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The Crash of Cougar Flight 491: A Case Study of Offshore Safetyand Corporate Social Responsibility
Susan M. Hart
Received: 22 September 2011 / Accepted: 5 April 2012
Springer Science+Business Media B.V. 2012
Abstract On March 12, 2009, a Sikorsky S-92A heli-
copter travelling to two offshore oil installations crashed
into the sea about 55 km away from the coastal city of St.
Johns in Newfoundland and Labrador (NL), Canada. It
sank quickly with the loss of 17 lives. There was one
survivor. The article examines the circumstances of the
crash to assess the effectiveness of an instrumental, busi-
ness case for safety and, by extension, for corporate social
responsibility (CSR). The article fills a gap in the business
and the management literature by adopting a qualitative,
case study methodology to complement earlier, predomi-
nantly quantitative research. The study analyzes a com-
prehensive set of documentary data available from the
offshore regulators public inquiry website, including many
days of verbatim testimony from the industry, the union,
regulators, investigators, the lone survivor and families of
the deceased, in addition to written submissions and expert
reports. Investigatory reports from the Transportation
Safety Board of Canada and the NL Inquiry were analyzed,
as were regulatory documents and media coverage.
Although offshore safety has improved since the Ocean
Ranger disaster in 1982 (Wells http://www.cnlopb.nl.
ca/ohsi_phase_one.shtml, 2010), the empirical evidence
in this case study adds to our understanding of how reliance
on a voluntary, instrumental business case for CSR in the
absence of a normative concept of CSR is likely to fail,
largely because of the existence of a powerful tension
between oil exploration and production and investment in
safety.
Keywords Business case for safety Corporate socialresponsibility Helicopter safety Offshore oil safety
Abbreviations
AD Airworthiness Directive
AFT Auxiliary fuel tank
ASB Alert Service Bulletin
CAPP Canadian Association of Petroleum Producers
CNLOPB Canadian-Newfoundland and Labrador
Offshore Petroleum Board
CBC Canadian Broadcasting Corporation
CEP Communication, Energy and Paperworkers
Union Local 2121
CSR Corporate Social Responsibility
EBS Emergency Breathing System
EFS Emergency Flotation System
ELT Emergency Location Transmitter
EASA European Aviation Safety Agency
FAA Federal Aviation Administration
HMDC Hibernia Management and Development
Company Ltd
HUMS Health and Usage Monitoring System
HUET Helicopter Underwater Escape Training
JOP Joint Operators Panel
JOSH Joint Occupational Safety and Health Committee
MGB Main gearbox
NL Newfoundland and Labrador
NLFL Newfoundland and Labrador Federation of
Labour
PLB Personal Locator Beacon
SAR Search and rescue
TSB Transportation Safety Board of Canada
S. M. Hart (&)Faculty of Business Administration, Memorial University,
St. Johns, NL A1B 3X5, Canada
e-mail: [email protected]
123
J Bus Ethics
DOI 10.1007/s10551-012-1320-8
http://www.cnlopb.nl.ca/ohsi_phase_one.shtmlhttp://www.cnlopb.nl.ca/ohsi_phase_one.shtml
We keep hearing about the concept of safety culture
but to ensure this idea, safety must come before profit
(widow of offshore worker and spokesperson for the
families of the deceased passengers, 2011)1
On March 12, 2009, a Sikorsky S-92A helicopter trav-
elling to the SeaRose and Hibernia offshore oil installa-
tions, carrying 16 passengers and two pilots, crashed into
the sea about 55 km away from the coastal city of St.
Johns in Newfoundland and Labrador (NL), Canada. It
sank quickly with the loss of 17 lives. There was one
survivor (Wells 2010). The crash brought back disturbing
memories of a previous offshore disaster off the shores of
NL, namely, the capsize and sinking of a large semi-sub-
mersible drilling rig, the Ocean Ranger, on Valentines
Day in 1982, when all on board died (Canada 1984; No
Signals from Locator Beacons in Crashed Helicopter:
Officials 2009; Murphy 2009). Inevitably, questions were
asked as to how far safety offshore had improved since the
Ocean Ranger tragedy and what steps were needed to
improve helicopter transportation safety (Helicopter Crash
Sparks Discussion of Safety Measures 2009; Ocean Ranger
Advice Never Followed, Inquiry Head Says after Heli-
copter Crash 2009).
The Transportation Safety Board of Canada (TSB), an
arms-length body attached to the federal government,
started an immediate investigation. On April 16, 2009, the
offshore safety regulatory body, the Canadian-Newfound-
land and Labrador Offshore Petroleum Board (CNLOPB),
appointed the Honourable Robert Wells., Q.C., as Com-
missioner of a public Inquiry into Matters Respecting
Helicopter Passenger Safety for Workers in the New-
foundland and Labrador Offshore Area (CNLOPB 2009).
The Inquirys general mandate was to inquire into, report
on and make recommendations on matters relating to the
safety of offshore workers in the context of Operators
accountability for escape, evacuation and rescue proce-
dures while travelling by helicopter over water to instal-
lations in the NL area (Wells 2010, p. 10). Specifically,
this was to include examination of the oil operators role in
ensuring that their approved safety plans with regard to
helicopter operators are maintained, the search and the
rescue obligations of the helicopter operators, and the role
of the offshore regulator, the CNLOPB (Wells 2010). The
Commissions mandate excluded considerations of causes
of the crash or airworthiness, which were the jurisdiction of
the TSB (Wells 2010).
Phase I of the NL Inquiry included public hearings from
October 19, 2009 to February 28, 2010 with examination
by legal Counsel representing the Inquiry and other parties
of standing2. Presentations were made by the industry
association, the Canadian Association of Petroleum Pro-
ducers (CAPP); the NL helicopter operator, Cougar Heli-
copters Inc.; the survival suit manufacturer, Helly Hansen
(Canada) Ltd.; three offshore oil companies active in the
offshore at the time, who presented separately and jointly,
Hibernia Management and Development Company
(HMDC), Suncor Energy, and Husky Oil Energy; the
provincial labour organization, the Newfoundland and
Labrador Federation of Labour (NLFL); the union repre-
senting the workers on the Hibernia and Terra Nova off-
shore installations, the Communication, Energy and
Paperworkers Union local 2121 (CEP); the families of the
deceased passengers; the families of the deceased pilots;
the lone survivor of the crash; the offshore survival training
organization, the Marine Institute; the federal regulator for
aviation, Transport Canada; the TSB; and the NL offshore
regulator, the CNLOPB. Any interested parties were asked
to provide written submissions on a set of issues identified
through a collaborative process between the Inquiry par-
ticipants (see Wells 2010, Chap. 7). Experts on safety
culture, comparative regulatory systems, and helicopter
transportation safety also participated (see Wells 2010,
Chap. 6). Finally, the Commissioner and Inquiry Counsel
visited the UK and Norway to consult with oil and gas
stakeholders groups there (Wells 2010). Commissioner
Wells Phase I report with 29 recommendations was
released by the CNLOPB in October 2010. The TSB
report, completed in late 2010, was released to the public in
February 2011. In July 2011, Commissioner Wells released
his Phase II report, his response to the TSB report, with
four additional recommendations,
This paper examines the circumstances of the Cougar
491 crash to explore the effectiveness of the business case
for safety, and, by extension, for corporate social respon-
sibility (CSR). The paper will continue with a short dis-
cussion of the CSR concept before moving on to
contextualize the case study by providing an overview of
the Canadian safety regulatory framework, how the off-
shore safety regime fits into it, and how the business case
for safety is linked with a goal setting approach. Then, a
short methodological section will lead into an analysis and
1 Lori Chynn, widow of John Pelley, at a press conference, Ottawa
(Wells 2011, Appendix I, p. 216). In July 2011, she said during a
media interview I just feel that once again were saying money is
trumping safety. Safety is taking a back seat to the bottom line which
is cost, and thats unfortunate when youre talking about peoples
lives (Tutton 2011, p. 2).
2 Parties of full standing were the three oil operators offshore at the
time of the crash; the NL helicopter operator, Cougar Helicopters; the
Communication, Energy and Paperworkers Union, Local 2121
(CEP); the NL Government; the families of deceased passengers
and of the flight crew; and the survival training organization, the
Marine Institute at Memorial University in St. Johns (Wells 2010,
p 47).
S. M. Hart
123
discussion of the research material and some concluding
comments.
Corporate Social Responsibility (CSR)
The notion that business has societal obligations is not
new; its historical origins belong to the days of the
Industrial Revolution in Britain (Smith 2003). Since then
there have been periods of particular interest in the idea,
such as in the late 1960s and early 1970s, but today the
concept of CSR has never been more prominent on the
corporate agenda (Smith 2003, p. 53). Partly, this renewed
interest is a reflection of a growing pressure on business to
behave in a socially responsible manner in a global econ-
omy, where business itself is more pervasive and more
powerful, combined with heightened media and NGO
activity resulting in far-reaching criticisms of business
(Smith 2003, p. 55).
Definitions of the concept vary but Smith (2003) argued
that the fundamental idea underlying most of them has
clear links to the origins of CSR in that business corpora-
tions are deemed to have an obligation to work for social
betterment (as in Frederick 1994, cited by Smith, p. 53).
Following the logic of this general definition, for the pur-
poses of this paper, companies engage in CSR when they
integrate social and environmental concerns in their busi-
ness operations and thereby improve human well-being
(Laudal 2010, p. 64). Laudal defines human well-being as
consisting of the interrelated components of security,
adequate supply of basic materials, personal freedoms,
good social relations, and physical health, to be being
consistent with the World Health Organization.
Laudal (2010) pointed out that a review of the CSR
literature since the 1950s by Kakabadse et al. (2005)
concluded that most scholars agree that being in compli-
ance with the law does not qualify as CSR, so it follows
logically that, for these researchers, CSR must involve
voluntary corporate action. Interestingly enough, Laudal
(2010) himself proposes a blurring of the lines between
mandatory and voluntary CSR for his purposes of exam-
ining it in the supply chain for the international clothing
business. Indeed, it is proposed here that to pose such a
simple dichotomy is perhaps to ignore some of the com-
plexities of corporate responsibility. A company that does
not comply with established standards or fails to monitor
the appropriateness of existing ones is hardly behaving in a
socially responsible manner, as will be discussed in the
case study below, and will not be meeting its obligations
for human well-being, given the adoption of the above
definition.
Another dichotomy evident in the CSR literature is
important as context for this paper, and that is the
difference between an instrumental motivation underlying
CSR, often seen as underlying the business case (for
example, Vogel 2005), and a normative one, based on
moral philosophy, that it is the right thing to do (Smith
2003, p. 58). As with the general idea that business has
social obligations, the notion that corporate responsibility
benefits business is not new either. Paternalistic capitalism
with its roots in enlightened self interest was known to
exist in nineteenth century Britain (Smith 2003). Put sim-
ply, the rationale for the business case is that CSR will,
either directly or indirectly, result in a corporations
improved financial performance, thus inciting them to
voluntarily behave in a socially responsible manner. Indi-
rect benefits claimed by proponents of the business case
have included an enhanced corporate image and the
reduction of reputational risk in consumer, labour, and
equity markets (Smith 2003, p. 60). The instrumentality of
the business case for CSR is illustrated by Husted and
Salazar (2006), who recommended that firms should find
the optimal point for maximal CSR and minimal cost.
Moreover, Vogel (2005) pointed out that a firm is more
likely to be punished for misdeeds rather than for excellent
CSR performance, so that companies are likely to perform
within a narrow range around a regulatory norm or, in a
few cases, such as child labour, a civil norm.
The Regulatory Framework for Workplace Safety
Canadian health and safety legislation is largely a provin-
cial matter, with the federal jurisdiction amounting to only
about 10 % of the workforce, but, nevertheless, all laws
incorporate the notion of internal responsibility. This
means that employers are required to provide a safe
workplace with the assistance of the work force through,
for example, employeremployee occupational safety and
health committees (Nichols and Tucker 2000). Employers
are assumed to have the resources and power to ensure
safety, and the development of goal setting and perfor-
mance-based regulatory frameworks ushered in a parallel
assumption that less government intervention is needed
than in more traditional, detailed, and prescriptive regula-
tory models. Overall, this regulatory approach has been
aptly named regulating self-regulation by Bluff et al.
(2004, p. 4), and emphasizes collaboration and persuasion,
such as training and education, rather than regulatory
development or enforcement (Nichols and Tucker 2000;
Walters 2005).
The federal and provincial governments have jointly
managed the NL offshore since 1986 through the
CNLOPB, which was established under the Atlantic
Accord (Canada 1986). The regulatory regime is compli-
cated (Cooper 1997; Hart 2005), with a dual responsibility
The Crash of Cougar Flight 491
123
for safety helicopter transportation. In other words, the
CNLOPBs approval of an offshore oil operators safety
plan, including the helicopter operators contract, is a
condition for any oil field development, but Transport
Canada (TC), a federal government agency, oversees avi-
ation matters. The regulatory framework has featured
aspects of both goal setting (a safety plan is required) and
prescription (detailed regulations cover specific activities
such as drilling or diving). However, the authorities
strengthened the goal setting approach in December 2009
with some new safety regulations that granted extensive
powers to the oil operators (Wells 2010, p. 270).
The Business Case for Safety
A goal setting approach, with fewer resources allocated to
inspection and enforcement in favour of more workplace
initiatives, encourages the promotion of a business case
for safety by governments (Tombs 2005; Walters 2005).
The business case argues that a corporation will benefit
economically, in the short- or long-term, from having a
safe workplace (Hart 2010; Tombs 2005). For example,
the NL Workplace Health and Safety Compensation
Commission states in one of its policy documents that
sound business strategies, processes and good health and
safety performance are the foundation of business suc-
cess (2007, p. 1); also the Ontario provincial government
argues that competitiveness and safety excellence are
complementary and mutually reinforcing (Nichols and
Tucker 2000, p. 301).
Employer acceptance of a business case for safety may
well be better than having to rely completely on gov-
ernment inspection and enforcement, but there are some
flaws in its logic. First, it is an instrumental rather than
normative motivation to ensure safety, as argued by Vo-
gel (2005). However, it may be that in some contexts, the
normative case for CSR with respect to safety comple-
ments the business case, where best practices become part
of an employers or industry associations guidelines for
safe operation. As noted by Hopkins (2000), high reli-
ability organizations exist in high risk sectors such as
naval aircraft carriers and air traffic control systems, their
hazard management systems distinguished by high levels
of mindfulness in their safety culture (p. 139). Also,
one of the strengths of the Norwegian offshore oil safety
system has been identified as the industrys early devel-
opment of quality assurance based safety management
systems, in conjunction with the working environment
legislation including a safety delegate system, and an
independent offshore regulator (Ryggvik 2000). That
being said, if the cost of a safety measure is factored into
a cost benefit analysis, it follows that the business case is
more likely to be convincing to a company if the safety
investment costs less. Indeed, worker safety activists have
reported that Joint Occupational Safety and Health
Committee (JOSH) recommendations for safety interven-
tions that required significant expenditures or redesign of
the production process were often resisted (Nichols and
Tucker 2000).
Second, the assumption of a common interest between
employer and employees ignores, at a theoretical level, the
inherent inequality between capital and labour. In practice,
it erroneously assumes that there is no conflict of interests
between production, ultimately profit, and safety (Bohle
and Quinlan 2000; Hart 2010; Walters 2005). One area of
common interest between employers and employees is the
cost to Canadian employers of unsafe workplaces in the
form of increased workers compensation premiums.
However, as noted by Dorman (2000) and Hart (2010),
economic incentives in the area of safety sometimes lead to
undesirable and unintended responses, such as underre-
porting of injuries or inappropriate return to work. Another
cost to employers that could point to the common interests
of employers and employees is the Canadian amendment to
the Criminal Code in 2003 to include a new crime of health
and safety criminal negligence as it works as a deterrent to
poor safety management (Keith 2004). A critique of this
law is beyond the scope of this paper, but, although perhaps
a step in the right direction, it is not aimed exclusively at
employers, boards of directors and their agents, so that any
individual employee, or union, may be found criminally
liable (Hart 2010). This could mean that the cost of flawed
safety management (an employers responsibility) may be
downloaded on to an individual, potentially ignoring
organizational factors such as inadequate training, or per-
formance evaluation including increasing production tar-
gets without recognizing the implications for safety (for the
importance of building in organizational factors, see Frick
and Wren 2000; Nielsen 2000; Nichols and Tucker 2000).
High-production targets and new patterns of work to cut
costs in a global economy, such as mobile maintenance
crews, continuous shift-work, or multi-tasking, can legiti-
mize action that meets the offshore oil and gas production
imperative but can undermine safety (Hart 2002). Some-
times, then, there is no business case. The limitations of a
business case founded upon a conflict between production
and profit is demonstrated by the Canadian legal principle
of requiring employers to spend money only up to the point
of being reasonably practicable (Nichols and Tucker
2000, p. 292). The Ocean Ranger Commissioners of
Inquiry recognized this difference in priorities when dis-
cussing the failure of all evacuation routes after the rig
capsized:
S. M. Hart
123
The offshore petroleum industry has faced and
overcome the problems associated with exploring for
and producing oil and gas under major environmental
constraints because, without these solutions, explo-
ration and production could not take place[they]are deemed essential to the rigs mission and there-
fore worthy of the latest innovations that technology
has to offer. The evacuation system does not meet
that same criterion of being essential nor does it elicit
the same response. (Canada 1985, pp. 104105)
In contrast to strong criticisms of the business case as a
vehicle for safety in the literature (Hart 2010; Tombs 2005;
Vogel 2005), the focus in business and management liter-
ature has largely been on building a quantifiable relation-
ship between CSR and firm performance (for example,
Griffin and Mahon 1997; Husted and Salazar 2006; Or-
litzky et al. 2003; Sen and Bhattacharya 2001; Waddock
and Graves 1997), with inconclusive results (McWilliams
et al. 2006).
Methodology
This paper contributes to the business and the management
literature in a number of ways. The qualitative case study
methodology complements much of the earlier research
into the effectiveness of the business case for CSR, which
has been predominantly quantitative, as noted by Lockett
et al. (2006) and by the author above. The paper focuses on
the validity of the business case as a vehicle for workplace
safety in a CSR literature mainly focused in recent years on
the environment (Lockett et al. 2006). As such, the case
study informs the current debate in the literature about the
effectiveness of the business case for CSR by highlighting
one important aspect of it, namely, the provision of a safe
workplace. Moreover, its focus on safety in the offshore oil
and gas industry in Canada is important for its potential to
inform future corporate and public policy and practice.
A qualitative approach emphasizes an increased under-
standing of complex circumstances and processes through
intensive study rather than breadth and generalization
(Bryman 1988; Glesne 2006). Case studies are useful
research strategies when how and why questions are
asked, when the investigator has little or no control over
events, and the subject of inquiry involves complicated
contemporary phenomena characterized by some real-life
context or a real-life event (Yin 1989), all of which apply
to the case study presented here. In order to tackle the
theoretical issue of the validity of the business case for
corporate social responsibility, a researcher must strive for
a good understanding of how and why the tragedy
occurred; he or she has no control over events in question,
which occurred in the past; and the Cougar crash was
clearly a real life event. Single cases are recognized in the
methodology literature as valid and offering rich learning
opportunities with the ability to inform or, in some cases,
generate theory (Berg 2007; Glesne 2006; Yin 1989).
The rationale for a single case could be one or more out
of three possibilities, according to Yin (1989). First, it
could be a critical case, which is used to confirm, chal-
lenge, or extend a theory; this research into the Cougar
crash informs the theory of the business case as a valid
vehicle for CSR, and, in the end, challenges it as effective
for achieving workplace safety. Second, a single case study
could be an extreme or unique case. The selection of this
case was because of its importance as an example of failure
in safety management of such magnitude that 17 lives were
lost; this, combined with NLs economic dependence on
the offshore oil sector over the next 30 years, reinforces the
need to prevent another similar tragedy. Third, a single
case could be revelatory, where there is an opportunity to
investigate and analyze a real-life situation previously
inaccessible to researchers. This crash is the first offshore
helicopter tragedy in Canada to result in a long and
intensive public inquiry where all participants were
required to provide evidence on oath, and where transcripts
of presentations and cross-examinations were publically
available. While there have been reports on comprehensive
industry investigations into general helicopter safety
available in other jurisdictions, such as in the Norwegian
offshore (SINTEF 2010), the availability in the public
domain of such rich data arising from a Commission of
Inquiry focusing on one particular event and helicopter
safety issues arising from it is unique. As noted by Silv-
erman (2000), one selection criterion for any qualitative
research has to be the accessibility of comprehensive data
to fully understand the complex relationships in a particular
situation, event, or process. Finally, when choosing a case,
Yin (1989) notes that an exemplary case is one that is
unusual and of general public interest, the underlying
issues should be nationally important either in theoretical
terms or in policy or practical terms, or both; it is argued
here that this case study of the Cougar crash in 2009 meets
both Yins criteria for an exemplary case.
Methodologically, within the qualitative paradigm, there
is no broad distinction made between the so-calledclassic (that is, single) case study and multiple case stud-
ies (Yin 1989, p. 52). Even though evidence from mul-
tiple cases is often considered as more compelling andthe evidence being more robust, Yin (1989, p. 52) makes
it clear that the rationale for single-case designs cannot
usually be satisfied by multiple cases (p. 52). If cases are
unusual, critical or revelatory, then they will likely be only
single cases, by definition (p. 53). On an operational
note, multiple cases are also costly and time consuming.
The Crash of Cougar Flight 491
123
That being said, the question of whether we can generalize
from a single case, or, indeed, multiple cases, is of interest,
and it is a concern more likely to arise from a quantitative
than from a qualitative paradigm. Yin (1989) advises
against selecting multiple case strategies with the aim of
generalization, as the logic in case study methodology is
not one of representation but one of possible literal or
theoretical replications rather than generalization or
applying a sampling logic, and the single case with a solid
rationale stands alone in its validity. Bryman (1988) makes
a similar point when he refers to case study researchers
integrating their findings with a theoretical context rather
than attempting generalization to populations or universes.
As noted, apart from the policy implications of the
research, the aim here is to use the findings of this case
study to develop theoretical insights as to the validity of the
business case for one component of CSR, namely, work-
place safety. Finally, it is important to note that single case
studies have long been established as useful and valid
research designs in the safety literature analyzing particular
tragedies, for example, the Challenger disaster (Casamayou
1993; Vaughan 1997), an Australian gas plant explosion
(Hopkins 2000) and an underground coal mining explosion
in Canada (Tucker 1999). Also, single case studies have
been successfully used to examine other CSR issues, as in
Lamberti and Lettieri (2009), who studied an Italian food
company, and Robinson (2010), who researched banana
plantations in Costa Rica.
Moving from research design to its implementation, the
archival analysis featured in this case study included sev-
eral sources. During the NL Inquiry, over 5 months of
testimony were provided by the parties of standing and
other interested parties, as noted above. Verbatim tran-
scripts of the Inquiry proceedings were posted on the
CNLOPBs website (http://www.oshsi.nl.ca/?Content=
TranscriptsandExhibits), as was all supporting documen-
tation, including written submissions from the parties of
standing and experts commissioned by the Inquiry. Other
major sources of data were Commissioner Wells Inquiry
reports (2010, 2011) and the TSB report (2010). Regulatory
documents and media coverage were also analyzed.
Testimony transcripts were analyzed by coding content
for themes, moving on to a systematic comparison of the
testimonies (see Silverman 2000), to generate broader
themes in the data (see Glesne 2006). It is proposed here
that a business case for safety would be strengthened if
industry and government had built into their rules and
practices lessons learned from the Ocean Ranger tragedy in
NL 30 years before, so analysis of the research material
was informed by the causes and aftermath of this tragedy
(for further details, see Hart 2005), as well as literature on
previous disasters and the business case debate. Triangu-
lation of data was used wherever possible. The article
continues with a discussion of the overarching theme
emerging from analysis of the research material, namely,
the tension between production and safety, echoing a
problem identified in the Ocean Ranger disaster (Canada
1985, pp. 104105; Hart 2005).
Tension Between Production and Safety
Although offshore safety has improved since the Ocean
Ranger disaster (Wells 2010), analysis of the research
material indicated that the industrys attention to helicopter
safety in practice did not always reflect their espoused
commitment, safety culture, or safety management sys-
tems. The following discussion attempts to link these
problems to an inherent tension between production and
safety, and hence to the effectiveness of the business case
in what was revealed to be, whether intended or not, a
system bordering on self-regulation.
That said, the following section deals with first, the
selection of the S-92 helicopter; second, the performance of
the helicopter in practice; third, the Cougar contract; and
fourth, survival and pilot training.
Selection of the S-92
The first Sikorsky S-92 helicopter was purchased in 2005
by Petro-Canada (later Suncor). During the Inquiry,
HMDC explained that moving to a common aircraft type
with Suncor and Husky will enhance synergies, improve
safety and reliability, and it would be more cost effective
(HMDC Testimony (T), January 18, 2010, p. 241). Cou-
gars recommendation of the S-92 was based on their
expertise as an international helicopter operator and was
accepted by the operators (Cougar T, February 2, 2010,
p. 69). The aircraft was endorsed by ExxonMobils Cor-
porate Aviation Services (HMDC T, January 18, 2010,
p. 240).
The S-92 effectively carried twice as many people as
the [existing] Super Puma (Cougar T, February 2, 2010,
p. 70), and production costs were favourable since:
commercially, the seat, cost per seat per mile was also
important in that evaluation (Cougar T, February 2, 2010,
p. 66). The operators noted the risk reduction of fewer
flights and a window for every row providing more
accessible emergency exits (HMDC, Husky Oil and Suncor
2010, Appendix B, 3). Also, an S-92 flight simulator was
immediately available for pilot training, unlike the closest
competitor Eurocopter EC225 (Cougar T, February 2,
2010, p. 8). The S-92s advanced technology listed in the
operators Appendix B (HMDC and Husky Oil Operations
Limited and Suncor Energy Inc. 2010) included, for
example, flaw/damage tolerant design; a rotor ice
S. M. Hart
123
http://www.oshsi.nl.ca/?Content=TranscriptsandExhibitshttp://www.oshsi.nl.ca/?Content=TranscriptsandExhibits
protection system; an enhanced ground proximity warning
system; enhanced emergency egress; a crash resistant fuel
system; enhanced lightening strike protection; and an
improved life raft system (HMDC and Husky Oil Opera-
tions Limited and Suncor Energy Inc. 2010). Also, at the
Inquiry, Cougar strongly promoted the aircrafts health and
usage monitoring system (HUMS), which provided:
a wealth of information about the helicopters
mechanical, electrical and avionics systems and may
flag an issue that requires maintenance or repair. The
HUMS data is downloaded to the HUMS ground
station [at Cougar] where it is analyzed and then
archived. Every day this data is also forwarded to the
aircraft manufacturer for their review and comparison
with the global fleet of S-92s. (Cougar T, February 2,
2010, p. 101)
Alongside HUMS was an older but standard technology
in the industry, consisting of cockpit warning lights
(Cougar T, February 2, 2010, pp. 133136). Bearing in
mind the list of advantageous features of the S-92 provided
by the operating companies and Cougars emphasis on the
new HUMS, the next section examines the effectiveness of
important aspects of this safety technology in practice.
Performance of the Helicopter in Practice
Flaw/Damage Tolerant Design
Only 8 days into its investigation, on March 20, 2009, the
TSB announced that it had found in the wreckage a broken
stud (or bolt) designed to hold together the oil filter bowl
attached to the main gearbox (MGB) (TSB 2009, p. 1). On
March 23, 2009, the American regulatory body, the Federal
Aviation Administration (FAA) issued an Emergency
Airworthiness Directive (AD) for the S-92s requiring,
before further flight, the replacement of all filter bowl
titanium studs with steel studs, which are stronger and less
vulnerable to metal fatigue (TSB 2010, p. 140)3. On April
27, 2010 the FAA issued another AD, this time for the
replacement of the MGB filter bowl assembly with a newly
designed part along with replacement of the mounting
studs (TSB, p. 141). As expected, in its conclusions as to
causes of the crash and contributory factors, the TSB
identified flaws in manufacturing design (p. 133, #s 13, 6).
The S-92 was designed to withstand damage fromflawed, damaged, scratched, corroded or dented parts(HMDC and Husky Oil Operations Limited and Suncor
Energy Inc. 2010, Appendix B, p. 1). No doubt the oper-
ators accepted this claim on good faith when selecting the
S-92. Yet, the TSB refers to such a major design flaw that it
led to a catastrophic failure, causing the helicopter to spiral
out of control due to the incapacitation of the tail rotor (pp.
119120, 133, # 6), explaining that: two studs broke in
cruise flight resulting in a sudden loss of oil in the MGB
(p. 111). Not only does this occurrence undermine the
manufacturers claim of a flaw/damage tolerant design but
it also raises serious questions about the helicopters HUMs
technology aimed at detecting impending failure of parts
and systems. Neither the Inquiry nor the TSB addressed
this latter issue, but a study of the failure of HUMs to
prevent a fatal Super Puma helicopter crash in the Nor-
wegian North Sea in 1997 is instructive. Wackers and
Korte (2003) noted that the pressures of implementing the
complex technology had led to a gap developing between
protocol and practice, and between reality and senior
management impressions, and concluded that: in hind-
sight we can see that there were no realistic ways in which
to balance the diverging goals of availability for produc-
tion, economy and safety (p. 203). Bearing in mind this
conclusion of an apparently irreconcilable tension between
production and safety, there appeared to be no evidence of
a normative concept of CSR in the company studied
otherwise safety would have been unquestionably priori-
tized. Bearing this research in mind, an apparent reluctance
to impede production for crucial maintenance can be
detected leading up to the Cougar crash, as discussed
below.
An Early Warning: The Australian Incident
The failure to pick up an impending metal fatigue failure
was not only to do with failed or underused diagnostic
technology. There was a clear warning the year before the
crash in NL that something was very wrong with the fun-
damental design of the helicopter transmission following a
forced landing on July 2, 2008, of an S-92 in the Australian
offshore oil industry, about 7 min after a sudden loss of oil
from the MGB, due to fractured studs (TSB, pp. 8687).
The manufacturer seriously underestimated the risk posed
by the failure of the filter bowl studs:
Following the Australian occurrence, Sikorsky and
the Federal Aviation Administration (FAA) relied on
new maintenance procedures to mitigate the risk of
failure of damaged mounting studs on the MGB filter
bowl assembly and did not require their immediate
replacement. (TSB, p. 133)
Sikorskys risk assessment had concluded that the tita-
nium studs should be replaced with steel. However, with
FAA approval, Sikorsky attempted to mitigate the risk
through the issuance of a Safety Advisory on October 8,
2008, telling helicopter operators of forthcoming changes
3 From now on, unless otherwise noted, all references to the TSB will
be from their report dated 2010.
The Crash of Cougar Flight 491
123
to the Aircraft Maintenance Manual including aninterim enhanced inspection procedure for the removal and
installation of the MGB filter bowl assemblyand man-datory replacement of used nuts with new nuts (TSB,
p. 89). With the revisions to the Manual announced on
November 5, 2008, Sikorsky made these enhanced
inspection procedures mandatory industry-wide (TSB,
p. 90). On January 28, 2009, Sikorsky issued an Alert
Service Bulletin (ASB) requiring the replacement of the
MGB filter bowl titanium studs with steel studs, within
1250 flight hours or 1 year (TSB, p. 90). The replacement
studs were not in place when the S-92 crashed on March
12, 2009.
Documents issued from aircraft manufacturers to oper-
ators vary depending on the urgency or severity of the
information being presented, and ASBs have the highest
priority (TSB, p. 92, footnote # 124), but priority with a
12-month compliance timeline is considered lower than
one with a much shorter timeline (TSB, p. 92). Moreover,
the TSB investigators found that there had developed a
general consensus among the S-92A community that the
issue was not urgent (p. 92), mainly because the Austra-
lian incident had been linked to improper maintenance.
This is consistent with Cougars evidence at the Inquiry
when asked about his companys response to the January
2009 ASB (T, February 4, 2010, pp. 142143). The TSB
criticized the manufacturer for their failure to communicate
the potentially fatal consequences of non-compliance
(TSB, p. 131).
There are hints in the TSB report that helicopter industry
discussions of the studs issue in Sikorsky-led webcasts
leading up to the ASB in January 2009 were production as
well as safety related, as we might reasonably expect. For
example, the investigators remarked that the compli-ance time was based on Sikorskys assessment of the risk
and the time it would take to replace the studs in the field
without compromising safety [my emphasis] (TSB,
p. 90). The end result of this deliberation on the part of
Sikorsky, including discussion with its customers through
its weekly webcasts, was the decision to respond in terms
of extra vigilance in maintenance rather than what was
really needed: a redesign of the filter bowl assembly (TSB,
p. 141). To replace the studs immediately, as an interim
measure, would have caused the grounding of the whole
fleet of 120125 helicopters world-wide. The aircraft were
only grounded after the crash when it became impossible to
continue flying them following the TSBs early
announcement of damaged studs and the FAAs subsequent
AD. There are clear production and profit implications
here, for the manufacturer and its future contracts with the
offshore industry, for the helicopter operators world-wide,
and for their customers, with the offshore oil industry a
lucrative market segment for any aircraft contractor. As
noted by Cougars General Manager, our customer base is
made up of major international oil and gas companies
(Cougar T, February 2, 2010, p. 26), and the company
operates in Australia, China, South America, and the Gulf
of Mexico as well as Newfoundland and Labrador (T,
February 2, 2010, p. 11).
The TSB also criticized the helicopter operators
response to the early warning of a catastrophic failure.
First, TSBs examination of the studs in the crashed heli-
copter showed that Cougar had not conducted the enhanced
inspection and repairs made mandatory by the manufac-
turer in October 2008, and therefore, damaged studs on
the filter bowl assembly were not detected or replaced
(TSB, p. 133, # 5, see also 92, 131). The TSB noted
similar damage in 59 studs sent in from various other
operators after the fleet had been grounded (pp. 93, 111).
Second, the January 28, 2009 ASB from Sikorsky requiring
the new steel studs had not been implemented at the time of
the crash (TSB, p. 133). Cougar ordered new parts and
tools for the required job on February 19, 2009, 3 weeks
after the ASB, and the purchase was marked as routine for
base stock, to be delivered the next consolidated shipment.
Third, the TSB noted representatives of Cougar in atten-
dance at three of Sikorskys weekly webcasts for its cus-
tomers between August and November 2008, all of which
included some discussion of the Australian incident, filter
bowl stud damage as its cause, and appropriate enhanced
maintenance procedures to be adopted by S-92 operators
(pp. 8889, 90).
Given their operations in Australia, knowledge of this
important near miss and associated information on it
available to them leading up to the time of the tragedy,
including their view that the prior incident was due to poor
maintenance, it is surprising that Cougar did not adhere to
the manufacturers maintenance instructions and, further,
did not immediately replace the studs when receiving the
ASB in January 2009. This is especially so when we
consider the companys Inquiry testimony describing their
proactive maintenance strategy, explaining that all ASBs
and ADs are implemented right away, we dont hesitate,
and that goes into our system immediately (Cougar T,
February 2, 2010, pp. 128129). This inconsistency
between their espoused safety culture and practice was
pursued by Counsel for the families of the deceased
workers (Cougar T, February 4, 2010, pp. 126143), with
special reference to the companys failure to replace the
bolts and, in turn, failure to notify the crew and passengers
of such a serious safety hazard. It is possible that by this
time there had developed between the manufacturer and the
helicopter operator an acceptance of risk despite evidence
to the contrary, partly because their perception of risk was
coloured by the crucial need to meet the customers
demand for continued production, and their own interests
S. M. Hart
123
in further contracts. This is not to say that any one
individual deliberately ignored risk or safety hazards;
rather, it is a matter of a safety culture that is different
on the surface from everyday practice affected by a pri-
oritization of commercial pressures. Something similar to
this development has been noted by other scholars, as
did Wackers and Korte in their study of the HUMS
technology (Casamayou 1993; Richard 1997; Vaughan
1997; Woolfson et al. 1997).
Trying to establish the operators level of responsibility
was a significant theme at the Inquiry. The companies
described in detail their safety management systems, which
included comprehensive risk identification and mitigation.
The possibility of oil operators being aware of the early
warning of problems with the S-92 or the subsequent ASB
sent to Cougar in January 2009 was not considered in the
TSB report; any comments here are based on analysis of
the Inquiry testimony.
Cougar considered the January 2008 ASB as an
internal matter and not a safety concern for communica-
tion beyond the Maintenance Department (Cougar T,
February 4, 2010, pp. 138141), which suggests that
operators may have been unaware of it. It may be that
they did not know about the Australian incident either. At
the same time, there was significant interface between
Cougar and their clients. Cougar purchases each heli-
copter through their parent company and then leases it to
the operators (Cougar T, February 4, 2010, p. 114), and
the pooling participants clearly define to our operations
manager how to manage each of the individual aircraft on
their behalf (Cougar T, February 2, 2010, p. 141).
A Helicopter Steering Committee manages this pooling
agreement. Its composition consists of Cougar represen-
tatives and an operations and finance person from each of
the operators, because [it] has a commercial compo-
nentits how we manage our operation and assetstogether (Cougar T, February 2, 2010, pp. 249250).
The Committee meets quarterly or more often if seen as
needed, as it did when the fleet was grounded (Cougar T,
February 2, 2010, p. 251). Also, there is a 7.30 am
operations call every day and each operating company has
a representative (usually a logistics coordinator) on these
calls (Cougar T, February 2, 2010, p. 241). In addition,
the Cougar base operations manager has weekly meetings
with each individual operating company to discuss any
specific issues (Cougar T, February 2, 2010, p. 248).
These close working relationships would lead us to expect
that any helicopter problems with operations implications
would likely be discussed; it would be surprising if the
Australian incident were not raised, given the interna-
tional operations of Cougar and the operators, although it
is impossible to confirm such discussions from the
research material.
However, there is an argument to be made that if the
operators did not know about the Australian incident or the
bolt replacement ASB, then they should have done if their
safety management systems were working effectively.
First, analysis of the Inquiry testimony revealed some other
indications that all was not well with the performance of
the helicopter, even though it is fair to say that it is always
easier to see these signals in hindsight than at the time.
When asked by Inquiry Counsel whether the companies
making up the Joint Operators Panel (JOP) had any
reason to believe that there were concerns with the S-92 in
terms of its safety and performance generally before the
crash, the Suncor Energy representative answered that the
issue of chip lights came up more prevalent with the
S-92and it may or may not be indicative of a prematureor impending failure (JOP T, January 11, 2010, p. 198),
acknowledging shortly afterwards that your chips areyour early warning system (JOP T, January 11, 2010,
p. 201). Also, Suncor Energy testimony showed that the
workforce had expressed concern about high levels of
vibrations with the S-92, but the company had understood
this as inherent to the design of the aircraft and not a safety
issue. The Husky Oil Energy and HMDC representatives,
both of whose companies had workers on the doomed
helicopter, stated categorically that their companies had
had no safety concerns regarding the S-92 (JOP T, January
11, 2010, p. 200).
Second, Cougars incident reporting to the operators was
pursued at the Inquiry. The companys representative
identified some regulatory confusion over what exactly had
to be reported to whom (Cougar T, January 4, 2010,
pp. 189190). Their internal system required the operations
manager to report to the logistics coordinator of the rele-
vant operator, but not to their safety, health and environ-
ment manager (T, February 4, 2010, pp. 104105). Given
the existence in theory of an interlocking safety manage-
ment system established to recognize and mitigate hazards
in offshore helicopter transportation, as conveyed by the
industry, in practice it would appear that there were gaps in
the coordinating mechanisms for incidence reporting.
Overall, the research material points to the failure of the
aviation and the NL operating companies to act upon an
early warning of impending tragedy. It is sobering to note
that failure to respond to early warnings is not uncommon
in the lead up to accidents or disasters with multiple
fatalities, such as explosions of the Challenger at NASA
(Casamayou 1993; Vaughan 1997), in an underground coal
mine explosion in Canada (Richard 1997) and on a North
Sea offshore oil platform (Woolfson et al. 1997). More-
over, the NL offshore oil industry apparently did not learn
from an important and ignored early warning of the Ocean
Ranger disaster. The rigs capsize was triggered by a list of
15 in stormy seas. The week before, the semi-submersible
The Crash of Cougar Flight 491
123
had unexpectedly listed 6, which, as noted by the Com-missioners, should have alerted management to the lack of
ballast control training on the part of the operators and the
marine master on board (Canada 1984, pp. 5051). A
normative model of CSR would be characterized in this
context by a proactive, vigilant approach to minimizing
risk, including organizational learning from past accidents
or near misses. Clearly, none of these characteristics was
present in this case. On the contrary, the research material
indicates that the corporations involved adopted an
instrumental, business case approach with a focus on cost
benefit analysis, leading to decisions that prioritized pro-
duction over vital maintenance of the aircraft.
Enhanced Emergency Egress
In explaining his almost miraculous escape from the
rapidly sinking, submerged helicopter (Wells 2010, p. 53),
the lone survivor explained that he was young and fit and
many times I have been thrown into the cold sea water
from an overturned boat [and] when the helicoptersuddenly filled with icy water it was like a reflex to takea breath and hold it and just stay calm until I could get to
the surface (Decker T, November 5, 2009, p. 84). The
TSB stated the preconditions for survival as recent high
fidelity underwater escape training, good swimming abil-
ity, previous cold water acclimatization, agility, physical
and mental fitness, a high pain threshold, no impairment
whatsoever, and a strong survival instinct (TSB, p. 32).
We should note that this is not a description of the average
offshore worker, and it assumes no injuries at all from
impact with the water.
The S-92s claim of enhanced emergency egress was
based on windows for every seating row. The survivors
experience led him to assert that the reality was different:
the chances of being able to escape from anoverturned helicopter being [in] the inside seat would
be next to impossibleYoud have to hold yourbreath and wait for the initial person who would be
directly next to the window to get out and clear out of
the way and the feet and kickingI just cant seehow this person would ever stand a chance (T,November 5, 2009, p. 90)
His view is consistent with a 2009 study finding that if
troops had to wait for someone else to exit, their escape
time was significantly higher than the 20 seconds breath-
hold egress threshold found in previous studies (Taber
2010, p. 20). Participants from the military can be rea-
sonably expected to be physically and mentally fitter and
more prepared than the average offshore worker. Never-
theless, even for them egress was seen as extremely chal-
lenging, regarding:
locating and functioning emergency exits, disori-entation, lack of visual acuity, poor breath-hold
ability in cold water, and aircraft attitude immedi-
ately after impact (Taber 2010, p. 5)
In particular, past research and experience available well
before the crash had demonstrated that any possibility of
escape is dependent upon a persons ability to breath-hold
for a considerable length of time, which is difficult if not
impossible for most people, as explained by one Inquiry
expert:
It has been recognized for some years that the time
needed to escape from a submerged or capsized
helicopter, estimated to be 45 to 60 s in a real inci-
dent, exceeds the time that most individuals can
breath-hold in cold water due to the effects of cold
shock4. In subjects wearing helicopter suits,
immersed in water colder than 10 degrees centigrade,
mean breath-hold time is likely to be close to 20 s,
but can be as little as 10 s in some individuals (Tipton
and Vincent, 1989; Tipton et al., 1995; Tipton et al.
1997). This would allow very little time for an indi-
vidual to escape from a capsized helicopter. (Cole-
shaw 2010, p. 13)
The risk of drowning before escape is therefore very
high (Coleshaw 2010, p. 3). The TSBs findings are
sobering in this respect. All passengers and crew survived
the impact with the water (TSB, p. 31), and all their deaths
were caused by drowning (TSB, p. 149). Six of the eight
occupants with minor or insignificant injuries were
seated next to a window or emergency exit (TSB, pp. 38,
125), but were nevertheless found by the rescue diving
team still strapped into their seats. Despite having the best
chance for survivalif they did not release their seatharnesses within a few seconds after the helicopter started
to sink, the effects of the cold water shock would have
likely caused them to break their breath holds in ten to
fifteen seconds (TSB, p. 125). These TSB findings alone
raise serious questions concerning the manufacturers
claim of an enhanced emergency egress system, but it has
to be said that it should not have been surprising given the
consistency of past research identifying the extreme diffi-
culty of escaping a rapidly sinking, inverted helicopter. For
example, a Canadian study (Taber and McCabe 2007), an
international meta-analysis of ditching reports, showed that
63 % of ditched helicopters capsized and filled with water
and that the majority of fatalities resulted when this
4 Cold shock is a reflex response causing an initial gasp and an
inability to control breathing for the first few minutes of immersion in
cold water (Coleshaw 2010, p. 3). Hyperventilation, involuntary
water intake, dangerously high levels of heart rate with the possibility
of cardiac arrest or arrhythmia, are other characteristics (TSB, p. 33).
S. M. Hart
123
happened and the aircraft sank rapidly. A much earlier
study in 1993 with similar findings was also noted by Taber
(Chen et al. 1993, cited in Taber 2010, p. 4).
Enhanced Emergency Flotation System
The enhanced emergency flotation system (EFS) listed as a
safety feature in the JOPs Appendix consisted of five float
bags. Although they were available at the time of purchase,
only the standard version of three float bags was installed
in NL (TSB, p. 16). The enhanced model was installed in
38 of the S-92s world-wide (TSB, p. 17), but not until
March 2011 in NL (see Wells 2011, p. 37), 2 years after the
crash. At impact, the flotation system was disabled,
allowing the helicopter to sink rapidly. The TSB recom-
mended the prohibition of flights in sea states beyond the
capability of the EFD to allow safe ditching and successful
evacuation, which was estimated to occur in NL 50 % of
the time over a year, and 83 % between December and
February (p. 149). The operators revised the sea state
protocol, but took into account the new enhanced flotation
system (Wells 2011, Appendix G, p. 186). Even so, the
TSB noted that as long as EFSs are designed only to work
in a ditching scenario, then there is a continued risk that
[they] will be disabled in survivable impacts contributing
to occupant deaths from drowning (TSB, p. 136, # 24).
Essentially, this means that even with the enhanced ver-
sion, the EFS would likely not have worked and the S-92
would have still sunk, given the impact. This is a serious
problem. Helicopters are top heavy and are likely to cap-
size once downed, with steep, breaking waves, posing the
highest risk (Coleshaw 2010), conditions typical of the NL
offshore.
A UK Civil Aviation Authority report published as
long ago as 1995 called for more research to develop
EFSs for survivability after a crash, as opposed to a
controlled ditching, including specially designed extra
flotation units (see TSB, p. 96). Also, side-floating flo-
tation devices would increase the chance of escape from
a submerged helicopter (see Commissioners comments
in JOP T, January 12, 2010, pp. 8081). A 2007 feasi-
bility study by the European Aviation Safety Agency
(EASA) recommended further research on this innova-
tion, finding that retrofit would involve a weight penalty
(at least two passengers or fuel equivalent), with devel-
opment costs estimated at several million euro (TSB,
p. 97). This research should be pursued by the offshore
oil industry. Echoing the Ocean Ranger Commissioners
on the industrys priorities in the early 1980s, there has
been little proactivity, if any, on this issue. There was
apparently no business case for the required level of
investment leading up to the crash.
Improved Life Raft Systems
The lone survivor testified that after he had managed to
escape from the fast sinking helicopter and had reached the
surface, even though the sea states were relatively calm
(Decker T, p. 28), he found it impossible to board a nearby
life raft as without an anchor with no one on board, it was
impossible to catch it. I guess it was driving in the wind,
driving in the waves, and it was a losing battle (Decker T,
p. 53). He explained that the sea anchor could only be
operated manually once inside (Decker T, p. 53). A big
disadvantage with life rafts is that they float quickly, often
away from the disaster site, a tendency exacerbated in
stormy seas. This knowledge is well established in the
seafaring and safety community (see Hart 2005). The
operators need to invest in research aimed at developing a
more effective life raft for helicopters, as they are the only
immediate sea rescue system available. As noted earlier,
the failure of the overall evacuation system in the Ocean
Ranger was a major issue, and none of the inflatable life
rafts had been occupied or used (Canada 1984, p. 147).
Crash-Resistant Fuel Systems
According to the JOP Appendix, the S-92 offered a safer
fuel system because the main fuel tanks were external. In
the aftermath of the crash, the industry practice of locating
auxiliary fuel tanks (AFTs) inside the passenger cabin
became a contentious issue. Three offshore workers,
including the President of CEP, filed work refusals citing
the increased risk of AFTs regarding stability in the event
of ditching, fuel leaks and impediment of egress from a
capsized helicopter (CEP Local 2121 T, February 9, 2010,
pp. 1730, 139151). A petition in support of the refusals
was signed by between 140 and 150 workers (CEP T,
February 9, 2010, p. 150). After investigation, the
CNLOPB, in recognizing the inherent risks of helicopter
travel, decided that the AFTs did not result in an unac-
ceptable increase in risk (cited in CEP T, February 9,
2010, p. 20).
At the Inquiry, the industry and the regulator defended
their position on the basis of compliance: both the design of
the AFTs and their location inside the passenger cabin were
approved by the FAA and TC. On the other hand, the
Director of the Offshore Safety and Survival Centre at the
Marine Institute, the organization providing underwater
escape training, stated it would be very difficult, if not
impossible to exit a submerged helicopter from a seat
inboard of an AFT (Marine Institute T, November 24,
2009, p. 62), and that there had been no consultation with
the Centre before the AFTs were installed. Also, Taber
(2010), a helicopter safety expert consulted by the Inquiry,
noted that an obstruction such as an AFT placed between
The Crash of Cougar Flight 491
123
an individual and an exit may impede egress due to
increased disorientation and lack of reference points (p.
16). He called for the regulation of interior helicopter
design with regard to overall underwater escapability.
The industrys response to workers concerns was to
change the location of the AFT from one side of the cabin to
the other, with no seats alongside it. With the development of
fields further away there will be two AFTs installed (T,
February 4, 2010, p. 92), so this slight improvement is only
temporary. Clearly, there is a cost element in terms of weight,
passenger capacity and engineering design and a return on
time and effort and investment as to what you can do on the
outside of an aircraft (Cougar T, February 3, 2010, p. 221).
To avoid the use of any AFTs, a larger, more powerful
helicopter is needed (Cougar T, February 3, pp. 242243),
but industry compliance to minimum standards has been the
focus here rather than a proactive attempt to develop a long-
term mitigation of risk.
The discussion so far has focused on how some
important selection features of the helicopter performed in
reality on March 12 2009. Insufficient attention was paid
by both the aviation and offshore industries to early
warnings of problems with the MGB design. The claimed
enhanced emergency egress did not take into account
readily available experience, knowledge and research on
the near impossibility of an average person escaping an
inverted and rapidly sinking helicopter. In 1985, the Ocean
Ranger Commissioners had recommended that industry
establish performance standards for safe evacuation sys-
tems (Canada, p. 159, # 107[a]). At the time of the Inquiry,
a CAPP produced Escape, Evacuation and Rescue Guide
was still in draft form (CAPP T, November 16, 2009,
pp. 16, 194) and omitted helicopter passenger transporta-
tion (Marine Institute T, November 24, 2009,
pp. 156157), as does the current, formalized document
(see CAPP 2010). Important survival technology (emer-
gency flotation systems, life rafts) was insufficient despite
experience and available research identifying problems
with it, and AFTs were installed in the face of existing
research asserting stability and egress problems when
evacuating.
The above analysis does not indicate the existence of a
normative concept of CSR in the industry. On the contrary,
the findings here support there being an instrumental
business case approach such that where there are no clear
commercial benefits to what are potentially costly safety
improvements, there are no investments in higher standard
survival technology to mitigate considerable risk to
employees while travelling offshore. This investment
would include, among other things, a bigger and more
powerful aircraft to avoid the use of AFTs and EFDs that
work in the prevailing NL weather and ocean conditions.
The next section is a review of gaps in the operating
companies contracts with Cougar, all of which became
evident after the crash.
Gaps in the Cougar Contract
There was a vital missing piece with regard to the heli-
copter itself and an absence of important safety technology
and procedures often available in other jurisdictions, as
discussed below.
30-Minute Run Dry Capability
One of the TSBs most important recommendations was
intended to keep every helicopter in the air where it
belongs, in the words of the survivor (Decker T, 2009,
p. 86). After the total loss of MGB oil the helicopter had
only 11-min flying time before catastrophic failure and the
crash (TSB, p. 4). There was considerable public debate in
the province, including media speculation, as to whether
the pilots had made their final decisions as if the aircraft
had 30-min flying time after the oil loss (Cougar T, Feb-
ruary 4, pp. 1718). Rather than start the emergency
ditching procedure they had apparently headed for the
closest emergency landing site (Cunningham 2011; Prob-
lems Seen Before Fatal N.L. Chopper Crash: Investigator
2011; TSB, p. 21), which was within 30-min flying time
(Huber 2010). A law suit filed against Sikorsky by Cougar
Helicopters in September 2010 claimed that the pilots had
turned around on the basis of an advertised 30-min run dry
capability.5
The TSB concluded Sikorskys early marketing had
misleadingly promoted their new commercial S-92 as
including this capability (TSB, pp. 104105), whereas it
only existed in the military version (TSB, pp. 9899).
Nevertheless, the 30-min run dry claim was in S-92 pro-
motional literature as late as 2007 (TSB, p. 105). Without
any clarification by Sikorsky, an inaccurate perception had
developed in the aviation community that the 30-min run
dry feature applied to all helicopters in the same
5 In September 2010, Cougar and their insurers sued Sikorsky for
misleading claims about the S-92s 30-min run dry capability,
alleging that the pilots of Cougar flight 491 acted properly in
attempting to fly back to land within 30-min flying time, when there
was catastrophic failure of the MGB and immediate loss of control of
the helicopter (Baird 2010; Huber 2010; Problems Seen Before Fatal
N.L. Chopper Crash: Investigator 2011). This law suit is ongoing,
having being mired in a dispute over whether the case should be heard
in the US or in NL, Canada. Families of the deceased passengers and
the lone survivor had earlier filed a lawsuit against Sikorsky, also
alleging false claims about the helicopters safety, and that the
corporation knew about the problems with the MGB yet still marketed
the S-92 as the safest helicopter in the world (Suit Over Deadly
Helicopter Crash Settled 2010; Moore 2011).The settlement with the
families occurred shortly after the Inquiry began, in January 2010 and
was confidential.
S. M. Hart
123
classification as the S-92, fostered by numerous sourcessuch as manufacturers brochures, websites, magazines,
and trade journals (TSB, p. 104). Interestingly, the TSB
reported no indications on the Flight Data Recorder that the
pilots had assumed the existence of a 30-min window, and
the TSB concluded Cougar pilots knew the difference
between military and civilian models (p. 112). The TSB
recommended regulatory reform so that all newly con-
structed Category A transport helicopters, including the
S-92, have a 30-min run dry capability, along with a
phased-in retrofit of the existing S-92 fleet (2010, see
Occurrence Summary). Also, the offshore oil industry was
to pursue the production of a helicopter capable of a longer
safety window (Occurrence Summary), being now tech-
nically feasible and economically justifiable, and given
frequent 2-hour flights and future development even farther
from land (TSB, p. 148).
Today, the S-92 is the only helicopter in its category not
certified by the FAA and TC up to the 30-min run dry
standard (TSB, pp. 100, 104). Thus, the closest competitor
of the S-92 at the time of purchase for the NL offshore, the
EC225, passed the certification test and has the vital
30-min run dry capability (see TSB, pp. 104, 112). The
S-92s regulatory history is interesting in its deregulatory
thrust and implications for industry influence. Certification
testing in 2002 of the S-92s 30-min run dry capability
resulted in catastrophic failure after only 11 min (TSB,
pp. 101, 104), which is the same length of time left to the
pilots after MGB oil loss until the helicopter plummeted
out of control on the day of the crash, 7 years later (TSB,
p. 4). Although the exact technical cause was not bolt
failure, the test showed without question that there were
serious problems with the transmission. Instead of this
failed test triggering the MGBs fundamental redesign,
Sikorsky and the FAA agreed after some minor technical
and emergency procedural changes that the risk of total
loss of oil from the MGB was extremely remote, a
decision made possible by the FAAs earlier regulation
including this loophole in September 1988 (TSB, p. 99).
The FAA certified the S-92 in 2002; the European Aviation
Safety Agency (EASA) and the TC followed suit in 2004
and 2005, respectively.
The 30-min rule as initially proposed by the FAA did
not include the extremely remote clause (TSB, p. 99). Its
inclusion, weakening the rule, occurred after the regulator
took into account comments received from stakeholders,
and industry practices (TSB, p. 99). Industry stake-
holders would likely include the aviation and offshore oil
sectors; the new S-92 was, and still is, being marketed
primarily to the offshore oil industry (CBC, 2011b; Cougar
T, February 2, 2010, pp. 11, 26). It is reasonable to assume
that redesigning a helicopter transmission system would
involve high development costs, affecting a manufacturers
revenues and customer price. When we combine the fore-
going with Sikorskys marketing of a high technology,
extremely safe aircraft, never publicly and unequivocally
denying the 30-min run dry feature (TSB, p. 105), and
scheduling the certification test very late in the overall S-92
certification program (TSB, p. 100), all indications are of a
commercially driven regulatory process.
This interpretation of a commercial imperative is
strengthened by the FAAs response to the TSB. The FAA
will delete or clarify the extremely remote risk clause,
but it will not require the retrofit of existing S-92s to
provide the 30-min window because it does not believe
that it is either practical or necessary [and] would have asignificant economic impact on the aviation community,
and the costs would outweigh any improvements to safety
(FAA 2011). In reaction, a TSB spokesman explained, the
studs have changed but the gearbox has not changed and in
the event of catastrophic oil loss, the S92A would still
crash in 11 min (Transport Canada Too Slow: Chopper
Crash Families 2011, p. 2; see also Cunningham 2011).
It is important to note that since the crash there have
been other, different, problems with the S-92 transmission.
A Sikorsky ASB in September 2009 established a 10-hourly
inspection regime for signs of cracks and corrosion in the
MGB (see FAA 2011, AD 2011-12-03). This manufac-
turers ASB was followed up by the FAAs October 2009
Emergency Airworthiness Directive, prompted by reports
of cracks in the mounting feet attaching the MGB to the
fuselage (see Helicopter Problem Worries N.L. Offshore
Workers 2009). Increasingly stringent inspection require-
ments to detect these cracks followed in regular ADs in
February, 2010 (FAA, AD 2009-23-51) and, the most
recent notification at the time of writing, in June 2011
(FAA, AD 2011-12-03). The EASA noted in its November
2010 AD that in one North Sea S-92 helicopter, a mounting
foot was found to be completely severed from the MGB
(AD 2010-0241). Moreover, in September 2011, an S-92 in
the Norwegian sector of the North Sea was forced to turn
around because of partial engine failure, triggering once
again worker anxieties and CEP disapproval of the air-
crafts safety record, including consistently high vibration
levels, mounting feet cracks and the continuing need for
10-hourly inspections (CBC 2011a). The fleet was groun-
ded in Norway until inspection was complete, but not in
NL, where production did not stop during Cougars
inspection (VOCM 2011). In a recurring pattern, even after
the crash and the aftermath, the regulator is not being
proactive in demanding that flights be suspended, and the
industry is still not moving beyond compliance. In the
meantime, TC initiated a coordinated formal review with
the FAA and the EASA of the 30-min rule in June 2011
(TSB 2011a), so any regulatory movement on the issue is
unlikely in the near future.
The Crash of Cougar Flight 491
123
It is difficult not to conclude that a costbenefit analysis on
the part of the aviation industry and, possibly, the offshore
industry, likely involved an instrumental, business case
concept of CSR resulting in the failure to proactively tackle a
design problem that was known to substantially increase risk
for employees travelling offshore in the event of an emer-
gency landing. This is especially the case when we consider
the Australian early warning and problems with the MGB
that have occurred after the crash, the latter suggesting that
the probability of a transmission failure is higher than was
realized at the time of the crash or, indeed, the Inquiry. Not
surprisingly, then, there is no indication of a normative
approach to CSR regarding this gap in the S-92s capability.
Cougar Search and Rescue (SAR)
Some SAR technology available in other oil and gas juris-
dictions was omitted from Cougars contract. One example is
an automatically deployable Emergency Location Trans-
mitter (ELT) for the helicopter, a regulatory requirement in
the British North Sea (TSB, p. 18). On March 12, 2009, the
S-92s ELT failed (TSB, p. 17), considerably lengthening the
SAR time (see TSB, p. 130). Even the enhanced British
version is not reliable after a helicopter is ditched in water
(see TSB, pp. 1718, 130), raising again the question of
inadequate investment by the industry to develop this
important device to suit offshore travel. Other missing
technology included auto-hover, enabling stable positioning
over a SAR site; a double winch for hoisting survivors from
the sea; and a forward looking infrared camera mounted
externally, indispensable in night-time operations (Wells
2010, p. 189). Cougar indicated that these options were
included in their proposal to the operators when the heli-
copter selection decision was being made (February 2010,
pp. 229230), and that the Helicopter Steering Committee
would normally deal with issues around enhancements to
the aircraft (T, February 2, 2010, p. 249).
Furthermore, before the completion of the Inquiry and
based on the hearings and his own research up to that time,
Commissioner Wells wrote to the Chair of the CNLOPB,
on February 8, 2010, about the adequacy of Cougars first-
response SAR capability, a matter requiring immediate
attention (Wells 2010, p. 187). First, he recommended
that night flying be restricted to emergencies until the auto-
hover and infrared devices were fitted into Cougars first-
response helicopter. Scheduled night flying was subse-
quently suspended on February 14, 2010, pending the
installation of this technology. Second, he criticized the
industrys long wheels up time (the time between an
emergency call and take off):
The present response from St. Johns does not meet
the highest standards. I learned in the past week that
Cougar has the ability to provide the kind of service
which I have described and they are already provid-
ing that service in Alaska, the Northwest Territories
and the Gulf of Mexico. They contracted only last
week to provide it in Greenland. Other companies are
providing comparable search and rescue responses in
the North Sea, with wheels up in 15 min. (2010,
p. 189)
The central importance of this issue at the Inquiry lar-
gely reflected a previously ignored Ocean Ranger recom-
mendation (Canada 1984, p. 156, # 56). As Commissioner
Wells remarked in his report, to me it is inconceivable
that C-NOLPB and the industry did not know about the
[Ocean Ranger] recommendation for a dedicated search
and rescue helicopter based in St. Johns (Wells 2010,
p. 282). Nevertheless, at the time of the crash in 2009,
25 years after this important recommendation, there was
still no dedicated standby helicopter provided by the NL
operators, permanently fitted with SAR equipment and
with a specialist standby crew. On the contrary, the Cougar
contract required all helicopters to be used for transporta-
tion. The first response specified in the contract was 1 h. It
was met as long as the next incoming flight was within
30 min of St. Johns; when that helicopter landed it would
become the standby helicopter if needed. This meant that
an extra 30 min had to be added to the 50 min taken to
reconfigure the aircraft, involving the removal of seats and
a door, and installation of SAR equipment (Wells 2010,
pp. 184185). The consequence of this organizational
choice (Wells 2010, p. 185) was that the total wheels-up
time became as much as 1 h 20 min, which did not meet
the contract requirement of 1 h (Wells 2010, p. 184). After
reconfiguration and calling in the rescue specialists, who
were off-site on the day of the crash (Cougar T, February 3,
2010, p. 121), 72 min had elapsed since the emergency call
at 9.40 a.m. by the time the lone survivor was hoisted up by
the SAR crew. As Commissioner Wells pointed out, by this
time the survivor was near death because his core body
temperature had fallen to 28 degrees (2010, p. 185).
Commissioner Wells noted that the oil operators
knew that the Department of National Defence SAR
wheels-up time was 30 min between 8 am and 4 pm and
120 min at other times, and to these times must be added
3045 min of flying time to arrive over St. Johns (2010,
p. 185). 6 Being aware of these limitations and of the high
risks of survival in our cold waters, especially at night,
clearly, the oil operators knew that they had to involve
themselves in first response helicopter SAR (2010,
6 On the day of the crash the federal government SAR helicopters
were all away from their base in Gander, NL, on a training mission in
the province of Nova Scotia. The standing arrangement was that
Cougar would provide standby SAR services in their absence.
S. M. Hart
123
p. 184). When asked about the flexibility of the 30-min
flying in time the operators responded that since the return
to service in May 2009, the arrangement had been stopped
(JOP T, January 11, 2010, p. 250; see also Cougar T,
February 4, p. 10). The companies noted in their defense
that the original 1 h wheels-up time in their Safety Plans
had been accepted by the regulator. Be that as it may, it is
argued here that the 30-min running time, arguably a
production, operational advantage, had been factored in at
the expense of a shorter, safer SAR response capability. In
his report, Commissioner Wells remarked that the NL
response time was two to four times as long as times
elsewhere, and that the industry for years had ignored
the improved response times in other jurisdictions, and
C-NLOPB did not insist that they step up to the plate (p.
283). The industry has now committed to a 1520 min
wheels-up time available in late 2011; there is a dedicated
helicopter and team already in place, along with a new
hangar under construction (Wells, 2011, p. 37).
In the case of the industrys SAR provision, there is
clear evidence of a compliance culture in that the operators
did not move beyond what was strictly required of them in
the NL jurisdiction even though it would be reasonable to
assume that they knew of higher standards existing in other
countries where they operated. Moreover, their flying in
arrangement made it virtually impossible, according to
Commissioner Wells calculations, to comply with the NL
standard of a 1-h wheels-up time. Thus, there was no
indication of normative CSR, of best practices or proactive
initiatives to improve SAR, at least until the Inquiry
revealed how low the standard was in an international
context. Investment in dedicated technology and personnel
was after the fact, and arguably reinforces an interpretation
of an instrumental, business case motivation for CSR; what
was not important before the crash now became salient and
triggered action.
Personal Survival Equipment
To minimize the risk of escaping from a submerged heli-
copter, the TSB recommended the mandatory use of
underwater breathing apparatus (TSB Recommendations,
Occurrence Summary). EBSs have been used by the
Canadian military since the end of 2001 (TSB, p. 47) and in
other offshore jurisdictions for a number of years (Wells
2010, p. 125). In 2000, the CNLOPB instructed the CAPP
to initiate the introduction of EBSs (CAPP T, November
16, pp. 255256). Despite periodic reminders from the
CNLOPB and the CAPPs knowledge of workers anxieties
about the lack of EBSs expressed in a 2003 employee
survey (CAPP T, November 16, 2009, pp. 178, 241263
and November 17, pp. 175), the devices were not intro-
duced until after the crash upon return to service (Wells
2010, p. 125). The EBS now attached to transportation suits
provides 2 min of air.
This 9-year delay in implementing what the CNOLPB
called a tried and tested methodology in a 2003 letter
(CAPP T, November 17, 2009, p. 22) emerged as a major
issue during the Inquiry (CAPP T, November 16, 2009,
pp. 3395, 241263 and November 17, pp. 175,
144150). It is worthwhile noting that as early as 2003
three companies operating in the North Sea using ESBs
were members of the CAPP (CAPP T, November 17, 2009,
pp. 2324). The CAPP explained the long delay by refer-
ence to the complexity of the decision, involving consid-
eration of the different types of device and their suitability
for frigid waters; redesign of suits to hold them;
researching medical implications; risk assessments; train-
ing and qualification standards; a technical standard for the
EBS; and development of a training video (T, November
16, 2009, pp. 3395). That said, no special committee had
been established to work on the project until the last half of
2004, 4 years after the CNLOPBs initial communication
(CAPP T, November 17, 2009, p. 9) and perhaps only then
because of a relatively pointed letter from the regulator in
April 2003 stating their expectation that implementation
would be in relatively short order (CAPP T, November
17, 2009, p. 22). Part of the delay seemed to be linked to
the operating companies decision to take the issue away
from CAPPs Safety Committee for a year to conduct
internal discussions (CAPP T, November 17, 2009,
pp. 4748).
CEP Counsel contrasted the time taken to achieve
important production deadlines with the lack of progress
regarding the EBSs:
the thing that leaps out at anyone who has been here
and heard this evidence today is that the people who
built the Hibernia platform or the Terra No