The final report into a fatal military helicopter crash off Canso, N.S., nearly two years ago found that the skills of the flying crew weren't up to standard, and the pilot should not have overridden the autopilot before attempting to hover over a fishing boat in Chedabucto Bay.
The 69-page Flight Safety Investigation Report released Tuesday at 14 Wing Greenwood found that search and rescue pilots aboard the Cormorant did not have enough training hours under their belts, and their skills weren't as sharp as they should have been.
The Cormorant, flown by Maj. Gordon Ireland, smashed into the ocean on the night of July 13, 2006, with a crew of seven on board.
Sgt. Duane Brazil, 39, of Gander, N.L., Master Cpl. Kirk Noel, 33, of St. Anthony, N.L., and Cpl. Trevor McDavid, 31, of Sudbury, Ont., were killed in the crash when they were unable to escape the submerged chopper.
They were practising nighttime search and rescue manoeuvres at the time.
The report found that although the crew's skills had declined as a result of flying hour restrictions and low Cormorant availability, that alone could not explain the crash.
"The fact that the Cormorant aircrew reported losing confidence in their proficiency, that did not of itself make this accident inevitable," the report said.
Despite that lowered confidence, it said, the pilots chose to manually override the automatic flight control system.
"The automated safety features of the Cormorant helicopter were a significant defence against this type of mishap, even in a scenario of generalized diminishing crew proficiency … Yet the actions of the pilots essentially negated the safety features of the aircraft," the report states.
"The inappropriate manipulation of the controls by the flying pilot made it impossible for the automation to maintain the helicopter within safe flight parameters.
The report said the air force needs to address the "cultural issue" of pilots who choose to ignore the sophisticated equipment.
"The concepts related to the use of automation did not become embedded in air force culture … As a result, pilots retained too much discretion as to how and when to use automation when manoeuvring the aircraft."
The report also found that the crew's monitoring of flight instruments was inadequate as a result of "misprioritization of cockpit duties" and nobody noticed they were on the verge of crashing.
Another factor cited in the report is the restrictions on the amount of training flights that were imposed as the result of persistent cracks in the Cormorant's tail rotor hubs.
It recommends that until flight restrictions are lifted, the simulator training frequency should be optimized to maintain a high level of proficiency.
Emergency exits blocked
The report concludes that the three men who died were unable to escape the submerged chopper because of blocked emergency exits, inaccessible emergency breathing equipment and harnesses that were difficult to release.
"A number of secondary escape exits were obstructed or partially obstructed by the equipment in the cabin. Some equipment, such as the ladder and the SAR basket had become dislodged and/or shifted at impact," the report found.
"The ladder, which normally blocks access to the lower pull tab of the right rear exit, had shifted towards the ceiling when the helicopter became inverted, and was blocking approximately 50 per cent of the exit. The rescue basket had also shifted and was partially blocking the route to the exit."
The report found that the crash was so sudden and unexpected that none of the crew members had a chance to prepare themselves, or even take a breath before "being completely and instantaneously submerged in cold sea water.
"The force of the helicopter's impact with the water and the crash dynamics were such that none of the crewmembers was fatally injured on impact," it said.
"The crash presented the worst-case egress situation given the total lack of warning and the massive destruction of the front end of the aircraft."