A sobering report which should be mandatory reading for al offshore pilots. I would suggest that the parameters recorded in the go-around should be used as the basis for a pre-briefed (to an individual - not the crew) pilot incapacitation 'event' in simulator training.
A couple of things I thought might have had more scrutiny or reference to:
- The visual appearance of the ADI at the point of control handover: It is my belief that at the pitch attitude reached, the ADIs would have been completely black and would not have been easy to interpret (especially in the dark) The use of 'fly up' chevrons as seen on modern EFIS displays might help greatly in these situations
- The pitch change that was effected (around 25 degess pull up) must have felt quite significant, especially in the dark, and with the likely g forces that would have resulted at the prevailing airspeed (looks close to 2g in the FDR trace). There must be some consideration to the idea that RHS pilot felt he had initiated a significant recovery manouevre, and that the actual degree of pitch change and rate required was likely to be totally unnatural to him. It is likely to have been of the order of 55-60 degrees of pitch change which is practically an aerobatic manouevre! (-38 to +15-20)
- No discussion was made by the AAIB or CAA as to whether the aircraft could actually have been recovered from this upset. What pitch change and rate of change would have been required, if at all recoverable, given the height and rate of descent that resulted?
- A brief reference is made to the G/A button (and HC mentions it above.) More information on the envelope within which it can be used might have completed it's reference, with the likely conclusion that it would not have responded quickly enough at the higher speeds, and would not be engageable at the lower speeds
- I'm surprised the letter from the CAA was published with the name and address of a nominated post holder for another operator. A disidentified letter would have served the intent, without any ability to construe a connection or inference
- The pathology report states injuries consistent with a high vertical speed and some forward motion. Surely it would be the other way round - I know 2000 ft/min is a high vertical speed, but I'm sure the 126 kts did more harm
Terribly sad, regardless, and we should heed the lessons carefully