Let's use the AAIB report to look at that - how a 10,000 hour commander and a 3000 hour co pilot flew the aircraft (perfectly serviceable) into the sea.
The co-pilot provided information to the investigation on the day following the accident and during subsequent interviews. He had a good recollection of most events, but did not have a complete picture of what had occurred during the latter stages of the approach.He stated, at interview, that he had been relying on the commander’s greater experience and had therefore not challenged his comments during the approach briefing. The co-pilot stated that he had accepted the helicopter’s deviation below the published vertical profile during the latter stages of the approach because this was allowed and he had seen other approaches flown in this way. He commented that during the final approach he had noticed the commander looking up at some stage, perhaps seeking external visual reference.
So a bit of a cockpit gradient - stuff you learn about in CRM, HF and MCC training.
Attention. The analysis of crew tasks does not provide evidence that either crew member’s attention was focussed on the airspeed or aircraft pitch (paragraph 32). The Commander was also observed by the Co-Pilot to glance outside the cockpit. If the airspeed and aircraft pitch was outside the Commander and Co-Pilot’s attentional focus it is unlikely that a change in these items would be detected.
poor instrument scan - highlighted in other places in the report. Not something you would expect from an experienced commander.
The crew were using non-standard terminology for their SOP communications which increases the likelihood of miscommunication. It is recommended that the norms Air Accident Report: 1/2016 G-WNSB EW/C2013/08/03 © Crown Copyright 2016 Appendix I (cont) Appendix I 246 associated with SOP calls are identified to determine the extent of the risk and actions put in place to address.
so although the SOPs are not good, they weren't following them anyway.
First AVAD alert. At approximately twelve seconds before impact and at a height of 300ft, the crew were alerted by the Automatic Voice Alarm Device (AVAD) stating “CHECK HEIGHT”. The Commander acknowledged the AVAD alert by stating “Checking the height”. It was, therefore, possible the Commander’s attention was then directed to the altimeter. 300ft is a MDA, where it would be anticipated that vertical descent profile would be levelled off. However, there was no evidence of G-WNSB slowing down or levelling, up to or after the 300ft MDA. There are many reasons why this may have occurred, however there was no evidence to indicate why this may have happened in this instance.
now we are in the realms of basic instrument flying procedures.
The investigation identified the following causal factors in the accident:
● The helicopter’s flight instruments were not monitored effectively during the latter stages of the non-precision instrument approach. This allowed the helicopter to enter a critically low energy state, from which recovery was not possible.
● Visual references had not been acquired by the Minimum Descent Altitude (MDA) and no effective action was taken to level the helicopter, as required by the operator’s procedure for an instrument approach.
The following contributory factors were identified:
● The operator’s SOP for this type of approach was not clearly defined and the pilots had not developed a shared, unambiguous understanding of how the approach was to be flown.
● The operator’s SOPs at the time did not optimise the use of the helicopter’s automated systems during a Non-Precision Approach.
● The decision to fly a 3-axes with V/S mode, decelerating approach in marginal weather conditions did not make optimum use of the helicopter’s automated systems and required closer monitoring of the instruments by the crew.
● Despite the poorer than forecast weather conditions at Sumburgh Airport, the commander had not altered his expectation of being able to land from a Non-Precision Approach.
the contributory factors are just that and smack of complacency with a routine task - the causal factors are just poor piloting.
You can defend them as much as you like HC, personally I feel very sorry for them, they will have to live with the consequences of their failures as a crew for the rest of their lives.
And, while it might surprise you that the MAA is as pink and fluffy as the CAA when it comes to not apportioning blame - this crew failed to do their job properly.
The aircraft was serviceable, the AP did exactly what is was asked to do, there was no other emergency or reasonable distractor to divert them from their task of either landing or going around at MDA/MAP.
You can call it what you like - but this was negligent operation of an aircraft.