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News release

Associated links (A21W0089)

TSB recommends that Transport Canada establish a framework for routine review and improvement to the Civil Aviation Medical Examiners’ guidelines

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.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-360-4376