FAI into Clutha crash opens

[sooty655]

https://www.bbc.co.uk/news/uk-scotland-glasgow-west-47831108

[dervish]

Thanks Sooty.

Disgusting behaviour in court as the 14 legal eagles present, plus their aides, drowned out the minute's silence and family statements. And then a hoohah over a daily tabloid getting hold of images from the CCTV.

[anchorhold]

I am really not sure what an enquiry of up to six months hope to achieve other than boosting the lawyers fees, The AAIB findings are clear. The relatives need closure, there claims in law are without question, and it would seem best that they have closure and financial settlement as soon as possible.

What is it about Britain, endless enquiries led by some retired judge, going on for months and years. A case in point, the Grenfell Tower, very obviously down to building standards/materials yet attempts to blame London Fire Brigade, who did there very best under the circumstances.

[DrinkGirls]

anchorhold
The relatives DO need closure. This isn’t endless inquiries, this is THE inquiry. The AAIB report will be part of it. An inquest doesn’t just look at why the helicopter crashed. It looks at post crash responses, lessons to be learned and more importantly, how EACH and every victim died. It looks at many many things other than the accident report. In other words, it’s vital. So, apology accepted.
Now, why don’t we all listen to what is said over the next 6 months, see if we can learn anything new about what happened and let the families have the inquest that they deserve. It’s not all about compensation you know.........

[tucumseh]

The FAI is also vital as it is the first time families will have the opportunity to ask questions. And a FAI is not the same as an Inquiry like Grenfell. It is the equivalent of a Coroner's Inquest.

[GC47G]

Is it me or does the industry outsiders ie the public understand what actually happened , but day two into the inquiry it’s so hard to read what the press is still publishing ! .

[KNIEVEL77]

It still worries me that we will never find out what actually happened, there are so many conflicting reports of the event that night.
For the families sake, I hope they get all of the answers they are looking for and nothing is covered up.

[DOUBLE BOGEY]

KNIEVEL - There are known facts. Such as the fuel remaining was located in the MAIN TANK and the SUPPLY tanks were all but empty. The Rotor RPM decayed beyond that what was recoverable.

The problem is how did these situations arise? There are known causes to get to these situation but we do not know what exactly occurred to deliver them. In my opinion, we will never know given that the helicopter did not have CVR/FDR.

Without the flight recorders major pieces of the puzzle are missing.

So not conflicting reports of what happened. What happened is relatively clear. The WHY is the bit that cannot be fully understood or answered.

I believe that as the inquiry progresses it will become clear to the board that without CVR/FDR data a complete understanding of why it happened will never be reached.

[Thomas coupling]

To emphasise:

Remaining fuel was not available to the main tank. Engine(s) stopped as a consequence.
The Nr decayed below its recoverable limit. Pilot was therefore unable to control the landing.

[RVDT]

To correct the emphasis -

To emphasise:

Remaining fuel was not available from the main tank. Engine(s) stopped as a consequence.
The Nr decayed below its recoverable limit. Pilot was therefore unable to control the landing.

All the remaining fuel was in the main tank.

My theory is that the POLIS know something as has been eluded to before - whether it comes out in the inquiry will be the interesting part.

[n5296s]

Seems to me this will forever remain a mystery, in the absence of a CVR. It's beyond comprehension how an experienced and by all accounts excellent pilot could have (a) ignored multiple low fuel warnings (b) forgotten to turn the transfer pumps back on and then (c) when the inevitable happened, failed to enter autorotation, for which you'd expect him to be spring-loaded considering the fuel situation.

It makes me think of some classic rail accidents where the driver's actions are just beyond comprehension: Moorgate in 1975, or Grantham in 1906 (where the driver was seen calmly staring ahead, travelling at full speed into a low speed curve).

[DrinkGirls]

n5296s, I agree.
RVDT, wise words. We have months of testimony to listen to. I think there COULD be a lot of information available to fill in the gaps from the AAIB report. There is no doubt with anyone as to WHAT happened, however I hope the families (and industry) can be educated further as to any reasons WHY it happened. I’m optimistic that Strathclyde Police have carried out a thorough unbiased investigation..........

[GC47G]

DrinkGirls, I think everyone would agree that the aaib report isn’t that far from the mark and the downloads much the same , can someone tell me what the ops procedure was at the time regarding fuelling Especially given the time of night and the very very limited locations to do at anytime of the day never mind that time of night, bottom half of page 17 and 18 to me answers a lot .

[tucumseh]

fill in the gaps from the AAIB report

It would seem the immediate concern of the families is that they want to see the original report, and hear an explanation of why bits were edited; but this has been refused. Much of this will be entirely innocent and routine, but there are well-known examples of Inspectors being overruled and the final report being a bit thin.

[Nige321]

From the BBC reports:

Mr Cook, who was part of the team that prepared the AAIB report, told the court about the communication on board helicopter.He said it was the responsibility of the pilot to liaise with Air Traffic Control. Separately, the Police Scotland Airwave system was used for operational purposes.He told the hearing both means of communication were recorded.



Perhaps the Airwave comms will come out in court...

[tigerfish]

That is the bit that I really want to hear. What were my colleagues saying their control room in the last minutes of that flight? Why had that flight been stretched to such a last few gasps of their endurance?.. The Strathclyde Unit had previously covered a fairly restricted area. Suddenly it was covering the whole of Scotland! So what pressures were now being put on that unit to succeed?

TF

[DOUBLE BOGEY]

Tiger fish. I understand your sentiments........but, majority of helicopters operations offer the opportunity to exploit your useable endurance. Try HOFO. You will spend majority of your flight time obsessed with your tank contents. Surely we cannot claim fuel management issues are not our fault cos we are under pressure. If that were the case FW and RW would be dropping out the sky every day.

[tigerfish]

DB, I think that you mis understand me! Firstly I was in direct control of a Police Air Unit for quite some time, so I do understand Police Air Ops. My comments fall under two main area's firstly to highlight the folly of expecting one aircraft to potentially cover the whole of Scotland! That single aircraft was fine and Adequate to cover its original patch - Strathclyde. but the whole of Scotland??? So I would look at the tasking of the Aircraft.

But more importantly I would be looking very closely at Police Control Room tapes. When a member of the Internal Investigations branch I seized such records very often and it is surprising what they can reveal! I would remind you of the tragic accident that befell the East Midlands Police twin Squirrel Aircraft that took off from an isolated base late one night and immediately ran into unseen low cloud. Disorientation followed and the aircraft crashed just outside its own base. BUT no - one knew that it had crashed until a badly injured crew member crawled back to the unit and used a phone there to call for assistance. As a result of that accident mandatory pre and post take off and landing transmissions had to be made to Police Control rooms. In addition police air units then started to speak to their control rooms more often ! So again I ask why was there no comment made in the AAIB report regarding the examination of the Airwave tapes? It is one of the first things that I as an investigator would have expected. It may well have been done, perhaps nothing was said by the Police Officers but I find that difficult to accept.

TF

[HeliComparator]

DB, I think that you mis understand me! Firstly I was in direct control of a Police Air Unit for quite some time, so I do understand Police Air Ops. My comments fall under two main area's firstly to highlight the folly of expecting one aircraft to potentially cover the whole of Scotland! That single aircraft was fine and Adequate to cover its original patch - Strathclyde. but the whole of Scotland??? So I would look at the tasking of the Aircraft.

But more importantly I would be looking very closely at Police Control Room tapes. When a member of the Internal Investigations branch I seized such records very often and it is surprising what they can reveal! I would remind you of the tragic accident that befell the East Midlands Police twin Squirrel Aircraft that took off from an isolated base late one night and immediately ran into unseen low cloud. Disorientation followed and the aircraft crashed just outside its own base. BUT no - one knew that it had crashed until a badly injured crew member crawled back to the unit and used a phone there to call for assistance. As a result of that accident mandatory pre and post take off and landing transmissions had to be made to Police Control rooms. In addition police air units then started to speak to their control rooms more often ! So again I ask why was there no comment made in the AAIB report regarding the examination of the Airwave tapes? It is one of the first things that I as an investigator would have expected. It may well have been done, perhaps nothing was said by the Police Officers but I find that difficult to accept.

TF

The airwave recordings are mentioned in the report. Amongst other things it says there were no communications hinting at fuel or aircraft concerns, and none at all in the few minutes before the first engine flamed out. Bottom of page 73.

[DOUBLE BOGEY]

Hi HC, how's it going? Trust you are keeping well.

[tigerfish]

DB,
HC has quite properly corrected me, and I am sorry for having doubted you. I only saw an abridged version of the report and that key bit of information was missing. Nevertheless I remain mystified as to how an experienced crew, who must have been aware of the developing situation, failed to convey their concern to their control room. I guess that we will never discover what really happened that night. The Pilot and the Police Crew were all experienced yet..........

TF

[DOUBLE BOGEY]

Tiger fish, just my opinion but I don’t believe the crew fully understood or were aware of their situation until the first engine failed. Knowledge, understanding, comprehension leading to appropriate behaviour. When the knowledge or understanding is deficient......................

[AnFI]

Tiger fish, just my opinion but I don’t believe the crew fully understood or were aware of their situation until the first engine failed. Knowledge, understanding, comprehension leading to appropriate behaviour. When the knowledge or understanding is deficient......................

yeah, that's the problem with complexity, in order for you to potentially benefit from the sliveringly thin upsides of engine redundancey, you have to FIRST not kill yourself by one of the other 100 times more likely causes of death... the biggest of which (OBVIOUSLY) is the point you make... "pilot *****d up" *... 80% of the reason anyone kills themselves.


*
btw "pilot *****d up" IS NOT neccessarily the pilot's fault.

IF the Regulator or Designer makes it possible for a pilot of THIS caliber to F'UP then OBVIOUSLY it is NOT his fault - it's their's. Right?

[DOUBLE BOGEY]

ANFI - Oh! the joy of your SEH/MEH debate. To be clear though, the EC135 has effectively 3 separate tanks. 2 transfers pumps (one effectively for redundancy) and no booster pumps. Its simple. Provided you understand how its supposed to work and be managed in flight. Almost identical to the BO105.
The helicopter I operate at the moment is about 40 years older by design, has 10 tanks, cross-feeds, interconnects, transfer pumps, booster pumps and a bunch of NRVs. The main reason for all this gubbins is the design of the airframe leaving only small spaces to house the fuel meaning lots of tanks.
In the case of the EC135, fuel starvation. The difference between the two supply tanks offers the pilots 30-40 seconds to react to what could happen next. Its not a lot and it requires the pilot to know this. Its the second engine that offers this chance.

Having said that, a pilot who understands the EC135 fuel system should NEVER end up with fuel starvation provided the contents and warning systems are working correctly!!! To put it another way, the opportunity for a pilot to remain in flight thinking "Ah, in a few moments the first engine will flame out and I will have 30-40 seconds to get the lever down before the second engine flames out" is/should be non-existent. What I mean by this, is if knowledge, understanding and comprehension is fully formed, a landing/ditching should have been carried out under power AND the pilot would NEVER try a relight knowing he has effectively run out of fuel.

So in this case, where a relight seems to have been attempted, two possibilities exist. either the pilot did not understand his system, indications etc OR the system//indications were misleading him to believe that the first engine flame out was not due to fuel starvation. Bearing in mind approx. 80kgs of fuel were remaining in the "system" albeit in the wrong place.

[Art of flight]

So in this case, where a relight seems to have been attempted, two possibilities exist. either the pilot did not understand his system, indications etc OR the system//indications were misleading him to believe that the first engine flame out was not due to fuel starvation. Bearing in mind approx. 80kgs of fuel were remaining in the "system" albeit in the wrong place.[/QUOTE]

just my twopeneth, I flew the various UK Police 135s and though I was pleased to see the evolution from T1 Cpds, through to P2+/I I thought the method of changing the illumination of the CDS etc left much to be desired, reaching across the cockpit in the dark trying to put a vibrating finger on the Dim/Brt keys and keeping said digit in contact for just the right amount of time to achieve the exactly desired result was an exercise in try and try again. During a long night flight into very dark countryside I'd be regularly adjusting the Dim to the point the screen could be very dim towards the end of the flight as night vision became better. Why on earth did the designers think a rotary knob was too old fashioned! It's apparently good enough for PFD and ND?
A few times returning towards base and doing a last minute job over the nearby town I realised the screen was then too dim to see anything because of the brighter town lighting outside changing my night vision, and then having to faff with the Brt key.

[Fortyodd2]

DB, for clarity in this case, a relight was not attempted.

[jimf671]

Not every fatal accident or sudden death in Scotland results in a FAI. However, the Act ensures that EVERY case of a death during the course of employment results in a FAI.

It is a unique form of inquisitorial procedure. It is not about blame or prosecution. It seeks the truth of a number of matters, defined in the Act as follows.

6.-(1) At the conclusion of the evidence and any submissions sheriff's thereon, or as soon as possible thereafter, the sheriff shall make determination a determination setting out the following circumstances of the etc. death so far as they have been established to his satisfaction-
(a) where and when the death and any accident resulting in the death took place ;
(b) the cause or causes of such death and any accident resulting in the death ;
(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided ;
(d) the defects, if any, in any system of working which contributed to the death or any accident resulting in the death ; and
(e) any other facts which are relevant to the circumstances of the death.

[HeliComparator]

Hi HC, how's it going? Trust you are keeping well.
Fine, thank you! You too I hope?

[HeliComparator]

Tiger fish, just my opinion but I don’t believe the crew fully understood or were aware of their situation until the first engine failed. Knowledge, understanding, comprehension leading to appropriate behaviour. When the knowledge or understanding is deficient......................

To me the most plausible explanation does seems to be that in fact the captions were not illuminated due to some fault in the panel or wiring. It seems incomprehensible that they just carried on as normal with all those lights on and nothing was said on RT or airwave.

I was involved in the Dutch accident enquiry into G-JSAR. One of the factors was an engine disturbance causing Ng fluctuations and intermittent illumination of DIFF PWR (or was it Diff Ng on the L2, can’t remember). Anyway all the various bits - anticipator, FCU, DECUs etc were sent off for analysis but no fault was found. But clearly something was wrong because there had been no previous cases of this sort of intermittent Diff Ng caption. The same applies to the reported control restrictions. No cause was ever found.

Of course the accident investigators don’t have the expertise and knowledge to test the equipment themselves, they have to rely on sending it to the manufacturer for testing. The manufacturers seem to put the equipment through routine testing such as might happen after manufacture or overhaul. It is not in their interest to determine that their specific piece of equipment was responsible for the accident and so I got the impression that the testing was superficial and minimal and certianly, they were not striving to prove that it was their equipment at fault. No doubt they didn’t lie, but they also perhaps didn’t expend as much effort as someone looking to prove something is faulty.

[FloaterNorthWest]

Helicomparator,

To quote the final AAIB report.

“It was not possible to determine precise timings but it was calculated that, before the helicopter reached Bothwell, the pilot was presented with a low fuel 1 warning caption, with the associated aural attention-getter. This aural attention-getter was acknowledged by the pilot. The warning caption then extinguished, before re-appearing after an undetermined interval. This, too, was acknowledged by the pilot. The caption extinguished again. The low fuel 2 warning caption then illuminated, with the associated aural attention-getter, and was also acknowledged. The time, in addition to the low fuel 1 caption then re-appeared a third low fuel 2 caption. This was acknowledged, before extinguishing again, leaving the low fuel 2 warning. The low fuel 1 and low fuel 1 warning caption then re-illuminated once more and was, again, acknowledged. After this, the low fuel 2 warnings captions remained illuminated for the rest of the flight.”

it would appear the warning system was working. The unexplained area is the continuing to fly and take tasks after they had illuminated.

Were they used to flying with Low Fuel captions so desensitised?

FNW

[RVDT]

Were they used to flying with Low Fuel captions so desensitised?

"LOW FUEL" is LOW FUEL. Triggered by a thermistor on the side of the fuel quantity transmitter. It is independent of the quantity system and part of the WARNING system. ~ 8-10 minutes remaining.

To get to that point you would have already passed "FUEL PUMP AFT or FWD" WARNING as appropriate which is triggered by measuring the current going to the pump and a time delay in the CPDS.

You would also have the CAUTION "FUEL" which is part of the quantity system indicating a total of the supply tanks being below a certain level.

If "LOW FUEL" captions were ever the norm and someone was desensitised by it something went wrong somewhere in the chain of events leading up to this accident.

[HeliComparator]

Helicomparator,

To quote the final AAIB report.

“It was not possible to determine precise timings but it was calculated that, before the helicopter reached Bothwell, the pilot was presented with a low fuel 1 warning caption, with the associated aural attention-getter. This aural attention-getter was acknowledged by the pilot. The warning caption then extinguished, before re-appearing after an undetermined interval. This, too, was acknowledged by the pilot. The caption extinguished again. The low fuel 2 warning caption then illuminated, with the associated aural attention-getter, and was also acknowledged. The time, in addition to the low fuel 1 caption then re-appeared a third low fuel 2 caption. This was acknowledged, before extinguishing again, leaving the low fuel 2 warning. The low fuel 1 and low fuel 1 warning caption then re-illuminated once more and was, again, acknowledged. After this, the low fuel 2 warnings captions remained illuminated for the rest of the flight.”

it would appear the warning system was working. The unexplained area is the continuing to fly and take tasks after they had illuminated.

Were they used to flying with Low Fuel captions so desensitised?

FNW

Yes I know, however what is not considered in the report is the integrity of these events stored in the memory of the central warning system. I get the impression that the system records a chain of events without time stamps, so a certain degree of guestimation is involved in matching the stored events to the preferred scenario.

The system thinks a caption was illuminated but clearly that system isn’t actually measuring light output from a bulb, it is something much further up a chain that thinks a caption OUGHT to be illuminated without actually knowing that it is.

The report isn’t explicit about how these events are detected and stored and so I remain a bit dubious as to whether they are concrete facts or just the most probable (in isolation) explanation. One thing I learnt from my days in HFDM is that it is very easy to imagine a match between flawed data and an expected scenario, when in fact no such match exists.

Given the choice between a pilot and 2 crew ignoring persistent warnings both trivial (prime pumps) and serious (low fuel x 2), over a prolonged period, vs a fault in the warning system that meant that, whilst the “brains” of the system wanted captions to be illuminated, in fact they weren’t, Occam’s razor might suggest that the latter is the simpler, and hence the correct, explanation.

[G0ULI]

If one is going to follow the Occam's Razor argument, then I would suggest that all the technical equipment was functioning perfectly. The helicopter was operating close to the limits of its' endurance and the pilot may well have expected fuel warning captions to start to operate. Confirmation bias led to the warnings being cancelled without fully taking in what they were indicating due to confirmation bias. The engines flaming out came as a complete shock to all concerned. Human error, late in the evening, after a longish deployment. The only thing anyone is thinking about is finishing the tasking and getting back on the ground for a welcome cuppa and a trip to the loo. Been there, done that, albeit at ground level.

[MaxR]

Given the choice between a pilot and 2 crew ignoring persistent warnings both trivial (prime pumps) and serious (low fuel x 2), over a prolonged period, vs a fault in the warning system that meant that, whilst the “brains” of the system wanted captions to be illuminated, in fact they weren’t, Occam’s razor might suggest that the latter is the simpler, and hence the correct, explanation.


Surely if the warnings were acknowledged by the pilot they must first have been presented to the pilot.

[DrinkGirls]

Devils advocate here. You have one cancel button for all warnings. If one caption is triggered but doesn’t illuminate and you then get a another less important caption that is cancelled..... you have cancelled both. Or many other reasons for pressing the button. The information used in the report was “best guess”, without a CVR. Is this robust enough to make a decision on all these lives and the reputation of a good pilot?
i think it isn’t
SOMETHING must have caused confusion in the cockpit that night.
was it pilot error? Probably
was he neglectful on purpose? No evidence at all
does that matter? Hell yes!
Why? So that it never happens again
could there be a fuel system indicator fault? Don’t know
dont know? Surely that needs addressing? .........

[kevin_mayes]

The secret lies in the shorted 24V tantalum capacitor on the warning panel that was reported in the original thread - I mentioned this ages ago and got shot down...via PM. But to me that's the smoking gun.

Kev.

[DOUBLE BOGEY]

If you look at the long history of posts in the original thread there is a consistent theme running through it. That pilots at the time may not have had 100% confidence in the LOW FUEL warning/caution system.

In fact after the accident several machines under test displayed erroneous contents indications when the warnings and cautions illuminated. Water seemed to be the culprit.

The clear and beautiful view from the "Hill-of-Hindsight" showed us that the FUEL LOW Red warnings were driven by Thermistors and generally applauded to be 100% accurate and a neat little backstop to the less reliable and pesky capacitance detectors driving both the contents indication system and the amber FUEL cautions (set for values ever so slightly above the RED FUEL LOW warnings). My God didn't we all Know this already???? (I am being cynical)!

So maybe, low confidence in the system WARNINGS, CAUTIONS and indications, "fuelled" (no pun intended) by the Pilots failure to appreciate the Hill of Hindsight we now all occupy (thanks to several 1000 hours of testing and conjecture), coupled with erroneous indications that the 79 kgs of fuel that remained (or at least some of it) was indicating in the supply tanks and the stage is set. Chuck in several previous exposures to same. Add the cultural disposition to "accept it for what it is" (how many of us do that), and the fickle finger of fate is poised and waiting to deliver the fatal blow.

In my considered opinion, there is much of all of us in this simple accident. There are many holes in the cheese that needed to line up. Some of them are already there, now, in our own working environments. Finding the holes and plugging them is the mission. Before, like this poor crew, it becomes too late.

The single most important legacy of this accident is us knowing how Fuel Thermistors work and thus believing their pesky Warnings when they appear.

[DeltaNg]

The lovely blue pixel indications of fuel as displayed on the screen does give you the impression of a nice reliable system. I have seen with my own eyes indications of supply tanks full when in fact they were empty. The thermistors are the more reliable measure, and the capcitance fuel probes, once the tiny droplet of water which causes the error is dried out - they indicate perfectly well afterwards on a bench.

[Pittsextra]

Question. One imagines that this kind of flying isnt easily pre-planned but which is closer to the usual SOPs? Fly around until the low fuel alarm and RTB or have some broad understanding of your fuel endurance prior to stepping to the aircraft? If it is the later then failing tech (beyond your personal Casio) is unlikely to snag you very much.

[DeltaNg]

The remaining fuel endurance of the helicopter was similar to what one would have expected from a mental calculation, it was unfortunately in the wrong tank.

[Fortyodd2]

Delta-Ng. - your last 2 posts - Spot on.

Pittsextra - option B - know what you have to start with and updated / re-assessed as you go.

[jeepys]

Pittsextra,

the trouble is fuel flow is not at a constant rate. Demands in S&L flight at 110 kts say could be a chunk less than sitting in the hover. Taking off with an hours worth of fuel, is that at best endurance or highest likely fuel flow required?

[Pittsextra]

Well quite but the general point being that with your expected endurance of 1 hour (via one assumes a combo of calculated/finger in the air from experience of your expected mix of best endurance v max fuel flow) if you see a fuel alarm at 50mins then surely your first thought is "oh i hadnt realised id been so greedy with the fuel today" rather than "the alarm is erroneous lets push on".?? Even with the fuel remaining had the aircraft landed successfully at its home goodness knows how these guys are living if landing with so little is standard.

[DOUBLE BOGEY]

Well quite but the general point being that with your expected endurance of 1 hour (via one assumes a combo of calculated/finger in the air from experience of your expected mix of best endurance v max fuel flow) if you see a fuel alarm at 50mins then surely your first thought is "oh i hadnt realised id been so greedy with the fuel today" rather than "the alarm is erroneous lets push on".?? Even with the fuel remaining had the aircraft landed successfully at its home goodness knows how these guys are living if landing with so little is standard.

Landing with so little???? 80kgs is more than the VFR FRF.

[Fortyodd2]

FRF / MLA is a limit not a target.

[DOUBLE BOGEY]

FRF / MLA is a limit not a target.

Obviously not an Offshore pilot because the FRF is often all that's left unless the air gods have been kind and left a little contingency to sweeten the deal!

[Fortyodd2]

Correct, not an Offshore Pilot - and if that's the "Offshore Attitude" to FRF / MLA then glad I stayed clear of it.

[DeltaNg]

FRF Should give you 20 minutes at loiter (VFR) and 30 minutes (IFR) and still be able to land safely.

[TeeS]

FRF Should give you 20 minutes at loiter (VFR) and 30 minutes (IFR) and still be able to land safely.

HI Delta
Unless my memory has let me down again, the VFR requirement is based on 20 mins cruise whilst the IFR requirement is 30 mins at holding speed - in the end they tend to produce a similar value.
Cheers
TeeS

[DrinkGirls]

It’s so simple you say. Start the clock and you should know what your endurance is?

WRONG

I have got airborne in a helicopter with faulty fuel gauges. They SHOWED 1:30 fuel but were over-reading by 15 minutes worth. In other words the fuel was not there at the start. It got very tense when the other warnings came on.

The only time you can be confident of your contents is when the tank is brimmed full or empty.

If this aircraft had faulty gauges, it could have lifted with god only knows what in the tanks. The stopwatch call would be irrelevant

As I said above, it happened to me

[DOUBLE BOGEY]

Correct, not an Offshore Pilot - and if that's the "Offshore Attitude" to FRF / MLA then glad I stayed clear of it.

FortyOdd, I like your feeling towards this and cannot fault you for wanting to avoid being low on fuel. It sucks and always will. However, its not an "Attitude" in HOFO its sometimes a commercial necessity and the Commander needs to be comfortable with it otherwise he can take "Additional Fuel required by the Commander" as is his prerogative under the rules. Majority of HOFO Pilots I have worked with like to take as much fuel as they can get in but sometimes the client wants all the available payload. That's the nature of the job. However, you can bet your pay packet that on those occasions we is watching the fuel gauges with deep suspicion until we land safely. We employ lots of little tricks to justify a little more fuel like planning with winds more punitive than forecast so the system calculates more fuel. It takes a really brave soul to plan minimum wx/absolute minimum fuel without at least a tweak here and their for the "wife and kids". Often this happens subconsciously during the planning. One day the bean counters will eventually stand over our shoulders and the cat will get out of our nav bag. Rue the day!!

[Pittsextra]

Landing with so little???? 80kgs is more than the VFR FRF.
Are we not nit picking? Using your 80kgs and the averged 3.3kg/min consumption at the point it fell through a roof, and that roof was a distance away from the planned landing site and absolutely no margin for any precautionary alternative....at night.

You can make general points at the margin but fundementally you know how much fuel has been uplifted and the watch gives you the rest. If your SOPs and crew allow you to operate such that a couple of dozen kgs of fuel make the difference it hardly seems logical that this same crew are not then super attentive to all of the information presented to them around fuel including where that fuel is.
That will not be answered because all are dead but what can be is the acceptance or otherwise of the fuel management process. I doubt very much that a similarly operated aircraft could crash with similarly low levels of fuel remaining as far away from its base today, which suggests SOPs will have been revised, suggesting the process that allowed this situation to occur was flawed.

[DeltaNg]

We are not nit picking. FRF figures are guidlines which are determined by Operators and Regulators with safety in mind as a sensible amount of fuel to land with as a minimum.

Fundamentally we all know how much fuel has been uplifted, and everyone who has flown for 20 years commercially is super attentive, but suddenly one day we don't just ignore a whole load of fuel warnings without some other factor in play.

[jayteeto]

Delta NG, that last line says it all

[AnFI]

"There are many holes in the cheese that needed to line up. Some of them are already there, now, in our own working environments. Finding the holes and plugging them is the mission."
2 layers of cheese with 2 holes each is easy to avoid holes lining up
4 layers with 300 holes each is very difficult.

Tight on fuel to assure engine accountability during takeoff is clearly a false safety trade-off.
Complexity leads to pilot error. Pilot error is about 4/5ths of accidetnts.
Complexity increases the probability of System Failures. About 1/5th of Fatal accidents are system failures.

Engines 1%.
Complexity kills. (to paraphrase Occam: "a helicopter should have a single reliable engine")

There is a level of engine reliability at which the extra risks (of 2 engines) are not worth it.
Anyone got a handle on what that figure is? IS THERE AN EXPERT out there?
Should be easy to calculate. Probably somewhere around the 10^-3 to 10^-6 mark. Trying to improve on that risks shooting one's self it the foot with an overcomplicated gun.

"a pilot who understands the EC135 fuel system should NEVER end up with fuel starvation provided..."
and the number of pilots that don't is? : 1 per 100,000? 1 per 1000? 1 per 10?

[DOUBLE BOGEY]

ANFI we all know what your bee in your bonnet is and it has f***k all to do with this accident.
One day you will grow up and realise you live in the real world where problems are real. Not imagined. Not hypothesised. Just real.
DeltaNg summarises this event very well in his last line. I would add, given the nature and background of the pilot that night..........there is most probably more to this story than what the current evidence implies. The subject pilot deserves at least that consideration.
BTW he was 2 minutes from landing at his home base. His calculated FRF would have been intact. If the events had not unfolded as they did it would have been just another professional pilot exploiting his available endurance efficiently to serve the public.
That is what this is about. Complexity and no of engines play no significant part.

[DOUBLE BOGEY]

Pitts. UPLIFTED FUEL. In professional aviation we make a big effort to ratify/verify the amount uplifted against the difference on the fuel gauges before and after refuel. But it is meaningless if the gross amount displayed before refuel is already erroneous AND we did not fill and witness to the brim.

Read/listen to what is being written. Anecdotal evidence of fuel indicating in the supply tanks that wasn’t there.

FUEL ENDURANCE - unless you are Stephen Hawkins, mentally calculating the predicted fuel consumption on a Police Ops flight is practically impossible. Hovering, balls-out, loiter type circling and everything in between was taking place on this flight. Other than a vague notion of what could have been used the pilot could easily be 10-20% out. Thus a very heavy reliance on gauge indications is necessary. And that is assuming the value indicated at all stages of flight is correct.

[DrinkGirls]

Double Bogey- spot on

For the record, it may not have happened in this case. BUT, if the aircraft had the same fault that happened to the Barton aircraft a few days later and was discovered in a few aircraft in the fleet check, then that’s a game changer. What if the fuel wasn’t ever in the tanks at take off? All the stopwatches in the world wouldn’t have helped.

However, even if the fault had been present, there was enough belt and braces systems to give the pilot the information he needed.

IF HE HAD BEEN TAUGHT AND UNDERSTOOD THE FUEL SYSTEM PROPERLY

Not looking for an excuse, just looking for a reasonable understanding of why Dave might have been confused

[DeltaNg]

Unfortunately, like an icicle used as a dagger, hard evidence of the fuel displays status & the water which caused the capacitance probes to fail has long since evaporated.

But I'd like to think others would consider the possibility that the professional pilot perhaps wasn't entirely to blame for this horrific event.

[AnFI]

But I'd like to think others would consider the possibility that the professional pilot perhaps wasn't entirely to blame for this horrific event.

However, even if the fault had been present, there was enough belt and braces systems to give the pilot the information he needed.

IF HE HAD BEEN TAUGHT AND UNDERSTOOD THE FUEL SYSTEM PROPERLY

Not looking for an excuse, just looking for a reasonable understanding of why Dave might have been confused

I agree with these 2 sentiments. From them and the pages of educational discussions on the EC135 fuel system, it is clear that it IS complex enough to expect a pilot failure rate. I don't think it's the pilots fault, just the complexity of what is required of him will result in accidents.

DB also 'Fuel Pressure', is a real world cause of accidents. AND "in the real world where problems are real. Not imagined. Not hypothesised. Just real." like this real world multiple fatal accident or Leicester? OR the imaginary world where engine redundancy is an imagined magic cure?

[DeltaNg]

I often wonder whether 2 engines have any real tangible benefit in the helicopter world.

For prolonged transits over 'hostile' terrain I can see the rationale - which was originally airline's reasons for having extra engines - but for non-complex operations, there must be statistics that suggest that B206's have done a lot better in some areas ...

[Flying Bull]

I often wonder whether 2 engines have any real tangible benefit in the helicopter world.

For prolonged transits over 'hostile' terrain I can see the rationale - which was originally airline's reasons for having extra engines - but for non-complex operations, there must be statistics that suggest that B206's have done a lot better in some areas ...

Well, the police NRW went for twins after a series singles having problems (crashing)
And even nowadays I d rather have a spare engine operating over congested areas, hovering prolonged times, day and night.
If a donk fails on you it’s just more relaxing having another one keeping you in the air instead of the need to react instantaneously to recover the Nr, getting speed, deciding where to autorotate to (especially at night with NVG).

How many engine failures had I?
One sputtering engine allowing limited power only, on a Bell206 where parts of the compressor housing went through the engine , several times when I tried to increase power - with passengers on board,
One engine to shut down on a Bo105
One engine to shut down on a BK117

The occurrences on the twins were much less stressful, nearly „non events“, except for the paperwork involved...

So ne question for me, what I prefer....

[chopjock]

If a donk fails on you it’s just more relaxing having another one keeping you in the air instead of the need to react instantaneously to recover the Nr, getting speed, deciding where to autorotate to (especially at night with NVG).




That could probably be just what this pilot and many others were thinking too...

[megan]

OR the imaginary world where engine redundancy is an imagined magic cure?You're going to need to justify that comment given the fact that 75.9% of the accidents caused by system failures are as a result of engine failures.

[AnFI]

You're going to need to justify that comment given the fact that 75.9% of the accidents caused by system failures are as a result of engine failures.

Good point, I don't recognise those figures though, 'taxonomy'.
It DOES NOT concur with the EASA data analysis, which gives about 10% of the 20% that are system failures.
Are you including engine accidents for twins there?

[Distant Voice]

anchorhold
The relatives DO need closure. This isn’t endless inquiries, this is THE inquiry. The AAIB report will be part of it. An inquest doesn’t just look at why the helicopter crashed. It looks at post crash responses, lessons to be learned and more importantly, how EACH and every victim died. It looks at many many things other than the accident report. In other words, it’s vital. So, apology accepted.
Now, why don’t we all listen to what is said over the next 6 months, see if we can learn anything new about what happened and let the families have the inquest that they deserve. It’s not all about compensation you know.........

What a pity that the Lord Advocate and the Crown Office of Scotland do not apply the same criteria to the Moray Firth Tornado collision. Are service families second class citizens?

DV

[chinook240]

I haven’t seen these posted before but this is the list of issues the FAI will address

SHERIFFDOM OF GLASGOW AND STRATHKELVIN
Court Ref: GLW-B1473-18
CONSOLIDATED LIST OF ISSUES

1. When and where each of the deaths occurred.

2. When and where the aircraft crash occurred.

3. The cause or causes of each of the deaths.

4. The cause or causes of the helicopter crash, including:-

4.1. how fuel was managed on the aircraft and in particular why both
transfer pumps were switched OFF, rendering unusable the
otherwise usable fuel in the main tank;

4.2. whether the Pilot’s Checklist was available to the pilot;

4.3. whether it was within the competence of a helicopter pilot
qualified to fly G-SPAO on police duties to comply with the
requirements of the Pilot’s Checklist;

4.4. at what stage in flight did the LOW FUEL warnings likely occur;

4.5. why, having acknowledged the LOW FUEL warnings, did the pilot
not complete the actions detailed in the Pilot’s Checklist;

4.6. whether the timing and/or the initially intermittent character of the LOW FUEL warnings contributed to the Pilot’s Checklist procedure not being completed;

4.7. whether there have been other instances of LOW FUEL warnings
not being followed;

4.8. whether the pilot believed the fuel transfer pumps were
operating, notwithstanding the LOW FUEL warnings, because he believed he had switched the fuel transfer pumps back ON, and if so whether the design or layout of the switches contributed to such errors occurring;

4.9. whether the pilot believed the transfer pumps were operating, notwithstanding the LOW FUEL warnings, as a result of erroneous fuel indications being displayed on the CAD;

4.10.what the root cause or causes were of any such erroneous fuel indications and whether they were adequately investigated and acted upon prior to the accident;

4.11.whether there was a failure of any part of the CAD prior to the accident;

4.12.what steps were open to a helicopter pilot qualified to fly this helicopter after both engines flamed out;

4.13.whether the designed time-interval between engine flame-outs was compromised by the design of the fuel tank system and, in particular, the undivided volume above the supply tanks, which, depending on the attitude of the helicopter, might have allowed fuel to migrate from one supply tank to another;

4.14.why autorotation, flare recovery and landing were not completed successfully;

4.15.whether the ability to carry out autorotation, flare recovery and landing was compromised by the design of the cockpit layout.

5. The precautions, if any, which could reasonably have been taken, and which, had they been taken, might realistically have resulted in the helicopter crash being avoided, including whether the crash might realistically have been avoided:-

5.1. by including within the fuel contents indication system a caution or warning that both transfer pumps were switched OFF;

5.2. by including within the fuel contents indication system a caution or warning that a fuel pump, having been switched OFF, has since been submerged in fuel;

5.3. by designing the fuel tank system and fuel contents indication system in such a way that the fuel transfer pumps did not require to be switched ON or OFF during flight;

5.4. by including within the fuel contents indication system a caution or warning, in the case of anomalous or implausible combinations of outputs from the sensors;

5.5. by designing the fuel tank system, and in particular the differential capacities of the supply tanks, in such a way as to ensure that the design objective of creating an interval of 3-4 minutes between engine flame-outs, or such other interval of time as would be represented by 4.5kg of fuel, or any other safe interval of time, was achieved;

5.6. by ensuring that power to the RADALT and steerable landing light was automatically maintained in the event of a double engine flame- out.

6. The defects, if any, in any system of working which contributed to the deaths or the accident, including:-

6.1. whether any aspect of the system of maintenance of G-SPAO, including its washing regime, contributed to the contamination of the fuel and/or the fuel tank system with water;

6.2. whether any aspect of the pre-flight check procedures contributed to the accident occurring;

6.3. whether any aspect of the training of pilots, in particular, with regard to fueling, pre-flight checks, the pilot handover procedure, the operation of the fuel contents indication system, erroneous fuel indications, the appropriate response to fuel cautions and warnings, and the execution of an autorotation at night, contributed to the accident occurring;

6.4. whether the practice of the “day-shift” pilot handing the aircraft over already fueled to the “night-shift” pilot contributed to the accident occurring.

7. any other facts which are relevant to the circumstances of the deaths, including:-

7.1. whether, and the extent to which, the Safety Recommendations of the AAIB in their Report 3/2015 have been adopted and implemented;

7.2. whether, and the extent to which, the operator, helicopter manufacturer and engine manufacturer have taken necessary and appropriate safety actions following the accident, including those considered by the AAIB in their Report 3/2015;

7.3. whether, and the extent to which, any recommendations should be made by this Court.



http://www.scotcourts.gov.uk/docs/default-source/fatal-accident-inquiries/clutha-list-of-issues-05-04-19.pdf?sfvrsn=2

[DrinkGirls]

Looks like the investigating officers have been asking the right questions. Hopefully the armchair investigators who had all the answers on Pprune will now realise there are many more issues that need to be addressed before we character assassinate Dave. The conclusion may or may not agree with the original board, however he will be able to rest in peace, knowing that he has been given a more thorough hearing. Everyone involved deserves that.

[jimf671]

Looks like the investigating officers have been asking the right questions. ,,,,

Yes. These are essentially the sub-sub-sections of section 6. sub-section (1) of the 1976 Act, with (a) and (b) each split into two streams to address the individual deaths and the crash event separately. It fleshes out the statutory purposes of the Inquiry to the next level of detail, almost certainly by the Procurator Fiscal, so that it provides a framework for the PF to present the evidence.

[Reely340]

Nice, encompassing questionaire, but there is one important question missing:

4.16 whether the ability to carry out autorotation, flare recovery and landing was compromised by Helicopter Police of Scotland (sp?)
through not providing sufficient opportunities for their pilots to practice real world EOLs in EC135 types, by day and night.

Now, lets see virtual hands from those EC135 drivers on pprune, that actually did practice real EOL in an 135!
And how many of you did practice them at night, w/o rad-alt?

anyone at all?

[Flying Bull]

Now, lets see virtual hands from those EC135 drivers on pprune, that actually did practice real EOL in an 135!
And how many of you did practice them at night, w/o rad-alt?

anyone at all?

No need to practice them for real.
But it would enhance the chance to get things right- i.e. switching the EmerShedBus early with the first problems arising, (low fuel warning i.e.), if pilots had a go in a simulator once or twice a year....

[Art of flight]

No need to practice them for real.
But it would enhance the chance to get things right- i.e. switching the EmerShedBus early with the first problems arising, (low fuel warning i.e.), if pilots had a go in a simulator once or twice a year....

Certainly saw a night and day different approach to risk management once the police employed us directly. As pilot's provided by a contractor we had the absolute minimum training the employer was mandated to provide. Once we were tupe'd across to direct employment the gravity of responsibility hit home with the police employer and we regular took part in simulator, first aid, fire fighting and dunked training.

[toptobottom]

I was flamed for suggesting this earlier, but as it's a rumour site, I'll try again...
Has there been any investigation into the personal relationships between the souls on board? All the points to be covered reflect technical issues - either physical systems, training, compliance, procedural, etc. but what about emotional factors? It wouldn't be the first time an aircraft was deliberately crashed...

[Evil Twin]

I fly a 135 most night shifts. I still don't understand why they ran out of fuel. There are so many warnings, notwithstanding basic airmanship that it makes no sense at all. Mission lock possibly coupled with poor CRM is the only conclusion that I can come up with.

[RVDT]

toptobottom,

+1

About the only thing that is plausible.

[G0ULI]

toptobottom, RVDT,

While personal relationships and personal issues may be relevant, they are unlikely to be considered outside of professional CRM issues aboard the aircraft. If there were known issues prior to the flight, management will be heavily censured and criticised for not doing anything about it. Close or familial relationships are generally forbidden between officers serving together, although it is not unknown for husband and wife to serve at the same station and/or work together in the same vehicle. The problem is that allegations of collusion will be levelled if an account of events by such officers is disputed.

If such matters are considered, it is likely that that part of the FAI will be heard behind closed doors and the conclusions omitted from the final report unless they point directly to being a primary cause of this incident.

[jayteeto]

Evil Twin. Luckily for us your narrow minded view is not shared by all

[DOUBLE BOGEY]

Evil Twin and RVDT - while I get this is a rumour forum and bearing in mind I did not know the Pilot I am struggling to understand how you can possibly come up with that hypothesis.

[DeltaNg]

https://www.youtube.com/watch?v=yp_l5ntikaU

[MightyGem]

Evil Twin. Luckily for us your narrow minded view is not shared by all
Well, it's better than toptobottom's wild theory. :hmm:

[DOUBLE BOGEY]

Evil, the available/released facts would seem to support your statement. However there may be facts as yet undiscovered. Rumsfords Unknown knowns or whatever!
You should realise that the closer people on this thread were to the PIC and/or the type of operation, the harder it is for them to accept the kind of statement you made in post #83.
Logic would dictate the story is most likely more complicated than that.
I would be mindful of peoples sense of decency and compassion. In particular the Hill of Hindsight is no place to grandstand unless you are of course perfect and without potential fault. For example, despite many years of experience in several different operating environments, I never really digested the difference between thermistor/capacitance detectors and the vital role they play in the indicating, caution and warning systems until this accident brought them to light. I suspect the PIC was similarly indisposed but that is just an opinion.

[jayteeto]

What he just said, agreed

[DOUBLE BOGEY]

I would also add, that being on the other side of the fence for a while, the OEM took some flack in this accident. However, when you fully understand the design concept of such systems and then listen to the engineers express their surprise at how poor the knowledge and understanding appeared to be, generally, amongst the Pilot community, it can be humbling. To a design engineer, us not understanding why he used thermistors as the backstop warning system, coupled with an apparent failure to follow the FM Procedure when the lights come on is just inexplicable to him.
As a community it is important WE do not seek to blame or achieve the simple satisfaction that comes with abrogated responsibility. In the end, we should always look inward. If it can happen to Dave....it can happen to me. What can I/Should I do about it?
The rest is just hot air and conjecture.

[jayteeto]

Even more agreed

[Evil Twin]

Look, we can all be under pressure to continue and get the max out of the aircraft endurance and are often pushed to use the absolute maximum available to get the job done. However, in this case the PIC used all of that and then all of his reserves and ignored the warnings until there was NONE left and the engines flamed out due to fuel starvation. At any time during flight the PIC should know their fuel state and that required to return to base or a safe point of landing with reserves intact, that didn't happen in this case.

[jayteeto]

No it didn’t

i wonder why?

it would be nice to find out

i know, let’s have an inquest to examine ALL the issues

genius

[Reely340]

No it didn’t
i wonder why?
it would be nice to find out
i know, let’s have an inquest to examine ALL the issues
genius





Personally, I don't need any special hidden story to picture what possibly had happened:

- your job is to fly a type notorious for various fuel level indicator flaws (stories from the fire fighter brigarde about pressure washing engines hot or cold, tiny but effective water droplets in the tank, etc)

- your boss tries to stretch a sortie as far as possible, almost bordering on having you cut into your fuel reserve

- its pitch dark outside

- you constantly have to toggle them dry-run sensitive fuel pumps, due to an inferiour fuel pump type (at least compared to EC135s ancestor BO105, which has a similar tank setup but dry-run capable pumps)

- these very important switches are overhead, hence out of sight

- you keep acknowledging the "faulty" low fuel warnings, while the main tank gauge indicates "~80kg remaining" (hence you are convinced they are as faulty as you've heard. Nobody told you about the sensor types and their extremely different sensitivity to ingressed water)

- while the display still indicates ~80kg of fuel the first engine dies on you

- with the home base lighting in sight, you frantically try to prepare for OEO flight, assured that you've got another 1,5 mins till silence, hence can fly home

- trying to get home on one engine with still "80 kgs remaining" indicated, the second engine goes silent "prematurely", some 30secs after the first

- now the cockpit goes truly black, rad-alt and landing-light gone, thanks to stupid electrical setup

- real panic sets in because nobody ever let you practize/demonstrate a "both engines at idle" autorotation, let alone a true EOL (not even in a sim?)

- the acoustic environment is waaay different than usual, RRPM indicator is as black as the rest of the cockpit, RRPM hard to tell by ear (wearing a helmet)

- between overrevving the MR and trying to arrest a "normal" RRPM, (hard to tell w/o instrument or visible blades) you are trying to pick a landing spot

- you end up below the min. end of the "RRPM power off" arc

- end of story


I don't see how this is survivable for anyone.
Who would have taken the time to mentally backtrack all previous actions to find the wrong pumps to be on?

So many systems were preceived by the pilot to have failed:
- recurring low fuel warnings while 80kg indicated in main tank, although one recalls humbly acting on the illuminating pump dry run indicator lights mutiple times in this very sortie, hence reasoning "it can't be the pumps"
- engine starving while 80kg indicated
- second engine starving way earlier than stated in the POH

There is only one on single contribution of the pilot to this accident:
having switched off both transfer pumps and switching on both prime pumps.

Anything else is airbus' fault:
bad choice of fuel pump type, necessitating unnecessary, error prone pilot work
bad choice of fuel sensor type, water-droplet sensitive fuel level sensors are a stupid choice
bad choice of emergency electrical power (it costs one(!) diode to fully automatically route battery power to the bus, thereby taking over supply when both generators fail)


That accident would never have happened in a BO105:
when both engines are running you make sure both transfers pumps are on, switch off the prime pumps and forget about pumps until you land and shutdown.

[Autonomous Collectiv]

Pretty interesting that the finger is being pointed at the manufacturer rather than the pilot that flew the aircraft out of fuel...

[Reely340]

Pretty interesting that the finger is being pointed at the manufacturer rather than the pilot that flew the aircraft out of fuel...
My take is that the manufacturer made it really easy to fly that type out of fuel,
especially considering the frequently recurring fuel indicator issues of the EC135 fleet
("When the manufacturer tested the fuel sensors that were returned from the worldwide fleet, for repair, it found about 70% had no fault. ")
and mixing fuel level indication sensors with very diffent technology (water ingress sensitivity)
and the finnincky fuel pump toggle-'em-switches setup,
let alone putting misleading instructions in the POH regarding time difference between engine fuel starvation left/right
nicely rounded off by an overhead shed-bus switch, that has to be manually addressed to get rad-alt working, right when one has all hands full attempting an autorotation.

It's hard to picture a design less fail safe than the EC135 fuel system,
which is a shame as the mentioned BO105 already showed how a zero attention fuel system might look like.

[Reely340]

Pretty interesting that the finger is being pointed at the manufacturer rather than the pilot that flew the aircraft out of fuel...

Then again maybe you are right. There is that BO105 that was NVG-readied by fixing a filter glass over the warning panel using some duck-tape(!) :ugh:

1 Pilot fogot to switch on main pumps after engine start,
2 DIY installed filter glass moved downward during flight, causing the duck tape to block the "low fuel" warning light
(the holes in the cheese are aligning)
=> and at 20 mins past midnight, over the river Elbe in Germany he had one engine die (200ft AGL) and 4(!) seconds later (150ft AGL) the second engine starved of fuel.

He did an AR at night into the shallow part of the river. :ok:
They got their ankles wet, noone injured, helicopter only slightly damaged.

Recommendation by the authority:
Change BO105 POH to required all four pumps to be on from before startup.

german language report: https://www.bfu-web.de/DE/Publikationen/Untersuchungsberichte/1999/Bericht_7X008-0.99.pdf?__blob=publicationFile

[Pittsextra]

When you are at the limit of endurance (which one assumes you are aware because of the watch/the physical position i.e. on the way home) at the point when the first engine flames out then surely you think fuel ahead of a wider problem?? And if you do think fuel dont all pumps go on by default and if you damage a pump through some dry running then so be it??

i just can not imagine that at this point in his trip fuel state isnt the assumed cause of all the problems and if 80kgs is being indicated at the point of engine flame out its hardly a time to over think things?

[DOUBLE BOGEY]

When you are at the limit of endurance (which one assumes you are aware because of the watch/the physical position i.e. on the way home) at the point when the first engine flames out then surely you think fuel ahead of a wider problem?? And if you do think fuel dont all pumps go on by default and if you damage a pump through some dry running then so be it??

i just can not imagine that at this point in his trip fuel state isnt the assumed cause of all the problems and if 80kgs is being indicated at the point of engine flame out its hardly a time to over think things?

Pitts, for the first time as I can recall you have got this one right. What you describe, checking pumps (and pump CBs) is the recommended immediate action when LOW FUEL warning illuminate. However, just bear in mind this door has been bolted long after Dobbin left the stable.

[GC47G]

Tigerfish

Having yourself been in the ops side of the air support unit , can you shed any light on my post on the 10th (post 13 ) regarding refuelling such late at night giving very little places to do so , totally understanding the ops side for the PIC while on duty . So my my question is to you was there any procedure for reporting such occurrences back to the air support unit ,out with the PIC having to lots of paperwork explaining why and how it was addressed from the air support side

[tigerfish]

GC47G Sadly I cannot remember the detail now. Its over 20 years since I retired. Our practise re overnight refuelling was this. We had a large capacity mobile bowser at the unit. It was powered by an on board diesel generator. The fuel farm which closed at about 6.00pm would come over last thing before finishing and ensure that our own bowser was fully topped up. Then the aircraft would be refuelled as required during the remainder of the night from our own bowser. Refueling would always be at the direction and supervised by the PIC. At that time all of our observers were long time members of the unit, and well versed in the method of refuelling. They worked very much as a team, which is why I have always pressed for detail of the crews conversation with their control room. I cannot believe that my guys would have just sat there with the warning lights illuminated and said nothing to their C/R. But we've been through this conversation before, and I accept that that avenue was covered.
It seems that there must have been some form of CRM failure.

TF

[skyrangerpro]

Seems to me this will forever remain a mystery, in the absence of a CVR. It's beyond comprehension how an experienced and by all accounts excellent pilot could have (a) ignored multiple low fuel warnings (b) forgotten to turn the transfer pumps back on and then (c) when the inevitable happened, failed to enter autorotation, for which you'd expect him to be spring-loaded considering the fuel situation.

It makes me think of some classic rail accidents where the driver's actions are just beyond comprehension: Moorgate in 1975, or Grantham in 1906 (where the driver was seen calmly staring ahead, travelling at full speed into a low speed curve).

If someone's actions are irrational then there are only two possibilities. The individual is irrational (possibly temporarily). Or he appears irrational because he is seeing something differently to you or seeing something that you can't see. We'll all have a different opinion on what happened here, but I made up my mind long ago that David Traill (and possibly the other occupants) was probably not mad but was relying on/basing his actions on information presented to him in some form that was erroneous. And that erroneous information may not have left footprints.

[John R81]

I am with SRP - The only way to understand "pilot error" is to try to understand why the actions taken looked rational to that pilot in those circumstances at that time.

A very good book on the subject

[BigFrank]

The on line weekly magazine "Scottish Review" has had a report from the enquiry since it began.

Here is the latest; published this morning.

If you look at the sidebar you can find the 3 or 4 previous articles.

Scottish Review: Maurice Smith (http://www.scottishreview.net/MauriceSmith479a.html)

[skyrangerpro]

I am with SRP - The only way to understand "pilot error" is to try to understand why the actions taken looked rational to that pilot in those circumstances at that time.

A very good book (https://www.amazon.co.uk/Field-Guide-Understanding-Human-Error/dp/0754648265) on the subject


that looks an interesting book, I'm going to read it. Thanks.

[[email protected]]

Big Frank's link has some worrying comments about how an experienced engineer who raises concerns about engineering workload at Glasgow, is ignored by his line manager and his action in reporting his concerns dismissed as 'unprofessional'..

[jimf671]

Yes. Complex long FAI need somebody there listening for the small but important details. The Determination is the final output document, that addresses the specific points in the Act that I posted previously, and is public, but the Transcript is available only to 'Interested Parties' (those legally represented). Even in the Transcript you will miss the emotional impact of some of the points and importance of tiny decisions made along the way: the smaller holes in the cheese.

[OvertHawk]

Big Frank's link has some worrying comments about how an experienced engineer who raises concerns about engineering workload at Glasgow, is ignored by his line manager and his action in reporting his concerns dismissed as 'unprofessional'..

Even if it was considered that what he wrote and how he wrote it was "unprofessional", any line manager who read such a thing should be asking themselves "How tired, stressed and desperate does Bloggs have to be to write something like that?" Even if they do not consider that the point he raises is a valid concern the manner in which he is speaking is indicative of a significant Human Factors problem that should have been raising flags.

[jayteeto]

BigFrank has posted a link to the reviews so far. I would recommend reading these reviews as they clear up some points that people have been raising over what was and wasn’t attempted

[Fortyodd2]

There is also a Twitter feed from BBC Journalist Paul O’Hare

https://mobile.twitter.com/pohareBBC

Most but not all days are covered.

[skyrangerpro]

https://www.scotsman.com/news/inquiry-told-of-defects-to-clutha-crash-aircraft-1-4925316

[GC47G]

Just read Big Franks post which is not good reading , but applying Occam’s razor , the lights are not on the panel for decoration and auriols for something to listen , it’s worrying this is going to head the total wrong way down the path looking for the answer , For me light comes on manage it.......

[sadgit]

For the record; DT had an excellent knowledge of the fuel system and had carried out auto’s with both engines at GI.

[toptobottom]

Toptobottom post #73
I flew with DT(as did many on this forum). He would never entertain deliberately crashing a helicopter and I never witnessed an argument with anyone he operated with.

I know this is a rumour forum, but that’s quite frankly out of order..... please stop.

high spirits - when the inexplicable occurs and all rational circumstances and behaviour have been thoroughly investigated, it's normal to start looking at seemingly ridiculous reasons, however unpalatable they may be. By all accounts DT was an excellent pilot, but he was still human and humans (as we see with alarmingly increased frequency) have a habit of appearing to behave perfectly 'normally', while harbouring psychological issues that only surface when it's too late to prevent tragedy. If we ignored certain avenues just because "I knew him and he would never do that", we're denying that unknown mental health issues exist and can manifest themselves in unpredictable behaviour. Sorry if you're offended, but it's a possibility that cannot be ignored, just because you never witnessed an argument between him and his colleagues.

[DOUBLE BOGEY]

TOPTOBOTTOM, There is some merit in what you post. We had a very strange set of circumstances surrounding a well respected and seemingly stable colleague who decided one day that life was just too much for him! Inexplicable.!
However, in this case I believe there is sufficient evidence (or lack of) to see DT being led down the garden path by the indications in front of him. Having said that, someone most probably switched both transfer pumps OFF during the flight!! In the end, that will most probably prove to be the root cause of this tragedy. It is no surprise that the current recommendation on seeing or hearing any fuel warning is to check the TFR pumps switches and CBs. It is simple fuel system. However, like most simple systems a "simple" simplex mistake can be catastrophic.
For these reasons I don't buy into the psychobabble theories.

Amber PUMP cautions = Pumps OFF = Supply Tanks Draining + Faulty Contents indications + Poor Confidence in the warning & cautions systems = No appropriate response from Pilot = 2 x Flameout = pressurised auto = uncontrolled descent.

It could be that the supply tanks indicated FULL throughout. It could be that despite the "Memory" in the CAD that neither the Visual or Aural warnings manifested themselves properly in the cockpit. However, for all that to happen the Transfer Pumps HAD to be switched OFF!. In my view this is the only tangible and relevant piece of information that current EC135 pilots needs to assimilate. If you leave the TRFR pumps OFF, the supply tanks will eventually run dry.

The sideshows of maintenance histories, anecdotal events of a similar nature, training, system design are all for the Sherriff to digest and decide upon.

[jayteeto]

Toptobottom. Your logic says that in this case, you must consider the unthinkable. You chose your unthinkable theories with no evidence whatsoever. So let’s show how ridiculous that is. I can offer some theories with real evidence in this situation.
What about Dave having a dashing ‘tash? Maybe he was a secret Village People fan? Maybe he couldn’t cope with being gay?
Dave visited Moscow a few years ago, maybe someone was about to oust him as a spy?
These two scenarios are ridiculous, however they meet your standards of evidence, ie “think the unthinkable”.

Come on man! His family and friends read what is said here. He can’t defend himself. Show at least a little bit of respect........

[OvertHawk]

Toptobottom

Sometimes the unthinkable does need to be thought. But after an exhaustive investigation by the AAIB (during which they will have considered the unthinkable, the thinkable and everything in between) they have come up with a number of facts and conclusions, none of which include the scenario you suggest.

To make this suggestion, in disregard of the investigation findings and with no evidence whatsoever to support your accusation (and much to disprove it) is scurrilous, ignorant and dishonourable.

OH

[BigFrank]

That certainly seems to be a rational conclusion given that the latest evidence, link below, says that it took them over a decade to come up with a solution for what seems to this layman to be a major safety issue of which they had been clearly informed .

Apparently that is the view too of a witness from a British helicopter operating company who stated that the attitude of Airbus appeared to be:

, " ...[Y]ou use your design department rather than us using ours to come up with a solution...."

Scottish Review: Maurice Smith (http://www.scottishreview.net/MauriceSmith480a.html)

[MightyGem]

From the Scottish Review:
Ms Shelagh McCall QC, representing Captain Traill's partner Dr Lucy Thomas, raised the possibility that the pilot may have been flying using 'visual contact' (VFR) rather than his night-time instruments, and therefore believed he would have enough fuel to land. 'If the pilot had thought he was operating on VFR and had 65kg in the tank, they would not have needed a Mayday,' she suggested. 'Correct,' said Mr Stobo(director of operations at Babcock mission critical services).
Well that's two people who have no idea what they are talking about.

[GC47G]

MightyGem , Agreed 1000% on that

[GC47G]

Sorry , but that theory doesn’t fit with endurance / distance covered with the tasks they covered ?....

[BigFrank]

Scottish Review: Maurice Smith (http://www.scottishreview.net/MauriceSmith481a.html)


(The FAI has, it reports, been put on ice till at least the beginning of July; though I presume that the timing of the next report mentioned in the text as early August is due to non-publication of the "magazine" in the month of July.)

More to the point, the brief report does seem to repeat/ reinforce previous testimony about a known degree of unreliability of warning lights.

And about a failure to address the problem?

[Flying Bull]

Does anyone recall (or have access to) what the required drill was for both a F PUMP FWD and a F PUMP AFT prior to Rev 12 (Jan 2014) of the Airbus Emergency Check List?

There's no mention of that drill in the AAIB report Appendix A, but it lists the drills separately. Does anyone know if it existed prior to the accident?

Actioning the drills separately could leave both pumps selected off if the main tank contents are 'low'.

if 2000 is early enough
FLIGHT MANUAL EC 135 T1 (CPDS)
Emergency and Malfunction Procedures
3 - 20
CAUTION INDICATIONS
F PUMP AFT
(MISC)
Conditions/Indications
Failure of aft fuel transfer pump, or dry run.
Procedure
1. Fuel level in the main tank – Check
If main tank fuel quantity is sufficient to keep both fuel pumps wet:
2. FUEL PUMP XFER-A sw – Check ON
3. XFER-A PUMP circuit breaker – Check in
If F PUMP AFT indication remains on:
4. FUEL PUMP XFER-A sw – OFF
If main tank fuel quantity is low:
2. FUEL PUMP XFER-A sw OFF
NOTE EEach fuel transfer pump is capable of feeding more fuel than both engines will
consume.
EIn hover flight conditions the unusable fuel can be up to 71 kg. The quantity of
unusable fuel can be reduced to 7.5 kg when flying with 80 KIAS or more.

FLIGHT MANUAL EC 135 T1 (CPDS)
Emergency and Malfunction Procedures
3 - 21
CAUTION INDICATIONS
F PUMP FWD
(MISC)
Conditions/Indications
Failure of forward fuel transfer pump, or dry run.
Procedure
1. Fuel level in the main tank – Check
If main tank fuel quantity is sufficient to keep both fuel pumps wet:
2. FUEL PUMP XFER-F sw – Check ON
3. XFER-F PUMP circuit breaker – Check in
If F PUMP FWD indication remains on:
4. FUEL PUMP XFER-F sw – OFF
If main tank fuel quantity is low:
2. FUEL PUMP XFER-F sw OFF
NOTE EEach fuel transfer pump is capable of feeding more fuel than both engines will
consume.
EIn forward flight conditions the unusable fuel can be up to 59 kg. The quantity
of unusable fuel can be reduced to 3.6 kg when flying with 80 KIAS or less.

[MightyGem]

Does anyone recall (or have access to) what the required drill was for both a F PUMP FWD and a F PUMP AFT prior to Rev 12 (Jan 2014) of the Airbus Emergency Check List?
There was no drill for the FAILURE of BOTH Transfer Pumps before the Main Tank was empty, if that is what you mean.

Having noticed this, not log after we got our 135, I can recall taking off with both pumps switched OFF(on purpose) to see what would happen. In the cruise, the contents of the Main Tank reduced as the fuel went through the "overflow"(correct term forgotten) into the Supply Tanks for a while, but at around 250kgs indicated in the Main Tank, the Supply Tank contents started to reduce, with the Main Tank contents staying the same.

So, if BOTH Transfer Pumps failed below 250kgs in the Main Tank, you would only have the contents of the Supply Tanks for use.

[MightyGem]

No, the only time that it should occur is when the main tank has run dry.

[Flying Bull]

I guess "should" being the operative word.
If you were in the hover or at a low speed surely the remaining fuel in the tank would be aft, leaving the forward pump uncovered, and resulting in the F PUMP FWD being selected off. As the pitch goes down to increase speed, surely the fuel moving forward would now uncover the aft pump, resulting in the F PUMP AFT being selected off. If there was no drill for captions on both fuel pumps and neither of the individual drills tells you that one of those should be turned back on, isn't there a chance that they can both remain off with some fuel still in the main tank?? If its compounded by the reported fuel sensor problems, surely there's a chance of both fuel pumps being off and believing the fuel is in the supply tanks?

Thats why you need a rating for flying helicopters, where in the theorie part - which requires a test to pass - things like the fuel system are covered.
(Tanks, capacity, pumps, usage i.e.)
When someone gets captions about the fuelstate, pilots normaly get realy sensitive, checking the fuel state and how much fuel is in which tank, knowing, that there might be unusable fuel, depending on which pump isn´t working.
Knowing, that the engines take their fuel from the feeder tanks does mean, that they are the tanks I focus on.
If fuel isn´t transfering from the main tank, I do something about it or make decisions to asure a safe landing.
We wont get an answer, why this time the obvious wasn´t done or which assumptions led to continuing the flight, despite the warnings.
But I won´t blame it on the general fueltank/pump setup, which is used in hundreds or even thousands of helicopters worldwide.
(Bo105, BK117 all variants, EC135, EC155) and except from an autorotation, where the crew covered the warning lights with duct tape, I don´t recal incidents which are related to the general setup.

[GC47G]

Inquiry back in session today .......

[skyrangerpro]

https://www.eveningtimes.co.uk/news/17746276.clutha-inquiry-pilots-tell-of-fuel-gauge-failures/

AIR ambulance pilots who flew the same type of helicopter as the one which caused the Clutha disaster have told how their fuel gauges failed during flight.

Two airmen giving evidence at the inquiry into the accident, which cost the lives of ten people, spoke of getting faulty readings during flights in an EC-135 helicopter which said fuel tanks were full when they were actually dangerously depleted.

William Bryers, a former flying instructor and John Taylor, now a flight lieutenant with the RAF, were working for the air ambulance service in England when the incidents happened.

Captain Bryers said that the gauge gave an incorrect reading “about 30-35 kilos [of fuel] either way” while it was being flown, depending on the pitch of the aircraft.

Flt Lt Taylor recounted a further incident in the same aircraft where low fuel warnings sounded during a flight, despite gauges showing that both supply tanks were still full.

Both were speaking at the ongoing hearing into the disaster, which is taking place at a temporary court Hampden Park before Sheriff Principle Craig Turnbull.

Ten people died when police helicopter G-SPAO fell from the sky and crashed into the crowded Clutha Vaults pub in Glasgow on 29 November 2013.

The pilot and all passengers aboard the aircraft were among the fatalities. The question of how much fuel the aircraft had and what the crew knew about it has been central to the inquiry.

The problems aboard Captain Byers’ helicopter occurred during three different flights he made on 10 December 2013. The pilot saw changes in fuel levels when transitioning from a ‘take-off and hover’ position to level flight.

He said: “I had never experienced that, and it stood out to me. So I made notes to that.

“When taking off there was around 30 kilos less. Moving forward there was about 30 kilos above.”

He said it was not connected to fuel being burned off while the aircraft was in operation, and that the fluctuations were greater than he had ever experienced before.

The incident was reported to Captain Bryers’ superiors, and noted in a technical log.

Details were also passed on to Flt Lt Taylor, who was flying the helicopter the next day. During a flight to Backpool where the aircraft was to be examined, the gauges failed again.

Despite showing the instruments showing full tanks, fuel pump warning lights were activated in the cockpit, causing confusion among the crew.

Flt Lt Taylor: “If they had both been on I would not have lifted. During the climb both came on. I don’t know which one came on first, but there was not much time between them.

“It took me a few minutes for the light to go on in my head, and I said to the paramedic [onboard] that ‘there’s something not quite right here’.”

The aircraft landed safely at Blackpool with the fuel indicators showing that both supply tanks were full, and that the main tanks also had some fuel left, despite Flt Lt Taylor knowing it had to be empty by this point. By this point red low fuel lights had been activated on the dashboard.

The court also heard that a technical “information notice” was dispatched in March the next year by the helicopter’s manufacturer, which explained that fuel displays could be affected by the pitch of the aircraft and give faulty readings.Flt Lt Taylor said this came as a surprise to the pilots, who were unaware if the aircraft’s fuel supply ‘logic’.

He said: “It was quite a shock to learn that ‘logic’. We did not know our own fuel systems. It was talked about a great deal.”

Pilot David Traill, 51; PC Tony Collins, 43; and PC Kirsty Nelis, 36, died along with seven customers who were in the bar when it was struck by the helicopter - Gary Arthur, 48; Joe Cusker, 59; Colin Gibson, 33; Robert Jenkins, 61; John McGarrigle, 58; Samuel McGhee, 56; and Mark O'Prey, 44.

The Inquiry continues.

[Flying Bull]

Nothing really new here.
differences in the fuel state depending on attitude is common - but if you understand, that the low fuel warning is independent from the displayed value the necessary actions are straight forward.
i f in doubt, play it save is a good advice in aviation.

[jayteeto]

Don’t believe every newspaper account of what was said

[BigFrank]

Their correspondent's perception of the main points raised in the final few days of the enquiry.

Scottish Review: Maurice Smith (http://www.scottishreview.net/MauriceSmith488a.html)

[KelvinD]

The final report has just been published:
https://www.bbc.co.uk/news/uk-scotland-glasgow-west-50220838

[mickjoebill]

The final report has just been published:
https://www.bbc.co.uk/news/uk-scotland-glasgow-west-50220838

Sky News UK top of the hour headline is (paraphrasing) ...ran out of fuel, pilot to blame.

mjb

[MightyGem]

Load of b@ll@cks.

[atceng]

Unnecessrialy complex fuel system, leaving the pilot to do what the aircraft system should do automatically by design.
Unreliable gauges and low level alarms routinely crying WOLF
Pump switches out of view
All waiting for innocent error and then, GOTCHA!
Pilot victim of booby trap, yet blamed.
Thank goodness my fuel gravity from two tanks,on-off, but gotcha flap switch detents back to 'up'

[nomorehelosforme]

Sky News UK top of the hour headline is (paraphrasing) ...ran out of fuel, pilot to blame.

mjb

BBC saying similar.Clutha crash: Inquiry says pilot 'took a chance' to ignore fuel warnings
https://www.bbc.com/news/uk-scotland-glasgow-west-50220838

[212man]

BBC saying similar.Clutha crash: Inquiry says pilot 'took a chance' to ignore fuel warnings
https://www.bbc.com/news/uk-scotland-glasgow-west-50220838

Well you would expect them to tally as they are quoting the Sheriff directly.

Interesting to see some of the family support:

Mr O'Prey's father Ian said he was "really angry" at the inquiry's findings and that Capt Traill had been made "a fall guy".

The Clutha's owner, Alan Crossan, also expressed "shock and disappointment" at the report and how "brutal" it had been towards Capt Traill.

[Blue_Circle]

The problem is that the media and public understanding of what happened and what it 'means' was always going to be different from that of an experienced professional. Understanding the underlying cause and the lessons to be learned doesn't sell papers.

[OvertHawk]

Well you would expect them to tally as they are quoting the Sheriff directly.

Interesting to see some of the family support:

I agree that there is more to this than a straightforward pilot error - that system was far from Murphy proof.

The support being shown by the families towards the pilot is refreshing in many ways but also must be taken in the context of "This is Glasgow". Glasgow is a very egalitarian city. It is the natural response of most people to support the wee guy against the big guy. When the big guy also happens to be the "Polis" then it's a no-brainer. Many people in Glasgow want this to be the police's fault rather than some poor bloke just doing his job.

[Dato_R44]

I would be interested to know the thoughts of Rotary Pilots who may have questioned some of the reports findings.
in particular I find it interesting that the report questions why ATC heard nothing from the Helicopter minutes and seconds before the impact.
As I recall from my training as a PPL(H) In all instances when airborne it is the practice to 1. Aviate, 2. Navigate and 3. Communicate In that order.
Might this explain the lack of COMM's leading up to the impact?
Also the fact that it appears that the attempt to effect autorotation 3 times on realisation that both engines had flared out the pilot was doing all he could to
limit the risk of injury or death by ditching in the River Clyde. Although the machine was so close to the water, this was also hampered by the fact that the 'steering light' was not switched on
which made it near impossible to gauge height, location and speed. There are some questions raised that cannot be answered but IMHO the pilot at the point of the double flare-out exercised
all his skill to auto the machine into the river to limit the risks of death and injury and he was so very close!
I am asking the question mindful of and with the deepest sympathy and respect to all who suffered in this tragic and heart-breaking event.

[Fortyodd2]

Atceng – “low level alarms routinely crying WOLF” Actually not. The Low Fuel sensors have been shown to be the one component that could and can be relied upon – unlike the Fuel Qty sensors which are prone to over reading if/when contaminated.

The Sherriff Principal has it right with his final paragraph:

[515] The central question for the inquiry is why did that happen? The answer is a simple one. Captain Traill ignored the LOW FUEL warnings he received. Had he followed the procedure set down in the Pilot’s Checklist in respect of the LOW FUEL 1 and / or LOW FUEL 2 warnings, the accident would not have happened. Put another way, Captain Traill took a chance that the LOW FUEL warnings he received were erroneous. That was a conscious decision on his part. It was a decision that had fatal consequences for ten people.

The responsibility for the outcome of every flight lies with the aircraft Captain - it's the price of the privilege of the 4 bars on their shoulders.

[idle stop]

Does anyone have a link to the actual FAI report, please?

[212man]

Does anyone have a link to the actual FAI report, please?
https://www.scotcourts.gov.uk/search-judgments/judgment?id=551d7ca7-8980-69d2-b500-ff0000d74aa7

[jivusajob]

I've read the full report (unlike the media, I fear). It is very factual and I believe balanced and reasonable. What the media will not pick up on/report is that the sheriff concluded that the fuel gauges were misreading. He sated this several times. He also said he believed Dave ignored the red captions because the information he was getting from the CAD (no yellow caption) and the indicated fuel contents contradicted what the red captions were saying. I always believed this to be the case and I'm glad the sheriff concluded this from the evidence. What is unpalatable to us but is factually correct is as the sheriff stated (and this is the only thing the press will pick up) if both transfer pumps had not been switched off and the red captions ignored then this accident would not have happened. Thats the fact. The why we will never know.

[HeliComparator]

I've read the full report (unlike the media, I fear). It is very factual and I believe balanced and reasonable. What the media will not pick up on/report is that the sheriff concluded that the fuel gauges were misreading. He sated this several times. He also said he believed Dave ignored the red captions because the information he was getting from the CAD (no yellow caption) and the indicated fuel contents contradicted what the red captions were saying. I always believed this to be the case and I'm glad the sheriff concluded this from the evidence. What is unpalatable to us but is factually correct is as the sheriff stated (and this is the only thing the press will pick up) if both transfer pumps had not been switched off and the red captions ignored then this accident would not have happened. Thats the fact. The why we will never know.

I agree it is a well considered and well written report. I haven’t finished reading it yet but I’m not sure you are right when you say the fuel gauges were misreading. I suspect they accurately reflected the fuel remaining in the main tank - it’s just that this fuel was not available to the engines. Misleading maybe, but not misreading. But I suppose I’d better finish reading it before I argue too much!

Edit - ah yes I see he is proposing that there was a fuel indication problem, although the primary reason for that conclusion is that it would be incomprehensible for DT to have ignored not only the amber fuel captions but also the red ones. To ignore red ones on their own is certainly more understandable. That said, he seems to have ignored the transfer pump lights.

[Distant Voice]

The Sheriff has clearly implied negligence on the part of the pilot, based on ‘the balance of probabilities’. According to Lord Philip (Mull of Kintyre Review), where aircrew have died and unable to defend themselves the ‘Standard of Proof’ is set higher to the level of ‘Absolutely no doubt whatsoever’ Furthermore, FAI are not set up to assign blame. This FAI fails to comply with these two criteria.

DV

[jayteeto]

Helicomparator. I gave 2 days of evidence to the enquiry. About a week after the tragedy I was flying an aircraft that had both red warnings come on in flight. The tanks showed 47/26/43 on the gauges and the amber/yellow fuel warning did not show. I landed very quickly, the tanks were drained and were nearly empty. We nearly repeated the accident. So the sherif WAS talking about this scenario.

ultimately, the conclusion is correct. I was confused but believed the “worst” warning. It appears Dave didn’t.

My argument ALWAYS was that whilst it was pilot error, I believed there were possible mitigating circumstances where Dave was confused by what he saw. I’m glad the sheriff has understood this and accepted that he may have been confused.

For the record, the court was totally fair with me, they gave me a hard time but they were also prepared to listen and consider my answers. Hopefully the families can find some peace now

[HeliComparator]

Helicomparator. I gave 2 days of evidence to the enquiry. About a week after the tragedy I was flying an aircraft that had both red warnings come on in flight. The tanks showed 47/26/43 on the gauges and the amber/yellow fuel warning did not show. I landed very quickly, the tanks were drained and were nearly empty. We nearly repeated the accident. So the sherif WAS talking about this scenario.

ultimately, the conclusion is correct. I was confused but believed the “worst” warning. It appears Dave didn’t.

My argument ALWAYS was that whilst it was pilot error, I believed there were possible mitigating circumstances where Dave was confused by what he saw. I’m glad the sheriff has understood this and accepted that he may have been confused.

For the record, the court was totally fair with me, they gave me a hard time but they were also prepared to listen and consider my answers. Hopefully the families can find some peace now

Yes it seems there wasn’t a clear understanding of the simplicity and reliability of the thermistor system vs the unreliability of the capacitor probe system. But even so, I don’t understand why when presented with the red low fuel warnings, one wouldn’t notice the transfer pump lights on. Just so I understand, in the cruise with that sort of fuel state, would it be normal for one pump to be switched off? I suppose not noticing that 2 captions as opposed to 1 were on, is a bit more understandable than if neither should have been on.

Finally, I rather dispute the Sheriff’s point about the types of pump. Surely it wouldn’t be a big deal to say (for UK aircraft at least) only the Fuchs pumps may be installed and hence there would be no need to ever fiddle with the switches. Routinely switching off the transfer pumps is surely at the heart of this accident. Or am I missing something?

[jayteeto]

No, you aren’t missing anything. I was receiving various cautions and warnings that my indications disagreed with. I will admit, I WAS confused, my quote in the cockpit was “I’m not sure what it is yet, but something is up with the fuel system”. The red warnings sealed the deal. Without a CVR we will never know

[212man]

When the EC155 entered service in Nigeria a crew experienced an engine flame out. One of the jet pumps in the LH Fuel group was blocked by debris and the main tank exhausted. They too were confused as the total quantities appeared normal but the LH Red Fuel Low caption was illuminated.

[Thud_and_Blunder]

...and to confuse things further: in my last job I was on task (in a CPDS P2) when the red FUEL warning (with gong) illuminated on one side. We packed in the task, started the clock (we observed the CDS P1 "only 8 minutes" across our small fleet) and turned for an (RN satellite) airfield not a million miles away. Reviewing the actions, I noted that the main tank was still delivering fuel, that both supply tanks were still indicating full and that there were no other indications of low fuel in the supply. I elected to knock the speed back to a figure using power below that required for OEI and turn for base, figuring that if - as I suspected - it was an erroneous warning, then only one engine would be affected and I could fly a single-engine approach. After approximately 15 minutes we flew a twin-engine approach back into home base.

Sure enough, the pump unit had a faulty thermistor so the moral is that even the usually-reliable component of the EC135 fuel indication system can have its off-days. Dave and jay were right to be confused - only jay made the safe call and is here to tell us about it.

I was disciplined for not following unit SOPs by putting the aircraft down within the specified time with a warning light illuminated, which I accepted as not everyone is inclined to analyse what the aircraft is doing versus what the indications are reading - can't go setting bad examples by using aircraft knowledge/ reasoning/ initiative.

[DOUBLE BOGEY]

I agree that there is more to this than a straightforward pilot error - that system was far from Murphy proof.

It is the natural response of most people to support the wee guy against the big guy. When the big guy also happens to be the "Polis" then it's a no-brainer. Many people in Glasgow want this to be the police's fault rather than some poor bloke just doing his job.

Nope...….they just wanted to sue the OEM who has the big bucks rather than the Pilots Estate that comparatively has peanuts!

[DOUBLE BOGEY]

Helicomparator. I gave 2 days of evidence to the enquiry. About a week after the tragedy I was flying an aircraft that had both red warnings come on in flight. The tanks showed 47/26/43 on the gauges and the amber/yellow fuel warning did not show. I landed very quickly, the tanks were drained and were nearly empty. We nearly repeated the accident. So the sherif WAS talking about this scenario.

ultimately, the conclusion is correct. I was confused but believed the “worst” warning. It appears Dave didn’t.

My argument ALWAYS was that whilst it was pilot error, I believed there were possible mitigating circumstances where Dave was confused by what he saw. I’m glad the sheriff has understood this and accepted that he may have been confused.

For the record, the court was totally fair with me, they gave me a hard time but they were also prepared to listen and consider my answers. Hopefully the families can find some peace now

Jayteeto's anecdotal evidence speaks volumes. The "Hill of Hindsight" is a wonderful thing but I will be honest and say that I never truly understood the significance or design intention of the Amber (Capacitance driven) and the Red (Thermistor Driven) indications before this accident. It is really clear to me now.

In Dave's defence, I feel for him to ignore the warnings like he did there must have been a clear mitigation in his assessment to do so. I therefore conclude in my own mind, he saw plenty of fuel indicating in the Supply Tanks....just as Jayteeto did. It is very easy to criticise but the hooded horseman of habit, gossip, routine "getting away with it" all probably coalesced that night to a horrific ending.

The Sherriff has it right and he is only supposed to deliver the facts. It is for the industry to try and work out the response. Note he also recommends a warning light system for the FUEL XFR lights, I am assuming in addition to the CAD notifications.

[Thomas coupling]

A tragic but inevitable outcome from the enquiry. A dark day for the industry.

[Arkroyal]

The Sheriff has clearly implied negligence on the part of the pilot, based on ‘the balance of probabilities’. According to Lord Philip (Mull of Kintyre Review), where aircrew have died and unable to defend themselves the ‘Standard of Proof’ is set higher to the level of ‘Absolutely no doubt whatsoever’ Furthermore, FAI are not set up to assign blame. This FAI fails to comply with these two criteria.

DV

you are mixing up a civil FAI and Military board of enquiry. Only the military require the criteria of ‘absolutely no doubt whatsoever.

The FAI is there to determine cause of death. That broad remit includes who’s at fault, surely?

[Rigga]

Tragically, we have all learned a little more about what we do, why we do it and how we do it. Because of illness my FAI evidence boiled down to a local interview and a few emails but, even though it was fairly light, I have now experienced much more about aircraft related failures than I need. Lets stay as safe as we can.

[jimf671]

you are mixing up a civil FAI and Military board of enquiry. Only the military require the criteria of ‘absolutely no doubt whatsoever.
The FAI is there to determine cause of death. That broad remit includes who’s at fault, surely?



As best I recall, the military case was bound by requirements in Queens Regulations Royal Air Force.

This Inquiry is conducted in accordance with the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016. Similar to its predecessor of 1976, this Act has very specific requirements for the outcome of the Inquiry as presented in the Sheriff's determination. At Section 26, sub-section (2), these are as follows.

The circumstances referred to in subsection (1)(a) are -
(a) when and where the death occurred,
(b) when and where any accident resulting in the death occurred,
(c) the cause or causes of the death,
(d) the cause or causes of any accident resulting in the death,
(e) any precautions which -. (i) could reasonably have been taken, and
. (ii) had they been taken, might realistically have resulted in the death, or any accident resulting in the death, being avoided,
(f) any defects in any system of working which contributed to the death or any accident resulting in the death,
(g) any other facts which are relevant to the circumstances of the death.

[falcon900]

Double Bogey,
I suspect you are wrong about the relatives wanting to sue anyone. They will have been compensated, at least in the financial sense, some time ago by the various insurers. In any event, the pilot was acting in the course of his employment, and any claims would fall to be met by his employer or their insurers.

Having followed this closely from the outset, I think what the Sheriff has concluded is correct. However, the question which continues to niggle me is why did such an experienced pilot elect to take this risk, which in turn brings me to the question what were the last taskings about. Why did he orbit two motorway junctions? What did the tasking ask him to look for? Was it an emergency, was life at risk? I have absolutely no idea, but the answers to these questions would surely have had a bearing on the pilots likely frame of mind when deciding to take the risk which he did.

[jayteeto]

He wouldn’t have “took the risk” like you think. He wouldn’t have thought “I’ve only got a few minutes but I’ll give it a go”, that’s not what people are concluding.
what the conclusion is talking about is that he believed the indications to be false, hence he continued to fly. The task is irrelevant here. The sheriff agreed with many of us that he believed (wrongly) that he had loads of fuel. Trust me, my first reaction was exactly that.

[falcon900]

Jayteto,
this may sound like a semantic point, but it isn’t. I don’t doubt the pilot thought the warning lights were wrong, ( I said as much on the original thread) but he didn’t know that they were By accepting the tasking, he took the risk. Full stop.
I remain puzzled by why the nature of the tasking remains a mystery, as I believe it could materially mitigate the assessment of the pilots actions.

[tucumseh]

STATEMENT BY DR LUCY THOMAS, FIANCÉE OF PILOT DAVID TRAILL Following the determination of the Fatal Accident Inquiry into the Clutha helicopter crash, Dr Lucy Thomas, fiancée of pilot David Traill, has issued the following statement.
"For almost six years I have remained silent in order to protect my privacy. However, such is my strength of feeling since the Sheriff Principal's Determination on the Fatal Accident Inquiry into the Clutha helicopter crash, I feel compelled to make this statement.
"I am overwhelmed by the support that I have received from so many people, many of whom don't know me and didn't know Dave. I am eternally grateful for this.
"It is my understanding that due to misleading information from the aircraft fuel gauge and display system, Dave had only moments to make decisions and carry out tasks in an attempt to respond to this issue. It is also my understanding that he should have had a significantly longer timescale in which to do so before the helicopter would lose both engines. The manufacturer's aircraft maintenance manual incorrectly recorded that the flameout time between engines was three to four minutes. This was incorrect information. The correct time available should have been in excess of 1 minute but due to the design of the fuel tanks allowing for fuel from one tank to slop over into another, he had only 32 seconds. That 32 seconds ended in tragedy and the loss of his and nine other valuable lives. This has devastated the lives of all who surround them and impacted on so many more.
"In my opinion, the Sheriff Principal's determination does no justice to the memories of Gary Arthur, Tony Collins, Joe Cusker, Colin Gibson, Robert Jenkins, John McGarrigle, Samuel McGhee, Kirsty Nelis, Mark O'Prey, and to the memory and reputation of Dave Traill; it insults the intelligence of those who know of the evidence presented at the Inquiry and are aware of the content of the initial AAIB report.
"Disbelief has been expressed by many family members of those who died and by members of the public at the conclusion drawn by Sheriff Principal Turnbull, who incredulously stated that Dave consciously took risks which caused the accident. This expression of disbelief speaks volumes and means much more to me than the opinion of the Sheriff Principal.
"I find it distressing and incomprehensible that given months, not moments, to consider the facts, the Sheriff Principal has come to this conclusion. He chose not to concentrate on the fact that the EC135 model of helicopter has a history of faults with the caution advisory display, specifically a history of erroneous or spurious fuel indications, amongst other technical problems such as contamination of the fuel tanks, issues still never fully resolved by the manufacturer. Instead, the Sheriff Principal has opted to sully the distinguished reputation of a pilot with an exemplary record who was renowned for his sense of responsibility and his regard for the safety of his crew.
"The opportunity for closure and maybe some peace for so many people has been denied.
"I once again request privacy and respect from the media."
ENDS
Dr Thomas will be making no further comment.

[HeliComparator]

Yes it must be horrible for her. I know what the sherif meant when he said “took a risk” and in the full context of the report it is not outwith the bounds of a reasonable phrase, but unfortunately it translates badly into press headlines, and that certainly does no justice to DT.
As a result of the FAI, those of us that understand the general issues I think now have a much better understanding of why it happened. Well I do, anyway. It would be nice if Dr Thomas understood that people in the industry don’t share the simplistic “took a risk” view that is published in the tabloids,

[jayteeto]

Agreed 100% HeliComparator

[jellycopter]

The biggest question for me, which does not seem to have been fully addressed, is the unsuccessful autorotation. Flaming-out both engines due to fuel starvation is one thing, but an accomplished pilot losing NR so catastrophically has me baffled.

[paco]

There is a world of difference between a real one (been there, done that) and practising, which is generally not done in twins*, and practice, especially when you do not expect it, and especially when you expect one engine to flame out after another over a rather longer timescale than is shown here. With modern helicopters having lighter blades, it would not be hard to lose NR.

*At least the 355 has a single engined equivalent to practice on.

I've not flown the type in question, but it seems to me that it has a similar quirk to the 206L where you can have much less fuel available that is indicated, and that doesn't even have a computer.

[Flying Bull]

Hi all,
I can understand Daves Finace - she's emotional involved.
Have more than 1.300 h under NVG - similar tasks - landed more than once with only fuel in the support tanks....
And there is more to the situation - there are more crew members involved - talking to each other, interrupting actions/thoughts, possible putting further pressure on or influencing the decision making....
(What is the employer saying, if you land in a field and order a fuel truck?)
So I think, I have also an general understanding for Daves situation.
Who thinks, it could´t happen to him should take some simulator sessions with an instructor putting pressure on....
Still - as nearly always - it is up to the pilot in command to make the decisions - and get blamed, if it was the wrong one.
What I learned from experience but also from this crash is - better safe than sorry - play it safe - if in doubt, expect the worst scenario.
We have a short reminder, which helps in the process, called
"FORDEC"
F-acts - what happened, what information do I have (cautions, indications i.e.)
O-ptions - which do I have - i.e. engine restart? land? where? continue?
R-isks - to the options I have evaluated
D-ecison
E-xecute - the decision
C-heck - wether my decision is working as planed - otherwise start from the top again.

By now I´m much more willing to say no / cancelling or delaying a mission - interrupting for refuel - without feeling bad - cause I know, what can happen, if someone lets the pressure influence the flight.
If this accident and the discussions leads to more safe decisions - it wasn´t worthless.

To the question about the autorotation - 30isch seconds between failure of the first and the second engine isn´t really much time, especially, if you haven´t expected the failure of the first engine at this time.
So while getting the picture of what happened and dealing with that emergency, the second done failed on Dave.
I´m not really surprised, that the Nr decayed during the autorotation.

Still - also something to learn for Eurocopter/Airbus pilots - if you expect an engine failure due to fuel starvation / and possible the failure of the second one, why not switch the Shed bus to on?
No harm done, if you don´t need it but time and hands of the controls saved in case of - a point for the O-ptions, when the Fuel lights come on.

[Georg1na]

I find it distressing and incomprehensible that given months, not moments, to consider the facts, the Sheriff Principal has come to this conclusion. He chose not to concentrate on the fact that the EC135 model of helicopter has a history of faults with the caution advisory display, specifically a history of erroneous or spurious fuel indications, amongst other technical problems such as contamination of the fuel tanks, issues still never fully resolved by the manufacturer.

I have never flown the type involved, but bearing in mind the above - and assuming that any pilot of the type is aware of these facts - would it not be prudent to fly with the maxim "if in doubt chicken out"?

[HeliComparator]

The biggest question for me, which does not seem to have been fully addressed, is the unsuccessful autorotation. Flaming-out both engines due to fuel starvation is one thing, but an accomplished pilot losing NR so catastrophically has me baffled.
I think it was addressed. Firstly the (false) expectation that there would be a much longer period between engine flameouts, and secondly that when 500’ agl over a city at night without a radalt or landing light, a successful autorotative landing is highly unlikely in reality. Which is true.

If you would like to demonstrate that you have made a successful engine off landing in a built up area from 500’ at night etc, then I might be persuaded otherwise but failing that, I’m with the sheriff. Those who think they could do it have never tried it..

[megan]

There is a world of difference between a real one (been there, done that) and practising, which is generally not done in twinsWas part of every ride in our outfit, throttles chopped at 1,000 for a 180° or straight in and power restored in the flare. One instructor (76) left the power at idle so you got to do one to the ground as a one off confidence builder, we all had plenty of 76 time by that stage. Not prebriefed, if it looked good he left you to it, very surprising when you pull and there's nothing there.

[jellycopter]

I think it was addressed. Firstly the (false) expectation that there would be a much longer period between engine flameouts, and secondly that when 500’ agl over a city at night without a radalt or landing light, a successful autorotative landing is highly unlikely in reality. Which is true.

If you would like to demonstrate that you have made a successful engine off landing in a built up area from 500’ at night etc, then I might be persuaded otherwise but failing that, I’m with the sheriff. Those who think they could do it have never tried it..

HeliComparator. I'm not saying that I would perform any better or worse in the circumstances as presented. I've certainly never done an EOL at night from low level over a city in an EC135 - but then I'm guessing no one else other than David Traill have either. Not having done it personally, does not preclude intellectual debate as to what might have happened.

My observations from the AAIB report are that the aircraft crashed with zero ground speed and zero rotor RPM. That's quite an achievement from 500(approx) feet agl and about 100kts groundspeed. If the pilot did nothing at all, the aircraft trajectory would still have some forward element would it not?

The report stated that the Low NR warning activated twice, was extinguished twice and then activated a third time and remained on. My hypothesis is that the first warning activated shortly after the second engine failed. The pilots instinctive reaction would be to lower the lever. If there was a restriction and the lever couldn't be lowered fully, only partially, a cyclic flare could recover the NR. This could potentially be achieved a second time but once forward airspeed and hence flare effect is depleted there's no further way to recover NR. This scenario could explain the rotor stall and the lack of ground speed.

Could something as simple as a clipboard or tasking folder have been in exactly the wrong place at the wrong time? I find this more plausible than a pilot of his experience, with heightened awareness after the first engine failure, simply mishandling the autorotation (albeit in exceptionally demanding circumstances).

JJ

[Fortyodd2]

With regard to Dr Thomas’ statement:

“Distressing” – understandable given her personal loss.

“Incomprehensible” – then she has not been listening.

“given months, not moments” – actually, the Captain of the aircraft had at least 8 minutes of the Low Fuel Sensors telling him to land the aircraft which he acknowledged but failed to act upon.
“history of faults with the Caution Advisory Display” – Not so - the CAD only displays what it is being told to display by the various sensors connected to it. Like any other computer, cr@p in – cr@p out.
“specifically, a history of erroneous or spurious fuel indications, amongst other technical problems such as contamination of the fuel tanks” - correct and still being reported.

Having experienced the phenomena of being told one thing by the display/qty sensors and another by the Low Fuel Sensors in similar circumstances to JT2as far back as 2007 and 2012, it also caused confusion initially but, nevertheless the aircraft was on the ground in very short order. As a result, like JT2, I also spent a day in the witness box at the FAI.

It wasn’t until I was being interviewed by Police Scotland during the evidence gathering process in 2017 that I actually did the maths on this one and it really hammered home the point. For those who haven’t done it yet:

Take off at 2044, crash at 2222 = 98 Minutes.

Fuel indicated at Startup = 400Kgs, Fuel found in wreckage 76Kgs = Fuel used 324Kgs.

EC135 Fuel planning figure 200Kgs per hour/3.33 per minute.

324Kgs used divided by 3.33 = 97.3 minutes.

[jayteeto]

Could I request that people take time to read the full report before any further comments on the Sheriff’s conclusion. The press are misrepresenting the gist of his words. What he is saying is not condemnation of Dave. It could have been worded better, but he disagrees with the AAIB to some extent. He believes that Dave’s actions were that of someone being Led/confused by the indication in front of him, leading to him doubting the red warnings and ignoring them. In other words, mitigating circumstances. However Dave’s decision to not believe the warnings was ultimately his decision. He didn’t recklessly accept a new task like the papers are implying, but he did choose to not believe the red warnings. That identification of the mitigation was the best outcome that I could have hoped for. He made an error of judgement, NOT a reckless decision.

[Flying Bull]

Could I request that people take time to read the full report before any further comments on the Sheriff’s conclusion. The press are misrepresenting the gist of his words. What he is saying is not condemnation of Dave. It could have been worded better, but he disagrees with the AAIB to some extent. He believes that Dave’s actions were that of someone being Led/confused by the indication in front of him, leading to him doubting the red warnings and ignoring them. In other words, mitigating circumstances. However Dave’s decision to not believe the warnings was ultimately his decision. He didn’t recklessly accept a new task like the papers are implying, but he did choose to not believe the red warnings. That identification of the mitigation was the best outcome that I could have hoped for. He made an error of judgement, NOT a reckless decision.

Well, the Sheriff isnˋt an aviator.
So his view is legit, but we know, that we as aviators can’t follow/understand Dave’s Decision making, especially knowing, that normally every pilot should have a general idea about his endurance.
As the calculations show, a started stopwatch at t/o would have given him the same information as the warnings did, which he ignored.
And getting a fuel warning, you surely check the indications, but also their plausibility against time flown.
There sure was a human factor involved, which isn’t covered, cause we don’t know, what conversation happened in the bird

[meleagertoo]

Did the Police ever provide a transcript of the police comms?

[MaxR]

As the calculations show, a started stopwatch at t/o would have given him the same information as the warnings did, which he ignored.

FB - I'm not sure that's the case. The calculation would have shown him that he had about 75kg left - which he did - the problem is not how much fuel he had (enough for a good twenty minutes) but where it was, ie not in the supply tanks. Or have I misunderstood something?

[Flying Bull]

FB - I'm not sure that's the case. The calculation would have shown him that he had about 75kg left - which he did - the problem is not how much fuel he had (enough for a good twenty minutes) but where it was, ie not in the supply tanks. Or have I misunderstood something?

Well, checking where the fuel is, when you get a warning, is part of the checklist.
Evenso I landed under minimum fuel required (a couple of times), I always had a very close eye, on where my fuel was (balancing it in another ship) to avoid an early flame out.
20 min was less than required for landing by the operator.
Going below minimum fuel can happen in aviation - but I think, a very very good reason is required to accept this extra risk - i.e. a life saving mission.
And when doing so, evaluating the associated risks - and having a plan B, in case of miscalculating the fuel available.
We don´t have the police control information here - but the flight path, hovering here, hovering there, which doesn´t really implement, that they found somebody where the ground forces needed guidons to rescue them.
I know, at the moment I´m more the devils advocate - but thats my point of view.

[jayteeto]

My ac had 46kg in the tanks. It read 116kg on the gauges.
i was expecting around 120 kg so it all looked ok.

what I DIDNT know was that at the start of the day, my 400kg on the gauges was actually around 320kg in the tanks.

A stopwatch was as much use as tits on a bull

[chinook240]

My ac had 46kg in the tanks. It read 116kg on the gauges.
i was expecting around 120 kg so it all looked ok.

what I DIDNT know was that at the start of the day, my 400kg on the gauges was actually around 320kg in the tanks.

A stopwatch was as much use as tits on a bull

I’m not familiar with civilian operation but didn’t the refuel log (tech log?) and the engineers who did the refuel not detect the discrepancy? Or was it a known fault but an acceptable defect?

[rotorspeed]

If tanks don’t get topped, run down to a warning light, or even more unlikely drained, one is surely not going to know whether the gauge readings are accurate. I guess in a police role with with heavy loads such a scenario could continue for several weeks and maybe months. Not of course that this should change response to a red low fuel warning.

[jayteeto]

Rotorspeed, correct. We suspected that it built up over a period and I was the first to run it that low for a while.

[sycamore]

Jay, is it not possible to use a `dipstick` ,or torch to check on the ground ( I know ,slope ,etc)...?

[Thud_and_Blunder]

sycamore, neither would work on a 135 - the filler tube goes through a 90-degree bend; fuel only sits in the upper portion of the filler when the main tank is within 8-10 kg of full, which would never be the case on a UK police operation.

[DOUBLE BOGEY]

.
As the calculations show, a started stopwatch at t/o would have given him the same information as the warnings did, which he ignored.


Fly Bull, me thinks there is a lot of "Bull***t" in your statement above.
Starting a stopwatch to calculate your endurance during Police Operations is about as much use as an ashtray on a motorbike!
Hovering, circling, balls-out to the next job. The fuel consumption is up and down like the proverbial whores draws!
Dave Trail deserves better. Like I said earlier. The hill of Hindsight is just that.

[sycamore]

T &B, thanks.....

[helonorth]

Fly Bull, me thinks there is a lot of "Bull***t" in your statement above.
Starting a stopwatch to calculate your endurance during Police Operations is about as much use as an ashtray on a motorbike!
Hovering, circling, balls-out to the next job. The fuel consumption is up and down like the proverbial whores draws!
Dave Trail deserves better. Like I said earlier. The hill of Hindsight is just that.
Fuel burn will vary but not to a large degree.

[212man]

Fuel burn will vary but not to a large degree.
I guess it depends on how you define “not to a large degree”. Airbus data online shows about a 35% reduction between cruise and Vy (I.e. cruise will be 50% higher than loiter). The difference between hovering OGE and Vy would be at least as big.

[Flying Bull]

Fly Bull, me thinks there is a lot of "Bull***t" in your statement above.
Starting a stopwatch to calculate your endurance during Police Operations is about as much use as an ashtray on a motorbike!
Hovering, circling, balls-out to the next job. The fuel consumption is up and down like the proverbial whores draws!
Dave Trail deserves better. Like I said earlier. The hill of Hindsight is just that.

double bogey,
I have really no clue whatsoever,
with a navy background, some freelancing and flying police ops since the year 2000 ...
with Bo105, BK117 (B2/C1 Variants), EC155, H145.
Hovering, cruising, transporting, loitering...
experiencing different fuel states between hover and cruise, switching pumps.
its standard, that the next mission(s) are given over radio- while on one mission.
may be its due training with the RN, that I do a fuel check before takeoff,
check the burn rate around every 30 min
and have a close eye on in which tank my fuel is.
Canceling warnings without reacting accordingly is just what I can’t understand from an aviator point of view
if that’s „Bull....“ for you, I don’t want to fly with you...

[HeliComparator]

double bogey,
I have really no clue whatsoever,
with a navy background, some freelancing and flying police ops since the year 2000 ...
with Bo105, BK117 (B2/C1 Variants), EC155, H145.
Hovering, cruising, transporting, loitering...
experiencing different fuel states between hover and cruise, switching pumps.
its standard, that the next mission(s) are given over radio- while on one mission.
may be its due training with the RN, that I do a fuel check before takeoff,
check the burn rate around every 30 min
and have a close eye on in which tank my fuel is.
Canceling warnings without reacting accordingly is just what I can’t understand from an aviator point of view
if that’s „Bull....“ for you, I don’t want to fly with you...


i suspect DT had very similar experience and probably more of it, operating in the same way as you have with the same degree of airmanship. That you don’t understand that a whole lot of human factors can come together on that worst day, and result in disaster, is worrying. That you think it could never happen to you, means I don’t want to fly with you.

[Flying Bull]

Helicomparator
you haven’t really read my posts, have you?
I wrote, that we don’t have - and I guess won‘t get the information, what was happening inside the bird in regards of communication/ human factors.
I really know, that if the holes start to line up, the risk of desaster increases exponentially.
Thats why you have to back off and re evaluate the situation sensing any hole, may it pressure on the crew, may it be weather, may it be any failure of hardware.
And at the end, decide for the safety of the crew.
With repeating warnings there is no really any reason to continue police work without solving that problem (hole in the cheese) first.
I won’t say, I couldn’t oversee something- which I wrote before, everybody can reach his limits (easily shown in a Sim, if someone doesn’t believe)
But been there I learned a lesson to back off early.
Dave didn’t had the luck.

[DOUBLE BOGEY]

Flying Bull...…"Bird" = Helicopter...really!!!
Chopper is bad but Bird...…….
Some sick just come into my mouth reading that.

[megan]

DB, you need to get out more :) it is part of the lexicon in some areas of the business, as much as you may hate it, one dictionary includes the definition,a man-made object (such as an aircraft, rocket, or satellite) that resembles a bird especially by flying or being aloftThen there is giving someone the bird. You hate these type of birds as well?

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/1340x2000/pexels_photo_460237_jpeg_7f876bdbe93741a8b4b30f9d10ab14679f3 4113a.jpg

[DOUBLE BOGEY]

Megan, I bow to your greater knowledge in favour of more "Bird" postings!

[Arkroyal]

FB - I'm not sure that's the case. The calculation would have shown him that he had about 75kg left - which he did - the problem is not how much fuel he had (enough for a good twenty minutes) but where it was, ie not in the supply tanks. Or have I misunderstood something?

indeed he was at no stage short of fuel and therefore never, in his mind, taking any risks. And I believe that is why the double flame out was such a shock and a successful outcome beyond his ability.

i think Captain Trail’s probable belief that both transfer pumps were on when in fact both were off persuaded him to ignore subsequent warnings.

i did read every word of the FAI report. I can’t help agreeing with its findings.

But I think that the fuel system of the 135 is an abomination waiting to trap the unwary in a totally false illusion that each engine has its own fuel supply to meet regulation.

ive never flown the type, but it seems to me that there is never a time when both transfer pumps would intentionally be off together.

so why not a single three position switch. Centre - Both on. Forward - Forward on Rear off. Rear - Rear on Forward off.

and if you ever need both off a separate guarded switch to turn both off.

[Sloppy Link]

“I've never flown the type, but it seems to me that there is never a time when both transfer pumps would intentionally be off together”

Yep, when main is empty and fuel is only being drawn from the supply tanks. In simple terms, when there is no fuel to be transferred from main to the supply tanks, the transfer pumps are turned off.

[Arkroyal]

Sloppy Link

Thanks for that. So only when the fuel state is quite low. Can’t remember the total contents of the supply tanks but roughly how much time would you have left once in that condition?

[MightyGem]

Sloppy Link
Can’t remember the total contents of the supply tanks ?
46 and 42kgs if my memory is correct. Approximately 22 minutes to tanks dry.

[GC47G]

Did the Police ever provide a transcript of the police comms?
meleagertoo.......... That’s the proverb able million dollar question !!!!!!! , I have always pondered on it myself, ( I DONT THINK SO ) But will always stand corrected if it has been provided , But the Dark place north of the Border Might never see the 9999 clarity to your question .

[HeliComparator]

“I've never flown the type, but it seems to me that there is never a time when both transfer pumps would intentionally be off together”

Yep, when main is empty and fuel is only being drawn from the supply tanks. In simple terms, when there is no fuel to be transferred from main to the supply tanks, the transfer pumps are turned off.
except that the transfer pumps don’t need to be turned off, unless they are the crappy ones. Why not get rid of the crappy ones and then things would be much simpler and safer? No-one has bothered to do a risk assessment of the downside of the crappy ones vs ensuring that the pumps are the Test Fuchs type. What price making the system more error tolerant?

[jimf671]

meleagertoo.......... That’s the proverb able million dollar question !!!!!!! , I have always pondered on it myself, ( I DONT THINK SO ) But will always stand corrected if it has been provided , But the Dark place north of the Border Might never see the 9999 clarity to your question .


Although Sheriff's determinations are available from the scotcourt website, transcripts are normally only available to the "interested parties" represented at the FAI.

[[email protected]]

DB - you are very quick to criticise FB for his terminology, rather childishly in fact, since English is not his first language you could just cut him some slack.

[212man]

Flying Bull...…"Bird" = Helicopter...really!!!
Chopper is bad but Bird...…….
Some sick just come into my mouth reading that.
Better write to Boeing and suggest they rename their MH-6......

[jayteeto]

Arnold Schwarzenegger says “get in da chopper! NOW!”.
He is the only one who can get away with it. I’ve never ever heard a British pilot or engineer call a helicopter a bird.
ive always referred to it as a helicopter or aeroplane/aircraft ��

[handysnaks]

Or cab (back in the day).
I hope Flying Bull continues to make his points and gives DB a severe ignoring.

[Sloppy Link]

except that the transfer pumps don’t need to be turned off, unless they are the crappy ones. Why not get rid of the crappy ones and then things would be much simpler and safer? No-one has bothered to do a risk assessment of the downside of the crappy ones vs ensuring that the pumps are the Test Fuchs type. What price making the system more error tolerant?
The pumps do need to be turned off if that is what the drill says.

[HeliComparator]

The pumps do need to be turned off if that is what the drill says.
But the drill wouldn’t need to say that if the only type of pump fitted was the Test Fuchs type. That is my point.

[Flying Bull]

Or cab (back in the day).
I hope Flying Bull continues to make his points and gives DB a severe ignoring.
TX s
bye the way - there is actually a helicopter, which is official named bird
MH-6 Little Bird Light Utility Helicopter | Military-Today.com (http://www.military-today.com/helicopters/mh6_little_bird.htm)
;-)

To fuel pumps - not really the ideal situation, that with only little fuel left, either the front or back pump runs dry (hovering / cruise).
Better to have pumps with run dry capability - but still, pumps are cautions, low fuel is a warning, which needs to be addressed accordingly.
Different to the normal aviation world, where you have time and need to do a proper preflight planning including fuel planning (normally on a sheet which needs to be taken onto the flight), police and SAR flights and some military - get missions while being airborne.
So you have to do inflight flight planning - but this should and normally does include fuel planning (trip / reserve fuel)
And the planning needs continues fine-tuning with changing mission parameters.
That it is demanding - at night - with two further crew members possible pushing towards mission completion - no question at all.
Everybody operating in a similar environment should therefore remember this crash and adjust his decision making towards safety.

[DOUBLE BOGEY]

FB, Crab and Handy Snaks, Thou have the right o call them "Choppers", "Cabs", "Birds", "Flingwings" etc.
Crab its been a long time since you have got your gander up at ,me. Now I am just getting to old to react.
However, its a "Helicopter" or and "Aircraft" and it will always et my teeth on edge when someone calls it an odd name and "Bird" is the one that gets to me the most.
FB, if you cant speak English proper like! Don't worry,

In truth I am slightly dismayed that this whole subject has been resurrected. I thought it had already been thrashed out completely.
Any way goona get back in me motor and mosey on down to the boozer before the Trouble and Strife finds out.

[nomorehelosforme]

Some great support for the pilot and criticism of the report from the police crew families in this news article

https://www.bbc.com/news/uk-scotland-glasgow-west-50585953

[Flying Bull]

Some great support for the pilot and criticism of the report from the police crew families in this news article

https://www.bbc.com/news/uk-scotland-glasgow-west-50585953

Well, does´t change the facts.
Good for the morale of the relatives - but ...

Don´t screw with Murphy (s law) (https://www.urbandictionary.com/define.php?term=Murphys%20Law)
It´s always better to be on the ground and wishing to be in the air - then to be in the air, wishing you were on the ground....
So if you have an indication in the cockpit, treat it, as if it is real - it actually might be, even if it was an false indication the last 20 or so times.
As Murphy would say, the moment you assume its false, it will be for real...

[Georg1na]

FB - you have it nailed in one.............................if in doubt chicken out.