Pasadena Police - two OH-58s make contact

[helihub]

Early reports suggest one was in the process of taking off and the other one landing - time was 4pm local Saturday. General scene of the result, followed by closer up shots of each - one with apparent damage to the rear fuselage, and the other to the front screen

http://kfmb.images.worldnow.com/images/20127952_BG1.jpg

http://cdn.abclocal.go.com/images/kabc/cms_exf_2007/news/local/los_angeles/8889534_600x338.jpg

http://i.i.com.com/cnwk.1d/i/tim/2012/11/18/police_helicopter_620x350.jpg

That last one is none too clear, but the only still I can find at the moment. There are some videos including this one

Pasadena police helicopter crash: Feds to probe collision | abc7.com (http://abclocal.go.com/kabc/story?section=news/local/los_angeles&id=8889807)

ALTADENA, LOS ANGELES COUNTY (KABC) -- A federal investigation is set to get under way into a crash involving two Pasadena police helicopters.

The National Transportation Safety Board was expected to begin their investigation Sunday morning.

Six people were injured - five officers and one civilian observer. All were taken to area hospitals to be treated for minor injuries.

Officials say the helicopters' rotary blades may have touched during a maneuver at the police helipad on Yucca Lane in Altadena Saturday at about 4 p.m. One helicopter was taking off while the other was landing at the time of the incident.

Each Bell OH-58 helicopter was extensively damaged. One helicopter was on routine assignment to calls for service and the other was assigned to the USC-UCLA game at the Rose Bowl. Each helicopter had a pilot and an observer. Two of the injured were not on board.

These helicopters monitor not only Pasadena, but also Altadena, Glendale and Monrovia. Some residents were concerned that the damaged helicopters could affect police patrol coverage. Authorities say there's nothing to worry about.

"Well, obviously having two helicopters down is a major problem for us. But because we have six, four of which are still completely operational, we will be able to patrol our area as well as provide our mutual aid service to other areas in our partnerships and our taskforce," said Lt. Phlunte Riddle with Pasadena police.

[Agaricus bisporus]

One aircraft terminally mangled from the cargo compartment aft and the other looking thoroughly second-hand above the gearbox platform and - am I mistaken, considerable disruption to the fuselage aft and boom too? Neither with gearbox or rotor system present.

one with apparent damage to the rear fuselage, and the other to the front screen

Fabulous understatement! That sounds like a softening-up report to the insurance company!

[PANews]

I wonder what the insurance value of even two 40+ year old Bell OH-58A's is.... bearing in mind that the buying in price was somewhere between zero and $100 .... insurance company's tend not to pay out on home improvements.....

They were lucky no-one was hurt.

It looks like they may have to look back into the cupboard at the Enstrom's they still seem to have in their charge to fly at all for the next few months.

[John R81]

I'm off to buy shares in T-Cut. It is going to take gallons to polish that out :)

[heli-cal]

Six people injured, two aircraft written off.

Professional pilots... Not!

[Anthony Supplebottom]

We can't really judge till we know a little more - but, on the surface, I admit it looks bloody silly.

[PANews]

It looks as if someone was reading my mind.... one of the latest reports on this accident states that.... 'damaged helicopters are Vietnam War-era Bell OH-58 models, and had minimal insurance coverage because they were obtained through a military program' and that they have three functional aircraft available for continued operations.

[heli-cal]

Whilst they still have airworthy helicopters, perhaps they'll consider recruiting pilots capable of flying them.

[John Eacott]

Video seems to have just surfaced showing this bingle:

https://www.youtube.com/watch?v=qHMhsD8OFCs

NTSB Accident report (https://www.ntsb.gov/about/employment/_layouts/ntsb.aviation/brief2.aspx?ev_id=20121118X14342&ntsbno=WPR13GA044A&akey=1)

[[email protected]]

How the hell did the guy stood by the nearest aircraft not die?????? Very lucky boy.

It isn't easy to see but it looks like there are painted squares on the dispersal which, if both aircraft are on them, give rotor clearance.

But, the one dragged out for what looks like a ground run, is positioned off to one side.

If the incoming pilot assumes the one on the ground is in the right place and just positions himself over the 'second' spot without checking, then intermeshing rotors do what intermeshing rotors do...............

[John Eacott]

Have you read the NTSB report, crab@?

[Cows getting bigger]

Disappointed in the hittee, mostly:

a. didn't switch off his strobe on vacating the aircraft.
b. didn't wander straight across to the hitter and thump him.

[finalchecksplease]

Disappointed in the hittee, mostly:

a. didn't switch off his strobe on vacating the aircraft.
b. didn't wander straight across to the hitter and thump him.

a. Would have been difficult because the switch is on the overhead panel which got chopped off.
b. Would have been difficult to hit him seeing its a her!

[[email protected]]

Have you read the NTSB report, crab@?

I have now! I am clearly regressing to youthfulness as I was only focussed on the shiny video rather than the link to the wordy bits:)

An interesting discrepancy in the pilots opinions on parking outside the 'box' - the less experienced guy on the ground says it was normal practice to park the aircraft outside the box - the very experienced lady who has been there 22 years said she had never seen the aircraft parked outside the box!

Perhaps the HF element of this is that if you operate in the same place for 22 years you get into a very established routine, make assumptions that it will always be the same and then fail to notice when something is out of the ordinary.

[Hughes500]

Experienced lady ?? I wouldn't expect a ppl to make such a fundamental error of judgement. Nothing quite like spacial awareness :ugh:

[DroneDog]

Reading the official report the female pilot stated visual conditions were not great with rainwater beading on the side windows. Fair enough I suppose, she also stated she was unsure if the other helicopters rotor was rotating, again I thought under those weather conditions it would be difficult to spot a rotor aligned front to back.
Until the actual impact. Then I could see the parked heli's rotor (as it fell off) had white strips. Not sure how she missed the spinning rotor with those white markings.

[atr-drivr]

To me it sure looks like the departing AC was not rolled out to the yellow marked pad and the inbound looks like they were landing on their yellow marked pad...:ugh:

[gator2]

For the life of me, I can't understand how this could happen. It says "DANGER" right there on the tarmac. In two places!

[SASless]

The Police Chief....said there were some "Lessons learned"....would one of them be hiring Professional Pilots and not putting experienced police officers through a very brief training course and making them Pilots be the wiser option?

I see some very STUPID actions in the video.

You cannot account for fits of Dumb Ass no matter who you hire, train, promote, retain.

[[email protected]]

And although the rain might have been beading on the sidewindows, she clearly yaws to point at the other aircraft after coming to the hover and moves forwards to the landing spot.

By the time she turns the tail again for landing, there is no way she couldn't have seen that the other aircraft was rotors running or that it wasn't on the square, yet she still carried on.

Sas - if she was a cop turned pilot, she can't have done too badly to get so many hours and have flown for so many years - unless she has had a long list of incidents that didn't make youtube.

[GrayHorizonsHeli]

Ive heard of police departments going great lengths to convince managers that a fleet upgrade to B3e's was necessary....this takes it to a whole new level. Congrats on the unique fleet renewal program that not many will undertake.

[r22butters]

Landing on the same spot, in the same way day after day for years, then one day things are slightly off and visibility is poor,...?

Sometimes **** just happens, and the scary truth is this could easily happen to any of us! Complacency's a bitch, and the only real way to avoid it, is to change jobs/aircraft/location every couple years or so.

,...or watch a video like this and remember in time.

[malabo]

The first complacency and lack of professionalism was from the doughheads that pushed the helicopter out and didn’t put it on the spot. Spots that are there to assure a safe distance. I’ve operated from a tight Apron with 8 pads, and if you were even a few inches off your ears got boxed. Chief needs his boxed for failing to promote a professional operation - as seen from the miscreant’s comments on positioning.

[[email protected]]

I think the report states that initially the second aircraft was intended to be tasked as well as the first one, so presumably the expectation was that ship #2 would be airborne long before ship#1 returned - that makes the positioning less vital if you are under pressure to get the aircraft airborne.

[Carbon Bootprint]

Among the other failings mentioned, the report notes there was no established UNICOM or uniform procedure for a helicopter on approach. Incoming aircraft were apparently detected only by hearing them, which nobody on the tarmac apparently did prior to this incident due to the bird running on the ground.

To their credit, the report states that after the fact, PFD did add monitored UNICOM and approach procedures to their toolbox. I Googled PFD air support section to see how/if they replaced these two ships, but the only reference I could find was one dated 2010 which still mentioned the OH-58s lost in the 2012 prang. Does anyone know the current state of affairs there?

[roscoe1]

There is the root cause, which is that the pilot of the moving helicopter hit a stationary machine. No getting around that fact (blades turning or not, that part is kind of like saying "I didn't know if it was loaded and it just went off"). Guns are always loaded and things are always in your way until you know they are not. Then there is the list of mitigating factors, the incorrect parking, the rain, hard to see turning rotors (the strobe should have been a giveaway, cant miss that), the intended departure prior to return of second aircraft all made it so that by being complacent and assuming clearance the pilot guided the aircraft into the other. What if it had been real gusty....still the pilot's fault. Pitch black and power failure of helipad lights....still pilot's fault. There are always safer but perhaps less convenient options that we simply ignore because we are basically sort of lazy. This happened because someone was complacent. That needs to be accepted. It is a real shame they parked the stationary ship where they did and I could see splitting the root cause and blame but one ship was moving and one was not.

[LRP]

There is the root cause, which is that the pilot of the moving helicopter hit a stationary machine. No getting around that fact (blades turning or not, that part is kind of like saying "I didn't know if it was loaded and it just went off"). Guns are always loaded and things are always in your way until you know they are not. Then there is the list of mitigating factors, the incorrect parking, the rain, hard to see turning rotors (the strobe should have been a giveaway, cant miss that), the intended departure prior to return of second aircraft all made it so that by being complacent and assuming clearance the pilot guided the aircraft into the other. What if it had been real gusty....still the pilot's fault. Pitch black and power failure of helipad lights....still pilot's fault. There are always safer but perhaps less convenient options that we simply ignore because we are basically sort of lazy. This happened because someone was complacent. That needs to be accepted. It is a real shame they parked the stationary ship where they did and I could see splitting the root cause and blame but one ship was moving and one was not.

As we used to say, "there it is".

[2016parks]

"she also stated she was unsure if the other helicopters rotor was rotating" Isn't it a fact that sometimes a rotating blade simply cannot be seen on reasonably quick examination--because it is moving! If so, are pilots trained to know that fact? How then could she safely rely on "the absence of a visible blade"?

[BigMike]

Or she could have just landed outside the other aircrafts estimated rotor disc like she should of, regardless of where it was parked...
There is only one person to blame for this accident.

The crew in the parked machine were bloody lucky...

[ZFT]

There is the root cause, which is that the pilot of the moving helicopter hit a stationary machine. No getting around that fact (blades turning or not, that part is kind of like saying "I didn't know if it was loaded and it just went off"). Guns are always loaded and things are always in your way until you know they are not. Then there is the list of mitigating factors, the incorrect parking, the rain, hard to see turning rotors (the strobe should have been a giveaway, cant miss that), the intended departure prior to return of second aircraft all made it so that by being complacent and assuming clearance the pilot guided the aircraft into the other. What if it had been real gusty....still the pilot's fault. Pitch black and power failure of helipad lights....still pilot's fault. There are always safer but perhaps less convenient options that we simply ignore because we are basically sort of lazy. This happened because someone was complacent. That needs to be accepted. It is a real shame they parked the stationary ship where they did and I could see splitting the root cause and blame but one ship was moving and one was not.

That's not a root cause

[r22butters]

"she also stated she was unsure if the other helicopters rotor was rotating" Isn't it a fact that sometimes a rotating blade simply cannot be seen on reasonably quick examination--because it is moving! If so, are pilots trained to know that fact? How then could she safely rely on "the absence of a visible blade"?

Say the other chopper's blades weren't spinning and she parks in her spot without incident,...they're still too close.

Now the other chopper starts to spin up and WHACK they hit!

Who's to blame now?

[John Eacott]

This incident reminds me of a similar helipad collision on an offshore pad on the Great Barrier Reef, IIRC out of Cairns, back in the early 90s. The pilot of the shut down helicopter (Bell 222?) had shut down with the blades fore and aft but unable to be tied down as the tail was out over the water. The landing helicopter (LongRanger?) collided with a blade and there was a fatality as a result. The 222 pilot was nowhere near the machine, yet ultimately was blamed for the accident which turned nasty with charges laid against him. IIRC his defence against accusations that he should have secured the blades with the rotor brake was that such an application was specifically prohibited in the Flight Manual.

I've searched for a reference without luck, someone else out there may remember the accident and have more accurate details but it never ceases to amaze me the unexpected outcomes of an accident. The pilot was well known and lost a significant amount of money on legal expenses which were unrecoverable as charges were ultimately withdrawn.

[ShyTorque]

Seems there is lots of real estate behind those helicopter landing points. The sensible thing to do, in case of any doubt of tip clearance, would be to have landed on the grass and sorted out the parking issue later, using a marshaller if necessary.

[Flyting]

According to Google Maps, looks like the two parking spots have now been replaced by one.

[skadi]

According to Google Maps, looks like the two parking spots have now been replaced by one.

Yucca Ln
Altadena, Kalifornien 91001, USA

https://goo.gl/maps/EkE1fdja3NA2

[601]

that makes the positioning less vital if you are under pressure to get the aircraft airborne.

No

That is why the bl00dy things are painted on the tarmac, to prevent this kind of accident.

Same as guidance lines and parking bays for fixed wing aircraft. They are there for a reason.

[2016parks]

"Say the other chopper's blades weren't spinning and she parks in her spot without incident,...they're still too close. Now the other chopper starts to spin up and WHACK they hit! Who's to blame now"

I would think that regardless of what markings are painted on the ground, the arriving machine has a duty to stay far enough away from the parked machine so that both can be safely operated. But: in addition, the parked machine should not , thereafter, spool up unless it knows that it can do so safely. It's like driving your car--"who has the right of way" becomes secondary when one has the opportunity to avoid an accident. The doctrine is called "last clear chance".

[r22butters]

"Say the other chopper's blades weren't spinning and she parks in her spot without incident,...they're still too close. Now the other chopper starts to spin up and WHACK they hit! Who's to blame now"

I would think that regardless of what markings are painted on the ground, the arriving machine has a duty to stay far enough away from the parked machine so that both can be safely operated. But: in addition, the parked machine should not , thereafter, spool up unless it knows that it can do so safely. It's like driving your car--"who has the right of way" becomes secondary when one has the opportunity to avoid an accident. The doctrine is called "last clear chance".

Seems to me that the reason those markings are there on the ground are to ensure the aircraft are parked a safe distance from each other in the event someone may be landing with less than ideal visibility and therefore cannot judge accurately their distance from the other parked aircraft?

Is that why those markings are there? Anyone know for sure, 'cause I'm just guessing?

[Fareastdriver]

If the first one had been pulled out of the shed and positioned on to the waiting square this accident wouldn't have happened.

[[email protected]]

No

That is why the bl00dy things are painted on the tarmac, to prevent this kind of accident.

Same as guidance lines and parking bays for fixed wing aircraft. They are there for a reason.

Regardless of what is painted on the tarmac (the area could be contaminated with oil/fuel etc) the accident was still very preventable if you don't land too close to the other aircraft.

This is a little 2-pad heliport not an international airport.

If you are expecting to launch immediately and the other aircraft isn't expected back until later then why be pedantic and take more time over exact positioning of the aircraft?

The failure to leave enough clearance by the pilot of the landing aircraft is the overriding cause of this accident - the other bits are additional holes in the swiss cheese.

[2016parks]

We trust that the painted markers are correct. We trust that the other machines will stay away from us. We trust that the landing instructions are correct. We trust that ATC is doing its job correctly. We trust that the other pilots are as smart as us. The entire scenario is built on trust. If we cannot trust, what do we do?

[Simplythebeast]

That could quite easily been prevented by having someone on the ground to meet the helicopter as it landed......he/ she could have used dayglo or illuminated batons. They could be called marshallers. Or is that a bit difficult?

[[email protected]]

It seems the Passadena police learned quite a lot from this accident as their dispersal is much bigger and very differently marked - I assume they now have comms as well.

We trust that the painted markers are correct. We trust that the other machines will stay away from us. We trust that the landing instructions are correct. We trust that ATC is doing its job correctly. We trust that the other pilots are as smart as us. The entire scenario is built on trust. If we cannot trust, what do we do? we never assume and always check as much as we can, never being afraid to ask questions whether it is of ATC or other pilots.

Blind trust is like expecting everyone else on the roads to drive perfectly all the time and we all know that doesn't happen.

If something is within your control - like checking the proximity of another aircraft, why not be sure rather than just 'trusting'.

The Flight Safety poster - ASSUME makes an ASS out of U and Me - seems appropriate.

[whoknows idont]

If you are expecting to launch immediately and the other aircraft isn't expected back until later then why be pedantic and take more time over exact positioning of the aircraft?

That's why:

[roscoe1]

That's not a root cause

Perhaps I wasn't clear enough. The root cause was that the pilot didn't take enough care in picking a landing spot because they were complacent about using the painted marks, or simply didn't take enough time to see what they were looking at. If you think that wasn't the root cause what would you suggest? Surely not that the stationary ship was poorly positioned?

[whoknows idont]

I think it's a bit like someone parking his car on a railroad crossing, assuming that he will be long gone by the time the train arrives or that the train driver will see him in time and avoid collision.

Sure, the arriving pilot messed up big time. I wouldn't give her much more than 50% of the blame though. The guys on the ground acted extremely negligent as well.

[pilot1234567]

The Police Chief....said there were some "Lessons learned"....would one of them be hiring Professional Pilots and not putting experienced police officers through a very brief training course and making them Pilots be the wiser option?

The pilot has 16,000 hours. It wasn't just some cop they pulled off the street and threw a few hundred flight hrs at.

[roscoe1]

I think it's a bit like someone parking his car on a railroad crossing, assuming that he will be long gone by the time the train arrives or that the train driver will see him in time and avoid collision.

Sure, the arriving pilot messed up big time. I wouldn't give her much more than 50% of the blame though. The guys on the ground acted extremely negligent as well.
Semantics always get in the way. Here is what I mean by root cause. Simply by parking an aircraft in the wrong place does not cause an accident. Arriving at the pad and hitting a parked aircraft....that causes an accident. There are many things that may make an accident more likley given normal human behaviour but there can only be one root cause by definition. I prefer to think of tap roots, one big root cause, rather than a dendritic mesh calling each factor a minor root clause. That allows us to focus on the action that caused the accident. If you choose to not blame the pilot because of the error someone else made by parking in the wrong place that is fine by me, but the root cause remains the same. It is always the pilot's responsibility to see and avoid obstacles, even if they are in unexpected places.

[r22butters]

Semantics always get in the way. Here is what I mean by root cause. Simply by parking an aircraft in the wrong place does not cause an accident. Arriving at the pad and hitting a parked aircraft....that causes an accident. There are many things that may make an accident more likley given normal human behaviour but there can only be one root cause by definition. I prefer to think of tap roots, one big root cause, rather than a dendritic mesh calling each factor a minor root clause. That allows us to focus on the action that caused the accident. If you choose to not blame the pilot because of the error someone else made by parking in the wrong place that is fine by me, but the root cause remains the same. It is always the pilot's responsibility to see and avoid obstacles, even if they are in unexpected places.

If this had been an open ramp at an airport it wouldn't have happened. If the weather hadn't reduced the pilots ability to judge her distance this wouldn't have happened.

If I couldn't tell my distance from another chopper when landing on marked company pads, I'd of done what she did and focused on the markings which are supposed to keep us appart, and crashed too.

If it was just an open ramp at the airport I'd of just set it down anywhere, no harm no foul.

The root cause was one pilot not parking where they should have combined with bad weather and another pilot trusting the safety measures which were in place, not realizing that they weren't.

Sure, she should have just set it down, and is partially to blame, but who can honestly say given the same scenario they would have done it differently?

You're coming home to a familiar company pad, the other chopper is running up, I think its safe to assume that most of us wouldn't even think that that other chopper wasn't where it should be.

[BOBAKAT]

"faith is nothing without doubt" Never trust anyone in this job ! Always be aware....

[601]

A root cause is an initiating cause of either a condition or a causal chain that leads to an outcome or effect of interest. The term denotes the earliest, most basic, 'deepest', cause for a given behavior; most often a fault.

The "earliest, most basic cause" was not parking the departure helicopter on the correct location.

If that helicopter on the ground was in the correct location, irrespective of the reason for being on the tarmac, that collision would not have happened.

[[email protected]]

The "earliest, most basic cause" was not parking the departure helicopter on the correct location.No, that is a strong contributory factor but the primary cause is that she landed too close (and with very good sight of) the other running helicopter.

If that square had been contaminated and was unusable due to a fuel or oil spill that the arriving pilot didn't know about and the aircraft had been positioned in the same way - but for a clearly good reason - then would you still blame 50% on the positioning crew? Of course not - it is down to the landing pilot to keep clear.

Whoknowsidont - sometimes operational urgency means getting things done as expeditiously as possible.

[EESDL]

It saddens me but I have to agree with Crab in this occasion ;-)
There could have been many reasons for the aircraft not to have used the box. The position of the chopper did not cause the crash - the landing helicopter caused the crash.
The parking position was a contributory factor, just as the reduced visibility due to the rain - but such factors did not cause the crash.
Such factors should not be regarded as ‘semantics’ but essential in an effective investigation.
Having lights on the parking box might have given a visual clue to the landing pilot that the parking was not as expected but that was not the cause - the cause was the landing pilot manoeuvring the chopper into the parked aircraft.

[Nubian]

No, that is a strong contributory factor but the primary cause is that she landed too close (and with very good sight of) the other running helicopter.

Crab,

What you are referring to is the result of several factors, not root cause. Flying your helicopter into another one sitting on the ground is a result of several factors, and when analysing this you can identify the root cause, which the collision it self is not.
The root cause was what the police has taken action on after this happened and changed, and that was the marginal clearance between the two pads, which has been a latent problem for a long time.

The crew parking the helicopter incorrectly was a contributing factor. The complacency (easy to get after 22years) of the landing pilot being used to land on its marked pad, and never seen helicopters parked outside their designated pad in 22 years and 16000+ hours. The SOP's, rain, end of shift, training, habits, pilots nearsightedness, etc. All contributing factors.
Take away the marginal clearance of the 2 pads, and we would not have this thread.

From the NTSB report, the helicopters would have less than 2 feet tip separation when running and parked on it's markers, as the rotor diameter of the OH58 is 35 feet and the free space between the two pads center was 37 feet. Would be ok for one helicopter rotors running at a time, but very close and no room for errors with 2 rotors running.

[Bull at a Gate]

John Eacott, the incident to which you refer was in late 1985.

https://www.atsb.gov.au/publications/investigation_reports/1985/aair/aair198503546/

[whoknows idont]

If that square had been contaminated and was unusable due to a fuel or oil spill that the arriving pilot didn't know about and the aircraft had been positioned in the same way - but for a clearly good reason - then would you still blame 50% on the positioning crew?

Yes, I would. You either put an aircraft on a pad or you don't. Never put it next to one with too little clearance and then start up. Especially if you know that one a/c is still out there yet to return to base. That is just sheer negligence. If one hasn't been usable, use the other one and make sure the one not usable is marked in a way and let arriving aircraft know via radio. Place someone on the ground watching out, marshalling the arriving aircraft.

The Flight Safety poster - ASSUME makes an ASS out of U and Me - seems appropriate. I'm with you; both the arriving pilot as well as the guys on the ground made a lot of unsafe assumptions that display a drastic lack of safety culture.

From the report:
The pilot stated that he placed the helicopter on the outside of Pad 1; he knew they would be off the ground in a couple of minutes or he would be up on radios. The pilot stated that his thought process was that, when he was up on radios he would check the weather, and request the pilot of N911FA start toward the priority call.That sort of complacency directly led to this accident. Yes, physically one airframe was moving and the other was not. Regardless of the verbatim definition of a root cause, for me there is clearly two main reasons for this accident to have happened. The pilot on the ground was obviously aware of the lack of physical clearance.
Everyone involved in aviation has to make sure to contribute a hole-free slice of swiss cheese. The goal must always be not to let complacency, assumptions, operational urgency or any other reasons get in the way of a safety based thought process.

Also I would give a good chunk of blame to the operation as apparently there were no clear procedures established and the design of the pad was questionable at best.

[[email protected]]

Nubian, if I drive my car into a bridge support that is just clear of the road (but was compliant with all the building regulations at the time it was built) is it the fault of the builder?

No, of course not, it is my fault because I misjudged the clearance (for whatever contributory reasons, rain, confusing road markings, not paying attention) - that is the root cause of the accident.

As with the helicopter, the second aircraft could have been parked there all day long without being the cause of an accident - the mishap only occurred with the introduction of the landing helicopter.

The primary and root cause was the pilot of the landing helicopter landing too close to the running one - she made a misjudgment, just as if she had taxied into the side of a hangar or a lighting stanchion.

[BigMike]

100% agree with Crab on this one...
You are landing a helicopter beside another, which is running, all your focus has to be on clearance from that aircraft.
If in doubt just land on the grass, and wait till they have departed...
Sorry, but this is all pretty basic.
Good news is, no one got seriously hurt... except for the Kiowas...

[SASless]

Rubbish!

If you are so dense to not be able to process a flashing strobe light, rotating rotor blades, and the position of the other helicopter on a pad you have used for YEARS...then you certainly have a very real problem with cognitive awareness.

There is a hanger building and fuel system for visual reference as well.

The arriving crew had multiple opportunities to figure out the situation.

Yes...I have flown OH-58’s in those conditions and have operated from aprons very similar to the one in question and have spotted aircraft on the MARKED spots.

No matter the departing crew parked the aircraft improperly...the handling pilot of the landing aircraft owns this one!



If this had been an open ramp at an airport it wouldn't have happened. If the weather hadn't reduced the pilots ability to judge her distance this wouldn't have happened.

If I couldn't tell my distance from another chopper when landing on marked company pads, I'd of done what she did and focused on the markings which are supposed to keep us appart, and crashed too.

If it was just an open ramp at the airport I'd of just set it down anywhere, no harm no foul.

The root cause was one pilot not parking where they should have combined with bad weather and another pilot trusting the safety measures which were in place, not realizing that they weren't.

Sure, she should have just set it down, and is partially to blame, but who can honestly say given the same scenario they would have done it differently?

You're coming home to a familiar company pad, the other chopper is running up, I think its safe to assume that most of us wouldn't even think that that other chopper wasn't where it should be.

[2016parks]

Is one taught to land/park far enough away from other aircraft so that if both aircraft start their rotors, there will be no engagement?

[Outwest]

This reminds me of an accident that happened in the early 80's in BC. At the companies main base the ramp space was limited and spots to land to be able to reach the fuel hose were also limited. A 206 was wheeled out of the hangar after maintenance and left there unattended with the blades fore and aft but not tied down. A company pilot came in and landed beside the parked 206 and was doing his cool down at ground idle when a newly hired apprentice seen that the parked 206's blades were not tied down. Having been told that it is not good to ever leave a 206 outside without the blades tied down......you can see where this is going.

Yes, he went and retrieved the tie down from the a/c, hooked the forward blade and proceeded, to the dismay of the pilot in the still at ground idle 206, to walk the blade around to tie it down. Luckily no one was injured in the ensuing catastrophe.

So, what was the root cause here? There were many factors that lead to this accident and breaking any one link in the chain could have prevented it, but IMHO the ROOT cause was either the small available ramp space or the limited length of the fuel hose.

[Nubian]

Nubian, if I drive my car into a bridge support that is just clear of the road (but was compliant with all the building regulations at the time it was built) is it the fault of the builder?

No, of course not, it is my fault because I misjudged the clearance (for whatever contributory reasons, rain, confusing road markings, not paying attention) - that is the root cause of the accident.

As with the helicopter, the second aircraft could have been parked there all day long without being the cause of an accident - the mishap only occurred with the introduction of the landing helicopter.

The primary and root cause was the pilot of the landing helicopter landing too close to the running one - she made a misjudgment, just as if she had taxied into the side of a hangar or a lighting stanchion.

No Crab. You're talking about the ''last hole in the swiss cheese'', the last factor that caused the accident, not the root cause.

Why do you think they redesigned the base after this accident? Surely if it was only the landing pilots fault, this would be unnecessary! Then you'd give the pilot some additional training, and all chances of this happening again would be gone!

I ask you: Would we have this thread if the base had looked like it does today?

There is a good reason that the NTSB have 4 recommendations, all related to the AC governing heliport design in this report.

I'm sure you have lots of SOP's and know them all by heart, but do you know WHY you have them?

You're right about ASSUME though... but that would not happen if the ramp looked like it does now, then there would not be a need of assuming anything.

[roscoe1]

As I stated above, if you collide with something while you are moving and the object you hit is stationary it is pretty much your fault. The root cause is always that you failed to see and avoid. You should try and not depend on others to always do what is expected to the extent that is humanly possible. Do not confuse what I'm saying with the fact that any or all of us might have had the same outcome causing those of us watching to say " yeah, that could have happened to anyone because they were set up by factors beyond their control". Yes, the scenario was beyond expectations of the pilot but that is why we drill and drill and pay big bucks for SMS programs that all have the same risk assessment matrix in them. If they had such a program and did an internal audit on ramp procedures perhaps the poor selection of how they parked aircraft would have popped and things might have been different. Laugh if you like about the chance that that would actually take place but if we follow our own advice and actually do these things, it might surprise those who are sceptics that it can work. That doesn't change the cause of this accident. The root cause doesn't necessarily go back to the one, two or ten things that might have prevented the accident. The root cause is that thing that actually allowed the rotors to hit. This factor was totally under the pilot's authority to prevent and that was the controlled flight of the aircraft in motion. You might argue the analogy but when you run over your kid's bicycle because they laid it down behind your car in the driveway, it is time to yell at the kid for being dumb. However, in those tragic accidents when it it a toddler that is injured or killed because someone didn't see them...is there really any blame placed on the child?

[[email protected]]

Roscoe1 - :ok::ok::ok:

Nubian There is a good reason that the NTSB have 4 recommendations, all related to the AC governing heliport design in this report.
yes, it is because they can do something to remove some of the layers of cheese, but other than taking away the licence of the pilot, they can't remove the root cause.

[Nubian]

Roscoe1 - :ok::ok::ok:

Nubian yes, it is because they can do something to remove some of the layers of cheese, but other than taking away the licence of the pilot, they can't remove the root cause.

Hehe, nothing beats good ol British arrogance! :D:D Pick and choose... Why don't you answer my question?

So you remove the landing pilot's license (your root cause) and this would never happen again?? Right....:rolleyes:

[Hughes500]

Nubian

Are you from this planet ? She hit the other aircraft there is no more to be said as to whose fault it is. so what you are saying is I am driving down the road, someone stops at traffic lights and I
hit the back of them and it is the traffic lights fault :ugh::ugh::ugh:

[whoknows idont]

so what you are saying is I am driving down the road, someone stops at traffic lights and I hit the back of them and it is the traffic lights faultNo, your fault.
But if the other guy intentionally stops where he is not supposed to, where he is not expected to be, i.e. in the middle of the road behind a blind corner in poor visability, then it's not solely your fault, is it?

[Nubian]

Nubian

Are you from this planet ? She hit the other aircraft there is no more to be said as to whose fault it is. so what you are saying is I am driving down the road, someone stops at traffic lights and I
hit the back of them and it is the traffic lights fault :ugh::ugh::ugh:

I just recognise yet another that has to use dubious scenarios because he does not understanding why accidents happens!

Of course the landing helicopter is at fault, but you folks fail to understand WHY it happened and what could prevent it, which is quite shocking! At least the NTSB and the Pasadena police got it.

All talks about driving into bridge supports and rear ending others in traffic, is just plain bollocks, and show that you have no understanding of how to prevent accidents or understand why they happen.

With your simple way of thinking, no measures will ever need to be put in place to prevent similar accidents from happening again, as it was just this ''dense'' pilots stupid fault.... full stop! Remove the pilot, and all is fine.... :D:rolleyes:


Hughes500,
I asked Crab a simple question above, which he very elegantly skipped, so lets see if you can answer it! Would we have this thread if the heliport looked like it does now, after the recommended changes??

[[email protected]]

Nubian - that accident could occur anywhere when one pilot lands too close to another aircraft, regardless of what marks are on the ground.

How many accidents have been caused when pilots got their aircraft too close to other aircraft, hangars, lights, wires etc etc etc? And then who was at fault, the person who built the hangar????

Yes, the pad at Passadena has been remodelled but another pilot could still show a lack of judgement by landing too close to a helo that isn't parked in the right place (or even one that was)

You can address design of a helipad, address local procedures and rebrief people, you can add comms systems, you can change everything to try and make sure that particular accident can't ever happen again - right up to the point where a pilot makes a misjudgment/mistake/error - then who will you blame?

If you want to go into the minutiae of why she made that error then you might be far closer to preventing similar accidents - the design of the helicopter windscreens and wipers, stop and go lights on the dispersal to give landing clearance, what safety seminars she had been to, what her mental condition was (family problems or similar causing distraction from the job) - the list is endless.

There will have been many, many factors that could be considered contributory but only one as the main cause - landing the aircraft too close (for whatever reason you choose to pick) to the other one - that's it, pure and simple.

If the second aircraft hadn't been there at all and she had tried to land on the normal square but drifted left and hit the fuel tanks, would you blame the installation of the fuel tanks or poor piloting?

really not sure why you think 'British arrogance' is a factor or is it my fault she crashed?

[roscoe1]

Ok, revoking, suspending or any other certificate punishment is not even close to being warranted because even though the root cause was the action of this pilot, there were some pretty compelling reasons why this was going to happen to someone. It was only partly to do with the attentiveness of the pilot and punishing this person is flat out wrong unless she was doing something so egregious that firing her was the only safe option and that would require a history of incidents and remedial training. In this case I can say with 100% certainty that she will be more careful than most when approaching an LZ. If this person had a good record then punishment is not as smart as some extra training and if you do that, whamo you have a better employee than if you took on an unknown quantity or someone with less experience.

[r22butters]

Its time we face reality. Sixteen thousand hours is obviously not enough to be a safe and competent pilot. Commercial pilot minimums must be raised to at least 20,000. Then and only then will we finally get pilots who will stop doing stupid irresponsible things! :ugh:

[ZFT]

Perhaps I wasn't clear enough. The root cause was that the pilot didn't take enough care in picking a landing spot because they were complacent about using the painted marks, or simply didn't take enough time to see what they were looking at. If you think that wasn't the root cause what would you suggest? Surely not that the stationary ship was poorly positioned?

A root cause is either a 'Process', a 'Responsibility' or a 'Resource' failure and once determine by analysis should be corrected so it cannot reoccur.

What appears to have happened here could happen again.

[[email protected]]

ZFT - by those terms, this was a responsibility and, other than grounding the pilot (which wouldn't prevent other pilots making similar mistakes)how would you suggest this is 'corrected'?

[Hughes500]

Nubian
It makes didley squat difference the redesign of the pad if a pilot decides to land too close too something. The locations of the pads are obviously a factor, where people had put the other machine was a factor, as was the rain. The root cause was the pilot. If the root cause was the size of the facility then they would have had accidents every time. I would agree that no risk assessment was obviously done when the pads were designed.
Lets be frank the pilot assumed that everything was ok, obviously not. although why the pilot's would accept a 2 ft clearance on such a facility is unbelievable. I think the expression what could possibly go wrong comes to mind, oh yes it did

[DOUBLE BOGEY]

There are ICAO rules for the design of heliports (ICAO-Annex-14-V2). These rules are designed to put in place the first barrier to an undesirable event. In this case, TLOF and taxiway markings that conform to the largest aircraft for which the facility is designed to accommodate.

Looking at the pad from the images available its does not look like the safe distances have ever been properly laid out.

If this is the case, pilots get into the habit of landing on many, many occasions where nothing goes wrong. However, "Risky Shift" is now in play. Caused not only by the assumed inaccurate layout but also those occasions where the safety distances provided are further eroded by poor placement and inaccurate landings. Habit.......leads to complacency.

However, I agree with Crab and Hughes500. Despite all the efforts that should be made to provide safety distances, markings etc, the ultimate responsibility for the flight trajectory always remains with the pilot!

If you have not read ICAO-Annex 14 V2, and you are routinely making decisions as to how close you can land to objects, fuel installations, other aircraft etc! now would be a good time to refresh.

A few years back, operating in NW Oz, I faced a similar problems with a bunch of pilots willing and ready to take considerable risks while manoeuvring in the ground taxi in very large helicopters. They were all good professional pilots but in my opinion, were suffering from a severe dose of "Risky Shift". I was not fully able to solve this problem despite being in a supervisory position due to the ingrained and learned behaviours of the crews. Incredulously, several years prior to my experiences, there had been a helicopter collision on the same manoeuvring area due to the same factors present.

Sometimes, we as pilots are our own worst enemies in our pursuit of expedience.

I do not agree that the problem gets solved by punishment. However, with 16K in the logbook its hard to explain why "Risk Aversion" has not fully set in for the individual. Therefore it would be safe to assume, that despite the "Risky Shift" factors in play, the final act of the pilot in question has to be considered as "completely inappropriate to the conditions", and as such, search for underlying causes of distraction in the personal closet of the pilot.

Finally, to consider that "Rain" and "Visibility" etc was a factor, we are ignoring the principle that when operating in such conditions, additional margins of safety need to be applied. This again sits with the judgement of the pilot.

Clearly to me, judgement was impaired by "Risky Shift", ..........and some other factor(s). Determining what those other factors were, and addressing them, is important IF that pilot is to return to service.

However, if this pilot were to fly tomorrow, I suspect her personal safe distances she is prepared to accept have somewhat increased exponentially. She is highly unlikely to make this mistake again.

[ZFT]

ZFT - by those terms, this was a responsibility and, other than grounding the pilot (which wouldn't prevent other pilots making similar mistakes)how would you suggest this is 'corrected'?

I don't have all the facts to do a root cause analysis but as you correctly state, grounding the pilot would not prevent a similar occurrence, however from what little we do know, I would suggest it was more a process issue with the incorrect positioning of the 'on ground' machine and if there were procedures in place to ensure correct positioning every time, then this thread would not be running?

[DOUBLE BOGEY]

To add some colour to my last post, the minimum safe distance between helicopters operating on adjacent TLOFs is 1/2 the width of the largest helicopter in play. Assuming the discs of these helicopters is around 10m, that would mean at least 5m between rotor tips.
Now in a dynamic situation we cannot expect the pilot to accurately judge 5m. However, in the video it looks to me like the landing helicopter actual descended "through the rotor tips" of the stationary running helicopter. That is clearly not 5m or anything like. WHY? because poor knowledge has led to risky shift which has been in play for a prolonged period where nothing has ever gone wrong.

Compliance is the first building block of Flight Safety. Had that pilot known on that day that the minimum distance should have been 5m, this accident would almost certainly not have happened.

(Note I am guessing the rotor diameter cos I am too lazy to look it up, however, if its 4, 5, 6 or even 7m I think you can get the principle I am applying).

Concepts such as risky shift, learned behaviours and poor compliance are symptomatic of Company Culture. If I have learned anything in my time in aviation its that of all things that may need to be changed, the hardest of them to change is Company Culture.

[Old Farang]

I have both owned and commercially flown helicopters. I have also worked on offshore oil rigs for many years. From time to time some industry operators run safety oriented seminars and training courses, usually presented by specialist companies.

One of the recurring facts to emerge from most of these seminars is how people's "perception" can and does vary from what is actually being evaluated, and how it can and does lead to disaster. Simply put, what we sometimes conclude as being a fact, may be what we are expecting it to be, rather than what it actually is.

This "perception" is more likely to occur with things that we are very familiar with and have used or done many times before. It is an unconscious reaction that happens automatically, more so if there are other factors that are demanding our immediate attention.

In this case we have a 16,000-hour pilot that is obviously skilled, probably well trained and definitely familiar with her surroundings and normal procedures. Something that she has probably done hundreds, if not thousands of times previously.

It is nothing to do with the weather, or the other helicopter. I am sure that she would have been aware of the parked helicopter, just as she was aware of the weather conditions. She may have been focusing on the weather, but the other helicopter was "just there", as it probably had been many times before. Her perception of it would not have led her to even consider that it may have been parked in the wrong place, or that it could possibly be a hazard.

It is one of the traits of being a human being. We are not machines that can be programmed, no matter how well trained we may be.

[Thomas coupling]

I can't believe we are arguing over this - scary to be honest.
ONE reason for this accident and one only:

HUMAN FACTORS.

Isn't there anything to distract us from continuing with this thread.

Dumb ass police pilot - not looking where they are going - simples.

[Reely340]

Is one taught to land/park far enough away from other aircraft so that if both aircraft start their rotors, there will be no engagement?
Over here in EASA land you are, at least I was defnitely made aware of my(!) duty to consider my hazard-radius with repect to nearby "obstacles". Actual "Eangagement" isn't the issue, meaning, I must not park too close to some light aircraft as my downwash might dislodge it let alone turn it upside down. Down to the point that a doofus who parked his plank too close to me, effectively has me grounded, as firing of my ship in a "now you'll learn aber not parking near a helo" attitude will definitely case me being liable for takeoff down-wash to his plank, even if he parked it after I landed. My option is only to scare up the ignorant and make him move his plane, an maybe complaint about him at authorities in repeat instances.

Basically there is not one single valid excuse for crashing into a stationary object, being it a wrongly parked car, a parked helo with rotors turning and lights flashing or fuel shack. In my book the one operating the moving object pays in full, always.

But back OT, I think that type of accident can bite anyone, even very famous and skilled pilots occasionally **** up : https://www.youtube.com/watch?v=ovGDeM0470g

[[email protected]]

Well that's clearly the fault of the person who built the hangar...............:E:E:E

[500e]

Well that's clearly the fault of the person who built the hangar...............:E:E:E

But the planning officer said It would be OK :ok:

[Bell_ringer]

I really feel for the poor pilot. Having just put the whole mess behind her and no doubt, fully appreciating where it all went wrong, thanks to a video upload she now is a social media star.
I am sure all the discussion, above, will be hugely comforting during this difficult time :}

[Thomas coupling]

Bell ringer - are you serious?
Sympathy for someone with 16k hours, been it, done it, seen it?
Total ineptitude - The ONLY good news is that no-one was kiilled. :ugh:

[Bell_ringer]

TC, the video footage is quite self-explanatory as to where responsibility lies and where the various holes all started lining up.

Everyone is fallible and have made, do make mistakes. Many are fortunate enough to prevent the final holes lining up, however every year people make errors and often pay with their lives and 16 hours or 16000 doesn't change the trend, though obviously some here find the idea of an experienced person making a rookie mistake quite unforgiveable.

Human error is inherent in everyone.
Perhaps one day we can all be fortunate enough to be error free in which case Human performance can be dropped from the curriculum in favour of a more meaningful life skill, such as knitting. ;)

[NutLoose]

Pasadena police helicopter crash: Feds investigate collision | abc7.com (http://abc7.com/archive/8889807/)

Understatement of the year

Officials say the helicopters' rotary blades may have touched during a maneuver.

[megan]

Everyone is fallible and have made, do make mistakesMight apply to you and me Bell_ringer, but not TC it would seem. He needs no explanation from those involved prior to hanging. Failed human factors? Even Chuck Yeager and Bob Hoover screwed the pooch and wrote off airframes, the first (F-104) through lack of instrument flying skill, the latter (Aero Commander) through refuelling a piston with jet fuel. Every accident has an explanation, there is more to the explanation than,Dumb ass police pilot - not looking where they are going - simplesSee the NTSB report, it spells it out pretty well.

[albatross]

So a pilot lands alone in a forest and hits a tree....who is at fault?

[[email protected]]

Understatement of the yearyes, 2012:ok:

So a pilot lands alone in a forest and hits a tree....who is at fault?the tree falls - who hears it?? Oh hang on I might have gone off topic;);)

[[email protected]]

See the NTSB report, it spells it out pretty well. not really - it lists some actions the Passadena PD have taken and suggested 4 changes As a result of the evaluation, the following actions were identified that would enhance heliport safety, and bring the facility into conformance with current heliport design standards (Advisory Circular Heliport Design AC 150/5390-2C dated April 24, 2012).

1. Recommend trimming of a 38-foot tall oak tree to a height below the transitional surface or remove the tree entirely. The tree was located 36 feet southwest of the Final Approach and Takeoff Area (FATO); it penetrated the heliport's Federal Aviation Regulation (FAR) Part 77, 2:1 Transitional Surface by approximately 20 feet.

2. Replace hooded light figures with flush green perimeter lights in accordance with Federal Aviation Administration (FAA) AC 150/5390-2C, Heliport Design, paragraph 216.

3. Mark the FATO in accordance with AC 150-5390-2C figures 2-22 and 2-23.

4. Remove all helicopter parking spot markings, and redesign the heliport parking plan in accordance with AC 150-5390-2C, paragraph 214, table 2-1, and figures 2-17 and 2-18. only the last of which was really pertinent to the accident.

The distance between pad 1 and the fuel farm was only 24 feet yet presumably the pilots operated quite happily with such small clearances - the distance between pad 1 and pad 2 was 33 feet so the parked aircraft could have been 9 feet closer to pad 2 and still be as far away as Pad 1 was from the fuel farm.

There is scant HF information and no assessment of the cause, and while I know a SMS isn't supposed to apportion blame, if you don't clarify the reason for the accident, you end up chopping down a tree and repainting things in a 'paper-safety' response.

[roybert]

Well that's clearly the fault of the person who built the hangar...............:E:E:E


Come on Crab We all know the Hanger jumped into the Rotors :)

[r22butters]

I would still consider hiring the chick that destroyed these police choppers, but the dude who destroyed the Cobra? Not a chance!

[Reely340]

I would still consider hiring the chick that destroyed these police choppers, but the dude who destroyed the Cobra? Not a chance!Interesting. That dude is RB's acrobatic B105 driver. Which proves even real pros occasionally make stupid mistakes, in his case the decaying coning angle while downing the pitch exposed his bad lateral distance judgement.
Btw. RB allegedly are restoring their Cobra.

[ThreeThreeMike]

How the hell did the guy stood by the nearest aircraft not die?????? Very lucky boy.

It isn't easy to see but it looks like there are painted squares on the dispersal which, if both aircraft are on them, give rotor clearance.

But, the one dragged out for what looks like a ground run, is positioned off to one side.

If the incoming pilot assumes the one on the ground is in the right place and just positions himself over the 'second' spot without checking, then intermeshing rotors do what intermeshing rotors do...............

I just began reading the thread, but you have indeed solved the problem. The little yellow rectangle was much more important than the pilot of #1 divined.

[Thomas coupling]

The 'in thang' these days is "Just Culture". God knows, I dole this stuff out continuously.. BUt....BUT the buck has to stop somewhere.
In this instance, the person who wheeled the stationary helo out, earlier and the female pilot each have to take responsibility for their mistakes. They have to own up (conscientiously) to the fact that they didn't concentrate at the time and nearly caused a loss of life.
Sympathies don't come into it. They own the problem and they redress it. Simples.
Rebrief them, get the pilot flying again ASAP and move on.

[SuperF]

so what we take from this, is that the little yellow safety guides that some places put on the ground are actually a hazard, as now people just bang along assuming that everything is in place, and don't check.

It is better, and safer to have NO guides on the ground, park where ever the heck you want, and everyone has to be more observant when the T/O or land. if this place had never had any guides on the ground, she would have come in, made sure that there was enough clearance then landed safely, with the safety guides, we get an accident...

or is someone going to tell me that is the wrong way to look at it?

[heliturbo]

how can someone hit a stationary object, be it a car, a fuel truck, a hangar, another ship, I just can't understand, there must be a logical explanation, such as a lack of focus, some distraction, definitely not lack of experience!
the explanation given by the PIC has Nothing to do with reality, just a way to minimize the situation, the huge mistake, a kind of cover up
saying we are all human, again, does not solve anything, other than justifying a loose approach towards our own responsability
its quite a load to drive a car, but to fly an airplane, an heli, is much much more load on the brain, and we must give it our utmost attention
otherwise, s.... happens, and the results are total disaster
really unfortunate, but avoidable:ugh:

[SuperF]

the most common example that is the closest comparison, is i went shopping today. It a place i go every day, been doing it for 30 years, for 15 years before that i went with my mum. Drove in the carpark, went to park in our normal spot but i had an accident, i smashed into another car that was half parked across my carpark.

It wasn't my fault, cos it was raining and the windscreen wipers were out of washer, and the car window was a bit dirty and it was a bit cloudy. I couldn't really see where i was going, but since i always park there i just drove in following the lines.....

well I'm sorry but you are a flaming idiot for writing off you car!!!

[[email protected]]

or is someone going to tell me that is the wrong way to look at it? helipad markings are excellent and, if used correctly, guarantee safe separation from other aircraft so going hard over to remove them would be a retrograde step.

The main issue with this accident was the pilot not recognising that the other aircraft wasn't positioned on the normal spot and adjusting her landing position to cater for it.

Whatever the cause of her not taking appropriate action (distraction, stress, complacency etc) the markings on the ground only represent one layer of safety you are still heavily reliant on the skill and actions of the pilot to prevent such a crash.

[Thomas coupling]

Lack of SA.............................bites another pilot again!

[r22butters]

the most common example that is the closest comparison, is i went shopping today. It a place i go every day, been doing it for 30 years, for 15 years before that i went with my mum. Drove in the carpark, went to park in our normal spot but i had an accident, i smashed into another car that was half parked across my carpark.

It wasn't my fault, cos it was raining and the windscreen wipers were out of washer, and the car window was a bit dirty and it was a bit cloudy. I couldn't really see where i was going, but since i always park there i just drove in following the lines.....

well I'm sorry but you are a flaming idiot for writing off you car!!!

Yep, a company controlled helipad/parking area governed by rules and policies vs. a public parking lot free for all.

That's the closest comparison you could find!:ugh:

[megan]

Given the water drenched nature of the pad, I wonder if the lady could actually see that the other was not parked on its pad.Lack of SA.............................bites another pilot again!There is a saying, "You should never assume. You know what happens when you assume. You make an ass out of you and me because that's how it's spelled." Judging distance by eye is fraught with danger, this is not the first, and nor will it be the last where helo drivers have run into obstructions, that's the main reason company's buy yellow paint and splash it about the concrete. In this case it's just a pity someone didn't make use of what the yellow paint was saying. Wonder what their SOP's were regarding positioning, if there were no SOP it leaves the door wide open and you have to ask why they wasted money on buying yellow paint. Looking back on past satellite photos the pads have changed position numerous times.

Cockpit conversation prior to the following.
‘Just check we are clear’ - PIC.
'Yes' - copilot.
‘Sure?’ - PIC;
‘yes’ - copilot.
‘Still clear?’ - PIC
‘yes’ - copilot.
BANG

https://www.youtube.com/watch?v=TkDjY3Zs_hE

[Nubian]

Megan,

You have to remember that according to Crab, TC and the other skygods, the importance is that someone f..ked up (which their immune to), and the underlying cause behind it is not important. It is just to state what kind of idiots they were, pull their license and problem solved.
Simples, as they say...

[[email protected]]

Nubian - you do seem to have a problem, just because I criticised your analysis of the accident.

None of us, especially me, are immune from f**kups but when you do mess it up there comes a point where all the excuses in the world can't hide the fact that you did, indeed, f**kup. You have to put your hand up to it and move on, hopefully having learned not to make the same mistakes again.

I didn't suggest pulling her licence - I said it was an option for the regulator.

[Thomas coupling]

Grow up Nubian and if you have to quote ....quote correctly.
I did not say pull her license, I said rebrief her and then get on with life.

You're not a Generation Snowflake are you:

https://en.wikipedia.org/wiki/Generation_Snowflake

Megan.

I didn't assume the pilot lost SA. I stated it!
Pilot taxi's into normal hover position over 'normal' ground markers
and doesn't "queue" the fact that the sister ship alongside........is not where it should be.
Call it what you like:
Complacency.
Unconscious bias.
Peripheral vision deficit.

I call it Lack of Spacial Awareness:

Spatial awareness is the ability to be aware of oneself in space. It is an organised knowledge of objects in relation to oneself in that given space. Spatial awareness also involves understanding the relationship of these objects when there is a change of position.

[whoknows idont]

I think this is one of the better discussions on this board. Good points being made on both sides.

crab, I can certainly see where you are generally coming from in this discussion. But I must say the following two paragraphs are completely contradictory:
helipad markings are excellent and, if used correctly, guarantee safe separation from other aircraft so going hard over to remove them would be a retrograde step.

The main issue with this accident was the pilot not recognising that the other aircraft wasn't positioned on the normal spot and adjusting her landing position to cater for it.

The whole point of these markings is that you know the helo will fit in there. You are pointing out that someone didn't use the markings correctly to guarantee safe separation. I agree. But how is this supposed to be the landing pilot as opposed to the one on the ground? :confused:

[[email protected]]

Because, regardless of what is painted on the ground, you have to recognise when the pads are being used correctly and when they are not.

If you assume they are being used correctly but don't bother to check and then exercise poor airmanship by not thinking about where your rotor is in relation to the aircraft on the ground then you have compounded the mistake made by the crew that didn't position the parked aircraft.

Just because it was parked in the wrong place doesn't absolve you as the pilot of the landing aircraft from the responsibility of keeping clear.

As you come into dispersal and see (positively) the other aircraft on its prescribed square then you know landing on the other square will keep you clear.

If you see the other aircraft isn't on its prescribed square then you must take extra care and modify your landing spot to ensure adequate clearance.

It is absolute basic airmanship.

[Good Business Sense]

Whilst training on big fixed wing I'd see people getting very sloppy about staying on the yellow line - to get a point across I had a little saying:

"If you hit anything when you're OFF the yellow line, you're **c ked. If you hit anything when your ON the yellow line you're **u ked !

[Nubian]

Nubian - you do seem to have a problem.

I didn't suggest pulling her licence - I said it was an option for the regulator.


Yeah Crab, it's definitely me...


Nubian yes, it is because they can do something to remove some of the layers of cheese, but other than taking away the licence of the pilot, they can't remove the root cause.

So how should I interpret your statement then?

I have not said that the pilot was blameless or that she did nothing wrong. I was highlighting the single cause that would prevent this from ever happening! If you read the whole report and look at the changes made, not only to the helipad layout, you might understand how this is measures that would prevent it from happening rather than what you suggest.

You can argue all you want that this would still very much be something that could happen, but then you can't have seen the way these, now 4 parking-pads+landingzone are spaced.(I am talking about THIS case, not in general) If now a pilot would fly into another one, that would be someone with either loss of aircraft control or someone that would do this deliberately. Then, you have a different root cause. Different story.


TC, you must know yourself good enough to know that your way of discussing is not really of diplomatic grade! Not that I need that (as I am not much diplomat either), just letting you know that if you come across arrogant and condescending, you'll be answered accordingly.


Btw, thanks for letting me learn a new term today. Never heard about Generation Snowflake.

My only point in all this and other cases is the why behind, not the key of what happened, which in this case is pretty obvious, so I can learn from other peoples f..kups before I do them myself, and I want to keep it that way!

[[email protected]]

So how should I interpret your statement then? in the way it was intended - they can treat the contributory factors (HLS layout, markings, lights, procedures etc) but the pilot made the mistake so you can either rebrief and retrain her and accept she had an off day or, in extremis, you can take her licence away, but you would have to demonstrate additional failings and prove professional negligence to justify that.

She made a mistake and the cost was only (fortunately) embarrassment and two trashed aircraft - I don't know if she got to keep her job but I am pretty sure she will be super-careful in future.

None of the measures recommended or actioned will prevent another pilot from making a mistake - they will help but they can't cater for an error in judgement.

Hence my assertion that the prime cause of this accident was pilot error which could have been avoided with a little extra care.

[whoknows idont]

Just because it was parked in the wrong place doesn't absolve you as the pilot of the landing aircraft from the responsibility of keeping clear.

Yes obviously, but nobody here said anything like that.

But it seems like in your eyes the landing pilot is the only one to blame here.

I'm saying "operational urgency" should never be used as an excuse for conciously neglecting the most obvious and basic safety measures.
That really is one of the worst excuses they could have come up with.

"he knew they would be off the ground in a couple of minutes or he would be up on radios" is not much better either.

"The pilot stated that it was not uncommon to place the helicopter outside of the box" is the only one that might remotely qualify. But then again, the other pilot basically stated the opposite.

This guy was obviously well aware that what he did played an essential role in letting this accident happen.

[[email protected]]

Yes obviously, but nobody here said anything like that. if you believe that having the aircraft parked in the wrong place caused this accident then you must believe that.

It was clearly a strong contributory factor - it shouldn't have been parked there unless there was good reason - the close proximity of the fuel pumps (24') might have been a reason that some pilots preferred the aircraft 'off' the spot - there is a clear discrepancy between what the 2 pilots said about that process.

[Nubian]

None of the measures recommended or actioned will prevent another pilot from making a mistake

Crab,

Have I said that these measures would prevent anyone making a mistake?? Nope!

But, with the layout as it is now, and I specify in THIS case (after all it is a specific case this thread is about, no?), the room for pilot error without the same result is greatly increased, so that this will happen again, well I will not hold my breath....

I asked you a question which you haven't bothered about although I repeated it and gave another poster a chance to answer which failed as well.


If the base had been like it is now, do you think we would have this discussion?


Judging by the available photos and video. I bet this base was originally intended for the use of 1 helicopter and dimensioned for that, then later on expanded to multiple helicopters without making the base appropriately bigger, only a set of new markings and maybe an SOP which is easy to not follow for various reasons. Now, if this is the case you have set a trap and it is only an unknown time to wait before the rest of the holes in the cheese line up and the ''dumb ass pilot'' conclude the story.

Don't get me wrong, lots of ''dense dumb ass pilots'' do unforgivable mistakes that cause accidents fatal or not, some should probably never have a license in the first place, but it is alway a more complex case than the pilot just being a dick and crash his machine. Very few crash intentionally!

youtube is full of these 15 second ''celebrities'' but you never know the story behind. Very easy to sit and watch idiots after each other do the silliest things like just having lost SA. etc. and conclude how stupid the pilot is.

But none of you have come up with any of the why's behind. Now, if you're going to prevent things from happening, you need to know why before you can change anything!

As for the 24 ft to the fuel-pump, the disc diameter of the OH58 is 35 feet, meaning the blade is 17,5 which gives you 6,5 feet lateral separation, so I think pilots that accept 2 feet rotor tip clearance don't have much problem with 6,5 + vertical component in addition.

[Vertical Freedom]

It's my SPOT & I'm landing here, no matter what the consequences said the Female driver :ooh: She'll win every-time :ouch:

[megan]

I bet this base was originally intended for the use of 1 helicopter and dimensioned for that, then later on expanded to multiple helicopters without making the base appropriately bigger, only a set of new markings and maybe an SOP which is easy to not follow for various reasons. Now, if this is the case you have set a trap and it is only an unknown time to wait before the rest of the holes in the cheese line up and the ''dumb ass pilot'' conclude the story. At one stage there was only one pad, positioned in the centre of square of tarmac adjacent to the fuelling point.

What most seem to be missing here is Mr. Reason and his Swiss cheese model. It's far from good enough to say the Lady is the one on whom all the blame falls, she was merely the one who pulled the trigger on a gun loaded by others. No one has an accident by choice, the pity is everyone is making assumptions as to why the accident occurred, as in lack of SA. If indeed it was lack of SA there can be explanations for that as well, divorce, death of child, duty hours etc. Nothing in the report gives a clear cut explanation, there are many other questions I would have wanted answered. We're all human - I think, and hope.

[What-ho Squiffy!]

This is similar to a rear-end car crash. The driver who smashes into the rear-end of a preceding car is almost always to blame - regardless of whether that preceding car was within the lane markings or even braked too hard. YOU as the following vehicle are required to allow ample spacing to avoid a crash.

In this incident, it might also be helpful to take the scenario a bit further...let's say the already-parked helicopter was much further out of the box...is it his/her fault still...or the landing pilot? What is the parked helicopter was half-way over the other parking spot...is it the fault of the landing pilot yet?

You don't land an aircraft unless you've ensured it is safe to do so. You can blame the umpire all you like, but the fault (and root cause) lies with you. Own your mistakes. I own a lovely acreage of mistakes, which I carefully tend to and nurture, so I NEVER forget them.

[Vertical Freedom]

At one stage there was only one pad, positioned in the centre of square of tarmac adjacent to the fuelling point.
What most seem to be missing here is Mr. Reason and his Swiss cheese model. It's far from good enough to say the Lady is the one on whom all the blame falls, she was merely the one who pulled the trigger on a gun loaded by others. No one has an accident by choice, the pity is everyone is making assumptions as to why the accident occurred, as in lack of SA. If indeed it was lack of SA there can be explanations for that as well, divorce, death of child, duty hours etc. Nothing in the report gives a clear cut explanation, there are many other questions I would have wanted answered. We're all human - I think, and hope.
Blame the divorce....hmmm been there too & done that, doesn't' reduce or excuse my responsibility as the PIC, that's 'Pilot in Command' & if You ain't fit to fly, then for God's sake decline the mission :eek: but wait someone is outside the designated parking spot, I'll show 'em...BOOM :mad:

This is similar to a rear-end car crash. The driver who smashes into the rear-end of a preceding car is almost always to blame - regardless of whether that preceding car was within the lane markings or even braked too hard. YOU as the following vehicle are required to allow ample spacing to avoid a crash.

In this incident, it might also be helpful to take the scenario a bit further...let's say the already-parked helicopter was much further out of the box...is it his/her fault still...or the landing pilot? What is the parked helicopter was half-way over the other parking spot...is it the fault of the landing pilot yet?

You don't land an aircraft unless you've ensured it is safe to do so. You can blame the umpire all you like, but the fault (and root cause) lies with you. Own your mistakes. I own a lovely acreage of mistakes, which I carefully tend to and nurture, so I NEVER forget them.
Too right Squiffy, too RIGHT...done the deed; own it! Don't blame the poorly parked machine, Your still the PIC, or is that no longer 'politically correct'? :{

[[email protected]]

I asked you a question which you haven't bothered about although I repeated it and gave another poster a chance to answer which failed as well.

If the base had been like it is now, do you think we would have this discussion?
just to keep you happy Nubian - my answer is yes, of course we could still have been having this discussion.

I think the points that I and others have made about it being the landing pilot's responsibility not to land on another aircraft - REGARDLESS of where that aircraft is parked - is paramount.

With the new HLS layout, it is less likely to happen again - that's why the NTSB recommended the changes but its also even less likely to happen again because it has happened once and plenty of lessons were learned from it.

If you want to hypothesise about whether the accident would have happened with a new layout then carry on because it is a pointless quest - it did happen with the layout that was there - the layout was a contributory factor and it has been changed but the landing pilot was soley to blame for where and how she landed her helicopter.

If you think I am going to say that the HLS marking was the prime cause of the accident then you will be waiting a long time.......

BTW - which pilots are happy with a 2 ft tip clearance?

[What-ho Squiffy!]

If you think I am going to say that the HLS marking was the prime cause of the accident then you will be waiting a long time.......

Indeed. Safety 1-0-1.

[megan]

Something I came across.Nowadays, pilots are encouraged to be open and honest about their mistakes. The industry has powerful, independent bodies designed to investigate crashes. Failure is not regarded as an indictment of the specific pilot who messes up, but as a precious learning opportunity for all pilots, all airlines and all regulators.

Of course, it’s entirely normal to have difficulty in accepting our own failures, be it in a presentation or on the golf course. But it turns out, failure to learn from mistakes has been one of the greatest obstacles to progress. Unfortunately, many companies have not yet established an open system in which these attitudes or patterns can be easily discussed and further consequences prevented. In most cases, they will be noticed by colleagues and whispered about or mentioned behind closed doors. Conventionally, errors are still stigmatised as deficits and associated with embarrassment, shame and fear.

Modern error management is different, and requires a different perspective. It accepts errors — and the reasons for them — as an unavoidable part of human behavior. Sure, those who make mistakes may still become annoyed at themselves, but they need not fear ridicule or sanctions from others. Instead, they should try to analyze what led to the mistake and attempt to eliminate this to prevent future problems.

We should consider redefining our relationship with failure, as individuals, as organizations, and as societies. Instead of denying failure, or spinning it, aviation teaches us to learn from it.The most complex piece of equipment in a machine is the operator, trouble shooting why someone did what they did is not obvious to casual observers such as we, see the UH-60 thread where the tailwheel was put over the side.If you think I am going to say that the HLS marking was the prime cause of the accident then you will be waiting a long time...Crab, you think there may be a memo iterating a necessity to be positioned on the pad?

[[email protected]]

Crab, you think there may be a memo iterating a necessity to be positioned on the pad? if there was one before the accident then it must have been ignored but I bet there is something in their local order book now:ok:

As humans we are often not very good at acknowledging our own failings and don't deal well with having them paraded in front of others - hence the modern safety management systems that encourage us to confess our errors but then try to erase the blame.

[Thomas coupling]

Megan - the human psychology is for another debate.
Given, aviators are not the best at dispensing it at times but please let's not cloud the issue here.
Please understand that there is a process to go through and the process should be based on the latest information we have when addressing a safety related incident such as this, which is "Just Culture" (Look it up sometime).

Just culture is not a NO blame game. We all learn from it but we must use the tools avaialble to find the ROOT cause of the problem.

In this instance, it is that a human being miscalculated / misinterpreted their position in space. We cannot then dissect it further by determining if the pilot missed breakfast or had an argument with their partner before leaving for work, or was abused whilst a child. We 'the aviation fraternity' are not in the business of psychological profiling or councilling. If we were, dozens of current pilots would be out of work, I would suggest!.

Once the cause is found, we can then apply just culture to determine the punitive actions. This is where the humanity comes in to compensate for the human factors that caused the problem in the first place.

BUT understand this, the pilot involved must be left in absolutely no doubt that it was they and they alone that caused this accident. Looking for someone else to contaminate (the person who ranged the first helo - is muddying the water). If the 2nd helo was from another police unit, coming for a visit; would they have done the same thing?

Try and move away from: "Society is to blame", often it boils down to an individual who drops the ball for a second. Plain and simple.

Debrief the pilot.
Admonish the pilot.
Educate the pilot.
Fly the pilot.

Bring them down.....................and then rebuild them.

[Nubian]

just to keep you happy Nubian - my answer is yes, of course we could still have been having this discussion.

:rolleyes: Ok then....

I think the points that I and others have made about it being the landing pilot's responsibility not to land on another aircraft - REGARDLESS of where that aircraft is parked - is paramount.

You think I disagree? Point is this was an accident waiting to happen due to that the Pasadena Police failed to identify the high risk that was present, with no room for pilot error. And as we have determined, pilots f..k up!


With the new HLS layout, it is less likely to happen again - that's why the NTSB recommended the changes but its also even less likely to happen again because it has happened once and plenty of lessons were learned from it.

First time solo students wouldn't be at risk there now....

BTW - which pilots are happy with a 2 ft tip clearance?

You haven't read the report have you?! Do you only comment on the comments?

I've cut this from the report for you:

Pad 1 was 49x49 feet; the center of pad 1 to its outside edge was 25 feet. The edge of pad 1 to center of pad 2 was 12 feet. Thirty-seven feet separated the center of pad 1 from pad 2

Again, the OH58's rotor diameter is 35',6'' (radius 17,8X 2 helicopters) will give you a little less than 2 feet if both helicopters running.

They have no doubt been operating like this, otherwise I'm quite sure the landing pilot would not try to land on ''her'' markings in the first place.

[Nubian]

Megan - the human psychology is for another debate.
Given, aviators are not the best at dispensing it at times but please let's not cloud the issue here.
Please understand that there is a process to go through and the process should be based on the latest information we have when addressing a safety related incident such as this, which is "Just Culture" (Look it up sometime).

Just culture is not a NO blame game. We all learn from it but we must use the tools avaialble to find the ROOT cause of the problem.

In this instance, it is that a human being miscalculated / misinterpreted their position in space. We cannot then dissect it further by determining if the pilot missed breakfast or had an argument with their partner before leaving for work, or was abused whilst a child. We 'the aviation fraternity' are not in the business of psychological profiling or councilling. If we were, dozens of current pilots would be out of work, I would suggest!.

Once the cause is found, we can then apply just culture to determine the punitive actions. This is where the humanity comes in to compensate for the human factors that caused the problem in the first place.

BUT understand this, the pilot involved must be left in absolutely no doubt that it was they and they alone that caused this accident. Looking for someone else to contaminate (the person who ranged the first helo - is muddying the water). If the 2nd helo was from another police unit, coming for a visit; would they have done the same thing?

Try and move away from: "Society is to blame", often it boils down to an individual who drops the ball for a second. Plain and simple.

Debrief the pilot.
Admonish the pilot.
Educate the pilot.
Fly the pilot.

Bring them down.....................and then rebuild them.


TC,

Nobody has said it is a no blame game when people make mistake. Just culture is just that! You do a deliberate/intended act which is a violation and there is no excuse, but if it was an unintended one based on misjudgement/honest mistake it is a whole different cup of tea.
The result (i.e.. crash) could be the exactly the same scenario.

Just saying she did wrong without finding the root cause is too simple, as you would not know how to fix the problem, and here is where I challenge Crab as to what was the root cause. He suggest as I quoted (exactly!) earlier to remove her license (what he considered the root cause).
If you and Crab seriously mean that the dumb-ass pilot would only need to be:
Debrief the pilot.
Admonish the pilot.
Educate the pilot.
Fly the pilot.

and the problem would be solved, I'll agree that would count for this pilot as she would sure as **** never want to do this over! But it is obvious that she was not operating there alone, so in your way of dealing with the case it would be a great chance for it to happen again, but to another complacent pilot (a few years down the line). You have treated the symptom, not the root cause.

If I'll use a comparison like som of the others do: If you have stomach pain due to cancer, you don't treat the pain with painkillers do you??

[Thomas coupling]

So what exactly are you saying the root cause is then, Nubian?

Given that "my" way of dealing with it would sort "this" particualr incident out, how would "you" deal with it in your quest to identify the root cause?

Let me give you a starter for ten:

IF you think for one minute that altering or highlighting the landing spots, is a part of the ROOT cause - forget it.

This is a red herring - tidying up the site.
A first time visitor will apply sound airmanship and SA and determine 'independent' of any ground markings - on where to land their helo. Making a landing spot compulsory, based on markings SHOULD not prevent the pilot from surveying the site before committing to land.

Now that this 'option' is out of the way, please tell me what the root cause (now) is?

[megan]

Once the cause is found, we can then apply just culture to determine the punitive actionsExcuse me!!!!! The antithesis of all the courses and reading I've done, but punitive is alive and well in many company's, oil and aviation, it's a counter productive process to anything outside of being deliberately nefarious .

[Thomas coupling]

https://www.caa.co.uk/uploadedFiles/CAA/Content/Standard_Content/Commercial_industry/Aircraft/Airworthiness/Seminars/Corporate_aviation_June_2016/FWM20160629_06_Just%20Culture.pdf


Errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.

https://www.vocabulary.com/dictionary/punitive

If by applying just culture, the individuals actions were found to be reckless or unjustifiable risk taking, I would take punitive action.

It seems the courses and reading you've done - were a waste of time Megan.

[[email protected]]

Nubian - You don't actually seem to have a point to make but at least get your facts right - the report says The distance between the outside of Pad 1 to the outside of Pad 2 was 33 feet, as measured by a total station provided by the Pasadena Police Department. note that says OUTSIDE to OUTSIDE so your 2 ft clearance is utter tosh.

And what on earth does First time solo students wouldn't be at risk there now.... have to do with anything here????

I have stated over and over what I believe the root cause to be - how it is dealt with is up to the regulators.

You seem to need to find a reason for her mistake to explain why she made it - if it is because she was having personal problems, what exactly would you do about dealing with that.

[Nubian]

So what exactly are you saying the root cause is then, Nubian?

Given that "my" way of dealing with it would sort "this" particualr incident out, how would "you" deal with it in your quest to identify the root cause?

Let me give you a starter for ten:

IF you think for one minute that altering or highlighting the landing spots, is a part of the ROOT cause - forget it.

This is a red herring - tidying up the site.
A first time visitor will apply sound airmanship and SA and determine 'independent' of any ground markings - on where to land their helo. Making a landing spot compulsory, based on markings SHOULD not prevent the pilot from surveying the site before committing to land.

Now that this 'option' is out of the way, please tell me what the root cause (now) is?

TC,

I don't think you'll ever get my point so I leave it here. We have 2 very different views to what was the primary cause behind this, and what would prevent it.
I trust the Pasadena Police acted on the root cause based on the NTSB's findings.

Cheers

[[email protected]]

The NTSB didn't identify any root cause.....

[r22butters]

The best way to make sure this never happens again?

Replace them with drones!

[ThreeThreeMike]

if you believe that having the aircraft parked in the wrong place caused this accident then you must believe that.

It was clearly a strong contributory factor - it shouldn't have been parked there unless there was good reason - the close proximity of the fuel pumps (24') might have been a reason that some pilots preferred the aircraft 'off' the spot - there is a clear discrepancy between what the 2 pilots said about that process.

It was parked there because the pilot and crew rolled it straight out of the hanger to the left of the markings, turned around, and walked away.

If they had spotted it correctly, the accident wouldn't have happened. Whether you view this as the primary cause or not is your discretion, but I think it the key event.

[Nubian]

Nubian - You don't actually seem to have a point to make but at least get your facts right - the report says note that says OUTSIDE to OUTSIDE so your 2 ft clearance is utter tosh.

And what on earth does have to do with anything here????

I have stated over and over what I believe the root cause to be - how it is dealt with is up to the regulators.

You seem to need to find a reason for her mistake to explain why she made it - if it is because she was having personal problems, what exactly would you do about dealing with that.


Utter tosh, huh?! The 33 feet is the distance between ''box1'' and ''box2'' and the box which is just about the footprint of the landing gear of the helicopter. Now, you do the math with 2 helicopters with 35 feet MR diameter!! I don't know what you think is acceptable clearance, but that is too f..king close in my book, and should never been approved for use in the first place.

You don't need to try to question my numbers on this one, as I am sitting looking at the official wreckage dimension sheet from the base.

If you don't understand the information in the cutout which I provided, it is your loss, sorry!
I know it will be unbelievable for you, but you can find this yourself if you wish.

As for the last slice..... before all went south.

From the NTSB docket:

At the time, the pilot did not realize that the parked helicopter was not in the “box.” The pilot’s state of mind was that the other helicopter was in the box; pay attention to your box when you land and you will be fine.


As with TC, I'll leave you with your opinion now. I have used enough energy on this case.


Cheers,




R22butter,

Yeah, it's bound to happen! There is only a matter of time before the first fatality from a falling drone or out of control drone causing a fatal accident. There has been several incidents already.

[[email protected]]

You don't need to try to question my numbers on this one, as I am sitting looking at the official wreckage dimension sheet from the base. Oh I really think I do

Lets just look at what the NTSB report actually says WRECKAGE AND IMPACT INFORMATION

On-scene documentation was conducted. The accident had been recorded on video. The recorded video showed that N96BM was moved out of the hangar toward Pad 1. The helicopter was parked to the west and outside of the painted square that denoted Pad 1, which placed N96BM in-between Pad 1 and Pad 2 facing south.

The distance between the outside of Pad 1 to the outside of Pad 2 was 33 feet, as measured by a total station provided by the Pasadena Police Department.

After the impact, both helicopters came to rest upright, with minimal displacement/movement of each helicopter. N911FA came to rest facing toward the northeast, and mostly inside of Pad 2; a portion of the aft skid came to rest outside of the Pad 2 box. N96BM remained to the west of Pad 1.

The transmission and main rotor blades separated from N96BM, and came to rest adjacent to the helicopter. The main rotor blades of N911FA separated from the transmission, and came to rest about 10 feet forward and to the left of the helicopter; directly behind N96BM. The transmission for N911FA remained attached to and inside the helicopter in its relative normal position. One main rotor blade from each helicopter, where they initially contacted each other, came to rest near the hangar, forward of N96BM, and near a chain link fence, behind N96BM.

During the on-site examination, the distance between the two parking pads as well as the distance between Pad 1 and the fuel farm was noted. Measurement of the separation distance between Pad 1 and Pad 2 was measured as 33 feet. The distance between Pad 1 and the fuel farm was measured as 24 feet. According to AC 150/5930-2C Heliport Design section 214 titled Helicopter Parking, parking pads size depends on the number and specific size of the helicopter that will be accommodated at the facility. The minimum distance between parking pads should be one-third the diameter of the main rotor blades. Additionally, under subsection e. fueling (2) it stated not to locate fueling equipment in the TLOF (touchdown and liftoff area), FATO (final approach and takeoff area), or safety area, maintaining a distance of one-half rotor diameter clearance from objects, and if that was not practical at the existing field to install long fuel hoses.

The square pad is approximately the same width as the skids (either 6 ft 4 in or 6 ft 8 in depending on which skid type is fitted) and the distances are quite clearly stated (first sentence in bold) from the outside edge of the square pad to the outside edge of the next one (33 Ft).

So you don't have to be a rocket scientist to acknowledge that the centre to centre distance is 33 ft PLUS the width of the painted square.

Even if we say the squares are only 6 ft across, that means the centre to centre distance is 39 ft.

The rotor diameter of the OH 58 is 35 ft 4 in so with both helicopters correctly positioned in the centre of their squares, there is an 3 - 4 ft clearance between the tips.

The report then says The minimum distance between parking pads should be one-third the diameter of the main rotor blades that is clearly nonsense as that would mean the pads could be 12 ft apart!!!

It seems more than reasonable to surmise that what they meant was that the clearance between 2 helicopters rotors on adjacent pads should be a minimum of 12 ft.

So, if the squares are 7 ft across and the distance between the outside edges of the pads is 33 ft you get a centre to centre distance of 40 ft - giving 5 ft clearance. Its not the 12 ft specified but neither is it 2 ft.

It isn't easy to say with more accuracy but the squares appear to be as wide, if not slightly wider than the width of the skids so they must be at least 6 ft wide and probably 7 ft. If they are wider than that - which is entirely possible, the clearance gets bigger - a 10 ft square would give 8 ft clearance.

OK Nubian - enough flannel - show how you get to 2 ft clearance based on what is actually in the report as opposed to what you think is in the report.

And are you honestly telling me that you believe they operated with a 2 ft rotor to rotor clearance for many years without anyone ever questioning it????

[Nubian]

Oh I really think I do

Lets just look at what the NTSB report actually says

The square pad is approximately the same width as the skids (either 6 ft 4 in or 6 ft 8 in depending on which skid type is fitted) and the distances are quite clearly stated (first sentence in bold) from the outside edge of the square pad to the outside edge of the next one (33 Ft).

So you don't have to be a rocket scientist to acknowledge that the centre to centre distance is 33 ft PLUS the width of the painted square.

Even if we say the squares are only 6 ft across, that means the centre to centre distance is 39 ft.

The rotor diameter of the OH 58 is 35 ft 4 in so with both helicopters correctly positioned in the centre of their squares, there is an 3 - 4 ft clearance between the tips.

The report then says that is clearly nonsense as that would mean the pads could be 12 ft apart!!!

It seems more than reasonable to surmise that what they meant was that the clearance between 2 helicopters rotors on adjacent pads should be a minimum of 12 ft.

So, if the squares are 7 ft across and the distance between the outside edges of the pads is 33 ft you get a centre to centre distance of 40 ft - giving 5 ft clearance. Its not the 12 ft specified but neither is it 2 ft.

It isn't easy to say with more accuracy but the squares appear to be as wide, if not slightly wider than the width of the skids so they must be at least 6 ft wide and probably 7 ft. If they are wider than that - which is entirely possible, the clearance gets bigger - a 10 ft square would give 8 ft clearance.

OK Nubian - enough flannel - show how you get to 2 ft clearance based on what is actually in the report as opposed to what you think is in the report.

And are you honestly telling me that you believe they operated with a 2 ft rotor to rotor clearance for many years without anyone ever questioning it????

Ok, one more post and I'll be quick.

Yes, I have misread and concluded the reference of 37 feet was from center to center. Having re-read this, I see they refer from one center to the egde of the other box. So, it will be a few feet more clearance.

My apology!

Now, pad2 was located slightly in front of pad1 and if now the clearance between the pads center-center are as you say 43feet (which may very well be) the lateral clearance 90 degree out the right side of pad1 to the helicopter coming into land (slightly from behind pad2) will not be 43 feet.

After all, the way the base was utilised with 2 pads that close, was a result of an expansion from one to more helicopters, and the Police was exempt from following the AC for heliport design as they were a public service outfit and the pad was built before the AC came out. This is the 3rd AC since 1994 on the subject, but the base was built in 1972.

This however, does not change my view on the cause of events and what ultimately caused the crash.

This does not mean that I think the landing pilot free from charges as it looks like you think. Not at all! She was the last ''slice'' that could have stopped this from happening, but didn't.

I just recognise that the Pasadena Police made the changes as they saw fit the best and that would reduce the chance for this ever happen again.

Cheers

[[email protected]]

Fundamentally, the report is not well written and a diagram would have helped enormously as would a more precise description of the dimensions.

Looking at the pad on Google Earth and using the history function, there are photos of the different aircraft (that the pad was designed for) but also one with a -58 on pad 1 - with a simple measurement of the rotor, you can see that even with the diagonal offset of pad 1 to 2, there is more than adequate clearance with 2 helos there - but clearly not the mandated minimum of 1/3 rotor.

It is possible that the measurement of 33 ft is edge to edge, ignoring the diagonal offset which would give a bigger safety margin but not by much.

The PD seemed to have ignored the reduced safety margin from introducing new helos and not even bothered to repaint the pads - perhaps the main contributory reason for the accident was an underlying laissez-faire attitude to safety - the classic 'we've done it this way for years and never had a problem'!

At least it is all sorted now and the fickle finger of youtube fame can 'having writ, move on'.

[SuperF]

Someone mentioned, further up the thread, that they would have to go back to 300's. maybe the pads would be a good size to operate 300's from, and as said above, nothing got changed when they got the 58's. even one 300 and a 58 would be fine.

[krohmie]

The incident was in 2012!

[airpolice]

Whilst they still have airworthy helicopters, perhaps they'll consider recruiting pilots capable of flying them.

N911FA

The 49-year old pilot of N911FA held a commercial pilot certificate with a rating for rotorcraft-helicopter issued on January 17, 1991. The pilot held a second-class medical issued on June 6, 2012, with the limitation that the pilot must have available glasses for near vision. The pilot's estimated total time was 16,200 total hours with an estimated 8,000 hours in the accident make and model. The pilot had been assigned to the Pasadena PD Air Operations division since 1989; 22 years as a pilot and one year as a Tactical Flight Officer (TFO).

N96BM

The 40-year old pilot of N96BM held a commercial pilot certificate with a rating for rotorcraft-helicopter issued in August of 2010. The pilot held a second class medical issued on March 22, 2012, with no waivers or limitations. The pilot's estimated total time was 13,065 hours with an estimated 725 hours in the accident make and model. The pilot had been assigned to the Pasadena PD Air Operations Division since 2005; 2 years as a pilot and 5 years as a TFO.

[DOUBLE BOGEY]

ICAO ANNEX 14 V2 states the minimum clearance should be 1/2 W ( W = widths of largest aircraft in play).

Therefore, tip to tip clearance should be at least 17.5 feet (18 feet) rounded up. Properly laid out, with each helicopter skid on the "inboard" lateral line of the landing box the clearance of 1/2 W between tips should be assured.

In Annex 14 there are no "thirds" calculations.

Could it be that the US regs are not compliant with ICAO requirements?

ALL HELICOPTERS PILOTS should know this ICAO separation standard. 1/2 of your own rotor ( at least) width is a lot bigger than a few feet so if the manoeuvre feels unduly tight then it cannot be compliant.

Whilst not wanting to be overly judgemental, ending a flight by descending my rotor disc through the spinning rotor of a landed helicopter would be 100% my fault regardless of what markings are on the ground. Rule number 1 - Don't bump into anything!

[JimL]

No pilot should be expected to 'know' the dimensions used in the design of a heliport; just as no pilot should be expected to ‘know’ exactly where the extremities of the helicopter are in space.

Heliports should be designed within criteria established by the appropriate authority – based upon the ‘Design Helicopter’ (an aggregate of measurements within which all helicopters, for which the heliport is designed, can be contained). The heliport should be marked with, and have promulgated, its ‘Design D’ and ‘Maximum Mass’.

Each of the defined areas (FATO, TLOF, Stand, Taxiway) should have visual cues (aiming points, touchdown and positioning markers, lead-in-lines, centre-lines) that ensure that a pilot observing the markings will be clear of all obstacles (including other helicopters in adjacent areas) by a safe margin. Normal errors of positioning should be accounted for within the design.

This was an ‘Organisational Accident’ (Reason 1997) because none of the above criteria was met and normal standards for design and marking (Annex 14 or AC 150-5390 2C) had not been used in the design of the heliport.

The accident investigation exists to establish all the elements that led up to, and resulted in, the accident, and publish recommendations that will prevent a further occurrence – in essence a barrier for each of the causal links.

It is not established to attribute blame – unlike PPRune!

Jim

[Spunk]

The 40-year old pilot of N96BM held a commercial pilot certificate with a rating for rotorcraft-helicopter issued in August of 2010. ... The pilot's estimated total time was 13,065 hours .... The pilot had been assigned to the Pasadena PD Air Operations Division since 2005; 2 years as a pilot and 5 years as a TFO.]

13,065 hours in 7.5 years??? That would be 1.742 hours per year :eek::eek:

Reason for accident found: fatigue

[airpolice]

The 40-year old pilot of N96BM held a commercial pilot certificate with a rating for rotorcraft-helicopter issued in August of 2010. ... The pilot's estimated total time was 13,065 hours .... The pilot had been assigned to the Pasadena PD Air Operations Division since 2005; 2 years as a pilot and 5 years as a TFO.]

13,065 hours in 7.5 years??? That would be 1.742 hours per year :eek::eek:

Reason for accident found: fatigue

No, total time 13,065 hours before the crash in 2012. I reckon that's a fixed wing conversion to rotary, or issue of a civilian rating in 2010. A lot, if not most of the people in that part of the industry, are ex military pilots, becoming cops first, then returning to flying.

[roybert]

13,065 hours in 7.5 years??? That would be 1.742 hours per year :eek::eek:

Reason for accident found: fatigue

Spunk


8760 hours in a year so 1742 hours a year is not excessive in my view. Average office worker is putting in 2080 hours a year based on an 8 hour day 5 days a week. Long haul truckers are legally allowed to drive 10 hours a day.


Roybert

[Thomas coupling]

You daft bugger roybert, this is flying hours not working hours.
Do you know the rules?

Are you an aviator, even?

[sandiego89]

While I fully understand the responsibility is always on the pilot flying, the spotting crew did her no favors.


If Mrs. SanDiego89 trips on the stairs due a misplaced toy, our forum would deem her at fault for poor navigation, poor risk assessment, conditioned response, and complacency, but you can damn sure bet the kids are going to get yelled at!

[Gordy]

Spunk
Long haul truckers are legally allowed to drive 10 hours a day.


Actually they can drive 11 hours a day in the US except interstate California where they are restricted to 10 hours.

FMCSA Hours of service summary (https://www.fmcsa.dot.gov/regulations/hours-service/summary-hours-service-regulations)

[roscoe1]

SD89,
That is because as humans, nothing is ever entirely our fault. Life would be so much better if the word "but" never came after "yes," . In this case the accident was caused by the moving pilot. The conversation should not be a "yes, but" conversation it should be a "yes, this was my fault. May we please do what we can to see it doesn't happen again? Landing on adjacent pads always demands caution. Why was my normal level of caution not sufficient in this case?" One thing I can't understand is why nobody involved in parking aircraft didn't look at what they were routinely doing and point out it was not a good sop for the obvious reason. Having said that, what they did is still not the cause of the accident. Had the second ship already landed and then they rolled out the other one and rolled it into the moving blades, then it would have been the fault of the ground handlers.

[roybert]

You daft bugger roybert, this is flying hours not working hours.
Do you know the rules?

Are you an aviator, even?

Thomas
It's been twenty years since I've been in a cockpit. So you can discount everything I say. Flying hours is the time spent on the controls only and not in flight planning. And if you can't handle flying for 5 hours a day then you need to look for a new career.

[megan]

No pilot should be expected to 'know' the dimensions used in the design of a heliport; just as no pilot should be expected to ‘know’ exactly where the extremities of the helicopter are in space.

Heliports should be designed within criteria established by the appropriate authority – based upon the ‘Design Helicopter’ (an aggregate of measurements within which all helicopters, for which the heliport is designed, can be contained). The heliport should be marked with, and have promulgated, its ‘Design D’ and ‘Maximum Mass’.

Each of the defined areas (FATO, TLOF, Stand, Taxiway) should have visual cues (aiming points, touchdown and positioning markers, lead-in-lines, centre-lines) that ensure that a pilot observing the markings will be clear of all obstacles (including other helicopters in adjacent areas) by a safe margin. Normal errors of positioning should be accounted for within the design.

This was an ‘Organisational Accident’ (Reason 1997) because none of the above criteria was met and normal standards for design and marking (Annex 14 or AC 150-5390 2C) had not been used in the design of the heliport.

The accident investigation exists to establish all the elements that led up to, and resulted in, the accident, and publish recommendations that will prevent a further occurrence – in essence a barrier for each of the causal links.

It is not established to attribute blame – unlike PPRuNe!Thank you Jim for injecting the thread with a dose of reality, I took the liberty of bolding the most important aspect. It's interesting that one pilot says they always used the pads whereas the other says no. The true story? Prune don't care, a few here take it upon themselves to be judge, jury and executioner, hang the guilty lass, it's all her fault, and hers alone. I wonder if TC was asleep during the "Organisational Failures" part of the lecture.

[[email protected]]

You could class it as an organisational accident IF it happened immediately after they changed from 300s to 58s and didn't remark the landing pads. That would be reasonable mitigation for the pilot who would have expectations that the new aircraft were introduced into a 'safe' working environment.

However, it is quite clear that they were operating for some time in this condition and had probably had the discussion about it in safety meetings eg Hey, we still haven't changed the pad layout and these helos are much bigger than the last ones'.

Call it laziness, lack of awareness or whatever you want but the reason that accident happened was poor piloting.

If you want real safety as opposed to paper safety, we need to get away from the culture of 'making excuses' for an accident which is clearly someone's fault (for whatever reason.)

[Thomas coupling]

Megan,
Don't tell me you're just another lemming in that whatever the NTSB or our AAIB says - goes. They, too are human (remember that argument about human error - well it exists inside even the most illustrious departments).
I would be only too happy to tell the NTSB that this conclusion is suspect, in the least and for the following reason:
Markings are 'guidelines'. They are not compulsory or legal.
Here's the interesting bit: Assuming the NTSB advice is compelling - how does a visiting aircraft, unfamiliar with the venue, fit into this organisational problem?
Does the visiting pilot assume that if he/she bumps into anything of their own volition - it's partly the organisation that is to blame? Of course not. YOU as a pilot are expected to navigate around obstructions and land on a spot that is free from harm. The markings on the helipad are very nice and no doubt very clear, but if a visiting pilot assesses there is something not quite right with the spacing and his/her SPATIAL AWARENESS, then FFS......they make adjustments. IF that adjustment (trying to avoid bumping into other objects) is defective and they do hit something, does one genuinely believe they are only partly to blame because surrounding arrangements were not what they should have been?

If I clip another car in the shopping mall car park because it wasn't perfectly inside its parking slot - can I genuinely accept only 90% of the blame?

This accident couldn't have been more black and white. Pilot brings cab number 2 home. Parks cab 2 on top of cab 1 because they didn't adjust accordingly.
Please let's not make more of this than what it is. A simple mistake by a simple pilot.:ugh:

[roscoe1]

TomCoupling,
Right on, Bob's your uncle, absolument,however you want to put it. Even the NTSB can be overly sympathetic when there are ways that culprets may be construed as victims for reasons that swirl around an accident. I'm not saying there were no mitigating factors, just that only one person could determine whether this accident happened or not and they could do that by doing perhaps the most important thing a VFR pilot has to do while flying and that is of course to see and avoid. That sometimes isn't enough even for the most vigilant among us. They don't have to fly straight or smooth; those are not life or death. The final report may and should have the mitigating factors listed but the cause was controlled flight into a stationary object (stationary even though the blades were turning). It doesn't mean she is a bad pilot. That may only be judged by a career wide view by people who are peers. It just means they had a split second lapse ( or a bit longer) and there but for the grace go most of us.
I caused an accident many years ago that had the potential to be the textbook example of a certain type of aviation accident. Multiple people could have been killed. We were all lucky that day and barely a drop of blood was spilled. There was much mechanical damage. In the end I knew I had trusted certain things to be true which it turned out were not, due to others shortcuts. Their shortcuts were not used as my excuses as much as I would have loved to defer the blame. Sometimes we goof. My life would have been very different if there had been injuries and almost unbearable if I had caused a death. The pilot in this accident should go to sleep every night with a smile that everyone walked away.