This report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability.
Aircraft Registration: ZS-JOA
Date of Accident: 13 November 2010
Time of Accident: 1007Z Type of Aircraft Piper-PA-31P-350 Chieftain
Type of Operation: Test Flight Pilot-in-command
Licence Type: Commercial
Licence Valid: Yes Flying experience: Total 843.3 Hours on Type: 42.3
Previous Accidents: On 10 January 2007 at Wonderboom aerodrome, a Piper PA-30 piloted by the pilot cart-wheeled.
Last point of departure: Lanseria (FALA)
Next point of intended landing: Lanseria (FALA).
Location of the accident site: On a farm Skeerpoort valley at GPS S25°56 ΄38.81 E027°48 ΄30.15.
Meteorological Information: Visibility, CAVOK: Temperature: 22°C.
On Saturday 13 November 2010, the pilot in command, with a valid test pilot Class 2 rating accompanied by two passengers, an AME, and a pilot not rated on aircraft type, departed Lanseria for a test flight in the local flying area after maintenance was conducted on the aircraft. According to the test pilot a thorough preflight inspection was performed before takeoff and the aircraft fuel quantity gauges indicated more than half full.
Start clearance was obtained from the Air Traffic Control and both engines started normally. The aircraft was taxied to threshold of runway 06L and pre-takeoff checks were carried out. Takeoff clearance was obtained and the PF commenced with the takeoff run. After exiting FALA CTR at 7 000 feet AMSL, the aircraft turned left towards Hartebeespoort Dam.
The PF reported that after 14 minutes flight time, the aircraft experienced an electrical failure and he immediately requested FALA tower to obtain inbound clearance. The aircraft turned towards FALA when the left engine started to splutter and subsequently stopped. The PF flew the aircraft on one engine and after a few minutes the right engine also stopped. The aircraft started to lose altitude and the PF immediately identified an open field with the intention to execute a forced landing. The PF lowered the undercarriage manually and maintained 120 mph indicated air speed. The PF reported that as the aircraft approached the area identified, he kept lowering the nose with the intention to maintain gliding speed with the flaps retracted.
The aircraft touched down on a rocky terrain and the undercarriage subsequently collapsed. The aircraft skidded for approximately 70 metres before it came to rest with the nose facing in a Westerly direction. After the aircraft came to rest the PF immediately switched OFF the master and ordered the passengers to exit the aircraft. The passengers disembarked unharmed and the aircraft was substantially damaged during the forced landing.
The PF exited the aircraft with back injuries and was later airlifted to 1 military hospital. The engineer immediately retrieved the aircraft hand held Halon fire extinguisher in case a fire started and disconnected the battery. The aerodrome crash alarm was activated and emergency response services quickly rushed to the scene to render some assistance and secure the area.
The aircraft fuel gauge readings were not accurate.
NOTE: According to the Airframe Logbook, the fuel gauges were calibrated on 14/05/2010. Six months previously.
Tests and Research: On-site investigation revealed no evidence of fuel leakage or spillage from either side of the aircraft and on the ground. Fuel tank caps were secured and were later opened for inspections using a dip stick where after no evidence of fuel was found. All fuel lines and fittings were inspected for cracks, leaks and loose attachments and none were found. On-site investigation revealed that the aircraft fuel gauge readings were not accurate.
According to the aircraft flight folio, 400 Litres avgas (105 USG) was uplifted at Kitty Hawk aerodrome on 23 July 2010. The endurance is 105 USG ÷ 42 = 2.5 hours. The aircraft was then ferried from Kitty Hawk to Lanseria for maintenance purposes with a flight time of 0.4 hrs (24 min). On 06 November 2010, the aircraft was flown on a test flight with a flight time of 0.6 hrs (36 min). On 10 November 2010, the aircraft was again flown on a test flight with a flight time of 0.3 hrs (18 min).
The aircraft was on the ground for approximately 3 months and 14 days. On November 2010, the aircraft was flown on the third test flight after the last MPI. The aircraft was airborne for approximately 14 minutes when the pilot experienced engine failures that was found due to fuel exhaustion. In order to determine the fuel that was consumed the following calculation was made: 400 litres (105 USG) ÷ 42 USG/hr = 2.5 hours endurance. The aircraft was then flown a total of 0.4 hrs (24 min) + 0.6 (36 min) + 0.3 hrs (18 min) during the ferry flight and the two test flight prior to the third test flight when the accident occurred: 2.5 hours endurance – 0.4 + 0.6 + 0.3 hrs flown = 2.5 – 1.3 = 1.2 hrs (+/- 50 USG) endurance remaining for the third test flight.
It later came to the attention of the investigator in charge (IIC) that an aircraft maintenance engineer overheard the pilot who was on board but not rated on the aircraft at FALA asking the test pilot how much fuel the aircraft had prior departure. The test pilot responded by saying 400 litres of aviation gasoline (Avgas LL 100) was uplifted at Kitty Hawk prior to ferrying the aircraft to FALA for maintenance. The test pilot also mentioned that only two short test flights were flown afterwards. The passenger again asked if he should add fuel just in case. The test pilot answered by saying that there should be about two hours worth of fuel in the tanks and that they will only be flying for an hour maximum.
According to CARS Chapter 91.07.12:
The pilot-in-command of an aircraft shall not commence a flight unless he or she is satisfied that the aircraft carries at least the planned amount of fuel and oil to complete the flight safely, taking into account operating and meteorological conditions and the expected delays.
The pilot-in-command shall ensure that the amount of usable fuel remaining in-flight is not less than the fuel required to proceed to an aerodrome where a safe landing can be made. If the usable fuel on board the aircraft is less than the final reserve fuel, the pilot-in-command shall declare an emergency.
The fact that the other passenger was questioning the fuel state, it is possible that the aircraft had only small amount of fuel left. The PF took a chance, ran out of fuel and lied afterwards about “half full” gauges. For unknown reasons the aircraft was defueled during the time it was not flying.
The pilot did not visually or by means of dip stick inspect the amount of fuel remaining in the aircraft fuel tanks and there is a possibility that the aircraft fuel gauges were faulty.
A superior pilot uses his superior judgment to avoid having to use his superior skill.
A superior pilot uses his superior judgment to avoid having to use his superior skill. In this case, you don’t need superior judgement to know it’s idiotic to take off when you don’t know how much fuel is in the tanks. A child of three could advise you on this.
Fuel is not a guessing game – it’s a numbers game. And we are talking very simple numbers that most people can do in their head. For example, 50 gallons at ten gallons per hour will last for five hours. Call it four hours to be safe. It could hardly be easier. Once you start juggling minutely accurate figures the chances are you need more fuel or shorter legs.
In this case the CAA’s calculations are a waste of time for two reasons:
1. They are based on a thumb-suck 42 GPH. In reality a Chieftain drinks 60 GPH in the climb and as little as 30 GPH in the cruise. They tell us that since refuelling the aircraft had done a ferry flight and two test flights. They don’t tell us whether the duration of these flights was tachometer time, Hobbs time or start-up to switch-off time. And there is no way of guessing fuel consumption on a test flight.
2. The calculations are rendered void by CAA’s own comment that the aeroplane was de-fuelled “for unknown reasons” during its more than 100 days in the AMO.
And that’s an interesting comment. Would I bet my life on the belief that no one had taken fuel out of the tanks while the aircraft languished in the hangar for all that time? I think not – but this pilot did. And he was wrong.
In the pilot’s defence – and it is a very weak defence – it’s almost impossible to tell how much fuel is in the tanks of a Chieftain. The report notes that the pilot did not check the tanks visually or use a dipstick. But that’s a pretty silly comment – you wouldn’t expect to see the fuel, visually, or on a dip-stick unless the tanks are almost full.
The first thing every pilot learns about a Chieftain – is that its fuel gauges are a joke. And the next thing you learn is that the countryside is scattered with Chieftains that have run out of fuel. So the CAA’s comment that the pilot “took a chance” is insightful, if somewhat crudely put.
What would I have done in this pilot’s shoes? I would have said, “I have no idea how much fuel is in the tanks, and there is no easy way of finding out. So, for a short local flight I will put a drum (50 US gallons or 200 litres) of fuel in each side.”
With these accidents I always like to ask myself whether I would have happily sat in the back seat of the aircraft. This is a surprisingly useful exercise, because we can use it for our own flying. Take stock of all the facts BEFORE you fly – it’s a good indicator of whether one should takeoff.
And if you learn to see trouble building up before someone else’s flight, surely you can do it for your own flying. As my mate Chalkie always says, “Takeoff is optional.” Wise words indeed.
So let’s look at this one. Here’s what we know before the flight.
1. This is a post-maintenance test flight
2. The aircraft has been out of service for a long time
3. The Chieftain is a reasonably fast, complex aeroplane
4. The Commercial pilot, although nearly 50, has only logged 843 hours
5. The pilot has already had one accident in a twin
6. Chieftain fuel gauges are notoriously unreliable
7. The co-pilot is worried about the fuel state
8. No one knows for certain how much fuel is in the tanks
The first seven points are a bit ho-hum but the last one is a clincher. The pilot was well aware of all these points, so I have to ask myself why would he NOT refuel? I can think of five reasons off the top of my head.
1. The aeroplane would have been too heavy. Not a chance.
2. The pilot didn’t have the money to buy fuel. Possible – but not worth risking your life for.
3. The pilot knew for certain that he had enough fuel. This was not the case.
4. The pilot was prepared to take a fat chance. Now we are getting there.
5. The pilot was in a hurry, or too lazy. Almost certainly. If a fairy had offered to refuel the aircraft with a wave of her… I suspect our pilot would have grabbed the offer.
This guy used his inferior judgement to put himself in a position where he has to glide at 120 mph in order to do an unnecessary forced landing in hostile territory. Madness.
Now I am going to do some bragging for which I make no apology. In a lifetime of flying, I have done some stupid, even reckless things, but I have never ever been worried about my fuel state. Not once.
Actually it’s not much to brag about is it? You simply have to ask, “Do I want to scare myself, or shall I just chuck some fuel in?” Not a difficult question. This is the sort of decision that the Live Cowards’ Club (LCC) members make every day.
It turns flying from fear into fun.
What can we learn?
The lessons are so obvious it’s embarrassing to list them. But for those who were practicing their speed-reading above, here they are again in slow, thoughtful reading:
• Before flying review all the potentially negative stuff
• Never be in a hurry around aeroplanes
• With fuel there is no such thing as “maybe”
• Always be wary of post-maintenance flights
• Conduct post maintenance flights within gliding distance of the field. This has often saved my bacon
• If it’s a matter of fuel or cargo – you know which one takes precedence
• Fuel calculations are simple – if they get complicated there is simply not enough
• Never trust your life on light aircraft fuel gauges
• Takeoff is always optional