aircraft serious incident investigation report
Contents
1. rin m AVOID CONTINUOUS OPERATION BETWEEN 1850 AND 2150 RPM ABOVE 24 IN MP Fuel Flow Indicator 17 Attachment Records of Radio Transmission Legend Tokyo Info Tokyo Information Tokyo FSC s call sign Yokota A D Yokota Approach Departure Note The aircraft s radio transmission with Yokota Tower is omitted because it took place after the landing Time Radio Station Transcription 3 26 29 JA3818 Ah Tokyo Information This is JA3818 Good afternoon 3 26 36 Tokyo Info 3818 Tokyo Information Go ahead 3818 present position about 20 nm northwest of Nagano city 9 500 ft operation normal 3 26 39 JA3818 Request destination change from Niigata to Matsumoto Also requests ramp use permission Over s e A3818 20 nm north west of Nagano Destination change from Niigata to Matsumoto s Standby for the permission 3 27 14 JA3818 Roger Matsumoto ETA will be 0450 3 27 23 Tokyo Info Matsumoto ETA 0450 roger 3 28 07 Tokyo Info A3818 let me confirm Destination change due to the weather 3 28 15 JA3818 3818 ah due to refuel Survey flight took more than expected Over 3 28 24 Tokyo Info Jue to refuel roger that The following coordination was done over telephone 13 29 Airport office this is AAAA Matsumoto airport office Tokyo FSC Hello this is BBBB Tokyo FSC Airport office Yes what can I do2. Category of airworthiness Airplane Normal N or Special X Total flight time 6 155 hr 50 min Flight time since last periodical check 12 hr 15 min Six month period check on October 6 2010 See Figure 2 Three Angle View of Cessna TU206G Engine Type Continental TSIO 520 M 2 3 3 2 4 2 5 2 6 2 6 1 2 6 2 Serial number 283267 R Date of manufacture August 3 1992 Total time in service 1 243 hr 58 min Weight and Balance When the serious incident occurred the airplane s weight was estimated to have been 3 050 pounds and its center of gravity CG was estimated to have been 48 4 inches aft of datum line both of which were estimated to have been within the allowable range maximum takeoff weight of 3 600 pounds and CG 42 5 to 49 7 inches corresponding to the weight of the airplane at the time of the serious incident Meteorological Information The aerodrome routine meteorological reports METAR for Yokota Airfield close to the time of the serious incident were as follows 13 55 Wind direction 070 Wind velocity 3 kt Visibility more than 10 km Cloud Amount FEW 1 8 2 8 Cloud base 18 000 ft Temperature 18 C Dew point 9 C Altimeter setting QNH 30 25 inHg Information on the Fuel and Lubricant The fuel used in the airplane was aviation fuel 100 The lubricating oil was Exxon 20W 50 MIL L 22851D Study on Fuel Starvation and Fuel Quantity Indication Fuel Starvation and Engine Competence The IIC confirme
3. for you Tokyo FSC Well I ve received a permission request for you Airport office TYes Tokyo FSC Well the registration is JA3818 Airport office 13818 Tokyo FSC Ah airplane type is Cessna 206 Airport office 1206 Tokyo FSC Matsumoto ETA is 0450 Airport office TAt 50 Tokyo FSC That s the ETA The airplane s original destination was Niigata Airport office TYes Tokyo FSC The airplane wants to land at Matsumoto for refueling Airport office I understand Ah I m afraid all ramp slots are booked today Tokyo FSC Oh Airport office Yes Tokyo FSC Ok convey your message to the pilot Airport office Yes Thank you Tokyo FSC Ok Good day 13 30 Airport office Thank you The radio transmission between the aircplane and Tokyo Info 3 30 16 Tokyo Info JA3818 Tokyo Info over 3 30 18 JA3818 This is 3818 go ahead Well I ve confirmed that the ramp slots are all booked at Matsumoto and it can not AYA accept your request May 1 have your intention 3 30 34 A3818 Stand by please 3 32 38 A3818 Tokyo nformation 3818 3 32 42 Tokyo Info Tokyo Information 3 32 45 JA3818 Ah I ve decided to fly back to Chofu ETA is 0515 3 32 57 Tokyo Info JA3818 flies back to Chofu understood ETA 0515 Ah have a nice flight 18 13 33 03 A3818 Radio transmission between the airplane and Yokota A D Ah Yokota Radar JA3818 good afternoon JA3818 Yokota Departure squawk five four six ze
4. if flown at 110 knot However because PIC s remaining fuel calculation was almost the same as the fuel gage indication it is probable that he thought it would be possible to fly back to Chofu Airfield although some of the reserve fuel would be consumed b Fuel management The fuel gage should indicate the remaining fuel quantity with reasonable error margin however with possibilities of indication system malfunction and fuel leak pilots have to without relying on fuel indication check remaining fuel based on elapsed time and FCR have a refueling plan at alternate aerodrome and 10 3 6 3 7 decide where to get it sooner in order to have enough reserve fuel Response of Tokyo FSC and Reception of Matsumoto Airport a Response of Tokyo FSC Tokyo FSC working as an intermediary between the PIC and Matsumoto Airport Office conveyed the PIC s request to the Matsumoto Airport Office made coordination and conveyed the Office s response to the PIC however it is probable that the FSC was not able to recognize the urgency of the PIC s request because the PIC did not show strong necessity of refueling Matsumoto Airport Office The person who was in charge of ramp slot management probably did not feel the urgency for the airplane s refueling while all ramp slots but No 4 were booked so that he replied to the FSC saying that all the slots are booked It is probable that the PIC s intention of refueling was not strong en
5. is zero at empty 1 2 gallons at points less than indication 11 5 gallons 2 gallons at other points meaning that the indications of both fuel indicators were out of standard at empty and 11 5 gallons 2 7 Additional nformation 2 7 1 Quantity of Fuel Onboard The Company s Airplane Operational Standard for Cessna TU206G stipulates the onboard fuel as follows excerpts 7 5 Calculation of onboard fuel Onboard fuel at the time of departure is calculated as follows VFR Ground taxi fuel Climb fuel Cruise fuel Reserve fuel 45 minutes Example for a cruise at 8 000 feet 2 400 rpm 24inHG Standard Air Temperature 1 C TIME QUANTITY Ax 26641 CLIMB 44 GAL CRUTSE 5 hr 26 min 71 2 GAL RESERVE 11 3 GAL TOTAL 6 hr 24 min 88 9 GAL 2 7 2 Airplane s Fuel Consumption Rate for Ordinary Flight Operations a The PIC s fuel consumption rate FCR taxi fuel inclusive based on his experience was 15 gallons per hour The PIC flies for 30 minutes with the fuel selector set to the tank at the time of takeoff Then he changes tanks every hour afterwards Usable fuel One wing tank stores 46 gallons of fuel with 2 gallons of unusable fuel making the total usable fuel 88 gallons Record of fuel feed The airplane was filled up on October 16 No flight was made until 23rd except an engine run up by a mechanic on 18th The PIC believed that the onboard fuel at the time of his engine start on 2
6. said that he had an airplane requesting a refueling stop there The Office replied saying that all the ramp slots are booked that day The FSC receiving this reply relayed the message to the airplane and asked its intentions 13 33 The PIC replied that he would return to Chofu Airfield and changed its heading for Chofu at the point 47 kilometers north of Matsumoto Airport 13 57 The PIC changed radio frequency to Yokota Airfield at the point 35 kilometers northwest of Chichibu City and established a radio contact with the airfield 14 10 The PIC declared a state of emergency 4 kilometers northwest of Yokota x2 ESC stands for Flight Service Center It is one of organizations of the Ministry of Land Infrastructure Transport and Tourism MLIT and is located at eight major airports in Japan It provides necessary information for airplane operations 2 1 2 3 Airfield and requested a landing there 14 11 The PIC changed his mind to land at Tachikawa Airfield and withdrawn his emergency declaration 14 12 The PIC changed his mind again and declared a state of emergency again 14 13 The airplane landed at Yokota Airfteld See Figure 1 Estimated Flight Route Attachment Radio Communication Records History of Flight by Statements of PIC The PIC came to his office at 08 00 and did preflight preparations such as vveather check filing a flight plan and preflight inspection The amount of fuel on board vvas about 86 gallons equivalen
7. 4th was about 86 gallons because about 2 gallons of fuel was consumed by engine run ups on 18th and 24th FCR calculated from the flight time and the consumed fuel amount The airplane s FCR was calculated to be 17 6 gallons per hour from the accumulated flight time of 13 months from August 2010 to August 2011 and consumed fuel amount thereof 2 7 3 Occupation of Ramp Slots at Matsumoto Airport a There are 14 ramp slots at Matsumoto Airport three for scheduled airlines No 1 to No 3 and 11 for small aircraft No 1 to No 11 Among slots for small aircraft No 1 is reserved for the Nagano Prefectural Police Aviation Unit No 3 for a helicopter of Nagano Prefectural Fire Disaster Prevention Aviation Unit Slots No 4 No 5 and No 11 are for twin engine airplanes 4 Civil Aeronautics Act of Japan requires air transport airplane and IFR airplane to carry certain amount of reserve fuel in article 63 On the other hand Part 11 2 2 3 6 ICAO Annex 6 and FAR 95 151 stipulate that a VFR airplane should carry reserve fuel for 30 minute daytime flight and 45 minute nighttime flight after arriving its destination FAR 91 applies to all the airplanes which fly in the U S A while the Annex 6 Part II to all the airplanes for international general aviation except air transport and aerial work airplane ay fate However slots No 4 and No 11 are usually not in use No 4 due to downwash generated by helicopter parked at No 3 slot No 11 du
8. AT2012 2 AIRCRAFT SERIOUS INCIDENT INVESTIGATION REPORT KAWASAKI AIR Co Ltd J A 3 8 1 8 March 30 2012 Japan Transport Safety Board The objective of the investigation conducted by the Japan Transport Safety Board in accordance with the Act for Establishment of the Japan Transport Safety Board and with Annex 13 to the Convention on International Civil Aviation is to prevent future accidents and incidents It is not the purpose of the investigation to apportion blame or liability Norihiro Goto Chairman Tapan Transport Safety Board Note This report is a translation of the Japanese original investigation report The text in Japanese shall prevail in the interpretation of the report AIRCRAFT SERIOUS INCIDENT INVESTIGATION REPORT KAWASAKI AIR CO LTD CESSNA TU206G 818 2 000 FT OVER THE BUILT UP AREA 2 KM SOUTHEAST OF YOKOTA AIRFIELD AT 14 12 LOCAL TIME OCTOBER 23 2010 February 24 2012 Adopted by the Japan Transport Safety Board Chairman Norihiro Goto Member Shinsuke Endoh Member Toshiyuki Ishikawa Member Sadao Tamura Member Yuki Shuto Member Toshiaki Shinagawa 1 PROCESS AND PROGRESS OF THE INVESTIGATION 1 1 Summary of the Serious Incident The occurrence covered by this report falls under the category of Shortage of fuel requiring urgent measures as stipulated in Clause 12 Article 166 4 of the Ordinance for Enforcement of the Civil Aeronautics Act and is classified as a serious in
9. PIC s statement in 2 1 2 it is probable that he decided to fly back to Chofu Airfield at 13 30 4 hours and 25 minutes into the flight With the FCR 15 gallons per hour described in 2 7 2 a it is calculated that 66 3 gallons of fuel had been consumed then and the remaining fuel was 19 7 gallons The PIC stated that he thought the airplane could fly about one hour with the remaining fuel judging from the fuel indicator reading of 16 to 17 gallons because the fuel was consumed as he calculated Without knowing the fuel indicator error which read more than actual quantity he thought it possible to fly back to Chofu Airfield as the fuel quantity indication and his calculation result matched However the fuel ran out in 43 minutes so that the airplane could not make it to the airfield which was 45 minutes away With 83 4 86 2 6 gallons of usable fuel quantity onboard fuel at takeoff subtracted by taxi fuel and 5 hours and 8 minutes of airborne time takeoff at 09 05 landing at 14 13 we get the actual FCR as 16 2 gallons per hour With this FCR actually consumed fuel and remaining fuel at 13 30 becomes 71 6 gallons and 11 8 gallons respectively This means that the remaining fuel was about 8 gallons fewer than the PIC s calculation and fuel quantity indication As described in 2 7 2 d average FCR for 13 months from August 2010 was 17 6 gallons per hour Given this fact it is possible that the FCR at the time of the serious incident occur
10. an while considering weather condition and aerial survey flight profile and such The Company did fuel gage calibration for all airplanes and installed new indicators to some airplanes to get more accurate fuel indication The Company instructed its flight crew to get advance approval of destination change as early as possible during an aerial survey flight and send clear message of refueling in a radio transmission with an air traffic controller 18 PI NAGANO PRE RS Figure 1 Estimated Flight Route Blowup Yokota Airfield and its vicinity NAGANO CITY f GUNMA PRE a decision of emergency landing was made T LAS Xu SATTAMA PRE CHICHIBU CITY IRUMA CITY KOFU CITY ter o See blowup 623 YAMANASHI PRE k CHOFU AIRFIELD KANAGAVA PRE Figure 2 Three Angle View of Cessna TU206G Unit m Figure 3 Ramp Diagram at Matsumoto Airport x A at 1 ey 2 to South Taxiway 4 1 l 1 1 il il 16 Photo 1 The Airplane Photo 2 Fuel Quantity Indicator AB AS50100 Raggy AN Di i 0 30 1 FNEL QTY gd Left Indicator b hight Indicator X a Pi 200 460 240 TEMP F L hid AZ m v rom sennae 5 niys vu
11. cident On October 23 Saturday 2010 a Cessna TU206G operated by Kawasaki Air Co Ltd took off from Chofu Airfield at 09 05 local time for aerial survey After completing the survey near the river mouth of the Kurobe River it departed for its destination changing it from Niigata Airport to Chofu Airfield however it declared a state of emergency due to fuel starvation and landed at Yokota Airfield Two persons on board the pilot in Command PIC and a cameraman suffered no injuries The airplane sustained no damage 1 2 Outline of the Serious Incident Investigation 1 2 1 Investigation Organization On October 24 2010 the Japan Transport Safety Board JTSB designated an investigator in charge IIC and another investigator to investigate this serious incident On October 29 another investigator was assigned for this investigation 1 2 2 Representatives From Relevant State An accredited representative of the United States of America as the State of Design and Manufacture of the airplane involved in this serious incident participated in the investigation 1 2 3 Implementation of the Investigation October 24 2010 Site investigation and interview October 28 2010 Airplane examination December 3 2010 Interview March 8 2011 Interview 1 2 4 Comments from Parties Relevant to the Cause of the Serious Incident Comments were invited from parties relevant to the cause of this serious incident 1 2 5 Comments from the Releva
12. condition got worse somewhere between Yokota and Tachikawa Airfields he made an emergency call to Yokota Advisory and made a final turn to runway 36 and landed After the landing he was instructed to enter a taxi way The engine stopped less than one minute after entering the taxi way The PIC was not allowed to check the quantity of remaining fuel by himself military personnel did that with a fuel quantity measuring stick and both fuel tanks revealed empty The fuel indications then were left tank about 10 gallons right tank almost zero The PIC was instructed to move the airplane to the apron in front of a flying club hanger This serious incident occurred 2 000 feet above the built up area 35 33 12 N 139 46 52 about 2 kilometers southeast of Yokota Airfield at 14 12 See Photo 1 The Airplane Photo 2 Fuel Quantity Indicator Flight Crew Information PIC Male Age 57 Commercial Pilot Certificate airplane September 7 1975 Type rating for land use single engine December 3 1974 Class 1 Aviation Medical Certificate Validity Until April 17 2011 Total flight time 10 015 hr 43 min Flight time in the last 30 days 21 hr 40 min Total flight time on the type of airplane 1 955 hr 39 min Flight time in the last 30 days 21 hr 40 min Airplane Information Airplane Type Cessna TU206G Serial number U20604670 Date of manufacture November 3 1978 Certificate of airworthiness Dai Tou 22 024 Go Validity Until April 15 2011
13. consumed fuel and fuel flow indication his calculation was that the airplane consumed fuel as planned so that he could fly for another hour At that moment the distance to Niigata Airport or Chofu Airfield was almost the same Calculation said it would take 45 minutes to either Chofu or Niigata He chose to return to Chofu He madea destination change to Chofu and extended estimated flight time to 5 hours 15 minutes He decided to take a direct course at 9 500 feet The PIC made a radio contact with Yokota Airfield and requested a radar advisory service At about 14 00 when he was flying near Ohme City engine run became unsteady due to fuel starvation so that he instinctively changed fuel selector from the left tank to the right tank and the symptom disappeared At 14 05 the engine got the same symptom so he changed the selector from the right to the left but the symptom remained He decided to make an emergency landing at Yokota Airfield and called the Advisory to declare a state of Radar Advisory Service is a service provided to an airplane with useful information or advice based on radar screen readouts 3 2 2 2 3 2 3 1 2 3 2 emergency He flew southward on the left downwind for runway 36 Fuel indication at this moment was left tank about 10 gallons right tank almost zero He felt engine condition recovered so that he withdrew the emergency landing and headed southeast for Tachikawa Airfield for landing But the engine
14. d the both wing fuel tanks empty on the hanger in Yokota Airfield next day When he turned on the battery switch both fuel quantity indicators showed zero Both fuel tank drain bolts were unscrewed and remaining fuel was collected amounting to be about 100 milliliter both tanks combined Then the wing tanks were filled with fuel left tank 6 9 gallons about 26 liters the right tank 9 5 gallons about 36 liters The corresponding fuel indicator readings were more than 5 GALS for the left tank and a little less than 10 GALS for the right tank The engine was started per the normal procedures and engine run up showed no anomalies Fuel Quantity Indication In order to examine the fuel quantity indication the airplane was placed in level attitude per the instruction of the service manual of the manufacturer Fuel quantity is measured by two float type fuel quantity transmitters The picture here shows the fuel quantity indication of a filled up fuel tank 5 2 6 3 The Pilot s Operating Handbook stipulates the empty indication and unusable fuel quantity as follows An empty tank is indicated by a red line and the letter E When an indicator shows an empty tank approximately 2 0 gallons remain in the tank as unusable fuel When both drain bolts are unscrewed and tanks were emptied the left tank indicator showed 5 GALS and the right tank indicator touched the red line Next after filling 3 gallons of fuel each Unit gal Rad
15. e to a blast generated by an airplane which taxies out after being pushed back from No 3 For a visiting aircraft it is necessary to book a ramp slot During one hour and half timeframe on and after 13 30 slot No 4 which was kept open was available and one of slots for scheduled airlines was available See Figure 3 Ramp Diagram at Matsumoto Airport 2 7 4 Matsumoto Airport Office a The Office is manned by prefectural employees and they are not aviation specialists The person who attended the refueling request from the Tokyo FSC stated as follows When he answered the request from the FSC he had some difficulties to understand the whole message due to quick manner of talking however he interpreted it as a destination change for refueling But the whole ramp slots had been booked already Destination changes for refueling were common and he did not confirm the urgency each time As the request was not urgent he declined it 3 2 3 3 3 4 ANALYSIS Crew Qualifications The PIC held valid airman competence certificate and valid aviation medical certificate Airworthiness Certificate The airplane had a valid airworthiness certificate and had been maintained and inspected as prescribed Meteorological Conditions The weather conditions at the time of the serious incident had no bearing with the occurrence of the serious incident Fuel Consumption and Fuel Indicator Indication a Fuel consumption Judging from the
16. el m amount of fuel shown here was added and amount ota Total 2 Left Right 2 5 00 e discrepancy between the usable fuel quantity and indication for usable fuel was gallons as shown here The fuel quantity transmitters are not adjustable Record of Fuel Quantity Calibration The Company did fuel gage calibration on April 2 2010 just before airworthiness inspection and the result is shown here its original table structure was converted to conform to the one shown in 2 6 2 This table shows that when the indicators show empty the airplane has about 1 gallon of usable fuel in each tank Unit gal Tek Tek 29 116 11 6 23 5 23 34 5 F Certain amount of fuel was filled to get indication E first then each amount was added to get indication shown in farthest right column Cessna Specification CES 1210G 1 November 1973 stipulates installation errors as follows The combined error of the instrument and transmitter installed in the airplane with the aircraft in level flight attitude shall be no greater than 8 percent of total dial scale from Empty to 4 tank and 20 percent of total dial scale at other points However in no case shall the instrument read more than Empty when the amount of fuel left in the tank is equal to the unusable fuel supply of the tank with the aircraft in level flight attitude When above mentioned values are compared to CES 1210G allowable error
17. ft have been filled tank fuel quantity from 83 4 right fuel tanks with 42 7 and 40 7 gallons of fuel respectively at the time of takeoff Although the accurate amount of fuel loaded at the time of takeoff was unknown the actual amount did not probably differ much from the above calculation only with the minor difference of how much fuel was consumed for daily engine run up Judging from this usable fuel at 13 30 was probably 10 3 gallons for the left tank and 1 55 gallons for the right tank Taking the error characteristics of both indicators into consideration the fuel indication then was possibly close to what the PIC mentioned left tank usable fuel 16 to 17 gallons right tank near empty 3 5 Flight Plan a Planned flight time and actual flight The PIC made a flight plan with 5 hours 00 minutes of total estimated elapsed time and 5 hours 30 minutes of fuel quantity expressed in endurance time As this does not meet the 45 minutes of reserve fuel stipulated in the Company s Airplane Operational Standard described in 2 7 1 it is probable that the Standard was not enforced in an all out manner It was 13 30 when the PIC requested a refueling stop at Matsumoto Airport 4 hours and 25 minutes into the flight In order to meet the 45 minutes reserve fuel standard he had to land within 20 minutes and at that moment Matsumoto Airport was the only destination which met the Standard to which the airplane could reach in about 15 minutes
18. ger than the calculation value The following two elements are considered to be probable contribution factors to the occurrence Proper amount of reserve fuel was not integrated into PIC s fuel plan and PICs intention of refueling was not clear or strong enough when he requested a refueling landing through the FSC 12 5 ACTIONS TAKEN a The Civil Aviation Bureau CAB Responding to this serious incident the Civil Aviation Bureau MLIT issued the directive titled Ramp Operation Koku Ku Yo No 242 December 22 2010 to prefectural municipal airport offices instructing to be attentive as follows Considering the fact that some airports lack some types of fuel service when an airport office receives a request of refueling landing even if an aircratt does not declare a state of emergency try to secure a temporary refueling slot In case of no available slot try to create a temporary one with the suggestion of CAB personnel b The Company The Company has taken the following measures to prevent recurrences 1 2 3 The Company issued oral and documented direction to its flight crew enforcing that 45 minutes subtracted from a standard endurance time calculated from the Airplane Operational Standard to be the airplane s endurance time It also encouraged them to manage fuel and land at the destination without fear of fuel shortage not to heavily depend on the fuel gauge indication or initial fuel pl
19. nt State Comments on the draft report were invited from the relevant State Japan Standard Time JST Unless otherwise stated all times are indicated in JST and on a 24 hour clock l 2 FACTUAL INFORMATION 2 1 History of the Flight A Cessna 206G registered JA3818 operated by Kawasaki Air Co Ltd hereinafter referred to as the Company took off from Chofu Airfield for aerial survey at 09 05 October 23 2010 The flight plan for the airplane is outlined as below Flight rules Visual flight rules VFR Departure aerodrome Chofu Airfield Cruising speed 110 kt Cruising altitude VFR Route Kawagoe Matsumoto Kurobe Niigata Destination aerodrome Niigata Airport Total estimated elapsed time 5 hr Fuel load expressed in endurance 5 hr and 30 min Persons on board 2 2 1 1 Events Generated From the ATC Communication Records and GPS Records Downloaded From the Survey Equipment 09 05 The airplane took off from Chofu Airfield 09 15 The airplane left Iruma City Saitama Prefecture and headed for Omachi City Nagano Prefecture 12 25 The airplane finished the aerial survey in the vicinity of Omachi City and headed for the river mouth of the Kurobe River 13 17 The airplane finished the aerial survey in the vicinity of the Kurobe River and headed for Matsumoto Airport 13 27 The PIC called Tokyo FSC and requested a destination change to Matsumoto Airport The FSC called Matsumoto Airport Office and
20. ough On the other hand booked slots do not mean they are parked with aircraft all the time some booked ones may be unoccupied depending on timeframe It is desirable that each airport office s flexible acceptance of refueling request when they receive a refueling destination change even aircraft does not declare a state of emergency Recurrence Preventive Measures In this serious incident the airplane went into a fuel starvation because the PIC did not know the actual FCR was bigger than his value of calculation and he did not notice that the fuel indicators read larger amount than the real one In order to prevent a fuel starvation from happening it is important for airplane operators to maintain accuracy of fuel gage reading and share latest FCR information among the concerned On the other hand when a PIC requests a landing for refueling he has to convey clear message for sooner refueling and maintain larger amount of fuel for remaining flight In addition the FSC and airport office concerned should be attentive to provide refueling for a requesting aircraft which wants it due to unexpected fuel consumption even if it does not declare a state of emergency mol PROBABLE CAUSE The airplane s flight with erroneous fuel indication resulted in shortage of fuel requiring urgent measures The indication error very likely obscured the PIC s recognition of erroneous fuel indication although the actual FCR was big
21. rence was bigger than that of PIC s b Fuel quantity indication As described in 2 6 2 the fuel quantity measuring system incorporates floats and the reading scale is as shown in 2 6 2 it is difficult to get an accurate reading The Company did a fuel gage calibration in April 2010 as described in 2 6 3 It is probable that the Company continued airplane operation because the reading of usable fuel was almost the same as the filled amount However as described in 2 6 2 the fuel indication study showed that the discrepancy between the usable fuel quantity and indication was 4 gallons and 4 5 gallons for left tank at 1 gallon and 12 5 gallons usable fuel right indicator was 9 accurate at 1 gal usable fuel Assuming the PIC changed fuel tanks alternately as described in 2 7 2 a and disregarding the amount of unusable fuel considerably used in the actual flight fuel consumption was calculated as the table below With the fact Unit gal deine ea og H me use from left tank at Tss s m 103 o about 1400 and eT a ez z 55 Tus ms n s 1 bee s wos FCR value was 035 1135 Right __ 162 ma 16 2 gallons per 709351035 Lek 162 265 hour the left and 0905 0935 Riem ssr s s o T 7 407 __ As the right fuel tank remaining quantity at 14 13 was unknown were calculated to right tank fuel quantity at 09 05 was obtained by subtracting le
22. ro A3818 ota A Yokota A D a A D ota A D ota A D Irrelevant por JA3818 Ra altimeter thr roger Af Irrelevant por 3818 uh roger G ant por cl h a A3818 you are Roger A38 roger declaring an emergency ions omitted ar contact four zero miles northwest of Yokota Maintain VFR The Yokota ee zero two four Say type aircraft ions omitted 3818 uh at this time uh low fuel uh request emergency landing Verify requesting emergency landing at Yokota firm Uh Yokota landing please ions omitted at this time cancel Yokota landing uh proceed to Chofu Airport maintain VFR for Chofu Airport Say your fuel on board ions omitted his time emergency I need stop uh uh Yokota landing please you are approved for landing at Yokota if you are an emergency Confirm hank you 8 Yokota Airport landing runway three six current winds are zero six zero at four runway three six cleared to land 14 13 2 Uh roger 3818 VVe re cleared to land Irrelevant portions omitted GPS altitude information revealed that the aircraft landed at rn how do you read A3818 3818 go ahead Yokota A D Contact Yokota Tover one three four point three A3818 Uh 3818 sorry say again frequency Irrelevant portions omitted 19 The following abbreviations and unit conversions are u
23. sed in this report Abbreviations NTSB National Transportation Safety Board QNH Altimeter setting VFR Visual flight rules Unit conversions 1 inch in 2 54 centimeter 1 knot kt 0 5144 meters per second 1 pound Ib 0 4536 kilograms 1 US gallon gal 3 785 liter
24. t to endurance of 5 hours and 30 minutes The airplane took off from Chofu Airfield at 09 05 with its destination Niigata Airport It was scheduled to have aerial surveys in the vicinity of Iruma City Saitama Prefecture Omachi City Nagano Prefecture Kurobe River mouth Toyama Prefecture and Niigata City before landing at the destination Because of erroneous data input into the survey equipment for Iruma area he skipped the area and headed for Omachi City The survey took more than expected in Omachi area due to reentries of survey flight course His plan at this time was if the weather was favorable for the flight over the Kurobe River mouth he would cancel flight to Niigata Airport and land at Matsumoto Airport for refueling if the survey near Kurobe River mouth was impossible he would take a direct course to Nigata He had no intention of landing at Toyama Airport because it has no available fuel service for the airplane Thanks to favorable weather over the Kurobe River mouth he did a survey flight and did not fly to Niigata Airport At 13 30 he made a radio contact with Tokyo FSC and requested a destination change to Matsumoto Airport for refueling service there however his request was denied due to fully booked ramp slots He confirmed the remaining fuel as follows left tank 16 to 17 gallons right tank almost empty Considering the ground speed GS obtained from the onboard GPS aerial survey equipment elapsed time and corresponding
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