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Accident investigation report completed and information captured
Narrative: On 2 March 2018, at 15:49 local time, a Skippers Aviation Cessna 441 Conquest, registered VH-LBY, departed on a scheduled passenger service from Fitzroy Crossing to Broome, Australia with one pilot and nine passengers on board. During descent, the FUEL LEVEL LOW annunciators illuminated. The pilot observed that both fuel quantity gauges indicated sufficient fuel remaining and continued flying towards Broome. The right engine began surging, followed by similar surging from the left engine. Subsequently, the right engine lost power and the pilot conducted the engine failure checklist. The pilot declared a MAYDAY and advised air traffic control that, as the left engine was still operating, the aircraft would be able to reach Broome. However, the left engine also lost power and both engines were unable to be restarted. The pilot landed the aircraft safely on the nearby highway. There were no injuries, and the aircraft was undamaged.
Due to water contamination in the fuel tanks, the aircraft’s fuel quantity gauges were significantly over reading on the day of the occurrence and on previous days. The water contamination had existed for some time without being detected by multiple pilots’ fuel quality testing. Although the pilot routinely compared indicated versus calculated fuel quantities, and indicated versus flight-planned fuel quantities, the pilot did not routinely conduct two other methods stated in the operator’s procedures for cross-checking fuel quantity gauge indications. In addition, although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its C441 fleet, there were limitations in the design, definition and/or application of these methods. The primary method used (indicated versus calculated fuel) was self-referencing in nature, and not able to detect gradual changes in the reliability of fuel quantity gauge indications. Pilots also did not record (and were not required to record) sufficient information on flight logs to enable trends or patterns in fuel quantity gauge indications to be effectively identified, and pilots did not routinely cross-check information from fuel quantity gauge indications with information from the independent fuel totaliser. The FUEL LEVEL LOW annunciators likely illuminated approximately 30 minutes before the fuel was exhausted in each tank, and when the aircraft was still within range of suitable alternative airports. However, the pilot disregarded the annunciations, and relied on the (erroneous) fuel quantity indications and continued to Broome until the engines lost power, at which point a forced landing on a highway was the only remaining option.