UK AAIB Oct 2012

[VeeAny]

HA-LFB Gazelle, 8 March 2011, Honister, Cumbria, UK

Aircraft crashed at night in poor weather, pilot was not night qualified.

http://www.aaib.gov.uk/cms_resources.cfm?file=/Aerospatiale%20SA.341G%20Gazelle%20HA-LFB%2010-12.pdf

[Geoffersincornwall]

If this is what is happening in the relatively strict EASA environment then I hate to think what is happening in the dark corners of those parts of the world that are almost devoid of oversight or where corruption dominates.

G. :ugh:

[Vie sans frontieres]

Jaw dropping in virtually every respect.

[Fortyodd2]

Geoffers - spot on. The only good news here is that he didn't take a passenger with him.

[Anthony Supplebottom]

A number of serious airworthiness issues were identified with the helicopter during the course of the investigation. None of these issues could be directly linked to the cause of the accident, but did raise concerns regarding the way the helicopter was operated. Given the number, complexity and severity of the issues found and the fact that they are common to a number of other fatal accident investigations conducted on foreign-registered aircraft in the UK, they will be covered in detail in a separate Safety Study report.

Does this mean the CAA might take another look at foreign-registered private helis. What are the benefits of an "HA" registration anyway?

[Cylinder Head]

Tragic and so avoidable. We don't know if the pilot had any night training but its likely he didn't. The main things you learn during Night Qualification training is how much you don't know and why its better not to do it as a PPL. I recommend to all PPL's that they get some night flying experience with a qualified instructor in a controlled environment. They soon realise that its not a good idea and whilst its an awesome experience, it must never be taken lightly. If combined with bad weather, challenging terrain and a lack of preparation, its a recipe for an AAIB bulletin.

Take heed guys, learn from this tragedy, don't let something similar happen to you.

[jayteeto]

Disagree on the last comment. Night flying is not too dangerous for a ppl. If they do it properly of course.
This chap involved was a larger than life character and a huge thread was on this very site after the accident. A lot of people reading the shocking revelations would say they are not actually shocked. Cowboy stuff like this will ALWAYS catch up on you........ Eventually. Luckily he didnt take a pax with him.

[Cylinder Head]

jayteeto (http://www.pprune.org/members/18938-jayteeto)

I agree whole heartedly that a cowboy attitude will eventually catch people out and that emphasises my point that unless you are properly trained, you don't realise what you don't know.

Incidentally, I did not say that night flying is too dangerous for a PPL, I said that training usually highlights why it generally is not a good idea. Single engine at night tends get more uncomfortable the more you do it.

[jayteeto]

True, I never really trusted the flare we fitted to the Gazelle. One of our QHIs got permission to do a test firing and found it lit up very well........... 200 yards behind the helicopter!

[sycamore]

J-T,nothing wrong with the flare,wrong technique by a QHI ,methinks..

[jetbox 21]

AS, Getting parts for UK civvy Gazelles is getting more & more difficult so registering as HA or YU is one way round this.

[jayteeto]

Technique was by the book............. The book was wrong.
Does the civil world fit flares to single engined helicopters for night flying?

[Old Age Pilot]

HI what did you think. of the plane crash program on ch4.:sad:

Random comment of the day!

[Helinut]

JT,

For SE, earlier "night kits" were as per military: flares.

Subsequently, lots of night kits are extra lights, either broad beam or steerable.

Flares are one-shot. Little or no opportunity to try them out in civi-land. The lights have a wider range of uses (e.g. precautionary landings). My experience is that they only illuminate the ground pretty late in the descent.

[rotorboater]

Surprised he didn't nip to Halfords for a set of spot lights to bolt on his bull bar, they would have been as legal as most of the parts on his machine

[Geoffersincornwall]

The main difficulty with night qualifications is that you have to be careful in what you accept as representing a night environment. A airport training circuit is not likely to be acceptable if it is well lit on a moonlit night with a city in the background. I would think that a Lake District valley on a dark night is about as tough as it gets overland.

G

[RINKER]

I remember when doing night training as a PPL out of Edinburgh airport and my instructor (rightly in my opinion) told me the qualification was not for heading over to the west of Scotland on a very dark night but more as an aid on a good moonlit night for getting back to the airport if a little bit late.
R

[ShyTorque]

If sufficient visual references are available to determine aircraft attitude and position then night VFR is perfectly OK, subject to suitable training and qualification(and always has been, despite the previously obtuse wording of the UK rules, now very recently changed to allow night VFR per se).

However, without those visual references, it's an IMC flight, there are no two ways about it. Flying in any hilly area such as the Lake District is a potentially lethal place to find oneself in inadvertent IMC, especially on a windy, gusty night, as appears to have been the case here.

But deliberately putting oneself in a position where one has no training or qualifications for night flying, let alone for IMC flight, then taking off where the former is a certainty and the latter quite likely, is naivety at best and more like gross stupidity.

Also taking into account the appalling disregard of proper and legal standards of airworthiness and maintenance, regrettably this accident appears not to have been a case of "if", but "when".

I hate accidents like these because it makes Joe Public regard all helicopters as dangerous things. It's actually what some people do with them, or try to do with them, that's dangerous. :(

[Helinut]

For me the other aspect is that he had his car where his helicopter was. Putting it bluntly, he died to save himself a few minutes and/or prove that he could fly in such conditions.

I think we all can warm to risk-takers in business and enterprise. Its just that the consequences of a business failure are bankruptcy: the consequences of dangerous flying are much more serious than that. Someone used to taking risks in business needs to re-calibrate for flying decisions.

[chopjock]

Surprised he didn't nip to Halfords for a set of spot lights to bolt on his bull bar, they would have been as legal as most of the parts on his machine

Just goes to show that having illegal parts do not necessarilly contribute to having an accident. Perhaps if he did fit extra (illegal) lights it might have helped him see where he was going.

[FSXPilot]

His car being there was the thing that most pissed me off reading that report. What an arrogant, idiotic moron! Even if his car hadn't been there he could have phoned someone to give him a lift.

[TRC]

having illegal parts do not necessarilly contribute to having an accident

What are you actually saying here - that it's OK to have bogus, time-x, un-certified (read forged Form 1), etc. parts on a helicopter?

Do tell.....

[fisbangwollop]

FSXPilot

What an arrogant, idiotic moron!


Dont forget some of Mark's family and friends read this...I being one....I find your comments rather distastefull..!!!

[madflyer26]

I agree with FBW, and the fact this chap paid with his life is enough. A lesson to all about the pearls of inclement weather and night flying. Report says all that needs to be said.

MF26

[chopjock]

What are you actually saying here - that it's OK to have bogus, time-x, un-certified (read forged Form 1), etc. parts on a helicopter?

Do tell.....

I didn't say it was ok. time-x parts? I didn't read that in the report.
But this helicopter had an overhauled, uncertified engine fitted which had nothing wrong with it.
None of these issues could be directly linked to the cause of the accident,

I'm sure we all think uncertified parts are dangerous, but actually quite often the part numbers are the same as certified parts costing ten times as much.

The helicopter was obviously signed off by the engineer and was perfectly safe to fly.

Come now, is there really something wrong with the Astazou IIIB?
No, of course not, but the alternative is pay 200K for a IIIA instead?

With crazy rules like this is it any wonder some are tempted to fit perfectly good alternative parts?

[stringfellow]

Il add some context to fishbang wallops comments.

Mark wasnt one to sit in the class room doing endless exams, he would rather be out there doing it. Sure he never did a night rating but flying around the circuit on a cloudless night has little in common with flying through the hills and valleys of the lakes in darkness. Its not something i would do and i don't condone it.. They are indeed character flaws but for every man who scoffs at such a cavalier attitude a hundred loved him for it.

And as for spare parts if a military piece of kit is perfectly serviceable for a fraction of the cost you have to ask why it is illegal?? The military variant of the engine seemed to work just fine, so what's the problem with it?? The answer its illegal just doesn't cut it... who makes these rules that we seem to just take on the chin and pay for?? If they are unsafe then fine that's good enough for me but are they??

The mine mark ran existed right on the line of economic viability and making it pay meant not necessarily cutting corners but constantly asking 'do i really need this....??' We all talk about this qualification and that qualification but mark had no formal qualification in business yet became a millionaire. Lets not talk about this regulation and such and such a thing in easa land.... what mark did in no way reflects what other private owners do he was a complete one off.. there won't be another.

The only thing that puzzles me is that although he was a serial risk taker he took calculated risks.. and there was nothing calculated about the weather that night... it just wasn't even close to being flyable.

[rotorboater]

Stringfellow,
IF you are a pilot & own a machine, expect a visit from the Belgrano:ugh:

[stringfellow]

Good evening rotorboater!!

Well yes i am a pilot but no i don't own a machine. I would dearly love to but don't have the brass!!

What do you mean by the belgrano??

[ShyTorque]

If he was constantly asking about the cost of everything, it must be asked: Did he really need a helicopter?

As the old saying goes, "If you think flight safety is expensive, try having an accident."

[Geoffersincornwall]

There is an old saying that goes:

RULES ARE FOR THE OBEDIENCE OF FOOLS AND THE GUIDANCE OF WISE MEN

Sometimes it's hard to accept that you are in the first category and not the second but there are times when you just have to accept that someone else knows better.

I'm not an engineer but from what I understand bogus parts come in all shapes and sizes:

1. Those that are recycled - serial numbers erased or changed and forged support papers to back it up. Very dangerous as the official life of the component will certainly be exceeded.
2. Parts manufactures in non-approved facilities and given false papers. (I visited Russia recently and they told me they had problems with TR blades being knocked up in small workshops in Asia)
3. Military parts. Lifed items are particularly vulnerable here and the reason military parts should not be seen as acceptable replacements is because the military use different limitations for their use and this will be reflected in the life it has.
4. Scrap parts being re-used after repair by unqualified or uncertified organisations.

The pilot in this case thought he knew better and paid for his arrogance or ignorance, or both, with his life. We have to be sure that we learn from this and that his loss in some way benefits the pilot/owner community.

G.

[stringfellow]

As usual great comments and a great platform for learning. Thank you.

Let me try and articulate my point a little clearer.
I dont for one second support the risks mr weir routinely took. I dont have the balls, and i don't have the energy to sort out any subsequent problems either. Its not for me.

But.. 1. Please don't discuss this issue like its a problem in the wider aviation community, its not. The way he operated was individually as a complete one off.

2. Does illegal mean unsafe?? if its a safety issue then the law is doing its job and great. If not why is it illegal??

3. And most importantly. Poor decision making killed mr weir, not (as far as the investigation can figure out) mechanical failure.

Its easy to sit and pass judgement. Lets talk about the failings that led to his death and not pillory the individual.

[Whirlygig]

like its a problem in the wider aviation community, its notGiven some comments that I have read in the past, here and elsewhere, one does wonder?

Stringfellow ... The Belgrano

http://www.newsteelconstruction.com/wp/wp-content/uploads/2012/07/20yrs-1.jpg

Cheers

Whirls

[Cows getting bigger]

Any idiot can kill himself in bad weather at night, regardless of the airworthiness state of the aircraft.

Surely the big question about the airworthiness should be aimed at the inability to apply common standards across various EASA states? It seems to me that EASA is failing in a core task. From their website:

The Agency promotes the highest common standards of safety and environmental protection in civil aviation in Europe and worldwide

[Geoffersincornwall]

If you venture on to the Transparency International website and inspect their Corruption Perception index then you will see at the bottom of the page,

2011 Corruption Perceptions Index -- Results (http://cpi.transparency.org/cpi2011/results/)

a table of the perceived levels of corruption in the world. From what I have seen during my 40+ years in the business the level of abuse of maintenance procedures is broadly in line with this table.

Note that the UK is 16th, the USA 24th, France 25th, Spain 31st, Hungary 54th, Italy 69th, Brazil 73rd and Serbia 86th. Figures for the year 2011.

We are not angels and the problem is I suggest one that is likely to grow logarithmically as you move down the table rather than a simple linear growth.

A few years ago I did a Maintenance Manager's course in the USA and all attendees had to do a compulsory session with a man from the FAA on the use of counterfeit or 'bogus' parts. They considered it to be the No1 global problem at that time.

G.

(CGB (above) I think we need to have a chat about your interest in live-stock) :)

[chopjock]

G.
but there are times when you just have to accept that someone else knows better.

1. Those that are recycled -
2. Parts manufactures in non-approved facilities and given false papers.
3. Military parts.
4. Scrap parts being re-used after repair by unqualified or uncertified organisations.

The pilot in this case thought he knew better and paid for his arrogance or ignorance, or both, with his life.Have to disagree with you.
He was arrogant yes (and that's not necessarilly a bad thing), but these parts had nothing to do with the cause of the crash, so perhaps he did know better in regards to the parts fitted?
Obviously he should have known better though not to fly that evening.

Stringfellow,
The pic of the Belgrano looks like the CAA building.

[Geoffersincornwall]

I think the thread has moved on a little from a simple analysis of Mr Weir's view of right and wrong.

If you go to the doctor and he misses the signs of a fatal disease you may feel he is not up to the mark. If you are then knocked down and killed by a bus the following day are we supposed to conclude that the doctor's ineptitude was irrelevant because you didn't die from the fatal disease?

Should we not say, here is a lesson learned for the autopsy will reveal that the signs of illness were missed.

For the good of other patients we need to know what those signs were and if the patient was covering them up how did he do that and how can we make sure that in future the Doctor (EASA) has the right medication (oversight) to diagnose a possible problem.

Aviation is about risk management and you don't minimise risk by ignoring the airworthiness requirements.

G.

[chopjock]

Aviation is about risk management Agreed

you don't minimise risk by ignoring the airworthiness requirements.
Agree sometimes. what about the ridiculous B206 TT straps fiasco?

[Geoffersincornwall]

........and the MBB105 CAA 'special requirements' modification to the fuel system that turned out to ADD a risk rather than remove one.

Yes we live in an imperfect world but anarchy will result if we all accept our own views on right and wrong. The prime mortgage scandal was an example of where one group decided to agree to follow their own interpretation of the rules and look what happened. The 'Libor Rate' scandal, ditto.

The old adage holds good - Rules are for the obedience of fools (read newbies or the untrained) and the guidance of wise men (read trained experts in their field).

G.

[ShyTorque]

Chopjock,

If a non-certified part is fitted, who is to say whether the aircraft is safe to fly or not? Ask any aircraft insurer for their views on the matter. Ask them if they would insure a helicopter if non-certified parts were fitted.

The reason the certification of aircraft parts has been mandated (it's not just the UK who do this, of course) is that in the past things have come apart in the air. How would you feel if an uncertified (and therefore illegally flown and probably uninsured) helicopter fell apart in the air and landed on your house and/or family?

[toptobottom]

This reminds me of the thread about using heating oil (kerosene) instead of Jet-A1. Chemically identical, but one is subject to much higher quality control processes and more stringent checks that maximise safety.

I imagine the main benefit of a certified component is that its provenance has been authenticated. A non-certified part may have a dubious provenance that could ultimately manifest itself in a catastrophic failure. I appreciate that the AAIB believed it found nothing on Mark's Gazelle that had a material effect on its airworthiness, however, there wasn't a lot left of the aircraft to check and there are several people who can recall stories of Mark's cavalier 'that'll be alright' attitude to his flying. The reality of this situation, is that although illegal, the aircraft was probably safe and it was the pilot's decision making process and attitude that was unsafe. Even though Mark was popular as a lively maverick, it was this attitude to 'the system' and common sense that lost him his life.

Stringfellow:The mine mark ran existed right on the line of economic viability and making it pay meant not necessarily cutting corners but constantly asking 'do i really need this....??' We all talk about this qualification and that qualification but mark had no formal qualification in business yet became a millionaire. I don't believe the mine was barely viable; as you said in the same sentence, it made him a millionaire. He could have afforded the certified 'legal' components if he'd wanted to.

[OvertHawk]

The relevance of the airworthiness issues is that they establish (as did his other legal divergences) that this individual was a man who was prepared to flout regulations because he did not think they were important or because he thought he knew better.

His cavalier attitude to the rules was both directly responsible for his death - had he not been illegally night flying he would not have died - and indirectly responsible as well - he thought he was more capable and knowledgable than he was.

He was an accident waiting for a place to happen and i'm glad that he did not take anyone with him. I happened to be visiting AAIB soon after they brought the wreckage of his aircraft in - very sad - all the more so because it was simply not necessary.

There are certain arenas that reward aggressive, contrarian behaviour and a flexible attitude towards rules... Aviation is not one of them!

I hope that people will learn from this sad tale - some will stalwartly refuse to and we will talk about them here when it is their turn.

OH

[chopjock]

ShyT
How would you feel if an uncertified (and therefore illegally flown and probably uninsured) helicopter fell apart in the air and landed on your house and/or family?

Come now, that's a bit like saying certified, legal, insured helicopters don't crash because it's componants are certified, therefore do not fail!

[ShyTorque]

Chopjock,

No, I'm not suggesting that at all. You seem to be very protective over the subject of "bogus" parts.

As I suggested, if in doubt, ask your insurance company.

[jayteeto]

Chopjock, If a legal insured helicopter injured my family, I would be devastated. If an illegal, cowboy maintained helicopter injured my family, I would find the person responsible and probably do them GREAT harm. So yes, there is a difference.

[John R81]

I am interested in understanding whether the C of A was valid, given the discrepencies noted by the AAIB report. If the C of A is not valid then I doubt that you have insurance for the flight.

In any case the lack of a night rating might be enough for the insurer to say that there was no qualified pilot for this flight and hence that the insurance is not valid.

Another good reason to keep the paperwork up to date and only operate within the rules: you bend it and the financial cost, including collateral damage, falls on you.

[Sir Niall Dementia]

I'd be astonished if he had anything better than third party, if that. He certainly doesn't come over as the type to worry about insurance. At one time he advertised rides to his mine from his home in this aircraft, believing he got round the CAT rules as it was also his ride to work, doubtless there but for the grace of god went a few people.

SND