Captain Jonathan Shelbourne, who has been stripped of his licence, was described as 'a broken man' by Sheriff Alexander Jessop, who conducted the inquiry into the crash off the Cormorant Alpha rig in March last year.
Shell, which operates the rig, was also criticised in the report for failing to ensure that its own rules requiring a stand-by vessel to be near by during flights were observed.
Ten oil workers and the co-pilot of the Super Puma helicopter died after it crashed into the sea less than two minutes after taking off in appalling weather to ferry the men to a nearby accommodation vessel.
Yesterday Sheriff Jessop called for an urgent safety review of the use of such aircraft in the North Sea oil industry. Almost 70 people have been killed in helicopter accidents in the past 10 years. Unions representing oil workers are concerned that no comprehensive code governing their use has been developed in spite of being the most common transport for men employed on rigs.
Sheriff Jessop, who conducted a public inquiry in Aberdeen, said that Capt Shelbourne caused the accident by failing to maintain his height and speed, not monitoring his instruments and then not taking effective corrective action. But he expressed sympathy for Capt Shelbourne, one of six men who survived the crash, who told the inquiry that he could remember nothing about the fatal flight.
He said: 'Never before in my experience have I seen a witness who was so clearly a broken man. I cannot, however, shrink from the responsibility placed upon me to determine that the cause of the accident was an error of judgement on the part of Captain Shelbourne.'
The Sheriff said that a garbled radio message may have distracted Capt Shelbourne's attention and a few seconds loss of concentration caused the tragedy. Shortly after the crash Capt Shelbourne, 30, volunteered for a Civil Aviation Authority medical examination. He was declared mentally unfit to fly and his pilot's licence was revoked for life.
The report said that Ian Hooker, the co-pilot who died in the crash, contributed to the disaster by failing to warn Capt Shelbourne of the helicopter's loss of speed.
Shell UK Exploration and Production, which operates the rig, was criticised for failing to provide effective rescue services.
The Sheriff said that the company did not enforce its own rules requiring a stand-by vessel to be told when helicopter flights were taking place. A boat should have been within 500 metres (550 yards) when the aircraft took off, but was two miles away trying to avoid heavy seas. He said: 'Had the stand-by vessel been advised of the movement of the helicopter and been in position . . . the deaths of some of the survivors of the accident might have been prevented.'
Shell said yesterday: 'The company took steps immediately after the accident to ensure that the procedures were adhered to.'
The Sheriff also said that some of those who died might have survived had the neck seals on their survival suits been zipped up fully. He called for all organisations involved in North Sea safety to carry out a combined inquiry into helicopter flights. This should include possible further restrictions on flying in bad weather.
The Civil Aviation Authority said it would be liaising with the Health and Safety Executive and government departments over the inquiry. A report by the Department of Transport's Air Accident Investigation Branch should be completed by the end of May.
Ronnie McDonald, secretary of the Offshore Industry Liaison Committee, the oil workers' union body, welcomed the report and particularly the call for the inquiry. He said: 'In the 28-year history of this industry no across-the-board regulations have been introduced and Shell had to introduce its own in-house rules.'Reuse content