Powell River | Bureau of Aircraft Accidents Archives

At about 1013 Pacific Standard Time, the amphibious Grumman G-21A (registration C-FPCK, serial number 1187), operated by Pacific Coastal Airlines, departed from the water aerodrome at the south terminal of the Vancouver International Airport, British Columbia, with one pilot and seven passengers for a flight to Powell River, British Columbia. Approximately 19 minutes later, the aircraft crashed in dense fog on South Thormanby Island, about halfway between Vancouver and Powell River. Local searchers located a seriously injured passenger on the eastern shoreline of the island at about 1400. The aircraft was located about 30 minutes later, on a peak near Spyglass Hill, British Columbia. The pilot and the six other passengers were fatally injured, and the aircraft was destroyed by impact and post-crash fire. The emergency locator transmitter was destroyed and did not transmit.

Probable cause:

Findings as to Causes and Contributing Factors
1. The pilot likely departed and continued flight in conditions that were below visual
flight rules (VFR) weather minima.
2. The pilot continued his VFR flight into instrument meteorological conditions (IMC),
and did not recognize his proximity to terrain until seconds before colliding with
Thormanby Island, British Columbia.
3. The indication of a marginal weather improvement at Powell River, British Columbia,
and incorrect information from Merry Island, British Columbia, may have
contributed to the pilot’s conclusion that weather along the route would be sufficient
for a low-level flight.
Findings as to Risk:
1. The reliance on a single VHF-AM radio for commercial operations, particularly in congested airspace, increases the risk that important information is not received.
2. Flights conducted at low altitude greatly decrease VHF radio reception range, making it difficult to obtain route-related information that could affect safety.
3. The lack of pilot decision making (PDM) training for VFR air taxi operators exposes pilots and passengers to increased risk when faced with adverse weather conditions.
4. Some operators and pilots intentionally skirt VFR weather minima, which increases risk to passengers and pilots travelling on air taxi aircraft in adverse weather conditions.
5. Customers who apply pressure to complete flights despite adverse weather can negatively influence pilot and operator decisions.
6. Incremental growth in Pacific Coastal’s support to Kiewit did not trigger further risk analysis by either company. As a result, pilots and passengers were exposed to increased risks that went undetected.
7. Transport Canada’s guidance on risk assessment does not address incremental growth for air operators. As a result, there is increased risk that operators will not conduct the appropriate risk analysis as their operation grows.
8. Previous discussions between Pacific Coastal and the pilot about his weather decision making were not documented under the company’s safety management system (SMS). If hazards are not documented, a formal risk analysis may not be prompted to define and mitigate the risk.
9. There were no company procedures or decision aids (that is, decision tree, second pilot input, dispatcher co-authority) in place to augment a pilot’s decision to depart.
10. Because the aircraft’s emergency locator transmitter (ELT) failed to operate after the crash, determining that a crash had occurred and locating the aircraft were delayed.
11. On a number of flights, pilots on the Vancouver–Toba Inlet route, British Columbia, departed over maximum gross weight due to incorrectly calculated weight and balances. Risks to pilots and passengers are increased when the aircraft is operating outside approved limits.
12. The over-reliance on global positioning system (GPS) in conditions of low visibility and ceilings presents a significant safety risk to pilots and passengers.
Other Finding:
1. The SPOT Satellite Messenger data transmitted before the crash helped to narrow the search area and reduce the search time to find the aircraft. The fact that the wrong data were consulted caused an initial delay in reporting the missing aircraft.

Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Powell River: 1 killed

Date & Time: Mar 8, 2006 at 1639 LT

Type of aircraft:

Piper PA-31-350 Navajo Chieftain

Operator:

Registration:

C-GNAY

Flight Phase:

Landing (descent or approach)

Flight Type:

Cargo

Survivors:

Yes

Site:

Airport (less than 10 km from airport)

Schedule:

Vancouver – Powell River

MSN:

31-8052095

YOM:

1980

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

1200

Copilot / Total flying hours:

500

Circumstances:

The aircraft departed from its home base at Vancouver, British Columbia, with two crew members on board. The aircraft was being repositioned to Powell River (a 30-minute flight) to commence a freight collection route. On arriving at Powell River, the crew joined the circuit straight-in to a right downwind for a visual approach to Runway 09. A weather system was passing through the area at the same time and the actual local winds were shifting from light southwesterly to gusty conditions (11 to 37 knots) from the northwest. The aircraft was lower and faster than normal during final approach, and it was not aligned with the runway. The crew completed an overshoot and set up for a second approach to the same runway. On the second approach, at about 1639 Pacific standard time, the aircraft touched down at least halfway down the wet runway and began to hydroplane. At some point after the touchdown, engine power was added in an unsuccessful attempt to abort the landing and carry out an overshoot. The aircraft overran the end of the runway and crashed into an unprepared area within the airport property. The pilot-in-command suffered serious injuries and the first officer was fatally injured. A local resident called 911 and reported the accident shortly after it occurred. The pilot-in-command was attended by paramedics and eventually removed from the wreckage with the assistance of local firefighters. The aircraft was destroyed, but there was no fire. The ELT (emergency locator transmitter) was automatically activated, but the signal was weak and was not detected by the search and rescue satellite.

Probable cause:

Findings as to Causes and Contributing Factors:
1. The downwind condition on approach contributed to the aircraft landing long and with a high ground speed. This, in combination with hydroplaning, prevented the crew from stopping the aircraft in the runway length remaining.
2. When the decision to abort the landing was made, there was insufficient distance remaining for the aircraft to accelerate to a sufficient airspeed to lift off.
3. The overrun area for Runway 09 complied with regulatory standards, but the obstacles and terrain contour beyond the overrun area contributed to the fatality, the severity of injuries, and damage to the aircraft.
Finding as to Risk:
1. Alert Service Bulletin A25-1124A (dated 01 June 2000), which recommended replacing the inertia reel aluminum shaft with a steel shaft, was not completed, thus resulting in the risk of failure increasing over time.
Other Findings:
1. The weather station at the Powell River Airport does not have any air–ground communication capability with which to pass the flight crew timely wind updates.
2. The decision to make a second approach was consistent with normal industry practice, in that the crew could continue with the intent to land while maintaining the option to break off the approach if they assessed that the conditions were becoming unsafe.

Final Report: