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
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
The TSB is online atwww.tsb.gc.ca. Keep up to date throughRSS,Twitter
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CO: Transportation Safety Board of Canada
-0- Sep/12/2013 12:30 GMT
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