What happened
While operating a return leg from Turkey Creek to Derby, Western Australia, the pilot of a Cessna 310 experienced dual engine surging. Believing the issue was caused by fuel starvation, the pilot attempted to switch fuel tanks to access remaining reserves. When this failed to resolve the issue, a MAYDAY call was issued to Brisbane Centre. The pilot instructed the passenger to brace for impact before performing a forced landing. During the maneuver, the right wing of the aircraft struck a tree, causing the plane to rotate 180 degrees and come to an abrupt halt at the edge of a highway. The incident resulted in one pilot with serious facial injuries and one passenger with minor injuries, with the aircraft sustaining substantial damage.
The investigation
The investigation focused on the pilot's fuel management and pre-flight planning. It was found that the pilot used flight planning software but did not input forecast winds, instead routinely planning for nil wind conditions. Consequently, the flight plan failed to account for the fact that the journey from Broome to Turkey Creek and back to Derby could not be completed with required reserves without an intermediate refuelling stop.
Furthermore, the pilot's use of the auxiliary tanks was limited by a personal assumption that they could not be used for more than 45 minutes without causing engine surges. This self-imposed restriction further reduced the aircraft's usable endurance. Investigators also examined the fuel distribution, noting that the pilot likely failed to utilize the right auxiliary tank during the first leg of the flight, leading to the depletion of the main tanks.
Findings
- The flight plan was inadequate as it did not account for wind conditions or the necessity of refuelling.
- The pilot failed to utilize the right auxiliary fuel tank and did not manage fuel usage according to the pilot's operating handbook.
- The pilot did not divert to the nearest airport or adjust altitude to increase safety margins once fuel depletion became apparent.
- The operator, Broome Aviation, provided insufficient supervision, guidance, and support for pilots transitioning to the Cessna 310.
- There were significant safety concerns regarding the operator, including pressure on pilots to fly aircraft with known defects and a failure to record defects on maintenance releases.
- Inaccurate fuel gauges and a lack of standardized in-flight fuel calculation procedures contributed to the risk.