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tubby linton
22nd May 2019, 18:09
Flight global has reported on the SI into the hard landing of ZH873.
Having read the SI report I would have personally placed the error as lack of currency rather than a loss of SA.
https://www.flightglobal.com/news/articles/lack-of-situational-awareness-blamed-for-raf-c-130j-458399/?cmpid=SOC%7CTwitter%7CFlightglobal%7Csf213125226%7Csf213125 226&sfid=701w0000000uP3H#sf213125226


https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/803287/20190517-HERC_ZH873_SI_Redacted_RT_Final-O.pdf A very comprehensive and thorough report.

safetypee
22nd May 2019, 21:20
An extensive report; ‘comprehensive and thorough’ to the point of using every flight safety and HF cliche in the industry.

If you require a crew to undertake a very challenging operation in limiting conditions, with significant operational hazards, then the better conclusion is that the accident was an operational risk.
Those on the front line managed what they could at the time; those in background, with hindsight might have managed to greater effect, but those distant managers conducted their tasks very well - never took their hands out of their pockets.

Tutamen1
22nd May 2019, 22:17
Not sure that either actually constitute an error

Tutamen1
22nd May 2019, 22:21
Not really. You might conclude that such an accident is an acceptable operational risk when weighing up the cost versus gain. But the purpose of an accident investigation is to understand its cause so as to minimise the likelihood of recurrence. Operational risk did not cause the accident!

reader8
23rd May 2019, 06:49
An extensive report; comprehensive and thorough to the point

The report states that the PF had been working 12 hour days for the three weeks before the accident, flew out to the operating location, had three days of acclimatisation in theater and was then sent off for the accident flight, the first of the crews rotation.

In the three day acclimatisation period they completed a handover, theatre read-in and mission planning.

The PF was unable to remember any details of the handover brief, nor did the PF or PNF manage to commit either the aircraft parking location or take off time to memory.

The use of the term "consistently fast" on the approach, which the PNF called out twice, is quaint. Maybe "approach speed was never stabilised"? That's also a good indicator of something...

"The panel concluded that fatigue was not a factor"

It appears that the definition of fatigue used now extends to 'they had a good sleep the night before' in a single section which considers fatigue through the narrowest of windows. To my reading, the rest of the report is littered with indications of significant fatigue factors.

The report is also spectacularly verbose, I opine.

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sycamore
23rd May 2019, 19:11
A real `double Leerdammer` for parts of the AT fleet.
Why is there no mention of the use of `tactical IR PAPIs`....? or are they `in stores`...?
Even a good google on GE would show up the slope......
Agree with SP, whilst the crew were unfortunate, a lot of others contributed along the way....
The word " should" in the recommendations `should` be replaced by "must"...!!!

Bing
23rd May 2019, 20:33
The word " should" in the recommendations `should` be replaced by "must"...!!!

In MAA speak should = must. You need to re-tune your mind when you read these things...

ORAC
23rd May 2019, 20:49
The report is also spectacularly verbose, I opine. Prolix, not verbose.

reader8
24th May 2019, 05:39
Prolix, not verbose.
Make a note of that word Darling. I like it, and intend to make use of it more in the future.

Chris Kebab
24th May 2019, 06:09
In MAA speak should = must. You need to re-tune your mind when you read these things...
I also find their use of the work "Shall" in their regulation equally unnatural. I always felt there were better plain English terms than should/shall.

charliegolf
24th May 2019, 11:27
'Must': do it or be in the crap.
'Should': if you can't demonstrate good reason for not doing it, you can expect to be in the crap.

That, as it happens, is the official usage of the words in Welsh Assembly documents. Who knew the Giant Parish Council would have the foresight eh?

CG

Herod
24th May 2019, 15:14
"Propose" = "I would like to do this if you approve" "Intend" = I will do this unless you tell me otherwise". I once flew with a captain who was a great user of "intend", as in "I intend that we will route AAA to BBB via a nightstop in XXX" XXX was always, of course a great place to nightstop.

212man
24th May 2019, 17:29
The word " should" in the recommendations `should` be replaced by "must"...!!!

​​​​​​​they wouldn’t be recommendations in that case

MPN11
24th May 2019, 17:51
But “must” implies an order to someone beneath you in the CoC, surely?

Anyway, a most interesting and detailed read.

212man
25th May 2019, 00:17
But “must” implies an order to someone beneath you in the CoC, surely?

Anyway, a most interesting and detailed read.
Yes, but these aren’t orders they’re recommendations from an independent body not in the CoC. It mirrors the AAIB and ICAO Annex 13

212man
25th May 2019, 00:53
But “must” implies an order to someone beneath you in the CoC, surely?

Anyway, a most interesting and detailed read.
Yes, but these aren’t orders they’re recommendations from an independent body not in the CoC. It mirrors the AAIB and ICAO Annex 13

sycamore
25th May 2019, 09:10
They`re not `independent of the CoC.....
Anyway,nobody answered my query about tactical IR PAPIs...?
50 Yrs ago we used to fly into DZ/LZs using torches mounted on bamboo poles,or Gurkhas holding torches,45 yrs ago I did trials on tactical ILS in helos and tac transports,;the Navy have been getting guys onboard at night using a man and illuminated tennis bats.,.........
Seems like not much `lateral/out of the box thinking` going on......

Gaius Petronius AD22-67

Must go and make up a few acronyms.....

Two's in
25th May 2019, 12:53
This SI is the crowning glory of the long growing trend to validate the "holes in the cheese" theory of accident cause (it even uses that graphic in the report). Yes, we all know there is seldom a single root cause, yes, we all know you have to look well past the smoking hole, and yes, we all know piss-poor organisation is a frequent driver for uninformed decision making in the cockpit, but my life, this outpouring of self-serving drivel is ridiculous. When I hear hoof beats I think horses, not zebras, but this report has looked for every zebra the AT fleet ever rode.

MPN11
25th May 2019, 18:10
(Not a pilot) Agreed, Sir! What also struck me from the surgical dissection was the voluminous documentation and cross-referencing and box-checking associated with operations these days. Yes, in my ATC days (69s-90s) we had [I guess] about a 2 to 3 ft pile of documentation to work from ... with a limited pile of ‘recall items’ within it. But nowadays it seems that operators are submerged in paperwork, as the comments about meeting actions never being actioned indicates.

I know safety is paramount, and things have progressed since my days, but I just wonder how much brain-power is required to trawl through, memorise or comply with the myriad of regulationary and other material required now.

Two's in
26th May 2019, 15:49
...I know safety is paramount, and things have progressed since my days, but I just wonder how much brain-power is required to trawl through, memorise or comply with the myriad of regulationary and other material required now....

A good friend of mine who used to operate the twin rotor non-essential bus out of Odiham used to regale me with tales of exactly how much paperwork and clearance materiel was required before you even attempted to commit aviation. And of course, being rotary, you were invariably operating below 2,000' for most of the sortie, so the Low Flying clearances were a byzantine structure of pooh-traps and gotcha's. That was bad enough, but God forbid you saw a single equine within a mile of your flight path at anything more than trot. That was, and is, a career defining event. Needless to say, he carefully weighed up the benefits of all that additional scrutiny against the joy of flying and is now happily retired building model boats or something...

MPN11
26th May 2019, 16:09
:ok:

Concerned about your ‘below the glidepath’ ... “adjust your rate of descent - now” ;)

Non-standard phraselology, which these days would probably result in my Talkdown ticket being withdrawn!

SASless
26th May 2019, 22:47
50 Yrs ago we used to fly into DZ/LZs using torches mounted on bamboo poles,or Gurkhas holding torches,45 yrs ago I did trials on tactical ILS in helos and tac transports,;

In my time we used to dream of such luxury!

Zippo Lighters, Torches shrouded by a Beer Can with both ends cut out it and aimed towards the aircraft, or a Parachute Flare shot nearby but not too close and we were good to go.

Then there was the infamous Figure 8 Tactical NDB approach or FM Homing methods.

Landing Albert to a field site is a different kettle of fish I would think....but with all the modern kit it should be a lot less arduous than the USAF guys did back in the 60's and early 70's.