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ASN Wikibase Occurrence # 179596
Last updated: 1 November 2020
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Date:15-SEP-2015
Time:18:21 CDT
Type:Silhouette image of generic PA31 model; specific model in this crash may look slightly different
Piper PA-31-350 Navajo Chieftain
Owner/operator:Keystone Air Service
Registration: C-FXLO
C/n / msn: 31-8052022
Fatalities:Fatalities: 0 / Occupants: 8
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Location:Thompson Airport, Thompson, Manitoba -   Canada
Phase: Initial climb
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Thompson Airport, Thompson, Manitoba (CYTH)
Destination airport:Winnipeg International Airport, Winnipeg, Manitoba (CYWG)
Narrative:
A Keystone Air Service Piper PA-31 Navajo en-route to Winnepeg (CYWG) attempted an emergency return to the point of departure at Thompson Airport (CYTH) shortly after departure. The aircraft impacted timbered terrain south of the airport, sustaining substantial damage. The two crew and six passengers on board were treated for minor injuries.

The investigation has confirmed that the aircraft received an incorrect type of fuel in Thompson, Manitoba, prior to departing for Winnipeg. The twin piston-engine aircraft requires aviation gasoline (AvGas), but was re-fuelled with turbine engine fuel (Jet A1).

The aircraft was destroyed by impact with trees and terrain; however, the aircraft cabin section remained largely intact. Almost all of the fuel was dispersed throughout the crash site from ruptured fuel cells but a sufficient quantity remained to obtain samples. There was no post-impact fire.

Findings as to causes and contributing factors:
Delivery of the incorrect type of aircraft fuel caused loss of power from both engines, necessitating a forced landing.
The fuelling operation was not adequately supervised by the flight crew.
A reduced-diameter spout was installed that enabled the delivery of Jet-A1 fuel into the AVGAS fuel filler openings.
The fuel slip indicating that Jet-A1 fuel had been delivered was not available for scrutiny by the crew.

Findings as to risk:
If administrative and physical defences against errors in aviation fuel operations are circumvented or disabled, there is a risk that the incorrect type of fuel will be delivered.
If a reduced-diameter spout is available to accommodate non-standard fuel filler openings, there is an increased risk that Jet-A1 fuel can be dispensed into an aircraft that requires AVGAS.

Other findings:
Aircraft that were manufactured prior to the current airworthiness standards, or that have been modified by the installation of turbine engines, may have fuel filler openings that do not meet the dimension requirements.
The airworthiness standards for rotorcraft do not specify the size of fuel filler openings.
The use of all of the available restraint systems in the aircraft contributed to the survival of the occupants.
There was no post-crash fire, likely due to the separation of the battery from the aircraft and to the rain-saturated crash site.
The absence of a post-impact fire contributed to the survival of all of the aircraft's occupants.

Sources:

1. https://winnipeg.ctvnews.ca/small-plane-crash-near-thompson-may-be-result-of-fuel-error-1.2565302
2. http://www.cbc.ca/news/canada/manitoba/8-injured-in-plane-crash-near-thompson-man-1.3229974
3. https://globalnews.ca/news/2252324/wrong-fuel-to-blame-for-thompson-plane-crash-investigation/
4. TSB Occurrence No:A15C0134 at http://www.tsb.gc.ca/eng/enquetes-investigations/aviation/2015/a15c0134/a15c0134.asp
5. http://www.tsb.gc.ca/eng/rapports-reports/aviation/2015/a15c0134/a15c0134.asp
6. [LINK NOT WORKING ANYMORE:http://www.baaa-acro.com/2015/archives/crash-of-a-piper-pa-31-in-thompson/]
7. CADORS Number:2015C3475


Revision history:

Date/timeContributorUpdates
16-Sep-2015 04:34 Geno Added
17-Sep-2015 18:06 harro Updated [Aircraft type, Registration, Cn, Embed code]
17-Sep-2015 19:12 Geno Updated [Time, Damage, Narrative]
25-Sep-2015 05:52 peterj Updated [Source, Narrative]
04-Oct-2015 11:23 Aerossurance Updated [Nature, Source, Narrative]
07-Nov-2015 15:40 Anon. Updated [Damage]
14-Mar-2016 17:43 Anon. Updated [Phase, Destination airport]
27-Sep-2016 08:14 Aerossurance Updated [Time, Location, Source, Narrative]
27-Sep-2016 08:15 Aerossurance Updated [Narrative]
27-Sep-2016 08:15 Aerossurance Updated [Narrative]
23-Oct-2017 17:51 Dr. John Smith Updated [Time, Location, Departure airport, Destination airport, Source, Narrative]

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