News release

Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A19P0142) into the September 2019 loss of control and collision with terrain of a Bell helicopter in Campbell River, British Columbia (BC).

On 24 September 2019, an E & B Helicopter Ltd. Bell 206B helicopter was conducting a flight from Campbell River Heliport, BC, to Moat Lake, BC, with only the pilot on board. Shortly after departure, while flying southeast along the coastline, the helicopter briefly levelled off at 615 feet above sea level (ASL), then began a descent. When the aircraft was at 417 feet ASL, it entered a right-hand climbing turn toward land and, following the turn, it began to descend again. During this descent, control of the helicopter was lost when it was about 200 feet above ground level and the helicopter fell to the ground, striking a building and 2 vehicles. The pilot was fatally injured. The helicopter was destroyed by the impact forces and a post-impact fire.

The investigation found that an engine power anomaly likely occurred while the helicopter was in cruise flight and, as a result, the pilot reversed course and entered a descent consistent with an autorotation. At some point during the flight, the main rotors became deformed. Although indications of fatigue were present post-occurrence, the extent to which this fatigue contributed to the deformation could not be determined. In the last moments of the flight, likely as a result of the deformed blades, the main rotor rpm decreased to a point that could not sustain autorotational flight, and the helicopter fell vertically and impacted the ground. The investigation also revealed that the engine fuel system did not have the appropriate accumulators and double check valve for installation on the Bell 206 helicopter. During the installation of the engine, the company maintenance control system was ineffective at ensuring that the engine installation complied with the manufacturer’s recommendations. If maintenance procedures do not include a thorough review of all related instructions and bulletins, there is a risk that an aircraft will be released into service in a non-airworthy configuration.

The investigation examined the air operator’s safety culture. The pilot was the company’s owner, accountable executive, and operations manager, and direction on how the maintenance department was to respond to a partial loss of engine power that occurred a week before the occurrence came from him. The investigation revealed that many operational and maintenance-related decisions were being made based on a single opinion, rather than a process of validation by a hierarchy of independent and skilled supervisors. In addition, several opportunities to improve the safety of the flight had been missed. If company management routinely deviates from regulatory requirements, there is an increased risk that an unsupportive safety culture will develop, affecting the entire organization.

Finally, the investigation examined Transport Canada’s (TC’s) approach to managing cardiovascular health and hypertension in pilots. Using a variety of different risk calculators and all available medical information about the occurrence pilot, an independent cardiology review was conducted as part of this investigation and revealed that the pilot possessed many of the key indicators for a high-risk cardiac event. In this occurrence, TC’s civil aviation medical examination to assess pilot fitness did not identify the level of risk presented by the pilot. If TC guidance material and the civil aviation medical examination report do not require a Civil Aviation Medical Examiner to perform a global cardiovascular assessment, when appropriate, there is an increased risk that a pilot with high cardiovascular risk factors will be incapacitated while operating an aircraft as a result of a medical event.

See the investigation page for more information.