And another Ottawa plane crash... near Calabogie

[Diadem]

My "educated hunch" is that he had at least one other doctor in his life, and that he had other problems that were secondary effects of his medical problems.

That's nice. The TSB doesn't operate under the same rules as you, and they aren't permitted to add "educated hunches" to their reports. They put in facts, and any conclusions to which those facts point. If they started putting in the possibility that the pilot had a heart attack, or smoked an ounce of meth, or was abducted by aliens, without any corroborating evidence, it would be of no value to anyone and the TSB would become irrelevant quite quickly. They have to adhere to pretty much the same rules as a lawyer in a trial: if you can't prove it beyond a reasonable doubt, it's not relevant to the case. Jumping from them not putting every single possibility into the report to them being pressured by politics, with absolutely nothing to back that up, makes you sound like a paranoid nut. They just didn't have enough info to draw any solid conclusions. Get over it.

Where are the recommendations regarding

(a) medical
(b) Oxygen?
(c) pressurization?
(d) Single Pilot operation by a pilot with known medical problems.
(e) Revision of medical standards.
(f) Mandatory reporting by doctors who prescribe medication to pilots.
(g) BMI requirements for passing medicals.

What recommendations would you have them write? The pilot had a valid medical, and there's absolutely no evidence that he had been seeing another doctor. Zero. If he went to another doctor and didn't report it he was in violation of the CARs, so would you have the TSB recommend that pilots not violate the CARs? Same with having sufficient emergency oxygen at their disposal: if the pilot doesn't turn the valve on before flying above 12500', they're breaking the law, so is it really necessary for the TSB to recommend that pilots not commit crimes? Besides which, "the possibility that the valve had moved to the OFF position during the impact sequence could not be ruled out", which again means that the investigators couldn't prove that the pilot had done anything illegal or negligent; they can't say the pilot did something unless they can prove it. The simple fact is that the pilot had a valid aviation medical and had passed his ECG, and the Civil Aviation Medical Examiner was aware of the medication he was taking. The decision to let him fly wasn't arbitrary, it was based on the hundreds or thousands of other pilots who fly every year with the same medical conditions with no issues. The fact that in this one instance he may have had a heart attack - or he may not have, if the aircraft had a sudden decompression - doesn't require a change in the medical standards. The very fact that you're listing so many potential causes of the accident, some of which point to a medical emergency and some of which point to an entirely unrelated depressurization, demonstrates that there isn't enough information on which to base a conclusion. There are too many variables, and not enough data. Stop trying to create a conspiracy where one doesn't exist.

[B52]

Diadem,
According to you, anything that I wrote that you don't agree with is a conspiracy theory.
That's not a critique, its a character assassination.

If I've made an error, or a wrong conclusion, I'm all ears. I'm the first to admit
if I made a mistake. I do my best not to but so far, I've not seen a single statement
that showed me I was biting the wrong tire.

As you point out, I'm not the TSB and I can voice an opinion about what I saw as the
shortcomings of that report.

If a pilot chooses to break CARS on a significant safety item and you think that's ok
that's your opinion and I don't share it.

The availability of Oxygen at FL290 in a single engine turbine, single pilot operation is essential.
It's a no go item or you fly below 10,000 and preferably even lower than that.
This particular pilot most probably had a low Vo2 max and most probably had a lower altitude
at which he was affected by Hypoxia.

You don't appear to have read the report.
The Oxygen Bottle had to be turned on during the pre-flight to be available during the flight.
He could not just reach over and turn it on as he went through "12,500" and apart from that,
he would have needed O2 at less than 12,500 if depressurized.

Depressurization without O2 turns an emergency into a fatal, event,
choosing to go without O2 means that he chose to play Russian Roulette
on at least two occasions at the start of the flight and lost.

Our medical examinations can be quite a joke. I can recall several doctors who had me in and out
in three minutes. I know of one pilot who had a valid medical but his
vision prevented him from driving. He could only fly in the right seat with someone who had eyesight
and a licence, the later being optional.

Your posts shows an inability to connect the possible causes and how they may have possibly related
to each other. You also fail to comment on the fact that the pilot was seen doing loops and inverted flight
at low altitude prior to his almost vertical dive into the ground that does not follow any profile of that aircraft
without control inputs.

Yes, the TSB, are very limited in what they can say but in my view, there is no harm whatsoever in
going over all the various possible combination of causes and that discussion will stimulate brains
which might prevent other accidents.

One of the problems with aircraft like this is that they dam near fly themselves, they are a very easy airplane to fly,
extremely reliable, a rich man toy and it can lull a pilot into feeling like a passenger
and that the aircraft can't make a mistake.

Now, in case you don't get it, I recognize that there is a hell of a lot the TSB cannot for one reason or
another place in a report. Their speculation into the accident is limited.
I'm not an investigator, I don't work for the TSB and can say what I like
and its rather interesting to see how the criticism is flawed.

[RatherBeFlying]

The spiral dive initiated at FL290 indicates that the pilot was aware of a pressurisation problem. Very likely he was incapacitated shortly after. You may not immediately recover from prolonged serious hypoxia below 14,000 or 10,000 or 8,000. The altitude chamber films show an oxygen mask put on after some 15 seconds and a very quick recovery.

Witness reports of the erratic maneuvers at lower level indicate lack of recovery from incapacitation.

Question: Does the preflight checklist require testing the emergency oxygen in the cockpit?

[B52]

No, he "may have" been aware of a pressurization problem or he "may not have" been aware.
He might have and probably did cause the spiral dive which indicates that
he was incapacitated but its a jump to conclude that he was aware of the problems
and by how much or what actions he took or didn't take.

Who does civilian chamber practice decompressions?

When I did mine, it was a hard to get rare experience.

There is another idea. I would think it a good idea for all single pilot flight over FL250
to have completed a chamber decompression.

[Diadem]

Diadem,
According to you, anything that I wrote that you don't agree with is a conspiracy theory.
That's not a critique, its a character assassination.

No, the only thing I said about you making conspiracy theories is that because the TSB didn't include every possible, hypothetical situation they've been influenced by "politics", as you put it. There's absolutely no evidence whatsoever that the TSB has been influenced by outside forces. I never said anything about your character, so stop trying to make yourself the victim.

If I've made an error, or a wrong conclusion, I'm all ears. I'm the first to admit
if I made a mistake. I do my best not to but so far, I've not seen a single statement
that showed me I was biting the wrong tire.

I never said you made a mistake. I never said that any of your hypotheses aren't plausible. I only said that for you to jump from "there are other possibilities not included in the report" to "the TSB is being manipulated behind the scenes" is an absolutely ridiculous statement. You can speculate all you want as to what happened, but when you start criticizing the TSB for not including the same speculations then you've lost the plot.

As you point out, I'm not the TSB and I can voice an opinion about what I saw as the
shortcomings of that report.

I never said you couldn't.

If a pilot chooses to break CARS on a significant safety item and you think that's ok
that's your opinion and I don't share it.

Your reading comprehension skills must be non-existent. I would like you to quote for me where I said that breaking the law is okay. I said that it's ridiculous for you to think that the TSB should include recommendations that pilots not break the law; that goes without saying, and it would be a complete waste of their time to have to include that in every report in which an infraction of the CARs is committed. You're demanding something absurd, and because it wasn't included in the report the TSB must have been influenced by "politics".

The availability of Oxygen at FL290 in a single engine turbine, single pilot operation is essential.
It's a no go item or you fly below 10,000 and preferably even lower than that.

Did I ever say anything contrary to this?

This particular pilot most probably had a low Vo2 max and most probably had a lower altitude
at which he was affected by Hypoxia.

Pure, total, complete speculation. There is zero evidence that this was the case, and it couldn't be determined without a full autopsy. The TSB could not include anything like this in the report without something to back it up.

You don't appear to have read the report.
The Oxygen Bottle had to be turned on during the pre-flight to be available during the flight.
He could not just reach over and turn it on as he went through "12,500" and apart from that,
he would have needed O2 at less than 12,500 if depressurized.

At what point did I say that he would have had to turn on the oxygen in-flight? If he was planning on flying over 12500' he would have had to turn it on before flight, and if he didn't he was both stupid and in violation of the CARs. However, if you read the report, or even the quote that I included, you can see that the TSB couldn't determine why the valve was closed; without the ability to tell whether it was never opened, or whether it closed during the crash, they couldn't lay fault with the pilot. You don't seem to understand that there's a standard of evidence required.

Our medical examinations can be quite a joke. I can recall several doctors who had me in and out
in three minutes. I know of one pilot who had a valid medical but his
vision prevented him from driving. He could only fly in the right seat with someone who had eyesight
and a licence, the later being optional.

That's nice. Prove that the pilot involved in the accident had a medical exam that was a "joke", or this statement is completely irrelevant.

Your posts shows an inability to connect the possible causes and how they may have possibly related
to each other. You also fail to comment on the fact that the pilot was seen doing loops and inverted flight
at low altitude prior to his almost vertical dive into the ground that does not follow any profile of that aircraft
without control inputs.

No. At no point have I speculated as to the causes of this accident. At no point have I said that anything you've hypothesized has been incorrect. The only point I've been making is that there's a standard of evidence on which the TSB must make its conclusions, and without that evidence they legally cannot present any conclusions. They aren't allowed to speculate, and for you to accuse them of acceding to "politics" because they didn't put in every possible crackpot theory is a completely ridiculous position. That's my only, single point, of everything I've posted.

Yes, the TSB, are very limited in what they can say but in my view, there is no harm whatsoever in
going over all the various possible combination of causes and that discussion will stimulate brains
which might prevent other accidents.

Yes there is. Are you not familiar with the role of the TSB? They are legally obligated to determine the most likely causes of an accident based on the available information, and to recommend ways to improve safety based on those conclusions. If there is no such information available, they are not permitted to speculate, and it would be detrimental to do so. As I said before, they're held to the same standard as lawyers in a trial, and in the case of a murder without a suspect a prosecutor wouldn't be permitted to lay charges against someone just for the sake of having a person convicted in the case; if they can't prove who did it, the case goes unsolved. If we start laying blame without the evidence to back it up, innocent people could have their reputations tarnished, and in the case of those who are deceased they won't be able to defend themselves. There are real-world consequences for things like this.

Now, in case you don't get it, I recognize that there is a hell of a lot the TSB cannot for one reason or
another place in a report. Their speculation into the accident is limited.
I'm not an investigator, I don't work for the TSB and can say what I like
and its rather interesting to see how the criticism is flawed.

Say what you like. I never told you that you couldn't. However, if you're going to accuse the TSB of being subject to political forces, you'd better damn-well have something to back it up. If the evidence you have is as strong as that you've used to draw conclusions on this accident, then I think we can safely agree that there's absolutely nothing to your absurd claim.

[KK7]

B52,

The investigation revealed facts about the accident, and demonstrated that there was not enough evidence to form a concrete conclusion, and I think it did a good job of that. There is no political correctness in presenting facts and presenting what can be proven. That is what an investigation is.

What you have done is taken those facts, and applied them into several hypotheses and opinions. There is no problem with that. One might argue it is reading between the lines. But you could not have done this without the information the investigation brought forward. You cannot, however, prove any of those hypotheses. I have little doubt that the investigators debated the very same scenarios as you have, but were unable to prove anything one way or another.

However if you do have additional information that is relevant to the investigation, then you should contact the TSB.

[B52]

Thanks KK,
On that note, I am very grateful to the TSB for their well written report and I could not have engaged
in my speculation without it. I hope that more facts will arise not just in this case, but in all accidents
especially those that lead to loss of life. If and when those additional facts surface, that may shine
a light on the relevant issues and perhaps provide reading material that aviation
will remember and hopefully, that will save lives.

[pdw]

Just after this accident was in the news there was some evidence discussed of a small area with icing potential passed thru fairly early in the long climb-out West. Nothing to speak of in general, except when looking for other potential contributing factors (ie; as a distraction).

If only on the tail the ice is not to be seen, but may also not be noticeable control-wise until getting up higher to a levell-off point where also flying in the clear the whole time and is not suspected. Then the tail ice becomes a very unnerving experience if there's some control effects (vibration etc) .... esp if this can delay until trimming a change in pitch and speed at the much later altitude ?

[justwork]

Just after this accident was in the news there was some evidence discussed of a small area with icing potential passed thru fairly early in the long climb-out West. Nothing to speak of in general, except when looking for other potential contributing factors (ie; as a distraction).

If only on the tail the ice is not to be seen, but may also not be noticeable control-wise until getting up higher to a levell-off point where also flying in the clear the whole time and is not suspected. Then the tail ice becomes a very unnerving experience if there's some control effects (vibration etc) .... esp if this can delay until trimming a change in pitch and speed at the much later altitude ?

So? The plane was and is certified for flight into ice, so that's the end of that. Most of the time, when you pick up ice in the climb, it's gone by the time you're in cruise. Unless you're suggesting it was flown through an area of severe icing, which typically takes more than a "small area with icing potential".

[PilotDAR]

The TSB investigator of this accident gave an excellent presentation about the investigation, at the TC safety seminar last night. His conclusion was that he had no conclusion about the clause. This is certainly one which contains some oddities, yet still defies explanation......

[Colonel Sanders]

there was some evidence discussed of a small area with icing potential

Complete misdirection. Wx was perfect.
Biggest problem that day was a sunburn.

Might as well blame UFO's for beaming him
aboard their spaceship.

[grimey]

there was some evidence discussed of a small area with icing potential

Complete misdirection. Wx was perfect.
Biggest problem that day was a sunburn.

Might as well blame UFO's for beaming him
aboard their spaceship.

Yea. I lived under the flight path. Weather was beautiful that day. Something went badly wrong with the plane and or the pilot, but there's not enough evidence left to do anything more than hint at what actually happened.

[Colonel Sanders]

Weather was beautiful that day

I know. I was flying that day, nearby. Icing
and variable winds were NOT a factor.

[pdw]

Someone have a Pirep from actually north of the track ? say about halfway between Take-off and the investigation site at around 5000-10,000. How far was that vis NW of Smiths Falls at noon ? ... YSH is still 50-60 miles south/southeast ....

A right course adjustment to Wiarton tracked towards Bancroft. Was colder in that direction up until late morning (some surface areas there were still at/below freezing by 9am). Fairly high moisture throughout that area. After the time of this accident, to the south of the track, the sustained winds were around ten knots and warmer from the south, but earlier Bancroft and Trenton point out some cooler air, light out of North/NorthEast, until late morning.
That's all, ... not to make more of the WX than existed.

Successfully determining an oxygen issue which may have existed for this accident also requires EVERYTHING that is known about the potential oxygen problem and its symptoms/causes to be profiled correctly. If something obvious is standing out from this report with regards to blood oxygen/C02then there's probably some more work to do in order to avoid another accident like this one.

[howard40]

Disclaimer. I have known the pilot for 34 yrs or so.
I listened to the tapes I could find on live atc, and in an uncharacteristic way, it took the pilot a few tries to get the squawk code input and read back correct. sitting in right seat, distraction, medical event etc could all cause this , as could programming or attempting to program the autopilot in a "new " plane. I think the other TBM he flew had a different dashboard etc. so things like squawk codes will be input a different way.
I have no idea about the oxygen system, but would it not be weird for either of the following scenarios?
1. they flew goderich to ottawa with the valve closed? and had red,and yellow lights and mfd alarms in alarm state all the way ? and simply silenced the alarm and flew on (without correcting at carp?) you would think the owner would simply be asked how the flight east went? wrt oxygen
there is no mention of asking the owner these questions but I highly doubt they did NOT interview him??

2. they had it open for flight to carp and closed it, before returning westbound on a 15 min stop? that does not make much sense? surely it is a last flight of the day thing to close? seems to hinted that you opend on first flight of the day. someone may have seen him reboard etc. ? if you forgot to open it eastbound and ignored it , odds are you would remember before you went westbound 15 mins later. if you had it open eastbound why would you close it suddenly on a 15 min quick turn?

there was not so much as a cloud in the sky over that way , i had looked at the visible satellite for other reasons.
condolences to family etc.

[grimey]

Someone have a Pirep from actually north of the track ? say about halfway between Take-off and the investigation site at around 5000-10,000. How far was that vis NW of Smiths Falls at noon ? ... YSH is still 50-60 miles south/southeast ....

I was living in Arnprior then, about 30 km from the crash site, and about 5-10 km north of track, and heard about it on the radio as I was driving between Arnprior and Renfrew. I looked out the window, weather was not a factor. And not "oh, just some CU, it's fine". There was nothing.