It was a tragedy the Transportation Safety Board says deeply undermined the confidence of Canada's float-plane industry.
A mother, the six-month-old daughter she held on her lap and four other passengers survived the November 2009 crash off British Columbia's coast, only to drown because they couldn't escape from the twisted fuselage. The pilot and another passenger escaped and survived.
The Seair Seaplanes Ltd. single-engine de Havilland Beaver crashed and sank in Lyall Harbour off Saturna Island, the southern-most Gulf Island between Vancouver Island and the mainland.
There were several reasons for the crash, but the board's recommendations were most concerned with the inability of the passengers to escape the damaged, sinking plane.
In its final report on the crash released Thursday, the TSB recommended Transport Canada require float-plane operators to install pop-out doors and windows and require passengers wear personal-flotation devices during flight.
It isn't the first time the safety board has recommended flotation devices. In fact, the agency has made the same recommendation in numerous reports over two decades.
Since 1989, 76 people have died in 109 float plane crashes across Canada, many because they either couldn't escape the plane or escaped but still drowned.
Safety board chair Wendy Tadros said three recent crashes in B.C. -- which together killed 15 people, including the six that died off Saturna Island -- brought attention to the problem.
"Sometimes it just takes one more accident and I think this is that one more accident," Tadros said.
"In Nov. 29, 2009, a tragedy occurred in British Columbia that deeply affected public confidence in float plane safety. The public rightly expects industry and government to do everything they can to protect passengers."
Dr. Kerry Morrissey and her baby daughter Sarah were among the dead. The other victims were Catherine White-Holman, Thomas Glenn, Cindy Shafer and Richard Haskett.
Accident investigator Bill Yearwood said a chain of events led to the tragedy.
The plane was overloaded in the back end. The wind was drifting the aircraft towards a nearby ridge. The pilot turned and the aircraft stalled, but the plane's stall warning horn and light weren't working.
The aircraft then slammed into the water.
The pilot was seriously hurt in the crash, limiting his ability to provide assistance to the passengers.
"Any one of those links in that chain, if you removed it, would likely have resulted in a different outcome," Yearwood said.
The pilot and another passenger survived because the doors they were sitting next to popped open on impact, the report said. The plane sank quickly, preventing the other passengers from being rescued.
Tadros said the proposed rules wouldn't guarantee lives would be saved in every crash.
"But what we're seeing with these two measures, if you could get out of that aircraft and if you can stay afloat, that the overall chances of survival will be increased," she said.
The recommendations are common sense, she said, adding there's no time to find safety equipment once the crash has already happened.
However, the TSB can't force change and doesn't assign fault or blame in such accidents. Transport Canada regulates the industry and would need to implement such policies.
A Transport Canada spokeswoman said Thursday the recommendation were complex, and the department would carefully review the report and respond within 90 days.
"Transport Canada has already taken safety actions in these areas and has actively been working with the industry on float plane safety," Melanie Quesnel said in an email.
Lyle Soetaert, the president of the Float Plane Operators Association, representing several companies in B.C., said many operators aren't waiting for Transport Canada regulations and are installing redesigned door handles and pop-out doors and windows on their own.
But the industry appears lukewarm on the issue of passengers wearing life jackets. Soetaert said his group would like to see studies that demonstrate wearing a life vest won't hinder a quick exit.
"They are meant to be inflated outside the aircraft, if they are inflated inside that does pose risks and hazards," he said.
Authorities in the United States and Australia are either implementing or have recommended regulations that require life jackets in float planes.
Two small B.C. companies, Air Cab and Bella Coola Air Ltd., already require their passengers wear flotation devices.
