A flight instructor out of the Cooking Lake airport and his student died when they failed to recover from a spin they were practicing as part of aviation training in Canada.
On Wednesday, the Transportation Safety Board of Canada(TSB) released its final report into the fatal crash near Tofield a year and a half ago.
It happened on Aug. 11, 2023, when a Diamond DA20-C1 aircraft owned by the Cooking Lake Aviation Academy was conducting a flight from the Cooking Lake Aerodrome, located southeast of Edmonton in Strathcona County.
It was a training flight for a private pilot licence, with flight instructor Alex Lanovaz and a 24-year-old student pilot from Leduc in the two-seater plane. The TSB said it was the student pilot’s 13th training flight toward obtaining his pilot’s licence.
What happened leading up to the fatal crash
The plane took off around 5:30 p.m. on an evening that was clear, warm, and calm with almost no wind. The TSB said weather was not a factor in the crash.
The purpose of that day’s training was to review slow flight and stalls, and then introduce spins and spiral dives.
Simulating such emergencies in order to know how to regain control of the plane and avoid a crash is part of learning to become a pilot.
The flight path information collected from the plane, later retrieved from NAV Canada during the investigation, was consistent with spiral dive training and spin training, the report said.
The flight path and crash site location near Cooking Lake, Alta. on Aug. 11, 2023.
Google Earth, with TSB annotations
The plane flew to a practice area over Beaverhill Lake, 20 nautical miles east of the Cooking Lake airport, and for the next 21 minutes the TSB said the instructor and student conducted upper-air work.
At 6:05 p.m., when the plane was at 5,725 feet above sea level (ASL), it entered the first of two spin manoeuvres.
The plane dropped 1,575 feet and recovered 15 second after starting the spin, at an altitude of 4,150 feet ASL. The plane climbed back up 575 feet over the next 36 seconds and prepared for its second spin and dive.
This is where things went sideways.
At 6:06 p.m., the plane entered its second spin at 4,725 feet above sea level, which was 2,531 feet above ground level.
The plane, however, did not recover. It remained in a spin and dove to the earth, hitting the shallow surface of Beaverhill Lake 30 seconds later.
A TSB graph showing the relationship between the occurrence aircraft’s altitude and ground speed during the two spins on Aug. 11, 2023.
Transportation Safety Board of Canada
There was no post-impact fire, but the plane was destroyed.
The emergency locator transmitter on the plane did not automatically activate upon crashing in the shallow water.
It was two hours later, when the flight was overdue to return, that the Cooking Lake Aviation Academy declared it missing and activated its emergency response plan.
The military’s Joint Rescue Coordination Centre in Trenton, Ont., then initiated a search and rescue at 9 p.m. The facility coordinates responses to air and marine incidents across much of Canada.
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Tofield RCMP, Beaver County Fire & Rescue, the Edmonton Police Service helicopter and Search and Rescue Canada participated.
Because the transmitter didn’t go off and a flight plan wasn’t filed, it took search and rescue crews a few hours to scour the area in the dark and find the crash site, the report said.
The aircraft was found shortly after midnight.
The crash site, looking south, on Aug. 11, 2023.
Transportation Safety Board of Canada
When first responders arrived at the crash site, Lanovaz was dead and his student pilot was found seriously injured.
He was taken to hospital in Edmonton, where he died of his injuries two days later.
The TSB said based on conclusions from the medical examiner, the crash was not survivable.
Pilot and student info
The TSB report found the instructor held the appropriate commercial pilot licence and ratings for the flight they took that evening, and his medical was up-to-date.
Lanovaz had worked at the flight school for four and a half years at the time of the crash, and had accumulated 363 hours as a flight instructor.
Overall, he had 671 hours under his belt as a pilot. His last time in the cockpit of a Diamond DA20-C1 for an evaluation flight by was a few months earlier, in March.
Alex Lanovaz died when the plane he was flying crashed into Beaverhill Lake near Tofield on Aug. 11, 2023.
Supplied
The student pilot had started his flight training at Cooking Lake in May 2018, with the intent of obtaining his private pilot licence.
He completed two training flights before pausing his training until May 2023. His medical certificate was also current but he had not yet completed the requirements for his student pilot permit.
“According to information gathered during the investigation, there was no indication that the flight instructor’s or student pilot’s performance was affected by medical, pathological, or physiological factors,” the report said.
The TSB noted a lack of a formal flight plan isn’t out of the ordinary for a training flight like the one Lanovaz and his student undertook that evening.
The agency said generally, pilots at the Cooking Lake flight school operate in the local practice area use a visual flight rules itinerary in lieu of filing a flight plan, because they are staying in the area.
Following a flight, the pilot-in-command completes a flight log with the updated aircraft times, an action the TSB said then closes the flight itinerary.
TSB inspection of aircraft wreckage
The wreckage of the plane was brought it back to the TSB regional office in Edmonton, where a more detailed inspection of the airframe, flight controls, and engine was completed.
There were no anomalies noted, the TSB said, adding the plane had last been inspected 10 days before the crash.
The TSB said there were no recorded defects with the aircraft at the time of the crash, and no indication a component or system malfunction played a role.
The aircraft did not have a flight data recorder or a cockpit voice recorder — neither are required by regulation.
The plane was equipped with a Garmin G500 TXi avionics suite, which had the capability to record flight-path data. However, the TSB said it was too heavily damaged during the crash and the damage couldn’t be recovered.
The investigation found that the emergency locator transmitter on board was serviceable but a connector wire was not installed, preventing it from activating automatically.
The TSB said it’s presumed the wiring had not been installed by the manufacturer during assembly.
“As a result, search and rescue crews did not have a precise location for the accident, which required a much larger search area than if the emergency transmitter had activated, increasing the time it took to locate the aircraft,” the report said.
Spin training not mandatory but recommended
The TSB said in the early 2000s, Transport Canada removed the requirement for a private pilot flight-test candidate to enter and recover from a spin.
Although removed from the flight test, the TSB said it’s still part of the private pilot licence training, and Transport Canada has emphasized the importance of the recognition and prevention of stalls that can lead to a spin during this training.
“The emphasis in the training is on recognition and immediate recovery—not on conducting multiple-turn spins. The guidance notes emphasize entering spins using real-world scenarios. They also state that during training, student pilots will enter and recover from a full spin on their own,” the TSB said.
As a general estimate, the TSB said most small aircraft can expect to lose about 500 feet of altitude per each three-second turn while spinning, but greater altitude losses can be expected at higher-density altitudes.
Spins should only be practiced when the plane is high enough up in the air to safely recover.
“Generally, even if the pilot takes the necessary measures to stop the rotation as soon as it begins, the aircraft is in a vertical position while accelerating rapidly, and sufficient altitude is necessary to regain a horizontal flight path,” the TSB said.
The TSB said the flight instructor seemed to be aware of this, as his ground-instruction lesson plan indicated recoveries should be made by at least 2,000 feet above ground level. The flight instructor did not have any lesson plans for the in-flight portion of the training.
A TSB illustration of an incipient spin.
Transportation Safety Board of Canada
Operator error likely cause of crash
In the end, the TSB wasn’t able to say for certain what caused the crash but eliminating weather, aircraft malfunction and medical episodes left operator error as one of the remaining factors.
“The investigation did not identify any issues related to the airframe or the engine that could have prevented a recovery from the spin. Additionally, it was not possible to determine the actions of the flight instructor and student pilot, or a reason why a spin recovery was unsuccessful because the flight data recordings were limited.”
“During spin training, the aircraft entered a spin and, for reasons unknown, the flight instructor and student pilot were unable to accomplish a recovery, and the aircraft collided with the surface of Beaverhill Lake.”
After the crash, manufacturer Diamond Aircraft Industries Inc., issued a mandatory service bulletin calling for the inspection of the ELT connector wiring and for action to be taken to ensure full functionality, if necessary.
Additionally, Cooking Lake Academy revised its flight operations manual, integrating emergency response procedures and formalizing a minimum altitude for upper-air work and spins.
At the time of the fatal crash, there were 108 Diamond DA20-C1 planes registered in Canada and approximately 750 operating worldwide.
TSB releases report on plane crash that killed Cooking Lake instructor, student
