Fuel exhaustion led to the forced landing of a Beechcraft 100 King Air in a field near the St-Mathieu-de-Beloeil Airport, Quebec, in June 2013, according to a report released by the Transportation Safety Board of Canada (TSB)
The TSB also identified deficiencies in the pilot’s performance and the company’s supervision of flights, as well as weaknesses in Transport Canada’s (TC) process for approving operators’ appointments of operations management personnel and in the regulatory oversight of flight operations.
On 10 June 2013 at 17:00 Eastern Daylight Time, a Beechcraft 100 King Air operated by Aviation Flycie Inc. took off from the Montréal/St-Hubert Airport (CYHU), Quebec, Canada, with one pilot and three passengers on board for a test flight. While on its way back to the airport, 24 minutes after take-off, the aircraft ran out of fuel. The pilot decided to divert to the St-Mathieu-de-Beloeil Airport. When the pilot realized that the aircraft would not reach the runway, the pilot attempted a forced landing in a field near the airport. The forced landing ended in an aerodynamic stall and the aircraft struck the ground 30 feet short of the selected field. The aircraft was extensively damaged, and the four occupants sustained minor injuries.
While preparing for the flight, the pilot relied exclusively on the fuel gauges, misread them, and assumed that the aircraft had enough fuel on board for the flight. During the flight, the pilot did not monitor the fuel gauges and, when returning to the airport, decided to extend the flight to practise a simulated instrument landing approach, without noticing there was insufficient fuel to complete it.
The investigation found the pilot had a history of performance that did not meet expected standards to act as pilot-in-command for that aircraft type. Despite a marginal performance during the check flight, the pilot had successfully passed a pilot proficiency check, and TC had approved the individual’s appointment to the position of chief pilot.
Meanwhile, the company’s operations manager, who had no previous experience in commercial air carrier operations, was unable to fully appreciate the significance of the chief pilot’s marginal performance or to detect deviations from regulations in the commercial flights performed over the company’s first three months of operations, which preceded the accident. TC had also approved the appointment of the operations manager.
In addition, the investigation revealed that the person responsible for maintenance (PRM), a new co-pilot on the company’s BE10, had no previous experience in maintenance or in air taxi flight operations. TC had also approved the appointment of the PRM.
The TSB determined that TC’s appointment approval process was not effective and that, once the appointments had been approved, the management team’s inability to perform the duties and responsibilities was not grounds for TC to revoke them.
The TSB has identified safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some transportation companies are not effectively managing their safety risks. The Board has been calling on TC to implement regulations requiring all operators in the aviation industry to have formal safety management processes, and for TC to oversee these companies’ safety management processes.