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Crash of a Cessna 208 Caravan 675 on Addenbroke Island: 4 killed

Date & Time: Jul 26, 2019 at 1104 LT
Type of aircraft:
Operator:
Registration:
C-GURL
Flight Phase:
Survivors:
Yes
Site:
MSN:
208-0501
YOM:
2008
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
8500
Captain / Total hours on type:
504.00
Aircraft flight hours:
4576
Circumstances:
Seair Seaplanes (Seair) was contracted by a remote fishing lodge on the central coast of British Columbia (BC) (Figure 1) to provide seasonal transport of guests and supplies between Vancouver International Water Aerodrome (CAM9), BC, and the lodge, which is located about 66 nautical miles (NM) north-northwest of Port Hardy Airport (CYZT), BC, and about 29 NM southeast of Bella Bella (Campbell Island) Airport (CBBC), BC. On 26 July 2019, the occurrence pilot arrived at Seair’s CAM9 base at approximately 0630. Over the next hour, the pilot completed a daily inspection of the Cessna 208 Caravan aircraft (registration C-GURL, serial number 20800501), added 300 L of fuel to the aircraft, and began flight planning activities, which included gathering and interpreting weather information. On the morning of the occurrence, 4 Seair visual flight rules (VFR) flights were scheduled to fly to the central coast of BC, all on Caravan aircraft: C-GURL (the occurrence aircraft) was to depart CAM9 at 0730, C-GSAS at 0745, C-FLAC at 0800, and C-GUUS at 0900. The first 3 flights were direct flights to the fishing lodge, while the 4th flight had an intermediate stop at the Campbell River Water Aerodrome (CAE3), BC, to pick up passengers before heading to a research institute located approximately 4 NM southwest of the fishing lodge. Because of poor weather conditions in the central coast region, however, all of the flights were delayed. After the crews referred to weather cameras along the central coast region, the flights began to depart, but in a different order than originally scheduled. It is not uncommon for the order of departure to change when groups of aircraft are going to the same general location. One of Seair’s senior operational staff (operations manager) departed CAM9 at 0850 aboard C-FLAC. C-GUUS, bound for the research institute, departed CAM9 next at 0906, and then the occurrence aircraft departed at 0932 (Table 1). The pilot originally scheduled to fly C-GSAS declined the flight. This pilot had recently upgraded to the Caravan, had never flown to this destination before, and was concerned about the weather at the destination. When Seair’s chief pilot returned to CAM9 at 0953 after a series of scheduled flights on a different type of aircraft, he assumed the last remaining flight to the lodge and C-GSAS departed CAM9 at 1024.After departing the Vancouver terminal control area, the occurrence aircraft climbed to 4500 feet above sea level (ASL) and remained at this altitude until 1023, when a slow descent was initiated. The aircraft levelled off at approximately 1300 feet ASL at 1044, when it was approximately 18 NM northeast of Port Hardy Airport (CYZT), BC, and 57 NM southeast of the destination. At 1050, the occurrence aircraft slowly descended again as the flight continued northbound. During this descent, the aircraft’s flaps were extended to the 10° position. At this point, the occurrence aircraft was 37 NM south-southeast of the fishing lodge. The aircraft continued to descend until it reached an altitude of approximately 330 feet ASL, at 1056. By this point, the occurrence aircraft was being operated along the coastline, but over the ocean. C-FLAC departed from the fishing lodge at 1056 on the return flight to CAM9. C-FLAC flew into the Fitz Hugh Sound and proceeded southbound along the western shoreline. At approximately 1100, it flew through an area of heavy rain where visibility was reduced to about 1 statute mile (SM). C-FLAC descended to about 170 feet ASL and maintained this altitude for the next 5 minutes before climbing to about 300 feet ASL. As the southbound C-FLAC entered Fitz Hugh Sound from the north at Hecate Island, the occurrence aircraft entered Fitz Hugh Sound from the south, near the southern tip of Calvert Island. The occurrence aircraft then changed course from the western to the eastern shoreline, and descended again to about 230 feet ASL (Figure 2), while maintaining an airspeed of approximately 125 knots. The 2 aircraft established 2-way radio contact. The pilot of C-FLAC indicated that Addenbroke Island was visible when he flew past it, and described the weather conditions in the Fitz Hugh Sound to the occurrence pilot as heavy rain showers and visibility of approximately 1 SM around Kelpie Point. The occurrence pilot then indicated that he would maintain a course along the eastern shoreline of the sound. At 1103, the 2 aircraft were separated by 2 NM and passed each other on reciprocal tracks, approximately 4 NM south of the accident site. The occurrence aircraft maintained a consistent track and altitude for the next 54 seconds, then slowly began a 25° change in track to the west (0.35 NM from the Addenbroke Island shoreline). Seven seconds after the turn started (0.12 NM from the island’s shoreline), the aircraft entered a shallow climb averaging 665 fpm. At 1104:55, the occurrence aircraft struck trees on Addenbroke Island at an altitude of approximately 490 feet ASL, at an airspeed of 114 knots, and in a relatively straight and level attitude. The aircraft then continued through the heavily forested hillside for approximately 450 feet, coming to rest at an elevation of 425 feet ASL, 9.7 NM east-southeast of the destination fishing lodge. The pilot and three passengers were killed and five other occupants were injured, four seriously.
Probable cause:
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.
1. The flight departed Vancouver International Water Aerodrome even though the reported and forecast weather conditions in the vicinity of the destination were below visual flight rules minima; the decision to depart may have been influenced by the group dynamics of Seair pilots and senior staff at the flight planning stage.
2. The pilot continued flight in reduced visibility, without recognizing the proximity to terrain, and subsequently impacted the rising terrain of Addenbroke Island.
3. The configuration of the visual and aural alerting systems and the colouration ambiguity in the primary flight display of the Garmin G1000 was ineffective at alerting the occurrence pilot to the rising terrain ahead.
4. The occurrence pilot’s attention, vigilance, and general cognitive function were most likely influenced to some degree by fatigue.

Findings as to risk:
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
1. If pilots do not receive specialized training that addresses the hazards of their flying environment, there is a risk that they will not be proficient in the specific skills necessary to maintain safety margins.
2. If aircraft are operated in excess of the maximum allowable take-off weight, there is a risk of performance degradation and adverse flight characteristics, which could jeopardize the safety of the flight.
3. If cargo is stowed in front of emergency exits, there is a risk that egress may be impeded in an emergency situation, potentially increasing evacuation time and risk of injuries.
4. If air operators do not employ a methodology to accurately assess threats inherent to daily operations, then there is a risk that unsafe practices will become routine and operators will be unaware of the increased risk.
5. If air operators that have flight data monitoring capabilities do not actively monitor their flight operations, they may not be able to identify drift toward unsafe practices that increase the risk to flight crew and passengers.
6. If Transport Canada’s oversight of operators is insufficient, there is a risk that air operators will be non-compliant with regulations or drift toward unsafe practices, thereby reducing safety margins.
7. If Transport Canada does not make safety management systems mandatory, and does not assess and monitor these systems, there is an increased risk that companies will be unable to effectively identify and mitigate the hazards associated within their operations.

Other findings:
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
1. The pilot was actively using a cellphone throughout the flight; the operator provided no guidance or limitations on approved cellphone use in flight.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Lyall Haarbour: 6 killed

Date & Time: Nov 28, 2009 at 1603 LT
Type of aircraft:
Operator:
Registration:
C-GTMC
Flight Phase:
Survivors:
Yes
Schedule:
Vancouver - Mayne Island - Pender Island - Lyall Harbour - Vancouver
MSN:
1171
YOM:
1958
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
2800
Captain / Total hours on type:
2350.00
Circumstances:
The Seair Seaplanes Beaver was departing Lyall Harbour, Saturna Island, for the water aerodrome at the Vancouver International Airport, British Columbia. After an unsuccessful attempt at taking off downwind, the pilot took off into the wind towards Lyall Harbour. At approximately 1603 Pacific Standard Time, the aircraft became airborne, but remained below the surrounding terrain. The aircraft turned left, then descended and collided with the water. Persons nearby responded immediately; however, by the time they arrived at the aircraft, the cabin was below the surface of the water. There were 8 persons on board; the pilot and an adult passenger survived and suffered serious injuries. No signal from the emergency locator transmitter was heard.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The combined effects of the atmospheric conditions and bank angle increased the load factor, causing an aerodynamic stall.
2. Due to the absence of a functioning stall warning system, in addition to the benign stalling characteristics of the Beaver, the pilot was not warned of the impending stall.
3. Because the aircraft was loaded in a manner that exceeded the aft CG limit, full stall recovery was compromised.
4. The altitude from which recovery was attempted was insufficient to arrest descent, causing the aircraft to strike the water.
5. Impact damage jammed 2 of the 4 doors, restricting egress from the sinking aircraft.
6. The pilot’s seat failed and he was unrestrained, contributing to the seriousness of his injuries and limiting his ability to assist passengers.
Findings as to Risk:
1. There is a risk that pilots will inadvertently stall aircraft if the stall warning system is unserviceable or if the audio warnings have been modified to reduce noise levels.
2. Pilots who do not undergo underwater egress training are at greater risk of not escaping submerged aircraft.
3. The lack of alternate emergency exits, such as jettisonable windows, increases the risk that passengers and pilots will be unable to escape a submerged aircraft due to structural damage to primary exits following an impact with the water.
4. If passengers are not provided with explicit safety briefings on how to egress the aircraft when submerged, there is increased risk that they will be unable to escape following an impact with the water.
5. Passengers and pilots not wearing some type of flotation device prior to an impact with the water are at increased risk of drowning once they have escaped the aircraft.
Final Report:

Crash of a De Havilland DHC-2 Turbo Beaver near Clearwater

Date & Time: Sep 22, 2000 at 1320 LT
Type of aircraft:
Operator:
Registration:
C-FOES
Flight Phase:
Survivors:
Yes
Schedule:
Clearwater - Clearwater
MSN:
1673
YOM:
1967
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Captain / Total hours on type:
900.00
Circumstances:
The de Havilland DHC-2T Beaver floatplane, serial number 1673TB43, was engaged in aerial application of fish fry to several lakes near Clearwater, British Columbia. The pilot and one other person were on board. The aircraft took off from Clearwater at about 1230 Pacific daylight time (PDT) to begin a planned series of drops to nearby lakes. The aircraft had dropped fish in four lakes before proceeding to Broken Hook Lake.When the aircraft was on approach to the northwestern end of Broken Hook Lake, the pilot reportedly advanced the power lever, but the engine did not respond. At this time, the aircraft was about 100 feet above ground level and struck several treetops. Within seconds, the aircraft descended, struck the terrain, and crashed into trees. The two occupants were seriously injured, and the aircraft was destroyed. There was no fire. The accident occurred at 1320 PDT.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot did not avoid the trees that obstructed his immediate flight path on descent to the lake.
2. The damage to the aircraft from the tree-strike seriously compromised the pilot's ability to control the aircraft, to the point where continued flight was impossible.
3. The pilot and the passenger suffered serious injuries. It is highly likely that proper use of a passenger restraint system would have lessened the injuries to both persons.
Findings as to Risk:
1. Canadian regulations regarding the use of seats and seat restraint systems are not sufficiently clear about high-risk, aerial work operations, such as aerial application.
2. Transport Canada was not advised of the fish-dropping operations and was unaware that the passenger in the cabin was unrestrained during high-risk operations.
3. Canadian regulations do not require specific training in aerial application techniques, such as fish-dropping.
4. The installation of the fish-hopper equipment constituted an aircraft modification, which had not been approved by Transport Canada.
Other Findings:
1. The operator did not maintain a proper logbook.
Final Report:

Crash of a Cessna 208A Caravan 675 in Abbotsford

Date & Time: Dec 28, 1999 at 0917 LT
Type of aircraft:
Operator:
Registration:
C-FGGG
Flight Phase:
Survivors:
Yes
Schedule:
Abbotsford - Billings - Nassau
MSN:
208-0310
YOM:
1999
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
85.00
Circumstances:
At 0916 Pacific standard time, the Seair Cessna 208 Caravan amphibious aircraft, serial number 20800310, took off from runway 19 at Abbotsford Airport, British Columbia, on the first leg of a private flight to the Bahamas. One pilot and five passengers were on board. About one minute later, as the aircraft was climbing through an altitude of about 400 feet above ground level and as the pilot retracted flaps from 10 to zero degrees, the aircraft became uncontrollable. The aircraft banked left, descended rapidly, and crashed in a field about one-half mile south of the runway threshold, in a left bank with a near-level pitch attitude. The aircraft was destroyed, and the pilot received serious injuries. Two passengers were also seriously injured, and three passengers received minor injuries. Daylight visual meteorological conditions prevailed at the time of the accident. There was no fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot took off with frost adhering to the aircraft's lifting surfaces, which increased drag and reduced the ability of the wings to produce lift.
2. At take-off, the aircraft was about 510 pounds in excess of its maximum take-off weight, adversely affecting aircraft performance.
3. The aircraft experienced an aerodynamic stall and loss of control when the flaps were retracted from 10 degrees to zero. Retracting the flaps reduced the amount of lift being produced by the wing, already performing poorly because of contamination.
Other Findings:
1. Appropriate entries were not recorded in the aircraft=s journey and maintenance logs, and the weight and balance documentation was not amended.
2. The floats absorbed much of the impact energy and likely enhanced survivability of the accident.
Final Report: