Findings of TSB Investigation A15P0081 into fatal in-flight breakup north of Vancouver, British Columbia, in April 2015
Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex – an accident is never caused by just one factor. The April 2015 accident near Vancouver, British Columbia, was no exception. The investigation findings are as follows:
Findings as to causes and contributing factors
- For unknown reasons, the aircraft descended in the direction of flight at high speed until it exceeded its structural limits, leading to an in-flight breakup.
- Based on the captain's blood alcohol content, alcohol intoxication almost certainly played a role in the events leading up to the accident.
Findings as to risk
- If cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
- If Canadian Aviation Regulations Subpart 703 operators are not required to have a Transport Canada–approved safety management system, which is assessed on a regular basis, there is a risk that those companies will not have the necessary processes in place to manage safety effectively.
- If safety issues, such as concerns related to drug or alcohol abuse, are not reported formally through a company's safety reporting system, there is a risk that hazards will not be managed effectively.
- Transport Canada's Handbook for Civil Aviation Medical Examiners (TP 13312) does not address the complete range of conditions that may be affected by drug or alcohol dependence. As a result, there is an increased risk that undisclosed cases of drug or alcohol dependence in commercial aviation will go undetected, placing the travelling public at risk.
- If there is no regulated drug- and alcohol-testing requirement in place to reduce the risk of impairment of persons while engaged in safety-sensitive functions, employees may undertake these duties while impaired, posing a risk to public safety.