TSB Recommends Mandatory Flight Recorder Installation

The TSB could not determine the cause of the accident due to the absence of flight recording systems on board the aircraft. Investigation by TSB found that the pilot did not have the recent night flying experience Transport Canada requires for carrying passengers at night.

The Transportation Safety Board of Canada (TSB) is recommending the mandatory installation of lightweight flight recording systems for all commercial and private business aircraft. The TSB is also concerned with Transport Canada’s oversight of private business aircraft operations. Both are addressed in the investigation report released Thursday into the 2016 fatal loss of control accident involving a Cessna Citation 500 in British Columbia. 


On October 13, 2016, a privately operated Cessna Citation 500 departed Kelowna Airport, British Columbia, on a night instrument flight rules flight to Alberta with a pilot and three passengers on board. Shortly after departing, the aircraft left controlled flight and entered a steep descending turn until it hit the ground. All four people on board were fatally injured, and the aircraft was destroyed by impact forces and a post-impact fire.


The TSB could not determine the cause of the accident due to the absence of flight recording systems on board the aircraft, but the most plausible explanation is that the pilot experienced spatial disorientation and left controlled flight shortly after takeoff. Investigation by TSB found that the pilot did not have the recent night flying experience Transport Canada (TC) requires for carrying passengers at night.


"We don't like having to say 'We don't know' when asked what caused an accident and why," TSB Chair Kathy Fox said. "This is why we are calling today for the mandatory installation of lightweight flight recording systems on commercial and private business aircraft not currently required to carry them."


TSB was also concerned by TC’s approach to oversight of Canadian private business aviation, having found in its investigation that there was no record of this aircraft operator ever having been inspected by TC. As a result, TC was unaware of safety problems in its operation. 


TC has said it will begin conducting targeted inspections of private business operators this month, and TSB will continue to monitor this issue.  

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