The pilot of a Eurocopter AS350 BA probably felt pressured by his employer, his client and his passengers when he flew an overweight helicopter into an area of deteriorating visibility in eastern Quebec, Canada, in August 2010, the Transportation Safety Board of Canada (TSB) said.
The 235-hour pilot of the charter flight lost visual contact with the ground and then lost control of the helicopter, which crashed 22 nm (41 km) north of Sept-Îles. The pilot and his three passengers were killed in the crash, and the helicopter was destroyed.
“When inexperienced pilots face operational pressures alone, without support from the company, they can be influenced to make decisions that place them and their passengers at risk,” the TSB said in its final report on the accident.
On Aug. 13, 2010 — four days before the flight — Hydro-Québec, a generator and distributor of electricity, contacted Héli-Excel to arrange for an AS350 B2 for the Aug. 17 charter flight from Sept-Îles to Poste Montagnais, 100 nm (185 km) north. Plans called for the helicopter to remain in the Poste Montagnais area for three days for inspections and maintenance of Hydro-Québec installations and to be flown back to Sept-Îles on Aug. 20.
Héli-Excel agreed to the charter request, although the specified load would have resulted in an overweight takeoff and the pilot had less experience than required by Hydro-Québec’s criteria.
Because an AS350 B2 was not available, an AS350 BA — with a maximum takeoff weight 330 lb (150 kg) less than the AS350 B2 — was selected instead, and plans were made to transport some of the anticipated 300 lb (136 kg) of baggage by airplane.
Nevertheless, the morning of the flight, the passengers, who presumably were unaware of the weight limit or the agreement to divert some of the baggage to the airplane, presented more than twice the expected amount of baggage — 761 lb (345 kg) — mostly consisting of work tools.
The flight was delayed more than 90 minutes because of instrument meteorological conditions (IMC), and departed from Sept-Îles at 1111 local time Aug. 17, 2010, carrying three Hydro-Québec employees, 561 lb (254 kg) of baggage and 600 lb (272 kg) of fuel — enough for two hours of flying, including the required 20-minute reserve.
The pilot had reduced the fuel load because of his concern about the weight the helicopter was carrying, the report said, adding that it was “reasonable to conclude that the pilot was facing pressure from the passengers, who wanted to keep their tools.”
At 1115, the pilot told Hydro-Québec that he might return to Sept-Îles because of the weather, but at 1121, as he flew north over the Moisie River at 150 ft above ground level (AGL), he said he expected to arrive at Poste Montagnais at 1215.
Although he had planned to follow the train tracks north to Poste Montagnais, he instead continued to follow the river at about 200 ft AGL, then changed directions several times — presumably because of poor visibility, the report said — before striking the ground on a plateau in a mountainous area.
A Hydro-Québec flight follower noticed at 1205 that the helicopter’s location on the satellite flight-following system had been unchanged for six minutes. Air traffic controllers had received no distress signal from the helicopter’s electronic locator transmitter, but the operations manager took off from the Sept-Îles base at 1328 and located the wreckage 14 minutes later.
The accident pilot had obtained his commercial pilot license in November 2007 and was hired by Héli-Excel in March 2008 as a “gopher” — who ran errands and sometimes flew helicopters on non-revenue flights. He began his first season as a commercial pilot in early 2010, receiving the required ground and flight training. He completed a pilot proficiency check and aircraft type rating in June 2010.
He lacked the minimum experience required under Canadian Aviation Regulations (CARs) for flight in reduced visibility and therefore was permitted to fly only if visibility was at least 1.0 mi (1.6 km).
The TSB report noted that he had not been provided with training in several areas — including “the dangers of VFR [visual flight rules] flight in … IMC, flying in reduced visibility, the dangers of loss of visual references, controlled flight into terrain, instrument training and recovery from an unusual attitude without visual references” — and that such training was not required under the CARs.
The pilot had flown to Poste Montagnais several times, and the route was not considered difficult.
The accident report said investigators found no indication that the pilot was tired the day of the accident flight.
There also were no indications of problems with the helicopter’s engine or flight controls that would have prevented normal operations.
Weather conditions at Sept-Îles on the morning of the accident flight included low clouds at 300 ft and visibility of 1.0 mi, with improvement forecast after 1000. The forecast for the area to the north, along the planned route of flight, included broken clouds at 3,000 ft AGL and visibility of 6.0 mi (9.7 km), with a slight chance of reduced visibility of 5.0 mi (8.0 km) and ceilings of 800 ft AGL. At the Sept-Îles Airport, 7 nm (13 km) southeast of the Héli-Excel base, the ceiling at 1100 was 300 ft and visibility was 8 mi (13 km).
Although the forecast for Poste Montagnais had called for a 900 ft AGL ceiling and visibility of 20 mi (32 km), helicopter pilots reported that ceilings in the Moisie and Nipissis river valleys were below the mountain peaks, with “adequate” VFR visibility.
The accident flight was conducted in uncontrolled airspace below 1,000 ft AGL and therefore subject to CARs requirements calling for visibility of at least 1 mi and for the aircraft to remain clear of clouds.
Fleet of 20
When the accident occurred, Héli-Excel had a fleet of 20 helicopters, including Bell 206s, 206Ls and 214B-1s, in addition to AS350s and AS355s.
The company is authorized under the CARs for day VFR flight in uncontrolled airspace with visibility of less than 1 mi, provided its flights meet several conditions, including that the pilot must have at least 500 flight hours as a helicopter pilot-in-command.
Transport Canada (TC) found “no non-compliance with any operational control aspect” during its February 2010 program validation inspection of Héli-Excel, the report said, noting that the inspections have become one of TC’s “primary surveillance tools” for operators.1
Héli-Excel has implemented a safety management system (SMS), but because smaller operators are not yet required to have the systems, TC has not evaluated its effectiveness. The TSB said it has urged all air carriers to implement SMS and added in the report that it is “calling for TC to effectively monitor the integration of SMS practices into day-to-day operations.”
Hydro-Québec’s Air Transport Unit is the helicopter services industry’s biggest customer in Quebec, averaging 15,000 hours of flight time a year. In 1992, in the aftermath of several accidents, the company established a qualification and technical audit program to evaluate the operators it uses and the way their aircraft are maintained. In 2005, the company developed a technical assessment program, which calls for an audit about every 18 months, followed by an assessment of the operator’s performance and its compliance with contract requirements. Héli-Excel was audited under the program in February 2010 and received an R2 rating, placing it at the second-highest level.
Hydro-Québec requires pilots to have at least 800 flight hours, including 100 hours on type; 250 hours total time is acceptable, however, “if the pilot has completed the training program offered by the Association Québécoise du Transport Aérien,” the report said, noting that the accident pilot had not completed the training.
VFR Flight in IMC
The report cited several earlier safety studies that found that about 80 percent of accidents associated with VFR flight into IMC involved fatalities. In Canada, those VFR-into-IMC accidents account for 15 percent of total accidents.2,3
An earlier TSB safety recommendation called for requiring commercial helicopter pilots to demonstrate their proficiency in basic instrument flying skills during annual check flights — a recommendation that would require helicopters to be equipped with an attitude indicator and a directional gyro. The accident helicopter lacked those instruments, and the CARs do not require them.
“The risks associated with VFR flights in adverse weather conditions are still significant, and TC has not indicated that it plans to take steps to ensure commercial helicopter pilots who are not qualified in instrument flying … maintain their proficiency in this regard,” the report said.
At one point in the flight, 43 minutes after takeoff, as the helicopter flew south over the Moisie River and then veered east, the helicopter had 77 minutes of fuel remaining (Figure 1). If the pilot had continued toward the junction of the Nipissis River and then on to Poste Montagnais, the helicopter’s low-fuel light would have illuminated at least seven minutes before arrival. Company policy is to land immediately if the light illuminates, and await a delivery of fuel by another helicopter.
“Because the aircraft was approximately 24 nm [44 km] from the departure point, it was still possible to return to the Sept-Îles base to refuel and depart again,” the report said. “However, the weather conditions had been marginal at takeoff, and the pilot had been unsure that he would make it to Poste Montagnais. …
“A helicopter pilot always has another option — namely, to set down in a safe place and wait for the weather to improve. However, none of these three options would sit well with passengers, and the pilot would have had to admit to the passengers, his employer and Hydro-Québec that he was unable to complete the flight assigned to him. As the flight was also monitored by Hydro-Québec, a delay would have raised questions about the history of the flight, increasing the likelihood that Hydro-Québec would realize that the pilot did not have the experience for the flight required under the contract. Consequently, the pilot probably chose to take a shortcut to the east in the hopes of reaching the Nipissis River valley and reducing the flight time to Poste Montagnais.”
Minutes later, he probably continued the VFR flight into IMC because he considered it “the best option,” the report said, adding that according to the theory of cognitive dissonance, “his subsequent decision to continue on in marginal conditions may have distorted how he weighed the choice between continuing the flight and initiating a diversion. The more consideration a pilot gives to his decision to continue flying, the more likely it is to reinforce his choice, further distorting the situation he is in and increasing the odds that he will make risky decisions.”
Immediately before the crash, the pilot lost visual reference and, because he was not qualified for instrument flight and the helicopter did not have the required instruments, he was unable to maintain aircraft control, the report said.
The circumstances of the accident indicate that the pilot “experienced operational pressures that caused him to make compromises that left him with less leeway than he had planned,” the report added.
“Resources exist to reduce these operational pressures in the form of direct supervision with the use of risk assessment and decision-making tools before takeoff. … With little support from the company, it seems that the safety of the flight rested on the pilot’s own ability to resist the operational pressures with which he was confronted. …
“From an organizational perspective, it does not make sense to expend so much effort to satisfy the CARs’ numerous operational requirements, Hydro-Québec’s audits and contractual stipulations, and then rely on a young, inexperienced pilot to ensure flight safety.”
In the aftermath of the accident, Héli-Excel has taken a number of steps toward remedial action, the report said, including installing more reliable digital flight instruments, adding managers to increase pilot supervision, creating a safety system manager’s position and upgrading pilot training.
In addition, Hydro-Québec introduced an air safety awareness program for its employees, increased surveillance of operators that provide its helicopter services and strengthened requirements for completion of weight and balance forms.
This article is based on TSB Aviation Investigation Report A10Q0132, “Loss of Visual Reference With the Ground, Loss of Control, Collision With Terrain; Héli-Excel Inc., Eurocopter AS350-BA (Helicopter) C-GIYR; Sept-Îles, Quebec, 22 nm N; 17 August 2010.
- A program validation inspection is defined in the report as “a process comprised of a documentation review and an on-site review of one or more components of an SMS or other regulated areas of a certificate holder.”
- ATSB. Aviation Research and Analysis Report B2007/0063, An Overview of Spatial Disorientation as a Factor in Aviation Accidents and Incidents. 2007.
- TSB. Aviation Investigation Reports. A08P0383, A09Q0111. A10A0056.