Aviation Safety Study SSA9301

After a take-off run of approximately one mile, the aircraft became airborne near the end of the lake. It struck tree tops on the shore and continued to fly over rising ground until it struck trees on a ridge 1,300 feet from the lake. The aircraft crashed inverted and was destroyed by fire. Examination of the wreckage did not reveal any malfunction of the engine, airframe or controls. It was estimated that the aircraft was overloaded by approximately 200 lbs.^{Footnote 1}

Between 1976 and 1990, there were 1,432 seaplane^{Footnote 2} accidents in Canada. During this period, 452 people died in 234 seaplane accidents. Figure 1 shows the seaplane accident experience by year.^{Footnote 3}

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Since there is no requirement for seaplane operators to report the number of hours flown, the accident rate (number of accidents per one hundred thousand hours) is unknown. Seaplanes account for 19% of the Canadian aircraft fleet and 18% of the total number of accidents. However, in most parts of Canada, seaplanes operate only about six months of the year. Thus, the number of seaplane accidents would appear to be disproportionately high. Unfortunately, different annual utilization rates for landplanes and seaplanes are unknown.

It is observed, however, that aeroplanes which are most frequently float equipped, such as Piper Cub "derivatives" (J3, PA11, PA12, PA14, PA18, PA20, PA22), Cessna 172, Cessna 180, Cessna 206, Beaver, and Otter, have more fatal accidents on floats than on wheels. When these aeroplanes are on wheels, 10% of the accidents are fatal, but when on floats, 17% are fatal.

The Transportation Safety Board of Canada (TSB) conducted an examination of these 1,432 seaplane accidents in order to identify areas of seaplane operations where safety deficiencies might exist and which might require further study.

For analysis purposes, accident investigation agencies around the world, including the TSB and its predecessors, use the International Civil Aviation Organization (ICAO) Accident/Incident Data Reporting (ADREP) system. Under ADREP, accidents are assigned standardized contributing factors^{Footnote 4}. During the initial examination of the seaplane accidents, it appeared that contributing factors which could be associated with the pilots' levels of skills, abilities, and knowledge had been cited in a significant number of cases. Contributing factors such as "improper operation of...," "pilot selected unsuitable area," "operation beyond ability," "pilot failed to...(abort take-off, maintain control, follow procedures)," and "improper decisions" were frequently cited.

This study aims to advance aviation safety by examining the seaplane accident record and identifying safety deficiencies associated with the levels of skills, knowledge, and decision-making abilities of pilots engaged in seaplane operations.

The study first describes the characteristics of seaplane accidents which differentiate them from other aeroplane accidents. It then considers the factors which have contributed to these accidents and examines the training and background of the pilots involved. Finally, the report describes the safety deficiencies identified and proposes safety actions to correct them.

Information from the accident files was analyzed in the context of the total Canadian fixed-wing seaplane accident record. However, the lack of normative data results in a lack of standards for evaluation. Therefore, because of the lack of information on non-accident seaplane pilots, the issues could not be analyzed in the context of all seaplane flying in Canada. This is not a serious limitation, however, as the focus of this study is on seaplane pilots who did have accidents.

Of the 1,432 accidents examined, 359 resulted in at least one fatality or serious injury. These 359 accidents will be referred to as "serious accidents" for the purposes of this study.

4.1 Phase of flight

Figure 2 shows the distribution of the accidents during the study period by phase of flight. (Appendix A provides the ICAO definitions of the phases of flight used in this report.)

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It can be observed that en route accidents account for a little less than a quarter of all accidents, but for more than a third of the serious accidents. Nevertheless, the focus of this study will be on those aspects of seaplane operations which differentiate them from other flying operations.

Except for small aerodynamic differences, handling seaplanes en route does not require skills and knowledge markedly different from those required for flying landplanes. Therefore, en route accidents involving seaplanes will not be examined in this study. For information purposes, the data concerning en route accidents is contained in Appendix B. It is worth noting that 23% of en route seaplane accidents are cases of VFR flight into adverse weather, a safety issue addressed by the TSB in a 1990^{Footnote 5} report.

4.2 Types of accidents

The following sections indicate the most frequent types of accidents for each phase of flight. (Appendix A gives the ICAO definitions of the types of occurrence used in this section.) In some cases, there are two types of occurrence for the same accident. In this study, only the first type of occurrence is taken into account in order to avoid using the same information twice. Generally, the second occurrence is triggered by the first one.

4.2.1 Standing and taxiing

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During the standing and taxiing phase, most accidents involved losses of control, propeller contacts, nose down/over, and collisions. As far as serious accidents (not on graph) are concerned, 15 resulted from propeller contact, 3 from nose down/over, and 2 from loss of control.

As engine power was reduced and the mixture pulled to cut-off, a passenger got out of the right door and walked forward on the float, presumably to tie the aircraft down. He walked into the propeller and received a fatal head injury.

4.2.2 Take-off

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Take-off accidents are those which occur between the beginning of the take-off run and the first power reduction after becoming airborne (see Appendix A for ICAO definitions). As can be seen in Figure 4, loss of control was, by far, the most frequent type of accident.

The most frequent types of serious accidents during take-off were loss of control in flight (47 accidents), engine failure (31 accidents), and collision with objects (16 accidents). Loss of control on the water surface and dragged wing were also frequent on take-off, but seldom resulted in serious or fatal injuries.

The engine failed as the pilot initiated a left turn after take-off from a lake. The pilot continued the turn in an attempt to land on a suitable water surface. Witnesses saw the aircraft dive into the lake after apparently stalling at about 150 feet. Subsequent inspection revealed fuel starvation as the cause of the engine failure.

4.2.3 Approach and landing

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During the approach and landing phase, although hard landings were the most frequent types of accident, loss of control in flight resulted in the largest number of serious accidents (15). Collisions with objects resulted in 12 serious accidents and nose down/over on the surface resulted in 11 serious accidents.

Following an uneventful flight, the aircraft was touching down in a light crosswind. The pilot reported that the wind lifted the left wing and caused the nose of the right float to dig in and the right wing-tip to strike the water. The aircraft nosed down and then slowly nosed over, coming to rest inverted.

4.2.4 Summary

The following table summarizes the most frequent types of accidents. En route accidents are excluded from this table^{Footnote 6}.

Figure 6 Most Frequent Types of Seaplane Accidents(En route accidents excluded)

In the following section, the contributing factors cited in seaplane accidents will be examined, in particular those factors associated with the types of occurrence of most relevance to this study. For instance, although propeller strikes are often serious, they are relatively rare occurrences which are normally not related to pilot knowledge, skills or decision-making, except when it is established that an injured passenger had not been briefed adequately by the pilot regarding the danger of the propeller. In an article titled "Strike one and you're out!" published in Issue 1 of Aviation Safety REFLEXIONS magazine, the consequences of inadequate safety briefing regarding the propeller were emphasized through selected excerpts from seaplane accident report summaries. Because this study looks at piloting skills, abilities, and knowledge, little attention will be dedicated to propeller strikes.

The ten most frequently cited contributing factors in the 1,432 seaplane accidents which occurred during the review period are listed in Figure 7. These factors accounted for approximately one-third of all factors cited. The contributing factors are defined in Appendix A.

Figure 7 Most Frequently Cited Contributing Factors

From this list of most frequently cited contributing factors, it appears that the accident seaplane pilots lacked the necessary skills, knowledge, and abilities to operate safely.

The factor "Failed to obtain/maintain flying speed" can result from poor technique, poor judgement, lack of knowledge or combinations of all three.

"Selected unsuitable area," "Inadequate pre-flight preparation," "Failed to follow approved procedures/directives," and "Operation beyond ability" are factors which suggest poor judgement and/or inadequate training.

"Unfavourable wind," "Improper wind compensation," "Improper landing flare," "Failed to see/avoid objects," and "Glassy water" are factors which are associated with poor technique.

These deficiencies are also apparent when, in the following sections, one looks at the most frequent contributing factors cited in the most common types of serious accidents.

5.1 Loss of control during take-off

5.1.1 Loss of control on the water during take-off

The four-seat float-equipped aircraft was being flown in support of a geological survey team. Two members had been picked up and the pilot was making his second cross-wind take-off attempt; the wind was from the left at 10 to 15 knots. The aircraft weathercocked left and developed an uncontrollable yaw. A float dug in and the aircraft came to rest on its back.

Accidents involving loss of control on the water during take-off had the following contributing factors cited:

Improper wind compensation 16

Failed to maintain directional control 14

Premature lift-off 9

Unsuitable area 9

Unfavourable wind 9

Sudden wind shift 6

Operation beyond ability 5

Rough water 5

The majority of the factors are related to the wind, (improper wind compensation, unfavourable wind, sudden wind shift, rough water), and suggest a lack of proper technique in dealing with various wind conditions. A seaplane is affected much more by wind during landing and take-off on water than is a landplane on a runway. For example, the steering of the aircraft is more difficult because there are no brakes and no nose or tail-wheel steering (this is particularly noticeable during the first part of the take-off when the aerodynamic rudder cannot totally compensate for the propeller-induced yaw). Lakes are frequently surrounded by hills which can cause unpredictable shifts in wind speed and direction. On rough water, there is a natural tendency for pilots to pull the aircraft out of the waves as early as possible to get away from the pounding of the take-off surface; however, rough water is often a consequence of strong gusty winds, and it is not unusual that an aircraft gets airborne on a gust and drops back onto the surface during a lull. A longitudinal oscillation when the aircraft is on the step can quickly develop and cause the aircraft to nose-over.

5.1.2 Loss of control in flight during take-off

Loss of control in flight is either a stall or a situation in which an aircraft goes out of control and strikes the ground, water or objects.

After taking off in the narrowest part of the lake, the pilot, at a height of about 20 ft, turned abruptly to the left towards the longer section of the lake. The aircraft stalled and struck the water in a nose-down, right-wing-low attitude.

The most frequently cited contributing factors in loss-of-control accidents during take-off were:

Failure to maintain flying speed 72

Pilot selected unsuitable area for take-off 24

Premature lift-off 20

Unfavourable wind 19

Operation beyond ability 15

Downdrafts and updrafts 15

Inadequate pre-flight preparation 14

Misused flaps or other high-lift devices 13

Failed to follow approved procedures 12

Failed to abort take-off 12

Improper operation of primary controls 10

Improper wind compensation 10

Many of these factors bring to mind a lack of skill or knowledge on the part of the pilot. Factors such as "Failure to maintain flying speed," "Premature lift-off," "Misused flaps," "Improper operation of primary controls," and "Improper wind compensation" are frequently related to poor technique or a lack of skill. Factors such as "Unsuitable area," "Inadequate pre-flight preparation," and "Failed to follow approved procedures" might demonstrate a lack of knowledge. Factors such as "Operation beyond ability" and "Failed to abort take-off" can result from poor judgement.

5.2 Engine failure during take-off

The take-off was normal until the aircraft reached the end of the lake, when, at a height of about 350 feet above ground level, the engine was heard to sputter and lose power. As the aircraft commenced a turn to the right, the engine regained power, and the aircraft then continued back on course. About one-half mile further on, the engine again lost power, and the aircraft again commenced a right turn. As the aircraft turned, the nose suddenly pitched down, and the aircraft spun to the ground. The aircraft was consumed by post-impact fire, and both occupants were fatally injured. The pilot had refuelled the aircraft from a water-contaminated drum of fuel, without using a filter or water trap, and the engine lost power due to water in the fuel.

The leading contributing factors in accidents involving engine failures on take-off are:

Water in fuel 21

Engine failure for undetermined reason 21

Inadequate pre-flight preparation 11

Improper operation of powerplant controls 11

Carburettor icing 10

Fuel starvation 8

Fuel mismanagement 7

Improper use of carburettor heat 7

"Water in fuel" ties with "Engine failure for undetermined reason" for number one contributing factor. It is surprising that fuel problems (water in fuel, fuel starvation, fuel mismanagement) are the most frequent contributing factors in take-off accidents since, in that phase of flight, no build-up of events has yet had time to develop: the pilot is not lost and out of fuel, no change of tank should be involved, and vapour-lock is improbable because the low altitude and the use of boost pump when applicable should preclude such a phenomenon.

On seaplanes, carburettor icing on take-off is a greater risk than on landplanes because of the high level of humidity, due in part to the water-spray on some models, during the take-off run.

"Improper use of carburettor heat," "Improper operation of powerplant controls," and "Inadequate pre-flight preparation" are behaviours which denote lack of knowledge or judgement.

5.3 Collision with objects during take-off

The most frequently cited contributing factors in collisions of seaplanes with objects during take-off are:

Pilot selected an unsuitable area for take-off 23

Failed to see and avoid objects 14

Hit hidden obstruction 11

Inadequate pre-flight preparation 10

Updrafts / downdrafts 10

Failed to abort take-off 8

Operations beyond ability 7

Unfavourable wind 6

Loaded improperly 5

The most frequently indicated factor, "Pilot selected an unsuitable area for take-off," suggests that the pilot exercised poor judgement. "Inadequate pre-flight preparation," "Failed to abort take-off," and "Operations beyond ability" also reveal behaviours in which poor judgement would have been a factor.

5.4 Loss of control during approach and landing

5.4.1 Loss of control in flight during approach

The pilot was attempting to land on a narrow strip of water situated between an island and shore. He encountered turbulence at tree top level and the aircraft stalled, dropped a wing, and struck the surface of the lake.

The contributing factors most frequently cited in the case of accidents involving loss of control during approach and landing were:

Failed to maintain directional control 12

Improper wind compensation 11

Unfavourable wind 10

Improper operation on ground 8

Unsuitable area selected for landing 6

In this case, more than three-quarters of the accidents attributed to the most frequently cited contributing factors indicate a failure on the part of the pilot to take the proper action.

These accidents were generally characterized by a stall, or a stall followed by a spin at low altitude while turning from base leg to final. Many of the visual cues and approach aids that are available to land-based aircraft are not there for seaplanes about to land on the water. Wind direction and strength may be difficult to gauge in the absence of an appropriately located wind sock, especially where local geography may affect the winds in the landing area. Mountainous or hilly terrain on the final approach may alter the pilot's perception of the correct approach angle. In the absence of a clearly defined and visible landing area, the turn from base to final can be easily misjudged and result in excessive angles of bank during a critical manoeuvre for landing. The illusions created by the topography and drift at low altitude can also contribute to approach accidents.

5.4.2 Loss of control on the water during landing

On arrival, the pilot carried out a flapless landing on glassy water and, just after touchdown, the aircraft's left float dug in. The aircraft pitched down, turned left, and the right wing struck the water. The aircraft then pivoted right, and the left wing struck the water. The force of both impacts shattered the windscreen and caused substantial damage to both wings.

The most frequently cited contributing factors in the case of loss of control on the water during landing are almost identical to the ones listed above for loss of control in flight during take-off:

Failed to maintain directional control 12

Improper wind compensation 11

Unfavourable wind 9

Improper operation on ground 8

Unsuitable area for landing 6

A case-by-case review of the accident records revealed that the majority of the loss of control accidents occurring during landing on water happened in cross-wind or glassy-water conditions. In numerous instances, the proper landing technique was not used.

A balked glassy-water landing frequently entails a loss of control. If the flare is too high, the aircraft stalls and the nose or one wing drops. If there is no flare, and with the slightest yaw and/or pitch down, the front end of one float hits the water first and creates an immediate and violent unbalance. In a stalled, nose-down condition, the aircraft usually noses over.

Many factors, particularly the ones which appear on top of the list under each of the most frequent types of occurrence, use wording such as "failed to...," "improper ...(action)," "unsuitable area for...," etc. Such wording leads one to believe that the accident pilots' behaviour was affected by a lack of knowledge or skill in the process of operating the aircraft controls or in electing the best course of action to follow. It is therefore appropriate to consider now the characteristics of the seaplane pilots as well as the seaplane operating and regulatory environment.

6.1 Licence category

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Figure 8 breaks out the accidents by licence category. The charts indicate little significant difference between commercial and private pilots overall. In the absence of normative data regarding the seaplane pilot population (e.g., hours flown in each category), it is not possible to determine whether one category of licence holder has a higher accident rate than the other.

However, when one looks at the breakdown of licence holders involved in the four most common serious accidents, some differences are apparent, as can be seen in Figure 9.

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While commercial and private pilots are spread fairly evenly in the case of collisions with objects and loss of control during take-off, it can be observed that, in accidents caused by loss of control during landing and engine failures during take-off, more private pilots were involved (see data in Table 4 of Appendix B). Other data regarding "engine failure on take-off" accidents show that 34% of accidents involving private pilots were serious while only 17% involving commercial pilots were serious. This indicates that, when the engine fails, commercial pilots are more likely to avoid serious injuries to themselves and their passengers than are their private counterparts.

6.2 Experience

Figure 10 shows the proportion of total accidents^{Footnote 8} that took place when pilots had 500 hours of flight or less in aeroplanes with a given undercarriage configuration, i.e., land or sea. The 500-hour mark was selected because, past that point, the accident versus experience curve flattens out. (This trend is already perceptible past the 300-hour mark in Figure 10.) As expected, pilots in the zero to 100-hour category assume the largest share of accidents. However, this is more so in the case of seaplane accidents than landplane accidents. It can be observed (for accidents where pilot experience is known) that 21% of the seaplane accidents occurred to pilots with 100 hours or less on seaplanes, compared with 17% for landplane accidents. This difference bears even more weight when considering that the majority of seaplane pilots have a total experience which includes landplane flying before upgrading to seaplanes; therefore, a 100-hour-on-seaplane pilot would typically have 160 to 200 hours total experience. The four percentage point difference (21%-17%) suggests that recently trained seaplane pilots may not be adequately prepared to operate that type of aircraft since they account for a higher proportion of accidents than their landplane counterparts, even though they probably have already acquired more total flying experience.

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Above 100-hours flight experience, the difference is in the opposite direction and it never reaches the magnitude observed in the first 100 hours on configuration.

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The above figure shows the five most common accident types which happened to pilots with less than 100 hours in sea-configured or land-configured aeroplanes. For the five accident types combined, it can be observed that seaplanes account for a greater percentage of the total number of accidents. The differences are particularly noteworthy in the case of engine failures, collisions with objects, and dragged wing occurrences. For the first two types of occurrences, the higher percentages belong to landplanes, but for the last one, dragged wing, seaplanes account for a significantly higher percentage, even though float-equipped aircraft are more likely to be of high-wing construction. Dragged wing accidents are generally associated with cross-wind, high wind, or glassy water take-offs and landings, for which no training is required by Transport Canada (TC) before the issuance of a seaplane rating (see section 7.2).

The overall percentages for the five types of occurrences may indicate that a greater proportion of low time seaplane pilots (21%) than landplane pilots (17%) would be lacking the necessary skills, knowledge, or decision-making abilities to safely operate in their particular environment.

Seaplane operations are generally conducted in the more remote parts of Canada. The operating conditions are demanding in that landing and take-off surfaces are not specifically prepared and marked, local topography can cause local variable wind conditions and restrictions to visibility, there is little supporting infrastructure available, etc.

By their nature, seaplane operations require a high degree of independence in problem solving. Updated weather information may not be readily available for pilots. Generally, there is not a control tower or even a Flight Service Station immediately available to relay safety-sensitive information. When in doubt, pilots have little recourse to discuss alternatives with personnel from the supporting infrastructure -- or even colleagues.

Such operating conditions pose a problem for the regulator too. Simply put, the vastness and remoteness of the areas where seaplane operations are conducted hamper effective surveillance of such flight operations.

7.1 Attitudes towards safety

Given this operating milieu, it is perhaps not surprising that a distinct operating culture seems to have evolved. There is a romantic mystique with respect to remote or wilderness flight operations from the water. Some have written about the "bush pilot" syndrome, and a bush pilot folklore has evolved in Canada. Such folklore is not always consistent with safe flight operations.

At the time of the accident, all seats, including the pilot's seat, had been removed from the aircraft to accommodate a load of particle board. During the take-off, the pilot was sitting on the boards and secured by a lap belt.

The pilot had advised his passengers not to wear seat-belts. He believed seat-belts would hamper the chance of escape should the aircraft overturn during the take-off or landing phases of the flight.

The rear seat was not installed, and the passenger, who was seated on one of the canisters, was without a seat-belt.

Reportedly, the pilot usually did not attach his seat-belt and lock his door until after taking-off.

These excerpts from seaplane accident summaries illustrate cases where basic safety procedures were not followed, as if pilots had their own ideas about safe operating practices. Apparently, flying unfastened passengers or passengers seated on canisters sometimes is not perceived as dangerous; and, contrary to the weight of evidence, even wearing a seat-belt is sometimes perceived as dangerous.

In addition, flying overloaded aircraft, particularly in commercial operations, sometimes appears to be an acceptable procedure in seaplane operations.

The take-off was attempted 800 lbs overweight (DHC-3 Otter).

The overload was computed to be 455 lbs (DHC-2 Beaver).

The aircraft was overweight by 454 lbs (Cessna 185).

A pilot who flies an overloaded aircraft can, in effect, be operating as an untrained test pilot, since the flight characteristics of the overloaded aircraft as well as the effects on the airframe have not been documented. Notwithstanding these facts, experienced bush pilots have admitted that flying overloaded aircraft is a fact of life in remote area commercial operations. The problem is not new: in 1925, J.R.K Main wrote in "Voyageurs of the Air" that "overloading an aircraft was general practice, but the degree of overloading varied."

These attitudes towards aircraft occupant restraint and weight limitations are but two examples of a problem which, although probably limited to a few individuals or to small pilot communities, may have serious consequences. The checks and balances built into the system are occasionally disregarded. It appears that, notwithstanding the safe procedures approved by the regulator, tips from friends, hearsay, local recipes, and tricks are sometimes being followed by some seaplane pilots.

Safe practices may indeed be learned through word of mouth, although only by those fortunate enough to be acquainted with the most seasoned seaplane pilots. However, learning from the experience of other pilots may also lead to the propagation of unsafe practices.

7.2 Training and certification requirements

The operation of seaplanes requires different techniques or skills and knowledge from those required for landplane flying. Although poor technique, poor judgement and lack of knowledge are not unique to seaplane operations, the unregulated and unpredictable environment in which seaplanes usually operate can be less forgiving of such deficiencies. Furthermore, decision-making abilities and judgement are called upon frequently in these operating conditions. It appears, from this examination of the accident record, that seaplane pilots are not acquiring or applying the requisite skills and abilities to reduce their operating risks.

The frequency and severity of seaplane accidents involving pilot knowledge, skills, and techniques, as well as judgement and decision making, call into serious question the adequacy of current Canadian requirements for training seaplane pilots.

The training requirements to obtain a seaplane rating are set out in Chapter 5 of the Personnel Licensing Handbook, Volume I, Part II. According to the handbook, the minimum conversion training to be completed in order for an applicant to be issued a seaplane endorsement consists of:

1. Five (5) hours of conversion training including:
   1. not less than three (3) hours dual instruction, and
   2. not fewer than five(5) take-offs and 5 landings as sole occupant of the aeroplane, except for 2 crew aircraft, in which case the take-offs and landings shall be done as pilot in command;
2. The following exercises shall be included in the conversion training:
   1. taxiing,
   2. sailing,
   3. docking,
   4. take-offs, and
   5. landings; and
3. Experience on glassy water, rough water as well as in crosswind conditions is recommended.

The conversion training may be provided by the holder of a Commercial, Senior Commercial or Airline Transport Pilot Licence endorsed for the aircraft being used in the conversion training provided that such holder has acquired at least 50 hours as pilot-in-command of seaplanes [...].

Of note, these minimum requirements address only the basic knowledge and skill required to operate seaplanes. For ratings such as an instructor's rating, an instrument rating, or a type rating, TC has established specific requirements for knowledge and skill training and testing. TC even publishes Flight Test Guides for those ratings so that applicants are made fully aware of required flight test standards and parameters. The basic seaplane endorsement, however, requires only a certain number of practice flying hours, without any ground instruction and without any flight test.

7.3 Trainers' qualifications

Any commercial pilot with 50 hours of pilot-in-command time on a seaplane is automatically granted the right to provide seaplane ground and flight instruction. His or her ability to teach has not been assessed, certified, and periodically re-assessed by TC. His or her "track record" is not maintained by TC since there is no testing for a seaplane rating. Therefore, there is no means for assessing a seaplane instructor's effectiveness as an instructor^{Footnote 9}.

On the other hand, TC does require that a trainer be specifically qualified as a flight instructor to teach night flying. These instructors must be certified by TC and must be periodically reassessed.

7.4 Learning and decision making

Seaplane pilots have to rely on their own experience and advice from others in the seaplane environment to develop their skill and knowledge. TC acknowledges the need for more in-depth learning in its Flight Training Manual. The summary of Exercise Twenty-Six, "Floatplanes," states:

At the completion of a float endorsement training course, remember that unless a course is lengthened to cover all the possible situations a float pilot might encounter, then an endorsement is merely a licence to learn. Approach situations you have not met during training with caution and the assistance of an experienced instructor or float pilot. (emphasis added)

It is well recognized that pilots continue to learn as they gain experience. Ironically, however, this "licence to learn" takes no account of what the bearer will be doing with the endorsement. The seaplane endorsement is identical for both the private pilot and the commercial pilot; yet the latter may "learn" about seaplane operations while carrying fare-paying passengers.

As discussed earlier, information shared between pilots can convey both truths and fallacies. Potentially dangerous acts and decisions which are apparently validated by personal success may become common practice.

TC has promoted a program of "Pilot Decision Making" designed to assist pilots in recognizing their own unsafe behaviour or thoughts and in reinforcing safety behaviour. The value of such a program is well recognized. However, there is no indication that these efforts are having an effect on reducing either the frequency or the severity of seaplane occurrences (the total number of seaplane accidents and the number of serious accidents have remained relatively stable since the early eighties).^{Footnote 10}

7.5 Proficiency

Generally, seaplane operations are conducted during the months of May to October. In more northern latitudes, ice conditions may limit operations to only two to three months. Consequently, the maintenance of currency in techniques for taking off from and landing on water surfaces suffers. Operating a seaplane in a remote environment requires skill and judgement, traits which can erode with the passage of time. The higher proportion of fatalities associated with seaplane accidents underlines the high costs of a lapse in skill.

Currency requirements have been historically weak in Canada, and the subject of safety critique on a number of occasions^{Footnote 11}. More recently, TC has moved to require five take-offs and landings in the previous six months if the licence holder wishes to carry passengers. No special provision has been made, however, for the operation of seaplanes.

7.6 Periodic flight review

In March 1992, TC published in the Aeronautical Information Publication (A.I.P. Canada) an Aviation Notice titled "Proposal to introduce a flight review." The proposal would require a pilot to successfully complete a flight review (ground and flight subject matters) within each 24-month period. The Aviation Notice mentions that: "The proposal is the result of numerous studies indicating that recurrent training is essential to the maintenance of pilot competency. Also, as a member of the International Civil Aviation Organization (ICAO), Canada has an obligation to meet the ICAO requirement that its member states, once having issued a licence, must ensure the holder maintains competency." At the time of writing this report, no change of regulations or ANO has been made on this issue, nor has Canada filed a difference from ICAO standards.

The proposal states that, "for the purpose of the flight review, sea and land class aeroplanes shall be deemed to be the same class. For example, an aeroplane pilot whose licence is endorsed for single and multi-engine land and sea aeroplane may complete the flight review requirement in a multi-engine land aeroplane."

This study demonstrates that, in many facets of their operations, landplanes and seaplanes differ so much, particularly in the taxiing, take-off, approach and landing phases, that skills applied in one class of aeroplane are not necessarily transferable to the other class. A flight review in a landplane would not ensure the competency of a seaplane pilot.

7.7 Commercial pilot proficiency check

The Air Navigation Order (ANO) Series VII No.3, Standards and Procedures for Air Carriers Using Small Aeroplanes in Air Transport Operations applies to most commercial seaplane operations because the majority of such operations are carried with small aeroplanes (12,500 pounds maximum certificated take-off weight). This ANO specifies, among other things, the training and crew qualification requirements for commercial pilots engaged in air carrier operations. Under the provisions of the ANO, the air carrier "shall establish and maintain a ground and flight training program to ensure that each pilot is adequately trained to perform his assigned duties, including those relating to abnormal and emergency procedures."

An air carrier is specifically required, under the ANO, to provide ground training for a pilot before he serves as a crew member; such training includes company operations specifications, operations manual, type of aeroplane to be flown, etc. There is also a specific requirement for annual recurrent ground training which applies to surface contamination (airframe icing) and emergency procedures.

In a Commercial Pilot Survey conducted by the TSB in 1991 on Level III to VI air carriers, 14% of the respondents reported that recurrent training never occurred or occurred less than once a year. Moreover, 29% of the pilots who only flew single engine aeroplanes reported the same; the majority of commercial seaplane pilots fly single-engine aeroplanes.

Regarding pilot qualification, the ANO states that to act as pilot-in-command or second-in-command of an aeroplane, the pilot must have completed within the preceding 90 days on the same type of aeroplane at least three take-offs and landings. It is apparently a current practice among seaplane operators to have the pilots conduct solo self-training (re-familiarization) at the beginning of the season to comply with the three-landing requirement and with the emergency training requirement. In April 1991, a pilot who had just reported for work at the start of the seaplane season was killed during a self-checkout session as he attempted landing on glassy water.

The ANO specifies that the air carrier shall "ensure that each crew member during emergency procedure training actually performs each emergency function or action appropriate to his duties, except where it can be shown that emergency functions can be adequately learned by demonstration."

Commercial pilot emergency training seems effective in ensuring the skills of commercial seaplane pilots when they face an actual emergency. For example, the data show that in case of an engine failure, commercial operations are less likely to be involved in a fatal or serious accident.

There is no annual pilot proficiency check (PPC) requirement for commercial pilots who fly single-engine aeroplanes. However, passing such a check every 12 months is mandatory for commercial pilots who fly multi-engine aeroplanes. In 1988, in an accident report concerning a six-seat seaplane, the CASB recommended that "the Department of Transport institute a method of ensuring the proficiency of pilots who are engaged in the commercial operation of single-engined aircraft in VFR operations only." Through its Air Carrier Advisory Circular (ACAC) No.0015R dated 21 September 1992, Transport Canada informed the community of its decision to implement a certification of competence for pilots involved in single-engine aeroplane commercial VFR operations. However, the proposed amendment states that the pilot shall have, "within the 12 months preceding and on the most complex aeroplanes in which he/she is to act, been certified as competent by the Chief Pilot or his/her delegate, in the performance of all those Pilot Proficiency Check items contained in Schedule IV (Schedule C), which are applicable to single-engine aeroplanes." This proposed new PPC would ensure the proficiency of pilots engaged in the commercial operation of single-engined aircraft. However, the safety benefits of such a proficiency check would be lost if it were performed on a landplane when the pilot is to operate seaplanes.

7.8 Summary

Seaplane operations are carried out in an unforgiving environment that requires special skills, knowledge, and decision-making abilities. In populated areas, transport activities are exposed to the scrutiny of the regulator and the public. Seaplanes are usually operated in remote areas; as a result, a distinct culture about their operations has evolved largely unchecked over the years. Consequently, seaplane pilots tend to acquire skills and knowledge through trial and error, peer example, and hearsay; this is not the most appropriate way to develop the required abilities.

Sound and proven basic training and proficiency checking would normally be the antidote to the propagation of unsafe flying practices. Unfortunately, there remain several anomalies with respect to the regulator's role in seaplane operations. There is no TC ground school syllabus and requirement; there is only sketchy TC flight training guidance; there is no TC requirement for training in demanding skills such as glassy water, cross-wind and rough water operating conditions; there is no TC training experience and certification requirement for seaplane trainers, no TC knowledge or skill test for the issuance of a seaplane rating, no TC seaplane currency requirement, and no TC periodic seaplane pilot flight review or proficiency check, not even for commercial pilots. There is no question that most Canadian seaplane pilots operate skilfully and safely, in an unforgiving environment. At the same time, the accident record strongly indicates a safety deficiency with respect to pilot proficiency (lack of knowledge, lack of skill, and/or lack of decision-making ability).

This examination of the occurrence record confirms that the incidence and severity of seaplane accidents is disproportionately high in comparison to landplanes. Loss of control during take-off, engine failure after take-off, collision with objects during take-off, and loss of control during approach and landing are the most frequent types of accident resulting in serious injuries or fatalities. The most frequently cited contributing factors in these accidents strongly indicate serious shortcomings in pilot knowledge, skills or techniques, and/or judgement in decision-making. In sum, the evidence calls into question the adequacy of current practices and requirements for initial and recurrent training from water.

8.1 Training

Presently, for training a pilot to fly seaplanes, it is assumed that the pilot need only be familiarized with the general handling characteristics of that class of aircraft. There are seldom any formal ground school sessions where the principles and practices of seaplane operations are explained, nor is any ground school required by regulations. Yet a pilot must be knowledgeable about a number of different operations and techniques to safely operate such aircraft. For example, knowledge of docking procedures, passenger safety procedures, float and hull design and construction, water leakage and drainage procedures, and proficiency in sailing, docking, glassy water, cross-wind and rough water take-offs and landings, etc.

In view of the frequency of seaplane accidents in which the pilot demonstrated inadequate knowledge of the practices and procedures for reducing the risks in operating seaplanes, or in which the pilot demonstrated inadequate technique or skills for the existing conditions, the Board recommends that:

and that

8.2 Trainers' qualifications

Seaplane conversion training may be conducted by any holder of a Commercial or Airline Transport Pilot Licence with 50 hours pilot-in-command experience on seaplanes. The pilot giving the training does not need to have ever submitted to a test of knowledge on seaplane operations, nor have any experience in training or flying training. In light of the circumstances of many of the occurrences which were studied, it is unrealistic to expect meaningful training, evaluation, and recommendation from a pilot whose only qualification is a minimum experience on seaplanes. Given the seasonal and remote nature of seaplane operations, maintaining quality control in the provision of sound pilot training for safe flight operations is a significant challenge. Yet, the occurrence record strongly indicates a need for improved methods for developing seaplane pilots' knowledge, skills, and judgement. In view of the unique requirements for safe flight operations from water, the Board recommends that:

8.3 Evaluation and certification

The attainment of a given standard of knowledge or skill, particularly in the field of motorized equipment operation, generally requires some type of examination. Still, in the case of seaplane operations, a pilot is not required to demonstrate that he or she has acquired an acceptable level of skill, knowledge and decision-making ability. A pilot only needs to have flown the number of seaplane flying hours set out in the Personnel Licensing Handbook to obtain a seaplane rating; there is no requirement to pass a written, oral, or flight test. As a result, TC has no evidence that the applicant has reached a minimum proficiency standard. Although it is normally the trainer's responsibility to recommend the applicant for the seaplane rating, there is room for a wide variety of proficiency level assessments among trainers since there are no established proficiency standards.

To ensure that a minimum level of knowledge, skill, and decision-making ability has been attained after the completion of all required training, the Board recommends that:

and that

8.4 Flying currency for passenger operations

Recently, TC has moved to require five take-offs and landings in the previous six months if the licence holder wishes to carry passengers. However, no special provision has been made for the operation of seaplanes.

The Board does not believe that the conduct of five take-offs and landings in a landplane several months before a flight in a seaplane takes adequate account of the unique skills required to operate a seaplane, nor adequately safeguards the lives of the passengers aboard such aircraft. Accordingly, the Board recommends that:

8.5 Periodic flight review

For the purpose of its proposed biennial flight review, TC states that sea and land class aeroplanes shall be deemed to be the same class. Since unique skills and knowledge are required to fly seaplanes, demonstration of skill in a landplane will not confirm competence in the specific skills required for seaplane operations. Therefore, the Board recommends that:

8.6 Commercial seaplane pilot proficiency check

A proposed new pilot proficiency check (PPC) to be implemented by TC would require an annual check on the most complex single engine aeroplane that the pilot is to operate commercially in VFR. However, for commercial pilots engaged in seaplane operations, the expression "most complex aeroplane" might not always mean a seaplane.

The frequency of seaplane accidents involving commercial pilots suggests shortcomings with respect to the current practices for ensuring pilot proficiency. Therefore, the Board recommends that:

Similarly, there is a requirement for pilots engaged in commercial operations to have completed within the preceding 90 days, on the same type of aeroplane they are to operate, at least three take-offs and landings. This requirement only applies to the type of aircraft, not the landing gear configuration. A seaplane pilot could therefore satisfy the requirement by having flown the same type of aircraft on wheels or skis in the preceding 90 days. By doing so, the intent of recency for take-offs and landings is defeated. Therefore, the Board recommends that:

8.7 Seaplane pilots' seminars

The decentralized nature of seaplane operations throughout Canada's remote regions requires that skills and techniques (beyond those acquired in initial seaplane training) be developed and passed on by experts in the field. These generally sound operating practices do not lend themselves to traditional regulatory controls. Therefore, seaplane pilots require alternative means for acquiring information to refresh and enhance their knowledge for safe seaplane operations.

Some industry representatives have indicated that local seminars would be an effective way of bringing experienced seaplane pilots together to share their experience regarding verified techniques and procedures with their peers. Therefore, in order to reinforce the foundation upon which certified seaplane pilots can build their piloting skills, abilities, and knowledge, the Board recommends that:

Appendix A  ICAO definations

(NOTE: The following definitions are extracted from the ICAO Definitions manual (Doc 9569) or the ICAO ADREP manual. In certain cases, the definitions are complemented by explanations mostly based on information obtained from various parts of these manuals.)

1) Phase of operations

TAXIING: Movement of an aircraft on the surface of an aerodrome under its own power, excluding take-off and landing, but including, in the case of helicopters, operation over the surface of an aerodrome within a height band associated with ground effect and at speed associated with taxiing, i.e. air-taxiing.

TAKE-OFF PHASE: The operating phase defined by the time during which the engine is operated at the rated output.

EN-ROUTE PHASE: The part of the flight from the end of the take-off and initial climb phase to the commencement of the approach and landing phase.

APPROACH PHASE: The operating phase defined by the time during which the engine is operated in the approach operating mode.

(NOTE: This definition is ambiguous because it is unclear what is meant by "the approach operating mode" of an engine; jet engine, in particular, are not operated in a different mode during the en-route and approach/landing phases. The new coding for the phases of operation sheds some light on this matter: "Approach" includes Holding (in the process of completing an approach), intermediate approach (from first fix to final approach), final approach, circuit pattern and missed approach/go-around.

LANDING: Landing is not defined in the ICAO Definitions. As stated before, it is not a phase on its own as it accompanies "Approach" to make the "Approach and landing phase." The new coding, under "Landing," lists: Level off/Touchdown, Landing roll, Aborted landing (after touchdown) and other.

2) Selected types of occurrence

COLLISION TERRAIN/WATER  CONTROLLED: Occurrences in which an aircraft under control of the pilot, strikes level ground or water, or fails to clear a hill or a mountain along its flight path.

COLLISION GROUND/WATER  UNCONTROLLED: Occurrences in which an aircraft capable of being controlled, but not under control of the pilot (disorientation, lack of ability/experience, incapacitation, etc.) strikes level ground or water, or fails to clear a hill or a mountain along its flight path.

COLLISION TERRAIN/WATER  CONTROL UNKNOWN: Occurrences in which it could not be established whether the pilot was in control of the aircraft.

COLLISION OBJECTS: Occurrences in which an aircraft in-flight or on the ground collides with an object on the ground.

DRAGGED WING/ROTOR TIP, POD OR FLOAT: Occurrences in which an aircraft drags a wing or rotor tip, a pod or a float while taxiing, taking-off or landing, without loss of directional control. (Note: When this is the result or a "Loss of control on ground/water" or a "Hard landing" use one of these two classifications, as appropriate.

HARD LANDING: Occurrences in which an aircraft touches down with an abnormally high vertical speed.

LOSS OF CONTROL ON WATER: Occurrences in which a loss of directional control or sudden swerve is experienced while taxiing, taking-off or landing.

LOSS OF CONTROL IN FLIGHT  STALL: Occurrences in which the aircraft spins, spirals or mushes into the ground or water as a result of a stall.

LOSS OF CONTROL IN FLIGHT  OTHER: Occurrences, other than stalls, in which the aircraft goes out of control and strikes the ground, water or objects.

NOSE-DOWN: Occurrences in which an aeroplane noses down on to the ground, water or runway without going on its back (inverted).

NOSE-OVER: Occurrences in which an aeroplane goes over on its back (inverted).

PROPELLER/ROTOR CONTACT: Occurrences in which a person is seriously or fatally injured on the ground as a result of contact with a rotating propeller or rotor.

3) Selected contributing factors

ATTEMPTED OPERATION BEYOND EXPERIENCE/ABILITY LEVEL: Refers to cases in which the pilot is not qualified in the type of aircraft or operation involved, or attempted flight under conditions beyond his experience and ability.

FAILED TO FOLLOW APPROVED PROCEDURES, DIRECTIVES, INSTRUCTIONS, ETC.: Disregard of standard procedures, written or verbal instructions, directives, operations manuals, etc., when such are known by, or available to, the pilot.

FAILED TO OBTAIN/MAINTAIN FLYING SPEED: Failure of the pilot to obtain and/or maintain sufficient airspeed for the conditions involved.

FAILED TO MAINTAIN DIRECTIONAL CONTROL: A general code used when the cause of the loss of control is not clear. Generally used in conjunction with loss of control during take-off or landing.

FAILED TO SEE OR AVOID OBJECTS OR OBSTRUCTIONS: Used where there is complete failure to see and avoid objects or obstructions other than aircraft and also where the pilot sees the object or obstruction too late to avoid it.

IMPROPER OPERATION, POWERPLANT CONTROLS: Improper operation of the powerplant through improper use of throttles, supercharger, cowl flaps, carburettor heat, mixture controls, propeller controls, etc., under the conditions and circumstances involved.

IMPROPER IN-FLIGHT DECISIONS OR PLANNING: The failure to use good judgement or follow good operating procedures while in-flight. Examples are: failure to refuel en route when reasonable prudence would require it (or failure to resolve problems arising in flight); miscalculated fuel consumption; poorly planned approach, etc.

IMPROPER OPERATION OF PRIMARY FLIGHT CONTROLS: Refers to pilot "technique" in the operation of flight controls in the air. Includes trim control. Excludes flaps, spoilers.

IMPROPER LANDING FLARE: Levelling off too high on a landing or failure to break glide properly and flying into the ground.

IMPROPER COMPENSATION FOR WIND CONDITIONS: Failure to make proper drift corrections or allowances for the wind conditions prevailing when taxiing, taking off or landing.

INADEQUATE PRE-FLIGHT PREPARATION AND/OR PLANNING: Refers to ground preparation for flight. The pre-flight check of the aircraft and its equipment, the planning of the flight, weather briefing, fuel reserve, etc., are examples of action which could be improperly performed or omitted.

LACK OF FAMILIARITY WITH AIRCRAFT: Refers to lack of experience with the aircraft involved for the type of operation attempted. It is not used interchangeably with "attempted operation beyond experience/ability level" as it is more specific and could apply to a pilot of broad general experience.

MISMANAGEMENT OF FUEL: Refers to the improper operation of, lack of attention to, the fuel supply. Examples are the failure to turn the proper tank on or to switch to the proper tank. Includes miscalculation of fuel consumption.

MISUSED OR FAILED TO USE FLAPS (OR OTHER LIFT DEVICES): Factor of pilot judgement, training, lack of familiarity with the aircraft or carelessness.

SELECTED UNSUITABLE AREA FOR TAKE-OFF, LANDING, TAXIING: Includes all cases where a pilot selected an unsuitable area for taxi, take-off or landing. Excludes cases where the pilot exercises normal and reasonable precautions, but encounters hidden hazards or conditions not easily determined. Excludes forced landings unless the pilot definitely had the choice of a more suitable area.

Appendix B  supporting data

Table 1 Accidents by Phase of Flight

Table 2 Serious Accidents by Phase of Flight

Table 3 Standing and Taxiing Accidents

Table 4 Take-off Accidents

Table 5 En Route Accidents

Table 6 Approach and Landing Accidents

Table 7 Summary of Types of Accidents

Table 8 Types of Serious Accidents

Table 9 Seaplane and Landplane Configuration Experience

Table 10 Most Frequent Accident Types Occurring to Pilots With Less than 100 Hours on Aeroplanes in Given Configuration (Landplane/Seaplane)