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: shart@mun.ca

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