Five Deaths Demand Justice Petition

[Longtimer]

There is another site for signing the petition:


http://www.petitiononline.com/cgaqw/petition.html

[Widow]

Interesting. Just received an email from the TSB Director of Air Investigations. Seems like they are going to finally respond to our demands "officially" .

I wonder what it will be?

[SAR_YQQ]

I heard you on the radio this afternoon "Widow".

[Widow]

I figured with the radio I didn't have to worry about brushing my hair.

PS. I really think you oughta find a hairbrush before your next tv interview.

[Mitch Cronin]

... I was thinking about that when I saw the post about you being on the radio...

[Widow]

FAMILIES SEEK JUSTICE IN WORKER DEATHS
On February 28, 2005, five forest workers died when an air taxi they were traveling in “disappeared” minutes after departure from Campbell River, BC. Two days later, the body of one of the passengers was found only ten kilometers away. The autopsy showed he had no serious injuries, but had suffered extensively from hypothermia before slowly drowning. The families of these forest workers have started a "Five Deaths Demand Justice Petition” at http://www.petitiononline.com/cgaqw/petition.html and have established a website at http://www.questforjustice.ca.

http://www.usw.ca/program/content/1876.php

http://www.steelworkers1-363.ca/

[Widow]

Perhaps this is another reason why the TSB does not feel the need to report and make recommendations on this case. They already sent this to my friend Mr. Preuss:

Transportation Safety Board of Canada

03 March 2006

Mr.Merlin Preuss
Director General, Civil Aviation
Transport Canada


Subject: AVIATION SAFETY SAFETY INFORMATION LETTER A060004-1 (A05Q0157)
Ineffective Means of Flight FolloWing Communication

Dear Mr. Preuss,

On 01 September 2005, a NordPlus float-equipped De Havilland DHC-2 Beaver, registration CFODG, serial number 205, departed the outfitter camp for Squaw Lake, Quebec, 127 nm southeast. Weather deteriorated en route and a precautionary landing was made on Lake Elross, 14 nm northwest of Squaw Lake. Although radio communication via HF radio had been reported to be very poor that day, the pilot did manage to communicate with company dispatch later that afternoon to say that there was a break in the weather and he would takeoff for Squaw Lake. Rescue efforts were initiated in the evening when the aircraft did not arrive at the base.

The aircraft was located the followingday, 11 nm from Squaw Lake. The aircraft was destroyed by a post-impact fire. The pilot, the sole occupant on board, sustained fatal injuries. The Transportation Safety Board investigation into this occurrence (A05QOI57) is ongoing.

NordPlus 1988 Ltd operates under 702/703 Canadian Aviation Regulations (CARs). The occurrence flight was operated under 703 CARs. Standard 723.16 requires a Type D operational control system whereby the flight's progress is monitored and the notification of appropriate air operator and search-and-rescue authorities can be accomplished if the flight is overdue or missing. Current information on the location of the air operator's aeroplanes shall be maintained and each aeroplane shall be equipped with serviceable and functioning communications equipment that permits the pilot-in-command to communicate With a ground radio station for the purpose or flight following .


The Transportation Safety Board investigation into this occurrence revealed that although the aircraft was equipped 'With serviceable and functioning communications equipment (in this case 'With a HF and a VrlF radio); neither means of communication was effective that day. The
operator reported that HF radio communication was reported to be very poor during the day and vHF radio coverage at low altitude was insufficient for the relaying of information. The pilot-in-command was therefore unable to communicate the flight's progress for most of the trip
and the operator was unable to follow the aircraft's progress.

Rescue and survivability are dependent on fast and effective communication. In this accident, considering the limited communications capability at the time, it was fortuitous that the pilot was able to notify the company of his intent to depart from Lake Elross. Othervvise the search
efforts would have had to cover a much larger area. This would certainly have delayed finding the aircraft and :increased the resources required in the search. Sadly the pilot of this aircraft was fatally injured in the accident. In other circumstances, had the pilot had been seriously
injured or had he been responsible for seriously injured passengers, the lack of reliable communications would have delayed the finding of the aircraft and the provision of medical care.

Modern technology has provided other means for more reliable communications, especially in remote areas. A search of the Transportation Safety Board occurrence data base, between the
years 2000 and 2005, revealed 21 occurrences, involving 46 occupants, where satellite phone played a key role in the quick rescue and survival of the aircraft occupants.

The foregoing is provided for whatever follow-up action is deemed appropriate.

Nick Stoss

Director of Air Investigations

Transportation Safety Board of Canada

cc: J. Taylor, Director, Aerodromes and Air Navigation, Transport Canada

Of course, that is almost exactly what I said in my report of March of last year (and over and over again in communications with both the TSB and TCCA). Perhaps since Mr. Preuss does not consider the fact that the "lack of reliable communications would have delayed the finding of the aircraft and the provision of medical care" is exactly what happened in our case, and that maybe, just maybe, somebody ought to try to figure out a better way.

BTW, this aircraft burned and could not be analyzed to determine what precipitated the crash.

[CD]

BTW, this aircraft burned and could not be analyzed to determine what precipitated the crash.

However, the TSB did make two findings in this accident:

Analysis
As forecast for the area of Squaw Lake, low ceilings, low visibility in rain showers, strong winds, moderate to severe turbulence, and possible wind shear most likely existed at the time of the occurrence. The pilot had made a precautionary landing on Elross Lake earlier that afternoon because of the poor weather. It is not known why the pilot, familiar with the area and the terrain, chose to navigate into the Howells River valley, which is usually not used as a bad weather route.

While the pilot held a valid instrument rating and had considerable experience in instrument flight, he was not in contact with air traffic control (ATC) and had no IFR clearance. Although the pilot was aware that weather at the Squaw Lake base was poor, he chose to take off from Elross Lake. It is possible that the pilot chose the more direct route to Squaw Lake because the aircraft would have had a low fuel state, especially if the pilot had not taken on more fuel during the day.

The severity and type of the damage and the angle at which the aircraft contacted the terrain indicates the aircraft was in an aerodynamic stall at the time of impact. In an attempt to cross the east ridge of the Howells River valley, the pilot perhaps lost visual reference to the ground and subsequently control of the aircraft and/or he encountered moderate to severe turbulence and strong updrafts causing the aircraft to stall. The low ceiling would have forced the pilot to fly 500-600 feet agl to maintain flight in visual meteorological conditions. The proximity of the aircraft to the ground meant the pilot had little time to recover control of the aircraft once it entered a stalled condition. The accident was not survivable due to the high impact forces and post-impact fire.

Had the pilot been unable to communicate his intentions to depart Elross Lake, search efforts would have needed to cover a much larger search area which in turn would have cost valuable rescue time. Had the pilot survived the accident with serious injury or had he had the responsibility of seriously injured passengers, communication would have been crucial. Where passengers survive and must attempt to call for help, they may not know how to operate the HF radio. A satellite phone provides a more effective means of communication, particularly in remote regions of the country.

Finding as to Causes and Contributing Factors
1. The pilot attempted to cross the mountain ridge in adverse weather, and the aircraft stalled at an altitude from which recovery was not possible. Loss of visual references, strong updrafts, moderate to severe turbulence and possible wind shear likely contributed to the onset of the aerodynamic stall.

Other Finding
1. Had this been a survivable accident, rescue efforts may have been compromised by a lack of communication. A satellite phone provides a more effective means of communication when in remote areas.

Safety ActionTaken
On 03 March 2006, the TSB issued Safety Information Letter A060004-1 - Ineffective Means of Flight Following Communication, to the Director General Civil Aviation. The Safety Letter highlighted the criticality of flight following communication as it relates to search and rescue (SAR) response in remote areas of the country and indicated the effectiveness of alternate means of communication such as satellite phones.

Aviation Investigation Report, Flight into Adverse Weather - Collision with Terrain - A05Q0157

[Widow]

Yes. And here we are almost two and a half years after the fact, and the TSB has issued NO PUBLIC REPORT or safety recommendations regarding the crash of AQW and subsequent deaths of five men. The only reason anyone knows anything, is because WE (the families of the five lost souls) have made public what we found out through Access to Information and Privacy.

How is it that ANYONE can find that acceptable?


BTW, the TSB investigation number is A05P0039 in case you'd like to try to find it on their website. Good luck.

[Mitch Cronin]

How is it that ANYONE can find that acceptable?

Hi Widow... As you know, I make my living as an aircraft mechanic, not as a pilot, so an answer from that perspective probably isn't what you're after.... so disregard if you choose...?

"How is it that ANYONE can find that acceptable?"

I suspect some find that tolerable (I doubt any with an interest would say "acceptable") because they believe all that could be learned from that particular accident has already been learned by those who are capable of learning...
-Engine failures are not new....
-Failed glassy water landing attempts are not new...
-Attempts to fly in iffy weather that winds up complicating other difficulties ... are not new...
-Downed Beavers for all sorts of reasons.... are not new...

However: I suspect the lack of an immediate response and the resultant loss of life is an unfamiliar issue which could easily be clouded into obscurity if not for your efforts!
If you'll forgive me for a moment: Your husband didn't die because of an aircraft accident! He died because nobody was paying any attention at the time that airplane had it's accident! (or so it appears to me) That's an issue which should be acceptable to no one at all!
That much is a bloody outrage! ... and I doubt it is acceptable to anyone who gives it any thought at all!

[Widow]

[ Your husband didn't die because of an aircraft accident! He died because nobody was paying any attention at the time that airplane had it's accident! (or so it appears to me) That's an issue which should be acceptable to no one at all!
That much is a bloody outrage! ... and I doubt it is acceptable to anyone who gives it any thought at all!

That is absolutely true, and is without question the impetus for my "vigilence". The fact that the type D flight following system has previously been criticized and addressed by the TSB should be of immediate concern. Had previous recommendations been acted upon, my husband would be alive today.

That being said, the issue of float maintenance standards and guidelines is something which has never been explored, and on the basis of this accident, absolutely should be. Knowing that floats are take off and landing gear, and that the majority of accidents happen in the take off or landing phase of flight, it is inexcusable that there are no specific mandatory requirements for overhaul, etc.

On top of that, the whole issue of the lack of communication/cooperation between the federal and provincial government jurisdictions could have prevented this accident from ever taking place. This is perhaps the most crucial problem that needs to be addressed. (You kind of have to know the WHOLE background to this owner/company to understand this part).

[snoopy]

Hi Widow,

If I might interject on one point: "...no specific mandatory requirements for overhaul, etc." In my opinion, the issue is not that there needs to be a mandatory overhaul on this specific component, rather there are Standards ALREADY in place for inspection, repair and condition of that component that appear to have been ignored.

Yet another example of Transport Canada neglecting in their oversight duties.

We already have a fairly logical and reasonable set of Standards in place - WHEN is the regulator going to start both abiding by and enforcing them? WHEN will Transport Canada become accountable to the regulations? WHEN will a legal review department, equally accessible to Transport Canada and to Industry, be put in place for this purpose? WHEN is the Transport Canada Inspectorate going to stand up and do their jobs?

[Widow]

While I agree with your points Snoopy, when the EDO 4580 floats were made, I'm sure no one was thinking about the same set of floats being used for 60 years. There were no manuals for them. For this reason, I believe the written standards are inadequate. This is from the Inspection Report done by TCCA on CGAQW's floats:

The DHC-2 Beaver Maintenance Manual PSM 1-2-2 does address float leakage. Section 2.34 allows water seepage from one compartment to another of one cup in ten minutes. The Manual does not explain how this measurement is to be done.

PSM 1.2.2 Section 2.35 states that “Water tests should be make after every overhaul as well as for the general detection of leaks.” The Manual specifies a test procedure of filling compartments with water to check for leakage between compartments and to the exterior. It does not specify any period for this test

.

Although floats are considered landing gear, and therefore integral to the safe operation of the aircraft, there is no mandatory overhaul and reskinning requirement after so many flight hours, with salt water and other corrosive effects taken into consideration. The maintenance of aircraft floats however, is covered only by Canadian Aviation Regulation 571.02(1) “Maintenance and Elementary Work Performance Rules”, which applies to all aeronautical products. Other reference material for maintaining EDO 4580 floats, (original Beaver manuals), are unclear and outdated.

Either the regulations/standards/guidelines need to be updated to reflect the current realities of their use, or they need to be phased out.

While good maintenance (including regular overhaul/reskinning) should be common sense, there could be other aircraft flying on thin floats. TCCA is seldom noted for its common sense approach. How often do they actually look at the floats on an aircraft? Somehow, no one snagged the dangerous repairs and condition of these floats. The TSB said they did not have the expertise to comment on the floats. What the f#&% If we had not hounded TCCA, the issue would have been completely ignored. After all, the paperwork was all in order.

[Longtimer]

While I agree with your points Snoopy, when the EDO 4580 floats were made, I'm sure no one was thinking about the same set of floats being used for 60 years. There were no manuals for them. For this reason, I believe the written standards are inadequate. This is from the Inspection Report done by TCCA on CGAQW's floats:

The DHC-2 Beaver Maintenance Manual PSM 1-2-2 does address float leakage. Section 2.34 allows water seepage from one compartment to another of one cup in ten minutes. The Manual does not explain how this measurement is to be done.

PSM 1.2.2 Section 2.35 states that “Water tests should be make after every overhaul as well as for the general detection of leaks.” The Manual specifies a test procedure of filling compartments with water to check for leakage between compartments and to the exterior. It does not specify any period for this test

.

Although floats are considered landing gear, and therefore integral to the safe operation of the aircraft, there is no mandatory overhaul and reskinning requirement after so many flight hours, with salt water and other corrosive effects taken into consideration. The maintenance of aircraft floats however, is covered only by Canadian Aviation Regulation 571.02(1) “Maintenance and Elementary Work Performance Rules”, which applies to all aeronautical products. Other reference material for maintaining EDO 4580 floats, (original Beaver manuals), are unclear and outdated.

Either the regulations/standards/guidelines need to be updated to reflect the current realities of their use, or they need to be phased out.

While good maintenance (including regular overhaul/reskinning) should be common sense, there could be other aircraft flying on thin floats. TCCA is seldom noted for its common sense approach. How often do they actually look at the floats on an aircraft? Somehow, no one snagged the dangerous repairs and condition of these floats. The TSB said they did not have the expertise to comment on the floats. What the f#&% If we had not hounded TCCA, the issue would have been completely ignored. After all, the paperwork was all in order.

I have lost the thread. How did float maintenance come into the equation. I thought the problem was suspected engine failure due to faulty maintenance???

[Widow]

The engine failure was survivable.

a) Unapproved (old) float deck rail coaming repairs influenced the extent of damage the right-hand float sustained in the accident. This significantly influenced the time Beaver C-GAQW stayed on the surface before sinking.

b) The quantity of missing hatch cover screws and resulting holes, total lack of sealer under the three center compartment hatch covers of the left hand float, as well as a lack of good sealer under the remainder of the hatch covers on the both floats, contributed to a large extent in how fast Beaver C-GAQW sank after hitting the water surface.

[Longtimer]

I see. Thanks.

Question for those operating float aircraft. Does your normal walk around include inspection of the floats? If so what is the go / no go point re the floats? Are the visual items identified in the report sufficient to ground the aircraft or since the screws would be on the top of the floats, is their absence something that is normally ignored? Reason I ask is that some pilots evidently have used the floats for extra stowage (from time to time) thus leading to missing screws and of course disruption of any sealant material. Or is this no longer happening?

[carholme]

Float hatches have a seal which makes contact between the float surface and the hatch surface, thus when closed and locked, provide a watertight seal. Of course they have to be maintained like anything else if they are function correctly.

Indivudual compartment covers are screwed to the float and have a similar seal. Missing screws mean that the anchor nuts for the screws are exposed and any water/rain over the top of the float will enter the compartment which obviously means more pumping out of the compartment on the walkaround. If we as engineers cannot even be bothered to replace mssing screws on a watertight cover, what does it say about the rest of the float?

This whole issue of Widows' loss is a disgrace to Canadian Aviation. From many of the other accidents discussed on this forum, the shitty operators are alive and well in Canada and nothing is being done about it

A TSB inspector from Chilliwack, on Pprune, who has since altered his profile to eliminate his profession has called Widow a trouble maker and made other erroneous statements. If he is an example of those investigating accidents in Canada, it is no wonder there is no official report as yet. They will now bide their time until they find a politically acceptable reason for the accident before submitting a tailored report.

As long as that engine lies on the bottom, the pilot is not being given a fair chance to clear his name. And who are the TSB to determine that everything has been found out about the 985 and its' problems. It must be hard to breathe with your head stuck so deep in the sand.

So much for SMS and Human Factors thinking being embodied by TSB or TC. They feel it appropriate to mandate it for the rest of us but not for themselves.

Regards

carholme

[Longtimer]

Float hatches have a seal which makes contact between the float surface and the hatch surface, thus when closed and locked, provide a watertight seal. Of course they have to be maintained like anything else if they are function correctly.

Indivudual compartment covers are screwed to the float and have a similar seal. Missing screws mean that the anchor nuts for the screws are exposed and any water/rain over the top of the float will enter the compartment which obviously means more pumping out of the compartment on the walkaround. If we as engineers cannot even be bothered to replace mssing screws on a watertight cover, what does it say about the rest of the float?

This whole issue of Widows' loss is a disgrace to Canadian Aviation. From many of the other accidents discussed on this forum, the shitty operators are alive and well in Canada and nothing is being done about it

A TSB inspector from Chilliwack, on Pprune, who has since altered his profile to eliminate his profession has called Widow a trouble maker and made other erroneous statements. If he is an example of those investigating accidents in Canada, it is no wonder there is no official report as yet. They will now bide their time until they find a politically acceptable reason for the accident before submitting a tailored report.

As long as that engine lies on the bottom, the pilot is not being given a fair chance to clear his name. And who are the TSB to determine that everything has been found out about the 985 and its' problems. It must be hard to breathe with your head stuck so deep in the sand.

So much for SMS and Human Factors thinking being embodied by TSB or TC. They feel it appropriate to mandate it for the rest of us but not for themselves.

Regards

carholme

Thanks. So it could be concluded that the regulations may be sufficient but the compliance / enforcement are lacking. So unless those working in the industry start to insist that at the very least, current regulations are being followed, then there would appear to be no hope in hell for the situation improving. Sad state of affairs.

Re the engine, guess only time and money will tell there.

[Cat Driver]

So unless those working in the industry start to insist that at the very least, current regulations are being followed,

Who do you insist ensures this compliance?

The crooked operators who will pencil whip compliance under SMS?

[Widow]

This is something that really disturbs me. The (illegal) repairs to the deck coamings were not new.

The unknowing public goes around believing that the government actually ensures our safety by looking at aircraft every so often to make sure they really are "airworthy" (whatever that REALLY means). These illegal (and obvious if you look) repairs went undocumented (surprise surprise) and "unnoticed" by everyone (AME/AMO, CP/OM, owner, TC) in a position to know/see.

How come "you and I" know that not all operators can be trusted to ensure compliance, but the government behaves as though it does not know?

Float owners out there, when was the last time TC looked at your floats?

[CD]

A TSB inspector from Chilliwack, on Pprune, who has since altered his profile to eliminate his profession has called Widow a trouble maker and made other erroneous statements. If he is an example of those investigating accidents in Canada, it is no wonder there is no official report as yet.

Just as a point of information, PPRuNe is an anonymous forum, just like this one. There is no independent method of verifying who any particular member is or claims to be. It is entirely possible that the "person" who posted that rediculous information is not who they claimed to be (although they are a rectal orifice, in my ever so humble opinion).

[Longtimer]

So unless those working in the industry start to insist that at the very least, current regulations are being followed,

Who do you insist ensures this compliance?

The crooked operators who will pencil whip compliance under SMS?

The folks flying and maintaining the aircraft would be a good starting point.

[CID]

The unknowing public goes around believing that the government actually ensures our safety by looking at aircraft every so often to make sure they really are "airworthy"

It's not the government's job to periodically inspect every airplane.

It's the responsibility of the operator to run a safe compliant operation in accordance with the regulations. If he doesn't he could (and should) be liable for damage and subject to litigation.

[Widow]

It is the governments job to keep the public safe.

MJM Air was not running a safe compliant operation in accordance with the regulations. Yet "they" are immune from liable for damage and are not subject to litigation.

Why should I find it acceptable that my husbands right to a safe workplace was denied, and that I am denied due process in the discovery of WHY my husband was left to die?

Every time the various officials tell me that everything was done according to regulations/rules/standards or to the letter of the law, they put another nail in his coffin, and dig the hole for the next grave.

Something is wrong with the system. The right to a safe workplace is being denied every working stiff without a union or other lobbying group. Amoral employers are granted carte blanche to make money at the expense of the worker, confident in the knowledge that should an employee be injured or killed on the job due to employer negligence, they may get a slap on the wrist ... while being permitted to carry on as before. Should the fines be too stiff to pay and stay in business, they simply declare bankruptcy and start up under another name. This problem is not exclusive to the aviation industry.

[Longtimer]

It is the governments job to keep the public safe.

.

It is not only the governments job, it is the job of the owners, the pilots, the mechanics and all staff. The government could only make the operation 100% safe, if they had a government inspector standing behind every airline employee (owner on down) to make sure they operated in a safe manner. As long as anyone in the chain of responsibility is willing to cut corners, operate unsafe equipment etc. the industry will never be truly safe.