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Safety communications for TSB investigation (A15Q0120) into the fatal August 2015 de Havilland DHC-2 aircraft accident near Tadoussac, Quebec


On August 23, 2015, a Beaver float plane, carrying a pilot and five passengers, took off from the waters of Lake Long, near Tadoussac, Quebec. The sun was shining, the skies were clear and the winds were light. In short, it was a perfect day for a 20-minute sightseeing flight. At the end of the flight, the pilot made a low-altitude turn to give the passengers a better view of some wildlife. An aerodynamic stall occurred, causing the aircraft to enter a spin. The aircraft struck the ground and was consumed by the fire that erupted after impact. The six occupants were killed in the accident.

TSB recommendations

The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry.

Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.

Recommendation made on 7 September 2017

Level of risk is determined by the probability and severity of adverse consequences. Given the number of DHC-2s without a stall warning system that used are in commercial operations, combined with the fact that low-altitude manoeuvres are an integral part of bush flying, it is reasonable to conclude that a stall at low altitude is likely to occur again. Because stalls at low altitude have catastrophic consequences, this type of accident carries a high level of risk.

Until, at a minimum, commercially operated DHC-2s registered in Canada are required to be equipped with a stall warning system, pilots and passengers who travel on these aircraft will remain exposed to an elevated risk of injury or death as a result of a stall at low altitude.

Therefore, the Board recommends that

the Department of Transport require all commercially operated DHC‑2 aircraft in Canada to be equipped with a stall warning system.
Transportation Safety Recommendation A17-01

TSB safety concern

Since 1998, the TSB has published 12 investigation reports on accidents involving DHC-2s that are not equipped with a stall warning system and that stalled and crashed (Appendix C).

In October 2013, in the conclusion of Aviation Investigation Report A12O0071, the TSB included a safety concern indicating that the DHC-2's buffeting does not provide pilots with adequate warning of an impending stall.

The TSB also noted the high frequency of accidents caused by aerodynamic stalls and the catastrophic consequences of these accidents when stalls occur at low altitude during critical phases of flight.

Outstanding recommendations

Lightweight flight data recording and flight data monitoring systems

The development of lightweight flight data recording systems presents an opportunity to extend flight monitoring to smaller operations. This technology, as well as flight data monitoring (FDM), will allow these operations to monitor activities such as compliance with standard operating procedures, pilot decision making, and adherence to operational limitations. FDM will also allow operators to identify problems in their operations and take corrective actions before an accident occurs. There is no CARs requirement for lightweight flight data recording systems to be installed on aircraft.

In the event of an accident, recordings from lightweight flight data recording systems would provide useful information that would better facilitate the identification of safety deficiencies in the investigation.

The Board acknowledges that issues remain to be resolved to facilitate the effective use of recordings from lightweight flight data recording systems, including questions about the integration of this equipment in an aircraft, human resource management, and legal issues such as the restriction on the use of cockpit voice and video recordings. Nevertheless, given the potential of this technology, combined with FDM, to significantly improve safety, the Board believes that no effort should be spared to overcome these obstacles.

Therefore, in the TSB Aviation Investigation Report A11W0048, the Board recommended that

the Department of Transport work with industry to remove obstacles to and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry these systems.
Transportation Safety Recommendation A13-01

In August 2013, Transport Canada (TC) held discussions intended to identify obstacles and barriers to FDM.

In February 2014, TC supported the recommendation and planned to draft an advisory circular to describe recommended practices regarding FDM programs.

In November 2015, TC agreed that FDM would enhance aviation safety in Canada. However, TC has not produced an advisory circular, and its revised proposed activity is to prepare an issue paper and revisit the risk assessment on FDM.

In its January 2017 response, TC indicated its renewed proposal to conduct a focus group in 2017, which it has been planning to do since 2013. However, until the focus group reaches conclusions as to the challenges and benefits associated with the installation of lightweight multi-function recording devices in small aircraft, and TC provides the TSB with its plan of action moving forward following those conclusions, it is unclear when or how the safety deficiency identified in Recommendation A13-01 will be addressed.

Therefore, the response to Recommendation A13-01 was assessed as Unable to Assess.

While TC has proposed some further study of the safety issue, no concrete actions are being taken to address the TSB recommendation. The TSB is therefore concerned that this could lead to protracted delays as observed on numerous other recommendations.

TSB Watchlist - Safety management and oversight

The Watchlist identifies the key safety issues that need to be addressed to make Canada's transportation system even safer. Safety management and oversight is a Watchlist 2016 issue.

This Watchlist issue was addressed in the TSB investigation report on an accident that occurred in May 2013. The report noted that approximately 90% of all Canadian aviation certificate holders are still not required by existing regulations to have an SMS, and that TC does not have assurance that these operators are able to manage safety effectively. The report highlighted the need for TC to adapt its approach to regulatory oversight to the competence of the operator.

Consequently, in the conclusion of Aviation Investigation Report A13H0001, this Watchlist issue was formalized in the following recommendations to the Department of Transport:

The Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.
Transportation Safety Recommendation A16-12

The Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.
Transportation Safety Recommendation A16-13

The Department of Transport enhance its oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk.
Transportation Safety Recommendation A16-14