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The wreck of the de Havilland Beaver is brought to the surface off Saturna Island, December 2009. (CBC)

The B.C. Coroners Service is recommending safety changes to seaplane operations on the West Coast, including installing emergency exits on all planes and requiring lifejackets during flights.

The proposed changes are part of 19 recommendations made by a special Death Review Panel that looked into four fatal crashes that killed a total of 23 people on the West Coast between 2005 and 2009.

Most of the recommendations, which are directed at several federal government bodies and the B.C. government, cover a wide range of safety issues including plane design, weather-forecasting and record-keeping.

"These recommendations should be considered very seriously by the agencies to which they're directed," said chief coroner Lisa Lapointe in a statement released on Tuesday.

"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."

Many of the recommendations echo those included in previous reports from the Transportation Safety Board investigations into the same crashes.

Transport Canada has said previously it will hold a focus group with industry members to decide how to address the past recommendations and the conclusion of the focus group recommendations will be presented to the Canadian Aviation Regulation Advisory Council this year.

B.C. Coroners' recommendations:

  1. 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. 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. Transport Canada create a regulatory requirement that illumination strips identifying emergency exits be installed onboard all commercial seaplanes. 
  4. 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. 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. Transport Canada create a regulatory requirement that all new and existing commercial aircraft be equipped with real-time satellite tracking systems. 
  7. 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. 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. 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. Transport Canada eliminate the granting of Operations Specifications that allow commercial VFR fixed-wing operations in reduced visibility conditions. 
  11. 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. 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. 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. Transport Canada develop standardized curricula for Mountain Flying Training and develop criteria for measuring students' proficiency in reaching the acceptable standard.
  15. 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. 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. 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. 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. 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.