Flight and Diversion
Helijet Airways flight 721 (JBA721), a scheduled flight from Vancouver to the Victoria Harbour helipad, British Columbia, carried 2 pilots and 11 passengers. En route, the pilots were advised that weather at Victoria Harbour was below landing limits. They diverted to Victoria International Airport and conducted the ILS/DME instrument approach to runway 09. At 1252 Pacific standard time, the crew initiated the published missed approach procedure at the decision height due to poor visibility in fog.
Weather Conditions
The 1233 PST Victoria terminal weather observation reported 100 feet scattered, measured ceiling 800 feet broken, 2800 feet overcast, with 3 miles visibility in light rain and fog. At 1300 PST, 10 minutes after the incident, the only change was 2700 feet overcast.
Crew Background
The captain, acting as pilot-not-flying, had accumulated about 4500 total helicopter flight hours, primarily in bush work and ab initio instruction, and about 1800 hours on the S-76. He received his initial class 4 instrument rating in 1992 and was upgraded to captain in April 1995. The first officer, the pilot-flying, had a military background with about 2500 hours in medium and large helicopters, and about 500 hours on the S-76 since joining Helijet in early 1995.
Approach Procedure
The published ILS/DME approach to runway 09 (dated 14 September 1995) was a conventional precision procedure with a 3-degree glide path, inbound track of 085 degrees magnetic, and a decision height of 255 feet above sea level (200 feet above ground level). The missed approach required climbing straight ahead on the localizer to 5 DME from the airport, then turning left and climbing to 3000 feet asl, traversing mostly open water and low-elevation islands. The approach document was correct and appropriate; the procedure and profile were not contributing factors.
Incident Sequence
During the approach briefing, the pilots decided to conduct the ILS at a reduced airspeed of 60 to 70 knots to improve chances of acquiring visual references, similar to Helijet's Loran step-descent approach to Victoria Harbour. Once established on the localizer, the pilot-flying reduced airspeed; the helicopter climbed on the glide path due to the higher nose attitude. To regain the glide path, he reduced collective pitch, and the rate of descent increased to about 800 feet per minute. The pilot-flying fixated on the glide-slope indicator. The captain noted the low airspeed and cautioned him to move the cyclic forward. At the missed approach point, the captain called for the missed approach. The pilot-flying applied climb power, and the helicopter turned about 100 degrees to the right without either pilot immediately detecting it. The aircraft continued on the incorrect heading for about 30 seconds until the captain saw the deviation and instructed a left turn back to the published heading. The Victoria Terminal air traffic controller also noted the discrepancy and issued radar vectors to prevent loss of separation with another aircraft on the same ILS approach. The helicopter then continued to Vancouver and landed without further incident.
Contributing Factors
According to the investigation, the helicopter flew off the published missed approach procedure because the pilot-flying lost situational awareness. Contributing to the incident was the crew's lack of low-speed ILS experience. The pilot-flying's unfamiliarity with the low-speed ILS profile led to a breakdown in instrument scan and loss of directional control. The turn was not detected due to masking by attitude changes and lack of external visual references. The captain's detection delay resulted from preoccupation with missed approach vital actions and talking the pilot-flying through the procedure.
Safety Actions Taken
Immediately after the incident, Helijet withdrew both pilots from flying duties and had them complete an instrument flying training, reassessment, and recertification program. After successful retesting by a Transport Canada air carrier inspector, both pilots returned to line flying. Shortly after, Helijet's Flight Safety unit conducted a crew resource management training seminar for all company pilots, using the incident as a primary training module. The training program was modified to include practising ILS approaches at both high and low airspeeds and continuing approaches past the missed approach point more often. Helijet's standard operating procedures were modified to require a minimum airspeed of 75 knots on instrument approaches. Additionally, Helijet introduced a new training requirement.