Human errors, ignored procedures led to Keystone Air crash last year: report

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This article was published 06/09/2016 (3507 days ago), so information in it may no longer be current.

OTTAWA — A Transportation Safety Board investigation into the crash of a Keystone Air plane near Thompson almost a year ago cites a laundry list of human errors and ignored operating procedures that led to the wrong fuel being pumped into the tanks before takeoff.

The report into the crash of Keystone Air Flight 208 on Sept. 15, 2015 was publicly released Tuesday.

“A number of administrative and physical defences have been introduced by aircraft operators, regulators and fuel suppliers to address the risks associated with fuelling of aircraft,” reads the report.

“As a result, the aviation fuel supply chain is a robust and reliable system. However, 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.”

The crash, which injured all six passengers and both pilots, ultimately led to the cancellation of Keystone’s air operator licence last December after several safety violations were uncovered. The airline had its licence suspended at least twice previously, and has had at least five crashes since 2000.

The TSB report says standard operating procedure required the pilot to supervise the refuelling of the plane and that at least one crew member be present during the refuelling to be responsible for the fuel type, grade and amount. It also requires the crew to sample fuel before takeoff after a plane has been powered down and left unsupervised. None of those things happened in this case.

As well, neither pilot ever instructed the refuelling tech about what kind of gas the plane used, and the tech, who had been on the job less than a month at that point, was unfamiliar with the plane and the type of fuel it required.

Neither pilot noticed the sign on the fuel truck identifying its contents as Jet A1 fuel, and the tech didn’t notice the placards next to the fuel filler openings identifying the type and grade of fuel required.

The refuelling tech did not present a refuelling form to the pilots before filling the plane, and while he printed a refuelling slip after finishing the job, he left it in the office and the pilots never saw it.

Jet A1 fuel spouts are designed, as are fuel filler openings, to prevent jet fuel being used on planes that require aviation gas and vice versa. However, there are some planes that require jet fuel but, for several reasons, can’t use the special Jet A1 flared spout. So there are times when the spout has to removed and replaced with a smaller one. The tech had done this before on other planes as required, so the fact the fuel spout didn’t fit did not tip him off that he was using the wrong fuel, the report said.

mia.rabson@freepress.mb.ca