Occurrence
On 24 September 2019, at approximately 1103 Pacific Daylight Time, a Bell 206B helicopter (registration C-GEBY, serial number 3375) operated by E & B Helicopters Ltd. was conducting a visual flight rules flight from the operator's base at Campbell River (E & B Heli) Heliport (CCR6) in Campbell River, British Columbia, to Moat Lake, British Columbia, with only the pilot on board.
Shortly after departure, while flying southeast along the coastline, the helicopter briefly levelled off at 615 feet above sea level, then began a descent. At 417 feet above sea level, it entered a right-hand climbing turn toward land and, following the turn, began to descend again. During this descent, control was lost when the helicopter was about 200 feet above ground level, and it fell to the ground, striking a building and two vehicles. The pilot was fatally injured; no one on the ground was injured. The helicopter was destroyed by impact forces and a post-impact fire.
Findings
The investigation found that an engine power anomaly likely occurred while the helicopter was in cruise flight, prompting the pilot to reverse course and enter a descent consistent with an autorotation.
Examination of the main rotor blades revealed several indications of structural failure in flight. Both main rotor blades became deformed. Fatigue indications were present post-occurrence on a small portion of the trailing edge of one blade, but the extent to which this fatigue contributed to the deformation could not be determined. In the last moments of the flight, likely as a result of the deformed blades, main rotor rpm decreased to a point that could not sustain autorotational flight, causing the helicopter to fall vertically and impact the ground.
Maintenance and Fuel System
The engine fuel system lacked the appropriate accumulators and double check valve for the Bell 206. During engine installation, the company's maintenance control system was ineffective at ensuring compliance with the manufacturer's recommendations. The investigation noted that if maintenance procedures do not include a thorough review of all related instructions and bulletins, an aircraft may be released into service in a non-airworthy configuration.
Safety Culture
The pilot was the company's owner, accountable executive, and operations manager. Many operational and maintenance-related decisions were based on a single opinion rather than validation by independent supervisors. Several opportunities to improve flight safety had been missed. The investigation stated that if company management routinely deviates from regulatory requirements, an unsupportive safety culture may develop.
Composite Main Rotor Blades
The helicopter was equipped with Van Horn composite main rotor blades. A structural fatigue test completed as part of the primary structural element threat assessment is intended to ensure continuing airworthiness. However, no dynamic assessment was carried out for certification of this blade model. Without dynamic assessment data, the fatigue test may not discover structural responses associated with damage. Additionally, Van Horn's quality assurance process has no established inspection for internal defects following production or criteria for permissible defect size. The investigation noted that if manufacturing processes do not include internal inspections, defects affecting structural integrity may not be identified.
Medical Fitness
An independent cardiology review conducted as part of the investigation determined that the pilot's actual annual risk for a sudden incapacitating cardiovascular event exceeded 5% per year, surpassing Transport Canada's (TC) 2% threshold and the 1% threshold recommended for single-pilot operations. Post-mortem results confirmed extensive atherosclerotic coronary artery disease in all four major coronary arteries, with significant stenosis. The investigation found that TC's civil aviation medical examination did not identify this level of risk. Additionally, the pilot was not forthcoming with Civil Aviation Medical Examiners (CAMEs) about conditions managed by his family physician, and the family physician did not report these conditions to TC. The investigation stated that if pilots and family physicians do not declare health issues, TC may not accurately assess medical fitness.
Probable Cause
Not stated.