Cougar Helicopters Flight 91
Encyclopedia
Cougar Helicopters
Cougar Helicopters
Cougar Helicopters is a St. John's based commercial helicopter company servicing offshore oil and gas fields off the coast of Newfoundland and Nova Scotia. Cougar has permanent facilities in St...

 Flight 91
(also known as Flight 491) was a scheduled flight of a Cougar Sikorsky S-92A
Sikorsky S-92
The Sikorsky S-92 is a four-bladed twin-engine medium-lift helicopter built by Sikorsky Aircraft for the civil and military helicopter market. The S-92 was developed from the Sikorsky S-70 helicopter and has similar parts such as flight control and rotor systems.The H-92 Superhawk is a military...

 (Registration
Aircraft registration
An aircraft registration is a unique alphanumeric string that identifies a civil aircraft, in similar fashion to a licence plate on an automobile...

 C-GZCH) which ditched
Water landing
A water landing is, in the broadest sense, any landing on a body of water. All waterfowl, those seabirds capable of flight, and some human-built vehicles are capable of landing in water as a matter of course....

 on 12 March 2009 en route to the SeaRose FPSO
SeaRose FPSO
SeaRose FPSO is a floating production, storage and offloading vessel located in the White Rose oil and gas field, approximately 350 kilometres east-southeast off the coast of Newfoundland, Canada in the North Atlantic Ocean...

 in the White Rose oil field
White Rose (oil field)
White Rose is an oil field development project 350 kilometres off the coast of Newfoundland. Husky Energy is the operator and 72.5 per cent interest holder in the White Rose oil fields....

 and Hibernia Platform in the Hibernia oilfield
Hibernia (oil field)
Hibernia is an oil field in the North Atlantic Ocean, approximately east-southeast of St. John's, Newfoundland, Canada.The production platform Hibernia is the world's largest oil platform and consists of a 37,000-tonne integrated topsides facility mounted on a 600,000-tonne gravity base structure...

 off the coast of Newfoundland 55 kilometres (34.2 mi) east-southeast of St. John's, Newfoundland.

Aircraft

The 2006-built Sikorsky S-92A
Sikorsky S-92
The Sikorsky S-92 is a four-bladed twin-engine medium-lift helicopter built by Sikorsky Aircraft for the civil and military helicopter market. The S-92 was developed from the Sikorsky S-70 helicopter and has similar parts such as flight control and rotor systems.The H-92 Superhawk is a military...

, with manufacturers' serial number 920048, was a 19-passenger helicopter powered by twin General Electric CT7 turboshaft engines. It has been registered C-GZCH to Cougar International Inc. since 12 April 2007. The main gearbox, which was reported as having lost oil pressure, couples both engines to the main and tail rotors, and also drives the hydraulic pumps and two electrical generators.

Flight

Cougar 91 is a regular 90 minute, 315 km shuttle flight from St. John's International Airport
St. John's International Airport
St. John's International Airport is an international airport located northwest of St. John's, Newfoundland and Labrador, Canada that serves the St. John's Metro Area and the Avalon Peninsula. The airport is part of the National Airports System, and is operated by St...

, usually servicing the Hibernia oilfield. This flight was carrying workers to the SeaRose FPSO
SeaRose FPSO
SeaRose FPSO is a floating production, storage and offloading vessel located in the White Rose oil and gas field, approximately 350 kilometres east-southeast off the coast of Newfoundland, Canada in the North Atlantic Ocean...

 (Floating Production Storage and Offloading
Floating Production Storage and Offloading
A floating production, storage and offloading unit is a floating vessel used by the offshore industry for the processing of hydrocarbons and for storage of oil. A FPSO vessel is designed to receive hydrocarbons produced from nearby platforms or subsea template, process them, and store oil until it...

 vessel) and the Hibernia Platform. The flight was under the command of Matthew Davis, with Tim Lanouette as first officer.

A Mayday
Mayday (distress signal)
Mayday is an emergency procedure word used internationally as a distress signal in voice procedure radio communications. It derives from the French venez m'aider, meaning "come help me"....

 call was issued after the aircraft reported zero oil pressure in the main gearbox at 9:40 a.m. NDT (12:10 UTC). Flight 91 attempted to return to St. John's but went down at 9:48 a.m. The aircraft was spotted, floating upside down, by a Provincial Airlines
Provincial Airlines
Provincial Airlines is an airline based in St John's, Newfoundland and Labrador, Canada. It operates passenger and cargo services, maritime surveillance and remote sensing and environmental monitoring operations. Its main base is St. John's International Airport. - History :The airline was...

 ice patrol airplane 25 minutes later. It later sank in 178 metres (584 ft) of water. Only one of the eighteen people aboard survived the sinking, although another managed to exit the aircraft.

Search and rescue

Weather conditions were reported as "good", with the water at 0 Celsius (32 Fahrenheit), waves at 2–3 metres (6–10 feet), and winds at 37 kilometres per hour (23 mph). The normal practice on these flights is to wear immersion suits for hypothermia protection. Survival times for adult men wearing the immersion suits in these conditions are estimated at 24 hours, but no signals had been received from the suit locator beacons. According to the company's website, the suits are Helly Hansen
Helly Hansen
Helly Hansen is a high-end producer of textiles and special gear for sports and work on the ocean and in the mountains, headquartered in Oslo, Norway .Today, the brand is recognized for its foul-weather fishing gear and can be seen both on television and...

 type E452 Survival / Marine Abandonment suits with their own inflatable life jackets. All passengers on these flights are required to have taken a five-day escape and survival course within the past three years, but escape from a ditched helicopter is difficult even when put down gently.

Reports indicated that 18 people were on board the helicopter. One survivor, Robert Decker of St. John's, was flown to hospital at St. John's in critical but stable condition with fractures and with salt water in his lungs. One woman was found dead on the surface. Two life rafts were found empty. The Canadian Coast Guard
Canadian Coast Guard
The Canadian Coast Guard is the coast guard of Canada. It is a federal agency responsible for providing maritime search and rescue , aids to navigation, marine pollution response, marine radio, and icebreaking...

, Canadian Forces
Canadian Forces
The Canadian Forces , officially the Canadian Armed Forces , are the unified armed forces of Canada, as constituted by the National Defence Act, which states: "The Canadian Forces are the armed forces of Her Majesty raised by Canada and consist of one Service called the Canadian Armed Forces."...

, Provincial Airlines
Provincial Airlines
Provincial Airlines is an airline based in St John's, Newfoundland and Labrador, Canada. It operates passenger and cargo services, maritime surveillance and remote sensing and environmental monitoring operations. Its main base is St. John's International Airport. - History :The airline was...

 planes and surface vessels continued to search the area for additional survivors.

Investigation

The investigation is being led by the Transportation Safety Board of Canada (TSB), which has assigned an initial team of twelve investigators, and the Royal Canadian Mounted Police
Royal Canadian Mounted Police
The Royal Canadian Mounted Police , literally ‘Royal Gendarmerie of Canada’; colloquially known as The Mounties, and internally as ‘The Force’) is the national police force of Canada, and one of the most recognized of its kind in the world. It is unique in the world as a national, federal,...

. As the state of manufacture, the United States is represented by eight investigators, from the National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...

, assisted by the FAA
Federal Aviation Administration
The Federal Aviation Administration is the national aviation authority of the United States. An agency of the United States Department of Transportation, it has authority to regulate and oversee all aspects of civil aviation in the U.S...

 and Sikorsky
Sikorsky Aircraft
The Sikorsky Aircraft Corporation is an American aircraft manufacturer based in Stratford, Connecticut. Its parent company is United Technologies Corporation.-History:...

.

Recovery phase

The TSB used two remotely operated vehicle
Remotely operated vehicle
A remotely operated vehicle is a tethered underwater vehicle. They are common in deepwater industries such as offshore hydrocarbon extraction. An ROV may sometimes be called a remotely operated underwater vehicle to distinguish it from remote control vehicles operating on land or in the air. ROVs...

s (ROVs), operating from the Atlantic Osprey
Atlantic Osprey
The Atlantic Osprey is an anchor handling tug supply vessel vessel, launched 17 April 2003.Built by Halifax Shipyard for operation by Atlantic Towing Limited, Atlantic Osprey is an Ulstein UT 722 L design intended for use in the offshore oil fields...

, to locate and examine the sunken aircraft, which was found on the bottom largely intact but with significant structural damage, and with the tail boom broken off and lying separately nearby.
The damage to the airframe was severe enough to prevent immediate recovery of the wreckage as originally planned, and efforts instead focused on recovering the remains of the passengers and crew. Images from the ROVs indicated the presence of between 10 and 13 bodies in the aircraft fuselage. Nine bodies were recovered from the wreckage on 14–15 March and were returned to St. John's in the early hours of 16 March aboard the Atlantic Osprey. On 17 March, the TSB announced that all bodies had been recovered, as were the Flight Data Recorder
Flight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...

 (FDR) and Cockpit Voice Recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...

 (CVR). The S-92 FDR/CVR is one box called a Multi-Purpose Flight Recorder, commonly referred to as a "combi-unit", manufactured by Penny and Giles in the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...

. The FDR/CVR was transferred to Ottawa
Ottawa
Ottawa is the capital of Canada, the second largest city in the Province of Ontario, and the fourth largest city in the country. The city is located on the south bank of the Ottawa River in the eastern portion of Southern Ontario...

, Ontario
Ontario
Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....

 for analysis by TSB personnel. On March 18, the Atlantic Osprey docked in St. John's carrying the main chassis of the helicopter in a basket on deck. The TSB's lead investigator indicated on 19 March that about 80% of the wreckage had already been recovered; by 26 March this figure had been increased to 95%.

Inspection, analysis, and recommendations

TSB identified a broken titanium stud as part of the gearbox oil filter assembly. Sikorsky had previously recommended that the titanium stud be replaced with a steel stud within one year or 1,250 flight hours of a 28 January 2009 Alert Service Bulletin, following a total loss of oil and emergency landing in Australia in August 2008. On 21 March Les Dorr, a spokesman for the FAA, indicated that it would release an Airworthiness Directive calling for the replacement of the studs on other S-92A aircraft, most likely on Monday 23 March, but that the Directive would apply only to US-registered helicopters. The FAA had issued previous Airworthiness Directives AD 2005-12-03, AD 2006-11-14, and AD 2006-15-19 for problems with the main gearbox of that type.http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/MainFrame?OpenFrameSet The FAA had also issued Special Airworthiness Information Bulletin (SAIB) number SW-09-19 Sikorsky S92A Main Gearbox Emergency Procedures dated 19 March 2009. The SAIB indicated that a recent procedural change, Sikorsky Safety Advisory (SSA) SSA-S92-08-006, dated 26 September 2008 may not have been appropriate and that it had not been approved. The European Aviation Safety Agency had already acted to highlight this problem.

Late on 23 March Sikorsky issued a news release indicating that it had furnished replacement studs and tools to all operators and that 50 of 91 aircraft had been reworked already. The FAA later grounded flights until the parts had been replaced, issuing Emergency Airworthiness Directive 2009-07-53 dated 23 March that required the replacement of the studs before further flight.

TSB disclosed at a news conference on 26 March that the flight data record indicated that oil pressure was lost, but that there was no anomaly other than the broken stud to explain that loss. The aircraft descended at 1000 ft/min. The aircraft lost electrical power, interrupting the data record. Damage analysis indicated that it struck the water belly-down and tail first with an acceleration of 20 g
G-force
The g-force associated with an object is its acceleration relative to free-fall. This acceleration experienced by an object is due to the vector sum of non-gravitational forces acting on an object free to move. The accelerations that are not produced by gravity are termed proper accelerations, and...

 (20 times that of the Earth's gravity).

In 2003 the S-92A initially failed a FAR/JAR-29 additional oil system loss of lubrication test (sometimes called the "run dry" test) conducted to determine whether it could sustain 30 minute operation without main gearbox lubrication, failing after 10 minutes. Subsequent design changes implemented an oil cooler bypass valve to eliminate what were seen to be the most likely sources of leakage, the cooler and external lines and fittings. Certification was obtained without meeting the 30 minute test as the chances of oil loss were calculated as being "extremely remote", a statistical chance of failure of approximately one in every 10 million flight hours. This was based on the assumption that all leaks would occur from the oil cooler, and so did not represent the type of leak that occurred to Flight 91.

All offshore helicopter flights from St Johns were suspended following the accident. Regular passenger flights to the platforms resumed on Monday, 18 May 2009; Cougar Helicopters is limiting the maximum altitude for passenger flights to 2134 metres (7,001.3 ft) as an additional safety precaution.

On 16 June 2009, the FAA released an additional Airworthiness Directive, AD 2009-13-01, requiring the Rotorcraft Flight Manual for the S-92A helicopter be modified to clarify emergency procedures in the event of a main gearbox failure due to loss of oil pressure, and in particular to identify the urgency of an immediate landing in the event of an oil pressure loss.

The TSB issued an update on the investigation on 18 June 2009, indicating that the pilot may have been trying to perform a controlled landing at the time of the accident. The main blades were apparently rotating at the time of impact; however, the tail rotor drive gears were severely damaged, which would result in a loss of thrust. An engine shutdown was initiated at an altitude of 500 feet (152.4 m), consistent with a tail rotor drive failure. The TSB was continuing to investigate the failure of the flotation system, which reportedly had been activated but did not operate correctly.

The Inquiry Commissioner took some interim measures to secure improved emergency response times in the North West Atlantic pending completion of the Commission's Report.

On October 23, 2009 the European Aviation Safety Agency
European Aviation Safety Agency
The European Aviation Safety Agency is an agency of the European Union with offices in Cologne, Germany, which has been given regulatory and executive tasks in the field of civilian aviation safety. It was created on 15 July 2002, and it reached full functionality in 2008, taking over functions...

 issued an airworthiness directive in response to the discovery of cracks in the mounting bolts of the main gearbox of S-92 helicopters operating in the North Sea.

On February 9, 2011 the Transportation Safety Board released its final report on the accident. It identified 16 separate factors that lead to the fatal crash but no single one was to blame.

Inquiry and Lawsuit

On 17 June 2009, the sole survivor and the families of the 15 passengers who died in the accident filed a U.S lawsuit against Sikorsky and its subsidiary Keystone Helicopter Corporation. On 14 July, the complainants announced that they had "voluntarily discontinued" legal action "to engage in alternative dispute resolution before further litigation". On 5 January 2010, lawyers for Sikorsky announced that an out-of-court settlement had been reached with the survivor and the families of the victims of the crash. The details of the settlement were not disclosed due to confidentiality agreements.

A public Commission of Inquiry into the accident (the Offshore Helicopter Safety Inquiry), headed by retired Newfoundland and Labrador Supreme Court judge Robert Wells, began hearings in Newfoundland on 19 October 2009. Robert Decker, the survivor of the accident, gave testimony at the inquiry in early November. The families of the victims of the accident, as well as lawyers representing the estates of the pilots, were allowed to ask questions at the inquiry. The Inquiry delivered its Phase I report to the Canada-Newfoundland and Labrador Offshore Petroleum Board on 17 November 2010. Phase II of the report was delivered to the C-NLOPB on 15 August 2011.

On 24 June 2010, Cougar Helicopters and its insurer filed a lawsuit against the aircraft manufacturer (Sikorsky), requesting more than $25 million in damages. The lawsuit alleged that Sikorsky "fradulently misrepresented" the ability of the S-92 helicopter to run for 30 minutes after losing oil pressure, and further failed to notify operators of the severity of a similar incident in Australia in 2008. Sikorsky had argued to move the legal proceedings to Connecticut, but this move was denied by the Newfoundland and Labrador Court of Appeal on 4 July 2010, and the case will proceed in court in St. John's.

Casualties

Pilot
Pilot in command
The pilot in command of an aircraft is the person aboard the aircraft who is ultimately responsible for its operation and safety during flight. This would be the "captain" in a typical two- or three-pilot flight crew, or "pilot" if there is only one certified and qualified pilot at the controls of...

 Matthew William Thomas Davis, 34, of St. John's, Newfoundland and Labrador
St. John's, Newfoundland and Labrador
St. John's is the capital and largest city in Newfoundland and Labrador, and is the oldest English-founded city in North America. It is located on the eastern tip of the Avalon Peninsula on the island of Newfoundland. With a population of 192,326 as of July 1, 2010, the St...

 and First Officer Tim Lanouette, 48, of Comox, British Columbia
Comox, British Columbia
Comox is a town of 12,000 people located on a small peninsula in the Georgia Strait on the eastern coast of Vancouver Island, British Columbia. The warm dry summers, mild winters, fertile soil and abundant sea life attracted First Nations thousands of years ago, who called the area kw’umuxws...

 both died in the accident. Of the fifteen passengers killed in the accident, thirteen were from Newfoundland and Labrador
Newfoundland and Labrador
Newfoundland and Labrador is the easternmost province of Canada. Situated in the country's Atlantic region, it incorporates the island of Newfoundland and mainland Labrador with a combined area of . As of April 2011, the province's estimated population is 508,400...

 while one each was from Nova Scotia
Nova Scotia
Nova Scotia is one of Canada's three Maritime provinces and is the most populous province in Atlantic Canada. The name of the province is Latin for "New Scotland," but "Nova Scotia" is the recognized, English-language name of the province. The provincial capital is Halifax. Nova Scotia is the...

 and British Columbia
British Columbia
British Columbia is the westernmost of Canada's provinces and is known for its natural beauty, as reflected in its Latin motto, Splendor sine occasu . Its name was chosen by Queen Victoria in 1858...

. The sole surviving passenger, Robert Decker, sustained serious injuries in the crash and following his escape.

External links

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