Backgrounder

Recommendations arising from the de Havilland DHC-2 Beaver crash (A12O0071) near Lillabelle Lake, Ontario, in May 2012

Occurrence

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

These recommendations are all about increasing the odds that people will get out of the floatplane and not die in otherwise survivable accidents.

RecommendationA13-02

[The Transportation Safety Board of Canada recommends that] 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.

Recommendation A13-03

[The Transportation Safety Board of Canada recommends that] he 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

The Board is concerned that the aerodynamic buffet of DHC-2 aircraft alone may provide insufficient warning to pilots of an impending stall.

Process

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. The Minister of Transport has 90 days as of 23 October 2013 to respond to recommendations made 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

The following recommendations arise from investigation A09P0397 (Lyall Harbour, British Columbia).

Recommendation A11-05

[The Transportation Safety Board of Canada recommends that] 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.

Status of recommendation: Unable to Assess

Recommendation A11-06

[The Transportation Safety Board of Canada recommends that] the Department of Transport require that occupants of commercial seaplanes wear a device that provides personal flotation following emergency egress.

Status of recommendation: 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; they can find information on Transport Canada’s website: http://www.tc.gc.ca/eng/civilaviation/standards/commerce-floatplanes.htm.