Pilot error led to a fatal helicopter crash off Shetland that killed four people, the Air Accidents Investigation Branch said today.
In its final report, the body concluded the Super Puma’s flight instruments were not monitored effectively during the latter stages of its approach into Sumburgh Airport on August 23, 2013.
The report also explains how the four passengers died – one in the liferaft from a chronic heart condition, likely to have been exacerbated by the stress of the evacuation.
A second managed to escape from the cabin, but drowned, while a third suffered a head injury during impact.
The fourth passenger died as a result of being unable to escape from inside the helicopter. They had tried to use the emergency breathing system.
In its conclusions, the AAIB stated the emergency breathing systems worked correctly, but were not used by the majority of passengers – either because they were unaware an air supply was available or because they were unable to locate the mouthpiece.
Those who escaped from the cabin used the windows as exits and a number of window panes were displaced during the initial impact, with others removed by passengers.
They described this as being harder than they had experienced during training.
Both liferafts were successfully deployed by the co-pilot using deployment handles fitted to the underside of the helicopter fuselage.
But the report concluded he was only aware of the additional handles as a result of an informal conversation with a pilot who had instructed in the Norwegian sector.
Those used were not standard for UK helicopters and had been fitted when the helicopter was operated on the Norwegian register.
The report said the flight manual describing the additional liferaft deployment handles had not been updated to reflect the helicopter’s change of registration.
It also found the co-pilot was unable to manoeuvre the second liferaft to recover passengers from the water due to the sea current.
The introduction of a minimum size for all removable exits has also been recommended as has a common standard for emergency exit opening mechanisms so it can be removed using one hand and in a continuous movement.
Additionally, the AAIB said EASA should require existing helicopters used in offshore operations to have a means of deploying each liferaft above the waterline, whether the helicopter is floating upright or inverted.
It also concluded operators should be required to demonstrate all passengers and crew travelling offshore on their helicopters have undertaken underwater escape training at an approved training facility, to a minimum standard defined by the EASA.
Four people were killed when the Super Puma helicopter they were travelling in ditched in the sea around two miles south of Fitful Head, Shetland, on August 23 2013.
Duncan Munro, 46, from Bishop Auckland, Sarah Darnley, 45, from Elgin, Gary McCrossan, 59, from Inverness, and George Allison, 57, from Winchester, all lost their lives in the accident.
A “check height” audio alert was sounded in the cockpit once the helicopter had fallen to 300 feet, the report noted.
The commander attempted to resolve the issue but “the situation was unrecoverable in the remaining height available”, according to the inquiry.
The AAIB stated: “The evidence suggests that the appropriate flight instrument displays were not being monitored adequately in the latter stages of the approach.”
One possible explanation given is that the 51-year-old commander – who “had a good training and operational record” – became focused on looking for visual references to aid landing.
A transcript of the final seconds before the crash reveals that the commander said: “Wow, what’s going on here? Wow, wow, wow. Oh no, oh no. No, no, no.”
He then let out an expletive before the impact occurred.
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