TSB Recommendation A24-01

Despite the prevalence of loss of visual reference accidents involving visual flight rules (VFR) helicopter operations, and even though some VFR helicopter pilots are authorized to fly in visibility as low as ½ statute mile, there is no requirement for Canadian commercial helicopter operators to ensure that company pilots possess the skills necessary to recover from inadvertent flight into instrument meteorological conditions (IIMC).

During this investigation, the TSB discovered that some Canadian commercial helicopter operators with pilots who possess instrument flight rules (IFR) flight experience place considerable importance on equipping their aircraft and training their VFR pilots for IIMC recovery when operating above the tree line during the winter months. However, other companies that only conduct VFR operations, including Great Slave Helicopters 2018 Ltd. (GSH), have adopted and rely on an “avoid-at-all-costs” approach to IIMC. This approach, which is permitted under the Canadian Aviation Regulations (CARs), relies on a pilot’s ability to avoid IIMC and to fly solely by reference to outside visual cues.

As seen in this occurrence, and many others highlighted in Air transportation safety investigation report A21C0038,See Air Transportation Safety Investigation Report A21C0038, sections 1.18.8.2 Previous investigations, 1.18.8.3 Australian Transport Safety Bureau Investigation AO-2013-216, and 1.18.9 TSB statistics on loss of visual reference accidents, and Appendix F TSB investigations involving loss of spatial awareness during commercial helicopter flights. it may be ineffective to rely on an approach predicated on intentionally avoiding something that is unintended. Given the number of IIMC accidents that have occurred, and that helicopter accidents are more than twice as likely to involve a loss of visual reference than are airplane accidents, it is apparent that the “avoid-at-all-costs” approach to IIMC is not effective when used in isolation. The reliance on this approach can place pilots and passengers at increased risk of IIMC accidents because that approach typically encourages pilots to fly lower and slower as the weather deteriorates until they determine it is no longer safe to do so. This approach typically puts helicopters at close proximity to the ground in a flight profile that could make it harder, if not impossible, to transition to flight instruments if visual references are lost.

When the occurrence pilot recognized the need to take evasive action, he lacked the skills necessary to safely transition to instrument flight and carry out a pre-determined IIMC recovery procedure, such as climbing straight ahead or conducting a 180° turn to return to visual meteorological conditions, before all external references were lost. Instead, the occurrence pilot most likely relied on the technique he was trained to use, which was to continue flying by reference to outside references, until inadequate visual cues existed. This technique resulted in the occurrence helicopter inadvertently impacting the terrain when the pilot likely encountered IMC due to flat light and whiteout conditions.

Following a series of flat light and whiteout condition accidents involving commercial VFR helicopters in the United States (U.S.), the U.S. National Transportation Safety Board issued several safety recommendations in 2002 aimed at reducing these types of occurrences. As a result of these recommendations, the U.S. Federal Aviation Administration made changes to the Federal Aviation Regulations. One of the most notable changes was an initial and recurrent requirement for commercial helicopter pilots to demonstrate that they possess the skills necessary to recover from an IIMC encounter.Federal Aviation Administration (FAA), Code of Federal Regulations, Title 14, Part 135, paragraph 135.293. The Helicopter Association International has also recognized the need for action and has developed a comprehensive approach to IIMC that includes training on both avoidance of, and recovery from, IIMC situations. This approach is endorsed by the United States Helicopter Safety Team and the Helicopter Association of Canada.

In Canada, the flight test to obtain the private and then the commercial helicopter licence requires that pilots demonstrate several skills such as hovering, steep turns, and autorotations. Additionally, a pilot must demonstrate the ability to maintain control by reference to flight instruments during simulated IIMC.Transport Canada, TP 3077, Flight Test Guide – Private and Commercial Pilot Licence (Helicopter), Third Edition (February 2013), Item Ex. 30 – Instrument Flying. This shows that helicopter pilots with limited instrument flying experience can be trained to carry out an IIMC recovery procedure solely by reference to flight instruments.

Once pilots obtain their commercial licence, several of these flight test requirements (e.g., autorotations) must be demonstrated during annual pilot proficiency checks. However, despite the number of helicopter IIMC accidents and associated fatalities, there is no requirement for commercial VFR helicopter pilots to demonstrate during pilot proficiency checks that they retain the skills necessary to recover from IIMC. Since there is no requirement to maintain this skill set, there is no requirement for commercial VFR helicopter operators to provide their pilots with IIMC recovery training. Without recurrent training, either in the aircraft or through other means, skill erosion will occur. The more time that has elapsed since pilots were last tested on the ability to recover from IIMC, the less likely they will have both the skill and confidence to carry out such a manoeuvre under real-life conditions.TSB Aviation Safety Study 90-SP002, Report of a Safety Study on VFR flight into adverse weather (13 November 1990).,Australian Transport Safety Bureau, AR-2012-122, Avoidable Accidents No. 7: Visual flight at night accidents: What you can't see can still hurt you, (17 December 2013). Therefore, the current regulations allow VFR helicopter pilots to operate in environmental conditions conducive to a loss of visual references, without any assurances that they possess the skills necessary to recover from an IIMC encounter.

In 1990, the TSB issued Recommendation A90-81 calling for Transport Canada (TC) to require verification of proficiency in basic instrument flying skills for commercially employed helicopter pilots during annual pilot proficiency flight checks. After a lack of action by TC over several years, the Board considered TC’s response to this recommendation to be Unsatisfactory and changed the recommendation status to dormant.The assessment determines that there is a residual risk, but no further action is planned to be taken, and continued assessment will not likely yield further results. Dormant recommendations will not be assessed on a regular basis. However, occasional reviews will be conducted to see if any dormant recommendations should be reactivated. The Board may also reactivate a dormant recommendation at any time if actions that significantly reduce the residual risk have been taken.

Because there is no requirement for commercial helicopter operators to ensure that pilots possess the skills necessary to recover from IIMC, the pilots and passengers who travel on VFR helicopters are at increased risk of collision with terrain following a loss of visual references.

Therefore, the Board recommended that