Associated links (A16P0186)
Kathy Fox, TSB Chair
and
Beverley Harvey, Investigator-in-charge, TSB
Calgary, Alberta
26 April 2018
Check against delivery.
Kathy Fox
Good morning.
On the evening of October 13, 2016, a privately operated Cessna Citation 500 took off from Kelowna, British Columbia, en route to Calgary, Alberta. On board were a pilot and three passengers.
Minutes later, the aircraft entered a steep descending turn and struck the ground. There were no survivors.
Today the Transportation Safety Board is releasing its investigation report into the occurrence. But after countless hours of analysis from experts poring over wreckage, radar data, and company and personnel records—we aren't much closer to knowing with certainty what caused this accident. We have no flight data recorder. We have no cockpit voice recorder. These were not required by regulation, and therefore we have no detailed sequence of what went on in the flight deck. All we have is a hypothesis—a scenario that doesn't have enough facts to be definitive.
And that simply isn't good enough—which is why today we are recommending that Transport Canada require the mandatory installation of lightweight flight recording systems by commercial operators and private business operators not currently required to carry them.
I'll talk more about that recommendation in a few minutes—along with the Board's concern regarding how Transport Canada conducts oversight of business aviation in Canada. But first I'll turn things over to the investigator-in-charge, Beverley Harvey. She will explain what we do know about what happened that night, how we came to learn it, and what we think it means.
Beverley?
Beverley Harvey
Thank you.
As Kathy said, there was no flight data recorder or cockpit voice recorder required on board the occurrence aircraft. So, to recreate the flight path, we used information from air-traffic control audio recordings, as well as radar data from facilities in Kelowna and Kamloops. That's how we know the aircraft began its takeoff roll at approximately 9:32pm. Afterward, the radar data—which offer much less detail than flight data recorders—showed that the aircraft experienced rapid changes in the initial rate of climb: from 4000 feet per minute down to just 600 feet per minute, then increasing to 6000 feet per minute, all within about 30 seconds. During this time, the aircraft also deviated to the right of its intended track by as much as 20 degrees.
On its own, this information is not enough to establish anything definitive: perhaps the autopilot was not engaged. If so, that might mean that the pilot was experiencing a heavier than usual workload. This might also account for a delay in the pilot making initial contact with the air-traffic controller.
But the investigation also revealed that the pilot, although experienced, had very little recent experience flying at night, with just two night takeoffs in the past six months. This did not meet Transport Canada's requirements to carry passengers at night.
Pilots who do not have sufficient night proficiency are at a greater risk of experiencing what's known as "spatial disorientation"—physical illusions like the feeling of tumbling backward, which may occur during periods of prolonged acceleration, such as during the initial climb after takeoff. And even though they are erroneous, these sensations can be intense—causing pilots to doubt their instruments, to incorrectly adjust controls, or even put the aircraft into an accidental spiral dive.
But again: without hard data, without verifiable data, we cannot know for certain what happened that night. All TSB investigators can do is develop a likely scenario, one where a pilot without enough recent night flights, and with "limited" recent experience flying by instruments, and who was likely dealing with a high workload associated with flying the aircraft alone, experienced spatial disorientation and departed from controlled flight shortly after takeoff.
This lack of concrete proof has been frustrating for investigators, especially after 18 months. To discuss what steps the TSB would like to see taken, I'll turn things back to Kathy Fox.
Kathy Fox
Seven years ago, in 2011, the TSB investigated the fatal crash of a de Havilland single-engine Otter northeast of Mayo, Yukon.Footnote 1 That investigation also concluded with just a single finding as to cause, stating that the aircraft had "departed controlled flight for reasons that could not be determined." We then issued a recommendation calling on Transport Canada to facilitate the installation of lightweight flight data recorders on board more commercial aircraft, both to aid investigators following an accident, and to help companies monitor how their aircraft are being flown.
Earlier this year, we released our report into another fatal accident, in les Îles-de-la-Madeleine, Quebec.Footnote 2 The pilot in that occurrence had not only developed a lightweight recorder of sorts, but installed it on board the aircraft—even though it was not required by regulation. It was an initiative that proved invaluable, allowing us to piece together a detailed history of the flight, moment by moment—including what happened in the final, fateful seconds.
But without that initiative, without the lightweight recorder installed on board, we would have faced the same situation as we did following the accident in the Yukon—the same situation we faced following this accident in Kelowna.
I want to make two things clear: First, the aircraft involved in this accident was not required to have a flight data recorder or cockpit voice recorder on board. Second, that needs to change.
We don't like having to say "We don't know" when asked what caused an accident and why. We want to provide definitive answers—to the victims' families, to Canada's aviation industry, to the Canadian public.
Although the recommendation issued by the TSB following the Yukon crash targeted commercial aircraft, it is now evident, more than ever, that the need for recorders applies to a much wider segment of aviation, specifically, one that includes "private business aircraft operators"— that is, those operating aircraft of a certain weight or engine type, or certified for more than 6 passengers. This does not include recreational aircraft. The TSB therefore recommends that Transport Canada require the mandatory installation of lightweight flight recording systems by all commercial and private business operators not currently required to carry these systems.
I'd now like to address the way Transport Canada has conducted oversight of these private business operators.
In 2011, following a 2007 accident involving a business jet in Fox Harbour, Nova Scotia,Footnote 3 Transport Canada announced it would take back oversight of private operators from the Canadian Business Aviation Association.
But then in 2016, shortly before the Kelowna accident, Transport Canada exempted private business operators from planned national surveillance on a temporary basis. Any oversight would only be conducted on a reactive basis—such as after a "serious incident or accident."
During the course of our investigation, the TSB found no record that the operator of this aircraft had ever been inspected by Transport Canada. Before or after the accident. Transport Canada was therefore unable to identify a number of safety risks, such as: carrying passengers at night despite the pilot not being qualified to do so; the company's failure to obtain approval for single-pilot operations on this type of aircraft; and non-compliance with maintenance inspection schedules for certain wing components.
Now, to be fair, all transportation operators have the primary responsibility to manage the safety risks within their own operations. But where companies are either unable or unwilling to manage safety effectively, it is vital that Transport Canada intervene, and that it does so in a way that changes unsafe operating practices. That's the job of the regulator, the guardian of public safety.
Recently, Transport Canada announced another change, saying it again plans to take a more active role in overseeing private business operators, with targeted inspections of some companies to come later this year. Only time will tell whether this actually happens or how effective it will be, but one thing is certain: a "reactive" approach to oversight, one in which private business operators are excluded from planned surveillance, leaves the business aviation sector exposed to higher risks that could lead to more accidents.
That's not just concerning to the TSB, it should be concerning to everyone.
Thank you.