Release of the Final Report into the Canadian Coast Guard Helicopter Accident in Marystown, Newfoundland and Labrador, in 2005
On December 7, 2005, the Messershmitt-Bolkow-Blohm (MBB) BO 105 helicopter was being used for various tasks associated with the upkeep and operation of lighthouse and coastal navigation facilities in the Burin Peninsula area of Newfoundland and Labrador. While returning to Marystown in the late afternoon, with one pilot and one passenger on board, the helicopter encountered heavy snow showers and, at about 1628 Newfoundland standard time, the helicopter crashed into the water of Mortier Bay, east of Marystown. Both the pilot and the passenger survived the water impact, and escaped from the helicopter. However, the pilot perished from hypothermia, and the passenger succumbed to drowning.
During the course of its investigation, the Board advised Transport Canada of safety concerns through an Aviation Safety Information (ASI) letter and five Aviation Safety Advisory (ASA) letters. Safety information letters are generally concerned with safety deficiencies posing relatively low risks, and are used to inform regulatory or industry stakeholders of unsafe conditions that do not require immediate remedial action. Safety information letters are used to pass information for the purposes of safety promotion or to support or clarify issues that are being examined by a stakeholder. Safety advisory letters are concerned with safety deficiencies that pose low to medium risks, and used to inform regulatory or industry stakeholders of unsafe conditions. A safety advisory letter suggests remedial action to reduce risks to safety. The letters related to the following safety concerns:
- Dukane Underwater Locator Beacon Signal Failure in Cold Water (ASI A060016-1)
- Requirements for Immersion Suit Use in CCG Helicopter Operations (ASA A060012-1)
- Survival Equipment Installations - Coast Guard Helicopter Operations (ASA A060020-1)
- Post-Accident Survivability - Direct-to-Airframe Helmet Cord Connections (ASA A060019-1)
- Liferaft Mounting Bracket Failure (ASA A060021-1)
- Safety Management - Transport Canada Aircraft Services Directorate (ASA A060023-1)
Transport Canada's Aircraft Services Directorate (TC ASD) and the Canadian Coast Guard (CCG) have established a Helicopter Operations Safety Working Group to review safety equipment, training and procedures and to make recommendations for improvements. This group has taken action on passenger helmets and survival equipment and is reviewing the policy with respect to wearing immersion suits as well as helicopter egress training. As a result of the efforts of the joint working group, the following actions have occurred:
- Lifejackets have been standardized for passengers and crews, and reflective tape is to be added to the edging of the cover of the jackets and a large orange patch added to the back.
- Laser flares have been purchased and sent out to the CCG bases to be attached via a cord and rings to each of the standardized high-visibility Switlik lifejacket model HV 35C also identified as S7200-2 and inserted in the customized pouch.
- Helmets have been purchased and issued for front seat passengers in all helicopters and their use is mandatory in CCG helicopters.
- The installation of a fixed intermediate helmet cord for both front seat positions in all BO 105 helicopters is nearing completion.
TC ASD is in the process of implementing a Safety Management System, adding the positions of assistant chief pilot helicopter and flight operation quality assurance intended to improve, where necessary, existing communication, documentation and risk assessment practices. Also, proposals were generated for the modification of the liferaft rack to prevent head injuries. All of the TC ASD defective underwater locator beacons have been replaced. The manufacturer is attempting to determine the cause of the metal delamination, and the potential scope of the failure. Once this has been accomplished, the manufacturer will consider a further course of action.
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