AAIB (H) UK November 2020 [Archive]

aa777888

12th Nov 2020, 18:15

It's absolutely amazing to me that the quality of the average Robinson pilot is such that Robinson has produced no less than two related "safety notices" that cover this exact situation, 41 and 44, https://robinsonheli.com/robinson-safety-notices/

To me these sort of safety notices are the equivalent of "coffee is hot".

That said, when I was still struggling to tune a radio without bobbling about, having a door open definitely required very careful consideration. I've never had a problem talking a pax through this the few times I screwed up and let it happen, but there are pax and then there are pax. It's really too bad that this pilot made a very reasonable decision to land and sort things out only to suffer from a mistake doing exactly that :(

rotorspeed

12th Nov 2020, 18:44

Firstly this should serve as a reminder as to why passengers should not be left to get in and out of a helicopter with rotors running unless they have professional assistance or are very experienced. There was no time pressure here either. Letting amateurs do doors, seat belts and headsets amidst the noise, downdraft and perceived urgency of a running helicopter is a recipe for disaster, as proven here.

Secondly I think it would be a very good idea if pilots were more aware of just how big a drama a door coming open on the helicopters they fly is. And what they should do about it. How often is this taught? I suspect rarely. And the flight manual should say this too. With greater knowledge I suspect this pilot would not have been as stressed, which lead him to become disoriented.

And then of course there is the big error of just not recognising he was making a downwind approach that was doomed to failure. Had he been monitoring his airspeed he would have seen it decay excessively and hopefully wondered why and recovered some to enable him to go around for take two into wind.

ShyTorque

12th Nov 2020, 21:19

I’m in now....the site in question was having a technical glitch.

Regarding the accident in the report... The answer is always fly the aircraft.

But as the saying goes, “When you’re up to your ar£e in alligators, it’s important to remember you’re actually there to drain the swamp”.

Thankfully, being married, I’ve had years of practice in avoiding distractions. My wife often chats away nineteen to the dozen when she’s my car passenger. She expects answers in great detail. Not only that, she reads a newspaper which she spreads out across the handbrake and gear lever. In years gone by I might have politely asked her to move it. These days I just grab it out of my way and say “OI!” She fumbles then drops her phone on the dashboard whilst talking very loudly to her mother. At critical times, such as joining busy traffic on the motorway she suddenly exclaims things in a panicked voice such as “Oh, NO! Did I leave the hair straighteners switched on?” Etc.

I mostly just ignore her. Great training.

RINKER

12th Nov 2020, 21:35

I always instructed pax how to close and open seatbelts and doors. Demonstrated it and got them
to show they could do it. Advised them if door unlatched it was no big issue as not pressurised like
an airliner and didn’t allow loose objects in cockpit. This was taught to me by my mentor an experienced CPLH.
R

[email protected]

13th Nov 2020, 05:58

Most of us will have experienced a problem with doors coming open in flight and managed to sort it out without too much drama (whether through luck or skill).

Unfortunately, such low time pilots are unlikely to have had it happen before and it is unlikely to have been covered in PPL training.

The accident was entirely preventable - through training of the pax or the person closing the doors as Rotorspeed and RINKER say - (every passenger in a military aircraft has to have been given an aircraft abandonment brief including opening and closing of the doors).

The fact that the pilot was overwhelmed by the situation was just another item in the list of human factors that so often lead to private pilots reaching their capacity limits with no-one to save them from basic airmanship failures.

Fortunately just minor injuries and a red face this time.

treadigraph

13th Nov 2020, 07:27

Unfortunately, such low time pilots are unlikely to have had it happen before and it is unlikely to have been covered in PPL training.
.
Surprises me as I've seen a few other accident reports starting with a door opening in flight. Friend with a fairly new FAA PPL had the pax door open on a C150 just after take off from Shoreham - passenger held the door as near to closed as possible, they did a circuit, landed, closed it, took off again. I think they both had a quick go at closing it in the air but he said it was no real drama. Whenever I flew with him he always insisted on a good shove on the doors as part of hatches and harnesses secure before starting.

Ascend Charlie

14th Nov 2020, 03:56

Bell_ringer

14th Nov 2020, 04:21

People don't seem to realise that even though the door is unlocked and open a bit, they couldn't fall out. They are strapped in, and the airflow outside is enough to push the door back against them and it would take a big effort to get out the door and jump off the skids.

The lower static air pressure compared to cabin pressure makes the door open a bit, but the dynamic pressure against the partly-open door won't let it get much further.

depends on the phase of flight.
there have been 22’s downed by departing doors impacting the main rotor.
PPL training is supposed to include pax briefings, it should be a preflight item so that basic ingress/egress, harnesses, doors and emergency procedures are covered.
Had a rear door on a 206 pop open once. As briefed the guy gave it a good slam shut. No drama.

bladegrabber

14th Nov 2020, 05:39

As everyone says it's good to know nobody was seriously injured . Interesting to see this report and I wonder if it will result in any action by the CAA. In the gyroplane world we had one tragic fatal accident when a door came open on a low time student pilot and they mandated that all UK Magni M24's be fitted with door open visual alarm and the manf also included an inhibit on the rotor tachometer to ensure the P1 is well aware of the doors being secure prior to pre-rotation and taking off . Having all of that I still make sure passengers know how to check the door is latched shut / how to open it in an emergency (once on the ground) and pre takeoff checks include hatches and harness's locked with an elbow push on the doors to be sure.

BG

RINKER

14th Nov 2020, 09:02

Hi Bell ringer. I think that’s why on the R22 part of check A said pins must be on door hinges
to stop it coming away from aircraft in the event of inflight opening. I did always check them.
R

Cylinder Head

14th Nov 2020, 11:13

Very unfortunate incident that should have been completely unavoidable. Fortunately no serious injuries and I am sure that the pilot has learned a great deal from the experience.

My observations are that simple basic airmanship could have prevented the factors lining up, long before the unfortunate development of a Vortex Ring state.
For what its worth, I have the following questions:-

1) How extensive was the legally required pre flight briefing? Delivering it to passengers when rotors running, is too late and never satisfactory.

2) Why was the door's poor latching not noticed during pre take off checks? It was a front door, so the handle would have been visible had it been checked or the passenger properly briefed.

3) Why were dual controls installed when the passenger was not a qualified instructor? The only reason is the provide the opportunity "to let a passenger have a go." Foolish!

4) Flights involving off airfield landings and "pleasure flying" are not the norm for PPL's and seeking advice from a more experienced pilot/instructor is always worthwhile.

The comments about training pilots how to deal with an open door are valid, we do not cover such incidents as a matter of course BUT don't tell me the pilot was not training to ensure that all doors were securely shut as part of the pre take off checks.

This is precisely the sort of accident that comes about with low time private pilots taking on challenges without adequate preparation. It is what terrifies me with this insane Wingly idea as referred to in the posts above. Commercial Pilots and Operators spend a fortune getting qualified to take on such flights and are subject to excessive, draconian oversight by the authorities and yet PPL's have suddenly been given a method to fly in this manner with absolutely no support, control or oversight.

aa777888

14th Nov 2020, 11:29

Correct RINKER. Same for the R44 and R66 as well.

I suspect few actual helicopter pilots are the least bit concerned about falling out of the helicopter or anything like that. Unless you live in cold climes, certainly we've nearly all spent a great deal of time flying around with the doors completely off. Well before I took up with helicopters, when I was taking my fixed wing training my instructor would try to rattle me by opening his door on on take-off. Sadly his gambit failed because I was already a very experienced skydiver and did not really care much for doors on airplanes, either ;)

The challenge can be more physical than intellectual for a low time pilot. I can reach every door in an R44 myself except for the left rear. But with a newly minted private certificate, to do that and keep flying straight and level might be quite difficult. It was for me! :}

To pile on with the aforementioned pax briefings, I also make all pax demonstrate their ability to open and reclose a door. This works great, as you know. But I also fly a lot of fair ride type concessions. When you fly 150 people in one day, sometimes even your very experienced and conscientious loaders make a mistake. Or perhaps your not so bright insta-passenger wonders what the shiny silver handle is for. I've never had a problem talking even the drunkest idiot through reclosing the door, but YMMV.

But I digress. This gent was a very low time pilot. His initial decision to solve the problem was a reasonable one. Very sad he got downwind, very, very sad he didn't handle that well either.

aa777888

14th Nov 2020, 11:39

4) Flights involving off airfield landings and "pleasure flying" are not the norm for PPL's and seeking advice from a more experienced pilot/instructor is always worthwhile.

Actually that probably describes 90% of the op's for newly minted, wealthy R44 owners in the US. The FAA says you are qualified to fly confined space landings with a private certificate, and pleasure flying is all you can do by definition.

Mind you I'm not entirely in disfavor of your thought. My own personal limits gauge was indicating near maximum so much after my private checkride that I rolled right into a commercial course of instruction. But not everyone feels that way, even if they should.

Bell_ringer

14th Nov 2020, 12:06

Actually that probably describes 90% of the op's for newly minted, wealthy R44 owners in the US. The FAA says you are qualified to fly confined space landings with a private certificate, and pleasure flying is all you can do by definition.

When you decide to spend your cash to fly recreationally, if on-field operations is all you intend doing, then you buy a fixed-wing.
When you go the rotary route, the intention is to squeeze it into as small a space as you're comfortable doing.
Sometimes it even fits. :E

evil7

14th Nov 2020, 13:56

aa777888 - no offence, but don´t you think proffesionalism is lacking a bit when you take "even the drunkest idiot" on board??

aa777888

14th Nov 2020, 16:10

aa777888 - no offence, but don´t you think proffesionalism is lacking a bit when you take "even the drunkest idiot" on board??
There's a bit of hyperbole in my post. The op's I'm associated with do not allow, and I personally don't allow, people who are grossly inebriated as passengers. However, depending on the type of event, the smell of alcohol is often noticeable. I.e. the average person, having a good time, with a little bit of Etoh inside them, is capable of operating the door. Not really any different than when flying a commercial airline. No drinks allowed on board or served in flight, though!

Continuing with this digression...I worry a great deal more when I am asked to host someone on board with mental disabilities. Mildly inebriated folks are relatively predictable. I have no idea what those with mental disabilities will do. In this PC day and age it is very difficult to gracefully refuse service to such. I have standing orders to put them in the back seat, preferably with a guardian of some sort. The Robinson T-bar cyclic is just too vulnerable to allow that kind of unpredictable or potentially impulsive behavior to be near it. Even with the precaution of the back seat, if things start to get weird the flight gets cut short.

Maximum digression: the passenger that I hate the most is the bully father who is making his scared-to-death kid go. This can be hard to detect on the ground, but in the air it is always evident. Those flights get cut short, too.

nomorehelosforme

14th Nov 2020, 19:09

There's a bit of hyperbole in my post. The op's I'm associated with do not allow, and I personally don't allow, people who are grossly inebriated as passengers. However, depending on the type of event, the smell of alcohol is often noticeable. I.e. the average person, having a good time, with a little bit of Etoh inside them, is capable of operating the door. Not really any different than when flying a commercial airline. No drinks allowed on board or served in flight, though!

Continuing with this digression...I worry a great deal more when I am asked to host someone on board with mental disabilities. Mildly inebriated folks are relatively predictable. I have no idea what those with mental disabilities will do. In this PC day and age it is very difficult to gracefully refuse service to such. I have standing orders to put them in the back seat, preferably with a guardian of some sort. The Robinson T-bar cyclic is just too vulnerable to allow that kind of unpredictable or potentially impulsive behavior to be near it. Even with the precaution of the back seat, if things start to get weird the flight gets cut short.

Maximum digression: the passenger that I hate the most is the bully father who is making his scared-to-death kid go. This can be hard to detect on the ground, but in the air it is always evident. Those flights get cut short, too.

aa777888,

Totally agree about keeping an eye on pax for signs of excessive alcohol or anything else taken in excess! Saw a pax refused a transfer flight in St Lucia because he was clearly very drunk. As far as been not very different to flying on a commercial airline I can’t seem to remember the last time I saw a pax helping close a door... not sure what commercial airline you fly with?

As for you cutting flights short, if you are flying 150 pax per day in your R44 your tour flights are probably a 10 minute trip, you can’t cut it much shorter than that!

aa777888

14th Nov 2020, 19:49

As far as been not very different to flying on a commercial airline I can’t seem to remember the last time I saw a pax helping close a door... Damn, you guys are literal! I mean in terms of being denied boarding. Show up at the gate staggering and too bad, so sad. Show up a little loud and happy and on you go.
As for you cutting flights short, if you are flying 150 pax per day in your R44 your tour flights are probably a 10 minute trip, you can’t cut it much shorter than that!Wanna bet? When the line is short 10 loads an hour, including turn-around time. When the line is long 12 loads an hour. When someone is freaking out (or freaking me out!) it might be a two minute flight. I'm still amazed that people will pay $30 to stand in line for 30 minutes or even longer for a 4 minute flight. But they all seem to love it. It's little different than at Disneyworld I suppose. Stand in line all day for a 4 minute ride.

nomorehelosforme

14th Nov 2020, 21:51

aa777888,

Of course we are literal, educated with Queens English is always a good start in life!

As for that quick tour work, you must have the patience of a Saint and the eyes of a hawk... how many checks do you carry out on a busy day?

pilotmike

14th Nov 2020, 22:11

Very unfortunate incident that should have been completely unavoidable.
So you're saying it was inevitable...?

aa777888

16th Nov 2020, 11:13

aa777888,

Of course we are literal, educated with Queens English is always a good start in life!In the immortal words of Korben Dallas: I only know two languages, English, and Bad English!

As for that quick tour work, you must have the patience of a Saint and the eyes of a hawk... how many checks do you carry out on a busy day?Probably 40 or 50 per day, per pilot at a busy event. Half that at a weak event. We generally bring two pilots, or if there are two helicopters three pilots, sometimes four. That way everyone can stay safely rested, fed and watered. First check is "who are they bringing me?" The loaders are good (many are student pilots), and the pilots not flying help, but sometimes the fat guy tries to sit in front, or too many fat people at once or, to the previous point, did you seriously think that guy was not too impaired? Doors, belts, "Hey person in the front seat, are you a pilot? No? Then don't touch this or that, please, thanks, ha ha!" Scan while you wind it up. Go. Return. Wind it down. Help sort headsets, get a swig of water while the loaders do their thing. Last check is "How am I feeling, how was my last touchdown, is it time to ask for relief?" Repeat. Fly your patterns (more than one so as to break up your noise footprint). Stay in sync with the second helicopter if there is one, meaning you're flying when the other is loading. On one hand you are a machine and trying to attain a perfection of safe, efficient and repeatable movement, perhaps a bit like slinging trees or ag work. All honor to the loaders, they are an absolutely critical part of the ballet, both efficiency and safety-wise, as important as any pilot. On the other hand every load is different, and the cargo does wear on you sometimes. Screaming children. Old folks. Young men ("Sorry dudes, this isn't the Red Bull helicopter). Young ladies (more screaming). Date night. For most loads you throw in a couple of steep turns at the end and it's all they remember from the flight, and they go and tell everyone how awesome it was :)

Bell_ringer

16th Nov 2020, 14:14

Probably 40 or 50 per day, per pilot at a busy event.

With that number of lifts, how do you manage staying within max take off power limits?
After all, they didn't plan on that many movements per hour in the POH.

aa777888

16th Nov 2020, 14:36

With that number of lifts, how do you manage staying within max take off power limits?
After all, they didn't plan on that many movements per hour in the POH.You know, that's a really good question, BR! I don't actually know the answer. I can't remember there being a duty cycle limit for 5 minute take-off power in the POH. A quick Google search turned up this thread (https://www.pprune.org/rotorheads/602042-5-minute-power-limits-r44-3.html) right here in "Rotorheads" (and which I actually posted in!) In that thread there never was a definitive answer, other than to say it is an engine life limit and not a MRGB limit.

I can tell you that we don't fly above max. continuous, in the 5 minute take-off power regime, for very long. 30 seconds or a minute, maybe. However, there is no question that the aircraft is worked hard! As an owner of one of them I can tell you that I am concerned about making the full 2200 hours on the engine.

These op's are also rough on the aircraft in other ways. Dents, scuffs and scratches everywhere, inside and out. General cosmetic wear and tear. After the first season of this the eight year old carpet looked twelve years old. I ripped it out and put in a very nice utility floor kit from RAMM Aero (https://www.rammaero.com/en/products/helicopters/product/r44-22/r44-grey-pre-cut-utility-floor-covering-71). It added 7lbs to the empty weight but I'm pretty sure there was nearly 7lbs of dirt in that carpet! Everyone who sees it loves it, and it is a dream to keep clean, 5 minutes with a vacuum and a damp cloth :ok: