Occurrence
On 24 April 2019, a Keewatin Air LP Beechcraft B200 (registration C‑FRMV, serial number BB979) was conducting an instrument flight rules positioning flight (flight KEW202) from Winnipeg/James Armstrong Richardson International Airport, Manitoba, to Rankin Inlet Airport, Nunavut, with a stop at Churchill Airport, Manitoba. The aircraft was configured for medical evacuation flights and carried 2 flight crew members and 2 flight nurses.
Sequence of Events
At 1814 Central Daylight Time, while cruising at flight level 250, the flight crew declared an emergency due to a fuel issue. They diverted to Gillam Airport, Manitoba, and initiated an emergency descent. During the descent, both engines flamed out. The flight crew attempted a forced landing on Runway 23, but the aircraft touched down on the frozen surface of Stephens Lake, 750 feet before the runway threshold. The landing gear was fully extended. The aircraft struck the rocky lake shore and traveled up the bank toward the runway area, coming to rest 190 feet before the threshold of Runway 23 at 1823:45 Central Daylight Time. None of the occupants was injured. The aircraft sustained substantial damage. The 406 MHz emergency locator transmitter activated. Emergency services responded. There was no fire.
Findings
The official investigation identified several findings as to causes and contributing factors:
- When the captain asked if the aircraft was ready for the flight, the first officer replied that it was, not recalling that the aircraft required fuel.
- While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officer’s prompt with a rote response that the fuel was sufficient, without looking at the fuel gauges.
- The aircraft departed with insufficient fuel on board to complete the planned flight.
- The flight crew did not detect insufficient fuel because the gauges had not been included in periodic cockpit scans.
- When performing the progressive fuel calculation, they did not confirm results against the fuel gauges, thus not drawing attention to the low-fuel state in time for a safe landing.
- Still feeling the effect of the startle response, the captain quickly became task saturated, leading to an uncoordinated response that delayed the turn toward Gillam Airport and extended the approach.
- The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23, making a successful forced landing on the runway impossible; the aircraft touched down on the ice short of the runway.
Findings as to risk noted that if procedures are not developed for pilot roles during line indoctrination flights, flight crew may not participate as expected or may work toward different goals. Another finding noted that emergency medical services and the fire department were not notified immediately about the declared emergency, so they were not on site before the aircraft arrived at Gillam Airport.