lawsuit vs. NTSB: $1.276 million damages to widow

[rotormatic]

Helicopter company found liable
Defective gyroscope was cause of crash, jury finds
By Louise Taylor
HERALD-LEADER STAFF WRITER

A federal jury, directly contradicting the National Transportation Safety Board's findings last year, decided yesterday that Goodrich Avionics was to blame for the deadly 1999 crash of a University of Kentucky medical helicopter and awarded the co-pilot's widow $1.276 million.

The eight jurors found Goodrich, of Grand Rapids, Mich., 100 percent at fault for the crash because the vertical gyroscope, which indicates the pitch and roll of a helicopter and is critical to pilots, was dangerously defective.

Judy Greene of Somerset, the widow of co-pilot Donald Greene -- who was flying the Sikorsky A-76 when it slammed into a remote Breathitt County mountain on a foggy June night -- wept as a court clerk read the verdict after a two-week trial in U.S. District Court in Lexington.

"You can smile now," one of her attorneys said, trying to coax her from her tears.

The crash killed four crew members on the helicopter that was named UK2: Greene, 46; pilot Ernest L. Jones, 48, of Cleveland; flight nurse Sheila Zellers, 43, of Elizabethtown; and paramedic Brian Harden, 31, of Richmond.

Judy Greene's lead attorney, Jerome Skinner of Cincinnati, said that the verdict cleared pilots Greene and Jones, who were found at fault in the crash by the NTSB, which after a two-year investigation concluded that the two were miscommunicating before the accident. The NTSB also pointed to fog and darkness as crash factors.

Nineteen seconds before impact, Greene said over his radio, "I think I've lost my gyro." Jones replied that he should keep his heading.

Within seconds, the magnitude of the problem was obvious. Jones' last words: "Turn right! Turn right."

Greene, however, was veering left, straight into the mountain.

The jury, after hearing evidence of about 29 incidents involving Goodrich gyros over six months and looking at a long record of repairs on the gyro of the UK helicopter, decided the federal investigators were simply wrong.

Goodrich attorney Arnold Taylor of Covington said the NTSB "made no attribution of any problems with the vertical gyros in this case" and that Greene had "no facts" on her side in pressing the lawsuit against the company.

The gyro itself was never recovered from the crash. "It is unfair for this case to even be submitted to a jury -- we can't defend ourselves," Taylor said minutes before the jury came back with its verdict after about 41/2 hours of deliberation.

On the other side, Skinner and his co-counsel, William Back, saw the verdict as clearing the pilots' names. "The NTSB concluded Mr. Greene caused the accident," said Skinner. "And the jury found that's not true," Back interjected.

Added Skinner: "Goodrich took the position that they couldn't lose, so getting 100 percent feels pretty good."

It was no great wonder, Skinner said, that the gyro was never found. The Sikorsky was plucked from the mountainside by another helicopter and flown, dangling, for many miles. "All along the route, pieces were falling off in the forest," he said. "We searched for it, but never found it."

The "clincher" in the trial, Skinner said, was evidence left in the forest that contradicted claims of pilot error and the helicopter's position at the time of the crash.

"Trees don't lie," he said. "They got sliced and cut in a direction" that supported the theory that the gyros were bad.

Judy Greene has been scraping by on her dead husband's workers' compensation benefits since the accident, Skinner said, so the money will be welcome relief.

Goodrich could appeal. Taylor said that he will discuss the matter with his clients and make that decision soon.


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At 2205:51, the CVR recorded the pilot-in-command (PIC) transmitting on UNICOM frequency, '...we'll be a uh... south departure right turn we, be uh west out of the area.' The airport manager acknowledged this.

At 2206:18, the CVR recorded the second-in-command (SIC) on interphone, 'I'm gonna lift to a hover, and we'll un get sixty knots before we get solid in it I guess. Try to keep it within the lights down here.' The PIC acknowledged this.

At 2206:51, the PIC stated, 'airspeed's alive, positive rate of climb.', and the PIC subsequently said, 'your at thirty [knots]', and then 'heading one nine zero.' This was followed by the PIC stating, 'I'm gonna kill the landing....[lights].' The SIC acknowledged this.

At 2207:22, the CVR recorded the PIC on interphone, 'and you're at eighty... wanna hold eighty. Or Vbroc [Velocity best rate of climb] rather.' The SIC acknowledged this.

At 2207:32, the PIC transmitted, 'indy center sikorsky ah two seven four three echo we're ah passing one thousand six hundred for four thousand.' AZQ replied, 'november two seven four three echo indy center roger, and ah understand climbing to four thousand say altitude leaving.', to which the PIC replied, 'one thousand six hundred for ah four thousand.' This transmission was acknowledged by AZQ.

At 2207:51, the PIC was heard to say, 'go ahead and stay on your heading.', after which two unidentified intercom transmissions were recorded, 'alright.', and then, 'its ok, you got five hours.'

At 2208:03, the PIC stated, 'ok your in a right hand turn and descending.' There was no acknowledgement from the SIC.

At 2208:05, the SIC stated, 'ok I think my gyro just quit.' There was no acknowledgement from the PIC.

At 2208:10, the SIC asked, 'you have the controls?' There was no acknowledgement from the PIC.

At 2208:11, the PIC stated, 'you're in a left hand turn and descending...turn turn back and level level us off. There was no acknowledgement from the SIC.

At 2208:16, the CVR recorded an increase in ambient noise level through the microphone-summing amplifier.

At 2208:18, the PIC stated, 'right hand turn.....right hand turn.' There was no acknowledgement from the SIC.

At 2208:24, the CVR recorded the initial sound of impact and ceased operation.

In the Air Taxi Operations Section, the following was found:
'Transfer of Controls'

'Transfer of aircraft control will be positive with the statement, 'You have the controls', 'I have the controls'. Do not use the phrase, 'I have it.' '

'Crew Cross-Checking'

'The PNF [pilot not flying] must, without hesitation, call attention to deviations outside given tolerances or procedures. The PF [pilot flying] must invite and accept cross-monitoring, and cross-checking. The keys to advanced crew coordination are mutual confidence, early detection, immediate verification, and correction of error. The crew must work together, avoiding overconfidence or complacency.'

The National Transportation Safety Board determines the probable cause(s) of this accident/incident as follows.
the failure of the PIC to adequately supervise the SIC, and maintain a positive climb. Factors were the fog and dark night.

[Hoverman]

Loyalty to fellow pilots makes me very pleased for their families, but it's a lucky result all the same. 2 crew plus 2 horizons and one failure shouldn't mean loss of control.

[Bluey Zarseoff]

I'm sorry but I have to agree with Hoverman, something's not quite right here. It sounds like (from what is posted here) that there may have been a breakdown in communication and sound CRM procedures. I'm not disputing that the SIC's ADI may have been U/S at the time but at 22 08 05 he stated that, "ok I think my gyro just quit".
At 2208:10, the SIC asked, 'you have the controls?' There was no acknowledgement from the PIC.
What’s wrong with this picture?
Well to start with the words are a statement but are asked as a question, so, my question is, who now is flying the aircraft?

At 2208:18, the PIC stated, 'right hand turn.....right hand turn.' There was no acknowledgement from the SIC.
So, was he (the PIC) saying, "commence a right hand turn", or was he saying, "your in a right hand turn"?

I don't mean to detract from the judgment made in court but I do mean to highlight the importance of clear cross-cockpit communications in modern two crew operating environments.

Bluey

[KENNYR]

This sounds as so the SIC had spatial disorientation. He probably fixated on the gyro

[slgrossman]

I wish I could comment in detail on this accident, but, alas I am constrained by propriety as an employee of the operator.

I will say that the accounts I've read do not do justice to the potential for disorientation encountered when departing this particular airport on a very dark night.

This was a very hard and painful lesson for all of us who fly for my company. It is still a very sensitive subject at the University of Kentucky program where I've had the privilege to fill in on occasion. I think we can all take some important lessons from this tragic accident, and in so doing, pay our respects to the crew who perished.

[S76Heavy]

I suppose it must be somewhat similar to an night offshore departure on wx limits. It is difficult, but one can train for it.

With the little knowledge of the tragedy that I have, I think the NTSB were right, although I don't begrudge the next of kin the payout. But that should have ben insurance money, IMHO

[helmet fire]

A tragic accident. The crew were risking their own lives to help others.

Appologies in advance to the above who are involved in the program, I do not mean to be insensitive, but I think there are numerous good lessons for the rest of us.

First and foremost is the limited panel flying. Is it not a requirement of the Instrument rating that limited panel flying be demonstrated? Don't we do this to enable recognition and correction of the very same situation as the crew found themselves in?

IMC departures should be a minimum competency requirement for an IFR EMS crew shouldn't' it? I agree with S76Heavy in this respect. The potential for disorientation is always present IFR, but rarely more so than during an accelerative climbing turn. Thus training is a critical factor here.

Bluey raises two excellent points about the CRM - although there are more, and this accident should benefit future CRM courses greatly. The first point is the inference that perhaps no one was flying when the aircraft impacted the ground. By the CVR, it certainly looks both a possibility and an explanation. Most transfer of control procedures are positive and three way, in that they contain an action command, such as "You have the controls" an acceptance statement of "I have the controls", and in advanced CRM programs, there is the occaisional third check of "You have the controls" being said again at which point the pilot relinquishing controls lets go. But this requires a constant discipline and is often allowed to lapse into complacency.

Secondly, there is a principle in CRM that requires acknowledgement or read back. If you have not had a readback on your third attempt at transmitting a message, you are to assume control and execute the requirement. Using this principle, the PIC may have said "You are descending and turning left. Climb and turn right now"...(no acknowledgement)..."You are still descending, climb now, and turn right"....(no acknowledgement)...."Climb and turn right now"...no acknowledgement).."I have the controls, and I am climbing and turning back to the right" and consider shouting "intercom failure". Again this example requires discipline and training.

IMHO, the CVR casts some doubt on wether or not the gyro actually failed at all! Was the SIC in a bad case of the leans and not believing his gyro? Was the message from the PIC then missinterpreted by the SIC as telling him to turn left and descend because that would match his leans? Why were there no comments on autopilot/stab system failures or warning indications? Doesn't the S76 have these?

slgrossman - can you give us some insight into the level and frequency of CRM training at your program?

I find it hard to believe that a failed gyro can be so totally condemned by the court. This is an aspect of the law that I do not grasp well. The peice of equipment in question has an expected occaisional fail rate such that the regulations require redundancy and training in how to utilise the extra display. Thus IMHO, a gyro failure is anticipated by the regulations and training progams and an appropriately trained pilot should "reasonably" be expected to cope with it. Given the question mark over training, the confusion indicated by the CVR, and IMHO, a doubt about the gyro serviceability in any event, I do not understand the verdict here. Is it the use of untrained jurors, or who employed the smartest lawyers and "expert witnesses"?

Same as S76Heavy, I don't begrudge the next of kin payout. There is precious little that will compensate for that sort of loss, but I would very much like to know how much of the payout went to lawyers who had to suffer working, and how much went to the family who had to suffer such a terrible loss.

:( :(

[Steve76]

Additional to Hovermans comment:
Its actually 2 pilots and 3 artificial horizons in the aircraft. Two main and the Standby AH which is independantly powered for complete essential power failure.