TSB Report Puts Pilot Health, Fitness Under Microscope

Canadian Occupational and Safety News – October 18th, 2011

An investigation into a deadly plane crash last year in Miramichi, New Brunswick exposed vulnerabilities in how Canada's transportation regulatory body evaluates a pilot's health and physical fitness, says a report from the Transportation Safety Board of Canada (TSB).

In April of 2010, 62-year-old pilot Ron Clowes, an employee of Forest Protection Limited, was taking a Grumman fire-fighting plane out for a practice water drop in the early afternoon (COHSN May 3, 2010). He suffered a heart attack and the plane began to descend, colliding with several trees and then crashing into the ground just minutes after taking off from Miramichi Airport, says the TSB report, released on October 6. No radio contact was made after the pilot took off.

An autopsy showed Clowes suffered from ischemic heart disease, which causes reduced blood flow to the heart. The TSB report found that despite the "defences built into the Civil Aviation Medicine system," his heart disease wasn't identified, leading to the accident.

Plane had logged almost 4,000 hours flight time

The plane - manufactured in 1954 and converted to add fire fighting capabilities in 1993 - experienced no mechanical defects or system failures and the weather did not contribute to the crash, the report notes. It had almost 4,000 hours flight time.

Clowes worked for Forest Protection Limited for about 10 years. He held his commercial pilot license and had well over 13,000 hours of flight experience, about 260 of those on planes like the Grumman.

Because Clowes was over 40 years old and had his commercial pilot license, Transport Canada (TC) regulations require him to have a medical examination every six months and an electrocardiogram to test his heart every year, which he had done.

But the pilot's doctor had neglected to report factors that put the pilot at a high risk of heart attack. The doctor was unaware he had to report any medical conditions that could affect flight safety, and because of this oversight the pilot was considered at a medium risk of cardiovascular problems and no further health assessments were ordered.

"A full risk profile of this pilot would have included his age, obesity, [body mass index], smoking habits, hypertension, elevated triglycerides and blood sugar, as well as prompted further investigations to detect underlying coronary disease," the report states. "These comprehensive investigations would likely have identified him as high risk for a cardiovascular event."

David Davies, the managing director of Forest Protection Limited, says that the company was relying on TC-approved doctors to ensure their pilots had a clean bill of health and were fit to fly. "There was obviously a flaw in the system," he says.

The lack of reporting from physicians to TC could be a widespread issue plaguing the Canadian flight safety system, leaving civil aviation medical examiners without enough information to accurately determine if a pilot is able to fly safely.

When compared to the United States, Canada has a much higher number of aircraft incidents caused by cardiovascular issues. From January 1976 to October 2008 there were 38 incidents in Canada, 28 resulting in fatalities. In the US, there were only 13 such incidents from 1982 to 2011.

Deficiencies exist in guidelines, report says

"The [TSB] 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," the report concludes.

The Civil Aviation Medicine branch of TC is in the process of rewriting their cardiovascular assessment guidelines following a workshop with cardiovascular specialists last year.

After the incident, Forest Protection Limited spoke with their pilots for the 2011 season about the need for their family doctors to share information with TC and took steps to ensure that the medical examiners from TC have full access to medical and prescription records from their pilots, Davies reports.

Forest Protection Limited has been operating since 1951. The province of New Brunswick, JD Irving Limited and other forestry stakeholders own the company, the company's website says.

Original article on Canadian Occupational Health and Safety News website.