NTSB Report on ERA S-76 CFIT

[SASless]

As usual....the NTSB points out how the FAA continues to ignore the Helicopter Industry


The last radar track data showed the aircraft in a steady state 120 FPM rate of descent for an extended period prior to impact.


The Helicopter Industry response will be...."Who's going to pay for this new kit?" (As if they cannot raise rates!)


OR IMMEDIATE RELEASE: March 7, 2006 SB-06-13

NTSB CALLS FOR TERRAIN COLLISION AVOIDANCE SYSTEMS FOR ALL TURBINE POWERED HELICOPTERS THAT CARRY AT LEAST 6 PASSENGERS

WASHINGTON, D.C. - The National Transportation Safety Board today called on the Federal Aviation Administration to require all U.S.-registered turbine-powered helicopters certificated to carry at least 6 passengers to be equipped with a terrain awareness and warning system. The recommendation is one of five contained in the final report of a fatal helicopter accident in the Gulf of Mexico.

On March 23, 2004, an Era Aviation Sikorsky S-76A++ helicopter, N579EH, crashed into the Gulf of Mexico at about 7:18 p.m., 70 nautical miles south-southeast of Galveston, Texas. Although visual meteorological conditions existed, it was a dark night with very few external visual cues. The aircraft was transporting eight oil service personnel to the Transocean drilling ship Discoverer Spirit; they and the two pilots perished in the crash.

The Board determined that the probable cause of the accident was the flight crew's failure to identify and arrest the helicopter's descent for undetermined reasons, which resulted in controlled flight into the water.

"A terrain warning system would have given the pilots enough time to arrest their descent and save the lives of all aboard," NTSB Acting Chairman Mark V. Rosenker said. "It is well past time for the benefits from these standard safety devices to be made available to passengers on helicopter transports as they are on fixed wing planes. More than 2 million passengers are carried on Gulf of Mexico oil industry operations alone."

The aircraft was not equipped with a flight data recorder, and the cockpit voice recorder was improperly installed, rendering the recording almost unusable. The Board, therefore, could not determine the sequence of events that led to the helicopter's inadvertent descent. However, since cockpit instrumentation was available to the pilots, the Board concluded that the flight crew was not adequately monitoring the helicopter's altitude and missed numerous cues to indicate that the aircraft was descending toward the water.

The Board noted that when the FAA required TAWS (terrain awareness and warning system) for airplanes having 6 or more passengers in 2000, the technology had not been developed for the unique characteristics of helicopter flight. However, TAWS technology is now available for helicopter flight and should be required, the Board said.

The Board disagreed with that assessment, stating, "because the information that investigators learn from FDR data can help prevent accidents and incidents from recurring, the lack of FDRs aboard helicopters undoubtedly affects safety." The NTSB noted that it had participated in the investigation of another S-76 helicopter crash in Estonia. This was the first accident known to involve a large helicopter for which FDR data was available. Those data were extremely valuable to investigators, the Board said. The lack of FDR data significantly hampered the Era investigation, the Board said, and it urged the FAA to require FDRs on commercial helicopters such as the one involved in the Gulf of Mexico crash.

The Board also recommended that cockpit voice recorders on aircraft be functionally checked before the first flight of each day and that a periodic maintenance check be accomplished as part of the approved maintenance check of the aircraft.

[B]Other recommendations to the FAA dealt with expedited implementation of an initiative to improve flight following where traditional radar coverage doesn't exist, such as in portions of Alaska and the Gulf of Mexico, and with proper training for certain flight control systems.
A summary of the Board's findings is available on the Board's website, www.ntsb.gov, under "Publications." The entire accident report will appear on the website in several
weeks.

NTSB Media Contact: Ted Lopatkiewicz, (202) 314-6100, [email protected]

[Hippolite]

A simple AVAD which costs little and has been in use for 25 years on the North Sea could have prevented this accident, even if the bug was improperly set, the 100' warning would have sounded.

Sikorsky has now made EGPWS standard in all new aircraft, at least they are adopting a responsible approach to the problem.

Its sad that operators have not used the experience gained by their European ownerhip exercises past and present (ERA - KLM, OLOG - Bristow) to take the good operational equipment and techniques and apply them to their GOM fleets. Lives have been lost because of lessons not learned.

Incorrectly installed or unserviceable CVRs are not unheard of, a recent fatal fixed wing accident in Australia also involved an aircraft with an unserviceable CVR. Maintenance intervals and function checking procedures should be revised. Simply pressing a button and a meter going into the "green" is not enough.

Monthly integrity checks of CVR recordings should be an integral part of Operations and Maintenance QA.

HH

[Helipolarbear]

I agree in total! problem is that the Operators don't want to foot the bill, especially where low profit margins on large fleets are concerned......usual story!!!:}

[ATPMBA]

Don't helicopters have altimeters?
Two pilots, two altimeters what were they doing? Being overwater they should have been more vigiliant.
Now Joe JetLonger ranger will probably have to spend $25,000 to $50,000 to keep his heli legal.

[NickLappos]

ATPMBA,

Good idea, blame the pilots - until its your turn to buy the farm. It is about time that we stop finding out how 5,000 hour pilots with 10 years experience "screw up" and instead admit that the job we do is very tough, and even the slightest mistake can be fatal. We must stop trying to slap more training band-aids onto this dead horse and instead accept and encourage the improvements that actually work, even at the paltry sums you find abhorant. If we do not, we are destined to be a small-potatoes piece of the industry beacise nobody can trust us to bring them home often enough. BTW, you are paying for the improvements right now, but the payment goes to lawyers and insurance companies instead of your cockpit.

I love the typical pprune attitude - add a few more engines, make the seats more comfortable and THEN we will have a real helicopter. Oh, yea, and when an accident happens, blame the pilot and train harder.

If we simply study what actually happens to our machines and fix these problems with existing technology, we will improve our statistics (which are about 5 times worse than airplanes) and make us legitimate members of the flying community. Until then (with attitudes like yours, ATPMBA) we will stay a side-show, and not a main attraction.

[Shawn Coyle]

I recently obtained all of Tony Kern's books on flight discipline (no, not that kind of discipline for all you of obvious deviant minds). Why are they not more widely quoted and used?
I'm also quite surprised at the data that points to 25% or so of pilots in helicopters with stabilization equipment and autopilots don't use it, or will revert to hand flying at the first sign of trouble...
Someone said we are 50 years behind the FW community, and I'm beginning to see that as very true.
Comments please from Nick, who has just transferred to the FW community.

[Hummingfrog]

Nick

The pilots in this case must take some of the blame as they had all the information in front of them but failed to notice their gradual descent. During my RAF training, however, we were taught and shown examples of the "chain of circumstances" breaking any link in the chain would have prevented the accident.

In this case, the chain includes:- a/c designers, the operator, the pilots, the FAA and the weather.

The a/c designers for not making a simple AVAD system standard equipment.

The operator for not installing an AVAD system and coupled autopilot if these were only supplied by the manufacturer as optional equipment.

The pilots for not noticing the loss of height or slow rate of descent or for not flying with height hold in if fitted.

The FAA for not insisting that a coupled autopilot and AVAD system be fitted to an offshore helicopter, which flew IFR, and at night.

If the weather had been better or it had been daylight the accident may have been avoided.

If any of those links in the chain had been broken then the accident would have been prevented.

The pilot flying the a/c at the time of the accident is not solely to blame it is all the support services behind the pilot who have to accept a proportion of the blame.

In the UK, we had a similar accident when a S61 enroute to the Scilly Isles in IMC slowly descended until it hit the sea killing some of the passengers. After that event there was a concentrated effort to prevent a further incident and rad alts with height warning bugs/voice calls are now standard on offshore helicopters and most also have a height hold facility.

HF

[Captain Catastrophy]

The answer to accidents lies in a bit of both. Yes technology can help but crew training, CRM and procedures also play a big part in it. A TAWS or basic AVAD / RADALT set up is useless if improperly used or not monitored - accidents continue to happen. We will never know why the pilots failed to pick up the ROD and yes, people do make mistakes. A technology bandaid alone will not fix it and we do have to ask why a crew did what they did to refine the training , CRM and procedures.

[SASless]

Nick has a point and I usually am the first to complain about accident reports that cannot explain the cause of a crash that kills the pilots and then goes on to "blame" the pilots.

This is just another of those occasions I fear. It is evident the pilots played a role in the final outcome...the aircraft flew into the water. There was no distress call, report of a malfunction, and the circumstantial evidence fails to point to anything other than CFIT.

I look at this tragedy as I do most...what can we learn from it...and how do we prevent another one from occurring (if at all possible).

One does not have to go very far to wonder how long the CVR had been installed incorrectly and seemingly inoperative since that point in time. If it had been tested and been working correctly, the investigators would have had a much better chance to track the crew's actions for the half hour prior to the accident and maybe know what configuration the autopilot and RadAlts were in and what the pilots were doing...or not doing as the case might be.

What could the pilots have done that would have set them up for this to happen? Did the investigators interview other crewmembers and determine how the PIC/SIC normally operated the aircraft....autopilot configuration, RadAlt setting procedures...altitude callouts and such. Was there a discussion of the approved procedures that would surface a potential problem in the cockpit procedures used by the company?

The company in question is in the process of merging two company operations into one.....did that play a role in this accident? Did the NTSB review training procedures and crewing decisions to see if there are any systemic problems in that regard? With recent shuffling and reassignment of personnel in the Chief Pilot, Training Department, and Base Management...did effective training take place or did something happen in all that turmoil?

What was the maintenance history of the aircraft? Any autopilot problems in the past? RadAlt problems? What was the deferred defects for the aircraft?

For Nick's sake, even if we accept it was Pilot Error.....the question has to be....what was it....and how did it happen to a very qualified and experienced crew?

For the dead pilots sake, did the NTSB, FAA, and other investigators merely pick over the carcass of the helicopter and only the information directly linked to the event or did they look at it with a view to determine the total situation that applied to the environment that the flight took place in, and consider ALL of the possible factors?

What does AVAD cost for a S-76? That alone could have prevented this one in all liklihood. That one last backup system that makes up for a human mistake sure seems cheap insurance after the fact.

[212man]

I once took a 76 A++ on a ferry flight after a long period of deep maintenance following its delivery to the UK from the USA by ship. During the final stages of its reconstruction it was interesting to observe that no AVAD or radalt was fitted, nor a cyclic stick guard. Initial requests were turned down due to costs. It was pointed out that the contractural requirements might require an AVAD, so that sorted that one (made a mess of the new paintwork, fitting the radalt !), and the engineers fitted the stick guard anyway, without telling anyone! I'm sure that wouldn't happen now, I hope.

I fully agree with the sentiments about TAWS systems, but would hesitate to push the AVAD system too enthusiastically; if you actually look at the CFIT accidents offshore, involving AVAD equiped a/c, it is clear it did little to stop the descents (Fulmer 76, Cormorant 332, KLM 76, Australian BHL 332 etc.) The correct way to go forward has to be the EGPWS; it really is an impressive prompt!

I also agree with the sentiments about discipline; I think that in general the Fixed Wing world are ahead of us in that regard. They have a far more rigid system of SOPs and standardisation. Finally, it doesn't matter how you word the arguments or aportion blame, at the end of the day, if you spend a few moments scanning your flight instruments, every few minutes or so, you will avoid inadvertent descent.

We often say to the lay public that, as pilots, the flying isn't the job: it's the mission that we get paid to do, whether it's military, offshore, corporate, ems or whatever, and the flying is a second nature that allows us to achieve the mision.

That's true to a large extent, but first and foremost YOU STILL HAVE TO FLY!!!

[SASless]

212man,

I shall ask a rude question .....what operator is so damn cheap that they would buy an S76A++ and NOT put a RadAlt on the thing (in this day and time)?

Probably the very same outfit that would have the S76A running around the GOM haulling passengers without any Stab or Instruments beyond the very basic panel that comes with a "Green" aircraft from the factory. That was caused by the backlog at Heli-Dyne for completions.

Can we agree that is an indicator of what the standards "used to be" in the GOM years ago and that is the mindset that has to be excised from our industry?

Granted I can recall having three BarAlts and no RadAlt on the North Sea despite flying in Norwegian waters in the same airspace that Helikopter Services flew in using RadAlts for altitude control. Thus we ponced around using a regional QNH setting in the same airspace as opposing traffic did using a more accurate method of determining height although our reference datum was different from theirs.

[IHL]

What I find amazing is that GOM operators fly approximately 400,000 hours a year, 300,000 in single engine helicopters. Given engine[only] failure rates of 1 per 100,000; that assures that at least 3 single engine aircraft a year will be bobbing around on their floats.

[bladebanger]

SASLESS

To answer your question JAYROW HELICOPTERS.
And they are operating them now.

BB

[NickLappos]

To avoid confusion, let me restate my observation:

Any endevor where crews of 5,000 hour people with 20 years experience regularly produce an accident rate 20 times higher than commercial airlines needs serious attention to all aspects. If you had an elevator with that track record, you'd take the stairs. If you had canned goods that harmed you that often, the Government would drive you out of business.

When you get to the point where "Blame" is how you characterize the way to solve the problem, you are doomed to fail. The "Right Stuff" is a term coined by Tom Wolf to describe the rationalization that test pilots use to decide how the job itself was not dangerous, it was those only those fools who lacked the "right stuff" that died.

Forget blaming the crew, start finding out how to better the system. When pilots just harumph and say "pilot error" they HELP the operators and regulators perpetuate the system we have, and they prevent any improvements beyond more training and more rules (with the same accident rate). When we pilots EXPECT perfection from ourselves to succeed then we help perpetuate the system that we have.

Go ahead, say "Pilot Error" and think that solves the problem. It only explains the crash, with the same accuracy and precision as if you had said "hydrodynamic impact forces".

The fellow in a hot air balloon call down to an old geezer, "Where am I?" he asked. The geezer answered, "You're in a b'loon, ya damn fool!" Same precision and accuracy, but no solution to the problem at all.

Gentlemen, solve the problem, do not jump into the same old rut.

[SASless]

Any endevor where crews of 5,000 hour people with 20 years experience regularly produce an accident rate 20 times higher than commercial airlines needs serious attention to all aspects. If you had an elevator with that track record, you'd take the stairs. If you had canned goods that harmed you that often, the Government would drive you out of business.

Perhaps Mr. Lappos is saying the helicopter industry has a management problem. That or the government is not doing its job and keeping the ptomaine poisoning out of the market.

IHL points out a mindset and way of doing business that confirms part of the mindset that suggests the helicopter industry in the GOM still suffers from the Bob Suggs School of Management attitude.

Bladebanger's post suggests some of our bad habits have spread to Oz.

As long as the helicopter industry has a hire and fire mentality, Nick...things are not going to change. Try to stand up to yer boss fellah and tell him how to run his private railroad and see how long you last.

As one of our posters has said...."One becomes 'known" in the industry.". That same poster also said folks that were Gypsies were not good candidates for hire.

I would suggest Nick, that is the part of the industry that needs changing....the old Bobby Suggs bunch that refuse to accept the fact "people" are the key to success of a business and not just the senior management pukes.

Has the FAA ever taken certificate action against an operator in the GOM or the EMS industry? Ever...at any time?

[NickLappos]

It is not a management problem, nor is it a pilot problem. Read the posts above, PILOTS get out the rubber stamp, put the accident in the right bin, and then go about their business as if they solved the cause.

The problem I am discussing is that the entire industry is shackled by its inability to seek technical solutions to technical problems.

I am in the business of building stuff, so when a problem is found, we FIX it. If my company lost 2% of its products coming down the assembly line due to a single cause, and we had tried unsuccessfully for years to train that problem out or the workforce, we would do something ELSE to FIX the problem.

Most management wouldn't fail to fix the problem, it is the pilots who I place most of the burden on, since they do not even ask for the fixes. Look at the series of posts on pprune where I perposely ask for safety improvement ideas, and every dumb bastard asks for more OEI safety, in spite of the fact that it is CFIT that gets us. Only when pilots connect the dots will there be solutions, but pilots are so busy believing they are infallable that they REFUSE to consider solutions where they are helped in their job. Otherwise, we would be screaming for helo airways, helo approaches, EGPWS and many other similar technical solutions.

[SASless]

Nick,

Why would Sikorsky build a 76 and not make a RadAlt a basic instrument package item?

Immediate answer will be....ah..it is a customer option.

Next question....why would an operator buy a 76 and not install a RadAlt?

Are you telling us the pilots driving the thing don't ask for the RadAlt?

If the pilot's ask for equipment and the operator does not install it....then what Nick? Strike action or something?

Sounds like you are on the side that thinks accidents are "pilot error" even if only through acquiesence as a subset of the aviation population.

[topendtorque]

I'm with you, may i remind people that it is not all that long ago that a certain RPT F/W perambulated for a lengthy time in an unstable state, prior to a bad time and it turned out to be nothing more than a patch over the static vents which played havoc with all of the aneroids.

I wouldn't go too hard on the drivers, especially if they were in a basic machine,--- dark night --- all that! ASI, -- yeah but -- weaving a bit -- but maybe ok, VSI not moving, both alt's not moving!!

[NickLappos]

SASless,
To my knowledge, NO S76 was ever delivered without a rad alt, it is part of the baseline cockpit, paid with the sales price, and it would cost more to take it out for 1 operator! The rad alt has settable low altitude warning lights. The one reported here might have been modified in the field. I also find it interesting that instead of discussing the point, you try lamely to attack me or the company I worked for as if that explains the problem! Sad try. What about the basic point I make?

topendtorque,
I have no idea what you are saying, is it that you speculate that all 5 altimeters in the aircraft were stuck? Not likely. You say I should not be so hard on the drivers, which means you completely miss my point. I am not hard on those pilots in the aircraft, I am being hard on those pilots on the ground at pprune and elsewhere who decide as long as it is "pilot error" the solution is found and the problem goes away.

We must all work to make BETTER helos and better airspace systems, so that we can eliminate all pilot error accidents at the source (i.e. improve the difficult task) and not at the convenient end point (the dead pilot).

[SASless]

Nick,

This time you are wrong on at least two counts.

The Air Log machines that first got delivered were "green" and had only the basic flight instruments and a standby attitude indicator. The completions were done at Heli-Dyne in Ft. Worth and IFR kit was installed there. Air Log pilots had to fly the aircraft without SAS or a proper set of instruments when the company ran into a backlog at the Heli-Dyne completion center.

This was in the days when Sikorsky was selling the 76 with the organic in-house SAS system and Air Log wanted the Sperry system. You do remember the phase I, II, and III SAS system configurations.

The aircraft were sold that way at the request of the customer.

Vice what you suggest, I am not "attacking" Sikorsky or you. Simple fact remains that manufacturers will sell the aircraft as the customer demands. From what you have reported in the past, Sikorsky has taken steps to add some items as basic standard fit and thus customers have to buy the kit.

The Sperry system far exceeded the in-house system in function and thus was the preferred SAS/Autopilot system.

[ATPMBA]

Airlines and CFIT

Several accidents come to mind:

A B-727 was cleared for approach to Dulles, the crew misread the approach plate and hit the top of a hill. During research of the accident it was determined another airliner did the same thing about a month earlier but barley cleared the hill in IFR conditions.
ATC procedures were soon changed to include an altitude to maintain once cleared for the approach.

The infamous Eastern L1011 crash where the crew were pre-occupied with a burned out landing light indicator. I believe the autopilot became disconnected with three crewmembers on deck and no one caught it. I believe CRM became a big push by the airlines after that but it took years to change institutional mindsets.

A B-727 ended up in the water off of Pensacola during an approach after the FE turned off the GPWS, he thought it was a false message. Anyone want to fly with that crew?


Cali, Columbia, I believe the crew input the wrong fix ID in the system. The wrong fix had an additional letter. It was late at night and at the end of a long flight.


--------------------------------------------------------------------------
In those accidents above I don’t think anyone is blaming the hardware

It appears the airlines lowered their accident rates some years after CRM was implemented and followed.

Also, when someone says 10 years of experience do they mean 10 years or 1 year repeated 10 times? As pilots we need to take the responsibility of improving ourselves.

[NickLappos]

SASless,
I am not wrong, those aircraft flew out with a ferry package only, because the customer was going to put his cockpit in. Don't blame the manufacturer when the customer decides to put his own entire cockpit into the aircraft!

[SASless]

Nick,

Slow down a mo' ol buddy....aim yer rockets before you pull the trigger....it's a computer keyboard not a full set of 17 pounders you got under your two index fingers.

From my post prior to yours....where is the finger pointing squire?

The Air Log machines that first got delivered were "green" and had only the basic flight instruments and a standby attitude indicator. The completions were done at Heli-Dyne in Ft. Worth and IFR kit was installed there. Air Log pilots had to fly the aircraft without SAS or a proper set of instruments when the company (Air Log) ran into a backlog at the Heli-Dyne completion center.

This was in the days when Sikorsky was selling the 76 with the organic in-house SAS system and Air Log wanted the Sperry system. You do remember the phase I, II, and III SAS system configurations.

The aircraft were sold that way at the request of the customer (Air Log).

From my post before that one.....

Why would Sikorsky build a 76 and not make a RadAlt a basic instrument package item?

Immediate answer will be....ah..it is a customer option.

Next question....why would an operator buy a 76 and not install a RadAlt?

[topendtorque]

none of those but thanks, it featured on the television black box series pilots were communicating for quite a while with control before they lost it, in the meatime they almost stalled it several times. somewhere off the south americas????

NICK, ah the theatre of it, nick I said I'm with you man! i also say again that we don't neeed to download too much on the drivers. have you never driven a machine with the static vents completely clogged up -- causes all sorts of indicator probs.

there was another recent and not so famous event in oz. a BRAND NEW 407 was found floating upside down the next morning offshore Queensland by the good old television media , seems the hero and crew, who all got out ok, had a known defect radalt, and still continued, planning???? to find by GPS and refuel at night on an offshore reef from jerry cans which he was carrying.

speculate on that one, or i should say speculate on the vacant space between the earlobes.

[SASless]

Airport....large well lit, fully instrumented, controlled area with visual approach aids, electronic approach aids, certified weather reporting, runway friction measuring, air traffic control and approach monitoring, used by fully instrumented crew served multi-engined airplanes monitored and assisted by company dispatch personnel, ground handling personnel, baggage and cargo personnel, and service facilities.

Helicopter landing site.....slightly fewer services and facilities than airports.

You wonder why we seem to do goofy things sometimes? You cannot have it both ways and still fly "helicopters". We start flying where the road ends (to quote a dear friend!).

Topend,

Would the crew have noticed something a bit odd on take off if the static ports were blocked? On a nice VFR night in a helicopter....it should have been noticable and easy to cope with as compared to the Boeing Jet that had the problem in South America. The re-enactment of that flight scares the Bejesus out of me just watching it on the TV.

[212man]

Having just read the NTSB extract, I note that the initial posting from SASless omits a significant point: the aircraft was equiped with a Honeywell SPZ-7600 autopilot. This would mean it was capable of being full coupled in all 4 axis, and equiped with a rad-alt, although obviously it wasn't equiped with an alerting device.

The recommendations include reference to training in the use of the autopilot, especially the coupling cues and annunciations. One can only wonder what modes were engaged at the time of the accident: none, IAS only, V/S? Not ALT I guess!

I forget the logic of the undercarriage audio warning, but would this not have triggered as the a/c descended through the rad-alt bug setting? Unless the rad-alt bug was set to zero (annoying bright orange lights at night?)

[SASless]

212man,

I raised a number of issues....and certainly not all of the possibilities. Any idea why they raised the autopilot training issue?

In the foggy recesses of my alcohol ravaged brain, I seem to recall the 76 uses a combinaton airspeed and RadAlt height to trigger the gear warning.

It seems that if you had a strong headwind and some forward speed the horn would not go off which makes me think it requires both inputs to trigger the warning. Someone more current on the 76 can tell us how that works.

Of course at cruise speed....it would not be the horn that woke you up when you hit the water.

[Helipolarbear]

:) SASLESS..You should get into Heliergonomics..a developing science......experienced pilots with great sense of humour should apply for position of Test Director of Manufacturer! And you have loads of experience.:cool: ;)

[212man]

SASless,
I thought it was Rad-Alt OR IAS that triggered it, but a lot of water has passed under the bridge since then!

The NTSB's issue of Autopilot training is twofold, I think. a) to highlight differences between the HPZ-7000 and HPZ-7600 (of which I am ignorant, having only seen the 7000!) and b) to ensure adequate training in knowledge of the use of coupled modes: how they function and the indications in the cockpit that show what modes are engaged. I assume the A++ in question had a 'round dial' cockpit so annunciations would be limited to the AP control panel and Flight Director control panel. On EFIS a/c the indications are normally presented on the Flight Mode Annunciator strip at the top of the PFD, and the calling and checking of FMA indications should be part of the SOPs for the a/c.

I cannot help but think that either the radalt was unserviceable (hopefully the final report will tell us), or the bugs were set at zero. If they had been set above zero there would have been sudden bright orange light as they passed the bugged height. It's designed to get your attention!:\

[SASless]

How many variations of cockpit configurations exist between all the 76's in a fleet. I know one nay...two Bristow Group companies that has just about every variation there is and over the years has tried to standardize them as much as possible but has not gotten there yet.

That brings up yet another issue to consider....fleet commonality. Had there been a change of aircraft for the crew that day, week, shift, hitch or customer? Are the cockpit procedures different enough or generic enough a mistake could be made due to that?

At one place I worked we thought ourselves as being on top of things only to discover that we as an institution had skipped right over a basic calibration procedure for one of the mission systems that led to some very bright red cheeks when we discovered what had happened. Granted the manufacturers Operator's Manual was written in Swahili and only the technical writer that composed the section dealing with that procedure could have understood it. One of the dangers of out sourcing technical work I guess.

[NickLappos]

SASless,
Those air log aircraft were shipped without a cockpit - because the customer was to install his own. The entire cockpit was deleted, not the rad alt. Why not blame me for shipping it without the rest of the cockpit, Kimo Sabe, and stop focussing on the rad alt?

[SASless]

Ah heck Nick, my cross check was never any good. I seemed to focus on the wrong indicator anyway. Always figgered if you took care of the big ones....the little ones would sort themselves out. Afterall RadAlts are rare items in some places and thus seem like really high tech stuff when you finally get to see one, thus they are fun to watch.

[George Semel]

Give it a rest, the NTSB wrote the report more for the FAA more than any one else. The FAA will file the thing in the Round file cabinet. Well I never flown S-76's only Bell 206's and every single one of those 206 had a different lay out. The Pilots are dead so its easy to blame them, and the rules make the pilots the ones that will be blamed when all else fails. The guys flew into the water, killed themselves and there Passingers. Would a Radar Alt have helped yep it would provide it was turned on and working and the Pilots were paying attention. It all comes back to two pilots for some reason not paying attention and well it hurt them. But it has to be somebodies fault, NSTB has an adjenda, the FAA has theirs, Era well we all know what happend to them because if it, Sikorsky gets tared and feathered for not doing total fitting out there products, never mind that customers like to do their own pannels. All in all that report is just another circle jerk. Take it for what it is, learn from it and move on.

[charron]

Seems every time someone hits the water we add another light and gadget to the panel. A rad-alt has been common on everything from Jetrangers to S92 flown offshore, but an ARA approach can still be flown without it. The NTSB recommendation is for EGPWS. So the next time that two pilots ignore the rad-alt, gear warning audio and light, both altimeters unwinding, both VSI negative for a long period, ground prox bar on the EFIS C+, AVAD, we are all confident and satisfied that they will notice the EGPWS. Maybe, maybe not since even those have the Offshore toggle so you don't lose your nav and radar at a bad time on an ARA approach. I don't think there has been a CFIT accident of a EGPWS equipped helicopter in the GOM yet. When there is, the NTSB will add some other warning to the panel for the pilots to not notice.

What about some proper CRM and CFIT training instead that is tailored to the offshore flying and to the aircraft systems and automation? Why do we waste a couple of days a year listening to some retired airline pilot drone on in a classroom about an Airbus hitting a mountain just to get that piece of paper that says "CRM"? What about SOP's that are written with helicopter IFR CRM and the automation in mind instead of treating them as two separate subjects?

[SASless]

From early on in this post Nick and I took the position that "Pilot Error" tells only a part of the story in this tragedy. This crew was experienced and was flying a well equipped aircraft in good weather at night over the ocean while in cruise. The report, without any other identifible cause points to the pilots.

That is improper in my book. If they cannot identify a cause then it remains unsolved in my view. They have not shown what the pilots did...or did not do that allowed the aircraft to impact the water.

The question that remains is simple..."What caused the aircraft to impact the water...what chain of events led to that happening?" Was there some failure of training or procedures that set the crew up for making a mistake that could have caused this?

Due to the lack of an operable CVR and no Data Recorder being installed, we will never know. The Pin the Tail on the Donkey game that gets played in these situations means the Pilots who are not here to defend themselves are going to be the Donkey unfortunately.

I wonder if ERA has had a third party review of its procedures and policies since that accident with a view towards confirming the adequacy of their training , check and procedures.

What makes this accident so strange is that it occurred in cruise over the ocean and not while on an ARA or takeoff. That is why an answer that correctly identifys the cause is so important.

[GLSNightPilot]

I agree with Nick on most of this, but just a quick niggle. Spend 9.5 hours in those seats (the S92 is even more uncomfortable than an S76 or even a 412) and see how much trouble you have concentrating on the altitude, airspeed, or indeed anything except the pain in your back and backside. Ergonomics has a large effect on safety.

The A++ can have the gear warning triggered by either the radalt or the airspeed. If this one was triggered by airspeed, and the airspeed never dropped below 60 kts, then there would be no gear warning horn. You can drive it into the water at 70 kts or 130 kts and never, ever get a warning. It isn't both, it's either airspeed or radalt.

Adding more technology is wonderful. But there needs to be training on how to use that technology. A couple of days at FSI is nice, but it won't teach you nearly everything you need to know, and neither will a one or two day class by the local training (checkride) department. Having 10,000 total hours won't help that much, either, if it's all in older models. It takes a lot of training time, which operators aren't willing to do, because that costs lots of money, both in aircraft flight time, unproductive pilot time, and loss of aircraft availability for customer charges. I don't have an answer, but I do think it involves both technology, and proper use of ergonomics for both pilot comfort and especially in making that technology easy to use and understand. Requiring pilots to monitor systems full-time is as dangerous as requiring them to hand-fly full time, perhaps more so. If the pilot is hand-flying, he is likely paying much closer attention to altitude, airspeed, etc. The technology has to be easy to use, and completely transparent. That isn't easy to do, of course.

[topendtorque]

"The Pin the Tail on the Donkey game that gets played in these situations means the Pilots who are not here to defend themselves are going to be the Donkey unfortunately."

This reminded me of one who has been here before and has written about it.

Author Campbell, Steuart
Title: Chinook Crash - the Crash of RAF Chinook Helicopter ZD576 on the Mull of Kintyre
Publisher: Pen & Sword / Leo Cooper

The carrier wave in this book is about a very professional outfit its great camaraderie, extra good training and, the odd dash of luck.
The real story is how the “system” blamed the drivers when there was nothing obvious happened in an accident and how the author is desperately and with great courage trying to clear his former colleagues. A good read and the author needs a big pat on the back.

The ‘system’ he talks about is the military which provided ‘butt cover’ for non decision or inability, which provides the ‘ineffectual system’.

Our ‘system’ is supposed to be different. It is investigation by ATSB or NTSB which is not supposed to be influenced by politicians, manufacturers or big companies looking for ‘butt cover’. They are supposed to be statutory and autonomous. Are they? If so why is this thread plainly unhappy with the finding?

If the finding is libel, then maybe there should be a class action against these sorts of findings when after all nothing has been proven. Why cannot investigation conclude that there was no recoverable evidence, as a finding instead of “pin the tail on the driver?”

It is not really a matter of, quote from another thread:- "I have plenty of operational experience, Civil and Military flying experience and enough hours to know that at some point all of us will experience some sort of accident or incident."

It may well be a matter of providing for a system where when you run into that inextricable problem that your wife, family, friends and colleagues will not be left with a tainted “pilot error” slur against your name.

[NickLappos]

The important point I am trying to make is that ALL pilots Err, and there is nothing shameful about it. If you think any human system will simply not err, you are mistaken (like that circular logic??)

It is no slur to have had a human error accident, any more than a baseball hero must make 100% hits while at bat. It is impossible for a human system to be infallible. To get the errors down in percentage, we must make the job easier and more predictable, and less reliant on extra-human capabilities. For that Chinook crew's family to hang their heads because an expert group had decided that they erred is not a shame on them, it is simply a fact that they undertook an enterprise that had slim margins, and that less than perfect behavior could cause a mishap. Since none of us can behave that way, a certain number of mishaps will occur. Remember, the military are those among us who decide how many lives a hill is worth.

It is clear from the posts on this thread that this concept is not understood, perhaps because I cannot adequately explain it.

[vertalop]

Nick,
If I remember correctly in the case of the UK military Chinook there was a slur. The families hung their heads not because the report found that there was a human factor involved when there was no particular evidence one way or the other, but because the pilots were found guilty of Gross Negligence without any particular evidence of human factors one way or the other. I note that, long after many horses have bolted, CVRs are now being fitted in UK military aircraft
The fact remains, on the UK side of the pond (in the 80s I think) an S61 crashed in fog but with bright sunlight which may have masked the little orange light on the radalt. As a result, all those years ago, an audio warning (AVAD) was mandated by the UKCAA. This goes off when the bugged height is reached and at 100ft, so even if the crew fail to set the bug they still get a 100ft warning in their headsets. It is not a full blown EGPWS, but it has the effect of advising the crew that something is amiss when flying offshore. Why did this not get adopted on the other side of the pond? Maybe no one took the time to take an interest in accidents outside the USA, or maybe it was a criminal attempt to save money. If the FAA had made AVAD compulsory on all offshore helicopters I am sure several lives would have been saved over the years and this accident may have been avoided.
Has this lesson now been learned?

[GLSNightPilot]

To err is human, and I've certainly proved my humanity many times. So far I've been lucky, and my errors have had no significant effects. It could have easily been otherwise, though, and I certainly welcome any technology which can help save my rear. EGPWS is a huge step forward, and IMO it should be required on any commercial aircraft. FMS and full flight directors take over the drudgery of flying, and keep the aircraft on course, on altitude, and allow the pilots to keep the big picture in sight. Reliance on technology without insuring it's doing what we want, not what we told it to do, can be dangerous, however. To coin an acronym, TAANSTAFL, and there are downsides to everything, of course. In the long term though, the upsides outweigh the downsides. I'll take all the technology I can get, and happily learn to cope with it.

[KikoLobo]

A garmin 296 could aid for terrain warnings...

[i4iq]

KikoLobo

I was wondering about that myself. Would rules and regulations prohibit it's use in the GOM or North Sea?

[GLSNightPilot]

No prohibitions in the GOM that I'm aware of. I used a handheld GPS for some time before ours were installed in the aircraft. Far better than the LORAN that was officially certified for IFR use. Lots of us had brackets made up by the sheetmetal repair guy to attach them to the glareshield or somewhere close.

[vertalop]

The Garmin 296 is a wonderful piece of kit, but so is the altimeter! In both cases you have to be looking at the thing to get the warning. The secret here is to have an audible alert which will get your attention whatever you happen to be doing at the time, even if you are sleeping. :eek: