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The pilot of a Piper PA-31 that made a forced landing near a Brisbane railway line last year had been awake for almost 20 hours, the ATSB has found.
VH-HJE ran out of fuel en route from Bankstown to Archerfield on 7 April 2023 on the return leg of a freight charter flight, the ATSB said in its final report. It struck multiple trees on its way down, sustaining “substantial” damage but inflicting only “very minor injuries” to the pilot.
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“Although the pilot reported changing from the auxiliary tanks to the main fuel tanks prior to descent, the quantity of fuel recovered from each tank after the accident, and fuel burn calculations, indicated that those selections had probably not been made and both engines lost power as a result of fuel starvation,” said ATSB director of transport safety Dr Stuart Godley.
According to the ATSB, as the plane was approaching Archerfield, the pilot observed a loss of engine power from the right engine, and then the left engine.
“Unable to reach Archerfield, the pilot conducted a gear-up forced landing alongside a railway line,” Godley said.
Post-accident inspections found no indication of a mechanical failure that could have caused the engines to fail. The ATSB investigation report notes that the pilot misdiagnosed the loss of engine power as a partial power loss, and did not carry out the loss of engine procedure.
“Following the first power loss on the right engine, the right propeller was not feathered, resulting in excessive drag,” Godley said.
The pilot operated the return flight late at night after working in outside employment during the day.
“A review of the pilot’s sleep history found that it is likely that the pilot was experiencing a level of fatigue shown to have an effect on performance,” Godley said.
“In this case it is likely that fatigue impacted the pilot’s incorrect tank selection as well as their ability to troubleshoot the loss of power.”
Following the accident, the aircraft operator issued a notice to aircrew and conducted a review of pilot training to include the recognition and management of fuel starvation, and updated its fatigue management manual to include external employment and restrictions around hours of work and duty times.
Godley said the occurrence highlights to pilots the importance of understanding their aircraft’s fuel system and being familiar with and proficient in its operation.
“During a power loss event, pilots should take the time to determine whether a total failure has transpired or if the engine is still delivering some power,” he said.
“While this may not be clearly apparent in all configurations, the consequences of misdiagnosing a failed engine can be fatal.”
Godley added that fatigue management is “a joint responsibility between the operator and the pilot”.
“This accident also reinforces the importance of obtaining some sleep during the day prior to commencing operations at night during normal periods of sleep.”
