Helicopter crash off the coast of Newfoundland - 18 aboard, March 2009
C'mon Brian: we all know what each means don't we. Let's not beat about the bush. There is no room for interpretation here.
What happened on that dark cold night was that the Captain of that a/c heard the words: land immediately but convinced himself that this would all be OK and physically flying his currently "flyable" helicopter into a bitterly cold wet place surely could wait a little longer. He stretched it and stretched it....he went into denial hoping to glimpse land.
It's all very well nodding and agreeing to what land immediately means in the warmth of the cre room or in the sim....but for real....an individuals psychology comes into play.
What 'may' have cleared the fog of judgement making would perhaps have been a better understanding of what exactly was going on in his gearbox!
RIP.
What happened on that dark cold night was that the Captain of that a/c heard the words: land immediately but convinced himself that this would all be OK and physically flying his currently "flyable" helicopter into a bitterly cold wet place surely could wait a little longer. He stretched it and stretched it....he went into denial hoping to glimpse land.
It's all very well nodding and agreeing to what land immediately means in the warmth of the cre room or in the sim....but for real....an individuals psychology comes into play.
What 'may' have cleared the fog of judgement making would perhaps have been a better understanding of what exactly was going on in his gearbox!
RIP.
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I have dug out the relevant passage from an ancient set of Flight Reference Cards for a UK military helicopter, which reads as follows:
The Urgency of the Need to Land
Following a system failure, it may be necessary to land the aircraft for safety considerations. The degree of urgency to land the aircraft depends on the nature of the failure and the prevailing conditions. The following terms are used to give guidance on the degree of urgency required but are not intended to be precise definitions:
Land Immediately
Land at once even if, for example, the outcome is ditching or landing in trees. The consequences of continued flight are likely to be more hazardous than those of landing at a site normally considered to be unsuitable.
Land As Soon As Possible
Do not continue flight for longer than is necessary to accomplish a safe but unhurried landing at the nearest site.
Land As Soon As Practicable
Land at the nearest aviation location or, if one is not reasonably close, at a safe landing site selected for subsequent convenience.
Overall, I think that this is a sensible approach as it does not mandate the crew's actions in advance. Whoever drafts and approves the emergency checklist cannot possibly foresee all the potential situations and ultimately, it should be the captain's decision what to do.
Tragically, in this case, the decision to continue flying was flawed, but we will never accurately know what the crew's assessement of their situation was, though I suspect that the pilots' mental models were significantly different. Personally, I am profoundly grateful that I have never been put in a similar position, even though I have speculated on what I would do if presented with a 'Land Immediately' situation do many times. Risk management in aviation is not a simple linear process and how many of us can claim that we make perfect decisions every time?
RIP
The Urgency of the Need to Land
Following a system failure, it may be necessary to land the aircraft for safety considerations. The degree of urgency to land the aircraft depends on the nature of the failure and the prevailing conditions. The following terms are used to give guidance on the degree of urgency required but are not intended to be precise definitions:
Land Immediately
Land at once even if, for example, the outcome is ditching or landing in trees. The consequences of continued flight are likely to be more hazardous than those of landing at a site normally considered to be unsuitable.
Land As Soon As Possible
Do not continue flight for longer than is necessary to accomplish a safe but unhurried landing at the nearest site.
Land As Soon As Practicable
Land at the nearest aviation location or, if one is not reasonably close, at a safe landing site selected for subsequent convenience.
Overall, I think that this is a sensible approach as it does not mandate the crew's actions in advance. Whoever drafts and approves the emergency checklist cannot possibly foresee all the potential situations and ultimately, it should be the captain's decision what to do.
Tragically, in this case, the decision to continue flying was flawed, but we will never accurately know what the crew's assessement of their situation was, though I suspect that the pilots' mental models were significantly different. Personally, I am profoundly grateful that I have never been put in a similar position, even though I have speculated on what I would do if presented with a 'Land Immediately' situation do many times. Risk management in aviation is not a simple linear process and how many of us can claim that we make perfect decisions every time?
RIP
Last edited by Mel Effluent; 25th Feb 2011 at 10:08. Reason: Spolling
Way back in the early days of the thread I offered up my htoughts on the mindset of continuing to fly until we hear ugly noises then ditch. I acknowledged having been of that persuasion for most my career having flown over some very inhospitable terrain or very unfriendly folks. I also suggested this was a common attitude amongst helicopter pilots.
It took this tragedy to disabuse me of that notion.
It also refreshed my concern about flying over such terrain in weather conditions that made such forced landings so dangerous.
When I heard the Captain make his intentions known to ATC.....knowing the actual outcome of the event....made me sit back and consider how lucky I have been in the past on a couple of occasions when guilty of the same thing.
No doubt there are others posting here that know they too have escaped from that flawed logic and its potentially catastrophic outcome.
I presume few of us hold to that mindset today as a result of the Cougar crash.....that is a postive outcome out of this tragedy.
Ernie Gann in "Fate Is The Hunter" discusses this very aptly.
It took this tragedy to disabuse me of that notion.
It also refreshed my concern about flying over such terrain in weather conditions that made such forced landings so dangerous.
When I heard the Captain make his intentions known to ATC.....knowing the actual outcome of the event....made me sit back and consider how lucky I have been in the past on a couple of occasions when guilty of the same thing.
No doubt there are others posting here that know they too have escaped from that flawed logic and its potentially catastrophic outcome.
I presume few of us hold to that mindset today as a result of the Cougar crash.....that is a postive outcome out of this tragedy.
Ernie Gann in "Fate Is The Hunter" discusses this very aptly.
Last edited by SASless; 25th Feb 2011 at 13:01.
I opine that the flight manual statement "Land immediately" should be ammended to also say "... and crash if you have to", if that's the reality of the situation. Let's call it what is is!
Ditch = land on the water in a controlled manner, rather than "crash" into the water.
Cheers.
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What happened on that dark cold night was that the Captain of that a/c heard the words: land immediately but convinced himself that this would all be OK and physically flying his currently "flyable" helicopter into a bitterly cold wet place surely could wait a little longer. He stretched it and stretched it....he went into denial hoping to glimpse land.
PIC wasn't aware of wet temperature bulb issue, checklist was too vague in getting to land immediately status (should have been a memory item).
No secondary indications of MRGB issue so PIC carried on flying back to land i.e. land as soon as possible. If PIC was aware of these issues I honestly believe he would have ditched. They tried their best too late once the T/R drive failed on them.
We can point fingers of blame at many factors as the TSB report quite rightly has i.e. SAC, FAA, and even Cougar for not picking up on the galled studs during filter changeout. It's not bringing anybody back.
All we can do is try and prevent this happening again, that's why one of the widows of 491 wants answers on the studs and an explanation for the lack of effective response to the Broome 2008 stud failure. How on earth the botch repair job to the Broome stud prior to failure was even approved by SAC stuns me never mind how they then dealt with the issue. SAC will no doubt try to cover themselves with the AMM but the proper action would have been change the studs immediately. For me that is gross negligance and SAC should be held accountable to the full extent of the law.
30-minute run-dry should be a given in our environment, not a work-around. SAC have let us all down here.
Safe flying
Max
II,
Are you 100% sure of that? Others on this board may disagree! It's a fact though that The bodged repair didn't fail - the two other studs failed! However, the repair led to a perception that dictated the urgency of the ASB......
Are you 100% sure of that? Others on this board may disagree! It's a fact though that The bodged repair didn't fail - the two other studs failed! However, the repair led to a perception that dictated the urgency of the ASB......
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II, from the TSB report the SAC rep did not disapprove so by virtue of consultation and no objection IMO accepted the repair.
212man, from section 2.1 of the Waldron report the "repaired" stub with the Nyloc nut was one of the failed studs.
VH-LOH was in the air for only 5 minutes from MRGB pressure loss and not as the local media stated the other day flown until the MRGB failed. I wish they would get their facts right.
Safe flying
Max
VH-LOH's MGB oil filter bowl had been removed and reinstalled 17 times during the helicopter's total time in service (1233.4 hours). Approximately 58 flight hours before the July 2008 incident, on 09 June 2008, a MGB oil filter bowl mounting stud had fractured during removal of the attachment nut. Because a new stud and the proper tools were not immediately available, after consulting with Sikorsky's local field service representative, CHC carried out a temporary repair, installing a self-locking nut on the fractured stud. The self-locking feature of this nut did not fully engage the shortened length of the fractured stud so a hole was drilled in the nut to lockwire it for security. Although Sikorsky's engineering department was not specifically consulted, no technical objections to the temporary repair were presented by the Sikorsky field service representative.
VH-LOH was in the air for only 5 minutes from MRGB pressure loss and not as the local media stated the other day flown until the MRGB failed. I wish they would get their facts right.
Safe flying
Max
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II, are you implying that the TSB mis-read the Waldron report and/or is there another version of this report, the one I have I got from CBC's 5th estate website a while ago?
Section 4.21 of the report states that two of the studs were mis-labeled, perhaps that is where the confusion exists.
Section 4.3.1 of the report states that the top stub was the one that had previously failed and had the Nyloc nut fitted. This stud was definitely one of the broken ones according to the report.
Section 4.5.1 states that the lower forward stud was the one that didn't fracture.
On 491 the top stud was the only one not to have fractured.
The TSB went to lengths to describe the Broome incident:
To me this reads like SAC is pointing the finger at the operators by placing the onus on them via non-implementation of the AMM. Why would SAC not compare the historical Blackhawk steel stud performance to the S92 titanium studs and immediately realize that there was a material issue as part of their risk analysis process?
I still say that SAC is at fault here for being grossly negligent, JMHO.
Safe flying
Max
Section 4.21 of the report states that two of the studs were mis-labeled, perhaps that is where the confusion exists.
Section 4.3.1 of the report states that the top stub was the one that had previously failed and had the Nyloc nut fitted. This stud was definitely one of the broken ones according to the report.
Section 4.5.1 states that the lower forward stud was the one that didn't fracture.
On 491 the top stud was the only one not to have fractured.
The TSB went to lengths to describe the Broome incident:
In the Australian occurrence the helicopter was not damaged and there were no injuries. The failure initially appeared to have been related to an isolated field repair. Sikorsky advised its customers of these early findings and also suggested that extra attention be given to the filter bowl fasteners.
After an independent engineering firm flagged galling as a possibility on the titanium studs, Sikorsky completed a safety review of the Australian accident and the failed studs. Sikorsky and the FAA came to understand that the source of the problem was in fact galling. Sikorsky, utilizing a risk management process, made an assessment of the Australian occurrence flight, noting that it was able to continue flight for several minutes following the loss of lubricant without causing serious damage to the helicopter. Based on this assessment, Sikorsky developed its safety action, which the FAA accepted. SSA-S-92A-08-007 was communicated on 08 October 2008 to alert operators of the upcoming AMM Revision 13. These mandatory enhanced inspection requirements aimed to ensure damaged studs would be detected and removed.
Believing that the mandatory enhanced maintenance procedures would mitigate risk to acceptable levels, Sikorsky established a compliance time to the Alert Service Bulletin for the replacement of the titanium studs of one year or 1250 flight hours.
As of 05 November 2008 (date of issue of AMM Revision 13), Sikorsky had not received any reports of damaged MGB oil filter bowl attachment studs. Therefore, all of the S-92A helicopters in service at that time (except VH-LOH) would have been equipped with the original MGB oil filter bowl attachment studs. These studs would have had the nuts installed and removed a minimum of 3 times and, in helicopters with similar flight hours as the occurrence helicopter, the nuts would have been installed and removed over 10 times.
The TSB's examination of new S-92A MGB studs and nuts, similar to the type used on the occurrence helicopter, showed that galling damage developed during the first installation of the nut and became progressively worse with repeated installations. The galling was further exacerbated when the nut was reused. AD 2009-07-53 was issued on 23 March 2009, about 5 months after AMM Revision 13. During this 5 month period, every time the MGB oil filter was changed, it was mandatory for operators to carry out the enhanced inspection and to replace any damaged studs.
After AD 2009-07-53 had been issued, Sikorsky requested that operators return the studs they had removed to comply with the AD. As operators were under no obligation to comply with the request, Sikorsky only received a total of 59 studs from various operators. All of these studs, as well as the studs recovered from the occurrence helicopter and the other Cougar helicopters, had different severities of galling, which would be consistent with a difference in the number of times the nut was installed and removed. Based on the S-92A fleet average monthly flying hours, and the average time between MGB oil filter replacements, it is likely that most, if not all, of the 59 studs returned to Sikorsky would have been subject to inspection at least once during that period.
Since the thread galling was detectable using the new procedures, and given that no damage was reported and that there were no reported problems complying with the enhanced inspection procedure, it must be concluded that most S-92A operators, including Cougar Helicopters, did not implement the new maintenance procedure as specified by AMM Revision 13 and, therefore, damaged studs on the filter bowl assembly were not detected or replaced. As these maintenance procedures were mandatory, the low compliance rate can perhaps be attributed to the possibility that operators did not clearly understand the underlying reasons behind the enhanced procedures and the need to detect and replace damaged studs. That is, they did not appreciate that a failed MGB filter bowl assembly mounting stud would cause an uncontrolled total loss of MGB oil that would eventually lead to the failure of the MGB
After an independent engineering firm flagged galling as a possibility on the titanium studs, Sikorsky completed a safety review of the Australian accident and the failed studs. Sikorsky and the FAA came to understand that the source of the problem was in fact galling. Sikorsky, utilizing a risk management process, made an assessment of the Australian occurrence flight, noting that it was able to continue flight for several minutes following the loss of lubricant without causing serious damage to the helicopter. Based on this assessment, Sikorsky developed its safety action, which the FAA accepted. SSA-S-92A-08-007 was communicated on 08 October 2008 to alert operators of the upcoming AMM Revision 13. These mandatory enhanced inspection requirements aimed to ensure damaged studs would be detected and removed.
Believing that the mandatory enhanced maintenance procedures would mitigate risk to acceptable levels, Sikorsky established a compliance time to the Alert Service Bulletin for the replacement of the titanium studs of one year or 1250 flight hours.
As of 05 November 2008 (date of issue of AMM Revision 13), Sikorsky had not received any reports of damaged MGB oil filter bowl attachment studs. Therefore, all of the S-92A helicopters in service at that time (except VH-LOH) would have been equipped with the original MGB oil filter bowl attachment studs. These studs would have had the nuts installed and removed a minimum of 3 times and, in helicopters with similar flight hours as the occurrence helicopter, the nuts would have been installed and removed over 10 times.
The TSB's examination of new S-92A MGB studs and nuts, similar to the type used on the occurrence helicopter, showed that galling damage developed during the first installation of the nut and became progressively worse with repeated installations. The galling was further exacerbated when the nut was reused. AD 2009-07-53 was issued on 23 March 2009, about 5 months after AMM Revision 13. During this 5 month period, every time the MGB oil filter was changed, it was mandatory for operators to carry out the enhanced inspection and to replace any damaged studs.
After AD 2009-07-53 had been issued, Sikorsky requested that operators return the studs they had removed to comply with the AD. As operators were under no obligation to comply with the request, Sikorsky only received a total of 59 studs from various operators. All of these studs, as well as the studs recovered from the occurrence helicopter and the other Cougar helicopters, had different severities of galling, which would be consistent with a difference in the number of times the nut was installed and removed. Based on the S-92A fleet average monthly flying hours, and the average time between MGB oil filter replacements, it is likely that most, if not all, of the 59 studs returned to Sikorsky would have been subject to inspection at least once during that period.
Since the thread galling was detectable using the new procedures, and given that no damage was reported and that there were no reported problems complying with the enhanced inspection procedure, it must be concluded that most S-92A operators, including Cougar Helicopters, did not implement the new maintenance procedure as specified by AMM Revision 13 and, therefore, damaged studs on the filter bowl assembly were not detected or replaced. As these maintenance procedures were mandatory, the low compliance rate can perhaps be attributed to the possibility that operators did not clearly understand the underlying reasons behind the enhanced procedures and the need to detect and replace damaged studs. That is, they did not appreciate that a failed MGB filter bowl assembly mounting stud would cause an uncontrolled total loss of MGB oil that would eventually lead to the failure of the MGB
I still say that SAC is at fault here for being grossly negligent, JMHO.
Safe flying
Max
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C'mon Brian: we all know what each means don't we. Let's not beat about the bush. There is no room for interpretation here.
SAS, indeed fate is the hunter, and some of us are blessed to be still around to ponder our good fortune. RIP Jerry Hardy.
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To me this reads like SAC is pointing the finger at the operators by placing the onus on them via non-implementation of the AMM. Why would SAC not compare the historical Blackhawk steel stud performance to the S92 titanium studs and immediately realize that there was a material issue as part of their risk analysis process?
I still say that SAC is at fault here for being grossly negligent, JMHO.
I still say that SAC is at fault here for being grossly negligent, JMHO.
Why is the a/c still flying today when it clearly does not meet the certification requirements?
Outwest...... The extremely remote criteria does not say it will not happen....it also does not say the failure will not happen on two consecutive flights. Study your Laws of Probability a bit and you will see the complete fallacy of that kind of thought? Ever dealt two Ace's in a row...perhaps three...or even four?
Add in the wonderful art of Statistics (I used "art" rather than "science" on purpose) and you can see how easily the numbers can be manipulated to meet that definition of "extremely remote".
We all reasonably assume the rotor blades will stay on the head every time we fly a helicopter. Statistically they should, in reality they do, right up to the point they don't. I suggest "probability" says we have a fifty/fifty split each flight....either they stay on or they do not. Statistics warp that number to the good side....but even then do not guarnatee us a thing in reality.
The oil filter module was a miserably failed design....that is the truth.
Commonsense should have prevailed all down the line from SAC to the line engineers maintaining the aircraft and pointed out the flaws in that desgin. Especially after the previous failures. Sadly....that did not happen in such a manner as to prevent the tragedy from occurring. That does not mean the 92 is unsafe today if appropriate improvements/modifications have been done.
Brian......I can add a long lost of folks starting with Jerry Hardy that we have lost due to the fickleness of Fate! He was a true Gentleman! I recently stood at the site where we lost a full crew when a Chinook decided to come apart. I fully understand what Gann was talking about.
Add in the wonderful art of Statistics (I used "art" rather than "science" on purpose) and you can see how easily the numbers can be manipulated to meet that definition of "extremely remote".
We all reasonably assume the rotor blades will stay on the head every time we fly a helicopter. Statistically they should, in reality they do, right up to the point they don't. I suggest "probability" says we have a fifty/fifty split each flight....either they stay on or they do not. Statistics warp that number to the good side....but even then do not guarnatee us a thing in reality.
The oil filter module was a miserably failed design....that is the truth.
Commonsense should have prevailed all down the line from SAC to the line engineers maintaining the aircraft and pointed out the flaws in that desgin. Especially after the previous failures. Sadly....that did not happen in such a manner as to prevent the tragedy from occurring. That does not mean the 92 is unsafe today if appropriate improvements/modifications have been done.
Brian......I can add a long lost of folks starting with Jerry Hardy that we have lost due to the fickleness of Fate! He was a true Gentleman! I recently stood at the site where we lost a full crew when a Chinook decided to come apart. I fully understand what Gann was talking about.
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SASless, I'm not a lawyer, but as I understand the certification process the a/c in question was required to have a 30 minute run dry capability "unless the probability of a total loss of oil was extremely remote"
Do I have that statement right?
If so, then it is no longer valid as it has been proven not once, but twice, that it no longer meets the "extremely remote" criteria.
Extremely Remote
* Qualitative: Not anticipated to occur to each item during its total life. May occur a few times in the life of an entire system or fleet.
* Quantitative: Probability of occurrence per operational hour is less than 1 \times 10^{-7} but greater than 1 \times 10^{-9}
As I've said before, I will give SAC and the FAA some slack in the initial certification, but after Broome they can no longer hide behind their own definition.
Do I have that statement right?
If so, then it is no longer valid as it has been proven not once, but twice, that it no longer meets the "extremely remote" criteria.
Extremely Remote
* Qualitative: Not anticipated to occur to each item during its total life. May occur a few times in the life of an entire system or fleet.
* Quantitative: Probability of occurrence per operational hour is less than 1 \times 10^{-7} but greater than 1 \times 10^{-9}
As I've said before, I will give SAC and the FAA some slack in the initial certification, but after Broome they can no longer hide behind their own definition.
Last edited by Outwest; 26th Feb 2011 at 03:46.
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Industry Insider says:
While TSB say about that CHC incident:
and
So what did CHC actually do as a result of their investigation into the Broome incident?
Safety alert on repair authorisation?
Tighter maintenance control at Broome?
Change in maintenance programme?
A notice to crew about oil loss and what 'Land Immediately' means?
revised training?
Anything?
Nobody outside of the operator's staff in Broome knew about it until after the landing.
Because a new stud and the proper tools were not immediately available, after consulting with Sikorsky's local field service representative, CHC carried out a temporary repair, installing a self-locking nut on the fractured stud. The self-locking feature of this nut did not fully engage the shortened length of the fractured stud so a hole was drilled in the nut to lockwire it for security. Although Sikorsky's engineering department was not specifically consulted, no technical objections to the temporary repair were presented by the Sikorsky field service representative.
It was the flight crew's understanding that the MGB would fail in a progressive manner rather than suddenly. Since the "less than 5 psi" condition coincided with the illumination of the red MGB OIL PRES warning message, the crew did not initially consider the low pressure to be a secondary indication of an impending gearbox failure. In addition, there were no other secondary indications detected and the MGB oil temperature remained below 80°C. This led the crew to respond as if they were in a "land as soon as possible" condition. The rapid drop in oil pressure was so different to their simulator training that they initially believed they had experienced a sensor or indicator problem. However, through collaboration, the pilots realized that the warning and oil pressure indication did not come from a single sensor, eliminating that possibility.
As the crew approached the only suitable landing area nearby, the rate-of-descent was increased and the pilots carried out a landing without further incident approximately seven minutes after the first warning. The captain indicated that if they had been flying over water, and there had been no other secondary indications, he would have continued flight toward land at an altitude of 200 feet agl and an airspeed of 80 knots.
As the crew approached the only suitable landing area nearby, the rate-of-descent was increased and the pilots carried out a landing without further incident approximately seven minutes after the first warning. The captain indicated that if they had been flying over water, and there had been no other secondary indications, he would have continued flight toward land at an altitude of 200 feet agl and an airspeed of 80 knots.
So what did CHC actually do as a result of their investigation into the Broome incident?
Safety alert on repair authorisation?
Tighter maintenance control at Broome?
Change in maintenance programme?
A notice to crew about oil loss and what 'Land Immediately' means?
revised training?
Anything?
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Squib - the silence is probably your answer. CHC have been very careful not to comment since the Cougar accident.
Here in Canada the familes are now pressing the Crown on why the S-92A was certified at all.
To read the letter, and everyone here should, click here
The letter asks the key question. "Did Transport Canada succumb to pressure of the United States Federal Aviation Administration (FAA) or Sikorsky, or did they simply fail to recognize a serious safety/certification issue?"
Some people in Canda have noticed already that after the accident Sikorsky have actually been rewarded by gained business replacing the lost aircraft and providing and extra SAR aircraft. Is that really right considering the magnitude of their actions n late 2002?
The group, Victims of Cougar 491 is comprised of the following individuals (listed below) who are signators of the letter sent to Minister Strahl:
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
Here in Canada the familes are now pressing the Crown on why the S-92A was certified at all.
Families of Cougar Flight 491 crash victims want action from Ottawa
Families of the victims of a tragic helicopter crash off Newfoundland are putting pressure on Ottawa to act in the aftermath of a report into the accident.
The request comes in a lawyer’s letter to Transport Minister Chuck Strahl on behalf of the families of the 15 passengers who died in the crash of Cougar Flight 491 in March 2009, as well as the sole survivor.
The Transportation Safety Board released its final report earlier this month, citing a number of factors in the crash of the Sikorsky S-92 including a severe loss of oil affecting the main gearbox.
The letter dated Feb. 18 calls on Strahl to investigate Transport Canada’s initial certification the S-92 helicopter.
“While the TSB report is extensive and detailed in many respects, it does not satisfactorily address critical questions pertaining to the manner in which the Sikorsky S-92 helicopter was initially certified by Transport Canada …” says the letter from the legal offices of Camp Fiorante Matthews.
The families also want Strahl to probe Transport Canada’s response to an incident involving the same type of chopper in Australia in July 2008. In that case, pilots of the helicopter arrived safely on land after losing oil pressure to the main gearbox.
Strahl has asked his department to respond to the TSB’s recommendations as soon as possible.
The families say they are looking for answers to questions about a number of issues in the interest of aviation safety and are not advancing a case for compensation.
Families of the victims of a tragic helicopter crash off Newfoundland are putting pressure on Ottawa to act in the aftermath of a report into the accident.
The request comes in a lawyer’s letter to Transport Minister Chuck Strahl on behalf of the families of the 15 passengers who died in the crash of Cougar Flight 491 in March 2009, as well as the sole survivor.
The Transportation Safety Board released its final report earlier this month, citing a number of factors in the crash of the Sikorsky S-92 including a severe loss of oil affecting the main gearbox.
The letter dated Feb. 18 calls on Strahl to investigate Transport Canada’s initial certification the S-92 helicopter.
“While the TSB report is extensive and detailed in many respects, it does not satisfactorily address critical questions pertaining to the manner in which the Sikorsky S-92 helicopter was initially certified by Transport Canada …” says the letter from the legal offices of Camp Fiorante Matthews.
The families also want Strahl to probe Transport Canada’s response to an incident involving the same type of chopper in Australia in July 2008. In that case, pilots of the helicopter arrived safely on land after losing oil pressure to the main gearbox.
Strahl has asked his department to respond to the TSB’s recommendations as soon as possible.
The families say they are looking for answers to questions about a number of issues in the interest of aviation safety and are not advancing a case for compensation.
The letter asks the key question. "Did Transport Canada succumb to pressure of the United States Federal Aviation Administration (FAA) or Sikorsky, or did they simply fail to recognize a serious safety/certification issue?"
Some people in Canda have noticed already that after the accident Sikorsky have actually been rewarded by gained business replacing the lost aircraft and providing and extra SAR aircraft. Is that really right considering the magnitude of their actions n late 2002?
The group, Victims of Cougar 491 is comprised of the following individuals (listed below) who are signators of the letter sent to Minister Strahl:
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
Much as we all- I'm sure - sympathise with the authors of the letter, it would carry more weight if it did not contain factual errors!
I'm not being pedantic - I just think if you are going to start making claims of this gravity, you need to be 100% accurate in your assertions.
On another note (partially related) I see some progess appears likely with the FAA certification of the SAR AFCS:
Federal Register | Special Conditions: Sikorsky Aircraft Corporation Model S-92A Helicopter; Installation of a Search and Rescue (SAR) Automatic Flight Control System (AFCS)
- The Super Puma does not have a 30 minute dry run capability
I'm not being pedantic - I just think if you are going to start making claims of this gravity, you need to be 100% accurate in your assertions.
On another note (partially related) I see some progess appears likely with the FAA certification of the SAR AFCS:
Federal Register | Special Conditions: Sikorsky Aircraft Corporation Model S-92A Helicopter; Installation of a Search and Rescue (SAR) Automatic Flight Control System (AFCS)
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Much as we all- I'm sure - sympathise with the authors of the letter, it would carry more weight if it did not contain factual errors!
* The Super Puma does not have a 30 minute dry run capability
* The Super Puma does not have a 30 minute dry run capability
The S-92 is not the first Part 29 aircraft certified by the FAA that does not have a 30 minute run dry capability
Outwest, I suspect you are correct about the 225 but it's sloppy work for a lawyer! You are also correct that I erroneously used First rather than Only, but my point is still correct - it's not the only aircraft.
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I'm not that well versed on this whole Part 29 issue, can you tell me which a/c are certified to this standard?
OK, now I see what the lawyer is getting at with statement #9 of his letter.
He is referring back to #7 where he contends that because there were 2 cases of complete loss of lubrication in about 100,000 hrs, the "extremely remote" (once in 1 million) is no longer valid.
So, although I agree that it was sloppy to group the 225 as a "Super Puma" I think his statement in #9 can be argued as factual.
OK, now I see what the lawyer is getting at with statement #9 of his letter.
He is referring back to #7 where he contends that because there were 2 cases of complete loss of lubrication in about 100,000 hrs, the "extremely remote" (once in 1 million) is no longer valid.
So, although I agree that it was sloppy to group the 225 as a "Super Puma" I think his statement in #9 can be argued as factual.
Last edited by Outwest; 28th Feb 2011 at 10:19.
CHC's response is well spelled out here,
Timeline - Cougar 491 | the fifth estate
About half way down the page, with links to various documents.
Timeline - Cougar 491 | the fifth estate
About half way down the page, with links to various documents.
And more recently here;
Investigator says problem flagged before fatal N.L. chopper crash - Business - The Telegram
Investigator says problem flagged before fatal N.L. chopper crash - Business - The Telegram