Accident de Havilland Canada DHC-6 Twin Otter 300 C-GNPS, Monday 1 November 2021
ASN logo
 

Date:Monday 1 November 2021
Time:18:51
Type:Silhouette image of generic DHC6 model; specific model in this crash may look slightly different    
de Havilland Canada DHC-6 Twin Otter 300
Owner/operator:Air Tindi
Registration: C-GNPS
MSN: 558
Year of manufacture:1978
Total airframe hrs:48887 hours
Engine model:Pratt & Whitney Canada PT6A-34
Fatalities:Fatalities: 0 / Occupants: 5
Other fatalities:0
Aircraft damage: Substantial, repaired
Category:Accident
Location:12,4 km NW of Fort Providence, NT -   Canada
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Yellowknife Airport, NT (YZF/CYZF)
Destination airport:Fort Simpson Airport, NT (YFS/CYFS)
Investigating agency: TSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
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 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:
cover
  
Investigating agency: TSB
Report number: A21W0098
Status: Investigation completed
Duration: 1 year
Download report: Final report

Sources:

TSB A21W0098

History of this aircraft

Other occurrences involving this aircraft

2 July 2001 C-GNPS Air Tindi 0 Exeter Lake, NT sub

Location

Revision history:

Date/timeContributorUpdates

The Aviation Safety Network is an exclusive service provided by:
Quick Links:

CONNECT WITH US: FSF on social media FSF Facebook FSF Twitter FSF Youtube FSF LinkedIn FSF Instagram

©2024 Flight Safety Foundation

1920 Ballenger Av, 4th Fl.
Alexandria, Virginia 22314
www.FlightSafety.org