Accident Beechcraft 100 King Air C-GXRX,

ASN Wikibase Occurrence # 321026

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Date:	Thursday 27 October 2011
Time:	16:12
Type:	Beechcraft 100 King Air
Owner/operator:	Northern Thunderbird Air
Registration:	C-GXRX
MSN:	B-36
Year of manufacture:	1970
Total airframe hrs:	26993 hours
Engine model:	Pratt & Whitney Canada PT6A-28
Fatalities:	Fatalities: 2 / Occupants: 9
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	0,7 km E of Vancouver International Airport, BC (YVR) - Canada
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Vancouver International Airport, BC (YVR/CYVR)
Destination airport:	Kelowna Airport, BC (YLW/CYLW)
Investigating agency:	TSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Beechcraft 100 King Air, C-GXRX, was climbing enroute from Vancouver International Airport, BC (YVR) to Kelowna Airport, BC (YLW) with 2 crew and 7 passengers when the left engine oil pressure gauge showed fluctuations. The crew requested a return to Vancouver and ATC cleared the aircraft to descend on vectors. During the descent they were asked if fire and rescue were needed and they declined. On short final the aircraft suddenly rolled left, pitched down and collided with the ground and a car. There was a post impact fire. All on board were rescued, however the pilot died a few hours later in hospital. The co-pilot succumbed to his injuries 2 weeks after the accident.

FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS:
1. During routine aircraft maintenance, it is likely that the left-engine oil-reservoir cap was left unsecured.
2. There was no complete pre-flight inspection of the aircraft, resulting in the unsecured engine oil-reservoir cap not being detected, and the left engine venting significant oil during operation.
3. A non-mandatory modification, designed to limit oil loss when the engine oil cap is left unsecure, had not been made to the engines.
4. Oil that leaked from the left engine while the aircraft was repositioned was pointed out to the crew, who did not determine its source before the flight departure.
5. On final approach, the aircraft slowed to below VREF speed. When power was applied, likely only to the right engine, the aircraft speed was below that required to maintain directional control, and it yawed and rolled left, and pitched down.
6. A partially effective recovery was likely initiated by reducing the right engines power; however, there was insufficient altitude to complete the recovery, and the aircraft collided with the ground.
7. Impact damage compromised the fuel system. Ignition sources resulting from metal friction, and possibly from the aircrafts electrical system, started fires.
8. The damaged electrical system remained powered by the battery, resulting in arcing that may have ignited fires, including in the cockpit area.
9. Impact-related injuries sustained by the pilots and most of the passengers limited their ability to extricate themselves from the aircraft.

Accident investigation: