Accident Beechcraft B200 Super King Air C-FRMV,

ASN Wikibase Occurrence # 319447

Date:	Wednesday 24 April 2019
Time:	19:15
Type:	Beechcraft B200 Super King Air
Owner/operator:	Keewatin Air
Registration:	C-FRMV
MSN:	BB-979
Year of manufacture:	1981
Engine model:	Pratt & Whitney Canada PT6A-42
Fatalities:	Fatalities: 0 / Occupants: 4
Aircraft damage:	Substantial, written off
Category:	Accident
Location:	Gillam Airport, MB (YGX) - Canada
Phase:	Landing
Nature:	Ferry/positioning
Departure airport:	Winnipeg International Airport, MB (YWG/CYWG)
Destination airport:	Churchill Airport, MB (YYQ/CYYQ)
Investigating agency:	TSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Beechcraft B200 medevac aircraft operated by Keewatin Air, was conducting positioning flight KEW202 from Winnipeg/James Armstrong Richardson Intl (CYWG), MB to Churchill (CYYQ), MB with 2 flight crew and 2 flight nurses on board.
A captain in training assumed the role of pilot-in-command (PIC) and Piot Flying while the line indoctrination captain acted as first officer (FO) and Pilot Monitoring on the flight.
The FO conducted a pre-flight inspection of the aircraft and noted that the aircraft had about 1600 pounds of fuel on board. Because he preferred to order fuel directly from a fuel technician, he went to the fuel office in the hangar, but could not find anyone to take the fuel order. Intending to return to the office later, he went to the lounge where he found out that the flight would be delayed pending the arrival of the 2nd flight nurse. When the captain asked if the aircraft was ready for the flight, the FO replied that it was.
When preparing for departure, the flight crew completed the BEFORE START checklist. The last step on the checklist was to start the engine. The flight crew then taxied to a run-up area and began the AFTER START checklist. When the FO read out the checklist item FUEL QUANTITY, the captain responded with the text that was printed on the checklist, "SUFFICIENT/BALANCED," but he did not check the fuel quantity indicators. When the checklist was complete, the crew taxied to the runway. The aircraft departed CYWG at 16:39.
Roughly 8 NM after the takeoff, while still in the climb, the captain performed a progressive fuel calculation. He did not look at the fuel quantity indicators during the process. The aircraft continued the climb and levelled off at flight level (FL) 250. During the rest of the flight, neither pilot performed periodic scans of the fuel quantity indicators.
At 18:13, when the aircraft was about 14 NM west-northwest of Gillam Airport (CYGX) and still level at FL 250, the left fuel pressure (L FUEL PRESS) warning light illuminated, indicating low fuel. The warning was followed almost immediately by power surging in the left engine. The captain turned the boost pump ON, and noticed that the fuel quantity indicators were showing 0 pounds. The captain asked the FO about the fuel quantity, at which point the FO realized that he had forgotten to order fuel. The flight crew declared an emergency with the Winnipeg Area Control Centre (ACC) at 18:14 and began an emergency descent. The weather conditions at CYYQ were marginal, so the decision was made to divert to the alternate aerodrome, CYGX; however, the aircraft continued on the same heading toward CYYQ for another 2 minutes
By 18:15, when the aircraft was at FL 220, the left engine had exhausted its fuel supply and lost power. The crew conducted the emergency engine shutdown procedure in the Emergency and Abnormal Procedures Quick Reference Handbook (QRH) to shut down the engine; however, the left propeller continued to windmill at speeds between 1300 and 2000 rpm throughout the ensuing descent. At 18:15:32, the FO programmed the FMS to display a track to CYGX and instructed the captain to turn right and follow the track. The FO moved the heading bugs, which were coupled on both FMS displays, to the CYGX heading. The captain then initiated a right turn toward CYGX.
The captain reduced the power setting of the right engine. From 18:15 to 18:18, the rate of descent varied between 3000 and 6000 fpm. The crew extended the landing gear in an attempt to set up a suitable descent angle to Runway 23. At 18:17, the flight crew informed the ACC that the nature of the emergency was fuel related. The ACC provided the flight crew with the weather at CYGX and informed them that emergency services at CYGX would be notified. As the aircraft descended through approximately 5000 feet above sea level (ASL), the FO obtained a vertical navigation (VNAV) profile to Runway 23 on the FMS. The crew retracted the landing gear as the aircraft intercepted the VNAV path.
By 18:20, the airspeed had decayed to approximately 100 knots and the captain was having difficulty controlling the aircraft. At times, the aircraft was descending below the VNAV path. Seeing this, the FO took over control and assumed the Pilot Flying duties. At 18:21, as the aircraft descended through 2800 feet ASL, the left propeller ceased windmilling as the rpm decreased from 1300 to 0 rpm. The flight crew made a Mayday call at 18:21:30 on the CYGX mandatory frequency. When the aircraft was at approximately 2000 feet ASL, it descended below the cloud base and the FO was able to visually identify CYGX.
At 18:22:34, when the aircraft was at 1300 feet ASL, roughly 835 feet above ground level (AGL), the right engine lost power. The aircraft could no longer maintain the VNAV path or a suitable visual approach to the runway. When the aircraft was at about 530 feet AGL and 1 NM from the runway, the crew shut down and feathered the right engine while continuing the right-hand curving visual approach to Runway 23.
The flaps remained up throughout the approach and subsequent landing. The crew selected the landing gear DOWN when the aircraft was at about 50 feet AGL and the aircraft touched down on the frozen surface of Stephens Lake with the landing gear fully extended.
Sufficient airspeed remained to enable the FO to raise the nose as the aircraft approached the rocky shoreline at the approach end of Runway 23. The aircraft struck the rocky shoreline in a nose-high attitude and skidded up onto the right edge of the runway area, coming to rest approximately 190 feet before the threshold .

Findings as to causes and contributing factors
1. 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.
2. While performing the FUEL QUANTITY item on the AFTER START checklist, the captain responded to the first officers prompt with the rote response that the fuel was sufficient, without looking at the fuel gauges.
3. The aircraft departed Winnipeg/James Armstrong Richardson International Airport with insufficient fuel on board to complete the planned flight.
4. The flight crew did not detect that there was insufficient fuel because the gauges had not been included in the periodic cockpit scans.
5. When the flight crew performed the progressive fuel calculation, they did not confirm the results against the fuel gauges, and therefore their attention was not drawn to the low-fuel state at a point that would have allowed for a safe landing.
6. Still feeling the effect of the startle response to the fuel emergency, the captain quickly became task saturated, which led to an uncoordinated response by the flight crew, delaying the turn toward Gillam Airport, and extending the approach.
7. The right engine lost power due to fuel exhaustion when the aircraft was 1 nautical mile from Runway 23. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway.

Accident investigation: