Opening Remarks for the publication of the
Transportation Safety Board Investigation Report into the
Loss of Control – Collision with Water Seair Seaplanes Ltd. de Havilland DHC-2 (Beaver), C‑GTMC Lyall Harbour, Saturna Island, B.C., 29 November 2009

Delivered by:
Wendy Tadros, Chair
Bill Yearwood, Investigator in Charge

17 March 2011
Vancouver, BC

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Wendy Tadros

Slide 3

Thank you for joining us today.

Just after four o'clock, on a gusty November day in 2009, a Seair floatplane lifted off from Saturna Island bound for Vancouver.  Minutes later, the plane hit the water. The pilot and one of the passengers managed to escape. Six others, including a mother and her infant daughter, did not.

For many on the British Columbia coast, floatplanes are a part of the daily commute – whether taking business travelers between cities or moving workers to remote sites. Given BC's challenging flying conditions, this essential means of transportation is not without its risks and there have been far too many accidents.

Slide 4

On the day of this accident, the TSB quickly launched an independent investigation. That's our job. And today we're reporting to Canadians on what we found. We're also going to tell you what needs to be done to make floatplane travel safer.

I now turn to Mr. Bill Yearwood, the Investigator-in-Charge who will tell you what happened that day and about the survival issues in this accident.

Bill Yearwood

Thank you, Madam Chair.

Slide 5

The Beaver floatplane was picking up passengers from the Gulf Islands, and Saturna Island was its third stop that day. With a full load of seven passengers and baggage, the pilot departed Lyall Harbour at around 4pm for the 15 minute flight to Vancouver.

The winds were from the southeast gusting from 32 to 47 kilometres per hour. (those are the big blue arrows)

Lyall Harbour faces west and that is most often the direction used for take-off. The pilot tried taking off to the west, but he could not get airborne before reaching the rougher waters outside the harbour. (These are the red arrows you see going west.)

Slide 6

The pilot then turned the aircraft east and took off into the wind and toward the island. (Red arrows pointing into the blue arrows.)

The aircraft became airborne quickly and climbed normally. Moments later, the aircraft encountered down flowing air and this caused the climb to slow. The pilot started a left turn in order to leave the harbour. (The winds are now behind the aircraft and are pushing.)

The pilot tightened the turn, the left wing suddenly lost its lift and dropped because of what is known as an "aerodynamic stall."

Let me be clear, we are not talking about an engine stall. We are talking about an aerodynamic stall of the wing. Pilots are trained to recognize the onset of a stall and recover from it. Many aircraft have systems to warn of an impending stall. The accident aircraft the stall warning was not working that day. This, combined with low altitude, meant the pilot had little time to react and recover from the stall before the aircraft hit the water.

Slide 7

In this investigation, we went beyond the immediate causes of the accident. We know the aircraft crashed wings level and nose up absorbing the impact by bending and breaking. Everyone survived the impact, but 6 of the 8 onboard drowned. They never got out of the aircraft. We've seen this before and that is why we focussed our investigation on the risk of drowning in floatplane accidents. We know the risk is high and we know it is twofold.

Slide 8

First, passengers often survive the crash but drown inside the floatplane because they cannot get out.

In this accident two of the aircraft's four doors were jammed shut – the other two were not. Those that escaped were next to the opened doors.

(You see in the diagram.)

The doors and windows on this aircraft could not be removed quickly in an emergency.

Slide 9

The second risk we see time and again, is that passengers will escape the sinking aircraft only to drown because they have no means of staying afloat until they are rescued. In this accident, none of the passengers, including the survivors, were wearing personal flotation devices. In fact, the survivors relied on marine bumpers that had floated out of the wreckage.

This concludes my presentation. Madam Chair.

Wendy Tadros

Slide 10

Thank you, Bill. As in so many of our investigations, this accident is about survival. Too often passengers survive the crash but drown.

This is not acceptable. More can and must be done to increase the chances of surviving a crash on water. That is the thrust of our recommendations. Floatplane passengers must be able to get out quickly and stay afloat 'til help arrives.

In Canada, from 1989 to 2010, 76 people lost their lives in 109 commercial float plane crashes on water – many of these were in B.C. In recent history five died after escaping a plane near Campbell River, six died trapped in the plane in Lyall Harbour, and, less than a year later, four more perished inside a float plane at Ahousat. More than any before, these three accidents shook public faith in the safety of floatplanes. This in turn sharply focused government and industry attention on the need to find solutions and restore confidence.

Slide 11

In the 16 months following the Lyall Harbour accident, we saw some important steps taken to improve safety. Transport Canada has upgraded its passenger education materials, in print and on its website.

Slide 12

Even more encouraging were industry-led initiatives. A number of float-plane operators have formed an association aimed at improving safety on the west coast. Moreover, some operators recently installed improved door handles and pop-out windows to make emergency escape easier. I just learned that some operators are leading the way and are providing personal flotation devices for their passengers and requiring they be worn at all times.

In a province where there have been far too many floatplane deaths, these are important initiatives, but our investigation clearly shows that more can and must be done to increase the chances of surviving a crash on water not only here in British Columbia but throughout Canada.

Slide 13

That is why we are calling for Transport Canada to require installation of doors and windows that come off easily – so that survivors can get out quickly.

If they do make it out, the risk of drowning is high. In an emergency, you only have seconds to orient yourself and get out of the plane. There is simply no time to find and put on crucial safety equipment.

That is why we are calling on Transport Canada to make sure everyone on board a floatplane wears a personal flotation device – so that survivors stay afloat 'til help arrives.

And we're not alone on this issue. After some accidents in Australia, that government proposed regulatory changes that will require the wearing of personal flotation devices while in a floatplane. In the U.S., the FAA has also recognize the importance of this issue. They have recommended that passengers wear life preservers.

Slide 14

The recommendations we are making are simple in concept – common sense really. Whether a floatplane is flying along the B.C. coast, over the tundra of the north, or to remote communities in Quebec, those on board, deserve the very best chances of surviving a crash. With these recommendations, we want to give floatplane passengers every chance to get out quickly and stay afloat 'til help arrives.

On November 29th, 2009 a tragedy occurred in B.C. that deeply affected public confidence in floatplane safety. The public rightly expects industry and government to do everything they can to protect passengers. And so does the Board. We at the TSB are looking for Canada to be a leader in floatplane safety.

That is why today the Transportation Safety Board of Canada is making two recommendations. First, we are calling for Transport Canada to require installation of doors and windows that come off easily after a crash – so that survivors can get out quickly. We also want rules to make sure everyone on board a floatplane wears a personal flotation device – so that survivors can stay afloat 'til help arrives.