Blog Post #950 – Causes Behind Forced Landing Cited

Excerpt from the OH&S Canada magazine

The Transportation Safety Board of Canada (TSB) released on August 09, 2018 the findings of investigation on the force lending of an aircraft in Calgary.

On April 25, 2018, Super T Aviation Piper PA-31-350 Navajo Chieftain departed Medicine Hat Airport in Alberta on an instrument flight rules like plan with two flight crewmembers and four passengers on board for a scheduled charter flight to Calgary International Airport. A decent was initiated when the aircraft was approximately 20 nautical miles southeast of the Calgary Airport.

Just prior to landing, the crew contacted the arrival controller about the loss of its right fuel pump. Moments later, the flight crew transmitted he made a call. Recognizing that the aircraft was not going to make it to the airfield, the flight crew attempted an emergency landing on the northbound lanes of 36 Street Northeast when its right wing contacted a light standard on the right side of the road, sheering off a part of the wing. There were no injuries to those on board the aircraft nor to people on the ground.

According to the TSB report, the air operators standard operating procedures (SOPs) did not include any guidance information on fuel monitoring or management the Capt. and first Ofc. use different methods to manage and monitor fuel consumption throughout the flight. When fuel management SOPs are not in place, fuel starvation can occur even if there is sufficient fuel remaining on board the aircraft to complete the plant flight.

Following the incident, the aircraft made several changes to its SOPs and normal procedures checklist for the aircraft, including adding to the company’s SOPs the following: guidance on procedures for accepting runway changes; more detail on aircraft- evacuation procedures; and enhanced procedures on preparing passengers for an emergency landing.

The training syllabus for new crew members and the company’s emergency response plan has also been amended, and an industry-supplied course on fatigue management and human factors has been scheduled.

My opinion

Further information has been located for this report.

Fuel on the plane is stored in flexible fuel cells — two in each wing panel: two outboard and two in-board, according to the TSB. The out-board cells, used during flight, each hold 40 U.S. gallons (but had 16 U.S. gallons each at takeoff). The in-board cells, used during takeoff and landing, hold 56 U.S. gallons each.

Not having switched back to the in-board cells before landing, the crew inadvertently starved the engines of fuel after consuming the out-board cells.

In response, the company has made several changes to its Piper Navajo SOPs, quick reference handbook and normal procedures checklist for the aircraft, and submitted them to Transport Canada. These changes include:

  • Step to set a timer when the out-board tanks are selected;
  • Step to switch from the out-board tanks to the in-board tanks has been moved from the before landing checklist to the descent checklist on the company-generated normal procedures checklist;
  • Guidance on procedures for accepting runway changes has been added to the company SOPs; and
  • More detail on aircraft evacuation procedures has been added to the SOPs.

Fortunately, no one was hurt but they should never have been placed at risk in the first place.

Ensure your workplace is a safe place.

Remember – In Ontario, “ALL Accidents are Preventable”

‘Work’ and ‘Play’ safe.

Daniel L. Beal

CHSEP – Advanced Level
VP & Senior Trainer
HRS Group Inc.

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