Official report on 2006 Cormorant crash

Pilot error, largely a result of insufficient flying time:

14 WING GREENWOOD — The Canadian air force knew its Cormorant helicopter pilots weren’t getting enough flight time in 2006 but did little to solve the problem, according to a report that links a deadly crash off Nova Scotia to training deficiencies.

The report into the crash, released Tuesday, says the flying pilot was improperly overriding the autopilot system and the flight crew was misreading its flight path as the CH-149 Cormorant prepared for a nighttime training exercise near Canso on July 13, 2006.

As a result, the search and rescue chopper with a crew of seven suddenly nose-dived into the Atlantic at 120 kilometres per hour, ripping the aircraft in two.

» Click here for the full report [Congratulations to the Chronicle Herald for the link, most unusual for a Canadian paper - MC.]

"None of the three pilots was effectively monitoring the helicopter’s final flight path as it descended toward the water," the 69-page report says, noting that the flying pilot had unknowingly allowed his credentials to lapse.

But behind the technical reasons for the crash is a key finding that the Cormorant fleet was so hampered by technical problems and a lack of training that crews weren’t able to maintain their skills.

Col. Christopher Shelley of the Directorate of Flight Safety, which conducted the investigation, confirmed that although staff at 1 Canadian Air Division headquarters were made aware of the problem, they did nothing to boost crews’ proficiency.

"The resultant risk to safety of flight that accumulated over time was underestimated and not mitigated effectively," he said at a news conference in a hangar at 14 Wing Greenwood, where the crew of the ill-fated chopper was based.

Brig.-Gen Yvan Blondin, a senior commander at 1 Canadian Air Division headquarters in Winnipeg, conceded that staff were well aware of the faltering proficiency.

But he said they were trying to strike a balance between maintaining training while dealing with a tail rotor that needed regular monitoring to check for flight risks because of cracking.

"It was certainly known at headquarters," he said in the sprawling hangar with a Cormorant behind him.

"But at the time you’ve got a technical problem, a technical risk . . . and the less you fly, proficiency is a problem and you’ve got to balance all this."

Blondin said flight restrictions have since been increased from three to five hours and that proficiency levels are at "satisfactory levels."

A relative of one of the crewmen who died in the crash said he was angered by the report and what he felt was the military’s attempt to spread responsibility for the accident too thinly among all of the crew.

"They’re not assigning the blame to any one person, they’re trying to say everybody was at fault and I don’t agree with that," Robert McDavid, whose son Cpl. Trevor McDavid was one of the flight engineers who perished in the rear of the helicopter, said from his home near Sudbury, Ont.

The report says all seven men aboard the helicopter survived the initial impact.

But the three who died — McDavid, 31, Sgt. Duane Brazil, 39, and Cpl. Kirk Noel, 31 — were unable to escape the submerged chopper because of blocked emergency exits, inaccessible emergency breathing equipment and harnesses that were difficult to release.

The report says the military has taken steps to fix these problems.

An air force official said the surviving crew would not comment on the report.

The initial restrictions on training flights, which were limited to just two hours, related to persistent cracks in the Cormorant’s tail rotor hubs that surfaced six years ago.

Blondin said the manufacturer has yet to produce a rotor replacement.

Training flights were extended to three hours two weeks before the crash, leaving the crew little chance to improve their skills, the report states.

"The crews could maintain currency by achieving the minimum requirements, but as time progressed, repeatedly meeting just these minimum requirements was not enough to keep their skills at a level where the . . . crews felt safe," the report says.

Despite repeated surveys registering the crews’ concerns with their deteriorating skills in the 18 months before the crash, it appears air force headquarters failed to address the worsening problem.

In 2005, the military’s Air Division headquarters in Winnipeg started a new process to identify "stress points" that could lead to flight safety issues. But the report says there "was no formalized process" at headquarters to respond.

The report revealed 14 Wing Greenwood in Nova Scotia had started reporting "red" stress points in June of 2005, warning that skills had "deteriorated to an unacceptable level" because of the training restrictions.

Instructors in England — the only place where Cormorant pilots train on a simulator — also reported that flight crews from Canada demonstrated a lower than expected level of proficiency.

A survey of Cormorant crews in 2006, for example, revealed they also felt their skills had declined to the point that their safety was at risk.

Still, no formal risk assessment was initiated to address these concerns, the report says.

The military has initiated 60 measures as a result of the crash, which is also being examined through a Board of Inquiry. The report concludes weather was not a factor in the crash — the sky was clear and the water was calm — and investigators found the aircraft was in good working order.

Earlier posts here and here.