Aviation news release 2010

TSB # A01/2010


(Gatineau, Quebec, January 28, 2010) – The Transportation Safety Board of Canada (TSB) announced today that several examinations of the aircraft are complete and that the investigation is progressing quickly. In its investigation of the November 29, 2009 seaplane crash, the TSB is reviewing not only the circumstances of this accident, but prior accidents to see where common safety deficiencies exist.

The TSB team is now engaged in the analysis of all data gathered to date and is working towards drafting its report for the next phase of the investigation – internal review.

Work Completed to Date

The team has done a significant amount of work. It oversaw the recovery of the aircraft from Lyall Harbour and its transport to the TSB facility in Richmond, British Columbia. Thorough examinations of the aircraft have been completed. Interviews with the pilot and surviving passenger were carried out and statements from witnesses in the area have been reviewed.

Factual Information

The Seair de Havilland Beaver was departing Lyall Harbour, Saturna Island, at about 1600 Pacific standard time, on a flight to Vancouver International Airport, British Columbia. There were eight persons on board—one pilot and seven passengers including an infant. The winds were generally from the southeast, but gusting and variable. In open areas, the wind was blowing to about 30  knots. After an attempt to take off to the northwest, the pilot turned the aircraft southeast and then took off into the harbour. Once airborne, the aircraft remained below the surrounding terrain and during a turn to the left, it descended and collided with the water near the north shore of the harbour. An immediate emergency response was initiated, but the aircraft sank quickly and was completely below the water surface before first responders arrived. Responders rescued the pilot and an adult passenger from the surface of the water. Exhaustive searches found no other survivors. Later, Canadian Coast Guard divers retrieved six bodies from the wreckage resting on the bottom of the harbour, in approximately 14 m of water.

The wreckage was retrieved from the bottom of the bay and transported to a facility in Richmond. Several examinations revealed damage consistent with a hard impact at a flat attitude with high engine power. The left cabin door, which is normally used for embarking and disembarking passengers, was jammed shut from the airframe's deformation on impact. The right cockpit door was found jammed shut by the divers, but investigators were able to force it open after the wreckage was retrieved. The right cabin door and the left cockpit door appear to have popped open. The two survivors were seated next to those two open doors.

Neither of the survivors donned lifejackets and none of the available lifejackets had been removed from the aircraft. Five were still in their storage pouches. Five of the passengers remaining in the aircraft were free from their seatbelts.

The aircraft appears to have been in good serviceable condition before impact. Records indicate that there were no outstanding maintenance deficiencies, and that all of its modifications were approved.

This accident echoes the findings from previous TSB investigations including:

  • occupants of submerged seaplanes who survive the accident continue to be at risk of drowning inside the aircraft;
  • occupants who escape a submerged seaplane may drown without floatation assistance; and
  • seaplanes may not be optimally designed to allow easy occupant escape while under water.

Investigation Activities in Progress

Flight tests on a similar aircraft are planned to acquire performance numbers in different configurations, and those will be compared.

Wind conditions at the time of the accident are being analysed to determine if they may have been a factor in the accident.

At the same time, investigators are researching other floatplane accidents in order to examine the recurring risks and what can and should be done to mitigate those risks. We are looking at our past safety communications and at the responses from the regulator and industry to resolve the concerns raised by the TSB. While the Board is not making new recommendations at this time, this investigation has focused the TSB's attention on a number of issues regarding jettisonable or push-out emergency exits on seaplanes, underwater egress training for air crew, pilot training for flight in mountainous areas, aircraft handling characteristics, and the wearing of personal floatation devices.

Cooperation with Others

The survivors and the families and loved ones of those lost in this accident are first in the thoughts of the TSB investigation team. We keep in contact with those involved and hope that our efforts will help everyone understand what happened, why it happened and what needs to be done in the future to prevent its recurrence.

Transport Canada is kept up to date through its Minister's Observer to allow for immediate action should critical safety issues be identified.

The Investigator-in-Charge is working closely with the British Columbia coroner to identify the risks to persons and mitigation strategies.

Next Steps in the Investigation Process

Once all the available data are analysed, an initial draft investigation report will be completed, the Board will review it and an approved confidential draft report will be sent to persons and corporations whose interests may be affected by the report and who are most qualified to comment on its accuracy. They then have the opportunity to dispute, correct or contradict information that they believe is incorrect or unfairly prejudicial to their interests.

This process is intended to ensure procedural fairness and the accuracy of the Board's final report. The Board considers all representations (comments) and will amend the report if required. Once the Board approves the final report, it is prepared for release to the public.

As the investigation continues, should the TSB identify risks requiring immediate action, it will issue safety communications advising industry and regulators what needs to be done to improve safety in this important segment of the aviation industry.

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.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: media@tsb.gc.ca