwork or having done a crap job of it, perhaps someone else along the chain involved gave them incorrect figures somewhere?

I'm curious to know exactly what effect water mixed in with the fuel would do to efficiency of the engines if not adequately picked up, someone has already said that it would contribute to fuel gauges overreading which is another possibility. Was it a case of some crappy Low Fuel Lights that "Always come on for no reason" that caused them to push on as well, wouldn't be the first crew to look at a major warning sign and say "Eh, don't worry, it always does that!" and continue on.

Bend Alot, Broome has a Satellite CASA office which I remember once upon a time was manned 2 weeks out of 4 (Quick google around shows an article from CASA even talking about it a couple of years ago but I don't know if that's still the case) and according to the CASA website Broome falls into the Western District which is covered by Perth as well:
https://www.casa.gov.au/standard-page/casa-office-locations-and-regions
https://www.casa.gov.au/standard-page/keeping-northern-australian-skies-safe
Once again, you're assuming that all CASA minions are out the door at 4.21pm, you have absolutely no way to know that. Which policy of CASAs is it that says "An SFP shalt take no less than 5 days to be issued..."? There isn't a Policy that dictates exactly how long an SFP takes, it depends on workload and when it gets there, doesn't mean one can't be processed in a short period when required or deemed a priority. You have no way to know at all whether an SFP was issued or not, you have no way to know at all if a LAME attended and signed off the MR before that flight, you have no way to tell what communications were made between Maintenance Personnel, CASA and the Operator. You're assuming all CASA personnel were gone by 4.21pm, you're assuming no Engineer went out there because no where does it implicitly tell you one did, you're assuming an SFP cannot be fast tracked because you've never had one fast tracked, you're assuming the defect was something not covered in the Manual and couldn't be signed off by a LAME and basically you're assuming all this because you can't imagine a possibility where your narrative is wrong so therefore all these assumptions must be correct.

Personally, I'm done with this conversation until more actual facts come out from the ATSB or someone with concrete first hand knowledge can fill us in.

[Lead Balloon]

Ix: The only “actual facts” you’re going to get are the second hand, massaged twaddle the ATSB publishes these days, and rumours on PPRuNe.

Do you actually fly aircraft and do fuel calculations and record fuel in and fuel out?

Would you jump into an aircraft and say: “The gauges say I have X amount of fuel so that’s the amount of fuel I have.” Really? If so, best to take a break from flying until you’ve done BAK again.

[Bend alot]

What if the Gauges were wrong Lead Balloon? They believed that had more fuel than they really had and didn't realise they were wrong till the noise stopped, would also explain why they'd be tempted to push on even with low fuel lows as apparently they did. Silly idea mind you as the Low Fuel Lights should have been good reason to stop and really check it out first but there's any number of organisational or environmental pressures that could lead them to pushing on and hoping the Gauges were right but the Low Fuel Lights were wrong? What if there was a butt load of water onboard for some reason? Fuel Exhaustion is a lack of usable fuel, not dry tanks, there could have been a significant amount of water in there somehow that caused whatever was in the tanks to no longer be "Usable Fuel". How about some sort of fuel leak that was fairly minor but not spotted meant they expected to land with min fuel but ended up not, or maybe the engines were burning way more than expected in conjunction with some fault gauges? There's a heap of possibilities and most of them would require the tanks to be drained and likely run through with fuel allowing them to take off with a known quantity of fuel to make the very short hop to Broome quite safely if they were only 39km away. Most of these should have been covered by good paperwork that would tell them the fuel figures didn't add up right to what the Gauges said but once again, plenty of Human Factor reasons that could explain them either ignoring the paperwork or having done a crap job of it, perhaps someone else along the chain involved gave them incorrect figures somewhere?

I'm curious to know exactly what effect water mixed in with the fuel would do to efficiency of the engines if not adequately picked up, someone has already said that it would contribute to fuel gauges overreading which is another possibility. Was it a case of some crappy Low Fuel Lights that "Always come on for no reason" that caused them to push on as well, wouldn't be the first crew to look at a major warning sign and say "Eh, don't worry, it always does that!" and continue on.

******** Every reason a CAsA or delegated person would want answers to before issuing a Special Flight Permit!!!! think about it! why take a responsibility if it does not benefit you!

Bend Alot, Broome has a Satellite CASA office which I remember once upon a time was manned 2 weeks out of 4 (Quick google around shows an article from CASA even talking about it a couple of years ago but I don't know if that's still the case) and according to the CASA website Broome falls into the Western District which is covered by Perth as well:
https://www.casa.gov.au/standard-page/casa-office-locations-and-regions
https://www.casa.gov.au/standard-page/keeping-northern-australian-skies-safe
Once again, you're assuming that all CASA minions are out the door at 4.21pm, you have absolutely no way to know that.


** Other than I know many current employees and Broome is covered by central region - https://www.casa.gov.au/book-page/casa-locations-and-contact-details

Which policy of CASAs is it that says "An SFP shalt take no less than 5 days to be issued..."?


** Show a post I said 5 days!

There isn't a Policy that dictates exactly how long an SFP takes, it depends on workload and when it gets there, doesn't mean one can't be processed in a short period when required or deemed a priority.

** Correct I agree, but only I.A.W within policy and regulation.


You have no way to know at all whether an SFP was issued or not, you have no way to know at all if a LAME attended and signed off the MR before that flight,


** Only having knowledge of how ATSB reports have been presented in the past and such initial maintenance was carried out and nil or found defects included in the report - there was no LAME certification carried out prior to the flight off the road to Broome, the first LAME inspection was in Broome.

you have no way to tell what communications were made between Maintenance Personnel, CASA and the Operator.

** Correct only need to follow paper and regulation tails along with policy knowledge to work out much of that.

You're assuming all CASA personnel were gone by 4.21pm,

** Yes particularly in the SF office, I know the staff well.

you're assuming no Engineer went out there because no where does it implicitly tell you one did,

** Correct.

you're assuming an SFP cannot be fast tracked because you've never had one fast tracked,


** No just saying they take time to be correct, more so in cases like this.

you're assuming the defect was something not covered in the Manual and couldn't be signed off by a LAME

** No assumption here, there is no approved data to cover this event.

and basically you're assuming all this because you can't imagine a possibility where your narrative is wrong so therefore all these assumptions must be correct.

** Correct or give a Manufactures Reference for inspections after fuel exhaustion - a simple request.

Personally, I'm done with this conversation until more actual facts come out from the ATSB or someone with concrete first hand knowledge can fill us in.

Yep you would need to say that now.

[Ixixly]

Personally Lead Balloon I wouldn't jump in and do that, I'm a little paranoid myself coming from a company where we'd routinely leave Aircraft alone in random places and pick up ones that have been left for a while so I got used to cross checking a few sources to make sure the last person actually did what the paper says and didn't just write it down assuming it was done or would get done and it saved my bacon a couple of times, but history is filled with people who have done just that. I think it is low on the list of possibilities I can think of, but still a possibility, just like Aliens beaming out their fuel is also a possibility, probably a bit less likely that one though :P As I said, could end up being a simple matter of someone writing down the wrong thing on a fuel calc or not checking their maths thoroughly enough.

IMHO I think this will be a good example of the swiss cheese model by the time the final report comes out with a few factors to it that came together for this particular event, it just doesn't seem likely a couple of trained pilots both jumped in to a seemingly perfectly functioning aircraft and managed to run out of fuel departing from somewhere that had fuel available with their Low Fuel Lights apparently staring them in the face but nor does it seem like any one particular mechanical failure would lead to it either.

[Lead Balloon]

The ATSB doesn’t subscribe to the Swiss cheese model any more. It’s so passé. The ATSB jumps to a conclusion and then finds “evidence” to support its conclusions. It’s a much more efficient methodology.

For those who like to understand what the data suggest, the data suggest that the most likely cause of hull loss or damage to aircraft flown by CPLs and ATPLs in Australia is fuel starvation or exhaustion. Every now and then “trained pilots” jump into a “seemingly perfectly functioning aircraft” that turns out to be an actually perfectly functioning aircraft that has insufficient fuel for the flight either absolutely or as a consequence of finger trouble.

[Ixixly]

If no one did that then we wouldn't have to bother with Human Factors Lead Balloon! Sounds a lot like Bend Alots method, maybe he works for the ATSB and does know more than I thought!

[Bend alot]

If no one did that then we wouldn't have to bother with Human Factors Lead Balloon! Sounds a lot like Bend Alots method, maybe he works for the ATSB and does know more than I thought!

Very strange comment - my method was to quote CAsA and major defects and lack of LAME involvement prior to flight and ATSB don't give a rats about the following flight after the incident.

You claim CAsA will issue SFP's with partial required info if urgency is a issue and a road is blocked.

[WingNut60]

Very strange comment - my method was to quote CAsA and major defects and lack of LAME involvement prior to flight and ATSB don't give a rats about the following flight after the incident.

You claim CAsA will issue SFP's with partial required info if urgency is a issue and a road is blocked.

12M x 15M - pretty sure a couple of burlie truckies could offer assistance to safely move the machine off the road.
It's a wide road reserve and lots of clear space.

[Ixixly]

Let me put this simply Bend Alot, you don't know if a LAME inspected it before it left, you don't know if an SFP was issued or not, you don't know what was or was not entered on the MR, you don't know what the defects were (if any) that led to the Fuel Exhaustion, you don't know what communication occurred between anyone involved on the day, you don't know that the CASA office involved was empty by 4.21pm and without knowing any of that then your entire suggestion that the Aircraft was flown out illegally and people were complicit in some type of "Cover up" is all based on assumptions drawn from voids that you've chosen to fill with your assumptions. I have no problems with people speculating on causes or asking questions, this is a rumour network after all, but there's a big difference between speculating and assuming.

[wishiwasupthere]

And the fact that they're still operating not only the aircraft type but the exact aircraft, on LCRPT, after such a high profile event, suggests that everything that occurred after the incident was 'more than likely' above board, despite protestations to the contrary.

[Bend alot]

And the fact that they're still operating not only the aircraft type but the exact aircraft, on LCRPT, after such a high profile event, suggests that everything that occurred after the incident was 'more than likely' above board, despite protestations to the contrary.

That an interesting statement.

I can not think of any reason that could stop that exact aircraft from still operating, there is no case to impound it.
Even less reasons to stop the operation of type as the incident has been confirmed as being not enough fuel for engines to operate.

ATSB do not lay blame, they just investigate and give the findings. They don't suspend or cancel AOC's or licences.

The job of CAsA is to use the findings from the ATSB and their own investigations and take action if required. This is not often done well or accurately or without internal politics.
CAsA need to build a case against who they have decided to blame (never a CAsA staff member) and this takes time and can be difficult. The sacrificial pilot may buy time if CAsA are after the company or if they were after the pilot they would be happy and case will be closed after ATSB finalize report.

Given the rumour the said pilot now has a job in the NT and CAsA Darwin look after Broome, I will assume that the pilot is not the person of CAsA's interest.

I will say CAsA may have no interest and may be happy it was just a one of error (but with the fuel lights I doubt it).

Many airlines get a fair bit of "compliance time" after incidents as many of them are critical to operations of large Australian Companies with prominent owners or government contracts.

The thing with ATSB reports is they list relevant events in the order they happened.

[FGD135]

Bend alot,

Your claim that:
More than one involved in this cover up I think!Seems to be based on your assumption that the words "unscheduled engine shutdown" apply in this case. To my reading, they do not. An engine running out of fuel is not a major defect. You also seem to believe that a "mayday" also somehow requires a MR entry. That is not the case. I suggest that your "cover up" does not actually exist.

Ixixly,

You seem to have the idea that there were two pilots on the Conquest - which seems to make the likelihood of fuel exhaustion so much more unfathomable to you. That operation is normally flown by one pilot. Where did you get the idea of two pilots from?

[Duck Pilot]

I’m a little perplexed as to exactly what’s being debated about on this public forum in relation to the incident, lots of armchair experts making a lot of assumptions.

Fact of the matter is that the pilot identified that he/she wasn’t happy with the fuel quantity on board the aircraft and made very good decision to do something about it which resulted in an excellent outcome - case closed if you had no business in the operation. Let the authorities do their job and let’s wait and see what the final report brings.

[Bend alot]

[QUOTE=FGD135;10145354]Bend alot,

Your claim that:
Seems to be based on your assumption that the words "unscheduled engine shutdown" apply in this case. To my reading, they do not. An engine running out of fuel is not a major defect.

QUOTE]

The engine was scheduled to be running on arrival in Broome - that did not go to the schedule and one of them decided it would just stop!

Now that is a pretty clear case of "unscheduled engine shutdown" and CAsA class that as a Major Defect - if you are unsure call the number and ask them or use the email so you can share the reply.

[Bend alot]

I’m a little perplexed as to exactly what’s being debated about on this public forum in relation to the incident, lots of armchair experts making a lot of assumptions.

Fact of the matter is that the pilot identified that he/she wasn’t happy with the fuel quantity on board the aircraft and made very good decision to do something about it which resulted in an excellent outcome - case closed if you had no business in the operation. Let the authorities do their job and let’s wait and see what the final report brings.

When the engine/s stopped it was decided - there was no decision to be made!

The pilot made a great choice of where to land and a great job of the landing.
The outcome was excellent.

Let the authorities do their job and let’s wait and see what the final report brings - This was mentioned often in the first thread, as was it ran out of fuel!

[FGD135]

Bend alot,

I think you will find that "unscheduled engine shutdown" is to be read as the shutting down of an engine, by way of a deliberate act from the pilot, at a time earlier than that at which the engine would normally be shut down.

To interpret it the way you wish to requires an instance of fuel exhaustion to be considered a major defect. Does that sound logical to you?

[Duck Pilot]

As I stated, the pilot made a good (forced) decision to land and the outcome was excellent.

The result could have been a lot worse, particularly in the environment where the incident occurred.

Anyway, I don’t understand what’s going to be achieved by people throwing their opinionated expert (or just rubbish) views on this forum. Remember that there are some trawlers who look at this website for all the WRONG reasons.

One thing that I do know is that I wasting my time typing these words.

At least show some respect and dignity for the pilot involved.

[Ixixly]

Bend alot,

Your claim that:
Seems to be based on your assumption that the words "unscheduled engine shutdown" apply in this case. To my reading, they do not. An engine running out of fuel is not a major defect. You also seem to believe that a "mayday" also somehow requires a MR entry. That is not the case. I suggest that your "cover up" does not actually exist.

Ixixly,

You seem to have the idea that there were two pilots on the Conquest - which seems to make the likelihood of fuel exhaustion so much more unfathomable to you. That operation is normally flown by one pilot. Where did you get the idea of two pilots from?

FGD, Someone mentioned talking to an FO in the previous thread which lead me to believe there was 2 crew on board but I'm happy to be corrected there as it's not really stated anywhere in particular if it was 1 or 2 crew. I don't dispute the fact that it was Fuel Exhaustion just to be clear, that part is cut and dry, I'm personally thinking it will be a few different factors that went into the part where it all went very quiet rather than any one particular reason, basing that on the fact that they specifically mention Fuel Contamination and water being found, they're looking particularly into the Fuel Indication System and Fuel system component serviceability as well so seems from the report so far that they're looking into a few different areas that wouldn't really be necessary if the Pilot simply had tried to take off with Low Fuel hoping for favourable tail winds, also the fact that someone mentions a Pilot was let go but is flying for another Operator now which says to me they aren't grounded by CASA which you'd think would have been done if they suspected negligence in the form of taking off without enough fuel.

[FGD135]

... Pilot was let go but is flying for another Operator now which says to me they aren't grounded by CASA which you'd think would have been done if they suspected negligence in the form of taking off without enough fuel.CASA would need to wait for the investigation to be complete before revoking his licence. The possible negligence may still be in play.

[sagesau]

If I speculate correctly do I win a cupie doll?

[Ixixly]

CASA would need to wait for the investigation to be complete before revoking his licence. The possible negligence may still be in play.

FGD, that is true, I can't remember but what happened with the Pel-Air Ditching case? Not on the same level as this one but I honestly can't remember if they revoked the PICs Licence or perhaps suspended his right to use it or not and it's the first case that comes to mind that is anywhere close to this.

[Bend alot]

Bend alot,

I think you will find that "unscheduled engine shutdown" is to be read as the shutting down of an engine, by way of a deliberate act from the pilot, at a time earlier than that at which the engine would normally be shut down.

To interpret it the way you wish to requires an instance of fuel exhaustion to be considered a major defect. Does that sound logical to you?

Fine - the pilot shut one down deliberately due surge (prior to landing at Broome), the other shut itself down also prior to Broome.

But supply a link that it needs to be deliberately shut down, love to see it.

[Badengo]

Exactly what I said in the original post. ZERO singing syrup! Water means nothing, we find water in the wings everyday along with microbial growth.

[Pilotette]

Where is this video of taxiing out of HLC with the low fuel light illuminated? I keep hearing about it but it would be good to see it. If this was the case, bad airmanship aside, surely this is against the Skippers SOPs? From what I know, the low fuel light is a separate system to the fuel gauges and activated by a float between 150-250lbs. So even if the gauges were overreading, surely the low fuel light would be enough to make you think twice about moving?

[Ixixly]

Pilotette, it was Horatio who mentioned the video, adds a bit of credence to it for me coming from him

[Pilotette]

Pilotette, it was Horatio who mentioned the video, adds a bit of credence to it for me coming from him

Yeah for sure and I’ve heard it from other sources too, apparently it was on Youtube but I haven’t been able to find it. I’m not really a Youtube user generally though.

[AbsoluteFokker]

I'll repost my cryptic clue in a previous post that nobody previously picked up on:
Holy maleficent mycelium, Batman!

[Eddie Dean]

Exactly what I said in the original post. ZERO singing syrup! Water means nothing, we find water in the wings everyday along with microbial growth.It is the water held in suspension, not necessarily free water, that affects capacitance type fuel sender units.

[Ixixly]

Interesting suggestion there AbsoluteFokker, that would be a heck of a growth would it not? Is this you postulating based on other incidents or is this something you've heard come out during this particular investigation?

[717tech]

I can't remember the numbers, but I've flown types where the manufacturer has specified minimum fuel level required for flight. The figure stated was less than the fuel required to trigger the "Fuel Level Low" warning captions.
The point being, so long as that figure equated to flight fuel plus reserves, you could very well end up in a situation where the caution lights are on and still be legal, compliant etc.

[Pilotette]

I can't remember the numbers, but I've flown types where the manufacturer has specified minimum fuel level required for flight. The figure stated was less than the fuel required to trigger the "Fuel Level Low" warning captions.
The point being, so long as that figure equated to flight fuel plus reserves, you could very well end up in a situation where the caution lights are on and still be legal, compliant etc.

True. I believe for the Conquest that it’s 208lbs/side.

[AbsoluteFokker]

Interesting suggestion there AbsoluteFokker, that would be a heck of a growth would it not? Is this you postulating based on other incidents or is this something you've heard come out during this particular investigation?

Yes - it's a heck of a growth. Only what I hear third-hand about this incident. Not directly corroborated, so is it's still rumour until we see the report. Apparently an isolated fungal incident, and therefore rather unexpected, but given the severity of the outcome (total power loss) I'm sure there'll be some additional checks recommended by ATSB for Jet-A1 aircraft in the tropics.

From my own perspective on previous posts to this thread: If crew ignored any fuel warning lights either because they were instructed/suggested to do so and didn't write it up in the MR then that's a cause for concern, but, again, might not indicative of a company-wide issue at all.

I've owned aircarft with certain characteristics that might seem abnormal to others (e.g. nose wheel/tail wheel shimmy, especially at higher-than-normal ground speeds) but not enough to write up on a MR, so it's a fine line.

Maybe one day we'll have a pilots-and-engineers-only "gripe sheet" for issues that the pilot doesn't think warrant an MR entry (the PIC may be wrong on this) but at least it can get reviewed. Swiss cheese and all that. Might save a job or two as well.

[Lead Balloon]

Yes - it's a heck of a growth. Only what I hear third-hand about this incident. Not directly corroborated, so is it's still rumour until we see the report. Apparently an isolated fungal incident, and therefore rather unexpected, but given the severity of the outcome (total power loss) I'm sure there'll be some additional checks recommended by ATSB for Jet-A1 aircraft in the tropics.So this enormous growth of mycelium was diagnosed as the problem out on the highway, then ‘dealt with’ on site, thus rendering it safe to kick the tyres and light the fires and take off. And the fuel uplift and usage records never suggested a disparity between actual and indicated.

What’s that technical term? I know: Bollocks!

[Ixixly]

AbsoluteFokker, would that not have made this a Fuel Starvation Event rather than a Fuel Exhaustion Event? Only way I could still see it being Exhaustion is if the Fuel onboard is then considered not usable due to the Fungal Growth but if the Fungal Growth fouled up the fuel intakes or some such it would then be Starvation, putting that particular one down low on my own list of possibilities, also wouldn't explain why a Pilot got the boot unless there is something more to that part we don't know which is always highly likely!

[Eddie Dean]

So this enormous growth of mycelium was diagnosed as the problem out on the highway, then ‘dealt with’ on site, thus rendering it safe to kick the tyres and light the fires and take off. And the fuel uplift and usage records never suggested a disparity between actual and indicated.

What’s that technical term? I know: Bollocks!Cladosporium Resinae comes to mind.

[Lead Balloon]

That’d be it: Kerosene fungus.

Easily fixed by the roadside and good to go in no time!

[AbsoluteFokker]

I don't know any of the individuals so I am speculating.

Perhaps pilot got the boot because he ignored earlier warning signs. (e.g. "fuel warning light XXX illuminated" - "don't worry about that mate, it always does that for the first 5 minutes"). Sacking such a pilot prior to investigation outcomes is just an exercise in prudence in public relations for any company. Same happens in every company and industry worldwide. It's a "you can see we made immediate changes, someone was sacked, justice was done etc." More cynical people may make alternate judgements!

So, if it is fungal, what is actually involved in rectification for flight?

What lessons can we learn as pilots to prevent this?

For those playing at home re fuel exhaustion vs fuel starvation: If lots of volume taken up by previously undetected foreign-volume-consuming-substances, how would you detect your tank actually has less usable capacity? Would you expect any crew on any given (short-haul) leg to figure this out?

[Capt Fathom]

What lessons can we learn as pilots to prevent this
Ahh, don’t skimp on fuel?

[AbsoluteFokker]

So if your usable fuel was far significantly lower than you expected, how would you respond?

I know from my own near fuel exhaustion events (one, an error of not swapping tanks, the other due to unexpected low-level flight due weather, then headwinds, then unusable landing sight, then more headwinds, then crazy cross-winds) I am now very conservative in this respect.

However, if I "filled to full" but my actual usable was "full less X" where X is significant, that would be a serious WTF event.

[Lead Balloon]

So if your usable fuel was far significantly lower than you expected, how would you respond?I know the answer to this one: Conduct a forced landing when the motion lotion runs out.

The questions de jour are:

(1) Why was your usable fuel “far significantly lower than you expected”; and

(2) Why didn’t you know about it.

[AbsoluteFokker]

Yep - all interesting questions after the event. Let's see what they say - maybe my info on the event is wrong too, but, as pilots, we need to understand that theoretically usable fuel isn't necessarily available.

I guess this is where fuel tank calibration helps, but significant blockages of fuel flow also need to be incorporated.

Perhaps fuel tank calibration needs be aligned with fuel flow. i.e. what comes from a fuel drain over X hours doesn't mean anything.

[Bend alot]

Fungal growth?

In both tanks at the same growth rate, to cause engines to stop at basically the same time!

Now that would call for some very time consuming road side maintenance on the independent fuel systems.

Such as.

Fuel tank inspection (all wing panels).
All growth removed.
All filters replaced/cleaned.
Again after engine ground runs.
Entire fuel system cleaned.
Possibly even FCU change.
Compulsory placard of some sort and
A bunch of paperwork.
A known quantity of fuel will need to be uploaded after inspections and ground runs, but prior to flight.

Unless this procedure is in the MM the actual maintenance/inspections will be given by CAsA or an Approved Person.

Questions - When the first engine surged why was it shut down?
Why no mention of fuel cross feed and attempted restart first?
Was it the same pilot that flew the aircraft out, as the one that landed it? (Company policy considerations also).

The 441 on one engine is not a slug, so there is time to trouble shoot or follow procedures.

Fuel calibrations are pretty regular and the system from memory pretty accurate and reliable, reweigh of the aircraft also a task to pick up on irregularity (such growth would need to be a fair size and weight), normal filter maintenance would also have signs of contamination.

[megan]

Perhaps pilot got the boot because he ignored earlier warning signs. (e.g. "fuel warning light XXX illuminated" - "don't worry about that mate, it always does that for the first 5 minutes"). Sacking such a pilot prior to investigation outcomes is just an exercise in prudence in public relations for any company. Same happens in every company and industry worldwide. It's a "you can see we made immediate changes, someone was sacked, justice was done etc." More cynical people may make alternate judgements! I'm one of your cynical people AF. When a company is so quick to sack someone following an event the suspicion of what they are trying to cover up arises, for me at least. If someone habitually flouts standards the company should know about it, and address it. If they don't know it indicates a serious flaw in oversight by management. Either way its a corporate failure. If its a one off by a previously reliable employee you find out the why and address that. Bristow helicopters had a one off event in WA and sacking the crew, both of whom had impeccable records previously, was the corporate solution. Court case arose for unfair dismissal, which the crew won, and at least one of the crew resumed employment, not sure of the other. Lloyd Helicopters had a similar case in WA where sacking the captain was the solution, even though the report details the lack of training was a significant cause. he too won an unfair dismissal case. The fact that he won is still to this day a canker in the side of some who were in management at the time, they blame him as being the sole cause of the accident. The company had decided sending crews to the US for simulator training was not commercially viable. So much for learning, if you think training is expensive try having an accident. Views have since changed in some areas of GA from those evident in this 17 year old accident.

Lloyds https://www.atsb.gov.au/media/24790/199100020.pdf

Bristow https://www.atsb.gov.au/media/24791/199100126.pdf

Will be an interesting report, particularly as the pilot in this Skippers incident was so readily snapped up by another employer. Innocent until proven guilty.

There is a tale in the corporate world where an individual cost the company a bucket load of money because of an errant decision. A flunky sidled up to the company owner at a function and commented, "Well, that's him for the chop then". Owner replied, "What, after all the money I just spent on his education".

[Squawk7700]

If the pilot is in fact "innocent" and was sacked, then they can make a complaint via the Human Rights Commission and they will make a ruling, not to mention the fair work commission.

[Ixixly]

Guessing they wouldn't do that till after the investigation though Squawk7700?

[Squawk7700]

Yes indeed.

But the investigation you speak of would be a CASA one (if there was to be one) and not the ATSB report. I don't recall charges being laid against anyone after the release of an ATSB report.

With these types of things you probably wouldn't be wanting your job back you'd think so that really only leaves limited outcomes.

[Lead Balloon]

Like all of us, you do occasionally speak complete rubbish Squawk.

What, precisely, would be the claim made in the Human Rights Commission by a pilot unfairly dismissed after a forced landing? Your nomination of the Fair Work Commission was a little closer to the mark.

And you do recall that the content of the latest attempt by the ATSB to credibly investigate the ditching of NGA was used by CASA to justify the continued administrative torture of Dom James?

[Ixixly]

I was just referring to an Unfair Dismissal Case with the FWC, wouldn't really get far claiming unfair dismissal until ATSB had completed the investigation and you had something to show a court that experts said it wasn't your fault.

But once again, we don't know what this Pilot was actually fired for, this incident may have been the proverbial straw that broke the camels back or perhaps he had some choice words for someone in the aftermath that were unwarranted? Perhaps he released the video for whatever reason and breached their Social Media Policies? would be interesting to find out.

[Capt Fathom]

As has been mentioned previously the pilot is gainfully employed elsewhere, so probably no reason to fight it.