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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

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Old 19th Jun 2009, 15:26
  #421 (permalink)  
 
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Does the S92 initial and recurrent training program cover tail-rotor failures through to a successful autorotative landing? Seems to be an exercise that pilots have difficulties with on other aircraft types, to the point of reluctance on the part of some TRTO to include it in the LPC check, lest all their candidates end up failing.

Since out here in the bush we don't have the whole wide ocean, or 10,000' runway to land on, we're taught from day one to precision auto to a spot with T/R failures. One of the benefits of small helicopters I guess, but you guys have Level D sims that should allow for some pretty representative full on autos without a tailrotor.

FWIW, I feel better about the 92 now with this latest revelation than I do about the L2 coming apart at 2000'. Hazards of partial knowledge.
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Old 19th Jun 2009, 15:52
  #422 (permalink)  
 
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The Flight Safety school includes full touchdown tail rotor failures. I recall the entry at 1000' doing a straight in. I don't recall doing 180 tail rotor failures - full autos -yes.

It appears they were headed north, back to land, with a very stiff wind from the south. Impact was heading west. Tough to get around 180 degrees under the best of circumstances from 800ft.

One other thing to keep in mind about overwater operations. Judging your height above the water can be difficult, even for experienced pilots. There have been a number of little ships that had engine failures and misjudged the height to begin the deceleration.

Going through Naval Flight School, we were taught that when descending in your parachute, wait until you feet touched the water before letting go of your chute. That policy was adopted in WW2 as a result of the earlier policy of dropping out of your chute at 5 to 10 ft. and the resulting deaths of pilots who misjudged their height above the waves.
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Old 19th Jun 2009, 15:56
  #423 (permalink)  
 
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I would question the usefulness of tail rotor failure exercises for larger types in the simulator; there is little or no data and you would be reliant upon the software engineer's (or someone else's) view of the probable flight characteristics.

We used to do them in the S61 simulator in Stavanger but only as a handling exercise, not as a representative failure exercise.

The last time I heard of a tail-rotor failure (to one of these larger helicopters) and auto-rotation in the North Sea it was G-TIGK; the crew's actions were exemplary. However, they did have a number of clues that a failure was imminent.

Jim
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Old 19th Jun 2009, 15:59
  #424 (permalink)  
 
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SAS - true, there is no info about the state of the rest of the gearbox, but with that much metal missing from the pinion, and with a gearbox that has proven it can't run for long with no oil in it, it seems likely that there would be significant degredation of the transmission drag. Not certain, just likely.

malabo - just how do you practice fulldown autos with no tail rotor drive in your aircraft? Or do you mean fulldown autos with the examiner planting his feet on the pedals so you can't move them? There is a massive difference! Or do you use a Sim?
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Old 19th Jun 2009, 16:18
  #425 (permalink)  
 
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When testing for competence in Emergency Procedures....is there a requirement for a "safe controlled touchdown" for every malfunction? How do we simulate "actual" failures in a safe manner in the actual aircraft particularly large complex aircraft like 61's/92's/225's/332's?

Or....are we checking for application of "procedure" with the hope of a satisfactory outcome even if not necessarily a damage free landing?

I submit we can begin to approximate some of these extreme emergencies but cannot "duplicate" them and the training point is recognition of the fault and applying the best action possible to minimize adverse consequences. That should be the pass fail point and not a pretty touchdown under "simulated" conditions.
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Old 19th Jun 2009, 16:18
  #426 (permalink)  
 
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Tail Rotor Malfunctions and training in the sim

I agree with Jim et al, tail rotor drive shaft failure is available as a malfunction in our sim but I always precede its use with a little speech that highlights the dangers of any 'lessons learnt' by developing techniques in the box.

I find it disturbing to hear folk leave us saying "well at least we now know how to handle a tail rotor failure". The reality is that simple drive failures are only 33% of all tail rotor failures (CAA data) and that complicated failures such as loss of blades, entire unit or entire gearbox can make the handling solution very different.

One thing it may teach us is that if you lose directional control you had better make your mind up pretty damn quick about reacting to the situation. The sim does at least allow you to exercise that thought process.

If the analysis is correct it seems the crew were reacting appropriately but as others have said, why no 'Land Immediately'.

Don't suppose there will be much dallying in the future.

G.
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Old 19th Jun 2009, 17:49
  #427 (permalink)  
 
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What about seizure of the hydraulic pumps and subsequently the flight controls douring the autorotation, most likely the final part of the emergency phase?
Could the loss of MGB oil have been the onset for the hydraulic pumps failure, being them normaly fitted on outputs coming from the MGB case?



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Old 28th Jun 2009, 20:46
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Any opinion?
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Old 29th Jun 2009, 00:49
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Without the FDR/CVR running I doubt if there would be any way of knowing this, unless the TSB can perceive this somehow from the wreckage.

Remember, there was one surviving PAX, Robert Decker, who has already spoke to the TSB investigators, allthough he may not have been able to provide more details on the final stages of the crash.

I'm sure that more will come out in the next TSB update, until then we'll have to wait and see...
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Old 11th Jul 2009, 01:54
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crash in newfoundland march 12

My brother was killed in the Cougar helicopter crash on march 12 of this year. I am trying to find the pilot of the helicopter S-92 that landed safely in aussie. My email is [email protected]
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Old 13th Jul 2009, 21:37
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i hardly think its appropriate to give out information on the Australian crew.


on a subject from the last page about the fuels tanks taking the life rafts with them. the fuel tanks will, and i believe in this case did happen, break away from the aircraft. the life raft compartment is not part of that break away section. With regard to the need for better floatation devices? well, i cant comment on the reason for not inflating, but i can tell you that there is a modification which has been around for some time called the Sea State 6 Mod. 2 extra floats fitted to the sponsons at the undercarriage mounts. UK SAR aircraft have them, as do many others in europe, but most are inhibbited waiting for something. dont know what though.

my personal opinion as a S92 type rated engineer? well, there has been about 1000 posts berating sikorsky and anyone else that can think of for the cause of this crash. while most of you guys are pilots and i understand your reluctance to do so, why cant you accept that the cause of the CRASH could just have been that the pilots didnt follow the RFM and LAND IMMEDIATLY. the failure of the oil system or the failure of the tail rotor, was only the initiation of the problem. infact does it not say in the last report that they dont know if the bolts on the oil filter bowl broke before or after the crash? they said there was signs of cracking, but didnt know when final failure occured. monitoring of the oil pressure and temperature, for those non 92 people is displayed on the EICAS screen in front of the pilot. its obvious when the pressure drops below limits as the box changes colour and the line goes from straight to having a big dip in it at the pressure read out. it also displays a numeric pressure readout, so whoever said before that you wouldnt notice a change from 5 psi to 0 psi, well you would, there is no needle to clutter things up. if either the input manifold pressure switch or the last jet pressure switch is tripped, a yellow "MGB OIL PRES" caption will appear. if both are tripped a Red "MGB OIL PRES" caption, a master caution will illuminate and a "GEARBOX PRESSURE" aural warning will sound. so there was no way to miss these things, as someone else intimated towards.

Also, if you are going to ignore the RFM and keep trying for land, knowing your gearbox could be on the way out 30 minute run dry or not, would you fly it at 130kts ??? or at 800ft???? a fall from 800ft, with no forward motion is still going to hurt, A LOT. ive spoken with s92 pilots on the matter including one who has survived a tail rotor failure of the s92. he said "30-40ft above the sea, and crawled in!" thats what the cougar guys should have done. i dont want to speak ill of the dead and they did pay with thier lives, but is this or is this not, the reason for the outcome in this case? thats not to say that lessons cant be learned, but lets stay focused.

i bet a lot of people on this thread were surprised to hear that the rotors were still turning at impact!!!!

now awaiting the backlash from angry pilots!!!

Last edited by you want what??; 13th Jul 2009 at 22:06.
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Old 13th Jul 2009, 23:49
  #432 (permalink)  
 
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You,

Some of us here have said pretty much what you just did.

Early on I questioned the level off at 800 feet and the return to a near normal cruise speed. That was after the radio conversation with Cougar Ops.

I posed a question that suggested the crew made a decision to continue flight despite the last line in the checklist that instructed them to "Land Immediately!" and I queried what that decision was based upon. I still do.

These were professional pilots, well trained, dedicated to their work. They died as a result of that decision which I am sure was not made lightly or without due regard to the checklist and both their experience and training.

Asking how this chain of events occurred is certainly a valid issue to be discussed here, in future training, and in CRM venues.

One thing to remember however, is Pilots die from their decisions, Pilots also die from Engineer's decisions, Engineers get to bury the results of their bad decisions. That is why we will always be a bit demanding of those who design, build, and maintain our flyiing machines.
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Old 14th Jul 2009, 01:21
  #433 (permalink)  
 
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Mixing lever,

regardless of the sea state, if you arent going to land immediatly, you should be skiming the tops of the waves and crawling!! am i wrong?

SAS,

i know some people including yourself, have asked that question, but there seems to be far to much focus on the wrong things. and as for what you said about making decisions. yes pilots can die from their decision, but think about how it affects engineers? we dont just bury it and get on with our lives. if we make a mistake and it kills the passengers and crew, how do you think that would affect us for the rest of our lives, having their ghosts haunting you till you die. i know of a number of engineers who have eventually committed suicide after making mistakes like that. not to mention that we could also go to jail. I'm not going to get into a fight over whats worse, but see it from both sides. i agree there are some technical issues that need to be adressed, and if there is wrongdoing, be accountable. but that needs to apply to everyone, not just the manufacturer. i also have dedication, extensive training, (3 years appreticeship, and 4 years to get a licence. type training on top of that. took about 10 years before i could take responsibilty for anything. how does that compare to a pilot?) and experience, but i am not allowed by law to make my own decisions. i must follow the procedures laid down, or i am liable to diciplinary action or even prosecution. i know things dont always work out that way to the letter, but you have to justify it and mitigate any potential outcomes, like if there is a bad sea state below you, keep it low and slow. not balls out at 800 ft.

no matter the circumstances, with a compromised gearbox, do you believe that was a bad decision? As someone else said earlier, sikorsky can always build you a new aircraft, thats what insurance is for isnt it?. i know hind-sight is 20-20!

on a slightly different matter, based on the reports over the families suing. if they take those arguments as reported to court, i believe they will loose.


these are the ramblings and opinions of myself and myself alone! i may not be a wise old man, but i hope im not too naive !

Last edited by you want what??; 14th Jul 2009 at 01:43.
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Old 14th Jul 2009, 02:12
  #434 (permalink)  
 
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To be fair I think the TSB is focusing on the right things, according to the items being reviewed/investigated (from the last TSB report) :

The reason the recorder stopped remains under investigation.

Further examination is being carried out by the TSB Engineering Laboratory to determine the cause and sequence of this loss of tail rotor drive.

A detailed metallurgical examination of the studs, nuts, and filter bowl is under way to identify the origin of the fatigue cracks and to determine the fracture mechanism.

The reason the collars failed to inflate is still under investigation.

In addition, pilot training, human performance aspects, crew resource management, and cockpit ergonomics will be evaluated.

As a result of the fracture of the filter bowl mounting studs, resulting in the loss of a large quantity of oil, the certification guidance material is being reviewed.

Additionally, the FAA and Sikorsky Aircraft are working to identify all the modes of failure that might lead to Sikorsky S-92A MGB oil loss, determining their probability of occurrence, and developing appropriate mitigation strategies.

A number of issues regarding survivability such as passenger immersion suit and crew flight suit effectiveness, use of underwater breathing devices, adequacy of survival training, adequacy of general ditching procedures, personal locator beacons, weather/sea state flight limitations, and Sikorsky S-92A flotation system are currently under investigation.

TSB will no doubt, when considering the human factors side, look at the background as to what could influence why certain decisions were or weren't made at the time and will have access to information from many levels that has not yet been the subject of public debate.

Still wondering if the risk assessment after the Broome incident will come under further scrutiny ?
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Old 14th Jul 2009, 03:07
  #435 (permalink)  
 
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You,

Not suggesting engineers are a uncaring lot.....not at all. The vast majority are as you describe....are very much aware of the importance of their responsibilities.

I was trying to point out the reason why those who ride in these things have a very real interest in the non-flying half of the equation.
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Old 14th Jul 2009, 04:18
  #436 (permalink)  
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mixing lever: What was the weather during the final moments of 491? Sea state, etc....
Myself (from first page of this thread):
Just checked the NOAA buoy data:
NDBC - Station 44251

Conditions at Station 44251 - Nickerson Bank as of
1600 GMT on 03/12/2009:

Wind Direction (WDIR): S ( 180 deg true )
Wind Speed (WSPD): 29.1 kts
Wind Gust (GST): 35.0 kts
Wave Height (WVHT): 7.9 ft
Dominant Wave Period (DPD): 7 sec
Atmospheric Pressure (PRES): 29.72 in
Pressure Tendency (PTDY): -0.20 in ( Falling Rapidly )
Air Temperature (ATMP): 36.0 °F
Water Temperature (WTMP): 32.4 °F
Wind Chill (CHILL): 22.3 °F
(maybe not the closest buoy to the scene, but close enough to get the big picture )

...I have to agree, 800 ft seems pretty high. It's a difficult call though; I can see a reason for the speed: the gearbox probably won't wait until you made it home crawling, so if you don't want to ditch, you'd have to find a compromise... and given the sea state and temperature, an intentional ditching would have almost certainly meant that somebody's gonna die - meanwhile there is always hope that it is not that bad. That's a decision I hopefully never have to make!

Last edited by Phil77; 14th Jul 2009 at 04:33.
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Old 14th Jul 2009, 06:42
  #437 (permalink)  
 
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Phil77, I completely agree - it is a position none of us would relish - a major gearbox malfunction miles from land over a very inhospitable sea.

The decision to deliberately ditch in such conditions would come with the high probability that some of your pax wouldn't survive - think of what was probably going through the pilots mind - it is tantamount to asking him to commit murder and, when there is a perceived option (admittedly based on supposition that the gearbox has a 30 min run-dry capability) to try and get closer to land (quicker rescue) or even make landfall, one can quite understand how all the training in the world might not help make the right decision.

I have immense sympathy for the families of the pilots as no doubt they will end up taking or sharing the blame for trying to make the best of a horrendous situation which should never have arisen had the manufacturers and regulators done their jobs properly.

As for this
Additionally, the FAA and Sikorsky Aircraft are working to identify all the modes of failure that might lead to Sikorsky S-92A MGB oil loss, determining their probability of occurrence, and developing appropriate mitigation strategies
Isn't that what they were supposed to have done before the aircraft flew - and isn't a 'mitigation strategy' the same bullsh*t as saying there is a very remote likelihood of a failure and then allowing a sidestepping of the FARs?
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Old 14th Jul 2009, 10:44
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Commentary

Crab and Phil have it right. Let's put ourselves in the cockpit. Any of us who've flown offshore know exactly what was going through those pilots' minds as they tried to make it back to the beach with no transmission pressure.

Rock and a hard place? Oh boy! Landing on the cold, inhospitable sea would have been tantamount to murder, or just as bad, suicide. With this in the very front of their minds, they decided to press on: Surely this thing has *some* run dry capability. Surely! It's one of the big safety selling points of this new ship. I mean, everything I've read has mentioned it..."30-minute run-dry capability of the main gearbox." Well, no, not the RFM but those damn lawyers probably wouldn't let Sikorsky put that in official writing. But surely...

Slow down? Not bloody likely, not when time is of the essence and slowing down would've increased the amount of time it would take to get back to dry land. Go down? Yeah...but if you get really low, then VHF commo and being seen on radar become issues. So 800 feet probably seemed "low enough" to the crew, a good compromise altitude.

I'm also certain both of them had their hearts in their throats...because mine would have been, desperately hoping that I'd at least get some sign of impending doom before it all came apart - a little warning...something...enough to let me get the damn thing down on the water if I really, really had to, which wouldn't take me long from 800 feet. But if that was their thinking, they figured wrong.

We pilots simply have to come to grips with the fact that no helicopter transmission can be guaranteed to run for any length of time without oil, no matter what the manufacturer might say in their fancy four-color sales brochure. Of all the things that we can have more than one of (e.g. engines, generators, hydraulics...) the main transmission is the one thing that still *cannot* be redundified (or for you pedants, "made redundant").

The Cougar accident is a sad, sobering reminder of this truth.
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Old 14th Jul 2009, 12:45
  #439 (permalink)  
 
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given the sea state and temperature, an intentional ditching would have almost certainly meant that somebody's gonna die
Is there something about that situation that needs considering.....such as why we are flying that day at all?

Let's add in the thought the Canadian Government SAR aircraft was away for training and Cougar knew it had to provide its own SAR aircraft by established agreement with the SAR folks.

The Cougar SAR bird was not configured for that mission on a ready basis but was rigged and launched very quickly after the ditching.

There is far more to this crash than meets the eye....and all of this figures into the factors that weighed upon the crew that day.

I have worried the usual "pilot error" tag would be applied to this accident and I think if that is done then the system will have done these two pilots well and truely dirty in all regard.

What we need to do is use this tragedy to point out the very real failures in the certification system, training system, and management policies of both the oil and helicopter industry that allowed this to happen.

Otherwise, more lives are going to be lost for the same reasons.
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Old 14th Jul 2009, 13:28
  #440 (permalink)  
 
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I have friends that work at Cougar, and it was an emotional time after the accident, waiting to find out if it was anyone of my friends that perished. Thankfully it was not, but that does not make it any easier.

In 1978 I lost my Godfather in an accident off Norway, in a series of accidents S-61's tossed main rotor blades. AS I was only 3 years old at the time I have no recollection of the hardships that were then, but I can certainly empathise with all who have lost someone in this tragic accident.

AS far as procedures, the only twin I am certified on, is a Twinstar, so not really relevant, only similarities are they are both helicopters, and both are twins,
Anyways, I always understood, that to reduce the impact or wear on the MRGB if you were to have any MAJOR problems, like fluid loss or excessive temps, was to slow down to "bucket" speed, and keep that, as there would be least wear and tear. This I believe is also the best rate of climbs speed, and least rate of descend in an auto. Not obviously knowing what went through the two pilot's minds during the last minutes, what made them choose to fly at this higher speed?

Reaching shore faster? as the pictures show, there was a loss of tail rotor drive, which would NOT have been as severe if they were flying at "bucket" speed...

Anyways, just my thoughts.
Cheers
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