I wonder if the Canucks (TSBC), while conducting their review of the ATSB, have touched on comparing investigation methodology with this just released TSBC
Final Report on a Squirrel accident...
Aviation Investigation Report A12P0079
...to the ABC Lake Eyre accident??
AO-2011-102_final_1_.pdf
Although not perfect in comparison e.g. terrain, day v night etc it does have enough similarities to explore differences in investigative methodology and to review the end result over investigations that were being run over a similar period and timeframe.
NOTE: The following passage from the TSB report is very interesting and also draws some remarkable parallels to the ATSB Final Report and SRs from the
17 October 2003 Bell 407 Cape Hillsborough accident..
During the period of January 2000 through May 201
2 in Canada, at least12 occurrences involved VFR helicopter flights colliding with terrain in instrument meteorological conditions (IMC). Of those occurrences, 4 involved a loss of control at sufficient height above the surface to result in collision with terrain in an unusual attitude. These 4 occurrences involved 9 persons, 7 of whom were injured, 3 fatally.
Previously, the Transportation Safety Board (TSB) had identified a safety deficiency associated with helicopter pilot instrument flying skills. On 13 November 1990, the TSB authorized the release of the following recommendation (A90-81):
Footnote 7The Board recommends that:
The Department of Transport require verification of proficiency in basic instrument flying skills for commercially-employed helicopter pilots during annual pilot proficiency flight checks.
On 05 September 2012, the TSB issued the following Board Assessment of Response to A90-81:
Footnote 8TSB does not dispute TC’s contention that “inadvertent” VFR into IMC events constitute a small percentage of the total VFR into IMC events. However, TSB believes that given the fatality rate of these events, TC’s efforts to date to reduce the causes of VFR into IMC events are inadequate.
Consequently, Recommendation A90-81 concerns itself with refreshing skills, acquired during licence training, which are designed to assist pilots in extracting themselves from a VFR into IMC event. The fact that the majority of VFR into IMC events may be preceded by poor pilot decision making does not diminish the value of maintaining piloting skills intended to deal with such an event.
TC’s response is critical of the 180-degree-turn procedure which is outlined in its TP9982E Helicopter Flight Training Manual. TC explains that, due to a combination of an unstabilized helicopter, a panicked pilot and the inherent difficulty in transitioning to instruments, the successful use of the 180-degree-turn procedure is unlikely. TC’s response suggests that this VFR into IMC situation is exacerbated by the pilot being “without any recency in instrument flight”. TSB understands that the instrument flying instruction as conducted during licence training does not qualify any pilot to fly IFR. However, the training emphasizes that the recommended 180-degree-turn procedure is to be used in an emergency and is characterized as the “safest and most expedient procedure” to transition back to VMC.
TC states that because Canadian regulations do not require day VFR aircraft to be equipped with the instruments necessary to safely fly in IMC, all such aircraft would need to be upgraded to accomplish manoeuvres such as a 180-degree turn. It concludes that implementing Recommendation A90-81 would be prohibitively expensive. TSB appreciates that the instrument flying taught during licence training is designed for a pilot who encounters a VFR into IMC event while flying a helicopter not suitably instrumented for IFR flight. The “basic instrument flying skills”, referred to in Recommendation A90-81, are those taught during licence training which does not require use of an IFR equipped helicopter. Therefore, a universal upgrade of the current day VFR helicopter fleet would not necessarily be required to implement Recommendation A90-81.
TC’s comparison between the U.S. and Canadian commercial helicopter experience operating under VFR into IMC focuses on the limitations of the U.S. air ambulance and a regional sightseeing phenomenon. The FAA’s NPRM, referred to in TSB’s assessment, is entitled Air Ambulance and Commercial Helicopter Operations, and the two referenced NTSB recommendations calling for enhanced training for commercial helicopter pilots resulted from accidents under flat light conditions involving commercial helicopters.
While TC believes there is value in including an instrument flying exercise as part of the licence training, its current analysis sees no benefit in enhancing recurrent training in the manner described in Recommendation A90-81. While it has stated a concern for the fact that 50% of VFR into IMC accidents result in fatalities, it maintains that the status quo in mitigating these risks is the obvious and most effective means of preventing these accidents.
Currently, the risks associated with VFR flight into adverse weather remain substantial and TC has not indicated it plans any action to reduce the risks associated with allowing a non-instrument rated commercial helicopter pilot’s basic instrument flying skills to deteriorate as described in Recommendation A90-81. Consequently the reassessment remains as Unsatisfactory.
Next TSB Action (05 September 2012):
The Board has determined that as the residual risk associated with the deficiency identified in Recommendation A90-81 is substantial and because no further action is planned by TC, continued reassessments likely will not yield further results.
The deficiency file is assigned a Dormant status.
The Canucks have definitely not moved on to
beyond all sensible reason and they still heavily rely on past Safety Recommendations i.e. their SR database...
Hmm now there's a point of difference in methodology!
