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

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

Old 13th Apr 2011, 04:34
  #1001 (permalink)  
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The response to the recommendations can be followed here:
C-NLOPB || Offshore Helicopter Safety Inquiry - Implementation

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

Also Aero Safety World have an article on the accident:
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Old 14th Apr 2011, 17:18
  #1002 (permalink)  
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Doesn't look like many real improvements have been achieved so far.

Autohover was already an OGP SAR requirement. Not sure how that was misssed.
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Old 24th Apr 2011, 04:38
  #1003 (permalink)  
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The Phase II submissions to the Wells Inquiry have now been published.

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

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

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

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

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

Sikorsky still refuse to contribute to the Inquiry.
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Old 22nd May 2011, 08:01
  #1004 (permalink)  
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Sikorsky still refuse to contribute to the Inquiry.
Not a huge surprise since everything comes back to their gearbox design:

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

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

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

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

As an aside, does anyone think that a rearcrewman might have noticed gearbox oil pouring down the side past the windows and alerted the pilots to the severity of the problem? The absence of a cabin attendant seems to be the norm in offshore ops (down to cost I suppose), but would a properly trained and experienced rearcrew in the cabin have a. helped the stressed front crew and b. been in a position to help the pax escape if he had been on a HUET system?
crab@SAAvn.co.uk is offline  
Old 22nd May 2011, 09:18
  #1005 (permalink)  
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What of the future

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

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

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

How does that old Nursery Rhyme go -

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

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

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Old 22nd May 2011, 17:43
  #1006 (permalink)  
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Originally Posted by [email protected]
As an aside, does anyone think that a rearcrewman might have noticed gearbox oil pouring down the side past the windows and alerted the pilots to the severity of the problem? The absence of a cabin attendant seems to be the norm in offshore ops (down to cost I suppose), but would a properly trained and experienced rearcrew in the cabin have a. helped the stressed front crew and b. been in a position to help the pax escape if he had been on a HUET system?
Firstly lets clear up some confusion. A rear crewperson would be found in your Sea Kings, and the civil SAR helicopter operators. A cabin attendant would be found in civil helicopters, like the Brunei Shell S92As. A cabin attendant would not normally receive the same amount of training & qualifications as a rear crewperson (e.g. no paramedic qualification).

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

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

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

Not carrying a Cabin Attendant is down to a client requirement, combined with the fact that most helicopters used offshore are only certified for 19 passengers or less. The Chinooks used on the North Sea required a Cabin Attendant, similarly the SK61Ns when carrying more than 19 passengers needed a Cabin Attendant. Cabin Attendants/Pilots Assistants were also carried on some single pilot IFR operations, until legislation/client requirements required the operations to be 2 crew.
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Old 22nd May 2011, 19:18
  #1007 (permalink)  
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CCC - I'm not saying a paramedic needs to be carried and it is not the medical but the aviation training that might have saved the day.

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

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

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

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

There is no excuse for crew and pax not to have Stass nowadays.
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Old 22nd May 2011, 20:52
  #1008 (permalink)  
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Rear seat crew!!

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

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

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

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Old 22nd May 2011, 21:37
  #1009 (permalink)  
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This was discussed eons ago but when SA asked what the passenger load would be and whether a crewmember was to be in the back, ALL customers wanted just the LEGAL amount of Pax in the back that did not REQUIRE an attendant and so the S92's 'Pax in the back' number was limited to what could be legally carried WITHOUT an attendant in the back.
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Old 23rd May 2011, 01:01
  #1010 (permalink)  
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Brazil leads the way then!

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

Following an AS332L2 accident in 2008 the Cabin Attendant received the Brazilian Air Force´s highest permissible decoration for her actions.
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Old 23rd May 2011, 06:39
  #1011 (permalink)  
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If Petrobras were focussed on safety and thought C/As were a good thing then they would feature on all types but they don't. Conclusion - Petrobras want to maximise payload and therefore have to carry a C/A because max payload equals more than 19 pax.

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

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Old 23rd May 2011, 07:11
  #1012 (permalink)  
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Crewies are great guys (and gals - BIH) but they cannot work miracles.
but I suspect that you, like I, have had your ass saved or embarrassment avoided by them in the past.

No prejudices, just a suggestion that despite much trumpeting about safety in offshore ops, without stricter world-wide legislation to force the customer to demand the best from the operators, the richest industry in the world will keep getting richer on the back of risks taken by the crews and pax.
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Old 23rd May 2011, 08:13
  #1013 (permalink)  
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Offshore ops......

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

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

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

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

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

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Old 23rd May 2011, 08:52
  #1014 (permalink)  
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We are concentrating on more and more esoteric issues and, consequently, may be missing one of the (more important) links in the causal chain.

(Extracts are selective)

In Paragraph of the accident report it is reported: TSB Examination of CHI91 Filter Bowl Mounting Studs and Nuts

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

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

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

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

The report then repeats the Sikorsky messages to the operators: Sikorsky Actions

About 2 months after the filter bowl stud problem was discussed during the Sikorsky webcast, Sikorsky issued SSA-S92-08-007 on 08 October 2008 that stated:
Sikorsky has been advised that an operator experienced the loss of MGB system oil due to a leak at the filter bowl. The investigation revealed that two of the three MGB filter bowl assembly titanium studs had sheared allowing the filter bowl to displace. As a result, Sikorsky is enhancing the current Aircraft Maintenance Manual (AMM) procedures to aid in identifying potentially damaged studs during the removal or installation of the filter bowl. It is recommended that particular attention and care be taken during the removal and installation of the MGB filter bowl assembly to minimize any potential damage to the threaded portions of the mounting studs.
Approximately 3.5 months after the SSA, Sikorsky released ASB 92-63-014 on 28 January 2009 to its customers, which stated:
Undetected damage to an oil filter stud can lead to failure of the stud. Enhanced procedures are being added to the maintenance manual to help identify potentially damaged studs. To further enhance reliability of this connection, the titanium studs are being replaced with steel.
Finally, the report comments on used studs received from the operators (in respect of expected actions by the operators):

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

On 23 March 2009, the FAA issued Emergency AD 2009-07-53 for Sikorsky S-92A helicopters, which required, before further flight, removing all titanium studs that attach the MGB filter bowl assembly to the MGB and replacing them with steel studs. Sikorsky did not receive any reports of damaged studs between issuance of AMM Revision 13 in November 2008 and when AD 2009-07-53 was issued in March 2009. However, it did receive 59 studs from various operators after they had complied with the AD. Sikorsky examined these studs and found that they had varying degrees of galling of the threads, indicating multiple nut removals. Some of the thread damage was visible without the use of magnification. Photo 16 shows a sample of studs returned to Sikorsky, with varying degrees of galling, ranging from coating loss and minor damage to the threads (stud 1), coating loss and moderate damage to the threads (stud 2), to extensive coating loss and severe damage to the threads (stud 3). The thread damage in stud 3 of Photo 16 was visible to the naked eye. Sikorsky could not provide the time-in-service for the returned studs; however, considering the timing of the AMM revision on 05 November 2008 and the issuing of AD 2009-07-53 on 23 March 2009, and the average S-92A utilization times, they would have come from helicopters that had their filter bowls removed at least three times.
If there is a lesson to be learnt here, it is that expectations resulting from 'soft' measures have to be tempered in the light of human involvement. Additional procedures are not always the best way to address issues and sometimes more direct action is called for. Having had the first occurrence (in Australia), it might have been prudent (in hindsight) for Sikorsky to sample 'galling' damage to other studs in the field. This could have been achieved by requesting photographic evidence from the operators whenever filter bowl intervention was necessary (extremely simple in this age of digital cameras). Comparisons could then have been shown in the weekly webcast.

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

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Old 24th May 2011, 06:43
  #1015 (permalink)  
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All Petrobras heavy aircraft offshore (S92 and EC225 - greater than 15 seats) have one cabin attendant and 18 passenger seats - conclusion, you have been away from Brazil for some time!

Last edited by tistisnot; 24th May 2011 at 07:02.
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Old 24th May 2011, 09:34
  #1016 (permalink)  
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Well that's a small step for man and great leap forward for mankind..... at least for Brazilian mankind. I hope the many other areas worthy of attention have also been addressed but I will be very surprised (and pleased) if I hear that the HUET training has been introduced. They should at least offer it.

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

My best regards to the guys in Macae and Rio.

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Old 24th May 2011, 12:06
  #1017 (permalink)  
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On the discussion of the merits of a flight attendant/ crew chief; let me add a practical need for an engineer/mechanic to be included as part of the crew. Since the rigs we fly to are Waaay! out there, an occasional minor problem that arises can often be fixed on the rig. Since the deck is fouled with our big beast, and the nearest platform may be 50-80 miles away, not having to send for maintenance can save the rig hours, if not more than a day.
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Old 24th May 2011, 18:56
  #1018 (permalink)  
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Originally Posted by Shell Management
Not only do Shell use cabin attendants on their S-92s in Brunei and their EC155s in Nigeria but also on S-92s in the GOM.
Is that voluntary, contractual, or statutory?

Originally Posted by Shell Management
It is only in places like the North Sea where the operators think they know better that no cabin attendant is carried.
You make good points, then you chew on your toes. It's downright maddening.
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Old 24th May 2011, 21:42
  #1019 (permalink)  
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Would that have helped in this case or would it have been another family added to the the grieving list? Probably the latter.
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Old 24th May 2011, 22:27
  #1020 (permalink)  
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If you, the customer, demand it for your aircraft, why blame the operators when other oil companies do not insist?
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