Bell 407 down off Queensland coast
Guest
Posts: n/a
Oh Doc.
Oh Doc, please don't be wise after the event.
This crew were responding to a request for assistance....they normally have no way to verify the judgement or decision to request them.....but we must fix that indeed.
If in fact the Medical Staff called for help without due judgement, then there will be a time for them to justify that call in the future....the more of these faceless people that are vilified [like the pilots always are] in front of the 6 O'Clock news cameras and Coroners Court, then the better our EMS will be.
If this patient was not requiring immeadiate second level care, then there will be more questions asked in the courts in the coming months.
And you can [sic] all you like....your friends arn't dead because of someone else's call....and by your inference, perhaps not justified.
Great. [I will indeed restrain myself]
This crew were responding to a request for assistance....they normally have no way to verify the judgement or decision to request them.....but we must fix that indeed.
If in fact the Medical Staff called for help without due judgement, then there will be a time for them to justify that call in the future....the more of these faceless people that are vilified [like the pilots always are] in front of the 6 O'Clock news cameras and Coroners Court, then the better our EMS will be.
If this patient was not requiring immeadiate second level care, then there will be more questions asked in the courts in the coming months.
And you can [sic] all you like....your friends arn't dead because of someone else's call....and by your inference, perhaps not justified.
Great. [I will indeed restrain myself]
Join Date: Jun 2003
Location: Awstraya
Posts: 197
Likes: 0
Received 0 Likes
on
0 Posts
High Nr
You seem to be making a few assumptions here, too:
a. That I know who made the call (do you? - EMS systems vary)
b. That I'm a medico!
c. That I'm in some way blaming the aircrew!
It's the system, stupid.
All inquiries (coronial and otherwise) into accidents are about being "wise after the event". The *observation* made about the non-dispatch of fixed-wing has nothing to do with hindsight, however.
Read my first posts on this - you're not the only one to lose friends and colleagues, although it's understandably hard to keep emotion in check at times like these. Cool it - there are others who share in your sorrow and don't want to see events repeated.
NOTAM'ed
You seem to be making a few assumptions here, too:
a. That I know who made the call (do you? - EMS systems vary)
b. That I'm a medico!
c. That I'm in some way blaming the aircrew!
It's the system, stupid.
All inquiries (coronial and otherwise) into accidents are about being "wise after the event". The *observation* made about the non-dispatch of fixed-wing has nothing to do with hindsight, however.
Read my first posts on this - you're not the only one to lose friends and colleagues, although it's understandably hard to keep emotion in check at times like these. Cool it - there are others who share in your sorrow and don't want to see events repeated.
NOTAM'ed
Join Date: Jul 2002
Location: Lost in thought
Posts: 103
Likes: 0
Received 0 Likes
on
0 Posts
All... I don't want to speculate on this particular accident... but the discussion about VFR night flight with little visual reference is very relevant. I don't think a lot of people appreciate the illusions that come into play during night VFR flying. Over DFW, and other highly populated areas, it's fairly easy to distinguish sky from ground at night. Same is true over completely unpopulated, dry ground, on a clear, starlit night. But I did my flight training in eastern Canada. Canada requires 5 hours of hood training to gain a night rating - for good reason. I was surprised, even when just outside the Ottawa area, how easy it is to lose your horizon. Reflections of stars from lakes and rivers, sparsely distributed ground lights that look like stars, combined with some cloud cover that can make areas of the sky look like ground, can easily conspire to turn the world up-side-down. I was lucky my instructor was one of the top Human Factors people in the business (Bob K.) and he gave me some great lessons on this.
I also don't think people understand how the current certification regulations stack against giving helicopters a better chance in these circumstances. There has been a lot of work in the FAR Part 23 (light airplane) world to lower the barriers to allow better technology in the cockpit. The Part 23 folks have recognized that "loss of situational awareness" kills way more pilots than misleading equipment and displays, yet the certification requirements for equipment and software keep going up, and the overall safety record keeps going down. Raising the bar on equipment is just not working.
For the most part, "complex" systems (ie: those with processors, software, and complex architectures) have to be certified via the air transport regs (AC25-1309 which leads to ARP4760, ARP-4754 and DO-178B for methods of compliance) Other directorates have simply adopted the Part 25 practice for complex systems, and so for primary flight instruments, the requirements look more like what you'd need in a 747 rather than a 407. That's why steam gauges live on.
The Part 23 folks (light fixed-wing aircraft) were the first to depart from air transport standards with AC23-1309-1C. They have proved their theory through the CAPSTONE project where new the technology (intuitive, synthetic vision displays, that don’t require the continuous currency training and mental gymnastics to interpret) were put in VFR aircraft. The result over the first two years of the study in Alaska (lots of water, lots of night, lots of VFR in near IMC, lots of stuff to run in to) was a 40% reduction in fatal accidents.
As a result of this Part 23 work we are seeing the new MFD flight screens from Avidyne, Garmin, Chelton(ex Sierra), Universal and the like that cost 1/4 of the heavy iron stuff. It's now going into the basic, fixed wing aircraft such as the Cessna 182, Mustang, Cirrus, etc.
Yet the technology barriers for Helicopters remain high. The big issue for Helicopter IFR is stability. Fixed wing aircraft tend to right themselves, most helicopters don’t. So in near IMC conditions, the helicopter pilot cannot afford to momentarily divert his attention (to retrieve a chart or similar) for fear to find the dirty side is no longer pointing down. The specific requirements for helicopter stability for IFR certification are detailed in Appendix B of FAR Part 27. Other than a few models (e.g. some Bell 206 models) few helicopters can meet the requirements without SAS or SCAS. With today’s technology, SAS or SCAS could be made cheaply. But now come the regulations.... Appendix B goes on to say that if a SAS is used to achieve that performance, then failure of the SAS has to be “extremely improbable”. The AC25-1309 interpretation of “extremely improbable” drives you to a triplex system and “level-A” software. For the most part, the certification authorities have accepted a dual system with “level-A” software, but that is because “they have cut us a break.” The DGAC noted in a recent meeting that they have been taking the more stringent interpretation of “extremely improbable” on recent certifications, and I suspect that is what led to the almost triplex implementation in the EC-135. So per the regulation, you either require nothing – if your aircraft is inherently stable, or you require duplex or triplex, level-A SAS (with dual hydraulics, etc). There’s no in between.
The point is that VFR helicopters would be safer in near IMC conditions if they were made more stable. They could be more stable if they had SAS. The bean counters don’t want to pay for SAS unless they get some kind of credit (i.e. IFR capable aircraft). For IFR credit, the regs require you meet “extremely improbable”, which means a high cost /redundant system. And so, the market for low-cost, VFR-only, SAS is soft. As a result, nothing gets done for light VFR helicopters. And accidents, such as possibly this one, continue to happen.
We need the same kind of thinking that went into the new Part 23 to be applied to Part 27. In the mean time, hold on... and good luck keeping the dirty side down.
I also don't think people understand how the current certification regulations stack against giving helicopters a better chance in these circumstances. There has been a lot of work in the FAR Part 23 (light airplane) world to lower the barriers to allow better technology in the cockpit. The Part 23 folks have recognized that "loss of situational awareness" kills way more pilots than misleading equipment and displays, yet the certification requirements for equipment and software keep going up, and the overall safety record keeps going down. Raising the bar on equipment is just not working.
For the most part, "complex" systems (ie: those with processors, software, and complex architectures) have to be certified via the air transport regs (AC25-1309 which leads to ARP4760, ARP-4754 and DO-178B for methods of compliance) Other directorates have simply adopted the Part 25 practice for complex systems, and so for primary flight instruments, the requirements look more like what you'd need in a 747 rather than a 407. That's why steam gauges live on.
The Part 23 folks (light fixed-wing aircraft) were the first to depart from air transport standards with AC23-1309-1C. They have proved their theory through the CAPSTONE project where new the technology (intuitive, synthetic vision displays, that don’t require the continuous currency training and mental gymnastics to interpret) were put in VFR aircraft. The result over the first two years of the study in Alaska (lots of water, lots of night, lots of VFR in near IMC, lots of stuff to run in to) was a 40% reduction in fatal accidents.
As a result of this Part 23 work we are seeing the new MFD flight screens from Avidyne, Garmin, Chelton(ex Sierra), Universal and the like that cost 1/4 of the heavy iron stuff. It's now going into the basic, fixed wing aircraft such as the Cessna 182, Mustang, Cirrus, etc.
Yet the technology barriers for Helicopters remain high. The big issue for Helicopter IFR is stability. Fixed wing aircraft tend to right themselves, most helicopters don’t. So in near IMC conditions, the helicopter pilot cannot afford to momentarily divert his attention (to retrieve a chart or similar) for fear to find the dirty side is no longer pointing down. The specific requirements for helicopter stability for IFR certification are detailed in Appendix B of FAR Part 27. Other than a few models (e.g. some Bell 206 models) few helicopters can meet the requirements without SAS or SCAS. With today’s technology, SAS or SCAS could be made cheaply. But now come the regulations.... Appendix B goes on to say that if a SAS is used to achieve that performance, then failure of the SAS has to be “extremely improbable”. The AC25-1309 interpretation of “extremely improbable” drives you to a triplex system and “level-A” software. For the most part, the certification authorities have accepted a dual system with “level-A” software, but that is because “they have cut us a break.” The DGAC noted in a recent meeting that they have been taking the more stringent interpretation of “extremely improbable” on recent certifications, and I suspect that is what led to the almost triplex implementation in the EC-135. So per the regulation, you either require nothing – if your aircraft is inherently stable, or you require duplex or triplex, level-A SAS (with dual hydraulics, etc). There’s no in between.
The point is that VFR helicopters would be safer in near IMC conditions if they were made more stable. They could be more stable if they had SAS. The bean counters don’t want to pay for SAS unless they get some kind of credit (i.e. IFR capable aircraft). For IFR credit, the regs require you meet “extremely improbable”, which means a high cost /redundant system. And so, the market for low-cost, VFR-only, SAS is soft. As a result, nothing gets done for light VFR helicopters. And accidents, such as possibly this one, continue to happen.
We need the same kind of thinking that went into the new Part 23 to be applied to Part 27. In the mean time, hold on... and good luck keeping the dirty side down.
Last edited by Avnx EO; 24th Oct 2003 at 02:52.
Join Date: Sep 2000
Location: Australia
Posts: 50
Likes: 0
Received 0 Likes
on
0 Posts
The whole situation makes me wonder about the training and protocols used by the tasking authority when it comes to these retrievals. What are the checks and balances in place for the medical authority responsible? The EMS community have their own go/no go requirements but as they are not told of the circumstances regarding the patient they rely implicitly on the sound judgement and risk assessment procedures in place at the requesting/tasking end of the process. If these processes are not sound or non existent then the EMS crew is being set up.
EMS operators do great work and have on many occasions been able to carryout tasks beyond what is generally required by the supported service. Perhaps this high level of success leads to a level of complacency within the tasking authority and they begin to think along the lines of its been done before it can be done again, and task the EMS agency beyond what it is technically able to perform. Perhaps tasking agencies get lazy and just opt for the admministratively/operationaly easiest option for them. This is why they need ironclad risk assessment procedures in place and people trained with detailed knowledge and understanding of the capabilities of the asset they are about to task.
Only the Medical service responsible for the callout really knows if they rigidly adhered to their procedures, but on face value and with the luxury of hindsight a lower risk alternative should have been utilised.
EMS operators do great work and have on many occasions been able to carryout tasks beyond what is generally required by the supported service. Perhaps this high level of success leads to a level of complacency within the tasking authority and they begin to think along the lines of its been done before it can be done again, and task the EMS agency beyond what it is technically able to perform. Perhaps tasking agencies get lazy and just opt for the admministratively/operationaly easiest option for them. This is why they need ironclad risk assessment procedures in place and people trained with detailed knowledge and understanding of the capabilities of the asset they are about to task.
Only the Medical service responsible for the callout really knows if they rigidly adhered to their procedures, but on face value and with the luxury of hindsight a lower risk alternative should have been utilised.
Join Date: Dec 2001
Location: Philadelphia PA
Age: 73
Posts: 1,835
Likes: 0
Received 2 Likes
on
2 Posts
It's actually slightly worse than we may realize.
First is there is no requirement in the certification rules for an attitude indicator in a Part 27 helicopter for even night flying. (Read Part 27 if you don't believe me), and check what the baseline, absolute bare bones equipment is that comes with most light helicopters - attitude indicator is an optional extra.
How can we allow this?
Second is the definition of VFR- it probably has been hammered at before, but it states something about navigation and orientation of the aircraft by use of visual references. At night, regardless of the visibility, if you're over the water or unpopulated territory, you can't really orient the aircraft by use of visual reference.
What do the insurance companies think about this? Might be good to have them consider an attitude indicator minimum equipment, and night flying as IFR, unless you are going to be staying over downtown.
First is there is no requirement in the certification rules for an attitude indicator in a Part 27 helicopter for even night flying. (Read Part 27 if you don't believe me), and check what the baseline, absolute bare bones equipment is that comes with most light helicopters - attitude indicator is an optional extra.
How can we allow this?
Second is the definition of VFR- it probably has been hammered at before, but it states something about navigation and orientation of the aircraft by use of visual references. At night, regardless of the visibility, if you're over the water or unpopulated territory, you can't really orient the aircraft by use of visual reference.
What do the insurance companies think about this? Might be good to have them consider an attitude indicator minimum equipment, and night flying as IFR, unless you are going to be staying over downtown.
Join Date: Jun 2003
Location: Off the Planet
Posts: 320
Likes: 0
Received 0 Likes
on
0 Posts
Shawn:
Where there is a defficiency in the Certification Standard, it is for the Operational Rules to prescribe. We cannot rely upon our Airworthiness colleagues as their world is dominated by the manufacturers.
This is clearly dealt with in most Operational Codes (ICAO and JARs both require the appropriate Standards for Night - FAR 135.159 does not require it for helicopter below 6000lbs (why?)). It is also rumoured that the US would like to revise the International Standards (ICAO) in line with FARs (why?).
For the requirement for flying in Night VFR, the FARs deal with this much better than other codes - they at least require suitable references
Why rely upon the insurance companies - can't we regulate our own industry?
Where there is a defficiency in the Certification Standard, it is for the Operational Rules to prescribe. We cannot rely upon our Airworthiness colleagues as their world is dominated by the manufacturers.
This is clearly dealt with in most Operational Codes (ICAO and JARs both require the appropriate Standards for Night - FAR 135.159 does not require it for helicopter below 6000lbs (why?)). It is also rumoured that the US would like to revise the International Standards (ICAO) in line with FARs (why?).
For the requirement for flying in Night VFR, the FARs deal with this much better than other codes - they at least require suitable references
135.207 VFR: Helicopter surface reference requirements.
No person may operate a helicopter under VFR unless that person has visual surface reference or, at night, visual surface light reference, sufficient to safely control the helicopter.
No person may operate a helicopter under VFR unless that person has visual surface reference or, at night, visual surface light reference, sufficient to safely control the helicopter.
Join Date: Mar 2002
Location: Canada
Posts: 690
Likes: 0
Received 0 Likes
on
0 Posts
Mars wrote: "We cannot rely upon our Airworthiness colleagues as their world is dominated by the manufacturers."
I do find the attitude of helicopter manufacturers deplorable (eg "the 'men in grey suits' will do as they are told and issue a TC"). F/JAR29 is meanwhile an incredibly archaic code, that is probably worse than UK (say) had 10 years ago (and its gut wrenching to hear manufacturers crowing that they meet the latest requirement when they 'negotiated' the F/JAR standard to the lowest common denominator).
The ops community however has is faults. In the helicopter world they are far too keen to follow on the coat tails of the oil companies with requirements that apply to oil and gas operations, while avoiding the onshore market that doesn't have that influence.
The JAR-OPS Flight Safety & Accident Prevention Programme is a joke - most authorities only apply it as rule that gives an excuse to employ a nearly-retired pilot to learn how file safety reports. Its not a patch on the SMS approach that most of the oil comapany majors now require and still doesn't include even basic things like health monitoring programmes.
You only have to look at a recent CAA Flight Ops missive to show how confused regulators can be. That document had three sets of 'recommendations' following 2 recent helicopter accidents. One just suggests operators should 'consider' doing something. One suggests that though certain operators are not required to do something they should discharge a 'duty of care' over the issue and effectively do it some of the time, and the third says operators should 'review' an issue by a specific date.
I do find the attitude of helicopter manufacturers deplorable (eg "the 'men in grey suits' will do as they are told and issue a TC"). F/JAR29 is meanwhile an incredibly archaic code, that is probably worse than UK (say) had 10 years ago (and its gut wrenching to hear manufacturers crowing that they meet the latest requirement when they 'negotiated' the F/JAR standard to the lowest common denominator).
The ops community however has is faults. In the helicopter world they are far too keen to follow on the coat tails of the oil companies with requirements that apply to oil and gas operations, while avoiding the onshore market that doesn't have that influence.
The JAR-OPS Flight Safety & Accident Prevention Programme is a joke - most authorities only apply it as rule that gives an excuse to employ a nearly-retired pilot to learn how file safety reports. Its not a patch on the SMS approach that most of the oil comapany majors now require and still doesn't include even basic things like health monitoring programmes.
You only have to look at a recent CAA Flight Ops missive to show how confused regulators can be. That document had three sets of 'recommendations' following 2 recent helicopter accidents. One just suggests operators should 'consider' doing something. One suggests that though certain operators are not required to do something they should discharge a 'duty of care' over the issue and effectively do it some of the time, and the third says operators should 'review' an issue by a specific date.
Join Date: Jun 2002
Location: home and abroad
Posts: 582
Likes: 0
Received 0 Likes
on
0 Posts
It is my understanding that in the UK a company and its CEO can be held responsible for corporate manslaughter if an accident occurs and it can be proven that the company did not take enough action to reduce the risks as much as is reasonably practical. The company will apparently have to produce evidence that states that it did consider the risks and the cost of reducing the risk and the residual risk and danger.
That seems quite a large stick to get companies moving in the direction of safer operations, as the CEO can actually end up in jail after an accident with a company helicopter. That will help against the grey suit syndrome.
That seems quite a large stick to get companies moving in the direction of safer operations, as the CEO can actually end up in jail after an accident with a company helicopter. That will help against the grey suit syndrome.
Join Date: Mar 2002
Location: Canada
Posts: 690
Likes: 0
Received 0 Likes
on
0 Posts
S76Heavy There have been difficulties with actually applying this in practice (eg Herald of Free Enterprise). And certainly all the cases in the UK have been against 'operators' or 'maintainers' never against an OEM.
Even when a problem is known about, compliance times for any necessary AD are agreed with CAA/FAA etc, so if another accident occurs before the fleet is fixed the OEM can point at the aviation authority and claim the timescales were government approved.
But I hope you are right!
Even when a problem is known about, compliance times for any necessary AD are agreed with CAA/FAA etc, so if another accident occurs before the fleet is fixed the OEM can point at the aviation authority and claim the timescales were government approved.
But I hope you are right!
Join Date: Jul 2003
Location: australia
Posts: 174
Likes: 0
Received 0 Likes
on
0 Posts
Any speculation into the 407 accident near Mackay may be put to rest very soon.
Don't be surprised to hear the words " massive component failure" from the ATSB by monday.
Most of the aircraft has been recovered less the engine and tail rotor so far. The main rotor system and trannie have been found.
Don't be surprised to hear the words " massive component failure" from the ATSB by monday.
Most of the aircraft has been recovered less the engine and tail rotor so far. The main rotor system and trannie have been found.
Join Date: Oct 2001
Location: 48 Deg South
Posts: 764
Likes: 0
Received 0 Likes
on
0 Posts
Dont be so sure. I spoke to my sources and they said that their opinion is that is a case of Spatial Disorientation and that Andy got a case of the "leans".
ATC tracking seems to back up their theories from what I am told but time will tell. I knew Andy and would be the last to say its pilot error, but I also trust my sources and they do accident investigation as a business.
I hope your theory is right but lets wait and see. One of us should be on the right track.
ATC tracking seems to back up their theories from what I am told but time will tell. I knew Andy and would be the last to say its pilot error, but I also trust my sources and they do accident investigation as a business.
I hope your theory is right but lets wait and see. One of us should be on the right track.
Autorotate,
It may be a good time to remove the "evil grin" as your signature. It isn't always a good/relevant response to some of the threads/posts that you make.
Just MHO.
It may be a good time to remove the "evil grin" as your signature. It isn't always a good/relevant response to some of the threads/posts that you make.
Just MHO.
Join Date: Jun 2001
Location: Oz
Posts: 124
Likes: 0
Received 0 Likes
on
0 Posts
John and crusty,
I couldn't agree more. It would seem that this type of thing brings out the worst in people and I think these ghouls need to take a long, hard look at themselves.
I couldn't agree more. It would seem that this type of thing brings out the worst in people and I think these ghouls need to take a long, hard look at themselves.
Join Date: Jul 2002
Location: Eastcoast
Posts: 18
Likes: 0
Received 0 Likes
on
0 Posts
Autorotate, Don't you think it's a tad un-ethical for your `sources' to be disclosing their `hunch' to you so you can blurt out it out on the www?
Until the report is complete (when all the components are located & inspected), it is pure speculation that the pilot suffered the `leans'. How would your source really know that Spatial Disorientation' was the case?
You astound me, your posts tell us how good a fellow this Andy Carpenter was and yet you are very willing to speculate and discredit a dead man. Nice one, friends like you, who needs enemies? Get a life. Let the investigation run its course, I'm sure your text-message buddy will let you know the outcome as soon as he can.
Until the report is complete (when all the components are located & inspected), it is pure speculation that the pilot suffered the `leans'. How would your source really know that Spatial Disorientation' was the case?
You astound me, your posts tell us how good a fellow this Andy Carpenter was and yet you are very willing to speculate and discredit a dead man. Nice one, friends like you, who needs enemies? Get a life. Let the investigation run its course, I'm sure your text-message buddy will let you know the outcome as soon as he can.
Join Date: Oct 2001
Location: 48 Deg South
Posts: 764
Likes: 0
Received 0 Likes
on
0 Posts
Deeper can say that something could be announced about major component failure and you say nothing. I make my comment and you insult me, certainly double standards there sunshine. First off I mentioned to my contact I was going to post his Opinion, not facts, but opinion, and he was happy with that.
Saying that it could be spatial disorientation is not discrediting Andy, its saying what caused the accident. I have since spoken to guys with many thousands of hours more than Andy who admit they have also had cases of the leans, so it can happen to anyone.
And with regards to your personal insults, simple, shove them up your ass. Have a nice day.
Saying that it could be spatial disorientation is not discrediting Andy, its saying what caused the accident. I have since spoken to guys with many thousands of hours more than Andy who admit they have also had cases of the leans, so it can happen to anyone.
And with regards to your personal insults, simple, shove them up your ass. Have a nice day.
Join Date: Jun 2002
Location: home and abroad
Posts: 582
Likes: 0
Received 0 Likes
on
0 Posts
I agree with Autorotate, every pilot has made mistakes and will make more. I certainly had my hairy moments, I'm not too proud to admit. Even birds make mistakes sometimes.
We all try to avoid the fatal one, and we have to put ourselves in a position where we are less likely to make that fatal mistake. For we're all human, and humans will fail.
We should therefore have proper redundancy in either crew, equipment or both for the missions at hand. From what I read about this mission, there was not. Perhaps it did not cause the accident, but it surely contributed to the workload.
We all try to avoid the fatal one, and we have to put ourselves in a position where we are less likely to make that fatal mistake. For we're all human, and humans will fail.
We should therefore have proper redundancy in either crew, equipment or both for the missions at hand. From what I read about this mission, there was not. Perhaps it did not cause the accident, but it surely contributed to the workload.
Join Date: Jan 2001
Location: Chilliwack, BC Canada
Posts: 564
Likes: 0
Received 0 Likes
on
0 Posts
I certainly see some double standards being displayed here, "Deeper" can go out on a limb with that slanderous statement against Bell, whereas Autorotate can not also offer up his thoughts even with the covering statement "I hope your theory is right but lets wait and see".
Nice bunch here ! , well posted Autorotate.
Nice bunch here ! , well posted Autorotate.