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TSB recommends mandatory installation of flight recorders for commercial and private business aircraft
26 April 2018

TSB Canada recommends mandatory installation of lightweight flight recording systems by all commercial and private business operators not currently required to carry them, in the wake of a fatal corporate jet accident.

The TSB is also concerned with Transport Canada’s reactive approach to oversight of private business aircraft operations. The details are in the investigation report (A16P0186) released today into the 2016 fatal loss of control and collision with terrain of a Cessna Citation 500 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. The most plausible scenario is that the pilot, who was likely dealing with a high workload associated with flying the aircraft alone, experienced spatial disorientation and departed from controlled flight shortly after takeoff. The investigation also determined that the pilot did not have the recent night flying experience required by Transport Canada for carrying passengers at night. Pilots without sufficient recent experience flying at night or by instruments are at a greater risk of loss of control accidents.

The Board also raised a concern with the way Transport Canada (TC) had conducted oversight of private business aviation in Canada. During the course of its investigation, the TSB found no record that the operator of this aircraft had ever been inspected by TC. As such, TC was unaware of safety deficiencies in its flight operations, such as the failure to obtain approval for single-pilot operation of the aircraft and the pilot’s lack of recent night flying experience required to carry passengers at night. Since this occurrence, TC has said that it will conduct targeted inspections of private business operators starting in April 2018. The Board will continue to monitor this safety issue.

Side view of C-GTNG’s climb profile (Source: Google Earth, with TSB annotations)