Remarks on the release of Aviation Investigation Report A12O0071
(Lillabelle Lake)

Wendy Trados
Chair of the Board, Transportation Safety Board of Canada
Ewan Tasker
Investigator-in-Charge, Transportation Safety Board of Canada
Richmond Hill, Ontario
23 October 2013

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Wendy Tadros

Thank you for joining us today.

On May 25, 2012, a de Havilland Beaver floatplane, operated by Cochrane Air Service, crashed into Lillabelle Lake in northern Ontario. There were three people on board. And while the initial impact was survivable, only one made it out of the wreckage.

The other two, trapped upside down in the submerged floatplane, drowned.

Today we’re here to give you the results of the TSB ’s investigation—to tell you what happened and to make a pair of recommendations aimed at improving the odds that anyone in a floatplane crash will not only survive the impact, but have an even better chance of getting out.  We are calling for 2 things:

  • First, for all commercial floatplane crews to take underwater egress training; and
  • Second, for small commercial floatplanes to have shoulder harnesses for all passengers.

I’ll talk more about these recommendations in a few minutes. But first, I have with me today Mr. Ewan Tasker, the Investigator-in-Charge. Mr. Tasker is a former air traffic controller, as well as a pilot with thousands of hours experience. He’s been heading TSB investigations for five years now, and he will take you through what went wrong that day.

Ewan Tasker

Thank you.

Commercial seaplanes—floatplanes—operate all over Canada because they can go places other aircraft cannot. Whether they are used as air taxis to ferry wilderness travellers in and out of remote lakes, or to get commuters to work every morning, they are a valuable—indispensable—part of Canada’s transportation network.

How valuable? In just one region—the Vancouver Harbour, there are about 33 000 floatplane movements a year, carrying about 300 000 passengers.

These flights are normally safe and have become routine in many ways, but occasionally there are situations where strong winds and bad weather can challenge even the best of pilots and aircraft.

On May 25, 2012, after a flight lasting a little over an hour, the pilot, who had several seasons of floatplane experience, was preparing to touch down on Lillabelle Lake.  He radioed ahead, seeking weather information, and was informed that winds were very strong. To account for this, he selected a southwest approach, into the wind. That’s standard procedure, and left about 1800 feet to complete the landing—a distance that was well within the aircraft’s capabilities. But winds can shift, and in the gusty conditions the pilot could not get the plane to settle on the water. So roughly halfway across the lake he chose to initiate what’s called a “go-around,” powering up with the intent to circle around and try again.

But as the pilot applied full power and increased the angle of attack, the airspeed dropped suddenly. The aircraft yawed to the left, due to torque from the addition of power, and a left roll quickly developed. This likely led to an aerodynamic stall and, with insufficient altitude to re-gain control, the aircraft flipped over and struck the water.

So that’s the physics of it: the application of full power, a high angle of attack, torque, a sudden drop in airspeed, a likely stall and then impact. Within seconds the plane was resting upside down, partially submerged in 3 metres of water.

But that doesn’t mean people needed to die that day. Because as Madam Tadros pointed out, this was a survivable impact, and one of the passengers managed to escape. And sadly, we have seen this kind of tragedy before.

Which is why I need to tell you about another accident, just off Vancouver Island, in 2009.

A little over two years ago, in the spring of 2011, we released our report into the investigation of a floatplane that crashed in Lyall Harbour, B.C. That crash also involved a de Havilland Beaver and a survivable impact. But of the eight people on board, just two escaped. The other six, just as at Lillabelle Lake, drowned inside the aircraft.

Following the Lyall Harbour investigation, the TSB made a recommendation for doors and windows that come off easily after a crash, to better permit rapid egress. We also recommended that all passengers wear personal flotation devices.

We did this because the Lyall Harbour crash fit into a larger pattern, involving floatplane fatalities. The statistics we have point to a single, sobering fact: roughly 70 percent of the fatalities involving aircraft that crash and are submerged in water … are from drowning. 70 percent! Not from the crash. Not from the impact. But because people are unable to get out. Or if they do, because they’re too exhausted or injured to stay afloat.

That’s why we made those two recommendations after Lyall Harbour, and that’s why today we’re making two more, aimed at improving the odds that anyone involved in a floatplane crash will not only survive the impact, but have an even better chance of getting out.

To explain these more fully, I return to Madam Tadros.

Wendy Tadros:

Thank you, Ewan.

Over the years at the TSB , we have looked at more than a thousand floatplane accidents, and one thing we have learned is that, in an emergency, you only have seconds to orient yourself and get out of that aircraft. 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. That is a fact.

Hence, our first recommendation to Transport Canada: We are calling for all commercial floatplane crews to take underwater egress training.

Our second recommendation has to do with giving passengers a better chance of staying conscious after a crash, and it boils down to two words: shoulder harnesses. If all you have is a lap belt, your body and head will snap forward on impact. But shoulder harnesses have been proven to reduce the risk of what we call an “incapacitating injury.” Head trauma. The kind that knocks people unconscious.

Commercial pilots already have shoulder harnesses. So do passengers in new floatplanes. But not passengers who fly in older aircraft. And that kind of loophole … the kind that says older planes don’t have to offer the same level of protection … is a loophole that can kill people.

Transport Canada needs to close that loophole. And that’s why today we’re recommending that small commercial floatplanes have shoulder harnesses for all passengers.

Before I close I’d like to talk a little bit about the history of floatplane safety. At the TSB , we’ve spent more than 20 years investigating accidents like this, all across Canada. And we’re not the only organization concerned about the risks involved. Just a few months after we released our report into the investigation at Lyall Harbour, the British Columbia Coroners Service convened a review panel to examine a series of recent floatplane accidents on the West Coast. Their conclusions echoed TSB recommendations about flotation devices and pop-out windows and doors—and they too suggested making underwater egress training mandatory.

Transport Canada has dabbled with voluntary compliance, in an effort to persuade operators to do the right thing. More recently they’ve committed to making flotation devices mandatory for all passengers. On exits there has been lots of study, and more is planned, but no decisions have yet been made to require that windows and doors come off easily after a crash. Meanwhile, people continue to die in otherwise survivable accidents.

This all goes back to what Ewan just mentioned, about a pattern of accidents involving float planes. Because the simple fact is, we can’t talk about what happened at Lillabelle Lake without talking about what happened at Lyall Harbour. And we can’t talk about Lyall Harbour without talking about decades of other accidents. In Kincolith, British Columbia.  In Rivière des Prairies, Quebec. Wabigoon Lake, Ontario. Noganosh Lake, Ontario. Lower Foster Lake, Saskatchewan. La Grande-Rivière, Quebec.

Now is the time to take action to prevent people from dying in otherwise survivable accidents. It’s time we had a common set of regulatory requirements, for everyone. It’s time for the regulator to regulate. Flotation devices may be coming, but we still need pop-out windows and doors. To those we add egress training for pilots. And shoulder harnesses for everyone.