Police helicopter crashes onto Glasgow pub: final AAIB report
SASless: I have flown the 105 and 117 and once we turned the Transfer Pumps ON....they stayed ON until the Shutdown Procedure after landing.
Are there any real reason that could not be the policy for the 135?
Are there any real reason that could not be the policy for the 135?
(p. 3 - 26):
.F PUMP FWD
(MISC)
Conditions/Indications
Failure of forward fuel transfer pump, or dry run.
Procedure
1. Fuel level in the main tank – Check
If main tank fuel quantity is sufficient to keep both fuel pumps wet:
2. FUEL PUMP XFER-F sw – Check ON
3. XFER-F PUMP circuit breaker – Check in
If F PUMP FWD indication remains on:
4. FUEL PUMP XFER-F sw – OFF
If main tank fuel quantity is low:
2. FUEL PUMP XFER-F sw OFF
NOTE Each fuel transfer pump is capable of feeding more fuel than both engines will
consume. In forward flight conditions the unusable fuel can be up to 59 kg. The quantity
of unusable fuel can be reduced to 3.6 kg when flying with 80 KIAS or less.
Firend of mine is flying HEMS in EC135 and confirmend that one has to switch between XFER-F ON and XFER-A ON between cruise and hover, IF you did not gass her up fully, because you were anticipating you have to climb to high places to rescue someone.
I accept there might be additional wear on the Pumps over time but as they do have OverTemp protection....is there any absolute need to shut them off?
Had those Pumps been turned on at Engine Start and left on until the After Landing/Shut Down procedure....would that have had any effect upon the outcome of this accident?
Had those Pumps been turned on at Engine Start and left on until the After Landing/Shut Down procedure....would that have had any effect upon the outcome of this accident?
IIRC the was a statement in the report that them pumps can survive 20min of running dry. Didn't sound as if ignoring dry running were a professional/safe thing to do.
edit: I've got to talk to said friend, as he is FI on BO105, too.
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This is not the first double engine flameout over a city
Fatal Japanese Police AW109 accident
Fatal Japanese Police AW109 accident
skyrangerpro quoted the AAIB report: "There was significant displacement of the cockpit overhead switch panel
which appeared to have been driven downwards on to the upper surface of
the instrument panel coaming.
which appeared to have been driven downwards on to the upper surface of
the instrument panel coaming.
skyrangerpro same post: Now to me that calls into question the reliability of the assessment of the position of all switches, particularly in the overhead cockpit
Especially as being "driven downwards onto the upper surface of the panel"
would mean that any switch that touched said panel during being driven
would be flipped into the "back" position, typically meaning OFF.
CJ Romeo - one of the biggest problems pilots have is that engineers design the aircraft and its systems to solve the engineering problems not to make pilots' jobs easier or safer.
In an engineer's brain, having to switch pumps on and off is a straightforward task that anyone can do - right up to the point where that person is flying the aircraft, prioritising tasks and making weather decisions whilst operating in a cockpit with lots of other brilliantly designed systems, in the dark and over relatively inhospitable terrain.
In an engineer's brain, having to switch pumps on and off is a straightforward task that anyone can do - right up to the point where that person is flying the aircraft, prioritising tasks and making weather decisions whilst operating in a cockpit with lots of other brilliantly designed systems, in the dark and over relatively inhospitable terrain.
Reely,
Beating your head on the wall.....really?
Why would the same exact pairs of switches be in the same position even though right next to one another in the over head panel.
What is more interesting is the configuration noted by the AAIB is exactly opposite of the switch position one would assume would be the case for normal operations.
This switch position thing is one of many issues that needs explaining if we are to make sense of what happened that night. Sadly, there is not going to be anyway to know definitively how they came to be in the positions they were found.
They could have been moved there by the Pilot, moved there by the Impact, or a combination of both....how does one determine the truth of the matter?
Beating your head on the wall.....really?
Why would the same exact pairs of switches be in the same position even though right next to one another in the over head panel.
What is more interesting is the configuration noted by the AAIB is exactly opposite of the switch position one would assume would be the case for normal operations.
This switch position thing is one of many issues that needs explaining if we are to make sense of what happened that night. Sadly, there is not going to be anyway to know definitively how they came to be in the positions they were found.
They could have been moved there by the Pilot, moved there by the Impact, or a combination of both....how does one determine the truth of the matter?
The AAIB report makes reference to issues with the fuel probes on G-SPAO earlier in the year, and explains that these were resolved. It does not explain whether the faults became apparent while the aircraft was in flight, and who was flying it at the time. I am wondering whether the accident pilot had some history with spurious fuel warnings on this aircraft.
Having re read the report this morning, I am curious as to why so little is said about the Bothwell/Uddingston/Bargeddie taskings. Without these interventions, the aircraft would have made it back to base, even with the transfer pumps off. The Bothwell and Bargeddie taskings are described as routine, (no description is offered for the Uddingston tasking) , but we are not told what constitutes routine for a police helicopter. It seems absolutely inconceivable that nothing was said over airwave during this period. Surely the aircraft would at least have had to have reported on the outcome of one task before moving on to the next? The nature and perceived urgency of these requests would have had a direct and material bearing on the workload and behavioural dynamic in the cockpit, and could not be more relevant.
Also missing is any form of analysis of the operational records of the Police helicopter unit. I would have thought for instance that some form of review of fuel loads at landing compared to MLA might have provided a meaningful insight into culture?
Having re read the report this morning, I am curious as to why so little is said about the Bothwell/Uddingston/Bargeddie taskings. Without these interventions, the aircraft would have made it back to base, even with the transfer pumps off. The Bothwell and Bargeddie taskings are described as routine, (no description is offered for the Uddingston tasking) , but we are not told what constitutes routine for a police helicopter. It seems absolutely inconceivable that nothing was said over airwave during this period. Surely the aircraft would at least have had to have reported on the outcome of one task before moving on to the next? The nature and perceived urgency of these requests would have had a direct and material bearing on the workload and behavioural dynamic in the cockpit, and could not be more relevant.
Also missing is any form of analysis of the operational records of the Police helicopter unit. I would have thought for instance that some form of review of fuel loads at landing compared to MLA might have provided a meaningful insight into culture?
Switch positions
Let's put the switch position debate to bed once and for all.
The AAIB are very professional and thorough. If there was the slightest possibility that the switch positions had been changed by an impact with the instrument console, then they would have looked to see if the switch was bent, or witness marks/paint transfer were evident.
There is no conspiracy here on the part of the AAIB or the manufacturer.
If you are told you are low on fuel, you RTB.
If you think there is a defect in a system, you RTB.
If you have been flying a 135 for 1:37, at night, over a city, you should be RTB.
The AAIB are very professional and thorough. If there was the slightest possibility that the switch positions had been changed by an impact with the instrument console, then they would have looked to see if the switch was bent, or witness marks/paint transfer were evident.
There is no conspiracy here on the part of the AAIB or the manufacturer.
If you are told you are low on fuel, you RTB.
If you think there is a defect in a system, you RTB.
If you have been flying a 135 for 1:37, at night, over a city, you should be RTB.
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If you are told you are low on fuel, you RTB.
If you think there is a defect in a system, you RTB.
If you have been flying a 135 for 1:37, at night, over a city, you should be RTB.
Thanks for that Sky Sports, that's genius, we hadn't thought of that.
But he didn't, did he? He wasn't a risk taker, so why did he do it??
I don't have the answer, but knowing Dave well, I don't THINK he would have been so cavalier in his flying. SOMETHING made him feel that all was ok. Personally, my OPINION is that he saw the same 'picture' as G-NWEM had in the report. It made him doubt the warnings (incorrectly) and when he realised what had happened, he made incorrect switch selections under EXTREME pressure.
So you can't put the switch position thing to bed with the information that has been released in the report. It doesn't exonerate the burden on the pilot, but it could start to explain why he did it.
If you think there is a defect in a system, you RTB.
If you have been flying a 135 for 1:37, at night, over a city, you should be RTB.
Thanks for that Sky Sports, that's genius, we hadn't thought of that.
But he didn't, did he? He wasn't a risk taker, so why did he do it??
I don't have the answer, but knowing Dave well, I don't THINK he would have been so cavalier in his flying. SOMETHING made him feel that all was ok. Personally, my OPINION is that he saw the same 'picture' as G-NWEM had in the report. It made him doubt the warnings (incorrectly) and when he realised what had happened, he made incorrect switch selections under EXTREME pressure.
So you can't put the switch position thing to bed with the information that has been released in the report. It doesn't exonerate the burden on the pilot, but it could start to explain why he did it.
Air Police,
I hear what you say, but the report specifically refers to Routine surveillance tasks, and refers to their completion before proceeding to the next task. If the crew were acting autonomously at this point, and there were no communications, how have the AAIB been able to conclude that there were discrete tasks, that they were routine surveillance, and that they had been completed? I take it you would agree that if the aircraft had been assigned to a task, it would be odd to assign it another without knowing the first was complete?
I also wonder whether Police Scotland were able to shed any light on events on the ground that night?
Events in the Bothwell area that night seem to me to be at the crux of this tragedy, and worthy of closer examination.
As for reviewing the landing fuel state records, I again hear what you say, but given how fastidious the AAIB have been in outlining all of the other steps they have taken, it would seem odd to exclude this one. Interesting that they note the operators increase of MLA in the aftermath of the accident though
I hear what you say, but the report specifically refers to Routine surveillance tasks, and refers to their completion before proceeding to the next task. If the crew were acting autonomously at this point, and there were no communications, how have the AAIB been able to conclude that there were discrete tasks, that they were routine surveillance, and that they had been completed? I take it you would agree that if the aircraft had been assigned to a task, it would be odd to assign it another without knowing the first was complete?
I also wonder whether Police Scotland were able to shed any light on events on the ground that night?
Events in the Bothwell area that night seem to me to be at the crux of this tragedy, and worthy of closer examination.
As for reviewing the landing fuel state records, I again hear what you say, but given how fastidious the AAIB have been in outlining all of the other steps they have taken, it would seem odd to exclude this one. Interesting that they note the operators increase of MLA in the aftermath of the accident though
"Thanks for that Sky Sports, that's genius, we hadn't thought of that.
But he didn't, did he? He wasn't a risk taker, so why did he do it??
I don't have the answer, but knowing Dave well, I don't THINK he would have been so cavalier in his flying. SOMETHING made him feel that all was ok. ... It doesn't exonerate the burden on the pilot, but it could start to explain why he did it."
Well said. (Sorry, I don't know how to quote but that is the perfect answer to Well I'm a really good pilot and I would never do x y and z".)
But he didn't, did he? He wasn't a risk taker, so why did he do it??
I don't have the answer, but knowing Dave well, I don't THINK he would have been so cavalier in his flying. SOMETHING made him feel that all was ok. ... It doesn't exonerate the burden on the pilot, but it could start to explain why he did it."
Well said. (Sorry, I don't know how to quote but that is the perfect answer to Well I'm a really good pilot and I would never do x y and z".)
SASless
Beating your head on the wall.....really?
<snip>
This switch position thing is one of many issues that needs explaining if we are to make sense of what happened that night. Sadly, there is not going to be anyway to know definitively how they came to be in the positions they were found.
They could have been moved there by the Pilot, moved there by the Impact, or a combination of both....how does one determine the truth of the matter?
Beating your head on the wall.....really?
<snip>
This switch position thing is one of many issues that needs explaining if we are to make sense of what happened that night. Sadly, there is not going to be anyway to know definitively how they came to be in the positions they were found.
They could have been moved there by the Pilot, moved there by the Impact, or a combination of both....how does one determine the truth of the matter?
That tiny half sentence of the report describing that the over head switch board got dislodged and moved downward over the cockpit panel, totally changed the weight of the"fact" where the switches were found to be!
In flight they could have been exactly as there were found post crash, or directly opposite or any mix in between, unless someone determines by abrasion analysis or other magic how they came to be in the positions found.
Hence the head banging simply referred to the extreme deterioration of that "fact" caused by said little sentence
in relation to how many people hinge all their blame (on pilot or manufacturer) on that rather soft evidence.
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Reely340
The supply tanks to the engines were found to be empty. The pump switches that supplied fuel from the main tank which still contained fuel were found in the off position. The adjacent prime switches were found in the on position. If the impact forces in the crash were sufficient to change the switch positions, all the switches would have been found to be either on or off and not as found, two on, two off. The switches were found to be in the exact reverse positions to those expected in normal flight. Only one person on the aircraft was responsible and permitted to operate those switches, the pilot. QED.
The supply tanks to the engines were found to be empty. The pump switches that supplied fuel from the main tank which still contained fuel were found in the off position. The adjacent prime switches were found in the on position. If the impact forces in the crash were sufficient to change the switch positions, all the switches would have been found to be either on or off and not as found, two on, two off. The switches were found to be in the exact reverse positions to those expected in normal flight. Only one person on the aircraft was responsible and permitted to operate those switches, the pilot. QED.
Reely makes good points as does Gouli but the truth is we are assuming the Pilot moved the Transfer Switches to the OFF position prior to the Crash and that the Prime Switches were turned ON by the Pilot.
As odd as those Switch positions were....they do in fact make sense in a left handed way if one assumes the Pilot mistakenly activated the Prime Switches thinking he had turned the Transfer Switches to the ON position.
That the Overhead Switch Panel made contact with the Glareshield Coaming does not guarantee any switches were moved by that contact or the G Forces sustained during the crash.
We do have to correlate other indications of what position the Transfer Pump Switches were in and had been in for at least long enough to generate the Caution/Warnings seen in the memory of the various systems.
It does appear the Pilot mistook the Prime Switches for the Transfer Switches in my view....as the suggestion during a Low Altitude loss of all engine power and the resulting loss of Avionics and other systems....the Pilot would be using the Prime Switches in an effort to restart the engines....but forget to ensure the Transfer Switches were in the ON position...seems a bit far fetched to me.
If I got a Fuel Low light in the 105/117/135....with their similar fuel system design....the first thing I would have done is ensure the Transfer Switches were on.....and would have done that check when I saw fuel low Lights illuminating.
In the dark....Single Pilot....with things going wrong...it would be very easy to confuse Transfer Switches for Prime Switches.
As odd as those Switch positions were....they do in fact make sense in a left handed way if one assumes the Pilot mistakenly activated the Prime Switches thinking he had turned the Transfer Switches to the ON position.
That the Overhead Switch Panel made contact with the Glareshield Coaming does not guarantee any switches were moved by that contact or the G Forces sustained during the crash.
We do have to correlate other indications of what position the Transfer Pump Switches were in and had been in for at least long enough to generate the Caution/Warnings seen in the memory of the various systems.
It does appear the Pilot mistook the Prime Switches for the Transfer Switches in my view....as the suggestion during a Low Altitude loss of all engine power and the resulting loss of Avionics and other systems....the Pilot would be using the Prime Switches in an effort to restart the engines....but forget to ensure the Transfer Switches were in the ON position...seems a bit far fetched to me.
If I got a Fuel Low light in the 105/117/135....with their similar fuel system design....the first thing I would have done is ensure the Transfer Switches were on.....and would have done that check when I saw fuel low Lights illuminating.
In the dark....Single Pilot....with things going wrong...it would be very easy to confuse Transfer Switches for Prime Switches.
Hi all,
we can discuss forever - cause we won´t get the answers cause there was no recording....
What we can do is learn a lesson.
Which is - start to listen to your bird.
With every action taken on bord the helicopter, we get a feedback from it in one way or another.
Lets not assume, that the action will take place - check, that the results correlate with our actions, the lights go on/off, pressure builds up and so on.
Thats the way to find mistakes we make with touching the wrong switches, doubletap ones, switching defect equipment and so on - in time.
And - I have to grab my own nose - keep up with the handbook - it is astonishing, how much information ones brain blurres, if time goes by...
Stay villigant - and stay alive
"Flying Bull"
we can discuss forever - cause we won´t get the answers cause there was no recording....
What we can do is learn a lesson.
Which is - start to listen to your bird.
With every action taken on bord the helicopter, we get a feedback from it in one way or another.
Lets not assume, that the action will take place - check, that the results correlate with our actions, the lights go on/off, pressure builds up and so on.
Thats the way to find mistakes we make with touching the wrong switches, doubletap ones, switching defect equipment and so on - in time.
And - I have to grab my own nose - keep up with the handbook - it is astonishing, how much information ones brain blurres, if time goes by...
Stay villigant - and stay alive
"Flying Bull"
Thanks for that Sky Sports, that's genius, we hadn't thought of that.
SOMETHING made him feel that all was ok.
Forget switch positions, warning lights, audio warnings etc. for one minute. He knew his fuel load on take-off, he knew the burn rate, he knew his endurance, he knew his flight time. He/they accepted that last tasking with an aircraft fuel state that was already lower than the aircraft had landed with in the last 125 sorties.
Even if the aircraft systems were all lying to them, and they had no warnings at all, Dave must have been thinking, I've been up for 1:37 this is going to be tight.
After that kind of flight time, what could possibly make him think that all was ok.
Last edited by Sky Sports; 25th Oct 2015 at 07:05.
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What can we (possibly) learn from this accident (just my thoughts and appologies for my very limited understanding of the Britisch language) ?
1. The fuel system needs to be changed: Why does the pilot has to put the XFER pumps ON or OFF depending on helicopter attitude ? The XFER pumps should be left on all the time, the system should switch OFF the respective pump if its running dry for 5 minutes and it should switch ON if it senses Fuel again AUTOMATICALLY. Do not bother the pilot with this task. Remove the XFER pump switches.
2. The CAD system should be black when flying in normal conditions. No room for advisory lights here. No room for the fuel indication also. There is too much going on on the CAD. I often dont bother to look at it at all.
3. The Master caution light has to be placed in a lower position. I cant see it even when my chair is in the lowest position.
4. Make the difference between the left and the right supply tank larger. So you have at least 5 minutes to understand that you are in a bad situation (and not a few seconds depending on aircraft attitude and movement).
5. Do not fly missions all the time using all the fuel there is. Everybody wants you to do this and we as pilots like to please our "customers". Land with at least 30 minutes of fuel, get more (night) refuel spots easily available.
6. Put your swivable landing light and the internal communications on the Essential busses. When two engines fail you are busy enough.
7. Fly realistic simulator sessions for at least six hous per year.
Just my thougts but the accident has got me thinking (for what its worth) about my own flying in the 135, certainly at night.
1. The fuel system needs to be changed: Why does the pilot has to put the XFER pumps ON or OFF depending on helicopter attitude ? The XFER pumps should be left on all the time, the system should switch OFF the respective pump if its running dry for 5 minutes and it should switch ON if it senses Fuel again AUTOMATICALLY. Do not bother the pilot with this task. Remove the XFER pump switches.
2. The CAD system should be black when flying in normal conditions. No room for advisory lights here. No room for the fuel indication also. There is too much going on on the CAD. I often dont bother to look at it at all.
3. The Master caution light has to be placed in a lower position. I cant see it even when my chair is in the lowest position.
4. Make the difference between the left and the right supply tank larger. So you have at least 5 minutes to understand that you are in a bad situation (and not a few seconds depending on aircraft attitude and movement).
5. Do not fly missions all the time using all the fuel there is. Everybody wants you to do this and we as pilots like to please our "customers". Land with at least 30 minutes of fuel, get more (night) refuel spots easily available.
6. Put your swivable landing light and the internal communications on the Essential busses. When two engines fail you are busy enough.
7. Fly realistic simulator sessions for at least six hous per year.
Just my thougts but the accident has got me thinking (for what its worth) about my own flying in the 135, certainly at night.
..and pratice EOL in twins twice a year.
In situations mirroring your kind of work.
(read: in the night if you work at night).
Lacking that skill was the major reason why all had to die.
In situations mirroring your kind of work.
(read: in the night if you work at night).
Lacking that skill was the major reason why all had to die.
Purveyor of Egg Liqueur to Lucifer
There is so much wheat and chaff in this thread that I hope any lawyer building a case based on the information gleaned in this 'professional pilots forum' gets it sifted. (Reely340's last post about practise EOL's being a classic example)
Eg;
Did three people really totally ignore all those warnings?
How do the NVG impinge on the roof when in the stowed position?
Would one really consider an engine restart at 1000' agl over a city?
How much use is the equipment that the EM Shed Buss will give you back?
Etc etc
Eg;
Did three people really totally ignore all those warnings?
How do the NVG impinge on the roof when in the stowed position?
Would one really consider an engine restart at 1000' agl over a city?
How much use is the equipment that the EM Shed Buss will give you back?
Etc etc
There is so much wheat and chaff in this thread that I hope any lawyer building a case based on the information gleaned in this 'professional pilots forum' gets it sifted. (Reely340's last post about practise EOL's being a classic example)
If pilots do not regulary pratice "twin EOL" (at least with power recovery at 10ft AGL), how should they be able to survive twin flame outs?
I'd say besides all switch position mishandling and warning bells ignorance the main issue here is
the demonstrated inability of a +5000h CPL to properly autorotate to somewhere close to ground.
(according to the report he did try, passing the 97% rrpm threshold multiple times)
Or would you pull out the exposure time vs. probability regime
and file such incindents under **** happens?
