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Probe Faults Pilot Skills in Cormorant Crash

Air Safety Week, March 24, 2008

A pilot's inappropriate flying techniques caused the July 13, 2006 crash of a CH-149 Cormorant during a nighttime training mission, Canadian Forces investigators have found.

The accident killed three of seven crewmembers onboard the search and rescue rotorcraft.

Contributing to the crash into the sea near Canso, Nova Scotia were flight restrictions triggered by tail-rotor cracking on the EH101 derivative.

Investigators found no evidence that any system malfunction on the AgustaWestland aircraft contributed to the fatal accident.

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The accident investigators said "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 accident report continued.

They also found that prolonged training restrictions due to ongoing tail- rotor half-hub cracking "had a serious detrimental effect on overall CH149 aircrew proficiency," whose "resultant risk to operational airworthiness was underestimated and not effectively mitigated."

Although the four cabin area crewmembers survived the water impact, only one was able to successfully exit the aircraft before his air supply was exhausted. Survivability issues noted as part of the probe 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 report said.

The Flight Safety Investigation Report included numerous recommendations to improve CH149 pilot proficiency, training and survivability / life support equipment issues for CH149 aircrew.

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Probe Faults Pilot Skills in Cormorant Crash

Air Safety Week, March 24, 2008

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