The BC Coroners Service has released 19 recommendations aimed at preventing future fatal accidents involving small commercial seaplanes along the British Columbia coast.

The recommendations are the conclusion of the work of a Coroners Service Death Review Panel, which brought together experts from all segments of the coastal aviation industry and safety professionals to examine systemic issues involved in float-plane crashes and how they might best be addressed.

The panel examined in detail four crashes, which occurred along the coast from 2005 to 2009. A total of 23 persons died in the four crashes.

"These recommendations should be considered very seriously by the agencies to which they're directed," said chief coroner Lisa Lapointe. "They are the result of open and frank discussion and review by a diverse blue-ribbon panel of experts in the field provincewide, and they are based on an aggregate review of several crashes, not a single incident. I extend my thanks to the panel members for their efforts and the diligence with which they approached this review."

The majority of the recommendations are directed toward improved regulation of the industry with others addressing such issues as plane design, weather-forecasting and record-keeping.

A summary of the recommendations is attached. The full Death Review Panel Report and a list of panel members are available on the BC Coroners website at: http://www.pssg.gov.bc.ca/coroners/publications/index.htm#deathreviewpanel

The death review panel process was instigated by the Coroners Service through a legislative amendment in 2007. It allows the service to examine issues and trends covering a specific category of death through a process of aggregate review, rather than simply a review of each individual death.

A backgrounder and factsheet follow.

For more information, please contact:

Barb McLintock
Coroner, Strategic Programs
BC Coroners Service
250 356-9253 or 250 213-5020

BACKGROUNDER

May 1, 2012 Ministry of Justice

BC Coroners Service

Summary of Recommendations

1. It is recommended that Transport Canada create a regulatory requirement that all new and existing commercial seaplanes be equipped with emergency exits that would allow rapid egress following a collision with water.

2. It is recommended that Transport Canada create a regulatory requirement that all passengers and crew of commercial seaplanes wear personal flotation devices (PFDs) during all stages of flight.

3. It is recommended that Transport Canada create a regulatory requirement that illumination strips identifying emergency exits be installed onboard all commercial seaplanes.

4. It is recommended that Transport Canada introduce a requirement that all certified aircraft be equipped with a battery-disconnect "gravity switch" or a similar system that severs connections with electrical power sources in a collision, thus removing a potential source of post-impact fires.

5. It is recommended that Transport Canada undertake a formal review of the efficacy of available stall warning systems, including angle of attack indicators, for applications in all certified aircraft, with the objective of identifying systems that would enhance pilot's awareness of the angle of attack and allow for early recognition of situations that my result in an aerodynamic stall if uncorrected.

6. It is recommended that Transport Canada create a regulatory requirement that all new and existing commercial aircraft be equipped with real-time satellite tracking systems.

7. It is recommended that Transport Canada initiate research into technologies that would allow seaplanes to stay afloat, or significantly delay the rate of sinking, following collisions with water.

8. It is recommended that the configuration of the pilot seat and restraint system as observed in the Beaver aircraft involved in the Saturna Island accident, and currently in use on some other Beaver aircraft, be examined to determine whether it meets its intended purpose of providing efficacious restraint of the occupant in a survivable collision.

9. It is recommended that Transport Canada develop a process for issuing of Operational Directives, similar to the existing Airworthiness Directives processes, to enable speedy and efficient dissemination of safety-related information and directives addressing operational safety issues.

10. It is recommended that Transport Canada eliminate the granting of Operations Specifications that allow commercial VFR fixed-wing operations in reduced visibility conditions.

11. It is recommended that Transport Canada require commercial VFR operators to provide their pilots with annual decision-making training specific to the scope of operations; and further, that Transport Canada require commercial VFR operators to provide annual decision-making training to all critical personnel that provide support to the pilot, including flight followers and company management.

12. It is recommended that Transport Canada develop standardized curriculum for underwater egress training and make underwater egress training mandatory for flight crews involved in commercial seaplane operations; and further, that enhanced safety briefings outlining underwater egress procedures be mandatory on all commercial seaplane flights.

13. It is recommended that Transport Canada create a requirement that all commercial seaplane pilots undergo training that includes a component on avoidance of, and recovery from, sudden encounters with hazards such as conditions that are below Visual Meteorological Conditions (VMC) minima, low level flight over glassy water and in poor visibility, and other typical hazards frequently encountered by seaplane pilots.

14. It is recommended that Transport Canada develop standardized curricula for Mountain Flying Training and develop criteria for measuring students' proficiency in reaching the acceptable standard.

15. It is recommended that NAV CANADA engage in a consultation process with Environment Canada Meteorological Services staff and British Columbia's floatplane community, with the objective of improving the quality of weather camera imagery available through the Aviation Weather website and increasing the number of web camera placements in critical coastal locations.

16. It is recommended that the British Columbia floatplane industry associations develop a strategy for gathering metrics that identify accident rates and patterns, show safety trends and support the development of accident prevention measures.

17. It is recommended that the British Columbia floatplane industry associations encourage the operators that make up their membership to formally compile information on significant hazards specific to the operators' routes and provide flight crews with formal briefings or training and information on such hazards, supplemented with information on standard operating procedures and best practices for mitigating these route-specific hazards.

18. It is recommended that the BC Forest Safety Council include in the SAFE Companies audit protocols a component that specifically addresses the issue of worker transport onboard aircraft; and further, that the BC Forest Safety Council develop a resource package specific to air carrier standards and best practices.

19. It is recommended that the WorkSafeBC consider development of guidelines to workers' compensation legislation promoting underwater egress training for employees who regularly commute to worksites over water on board aircraft.

For more information, please contact

Barb McLintock

Coroner, Strategic Programs

BC Coroners Service

250 356-9253 or 250 213-5020

Connect with the Province of B.C. at: www.gov.bc.ca/connect

FACTSHEET

May 1, 2012 Ministry of Justice

BC Coroners Service

Aviation incidents in British Columbia

• Number of fatal aviation incidents in B.C. from January 2000 through December 2009: 111.
• Number of persons who died in those incidents: 202.
• Commercial flights were involved in 34 per cent of the incidents.
• A total of 42 per cent of the deaths occurred on commercial flights.
• The largest percentage of commercial aviation deaths resulted from incidents involving transport of workers to remote work sites or camps.
• Incidents studied in detail by the Death Review Panel:
• Feb. 28, 2005: Aircraft carrying pilot and four passengers to remote worksites in Knight Inlet area crashed into water. Five deaths, no survivors.
• Aug. 3, 2008: Aircraft carrying pilot and six passengers to remote logging operation crashed into steep, forested slope near Alice Lake, 14 miles from Port Hardy. Five deaths, two survivors.
• Nov. 16, 2008: Aircraft carrying pilot and seven passengers to remote worksite at Toba Inlet crashed into hillside on South Thormanby Island. Seven deaths, one survivor.
• Nov. 29, 2009: Aircraft carrying pilot and seven passengers on commercial flight from southern Gulf Islands to Vancouver International Airport crashed into water shortly after takeoff. Six deaths, two survivors.

For more information, please contact:

Barb McLintock
Coroner, Strategic Programs
BC Coroners Service
250 356-9253 or 250 213-5020