The Cessna 208 Caravan involved in TSB’s investigation crashed into a hillside in July 2019 about 17 kilometres from its fishing lodge destination. (Photo: TSB)

TSB on March 10 released its investigation report (A19P0112) into a July 2019 controlled flight into terrain occurrence on Addenbroke Island, British Columbia, noting how the decision to continue flying in poor weather led to the fatal accident.

On July 2019,26, at around 9:30 local time, TSB explains a float-equipped Cessna 208 Caravan aircraft, operated by Seair Seaplanes, departed Vancouver International Water Aerodrome, BC, for a visual flight rules (VFR) flight to a fishing lodge near Port Hardy, BC, with one pilot and eight passengers on board. At 11:04 local time, TSB explains the aircraft struck the hillside of Addenbroke Island, 9.7 nautical miles from the destination. The pilot and three of the passengers were fatally injured. Four of the surviving passengers received serious injuries, and one received minor injuries. The aircraft was destroyed.

The investigation found that the flight departed the Vancouver International Water Aerodrome despite reported and forecasted weather conditions that were below VFR requirements near the destination, and that the decision to depart may have been influenced by group dynamics. After encountering poor weather conditions, TSB explains 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, TSB notes they were configured in a way that made the system ineffective at alerting the pilot to the rising terrain ahead. Additionally, TSB states the pilot’s attention, vigilance and general cognitive function were likely influenced to some degree by fatigue, a key safety issue on the TSB Watchlist.

Although the aircraft was equipped to capture flight data, Seair had not established a flight data monitoring (FDM) program, nor was it required to by regulation. An FDM program can help operators improve operational efficiency and detect safety issues before they cause an accident. If air operators that have FDM 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. The acceptance of unsafe practices is one of the underlying factors identified in TSB’s safety issue investigation Raising the bar on safety: Reducing the risks associated with air-taxi operations in Canada (A15H0001).

TSB notes, however, air operators are not alone in monitoring for safe operations; and that 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, TSB notes Transport Canada (TC) did not conduct any reactive surveillance, initiate new surveillance activities, escalate upcoming surveillance activities, or conduct targeted or compliance inspections. If TC does not apply sufficient oversight of operators, according to TSB, there is a risk that air operators will be non-compliant with regulations or drift toward unsafe practices, thereby reducing safety margins. Regulatory surveillance is also a key safety issue on the TSB Watchlist.

Following the occurrence, TSB explains Seair contracted an aviation consulting company to conduct an operational and maintenance review, updated its standard operating procedures to highlight the limitations of the autopilot system, and added an acceptable use policy on personal electronic devices in the cockpit.

For a full report and conclusions visit TSB’s investigation page.