Cougar 851 Report Out

[HeliHenri]

.
TSB releases report on inadvertent descent of Cougar Helicopters S-92 :

The Transportation Safety Board of Canada (TSB) today released its investigation report (A11H0001) into an incident where a Sikorsky S-92A operated by Cougar Helicopters Inc. inadvertently descended and came within seconds of striking the water in July 2011.


"The aviation industry is increasingly relying on cockpit automation in its day-to-day operations," said Daryl Collins, the Investigator-in-Charge. "Despite the many benefits of cockpit automation in aviation, it is vital that flight crews maintain their hands-on visual and instrument flying proficiency so that they have the experience and confidence to deal with unusual situations."

Since the incident, Cougar Helicopters improved its unusual attitude training and now requires pilots to fly a minimum of 2 manually flown instrument approaches every 90 days. It has also clarified its standard operating procedures related to unusual attitude recovery, subtle incapacitation, and autopilot usage.


Transportation Safety Board of Canada: Full Report (http://www.cbc.ca/news/pdf/nl-tsb-cougarjuly2011-20130912.pdf)
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[rotorspeed]

So from the interesting TSB Canada S-92 report, Cougar are now requiring two hand flown instrument approaches every 90 days. Is any NS operator implementing anything similar?

Whilst extensive use of automation should be the norm, is not practising hand flown approaches, with the heightened awareness of particularly speeds, pitch attitudes, height and VS that follows from it, not an important part of being able to use the autopilot and upper modes competently? When hand flying an approach we are constantly focussed on trying to keep those parameters around target and appreciate more what's involved. It's hard work - and when we fail, things go wrong very quickly. It easy to see why complacency creeps in if you're just always monitoring.

[nomorehelosforme]

So it's not only super pumas that have problems off shore?

[DOUBLE BOGEY]

Recovery from UAs has been on the LPC/OPC schedule certainly since I started offshore neary 25 years ago.

The report details incorrect use of the automation. As far as I can tell, as I am not rated 92, the Pilot "flew through" the go-around mode leading to a disassociation between trim and auto trim.

This has nothing to do with hand flying.

DB

[rotorspeed]

DB

Sorry but this has a lot to do with hand flying - and a lack of competency at it.

The original diversion from the desired climb out profile may well have been due to inappropriate use of autopilot coupling and particulary GA mode engagement, but that's not the reason this aircraft nearly hit the water.

That was because the pilot, mainly the captain flying, did not recognise the unusual attitude (excessive pitch up with decreasing AS) that prevailed for quite some time and take adequate measures to rectify it. Recovery from unusual attitudes must be something that a professional pilot can achieve. And that must ultimately be a hand flying skill. Ok sometimes pushing the GA button can help, but only sometimes, and subject to a good understanding of what other parameters must be established for that to work.

This smacks of the pilot almost continuing to bash the keyboard from the Children of Magenenta film whilst he should have, knowing that things were getting out of control, simply uncoupled completely, got the wings level, established an appropriate pitch attitude, power setting and airspeed, re-established a sensible climb. Then engage upper modes to stabilise thing, take stock, and continue.

Surely you can't argue about this? Or do you believe that big sophisticated helicopters have become too complex for pilots to be expected to be able to revert to basic PPL IMC techniques if the autopilot isn't doing what you wanted it to? Is there just too much panel info, making it hard to identify the basic instruments/displays to refer to?

It's easy to see how precious seconds can be lost trying to figure out why the aircraft isn't doing quite what you want when the AFCS is being used, when all the time the upset is worsening, and stress of trying to figure it out increasing. If hand flying skills were more current, I can't help but feel such pilots would be more ready to uncouple, recover by hand, get the aircraft flying again and then re-engage the AFCS carefully.

[pilot and apprentice]

Part of the issue/discussion here, and the Sumburgh accident as well, is that practice UA's on a ride or in a sim don't fully replicate a true UA.

If you have intact SA, you are not in what we regularly call a UA, you know where you are and effecting a recovery is much easier. This includes the 'eyes closed' practice UA's.

When, for whatever reason, you suddenly realize that your idea of what the a/c is doing/where it is does not match reality, it takes time to accept it, to acquire data, and regain some semblance of SA. If you have marginal VMC, it can be hard, but IMC is very tough!

I've had this happen 3 times in my career. The training UA's we do are great for practicing the latter stages of recovery but do not give insight into prevention, recognition, or acceptance.

[DOUBLE BOGEY]

ROTORSPEED. IMC UA recovery for a PPL(H) in a light single bears little resemblance to attempting to do the same in a 12T helicopter.

You, and the others posting similar on this and other threads are missing the point. Every NS pilot undergoes IMC UA recovery, training and checking, every six months. We all pass!!

However, I have had two horrific, real IMC UA recoveries in a heavy helicopter. I inherited one from an Analogue AP input and one from the Commander. I survived both by the very skin of my teeth. One of them led me to draft the Night Stabilised Approach procedures only 2 weeks before the first Bond ETAP CFIT.

The common element in both recoveries was the incredible inertia required to overcome the fu*cked up flight path I was presented with. It is not like the simulator. It is real, the adrenalin explodes into you heart and time slows down to make the recovery even harder. I have given both events a lot of thought. I concluded that if I was a little bit more patient with my inputs recovery would have been smoother in both events....but the time thing really distorts your perception.

I reflect on both incidents knowing only that I was very lucky and I never want to face an event like this again. Both were deeply harrowing and humbling experiences.

When I speak of Unusual Attitude recoveries I consider myself unfortunately experienced. I cannot recall in either event following any structure to the recovery. I took action and I really feel luck played a great part.

Both events were reported IAW the Company procedures.

History, repeated time and time again has shown that we usually arrive in these situations BY HAND FLYING THERE. If you do not believe this then do some research. The sad truth is even when there were no couplers, everything being hand flown and most pilots were ex military,we dunked an awful lot more in the ocean than your rosé tinted glasses allow you to see.

My first event was AP related. The second, my Commander "Hand Flew" me into it (we had a 4 axis coupler) because there was nothing in our OM to say he could'nt and thus nothing but my airmanship remained to protect us.

I remain convicted that the only sure way forward is DAFCS, envelope protections and full and complete training and checking of the pilots using these systems. Pilots perceptions of their skill sets and emphasis during Training needs to change. Cultures need to change. AW and Sikorsky NEED TO build better AFCS to support their products.

Above all we need to trade in real, tangible currencies here. By this I mean there is no quantifiable way to subjectively assess hand flying skills such that we could improve the performance of the pilot leading to an end to these events.

We should remember that every one of these pilots will have successfully demonstrated and flown approaches and UA recoveries within the proceeding 6 months.

DB

[satsuma]

Two aspects stand out for me.

Although the first officer had almost 1000 total flight hours on the S-92A, many of those hours were spent in coupled flight during instrument flight rules (IFR) flights to and from the offshore facilities, and not hand flying the helicopter. As a result, the first officer did not feel confident about having the necessary instrument flying skills to safely recover from the unusual attitude that had developed

WTF? :confused: A pilot that's not confident that he can fly the helicopter?

and despite the existence of


a just and learning approach that does not seek to apportion blame as its primary thrust


where

It is recognized that human error can occur

and

blame and subsequent punishment will not be delivered as the resolution to the problem

the Captain was sacked. Not demoted, not sent for re-training, sacked.

[rotorspeed]

DB

Only just caught up. Appreciate your extensive reply and certainly food for thought. My world is SP in light IFR twins and I've never flown anything like a 12t heli.

Certainly have to respect your experience and judgement in this area and can see that as you say, the sheer inertia of 12t could make recovery from UA a very different deal from a 3t heli. But what happened in the days of presumably pretty simple old S61s? Were they equally hard to sort out from UA?

The Sumburgh and this Cougar incident, and pprune posts from them, have certainly had me thinking. I've already modified my IFR let down profiles to allow more time to stabilise and refine upper mode use. And today I experimented with engaging GA at too low a Tq and see what's involved in taking over by hand once the VS and AS were plummeting. Got to say, even though I knew it was coming, I was surprised how slushy it was and how long it took to regain attitude and a sensible profile. Maybe I was verging on VRS, even though Tq low. I was certainly relieved I was experimenting at a reasonable altitude.

Moral being, don't let it get there in the first place. Which, in IMC, is back to the importance of being right on top of monitoring all key parameters and immediately addressing any deviations.

[DOUBLE BOGEY]

ROTORSPEED. My god you have got this captured. Your description of the training you did yesterday, and the experience it gave you, I believe is the key here.

What you did was deliberately set up a flight path that would eventually fail, almost letting it do so and learned valuable information about you, your helicopter and its systems in the process.

At present we seem to miss this bit out during regulated training. We setup to succeed and monitor performance and then move immediatly to "it has failed" (the UA recovery), ignoring the bit in the middle that you did yesterday.

We have FFS to help us do this.we can do it safely. I commend your efforts to expand your skills in the actual AC but without patronising, and from the heart, be bloody careful because despite our experience, none of it is normally at the edges of the safe flight envelope and it gets really nasty there.

Stay Safe.

DB

[SASless]

I always suffered from the attitude of "Well....let's give this a try and see what happens...school of thought." I studied up on the topic and carefully considered what I was doing....but nothing beats experience....VRS, Settling with Power, RBS, low speed UA's....tail rotor failures....hydraulic failures....stuck collective....all sorts of fun things. Mind you I did all those under controlled circumstances and always with well thought out parameters....and never really scared myself or those with me beyond what my normal flying skills did anyway.

While instructing when a Student let the aircraft get away from him...I refused to take the controls unless it was really necessary and instead forced the Student to regain control....all the while reminding them I would not always be along for the ride in the future and they had to be able to make the Helicopter or airplane do what they wanted it to do.

Simulators are just that "simulators" and do not actually replicate the handling qualities of the actual aircraft.

One short coming is the delay with the aircraft computer and the visual computer....some are better than others but there is always a slight delay between the pilot's input and the movement of the visual....as even electrons travel a bit slower than the human eye can perceive movement on the visual and bounce it off the brains signals to the hands and feet.

The more you can experiment with the actual aircraft the better off you are....but do it very carefully.

[[email protected]]

DB - two points - firstly I don't think a 6 monthly requirement for UA/UPs is good enough, monthly would be much better. Secondly - pilots should practice them in the real aircraft because, no matter how good your sim, it can't accurately replicate all the 'seat of the pants' proprioceptive feedback from the real machine.

I don't think there is any difference in a UP recovery between in a light single and a heavy twin.

Are there set parameters for the 6 monthly sim UPs?

[rotorspeed]

DB - yes, from my experiences I'd agree something is missing from training here. And as you say SAS, some training in the actual aircraft is essential.

Basically I set up what I thought was going to be a simple verification exercise of my matter of fact comments on recovery from UA from poor use of GA. Straight and level at 2000ft, reduce Tq to low level, watch AS decay to 80 kts or so, select GA and wait. After a minute or two, after the initial climb, AS had decayed to 30kts and reducing, VS to 300ft/min descent and increasing, attitude 10 deg or so nose up.

From a pretty uncomfortable attitude, time to intervene by hand. Simple - wings level, forward cyclic to obtain I thought say 5 deg nose down, watch AS, as exceeded 40 kts ish pull power, level pitch, sorted. Except it wasn't quite like that.

The big thing that surprised me - and alarmed me - was how slow the acft was to react to forward cyclic forward and reduce the pitch up. Despite what I thought was an appropriate forward movement, nothing happened for several seconds - the cyclic seemed initially completely ineffective. Eventually it lazily did what I wanted. Then I found that although pressing trim release, I'd forgotten to uncouple GA, which was still on and resumed as soon as I released trim release after recovery. So I did it all a second time, first uncoupling GA, then trim release. Same initial cyclic laziness but at least no risk of the upset happening again from re-engagement of GA. But - two buttons to have to remember to press in a crisis!

Don't get me wrong, this wasn't a major drama, just a bit disconcerting and certainly illuminating. I'm not sure if this little exercise was truly representative of how things really feel with other acft in a similar situation - quite possibly. But I'd never experienced this in training, and it would have been good to have done so and learn to patient and be confident recovery would follow. As we have seen from the Cougar incident and possibly the Sumburgh accident, autopilot mis-handling can lead to exactly the type of phase of flight I experienced.

With regard to training/learning tools, it did occur to me that it would be good if the controls were data logged so movement extents and rates etc could be reviewed in a de-brief - and initial briefing. Does this happen on heavy acft training?

And DB, your point on caution on experimentation is well made and indeed occurred to me too!

[Flying Lawyer]

Upon landing, the crew submitted an SMS report. :ok:
They both cooperated fully with the company’s SMS investigation. :ok:
The Captain was fired. :(

2.9.1 Just Culture and Non-Punitive Reporting

Cougar Helicopters’ safety management system (SMS) manual and other related company documents advocate a non-punitive reporting system as a core element of a healthy SMS. In this occurrence, both pilots reported the occurrence and cooperated fully with the company’s SMS investigation.

The decision was made to terminate the captain’s employment based on the company’s determination that the captain could not operate safely in the offshore IFR environment. To some employees, this appeared to be in conflict with the principles and processes outlined in Cougar Helicopters’ SMS and with non-punitive reporting.

The reporting of hazards is a cornerstone of a robust SMS. A non-punitive reporting policy encourages open reporting of safety occurrences. At the same time, companies have a responsibility to ensure that their employees are competent to carry out their duties in a safe manner. This means that, from time to time, companies may take significant measures, including termination of employees who are involved in safety incidents. Therefore, when introducing a non-punitive reporting system and a Just Culture decision tree model, organizations must be clear with their staff about the types of situations that could result in disciplinary measures, or other company actions including termination. Otherwise, subsequent management actions may undermine the trust employees have in such systems.

When actions taken by a company are perceived by employees to be inconsistent with its non- punitive reporting and Just Culture policy and processes, there is a risk that employees will not report safety occurrences for fear of reprisal.

[Winnie]

Have heard that the issue may not be the UA, but carrying on to shore after a massive overtorque.

Courtcase for wrongful dismissal is ongoing.

[DOUBLE BOGEY]

If the report is taken at face value, this man demonstrated a skill that has managed to elude many that have gone before him, to fly into a UA of his own making, diagnose it, and fly out of it saving the AC crew and PAX in the process.

If you are reading this and feeling **** about what happened. Don't. It can happen to any of us. You just got asked the question and unlike many, you were not found wanting.

Shame on Cougar!!

[SASless]

I would suggest most UA events are self inflicted rather than caused by some malfunction of the machine. No matter how you get into the situation....the recovery procedure should be pretty straight forward I should think.

Stop Turn, Wings level, Climb Pitch attitude, climb power....stabilize Airspeed at Vy or higher.

Dropping the Auto Pilot but retaining SAS and Attitude Hold function would also be a good move I should think.

Once the recovery is complete and the aircraft is back under control....reverting to using the Auto Pilot would be my next move....unless it was an Autopilot malfunction that caused the upset.