Incident Overview

Date: Monday 1 November 2021
Aircraft Type: de Havilland Canada DHC-6 Twin Otter 300
Owner/operator: Air Tindi
Registration Number: C-GNPS
Location: 12,4 km NW of Fort Providence, NT – ÿ Canada
Phase of Flight: En route
Status: Substantial, repaired
Casualties: Fatalities: 0 / Occupants: 5
Component Affected: Fuel quantity check and checklist adherence.Fuel quantity check and checklist adherence.
Investigating Agency: TSBTSB
Category: Accident
On July 17, 2023, a DHC-6 Twin Otter aircraft, en route from Yellowknife Airport to Fort Providence, Northwest Territory, Canada, experienced an emergency landing due to insufficient fuel. The aircraft diverted to Fort Providence, NT (CYJP) after a loss of engine power, and subsequently landed in a remote area of the Bluefish Creek area. The crew, including the captain, successfully recovered after approximately 14 kilometers from the airport. Initial investigation revealed a series of contributing factors including a miscalculated fuel quantity, a missed fuel check, a departure with insufficient fuel, and a captain’s adaptation to routine checklist procedures. The aircraft sustained significant damage during the forced landing, primarily due to fuel starvation in the remote wilderness.On July 17, 2023, a DHC-6 Twin Otter aircraft, en route from Yellowknife Airport to Fort Providence, Northwest Territory, Canada, experienced an emergency landing due to insufficient fuel. The aircraft diverted to Fort Providence, NT (CYJP) after a loss of engine power, and subsequently landed in a remote area of the Bluefish Creek area. The crew, including the captain, successfully recovered after approximately 14 kilometers from the airport. Initial investigation revealed a series of contributing factors including a miscalculated fuel quantity, a missed fuel check, a departure with insufficient fuel, and a captain’s adaptation to routine checklist procedures. The aircraft sustained significant damage during the forced landing, primarily due to fuel starvation in the remote wilderness.

Description

Air Tindi flight 223, a DHC-6 Twin Otter, made an emergency landing in the Bluefish Creek area, about 12,4 km northwest of Fort Providence, Northwest Territory, Canada. The aircraft departed Yellowknife Airport at 17:48 hours local time and approximately 40 minutes into the flight, a loss of engine power forced the crew to divert to Fort Providence, NT (CYJP). The aircraft was not able to reach the airport and a forced landing was performed at 18:51, approximately 14 km from the airport. There were no injuries to the flight crew or passengers. Approximately 8 hours after the forced landing, all occupants were recovered by rescue personnel. Findings as to causes and contributing factors 1. When the captain saw the pink fuel slip in the door of the aircraft, it reinforced his belief that the aircraft had been fuelled for the last flight of the day, when, in actuality, it had not been refuelled. 2. While conducting the Before Start checks from memory, the captain interrupted his routine by conversing with a passenger. Consequently, the fuel quantity check was missed and the preparation for flight continued without the captain being aware that the aircraft did not have sufficient fuel for the flight on board. 3. Over time, the captain developed an adaptation of not conducting the challenge and response checklists where required by the standard operating procedures. The absence of negative consequences reinforced the captain’s practice until it became routine. 4. On the day of the occurrence, the first officer’s adaptation regarding checklist usage was influenced by the seniority of the captain, the captain’s non-standard use of checklists, and the absence of negative repercussions from this adaptation. 5. While taxiing to the runway, the captain conducted the Taxi checks alone, silently, and from memory. Consequently, the fuel check on the checklist was missed and the aircraft departed with insufficient fuel for the flight. 6. The first officer completed the cruise checks silently and without reference to a checklist. As a result, the fuel state of the aircraft was not identified by either flight crew member. 7. As a result of fuel starvation, the flight crew conducted a forced landing into muskeg, which resulted in significant aircraft damage.

Primary Cause

Miscalculated fuel quantity and a missed fuel check during a routine flight.Miscalculated fuel quantity and a missed fuel check during a routine flight.

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