G/A Light Aircraft ditches off Leighton Beach, WA
I hesitate to summarise but perhaps the short version is that things were pretty overwhelming, it wasn't a deliberate decision, and she has a better appreciation of checklists/mnemonics now?
That said, in my view, it'd be best to listen to what the pilot had to say, which more comprehensively explains how this came about in context and contains a decent self-appraisal of things learnt.
FP.
Footnote: I meant to comment on the ergonomics of PA28 series fuel tank valves; they are truly awful! However the fuel pump switch and fuel pressure gauge are reasonably within eyeshot and more easily reached, hence my technical interest in these two items from both a human factors and mechanical perspective.
That said, in my view, it'd be best to listen to what the pilot had to say, which more comprehensively explains how this came about in context and contains a decent self-appraisal of things learnt.
FP.
Footnote: I meant to comment on the ergonomics of PA28 series fuel tank valves; they are truly awful! However the fuel pump switch and fuel pressure gauge are reasonably within eyeshot and more easily reached, hence my technical interest in these two items from both a human factors and mechanical perspective.
Last edited by First_Principal; 5th Jul 2023 at 22:09. Reason: Be more specific over which gauge I meant
hi why would you not switch the fuel tanks (truly curious)
I thought the F in FCMIT is "fuel most full". practically it should be Fuel Pump+switch fuel tank (unless you are 100% sure that the other tank has been bled dry?).
i have practically zero time in a PA-28. I prefer flying high wing so we don't have to bother about switching fuel tanks tbh (my instructor keeps going on about him liking the Piper better - but i dont like them because of single door and this switching tank stuff (and doesnt feel convenient to reach that knob...))
I thought the F in FCMIT is "fuel most full". practically it should be Fuel Pump+switch fuel tank (unless you are 100% sure that the other tank has been bled dry?).
i have practically zero time in a PA-28. I prefer flying high wing so we don't have to bother about switching fuel tanks tbh (my instructor keeps going on about him liking the Piper better - but i dont like them because of single door and this switching tank stuff (and doesnt feel convenient to reach that knob...))
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Sometimes those decisions are the correct ones.
Someone fiddling with tanks or something then trying another restart, before you know it your height is 500ft, glide speed has got away from you, and the focus on landing has been reduced.
We have seen enough fatals over the years with people playing with levers, dials and what not, and before they know it, they are about to stall, and dive into the ground.
Someone fiddling with tanks or something then trying another restart, before you know it your height is 500ft, glide speed has got away from you, and the focus on landing has been reduced.
We have seen enough fatals over the years with people playing with levers, dials and what not, and before they know it, they are about to stall, and dive into the ground.
While I agree that the prime concern should always be gliding and picking a suitable landing area you should be able to carry out some quick trouble checks without much distraction. I haven't flown a piston for some time now, but I still have FMOST drilled in my head for if things went quiet. Starting with "F" Fuel - Pumps ON, contents checked, change tanks. While its nice to have individual procedures specific to the type it's way easier to remember a generic acronym that sticks in your head for almost every piston type you could fly. And I remember doing this drill with students at low level so they could practice whether they had time to complete the checklist or not and just focus on landing.
Having a lot of time on PA28s I could say the fuel system is very simple with just the one vice that you have to change tanks regularly. Ergonomics wise, its not that difficult, 3 place selector OFF/LEFT/RIGHT. I've seen much worse in various other aircraft. Fuel gauges are not hidden by any means and in a reasonable location. However as with any older aircraft there is no quantity warning system, and the pilot has to keep a fuel log to ensure burn is matching plan and gauge indication. CLEAR-OFF checks at 30 minute intervals usually were enough to keep track of fuel logs, with all the fancy iPad things these days I'm sure you could get an alarm to go off every 30 minutes to do your navigation checks.
Having a lot of time on PA28s I could say the fuel system is very simple with just the one vice that you have to change tanks regularly. Ergonomics wise, its not that difficult, 3 place selector OFF/LEFT/RIGHT. I've seen much worse in various other aircraft. Fuel gauges are not hidden by any means and in a reasonable location. However as with any older aircraft there is no quantity warning system, and the pilot has to keep a fuel log to ensure burn is matching plan and gauge indication. CLEAR-OFF checks at 30 minute intervals usually were enough to keep track of fuel logs, with all the fancy iPad things these days I'm sure you could get an alarm to go off every 30 minutes to do your navigation checks.
Last edited by 43Inches; 6th Jul 2023 at 02:17.
I agree that PA28 fuel systems are not complex compared to some, but I don't consider the tank switch/tap an example of good ergonomic design.
To some extent that's a function of the times, ergonomics and human factors weren't really thought about back then, and there are many examples of even worse systems! However it's my view that, as much as you can try and 'train out' the designed-in flaws, they can still affect the outcome of an unexpected event; this may be an example.
To whit; objects have affordances; a door handle is directly visible and affords pulling on it, a door plate affords pushing on it. A PA38, or even a 172 fuel tap is directly visible to the pilot (IIRC?), and they point laterally to the fuel tank in question. On the other hand the PA28 tap is not especially visible, it is awkward to operate, and the longitudinal operation doesn't easily relate to the tank you're operating on, or have been operating on.
So, in the event of an 'oh sh*t' moment, and while you'd hope training will kick in and you do everything right, something that's not especially visible and doesn't tell you what it's doing (ie. which tank it's pointing to) doesn't exactly put itself out there for you to attend to with the limited processing you're likely to have at that time. OTOH the pressure gauge and pump switch are more line of sight, and so may be less likely to be missed. Having said that you've then got the issue, especially in this part of the world, of which way the switch should be when it's ON! Then there's the gauge which is doesn't exactly stand out from the others...
Now, like you I haven't flown one of these in quite a while but the drill is very clearly loud in my head and I'd like to think the fuel tank switch would be within one of the first few things I did (after carb heat, mix, pump), yet I've been fortunate and I've not needed to do this in anger - at least not in a PA28 - and so I've not been tested for real. This pilot was tested, and she's berated herself for not following the drill, and while I don't think the PA28 fuel switch design excuses that, it could perhaps explain it to a certain extent (along with other things discussed in the audio).
Where I'm heading with this is, what could we as pilots or instructors do to counter this? Mnemonics and memory training are all very well, but in the heat of the moment is there something that would assist us to get things right? With some of the 'planes I flew we had a QRH goto just for such an event, but in this era of inexpensive electronics I wonder if there's a place for a 'big red button' that you hit following which a voice starts telling you the drill, or it's put up on a screen?
I put this explanation and these ideas up as points for discussion and 'what can we learn' from this event in order to improve what we do now and in the future, and to - hopefully - reduce the likelihood of it happening again. That Michelle has been direct and truthful about what happened assists us all in this, but I think but we actually need to do something with that information for it to be effective.
FP.
To some extent that's a function of the times, ergonomics and human factors weren't really thought about back then, and there are many examples of even worse systems! However it's my view that, as much as you can try and 'train out' the designed-in flaws, they can still affect the outcome of an unexpected event; this may be an example.
To whit; objects have affordances; a door handle is directly visible and affords pulling on it, a door plate affords pushing on it. A PA38, or even a 172 fuel tap is directly visible to the pilot (IIRC?), and they point laterally to the fuel tank in question. On the other hand the PA28 tap is not especially visible, it is awkward to operate, and the longitudinal operation doesn't easily relate to the tank you're operating on, or have been operating on.
So, in the event of an 'oh sh*t' moment, and while you'd hope training will kick in and you do everything right, something that's not especially visible and doesn't tell you what it's doing (ie. which tank it's pointing to) doesn't exactly put itself out there for you to attend to with the limited processing you're likely to have at that time. OTOH the pressure gauge and pump switch are more line of sight, and so may be less likely to be missed. Having said that you've then got the issue, especially in this part of the world, of which way the switch should be when it's ON! Then there's the gauge which is doesn't exactly stand out from the others...
Now, like you I haven't flown one of these in quite a while but the drill is very clearly loud in my head and I'd like to think the fuel tank switch would be within one of the first few things I did (after carb heat, mix, pump), yet I've been fortunate and I've not needed to do this in anger - at least not in a PA28 - and so I've not been tested for real. This pilot was tested, and she's berated herself for not following the drill, and while I don't think the PA28 fuel switch design excuses that, it could perhaps explain it to a certain extent (along with other things discussed in the audio).
Where I'm heading with this is, what could we as pilots or instructors do to counter this? Mnemonics and memory training are all very well, but in the heat of the moment is there something that would assist us to get things right? With some of the 'planes I flew we had a QRH goto just for such an event, but in this era of inexpensive electronics I wonder if there's a place for a 'big red button' that you hit following which a voice starts telling you the drill, or it's put up on a screen?
I put this explanation and these ideas up as points for discussion and 'what can we learn' from this event in order to improve what we do now and in the future, and to - hopefully - reduce the likelihood of it happening again. That Michelle has been direct and truthful about what happened assists us all in this, but I think but we actually need to do something with that information for it to be effective.
FP.
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i think at the end of the day, its all good/well in theory... but the startle effect is very real. (learnt that from spin training where i was recovering well with 100% success. then we are cruising along and my instructor puts me into an unanticipated spin and i froze and failed to recover on my own... )
i'm not sure how you mitigate that apart from a bit more training in your type (until it becomes muscle memory).
or every 30 mins as part of clearoff rehearse the engine failure drill to keep you in anticipation (you are meant to kee[ scanning for forced landing spot. but i admit that i dont do this often)
at end of day though, the pilot brought the plane down safely and followed the golden rule which was to fly the plane foremost and walked away with her family without a scratch so that has got to be a win.
i'm not sure how you mitigate that apart from a bit more training in your type (until it becomes muscle memory).
or every 30 mins as part of clearoff rehearse the engine failure drill to keep you in anticipation (you are meant to kee[ scanning for forced landing spot. but i admit that i dont do this often)
at end of day though, the pilot brought the plane down safely and followed the golden rule which was to fly the plane foremost and walked away with her family without a scratch so that has got to be a win.
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For those that don't have PA-28 time - The fuel selector is easily operated with the right hand and its position can be seen by the pilot. It only has two positions that can be easily selected. Don't like the tank it's on then select the other one. I don't think I could select "Off" in flight as it is damn awkward on the ground and usually takes two hands. An experienced PA-28 pilot could operate the fuel valve blindfolded in less than 5 seconds.
I do not believe the ergonomics of the PA-28 fuel valve were a factor in this accident.
What is of interest to me is why one tank did not have the standard fuel strainer fitted. Was it never fitted when the airplane was manufactured? Who in their right mind would remove it and make no log entry? Without the strainer any piece of debris as large as the fuel port could completely cut off the fuel supply. Very difficult for the whole surface area of the strainer to be obstructed.
In over 1,000 hours in my PA-28 I don't think I have ever found water or any other contamination in the fuel. My only engine scare was in a C-182 with bladder tanks. It released trapped water in a Vx climb. Can't trap water in the PA-28 tanks.
I do not believe the ergonomics of the PA-28 fuel valve were a factor in this accident.
What is of interest to me is why one tank did not have the standard fuel strainer fitted. Was it never fitted when the airplane was manufactured? Who in their right mind would remove it and make no log entry? Without the strainer any piece of debris as large as the fuel port could completely cut off the fuel supply. Very difficult for the whole surface area of the strainer to be obstructed.
In over 1,000 hours in my PA-28 I don't think I have ever found water or any other contamination in the fuel. My only engine scare was in a C-182 with bladder tanks. It released trapped water in a Vx climb. Can't trap water in the PA-28 tanks.
I agree entirely with what you are saying, my comments regarding the PA28 fuel selector was not that it was great, but is probably towards the better end of the spectrum for the design era.
The offending fuel selector from a 1978 PA28 Warrior II, taken 20+ years ago, but I assume they haven't changed much.
The only real issue with it was it's location down the left side of the cockpit which made it slightly awkward to operate. The "Off" locking mechanism can be seen to prevent inadvertently going through the "Left" position hastily.
As for procedures, nothing beats the old standard mnemonics. However pretty sure you can get all sorts of gadgets/apps, on iPads/Phones these days that you can set a basic alarm to remind you to change tanks. Have it yell "Hey Moron, check your fuel" through your bluetooth headset, or whatever will get your attention.
As for Vital actions, really can't be stressed those initial actions need to be from memory. Scrounging around for a checklist, paper or on an iPad or similar is not what you want to be doing low to the ground. One very good way to remember these things is to create flash cards, put em in the toilet to read and test yourself while on the throne. Make a home made quiz using one of the free quiz apps and set aside some time to do it regularly, keep adding stuff to your cards/quiz that will help you not only in emergencies, but on tests/renewals IPCs etc... Armchair fly, instead of paying for Yoga or TaiChi, sit in a chair and meditate on flying. There is a multitude of cheap things that you can do, and make sorta fun that can help you memorize your flying needs.
The offending fuel selector from a 1978 PA28 Warrior II, taken 20+ years ago, but I assume they haven't changed much.
The only real issue with it was it's location down the left side of the cockpit which made it slightly awkward to operate. The "Off" locking mechanism can be seen to prevent inadvertently going through the "Left" position hastily.
As for procedures, nothing beats the old standard mnemonics. However pretty sure you can get all sorts of gadgets/apps, on iPads/Phones these days that you can set a basic alarm to remind you to change tanks. Have it yell "Hey Moron, check your fuel" through your bluetooth headset, or whatever will get your attention.
As for Vital actions, really can't be stressed those initial actions need to be from memory. Scrounging around for a checklist, paper or on an iPad or similar is not what you want to be doing low to the ground. One very good way to remember these things is to create flash cards, put em in the toilet to read and test yourself while on the throne. Make a home made quiz using one of the free quiz apps and set aside some time to do it regularly, keep adding stuff to your cards/quiz that will help you not only in emergencies, but on tests/renewals IPCs etc... Armchair fly, instead of paying for Yoga or TaiChi, sit in a chair and meditate on flying. There is a multitude of cheap things that you can do, and make sorta fun that can help you memorize your flying needs.
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Other points are:
1. Some of the older versions (60's - 70's-ish) don't have locking detents, making it perfectly possible to turn the fuel off in flight if you're on Left but think you're on Right. (Fortunately I've only ever done this once and that was in the run-up bay... never again!)
2. The corollary is that, on the newer version like the one shown it's next to impossible to turn the fuel off on final for a forced landing and maintain a glide at the same time. The solution? Just don't bother.. it's not worth your life as it is.
The piper seems unintuitive. Off left right.
I fly the grob.it has the tank selector in the middle with Left Off Right.
more intuitive. Horses for courses.
i prefer Cessnas both tanks.
never has big urge to fly a piper.
I fly the grob.it has the tank selector in the middle with Left Off Right.
more intuitive. Horses for courses.
i prefer Cessnas both tanks.
never has big urge to fly a piper.
Otherwise I'm pleased you didn't use the word 'easily' with respect to actually viewing the thing, it's not exactly in one's normal field of view...
zegnaangelo I think you're quite right re the startle, I had something similar when a friend 'failed' an engine on me in a twin when I was trundling along happily looking out at some mountains on a sunny day .. took me more seconds than it should have done to figure out what was going on. Until it actually happens we'll never know how we will react in real life, and while practice is very important we can only hope it's enough, hence my interest in additional methodologies to assist us in the event.
FP.
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Interesting, while it's been a while since I flew one I don't think I ever tried switching tanks with my right hand - always the left. Perhaps it's like the Auster flaps where some people like reaching over with their right arm, whereas others just reach straight up with their left, anyway I wonder if there's a reason why you do it this way?.
With that sort of thinking magnetos would be LEFT-OFF-RIGHT-BOTH or something like that.
In any case the Grob 115 at least is a good example of bad design. I personally know of one that has turned the fuel off and crashed as a result, thankfully they are built like F1 cars and the occupants survived with only a scratch. The fuel selectors being between the pilots but slightly behind so out of normal visual arcs.
Reminds me of the Seneca I & II having the Left mags, Landing lights and Fuel pumps all on top of each other so if you don't visually check what you are switching, you might just give yourself an engine failure while switching off the landing lights. Which is probably the cause of the Seneca accident in NW WA a while back, unfortunately that didn't end well for the pilot.
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It's a Piper Archer VH-FEY and the pilot is the owner. She has a CPL, is very capable and handled the ditching really well.
She owned that aeroplane, knew it inside out and did her hour building in it including adventures into remote areas.. She keeps meticulous fuel logs. So what happened? Maybe we'll never know, but it's been disappointing to see how many on social media have had said that being female is a contributing factor in "running out of fuel", I would dare any of them to say it to her face! Or mine!
She owned that aeroplane, knew it inside out and did her hour building in it including adventures into remote areas.. She keeps meticulous fuel logs. So what happened? Maybe we'll never know, but it's been disappointing to see how many on social media have had said that being female is a contributing factor in "running out of fuel", I would dare any of them to say it to her face! Or mine!
FWIW, my fuel management strategy is based on laziness with a dose of forgetfulness. Takeoff and climb on one tank. Once at TOC, switch to the other tank and fly for 165 minutes. At the 160 minute mark, monitor fuel pressure, have my hand on or near the fuel valve and get ready to switch. When pressure drops and engine stumbles, change tanks. No balancing the tanks, no "fly 30 minutes and swap over" while trying to remember what level is in what tank. I change once and that's it. YMMV - but I'd like to think such a method would have avoided this.
Originally Posted by The ATSB
n 20 April 2023, a Piper Archer single-engine light aircraft departed Carnarvon for a private flight to Jandakot, via Geraldton. About 10 km north of Fremantle, engine power subsided then recovered a number of times.
“Unable to maintain height, the pilot decided to turn into wind for a forced landing on the adjacent Leighton Beach, but then opted to ditch into the ocean after observing a number of people on the beach,” ATSB Director Transport Safety Stuart Macleod said.
After a successful ditching, the uninjured pilot and passenger were able to egress and swim to shore. The aircraft was substantially damaged. The ATSB’s investigation concluded the pilot had left Carnarvon with enough fuel on board for the planned flight, but did not carry out regular fuel quantity checks in accordance with regulatory guidance, or keep a written log of fuel consumed from each tank during the flight.
“The engine power issues probably occurred due to a lack of fuel in the selected right tank,” Mr Macleod said. “The pilot responded to power anomalies by carrying out some of the emergency procedures, but did not select the other – left – tank, which contained usable fuel.”
Source
“Unable to maintain height, the pilot decided to turn into wind for a forced landing on the adjacent Leighton Beach, but then opted to ditch into the ocean after observing a number of people on the beach,” ATSB Director Transport Safety Stuart Macleod said.
After a successful ditching, the uninjured pilot and passenger were able to egress and swim to shore. The aircraft was substantially damaged. The ATSB’s investigation concluded the pilot had left Carnarvon with enough fuel on board for the planned flight, but did not carry out regular fuel quantity checks in accordance with regulatory guidance, or keep a written log of fuel consumed from each tank during the flight.
“The engine power issues probably occurred due to a lack of fuel in the selected right tank,” Mr Macleod said. “The pilot responded to power anomalies by carrying out some of the emergency procedures, but did not select the other – left – tank, which contained usable fuel.”
Source
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Full report. https://www.atsb.gov.au/publications...rt/ao-2023-021
No fuel log kept and tank not changed even when the engined stopped making power. Pretty cut and dried case, but the ATSB felt the need to harp on about the fact that engine had been in service for 28 years.
“The engine had been in service for 28 years, which was more than double the recommended time before overhaul (TBO) of 12 years. Given there were no engine defects, and the required maintenance was carried out, the extended TBO was not identified as a factor in the occurrence.”
Given that this is perfectly legal and was not a factor in the incident one wonders why they had to mention it 4 or 5 times unless they have an agenda to stop the practice of running engines on condition.
No fuel log kept and tank not changed even when the engined stopped making power. Pretty cut and dried case, but the ATSB felt the need to harp on about the fact that engine had been in service for 28 years.
“The engine had been in service for 28 years, which was more than double the recommended time before overhaul (TBO) of 12 years. Given there were no engine defects, and the required maintenance was carried out, the extended TBO was not identified as a factor in the occurrence.”
Given that this is perfectly legal and was not a factor in the incident one wonders why they had to mention it 4 or 5 times unless they have an agenda to stop the practice of running engines on condition.
Apart from running the tank in use dry, it would appear. Then neglecting to change tanks while troubleshooting...Female or not. CPL or not. If you don't change tanks when you run the selected one dry, you're going to star in your very own ATSB report. And PPrune thread, too it would seem...
FWIW, my fuel management strategy is based on laziness with a dose of forgetfulness. Takeoff and climb on one tank. Once at TOC, switch to the other tank and fly for 165 minutes. At the 160 minute mark, monitor fuel pressure, have my hand on or near the fuel valve and get ready to switch. When pressure drops and engine stumbles, change tanks. No balancing the tanks, no "fly 30 minutes and swap over" while trying to remember what level is in what tank. I change once and that's it. YMMV - but I'd like to think such a method would have avoided this.
FWIW, my fuel management strategy is based on laziness with a dose of forgetfulness. Takeoff and climb on one tank. Once at TOC, switch to the other tank and fly for 165 minutes. At the 160 minute mark, monitor fuel pressure, have my hand on or near the fuel valve and get ready to switch. When pressure drops and engine stumbles, change tanks. No balancing the tanks, no "fly 30 minutes and swap over" while trying to remember what level is in what tank. I change once and that's it. YMMV - but I'd like to think such a method would have avoided this.
9 pages of pprune discussion and 7 months of taxpayer funds and effort at the ATSB to find out she ran out of fuel in one tank.
The on-condition is an interesting point, but could be a case of grandpa’s axe in many cases. It does sound like a bloody long time though, only 16 years over 12 year calendar life.
The on-condition is an interesting point, but could be a case of grandpa’s axe in many cases. It does sound like a bloody long time though, only 16 years over 12 year calendar life.
FWIW, my fuel management strategy is based on laziness with a dose of forgetfulness. Takeoff and climb on one tank. Once at TOC, switch to the other tank and fly for 165 minutes. At the 160 minute mark, monitor fuel pressure, have my hand on or near the fuel valve and get ready to switch. When pressure drops and engine stumbles, change tanks. No balancing the tanks, no "fly 30 minutes and swap over" while trying to remember what level is in what tank. I change once and that's it. YMMV - but I'd like to think such a method would have avoided this.
9 pages of pprune discussion and 7 months of taxpayer funds and effort at the ATSB to find out she ran out of fuel in one tank.
The on-condition is an interesting point, but could be a case of grandpa’s axe in many cases. It does sound like a bloody long time though, only 16 years over 12 year calendar life.
The on-condition is an interesting point, but could be a case of grandpa’s axe in many cases. It does sound like a bloody long time though, only 16 years over 12 year calendar life.
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