GATINEAU, QC, Dec. 6, 2012 /CNW/ - The Transportation Safety Board of
Canada (TSB) released its investigation report (A11Q0036) today
concerning the March 2011 helicopter forced landing in Forestville,
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
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.
SOURCE: Transportation Safety Board of Canada
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