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Backgrounder: A15P0081-20171102-1

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

  1. 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.
  2. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.