Crash of a Piper PA-60-602P Super 700 Aerostar on Gabriola Island: 3 killed

Date & Time: Dec 10, 2019 at 1805 LT
Operator:
Registration:
C-FQYW
Flight Type:
Survivors:
No
Schedule:
Cabo San Lucas – Chino – Bishop – Nanaimo
MSN:
60-8265-020
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
320
Aircraft flight hours:
5752
Circumstances:
On 09 December 2019, a private Piper Aerostar PA-60-602P aircraft (registration C-FQYW, serial number 60-8265020), departed Cabo San Lucas International Airport (MMSL), Baja California Sur, Mexico, with 3 people on board, for a 2-day trip to Nanaimo Airport (CYCD), British Columbia (BC). As planned the aircraft stopped for an overnight rest at Chino Airport (KCNO), California, U.S. At 1142, on 10 December 2019, the aircraft departed KCNO on a visual flight rules (VFR) flight plan to Bishop Airport (KBIH), California, U.S., for a planned fuel stop. The aircraft departed KBIH at approximately 1425 on an instrument flight rules (IFR) flight plan to CYCD. On 10 December 2019, night started at 1654. At 1741, the Vancouver area control centre air traffic controller advised the pilot that an aerodrome special meteorological report (SPECI) had been issued for CYCD at 1731. The SPECI reported visibility as 2 ½ statute miles (SM) in light drizzle and mist, with an overcast ceiling of 400 feet above ground level (AGL). The pilot informed the controller that he would be conducting an instrument landing system (ILS) approach for Runway 16. At 1749, when the aircraft was approximately 32 nautical miles (NM) south of CYCD, the pilot contacted the controller to inquire about the weather conditions at Victoria International Airport (CYYJ), BC. The controller informed the pilot that a SPECI was issued for CYYJ at 1709 and it reported the visibility as 5 SM in mist, a broken ceiling at 600 feet AGL, and an overcast layer at 1200 feet AGL. The controller provided the occurrence flight with pilot observations from another aircraft that had landed at CYCD approximately 15 minutes before. That crew had reported being able to see the Runway 16 approach lights at minimums, i.e., at 373 feet AGL. Between 1753 and 1802, the controller provided vectors to the pilot in order to intercept the ILS localizer. At 1803, the controller observed that the aircraft had not intercepted the localizer for Runway 16. The aircraft had continued to the southwest, past the localizer, at an altitude of 2100 feet above sea level (ASL) and a ground speed of 140 knots. The controller queried the pilot to confirm that he was still planning to intercept the ILS for Runway 16. The pilot confirmed that he would be intercepting the ILS as planned. The aircraft made a heading correction and momentarily lined up with the localizer before beginning a turn to the west. At 1804:03, the pilot requested vectors from the controller and informed him that he “just had a fail.” The controller responded with instructions to “turn left heading zero nine zero, tight left turn.” The pilot asked the controller to repeat the heading. The controller responded with instructions to “…turn right heading three six zero.” The pilot acknowledged the heading; however, the aircraft continued turning right beyond the assigned heading while climbing to 2500 feet ASL and slowing to a ground speed of 80 knots. The aircraft then began to descend, picking up speed as it was losing altitude. At 1804:33, the aircraft descended to 1800 feet ASL and reached a ground speed of 160 knots. At 1804:40, the pilot informed the air traffic controller that the aircraft had lost its attitude indicator.Footnote6 At the same time, the aircraft was climbing into a 2nd right turn. At 1804:44, the air traffic controller asked the pilot what he needed from him; the pilot replied he needed a heading. The controller provided the pilot with a heading of three six zero. At 1804:47, the aircraft reached an altitude of 2700 feet ASL and a ground speed of 60 knots. The aircraft continued its right turn and began to lose altitude. The controller instructed the pilot to gain altitude if he was able to; however, the pilot did not acknowledge the instruction. The last encoded radar return for the aircraft was at 1805:26, when the aircraft was at 300 feet ASL and travelling at a ground speed of 120 knotsControl of the aircraft was lost. The aircraft collided with a power pole and trees in a wooded park area on Gabriola Island, BC, and then impacted the ground. The aircraft broke into pieces and caught fire. The 3 occupants on board received fatal injuries. As a result of being damaged in the accident, the emergency locator transmitter (Artex ME406, serial number 188-00293) did not activate.
Probable cause:
The occurrence aircraft was equipped with a BendixKing KI 825 electronic horizontal situation indicator (HSI) that was interfaced to the flight control system and GPS (global positioning system) Garmin GNS530W/430W. The HSI also supplies the autopilot system with heading information. The investigation determined that the HSI had failed briefly during operation on 22 November 2019 and a 2nd time, 3 days later, on 26 November 2019. The KI 825 HSI is electrically driven and therefore is either on and working, or off and dark with no display. The aircraft owner was in contact with an aircraft maintenance organization located at Boundary Bay Airport (CZBB), BC, and an appointment to bring the occurrence aircraft in for troubleshooting of the 2 brief HSI malfunctions had been made for 11 December 2019, i.e., the day after the accident. In total, 13 flights had been conducted after the 1st failure of the HSI. There were no journey log entries for defects with the HSI or evidence of maintenance completed. RegulationsFootnote9 require that defects that become apparent during flight operations be entered in the aircraft journey logbook, and advisory guidance in the regulatory standardsFootnote10 states that all equipment required for a particular flight or type of operation, such as the HSI in this case, be functioning correctly before flight. The HSI was destroyed in the accident and the investigation was unable to determine if it was operational on impact. Similarly, it could not be determined if the HSI was supplying the autopilot with heading information, or if the autopilot was engaged during the approach.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Comox: 2 killed

Date & Time: Apr 22, 2005 at 0741 LT
Operator:
Registration:
C-GVCP
Flight Type:
Survivors:
No
Schedule:
Nanaimo – Comox
MSN:
31-7652080
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft was on a scheduled cargo flight from Nanaimo, British Columbia, to the civilian terminal on the south side of the military airbase at Comox, British Columbia. The crew members established communication with the Comox tower when they were at about 2000 feet over Hornby Island, 12 nautical miles southeast of Comox, and requested a practice back course/localizer approach to Runway 30, circling for landing on Runway 18. The request was approved and the aircraft continued inbound. When the aircraft was about two miles from the threshold of Runway 30, the crew declared an emergency for an engine fire in the right engine. The tower alerted the airport response teams and requested standard data from the crew concerning the number of people and amount of fuel on board. Less than 30 seconds after the crew first reported the emergency, the aircraft was engulfed in flames. Shortly thereafter, at 0741 Pacific daylight time, the aircraft rolled inverted and struck the ground in a steep, nose-down, left-wing-low attitude. The aircraft broke apart and burned. Both crew members were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. At some point after 01 April 1999, a bad gasket (P/N LW-13388) was installed in the accident engine.
2. The requirement of Airworthiness Directive 2002-12-07 (to ensure that old converter plate gaskets were removed and replaced by new parts) was not carried out on the accident engine.
3. The improper oil filter converter plate gasket in the right engine compartment failed, allowing pressurized oil to spray into the engine compartment and ignite on contact with hot turbocharger and exhaust components.
4. The firewall fuel shut-off valve remained in the OPEN position, allowing pressurized fuel to be delivered to the engine-driven fuel pump by the aircraft’s boost pumps.
5. The initial oil-fed fire generated considerable heat, which melted the casing of the engine-driven fuel pump, allowing pressurized fuel to intensify the fire.
6. The flames breached the main fuel tank, inboard of the engine, causing the aircraft to become engulfed in flames.
Findings as to Risk:
1. Inappropriate converter plate gaskets, identified by part number LW-13388, are known to have remained in the aviation system after the date of the terminating action required by Airworthiness Directive (AD) 2002-12-07.
2. Compliance with the full requirements of AD 2002-12-07 is not always being accomplished with respect to vibro-peening and proper gluing procedures.
Final Report:

Crash of a Beechcraft C18S off Nanaimo: 7 killed

Date & Time: Jan 27, 1992
Type of aircraft:
Operator:
Registration:
C-FRVR
Flight Phase:
Survivors:
Yes
Schedule:
Nanaimo - Port Mellon
MSN:
6148
YOM:
1943
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The float equipped Beechcraft C18S was chartered to carry eight workers from Nanaimo to Port Mellon. After takeoff from the Nanaimo-Cassidy seaplane base, the pilot encountered difficulties to gain height. In poor weather conditions, the twin engine aircraft continued at a height of about 16 metres and rolled left and right. The aircraft entered a 30° left turn, causing the left wing tip to struck the water surface. The aircraft cartwheeled, crashed, exploded and sank. Quickly on the scene, in the Strait of Georgia, fishermen were able to rescue two passengers who were seriously injured (burned) while seven other occupants were killed.
Probable cause:
It was determined that the aircraft suffered atmospheric turbulences after takeoff in poor weather conditions. The pilot was unable to gain sufficient height because of atmospheric turbulences and unfavorable currents. The aircraft was operated within limits while the pilot's experience was limited.

Crash of a Rockwell Grand Commander 690A in Ryderwood: 5 killed

Date & Time: Nov 30, 1990 at 1841 LT
Operator:
Registration:
N400N
Flight Type:
Survivors:
Yes
Site:
Schedule:
Nanaimo - Kelso
MSN:
690-11156
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
11714
Captain / Total hours on type:
2647.00
Circumstances:
As the flight was approaching the destination, at night, the pilot obtained vectors for a descent over mountainous terrain. During the approach, he cancelled the IFR flight plan and the aircraft descended below radar coverage. Subsequently, the aircraft crashed in mountainous terrain, northwest of the destination airport. Impact occurred in a wooded area at an elevation of about 2,700 feet. The ELT did not activate during the accident. A search was initiated on 12/1/90, but the aircraft and surviving passenger were not found until the next day. The Canadian ATP pilot and other four passengers were fatally injured. After initial impact with trees, the main portion of the fuselage traveled about 1,000 feet before coming to rest. No preimpact mechanical problem was found.
Probable cause:
The pilot's improper inflight planning and failure to maintain proper altitude in mountainous terrain at night.
Final Report:

Crash of a Grumman G-21A Goose on Mt Hooper: 11 killed

Date & Time: Sep 9, 1974
Type of aircraft:
Registration:
C-FPVE
Flight Phase:
Survivors:
No
Site:
Schedule:
Tofino - Nanaimo
MSN:
1200
YOM:
1942
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
While cruising in marginal weather conditions, the seaplane struck the slope of Mt Hooper located 45 km southwest of Nanaimo. The aircraft was destroyed upon impact and all 11 occupants were killed.

Crash of a Canadian Vickers PBV-1 Canso near Nanaimo: 23 killed

Date & Time: Oct 17, 1951 at 1855 LT
Operator:
Registration:
CF-FOQ
Flight Phase:
Survivors:
No
Site:
Schedule:
Kildala – Vancouver
MSN:
CV-395
YOM:
1941
Flight number:
QCA102
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
23
Circumstances:
The aircraft left Kildala at 1532 bound for Vancouver carrying twenty passengers and a crew of three. At 1733 the aircraft reported over Sullivan Bay and gave its ETA Vancouver as 1840. At 1825 the ETA Vancouver was revised to 1903 on account of strong southeast winds. The next and last radio transmission received was at 1848 when the aircraft reported it was 20 miles west of Vancouver at 2,000 feet and requested clearance to the tower frequency. At approximately 1855 hours the aircraft crashed into Mount Benson. All occupants were killed and the aircraft was destroyed.
Probable cause:
The probable cause of this accident was the continuance of the flight VFR at night under conditions of restricted visibility. Whilst it cannot be determined conclusively, it is probable that through a navigation error the pilot mistook Nanaimo for Vancouver. This may have been precipitated by inadequate pre-flight preparation in that the latest Meteorological Information was not obtained by the pilot before taking off on the south bound flight.
Final Report:

Crash of a Noorduyn Norseman in Nanaimo

Date & Time: Oct 29, 1940
Type of aircraft:
Registration:
CF-AZE
Flight Phase:
Survivors:
Yes
Schedule:
Vancouver – Zeballos
MSN:
3
YOM:
1936
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route from Vancouver to Zeballos, the engine caught fire. The pilot reduced his altitude in an attempt to make an emergency landing. Upon touchdown, the single engine aircraft overturned and came to rest upside down, bursting into flames. All four occupants were seriously injured and the aircraft was destroyed.
Probable cause:
Engine fire in flight.