Edmonton, Alberta, 14 March 2023 — Today, the Transportation Safety Board of Canada (TSB) is issuing a recommendation aimed at improving the Civil Aviation Medical Examiners’ guidelines. It is being issued as part of investigation (A21W0089) in which an amateur-built Cavalier SA102.5 aircraft entered into an aerodynamic stall and collided with terrain, in Lacombe, Alberta, on 09 October 2021, resulting in the death of the pilot.
The Office of the Chief Medical Examiner in Alberta reported that the cause of death was attributed to blunt force trauma, with cardiovascular disease as a significant contributing factor. The report also noted that the pilot had evidence of a heart attack, although it was not possible to determine the exact time of this event.
Since 2000, TSB has investigated eight accidents, including this one, involving commercial pilots in which cardiovascular disease was identified as a finding as to risk or finding as to cause.
Recommendation to Transport Canada
Following a loss of control and collision with terrain that took place in Miramichi, New Brunswick, on 23 April 2010 (investigation report A10A0041), the Board issued a safety concern indicating that medical practitioners may not always be aware of the need or importance of transmitting reportable medical conditions and, further, that deficiencies exist in the guidelines designed to screen for cardiovascular risks.
If Transport Canada guidance material and the civil aviation medical examination report do not include up-to-date cardiovascular screening methods to perform a global cardiovascular assessment when appropriate, there is an increased risk that cardiovascular disease will remain unidentified and pilots may become incapacitated while operating an aircraft.
Therefore, the Board recommends that the Department of Transport establish a framework for routine review and improvement to the Handbook for Civil Aviation Medical Examiners to ensure it contains the most effective screening tools for assessing medical conditions such as cardiovascular health issues. (TSB Recommendation A23-01)
These updated screening guidelines would reduce the likelihood of pilots becoming incapacitated while operating an aircraft and mitigate the risk of another accident such as this one.
See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Collision with terrain
Cavalier SA102.5 (amateur-built aircraft), C-FBWF
Lacombe Aerodrome, Alberta, 14 NM E
09 October 2021
On 09 October 2021, the privately registered, amateur-built Cavalier SA102.5 aircraft (registration C-FBWF, serial number 6958) was conducting a local recreational flight from Lacombe Aerodrome, Alberta, with 1 pilot and 1 passenger on board. When the aircraft was 14 nautical miles east of the aerodrome, it entered an aerodynamic stall, resulting in a left-hand spin and collision with terrain. The pilot, who was seated in the left seat, was fatally injured; the passenger received serious injuries. The aircraft was substantially damaged; there was no post-impact fire. The 406 MHz emergency locator transmitter activated. A satellite tracking device also helped locate the aircraft.
1.0 Factual information
1.1 History of the flight
At approximately 1516 on 09 October 2021, the privately registered, amateur-built Cavalier SA102.5 aircraft (registration C-FBWF, serial number 6958) departed Lacombe Aerodrome (CEG3), Alberta, for a local recreational flight with the owner/pilot and 1 passenger on board.
After departing CEG3, the aircraft flew generally eastward. Details of the flight path (Figure 1) were captured every 10 minutes by a SPOT satellite tracking device on board. The last recorded position of the aircraft while it was airborne was at 1556, at an approximate altitude of 5095 feet above sea level (ASL). Following this, the aircraft changed direction to a south-southeast heading and at some point between this position and the accident site, the aircraft entered an aerodynamic stall, resulting in a spin and collision with terrain. The accident site was approximately 14 nautical miles east of Lacombe Aerodrome, Alberta, at an elevation of 2644 feet ASL.
At 1605, the 406 MHz emergency locator transmitter (ELT) activated and a signal was detected by the Canadian Mission Control Centre, which relayed the information to the Joint Rescue Coordination Centre in Trenton, Ontario. The Joint Rescue Coordination Centre contacted first responders within 2 minutes.
First responders arrived at the site approximately 1 hour and 46 minutes after the accident. The pilot was fatally injured, and the passenger was seriously injured.
See the investigation page for more information.
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