The ATSB's investigation of a Cessna 310 forced landing accident on a highway in Western Australia's Kimberley has identified concerns regarding operator and regulator oversight.
On 20 June 2023, a Broome Aviation operated twin-engined Cessna 310R was being used on a series of air transport flights with a pilot and passenger on board.
The planned trip was from Broome to Turkey Creek and return, with a stop during the return leg to refuel at Derby.
Before leaving Broome, the pilot had used software provided by the operator to calculate the projected fuel consumption, but they did not know how to input forecast winds into the software. In addition, the pilot did not intend to use all the available fuel in the aircraft's auxiliary tanks and did not take this into consideration in their planning.
ATSB calculations, which included wind considerations, found the pilot's planned route from Broome to Turkey Creek to Derby could not be achieved while maintaining fixed reserve and contingency fuel.
Further, the investigation found that the pilot did not monitor or manage fuel correctly during the flights, resulting in the depletion of fuel in the main tanks.
Unable to maintain altitude, the pilot conducted a forced landing on a highway, about 5 km short of Derby Airport, during which the aircraft struck a tree and came to rest off the side of the road
ATSB Chief Commissioner Angus Mitchell noted the preventable nature of fuel mismanagement, a regular contributing factor in aviation accidents.
"Pilots are responsible for ensuring there is sufficient fuel prior to flight, and that they are familiar with their aircraft's fuel system," he said.
"In this case, the ATSB found the pilot's lack of understanding of the fuel system was not detected by the operator due to a lack of consolidation training, and limited to no operational oversight."
In the eight months prior to this accident, the operator transitioned its pilots to the Cessna 310, which has a relatively complex fuel system, with limited supervision, guidance and support.
Mr Mitchell said it was best practice for operators to provide its pilots the opportunity for skill consolidation during and following the initial training on a new aircraft type.
"The investigation also found that current and former Broome Aviation pilots reported experiencing pressure not to report aircraft defects on maintenance releases, and pilots experienced or observed pressure from management to fly aircraft they considered unsafe," he continued.
"A reporting culture - where employees are comfortable to report all safety concerns and maintenance issues - is a safe culture."
Mr Mitchell urged pilots to report maintenance issues through the appropriate channels within their operation, and to take action if they are pressured not to.
"Operators should encourage a reporting culture, and if there are any issues or concerns with this, pilots can and should make a report, confidentially, via reporting schemes run by either the Civil Aviation Safety Authority (CASA) or the ATSB."
The ATSB's investigation also identified a number of safety issues relating to CASA's oversight of Broome Aviation before and after the accident.
Prior to the accident, CASA conducted a level 2 surveillance activity on Broome Aviation in response to a complaint from a former pilot. After the accident, it conducted a level 1 surveillance activity in response to further complaints.
"In both cases, the subjects of these complaints were not properly considered by the CASA surveillance activities," Mr Mitchell explained.
The investigation also identified CASA had approved a head of flying operations (HOFO) for Broome Aviation six months before the accident via an abbreviated assessment, due to the expectation it was an interim appointment.
"However, when the HOFO subsequently remained in the position for much longer than expected, including staying on in the role when they returned to work as a pilot and alternate HOFO at their former operator, CASA did not fully assess the HOFO's ability to do this."
Broome Aviation has taken a range of safety actions in response to the accident, the ATSB's investigation, and CASA's audits.
These include updating its operations manual, incorporating an in-flight fuel management procedure, and appointing a full time HOFO and alternative HOFO.
It has also modified its check and training system, changed processes to ensure all defects are reported, and has implemented a safety management system in line with the current regulations, with monthly safety meetings now being held to address safety concerns.
CASA has also advised it will consider the issues of organisational pressure when it conducts its next surveillance event on the operator.
Finally, Mr Mitchell said the accident again demonstrated the importance of pilots and passengers wearing all available restraints.
The pilot, who was not wearing their sash-type upper torso restraint, sustained avoidable head injuries during the collision.
The passenger sustained minor injuries, and the aircraft was substantially damaged.
"It was very likely the severity of the pilot's head injuries would have been reduced if they had been wearing the available upper torso restraint," Mr Mitchell concluded.
You can find here the report: Fuel starvation and forced landing involving Cessna 310R, VH-DAW, about 5 km south-east of Derby Airport, Western Australia, on 20 June 2023
