Pilot error led to fatal Cormorant crash: report


SOF Support
Feb 8, 2007
Land of Swine and Maple Syrup
This is not good news but it's good that it came out in the report.

Pilot error led to fatal Cormorant crash: report

3 men killed in 2006 off Canso, N.S., couldn't escape submerged chopper

Last Updated: Tuesday, March 11, 2008 | 12:40 PM AT Comments0Recommend30

CBC News

The final report into a fatal military helicopter crash off Canso, N.S., nearly two years ago found that the skills of the flying crew weren't up to standard, and the pilot should not have overridden the autopilot before attempting to hover over a fishing boat in Chedabucto Bay.
The 69-page Flight Safety Investigation Report released Tuesday at 14 Wing Greenwood found that search and rescue pilots aboard the Cormorant did not have enough training hours under their belts, and their skills weren't as sharp as they should have been.
The Cormorant, flown by Maj. Gordon Ireland, smashed into the ocean on the night of July 13, 2006, with a crew of seven on board.
Sgt. Duane Brazil, 39, of Gander, N.L., Master Cpl. Kirk Noel, 33, of St. Anthony, N.L., and Cpl. Trevor McDavid, 31, of Sudbury, Ont., were killed in the crash when they were unable to escape the submerged chopper.
They were practising nighttime search and rescue manoeuvres at the time.
The report found that although the crew's skills had declined as a result of flying hour restrictions and low Cormorant availability, that alone could not explain the crash.
"The fact that the Cormorant aircrew reported losing confidence in their proficiency, that did not of itself make this accident inevitable," the report said.
Despite that lowered confidence, it said, the pilots chose to manually override the automatic flight control system.
"The automated safety features of the Cormorant helicopter were a significant defence against this type of mishap, even in a scenario of generalized diminishing crew proficiency … Yet the actions of the pilots essentially negated the safety features of the aircraft," the report states.
"The inappropriate manipulation of the controls by the flying pilot made it impossible for the automation to maintain the helicopter within safe flight parameters.
The report said the air force needs to address the "cultural issue" of pilots who choose to ignore the sophisticated equipment.
"The concepts related to the use of automation did not become embedded in air force culture … As a result, pilots retained too much discretion as to how and when to use automation when manoeuvring the aircraft."
The report also found that the crew's monitoring of flight instruments was inadequate as a result of "misprioritization of cockpit duties" and nobody noticed they were on the verge of crashing.
Another factor cited in the report is the restrictions on the amount of training flights that were imposed as the result of persistent cracks in the Cormorant's tail rotor hubs.
It recommends that until flight restrictions are lifted, the simulator training frequency should be optimized to maintain a high level of proficiency.
Emergency exits blocked

The report concludes that the three men who died were unable to escape the submerged chopper because of blocked emergency exits, inaccessible emergency breathing equipment and harnesses that were difficult to release.
"A number of secondary escape exits were obstructed or partially obstructed by the equipment in the cabin. Some equipment, such as the ladder and the SAR basket had become dislodged and/or shifted at impact," the report found.
"The ladder, which normally blocks access to the lower pull tab of the right rear exit, had shifted towards the ceiling when the helicopter became inverted, and was blocking approximately 50 per cent of the exit. The rescue basket had also shifted and was partially blocking the route to the exit."
The report found that the crash was so sudden and unexpected that none of the crew members had a chance to prepare themselves, or even take a breath before" being completely and instantaneously submerged in cold sea water."
"The force of the helicopter's impact with the water and the crash dynamics were such that none of the crewmembers were fatally injured on impact," it said.
"The crash presented the worst-case egress situation given the total lack of warning and the massive destruction of the front end of the aircraft."
Yep, I remember going through the dunker at NAS Lemore and I NEVER want to be in that situation again. When we did day/night water operations one thing I always kept first and formost in my mind was SA on where the helo was, where the "survivor" was and how the crew as a whole was performing.

I tell you what, there is almost nothing more interesting then flying night water ops blacked out and doing a 40 foot hoist on a moonless night in calm seas. I dont know how many times I had to take a moment and clear my head because you can loose the horizon very quickly (because the stars reflect off the water) and vertigo can kick in quickly since there are few, if any, refrences for us to hover off of.

As for the Cormorant, yes it is the Canadian version of EH-101. The're having major issues with the tail rotors because they modded thier aircraft without Augusta Westalnds approval and cracks have started to appear.:doh:
Here's the occurrence report from the Directorate of Flight Safety. The basics seem to be lack of available flying time due to restrictions because of the tail rotor cracking and SOP's wrt NVG flying.

Occurrence Report

CH149914 Cormorant


Date: 13 July 2006
Location: Chedabucto Bay, near Canso, Nova Scotia

From the Investigator (FTI) (pdf 113 kb)
Flight Safety Investigation Report (FSIR) (pdf 3,350 kb) Posted 2008-03-11
Epilogue (EPI) (pdf 85 kb) Posted 2008-03-11
The accident involved a CH149 Cormorant Search and Rescue (SAR) helicopter with a crew of seven that was on a training mission to practice night boat hoists from the fishing vessel Four Sisters No.1. The cockpit crew consisted of a First Officer (FO) in the left pilot seat, an FO acting as Aircraft Captain (AAC) in the right pilot seat and the actual Aircraft Captain (AC), seated in the cockpit jump seat. The crew in the cabin area comprised a Flight Engineer (FE), a Flight Engineer under training (FEUT), a SAR Tech Team Lead (SAR Tech TL) and a SAR Tech Team Member (SAR Tech TM).
The accident occurred during an attempted go-around from an approach to a fishing vessel. During the go-around the helicopter entered a nose-low attitude and seconds later the aircraft impacted the water with 69 knots forward speed in an 18 degree nose-down attitude. The three pilots and the SAR Tech TL were injured but survived the crash. The two flight engineers and the SAR Tech TM were unable to egress the aircraft and did not survive. The aircraft sustained damage beyond economical repair.
No evidence was found that any system malfunction contributed to the accident, so the investigation focused on the environment, organizational and human factors. The investigation found that the flying pilot's trim technique caused the flight control pitch actuators to become saturated, which in turn caused the loss of the helicopter's automatic stabilization system. In this condition, the helicopter's inherent instability combined with the pilot's inputs to create a large but unrecognized nose down attitude and descending flight path.
The environmental conditions (darkness, distant dim horizon and calm water) were not suitable for continued flight using outside references only. The nose down attitude and descent was not noticed by any of the three pilots in the low visual cueing environment because they did not adequately reference their flight instruments.
The investigation also found that prolonged training restrictions imposed due to on-going tail-rotor half-hub cracking had a serious detrimental effect on overall CH149 aircrew proficiency, particulary at 413(TR) Squadron. The resultant risk to operational airworthiness was underestimated and not effectively mitigated.
Although the four cabin area crew members survived the impact, only one was able to successfully egress the aircraft before his air supply was exhausted. Survivability issues included cabin layout, storage of equipment, and the suitability of the Aircraft Life Support Equipment. Activity is underway to rectify many of the safety deficiencies identified through the course of the investigation. The Flight Safety Investigation Report contains many recommendations to improve CH149 pilot proficiency, training and survivability / life support equipment issues for CH149 aircrew.
As for the Cormorant, yes it is the Canadian version of EH-101. The're having major issues with the tail rotors because they modded thier aircraft without Augusta Westalnds approval and cracks have started to appear.:doh:

What kind of mods did they do.

All original design mods were done by AW or companies approved by AW.

GKN Westland Helicopters and Agusta SpA assembled several Canadian companies to work with them to supply the EH101 Cormorant for the Canadian Government's requirement for up to 15 search and rescue (SAR) helicopters. Operating under the banner of Team Cormorant the core members include Bombardier, Bristol Aerospace and CAE. In addition, Canadian Helicopters from St-John's, Newfoundland, joined the team to provide for a leasing option and follow-on maintenance as outlined by the Canadian Minister of National Defence.