Introduction
On the afternoon of the accident, a float-equipped Cessna 185A (registration C-FBWP, serial number 185-0430) operated by West Caribou Air Service Inc. departed Summer Beaver, Ontario, with one pilot and one passenger on board. The flight was conducted under visual flight rules to Thunder Bay, Ontario. While approaching Thunder Bay, the pilot orbited to contact the control tower. During a gradual right turn, the engine lost power, and the pilot performed a forced landing into trees approximately 10 nautical miles northeast of Thunder Bay. The pilot and passenger were not injured, but the aircraft was substantially damaged. The accident occurred at 1458 Eastern Daylight Time during daylight hours.
Weather
The 1500 aviation routine weather report (METAR) for Thunder Bay Airport reported wind 060° True at 10 knots, visibility 20 statute miles, temperature 3°C, overcast cloud at 1400 feet above ground level, and an altimeter setting of 29.83 inches of mercury. Forecast upper winds for 3000 feet above sea level valid between 0500 and 1400 indicated 210°T at 12 knots for Big Trout Lake and 140°T at 12 knots for Armstrong. These winds would have produced a 10-knot headwind component for both the earlier flight between Webequie and Summer Beaver and the occurrence flight between Summer Beaver and Thunder Bay.
Pilot Qualifications
The pilot held a commercial pilot licence valid for single-engine land and sea aeroplanes, with night and class IV instructor ratings, and a category 1 medical certificate valid until 01 July 2010. He graduated from an aviation college training program in spring 2009 and was hired by the company in September 2009. Available records indicate the pilot had accumulated approximately 450 hours of total flight time prior to the occurrence, with about 33 hours on the accident aircraft.
Company Training
The pilot underwent a company training program covering dangerous goods, company policy, and flight training and emergency procedures on the Cessna 185 and Norseman aircraft. The company operations manual (COM) requires a minimum of three hours of initial flight training for each aircraft type flown, consistent with the Commercial Air Services Standards (CASS). For day VFR operations, the CASS requires the chief pilot or delegate to certify the pilot's competency on the most complex single-engine aeroplane. The minimum 3.0 hours of initial flight training may include flight time during a pilot competency check.
An examination of company training files, aircraft journey logs, and the pilot's flying log revealed discrepancies. The training pilot's flying log was not up to date and did not document any of the occurrence pilot's training flights. Records showed the pilot received 0.5 hours on 19 September 2009, 1.5 hours on 04 October 2009 with a 1.0-hour pilot competency check, and an additional 1.9 hours during line operations on 05 October 2009. Some flights were not recorded in all required documents. The COM specifies that only flight crew essential to training shall be carried on board or other company personnel for familiarization during a training flight. The COM also requires six hours of technical ground training; the pilot had not received any classroom training but was provided a Cessna 185 owner's manual for self-study. The training file indicated the pilot completed technical ground training between 19 September and 04 October 2009, but without a record of the amount of training provided.
Pre-Flight Preparations
The aircraft was stationed at the company's float plane base in Webequie. The evening before, the pilot was told to pick up a passenger in Summer Beaver at noon and fly to Thunder Bay. The acting chief pilot instructed the pilot to fill the aircraft with fuel but did not specify which fuel filler openings to use. The acting chief pilot estimated the flight would last 3 to 3.5 hours and that a full fuel load would provide 4.5 hours endurance plus 0.5 hours reserve, based on the aircraft's full fuel capacity of 84 US gallons and a full rich mixture fuel consumption of 16 US gallons per hour (gph).
The aircraft was equipped with Wipline model 3700 floats, for which cruise performance charts are not available. The Cessna 185 Floatplane owner's manual supplement for EDO Model floats provides a cruise performance chart based on a normal lean mixture; no figures are available for full rich mixture operation. Specified endurance at 2500 feet asl at 70% power (24 inches manifold pressure and 2450 rpm) with no reserve is 5.5 hours with 81 US gallons usable fuel and 4.2 hours with 62 US gallons usable fuel.
On the day of the accident, the pilot fuelled the aircraft from the company's facility. The aircraft had an early model ON-OFF fuel system with long range tanks consisting of bladder style wing tanks (one per wing) with inboard and outboard fuel filler openings. Filling through the inboard openings provides a total fuel capacity of 65 US gallons (62 usable); filling through the outboard openings provides 84 US gallons (81 usable). The pilot filled using the inboard openings and used a dip stick to confirm 32.5 US gallons per side. He had never used the outboard openings during his time with the company or during training. During company training, the pilot was told that a full fuel load provides 4.5 hours endurance; he believed this was based on inboard filling and an average fuel consumption rate of 15 US gph at 24 inches mp and 2450 rpm. Based on a direct distance of about 350 nm and average groundspeed of 120 mph, the pilot estimated total flight time from Webequie to Summer Beaver to Thunder Bay as 2.5 to 3.0 hours with a total fuel burn of approximately 38 US gallons.
The aircraft fuel gauges had been reading intermittently prior to the accident and were not monitored during flight. The gauges would sometimes read empty when tanks were full, but the fault could not be duplicated during maintenance. The pilot was instructed to dip the tanks before each flight and use fuel calculations to ensure adequate fuel.
History of Flight
The aircraft departed Webequie at 1037 after taxiing to the north end of the lake. The pilot conducted normal pre-flight engine checks before taking off into wind towards the south. He turned west toward Summer Beaver and climbed to 2000 feet asl. The pilot selected a full-rich mixture setting in accordance with company policy for flights below 5000 feet asl to prevent high engine temperatures. Upon reaching Summer Beaver, he circled, observed ice on part of the lake, and landed on an ice-free area, arriving at the dock at 1125.
The passenger arrived with more baggage than expected; the rear seats were removed and stowed to make room. No scale was available; the pilot estimated the weight of each piece. Baggage was placed in the cabin behind the cockpit seats without a cargo net; ropes were available but not used. The aircraft's total weight was estimated at 3310 pounds, the maximum authorized gross weight.
The aircraft departed Summer Beaver at 1203 and climbed to 4500 feet asl. At full rich mixture, the fuel flow gauge indicated about 16.5 to 17 US gph, and groundspeed varied between 110 and 120 mph as displayed by the GPS. At 1450, the pilot advised Thunder Bay tower that the aircraft was 15 miles north and would land at the water aerodrome in 6 minutes. The tower instructed the pilot to report on final approach to the harbour. The pilot could not understand the controller due to poor radio reception.
Not knowing if he was cleared to enter the control zone, the pilot began a shallow right turn to avoid entering controlled airspace without clearance and repeated his intentions. Approximately 3 minutes into the turn at 3000 feet asl (1700 feet agl), the engine began to sputter and lose power. The pilot levelled the wings and performed the engine power-loss check from memory. The mixture was confirmed full rich, magnetos set to BOTH, and the throttle was pumped but the engine did not respond. The electric auxiliary fuel pump, required by the owner's manual to be activated in case of engine failure during flight, was not turned on.
The pilot informed the tower that the aircraft was out of fuel; no further communications were exchanged. The aircraft banked left toward a small lake but was too low to reach it. The pilot slowed the aircraft just prior to entering the trees. The aircraft came to rest in a left wing low, nose-down attitude at the base of a large tree. Both wings and floats were substantially damaged; both cockpit doors were jammed shut. The baggage had shifted but did not enter the cockpit. The pilot and passenger were uninjured and exited through the right cockpit door window.
The aircraft was equipped with a newly-installed 406 MHz emergency locator transmitter (ELT) and a SPOT satellite device. The company had been tracking the flight via SPOT. At 1515 the pilot activated the SOS/911 button on the unit.