Scudrunners

3.0 Findings
3.1 Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.

When the captain saw the pink fuel slip in the door of the aircraft, it reinforced his belief that the aircraft had been fuelled for the last flight of the day, when, in actuality, it had not been refuelled.
While conducting the Before Start checks from memory, the captain interrupted his routine by conversing with a passenger. Consequently, the fuel quantity check was missed and the preparation for flight continued without the captain being aware that the aircraft did not have sufficient fuel for the flight on board.
Over time, the captain developed an adaptation of not conducting the challenge and response checklists where required by the standard operating procedures. The absence of negative consequences reinforced the captain’s practice until it became routine.
On the day of the occurrence, the first officer’s adaptation regarding checklist usage was influenced by the seniority of the captain, the captain’s non-standard use of checklists, and the absence of negative repercussions from this adaptation.
While taxiing to the runway, the captain conducted the Taxi checks alone, silently, and from memory. Consequently, the fuel check on the checklist was missed and the aircraft departed with insufficient fuel for the flight.
The first officer completed the cruise checks silently and without reference to a checklist. As a result, the fuel state of the aircraft was not identified by either flight crew member.
As a result of fuel starvation, the flight crew conducted a forced landing into muskeg, which resulted in significant aircraft damage.