Cessna Aircraft Company 207, VH-LFU

The engine failed after exhaustion of the fuel from the selected
tank. Despite the pilot's engine failure recovery actions, 700 to
800 ft of altitude was lost before the engine restarted. If the
engine failure had occurred while the aircraft was below 700 ft
AGL, it would have resulted in a forced landing.

The different fuel management procedures at the two operational
bases led to the inappropriate fuel selector position for
operations from Jabiru. The pilot then overlooked the specific fuel
tank selection during the pre-flight checks, because he had an
expectation that it would already be appropriately positioned.
During both the preceding and the occurrence flight, the fuel
gauges had the potential to alert the pilot to the developing
unsafe condition. This required reliable fuel gauges and regular
comparison of their indications with planned fuel usage and fuel
tank selection.

The pilot's response to the engine failure was not consistent
with the aircraft manufacturer's or the operator's emergency and
abnormal checklist instructions. It is likely that sustained
operation of the auxiliary fuel pump introduced excessive fuel into
the engine preventing an immediate restart. Selection of the fuel
pump to the OFF position after priming the engine in accordance
with the operator's Cessna 207 emergency and abnormal checklist
should have resulted in a quicker restart with minimal altitude
loss.

Although the pilot had read the operations manual that contained
the relevant checklist, the operator did not require him to be able
to recall the specific checklist items following an engine failure.
The operator's induction training did not ensure that the pilot was
able to follow the type-specific procedure when responding to an
engine failure at a relatively low altitude. Standard operating
procedures are an accepted means of reducing the risk of aircraft
operation. By allowing the use of procedures that were inconsistent
with the operations manual, the operator reduced the effectiveness
of that risk control.

The chief pilot's belief that emergency procedures learned
during early training could be effectively applied to any general
aviation aircraft did not allow for significant variations between
aircraft systems and in particular fuel systems. For example, the
in-flight engine restart procedure for a low-wing aircraft with a
carburetted engine that is commonly used for initial flight
training is significantly different from the engine restart
procedure for the Cessna 207, which is a high-wing aircraft with a
fuel injected engine.

Induction training that facilitated memorisation of the Cessna
207 `engine failure during flight (restart procedures)' checklist
with the opportunity for in-flight simulated engine failures would
have decreased the risk of an inappropriate response to an engine
failure.

The Australian Transport Safety Bureau did not conduct an
on-scene investigation of this occurrence.

During the early afternoon of 30 August 2004, the pilot and six
passengers onboard a Cessna Aircraft Company 207 Stationair (Cessna
207) departed Jabiru, NT for a 30 minute scenic charter flight.

The pilot reported that about 10 minutes after departure and
while cruising at about 1,500 ft above ground level (AGL), the
engine abruptly failed. The pilot reset the mixture and throttle
controls, changed the selector position from the left to the right
fuel tank, switched the auxiliary fuel pump to ON and established a
glide speed of 80 kts. When the engine did not immediately respond,
the pilot positioned the aircraft for a forced landing at a nearby
outstation airstrip. At about 750 ft AGL the engine restarted.
Unsure of why the engine had lost power, the pilot continued with
the approach and transmitted a PAN alert. When assured of a landing
he shut down the engine as a precaution against fire and
landed.

The left fuel tank was found to contain no usable fuel and the
right tank about 100L. The aircraft was ferried back to Jabiru with
the right fuel tank selected and was operated on subsequent flights
without incident.

The day before the occurrence, the aircraft was relocated to
Jabiru from a remote base. The procedure at the remote base was to
use the left fuel tank for flight fuel, and the right tank for
reserve fuel. The fuel selector was positioned to the left tank
when the aircraft arrived at Jabiru. However, for scenic flights
from Jabiru the procedure was the opposite. The aircraft was
refuelled to provide 40L reserve in the left tank and 100L in the
right tank. The operator advised that these procedures were
intended to reduce the risk of fuel starvation during scenic
flights.

Early on the day of the occurrence, the pilot conducted a daily
inspection of the aircraft and by dipping the tanks, visually
confirmed that the fuel quantity accorded with the operator's
procedure. He then conducted a 30 minute scenic flight without
incident. As the total fuel on board for the occurrence flight was
adequate, the quantity of fuel in each tank was not verified
visually. The operator stated that the fuel gauges were
serviceable. However, the pilot stated that the fuel gauge
indicators constantly flickered between full and empty, which
prompted him to disregard them.

The operator's maintenance controller informed the ATSB that the
maintenance release had not been annotated with details of a fuel
gauge defect. A check following the incident revealed that the
indications on the aircraft's fuel gauges matched the dip stick
measurements for the left and right fuel tanks. He advised that the
aircraft was returned to service and there has been no report of a
fuel gauge defect.

The aircraft's fuel selector valve had LEFT, OFF and RIGHT
positions. The pilot said that, during the pre-flight cockpit
checks for both the preceding flight and the occurrence flight, he
had checked that the fuel selector was positioned to a fuel tank,
but did not realise that it was positioned to the tank containing
only reserve fuel.

The Cessna 207 `engine failure during flight (restart
procedures) checklist' in the operations manual was similar to the
corresponding procedure produced by the aircraft manufacturer.
Importantly, both identified the need to use the auxiliary fuel
pump only briefly. However, the pilot said that he had applied a
memorised generic engine failure procedure that he had learnt in
initial flight training. That procedure did not address specific
use of the auxiliary fuel pump. The pilot said that, had there been
more time after the engine failure, he would have referred to the
copy of the operations manual checklist in the aircraft.

Information provided by the operator indicated that, one week
prior to the occurrence, the pilot's induction training had
included discussion of engine failure procedures based on a generic
procedure similar to that used by the pilot. That training did not
include the Cessna 207 `engine failure during flight (restart
procedures) checklist' in the operations manual, or in-flight
simulated engine failures.

The chief pilot reported that the operator's pilots were
required to apply whatever normal and emergency/abnormal procedures
they had learnt during early training. The chief pilot stated that:
`Once learnt, I believe these checks stand a pilot in good stead
for their entire flying career in GA [general aviation] and cannot
see any reason to change that approach.' The chief pilot added
that: `… all pilots are told when time permits to use the supplied
check lists in an emergency.'

The ATSB recently completed an investigation into an engine
failure involving a similar aircraft type (Cessna 206, ATSB report
200402049). Although there was fuel on board and no identified
aircraft defects, the engine did not restart. The four occupants
were seriously injured during the subsequent forced landing. The
investigation found that the in-flight engine restart procedures
published by the aircraft manufacturer were not followed.