So here is the latest refusal from TSB to do an investigation for cause. I have commented in
bold.
Dear Mrs. Stevens:
Thank you for your email of 25 May 2007, in which you requested that the Transportation Safety Board (TSB) investigate the cause of the MJM Airlines aircraft accident involving your husband. I would first like to say that I understand your loss and the losses of the other involved families as a result of this tragic accident, and your desire to know the reasons why this occurrence happened and what can be done to prevent future recurrences. I also appreciated the opportunity to meet you last week while you were in Ottawa, and to hear your concerns first hand.
I have now completed my examination of the background of this occurrence and can provide the following comments. I understand that in the time since this accident, our investigators have kept you and other affected families informed of the circumstances of the accident, our TSB mandate, and our Occurrence Classification Policy. In accordance with this policy, the TSB assesses each reported occurrence and determines those it will investigate.
While I understand that you are familiar with many of the following details, I am providing them again to ensure that I have addressed your concerns to the extent possible. On 28 February 2005, when the aircraft was declared missing, our investigators began file and document reviews, as well as the collation and evaluation of reports from other involved agencies. When your husband was found on 3 March 2005, an investigation into the cause of his death was initiated by the BC Coroners Service (BCCS) as required by provincial law. In accordance with the Memorandum of Understanding between the Attorney General for B.C. (the BC Coroners Service is part of the Ministry of Public Safety and Solicitor General) and the TSB, our role became one to assist the BCCS in its investigation through the assigned coroner.
After the Department of National Defence Search and Rescue personnel could not find the aircraft and ended their search, our Regional Manager solicited and received Department of Fisheries and Oceans' support to help the families' ongoing search for the aircraft. That search was also unsuccessful in finding the sunken wreckage. Although the TSB had dispatched an Air Operations investigator to stand by during that search, there was no wreckage, accident location, accident time, radar data, or voice communication obtained. At that time, our efforts were necessarily limited to file and document review and to the collation and evaluation of reports from other involved agencies.
Once the wreckage was located and retrieved, we dispatched two TSB investigators on 29 July 2005 to examine the wreckage. While the engine was not recovered, that and subsequent examinations of the recovered wreckage determined that the engine was producing considerable power at the time of impact, based on the propeller scars on the floats. We also confirmed there was continuity of the flight controls, and all the fracture surfaces of broken components were characteristic of overload resulting from the forces of impact. There was a considerable amount of unburned engine oil inside the wreckage and some on the outside surfaces, and the distribution patterns were consistent with oil leaking from the engine oil reservoir after the accident, mostly during the recovery phases. There was no indication of in-flight fire. All this factual information and relevant risk factors were provided to the coroner in two TSB letters dated 22 June 2005 and 21 September 2005, and I understand you and the other families were briefed on their content.
We have never contended there was a fire, but rather leaking and burning oil - smoke which obscured the pilot's vision. While there certainly was a lot of oil which leaked on recovery, the evidence on the fuselage points to leaking oil and smoke ... relevant risk factors (such as the ineffectiveness of Type D flight following) were not reported on - the letter to the coroner is available on our website.
Although this accident is designated a Class 5 occurrence, it can be noted that we have not limited our attention because of that classification. Seven TSB investigators have been tasked at various stages to look at information or to review it. We have opened four TSB Engineering Branch laboratory projects to examine selected technical issues. All of the information we have uncovered to date has been passed on to the appropriate agents, and made available to you. As we discussed last week, I can also confirm that the conditional offer to pay the families' representative $10,000.00 toward the engine recovery, if it is recovered and handed over to the TSB in accordance with our original commitment, is still in place.
$10,000 reward for engine!
During this process, TSB personnel have considered each issue that has been brought to our attention since the accident, including the following: the possibility of an in-flight engine fire; the possibility of an engine stoppage; the legality and effectiveness of Type D Operational Control; the airworthiness of the floats fitted to the aircraft; the adequacy of the maintenance that was performed on the aircraft; the perceived flaws in the manufacture of engine cylinder hold-down studs; and the adequacy and frequency of Transport Canada Civil Aviation audits. These technical examinations did not reveal any safety issues that could compromise safe transportation operations.
Again, we never said fire - we said smoke - which evidence was obfuscated by the length of time between recovery and examination by TSB engineers, and the fact that they did not have/use the appropriate equipment to test for smoke as opposed to fire. We did not claim engine stoppage - but partial failure. How can they claim the Type D system did not affect the outcome/survivability of this accident? How can they claim the airworthiness of the floats had no effect ... they told us they did not have the knowledge to inspect them - they were inspected by TCCA Safety which resulted in an enforcement action ... They have refused to examine the financial records in comparison to the maintenance logs to confirm their validity - and the TCCA Safety Inspection clearly shows the logs were not kept accurately and that several irregular/illegal repairs were made! The engineering report on the sample studs (obtained well over a year post-accident) showed they were not made exactly to spec - according to TSB the differences were acceptable, according to our experts - probably not acceptable - especially if not bing properly maintained and at the end of life. As for audits/inspections ... since I have been informed "The Frequency of Inspection Policy Document directs Transport Canada to audit Air Taxi operators every 2.32 years and complete a mandatory inspection every 1.75 years. CAD 20 allows adjustments to these inspection and audit intervals based on the available resources and the risk indicators as listed in appendix “A” in CAD 20." ... I wonder how an inspection in 2001 followed by an audit in 2004 can possibly be acceptable?
You also wished to know if any additional information had been or will be provided to the Coroner. Since our second letter to the coroner on 21 September 2005, we continually have provided the coroner with all new information that we acquired, including the results of our technical examinations of parts.
I guess I'm going back to Access to Information, since we still haven't received the maintenance logs ourselves, nor any further copies of correspondance to the coroner.
We also discussed your concerns that the lack of a TSB investigation has hampered investigations by other Canadian government and provincial authorities. Please rest assured that the Canadian Transportation Accident Investigation and Safety Board Act specifically permits other organizations to conduct investigations in support of their respective legislation and mandates. Following our meeting, I asked our staff to contact Transport Canada and the Coroner to ensure there is no misunderstanding in this regard. They have confirmed that decisions on investigations under their responsibility are independent of our decisions on whether or not to investigate a specific occurrence. You may wish to contact Transport Canada, Human Resources and Social Development Canada, the Coroner, the RCMP or Worksafe BC to request information on the status of their investigations.
I have contacted them all, and they are all doing nothing, or waiting for more info from the TSB.
Regarding your request for the TSB to conduct a full investigation into this accident, I must conclude that a Class 5 designation is appropriate, and consistent with the Board's Occurrence Classification Policy. Specifically, any decision to raise the level of the occurrence classification would have to be based on the potential for an investigation to acquire new knowledge of the underlying safety deficiencies compromising safe transportation operations, as well as the potential of an investigation to advance transportation safety. To date, the information available to us is not sufficient to proceed to a full investigation. I can assure you that should any new information become available, we would re-evaluate whether or not to upgrade to a full investigation.
Yours sincerely,
Terry Burtch, P. Eng.
Director General, Investigation Operations/
Directeur général, Coordination des enquêtes
tel: (819)994-4135
So it seems to me that they are still basically saying, "unless you prove otherwise ... we stand by our theory that the pilot chose to fly into the water and kill everyone and there is nothing to learn from this accident which would prevent future incidents/accidents. The lack of flight following, communications, crash indicators, or other emergency devices/procedures have no bearing". Knowing my husband was still calling for help three hours later, then drowned slowly - means that I will never accept this position. With or without the engine I will be pursuing this issue.
But we still want the engine. We still believe that it is important to know what made the pilot turn around that day - we know something happened.
So, the final push is on. We need your help.
We believe we know how to do it. We know the approximate location, and can easily find the engine with the right equipment. But we need more money.
If you have a few spare dollars, and you agree this is a worthy cause ... please help fund the recovery:
TD Canada Trust
1400 Island Highway
Campbell River, BC
Transit # 9038
Acct #6259768
"Allison Decock In Trust"
If you know anyone with experience in deep water salvage, we have questions and ideas we would like to bounce around. If you know anyone who might be willing to help with donated/volunteered equipment or a boat (come hang around in an incredibly beautiful place) please let us know ...
Here is what we believe we need - an ROV able to go to depths up to 1000 feet, with a manipulator, real-time camera and sonar. We need more knowledge about dredging - the best way to blow silt at that depth ... We know this should be a relatively easy operation for someone experienced in deep water salvage - ancient wreck guys and treasure hunters and such ...
Who do you know? What can you do? Can or will you help?
