ETAP ditching AAIB report delayed

[FrustratedFormerFlie]

Announced in Commons reply to written question today that the AAIB report on Feb's Super Puma ditching (near ETAP platform, North Sea, no casualties to avoid confusion with later unrelated disaster) will be delayed until at least next summer(ie well beyond the usual 12 months) as the investigation was "complex in nature" and required "significant consultation" with the helicopter manufacturer (clipped from BBC site today). Is anyone else confused?

[Oilandgasman]

Yes me too, have written to the MP concerned and requested clarification as to which incident the Government are referring. I could well understand a delay in the AAIB reporting on the fatal incident, but another 6 months at least for the ETAP incident regarding CFIT(W) to discuss the matter with the Manufacturer seems a long time to me.
I will post any reply I receive from the MP such that the matter is clarified.

[212man]

Yeah, you're right. It was pilot error - just print the damn report and get on with it! What's to learn from the accident? Nothing - it was pilot error.:ugh:

Maybe the AAIB take a different view on this. Maybe this was another G-BLUN that was narrowly avoided. Maybe we should detach ourselves from the 24 hours TV news culture, of instant gratification, and look forward to a detailed and indepth report that may help us all in the future :ok:


http://www.picgifs.com/graphics/f/flashing-light/graphics-flashing-light-448237.gifPS. I see from other threads, that facetiousness is often lost in the written word. For the sake of dispelling doubt, the first paragraph was facetious! http://www.picgifs.com/graphics/f/flashing-light/graphics-flashing-light-448237.gif

[Tuckunder]

212 Man, I do not agree that there is nothing to be learned from the ETAP accident. The 225 has so many "help the pilot stay out of the water" features which in this case were either not used or wrongly used. Not to mention very iffy SOPs with non flying pilot being requested to look out rather than in and some very questionable descent procedures in and out of cloud.

Whereas I think my own company operate to very safe SOPs it is always good for us to look objectively at our own fying/ procedures and ask the question could that ever have been me? A comprehensive report will provide us with definative truth as to what happened and hopefully by default make us all that little bit safer.

Tuck

[Camper Van Basten]

212 Man, I do not agree that there is nothing to be learned from the ETAP accident. The 225 has so many "help the pilot stay out of the water" features which in this case were either not used or wrongly used. Not to mention very iffy SOPs with non flying pilot being requested to look out rather than in and some very questionable descent procedures in and out of cloud.

Whereas I think my own company operate to very safe SOPs it is always good for us to look objectively at our own fying/ procedures and ask the question could that ever have been me? A comprehensive report will provide us with definative truth as to what happened and hopefully by default make us all that little bit safer.

Tuck Today 00:56

Jesus wept. :rolleyes:

[Variable Load]

Well Tuck, thanks for making me chuckle, although I know you didn't mean to.

212man finished his posting thus
For the sake of dispelling doubt, the first paragraph was facetious!

Just to help out, here is a web definition of facetious:
Treating serious issues with deliberately inappropriate humor



Thanks again for helping me smile after a long day at work :ok:

[212man]

PS. I see from other threads, that facetiousness is often lost in the written word. For the sake of dispelling doubt, the first paragraph was facetious!

Sorry, next time I'll write in bold and put flashing lights on it :ok:

[HeliComparator]

I am interested in what they will say about the EGPWS 100' audio warning that failed to sound. At a recent conference I attended, Eurocopter Safety Department said this was not a factor in the accident - perhaps they are right in that the 100' warning is too late to recover, but surely to have a warning system designed to stop you falling into the sea, but which didn't work when they were falling into the sea, is at least worthy of consideration as a factor?

I don't like the way that the EC225 EGPWS can be completely dead (eg circuit breaker popped) and yet there is no CWP warning, and if you have not selected the MISD display (and why would you?) you just get a small red "TAWS" on the FND which you may not notice if flying "visually" at night. Bring back AVAD, all is forgiven!

HC

[Hoppit]

Playing Devil's advocate, perhaps things aren't as easy as we might imagine.

Yes the actual ditching part may be straight forward, but there are probably lots of other things that aren't, such as the weather reporting at the destination, gotchas when dual rating on the L2 and 225 etc. There are probably lots of other contributary factors which could be holding up the publication.

Just a suggestion of course.........

[HeliComparator]

Hoppit, I don't think anyone is trivialising this report, as you say there will be a lot of interesting stuff if its well written (though some recent AAIB reports seem to be written by people who don't understand helicopters). I totally agree that dual rating L2 and 225 (esp during the same duty period, if that's true?) is not best practice. Unfortunately for the time being its quite legal.

I was dual rated on L and L2 for a while, didn't find that too much of a problem since they are quite different beasts. Then I was dual rated on L2 and 225 for a brief period, I found that much more of a problem, so similar and yet so different. The probability of pressing the right FADEC button under the collective in the event of an engine failure was minimal, and operating techniques to get the best out of the automation are completely different.

HC

[212man]

though some recent AAIB reports seem to be written by people who don't understand helicopters

Well, I know for a fact that the senior investigator is a very experienced helicopter pilot, and also a frequentor of these forums (since 1998, in fact!) I was fortunate enough to chat with him briefly very recently, although sadly not long enough to get into much detail on this topic.

I agree wholeheartedly about the dual rating issues, and was extremely disappointed that the operators pushed the regulator(s) to move away from separate type ratings - as JAR FCL-2 envisaged - and moved to single type with differences. If they were different types it would not be possible to fly as commander on both, in the same day (under OPS-3.)

Regarding the TAWS, I wonder if in the final stages of the descent the 100 ft call was inhibited by the normal rate of descent filtering designed to prevent nuisance warnings (crossing deck edge?) AVAD has this too - let's not open that old debate again......More to the point - why was there no TERRAIN warning ('soft' and 'hard')? My experience of the MK XXII is that it will give warning when attempting to fly into the sea.

I think this will be a good report, and will cover a whole range of issues both technical and Human Factors, as well as procedural. Questions about the use of automation will no doubt figure, and further impetus to improve the deck lighting will arise. The recent initiative by ECF to improve the flight envelope for the AFCS, for free, is very welcome, and hopefully will spur their competitor to do likewise!

[HeliComparator]

212 - well lets hope your man does a good report then. Did he also do the G-BLUN report (which IMHO missed a number of key factors and whose recommendations would do nothing much to prevent a recurrence but contained some red herrings)?

Having the 225 as a variant was a great help to us introducing the type since it cut down on the beurocratic side, but in terms of flying training and operating we have considered the 225 to be a different type (well "significanly different variant" anyway). So if the 225 L2 and L were made different types, it would not affect how we operate, what it would do is to make the beurocratic burden much higher. eg you carry out a type rating on an L pilot to EC225 (same hours etc as our current differences and operator conversion training) but instead of the TRE being able to sign your licence and start line training the next day, you can now wait 3 weeks without being able to work whilst PLD processes the paperwork, or else you can fly 500 miles to Gatwick, stay over night, wait in a long queue, then if you are lucky fly back on the 2nd day with your type rating.

Regarding the EGPWS filter for high descent rates, its the same as the AVAD in v26 - 5000'/min. That's 55mph straight down and I think if they had hit the water at that speed, it would have been a completely different outcome.

The myth that the EGPWS will give "Terrain" "Pull Up" or "Caution/Warning Terrain" to stop you falling into the sea is a bit like the myth that the S92 had 30 mins dry running time - a myth which was nevertheless believed by some pilots, possibly to their detriment and as such a dangerous myth.

I know we have been here before but there are clearly still some disbelievers so I will run through it again!

GPWS modes - Mode 1 (not active on 212's aircraft but active on the EC225) you need at least 950'/min approaching the surface to activate it.
Mode 2 - not active if the "E" part (ie the terrain database and gps position) is working
Mode 3 - takeoff phase only
Mode 4 - with gear down, only activates if IAS above about 80kts at the surface, rising to 120kts at 100'
Mode 5 - relevant to ILS only

Mode 6 - the general callouts including the "check height" and the "100". Both should have activated but I believe the suspend button was used prior to the "check height" and the "100" never sounded due to a technical fault. These are the only 2 that might have helped had they not been suspended /worked correctly.

Regarding the "E" part, ie the terrain database and gps position, as you go slower you get less look-ahead prediction until its zero below 70kts IAS, so for a profile that doesn't look too unlike a deliberate landing you don't get any warnings at all. This is why you don't get a "Caution/Warning Terrain" when you land normally, even if you land off airport ie in the jungles of Borneo!

But in this case its suspected that there were no warnings because the EGPWS box had failed.

HC

[212man]

So if the 225 L2 and L were made different types, it would not affect how we operate

Well, that's good, but is an operator driven decision that is not immune to commercial pressure - both internally and externally. Maybe other operators do not follow that philosophy. The point is that to all intents and purposes they are different types, and that has to be understood.

Regarding the "E" part, ie the terrain database and gps position, as you go slower you get less look-ahead prediction until its zero below 70kts IAS

Of course, you are correct - a brain fart on my part after a long day. The Terrain Floor activates at 70 KIAS and disappears on deceleration through that figure. However, it will be very prominent between those values, as I have seen - albeit not the case in this accident.

Mode 6 - the general callouts including the "check height" and the "100". Both should have activated but I believe the suspend button was used prior to the "check height" and the "100" never sounded due to a technical fault. These are the only 2 that might have helped had they not been suspended /worked correctly.

And this differs from AVAD in which regard?

But in this case its suspected that there were no warnings because the EGPWS box had failed.

Which would have been blindingly obvious if Terrain was a normal display on one(or more) of the displays!

[HeliComparator]

212 - your first point, no argument there! To be fair to the authorities, once it had been agreed that L and L2 were the same type rating (in 1992) it was pretty hard to say that L2 and 225 were not the same type. The difference between L and L2 is greater than the difference between L2 and 225. Therefore by association the L and 225 ended up as the same type.

Third point, not quite sure what you are saying but the whole point is that its very similar to AVAD. Its not quite as good because there are no attensons and its not repeated. Its also part of a very complicated box that is probably inherently less reliable than the very simple AVAD.

Fourth point, if an operator wanted to have the EGPWS display up all the time, there is nothing to stop them, however as a means to detect failure surely an effective CWP caption is a much better idea rather than tying up a whole screen? We don't like the EGPWS display offshore because as we all know it only contains some of the obstacle data, so is misleading whilst looking rather like radar. It doesn't tell you anything you don't already know apart from the fact that its working, but does fail to tell you things you do (hopefully) already know such as obstacles in front of you that you could hit.

HC

[marcr]

Why not adapt the take off mode to include an approach mode ?

At less than 70Kts IAS and descending, this mode could be enabled to give a SINK RATE / PULL UP warning in relation to rate of descent and RADALT height....... at values that are appropriate to helicopter operations!!

Arguably of more use than a 100' call and, with the technology now available, a practical and cost effective (?) safety enhancement.

[212man]

Why not adapt the take off mode to include an approach mode ?

Why not indeed? Sounds like a good topic for the H-TAWS working group to look at!

[HeliComparator]

marcr

Its certainly worth looking at, but to modify the EGPWS you have to have Honeywell on board, something we don't have at present. But I think the primary difficulty is how would the system diffentiate between a normal landing on a ship, semisub etc versus an unintentional landing on the water. In the case of the ETAP event, gear was down, "AVAD" suspended and all set for landing - they just landed a couple of hundred metres short! If the system gave a false warning every time you landed offshore, it would be ignored, switched off etc and add no value.

Theoretically you could for example have all the installations with their deck elevations in a database linked to the FMS/GPS so that it knew what your destination was (assuming you put it in the FMS/GPS as the destination, which I think we all do), then if you descended below deck height +50' more than (say) 50 metres away you would get a warning.

Difficulties:

1) Need to keep the database of semisubs, ships etc right up to date, tricky for moving ships and for FPSOs where the helideck swings around a large area in currents/wind.

2) This system doesn't exist, who is going to mandate or pay for it?

Perhaps more robust SOPs are a better solution? At the moment all 3 N Sea operators follow completely different SOPs and the CAA are powerless to standardise us - all they can do is check compliance with JAR-OPS 3, which of course we all are.

HC

[marcr]

I accept that this adaptation wouldn't be straight forward but, given the circumstances, more than worth pursuing.

The main point really is to see this as an approach mode and not a landing one. If the primary alert trigger is an excessive rate of descent once deemed in the approach phase then databases of deck heights etc are not an issue. Onshore, the approaches are in part covered and protected by the ILS mode. Does the CAA/EASA mandate this for fixed wing?

I agree wholeheartedly that robust SOPs are an essential part of creating a safer environment in which to operate. However, having an SOP is one thing, always and strictly operating to it is another.....

Adapting the TAWS, using available technology, would provide a last line of defence when, for whatever reason, an aircrew find themselves near the surface and in difficulty. This I believe was the original intent of the 100' call.

It's a pity that Honeywell aren't on board. Perhaps they can be persuaded.

If I was flying a computer that had the capacity (?) to warn me that I was approaching the water very quickly, (and, crucially, at a point where the aircraft still had the capability to fly away), shouldn't I and my passengers be disappointed, (understatement), that an alarm is not generated ? (Though the event is perfectly recorded!)

The 100' call was perhaps appropriate to the technology at the time its usefulness became apparent. Modernise......

Marc

[FrustratedFormerFlie]

Having started this thread I guess I'm allowed to come back. First off, I'm not a journo: ex fixed wing pilot, now working in oil industry, non flying. My confusion was why extended consultation with the manufacturer would be required re an incident where an aircraft which, by all accounts was serviceable at the time, made an uncontrolled landing on water. I can understand any amount of discussion with crew, aircraft operator, or even (in light of informed debate here about same-family multi-typing which I was unaware of) the regulators. But why the manufacturer instead?

[Training Centre]

I see scope for another forum here (Moderator?) The question I would like all offshore pilots to consider is whether TAWS/EGPWS is fit for purpose in your environment - particularly at night or when weather is at minima.
There is a suggestion that there may be an issue between helicopter installations (i.e. it works well in some types and is cr@p in others).
Your thoughts please?
TC

[212man]

It would be interesting to find out if the missed 100ft call was an infrequent but known problem amongst crews. On the 92 the EGPWS is used to generate all the aural alerts - not just the TAWS ones - and it is not uncommon for us to look at each other and say "did you hear the xyz call?" (normally "LEVEL OFF" or "ALTITUDE, ALTITUDE".) Going back to the RoD filtering, I also wonder if the rate of pitch up could contribute to the perceived RoD?

Training Centre,
I would say it is not perfect and has room for improvement, but is streets ahead of AVAD! Hopefully the H-TAWS group will make progress in addressing these shortfalls, if Honeywell can be persuaded to listen/understand.

[HeliComparator]

Training Centre

Clearly 212 and I disagree on this point, but that's OK, its a purely subjective matter!

My experience is that pilots don't like it for offshore because it gives too many spurious warnings - eg approach a platform just a little too fast (not too fast for safety, just too fast for the EGPWS) and you get a "CAUTION OBSTACLE" nuisance warning. Carry out a rejected takeoff in accordance with the Flight Manual, you get a "TAIL TOO LOW" nuisance warning. Fly over 150kts with the gear down (not applicable to the S92!) and you get a TAWS CWP caption with amber CAUT attention getter.

And then, when someone successfully flies into the sea, no warnings!

Rumour had it that in a certain African country it was standard practice to switch the whole thing off once offshore - that is what you get when a piece of equipment is too distracting and irritating.

Now for onshore ops, as I have said, its very good, but then how much of our time do we spend doing that?

HC

[212man]

I would say it is not perfect and has room for improvement

I would have thought that was your view too, HC, n'est pas? :ok:

My experience is that pilots don't like it for offshore because it gives too many spurious warnings - eg approach a platform just a little too fast (not too fast for safety, just too fast for the EGPWS) and you get a "CAUTION OBSTACLE" nuisance warning

Liaise with the TAWS and airframe manufacturers to change the parameters, if this is the case. Adopt SOPs that set the LOW ALT mode when entering the field?

Carry out a rejected takeoff in accordance with the Flight Manual, you get a "TAIL TOO LOW" nuisance warning.

In the 92 it is not a spurious warning - there is very little tolerance with this alert. It doesn't mean you have hit the tail, just that you are uncomfortably close to doing so.

Fly over 150kts with the gear down (not applicable to the S92!) and you get a TAWS CWP caption with amber CAUT attention getter

Again, liaise with the OEMs if it's a genuine problem. Or, maybe, devise SOPs that don't have the gear down so early. When do FW lower their gear? Normally around G/S capture. One thing (E)GPWS will do well is tell you the gear is up and, last time I checked, we can hover, so it's not the end of the world!

I'm sure that the big three UK operators can effect changes from the OEMs with a combined voice. I managed to get SAC to accept that having the Flight Director mode annunciator in Green, regardless of coupled status, was a bad thing and it was changed (albeit it's now yellow when uncoupled, and I hope/believe that will change in the future) so I'm sure the TAWS amendments you seek must be attainable, with the clout you all have.

Surely the way forward must be to accept that H-TAWS is a good thing in general, use it in it's current state and then give feedback and suggested improvements on the shortfalls to make it the way it needs to be? Adopting the comfort blanket approach of "I just want my HSI and AVAD" get's us nowhere! :E

[HeliComparator]

212

The problem with "CAUTION OBSTACLE" is that if you decrease the lookahead sensitivity, you also do that for a genuine obstacle such as a radio mast, so that you lose the protection onshore. The problem is that we are trying to land on the obstacle! It would be better IMHO not to have any platforms in the database, since as we already said its not the complete picture as it doesn't include semisubs etc. I have found Honeywell to be pretty unresponsive to the requirements of a sector that represents a tiny minority of its sales (ie offshore helis) so whilst the configuration could be changed (by EC) I doubt the underlying system nor database concepts could be.

I don't particularly like Low Altitude mode since it dumbs the system down and it has to be reset manually. Why have a warning system when you dumb it down just when you probably need it most?

In the 225 Flight Manual it says that if you get the "TAIL TOO LOW" on a reject, just ignore it and carry on with the profile as per the Cat A procedure. The callout gets triggered not just from the proximity of the tail (ie radalt height) but also its rate of change, so with a "positive" flare to 20 deg nose up (IAW RFM) you get the warning even though you might be at 30' or so.

Don't forget that we can fly ILS above 150kts with the gear down, so even if we put the gear down late (on GS capture) we would still get the warning. And on descent into the field offshore we normally do the approach checks including gear down at 10nm or so on descent, IAS approaching 160kts.

Of course we could fly slower, alter our SOPs to cater for the deficiencies of the EGPWS but surely that is cart before horse? It should be a system that helps us and improves safety, not one that has to be "flown around" and possibly introduces new hazards (eg late gear down).

Bottom line is that offshore, I can't think of a scenario where it gives me anything significant better than correctly set radalt bugs and AVAD. But it does create nuisance warnings, has to be fiddled with and adapted to. But maybe you can think of an offshore scenario where there is benefit?

HC

[Avnx EO]

A few things stike me as odd here. For one, it looks like the EGPWS is being used as a means to meet JAR-OPS 3.660 which requires that all helicopters flying extended over water be equiped with a radio altimeter providing aural and visual warnings when descending below a pre-determined height. By regulation, the alerting point is not allowed to be adjustable by the pilot. AIL/0114 recommends that height to be not coincident with standard approach decision heights, etc. so 100 or 150 feet heights are typically considered appropriate. It appears, however, the EGPWS (Class A) is being used to satisfy this requirement (Class A because it uses rad-alt in its algorithms - but as noted, there are conditions for which those algorithms are inhibited.)

So because of these other features, the aural alerting is being allowed to be inhibited in order reduce nuissance alerts which occur. But this is also inhibiting the basic, required-by-reg radar altitude based alerting ?? Am I getting that right ???

This stikes me as thowing away the baby with the bath, and I'm a bit surprised that the installation this way is considered compliant. (i.e. the reg doesn't allow the alert to be adjusted - supposedly to prevent it from being set at too high, too low, or at a level out-of-range to effectively inhibit its function, like you could a DH alert - but then they allow the pilot to punch it off completely with a button press in flight ???)

I would have expected the rad-alt based call-out to be non-inhibitable regardless (whether the aural is provided by the EGPWS or by a second, independent system connected to the rad-alt.)

I'm assuming in this case the CFIT was a slow descent into terrain (water) where the simple, required, rad-alt based alerting alone would have been effective.

Sometimes it seems to be the complexity that bites us.

[HeliComparator]

Avnx

The Bond aircraft had EGPWS Mk XXII v26 In that version the suspend button behaves just like the one for AVAD - it suspends the "check height" generated by going below the pilot-set radalt bug, but does not affect the "100" call. The EGPWS audio inhibit button inhibits all audio warnings for 5 minutes, except the "check height" and "100" which are unaffected. Its true that there is an on/off switch for the whole system, therefore its slightly easier to turn the whole system off than for AVAD, where it was necessary to pull the circuit breaker.

Although there is filtering to prevent nuisance warnings when measured rate of change of radalt is >5000'/min, this is the same as for AVAD. The radalt data is otherwise used directly to trigger the mode 6 "check height" and "100" callouts, without further processing or algorithms. However as you say, complex does not necessarily mean better and it is perhaps true that the EGPWS is a complex box full of software and therefore could be considered less reliable than a straight AVAD, but otherwise it is a fair replication of the functionality of AVAD.

Therefore I consider that the EGPWS does comply fully with JAR-OPS 3.660, but it is complex thus affecting pilot's understanding of how it works as well as reliability and probably its effectiveness offshore.

HC

[hands_on123]

G-REDU report is out

Air Accidents Investigation: 1/2011 G-REDU (http://www.aaib.gov.uk/publications/formal_reports/1_2011_g_redu.cfm)


>>>> Summary

Report on the accident to Eurocopter EC225 LP Super Puma, G-REDU near the Eastern Trough Area Project (ETAP) Central Production Facility Platform in the North Sea on 18 February 2009
Report name:
Report on the accident to Eurocopter EC225 LP Super Puma, G-REDU near the Eastern Trough Area Project (ETAP) Central Production Facility Platform in the North Sea on 18 February 2009
Registration:
G-REDU
Type:
Eurocopter EC225 LP Super Puma
Location:
Near the Eastern Trough Area Project (ETAP) Central Production Facility Platform in the North Sea
Date of occurrence:
18 February 2009
Category:
Public transport - Helicopters
Summary:

The Aeronautical Rescue Co-ordination Centre (ARCC) notified the Air Accidents Investigation Branch (AAIB) of the accident at 1912 hrs on 18 February 2009 and the investigation commenced the following day.
In accordance with established international arrangements, the Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) of France, representing the State of Design and Manufacture of the aircraft, appointed an Accredited Representative and was supported by additional investigators from Eurocopter. The operator co?operated with the investigation and provided expertise as required.

Prior to this Final Report, the AAIB published Special Bulletins on 24 March 2009 and 23 June 2009.

Twenty-seven Safety Recommendations have been made.

The helicopter departed Aberdeen Airport at 1742 hrs on a scheduled flight to the Eastern Trough Area Project (ETAP). The flight consisted of three sectors, with the first landing being made, at night, on the ETAP Central Production Facility Platform. Weather conditions at the platform deteriorated after the aircraft departed Aberdeen; the visibility and cloud base were estimated as being 0.5 nm and 500 ft respectively. At 1835 hrs the flight crew made a visual approach to the platform during which the helicopter descended and impacted the surface of the sea. The helicopter remained upright, supported by its flotation equipment which had inflated automatically. All those onboard were able to evacuate the helicopter into its liferafts and they were successfully rescued by air and maritime Search and Rescue (SAR) assets.

The investigation identified the following causal factors:

1. The crew’s perception of the position and orientation of the helicopter relative to the platform during the final approach was erroneous. Neither crew member was aware that the helicopter was descending towards the surface of the sea. This was probably due to the effects of oculogravic[1] and somatogravic[2] illusions combined with both pilots being focussed on the platform and not monitoring the flight instruments.

2. The approach was conducted in reduced visibility, probably due to fog or low cloud. This degraded the visual cues provided by the platform lighting, adding to the strength of the visual illusions during the final approach.

3. The two radio altimeter-based audio-voice height alert warnings did not activate. The fixed 100 ft audio-voice alert failed to activate, due to a likely malfunction of the Terrain Awareness Warning System (TAWS), and the audio-voice element of the selectable 150 ft alert had been suspended by the crew. Had the latter not been suspended, it would also have failed to activate. The pilots were not aware of the inoperative state of the TAWS.

The investigation identified the following contributory factors:

1. There was no specified night visual approach profile on which the crew could base their approach and minimum heights, and stabilised approach criteria were not specified.

2. The visual picture on final approach was possibly confused by a reflection of the platform on the surface of the sea.


[1] An oculogravic illusion is a visual illusion that affects the apparent position of an object in the visual field. A full explanation is provided in Appendix A and B to this report.

[2] A somatogravic illusion is a non-visual illusion that produces a false sensation of helicopter attitude. A full explanation is provided in Appendix A and B to this report.

[WaveWarrior]

While a considerable amount of time and effort has clearly gone in to compiling this report, there are 2 key areas which have not been sufficiently dealt with, namely the operating philosophy of Bond Offshore Helicopters at the time of the crash, and the regulatory oversight of its operations by the CAA.

Night Operating Procedures.

In many decades of both miltary and civil VMC operations to offshore decks at night, it has always been the norm to fly to a "gate" to establish a safe range, height, speed and into wind heading from which to obtain full visual contact with the surface and landing area (ie the helideck or its immediate vicinity) and to then fly a stabilised approach with regular and frequent reference to the instruments to ensure that the approach remains under control. This procedure was valid for both single pilot and multi crew operation.

The minima for night VMC operations, ie 5k visiblity and 1200ft cloud base with a minimum operating height of 1000ft, were in use by both the other major offshore operators at the time of this crash. Descent below this height was not permitted until within 10nm of the destination and in full visual contact with the surface and the destination. If these conditions could not be met, an ARA should be flown.

It would appear from this report, that Bond's SOPs permitted the crew to descend to 300ft outside 10 nm of their destination and neither in sight of the surface nor in visual contact with the helideck. They did not appear to use the "Gate" philosophy at the time of the crash. Their use of a radalt bug setting of 150ft when operating over the sea at night was also lower than the norm of 300ft which affords significantly more time to correct a potentially dangerous situation.

This SOP seems to have been such a significant departure from the accepted operating norm, that I cannot understand how Bond's operational management can have proposed such potentially unsafe operational limits in their Operations Manual, and how the CAA regulators can have approved them. By allowing the crew to operate in this way, the Operator and Regulator had removed a significant amount of the protection afforded to the passengers and crews of other companies conducting night operations on the North Sea.

Operating the EC225.

The EC225 has a superb 4 axis autopilot which affords an excellent level of safety if its capabilities are fully exploited. It allows the Handling Pilot to retain fully coupled control of the aircraft while making fine adjustments to heading, speed, height or rate of descent. This allows him to remain totally in control of the aircraft at a minimum airspeed of 30kts and offloads him from the intense concentration required when flying manually to exacting limits close to the surface. It gives him the time to assess his landing area and to decide whether to proceed with the approach or execute a Go-Around. The Monitoring Pilot therefore remains free to monitor the instruments and identify departures from safe parameters for the approach.

When executing a Go Around, both All Engines Operating and One Engine Inoperative, the autopilot will use the full power available by pulling to the first limit (TQ, TOT or N1) thus giving maximum take-off power when AEO, or if an engine failure has occurred, will droop the Nr to 96% and accelerate the aircraft to the indicated Vtoss, pulling OEI High power, before climbing the aicraft at that power until a lower power setting is selected by the Handling Pilot.

Reading the report, it appears that Bond's operating philosophy was to use the EC225 as if it were an inferior AS332L2 and neither to use the go-around protection at low speed (below 80 knots), nor to make continuous use of the upper modes of the autopilot until the final third of a mile when commencing the final descent on sight picture to the deck. It begs the question - why buy a state of the art machine and not use the fantastic safety features it offers to protect the passengers and crew?

Once again, it seems that Bond's operational philosophy did not follow best practice or make full use of the safety features designed in to the aircraft. Why not, and why was this situation not picked up during the inspection regime and corrected by the regulatory authority?

2 Crew Operations.

The report has identified that Bond's Operations Manual did not adequately define the responsibilites of Handling Pilot and Monitoring Pilot during the approach phase of night deck operations. This lack of clarity and inadequate training allowed both the crew to be sucked in to concentrating on external references, rather than dividing their tasks so that effective monitoring could identify dangerous parameters building up, allowing early and decisive intervention.

Once again, Bond's procedures seem to have been lacking and this was not identified and corrected by the regulatory authority.

Bond's response to the Morcambe Bay crash.

The risk assessment carried out by Bond's management following the fatal crash determined that their common procedures for the L2 and the EC225 were robust. If one accepts the erronious premise that operating to the lowest common denominator of capability of 2 significantly different variants of an aircraft type is sensible, then one can see why they came to that in-house conclusion. Why did the CAA not point out the flaw in their logic and require best practice to be adhered to.

Given the specific remit by the CAA to review their procedures following a fatal accident, why did Bond's management not make the decision to separate their AS332L2 and EC225 fleets and operate them with separate crews, making full use of the EC225s superior safety features? Why did the CAA oversight not identify this shortcoming, when other operators were already operating to higher standards?

Overall Thoughts.

It seems to me that the AAIB report has not fully covered the corporate and regulatory aspects of this crash.

While the crew's actions have been analysed in considerable detail, the apparent failures of Bond's management to operate their aicraft using their full safety features and to use procedures which complied with industry best practice have not been properly addressed. Similarly, there seems to be little or no analysis of the CAA's responsibility for exercise of proper regulatory oversight of Bond's activities and to ensure that Bond's Operations Manual was up to date with current best practice, especially in the light of the directions given to them in 2007, and that their Type Rating Training Organisation methods were rigorously scrutinised.

Neither of these major areas of concern have been sufficiently examined and exposed by this report. Had the proper procedures been in place in Bond Offshore Helicopters, as they were in the other 2 main North Sea operators, this crash could have been avoided. Fortunately the Automatic Float Deployment System fitted to aircraft prevented the crash becoming a tragedy.

[bondu]

TV - surely it doesn't really matter who WaveWarrior works for, the points raised are totally valid. After the Morecambe Bay crash (when I personally lost a friend), one would have thought that good SOPs for night approaches, with appropriate 'gates' and monitoring, would have been introduced. When I worked for the 'old' Bond, we had 'gates' and good SOPs for night approaches, so what has changed?
WW has made some very pertinent points which deserve an answer from the appropriate authorities.

bondu :\

[ScotiaQ]

Readers of this thread need to remember that "Old" Bond Management was dispersed to the four corners of the world, at the time of the merger with BIH. The Management of Bond Offshore is a totally different animal, the only common denominator is Peter & Stephen Bond.

Also remember that the accident to G-BLUN was under the ownership of CHC and not Bond.

Sq

[HeliComparator]

TV, a little defensive if I may say so! Perhaps it would be more constructive to learn from the report rather than just lashing out at any criticism of your great company!

Anyway, I think what frustrates the longer-established operators is that we had these accidents at least 20 years ago and consequently our Ops Manuals had reasonably robust procedures to address the issues. Which by the way is not to say that nothing was learnt from Morecombe Bay and to a lesser extent this accident.

Because we are longer-established, we have more baggage aka more overhead costs, but we consider that the extra cost is justified in terms of enhanced safety. Then along comes the brash new upstart Bond with very light experience and an immature Ops Manual, but has low overhead costs and thus can undercut BHL and CHC on many contracts. The oil companies, despite all the bluster about safety, just go for the cheapest option which is Bond. And continue to do so after an accident which is easily put down to the immaturity of the company.

That causes us frustration! But not with Bond, rather with the oil company culture where bottom line is everything!

WW - the only thing I would say about your criticism of the regulatory oversight by CAA is that its actually quite difficult for them to do much other than check for compliance with JAR-OPS, JAR-FCL etc. The nuances of such things as night offshore operating procedures are something that CAA are probably not the experts on.

But I do agree with your point that the accident was caused by the company culture, not by the individuals in the cockpit at the time.

HC

[Hummingfrog]

Interesting reading the report as I have been based on ETAP. The weather reports at night from ETAP cannot in reality be anything more than a guess by the platform personnel.

There is no method of measuring cloudbase or visibility. When the offshore shuttle was moved from the 40s (which had a cloudbase measurer) a similar system was asked for but not forthcoming.

The removal of the standby boat removed any way of estimating visibility as the nearest platform is in excess of 10nm away so once viz comes below 10nm you are staring into blackness and it is impossible to say, with any form of accuracy, what the viz is. The flare stack is approx 500ft high so if the cloud can be seen scudding through it you know it the cloudbase is around or below 500ft. Otherwise pure guess work.

One question that should be asked is why there was no cloudbase recorder fitted - especially after a request was made for one circa 2007?

The N Sea has many local weather patterns so you can't rely on cloudbases measured from other rigs. I have seen ETAP VMC while the 40s about 45nms away was in fog.

HF

[squib66]

Is there any action to give weather observers better equipment?
Has Bond changes its FORA procedures?
Are the other operators flying offshore in the UK (CHC, Bristow, NHV, British International) making any changes after this accident?

[HeliComparator]

Bristow reviewed its Ops Man and training after the Morecombe Bay accident to tighten up on the offshore approach procedure, esp the visual bit. After the initial report on ETAP, there was a further minor amendment, not really to change what we did but more to make it more rigorous (and this accident had different factors). I don't think we will be changing it again now that the full report is out. Having a 225 Sim (or two!) and 92 Sim in Aberdeen of course makes training in preparation for dark nights much easier and better for those fleets.

[Brian Abraham]

The oil companies, despite all the bluster about safety, just go for the cheapest optionHope you're not tarring Shell with that brush HC. "Shell Management" will take umbrage. ;)

[212man]

The report has identified that Bond's Operations Manual did not adequately define the responsibilites of Handling Pilot and Monitoring Pilot during the approach phase of night deck operations

Sounds remarkably familiar! Look at Finding (vii) in the following report (1987 S76A incident)

http://www.aaib.gov.uk/cms_resources.cfm?file=/5-1988%20G-BHYB.pdf

vii) The layout of the non-handling pilot's duties, in the Operations Manual volumes pertinent to the S-76A, may have led to some confusion as to the co-pilot's required participation in the flight.

[HeliComparator]

Brian - not yet, after all they remain as one of our prime customers (for the time being!)

[212man]

HC,
out of interest do you operate your 225s using CR.HT and IAS hold down to 30 kts (wind allowing) for night ops? Also, have you embodied the mod that ECF announced last year that gives velocity hold (I think)?

[HeliComparator]

Hi 212,

No, we use pressure alt hold rather than CR.Ht for the following reasons:

It is more precise
It has 3 sources of compared data (2 ADC + ISIS) as opposed to a single radalt, so much higher integrity.
ALT is arrived at via vertical speed mode over which the pilot has control, CR.HT engages straight away and the a/c goes to the set height not under vertical speed control of the pilot.
GA mode from CR.HT with the current version of software we have, just climbs to 300' then levels off, whereas GA mode from ALT transitions you away on 1 or 2 engines hands off. (The issue of GA from CR.HT is fixed in the latest software which we don't have for other buggy reasons!).

ALT can be engaged down to zero IAS, and we use IAS hold down to 30 kts if necessary. One needs to be careful with IAS datum at 30 kts because if turbulence causes IAS to go below 25kts or so for several seconds, it may drop out. On the other hand, turbulence is normally associated with wind so if it is turbulent, you don't need to go right down to 30kts or you would be going backwards!

The mod for x y velocity mode (GSPD mode) is part of the latest software that we don't like for other reasons. We tried it and didn't like it! We should get a "fixed" version later this year. It was nice of EC to give it to us for free, but to be honest I don't rate the x y velocity hold for offshore arrival because it is designed for SAR, not offshore approaches. The hover-meter display is nice for IMC SAR but when approaching a rig you need to be looking out! When in that mode, the accel/decel rates are very slow compared to IAS mode, and the aircraft will maintain a constant heading even if you bank it with the cyclic. It is very uncomfortable and cumbersome compared to using ALT, IAS and Heading hold (down to 30 kts IAS), those modes are great. But EC have some much better modes under development!

[212man]

Thanks HC - very interesting and I look forward to hearing more about the new modes when they appear. I must say that I wish the S-92 IAS hold went down to 30 kts (it's 55 kts) as that would make a big difference in the ability to remain coupled for approaches at night and in DVEs. Lets see how the new approach mode turns out.......:ok: