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Pittsextra
13th Jan 2014, 13:14
Oi oi thanks for the little tickle... come on lets not turn another thread into a big old moan up.

As to the previous decisions not to prosecute, they were of course made by parties who were close to the events, or based on their reports, and perhaps might be considered to be not totally impartial as a result. Whereas the FAI should be totally impartial with no internal axe to grind. It will be a good thing, albeit rather late as you and others have said.

Surely the decision to prosecute or not comes from the Crown and should be absolutely impartial?

HeliComparator
13th Jan 2014, 13:21
Surely the decision to prosecute or not comes from the Crown and should be absolutely impartial?

The decision to prosecute or not does come from the crown (Procurator Fiscal in Scotland I think) but has to be based on the available evidence. When most of the evidence comes from an interested party (CAA) then ultimately how impartial can it possibly be?

For example, I would say the CAA has a degree of culpability for not requiring hums to be downloaded and processed prior to the next flight, especially when some operators did that anyway (and therefore it was demonstrably not onerous). So the whole area of HUMS downloading, processing and acting on the results, which was a major factor in this accident, might get a light touch in a report from a CAA who realise they are implicated.

Pittsextra
13th Jan 2014, 13:46
The decision to prosecute or not does come from the crown (Procurator Fiscal in Scotland I think) but has to be based on the available evidence. When most of the evidence comes from an interested party (CAA) then ultimately how impartial can it possibly be?


OK but when the meat of the analysis is available for all and sundry via the AAIB how does the CAA steam roller things?

For example, I would say the CAA has a degree of culpability for not requiring hums to be downloaded and processed prior to the next flight, especially when some operators did that anyway (and therefore it was demonstrably not onerous). So the whole area of HUMS downloading, processing and acting on the results, which was a major factor in this accident, might get a light touch in a report from a CAA who realise they are implicated.

Surely anyone acting for the CAA just points to the manufacturer and says they were advised appropriately? Going further with regards to best practice how do we view the in flight data that forms part of the interim fix for EC225 in terms of being retained going forwards?

HeliComparator
13th Jan 2014, 20:18
OK but when the meat of the analysis is available for all and sundry via the AAIB how does the CAA steam roller things?

Surely anyone acting for the CAA just points to the manufacturer and says they were advised appropriately? Going further with regards to best practice how do we view the in flight data that forms part of the interim fix for EC225 in terms of being retained going forwards?

The AAIB are always careful not to attribute blame. Their remit is to find out what happened and why, not to try to apportion blame.

The manufacturer does not require hums use at all - it is a bolt-on extra as far as they are concerned. The requirement for hums came originally from the industry, adopted by CAA and finally adopted rather weakly by EASA. If you look at the document setting out how to use HUMS etc - CAA's CAP753 - it is rather weak in some areas, certainly in the area about data download frequency.

Regarding your last sentence, sorry I am unable to comment or answer any sentences that includes the phrase "going forwards" because my mind becomes bogged down with the other possibilities such as "going backwards" or "going sideways". If you would like to resubmit your query using English, I will try to respond to it.

jimf671
13th Jan 2014, 20:28
... ... surely digging out the facts ...

Facts? Oh dear! What a disturbing concept.


The objective of obtaining a prosecution, an adversarial court procedure and related constraints of rules of evidence mean that this is not the same as finding the truth about an event or preventing a re-occurrence.


Tonight's homework.
http://www.copfs.gov.uk/images/Documents/Prosecution_Policy_Guidance/Prosecution20Code20_Final20180412__1.pdf

Pittsextra
13th Jan 2014, 21:14
The AAIB are always careful not to attribute blame. Their remit is to find out what happened and why, not to try to apportion blame.

Sure. So how have the CAA distorted the AAIB's reports and become impartial?


The manufacturer does not require hums use at all - it is a bolt-on extra as far as they are concerned. The requirement for hums came originally from the industry, adopted by CAA and finally adopted rather weakly by EASA. If you look at the document setting out how to use HUMS etc - CAA's CAP753 - it is rather weak in some areas, certainly in the area about data download frequency.

Yes although I'm not sure how HUMS becomes more rigidly regulated and certainly given the time that has passed it doesn't seem that even the industry can find something better. Lets be frank this isn't new, the AAIB report on the accident contained a great many safety recommendations and yet how much traction has been made?


Regarding your last sentence, sorry I am unable to comment or answer any sentences that includes the phrase "going forwards" because my mind becomes bogged down with the other possibilities such as "going backwards" or "going sideways". If you would like to resubmit your query using English, I will try to respond to it.

Dear oh dear. I'm just curious with the attitude that you seemed to take when you said:-

I would say the CAA has a degree of culpability for not requiring hums to be downloaded and processed prior to the next flight, especially when some operators did that anyway (and therefore it was demonstrably not onerous). So the whole area of HUMS downloading, processing and acting on the results, which was a major factor in this accident, might get a light touch in a report from a CAA who realise they are implicated.

Firstly why single out the CAA? Why not comment about other factors? I mean you might include the manufacturer not supporting spectrometric analysis of the gearbox oil, for example.

My comment on the interim fix for EC225 is that, one assumes, at some point inspection frequency will reduce and HUMS downloads more relaxed, yet what makes the relaxation of those measures any different?? In fact if you want to take it further who and what validates the certification that requires failure modes to be extremely remote or extremely improbable?

Seems to me that there is some cherry picking around what level of rigour you want.

Pittsextra
13th Jan 2014, 21:39
The objective of obtaining a prosecution, an adversarial court procedure and related constraints of rules of evidence mean that this is not the same as finding the truth about an event or preventing a re-occurrence.

Crikey that suggests non-pilots might be required to take a view.

HeliComparator
13th Jan 2014, 21:48
You are doing your usual scatter-gun impression. Due perhaps not to malice, but to not understanding where the various bodies fit into the big picture.

Have we seen the CAA report you mention? Not sure I have, only the AAIB one. Therefore the CAA report may or may not be entirely impartial but of course it was addressing a completely different area from the AAIB one - ie have any laws been broken which should result in a prosecution. Since as I said the CAA are very close to the issues and have vested interest, complete impartiality should not be assumed without checking.

Why single out the CAA / Hums? Well it was just in response to your previous post, giving an example of where there might be vested interest, hence lack of impartiality. Of course there are other factors and parties.

Regarding any relaxation of HUMS download frequency, I think finally everyone has got the message and I very much doubt there will be move back to a rather lackadaisical approach to downloading the data (from some operators). Hopefully an outcome of CAA's own report into N Sea heli safety will include a strengthening of CAP753 in this area (amongst others). There may even be sufficient pressure on the manufacturer to mod the L2 hums so as to allow hums download during rotors running turnarounds. Or I suppose to ban rotors running turnarounds at base, for aircraft that can't do a RRTR download.

HeliComparator
13th Jan 2014, 22:42
By the way, whilst I am lobbing a few grenades around, does anyone think there is any prospect of "the authority" - aka CAA and EASA - finally working out that oversight of maintenance organisations based solely on looking at bits of paper, is fundamentally flawed? (And lazy and pointless)

There is far too much emphasis placed on the paper trail and waffly bits of writing, instead of looking at the fundamental engineering practices of an organisation. A CAA surveyor coming to grant a Certificate of Airworthiness, or to carry out an audit, spends 99% of time trying to pick holes in the paperwork and 1% actually looking at the aircraft - he certainly doesn't have time to actually open the cowlings and look inside!

When was the last time they said "Oy that wire locking is pants", "Get that dirty oily transmission deck cleaned up" or "why is the erosion strip on that blade worn through and patched up with araldite" etc. or whatever it is that engineering chaps should be talking about!

SASless
13th Jan 2014, 22:57
HC,

Where is it the CAA's job to "inspect" the aircraft itself?

The Operator is supposed to conduct all engineering within established guidelines and procedures. Surely the CAA only has to make sure all the Pubs are current, SOP's and Engineering Practices conform to those standards.

The cannot be expected to actually open a Cowling or stand by and actually watch Engineers plying their trade.....that would take them away from their subsidized lunches and paid exercise hours.....and add to their Dry Cleaning bill should they get grease stains on their fine Attire.

Plus.....do the CAA Engineering Inspectors actually know what a helicopter looks like except in photographs and drawings?

There was an Operator down in the Gulf of Mexico that was well known to use Time Ex Parts and other discarded components from other Operators.

Even the FAA caught with him but it was only after many tens of years.

How many Operators have the CAA shut down based upon catching them in the act of doing wrong?

However.....if you think about what you are saying.....be careful what you wish for....you may just get it.

Pittsextra
14th Jan 2014, 08:24
HC - Lets just pause for a minute because I'm not trying to pick a fight, which is something that seems all too easy to find.

My initial post was simply to ask what the point of the FAI was given the work already done and published on the Crown timeline.

The salient point being "Crown Counsel consider HSD report (which in itself has been produced after circa a years worth of investigation/review with AAIB, CAA and Police). Crown Counsel Instruct that there are to be no criminal proceedings."

All I suggested was why not simply report the findings that led to that decision that was taken 1 year ago?

I've never claimed I've seen any CAA report but:-

"19 December 2012 – Meeting involving Grampian Police, COPFSCrown Office and Procurator Fiscal Service (http://www.copfs.gov.uk/component/glossary/COPFS-1/C/COPFS-7/)and CAA to discuss the Report."

So when you say:-

. Since as I said the CAA are very close to the issues and have vested interest, complete impartiality should not be assumed without checking.


The AAIB report was available from Nov 2011 so anyone who was interested had a year to look at the detail and in fact if you read the timeline from the Crown a body of work was undertaken :-

December 2011 – December 2012 - Grampian Police under the direction of the Health & Safety Division carried out further enquiries including liaison with AAIB to secure evidential statements relating to their report.

I think finally everyone has got the message and I very much doubt there will be move back to a rather lackadaisical approach to downloading the data (from some operators).

An ATPL with 2575 hours total time and 1870 on type signed and flew off in REDL and was working with one of the " from some operators". So what made him ignore everything that you seem to suggest was obvious?

You might well be right when you say I don't understand the north sea helicopter industry but then I don't work in it. Some of you do, so what has changed and when?

terminus mos
14th Jan 2014, 08:58
When was the last time they said "Oy that wire locking is pants", "Get that dirty oily transmission deck cleaned up" or "why is the erosion strip on that blade worn through and patched up with araldite" etc. or whatever it is that engineering chaps should be talking about!

Agreed HC, that's why the industry needs oversight from its main customers' own highly experienced experts. Now that helicopter companies are run by accountants and not real helicopter people with knowledge and pride in their fleet, corners will be cut where a $ can be saved.

HeliComparator
14th Jan 2014, 09:25
Agreed HC, that's why the industry needs oversight from its main customers' own highly experienced experts.

Ha Ha, good one son of Shell Management!

HeliComparator
14th Jan 2014, 09:47
Pitts, I know you are not trying to pick a fight, but as an outsider without an understanding of the industry, you are quite a demanding poster, asking questions and posing thoughts seemingly at random without much structure. It makes your posts very hard to answer, and every time I answer I know for certain that it will result in another round of random points and questions. Which is another way of saying you are high maintenance!


Since there is not a clear thread in your last post to respond to, I shall have to resort to the red writing within the post



My initial post was simply to ask what the point of the FAI was given the work already done and published on the Crown timeline.


As said before, the point of the FAI is that it is enshrined in Scottish law for any fatal accident in a workplace (amongst other things). It is not specifically to do with aviation. Whether or not you, or I, see any point to it is irrelevant.

The salient point being "Crown Counsel consider HSD report (which in itself has been produced after circa a years worth of investigation/review with AAIB, CAA and Police). Crown Counsel Instruct that there are to be no criminal proceedings."

All I suggested was why not simply report the findings that led to that decision that was taken 1 year ago?


AAIB report - what happened and why, but not who was to blame.


CAA report and PF decision whether to prosecute - have any laws been broken that should, in the public interest, result in a prosecution?


FAI - totally independent and wider ranging enquiry giving, amongst other things, an opportunity for the relatives to better understand why their loved ones didn't come home. The output from the FAI is: a) time and place of the death; b) the cause of death; c) any precautions which may have avoided the death; d) any defects in the system of working which may have avoided the death, and; e) any other relevant considerations.


So it is fully independent and not clouded by the familiarity with the industry and possible vested interests that other parties could have.


I've never claimed I've seen any CAA report but:-

"19 December 2012 – Meeting involving Grampian Police, COPFSCrown Office and Procurator Fiscal Service (http://www.copfs.gov.uk/component/glossary/COPFS-1/C/COPFS-7/)and CAA to discuss the Report."

So when you say:-



The AAIB report was available from Nov 2011 so anyone who was interested had a year to look at the detail and in fact if you read the timeline from the Crown a body of work was undertaken :-

December 2011 – December 2012 - Grampian Police under the direction of the Health & Safety Division carried out further enquiries including liaison with AAIB to secure evidential statements relating to their report.



An ATPL with 2575 hours total time and 1870 on type signed and flew off in REDL and was working with one of the " from some operators". So what made him ignore everything that you seem to suggest was obvious?


A pilot is the product of his environment - training and company culture. If you came from puddle jumper basic training, joined one of the few helicopter operators to have HUMS infrastructure, it is pretty inevitable that you will become accustomed to the way things are done there. You will be quite happy that the HUMS data is only downloaded once a day or whatever, because you don't know any better and anyway it is all engineering gobbledygook that you don't really understand. So I don't think you can attribute one iota of blame to the pilot for accepting the aircraft, just as he and all his colleagues had always done.


You might well be right when you say I don't understand the north sea helicopter industry but then I don't work in it. Some of you do, so what has changed and when?

Pittsextra
14th Jan 2014, 10:21
Enquiring as to what the point of the FAI is and saying that there is no point to it are two totally different things - I asked what the point of it was. Its answered and the FAI is happening, lets see what it reports and leave it there shall we?

Regarding the pilots there is of course a common element that binds everything together and that perhaps is the manufacturer and one might imagine that at some point the manufacturer sees how each operator...operates? Perhaps things even get discussed in the helicopter safety group?

Since the accident report on REDL came out in 2011 what has that group and/or the manufacturer done to ensure best practice around HUMS? [note its a question - I've no idea either way - there might have been heaps, there might have been nothing]

jimf671
13th Mar 2014, 10:48
UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976

IN THE SHERIFFDOM OF GRAMPIAN, HIGHLAND AND ISLANDS AT ABERDEEN

FATAL ACCIDENT INQUIRY

INTO THE DEATHS OF JOHN BRIAN HUGH BARKLEY, PAUL STEPHEN BURNHAM, JAMES ANTAL REAMONN STEPHEN COSTELLO, ALEXANDER GORDON DALLAS, RAYMOND STEELE DOYLE, JAMES JOHN EDWARDS, VERNON JOHN ELRICK, NAIRN JAMES FERRIER, NOLAN CARL GOBLE, GARETH WYN HUGHES, RICHARD ANTHONY MENZIES, WARREN GEORGE MITCHELL, DAVID JOHN RAE, LESLIE STANLEY TAYLOR, STUART LEE WOOD AND MIHAILS ZURAVSKIS

DETERMINATION
by
SHERIFF PRINCIPAL DEREK C W PYLE (http://www.scotcourts.gov.uk/opinions/2014FAI5.html)

Thomas coupling
13th Mar 2014, 11:18
Almost 5 years has passed since this awful tragedy. I presume the maintenance organisation responsible for the upkeep of this a/c have already made amends to ensure the same swiss cheese doesn't happen again.
Onbly time will telll - but a damming report nonetheless. RIP.

FrustratedFormerFlie
13th Mar 2014, 12:13
John 8 v7: "He that is without sin among you, let him first cast a stone"

There is no 'smoking gun', but there remain 16 innocent souls departed.

That fact, more than this finding, is what should give everyone in the industry pause for thought - again.

And tomorrow is the 22nd anniversary of the Cormorant A crash, in which 11 people were lost

HeliComparator
13th Mar 2014, 12:50
It's the first FAI determination I have read, but I though it was well written, clear and logical.

tyreschredder
13th Mar 2014, 19:32
Like many this is the first FAI report I have read and it was very moving .
I am surprised there is so little criticism of the helicopter manufacturer but like every one else I hope that lessons will be learned by all .

Mel Effluent
14th Mar 2014, 08:44
I agree that the report was thoughtful and accurate. The Procurator Fiscal worded his conclusions very carefully and I am disappointed, but not surprised, that the media interpreted his conclusion that:

It is possible that if the following failures by Bond had not occurred the accident might have been avoided:

as a direct causal link between those omissions and the accident. This does no-one any favours.

FrustratedFormerFlie
14th Mar 2014, 10:28
Mel Effluent
Agreed. The FAI is very circumspect. IF these actions had been taken, or taken differently, and IF a whole nother set of holes had lined up in the Swiss cheese, then its is POSSIBLE (not certain or even probable) that these actions MIGHT (not would) have produced a different outcome.
Thats a long way from the press headlines 'accident could have been prevented'.
The media reporting is, of course, intended to hound the companies and managements involved - and to prolong the story.
But its single greatest effect is to prolong the agony for the bereaved families.
If there is one thing the FAI makes plain it is that there is no single action, individual or business upon which this tragedy can be blamed. For the media, or ambulance-chasing lawyers, or anyone else to try to tell the families otherwise is to heap new cruelty on their enduring suffering.
And before anyone leaps to another wrong conclusion, I have no professional connection to the manufacturer, operator or other such interested party. My profesional involvement these days is all with people who fly as pax on these aircraft.
The offshore, aviation and wider Scottish comunities responded with great dignity to the loss of 85N. It would be best for everyone if we accept the Sherrif Principal's findings that 'there is no smoking gun' with more of that same dignity. And then go back to the continuing, meticulous, unexciting business - away from the media spotlight - of making offshore helicopter operations ever safer

Harry O
28th Jul 2014, 21:10
A helicopter crash which killed its co-pilot and 15 other men could have been prevented, an inquest has found.
Richard Menzies, 24, from Droitwich Spa, was on board the Bond Super Puma when it crashed into the North Sea, killing all those on board.
Worcestershire Coroner Geraint Williams said the April 2009 crash, off Peterhead, came after a "catastrophic" gearbox failure.
He echoed an earlier inquiry which found proper checks were not performed.
'Significant fault'
Returning a narrative verdict, Mr Williams identified "a number of failures" in the helicopter's maintenance programme.
Full verdict below.
BBC News - Super Puma co-pilot death 'preventable', says coroner (http://www.bbc.co.uk/news/uk-england-hereford-worcester-28464287)

AnFI
29th Jul 2014, 18:48
The evidence did not state that there is greater proportional risk from gearboxes in a multi engined helicopter.

Jarvis:
During the course of his evidence, I asked Mr Jarvis if he thought there was something inherently more dangerous in helicopters compared to other aircraft. He replied as follows[48]:
"It's a function of the design of helicopters, my Lord, in that rotory wing aircraft, helicopters, essentially have a critical load path through the gearbox to the rotor. Fixed wing aircraft can have - fixed wing aircraft fly by means of structure which can be made inherently fail-safe. Helicopters fly by means of a mechanism which is a mechanical unit and is thereby potentially more prone to failure and that really is the issue between fixed wing and rotary wing aircraft, my Lord. One flies by means of a mechanism; the other flies by means of its structure and that gives you different levels of achievability in terms of safety and redundancy."
(my underline, gotta love the statement: helicopters fly by means of a mechanism. (anyway helicopters use wings in tension whereas aeroplanes use wings in sheer.))



So:
Section 6(1)(d) - The defects, if any, in any system of working which contributed to the deaths or the accident resulting in the deaths
On the evidence, no such defects exist.



... but then they didn't consider that where a highly complex gearbox is required there is an increased inherent risk.

That's how many gearbox fatals in twins now? (Less engine fatals more 'other systems' fatals instead - obvious no?)

Blackadder: The proportion of mechanical failures is too high!
Baldrick: Let's increase the pilot-error rate then !

212man
29th Jul 2014, 19:46
Mmmm, trying to work out how to reply without an instant ban..:ugh::ugh::ugh: GFY isn't really close enough...