Air Transportation Safety Advisory Letter A21W0089-D2-A1

January 11, 2023

Director General, Civil Aviation
Transport Canada

On 09 October 2021, the privately registered, amateur-built Cavalier SA102.5 aircraft (registration C-FBWF, serial number 6958) was conducting a local recreational flight from the Lacombe Aerodrome (CEG3), Alberta, with 1 pilot and 1 passenger on board. When the aircraft was 14 nautical miles east of the aerodrome, it entered an aerodynamic stall, resulting in a left-hand spin and collision with terrain. The pilot, who was seated in the left seat, was fatally injured; the passenger received serious injuries. The aircraft was substantially damaged; there was no post-impact fire. The 406MHz emergency locator transmitter activated. A portable tracking device also helped locate the aircraft. The Transportation Safety Board of Canada (TSB) investigation into this occurrence (A21W0089) is ongoing.

The Office of the Chief Medical Examiner in Alberta determined that the cause of death was attributed to blunt force trauma with cardiovascular disease as a significant contributing factor. The Chief Medical Examiner also noted that the pilot had evidence of a heart attack, although it was not possible to determine the exact time of this event.

From September 2019 to July 2021, the pilot had visited his family physician on 5 different occasions with an acute medical condition unrelated to cardiovascular health. In May 2021, the pilot was prescribed 3 medications to treat this condition, but reportedly none were taken. The pilot was not scheduled for work in May 2021. As confirmed by an independent cardiology review performed for this occurrence, one of these medications has significant central nervous system side effects, including drowsiness and dizziness, and should not be used within several days of flying or performing safety-sensitive duties. In overdose, it can cause cardiac arrhythmias (irregularities of heart rhythm).

The Aeronautics Act states

[w]here a physician […] believes on reasonable grounds that a patient is a flight crew member […] or other holder of a Canadian aviation document that imposes standards of medical […] fitness, the physician […] shall, if in his opinion the patient has a medical […] condition that is likely to constitute a hazard to aviation safety, inform a medical adviser designated by the Minister forthwith of that opinion and the reasons therefor.^{Footnote 1}

As part of provincial licensing, physicians are informed about their provincial and federal mandatory reporting responsibilities. Physicians are also provided with the Canadian Medical Association’s document CMA Driver’s Guide: Determining medical fitness to operate motor vehicles,^{Footnote 2} which contains a section on Aviation. This section includes details of the Aeronautics Act’s reporting requirements, as well as an alert that states

[p]hysicians are required by law to report to regional aviation medical officers of Transport Canada any pilots, air traffic controllers or flight engineers with a medical condition that could affect flight safety. Common conditions requiring mandatory reporting are listed in this section.^{Footnote 3}

The investigation into this occurrence revealed that the pilot had been prescribed medications that may have affected his cardiovascular health and, therefore, could have affected flight safety. The family physician was not aware of the requirement to provide such information to Transport Canada (TC); therefore, neither the medications nor the condition for which they were prescribed were reported to TC by the family physician. The pilot also did not report either the condition or the medications to TC.

In 2011, following the TSB investigation into a loss of control and collision with terrain that took place in Miramichi, New Brunswick, on 23 April 2010,^{Footnote 4} the Board issued the following Safety Concern:

The Board is concerned 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. As a consequence, there continues to be a risk that cardiovascular risk factors will go undetected in aviation personnel.

Since 2000, there have been 8 accidents, including this one, in which a finding as to risk was made regarding pilots who had medical conditions that affected safety but were not reported to TC.^{Footnote 5} These accidents resulted in 10 fatalities and 7 serious injuries.

As shown in this occurrence, not all physicians are aware of the requirement to inform TC about medical conditions and/or prescribed medications that could affect the safe operation of an aircraft. Given the potential significant consequences of certifying pilots who have these conditions or are taking these medications, the TSB encourages the TC Civil Aviation Medical Branch, in cooperation with the Canadian Medical Association, to develop communication strategies to increase the awareness of the reporting requirements for physicians under the Aeronautics Act.

The TSB would appreciate being advised of any action that is taken in this regard. Upon completion of investigation A21W0089 the Board will release its report into the occurrence.

Yours sincerely,

Cc:

• Director, Medicine, Transport Canada
• Director, Safety Policy and Intelligence – Civil Aviation, Transport Canada
• Chair, Canadian Medical Association