Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005
On the 6 August 2005 a Tuninter ATR72 turboprop aircraft, TS-LBB, flying from Bari, Italy to Tunis, Tunisia, ran out of fuel and ditched off the northern coast of Sicily. Of the 39 people on board, 16 died.
The aircraft had been erroneously fitted during maintenance with the Fuel Quantity Indicator (FQI) for the smaller ATR42. The ATR72 FQI was not found in the stores because its part number had been entered into the stores database without the integral ‘dashes’ and the database mistakenly indicated that the ATR42 part, which was found in the database, was compatible with both aircraft types.
With the wrong FQI, the quantity displayed exceeded the actual fuel. When fuelled, the difference between the expected fuel and that indicated was not initially noticed. When it was, it was incorrectly believed that a further fuelling had taken place and the records misplaced.
When the engines flamed out the crew did not feather the propellers to reduce drag as they were attempting to restart the engines, believing fuel remained (as indicated by the FQI). Consequently they did not fly the aircraft at the optimum speed to extend the gliding distance.
This was a classic ‘organisational accident’ unfortunately the a number of individuals were prosecuted. There was also considerable condemnation over the use of the CVR by the prosecutors.
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Aerossurance has previously examined:
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Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements:
Aerossurance sponsored the 2017 European Society of Air Safety Investigators (ESASI) 8th Regional Seminar in Ljubljana, Slovenia on 19 and 20 April 2017. ESASI is the European chapter of the International Society of Air Safety Investigators (ISASI).
Aerossurance is pleased to be supporting the annual Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference for the third year running. We will be presenting for the second year running too. This year the conference takes place 13 to 14 November 2017 at the Hilton London Gatwick Airport, UK with the theme: How do we improve human performance in today’s aviation business?
Aerossurance is pleased to be both sponsoring and presenting at a Royal Aeronautical Society (RAeS) Human Factors Group: Engineering seminar Maintenance Error: Are we learning? to be held on 9 May 2019 at Cranfield University.