A Piper PA-31-350 arrived at Thompson, Manitoba (Canada) on a series of schedules flights for a refuelling stop. As the Pilot In Command (PIC) completed the shutdown checks the Co-Pilot escorted the passengers to the terminal so they could wait for refuelling being comp;eted. A red-and-white fuel truck was observed in front of the aircraft. As the Co-Pilot placed chocks on the nose wheels he noticed the refueller had problems identifying the fuel caps for the main- and auxiliary tanks. He instructed the refueller on fuel quantities and location of the fuel caps for each tank and then escorted the passengers to the terminal.
The aircraft in its final position (Source & © TSB)
In the meantime the refueller commenced refuelling the aircraft, however he noticed the JET-A1 flared spout could not fit through the refuel-openings. He therefor changed the spout for a brass reduced-diameter spout and filled the tanks as instructed. After refuelling was completed the refueller printed a fuel slip and returned to his office. After noticing the refueller had left the PIC went to the refuellers office, but could not gain access to the office, and could not see a fuel slip on the counter.
Neither of the pilots attempted to access the office through the side door.
Exemplar flared spout (left) and reduced diameter (brass) spout (Source & © TSB)
The passengers were boarded and Co-Pilot removed the chocks after checking the fuel caps were installed correctly and boarded the aircraft. A safety briefing was given to the passengers, they all had there lap-belts fastened, the pilots strapped themselves in and completed the pre-flight checks (there were no fuel samples taken from the fuel sumps). At 18.13 lt. (local time) the engines were started and the aircraft taxied towards runway 06 after obtaining there IFR clearance, which would expire at 18.19 lt. Take-off was initiated at 18.17 lt with the Co-Pilot as Pilot Flying
One of the refuel caps with adjacent information fuel placard (Source & © TSB)
During the take-off roll both engines (a Lycoming TIO 540 J2B and a LTIO 540 J2B) were operating normally. However after rotating the aircraft the acceleration and climb performance of the engines was not as expected, and the manifold pressure on the engines had decreased. The landing gear and the flaps were retracted and all efforts were aimed at maintaining airspeed, the maximum altitude they reached was 400 feet on the climb.
The PIC contacted The airports flight Service station, advising they would circle back for a landing on runway 06. When it became apparent that they could reach the airport the PIC took over control of the aircraft as Pilot Flying. An emergency landing on a highway was considered, however due to traffic it was decide to perform a forced landing in a partially cleared wooded area approximately 50 metres north of, and parallel to, the highway. The aircraft came to rest in a partially cleared area, the ELT (emergency locator transmitter activated at 18.21 lt. All occupants sustained varying serious injuries but were able to assist each other and exit the aircraft. One of the pilots flagged down a passing sheriffs vehicle and emergency services were alerted.
Damage to the aircraft was huge, it was written off.
The aircraft in its final position (Source & © TSB) The accident was reported to the Transportation Safety Board of Canada (TSB) who launched an investigation. In their report (which served as the source for this blog) the conclude that there were the following findings as to causes and contributing factors;
Delivery of the incorrect type of aircraft fuel caused loss of power from both engines, necessitating a forced landing.
The fuelling operation was not adequately supervised by the flight crew.
A reduced-diameter spout was installed that enabled the delivery of Jet-A1 fuel into the AVGAS fuel filler openings.
The fuel slip indicating that Jet-A1 fuel had been delivered was not available for scrutiny by the crew.
Several findings as to risk and other findings were incorporated in the report, which can be accessed below, at the end of the blog.
The aircraft in its final position (Source & © TSB)
On the 29th of December 0215 the operators AOC (air operator certificate) was cancelled, citing public interest and the company's aviation safety record following an audit of the operator by Transport Canada.
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