Wrong fuel caused northern Manitoba plane to crash, injuring eight

WINNIPEG — A new report by the Transportation Safety Board of Canada found use of the wrong fuel and inadequate supervision were to blame for a small plane crash near Thompson, Man., that injured eight people last fall.

Keystone Flight 408 left Thompson on Sept. 15, 2015, en route to Winnipeg, but had problems and turned around, crashing just short of the runway at the Thompson Airport.

Eight people on board were taken to hospital, including six passengers and two pilots.

The investigation concluded a fuel handling technician with little experience used the wrong fuel, and procedures that might have caught the mistake weren’t followed.

Keystone Air had its air operator certificate cancelled last year.

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The investigation found the flight was operating a series of trips to several northern Manitoba communities that day.

It landed in Oxford House and was scheduled to leave for Pikwitonei Airport, but the crew determined the weather made the trip too dangerous so they decided to fly to the Thompson Airport to refuel.

A fuel dealer was contacted to meet the flight, but the investigation found the chief pilot was too busy with post-flight duties to deal with the fuel handling technician, and handed off the job to the deputy pilot.

The deputy pilot noticed the technician was having trouble finding which fuel filler openings were for the main tank, so pointed them out. However, he did not specify what type of fuel was needed, and the technician used Jet-A1 fuel instead of the required AvGas fuel.

The report said the technician had about one month experience fuelling aircrafts and had only just begun to work without supervision.

He was required to present a fuel order form where the crew would have specified the fuel type, but the report noted the form was almost never used by the fuel dealer’s employees.

The report said when the crew started the engines, the remainder of the AvGas fuel was still being used by the plane, so the engines were performing normally.

Later, however, both engines started to fail. The plane then tried to perform a forced landing on Highway 391, but oncoming traffic foiled the plan.

The plane then landed in a partially cleared wooded area, with the cabin door forced open during impact with the ground.

The report said those on the plane sustained various serious injuries, but were able to help each other to exit the aircraft.

The TSB said a post-accident inspection found safety concerns and Keystone’s air operator certificate was suspended. After an in-depth review of the company’s safety record, the Minister of Transport cancelled its air operator certificate in December 2015.

(CTV Winnipeg)

The Canadian Press