Aviation Safety Letter 1/2005

From The Investigator's Desk:  Passenger Briefings and Safety Features Cards in Seaplane Operations

An Aviation Safety Information Letter from the Transportation Safety Board of Canada (TSB)

Dramatic visualization of a panic-stricken passenger facing a life-or-death underwater evacuation. True visibility would be much worse than illustrated.

Dramatic visualization of a panic-stricken passenger facing a life-or-death underwater evacuation. True visibility would be much worse than illustrated.

On June 7, 2004, a Cessna A185F seaplane carrying one pilot and three passengers crashed while landing at Ferguson's Cabin on the Taltson River, NWT. The circumstances of the accident indicate that the aircraft dug the left float at touchdown, then dragged the left wing in the water and cartwheeled. The aircraft sustained substantial damage, and came to rest floating inverted with only the bottoms of the floats visible on the surface of the river. The windshield and the left cabin door window broke out at impact, and the cabin immediately filled with water. The pilot and the right front-seat passenger were unable to open either of the main exits after the aircraft submerged, and they egressed through the broken window in the left cabin door. Four fishermen responded to the accident in boats and assisted the survivors, who sustained non-life threatening serious injuries. The two rear-seat passengers sustained no physical injuries during the occurrence; however, they drowned. One victim was found inside the aircraft. The second victim was found two days after the accident, near where the aircraft crashed, in 55 feet of water. The investigation (A04W0114) is ongoing.

All occupants had been restrained with lap-belts, and the impact forces were well within the range of human survivability. Despite having received no immobilizing injuries, the survivors were unable to unlatch and open the cabin doors from the cockpit seats, which delayed their egress from the submerged and inverted aircraft. Post-accident examination determined that the cabin door handles were functional and appropriately placarded; however, impact damage to the airframe may have prevented the doors from opening, even if the door handles had been rotated to the unlocked positions. Egress actions by the victims were not determined, although both had released their seat belts.

The passengers had been provided a standard safety briefing prior to departure. The safety briefing included information on the use of available restraints, the location and use of the life preservers, and the use of the main cabin doors as emergency exits. Information related specifically to underwater egress, such as likelihood of occupants becoming disoriented under water or the expectation that the cabin doors may not open until the fuselage had filled sufficiently with water to equalize the internal/external water pressure, was not provided during the briefing and was not presented on the available safety features card. Because it is probable that impact damage precluded the normal operation of the cabin doors, the extent to which the lack of underwater egress information may have diminished passenger response and egress has not yet been determined.

Transport Canada established the Safety of Air Taxi Operations (SATOPS) Task Force in January of 1996 to address the high accident rate among 703 operations. The resulting report contained 71 recommendations to improve the safety of the Air Taxi sector. The report stated: "There is a lack of information available to passengers in floatplanes and helicopters about underwater egress in the event the aircraft flips over on take-off or landing or ditches and rolls over...".

The report went on to recommend that: "Float-plane pilots and helicopter pilots operating over water include information on underwater egress procedures in the passenger briefing."

The seaplane was being operated under Canadian Aviation Regulations (CARs) 703 at the time of the occurrence. CAR 703.39 requires that passengers be given a pre-flight safety briefing in accordance with the Commercial Air Service Standards. Similarly, CAR 602.89 requires passengers on board a private aircraft be provided a passenger briefing before takeoff. Neither regulation is instructive with regard to a requirement for the briefing to include information specific to underwater egress procedures in seaplane operations. CAR 703.39 also requires an air operator to provide each passenger, at the passenger's seat or by means of clearly visible placards, with the safety information required by the Commercial Air Standards. There is no requirement for seaplane safety feature cards to display information or special procedures unique to underwater egress. Consultation with several operators has determined that it is not a standard practice to include that type of information in a seaplane briefing or on a seaplane safety feature card.

Federal Aviation Administration Advisory Circular AC 91-69A (Seaplane Safety for 14 CFR Part 91 Operators) provides valuable information regarding seaplane passenger briefings and egress under water. Other worthful references include the current edition of the Transport Canada Instructor Guide, Seaplane Rating and Transport Canada Publication TP 12365E (Seaplanes: A Passenger's Guide). TP 12365E does contain useful information on passenger egress from submerged aircraft. Several seaplane operators were contacted and most were not aware of the existence of the TP 12365E pamphlet.

When a seaplane submerges, occupant survivability is predicated on the ability of the occupants to remain mobile and to rapidly get out of the cabin. There are currently hundreds of seaplanes being operated seasonally in Canada, in both private and commercial service, and this and other recent accidents indicate that a high percentage of seaplane occupants continue to survive a water impact only to drown as the consequence of being trapped inside the cabin. The risks associated with seaplane occupants being trapped inside a submerged aircraft are increased when the pre-flight safety briefing and the safety features card do not include information specific to underwater egress. The foregoing is provided for whatever follow-up action is deemed appropriate.

Section 703.39 of the CARs requires air operators to brief passengers seated next to an emergency exit on how that exit operates. This section also requires either a safety features card or a placard at the passenger's seat. These regulatory requirements are deemed appropriate for seaplane operations. Nevertheless, since Transport Canada is moving towards performance-based regulations as part of the safety management system (SMS) implementation, it is our goal to have better training for our inspectors and better awareness for our 703 operators that will address the concerns expressed in the TSB letter.

We have developed several promotional documents in recent years to increase awareness of emergency underwater evacuation procedures, both for passengers and crews. Among those for the passengers was a brochure produced in 1995, entitled Seaplanes - A Passenger's Guide (TP 12365E). This brochure was widely distributed to floatplane operators through the System Safety regional offices. The challenge was to reach the passengers, and cooperation from the floatplane operators and pilots was, and still is, a must in including this information in their mandatory passenger briefings. The original TP 12365E is currently available as an on-line brochure only from our System Safety Web site. Still, we are in the process of updating it for a wide release, as a paper brochure, prior to the 2005 floatplane season. Floatplane operators and pilots are therefore strongly encouraged to include specific underwater egress instructions as part of their pre-flight safety briefing to passengers, including situational awareness effects.

However, awareness and education can't do it all. A philosophical change is needed in the way that floatplane operators view safety, and hopefully the move to SMS will help achieve this. This not only applies to the issuance of detailed underwater egress instructions, but also to the use of inflatable life vests that meet the TSO C13f standard. Many of those who escaped the aircraft, only to become the victims of drowning, could have survived if they had been wearing an inflatable life vest. Most operators already have the TSO C13f (inflatable) life vests but many pilots and passengers do not wear them. Some argue they scare the passengers, or that some passengers may inflate them prior to exiting, therefore making the egress less likely. I believe that a passenger who has been properly briefed on when and how to inflate a life vest has a better chance of survival than if they elect not to wear it during flight. The regulations do not mandate the wear of these life vests, and are not likely to do so either. There is nothing stopping operators from going beyond the safety margins offered by the regulations. Most offshore helicopter operators mandate that all on board wear them. This is an example of philosophical difference and one that improves survivability. - Ed.

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