De Havilland DHC-2 Beaver

Findings as to causes and contributing factors:
1. The pilot flew just above the tree tops into instrument meteorological conditions and rising terrain, and the aircraft struck a tree that was significantly taller than the others.
2. The pilot and 1 passenger did not exit the aircraft before it was consumed in the postimpact fire.
3. Air Nootka did not have effective methods to monitor its pilots’ in-flight decision making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behavior or poor decision making such as occurred on this flight.
Findings as to risk:
1. If aircraft are not fitted with technology to reduce fuel leakage or to eliminate ignition sources, the risk of post-impact fire is increased.
2. If aircraft are not equipped with shoulder harnesses for all seating positions then there is an increased risk of injuries.
3. If aircraft are not equipped with some alternate means of escape such as push-out windows, then there is a risk that post-crash structural deformation will jam doors shut and restrict exit for the occupants.
4. If companies operating under self-dispatch do not monitor their operations, they risk not being able to identify unsafe practices that are a hazard to flight crew and passengers.
5. If flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.

The failure of the n°1 linkrod bushing or the bottom portion of the linkrod, which resulted in a total loss of engine power.

The pilot’s failure to maintain adequate altitude above the trees, and his subsequent failure to maintain adequate airspeed while maneuvering to avoid the trees, which resulted in an
inadvertent aerodynamic stall/spin and an uncontrolled descent.

The pilot’s failure to maintain adequate ground clearance during his landing approach, which resulted in a collision with terrain.

Findings as to Causes and Contributing Factors:
1. On the windward side of the landing surface, there was significant mechanical turbulence and associated wind shear caused by the passage of strong gusty winds over surface obstructions.
2. During the attempted overshoot, the rapid application of full power caused the aircraft to yaw to the left, and a left roll quickly developed. This movement, in combination with a high angle of attack and low airspeed, likely caused the aircraft to stall. The altitude available to regain control before striking the water was insufficient.
3. The pilot survived the impact, but was unable to exit the aircraft, possibly due to difficulties finding or opening an exit. The pilot subsequently drowned.
4. The rear-seat passenger did not have a shoulder harness and was critically injured. The passenger’s head struck the pilot’s seat in front; this passenger did not exit the aircraft and drowned.
Findings as to Risk:
1. Without a full passenger safety briefing, there is increased risk that passengers may not use the available safety equipment or be able to perform necessary emergency functions in a timely manner to avoid injury or death.
2. Not wearing a shoulder harness can increase the risk of injury or death in an accident.
3. Not having a stall warning system increases the risk that the pilot may not be aware of an impending aerodynamic stall.
4. Commercial seaplane pilots who do not receive underwater egress training are at increased risk of being unable to exit the aircraft following a survivable impact with water.

There was no indication that an aircraft system malfunction contributed to this occurrence. There were no drastic changes in the aircraft’s flight path, and no emergency calls from the pilot to indicate that an in-flight emergency was experienced. The constant ground speed and flight path would also suggest that the aircraft was under the control of the pilot. As a result, this analysis will focus on the phenomenon of controlled flight into terrain (CFIT).
Findings as to Causes and Contributing Factors:
1. The combination of relatively high weight, effects of density altitude, and down-flowing air likely reduced the climb performance of the aircraft, resulting in the aircraft’s altitude being lower than anticipated at that stage in the flight.
2. The pilot’s vision was likely impaired by the sun, and the pilot may have been exposed to visual illusions; both were factors that contributed to the pilot not noticing the trees and the rising terrain, and colliding with them.
Findings as to Risk:
1. Visual illusions cause false impressions or misconceptions of actual conditions. Unrecognized and uncorrected spatial disorientation, caused by illusions, carries a high risk of incident or accident.
2. When there are no special departure procedures published for airports in mountainous regions surrounded by high terrain, there is a risk of pilots departing the valley at an altitude too low for terrain clearance.
Other Findings:
1. Information from the Wide Area Multilateration system was not preserved following the occurrence, as local NAV CANADA personnel were not aware that unfiltered data were only available for a limited time.

The pilot's decision to depart in marginal visual meteorological conditions, and his continued visual flight into instrument meteorological conditions.

Findings as to Causes and Contributing Factors:
While manoeuvring at low level, the aircraft's critical angle of attack was likely exceeded and the aircraft stalled. The stall occurred at an altitude from which recovery was not possible.
Other Findings:
The separation of the propeller blade tip likely resulted from impact forces.
The investigation could not determine whether the fuel pressure warning light was illuminated prior to the accident.