A failure of the main rotor blade during an emergency landing was the cause of a 2019 fatal helicopter incident in Campbell River, according to the Transportation Safety Board of Canada (TSB).
The investigation report into the Sept. 24, 2019 incident was released on Dec. 8. Investigators found that a deformation of the main rotors caused the craft to crash into the ground.
The incident involved an E & B Helicopter Ltd. Bell 206B helicopter that took off from the Campbell River Heliport bound for Moat Lake near Mt. Albert Edward. Shortly after departure while flying southeast along the coastline, the helicopter levelled off at 615 feet above sea level, and then began to descend.
After it reached 417 feet, it began a right-hand climbing turn towards land, after which it began to descend again. It was during this descent that control was lost, causing the helicopter to fall to the ground from about 200 feet. It struck a building and two vehicles, destroying the helicopter and causing a fire.
The pilot, who was the only person on board, was fatally injured.
Investigators found that there was an engine power anomaly, which caused the pilot to reverse course and descend in auto-rotation, which is a method for pilots to descend safely even if their engine loses power. However, at some point during the flight the main rotors were deformed, likely slowing them to the point where auto-rotation was impossible. That caused the helicopter to drop.
Investigators also noted the engine fuel system did not have the appropriate accumulators and double check valve for installation on a 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,” the 51-page report says. “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.”
A partial loss of power was also recorded a week before the accident. As part of its investigation, TSB also identified conditions and risks that did not directly affect this accident, but could have adverse consequences in the future. As part of that, investigators looked into the company’s safety culture. The pilot was also the company’s owner, accountable executive and operations manager.
“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 report states. “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.”
The report says several opportunities to improve safety had been missed, and that “if company management routinely deviates from regulatory requirements, there is an increased risk that an unsupportive safety culture will develop, affecting the entire organization.”
The investigation also looked at how Transport Canada approaches cardiovascular health and hypertension in pilots.
Though the accident was not caused by a medical issue, an independent cardiology review found that the pilot “possessed many of the key indicators for a high-risk cardiac event” though those indicators were not made known to the pilot by Transport Canada.
It concluded that Transport Canada could require pilots undergo cardiovascular assessments regularly to reduce risk.