Aviation Occurrence Report Fuel Exhaustion Buffalo Airways (1986) Ltd. Douglas Dc-3C C-Frod Fort Simpson Airport, Northwest
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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 SW 26 JUNE 1994 REPORT NUMBER A94W0106 MANDATE OF THE TSB The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework governing the TSB's activities. Basically, the TSB has a mandate to advance safety in the marine, pipeline, rail, and aviation modes of transportation by: ! conducting independent investigations and, if necessary, public inquiries into transportation occurrences in order to make findings as to their causes and contributing factors; ! reporting publicly on its investigations and public inquiries and on the related findings; ! identifying safety deficiencies as evidenced by transportation occurrences; ! making recommendations designed to eliminate or reduce any such safety deficiencies; and ! conducting special studies and special investigations on transportation safety matters. It is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board must not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings. INDEPENDENCE To enable the public to have confidence in the transportation accident investigation process, it is essential that the investigating agency be, and be seen to be, independent and free from any conflicts of interest when it investigates accidents, identifies safety deficiencies, and makes safety recommendations. Independence is a key feature of the TSB. The Board reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be fully objective in arriving at its conclusions and recommendations. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Occurrence Report Fuel Exhaustion Buffalo Airways (1986) Ltd. Douglas DC-3C C-FROD Fort Simpson Airport, Northwest Territories .5 nm SW 26 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 the Flight Service Station that they were attempting a forced landing on a road. The aircraft crashed into trees about one-half nautical mile short of the runway and was substantially damaged. The first officer was seriously injured and the captain received minor injuries. The Board determined that the flight was commenced with a fuel quantity below the minimum requirements, resulting in loss of engine power because of fuel exhaustion. Contributing to the occurrence was the lack of flight crew coordination. Ce rapport est également disponible en français. TABLE OF CONTENTS Table of Contents Page 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 TRANSPORTATION SAFETY BOARD iii TABLE OF CONTENTS 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 Appendices Appendix A - Occurrence Flight Path............................................. 19 Appendix B - Glossary......................................................... 21 List of Figures Figure 1 - Flight Segments...................................................... 2 iv TRANSPORTATION SAFETY BOARD FACTUAL INFORMATION 1.0 Factual Information were loaded on board, then the aircraft departed at 1049. The captain climbed the aircraft to an altitude of 3,500 feet asl. After he 1.1 History of the Flight levelled off the aircraft, the captain adjusted the engines to 575 brake horsepower (bhp) settings. Buffalo Air Flight 526, a Douglas DC-3C freighter based in Yellowknife, was hauling jet At 1120, the aircraft landed at fuel to Trout Lake from Fort Simpson, Trout Lake and the drums were off-loaded, and Northwest Territories, in support of forest fire at 1135 the aircraft was once again airborne on suppression operations. the second round-trip shuttle flight. Before the departure from Yellowknife Thirty-five minutes later the aircraft to Trout Lake, the flight crew checked the landed at Fort Simpson. While the cargo was en route weather and filed a company flight being loaded on the aircraft, the flight crew itinerary. Dispatch issued the flight crew an discussed their different calculations regarding aircraft-fuel-load receipt which indicated that the aircraft's fuel quantity. The first officer the aircraft had been fuelled the night before indicated that the aircraft required fuel. The with a total fuel quantity of about 436 imperial captain calculated that the aircraft had sufficient gallons (imp. gal.): full main tanks (336 imp. fuel remaining. The captain decided that they gal.), and 50 gallons in each auxiliary tank (100 would refuel at Fort Simpson on the next imp. gal.). The first officer confirmed this shuttle flight; nonetheless, since the flight crew quantity with a fuel dip-stick borrowed from considered the cockpit fuel gauges unreliable, the refueller. the captain requested that the first officer confirm the fuel quantity using a dip-stick. At 0740 mountain daylight saving time (MDT)1, the flight crew departed Yellowknife At 1228, the aircraft departed in accordance with visual flight rules (VFR)2. Fort Simpson and climbed to 5,000 feet asl. On board the aircraft were 17 full 45-imperial- About eight minutes later, the flight crew 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 at Trout Lake, and the 17 drums of jet fuel were off-loaded; the aircraft then departed for Fort Simpson at 0945. The 82-nautical-mile (nm) flight to Fort Simpson was flown at an altitude of about 2,500 feet above sea level (asl); the flight crew reported encountering light headwinds. At 1020 the aircraft landed at Fort Simpson. Once again 17 drums of jet fuel TRANSPORTATION SAFETY BOARD 1 FACTUAL INFORMATION