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Small plane stalled before fatal crash near Lacombe in 2021: investigation

Pilot killed and passenger badly injured in Oct. 9, 2021 crash
The pilot was killed and his passenger badly injured in this plane crash 14 km east of Lacombe on Oct. 9, 2021. Transportation Safety Board of Canada issued a report on the incident on Tuesday. (Photo from Transportation Safety Board of Canada)

An October 2021 plane crash that killed the pilot and badly injured the passenger happened after the plane stalled and went into a spin before hitting the ground near Lacombe, says a Transportation Safety Board of Canada report.

An autopsy determined that the “cause of death was attributed to blunt force trauma with cardiovascular disease as a significant contributing factor,” says the Transportation Safety Board (TSB) report released on Tuesday. “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.”

An independent cardiologist confirmed that the pilot’s cardiovascular disease and evidence of a heart attack “provide a very plausible, even if remote, scenario for an in-flight acute medical incapacitation…”

However, TSB investigators said it could not be determined if the pilot’s heart issues incapacitated him while he was flying or caused his death shortly before or after the plane hit the ground.

The pilot, who was a commercial airline pilot, and his passenger took off from Lacombe airport for a recreational flight at 3:16 p.m. on Oct. 9, 2021 in an amateur-built Cavalier SA102.5. At around 4:05 p.m., the plane went into an aerodynamic stall and spun into the ground about 14 km east of Lacombe.

The plane was equipped with dual controls, however, “the investigation could not determine whether the passenger attempted to fly the aircraft at any time during the flight.”

The aircraft was equipped with an emergency locator transmitter, which was activated by the crash. Within two minutes, the Joint Rescue Coordination Centre in Trenton, Ont. had notified first responders in the area. A satellite tracking device was also on board, which helped first responders find the plane. They were on scene within one hour and 46 minutes.

“As a result, the passenger received first aid treatment quickly, which contributed to his survival.”

The report goes into significant detail about the pilot’s health history and the regulations and standards included in Transport Canada’s aviation medical certifications.

As a commercial pilot, annual medical examinations were required, although one was not performed in 2021 because of the pandemic. Instead, a form was filled out attesting that he did not have any issues that would affect his ability to hold a pilot’s licence.

TSB investigators and a cardiologist reviewed the pilot’s civil aviation and family physician medical records as part of the investigation.

“No obvious risk factors were noted that would have placed the pilot at an increased risk of cardiovascular disease or an associated incapacitating event.”

However, the TSB report notes that Transport Canada’s 2012 Civil Aviation Medicine Cardiovascular Guidelines have not been updated to include advances in the recommended approach for screening for cardiovascular atherosclerosis.

“The cardiologist concluded that, in this occurrence, if such screening methods were followed, risk factors contributing to the pilot’s heart attack may have been identified.”

As of October 2022, there were 32,900 Canadian pilots with Category 1 medical certificates, required for those holding commercial, multi-crew or airline transport pilot licences.

TSB says that since 2000 there have been eight accidents involving commercial pilots in which cardiovascular disease was identified as a finding as to risk or finding as to cause.

TSB recommends Transport Canada 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.

In January 2023, TSB sent a letter to Transport Canada alerting it that not all doctors are aware they must report any conditions their pilot patients may have that could affect their ability to fly safely. Transport Canada Civil Aviation Medicine said later that month it was working with the Canadian Medical Association to raise awareness about the requirement with physicians.