Pilots in Gillam medevac plane crash failed to notice fuel shortage, report says
Captain, training pilot didn't check fuel gauges before, after takeoff, TSB says
The pilots of a medevac plane that crash-landed near Gillam, Man., last year made numerous mistakes and missed multiple opportunities to discover the fuel shortage that forced it to make the emergency landing, according to a report by the Transportation Safety Board.
No one was injured when the medevac flight landed on the frozen surface of Stephens Lake, almost 230 metres (750 feet) short of the runway at Gillam Airport on April 24, 2019. Gillam is about 735 kilometres north of Winnipeg.
The Keewatin Air LP Beechcraft B200 plane suffered heavy damage, however, when it hit the ice.
The flight was on its way from Winnipeg to Rankin Inlet Airport, with a stop planned in Churchill, Man. The captain was receiving instruction from a training pilot, who had assumed the role of first officer on the flight.
Two flight nurses were also on board.
Investigators found that the flight crew missed "multiple opportunities" to discover the fuel shortage. Before leaving Winnipeg, the captain asked the first officer if the plane was ready for takeoff. The first officer replied that it was, without recalling that the plane needed fuel.
After takeoff, while completing an after start checklist, the captain responded with an automatic response to the first officer's prompt regarding fuel quantity, without actually looking at the fuel gauges
The flight crew also didn't check the fuel gauges during their periodic cockpit scans during the flight, nor did they check the fuel gauges to compare against their progressive fuel calculations, the Transportation Safety Board report said.
If they had done this, they might have had enough fuel to make a safe landing, the report says.
During the flight, once the fuel pressure warning light went on, the flight crew became startled and failed to take appropriate action soon enough to make it to the airport safely. They declared a fuel emergency with air traffic control and started an emergency descent, at which point the left engine lost power.
"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 report said.
The right engine lost power and a safe forced landing became impossible, the report said.
Keetwatin Air issued a bulletin to pilots and flight coordinators on proper procedures for checking fuel during flights. The report did not include any mention of disciplinary action against any members of the flight crew.