Checklist complacency and risky habits cited in TSB report

One person died and five others were injured when plane crashed in Yukon in June 2024

Checklist complacency and risky habits cited in TSB report
Aircraft’s actual flight path retrieved from the Garmin 296 compared to a straight-ahead glide path from the point of turn initiation (Source: Google Earth, with TSB annotations)

The Transportation Safety Board of Canada (TSB) has released its final report into the fatal June 2024 aircraft crash at Haines Junction Aerodrome, Yukon, citing a combination of checklist non-compliance, operational shortcuts, and steep maneuvering at low altitude as contributing factors. The crash claimed one life and seriously injured five others, including the pilot.

On June 10, 2024, a Cessna U206G operated by Rocking Star Adventures Ltd. was conducting a sightseeing flight to Kluane National Park when it experienced a complete engine power loss during approach. The pilot attempted to return to the runway but lost control during a steep turn, resulting in a crash on aerodrome property.

The TSB investigation (Report A24W0066) concluded the aircraft's engine failure was caused by fuel starvation, a direct result of the pilot failing to follow the published before-landing checklist.

“The pilot routinely relied on memory rather than checklists in his day-to-day operations,” the TSB stated in the report. “As a result, the fuel selector remained on the nearly empty tank, which led to a total engine power loss.”

While the aircraft was equipped with a checklist directing the pilot to switch to the fuller tank prior to landing, the TSB found that this step was omitted. An attempted restart of the engine was unsuccessful, in part because it did not follow the manufacturer’s recommended in-flight procedure.

In a critical moment, the pilot attempted a 180° turn back toward Runway 23. The steep bank angle—recorded at approximately 54°—resulted in an accelerated aerodynamic stall at an altitude too low for recovery.

“The steep turn resulted in an unrecoverable stall,” the TSB said, “and the aircraft impacted terrain in a nose-down, left-wing-low attitude and came to rest inverted.”

The TSB also raised concerns about the operator’s training and oversight practices. Although Transport Canada does not require air-taxi operators like Rocking Star Adventures Ltd. to have a Safety Management System (SMS), the Board emphasized the need for stronger organizational controls.

“The occurrence pilot had developed unsafe operating practices over time,” the TSB noted. “The operator did not identify or correct these practices because it did not actively monitor for deviations from standard operating procedures.”

While the operator documented recurrent training and pilot competency checks (PCCs), the TSB found that emergency procedures were often only “briefed” rather than practically demonstrated.

Following the accident, Rocking Star Adventures Ltd. implemented enhanced training protocols and revised operational procedures to promote checklist use and decision-making under emergency conditions.

For health and safety leaders, the report serves as a stark reminder of how organizational culture, procedural discipline, and human factors interact to influence safety outcomes.

“Procedural drift—where staff depart from standard practices—must be actively managed,” said the TSB. “Even experienced personnel can develop habits that increase risk if not monitored.”

The full investigation report, including safety analysis and operational recommendations, is available on the TSB website.