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Date: | Tuesday 26 June 2007 |
Time: | 08:30 |
Type: | Embraer EMB-120ER Brasilia |
Owner/operator: | Skippers Aviation |
Registration: | VH-XUE |
MSN: | 120115 |
Year of manufacture: | 1988 |
Fatalities: | Fatalities: 0 / Occupants: 31 |
Other fatalities: | 0 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | Jundee Aerodrome -
Australia
|
Phase: | Approach |
Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
Departure airport: | Perth Airport, WA (PER/YPPH) |
Destination airport: | Jundee, WA |
Investigating agency: | ATSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:The EMB-120ER aircraft, registered VH-XUE, departed Perth, WA on a contracted passenger charter flight to Jundee Airstrip. There were two pilots, one flight attendant, and 28 passengers on the aircraft.
While passing through 400 ft above ground level on final approach to Jundee Airstrip, with flaps 45 set, the aircraft drifted left of the runway centreline. When a go-around was initiated, the aircraft aggressively rolled and yawed left, causing the crew control difficulties. The crew did not immediately complete the go-around procedures. Normal aircraft control was regained when the landing gear was retracted about 3 minutes later.
The left engine had sustained a total power loss following fuel starvation, because the left fuel tank was empty.
Contributing safety factors:
• Regulatory guidance regarding the measurement of fuel quantity before flight lacked clarity and appropriate emphasis and did not ensure that the fuel quantity measurement procedures used by operators included two totally independent methods. [Safety issue]
• The practices used by the operator’s pilots for measuring and logging of fuel quantity were inconsistent. [Safety issue]
• Faults within the fuel quantity indicating system caused the left fuel quantity indicator to over-read.
• The left engine lost power when the fuel in the left tank was exhausted.
• The flight crew did not detect the engine power loss.
• The aircraft became misaligned with the runway.
• The flight crew did not complete the go-around procedure actions.
• There was a significant delay before the crew configured the aircraft appropriately for one-engine inoperative flight.
• The absence of simulator training meant that the endorsement and other training the flight crew had undergone did not adequately prepare them for the event. [Safety issue]
• There was no regulatory requirement for simulator training in Australia. [Safety issue]
• The minimum requirements for endorsement training where simulator training was not involved did not ensure pilots were aware of indicators and/or aircraft behaviour during critical emergency situations. [Safety issue]
• The aircraft operator was not aware of important safety-related information regarding the EMB-120 fuel system. [Safety issue]
Accident investigation:
|
| |
Investigating agency: | ATSB |
Report number: | |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
https://www.atsb.gov.au/publications/investigation_reports/2007/aair/ao-2007-017.aspx Revision history:
Date/time | Contributor | Updates |
20-Feb-2017 19:38 |
TB |
Updated [Narrative] |
10-Jun-2020 06:47 |
Aviationfan100 |
Updated [Total occupants, Phase] |
10-Jun-2020 06:50 |
harro |
Updated [Narrative, Accident report, ] |
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