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Old 12th Feb 2006, 02:00   #81 (permalink)
 
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Schreiner have 2 in Holland, BHL will have 4 in the SNS; 2 Norwich and 2 den Helder by end of the year, I think.

TC, it doesn't have an icing clearance, yet.
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Old 25th May 2006, 13:15   #82 (permalink)

 
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Hong Kong GFS EC155 Accident Report.

Joker's Wind posted this on the Fragrant Harbour Forum. It needs to be here also.
.............................

After 33 months of waiting, the accident report into the HK GFS EC155 crash of 26 August 2003 was finally made public.

The report can be downloaded at:

http://www.cad.gov.hk/reports/Accide...6_of_B-HRX.pdf

It's a large file (26 megs), but well worth the read.

My heart goes out to the two flight crew who perished in the crash. Having read the report thoroughly, it seems to me neither crew member was fully focused on the job that night, in that they seemed to be watching the clock quite closely.

Flight crew performing a task such as these gentlemen were, should NOT have to worry about receiving a bollocking if they don't meet certain time-related "performance pledges".

JW
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Old 25th May 2006, 13:25   #83 (permalink)
 
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working link (sortof):

http://www.cad.gov.hk/reports/Accide...6_of_B-HRX.pdf
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Old 25th May 2006, 16:56   #84 (permalink)
 
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No recommendation for an EGPWS, as if the device does not exist or that the device would not have prevented this accident!

Also, no call for 2-pilot operations! As if that would not help this case.

Also, no call for mandatory Mode C transponder operations at all times, as if that would not help this accident!

Some investigation!
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Old 25th May 2006, 17:20   #85 (permalink)

 
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One thing jumped out at me from this report; and I agree, it’s not the best.

The Radalt could have saved the day here. A reasonable Decision Height, set after take off, could well have given a warning of unexpected terrain closure with time enough to go skywards.

Yet the Report says

……………………

1.6.4.5 Radio Altimeter System with AVAD (Automatic Voice Alert Device.)

Sine the AVAD was designed for over-water flight and had no look forward or predictive capability it was of limited use over land. (??)

1.12.1.

At the point of impact with gently rising terrain……….

………………
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Old 26th May 2006, 02:21   #86 (permalink)
 
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HELP Guys, Tried to download and keep getting a "bad encrypt dictionary" error message (whatever that means). Dont have any trouble with other PDF files from the cad.gov.hk site, just the EC155 report.
Blue Skies,
Brian
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Old 26th May 2006, 02:40   #87 (permalink)
 
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I used the second link (no particular reason) and it worked fine with the standard right click and save target as.

What a terribly sad report, full of "what ifs". What if they had been 50 ft higher, or 200 m left of their track (like, over the road). Also, how close to the steep drop off to the coast they were: so near but so far.

I agree that an AVAD DH setting policy may have helped and of course EGPWS. However, what degree of fidelity would the EGPWS have to allow flight through the pass without warnings, even if clear of the ridge in question?

Despite the lack of DH setting, though, the pilot would have an indication of approaching ground as the altimeter tape on the PFD depicts the ground level as a brown base that would have been slowly rising to the datum point (also a similar brown base on the radalt display on the ND). I can only guess that in the conditions he would have been more occupied with looking out the window, rather than at his instruments, especially with AP holds engaged.

One or two comments (after a quick speed read) seem a bit crass:

"Survivable if seats and structure built to a higher spec?" I guess you could say that about all accidents!

"Attempted to shut the engines down" Really? You've just had an unexpected impact with terrain, at night in bad weather, which results in the blades disintegrating, and then in the subsequent 2.5 seconds as you tumble 100 ft down to the ground you calmly reach up and retard the fuel cut off lever, open the engine switch guard and turn the switch off, then pull the emergency electrical cut off ganbar! I doubt you could do all that while sitting on the ground, in daylight, having primed yourself to do it!! How about impact forces and objects (branches etc) penetrating the cockpit being the more likely answer?

I was also struck by the fact that theories were put forward as facts, such as "the pilot WAS subjected to confirmation bias". I'm sure NTSB/AAIB etc would have used expressions like "the pilot MAY have been ..."

Finally, it illustrates perfectly a statement that was in Flight International a year or so ago when they were reviewing the annual airline accidents for that year and discussing the fact that CFIT was still the major cause of accidents. It said that in almost all cases of CFIT, the CVR showed that the crew were experiencing a feeling of unease prior to impact. If in doubt, there is no doubt!

Last edited by 212man; 26th May 2006 at 03:35.
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Old 26th May 2006, 07:20   #88 (permalink)
 
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212man, thanks - fixed problem by getting rid of V6 and getting V7.
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Old 26th May 2006, 23:57   #89 (permalink)

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Personally terribly sad about this accident. As an ex of that employ and as someone who knew the pilot, I can say I always had grave concerns about that so-called VFR route from its inception. Not a brilliant idea to put one over some of the steepest rising and highest bits of terrain in the area... At night it was just a black hill with a row of roadside lights up it. There would have been no back lighting to assess the cloud cover. Last time I was up there at night it was whilst flying an NVG SAR mission; even that wasn't easy.
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Old 27th May 2006, 06:28   #90 (permalink)
 
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What jumped out of the report for me was,
Quote:
GFS had a quality system for the internal monitoring of standards within flight operations. (be there in 20 mins) There was no documented system for the proactive identification of hazards and systematic management of risk.
and
Quote:
The pilot returned to work with a GFS colleague. In conversation during the journey the pilot expressed his growing concern in relation to the targets that had been set by the GFS.
Having made those feelings felt only shortly before the accident you can understand why he may have done what he did in terms of route selection, particularly if some comment had been made about his turn around previously. Also the report does not make clear that the crew KNEW it was a non emergency case.
I'm reminded of a crew where I worked being criticised by the head C & T'er when doing a annual SAR check for "wasting time" by doing a brief prior to stepping. Trip was also being used as a trainer for a back seater on his first trip. Cant please everybody it seems.
The report seems to want to hang it all on the pilot. (he screwed up despite all the training we gave him - CRM etc. Once again, as with the first quote, my humble opinion is that its time management started to attend CRM to understand the impact and effect their decisions can have.)
To quote Stanley Roscoe
Quote:
The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.
Everyone else, including other crew members, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programmes or procedural
indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident
There is a lot of truth in as well,
Quote:
Career flying is an uptight, stressful occupation. Laymen have little conception of the pressures under which a professional works. His work is regulated to the point of absurdity by non flying management and federal officials who pretend to understand flying better than he does. He carries a thick book of rules so confusing even its authors can’t explain them. In effect, a committee of deskbound experts ride with him on every trip, instructing, admonishing, warning, watching – until there’s a problem. Then all fingers are pointed at him.
May God rest their souls.
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Old 27th May 2006, 22:31   #91 (permalink)
 
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A very sad story.

There are clear elements of 'mission creep' in this organisation's op. Even at 1500, those guys would have only cleared the pass by a few hundred feet, and there is not a not of room to conduct a 180, right at the top of the pass, with rapidly rising high ground on either side.

We should all examine our daily/nightly ops and ensure that the mission does not grow beyond the capability of the crew or the aircraft...

On 'pledge'...is something lost in the translation there? Are they referring to the mission, or do they really mean 'pledge?'
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Old 28th May 2006, 08:51   #92 (permalink)

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Unhappy

The response time of 20 minutes was a performance target set some years before. Unrealistic, considering that the pilot might actually be asleep when the call comes in (although he wasn't in this instance).

I was very surprised that wearing of flying helmets, rather than headsets, was not seen as a priority, especially as it was a night flight when ambient temperatures are lower and personal comfort shouldn't have been a major issue. Complacency a factor in personal survival issues?
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Old 28th May 2006, 10:56   #93 (permalink)
 
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It should also be remembered that not all cultures are intent on making sure the blame is correctly placed. Some are intent in ensuring that blame is not placed on superiors, local nationals (when a foreigner may be a convenient scapegoat), etc.
I was involved in an investigation where several tourists were killed in a helicopter crash in foreign country. Despite strong evidence to the contrary which I produced, the board of enquiry concluded that the cause was one of the passengers shutting off the fuel...
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Old 28th May 2006, 11:48   #94 (permalink)
 
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Read up on ICAO - an accident report should not be allocating blame. Although some investigators do spend more time eliminating anything in their reports that may cause others to allocate blame.
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Old 29th May 2006, 04:33   #95 (permalink)
 
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Any cue on the policy. Poor Head created poor tail. How to prevent the accident b4 it is happen. Why there is no way to take it away before it really drop into shtt.
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Old 29th May 2006, 07:37   #96 (permalink)

 
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I suspect that there were a number of re-writes and edits before this version was published, hence the long delay. As I understand it not ‘everyone’ was pleased with the original findings.

Does anyone know which bits were required to be modified?
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Old 29th May 2006, 07:48   #97 (permalink)
 
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That was a really useful contribution, Windbird! I look forward to many more enlightening and constructive inputs!
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Old 3rd Jun 2006, 15:37   #98 (permalink)
 
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Where have all the flowers gone?
Long time passing
Where have all the flowers gone?
Long time ago
Where have all the flowers gone?
Girls have picked them every one
When will they ever learn?
When will they ever learn?

Where have all the young girls gone?
Long time passing
Where have all the young girls gone?
Long time ago
Where have all the young girls gone?
Taken husbands every one
When will they ever learn?
When will they ever learn?

Where have all the young men gone?
Long time passing
Where have all the young men gone?
Long time ago
Where have all the young men gone?
Gone for soldiers every one
When will they ever learn?
When will they ever learn?

Where have all the soldiers gone?
Long time passing
Where have all the soldiers gone?
Long time ago
Where have all the soldiers gone?
Gone to graveyards every one
When will they ever learn?
When will they ever learn?

Where have all the graveyards gone?
Long time passing
Where have all the graveyards gone?
Long time ago
Where have all the graveyards gone?
Covered with flowers every one
When will we ever learn?
When will we ever learn?
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Old 5th Jun 2006, 09:13   #99 (permalink)
 
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Could the pilot alone constitute this mishap?

Brain Abrham, you are right, the management of Gravity Flying School GFS had never thought of the risk until the so-called accident was happened. The management was shocked, but still they put all the responsibility to the poor pilot. Have they ever thought of the poor leadership which truly dragged the chopper and brought the aircrew to the God.

In fact, the mishap was sitting there for a long time, it was not the first working day of the pilot and the traps ( the reasons of this accident) were sitting there for years. Were they daydreaming before the mishap?

The CAD found out that the pilot swore the 20 minutes TOS policy on the way back to work. He did not do the flight planning, he and his crew did not wear helmets. He continued to swear the 20 minutes TOS rule. He did not select the less risky route to fly to the destination. He ignored the SOP (standard operation procedure) of flying in the wrong altitude and high speed. He ignore the repetitive reminder from the crewman at the back and attempted speedy flying. He placed the 20 min TOS with higher priority than his life.

If the headmaster and the deans of each faculty had done their jobs, this mishap would have not happened. Why the pilot had such a sub-standard EQ and IQ was able to pass the recruitment test, training, simulator training, CRM, human factor training, annual checks &....... Why the crewman could not use a stronger word to remind the pilot in order to keep his life. It was because of the poor culture running around in the school for years.

The culture of " I dont care, just do it", " No need to explain to me!", " are you going to argue with me now?" , and "The door is always open, (for kicking you out)" should be completely abolished.
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Old 5th Jun 2006, 12:08   #100 (permalink)

 
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Speediwings,

You make it all sound so simple and obvious…but to just take up a few of your points.

He did not do the flight planning, he and his crew did not wear helmets.”

1. From the GFS base to Cheung Chau is effectively just down the road…it is a case of out through the pass a touch left and it is straight ahead…there was not a hell of a lot more that they needed to do, and I am sure that this route had been done by this pilot many times before.

2. Surely wearing the helmet would not have prevented the accident. If management thought that my safety depended on me wearing a helmet I would suggest it is too dangerous to go. As pilot of a civilian registered helicopter conducting a passenger carrying flight it is, IMHO, my job to ensure that a helmet is not needed.

“He placed the 20 min TOS with higher priority than his life.”

Really? I don’t think so…you may think he did…but I doubt that thought he did.


“Why the pilot had such a sub-standard EQ and IQ was able to pass the recruitment test, training, simulator training, CRM, human factor training, annual checks &.......”

To make such a damming statement you must have had a very intimate personal knowledge of the pilot in question, however I am not sure that everyone who knew the pilot would agree with you, or appreciate your comments.

SIIS

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