Keystone Air Service

Findings as to causes and contributing factors:
1. Delivery of the incorrect type of aircraft fuel caused loss of power from both engines, necessitating a forced landing.
2. The fueling operation was not adequately supervised by the flight crew.
3. A reduced-diameter spout was installed that enabled the delivery of Jet-A1 fuel into the AVGAS fuel filler openings.
4. The fuel slip indicating that Jet-A1 fuel had been delivered was not available for scrutiny by the crew.

Findings as to risk:
1. If administrative and physical defences against errors in aviation fuel operations are circumvented or disabled, there is a risk that the incorrect type of fuel will be delivered.
2. If a reduced-diameter spout is available to accommodate non-standard fuel filler openings, there is an increased risk that Jet-A1 fuel can be dispensed into an aircraft that requires AVGAS.

Other findings:
1. Aircraft that were manufactured prior to the current airworthiness standards, or that have been modified by the installation of turbine engines, may have fuel filler openings that do not meet the dimension requirements.
2. The airworthiness standards for rotorcraft do not specify the size of fuel filler openings.
3. The use of all of the available restraint systems in the aircraft contributed to the survival of the occupants.
4. There was no post-crash fire, likely due to the separation of the battery from the aircraft and to the rain-saturated crash site.
5. The absence of a post-impact fire contributed to the survival of all of the aircraft's occupants.

Findings as to causes and contributing factors:
1. The pilot's decision to conduct an approach to an aerodrome not serviced by an instrument flight rules approach in adverse weather conditions was likely the result of the pilot's inexperience, and may have been influenced by the pilot's desire to successfully complete the flight.
2. The pilot's decision to descend into cloud and continue in icing conditions was likely the result of inadequate awareness of the Piper PA31-350 aircraft's performance in icing conditions and of its de-icing capabilities.
3. While waiting for the runway to be cleared of snow, the aircraft held near North Spirit Lake (CKQ3) in icing conditions. The resulting ice accumulation on the aircraft's critical surfaces would have led to an increase in the aircraft's aerodynamic drag and stall speed, causing the aircraft to stall during final approach at an altitude from which recovery was not possible.
Findings as to risk:
1. Terminology contained in aircraft flight manuals and regulatory material regarding “known icing conditions,” “light to moderate icing conditions,” “flight in,” and “flight into” is inconsistent, and this inconsistency increases the risk of confusion as to the aircraft’s certification and capability in icing conditions.
2. If confusion and uncertainty exist as to the aircraft’s certification and capability in icing conditions, then there is increased risk that flights will dispatch into icing conditions that exceed the capability of the aircraft.
3. The lack of procedures and tools to assist pilots in the decision to self-dispatch leaves them at increased risk of dispatching into conditions beyond the capability of the aircraft.
4. When management involvement in the dispatch process results in pilots feeling pressure to complete flights in challenging conditions, there is increased risk that pilots may attempt flights beyond their competence.
5. Under current regulations, Canadian Aviation Regulations (CARs) 703 and 704 operators are not required to provide training in crew resource management / pilot decision-making or threat- and error-management. A breakdown in crew resource management / pilot decision-making may result in an increased risk when pilots are faced with adverse weather conditions.
6. Descending below the area minimum altitude while in instrument meteorological conditions without a published approach procedure increases the risk of collision with terrain.
7. If onboard flight recorders are not available to an investigation, this unavailability may preclude the identification and communication of safety deficiencies to advance transportation safety.

Findings as to Causes and Contributing Factors:
1. The pilot did not correctly calculate the amount of fuel required to accomplish the flight from Winnipeg to Gunisao Lake and return, and did not ensure that the aircraft carried sufficient fuel for the flight.
2. The ILS approach was flown above the glideslope and beyond the missed approach point, which reduced the possibility of a safe landing at Winnipeg, and increased the risk of collision with terrain.
3. During the missed approach, the aircraft's engines lost power as a result of fuel exhaustion, and the pilot conducted a forced landing at a major city intersection.
4. The pilot did not ensure that the aircraft was equipped with an autopilot as specified by CARs.
Findings as to Risk:
1. The company did not provide an adequate level of supervision and allowed the flight to depart without an autopilot.
2. The company operations manual did not reflect current company procedures.
3. The company did not provide an adequate level of supervision and allowed the flight to depart without adequate fuel reserves. The company did not have a safety system in place to prevent a fuel exhaustion situation developing.
Other Findings:
1. The pilot did not advise air traffic control of his critical situation in a timely fashion.