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AVIATION OCCURRENCE REPORT

FUEL EXHAUSTION

BUFFALO AIRWAYS (1986) LTD.DOUGLAS DC-3C C-FROD

FORT SIMPSON AIRPORT, NORTHWEST TERRITORIES .5 nm SW26 JUNE 1994

REPORT NUMBER A94W0106

MANDATE OF THE TSB

The Canadian Transportation Accident Investigation and Safety Board Actprovides the legal framework governing the TSB's activities. Basically, theTSB has a mandate to advance safety in the marine, pipeline, rail, andaviation modes of transportation by:

! conducting independent investigations and, if necessary, publicinquiries into transportation occurrences in order to make findings asto their causes and contributing factors;

! reporting publicly on its investigations and public inquiries and on therelated findings;

! identifying safety deficiencies as evidenced by transportationoccurrences;

! making recommendations designed to eliminate or reduce any suchsafety deficiencies; and

! conducting special studies and special investigations ontransportation safety matters.

It is not the function of the Board to assign fault or determine civil or criminalliability. However, the Board must not refrain from fully reporting on thecauses and contributing factors merely because fault or liability might beinferred from the Board's findings.

INDEPENDENCE

To enable the public to have confidence in the transportation accidentinvestigation process, it is essential that the investigating agency be, and beseen to be, independent and free from any conflicts of interest when itinvestigates accidents, identifies safety deficiencies, and makes safetyrecommendations. Independence is a key feature of the TSB. The Boardreports to Parliament through the President of the Queen's Privy Council forCanada and is separate from other government agencies and departments.Its independence enables it to be fully objective in arriving at its conclusionsand recommendations.

The Transportation Safety Board of Canada (TSB) investigated this occurrence for thepurpose of advancing transportation safety. It is not the function of the Board to assign faultor determine civil or criminal liability.

Aviation Occurrence Report

Fuel Exhaustion

Buffalo Airways (1986) Ltd.Douglas DC-3C C-FRODFort Simpson Airport,Northwest Territories .5 nm SW26 June 1994

Report Number A94W0106

Synopsis

The Douglas DC-3C freighter was on a charter flight from Trout Lake to Fort Simpson,Northwest Territories. While turning final for runway 31 at Fort Simpson, the flight crew advised theFlight Service Station that they were attempting a forced landing on a road. The aircraft crashed intotrees about one-half nautical mile short of the runway and was substantially damaged. The first officerwas seriously injured and the captain received minor injuries.

The Board determined that the flight was commenced with a fuel quantity below the minimumrequirements, resulting in loss of engine power because of fuel exhaustion. Contributing to theoccurrence was the lack of flight crew coordination.

Ce rapport est également disponible en français.

TABLE OF CONTENTS

TRANSPORTATION SAFETY BOARD iii

Table of ContentsPage

1.0 Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of the Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.6 Aircraft Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.10 Aerodrome Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.12.1 Accident Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.12.2 Aircraft Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.12.3 Ground Scars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.12.4 Airframe Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.12.5 Propeller Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.12.6 Engine Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.12.7 Fuel System Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.13 Medical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.16 Fuel Services Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.17 Company Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.18 Fuel Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.18.1 Air Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.18.2 Company Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.19 Fuel Calculations and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.19.1 Fuel Load . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.19.2 Start, Taxi, Run-up, and Take-off Fuel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.19.3 Climb and Cruise Fuel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.19.4 Fuel Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.20 Crew Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.0 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

TABLE OF CONTENTS

iv TRANSPORTATION SAFETY BOARD

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.2 Fuel Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.3 Pilot Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.4 Crew Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2.5 Shoulder Harnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.0 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

3.2 Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.0 Safety Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

5.0 AppendicesAppendix A - Occurrence Flight Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Appendix B - Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

List of FiguresFigure 1 - Flight Segments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

FACTUAL INFORMATION

TRANSPORTATION SAFETY BOARD 1

1.0 Factual Information

1.1 History of the Flight

Buffalo Air Flight 526, a Douglas DC-3Cfreighter based in Yellowknife, was hauling jetfuel to Trout Lake from Fort Simpson,Northwest Territories, in support of forest firesuppression operations.

Before the departure from Yellowknifeto Trout Lake, the flight crew checked theen route weather and filed a company flightitinerary. Dispatch issued the flight crew anaircraft-fuel-load receipt which indicated thatthe aircraft had been fuelled the night beforewith a total fuel quantity of about 436 imperialgallons (imp. gal.): full main tanks (336 imp.gal.), and 50 gallons in each auxiliary tank (100imp. gal.). The first officer confirmed thisquantity with a fuel dip-stick borrowed fromthe refueller.

At 0740 mountain daylight saving time(MDT)1, the flight crew departed Yellowknifein accordance with visual flight rules (VFR)2. On board the aircraft were 17 full 45-imperial-gallon drums of Turbo-B jet fuel.

1 All times are MDT (Coordinated Universal Time [UTC]minus six hours) unless otherwise stated.

2 See Glossary for all abbreviations and acronyms.

At 0925 the aircraft landed atTrout Lake, and the 17 drums of jet fuel wereoff-loaded; the aircraft then departed forFort Simpson at 0945. The 82-nautical-mile(nm) flight to Fort Simpson was flown at analtitude of about 2,500 feet above sea level (asl);the flight crew reported encountering lightheadwinds.

At 1020 the aircraft landed atFort Simpson. Once again 17 drums of jet fuel

were loaded on board, then the aircraftdeparted at 1049. The captain climbed theaircraft to an altitude of 3,500 feet asl. After helevelled off the aircraft, the captain adjusted theengines to 575 brake horsepower (bhp) settings.

At 1120, the aircraft landed atTrout Lake and the drums were off-loaded, andat 1135 the aircraft was once again airborne onthe second round-trip shuttle flight.

Thirty-five minutes later the aircraftlanded at Fort Simpson. While the cargo wasbeing loaded on the aircraft, the flight crewdiscussed their different calculations regardingthe aircraft's fuel quantity. The first officerindicated that the aircraft required fuel. Thecaptain calculated that the aircraft had sufficientfuel remaining. The captain decided that theywould refuel at Fort Simpson on the nextshuttle flight; nonetheless, since the flight crewconsidered the cockpit fuel gauges unreliable,the captain requested that the first officerconfirm the fuel quantity using a dip-stick.

At 1228, the aircraft departedFort Simpson and climbed to 5,000 feet asl. About eight minutes later, the flight crew

FACTUAL INFORMATION

2 TRANSPORTATION SAFETY BOARD

Figure 1 - Flight Segments

noticed that the fuel pressure was fluctuating,indicating that the auxiliary tanks were empty. The captain repositioned the fuel tank selectorsto their respective main tanks and enquiredabout the dip-stick measurements. The firstofficer responded that he had not checked thefuel quantity because the fuel dip-stick wasmissing. The crew discussed the fuel quantityremaining and the captain calculated that theaircraft had approximately 45 minutes of fuelremaining.

Following the 1300 touchdown atTrout Lake, the cargo was unloaded and 31empty fuel drums were loaded on board theaircraft for Fort Simpson.

At 1325 the aircraft departed TroutLake. The first officer was the pilot flying (PF)the aircraft, and was in the right seat. Thecaptain performed the duties of the pilot notflying (PNF). Twenty miles southwest ofFort Simpson, the PNF reported their positionto Fort Simpson Flight Service Station (FSS). He also requested that the aircraft refueller beadvised that they would require fuel on arrival. The flight crew then completed the descentchecks and, at 10 miles southwest of theairport, the PNF updated FSS of their positionand received the airport advisory.

Approximately six miles from theairport, at an altitude of about 400 to 500 feetabove ground level (agl), the PF advised thePNF that the left engine was losing fuelpressure. Shortly thereafter, the left engine lostpower. Immediately, the PNF switched the leftfuel boost pump to the ON position, and theleft fuel selector from LEFT MAIN to LEFTAUXILIARY tank position. The engineresumed power momentarily, but lost poweragain. The PNF then switched the left fuelselector to the RIGHT AUXILIARY tankposition and the engine regained power;however, it promptly lost power again.

Realizing that the fuel had beendepleted in three of the four tanks, the captaintook control of the aircraft and headed straightfor runway 31. As the captain called for theengine failure check for the left engine, the firstofficer advised the captain that the right enginewas losing power. With a loss of power in bothengines, and without sufficient altitude to glideto the airport, the first officer called theFort Simpson FSS to advise that the flight crewwould attempt a landing on the road(Mackenzie Highway) north of the Liard River. However, the approach to the road was

FACTUAL INFORMATION


unsuccessful and the aircraft crash-landed intoa treed area. (See Appendix A.)

At about 1403, several witnesses at theLiard River ferry crossing observed the aircraftflying low in a northwesterly direction. Theaircraft was estimated to be at about 40 feet aglwhen it crossed overhead the ferry terminal andwas descending. The witnesses reported thatthey heard the sound of the engines cutting inand out before the aircraft passed overheadtheir vantage points. They also reported seeingthe landing gear being extended. The aircraftthen disappeared from view behind the trees.

3 Units are consistent with official manuals, documents,reports, and instructions used by or issued to the crew.

Immediately thereafter, the aircraftstruck trees near the road, and crashed about1/2 nm short of runway 31. The aircraft hadbeen flown for approximately 4 hours and37 minutes since its last refuelling.

The aircraft struck terrain at latitude61°45'N and longitude 121°14'W, at anelevation of 450 feet asl3, at approximately 1404during the hours of daylight.

1.2 Injuries to Persons

Crew Passengers Others Total

Fatal - - - -Serious 1 - - 1Minor/None 1 - - 1Total 2 - - 2

Both pilots received injuries to the headand upper body.

1.3 Damage to Aircraft

The aircraft sustained substantial damage.

1.4 Other Damage

There was no other damage.

1.5 Personnel Information

FirstCaptain Officer

Age 38 28Pilot Licence ATPL CPLMedical Expiry Date 01 Sept 94 01 Mar 95Total Flying Hours 14,000 1,300Hours on Type 9,000 850Hours Last 90 Days 315 200Hours on Type Last 90 Days 315 170Hours on Duty Prior to Occurrence 7.5 7.5Hours off Duty Prior to Work Period 8.5 8

The flight crew was certified, trained,and qualified for the flight in accordance withexisting regulations. Information regarding thecrew members' flying experience was obtainedfrom their personal records and company files.

The captain was described by the chiefpilot, colleagues, and himself as a highlyexperienced pilot who would always attempt toget the job done as quickly and efficiently aspossible.

The first officer commenced his flyingcareer with this company and his licence wasendorsed for DC-3 and DC-4 aircraft. He wasdescribed by colleagues as a professional pilotand a hard worker with a good attitude. Hewas also described as a pilot who wouldgenerally assert himself when necessary.

FACTUAL INFORMATION


1.6 Aircraft Information

Manufacturer Douglas Aircraft CorporationType and Model DC-3CYear of Manufacture 1942Serial Number 12307Certificate of Airworthiness (Flight Permit) ValidTotal Airframe Time 18,456 hrEngine Type Pratt & Whitney R-1830-92 (number of) (2)Propeller/Rotor Type Hamilton Standard (number of) 23E50-437 (2)Maximum Allowable Take-off Weight 26,899 lbRecommended Fuel Type(s) 100/130, 100 LLFuel Type Used 100 LL

The aircraft was certified, equipped, andmaintained in accordance with existingregulations and approved procedures.

The aircraft's weight and centre ofgravity (C of G) for the occurrence flight werewithin the prescribed limits. The weight andbalance, manifest forms, and a flight plan formwere all located in the cockpit of the aircraft. These documents were completed in advanceof the flight, in accordance with companyprocedures.

The company maintenance departmentreported that the aircraft was functioningnormally on previous flights; no discrepanciesregarding abnormal fuel consumption werenoted in the maintenance records.

1.7 Meteorological Information

The Fort Simpson and vicinity sky conditionsforecast by Environment Canada AtmosphericEnvironment Service (AES) were broken toovercast, with cloud bases at 1,500 feet agl. The visibility was forecast to be six miles andbetter, with a few light rain showers.

A pilot report (PIREP) issued fourminutes prior to the accident reported the basesof cloud at 2,800 feet agl.

The 1400 Surface Weather Recordissued by AES indicated the visibility was15 miles, the wind was from 320 degrees at10 knots, and the temperature was 13 degreesCelsius.

The 1800 850-millibar (mb) chartindicates that the winds over the upperMackenzie valley at 5,000 feet asl were from310 to 320 degrees at about 10 knots.

1.8 Aids to Navigation

At the time of the accident, the Fort SimpsonAirport was served by the followingnavigational aids: one non-directional beacon(NDB), a very high frequency omni-directionalrange (VOR), and distance measuringequipment (DME). Both the NDB and theVOR/DME were serviceable, and were beingused by the crew for navigation to and fromFort Simpson.

The crew was also using a GlobalPositioning System (GPS) for en routenavigation.

1.9 Communications

Very high frequency (VHF) radiocommunications between Flight 526, the FSSspecialist, and other aircraft on the mandatoryfrequency (MF), 122.2 megahertz (MHz), hadbeen established and were functioning normallyat the time of the accident. A record of thecommunications was transcribed from the FSStape recordings.

1.10 Aerodrome Information

The Fort Simpson Airport is certified and isoperated by Transport Canada. It is locatedabout 6 nm southeast of the town site, with afield reference elevation of 555 feet asl. Runway 31/13 is a 6,000-by-150-foot, asphaltrunway.

FACTUAL INFORMATION


The terrain immediately southeast ofthe airport slopes downward toward the LiardRiver. The vegetation succession levels rangefrom shrubs near the river edge, to willows, andfinally to about 125-foot-tall coniferous anddeciduous trees. The aircraft's initial point ofimpact was approximately 100 feet below therunway elevation.

Airport emergency response services(ERS) are available for on-aerodromeoccurrences.

1.11 Flight Recorders

The aircraft was not equipped with a flight datarecorder or a cockpit voice recorder, nor waseither required by regulation.

1.12 Wreckage and Impact Information

1.12.1 Accident Site

The aircraft struck the trees and rising rivervalley terrain approximately 2,900 feet from thethreshold of runway 31. The accident site isimmediately adjacent to the MackenzieHighway near the Liard River ferry crossing.

1.12.2 Aircraft Wreckage

During its final flight path, the aircraft strucktrees on a heading of about 300 degreesmagnetic (°M), in a shallow descent ofapproximately 5 degrees, and with a 28-degreeright-wing-low attitude. The aircraft continuedthrough the trees in this direction and attitudefor about 97 feet; it then swung to the right andthe nose struck the ground in a flat cartwheelmotion. The aircraft came to rest, right side up,164 feet from the point of initial impact, on aheading of 100°M. The tail was propped up in12-inch diameter poplar trees.

1.12.3 Ground Scars

The ground and tree scars left by the aircraftindicated deceleration and were consistent withthe direction of travel of the aircraft. Therewas no evidence found of propeller rotationalsignatures.

1.12.4 Airframe Systems

A post-accident examination of the airframerevealed no evidence of pre-impact structuralfailure or loss of control continuity. Theimpact airspeed could not be determined fromthe examination of the aircraft instruments.

1.12.5 Propeller Examination

The right propeller was located on the rightside of the wreckage trail 141 feet past the pointof initial impact. One blade on each of thethree-bladed propellers was bent back in anasymmetrical position. Neither propeller was ina high-blade angle or feathered position, andneither revealed evidence of rotational,torsional, or leading edge damage.

The absence of propeller bladerotational damage and leading edge damage isconsistent with the absence of engine power atthe time of impact.

1.12.6 Engine Examination

The engines were examined to the degreepossible, and no evidence of a malfunction wasfound.

1.12.7 Fuel System Examination

A visual field inspection of the aircraft's fueltanks revealed that there was no usable fuel onboard. The fuel that was remaining in theaircraft's tanks was removed, measured, andexamined. The absolute quantity extractedfrom all four tanks totalled about three imp.gal., and was of the proper grade and quality.

The fuel system was examined andthere was no evidence of a system defect ormalfunction prior to or during the flight.

The aircraft departed Yellowknife withan approximately balanced wing fuel quantity,and the cross-feed system was not utilizedduring the flight segments until engine powerwas lost. On final approach, both engines lostpower within about two minutes of each other. The almost simultaneous loss of powerindicates that there was equal fuel consumption

FACTUAL INFORMATION


between engines. It is, therefore, unlikely thatfuel leakage, rich carburation, or an enginemalfunction occurred.

During the wreckage examination, thefuel dip-stick was located under the auxiliarypower unit platform at the rear of the aircraft. The dip-stick is normally stored in this area.

1.13 Medical Information

There was no evidence that incapacitation orphysiological factors affected the crew'sperformance.

1.14 Fire

There was no evidence of fire either before orafter the occurrence.

1.15 Survival Aspects

The accident final flight path decelerationforces were attenuated, and progressivelyabsorbed, by a growth of thick willows, smallertrees, and finally larger trees. In addition, the28-degree right-wing-low attitude caused theaircraft to pivot in a flat cartwheel type ofmanoeuvre during contact with the thick willowgrowth. During this manoeuvre, much of theforward energy was dissipated, and the aircraftslid backwards before coming to a stop.

The cabin area maintained its integritythroughout the accident; however, the cockpitimmediately forward of the seats was severelydamaged.

The aircraft was not equipped withshoulder harnesses, nor were they required byregulation.

The emergency locator transmittersurvived the crash. It activated and functionednormally after the impact.

The easy access to the crash site,located about 150 feet north of the Mackenzie

Highway, allowed rescue personnel to quicklyevacuate the flight crew.

1.16 Fuel Services Available

Fuel service is available at the Fort SimpsonAirport. The fuel facility is locatedapproximately 2,500 feet south of the forestrybase where the DC-3C was loading andunloading its cargo. The hours of operation ofthe fuel service follow regular working hoursfrom Monday to Friday. A callout charge islevied for after-hours and weekend fuelservices. The occurrence flight was conductedon a Sunday.

There is no fuel service available inTrout Lake.

1.17 Company Operations

Buffalo Airways employs a pilot self-dispatchsystem. Accordingly, the pilot-in-command ofany flight has the sole authority to makedecisions as to initiation, continuation, delay,diversion or re-routing, and refuelling of theflight when conditions are such that operationaldecisions are necessary. The pilot-in-commandhas the sole responsibility for ensuring that theflight is conducted safely.

During the investigation, it wasdetermined that the company pilots were notsubject to management pressure to operateaircraft below the company minimum fuelrequirements. In addition, the flight crew wasdirected by the chief pilot to refuel on every leg,when possible, for the assurance of meeting thefuel requirements and the carriage of optimumcargo loads.

1.18 Fuel Requirements

1.18.1 Air Regulations

For flight planning purposes and for ensuringthat adequate fuel is carried on board, AirRegulation 544 states the following:

The amount of fuel and oil carried onboard any aircraft ... at the

FACTUAL INFORMATION


commencement of any VFR flight shallbe sufficient, taking into accountanticipated wind and other weatherconditions, to fly to the place ofintended landing and thereafter

a) in the case of an aircraft otherthan a helicopter, for 45minutes at normal cruisingspeed.

Excerpts from sections 26, 27, and 29of Air Navigation Order (ANO) Series VII,No. 2, state the following:

No person shall authorize a flight andno person shall commence a flight,unless, having regard to themeteorological conditions and delaysthat are expected in flight, theaeroplane carries

a) sufficient fuel and oil to ensurethat the flight can be completedsafely;

The fuel and oil carried ... in the case ofa propeller-driven aeroplane, be at leastsufficient to allow the aeroplane,

a) when an alternate airport is notrequired,

i) to fly to the airport towhich the flight isplanned and thereafterfor a period of 45minutes at normalcruising speed, and

ii) to have a reserve offuel, based onconsideration of ...contingency factors.

In computing the amount of fuel andoil, ... the following contingency factorsshall be considered:

(a) meteorological conditionsforecast;

(b) anticipated air traffic controlroutings and traffic delays;

(c) one instrument approach at theairport to which the flight isplanned, including a missedapproach;

(d) the procedures set out in an aircarrier's operations manual forloss of pressurization, whereapplicable, or failure of onepower unit while en route; and

(e) any other conditions that maydelay the landing of theaeroplane.

1.18.2 Company Requirements

The company minimum fuel requirements asoutlined in Section 1, page 33, of the CompanyOperations Manual are as follows:

Fuel Loading

The minimum quantity of fuel withwhich it is permissible to operate theaircraft on any flight, from any station,is to be 146 Imperial gallons plus taxifuel which must be distributed in thefollowing order:

a. Under all conditions each reartank must carry a minimum often Imperial gallons.

b. The remainder (126 Imp. gal.plus ten Imperial gallons taxifuel) is to be evenly distributedbetween the two front tanks.

Neither pilot was sufficiently consciousof the minimum fuel requirements outlined inthe Company Operations Manual.

1.19 Fuel Calculations and Monitoring

1.19.1 Fuel Load

FACTUAL INFORMATION


At the start of the day, the aircraft had a totalfuel quantity, as indicated on the fuel receipt, ofabout 436 imp. gal.: full main tanks (336 imp.gal.), and 50 gallons in each auxiliary tank (100imp. gal.). The first officer confirmed thisquantity with a fuel dip-stick.

Section 1, page 33, of the CompanyOperations Manual refers to the aircraft's unusablefuel quantity. Subsection 10, paragraph (3),under the title "Fuel System" states:

When it is necessary to conserve fuel,tanks can be drained to approximatelytwo gallons by flying 3° to 5° wing lowon the side opposite to the tank beingdrained and in a slight climb.

The captain reported banking theaircraft during the final descent, in an attemptto conserve fuel. The total unusable fuel wouldthen be 8 imp. gal.; therefore, the aircraft had atotal usable fuel quantity of 428 imp. gal.

1.19.2 Start, Taxi, Run-up, and Take-off Fuel

Section 6, page 1, of the Company OperationsManual states that "normally all flights will beplanned using 550 bhp per engine." Inaddition, the manual states that an "additional10 Imp. gal. will be allowed for every run-up,taxi, and take-off."

If a run-up is not required beforedeparture, the company pilots use an amountless than 10 imp. gal. The captain stated heused a figure of 7 imp. gal. for taxi and take-off;this occurrence flight had six take-offs.

1.19.3 Climb and Cruise Fuel

A Climb Performance Chart located in Section6, page 6, of the Company Operations Manualoutlines the fuel requirements for the aircraft toclimb to altitude with the climb power settingof 785 bhp.

This chart has many parameters, suchas outside air temperature, the altitude at whichthe climb was started, the altitude at which theclimb was completed, the time to climb, thedistance to climb, the fuel required to climb,

etc. For example, the fuel required to climbfrom sea level to 5,000 feet asl is 22 imp. gal.and the fuel required from sea level to2,000 feet asl is 9 imp. gal. This aircraft had sixclimbs ranging from 1,000 feet to 5,000 feet.

The Power Chart as outlined in Section3, page 3, of the Company Operations Manual states:

The fuel consumption for both enginesat 550 bhp engine settings, below 5,000feet asl, and with the mixture controlset to AUTO LEAN is about 71Imperial gallons per hour. The fuelconsumption for both engines at 575and 600 bhp engine settings, with theabove conditions, is about 75 and 77Imperial gallons per hour respectively.

Neither the captain nor the first officerconsulted the fuel consumption charts duringtheir fuel calculations and related discussions. All the flight segments on the day of theoccurrence were flown with the engine set to575 bhp with the mixture in the AUTO RICHposition; the fuel consumption would havebeen greater than the stated 75 imp. gal. perhour.

To expedite flight planning and fuelcalculations, some flight crew add 10 to 15 imp.gal. per hour to the fuel consumptioncalculations instead of computing the climb fuelrequirements. The flight crew of another DC-3, which was substituted to complete the fuelhaul after the accident, reported that theirestimated fuel consumption for the remainingflights was between 85 to 90 imp. gal. per hour.

1.19.4 Fuel Monitoring

To monitor the aircraft's fuel quantity, thepilots of the occurrence aircraft used thecockpit fuel quantity indicator, which theyreported as unreliable, and a fuel tank dip-stick. No visual checks of the fuel quantity wereconducted by the flight crew.

To visually check the fuel quantity,there are many rules of thumb used by DC-3pilots. If, during the visual inspection, the fuelcannot be seen by looking straight down into

FACTUAL INFORMATION


the tank through the eight-inch diameter fillercap, the fuel quantity is usually less than 35 imp.gal. The fuel tank seams are also used forvisual fuel quantity checks. The first seam fromthe bottom of the tank equates to about 50imp. gal., and the second seam from thebottom equates to about 100 imp. gal. Thismethod, however, can only be utilized with theaircraft in a level, three-point attitude.

1.20 Crew Coordination

The captain had flown approximately 30 hourswith the first officer in the previous year.

The flight crew had not received anyformal training from the company in crew orcockpit resource management (CRM) or pilotdecision making (PDM). The captain hadpreviously received CRM and PDM trainingfrom a former employer. CRM is commonlydescribed as the effective use of all resourcesavailable to flight crew, including equipment,technical/procedural skills, and thecontributions of flight crew to others.

The objective of CRM training hasbeen stated as follows:

To use all available resources to ensuresafe and efficient flight operations,while at the same time providing thetechnical and pilot skills training that isneeded to maintain proficiency in themost effective way possible.

ANALYSIS


2.0 Analysis

2.1 Introduction

Because it was determined that the aircraft wasairworthy prior to impact, and that the weatherwas suitable for visual flight at the time of theoccurrence, it was necessary to concentrate onthe human areas of flight planning in order todetermine why the accident occurred. Thefollowing analysis, therefore, focuses primarilyon fuel management and crew coordination.

2.2 Fuel Calculations

During a discussion with the first officer on thelast flight into Trout Lake, about 15 minutesout of Fort Simpson, the captain stated that theaircraft had 45 minutes of fuel remaining. Afterlanding in Trout Lake with approximately30 minutes of fuel remaining, the aircraftdeparted for Fort Simpson with less fuel thanthe minimum required as outlined in the AirRegulations and company requirements. Theprevious two flights to Fort Simpson had taken35 minutes; however, the captain still felt thatthere was enough fuel remaining to completethe flight to Fort Simpson. Neither pilot wassufficiently conscious of the minimum fuelrequirements outlined in the Company OperationsManual.

There was no evidence that companymanagement placed any pressure on companypilots to continue flights with less than theminimum fuel requirements. The self-dispatchpolicy used by the company placed fullresponsibility for all decisions, after the flightwas assigned, with the pilot-in-command.

The fuel dip-stick, which is used tocross-check the accuracy of the fuel gauges,could not be located during the last station stopfuel check. Although the accuracy of the fuelgauges may have been jeopardized without thedip-stick reading, a visual check of the fueltanks through the eight-inch diameter filler capwould have revealed the approximate fuelquantity. Thus, the dip-stick would merely

have confirmed the low fuel status as indicatedon the fuel gauges.

2.3 Pilot Decision Making

In the absence of any management pressure,mechanical malfunction, or any other identifiedsource of external influence, it is apparent thatthe captain chose to attempt the flight with fuelbelow the minimum requirements. Thecompany requirements and the aviationregulations require extra fuel for reserves andcontingencies to provide for a margin of safety. It was the captain who decided the flight couldbe completed safely. His calculations musthave been incorrect.

The final decision to fly with low fuelwas also made in the context of risk assessmentattitudes influenced by remote flying operationswhich, at times, may result in higher levels ofrisk. However, it is clear that, in deciding onthis course of action, the captain misjudged thefuel requirements necessary to safely completethis flight.

2.4 Crew Coordination

In multi-crewed aircraft, team-work is essentialfor the detection of errors in various areas, suchas fuel management. Effective cockpitcommunications are essential to good team-work. Neither the captain nor the first officerhad received formal training from this companyin CRM or PDM, although the captain hadtaken a CRM course with a previous employer.

Following a discussion regarding theaircraft's fuel status at the previous station stop,the captain's fuel calculations and decision toconduct the accident flight were consequentlyaccepted by the first officer. Although thecalculations differed, the first officer, who hadmuch less flying experience than the captain,did not sufficiently assert himself regarding theaircraft's low fuel state.

2.5 Shoulder Harnesses

ANALYSIS


Both pilots received injuries to the head andupper body, likely because they were thrownforward against the instrument panel andcontrols on impact.

The aircraft was not equipped withshoulder harnesses. If shoulder harnesses hadbeen available and worn by the flight crew, theinjuries might have been less severe, orprevented.

CONCLUSIONS


3.0 Conclusions

3.1 Findings

1. The flight crew was certified, trained,and qualified for the flight inaccordance with existing regulations.

2. The aircraft was certified, equipped,and maintained in accordance withexisting regulations and approvedprocedures.

3. The aircraft was airborne for 4 hoursand 37 minutes without refuelling.

4. The engines stopped on approachbecause of fuel exhaustion.

5. There was no evidence found of anyairframe failure or system malfunctionprior to or during the flight.

6. Damage to the propeller systems wasconsistent with a lack of power at thetime of impact.

7. The flight crew operated the aircraftwith less than the required companyminimum quantity of fuel as outlined inSection 1, page 33, of the CompanyOperations Manual.

8. The flight crew operated the aircraftwith less than the minimum requiredquantity of fuel as outlined in ANO,Series VII, No. 2, sections 26 and 27,and Air Regulation 544.

9. Neither of the flight crew members hadreceived formal CRM or PDM trainingfrom the company.

10. Shoulder harnesses, although notrequired by regulation, were not

installed in the aircraft, and both crewmembers received injuries to the headand upper body.

3.2 Causes

The flight was commenced with a fuel quantitybelow the minimum requirements, resulting inloss of engine power because of fuelexhaustion. Contributing to the occurrencewas the lack of flight crew coordination.

SAFETY ACTION


4.0 Safety Action

The Board has no aviation safetyrecommendations to issue at this time.

This report concludes the Transportation Safety Board'sinvestigation into this occurrence. Consequently, the Board,consisting of Chairperson John W. Stants, and membersZita Brunet and Hugh MacNeil, authorized the release ofthis report on 07 June 1995.

APPENDICES


Appendix A - Occurrence Flight Path

APPENDICES


APPENDICES


Appendix B - Glossary

AES Atmospheric Environment Serviceagl above ground levelANO Air Navigation Orderasl above sea levelATPL airline transport pilot licencebhp brake horsepowerC of G centre of gravityCPL commercial pilot licenceCRM crew resource managementDME distance measuring equipmentERS emergency response servicesFSS Flight Service Stationgal gallon(s)GPS Global Positioning System hr hour(s)Imp Imperiallb pound(s)LL low leadmb millibarMDT mountain daylight timeMF mandatory frequencyMHz megahertzN northNDB non-directional beaconnm nautical milesPDM pilot decision makingPF pilot flyingPIREP pilot report of weather conditions in flightPNF pilot not flyingTSB Transportation Safety Board of CanadaUTC Coordinated Universal Time VFR visual flight rulesVHF very high frequencyVOR very high frequency omni-directional rangeW west' minute(s)° degree(s)°M degrees of the magnetic compass

TSB OFFICES

HEAD OFFICE

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*Services available in both officiallanguages

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