A tragic accident. The crew were risking their own lives to help others.
Appologies in advance to the above who are involved in the program, I do not mean to be insensitive, but I think there are numerous good lessons for the rest of us.
First and foremost is the limited panel flying. Is it not a requirement of the Instrument rating that limited panel flying be demonstrated? Don't we do this to enable recognition and correction of the very same situation as the crew found themselves in?
IMC departures should be a minimum competency requirement for an IFR EMS crew shouldn't' it? I agree with S76Heavy in this respect. The potential for disorientation is always present IFR, but rarely more so than during an accelerative climbing turn. Thus training is a critical factor here.
Bluey raises two excellent points about the CRM - although there are more, and this accident should benefit future CRM courses greatly. The first point is the inference that perhaps no one was flying when the aircraft impacted the ground. By the CVR, it certainly looks both a possibility and an explanation. Most transfer of control procedures are positive and three way, in that they contain an action command, such as "You have the controls" an acceptance statement of "I have the controls", and in advanced CRM programs, there is the occaisional third check of "You have the controls" being said again at which point the pilot relinquishing controls lets go. But this requires a constant discipline and is often allowed to lapse into complacency.
Secondly, there is a principle in CRM that requires acknowledgement or read back. If you have not had a readback on your third attempt at transmitting a message, you are to assume control and execute the requirement. Using this principle, the PIC may have said "You are descending and turning left. Climb and turn right now"...(no acknowledgement)..."You are still descending, climb now, and turn right"....(no acknowledgement)...."Climb and turn right now"...no acknowledgement).."I have the controls, and I am climbing and turning back to the right" and consider shouting "intercom failure". Again this example requires discipline and training.
IMHO, the CVR casts some doubt on wether or not the gyro actually failed at all! Was the SIC in a bad case of the leans and not believing his gyro? Was the message from the PIC then missinterpreted by the SIC as telling him to turn left and descend because that would match his leans? Why were there no comments on autopilot/stab system failures or warning indications? Doesn't the S76 have these?
slgrossman - can you give us some insight into the level and frequency of CRM training at your program?
I find it hard to believe that a failed gyro can be so totally condemned by the court. This is an aspect of the law that I do not grasp well. The peice of equipment in question has an expected occaisional fail rate such that the regulations require redundancy and training in how to utilise the extra display. Thus IMHO, a gyro failure is anticipated by the regulations and training progams and an appropriately trained pilot should "reasonably" be expected to cope with it. Given the question mark over training, the confusion indicated by the CVR, and IMHO, a doubt about the gyro serviceability in any event, I do not understand the verdict here. Is it the use of untrained jurors, or who employed the smartest lawyers and "expert witnesses"?
Same as S76Heavy, I don't begrudge the next of kin payout. There is precious little that will compensate for that sort of loss, but I would very much like to know how much of the payout went to lawyers who had to suffer working, and how much went to the family who had to suffer such a terrible loss.
