Occurrence
A deHavilland DHC-8-102, registration C-GWPS, serial number 120, operating as Perimeter Aviation flight PAG107, departed from Winnipeg/James A. Richardson International Airport under instrument flight rules for a scheduled flight to Island Lake, Manitoba. On board were 2 pilots, a flight attendant, and 22 passengers. At about 1250 Central Daylight Time, during the climb check, the crew determined that the fuel quantity was insufficient for the intended flight. The flight returned to Winnipeg and landed at 1306 without further incident.
History of the Flight
On the preceding leg inbound to Winnipeg, the crew calculated fuel required for the next leg to Island Lake. The calculation showed 4070 pounds of fuel was required for the round trip to Island Lake and back to Winnipeg under instrument flight rules. This was rounded up to 4200 pounds to account for taxi time and ease of fuelling.
At about 1125, the crew contacted a customer service representative (CSR) at a Winnipeg fixed base operator (FBO) and provided the estimated time of arrival and desired fuel load. The crew requested the fuel truck meet the aircraft at the Perimeter Aviation apron for a quick turnaround. The CSR wrote the fuel load information on a notepad. This information was not passed on to the FBO line foreman; the CSR became distracted and later assumed the information had been passed. The fuel load was not transcribed to the log sheet.
The flight arrived at 1138. Fuel remaining at shutdown was 1540 pounds. The crew completed the shutdown check and instrument cross-check, and partially completed the BEFORE START–ENROUTE checklist. The "fuel quantity" and "fuel on caution light" items were deferred because the aircraft had not yet been fuelled. The crew placed a fuel transfer card on the glare shield as a reminder of the deferred items and also to remind them to close the cockpit escape hatch, which they opened to the vent position.
The BEFORE START–ENROUTE checklist matched the sequence of events during turnarounds, but deferring the fuel quantity check had become an accepted practice at the company. This adaptation allowed pilots to complete the checklist to the line before engine start, reducing time. Pilots used various reminders to ensure they checked fuel quantity. The PAG107 pilots used the fuel transfer card as a reminder for both the deferred fuel check and the open hatch.
Pilot supervision of fuelling is intended to ensure safety and verify fuel quantity as per the company operations manual. However, Perimeter pilots in Winnipeg considered the fuel truck operators familiar with the aircraft, so they did not supervise fuelling. This eliminated an opportunity to verify fuel. Both pilots saw the fuel truck connected to the aircraft and assumed the operator knew the fuel requirement. When they returned, the truck was gone, confirming in their minds that fuel had been uploaded.
Fuel truck operators obtained fuel requirements through informal, undocumented FBO processes. The FBO's informal defence required the truck operator to confirm the upload with a pilot. In this occurrence, the truck operator arrived not knowing the requested fuel load and did not commence fuelling. The crew assumed the requirements had been communicated. The operator later disconnected, fuelled another aircraft, reconnected, and eventually concluded the flight was delayed or cancelled, leaving without fuelling. Perimeter was not notified. Fuel slip distribution had been discontinued, removing another opportunity to verify.
When the pilots returned to the cockpit, the fuel transfer card prompted them to close the escape hatch, but the deferred fuel quantity check was forgotten. The fuel quantity indicators were not checked before departure.
Findings
The fuel requirements were not passed on to the line foreman or truck operator. Consequently, the aircraft was not fuelled. The crew discovered the fuel shortage during the 10 000-foot level check and returned to Winnipeg, avoiding fuel exhaustion.
Perimeter investigated the occurrence under its safety management system. Short-term corrective action included a memo on 29 June 2010 directing all pilots to cease the practice of doing the Before Start Checklist while passengers deplaned and after leaving the aircraft. Long-term corrective action included using the occurrence as a case study for crew resource management training.