Aviation Investigation A16P0186

Collision with terrain

The occurrence

On 13 October 2016, a Cessna C500 (Citation) departed Kelowna Airport (CYLW) at 21:32 PDT for a flight to Calgary/Springbank Airport (CYBW). The aircraft disappeared off the radar. RCMP located the accident site north of Kelowna, east of Wood Lake, British Columbia, and confirmed that all persons on board had perished. There were no emergency calls or signals.

Map of the area

What we know

  • A Cessna Citation departed Kelowna, British Columbia (CYLW) at 21:32 (Pacific Daylight Time), destined for Calgary/Springbank Airport, (CYBW).
  • The aircraft struck terrain approximately 11 km north of Kelowna Airport at approximately 21:40 local time (Pacific Daylight Time).
  • At this time we believe there was one pilot and 3 passengers on board, all of whom sustained fatal injuries.
  • The aircraft was not equipped with, nor was it required to carry, a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR); however, the team will be reviewing any electronic components on the aircraft from which they can retrieve data to help understand the flight profile.
  • The air‎craft was destroyed from high deceleration forces after a vertical descent.
  • There were no emergency or distress calls made. No emergency locator transmitter signal was received.

Update: 19 October 2016

The examination and documentation of the wreckage scene is complete and investigators have collected the data they needed from the accident site. The wreckage will be removed by helicopter and transported to a facility for further analysis.

Next steps

With the conclusion of the Field Phase begins the Examination and Analysis Phase. TSB investigators from across Canada are involved in helping with this ongoing investigation. While there are no definitive findings to report at this time, there are some important next steps.

In the coming days and weeks, the team will:

  • Review drone images—filmed with the assistance of the RCMP
  • Examine components such as instrumentation and any device that contains non-volatile memory
  • Send selected wreckage to the TSB Laboratory in Ottawa for further analysis
  • Gather additional information about weather conditions
  • Gather information on air traffic control communications and radar information
  • Examine aircraft maintenance records
  • Examine pilot training, qualifications, proficiency records and medical history
  • Continue interviews with witnesses, the aircraft operator and others
  • Review operational policies and procedures
  • Examine the regulatory requirements
  • Create simulations and reconstruct events to learn more about the accident sequence (i.e., to validate data, test hypotheses, and verify assumptions)

Working with others

The TSB conducts independent investigations. However, we would like to recognize the contribution of other organizations:

  • The RCMP protected the site and provided essential family liaison services.
  • The BC Coroners Service secured the site and provided TSB investigators access so that investigation work could start right away.
  • The BC Coroners Service and the RCMP Forensic Search and Evidence Recovery Team conducted extremely meticulous recovery work.
  • A Transport Canada Minister's Observer was assigned and present at the accident site.
  • The National Transportation Safety Board (NTSB) of the United States, as State of Design and Manufacture of the aircraft, appointed an Accredited Representative to the TSB investigation.
  • Representatives from the aircraft manufacturer assisted on site as technical advisors to the US Accredited Representative.
  • Technical experts from the engine manufacturer also assisted on site.

Absence of flight data recorder and cockpit voice recorder

The absence of a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR) will make this investigation particularly challenging.

The privately-operated Cessna Citation involved in the crash was not equipped with, nor was it required to carry, a CVR or FDR. In Canada, only multi-engine, turbine-powered commercial aircraft flown by two pilots and carrying six or more passengers are required to carry a CVR on board.

As early as 1991, the Board made a recommendation calling for the upgrade of flight recorder requirements.

Following TSB investigation A88O0491, the Board issued the following recommendation in 1991:

The Department of Transport expedite legislation for upgrading the flight recorder requirements for Canadian-registered aircraft.

Since then, the aviation industry has developed several different lightweight flight recording systems which could be installed in smaller aircraft at a low cost. These flight recording systems could be used by accident investigators to identify safety deficiencies and reduce risk in a timely manner.

As part of TSB investigation A11W0048, in 2013 the Board recommended that:

The Department of Transport work with industry to remove obstacles to and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry these systems.

The TSB urges the industry and private corporate aircraft owners to take advantage of the new, low-cost flight recording technology to advance safety in their operations.

Communication of safety deficiencies

Investigations are complex and we take the time needed to complete a thorough investigation. However, should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay.

Further, it is important not to draw conclusions or speculate as to causes at this time. There are often many factors that can contribute to an accident.

Investigator-in-Charge

Beverley Harvey has 30 years of civil aviation experience. She joined the TSB in 2008 as an investigator/operations specialist in the TSB Air Investigations Branch at Head Office, Gatineau, Quebec.

Prior to joining the TSB, she was an inspector at Transport Canada, and a pilot with a commuter airline. During that time she flew different aircraft types, from small aircraft to larger commuter aircraft.

Since joining the TSB, Ms. Harvey has participated in several TSB investigations. On behalf of the TSB, she has assisted foreign investigation agencies in their investigations of accidents abroad.

Photos

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Link to the TSB Flickr page

See more high resolution pictures on the TSB Flickr page.


Transportation Safety Board investigation process

There are 3 phases to a TSB investigation:

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.


Media

Deployment notice
 
2016-10-14

TSB deploys a team of investigators to an air accident north of Kelowna, British Columbia
Read the deployment notice

Media advisory
 
2016-10-15

TSB will provide a brief update on its investigation into the accident involving a Cessna Citation north of Kelowna, British Columbia
Read the media advisory

News release
 
2016-10-19

Kelowna investigation update: on-site operations wrapping up
Read the news release

2016-10-17

TSB reiterates call for expanded requirements for the use of Cockpit Voice Recorders and Flight Data Recorders, following the Kelowna accident
Read the news release

2016-10-15

TSB launches investigation into the accident involving a Cessna Citation north of Kelowna, British Columbia
Read the news release