Transport Canada's response to the Aviation Safety Recommendations A11-01, A11-02, A11-03 and A11-04 issued by the Transportation Safety Board of Canada (TSB)

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A09A0016 - Main Gearbox Malfunction/Collision with Water Cougar Helicopters Inc. Sikorsky S-92A, C-GZCH
St. John's, Newfoundland and Labrador, 35 nm E
12 March 2009

Link to TSB Report A09A0016
(http://www.tsb.gc.ca/eng/rapports-reports/aviation/2009/A09A0016/A09A0016.asp)

Synopsis

On 12 March 2009, at 0917 Newfoundland and Labrador daylight time, a Cougar Helicopters' Sikorsky S-92A (registration C-GZCH, serial number 920048), operated as Cougar 91 (CHI91), departed St. John's International Airport, Newfoundland and Labrador, with 16 passengers and 2 flight crew, to the Hibernia oil production platform. At approximately 0945, 13 minutes after levelling off at a flight-planned altitude of 9000 feet above sea level (asl), a main gearbox oil pressure warning light illuminated. The helicopter was about 54 nautical miles from the St. John's International Airport. The flight crew declared an emergency, began a descent, and diverted back towards St. John's. The crew descended to, and levelled off at, 800 feet asl on a heading of 293 ° Magnetic with an airspeed of 133 knots. At 0955, approximately 35 nautical miles from St. John's, the crew reported that they were ditching. Less than 1 minute later, the helicopter struck the water in a slight right-bank, nose-high attitude, with low speed and a high rate of descent. The fuselage was severely compromised and sank quickly in 169 metres of water. One passenger survived with serious injuries and was rescued approximately 1 hour and 20 minutes after the accident. The other 17 occupants of the helicopter died of drowning. There were no signals detected from either the emergency locator transmitter or the personal locator beacons worn by the occupants of the helicopter.

Recommendations

Transport Canada Response to the Aviation Safety Recommendations A11-01, A11-02, A11-03 and A11-04 issued by the Transportation Safety Board of Canada

Transportation Safety Board of Canada Recommendation A11-01

“The Federal Aviation Administration, Transport Canada and the European Aviation Safety Agency remove the “extremely remote” provision from the rule requiring 30 minutes of safe operation following the loss of main gearbox lubricant for all newly constructed Category A transport helicopters and, after a phase-in period, for all existing ones.”

Transportation Safety Board of Canada Recommendation A11-02

“The Federal Aviation Administration assess the adequacy of the 30 minute main gearbox run dry requirement for Category A transport helicopters.”

Transportation Safety Board of Canada Recommendation A11-03

“Transport Canada prohibit commercial operation of Category A transport helicopters over water when the sea state will not permit safe ditching and successful evacuation.”

Transportation Safety Board of Canada Recommendation A11-04

“Transport Canada require that supplemental underwater breathing apparatus be mandatory for all occupants of helicopters involved in overwater flights who are required to wear a PTSS.”

Transport Canada Response to Recommendations A11-01 and A11-02

Transport Canada (TC) has initiated, through a meeting in June, a coordinated formal review with the Federal Aviation Administration (FAA) and the European Aviation Safety Agency (EASA) of the rules related to the extremely remote provision and the 30 minute requirements. The objective of the review is to reach an international agreement on what changes may be required to the rules.

While the recommendation to assess the complete loss of lubricant in Category A helicopters is not directed to TC, it deals with the same part of the rules and will form part of the review. Any amendments to the airworthiness rules would follow the regulatory process in each jurisdiction.

TC is accelerating a review of the guidance material relating to the application of standards referred to in these recommendations to identify, by early fall of 2011, additional direction or clarification for the Canadian certification of Category A helicopters.

Transport Canada Response to Recommendations A11-03 and A11-04

Transport Canada is initiating a focus group during the summer of 2011 with industry stakeholders to review the recommendations related to when the sea state will not permit safe ditching, and successful evacuation as well as mandatory supplemental breathing apparatus be made mandatory for all occupants of helicopters involved in overwater flights who are required to wear a Passenger Transportation Suit System (PTSS).

On the basis of these discussions, Transport Canada will develop an advisory bulletin for publication in the fall of 2011. Transport Canada will also present the results from the focus group to the Canadian Aviation Regulation Advisory Council (CARAC) at the next meeting in fall 2011 as the basis for amendments to the rules that would be consulted using the accelerated process.

Transport Canada has further initiated a comprehensive review of other offshore helicopter operations (such as North Sea operations) and the existing Canadian regulatory framework to determine if other specific regulations are required.

Transport Canada will also continue to work with the Canada Newfoundland and Labrador Offshore Petroleum Board (CNLOPB) enquiry and the resulting recommendations, expected by the fall of 2011 that may need to be taken account of in changes to the rules.