Five Deaths Demand Justice Petition

[dhc2widow]

Please visit http://www.petitiononline.com/cgaqw/petition.html and sign our "Five Deaths Demand Justice Petition". More information is available at www.questforjustice.ca (http://www.questforjustice.ca/). FYI I have been posting at AvCanada as "widow" for over a year. I think many would support the fact that I know about as much about the 703 sector as anyone not in the industry. Please, Stay safe.
To: Prime Minister of Canada To The Honourable Stephen Harper, Prime Minister of Canada; On the 28th of February 2005, five souls were lost after the air taxi they travelled in “disappeared” minutes after departure from Campbell River, British Columbia. Two days later, the body of one of the passengers was found not ten kilometers away. The autopsy showed he had no serious injuries, but had suffered extensively from hypothermia before slowly drowning. Countless family members, friends and fellow Canadians have been permanently scarred by these fatalities. Three women and ten children are now supported by WorkSafe BC pensions, instead of by their husbands and fathers. Despite the far-reaching implications, government officials have virtually ignored the seriousness of this fatal accident. The families and volunteers from their communities spent huge amounts of money and their own valuable time to search for and recover the aircraft using information that was immediately available to the Joint Rescue Co-ordination Centre and the RCMP. The Transportation Safety Board (TSB) ignored witness reports and physical evidence of engine failure and poor management, instead taking the easy road and blaming the pilot. The TSB’s failure to accurately report on the accident, resulted in Transport Canada Civil Aviation (TCCA) Occupational Health & Safety (OH&S) department closing its file, thus failing to investigate infringements of the Canada Labour Code. The families and their communities continue with efforts to raise the aircraft engine from the ocean floor to provide conclusive evidence. Although the TSB continue to “investigate”, they contend that an engine failure “should not cause the accident” and they can learn nothing by retrieving the engine. Not-withstanding the age of the engine type and its known issues, the families’ and many in the aviation community contend that R-985 is very much in use and can still be learned from, most specifically because of its age. Yet the accident remains a “Class 5 Occurrence” with no investigation for cause. More than two years have passed since these five men lost their lives, yet the BC Coroner Service, the RCMP and WorkSafe BC are unable to further their investigations. The engine remains in a documented location on the ocean floor, with the four missing souls likely nearby. Significant evidence has been provided justifying a public inquiry by the TSB to: reduce the risk involved in the air taxi, and more specifically floatplane, transportation service sector; uncover otherwise hidden facts; initiate remedial action; reflect the actual extent of lost lives; appease public interest and concern; and to address the deficiencies of Transport Canada Civil Aviation. Evidence indicates that both public and private sectors have much to learn from a speedy resolution to this investigation. We the undersigned, demand that an official government body immediately begin a public inquiry into the circumstances surrounding the fatal accident of the aircraft mark C-GAQW and the subsequent investigation into five unnecessary deaths. Sincerely, The Undersigned (http://www.petitiononline.com/mod_perl/signed.cgi?cgaqw)

[investdude]

This woman is a troublemaker. The aircraft did not crash because the engine failed. The aircraft crashed because the pilot was flying in very bad weather--very low ceiling and very poor visibility. All the evidence from the wreckage supports this. The TSB does not recover wreckage. That is the responsibility of the insurer or the owner if there is no insurance. It is not the responsibility of the TSB to recover the engine in order to prove it did not fail. There is already enough evidence from the wreckage which has been recovered to conclude the cause of the crash was flight into well below VFR weather conditions, not an engine failure.

[dhc2widow]

If that is true, why was everyone else on the CR spit and area flying in very bad weather, below VFR minimums?

Think about it. You are just starting your flight. As you are gaining altitude over low mountains, your engine fails. Plenty of people heard "coughing and sputtering". Oil is spraying on the windshield. Smoke is coming off the exhaust. You have no choice but to head for water ... where there is a low fog bank and glassy water. Edited to add: And the lack of injury to my husband would indicate the pilot did a fabulous job of getting the aircraft down under frightening conditions.

Look at the wreckage for yourself.


http://www3.telus.net/public/t9232724/home_files/image014.jpg

http://www3.telus.net/public/t9232724/home_files/image016.jpg

I'm not a troublemaker. The air taxi industry in Canada is in poor shape. Have you compared our accident rates to those of other countries? Do you know that you are more likely to die on the job as an air taxi pilot than you are as a logger here in BC?

The insurance company paid out to the owner before the wreck was found. They have never had any interest in viewing it. The owner promised to sign it over to us before we found it.

There is good reason to recover that engine. And good reason to do an investigation for cause - which causes began long before the flight.

[saudipc-9]

SPECI CYBL 281831Z 00000KT 4SM -RA BR BKN002 OVC040 RMK SF5SC3

I wouldn't call that VFR weather!

[dhc2widow]

If the weather was marginal, then everyone around was flying anyway. Do you see a problem with that, or does it only become a problem when there is an accident, and then only a problem for the pilot involved? If the pilot was flying at below minimums, where was his operational support?

What is most indicative of the manner in which the company operated, is the fact that they did not know where the aircraft was going, and did not report it to SAR according to the procedures in their Operations Manual once they determined that it was missing, but instead waited an additional three hours.

That failure certainly cost my husband his life, and may also have cost the lives of the four other men. They did all escape the aircraft. The owner's log-road building company had already been found responsible for a death due to poor maintenance and safety practices by Worksafe BC and the BC Coroner Service. What does that tell you?

[investdude]

"If that is true, why was everyone else on the CR spit and area flying in very bad weather, below VFR minimums?"

What everyone else may have been doing has no bearing on this accident. If you try to fly VFR in below VFR weather you have nobody to blame but yourself if you lose control of the aircraft and crash.

[dhc2widow]

What everyone else may have been doing has no bearing on this accident. If you try to fly VFR in below VFR weather you have nobody to blame but yourself if you lose control of the aircraft and crash.

Looking at those pictures, are you sure you want to stick with the cause of the accident being the pilot "losing control of the aircraft"? Just how much control was he supposed to have with that oil spray/smoke? He landed that aircraft on the water in such a way that at least one passenger was uninjured, and they all survived.

If it is common practice to fly below minimums, is that not cause for concern? If accidents are caused by pilots commonly flying below mins, then THAT should be addressed by the TSB/TCCA.

Sure blame the pilot. Do you have something to lose by the specifics of this case becoming public?

[investdude]

Alexander Pope said it best: "A LITTLE knowledge is a dangerous thing." There is no evidence, including those pictures, of an engine failure. Even if the engine had failed it should not have led to an accident. The pilot could have simply made a forced landing on the water (provided the weather was not too bad).

[dhc2widow]

He did. And the floats failed. Because they had not been maintained safely. We have plenty of proof of this, including a TCCA M&M Safety Inspection Report.

You sound like Bill Yearwood. Even if there was an engine malfunction, it doesn't make the aircraft uncontrollable. It shouldn't cause the accident...Historically, engine failures don't cause accidents like this.

Historically, people take better care of their aircraft.

[investdude]

The floats did not fail, they were damaged by the impact.

[dhc2widow]

Failed because the floats were in such terrible condition. From the TCCA M&M Report:


Review of the aircraft’s technical record revealed that reference to required data relating to numerous observed repairs was missing.
There were numerous repairs to all the Deck Combings.

You aren't supposed to do repairs to the deck combings. It corrupts their strength.

There were numerous structural patches and evidence of sealant being applied inside the right float
Inspection of the float access panels indicated that there was no sealant in place

The float bottoms had a thin coating of paint over corroded areas.
Over a year before the crash the ops manager was arranging to have the floats completely overhauled and reskinned. The owner decided they couldn't afford to do it. But they flew another at least 1000 hours before this crash.

[dhc2widow]

PS. Because of the following letter, TCCA issued this: http://www.tc.gc.ca/civilaviation/certification/continuing/Advisory/2007-02.htm


To Whom it may concern.

As a Aircraft Maintenance Engineer with 28 years of experience working on DHC-2’s, and having been involved with the Ministers Delegate Maintenance program for 6 years, I have been asked by the family members of the victims of the fatal accident of DHC-2 C-GAQW to inspect the retrieved aircraft and submit a report on my observations with respect to causative factors of this accident. I also have possession of video taken at the site as well as of the recovery process which I have reviewed.

On April 28, 2006 I attended the storage locker where the aircraft has been kept, in dry secure storage. The recovered portions of the aircraft included both floats, empennage, LH wing and flight controls, and the fuselage including the engine mount, engine accessory section. Sections remaining at the accident site would include the RH wing, engine power section, propeller and cowlings. The power section did not come up with the accessory section due to magnesium construction of the blower/ intake section having corroded away due to salt water emersion.

Most of the aircraft has a layer of organic growth due to being submerged for some period of time. Due to the storage conditions this growth is now dried up. Immediately apparent is the fact the windscreen, lower inboard section of the left wing, the right side of the fuselage including approximately 1 foot up the side of the vertical fin, as well as the right inboard leading edge of the horizontal stabilizer, have been covered with engine oil. This pattern of oil leakage is consistent with a major oil leak suddenly developing in flight, concentrated on the right side due to prop wash, which adheres to the colder dry surface of the aluminum, and is not easily removed. Subsequent to the accident, oil would be very unlikely to stick to the surfaces as they would be wet with water, and the oil contamination pattern would not be so well defined.

The aircraft damage viewed would suggest the mechanics of the accident involved a forced landing due to lack of visibility through the aircraft windscreen compounded by poor visibility due to meteorological conditions at the time. A power off nose up attitude would produce a rapid decent with a heavily loaded aircraft. The aft section of the RH float is bent up, with suggests a heal dig which would have bounced the aircraft back into the air. A slight kink in the upper LH wing half way between the strut and tip, plus the tip being knocked off in an upward motion suggest the LH wing may have contacted the water at some point in the chain of events. The most significant damage appears to have been caused by the aircraft subsequently stalling and striking the water in a nose and RH wing down attitude with a sideways component to the direction of travel. Both upper diagonal tubes of the engine mount have tension fractures (are completely separated mid tube), and both lower mount tubes have compression bulges just above the firewall mount, indication a significant vertical inpact The forward section of the right float has basically exploded from the impact of being driven up and being struck by the propeller and impact with the water. At the same instant the right wing impacted the water and was torn from the fuselage, as indicated by upper cabin damage. Video shows the right wing on the bottom with a near 90 degree bend upward, just outboard of the outer flap attach, also what appears to be the exhaust intensifier tube is completely flattened by the impact. Compression damage to the left mid section of the fuselage suggests the aircraft struck the water with a sideways component consistent with a stall.

I do not believe the aircraft cart wheeled into the water as there is very little damage to the Left wing, the horizontal stab, elevators, or rudder and vertical fin as viewed in underwater video. Damage to the fin, rudder, and elevator tip was incurred during salvage.

Based on my experience and my observation of the aircraft I would conclude that the initiating cause of this accident was a failure of one of the upper cylinders, or given the amount of oil and the short duration of the flight, a failure of the cylinder base studs. I support this with reference to the Transport Canada Service Difficulty Reporting Data base www.tc.gc.ca/wsdrs/ (http://www.tc.gc.ca/wsdrs/) quick search of Pratt & Whitney R-985-AN 14 and 14B, between April
of 2000 and today shows 99 service difficulty reports were submitted related to cylinders and power section problems. Of these 39 were related to Cylinder cracking or complete head separation. 9 incidents were
reported of cylinder base stud failures. The remaining reports included cracked crankshafts, cracked cases, cracked or broken pistons, and broken or bent connecting rods. These are only reported incidents, more are likely to have occurred which are not reported.

Several problems can create the circumstances for these types of failures. Most of these cylinders are old and are heat cycle fatigued; they may have been overhauled several times, and are subject to mandatory ultrasonic testing at overhaul, as well as a visual inspection every 100 hrs. Unfortunately many cylinders continue to fail, even within 50 hrs after the UT testing has been completed. Often the visual inspections can miss crack indications due to oil staining and difficulty in accessing the full circumference of the cylinder head area. It is my belief that a crack can start internally within the head and progress into a complete head separation in far less than the 100 hrs specified in the inspection requirement. As these are supercharged engines another factor may be over boosting an engine (too much manifold pressure for the given engine rpm). This is not common or likely with experienced pilots.
The third and most troubling possibility is the use of substandard parts. As these engines are so old, many of the parts are now being made by after market suppliers, referred to as FAA-PMA. Such parts are suppose to be equal to the original manufactures parts, however this is not always so. Items such as cylinder base studs could easily fall into this classification.

In light of this information I would consider a review of the engine technical logs to identify if any cylinders have been replaced due to cracking, or if any base studs have been replaced due to failing. This would be indicative of the overall condition this engine at the time of the accident.

Given the number of reported occurrences of these types of failures, that in my opinion has a very high probability of being what initiated the unfortunate chain of events that lead to the death of the occupants of C-GAQW, I believe that the recovery of the power section of this engine for more detailed investigation should be essential in ensuring safety for the large number of people in remote locations who travel in aircraft equipped with these engines. Further, a fair question to be asked would be to inquire what follow up investigations have been carried out with respect to the 9 instances of cylinder base stud failure reported, and what actions have been initiated to reduce these occurrences.

As part of my review I have a copy of Bill Yearwood’s letter to Ms. Larcombe at the Chief Coroners office related to this accident, dated September 21, 2005. With respect to comments related to TSB’s examination of the wreckage on July 29, 2005. I would like to forward two comments which may have a bearing on the conclusions arrived at. First, the statement that the engine mounts were in place and showed no sign of impact damage is contrary to my observations as noted above. At the retrieval the aircraft was upside down which would have made the damage I observed very difficult to detect. Second, the propeller control was set to fine pitch. This position according to the DHC-2 flight manual is used for take off, prior to landing, and in the event of an engine failure. Had the pilot flown into the water would the prop control not have been pulled back to 1850 rpm, the recommended cruise setting?

This concludes my observations and comments. In the interest of public safety I would be happy to discuss this matter with anyone concerned.

Respectfully

[carholme]

Investdude;

Obviously you have not read the file on the accident, or you wouldn't have published such an insulting post. When you have read everything, maybe you can offer an apology. You sound an awful lot like a poster on another forum who belittles everything and offers nothing.

Keep it going Widow, your efforts will be rewarded.

Regards

carholme

[carholme]

Investdude;

Your profile states that you are an accident investigator with TSB. I would find that hard to believe in that TSB inspectors would have more tact and intelligence, especially in dealing with a victim of such an unfortunate accident. If you are actually what you say you are, I will take that up.

carholme

[dhc2widow]

Hey! Maybe it's the same accident investigator from TSB, that when vieweing the wreckage with us, did not know the order of the cylinders on an R-985 ... that would explain what he has to lose by my being "proven" right.

[TERRIER two]

Your posts are unprofessional and derogatory. If you are a TSB Investigator then what we need are many more troublemakers because you are obviously not in the business of investigating accidents with a view to making the industry safer in the future, and the public may well need to take this type of action themselves. If so, what are you being paid for?

[slowstream]

Investdude;

You have failed as a TSB investigator and especially as a human being!! You should be ashamed of yourself and your office!! You’re pathetic in your attempt to ridicule Widow, as most of us are all too aware of the problems in that area of aviation in this country and especially in that region. I have addressed this in an upcoming article in a Canadian Aviation Magazine and fortunately we have people out there like Widow who are willing to challenge and fight the system and government for much needed change.

[Pilot DAR]

I have had direct, very indepth, involvement with Pacific TSB on a completly unrelated single fixed wing crash. Perhaps I will be impressed with their thoroughness and professionalism one day... That day has yet to happen...

Pilot DAR

[dhc2widow]

FYI This petition is being officially endorsed by the Steelworkers Union and the BC Federation of Labour.

Think about it. Well over two years since this crash. Five men died. Yet the TSB has made NO PUBLIC FINDINGS, no safety recommendations. How can that be acceptable to anyone?

[Left Coaster]

To quote Judge Smails..."Well? We're waiting!" Where's your biting reply?

[dhc2widow]

Oddly, investdude has gone silent. And changed his profile so in no longer reads TSB investigator. Huh.

[slowstream]

One can only assume (pardon the pun) then that matter is closed, that this is clear and firm evidence that he lacks the experience, intelligence, integrity and common sense, I see no further need to debate this, or look for further evidence to support the question of him being a human being or professional. Therefore with the overwhelming evidence presented, he must work for the government either the Pacific Region TSB or T.C. and sadly, as citizens we are stuck paying for _sshole's like these.

CASE CLOSED!

Investerdude, isn’t life a bitch?

[carholme]

Well the case is not closed for me. I am sending a letter to the TSB to lodge a formal complaint about this smart ass. When we are paying taxes to be controlled by jerks like this, it is high time we stood up to them.

carholme

[spitfires rule]

Who knows if he is even a TSB investigator :suspect:. Probably just someone being a sh*t disturber. Anyways keep up the good work Widow :ok:

[dhc2widow]

For those of you interested in this investigation, Senator Gerry St. Germain (http://www.parl.gc.ca/common/senmemb/senate/isenator_det.asp?senator_id=90&sortord=&Language=E&M=M)(a commercial pilot) has recommended the case be considered by the Senate Committee on Transportation and Communications in a letter to the Vice Chair, David Tkachuk, dated June 21st, 2007.

[extreme P]

No reason for investdude to change his profile unless he had something to hide from somebody (perhaps his employer?) finding out how he conducts himself. Did that letter get written?

[dhc2widow]

The W-Five episode was rebroadcast yesterday without prior warning to us, or asking for updates.
We appreciate any help you can provide in spreading the word ... We now have a Facebook group, called "We Support the Quest for Justice" to increase publicity. There are existing posts on babble and freedominion, on aviation forums, etc. Much media has been contacted, although frankly, I think the issues are too wide-spread for them to cover in two minute clips, etc. Our local news stations and papers (Vancouver Island/Vancouver) have been pretty good about keeping the pubic up to date.
If you know anyone with experience in deep water salvage, we have questions and ideas we would like to bounce around. If you know anyone who might be willing to help with donated/volunteered equipment or a boat (come hang around in an incredibly beautiful place) please let us know ...
Here is what we believe we need - an ROV able to go to depths up to 1000 feet, with a manipulator, real-time camera and sonar. We need more knowledge about dredging - the best way to blow silt at that depth ... We know this should be a relatively easy operation for someone experienced in deep water salvage - ancient wreck guys and treasure hunters and such ... We have a $10,000 "reward" promised by the TSB if we are successful ...
So we are currently doing a last financial drive to enable us to retrieve the elusive engine. Donations are being gratefully accepted by ...
TD Canada Trust
1400 Island Highway
Campbell River, BC
Transit # 9038
Acct #6259768
"Allison Decock In Trust"

Stay Safe,
Kirsten Stevens
[email protected]
Website: http://www.questforjustice.ca
Petition: http://www.petitiononline.com/cgaqw/petition.html

[dhc2widow]

Camera's Make Great Bait

On the afternoon of September 10th, as he drifted over the area alone in a small boat with his camera-bated hook, Kevin Decock caught something very heavy that looked suspiciously like our treasure. Last minute volunteers were found and it was towed closer to shore as it was winched. It broke surface about 9.30 this evening and it was soon confirmed to be the engine of C-GAQW, propeller still intact. By midnight the engine had been pulled aboard.

The engine has now been delivered to the Transportation Safety Board in Vancouver.

We have had a few AMEs have a look, and while there are some ideas we have decided to give the benefit of the doubt to the TSB and wait for their analysis. Mr. Yearwood has told us that the initial analysis will begin on Monday morning with an investigator from another region with whom we have previously dealt and are OK, TC, and other "interested" parties (P&W, Hamilton Standard, etc.). We are currently in discussions to find a designated observer to represent us in the analysis, one that TSB will approve.

In the meantime, I've put together the following slideshow so everyone can play armchair quarterback!

When viewing, please keep in mind that these are photos I have selected because I think they look "suspicious", or may be relevent. We have plenty more photos, as well as lots of Hi8 video.

http://www.youtube.com/watch?v=D-_dJY_1upo (http://www.youtube.com/watch?v=D-_dJY_1upo)

Newsreels here: http://www.youtube.com/watch?v=CxfQnzv8qn0

If you haven't already signed our petition, now would be a great time!

http://www.petitiononline.com/cgaqw/petition.html (http://www.petitiononline.com/cgaqw/petition.html)

[Yacov]

Just got the engine news Widow
Congrats!
and may truth reign
God Bless from the Kootenays

[dhc2widow]

On the 28th of February, 2005, pilot Arnie Feast and his passengers Dave Stevens, Fabian Bedard, Doug and Trevor Decock died following a survivable floatplane accident. All five men were working, or on their way to work and yet no investigation has ever been done into the Occupational Health and Safety hazards which contributed to these five deaths. There has been no coroner’s inquest. There has been no investigation for cause. An RCMP investigation remains open.

On March 2nd, two days before four Alberta RCMP officers were killed in the line of duty,the body of Dave Stevens was recovered barely five miles from the aircraft base. But it was not until the 28th of July, 2005 that the fuselage (without power section) was recovered at the physical, emotional and financial expense of the families of Arnie, Dave, Fabian, Doug and Trevor. The four missing men were not on board. All seatbelts were unbuckled, although life jackets were all still stowed.
Although there was considerable evidence of engine failure on the retrieved wreckage and amongst the witness reports, which led to the ability to locate the aircraft, the Transportation Safety Board did not take possession of the wreckage, or do more than a cursory examination. They concluded their investigation with a letter to the coroner in September 2005, which left the implication that the accident had been the result of weather and pilot error.
Dissatisfied, the families produced their own report, and insisted the TSB take responsibility for recovering the engine and determining the cause of the accident. Instead they offered $10,000 in May 2006, should the families be successful in their privately financed efforts. This has led to understandably considerable delays.
With more pressure from the families, the TSB sent a new investigator to inspect the wreckage in November 2006. By this time considerable corrosion had set in, and, as expected, the results were inconclusive.
As the families continued their research, they discovered that due to jurisdictional access, Worksafe BC was not authorized to take part in the investigation. Rather, under a joint agreement with the Minister of Labour, Transport Canada Civil Aviation is expected to appoint a Minister’s Observer. Yet no Minister’s Observer was assigned to this case. Instead of immediately investigating the company operating the aircraft, Transport Canada began an Enforcement Action for “Unknown” infractions against the missing pilot. It was not until December 2006 that they sent their own inspectors to examine the wreckage. This resulted in an Enforcement Action being initiated against the Approved Maintenance Organization.
After a very expensive recovery effort failed in March 2007, the families began to appeal to, amongst others, the Federal Ministers of Transportation, Labour, Public Safety and Justice. In late May, a petition was begun addressed to Prime Minister Stephen Harper and demanding a Public Inquiry into the circumstances surrounding this accident. Having been officially endorsed by the United Steelworkers and the BC Federation of Labour, the petition is being signed on-line and on paper editions across the country.
On September 11, 2007, the families were finally successful in recovering the power section of the aircraft, and duly turned it over to the TSB for examination on September 13th.
Although some assurances have been received, the families no longer trust the officials to “do the right thing”. We have written letters to the Director General of Transport Canada Civl Aviation, Merlin Preuss, and the Director of the Transportation Safety Board of Canada, Terry Burtch, outlining our expectations. (Available on website)
With this open letter to All Canadians, we appeal to you to help protect the safety of workers and other members of the travelling public by Printing this letter in your newspapers, copying and sending it to all your MPs, MLAs, and all the contacts in your email address book. Demand a public inquiry into this accident.
Please help protect the future safety of your loved ones. Let us learn from this accident, before another unnecessary death takes place.
Visit www.questforjustice.ca for more information, to download a paper copy, or to link to the on-line petition.


Kirsten Stevens, Campbell River BC

Website: www.questforjustice.ca
Petition: www.petitiononline.com/cgaqw/petition.html

[dhc2widow]

"Five Deaths Demand Justice" now on youtube:

http://www.youtube.com/watch?v=YguVSKapEcY

[dhc2widow]

The follow-up W-Five episode to "A Routine Flight" has been scheduled for December 29th, 2007.



The episode, titled "Kevin's Quest", continues the chronicle of the families' efforts to find answers, focusing on the recent recovery of the engine from C-GAQW, the aircraft whose loss also resulted in the loss of our loved ones, Arnie Feast, Fabian Bedard, Dave Stevens, and Kevins' brothers, Doug and Trevor Decock on the 28th of February, 2005. The story will air the second half of the program.





We hope you will join us in watching "Kevin's Quest".

[Coleman Myers]

:D

Keep it up !.

[carholme]

Extreme P;

The letter got written for sure and still no response from those to whom it was addressed, after two followups.

carholme

[Soap Box Cowboy]

There is one very simple ammendment to the law that could close a loop hole that operators round the world use.

Most laws state

"It is the responsibility of the pilot to ensure that the aircraft is operated safely"

Change it to the following

"It is the responsibility of the pilot and operator to ensure that the aircraft is operated safely"

Now the operators get out of jail free card is blocked, in South Africa the law was changed in this way due to a realisation that often in small companies who hire predominently low time pilots, who are desperate for any job they can get their hands on in order to get experience.

It took the death of nine people in a particularily brutal accident to do this. There should be more support for a pilots decision to say no. In many places if you say no you loose your job and there are ten guys waiting to take your slot.

[20driver]

There was a prosecution of a pilot of ran out of gas in Winnipeg, was this some of the nine deaths you refer to?
In that case I was stunned the operator was not prosecuted for dispatching a plane without enough fuel.
Hate to say it but a few owners in pokey and the insurance refusing to pay up would be all that is required. Pilots sadly are easy and cheap to replace.
20driver

[cplpilot]

To investdude:

Whit out recover the engine, how can you say that an engine failure was not a factor? can you say FOR SURE that all possible causes are analyzed?
I pay my taxes, how do you think i am feeling when one of my employee (i am paying your salary) say that is not your job to recover the engine? Get on the phone and get someone to recover it!!!!
We (taxpayers) don't want you well-payed chair-warmer to jump to conclusion, we want the truth!!! if the engine is analyzed and you are right, well you have done your job, until then YOU are the troublemaker!

[dhc2widow]

Soap Box Cowboy - that is a very interesting alteration to the simple wording that could indeed make all the difference. Certainly here in Canada, even with changes to the criminal code making employers responsible for safety, the almighty dollar can still land on top and leave the pilot (and his pax) on the bottom.

In this case, ostensibly because the pilot's body has never been recovered and therefore there is no confirmed cause of death for the air industry employee, the operational shortfalls which led to these five fatalities have never been identified by the regulators. The law, however, states that the CDN Civil Aviation Safety Inspectors (OH&S) are responsible to investigate for ANYONE who has been allowed access to the a/c by the owner/operator.

TSB does not want to be proven wrong, and Transport Canada doesn't care about small ops.

[dhc2widow]

For those interested, "Kevin's Quest" can now be viewed here (http://www.ctv.ca/servlet/HTMLTemplate?tf=/ctv/mar/video/new_player.html&cf=ctv/mar/ctv.cfg&hub=WFive&video_link_high=mms://a180.v31560.c31560.g.vm.akamaistream.net/7/180/31560/55ce8bb3/fs6.insinc.com/akamai/ctv/w5/wfive_071229_3.wmv&video_link_low=mms://a180.v31560.c31560.g.vm.akamaistream.net/7/180/31560/55ce8bb3/fs6.insinc.com/akamai/ctv/w5/wfive_071229_3.wmv&clip_start=00:00:00.00&clip_end=00:12:48.00&clip_caption=W-FIVE:%20Kevin's%20Quest,%20part%20one&clip_id=ctvnews.manually_insert.wfive_071229_3&subhub=video&no_ads=&sortdate=20071221&slug=wfive_kevinsquest_071221&archive=CTVNews).

[dhc2widow]

January 23, 2007

Your file: Z 5015-11760 U
RDMIS# 3845196
Mrs. Kirsten Stevens
492 S. McPhedran Road
Campbell River, BC
V9W 5K5


Dear Mrs. Stevens,

I am responding to your e-mail correspondence dated December 5,2007. The department has no further information to provide you beyond what has previously been communicated to you. However, to reiterate:

With regards to your Access to Information request, every effort is made to ensure requested documents are provided should they be in the custody of Transport Canada. The training records of the flight follower are not in our possession, nor are they required to be by regulation or policy.

As stated in previous correspondence, an investigation was initiated with respect to the Canada Labour Code and the Civil Aviation Occupational Health and Safety Program. It is recognized that your husband and the other passengers onboard the aircraft were deemed "persons granted access" to a federally designated workplace, but unfortunately there were no witnesses to this accident, and no determined cause of death of the pilot due to the body never being recovered. ( http://www.avcanada.ca/forums2/images/smilies/icon_question.gif http://www.avcanada.ca/forums2/images/smilies/icon_question.gif http://www.avcanada.ca/forums2/images/smilies/icon_question.gif ) As a result of very limited information, the investigation was closed. Since the closing of the investigation, there has been no additional factual information brought forward that would have influenced the decision to close the investigation.

Your recommendation that float plane pilots be required to undertake egress training, will be forwarded to the Secretariat, Civil Aviation Regulatory Advisory Council, on your behalf.

As noted in previous correspondence, a Minister's Observer was and continues to be assigned to this accident. In addition, we also reiterate the company was operating in compliance with CAR 723.16(1)(d).

I would like to take this opportunity to again express our condolences on your loss as a result of this accident and also thank you for sharing your views.

Yours truly,

David J. Nowzek
Regional Director, Civil Aviation

As I'm sure you can imagine, I find it extremely frustrating that having a clear cause of death for MY HUSBAND, has no affect on the decision to investigate for infringements of the labour code.

So, if we go down, we go down with guns blazing ...


We are in what we hope will be the final leg before finally getting some (proof positive) answers. In order to help ensure this becomes a reality, we ask for your help in finalizing the petition. If you have not already done so, please sign and pass on to anyone else you think may be interested in our cause. If you have been collecting signatures on a paper petition, please contact me at [email protected] ([email protected]), or via facebook, as soon as possible, to arrange for their return.

Thanks all and, as always, stay safe.

http://www.petitiononline.com/cgaqw/petition.html (http://www.petitiononline.com/cgaqw/petition.html)

[dhc2widow]

I know a few people here were following our story.

Here's some of my recent correspondance


----- Original Message ----- Sent: Monday, June 02, 2008 3:51 PM
Subject: Re: Accident A05P0039



Dear Mr. McDonald (TSB: Executive Dir.),

Thank you for your response to my inquiry. After a more than three years, you are the first person to clarify to whom the responsibility for the investigation into CLC infringements in my husband's death should have fallen. Unfortunately, neither the Minister of Labour, nor the Minister of Human Resources Social Development has responded to my inquiries regarding their investigation.

I should like to state, for the record, that in light of five deaths it is reprehensible that the TSB should have deemed this a Class 5 Occurrence. When the fuselage was recovered in July of 2005, the airframe fuel system was recovered in it's entirety. Yet none of the fuel system (known to be of interest with respect to Beaver accidents) was examined at that time. After the engine was recovered in September 2007, the investigation was still limited with respect to the fuel system. Witness accounts which led the family to locate the wreckage in the beginning, as well as witnesses who contacted the RCMP on the day of the accident, and who contacted the JRCC after the missing aircraft was on the news, clearly indicate that there was something wrong with the aircraft. If it was not mechanical, then there is still a good chance it was a problem with the fuel system. Further, as the evidence indicates that the accident was survivable, and that my husband drowned after suffering extensively from hypothermia, it would seem that the TSB should have examined the flight following, reporting of missing aircraft, underwater egress, floatation devices, etc. as they have in other accidents in the past. I do understand that the TSB has been co-operating with the Coroner with respect to recommendations, however this does not, in my mind, excuse the TSB from fulfilling their responsibility. Furthermore, this information, as well as information about uncertified parts (e.g. carburetor/fuel inlet) was not included in the TSB engineering report, and therefore may not have passed to Transport Canada and/or the HRSDC. Without information with respect to the condition of the aircraft (including floats - which I am told the TSB does not have the expertise to comment on!), engine hours (almost 1600 - how did they get approval for this??!), operational factors, failure to adhere to safety standards and emergency procedures, etc., how can TCCA or HRSDC make appropriate decisions with respect to their investigations? Considering that the TSB's mandate includes:


conducting independent investigations, including public inquiries when necessary, into selected transportation occurrences in order to make findings as to their causes and contributing factors;
identifying safety deficiencies, as evidenced by transportation occurrences;
making recommendations designed to eliminate or reduce any such safety deficiencies;
and reporting publicly on our investigations and on the findings in relation thereto.I cannot help but disagree that a full and formal investigation would have had different results. It is not just the cause of the accident which is important, but the contributing factors which resulted in an incident becoming a fatal accident. There are many people, both in and out of the industry, across the country that still follow this investigation and its results. The TSB has not instilled confidence in its investigative process.

The aircraft wreckage is now in the hands of R.J. Waldron & Co (http://www.rjwaldronco.com/). Should these forensic aviation specialists be able to determine the mode of failure, will the TSB upgrade the class of investigation and complete a full report?

Respectfully,

Kirsten Stevens

----- Original Message ----- Sent: Monday, June 02, 2008 5:55 PM
Subject: Re: Follow-up: NCAP



Dear Mr. McDonald

Once again, thank you for your response to my inquiries with respect to the NCAP. As you have advised me that the TSB has instead developed the FLS program, I would like to take the time to state emphatically that this program did not work for the families of those lost with C-GAQW. As a representative of the families of all five men on board, I can speak with authority.

I note that the document you have sent with respect to the FLS indicates that a Post-Investigation Evaluation is normally done following the release of the TSB’s final report. Although this accident will not have a final report (unless you advise differently in your response to my email dated June 2nd, 2008), I would like to formally request that an evaluation and lessons-learned report of the FLS in respect of A05P0039 be completed in consideration of the following information.

To begin with I shall clarify for you whom the primary contact should have been for each person on board the aircraft.

Arnie Feast (pilot): Sally Feast (sister, only living relative)
David Stevens (pax): Kirsten Stevens (spouse)
Doug Decock (pax): Allison Decock (spouse) - secondary contact Kevin Decock (brother)
Trevor Decock (pax): Doug Decock Sr. (father) - secondary contact Kevin Decock (brother)
Fabian Bedard (pax): Darla MacDonald (common-law spouse)

When the aircraft was declared missing, contrary to the Principles of the Policy which states “that the carrier/operator has the fundamental responsibility to the victims and their families for dealing with their individual needs”, not one next of kin was contacted by MJM Air to inform us that the aircraft had been declared missing at approximately 2:15pm on the 28th of February 2005. Passenger next-of-kin were contacted by their respective employers after 6pm, while the next-of kin to the pilot was left a message on her answer machine by a stranger after 8pm. At no time in the weeks immediately following the accident, did MJM Air representatives contact any family member to express their condolences or offer support, or to explain what would happen “next”. I have learned that this is common practice from operators who may be, at least in part, culpable. So much for the operator’s fundamental responsibility.

No family member was contacted by anyone at the Transportation Safety Board following the accident. No explanation was ever received about how an investigation would (or would not) proceed, or what that investigation would (or would not) entail. The first contact any of us had with the TSB was in June 2005 when an advisor to the families contacted the TSB to request assistance long after the official search was called down. Even at this time, the investigator met only with Kevin Decock and there was no discussion with respect to the accident investigation itself. When the TSB sent it’s first “letter to the coroner” in June 2005, the families were not notified. Although the aircraft wreckage (sans engine) was recovered (by the families) on July 28, 2005 the TSB examination was cursory, and nothing was taken at that time for examination. We were advised by our legal representatives to await the TSB report. When the second letter, post recovery, was sent to the coroner in September 2005, again the families were not notified. It was only through our contact with the coroner in October 2005 that we learned a letter had been released and requested a copy, which was received in November.

Greatly dissappointed with the contents of the letter, we requested a meeting with the TSB, the Coroner and TCCA, which took place in December, 2005. Although TCCA refused the request, this was the first time other family members had any contact with anyone from the Transportation Safety Board, and the first time for any of us with respect to the accident investigation. Unfortunately, the comments and conduct of one of your investigators was so insulting to grieving family members, and both he and the second investigator seemed so uninformed with respect to aircraft type, that we preferred to limit further contact to the Regional Manager. Mr. Yearwood has been, since this meeting, compassionate and communicative and most helpful within his mandate, including calling in a knowledgeable investigator from another region in December 2006. Of course, this led to our being informed that the TSB did not have the expertise to comment on how float condition (landing gear) may have contributed to the fatal nature of the accident! Most surprising as this was hardly the first floatplane accident in Canada.

Unfortunately, the communication from the TSB with other involved agencies has also been poor. To exemplify this, we were recently informed by the Coroner Service that the reason for the delay in their Judgement of Inquiry (and decision with respect to an Inquest) was that they had never been informed by the TSB that a full report would not follow the initial “letter to the coroner” - that the accident had been given a Class 5 Occurrence designation. Had they known this, it is likely the families would have received some measure of closure through the Coroner’s Report in early 2006.

None of this addresses the fact that at no time preceding your email of June 2, 2008 did anyone explain to us who would be responsible for a Canada Labour Code investigation, fines and enforcement action if deemed necessary. We had considerable information within days of the accident that was relevant to this part of the investigation (as well as the TSB investigation), but grieving as we were, we expected the official agencies to uncover and investigate the same issues we had identified. With four working loggers on board, we were horrified to learn (in 2007) that the WCB had no jurisdiction to investigate, fine or enforce, despite being an insuring party. We were informed by the WCB that a CLC investigation was the responsibility of Transport Canada. As you know (but we did not) Transport is only responsible for an investigation into the safety of the pilot, whose remains have never been recovered – which they use as an excuse not to investigate. The RCMP file remains open, and they have informed me that they did not receive a copy of the last engineering reports from the TSB.

We are of the opinion that, in the case of this accident, the TSB investigators assigned decided in advance of recovery (and without respect to the many witnesses who heard the aircraft in trouble that morning, information about poor operational practices and dispatcher training by MJM Air, or on-going maintenance issues with the aircraft C-GAQW - all of which the families were aware), that the accident was due to weather and/or pilot error. Instead of actually looking for a cause, they used only the information which suited their pre-determination after the fuselage, and then the engine, were recovered - again by the families.

All of this has lead to continued hardship, both emotional and financial, for all the families (and their friends). I do not believe this to be a part of the FLS policy.

As you may be aware, my continued research and advocacy has resulted in my contact with the grieving loved ones from several other aviation accidents in recent years. They have expressed to me a similar dissatisfaction with communication and compassion received from the TSB. I would be happy to provide you with further information should you so request.

Please confirm that an evaluation and lessons-learned report will be initiated with respect to the FLS and the accident A05P0039, and that we will receive a copy once complete.

Respectfully,

Kirsten Stevens
Campbell River, BC


TSB Policy on Occurence Information Dissemination to Families, Loved Ones and Survivors (FLS) (http://www3.telus.net/public/t9232724/index_files/TSB%20%20Policy%20on%20Families%20Loved-ones%20and%20Survivors.2005-09-16.doc)

[CrimsonSkies]

DHC widow.....I think you are just an annoying squak box who is trying to find a fault in everything. Get on with your life! Aviation over the years has had many unfortunate accidents, many have gone unsolved and others have had multiple events leading to the disasters. I think that by you trying to pin this whole incident on an engine failure, only shows that you are simply trying to put blame on one specific event leading to the crash, perhaps you should open your eyes and look outside the box. Over the year, I have read your posts, but I do not agree with the position you take. I feel that you are just looking to try and change an industry that comes with some risks, or most likely you are just trying to set yourself up for a big payday in the end. I'm tired of seeing your posts on various websites, and I believe that your attitude is purely self serving and that you are simply trying to build yourself a case so that you have grounds for a lawsuit in hopes of hitting the cash cow. Your opinion and twists of the facts hold no weight with me, and I hope that you would just go away, you obviously would love to shut down or at least have an impact on our industry with your "opinions". Nobody forced anyone into the plane, yet in our industry there are so many times that passengers want to get something for nothing. If you think that the industry has to set a standard that would eliminate all the risks of flying.......who would be able to afford a flight on such a plane??? Perhaps you were a big fan of Jetsgo and the $1 fare they charged also...Why can't the public get the fact that you get what you pay for! Now don't go barking at my opinion, I am entitled to post my thoughts, just as you have for the last year. I'm just sick of reading your posts and I can see that you have only posted out of anger. BTW....why didn't you start posting your thoughts about our industry before this accident occured if you have such knowledge? Perhaps you should be included in any lawsuit that takes place in the future....imagine, you can then sue yourself! Or perhaps the reason you didn't post prior to the accident was because you were fully aware of the risks involved in flying but you just wanted to ensure that you could still enjoy a flight for as cheap as you could get. I bet that there were other options available that day, but that the decision to go was based on being able to buy the cheapest flight. Well guess what.......that option is available in almost any industry or profession you use today. I just feel that you are just looking for an easy way out because you can't cope with the consequences of the decisions made that fatal day. It's all about money right?? DON'TGO AWAY MAD.........JUST GO AWAY!

end of rant

[dhc2widow]

Sure my husband had a choice ... fly with MJM Air or buy his own ticket to work ... and, he was working, therefore, we cannot sue.

Money has nothing to do with this.

[HansFlyer]

Why can't the public get the fact that you get what you pay for! Now don't go barking at my opinion, I am entitled to post my thoughts, just as you have for the last year. I'm just sick of reading your posts and I can see that you have only posted out of anger. BTW....why didn't you start posting your thoughts about our industry before this accident occured if you have such knowledge? Perhaps you should be included in any lawsuit that takes place in the future....imagine, you can then sue yourself! Or perhaps the reason you didn't post prior to the accident was because you were fully aware of the risks involved in flying but you just wanted to ensure that you could still enjoy a flight for as cheap as you could get. I bet that there were other options available that day, but that the decision to go was based on being able to buy the cheapest flight. Well guess what.......that option is available in almost any industry or profession you use today.

In this quote you have also shown your own ignorance!!!:}

Why cant the public get the fact that they get what they pay for?
Well maybe there are always guys trying to cut corners to be cheaper than the other one - including not doing proper maintenance?

I bet that there were other options available that day, but that the decision to go was based on being able to buy the cheapest flight.
These guys were transported by (or is it on behalf of) their employers in Hired transport to their place of work or back to their place of abode???

BTW....why didn't you start posting your thoughts about our industry before this accident occured if you have such knowledge?
And by the way - yes sometimes it takes something like an accident to open ones eyes to the circus in the aircraft and charter or taxi industry in some parts of the world. I can think of at least one such occurance in history?:D

So yes maybe this is looking for a big payday - why not have someone pay if they f!@#ed up? - But sometimes that is all that is required to clear the industry of operators taking chances with other peoples lives while lining their own pockets?

I bet that if this goes the way it will clear the way for some major changes in the industry in Canada - probably making the process of flying less affordable but somewhat safer?

The fact that the investigators took a stubborn one dimensional :ugh: :mad: approach will cause many issues all over the world. If an accident does happen - at least try to get to the real cause and try to prevent it in the future? But to decide it was the pilot flying in poor weather and not even looking at the other contributing factors - is smelling of something far worse than a rat!!!

HansFlyer

[cplpilot]

I think that Canadian aviation industry has big holes on safety!!! there are many proof, just look around!!
If my wife was on that airplane, i would ask myself how the authority jump to conclusions without recovery and/or seen all the pieces.
I am sure once all is looked carefully, i would accept the evidence and maybe recognize the first conclusions as correct. Until then, keep the fight on!!! and wish that some of your worst critics (or their family) don't find them self in your situation!!! would be very embarrassing for them!

[Chuck Ellsworth]

Crimson Skies:


I'm just sick of reading your posts and I can see that you have only posted out of anger

It is simple, don't read her posts.

That will save the rest of us making the mistake of reading yours.

[sepia]

Crimson Douche bag: How bout you just go away instead?

[J.O.]

Crimson Skies:

It would appear that Kirsten has learned alot more about the industry since the tragic loss of her husband than you apparently have so far. I suspect that you are still young and new to the business (the way you speak suggests this) and you still have alot to learn, and that's okay. But sometimes when you have alot to learn, you can learn more by listening than by talking (take it from someone who learned that lesson the hard way a time or two).

It is obvious that Kirsten is unsatisfied with the way the investigation was carried out. Based on the evidence she has provided in her postings, I think she has a valid point. She is a taxpayer (as was her husband) and she has a right to demand the best from the people who are mandated to protect the public (TSB and TCCA).

Each of us deals with our grief and sense of loss in different ways. When that loss comes suddenly and appears to have been unfair, it is not unreasonable to try to come to grips with it by getting to the true root cause of the loss. While it won't bring her husband back, it may help her to heal and move on with life. To criticize her for trying to achieve some closure is not only rude, it is highly insensitive. If you are half a man, you will remove your insensitive posting and replace it with an apology.

[grizzled]

J.O. said it all so well.
Crimson, you clearly are no expert in aviation safety issues. And you also clearly don't understand the position Kirsten has taken and the reasons she has done so. But those facts are unimportant compared to your rant, which was both rude and ignorant.
If you are at all interested in doing something worthwhile, remove the posting.

Grizzled

[potters tiger]

I aggree. More needs to be done to protect ourselves:D

[dhc2widow]

For those of you who have followed this case, George Heath of RJ Waldron & Co. recently released the findings of their investigation and a letter of recommendation to the Coroner.


R. J. Waldron & Company (1987) Ltd.
110-5920 No. 2 Road, Richmond, B.C. V7C 4R9 (604) 270-2722
30 October 2008
07-313
Summary Report
Wreckage Examination
MJM Air Ltd
DHC2 Beaver, C-GAQW
Near Quadra Island
28 February 2005


Introduction

The aircraft departed from Campbell River spit on a VFR flight to Frances Bay/Knights Bay with four passengers and the pilot on board. The aircraft did not arrive at either destination. The official search did not locate the aircraft but floating debris was identified and the body of David Stevens, who died from exposure and drowning, was found on shore. The remaining occupants have not been recovered.

A search and recovery effort financed and conducted by the victims’ families in July 2005 located the crash site and the aircraft was recovered on 28 July 2005. All of the occupants had exited the aircraft following the crash, indicating that the impact did not induce any incapacitating injuries.

R.J. Waldron & Co. was initially retained by Work Safe BC to attend the Transportation Safety Board of Canada examination of the engine at Valley Aero Engines in Langley, BC on 25 Sept. 2007. Subsequently, WSBC released George Heath to investigate for the victim’s families.

This summary report will document the observations, findings and conclusions of the R.J. Waldron & Co. investigation.


Scope of R.J. Waldron & Co. Investigation

R.J. Waldron & Co. was directed to complete the examination of the airframe physical evidence that had not been carried out by the Transportation Safety Board of Canada. Examination of the engine had not revealed any evidence of mechanical failure; however, examination of the propeller indicated rotation at low power at impact. The TSB noted that the propeller control was set to fine
pitch and that the counterweight assembly and blade shim impact marks were in the fine pitch range. The propeller is normally set to Fine PITCH for landing and during emergency power requirements – the propeller control is set toward the Decrease RPM setting in normal cruise flight. The propeller evidence suggested a possible precautionary or forced landing situation.

Various witness accounts reported hearing abnormal engine sounds as the aircraft passed nearby. These witness testimonies were documented by the families and the information was used to successfully locate the wreckage.

The primary objectives of this investigation were;
• Examination of the all fuel system components, including tanks, fittings, plumbing, filters, selector valve system and vent system.
• Examination of engine control systems.
• Examination of primary flight control systems
· Examination and evaluation of the oil deposits on various parts of the aircraft.

In addition, a detailed examination and analysis of the non-standard carburetor plumbing, and an assessment of the floats was requested.

Airframe Components

1. Airframe Overview

Time is the enemy of effective aircraft accident investigations. Depending on the environment and other factors, as time passes
the condition of the physical evidence changes and deteriorates. The Coast Guard failed to locate this wreckage during the initial
search, but it was found by the families through private searching about five months later. The subsequent recovery, storage and
transportation of the wreckage unavoidably caused further change and deterioration to the wreckage.

The Transportation Safety Board of Canada carried out three separate examinations in response to pressure by the families to
conduct an investigation. The airframe inspections were narrow in scope and cursory in most regards.

The exception was the engine, which was recovered 2 ½ years after the crash – the engine examination was complete and
thorough. If the cause had turned out to be readily apparent – a catastrophic engine failure for example – the deterioration might not
have presented a difficult problem. Since the actual cause is more obscure and may have been lost, the deterioration was a significant
obstacle to the investigation. Definitively separating post and precrash damage and corrosion was not possible in many areas.

The interior and floor were removed to allow access to the concealed system components.

2. Aileron flight control system

The aileron flight controls were secure and functional through the fuselage and the left wing. The right wing has not been recovered,
but its’ location on the ocean floor is documented. Separation of the right wing occurred during the initial impact sequence and rollover.

3. Elevator flight control system The elevator flight controls were secure and functional through the fuselage.

4. Rudder flight control system

The rudder flight controls were secure and functional through the fuselage.

5. Flap flight control system

The flap system was secure and functional through the fuselage and the left wing. The right wing has not been recovered. The flap
actuator was found in the retracted position indicating flaps UP. The flap selector was in the neutral (normal cruise) position.

6. Fuel Selector and Fuel filter

As examined the fuel selector would not rotate between the three tank positions – it was seized in the REAR position. The cable
system between the selector handle and the selector was secure and capable of normal operation. When the cable was
disconnected from the selector, the cockpit handle moved freely.

The fuel selector was removed, examined and disassembled. It appeared normal externally with no impact damage or signs of
corrosion. It was seized and could not be rotated. It was completely blocked and did not flow through from inlet to outlet. Disassembly
disclosed that the unit was packed with internal corrosion byproduct material.

The fuel filter lockwire was intact, indicating that the filter was not inspected during the TSB investigation. Examination of the filter
revealed that it was about 20% blocked by corrosion materials and fragments of the disintegrating filter. These contaminants were
judged to be post crash.

7. Fuel tanks, fuel plumbing & venting

The three fuel tanks were opened for internal inspection. The quantity transmitters for all three tanks were intact and capable of
normal movement. The three fuel outlet screens were open and the plumbing from the tanks to the selector valve was unobstructed.

The rear tank was removed with difficulty due to deformation of the tank and the enclosing structure – the bottom surface of the
fuselage was hydro-formed upward and the bulkheads were displaced. Overall, the tank was free from corrosion; however,
there were two small holes corroded through the bottom of the tank. There is no conclusive method to determine if these holes formed before or after the crash.

The plumbing from the fuel filter outlet to the firewall was open and secure.

The fuel tank venting system consists of a vent pipe from each tank merging into a single tube that extends up into the left wing root.
The inlet/outlet of the vent tube was found crushed and sealed, which would have prevented normal function. However, examination of the damaged end determined that the crushing occurred during recovery, storage and/or transporting the aircraft.

Unexpectedly, no fuel was found in any tank, line, or in the filter housing or fuel selector. It was anticipated that at least small
quantities of fuel would be found in closed and protected areas such as the filter housing. The pilot’s hand primer was found in the
open and unlocked position, indicating that he may have been hand pumping fuel.

8. Airframe Structures

There was substantial crushing (hydroforming) of the aircraft belly from the fire wall to empennage. The floor did not deform
significantly and the seats remained relatively undamaged and attached. Overall, the impact damage was moderate and
concentrated on the front and bottom of the aircraft. The left wing remained attached to the aircraft and was undamaged except for
the tip.

The right wing remained at the accident site.

There was substantial corrosion of steel parts and the magnesium control wheel had completely dissolved. However, overall corrosion
was not as severe as expected.

9. General wiring and plumbing

There were several non-conforming wiring installations associated with accessory electronic parts. The non-conformities included the
use of uncertified non-aircraft wire, bundling of large coils of surplus wire length and inappropriate use of crimped connectors. There
was an automotive style cigarette lighter wired into the aircraft system and attached to the pilot side pedestal.

Oil Deposits

An oily film was found on the windscreens and the right side of the fuselage. It was suspected that these deposits may have been an
indication of major inflight oil loss due to engine failure or hose rupture. The deposits on the windscreens were examined with an optical zoom stereo microscope. Five samples were collected for scanning electron microscope and chemical analysis from the inside and outside of both left and right windscreens and a representative fuselage sample.

Visually, the inside and outside surfaces of the windscreen looked similar. They appeared to have a relatively uniform oily/greasy layer with sporadic filiform organics in some areas. On top of that was a variety of environmental contaminants – dust, salt, pollen etc. As confirming evidence, we looked for the unique chemical signatures of used engine oil – specifically lead and bromine, using the EDS (energy dispersive spectrometer) capability of the scanning electron microscope. We found these elements in all five specimens. There was a relatively uniform layer of engine oil on the inside and outside of both right and left windscreen and the right side of the fuselage from the firewall to the tail cone.

However, I do not think that this oil was deposited on the aircraft in flight for the following reasons;

• The deposit on the fuselage is present in the protected wing root area. That area only became exposed when the right wing
separated at impact. Therefore the oil deposit on the right side of the fuselage could only have occurred sometime after the wing
separation.
• The oil deposit being on both the inside and the outside of the windscreen reduces the likelihood of inflight oil leak.
• The pattern of the oil deposit on the right side of the fuselage is inconsistent with inflight oil loss. When oil is lost in flight, it streaks
rearward, leaving clean spots behind rivet heads, sheet metal joints and other protuberances. These typical features were absent.
Carburetor Fitting

A brass reducer was found separated from the inlet to the carburetor when the aircraft was recovered. The carburetor inlet had been
repaired by installing a brass insert into the body, but this would not allow the standard 90 degree steel elbow fitting to be installed. This
brass reducer was apparently installed to bridge these parts.

The brass insert in the carburetor body is apparently a repair scheme developed by the overhauler without manufacturer, type certificate holder or Transport Canada approval. It was reported that the carburetor was removed from another aircraft and installed on C-F C-GAQW without proper documentation or certification. The airworthiness of this installation is suspect.

The reducer is a 3/8 NPT (National Pipe Thread) on the male end and ½ NPT on the female side. It was not a certified aircraft part and was not part of the normal installation. The reducer is likely a commercial plumbing fitting for boilers or similar device. The reducer constricted the fuel flow at that location by about 40%.

Floats

The aircraft had a set of EDO 58-4580 floats installed. The right float was substantially damaged by impact forces and contact with the propeller while the left float was relatively intact. Both floats exhibited fairly even compression damage at the rear, which indicates a wings-level attitude at initial contact.

Both floats exhibited numerous patches and large areas of thin zinc chromate paint spray. The zinc chromate was a questionable repair for areas with missing paint that had already exhibited signs of corrosion. For reference, the float compartments in each float were numbered from one through five, front to back.

The right float compartments 1, 2, 3, and 4 had sustained substantial impact damage. Propeller slash marks were visible on the deck and sides of compartments 1 and 2, and the float had been torn into two sections through the step compartment. The sides and bottoms of compartments 1 and 2 were skewed left; consistent with the forward half of the right float being side loaded inward under the engine and propeller during the impact sequence. The bottom skin on compartment 4 was torn open. Compartment 5 was intact but the keel and bottom skins were displaced inward. The impact damage to the right float would have precluded compartments 1, 2, 3 and 4 from providing any positive buoyancy after he accident.

The left float (SN 1441), was relatively intact. There was a hole in each sidewall of compartment 1 introduced during salvage. There was a large hole in the float deck above compartment 3, near the rear strut attachment fitting that could be either impact or salvage damage. There were small recovery damage holes in the outboard bottom skin of compartment 4 and 5.

All five left float compartment hatch covers had sealing defects; sealant was absent under the edges of the hatch covers on compartments 1, 2, and 3 and the 4 and 5 hatch cover seals were badly deteriorated and ineffective.

Most of the pump-out ports on both floats were open and the ones that were sealed used halved rubber balls instead of the expanding and locking plugs called for by the type design.

Buoyancy

Total float buoyancy for the EDO 58-4580 floats was 9,160 pounds in fresh water and about 9,435 pounds in salt water. The actual empty
weight of the aircraft as recovered (with right wing detached) is unknown but would be less than the book figure of approximately 3,300 pounds. All of the materials that are present in the aircraft weigh less when submerged in water than in air – even the heavy materials like steel. One hundred pounds of magnesium becomes 41 pounds when submerged and 100 pounds of aluminum – the major constituent of the aircraft weighs only 63 pounds when submerged – in fresh water. Submersion in salt water decreases the weight a further 3 %.

The displacement of water by submerged material lowers its weight but an even greater effect is achieved by trapped air, fuel and oil which have positive buoyancy. It is likely that between the loss of weight due to the separated right wing and the displacement of water by the wreckage, the submerged weight was less than 1500 pounds.

Investigator Bill Kemp from the Transportation Safety Board of Canada determined that the left float’s three good compartments were capable of providing about 2748 pounds of buoyancy and the one unbreached compartment in the right float would add another 916 pounds. Therefore, about 3664 pounds of buoyancy should have been available - more than sufficient to support the wreckage at the surface. Keeping the wreckage afloat would have provided the five initial survivors with a means of floatation and perhaps a perch out of the water. Furthermore, the floating wreckage would be far easier and quicker to locate by search aircraft and boats than a few bobbing heads. In a situation like this time is critical.

The separated right wing and the rest of the wreckage were found within 150 feet. Current at the surface was reported to be in the 5 to 7 knot range, so the fact that all the wreckage is close together indicates that the main aircraft and float portion sank almost as fast as the wing which would not have floated.

Obviously, the four good compartments flooded and lost buoyancy quickly. Water likely entered through unsealed or poorly sealed hatch covers, unplugged pump-out ports, leaks between watertight compartments and through various seems and joints of the float structure. The aircraft likely sank in one or two minutes.

Conclusions

The R.J. Waldron & Co. investigation determined that the aircraft crashed while the engine was at a low power condition, possibly indicating an intention to land – either forced or precautionary. There was no evidence of mechanical failure of the engine but it was not possible to determine if the carburetor, fuel, or ignition systems were functioning properly.

The rapid and unexpected sinking of the floats was the likely cause that turned this survivable accident into five fatalities.

Recommendations to prevent a recurrence of this accident and to remedy identified safety deficiencies are contained in a separate document addressed to the BC Coroner Service.


Prepared by:
George Heath
R.J. Waldron & Co. Ltd.

R. J. Waldron & Company (1987) Ltd.
110-5920 No. 2 Road, Richmond, B.C. V7C 4R9 (604) 270-2722
30 October 2008
BC Coroners Service Island Region
PO Box 9272 Stn Prov Govt
Victoria BC
V8W 9J5

Attention: Lyn Blenkinsop
Dear Ms. Blenkinsop

RE: MJM Air Ltd
DHC2 Beaver, C-GAQW
Near Quadra Island
28 February 2005

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. R.J. Waldron & Co. conducted a limited investigation on behalf of Work Safe BC and the families of the victims.
R.J. 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% - 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 “liferaft” 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% 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 R.J. 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% 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

[20driver]

Why do they think the plane was at a low power setting?
How many hours had being flown after the carb was replaced?

20driver

[dhc2widow]

The TSB did a thorough examination of the engine. I do not know enough to tell you why the determination of low power setting was made, but I will see if I can find out.

As for the carb, I cannot tell you how long it was in service, as there is nothing in the maintenance logs inidicating this carb was installed.

[sya]

Someone needs to stop this talk about a man who was very very bad, everyone knows that... and the "widow" makes him out to be a good man... its ok we all know what he did in his life, people all know!

[dhc2widow]

Pardon me?

[grizzled]

The post by “sya” (probationary ppruner) should have been removed immediately after it was posted. First, it has no relation to the thread. Second, it is exactly the type of post that pprune’s stated philosophy says is unacceptable. Third, it’s a nasty, even vicious, post – with no facts in support. Last, if pprune’s stated rules and aims are more than just words, this is exactly the type of post that must be removed, and the “poster” should be banned. If “first posts” such as this are permitted it tells everyone that anonymous cowards are encouraged on the site.

Lastly, the person who is the subject of the disgusting post is deceased. Moderator(s), for God’s sake do your job.

On the subject of the thread, I have never met dhc2widow, nor do I believe I met her late husband, though I may well have, as I spent a lot of time as a pax on floatplanes in that part of the world. I now live in a different part of the world but aviation safety is still my profession – as it has been for 30 years.

Since the accident which took her husband's life, this woman has educated herself about accident investigation in Canada and elsewhere, and she has campaigned responsibly and objectively for changes that would make the process more thorough and more appropriate, and therefore enhance aviation safety. With all she has been through – including some classic examples of bureaucratic obfuscation – she deserves kudos for her perseverance and professionalism. Thanks to her efforts to insist a proper investigation and a coroner's inquest be conducted, other people in the future will benefit. Her determination to seek the truth is admirable.

Grizz

[J.O.]

Thank you Grizz, I doubt that anyone could express it better. I hope that the mods do the right thing here. But then again, when I check the bottom of the Canada forum page, there are no moderators listed for this forum. We used to have a couple, I wonder what happened?