AW139 G-LBAL helicopter crash in Gillingham, Norfolk
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Non PC Plod
Does that mean that we are doing everything right and that accidents are merely the product of a personality defect?
No, of course not. The Ransom model has it that we put a series of barriers in the way of the accident trajectory and that only when the holes in those barriers are aligned do we have an accident. One of those barriers is licensing. Licensing systems are designed (presumably) to deliver an optimum outcome - a competent pilot. Accordingly all the rules developed to deliver a licensed professional pilot must be designed to deliver this 'competent individual'. It therefore follows that the barrier (Swiss Cheese) called licensing is free of holes. We know different of course.
Similarly the barrier called 'Training' is designed to be compliant with the rules produced by the licensing authority. If fully compliant the schools delivering the training have every right to expect the result to be, once again, a 'competent individual'. Schools management MUST therefore focus on compliance in order to retain their approval to operate. The assumption therefore, once again, is that the 'Training' barrier (Swiss Cheese) has no holes in it. We know different here also.
I have a list of 'holes' that experience has allowed me to identify but I don't want to sound like a worn out record banging on about them. Maybe you other guys and gals out there can pitch in with your experience and tell us what 'holes' in both the Licensing and the Training Swiss Cheeses you have identified. Maybe between us we can identify a definitive list and use it to inform those that need this knowledge. A kind of bottom-up feedback.
G.
No, of course not. The Ransom model has it that we put a series of barriers in the way of the accident trajectory and that only when the holes in those barriers are aligned do we have an accident. One of those barriers is licensing. Licensing systems are designed (presumably) to deliver an optimum outcome - a competent pilot. Accordingly all the rules developed to deliver a licensed professional pilot must be designed to deliver this 'competent individual'. It therefore follows that the barrier (Swiss Cheese) called licensing is free of holes. We know different of course.
Similarly the barrier called 'Training' is designed to be compliant with the rules produced by the licensing authority. If fully compliant the schools delivering the training have every right to expect the result to be, once again, a 'competent individual'. Schools management MUST therefore focus on compliance in order to retain their approval to operate. The assumption therefore, once again, is that the 'Training' barrier (Swiss Cheese) has no holes in it. We know different here also.
I have a list of 'holes' that experience has allowed me to identify but I don't want to sound like a worn out record banging on about them. Maybe you other guys and gals out there can pitch in with your experience and tell us what 'holes' in both the Licensing and the Training Swiss Cheeses you have identified. Maybe between us we can identify a definitive list and use it to inform those that need this knowledge. A kind of bottom-up feedback.
G.
Avoid imitations
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Geoffers, here's one for a start. The A139 is certified for SPIFR, as are other similar helicopters. Pilots are trained, licensed and tested to operate single pilot IFR. But a private owner or operator can require two pilots up front when flying passengers (it is an insurance requirement for some). Then, in some cases, the only time a SPIFR pilot flies by himself is during his check rides, or during positioning flights.
The US FAA sets up a situation for problems when it defines IMC/VMC using Cloud Height and Visibility alone for that in our FAR Part 91. Example is the JFK Jr Fatal Crash where Night VFR for Non-Commerical operations requires no surface or celestial lighting to maintain control of the aircraft yet for Commercial Operations under FAR Part 135 it does specify surface lighting sufficient to control the aircraft.
That US EMS Helicopter Operators routinely ignore that requirement never sees enforcement action by the FAA.
Regulation....Fail
Enforcement....Fail
Training.....Fail
SOP's Operator Procedures.....Fail
Judgement.....Fail
All the Holes line up neatly far too often as a result as some of them are quite large thus facilitating the smaller ones a lot of room to line up.
That US EMS Helicopter Operators routinely ignore that requirement never sees enforcement action by the FAA.
Regulation....Fail
Enforcement....Fail
Training.....Fail
SOP's Operator Procedures.....Fail
Judgement.....Fail
All the Holes line up neatly far too often as a result as some of them are quite large thus facilitating the smaller ones a lot of room to line up.
Tightgit
Licensing systems are designed (presumably) to deliver an optimum outcome - a competent pilot.
They probably were competent for the purpose of licensing. They just weren't competent enough for the purpose of their operation. In non-private flying, it is the OPC and Line Check that should determine whether a pilot is competent to carry out the role that his or her employers are paying for. The issue here is that in a number of corporate operations, because they are carried out under the flag or private flying, there is no oversight from the regulator! What's more, as the regulator doesn't get to determine who it regulates, it seems to me that casting blame in that direction is wrong.
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Handysnaks
I think that you have made a vitally important observation - perhaps without realising it. You could maybe expand on this theme.
I am talking about your acute awareness that there is a relationship between competence and the role the professional undertakes. How would it be, do you think if the regulations required that before you were permitted to work in a discrete market sector you were required to hold a license extension that included that sector.
This you would not be permitted to work in any of the following without an appropriate 'role related' rating: -
BASIC VFR Day
BASIC Night
IFR
SPIFR
MCC
Offshore - Day only Hostile environments
Offshore - Day only Non Hostile environments
Offshore - Day/Night Hostile environments
Offshore - Day/Night Non Hostile environments
HEMS - Day only
HEMS - Day/Night
FIRE
SLING
LAW ENFORCEMENT
SAR - Overwater
SAR - Overland
(any more????)
More bl**dy bureaucracy I hear you protest but if you make it the responsibility of the employer to ensure that appropriate role training is delivered in order to achieve the - let's call it a 'Role Rating - you have - at least in regulatory terms brought together the job with appropriate training.
G.
I am talking about your acute awareness that there is a relationship between competence and the role the professional undertakes. How would it be, do you think if the regulations required that before you were permitted to work in a discrete market sector you were required to hold a license extension that included that sector.
This you would not be permitted to work in any of the following without an appropriate 'role related' rating: -
BASIC VFR Day
BASIC Night
IFR
SPIFR
MCC
Offshore - Day only Hostile environments
Offshore - Day only Non Hostile environments
Offshore - Day/Night Hostile environments
Offshore - Day/Night Non Hostile environments
HEMS - Day only
HEMS - Day/Night
FIRE
SLING
LAW ENFORCEMENT
SAR - Overwater
SAR - Overland
(any more????)
More bl**dy bureaucracy I hear you protest but if you make it the responsibility of the employer to ensure that appropriate role training is delivered in order to achieve the - let's call it a 'Role Rating - you have - at least in regulatory terms brought together the job with appropriate training.
G.
Last edited by Geoffersincornwall; 20th Oct 2015 at 16:40. Reason: adding to the list
A perfect recipe for Empire Building and Turf Guarding by far too many people.
Your UK Licensing System is far too complex and convoluted as it is now.....why add to that Monster.....not to forget Lots of Lots of Cost!
In a cold view....would that be cost effective as compared to the real cost in machines and lives?
Are there cheaper and far less complicated ways of achieving the same goal?
Your UK Licensing System is far too complex and convoluted as it is now.....why add to that Monster.....not to forget Lots of Lots of Cost!
In a cold view....would that be cost effective as compared to the real cost in machines and lives?
Are there cheaper and far less complicated ways of achieving the same goal?
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SAS and II
If there is a cheaper way please show me.
Don't you think you are in denial. A licensing system must be fit for purpose. The CPL as is leaves the newly licensed rotary wing professional facing a huge skill gap before he can be of any use as a functional crew member in most helicopter roles.
At present we rely on a patchwork of 'on-the-job' training that clearly doesn't work. Agreed the big operators tend to recognise the realities and put their people through a comprehensive programme that takes them all the way from Newbie to 'good-to-go' line pilot. They would not incur any additional costs if they put their programme forward as an 'AMC'.
The effect of a 'role rating' would be to codify what is expected by way of 'Best Practice'.
G.
Don't you think you are in denial. A licensing system must be fit for purpose. The CPL as is leaves the newly licensed rotary wing professional facing a huge skill gap before he can be of any use as a functional crew member in most helicopter roles.
At present we rely on a patchwork of 'on-the-job' training that clearly doesn't work. Agreed the big operators tend to recognise the realities and put their people through a comprehensive programme that takes them all the way from Newbie to 'good-to-go' line pilot. They would not incur any additional costs if they put their programme forward as an 'AMC'.
The effect of a 'role rating' would be to codify what is expected by way of 'Best Practice'.
G.
Back at the start of this thread, I pleaded that there should be no more regulation. Enforcement maybe, but regulation..... NO!
I struggle to beleive what I'm reading here.
Two under-'qualified' pilots put themselves in an entirely avoidable situation. Launching at night in IMC and making it up as they went along was always going to end one way. If not on the night of the accident, then surely some time later.
I apologise if this sounds callous, it's not meant to. However, let's not regulate to the lowest common denominator. Regulation alone doesn't work; there will always be Darwin Award candidates that think they can circumvent the system. It's down to training and testing being made more appropriate to the real world and the acceptance that helicopter flying is a risk strewn business that CAN be managed.
JJ
I struggle to beleive what I'm reading here.
Two under-'qualified' pilots put themselves in an entirely avoidable situation. Launching at night in IMC and making it up as they went along was always going to end one way. If not on the night of the accident, then surely some time later.
I apologise if this sounds callous, it's not meant to. However, let's not regulate to the lowest common denominator. Regulation alone doesn't work; there will always be Darwin Award candidates that think they can circumvent the system. It's down to training and testing being made more appropriate to the real world and the acceptance that helicopter flying is a risk strewn business that CAN be managed.
JJ
So we come back to this case where the helicopter IR is clearly not fit for purpose - no flight below Vmini is ridiculous - the mil IR in many fleets specifies a low speed UP/UA recovery and an IF take off (from the hover) for exactly the reason that this crash occurred - people will use the helicopter to achieve an aim.
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Jelly
Two under-'qualified' pilots put themselves in an entirely avoidable situation.
It's down to training and testing being made more appropriate to the real world
I agree that our current system would work better if there was more rigour and better enforcement. The problem I am pointing at is that our system is based on the fixed wing philosophy that sees Joe Pilot pop from CPL FHT to airline with no serious issues but we cannot do that in most cases because the skills gap between the New CPL and the functioning crew member is simply too great. We need another way.
G.
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The experience gap is here to stay for quite some time, it seems. The onshore corporate world is a highly demanding role. Quite often these days, it seems no sooner has a pilot obtained his twin rating, he is in the job as single pilot corporate captain, often coming under a lot of commercial pressure, with little guidance from more experienced colleagues, as used to be the case.
Unfortunately, Jellycopter, legislation sometimes has to take account of the lowest common denominator. I probably feel just as strongly as you about not clipping everyone's wings for the sake of a few (and as you know, I've been around the bazaars for a while) but tbh, I'm becoming increasingly concerned about the terrible damage these unnecessary and preventable accidents have had on the way our business is regarded by Joe Public. Giving pilots a more simply understood set of weather limits will make it easier for the inexperienced to stand up to undue pressure to launch against their better judgement, as it seems occurred in this case.
Unfortunately, Jellycopter, legislation sometimes has to take account of the lowest common denominator. I probably feel just as strongly as you about not clipping everyone's wings for the sake of a few (and as you know, I've been around the bazaars for a while) but tbh, I'm becoming increasingly concerned about the terrible damage these unnecessary and preventable accidents have had on the way our business is regarded by Joe Public. Giving pilots a more simply understood set of weather limits will make it easier for the inexperienced to stand up to undue pressure to launch against their better judgement, as it seems occurred in this case.
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C G B
Yes, yet we sign up to a scheme that promotes the notion that newbies can hours-build teaching other newbies and that this is an intelligent interpretation of the (completely idiotic) notion that more hours = more competence.
6 out of the top 10 causal factors (FAA data and EASA data) in aviation accidents involve decision making errors.
The academic papers that explore poor decision making in aviation tend to repeat one important word - EXPERIENCE. Yes you are right you cannot teach experience but if you place a newbie alongside an experienced instructor then as the academics point out you have increased the range of decision options that the newbie is exposed to.
IMHO all FI's and TRI's should all have at ATPL before being allowed to teach.
G.
6 out of the top 10 causal factors (FAA data and EASA data) in aviation accidents involve decision making errors.
The academic papers that explore poor decision making in aviation tend to repeat one important word - EXPERIENCE. Yes you are right you cannot teach experience but if you place a newbie alongside an experienced instructor then as the academics point out you have increased the range of decision options that the newbie is exposed to.
IMHO all FI's and TRI's should all have at ATPL before being allowed to teach.
G.
Tightgit
Crab.
I think the helicopter I/R is fit for its basic purpose, which is to fly from anyplace with an official IFR departure procedure to any other place with an official IFR arrival procedure. The problem is depending on your point of view;
1. The rules are not strict enough and therefore allow pilots to get into the situation that started this thread or
2. The rules are strict enough but human nature being what it is, these accidents will happen if pilots don't assess their own capabilities honestly and decline to carry out operations that they are not competent enough to carry out safely every time.
SASless.
The UK licensing system (actually, the European licensing system now), is certainly more onerous than the US system and certainly more expensive, but I don't think it is much more complex or convoluted. In effect there are still only three possible things to achieve, a CPL, an ATPL and an I/R. Should you fly from airfield to airfield then any of those should allow you to do it reasonably competently within the constraints of the licence held.
Geoffers.
In a sense, that role related training that you write about already exists. Maybe not to the standard you would like it to be but within PT or Aerial Work, all organisations are required to show that they are complying with the 'spirit' of the regulations by providing OPC's and Line Training before a pilot is released to work. ( I think that is true for aerial work but happy to be shot down in flames if it is not). What you are asking for seems to be moving away from the EASA methodology, which seems to be to get operators to regulate themselves in accordance with the EASA/national and company regulations and for the local representatives of EASA to verify that each companies method of self regulation is fit for purpose. However, the 'problem' in the case mentioned is that as a private flight, the operation was not subject to any regulation. Now on the one hand it seems a bit strange that an operation that has employed pilots on its books, who are paid to fly an aircraft in the service of a company, is not subject to the same regulation as others who do virtually the same thing. On the other hand, the corporate market in the UK is (I believe), larger than most other countries in Europe. Maybe this is a case where we actually have a lot of flexibility in the industry, rather than the overly bureaucratic system that quite a lot of our number criticise regularly. Even trying to get a buy in from the private operators via the BHA is unlikely to work as many don't join. There have been a few discussions in the past regarding whether piloting aircraft is a profession or not. One of the requirements of being a member of a profession is the obligation to commit to a programme of Continuing Professional Development. Perhaps this is one of those examples that shows that maybe it is not, in that although we have to maintain our skills via OPC LPC or LC, there is very little continuing professional development that we as individual pilots are required to do, to 'keep up to the latest standards.
I think the helicopter I/R is fit for its basic purpose, which is to fly from anyplace with an official IFR departure procedure to any other place with an official IFR arrival procedure. The problem is depending on your point of view;
1. The rules are not strict enough and therefore allow pilots to get into the situation that started this thread or
2. The rules are strict enough but human nature being what it is, these accidents will happen if pilots don't assess their own capabilities honestly and decline to carry out operations that they are not competent enough to carry out safely every time.
SASless.
The UK licensing system (actually, the European licensing system now), is certainly more onerous than the US system and certainly more expensive, but I don't think it is much more complex or convoluted. In effect there are still only three possible things to achieve, a CPL, an ATPL and an I/R. Should you fly from airfield to airfield then any of those should allow you to do it reasonably competently within the constraints of the licence held.
Geoffers.
In a sense, that role related training that you write about already exists. Maybe not to the standard you would like it to be but within PT or Aerial Work, all organisations are required to show that they are complying with the 'spirit' of the regulations by providing OPC's and Line Training before a pilot is released to work. ( I think that is true for aerial work but happy to be shot down in flames if it is not). What you are asking for seems to be moving away from the EASA methodology, which seems to be to get operators to regulate themselves in accordance with the EASA/national and company regulations and for the local representatives of EASA to verify that each companies method of self regulation is fit for purpose. However, the 'problem' in the case mentioned is that as a private flight, the operation was not subject to any regulation. Now on the one hand it seems a bit strange that an operation that has employed pilots on its books, who are paid to fly an aircraft in the service of a company, is not subject to the same regulation as others who do virtually the same thing. On the other hand, the corporate market in the UK is (I believe), larger than most other countries in Europe. Maybe this is a case where we actually have a lot of flexibility in the industry, rather than the overly bureaucratic system that quite a lot of our number criticise regularly. Even trying to get a buy in from the private operators via the BHA is unlikely to work as many don't join. There have been a few discussions in the past regarding whether piloting aircraft is a profession or not. One of the requirements of being a member of a profession is the obligation to commit to a programme of Continuing Professional Development. Perhaps this is one of those examples that shows that maybe it is not, in that although we have to maintain our skills via OPC LPC or LC, there is very little continuing professional development that we as individual pilots are required to do, to 'keep up to the latest standards.
Avoid imitations
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Geoffers, I concur. One aspect of this accident apparently not taken into account by the AAIB was that the captain had previously been the instructor of the co-pilot, during his more recent basic rotary training. There may have been a subtle cross-cockpit gradient; the CVR revealed that one of the pilots mentioned that he wasn't happy to depart in view of the conditions.
I think the helicopter I/R is fit for its basic purpose, which is to fly from anyplace with an official IFR departure procedure to any other place with an official IFR arrival procedure. The problem is depending on your point of view
We still have the same limits for NDB tracking as VOR despite the former (in all helis I have flown) being something of an area weapon.
How many RW pilots regularly conduct NDB or VOR holds (on the job, not for training).
The ability to get from place to place using radio aids is still just about valid but GPS will be the weapon of choice for corporate pilots I expect, with the radio aids being there for back up.
If we ignore the realities of the onshore corporate world and pretend everyone is an offshore IF God the we will keep seeing accidents like this.
Like so many accidents, this one had a number of causal factors, some of which you just can't legislate for (bad decision making or poor CRM due to previous cockpit gradient) but the mechanics of the takeoff could have been taught and tested early in both pilots careers.
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Shy T & Handy
I believe there is merit in seeking out best practice in each area of helicopter operations and using it to codify the requirements.
If I understand things correctly all EASA operations of non commercial complex helicopters will require AOC like provisions next year.
CRM - It's sad that it takes hindsight for the subtle cross-cockpit gradient to be so obvious and sad that it was not commented upon.
I wonder if AAIB get a few spare moments to read up on the academic studies that discuss bad decision making in aviation?
Could I add 'Corporate Ops' to my list of Role-Ratings. There would be the opportunity to learn about and develop strategies for dealing with problem owners/customers. I've been there too, it's no fun but if handled correctly you get away with a bit of huffing and puffing but they see sense in the end. Those that don't can be VERY difficult but not impossible because in the end you simply have to say no.
Crab - To extend the training into an area outside the RFM flight envelope wouldn't be allowed but your point is valid, helicopter pilots will want to use the full capabilities of the machine even when they know it's not kosher. As an ex-mil pilot I could refer back to the training you describe but those that have never been there will be standing into danger if and when they try to do the same thing.
G.
If I understand things correctly all EASA operations of non commercial complex helicopters will require AOC like provisions next year.
CRM - It's sad that it takes hindsight for the subtle cross-cockpit gradient to be so obvious and sad that it was not commented upon.
I wonder if AAIB get a few spare moments to read up on the academic studies that discuss bad decision making in aviation?
Could I add 'Corporate Ops' to my list of Role-Ratings. There would be the opportunity to learn about and develop strategies for dealing with problem owners/customers. I've been there too, it's no fun but if handled correctly you get away with a bit of huffing and puffing but they see sense in the end. Those that don't can be VERY difficult but not impossible because in the end you simply have to say no.
Crab - To extend the training into an area outside the RFM flight envelope wouldn't be allowed but your point is valid, helicopter pilots will want to use the full capabilities of the machine even when they know it's not kosher. As an ex-mil pilot I could refer back to the training you describe but those that have never been there will be standing into danger if and when they try to do the same thing.
G.
Last edited by Geoffersincornwall; 20th Oct 2015 at 20:23. Reason: for Crab
Geoffers - I agree but perhaps there needs to be a clarification of what Vmini actually means.
It is sensible to have a minimum speed for cruise flight where the pitot system is accurate and the stability isn't an issue but to say that the aircraft CAN'T be flown on instruments safely to get to or from the hover is a nonsense. It isn't outside the flight envelope, simply below the figure in the RFM for flight on instruments.
I don't know what the criteria are for certification purposes or what has to be demonstrated or guaranteed when dictating Vmini but it does seem that the manufacturers have painted the pilots into a corner.
It is sensible to have a minimum speed for cruise flight where the pitot system is accurate and the stability isn't an issue but to say that the aircraft CAN'T be flown on instruments safely to get to or from the hover is a nonsense. It isn't outside the flight envelope, simply below the figure in the RFM for flight on instruments.
I don't know what the criteria are for certification purposes or what has to be demonstrated or guaranteed when dictating Vmini but it does seem that the manufacturers have painted the pilots into a corner.
Tightgit
but it is just a FW IR profile flown in a helicopter rather than something that reflects the realities of RW IFR.
We still have the same limits for NDB tracking as VOR despite the former (in all helis I have flown) being something of an area weapon.
How many RW pilots regularly conduct NDB or VOR holds (on the job, not for training).
We still have the same limits for NDB tracking as VOR despite the former (in all helis I have flown) being something of an area weapon.
How many RW pilots regularly conduct NDB or VOR holds (on the job, not for training).
Geoffers.
I believe there is merit in seeking out best practice in each area of helicopter operations and using it to codify the requirements.
What is the "NDB" thing they speak of....are they not NDB Approaches a thing of the past with the advent of GPS?