Inadvertent descent of Cougar Helicopters Sikorsky S-92A highlights importance of maintaining hands-on flying proficiency when

Inadvertent descent of Cougar Helicopters Sikorsky S-92A highlights importance 
of maintaining hands-on flying proficiency when flying automated aircraft 
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 CougarHelicopters Inc. inadvertently 
descended and came within seconds of striking the water in July2011. 
"The aviation industry is increasingly relying on cockpit automation in its 
day-to-day operations," said DarylCollins, 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 
In this incident, the flight departed an oil platform for St. John's 
International Airport, Newfoundland and Labrador with 2crew 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 
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 
Transportation Safety Board of Canada Media Relations 819-994-8053 
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CO: Transportation Safety Board of Canada
ST: Quebec
-0- Sep/12/2013 12:30 GMT
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