Victoria

The pilot’s loss of control due to spatial disorientation. Contributing to the accident were the inoperative attitude indicator and horizontal situation indicator on the pilot’s side of the cockpit, and the pilot’s failure to reference the flight instruments that were operative.

Findings as to Causes and Contributing Factors:
1. APEX 511 turned onto the final approach course within the wake turbulence area behind and below the heavier aircraft and encountered its wake, resulting in an upset and loss of control at an altitude that precluded recovery.
2. The proximity of the faster trailing traffic limited the space available for APEX 511 to join the final approach course, requiring APEX 511 not to lag too far behind the preceding aircraft.
Findings as to Risk:
1. The current wake turbulence separation standards may be inadequate. As air traffic volume continues to grow, there is a risk that wake turbulence encounters will increase.
2. Visual separation may not be an adequate defence to ensure that appropriate spacing for wake turbulence can be established or maintained, particularly in darkness.
3. Neither the pilots nor Canadian Air Charters (CAC) were required by regulation to account for employee duty time acquired at other non-aviation related places of employment. As a result, there was increased risk that pilots were operating while fatigued.
4. Not maintaining engine accessories in accordance with manufacturers’ recommendations can lead to failure of systems critical to safety.
Other Finding:
1. APEX 511 was not equipped with any type of cockpit recording devices, nor was it required to be. As a result, the level of collaboration and decision making discussion between the 2 pilots remains unknown.

A loss of power on the left engine shortly after takeoff for undetermined reasons.
The following contributing factors were identified:
- A probable inadequate compliance with emergency procedures,
- Probable little and discontinuous flight activity on the aircraft type during the year 2008,
- Low turn.

The pilot's failure to maintain altitude/distance from obstacles during an IFR circling approach, and his failure to follow the instrument approach procedure. Contributing to the accident was clouds.

The loss of airplane pitch control (trim runway and mistrim condition) resulting from a failure in the airplane's electric pitch trim system. Factors that contributed to the accident were the manufacturer's inadequate design of the pitch trim circuitry that allowed for a single-point failure mode, and the absence of an adequate failure warning system to clearly alert the pilot to the pitch trim runaway condition in sufficient time to respond in accordance with the manufacturer's checklist instructions.

Findings as to Causes and Contributing Factors:
1. A planetary gear disintegrated in the propeller reduction gearbox of the No. 2 engine and caused the engine drive shaft to disconnect from the propeller, resulting in a loss of propulsion from this engine.
2. The planetary gear oil strainer screen wires fractured by fatigue as a consequence of the installation at the last overhaul. This created an unsafe condition and it is most probable that the release of wire fragments and debris from this strainer screen subsequently initiated or contributed to distress of the planetary gear bearing sleeve and resulted in the disintegration of the planetary gear.
3. Although airspeed was above Vmc at the time of the power loss, the aircraft became progressively uncontrollable due to power on the remaining engine not being reduced to relieve the asymmetric thrust condition until impact was imminent.
Findings as to Risk:
1. The propeller reduction gearboxes were inspected in accordance with the West Coast Air maintenance control manual. These inspections exceeded requirements of the de Havilland Equalized Maintenance Maximum Availability program. Since the last inspection, 46 hours of flight time before the accident, did not reveal any anomaly, a risk remains of adverse developments with
resulting consequences occurring during the unmonitored period between inspections.
2. Regulations require the installation of engine oil chip detectors, but not the associated annunciator system on the DHC-6. Without an annunciator system, monitoring of engine oil contamination is limited to the frequency and thoroughness of maintenance inspections. An annunciator system would have provided a method of continuous monitoring and may have warned the crew of the impending problem.
3. Although regulations do not require the aircraft to be equipped with an auto-feather system, its presence may have assisted the flight crew in handling the sudden loss of power by reducing the drag created by a windmilling propeller.
4. Since most air taxi and commuter operators use their own aircraft rather than a simulator for pilot proficiency training, higher-risk emergency scenarios can only be practiced at altitude and discussed in the classroom. As a result, pilots do not gain the benefit of a realistic experience during training.
Other Findings:
1. The fact that the aircraft remained upright and floating in daylight conditions contributed to the successful evacuation of the cabin without injury and enabled about half of the passengers to locate and don their life vests.
2. The aircraft was at low altitude and low airspeed at the time of power loss. The selection of full flaps may have contributed to a single-engine, high-drag situation, making a successful landing difficult.

Findings as to Causes and Contributing Factors:
1. The accident flight was not conducted in accordance with the night obstacle clearance requirements of Canadian Aviation Regulation (CAR) 705.32.
2. The Kelowna Flightcraft company operations manual did not reflect the restrictive conditions imposed on night visual flight rules (VFR) flight by CAR 705.32. Such information might have
prevented the accident by ensuring the crew's awareness of those night obstacle clearance standards.
3. As the aircraft approached Mayne Island, it encountered a low cloud ceiling that was based about 800 feet and that reduced visual reference with the surface.
4. When the aircraft struck trees, it was being flown in controlled, level flight at an altitude below the surrounding terrain.
5. The aircraft was not equipped with a ground proximity warning system or any other similar system that could warn the crew of an impending collision with terrain. Such systems were not required by regulation.
Findings as to Risk:
1. Kelowna Flightcraft flight operations personnel were not aware that most of the DC-3 flights were being conducted under VFR.
2. First responders were not aware of the presence of the dangerous goods and were therefore at increased risk during their response activities on the site.
Other Findings:
1. Transport Canada officials responsible for monitoring this operation were not aware that most of the DC-3 flights were being conducted under VFR at night and below the required obstacle
clearance altitudes.

Findings as to Causes and Contributing Factors:
A. Although weather information was available by radio from the Vancouver FSS specialists or from the Victoria Terminal controllers, there is no indication that the pilots requested weather updates from either of these units.
B. The crew of RXX434 would have encountered the lower ceiling in the vicinity of Beaver Point. This lower layer of cloud would have restricted the crew's view of the ground lighting and reduced the ambient lighting available to navigate by visual means.
C. With the loss of ground references, it is unlikely that the crew would have been able to perceive the divergence of the aircraft's flight path away from its intended track by visual means.
D. The crew was unable to maintain separation between the aircraft and the terrain by visual means.
E. The published VFR arrival and departure routes for Victoria were not consistent with obstacle clearance requirements for commercial operators.
F. Regency Express Air Operations' crew manual suggested an en route altitude of 1,500 feet for this particular flight. That route and altitude combination is not consistent with published obstacle clearance requirements.
Other Findings:
1. At the time the crew completed their flight planning, the weather at the departure airport of Vancouver and the arrival airport of Victoria was suitable for a night VFR flight.
2. An amended terminal forecast for Victoria indicating the presence of a temporary ceiling at 2,000 feet asl was issued after the crew had completed their preflight planning activities.
3. The regulation requiring GPWS equipment does not apply to air taxi operations because the aircraft used in those operations do not meet weight or propulsion criteria.