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