Comment on AAIB report
While a considerable amount of time and effort has clearly gone in to compiling this report, there are 2 key areas which have not been sufficiently dealt with, namely the operating philosophy of Bond Offshore Helicopters at the time of the crash, and the regulatory oversight of its operations by the CAA.
Night Operating Procedures.
In many decades of both miltary and civil VMC operations to offshore decks at night, it has always been the norm to fly to a "gate" to establish a safe range, height, speed and into wind heading from which to obtain full visual contact with the surface and landing area (ie the helideck or its immediate vicinity) and to then fly a stabilised approach with regular and frequent reference to the instruments to ensure that the approach remains under control. This procedure was valid for both single pilot and multi crew operation.
The minima for night VMC operations, ie 5k visiblity and 1200ft cloud base with a minimum operating height of 1000ft, were in use by both the other major offshore operators at the time of this crash. Descent below this height was not permitted until within 10nm of the destination and in full visual contact with the surface and the destination. If these conditions could not be met, an ARA should be flown.
It would appear from this report, that Bond's SOPs permitted the crew to descend to 300ft outside 10 nm of their destination and neither in sight of the surface nor in visual contact with the helideck. They did not appear to use the "Gate" philosophy at the time of the crash. Their use of a radalt bug setting of 150ft when operating over the sea at night was also lower than the norm of 300ft which affords significantly more time to correct a potentially dangerous situation.
This SOP seems to have been such a significant departure from the accepted operating norm, that I cannot understand how Bond's operational management can have proposed such potentially unsafe operational limits in their Operations Manual, and how the CAA regulators can have approved them. By allowing the crew to operate in this way, the Operator and Regulator had removed a significant amount of the protection afforded to the passengers and crews of other companies conducting night operations on the North Sea.
Operating the EC225.
The EC225 has a superb 4 axis autopilot which affords an excellent level of safety if its capabilities are fully exploited. It allows the Handling Pilot to retain fully coupled control of the aircraft while making fine adjustments to heading, speed, height or rate of descent. This allows him to remain totally in control of the aircraft at a minimum airspeed of 30kts and offloads him from the intense concentration required when flying manually to exacting limits close to the surface. It gives him the time to assess his landing area and to decide whether to proceed with the approach or execute a Go-Around. The Monitoring Pilot therefore remains free to monitor the instruments and identify departures from safe parameters for the approach.
When executing a Go Around, both All Engines Operating and One Engine Inoperative, the autopilot will use the full power available by pulling to the first limit (TQ, TOT or N1) thus giving maximum take-off power when AEO, or if an engine failure has occurred, will droop the Nr to 96% and accelerate the aircraft to the indicated Vtoss, pulling OEI High power, before climbing the aicraft at that power until a lower power setting is selected by the Handling Pilot.
Reading the report, it appears that Bond's operating philosophy was to use the EC225 as if it were an inferior AS332L2 and neither to use the go-around protection at low speed (below 80 knots), nor to make continuous use of the upper modes of the autopilot until the final third of a mile when commencing the final descent on sight picture to the deck. It begs the question - why buy a state of the art machine and not use the fantastic safety features it offers to protect the passengers and crew?
Once again, it seems that Bond's operational philosophy did not follow best practice or make full use of the safety features designed in to the aircraft. Why not, and why was this situation not picked up during the inspection regime and corrected by the regulatory authority?
2 Crew Operations.
The report has identified that Bond's Operations Manual did not adequately define the responsibilites of Handling Pilot and Monitoring Pilot during the approach phase of night deck operations. This lack of clarity and inadequate training allowed both the crew to be sucked in to concentrating on external references, rather than dividing their tasks so that effective monitoring could identify dangerous parameters building up, allowing early and decisive intervention.
Once again, Bond's procedures seem to have been lacking and this was not identified and corrected by the regulatory authority.
Bond's response to the Morcambe Bay crash.
The risk assessment carried out by Bond's management following the fatal crash determined that their common procedures for the L2 and the EC225 were robust. If one accepts the erronious premise that operating to the lowest common denominator of capability of 2 significantly different variants of an aircraft type is sensible, then one can see why they came to that in-house conclusion. Why did the CAA not point out the flaw in their logic and require best practice to be adhered to.
Given the specific remit by the CAA to review their procedures following a fatal accident, why did Bond's management not make the decision to separate their AS332L2 and EC225 fleets and operate them with separate crews, making full use of the EC225s superior safety features? Why did the CAA oversight not identify this shortcoming, when other operators were already operating to higher standards?
Overall Thoughts.
It seems to me that the AAIB report has not fully covered the corporate and regulatory aspects of this crash.
While the crew's actions have been analysed in considerable detail, the apparent failures of Bond's management to operate their aicraft using their full safety features and to use procedures which complied with industry best practice have not been properly addressed. Similarly, there seems to be little or no analysis of the CAA's responsibility for exercise of proper regulatory oversight of Bond's activities and to ensure that Bond's Operations Manual was up to date with current best practice, especially in the light of the directions given to them in 2007, and that their Type Rating Training Organisation methods were rigorously scrutinised.
Neither of these major areas of concern have been sufficiently examined and exposed by this report. Had the proper procedures been in place in Bond Offshore Helicopters, as they were in the other 2 main North Sea operators, this crash could have been avoided. Fortunately the Automatic Float Deployment System fitted to aircraft prevented the crash becoming a tragedy.