An Australian Transport Safety Bureau (ATSB) investigation report into the crash of a C210 on Groote Eylandt has concluded that the pilot probably took off with the fuel mixture still leaned.
VH-FTM was on a passenger transport flight out of Groote Eylandt with pilot and five passengers on board when the engine suffered a partial power loss, characterised by surging and fluctuating fuel flow, just after take-off.
In an attempt to return to the runway, the pilot overflew the airport diagonally, but the aircraft touched-down on a grassed area outside the airport boundary before striking an embankment and overturning onto a service road. Three passengers were seriously injured, whilst the pilot and the other two passengers sustained minor injuries.
Investigators found that the operator's procedures called for the mixture to be leaned whilst running on the ground, and the aircraft was fitted with an EDM 900 engine monitoring system. The EDM showed that the fuel flow on take-off reached 66 lph, which was 33 lph lower than recorded for other flights that day.
Investigators concluded that the mixture was probably left in the "ground lean" position for take-off, and that the pilot did not manage the partial power loss situation effectively.
"The pilot was likely surprised by the partial power loss, which was compounded by their limited experience of flying the Cessna 210, and took no action to resolve the situation, and did not effectively manage the attempted landing,” ATSB Director Dr Stuart Godley said.
“Notably, the ATSB found the pilot’s take-off safety self-brief, and the aircraft operator’s documented example brief, did not detail actions to be taken in the event of a partial power loss.
“Forward planning, such as a well-structured take-off safety brief, increases a pilot’s situation awareness, reduces mental workload under stress, and increases the prospect of a safe and well-managed outcome in the event of an emergency,”
Investigators also noted that FTM had been fitted with a time-expired fuel pump, that increased the risk of failure even though it was not listed as a contributing factor in the crash.
The full accident investigation report is on the ATSB website.