Helicopter crash off the coast of Newfoundland - 18 aboard, March 2009

[zalt]

The response to the recommendations can be followed here:
C-NLOPB || Offshore Helicopter Safety Inquiry - Implementation (http://www.cnlopb.nl.ca/ohsi_implementation.shtml)

The recommendation on restricting night flights (due to the lack of autohover) is #12.


Also Aero Safety World have an article on the accident:
http://flightsafety.org/asw/mar11/asw_mar11_p19-23.pdf

[Shell Management]

Doesn't look like many real improvements have been achieved so far.:sad:

Autohover was already an OGP SAR requirement. Not sure how that was misssed. :ugh:

[zalt]

The Phase II submissions to the Wells Inquiry have now been published.

Industry and regulators basically want the Inquiry to wrap up (TC noting they are constrained because Cougar are suing them).

Unions, famlies and politicians are gunning for the S-92 and demanding that 'run dry time' be considered at when helicopter contract are decided and in one case explicitly requesting that the S-92 is replaced by the EC225.

Commissioner Wells has received Phase II Submissions from the following participants:

Canada-Newfoundland and Labrador Offshore Petroleum Board (C-NLOPB)
Joint Operator [Hibernia Management and Development Company Ltd. (HMDC), Suncor Energy Inc. (Petro-Canada) and Husky Oil Operations Limited]
Cougar Helicopters Inc.
Government of Newfoundland and Labrador
Families of Deceased Passengers
Estate of Matthew Davis (Pilot) and Estate of Timothy Lanouette (Co-Pilot)
Communications, Energy and Paperworkers Union, Local 2121
Offshore Safety and Survival Centre, Marine Institute, Memorial University
Helly Hansen Canada Limited
Jack Harris, QC, Member of Parliament for St. John’s East
Canadian Association of Petroleum Producers

These Submissions were posted on this website. As well, the Commissioner has received a number of Phase II Submissions from the public and he is now in a position to begin to evaluate all Submissions and write a Phase II Report. It is anticipated that the Report will be finished by June 30th.

Offshore Helicopter Safety Inquiry : Phase Two Submissions (http://www.oshsi.nl.ca/?Content=submissions1)
Offshore Helicopter Safety Inquiry : Phase II Submissions from Phase I Presenters (http://www.oshsi.nl.ca/?Content=Submissions_from_Presenters)

Sikorsky still refuse to contribute to the Inquiry.

[[email protected]]

Sikorsky still refuse to contribute to the Inquiry. Not a huge surprise since everything comes back to their gearbox design:

It failed the 30 min run dry and their engineers had to find a workaround - ie exploit the extremely remote clause without (or maybe with) considering a filter bowl failure.

The assertion that a total loss of lubricant was extremely remote drove the drills and procedures in the RFM and the training on the aircraft conversion such that the pilots were slow in identifying the actual failure because it was assumed that such a failure couldn't occur and any MRGB malfunction would have an oil temp indication to help diagnose it.


All of the other issues of survivability come down to the severity of the impact and that crashworthiness over water assumes a controlled ditching - not a TR pinion failure at 400 ft - but the main reason they found themselves in that situation was a poorly designed MRGB not fit for purpose.

I hope Sikorsky are hanging their heads in shame over this sad accident - totally preventable if your business ethos is moral and ethical and you don't try to bend the rules to accomodate a flawed product.

As an aside, does anyone think that a rearcrewman might have noticed gearbox oil pouring down the side past the windows and alerted the pilots to the severity of the problem? The absence of a cabin attendant seems to be the norm in offshore ops (down to cost I suppose), but would a properly trained and experienced rearcrew in the cabin have a. helped the stressed front crew and b. been in a position to help the pax escape if he had been on a HUET system?

[Geoffersincornwall]

There is a general misconception in the helicopter manufacturing industry that their customers are the 'operators' which is unfortunate because many of us wish they recognised that in a major part of the marketplace their customers are in fact the companies that supply the 'self-loading cargo' and who have a duty of care to the same.

A while back I was a guest of one such (oil) company and took part in a video-conference and presentation with a Sikorsky team. Sikorsky were given the benefit of a presentation at the end of which it was suggested to Sikorsky (and other manufacturer's please note) that this particular (oil) company would be grateful if they took 10 kilos away from the disposable load and put 10 kilos of metal back into the structure of their helicopters.

Tell me if I am wrong but I think this particular customer was frustrated by the many years of living with structures and systems with sometimes extremely low damage-tolerance.

How does that old Nursery Rhyme go -

For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.

Sometimes I think the pressure on Weight Engineers exceeds their ability to understand the concept of damage-tolerance.

G. :ok:

[C.C.C.]

As an aside, does anyone think that a rearcrewman might have noticed gearbox oil pouring down the side past the windows and alerted the pilots to the severity of the problem? The absence of a cabin attendant seems to be the norm in offshore ops (down to cost I suppose), but would a properly trained and experienced rearcrew in the cabin have a. helped the stressed front crew and b. been in a position to help the pax escape if he had been on a HUET system? Firstly lets clear up some confusion. A rear crewperson would be found in your Sea Kings, and the civil SAR helicopter operators. A cabin attendant would be found in civil helicopters, like the Brunei Shell S92As. A cabin attendant would not normally receive the same amount of training & qualifications as a rear crewperson (e.g. no paramedic qualification).

Had this accident S92A been carry a cabin attendant he/she would have been sitting at the front of the cabin and probably would not have seen the MGB oil leaking externally. We brief our Northern North Sea offshore passengers to come forward and advise us of anything they wish to bring to our attention (in cruise flight). However given that the total loss of MGB oil occurred during this accident in 1:55 mins and the helicopter was in an emergency descent (where all passengers and crew should be securely seated) then a warning to the crew about the external oil leak was unlikely.

Let's remember the Kegworth B737 accident. Despite the fact that several of the passengers and 3 of the cabin attendants observed flames from the No 1 engine, this message was not passed to the crew (they shutdown the No 2 engine). This resulted in the recommendation for Training exercises for pilots and cabin crew should be introduced to improve co-ordination between technical and cabin crews in response to an emergency.

When you say HUET system I assume you mean an Emergency Underwater Breathing System (EUBA or STASS - the accident crew & passengers were HUET trained). Why would a Cabin Attendant have been provided with an EUBA/STASS when neither the crew or passengers were at the time of the accident? Whilst our NNS offshore passengers are provided with an EUBA/STASS the crew are not.

Not carrying a Cabin Attendant is down to a client requirement, combined with the fact that most helicopters used offshore are only certified for 19 passengers or less. The Chinooks used on the North Sea required a Cabin Attendant, similarly the SK61Ns when carrying more than 19 passengers needed a Cabin Attendant. Cabin Attendants/Pilots Assistants were also carried on some single pilot IFR operations, until legislation/client requirements required the operations to be 2 crew.

[[email protected]]

CCC - I'm not saying a paramedic needs to be carried and it is not the medical but the aviation training that might have saved the day.

Following the initial indications of a MRGB problem, before the emergency descent was initiated (or even during) a properly trained rearcrew member could have had a quick once round the cabin checking not only for signs of leaks or damage but also to ensure all the pax were correctly secured and seated.

The pax in the Cougar crash didn't have Stass and if they had they would probably have been trained not to use it until after the impact - again a well trained rearcrew might have been on air before impact and been more likely to be able to help the pax escape. Granted that in the Cougar crash the severity of the impact was such that that would have been unlikely but those Newfoundland oil workers weren't given the best chance of survival.

The Kegworth crash is an excellent example of the value of switched on rearcrew - just a shame they didn't go and hammer on the cockpit door to ensure the message got passed - that is a failing of CRM and indicative of an 'us and them' rearcrew vs front crew philosophy.

The legislative requirement for rearcrew is exactly what is missing - the lawmakers say more than 19 pax so the operators put 19 or less seats in - is that really a pro-safety attitude or just a cynical way of keeping pay costs down?

There is no excuse for crew and pax not to have Stass nowadays.

[Geoffersincornwall]

This argument is reminiscent of the one that followed the demise of the Flight Engineer and will suffer the same fate. Alas the genie is out of the bottle and despite this one incident I doubt that there is overwhelming evidence that offshore operations without a cabin attendant are any less safe now than in the days when they were carried.

I think Crab's contemplations about what might have been are a trifle on the optimistic side. Crewies are great guys (and gals - BIH) but they cannot work miracles.

Crab - We can all wish for a better outcome but re-shaping your own prejudices about rear seat crews to justify a different game-plan wont fit these circumstances. You need a better sample to hang your hat on.

G. :ok:

[Dan Reno]

This was discussed eons ago but when SA asked what the passenger load would be and whether a crewmember was to be in the back, ALL customers wanted just the LEGAL amount of Pax in the back that did not REQUIRE an attendant and so the S92's 'Pax in the back' number was limited to what could be legally carried WITHOUT an attendant in the back.

[tistisnot]

In Brazil Petrobras, the customer, demands to have Cabin Attendants in their S92 and EC225 aircraft. On some flights an engineer will also be taken along.

Following an AS332L2 accident in 2008 the Cabin Attendant received the Brazilian Air Force´s highest permissible decoration for her actions.

[Geoffersincornwall]

If Petrobras were focussed on safety and thought C/As were a good thing then they would feature on all types but they don't. Conclusion - Petrobras want to maximise payload and therefore have to carry a C/A because max payload equals more than 19 pax.

It's been my experience that you would be pushed to find the Brazilian offshore helicopter industry leading in any aspect of flight operations. For example, it is, as far as I know, the only major offshore helicopter centre that has ignored the benefit of underwater escape training so anyone focussing on passenger safety should be worried about that. There is a state of the art HUET centre in Macae and more than 45,000 offshore workers who have been persuaded that they don't need it.

G.:ok:

[[email protected]]

Crewies are great guys (and gals - BIH) but they cannot work miracles. but I suspect that you, like I, have had your ass saved or embarrassment avoided by them in the past.

No prejudices, just a suggestion that despite much trumpeting about safety in offshore ops, without stricter world-wide legislation to force the customer to demand the best from the operators, the richest industry in the world will keep getting richer on the back of risks taken by the crews and pax.

[Geoffersincornwall]

It was ever so. The rot set it in the '70s when the UK government accepted that quasi-military standards of operations were acceptable in pursuit of the national interest. They are not my words they are the words of the head of the CAA in 1978.

It has been a struggle ever since but to give the UK oil industry it's due many of the safety related research and subsequent developments were financed by them and frequently were miles ahead of the legislation. HUMS, Suits, HUET, Rebreathers to name but a few.

The rest of the world could have looked at the mistakes we made in the North Sea and progressed straight to the 'right answer' but many chose the way of profit rather than safety and I look to the FAA as being the major guilty party. They are learning now but about 25 years too late for many.

How do you justify an organisation that has a dual remit to both encourage and regulate Commercial Aviation. The conflicts of interest must be enormous.

As for having my ass saved by my back-seat crew I would say it goes with the territory, that's why we are a 'crew' and not a collection of individuals. Unfortunately, having worked with CAs in the North Sea, Greenland, Scillies, Brunei and Spain it has to be said that good as they are they are different animals to the Winch Op/Winchman you get in a SAR crew and I mean that in a complimentary way to both groups. I have reason to appreciate them all.

G. :ok:

[JimL]

We are concentrating on more and more esoteric issues and, consequently, may be missing one of the (more important) links in the causal chain.

(Extracts are selective)

In Paragraph 1.18.3.8 of the accident report it is reported:

1.18.3.8 TSB Examination of CHI91 Filter Bowl Mounting Studs and Nuts

Fatigue initiation was at the minor diameter of the first fully engaged thread on one stud and at the inboard radius of the serrations of the other stud. Fatigue cracking in the first engaged thread of a stud is consistent with insufficient preload causing an excessive vibratory loading to be transmitted to the stud.

Galling was observed on the threads of the occurrence helicopter’s studs, as well as on some of the studs removed from other Cougar helicopters. The galling noted on these studs would have been detectable using 10X magnification, and on some studs the damage would have been visible without the aid of magnification (see circled area – Photo 15). The TSB examination suggested that the occurrence nuts and studs had accumulated sufficient galling damage to prevent the correct preload from being applied during installation. The reduced preload led to an increase of the cyclic load experienced by the studs during operation and to initiation and propagation of fatigue cracks. The TSB’s examination of new studs found that even though the studs were manufactured with a coating to prevent galling, galling damage developed after the first installation of a nut, and the damage became more severe the more frequently the nut was removed and re-installed. The occurrence helicopter, as well as at least three other Cougar helicopters, had MGB oil filter bowl attachment nuts with a grey paint residue that had been applied when the MGB was manufactured.

In observation of the intent of the Cougar implementation of the Sikorsky measures, the report states:

1.18.3.9 TSB Examination of Cougar Helicopters’ MGB Filter Replacement Practices

On 07 November 2008, Cougar Helicopters inserted AMM Revision 13 into its maintenance computers and acknowledged it by signing off on the revision. Company procedures require that maintenance personnel become aware of AMM revised procedures. Cougar Helicopters maintenance personnel are required to read each new instruction and acknowledge having done so, by signing off on the mandatory “Must Read” board.
...

Between the time the occurrence helicopter was manufactured and the accident the helicopter underwent 11 MGB oil filter replacements. During the last two MGB oil filter replacements on the occurrence helicopter, AMM Revision 13 was in effect. At the time of the accident, there was no record of the 10X magnification inspection being performed, nor was there a record of a torque wrench being used to measure the run-off torques on any of Cougar Helicopters’ S-92As, even though required by AMM Revision 13. AMM Revision 13 also required the oil filter mounting nuts to be changed at each removal; however, the nuts installed on the occurrence helicopter were original.

...

The report then repeats the Sikorsky messages to the operators:

1.18.3.10 Sikorsky Actions

About 2 months after the filter bowl stud problem was discussed during the Sikorsky webcast, Sikorsky issued SSA-S92-08-007 on 08 October 2008 that stated:
Sikorsky has been advised that an operator experienced the loss of MGB system oil due to a leak at the filter bowl. The investigation revealed that two of the three MGB filter bowl assembly titanium studs had sheared allowing the filter bowl to displace. As a result, Sikorsky is enhancing the current Aircraft Maintenance Manual (AMM) procedures to aid in identifying potentially damaged studs during the removal or installation of the filter bowl. It is recommended that particular attention and care be taken during the removal and installation of the MGB filter bowl assembly to minimize any potential damage to the threaded portions of the mounting studs.

Approximately 3.5 months after the SSA, Sikorsky released ASB 92-63-014 on 28 January 2009 to its customers, which stated:

Undetected damage to an oil filter stud can lead to failure of the stud. Enhanced procedures are being added to the maintenance manual to help identify potentially damaged studs. To further enhance reliability of this connection, the titanium studs are being replaced with steel.

Finally, the report comments on used studs received from the operators (in respect of expected actions by the operators):

Between 05 November 2008 and 23 March 2009, none of the S-92A operators reported to Sikorsky they had found any damaged studs while performing the enhanced inspection, nor had they contacted Sikorsky to
comment on the steps involved with the enhanced procedures.

On 23 March 2009, the FAA issued Emergency AD 2009-07-53 for Sikorsky S-92A helicopters, which required, before further flight, removing all titanium studs that attach the MGB filter bowl assembly to the MGB and replacing them with steel studs. Sikorsky did not receive any reports of damaged studs between issuance of AMM Revision 13 in November 2008 and when AD 2009-07-53 was issued in March 2009. However, it did receive 59 studs from various operators after they had complied with the AD. Sikorsky examined these studs and found that they had varying degrees of galling of the threads, indicating multiple nut removals. Some of the thread damage was visible without the use of magnification. Photo 16 shows a sample of studs returned to Sikorsky, with varying degrees of galling, ranging from coating loss and minor damage to the threads (stud 1), coating loss and moderate damage to the threads (stud 2), to extensive coating loss and severe damage to the threads (stud 3). The thread damage in stud 3 of Photo 16 was visible to the naked eye. Sikorsky could not provide the time-in-service for the returned studs; however, considering the timing of the AMM revision on 05 November 2008 and the issuing of AD 2009-07-53 on 23 March 2009, and the average S-92A utilization times, they would have come from helicopters that had their filter bowls removed at least three times.

If there is a lesson to be learnt here, it is that expectations resulting from 'soft' measures have to be tempered in the light of human involvement. Additional procedures are not always the best way to address issues and sometimes more direct action is called for. Having had the first occurrence (in Australia), it might have been prudent (in hindsight) for Sikorsky to sample 'galling' damage to other studs in the field. This could have been achieved by requesting photographic evidence from the operators whenever filter bowl intervention was necessary (extremely simple in this age of digital cameras). Comparisons could then have been shown in the weekly webcast.

No-one comes well out of this accident but it is now clear that complacency was a real issue - perhaps because of the perceived 'safety' of the latest certification standards.

Jim

[tistisnot]

All Petrobras heavy aircraft offshore (S92 and EC225 - greater than 15 seats) have one cabin attendant and 18 passenger seats - conclusion, you have been away from Brazil for some time!

[Geoffersincornwall]

Well that's a small step for man and great leap forward for mankind..... at least for Brazilian mankind. I hope the many other areas worthy of attention have also been addressed but I will be very surprised (and pleased) if I hear that the HUET training has been introduced. They should at least offer it.

It would be nice to know if Lufthansa Consulting's 5 year relationship with BR had any beneficial effects. I hope so. They are good people down there and just need the necessary encouragement to find out where in the world the best solution to any problem can be found.

My best regards to the guys in Macae and Rio.

G. :ok:

[js0987]

On the discussion of the merits of a flight attendant/ crew chief; let me add a practical need for an engineer/mechanic to be included as part of the crew. Since the rigs we fly to are Waaay! out there, an occasional minor problem that arises can often be fixed on the rig. Since the deck is fouled with our big beast, and the nearest platform may be 50-80 miles away, not having to send for maintenance can save the rig hours, if not more than a day.

[Hedge36]

Not only do Shell use cabin attendants on their S-92s in Brunei and their EC155s in Nigeria but also on S-92s in the GOM.


Is that voluntary, contractual, or statutory?


It is only in places like the North Sea where the operators think they know better that no cabin attendant is carried.


You make good points, then you chew on your toes. It's downright maddening.

[lynx-effect]

Would that have helped in this case or would it have been another family added to the the grieving list? Probably the latter.

[tistisnot]

If you, the customer, demand it for your aircraft, why blame the operators when other oil companies do not insist?

[maxwelg2]

It is only in places like the North Sea where the operators think they know better http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/cwm13.gif that no cabin attendant is carried.


SM, do you honestly think that a cabin attendant would have made any difference in the historical accidents/crashes?

Is the issue not that there is sometimes insufficient robustness in the A/C's mechanical components, either due to a compromise on acceptable limits and/or design flaws?

Nothing is perfect, to believe so is false, so is putting faith in effectively another PAX who will have no effective control in the event of a MR/TR failure.

PAX are trained to evacuate the A/C in the event of a ditching/capsize, that's only ones of a few areas that require improvement IMO.

All 491 crew and PAX were unconscious from impact, so even a cabin attendant would have been in the same unfortunate situation.

These A/C are designed to stay in the air and thankfully most of the time they do. Placing a cabin attendant and/or mechanic in the rear smacks of other inadequecies. PAX and crew should have 100% confidence in the A/C and the maintenance/condition monitoring system, negating the need for another set of "condition monitoring eyes" or a morale booster to PAX.

We have made some progress, but until the mechanical design issues and pro-active maintenance procedures are properly addressed/implemented and all 16 recommendations from phase 1 of the inquiry are actioned we are no further forward apart from self-awareness by all involved.

Regarding reliability of A/C types in general I've just returned from offshore Malaysia where numerous A/C types are in use by MHS and Westar. It's worth noting that Westar were brought in partially due to the poor accident record of MHS with 3 AS332 accidents and one S61 (see extract below from Malaysian Wings).

"QUOTE
“Since its operation in 1981 in Miri, MHS has been providing excellent service. It only encountered one major accident off Bintulu in Jan 29 last year which resulted in just one death,” he said when met yesterday.


I personally find the phrase "just one death" somewhat disturbing and insulting to the family of the deceased! MHS have lost the work because they actually had 4 major accidents in a very short period of time. One involved an S61 helicopter just after take off from Kerteh (May 2005). Another involved AS332L2 9M-SPA being flown into the water on a flight from Kerteh (Nov 2006). On services from Miri they had two ditchings with Super Pumas with "just one death", AS332L 9M-STT (Jun 2005) and AS332L2 9M-STR (Jan 2007). The customers in Miri lost faith in their services and brought in CHC to take over.

As mentioned previously CHC have now set up a Malaysian Company with local businessmen called Awan Inspirasi Sdn Bhd."

IMO the above is an excellent example of where you cannot just blame the A/C type. I believe that's what commissioner Wells was implying in his report.

Safe flying

Max

[Variable Load]

It is only in places like the North Sea where the operators think they know better that no cabin attendant is carried.

C'mon SM, you really are one big TROLL :ugh:

If the N Sea contract called for cabin attendants then that's what Shell would get. Bottom line is that it costs money, so it doesn't happen. We have been pushing Shell in Malaysia to pay for cabin attendants on the S92s here, but I'm sure you already know what the answer is - NO, NO and NO again! :{

I really do hope that you don't actually believe the bo**ocks that you continue to spout in these forums.

[Brian Abraham]

VL, please don't confuse Smellie with facts. He has enough trouble with comprehension as it is.

then you chew on your toes

Thats bound to happen when ones foot is in ones mouth.

[Horror box]

Whilst I agree that generally a cabin attendant might not add a huge amount to the overall safety, I can say from experience that a good rear crewman is worth their weight in gold when required. The problem here is that the times when a crewman is really required for normal civilian offshore ops is so seldom that nobody really is going to justify the cost. Of course it would be a very nice to have in many situations, and emergency handling in a 3 crew environment can be far slicker than in a 2 crew, if trained correctly. But here we are talking about a nice to have not an absolute necessity. In the cougar aircraft a rearcrew could have helped by looking out of the window and confirming the oil coming out of the side, and could have assisted with the checklist, maybe even offered a "casting vote" on the land immediately situation the crew were in and in slight disagreement about - however the last is purely speculation and it could have been easily the other way. A crewman would also be very nice when landing on the platform especially at night and in bad weather, giving additional guidance and clearance, but we have been doing it for years without one so difficult to suddenly justify. All of this however could also be done much more easily and cheaper, and it amazes me that today we still have not come fully on board. The use of a camera on the tail boom can certainly go some way to giving more vital info to the crew. Whilst some aircraft already have these fitted, it is far from standard in the industry. Even my car has one to stop the wife from hitting the lamp post! (Sorry wife!). Even the 332 L had mirrors fitted to allow the pilot to have a look behind at the top of the aircraft.
In the cougar case the crew would likely have been able to see something awry if they had a view forward over the fuselage. This is also an extremely nice feature to have in cases of engine fires, various oil leaks and other things that can go wrong. In addition it greatly enhance safety when landing during normal ops.
A more relevant question to raise might be why are externally mounted aircraft monitoring cameras not installed as standard, as opposed to why are we not carrying a cabin attendant.

[zalt]

While DND still refuse to accept the Sikorsky Cyclone helicopter there is a belated push to fix the faulty gearbox on the civilian S-92, as TC announce a summit with FAA and EASA.

Not everyone is happy though with the slow pace to resolve the fatal compromise Sikorsky and FAA agreed in late 2002.

A woman whose husband died in the Cougar helicopter tragedy east of St. John's in 2009 is frustrated the federal government hasn't acted more quickly to improve offshore chopper safety.

Newfoundland resident Lori Chynn said the families of people who died in the crash want helicopters that transport workers to offshore oil platforms to run for at least 30 minutes after losing oil pressure.

"It's very frustrating. There's been lots of discussion, lots of investigation. We know what the problem is. So let's put some action into place and let's fix the problem," said Chynn.

Cougar flight 491 crashed in to the ocean east of St. John's on March 12, 2009, killing 17 people. The chopper hit the water 11 minutes after oil pressure dropped in the main gearbox.

Transport Canada is looking into the issue, but said it is consulting with other countries before making any decision to legislate changes.

Transport Canada regulates the aviation industry

TSB recommended changes

In February, the independent body that investigates crashes, the Transportation Safety Board, recommended several improvements to offshore helicopter travel in its report on the crash of Cougar Helicopters flight 491.

The TSB said helicopters must:

Have a main gearbox able to run without oil for 30 minutes.
Not fly in rough conditions.
Have an air supply on all helicopters that fly over water.
Its investigators also highlighted the fact that Cougar Flight 491 crashed 11 minutes after problems were detected.

"There was a complex equation of 16 factors involved in this accident. No one factor stands out above the others," said board spokeswoman Wendy Tadros in St. John's on Wednesday. "The manufacturer, the regulator and Cougar have largely address the problems that have been identified, but risks still exist."

The board's Mark Clitsome said the Sikorsky S92A still cannot run without oil for 30 minutes.

"The Sikorsky S92A came to be certified without a 30-minute run-dry time.The studs have changed, but the gearbox has not changed and in the event of catastrophic oil loss, the S92a would still crash in 11 minutes."




Transport Canada too slow: chopper crash families - Nfld. & Labrador - CBC News (http://www.cbc.ca/news/canada/newfoundland-labrador/story/2011/06/09/nl-chynn-helicopters-609.html)

[zalt]

Cuts in SAR cover make improvements in the S-92's safety (or its replacement) even more important: Budget cuts deep at sea - Local - News - The Telegram (http://www.thetelegram.com/News/Local/2011-06-09/article-2570551/Budget-cuts-deep-at-sea/1)

[zalt]

There is a campaign to reverse the cuts
Campaign to save N.L. marine rescue centre ramps up after deadly weekend | iPolitics (http://ipolitics.ca/2011/06/20/campaign-to-save-n-l-marine-rescue-centre-ramps-up-after-deadly-weekend/)

[squib66]

The Wells Inquiry into offshore helicopter safety made an early recommendation on helmet use after they recieved the pathologist's reports on the crew. From the TSB report:


Although not fatally injured during the impact sequence, both pilots received severe injuries due in part to striking their heads/faces against the instrument panel. Neither pilot was wearing head protection (i.e., approved helmet, complete with visor).

No helmet use policy was in place at Cougar Helicopters at the time of the occurrence, and helicopter pilots were under no regulatory requirement to wear head protection. Prior to the occurrence, approximately 10% of the Cougar Helicopters' pilots were routinely wearing head protection.


and

As shown in this occurrence, without ongoing promotion of the benefits of head protection usage, helicopter pilots will continue to operate without head protection, increasing the risk of head injury and consequent inability to provide necessary assistance to crew or passengers. The lack of a requirement for pilots to wear helmets and visors places them at greater risk of incapacitation due to head injuries following a ditching or crash. This type of injury jeopardizes the pilots' ability to assist in the safe evacuation and survival of their passengers.

But it seems Cougar pilots are resisting the use of helemts in a the 15-person team tasked with finding ways to implement the recommendations of the Wells Inquiry.


Another Wells Inquiry recommendation is mandatory helmets for all pilot’s flying offshore.

Daniel Bourgeois, a reservoir engineer with the CNLOPB, said it was the first recommendation the implementation team studied — believing it would be straight-forward and easily done.

But, he, said the issue of potential neck injuries among pilots regularly wearing a three-pound helmet was raised by a team member who is a senior pilot with Cougar.

The issue has been further studied, and Bourgeois said the team will meet in July to come up with an action plan.

Acting on the Wells Inquiry - Business - The Telegram (http://www.thetelegram.com/Business/2011-06-22/article-2603196/Acting-on-the-Wells-Inquiry/1)

While helemt use is rare on offshore transport use they are not in SAR an military operations. Therefore arguments two years after this accident about "potential neck injuries among pilots regularly wearing a three-pound helmets" give more of a clue on the state of Cougar's SMS and safety culture.

[Shell Management]

There was a lot of resistance in GOM to the Shell Aircraft initiative to introduce safety glasses and helemts after the S-76C bird strike accdient in 2009.:sad:

[squib66]

It looks like some experts (EASA, FAA & TC) have agreed that the means of compliance used for the S-92s certification is adaquate and should not be perpetuated:

Transportation board says foreign regulators to review helicopter certification - thestar.com (http://www.thestar.com/news/canada/article/1013962--transportation-board-says-foreign-regulators-to-review-helicopter-certification)

Foreign regulators have promised to review controversial certification rules linked to the crash of a Sikorsky helicopter off Newfoundland, the Transportation Safety Board of Canada said Thursday.
The board said the Federal Aviation Administration, Transport Canada and the European Aviation Safety Agency will undertake the review with a view to possibly changing how the aircraft is certified.

The pledge was part of the regulators’ response to recommendations made by the board last February after the crash of a Sikorsky S-92 helicopter in 2009.

The accident killed 17 people and revealed that the helicopter had been given a 30-minute run-dry certification, based on the assumption that the chances of an oil leak were “extremely remote.”

The safety board found the primary cause of the 2009 crash was a massive loss of oil to the chopper’s main gearbox after two of three titanium studs snapped off the oil filter assembly during flight.

The safety board recommended that Transport Canada change regulations so that offshore helicopters are capable of flying without oil in the main gearbox for at least 30 minutes.
The helicopters can still only fly for 11 min
utes in the event of a total loss of oil and the board says it needs a commitment that they will be able to fly for at least 30 minutes after a major oil loss.

“We’d like to have a minimum standard so that all the helicopters in that category, if they lose oil they’ll be able to fly for 30 minutes,” Wendy Tadros, chairwoman of the safety board, said in Gatineau.
“There seems to be good intent there, but we don’t have firm plans or commitments there.”

Tadros said the FAA has said it will look at proposing rule changes to either clarify or eliminate the extremely remote provision.

But she added that changes to the certification may only affect future helicopters and not the S-92.

Some of the families of those lost in the Newfoundland crash have been calling on the regulators to demand that the helicopters be able to fly for at least 30 minutes after a massive oil loss.

The board would like to see that eventually, following a phase-in period.
“The responses are a little bit tentative now,” she said, adding that they include the creation of a task force and focus group. “They have to be firmed up ... so we’ll take another look at them in six months.”


Make offshore oil choppers safer now, says TSB - Business - CBC News (http://www.cbc.ca/news/business/story/2011/06/23/nl-tsb-choppers.html)


"It is going to take more than promises to solve the safety problems we found," said Tadros [TSB Chair].

"We need firm commitments and action to make these helicopters safer."


They do seem content to leave the S-92 without a full 30 minute capability which is a great concern but at least they are:

1) confirming that the S-92 has an MGB no better then aircraft a generation before it
2) that the marketing of the S-92's safety was hype
3) the 'social media' discussions by 'senior Sikorsky managers' (discussed in the TSB report) rubbishing other types were, at best, grossly misguided

One would at leat hope Sikorsky have the commercial sense to develop the S-92 to match the capability that their competitors have or that their competitors will be required to demonstrate in the products they are currently developing.

[riff_raff]

"They do seem content to leave the S-92 without a full 30 minute capability which is a great concern but at least they are:

1) confirming that the S-92 has an MGB no better then aircraft a generation before it
2) that the marketing of the S-92's safety was hype
3) the 'social media' discussions by 'senior Sikorsky managers' (discussed in the TSB report) rubbishing other types were, at best, grossly misguided

One would at leat hope Sikorsky have the commercial sense to develop the S-92 to match the capability that their competitors have or that their competitors will be required to demonstrate in the products they are currently developing."

squibb66,

There are some changes that Sikorsky can make to the existing S-92 gearbox that might actually give it a 30 minute run-dry capability. Designing a gearbox to achieve a run-dry capability is ultimately an exercise in heat transfer. There are some new types of gear steels (C61/C64) that have been developed in the last 2 or 3 years, which have a very high tempering temperature (up to 900degF vs. 400degF for conventional gear steels). Having a gear steel that maintains its hardness/strength at high temps is a critical factor in achieving gearbox loss-of-lube operational capability.

The critical gears in the S-92 gearbox could have their material replaced with these newer C61/C64 alloys, without any other dimensional changes. So it would be a "drop-in" replacement. Of course the C61/C64 alloys are also much more expensive than conventional aircraft-grade gear steels, and require different processing. But the additional thermal margin provided by C61/C64 gear alloys might be enough to give the S-92 gearbox a full 30 minute run-dry capability. The only question being would Sikorsky management accept the cost involved?

[Shawn Coyle]

How much is the increase in cost in the total price of an S-92? 1%? 10%?
Most likely small potatoes in the big picture.
It would also likely have some unintended positive side effects, like increased overall gearbox life, etc.
And probably a very good marketing point to.

[OEI-Dave]

How much is the increase in cost in the total price of an S-92? 1%? 10%?
Most likely small potatoes in the big picture.
It would also likely have some unintended positive side effects, like increased overall gearbox life, etc.
And probably a very good marketing point to.

Not really, they would just be living up to the 30 minute dry run capability they claimed when they sold the A/C.

[riff_raff]

Shell Management-

The materials were developed by QuesTek Innovations using computational design techniques. Latrobe Steel is the licensee.

Here's a good overall presentation. (http://www.questek.com/filebase/src/Material_Specific_Presentations/QuesTeksFerriumC61C64andC6.pdf) Slide 11 gives a good comparison between C61/C64/C69 and 9310 alloys.

riff_raff

[zalt]

Commissioner Wells has written his Phase II Report and it was with the inquiry's editor late last month.

The final piece of information necessary for completion was received on June 23rd past when the TSB published its response to submissions made to it by the FAA and Transport Canada.

After editing, formating and printing it is expected the report will be delivered to C-NLOPB in mid-August

[NoBiggie]

After reviewing the CTSB report it is apparent that the T/R output pinion tapered roller bearing shoulder failed as they can do in a lube starvation situation which allowed the pinion to back out of mesh. Thus neither the Questek C series steels nor nitrided steels (also hardened at higher than 400°F) would have helped here.

[zalt]

I doubt a simple material change will suffice. However, when Sikorsky bow to the inevitable they need to publically prove that they can fulfill the 30 minute certification test and not the certification-lite test that was used by a poster here to claim they could run for 3 hours after an oil loss, patently a BS claim.

Sikorsky have lost an appeal in court:

Sikorsky loses appeal in Cougar crash dispute - Nfld. & Labrador - CBC News (http://www.cbc.ca/news/canada/newfoundland-labrador/story/2011/07/04/nl-sikorsky-suit-location-704.html)

Aviation manufacturer Sikorsky has lost another court challenge in its attempt to move a lawsuit over the fatal 2009 Cougar Helicopters crash to the U.S.

Sikorsky Aircraft Corp., which manufactured the S-92A chopper that crashed into the Atlantic Ocean in March 2009, has argued that a pending lawsuit should be heard in Connecticut, where the company is based.

In a new decision the Newfoundland and Labrador Court of Appeal has upheld a lower court decision that ruled that the case — in which Cougar Helicopters and an affiliate of insurer Lloyd's of London, are suing Sikorsky — can proceed in St. John's.

"It follows that the courts of this province have jurisdiction to decide Cougar's claim," a panel of three judges wrote.

Seventeen people died in the crash. The Transportation Safety Board of Canada said 16 inter-connected factors led to the disaster, including broken studs and catastrophic drop in oil pressure in the aircraft's gearbox.

Sikorsky reached a settlement in January 2010 with Robert Decker, the sole survivor of the crash, as well as the families of the deceased.



How unreasonable of a Canadian court to expect a case on the loss of a Canadian registered, Candian ownered, Canadian operated helicopter, being flown by Canadians, in Canadian airspace, on charter to Canadian companies, carrying Canadian passengers, from a Canadian airport to Canadian oil rigs to be held in Canada.:E

[SASless]

How unreasonable of a Canadian court to expect a case on the loss of a Canadian registered, Candian ownered, Canadian operated helicopter, being flown by Canadians, in Canadian airspace, on charter to Canadian companies, carrying Canadian passengers, from a Canadian airport to Canadian oil rigs to be held in Canada.

.....and certified by Canadian MOT....

Now do you blame their lawyers for trying to get the trial moved to a venue that would give a " Home Court" advantage? Nice try.... but I would guess they had not made any wagers on their winning!

[zalt]

SASless Well I suppose the guilty always look for a friendly jury.

BTW Do you blame OJ for struggling to make the glove fit?

[SASless]

OJ....who won in criminal court....lost in civil court....and lost again in criminal court and is now in Prison....that OJ?

Shame I was not on the Jury, Sir!

I suppose the trail of blood leading from his Bronco into his front door...which then hid in his socks....the cuts on his hand....the glove found beside his house...all very circumstantial along with his attempted escape and threatened suicide....naw.....the Jury came to a rightous decision did they not?

Now all that being said....perhaps a change of Venue might be in order....at least to some location a bit remote from the place all this happened.

I can see a lynching coming....as I see a whole lot of shared responsibility in this tragedy that will not be fairly considered. I would happily take on either side of the argument as an Attorney as in the end....the attornies shall be the only winners out this.

[squib66]

Its clear that some people would lkike to see Sikorsky have their day in open court to justify their design decisions.

Here is a thoughtful editorial from the local St Johns paper:


Once, there was a helicopter known as the Sikorsky S-92A. In this province, we're well familiar with it: it's the type of helicopter that crashed into the North Atlantic just over a year ago, killing 17 passengers and crew.

The helicopter crashed because studs broke in its main gearbox, causing oil to leak out and the gearbox to seize up just 11 minutes after the oil leaked.

It wasn't supposed to be that way.

Originally, the S-92A was supposed to be able to run with a dry gearbox for 30 minutes, and the aircraft was originally tested to do exactly that.
Problem was, during the test, the gearbox seized up and flew apart - 11 minutes into the test.

So instead of modifying the gearbox, Sikorsky successfully argued to U.S. regulators that a total loss of oil from the gearbox would be an extremely remote event - and, as such, the aircraft wouldn't need to worry about meeting the 30-minute standard.

"Extremely remote" wasn't remote enough. Both Cougar Helicopters Flight 491 and another S-92A, working in Australia, suffered catastrophic oil pressure loss because of faulty studs. The Australian aircraft was lucky enough to be flying over land - the Cougar helicopter was not.

Now, the U.S. Federal Aviation Administration (FAA) is saying existing S-92A helicopters won't have to be retrofitted with new gearboxes because the changes would neither be practical nor necessary. New helicopters of that model, however, will have to have a gearbox capable of running without oil for 30 minutes.

You can understand why the FAA would suggest that forcing Sikorsky to switch out the old gearboxes in 140 operating helicopters would be impractical. There are those who might argue that the S-92A's gearbox studs have now been replaced, making the chance of a gearbox loss of oil "extremely remote" all over again. Replacing the gearboxes on all 140 aircraft would be a lengthy, taxing and expensive job.

At the same time, impracticality shouldn't enter into the discussion. The FAA's actual memo on the issue says, "Furthermore, modifying these helicopters to be equipped with new main gearboxes would have a significant economic impact on the aviation community, and the costs would outweigh any improvements in safety."

The clear and obvious costs of designing a new gearbox for future helicopters, on the other hand, apparently would not outweigh any improvements in safety. It is a bottom-line decision, and what it means is that there are really two classes of passengers and crew: those who deserve aircraft that meet a particular safety standard, and those who do not.

Improvements to safety are never impractical - unless, of course, the practical finances of helicopter companies are actually more important than the lives of the people who fly in them.

Once bitten, twice shy - Editorial - Opinion - The Telegram (http://www.thetelegram.com/Opinion/Editorial/2011-07-21/article-2668929/Once-bitten-twice-shy/1)

[NoBiggie]

The fact that "a gearbox" lasted 11 minutes in bench test does not mean all gearboxes will last 11 minutes after loss of cooling, er, oil I mean. A different assembly may last 2, 11, 20 or 40 minutes.

If the writer of that article does not recognize reality and the fact that aircraft design is always a compromise between affordability (can a customer afford it?) and performance and people agree with him then Houston, we have a problem.
:ugh:

[SASless]

Hangin your hat on the FAA's concern for Safety is fraught with peril!

I do not mean to re-argue past events but I still wonder how this would have turned out if the crew had carried out a timely descent and ditching? Would this tragedy have turned out much differently?

If they had....would we be discussing equally important but quite different safety issues...but would now be litigating the issues at hand now.

That is not to say Sikorsky and the MGB issue should not be discussed but should we get too focused on that alone to the exclusion of the other issues that contributed to the loss of the people aboard the helicopter that day?

I submit there is blame enough to go around to just about everyone and every organization involved in this tragedy as has been suggested by the investigations. I do defend Sikorsky but think fair is fair. Let's keep the finger pointing at each link of this accident chain and demand proper action to correct all the shortcomings no matter the source.

[riff_raff]

NoBiggie,

Your point about setting a benchmark based on a single test is well made. The particular MRGB build that failed 11 minutes into the loss-of-lube test may have been a statistical anomaly. The way the current 30 minute loss-of-lube qualification test is structured, there are simply far too many variables involved to conclude that if a single example of an MRGB design lasts 30 minutes, then all conforming production units will also last at least 30 minutes under loss-of-lube conditions. Also consider that while the qual test unit is usually an MRGB with very low hours, would an MRGB in service with high hours perform as well as the qual unit under loss-of-lube conditions?

Performing a thorough analysis of MRGB components under loss-of-lube conditions (heat transfer, frictions, etc.) would be extremely complex and costly. Thus the loss-of-lube qual test is usually one of the few test procedures that does not have substantial analysis for validation. Until the analysis capabilities needed for thoroughly analyzing loss-of-lube function become available and reliable, then the loss-of-lube qual test procedures should be restructured. The test parameters should be more controlled, the test duration should be 1.5 or 2 times the qualification period, and the configuration/condition of the test article should represent the "worst case condition" expected in service.

riff_raff

[Geoffersincornwall]

Your comments are well observed and in the context of recent history they sketch out a way forward. However, before we had the 30 minute run-dry qualification test there was....... let me think ..... nothing!!!

Those of us that remember the UK HARP report of the 1980s which sought to remedy a long held belief that helicopters could and should be built to higher engineering and airworthiness standards will take comfort, albeit small comfort, in the fact that airworthiness standards have improved substantially in some areas (crashworthiness, design integrity, damage tolerance) but seem to have further to go.

This would seem to be the case with composite structures which appear not to be well understood (thanks BLACKMAX for your very valuable contribution to the debate), and with transmission components which have come a long way from the troublesome S61 MGB and the potentially catastrophic AS332 MGB but arguably should go further. The challenge is enormous. I remember the Westland gearbox designer telling us at lecture at Bristol Uni that if the helicopter MGB was designed using the (then current) car design philosophy, then it would be so heavy that it would consume all the disposable load even if the material used was aviation grade lightweight alloy.

Clearly gearboxes must have a development pathway that is realistic and affordable but this does not mean that we cannot set hurdles for manufacturers to jump over and in doing so an ethical way of dealing with shortcomings must be found. Simply coming up with a convenient probability calculation ignores the realities of our world.

INTEGRITY - Integrity is a keyword and I mean it should be applied to the structure AND the people involved in certification.

G. :ok:

[henra]

The fact that "a gearbox" lasted 11 minutes in bench test does not mean all gearboxes will last 11 minutes after loss of cooling, er, oil I mean. A different assembly may last 2, 11, 20 or 40 minutes.

If the writer of that article does not recognize reality and the fact that aircraft design is always a compromise between affordability (can a customer afford it?) and performance and people agree with him then Houston, we have a problem.
:ugh:

while I agree that another assembly might have lasted a few minutes more or less, it is pretty safe to assume that the differences will be pretty sure smaller than +/- 5 minutes under identical conditions.
coincidentally the MRGB in the Cougar 491 lasted pretty exactly these 10 or 11 minutes.
This was not a one off bad luck failure. This was systematic.
And in other Helo's the same manufacturer is able to make it last 30 minutes in the same test.
Go figure....
Where I do agree is that the test will not be representative of all real world cases. There you will see much more variation due to environmental conditions.

[500e]

"And in other Helo's the same manufacturer is able to make it last 30 minutes in the same test."
Would be interested in the design differences in the 2 boxes +.expected loadings.
The 30 min is at least a yardstick to start with.
That 3 boxes failed around 11 min (I beleive the test box failed at aprox same run time) would suggest there was a trend.
Has there been any change to flight Manuels or Co. SOP regarding the way to deal with oil loss

[js0987]

The RFM states that less than 5psi MGB oil pressure - Land Immediately - same as before the accident.

[zalt]

js Please read the thread, the inadequacies of the RFM have been covered.

Today the Phase 2 Public Inquiry report was issued. More stinging criticism of Sikorsky and the weaknesses of the S-92.
C-NLOPB || Offshore Helicopter Safety Inquiry (http://www.cnlopb.nl.ca/ohsi_report.shtml)

[Variable Load]

Zalt,

js is entitled to express his opinion just as much as you are.

I'm with js on this one though.

[Thomas coupling]

How much is this going to cost Sikorsky overall to cover the 17 unfortunate individuals? 17, 27 or 37 million dollars is much cheaper than rectifiying their current fleet, I would suggest.

I recall the same sort of issue with the 737 rudder screwthread jack (1980's)that failed in the past on several occasions. The US safety board agreed with industry and the FAA that the projected costs of paying off the deceased estates was infinitely smaller than finding and fitting a fix. In fact the maths worked out to show each passenger in a 737 over its life time was worth only $820....dead :=

[Flyt3est]

TC - Good point. I am surprised that today we are still having the arguments about modification and safety improvements being made regardless of cost..

If you were Jeff Pino, would you sink every last penny into designing and building a helicopter that was as safe as humanly possible, knowing that the selling price of your aircraft would be x% higher than your competitors? Would you take the moral initiative and hope your competitors follow suit, whilst risking financial catastrophe? Please note I refer to any new flight safety developments here, not purely the dry gearbox argument in isolation.

This is simple risk analysis.. cost v probability v consequence of occurence.

Any business has a goal of making as much money as possible.. why is anybody surprised that certain modifications can fall into a category of "Too expensive"?? I am not defending anyone here by the way, just stating the obvious.

All that said, there was a time when HUMS was considered hugely and sometimes prohibatively expensive, but it did eventually find it's way into the world..

[Variable Load]

There is continuous improvement with the product. There is no sign that this process is slowing or stopping.
Sikorsky are no where near saying "Well there it is". :D

[industry insider]

Flyt3est

I think if you were to contact Jeff Pino at Sikorsky, he would confirm that the company is putting millions of $ into improving the S-92 MGB. The phase 3 MGB is being fielded now and the IDMGB will be fielded from 2012. There are other product improvements in the pipeline which will significantly extend the capabilities of the S-92.

If you contact your regional FSR or Sikorsky sales person, I am sure you will be able to get an update on the MGB continuous improvement process.

If you work for an S-92 operator, you should have already been briefed by your company or should be able to request a briefing. My company receives regular briefings and participates in 3 day maintenance and operations reviews with Sikorsky.

[riff_raff]

Flyt3est,

Your point about cost/risk analysis is well made. I would also add that executives in the aircraft business are not the greedy, crass, heartless people some make them out to be. Upper level private-sector business executives in modern democracies are often held accountable for their actions and decisions by public regulatory agencies. In fact, private sector businessmen are held to higher standards than their counterparts in the public-sector. These public corporation executives must, as you noted, take cost into account with any decision they make. We must also consider, in view of our current litigious business environment, that for a company to unilaterally make safety-related changes to their existing product would open them up to serious civil liabilities, whether justified or not.

We should try to be cautious when assigning blame (in hindsight) to any business decision that caused problems, especially one which the general public does not have full insight to all factors that influenced that particular decision. While discussing and speculating on such issues is what makes these forums interesting, there should never be a point at which the discussion becomes accusatory in nature.

Improving safety and reliability in aircraft is a slow and methodical evolutionary process. Unfortunately, human nature tends to make us focus on our current shortcomings, rather than on how much substantial progress we have made in the short history of commercial rotorcraft. I am especially thankful that most of us live in open democratic societies where we have regulatory systems that promote cooperation between public agencies and private enterprises to make improvements for the public good. Our system may not yet be perfect, but it's a far sight better than those of authoritarian governments where such embarrassing issues are swept under the rug.

Best regards,
riff_raff

[squib66]

riff_raff

It would help prevent future accidents if the people who made the decision after the loss of lubrication test failure in August 2002 to fit a simple cooler bypass valve and assessed oil loss from elsewhere as 'extremely remote' explained their logic. That might dismiss the thought that it was mere commercial expediency.

I saw this today too: C-NLOPB Responds to Offshore Helicopter Safety inquiry phase II report | Shephard Group (http://www.shephard.co.uk/news/rotorhub/c-nlopb-responds-to-offshore-helicopter-safety-inquiry-phase-ii-report/9800/)

Looks like Canadian offshore workers will be told about every ASB now.

[maxwelg2]

Looks like Canadian offshore workers will be told about every ASB now.

This has been happening over here for quite some time now. Being an infrequent offshore visitor these days I don't keep track of them, but suffice to say all workers are made aware of all relevant information regarding A/C operations and incidents as they occur.

I can only see this as positive progress and long-awaited, the more focus that is placed on this key piece of operating and safety equipment that we rely on so heavily over here in the Grand Banks the better.

I hope to hear of progress soon on the improved MRGB and the outcome of the recent Searose AP incident, preferably officially.

Safe flying

Max

[John R81]

Sikorsky v Lloyd's TSB General Leasing (No 20) 2011 NLCA 49.

The Newfoundland and Labrador court of Appeal have upheld the February decision of the Newfoundland court that the trial can take place in Newfoundland, not in Connecticut as Sikorsky contended. Sikorsky therefore loses it's appeal with costs.

If you are intrested in the arguments of jurisdiction of the claim, and the reasons for the answer, see
Newfoundland court dismisses appeal in Sikorsky case - International Law Office (http://www.internationallawoffice.com/newsletters/detail.aspx?g=0fcda7c4-ab6c-4fc4-b4a3-0cd956fccf8b#page=1)

[squib66]

VOCM.COM|Search and Rescue Technician to get Medal of Bravery | Article (http://www.vocm.com/newsarticle.asp?mn=2&id=17929&latest=1)
The man who rescued the only person to survive the Cougar helicopter crash is getting the Governor General's Medal of Bravery award. Ian Wheeler is a search and rescue technician with Cougar Helicopters. Cougar Flight 491 was heading to the offshore when it crashed into the Atlantic on March 12th, 2009. Robert Decker escaped the aircraft, severely injured. He was falling in and out of consciousness as he floated in a field of debris. Wheeler was lowered from a rescue chopper and fought two-metre-high waves and the wind action from the rotor blades to reach him. The rescue basket was lowered to them, and after many attempts, Wheeler was able to place Decker inside. Wheeler remained un-tethered during the lift as he tended to Decker, who was hypothermic. Wheeler ensured he was safe and well secured. The Governor General's office says the Medal of Bravery will be presented to Wheeler at a later date.


Would a double strop not have been quicker?

[Aser]

VOCM.COM|Search and Rescue Technician to get Medal of Bravery | Article (http://www.vocm.com/newsarticle.asp?mn=2&id=17929&latest=1)


Would a double strop not have been quicker?

Maybe they were thinking about hypothermia. the less vertical, the better.

[squib66]

A double on the casualty, one under the arms and one under the knees to lift more horizontally.

[squib66]

Seems there were problems with the winch that were not mentioned in the TSB report.


Ian Wheeler remembers heading into work at the Cougar offices in St. John's, N.L., on what was looking to be a pretty typical day at the aviation company.

The rescue specialist planned to do some hoist training with his crew in one of the company's Sikorsky S-92 helicopters.

As he walked along the flight ramp, he saw 18 crew and rig workers filing onto another helicopter for a short, routine trip out to one of the offshore platforms.

It was just after 9 a.m. on March 12, 2009, and Wheeler was in the control centre gearing up for training when word came that the helicopter he had just waved off was having an oil pressure problem.

The news soon grew more dire as Wheeler saw a maintenance worker race to get a rescue helicopter ready, saying that Flight 491 might have to ditch in the water. Minutes later, he heard that the aircraft had gone down, prompting him and his team to head to the scene about 55 kilometres east of St. John's.

But the veteran specialist, who is being rewarded for his rescue work by the Governor General, says he was stunned to see a debris field that contained a mess of chopper parts, luggage, the bulkhead and empty life-rafts, but no immediate sign of survivors.

"We were looking around and not seeing anybody so it's starting to set in that, 'My God, where is everybody?'" Wheeler said from his home in Torbay, N.L., more than a week after finding out he is one of nine Canadians to receive a Medal of Bravery from the Governor General this year.

"They couldn't have drifted very far. If they're not on the surface, my God, they must be in the aircraft and the aircraft is gone."

Wheeler, 49, and his four crew mates did a broad, structured sweep of the area, scanning for telltale orange survival suits and signs of life.

In the midst of a tangle of netting, baggage and other debris, the crew saw someone in an orange suit who managed a faint wave from the frigid waters.

Wheeler was carefully lowered down to the site in two-metre waves and swam up to the man, who was slipping in and out of consciousness following 75 minutes in the water after a terrifying scramble out one of the helicopter's windows.

The hypothermic man, who was almost delirious and speaking in a slur, repeated a pleading question.

"He kept asking me over and over again, 'Are we OK? Are we OK?' " Wheeler said.

Wheeler assured the man he would get him out, later learning he was 27-year-old was Robert Decker. But Wheeler had trouble with the hoist and told him he would get another device to raise him up.

Panicked, Decker misunderstood and thought Wheeler was leaving.

"He looked at me and said, 'Don't leave me here, don't leave me,' " Wheeler said. "I looked him straight in the eye and said, 'I'm not going anywhere.' "

Hopes rose of more survivors when they spotted a dark suit that matched those worn by the pilots and what appeared to be an arm waving in the steady wind.

But when they got closer, they realized it was a kit bag with a black strap blowing in the breeze.

"There was a bit of disappointment there," he said. "We realized relatively quickly that the likelihood of seeing anybody else was very remote."
He said the gravity of what happened began sinking in for him when he arrived at the hospital with Decker and saw a line of 15 ambulances waiting for survivors. He told a doctor not to expect any more survivors.

It became more difficult when he returned to the Cougar office and had to tell dozens of anxious colleagues that their co-workers were likely lost.
Only then did Wheeler find out that several of his friends were on the flight, including First Officer Tim Lanouette, who he had lunch with five days earlier.
"I knew a lot of these guys going and coming," he says. "It's a pretty unique situation. ... Everybody knows everybody."

What stays with him are those initial sights of the debris scene, the empty life-rafts and his first face-to-face encounter with Decker, who later met the crew to thank them for saving him.

An official with the Governor General's office said the award would be handed out some time in the new year.


Rescuer in Cougar 491 crash recalls sole survivor waving faintly in Atlantic - Winnipeg Free Press (http://www.winnipegfreepress.com/canada/breakingnews/rescuer-in-cougar-491-crash-recalls-sole-survivor-waving-faintly-in-atlantic-133082753.html)

[zalt]

The 24/7 SAR capability is not expected for another winter, 7 years after Cougar claimed they had it and 3 years after the accident.

CNLOPB have been having a safety seminar this week. I wondered if that was discussed.

Communication key issue at helicopter safety forum: Ruelokke - Business - The Telegram (http://www.thetelegram.com/Business/2011-11-01/article-2792385/Communication-key-issue-at-helicopter-safety-forum%3A-Ruelokke/1)

[maxwelg2]

Seems there were problems with the winch that were not mentioned in the TSB report


That's correct, what we heard was that the primary winch failed and the secondary winch was used to retrieve Robert.

Ian Wheeler and the SAR crew did an excellent job considering they were flying in the same A/C type that just went down. I'm assuming all the SAR team is being awarded.

Safe flying

Max

[squib66]

Amazing that TSB didn't examine the winch failure.

Robert Dekker may only be alive because an aircraft was already fitted with a dual hoist for the exercise mentioned. I wonder how much longer he would have been in the water otherwise? 20 minutes? 30 minutes?

[Aser]

Do you mean the second hoist is not standard equipment??

[zalt]

Cougar have single and double hoists. The latter are more difficult to install.

It is only recently that they have had an aircraft actually on stand-by with a hoist. Before that a crew change aircraft needed to be re-roled for SAR (well really LIMSAR). During a busy flying programme it might have been necessary to land to offload pax first.

[zalt]

Open Letter to Federal Minister Regarding Cougar Flight 491 Helicopter Crash
Nov 4th, 2011 10:07 AM
The following is an open letter sent to Minister of Transport, Infrastructure and Communities Denis Lebel, by the families of the passengers killed in, and the sole survivor of, the crash of Cougar Flight 491. For more information, please contact: Michael Zupanic, Environmental Communication Options, at 416-972-7401 or [email protected]


Office of the Honourable Denis Lebel
Minister of Transport, Infrastructure and Communities

Dear Minister:

Re: An Open Letter From Brenda Anwyll, Janet Breen, Cecilia Corbett, Robert Decker, Wanda Drake, Melinda Duggan, Karen Eddy, Janet Escott, Susan March, Richard and Marjorie Maher, Heather Warren, Roxanne Mullowney, Marilyn Nash, Lori Chynn, and Sharon Pike - the Families of the Passengers Killed in, and the Sole Survivor of, the Crash of Cougar Flight 491.

As you are aware, on March 12, 2009 a Sikorsky S-92 helicopter, operated by Cougar Helicopters, carrying 2 pilots and 16 passengers crashed into the seas off St. John's, NL following the failure of the helicopter's main gearbox ("MGB"). The crew and all but one of the passengers were killed in the crash.

We wrote to your office on February 18, 2011 on behalf of the sole survivor and the families of the deceased passengers of Cougar Flight 491 seeking answers to various questions relating to the manner in which Transport Canada certified the MGB of the S92.

These families have been devastated by this accident. They are entitled to the courtesy of a response. More troubling is the fact that it appears from your silence that you are unwilling to investigate how this helicopter was certified so that the steps necessary to prevent recurrence of this tragedy can be properly identified and implemented.

The victims are not alone in raising concerns about the role which Transport Canada played in this accident. In July 2011, the Commissioner of the Offshore Helicopter Safety Inquiry, retired Newfoundland and Labrador Supreme Court Judge Robert Wells, issued his second phase report which raises many of the same concerns voiced by our clients. Like the families, Commissioner Wells found it difficult to understand how the regulators could have failed to grasp the significance of the incident in Western Australia involving a loss of transmission oil in the Canadian Helicopters S92, (the same model helicopter and MGB as involved in this accident) due to stud failure:

I find it difficult to understand why the replacement studs could not have been installed forthwith or as quickly as possible. The same applies to the three-month delay in issuing the Alert Service Bulletin. Even less can I understand the replacement time frame of one year or 1250 flight hours. It is clear from their submissions that the families of the passengers who died in the March 12, 2009, crash also have difficulty understanding why the titanium studs were not required to be replaced much sooner, and so do many offshore workers and members of the public. It is also difficult to understand why the FAA did not insist on earlier replacement, because the October 20, 2008, determination had included FAA consultations. It was well known that the S-92A was being used to transport passengers long distances over hostile ocean waters. Despite the apparent lack of urgency, Cougar Helicopters, to its credit, ordered the steel studs within three weeks of the Alert Service Bulletin, but unfortunately the parts did not begin to arrive until shortly after March 12, 2009.

Commissioner Wells went on to note:

The foregoing information raises a serious question: why did not Sikorsky and the aviation regulators recognize the danger and cause the titanium studs to be replaced as quickly as possible?

This is indeed a serious question and it is the same one raised by our clients in their letter of February 18, 2011. It is worthy of a serious response.

We look forward to hearing from you.


Yours truly,

Camp Fiorante Matthews

Of course it was a CHC Australia aircraft at Broome.

[zalt]

More press coverage on this:

Lone crash survivor, families seek answers - Local - The Telegram (http://www.thetelegram.com/News/Local/2011-11-05/article-2796775/Lone-crash-survivor,-families-seek-answers/1)

“The accident itself and then the Wells commission both point to the fact that there were signs of an obvious safety defect in the transmission of that helicopter and it’s never been adequately explained how our regulator, Transport Canada, missed that,” Fiorante said.

“What (the families) are calling on the minister to do is to investigate how the regulatory system failed. In other words, why the safeguards that are supposed to be in place to protect the flying public didn’t work in this case, and there’s never been an adequate explanation for that. It’s not something that the Transportation Safety Board went into.”

The truth is out there.

[zalt]

At least TC are working with FAA and EASA even if the Transport Minister won't engage on why Advisory material was used to water down a certification test.

Ottawa sent "platitudes" to N.L. chopper crash victims - Nfld. & Labrador - CBC News (http://www.cbc.ca/news/canada/newfoundland-labrador/story/2011/11/08/nl-lebel-response-1108.html)

Ottawa sent "platitudes" to N.L. chopper crash victims
CBC News
Posted: Nov 8, 2011 5:47 PM NT

A lawyer for people affected by the crash of Cougar Flight 491 says a response received from the federal transport minister is not acceptable.

"Our take is that the letter is long on platitudes about safety and short on answers to the serious question of what went wrong in the certification process of the S-92A's main gearbox," lawyer Joe Fiorante wrote in an email to CBC News.

The letter from Transport Minister Denis Lebel is a response to three letters from the families and Robert Decker, the only person who survived the crash.

Those letters call on the minister to answer questions the families say were not addressed by the Transportation Safety Board’s investigation into the March 2009 crash that killed 17 people southeast of St. John’s.

They want to know why the Sikorsky S-92A’s main gearbox was certified to fly for 30 minutes after losing oil pressure — when it clearly couldn't.

They also want to know why a similar S-92A main gearbox failure in Australia, months before the crash southeast of St. John’s, wasn't followed up and acted on more quickly.

Minister apologizes

Monday Federal Transport Minister Denis Lebel responded after Lori Chynn, whose husband John Pelley died in the crash, publicly called on the federal government to respond to the families.

"Please accept my apologies for the delay in responding," he wrote.

"My department continues to work with the FAA and EASA to review the regulations and guidance material to reach an international agreement on any changes that are necessary … we will continue to work with the TSB, the C-NLOPB to maintain and enhance the safety of Canadian Aviation."

Regarding recommendations made by the Offshore Helicopter Safety Inquiry following the crash, Lebel said:

"I will be in a position to provide a response to the board very soon."

The families wrote their first letter asking the federal transport minister to investigate the certification of the Silkorsky S-92A on Feb. 18, 2011.

The Transportation Safety Board of Canada (TSB) released its final report on the crash on Feb. 9, 2011.

Retired Supreme Court Justice Robert Wells, who led the Offshore Helicopter Safety Inquiry, called on Transport Canada to adopt and act on the four recommendations of the Transportation Safety Board.

The TSB's report recommended helicopters must:
Have a main gearbox able to run without oil for 30 minutes.
Not fly in rough conditions.
Have emergency breathing equipment on all flights where survival suits are worn.
Have an emergency flotation system to keep a chopper afloat long enough to evacuate safely.

[squib66]

On the next edition of CBC's The Current:

... the sole survivor of a helicopter crash that killed 17 people speaks out about concerns he has for the safety of Canadians who commute to work by helicopter. Robert Decker was on his way to work on the Hibernia offshore oil platform on March 12, 2009. He never made it. His helicopter crashed in the Atlantic, killing 17 of it passengers. He'll tell his story on Wednesday's program.

[espresso drinker]

He's told his story today (Wed 23 Nov) and it's been reported here Cougar chopper crash survivor criticizes Ottawa - Nfld. & Labrador - CBC News (http://www.cbc.ca/news/canada/newfoundland-labrador/story/2011/11/22/nl-decker-current-122.html)

There is no doubt that quicker action should have been taken after the Australian incident, but hindsight is a wonderful thing.

The question is surely it's certification should have been revoked after the second fatal accident, or are the steel studs all that was needed to satisfy the 'extremely remote' loop hole added to the certification requirements after the S92 failing the dry run testing?:confused:

[zalt]

A powerful piece, the main thrust was the slow Sikorsky response to the first filter failure, the lack of regulatory action until the second event and why the type was ever certified.

Cougar crash survivor's concerns reach Parliament - Nfld. & Labrador - CBC News (http://www.cbc.ca/news/canada/newfoundland-labrador/story/2011/11/23/nl-cougar-survivor-reaction-1123.html)

[squib66]

I'm told C-NLOPB and Transport Canada attended the last meeting of the UK's Helicopter Safety Research Committee to discuss lessons learned from this accident and that liaison on common initiatives to respond to it is planned.


TSB are making a public presentation in Cologne next month on this accident.

[FH1100 Pilot]

espresso drinker:The question is surely it's certification should have been revoked after the second fatal accident, or are the steel studs all that was needed to satisfy the 'extremely remote' loop hole added to the certification requirements after the S92 failing the dry run testing?

Well of course the S-92's airworthiness certificate should have been revoked following the Cougar crash! Of course. That's not even in question anymore.

SAC managed to convince the FAA guy (whose name we don't need to mention because everyone already knows who signed-off on it) that the ONLY possible source of a leak of transmission oil would be the lines leading to the oil cooler. Filter won't/can't leak...driveshaft inputs can't leak...the mast seal can't leak...the list goes on!

And the (unnamed) FAA guy said, "Yup, I agree!" But if they were using the S-92 design to justify that "extremely remote" crap, they had no historical base to draw from. If they (SAC) were using an industry-wide base for loss of transmission oil, they STILL were not on solid ground, because such things happen more than extremely remotely. (Admittedly they don't happen often, but "extremely remote" is a defined term.) SAC took the awkward wording of section 29.927(c)(1) and used it to their financial advantage.

So no, the S-92 does not IN FACT meet the requirements of FAR part-29 when it comes to the transmission. I would venture to say that there is no helicopter in existence that would qualify under that "extremely remote" clause. Why do we care? Because when you design an aircraft that's going to take LOTS of people out over some very inhospitable parts of the earth, then you are - and should be - held to a higher standard.

We know now that the S-92 transmission cannot withstand a complete loss of oil. Sikorsky admitted that their testing showed (and Cougar proved in the field) that you get "about" ten minutes of run time with no oil. This is undisputed. What's truly disturbing to me is that so few people seem to care. Pilots in particular are so very cavalier about this, as if it's a trivial or inconsequential point. It boggles my already-feeble mind.

What it boils down to is that it would have been economically unfeasible, unrealistic and unreasonable to summarily ground the S-92 fleet and force Sikorsky to redesign the transmission. Passenger safety takes a back seat to money. It's not the first time this has happened in aviation. Shamefully, it probably won't be the last. Personally, I think we owe the paying passengers - and the pilots who fly them! - more than that...better than that.

I mean, why have rules at all if exemptions and "work-arounds" are allowed and applied so freely?

[zalt]

FH1100 - good post. As stated above, the S-92's inadequacies probably do not justify canceling the type certificate, but changing the type certificate data sheet to show it only achieved a much earlier certification basis would be a reasonable action in the circumstances.

It seems that having stalled and fought to have the case brought by Cougar and their insurers held in the US (and lost), Sikorsky have now settled out of court and avoided legal determination on the claim that Sikorsky were negligent and misrepresented the S-92 safety in their marketing claims:

The Canadian Press

Date: Friday Nov. 25, 2011 4:32 PM ET

ST. JOHN'S, N.L. — A Newfoundland-based helicopter operator that sued Sikorsky Aircraft Corp. after a fatal helicopter crash in March 2009 has reached an out-of-court settlement with the American company.

Cougar Helicopters of St. John's and eight insurance companies had filed a lawsuit against Sikorsky, alleging negligence and misrepresentation in their statement of claim.

Those claims were not proven in court.

On Friday, Cougar spokeswoman Candace Moakler said the settlement prevents her from discussing the deal that was recently reached with Sikorsky.

"We were seeking damages for the loss of aircraft against Sikorsky," Moakler said in an interview. "That action has been settled, and the action has been discontinued."

Cougar's statement of claim sought almost $27 million in damages.

It accused Sikorsky of using a flawed analysis to claim its S-92 helicopters could run without oil in the main gearbox for 30 minutes.

The pilots of Cougar Flight 491 reported a loss of oil pressure in their S-92's main gearbox about 11 minutes before plunging into the North Atlantic, killing 17 of the 18 people on board.

Two weeks after the disaster, the Transportation Safety Board of Canada said two of three titanium studs that secure the oil filter bowl assembly to the helicopter's main gearbox sheared off mid-flight.

The board concluded in a report last February that the resulting loss of oil pressure was one of a "complex web" of factors that contributed to the crash. It also blamed unclear safety and training procedures.

Despite the loss in pressure, the pilots thought there was still oil in the gearbox, which is why they decided to fly on to St. John's rather than risk a controlled ditching in the ocean, the board said.

In January 2010, the families of 15 passengers who died in the crash, as well as the sole survivor of the tragedy, Robert Decker, reached a settlement in their lawsuit against the U.S. company.

Their 2009 lawsuit alleged Sikorsky and its parent company, United Technologies Corp., made false claims about the aircraft's safety. Again, those claims were not proven in court.

At the time, a Sikorsky spokesman confirmed that a similar settlement had been reached with the families of the helicopter's two pilots.

N.L. chopper operator settles lawsuit after fatal crash | CTV News (http://www.ctv.ca/CTVNews/Canada/20111125/newfoundland-helicopter-crash-lawsuit-settled-111125/)

[riff_raff]

While a properly qualified transmission 30-minute loss of lube capability is a good idea, it doesn't completely eliminate lube system related failures in the transmission. Here's a fatal crash that occurred in 1982 with a CH-47.

The crash of Boeing's CH-47C Chinook 74-22292. (http://www.chinook-helicopter.com/history/aircraft/C_Models/74-22292/74-22292.html)

The final catastrophic structural failure was preceded by a sequence of failure events, which were initiated by a loss of lube oil flow to one single point in the input nose gearbox module (an oil jet clogged by debris). As I understand it, the rest of the lube system was still functioning right up until the structural failure. Just a few moments prior to the crash the crew received some sort of warning indication and were attempting to land. I'm not sure of the failed gearbox's maintenance history, but it is quite possible the aircraft had been operating for some time with this condition (ie. longer than 30 minutes), and it didn't manifest itself until the drivetrain was loaded sufficiently.

The point of the story is that there is no direct method to monitor for this type of failure in transmissions. There are only indirect detection methods such as chip detectors or local thermocouples. Having said that, a clogged oil jet is no longer likely to occur because all modern gearbox designs typically use "last chance" filter screens on every oil jet.

riff_raff

[Tcabot113]

Riff Raff

Things inside of a transmission are rarely without all lube even if jets are clogged due to misting of all of the oil flowing around. I attended an AHS meeting where Bell Helicopter showed a HUMS trace from a 412 where the tail rotor output quill of the main transmission had restricted lube to the bearings due to "cork" in the oil port (not known until inspected). The vibration of the quill was monitored for one year before the decision was made to overhaul it where the cork was found. The bearings had sufficient damage to cause vibration alerts, but no chip indications.

One reason the 412 quill did not fail is its basic design uses bearings more forgiving to many defects than the type used in the S-92.

Tcabot113

[espresso drinker]

I feel somewhat cheated with the out of court settlement. I feel that we have been denied the opportunity of having some of the questions answered in public. And no admission of guilt on anyones part.

Not that I want a witch hunt, just for the failures in the system to be highlighted to everyone and steps to be taken to prevent this sort of thing happening again.

At least everyone flying this aircraft now knows that they don't have a 30 minute window and to get it down asap if there is a problem with the MGB.

Hopefully the MGB will be better on the military version Canada 'might' be getting some time soon.

[TiPwEiGhT]

I noticed the other week on a new machine that the ACFT CONFIQ. page showed something alongs the lines of "MGB AUX. LUBE", obviously is was not installed, but does anyone know of Sikorsky´s progress with this system?

TiP

[Shell Management]

With the court case out of the way hopefully in-works product improvements will now become public

Nick - can you now enlighten us?

[zalt]

As FH1100 correctly explains, the S-92 accident was down to a design choice to preserve design schedule:

SAC managed to convince the FAA guy (whose name we don't need to mention because everyone already knows who signed-off on it) that the ONLY possible source of a leak of transmission oil would be the lines leading to the oil cooler. Filter won't/can't leak...driveshaft inputs can't leak...the mast seal can't leak...the list goes on!

And the (unnamed) FAA guy said, "Yup, I agree!" But if they were using the S-92 design to justify that "extremely remote" crap, they had no historical base to draw from. If they (SAC) were using an industry-wide base for loss of transmission oil, they STILL were not on solid ground, because such things happen more than extremely remotely. (Admittedly they don't happen often, but "extremely remote" is a defined term.) SAC took the awkward wording of section 29.927(c)(1) and used it to their financial advantage.

So no, the S-92 does not IN FACT meet the requirements of FAR part-29 when it comes to the transmission. I would venture to say that there is no helicopter in existence that would qualify under that "extremely remote" clause. Why do we care? Because when you design an aircraft that's going to take LOTS of people out over some very inhospitable parts of the earth, then you are - and should be - held to a higher standard.

We know now that the S-92 transmission cannot withstand a complete loss of oil. Sikorsky admitted that their testing showed (and Cougar proved in the field) that you get "about" ten minutes of run time with no oil. This is undisputed. What's truly disturbing to me is that so few people seem to care.

To final announce such a u-change here to add emergency lube (as should have been done in late 2002 even if it meant a delay to the certification) could be seen as tantamount to agreeing that the decisions made behind closed doors in the fall of 2002 were negligent.

On another thread SASless wrote

Government never wants to admit a mistake....even when it is patently clear to everyone involved.

That is a trait that is often shared by individuals & companies too. Yet product safety starts with management behaviour.

However, considering the unique acknowledgement in the TSB report of a certain Sikorsky Manager's postings on a certain 'social network' site on the S-92 loss of lube, and considering all the court cases are now over, perhaps we can see a frank admission on the very same site.

Though at least the Canadian DND are continuing to insist that Sikorsky's MHP has a full 30-minute capability, as per the requirements the S-92 failed to achieve.

[zalt]

Cougar SAR-ready at St. Johns (http://www.thetelegram.com/News/Local/2012-01-05/article-2855345/Cougar-SAR-ready-at-St.-John%26rsquos-International/1)

Great news that there has been an upgrade in SAR capability!

No mention of the S-92 autohover being aproved for use in Canada yet. Can anyone confirm the current status?

[Shell Management]

I'm sure if they had it, they wouldn't just be crowing that they had finished building a tin shed:=

[212man]

Yes it is - see here (near the end):

List of Approved Special Conditions - Airworthiness - Transport Canada (http://www.tc.gc.ca/eng/civilaviation/standards/standards-reg-standards-special-3186.htm)

it was approved shortly after the FAA did - about 4 years after EASA :ugh::ugh::ugh::ugh:

[squib66]

212man

The link you posted is to the agreed extra certification conditions the equipment needs to meet.

But is it actually certified in Canada yet?

I agree 4 years seems amazing.

[Savoia]

Energy clients seek to lift of ban on Canadian offshore night flights

An agreement between the Canada-Newfoundland and Labrador Offshore Petroleum Board (CNLOPB) and the oil companies operating offshore restricted flights to daylight hours after the crash of Cougar Flight 491.

On Tuesday, representatives for the offshore operators — specifically Suncor, Husky Energy and the Hibernia Management and Development Corp. (HMDC) — pointed to the advances in helicopter safety since the crash, including increased pilot training, machine upgrades and the creation of a dedicated search and rescue service.

The company representatives then said they would seek a change in the ban on night flights, and make a formal filing with the CNLOPB in near future.

The request comes following consultations with offshore workers, they said.

It would not be a full removal of the ban on night flights, but would allow for flights to land at night, just after dusk.

It amounts to about an extra hour and a half of flying time each day.

“This really is an attempt by the oil operators to get a full return to night flights,” said a less-than-impressed Lana Payne, Atlantic director for Unifor.

The union represents workers on the Terra Nova FPSO and the Hibernia oil platform.

Payne acknowledged some workers at both sites may be OK with extending the flying day — as has been indicated by representatives for the employer companies — but Unifor is not supporting any change to the status quo, she said.

Cool response from some to extending offshore flying day - Regional - The Gander Beacon (http://www.ganderbeacon.ca/News/Local/2013-10-31/article-3459382/Cool-response-from-some-to-extending-offshore-flying-day/1)

[Savoia]

New rules focus on dangers of flights to offshore drilling sites

http://www.windsorstar.com/business/cms/binary/9177150.jpg?size=620x400s
The Hidernia oil-drilling platform 315 kilometres off the coast of Newfoundland

Nearly five years after a helicopter crash killed 17 people en route to the White Rose and Hibernia oilfields off the coast of Newfoundland, new aviation safety regulations are in the works to prevent similar tragedies in the future.

The proposed amendments to the Canadian Aviation Regulations would require emergency floatation systems and breathing apparatus for over water flights involved in offshore operations.

They would also prevent flights in weather where sea conditions at the destination exceed the measures for safe “ditching” of the vessel, except in emergency situations. Additionally, the proposals, laid out in the Canada Gazette quarterly index, would amend a requirement that crew members wear passenger transportation suits – survival suits – when flying over water with a temperature less than 10 C.

Crew members instead would be able to wear specialized suits tailored to their duties as the passenger suits can interfere with their ability to manipulate controls and “increases the likelihood of thermal exhaustion.”

The proposals take into account several recommendations made by the Transportation Safety Board in 2011 after its investigation of the 2009 Cougar Helicopters crash that left 17 people dead and raised concerns about aviation safety in Canada.

The accident’s lone survivor, Robert Decker, as well as family members of the victims have been critical of Canada’s aviation safety protocol and its slow response to outdated regulations.

Some of the recommendations are already in place, but mandated by the industry rather than government.

Petroleum boards overseeing offshore activity in Newfoundland and Nova Scotia require helicopter operators bidding on contracts to supply emergency floatation systems, which keep the helicopter frame from sinking, and emergency underwater breathing apparatus for each passenger. But with interest in offshore drilling expected in Canada’s arctic and Northern B.C., the proposed changes would be mandatory across the country.

“The safety of passengers and crews of Canadian offshore operations flights cannot be left to reactive contractual obligations,” says the gazette.

The regulations would apply to offshore drilling flights, sea-pilot transfer flights and search and rescue. Failure to comply would be met with a fine of $3,000 for individuals and $15,000 for corporations.

New aviation safety rules focus on dangers of flights to offshore drilling sites (http://www.windsorstar.com/business/aviation+safety+rules+focus+dangers+offshore+drilling+sites/9177149/story.html)

[500e]

Tcabot113 Riff Raff

Things inside of a transmission are rarely without all lube even if jets are clogged due to misting of all of the oil flowing around. I attended an AHS meeting where Bell Helicopter showed a HUMS trace from a 412 where the tail rotor output quill of the main transmission had restricted lube to the bearings due to "cork" in the oil port (not known until inspected). The vibration of the quill was monitored for one year before the decision was made to overhaul it where the cork was found. The bearings had sufficient damage to cause vibration alerts, but no chip indications.

So are you saying there was a 12 month knowledge with the HUMS regarding unexplained vibration on quill :ugh::ugh:

[The Sultan]

500e

Your analysis is completely wrong. The point they were making was a properly designed quill with robust bearings can survive extended operations with reduced/no lubrication. It took one year before the take action level was reached, not that it is flying one year above the highest alert level. Anyone familiar with HUMS knows extremely minor damage can light off lower alerts that have no impact on safety and even the highest are set with significant margin.

The point is Sikorsky screwed up and choose a tail rotor output quill bearing configuration which fails in 12 minutes after loss of lube. This resulted in gears moving and chewing themselves to pieces. The pathetic part was that the failure on the 92 was exactly what was seen in the failed oil out demonstrations. It was loss of tail rotor drive that caused the crash, there was no loss of rotor drive.

Another post showed that Bell presented an AHS paper where the Bell 429 main transmission, in a realistic loss of lube test, ran four hours after the main oil volume was lost in a similar way as the 429. These tests were conducted a minimum continue flight torque up to Max cont power. Bell knows how to design transmissions.

The Sultan

[Savoia]

Another post showed that Bell presented an AHS paper where the Bell 429 main transmission, in a realistic loss of lube test, ran four hours after the main oil volume was lost in a similar way as the 429.

:confused:

[500e]

"It took one year before the take action level was reached, not that it is flying one year above the highest alert level. Anyone familiar with HUMS knows extremely minor damage can light off lower alerts that have no impact on safety and even the highest are set with significant margin".
I thought HUMS was a trend forecast, so if there is a trend that is monitored getting closer to failure mode over a relativity short period, perhaps ?.
I did not think it had been above safe level for a year if it had surely that would would be irresponsible at least
I do appreciate there has to be a level that is to low to warrant action but as the trend was progressing in hind sight a look may have been a good idea.

[The Sultan]

500

When removed the bearings were completely serviceable but showing the initial signs of minor surface damage. No spalling occurred, no chips generated, etc. Same can not be said off Canada.

Savoia

Sorry the last 429 should have been the 92.

The Sultan

[FH1100 Pilot]

Bob, it gets down to an issue of trust. To wit: Do you trust your aircraft to get you to Point B? Most helicopter pilots don’t. Either consciously or sub-consciously, many helicopter pilots have a nagging feeling of dread that a catastrophic failure of some sort will occur which will require them to be on the ground RIGHTFRIGGIN’ NOW! And so they fly low, as SASless notes. They don’t want to be “way up there” when Something Bad happens.

I’m no Sigmund Freud, but I think I know why. Most helicopter pilots are pretty untrustworthy people. There, I said it. And it’s true. If you’ve met many of them you can vouch for this on your own. You can’t trust a helicopter pilot to tell you the time of day, unfortunately. Some will vehemently pretend to deny this, but again, stick around this industry for a while and you’ll see what I mean.

Hand and hand with this personality “quirk” is the fact that most helicopter pilots don’t trust anything or anybody. This lack of trust explains why so many helicopter pilots are fearful, paranoid atheists. (Want to know how paranoid a helicopter pilot is? Just ask him about politics - then stand back!)

Helicopter pilots feel that they are absolutely in charge of their own destiny, and giving up even one small iota of that control is totally unacceptable and abhorrent. Helicopter pilots don’t trust the maintenance guys and they certainly don’t trust their machines, heavens no! Thus, that helpless feeling of being up high in a helicopter when the poop hits the fan is utterly intolerable; too much for them to bear.

They’ll rationalize it. They’ll worry, “What if you get a chip light?” Or, “What if you lose all your transmission oil?” Or, “What if the engine catches on fire?” Or, "What if the rotor blades fly off?" Because in their mind (either the front or back of their mind), every time they fly all of those things are imminent. They’ll tell you, “Oh, the scenery is so much better down low!” But that’s just a mask to hide their real fear. And yes, it’s fear.

Like you, I fly airplanes too. When I’m flying along up high in a single-engine airplane I sometimes wonder to myself, “Gee, what if the engine caught on fire? How fast could I get ‘er down before my feet burned off?” The answer to that could be troubling. But then I ask myself, “...And how likely is that to happen?” The answer is: Not very. So I relax and have myself a sandwich.

There are a number of emergencies that might cause a typical helicopter pilot to want to be on the ground pretty quickly. There’s always the dreaded chip-light (“LAND IMMEDIATELY!!!) that makes a lot of pilots panic. There are also a lot of spinny things (bearings and linkages and such) in our aircraft that can come askew. But aside from in-flight fire, the worst-case scenario is probably a total loss of transmission oil. Yikes! Does that ever happen??

Well…yeah. In 2009 this actually did happen to the crew of a Sikorsky S-92 that was cruising along eastbound off the coast of Canada at 9,000 feet. The crew reversed course, descended to 800 feet and headed toward land. They erroneously thought (due to their knowledge of aircraft certification regulations) that they had at least 30 minutes of “run-dry” capability in their transmission. That’s what the rules call for. But there is a loophole (isn’t there always?).

What they didn’t know, but what Sikorsky did know (but didn’t tell anyone) is that with no trans juice at all the S-92 transmission would last about nine minutes before it did its impersonation of a hand grenade. And, wouldn’t you know it, about nine minutes after the transmission pressure went to zero in that S-92 off the Canadian coast, the transmission came apart. The pilots lost control and the helicopter crashed into the sea. Of the 18 people on board, only one survived.

So the typical helicopter pilot would point excitedly to this event and say, “See?! I told ya so! Bad **** happens!”

The fact is, stuff like that RARELY happens. And even if the S-92 had been up at 10,000 feet when the transmission lost all its oil, the crew still could have initiated a 1500 fpm descent and landed safely if they actually followed the emergency procedures set out in their RFM (although in the case referenced above they did not). But don’t tell that to a paranoid helicopter pilot who’s so worried about getting an engine chip light that he feels uncomfortable and squirms when he gets above 1,000 feet.

Like a few of the guys on this board, I’ve been flying for a living for over 30 years and I’ve got a logbook full of hours, mostly in single-engine helicopters. And me, I fly high. It’s cooler up there, often smoother, and sometimes you can find a ripping tailwind. Plus, I like the view from altitude. If I were that distrustful of my equipment…if I were that paranoid…that afraid of Something Bad happening to my helicopter, I just could not fly it at all - not at any altitude! But see, I also have faith. Faith in the designers, faith in the builders, and faith in the maintainers. Without that faith, I doubt I could even climb into one of these crazy contraptions in the first place.

If the pilot with whom you are ferrying that helicopter is a “typical”helicopter pilot, I’ll bet that you’ll likely spend the whole trip dogging along down at 1,000’ agl. Or less. If that happens, you’ll know some other things about him too...perhaps things that you'd rather not know.

[SASless]

You can’t trust a helicopter pilot to tell you the time of day,

Self fulfilling prophecy there FH?

Sad you have to prove your own point.

Mr. Santa not leave you anything in yer stocking last night or something?

Tis the Season to be of Good Cheer.....try it....you will find it much more enjoyable just as ol' Scrooge hisself did!


This has been put to bed by the Canadian TSB.....read the report of their review of that situation.

You do need to quit talking Bollocks FH!


Well…yeah. In 2009 this actually did happen to the crew of a Sikorsky S-92 that was cruising along eastbound off the coast of Canada at 9,000 feet. The crew reversed course, descended to 800 feet and headed toward land. They erroneously thought (due to their knowledge of aircraft certification regulations) that they had at least 30 minutes of “run-dry” capability in their transmission. That’s what the rules call for. But there is a loophole (isn’t there always?).

[FH1100 Pilot]

I have read the report, SAS, and it did nothing of the sort. You ought to shut yer...how do they say it in your country?...gob.

1. Trans ran dry.
2. Pilots believed that they had "30-minute run-dry" capability as per FAR Part 29.
3. Sikorsky knew it would only last 9 minutes (or so) with no oil at all.
4. Transmission (tail rotor drive) came apart 9 minutes into emergency.
5. Pilots screwed up emergency landing.
6. Everybody died except one pax.

Perhaps you'd like to counter my post with some, you know, FACTS? That is, if it wouldn't trouble you too much. I know that you mostly like to just post innuendo, half-baked opinions and fond remembrances of back when you used to be a pilot some time ago (as opposed to us who still are active pilots), but you're not THAT out of it, are you?

Happy Xmas.

[SASless]

FH......FFS Man....how far is Destin from Pensacola?


FYI....we just went through this discussion a few weeks ago. During that I posted quotes from the TSB Report here at Rotorheads.

I suggest you do a search....catch up on what was posted, what was argued, and how it turned out.

It is all there for you to read....and I care not to go through that again just for your education....and I am sure the rest of the folks here do not want to have to go through it again either.

You are altogether too rude....plainly do not have the facts....and border on being quite offensive in the tone and sentiment of your posts....especially when there is absolutely no call for it.

I know you.....know your background....and had some respect for you in the workplace but here at Rotorheads your manner greatly harms what respect I had for you back then.

The TSB Report does not support your comments re the reasons for the Ditching or the Times you cite along with several other glaring differences.

You have been called out by others, one right after another, and you persist in your crass ways.

Why?

[FH1100 Pilot]

SAS, I'm not sure if you try to be obtuse and argumentative or if it just comes naturally to you. Either way, your posts are tiresome.

But okay SAS, you're right: I'm such an idiot. I absolutely got it wrong. It wasn't nine minutes from loss of transmission oil to transmission failure - it was eleven minutes. And it wasn't nine minutes that the CHI crew got after they noticed a low transmission gearbox pressure to the time their gearbox failed, it was ten minutes. Silly, silly me. Mea culpa, mea culpa, you dick.

Look, I'll play your silly game and make it easy on you. Which one of the following statements is not true?

1. Trans ran dry.
(True/False)

2. Pilots believed that they had "30-minute run-dry" capability as per FAR Part 29.
(True/False)

3. Sikorsky knew it would only last (edited) 11 minutes with no oil at all.
(True/False)

4. Transmission (tail rotor drive) came apart (edited) 10 minutes into the emergency.
(True/False

5. Pilots screwed up emergency landing.
(True/False)

6. Everybody died except one pax.
(True/False)

Here is the synopsis from the Transport Canada report on the accident:On 12 March 2009, at 0917 Newfoundland and Labrador daylight time, a Cougar Helicopters' Sikorsky S-92A (registration C-GZCH, serial number 920048), operated as Cougar 91 (CHI91), departed St. John's International Airport, Newfoundland and Labrador, with 16 passengers and 2 flight crew, to the Hibernia oil production platform.

At approximately 0945, 13 minutes after levelling off at a flight-planned altitude of 9000 feet above sea level (asl), a main gearbox oil pressure warning light illuminated. The helicopter was about 54 nautical miles from the St. John's International Airport. The flight crew declared an emergency, began a descent, and diverted back towards St. John's. The crew descended to, and levelled off at, 800 feet asl on a heading of 293° Magnetic with an airspeed of 133 knots.

At 0955, approximately 35 nautical miles from St. John's, the crew reported that they were ditching. Less than 1 minute later, the helicopter struck the water in a slight right-bank, nose-high attitude, with low speed and a high rate of descent. The fuselage was severely compromised and sank quickly in 169 metres of water. One passenger survived with serious injuries and was rescued approximately 1 hour and 20 minutes after the accident. The other 17 occupants of the helicopter died of drowning. There were no signals detected from either the emergency locator transmitter or the personal locator beacons worn by the occupants of the helicopter.


Bob Denny, here is the link to the Transport Canada TSB report:

Transportation Safety Board of Canada - Aviation Investigation Report A09A0016 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2009/a09a0016/a09a0016.asp)

To save time, I bid you to please refer to Section 1.18.5 S-92A MGB Certification.

There you'll read about how FAR 29.927(c)(1) calls for a helicopter transmission to run for 30 minutes after the loss of lubricating oil.

Sikorsky drained all the oil out of an S-92 gearbox and it ran for eleven minutes until it came apart.

But wait! Like I said, there's a loophole. The FAA permits manufacturers to forego that "30-minute run-dry capability" (as it's informally known in the industry) if such incidences of total loss of oil are "extremely remote." And while extremely-remote is not specifically defined in the 29.927(c)(1) it is generally considered to be one in 10 to the seventh power to 10 to the ninth power. Gee, that's pretty remote!

In Section 1.18.5 of the TSB report you'll read about how Sikorsky convinced the FAA that the only real failure of the trans would be the lines going to and from the transmission oil cooler. Yes, yes, sounds good. Never mind the external oil filter (oh, those never leak!) or the seals on things like accesssory drives (e.g. the generator) or the tail rotor drive shaft or the seals on the two input drive shafts from the engines. Nope, none of those would never leak either!

So Sikorsky simply came up with a means of bypassing the transmission oil cooler. Once the pilots got the "Low Trans G/B Press" caption they had five seconds to activate the emergency bypass, or all of the transmission oil might have been lost. Problem solved! With the cooler isolated and "some" oil lost, the trans oil temp would probably climb up into the red, but hey, at least you'd have some oil circulating around! The trans can run for a long time with hot oil. It just can't run for 30-minutes with no oil.

Handshakes were made and all agreed that no transmission would fail in that way in 10 to the seventh power of flight time. Bing- certified! Aren't their faces red now! Well...no...but they ought to be.

And so that's what happened. A big sun gear in the transmission failed. The drive to the tail rotor disintegrated - like hot melted plastic. While the transmission did not explode or sieze, it was definitely coming apart and would not have lasted much longer with all that molten metal flinging around inside it. But it didn't matter. Flight tests showed that the S-92 was incapable of level flight after a tail rotor failure. (TSB Section 1.18.1.4) Either way, that ship was going down.

In this case, the PF screwed up the auto and pretty much leveled and cushioned at 90 feet or so. Oops! It was a long way to fall.

SASless may tell you I've got things wrong with my description of this accident, but he won't provide a reference. I do not have it wrong. He is mistaken. But he's old (and possibly senile) and apparently not a pilot anymore, so his opinions cannot be confidently relied upon.

In any case, the peculiar CHS S-92 accident should not deter you from flying up an altitude higher than 500' agl. Me? I agree with guys like Shawn Coyle. And if he says to fly high, that should be good enough for the rest of us too.

[rotorspeed]

FH

Interesting, presumably factually accurate post FH, and a good read as usual, thanks.

SAS - have to say that FH does seem to have responded very pertinently, and I for one would like to hear which of his facts you believe are wrong - and do not have the time or inclination to trawl through old info on the S92 accident. FH duly presented a summary - could you do the same please?

High or low? Bit of both for me on a trip of this length. High if I've got a good tailwind, am bored of sightseeing and want to make some smooth progress, but low if not and the view's good!

[SASless]

Superificially and cherry picked only that which tends to support his argument.

Now go back into the Report....Read what is there.....all of it....and check back with us.

Read up on the entire sequence of events where Sikorsky, the Operators including Cougar, and the Authorities worked towards resolving the Oil Filter problem.

There is specific mention to a Senior Cougar Manager and several Cougar Pilots attending a popular, well know internet media site where that issue had been argued, discussed, debated, and talked about for several years.

Also read what they describe as being the cause of the Crash.....and you will see they make no mention of the Run Dry Issue. It all comes down to the Captain made several bad decisions beginning with an improper diagnosis of the problem, followed by failing to comply with Company SOP's for Emergency Descents, and failing to comply with the Company Checklist instruction to Ditch the Aircraft despite the Co-Pilot telling him that on at least three occasions. They go into great detail about bad engineering practices at Cougar re the Oil Filter Studs and Self Locking Nuts, along with other issues that led to the tragedy.

But....they do not say anywhere the Crew made any decision based upon the 30 Minute notion. They do go to lengths to dispel that idea as being part of the decisions the Crew made. There is no other way to read the Report's findings.

If you have not read the TSB report.....word for word....you are not adequately sourced to discuss this.

As I have told FH....he is late to the Party.....must be that Infamous American site ran him off and now he is back here thinking he can carry on in the same manner as is acceptable there but not here.

[26500lbs]

I think what SAS is pointing to is the fact that total loss of MGB OIL PRESSURE is a land immediately situation and was described as such in the ECL at the time of the accident. The crew chose not to do this. Had they ditched immediately then the outcome would likely have been very different.

[SASless]

The TSB wrote a very detailed Report...and conducted a wide ranging investigation and documented their work.

They addressed the Run Dry issue, and clearly described the situation that existed at the time of the Accident.

The had access to the CVR and know the content and context of the discussion between the Cougar Base and the Crew....but do not go into detail what that was.

They plainly reported their findings which included the conversation held between the Captain and the The Base so we have to accept the TSB would have reported any mention of a 30 Minute Run Dry Time. They did not....therefore it follows there was none.

The CVR also had no mention of that.

The RFM had no mention of that.

The Cougar SOP had no mention of that.

The Checklist had no mention of that.

The TSB discussed the multi-year long argument here at Rotor Heads, without naming the site, and concluded the 30 Minute Run Dry situation had reached a point that no reasonable assumption could be made that it was valid.

Sikorsky and the Operators of the 92 held weekly Web Casts discussing 92 issues amongst which was the MGB and all the issues surrounding that.

Folks who cling to the Myth this accident occurred because the Crew thought they could fly for 30 minutes with a Dry MGB are just not accepting the facts.

The TSB very clearly challenged the FAA and other Authorities over the Certification process and the Run Dry issue, as well as Sikorsky. They did a very good job at discussing the entire issue of Run Dry Gearboxes.....and did not just limit themselves to the Cougar 92.

Strongly held False Ideas, no matter how firmly believed....are still wrong. FH is welcome to his opinion but he is not entitled to his own set of facts. I take mine from the TSB Report.....all of it.

[212man]

Folks who cling to the Myth this accident occurred because the Crew thought they could fly for 30 minutes with a Dry MGB are just not accepting the facts.

I agree...:ok:

[Variable Load]

I'm not sure what motivated FH to post what he just did, but I'm with SAS and 212man on this one - there is nothing in the TSB report that indicates the captain based his decisions on a belief that the MGB would run for 30 minutes without oil.

[SASless]

If a pilot is concerned that a loss of lubricant may have occurred, knowledge of the run dry capabilities of the aircraft is of critical importance in determining the necessary flight profile to ensure that the helicopter is landed or ditched prior to a potential failure of the MGB or related component failure due to a loss of MGB lubricant.

FH....cite the evidence in the TSB that showed the Pilots thought they had lost all their MGB oil?

The fact you cannot grasp is they never thought they had lost all the Oil....they thought they had other problems....not a complete loss of Oil.

That is documented in the Report.

This is not the "Little Ship Table" in a PHI Crew Room.....we deal with facts here and polite discussion here unlike the LST.

Quote us the section in the Report where the TSB explains the Trouble Shooting and mistakes the Crew made in that regard....and the reasons they made that false diagnosis. You will see they did not recognize the absence of an increase in the MGB Oil Temperature as being an indication the was not as expected for the case of having some Oil left and the absence of an increasing Oil Temperature would suggest the "lack" of Oil.

They were good Guys....but just got it wrong. The Captain made some bad decisions, the Co-Pilot was not assertive enough despite knowing what the "right" action was......as he pointed it out the Captain.

If you do....you will have to see the truth of the matter.

[FH1100 Pilot]

Good God. Do we HAVE to go through this again? Somebody shoot me...PLEASE shoot me in the head. I'd rather that happen than have one of these pointless arguments with SASless.

(And Variable Load, the post was moved over to this thread from another thread discussing the merits of flying high versus flying low. This accident was one I used as an example of the type of catastrophic failures that some pilots worry about in their irrational justification to fly low. My point was that even without the mythical "30-minute run-dry time" the crew of CHI91 had plenty of time to get the ship down and land safely. But they chose not to.

As for why the Moderators moved the post, I have no earthly idea. I don't know why the Moderators of this forum do the things they do. Sometimes I just shake my head.)

Moving on to the S-92 crash...

Look, we cannot know what any pilot was thinking right before he crashed. We cannot know what was *not* said over the intercom or radio; we only know what *was* said.

However, we know that while the SIC mentioned a couple of times that they were at the "Land Immediately" point in the emergency checklist (and the PIC certainly knew what "land immediately" meant), the PIC did not do this. And it wasn't like he merely chose to not exercise that option, for it was not an option. He consciously chose to contradict the emergency procedure. And so we have to ask ourselves why a mature, professional, properly-trained and experienced aviator would disregard such clear instructions? It even puzzled the TSB investigators.

Even though there was no direct mention of the 30-minute run-dry capability by the crew, we know that both pilots were aware of it. How do we know this? Because WE ALL are aware of it. And, despite SASless's disingenuous protestations to the contrary, the TSB did talk about it in Section 1.18.1.3 of their report. It gets to the heart of what we're saying here. The PIC balanced the risk of ditching against the risk of a MGB failure.
The decision to land or ditch immediately could hinge on the pilots' interpretation of the "land immediately" definition and their assessment of the risks associated with landing immediately versus prolonging flight to reach a more suitable landing area. One possible factor which can influence a pilot's decision-making process is the consideration of a helicopter's run dry capability. If a pilot is concerned that a loss of lubricant may have occurred, knowledge of the run dry capabilities of the aircraft is of critical importance in determining the necessary flight profile to ensure that the helicopter is landed or ditched prior to a potential failure of the MGB or related component failure due to a loss of MGB lubricant.

So it's not correct to say that the TSB report "never mentioned" the 30-minute run-dry capability. It did. Obviously. (Do some of you suffer from reading comprehension issues? I think you must.)

And it's equally not correct to say that the pilot(s) did not consider the run-dry capability of the S-92 simply because neither one of them mentioned directly. It had to play a role, as the TSB agrees.

There is no question that the PIC failed to follow the emergency procedure for the indications he was given. No question. But to say that his knowledge of the run-dry capability absolutely had nothing to do with that decision is just stupid. I mean, it's asinine. Idiotic.

[SASless]

I don't know about this shooting folks in the Head thing.....but I do on the rare occasion shift them to the Peanut Gallery. It is a rare thing at Rotor Heads but it does happen. Adidos Muchacho!

[FH1100 Pilot]

SADfull:I don't know about this shooting folks in the Head thing.....but I do on the rare occasion shift them to the Peanut Gallery. It is a rare thing at Rotor Heads but it does happen. Adidos Muchacho!

Awwwwwww, again? I'm inconsolable!

Actually, this is not the first time SAS has put me on "Ignore." But he absolutely cannot resist arguing with people. So he generously takes me back. And then puts me on "Ignore" again. It's a neurosis, I think.

So SAS won't be able to see any of my posts anymore (at least until he does). And *I'M* supposed to feel bad? Heh.

Any of you readers who think that the CHI 91 accident occurred because the pilot absolutely, positively did not: a) at least consider the possibility that they'd lost all their oil (even though that possibility was never verbalized) and that b) the PIC absolutely, positively did not consider the run-dry time of the S-91 transmission...either you are not helicopter pilots or you're not very good helicopter pilots. Of course he did. OF COURSE HE DID.

Put yourself in his shoes. He was not a complete moron. He was a pilot, probably a lot like me and you (if *you* are actually a pilot and not just playing one on silly internet forums). He saw that his MGB pressure had gone to zero (or nearly so). He isolated the oil cooler using the Emergency Bypass, but did *not* see the expected rise in MGB temperature. Yet he knew...KNEW from his training in the ship that a rise in MGB temperature was to be EXPECTED. Hmm.

Somewhere in the deep, dark recesses of his mind he had to think, "Maybe there is no oil?" He might not have thought it consciously, but that possibility was there in his brain. It had to be...unless he was a complete noob with zero flight time. Because from our earliest days of flying we are taught that if you have zero gearbox pressure and the the temperature does not go up, THEN YOU MIGHT NOT HAVE ANY OIL. In a loss of MGB pressure, a lack of temperature increase IS the secondary indication! To say he was totally unaware of this phenomenon is just, as I say, stupid, because it is just *one* of the possibilities that would be running through ALL of our minds.

So although he did not actually say out loud into the intercom, "Gee, maybe we lost all our gearbox oil!" he had to be thinking it on some level. To assume otherwise is to give him a very serious insult and discredit. He made a decision based on what he knew...based on ALL of the things he knew, not just what was showing on his gauges.

[Helilog56]

:ugh:....keeripes

[Thomas coupling]

A nobody; a nitwit; a pilot; a motorcyclist; a raconteur; a lover...of life - who loves to laugh, who tries to not take myself (or anything) too seriously...just a normal guy who knows his place in the universe by being in touch with my spiritual side. What more is there?.

FN1100: Chill out bubba. You're semi retired, with all the physical accoutrements of either a TIA or an MI. Don't speed up what fate already has in store for you by reiterating your views in a derogatory or offensive manner.
Stick with your own description of yourself and you won't go far wrong.

And SAS: Don't take it so seriously bud: You seem to be parking too many of us in that "peanut Gallery" (whatever that is). You'll be talking to yourself in here soon.........:( You know what they say,.."if you can dole it out, then be prepared to take it too".......


Geez....you yanks...if you're not beating up the rest of the world, you're beating each other up.

[zalt]

6 years on
RIP the Cougar 17
Cougar 491 crash remembered 6 years later - Newfoundland & Labrador - CBC News (http://www.cbc.ca/news/canada/newfoundland-labrador/cougar-491-crash-remembered-6-years-later-1.2991668)

[Variable Load]

More importantly....remember to follow the ECL

[Arnie Madsen]

Interesting Cougar Memorial ... looks like Leonardo da Vinci’s Air Screw

Cougar 491 crash remembered 6 years later - Newfoundland & Labrador - CBC News (http://www.cbc.ca/news/canada/newfoundland-labrador/cougar-491-crash-remembered-6-years-later-1.2991668)

[zalt]

On Fa(r)cebook their is a group called Sikorsky S-92 professionals and a discussion on PHI S-92s deploying to Barrow, AK.

Two messages posted yesterday, one a question the other an answer:

David Franklin
Why did phi go to seastate 6 floats I hate those sponson floats

Nick Lappos
International pressure from the CAA. They mandated the SS6 floats, against the massive data to show how seldom they would be used.

Is this an official Sikorsky position?

[NickLappos]

zalt, you should know better than that!

[inputshaft]

OK I'll be the one to bite.

How can anyone "hate" Sea State 6 floats? I can understand a discussion that statistically they may not be necessary, but to focus a level of emotion that I reserve for sweet wine wine and jazz compilations bought from Starbucks on a piece of kit that can only improve safety does seem a little strange.

[NickLappos]

Inputshaft,
First, recognize (unlike zalt) that we on the supply side of this collective effort provide what our customers want and need, so any discussion of the relative merit of SS6 floats is nearly academic - we deliver what you folks want to buy.
The issue is not that any particular piece of kit makes things "safer", because by that logic, we pile it all on until we are absolutely as safe as can be, and carry one passenger in a 50,000 lb machine.
The question is always "What is the next most valuable pound of weight and dollar of cost going to buy that makes the aircraft safer?" Example: should we spend 100 lbs (invented number) going from SS5 to SS6 on the floats, or provide 100 more horsepower when OEI? Both weigh 100 lbs, which makes the aircraft safer? Which do we burden the aircraft with?


That is the essence of design, and operators, manufacturers and regulators all dance together to balance the equation.

[zalt]

Blame the regulator for SS6 floats then blame an early customer for buying the default SS4 floats.

So how much weight did titanium studs save?

[NickLappos]

dirty shot, zalt.
All of us in this industry, in every job, strive to make the best total operations - manufacturers of components, aircraft, engines, operators of the aircraft, pilots, engineers, logistics experts, refuellers, regulators - all of us work our careers to give our passengers the proper safe comfortable and productive flight.


The pilots and engineers that I know from AW, Bell, Mil, Kamov, Airbus and Sikorsky (and I know lots of them) are all professionals, and they lose sleep, as I do, when our best efforts aren't good enough.

[Never Fretter]

It's not an unreasonable question. From reading the TSB report stainless steel used on the UH-60 was replaced with more expensive titanium. As I've never heard of an aircraft that was 'too light' perhaps it was for weight saving. Or perhaps there was another perfectly sensible reason to switch. The trouble is the TSB don't explain why that design choice made perfect sense at the time.

It would be a service to all those other dedicated designers out there, who are perhaps working on components for the next generation of helicopters, if they could better understand those decisions.

[DOUBLE BOGEY]

Nick. Good post!

[Lonewolf_50]

All of us in this industry, in every job, strive to make the best total operations - manufacturers of components, aircraft, engines, operators of the aircraft, pilots, engineers, logistics experts, refuellers, regulators - all of us work our careers to give our passengers the proper safe comfortable and productive flight.

The pilots and engineers that I know from AW, Bell, Mil, Kamov, Airbus and Sikorsky (and I know lots of them) are all professionals, and they lose sleep, as I do, when our best efforts aren't good enough.
A question well asked about "the system" (with all of those folks in it) remains: how was the lesson learned in the incident in Australia (previous to this tragic crash) spread among the interested parties? A variety of "if we know this, what do we do with that information" arises every time things are discovered in the field. This question is informed by the case of a swashplate bearing and the eventual addition of the bearing monitor panel, in another model of aircraft.

[crunchingnumbers]

The question is always "What is the next most valuable pound of weight and dollar of cost going to buy that makes the aircraft safer?" Example: should we spend 100 lbs (invented number) going from SS5 to SS6 on the floats, or provide 100 more horsepower when OEI? Both weigh 100 lbs, which makes the aircraft safer? Which do we burden the aircraft with?


Nick thanks for the insightful and (at least for me) illuminating information on the engineering considerations - well put.

[zalt]

LW50 and NF ask excellent questions.

On the question of weight: Would these 17 fatalities been avoided if the crew has SS6 floats appropriate for the Atlantic and been more comfortable ditching? SS4 is only good for ditching along side those in d'Nile after all.

I wonder how the trade off was made on the failure to achieve 30 minutes running after a loss of lubrication. There was over 2 years from the failed test to entry into service and over 6 until Cougar. So time to act. Too expensive (like the Ford Pinto) or too heavy? Another Sikorsky helicopter had a total oil loss in Canada in 2002 so the alarm bells should have been ringing with Sikorsky and the 'extremely remote' argument was already 'optimistic'. Or should we just going to hear the FAA were to blame for letting Sikorsky deliver the aircraft?

[Hilife]

NF. Look again, the reasoning is recorded in the report.

1.6.3 S-92A Main Gearbox

The oil filter bowl is attached to the MGB housing by three equally spaced titanium alloy stud and self-locking nut assemblies. The manufacturer decides what type of fastener to use, as there is no specific rule that defines the type of fastener to be used for what application. In selecting a fastener, aircraft manufacturers typically use similar product history, published material specifications (i.e. American Society for Testing and Materials), and/or develop their own process specifications.

Titanium is desirable in certain applications due to its corrosion resistance and lighter weight as compared to steel. Sikorsky selected the titanium alloy stud because these had been used successfully on other Sikorsky products, such as the CH-53E Sea Stallion which utilizes six titanium studs to attach the oil filter bowl to the MGB. Also, Sikorsky declared that there was no reported history of in-service titanium stud failures.

The fastening system for the oil filter bowl of the S-92A used anodized titanium alloy studs, silver-plated steel nuts and cadmium-plated steel washers. Anodizing and plating increases resistance to corrosion, wear and galling.

http://http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2009/a09a0016/a09a0016.asp#sec1_6_3 (http://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2009/a09a0016/a09a0016.asp#sec1_6_3)

As always I stand to be corrected, but I think you will find the UH-60 series MGB has titanium studs and still the case today for the reasons noted above.

Read the following paragraph as to why the S-92 was unique in having problems with the titanium studs.

1.6.3.3 S-92A Main Gearbox Oil and Filter Replacement

[The SAR RC]

Would these 17 fatalities been avoided if the crew has SS6 floats appropriate for the Atlantic and been more comfortable ditching?

The impact of this crash was sufficient for the sponsons (and their integral dinghies) to detach as I recall. I very much doubt sea state six floats would have made any difference to the poor souls with multiple broken bones who drowned in the freezing cold water.

You can talk about the design flaw and the inadequate run-dry time for decades if you like. The simple truth is that if the Captain had listened to his co-pilot, who twice told him that they had reached the words 'Land Immediately' in the checklist, there would have been no accident to survive, merely a controlled ditching.

[HeliComparator]

The impact of this crash was sufficient for the sponsons (and their integral dinghies) to detach as I recall. I very much doubt sea state six floats would have made any difference to the poor souls with multiple broken bones who drowned in the freezing cold water.

You can talk about the design flaw and the inadequate run-dry time for decades if you like. The simple truth is that if the Captain had listened to his co-pilot, who twice told him that they had reached the words 'Land Immediately' in the checklist, there would have been no accident to survive, merely a controlled ditching.


I think you are missing the point, which is that the sea state at the time was above 4 and perhaps that was a factor in the captain's denial about the need to ditch - ie he knew it would not be a safe ditching and possibly felt that continued flight was the safer option. But of course we don't know that.

[zalt]

SAR RC sounds like your answer to my question is either "possibly" or "probably". Unless you think someone believed the oil loss marketing hype and pressed on for the Cape...

Another conclusion from what you write is that survivability features mitigate design flaws (among other things) and if a manufacturer runs out of options and has to say "Land Immediately" in the RFM they shouldn't begrudge investing in them! If they do perhaps it's a sign they aren't going to make much of an effort either

I can understand if Sikorsky are sensitive on survivability. Flack have a C$200k research contract to look at the S-92 exit windows and see if they can actually be opened in a real scenario. The CAA / UK oil company cabin size project has made the S-76 an 8 seater (and any one here who is Xtra Broad shouldn't argue with that considering there have been a trio of S-76 ditchings in recent years), its floatation performance is poor and the 76D isn't likely to survive until next HeliExpo under new owners. Plus I believe the European survivability rule making proposal to change Part 29 hits the streets in a few weeks.

[Lonewolf_50]

As always I stand to be corrected, but I think you will find the UH-60 series MGB has titanium studs and still the case today for the reasons noted
above. And the SH-60 (now MH-60) family as well.

[Never Fretter]

Hilife Thanks for taking the time to do that research.

Hilife / Lonewolf_50 Contacts at Fort Rucker insist the H-60 started with stainless steel bolts not titanium studs.

I see "the CH-53E Sea Stallion which utilizes six titanium studs". Why only three studs on the S-92A? Weight again?

With even just 4 studs, geometrically the filter housing would have been less susceptible to the loss of one stud.

The fastening system for the oil filter bowl of the S-92A used anodized titanium alloy studs, silver-plated steel nuts and cadmium-plated steel washers. Anodizing and plating increases resistance to corrosion, wear and galling.

Really?! Wasn't galling the failure mode here?! This just begs more questions than it answers.

This question by Lonewolf_50 remains valid:

...how was the lesson learned in the incident in Australia (previous to this tragic crash) spread among the interested parties? A variety of "if we know this, what do we do with that information" arises every time things are discovered in the field.

This question is informed by the case of a swashplate bearing and the eventual addition of the bearing monitor panel, in another model of aircraft.


I understand this comment to mean the H-53 disaster after a quality control deception by a Sikorsky supplier discussed here: http://www.pprune.org/rotorheads/20264-ch-53e-swashplate-bearing-failure.html
and
At Sikorsky Aircraft, A Flight Gone Wrong - NYTimes.com (http://www.nytimes.com/1996/06/23/nyregion/at-sikorsky-aircraft-a-flight-gone-wrong.html)

[Lonewolf_50]

Hilife / Lonewolf_50 Contacts at Fort Rucker insist the H-60 started with stainless steel bolts not titanium studs. Are you referring only to what secures the oil filter to the main module (actually, the sump) or all of the studs holding the transmission together?

[zalt]

As soon as the FAA introduce a means for employees to raise concerns about poor certification decisions, some in industry challenge the idea!
FAA Safety Review Prog delaying Aircraft Cert? | JDA Journal (http://jdasolutions.aero/blog/safety-review-program/)

[Never Fretter]

Lonewolf_50
The filter.

[Lonewolf_50]

Lonewolf_50
The filter. Ah. Was thinking all studs ...

[riff_raff]

There was quite a bit of discussion on this thread about the design issues with the S-92 MRGB. As I pointed out, in my opinion, the use of just 3 fasteners to attach the oil filter housing did not provide a sufficient level of fault tolerance in the event one of the fasteners were to fail.

Also, in my opinion, titanium fasteners should never be used for an application that involves regular removal and re-installation of the fastener, such as attachment of an oil filter housing . Titanium fasteners work well for situations where the fastener is installed under carefully controlled conditions and never is removed. But due to titanium's inclination to gall and inherent notch sensitivity, it does not make a good fastener material for service applications. The miniscule weight savings provided by using titanium studs rather than more reliable A286 cres studs for this application cannot be justified, in my opinion.

I won't go into the obvious design issues in the EC225 MRGB.

[Hilife]

Quote:
The fastening system for the oil filter bowl of the S-92A used anodized titanium alloy studs, silver-plated steel nuts and cadmium-plated steel washers. Anodizing and plating increases resistance to corrosion, wear and galling.
Really?!

Wasn't galling the failure mode here?! This just begs more questions than it answers.

Your not reading the report are you NF.

I say again, read the following paragraph as to why the S-92 was unique in having problems with the titanium studs (historically not an issue on the 53 and 60 Series with millions of flight hours between them) and note that the design scheduled number of times that the oil filter bowl should have been removed during the life of the MGB was just five, but Cougar was averaging around 220 hours instead of the anticipated 500 to 1000 hours.

1.6.3.3 S-92A Main Gearbox Oil and Filter Replacement

When digested, then take a butchers at points 1. to 5. of the conclusions.

3.0 Conclusions

3.1 Findings as to Causes and Contributing Factors

1. Galling on a titanium attachment stud holding the filter bowl assembly to the main gearbox (MGB) prevented the correct preload from being applied during installation. This condition was exacerbated by the number of oil filter replacements and the re-use of the original nuts.

2. Titanium alloy oil filter bowl mounting studs had been used successfully in previous Sikorsky helicopter designs; in the S-92A, however, the number of unexpected oil filter changes resulted in excessive galling.

3. Reduced preload led to an increase of the cyclic load experienced by one of the titanium MGB oil filter bowl assembly attachment studs during operation of CHI91, and to fatigue cracking of the stud, which then developed in a second stud due to increased loading resulting from the initial stud failure. The two studs broke in cruise flight resulting in a sudden loss of oil in the MGB.

4. Following the Australian occurrence, Sikorsky and the Federal Aviation Administration (FAA) relied on new maintenance procedures to mitigate the risk of failure of damaged mounting studs on the MGB filter bowl assembly and did not require their immediate replacement.

5. Cougar Helicopters did not effectively implement the mandatory maintenance procedures in Aircraft Maintenance Manual (AMM) Revision 13 and, therefore, damaged studs on the filter bowl assembly were not detected or replaced.

[zalt]

This just begs more questions than it answers.

Indeed.

As confirmed by Hilife...

note that the design scheduled number of times that the oil filter bowl should have been removed during the life* of the MGB was just five, but Cougar was averaging around 220 hours instead of the anticipated 500 to 1000 hours.* I assume you mean the TBO

...the expected MTBUR of the filters was massively optimistic meaning the comments on the success of titanium on other fleets are irrelevant.

Any news on the new MGB being designed?

[[email protected]]

So why were the filters being removed so frequently? Where there other issues that led to this practice?

[212man]

So why were the filters being removed so frequently? Where there other issues that led to this practice?

The filter mesh was smaller than the naturally occurring particulates in canned oil, so they clogged prematurely. Some operators bought filtering equipment, but most didn't (and why should they?)

[terminus mos]

We have some S-92s contracted at the moment. They fly 8 hours per day each on busy days. In 18 months, we have had 2 or 3 MGB Oil Filters pop into bypass mode which have been discovered on turnaround. Each time we have consulted the OEM but it has never caused much additional maintenance other than some checks.

So far, we haven't had a technical RTB. As a customer, I find the S-92 is pretty reliable, it always starts, the oil stays in the boxes and passengers like it and trust it.

[SansAnhedral]

In 18 months, we have had 2 or 3 MGB Oil Filters pop into bypass mode which have been discovered on turnaround.

Are these the 6-bolt housings with the reverse-flow filter cartridges?

[maxwelg2]

Tomorrow will be the 10th anniversiary of Cougar 491. I looked back to this thread and the question on the oil filter caught my eye. When did the filter design get changed if at all to reduce the number of bypass conditions being found?

If only Sikorsky has made that change out of the studs an AD instead of a SB my lost friends would still be here.

if you want an insight into how this tragedy has affected the families of those lost souls there is a book by Rod Etheridge called “18 Souls the loss and legacy of Cougar Flight 491”, ISBN 978-1-7752345-0-0,