Accident de Havilland Canada DHC-6 Twin Otter 300 C-GNPS,

ASN Wikibase Occurrence # 318913

Date:	Monday 1 November 2021
Time:	18:51
Type:	de Havilland Canada DHC-6 Twin Otter 300
Owner/operator:	Air Tindi
Registration:	C-GNPS
MSN:	558
Year of manufacture:	1978
Total airframe hrs:	48887 hours
Engine model:	Pratt & Whitney Canada PT6A-34
Fatalities:	Fatalities: 0 / Occupants: 5
Aircraft damage:	Substantial, repaired
Category:	Accident
Location:	12,4 km NW of Fort Providence, NT - Canada
Phase:	En route
Nature:	Passenger - Scheduled
Departure airport:	Yellowknife Airport, NT (YZF/CYZF)
Destination airport:	Fort Simpson Airport, NT (YFS/CYFS)
Investigating agency:	TSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
Air Tindi flight 223, a DHC-6 Twin Otter, made an emergency landing in the Bluefish Creek area, about 12,4 km northwest of Fort Providence, Northwest Territory, Canada.
The aircraft departed Yellowknife Airport at 17:48 hours local time and approximately 40 minutes into the flight, a loss of engine power forced the crew to divert to Fort Providence, NT (CYJP). The aircraft was not able to reach the airport and a forced landing was performed at 18:51, approximately 14 km from the airport. There were no injuries to the flight crew or passengers. Approximately 8 hours after the forced landing, all occupants were recovered by rescue personnel.

Findings as to causes and contributing factors
1. When the captain saw the pink fuel slip in the door of the aircraft, it reinforced his belief that the aircraft had been fuelled for the last flight of the day, when, in actuality, it had not been refuelled.
2. While conducting the Before Start checks from memory, the captain interrupted his routine by conversing with a passenger. Consequently, the fuel quantity check was missed and the preparation for flight continued without the captain being aware that the aircraft did not have sufficient fuel for the flight on board.
3. Over time, the captain developed an adaptation of not conducting the challenge and response checklists where required by the standard operating procedures. The absence of negative consequences reinforced the captains practice until it became routine.
4. On the day of the occurrence, the first officers adaptation regarding checklist usage was influenced by the seniority of the captain, the captains non-standard use of checklists, and the absence of negative repercussions from this adaptation.
5. While taxiing to the runway, the captain conducted the Taxi checks alone, silently, and from memory. Consequently, the fuel check on the checklist was missed and the aircraft departed with insufficient fuel for the flight.
6. The first officer completed the cruise checks silently and without reference to a checklist. As a result, the fuel state of the aircraft was not identified by either flight crew member.
7. As a result of fuel starvation, the flight crew conducted a forced landing into muskeg, which resulted in significant aircraft damage.

Accident investigation: