Question about widow

Widow · Post by **Widow** » Wed Apr 18, 2007 3:44 pm

CID, every aviation authority under the sun has made it clear that pilot error is very often the result of a failure of operational circumstances prior to/during an occurance/accident, and that these circumstances need to be thoroughly explored.

I believe Beaufort understands that the CGAQW pilot may have made judgement errors ... but for the authorities to publically state that the only contributing causes of the accident were weather and pilot error is a gross fallacy. It is unjust not only to the pilot, but to the families of those passengers and the many credible witnesses who heard the aircraft during that short flight. Remember, this is the conclusion that was submitted to the coroner as final. And the coroner, like us, awaits a new report - although "we" do not know if TSB is ever going to do another.

Cat Driver · Post by **Cat Driver** » Wed Apr 18, 2007 4:41 pm

widow, your quest for justice is not being helped in the least trying to point out what we all believe happened to people who have no first hand experience flying in your area.

My personal opinion is that the most likely direct cause for that unfortunate accident was an engine failure over glassy water with a low ceiling and no shoreline reference.

There is not a pilot on earth who can make a safe landing under that circumstance.

Your husband and maybe others would have survived had someone got to them before the cold water finally caused their deaths.

I am fairly certain that that will be the findings if they ever get the engine up.

phillyfan · Post by **phillyfan** » Wed Apr 18, 2007 5:13 pm

I had always heard that this accident was caused by a pilot flying in weather he should not have? Got caught running around in fog and glassy water. Was there actually evidence to the contrary? I appologize if it was posted earlier. I just don't have the patience to read through 4 pages of posts.
The conclusion that it was weather always seemed to make sense.

Check Pilot · Post by **Check Pilot** » Wed Apr 18, 2007 5:42 pm

There are three key questions that need to be answered:

1. Why did the engine fail?
2. Why did the pilot not execute a safe forced landing?
3. Why did the Company not know the aeroplane was missing?

How did these 3 holes in the "swiss cheese" line up that day and nobody took any action to stop it?

Widow · Post by **Widow** » Wed Apr 18, 2007 6:23 pm

This was not a weather accident. There were many witnesses to a very rough running engine including sputtering noises immediately prior to the accident. Besides,

this does not indicate a weather problem.

Check Pilot is correct.

Cat Driver · Post by **Cat Driver** » Wed Apr 18, 2007 6:30 pm

Are you saying there was wind that day at the accident site and at the time of the accident and glassy water could not be the problem?

If there was no glassy water to contend with the pilot should have just landed from any altitude after an engine failure, unless he had a heart attcak or something.

So if there was no glassy water then something really weird happened.

I have been flying sea planes for over fifty years and running into glassy water is a very common problem, even if the weather station in Campbell River was showing wind that does not mean anything several miles away.

phillyfan · Post by **phillyfan** » Wed Apr 18, 2007 7:05 pm

Certainly looks like there might have been something out of the ordinary going on. It's not uncommon to get some oil coming out of the pushtubes etc causing some staining but that seems like a whole lot more than that. On the windshield was there evidence of heat damage. Just hard to tell if what i'm seeing is algae or heat damage? Cat Driver is correct though. Engine failure in itself would not cause a fatal accident over ideal water conditions. Sure would be interesting to take a look at that engine. Seems like without all the pieces Transport is always way too eager to classify everything as "Pilot Error"
What was the response of the accident investigators when presented with the same evidence you just showed us in those pictures? Did they dismiss it as a previous condition or as a result of impact. Seems that either way they would have to explain it?

Widow · Post by **Widow** » Wed Apr 18, 2007 7:13 pm

No wind. Glassy water conditions. Fog patches.

Engine failure precipitated the need to land in these conditions.

When we had the inspectors return to review the wreckage with our experts, they told us that look was (or could be) normal. They took no samples for testing (except for a mag), and claimed the oil up the windshield and fuselage to the tail were post-impact. I've posted this before, but here was an expert take:

April 29, 2006

To Whom it may concern.

As a Aircraft Maintenance Engineer with 28 years of experience working on DHC-2’s, and having been involved with the Ministers Delegate Maintenance program for 6 years, I have been asked by the family members of the victims of the fatal accident of DHC-2 C-GAQW to inspect the retrieved aircraft and submit a report on my observations with respect to causative factors of this accident. I also have possession of video taken at the site as well as of the recovery process which I have reviewed.

On April 28, 2006 I attended the storage locker where the aircraft has been kept, in dry secure storage. The recovered portions of the aircraft included both floats, empennage, LH wing and flight controls, and the fuselage including the engine mount, engine accessory section. Sections remaining at the accident site would include the RH wing, engine power section, propeller and cowlings. The power section did not come up with the accessory section due to magnesium construction of the blower/ intake section having corroded away due to salt water emersion.

Most of the aircraft has a layer of organic growth due to being submerged for some period of time. Due to the storage conditions this growth is now dried up. Immediately apparent is the fact the windscreen, lower inboard section of the left wing, the right side of the fuselage including approximately 1 foot up the side of the vertical fin, as well as the right inboard leading edge of the horizontal stabilizer, have been covered with engine oil. This pattern of oil leakage is consistent with a major oil leak suddenly developing in flight, concentrated on the right side due to prop wash, which adheres to the colder dry surface of the aluminum, and is not easily removed. Subsequent to the accident, oil would be very unlikely to stick to the surfaces as they would be wet with water, and the oil contamination pattern would not be so well defined.

The aircraft damage viewed would suggest the mechanics of the accident involved a forced landing due to lack of visibility through the aircraft windscreen compounded by poor visibility due to meteorological conditions at the time. A power off nose up attitude would produce a rapid decent with a heavily loaded aircraft. The aft section of the RH float is bent up, with suggests a heal dig which would have bounced the aircraft back into the air. A slight kink in the upper LH wing half way between the strut and tip, plus the tip being knocked off in an upward motion suggest the LH wing may have contacted the water at some point in the chain of events. The most significant damage appears to have been caused by the aircraft subsequently stalling and striking the water in a nose and RH wing down attitude with a sideways component to the direction of travel. Both upper diagonal tubes of the engine mount have tension fractures (are completely separated mid tube), and both lower mount tubes have compression bulges just above the firewall mount, indication a significant vertical inpact The forward section of the right float has basically exploded from the impact of being driven up and being struck by the propeller and impact with the water. At the same instant the right wing impacted the water and was torn from the fuselage, as indicated by upper cabin damage. Video shows the right wing on the bottom with a near 90 degree bend upward, just outboard of the outer flap attach, also what appears to be the exhaust intensifier tube is completely flattened by the impact. Compression damage to the left mid section of the fuselage suggests the aircraft struck the water with a sideways component consistent with a stall.

I do not believe the aircraft cart wheeled into the water as there is very little damage to the Left wing, the horizontal stab, elevators, or rudder and vertical fin as viewed in underwater video. Damage to the fin, rudder, and elevator tip was incurred during salvage.

Based on my experience and my observation of the aircraft I would conclude that the initiating cause of this accident was a failure of one of the upper cylinders, or given the amount of oil and the short duration of the flight, a failure of the cylinder base studs. I support this with reference to the Transport Canada Service Difficulty Reporting Data base http://www.tc.gc.ca/wsdrs/ quick search of Pratt & Whitney R-985-AN 14 and 14B, between April of 2000 and today shows 99 service difficulty reports were submitted related to cylinders and power section problems. Of these 39 were related to Cylinder cracking or complete head separation. 9 incidents were
reported of cylinder base stud failures. The remaining reports included cracked crankshafts, cracked cases, cracked or broken pistons, and broken or bent connecting rods. These are only reported incidents, more are likely to have occurred which are not reported.

Several problems can create the circumstances for these types of failures. Most of these cylinders are old and are heat cycle fatigued; they may have been overhauled several times, and are subject to mandatory ultrasonic testing at overhaul, as well as a visual inspection every 100 hrs. Unfortunately many cylinders continue to fail, even within 50 hrs after the UT testing has been completed. Often the visual inspections can miss crack indications due to oil staining and difficulty in accessing the full circumference of the cylinder head area. It is my belief that a crack can start internally within the head and progress into a complete head separation in far less than the 100 hrs specified in the inspection requirement. As these are supercharged engines another factor may be over boosting an engine (too much manifold pressure for the given engine rpm). This is not common or likely with experienced pilots.
The third and most troubling possibility is the use of substandard parts. As these engines are so old, many of the parts are now being made by after market suppliers, referred to as FAA-PMA. Such parts are suppose to be equal to the original manufactures parts, however this is not always so. Items such as cylinder base studs could easily fall into this classification.

In light of this information I would consider a review of the engine technical logs to identify if any cylinders have been replaced due to cracking, or if any base studs have been replaced due to failing. This would be indicative of the overall condition this engine at the time of the accident.

Given the number of reported occurrences of these types of failures, that in my opinion has a very high probability of being what initiated the unfortunate chain of events that lead to the death of the occupants of C-GAQW, I believe that the recovery of the power section of this engine for more detailed investigation should be essential in ensuring safety for the large number of people in remote locations who travel in aircraft equipped with these engines. Further, a fair question to be asked would be to inquire what follow up investigations have been carried out with respect to the 9 instances of cylinder base stud failure reported, and what actions have been initiated to reduce these occurrences.

As part of my review I have a copy of Bill Yearwood’s letter to Ms. Larcombe at the Chief Coroners office related to this accident, dated September 21, 2005. With respect to comments related to TSB’s examination of the wreckage on July 29, 2005. I would like to forward two comments which may have a bearing on the conclusions arrived at. First, the statement that the engine mounts were in place and showed no sign of impact damage is contrary to my observations as noted above. At the retrieval the aircraft was upside down which would have made the damage I observed very difficult to detect. Second, the propeller control was set to fine pitch. This position according to the DHC-2 flight manual is used for take off, prior to landing, and in the event of an engine failure. Had the pilot flown into the water would the prop control not have been pulled back to 1850 rpm, the recommended cruise setting?

This concludes my observations and comments. In the interest of public safety I would be happy to discuss this matter with anyone concerned."

Cat Driver · Post by **Cat Driver** » Wed Apr 18, 2007 7:20 pm

" No wind. Glassy water conditions. Fog patches.

Engine failure precipitated the need to land in these conditions. "

Which accounts for the accident.

It is close to impossible to judge height to land in those conditions with an engine failure.

Widow · Post by **Widow** » Wed Apr 18, 2007 7:22 pm

Would you mind giving TSB a call Cat? They don't seem to have figured that out yet. By their interpretation of evidence, the pilot changed course and crashed into the water not because of engine failure, but because he was a bad pilot.

Cat Driver · Post by **Cat Driver** » Wed Apr 18, 2007 7:28 pm

" Would you mind giving TSB a call Cat? They don't seem to have figured that out yet. "

widow, the TSB knows full well that it is virtually impossible to land on glassy water after a complete engine failure.

In fact I would be willing to bet there is not a sea plane pilot on earth who would be willing to demonstrate that senario.

You deserve to know what happened, and do not quit until you find out.

I wouldn't trust any statement made by any government agency.

phillyfan · Post by **phillyfan** » Wed Apr 18, 2007 7:35 pm

That engine needs to be found. Keep at it Widow. I don't think your barking up the wrong tree. From the limited evidence I have seen. Simple Pilot vs Fog = pilot loses. Seems too simple.

duCapo · Post by **duCapo** » Wed Apr 18, 2007 7:36 pm

Difficult to land in foggy drizzle glassy water conditions? you bet!
Especially with oil on that flat windscreen. It is hard enough without the extra excitement of an engine failure at low level. Getting the aircaft on the water relativley intact under those condtions is a testiment to the pilots skill level. I knew others who just disappeared under similar circumstances.

blachang · Post by **blachang** » Wed Apr 18, 2007 7:39 pm

Widow was your husband the pilot of that aircraft, or did he work for the company operating it? Or were they just chartering it for a fishing trip?

Cat Driver · Post by **Cat Driver** » Wed Apr 18, 2007 7:46 pm

" Widow was your husband the pilot of that aircraft, or did he work for the company operating it? Or were they just chartering it for a fishing trip? "

What possible difference would that make to the cause of the accident and the failure to rescue her husband before the cold water killed him

Widow · Post by **Widow** » Wed Apr 18, 2007 7:54 pm

blachang, my husband was a logger. The international logging firm he worked for had a contract with the operator. He was on his way to work. Wearing his floater coat as usual.

Vickers vanguard · Post by **Vickers vanguard** » Wed Apr 18, 2007 8:16 pm

Widow wrote:

Oh, I'd be interested in a poll myself. For those of you who are tired of me ... if you turned out to be the majority, I would remove myself from the board and leave very grateful for everything I have learned here, and through those of you who have given me support privately.

...hope you're joking......
Good luck in your quest for justice

happily.retired · Post by **happily.retired** » Thu Apr 19, 2007 12:46 am

Glassy water and emergency landings are among the more dangerous things to deal with - we all know that and so does TC (they stress it in all the bloody training manuals) But one is largely avoidable, the other not so much so. It is infuriating that Transport isn't focusing on the apparently preventable engine failure and trying to improve safety in the future. Back when I believed in this industry and everything associated with it I thought that was what we were paying TC to do.

LostinRotation · Post by **LostinRotation** » Thu Apr 19, 2007 5:19 am

The biggest problem with women like widow, there aren't enough like her out there.

-=0=LiR=0=-

Widow · Post by **Widow** » Thu Apr 19, 2007 7:08 am

The above letter did mobilize TC - and they have put out the new Service Difficulty Advisory on the R-985. This, despite not knowing if it was a cylinder failure on CGAQW. This is good and I applaud TC for taking this action.

happily.retired · Post by **happily.retired** » Thu Apr 19, 2007 11:00 am

Thank you Widow for getting a new sevice difficulty advisory issued. There are many pilots and even more passengers who are safer as a direct result of you efforts!

I only wish someone like you could have come along sooner and saved you husband by doing for him what you are doing for us now.

You have our thoughts and support.

BigWillyStyle · Post by **BigWillyStyle** » Thu Apr 19, 2007 5:24 pm

Widow: Keep at it.

Cat: Keep at it.

Anyone who has been flying for 17000 hours and has given up trying to improve safety: RETIRE.

The more accidents, the more regulations will be tightened in the name of prevention. The more regs, the more honest operators will say "screw this". The more honest operators that bail, the more scumbags will pick up the slack. The more scumbags, the more corner-cutting, and more accidents. Repeat as desired.

It's up to us to show some backbone, and get the charlatans shut down. Cowards don't deserve to critique. Paychecks come and go. You've only got one life.

BWS

Cat Driver · Post by **Cat Driver** » Thu Apr 19, 2007 5:35 pm

BigWilly :

There has always been sufficient laws and rules to use to shut down unlawful operators.

The problem is there has not been the willingness on the part of the regulator.

For anyone to suggest that TC is not aware of who are the lawbreakers is ludicrious.

Thankfully I'm no longer in the flying business in Canada so it does not directly affect me, unless of course I were to fly on a Canadian commercial aircraft operated by a law breaker.

The issue that should scare the living shit out of every member of the aviation community with an IQ over room temperature is the trend of regulatory oversite is declining not improving.

confused · Post by **confused** » Thu Apr 19, 2007 6:06 pm

What was the pilot doing over glassy water,low level in foggy patches in the first place?Even if the engine did not fail and the pilot had to make a emergancy landing for another reason......would most likly be the same outcome.Throw in a engine failure and you're fucked.Should you not island hop,go way out of your way to follow a shoreline or not go.Again no disrespect meant to anyone involved.

snaproll20 · Post by **snaproll20** » Thu Apr 19, 2007 6:12 pm

Yes, confused, you sure are...............