Six days before Christmas 2021, the plane left Redcliffe aerodrome north of Brisbane in fine weather just after 9am, for the private scenic flight.
Less than three minutes later the single engine Rockwell International 114 aircraft crashed into mangroves near the shoreline, coming to rest upside down.
Pilot Roy Watterson, 67, and his three passengers - Cris Mocanu, 41, his nine-year-old son and daughter aged 10 - were unable to escape and died.
Video recovered from a passenger's phone included footage inside the plane before take-off as well as the brief flight.
It showed the pilot was doing pre-takeoff checks from memory and not using any written lists.
The video also revealed a perceived technical difficulty distracted Mr Watterson during the checks and he did not complete them, failing to look at fuel tank selection.
The Australian Transport Safety Bureau (ATSB) said most of the fuel had moved to the plane's right wing tank while stored in the hangar.
Less than three minutes after take-off, the Rockwell International 114 crashed near the shoreline. (HANDOUT/NINE NEWS)
However they said it was likely that the fuel tank selection prior to take-off was switched to the almost empty left wing which led to the engine stopping soon after take-off.
The video showed Mr Mocanu asking the pilot about fuel coming out of the right wing soon after takeoff but Mr Watterson did not respond.
"If the fuel selector was placed on both tanks then it is likely, even with one fuel tank having most of the fuel and the other almost empty, that fuel supply to the engine would remain unaffected," an ATSB report said.
The engine stopped barely 90 seconds after takeoff and Mr Watterson attempted to return to the runaway for landing.
"The pilot, likely experiencing the effects of stress and time pressure following the engine power reduction and then stoppage, did not conduct initial emergency actions," the ATSB report said.
Mr Watterson did not maintain glide speed and the aircraft impacted water near the shoreline.
He had extended the undercarriage for landing which the ATSB believed contributed to the aircraft inverting when it collided with 2m-deep, murky water.
Police forensic teams were the first called to the crash scene on Sunday, December 19, 2021. (Danny Casey/AAP PHOTOS)
"This likely resulted in occupant disorientation and added difficulty in operating the exits, reducing their ability to escape," the report said.
"Once the cabin filled with water, visibility would have been extremely low, which would have further reduced the likelihood of occupants being able to visually locate and operate the aircraft door handles."
The ATSB also noted that one of the children was seated next to an exit.
"(That) meant that a less suitable passenger was available to operate the exit," it said.
The ATSB said the incident highlighted the need for approved, readily available, written checklists and for pilots to get into the habit of restarting them from the beginning when interrupted.
It also placed a focus on fuel management, proper safety briefings and seating consideration in case of an emergency.
Mr Watterson was chairman and founder of industrial equipment supplier Lincom Group while Mr Mocanu was the company's national hire fleet coordinator.
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