A complex series of events involving 16 significant factors contributed to the crash of Cougar Helicopters Flight 491 in early 2009 and the loss of 17 souls according to the Transportation Safety Board released Wednesday after a two year investigation.
The complete report is available here: S-92 investigation report. It is comprehensive and covers all relevant factors from crew backgrounds to key operating systems to passenger injuries and safety equipment.
The TSB investigation made four recommendations:
- 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.
- The Federal Aviation Administration assess the adequacy of the 30 minute main gearbox run dry requirement for Category A transport helicopters.
- Transport Canada prohibit commercial operation of Category A transport helicopters over water when the sea state will not permit safe ditching and successful evacuation.
- 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 Passenger Transportation Suit System.
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