Descripción del Accidente ASN 01 NOV 2021 de Havilland Canada DHC-6 Twin Otter 300 C-GNPS - Fort Providence, NT
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Estado:Accident investigation report completed and information captured
Fecha:lunes 1 noviembre 2021
Hora:18:51
Tipo:Silhouette image of generic DHC6 model; specific model in this crash may look slightly different
de Havilland Canada DHC-6 Twin Otter 300
Operador:Air Tindi
Registración: C-GNPS
Numéro de série: 558
Año de Construcción: 1978-03-06 (43 years 8 months)
Horas Totales de la Célula:48887
Motores: 2 Pratt & Whitney Canada PT6A-34
Tripulación:Fatalidades: 0 / Ocupantes: 2
Pasajeros:Fatalidades: 0 / Ocupantes: 3
Total:Fatalidades: 0 / Ocupantes: 5
Daños en la Aeronave: Considerable
Consecuencias: Repaired
Ubicación:12,4 km (7.8 milles) NW of Fort Providence, NT (   Canadá)
Fase: En ruta (ENR)
Naturaleza:Vuelo Doméstico Programado
Aeropuerto de Salida:Yellowknife Airport, NT (YZF/CYZF), Canadá
Aeropuerto de Llegada:Fort Simpson Airport, NT (YFS/CYFS), Canadá
Número de Vuelo:TN223
Descripción:
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.

Probable Cause:

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.

Accident investigation:
Investigating agency: TSB Canada
Status: Investigation completed
Duration: 1 year
Accident number: A21W0098
Download report: Final report

Fuentes:
» TSB A21W0098


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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Yellowknife Airport, NT to Fort Simpson Airport, NT as the crow flies is 359 km (224 miles).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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