Pushing a series of four key reforms to improve helicopter safety, the Transportation Safety Board today released its final report into the fatal 2009 crash of Cougar Flight 91 off the coast of Newfoundland.

“We want the legacy of this accident to be a safer system for all those who fly over water,” said Board Chair Wendy Tadros. “We know what happened that day; our goal now is to make sure helicopter safety is improved, from takeoff to touchdown.”

The report which highlights a complex web of 16 factors, states that Flight 91 ran into trouble when titanium studs broke on the main gearbox filter bowl. This led to a total loss of oil, which 11 minutes later ultimately brought the helicopter down.

Although upgrades have since been made to all S-92A’s worldwide, Tadros said the Board’s final report goes further, citing specific concerns about certification standards, and whether helicopters should be able to operate longer following a massive loss of oil.

“All S-92A helicopters should be able to ‘run-dry’ for at least 30 minutes. That’s key. In addition, we want the FAA to look at today’s operating environments—Hibernia, the Arctic, the North Sea, any of these extreme locations—and decide whether even 30 minutes is enough time.”

Tadros said the Board also focused on passenger survival over Canada’s often hostile waters. “If the sea state is too rough for a successful emergency ditching, then a helicopter shouldn’t be operating. Period. In addition, we’re calling for emergency air supply on all helicopter flights that require survival suits, not just those off Newfoundland.”

Flight 91, which was taking workers to the offshore Hibernia oil production platform, went down approximately 35 nautical miles from St. John’s. Only one person survived.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.