What happened

On 30 May 2018, a Cessna 206 departed Oenpelli, Northern Territory (NT), for Croker Island, NT with a pilot and four passengers on board. After unloading the passengers at Croker Island, the pilot departed for the return flight to Oenpelli.

During the return leg at approximately 1705 Central Standard Time while the aircraft was cruising at 1,500 ft, the engine lost power and failed. The pilot noted that the airspeed had dropped back to 70 knots and was unable to maintain height. The pilot turned towards a mud flat, checked the fuel, mixture, and magnetos however the engine failed to respond. The pilot made a MAYDAY^[1] call and set up the aircraft for landing. The aircraft landed on a mud flat with no damage.

The post-flight engineering inspection did not reveal any faults with the engine and there was sufficient fuel and oil. The aircraft was later flown out from the mud flat.

Pilot comments

The pilot commented that the low altitude of the aircraft resulted in limited time to troubleshoot the cause of the engine failure. As a result, the engine failure checks and forced landing was required to be done quickly, with increased possibility of error.

Safety message

Although the cause of the engine failure could not be identified, the quick response by the pilot resulted in landing the aircraft in a suitable area without damage. Engine failures can happen at any time. If an engine fails at low level, the time to troubleshoot failures and glide to a suitable area is limited.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

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1. MAYDAY: an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are being threatened by serious and/or imminent danger and the flight crew require immediate assistance.

What happened

On 16 May 2018, at about 0700 Eastern Standard Time (EST), an Airbus A330-303 was beginning its descent into Melbourne, Victoria (Vic.). The aircraft was on a scheduled passenger flight from Tokyo, Japan with 12 crew members and 297 passengers on board.

The flight crew received clearance from air traffic control (ATC) to conduct a descent to 9,000 ft. Shortly after commencing a managed descent,^[1] the first officer (FO) observed the aircraft was slow of its commanded speed. The FO selected OP DES^[2] and the aircraft accelerated towards a managed speed of 310 kt. The aircraft’s maximum allowable operating speed (VMO) was 330 kt.

Passing through flight level (FL) 320^[3], the wind direction shifted from a crosswind to a headwind and consequently the aircraft rate of descent increased. The flight crew deployed the speed brakes and levelled the aircraft, by selecting ‘PUSH TO LEVEL OFF’ on the flight control unit, to reduce speed. Despite these actions, the aircraft continued to accelerate. During the descent, the aircraft reached a maximum speed of 336 kt for 6 seconds.

The aircraft landed at Melbourne without further incident. There was no damage to the aircraft or injuries sustained to crew or passengers.

Engineering Inspection

Following the incident, the operator’s engineering team examined the details of the occurrence and determined that the maximum speed obtained was within the permissible limits of the aircraft maintenance manual. No inspections of the airframe were required, and the aircraft was returned to service.

Safety message

This occurrence highlights that unexpected changes in weather can occur at any time. Sudden shifts in wind direction can have a significant impact to aircraft speed. Flight crews should pay particular attention to monitoring the aircraft’s speed during descent when operating with a reduced margin to VMO as the impact of a wind gradient can result in an airframe overspeed. In particular, when flying close to the wind direction or in turbulent conditions, flight crew should adjust the speed target to allow adequate margin below VMO.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

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1. In the managed descent mode, the aircraft follows a pre-computed descent profile that allows for aircraft deceleration and airspace restrictions along the active flight planned route.
2. OP DES: allows the aircraft to climb or descend uninterrupted toward flight control unit selected altitude, maintaining a target speed (managed or selected) with a fixed given thrust.
3. Flight level: at altitudes above 10,000 ft in Australia, an aircraft’s height above mean sea level is referred to as a flight level (FL). FL 320 equates to 32,000 ft.

What happened

On 31 March 2018 at 0745 Eastern Daylight-saving Time, the pilot of a Kavanagh E-300 balloon was on final approach to land near Billinudgel, New South Wales with a pilot and 11 passengers on board.

As it was a new landing area, the pilot had asked the ground crew following the balloon to check the landing site and adjacent road and report any powerlines. The ground crew reported none and the pilot directed his attention to managing the landing. Neither the pilot nor passengers had identified any powerlines on the approach path to the landing site.

Just before landing, at 3-4 kt and 10 ft above ground level, the pilot saw two wires in front of the balloon, about a third of the way up the envelope. The pilot immediately pulled the red rip line to deflate the balloon, but the envelope struck the powerlines, which snapped and fell to the ground. The powerlines short-circuited five times and then stopped sparking.

No one was injured, and a subsequent inspection found no tears, burns or abrasion marks on the balloon envelope. The owner of the property was advised, and the ground crew contacted the power supplier to report the incident.

Pilot comment

The powerlines had only become visible when seen against the sky. On approach, against the dark green surface of the landing site, neither the pilot nor passengers had seen the wires.

Once the ground crew had advised there were no powerlines on the approach path to the landing site the pilot had concentrated on landing the balloon, rather than looking for wires.

Safety action

As a result of this occurrence, the balloon’s operator has advised the ATSB that they have spoken to the ground crew about the importance of identifying powerlines adjacent to landing sites and communicating that information to the pilot. The operator’s other pilots and ground crew received a comprehensive briefing on the incident.

Safety message

The Australian Ballooning Federation’s Pilot Circular No 18, dated February 2012, emphasised the importance of avoidance and made the following points:

• Pre-flight planning: Critical for ballooning, maps, charts and information must be current. Consult council staff, locals and farmers, topographic map in hand, for precise location of powerlines and those not on the maps.
• Complacency: Familiarity and repetition regarding operation and location can lead to complacency. Be aware of this and hence be vigilant. Data shows the worst accidents are often made by the most experienced and skilled operators.
• Crew/passenger briefing: Stress to crew and passengers pre-take-off and before approach: (1) you are only human and may not see threatening powerlines, and (2) to feel free to point them out to you.
• Reduced visibility: Sun, mist, haze, contrast. Be vigilant and conservative under these conditions.
• See and Avoid scanning technique: Avoid focusing too long on close objects or scanning quickly left and right. Focus at a distance and move attention slowly over small arcs pausing briefly for a few seconds each time to closely examine the area.
• Country flying: Expect lines to be along roads with feed offs to farmhouses. Often, single wires can be identified only by first locating their poles, so look for them first and assume lines run between them. They also cross paddocks to connect to other facilities. In this case be aware poles are often placed among trees making them difficult to see.
• Minimum safety altitude: Most power line strikes involve wires which are usually no more than 15 metres (50 feet) above ground level. Except for take-off and landing, staying above this height when flying in unfamiliar or risky areas is great insurance against hitting a wire.
• Distraction on approach: Checks, fuel, pilot lights, passengers, stock, obstacles, stress, tunnelling. All are Human Factors aspects that must be recognised and managed early such that full attention is then available for approach and landing.

The Civil Aviation Safety Authority web site includes a list of wire strike resources that specifically address this hazard.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 11 April 2018, at about 0643 Eastern Standard Time, an Airbus A320 (A321-231) took-off from Melbourne Airport, Victoria bound for Hobart Airport, Tasmania. During initial climb, after retracting the landing gear, the flight crew received an ECAM^[1] alert indicating low fluid pressure in the green hydraulic system. The green hydraulic system is one of three independent operating hydraulic systems on the Airbus A320 aircraft.

Upon receipt of the warning, the flight crew contacted air traffic control (ATC) on the departures frequency to notify them of the alert and requested to maintain flight at 5,000 ft in order to further asses the issue. The flight crew then completed checks in the ECAM system and identified that they had lost fluid from the green hydraulic system.

Having identified the issue, the crew advised ATC that they intended to return to Melbourne and required 20 minutes holding time before commencing approach in order to complete necessary checks and preparations. ATC approved the request to hold at current position and declared an INCERFA^[2] and Local Standby services^[3].

During the hold, the flight crew established that due to the green hydraulic system failure, they would not have normal brakes or nose wheel steering available on landing. The crew subsequently briefed the cabin manager of the situation and made a public address call to the passengers. The public address notified the passengers of the technical fault and the intention to return to Melbourne, advising that the landing would be normal but that the aircraft would need to be towed back to the gate due to brake and steering issues. The crew also notified their ground services of this requirement and a tug was made available for use.

Before commencing approach to land, the crew completed a landing gear gravity extension procedure using the checklist and then conducted an instrument landing system approach to land on runway 16. The aircraft vacated the runway on the roll onto high speed taxiway G and came to a stop clear of the runway. The aircraft was then towed back to the terminal where passengers and crew were disembarked.

An engineering inspection was subsequently conducted which identified that a ruptured steel hydraulic pipe in the left wing was the cause of the fluid loss. Removal and inspection of the failed pipe occurred and the maintainer reported that the failure was the result of fretting wear to the outer surface of the pipe due to repeated rubbing from a bolt over a long period of time. Pictures of the failure surface of the hydraulic line and its location relative to the bolt head are shown in Figures 1 and 2.

The engineering inspection also identified that there was insufficient clearance between the line and bolt though it was not known how this had occurred.

Figure 1: Failure surface of the green system hydraulic line showing fretting wear

Source: Aircraft maintainer

Figure 2: Location of the failed hydraulic pipe (blue outline) relative to a flap guide fixation bolt (red outline)

Source: Aircraft maintainer, annotated by ATSB.

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they have taken the following safety actions:

Inspection of hydraulic lines on similar aircraft within the fleet, no additional instances of damage have been noted.

Safety message

The actions of all parties in response to this event reaffirms the importance of having and utilising correct event response procedures when experiencing technical failures in-flight. The actions of the flight crew, ATC and ground staff in coordinating and dealing with the event resulted in a safe outcome.

In the past 12 months (to June 2018), the ATSB has received more than 30 occurrence reports where the flight crew of air transport high-capacity aircraft received hydraulic system fault warnings during operation including an occurrence that is currently being investigated (AO-2018-014). A similar hydraulic failure event, on landing in an air transport low-capacity aircraft, was reported to the ATSB on 30 March 2018 and published as an occurrence brief (AB-2018-046). In these cases, the flight crew successfully identified and managed the failure.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

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1. Airbus Electronic Centralised Aircraft Monitor (ECAM): A system that monitors aircraft functions and relays them to the pilots. The specific alert displayed by ECAM in this occurrence was HYD G SYS LO PR indicating a loss of hydraulic pressure in the Green hydraulic system.
2. Uncertainty phase (INCERFA): emergency phase declared by the air traffic services when uncertainty exists as to the safety of an aircraft and its occupants. it is the lowest of the three possible alert levels.
3. Local Standby: a nationally recognised level of aerodrome emergency response that notifies airport based rescue and firefighting services and the aerodrome safety officer of the event. A local standby is the normal response when an aircraft approaching the airport is known, or suspected to have developed some defect but it would not normally involve serious difficulty in effecting a safe landing.

What happened

On the morning of 23 June 2018, a Cirrus SR20 returned to Archerfield, Queensland from a private flight with one pilot and one passenger on board.

During the final approach to runway 28R, the pilot observed an aircraft ahead commencing its take-off as well as an aircraft holding at the taxiway intersection. Passing 300 ft on final approach, the preceding aircraft became airborne and the pilot then realised that he may be approaching the incorrect runway. The pilot elected to continue the approach as the runway was clear and he believed a go-around may cause more issues. On the landing roll, ATC advised the pilot to contact the Tower. The ground controller confirmed that the aircraft had landed on the incorrect runway.

Post-incident, the pilot advised that due to the increased workload of ATC transmissions, having a passenger on board and losing some situational awareness, he became tunnel-visioned leading to the error. The pilot plans to fly with his instructor to further practice joining the circuit.

Safety message

This incident highlights the need for pilots to anticipate, plan and execute early and correctly performed go-arounds if a safe landing is in doubt.

The ATSB newsroom report, News: Know when to go-around, is available from the ATSB website. More information on when and how to execute a go-around can be found at the FAA’s

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 15 May 2018, at about 1500 Western Standard Time (WST), a Fokker F100 was on a scheduled passenger flight from Perth, Western Australia (WA) to Kununurra, WA. The flight crew was comprised of the captain and the first officer (FO).

Passing through 10,000 ft on descent, the crew received a “LG Not Down”, triple chime alert. The flight crew identified that that the Radio Altimeter 1 (RA1) was erroneously indicating ‘zero feet’, which triggered the gear unsafe alert. The flight crew discussed the situation and decided to configure the aircraft for landing early, with the view to extend the gear as soon as practicable, in order to silence the triple chime alert.

Shortly after, the crew observed the autopilot disconnect and a ‘STAB TRIM 1 and 2’ fault alert. The captain took over flying the aircraft manually, commenced speed reductions and called for ‘Flaps 8’. Immediately following, RA1 appeared to return to normal operation and all alerts ceased.

Descending through 7,000 ft, RA1 returned to a reading of ‘zero feet’. The flight crew observed all of the previous alerts, in addition to a “TOO LOW GEAR” GPWS alert. The crew reviewed the situation and agreed to continue with the plan to configure the aircraft early for landing. The remainder of the approach and landing were conducted without further incident.

Once on the ground, the captain contacted Maintenance Watch and the Manager Flight Technical for guidance. In preparation for the return flight to Perth that afternoon, the team made the decision to dispatch the aircraft under the Minimum Equipment List (MEL).

At about 1630 WST, after a lengthy turnaround, the flight crew began the performance calculations for take-off on runway 12. The take-off flap position of ‘Flaps 15’ was correctly identified and circled on the Take-Off and Landing Data (TOLD) Card, to highlight the infrequently used setting.

After start, the flight crew became aware of an inbound aircraft on long final. The flight crew initiated a radio call to the crew on board the approaching aircraft to confirm their intended surface movements. As the departing aircraft approached the runway, the other aircraft made a radio transmission expressing confusion regarding the use of the taxiways. The confusion was resolved and the captain of the departing aircraft began the pre-take off sequences.

Distracted by the earlier confusion and eager to depart, the captain called for ‘Flaps 8’, the more commonly used take-off configuration. The captain then glanced at the TOLD card to cross check the numbers and continued with the take-off.

The aircraft’s speed had climbed above 100 kts before the FO and captain identified the incorrect flap setting. The captain called continue and the take-off was completed without further incident.

Safety message

This incident highlights the importance of managing operational pressures and distraction. The traffic on the taxiway, the events of the previous flight and the extended turnaround time had distracted the crew from completing the pre-flight sequences in a conscious manner. During times of high workload, distraction and perceived time pressures can often lead to human error.

External pressures and distractions are sometimes unavoidable, however, there are effective ways to manage them, as discussed in the ATSB research report B2004/0324, ‘Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004’.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 7 July 2018 at 0915 Eastern Standard Time, a Victa Airtourer with two crew was on a private flight from Kilcoy, Queensland (Qld) to a private grass airstrip near Somerset Dam, Qld. Weather conditions were reported as cloud at 2,500 ft with a slight crosswind.

During landing, the pilot landed long on the airstrip which was made up of wet grass. The pilot considered conducting a go-around or conducting a controlled ground-loop^[1]. The pilot briefly opened the throttle to attempt the go-around, but quickly closed it as the aircraft was reaching the end of the strip.

The aircraft overran the strip and collided with a barbed wire fence. After shutting down the aircraft, both occupants evacuated uninjured.

The aircraft was assessed to have sustained extensive damage including to the left-wing leading edge, right aileron, bent propeller blades and a torn off landing gear and nose wheel.

Contributing factors to the overrun include:

• wet grass runway
• minimal wind conditions
• a long touchdown on the strip
• opening the throttle late.

Safety message

When conducting flights into unfamiliar locations, pilots should attempt to research the airstrip or field prior to departure. For private or undocumented strips, conducting a pass over the strip first before landing will aid in determining runway length and characteristics.

In some cases, a wet runway may not be evident prior to landing. Utilising the full length of the strip allows pilots extra time to execute recovery manoeuvres (such as conducting a go-around) from compromising situations such as a wet runway, which can limit an aircraft’s braking abilities.

Additionally, pilots should familiarise themselves with their aircraft operating handbook to build confidence on their decision making in time-critical situations.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

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1. A ground loop is an ‘involuntary uncontrolled turn while moving on the ground, especially during take-off or landing’ (Bill Gunston, The Cambridge Aerospace Dictionary, New York, New York; Cambridge University Press, 2004, p.275).

What happened

On 13 May 2018, a remotely piloted Da-Jiang Innovations (DJI) Phantom 4 aircraft was launched from a lookout near Hope Downs 4 Mine, with the pilot and observer intending to conduct an aerial berm^[1] inspection within one of the mining pits. At about 0735 Western Standard Time, the aircraft lost power and fell to the pit floor, resulting in the aircraft being destroyed.

During the flight, witnesses observed the battery separate from the body of the aircraft and fall to the ground. An inspection revealed hairline fractures around the catch, which locks the battery in place. The recovered battery was also fractured in this area.

Later, it was determined that a post-flight check had not been completed on the previous flight. In addition, the pre-flight inspection of the aircraft just prior to the accident flight had not included a check of the battery connection and locking mechanism.

Safety action

As a result of this occurrence, the remotely piloted aircraft operator has advised the ATSB that they have taken the following actions:

• modifying their procedures to include the recording of all maintenance activities to their sub 2 kg remotely piloted aircraft
• including in their pre-flight checklist that the observer or a secondary person will check the installation of the battery.

In addition, the operator has emphasised the importance of pre and post-flight checks of the aircraft.

Safety message

This accident highlights the importance of pre and post-flight inspection of remotely piloted aircraft. Aircraft manufacturer user manuals, which are generally accessible online, provide specific guidance in relation to each model of aircraft, including information in relation to the correct fitment of the battery. Additionally, the Civil Aviation Safety Authority provides generic guidance in relation to the operation of remotely piloted aircraft and the training requirements of operators on their Flying drones/remotely piloted aircraft in Australia web page.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

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1. Berm is a term used to describe a barrier, such as a wall.

What happened

On 1 August 2018 at approximately 1200 Eastern Standard Time, the pilot of a Lancair 360 commenced his pre-flight inspection at Roma Airport, Queensland (Qld). The sequence of the pre-flight inspection was altered due to the need to refuel prior to departure. During the inspection, the pilot was also interrupted on multiple occasions where he was required to leave the aircraft. When he returned, he approached the aircraft from behind and inadvertently omitted to inspect the front.

The pilot completed pre-flight checks and believed that the aircraft was ready for flight. During the climb, the pilot noticed a slight vibration, which discontinued once in cruise configuration. The pilot also noted that the oil temperature was one to two degrees lower than normal during the flight. No further unusual events were observed throughout the flight and the aircraft landed safely at Gold Coast Airport, Qld.

Upon unloading the aircraft, the pilot noticed that he had not removed the tow bar from the aircraft prior to departure. He contacted Roma Airport ground staff and advised that the tow bar handle may have fallen off on the taxiway; they were unable to locate it. The next day the pilot received a phone call from Gold Coast Airport staff advising him that they had located and removed his tow bar handle from the runway. No damage was sustained to the aircraft. The tow bar handle was slightly bent and scratched.

Safety message

The incident highlights the importance of ensuring that all pre-flights checks are carried out systematically and with minimal interruption. If interrupted, it is best practice to start again from the beginning to ensure that nothing is missed.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 2 April 2018, a student pilot was conducting solo circuit training in a Piper PA-28 from Bankstown Airport, New South Wales.

At 1114 Eastern Standard Time, the aircraft was passing through 700 ft on climb to circuit height on the crosswind leg runway 29L, when the engine failed. The pilot immediately turned the aircraft towards the airport and conducted a forced landing, omitting the required checks. During landing, the aircraft contacted trees resulting in substantial damage. The pilot was not injured.

Post-flight it was determined that fuel starvation was the cause of the engine failure. The pilot stated they thought the right fuel tank was full and the left fuel tank was just under full before the flight. After the accident, fuel on board prior to the flight was calculated to be 24 litres in the left tank and 43 litres in the right tank. After the engine failed, the pilot did not switch fuel tanks.

The operator has an arrangement with a local refueller whereby they fill up the aircraft to full tanks and leave a chalk mark on a tyre. When an aircraft has been moved, the refueller can see this and tops up the tanks to full capacity. This did not occur on this occasion and may have led to complacency with the expectation that the tanks would be full.

Safety message

Accurate fuel management starts with knowing exactly how much fuel is being carried at the commencement of a flight. This is easy to know if the aircraft tanks are full, or filled to tabs. If the tanks are not filled to a known setting, then a different approach is needed to determine an accurate quantity of usable fuel.

Fuel starvation continues to be a common cause of engine failure. Effective fuel management in flight and the checking of fuel quantities reduces the risks of a fuel starvation event. Once an engine has failed or runs rough due to fuel starvation, changing the selected tanks should restore power but may take some time to take effect. Fuel tank changes should be done in conjunction with any other checks as recommended by the aircraft flight manual. For more information on fuel management, see ATSB research report, Starved and Exhausted: Fuel management aviation accidents (AR-2011-112).

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.