Originally Posted by
rotorspeed
It has been interesting to read of the recent debate here, which broadly agrees that the crew made the mistake(s) that caused the accident, but differs on who was to mainly to blame. It seems HC leads the lack of adequate SOPs and CRM view so therefore the fault of the operating organisation, and Crab the pilots made errors they never should have view.
I’ve never flown North Sea, or even really any multi crew, but have flown a lot of SP IFR obviously on twins in corporate ops. Skimming through the accident report again, the following seem key points. Firstly there was clearly woefully inadequate monitoring of airspeed by the crew. The need to do this on any approach, IFR or not, is clearly a fundamental piloting skill that you learn before you even go solo when training for your first licence. However as we all know, when IMC with the lack of visual cues, the scan becomes essential to ensure this. I think pretty much all of us agree that coupling to IAS not VS is a far better way to conduct an approach on 3 axis. However using VS is not disastrous – I used to use it, and clearly thousands of IFR approaches have been successfully made using it. What is used should just highlight what is left for the pilots to focus on and monitor. Being basic, with this localiser DME approach using VS, the pilots do not have to really monitor roll/heading or vertical speed, as these were coupled. The one main thing they did have to monitor closely was airspeed, and control it with collective. Even height was secondary, at least in the early stages of the approach, as it should have been more or less right given they started from a set known distance, height and VS – had the airspeed been in the window. So why didn’t the PF do this? Well, amongst the considerable chat between the crew which included bits of briefings, there was no mention at all of the fact that they were doing a VS coupled approach so that monitoring IAS was their number one priority. Of course the PF should have known this – basic stuff – and almost certainly did, but he certainly didn’t seem focussed on it at the critical time. And there was quite a bit of non-pertinent chat before the approach started. I’ll come back to this.
What made the need to monitor IAS carefully far more important than normal was they had not truly established a stabilised approach far enough out. According to the AAIB report, they had. And indeed technically they had, according to the definition. But this is an example of where reliance on the specifics of ever more extensive documentation can be counter-productive, eroding the responsibility for intelligent thought and judgement. When 1000ft at circa 3 miles they were at 108kts – upper end of the SOPs 80kt -120kt window. Right height, right course, right descent rate. But the PF had said that as the weather was on minimums, he would slow the approach to 80kts. So he only had a mile or two to slow a ? 7 tonne helicopter from 108kts to 80kts. Which clearly was going to take a big reduction in torque, which would then have to be partly reapplied to maintain the 80kts. Hardly a stabilised situation. And going to need close monitoring of AIS throughout, until a properly stabilised approach was achieved, belatedly. Surely a 10,500 hour commander with a 3000 co-pilot hour should have known that especially given the marginal weather and desire for a slow approach this should have been set up much earlier, regardless of any SOP detail and compliance?
So why did this occur? Well interestingly the other two localiser 09 approaches the commander made to Sumburgh included in the AAIB report showed similar higher speed at the start of the approach. But the difference here was far better weather – eg 900ft cloudbase – which meant that the commander was under no pressure to slow and not bothered about getting in on around minimums, so got visual still at 110kts ish and slowed much later to land VFR. It seemed that he adopted a similar early approach technique but this time belatedly intended to implement his objective of a 80kt approach, with catastrophic consequences.
The intercom chat between PF and PM to me demonstrated a dangerous blend of awareness of the weather being minimums and being challenging, yet with the slightly nervous banter and bravado of a crew trying to gloss it over and treat it too casually so neither wanted to appear too concerned to the other. I see this as a real hazard of multi crew operations – the obligation to have bandwidth to communicate as well as just concentrate on what matters flying the aircraft safely, with the assumption that the other guy knows what he is doing even if you’re not 100% sure. But then that’s where CRM is so important.
So in summary where am I on responsibility? I have to say much more on crew than operator systems. Sure the systems can improved, no doubt were and will continue to be. But this was not a situation in which a new operating system had resulted in an accident pretty soon after implementation. No doubt thousands of flights and IFR approaches had been previously carried out successfully using the operators systems, many with less experienced crew. I think we all feel for the crew’s angst from this, and also know we all make mistakes. But I also think an important way to minimise this, and hopefully eliminate the big ones, is for us all to understand how much responsibility rests on our own shoulders and not to be too quick to pass the buck to an inadequate environment.
Your individual points are all valid of course, but I come to a different overall conclusion.
Yes of course the pilots should have been monitoring the airspeed more closely. But as I have intimated, humans make mistakes and the whole point of SOPs and multi-pilot ops is to reduce the severity of a mistake to the point that it becomes inconsequential. Nor is it “back and white” - yes lots of people including this crew, had made approaches along the same lines without incident. But that doesn’t really matter. The question should be, were the SOPs and MCC reasonably optimal to prevent a mistake from becoming catastrophic - that being the duty of an operator, surely? I suggest the answer is No.
So when the **** hit the fan and the circumstances and mistakes lined up, did the company SOPs help avoid a catastrophe? No.
And what about the training programme. Had the copilot ever had any formal training about the role of PM during an onshore instrument approach? I’m not sure, but I strongly suspect not. This, as I said earlier, due to a regulatory obsession with the PF role despite it being a multi-pilot helicopter. I well remember the standard briefing for many years given by the examiner to a crew undergoing a check in the sim - “The copilot will be competent but without showing any initiative”. What a great way to train for PM role!
And whilst I am on about the regulator, for years the regulator disallowed automation to be used during checks. The autopilot was deemed to be in the mythical state whereby the basic stabilisation, attitude hold, maintaining current heading hold and co-ordinated turn were all functional, but altitude hold, IAS hold, selected heading hold and coupling to nav, ILS, VOR were all deemed inoperative. So all the training was about manual flying, none of it was about correct use of automation. How crazy is that!?
By 2013 in our company, due to a lot of fighting by me and a sensible flight ops inspector, we were eventually allowed to use the automation as intended during checks on the 225 fleet. But it was a major struggle and one which I’m not sure CHC ever fought or won.
So yes the pilots should have monitored airspeed better and should have been coupled to IAS, but their safety net in terms of company SOPs and the culture extant both in the company and the regulator, failed them and their passengers.