The report is
out.
Unimpressive mission readiness.
Immediate Causes:
•Little experience of the crew regarding the applicable procedures at night over sea
•The approach deviated from the described approach procedure
•In regard to the altitude, the airspeed, and the rate of descent the approach was not stabilised
•The descent was commenced prior to being on final approach and without visual contact with the ship
•Insufficient monitoring of the flight instruments
•Loss of situational awareness in combination with loss of control
•Non-reaction to visual and audio altitude warnings of the radio altimeter
Systemic Causes:
•Insufficient descriptions of tasks and procedures regarding the flight-safety improving crew cooperation particularly for the offshore scenario
•Insufficient company specifications for the use of the flight attitude stabilising functions of the autopilot system during approaches and departures and in traffic circuits above sea
•Lack of go-around criteria for a non-stabilised approach
•Lack of aviation regulations for offshore helicopter flight operations in Germany
•Insufficient assessment of the operator’s procedures by the responsible supervising authority
•Insufficient understanding for the characteristics of offshore helicopter operations by the responsible supervising authority