CAA ACCIDENT REPORT SUMMARY: Cessna 177 (Cardinal)
Date of accident: November 28 2009
Time of accident: 0955Z (1155 local time)
Aircraft registration: ZS-JXD
Type of aircraft: Cessna 177 (Cardinal)
Pilot age: 43
Licence type: PPL
Pilot-in-command flying experience: Total flying hours: 136.0
Hours on Type: 35.0
Last point of departure: Stellenbosch Aerodrome (11 NM E of Cape Town)
Next point of intended landing: Stellenbosch Aerodrome
Location of the accident site: 5 NM NE of Fisantekraal (14 NM NNE of Cape Town)
Meteorological information: 20ºC, CAVOK, wind calm
Number of people on board: 1+3
Number of people injured: 0
Number of people killed: 0
The pilot took off with three passengers from Stellenbosch Aerodrome on a private flight
to the general flying area.
The pilot stated that he refuelled the aircraft before the flight and that the dipstick indicated that the right-hand tank was 3/4 full and the left-hand tank 1/2 full, with an estimated endurance of 3h30min. The flight was planned to be 2h15 minutes. The pilot stated that while en route back to Stellenbosch, the engine started to “stutter” (run rough) and that he then decided to land at Fisantekraal.
The pilot experienced a complete loss of power and executed a forced landing on an open field. The aircraft landed hard, causing the nose wheel to break off and the right-hand wing tip to impact the ground. The pilot and two passengers were not injured during the incident. The Air Mercy Services (AMS) helicopter arrived on site and one of the passengers was treated for a bruised arm.
The accident was attributed to an unsuccessful forced landing after fuel exhaustion. Contributory factors:
1. Poor pre-flight planning and not ensuring that the aircraft had sufficient fuel on board.
2. The pilot used an incorrectly calibrated dipstick to measure the fuel for the flight. The aircraft had two dipsticks with the same aircraft registration on them.
This is a very interesting one because it appears to go against my generalisation that with light aircraft accidents you can normally blame either the pilot or the aircraft. In this case I initially thought that neither was at fault. However on reflection, I guess the dipstick is as much part of the aircraft as is the Pilot’s Operating Handbook (POH) and the weight and balance graphs and the Certificate of Airworthiness and so on. If it is not the correct one for that aeroplane then the aeroplane is deficient. In practice I blame the flying club from which the aircraft was hired. It was poor management to have allowed the aircraft to contain two different dipsticks.
This brings me to a more modern and sophisticated approach to accident investigation. It uses the five Ms – Medium, Machine, Mission, Man, and Management. So in this case I would say poor management was the basic problem.
Further, I think the CAA has treated the pilot disgracefully. In my book, when you walk away from a forced landing with no injuries – then it is a successful forced landing. And how can they blame the pilot for poor pre-flight planning when the aircraft was equipped with the wrong dipstick?
In paragraph 2.2 of the body of the report (not shown here) it says: The pilot ignored the fuel gauges, as he knew that they were unreliable. The pilot did not do a proper flight planning as he ignored the discrepancies between the dipstick and the gauges.
I can make no sense of this. Of course the pilot ignored the discrepancies between the unreliable gauges and the dipstick. What else is he meant to do – believe the gauges? In my view the pilot is to be complimented, not condemned.
Remember the ‘Gimli Glider’ – the Air Canada Boeing 767 that ran out of gas and glided to a safe landing on a disused strip. They had known problems with the fuel gauges so they used float-sticks (fancy dipsticks) – exactly what this PPL did. The problem is that the 767 crew then made a mess of converting from imperial to metric quantities. Instead of 22,300kg of fuel, they had 22,300 pounds on board (a little over 10,000kg) which was less than half the amount needed to reach their destination.
If they can stuff it up that badly we can hardly blame a poor, low-time PPL who did the sensible thing to ensure he had enough gas.
Well done to him for not letting other peoples’ errors kill him and his pax.
What can we learn?
There is certainly a lesson here for flying club and air school operators – make sure that the equipment and documentation in the aircraft are correct for that specific aircraft, and are accurate, up to date and serviceable.
For pilots, if it’s an aeroplane you fly regularly – why not get your own dipstick and keep it in your nav-bag? With Cessnas it’s difficult to peer into the tanks because you don’t always have a ladder, and the strutless ones give you nothing to stand on. I love the Cherokees for their ease of checking and for the very useful little tab in the tank.
Jim Davis has 15,000 hours of immensely varied flying experience, including 10,000 hours civil and military flying instruction. He is an established author, his current projects being an instructors’ manual and a collection of Air Accident analyses, called Choose Not To Crash. Visit Jim's website by clicking here.
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