Air transportation safety investigation A23C0096

Table of contents

    Incorrect fuel type and forced landing
    SkyCare Air Ambulance
    Piper PA-31-350, C-GQXD
    Sioux Lookout Airport (CYXL), Ontario

    The occurrence

    On 14 October 2023, a Piper PA-31-350 aircraft, operated by SkyCare Air Ambulance, was conducting a flight from Pickle Lake Airport, Ontario, to St. Andrews Airport, Manitoba.

    Before the flight, the aircraft was fueled by a local fueling company at the Pickle Lake Airport. As the aircraft was taking off, the fueler realized that the aircraft was given the wrong type of fuel, and then called NAV CANADA to relay the message to the flight crew.

    The engines continued running and the crew diverted to Sioux Lookout Airport, Ontario, where the aircraft landed without incident. The TSB is investigating.

    Investigation information

    Map showing the location of the occurrence

    A23C0096

    Incorrect fuel type and forced landing
    SkyCare Air Ambulance
    Piper PA-31-350, C-GQXD
    Sioux Lookout Airport (CYXL), Ontario

    Investigator-in-charge

    Image
    Photo of Ray McNabb

    Mr. Ray McNabb joined the TSB in 2015 and is a Senior Technical Investigator Air Central Region office located in Winnipeg. Mr. McNabb worked for Transport Canada Aircraft Services Directorate for 23 years. He joined Aircraft Services as an Aircraft Maintenance Engineer and held the position of Regional Team Lead before leaving to join TSB.

    Prior to joining Aircraft Services Mr. McNabb held various positions maintaining numerous types of aircraft. Mr. McNabb has extensive experience in the Repair and Overhaul of Gas Turbine Engines and held the position of Field Service Representative which included Field Service work and troubleshooting throughout North America. He holds a valid class M1 and M2 Aircraft Engineers License and holds a Commercial pilot license with float, ski, and Multi-engine endorsements with 1700 hours of flying experience.

      Download high-resolution photos from the TSB Flickr page.

    Class of investigation

    This is a class 4 investigation. These investigations are limited in scope, and while the final reports may contain limited analysis, they do not contain findings or recommendations. Class 4 investigations are generally completed within 220 days. For more information, see the Policy on Occurrence Classification.

    TSB investigation process

    There are 3 phases to a TSB investigation

    1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
    2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
    3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

    For more information, see our Investigation process page.

    The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.