Five Deaths Demand Justice Petition
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Five Deaths Demand Justice Petition
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. 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
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Don't Do It!
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.
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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.
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.
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.
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.
Last edited by dhc2widow; 28th May 2007 at 20:38. Reason: To add comment.
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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?
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?
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"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.
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.
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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.
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?
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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).
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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.
Historically, people take better care of their aircraft.
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.
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Failed because the floats were in such terrible condition. From the TCCA M&M Report:
You aren't supposed to do repairs to the deck combings. It corrupts their strength.
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.
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.
There were numerous repairs to all the Deck Combings.
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.
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PS. Because of the following letter, TCCA issued this: http://www.tc.gc.ca/civilaviation/ce...ry/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/ 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
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/ 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
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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
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
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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
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
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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.
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If this is a trouble maker we need more of them
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?
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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.
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.
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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
Pilot DAR
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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?
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?