Widow writes another letter

[Widow]

Any suggestions on other places I should send this letter?

----- Original Message -----
From: Kirsten Stevens
To: LCS.Minister@gov.bc.ca ; Blackburn.J@parl.gc.ca
Cc: Claire Trevena ; Catherine Bell ; lavalc@parl.gc.ca ; Silva.M@parl.gc.ca ; daviel@parl.gc.ca ; Ambrose.R@parl.gc.ca ; John.Les@gov.bc.ca ; Day.S@parl.gc.ca ; carriro@parl.gc.ca
Sent: Monday, May 07, 2007 1:34 PM
Subject: Failure to Investigate Workplace Deaths


Attention:

Hon. Jean-Pierre Blackburn (Federal Minister of Labour)
Hon. Olga Ilich ( BC Minister of Labour and Citizens' Services)

C.C.'ed for the consideration of:

Rona Ambrose, President of the Queen's Privy Council for Canada
Stockwell Day, Federal Minister of Public Safety
John Les, BC Minister of Public Safety
Libby Davies, NDP Labour Critic
Mario Silva, Liberal Labour Critic
Carole Lavallée, Bloc Québécois Labour Critic
Catherine Bell, MP (Vancouver Island North)
Claire Trevena, MLA (Vancouver Island North)
Peter Julian, NDP Transport Critic
Joe Volpe, Liberal Transport Critic
Robert Carrier, Bloc Québécois Transport Critic


Dear Mr. Blackburn and Ms. Olich,

We are writing to you today to bring to your attention a disgraceful lack of importance placed on the loss of five working souls. On the 28th of February 2005, a float-equipped "Beaver" aircraft operated by MJM Air Ltd. departed Campbell River, BC at 10:10 am and was never heard from again. Although the company was aware the aircraft was missing, and had begun a communications search by 11:15 (according to Access to Information and Privacy received from the Joint Rescue Co-ordination Centre), Search and Rescue was not contacted until 14:16. Two days later, the body of one of the passengers (my husband) was found barely five kilometres away. Although he suffered no serious injuries and wore a floater coat, he drowned several hours post-accident having suffered extensively from hypothermia. Despite many witness reports of the engine "coughing and sputtering" immediately prior to being heard crashing into the Sutil Channel, the official search for the aircraft was abandoned.

For the next several months, the families' of the souls lost continued the search, with substantial personal expense, and eventually located the aircraft. On the 28th of July, 2005, the majority of the aircraft wreckage was raised from the ocean's floor, again at the families' expense. Although the magnesium parts holding the engine in place had corroded, leaving the engine on the ocean floor and unanswered questions regarding the cause of the crash, the evidence suggested that everyone had survived (no bodies were on board, the seatbelts were all unbuckled).

Despite repeated appeals to the Transportation Safety Board, Transport Canada Commercial and Business Aviation, the Director General of Civil Aviation, and both the provincial and federal Ministers of Transport, this accident remains in the TSB system as a Class 5 Occurrence, no investigation for cause is forthcoming, no Minister's Observer has ever been appointed and the Civil Aviation Occupational Health and Safety investigation was closed for lack of evidence/information in June 2006. Significant evidence and information has been gathered since then, but the BC Coroner's Service, the RCMP and WorkSafe BC have been unable to complete their investigations.

Our concerns are very real. There is a general feeling in industry that the Air Taxi sector suffers from a considerable lack of effective oversight and enforcement. Many concerns which were addressed by Transport Canada in the Safety in Air Taxi Operations (SATOPs) Final Report (1998) and which related to the problems of occupational health and safety as well as oversight in this sector have never been corrected. This sector suffers from a high accident rate. As many of these accidents involve persons being transported for other industry purposes (loggers, Medevac, oil, fisheries, etc.), this should be of great concern to the Ministers of Labour.

To add to these concerns, the owner of MJM Air Ltd. had previously been found responsible for a logging industry death by WorkSafe BC and the BC Coroner's Service. There are “rumours” that the same owner may have had some responsibility in a further logging death in February 2007. It is possible that had MJM Air been inspected for compliance after the logging death in 2003, the accident which claimed five souls in 2005 may have been prevented. It is further possible that had the air taxi accident been properly investigated and acted upon, the 2007 death may never have occurred.

The lack of co-operation and information sharing between the interested agencies is unacceptable. This complete lack of inferred importance and considered investigation into the loss of five souls may have already resulted in further injuries and deaths.

Our story was recently aired on W-Five (you may view the episode by following the "video" link on the right hand side of the episode page) as "A Routine Flight". This has raised extensive public awareness of this accident, and has made the TSB appear somewhat incompetent. Mr. Yearwood’s contention that "even if there was an engine malfunction, it doesn't make the aircraft uncontrollable. It shouldn't cause the accident..." is inaccurate at best.

We respectfully request that your Ministry make itself familiar with Transport Canada Docket #AAR2006G097207 and take responsibility for ensuring the immediate appointment of a Minister's Observer and an investigation into the failure of MJM Air to ensure the safety of its pilot and passengers.


Stay Safe,



Kirsten Stevens

On behalf of the families' of the souls lost
492 S. McPhedran Rd
Campbell River, BC
V9W 5K5
kis.ca@telus.net
Tel: (250)287-2725
Website: http://www.questforjustice.ca

[shitdisturber]

How about adding Stevie Wonder Harper, the Globe and Mail, and CBC, CTV? The more publicity the merrier.

[Golden Flyer]

As a matter of fact, you should photocopy all letter sent back between you and the government. Place them in chronological order, and then send them in to a media outlet.

[CID]

One thing you may want to consider widow is staying away from conjecture. You state that;

There are “rumours” that the same owner may have had some responsibility in a further logging death in February 2007.

Then you go on to surmise that;

It is further possible that had the air taxi accident been properly investigated and acted upon, the 2007 death may never have occurred.

At best its a leap to associate the two with little more than "rumours". Over all it has the potential (in my opinion) to weaken your case. Conjecture like that often puts people off.

One other small thing regarding your statement;

Mr. Yearwood’s contention that "even if there was an engine malfunction, it doesn't make the aircraft uncontrollable. It shouldn't cause the accident..." is inaccurate at best.

I think the last statement is a little strong. In my opinion, (again) it's not an innacurate statement. For the most part single engine airplanes remain controllable following an engine failure if there are no other complications. For the benefit of those that will most certainly slag me for stating that, yes, I know there MAY have been complicating factors in the subject accident.

As always, I don't mean to derail your efforts widow, just pointing out what I think may be improvements to your letter that will help rather than hinder your efforts.

[Widow]

CID, while normally I would not have used such "rumours", in reality there are "insiders" who have come to us with information which should have been provided to WorkSafe BC in their investigation of the 2007 death. Furthermore, we had been actively lobbying WorkSafe BC to take an in-depth look into the owner's group of companies, including a very prophetic letter less than two weeks before that accident. If you knew what we know as fact, and what we have been told by these insiders, you would understand why I decided to use this information. Our concerns and demands are well documented.

As for my statement regarding Yearwood, perhaps it is a little strong. I was going for strong. Nor am I alone in this opinion, as you know.

Nonetheless, I thank you for your suggestions.

shitdistuber & Golden Flyer, I have sent the letter to a few media outlets which have previously been supportive, but will certainly be sending to more as time goes on. Although the suggestion of compiling a volume of my correspondence with the various government officials for the media is great - that would be hundreds, maybe thousands of pages not including the many thousands of pages of references. I've got it all here, in my "office", on my computer, and backed up and stored in a different location. Several media outlets already have the majority of the correspondence.

[ybp]

Widow,
I have just recently heard of this accident -- when it was posted on here that it was going to be on W-five. I have read quite a bit about it since then and I too am appalled at the reactions of the government at all levels.

I think that I can speak for the industry as a whole when I say that what you are doing will benifit us all in the long run. I wish you all the best and I will be following this story in the future.

Thanks

[gli77]

It seems to me that the letter highlights many different areas of concern. Spanning from SAR to TSB to TC/SMS to business law. I would imagine it is impossible for anyone to reslove all those issues, with the likely outcome to be nothing accomplished.

[Lommer]

Widow, I think your statement regarding Mr. Yearwood was bang on. On the other hand, I think CID is right (ugh) when says that "rumors" sounds flakey. I understand that you may be restricted by what you can say without harming the insiders who gave you information, but you need to hit these suckers with everything you've got. If you're alleging something more serious than rumors - say so.

Overall a great letter and I for one am amazed, impressed, and extremely thankful for your unwavering dedication to fixing what's wrong.

Edited for spelling.

[CID]

Lommer,

Obviously you're not under any obligation to offer clarifications to your opinion but just out of curiosity, if a single engine float equipped airplane operating VFR over water in VMC loses an engine with no additional complicating factors (no oil on the windscreen etc.), what do you think the the odds of getting the airplane down safely are?

Also, does the airplane become "uncontrollable" in this situation?

What would the effect of complicating factors like oil on the windscreen be? Or glassy water? Or IMC?

[Widow]

Examples from CADORS:

CADORS Number: 2003C1074

UPDATE TSB reported that the privately-registered De Havilland DHC-2 Beaver, C-GUXW, was en route from Pelican Narrows, SK, to Jan Lake, SK. When the aircraft was overdue for arrival, another aircraft was dispatched to search. The accident aircraft was discovered partially submerged in Sully Lake. Two survivors had exited the aircraft with serious injuries, spent the night on shore and were evacuated to hospital the following day. The pilot's body was recovered by RCMP divers. TSB investigators were dispatched to the scene. The Class of TSB investigation is being assessed.

User Name: Ridley, Rod
Date: 2003/08/14
Further Action Required: No
O.P.I.: System Safety
Narrative: UPDATE TSB reported that a cracked cylinder resulted in a loss of engine power and an attempt at a forced landing on a small lake. The altitude at which the event began may have given the pilot very little time to successfully complete a forced landing. TSB will probably classify the investigation a Class 5.

CADORS Number: 2005P1441

Binnema, Gerry
Date: 2005/07/25
Further Action Required: Yes
O.P.I.: Maintenance & Manufacturing
Narrative: The American registered Dehavilland Beaver reported moisture on windshield and rough running engine to Victoria Tower. Precautionary landing in Cowichan Bay. Boat towed into dock area. RCMP, RCC, Coastguard advised.

User Name: Binnema, Gerry
Date: 2005/07/28
Further Action Required: No
O.P.I.:
Narrative: Update from the TSB: The american registered De Havilland DHC2 Beaver, [N741DB], was in cruise flight when the pilot reported a rough running engine (Pratt & WHittney R-985) and moisture (oil) on the windshield. He advised Victoria ATC and performed a precautionary landing in Cowichan Bay. The floatplane was towed to Patricia Bay and subsequently examined at Victoria Air Maintenance. It was determined that a cylinder had lifted off its base and interacted with the adjoining number 5 cylinder. The piston skirt had impacted the master rod; this prompted the removal of the engine.

From a post on the W-Five forum:

At a remote logging camp I was on the dock waiting for the Beaver. I was not the only kid in camp. All the boom boats operators were roaring around in circles, the water was glassy. I heard the Beaver approaching for landing and the boom boats got out of its way. Before taking off the boom boats were again roaring around in circles chopping up the water.

When I read that the Beaver bounced on landing I thought glassy water. I think it is remarkable that anyone survived the landing under conditions of engine failure, fog, oil on the windscreen and a pilots nightmare, glassy water. I did not think pilot error, I thought pilot skill.

Edited to add from the JRCC records:

Sounded like a plane either in the air or on the water having problems. Engine cutting in and out and the sound of something like pontoons hits the water repeatedly. Then he heard a big thump (something like the sound you hear when lighting a BBQ). Difficult to determine direction of sounds but feels it may have been in the area bounded by Rebecca Spit, South tip of Cortes Is, and Mittlenatch Island. However, could have been further north.

[CID]

Or this one from yesterday;

A turbine powered single Otter, on a VFR flight from Whistler to Victoria Harbour, got trapped above cloud. Vectored to the south and was able to break out VFR. Landed CYWH safely.

[Widow]

What does that have to do with an engine failure?

[Cat Driver]

What does that have to do with an engine failure?

I was wondering the same thing widow.

But my gut feeling is CID is muddying the waters for you, by trying to tie all incidents and accidents to pilot error.

If you read his thoughts on flying on the west coast it is evident he knows SFA about flying, and tars all float plane pilots with the same brush.

I'm amazed they let him get away with it.

[CID]

What does that have to do with an engine failure?

If he did experience an engine failure, his chances of conducting a safe landing would be seriously reduced.

I'm amazed they let him get away with it.

Who?

And no Cat Driver, I'm not doing what you suggest. Just looking for straight answers. You're an experienced pilot. What do you think? Does as single engine airplane in VMC become uncontrollable when the engine quits? What circumstances would make it uncontrollable?

By the way, besides the equipment requirements, here are the Air Taxi standards for VFR OTT;

723.33 VFR OTT (Over the Top) Flight

The following standard shall be complied with for flights operating VFR OTT:

(1) the flight shall be conducted in accordance with the requirements of Section 602.116 of the Canadian Aviation Regulations;

(2) for multi-engined aeroplanes where the pilot holds a valid Instrument Rating for the group of aeroplane, the flight shall be operated under conditions allowing descent under VMC or continuation of the flight under IFR or VMC if its critical engine fails;

(3) for multi-engined aeroplanes where the pilot does not hold a valid Instrument Rating for the group of aeroplane, or that can not comply with (2) above, and for single-engine aeroplanes, the flight shall be operated under conditions allowing:

(a) for multi-engined aeroplanes, descent under VMC, or continuation of the flight under VMC conditions if its critical engine fails;

(b) for single-engined aeroplanes, descent under VMC if its engine fails.

Again, in your opinion Cat Driver do you think the Otter pilot met the requirements and operated under conditions allowing descent under VMC if the engine failed?

[Widow]

CID, if there wasn't something wrong with the engine, what do you think the "coughing" and "sputtering" and "cutting in and out" sounds were? These sounds were heard by AT LEAST twenty different people.

[CID]

Widow,

I never said nothing was wrong with the engine. There seems to be evidence to support that.

What I'm saying is that the engine failure is a contributing factor in the subsequent forced landing, not the only factor. In itself, it shouldn't have resulted in a crash and fatalities. If I was convinced that all single engine airplanes suddenly become uncontrollable if the engine quits I would never step on one again.

[Widow]

I'm not a pilot, but I would think it would depend on what kind of engine failure you had, to determine how controllable the aircraft would have been, or additional mitigating factors (like oil on the windscreen, smoke, altitude, terrain, water conditions, etc., etc.)

That being said, what you seem to be failing to recognize CID, is that everyone got out of the aircraft - at least one person was basically uninjured. That would indicate that the pilot got the aircraft down onto the water relatively safely, despite whatever factors there may have been. But then the airplane sank. Fast. So fast they didn't have time to get their life jackets. One float was basically undamaged (though unsealed). Both floats were still attached.

[pushyboss]

Widow,

I believe what CID is pointing at is that in and of itself an engine failure in a single engine aircraft should not be cause for the aircraft to become uncontrollable. The fact that the aircraft sank extraordinarily fast points to a forced landing that was either handled poorly by the pilot or that weather conditions were such that a succesful forced approach was difficult if not impossible. I would hazard a guess that the latter is more probable. If the operator dispatched an aircraft in less the weather required by the regulations, and the pilot accepted such an assignement, the engine failure would have become the final error in the error chain. The Swiss Cheese model if you are familiar with error management training.

This does in no way change or diminish any of your allegations. But I do believe, from my reading of your posts, that you are focusing your investigation on the engine failure when in fact it may only have been the final straw.

It is clear that west coast aviation does operate in a unique envrionment and that a strict interpretation (if that is possible) of the CARS would virtually ground most single engine west coast operators 300 days a year.

My question is, had the operator required his pilots to fly in weather that was truly VMC (as defined in the CARS) would the result of this engine failure have ended in the same tragic way. Maybe a revisiting of the way west coast operators operate would be in order as there seems to be significantly more "vfr" CFIT accidents there than anywhere else in Canada.

Keep fighting the good fight.

P.S. yes I am a grey hair who has flogged airplanes up and down the coast.

[Widow]

It is these very links in the chain that we are insisting are fully investigated. The TSB & TCCA current stance, is that there was no engine failure, but only weather and pilot error. Nothing has been explored (directly) by officials regarding any "holes" other than weather and pilot error. Nothing regarding maintenance, operational control, oversight, pilot pressures, emergency procedures, etc. The engine was neither the first nor the last link in the chain.

It was not engine failure, or bad weather, or pilot error, or even a combination of these, that killed my husband.

[Lommer]

Lommer,

Obviously you're not under any obligation to offer clarifications to your opinion but just out of curiosity, if a single engine float equipped airplane operating VFR over water in VMC loses an engine with no additional complicating factors (no oil on the windscreen etc.), what do you think the the odds of getting the airplane down safely are?

Also, does the airplane become "uncontrollable" in this situation?

What would the effect of complicating factors like oil on the windscreen be? Or glassy water? Or IMC?

At the risk of getting drawn into something that I really don't want to engage in, I will clarify my opinion. I will concede that in an engine failure with absolutely no complicating factors, most aircraft will remain controllable and the chances of safely landing a plane are decent. However, I would further say that "no complicating factors" occurs extremely rarely, and oil on the windscreen, less than perfect visibility, chop or swells or glassy water, winds, and everything else that occurs in the real world may significantly reduce the chances of a safe landing. One must also consider the possibility that a landing in which all the occupants are unharmed may be made, but the floats (which may not be at 100% integrity to begin with) are damaged to the point where the aircraft sinks.

Given that operators are allowed, and expected, to fly with many complicating factors on a regular basis, I find "innacurate at best" a good description of Mr. Yearwood's assertion that "an engine malfunction ... shouldn't cause the accident".

[CID]

It was not engine failure, or bad weather, or pilot error, or even a combination of these, that killed my husband.

widow, I really don't understand that statement. From what I understand and read, all those were contributing factors. Possibly the primary factors.

Given that operators are allowed, and expected, to fly with many complicating factors on a regular basis, I find "innacurate at best" a good description of Mr. Yearwood's assertion that "an engine malfunction ... shouldn't cause the accident".

Lommer, remember this was supposed to be a VFR flight. That means good weather and good visibility. As far as the rest of the complicating factors go, they are possibilities even with the engine running. Does the water get glassier or choppier and the wind get windier when an engine quits?

How can it be "extremely rare" to have no complicating factors on a VFR flight? Shouldn't the same apply to normal landings as well? Except for the oil on the windscreen of course.

Given that operators are allowed, and expected, to fly with many complicating factors on a regular basis....

Does that mean dispatching a VFR flight in IMC or when a water landing would be hazardous because of water conditions is typical?

Remember, we're not talking about launching an A330 over the pole at night.

[Widow]

CID, my husband was uninjured. He got out of that plane and floated around for HOURS, alive and concious, before hypothermia finally got him and he drowned - slowly. Would you like to see his autopsy report? He would not have been in the water if it were not for the engine failure, and all other factors considered, it was the failure of the company to report the missing airplane that killed him.

And if I'm not mistaken, Lommer meant it is "extremely rare" for there not be be complicating factors when an engine fails.

[Cat Driver]

widow, you are going around in circles with these discussions regarding float plane flying on the west coast with CID.

Why spend so much time defending your cause with someone who obviously knows nothing about the subject.

Does that mean dispatching a VFR flight in IMC or when a water landing would be hazardous because of water conditions is typical?

The above nonsense is typical of the lack of understanding of the subject by this individual, can you imagine the difficulty a company would have dispatching flights based on the probability of water conditions on the route to be flown?

[CID]

Cat,

The CARs say "The pilot-in-command of an aircraft shall, before commencing a flight, be familiar with the available weather information that is appropriate to the intended flight."

They also say "No person shall commence a VFR flight unless current weather reports and forecasts, if obtainable, indicate that the weather conditions along the route to be flown and at the destination aerodrome will be such that the flight can be conducted in compliance with VFR."

They also state:

Fuel Requirements

602.88 (1) This section does not apply in respect of any glider, balloon or ultra-light aeroplane.

(2) No pilot-in-command of an aircraft shall commence a flight or, during flight, change the destination aerodrome set out in the flight plan or flight itinerary, unless the aircraft carries sufficient fuel to ensure compliance with subsections (3) to (5).

(3) An aircraft operated in VFR flight shall carry an amount of fuel that is sufficient to allow the aircraft

(a) in the case of an aircraft other than a helicopter,

(i) when operated during the day, to fly to the destination aerodrome and then to fly for a period of 30 minutes at normal cruising speed, or

(ii) when operated at night, to fly to the destination aerodrome and then to fly for a period of 45 minutes at normal cruising speed; or

(b) in the case of a helicopter, to fly to the destination aerodrome and then to fly for a period of 20 minutes at normal cruising speed

.

So if I understand you, its OK to launch a VFR float equipped Beaver on a 1 hour trip with 30 minutes of reserve with no alternate without checking the weather enroute and/or the consider the possible water conditions at the destination based on the weather report?

When do you start to worry? When you arrive and deem the water too rough? What you gonna do with your 30 minutes of fuel? I think people DO consider the enroute water conditions. Would you fly a single engine airplane VFR over the ocean if you knew the sea was extremely rough?

And Cat, you're right in a way. I think I've gone as far in this discussion as I need to.

There's nothing new to discuss but I must say I've learned alot about why accident rates are so high on the left coast.

[Cat Driver]

Thanks for the CAR's references CID, but have you ever considered that posting such basic regulations may be insulting to pilots who actually fly for a living?

And Cat, you're right in a way. I think I've gone as far in this discussion as I need to.

There's nothing new to discuss but I must say I've learned alot about why accident rates are so high on the left coast.

Unfortunately you have not learned that some of us have flown in this enviroment for tens of thousands of hours without any need for an insurance claim, so why don't you find another hobby horse to ride and let people who understand these issues discuss them without all this hand wringing about what if's from you?