Investigation number
200403210
Occurrence date
Location
19 km NE Jabiru, (ALA)
State
Northern Territory
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence category
Fuel starvation
Occurrence class
Incident
Highest injury level
None

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.

Aircraft Details
Manufacturer
Cessna Aircraft Company
Model
207
Registration
VH-LFU
Serial number
20700296
Operation type
Charter
Sector
Piston
Departure point
Jabiru, NT
Departure time
1303 hours CST
Destination
Jabiru, NT
Damage
Nil