Five Deaths Demand Justice Petition
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I know a few people here were following our story.
Here's some of my recent correspondance
TSB Policy on Occurence Information Dissemination to Families, Loved Ones and Survivors (FLS)
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:
The aircraft wreckage is now in the hands of R.J. Waldron & Co. 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
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.
The aircraft wreckage is now in the hands of R.J. Waldron & Co. 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
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
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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
end of rant
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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.
Money has nothing to do with this.
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Crimson - You have not read her posts!
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.
Why cant the public get the fact that they get what they pay for?
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.
BTW....why didn't you start posting your thoughts about our industry before this accident occured if you have such knowledge?
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
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
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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!
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!
Last edited by cplpilot; 12th Jun 2008 at 12:56.
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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.
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.
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.
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.
Last edited by J.O.; 12th Jun 2008 at 01:22.
To Crimson Skies
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
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
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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;
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.
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.
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;
George Heath
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.
- 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.
George Heath
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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.
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.
Join Date: Dec 2008
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not a good man!!!
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!
Moderator Please!
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
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
Last edited by grizzled; 12th Dec 2008 at 12:47.
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?
Last edited by J.O.; 15th Dec 2008 at 16:54.
