Occurrence
On July 26, 2019, at 0932 Pacific Daylight Time, a 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 (VFR) flight to a fishing lodge approximately 66 nautical miles north-northwest of Port Hardy Airport. On board were 1 pilot and 8 passengers.
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.
Investigation Findings
The investigation found that the flight departed the Vancouver International Water Aerodrome even though reported and forecast weather conditions were below VFR minima in the vicinity of the destination. 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, which recommended that the Department of Transport require mandatory installation of lightweight flight recording systems by commercial and private operators not currently required to carry these systems.
The investigation also highlighted the value of on-board recorders to air operators, as these systems can allow regular monitoring of normal flight activities, helping operators improve operational efficiency and detect safety issues before they cause an accident. The investigation found that if air operators with flight data monitoring capabilities do not actively monitor their flight operations, they may not be able to identify drift toward unsafe practices that increase risk to flight crew and passengers.
Oversight and Safety Management
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. The investigation noted that 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 monitors airline operations using operators’ safety management systems (SMS), but 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, 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.
The TSB previously recommended (Recommendation A16-12) that the Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system. Safety management and regulatory surveillance remain on the TSB Watchlist.
Fatigue Factors
Fatigue management is also a key safety issue 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.