Aviation safety investigations & reports

Technical review of the Transportation Safety Board of Canada's investigation A19Q0109 - Main rotor blade failure in flight, Robinson R44 helicopter C-FJLH, 10 July 2019

Investigation number:
AE-2021-019
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download technical review report
[Download  PDF: 227KB]
 

What happened

On 10 July 2019, a Robinson Helicopter Co model R44 helicopter, registered C-FJLH, with two persons on board, collided with terrain near Lac Valtrie, Quebec, Canada. Both persons died as a result of the accident.

The Transportation Safety Board of Canada (TSB) investigated the accident and released a public report on 31 March 2021 (A19Q0109). Subsequently, the helicopter manufacturer (Robinson) formally requested that the TSB reconsider its reported findings in relation to the role of the helicopter's main rotor blades (specifically the localised disbonding of the lower aerofoil skin of one blade) in the development of the accident.

ATSB involvement

In support of this request, on 13 May 2021, the TSB Chair formally requested assistance from the ATSB Chief Commissioner in the conduct of an independent review of the TSB report’s findings relating to the main rotor blades' role in the accident. Supporting materials were provided, including the TSB's laboratory report on the blade examination and, with the permission of the helicopter manufacturer, the submissions it provided on the laboratory, draft and public reports.

To support the review and ensure appropriate protections were afforded to the information provided, the ATSB commenced an External Aviation investigation (AE-2021-019) under the Australian Transport Safety Investigation Act 2003 (TSI Act). As such, all information received from the TSB was classified as Restricted Information in accordance with Section 60 of the TSI Act.

Investigation outcomes

The ATSB has completed its review of the TSB investigation and provided detailed feedback to the TSB management and Board under the provisions of s.62 of the TSI Act.

As such, all inquiries regarding the outcomes of this review should be directed to the Transportation Safety Board of Canada via their website: General enquiries - Transportation Safety Board of Canada (tsb.gc.ca)

Download technical review report
[Download  PDF: 227KB]
 
 
 

Summary

Following the publication of the Transportation Safety Board of Canada’s report on their investigation of this accident, a directly involved party to that investigation requested the Board reconsider some of its findings as to causes and contributing factors.

Accordingly, the Board requested the assistance of the Australian Transport Safety Bureau in conducting an independent review of the investigation report; specifically, the role of the main rotor blades in this occurrence based on the available evidence and technical analysis conducted by the TSB Engineering Laboratory.

In support of this request and to ensure the protection of any sensitive information provided, the ATSB has initiated an external investigation under the Transport Safety Investigation Act.

General details
Date: 10 July 2019   Investigation status: Completed  
  Investigation level: Short - click for an explanation of investigation levels  
Location: Near Lac Valtrie, Quebec, Canada   Investigation phase: Final report: Dissemination  
State: International   Occurrence type: Collision with terrain  
Release date: 31 August 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Robinson Helicopter Co  
Aircraft model R44  
Aircraft registration C-FJLH  
Serial number 2044  
Type of operation Private  
Sector Helicopter  
Damage to aircraft Destroyed  
Departure point Lac de la Bideire, Quebec, Canada  
Destination Sainte-Sophie, Quebec, Canada  
Last update 31 August 2021