Lack of training cited in fuel mix-up that brought down helicopter
Human Resources Training/Professional Development
GATINEAU, Que. (Canadian OH&S News)
GATINEAU, Que. (Canadian OH&S News)
The Transportation Safety Board of Canada (TSB) has determined that a case of bad gas brought down a helicopter in Quebec last year.
The board has released its findings into a helicopter incident in March of 2011 that sent two passengers to hospital, finding three helicopters, including the one that crashed, were refuelled with Jet A-1 fuel instead of the required AVGAS 100LL.
The three Robinson R44 II helicopters had been travelling from Port-Menier, Que. to Quebec City when they stopped for fuel in an unplanned detour, due to weather, in Forestville, Que. The employee at the aerodrome where they landed, working alone, had only worked at the fuel station for about four months and had never refuelled a helicopter with AVGAS, the TSB investigation noted, and their training also did not mention some helicopters use AVGAS.
During the doomed helicopter’s initial climb, it lost engine power at about 1,000 feet, forcing the pilot to land in a residential neighbourhood, the investigation report said, substantially damaging the helicopter and injuring the two occupants. The other two birds were able to land nearby safely.
“It would be like putting diesel fuel in your car,” explained Yanick Farazin, the lead investigator on the incident and a senior investigator at the TSB in Ottawa. Jet A-1 fuel is similar to a refined diesel and is used to fuel turbine engines, whereas AVGAS is for piston engines similar to unleaded fuel.
“Usually we’ll see two categories of gasoline,” Farazin said, but “in those two different categories there are many types.”
Farazin said the helicopter that crashed was the last aircraft to take off after refuelling, and it ran on the ground for longer than the other two, who took off quickly after refuelling.
“We suspect that because of the way it was fuelled, the Jet A-1 fuel entered the system quicker than the others. As soon as they discovered this loud bang and realized the wrong fuel was added, the other two aircraft landed as soon as possible … They didn’t take any chances,” he said. “If they would have stayed airborne and said ‘wow, I wonder what’s going on with the third aircraft’ they would have had issues.”
No standards set by regulator in refueller training
The craft’s operating handbook recommends pilots take fuel samples after refuelling, as fuel can be distinguished by colour — AVGAS is blue while Jet A-1 is a light yellow. But the investigation report noted that pilots do not typically take samples after refuelling because it does not allow time for any contaminants to settle. The pilots were also in a rush to get back to Quebec City before nightfall, as they were not certified to fly at night.
“If they stopped and fuelled right away, they would have had to delay their departure, let’s say 30 minutes, then verify the fuel. For them that was not an option, the night was coming and they had to get to Quebec City, so there was a little bit of pressure they put themselves into at that point,” Farazin said.
While Transport Canada does not set standards for refueller training programs or qualifications, the investigation report noted that the employee would have “greatly benefitted from a more detailed training program” and having aircraft reference material onhand would have helped bolster the defences against accidents like what occurred.
Other contributing factors, the TSB noted, were that the pilots did not supervise the employee during refuelling and the Jet A-1 fuel nozzle had been modified to be smaller than normal so it would be able to refuel more helicopters, but also into the smaller AVGAS tanks.