Report: Continued flight in poor weather
led to 2019 Cessna Caravan floatplane crash in Canada
In its
investigation report released today, the Transportation Safety Board of
Canada (TSB) found that the decision to continue flying in poor weather led
to the fatal July 2019 controlled flight into terrain occurrence on
Addenbroke Island, British Columbia (BC).
On 26 July 2019,
at around 9:30 local time, 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, 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, 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 (G1000), they were
configured in a way that made the system ineffective at alerting the pilot
to the rising terrain ahead. Additionally, the pilot’s attention, vigilance
and general cognitive function were likely influenced to some degree by
fatigue. 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.
However, air
operators are not alone in monitoring for safe operations. Following this
occurrence, 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, there is a risk that
air operators will be non-compliant with regulations or drift toward unsafe
practices, thereby reducing safety margins.
Following the
occurrence, 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.
REPORT: https://tinyurl.com/3zamhms9
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