Helicopter crash off the coast of Newfoundland - 18 aboard, March 2009
Perhaps I am wrong but don't the Oil Companies (The Customer) have aviation experts and safety operations that are supposed to be monitoring and auditing helicopter operations?
It gets back to my point the Customer/The Oil Companies are the folks that dictate the standards for their operations.
Why then are the Operators, Regulators, and other service providers allowed to get away with this perceived lack of safety and compliance with standards?
When I buy a bag of Dorito's I expect them to be fresh, ready to eat, and in a sealed bag that promises me they are safe from tampering.......why not the helicopter industry?
It gets back to my point the Customer/The Oil Companies are the folks that dictate the standards for their operations.
Why then are the Operators, Regulators, and other service providers allowed to get away with this perceived lack of safety and compliance with standards?
When I buy a bag of Dorito's I expect them to be fresh, ready to eat, and in a sealed bag that promises me they are safe from tampering.......why not the helicopter industry?
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Hi SASless,
My last post was going on a bit and I did not want it to be a book. Yes absolutely as I mentioned the client has as you indicate. As one who has been subject to many audits from oil companies and airworthiness authorities, been interrogated and had to demonstrate compliance for not only the contractual obligations but the requirements of legislation I know the form. The detailed inspection of records, and company procedures, and on and on. However the audit report and grading of the findings and the response from the operator and the compliance to the audit findings is never the end.
Yes the oil company douse, but only to the specific requirements they have. They do not dictate the legislation and never will, they can however control there own standard and safety requirements. In some cases they would be expected to pay additional costs to support, (HUMS when it originally was introduced to the NS was financed by Shell and the authority) as an example.
Please when being critical one must be specific, you cannot lump a statement re safety, operators, regulators and other service providers all have different responsibilities.
Comment re Perceived lack of safety and compliance with standards needs clarification, then discussion is productive.
I will state that to a question “Has Helicopter Safety improved in your experience” the answer is “YES”. Is continued improvement required ‘’YES’’ to the question is enough being done to regulate and control ‘’NO’’
O
My last post was going on a bit and I did not want it to be a book. Yes absolutely as I mentioned the client has as you indicate. As one who has been subject to many audits from oil companies and airworthiness authorities, been interrogated and had to demonstrate compliance for not only the contractual obligations but the requirements of legislation I know the form. The detailed inspection of records, and company procedures, and on and on. However the audit report and grading of the findings and the response from the operator and the compliance to the audit findings is never the end.
Yes the oil company douse, but only to the specific requirements they have. They do not dictate the legislation and never will, they can however control there own standard and safety requirements. In some cases they would be expected to pay additional costs to support, (HUMS when it originally was introduced to the NS was financed by Shell and the authority) as an example.
Please when being critical one must be specific, you cannot lump a statement re safety, operators, regulators and other service providers all have different responsibilities.
Comment re Perceived lack of safety and compliance with standards needs clarification, then discussion is productive.
I will state that to a question “Has Helicopter Safety improved in your experience” the answer is “YES”. Is continued improvement required ‘’YES’’ to the question is enough being done to regulate and control ‘’NO’’
O
Outhouse,
Thus we agree.....but add in the other position that I take and you will see why I am very critical of the oil companies. That being....the use of "Best Practice" standards would require the individual oil company to use the most stringent standard worldwide in their operations even if they exceeded the "local" standard. If that were so....the Gulf of Mexico would be a much different place than it is now. Nigeria would be a much different place than it is now.
I dare say there is a particular operation in Oz that would be very much different.
How can an oil company operate to different standards using the "local regulations" as the base for their standards and thus operate so very much differently within their own company as a result?
I again lay the primary responsibility squarely on the back of the oil companies. We could say the same thing about Helicopter Operators....Industry Best Practice Standards should be the requirement and be standardized throughout the company operations.
That would put the oil company into synch with the operators.....as the oil company would then not do business with the operators which fell short of the desired standard possessed by the industry leaders.
We know the oil company prefers the lowest bidder....and will accept a minimum standard rather than pay for the "Industry Best Standards Model".
Thus we agree.....but add in the other position that I take and you will see why I am very critical of the oil companies. That being....the use of "Best Practice" standards would require the individual oil company to use the most stringent standard worldwide in their operations even if they exceeded the "local" standard. If that were so....the Gulf of Mexico would be a much different place than it is now. Nigeria would be a much different place than it is now.
I dare say there is a particular operation in Oz that would be very much different.
How can an oil company operate to different standards using the "local regulations" as the base for their standards and thus operate so very much differently within their own company as a result?
I again lay the primary responsibility squarely on the back of the oil companies. We could say the same thing about Helicopter Operators....Industry Best Practice Standards should be the requirement and be standardized throughout the company operations.
That would put the oil company into synch with the operators.....as the oil company would then not do business with the operators which fell short of the desired standard possessed by the industry leaders.
We know the oil company prefers the lowest bidder....and will accept a minimum standard rather than pay for the "Industry Best Standards Model".
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Compliance - not the end but the beginning
SAS, OH, et al
The question of standards being dictated by regulation is outdated and it will not achieve the desired improvements in accident rates. Regulations set the lower limits of accepability and should only be used where no 'best practice' standard accepted by industry is available.
The right approach is to look around and see who does it best and how achievable that is in a price sensative market. Note that I didn't suggest that price is the single most important factor. Compromises will always be required but sometimes that means that the customer must pay a little bit more and accept it as the price of progress. The safest way to operate a helicopter is to leave it in the hangar and close the doors but life is about taking risks so we have to get out there in the real world and learn to live with the occasional failure. We must however learn from our failures and seek to raise the benchmark when the balance of cost over safety leans in favour of spending a bit more.
We need to stop berating the authorities for lack of stiff regulation and as professionals demand a minimum acceptable operating standard from our employers on behalf of the many powerless passengers we fly every day.
It was only 50 years ago that the UK government, the UK CAA, the national airline of UK (BOAC), the manufacturers (De Havilland) and the accident investigators* all conspired to hide the cause of fatal accidents caused by performance difficiencies in the Comet airliner. They allowed the famous words 'pilot error' to be attached to the accident reports that lead to the demotion of one Captain and the death of others. It wasn't any of those illustrious bodies that blew the whistle but the pilots. If you don't want to be party to another such event then the remedies are in your hands.
G
*the accident investigators in those days were I believe part of the CAA and this incident may well have been the reason for the creation of the independent body - the AAIB. All those without such an independent bunch of investigators have good cause to be disappointed. (edited for clarity)
The question of standards being dictated by regulation is outdated and it will not achieve the desired improvements in accident rates. Regulations set the lower limits of accepability and should only be used where no 'best practice' standard accepted by industry is available.
The right approach is to look around and see who does it best and how achievable that is in a price sensative market. Note that I didn't suggest that price is the single most important factor. Compromises will always be required but sometimes that means that the customer must pay a little bit more and accept it as the price of progress. The safest way to operate a helicopter is to leave it in the hangar and close the doors but life is about taking risks so we have to get out there in the real world and learn to live with the occasional failure. We must however learn from our failures and seek to raise the benchmark when the balance of cost over safety leans in favour of spending a bit more.
We need to stop berating the authorities for lack of stiff regulation and as professionals demand a minimum acceptable operating standard from our employers on behalf of the many powerless passengers we fly every day.
It was only 50 years ago that the UK government, the UK CAA, the national airline of UK (BOAC), the manufacturers (De Havilland) and the accident investigators* all conspired to hide the cause of fatal accidents caused by performance difficiencies in the Comet airliner. They allowed the famous words 'pilot error' to be attached to the accident reports that lead to the demotion of one Captain and the death of others. It wasn't any of those illustrious bodies that blew the whistle but the pilots. If you don't want to be party to another such event then the remedies are in your hands.
G
*the accident investigators in those days were I believe part of the CAA and this incident may well have been the reason for the creation of the independent body - the AAIB. All those without such an independent bunch of investigators have good cause to be disappointed. (edited for clarity)
Last edited by Geoffersincornwall; 26th Mar 2009 at 14:55.
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SASless.
Good stuff, specific topics and discussion points. Common standards based on the best available is what we would all want. Unfortunately as most know some local airworthiness authorities are behind the drag curve. So can a client insist that his safety and operating requirements exceed. Bugger, not so, answer, very nasty and political trying to upgrade the local authority requirements. Maybe the oil company could insist on contract, accept cost penalty and create an even playing field on contract response submission and acceptance. Will this happen NO; the money men are the deciding factor so is real safety a commitment? Possibly NO. Evidence client commitment to accept a higher bid and higher standards.
Operators, outside of a well and defined safety culture and authority that actually has an acceptable airworthiness system will use the advantages available to reduce costs, its life. So unless the oil clients have the commitment to safety and unless the above is there culture, then lower standards and the hazards involved will prevail.
So the end analysis follows yours. Operators of helicopters will I feel want to maintain best standard of safety. In a well regulated environment then it should work (assuming that all regulation requirements are followed) once away from this environment, e.g. Nigeria and similar, oil companies really don’t give evidence that they have any commitment to a true safety culture.
Would have expected that as GOM was in the US that a third world safety culture was difficult to grasp in that area. Still a crap safety record must demonstrate a failing and some response?
O
Good stuff, specific topics and discussion points. Common standards based on the best available is what we would all want. Unfortunately as most know some local airworthiness authorities are behind the drag curve. So can a client insist that his safety and operating requirements exceed. Bugger, not so, answer, very nasty and political trying to upgrade the local authority requirements. Maybe the oil company could insist on contract, accept cost penalty and create an even playing field on contract response submission and acceptance. Will this happen NO; the money men are the deciding factor so is real safety a commitment? Possibly NO. Evidence client commitment to accept a higher bid and higher standards.
Operators, outside of a well and defined safety culture and authority that actually has an acceptable airworthiness system will use the advantages available to reduce costs, its life. So unless the oil clients have the commitment to safety and unless the above is there culture, then lower standards and the hazards involved will prevail.
So the end analysis follows yours. Operators of helicopters will I feel want to maintain best standard of safety. In a well regulated environment then it should work (assuming that all regulation requirements are followed) once away from this environment, e.g. Nigeria and similar, oil companies really don’t give evidence that they have any commitment to a true safety culture.
Would have expected that as GOM was in the US that a third world safety culture was difficult to grasp in that area. Still a crap safety record must demonstrate a failing and some response?
O
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Does anyone else have a checklist that specifies a secondary indication (ie oil temp, chip lights, noises) to effect a land immediately? Or does just a complete loss of oil pressure effect a land immediately?
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Hi Geoff,
Personally I agree with you, however the bottom line is as we all know and the guide is the regulation.
However, question to all.
Your company has not had a fatal accident for 25 years; you are operating to EASA standards and have a large international oil based client bank.
Following the general drift of this conversion, and wishing to improve your standards above the required legalisation requirements, and having the opportunity to address the Board of Directors of your company.
What would be your priorities and justification?
O
Personally I agree with you, however the bottom line is as we all know and the guide is the regulation.
However, question to all.
Your company has not had a fatal accident for 25 years; you are operating to EASA standards and have a large international oil based client bank.
Following the general drift of this conversion, and wishing to improve your standards above the required legalisation requirements, and having the opportunity to address the Board of Directors of your company.
What would be your priorities and justification?
O
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No, check lists above in the thread, seems lacking as no mention of the possible 5 psi alleged single pump indication. Seemed last time I looked not to mention the 5 second switching thing. Best ignored and if you are flying the 92 check your own.
O
O
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Canada TSB Update S92 Accident
TSB just announced that on descent, zero MGB pressure at 5700'. Full timeline from information available will be published by TSB today.
Power supply to CVR/FDR interrupted at 800', no data from them after that point. A/c struck surface slight tail down attitude.
They hit hard - TSB estimates + 20g's.
MGB is at SAC for inspection.
Power supply to CVR/FDR interrupted at 800', no data from them after that point. A/c struck surface slight tail down attitude.
They hit hard - TSB estimates + 20g's.
MGB is at SAC for inspection.
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SASless, nevermind the Doritos, how about peanut butter? Due to the rush to limit government over the past 8 years, inspection of all sorts of food products has been dispensed with, as being too costly to the companies being inspected, and to the government paying the inspectors. That has resulted in many deaths from contaminated food products, which everyone assumed was safe because the government was supposed to be inspecting them. Limit the government too much, and people die. The FAA has been limited as much as any other department, but has always used its power arbitrarily, as shown by the Bob Hoover fiasco. Without continuous Congressional oversight, we will never have adequate safety regulation or enforcement. What we have is the golden rule - those who have the gold get to make the rules, and the rest of us have no say in anything.
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Fellas,I note from this thread a lot of Sikorsky Bashing (I don't work for them) a lot of oil company bashing (I don't work for them either) and a few questions of the regulatory bodies (Guess who I don't work for either) I have no axe to grind here, however given the basics that a helicopter, by its very nature will ALWAYS have single critical load paths, of which the main tx is one, and also given that even a complex HUMS system would have given no more warning of the failure than an oil px gauge.. since there is much arguments as to the validity of displaying HUMS data to the pilot in flight.. Couple this with the fact that the aircraft is designed and built by men who do their absolute best to deliver the best product they can (I know a lot of the guys at SAC personally.) they select components carefully.. If the studs are titanium, then they were titanuim for a damn good reason. Sadly it seems to me that with the best will in the world, there are times when us mere mortals get caught out. I'm sure SAC will learn, as will everyone, pilots included. But it seems to me that without hindsight, there was very little anyone could do to prevent this.
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Alloa,
You are wrong. The S-92 shows there were many missed opportunities to avoid this.
The Sultan
You are wrong. The S-92 shows there were many missed opportunities to avoid this.
The Sultan
Precisely, and I hope SAC gets their A##es sued off!!!!
Last edited by Outwest; 27th Mar 2009 at 01:17.
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Chronology of events
11:48:07 Cougar Flight CHI91 departs St. John's.
12:05:52 CHI91 advises Gander Area Control Centre (ACC) that they have levelled off at 9,000 feet and that their estimated time of arrival at the Hibernia platform is 13:10. Speed is 110 knots.
12:15:05 Rapid loss of main gearbox oil pressure occurs. No abnormal indications of any kind recorded on flight data recorder prior to this event.
12:15:19 CHI91 begins a right turn.
12:15:24 Main gearbox oil pressure decreases to approximately five psi.
12:15:27 CHI91 issues mayday call to Gander ACC and begins descent from 9,000 feet. They are 53 nautical miles from St. John's.
12:15:32 CHI91 advises Gander ACC that they have main gearbox oil pressure problems and requests immediate clearance to return to St. John's.
12:15:43 CHI91 heads back to the coast. Their heading is 290 degrees and their speed is 120 knots.
12:17:04 Main gearbox oil pressure reaches 0 psi.
12:17:25 CHI91 advises Gander ACC that they are heading for nearest land. Their heading is 292 degrees and their speed is 122 knots.
12:17:42 CHI advises Gander ACC that they have lost all main gearbox oil pressure. CHI91 is descending through an altitude of 5,740 feet.
12:18:25 Gander ACC advises CHI91 that they are 42 miles from Cape Spear.
12:19:10 Gander ACC advises CHI91 that search and rescue has been notified.
12:19:18 CHI91 advises Gander ACC that Cougar dispatch has been advised and that another helicopter is being readied.
12:22:20 CHI91 levels off at approximately 800 feet. Their heading is 292 degrees and their speed is 133 knots.
12:24:44 A power interruption to the Flight Data Recorder/Cockpit Voice Recorder occurs.
12:25:36 CHI91 advises Gander ACC that they are preparing to ditch.
12:25:52 St. John's radar records CHI91 at 800 feet. CHI91 subsequently descends to 300 feet in approximately 29 seconds which equates to an approximate rate of descent of 1,000 feet per minute.
12:26:26 St. John's radar records the last radar return of CHI91 at 300 feet.
12:26 Gander ACC advises search and rescue that CHI91 has ditched. Cougar dispatch confirms the ditching with search and rescue, and advises that they will launch Cougar 61 as a rescue helicopter.
12:42 A Provincial Airlines patrol aircraft arrives at crash site and observes two people in orange immersion suits in the water.
13:07 Cougar rescue helicopter departs St. John's.
13:25 Cougar rescue helicopter arrives at crash site and spots two people (one of whom is later confirmed dead), two rafts and helicopter debris.
13:33 Cougar rescue helicopter lowers a rescue person toward the people in the water.
11:48:07 Cougar Flight CHI91 departs St. John's.
12:05:52 CHI91 advises Gander Area Control Centre (ACC) that they have levelled off at 9,000 feet and that their estimated time of arrival at the Hibernia platform is 13:10. Speed is 110 knots.
12:15:05 Rapid loss of main gearbox oil pressure occurs. No abnormal indications of any kind recorded on flight data recorder prior to this event.
12:15:19 CHI91 begins a right turn.
12:15:24 Main gearbox oil pressure decreases to approximately five psi.
12:15:27 CHI91 issues mayday call to Gander ACC and begins descent from 9,000 feet. They are 53 nautical miles from St. John's.
12:15:32 CHI91 advises Gander ACC that they have main gearbox oil pressure problems and requests immediate clearance to return to St. John's.
12:15:43 CHI91 heads back to the coast. Their heading is 290 degrees and their speed is 120 knots.
12:17:04 Main gearbox oil pressure reaches 0 psi.
12:17:25 CHI91 advises Gander ACC that they are heading for nearest land. Their heading is 292 degrees and their speed is 122 knots.
12:17:42 CHI advises Gander ACC that they have lost all main gearbox oil pressure. CHI91 is descending through an altitude of 5,740 feet.
12:18:25 Gander ACC advises CHI91 that they are 42 miles from Cape Spear.
12:19:10 Gander ACC advises CHI91 that search and rescue has been notified.
12:19:18 CHI91 advises Gander ACC that Cougar dispatch has been advised and that another helicopter is being readied.
12:22:20 CHI91 levels off at approximately 800 feet. Their heading is 292 degrees and their speed is 133 knots.
12:24:44 A power interruption to the Flight Data Recorder/Cockpit Voice Recorder occurs.
12:25:36 CHI91 advises Gander ACC that they are preparing to ditch.
12:25:52 St. John's radar records CHI91 at 800 feet. CHI91 subsequently descends to 300 feet in approximately 29 seconds which equates to an approximate rate of descent of 1,000 feet per minute.
12:26:26 St. John's radar records the last radar return of CHI91 at 300 feet.
12:26 Gander ACC advises search and rescue that CHI91 has ditched. Cougar dispatch confirms the ditching with search and rescue, and advises that they will launch Cougar 61 as a rescue helicopter.
12:42 A Provincial Airlines patrol aircraft arrives at crash site and observes two people in orange immersion suits in the water.
13:07 Cougar rescue helicopter departs St. John's.
13:25 Cougar rescue helicopter arrives at crash site and spots two people (one of whom is later confirmed dead), two rafts and helicopter debris.
13:33 Cougar rescue helicopter lowers a rescue person toward the people in the water.
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Brian, stated earlier in the Thread:
A gale force warning is in effect for the area with winds south at 20 knots increasing to 35 early this afternoon. Seas are said to be two-to-three metres and the visibility is 10 nautical miles.
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OUTWEST / SULTAN
I understand that the gearbox has been a topic of discussion for some time, but surely you would agree that anyone who thinks aircraft are built on limitless budgets has their head seriously in the clouds.
People like you and me do their jobs, the best they can with the resource available. I'm not defending SAC as a corporation, rather the guys who do those jobs which dictate things like material and parts selection. I'm sure if they had budgets as big as Oil company profits, then they could build something resembling your idea of a great aircraft.
In this case, Men designed an aircraft according to a budget within Sikorsky. SAC are a business like any other whose sole purpose is to make money and keep people in jobs. To achieve this SAC have to base their budget on the limits imposed by the customer, and the competition. They must also adhere to the regulations imposed by EASA / FAA.
when you design, build and sell and aircraft which meets all of the above, and everyone from the manufacturer to the end user is happy, and then something like this happens, who is to blame??? You say that there were many missed opportunities for SAC to avoid this accident, so why are people buying it? is it their fault? is someone guilty of sending men offshore repeatedly in an aircraft not fit for purpose?
would you buy an automobile with a known problem in the transmission? would you take your family on a drive across the desert in it??
The list of blame / questions goes on and on. My initial point being, can you realistically blame one person / organisation or would you agree, like most accidents, there were a number of contributary factors?
I appreciate emotions run high here, and if I sound like I don't care about the families involved, then be assured that is not the case.
I understand that the gearbox has been a topic of discussion for some time, but surely you would agree that anyone who thinks aircraft are built on limitless budgets has their head seriously in the clouds.
People like you and me do their jobs, the best they can with the resource available. I'm not defending SAC as a corporation, rather the guys who do those jobs which dictate things like material and parts selection. I'm sure if they had budgets as big as Oil company profits, then they could build something resembling your idea of a great aircraft.
In this case, Men designed an aircraft according to a budget within Sikorsky. SAC are a business like any other whose sole purpose is to make money and keep people in jobs. To achieve this SAC have to base their budget on the limits imposed by the customer, and the competition. They must also adhere to the regulations imposed by EASA / FAA.
when you design, build and sell and aircraft which meets all of the above, and everyone from the manufacturer to the end user is happy, and then something like this happens, who is to blame??? You say that there were many missed opportunities for SAC to avoid this accident, so why are people buying it? is it their fault? is someone guilty of sending men offshore repeatedly in an aircraft not fit for purpose?
would you buy an automobile with a known problem in the transmission? would you take your family on a drive across the desert in it??
The list of blame / questions goes on and on. My initial point being, can you realistically blame one person / organisation or would you agree, like most accidents, there were a number of contributary factors?
I appreciate emotions run high here, and if I sound like I don't care about the families involved, then be assured that is not the case.
CFO,
First the post should have read S-92 thread.
As to your question.
Norsk,
Two Shell Brunei
Australia
The mysterious Sept draft RFM that no one can share.
The Jan ASB.
While for different reasons, they point to an apparent vunerability of the "worlds safest helicopter". I am not sure of others. History repeats itself.
Read Fineman's Challenger Appendix F (google it).
The Sultan
First the post should have read S-92 thread.
As to your question.
Norsk,
Two Shell Brunei
Australia
The mysterious Sept draft RFM that no one can share.
The Jan ASB.
While for different reasons, they point to an apparent vunerability of the "worlds safest helicopter". I am not sure of others. History repeats itself.
Read Fineman's Challenger Appendix F (google it).
The Sultan