First and foremost, the views and opinions expressed here are those of the author. The content is not intended to malign any individual, group, organization or company, nor imply any illegal act occurred. I’ve authored this simply to raise questions on the appropriateness and efficacy of current policies, procedures and oversight of Part 135 helicopter operations. My opinions are primarily derived from information provided in the NTSB accident investigation docket. Please bear with me, this is lengthy.
Do you think this pilot was prepared to perform an IIMC recovery--because the checked boxes seem to say so?
On June 21, 2019 (218 days prior to the accident), the accident pilot completed a concurrent FAA Part 135.293 and 299 check flight in the S-76. The check was conducted by the FAA POI and lasted only 1.0 hour. During this flight, among other maneuvers, the pilot was evaluated performing both “IIMC MANEUVER” and “ILS DEMO.” No additional instrument approaches were evaluated. During this flight, which was accomplished at Long Beach, the maneuvers “High Altitude Takeoff & Landings,” “Autorotations (Single Engine)” and “Hovering Autorotations (Single Engine)” were also checked.
The previous year’s (2018) concurrent Part 135.293/299 S-76 check flight lasted just 36 minutes and it was noted the pilot was evaluated performing “IIMC MANEUVER” and “ILS OPERATION.” No additional instrument approaches were evaluated. Is 36 minutes, or even 1-hour adequate time to conduct an FAA Part 135.293/299 checkride in a complex helicopter like the S-76?
On May 10, 2019 (260 days prior to the accident), the NTSB docket notes the pilot performed two S-76 training flights with a contract training company. These two flights lasted a total of 3.6 hours. The document notes, among many others, an “IIMC MANEUVER” and “ILS Operation” were graded satisfactorily, with no other instrument approaches noted.
During the NTSB interview of the instructor for the above flight, regards wearing a view limiting device during IIMC training, the instructor stated, “so sometimes yes, sometimes no. Especially if you wear a helmet it's difficult to use a hood on something like that. If you wear a headset that may or may not. It depends on what's available, somebody wants it, somebody doesn't want it. Again, it is more tailored for the check ride.” And specifically, on whether the accident pilot wore a view limiting device, the instructor stated, “I don't remember that part.” How was the time logged? Shouldn’t this be stipulated by policy and regulation?
Furthermore, the FAA POI characterized the training with this company as not part of the operator’s approved training program, stating, “it was never something where, you know, I either approved, accepted, or required it, or, you know, anything to that effect.” And when asked if he would say that it meets the definition of best practices as the FAA uses that term, he added, “I can't answer that. Because I just don't -- you know, I'm not an expert on their training, or their facility, or really you know, I don't have information -- enough information to make that distinction.” This was the only training in the year prior to the accident that was noted in the NTSB docket.
An example of uninhibited check-boxing occurred in 2018, with the accident pilot receiving in-house training. Accordingly, the pilot completed the following maneuvers in two flights (0.8 and 0.5) totaling 1.3 hours: ILS and VOR approach, company heliport, oil-rig, confined area, pinnacle and slope landings, rapid deceleration, unusual attitude, IIMC, landing gear failure, T/R control failure, generator failure, engine fire, loss of engine in cruise, loss of engine during takeoff, loss of engine hovering OGE (both landing and fly-away), loss of engine IGE and loss of engine hover taxi, engine trim failures, cyclic trim failure, SAS failure, steep approach, Vy climb, steep turns, max-endurance and MCP flight, shallow approach and run-on landing. Further compounding incredulity, all of the above maneuvers with the exception of the VOR approach are checked on both flights. Is this just an example of sloppy bookkeeping?
Given all of the above, what exactly was being checked? According to the FAA, the “IIMC Maneuver” is a recovery from IIMC, and must include attitude instrument flying, recovery from unusual attitudes, navigation, ATC communications, and at least one instrument approach. Further complicating matters, the demonstration should be scenario-based. The instrument approach is apparently the “ILS DEMO.” Which begs the question, can a pilot fail a demonstration?
Indications from the docket are not completely clear on whether the operator even had procedures for unusual attitude recovery and IIMC. These procedures may have been absent from the operator’s S-76 maneuvers guide and training manual. Evidence shows that procedures were “added” versus “replaced” in the company’s documents after the accident (3/6/20). However, the docket information is not entirely clear what, if any procedures were in place at the time of the accident. Furthermore, the added material lacks proper indications highlighting what text was altered. During an NTSB interview, an FAA lawyer interjected comments, that if nothing else, displayed a heightened sensitivity towards the topic. In the absence of a specific delineated procedure, maybe the accident pilot was attempting to perform exactly what the operator’s GOM instructed him to do, “pilots will never take an aircraft into IMC…”?
To my knowledge, the Part 135 IIMC training and checking have existed at least since 2014. FAA Inspector guidance states they must ensure that operators have procedures for recovery from IIMC and that these procedures are incorporated into the certificate holder’s initial, transition, upgrade, and recurrent training curriculums. In addition to training, the certificate holder should establish a GOM loss of control IIMC avoidance policy that supports the emergency authority of the pilot to divert, make a precautionary landing, or make an emergency transition to IFR. Within 60 days of the FAA’s Part 135 Helicopter Training and Qualification Program Review and Competency Check Requirements notice, POIs should have conducted a “focused review of the helicopter training and qualification programs for their assigned certificate holders to identify whether the programs include the required training and testing on procedures for … training and checking on recovery from IIMC.” Was this overlooked by both the FAA and the operator?
But one must acknowledge that the totality of the FAA requirements is convoluted and confusing. The final rule for IIMC recovery training and checking was published in 2014, compliance required in 2015, POI focused review in late 2017, and then the policy with its invaluable guidance was cancelled in late 2018. What’s an operator to do?
Further, regarding Part 135.293 checking of a pilot’s knowledge of “escaping from severe weather situations, in case of inadvertent encounters,” (assuming IFR is viewed as “severe weather” to a VFR operator) the FAA acknowledges this area relates to general aeronautical knowledge and not aircraft specific, and only requires the areas associated with aircraft operational capabilities to be evaluated on separate check flights. Yet, in an aircraft like the S-76, these related areas would seem manifold (performance, instrumentation, autopilot, approach capability, etc.).
Yet, how effective is the prescribed annual IIMC training and checking? During the NPRM period many operators commented that the IIMC recovery training should be demonstrated semi-annually, while several individual commenters recommended quarterly training for pilots to maintain proficiency. Identical comments from two individuals suggested requiring frequent short training sessions involving unplanned entry into IMC followed by an instrument approach to landing at least quarterly in an approved aircraft or simulator. They suggested a requirement that a table-top PC-based navigation system trainer or similar device be used at least monthly. These were primarily pilots, practically begging for more training.
The Part 135 regulations are equally valid for both Helicopter Air Ambulance (HAA) and commercial operators. With this in mind, the NTSB agreed with the NPRM requirement for a HAA pilot to hold an instrument rating, and stated that HAA pilots should maintain instrument currency. It commented that instrument currency is generally acknowledged to be a skill that deteriorates rapidly without continued practice and use. Numerous other commenters also suggested that the FAA require HAA pilots to maintain currency or routinely demonstrate the ability to recover from IIMC. Several commenters noted that this requirement should be applied to all commercial pilots.
However, the FAA concluded that an annual check is sufficient because it can be incorporated into a certificate holder's existing competency check schedule. Does that sound like the convenience of the annual implementation overshadowed any concern for effectiveness?
The system seems to be failing us. Have we reached the point where the paperwork has become the exercise and effectual training is secondary? Could the requisites and paperwork be so unclear, complicated and baffling that they have actually become a hinderance? We should all ask ourselves, “what is the purpose of a check box?” Because ultimately, the pilot is the victim of an unmindfully checked box.
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References
NTSB DCA20MA059 Accident Investigation Docket
14 CFR § 135 Operating Requirements: Commuter and On Demand Operations and Rules Governing Persons on Board Such Aircraft
Federal Register, Vol. 79, No. 35, Part II, FAA 14 CFR Parts 91, 120, and 135 Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations; Final Rule
FAA FSIMS 8900.1, Volume 3, Chapter 19 Flightcrew Member Training and Qualification Programs
FAA National Policy, 8900.270, Part 135 Check Pilot (Check Airman) Functions
FAANational Policy , 8900.437, Part 135 Helicopter Training and Qualification Program Review and Competency Check Requirements