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Skippers Aviation Cessna Conquest makes forced landing on highway

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Skippers Aviation Cessna Conquest makes forced landing on highway

Old 4th Jun 2021, 11:35
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Skippers Aviation Cessna Conquest makes forced landing on highway

Skippers Aviation Cessna Conquest makes forced landing on highway

The previous thread about this incident was closed, perhaps for too much conjecture. The report is out, perhaps some of the conjecture wasn’t far off.

https://www.atsb.gov.au/media/577972...-019-final.pdf

What the ATSB found

Due to water contamination in the fuel tanks, the aircraft’s fuel quantity gauges were significantly over reading on the day of the occurrence and on previous days. The water contamination had existed for some time without being detected by multiple pilots’ fuel quality testing.

Although the pilot routinely compared indicated versus calculated fuel quantities, and indicated versus flight-planned fuel quantities, the pilot did not routinely conduct two other methods stated in the operator’s procedures for cross-checking fuel quantity gauge indications.

In addition, although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its C441 fleet, there were limitations in the design, definition and/or application of these methods. The primary method used (indicated versus calculated fuel) was self-referencing in nature, and not able to detect gradual changes in the reliability of fuel quantity gauge indications. Pilots also did not record (and were not required to record) sufficient information on flight logs to enable trends or patterns in fuel quantity gauge indications to be effectively identified, and pilots did not routinely cross-check information from fuel quantity gauge indications with information from the independent fuel totaliser.

The FUEL LEVEL LOW annunciators likely illuminated approximately 30 minutes before the fuel was exhausted in each tank, and when the aircraft was still within range of suitable alternative airports. However, the pilot disregarded the annunciations, and relied on the (erroneous) fuel quantity indications and continued to Broome until the engines lost power, at which point a forced landing on a highway was the only remaining option.



Last edited by Cloudee; 4th Jun 2021 at 11:49.
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Old 4th Jun 2021, 21:42
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Originally Posted by Cloudee View Post
Skippers Aviation Cessna Conquest makes forced landing on highway

The previous thread about this incident was closed, perhaps for too much conjecture. The report is out, perhaps some of the conjecture wasn’t far off.

https://www.atsb.gov.au/media/577972...-019-final.pdf

What the ATSB found

Due to water contamination in the fuel tanks, the aircraft’s fuel quantity gauges were significantly over reading on the day of the occurrence and on previous days. The water contamination had existed for some time without being detected by multiple pilots’ fuel quality testing.

Although the pilot routinely compared indicated versus calculated fuel quantities, and indicated versus flight-planned fuel quantities, the pilot did not routinely conduct two other methods stated in the operator’s procedures for cross-checking fuel quantity gauge indications.

In addition, although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its C441 fleet, there were limitations in the design, definition and/or application of these methods. The primary method used (indicated versus calculated fuel) was self-referencing in nature, and not able to detect gradual changes in the reliability of fuel quantity gauge indications. Pilots also did not record (and were not required to record) sufficient information on flight logs to enable trends or patterns in fuel quantity gauge indications to be effectively identified, and pilots did not routinely cross-check information from fuel quantity gauge indications with information from the independent fuel totaliser.

The FUEL LEVEL LOW annunciators likely illuminated approximately 30 minutes before the fuel was exhausted in each tank, and when the aircraft was still within range of suitable alternative airports. However, the pilot disregarded the annunciations, and relied on the (erroneous) fuel quantity indications and continued to Broome until the engines lost power, at which point a forced landing on a highway was the only remaining option.
Water contamination and both motors stop at the same time - good independent fuel and indication systems!

Still how did the aircraft depart the scene legally?

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Old 5th Jun 2021, 05:16
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Originally Posted by Bend alot View Post
Water contamination and both motors stop at the same time - good independent fuel and indication systems!

Still how did the aircraft depart the scene legally?
From the report:
Post-occurrence actions and maintenance
On the day following the occurrence (3 March 2018), a fuel drain was conducted and a significant but unquantified amount of water was drained. The aircraft was then refuelled with 650 lb of fuel from sealed drums and the subsequent fuel drain did not contain a significant amount of water. The engines were ground run and no fuel leaks were evident. The fuel pump pressure low and fuel level low annunciators were checked to be operating as satisfactory.
Based on this evidence, and an assessment that both engines had likely lost power due to fuel exhaustion, the Civil Aviation Safety Authority (CASA) issued the operator with a special flight permit to allow the aircraft to be flown to Broome.
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Old 5th Jun 2021, 10:38
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Whatever happened to the paste or syringe pill tests? If I ever get evidence of water in any tanks, I just open the fuel drain and let it drain out until the water disappears, particularly in a bug smasher. Dash 8, let the engineers deal with it and I’ll call the flight attendant for another black coffee!
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Old 5th Jun 2021, 12:51
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Originally Posted by Cloudee View Post
From the report:
Post-occurrence actions and maintenance
On the day following the occurrence (3 March 2018), a fuel drain was conducted and a significant but unquantified amount of water was drained. The aircraft was then refuelled with 650 lb of fuel from sealed drums and the subsequent fuel drain did not contain a significant amount of water. The engines were ground run and no fuel leaks were evident. The fuel pump pressure low and fuel level low annunciators were checked to be operating as satisfactory.
Based on this evidence, and an assessment that both engines had likely lost power due to fuel exhaustion, the Civil Aviation Safety Authority (CASA) issued the operator with a special flight permit to allow the aircraft to be flown to Broome.
3rd of March being a Saturday.

Hello Casa on a Saturday.

Aircraft was disturbed following the "emergency" and NO detail of water quantity recorded.

Stick in fuel (it indicated it had fuel prior) and ground run it.

No fuel leaks - No surprise it did not have enough before the noise stopped. IT WAS NOT A FUEL LEAK ISSUE!

With that "evidence" issue a Special Flight Permit.

No filter changes or checks of the engine fuel system or any real fuel system maintenance checks.

Yep nothin fishy here.

CASA again on a Saturday!!!!!! nothin fishy here.
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Old 6th Jun 2021, 01:49
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If fuel exhaustion was, in fact, the cause of the problem, what else could usefully be done to render the aircraft airworthy, other than to add fuel?

The aircraft flew away. Has it subsequently suffered any fuel system problem?
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Old 6th Jun 2021, 02:04
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Whatever happened to the paste or syringe pill tests? If I ever get evidence of water in any tanks, I just open the fuel drain and let it drain out until the water disappears, particularly in a bug smasher. Dash 8, let the engineers deal with it and I’ll call the flight attendant for another black coffee!
Not only that but how could you do a fuel drain and not notice that water was coming out and not fuel?? It's obvious when it happens. I've experienced it numerous times both with AVGAS and Jet-A1. Honestly if I was the ATSB I would have been pumping the pilots about whether they really were doing the fuel drains. After seeing it few times for real I cannot believe that you could be doing the fuel drains and not know.

Last edited by neville_nobody; 6th Jun 2021 at 02:35.
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Old 6th Jun 2021, 04:53
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If there was as much water as they say then the whole drain would be homogenous. It was drilled in to me early in that if there is no evidence of water (immiscible liquids) then check that the whole lot isn’t water. Smell it, touch it etc.
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Old 6th Jun 2021, 06:57
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Originally Posted by Lead Balloon View Post
If fuel exhaustion was, in fact, the cause of the problem, what else could usefully be done to render the aircraft airworthy, other than to add fuel?

The aircraft flew away. Has it subsequently suffered any fuel system problem?
Yes the fuel was exhausted but not the fluid!

Know what happens to a diesel engine (and its fuel pump) when it swallow's water not diesel?

"Water contamination is one of the chief enemies of any diesel-fueled equipment. All fuels contain some water in suspension, but unlike gasoline, diesel fuel is less refined and will hold a much larger amount. This water can cause severe problems with water separators on the equipment. It can also cause the fuel injector tips to explode, resulting in expensive repairs. In fact, slugs of water in the fuel can cause sudden cooling in the engine and may result in shortened engine life."https://www.forconstructionpros.com/equipment/fleet-maintenance/article/10667628/water-in-diesel-fuel-can-wreak-havoc-in-engines

So it is OK to run this aircraft experimental?

Point/Fact there is not a AMM procedure for this event.
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Old 6th Jun 2021, 07:30
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I wasn’t aware there was a diesel engined version of a Conquest.

How did it make it safely to Broome?

Presumably you reckon the aircraft should still be at the location of the forced landing, or taken to Broome by truck?

It would help if you could provide more detail around the conspiracy you’re alleging. Is it that Skippers got special treatment from CASA in the form of an ‘after hours’ ‘quick and dirty’ SFP, or that the ATSB has told fibs about the existence of an SFP in its report? Nothing would surprise me!
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Old 6th Jun 2021, 09:43
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Picture of the panel, I wonder if the rest of the aircraft looked as good.

This was a scheduled passenger service with 9 passengers in a ME turboprop aircraft that ran out of fuel! With some piloting skill and lots of good luck no one died or even got injured. The organisation that operated this aircraft and under whose watch this happened then goes out to the aircraft, drains an unrecorded amount of water from the tanks, checks it out and calls CASA who say sure, take off from the highway and take it home, we’ll look at it later. On a Saturday.

I personally would have thought quarantining the aircraft until an on-site CASA visit occurs might be warranted.

Last edited by Cloudee; 6th Jun 2021 at 10:18.
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Old 7th Jun 2021, 00:29
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How long would it have taken and how much would it have cost for CASA to go to the site, and what deep insights and wisdom would CASA have brought to the technical issues?

Don’t get me wrong: I reckon it’s ‘waaay dodgy’ all round. But Australia is, after all and as they say, the only third world aviation nation where you can drink the tap water. I despair when there are calls for the CASA Keystone Kops to ‘do’ more, when that usually entails delay, cost and amateur hour analysis.
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Old 7th Jun 2021, 06:08
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Originally Posted by Lead Balloon View Post
I wasn’t aware there was a diesel engined version of a Conquest.

How did it make it safely to Broome?

Presumably you reckon the aircraft should still be at the location of the forced landing, or taken to Broome by truck?

It would help if you could provide more detail around the conspiracy you’re alleging. Is it that Skippers got special treatment from CASA in the form of an ‘after hours’ ‘quick and dirty’ SFP, or that the ATSB has told fibs about the existence of an SFP in its report? Nothing would surprise me!
You Lead Ballon, simply do not get it!

I never ever said there was a diesel version of the Conquest - but I do know there are written procedures to allow it's use in the Garrett engine.

The point is you have zero idea (nor do I) of what damage was done to the engines if any - even though it made a short flight without "further" incident.

It could have effects on the fuel nozzle that torch the turbine to extent that it showered Broome with blade fragments killing several people or simply clog the fuel system and fail the engine again after X minutes of running.

I doubt either the engine or airframe manufacturers would say simply add fuel and go - but what would they know.

On piston engine aircraft water blocks the nozzles & requires a fair amount of work to remove it once ingested.
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Old 7th Jun 2021, 06:40
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but I do know there are written procedures to allow it's use in the Garrett engine
Not in the Conquest it's not, what TPE331 installations allow diesel?
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Old 7th Jun 2021, 08:13
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Originally Posted by Bend alot View Post
You Lead Ballon, simply do not get it!

I never ever said there was a diesel version of the Conquest - but I do know there are written procedures to allow it's use in the Garrett engine.

The point is you have zero idea (nor do I) of what damage was done to the engines if any - even though it made a short flight without "further" incident.

It could have effects on the fuel nozzle that torch the turbine to extent that it showered Broome with blade fragments killing several people or simply clog the fuel system and fail the engine again after X minutes of running.

I doubt either the engine or airframe manufacturers would say simply add fuel and go - but what would they know.

On piston engine aircraft water blocks the nozzles & requires a fair amount of work to remove it once ingested.
So the aircraft should have been dismantled and transported in major subassemblies to a laboratory for extensive examination and testing.

That didn’t happen.

Oh the humanity.

You’re starting to sound like the scaremongers who shut down Glen Buckley.
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Old 7th Jun 2021, 09:45
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Way more questions than answers here for me. Interesting to know where the fuel pickups are located. Surely if there was enough water to affect the fuel quantity indications and water sinks to the bottom, why didn't the problem show up on first start? I know from operating in the Kimberly that water in fuel is a constant threat and one that any pilot operating there should be really aware of and double check.
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Old 7th Jun 2021, 11:46
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It ran out of fuel and landed undamaged on the highway. After the initial investigation, fuel was added and it was flown out.

An official investigation followed and many recommendations made. So why do people continue to make a big deal of it.

If you have questions and there are no answers for you in the ATSB report, get hold of a Conquest pilot and ask them!
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Old 7th Jun 2021, 12:52
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Water = ice at Alt, that's the biggest worry!
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Old 12th Jun 2021, 21:44
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You want to ensure pilots do “generous” and frequent fuel drains? Simply make sure they’re poor and they drive old diesel engined vehicles.
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Old 13th Jun 2021, 01:34
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Originally Posted by Bend alot View Post
You Lead Ballon, simply do not get it!

I never ever said there was a diesel version of the Conquest - but I do know there are written procedures to allow it's use in the Garrett engine.

The point is you have zero idea (nor do I) of what damage was done to the engines if any - even though it made a short flight without "further" incident.

It could have effects on the fuel nozzle that torch the turbine to extent that it showered Broome with blade fragments killing several people or simply clog the fuel system and fail the engine again after X minutes of running.

I doubt either the engine or airframe manufacturers would say simply add fuel and go - but what would they know.

On piston engine aircraft water blocks the nozzles & requires a fair amount of work to remove it once ingested.
If there had been a lot of damage would not the ground runs have shown this pretty quickly? Wouldn't they have seen evidence of severe damage even with just a basic check of the fuel nozzles etc...? Also I'm sure this isn't the first time someone has managed to do this, undoubtedly the Engineers have either seen it themselves or knew someone they could contact that have seen it happen.

Last edited by Ixixly; 13th Jun 2021 at 02:16.
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