UK AAIB October 2009

[VeeAny]

G-CBXT Gazelle 1 Nov 2008
Continued into IMC enroute and crashed while turning back.
Raises issues of who can be carried in Permit Aircraft.
http://www.aaib.gov.uk/cms_resources/Gazelle%20HT.MK3,%20G-CBXT%2010-09.pdf

G-TTHC R22 14 February 2009
Probable cause only Left Magneto selected , that magneto then failed in flight causing the engine to stop. Pilot allowed RRPM to droop beyond recoverable limit, possibly due to his inexperience.
http://www.aaib.gov.uk/cms_resources/Robinson%20R22%20Beta,%20G-TTHC%2010-09.pdf

G-CLPR R44 May 2009
Student Pilot rolled over during landing, shrapnel hit and seriously injured workman on the airfield.
http://www.aaib.gov.uk/cms_resources.cfm?file=/Robinson%20R44%20Clipper%20II,%20G-CLPR%2010-09.pdf

[BoeingMEL]

Another 'copter flies into IMC and crashes, killing all occupants. Another Robbo has its tail chopped off. On the fixed-wing side, 3 wheels-up landings and another fatal following low-level aerobatics/extreme manoeuvres. In several cases documentation, maintenance, licences, medicals invalid/expired. What can be done? Such a tragic waste. :confused:

[Torquetalk]

I wondered about that too. The aircraft will usually vibrate noticeably (and uncomfortably) on one mag due to poorer combustion.

He was really unlucky all the same. Poor sod.

[ShyTorque]

The Gazelle accident highlights a glaring deficiency in the medical examination / licensing scheme for a PPL.

I wonder how many other pilots are illegally flying with invalid medicals, and therefore invalid licences?

Also, why did this pilot take passengers with him, when he would certainly have known that this was specifically disallowed?

Next time I see this occur, I'll be very much inclined to report it to the authority, rather than just passing comment on it at the time. I did see what appeared to be passengers disembarking from another ex Shawbury Gazelle only a fortnight ago. I do recall the registration of that one, I looked up the aircraft to see if it's in my logbook, from my time instructing on these aircraft, and it is.

Presumably, either, or both, of these illegalities could invalidate the aircraft insurance.

[biggles99]

Re the Gazelle.

ShyTorque -- I doubt whether the medical, or the passengers contributed to this accident.

A classic case, as we've said so many times before of a pilot flying "in conditions beyond his capability". One bad decision, that's all it takes.

Re the R44 on take off.

I know of FOUR similar accidents in 2009. There could be more. All in R44s. All with the same result. Written off aircraft, no or minor injuries to the people inside the aircraft. But it won't be long before someone gets hurt or killed.

Could it be the way the pre-flight checks are being done that set up these accidents? Could it be that it newish "GOVERNOR ON" method is actually contributing to a loss of control - ie the aircraft getting airbourne before the pilot was ready?

Re the R22 on one Magneto.

A long, long time ago I flew from Shobdon to Redhill. It's about a 2 hour trip.

On the way down I noticed that the aircraft was flying a bit slower, using more power and sounding a bit rougher than usual.

When I did the post-flight mag check, I clicked left, and yes, you've guess it, the engine cut straight away.

So I'd flown all the way one one Mag, and even noted that the aircraft wasn't flying quite right, but still I didn't notice or check that I had "Mags on both".

Would I have survived had the engine quit? Probably, I had a few hundred hours by then. Would I have crashed? Almost certainly.

My bag of luck was obviously not yet empty, unlike the poor soul in the accident report, but I can attest that a mistake like that is very, very easy to make.

Hope this helps you all take extra care on your pre-flights.

Big Ls.

[61 Lafite]

The R44 was landing, not taking off.

Just like we've all done when students, he blew it setting down when solo and it got to be a handful, it's a scary place to be with limited experience and nobody to help you.

He just didn't get lucky like most of the rest of us did.

Lafite.

[md 600 driver]

shy

Also, why did this pilot take passengers with him, when he would certainly have known that this was specifically disallowed

where does it say on the permit that it was disallowed ? you are allowed to carry ground crew for assistance in moving the helicopter on the ground

item 5 on the gazelle permit to fly states

maximum number of occupants authorised to be carried[ including crew] FOUR ,two flight crew and 2 ground crew


just because prior to the flight there was assistance available on the ground to help manhandle the helicopter into the hanger what would happen if they were busy at the time ,Called out on breakdown , or gone to lunch [ or tiffin ]

i have spoken to the maintenance organisation about this very same matter and they told me there was someone available when the pilot left but it would not be guaranteed that they would be available when he arrived if he had his own helpers it would be guaranteed that the helicopter would be able to be put away safely

[Epiphany]

The arrogance of an individual who feels that it is pefectly OK to fly with passengers without a valid medical and licence is also the arrogance that causes flight into IMC and shortly afterwards into a hillside.

[Torquetalk]

I doubt whether the medical, or the passengers contributed to this accident.

As a cause perhaps not: But as a part of the wrong mindset about flying a helicopter maybe.


Could it be the way the pre-flight checks are being done that set up these accidents? Could it be that it newish "GOVERNOR ON" method is actually contributing to a loss of control - ie the aircraft getting airbourne before the pilot was ready?


The governor coming in because the RRPM has crept up from 75-80% and caught the pilot unawares should not lead to the aircraft becoming airborne in anything like normal conditions (i.e. no excessive wind speeds) as pitch should be full down. Maybe unexpected yaw on a very low friction surface when light could cause a nasty surprise though.

What some folks do is carry on with other tasks after the aircraft is at operating RRPM, with their eye off the ball and cyclic friction on. Losing control here can happen easily with or without governor. As you say, the aircraft is ready for flight but the pilot isn't.

In fact, the risk of losing control may well be greater without the governor as the RRPM would be higher with an uncommanded increase in pitch due to correlation error: You'd be getting a even more rotor thrust

A high rate of roll-overs in R44s in a short period of time would point towards a training/refresher training defecit.

[ShyTorque]

Re the Gazelle.

ShyTorque -- I doubt whether the medical, or the passengers contributed to this accident.

I completely disagree.

The pilot ignored those regulations in two major respects.

If he hadn't taken the pax with him, in breach of the Permit to Fly, they wouldn't have been in the accident.

According to his GP he was taking medication for migraine attacks which occurred once a week (that's a lot of migraines). The CAA, had they known about it, would have suspended him from flying until clear of these atacks and off medication for at least two months. Migraines can be brought on by stress - he was undoubtedly quite stressed on this flight, due to the poor weather he encountered. My son is an occasional migraine sufferer - I've seen how suddenly and how badly he can be affected by a migraine attack.

If he had been honest with his medical declaration, he probably wouldn't have been flying at all that day. In that event the accident would not have occurred.

[md 600 driver]

shy

If he hadn't taken the pax with him, in breach of the Permit to Fly, they wouldn't have been in the accident

the permit to fly says he can take them with him. .When when did he breach the permit ?


i didnt disagree with the other item at all

[airborne_artist]

Shy:

If he had been honest with his medical declaration, he probably wouldn't have been flying at all [and not therefore on] that day is more likely, given the two-month rule quoted.

Frankly you wonder why all CAA medicals are not carried out with full, but confidential access to the applicant's GP's notes. Nothing to hide, nothing to fear, surely?

[ShyTorque]

MD600,

That's really down to who constitutes "ground crew" and who is a "passenger", in the true meaning of the definitions. Those of us in the profession know this has regularly been exploited, as a perceived loophole in the Permit to Fly for the Gazelle.

So, were these 'passengers' or 'groundcrew' prior to the flight?

Read the CAA's own definition of 'ground crew' given in the report, page 59, lined box, top right. Were the other two occupants "engineering staff required for the maintenance of the aircraft away from base"?

Was their attendance required for the 25 hour inspection, or could it have been carried out without their presence?

If not, both were passengers on the flight and should not have been carried. The report stated that neither passenger had any engineering qualifications in this respect. I noted that the term "passenger" was used, not "ground crew", for both of them.

We used to move Gazelles around with only two people, btw. One to steer whilst holding the tail, the other to push on a rear skid tube. Including this particular aircraft when it was still XW898, in it's previous, RAF use.

[md 600 driver]

shy
i will agree that its all in the defination of ground crew and that it gets stretched and misused

Read the CAA's own definition of 'ground crew' given in the report, page 59, lined box, top right. Were the other two occupants "engineering staff required for the maintenance of the aircraft away from base"?
this isnt the caa definition as you state , it is the wording that is on that aircrafts permit to fly issued by the CAA

it would be helpfull to know if the caa has a differerent defination for ground crew than the oxford dictionary

here is the wikipedia /oxford dictionary defination

In aviation, the groundcrew is the support crew supplying the aircraft with fuel and maintenance, as opposed to the aircrew.

In airlines, ground crew members include

Airframe and powerplant technicians
Avionics technicians
Baggage handlers
Rampers
Gate agents
Ticket agents
Passenger service agents (such as airline lounge employees)
Flight dispatchers
Some ground crew members are responsible for clearing the runway and gate area of any debris or garbage, in order to prevent Foreign Object Damage by an object being sucked into an engine.[citation needed] The crew visually inspects the tarmac and removes any items found; this is typically called a "FOD Walk" and is done prior to aircraft arrival and departure

i know that in the raf you may have pushed the aircraft into the hanger but it would depend on the lenth you was pushing if you was pushing 100 mtrs you may would want additional help

i was refering to the written permit to fly that is issued by the caa ,not the accident report , as the aircraft is flown to conditions that are in the permit to fly maximum number of occupants authorised to be carried[ including crew] FOUR ,two flight crew and 2 ground crew

not what is written in a accident report

[jeepys]

Carrying 'passengers' in ex mil aircraft namely Gazelle and Scout is nothing new and I am sure the CAA know it goes on but have turned a blind eye perhaps until now.
I remember seeing a Scout on the front page of a heli mag being flown with a child in the back. Now that surely cannot be classed as a ground crew!

A question for the legal buffs out there. Would the insurance company try and prove that a passenger(s) onboard such an aircraft cannot be classed as part of that flight in light of a pay out of some description?

We all know it goes on and 9 times out of ten it goes unoticed.

[biggles99]

Shy,

you make a cogent and compelling case, and I can see exactly what you mean.

I still don't think the passengers were a factor in causing the accident. Of course you are correct about the medical, or lack of it, but this is an attitude of mind.

Yet again, is this not a classic case of the Law of Unforeseen Consequence?

If the rules are so stringent for keeping your medical that for some people it becomes impossible, you drive the problem underground.

Some will simply flaunt the law and others will find work-arounds.

Surely the authorities need to encourage pilots to come forward and get checked out without them dreading that they will be grounded?

Please note, my views here are primarily relating to Class II medicals, but the principles are the same for both Class I and Class II.

I say all this not to be contentious, but rather to fuel the debate.

Big Ls
(Class I medical holder)

[toptobottom]

Given the AAIB's inclusion of both its definition of 'Ground Crew':

5.1 Maximum number of occupants authorised to be carried (including crew): Four (Two flight crew and two ground crew, i.e. engineering staff required for the maintenance of the aircraft away from base).’

and the specific reference to the the maintenance organisation's confirmation that it had sufficicient resources to manoeuvre the machine:

The maintenance organisation stated that G-CBXT was coming to them for a 25 hr inspection. They added that they had sufficient personnel to manoeuvre the helicopter into the hangar to complete this.

the inference (thanks Whirls :ok:) is that the AAIB believes the two passengers were not authorised occupants. The CAA does seem to have turned a blind eye to the frequent flouting of this regulation, presumably because it has no material affect on the safe flight of an aircraft and, I imagine, because of the burden of proof. I can't see how carrying passengers in this case contributed to the accident, unless the pilot had a 'macho' attitude that was fuelled by his passengers' presence.

The lack of disclosure of certain (and potentially serious) medical conditions and the ease of concealment IS a worry and i agree with Big Ls that unless changes are made, pilots may continue to risk their lives and others unless better checks are put in place. I don't know how quickly a migraine can develop in a stressed environment, but it seems to me that this pilot's medical condition could very well have contributed to the accident.

TTB

[md 600 driver]

ttb
Given the AAIB's inclusion of both its definition of 'Ground Crew':


Quote:
5.1 Maximum number of occupants authorised to be carried (including crew): Four (Two flight crew and two ground crew, i.e. engineering staff required for the maintenance of the aircraft away from base).


this is not the aaib inclusion of both its definition of 'Ground Crew' it is the limitations that is written on the aircrafts permit to fly i cant see anywhere a defination by the aaib ior the caa

[JTobias]

Hi All,

Just so I understand this correctly. Are we saying that it was illegal (or whatever) to carry passengers in the aircraft full stop or simply that it was illegal to carry passengers on the flight to the maintenance company.

Joel:ok:

[toptobottom]

Joel

Illegal full stop, unless the pax were bone fide Ground Crew. The report states that there were sufficient Ground Crew at the aircraft's destination to manoevre the machine. Given that the passengers were not qualified in any other relevant way, there was no legitimate reason for them to be on board.

TTB

[ShyTorque]

Biggles, I also doubt the pax were a contributory factor in the accident (I certainly never said they were) but that isn't the point. It appears that they were carried against the terms of the permit to fly. Had those terms been complied with, they would not have been there.

MD600, You appear to be trying to split hairs over definitions of definition. The relevant definition is the one in the CAA Permit to Fly, which is the one the AAIB referred to in the report.

[JTobias]

Thanks TTB,

I therefore have to ask the question, why would anyone want a helicopter that they can't take passengers in?

Joel

[MightyGem]

The Gazelle accident highlights a glaring deficiency in the medical examination / licensing scheme for a PPL.

It's not that different with class 1 medicals. The doc's only got my word for it when I go for my medical.

I've contacted the CAA medics at Gatwick on two occasions regarding medical questions. The first was regarding prescription drugs. Yes I could take them, but I would have to ground myself for two weeks incase of side effects(low blood pressure). Should I have my BP monitored by my GP? No. Should I contact them after two weeks? No.

The second was for a hospital stay to free a frozen shoulder. I would need a week of for physio afterwards. Need I check with my AME to check that I was fit to fly afterwards? No.

On both occassions I told them that I was a class 1 and ATPL. On neither occassion did they ask for my name nor my license number.

[toptobottom]

...why would anyone want a helicopter that they can't take passengers in?

It's worse! As well as not taking passengers, a P to F aircraft means you can't fly over congested areas. Or fly at night. Or fly abroad (without permission from destination country). The CAP 733 (http://www.caa.co.uk/docs/33/CAP733.PDF) describes all there is to know about P to Fs, but in the main it's a way to allow home-builds, ex-military, vintage and gyro/microlight aircraft to get in the air when they wouldn't otherwise qualify for a C of A. Your jetbox will almost certainly have had a temporary P to F when it was new, in lieu of its C of A being issued.

So why do people buy them? They're much cheaper. When the MOD auctioned off its Gazelles, I believe some were going for well under £120k (Shy will prolly know the exact number) - not bad for a well maintained, 5 seat (and very fast) turbine. Unfortunately however, the insurance companies don't like them and it's virtually impossible for new owners to get insurance - which has driven the prices for all Gazelles down. But that's another story... ;)

TTB

[JTobias]

Cheers TTB

I was thinking I'd lost the plot!


Joel :ok:

[B47]

Are their any recorded successful autos following engine failure in an R22? It's 20 years since I owned one, and now fly a 44, but there have been enough fatal accidents attributed to, for example, carb icing with R22s, to now convince me that the real situation - engine coughs, perhaps not stops immediately, uncorrected yaw, 'is this really happening?' thoughts, waste the very small amount of time you have to get the lever down.

Practice EOLs are so unlike the real event, I'm personally not convinced that any amount of previous training equips you for this emergency in a 22 with so little head inertia. I think the student is far more concerned about what happens at the bottom, when the real issue is at the top where it is deceptively easy to practice entry to auto.

Aside from instructors, who must be on high alert and current if they spend their flying days in a 22, has any PPL ever got a silent 22 down and walked away?

[rotorspeed]

Ref the Gazelle accident, the real issue here is why did the pilot keep (pretty accurately) to a presumably straight line route that he had planned, rather than simply divert a few miles west, which would have enabled him to keep to much lower ground to the west of Gloucester where the cloud base was quite adequate at 1000ft. He was obviously aware of the lowering cloud base and rising ground, causing him to descend to an unsafe and probably illegal height.

He was clearly being too rigid in his navigation. Mention is made of him having a hand written note of his route, so he had flight planned to an extent. But was it because he was being too inflexible? Are pilots taught enough in training to be prepared to improvise in flight and modify their routing when weather requires?

[VeeAny]

Rotorspeed

I guess none of us will ever really know, but there is a disturbing trend in accidents like this where pilots tend to get on 'the pink line' on the GPS and stay on it. That may be why the AAIB elected to mention it, they can't know what he was thinking but he was tending towards the line on the GPS which took him to where the accident happened.

I am sure the phrase has been coined before but I am doing some research into what I term 'The Dangers of Direct To' and will make the results publicly available when I have something concrete.

Several people have known to six decimal places where they died in the last few years, when there was absolutely no need for them (or their passengers) to do so.

GS

[Dantruck]

VeeAny

Leaving this latest Gazelle tragedy to one side, I agree there is a great potential for the 'DirectTo..itis' you describe. I also believe it could be a growing phenomena given that, as time progresses, fewer pilots ever flew without GPS. The potential for over-reliance on any piece of technology that in every other regard improves navigation, aids safety and reduces workload, is ever present, afterall.

Try, as I have, flying with a pilot who never knew life before GPS and all that moving maps have to offer. Then try switching it off mid sector and asking: "What are you going to do now?" It shouldn't matter to a well prepared person with a plan, or even a map (which sadly also seem to be disappearing at a rate of knots), but see how many start to sweat and mutter excuses about how that never really happens; the first indicator that they don't know where they are, and don't know what comes next.

I think I'm right in saying it is still illegal to go flying without a paper map...at least it was in my day. The other great problem in doing everything on your latest Garmin is that you cannot unbolt the thing from the dash and take it inside to the kitchen table. This is where we all used to plan our flights, on our paper maps, the night before. Now, I see too many pilots planning everything between engine start and pulling collective...and in some cases even later than that. There is then a tendency for other routine flight planning to get left behind...notams, weather, PPR?... you know...the little things :rolleyes: The danger lies in the facts modern GPS is almost too good, and looks and feels like it can do everything for you. Even the ads claim as much. Then add in the human propensity for laziness and we have the first links in the chain that leads to every AAIB report.

Psychologists talk about 'set,' the propensity for humans under stress to stick doggedly to one task, even when it is not a priority and even when it is becoming increasingly irrelevant as the situation deteriorates. The effects of set can also become stronger as stress rises gradually over time, for example: as a pilot becomes steadily more concerned as the weather deteriorates. Rotorspeed has a point in that maybe, just maybe, this pilot was clinging to the GPS's track for the comfort it provided, rather than re-appraising everything and maybe turning toward lower ground, or even home. I'm assuming his viz, cloud base, etc was deteriorating gradually, but you get my point.

Would be interested to see the fruits of your research Vee. Try reading 'The Naked Pilot,' too. It will tell you all about set and the problems it has caused in the cockpit.

Dan