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Continued flight in poor weather led to 2019 Cessna Caravan floatplane crash in Canada
10 March 2021

In its investigation report released today, the Transportation Safety Board of Canada (TSB) found that the decision to continue flying in poor weather led to the fatal July 2019 controlled flight into terrain occurrence on Addenbroke Island, British Columbia (BC).

On 26 July 2019, at around 9:30 local time, a float-equipped Cessna 208 Caravan aircraft, operated by Seair Seaplanes, departed Vancouver International Water Aerodrome, BC, for a visual flight rules (VFR) flight to a fishing lodge near Port Hardy, BC, with one pilot and eight passengers on board. At 11:04 local time, the aircraft struck the hillside of Addenbroke Island, 9.7 nautical miles from the destination. The pilot and three of the passengers were fatally injured. Four of the surviving passengers received serious injuries, and one received minor injuries. The aircraft was destroyed.

The investigation found that the flight departed the Vancouver International Water Aerodrome despite reported and forecasted weather conditions that were below VFR requirements near the destination, and that the decision to depart may have been influenced by group dynamics. After encountering poor weather conditions, the pilot continued the flight in reduced visibility, without recognizing the proximity to terrain, and subsequently impacted the rising terrain of Addenbroke Island.

Although the aircraft was equipped with advanced avionics devices (G1000), they were configured in a way that made the system ineffective at alerting the pilot to the rising terrain ahead. Additionally, the pilot’s attention, vigilance and general cognitive function were likely influenced to some degree by fatigue. Although the aircraft was equipped to capture flight data, Seair had not established a flight data monitoring (FDM) program, nor was it required to by regulation.

However, air operators are not alone in monitoring for safe operations. Following this occurrence, Transport Canada (TC) did not conduct any reactive surveillance, initiate new surveillance activities, escalate upcoming surveillance activities, or conduct targeted or compliance inspections. If TC does not apply sufficient oversight of operators, there is a risk that air operators will be non-compliant with regulations or drift toward unsafe practices, thereby reducing safety margins.

Following the occurrence, Seair contracted an aviation consulting company to conduct an operational and maintenance review, updated its standard operating procedures to highlight the limitations of the autopilot system, and added an acceptable use policy on personal electronic devices in the cockpit.