Five Deaths Demand Justice Petition

[Widow]

S'alright, now that I've been told ...

It is incumbent upon me to inform you that the TSB now considers this matter closed.

... it's just time to move on up the food chain.

[Cat Driver]

... it's just time to move on up the food chain.

Don't forget to spit that one out widow, it was full of poison.

[mag check]

I am sure you can appreciate that these decisions cannot and will not be based on the prospect for current or future legal claims

Did I miss something here? I take this to mean that they (the TSB) only look for the causes, and are not concerned with any "legal" results. To me this says they are only looking for the truth, regardless of who is at fault. Isn't this a good thing?
Why would this upset you Widow?

[Widow]

mag check, we wanted them to write a public report indicating cause (if it could be found) and contributing factors and making recommendations (if necessary) and as they should be obliged to do in order to assist other interested government agencies (Coroner, Worksafe BC, TC, etc), especially when there are working fatalities. If they had done that when the fuselage had come up (there was plenty of "evidence" for them to work with) - even if all they had done was to tell us - or the Coroner - that they were not going to do a public accident report, we would have had a Coroner report years ago and I would not be here today.

Ms. Tadros' statement implies that we desired a public report based on the prospect for current or future legal claims and not because what we wanted was the truth.

Simply put, if instead of fighting us for three (plus) years they had simply produced a public report, it would have cost them and us LESS money than it has ultimately cost both parties ... AND we would have been satisfied. Besides which, corrosion would not have obfuscated the evidence brought up with the fuselage and we might actually know the cause, as well as the contributing factors.

[Cat Driver]

Ms. Tadros' letter is typical of people who rise to positions of power within the system.

Rather than address issues in an open minded and fair manner they are experts at obfuscation and the art of stonewalling anyone who may be seen as a threat to their system until their tormentor just gives up.

I hope you are successful in showing the industry how arrogant and unproductive some of these people really are widow.

The difference between you and her widow is regardless of what she writes in her letters her paycheque still remains the same, she could sit down and write you the story of Momma Bear and Daddy Bear and Baby Bear and her pay would remain the same.

[Prairie Chicken]

Cat is looking for an explanation of public servant ethics and values. Here it is:

Public Service Values
Public servants shall be guided in their work and their professional conduct by a balanced framework of public service values: democratic, professional, ethical and people values.

These families of values are not distinct but overlap. They are perspectives from which to observe the universe of Public Service values.

Democratic Values: Helping Ministers, under law, to serve the public interest.

Public servants shall give honest and impartial advice and make all information relevant to a decision available to Ministers.
Public servants shall loyally implement ministerial decisions, lawfully taken.
Public servants shall support both individual and collective ministerial accountability and provide Parliament and Canadians with information on the results of their work.
Professional Values: Serving with competence, excellence, efficiency, objectivity and impartiality.

Public servants must work within the laws of Canada and maintain the tradition of the political neutrality of the Public Service.
Public servants shall endeavour to ensure the proper, effective and efficient use of public money.
In the Public Service, how ends are achieved should be as important as the achievements themselves.
Public servants should constantly renew their commitment to serve Canadians by continually improving the quality of service, by adapting to changing needs through innovation, and by improving the efficiency and effectiveness of government programs and services offered in both official languages.
Public servants should also strive to ensure that the value of transparency in government is upheld while respecting their duties of confidentiality under the law.
Ethical Values: Acting at all times in such a way as to uphold the public trust.

Public servants shall perform their duties and arrange their private affairs so that public confidence and trust in the integrity, objectivity and impartiality of government are conserved and enhanced.
Public servants shall act at all times in a manner that will bear the closest public scrutiny; an obligation that is not fully discharged by simply acting within the law.
Public servants, in fulfilling their official duties and responsibilities, shall make decisions in the public interest.
If a conflict should arise between the private interests and the official duties of a public servant, the conflict shall be resolved in favour of the public interest.
People Values: Demonstrating respect, fairness and courtesy in their dealings with both citizens and fellow public servants.

Respect for human dignity and the value of every person should always inspire the exercise of authority and responsibility.
People values should reinforce the wider range of Public Service values. Those who are treated with fairness and civility will be motivated to display these values in their own conduct.
Public Service organizations should be led through participation, openness and communication and with respect for diversity and for the official languages of Canada.
Appointment decisions in the Public Service shall be based on merit.
Public Service values should play a key role in recruitment, evaluation and promotion.

Now do try not to choke on your coffee while reading this Cat.

[mag check]

Widow,
I understand your view, I just didn't get that from the letter.

Prarie Chicken,
That is quite possibly the funniest thing that I have read in a long time.
I love how they throw the "should", "shall", in there.
Wouldn't the world be a great place if that was actually how they operated.

[Cat Driver]

Prairie Chicken:

Naw I wouldn't choke reading that because I have seen first hand how those at the top actually work.

If you want another interesting read have a go at the pablum that TCCA's " Quality Assurance " department puts on their site.

The real way they work is 180 degrees from what they claim to be.

When Preuss found out that I was not going to go away he used their quality assurance department as a buffer and a means to stonewall me for about a year.

At the time the guy in charge was Robert Sincennes, usually I am able to find words to describe people but that guy has me at a loss for a proper description.

To say he was dishonest, evasive, terminally stupid, a knee pad wearing carpet kneeling suckling for Preuss would maybe be close but even that does not really describe the crap I was subjected to between those two people.

At one point I was flying in Portugal and received a letter from that prick that was so insulting I almost got on an airplane and flew to Ottawa to confront him in his office.....fortunately I was able to suppress my emotions and did not.

The system is so morally corrupted by these people only a revolution by the citizens will change anything in my opinion.

So there you go.....my opinion naming names from my own experience with them.

[Prairie Chicken]

I must say, I am utterly astounded at the insensitivity and prevarication of this statement:


Quote:
I am sure you can appreciate that these decisions cannot and will not be based on the prospect for current or future legal claims.

Widow, those of us who have read your continuing story know that liability claims are not why you`re still fighting this battle. Unfortunately, I suspect the view is that all survivors are not as pure of intent as you are. Perhaps justified in other cases, perhaps not. Either way, I`m sorry that is their view.

Now, is this something you can use to your advantage?

[Widow]

Thank you Prairie Chicken.

Can I use this to my advantage? Only time will tell ... I certainly plan to try

[jeta1]

I actually think the letter from W. Tadros is unusually candid from an outfit like the TSB, and they while you may not like the outcome, it spoke the truth. They obviously know you're all over the web with the request to go public too. The TSB will not come back on that particular accident, but at least you made your point.

[Cat Driver]

Now if only she can get enough media exposure to force a Federal inquiry into the way TCCA is managed in Tower C maybe a few of the rats in that nest will be exterminated so to speak.

[Widow]

jeta1, I'm curious what you find candid about Tadros' letter? She has not said anything that is not already publicly available information (through my website, if nowhere else). In other words, she has told me nothing I did not already know. She certainly hasn't made me feel as though she was sincere in her understanding of my concerns. And quite frankly, the DOI relied on an investigator who had a something of a conflicting interest in the case, besides knowing nothing about floatplanes, or even R-985's. Frankly, it was remarked to me by someone who would know, that the particular investigator that was relied upon had already retired, despite still being on the job. Once a decision had been made, it would have looked pretty bad to turn it around.

I am fully aware the TSB is not going to publicly report on this accident, have been aware for quite some time. But responding as though none of my concerns are valid makes me fear that this will not be the last serious accident to be failed by the Board.

I deserve an apology, if for nothing more than the fact that their failure to inform the Coroner has resulted in extended grief and lack of closure.

[xsbank]

"Unfortunately, I suspect the view is that all survivors are not as pure of intent as you are."

I am mystified that there is such a strong anti-litigation bias on this site. I think that those who have been wronged by some entity that promises to (in this case) fly your family safely to their destination yet injures or kills them instead should be exposed to civil penalties if it can be proven that they were negligent in some way.

What is wrong with that? Its as if you are somehow threatened by the fear that someone might be getting something for nothing? Would you be willing to swap a loved one for a million or two, less lawyer's fees and costs? How about your wife? Son? Husband? How about 2 million for your father?

Should you just slink away and forget it? Let the company continue to play fast and loose with its passengers?

Why do you think this is unreasonable and why are bereaved families reviled as being rapacious?

Do you really think the money is a true compensation?

I, for one, wouldn't bat an eye if Widow was able to sue the *ss off of everybody involved in this fiasco, including all the government WOS' she can hit with a firehose. I know MJM doesn't exist anymore and she has personal reasons for how she is conducting herself but walk a mile in her shoes before making such fatuous remarks about litigation.

[jeta1]

jeta1, I'm curious what you find candid about Tadros' letter? She has told me nothing I did not already know.

You know a lot, and certainly more than most of us about the mandate of the TSB, so what I think is irrelevant. What I find interesting is that she addresses you again by name in the middle of the letter - for emphasis - like taking you by the shoulders and sHOUTING IN BOLD LETTER!! It speaks a lot of your efforts to have the Chair of the TSB write to you like this. However I also think it was meant to bring them closure, not to you. What's next for you to do now that the TSB said thsk but now go away?

[swordfish]

A classic Government example of "we're covering our asses with policy" at the same time as the aviation industry's collective intelligence is being insulted. There are so many holes in that snide, condescending, denigrating document, clearly written by an experienced escape-artist, that dissection of the elements would take all night ("Let me explain to you, little girl, just how we work...")

She ought to be working for the media. This statement is correct, of course:

none of these theories could ever be proven with certainty and would forever remain speculation

exactly the way 99.9% of court cases based on circumstantial evidence, are resolved.

Maybe she's never heard of the expression: "overwhelming body of corroborative and converging evidence"...?

Maybe she thinks we all need CERTAINTY to draw reasonable conclusions. Tell that to the Supreme Court, madam.

[snoopy]

Well, I am surprised nobody found this interesting:

"With over 380 aviation accidents reported to the TSB annually..."

That equates to more than one accident each and every day of the year! Aren't we supposed to be "the safest country in the world" according to that doorknob at the top of the food chain?

If we're having so many accidents that we can't afford to investigate them all.... maybe we're having too many accidents? Perhaps we have a problem?

[Widow]

jeta1, I'm curious what you find candid about Tadros' letter? She has told me nothing I did not already know.

You know a lot, and certainly more than most of us about the mandate of the TSB, so what I think is irrelevant. What I find interesting is that she addresses you again by name in the middle of the letter - for emphasis - like taking you by the shoulders and sHOUTING IN BOLD LETTER!!

Interesting that you should point that out. Let's just look at that paragraph a little more deeply though, shall we ...

Mrs. Stevens, with respect to the deHavilland Beaver C-GAQW which crashed into the waters near Quadra Island, a decision was made to fund the recovery of the wreckage to a maximum of $10,000.00 and this commitment was honoured.

She has this wrong. It was not the wreckage, but the engine. They did not help with the wreckage in July of '05. I am also 100% certain that in May of 2006 when they offered us $10,000 to "fund the recovery" of the engine, nobody but us believed we would ever be able to do so. They only offered because we kept insisting they investigate for cause and contributing factors, and they gave us to believe that without the engine, an investigation for cause (and therefore, contributing factors either) could not be completed.

In addition, dedicated and experienced TSB investigators spent countless hours analyzing the available evidence including a thorough tear down and examination of the engine.

Nobody from the TSB did anything but visuals and photo-taking prior to the recovery of the engine in September 2007. Further, the original investigator in charge was neither dedicated nor experienced on type. A knowledgeable investigator (from another region) was not pulled in until December of 2006 - at our insistence. By then, the wreckage had been moved to very cramped quarters and further damaged en route - besides being subject to almost a year and a half of corrosion. He looked at things, took some pictures ... At that time, everyone still thought the "cause" lay with the engine, and only we, the families, were interested in the contributing factors. She's right though, the engine teardown and examination was very thorough. Although not 100% accurate. There was also information missing.

The TSB then made public the laboratory report on the engine which concluded the engine was developing power at impact.

The TSB did not make the lab report public, they provided it to us as the owners. I've already commented on her final statement about the expending of public resources.

What's next for you to do now that the TSB said thsk but now go away?

Queen's Privy Council, with the hope that I can prevent this from happening to anyone else.

[justplanecrazy]

I've read briefly the exchange between TSB and the incident, and I can't seem to find anything that makes me believe that there was gross incompetence displayed by TSB with the situation. As someone pointed out earlier, TSB had 380 accidents reported to them. We all pay for the operation of the TSB, and there is a limited amount of resources that can be allocated to each of those 380 accidents. I think the following quote sums up their overall position.

In other words, there is no reasonable prospect that additional investigative time and resources will yield greater significant causal or safety information which will significantly advance transportation safety.

With the aircraft at the bottom of the ocean, the costs to recover any of the details of this accident, were going to be astronomic and unfeasible for a limited resource operation. In a perfect world, there'd be money and manpower to cover every incident thoroughly. Unfortunately, as tough as it is, TSB is responsible for balancing hundreds of accidents and using what money they have to focus on those that will yield the greatest result from the smallest investment. Just like a paramedic being thrown into a catastrophe, triage needs to take place. In this case, they knew the investment for recovery was large and the possibility of a significant finding small. In the end, Widow managed to raise the necessary funds on her own but aside from mitigating circumstances, was anything discovered in this $240,000 expenditure that would prevent future accidents, not deaths after accidents but accidents?

TSB's biggest value is in preventing large catastrophic accidents. If this was an airliner that inexplicably crashed, then yes I would say dish out the 240g in a heartbeat, because thousands of lives may be at stake. Unfortunately, investigating a small aircraft can only yield widespread lifesaving results, if there is a common problem among many of the same type of aircraft. If 5 beavers had crashed in recent history with possible engine failures and no explanation as to why, then yes 240g just for recovery, may be well worth the effort in trying to discover what happened. This wasn't the case though and it was believed to be an isolated event where the possibility of making a discovery that would prevent a future event from happening again, was highly unlikely. After the recovery, it still appears this is the case.

Do I wish TSB could find the cause of every accident of the 308 reported to them and prevent them from ever happening again... yes! Do I believe this is likely? Unfortunately I think if their mandate was brought to this level, the funding and manpower required would cripple any ability to be able to allocate the available resources for situations that can provide widespread lifesaving results. It sucks, but in real life numbers need to be attached or we better start opening up our pocket books and donating money to the TSB in a big way.

If I'm way off base, please correct me. The above is just the thoughts of someone totally removed from the situation and I imagine if I'm thinking it, I'm not alone. I don't mean this as a confrontation with you Widow, only questioning what you're fighting, so that you may better explain yourself. Maybe I've missed the issue in 9 pages of discussion and in that case you can restate it. It would help myself and anyone else semi-following this to fully support you. Right now, I have trouble condemning those that are saving thousands of lives through many other investigations and AD's, without a blatant show of incompetence.

I've watched TSB wade through charred wreckage, complete with bodies, twice. It is not a job that I could do, nor do I wish it on my worst enemy. I have to tip my hat to anyone with the willpower to be able to deal with these situations on a daily basis. As well I have to say that I do admire your drive and willpower Widow and am greatly appreciative of any improvements in safety, that your fight has brought to our industry.

[armchair]

.

[Cat Driver]

justplanecrazy, I might be mistaken but from what I know about the situation I believe there was far more to this than how the TSB handled their end of it.

Wasn't there some issues found concerning the floats and lack of proper maintenance of same?

As I recall widow and a few others think that due to shoddy maintenance one of the floats failed on contact with the water.......

[swordfish]

justplanecrazy, actually you DO need to re-read the whole 9 pages to properly understand what widow's concerns are. To date, there has been no accountability or responsibility accepted for this accident in the presence of overwhelming evidence of:

• 1. apathy, indolence, and denial on the part of the TSB
  2. contradiction on the condition of the engine, and even whether it was developing power or not at the time of landing
  3. contradiction on the condition of the aircraft, specifically the floats, having a direct bearing on maintenance standards of the company.

Widow has no closure to the event because none of the jurisdictions involved appear to give a @#$!. Someone, either corporate or individual, is responsible for this accident. She also wants to - in the global scope of these events - prevent a reocccurrence of the accident.

If that's unclear to you after reading the 9-page history, then you need to avoid jumping in at the end with mindless queries of what her purpose is.

[swordfish]

p.s. I hope you have contributed to her fund.

[mag check]

I have read all 9 pages, and I don't remember any obvious problems with the floats.
I seem to remember that there was a suspected unapproved repair on a combing, but I thought that there was a comment that it was an approved repair, the only other float "defect" I remember was that there was some leaks in the deck, but seeing that the decks are drilled from the factory with vent holes, I don't see how that would be a problem.

I thought that the main "problem" found with the aircraft was the unknown brass fitting on the carb.

[Widow]

Page 1, my post "Float observations/Issues".
Backed up by the Waldron Report linked on Page 8, or in full on this thread http://www.avcanada.ca//forums2/viewtop ... 54&t=47817. Please note the hatch sealant "defects" on the left float. The Waldron Report clearly outlines the excessively poor condition of the entire aircraft prior to the accident. It should not have been in the air.

The maintenance guidelines for these floats are wholly inadequate, especially noting how extensively they are still used despite their age. 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 is covered only by Canadian Aviation Regulation 571.02(1) "Maintenance and Elementary Work Performance Rules", and AC43-13, which apply to all aeronautical products. Other reference material for maintaining EDO 4580 floats, (original Beaver manuals), are unclear and outdated.

So yes, I believe that something important was learned from the great financial expenditure (which, by the way, would have been covered by the Coroner's Service if there had been bodies on board) of the families in recovering the wreck. A reworking of float maintenance guidelines WOULD result in the prevention of future accidents.

The TSB does great work. Most of the time. But, because of financial constraints and the limited ability of some 220 odd TSB investigators for all Transportion sectors to examine the causes of all accidents, occupational injuries and deaths are not always investigated for cause and contributing factors. THIS is where the problem lies. The "lack of information" touted by the TSB resulted in no investigation into infringements of the Canada Labour Code and the responsibilities of the company to maintain a safe working environment, either by TC or Worksafe. I believe that the Worker's Compensation Boards and/or Occupational Health and Safety Boards for all the provinces and territories REQUIRE an investigation for cause/contributing factors in order to do their jobs effectively. They are not aviation experts, which makes it incumbant on the TSB to produce a report. Further, WCBs/OHSBs should be allowed to be actively involved in accident investigations where injuries or deaths of worker's have occurred. TCCA's OH&S department is not effective, and is only responsible for aviation employees. The Federal and Provincial Ministries of Labour continue to do battle over whose job it should have been/is.

Again, as the TSB neglected to tell the Coroner that they were not doing a full report, the Coroner's investigation and report has been unacceptably delayed. The TSB had no interest in the floats, but have now further delayed (and likely stymied) the Coroner by rebutting the Waldron Report.

There were many issues at play in this accident which were not "new" (e.g. Type "D" Flight Following, contacting SAR, lifejackets/whistles/dye markers, GPS, egress training, ELT's, Transport oversight of small ops, etc., etc.) ... IMHO, the very fact that these are KNOWN issues which have had previous recommendations that have not been acted upon by TCCA makes them issues worthy of reiteration. Yet not one Safety Advisory or Safety Information Letter was prepared by the TSB and sent to TC with respect to this accident. If they had prepared a Safety Letter, I (we) would have been much more accepting of the Class 5 designation.