gimmick flying schoo

Thank god ! the long awaiting accident report was open to the public lately. What a pity that all the arrows seem pointed to the poor winged-man though he was in the history. Would it be more fair to look into the system. The 20 minutes target has been nuts to all the rescuers. Why 20, why not 15, 25 or 35? Dont ever pass the bugs to the guy who work night and day, hot and cold, sunny or typhoon 10. Dont ever squeeze the drivers to earn promotions in the hope of replacing the God's position. The old guy BaBy simply overlooked and did a poor job - without preventing the ever accident in GFS.

petitfromage

OTP conceptually is a great idea. Setting a target to aim for, setting timelines etc really does help you judge progress & adjust rates of effort to acheive goals.

But OTP should not be a driving force. If individually, organisationally or culturally you are unable to see the difference between OTP as a concept/aim or if you see it as a 'real' indicator of performance then there maybe fatal results (and you need your head read)

The 20mins target set by GFS to be 'on scene' is entirely reasonable so long as the pilots, crews, managers understand that it is a guide and by no means essential to the overall success of the task.

Crashing enroute means you will miss the target...so, why not fly safer and be 2-3mins late? Its better than being dead!

Somehow this concept seems lost amongst some cultures.......and they would rather die trying than lose face. (Not to mention the supervisors who cannot see the woods for the trees)

OTP can never be more important than the process of safe decision making.

pokemon

petitfromage,

You are probably right in that the OTP shouldn't be viewed as a real indicator of performance. The crews know this. The management verbally and explicitly mentioned this. But the probelm is: did the management honor their golden words? Unfortunately, can we know what might have actually happend there, esp between the management and crews who couldn't made the 20 mins by just 2 mins. If you (as a crew) got some words from your supervisor, can't you say those 2 extra mins is no more important than your bug's life?

petitfromage

Pokemon, I agree with you whole-heartedly.
I think everybody knows what really happened in this awful accident.
The final failure is almost certainly with the flight crew in any accident but the systemic failures & corporate/cultural mindsets all contribute to the 'james reason' (swiss cheese) model....and ultimately therefore must shoulder some responsibility.

No doubt there was some ducking and diving at GFS as to the actually or implied importance of OTP when CAD came knocking.
Sadly we know that what is said publicly doesnt always ring true behind closed doors.

I hope for the sake of the GFS crews and the public at large who may one-day be in receipt of GFS's invaluable service, that the Managers and Supervisors have taken on board the real importance of OTP.

If the HK public can grasp the theory vs reality vs practicality then one hopes the Commanders can too?

**Ps: Ive had a few PMs about my use of the word 'cultural'. Im not talking about race's eg: canto, gweilo etc....but rather corporate culture; so please dont play the racism card; youre well off the mark & simply displaying ignorance wrt flight safety.

moosp

Please forgive me if I tread on sensitive toes at this time, but wasn't the clinic on Cheung Chau renowned for calling out GFS at all times of the day and night for what other medics considered non critical medical cases? It was so reported in the SCMP, that bastion of accuracy, at the time.

A good risk assessment model is used in some EMS operations to balance the risk of dispatch to the seriousness of the medical case and the environmental and operational conditions. I am sure you have such a model at GFS, but did this operation slip through a James Reason hole?

TDP

Performance Pledge!!! This is one major root cause of this unfortunate accident, in concert with the organizational failures of management. Regardless of the severity of any casevac, is it responsible to put time pressure such as this Performance Pledge of "20 minutes to land on site" on aircrews? Nothing wrong with OTP, but it must be recognized that the pilot has little control of circumstances once airborne (ATC, Traffic, Weather etc.). Why was the pilot discussing the pressure of this Performance Pledge continuously throughout his journey to work and as recorded on the CVR? Obviously he (and maybe others still alive) had some problem with it. A pledge to be airborne within a reasonable time period would seem more appropriate and would allow the crews to be properly prepared for what awaits them. Search & Rescue and EMS crews are not immune to human failings and are just as susceptible to the same problems as any other aircrew. It is not good enough to say that the pilot made errors; it is deeper than that, and rests with those that made the policy. GFS is an ISO 9001 certified organization to which customer satisfaction is a main criteria. Did the HK Gov't institute this performance pledge to meet that criteria? Are the aircrews pressured just so an ISO standard can be measured? No mention in the accident report of interviews with the medical staff at Cheung Chau: why is it that there are an inordinate number (usually nightly) callouts to a single island? Are the callouts actually abusing the system and costing HK taxpayers (and in this case lives) unnecessarily? I think the Accident Report leaves a lot of open questions and was unsuccessful in deflecting the blame onto the pilot and crewman.

moosp

TDP I think you are right that sometimes the public and some members of the medical and paramedical professions abuse the abilities and services of GFS. Have you ever "rescued" a walker from a country park trail with "exhaustion" or a "sprained ankle"? Dropped them at Chai Wan and they run to the ambulance? Or asked the case history of a patient being lifted at 0200 from CC to be told that it's a broken wrist?

I haven't, and these examples are heresay But you may know of similar cases.

What concens me is that GFS continues to operate such low urgency and sometimes high risk flights. Is it some desire to keep the Government funding, so that the ratio of operational flights to training flights is kept to a reasonable level? You may remember that at one point a few years ago it was reported that over 60% of GFS operations were training, and a further 18% (I think) were VIP travel.

You guys do an amazing job, and win world awards for heroism but heroism has its place, when life is in danger. Putting life and machines at risk for either the public image of a medical practitioner, or the political advantage of GFS should never be allowed.

TDP

Hi MOOSP. I hear you but my real question is why the investigation fell short of interviewing the reasons for the flight in the first place. That issue never seems to be in questioned. The number of callouts to Cheung Chau during the year is unprecedented anywhere else. It seems that those making callouts for ridiculous reasons and then GFS management making ridiculous demands upon aircrew to meet unreasonable time limits need to be scrutized and held accountable. Why was the pilot so upset by the performance pledge when he should have been used to it by then.
The report hints at it but doesn't really say that management decisions are a causal factor. It sure pointed out the pilots mistakes though! Perhaps whoever wrote the report was stifled from putting what really happened, but left enough hints in it to raise some questions by the courts down the road.

Speediwings

The management of Gravity Flying School GFS had never thought of the risk until the so-called accident was happened. They were shocked, but still they put all the responsibility to the poor pilot. Have they ever thought of the poor leadership which truly dragged the chopper and brought the aircrew to the God.

In fact, the mishap was sitting there for a long time, it was not the first working day of the pilot and the traps ( the reasons of this accident) were sitting there for years. Were they daydreaming before the mishap?

The CAD found out that the pilot swore the 20 minutes TOS policy on the way back to work. He did not do the flight planning, he and his crew did not wear helmets. He continued to swear the 20 minutes TOS rule. He did not select the less risky route to fly to the destination. He ignored the SOP (standard operation procedure) of flying in the wrong altitude and high speed. He ignore the repetitive reminder from the crewman at the back and attempted speedy flying. He placed the 20 min TOS with higher priority than his life.

If the headmaster and the deans of each faculty had done their jobs, this mishap would have not happened. Why the pilot had such a sub-standard EQ and IQ was able to pass the recruitment test, training, simulator training, CRM, human factor training, annual checks &....... Why the crewman could not use a stronger word to remind the pilot in order to keep his life. It was because of the poor culture running around in the school for years.

The culture of " I dont care, just do it", " No need to explain to me!", " are you going to argue with me now?" , and "The door is always open, (for kicking you out)" should be completely abolished

Speediwings

The call out from Cheung Chau is not related at all. NO matter who calls out the task, the School should provide a safe flight to the customers.

maxitorque2001

Be proactive for god's sake. What did the top men do to prevent this accident before it was happend. The god dm.. accident will repeat itself if individuals are still sitting on their butts blind-shooting at the unrelated stuff.

moosp

Speediwings, I hear you on your 1718 of the 5th June but disagree. Maxi has brought this back to the top with a very apposite use, in GFS, of a euphemism for bottom.

The call out to Cheung Chau is related. It is one of the critical points in the accident that was not investigated, as it was outside of the remit of the investigation. This was not a coroner’s court, and the CAD did not have total investigative powers in this inquiry.

In the country that your profile shows you to be from, EMS operations, I understand, need to have as part of their operations manual a risk assessment matrix. My "matrix" wording may be wrong, but the requirement should assess the risk of every operation, to decide whether it is safely viable. Thus a dispatch at 0300 in IMC to a remote uncharted site at the limit of range which is in low visibility, to pick up a patient that has been assessed by medical staff on the scene as "minor injury, no immediate hospitalisation required" would be disallowed.

Speak to one of the guys who has set up a risk assessment model for an EMS in Oz and they are very interesting people to talk to. It can be proven to save more lives over time by not going, than dispatching to a cut finger.

CC (and other clinics) and the general public in Hong Kong have, I think, a cavalier attitude to using GFS. They also mis-use the ambulance services, as I assume you know.

I think this flight should never have dispatched. As I understand from the media, there was no critical medical requirement for the patient to be moved that night. A risk assessment model for flight operations would have enabled them to make a sound decision on go/no-go.

Forgive me for not understanding another point that you made, as I am unfamiliar with your phrases, "...that the pilot swore the 20 minutes TOS policy..." and, "He continued to swear the 20 minutes TOS rule..."

Is it required to "swear" as in "make an oath" before flight that you will complete the dispatch in 20 minutes? I am not being facetious here; I simply do not understand the word. Thank you.

Cripple 7

Anyone know why the PIC left CX?

Flying Bagel

I think the poor chaps should rest in peace. Really, it all seems to be in a bit of bad taste to talk about their past histories.

Let's just stick to the issues, and not the people involved.

moosp

Bagel I agree with you completely.

However to dispel any innuendo that Cripple has intimated, to my knowledge the pilot left CX of his own volition, for honest and honourable pilotage reasons. That is, he wanted real flying.

Can we leave it there please?

Cripple 7

I never suggested anything untowards. I merely asked a question about the fella. The fact that the fella went through the CPP and was one of the 4 graduated from his class was a testament to his flying skills. I came across the fella at that time and with a name like his, it was't easy to forget.

RIP.

pokemon

Hi flyers,

Let's get back to rational track. The management appears as so generous to tell the crews that the 20 min perf pledge is onlt a guideline for organizational performance. You guys, the flyers should have the professionalism to decide on how to manage the task withour compromising flight safety. Well, this is so nice to sound out.

Sadly, the reality turns out to be another side of the coin. (or the coin is actually twin faced!) Some of us may have such experience that you were late on scene by just 2 mins due whatever reasons: wx, ATC, tech problem when start up.... to name a few. You supervisor then stabbed your axx with some words. You are not properly penalized (on record) but properly debriefed later then.

Have you also ever been asked to attend meetings after the C shift (overnight shift) and then come back on the same night for another C? Have the supervisors ever thought about an appropriate date (not to fall on the personal time of crews) before calling for a meeting?

The management culture is sick but sadly they don't see the problems. Only our flyers know, "the epidemic is around!" Just do it la, comrades

Pokemon

Trial Marcher

Guys, please open your eyes on the Earth. If I were one of the senior guys, I would have resigned and donated all my grauity to the families of the poor scrape goat and the back sitter for inability managment, poor employee filtration, training, quality control and no preventive actions - which sadly caused two fatals.

Why given of this level of budget and power, the GFS cannot turn down some absurd call outs especially during the bad weather.

Why the accident report only pointing the finger to the poor front seat chap. Why in the accident report the managment is unbelievably "Clean" ? Should the CAD also share her part of fail to monitor GFS sucessfully.

pokemon

The CAD didn't have the capability to touch on the senior management of GFS. If you have a glance on the report, you will find a familiar tone and words of typical CAD ways: lack of vision, bureaucratic, finger pointing, and above all, file closing ASAP. What CAD knows is to bluff and engage in paper furnishing. You may judge from how well their officers pretend to be in front of the laymen. They failed in GFS flying but still struggling in other operators like DA, CX... whoever having his neck grabbed by CAD.

GFS senior management will never have the courage to turn down unreasonable request from outside. What it dares to do is to bark and bite on the tail of those poor flyers in the front, who were nurtured up by taxpayers' money and were thought of bearing liability to be persecuted.