Vancouver

Findings as to causes and contributing factors:
1. For unknown reasons, the aircraft descended in the direction of flight at high speed until it exceeded its structural limits, leading to an in-flight breakup.
2. Based on the captain’s blood alcohol content, alcohol intoxication almost certainly played a role in the events leading up to the accident.

Findings as to risk:
1. If cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
2. If Canadian Aviation Regulations Subpart 703 operators are not required to have a Transport Canada–approved safety management system, which is assessed on a regular basis, there is a risk that those companies will not have the necessary processes in place to manage safety effectively.
3. If safety issues, such as concerns related to drug or alcohol abuse, are not reported formally through a company’s safety reporting system, there is a risk that hazards will not be managed effectively.
4. Transport Canada’s Handbook for Civil Aviation Medical Examiners(TP 13312) does not address the complete range of conditions that may be affected by drug or alcohol dependence. As a result, there is an increased risk that undisclosed cases of drug or alcohol dependence in commercial aviation will go undetected, placing the travelling public at risk.
5. If there is no regulated drug- and alcohol-testing requirement in place to reduce the risk of impairment of persons while engaged in safety-sensitive functions, employees may undertake these duties while impaired, posing a risk to public safety.

Findings as to causes and contributing factors:
During routine aircraft maintenance, it is likely that the left-engine oil-reservoir cap was left unsecured.
There was no complete preflight inspection of the aircraft, resulting in the unsecured engine oil-reservoir cap not being detected, and the left engine venting significant oil during operation.
A non-mandatory modification, designed to limit oil loss when the engine oil cap is left unsecure, had not been made to the engines.
Oil that leaked from the left engine while the aircraft was repositioned was pointed out to the crew, who did not determine its source before the flight departure.
On final approach, the aircraft slowed to below VREF speed. When power was applied, likely only to the right engine, the aircraft speed was below that required to maintain directional control, and it yawed and rolled left, and pitched down.
A partially effective recovery was likely initiated by reducing the right engine’s power; however, there was insufficient altitude to complete the recovery, and the aircraft collided with the ground.
Impact damage compromised the fuel system. Ignition sources resulting from metal friction, and possibly from the aircraft’s electrical system, started fires.
The damaged electrical system remained powered by the battery, resulting in arcing that may have ignited fires, including in the cockpit area.
Impact-related injuries sustained by the pilots and most of the passengers limited their ability to extricate themselves from the aircraft.
Findings as to risk:
Multi-engine−aircraft flight manuals and training programs do not include cautions and minimum control speeds for use of asymmetrical thrust in situations when an engine is at low power or the propeller is not feathered. There is a risk that pilots will not anticipate aircraft behavior when using asymmetrical thrust near or below unpublished critical speeds, and will lose control of the aircraft.
The company’s standard operating procedures lacked clear directions for how the aircraft was to be configured for the last 500 feet, or what to do if an approach is still unstable when 500 feet is reached, specifically in an abnormal situation. There is a demonstrated risk of accidents occurring as a result of unstabilized approaches below 500 feet above ground level.
Without isolation of the aircraft batteries following aircraft damage, there is a risk that an energized battery may ignite fires by electrical arcing.
Erroneous data used for weight-and-balance calculations can cause crews to inadvertently fly aircraft outside of the allowable center-of-gravity envelope.

Findings as to Causes and Contributing Factors:
1. The combined effects of the atmospheric conditions and bank angle increased the load factor, causing an aerodynamic stall.
2. Due to the absence of a functioning stall warning system, in addition to the benign stalling characteristics of the Beaver, the pilot was not warned of the impending stall.
3. Because the aircraft was loaded in a manner that exceeded the aft CG limit, full stall recovery was compromised.
4. The altitude from which recovery was attempted was insufficient to arrest descent, causing the aircraft to strike the water.
5. Impact damage jammed 2 of the 4 doors, restricting egress from the sinking aircraft.
6. The pilot’s seat failed and he was unrestrained, contributing to the seriousness of his injuries and limiting his ability to assist passengers.
Findings as to Risk:
1. There is a risk that pilots will inadvertently stall aircraft if the stall warning system is unserviceable or if the audio warnings have been modified to reduce noise levels.
2. Pilots who do not undergo underwater egress training are at greater risk of not escaping submerged aircraft.
3. The lack of alternate emergency exits, such as jettisonable windows, increases the risk that passengers and pilots will be unable to escape a submerged aircraft due to structural damage to primary exits following an impact with the water.
4. If passengers are not provided with explicit safety briefings on how to egress the aircraft when submerged, there is increased risk that they will be unable to escape following an impact with the water.
5. Passengers and pilots not wearing some type of flotation device prior to an impact with the water are at increased risk of drowning once they have escaped the aircraft.

Findings as to Causes and Contributing Factors:
1. APEX 511 turned onto the final approach course within the wake turbulence area behind and below the heavier aircraft and encountered its wake, resulting in an upset and loss of control at an altitude that precluded recovery.
2. The proximity of the faster trailing traffic limited the space available for APEX 511 to join the final approach course, requiring APEX 511 not to lag too far behind the preceding aircraft.
Findings as to Risk:
1. The current wake turbulence separation standards may be inadequate. As air traffic volume continues to grow, there is a risk that wake turbulence encounters will increase.
2. Visual separation may not be an adequate defence to ensure that appropriate spacing for wake turbulence can be established or maintained, particularly in darkness.
3. Neither the pilots nor Canadian Air Charters (CAC) were required by regulation to account for employee duty time acquired at other non-aviation related places of employment. As a result, there was increased risk that pilots were operating while fatigued.
4. Not maintaining engine accessories in accordance with manufacturers’ recommendations can lead to failure of systems critical to safety.
Other Finding:
1. APEX 511 was not equipped with any type of cockpit recording devices, nor was it required to be. As a result, the level of collaboration and decision making discussion between the 2 pilots remains unknown.

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.

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.

Findings as to Causes and Contributing Factors:
1. The engine lost power when a compressor turbine blade failed as a result of the overstress extension of a fatigue-generated crack. The fracture initiated at a metallurgical anomaly in the parent blade material and progressed, eventually resulting in blade failure due to overstress rupture.
2. The combination of aircraft position at the time of the engine failure, the lack of equipment enabling the pilot to locate and identify high terrain, and the resultant manoeuvring required to avoid entering instrument flight conditions likely prevented the pilot from attempting to glide to the nearest airfield.
Findings as to Risk:
1. Single-engine instrument flight rules (SEIFR) operations in designated mountainous regions have unique obstacle risks in the event of an engine failure. Canadian equipment requirements for such operations do not currently include independent terrain mapping, such as terrain awareness and warning systems (TAWS).
2. Airline operators are not currently required to conduct any additional route evaluation or structuring to ensure that the risk of an off-field landing is minimized during SEIFR operations.
3. Pilots involved in commercial SEIFR operations do not receive training in how to conduct a forced landing under instrument flight conditions; such training would likely improve a pilotís ability to respond to an engine failure when operating in instrument meteorological conditions (IMC).
4. Mean time between failure (MTBF) calculations do not take into account In Flight Shut Downs (IFSDs) not directly attributable to the engine itself; it may be more appropriate to monitor all IFSD events.
5. The design of the Cessna 208B Caravan fuel shutoff valves increases the risk that the valves will open on impact, allowing fuel spillage and increasing the potential for fire.
Other Finding:
1. Sonicblue Airways was not providing downloaded engine parameter data for engine condition trend monitoring (ECTM) evaluation at appropriate intervals.

Findings as to Causes and Contributing Factors:
1. During the take-off, the left engine combustion chamber plenum split open due to a fatigue crack. The rupture was so extensive that the engine flamed out.
2. The crew did not feather the left engine or retract the flaps, and the aircraft entered a moderate left-hand turn after take-off; the resulting drag caused the aircraft to descend until it contacted trees.
3. The first officer’s flying skills may have been challenged during the handling of the engine failure, and the checklist was conducted out of sequence, suggesting that there may have been uncertainty in the cockpit. A contributing factor may have been the captain’s unfamiliarity with handling an emergency from the right seat.
4. The use of flap 20 for take-off, although in accordance with company policy, contributed to the difficulty in handling the aircraft during the emergency.
Findings as to Risk:
1. The TPE331 series engine plenum is prone to developing cracks at bosses, particularly in areas where two bosses are in close proximity and a reinforcing weld has been made. Cracks that develop in this area cannot necessarily be detected by visual inspections or even by fluorescent dye-penetrant inspections (FPIs).
2. Because the wing was wet and the air temperature was at 0°C, it is possible that ice may have formed on top of the wing during the take-off, degrading the wing’s ability to generate lift.
3. Being required to conduct only flap 20 take-offs increases the risk of an accident in the event of an engine problem immediately after take-off.
Other Finding:
1. The plenum manufactured with a single machined casting, incorporating the P3 and bleed air bosses, is an improvement over the non-single casting boss plenum; however, cracks may still develop at bosses elsewhere on the plenum.