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TSB releases report into 2019 crash that killed Ramara pilot

The Cessna landed on lake with wheels down, causing plane to flip over; Six family members escaped and were stranded near shore overnight before being rescued

The Transportation Safety Board of Canada (TSB) has released its investigation report into the August 2019 crash in which pilot Jeff Mavor, of Ramara Township, was killed.

Mavor was piloting an amphibious Cessna, which he had completely rebuilt, on Aug. 4. Six family members and the family dog were also in the plane as the family took off from the Orillia Rama Regional Airport for its 48-nautical mile journey to their cabin on Upper Raft Lake.

According to the TSB, Mavor had originally planned to make two separate flights. “However, because of a previously planned family engagement, he decided to fly a single flight in order to save time,” the report notes.

The report says that at 12:59, the aircraft touched down on the water of Upper Raft Lake with the wheels in the down position. As a result, the plane flipped over, coming to rest in an inverted position.

“The passengers sustained minor injuries from the impact and managed to egress from the right side of the aircraft,” notes the report. “The pilot, however, did not egress the aircraft and subsequently drowned. The dog also drowned.”

The aircraft was equipped with an emergency locator transmitter which activated, but no signal was received.

The passengers - Mavor’s wife and five of his six children - climbed onto the aircraft’s floats. 

“They paddled the aircraft to the east shore, tied it to a rock, and waited on shore for assistance,” notes the report. They were unable to call for assistance because their mobile telephones were in the aircraft. 

They spent the night on the shore near the aircraft. At approximately 9 a.m. the next morning, another family member informed a seaplane operator at the Orillia Rama airport that the aircraft had not yet returned. 

The operator dispatched an aircraft and the seaplane was located about an hour later on Upper Raft Lake. 

“The pilot landed to assist the survivors,” notes the TSB. 

The flight information centre in London and the Joint Rescue Coordination Centre in Trenton were then notified. 

Shortly after, the Joint Rescue Coordination Centre dispatched two aircraft to the site and the survivors were airlifted to hospital.

Mavor was certified and qualified for the flight in accordance with existing regulations. 

The TSB report noted Mavor obtained his commercial pilot licence in March 2005, and obtained his seaplane rating in June 2005. He had accumulated approximately 3,100 total flight hours.

The report concludes weather was not considered a factor.

However, the aircraft touched down on the surface of the water with the wheels down; that caused it to flip over, says the TSB report.

Typically, for a water landing, the wheels would not be down.

When it flipped, the aircraft came to rest inverted; the floats above the water kept it afloat.

The TSB notes the aircraft was recovered from Upper Raft Lake five days after the occurrence. It had sustained substantial damage. 

“All damage to the airframe was attributable to impact forces when the aircraft flipped over,” noted the report.

All of the control surfaces were accounted for; the flaps were found set to 30º. The aircraft’s flight instruments were intact. 

A global positioning system (Garmin Aera 660) was removed from the aircraft and sent to the TSB Engineering Laboratory in Ottawa, Ontario, for analysis. The unit provided information pertaining to the occurrence flight, including the flight path.

All of the wheels were found fully extended and the landing-gear selector handle was found in the UP position. 

It could not be determined if the handle had been selected up by the pilot at some point, or if it had moved to the UP position as part of the impact and egress sequence.

The landing-gear system on the aircraft was powered by an electro-hydraulic power pack made up of an electrical pump and a hydraulic fluid reservoir mounted as a unit on the forward left-hand side of the engine firewall.

The aircraft was equipped with an amphibious landing-gear position advisory system, which was meant to provide an aural warning as to the landing gear position when the aircraft decelerated through a specific airspeed. 

This system was examined to determine the threshold airspeed at which the advisory would activate and to confirm if the aural warnings were serviceable. It was determined that the threshold airspeed setting was set to activate the unit once the airspeed was reduced to 95 mph or below.

The electrical ground connection for the amphibious landing-gear position advisory system was broken. Following the prolonged water immersion of five days in the lake, the advisory system could not be repaired and remained defective, providing no aural advisory or warning light.

The investigation could not determine if the unit was operational during the flight.

The hydraulic pump and motor were examined and appeared to have no deficiencies that would have affected normal operation, the TSB report noted. The landing-gear selector assembly was fully functional and leak-free.

SAFETY MESSAGE
The TSB’s probe was “a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues,” notes a media release.

The report concludes with a safety message.

There were two adults and five children on board the aircraft, but only four seats and restraint systems. 

The two available shoulder harnesses were not used by the front-seat occupants. One child was held on an adult’s lap and was unrestrained; another child was not sitting in a seat at all. Two children were sharing one seat and not wearing the available safety belt.

“It is important that each occupant has their own seat and uses the available restraint system to improve the odds of survival and egress from an aircraft involved in an accident,” notes the report.

“The passengers in this occurrence were able to exit the aircraft after the impact. However, there were not enough personal flotation devices for everyone on board,” the report notes. “It is important that aircraft have enough personal flotation devices on board for all occupants in case of an accident on water.”

In addition, the report notes the pilot had not received underwater egress training. 

“This training has been demonstrated to improve the chances of survival in seaplane accidents and should be considered by private seaplane operators,” the report notes.

THE PLANE

The report notes Mavor was piloting a single-engine, six-seat plane manufactured by Cessna Aircraft Company in 1968. During the flight, it was equipped with four seats. It was privately registered and was maintained on an annual inspection program as specified in the Canadian Aviation Regulations.

The aircraft had been in a previous accident in 2013. It had been completely rebuilt by the pilot, who was also a licenced aircraft maintenance engineer. During the rebuild, which was completed in February 2019, some modifications were installed, all in conformance with the supplemental type certificates approved for the type and model of the aircraft, notes the report.

The aircraft had been flown approximately 23 hours since it had been rebuilt. In July 2019, after approximately 14 hours of air time since the aircraft had been rebuilt, Wipaire 3730 amphibious floats were installed. 

The floats incorporated a retractable landing-gear assembly that enabled the aircraft to land on runways or on water. The aircraft had then flown approximately nine hours before the accident.

Click here to read the report.


Dave Dawson

About the Author: Dave Dawson

Dave Dawson is community editor of OrilliaMatters.com
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