TSB finds Air Tindi pilots that ran out of fuel missed multiple checks
Pilots of an Air Tindi flight forced to land in muskeg outside Fort Providence missed multiple chances to notice the plane had not been refuelled, a report into the accident states.
There were two pilots and three passengers on board when the Twin Otter ran out of fuel and ditched north of Fort Providence on the evening of November 1, 2021.
Nobody was seriously hurt but all on board were treated for hypothermia after a four-hour wait to be rescued. The partially frozen muskeg was so tricky to cross that a search party had to abandon ATVs and walk in the dark, sometimes falling through the ice into waist-deep water.
The Transportation Safety Board of Canada noted “several instances where checklists were not completed in accordance with company procedures.”
According to the TSB, some experienced Air Tindi captains “had developed the unsafe practice of performing some of the checks by memory only” – and first officers, while aware of that practice, had not submitted formal safety reports that would have ensured managers were alerted.
The flight, bound for Fort Simpson, was 40 minutes old before the crew noticed their plane had not been refuelled in Yellowknife as they had thought. They diverted to Fort Providence as the nearest available airfield but did not reach it.
The TSB’s final report stated the captain had seen a pink fuel receipt in a pocket of a cockpit and assumed the aircraft had been refuelled. However, that receipt was from a flight three days earlier.
As a result, the aircraft departed with approximately 533 lb of fuel rather than the 2,500 lb that would be standard for a flight to Fort Simpson.
By the time the flight reached cruising altitude, the TSB stated, the captain and first officer had missed three separate occasions on the cockpit checklist that would have called for them to check their fuel.
When a fuel company at Yellowknife Airport called Air Tindi to ask if the flight needed fuel, the caller was told the aircraft was already airborne.
In a bid to reach Fort Providence once the error had been noticed, the pilots shut down one engine to conserve fuel. However, the other engine flamed out shortly afterward and the captain, bereft of options, glided the plane into the muskeg.
The captain had been with Air Tindi since 2008 and had been a Twin Otter captain since 2019. The first officer had been hired by the company in April 2021, half a year before the incident. This was their first day flying together, the TSB said.
Airline has made changes
TSB reports do not assign blame or civil or criminal liability. The safety board routinely states its investigations are designed simply to figure out what happened and if lessons can be learned.
In this instance, the TSB said checklists weren’t being used properly.
The captain had interrupted an initial pre-flight checklist to talk to a passenger, missing a fuel check that should have been performed. A second check while taxiing to the runway was conducted by the captain “alone, silently, and from memory,” the TSB stated. A subsequent check by the first officer was completed “silently and without reference to a checklist.” Nobody noticed the missing fuel.
Carrying out checks in this manner had become normal, the TSB found, stating: “The absence of negative consequences reinforced the captain’s practice until it became routine.”
In their attempt to bring the plane down safely, the crew descended slightly earlier than was necessary and appeared to inadvertently hit a switch that removed access some of the little remaining fuel, lessening their chances of reaching Fort Providence successfully, the investigation reported.
More: Read the TSB’s final report in full
In an interview after this article was first published, Air Tindi president Chris Reynolds said the accident was “completely needless” and “should never have happened.”
“There were really strong procedures in place to prevent it from happening and the procedures weren’t followed,” Reynolds told Cabin Radio. He would not discuss whether the crew members involved remain employed at the airline.
The Transportation Safety Board said the airline had spoken with every Twin Otter pilot after the incident and issued a memo that emphasized the requirement “to follow all procedures and checklists.”
Further memos instructed captains to sign an acknowledgement on every fuel slip before starting a plane’s engines for a flight, and to verbally confirm with flight controllers that fuel is on board before departing.
The checklists used and the way those checks are verified have also been revised, the TSB stated.
“You’re supposed to check for fuel numerous times with the checklists. When I’m flying, I check it about 10 times more than I’m required to check it. It’s what you do in your own vehicle, right?” Reynolds said.
“We’ve put a process in place that reinforces the following of procedures and a monitoring system that, for years to come, will just make sure that nothing slips.”