Aviation Investigation A17W0024

Collision with terrain

The occurrence

On 13 February 2017, a Tecnam P2006T aircraft operated by Mount Royal University, was conducting a visual flight rules instructional flight originating out of Calgary/Springbank Airport, AB (CYBW), Calgary, Alberta. Approximately 30 minutes into the flight, the aircraft collided with terrain 32 nautical miles northwest of CYBW. There was a post-impact fire and the aircraft was destroyed. The two occupants were fatally injured.

Map of the area

What we know

• A Tecnam P2006T twin-engine aircraft, operated by Mount Royal University departed CYBW at 1635 (Mountain Standard Time), during daylight hours.
• The aircraft climbed to 8000 feet above sea level and progressed to the northwest.
• Thirty minutes after departure, the last radar return from the aircraft was recorded at 7900 feet above sea level. This last radar return was 0.13 nautical mile southeast of the accident site location. The aircraft struck terrain 32 nautical miles northwest of CYBW at approximately 1705 (Mountain Standard Time).
• All of the major aircraft components were located at the accident site but were destroyed by impact forces and a post-impact fire.
• The aircraft was not equipped with, nor was it required to carry, a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR).

Update: 27 February 2017

The examination and documentation of the wreckage scene is complete and investigators have collected the data they needed from the accident site.

The wreckage was removed and transported to the TSB facility in Edmonton, Alberta, for further analysis.

We have requested the aircraft's maintenance history.

We have obtained most of the radar data and most of the Air Traffic Control audio; we are waiting for a few more files and we are in the process of analyzing it.

Next steps

With the conclusion of the Field Phase, the Examination and Analysis Phase begins. In the coming days and weeks, as part of its investigation process, the team will

• Examine components such as the engines and propellers
• Send selected components to the TSB Laboratory in Ottawa, Ontario, for further analysis
• Gather additional information about weather conditions
• Gather information on air traffic control communications and radar information
• Examine aircraft maintenance records
• Examine pilot training, qualifications, proficiency records and medical history
• Continue interviews with the aircraft operator and other such witnesses
• Review operational policies and procedures
• Examine the regulatory requirements
• Reconstruct events to learn more about the accident sequence (i.e., to validate data, test hypotheses, and verify assumptions)

Working with others

The TSB conducts independent investigations. However, we would like to recognize the contribution of other organizations:

• The Royal Canadian Mounted Police (RCMP) protected the site and provided essential family liaison services.
• Representatives from Mount Royal University are cooperating fully in providing documentation.
• Technical experts from the engine manufacturer have made themselves available to assist with the engine tear down.

Absence of flight data recorder and cockpit voice recorder

The absence of a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR) will make this investigation particularly challenging.

The Tecnam P2006T involved in the crash was not equipped with, nor was it required to carry, a CVR or FDR. In Canada, only multi-engine, turbine-powered commercial aircraft flown by two pilots and carrying six or more passengers are required to carry a CVR on board.

As early as 1991, the Board made a recommendation calling for the upgrade of flight recorder requirements.

Following TSB investigation A88O0491, the Board issued the following recommendation in 1991:

The Department of Transport expedite legislation for upgrading the flight recorder requirements for Canadian-registered aircraft.

TSB Recommendation A91-13

Since then, the aviation industry has developed several different lightweight flight recording systems which could be installed in smaller aircraft at a low cost. These flight recording systems could be used by accident investigators to identify safety deficiencies and reduce risk in a timely manner.

As part of TSB investigation A11W0048, in 2013 the Board 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.

TSB Recommendation A13-01

The TSB urges the industry and private corporate aircraft owners to take advantage of the new, low-cost flight recording technology to advance safety in their operations.

Communication of safety deficiencies

Investigations are complex and we take the time needed to complete a thorough investigation. However, should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay.

Further, it is important not to draw conclusions or speculate as to causes at this time. There are often many factors that can contribute to an accident.

Investigator-in-Charge

Fred Burow is a senior operations investigator with the TSB Western Regional Office in Edmonton. Fred has been with the TSB since January of 2013. Before joining the TSB, Fred worked at Transport Canada where he gained experience as an inspector for aerodrome safety, air carrier inspections and as a flight operations manager and training pilot for Transport Canada's Aircraft Services Directorate. Besides extensive fixed-wing aircraft experience, Fred gained valuable rotary-wing experience with the Canadian Armed Forces as a crew commander, flight safety officer, squadron standards officer and manager of flight operations at the Canadian Forces Flight Training School.

Photos

Transportation Safety Board investigation process

There are 3 phases to a TSB investigation:

1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

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