VH-LBY Skippers C-441
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.
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.
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.
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, 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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
** 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.
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?
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-pag...ns-and-regions
https://www.casa.gov.au/standard-pag...ian-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.
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-pag...ns-and-regions
https://www.casa.gov.au/standard-pag...ian-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.
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.
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.
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-pag...ns-and-regions
https://www.casa.gov.au/standard-pag...ian-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/ca...ontact-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.
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-pag...ns-and-regions
https://www.casa.gov.au/standard-pag...ian-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/ca...ontact-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.
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.
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.
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.
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.
Last edited by Lead Balloon; 12th May 2018 at 11:27.
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!
You claim CAsA will issue SFP's with partial required info if urgency is a issue and a road is blocked.
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.
You claim CAsA will issue SFP's with partial required info if urgency is a issue and a road is blocked.
It's a wide road reserve and lots of clear space.
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.
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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.
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.
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.
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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?
Your claim that:
More than one involved in this cover up I think!
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?