Public Values

Three years later, floatplane fatality's widow still seeks workplace accident investigation

Independent forensic aviation specialist concludes: "The Transportation Safety Board of Canada did not fulfill its obligation in this occurrence."

Kirsten Stevens has been campaigning against airline safety deregulation since her husband's death in a floatplane accident in 2005. Outraged by Transport Canada's decision not to investigate this occurrence as a workplace accident for infringements of the Canada Labour Code, she hired an independent forensic aviation specialist, George Heath, to conduct his own examination. The result, his "Coroner's Recommendation Letter", is below.


From: R J Waldron & Company (1987) Ltd., 110-5920 No. 2 Road, Richmond, BC, V7C 4R9

To: BC Coroners Service Island Region, PO Box 9272 Stn Prov Govt, BC, V8W 9J5

30 October 2008

Attention: Lyn Blenkinsop, re: MJM Air Ltd., DHC2 Beaver, C-GAQW, Near Quadra Island, 28 February, 2005

Dear Ms. Blenkinsop,

Background

On 28 February, 2005 a deHavilland Beaver C-GAQW crashed into the waters near Quadra Island. All five occupants survived the impact and exited the aircraft before it sank — likely within a couple of minutes. The aircraft sank quickly, reducing the chances of survival for the occupants.

The Transportation Safety Board of Canada, the federal government agency responsible for aircraft accident investigation did not investigate this accident for cause. RJ Waldron & Co. conducted a limited investigation on behalf of Work Safe BC and the families of the victims.

RJ Waldron & Co. concluded that the aircraft contacted the water while the engine was in a low power condition, indicating a possible forced or precautionary landing attempt. The investigation was unable to determine the cause of the low power, but eliminated engine mechanical failure and in-flight fire.

Regardless of how and why the aircraft crashed, the main reason that there were five fatalities instead of five survivors was the rapid sinking of the wreckage.

Floatplane Accident Overview

The majority of float plane accidents — probably more than 90 percent — conclude with the aircraft submerged upside down suspended from the inverted floats. Aircraft can typically remain in this attitude indefinitely. The most common cause of fatalities in floatplane accidents is the occupants drown before exiting the often undamaged aircraft. When the occupants do escape the submerged cabin, they rely almost entirely on the floats for survival.

Although all floatplanes carry lifejackets by regulation, they seldom provide any assistance because the initiating event is sudden and unexpected. The occupant's priority is getting to the surface, not locating and donning a life jacket. Failure of C-GAQW to Float

Although four float compartments remained viable and should have easily kept the wreckage on the surface, providing initial survivors with a means of flotation and assisting in location by Search & Rescue, they did not. The most likely reasons that the functional float compartments flooded were;

— unsealed or poorly sealed hatch covers,

— unplugged pump-out ports,

— leaks between watertight compartments,

— and through various seams and joints of the float structure.

In addition, the six remaining compartments sustained various levels of impact damage that caused a loss of watertightness.

Defining the Safety Deficiency

This accident has highlighted the need for improvements in float requirements. In this case, had the aircraft remained floating, there is a very good chance that most if not all the occupants would have survived with no major injuries. Instead there were five fatalities.

It helps to define the problem and then explore options to address the defined problem. In this case, we want to reduce the probability of the aircraft and/or floats sinking so that they can be used for emergency flotation. There may be different ways to achieve the desired goal, but in general, requiring an engineering change that would result in sufficient positive buoyancy to keep the wreckage at the surface and provide a "life- raft" for survivors is the objective. Regardless if the compartments are flooded due to impact damage, poor condition and maintenance, or any other reason, positive flotation will provide the needed remedy.

Since achieving about 35 percent total buoyancy would be enough to keep the submerged aircraft at the surface and a place for survivors to hang on, all the float compartments would not have to achieve complete positive displacement. Sealed foam blocks could be installed through the hatches without filling all voids. The blocks could be removed for inspection or repair of the floats and could be periodically weighed to ensure that they do not increase in density. An alternate method of achieving the same objective would be air bladders.

Another area that could be addressed is the lack of water-tight integrity of the existing design — for example every compartment is at risk of flooding due to the archaic pump-outs. A simple check-valve in this system so that water can be extracted but no water can enter could be designed and installed. The common use of children's balls in the pump-outs should be eliminated and the original expanding and locking plugs reinstated.

A rope around the perimeter of the floats for survivors to hang on to and allow them to pull themselves out of the water would be a useful addition.

Florescent dye packs that release on impact or manually by survivors could aid it locating the aircraft in a timely manner.

Please see the RJ Waldron & Co. Summary Report for supporting information and detail.

Recommendations to Prevent Recurrence

We recommend that the BC Coroner Service make the following recommendations to Transport Canada to improve floatplane safety and prevent a recurrence of these circumstances;

1. Require aircraft floats to incorporate features that ensure at least 35 percent positive buoyancy.

2. Remind floatplane owners' and maintainers through the Transport Canada Service Difficulty Advisory publication that floats are an integral part of the aircraft and are governed by the same airworthiness standards as the rest of the aircraft. Transport Canada Airworthiness must enforce existing regulations and ensure compliance with airworthiness requirements for floats.

3. Require aircraft floats or floatplanes to incorporate an automatic and manual fluorescent dye pack that can be released in the event of an accident to enhance locating the wreckage and survivors.

4. Require aircraft floats to incorporate a perimeter rope to give survivors a hand hold and a means of getting out of the water.

5. Require occupants of floatplanes to wear a floatation device during the flight. History has demonstrated that it is unrealistic to deploy a lifejacket after a crash. We recommend that the BC Coroner Service make the following recommendations to the Transportation Safety Board of Canada;

6. The Transportation Safety Board of Canada should review its occurrence classification policy to achieve the legislated mandate of investigating aircraft accidents to determine the cause, and to make recommendations to prevent recurrence. The Transportation Safety Board of Canada did not fulfill its obligation in this occurrence.

Yours truly,

George Heath

To read further. . .

Links and sources
  Deaths of pilots, passengers merits no workplace investigation under airline safety regulatory freefall, by Kirsten Stevens, Public Values, June 10, 2008
  Canadian aviation accident statistics and analysis, by Kirsten Stevens, Public Values, June 11, 2008

Posted: November 13, 2008

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