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10th of June 2013, fuel exhaustion, Blog #655

A 42-year-old Beechcraft King Air was scheduled to operate a test flight to check the rudder trim indicator and to confirm a reported autopilot-GPS issue. The pilot performed an external walk-around of the aircraft and completed the procedures to get the aircraft ready for flight. The flight was operated as a VFR (Visual Flight Rules) flight and would last 15 to 20 minutes. Besides the pilot, an engineer and two passengers were on board.

The aircraft in its final position (Source; baaa-acro.com ©D. St-Pierre)

The engines were started at approximately 16.53 lt (local time), after which the aircraft taxied to the runway at Montreal-St. Hubert Airport (Quebec, Canada). At 17.00 lt the aircraft lifted off from the runway. less than 15 minutes later the tests were completed and the aircraft set course for Montreal-St. Hubert Airport, for which a simulated ILS approach to runway 24R was requested, and approved by ATC.


While returning the pilot noticed that the propellor sound changed and a RH FUEL PRESSURE light came on. He then also noticed that the gauges for the nacelle fuel tanks indicated 'E' (Empty). The crossfeed valve was opened and the auxiliary boost pumps were switched on.

The fuel panel as found by the TSB (Source & © TSB)

As the aircraft intercepted the localizer at an altitude of 2800 feet for Runway 24R the right-hand engine flamed out. At that time the aircraft was 2,5 nm northwest of St-Mathieu-de-Beloeil Airport and was chosen by the pilot as the diversion airport, for which ATC cleared them.

The aircraft in its final position (Source; baaa-acro.com ©D. St-Pierre)

Just 19 seconds later the left engine also flamed out as the pilot was turning towards their diversion airport, the speed dropped to 110 knots.

Less than a minute later at an altitude of 1600 feet, the landing gear was lowered and the stall warning horn sounded. (in the following 10 seconds it would sound 3 more times). Just under a mile from Runway 15 at St-Mathieu-de-Beloeil Airport at an altitude of only 450 feet AGL, the pilot concluded that they would make the airport and decided for an off-field landing in a field. The pilot informed the passengers of the imminent emergency landing.

Close-up of the damaged aircraft (Source; Aviation-Safety.net ©G. Blanc)

Just before touchdown an aerodynamic stall occurred, the right wingtip struck the ground at an 45º roll-angle. The aircraft hit a fence and a three before violently striking the ground. It continued for another 120 feet before coming to a stop. All occupants sustained minor injuries but were able to evacuate the aircraft via the emergency exit on the righthand side of the severely damaged aircraft.


The Transportation Safety Board of Canada (TSB) was alerted and an investigation into the accident was started. During the investigation, it became apparent that several issues caused the accident varying from pilot error to ineffective processor at Transport Canada. In their report (available as .pdf file below this blog) the TSB listed the following findings as to causes and contributing factors;

  1. The pilot relied exclusively on the gauge readings to determine the quantity of fuel on board, without cross-checking the fuel consumption since the last fuelling to validate those gauge readings.

  2. The pilot misread the fuel gauges and assumed that the aircraft had enough fuel on board to meet the minimum fuel requirements of the Canadian Aviation Regulations for this visual flight rules flight, rather than adding more fuel to meet the greater reserves required by the company operations manual.

  3. The pilot did not monitor the fuel gauges while in flight and decided to extend the flight to carry out a practice instrument approach with insufficient fuel to complete the approach.

  4. The right engine stopped due to fuel exhaustion.

  5. The pilot did not carry out the approved engine failure procedure when the first engine stopped, and the propeller was not feathered, resulting in significant drag which reduced the aircraft’s gliding range after the second engine stopped.

  6. The pilot continued flying toward Montréal/St-Hubert Airport (CYHU), Quebec, despite having advised air traffic control of the intention to divert to the St-Mathieu-de-Beloeil Airport (CSB3), Quebec, and without communicating the emergency. The priority given to communications resulted in the aircraft moving farther away from the intended diversion airport.

  7. The left engine stopped due to fuel exhaustion 36 seconds after the right engine stopped when the aircraft was 7.4 nautical miles from Runway 24R at Montréal/St-Hubert Airport (CYHU), Quebec, and 2400 feet above sea level.

  8. The pilot’s decision to lower the landing gear while the aircraft was still at 1600 feet above sea level further increased the drag, reducing the aircraft’s gliding range. As a result, the aircraft was not able to reach the runway at St-Mathieu-de-Beloeil Airport (CSB3), Quebec.

  9. The operations manager was unable to perform the duties and responsibilities of the position related to monitoring and supervision of flight operations. As a result, the safety of more than half of the flights was compromised.


Besides these findings as to causes and contributing factors, there were also 21 additional findings (18 findings as to risk and 3 other findings). Check them out in the .dpf file below which served as the source for this blog;


02Jun2005 800XP Rigging Error
.pdf
Download PDF • 439KB



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