Helicopter crash off the coast of Newfoundland - 18 aboard, March 2009
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Hi there,
I heard of this accident shortly after the cause was in the press. I'm still wondering why the FAA and EASA aren't more into it? I mean the 30 min is not just a good idea it is a requirement and this requirement is obviously not met by this sikorsky gear box, is it?
cheers
eastwood
I heard of this accident shortly after the cause was in the press. I'm still wondering why the FAA and EASA aren't more into it? I mean the 30 min is not just a good idea it is a requirement and this requirement is obviously not met by this sikorsky gear box, is it?
cheers
eastwood
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For clarity the requirement states that it must have 30 minutes dry run capability unless the likelihood of total oil loss was extremely improbable.
In the case of the S92 the safety case determined that it was extremely improbable and therefore did not require a 30 min capability.
therefore at the time of the accident the S92 was correctly certificated.
in hindsight asking if the safety case is adequate is a whole different question
DM
In the case of the S92 the safety case determined that it was extremely improbable and therefore did not require a 30 min capability.
therefore at the time of the accident the S92 was correctly certificated.
in hindsight asking if the safety case is adequate is a whole different question
DM
I don't want to go through the whole debate again, but its a brave pilot who ditches the aircraft and seventeen passengers into a cold North Atlantic, when he still thinks there are 20 minutes still left in the gearbox.
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The article is a bit vague as to the claim by Cougar that Sikorsky "fraudulently misrepresented" the aircraft could could continue to operate after a loss of oil pressure. That's different than being able to operate for 30 minutes with no oil. The RFM has always stated that MGB oil pressure below 5psi is a "land immediately."
It will be interesting to see in depositions and testimony just who said what to whom, what claims were made and how those claims were understood. It will also be interesting to see if the case goes forward to trial or gets settled.
It will be interesting to see in depositions and testimony just who said what to whom, what claims were made and how those claims were understood. It will also be interesting to see if the case goes forward to trial or gets settled.
when he still thinks there are 20 minutes still left in the gearbox.
Most (perhaps all?) S92 pilots that I know did not think the aircraft had 30 mins run-dry before the accident. The RFM was clear (less than 5 psi = Land Immediately). The details of certification requirements are not something your average pilot would ever look at. The FlightSafety pilot training courses never mentioned 30 mins run dry, but I can't comment on the Cougar course!
I actually think they were presented with some unusual indications that led them to believe that the lack of oil pressure might be a false indication.
But until CVR extracts are made public I do not think we will know for sure.
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Was there not a Sikorsky Safety Advisory on a change to the RFM to detail indications of gearbox oil loss that could (according to Sikorsky) be ignored that was issued just a few weeks after the CHC Australia emergency landing in WA?
Could this have caused confusion?
If I recall Sikorsky also said that smoke in the cabin should not be considered an emergency.
Certainly days after the Cougar crash, EASA issues an emergency directive that the Sikorsky advisory was a proposal and had been rejected. Even the FAA then came out against Sikorsky.
Could this have caused confusion?
If I recall Sikorsky also said that smoke in the cabin should not be considered an emergency.
Certainly days after the Cougar crash, EASA issues an emergency directive that the Sikorsky advisory was a proposal and had been rejected. Even the FAA then came out against Sikorsky.
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Pilots? families push for helmets - Local - News - The Telegram
Is the TSB implying that the crew may have been able to escape if they had been better protected?
“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,” said the [TSB] advisory.
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Crash probe unfair?
CBC News - Nfld. & Labrador - Helicopter crash probe review unfair: lawyer
The Transportation Safety Board probe into a deadly helicopter crash off Newfoundland is flawed and unfair, say lawyers for the victims of Cougar Flight 491.
A confidential draft of the board's report into last year's tragedy began circulating among reviewers the board selected last month.
It's part of the federally mandated process to collect feedback before the report is finalized and made public.
But lawyers for the crash victims are questioning why they've been shut out of the process. Neither sole survivor Robert Decker nor the families of the two pilots and 15 passengers who died March 12, 2009, were deemed "interested parties" entitled to assess the draft report, they say.
'Closed-door'
"I think the concern that the public should have is that the investigative process appears to be closed-door," said Vancouver lawyer Joe Fiorante.
"We know that ... the operator Cougar and the manufacturer Sikorsky are given access and the opportunity to comment on the draft report whereas the victims are not. So, I think what's at stake is the appearance of whether the investigation is impartial and conducted fairly."
Fiorante, a civil litigator specializing in international aviation, says the board has consistently taken the position in the past that passengers are not to be included in the report review stage.
"It has come as a shock to all of our clients in past cases — and in this case — that they're being shut out of a government investigative process in which Mr. Decker himself personally survived, or in other cases, their loved ones were killed.
"They are put in the same position as the rest of the public and told to wait for final findings."
The Canadian Transportation Accident Investigation and Safety Board Act directs the TSB to send its draft report to "anyone who, in the opinion of the board, has a direct interest in the findings of the board."
2 categories of reviewers
TSB spokesman John Cottreau said the identities of those who received a draft copy are confidential. But he said they fell into two categories the board looks at "for according draft reviewer status."
"The first category is those whose performance or behaviour or products might be commented on in the report and who might see themselves as being adversely affected by the report. The second category is those who can contribute to the completeness and accuracy of the scientific report.
A confidential draft of the board's report into last year's tragedy began circulating among reviewers the board selected last month.
It's part of the federally mandated process to collect feedback before the report is finalized and made public.
But lawyers for the crash victims are questioning why they've been shut out of the process. Neither sole survivor Robert Decker nor the families of the two pilots and 15 passengers who died March 12, 2009, were deemed "interested parties" entitled to assess the draft report, they say.
'Closed-door'
"I think the concern that the public should have is that the investigative process appears to be closed-door," said Vancouver lawyer Joe Fiorante.
"We know that ... the operator Cougar and the manufacturer Sikorsky are given access and the opportunity to comment on the draft report whereas the victims are not. So, I think what's at stake is the appearance of whether the investigation is impartial and conducted fairly."
Fiorante, a civil litigator specializing in international aviation, says the board has consistently taken the position in the past that passengers are not to be included in the report review stage.
"It has come as a shock to all of our clients in past cases — and in this case — that they're being shut out of a government investigative process in which Mr. Decker himself personally survived, or in other cases, their loved ones were killed.
"They are put in the same position as the rest of the public and told to wait for final findings."
The Canadian Transportation Accident Investigation and Safety Board Act directs the TSB to send its draft report to "anyone who, in the opinion of the board, has a direct interest in the findings of the board."
2 categories of reviewers
TSB spokesman John Cottreau said the identities of those who received a draft copy are confidential. But he said they fell into two categories the board looks at "for according draft reviewer status."
"The first category is those whose performance or behaviour or products might be commented on in the report and who might see themselves as being adversely affected by the report. The second category is those who can contribute to the completeness and accuracy of the scientific report.
"Essentially, the families do not fall under those two broad categories so they are not accorded draft reviewer status."
Fiorante, part of a consortium of lawyers representing the Cougar families, says that approach defies logic.
"Mr. Decker survived this ordeal. He may well have information that could touch on the survivability of these types of accidents in the future and what could be done to prepare passengers for an ocean ditching."
The pilots were taking offshore oil workers to the Hibernia and White Rose sites when they reported a loss of oil pressure in the chopper's main gearbox and headed back toward land. Eleven minutes later, the helicopter plunged into the sea about 55 kilometres east of St. John's.
Two weeks after Flight 491 went down, the TSB said two of three titanium studs that secure the oil filter bowl assembly to the helicopter's main gearbox broke in flight, causing the loss of oil pressure.
Fiorante, part of a consortium of lawyers representing the Cougar families, says that approach defies logic.
"Mr. Decker survived this ordeal. He may well have information that could touch on the survivability of these types of accidents in the future and what could be done to prepare passengers for an ocean ditching."
The pilots were taking offshore oil workers to the Hibernia and White Rose sites when they reported a loss of oil pressure in the chopper's main gearbox and headed back toward land. Eleven minutes later, the helicopter plunged into the sea about 55 kilometres east of St. John's.
Two weeks after Flight 491 went down, the TSB said two of three titanium studs that secure the oil filter bowl assembly to the helicopter's main gearbox broke in flight, causing the loss of oil pressure.
Decker, then 27, survived 75 minutes in the frigid North Atlantic after a harrowing escape from the fast-sinking chopper. He was interviewed by the safety board, Fiorante said.
"But he certainly isn't going to get a chance to see what their take is and how they view it in terms of their analysis of the accident in a draft, confidential report."
St. John's lawyer Steve Marshall, who is also representing the crash victims, said an exclusive review process undermines the perception of fairness.
"They should all be in the same category," Marshall said.
Cottreau said the process is independent and thorough.
"The Transportation Safety Board of Canada performs complete, fair and unbiased investigations to get at what happened, why it happened and how we might be able to prevent it from happening again."
30 days for comments
Reviewers had 30 days to make comments on the draft report. The board responds to the comments in writing. Reviewers can request extensions, however, and Cottreau would not speculate on when the final report will be made public.
Fiorante isn't convinced the document will be as complete as it should be.
"We're going to review it very carefully on behalf of the families, and we are going to look to make sure that it is thorough," he said. "But our past experience has been that we believe firmly that the passengers and their families have information that's important to an investigation of the cause of the crash.
"And we've had a number of cases where we felt the final report didn't fully canvass all the causes or all the important information."
"But he certainly isn't going to get a chance to see what their take is and how they view it in terms of their analysis of the accident in a draft, confidential report."
St. John's lawyer Steve Marshall, who is also representing the crash victims, said an exclusive review process undermines the perception of fairness.
"They should all be in the same category," Marshall said.
Cottreau said the process is independent and thorough.
"The Transportation Safety Board of Canada performs complete, fair and unbiased investigations to get at what happened, why it happened and how we might be able to prevent it from happening again."
30 days for comments
Reviewers had 30 days to make comments on the draft report. The board responds to the comments in writing. Reviewers can request extensions, however, and Cottreau would not speculate on when the final report will be made public.
Fiorante isn't convinced the document will be as complete as it should be.
"We're going to review it very carefully on behalf of the families, and we are going to look to make sure that it is thorough," he said. "But our past experience has been that we believe firmly that the passengers and their families have information that's important to an investigation of the cause of the crash.
"And we've had a number of cases where we felt the final report didn't fully canvass all the causes or all the important information."
I agree with TSB. If all passengers in an accident had editorial powers (or even commenting power) in the report it would be a nightmare and there would be all sorts of rubbish flying around. Its an expert report on a very technical matter and sorry but passengers don't usually have the expertise to keep their thoughts relevant or technically accurate.
The passengers views are taken into account in a report - following extensive interviewing of the survivor(s) by the investigators, but they have to be screened by the expert interviewer to keep the content within the bound of sanity. TSB's definition of the two groups is totally reasonable (and I suspect an ICAO standard).
What can relatives of deceased passengers possibly bring to a report, other than something they heard on "Air Crash Investigations" on the TV?
HC
The passengers views are taken into account in a report - following extensive interviewing of the survivor(s) by the investigators, but they have to be screened by the expert interviewer to keep the content within the bound of sanity. TSB's definition of the two groups is totally reasonable (and I suspect an ICAO standard).
What can relatives of deceased passengers possibly bring to a report, other than something they heard on "Air Crash Investigations" on the TV?
HC
HC,
Perhaps Mr. Decker, the sole survivor, could have some first hand observations that might be credible. As he is alive and able to read.....perhaps his review of what the expert interviewer said he said...and what the interveiwer thought important and by omission what was not important might prove beneficial.
He for one is entitled to know what happened to him.
Perhaps Mr. Decker, the sole survivor, could have some first hand observations that might be credible. As he is alive and able to read.....perhaps his review of what the expert interviewer said he said...and what the interveiwer thought important and by omission what was not important might prove beneficial.
He for one is entitled to know what happened to him.
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I totally agree SASless, surely a survivor's account and review will provide another valuable insight into this tragic event, especially from a safety procedural context in relation to the difference in brace position adopted versus the stated safety briefing version.
Safe flying
Max
Safe flying
Max
You are both assuming that Mr Decker's account will not be covered in the report, including any feedback from him on theories that might have arisen during the investigation. I am totally confident that you will be proven entirely wrong! Having been involved in such investigations myself (fortunately non-fatal) I can tell you that the state investigators are only too keen to get as much information and feedback from as many sources as possible, including survivors. So in effect, Mr Decker will already have had the opportunity to indicate his agreement or otherwise with the report. But ultimately it must be up to the reporters to form their final opinion on what goes into the report.
So if you think he should be able to edit the report as he sees fit, with his very limited knowledge of aviation, you are mistaken.
Many of our passengers think that if the engines stop, the rotors start going round the other way. That is the sort of level of passenger knowledge the TSB might be up against.
As for the relatives, what could they possibly bring to the report except hearsay
HC
So if you think he should be able to edit the report as he sees fit, with his very limited knowledge of aviation, you are mistaken.
Many of our passengers think that if the engines stop, the rotors start going round the other way. That is the sort of level of passenger knowledge the TSB might be up against.
As for the relatives, what could they possibly bring to the report except hearsay
HC
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Many of our passengers think that if the engines stop, the rotors start going round the other way. That is the sort of level of passenger knowledge the TSB might be up against.
Oh, and I think you'll find that PAX are much more technically aware of helo operations these days, that tends to happen when you're made aware of the hazards and risks involved through real-life experiences.
Safe flying
Max
Max, I still disagree. Robert will have had an opportunity to review the parts of the report to which he contributed. As explained by the TSB, the purpose of the external review is to allow those 2 catogories mentioned to review: experts to check for technical error, and those who might come out of the report badly to have the opportunity to defend themselves.
Accident investigation and reporting is done in accordance with ICAO standards (annex 13 I seem to recall), I am sure this private review process is part of that standard. You cannot deviate from the standard on a report-by-report basis just because it hits the newspapers or just because there was only one survivor. If you allowed all passengers to have a review, how would that work out if an A380 crunched in a bit hard - all the pax would want to have their say, it would mostly be about the food and cabin service!
Not surprisingly, this matter is very close to your heart, but sorry the cold reality is that its just another report to the TSB and it must and will be done in the standard way, whether you like it or not.
HC
Accident investigation and reporting is done in accordance with ICAO standards (annex 13 I seem to recall), I am sure this private review process is part of that standard. You cannot deviate from the standard on a report-by-report basis just because it hits the newspapers or just because there was only one survivor. If you allowed all passengers to have a review, how would that work out if an A380 crunched in a bit hard - all the pax would want to have their say, it would mostly be about the food and cabin service!
Not surprisingly, this matter is very close to your heart, but sorry the cold reality is that its just another report to the TSB and it must and will be done in the standard way, whether you like it or not.
HC
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Thanks for the clarification HC, I wasn't aware that Robert will have had the opportunity to review his input to date.
I totally agree that standards have to be followed otherwise there is chaos.
With a subject so close to the heart 3rd party expertise is key in obtaining the optimum way forward for all.
I'm sure we all, pilots and PAX alike, will await the final public issue of the TSB report with bated breath. The hard fact is that as the TSB report is going to be used as a pivotal piece of evidence in the ongoing safety inquiry there is tremendous focus on its pending issue right now. We are all waiting for the conclusive answer on why 491 was not put down immediately, and whose call it was to continue flying and on what basis.
Safe flying
Max
I totally agree that standards have to be followed otherwise there is chaos.
With a subject so close to the heart 3rd party expertise is key in obtaining the optimum way forward for all.
I'm sure we all, pilots and PAX alike, will await the final public issue of the TSB report with bated breath. The hard fact is that as the TSB report is going to be used as a pivotal piece of evidence in the ongoing safety inquiry there is tremendous focus on its pending issue right now. We are all waiting for the conclusive answer on why 491 was not put down immediately, and whose call it was to continue flying and on what basis.
Safe flying
Max
HC,
You erred in some of your assumptions and assertions.
I said Mr. Decker should be allowed to review that portion of the report to which he contributed as the sole survivor. I noted in my post, which you must have missed, his review should be re what the professional interviewer said he said...and what the professional interviewer thought important and contained in the report or what was not thought important by its omission in the report. I would submit Mr. Decker is fully qualified to make statements about his escape, what went well, what did not, what gear worked, what gear did not, specify what training was effective, what was not....how things could be improved and the like! After all....he is the one guy that got out of the machine and made it to the surface alive and was able to continue living until rescued.
As to parties being harshly treated to have a heads up to defend themselves....pray tell why that is a reason they should be given preferential treatment? They can bloody well defend themselves after the investigative report is published. Are you saying they should be allowed to offer up issues and statements they want to see edited before the report is published?
Just what kind of safety briefings do you guys do these days HC?
Might be a bit of confusion if some of them are old enough to have flown on the 61's....and now have to do the changeover to EC products which turn the wrong way to as we all well know!
You erred in some of your assumptions and assertions.
I said Mr. Decker should be allowed to review that portion of the report to which he contributed as the sole survivor. I noted in my post, which you must have missed, his review should be re what the professional interviewer said he said...and what the professional interviewer thought important and contained in the report or what was not thought important by its omission in the report. I would submit Mr. Decker is fully qualified to make statements about his escape, what went well, what did not, what gear worked, what gear did not, specify what training was effective, what was not....how things could be improved and the like! After all....he is the one guy that got out of the machine and made it to the surface alive and was able to continue living until rescued.
As to parties being harshly treated to have a heads up to defend themselves....pray tell why that is a reason they should be given preferential treatment? They can bloody well defend themselves after the investigative report is published. Are you saying they should be allowed to offer up issues and statements they want to see edited before the report is published?
Many of our passengers think that if the engines stop, the rotors start going round the other way.
Might be a bit of confusion if some of them are old enough to have flown on the 61's....and now have to do the changeover to EC products which turn the wrong way to as we all well know!
TSB spokesman John Cottreau said the identities of those who received a draft copy are confidential. But he said they fell into two categories the board looks at "for according draft reviewer status."
"The first category is those whose performance or behaviour or products might be commented on in the report and who might see themselves as being adversely affected by the report. The second category is those who can contribute to the completeness and accuracy of the scientific report.
"The first category is those whose performance or behaviour or products might be commented on in the report and who might see themselves as being adversely affected by the report. The second category is those who can contribute to the completeness and accuracy of the scientific report.
This is the Annex 13 guidance:
6.3.1 Recommendation.—
The State conducting the investigation should send, through the State of the Operator, a copy of the draft Final Report to the operator to enable the operator to submit comments on the draft Final Report.
6.3.2 Recommendation.—
The State conducting the investigation should send, through the State of Design and the State of Manufacture, a copy of the draft Final Report to the organizations responsible for the type design and the final assembly of the aircraft to enable them to submit comments on the draft Final Report
The State conducting the investigation should send, through the State of the Operator, a copy of the draft Final Report to the operator to enable the operator to submit comments on the draft Final Report.
6.3.2 Recommendation.—
The State conducting the investigation should send, through the State of Design and the State of Manufacture, a copy of the draft Final Report to the organizations responsible for the type design and the final assembly of the aircraft to enable them to submit comments on the draft Final Report
Last edited by 212man; 8th Sep 2010 at 08:08.