What happened
On 24 September 2019, a Bell 206B helicopter, registered as C-GEBY, was performing a visual flight rules flight from the E & B Heliport in Campbell River, British Columbia, to Moat Lake. The aircraft was operated by E & B Helicopters Ltd. with only the pilot on board.
During the flight along the coastline, the aircraft experienced an engine power anomaly. In response, the pilot reversed course and began a descent. As the helicopter descended, it entered a right-hand climbing turn toward land. At approximately 200 feet above the ground, the pilot lost control of the aircraft. The helicopter struck a building and two vehicles, resulting in one fatality. The impact and subsequent fire destroyed the aircraft, though no individuals on the ground were injured.
The investigation
The investigation focused on several critical areas, including the mechanical state of the engine and rotor system, the operator's maintenance and safety culture, the certification process of the composite blades, and the medical fitness of the pilot.
Investigators examined the engine fuel system and found it lacked the necessary accumulators and double check valve required for the Bell 206B. Furthermore, the company's maintenance control system failed to ensure the engine installation met manufacturer recommendations. The investigation also scrutinized the certification of the Van Horn composite blades, noting a lack of dynamic load assessment during their certification and a lack of internal defect inspections during production.
Regarding the operator, the investigation looked into the safety culture of E & B Helicopters Ltd., specifically noting that the pilot served as the owner, accountable executive, and operations manager. Finally, a medical review was conducted to assess the pilot's cardiovascular health and the effectiveness of Transport Canada's medical examination processes.
Findings
- Structural failure of the main rotor blades occurred during flight, with both blades becoming deformed. This deformation likely caused the main rotor RPM to drop below the level required to sustain an autorotation.
- The engine fuel system was configured incorrectly, lacking the appropriate components for the aircraft model.
- The operator's safety culture was compromised by a lack of independent oversight, as many critical decisions were based on a single individual's opinion.
- The certification of the composite blades lacked a dynamic load assessment, and the manufacturer's quality assurance process did not include inspections for internal defects.
- The pilot's high risk for a sudden cardiovascular event was not identified by Transport Canada's medical examination process, partly because the pilot did not disclose certain health conditions and the family physician did not report them.