A report into a North Sea helicopter crash which claimed four lives has found that the pilots failed to properly monitor the flight instruments, according to air accident investigators.
They failed to notice their airspeed was decreasing until it was too late to avoid the Super Puma plunging into the sea off Shetland, a final report by the Air Accidents Investigation Branch (AAIB) found.
No mechanical fault was discovered with the helicopter, which was returning from the Borgsten Dolphin support vessel to Sumburgh Airport.
A series of recommendations for operators and pilots have been made in the wake of the crash on August 23 2013.
A "check height" audio alert was sounded in the cockpit once the helicopter fell to 300 feet, the report noted.
The commander attempted to resolve the issue but "the situation was unrecoverable in the remaining height available", according to the inquiry.
The AAIB stated: "The evidence suggests that the appropriate flight instrument displays were not being monitored adequately in the latter stages of the approach."
One possible explanation given is that the 51-year-old commander - who "had a good training and operational record" - became focused on looking for visual references to aid landing.
A transcript of the final seconds before the crash revealed that the commander said: "Wow, what's going on here? Wow, wow, wow. Oh no, oh no. No, no, no."
He then let out an expletive before the impact with the water occurred.
The helicopter rolled upside down and rapidly filled with water, but did not sink due to two automatically inflated floats, the AAIB said.
Twelve passengers and two crew escaped and survived the crash.
Of the four oil workers who died, two failed to escape from the upturned fuselage and one was found floating on the surface of the water.
A fourth passenger did make their way onto a life raft but then died. A post-mortem examination found evidence of "significant" pre-existing heart disease.
The victims were Duncan Munro, 46, from Bishop Auckland in County Durham, George Allison, 57, from Winchester, Hampshire, Sarah Darnley, 45, from Elgin, Moray and Gary McCrossan, 59, from Inverness.
The measures recommended by the AAIB include a requirement for pilots who are licensed to fly through bad weather to receive regular training on how to read the flight instruments which are specific to the type of helicopter being operated.
They called for helicopters which already must have cockpit voice recorders to also be fitted with devices to capture images.
The AAIB also recommended that large helicopters certified for offshore operation should only have cabin seating layouts which would mean that in an emergency each exit would need to be used by no more than two passengers.
The British Airline Pilots Association issued a statement, saying: "Many safety improvements have already been made to helicopter operations since this tragic accident but pilots and safety experts will be examining the report to identify what more can be done to avoid a repeat."
Keith Conradi, AAIB's chief inspector of air accidents, said: "The final report follows an in-depth and careful investigation of the causal and contributory factors.
"This has led us to make a number of safety recommendations concerning improvements to operational procedures, training, offshore helicopter design requirements and the use of technology to prevent similar accidents in the future."
(culled from home.bt.com)
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