False engine fire warning led to runway overrun according to TSB investigation
On the surface, this looked like a routine overnight medevac: a Keewatin Air Beechcraft King Air B200, two pilots, two medical staff, and a patient, departing Goose Bay in the early hours of 13 April 2024, bound for Québec City.
Just minutes after takeoff from Runway 26, that changed.
The crew got a left‑engine fire warning and smelled something burning. In the words of the Transportation Safety Board of Canada (TSB), “The flight crew believed that the left engine was on fire based on the combination of an illuminated engine fire warning annunciator and a perceived burning smell.” Faced with what they believed was an active engine fire on a critical medevac flight at night, the pilots did what many would expect: they shut down the engine using memory items and asked to return immediately.
They levelled the aircraft at about 2200 feet above sea level and accepted a contact approach to the reciprocal Runway 08. Conditions were dark, with broken cloud around 1300 feet above ground and an overcast layer above that. Instead of climbing to the published minimum sector altitude of 3100 feet, the crew chose to stay lower to keep the ground in sight. The TSB later warned that, in such situations, remaining low “rather than climb to the minimum safe altitude” at night and in low‑light areas increases the risk of controlled flight into terrain.
High, fast, and committed
As air traffic control vectored the aircraft back toward the field, workload and time pressure ramped up. The crew did not program an emergency approach into the GPS and did not work through all of the emergency and one‑engine‑inoperative checklists. The Board summed it up as a classic speed–accuracy problem: “The flight crew’s decision to expedite the return to the airport resulted in a speed–accuracy trade-off” that included operating below the safe altitude and “deviations from the stabilized approach criteria.”
By the time they were lined up with Runway 08, the numbers told the story. At 0.8 nautical miles from the threshold, the aircraft was around 1350 feet above sea level, with a ground speed of 198 knots and a descent rate above 2200 feet per minute. Crossing the threshold, the King Air was still about 400 feet above the runway with a groundspeed of 200 knots—well outside the company’s stabilized approach limits for speed and descent rate.
Touchdown came very late. The aircraft made contact with the wet runway about 9075 feet down the 11 052‑foot strip, leaving roughly 1975 feet to stop. On the wet surface, the aircraft hydroplaned. With only the right engine available for reverse thrust, deceleration was limited and directional control became a challenge. The King Air slid, yawed, and overran the end of the runway at about 20 knots, striking two runway end lights before stopping roughly 40 feet beyond the pavement on the prepared surface.
No one was hurt. Damage was confined to the right propeller and engine, four main tires showing reverted‑rubber damage, and the two runway end lights.
Only later did the root of the “fire” emerge: investigators found abraded insulation on a wire to a left‑engine flame detector that had chafed against the firewall, creating a false fire indication. There was no evidence of an actual fire.
Takeaways for health and safety leaders
For health and safety leaders, especially in medevac and charter environments, this occurrence pulls several threads together: training realism, equipment differences, checklist design, and hard limits on stabilized approaches.
Keewatin Air operates 15 King Air B200s with different configurations; five are equipped with engine fire extinguishing systems. The simulator used to train this crew did not have that system installed. The TSB cautioned that “If aircraft and flight simulators are equipped differently […] there is a risk that flight crews may not be aware whether a system is available, especially under high mental workload conditions, such as an emergency.”
In practice, that means leaders should be asking:
- Do our simulators and training scenarios match the actual equipment our crews will see on the line?
- Are emergency procedures and checklists written and trained in a way that is easy to follow under pressure, without burying critical steps?
- Are stabilized approach criteria treated as hard limits—even in emergencies—unless the alternative is clearly more dangerous?
- Do crews have clear guidance on when to prioritize climbing to minimum sector altitude versus staying low to maintain visual contact, particularly at night and in low‑light environments?
Keewatin Air has responded with changes to training and procedures, including extra emphasis on stabilized approach go‑around criteria, performance on wet or contaminated runways with one engine inoperative, and the effective but controlled use of stopping devices. The occurrence is now used as a crew resource management case study.
For organizations overseeing safety‑critical operations, this event is a reminder that emergencies rarely unfold exactly as scripted. How well teams perform in those moments depends heavily on how closely training, equipment, procedures, and culture are aligned before anything goes wrong.
