A crash landing by a Churchill-bound medevac plane whose pilots tried to land at the Gillam Airport on April 24, 2019 happened because the flight crew failed to ensure there was sufficient fuel in the tanks for the flight, the Transportation Safety Board of Canada (TSB) said in a report released July 27.
The Beechcraft B200 landed on the frozen surface of Stephens Lake just short of the airport runway and lost its landing gear when it hit the lake shore and skidded up onto the runway, which was about 12 feet higher than the frozen lake at the time. Neither the pilot nor the first officer nor either of the two flight nurses on board was injured in the crash.
The flight was to reposition the plane, operated by Keewatin Air, from Winnipeg to Rankin Inlet, Nunavut with a stop in Churchill to drop off one of the flight nurses.
The crash happened shortly after 6 p.m. after the pilot redirected to Gillam Airport when the low fuel warning light came on. Both engines had shut down by the time the plane landed on the frozen lake.
The plane had flown to Winnipeg from Baker Lake, Nunavut the previous day but the arriving flight crew couldn’t find a fuel technician to refuel it, as was common practice for the airline, to ensure planes were ready to be deployed for emergency medevac flights.
When the first officer could not find a fuel technician to refuel the plane in preparation for the flight to Churchill and Rankin Inlet on April 24, he went to the lounge, found out that the flight would be delayed pending the arrival of the second flight nurse and loaded some bottled water onto the plane, forgetting to get it fuelled up. The captain did not check the fuel quantity indicators when the flight crew completed their after start checklist or when he performed a progressive fuel calculation following takeoff. Neither of the pilots performed periodic scans of the fuel quantity indicators while en route to their destination and the first officer did not remember that he had forgotten to order fuel until the left fuel pressure warning light came on when the aircraft was about 14 nautical miles west-northwest of Gillam Airport, the TSB report said.
Within 10 days after the accident, Keewatin Air issued a safety bulletin to all pilots and flight co-ordinators instructing them all to confirm the number of pounds of fuel when completing their checklists by visually checking the fuel quantity indicators.
The TSB says the Town of Gillam and RCMP also held a post-crash briefing regarding emergency services’ response to the crash, as the on-call airport operator didn’t notify emergency medical services and the fire department until about an hour after first learning of the fuel emergency. Though there was no fire or injuries as a result of the crash, if there were, emergency responders would not have been onsite immediately because of the delay in being notified. The TSB report says the Town of Gillam prepared a Gillam Airport Emergency Response Quick Reference document to detail the priority in which agencies should be notified and the actions that the on-call airport operator should take when notified of an aviation emergency or incident.