What happened
A deHavilland DHC-8-102, registered as C-GWPS, was scheduled for an instrument flight from Winnipeg/James A. Richardson International Airport to Island Lake, Manitoba. The flight, operated by Perimeter Aviation, included 22 passengers and three crew members.
Prior to departure, the crew had requested a specific fuel load from a local fixed base operator to ensure enough fuel for the round trip. However, due to a communication failure at the fuel provider, the request was never processed, and the aircraft was not refueled. During the climb phase of the flight, the crew performed a level check at 10,000 feet and realized the fuel quantity was inadequate for the intended mission. The aircraft returned to Winnipeg and landed safely.
The investigation
The investigation focused on why the fuel shortage went unnoticed during the turnaround. It was established that the fuel provider's customer service representative failed to pass the fuel requirements to the line foreman or the truck operator.
Investigators also examined the cockpit procedures used by the crew. The pilots had adopted a practice of performing the 'Before Start–Enroute' checklist partially during the arrival phase to save time. To manage the incomplete items, the crew used a fuel transfer card on the glare shield as a visual reminder. However, because the card was also being used as a reminder to close the cockpit escape hatch, the crew removed the card after closing the hatch, inadvertently removing the reminder to verify the fuel quantity.
Findings
- The fuel requirements were never communicated to the fuel truck operator.
- The pilots did not supervise the refueling process, despite company policy, and incorrectly assumed the task was being completed because they saw the fuel hose connected to the aircraft.
- The crew failed to verify the fuel quantity due to a reliance on an informal checklist adaptation and the removal of a visual reminder.
- The lack of formal documentation, such as fuel slips, removed a final opportunity for the crew to confirm the load.