Number Of Issues With 2018 C206G Seaplane Crash
The Transportation Safety Board of Canada (TSB) (*) has released its final accident investigation results on a Simpson Air Ltd. Cessna 206G which bounced on landing and – for lack of effective corrective measures by the pilot- ended up inverted and submerged in Little Doctor Lake in the Northwest Territories of Canada. At the time, the pilot and one passenger were able to escape the aircraft, yet three remaining passengers found themselves unable to exit the cabin and subsequently drowned, despite the pilots attempt to dive, to get the passengers out. The pilot reportedly encountered severe difficulty in getting her own pilot door to open and reportedly proceeded to kick the window out, in order to egress the cabin.
Pilot Skills And Experience
(Direct Copy From Accident Report) — Records indicate that the pilot was certified and qualified for the flight in accordance with existing regulations. She held a Canadian commercial pilot licence – aeroplane with a seaplane rating. The pilot had begun working at Simpson Air in June 2017, and, at that time, had 7 hours of float time—the minimum required by regulation to obtain and hold a seaplane rating.
The pilot’s first season working for Simpson Air was spent flying a Cessna U206G on wheels. In June 2018, the pilot began training on the Cessna U206G on floats. This training was provided by both a contract pilot and the owner of Simpson Air, and it was completed on 05 July 2018.
The Simpson Air pilot training manual describes the elements required by section 703.98 of the CARs for flight crew training. Section 3.5.7 of the training manual states the following:
Where the aircraft undergoes a seasonal change in the gear configuration, the pilot shall compete [sic] a minimum conversion training program of three take-off and landings in each alternate configuration. This training shall cover those items from the flight training syllabus, as applicable to the gear configuration.
During the initial training, it was noted that the pilot had difficulty carrying out water landings in the manner preferred by the company. The pilot had a tendency to fly level near the surface of the water and then cut the power and drop onto the water. The company’s preferred method was to set a pitch attitude, controlling the descent with power, and land with power on. As the training continued, the pilot’s performance improved, and she was cleared for duty.
After the pilot’s training was completed, 2 flights were carried out under the supervision of the company owner. The 2 flights totaled 6.4 hours and involved 6 water takeoffs and landings on floats. Two weeks after those flights, on 03 August 2018, the owner scheduled another training flight for the pilot, which he supervised, to practice takeoffs and landings.
The pilot successfully conducted 6 flights on the occurrence aircraft between 08 and 11 August 2018, which involved 6 water takeoffs and landings. Earlier in the day on 16 August 2018, the pilot had landed successfully at Virginia Falls; the accident took place during the second landing of the day.
No Egress Training For Pilot Completed
(Direct Copy From Accident Report) — Emergency underwater egress training has been available in Canada for several years, but was not required by regulation at the time of the accident. The occurrence pilot had not received underwater egress training; however, she had discussed the procedure with other pilots who had received the training.
Repetitive Cargo Door Issues Remain A Topic
(Direct Copy From Accident Report) — The rear double cargo doors have been identified as a risk to passengers in emergency situations for many years. As a result, the TSB and other investigative agencies have been advocating for changes to the door design.
On 22 March 1991, Cessna issued Service Bulletin SEB91-4, providing a service kit and asking owners to incorporate a spring assembly that would automatically retract the handle on the aft door to allow the aft door to pass the forward door. The service kit also included luminescent placards to indicate the location of the door handle and to provide instructions on how to operate it. On 16 October 1997, Transport Canada (TC) issued Service Difficulty Alert AL-97-04, which strongly recommended that owners and operators incorporate Service Bulletin SEB91-4 if they had not already done so. Although incorporating the service bulletin simplifies the procedure to open the double cargo doors, it does not eliminate another problem: the jamming of the forward cargo door against the flaps.
Service Bulletin SEB91-4 had not been incorporated on the occurrence aircraft, nor was such action mandatory under the CARs. In 1998, after a 12-year hiatus in the production of Cessna 206, the Cessna Aircraft Company began producing the Cessna 206H, which was certified based on Part 23 of the U.S. Federal Aviation Regulations. The new model was essentially the same airframe as the U206G, which had been produced up until 1986. The difference between the 2 models lay mainly in the power plant and avionics.
Shortly after production resumed, the Cessna Aircraft Company submitted an application to TC for a Canadian type certificate. The previous Cessna 206 had been accepted by TC based on the U.S. Federal Aviation Administration’s (FAA’s) type certificate. However, by 1998, TC’s policy had changed and it no longer accepted applications for Canadian type certificates simply based on FAA type certificates.
During the certification process, TC determined that the new Cessna 206H did not meet the requirements of section 23.807 of the U.S. Federal Aviation Regulations and that the rear double cargo doors could not be considered an emergency exit because they were not readily accessible and because the opening was not simple and obvious.
Between 1999 and 2003, TC, the FAA, and Cessna worked together to come up with a design change that could be applied to the 206H and used to retrofit the previous Cessna 206 fleet. However, no acceptable solution was found, and the matter was dropped. This left the Cessna 206H with a 5-occupant limit and the Cessna U206G and previous Cessna 206 aircraft with a 6-occupant limit.
By 2005, TC determined that some form of action was warranted to address the discrepancy in the number of certified seats in the various models of Cessna 206 aircraft—if only for seaplane operations—given the similarity of the rear double cargo door design. TC proposed an Airworthiness Directive to limit the seating capacity to 5 on all models of Cessna 206 aircraft on floats. After consultation with industry, TC decided in June 2006 to put the Airworthiness Directive on hold until the results of an evaluation of egress from submerged seaplanes became available, which was in August 2006. Ultimately, TC decided to leave the 5-occupant limit on the 206H model. No further action was taken in regard to earlier Cessna 206 series aircraft or to modifying the rear double cargo door. Results of the evaluation indicated there were no suitable design changes that could feasibly be applied to the entire Cessna 206 fleet. By May 2008, TC decided to put the file on hold because of other priorities and the absence of a clear way forward. There are currently 190 Cessna U206 aircraft, 50 Cessna TU206 aircraft, and 11 Cessna 206H aircraft being operated in Canada, in private or commercial service.