G-LAWX S92 Incident AAIB

[JulieAndrews]

14 Oct 2019G-LAWXSIKORSKY S-92A High rate of decent on landing,Under Investigation (https://www.gov.uk/government/publications/aaib-current-field-investigations/air-accidents-investigation-branch-current-field-investigations)
Anyone able to share anymore info?

"High Rate of Decent on Landing" - would that not just be a "heavy landing" or is there more to this if we read between the lines?
As this is simply a rumour network:
Was this a case of failing to "practice what you preach"?
Or a lack of recency and credible experience 'on-type'?
Was it another 'Paul McCartney-esque' incident?
Cant wait years for the official report so need to speculate now ...........
On a more serious note - just thankful that everyone got away this time
​​​​​​​

[helicrazi]

High RoD n landing and heavy landing are 2 very different things

[jeepys]

14 Oct 2019G-LAWXSIKORSKY S-92A High rate of decent on landing,Under Investigation (https://www.gov.uk/government/publications/aaib-current-field-investigations/air-accidents-investigation-branch-current-field-investigations)
Anyone able to share anymore info?

"High Rate of Decent on Landing" - would that not just be a "heavy landing" or is there more to this if we read between the lines?
As this is simply a rumour network:
Was this a case of failing to "practice what you preach"?
Or a lack of recency and credible experience 'on-type'?
Was it another 'Paul McCartney-esque' incident?
Cant wait years for the official report so need to speculate now ...........
On a more serious note - just thankful that everyone got away this time


Yes the 92 is a jolly decent machine. I wonder if descent auto corrected to decent!
​​​​​​​

[helisniper]

Helicrazi,

Would you mind sharing your wisdom on this matter with us then?

HS

[Jimmy.]

Wasn't this the one that lost too much height on the approach to an oli rig, had an overtorque and heading deviation upon recovering?
I couldn't find the thread here nor the link, sorry.

[heli14]

Wasn't this the one that lost too much height on the approach to an oli rig, had an overtorque and heading deviation upon recovering?
I couldn't find the thread here nor the link, sorry.

don’t think so. G-LAWX is a vip/corporate-configured s92, Starspeed AOC

[industry insider]

Wasn't this the one that lost too much height on the approach to an oli rig, had an overtorque and heading deviation upon recovering?
I couldn't find the thread here nor the link, sorry.

No, that one was in Canada. Regardless of the circumstances the parameters were approximately:

1700fpm ROD, 10 KTS, 30’ off the water and pulled 145% torque drooping to 78% NR, both ACs off line and that S-92 still flew home.

It’s one tough aircraft.

[Jimmy.]

No, that one was in Canada. Regardless of the circumstances the parameters were approximately:

1700fpm ROD, 10 KTS, 30’ off the water and pulled 145% torque drooping to 78% NR, both ACs off line and that S-92 still flew home.

It’s one tough aircraft.
Insider, I think you are talking about the Cougar incident after takeoff from a rig some years ago. IMC after takeoff, too much pitch up, FD coupled with airspeed dropping (and decoupled), descent IMC at very low airspeed at high rate and then VMC, overtorque...
The incident I mentioned was this year, during approach, "sudden" loss of height and then NR drop combined with heading change (probably rapid collective increase), but I couldn't find the source.
Agree with you, very tough aircraft.

[helicrazi]

Insider, I think you are talking about the Cougar incident after takeoff from a rig some years ago. IMC after takeoff, too much pitch up, FD coupled with airspeed dropping (and decoupled), descent IMC at very low airspeed at high rate and then VMC, overtorque...
The incident I mentioned was this year, during approach, "sudden" loss of height and then NR drop combined with heading change (probably rapid collective increase), but I couldn't find the source.
Agree with you, very tough aircraft.

no, Insider was referring to the much more recent incident, which occurred on approach.

[Jimmy.]

no, Insider was referring to the much more recent incident, which occurred on approach.
Thanks! Do you have a link, please?

[212man]

Thanks! Do you have a link, please?
https://www.cnsopb.ns.ca/news/update-offshore-helicopter-occurrence

[Jimmy.]

Thank you, 212man.

[pilotmike]

High RoD n landing and heavy landing are 2 very different things

Well go on then, we're all ears. Sounds crazi.

[SASless]

Explored the linked sites data.....came away thinking the Canadians must have some serious problems with excessive gravity with all the "Collided With Terrain" investigations.

The other thing that posed some interest was the "Collided With Trees" as compared to "Collided With Terrain"......whats the difference I wonder?

[212man]

Well go on then, we're all ears. Sounds crazi.
Doesn’t seem difficult - a hard landing is where you have a high rate of descent during the touchdown. Depending on the actual rate, and the subsequent forces exerted, that may or may not exceed the design limits and result in structural damage. A high rate of descent during the landing ‘phase’ can be arrested prior to touchdown or a missed approach carried out. The circumstances behind how and why the high rate of descent occurred might constitute a ‘serious incident’ and warrant an investigation - I’m guessing that’s what is happening here.

[OvertHawk]

Julie

From your wording it's fairly plain that you think you know more about this than you're letting on.

There was a serious incident - that much is plain otherwise AAIB would not be looking into it.

It was reported by the crew - it's being investigated.

I'm not invloved with the operator and never have been. Nor am I going to suggest people don't speculate - this is, as you say a rumour network.

You however are not speculating - you're clearly trolling and one has to consider your motivation.

OH

[JulieAndrews]

TOH
Not sure if I know anything more than anyone else in the UK Onshore Industry whom uses Pprune, waiting to see..........
Also - waiting to see how this incident fits within the scope of CAA’s recent report of the industry and it’s safety levels.
I’ve attended various seminars, briefings and functions where a lot of back slapping goes on but the old spectre of commercial pressure remains. Couple that with the helicopter pilots’ natural eagerness to ‘push on’ and we get the repeat headlines - irregardless of how many CAA Industry Reports are published.
Personally, I will be disappointed if it turns out to be another case of a crew thinking they did not require a dynamic risk assessment and ‘pushed on’, leading to an incident, further CAA restrictions and bad press for the industry.

Maybe if you hear more details you can share them with us in a timely manner, rather than having to wait for the investigation report etc etc - which is the whole purpose of the thread; which, to be frank, I thought was fairly obvious?
From what I have learnt since starting the thread is that there are various accounts of the information you have shared already.

[Sir Niall Dementia]

And WHOOPEE!! CAA SOC16 arrives in your in-box, to be completed by 31 December detailing how you conduct night off-airfield landings.

SND

[Robbo Jock]

SASless, about twenty to thirty feet I'd guess :8

[cyclic]

And WHOOPEE!! CAA SOC16 arrives in your in-box, to be completed by 31 December detailing how you conduct night off-airfield landings.

SND

....it is making the industry a safer place though.

[EESDL]

8-months since G-LAWX Incident - has anyone seen a report of findings / lesson learnt ?

[OvertHawk]

8-months since G-LAWX Incident - has anyone seen a report of findings / lesson learnt ?

AAIB website lists the incident as "Still under investigation" which would be as expected in terms of time frame.

[EESDL]

Beggars belief that such a single-aircraft incident could take so long.
I guess we’re back to AAIB struggling to promulgate safety-related Information in a timely fashion.
I wonder if this is another COVID casualty or simply down to a lack of resources?

[JulieAndrews]

Some news at least
https://www.gov.uk/government/news/sikorsky-s-92a-g-lawx-anniversary-statement?utm_source=6c38607b-e03f-4932-a9e9-12c91d125710&utm_medium=email&utm_campaign=govuk-notifications&utm_content=daily

[heli14]

sounds vaguely similar to the Harrods Paul McCartney S76 incident a few years ago......an update on the ongoing AAIB investigation into a serious incident involving Sikorsky S-92A, G-LAWX, near Shipston-on-Stour, Warwickshire on 14 October 2019.

Whilst making an approach to a private landing site in conditions of reduced visibility the helicopter descended to within 28 ft of rising terrain close to a house. During the subsequent missed approach, at low indicated airspeed, engine torque increased to 131% and the pitch attitude of the helicopter was unstable. The helicopter then made a successful approach to the landing site without damage or injury.

To date no pre-existing mechanical defects have been identified that might have contributed to the occurrence.

The AAIB investigation of the occurrence has explored the operation of the helicopter, flight planning, organisational supervision, the regulatory requirements related to non-commercial complex helicopter operations in visual meteorological conditions, and the provision and effectiveness of terrain awareness and warning systems in the onshore helicopter environment.

A full report of the investigation will be published in due course.

I know they are not the AOC operator but are Harrods are still involved in the management/private operation of G-LAWX (they were a few years ago) or have all operations switched to the current AOC holder?

[212man]

sounds vaguely similar to the Harrods Paul McCartney S76 incident a few years ago...

I know they are not the AOC operator but are Harrods are still involved in the management/private operation of G-LAWX (they were a few years ago) or have all operations switched to the current AOC holder?
my thoughts too. Plus this one https://assets.publishing.service.gov.uk/media/5422f8a640f0b61346000755/AS355F2_Twin_Squirrel__G-BYPA_11-08.pdf

[Reflex]

Harrods have had nothing to do with the operation of GLAWX for at least 5 years.
The only Harrods input is the maintenance and hangarage

[bellboy]

Starspeed me thinks

[Napoleon1]

UPDATE - NOT ABLE TO POST URL as have not posted at least 10 times. !

GOV.UK
SIKORSKY S-92A
G-LAWX
ANNIVERSARY STATEMENT

[Bravo73]

Don’t worry, Boney. The link was posted 5 posts above your’s. ;)

[Helimuttslovechild]

Harrods have had nothing to do with the operation of GLAWX for at least 5 years.
The only Harrods input is the maintenance and hangarage

Did Starspeed ‘take’ the IMC letdown that you and ST used to fly in GLAWX though when they took over operating the aircraft 🤔

[JulieAndrews]

ok - this is ridiculous - still nuffink! negates the point of an investigation if timing is not an issue........

[Roger out]

The AAIB Serious Incident report into G-LAWX has now been published on the AAIB website. I am afraid I am not allowed to post any links yet so google will have to be your friend. Suffice to say that it makes some pretty eye-watering reading!

[Ex Machina]

https://www.gov.uk/aaib-reports/aaib-investigation-to-sikorsky-s-92a-g-lawx

[ShyTorque]

That report is one of the most comprehensive I’ve read since I began flying, over forty five years ago.

[Torquetalk]

Oh my.. Got lucky when luck wasn’t needed; just better decision-making and robust procedures. Simply astounding that a second approach was attempted after the first was so badly managed; and that one was also then badly managed.

The decision to fly manually seems suggestive of a lack of familiarity and confidence in using the automatics. With less than 500 on type and few hours on-type in the period pre-incident, versatility and confidence in using the AFCS to full advantage may have been lacking. This was also accepted by the more experienced pilot on type, who was also a commander. Given the seniority in the company of the commander on the day, it is hard to escape the impression that the P2 went along with a lot more that they should have. In fairness, irrespective of culture and hierarchy, SOPs on challenge and intervention are often not very comprehensive, specifying a very narrow set of deviation parameters, which offer little help for a broader set of circumstances which can be implicitly dangerous and need action. The flight read anything but safe and well-judged.

Glad all came out of it safely and provided us with things to learn from.

[Jwscud]

As a fixed wing pilot with corporate experience this reads to me frighteningly close to the N303GA accident in Aspen (https://www.ntsb.gov/investigations/AccidentReports/Reports/AAB0203.pdf)

Very lucky indeed.

[ApolloHeli]

I think the Safety Recommendation 2021-027 stands out and I believe that PinS approaches should be widely developed and be available for civil onshore helicopter operations. Planning and flying IFR en-route and provides a black & white 'visual, landing' or 'go around' decision at the end of an instrument procedure, which offers easier decision making than scud running and saying "I'm just going to try one more mile" (in my opinion).

I believe that knowing that the flight would be IMC and planning to use a PinS approach at the end also makes the possibility of not reaching the destination due to weather much more difficult to ignore and necessitates a back-up IFR diversion, which in this case seemed to have been ignored as the possibility of IIMC was not considered and Wellesbourne was discussed as the diversion (Birmingham was only brought up by the crew as a diversion once they had already gone IIMC).

[paco]

Do we as helicopter pilots have a mass self-esteem problem or something? You would be daft to try this in a 206, that is getting the customer through bad weather, let alone something a lot bigger. Why do we keep thinking we have to solve other peoples' problems? If the weather is bad, that's it, go by car.

What is the point of us teaching our students that this is not part of the service we should be providing? This flight should have been thrown away a lot earlier, and I speak as a corporate pilot of many years' standing.

[ShyTorque]

In jobs like this, where the weather goes against you, the pressure to go is always present or implied, much more so than in the airline world. The pilot has the option of possibly being stood up against the wall by the CAA, if it goes badly wrong, or directly on the day by the customer if a more cautious no-go option is chosen. I've often taken the latter option and then been taken to task by the aircraft owner, who after the event asks the opinions of non experts, such as his estate manager or taxi driver and tells you it was the wrong choice because "You would have got in".

Such is the lot of the corporate heli pilot and one needs to have very broad shoulders.

[Torquetalk]

In jobs like this, where the weather goes against you, the pressure to go is always present or implied, much more so than in the airline world. The pilot has the option of possibly being stood up against the wall by the CAA, if it goes badly wrong, or directly on the day by the customer if a more cautious no-go option is chosen. I've often taken the latter option and then been taken to task by the aircraft owner, who after the event asks the opinions of non experts, such as his estate manager or taxi driver and tells you it was the wrong choice because "You would have got in".

Such is the lot of the corporate heli pilot and one needs to have very broad shoulders.


Yes, it is fair to say that the lot of onshore charter pilots is more fraught with cultural pressures and often operationally challenging environments (unofficial weather measurements/assessments; off-field landings; ad hoc flights to new and perhaps unsurveyed environments) than that of offshore peers. But there has to be a line drawn when one or more decision points run up against better judgement. Gratitude for getting the job in critical conditions is perishable (at best); the consequences of a proper cock-up are severe and long-lasting. Ultimately, no one will thank you for killing them.

[ve3id]

Explored the linked sites data.....came away thinking the Canadians must have some serious problems with excessive gravity with all the "Collided With Terrain" investigations.?

Well we do have the magnetic North Pole! Santa Claus lives here, not Lapland. Kids can mail letters to him using the Canadian Postal Code H0H 0H0 and they get answered!

[212man]

If the commander is who I assume him to be from the report description, there is more than a little irony to this event, and potentially salient lessons for all, given his other roles and qualifications.

[Jhieminga]

I think I know what you're trying to say, but to me it also shows how being in that seat and being in command is a great equaliser. At that point everything that's on your business card is suddenly irrelevant and you're just another pilot, having to deal with the situation and the pressures.

[sycamore]

Is this the same Company that do the Royal Flights....?

[FloaterNorthWest]

Is this the same Company that do the Royal Flights....?

No it isn’t.

[sycamore]

FNW, TVM......

[ApolloHeli]

Is this the same Company that do the Royal Flights....?
It's the same company that the report references as "the operator" in writing, yet names them directly in three of the eight safety recommendations.

[helisniper]

I thought I would refresh my knowledge of the operator but reading the website of an operator at a time like this is an extremely strange experience with a whole range of emotions and thoughts. Just the company strapline “As a pilot you cannot buy experience; as our customer, you can” provokes a wide gamut of emotions but mainly sorrow.

Sorrow for those directly involved in this event, sorrow for the other employees in the company, sorrow for those in the industry that do a good job and feel sick to the core when reading of incidents such as 'LBAL, CRST, WIWI, N72EX, but most of all, sorrow that not all in our sector seem to have learnt from the numerous similar accidents that have happened in recent years. Thanks heavens no one lost their lives, but reading the report leaves me feeling almost as sad as if they had.

HS

[SASless]

Once again....we see a Report that read over Tea and Biscuits in the lounge with a soft fire behind the hearth makes one simply wonder how it could happen to such qualified, experienced, and decent people.

But, the other venue....in the hot seat on that miserable day with darkness approaching and a customer that of all appointments is running late.....that Tea is cold and bitter and the biscuits a bit stale.

Why is the hardest word in the Pilot's vocabulary to say....is the word "NO!",

The problem is when the weather is marginal but legal that we too often find ourselves wishing we had held onto discarded options. Most of us survive those less than stellar decisions but sadly too many of us do not survive.

When you see your options slithering away like folks owing you money that see you coming towards them with outstretched hand....perhaps it is time to opt for some fresh hot tea and biscuits and arrange ground transport for the Landed Gentry.

Mucking about in the dark and. murk over uneven terrain in what is arguably a very well kitted out aircraft with just about every kind of Gucci Kit you could reasonably ask for.....and then some....and not just filing IFR and going to the nearest Airfield with an approved IAP just has to make you wonder.

The very good news is no one got hurt, the aircraft was not damaged....some hat sizes got shrunk....and perhaps some real lessons learnt.

A for what it is worth.....an EMS Operator in my hometown lost a Bell 412 in Bluefield, West Virginia one afternoon....killed two pilots and the two Flight Nurses when they flew smack into a very hard mountain on the far side of the Airport while doing an Instrument Approach.

The Captain was the Base Manager, Training Captain, and Safety Officer all at one time. He was a good and decent Man, a well qualified pilot, married with children.

There is some wisdom in spreading the jobs around to different people so there is a widely exposure in the decision making. process....which done properly enhances safety.

We are all human with the vulnerabilities that entails.

Why oh why do we reject the automation and insist upon manipulating the flight controls ourselves when we could be seen as being rather dashing as we push buttons and twist plastic knobs.....and not get ourselves into the pickles we do that a properly managed Autopilot system would not.

[Aucky]

I think the Safety Recommendation 2021-027 stands out and I believe that PinS approaches should be widely developed and be available for civil onshore helicopter operations. Planning and flying IFR en-route and provides a black & white 'visual, landing' or 'go around' decision at the end of an instrument procedure, which offers easier decision making than scud running and saying "I'm just going to try one more mile" (in my opinion).

I believe that knowing that the flight would be IMC and planning to use a PinS approach at the end also makes the possibility of not reaching the destination due to weather much more difficult to ignore and necessitates a back-up IFR diversion, which in this case seemed to have been ignored as the possibility of IIMC was not considered and Wellesbourne was discussed as the diversion (Birmingham was only brought up by the crew as a diversion once they had already gone IIMC).

Couldn’t agree more. So many lessons to learn from this that it needs to be re-read and digested numerous times. PinS won’t be the answer to everyone’s problems as many corporate variants of 92, 109, 76 aren’t appropriately equipped, and should they exist in the U.K. PinS would be expensive to implement and only useful to well frequented sites which makes up a small proportion of the overall charter market. Is any variant of S92 certified for PinS? However for that portion that does frequent the same landing site time and time again, in a fully RNP APCH certified modern machine like a 145/169, and is willing to invest in approach design and certification, it has to be said that the UK regulator have been far from helpful or progressive in approach. At this time the CAA are processing around 10 RNP approaches a year, mostly to airfields with an ILS. The DfT haven’t been overly forward thinking or helpful either, EGNOS SOL service participation ending in a weeks time. Expect the LPV option for U.K. approaches in your FMS to disappear in the next AIRAC cycle post 25/6/21 (15th July). To me it’s depressing that the technology is there to make life safer, but in the U.K. your hands are tied from using it. In continental Europe on the other hand numerous hospitals have PinS approaches and connecting networks. A real shame.

[gulliBell]

At least the co-pilot said and did something which may have averted a far less fortunate outcome. Plenty of times whilst I've instructed experienced crews in the simulator the co-pilot said nothing and did nothing and seemed perfectly happy to arrive at the scene of the accident sitting on his hands in silence.

[paco]

Yes, credit where it's due....

[212man]

I think I know what you're trying to say, but to me it also shows how being in that seat and being in command is a great equaliser. At that point everything that's on your business card is suddenly irrelevant and you're just another pilot, having to deal with the situation and the pressures.
I partly agree, but would also expect the greater knowledge to have led to more informed decision making. Hopefully the lessons learned will add to the quality and authenticity of the courses he teaches.

For clarity - I’m not having a dig

[SASless]

Point in Space approaches have been demonstrated by Sikorsky in the past.

The technology exists and is installed in many helicopters.

Low Level IFR route structure is within the capability of the Industry with the major hurdle being the Authorities around the World that seems to be the hardest nut to crack.

Many EMS operations in the United States have an IAP to the Hospital Landing Pad which are off airport and are such IAP's.

I attended a Safety Seminar in Raleigh, North Carolina at least ten years ago where Nick Lappos talked of that work by Sikorsky using an S-76 to do those Point in Space Approaches.

He was a very strong advocate for the expansion of Helicopter IFR flight in non-traditional IFR environments.....or in plain language....doing Helicopter IFR using the unique ability to land at places other than legacy airport facilities.

That is the hard task...getting the authorities to bless and embrace that change in thinking .

It can be done...and done safely with the right equipment and training, combined with a careful intiial survey of the intended approach and surveillance of that to ensure no changes occur....much as has to be done with current on-airport IAP's..

[Undecided]

I’m a great fan of PiNs approaches and I have no doubt that they would bring huge safety benefits if they were embraced by the regulator in the U.K. However aren’t we missing the point here; it seems that (according to the AAIB report) the crew may have breached multiple rules and Company Procedures whilst attempting to carry out a VFR approach in a MP helicopter with what appears to be very poor MCC procedures. .

[tu154]

Some offshore operators mandate procedures for night VGA approaches including the use of automation, based on hard won experience. This seems like a procedure that is crying out for the same.

[SASless]

Was it Double Bogey that was involved in the improvements in Night Offshore Approaches?

One of the regulars was....and my fading memory tells me it might have been he that was involved.

[SpindleBob]

Can you truly regulate a PiNs approach? Night offshore has a certain level of expectation that you are flying into a clear area and the destination will follow given rules, lighting, obstacle clearance etc. The weather radar will pick out other targets.

PiNs into private landing site at night - Doesn't that just give you a better level of comfort until you discover that Vodaphone have put up a new mast or the trees have grown taller over the last 7 years since it was last surveyed?

[Torquetalk]

Can you truly regulate a PiNs approach? Night offshore has a certain level of expectation that you are flying into a clear area and the destination will follow given rules, lighting, obstacle clearance etc. The weather radar will pick out other targets.

PiNs into private landing site at night - Doesn't that just give you a better level of comfort until you discover that Vodaphone have put up a new mast or the trees have grown taller over the last 7 years since it was last surveyed?

We do 2D & 3D approaches to low minima in environments that are either strictly regulated and surveyed, or checked on board by means of weather radar in the case of offshore. For ad hoc sites onshore all that is needed are higher minima to take account of near terrain, obstacles and navigation performance. Because no fool is going to fly down blind into an environment that has not been surveyed for currency, where another fool might be flying in conditions unsuitable for VFR flight. Surely.

[Undecided]

I believe that PiNs approaches would allow the full capabilities of modern helicopters to be used which will have huge safety benefits for the onshore community. However any flying in IMC requires a level of discipline and adherence to rules and procedures. From what I have read in the report this was not present during this flight, some or most of it was IMC given that it was below VMC limits.

I worry that the regulator will cite this as a reason for not implementing PiNs approaches on the basis that we can’t be trusted to follow the rules. It appears that no follow up action has been taken by the regulator and his company bar some minor Ops Manual amendments.

Pilots are often held to account for minor airspace infringements but not the big stuff. As a previous poster commented, luck was on their side that day on a day when luck should not have been needed. If that luck had not been there we would be looking at another Shoreham type accident.

[[email protected]]

So you increase the minima to make it safer which means they still can't get the customer into his home site - so what next?

Pilots like these seem happy to break the VFR rules to try and get in - what will stop them ignoring the new safer minima to do the same thing?

Doing something dodgy and getting away with it a few times does not prove its safety or guarantee the next attempt will be successful but that appears to be how some onshore pilots work.

[ACW599]

Forgive my naivety -- all I know about the rotary world is derived from enjoying seeing Shawbury's aircraft using one of our fields -- but what kind of corporate client is important enough to generate this sort of decision-making? Why is it so difficult to say "no" to them? Are some clients so exalted that a car pickup from Wellesbourne (or even Birmingham) just wouldn't have been acceptable? Or are there genuine issues such as security, perhaps?

[gulliBell]

High net worth clients are mostly accepting of pilot operational decisions. It is when pilots get the false impression that said high net worth clients might not be so accepting of said pilot operational decisions that self-imposed pressure causes prudent sensible decision making to be thrown out the window and the "can do" mentality over-rides everything.

[paco]

One legend in his own lunchtime whose body was found circling the sharks near his yacht was well known to put pressure on pilots and engineers. There was also the accident in Norfolk. It really can be that bad at that level, hence my comments about self-esteem above. Corporate pilots need to have a good opinion of themselves, which is rather contrary to the company person suggested by EASA in their KSA 100 exam. It caused quite a stir when I suggested that pilots actually need to be a little anti-authority.

Phil

[SASless]

When an Authority can say one check ride every six months and you are both current and proficient in IFR/IMC flight....being a bit anti-authority might just save your life.

Just because the Authority says you can....doesn't mean you must or should.


Crab,

With the advent of GPS, FMS systems, Autopilots with four axis capability, RadAlts, TAWS, GPWS.....and FLIR....can you with your SAR experience....envision an IAP for that landing site that if properly surveyed, flight checked, and re-surveyed monthly for changes in the way of obstructions to include checking with the local authority to see if there. have been any Building Permits filed for or approved within the surveyed flight path?

What Minimums would you think workable and safe?

The Operator/Client had gone to the lengths to provide a visual glide slope and landing azimuth device....which shows their intent was to find ways to make their operation safer by seeking some usable technical assistance.

Would not that Point in Space IAP be one such thing that would have worked for them had they had that option?

[[email protected]]

Crab,

With the advent of GPS, FMS systems, Autopilots with four axis capability, RadAlts, TAWS, GPWS.....and FLIR....can you with your SAR experience....envision an IAP for that landing site that if properly surveyed, flight checked, and re-surveyed monthly for changes in the way of obstructions to include checking with the local authority to see if there. have been any Building Permits filed for or approved within the surveyed flight path?

What Minimums would you think workable and safe?
Yes, of course you could create a workable instrument approach to the LS - it has the advantage of being on the top of a hill so the obstacle planes would be fairly benign.

However, you still have to revert to visual flight once you get to your minima since you don't have all the advantages of airfield lighting to help you identify the LS in the dark.

With all the caveats you suggest in place, 150' minima above the elevation of the LS would seem reasonable but probably at a low speed of circa 60 kts to enable quick transition from instrument descent into visual approach and landing.

The problem with this flight wasn't the aircraft capability though - it was poor decision making and self-imposed pressure (as we see all too often) - clearly the suggestion to go straight to Wellesbourne would have been the adult decision.

I note they were both ex-Mil and ex-Sea King but don't know which Service they had been in - that may have had a bearing on their decision-making.

[rotorspeed]

I think what made this particularly vulnerable to making the major error the commander (particularly) did, was that the flight was actually ok - if marginal - for 24 of the 25 miles of the route, over the lower ground that formed all but pretty much the final approach. It was the rapidly rising ground of the sharp 500ft hill, towards the top of which was the LS, that suckered the commander into having a go. Had the LS been on much lower ground just 1.5 nm to the east he would have landed routinely, but trying to get that last mile or so took him in to higher ground surrounded by mist – in the twilight. He didn’t actually descend to end up 28ft above the ground – the ground rose up as he was flying along, fairly level, albeit in far too poor vis for that last mile.

If an alternative LS had been identified and arranged for poor weather use somewhere on this much lower open ground 1.5nm away, it would have been a far more appealing divert option than heading back to Wellesbourne, let alone back Birmingham which had the only instrument approach. And the flight could have been undertaken legally and safely. Given the scale of the operation I would have thought this would not have been too difficult. Maybe for other frequently used LSs on hills with low ground nearby, this would be a wise idea……

I’m certainly not suggesting the crew were not at major fault – just putting some context into how they might have got themselves into the situation.

[[email protected]]

From the report History of the flight The pilots of the Sikorsky S-92A (S92) had been operating for several days from the landing site (LS) in the northern Cotswolds They can't cite unfamiliarity with the terrain and local area as an excuse.

[Jhieminga]

I agree, yet familiarity may lead to complacency, or at least a slightly lower level of attentiveness towards the risks of this particular combination of rising ground, low visibility and all the other factors. I am not trying to absolve the crew of any blame, but it is very easy to sit here and come up with what should have been done at the time. The crew painted themselves into a corner, were fortunate to come out of it with only some dents in their ego instead of in the airframe, and we've got a good report out of it that should lead to some significant improvements in the industry (hopefully). If you've ever found yourself in a situation that you should have avoided, you know how long you can continue to kick yourself for being so stupid. I suspect that the crew has done enough of that already.

[SASless]

Incidents like this one should be analyzed and with the benefit of hind sight....provide a forensic examination of what happened....how it happened...why it happened....and provide Lessons Learned for everyone....the Crew, the Operator, the Client, and every other Pilot and Crew that goes forth doing what we do as Helicopter Pilots.

Otherwise there is no really good outcome to these things.

The Crew are good and decent people....but they as we all are....are Human and thus susceptible to make mistakes as we all do.

I do not look down on them or find them to worthy of being branded for life over this one event....they were trying hard to carry. out their assigned task in marginal weather and approaching darkness.

They made some decisions that I bet you if there was a way to re-wind the Tape and have a Re-Do....they would do things differently.....but that is not real life.

At least they lived to tell the tale....unllike so many others that wound up in a smoking pile of wreckage.

What is interesting to me would be hearing from them about how upon reflection they would do the flight again if they could.

We should learn from our mistakes not be crucified for them.....as long as we make them while trying to do it right.

Sometimes even the most experienced Pilot or Crew is set up for failure by a training deficiency, SOP, or Rule which only comes to light when something like this happens.

[Undecided]

SASLESS, I agree with your sentiments with regards to the co-pilot but not sure it holds true for the Commander.
For me, the most damning part of the report is the part when, having got horribly out of shape during the first approach and almost hit the ground which culminated in a massive over-torque, he elected to have another go even though they knew the weather was nowhere near suitable. Personally I don’t buy into the ‘we needed to get the aircraft on the ground because of the over-torque’ argument. There is no evidence in the report that this was never discussed as a crew, no checks were run and no emergency call was made. Would we be so dismissive of a driver who was driving at 120mph because his passengers were late and wanted to get home?’

[212man]

https://www.helicopterinvestor.com/articles/starspeed-pilots-to-get-advanced-automation-training-457/
I was aware of this already but not sure if it was initiated before or after the incident?

[SASless]

Gulli has been telling us of how common it is for Sim Students arriving without full understanding of the avionics onboard the aircraft they fly in the course of their employment.

I saw that in the Sim as well.

I also see a common thread in too many crashes where Pilots refuse to use the full capabilities of the aircraft and insist upon hand flying the machine when they need to reduce their workload.

That is a direct byproduct of the lack of proper training, poor SOP's, and a failed SMS.....which all can be laid at the feet of Management.

Pilots....Line Crews and Training Captains have a role to play in seeking Industry Best Practices for their own Operations and that requires looking outside their own to others to seek those better ways of doing business.

So....a question is why is this "new" training "new" an "unique"?

It is for sure needed and shall prove to be beneficial.

[[email protected]]

212man - given the Company is the same, perhaps it is born of 'lessons learned' or some form of atonement.

[Torquetalk]

https://www.helicopterinvestor.com/articles/starspeed-pilots-to-get-advanced-automation-training-457/
I was aware of this already but not sure if it was initiated before or after the incident?

The director’s comments on AFCS authority versus pilot authority aren’t very inspiring.

[Undecided]

I followed the link reference the automation training being offered. The other articles were about the EC225 receiving certification in Russia which took place in 2015. Therefore it looks like the article pre-dates this incident.

[ShyTorque]

I also see a common thread in too many crashes where Pilots refuse to use the full capabilities of the aircraft and insist upon hand flying the machine when they need to reduce their workload.

That is a direct byproduct of the lack of proper training, poor SOP's, and a failed SMS.....which all can be laid at the feet of Management.

It's not many years at all since the CAA insisted on hand flown instrument approaches during check-rides, rather than being allowed to "cheat" by using the automatics and coupling it all up.

[212man]

It's not many years at all since the CAA insisted on hand flown instrument approaches during check-rides, rather than being allowed to "cheat" by using the automatics and coupling it all up.
Yes - I have commented on that before. At one point, around 2004, the Head of Training relented to lobbying and allowed the use of ALT hold while copying the METAR - I have seen it in the minutes of a TSLG meeting! There were some more enlightened FOTIs, but they were using common sense rather than policy, based on their currency on the EC225 etc. Policy changed once the Head of Training had his 'road to Damascus' moment after being on the S-92 JAA OEB team, and took a 180 degree view on the topic.

[SASless]

Shy,,,,,Perhaps the CAA might get out of the Dark Ages and start looking outside of their own small circle for Industry Best Practices THEN issue Mandates and Rules.

Our FAA is just as bad in that regard.....far too often the aircraft designers are far ahead of the technical expertise of the FAA which has an adverse effect on related. outcomes.

I am sure the CAA is no different.

[Undecided]

I agree SASless, I have seen some woeful use of automation over the years. Correct use of automation should be an integral part of a type rating. We don’t want to lose hand flying skills as is happening in the airline world but having just got way out of shape and massively over-torqued the only sensible option in this incident was to engage the autopilot and then start working as a crew as to what they were going to do next. I am still completely mystified as to why a 6000 hour plus pilot would chose not to (or didn’t have the knowledge how to) engage simple altitude hold and heading hold modes. I can’t imagine how frustrating that must have been for the co-pilot with the poor manual flying skills being displayed by the Commander.

[ShyTorque]

I presume you mean “automation”…..but then again, maybe not; I’ve seen a few “automatons” in the cockpit in my time, too.

[Undecided]

Corrected! But me too.

[ShyTorque]

Shy,,,,,Perhaps the CAA might get out of the Dark Ages and start looking outside of their own small circle for Industry Best Practices THEN issue Mandates and Rules.

Our FAA is just as bad in that regard.....far too often the aircraft designers are far ahead of the technical expertise of the FAA which has an adverse effect on related. outcomes.

I am sure the CAA is no different.

Thankfully, they do now have a more enlightened staff when it comes to the rotary world and due to the efforts of certain individuals, the tide seems to be turning. There is some way to go with regard to other operational issues, but as I come to the twilight of my career, that is unlikely to happen in my time in the cockpit.

[torqueshow]

I agree SASless, I have seen some woeful use of automation over the years. Correct use of automaton should be an integral part of a type rating. We don’t want to lose hand flying skills as is happening in the airline world but having just got way out of shape and massively over-torqued the only sensible option in this incident was to engage the autopilot and then start working as a crew as to what they were going to do next. I am still completely mystified as to why a 6000 hour plus pilot would chose not to (or didn’t have the knowledge how to) engage simple altitude hold and heading hold modes. I can’t imagine how frustrating that must have been for the co-pilot with the poor manual flying skills being displayed by the Commander.

Proper understanding of automation is essential. I’m certainly not against the view of manually flying in IMC for the purposes of maintaining a perishable skill, however once presented with the evidence that your manual flying is of a detriment to the flight then it’s time to leave it to the autopilot. Personally I think I would have been so spooked by the initial incident that I wouldn’t hesitate to let the automation do it for me, instant stress reliever.

[Undecided]

Proper understanding of automation is essential. I’m certainly not against the view of manually flying in IMC for the purposes of maintaining a perishable skill, however once presented with the evidence that your manual flying is of a detriment to the flight then it’s time to leave it to the autopilot. Personally I think I would have been so spooked by the initial incident that I wouldn’t hesitate to let the automation do it for me, instant stress reliever.

Indeed. I can’t imagine there are many pilots out there who are not 100% behind this comment. This was a very strange (and probably the least safe) decision in a stream of questionable decisions. I can’t help but think that the CAA must be left in a difficult position now with regards to the AM position. It's one thing saying the right thing to pass an audit but when you are presented with concrete evidence of not doing the right thing - are they able to turn a blind eye?

[SASless]

Food for thought....taken from the US FAA discussing Helicopter IFR Operations.

There are sections of the document that could be used to compare the actions of the Pilots in this incident and the Bryant tragedy, the OZ Huey crash...or every other CFIT crash....no matter what jurisdiction they occurred within.

Helicopter flying in marginal weather shall always be fraught with risk.....managing that risk is the key.




https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/instrument_procedures_handbook/media/FAA-H-8083-16B_Chapter_7.pdf

[Undecided]

[QUOTE=SASless;11067530]Food for thought....taken from the US FAA discussing Helicopter IFR Operations.

There are sections of the document that could be used to compare the actions of the Pilots in this incident and the Bryant tragedy, the OZ Huey crash...or every other CFIT crash....no matter what jurisdiction they occurred within.

Helicopter flying in marginal weather shall always be fraught with risk.....managing that risk is the key.



I had not seen this document before and it contains some great advice. However, as you allude to, it does seem that some pilots are incapable of taking such advice no matter where they come from or their experience level. Perhaps it’s time to rethink safety and rather than introduce more regulation that produces an increased admin burden on those that already comply, we simple identify those that are prone to taking risks and non compliance and stop them flying. This is what the motor industry does either through licence suspension or increased insurance premiums so it is not financially viable to drive.

[ShyTorque]

Helicopter flying in marginal weather shall always be fraught with risk.....managing that risk is the key.

I’ve always said that VFR is safe. IFR is safe. It’s in between the two that is the tricky part. The main thing is to make a safe plan of how to do it and how to escape - and stick to it.

[gulliBell]

Gulli has been telling us of how common it is for Sim Students arriving without full understanding of the avionics onboard the aircraft they fly in the course of their employment..

That's right. Everything you need to know about it is written in the RFM and the AP manual, both of which are required to be carried in the aircraft. How it is that pilots arrive on annual recurrent simulator courses without knowing the system basics, or having a thorough functional knowledge of system operation, or knowing system operating limitations for that matter, when it is well documented in publications carried in the aircraft is an eternal mystery to me.

[SASless]

Gulli.....you ask a. question that you very well know the answer.

Because t hey do not use that equipment on a daily basis, have no intention of using it, and therefore perceive there is not need to know anything about it.

That they are being flat assed stupid for all of t hat alludes them.

Far too often...we read of them in the newspapers and folks wonder how it could be they are no longer with us.

Every time those of that mindset crash in a simulator.....that should be a jolt to their sense of complacency they live in.....but they laugh it off and think the Sim is just a big ol' video game.

Many times I stopped the training after the first flight.....sent them to the classroom and turned on the video of "THEIR" performance in the cockpit.....then went for coffee while they watched "Their"" performance that resulted in what would surely have been a fatal accident.

Most times that was all that was needed to change their view about the seriousness of Simulator Training.

If I. did not see visible signs of a reawakening of the two....we did a step by step analysis of what they had done to kill themselves and every time we had to do that....I had their full and undivided attention afterwards.

Then it seemed the Sim sessions went a lot better.

It was. not "me" that made the difference....it was the accumulated experience of the Sim Instructors over the many Years that was analyzed and adopted into a program designed to expose trainees to procedures, techniques, and various ways of enhancing the safe operation of the aircraft....all of which were gleaned from earlier Trainees as well as the Instructors.

That is one example of going outside your own Operation to. look for new and/or better ways of doing what you do in your Operation.

:Lots of folks around the World are flying. Helicopters....we can and should learn from all of them as best we can.

One thing for sure is no one Operator or Authority has the monopoly on how to do this helicopter flying thing in a safe and efficient way.....as sometimes there are several right ways to do the same task....picking the best way is the key.

If you hold a ATPL....you are supposed to be a Professional....and that requires continuing study, learning in your Profession, meeting high standards of Professionalism.....and of course mentoring those who are new to the Profession.

I learned a lot while teaching in the Simulator....as lots of very good people passed through the school and they were a knowlege source that bore listening to when doing your instructing.

There were also some that Gulli describes that did not want to be there and resisted the opportunity to learn....and sadly even displayed a patently bad attitude of refusing to entertain the notion the Sim Training was of any value to them.....and it was them that needed that training the most.



“No matter how much experience you have, there’s always something new you can learn and room for improvement.”
― Roy T. Bennett, The Light in the Heart (https://www.goodreads.com/work/quotes/49604402)

[Undecided]

Interesting post SASless. Seems there are a few in the industry who just refuse to learn and looks like the industry doesn’t intend to do anything about it. Sad state of affairs really. Seems that even politicians have more honour - Matt Hancock quoted as saying - Those of us who make the rules have to stick by them and that’s why I have to resign.

[Hilico]

Report published: link to report on G-LAWX (https://www.gov.uk/aaib-reports/aaib-investigation-to-sikorsky-s-92a-g-lawx)

[Nige321]

Report published: link to report on G-LAWX (https://www.gov.uk/aaib-reports/aaib-investigation-to-sikorsky-s-92a-g-lawx)
Post #34 - it was published mid-June...

[Hilico]

Sorry - it was on August 2021's list...

[Nige321]

Sorry - it was on August 2021's list...
Yes, they seem to ‘re-publish’ bigger reports with the end of month summaries now. Trying to ensure it gets seen I suppose..

[Undecided]

Ironic or good value for money?
https://www.cranfield.ac.uk/courses/short/transport-systems/aviation-safety-management

[Jhieminga]

I can recommend that course, certainly worth your time!

[212man]

Ironic or good value for money?
https://www.cranfield.ac.uk/courses/short/transport-systems/aviation-safety-management
I alluded to that in post 43

[Undecided]

I can recommend that course, certainly worth your time!

Can’t comment on the course as I have never completed it however, if my 30 minutes on Google has given me the correct information than is this the biggest case of ‘do what I say not what I do’ in the history of aviation?

[Undecided]

I alluded to that in post 43

Thanks 212man, I see that now. Took me a while to join the dots. It really does beggar belief.

[flight beyond sight]

It is an insult to the industry

[all_mod_cons]

Flight beyond sight, I couldn’t agree more!

[Undecided]

It is an insult to the industry
I completely agree. I thought it was bad but it appears it is much worse than first meets the eye. It looks as though we have a Commander who is also the MD, Accountable Manager and Safety Manager whose actions lead to a serviceable helicopter coming within 28' of impacting the ground.
On the information presented the individual suffers no sanction from the Company or Regulator and continues to lecture on Aviation Safety Management at an international recognised university.

[Undecided]

You raise some excellent points highrpm. Given the points you raise I simply don't understand why Cranfield continue to allow the individual concerned to be part of their academic staff.

[Jhieminga]

ICAO Annex 13:
3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents.
It is not the purpose of this activity to apportion blame or liability.

I would suggest taking part in that particular Cranfield course before crucifying both a person and his relationship with the university. I did that module before this particular incident but it would not surprise me if the topic will be discussed during the upcoming version of the course.

[Undecided]

Surely if you don’t practice what you preach you have to be held accountable for your actions? I’m not a great fan of politicians but generally they fall on their swords when they are busted breaking the rules. Why is it acceptable for a senior manager and pilot who held the very rules which he preached with such disregard himself to be allowed to reach atonement by lecturing other people on why they must follow the rules?
I’m aware of other pilots in the same regulatory regime who have had their collars felt for minor airspace infringements. Will they be absolved from any punitive action if they are paid to lecture us on why we shouldn’t bust airspace? Probably not.

[Jhieminga]

...it is one thing to understand the theory, and quite a different skill to apply it daily and effectively in decision making. This in itself should be a key learning point.
Trust me, this is covered in that particular course.
...when you have elevated yourself to being a public figure and authority on safety, as well as a most senior figure in one of the largest onshore operators, people will naturally hold you more accountable to your actions.
I don't know if we can call him a public figure, he hasn't been on Strictly Come Dancing yet AFAIK. But seriously, is there such a thing as 'more accountable'? You either are or you're not. In this situation the aircraft commander is the person who is accountable when a flight doesn't go as planned, and an accountable manager is where the buck stops when the situation warrants the attention of any kind of authority. We tend to hold persons in positions such as these to certain higher standards, but is that fair? I mentioned in an earlier post that even though someone has lots of titles on his or her business card, when it's your behind on that flight deck seat you're just another pilot stuck with the same limited information that any pilot has and having to take the same split-second decisions that every other pilot will have to make on a day to day basis. And that process is just as liable to include errors of any kind as any other process that includes humans. I would even go so far as to state that having an extra responsibility within a company can make the process of taking those decisions even more daunting as you can't push the job of explaining everything to the client/boss/authorities towards someone else.
I strongly believe that in order to generate a healthy safety culture, where the size of the organisation permits, the post-holder of safety manager should not be the flight ops manager, the accountable manager, or the MD/CEO of the company due to the detrimental effect it can have on an open and honest reporting/investigating culture.
I agree, but as you already mentioned, it depends on the size of the organisation. Yet, this is something that the company has already addressed, see 'Safety Actions' on page 64 of the report.
I’m keen to know whether this view is supported in Cranfield’s evidence based teachings on the role of leadership and structure in a mature safety management system.
We're linking two different topics here as the outcome of this particular safety investigation and the subjects taught in a particular Cranfield course are not in itself connected to each other. Having said that, based on my participation in that course a few years ago I would say that the role of leadership and the structure of the SMS system are very much part of the course, were discussed extensively and I was under the impression that no subject was taboo. The lecturers (it wasn't just one person lecturing during those five days) were all very open in discussing incidents and accidents that were relevant to the subject at hand and personal experiences were very much a part of those stories. Because of this I would not be surprised if the G-LAWX incident under discussion here will be addressed during that course, but the only way to find out is to go there and take part in the course.
Why should it be acceptable for a senior manager and pilot who held the very rules which he preached with such disregard himself be allowed to reach atonement by lecturing other people on why they must follow the rules?
You don't go into lecturing to reach any kind of atonement. Also, does that mean that a lecturer cannot make any mistakes, and is not allowed to have made any mistakes at any point in the past? I'm playing devil's advocate here but in my personal opinion, someone who does know what it is like to be involved in a sticky situation may well be the better lecturer on that subject. Also, please do not forget that it takes a brave person to stand up in front of a group of professionals and admit that you have done the unthinkable at some point in the past. The whole culture that we are trying to achieve within aviation is one where we can have adult conversations about these topics, where we can admit that yes, we have perhaps erred at some point in the past and where we can take this experience and learn from it so that it doesn't happen again. I don't see where doing this in front of a classroom instead of within the company is in any way wrong.

[Undecided]

Jhieminga - I don't disagree with the underlying sentiments of your post however I hope that you can understand the issue regarding a 'Just Culture' in that this individual was involved in a serious incident as outlined in the AAIB report. We have all done things which we regret and would have done differently and sharing those experiences so that others can learn should be commended however I suggest that you have another read of this report. The Commander claims that he did not engage the autopilot as he was aware of skill fade and wanted to practice his manual flying skills even though any sane person would say that that was not the time for IF practice. He also goes on to state that he was aware of the overtorque and used that as the justification for the second ill advised approach when the reports mention that at some point prior to this they were visual with the ground (so could have landed in the nearest suitable field or returned to Birmingham to shot an ILS.)

[Torquetalk]

[QUOTE=Undecided;11110568]…his job was to protect his pilots from commercial pressure yet it is clear that he succumbed to it on the day of the incident and therefore it is most likely that this was not a one off.]

Particularly this. It is a near certain thing that the way the decisions got made followed a pattern. In this event, even the first approach which should have chastened the Commander into a rethink was not enough to break it. Absolutely shocking. And that the PM did not put in a robust challenge speaks volumes about the real culture irrespective of what is on paper.

[ShyTorque]

The main point to come out of this is how pressure to get the job done can sometimes overcome common sense and good judgment. It’s easy to smugly pour scorn on this from an armchair but I’ve always said that the most difficult thing about corporate rotary is when to take stock and say no!

[[email protected]]

I’ve always said that the most difficult thing about corporate rotary is when to take stock and say no! That comment holds true for SAR and, I suspect, HEMS as well.

This is the sort of incident that is dissected well on military (and I'm sure civilian) Flight Safety courses - too much focus on achieving the task, poor weather, adverse cockpit gradient and a breakdown in CRM - leading to poor decision making - all ingredients we have seen so often in so many accidents.

Such dissections allow you to measure yourself against the decisions made - you can ask yourself how far down that same path would you have gone before you said no. If you get to the end and still don't see a problem - then you are the problem!

[ShyTorque]

That comment holds true for SAR and, I suspect, HEMS as well.

I agree, having done both.
However, having the man who pays your salary (and who can dismiss you from your hard earned job with a wave of his hand) sitting behind you in the cabin adds a certain extra pressure.

I've never forgotten the story of one pilot who landed on the aircraft owner's lawn on his first day in the job, but slightly in the wrong place. He hadn't been briefed on the correct place. He was told he was incompetent and never to return.

[Undecided]

I agree, having done both.
However, having the man who pays your salary (and who can dismiss you from your hard earned job with a wave of his hand) sitting behind you in the cabin adds a certain extra pressure.

I've never forgotten the story of one pilot who landed on the aircraft owner's lawn on his first day in the job, but slightly in the wrong place. He hadn't been briefed on the correct place. He was told he was incompetent and never to return.ShyTorque and Crab, I completely agree with your points which is why this particularly incident is so shocking. As we are agreed that the hardest part of the job is knowing when to say no, those pilots that work for a management company/AOC need as much support and back up from their superiors as possible. This is the whole point of having a management structure and a SMS structure to identify these hazards and mitigate the risks. We are all aware that feeling pressurized to operate below legal limits or those limits that the pilot feels comfortable with (whichever is higher) is a fast way to yet another high-profile accident.

[ShyTorque]

Undecided,
I'm making a general comment based on my own experiences. I don't know the pilot concerned and would never make a personal and public attack based on what appears to be hearsay.

[Undecided]

Undecided,
I'm making a general comment based on my own experiences. I don't know the pilot concerned and would never make a personal and public attack based on what appears to be hearsay.

I’m making my comments based on factual information that is contained in the report. I believe these matters should be discussed in forums such as this in a genuine attempt to make our industry safer and trying to understand why accidents and incidents such as this keep happening. It seems clear that a management structure and mature SMS system did nothing to prevent this incident.

[[email protected]]

Undecided - I agree, you can tick all the SMS boxes you want on paper but when someone wilfully disregards the protocols - as we saw also with the Kobe Bryant crash - the result is almost inevitable.

I find it difficult to understand how Cranfield allow him to lecture on safety when he appears to have a total disregard for it other than in an academic way.

Perhaps this is intellectual arrogance at its worst, someone who knows all the reasons for safety protocols but believes himself to be above them.

[ShyTorque]

I’m making my comments based on factual information that is contained in the report.

But not here: Other posters have alleged that this was not a one of occurrence and has happened before (and even more shockingly) after the event.

[ShyTorque]

Please note that I haven’t defended the pilot involved. As I said, I don’t know him and have no reason to defend him. However, I have read the report and it’s obvious a lot of errors of judgement were made and things could have gone even more badly wrong, thank goodness they did not.

On a public forum such as this, further accusations against an individual based on hearsay (as in outside of the published report in this case) may require the individual making them to justify themselves in a court of law. The forum rules are quite clear on this; although it’s an anonymous place on the face of it, the owners of the website may be obliged to pass on details of any of us and will do so if required to do so in a legal situation. I have no desire to get involved in such an issue - having very recently seen the price lawyers charge these days I value my house too much. Having been a member of this forum since 1995, I tread the line carefully.

P.S. I hold absolutely no clout over the actions of the CAA!

[DOUBLE BOGEY]

Was it Double Bogey that was involved in the improvements in Night Offshore Approaches?.
Hi SAS, indeed twas me..........the odd thing was I met a lot of resistance amongst my very close training colleagues. Some of which simply could not make the adjustment that the Pilot Monitoring really has an Executive role to play in these types of approaches and the role of the Advanced cockpit and Automation could play. Lots of agreement and support form the Regulator and the wider Rotorheads community. I have to say it did not make me too popular with my own Company Training colleagues, many of which I felt understood more after the following spate of NS HF/Automation cock-ups. Looking back, the helicopters we began to operate were far more advanced than our thinking, strategy and understanding at the time. This led to very poor training responses which at the time were best characterised by an over reliance on manual handling skills. Most of the TR course for complex heavies still treat the automation like an afterthought rather than integrating the concepts right from the get-go. In my later role for the OEM we had one operator using EC225 and L2 with dual rated pilots. There risk assessment and analysis led them to conclude that "If the L2 doesn't have that feature we will not use it on the EC225", effectively reducing the 225 to an L2! As [pilots, trainers and managers we are the most influential players in our expert field! When we fail to analysis/adjust/mandate effectively it leads to horror shows like this one. Fear is the great moderator and a pilot without fear due to lack of understanding of the dangers he is about to experience is the most at risk.

Safety Officers, Risk Assessors and Nominated Post holders need a healthy active imagination in order to identify hazards and risk and mitigate effectively. Sadly, the modern SMSA, in my opinion, is an overly complicated and huge administrative burden on Operators that its true value and effectiveness is often lost in the ether.

Good to see you back in the Fray SAS long may it continue.

DB.

[Undecided]

https://www.helis.com/database/cn/16331/

I wonder if the sale is related to the incident? Must have been some ride for the passengers.

[JulieAndrews]

i'm betting that both the toilet and the gearbox need attention ;-)

[Hadley Rille]

Deleted nonsense

[nowherespecial]

https://www.helis.com/database/cn/16331/

I wonder if the sale is related to the incident? Must have been some ride for the passengers.

My understanding is no, the owner never flew in it a lot anyway. As a multi billionaire it's not about the money, he just doesn't use it any more and he is withdrawing from public life, likely because of his age (he's 84). It's been informally for sale for a while but I think we have now moved to active marketing. There are not many VIP S-92 for non Heads of State/ Royalty so what happens to it next will be interesting.

[212man]

1400 hours in 14 years - and I bet a chunk of that was on the Penzance - Isles of Scilly route recently. Also, not a traditional VIP cabin as intended to ferry reasonable numbers around.

[DrSM]

Many of the contributors to this thread might be surprised to see a response from me, but I feel that if we are committed to making things better, and if any change for the better come is to from my bad example, then a degree of honesty and acceptance of criticism is warranted. I have not seen all the comments, but I can imagine what most of them say - and who they blame. For the avoidance of any doubt, may I set out here that I will never take umbrage or hold any personal grudge (nor will I ever seek or look to take action) against anyone who quite rightly questions and expressing shock and dismay at the apparent failings and errors highlighted in this most unfortunate - and ultimately avoidable - tale. Whatever is said and how ever it is said, I accept your right to say it.

I have seen a few comments that make reference to both the CAA and the Owner. May I state for the record, that the behaviour of both these has been exemplary and they have both set the highest standards of Just Culture and conduct. Neither of these people or organisations warrant or deserve the slightest criticism, and in fact they deserve your admiration and praise for their highest standards of conduct and empathy. I made two telephone calls within the first hour of landing. The first was to the Owner's office and the second was to the CAA to report what had happened. I will not share the details, but needlessly to say the Owner's office question was 'was this dangerous?', and my reply was that it was and it was my fault. The fact that they subsequently looked to understand the circumstances more fully rather than sacking me on the spot, is beyond belief and much to their credit - they are very rare people and deserve nothing less than your admiration. Similarly with the CAA, they accepted the information I gave them and rightly put me on notice that I may be subject to action following further investigation, but again - if you ever doubted that the CAA understands and follows Just Culture, I am an example that they do. The AAIB report paints a picture, but it is a picture of the incident - and you should all trust that the CAA make their own judgements. I was always fully ready to accept the judgement, whatever it was going to be.

I wish to also make sure everyone, who might not have a true understanding of the pressures and threats that are fundamentally part of Corporate Aviation (and you will never eliminate them, they can only be managed - it is like asking a fish not to swim in water); there was absolutely zero pressure applied by the owners in this story. Any pressure that might have been there (and there will always be pressure in any commercial aviation), it was not from them.

The reality is that no matter what your experience, and no matter how many excellent jobs or flights you have done in your past, we must all accept (or we should accept) that on any given day you will be in jeopardy of making errors in judgement and skill for as long as you sit in a cockpit. You may hope and pray that your worst day does not end up under the microscope of the AAIB, but it may - and you should never relax from watching out for the traps and pitfalls that can build quietly and silently into your otherwise 'normal day'. You all have a right to be brutally critical of my errors and mistakes, but I caution you to be careful - to fully understand any environment (and corporate aviation to off airfield landing sites at night are a very particular environment) there are many things you need to experience first hand to fully understand. It is very easy to say 'I would never' or 'that would never be me' - and I sincerely hope that it will never be you, if for no other reason than you have read this AAIB report - but there are a few things that I will tell you now: In an incident that rapidly develops into a life threatening situation, for the pilot flying (with all the other normal demands on attention in the cockpit) it cascades from normal to emergency like falling off a cliff, and the demands on your attention jump from 10 per second to a 1000 per second and if you think you will be reliably 100% of the professional pilot you are in the simulator - you are deluded. My experience, and you can disagree again, is that you will be lucky to hang onto 20% of that normally competent and good pilot - and you just hope that the remaining 20% is the skill and experience that climbs you out of the hole alive. I am not talking about the normal emergency situation, I am talking about the type of emergency situation where you know that what you do in the next 3 seconds determines the fate of you and everybody on board - and if you question whether that conscious thought actually takes place, remarkably enough, the answer is yes.

Should I have resigned? If anyone in this forum doesn't think that was my first, second and third thought - you do me an injustice. I ask you to understand that in my role I had to think about what that would have meant for the jobs and security of all the extremely valuable, professional and superb people that work in our team. I owed them my heartfelt apologies for letting them down so badly, but I also owed them every ounce of my energy and effort to make sure their jobs would be ok after it.

We have discussed this very openly and completely transparently in the team - when it first happened and when the report was published. I have no issues talking about it with anyone who genuinely wants to learn something about avoiding this again.

The microscopic examination and judgement of an AAIB investigation is never a kind or friendly experience, but it is a necessary and useful thing. You should note that there are possibly a thousand things you do in a day that are 'normal' variations on your best performance, and they will never be judged until the day there is a bad outcome; but once there is a bad outcome, everyone of them will be examined as an ;'error' or 'failing' that could or would contribute to the bad outcome - whether it did or didn't (because nobody can reliably know for sure).

I do not expect anyone to agree with whether I should still have a job, or whether I should still have a licence, but I ask you to listen to me when I advise you to never relax your attention to the subtle changes in threats in your normal day, that will build up without making a big noise or having one critical moment. I also advise you to recognise that no matter how good a pilot your are, as long as you sit in a cockpit, you are in jeopardy of making bad calls and bad judgements. Finally, my recommendation is that you listen to any first question of doubt in your mind during pre-flight planning, pause and check the cause for doubt - once your are airborne, the corridor of options can collapse around you and leave you just one door of consequence at the end remarkably quickly and possibly quicker than you can react.

I would ask you to all respect that this is not my finest moment, and my career will forever be coloured by this day in my life, but it is right and proper you should learn from it - as that is what we all owe to the future generation of pilots, learn from other's mistakes.

I understand your anger, but do not for a minute think that this matches my shame. But as an industry, hopefully, we will be better.

I do not propose to respond to any other posts on this thread - but you will have no objections from me regardless of what you feel the need to say.

[helmet fire]

Up there with the very best of posts this forum has ever seen. Thank you.

[megan]

I also advise you to recognise that no matter how good a pilot your are, as long as you sit in a cockpit, you are in jeopardy of making bad calls and bad judgementsI would highly recommend everyone to have this very thought at the fore of their memory banks.

DrSM, thank you for your forthright post, I'm unable to remember when anyone, besides Dennis Kenyon, has given such a self examination in public,

Thank you Sir, and Salute.

[SimonK]

DrSM I don’t know you but that was a very humble and honest post, thank you. Best of luck for the future….”there but for the grace of god, go I”

[[email protected]]

It is a very open and honest post - it is a shame that DrSM had to nearly crash before understanding the harsh realities of being a pilot and, that no matter how good you or others think you are, a situation can come and bite you in the arse if you are too confident in your own abilities to realise you are human.

Flying is so much more than being good on the sticks and poles - personality, attitude and self-awareness are key factors that colour the ultimate reason for every successful flight or disastrous one- Decision Making.

I have scared myself most in my career at night without doubt, mainly before the advent of NVG and anyone operating in such a regime should make huge extra allowances for human failings and err on the side of caution, no matter how clever the aircraft you are flying is.

[Heathcliff]

Up there with the very best of posts this forum has ever seen. Thank you.

Indeed. Thank you sir. We all need to take a lesson from you regarding humility, self-awareness and honesty, as much as safety.

[jimjim1]

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/362x96/pprune_1_3c5439b49d4cfc75b0642843b4d5d12f6910991a.png

Indeed. Thank you sir. We all need to take a lesson from you regarding humility, self-awareness and honesty, as much as safety.

I agree,
Thanks.

[helonorth]

It is a very open and honest post - it is a shame that DrSM had to nearly crash before understanding the harsh realities of being a pilot and, that no matter how good you or others think you are, a situation can come and bite you in the arse if you are too confident in your own abilities to realise you are human.


What an asshat.

[ShyTorque]

DrSM I don’t know you but that was a very humble and honest post, thank you. Best of luck for the future….”there but for the grace of god, go I”

I concur with all of that.

[EESDL]

Appreciate fully what Crab is saying.
Not sure how else anyone expected SM to respond if going ‘public’ - it was a very thoughtful post and well conveyed. For whatever reason the crew messed-up in spades - if it was truly multi-crew rather than 2-pilot.
Some of us have been fortunate enough to receive such a kick-up-the-ar5e early in our flying career and mentally-adjusted accordingly - we are all human and therefore will make mistakes but some of us don’t make a living preaching about it so do not open ourselves to such publicity.

[Heathcliff]

What an asshat.

Quite. I reiterate my previous post.

[[email protected]]

Helonorth and Heathcliff - I really don't see why you seem to have a problem is with my post.

Is it because I said he had to have a near accident to be open and honest about human frailties?

[OvertHawk]

Crab

As someone who knows the gentleman concerned, professionally, (and no i don't work for him and never have) and who has attended several of the training courses he has run at Cranfield, i can say with absolute certainty that he was well aware of "the harsh realities of being a pilot" and was more than prepared to be "open and honest about human frailties" long before the incident occurred. One of the most recurring comments arising from his presentations was regarding how open and honest he was in using case studies involving himself and his company.

This event proves that no matter who you are you can be wrong and you can get it wrong.

Should he have got it wrong? - No of course he should not (nor should any pilot) and he more than anyone will be aware of that. But we are all human and we are all subject to making errors.

What we should be doing now is reflecting on the lessons of this rather than taking cheap shots at people from the comfort of our anonymous armchairs.

You refer to the nights where you have scared yourself... I wonder how close any of those events were to becoming an incident such as this one? Perhaps closer than you would like to think or admit.

In the event that your actions on those nights were subject to the level of scrutiny and analysis that has been brought to bear here I wonder how you would come out of it looking?

I think that what people are taking exception to is your holier than thou attitude.

[[email protected]]

I think that what people are taking exception to is your holier than thou attitude. In that case they are reading into my post something that isn't there - why else did I allude to situations when I had learned hard lessons about my own frailties?

[Heathcliff]

Your contention that he had only understood his human frailties after his own mistake is a bizarre one. There is no suggestion that this is the case, as those who have attended his course will verify.

[Bell_ringer]

Your contention that he had only understood his human frailties after his own mistake is a bizarre one. There is no suggestion that this is the case, as those who have attended his course will verify.

It shouldn’t be a surprise, particularly in aviation, that people have a habit of only recognising their frailties after a near death experience. Presuming of course they are fortunate enough to survive the lesson.
Crab may be a bit crabby in his response but he is quite right. A bruised ego may just save someone’s life. Moving on..

[Heathcliff]

Nowhere has it been said or even suggested that this is the case though. It's an assumption. Admittedly it is true of most of us, and indeed I count myself amid that number, but I wouldn't assume it of anyone.
It seemed a strange thing to take away from that post, that's all.

[Bell_ringer]

Nowhere has it been said or even suggested that this is the case though. It's an assumption. Admittedly it is true of most of us, and indeed I count myself amid that number, but I wouldn't assume it of anyone.
It seemed a strange thing to take away from that post, that's all.

HC, I don’t know you. You don’t know me, I certainly don’t know crabcakes. I do understand being misunderstood. I seriously doubt that what was read into the comment was what was intended.
The internet is full of static and has terrible signal on a good day.

[Heathcliff]

Very good point. I apologise if I have misread. And a great phrase to take away from the thread as well as everything else!

[[email protected]]

Just for clarity - I was trying to emphasise an old aviation adage - Experience is what you get just after you really needed it - ie those close calls should and hopefully do, improve us as pilots because we should learn from our own mistakes as well as those of others. I know I have and when it comes to flying, I am my own harshest critic.

Has my ego led me to make mistakes in the air? Most certainly, especially in my younger days.

I'm not taking cheap shots from an anonymous armchair, I am pointing out that Dr SM would likely never again put himself in a similar position because he did learn from it - I'm sure he was aware of how poor decision making can escalate rapidly before he had this incident but it still happened to him. He has moved on, older and wiser and to his credit not shied away from understanding the causes but discussed them openly.

[megan]

The internet is full of static and has terrible signal on a good dayThat's a keeper B r, do you mind?

[Jhieminga]

That certainly is a true statement, on a good day! Anyway, we need a like button for post #131.

[Bell_ringer]

That's a keeper B r, do you mind?

In the interest of internet-based harmony and understanding, go forth and use liberally.. :ok:

[Heathcliff]

Apologies again Crab, and amen to all that!

[[email protected]]

Apologies again Crab, and amen to all that! No worries:ok: Bell Ringer's observation re t'interweb is spot on - not the first time my posts have been construed to mean something that wasn't intended.

[Wide Mouth Frog]

No worries:ok: Bell Ringer's observation re t'interweb is spot on - not the first time my posts have been construed to mean something that wasn't intended.
If this is not the first time your meaning has been misconstrued, it's possible that there's another learning opportunity here.

[[email protected]]

If this is not the first time your meaning has been misconstrued, it's possible that there's another learning opportunity here. Yes, for everyone who uses social media :ok:

[RVDT]

In aviation - Learn from the mistakes of others, as you will not live long enough to make them all yourself.

[Sumpor Stylee]

I'm not taking cheap shots from an anonymous armchair, I am pointing out that Dr SM would likely never again put himself in a similar position because he did learn from it - I'm sure he was aware of how poor decision making can escalate rapidly before he had this incident but it still happened to him. He has moved on, older and wiser and to his credit not shied away from understanding the causes but discussed them openly.

Any Penzance Helicopters, Sloane Helicopters, Castle Air or whoever else has operated the Scilly Isles runs when the same crew and S92 were present care to elaborate on the applicable weather minima v what actual weather the S92 was conducting approaches into Mounts Bay in, post incident clearly but also post report publication? This is a question not an assertion before anybody jumps on it.

[megan]

If this is not the first time your meaning has been misconstruedThe problem with communication is the belief that it has occurred.

[DickieB]

I have been a regular visitor to PPRUNE as a guest for quite some time and I have been entertained and educated in equal measures over the years, but it is only today that I have actually registered to enable me to post a response to this thread which I have been reading with interest since this unfortunate incident happened.

Who cannot be moved by Dr SM’s soul searching and apparent words of wisdom to help us all learn from this unfortunate incident? I have experience of corporate aviation and I can empathise with what the good Doctor says as a pilot – especially with regards to the making a night approach to an off-airfield site – I have done more than my fair share of them and it is rarely a relaxing experience.

However, what has driven me to register and exercise the right to comment on this thread, as Dr SM has invited us to do, is that if we are going to have an open and honest discussion about this matter than we should do this in full visibility of all of the information. I know Dr SM well and he knows me, unfortunately our relationship has not been harmonious.

There is no doubt that Dr SM is a charming character, there are many that have been seduced by his silver tongue and even I have been tempted to rush out and stock up on his own unique brand of aviation inspired Snake Oil. However I feel that I must also mention that I am involved in legal proceedings with a company (over which he presides) during which I will aver that I have suffered significant financial lose for making protected disclosures around matters concerning MCC. A ‘whistleblowing’ claim as it is known.

MCC is at the heart of my legal dispute and I believe that is also at the heart of this incident. The AAIB report itself is long, technical and complex and I expect there are few of us that have the time or inclination to read it all again so perhaps I can urge you to re-read Dr SM’s recent post on this thread and consider it from a slightly different perspective.

Firstly he mentions the CAA and the owners office and heaps praise on them for their attitude towards a Just Culture (I can tell you at this point that the HR Manager for the company that Dr SM presides over had previously informed me that she had never heard of a Just Culture). I support these comments from Dr SM. He does not extend the same praise to the AAIB who have carried out a thoroughly professional and detailed report and are perhaps, the one organisation that have genuinely attempted to ensure that lessons are learnt. In the execution of this process, they have been critical of his actions and the organisational structure of the company which he oversees. He describes them as ‘painting a picture’, perhaps inviting us to believe that this was the artist impression of what happened rather than a full and detailed report on what actually happened based on hard and unequivocal data that has not the benefit if any ‘spin’ applied to the narrative?

He then takes us inside the cockpit and starts by making the broad point that to err is human. Who can deny that this is true but then he goes on to infer that we must be cautious of being too critical because of commercial pressure (of which he seems to infer that that he was a victim of such pressure even if the pressure wasn’t direct pressure) and that night off airfield landings are a particular hazard and only those who have experienced them can truly understand? Is this the equivalent of the Hollywood portrayal of the Vietnam veteran being probed about his actions who dismisses the questions with the response ‘You weren’t there man’?

He then goes on state that if we think that we, as pilots that train in the simulator, will take that training to the real world and do as we do in the simulator then we are ‘deluded’. What does this tell us about his own personal attitude to training? Can we draw anything from this as to what value he places on such training? Does he believe that TRE’s knowingly sign pilots’ licences secure in the knowledge that if they get a ‘real’ emergency they can only be expected to remember 20% of what they have been taught? Is it fair for him to assume that because his own performance was found lacking, in the same situation everybody else’s would be as well? He talks about the emergency developing as quickly as failing off a cliff. Let us remember that this was not a catastrophic gearbox failure, this was a planned approach into a site that he was very familiar with in a perfectly serviceable airframe fitted with all the bells and whistles and with the benefit of a highly experienced pilot by his side.

Dr SM seems to be asking as to be guided by him on our views and opinions as he has experienced this first-hand and we haven’t. Whilst it is true that none of us were there, wouldn’t the debate more constructive if he centred it around why he was? Surely this was never meant to be a night landing, it was planned to be a day VFR approach and the AAIB report seems to infer that the weather wasn’t even suitable for this.

The report doesn’t shy away from the fact that the dangers associated with attempting the flight were known by Dr SM prior to take–off; “We are really up against it”. I would also make the point that any decisions that were made, were made by Dr SM and Dr SM alone. My reading of the report is that the cockpit gradient was completely wrong and if I am correct in this where should the blame sit? With the F/O or the Commander? Did the F/O not attempt to air some concerns and offer alternative and safer options that fell on deaf ears? When the wheel really came off would it be true to say it that there was very little acceptance that the other half of the team may have had a view and would be able to make a valuable contribution?

It seems to me that there is a strong possibility that Dr SM was of the view that he, and he only, knew what was best. He adds drama with comments alluding to the fact that unless he did something in the next three seconds they would all perish. The counter to this is that if he had listened to the F/O he wouldn’t have been in that situation and had he allowed the F/O to take control, the F/O would have most likely calmly pressed the go-round button and engaged the autopilot to get the helicopter safely climbing away back to Birmingham to position for an ILS and avoid any endangering of life or overtorque of the aircraft. Interestingly Dr SM generally talks in the singular when discussing the incident as if the F/O wasn’t there.

Dr SM then discusses how he considered resignation. He claims that this was at the forefront of his mind and states that he did not do this to protect the jobs of others that work in the company. Let’s consider this for a second or two. The Company has been around for over 40 years and is owned by Lux Aviation and yet Dr SM seems to believe that without him at the helm the company would fail and employees would lose their jobs. What does this tell us about his ego? Would it be fair to say that during the incident it appeared that he felt that he and he alone knew what was best for the flight and now he alone knows what’s best for the company? What does this say about his view of MCC procedures?

What I can tell you is that 6 weeks after the incident I sent an email concerning a company pilot who was transferring to a MP operation within the company and required an initial MP type rating which concluded with the following paragraph “However, whilst not wanting to interfere with the way Fairoaks works, I have been puzzled by the amount of time we have spent trying to prove that an MCC Course is not required. Given that all of his previous MP experience was almost 20 years ago, my recommendation from a risk mitigation point of view, would be that he completed an MCC Course prior to doing the 10 hours MP training or we complete the combined initial MP/MCC course where he is schooled in the (company name) MP SOP’s simulating (company name) operations. This appears to be an opportunity to get things right and provide the best possible training. It is my personal view that a lot of onshore operators have made a mess of the transition to MP operations and end up paying for two pilots but not receiving the safety benefits of a well organised and well trained for MP operation with robust SOP’s and experience and training that is relevant to their operation” To the best of my knowledge the pilot concerned never completed the MCC training. This is why I have an open mind about the rumours that are circulating concerning the aircraft continuing to operate in poor weather.

Dr SM has indicated that the focus should be on making things safer (on this matter at least we whole heartedly agree). If we are to focus on this then I believe we should be looking at all of the issues that surround this subject both pre and post incident. For those of you that are interested the legal aspects of my dispute with Dr SM’s company will be decided at Bristol Employment Tribunal from the 21st to the 24th of February next year. Employment Tribunals are public which means that the press and members of the public are welcome to attend and listen to the evidence heard and the judgments delivered. Given what Dr SM has said in his post, I hope that he will stand by his words and he and his legal team will not oppose this incident being discussed under oath as I believe that MCC training is at the heart of my claim and indeed this incident. I also hope that certain documents that I have requested regarding this matter – such as the internal company report relating to this incident will be released – up until now there has been a reluctance to do this.

[LOONRAT]

A very thought provking responce by Dickie B and for me the following is particulary cogent.

‘’ My reading of the report is that the cockpit gradient was completely wrong and if I am correct in this where should the blame sit? With the F/O or the Commander? Did the F/O not attempt to air some concerns and offer alternative and safer options that fell on deaf ears? When the wheel really came off would it be true to say it that there was very little acceptance that the other half of the team may have had a view and would be able to make a valuable contribution

I retired from flying some years ago but during my spell as CP of a corporate S76 operation I included the following in our corporate operations manual to ensure the Pilot Monitoring (called co pilot in the old days and another captain but sat in the left seat) was fully empowerd and briefed prior to any approach.



‘’ duties, responsibilities and calls to be made by the co pilot including actions he should take in the event of failure of the handling pilot to adhere to minimum altitudes/heights, RVR’s, approach bans and descent below MDA/DA.

The form of words for the briefing should be along the lines of:

‘ In the event of descent below minimum specified Altitude/Height or continued approach below specified RVR/MDA/DA without the required visual references you are to verbally warm me by calling ‘Go Around I say again Go Around’. In the event of non immediate corrective/overshoot action by me you are to take control with the words’’ I have control’’ and take overshoot action’

It's not perfect but at least it addressed a serious issue at a critical time.

[Torquetalk]

Whilst Dr SM’s contrition is laudable, I welcome the shift that the last couple of posts has brought. The previous very mild criticisms that had been made were heavily criticized by some willing to accept DrSMs humility and contrition at face value when, in detail, his post was threadbare in any examination of why the flight was executed so badly. It is all very well reaching the conclusion that you should heed your doubts whilst still on the ground, but this glosses over why, once airborne, a lack of protocols and MCC & CRM nearly resulted in a fatality with two pilots and such a capable aircraft.

The lack of procedural definition, including at which points a missed approach would be initiated and how this would be done is a glaring deficiency. And the second poorly planned approach after the first went dangerously wrong, and following an overtorque, was a stunnigly bad decision and insufficiently challenged. Honourable mention should also go to hand flying an S92 because you are a bit out of practice in deteriorating light and marginal weather conditions. That isn’t just a bad decision; it is a failure to understand that important levels of protection are being removed for the wrong reasons at the wrong time.

Was the flight dangerous? Yes, but only because the crew made a series of very poor active and passive decisions. This event did not just involve one bad decision or error of judgement; it was replete with them.

It is also not unfair or unreasonable to question why someone in DrSMs position could conduct a flight like this and there to have been so few protections to have stopped him doing so when he failed to apply long established industry standards. Were they lacking in the operation, or simply ignored because that is just stuff on paper?

[Heathcliff]

Question him, then. He does offer for anyone to do so if they wish but said he would not respond further to the thread. Alternatively, if you just want to keep villifying someone on a forum where you feel anonymous, then carry on, but you will not learn anything. Which is, after all, what you are asking to do.

[megan]

Question him, then. He does offer for anyone to do so if they wishI'm afraid I don't see where he made the offer.

[Torquetalk]

Question him, then. He does offer for anyone to do so if they wish but said he would not respond further to the thread. Alternatively, if you just want to keep villifying someone on a forum where you feel anonymous, then carry on, but you will not learn anything. Which is, after all, what you are asking to do.

Heathcliff, I would say that your continued readiness to defend DrSM and attempts to shut up those offering critical comment on the flight is not actually in the interests of flight safety or learning lessons. There is, in fact, much to learn from what happened (in the report) and the point is to learn it through discussion and applying the lessons into practice and not have to learn it the hard way. The fact that these are acutally lessons that should have already been learnt and involve mistakes that need not be repeated, especially by someone teaching the subject, is a perfectly reasonable criticism which an apology does not nullify. If those charged with teaching and implementation of good practice don't actually do it, there is not much reason to be optimistic about future flight safety.
.

[Undecided]

I have been critical of the Commanders action in previous posts. Having read Dr SM's post in detail my views have changed very little. He is insistent that the CAA followed a Just Culture which lead to their decision not to revoke his licence or apply any punitive actions. He says that this is because they accepted the information he gave them but also says he isn't going to share the details with us of what he told them. He says that the CAA understood. It is almost as if he wants us to believe that there is more to the story which the CAA know and the AAIB don't.
Way too much smoke and mirrors for me, if Dr SM is genuinely interested in being open and honest and making things safer then don't say your piece and then say you are not going to respond further on this forum. There have been some excellent questions asked over the last few posts - if he wants to assist with safety, come back and answer them so we can all learn from his mistakes. I hadn't considered the issue of the internal report before but it is an interesting one - as AM and SM he was marking his own homework. Why doesn't he share with us how he marked himself?

[Heathcliff]

I'm afraid I don't see where he made the offer.

Ah, maybe I misread it: " I have no issues talking about it with anyone who genuinely wants to learn something about avoiding this again." Maybe that wasn't meant for posters on here as I thought - hence my ONE attempt to steer the questioning to where I thought it would be answered - although I thought DrSM was referring to his course too.

I'm not convinced the ire expressed by some repeatedly against one individual is entirely about flight safety, and I certainly don't see how posting that on here improves it when no public discourse will be entered into whereby lessons could be learned, but in my mostly silent years on here I've noticed that's the lifeblood of this forum. I suspect I have become too old for the internet! I shall retire forthwith as I seem no better at it than anyone else. Godspeed.

[Undecided]

Heathcliff, I have been one of those that have been critical of the conduct of the flight so I suspect that your comment is made (at least partially) at me.
You are probably correct that there are two points here - one is expressing ire and the other is learning to prevent reoccurrence. As far as flight safety is concerned there have been some excellent points raised as to where it all went wrong however it appears that there are no new lessons to be learnt here so the real question, which remains unanswered is - why did it all go so badly wrong? By this I mean why were the SOP's so poor and why weren't those that were there not adhered to? Why did Dr SM chose to push on and on and on, ignoring all wisdom and common sense even once the aircraft has almost impacted the ground? I guess the only person who can really answer this question is Dr SM but he has chosen not to engage and help us with this bar telling us to be cautious without explaining why he himself wasn't.
The other point is expressing ire. When incidents like this occur (thankfully they are rare), personally I am both relieved that the result was not far worse but frustrated (and yes probably angry) that behaviour like this is tolerated within our industry. I am not without fault and I have done things which, with the benefit of hindsight, I would do differently, but for me - this lack of adherence to any kind established procedures is reckless and it damages the reputation of the whole industry. It is akin to the driver that cuts you up on the motorway doing 120mph - I believe it to be unnecessary and dangerous so I don't shed a tear when such drivers are banned but I do get frustrated if they are caught but not punished.
To put this is perspective, have a read of this article.
https://www.dailymail.co.uk/news/article-548731/City-banker-jailed-flashing-torch-helicopter.html
Personally I believe that the gentlemen concerned (Mr Voice) was reckless and it was good that some kind of punitive action followed. I assume that DrSM also felt that the action was reckless as I would imagine it would have been impossible to secure a conviction without a statement from him as the pilot. So I wonder what the view from fellow readers is with regards to whether there is any comparison (in terms of endangering the helicopter) with the way Mr Voice acted when he chose to shine his torch and the way that Dr SM acted when he chose to operate the helicopter in the way that he did?