Equipment failure, disorientation led to deadly Gabriola Island plane crash, TSB says
'Looking out the window of the aircraft, it would have been dark and grey,' says lead investigator
The data from the final moments of the small twin-engine Piper Aerostar that crashed on Gabriola Island, B.C., last December paints a harrowing picture.
The aircraft went down on Dec. 10, 2019, at the end of a two-day journey from Cabo San Lucas, Mexico, to Nanaimo, B.C.
In the last minute before air traffic control lost contact with the plane, the aircraft lost and gained altitude several times. Over the radio, its pilot informed the controller that the craft's attitude indicator, which informs the pilot of the plane's orientation, was failing.
Outside the window, it was dark and grey.
Those are some of the findings contained in a Transportation Safety Board of Canada report into the incident.
The report says the pilot acknowledged instructions from the controller and momentarily lined up with a runway landing system, but the aircraft continued turning, climbing and then losing altitude. At that point, it says the pilot reported the aircraft had lost its attitude indicator, which shows the plane's orientation or pitch relative to the horizon.
At 6:04 p.m., the plane made a second tight right turn. It began to lose altitude dropping to 300 feet above sea level.
It crashed into a power pole and trees in a wooded park area and then hit the ground, breaking into pieces and catching fire, killing all three people on board.
The report released following a months-long investigation into the crash by the TSB found the the plane lost its altitude indicator and the pilot may have been susceptible to spatial disorientation.
"The aircraft appeared to have difficulty maintaining a heading (the direction a plane is travelling), maintaining an altitude and maintaining speed," said lead TSB investigator Dan Clarke.
The loss of vital equipment
On the night of the crash, there was a heavy mist near Gabriola Island and visibility was low, according to Clarke.
"Looking out the window of the aircraft, it would have been dark and grey," he said.
When pilots aren't able to depend on their own eyes for information about their surroundings, they can still rely on the equipment inside their craft.
But that wasn't the case in this instance, because the attitude indicator had failed and was unable to provide a reading on the plane's orientation relative to the ground.
When it's dark outside and the indicator is malfunctioning, Clarke says it can be difficult for a pilot to gauge whether the plane is nose up, nose down, or even in a turn.
"It can become very difficult to maintain [your aircraft,] he said.
The investigation found that the pilot most likely suffered from spatial disorientation, due to the failing mechanics and the lack of visibility outside.
In the report, Clarke wrote that pilots who are experiencing high cognitive workload conditions — in this case, having to unexpectedly re-establish situational awareness without reference to external visual cues or internal readings — are at "an increased risk of experiencing spatial disorientation, if they rely too heavily on their perceptions of motion and orientation."
It's basically like flying with your eyes closed, Clarke said, adding that you end up flying while relying on your inner ear.
Unclear who was flying the plane: TSB
Alex Bahlsen and Allan and Katheryn Boudreau were flying back to Canada from a vacation in Mexico.
The plane belonged to Bahlsen, but Clarke says it's difficult to know who was flying the craft when it crashed because both men were sitting up front and both held valid pilot licences.
Boudreau was sitting in the front left seat, which is traditionally the pilot's seat, and to his right sat Bahlsen.
Bahlsen had accumulated over 13, 000 hours total flight time; Boudreau had over 320 hours and was in the process of completing his commercial pilot's licence.
Friends of the Boudreaus remember them as part of a tight-knit community in Ladysmith, B.C., while Bahlsen's loved ones say he was generous and had a passion for flying.
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