GATINEAU, QC, Sept. 12, 2013 /CNW/ - The Transportation Safety Board of
Canada (TSB) today released its investigation report (A11H0001) into an
incident where a Sikorsky S-92A operated by Cougar Helicopters Inc.
inadvertently descended and came within seconds of striking the water
in July 2011.
"The aviation industry is increasingly relying on cockpit automation in
its day-to-day operations," said Daryl Collins, the
Investigator-in-Charge. "Despite the many benefits of cockpit
automation in aviation, it is vital that flight crews maintain their
hands-on visual and instrument flying proficiency so that they have the
experience and confidence to deal with unusual situations."
In this incident, the flight departed an oil platform for St. John's
International Airport, Newfoundland and Labrador with 2 crew members
and 5 passengers aboard. During the departure, the captain made a
large, rapid aft control input just prior to activating the go-around
mode, causing the helicopter to enter a nose-high, decelerating pitch
attitude in cloud. As the helicopter's airspeed decreased below the
minimum control speed, a rapid descent occurred. The captain, subtly
incapacitated, possibly due to spatial disorientation, did not take
action to recover from the descent in a timely manner. The first
officer, lacking confidence in his abilities to recover from the
inadvertent descent, did not take control of the helicopter, as
required by the company's standard operating procedures. When the
helicopter exited the bottom of the clouds at 200 feet above the water,
the flight crew saw the water below and the captain increased
collective pitch, which increases the amount of lift produced by the
main rotor system, and the descent was arrested 38 feet above the
water. There were no injuries or damage to the aircraft.
The investigation found numerous operational, procedural and training
issues that contributed to this occurrence. Flight crews, for example,
did not routinely practice unusual attitude recoveries, nor were they
trained to recognize and respond to subtle incapacitation. This could
reduce pilots' confidence to take control in these situations and
increase the risk of an accident.
Since the incident, Cougar Helicopters improved its unusual attitude
training and now requires pilots to fly a minimum of 2 manually flown
instrument approaches every 90 days. It has also clarified its standard
operating procedures related to unusual attitude recovery, subtle
incapacitation, and autopilot usage.
The TSB is an independent agency that investigates marine, pipeline,
railway and aviation transportation occurrences. Its sole aim is the
advancement of transportation safety. It is not the function of the
Board to assign fault or determine civil or criminal liability.
SOURCE: Transportation Safety Board of Canada
For further information:
Transportation Safety Board of Canada
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