View Full Version : Fatigue theory over Islander air rescue deaths

10th Nov 2006, 09:37
The investigation identified the following causal factors:
1. The pilot allowed the aircraft to descend below the minimum altitude for the aircraft’s position on the approach procedure, and this descent probably continued unchecked until the aircraft flew into the sea.
2. A combination of fatigue, workload and lack of recent flying practise probably contributed to the pilot’s reduced performance.
3. The pilot may have been subject to an undetermined influence such as disorientation, distraction or a subtle incapacitation, which affected his ability to safely control the aircraft’s flightpath.

AAIB Report here;

10th Nov 2006, 18:05
I admit, I haven't read the report but I am surprised why he would be 'fatigued' and have 'workload', when he had 'lack of recent flying practise'?

Doesn't make sense.

10th Nov 2006, 18:30
Sugest you read the report then!

10th Nov 2006, 18:45
Mr Bernoulli, lack of recent experience would lead to a higher workload, however that link is no more than a casual factor here, the increased workload was due to a Single Pilot IFR flight at night in very poor weather conditions. If you have never operated in these conditions, well I have, and can assure you a 'high workload' is a realistic description.

If you read the report those points will become clear.

The report makes very sober reading, especially to one who knew the Pilot. I do not agree with the whole report but on balance perhaps it is not too far from what actually happened that fateful night. The linking of the Liverpool accident is probably relevant, however this accident http://www.aaib.dft.gov.uk/sites/aaib/cms_resources/dft_avsafety_pdf_501869.pdf is probably more relevant.

On an aside, Loganair have lost 3 hulls in the last 10 years, 5 aircrew killed in these accidents, makes you think.... :(

11th Nov 2006, 01:38
No one would seriously suggest that the BN2 crashes were in any way linked to the SD 360 accident but they may be indicative of of a company culture. As anyone who has operated the BN2 Air ambulance will admit there but for the grace of God................I think we can all see the truth in the the detailed analysis, it was a f**king hard job, limited resources and very difficult operating situations, eat your heart out routine operations with computer generated weather,notams and all the rest, these guys operated with minimum information and maximum commitment. God bless you Alan and Guy you were doing a job you believed in.

11th Nov 2006, 08:52
'Meeb', don't quite get your point that you don't agree with the report's findings ! What is it you don't agree with ?
This was a routine amb. flight to Cal and as such would have been the most frequently operated flight of the Western Isles,as indeed it still is today albeit by a different operator.
Those in the know will realise that it would not have been a difficult approach in the weather conditions of that evening and it would be bread and butter for any of the Loganair Amb. pilots .
For any one who has done that approach especially at night will know just how difficult it is to attain any kind of visual reference during both the outbound and base turn segments of the approach due to the approach being over the sea.In my opinion the pilot may have tried to convert to a visual approach during the turn and lost sight again of visual references.In this case it becomes very similar to the G-BEDZ accident in Tingwall,Shetland several years ago !
As someone else said.......'There but for the grace of God'......


11th Nov 2006, 12:20
bral and waaf, thank you for your comments. The reason for my last statement was merely because it was a statement of fact! I cannot think of any airline in the UK who has lost 3 hulls in the last 10 years, thats why I said it must make one think... surely? Safety culture, well, that opens a whole new can of worms and after the MT accident there was a changing of the guard, so maybe, but if so, it leaves many more questions...

bilderberger, you really need to read my post a little more carefully... :rolleyes:

'Meeb', don't quite get your point that you don't agree with the report's findings !

I did not say I don't agree with the reports findings, I said I did not agree with the whole report, a significant error on your behalf.

Then you mention that this accident had similarities to the accident to G-BEDZ, which I had already stated in my post, did you even bother to read my post at all...??:rolleyes: If you had, you might have seen that I was alluding to the same conclusion, but with a very different prognosis.

Those in the know will realise that it would not have been a difficult approach in the weather conditions of that evening


In my opinion the pilot may have tried to convert to a visual approach during the turn and lost sight again of visual references

I do not agree with that at all! The weather conditions were not suitable for a visual approach, the weather conditions were rapidly deteriorating with lowering cloud base and reducing visibilty. The report states that the Pilot would be in a situation of high workload, increased somewhat by the weather, and because it was in darkness, therefore difficult.

Machrihanish is not in the Western Isles, it is on the Kintyre Peninsula which is a region of the mainland of Scotland. It is a long road journey to get to a fully equiped hospital and so the air ambulance is frequently used.

I agree it is a common destination for air ambulance flights, but to suggest that this, or indeed any mission to a remote airfield in poor weather was routine, is simply not true, and confirms your lack of knowledge on this subject.

When I operated the BN2 on air ambulance missions no flight was ever routine... how ridiculous to even say such a thing, especially when a fine gentleman and aviator lost his life during this mercy mission.

People like you who pontificate on PPRuNe about things you know nothing about really p*ss me off.... :mad:

11th Nov 2006, 13:25
Thank you for that !

There are lots of you here who are instant experts !

I'll say it again........It is not and never has been a 'difficult approach' as you call it !

It's a straightforward procedure turn at a dme dist. to intercept a radial inbound.

Also what is is you don't 'agree' with in the AAIB report ?

God,you've got a brass neck !


11th Nov 2006, 13:49
It is not and never has been a 'difficult approach' as you call it !

I did not say it was a difficult approach....:rolleyes:

What I said was:

The report states that the Pilot would be in a situation of high workload, increased somewhat by the weather, and because it was in darkness, therefore difficult.

You introduced the word 'difficult' in that you said the approach 'was not difficult'. I stated that the approach was difficult when taken in view of the other factors. The report does state this, adding the word 'difficult' I just tried to make you see that you were wrong. If you cannot accept that, fair enough, but you are quite wrong.

11th Nov 2006, 14:00
The then operator of the Scottish Air Ambulance always found it difficult to recruit people to the Islander operation largely due to the pathetic rates of pay which didn't reflect the necessity for superior basic flying skills and to compensate for the fact the fact that flying the Islander wasn't the ideal path to the left or right seat of a shiny jet.

The operation was always treated too casually although it generated proportionally more(?) incidents over the years than any other UK (or European ?) civil operation. IMHO there is no way that the pilot should have been allowed to operate after 30+ days off and a quick circuit. As it was I don't suppose he had a choice.

11th Nov 2006, 14:18
I don't know the guys involved. I have no axe to grind. I did spend 5 years flying the BN2 for Logy, and I'm afraid I would have to say Machrihanish was very routine. It was a very very common callout, and a simple procedure. Now if you know the job, you know about night Barras, night Islays, or night Orkneys or Shetland (Foula omigod!!!!!) where things were very different. Just like pickups from, say Dundee or Perth in the middle of the night and a long haaul down to BHX or CAM to get to a transplant hospital. Single pilot all that way, and back, IFR/IMC, hmmmm, not a career choice, and hence the turnover. I'm not trying to judge anything, just to agree that to lose three hulls with those fatalities HAS to say something about the operator, and possibly its oversight of training and experience on the job.

11th Nov 2006, 14:51
Ironically this operator was mentioned in the House of Commons Transport Commitee report on the work of the CAA. Read appendix 39 of the report.

Report available here http://www.publications.parliament.uk/pa/cm200506/cmselect/cmtran/809/809.pdf

11th Nov 2006, 14:52
That was a well judged post Cornflake. I flew the BN2 for LC as well and remember at least 3 hull losses and I don't know how many lives also numerous "dings and scratches". I remember one period when we seemed to feature almost monthly in the accident digests. The question is.. Where was the CAA in all of this.

11th Nov 2006, 15:07
I've just followed the link to that Transport Committee report, that appendix is rather interesting reading. I'm glad I don't work for LC anymore, but I'm astonished that they got away with that one. Not much justice there, and as for overuling Huz - no wonder he left. You would think things like this could not happen, I also note the references to Scotty, can't say I'm surprised there, I'll just bet he 'couldn't recollect!":hmm: It all goes to show you can't trust anyone but yourself.
However, with ref the fatal accident discussed in this thread, the VOR and the flightpath make rather interesting reading - objectively speaking - as does the track of the procedure.

11th Nov 2006, 15:30
I've just followed the link to that Transport Committee report, that appendix is rather interesting reading. I'm glad I don't work for LC anymore

Something of an undersatement.

I like the bit where it says There had been no AAIB investigation because this occurrence had not been reported to them

Well thats alright then!

11th Nov 2006, 15:55
Anyone help out here.. ?
Although I can get to the Face page of the report, when trying to access any of the sub categories the whole thing jams up... Having spent a few years driving turbo-props around up there I have the greatest respect for anyone flying BN2's around single crew on short notice medivac ops 12 months of the year...
Would be intersted to know what sort of experience level the pilot had.. and was icing firmly discounted as a possible contributing factor in the report ?

Mr Moustache
12th Nov 2006, 14:00
The report makes for some sober reading.
As an ex-LC amb pilot, I was once in a similiar position. I came back off leave to find myself out of 28 day currency/recency. I advised Ops and was told to come in slighty early for my afternoon airport standby and get myself current again. I told them that I would fly over to Cumbernauld, do a couple of circuits than come back to GLA for an ILS. This was agreed to without hestitation.

To be out of currency at the start of night standby is not smart. Generally you only got called out from night standby if there was an element of urgency about it and that puts pressure on you. To have to get current first probably put him in the position of doing the dead minimum. One visual night circuit at GLA in heavy rain is not enough to get happy again after 32 days without flying. Add the fact that he had been up 17 hours at the start of the approach and you have someone not able to give of their best. Add some serious IMC (low cloud) and things are stacking up.

I shall take his death (and that of his crew, the paramedic) as a reminder about the effects of fatigue. Sad though.

14th Nov 2006, 02:15
Where in the report is LC mentioned? Stuffed if I can find it.

14th Nov 2006, 14:26
Pages 357 to 363 (appendix 39)of the Transport report make interesting reading!
All very sad!

John Farley
15th Nov 2006, 07:14

Logonair is mentioned in Page 360 penultimate para and note 51 on the same page


15th Nov 2006, 13:49
Thank you. Found it now.

18th Nov 2006, 23:03
'Appendix 39' also here, on it's own web page:


Xploy Ted
20th Nov 2006, 17:02
What a very sad story and a preventable one too. Anyone who has done this type of work, will know only too well how easy it would be to get it wrong in the circumstances experienced by this guy.

The AAIB also clearly know it too yet see how reluctant the CAA is to take the obvious and recommended (2 crew) action. Because it is "only" a small aeroplane and 2 people, the tragedy recieves little public attention, in spite of the fact that it is the same regulator who deals with the larger operators.

The operator should not escape responsibility as cannot operators of lager aircraft who get away with rule abuse, entirely due to many factors we all know well enough.

Wake up CAA & stop letting the driver take the blame.

1st Dec 2006, 04:05
G-BOMG crashed into the sea during a non-precision night approach to Campbelltown, Ayrshire, Scotland.
Within their Accident Report narrative the UK AAIB examined all possibilities but then in the analysis, conclusions and findings, proceeded to fail to mention the most likely cause (IMHO) - which they themselves had raised as a probability in their own precursor deliberations.
I find this omission exceeding strange and an illogical non-sequitur.
It's discussed here (http://www.iasa-intl.com/folders/belfast/G-BOMG/G-BOMG_comments.htm) ( http://tinyurl.com/y9mo2e )
and there's also a link to the report.
Possible explanations would be welcome.

Human Factor
1st Dec 2006, 09:54
Whether or not it turned out to be a factor in this case, I'm of the opinion that you will almost certainly never see the "F word" written in a UK commercial accident report.

The main reason being that as all UK operators are supposed to operate in accordance with CAP371 or a similar approved FTL scheme, which has been "scientifically" tested, any indication of fatigue as a causual factor would indicate that either CAP371 or the "Scheme" is flawed or that the company in question had been operating outside the "Scheme" or the spirit of it, in which case the Ops Inspectorate is flawed.

Just a thought.

1st Dec 2006, 10:23
Just being pedantic but Campbeltown is not in Ayrshire, it's in Kintyre. Just a thought when the report contains a simple innacuracy like this.

1st Dec 2006, 10:28
"The main reason being that as all UK operators are supposed to operate in accordance with CAP371 or a similar approved FTL scheme,.........."

Should read ".......are supposed to operate within the SPIRIT of CAP371........"

That has never been policed by the very organisation that wrote it, but has always been used as their 'get out' clause from doing anything. Imagine the chaos if the social legal system relied mostly on the good will and self discipline of the general public to uphold the law. No police force. It would be fun for a while, but then......? This abuse of the system has been going on for 30 years and getting worse.

1st Dec 2006, 18:29
I think I agree with theShadow, having looked at his link.
The AAIB Report introduced not the possibility of carby icing but the probability of it - and then went on to ignore it in their further analysis and findings.
That seems to be puzzling at least. Perhaps BN2 operators MEEB and CORNFLAKE could comment after looking at theShadow's post and link.
The cause of this ditching is also possibly due to carburettor icing. This claims many pilots who just tend to forget about it (carby heat). The conditions certainly demanded it - but it wasn't being used. That type of icing can be insidious (the power simply not being there when you go for it).The possibility of carby ice affecting both engines equally and simultaneously is very high.
The thing to remember is that if the conditions are conducive to carby ice forming, it WILL form in the carby throat. The only question is then whether enough will form to choke the gas flow and affect the engine's power output. In a low power descent Instrument Approach you're not likely to find out until you go to apply power. The surprise factor is then going to make carby icing possibly the last thing that you think of.
The other nasty aspect of carby icing is that by the time you get the symptoms (usually of power loss or failure to increase power on demand) it's too late. Why? because the engine by then isn't capable of generating sufficient heat fast enough to melt the icing build-up. A selection of HOT immediately after becoming aware of carby icing can also lead to a rich cut if the throttle is anyways OPEN (Ice dislodges and blocks all airflow past the venturi throat).
Although the report canvasses the possibility of carby icing, it's also given it insufficient analysis (i.e. no mention at all) as a probable cause.
Almost unbelievably there's nothing whatsoever in the findings or causal factors about the possibility of carby icing having knocked out any power re-application from either engine. A double engine failure from carby icing is certainly a possibility. The engine doesn't really "fail" as such. It keeps running at low power but fails to produce any power on demand. I've seen that a number of times after a protracted descent in very humid conditions on a piston-powered machine without fuel injection.
The crash position was around about where the pilot would have been going for power in the conditions (i.e. he needed a break-out of cloud at around 1000ft to be able to legally circle for r/way 25 - his expressed intention.). So he needed to level off at 1000ft and drive in. That's about when he would've found the power on demand just wasn't there. At that point he'd have been checking fuel and even if he had thought of carby icing as a cause, it wouldn't have made any difference at that late stage.

John Farley
1st Dec 2006, 20:02
Carb icing could well have been a distracting event in the overall process but the state of the wreckage does indicate a crash into the sea rather than a controlled ditching because there was not enough power to maintain height.

2nd Dec 2006, 03:46
pg 45 (53 of 81)
Don't agree John. Last sentence below reads:
"Overall the impact damage and consequent breakup is consistent with a controlled flight into the sea at or close to a normal descent rate and speed."
I think the AAIB uncharacteristically blew it on this one.

2nd Dec 2006, 06:31
From the Report
The Report says that "neither carburettor heat selector was set to HOT"
These are gated controls (not likely to move during the accident).

John Farley
2nd Dec 2006, 10:53
Point taken Shadow and I would not argue against your view. I just interpret the same words a little differently. My reading of them is that the aircraft was under control etc and doing the sort of manoeuvre to be expected at that inbound stage of the flight but at the wrong height. That to my mind is not quite the same thing as what it would have been doing if Guy was afraid of hitting the water (seen the altimeter at the last moment) or realised he had no choice but to land on the water (lack of power).

I am sure anybody who has real experience of flying at night single crew in the very special true darkness that exists low over the water knows how little it takes to distract one from the altimeter for those few seconds that are sadly all it takes. As to what the distraction might have been - well the list is bordering on endless.

4th Dec 2006, 07:03
It can all happen very quickly and confusingly
Meanwhile, the four student pilots on the plane forced to make an emergency landing in Hawke's Bay yesterday, 02 Dec 06, were unaware they were in danger.
Their six-seater Partenavia P68B plane ZK-LAL suffered a double engine failure, forcing their instructor to make an emergency landing in a small field about midday.
Instructor Ravindrah Singh said the students thought they were being tested on emergency procedures until the plane hit the ground.
"That's the time they realised it was the real thing."
The private students from the Manawatu Aero Club were returning to Palmerston North from Napier when their first engine failed about 760m above Takapau.
While running through emergency procedures, the second engine failed and Singh took over the controls to make the landing.
Singh said the students were in good spirits and the incident had been good for their emergency training.

4th Dec 2006, 09:26
Shows how much I know, I always thought the Islander had injected engines with no carb heat, only alternate air. Oh well. I wouldn't have thought the carb heat control positions were that significant anyway; from what little I know the system is designed for periodic use so could have been recently used and switched off. I flew with Guy on the Saab a couple of times and from what I saw wouldn't have thought that icing conditions would have been anything other than routine for him, unlikely even to have provided a distraction.

Capt Snooze
4th Dec 2006, 10:21

From memory, the Partenavia came standard with injected engines. Was this one modified?

Of course my memory could be failing..............................


4th Dec 2006, 14:37
I only flew the Partenavia a few times, but on my conversion, by Pete Green, was told it was the air intakes that blocked, VERY quickly.

I've not flown the Islander, but did a year on the Trislander, and there the carb heat levers were at the bottom on the throttle pedestal, awkard inconvenient and invisible.

4th Dec 2006, 15:08
The BN2s used by LC were all carburetted with manual carb heat. Carb icing was so common it soon became routine select it on every 5 - 10 mins in cruise and for every power reduction - sometimes even at climb power. It became as automatic an action as changing power by using the throttle or leaning using the mixture control.

Ambulance 'Charlie Alpha'
5th Dec 2006, 11:40
1) The Islanders still used today by Loganair are carb'ed. Don't quite see the problem really. Do you really think that we ambulance drivers would've been taken by surprise with sudden carb icing....in Scotland....in the winter!? The levers are below the flap switch on the centre console. They're not hard to find, even with your eyes shut. As others have said, flying with your hands permanently fixed to the levers was common place and not something that would cause a distraction. It was when there was no carb icing that you didn't quite know what to do with the spare hand.

2) Flying a non-precision approach in the BN2 was not an issue either, especially with the 3-axis autopilot taking the workload off when IMC.

3) It has been mentioned about flying 120 kts down the approach in the same chat about possible carb icing and engine power loss. Do you know how much engine power the BN2 requires to be 'driven' down the approach at that speed? If it really was maintaining the slope and correct attitude at that speed to the water, then it would have been under power, not power loss. It isn't exactly a slick aerodynamic machine.

Cheers ACA

Xploy Ted
5th Dec 2006, 12:49
A freind of mine & his passengers all died in a Partenavia in very similar cicumstances to this one. Night approach over water and no carb heat selected. The engines stopped at low level on an SRA and in they went.

As a previous poster said, the aircraft was known for rapid ice build up in these circs.

Capt Snooze
5th Dec 2006, 15:33
At the risk of further thread drift........................

The discussion at this point centers around the possibility or probability of carburettor icing as a factor in the Islander accident. The Islander came equipped with either 260 hp carburetted engines, or 300 hp injected engines (or Allison 350 turbines), and apparently this one was carburetted.

In support of the carby ice possibility, two Partenavia apparent double engine failures have been cited as due to carby ice.

The P68B, P68C and P68 Observer aircraft were delivered with Lycoming IO-360 engines. Note the 'IO'. That's injected, not carburetted. The P68TC featured a turbocharged, injected engine from the same manufacturer. Various other engine / airframe combinations were mooted or marketted, but without much success. Before anyone asks, the P68A refers to the several pre-production aircraft.

Another poster has observed that during his conversion onto the Partenavia, he was advised that the (cooling) air intakes (located on the front of the engine cowling) were very prone to blocking with ice. This may or may not be so, but is in any case irrelevant to the Islander discussion, with different engines and cowls, and it's not carby icing.

The standard Partenavia, as delivered, does not suffer from carburettor icing. It doesn't have carburettors! (or carby heat, or carby heat selectors )-: )

Xploy Ted,
I'm sorry to hear that your friend and his passengers perished in a Partenavia accident. Like most light twins, it is not a forgiving aircraft to operate in adverse conditions. You can be assured though, that their demise was not due to his error in not selecting carby heat.

Now, can we get back to discussing Islanders please!

The Rage
5th Dec 2006, 15:49
Put it to rest gentlemen,

Its sometimes not very nice to say that he should have done this or that, they are gone and their loved ones could be reading this. How would they feel? I knew Guy in training school, so maybe this might be a bit of an emmotional post. Let them rest in peace.

Xploy Ted
5th Dec 2006, 15:49
Thanks for that feedback. It was a long while ago, so my memory may be in error. However, I have the report somewhere & will just check.

I take your point about differing types but the thread is seeking an explanation for a piston twin hitting the water unexpectedly, during approach. If the engines stopped, that would do it no?

Anyhow, I bow to your superior knowledge, I've never flown a either type.

White Knight
5th Dec 2006, 17:49
Sorry "the rage" - but if discussion on a forum such as this prevents a similar accident then let everyone speak freely. We've all lost friends in air accidents - but that my dear chap is the way the world turns...

5th Dec 2006, 21:34
Sorry white knight but if you have to rely on a forum like this to appreciate and understand carb icing then you should not be flying the beast concerned.
Please have a regard for the deceased's relatives and friends.
Thats all that is being asked!