What happened
On 26 July 2019, a float-equipped Cessna 208 Caravan, registered C-GURL, departed from the Vancouver International Water Aerodrome. Operated by Seair Seaplanes, the aircraft was performing a visual flight rules flight to a fishing lodge located approximately 66 nautical miles north-northwest of Port Hardy Airport, British Columbia. On board were the pilot and eight passengers.
At 1104, the aircraft struck a heavily forested hillside on Addenbroke Island, which was situated about 9.7 nautical miles east-southeast of the intended destination. The impact destroyed the aircraft. The crash resulted in four fatalities (the pilot and three passengers) and left five others with injuries, including four serious and one minor injury.
The investigation
Investigators examined the flight conditions and the aircraft's technical configuration. Although the aircraft was not legally required to carry flight recorders, it was equipped with three devices capable of capturing flight data. This data proved essential to the reconstruction of the event. The investigation also looked into the pilot's physiological state, conducting a fatigue analysis that identified three specific risk factors present on the day of the accident.
Furthermore, the TSB reviewed the regulatory oversight provided by Transport Canada and the effectiveness of the operator's safety management systems. The investigation noted that the pilot's decision-making was likely influenced by group dynamics and that the aircraft's advanced avionics were not configured to provide effective terrain alerts.
Findings
- The flight began despite weather forecasts indicating conditions below visual flight rules minima at the destination.
- The pilot continued the flight in reduced visibility without recognizing the proximity of rising terrain.
- The aircraft's advanced avionics were configured in a manner that rendered the terrain alert system ineffective.
- Fatigue risk factors were present, which likely impacted the pilot's cognitive function, attention, and vigilance.
- Group dynamics may have influenced the decision to depart despite unfavorable weather.
Safety action
- The TSB highlighted the importance of TSB Recommendation A18-01, which suggests the Department of Transport should mandate lightweight flight recording systems for commercial and private operators not currently required to carry them.
- The investigation noted the need for more robust regulatory surveillance and the implementation of formal safety management systems for all commercial aviation operators.