TSB reports "Insufficient fuel" cause for Keewatin Air

[A321]

The April 24th, 2019 Keewatin Air B200 crash landing near Gillam MB has been reported by the TSB on July 27, 2020 as an accident resulting from insufficient fuel for flight. It is reported that the left seat was a "Captain in training" so I would assume the right seat would be someone who was a captain with company or at least a contract training captain.

I wonder if an accident such as this would be career ending for both pilots at Keewatin Air? Moreover, how do you sell your pilot skills after an accident such as this to another air carrier? I believe the Air Canada "Gimli Glider" which ran out of fuel and glided to a successful landing in Gimli MB July 23, 1983 saw both pilots eventually return to work with the captain being demoted for 6 months and the F/O suspended for 2 weeks.

[Caterpillar]

Two captains flying together is probably one of the biggest threat in the 703 world...

Everyone who flew 703 in those kind of operations knows the FO is mostly doing all the work, coordination and planning.

How many time have I seen chocks being left on, prop ties, wrong fuel in or no flight plan deposed in beyond the number of fingers I have.

It’s so bad that I have heard companies asking for a “natural FO” to tag along those trips, since those things are too often left forgotten.

[digits_]

Two captains flying together is probably one of the biggest threat in the 703 world...

Especially in a training captain / captain situation where the person in the simulated FO role is actually in charge, but not legally, yes somehow he is.

Everyone who flew 703 in those kind of operations knows the FO is mostly doing all the work, coordination and planning.

That's a bit of a stretch.

[mmm..bacon]

Insufficient fuel, yes....and *multiple* opportunities to correct that.

Wow!

"The investigation found that the flight crew had multiple opportunities to identify the shortage of fuel on board the aircraft. Before takeoff, when the captain asked if the aircraft was ready for flight, the first officer replied that it was, not recalling that the aircraft required fuel. Then, while performing the Fuel Quantity item on the After Start checklist, the captain responded to the first officer’s prompt with an automatic response that the fuel was sufficient without looking at the fuel gauges. As a result, the aircraft departed Winnipeg with insufficient fuel on board to complete the planned flight.

During the flight, the crew did not include the fuel gauges in their periodic cockpit scans nor did they confirm their progressive fuel calculations against the fuel gauges. As a result, their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing."

[EPR]

What time of the day was this flight/accident? Was the crew asleep at the wheel, and if they were, how would the TSB/TC know in order to include that in the report?

[porcsord]

Regardless of time of day... to not check the fuel ONCE during a flight is grossly negligent.

[leftoftrack]

does Keewaitin have scheduled crew rest, or is it a 1st call 2nd call 3rd call scenario?

[digits_]

does Keewaitin have scheduled crew rest, or is it a 1st call 2nd call 3rd call scenario?

I don't know the current situation, but at the time of the incident, it was a "duty starts when you receive a call" scenario. Seems to be the typical Manitoba medevac scenario. Now that people can't move on to other operators anymore, I suspect we'll see more medevac incidents.

[pelmet]

"The investigation found that the flight crew had multiple opportunities to identify the shortage of fuel on board the aircraft. Before takeoff, when the captain asked if the aircraft was ready for flight, the first officer replied that it was, not recalling that the aircraft required fuel. Then, while performing the Fuel Quantity item on the After Start checklist, the captain responded to the first officer’s prompt with an automatic response that the fuel was sufficient without looking at the fuel gauges. As a result, the aircraft departed Winnipeg with insufficient fuel on board to complete the planned flight.

Many years ago, we had a flight where the crew did not discover that they didn't have the proper fuel quantity until taxiing out and had to return(poor checklist management). It seemed to me that it was the kind of thing that I would end up eventually doing. Therefore, I started actually looking at the required fuel written down on the flight plan versus the actual fuel on the guages at some point prior to departure for every flight.

At a previous company on one of the aircraft it was a checklist response to say the required fuel but at the most recent company I have been working for there is no mention of fuel on the checklist anywhere(probably because the manufacturer's checklist doesn't have this item).

If it is on the checklist and one gets to that call and hasn't actually done the comparing(or can't remember doing this), it is a good time to reach over, grab the clipboard and compare flight plan fuel to guage quantity. If it is not on the checklist, do your best to remember to compare the numbers at some point, such as if your operation has you sign the fuel bill in the cockpit.

[iflyforpie]

They have FTU style checklists but they don’t have an actual fuel quantity? Ours are XXXXlbs, balanced, sufficient on the before start checklist (no point in starting if you need to get gas). And as an FO I always checked that number against fuel required on the OFP.

Same with cruise checks. Look at the gauges, update the performance data in the FMS, and look at the FMS data page to see pounds remaining at destination, alternate, and how much above reserves. You don’t ever assume that the FMS is accurate without verifying it against the primary data. GIGO.

Do it in your head too. You do these trips often enough that you should have a rough idea of how much gas you need, and a value on the gauges.

[mmm..bacon]

Therefore, I started actually looking at the required fuel written down on the flight plan versus the actual fuel on the guages at some point prior to departure for every flight.

At a previous company on one of the aircraft it was a checklist response to say the required fuel but at the most recent company I have been working for there is no mention of fuel on the checklist anywhere(probably because the manufacturer's checklist doesn't have this item).

If it is on the checklist and one gets to that call and hasn't actually done the comparing(or can't remember doing this), it is a good time to reach over, grab the clipboard and compare flight plan fuel to guage quantity. If it is not on the checklist, do your best to remember to compare the numbers at some point, such as if your operation has you sign the fuel bill in the cockpit.

Dosn't everyone's checklist include: 'FUEL? Sufficient and balanced." ??

[pelmet]

Therefore, I started actually looking at the required fuel written down on the flight plan versus the actual fuel on the guages at some point prior to departure for every flight.

At a previous company on one of the aircraft it was a checklist response to say the required fuel but at the most recent company I have been working for there is no mention of fuel on the checklist anywhere(probably because the manufacturer's checklist doesn't have this item).

If it is on the checklist and one gets to that call and hasn't actually done the comparing(or can't remember doing this), it is a good time to reach over, grab the clipboard and compare flight plan fuel to guage quantity. If it is not on the checklist, do your best to remember to compare the numbers at some point, such as if your operation has you sign the fuel bill in the cockpit.

Dosn't everyone's checklist include: 'FUEL? Sufficient and balanced." ??

No. Something like that would be useful.

[propfeather]

Therefore, I started actually looking at the required fuel written down on the flight plan versus the actual fuel on the guages at some point prior to departure for every flight.

At a previous company on one of the aircraft it was a checklist response to say the required fuel but at the most recent company I have been working for there is no mention of fuel on the checklist anywhere(probably because the manufacturer's checklist doesn't have this item).

If it is on the checklist and one gets to that call and hasn't actually done the comparing(or can't remember doing this), it is a good time to reach over, grab the clipboard and compare flight plan fuel to guage quantity. If it is not on the checklist, do your best to remember to compare the numbers at some point, such as if your operation has you sign the fuel bill in the cockpit.

Dosn't everyone's checklist include: 'FUEL? Sufficient and balanced." ??

No. Something like that would be useful.

For us in the BE20 it's in the pre start flow, before takeoff checklist, cruise checklist, and approach checklist. Along with the obvious check in the walk around.

[Dry Guy]

I always though it's something that gets checked so often that putting it on checklists seems unnecessary and a bit silly. But I was wrong.

Soon we'll have Wings - "2 Normal and Attached" on checklists.