More shoulder harnesses, alternate escape routes and improved pilot-monitoring practices were three factors outlined in the national safety agency's investigation into the fatal float plane crash.
"This accident should have been survivable, had the injured passengers been able to get out … or had the fire not started," said Bill Yearwood, a TSB regional manager.
"There are no new recommendations. What we did was highlight recommendations from past investigations," he added about the recently released investigation, targeted at Transport Canada.
"Those recommendations have not been taken to a satisfactory level."
The Air Nootka Ltd. single-engine, de Havilland Beaver DHC-2 float plane took off on the morning of Aug. 16 in rain and foggy conditions en route to company's base near Gold River after picking up five hikers at Hesquiat Lake, about 85 kilometres northwest of Tofino.
The report stated that the cloud ceiling was around 400 feet above sea level at the time, with visibility just over 4.5 kilometres.
Despite the bad weather, Yearwood was reluctant to place too much fault on the poor flying conditions.
"We can't blame the weather," he said. "The weather's there. How we operate in it is important."
The report further outlined that, although the pilot lacked the qualifications to fly using just the cockpit instruments, he entered into low cloud shortly after takeoff and the plane struck a tree while trying to cross a peninsula.
Everyone survived the crash but the pilot and a passenger were killed because they couldn't get out of the wreckage before it burst into flames after impact.
Two other passengers were critically injured while the remaining two escaped unharmed.
Each seat in the aircraft was equipped with a lap belt but only the front two seats had a shoulder harness.
According to national aviation regulations, small planes built after 1986 require shoulder harnesses for each passenger seat — a policy that did not exist when the Air Nootka craft was manufactured in 1956.
The report stated that the "vast majority of the commercial float-plane fleet" in Canada was built before the regulatory change was introduced.
The TSB also wrote that Air Nootka's plane, which it had operated since 2006, lacked any lightweight flight data monitoring systems, including a flight data recorder and a cockpit voice recorder.
While these systems were not required by regulation, the board said that their absence hinders valuable safety lessons from being learned in advance of an incident.
"Air Nootka did not have effective methods to monitor its pilots' in-flight decision-making and associated practices," read the TSB report.
"If companies operating under self-dispatch do not monitor their operations, they may not be able to identify unsafe practices that increase the risk to flight crew and passengers."
The TSB announced last November it would conduct a safety issues investigation into air-taxi operations to address this disproportionate number of fatalities in the air-taxi industry.
Of the 777 total commercial aviation accidents that took place between 2004 and 2013, 485 of them involved air taxis. And of the 256 fatalities, air taxis made up 176, equalling more than 65 per cent.
The study is scheduled to begin in early 2015, though Yearwood said the board has yet to finalize the terms of reference.Suggest a correction