Détails:
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 captains practice until it became routine.
4. On the day of the occurrence, the first officers adaptation regarding checklist usage was influenced by the seniority of the captain, the captains 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.
| Statuts: | Accident investigation report completed and information captured |
| Date: | lundi 1 novembre 2021 |
| Heure: | 18:51 |
| Type/Sous-type: |  de Havilland Canada DHC-6 Twin Otter 300 |
| Compagnie: | Air Tindi |
| Immatriculation: | C-GNPS |
| Numéro de série: | 558 |
| Année de Fabrication: | 1978-03-06 (43 years 8 months) |
| Heures de vol: | 48887 |
| Moteurs: | 2 Pratt & Whitney Canada PT6A-34 |
| Equipage: | victimes: 0 / à bord: 2 |
| Passagers: | victimes: 0 / à bord: 3 |
| Total: | victimes: 0 / à bord: 5 |
| Dégats de l'appareil: | Substantiels |
| Conséquences: | Repaired |
| Lieu de l'accident: | 12,4 km (7.8 milles) NW of Fort Providence, NT ( Canada)
|
| Phase de vol: | En vol (ENR) |
| Nature: | Transport de Passagers Nat. |
| Aéroport de départ: | Yellowknife Airport, NT (YZF/CYZF), Canada |
| Fort Simpson Airport, NT (YFS/CYFS), Canada | |
| Numéro de vol: | TN223 |
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 captains practice until it became routine.
4. On the day of the occurrence, the first officers adaptation regarding checklist usage was influenced by the seniority of the captain, the captains 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:
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Sources:
» TSB A21W0098Photos
Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Yellowknife Airport, NT et Fort Simpson Airport, NT est de 359 km (224 miles).
Accident location: Exact; as reported in the official accident report.
La distance entre Yellowknife Airport, NT et Fort Simpson Airport, NT est de 359 km (224 miles).
Accident location: Exact; as reported in the official accident report.
Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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