No one was injured when a Cougar Helicopters flight fell to within 11 metres of the ocean's surface after takeoff from the SeaRose offshore oil production vessel on July 23, 2011.
A report resulting from an investigation into the afternoon flight was issued Thursday by the Transportation Safety Board (TSB).
It explains how the helicopter, with two crew members and five passengers aboard, lost speed and rapidly dropped more than 150 metres, with emergency warnings sounding.
The captain and first officer regained control, but only a second from disaster.
The TSB found the near-crash was not a result of a mechanical failure. Gaps in training and procedural issues were pointed to as contributing causes.
The captain brought on an automatic control early in the flight. The helicopter's nose tipped up in response. Speed dropped, the autopilot shut down and the aircraft lost altitude.
The person at the controls was apparently shaken up.
"The captain, subtly incapacitated possibly due to spatial disorientation, did not lower the nose of the helicopter," the TSB found. "This contributed to the excessive amount of altitude that was lost during the inadvertent descent."
The helicopter was saved by the crew when it was about the length of a standard school bus away from the ocean's surface.
"Sea spray was being kicked up by the helicopter's rotorwash and it was covering the windows," the TSB report states.
In the crash of Cougar Helicopters Flight 491 in March 2009, a drop in oil pressure began 28 minutes into the flight.
Capt. Matthew Davis and his co-pilot, Tim Lanouette were calling a mayday to Gander just 22 seconds after the oil problem first emerged, but used their training to continue to work the problem over the course of 11 minutes before, largely as a result of a mechanical failure beyond their control, their helicopter fell to the water.
In 2011, there was much less time.
The flight was less than a minute away from the helipad when the trouble with speed and altitude started. To the point of recovery, the entire incident lasted less than two minutes.
The release of the TSB's report was followed by statements from the provincial NDP and Liberals criticizing the Canada-Newfoundland and Labrador Offshore Petroleum Board (CNLOPB) for not having provided more information sooner on the close call - now more than two years in the past.
"I am shocked that we find out only today, and only courtesy of the federal agency, what exactly happened ... and what exactly Cougar did to help prevent a recurrence," stated NDP leader and MHA for Signal Hill-Quidi Vidi Lorraine Michael.
"One of the recommendations Judge Robert Wells made in his November 2010 report on the Cougar 491 tragedy was the creation of a powerful independent offshore safety authority, as has been done in more progressive jurisdictions around the world such as Norway, Australia and the United States."
She suggested a separate safety authority would have issued "ongoing updates" on the case.
Liberal Transportation and Works Critic Tom Osborne said the 2011 event was "too close for comfort."
"Government needs to step up to the plate and establish a safety regulator that can be proactive instead of reactive to ensure that we are doing everything we can to prevent incidents like these and tragedies like those of Cougar 491," he stated.
"Ultimately, an incident like this is the mandate of the TSB to investigate," said CNLOPB chief safety officer Dan Chicoyne.
Unlike the TSB, he said, the CNLOPB has no access to onboard voice and data recorders or ability to call forth witnesses.
Information gathered by the board in this case was provided in a public "incident bulletin," issued the day of the close call.
The board offered an update in a second written statement, issued Aug. 11.
"Aside from the initial incident itself, we didn't have much information to put forward," Chicoyne said, adding the board is careful not to issue statements of fact if there is a risk they might be incorrect.
However, he said, the likelihood of pilot disorientation having potentially played a role in the case was an early finding and led the CNLOPB to push for an increase in simulator training for pilots, focused on spatial disorientation.
"The only way to overcome that is with training in the simulator," he said.
One pilot not given new training hours was the one in charge during the close call. He was fired on July 28.
The same day, the rest of Cougar's pilots were told the captain had "made no attempt to recover the aircraft from an easily recoverable situation which resulted in coming as close to a crash as you can without crashing."
In an emailed statement Thursday morning, a spokeswoman for Cougar Helicopters said any recommendations coming from the TSB will be followed.
"Cougar continues to be a leader in safety awareness and, through its commitment to continuous improvement, it is a leader and an advocate of the promotion of Canadian, indeed global, aviation safety. The organization continues to strive for and target excellence in every aspect of its day-to-day operations - some of which is from lessons learned," she said.
"Actions noted from past experiences are, where appropriate, incorporated into pilot and engineer continuous recurrent training. Further, as noted within the TSB report, Cougar has already initiated new enhancements within its flying program."