Accident investigation board report on fatal 2005 helicopter crash criticises operator Copterline’s safety culture

Company denies claims of missed test; Finnish authorities also blame for lax supervision

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The final report of the accident investigation board set up to determine the cause of the fatal August 2005 helicopter accident in the Gulf of Finland states that the crash that took fourteen lives was triggered by a technical fault in the Copterline Sikorsky S-76 helicopter.
      The aircraft plunged into the sea soon after take-off from the Estonian capital Tallinn, killing both pilots and all twelve passengers. The accident was caused by an uncommanded extension of the main rotor forward actuator and subsequent loss of control of the aircraft. Large pieces of aluminium bronze coating had flaked off the actuator’s pistons, resulting in blockages and causing the forward actuator to malfunction.
     
This is the finding of the Estonian investigation committee in its definitive report published on Monday, three years and one day after the accident took place. The cause of the accident remains the same as in the previously-released interim report.
      Still, the final report includes plenty of new information as well. It heavily criticises the operator Copterline for deficiencies in its safety culture.
      The committee even suggests that the accident was partly caused by the company’s failure to notice that there was an internal leakage in the main rotor forward actuator. This leakage was caused by the wear and deformation of the actuator piston rings.
     
According to the latest document Copterline’s inadequate safety culture did little to encourage the company’s pilots or technical staff to report the faults that they noticed, which is the absolute cornerstone of a functioning safety culture.
      “Particularly illuminating was the picture of a company in which defect reporting and its role in safe operations was not encouraged and taken seriously”, the report says.
      The report also states that Finland’s Civil Aviation Authority did not pay adequate attention to the problems detected in Copterline’s operations, especially the servicing of the fleet.
     
The accident resulted in a collapse in passenger figures and the subsequent termination of regular passenger service between Tallinn and Helsinki in 2006. After that, virtually the only thing that remains of the old Copterline is the company name. The firm aims to start afresh with the help of new owners, new aircraft fleet, and new management.
      Copterline’s new chief executive Kaj Takolander promises to pay close attention to the content of the report. He concedes the investigator’s claims that there were deficiencies in the maintenance record-keeping, but denies that this would have contributed to what happened, or that the fatal flaw in the helicopter would definitively have been detected by additional tests that were not performed before the accident.
     
The report will almost certainly have great weight in the ongoing legal proceedings in the United States. In the court case in the State of Connecticut, Copterline and the next of kin of the pilots and passengers who lost their lives in the accident are seeking damages from Sikorsky, its subsidiary HSI, which sold the faulty forward actuator, the actuator manufacturer Textron, and a company called PTI, which provided the plasma coating for the actuator’s pistons.
      In the latest statement of claims, Copterline alone seeks a minimum of 30 million US dollars in damages.
      The report by the Estonian officials both strengthens and weakens the position of the Finns in the case. The report unambiguously confirms the cause of the accident, but also shifts part of the responsibility to the operator.
      The court case is expected to last for some time.


Previously in HS International Edition:
  Press report: Sikorsky pays massive damages to families of copter crash victims (2.8.2007)
  Fourteen passengers and crew dead after helicopter crashes in the sea off Estonian coast (11.8.2005)
  Copterline facing partial defeat at court hearing in USA (12.9.2007)
  Loosened servo piston plasma coating confirmed as cause of Copterline crash (8.8.2007)

Links:
  Estonian Ministry of Economic Affairs and Communications: Aviation and Maritime Reports
  Copterline Flight 103 (Wikipedia, also contains links to several IntEd articles))

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