Air transportation safety investigation A19P0112

Controlled flight into terrain

Cessna 208 Caravan, C-GURL
Addenbroke Island, British Columbia
26 July 2019

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The occurrence

At 0932 Pacific Daylight Time on 26 July 2019, the float-equipped Cessna 208 Caravan aircraft (registration C-GURL, serial number 20800501), operated by Seair Seaplanes, departed Vancouver International Water Aerodrome, British Columbia, for a visual flight rules flight to a fishing lodge approximately 66 nautical miles north-northwest of Port Hardy Airport, British Columbia, with 1 pilot and 8 passengers on board.

At 1104, the aircraft struck the heavily forested hillside of Addenbroke Island, 9.7 nautical miles east-southeast of the destination fishing lodge. The Canadian Mission Control Centre detected an emergency locator transmitter signal from the aircraft. The pilot and 3 passengers were fatally injured. Four of the surviving passengers received serious injuries, and 1 received minor injuries. The aircraft was destroyed.

The investigation found that the flight departed the Vancouver International Water Aerodrome even though reported and forecast weather conditions that were below visual flight rules minima in the vicinity of the destination and the decision to depart may have been influenced by group dynamics. After encountering poor weather conditions, the pilot continued the flight in reduced visibility, without recognizing the proximity to terrain, and subsequently impacted the rising terrain of Addenbroke Island. Although the aircraft was equipped with advanced avionics devices, they were configured in a way that made the system ineffective at alerting the pilot to the rising terrain ahead.

The occurrence aircraft was not required to carry on-board flight recorders. However, it contained 3 devices capable of recording flight data. These devices greatly aided this investigation, and the value in the data supports TSB Recommendation A18-01, in which the TSB recommended that

The investigation also highlights the value of on-board recorders to air operators. These systems can allow regular monitoring of normal flight activities, which helps operators improve operational efficiency and detect safety issues before they cause an accident. The investigation found that 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.

However, air operators are not alone in monitoring for safe operations. The role of the regulator is to ensure that operators are capable of managing the risks inherent in their operations, that measures to enhance safety are working effectively to identify hazards and mitigate risks, and that any non-compliance with regulations is addressed promptly and corrective action is taken. Following this occurrence, Transport Canada (TC) flight operations did not conduct any reactive surveillance, initiate new surveillance activities following the serious occurrence, escalate upcoming surveillance activities, or conduct targeted or compliance inspections. If TC does not apply sufficient oversight of operators, there is a risk that air operators will be non-compliant with regulations or drift toward unsafe practices, thereby reducing safety margins.

TC also monitors airline operations using the operators’ safety management system (SMS ), which is a documented system for managing risks. However, there is no regulatory requirement for air-taxi operators, such as Seair Seaplanes, to implement and maintain an SMS. Therefore, for air-taxi operators that do maintain an SMS, as Seair Seaplanes does, TC does not monitor the effectiveness of the SMS through surveillance. As a result, operators receive no feedback on the overall effectiveness of their SMS, including the system’s ability to identify hazards and mitigate them before they result in an incident or accident.

Following the TSB's investigation into a fatal helicopter accident that occurred in 2013 (TSB aviation investigation report A13H0001), the Board recommended that

In addition, safety management and regulatory surveillance remain on the TSB Watchlist, which identifies the key safety issues that need to be addressed to make Canada’s transportation system even safer.

Fatigue management is also one of the key safety issues on the TSB Watchlist. The investigation conducted a fatigue analysis of the pilot and determined that 3 fatigue risk factors were present, which most likely influenced the pilot’s performance, attention, vigilance, and general cognitive function to some degree on the day of the accident.

Media materials

News release

Deployment notice

Investigation information

Map showing the location of the occurrence

Investigator-in-Charge

Scott Ludlow joined the TSB’s Air Investigations Branch in 2019 after having spent 15 years in private sector aviation. He has flying and training experience in commercial operations under subparts 702, 703, 704 & 705 of the CARs, and as a flight instructor. The majority of his experience was acquired in Newfoundland-and-Labrador and the Maritime provinces. He has also worked in Montreal, Qc, and Comox, BC, flying King Airs, Citations, and Dash-8. Mr. Ludlows holds a Bachelor’s degree in science (physics) and is completing his Master’s degree in Aeronautical Science (human factors and safety management).

Photos

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Class of investigation

This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.