Gatineau, Quebec – 6 December 2012— The Transportation Safety Board of Canada (TSB) released its investigation report (A11Q0036) today concerning the March 2011 helicopter forced landing in Forestville, Quebec.
On 1 March 2011, the Robinson R44 Raven II helicopter (C-FNZO) was accompanied by two other Robinson R44 II helicopters for a trip from Port-Menier, Quebec, to Quebec City, with two people on board and two refuelling stopovers planned. On their way back from the trip, all three helicopters stopped in Forestville to refuel. The refueller was asked to refuel the helicopters and none of the pilots noticed that the incorrect Jet A-1 fuel was used instead of the required AVGAS 100LL.
During take-off, the fuel gauges were showing less than full. After a few radio exchanges among the three helicopters, and at approximately 1000 feet above ground level, the pilots concluded that the wrong fuel had been used. C-FNZO lost engine power and the pilot made a forced landing in a residential neighbourhood in Forestville. Both people on board had minor injuries and were taken to hospital. The helicopter was substantially damaged. The other two helicopters landed near C-FNZO and sustained no damage.
A number of successful defences have been introduced in aviation safety to address the risks associated with refuelling errors. However, as with all mitigated risks, when these measures are not followed, the risk of error increases considerably. When the aircraft landed in Forestville, the refueller had already started to pull out the Jet A-1 fuel hose to refuel the three helicopters. Relying on prior experience, the refueller was prepared to refuel the helicopters with Jet A-1 fuel. His training had not mentioned that some helicopters use AVGAS.
Transport Canada does not set any standards for refueller training or qualifications. In this case, the refueller would have greatly benefitted from a more detailed training program. Also, having aircraft refuelling reference material available would have provided additional defences necessary to reduce the risk to aviation safety.
On 20 May 2011, a safety advisory was sent to Transport Canada containing information about the accident and informed the regulator of the safety deficiencies. The advisory urged the Department to take appropriate corrective action. On 28 September 2011, in response to the TSB safety advisory, Transport Canada published an article reminding pilots to ensure the use of the proper fuel when refuelling their aircraft.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
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