The Transportation Safety Board of Canada (TSB) released its investigation report on the 2021 fatal crash of an Airbus AS350 helicopter on Griffith Island in Nunavut, Canada.

According to the TSB, the inadequacy of regulatory requirements and protection measures to prevent accidents resulting from loss of visual references contributed to the tragic accident.

The helicopter, registered C-FYDA and operated by Great Slave Helicopters, was returning to Resolute Bay on April 25, 2021, when it collided with terrain, killing the two crew members and the passenger on board.

The investigation revealed that weather conditions, combined with the uniformly snow-covered terrain lacking distinct features, likely led to an unexpected loss of visual references with the horizon, a phenomenon known as “inadvertent entry into instrument meteorological conditions” (inadvertent IMC).

“For more than 30 years, the TSB has been calling for the implementation of safety measures to mitigate the risks that persist in helicopter reduced visibility operations,” Kathy Fox, TSB Chair, commented. “These are systemic safety issues that continue to put at risk the lives of thousands of pilots and passengers every year.”

The TSB issued four recommendations to Transport Canada, including requiring commercial helicopter operators to ensure pilots have the necessary skills to recover from inadvertent IMC flights and implement technologies to help avoid such situations. Additionally, single-pilot operators must develop standardized operating procedures to support pilot decision-making. Finally, it required strengthening requirements for helicopter operators conducting operations in uncontrolled airspace with reduced visibility to ensure that pilots are adequately protected against inadvertent IMC.

Following the accident, Great Slave Helicopters implemented several safety measures, including modifications to operating procedures, updates to pilot training, and the establishment of quarterly safety management meetings.

The TSB has previously identified spatial disorientation as a contributing factor in several past investigations and has issued similar recommendations to prevent such accidents.