Winnipeg, Manitoba, 28 March 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A23C0096) into an incident where a Piper PA-31-350 aircraft, operated by SkyCare Air Ambulance, was re-fuelled with the wrong type of fuel (Jet A-1 rather than aviation gasoline) on October 14, 2023, at Pickle Lake Airport, Ontario.

The TSB conducted a limited-scope, class 4 investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues. See the Policy on Occurrence Classification for more information.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

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Investigation Report (A23C0096)

History of the flight

At approximately 1420 on 14 October 2023, the 2080061 Ontario Inc. (doing business as SkyCare Air Ambulance [SkyCare]) Piper PA-31-350 aircraft (registration C-GQXD, serial number 31-8052063) landed at Pickle Lake Airport (CYPL), Ontario, with 2 flight crew members—a captain and a first officer (FO)—on board. The aircraft had been conducting flights in the area of Pickle Lake, Ontario, since 10 October 2023, and the pilots had made arrangements with North Star Air Ltd. (North Star Air) to be supplied with aviation gasoline (AVGAS).

At CYPL, fuel is stored in above-ground fixed storage tanks (Figure 1), which are placarded according to the type of fuel. Aircraft must taxi or be towed to the designated refuelling area.

At approximately 1500, the occurrence aircraft taxied to the refuelling pad, where it had been refuelled over the course of the previous 4 days. The captain then left the refuelling area to work on flight planning while the FO stayed with the aircraft. The FO requested that the refuelling agent add fuel to the aircraft, and the refuelling agent proceeded to refuel the aircraft with Jet A-1. Video footage obtained from North Star Air shows the refuelling agent and the FO communicating before, during, and after the refuelling event, though it does not show the whole aircraft or the refuelling process. Once fuelling was completed, the refuelling agent handed the FO a fuel receipt (Figure 2), and the FO signed it and retained a copy. The FO then handed the receipt to the captain, who did not review it. At approximately 1700, the refuelled aircraft departed CYPL for Winnipeg/St. Andrews Airport (CYAV), Manitoba, with the flight crew on board.

Just before takeoff, take-off power was applied to both engines. During the application of power, the FO, who was the pilot flying, heard an abnormal sound and perceived a fluctuating manifold pressure indication on both engines. The captain, who was the pilot monitoring, observed that all engine parameters were normal.

In the climb through 200 feet above ground level, the flight crew noticed that cylinder head temperatures for both engines were above 500 °F, oil temperatures were approximately 250 °F, and oil pressures indicated 50 to 60 psi (Figure 3).

A co-worker of the refuelling agent noticed unusual emissions trailing from the aircraft on departure and contacted the refuelling agent, who was leaving work after his shift. During the ensuing conversation, they decided that the emissions had likely been caused by fuel venting due to full auxiliary fuel tanks. Shortly after, the refuelling agent consulted the internet and realized that PA-31-350 aircraft normally take AVGAS and that the occurrence aircraft had instead been fuelled with Jet A-1 fuel. He subsequently reported this incident to his manager at North Star Air, who then contacted SkyCare dispatch and the London Flight Information Centre (FIC) to inform them that the occurrence aircraft had been fuelled with Jet A-1, the wrong type of fuel.

Approximately 15 minutes after departure, the flight crew received a radio call from the London FIC informing them that their aircraft had been fuelled with Jet A-1. SkyCare dispatch also informed the crew of the incorrect fuel type directly, via text message. Due to the fact that Jet A-1 had been added to the inboard tanks and there was no additional fuel available in the outboard tanks, the flight crew decided to divert to Sioux Lookout Airport (CYXL), Ontario, and notified air traffic control. The aircraft landed at CYXL without incident.

Aircraft information

The PA-31-350 is a twin-engine aircraft certified for day and night visual flight rules and instrument flight rules operations. It is equipped with reciprocating engines (Lycoming Engines TIO-540-J2BD) that require AVGAS with a minimum 100 octane rating. The occurrence aircraft had complied with Federal Aviation Administration (FAA) Airworthiness Directive (AD) 87-21-01,which narrowed the fuel filler opening to 58 mm in accordance with Piper Aircraft, Inc. Service Bulletin No. 797B, dated 01 September 1987.^Footnote4

The occurrence aircraft’s fuel filler opening had a placard (Figure 4) that indicated the type and grade of fuel and conformed to the FAA’s certification regulations, which state, in part:

(c) Fuel, oil, and coolant filler openings. The following apply:

1. Fuel filler openings must be marked at or near the filler cover with—
   1. For reciprocating engine-powered airplanes—
      1. (A) The word “Avgas”; and
      2. (B) The minimum fuel grade.

Personnel information

The captain had been employed by SkyCare since 10 October 2022. From that date until 07 December 2022, he was an FO on the PA-31-350. On 07 December 2022, he completed the Fairchild Aircraft Corporation SA227 pilot proficiency check and became an FO on this aircraft type. On 17 September 2023, he was assigned to the PA-31-350 as a captain and was based out of CYAV.

Before the occurrence, he had accumulated 1275 total flight hours, including 116 hours as captain and about 40 hours as FO on the PA-31-350.

The FO had been employed by SkyCare since 25 October 2022 and was a PA-31-350 FO with 277.3 hours on type.

The refuelling agent had been employed by North Star Air since 11 September 2023 and had received company training that consisted of procedures for fuelling aircraft from stationary tanks.

Aircraft refuelling

In a discussion of operational engine failures caused by misfuelling accidents, FAA Advisory Circular (AC) 20-105C explains that

[r]eciprocating engines that burn jet fuel at high-power settings may suffer detonations, rapid loss of power, and high Cylinder Head Temperatures (CHT). A complete engine failure can quickly follow these conditions.

Transport Canada (TC) does not regulate or perform oversight of fuel dealers. However, TC AC 300-012 provides information and guidance to those involved with the fuelling of aircraft at aerodromes and states TC’s position regarding the storage, handling, and dispensing of aviation fuels. Referring to the Canadian Standards Association (CSA) Standard B836, the TC AC states that

[it] is Transport Canada’s view that [the CSA standard] provides industry the best practices. Since the introduction of this standard, Transport Canada also recommended that all aerodrome operators adopt the standard for their individual operations.

CSA Standard B836:22 outlines requirements for aviation fuel at Canadian aerodromes. In particular, section 8 states the qualifications and training requirements for all personnel involved in fuelling aircraft. According to the CSA standard,

[f]acility and fuelling equipment operators shall have a documented training program and are responsible for ensuring that all personnel under their direction and control are properly trained or performing tasks assigned to them as specified in this Standard.

In addition, section 4.3.14 explains the required features of overwing fuel nozzles, which are designed to prevent aircraft from being filled with the wrong type of fuel. It states:

Overwing fuel nozzle spouts for aviation turbine fuel shall meet the requirements of SAE AS1852D. Overwing fuelling nozzles shall be grade-marked and colour-coded (black handle or body for jet fuel and red or blue handle or body for avgas). Nozzle spouts shall not be painted or coated.

1. For avgas fuelling, nozzle spouts with a maximum external diameter of 49 mm, fitted with a dust cap, shall be used.
2. Selective spout: For jet fuel overwing fuelling, a nozzle with a selective spout having a major axis of 67 to 70 mm shall be fitted.

Notches, latches, and hold-open devices shall not be used on overwing fuel nozzles.

In cases where the fuel nozzle spout does not fit the aircraft fuel tank opening and aviation turbine fuel is required, a documented procedure may be followed to temporarily change the SAE AS1852D nozzle spout for that aircraft only. […]

Note: This Clause is intended to prevent piston-engine aircraft from being refuelled with aviation turbine fuel.

At the time of the occurrence, North Star Air was aware of the CSA Standard B836.

Read more from the investigation report (A23C0096)

Gatineau, Quebec, 20 February 2024 — Today, the Transportation Safety Board of Canada (TSB) released its summary of preliminary transportation occurrence statistics from 2023, which show accidents are below the five-year average across all modes

^* Does not include incidents reported to the TSB.Data table: Transportation accidents reported to the TSB in 2023

Air transportation

In 2023, a total of 1014 air transportation occurrences (accidents and incidents) were reported to the TSB, an increase of 14% over the previous year (893).

Of these occurrences, a total of 181 were aviation accidents, an increase from the 166 accidents reported in 2022, but 5% lower than the five-year average of 191. Nineteen of these were fatal, resulting in 33 fatalities compared to 24 fatal accidents and 34 fatalities in 2022.

Accidents involving commercial operators increased from 56 in 2022 to 78 in 2023, while those involving private operations (by recreational operators, holders of a private operator registration document, or others) decreased from 108 to 100.

Of the total occurrences, 833 were aviation incidents, which is an increase from the previous year (727) and above the five-year average (685).

See the data on air transportation occurrences in December 2023.

The statistics presented above reflect the information contained in TSB modal occurrence databases on 15 January 2024. Since the occurrence data are constantly being updated in the live database, the statistics may change slightly over time. The TSB will release its complete and final statistical reports for 2023 in late spring; these will include accident rates and a more thorough analysis of the updated data (which may vary slightly from this preliminary data).

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The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

GATINEAU, QC, Feb. 15, 2024 /CNW/ – In its investigation report (A21C0038) released today, the Transportation Safety Board of Canada (TSB) found that insufficient regulatory requirements and defences to protect against loss of visual reference accidents led to the fatal 2021 crash of an Airbus AS350 helicopter on Griffith Island, Nunavut (NU). As such, the Board is issuing four recommendations to the regulator, Transport Canada.

On 25 April 2021, the helicopter, operated by Great Slave Helicopters 2018 Ltd., was returning to Resolute Bay, NU, when it collided with terrain killing all three on board – the pilot, an aircraft maintenance engineer, and a biologist.

The investigation found that as the helicopter approached the highest elevation on Griffith Island, the uniformly snow-covered and featureless terrain, an overcast sky, and snow squalls likely created flat light and whiteout conditions. This led to an unexpected loss of visual reference to the horizon, also known as inadvertent flight into instrument meteorological conditions (inadvertent IMC). While the pilot was likely attempting to visually manoeuvre the helicopter in response to inadvertent flight into IMC, an unintentional descent resulted in the helicopter colliding with terrain.

“For more than 30 years, the TSB has been calling for the implementation of safety measures to mitigate the risks that persist in helicopter reduced visibility operations.” said Kathy Fox, TSB Chair. “These are systemic safety issues that continue to put at risk the lives of thousands of pilots and passengers every year.”

The investigation determined that currently there are no regulatory requirements for commercial helicopter operators to ensure that pilots have the training and technology required to be able to recover from an inadvertent flight into IMC. Additionally, single-pilot operators (either helicopter or airplanes) are not required to have standard operating procedures, which would provide pilots with pre-determined successful solutions for specific situations that may be encountered, including an inadvertent flight into IMC.

TSB research has found that although “loss of visual reference” accidents are more than twice as likely to involve helicopters than airplanes, requirements for helicopters are less stringent. These differences permit helicopters to operate at half the visibility applicable to airplanes, but without the same level of defences. 

This is why the Board is issuing the following four recommendations calling on Transport Canada to:

1. require commercial helicopter operators to ensure pilots possess the skills necessary to recover from inadvertent flight into IMC. [A24-01]
2. require commercial helicopter operators to implement technology that will assist pilots with the avoidance of, and recovery from, inadvertent flight into IMC. [A24-02]
3. require private and commercial operators conducting single-pilot operations to develop standard operating procedures based on corporate knowledge and industry best practices to support pilot decision-making. [A24-03]
4. enhance the requirements for helicopter operators that conduct reduced-visibility operations in uncontrolled airspace to ensure that pilots have an acceptable level of protection against inadvertent flight into IMC accidents. [A24-04]

Following the accident, Great Slave Helicopters 2018 Ltd. implemented numerous safety actions, including: amending standard operating procedures, revising and updating pilot training, implementing new procedures, and establishing quarterly safety management meetings.

The risks associated with the loss of visual references due to flat light and/or whiteout conditions are not new. The TSB has identified loss of spatial awareness in 13 investigations involving commercial helicopter flights conducted between 2010 and 2018 and has issued 10 recommendations to Transport Canada aimed at preventing inadvertent IMC accidents.

For more information about this investigation visit: tsb.gc.ca/eng/A21C0038 

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

The TSB is online at www.tsb.gc.ca.

Undetected aircraft maintenance error led to loss of control and collision with terrain at London International Airport, Ontario

Richmond Hill, Ontario, 5 January 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22O0060) into the 2022 aircraft loss of control and collision with terrain at the London International Airport, Ontario.

On 25 May 2022, a Diamond Aircraft Industries GmbH DA 42 NG aircraft departed from London International Airport, Ontario, on a local test flight following a major overhaul that had been completed at the Diamond Aircraft Industries Inc. facilities at the airport.

Shortly after takeoff, the United States-registered aircraft yawed abruptly to the left. The pilot attempted to correct the unexpected yaw but had difficulty maintaining directional control of the aircraft. The pilot then attempted to make an emergency landing on Runway 27. However, during the approach, the pilot continued to have difficulty controlling the aircraft and instead attempted to land on Taxiway A before ultimately landing on the grass between the runway and the taxiway. The pilot was not injured. The aircraft was substantially damaged.

The investigation determined that the installation of the rudder cable guide tubes was done without the aid of specific procedures, guidance, or supervision. As a result, the rudder cable guide tubes were installed incorrectly, running parallel to each other instead of crossing over at the rear of the fuselage as prescribed in the airplane maintenance manual. When the rudder cables were threaded through the rudder cable guide tubes, they also ran in parallel when connected to the rudder lower mounting bracket in the rear of the aircraft. As a result, the rudder moved in the direction opposite to the pilot’s input. Since it is very difficult to see the rudder surface from the cockpit, and the rudder pedals from the tail area, the flight control portions of the annual and pre-flight inspections, which were accomplished by a single individual, did not identify that the rudder was rigged in reverse.

The investigation also determined that if procedures requiring the inspection of flight controls do not provide specific instructions regarding how to ensure the rudder surface is moving in the correct direction, flight controls that have been rigged in reverse may not be recognized.

See the investigation page for more information.

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The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Dorval, Quebec, 6 June 2023 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21Q0087) into the 2021 runway overrun at Sept-Îles Airport, Quebec.

On 12 September 2021, an Airmédic Inc. Pilatus PC-12/47E aircraft was flying from Québec/Jean Lesage International Airport, Quebec, to Sept-Îles Airport, Quebec, with two crew members on board. The aircraft landed approximately 2525 feet beyond the threshold of Runway 09, which was wet, and ended up overrunning the runway by approximately 590 feet in the grass before making a right turn around an approach light and returning to the runway. No one was injured. There was no damage to the aircraft.

The investigation found that during the flight, the captain, who was paired with a first officer with little experience on the Pilatus PC-12, decided to demonstrate a high-speed final approach, decelerating just before reaching the runway. During the high-speed approach, the first officer had doubts that the aircraft could land successfully; however, he deferred to the captain’s experience and did not feel comfortable making the actionable go-around call. When the aircraft was approximately 1.7 nautical miles from the runway, flying at an airspeed of 238 knots at 500 feet above ground level, it was no longer possible to decelerate and continue the descent to reach the runway threshold in a stabilized landing configuration. However, perceiving that it was still possible to land within the first third of the runway, the captain continued with the approach.

The aircraft crossed the runway threshold at 200 feet above ground level at 180 knots indicated airspeed, with a rate of descent of 2000 fpm, the landing gear in transit and the flaps in the fully retracted position. Under such conditions, it was impossible to stop the aircraft on the wet runway. The aircraft landed on the runway approximately 2525 feet from the threshold at an airspeed of 159 knots. Given that the excessive speed, combined with other factors, increased the landing distance, the aircraft overran the runway.

The report also cites findings as to risk with regards to company standard operating procedures (SOPs). If SOPs and training do not incorporate runway overrun risk factors, they may not be taken into consideration during approach. Also, if SOPs do not include mandatory and actionable go-around calls when approaches become unstable, pilots may choose to continue with an unstable approach, increasing the risk of a runway overrun. If operators do not have lightweight data recorders and flight data monitoring systems, they may not be able to oversee compliance with policies, procedures, and operational limits. Finally, if Transport Canada does not assess the quality, consistency, accuracy, conciseness, clarity, and relevance of an operator’s SOPs, these procedures may not be effective, increasing the risks to flight operations.

Runway overruns have been on the TSB Watchlist since 2010. Despite the actions taken to date, the number of runway overruns in Canada has remained constant since 2005 and demands a concerted effort to be reduced.

Following the occurrence, Airmédic Inc. amended its SOPs to reduce ambiguities and to respond to observations made by Transport Canada during the reactive process inspection. For its part, the Sept-Îles Airport authority established a procedure to notify pilots when there is more than 1/8 inch of rain or standing water on the runway and includes runway condition checks in its daily inspection records.

See the investigation page for more information.

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The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.