Human error and inadequate training were the primary causes of a fatal 2006 Cormorant military helicopter crash off Canso, N.S., the military has found.

Three of seven crew members died of drowning on July 13, 2006, after the search and rescue helicopter nosedived into the Atlantic Ocean while out on a night-time training exercise, breaking the helicopter in two.

Crew members survived the initial impact, but some were unable to escape because of blocked emergency exits, according to a final report on the incident released Tuesday. They also couldn't reach emergency breathing equipment, and seat harnesses were difficult to release.

The accident itself occurred because of the pilot's flying technique and the flight crew's "misperception" of their aircraft's flight path.

CTV Atlantic's Rick Grant said that the pilot hadn't been behind the controls for roughly 90 days, had very little Cormorant experience, had no over-water experience and hadn't fulfilled retraining requirements.

The pilot "had overridden the autopilot and was trying to carry out manoeuvres on his own," he said.

Grant said the pilot was also vainly trying to gain a visual reference from the water.

The helicopter was attempting to carry out a night-time hoist from a fishing boat, something that Cormorant pilots consider among the most difficult maneouvres they have to carry out, Grant said.

The report found the crew's monitoring of its flight instruments was "inadequate." It said the helicopter was in good mechanical shape and weather was not a factor.

Training an issue

Training flights were restricted and limited to only a couple of hours because of persistent cracks in the aircraft's tail rotor hubs, according to the report.

The impact of that was "underestimated and inadequately addressed," it said.

The report also noted: "The crews could maintain currency by achieving the minimum requirements, but as time progressed, repeatedly meeting just these minimum requirements was not enough to keep their skills at a level where the . . . crews felt safe."

A senior officer with 1 Canadian Air Division says that restrictions have been lifted. Brig.-Gen. Yvan Blondin says flights have been increased to five hours and proficiency is now at "satisfactory levels."

Cormorant crews told a January 2006 survey that they were concerned about their declining skills.

British instructors who operate flight simulators had noted that Canadian crews shown lower than expected levels of proficiency.

However, the military never formally studied the issue.

Grant said the report makes 26 recommendations for improvements, with the military saying 21 have already been implemented.

More than 60 changes in total have been implemented in the Air Force in response to issues arising from this crash.

The interior layout of the Cormorant has also been changed so that crew members could escape more easily in the event of another crash, he said.