Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
On 24 July 2018, a single engine Cessna was conducting a sightseeing charter flight with one pilot and two passengers on board. During a stop for lunch, the pilot refuelled the aircraft prior to conducting the second leg of the charter.
The pilot used a ladder to gain access and incrementally refuelled both wings. The pilot stepped off the ladder several times to check the bowser gauge. The pilot recalled hastening the left wing refuelling because two people had arrived to use the bowser.
The pilot recorded the fuel load, checked the fuel for water and repositioned the aircraft closer to where the passengers were having lunch. The pilot was concerned about daylight time constraints so hurried up as much as possible to begin the second leg of the charter.
After take-off, the aircraft tracked to the sightseeing area. At cruise altitude, the pilot identified the fuel level in both wing tanks was lower than expected. The pilot cross checked the fuel indications and confirmed the position of the fuel selector.
The pilot observed fuel siphoning from both wings and realised he did not secure the fuel caps after refuelling.
The pilot elected to return to the airport, reducing power to conserve fuel. He could not ascertain the rate of fuel loss, and proactively identified suitable landing areas en route. The pilot was confident of reaching the airport and did not declare an emergency. He briefed the passengers and landed safety with 92 litres of fuel remaining.
Distraction in flight; or when carrying out safety critical tasks on the ground, has contributed to a number of aviation accidents and incidents. The sources of most pilot distractions are not unique to any one type of operation. The findings from ATSB publication Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004 suggest that distractions can arise unexpectedly, during periods of high or low workload, or during any phase of the flight.
Fuel exhaustion or starvation can and do occur in any phase of flight, including takeoff. Most reported occurrences have been in the cruise or in the descent, approach and landing phases of flight. However, a quarter of fuel starvation occurrences involved the taxi, takeoff and climb phases.
ATSB publication Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents found of the reported fuel exhaustion occurrences from 2001 to 2010, most (82 per cent) led to a forced or precautionary landing off an aerodrome or ditching (but no fatalities or serious injuries).
This incident reinforces the need to:
- avoid interruptions when completing safety critical tasks on the ground
- conduct a thorough pre-flight inspection
- determine prior to flight the expected rate of fuel consumption
- monitor fuel consumption during flight.
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.
|Date:||24 July 2018||Investigation status:||Completed|
|Location:||near William Creek|
|Release Date:||17 December 2018||Occurrence category:||Incident|
|Aircraft manufacturer||Cessna Aircraft Company|
|Type of operation||Charter|
|Damage to aircraft||Nil|