Richmond Hill, Ontario, 23 October 2013 — Highlighting the fact that egress training and shoulder harnesses would have improved the chances for survival in a fatal floatplane accident at Lillabelle Lake, Ontario, in 2012, the Transportation Safety Board of Canada (TSB) today released its report (A12O0071) into the accident.
On 25 May 2012, a de Havilland Beaver floatplane, operated by Cochrane Air Service, crashed following an aborted landing on Lillabelle Lake in northern Ontario. When gusty conditions prevented the plane from settling on the water, the pilot initiated a “go-around.” But as the pilot applied full power and began to climb, the airspeed dropped suddenly. The aircraft yawed to the left and rolled. This likely led to an aerodynamic stall and, with insufficient altitude to re-gain control, the aircraft flipped over, struck the water and was partially submerged. All three people onboard survived the initial impact, but only one person was able to successfully escape; the other two drowned.
The TSB is making two recommendations aimed at improving the odds that anyone who survives a floatplane crash will get out alive. “In an emergency, you only have seconds to orient yourself and escape and the right training can make the difference between life and death. Pilots with underwater egress training stand a better chance of helping themselves and their passengers survive,” said TSB Chair Wendy Tadros. “Another thing that will help immeasurably is shoulder harnesses. Too many passengers survive a floatplane crash only to drown because they have suffered some kind of head trauma and can’t get out of the aircraft.”
The TSB recommendations call for underwater egress training for all flight crews engaged in commercial seaplane operations (A13-02), and for all commercial seaplanes certificated for nine or fewer passengers to be fitted with seat belts that include shoulder harnesses on all passenger seats (A13-03).
These new recommendations build on to two outstanding TSB recommendations aimed at making floatplanes safer. In its investigation into the fatal 2009 floatplane crash that killed six passengers in Lyall Harbour, British Columbia (A09P0397), the Board made two recommendations: one calling for pop-out windows and doors to better facilitate egress (A11-05), and another calling for personal flotation devices for all passengers (A11-06).
Transport Canada has committed to making flotation devices mandatory, but has not committed to requiring floatplane doors and windows to come off easily after a crash. “When a floatplane crashes on water, approximately 70% of crash victims die from drowning. All four Board recommendations are aimed at changing that reality,” said Tadros. “Transport Canada needs to treat all four recommendations with the seriousness they deserve, and take every measure to prevent more from dying in otherwise survivable accidents.”
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
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BACKGROUNDER
Recommendations for de Havilland DHC-2 Beaver crash (A12O0071)
near Lillabelle Lake, Ontario in May 2012
Occurrence
On 25 May 2012, the Cochrane Air Service de Havilland DHC-2 Mk.1 Beaver floatplane departed Edgar Lake, Ontario, with 2 passengers and 300 pounds of cargo destined for the company’s main base located on Lillabelle Lake approximately 77 miles to the south. On arrival, a southwest bound landing was attempted across the narrow width of the lake as the winds favored this direction. The pilot was unable to land the aircraft in the distance available and executed a “go-around.” Shortly after full power application, the aircraft rolled quickly to the left and struck the water partially upside down. The aircraft came to rest on the muddy lake bottom, partially suspended by the undamaged floats. The passenger in the front seat was able to egress the aircraft and was subsequently rescued. The pilot and rear seat passenger were not able to egress, and drowned. The emergency locator transmitter activated on impact.
Recommendations - Lillabelle Lake, Ontario (A12O0071)
These recommendations are all about increasing the odds that people will get out of the floatplane and not die in otherwise survivable accidents.
The Department of Transport require underwater egress training for all flight crews engaged in commercial seaplane operations.
A13-02
- The TSB is considers that, underwater egress training can make a real difference, and pilots who have this training stand a better chance of getting out of a submerged plane- and a better chance of helping their passengers get out.
The Department of Transport require that all seaplanes in commercial service certificated for 9 or fewer passengers be fitted with seatbelts that include shoulder harnesses on all passenger seats.
A13-03
- The TSB considers that, given the additional hazards associated with an accident on water, shoulder harnesses for all seaplane passengers will reduce the risk of incapacitating injury thereby improving their ability to egress.
Safety Concern - Lillabelle Lake, Ontario (A12O0071)
The Board is concerned that the aerodynamic buffet of DHC-2 aircraft alone may provide insufficient warning to pilots of an impending stall.
Process
Under the Canadian Transportation Accident Investigation and Safety Board Act , federal ministers must formally respond to TSB recommendations and explain how they have addressed or will address the safety deficiencies. As of 23 October 2013, the Minister of Transport has 90 days to respond to recommendations put forth in investigation A12O0071.
Using an Assessment Rating Guide (which includes definitions for the status of recommendations), the Board evaluates the responses and their overall effectiveness. Each response is assessed as Fully Satisfactory, Satisfactory Intent, Satisfactory in Part, or Unsatisfactory. Progress made to address TSB recommendations is assessed by the Board on an ongoing basis.
OUTSTANDING FLOATPLANE RECOMMENDATIONS
Recommendations – Lyall Harbour, British Columbia (A09P0397)
The Department of Transport require that all new and existing commercial seaplanes be fitted with regular and emergency exits that allow rapid egress following a survivable collision with water.
A11-05 Unable to Assess
The Department of Transport require that occupants of commercial seaplanes wear a devicethat provides personal flotation following emergency egress.
A11-06 Satisfactory intent
Following the Lyall Harbour accident, Transport Canada developed posters and pamphlets for distribution to floatplane passengers to increase awareness of their role in safety. Floatplane passengers should fly informed, and they can find information on Transport Canada’s website: http://www.tc.gc.ca/eng/civilaviation/standards/commerce-floatplanes.htm.
