Insufficient fuel for flight resulted in forced landing near Gillam, Manitoba
Winnipeg, Manitoba, 27 July 2020 — In its investigation report (A19C0038) released today, the Transportation Safety Board of Canada (TSB) identified that an unnoticed fuel shortage resulted in fuel exhaustion and the subsequent forced landing of a Beechcraft B200 medevac aircraft operated by Keewatin Air LP in April 2019.
On 24 April 2019, the Keewatin Air LP Beechcraft B200, was on a positioning flight from Winnipeg/James Armstrong Richardson International Airport, Manitoba to station the aircraft at Rankin Inlet Airport, Nunavut, with a stop planned in Churchill, Manitoba. The captain was receiving line indoctrination training from the training pilot, who assumed the role of first officer during the flight. Two flight nurses were also on board.
At 6:14 p.m. Central Daylight Time while in cruise flight, the crew declared an emergency due to a fuel issue. The flight crew diverted to Gillam Airport, Manitoba, and initiated an emergency descent. During the descent, the fuel supply was exhausted and both engines eventually lost power. The crew attempted a forced landing on Runway 23, but instead touched down on the frozen surface of Stephens Lake, 750 feet short of the runway threshold. There were no injuries, although the aircraft sustained substantial damage.
The investigation found that the flight crew had multiple opportunities to identify the shortage of fuel on board the aircraft. Before takeoff, when the captain asked if the aircraft was ready for flight, the first officer replied that it was, not recalling that the aircraft required fuel. Then, while performing the Fuel Quantity item on the After Start checklist, the captain responded to the first officer’s prompt with an automatic response that the fuel was sufficient without looking at the fuel gauges. As a result, the aircraft departed Winnipeg with insufficient fuel on board to complete the planned flight.
During the flight, the crew did not include the fuel gauges in their periodic cockpit scans nor did they confirm their progressive fuel calculations against the fuel gauges. As a result, their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
When the left fuel pressure warning light illuminated and the flight crew realized they had insufficient fuel, they became startled. After declaring a fuel emergency with air traffic control, and initiating an emergency descent, the left engine lost power due to fuel exhaustion. Still feeling the effect of the startle response, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn towards Gillam and extending the approach. The right engine lost power due to fuel exhaustion when the aircraft was one nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible.
Following the occurrence, Keewatin Air LP carried out an internal investigation and issued a safety bulletin to pilots and flight coordinators detailing the actions to be taken by flight crews when conducting the Fuel Quantity item of the After Start check. The bulletin also clarified the fuel status information that flight crews are to provide to the flight coordinator during the flight.
See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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