Inadvertent fuel shutoff led to 2019 plane crash near Ontario First Nation: TSB

Canada's Transportation Safety Board (TSB) says the inadvertent movement of fuel levers was the likely cause of the 2019 crash of a North Star Air plane nearEabametoong First Nation in northern Ontario.

The crash occurred on June 21, at about 1:40 a.m., and involved a Douglas DC-3C Basler Turbo Conversions TP67, the TSB said in a report released on Monday.

The plane had just taken off from Eabametoong it was travelling to Pickle Lake when both engines lost power simultaneously just as the landing gear was raised, which occurred at an altitude of about 200 feet.

The plane was forced to land on Eabamet Lake in total darkness.

The plane had two crew members on board; neither the first officer, who was flying the aircraft, nor the captain, were injured, and they swam to shore.

They then started a fire on shore to warm up, which was spotted by a patrolling Nishnawbe Aski Police Service officer, who then transported the two pilots to the Eabametoong First Nation for a medical assessment.

The plane sustained heavy damage, the TSB said.

No time to restart engines

In its report, the TSB said sounds captured by the cockpit voice recorder suggest that the captain inadvertently moved the fuel condition levers to "stop" after raising the landing gear.

Due to the plane's low altitude, and lack of time available to the crew, the engine couldn't be restarted before the plane hit the water.

The TSB also notes that its investigation found the crew did not follow the latest revision of the airplane flight manual supplement, which specifies setting the ignition switches to "continuous mode" for takeoff.

That, the report states, led to the crew not having enough time to reignite the engines before the crash.

Feathering system not enabled

Finally, the TSB found the plane's automatic feathering system, which quickly reduces drag associated with a failed engine, was not enabled.

"In this occurrence, the crew did not arm the system," the report states. "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."

The TSB said itsaim is the advancement of transportation safety, andthe board does not assign fault or determine civil or criminal liability.