The Transportation Safety Board of Canada’s final report on the crash of a Beechcraft King Air 100 at Vancouver International Airport in October 2011 concluded that the chain of events that led to the accident began with poor pilot preflight action. Neither of the two pilots noticed the left engine’s oil reservoir cap was not firmly latched shut.

The crew was alerted to an oil leak in the left engine before takeoff but failed to take action until receiving a low oil pressure warning light about 10 minutes after takeoff.

The aircraft returned to Vancouver for a visual approach, but on short final to Runway 26 Left, when the captain advanced the power lever on the right engine to increase the aircraft’s speed, the aircraft had already slowed to near minimum controllable airspeed (Vmc). As soon as the crew increased power to the right engine, the aircraft rolled left and pitched down 50 degrees.

While the crew was able to level the King Air’s wings, there was insufficient altitude to recover before the aircraft collided with the ground in a 30-degree nose-low attitude.

All passengers survived with serious injuries. The two pilots, however, succumbed to their injuries in a local hospital.