CASNR 08.001 - March 11, 2008
OTTAWA - The Flight Safety Investigation Report (FSIR) on the crash of Cormorant helicopter CH149914 that killed three Canadian Forces Search and Rescue crew members and injured four others was released today and can be found on the Directorate of Flight Safety website at Directorate of Flight Safety.
The report, which contains the major facts, findings and recommendations from the investigation, identified multiple cause factors that contributed to this accident.
"This investigation had two main objectives," said Colonel Christopher Shelley, Director of Flight Safety for the Air Force. "First, to determine why multiple layers of safety defences failed to keep the crew of the Cormorant safe and second, to recommend measures that will improve the safety of search and rescue operations and prevent further occurrences."
In essence, the report concludes that the aircraft was serviceable at the time of the accident and that weather was not a factor. The primary causes identified were the pilot's flying technique and the cockpit crew's misperception of the aircraft's attitude and flight path. This was due to a complete lack of visual references in the dark, over-water environment and their inadequate scan of the helicopter's onboard instrumentation.
Additional findings revealed that blocked emergency exits, inaccessibility of emergency breathing equipment, and difficulties in releasing the safety harnesses impeded three of the four cabin-area crew from successfully exiting the aircraft.
Additionally, restrictions imposed on the length of training flights in October 2004, due to on-going tail rotor half-hub cracking, had a detrimental effect on overall crew proficiency. The cumulative effect of these restrictions was underestimated and therefore inadequately addressed. The overall lack of system knowledge and flying proficiency on the part of the pilots, coupled with the aircraft captain's decision to allow the two first officers to occupy the control seats during this training flight, contributed to the accident.
Also a factor was the lack of detailed information in the Cormorant Standard Manoeuvre Manual describing the specific duties, techniques and procedures to be used by Cormorant crews.
The Air Force has already implemented a number of preventive measures recommended in the report. These include: confirmation of the co-pilot's duties and over-water procedures; increased communication with respect to altitude, airspeed and situational awareness as part of cockpit procedures; and shifting seats and equipment inside the cabin of the Cormorant to provide greater access to emergency exits.
"Although the report recommends 26 preventive measures, the Air Force has in fact already
initiated over 60 actions to improve the safety of our Search and Rescue personnel," said Brigadier-General Yvan Blondin, Deputy Commander of Force Generation for the Air Force. "The safety of our people must be paramount."
The purpose of a Flight Safety Investigation is to determine the cause factors that lead to an aircraft accident and to recommend measures that have the potential to prevent future accidents. It does not assign blame or accountability. The proceedings of a Flight Safety Investigation cannot be used as evidence to support disciplinary actions, an administrative review or any civil litigation.
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