Crash of a De Havilland DHC-2 Beaver near Kennedy Lake

Date & Time: Jun 25, 2014 at 1425 LT
Type of aircraft:
Operator:
Registration:
C-FHVT
Survivors:
Yes
Schedule:
Sudbury - Kennedy Lake
MSN:
284
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
1000.00
Circumstances:
The Sudbury Aviation Limited float-equipped de Havilland DHC-2 Beaver aircraft (registration C-FHVT, serial number 284) was on approach to Kennedy Lake, Ontario, with the pilot and 2 passengers on board, when the aircraft rolled to the left prior to the flare. The pilot attempted to regain control of the aircraft by applying full right rudder and right aileron. The attempt was unsuccessful and the aircraft struck rising tree-covered terrain above the shoreline. The aircraft came to a stop on its right side and on a slope. The pilot and the passenger in the rear seat received minor injuries. The passenger in the right front seat was not injured. All were able to walk to the company fishing camp on the lake. There was no fire and the 406 megahertz emergency locator transmitter (ELT) was manually activated by one of the passengers. One of the operator's other aircraft, a Cessna 185, flew to the lake after C-FHVT became overdue. A search and rescue aircraft, responding to the ELT, also located the accident site. Radio contact between the Cessna 185 and the search and rescue aircraft confirmed that their assistance would not be required. The accident occurred at 1425 Eastern Daylight Time.
Probable cause:
Prior to touchdown in a northerly direction, the aircraft encountered a gusty westerly crosswind and the associated turbulence. This initiated an un-commanded yaw and left wing drop indicating an aerodynamic stall. The pilot was unsuccessful in recovering full control of the aircraft and it impacted rising terrain on the shore approximately 30 feet above the water surface.
Final Report:

Crash of a Swearingen SA227AC Metro III in Red Lake: 5 killed

Date & Time: Nov 10, 2013 at 1829 LT
Type of aircraft:
Operator:
Registration:
C-FFZN
Survivors:
Yes
Schedule:
Sioux Lookout - Red Lake
MSN:
AC-785B
YOM:
1991
Flight number:
BLS311
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
5150
Captain / Total hours on type:
3550.00
Copilot / Total flying hours:
2200
Copilot / Total hours on type:
1060
Aircraft flight hours:
35474
Circumstances:
Flight from Sioux Lookout was uneventful till the final descent to Red Lake completed by night and in light snow with a ceiling at 2,000 feet and visibility 8 SM. On final approach to runway 26, crew reported south of the airport and declared an emergency. Shortly after this mayday message, aircraft hit power cables and crashed in flames in a dense wooded area located 800 meters south of the airport. Two passengers seating in the rear were seriously injured while all five other occupants including both pilots were killed.
Probable cause:
A first-stage turbine wheel blade in the left engine failed due to a combination of metallurgical issues and stator vane burn-through. As a result of the blade failure, the left engine continued to operate but experienced a near-total loss of power at approximately 500 feet above ground level, on final approach to Runway 26 at the Red Lake Airport. The crew were unable to identify the nature of the engine malfunction, which prevented them from taking timely and appropriate action to control the aircraft. The nature of the engine malfunction resulted in the left propeller being at a very low blade angle, which, together with the landing configuration of the aircraft, resulted in the aircraft being in an increasingly high drag and asymmetric state. When the aircraft’s speed reduced below minimum control speed (VMC), the crew lost control at an altitude from which a recovery was not possible.
Final Report:

Crash of a Beechcraft D18S off Red Lake: 2 killed

Date & Time: May 30, 2013 at 1727 LT
Type of aircraft:
Registration:
C-FWWV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Red Lake - Red Lake
MSN:
A-618
YOM:
1951
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The pilot and his wife, a couple from Phoenix, were performing a flight from the Red Lake Seaplane base to a tourist Camp located north of Red Lake. The twin engine aircraft took off at 1727LT in marginal weather conditions consisting of wind and rain showers. Shortly after departure, the aircraft crashed into the Bruce Channel located between Cochenour and McKenzie Island. The aircraft sank and both occupants were killed.

Crash of a Socata TBM-850 near Calabogie: 1 killed

Date & Time: Oct 8, 2012 at 1219 LT
Type of aircraft:
Registration:
C-FBKK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Carp - Goderich
MSN:
621
YOM:
2012
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
19200
Captain / Total hours on type:
700.00
Aircraft flight hours:
64
Circumstances:
The privately owned SOCATA TBM 700N (registration C-FBKK, serial number 621) departed from Ottawa/Carp Airport, Ontario, on an instrument flight rules flight plan to Goderich, Ontario. Shortly after takeoff, the pilot and sole occupant altered the destination to Wiarton, Ontario. Air traffic control cleared the aircraft to climb to flight level 260 (FL260). The aircraft continued climb through FL260 and entered a right hand turn, which quickly developed into a spiral dive. At approximately 1219 Eastern Daylight Time, the aircraft struck the ground and was destroyed. Small fires broke out and consumed some sections of the aircraft. The pilot was fatally injured. The 406 MHz emergency locator transmitter on board the aircraft was damaged and its signal was not sensed by the search and rescue satellite-aided tracking (SARSAT) system.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot lost control of the aircraft for undetermined reasons and the aircraft collided with terrain.
Findings as to Risk:
1. Operating an aircraft above 13 000 feet asl without an available emergency oxygen supply increases the risk of incapacitation due to hypoxia following depressurization.
Other Findings:
1. The avionics system had the capability to record data essential to the accident investigation but the recording medium was destroyed in the accident.
Final Report:

Ground fire of an Avro 748-264-2A in Sandy Lake

Date & Time: Jun 12, 2012 at 1343 LT
Type of aircraft:
Operator:
Registration:
C-FTTW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pickle Lake – Sandy Lake
MSN:
1681
YOM:
1970
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was parked on the ramp at Sandy Lake Airport. The flight crew had disembarked and were off-loading the cargo (JET A-1 jet fuel drums) from the aircraft to fuel tanks adjacent to the ramp. A fire broke out and the flight crew used the available fire extinguishers but the fire spread and consumed most of the aircraft that was totally destroyed. There were no injuries.
Probable cause:
A leak occurred in a hose downstream of the pumps (located on the ground beside the aircraft). The ambient wind blew vapors toward the pumps and a fire broke out. No official investigation was conducted by the TSB on this event.

Crash of a De Havilland DHC-2 Beaver in Lillabelle Lake: 2 killed

Date & Time: May 25, 2012 at 1408 LT
Type of aircraft:
Operator:
Registration:
C-FGBF
Survivors:
Yes
Schedule:
Edgar Lake - Lillabelle Lake
MSN:
168
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1100
Captain / Total hours on type:
300.00
Aircraft flight hours:
22000
Circumstances:
The Cochrane Air Service de Havilland DHC-2 Mk.1 Beaver floatplane (registration C-FGBF, serial number 168) departed Edgar Lake, Ontario, with 2 passengers and 300 pounds of cargo on board. The aircraft was destined for the company’s main base located on Lillabelle Lake, Ontario, approximately 77 miles to the south. On arrival, a southwest-bound landing was attempted across the narrow width of the lake, as the winds favoured this direction. The pilot was unable to land the aircraft in the distance available and executed a go-around. At 1408, Eastern Daylight Time, shortly after full power application, the aircraft rolled quickly to the left and struck the water in a partially inverted attitude. The aircraft came to rest on the muddy lake bottom, partially suspended by the undamaged floats. The passenger in the front seat was able to exit the aircraft and was subsequently rescued. The pilot and rear-seat passenger were not able to exit and drowned. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On the windward side of the landing surface, there was significant mechanical turbulence and associated wind shear caused by the passage of strong gusty winds over surface obstructions.
2. During the attempted overshoot, the rapid application of full power caused the aircraft to yaw to the left, and a left roll quickly developed. This movement, in combination with a high angle of attack and low airspeed, likely caused the aircraft to stall. The altitude available to regain control before striking the water was insufficient.
3. The pilot survived the impact, but was unable to exit the aircraft, possibly due to difficulties finding or opening an exit. The pilot subsequently drowned.
4. The rear-seat passenger did not have a shoulder harness and was critically injured. The passenger’s head struck the pilot’s seat in front; this passenger did not exit the aircraft and drowned.
Findings as to Risk:
1. Without a full passenger safety briefing, there is increased risk that passengers may not use the available safety equipment or be able to perform necessary emergency functions in a timely manner to avoid injury or death.
2. Not wearing a shoulder harness can increase the risk of injury or death in an accident.
3. Not having a stall warning system increases the risk that the pilot may not be aware of an impending aerodynamic stall.
4. Commercial seaplane pilots who do not receive underwater egress training are at increased risk of being unable to exit the aircraft following a survivable impact with water.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in North Spirit Lake: 4 killed

Date & Time: Jan 10, 2012 at 0957 LT
Operator:
Registration:
C-GOSU
Survivors:
Yes
Schedule:
Winnipeg - North Spirit Lake
MSN:
31-7752148
YOM:
1977
Flight number:
KEE213
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2400
Captain / Total hours on type:
95.00
Circumstances:
The Piper PA31-350 Navajo Chieftain (registration C-GOSU, serial number 31-7752148), operating as Keystone Air Service Limited Flight 213, departed Winnipeg/James Armstrong Richardson International Airport, Manitoba, enroute to North Spirit Lake, Ontario, with 1 pilot and 4 passengers on board. At 0957 Central Standard Time, on approach to Runway 13 at North Spirit Lake, the aircraft struck the frozen lake surface 1.1 nautical miles from the threshold of Runway 13. The pilot and 3 passengers sustained fatal injuries. One passenger sustained serious injuries. The aircraft was destroyed by impact forces and a post-impact fire. After a short period of operation, the emergency locator transmitter stopped transmitting when the antenna wire was consumed by the fire.
Probable cause:
Findings as to causes and contributing factors:
1. The pilot's decision to conduct an approach to an aerodrome not serviced by an instrument flight rules approach in adverse weather conditions was likely the result of the pilot's inexperience, and may have been influenced by the pilot's desire to successfully complete the flight.
2. The pilot's decision to descend into cloud and continue in icing conditions was likely the result of inadequate awareness of the Piper PA31-350 aircraft's performance in icing conditions and of its de-icing capabilities.
3. While waiting for the runway to be cleared of snow, the aircraft held near North Spirit Lake (CKQ3) in icing conditions. The resulting ice accumulation on the aircraft's critical surfaces would have led to an increase in the aircraft's aerodynamic drag and stall speed, causing the aircraft to stall during final approach at an altitude from which recovery was not possible.
Findings as to risk:
1. Terminology contained in aircraft flight manuals and regulatory material regarding “known icing conditions,” “light to moderate icing conditions,” “flight in,” and “flight into” is inconsistent, and this inconsistency increases the risk of confusion as to the aircraft’s certification and capability in icing conditions.
2. If confusion and uncertainty exist as to the aircraft’s certification and capability in icing conditions, then there is increased risk that flights will dispatch into icing conditions that exceed the capability of the aircraft.
3. The lack of procedures and tools to assist pilots in the decision to self-dispatch leaves them at increased risk of dispatching into conditions beyond the capability of the aircraft.
4. When management involvement in the dispatch process results in pilots feeling pressure to complete flights in challenging conditions, there is increased risk that pilots may attempt flights beyond their competence.
5. Under current regulations, Canadian Aviation Regulations (CARs) 703 and 704 operators are not required to provide training in crew resource management / pilot decision-making or threat- and error-management. A breakdown in crew resource management / pilot decision-making may result in an increased risk when pilots are faced with adverse weather conditions.
6. Descending below the area minimum altitude while in instrument meteorological conditions without a published approach procedure increases the risk of collision with terrain.
7. If onboard flight recorders are not available to an investigation, this unavailability may preclude the identification and communication of safety deficiencies to advance transportation safety.
Final Report:

Crash of an Embraer ERJ-145LR in Ottawa

Date & Time: Sep 4, 2011 at 1529 LT
Type of aircraft:
Operator:
Registration:
N840HK
Survivors:
Yes
Schedule:
Chicago - Ottawa
MSN:
145-341
YOM:
2001
Flight number:
UA3363
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
4800
Copilot / Total hours on type:
3800
Aircraft flight hours:
25655
Aircraft flight cycles:
23335
Circumstances:
At 1406, United Express Flight 3363 (LOF3363), operated by Trans States Airlines LLC (TSA), departed Chicago O’Hare International Airport, Chicago, United States. Before commencing the descent into Ottawa/Macdonald-Cartier International Airport (CYOW), Ontario, the flight crew obtained the automatic terminal information service (ATIS) information Yankee for CYOW issued at 1411. Based on the reported wind speed and direction, the flight crew calculated the approach speed (VAPP) to be 133 knots indicated airspeed (KIAS). Runway 25 was identified in ATIS information Yankee as the active runway. However, as a result of a previous overrun on Runway 07/25 in August 2010, TSA prohibited its flight crews from landing or taking off on Runway 07/25 when the surface is reported as damp or wet. Because rain showers were forecast for CYOW and Runway 32 was the longest runway, the flight crew decided at 1506 to carry out an instrument landing system (ILS) approach to Runway 32. At 1524, the CYOW terminal air traffic controller (ATC) advised the flight crew that it was starting to rain heavily at CYOW. About 2 minutes later, the aircraft intercepted the glideslope for the ILS to Runway 32. Final descent was initiated, the landing gear was extended, and the flaps were selected to 22°. Upon contacting the CYOW tower controller, the flight crew was advised that moderate rain had just started at the airport and the wind was reported as 310° magnetic (M) at 10 knots. The aircraft crossed the GREELY (YYR) final approach fix at 4.3 nautical miles (nm), slightly above the glideslope at 174 KIAS. About 1528, the aircraft passed through 1000 feet above ground level (agl) at 155 knots. Moments later, the flaps were selected to 45°. The airspeed at the time was approximately 145 KIAS. The tower controller advised the flight crew that the wind had changed to 320°M at 13 knots gusting to 20 knots. To compensate for the increased wind speed, the flight crew increased the VAPP to 140 KIAS. About 1 minute later, at 1529, the aircraft crossed the threshold of Runway 32 at about 45 feet agl, at an airspeed of 139 KIAS. As the aircraft crossed the runway threshold, the intensity of the rain increased, so the flight crew selected the windshield wipers to high. When the aircraft was about 20 feet agl, engine power was reduced and a flare was commenced. Just before touchdown, the aircraft encountered a downpour sufficient to obscure the crew’s view of the runway. Perceiving a sudden increase in descent rate, at approximately 5 feet agl, the captain applied maximum thrust on both engines. The master caution light illuminated, and a voice warning stated that the flaps were not in a take-off configuration. Maximum thrust was maintained for 7 seconds. The aircraft touched down smoothly 2700 feet beyond the threshold at 119 KIAS; the airspeed was increasing, and the aircraft became airborne again. The aircraft touched down a second time at 3037 feet beyond the threshold, with the airspeed increasing through 125 KIAS. Airspeed on touchdown peaked at 128 KIAS as the nosewheel was lowered to the ground, and then the thrust levers were retarded to flight idle. The outboard spoilers almost immediately deployed, and about 8 seconds later, the inboard spoilers deployed. The aircraft was about 20 feet right of the runway centreline when it touched down for the second time. Once the nosewheel was on the ground, the captain applied maximum brakes. The flight crew almost immediately noted that the aircraft began skidding. The captain then requested the first officer to apply maximum brakes as well. The aircraft continued to skid, and no significant brake pressure was recorded until about 14 seconds after the outboard spoilers deployed, when brake pressure suddenly increased to its maximum. During this time, the captain attempted to steer the aircraft back to the runway centreline. As the aircraft skidded down the runway, it began to yaw to the left. Full right rudder was applied, but was ineffective in correcting the left yaw. Sufficient water was present on the runway surface to cause the aircraft tires to send a spray of water, commonly known as a rooster tail, to a height of over 22 feet, trailing over 300 feet behind the aircraft. At some point during the landing roll, the captain partially applied the emergency/parking brake (EPB), and when no braking action was felt, the EPB was engaged further. With no perceivable deceleration being felt, the EPB was stowed. The aircraft continued to skid down the runway until about 7500 feet from the threshold, at which point it started skidding sideways along the runway. At 1530, the nosewheel exited the paved surface, 8120 feet from the threshold, at approximately 53 knots, on a heading of 271°M. The aircraft came to rest on a heading of 211°M, just off the left side of the paved surface. After coming to a stop, the flight crew carried out the emergency shutdown procedure as per the company Quick Reference Handbook (QRH), and consulted with the flight attendant on the status of everyone in the passenger cabin. The flight crew determined that there was no immediate threat and decided to hold the passengers on board. When the aircraft exited the runway surface, the tower activated the crash alarm. The CYOW airport rescue and firefighting (ARFF) services responded, and were on scene approximately 3 minutes after the activation of the crash alarm. Once ARFF personnel had conducted a thorough exterior check of the aircraft, they informed the flight crew that there was a fuel leak. The captain then called for an immediate evacuation of the aircraft. The passengers evacuated through the main cabin door, and moved to the runway as directed by the flight crew and ARFF personnel. The evacuation was initiated approximately 12 minutes after the aircraft came to a final stop. After the evacuation was complete, the firefighters sprayed foam around the aircraft where the fuel had leaked.
Probable cause:
Findings as to causes and contributing factors:
1. Heavy rainfall before and during the landing resulted in a 4–6 mm layer of water contaminating the runway.
2. The occurrence aircraft’s airspeed during final approach exceeded the company prescribed limits for stabilized approach criteria. As a result, the aircraft crossed the runway threshold at a higher than recommended VREF airspeed.
3. A go-around was not performed, as per standard operating procedures, when the aircraft’s speed was greater than 5 knots above the appropriate approach speed during the stabilized portion of the approach.
4. The application of engine thrust just before touchdown caused the aircraft to touch down 3037 feet from the threshold at a higher than recommended airspeed.
5. The combination of a less than firm landing and underinflated tires contributed to the aircraft hydroplaning.
6. The emergency/parking brake was applied during the landing roll, which disabled the anti-skid braking system and prolonged the skid.
7. The aircraft lost directional control as a result of hydroplaning and veered off the runway.

Findings as to risk:
1. The typical and frequently used technique for differential braking that pilots are trained to use may not be effective when anti-skid systems require different techniques.
2. If aircraft electrical power is applied with an active fuel leak, there is a risk that an electrical spark could ignite the fuel and start a fire.
3. The use of non-grooved runways increases the risk of hydroplaning, which may result in runway excursions.
4. If there is an absence of information and training about non-grooved runways, there is a risk that crews will not carry out the appropriate landing techniques when these runways are wet.
5. The use of thrust reversers reduces the risk of runway excursions when landing on wet runways.
6. If pilots do not comply with standard operating procedures, and companies do not assure compliance, then there is a risk that occurrences resulting from such deviations will persist.

Other findings:
1. The central maintenance computer was downloaded successfully; however, there were no data present in the memory unit.
2. Although the Transportation Safety Board was able to download high-quality data from the flight data recorder, the parameters that were not recorded due to the model type and input to the flight data recorder made it more difficult to determine the sequence of events.
Final Report:

Crash of a Dassault Falcon 10 in Toronto

Date & Time: Jun 17, 2011 at 1506 LT
Type of aircraft:
Operator:
Registration:
C-GRIS
Flight Type:
Survivors:
Yes
Schedule:
Toronto-Lester Bowles Pearson - Toronto-Buttonville
MSN:
02
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
7100
Copilot / Total hours on type:
475
Aircraft flight hours:
12697
Circumstances:
Aircraft was on a flight from Toronto-Lester B. Pearson International Airport to Toronto-Buttonville Municipal Airport, Ontario, with 2 pilots on board. Air traffic control cleared the aircraft for a contact approach to Runway 33. During the left turn on to final, the aircraft overshot the runway centerline. The pilot then compensated with a tight turn to the right to line up with the runway heading and touched down just beyond the threshold markings. Immediately after touchdown, the aircraft exited the runway to the right, and continued through the infield and the adjacent taxiway Bravo, striking a runway/taxiway identification sign, but avoiding aircraft that were parked on the apron. The aircraft came to a stop on the infield before Runway 21/03. The aircraft remained upright, and the landing gear did not collapse. The aircraft sustained substantial damage. There was no fire, and the flight crew was not injured. The Toronto-Buttonville tower controller observed the event as it progressed and immediately called for emergency vehicles from the nearby municipality. The accident occurred at 1506 Eastern Daylight Time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew flew an unstabilized approach with excessive airspeed.
2. The lack of adherence to company standard operating procedures and crew resource management, as well as the non-completion of checklist items by the flight crew contributed to the occurrence.
3. The captain’s commitment to landing or lack of understanding of the degree of instability of the flight path likely influenced the decision not to follow the aural GPWS alerts and the missed approach call from the first officer.
4. The non-standard wording and the tone used by the first officer were insufficient to deter the captain from continuing the approach.
5. At touchdown, directional control was lost, and the aircraft veered off the runway with sufficient speed to prevent any attempts to regain control.
Finding as to Risk
1. Companies which do not have ground proximity warning system procedures in their standard operating procedures may place crews and passengers at risk in the event that a warning is received.
Final Report:

Crash of a Rockwell Aero Commander 500B near Armstrong

Date & Time: Nov 30, 2007 at 0917 LT
Operator:
Registration:
C-GETK
Flight Phase:
Survivors:
Yes
Schedule:
Dryden – Geraldton
MSN:
500-1093-56
YOM:
1961
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed from Dryden, Ontario, en route to Geraldton, Ontario. The flight was conducted under visual flight rules at 5500 feet above sea level with ambient temperatures aloft of -33°C. Approximately 40 minutes into the flight, the crew observed an abnormal right engine fuel flow indication. While troubleshooting the right engine, the engine rpm and fuel flow began to decrease and the crew diverted toward Armstrong, Ontario. A short time later, the left engine rpm and fuel flow began to decrease and the crew could no longer maintain level flight. At 0917 central standard time, the crew made a forced landing 20 nautical miles southwest of Armstrong, into a marshy wooded area. The captain sustained serious injuries and the co-pilot and passenger sustained minor injuries. The aircraft was substantially damaged. The crew and passenger were stabilized and transported to Thunder Bay, Ontario, for medical assistance.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Suspended water in the fuel system precipitated out of solution and froze in the fuel distributor valve. This blocked the fuel supply to the fuel nozzles and led to the loss of engine power.
2. The aircraft was being operated without a fuel additive icing inhibiter. Use of such an additive would have inhibited ice formation in the aircraft’s fuel system and would likely have prevented the fuel system blockage.
Findings as to Risk:
1. The fuel distributor valve on the Aero Commander 500B is exposed directly to the cooling blast of the outside air, which under extremely cold conditions, can lead to the freezing of super-cooled water droplets present in the fuel stream.
2. The operator did not have procedures to describe how fuel additive icing inhibiter should be used during winter operations.
Final Report: