FLIGHT INTO TERRAIN WESTLAND HELICOPTERS INC. BELL 206 BIII JETRANGER C-GRAH HOUSTON, BRITISH COLUMBIA 2.5 mi N 29 JANUARY 1994

Safety Action Taken

Hydraulic Servo Contamination

On 15 December 1994, Transport Canada (TC) advised the Federal Aviation Administration (FAA) of the metallic contamination found in the helicopter's collective servo actuator. In their correspondence, TC suggested that the FAA ensure that the servo manufacturer takes appropriate quality control/assurance actions.

Interim TSB Aviation Safety Recommendations

Based on information compiled during this investigation, and frequent evidence of a lack of appreciation on the part of helicopter operators/pilots of the risks involved in conducting VFR flights into adverse weather, especially in mountainous terrain, the Board notified the Minister of Transport in August 1994 of three interim Safety Recommendations.

Flight Into Adverse Weather - Risk Awareness

A TSB safety study on VFR into adverse weather found that VFR-into-instrument-meteorological-conditions (IMC) accidents accounted for only 6% of the total number of aircraft accidents in Canada; yet, they involved 23% of all fatal accidents and took the lives of 418 persons between 1976 and 1985. Half of the VFR-into-IMC accidents had occurred in mountainous or hilly terrain; approximately 10% of VFR-into-IMC accidents involved helicopters, and one third of these were fatal. Since the release of the safety study and its associated recommendations in December 1990, there have been 10 commercial helicopter accidents in Canada involving VFR flight in adverse weather, resulting in six fatalities. The Board believes that some VFR-rated helicopter pilots, especially those operating in mountainous areas, have adopted the practice of intentionally penetrating localized areas of extremely reduced visibility in order to reach areas of better weather.

Commercial helicopter accidents in adverse weather continue, despite frequent emphasis in TC safety newsletters and presentations on the importance of adhering to established VFR limits. The Board believes that proper training and education are important in the prevention of adverse weather accidents; however, the Board was not aware of any substantial measures in this vein being taken by TC or the helicopter industry following the recommendations of its 1990 study. Therefore, the Board recommended that:

The Department of Transport, in consultation with the aviation industry, implement a special safety campaign to inform the helicopter community of the inherent risks involved in the ad hoc practice of penetrating cloud/fog in VFR operations, particularly in mountainous regions. (A94-18, issued August 1994)

Transport Canada Response:

Transport Canada Aviation (TCA) agrees with the concerns of the Transportation Safety Board regarding the inherent risks involved in the ad hoc practice of penetrating cloud/fog in VFR operations, particularly in mountainous regions. In this regard, TCA regularly stresses in its safety newsletters and presentations across the country the importance of adhering to establish VFR limits and the practice of good airmanship while flying in areas of adverse weather.

TCA will promote the Board’s concerns in a feature article in the specialized helicopter safety newsletter, the Aviation Safety Vortex, which is distributed free of charge to all holders of a valid Canadian helicopter pilot license. In addition to the Vortex feature article, and after the release of the Board’s Final Report into the Houston accident, the Regional Aviation Safety Officers (RASOs) across the country will be provided with a special promotional package concerning this accident and the practice of voluntarily penetrating cloud/fog in VFR operations, so that they may distribute it to the helicopter industry during their regional visits. In the meantime, the RASOs have been provided with copies of the Board’s Communiqué and background information on the three recommendations.

Regulatory Compliance & Industry Self-Regulation

ANO V, No. 3, Para 6 does not permit VFR flight in cloud. The Board believes that the extent to which the unsafe practice of cloud penetration is prevalent might suggest a lack of respect for the need for regulatory compliance; operators/pilots may feel that there is only a remote possibility of being found in violation of the ANO. In a 1991 TSB survey of commercial pilots, 38% of respondents stated that TC's inspections of company facilities are not sufficiently frequent to ensure that regulations are respected. It is understood that Transport Canada has not recorded any violations under ANO V, No. 3, Para 6 in the mountainous regions of western Canada in the last ten years.

The Board is well aware that climatic conditions in many locations prevent some VFR-only operators from conducting their business at certain times of the year. However, if these operators ignore the weather limits in the ANO, they negate the safety buffer provided by the regulation, and put themselves and their passengers at risk. Furthermore, the Board believes that within the helicopter industry in general, the practice of "pressing-the-weather" is tacitly accepted and is viewed as a part of doing business. There does not appear to be self-regulation through condemnation by peers in this regard within the industry.

The Board believes that neither the regulator nor the commercial helicopter industry are effectively ensuring compliance with established weather limits. Therefore, the Board recommended that:

The Department of Transport place increased emphasis on achieving compliance with respect to VFR weather limits for commercial helicopter operations; and (A94-19, issued August 1994)

The Department of Transport, in conjunction with industry, explore measures to counter attitudes that "pressing-the-weather" is an acceptable practice in commercial VFR helicopter operations.(A94-20,issued August 1994)

Transport Canada Response - A94-19

Transport Canada Aviation (TCA) agrees with the requirement to achieve compliance with the respect to VFR weather limits for commercial helicopter operations. Compliance is achieved through education, training, inspections and surveillance. Regional air carrier branches will be tasked to place increased emphasis on commercial helicopter operations in adverse weather conditions. As well, an Air Carrier Advisory Circular (ACAC) will be issued to address the risks involved in conducting VFR flight into adverse weather, especially in mountainous terrain. This Circular will emphasize the hazards of the practice adopted by some helicopter pilots, of intentionally penetrating localized areas of reduced visibility to reach areas of better weather.

Transport Canada Response - A94-20

Transport Canada Aviation (TCA) agrees with the intent of this recommendation and will send a letter to the major helicopter associations across Canada which will reflect the Board’s concerns and to ask them to impress upon their members that “pressing-the-weather” is not an acceptable practice in commercial VFR helicopter operations. The letter will stress, among other things, the importance of risk awareness, regulatory compliance, industry self-regulation, various types of pressures and respect for the weather. TCA believes that this letter, in addition to the actions described in response to the Board’s recommendations A94-18 and A94-19, will satisfy the intent of this recommendation.

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