Victoria

A Cessna 208B airplane collided with a powered paraglider during cruise flight at 5,000 feet mean sea level (msl) in Class E airspace. Based on video evidence, the powered paraglider operator impacted the Cessna’s right wing leading edge, outboard of the lift strut attachment point. The outboard 10 ft of the Cessna’s right wing separated during the collision. The Cessna impacted terrain at high vertical speed in a steep nose-down and inverted attitude. The powered paraglider operator was found separated from his seat style harness. The paraglider wing, harness, and emergency parachute were located about 3.9 miles south of the Cessna’s main wreckage site. Based on video evidence and automatic dependent surveillance-broadcast (ADS-B) data, the Cessna and the powered paraglider converged with a 90° collision angle and a closing speed of about 164 knots. About 8 seconds before the collision, the powered paraglider operator suddenly turned his head to the right and about 6 seconds before the collision, the powered paraglider maneuvered in a manner consistent with an attempt to avoid a collision with the converging Cessna. Research indicates that about 12.5 seconds can be expected to elapse between the time that a pilot sees a conflicting aircraft and the time an avoidance maneuver begins. Additionally, research suggests that general aviation pilots may only spend 30-50% of their time scanning outside the cockpit. About 8 seconds before the collision (when the powered paraglider operator’s head suddenly turned to the right), the Cessna would have appeared in the powered paraglider operator’s peripheral view, where research has demonstrated visual acuity is very poor. Additionally, there would have been little apparent motion because the Cessna and the powered paraglider were on a collision course. Under optimal viewing conditions, the powered paraglider may have been recognizable to the Cessna pilot about 17.5 seconds before the collision. However, despite the powered paraglider’s position near the center of his field of view, the Cessna pilot did not attempt to maneuver his airplane to avoid a collision. Further review of the video evidence revealed that the powered paraglider was superimposed on a horizon containing terrain features creating a complex background. Research suggests that the powered paraglider in a complex background may have been recognizable about 7.4 seconds before the collision. However, the limited visual contrast of the powered paraglider and its occupant against the background may have further reduced visual detection to 2-3 seconds before the collision. Thus, after considering all the known variables, it is likely that the Cessna pilot did not see the powered paraglider with sufficient time to avoid the collision. The Cessna was equipped with a transponder and an ADS-B OUT transmitter, which made the airplane visible to the air traffic control system. The operation of the powered paraglider in Class E airspace did not require two-way radio communication with air traffic control, the use of a transponder, or an ADS-B OUT transmitter and therefore was not visible to air traffic control. Neither the Cessna nor the powered paraglider were equipped with ADS-B IN technology, cockpit display of traffic information, or a traffic alerting system. Postmortem toxicological testing detected the prescription antipsychotic medication quetiapine, which is not approved by the Federal Aviation Administration (FAA), in the Cessna pilot’s muscle specimen but the test results did not provide sufficient basis for determining whether he was drowsy or otherwise impaired at the time of the collision (especially in the absence of any supporting details to suggest quetiapine use). Testing also detected ethanol at a low level (0.022 g/dL) in the Cessna pilot’s muscle specimen, but ethanol was not detected (less than 0.01 g/dL) in another muscle specimen. Based on the available results, some, or all of the small amount of detected ethanol may have been from postmortem production, and it is unlikely that ethanol effects contributed to the accident. The Cessna pilot likely did not have sufficient time to see and avoid the powered paraglider (regardless of whether he was impaired by the quetiapine) and, thus, it is unlikely the effects of quetiapine or an associated medical condition contributed to the accident.

The airline transport pilot departed on a night cargo flight into conditions that included an overcast cloud ceiling and “hazy” visibility, as reported by another pilot. About one minute after takeoff, the pilot made a series of course changes and large altitude and airspeed deviations. Following several queries from the air traffic controller concerning the airplane’s erratic flight path, the pilot responded that he had “some instrument problems.” The pilot attempted to return to land at the departure airport, but the airplane impacted terrain after entering a near-vertical dive. The airplane was one of two in the operator’s fleet equipped with an inverter system that electrically powered the pilot’s (left side) flight instruments. Examination of the annunciator panel lighting filaments revealed that the inverter system was not powered when the airplane impacted the ground. Without electrical power from an inverter, the pilot’s side attitude indicator and horizontal situation indicator (HSI) would have been inoperative and warning flags would have been displayed over the respective instruments. The pilot had a history of poor procedural knowledge and weak flying skills. It is possible that he either failed to turn on an inverter during ground operations and did not respond to the accompanying warning flags, or he did not switch to the other inverter in the event that an inverter failed inflight. Due to impact damage, the operational status of the two inverters installed in the airplane could not be confirmed. However, the vacuum-powered flight instruments on the copilot’s (right side) were operational, and the pilot could have referenced these instruments to maintain orientation. Based on the available information, the pilot likely lost control of the airplane after experiencing spatial disorientation. The night marginal visual flight rules conditions and instrumentation problems would have been conducive to the development of spatial disorientation, and the airplane’s extensive fragmentation indicative of a high-energy impact was consistent with the known effects of spatial disorientation. Ethanol identified during toxicology testing may have come from postmortem production and based on the low levels recorded, was unlikely to have contributed to this accident. Morphine identified in the pilot’s liver could not be used to extrapolate to antemortem blood levels; therefore, whether or to what extent the pilot’s use of morphine contributed to the accident could not be determined.

The Canadian Air Charters Piper PA-31-350 Chieftain (registration C-GNAF, serial number 31-8052130) was operating under visual flight rules as APEX 511 on the final leg of a multi-leg cargo flight from Vancouver to Nanaimo and Victoria, British Columbia, with a return to Vancouver. The weather was visual meteorological conditions and the last 9 minutes of the flight took place during official darkness. The flight was third for landing and turned onto the final approach course 1.5 nautical miles behind and 700 feet below the flight path of a heavier Airbus A321, approaching Runway 26 Right at the Vancouver International Airport. At 2208, Pacific Daylight Time, the target for APEX 511 disappeared from tower radar. The aircraft impacted the ground in an industrial area of Richmond, British Columbia, 3 nautical miles short of the runway. There was a post-impact explosion and fire. The 2 crew members on board were fatally injured. There was property damage, but no injuries on the ground. The onboard emergency locator transmitter was destroyed in the accident and no signal was detected.

Shortly after a night takeoff from runway 05 at Buenos Aires-San Fernando Airport, the pilot initiated a left turn at low altitude when the twin engine aircraft collided with two poles and two parked trucks then crashed on the ground, bursting into flames. The aircraft was totally destroyed and both occupants were killed.

The private, instrument-rated pilot, was on an IFR cross-country flight, and had been cleared for a GPS approach. He reported that he was 5 minutes from landing, and said he was circling to the left, to land the opposite direction from the published approach. The traffic pattern for the approach runway was right traffic. Instrument meteorological conditions prevailed, and the weather conditions included a visibility of 3 statute miles in light rain and mist; few clouds at 400 feet, 1,000 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F. The minimum descent altitude, either for a lateral navigation approach, or a circling approach, was 580 feet, and required a visibility of 1 mile. The missed approach procedure was a right climbing turn. A circling approach north of the runway was not approved. Witnesses reported that the weather included low clouds and reduced visibility due to fog and drizzle. The airplane was heard, but not seen, circling several times over the city, which was north of the runway. Witnesses saw the airplane descending in a wings level, 30-45 degree nose down attitude from the base of clouds, pitch up slightly, and then collide with several trees and an unoccupied house. A postcrash fire consumed the residence, and destroyed the airplane. A review of FAA radar data indicated that as the accident airplane flew toward the airport, its altitude slowly decreased and its flight track appeared to remain to the left side (north) of the runway. The airplane's lowest altitude was 800 feet as it neared the runway, and then climbed to 1,700 feet, where radar contact was lost, north of the runway. During the postaccident examination of the airplane, no mechanical malfunction was found. Given the lack of any mechanical deficiencies with the airplane, it is likely the pilot was either confused about the proper approach procedures, or elected to disregard them, and abandoned the instrument approach prematurely in his attempt to find the runway. It is unknown why he decided to do a circle to land approach, when the tailwind component was slight, and the shorter, simpler, straight in approach was a viable option. Likewise, it is unknown why he flew towards rising terrain on the north side of the runway, contrary to the published procedures. From the witness statements, it appears the pilot was "hunting" for the airport, and intentionally dove the airplane towards what he perceived was an area close to it. In the process, he probably saw
trees and terrain, attempted to climb, but was too low to avoid the trees.

The corporate jet airplane experienced a loss of elevator trim control (runaway trim) that resulted in an uncommanded nose-low pitch attitude. The pilot reported that following the loss of elevator trim authority the airplane was extremely difficult to control and the elevator control forces were extremely high. The pilot continued to maneuver the airplane, but eventually ditched it into a nearby marine cove. The runaway trim condition was not immediately recognized by the pilot and he stated that, by that point in the event sequence, the control forces were so great that he had little time to troubleshoot the system and elected to continue on his established heading and ditch the airplane. Pulling the circuit breaker, which is called for by the checklist in the event of a trim runaway, would have arrested the trim movement. Post accident examination and functional testing of the airplane's electric pitch trim printed circuit board (PCB) showed a repeatable fault in the operation of the PCB's K6 relay, resulting in the relay contacts remaining closed. This condition would be representative of the autopilot pitch trim remaining engaged, providing an electrical current to drive continuous nose-down trim to the elevator trim motor. Examination of the airplane's maintenance records showed that the PCB was removed and replaced in conjunction with the
phase inspection prior to the accident. Further examination of the airplane's maintenance records revealed that the replacement PCB was originally installed in an airplane that experienced an "electric trim runaway on the ground." Following the trim runaway, the PCB was removed and shipped to the manufacturer. After receiving the PCB the manufacturer tested the board and no discrepancies were noted. The unit was subsequently approved for return to service and later installed on the accident airplane. The investigation revealed a single-point failure of trim runaway (failed K6 relay) and a latent system design anomaly in the autopilot/trim disconnect switch on the airplane's pitch trim PCB. This design prohibited the disengagement of the electric trim motor during autopilot operation. As a result of the investigation, the FAA issued three airworthiness directives (AD 2003-21-07, AD 2003-23-20, and AD 2004-14-20), and the pitch trim printed circuit board was redesigned and evaluated for compliance with safety requirements via system safety assessment.

A de Havilland DHC-6-100 float-equipped Twin Otter (serial number 086), operated by West Coast Air Ltd., was on a regularly scheduled flight as Coast 608 from Vancouver Harbour water aerodrome, British Columbia, to Victoria Harbour water aerodrome. The flight departed at about 1510 Pacific standard time with two crew members and 15 passengers on board. Shortly after lift-off, there was a loud bang and a noise similar to gravel hitting the aircraft. Simultaneously, a flame emanated from the forward section of the No. 2 (right-hand) engine, and this engine completely lost propulsion. The aircraft altitude was estimated to be between 50 and 100 feet at the time. The aircraft struck the water about 25 seconds later in a nose-down, right wing-low attitude. The right-hand float and wing both detached from the fuselage at impact. The aircraft remained upright and partially submerged while the occupants evacuated the cabin through the main entrance door and the two pilot doors. They then congregated on top of the left wing and fuselage. Within minutes, several vessels, including a public transit SeaBus, arrived at the scene. The SeaBus deployed an inflatable raft for the occupants, and they were taken ashore by several vessels and transported to hospital for observation. There were no serious injuries. The aircraft subsequently sank. All of the wreckage was recovered within five days.

The accident aircraft, a Douglas DC-3C, C-GWUG, was owned and operated by Kelowna Flightcraft Air Charter Ltd. (Kelowna Flightcraft) and was under charter to Purolator Courier Ltd. (Purolator). Since April 1998, the aircraft had been dedicated to transporting cargo on a route between Vancouver and Nanaimo, British Columbia. On occasion, it was also used for flights to Victoria to meet Purolator=s scheduling or cargo-loading contingencies. On the day of the accident, the aircraft, operating as KFA300, was rerouted and tasked to fly from Vancouver to Victoria and then proceed to Nanaimo. This change was precipitated by the delayed arrival of Purolator=s Boeing 727 at Vancouver because of inclement weather in the Toronto/Hamilton, Ontario, area. Warning of this route change was passed to the crew members with their pre-flight planning package, which included filed instrument flight rules (IFR) flight plans for the Vancouver-to-Victoria and Victoria-to-Nanaimo legs of the trip. The captain of the occurrence flight cancelled his IFR flight plan and refiled visual flight rules (VFR) on first contact with air traffic control. Vancouver tower cleared KFA300 for take-off at 0622 Pacific standard time (PST) from runway 26L. After take-off, the aircraft turned left on a track toward Active Pass, as seen in Figure 1. During the departure climb, the captain requested an altitude of 1000 feet above sea level (asl); the tower controller approved this request. Recorded radar data indicate that the aircraft climbed to and levelled at 1000 feet asl and then accelerated to a steady en route ground speed of 130 knots. The aircraft left the Vancouver control zone at 0626 and entered Class E (controlled) airspace. There are no special requirements for VFR aircraft operating within this class of airspace, nor are any specific services required of the air traffic control system. As the aircraft approached the Gulf Islands, it descended slightly and remained level at 900 feet asl. It crossed about 0.25 nautical mile (nm) west of the Active Pass non-directional beacon (NDB) at 0632 while remaining steady at 130 knots (ground speed) and level at 900 feet asl. At 0633:04, the aircraft descended to 800 feet asl for about nine seconds. The last radar data show the aircraft at 900 feet asl and 130 knots. The last radar-depicted position of the aircraft is on a bearing of 189 degrees (true) and 21.8 nm from the Sea Island radar source, coincident with the crash location.

Regency Express Air Operations Flight 434, a Cessna 208 Caravan (serial number 208B0061), was en route from Vancouver International Airport to Victoria International Airport, British Columbia, on a night visual flight rules (VFR) flight when it collided with trees on Saltspring Island, about five nautical miles (nm) north of the Victoria International Airport. The aircraft broke apart on impact and a post-crash fire occurred. The two pilots, who were the sole occupants of the aircraft, sustained fatal injuries, and the aircraft was destroyed. The accident occurred at 0030 Pacific standard time (PST).

The pilot, sole on board, was completing a positioning flight from Victoria to Castlegar-West Kootenay Airport. On final, the twin engine airplane struck trees and crashed in a wooded area located on Mt Sentinel, few km from the airfield. The aircraft was destroyed and the pilot was killed.