Distraction in the cockpit was likely to blame for a fighter jet crash near Cold Lake, Alta., that killed a Canadian Forces pilot, an investigation concludes.

The final report on the CF-18 crash that killed Capt. Thomas McQueen in 2016 was released by the Department of National Defence on Friday.

It describes the crash as a "preventable accident" and recommends expanded training on low-level flight techniques.

'A few seconds of distraction'

"This accident once again demonstrates that old but hard learned lessons can sometimes be forgotten and that the low-level environment is an inherently hazardous and unforgiving region where only a few seconds of distraction can mean the difference between life and death," the report says.

McQueen, 29, was killed when the jet struck the ground in a descending left turn during a training mission near 4 Wing Cold Lake on Nov. 28, 2016.

Investigators ruled out mechanical failure, a bird strike or pilot incapacitation as possible causes of the crash, suggesting instead pilot error played a role.

The tail section of the CF-18 that crashed near 4 Wing Cold Lake on Nov. 28, 2016. (Department of National Defence) "It appears that the pilot was capable of controlling the aircraft but did not adequately monitor the aircraft's flight path while manoeuvring in the low level environment, and allowed the aircraft to enter an overbank situation and the nose to drop well below the horizon."

According to the report, McQueen may have attempted to recover at the "last second," but the aircraft was too low to the ground to regain control.

"While the reason for this lack of flight path monitoring is not knowable with any certainty, circumstantial evidence suggests that the pilot may have been distracted from the critical task of terrain clearance while attempting to spot his weapon impact."

McQueen, a 10-year Royal Canadian Air Force veteran originally from Hamilton, was flying the lead CF-18 in a two-aircraft training mission.

The object of the mission was to deliver two inert bombs followed by two laser-guided training rounds — simulating laser-guided bombs — at the Cold Lake Air Weapons Range.

Each pilot was to perform a "safe escape manoeuvre" after dropping the bombs to avoid simulated bomb fragmentation.

McQueen was flying at low altitude, about 600 feet above the ground, when he attempted the manoeuvre.

His jet climbed 50 feet, when the nose of the aircraft began to drop below the horizon.

About 1.5 seconds before impact, the aircraft began rolling right.

McQueen did not make any mayday calls or eject from the cockpit. A parachute was discovered at the crash site.

He was killed when his aircraft struck the ground while making a descending left turn.

A parachute was discovered at the crash site, but the pilot did not eject. (Department of National Defence)

Investigators also suggest McQueen's failure to follow safe flying practices triggered the "unsurvivable" crash.

"The low-altitude flying did increase the risk level, but did not necessarily lead to the accident. Ultimately, it was the unnecessary manoeuvring and a disregard of the LLAT (Low Level Awareness Training) principles that placed the aircraft in a position from which recovery was unlikely."

'It is concerning that something as basic as a minimum flying altitude could be interpreted differently.' - Department of National Defence report

Although McQueen was flying at about 600 feet, the report says dropping weapons from altitudes below 1,000 feet is not authorized.

Many of the pilots interviewed for the investigation said they were unaware of the prohibition, and had flown similar training missions in recent years.

"Generally, this was done because they believed that in the future there may be a tactical requirement for them to operate in the low-level environment," the report says. "However, for other pilots, it was clear in their mind that this was prohibited."

A directive was sent out shortly after the accident, clarifying the prohibitions on low altitudes.

The report recommends that all CF-18 squadrons reinforce training to emphasize the recommended strategies for maintaining a safe flight path and the inherent risks.

"It is concerning that something as basic as a minimum flying altitude could be interpreted differently by pilots within the same community," it says.

"It appears the intent of the minimum altitude published in the FFTR (Fighter Force Training Rules) was lost over time and, to at least a few pilots, new interpretations eventually crept in.

"This exemplifies the requirement for clear, unambiguous direction and the importance of strong, well-communicated standards."