Inadvertent movement of fuel levers lead to engine power loss

From: Transportation Safety Board of Canada

On 21 June 2019, at approximately 01:40 Eastern Daylight Time, a North Star Air Ltd. Douglas DC-3C Basler Turbo Conversions TP67 aircraft was conducting a flight from Fort Hope Airport (CYFH), Ontario, to Pickle Lake Airport (CYPL), Ontario, with two flight crew on board: the first officer acting as the pilot flying (PF), seated in the right seat, and the captain acting as the pilot not flying (PNF), seated in the left seat. Shortly after takeoff, both engines lost power simultaneously. The flight crew executed a forced landing on Eabamet Lake, Ontario. After landing, the crew evacuated the aircraft via the main cabin door and swam to shore. The Nishnawbe Aski Police Service responded and took the crew to a nursing station for treatment. There were no injuries. The aircraft sustained substantial damage and there was no post-impact fire.

Sounds captured by the cockpit voice recorder (CVR) suggest that, after lifting the landing gear control handle, the captain’s left hand, which was on or near the throttle quadrant, may have inadvertently moved the fuel condition levers to the STOP position, cutting the fuel to both engines simultaneously. Due to insufficient altitude and time available to the crew, no engine relight options were available before the aircraft collided with the water surface.

The investigation determined that the crew followed the operator’s before-takeoff checklist that did not reflect the latest revision of the airplane flight manual supplement (AFMS), which specifies setting the ignition switches to CONT (continuous mode) for takeoff. If operators do not follow manufacturers’ directions to amend procedures, operators will use incorrect operating procedures, increasing the risk of compromising safety margins.

The investigation concluded that with the ignition system switches not set to CONT, the flight crew did not have enough time to complete an in-flight engine relight procedure before the aircraft collided with the water surface. Additionally, the before-takeoff checklist also required that the automatic feathering system, which quickly reduces the drag associated with a failed engine, be armed for takeoff. In this occurrence, the crew did not arm the system; therefore, it would not have been available if it had been required. If the propeller automatic feathering system is not armed, there is a risk that, in the event of an engine failure, the aircraft would not be able to maintain the required climb gradient and obstacle clearance would not be guaranteed.

See the investigation page

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