AS332L2 Ditching off Shetland: 23rd August 2013

[DOUBLE BOGEY]

Hi Crab, with the V/S installed in 3 axis mode it is active on the Cyclic "Pitch" channel. I was fairly certain they had set an ALT.A at MDA.
The incipient reduction in IAS during the descent would have been small compared to the effect when the ALT engaged automatically at the MDA.

During our L2 Type Training at the same Operator, the Training Staff went to great lengths to demonstrate this effect to us to dissuade us from engaging in this potentially dangerous practice,. We called it "The L2 tail slide" as that is what it felt like at the extreme.

As an aside, the PM took a hit for not monitoring the IAS. However, at the point of level off at MDA, the PF should be primarily monitoring the Instruments and the PM looking out for the Required Visual References. It raises an interesting argument and further supports the practice of CDFA where there is no level off and therefore no prolonged attempt to gain visual references and thus less opportunity to lose the IAS.

This single accident raised a lot of issues. All inter related and all significant.

[[email protected]]

This single accident raised a lot of issues. All inter related and all significant. Agreed - if you had a known or suspected collective issue, wouldn't you be extra vigilant knowing you had selected a cyclic mode (VS) where power controls speed? he seems to have made a power adjustment at 80 Kts but not looked to see if it had the desired effect of stablising IAS.

Personally I dislike CDFA profiles - may be my age - but the ability to level off at MDA and run in until the MAPt is ideally suited to helicopters in marginal conditions.

The fact that they managed the 'L2 tail slide' without using ALT.A speaks volumes for the lack of CRM.

[heli61]

You have to remember, the L2 was a very early first generation glass cockpit helicopter and coupler.

Compared to anything else I’d flown before, it was without doubt the best thing since sliced bread.

Treated with respect the 3 axis AP function was more than adequate

Like any other it did have vices which could jump up and bite.

The vertical bar indication for IAS was difficult and non intuitive

Thankfully with time progress has been made with AP flight envelope protection

[Variable Load]

Despite DBs assertions that the L2 AP was great, that wasn't a view shared by the majority of line pilots. The collective coupling was very slow to react to required changes and then had a habit of overreacting in an attempt to play "catch-up" and could cause momentary overtorques. As the data in the AAIB report indicates, most crews would chose not to use the collective channel i.e. only use 3 axis coupling.

The choice of 3 axis rather than 4 axis coupling wasn't itself a fundamental mistake, it was the choice to couple altitude to pitch rather than speed. The lack of speed monitoring at 80 KIAS and below was the final hole in the Emmental.

[[email protected]]

it was the choice to couple altitude to pitch rather than speed. or rather to ask the AP to use the cyclic channel to control RoD (VS) leaving the pilot in the counter-intuitive position of controlling speed with collective.

[marcr]

Ok. If it was widely understood and accepted, as evidenced, that most pilots would choose to fly an approach in the L2 with only 3-axes engaged, as the AP struggled in 4-axes, I'm imagining that the 6 monthly training and checking would also have reflected that.

Leaving manually flown approaches aside, if it was standard practice to fly a coupled approach with only 3-axes engaged, knowing the risks associated with this, it must have become part of routine training to demonstrate the dangers and regularly check competency in this DEGRADED mode. What benefit would be gained from successfully completing a 4-axes approach in the sim if it did not match the reality of how the aircraft was operated?

Risk assessment + mitigation through SOP + training needs analysis + demonstration and practice + assessment = role competent pilot / crew.

To pinch a line from a colleague, "Why do good pilots make poor choices?" - generally, not knowingly.

[Variable Load]

or rather to ask the AP to use the cyclic channel to control RoD (VS) leaving the pilot in the counter-intuitive position of controlling speed with collective.

or rather coupling VS and ALT.A to pitch :O

[[email protected]]

They didn't have ALT.A coupled according to the report, just VS. Unless I have read it wrong.

I was trying to clarify the phrase 'coupling to pitch' since it could be pitch channel, pitch attitude or collective pitch.:ok:

[Variable Load]

They didn't have ALT.A coupled according to the report, just VS. Unless I have read it wrong.

I was trying to clarify the phrase 'coupling to pitch' since it could be pitch channel, pitch attitude or collective pitch.:ok:

My mistake, ALT.A was not selected. Perhaps passing of time had blurred my memory - that's my excuse anyway :sad:.

As for coupling modes, I've always talked about the principal axes of motion as being pitch, roll and yaw. A certain French manufacturer does confuse things by having blade pitch as a fundamental measure of collective application, but I dismiss such things as an aberration of poor judgement and odd Gallic tendencies ;)

[DOUBLE BOGEY]

VR your memory is not clear. The L2 was powerprotected in all coupled modes with the sole exception of CRHT. Height Capture. Which, in our outfit, was mandated not to be used. Other than this, in 4K hrs offshoreL2 I never experienced poor AP performance. There are limits, well documented in the AFM. Operations outside those limits could be exciting.......but until APM 2000 came along, the L2 AP was far better than most of the alternatives.

We regularly and routinely flew approaches in 4 axis. Oddly. We cruised in 3 axis mode to reduce the power modulations in turbulence etc.

[[email protected]]

VL - I get where you are coming from - on the Mk3A Sea King we had an SN500 duplex AP, when selecting TAS hold for example, the PF would acknowledge coupled in pitch, that was why I wanted to clarify the term - coupled in Pitch or Roll or Yaw is quite specific to the AP channel, coupled to pitch is more ambiguous.:ok:

[DOUBLE BOGEY]

VL - I get where you are coming from - on the Mk3A Sea King we had an SN500 duplex AP, when selecting TAS hold for example, the PF would acknowledge coupled in pitch, that was why I wanted to clarify the term - coupled in Pitch or Roll or Yaw is quite specific to the AP channel, coupled to pitch is more ambiguous.:ok:

It does get confusing but going back to basics help;

Channel - PITCH about the lateral axis.
Channel - ROLL around the Longitudinal axis
Channel - YAW around the Normal axis.

These are Attitude modulations.

The commanded collective channel does not create attitude changes (intentionally) and is the oddity.

[[email protected]]

I didn't think it was confusing, just a terminology question.

[HeliComparator]

On the subject of manual flying skills and training, this is an issue that I finally managed to rectify in our company for the 225, shortly before I retired. It was a struggle though! Basic problem is that for 6 monthly checks, the rules said that you must fly manual approaches. That is, approaches with full autopilot functionality in terms of attitude hold when cyclic release, artificial stability when cyclic operated, co-ordinated turn, heading hold when wings level etc. But not allowed to use the upper modes. Crazy, because that scenario is just about impossible.

So a lot of training time had, by CAA edict, to be spent manually flying. So no time left to properly explore how best to use the automation, how to deal with partial automation etc. Crazy! The whole industry, including the CAA, is culpable for this accident. But unfortunately they get away with it and just blame the pilots.

As I mentioned I finally persuaded CAA to allow fully coupled approaches by default for OPC /LPC, albeit with some partial (and hence realistic) malfunction thrown in for one of the approaches. It is just crazy to train for stuff that you never have to do in reality, and to not train for the stuff that is your bread and butter. And to take the view that certainly prevailed at the time with CAA and EASA - that real pilots flew manually, anyone using the coupled modes was cheating.

Been away for 7 years now, it would be great to think things had changed a bit but I rather doubt it!

Oh and in summary, they should have been using IAS mode. Maybe with Vs on collective, or not, doesn’t matter too much but the key thing was to have IAS engaged. If they had done that, the accident wouldn’t have happened. But nothing in CHC ops man at the time that told them what to engage or the perils of not engaging IAS.

[DOUBLE BOGEY]

HC I agree with much of your post but would caution that it is unfair to blame CAA and the regulators in general. The experts in these areas were in fact us. The Industry. In hindsight types where failure of the upper modes or indeed, the AFCS were reasonably expected, it was prudent to practise manually flown procedures. However, it took us all a while to realise that these policies were not suitable once the full digital age had arrived. You were undoubtedly a key voice in this change. I think it is important to understand that the regulator is simply a mirror, reflecting back what happens in the industry.
Still I feel EASA have missed the boat on this one. I am obliged to cover vortex ring and settling with power at each OPC/LPC when I feel much more should be made of the incipient hazards of poor application of automation. Just look at the many pages in the regs prescribing FW LOC (Upset) training. Nothing in there about helicopter AFCS except a few headline policy requirements.
We are in a better place than 10-15 years ago. However it has taken that time for us all to better understand how to fully exploit the new technology. I think we are still learning.

it is often much more beneficial to demonstrate to crews poor technique than to simply demand they apply the correct one.

[marcr]

DB - "This single accident raised a lot of issues. All inter related and all significant."

HeliComparator - "The whole industry, including the CAA, is culpable for this accident."

Thank you both.

Telling the pilots what they "should have been doing" is the easy part.

Dealing with what got us to this point, is a task that demands attention and begs greater engagement from us all - and across the board. It is not of huge benefit if the "joined up" response at executive level only serves to create an illusion of progress, when very little has actually changed for the crews. How many North Sea pilots have even seen the FCOM for their aircraft?

As for the CAA. I think it is fair to include the organisation as a contributing factor. "Light touch" regulation just doesn't work. If expert help is needed - get it.

There are more avoidable accidents waiting to happen - who will we be trying to blame the next time?

[HeliComparator]

HC I agree with much of your post but would caution that it is unfair to blame CAA and the regulators in general. The experts in these areas were in fact us. The Industry.


Surely it rather begs the question what is the point of the regulator, if they take their lead from the status quo and from those they are supposed to be regulating?

[HeliComparator]

. How many North Sea pilots have even seen the FCOM for their aircraft?


And of course at the time of the subject accident, there was no FCOM for the aircraft.

[DOUBLE BOGEY]

And of course at the time of the subject accident, there was no FCOM for the aircraft.

True...…..guess who inherited that task!

[Nige321]

Enquiry ends... (https://www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-54461880)

An offshore helicopter crash in which four people died was caused by pilot error, an inquiry has ruled.

Sheriff Principal Derek Pyle said the Super Puma had not maintained the correct speed as it approached its landing in Shetland in 2013.

He said the reason for the error remained unknown - but that there had been "no wilful neglect" by the pilot.

A total of 18 people were on board when the helicopter hit the sea on its approach to Sumburgh.

The Super Puma overturned and filled with water, but it did not sink due to its flotation devices.

Sarah Darnley, 45, from Elgin; Duncan Munro, 46, from Bishop Auckland; and George Allison, 57, of Winchester, drowned in the accident.

Gary McCrossan, 59, from Inverness, who had cardiac disease, died from heart failure following the crash.

The inquiry also heard that one survivor, Sam Bull, took his own life four years later aged 28 after suffering post-traumatic stress disorder (PTSD).

Pilot Martin Miglans and co-pilot Alan Bell were among those who escaped.


There was a 5th victim...
What a sad case... (https://www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-54369576)


Sam Bull was one of the first of the survivors to escape from a submerged helicopter after it crashed into the North Sea off Shetland.

He helped with the life rafts, and tried to resuscitate one of his fellow passengers - although those efforts would prove to be in vain.

The man he tried to save was one of four people who lost their lives on the day of the crash in August 2013.

Sam was haunted by the harrowing events. Four years later, at the age of 28, he took his own life after suffering post-traumatic stress disorder (PTSD).

As the findings of a fatal accident inquiry are published, Sam's father Michael spoke to BBC Scotland News in the hope of raising awareness of the impact that trauma can have on people.

[[email protected]]

Sounds like a bit of a whitewash - clear negligence by the crew!

[HeliComparator]

Sounds like a bit of a whitewash - clear negligence by the crew!

A bit harsh, but I suppose a reasonable response from someone who has never made a mistake.

They made a mistake, but not from lack of interest or lack of workload. They were concentrating on the approach and doing their best, but clearly they were not concentrating on the right things and as it turns out, their best wasn’t good enough. You can call that negligence if you like, but to most people negligence is associated with not bothering or caring. If they had been texting their wives/girlfriends at the time then I would cry “negligence”. But otherwise, “negligence” is just an emotive word for “they got it wrong” and would only be uttered by someone who thinks it could never happen to them.

Of course it is pathetically easy to call it negligence, but it requires a bit of intelligence, effort and insight to work out WHY they made the mistakes they did. Which is necessary if there is any interest in preventing a recurrence.. But of course some people are just happy to blame the pilots and that be an end to it.

[Bell_ringer]

Why is it harsh to be critical?
Should there only be criticism when there was some form of intent? Who actually intends to have an accident?
Negligence is about failing to take proper care to operate an aircraft, it doesn't require intent.
If anyone fails to do their job properly, for whatever reason, it is still considered negligence, as difficult as that is to swallow.
The families of the deceased won't feel any better because the crew just made a mistake and didn't mean to.

[Twist & Shout]

“I’ll just cast this stone....No, wait, on second thoughts.....”

[Bell_ringer]

“I’ll just cast this stone....No, wait, on second thoughts.....”

who’s casting stones?
Most people probably won’t care what gets said after an accident, it comes with the territory.
If you don’t want to be the subject of discussion then don’t have an accident.
It is of course not that easy but part of avoiding one is not mincing around the bush when dissecting performance.
We are all fallible and most accidents are a result of making errors, we need to own that.

[[email protected]]

One pilot having an off day is completely understandable but that is why you have two crew for these operations - PF and PM - neither of whom did their jobs properly.

Helicomparator - you cant defend them by saying they were concentrating on the approach - every pilot does that or they shouldn't be in the seat.

Of course I have made mistakes - mine just didn't cost the lives of 4 people directly - it is a fatuous argument.

If you can't acknowledge the errors - from the choice of approach profile to the mindset they were going to get in to the complete lack of CRM and monitoring of the aircraft - then perhaps you were part of the problem in the N Sea..

According to your logic, I could have a blade strike on a mountain SAROP, roll down the hill and kill several occupants and then claim I wasn't negligent but I was concentrating on the wrong thing!!!

A straightforward instrument approach turned into a horrendous - yet completely preventable - accident costing lives with 2 pilots holding professional commercial licences at the controls. How is that not negligent?

[SimonK]

A bit harsh, but I suppose a reasonable response from someone who has never made a mistake.

They made a mistake, but not from lack of interest or lack of workload. They were concentrating on the approach and doing their best, but clearly they were not concentrating on the right things and as it turns out, their best wasn’t good enough. You can call that negligence if you like, but to most people negligence is associated with not bothering or caring. If they had been texting their wives/girlfriends at the time then I would cry “negligence”. But otherwise, “negligence” is just an emotive word for “they got it wrong” and would only be uttered by someone who thinks it could never happen to them.

Of course it is pathetically easy to call it negligence, but it requires a bit of intelligence, effort and insight to work out WHY they made the mistakes they did. Which is necessary if there is any interest in preventing a recurrence.. But of course some people are just happy to blame the pilots and that be an end to it.

Well said. I think you hit the nail on the head, some of the ‘characters’ on here piling in on the pilots (I don’t know them, but I know both were highly thought of) need to take a long hard look in the mirror and remember the last time when they f****ed up too, as we all do from time to time. This was a tragic, awful mistake that happened to 2 decent pilots - it could have happened to any of us.

[[email protected]]

SimonK - would you feel the same if it had been a friend or relative in the back who didn't make it out?

[SimonK]

SimonK - would you feel the same if it had been a friend or relative in the back who didn't make it out?

Were your friends or relatives in the back? No, good and glad to hear it - so let’s take emotion out of the argument and discuss it like grown-ups. That’s why crime victims don’t get to set the sentences in this country....much as we’d like to ;)

They made a mistake - some was their fault (most?) and some was organisational. They very very nearly died themselves and a colleague at their company told me how they only just got out of that cockpit with extreme difficulty.

I wonder how many near misses you, me and the other posters here have had over the years which were stopped at some stage by a shout from the Winchop or an intervention from the other pilot and there but for the grace of god go most of us.

[[email protected]]

I wonder how many near misses you, me and the other posters here have had over the years which were stopped at some stage by a shout from the Winchop or an intervention from the other pilot and there but for the grace of god go most of us. yes that s the point of CRM and training procedures and that was a major factor in the accident - they were going through the 'mouth music' of the CRM procedures without actually noticing the elephant in the room.

It's all very well saying they were 'well respected' as if this somehow confers an absolution for blame - Harold Shipman was a 'well respected' doctor - need I say more.

The fact that the crew only just got out is an emotional offering as well - it is irrelevant because their mistakes meant 4 people didn't.

If you run up the back of another car at a roundabout because you were looking at the traffic on the roundabout and didn't notice the car in front of you had stopped - would that be driving without due care and attention (negligence in other words)?

You can't blame the driving test or the training you took to pass it it - it is your mistake for not concentrating on the right thing at the right time and you have to own that error 100%.

[HeliComparator]

One pilot having an off day is completely understandable but that is why you have two crew for these operations - PF and PM - neither of whom did their jobs properly.

Helicomparator - you cant defend them by saying they were concentrating on the approach - every pilot does that or they shouldn't be in the seat.

Of course I have made mistakes - mine just didn't cost the lives of 4 people directly - it is a fatuous argument.

If you can't acknowledge the errors - from the choice of approach profile to the mindset they were going to get in to the complete lack of CRM and monitoring of the aircraft - then perhaps you were part of the problem in the N Sea..

According to your logic, I could have a blade strike on a mountain SAROP, roll down the hill and kill several occupants and then claim I wasn't negligent but I was concentrating on the wrong thing!!!

A straightforward instrument approach turned into a horrendous - yet completely preventable - accident costing lives with 2 pilots holding professional commercial licences at the controls. How is that not negligent?

Were the pilots carrying out the approach in accordance with normal practice for their company? Yes. A bad practice IMO, but normal for their company’s culture. Whose fault was that?
The copilot was 6 months in from getting his first job. In that time he had been flipped between the L2 and the 225 several times. Yes the same type, but completely different helicopters to operate. During typical type rating courses and differences courses, nearly all the focus is on the role of pilot flying. Pilot monitoring barely gets a look-in except for the offshore radar approach. And yet here he was acting as PM for an onshore approach in very marginal weather. It is obvious that he didn’t really understand the most important role of PM. Was he stupid? No I don’t thing so. Was he given clear parameters to monitor for? No. So how is he expected to monitor?

Was he a product of the training system that prioritises PF role and fatuous things like engine failures that virtually never happen, as opposed for training for the “day job” of what happens 99.99% of the time. Yes i would say so. Was he, 6 months into a rather disorganised career, to blame for not understanding the primary role of PM during an onshore instrument approach? No I don’t think so, I would say he was a victim as much as any of the passengers, of a training system little changed from the dark ages.

These are the sorts of questions one has to consider if any attempt to improve things is the aim. To just blame the pilots is ignorant and futile, although I will agree it is in the culture of unthinking people trained in the military who think they are so superior.

[staticsource]

Were the pilots carrying out the approach in accordance with normal practice for their company? Yes. A bad practice IMO, but normal for their company’s culture. Whose fault was that?
The copilot was 6 months in from getting his first job. In that time he had been flipped between the L2 and the 225 several times. Yes the same type, but completely different helicopters to operate. During typical type rating courses and differences courses, nearly all the focus is on the role of pilot flying. Pilot monitoring barely gets a look-in except for the offshore radar approach. And yet here he was acting as PM for an onshore approach in very marginal weather. It is obvious that he didn’t really understand the most important role of PM. Was he stupid? No I don’t thing so. Was he given clear parameters to monitor for? No. So how is he expected to monitor?

Was he a product of the training system that prioritises PF role and fatuous things like engine failures that virtually never happen, as opposed for training for the “day job” of what happens 99.99% of the time. Yes i would say so. Was he, 6 months into a rather disorganised career, to blame for not understanding the primary role of PM during an onshore instrument approach? No I don’t think so, I would say he was a victim as much as any of the passengers, of a training system little changed from the dark ages.

These are the sorts of questions one has to consider if any attempt to improve things is the aim. To just blame the pilots is ignorant and futile, although I will agree it is in the culture of unthinking people trained in the military who think they are so superior.

Not too sure where you get the 6 months experience from for the Copilot? He had been an instructor before this for around 8 years and a TRE for a couple of years with an onshore AOC operator with over 2000hrs 🤔

Im sure he was old enough and big enough to speak up if he didn’t receive the correct training or if he felt something wasn’t right?

Or is this the old adage where he’s got a new job, I don’t want to say anything and ruffle feathers and go with the flow?

[HeliComparator]

Not too sure where you get the 6 months experience from for the Copilot? He had been an instructor before this for around 8 years and a TRE for a couple of years with an onshore AOC operator with over 2000hrs 🤔

Im sure he was old enough and big enough to speak up if he didn’t receive the correct training or if he felt something wasn’t right?

Or is this the old adage where he’s got a new job, I don’t want to say anything and ruffle feathers and go with the flow?

Yes sorry you are right, I should have said first offshore job. I think it was also his first multi-pilot job but not sure? Aviation is very role-specific, for example you could have thousands of hours as an ab-initio instructor and no clue what offshore IFR flying is all about.

[staticsource]

Yes sorry you are right, I should have said first offshore job. I think it was also his first multi-pilot job but not sure? Aviation is very role-specific, for example you could have thousands of hours as an ab-initio instructor and no clue what offshore IFR flying is all about.

Yes fair enough and totally agree re thousands of hours and role specific jobs👍

[olster]

I know the first officer well. He took me through my ppl h @ Perth. I was a current airline pilot at the time and Alan nursed me through my ham fisted attempts at hovering. All I will say is that he is a gent, a fantastic pilot and instructor. If he reads this I send him my very best wishes.

[helicrazi]

I know the first officer well. He took me through my ppl h @ Perth. I was a current airline pilot at the time and Alan nursed me through my ham fisted attempts at hovering. All I will say is that he is a gent, a fantastic pilot and instructor. If he reads this I send him my very best wishes.

I'd hope for their own sanity that the crew forgets pprune exists...

[[email protected]]

To just blame the pilots is ignorant and futile, although I will agree it is in the culture of unthinking people trained in the military who think they are so superior. Oh dear we are back to that bitter note again.

If they had been military pilots I would be equally critical.

The fact that they are nice guys is irrelevant too as is much of the guff about hours and training - when you fly a perfectly serviceable helicopter into the water because you weren't paying attention to the IAS (and kill several pax) you can blame as many of the contributory factors as you like but the main cause is pilot (both PF and PM) error, plain and simple.

[HeliComparator]

Oh dear we are back to that bitter note again.

If they had been military pilots I would be equally critical.

The fact that they are nice guys is irrelevant too as is much of the guff about hours and training - when you fly a perfectly serviceable helicopter into the water because you weren't paying attention to the IAS (and kill several pax) you can blame as many of the contributory factors as you like but the main cause is pilot (both PF and PM) error, plain and simple.

In these times of Covid and brexit it is comforting to see that some things never change.

Anyway back to the point, the cause was as you say, and as the report says, pilot error. The pertinent question for anyone not living in a 1960s aviation culture, is why did they make that error. I have tried to address that question but it seems you aren’t interested.

[ApolloHeli]

Was he given clear parameters to monitor for? No. So how is he expected to monitor?

In my view, if the PF did not brief the PM properly and state clear parameters to monitor during the approach (especially airspeed), then there is a share of responsibility for the PM to request those parameters so that both are on the same page. As stated, pilots are fallible and forgetting to state at which IAS you plan to fly the approach at may be a simple mistake - easily forgiven, however the PM should pick up on this missing information and request it. (I cannot remember if this was a factor in this accident and I cannot re-read the report and check right now. This is more of a response to what's quoted.)

Regardless, if a pilot is rated on type, then they should definitely know the airspeed limitations of that type and I would argue that minimum IFR speed is high on that list when you're hard IMC, so that either of them let the aircraft fall below V min IFR is not excusable because "pilots make mistakes", particularly when lives were lost as a result.

[HeliComparator]

In my view, if the PF did not brief the PM properly and state clear parameters to monitor during the approach (especially airspeed), then there is a share of responsibility for the PM to request those parameters so that both are on the same page. As stated, pilots are fallible and forgetting to state at which IAS you plan to fly the approach at may be a simple mistake - easily forgiven, however the PM should pick up on this missing information and request it. (I cannot remember if this was a factor in this accident and I cannot re-read the report and check right now. This is more of a response to what's quoted.)

Regardless, if a pilot is rated on type, then they should definitely know the airspeed limitations of that type and I would argue that minimum IFR speed is high on that list when you're hard IMC, so that either of them let the aircraft fall below V min IFR is not excusable because "pilots make mistakes", particularly when lives were lost as a result.

Agree with most of that, but it didn’t happen. Why not? Was it because the pilots were lazy, stupid, evil, baby-eating people playing candy crush on their phones during the approach? Or something else?

[[email protected]]

Let's use the AAIB report to look at that - how a 10,000 hour commander and a 3000 hour co pilot flew the aircraft (perfectly serviceable) into the sea.
The co-pilot provided information to the investigation on the day following the accident and during subsequent interviews. He had a good recollection of most events, but did not have a complete picture of what had occurred during the latter stages of the approach.He stated, at interview, that he had been relying on the commander’s greater experience and had therefore not challenged his comments during the approach briefing. The co-pilot stated that he had accepted the helicopter’s deviation below the published vertical profile during the latter stages of the approach because this was allowed and he had seen other approaches flown in this way. He commented that during the final approach he had noticed the commander looking up at some stage, perhaps seeking external visual reference.

So a bit of a cockpit gradient - stuff you learn about in CRM, HF and MCC training.

Attention. The analysis of crew tasks does not provide evidence that either crew member’s attention was focussed on the airspeed or aircraft pitch (paragraph 32). The Commander was also observed by the Co-Pilot to glance outside the cockpit. If the airspeed and aircraft pitch was outside the Commander and Co-Pilot’s attentional focus it is unlikely that a change in these items would be detected. poor instrument scan - highlighted in other places in the report. Not something you would expect from an experienced commander.

The crew were using non-standard terminology for their SOP communications which increases the likelihood of miscommunication. It is recommended that the norms Air Accident Report: 1/2016 G-WNSB EW/C2013/08/03 © Crown Copyright 2016 Appendix I (cont) Appendix I 246 associated with SOP calls are identified to determine the extent of the risk and actions put in place to address. so although the SOPs are not good, they weren't following them anyway.

First AVAD alert. At approximately twelve seconds before impact and at a height of 300ft, the crew were alerted by the Automatic Voice Alarm Device (AVAD) stating “CHECK HEIGHT”. The Commander acknowledged the AVAD alert by stating “Checking the height”. It was, therefore, possible the Commander’s attention was then directed to the altimeter. 300ft is a MDA, where it would be anticipated that vertical descent profile would be levelled off. However, there was no evidence of G-WNSB slowing down or levelling, up to or after the 300ft MDA. There are many reasons why this may have occurred, however there was no evidence to indicate why this may have happened in this instance. now we are in the realms of basic instrument flying procedures.


The investigation identified the following causal factors in the accident:

● The helicopter’s flight instruments were not monitored effectively during the latter stages of the non-precision instrument approach. This allowed the helicopter to enter a critically low energy state, from which recovery was not possible.

● Visual references had not been acquired by the Minimum Descent Altitude (MDA) and no effective action was taken to level the helicopter, as required by the operator’s procedure for an instrument approach.

The following contributory factors were identified:

● The operator’s SOP for this type of approach was not clearly defined and the pilots had not developed a shared, unambiguous understanding of how the approach was to be flown.

● The operator’s SOPs at the time did not optimise the use of the helicopter’s automated systems during a Non-Precision Approach.

● The decision to fly a 3-axes with V/S mode, decelerating approach in marginal weather conditions did not make optimum use of the helicopter’s automated systems and required closer monitoring of the instruments by the crew.

● Despite the poorer than forecast weather conditions at Sumburgh Airport, the commander had not altered his expectation of being able to land from a Non-Precision Approach.

the contributory factors are just that and smack of complacency with a routine task - the causal factors are just poor piloting.

You can defend them as much as you like HC, personally I feel very sorry for them, they will have to live with the consequences of their failures as a crew for the rest of their lives.

And, while it might surprise you that the MAA is as pink and fluffy as the CAA when it comes to not apportioning blame - this crew failed to do their job properly.

The aircraft was serviceable, the AP did exactly what is was asked to do, there was no other emergency or reasonable distractor to divert them from their task of either landing or going around at MDA/MAP.

You can call it what you like - but this was negligent operation of an aircraft.

[HeliComparator]

Let's use the AAIB report to look at that - how a 10,000 hour commander and a 3000 hour co pilot flew the aircraft (perfectly serviceable) into the sea.


So a bit of a cockpit gradient - stuff you learn about in CRM, HF and MCC training.

poor instrument scan - highlighted in other places in the report. Not something you would expect from an experienced commander.

so although the SOPs are not good, they weren't following them anyway.

now we are in the realms of basic instrument flying procedures.
the contributory factors are just that and smack of complacency with a routine task - the causal factors are just poor piloting.

You can defend them as much as you like HC, personally I feel very sorry for them, they will have to live with the consequences of their failures as a crew for the rest of their lives.

And, while it might surprise you that the MAA is as pink and fluffy as the CAA when it comes to not apportioning blame - this crew failed to do their job properly.

The aircraft was serviceable, the AP did exactly what is was asked to do, there was no other emergency or reasonable distractor to divert them from their task of either landing or going around at MDA/MAP.

You can call it what you like - but this was negligent operation of an aircraft.

But you still haven’t addressed the question of why those mistakes were made. As I mentioned earlier, not addressing that question is what kept accident rates high in the early days of commercial air transport. There was an accident, the pilots were at fault. End of. And then the same accident would happen sometime later. Pilots at fault. End of. Rinse and repeat.

Eventually (and many years ago for most people) it was worked out that this wasn’t a good way to carry on. One needed to examine why accidents happened, not just how they happened, if one wanted to improve flight safety.

Put it another way, by all accounts these pilots were pretty average in their apparent competence and diligence, right up to the moment they crashed. This despite 6 monthly checks lasting several hours, and, in the case of the copilot, a lot of time recently spent on training for the aircraft type and the role.

A layman looking at that information would surely say “well they seemed competent, they had all that training and checking, and yet the two of them jointly made fundamental errors that killed 4 people. If nothing changes, how can I have any confidence that the same, or similar, accident won’t happen again?“

Only someone totally entrenched in the status quo would fail to see that,

[olster]

Kind of wish I hadn’t posted now. I agree I hope the crew do not read this stuff. They did not intend to end up where they did and I would prefer to let the official bodies find out why rather than trawl through this guff. Crab you are obviously the fount of all rotary wisdom but your posts are just a bit vomit inducing as you have obviously never made a mistake.

[[email protected]]

But this wasn't the early days of commercial transport - this was 2013 after many decades of operation in the N Sea and elsewhere and pretty much all the lessons should have been learned by then.


HC, ISTR that you were a senior trainer - I don't know with which company - so why do you think two pilots made such glaring, yet BASIC, errors on a simple instrument approach? And if you were aware of similar shortcomings, what did you do about it?


You have said they had adequate training and checks so what was the problem? A cultural issue perhaps? Pilots regarding themselves as superior because of the salaries they were able to demand?


If you discount mechanical failure, disorientation, fatigue or major distraction you are left with a crew underperforming for no reason unless they were complacent or there was a major personality clash in the cockpit.


A supposedly competent and capable crew flew into the water because they didn't do their job properly - only someone who can't stand to hear the truth would fail to see that. You can't fix the problem unless you acknowledge there is one.

Olster - I have made many mistakes and put my hand up when I did so. I have also attended too many flight safety courses where accidents like this are dissected and discussed in order to determine why crews make such mistakes - there are often linked events (the holes in the Swiss cheese) that combine to create an unfortunate scenario that encourages human errors - I don't see any in this case except the failure to follow basic procedures.

As much as HC bangs on about finding the reasons for the accident - neither the AAIB or the Inquiry have found anything except pilot error - sometimes the blame really does lie with the pilots.

[olster]

Ok Crab fair point. As an amateur heli pilot and a retired commercial pilot my view is always that wilful negligence apart no pilot sets out to make mistakes that end in catastrophe. I have a son going into offshore heli flying and I guess we are a little bit sensitive but reassure ourselves that the operational standards are indeed very high.My comments about the co pilot were made as I am desperately sorry for what happened on his behalf and he is indeed a gent; I did note that he was commended by the enquiry for his management of the aftermath. In aviation sh1t really can happen.

[[email protected]]

In aviation sh1t really can happen. that is the truth and I do feel genuinely sorry for the crew, a colleague of mine made a mistake many years ago and killed 2 people, one of them from our own Sqn, and has had to live with that ever since. he has never hidden from the fact that it was his fault.

[DOUBLE BOGEY]

● The operator’s SOP for this type of approach was not clearly defined and the pilots had not developed a shared, unambiguous understanding of how the approach was to be flown.

● The operator’s SOPs at the time did not optimise the use of the helicopter’s automated systems during a Non-Precision Approach.

CRAB - in your haste to crucify the crew you are missing these two elements of the findings!!

The performance of the crew in this instance can be easily inferred from the rest of the report. However, nothing is ever as simple as "Pilot Error" unless the man on the sticks shouts "Geronimo" and pushes the cyclic forward to hit the sea.
SOPs, Limitations and Automation Management have to be defined holistically to ensure that on those days where any one of us may be underperforming, we may stand a chance of getting away with a howler with little more than a bruised ego.
It is this "Holistic" approach to systems and procedures management that is the issue here. After this accident a lot of good quality progress was made by all the major players in this area. In the defence of the Operators, some of the vital information necessary to determine solid procedures for the management of automation was missing in the OEMs available data. Much of this has now been addressed.
CRAB the reason why other posters object to your one dimensional response to this accident is because much of the progress that has been made since would not have been possible if we all took your view.
In the black and white pages of an AAIB report ity is oh so easy to see the mistakes others make. Its a little harder to soul search and ask if it could have happened to you. However, in doing so you stand a chance of unlocking the mysteries that surround accidents and make real progress. It is for this reason that when I am asked what the number one quality of an Instructor should be, I reply, empathy! Without it we are blinded by ego and prejudice.

DB

[HeliComparator]

1/ pretty much all the lessons should have been learned by then.

2/ HC, ISTR that you were a senior trainer - I don't know with which company - so why do you think two pilots made such glaring, yet BASIC, errors on a simple instrument approach? And if you were aware of similar shortcomings, what did you do about it?

3/ You have said they had adequate training and checks so what was the problem? A cultural issue perhaps? Pilots regarding themselves as superior because of the salaries they were able to demand?


4/ As much as HC bangs on about finding the reasons for the accident - neither the AAIB or the Inquiry have found anything except pilot error - sometimes the blame really does lie with the pilots.

1/ it will be a sad day when we think we know it all and all lessons have been learnt. For starters, that can’t possibly be the case until there have been no accidents in aviation for several years.

2/ Not the same company as I worked for so I can’t comment on their training or procedures, but the AAIB did in the bullet points referred to by DB. Clearly I couldn’t have done anything about it even if I was aware. But as also indicated earlier, one of the problems is that unlike the airlines, there is (or was) no standard way to operate. It was left to individuals like me, with no specific training on how to create operational procedures, to make it up as we went along. And in doing so one obviously tends to have “baggage” from experience on previous types.
We only had one L2, for which I wrote the OMB. To be honest I doubt it specifically said “don’t use VS mode near Vy unless you have IAS engaged”. In part, because it seems obvious to me and you can’t include every possible minutia in a part B. But clearly, it wasn’t obvious to numerous pilots who according to AAIB routinely flew non precision approaches coupled to VS and not to IAS. It was SOP to climb out in IAS mode set to something like Vy+20 and accept whatever VS you got, because to climb out in VS mode clearly invited falling off the back of the drag curve.

3. I did not say they had adequate training and checking, I said they had extensive training and checking. Due to the archaic attitudes of the regulator, much of this time was spent doing pointless stuff and not enough time spent doing relevant stuff. For example, one could do an entire type rating and operator conversion in the aircraft and never be exposed to acting as PM during an onshore instrument approach. How can that be adequate? And this is the main thrust of my argument, that training, especially in those days, was very formulaic, very focussed on PF role and not orientated to the actual job. With increasing use of simulators these days I think there is much more exposure to PM role but from a regulatory point of view it is still optional. During an OPC or LPC there is no requirement to demonstrate competence in PM role. It all goes back to the good old days when the captain was there to fly the aircraft and the copilot was there to shut up and make the coffee. The regulator hasn’t really moved on from then.

4. The AAIB are not particularly clever when it comes to that sort of thing. Indeed I had sight of the draft report and had to send an extensive note to them correcting the many mistakes they had made in describing how the L2 autopilot system worked, amongst other points.

[[email protected]]

We are still only talking about 2013 - only 7 years ago in the familiar environment of the N Sea.

Can you really be serious that training, checking and SOPs were still inadequate to prevent this accident only 7 years ago?

If that were really the case there would have been far more incidents and accidents since IMC approaches are normal fare for aviation in those parts.

That hasn't happened - or has been well covered up - so you can only draw the conclusion that, whilst not perfect, the training, checking and SOPs were adequate for the vast majority of pilots on the vast majority of days.

There was nothing special to differentiate this flight from thousands of others - EXCEPT they crashed by the simple action of failing to notice the IAS on an instrument approach - not 10 or 20 kts missed and a correction made, but all the way to below 30 and VRS.

Do explain how that is not negligent.

I'm not trying to crucify them - I don't know them nor the pax that died but I know where my sympathies lie in this sad case.

[HeliComparator]

We are still only talking about 2013 - only 7 years ago in the familiar environment of the N Sea.

Can you really be serious that training, checking and SOPs were still inadequate to prevent this accident only 7 years ago?

If that were really the case there would have been far more incidents and accidents since IMC approaches are normal fare for aviation in those parts.

That hasn't happened - or has been well covered up - so you can only draw the conclusion that, whilst not perfect, the training, checking and SOPs were adequate for the vast majority of pilots on the vast majority of days.

There was nothing special to differentiate this flight from thousands of others - EXCEPT they crashed by the simple action of failing to notice the IAS on an instrument approach - not 10 or 20 kts missed and a correction made, but all the way to below 30 and VRS.

Do explain how that is not negligent.

I'm not trying to crucify them - I don't know them nor the pax that died but I know where my sympathies lie in this sad case.

I do find it worrying that you have any involvement in training, you don’t seem to grasp the very basics of flight safety.

Firstly it is surely blatantly obvious to nearly everyone that the training, checking and SOPs were inadequate to prevent this accident. Otherwise, it wouldn’t have happened. To put it politely, “Duh!”.

Secondly you appear to have some fantasy that these things are black and white, or “binary” in modern parlance. Either something is safe, or something isn’t safe, adequate or inadequate. No middle ground. Which I find amazing and scary.

With the training regime extant at the time, people were accustomed to flying an onshore NPA in various different ways with various different upper mode engagements. There was no standardisation simply because there was no laid down standard to adhere to. Yes Ok nearly everyone coped with that, but being accustomed to using VS mode during an NPA with speed reduction was an accident waiting to happen. So not surprisingly it eventually did happen when the cheese holes lined up, especially when there was no proper stabilised approach policy either.

Of course they made a mistake and failed to control and monitor the speed. But we need to bear in mind that humans (of which group most pilots are allegedly a member) make mistakes. They do, so get over it! (Apart from you, obviously). Because we know that humans make mistakes we need to design error-tolerant procedures so that when they do make a mistake, and they will, it isn’t catastrophic.

Hmmm, let me think how could we make flying a NPA error tolerant in terms of airspeed control? Oooh, I know, let’s make the pilots use IAS mode! There, the problem is solved in an instant and the accident won’t happen again. Quite easy really, wasn’t it! Just a pity the company’s SOPs didn’t require that and lots of people were in the habit of not doing so. That cost 4 lives.

[Shell Management]

Crab is right. There needs to be a system of Consequence Management within every operator's SMS to manage human factors like this, otherwise there will be mayhem:=. Shell Aircraft will have drilled this into CHC in recent years:ok: Bristow was first, NHV are getting educated now and soon it will be Babcocks turn:).

[helicrazi]

Crab is right. There needs to be a system of Consequence Management within every operator's SMS to manage human factors like this, otherwise there will be mayhem:=. Shell Aircraft will have drilled this into CHC in recent years:ok: Bristow was first, NHV are getting educated now and soon it will be Babcocks turn:).

Surely you are setting bait with that comment

[ApolloHeli]

Just a pity the company’s SOPs didn’t require that and lots of people were in the habit of not doing so. That cost 4 lives.

From the summary: "insufficient collective pitch control input was applied by the commander to maintain the approach profile and the target approach airspeed of 80 kt. This resulted in insufficient engine power being provided and the helicopter’s airspeed reduced continuously during the final approach."

Yes, the SOPs sound daft but that should have been a red flag to any competent pilot and additional focus should have been used in the cockpit to work around it until common sense prevailed and led to a change. In the meantime, during a mechanical failure-free NPA, it was the PF who failed to lift up on the collective, and the PM who failed to monitor and register the decreasing airspeed.

FWIW I'm with Crab on this one to a certain extent. Given the plethora of good pilots willing to fly there, if a pilot is lucky enough to hold a seat in the north sea they should be exceptional at their job. A PF not flying properly, and a PM not monitoring properly isn't something that can be glossed over because the SOPs were back-to-front.

[Variable Load]

Crab is right. There needs to be a system of Consequence Management within every operator's SMS to manage human factors like this, otherwise there will be mayhem:=. Shell Aircraft will have drilled this into CHC in recent years:ok: Bristow was first, NHV are getting educated now and soon it will be Babcocks turn:).

Response written and then deleted.

Can someone else make him stop!

[[email protected]]

I do find it worrying that you have any involvement in training, you don’t seem to grasp the very basics of flight safety.

Firstly it is surely blatantly obvious to nearly everyone that the training, checking and SOPs were inadequate to prevent this accident. Otherwise, it wouldn’t have happened. To put it politely, “Duh!”.

Secondly you appear to have some fantasy that these things are black and white, or “binary” in modern parlance. Either something is safe, or something isn’t safe, adequate or inadequate. No middle ground. Which I find amazing and scary.

With the training regime extant at the time, people were accustomed to flying an onshore NPA in various different ways with various different upper mode engagements. There was no standardisation simply because there was no laid down standard to adhere to. Yes Ok nearly everyone coped with that, but being accustomed to using VS mode during an NPA with speed reduction was an accident waiting to happen. So not surprisingly it eventually did happen when the cheese holes lined up, especially when there was no proper stabilised approach policy either.

Of course they made a mistake and failed to control and monitor the speed. But we need to bear in mind that humans (of which group most pilots are allegedly a member) make mistakes. They do, so get over it! (Apart from you, obviously). Because we know that humans make mistakes we need to design error-tolerant procedures so that when they do make a mistake, and they will, it isn’t catastrophic.

Hmmm, let me think how could we make flying a NPA error tolerant in terms of airspeed control? Oooh, I know, let’s make the pilots use IAS mode! There, the problem is solved in an instant and the accident won’t happen again. Quite easy really, wasn’t it! Just a pity the company’s SOPs didn’t require that and lots of people were in the habit of not doing so. That cost 4 lives.

HC your tiresome and bigoted attacks on me with your very anti-military standpoint don't do you any favours and certainly don't make any case for changing my mind about this accident.

[HeliComparator]

HC your tiresome and bigoted attacks on me with your very anti-military standpoint don't do you any favours and certainly don't make any case for changing my mind about this accident.

Oh I know there is no hope of that! But you are not the only person reading.

HELLOelloello IS THERE ANYBODY THEREerer?

Ok, maybe you are the only other person reading after all.

[HeliComparator]

From the summary: "insufficient collective pitch control input was applied by the commander to maintain the approach profile and the target approach airspeed of 80 kt. This resulted in insufficient engine power being provided and the helicopter’s airspeed reduced continuously during the final approach."

Yes, the SOPs sound daft but that should have been a red flag to any competent pilot and additional focus should have been used in the cockpit to work around it until common sense prevailed and led to a change. In the meantime, during a mechanical failure-free NPA, it was the PF who failed to lift up on the collective, and the PM who failed to monitor and register the decreasing airspeed.

FWIW I'm with Crab on this one to a certain extent. Given the plethora of good pilots willing to fly there, if a pilot is lucky enough to hold a seat in the north sea they should be exceptional at their job. A PF not flying properly, and a PM not monitoring properly isn't something that can be glossed over because the SOPs were back-to-front.

Well I’m sure your passengers will be delighted to hear that it couldn’t possibly happen to you.

[ApolloHeli]

Well I’m sure your passengers will be delighted to hear that it couldn’t possibly happen to you.

So, hypothetically, if a crew crashed the heli in the sim during a routine NPA without any systems emergencies, should the examiner say "oh well, the SOPs are backwards and pilots make mistakes, so no biggie, you pass"? This same situation, but in a simulator without consequences, or if one of the pilots on board had been competent in their role as a professional pilot and prevented the crash, the pilot(s) at fault for cocking up the flight would be put under the microscope without hesitation.

I don't think that because now that 4 or 5 people died as a result of this crash, we should pan out and find a bigger fish to paint the blame on, and ignore the fact that the crew did not do their job. If you believe that not all the blame falls on the crew, that is perfectly reasonable and supported by the facts of the report (reminder to readers that reports do not apportion blame - our individual interpretations of those facts do), but to say that the crew were victims of some bigger systematic failure that placed them into an inevitable accident when they were in fact the last line of defence from stopping the helicopter from flying into the water, I find highly questionable. The helicopter functioned exactly as described on the tin. The crew however, did not.

As always, this is simply my opinion, through my interpretation of the facts.

[[email protected]]

Ah DB, still HCs attack poodle.

News flash - NS pilots are not superior beings, they make mistakes like all other pilots and when they make those mistakes, they should own them - that is the way to learn from them not shot-gunning the blame around to preserve reputation.

Now I'm pretty sure the crew involved have done that and are rebuilding their lives, it's just the outraged ex-NS mob who seem to have a problem with it.

Not sure where apolloheli said it could never happen to him - just seems like a reflex lashing out in the playground.

[HeliMannUK]

We are still only talking about 2013 - only 7 years ago in the familiar environment of the N Sea.

Can you really be serious that training, checking and SOPs were still inadequate to prevent this accident only 7 years ago?

If that were really the case there would have been far more incidents and accidents since IMC approaches are normal fare for aviation in those parts.


There is a very thin line between a normal flight and a disaster, as pilots we SHOULD all know this. When we move away from SOPs in the cockpit or when the SOPs are flawed this line becomes thinner (not to mention the many other reasons). What I'm saying here is as pilots we get away with it, when we are close to disaster and we don't even know it. Which leads to us thinking if there hasn't been an accident for a while then its all working fine.

This is why there should be endeavours to find out why it happened and then to mitigate. Why do experts make mistakes? I think its a good question.

Crab, the OP manuals I work are updated once a year, sometimes two with many smaller directives in-between. We are constantly improving, learning, moving forward to keep safety at the forefront. I suspect CHCs ops manuals are nearly unrecognisable now than before this accident.

Flying is not that black and white.

[roundwego]

It’s not just about having good SOPs, it’s about compliance and the cultural acceptance of non compliance. It’s all very well for the company to produce perfect Ops Manuals and perfect training in the simulator but if there is a general acceptance of, and by crews to informally adopt “I know a better way of doing this” routines, it leads to the slippery slope downwards. Compliance requires good, sensible and workable SOPs and good monitoring on a day to day basis. It also requires a high level of training, not just technical but also cultural, to ensure good compliance. The number of organisational changes and economic pressures on some North Sea helicopter operators had caused a degradation of standards and standards monitoring which allowed a significant amount of SOP variations to the point when all the holes lined up and the accident occurred.

[ODEN]

Old view vs the new view

HC has moved on to the new view...some others have not...

[[email protected]]

From the Cambridge dictionary negligence
noun [ U ] (https://dictionary.cambridge.org/help/codes.html)
UK /ˈneɡ.lɪ.dʒəns/ US /ˈneɡ.lə.dʒəns/
C2
the fact (https://dictionary.cambridge.org/dictionary/english/fact) of not giving enough care (https://dictionary.cambridge.org/dictionary/english/care) or attention (https://dictionary.cambridge.org/dictionary/english/attention) to someone or something:

Miriam Webster negligence noun (https://www.merriam-webster.com/dictionary/noun)

neg·​li·​gence | \ ˈne-gli-jən(t)s \Definition of negligence
1a: the quality or state of being negligent (https://www.merriam-webster.com/dictionary/negligent)

b: failure to exercise the care that a reasonably prudent person would exercise in like circumstances

Collins Definition of 'negligence'negligence(neglɪdʒəns )
UNCOUNTABLE NOUN
If someone is guilty (https://www.collinsdictionary.com/dictionary/english/guilty) of negligence, they have failed (https://www.collinsdictionary.com/dictionary/english/fail) to do something which they ought to do.

You should be asking the question - why were they negligent? Instead of blaming poor SOPs. Poor SOPS didn't cause them to ignore the IAS. This has the hallmarks of a cultural problem which I sincerely hope has been addressed.

Nuff said

[roundwego]

From the Cambridge dictionary

Miriam Webster

Collins

You should be asking the question - why were they negligent? Instead of blaming poor SOPs. Poor SOPS didn't cause them to ignore the IAS. This has the hallmarks of a cultural problem which I sincerely hope has been addressed.

Nuff said


“Nuff said” demonstrates a completely closed mind and inability to think about the issue from a wider angle.

The word “negligent” is a subjective, opinionated and emotive word which does little to contribute to a considered and intelligent analysis of the causes of this event.

[Torquetalk]

This has the hallmarks of a cultural problem which I sincerely hope has been addressed.

Exactly. The badly managed approach is a CRM issue. Look at all the bits that contributed to it and fix them. Proper MCC and SOP adherence included.

Saying the crew were negligent doesn't‘ really do much to stop the next badly managed approach. I bet the crew concerned would give their eye teeth to go back and do it differently. And would never do it like that again. But without an analysis of why they did it that way, why the monitoring broke down, why the MCC/CRM was inadequate, the same and other needless events await to befall other crews. The crew know they buggered up. Understanding why is the lesson for all of us.

I cannot tell you how many VS mode descents with the airspeed being flown with the collective I‘ve witnessed. It was certainly the preferred method at one company. This crew were the saps who demonstrated why it isn’t a smart way to fly a helicopter.

[megan]

Sheriff Principal Derek Pyle said the reason for the error remained unknown - but that there had been "no wilful neglect" by the pilot.

In his findings he said the cause of the accident had been pilot error, but the reasons for this remained unknown."At the end of the day we know that for whatever reason or reasons the commander failed to maintain the target approach speed," he said.

He said one possible reason was in the developing knowledge of the inability of the human brain to monitor flight instruments continuously.

"There was plainly no wilful neglect," he added.

"Rather, there was, as one witness described it, a perfect storm of circumstances which resulted in all the safety barriers in place not preventing - or remedying - his one failure, to maintain the correct speed."They weren't negligent according to the inquiry.Nuff said” demonstrates a completely closed mind and inability to think about the issue from a wider angle.

The word “negligent” is a subjective, opinionated and emotive word which does little to contribute to a considered and intelligent analysis of the causes of this event.:ok: roundwego I assume crab would deem the Sheriff Principal incompetent given his finding.

The official accident report addresses human factors in some detail, so I can't understand why crab, with his extensive experience in the industry, fails in his comprehension. The trouble with human factors is it is often difficult to explain exactly the "why". Flight into the water has been a regular event in offshore operations, for various reasons, we had a Puma flown by two check and training captains go into the water on a night VMC approach to a ship, human factors had a big role to play. Interestingly some have not even been the subject of investigation, the Puma in Nigeria which went into the water for example. A lesson foregone.

https://www.youtube.com/watch?v=GLplm2nYyis

I've been involved in my own near miss on an approach to a platform in severe clear VMC, all due to human factors, which I won't elaborate on in deference to those involved, and who still don't know how they contributed, it would take volumes to explain.

[Bell_ringer]

The sheriff clearly stated “wilful neglect” ie there were no intentional faults.
It is semantics - you don’t require intent to be negligent, you simply need to not take the care and attention required to do the job properly.

Sticking your tailrotor into a bush on takeoff and ruining the aircraft is negligence - you didn’t intend to do it but you could have done more to avoid hitting it.

[[email protected]]

Wilful neglect would surely lead to criminal proceedings but that isn't the answer here.


The accident has been dissected by both the AAIB and the Sheriff Principal yet no reason can be found for the breakdown in CRM and basic piloting in this case.

Is is a Human Factors issue? Almost certainly but all the usual suspects have been looked at so what is the answer?

​​​​​​​The word negligent is hardly subjective as the different dictionary definitions show.

I stand by my original post of negligence (not wilful or intentional) because for whatever reason they failed to do what they were supposed to do despite training, checks and a great deal of experience (especially rom the commander).

Was the commander the issue? Was it a personality clash? Was it too much deference to experience?

If people don't tell the truth then we won't know - pretending they weren't negligent and that there is a mysterious and as yet unknown human factor at work is the decision of the really closed mind.

[Torquetalk]

Wilful neglect would surely lead to criminal proceedings but that isn't the answer here.


The accident has been dissected by both the AAIB and the Sheriff Principal yet no reason can be found for the breakdown in CRM and basic piloting in this case.

Is is a Human Factors issue? Almost certainly but all the usual suspects have been looked at so what is the answer?

The word negligent is hardly subjective as the different dictionary definitions show.

I stand by my original post of negligence (not wilful or intentional) because for whatever reason they failed to do what they were supposed to do despite training, checks and a great deal of experience (especially rom the commander).

Was the commander the issue? Was it a personality clash? Was it too much deference to experience?

If people don't tell the truth then we won't know - pretending they weren't negligent and that there is a mysterious and as yet unknown human factor at work is the decision of the really closed mind.


Clearly they were negligent: The PF neglected to maintain safe flight parameters; the PM neglected to monitor those parameters and intervene. Arguably, they neglected to agree and fly one or more methods of flying the approach which would have have been safer, including flying by hand.

But that doesn’t lead anywhere. It is the analysis of how they made the decisions they did which is of interest. That it was a baldy executed approach is obvious. Attributing responsibility to the crew beyond this simply has no value. They clearly did not set out to crash. What was the context in which this was possible tells us much more and will help prevent more “CRM mouth music” as you rightly said.

[DOUBLE BOGEY]

CRAB, please explain why, after this accident, the CAA launched an investigation into HOFO procedures AND substantial changes were made to all Operator's SOPs. None-the-least of which was a requirement to properly define automation management procedures. That meant Operator's, for the first time, were require to mandate when and how the automation was utilised for any given approach. In addition, SOPs require very clear Intervention Parameters to be defined and the associated calls/action required of the PM.
This was a case of bolting the door after the horse had done a runner. However, none of this could have been driven if we all sat back and simply blamed the pilot.
Having said this, there is some evidence that laid down procedures were not followed. EG, PF looking up when he should be monitoring the Instruments.

Flying a coupled approach does not require particular handling skills but does require a firm understanding of the automation management, SOPs and the pitfalls of each mode. Transitioning from IMC to VMC and the detection, recognition and acceptance of the required visual references takes experience which is exponential as the conditions approach marginal. For this reason, many HOFO seasoned Commanders would sit the P2 at the sticks (as PF) and monitor the approach themselves as they are then in the ideal position to make the difficult decisions at the bottom and take control for the landing. In addition, one can assume that the Commander's greater handling skillset facilitate an optimum deceleration to land without loosing the references.

This accident highlights many things and CRM deterioration is offered as a complicit factor. However, the decision to be PF or PM in marginal approach conditions sits with the Commander. Maybe this should be mandated to ensure that each approach exploits the optimum experience and skills of each Pilot.

In short, when the PF looks up from the Instruments without the Required References being acquired no one is really flying the helicopter.

When the safety of the approach relies on commons sense and/or best practise and not mandated procedures there will always be an opportunity for the fickle hand of fate to intervene and some poor sap to invent a new wheel (that is subsequently discovered to square).

HOFO flying is boring, repetitious and tedious because it should leave little room for original thought during NORMAL procedures.

Now CRAB, for this accident, if the Automation procedures were not defined or mandated and If the crew duties were left entirely at the discretion of the Commander how can he alone take the full blame for the result?

[rotorspeed]

It has been interesting to read of the recent debate here, which broadly agrees that the crew made the mistake(s) that caused the accident, but differs on who was to mainly to blame. It seems HC leads the lack of adequate SOPs and CRM view so therefore the fault of the operating organisation, and Crab the pilots made errors they never should have view.

I’ve never flown North Sea, or even really any multi crew, but have flown a lot of SP IFR obviously on twins in corporate ops. Skimming through the accident report again, the following seem key points. Firstly there was clearly woefully inadequate monitoring of airspeed by the crew. The need to do this on any approach, IFR or not, is clearly a fundamental piloting skill that you learn before you even go solo when training for your first licence. However as we all know, when IMC with the lack of visual cues, the scan becomes essential to ensure this. I think pretty much all of us agree that coupling to IAS not VS is a far better way to conduct an approach on 3 axis. However using VS is not disastrous – I used to use it, and clearly thousands of IFR approaches have been successfully made using it. What is used should just highlight what is left for the pilots to focus on and monitor. Being basic, with this localiser DME approach using VS, the pilots do not have to really monitor roll/heading or vertical speed, as these were coupled. The one main thing they did have to monitor closely was airspeed, and control it with collective. Even height was secondary, at least in the early stages of the approach, as it should have been more or less right given they started from a set known distance, height and VS – had the airspeed been in the window. So why didn’t the PF do this? Well, amongst the considerable chat between the crew which included bits of briefings, there was no mention at all of the fact that they were doing a VS coupled approach so that monitoring IAS was their number one priority. Of course the PF should have known this – basic stuff – and almost certainly did, but he certainly didn’t seem focussed on it at the critical time. And there was quite a bit of non-pertinent chat before the approach started. I’ll come back to this.

What made the need to monitor IAS carefully far more important than normal was they had not truly established a stabilised approach far enough out. According to the AAIB report, they had. And indeed technically they had, according to the definition. But this is an example of where reliance on the specifics of ever more extensive documentation can be counter-productive, eroding the responsibility for intelligent thought and judgement. When 1000ft at circa 3 miles they were at 108kts – upper end of the SOPs 80kt -120kt window. Right height, right course, right descent rate. But the PF had said that as the weather was on minimums, he would slow the approach to 80kts. So he only had a mile or two to slow a ? 7 tonne helicopter from 108kts to 80kts. Which clearly was going to take a big reduction in torque, which would then have to be partly reapplied to maintain the 80kts. Hardly a stabilised situation. And going to need close monitoring of AIS throughout, until a properly stabilised approach was achieved, belatedly. Surely a 10,500 hour commander with a 3000 co-pilot hour should have known that especially given the marginal weather and desire for a slow approach this should have been set up much earlier, regardless of any SOP detail and compliance?

So why did this occur? Well interestingly the other two localiser 09 approaches the commander made to Sumburgh included in the AAIB report showed similar higher speed at the start of the approach. But the difference here was far better weather – eg 900ft cloudbase – which meant that the commander was under no pressure to slow and not bothered about getting in on around minimums, so got visual still at 110kts ish and slowed much later to land VFR. It seemed that he adopted a similar early approach technique but this time belatedly intended to implement his objective of a 80kt approach, with catastrophic consequences.

The intercom chat between PF and PM to me demonstrated a dangerous blend of awareness of the weather being minimums and being challenging, yet with the slightly nervous banter and bravado of a crew trying to gloss it over and treat it too casually so neither wanted to appear too concerned to the other. I see this as a real hazard of multi crew operations – the obligation to have bandwidth to communicate as well as just concentrate on what matters flying the aircraft safely, with the assumption that the other guy knows what he is doing even if you’re not 100% sure. But then that’s where CRM is so important.

So in summary where am I on responsibility? I have to say much more on crew than operator systems. Sure the systems can improved, no doubt were and will continue to be. But this was not a situation in which a new operating system had resulted in an accident pretty soon after implementation. No doubt thousands of flights and IFR approaches had been previously carried out successfully using the operators systems, many with less experienced crew. I think we all feel for the crew’s angst from this, and also know we all make mistakes. But I also think an important way to minimise this, and hopefully eliminate the big ones, is for us all to understand how much responsibility rests on our own shoulders and not to be too quick to pass the buck to an inadequate environment.

[HeliComparator]

It has been interesting to read of the recent debate here, which broadly agrees that the crew made the mistake(s) that caused the accident, but differs on who was to mainly to blame. It seems HC leads the lack of adequate SOPs and CRM view so therefore the fault of the operating organisation, and Crab the pilots made errors they never should have view.

I’ve never flown North Sea, or even really any multi crew, but have flown a lot of SP IFR obviously on twins in corporate ops. Skimming through the accident report again, the following seem key points. Firstly there was clearly woefully inadequate monitoring of airspeed by the crew. The need to do this on any approach, IFR or not, is clearly a fundamental piloting skill that you learn before you even go solo when training for your first licence. However as we all know, when IMC with the lack of visual cues, the scan becomes essential to ensure this. I think pretty much all of us agree that coupling to IAS not VS is a far better way to conduct an approach on 3 axis. However using VS is not disastrous – I used to use it, and clearly thousands of IFR approaches have been successfully made using it. What is used should just highlight what is left for the pilots to focus on and monitor. Being basic, with this localiser DME approach using VS, the pilots do not have to really monitor roll/heading or vertical speed, as these were coupled. The one main thing they did have to monitor closely was airspeed, and control it with collective. Even height was secondary, at least in the early stages of the approach, as it should have been more or less right given they started from a set known distance, height and VS – had the airspeed been in the window. So why didn’t the PF do this? Well, amongst the considerable chat between the crew which included bits of briefings, there was no mention at all of the fact that they were doing a VS coupled approach so that monitoring IAS was their number one priority. Of course the PF should have known this – basic stuff – and almost certainly did, but he certainly didn’t seem focussed on it at the critical time. And there was quite a bit of non-pertinent chat before the approach started. I’ll come back to this.

What made the need to monitor IAS carefully far more important than normal was they had not truly established a stabilised approach far enough out. According to the AAIB report, they had. And indeed technically they had, according to the definition. But this is an example of where reliance on the specifics of ever more extensive documentation can be counter-productive, eroding the responsibility for intelligent thought and judgement. When 1000ft at circa 3 miles they were at 108kts – upper end of the SOPs 80kt -120kt window. Right height, right course, right descent rate. But the PF had said that as the weather was on minimums, he would slow the approach to 80kts. So he only had a mile or two to slow a ? 7 tonne helicopter from 108kts to 80kts. Which clearly was going to take a big reduction in torque, which would then have to be partly reapplied to maintain the 80kts. Hardly a stabilised situation. And going to need close monitoring of AIS throughout, until a properly stabilised approach was achieved, belatedly. Surely a 10,500 hour commander with a 3000 co-pilot hour should have known that especially given the marginal weather and desire for a slow approach this should have been set up much earlier, regardless of any SOP detail and compliance?

So why did this occur? Well interestingly the other two localiser 09 approaches the commander made to Sumburgh included in the AAIB report showed similar higher speed at the start of the approach. But the difference here was far better weather – eg 900ft cloudbase – which meant that the commander was under no pressure to slow and not bothered about getting in on around minimums, so got visual still at 110kts ish and slowed much later to land VFR. It seemed that he adopted a similar early approach technique but this time belatedly intended to implement his objective of a 80kt approach, with catastrophic consequences.

The intercom chat between PF and PM to me demonstrated a dangerous blend of awareness of the weather being minimums and being challenging, yet with the slightly nervous banter and bravado of a crew trying to gloss it over and treat it too casually so neither wanted to appear too concerned to the other. I see this as a real hazard of multi crew operations – the obligation to have bandwidth to communicate as well as just concentrate on what matters flying the aircraft safely, with the assumption that the other guy knows what he is doing even if you’re not 100% sure. But then that’s where CRM is so important.

So in summary where am I on responsibility? I have to say much more on crew than operator systems. Sure the systems can improved, no doubt were and will continue to be. But this was not a situation in which a new operating system had resulted in an accident pretty soon after implementation. No doubt thousands of flights and IFR approaches had been previously carried out successfully using the operators systems, many with less experienced crew. I think we all feel for the crew’s angst from this, and also know we all make mistakes. But I also think an important way to minimise this, and hopefully eliminate the big ones, is for us all to understand how much responsibility rests on our own shoulders and not to be too quick to pass the buck to an inadequate environment.

Your individual points are all valid of course, but I come to a different overall conclusion.
Yes of course the pilots should have been monitoring the airspeed more closely. But as I have intimated, humans make mistakes and the whole point of SOPs and multi-pilot ops is to reduce the severity of a mistake to the point that it becomes inconsequential. Nor is it “back and white” - yes lots of people including this crew, had made approaches along the same lines without incident. But that doesn’t really matter. The question should be, were the SOPs and MCC reasonably optimal to prevent a mistake from becoming catastrophic - that being the duty of an operator, surely? I suggest the answer is No.

So when the **** hit the fan and the circumstances and mistakes lined up, did the company SOPs help avoid a catastrophe? No.

And what about the training programme. Had the copilot ever had any formal training about the role of PM during an onshore instrument approach? I’m not sure, but I strongly suspect not. This, as I said earlier, due to a regulatory obsession with the PF role despite it being a multi-pilot helicopter. I well remember the standard briefing for many years given by the examiner to a crew undergoing a check in the sim - “The copilot will be competent but without showing any initiative”. What a great way to train for PM role!

And whilst I am on about the regulator, for years the regulator disallowed automation to be used during checks. The autopilot was deemed to be in the mythical state whereby the basic stabilisation, attitude hold, maintaining current heading hold and co-ordinated turn were all functional, but altitude hold, IAS hold, selected heading hold and coupling to nav, ILS, VOR were all deemed inoperative. So all the training was about manual flying, none of it was about correct use of automation. How crazy is that!?

By 2013 in our company, due to a lot of fighting by me and a sensible flight ops inspector, we were eventually allowed to use the automation as intended during checks on the 225 fleet. But it was a major struggle and one which I’m not sure CHC ever fought or won.

So yes the pilots should have monitored airspeed better and should have been coupled to IAS, but their safety net in terms of company SOPs and the culture extant both in the company and the regulator, failed them and their passengers.

[ApolloHeli]

Your individual points are all valid of course, but I come to a different overall conclusion.
Yes of course the pilots should have been monitoring the airspeed more closely. But as I have intimated, humans make mistakes and the whole point of SOPs and multi-pilot ops is to reduce the severity of a mistake to the point that it becomes inconsequential. Nor is it “back and white” - yes lots of people including this crew, had made approaches along the same lines without incident. But that doesn’t really matter. The question should be, were the SOPs and MCC reasonably optimal to prevent a mistake from becoming catastrophic - that being the duty of an operator, surely? I suggest the answer is No. (Bold added for emphasis)

If both pilots aren't doing their job, then SOPs are irrelevant. In this case, as recently brought up, the PF wasn't abiding by SOPs anyways as both crew had their heads out of the cockpit simultaneously.

I feel like we all agree that the SOPs could have been better - I'm yet to see someone make a claim to the contrary, but while I believe that the crew's performance on this approach most likely would have led to an accident regardless of the SOPs, I get the impression that you seem to believe that with both crew staring out of window and no eyes on the flight parameters, that a different set of SOPs would have stopped them from hitting the water.

I concede to your point (highlighted in bold), maybe with different automation guidelines they might have been able to pull it out of the bag once the EGPWS starting howling if the IAS had been kept above ETL by virtue of different SOPs, but I believe to say that the crew were simply victims here is going too far. As crab stated, they were negligent. Not wilfully, but negligent in their responsibility as flight crew members nonetheless.

[212man]

And whilst I am on about the regulator, for years the regulator disallowed automation to be used during checks. The autopilot was deemed to be in the mythical state whereby the basic stabilisation, attitude hold, maintaining current heading hold and co-ordinated turn were all functional, but altitude hold, IAS hold, selected heading hold and coupling to nav, ILS, VOR were all deemed inoperative. So all the training was about manual flying, none of it was about correct use of automation. How crazy is that!?

By 2013 in our company, due to a lot of fighting by me and a sensible flight ops inspector, we were eventually allowed to use the automation as intended during checks on the 225 fleet. But it was a major struggle and one which I’m not sure CHC ever fought or won.

So yes the pilots should have monitored airspeed better and should have been coupled to IAS, but their safety net in terms of company SOPs and the culture extant both in the company and the regulator, failed them and their passengers.

Beat me to it!

At the time of the As332L2 introduction - and even the 225 later - the CAA were in the absolute dark ages when it came to policy on the use of automation and FMS in training and testing for RW aircraft, despite an entirely logical and appropriate attitude for FW for many years. Consequently, the associated SOPs were poorly developed and were not actually used during testing/checking, as the pilots were busy hand flying as if they were in an S61!

I well remember seeing the minutes of a meeting of the CAA Training Standards Liaison (with industry heads of training) Group in 2004, when it was stated that the use of ALT hold could be condoned whilst writing down the ATIS! Can you imagine where BA would have been at that time? They certainly didn't have their B777 pilots hand flying approaches and following green needles.

As HC says, it was the lobbying by him and his company, plus the increased exposure of CAA Ops Inspectors to line flying these newer machines, that led to a change in policy. As a UK TRE, introducing the EC155 into service, I wrote to the CAA Head of Training and Standards around 2002 querying this very subject. To this day, I wish I had printed and framed his response. As we were not actually operating under that regulatory environment I carried on and did what I thought was right - and our actual regulator's inspectors, who had purely FW airlines backgrounds, did not bat an eyelid when observing our simulator sessions. To his credit, a few years later he was on the S92 JOEB, and had a 180 degrees change of view.

That said, I am as bemused as anybody as to how there was such a breakdown in monitoring. Regardless of the IAS, there would have been other cues too - pitch attitude, wind noise, rotor noise, 'seat of the pants' rate of descent increase. All in all, very sad.

[HeliComparator]

(Bold added for emphasis)

I concede to your point (highlighted in bold), maybe with different automation guidelines they might have been able to pull it out of the bag once the EGPWS starting howling if the IAS had been kept above ETL by virtue of different SOPs.

So let’s re-run the approach with the same crew, same weather, same monitoring of IAS but with one difference - SOP mandated, and company culture supported, the use of IAS mode during such approaches. The accident would not have happened. I’m not sure how much clearer it could be!

[rotorspeed]

But HC surely the issue here is not primarily on whether IAS or VS coupling was used - it is that the crew were supposed to be monitoring a parameter and weren’t. With AIS hold, that type of error could have caused them to not monitor VS sufficiently with the result they dived the aircraft into the sea with a grossly excessive ROD and not enough time to recover.

[[email protected]]

DB CRAB, please explain why, after this accident, the CAA launched an investigation into HOFO procedures AND substantial changes were made to all Operator's SOPs. I would think that it was because they were horrified that a licensed, professional crew could make such fundamental errors and needed to find out why this crew did things so badly compared to others. I'm sure the CAA inspector's first thought on this was 'How the f*** did they manage that?'

HC So let’s re-run the approach with the same crew, same weather, same monitoring of IAS but with one difference - SOP mandated, and company culture supported, the use of IAS mode during such approaches. The accident would not have happened. I’m not sure how much clearer it could be! If your pilots aren't going to follow SOPs anyway, what difference would it make? It was so much more than just the use of VS mode, it was, as rotorspeed highlights, their whole attitude to the approach that was wrong.

You can't absolve them of their responsibility to fly the F'ing aircraft - that doesn't need to be in SOPs, that is a BASIC tenet of airmanship.

Rotorspeed - great post last but one, very reasoned:ok:

[HeliComparator]

But HC surely the issue here is not primarily on whether IAS or VS coupling was used - it is that the crew were supposed to be monitoring a parameter and weren’t. With AIS hold, that type of error could have caused them to not monitor VS sufficiently with the result they dived the aircraft into the sea with a grossly excessive ROD and not enough time to recover.

No I disagree. There is a massive difference between response to the collective with high RoD and low airspeed, vs the response with high Rod and airspeed around Vy. In the former case, as the accident demonstrates, pulling up the collective doesn’t do much. In the latter case, pulling on the collective has a nearly immediate result of stopping and reversing RoD. And of course there is scope to raise the nose too, to convert horizontal speed into vertical speed which isn’t the case with very low airspeed.

Just like a fixed-wing, IAS is THE most important parameter because with adequate airspeed, the helicopter is easily controllable. With inadequate airspeed, the helicopter is barely controllable as this accident demonstrates. If the collective had been raised at the same altitude as it was raised in this accident, but with plenty of airspeed, the accident wouldn’t have happened.

[rotorspeed]

Sorry HC but I think you’re being naive here. You can’t just take exactly the same circumstances. It is the principle that matters. The wx could easily have been say 100ft base and 300m vis 1 mile out. Or even on the deck. Without VS monitoring and a high ROD they’d be in the sea. All the time pilots are allowed to be pilots, utilising judgment and skill, there will be the potential for mistakes and accidents if things are not done properly.

Thanks Crab! 👍

[roundwego]

It is interesting that no one has mentioned the different ability to recognise changing parameters using vertical strip indicators rather than clock style ones. On a clock style indicator one just has to glance at the position of the needle to recognise a relative value. On a strip indicator, one has to actually read a numeric value and then translate that into a value which is then compared with “normal”. For example, if the 3 o'clock position on a conventional ASI relates to Vy then a glance at the gauge will ring an unconscious bell saying “I am at the point where any reduction in speed will need more power to stop an increase in ROD”. A strip indicator requires one to read a digital value, convert it to an analogue mental model and then compare that with a Flight Manual graph before concluding a consequence.

Which option do you think is the easier processing function?

[[email protected]]

It's a good point Roundwego and one reason the Military kept with QFE since when the clock got to zero you were at the ground.

I converted to glass cockpit after 32 years of analogue and it was strange to start with but soon became second nature - you have in your head your minima on approach and on some displays you can put a bar there as a visual reminder (this was 365 N3).

Having got used to screens and then going back to analogue, that was equally strange and took a while to get used to.

I don't know what the AS332L2 had but it seems from other posters that it would be normal to have the ALTA set at MDA - this crew did not and it might have saved them.

[helicrazi]

It's a good point Roundwego and one reason the Military kept with QFE since when the clock got to zero you were at the ground.

I converted to glass cockpit after 32 years of analogue and it was strange to start with but soon became second nature - you have in your head your minima on approach and on some displays you can put a bar there as a visual reminder (this was 365 N3).

Having got used to screens and then going back to analogue, that was equally strange and took a while to get used to.

I don't know what the AS332L2 had but it seems from other posters that it would be normal to have the ALTA set at MDA - this crew did not and it might have saved them.

How would ALTA have helped? Its IAS that would have helped. Without IAS, ALTA would have hindered the situation.

[HeliComparator]

How would ALTA have helped? Its IAS that would have helped. Without IAS, ALTA would have hindered the situation.

Exactly so. Let’s hope Crab is never in a position to write SOPs!

[DeltaNg]

It is interesting that no one has mentioned the different ability to recognise changing parameters using vertical strip indicators rather than clock style ones. On a clock style indicator one just has to glance at the position of the needle to recognise a relative value. On a strip indicator, one has to actually read a numeric value and then translate that into a value which is then compared with “normal”. For example, if the 3 o'clock position on a conventional ASI relates to Vy then a glance at the gauge will ring an unconscious bell saying “I am at the point where any reduction in speed will need more power to stop an increase in ROD”. A strip indicator requires one to read a digital value, convert it to an analogue mental model and then compare that with a Flight Manual graph before concluding a consequence.

Which option do you think is the easier processing function?

I certainly think UA's in a Glass Cockpit require a few hundred milliseconds more thought than an analogue cockpit. Same for engine intruments, the bodies used to be rotated so in the normal range the needle pointed vertically upwards. Easy to spot one needle abnormal as a quick glance, before it gets to the amber. Not so with digital.

I'm all for technology, but I have always been disappointed with 'next gen' helicopters.

[HeliComparator]

On round vs strip, I certainly used to think round was better. But once I had got used to strip, I can’t say it was an issue. Strip ASI has the advantage of the trend arrow so you can see at a glance what if any rate of change of airspeed you have, rather than having to check the round gauge twice, or once for longer than ideal.

[212man]

HC - does the L2 have the speed trend arrow? If it does it makes this event even more baffling.

[helicrazi]

HC - does the L2 have the speed trend arrow? If it does it makes this event even more baffling.

Only if they looked at it, which they obviously weren't, so it wouldnt have mattered how many trend arrows there were, isnt the point that no one was watching the instruments?

[DeltaNg]

I think that Airbus vs Leonardo displays have different pros and cons.

[212man]

I think that Airbus vs Leonardo displays have different pros and cons.
What cons do the airbus ones have?

having relooked at the report I see there is a speed trend arrow. I also see a lot of altimeter vs range cross-checking, so clearly the PFD was being looked at. Hard to imagine how the rapidly growing yellow arrow would not catch your eye.

interesting to see also that they were briefing to break the minimums if they did a second approach!

[helicrazi]

interesting to see also that they were briefing to break the minimums if they did a second approach!

when you have no fuel for anywhere else, what else would you do?

[HeliComparator]

What cons do the airbus ones have?

having relooked at the report I see there is a speed trend arrow. I also see a lot of altimeter vs range cross-checking, so clearly the PFD was being looked at. Hard to imagine how the rapidly growing yellow arrow would not catch your eye.

interesting to see also that they were briefing to break the minimums if they did a second approach!

Without trawling through the report again - so from memory: the rate of deceleration was initially fairly modest. IIRC PM called “airspeed” when it was still around 40kts, this more or less coincided with the nose pitching up and rate of deceleration increasing markedly, so possibly it was the arrow that attracted his attention. At 40kts a recovery was still quite possible but for whatever reason the captain only applied the collective very slowly - something like 8 seconds to go from not much collective to a too-late armful. Some kind of internal denial that the situation was critical, perhaps?

[212man]

when you have no fuel for anywhere else, what else would you do?
Did they not have fuel for Scatsta?

[Shell Management]

Did they not have fuel for Scatsta?
The Total radio operator had neglected to give them Scatsta weather.:ugh:That would never have happened at a Shell facility:ok:

[helicrazi]

Did they not have fuel for Scatsta?

Im unsure, however, having fuel for Scatsta and getting into Scatsta are very different things

[ApolloHeli]

I think it's important to re-mention that they had planned for two approaches at Sumburgh and then a diversion to Scatsta. This accident occurred on the first approach to Sumburgh.

[SimonK]

Im unsure, however, having fuel for Scatsta and getting into Scatsta are very different things

Indeed.. I was flying that day into Scatsta and have a photo somewhere at about the same time the 332 crashed, i seem to recall it was glorious weather and in my experience of 7 years of flying out of there, my opinion is that the weather was generally significantly better at Scatsta than down at Sumburgh which was I believe, one of the original factors behind the decision to start Scatsta up again all those years ago. Sadly the islands aren’t big enough (or the oil price isn’t anymore) to support 2 IFR airfields in the Shetlands.

[ApolloHeli]

Indeed.. I was flying that day into Scatsta and have a photo somewhere at about the same time the 332 crashed, i seem to recall it was glorious weather and in my experience of 7 years of flying out of there, my opinion is that the weather was generally significantly better at Scatsta than down at Sumburgh which was I believe, one of the original factors behind the decision to start Scatsta up again all those years ago. Sadly the islands aren’t big enough (or the oil price isn’t anymore) to support 2 IFR airfields in the Shetlands.
(Bold added by me for emphasis)

How come the report states the weather at the time as BKN/OVC* 300ft at the time of the accident?

*Correct as necessary - I just remember from the report it was similar to the conditions at Sumburg.

[helicrazi]

Indeed.. I was flying that day into Scatsta and have a photo somewhere at about the same time the 332 crashed, i seem to recall it was glorious weather and in my experience of 7 years of flying out of there, my opinion is that the weather was generally significantly better at Scatsta than down at Sumburgh which was I believe, one of the original factors behind the decision to start Scatsta up again all those years ago. Sadly the islands aren’t big enough (or the oil price isn’t anymore) to support 2 IFR airfields in the Shetlands.

You and I have different interpretations of glorious...

Having reread the report, the 1720 at Scatsta (within minutes of the accident) the vis was 4700m and cloud overcast at 300ft.

[SimonK]

You and I have different interpretations of glorious...

Having reread the report, the 1720 at Scatsta (within minutes of the accident) the vis was 4700m and cloud overcast at 300ft.

Yeah fair point about the “glorious”. I landed at 1635 in Scatsta with Capt Jean on the 23rd and the 1620z Metar shows broken at 700’ and 5000m, however I distinctly remember it was lovely weather most of the way home and an easy approach into Scatsta. As anyone who’s flown out an island airport knows, the weather forecast, actual and what is really happening can be 3 very different situations.

My experience of flying out of the Shetlands is that local knowledge was worth its weight in gold, those south-easterly winds always brought on a cold sweat at the prospect of the rapid onset of fog. Luckily for us up there Sumburgh normally fogged out first and on ‘interesting’ weather days we’d be listening to the Sum ATiS on the way out to the basin not just on the way back and more than once I’ve turned around as Sum started fogging out.

RIP.

Edit: 1650z metar is almost identical too 5000m and BKN007, but as others above mentioned 1720 shows rapid decline to OVC003. The accident was at 1717.

[[email protected]]

How would ALTA have helped? Its IAS that would have helped. Without IAS, ALTA would have hindered the situation. It is the thought process that it would have helped - highlighting the need to obey minimums and plan to level off or go around at MDA.

You just can't help yourself having a pop can you HC?

I spent my Friday and Saturday teaching NVD and SAR, what did you do?

[HeliComparator]

It is the thought process that it would have helped - highlighting the need to obey minimums and plan to level off or go around at MDA.

You just can't help yourself having a pop can you HC?

I spent my Friday and Saturday teaching NVD and SAR, what did you do?

Yes I do apologise, it is most unpleasant when you are on the receiving end of someone accusing you of negligently supplying dangerously misleading information.

Thanks for asking, I spent my Friday and Saturday on my boat.

[[email protected]]

Yes I do apologise, it is most unpleasant when you are on the receiving end of someone accusing you of negligently supplying dangerously misleading information.At what point did I accuse you of that? Since that is what you seem to be implying.

Thanks for asking, I spent my Friday and Saturday on my boat. Far away from aircraft then:E

[DOUBLE BOGEY]

At what point did I accuse you of that? Since that is what you seem to be implying.

Far away from aircraft then:E

My Dear CRAB, HC is enjoying his well earned retirement. All in all...…..the boat sounds better than droning around the sky.

I know you like to think you "Own" the glory days of mandrualic flying. Well...… we used to fly into Sumburgh with nowt but a an NDB needle (twitching like the tail of a ****ting dog), black and white stormscope radar (the only colour on it was egg from the last crews breakfast) and a very good idea of what the ground looked like on the radar screen (lumpy bits).
This was an S61NM with an AFCS that did not have holds. Just stabilisation!! (Oh and a little blue triangle know that let you change the heading automatically by I think about 6 degrees - memory failing).

[[email protected]]

I know you like to think you "Own" the glory days of mandrualic flying. Not sure where you got that idea either..........But I'll see your NDB and raise you Decca Nav and a coffee grinder ADF on the Wessex:)

the boat sounds better than droning around the sky. I'll stay flying while I'm still young enough to do so thanks, saving boats and golf for when I am properly old:) Much of my experience with boats has been rescuing people from them:ok:

And for HC - this is where I got the idea that it was normal to use ALTA on a coupled approach My understanding of this approach was the V/S was active to a preset ALT.A. So ALT would deploy at the set altitude. The previous stabilised approach during the descent then destabilised as there was no automatic or manual modulation of the power (collective). That was DB earlier in the thread.

[DOUBLE BOGEY]

Hi Crab,

It is normal to use ALT.A for 2D approach (provided it is not CDFA) but normaly only in 4-Axis mode, to capture a MDA/H.

I also spent a year when the DECCA+Moving Map was still the primary area navaid on a couple of our 61s.

Going back further, Gazelle AH1 SPIFR with no SAS and with Doppler mini-TANs in the BAOR IF Corridor...………..

So I will see your DECCA and raise you Doppler Mini-TANs which was as much use as tits on a fish!

We keep going until we get to a magnetised darning needle in a pool of the co-pilots piss and a hand drawn map from a Pirates stash!

[HeliComparator]

At what point did I accuse you of that? Since that is what you seem to be implying.


You didn’t and I wasn’t.


<Note to self: next time I need to bear in mind the cognitive abilities of the recipient>

[Fareastdriver]

Going back further, Gazelle AH1 SPIFR with no SAS and with Doppler mini-TANs in the BAOR IF Corridor...……….

Or going back further Whirlwind 10s with no AFCS, or trim: Let the stick go and it fell over and the aeroplane followed it. Even further back the Sycamore with no AFCS, no hydraulics and controls that were so heavy that there were wheel operated springs so you could control the the wooden rotor system. That was after you had pumped a water/glycol mix to or from the boom so it would stay within CofG limits.

You telling us you have to write an SOP to punch FMS buttons?????

[helicrazi]

Or going back further Whirlwind 10s with no AFCS, or trim: Let the stick go and it fell over and the aeroplane followed it. Even further back the Sycamore with no AFCS, no hydraulics and controls that were so heavy that there were wheel operated springs so you could control the the wooden rotor system. That was after you had pumped a water/glycol mix to or from the boom so it would stay within CofG limits.

You telling us you have to write an SOP to punch FMS buttons?????

I'll top trump you all, I survived an R22 :E

[[email protected]]

<Note to self: next time I need to bear in mind the cognitive abilities of the recipient> Well you are the senior citizen so cognitive abilities are bound to concern you more than me:)

So I will see your DECCA and raise you Doppler Mini-TANs which was as much use as tits on a fish! DB, I've done the IFR AH1 Gazelle stint too - the LWNA, lightweight nav aid was no better - just a doppler based system that always wandered.:ok: The Lynx TANS was just as crap!

We keep going until we get to a magnetised darning needle in a pool of the co-pilots piss and a hand drawn map from a Pirates stash! or Wessex night flying in the mountains with no goggles using a clock and the compass:)

[[email protected]]

I'll top trump you all, I survived an R22 Helicrazi - me too but one on its side in a field:)

[handysnaks]

The Lynx TANS was just as crap!

But good for useless memory recall!
I last operated in a Lynx AH1 as a ACM(O) in early 1984, I can still remember the Lat and long we used to enter for the Apron/Dispersal at Detmold was N51565 E008543 and I'm pretty sure the 10 figure Grid Reference was 49530 85470

[[email protected]]

Hahaha - excellent handysnaks:ok:

[diginagain]

The Total radio operator had neglected to give them Scatsta weather.:ugh:That would never have happened at a Shell facility:ok:
I'm sure that had they asked, the Borgsten's RO could have provided it, or I could have walked across the helideck and handed it to them.

[Medmerry]

I used to work on XZ244 in 1981/82. I remember quizzing Peter Brouard on the need for door maintenance as he worked on the starboard door. He said if it came off in flight it would hit the tail rotor and he knew the height and speed which was best for crew survivability if that happened, over the sea that is.

[212man]

I used to work on XZ244 in 1981/82. I remember quizzing Peter Brouard on the need for door maintenance as he worked on the starboard door. He said if it came off in flight it would hit the tail rotor and he knew the height and speed which was best for crew survivability if that happened, over the sea that is.
I saw its remnants in the RN accident investigation branch hangar. A very sad incident but hard to see how it relates to this post? They went ‘feet dry’, opened the door that then came off and struck the TR. They crashed on land.

[Medmerry]

XZ244 was mentioned in this post by someone else, that's why I mentioned it.