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Backgrounder: A16P0186-20180426-2

New and previous safety communications for TSB investigation (A16P0186) into fatal October 2016 loss of control and collision with terrain near Kelowna, British Columbia


On 13 October 2016, a Cessna Citation 500 that was privately operated by Norjet Inc. departed Kelowna Airport, British Columbia, on a night instrument flight rules flight to Calgary/Springbank Airport, Alberta. The pilot and three passengers were on board. Shortly after departure, the aircraft departed controlled flight, entering a steep descending turn to the right until it struck the ground. No emergency call was made. All of the occupants were fatally injured. Impact forces and a post-impact fire destroyed the aircraft.

Because there were no flight recording systems on board the aircraft, the TSB could not determine the cause of the accident.

TSB recommendations

Previous recommendation: Lightweight flight recording systems for commercial aircraft

In 2013, following its investigation into a fatal in-flight breakup occurrence in March 2011 northeast of Mayo, Yukon, the TSB concluded there was a compelling case for implementing lightweight flight data recording (FDR) systems for all commercial operators, and 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.
Transportation Safety Recommendation A13-01

In August 2013, Transport Canada (TC) held discussions intended to identify obstacles and barriers to flight data monitoring (FDM).

In February 2014, TC supported the recommendation and planned to draft an advisory circular to describe recommended practices regarding FDM programs.

In November 2015, TC agreed that FDM would enhance aviation safety in Canada. However, TC has not produced an advisory circular, and its revised proposed activity is to prepare an issue paper and revisit the risk assessment on FDM.

In January 2017, in its most recent response to Recommendation A13-01, TC indicated its renewed proposal to conduct a focus group in 2017, which it has been planning to do since 2013. However, until the focus group reaches conclusions as to the challenges and benefits associated with the installation of lightweight multi-function recording devices in small aircraft, and TC provides the TSB with its plan of action moving forward following those conclusions, it is unclear when or how the safety deficiency identified in Recommendation A13-01 will be addressed.

Therefore, the response to Recommendation A13-01 was assessed as Unable to Assess.

New recommendation: Lightweight flight recording systems for private business aircraft and commercial aircraft

In a recent occurrence, a privately operated Mitsubishi MU-2B-60 aircraft struck terrain on its final approach to Îles-de-la-Madeleine Airport, Quebec. All seven occupants were fatally injured. A lightweight FDR system was on board the occurrence aircraft, although it was not required by regulation. By recovering the recorder and analyzing its data, the investigation was able to better understand the sequence of events that led to the aircraft's departure from controlled flight. Had a recording system not been on board, crucial information to understand the circumstances and events leading up to this occurrence would not have been available to the investigation.

In contrast, this investigation could not determine why the aircraft departed controlled flight and collided with terrain. Because the occurrence aircraft was not equipped with any type of FDR or cockpit voice recorder (CVR), the lack of flight data precluded investigators from fully identifying and understanding the sequence of events and the accident's underlying causes and contributing factors.

The contrast in available evidence demonstrated between the Îles-de-la-Madeleine accident and this occurrence highlights the value of installing lightweight FDR systems on privately operated aircraft. This investigation demonstrates that investigators are at a disadvantage in determining the root causes of an occurrence when there are no flight data available, regardless of whether the investigation involves a commercially operated aircraft or a privately operated business aircraft.

There is compelling evidence that the lack of recording devices on board commercial aircraft and private aircraft operated under CARs Subpart 604 continues to impede the TSB's ability to advance transportation safety. Therefore, the Board recommends that

the Department of Transport require the mandatory installation of lightweight flight recording systems by commercial operators and private operators not currently required to carry these systems.
Transportation Safety Recommendation A18-01

Board safety concern

Transport Canada oversight

This occurrence demonstrates how the safety of private operators may be compromised when TC excludes the entire business aviation sector from its planned surveillance program. Because the TSB found no record that the operator of this aircraft had ever been inspected by the regulator, TC was unaware of safety deficiencies in its flight operations.

In 2011, following a 2007 accident involving a business jet in Fox Harbour, Nova Scotia, TC resumed the oversight and administration of business aviation, which had previously been delegated to the Canadian Business Aviation Association, and, in 2014, implemented new regulations for private operators. However, in 2016, TC introduced temporary changes to its surveillance policy to exclude private operators and other certificate holders from its national oversight program. Therefore, concerns still persist in this sector.

In 2016, following its investigation into a May 2013 fatal helicopter accident in Moosonee, Ontario, the TSB determined that TC's approach to surveillance at the time of the occurrence, along with issues in the implementation of safety management systems (SMS), precluded TC from ensuring that operators were effectively managing safety. Therefore, the TSB recommended that

The Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.
Transportation Safety Recommendation A16-13

Although Recommendation A16-13 was issued in the context of an investigation involving a commercial operator, this accident demonstrates, in a similar fashion, that the lack of regular surveillance in the business aviation sector currently does not allow TC to assess the capability of private operators to effectively manage safety.

Under TC's current surveillance policy, and its reactive approach to oversight of the private business aviation sector, there is the potential for another serious incident or accident involving a private operator. Without regular surveillance audits and inspections, TC cannot validate the effectiveness of a private operator's SMS or identify and address safety deficiencies in a timely manner, thus allowing unsafe practices to emerge and persist.

Therefore, the Board is concerned that a reactive approach to oversight, in which private operators are excluded from TC's national planned surveillance program, may expose the business aviation sector to higher risks that could lead to an accident.

The Board will continue to monitor this safety issue.

TSB Watchlist

The Watchlist identifies the key safety issues that need to be addressed to make Canada's transportation system even safer. Safety management and oversight is a Watchlist 2016 issue.

Numerous recent investigations have found companies that have not managed their safety risks effectively, either because they were not required to have an SMS or because their SMS was not implemented effectively.

This issue will remain on the Watchlist until: