NTSB Report on ERA S-76 CFIT
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NTSB Report on ERA S-76 CFIT
As usual....the NTSB points out how the FAA continues to ignore the Helicopter Industry
The last radar track data showed the aircraft in a steady state 120 FPM rate of descent for an extended period prior to impact.
The Helicopter Industry response will be...."Who's going to pay for this new kit?" (As if they cannot raise rates!)
OR IMMEDIATE RELEASE: March 7, 2006 SB-06-13
NTSB CALLS FOR TERRAIN COLLISION AVOIDANCE SYSTEMS FOR ALL TURBINE POWERED HELICOPTERS THAT CARRY AT LEAST 6 PASSENGERS
WASHINGTON, D.C. - The National Transportation Safety Board today called on the Federal Aviation Administration to require all U.S.-registered turbine-powered helicopters certificated to carry at least 6 passengers to be equipped with a terrain awareness and warning system. The recommendation is one of five contained in the final report of a fatal helicopter accident in the Gulf of Mexico.
On March 23, 2004, an Era Aviation Sikorsky S-76A++ helicopter, N579EH, crashed into the Gulf of Mexico at about 7:18 p.m., 70 nautical miles south-southeast of Galveston, Texas. Although visual meteorological conditions existed, it was a dark night with very few external visual cues. The aircraft was transporting eight oil service personnel to the Transocean drilling ship Discoverer Spirit; they and the two pilots perished in the crash.
The Board determined that the probable cause of the accident was the flight crew's failure to identify and arrest the helicopter's descent for undetermined reasons, which resulted in controlled flight into the water.
"A terrain warning system would have given the pilots enough time to arrest their descent and save the lives of all aboard," NTSB Acting Chairman Mark V. Rosenker said. "It is well past time for the benefits from these standard safety devices to be made available to passengers on helicopter transports as they are on fixed wing planes. More than 2 million passengers are carried on Gulf of Mexico oil industry operations alone."
The aircraft was not equipped with a flight data recorder, and the cockpit voice recorder was improperly installed, rendering the recording almost unusable. The Board, therefore, could not determine the sequence of events that led to the helicopter's inadvertent descent. However, since cockpit instrumentation was available to the pilots, the Board concluded that the flight crew was not adequately monitoring the helicopter's altitude and missed numerous cues to indicate that the aircraft was descending toward the water.
The Board noted that when the FAA required TAWS (terrain awareness and warning system) for airplanes having 6 or more passengers in 2000, the technology had not been developed for the unique characteristics of helicopter flight. However, TAWS technology is now available for helicopter flight and should be required, the Board said.
[BIn 2003, the FAA exempted S-76A and several other helicopter models from its requirement that they be equipped with flight data recorders. In an earlier letter to Era, the FAA had stated that exempting the helicopters from the FDR requirement "would be in the public interest and would not adversely affect safety."[/B]
The Board disagreed with that assessment, stating, "because the information that investigators learn from FDR data can help prevent accidents and incidents from recurring, the lack of FDRs aboard helicopters undoubtedly affects safety." The NTSB noted that it had participated in the investigation of another S-76 helicopter crash in Estonia. This was the first accident known to involve a large helicopter for which FDR data was available. Those data were extremely valuable to investigators, the Board said. The lack of FDR data significantly hampered the Era investigation, the Board said, and it urged the FAA to require FDRs on commercial helicopters such as the one involved in the Gulf of Mexico crash.
The Board also recommended that cockpit voice recorders on aircraft be functionally checked before the first flight of each day and that a periodic maintenance check be accomplished as part of the approved maintenance check of the aircraft.
Other recommendations to the FAA dealt with expedited implementation of an initiative to improve flight following where traditional radar coverage doesn't exist, such as in portions of Alaska and the Gulf of Mexico, and with proper training for certain flight control systems.
A summary of the Board's findings is available on the Board's website, www.ntsb.gov, under "Publications." The entire accident report will appear on the website in several
weeks.
NTSB Media Contact: Ted Lopatkiewicz, (202) 314-6100, [email protected]
The last radar track data showed the aircraft in a steady state 120 FPM rate of descent for an extended period prior to impact.
The Helicopter Industry response will be...."Who's going to pay for this new kit?" (As if they cannot raise rates!)
OR IMMEDIATE RELEASE: March 7, 2006 SB-06-13
NTSB CALLS FOR TERRAIN COLLISION AVOIDANCE SYSTEMS FOR ALL TURBINE POWERED HELICOPTERS THAT CARRY AT LEAST 6 PASSENGERS
WASHINGTON, D.C. - The National Transportation Safety Board today called on the Federal Aviation Administration to require all U.S.-registered turbine-powered helicopters certificated to carry at least 6 passengers to be equipped with a terrain awareness and warning system. The recommendation is one of five contained in the final report of a fatal helicopter accident in the Gulf of Mexico.
On March 23, 2004, an Era Aviation Sikorsky S-76A++ helicopter, N579EH, crashed into the Gulf of Mexico at about 7:18 p.m., 70 nautical miles south-southeast of Galveston, Texas. Although visual meteorological conditions existed, it was a dark night with very few external visual cues. The aircraft was transporting eight oil service personnel to the Transocean drilling ship Discoverer Spirit; they and the two pilots perished in the crash.
The Board determined that the probable cause of the accident was the flight crew's failure to identify and arrest the helicopter's descent for undetermined reasons, which resulted in controlled flight into the water.
"A terrain warning system would have given the pilots enough time to arrest their descent and save the lives of all aboard," NTSB Acting Chairman Mark V. Rosenker said. "It is well past time for the benefits from these standard safety devices to be made available to passengers on helicopter transports as they are on fixed wing planes. More than 2 million passengers are carried on Gulf of Mexico oil industry operations alone."
The aircraft was not equipped with a flight data recorder, and the cockpit voice recorder was improperly installed, rendering the recording almost unusable. The Board, therefore, could not determine the sequence of events that led to the helicopter's inadvertent descent. However, since cockpit instrumentation was available to the pilots, the Board concluded that the flight crew was not adequately monitoring the helicopter's altitude and missed numerous cues to indicate that the aircraft was descending toward the water.
The Board noted that when the FAA required TAWS (terrain awareness and warning system) for airplanes having 6 or more passengers in 2000, the technology had not been developed for the unique characteristics of helicopter flight. However, TAWS technology is now available for helicopter flight and should be required, the Board said.
[BIn 2003, the FAA exempted S-76A and several other helicopter models from its requirement that they be equipped with flight data recorders. In an earlier letter to Era, the FAA had stated that exempting the helicopters from the FDR requirement "would be in the public interest and would not adversely affect safety."[/B]
The Board disagreed with that assessment, stating, "because the information that investigators learn from FDR data can help prevent accidents and incidents from recurring, the lack of FDRs aboard helicopters undoubtedly affects safety." The NTSB noted that it had participated in the investigation of another S-76 helicopter crash in Estonia. This was the first accident known to involve a large helicopter for which FDR data was available. Those data were extremely valuable to investigators, the Board said. The lack of FDR data significantly hampered the Era investigation, the Board said, and it urged the FAA to require FDRs on commercial helicopters such as the one involved in the Gulf of Mexico crash.
The Board also recommended that cockpit voice recorders on aircraft be functionally checked before the first flight of each day and that a periodic maintenance check be accomplished as part of the approved maintenance check of the aircraft.
Other recommendations to the FAA dealt with expedited implementation of an initiative to improve flight following where traditional radar coverage doesn't exist, such as in portions of Alaska and the Gulf of Mexico, and with proper training for certain flight control systems.
A summary of the Board's findings is available on the Board's website, www.ntsb.gov, under "Publications." The entire accident report will appear on the website in several
weeks.
NTSB Media Contact: Ted Lopatkiewicz, (202) 314-6100, [email protected]
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A simple AVAD which costs little and has been in use for 25 years on the North Sea could have prevented this accident, even if the bug was improperly set, the 100' warning would have sounded.
Sikorsky has now made EGPWS standard in all new aircraft, at least they are adopting a responsible approach to the problem.
Its sad that operators have not used the experience gained by their European ownerhip exercises past and present (ERA - KLM, OLOG - Bristow) to take the good operational equipment and techniques and apply them to their GOM fleets. Lives have been lost because of lessons not learned.
Incorrectly installed or unserviceable CVRs are not unheard of, a recent fatal fixed wing accident in Australia also involved an aircraft with an unserviceable CVR. Maintenance intervals and function checking procedures should be revised. Simply pressing a button and a meter going into the "green" is not enough.
Monthly integrity checks of CVR recordings should be an integral part of Operations and Maintenance QA.
HH
Sikorsky has now made EGPWS standard in all new aircraft, at least they are adopting a responsible approach to the problem.
Its sad that operators have not used the experience gained by their European ownerhip exercises past and present (ERA - KLM, OLOG - Bristow) to take the good operational equipment and techniques and apply them to their GOM fleets. Lives have been lost because of lessons not learned.
Incorrectly installed or unserviceable CVRs are not unheard of, a recent fatal fixed wing accident in Australia also involved an aircraft with an unserviceable CVR. Maintenance intervals and function checking procedures should be revised. Simply pressing a button and a meter going into the "green" is not enough.
Monthly integrity checks of CVR recordings should be an integral part of Operations and Maintenance QA.
HH
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Don't helicopters have altimeters?
Two pilots, two altimeters what were they doing? Being overwater they should have been more vigiliant.
Now Joe JetLonger ranger will probably have to spend $25,000 to $50,000 to keep his heli legal.
Two pilots, two altimeters what were they doing? Being overwater they should have been more vigiliant.
Now Joe JetLonger ranger will probably have to spend $25,000 to $50,000 to keep his heli legal.
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ATPMBA,
Good idea, blame the pilots - until its your turn to buy the farm. It is about time that we stop finding out how 5,000 hour pilots with 10 years experience "screw up" and instead admit that the job we do is very tough, and even the slightest mistake can be fatal. We must stop trying to slap more training band-aids onto this dead horse and instead accept and encourage the improvements that actually work, even at the paltry sums you find abhorant. If we do not, we are destined to be a small-potatoes piece of the industry beacise nobody can trust us to bring them home often enough. BTW, you are paying for the improvements right now, but the payment goes to lawyers and insurance companies instead of your cockpit.
I love the typical pprune attitude - add a few more engines, make the seats more comfortable and THEN we will have a real helicopter. Oh, yea, and when an accident happens, blame the pilot and train harder.
If we simply study what actually happens to our machines and fix these problems with existing technology, we will improve our statistics (which are about 5 times worse than airplanes) and make us legitimate members of the flying community. Until then (with attitudes like yours, ATPMBA) we will stay a side-show, and not a main attraction.
Good idea, blame the pilots - until its your turn to buy the farm. It is about time that we stop finding out how 5,000 hour pilots with 10 years experience "screw up" and instead admit that the job we do is very tough, and even the slightest mistake can be fatal. We must stop trying to slap more training band-aids onto this dead horse and instead accept and encourage the improvements that actually work, even at the paltry sums you find abhorant. If we do not, we are destined to be a small-potatoes piece of the industry beacise nobody can trust us to bring them home often enough. BTW, you are paying for the improvements right now, but the payment goes to lawyers and insurance companies instead of your cockpit.
I love the typical pprune attitude - add a few more engines, make the seats more comfortable and THEN we will have a real helicopter. Oh, yea, and when an accident happens, blame the pilot and train harder.
If we simply study what actually happens to our machines and fix these problems with existing technology, we will improve our statistics (which are about 5 times worse than airplanes) and make us legitimate members of the flying community. Until then (with attitudes like yours, ATPMBA) we will stay a side-show, and not a main attraction.
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I recently obtained all of Tony Kern's books on flight discipline (no, not that kind of discipline for all you of obvious deviant minds). Why are they not more widely quoted and used?
I'm also quite surprised at the data that points to 25% or so of pilots in helicopters with stabilization equipment and autopilots don't use it, or will revert to hand flying at the first sign of trouble...
Someone said we are 50 years behind the FW community, and I'm beginning to see that as very true.
Comments please from Nick, who has just transferred to the FW community.
I'm also quite surprised at the data that points to 25% or so of pilots in helicopters with stabilization equipment and autopilots don't use it, or will revert to hand flying at the first sign of trouble...
Someone said we are 50 years behind the FW community, and I'm beginning to see that as very true.
Comments please from Nick, who has just transferred to the FW community.
Nick
The pilots in this case must take some of the blame as they had all the information in front of them but failed to notice their gradual descent. During my RAF training, however, we were taught and shown examples of the "chain of circumstances" breaking any link in the chain would have prevented the accident.
In this case, the chain includes:- a/c designers, the operator, the pilots, the FAA and the weather.
The a/c designers for not making a simple AVAD system standard equipment.
The operator for not installing an AVAD system and coupled autopilot if these were only supplied by the manufacturer as optional equipment.
The pilots for not noticing the loss of height or slow rate of descent or for not flying with height hold in if fitted.
The FAA for not insisting that a coupled autopilot and AVAD system be fitted to an offshore helicopter, which flew IFR, and at night.
If the weather had been better or it had been daylight the accident may have been avoided.
If any of those links in the chain had been broken then the accident would have been prevented.
The pilot flying the a/c at the time of the accident is not solely to blame it is all the support services behind the pilot who have to accept a proportion of the blame.
In the UK, we had a similar accident when a S61 enroute to the Scilly Isles in IMC slowly descended until it hit the sea killing some of the passengers. After that event there was a concentrated effort to prevent a further incident and rad alts with height warning bugs/voice calls are now standard on offshore helicopters and most also have a height hold facility.
HF
The pilots in this case must take some of the blame as they had all the information in front of them but failed to notice their gradual descent. During my RAF training, however, we were taught and shown examples of the "chain of circumstances" breaking any link in the chain would have prevented the accident.
In this case, the chain includes:- a/c designers, the operator, the pilots, the FAA and the weather.
The a/c designers for not making a simple AVAD system standard equipment.
The operator for not installing an AVAD system and coupled autopilot if these were only supplied by the manufacturer as optional equipment.
The pilots for not noticing the loss of height or slow rate of descent or for not flying with height hold in if fitted.
The FAA for not insisting that a coupled autopilot and AVAD system be fitted to an offshore helicopter, which flew IFR, and at night.
If the weather had been better or it had been daylight the accident may have been avoided.
If any of those links in the chain had been broken then the accident would have been prevented.
The pilot flying the a/c at the time of the accident is not solely to blame it is all the support services behind the pilot who have to accept a proportion of the blame.
In the UK, we had a similar accident when a S61 enroute to the Scilly Isles in IMC slowly descended until it hit the sea killing some of the passengers. After that event there was a concentrated effort to prevent a further incident and rad alts with height warning bugs/voice calls are now standard on offshore helicopters and most also have a height hold facility.
HF
The answer to accidents lies in a bit of both. Yes technology can help but crew training, CRM and procedures also play a big part in it. A TAWS or basic AVAD / RADALT set up is useless if improperly used or not monitored - accidents continue to happen. We will never know why the pilots failed to pick up the ROD and yes, people do make mistakes. A technology bandaid alone will not fix it and we do have to ask why a crew did what they did to refine the training , CRM and procedures.
Thread Starter
Nick has a point and I usually am the first to complain about accident reports that cannot explain the cause of a crash that kills the pilots and then goes on to "blame" the pilots.
This is just another of those occasions I fear. It is evident the pilots played a role in the final outcome...the aircraft flew into the water. There was no distress call, report of a malfunction, and the circumstantial evidence fails to point to anything other than CFIT.
I look at this tragedy as I do most...what can we learn from it...and how do we prevent another one from occurring (if at all possible).
One does not have to go very far to wonder how long the CVR had been installed incorrectly and seemingly inoperative since that point in time. If it had been tested and been working correctly, the investigators would have had a much better chance to track the crew's actions for the half hour prior to the accident and maybe know what configuration the autopilot and RadAlts were in and what the pilots were doing...or not doing as the case might be.
What could the pilots have done that would have set them up for this to happen? Did the investigators interview other crewmembers and determine how the PIC/SIC normally operated the aircraft....autopilot configuration, RadAlt setting procedures...altitude callouts and such. Was there a discussion of the approved procedures that would surface a potential problem in the cockpit procedures used by the company?
The company in question is in the process of merging two company operations into one.....did that play a role in this accident? Did the NTSB review training procedures and crewing decisions to see if there are any systemic problems in that regard? With recent shuffling and reassignment of personnel in the Chief Pilot, Training Department, and Base Management...did effective training take place or did something happen in all that turmoil?
What was the maintenance history of the aircraft? Any autopilot problems in the past? RadAlt problems? What was the deferred defects for the aircraft?
For Nick's sake, even if we accept it was Pilot Error.....the question has to be....what was it....and how did it happen to a very qualified and experienced crew?
For the dead pilots sake, did the NTSB, FAA, and other investigators merely pick over the carcass of the helicopter and only the information directly linked to the event or did they look at it with a view to determine the total situation that applied to the environment that the flight took place in, and consider ALL of the possible factors?
What does AVAD cost for a S-76? That alone could have prevented this one in all liklihood. That one last backup system that makes up for a human mistake sure seems cheap insurance after the fact.
This is just another of those occasions I fear. It is evident the pilots played a role in the final outcome...the aircraft flew into the water. There was no distress call, report of a malfunction, and the circumstantial evidence fails to point to anything other than CFIT.
I look at this tragedy as I do most...what can we learn from it...and how do we prevent another one from occurring (if at all possible).
One does not have to go very far to wonder how long the CVR had been installed incorrectly and seemingly inoperative since that point in time. If it had been tested and been working correctly, the investigators would have had a much better chance to track the crew's actions for the half hour prior to the accident and maybe know what configuration the autopilot and RadAlts were in and what the pilots were doing...or not doing as the case might be.
What could the pilots have done that would have set them up for this to happen? Did the investigators interview other crewmembers and determine how the PIC/SIC normally operated the aircraft....autopilot configuration, RadAlt setting procedures...altitude callouts and such. Was there a discussion of the approved procedures that would surface a potential problem in the cockpit procedures used by the company?
The company in question is in the process of merging two company operations into one.....did that play a role in this accident? Did the NTSB review training procedures and crewing decisions to see if there are any systemic problems in that regard? With recent shuffling and reassignment of personnel in the Chief Pilot, Training Department, and Base Management...did effective training take place or did something happen in all that turmoil?
What was the maintenance history of the aircraft? Any autopilot problems in the past? RadAlt problems? What was the deferred defects for the aircraft?
For Nick's sake, even if we accept it was Pilot Error.....the question has to be....what was it....and how did it happen to a very qualified and experienced crew?
For the dead pilots sake, did the NTSB, FAA, and other investigators merely pick over the carcass of the helicopter and only the information directly linked to the event or did they look at it with a view to determine the total situation that applied to the environment that the flight took place in, and consider ALL of the possible factors?
What does AVAD cost for a S-76? That alone could have prevented this one in all liklihood. That one last backup system that makes up for a human mistake sure seems cheap insurance after the fact.
I once took a 76 A++ on a ferry flight after a long period of deep maintenance following its delivery to the UK from the USA by ship. During the final stages of its reconstruction it was interesting to observe that no AVAD or radalt was fitted, nor a cyclic stick guard. Initial requests were turned down due to costs. It was pointed out that the contractural requirements might require an AVAD, so that sorted that one (made a mess of the new paintwork, fitting the radalt !), and the engineers fitted the stick guard anyway, without telling anyone! I'm sure that wouldn't happen now, I hope.
I fully agree with the sentiments about TAWS systems, but would hesitate to push the AVAD system too enthusiastically; if you actually look at the CFIT accidents offshore, involving AVAD equiped a/c, it is clear it did little to stop the descents (Fulmer 76, Cormorant 332, KLM 76, Australian BHL 332 etc.) The correct way to go forward has to be the EGPWS; it really is an impressive prompt!
I also agree with the sentiments about discipline; I think that in general the Fixed Wing world are ahead of us in that regard. They have a far more rigid system of SOPs and standardisation. Finally, it doesn't matter how you word the arguments or aportion blame, at the end of the day, if you spend a few moments scanning your flight instruments, every few minutes or so, you will avoid inadvertent descent.
We often say to the lay public that, as pilots, the flying isn't the job: it's the mission that we get paid to do, whether it's military, offshore, corporate, ems or whatever, and the flying is a second nature that allows us to achieve the mision.
That's true to a large extent, but first and foremost YOU STILL HAVE TO FLY!!!
I fully agree with the sentiments about TAWS systems, but would hesitate to push the AVAD system too enthusiastically; if you actually look at the CFIT accidents offshore, involving AVAD equiped a/c, it is clear it did little to stop the descents (Fulmer 76, Cormorant 332, KLM 76, Australian BHL 332 etc.) The correct way to go forward has to be the EGPWS; it really is an impressive prompt!
I also agree with the sentiments about discipline; I think that in general the Fixed Wing world are ahead of us in that regard. They have a far more rigid system of SOPs and standardisation. Finally, it doesn't matter how you word the arguments or aportion blame, at the end of the day, if you spend a few moments scanning your flight instruments, every few minutes or so, you will avoid inadvertent descent.
We often say to the lay public that, as pilots, the flying isn't the job: it's the mission that we get paid to do, whether it's military, offshore, corporate, ems or whatever, and the flying is a second nature that allows us to achieve the mision.
That's true to a large extent, but first and foremost YOU STILL HAVE TO FLY!!!
Thread Starter
212man,
I shall ask a rude question .....what operator is so damn cheap that they would buy an S76A++ and NOT put a RadAlt on the thing (in this day and time)?
Probably the very same outfit that would have the S76A running around the GOM haulling passengers without any Stab or Instruments beyond the very basic panel that comes with a "Green" aircraft from the factory. That was caused by the backlog at Heli-Dyne for completions.
Can we agree that is an indicator of what the standards "used to be" in the GOM years ago and that is the mindset that has to be excised from our industry?
Granted I can recall having three BarAlts and no RadAlt on the North Sea despite flying in Norwegian waters in the same airspace that Helikopter Services flew in using RadAlts for altitude control. Thus we ponced around using a regional QNH setting in the same airspace as opposing traffic did using a more accurate method of determining height although our reference datum was different from theirs.
I shall ask a rude question .....what operator is so damn cheap that they would buy an S76A++ and NOT put a RadAlt on the thing (in this day and time)?
Probably the very same outfit that would have the S76A running around the GOM haulling passengers without any Stab or Instruments beyond the very basic panel that comes with a "Green" aircraft from the factory. That was caused by the backlog at Heli-Dyne for completions.
Can we agree that is an indicator of what the standards "used to be" in the GOM years ago and that is the mindset that has to be excised from our industry?
Granted I can recall having three BarAlts and no RadAlt on the North Sea despite flying in Norwegian waters in the same airspace that Helikopter Services flew in using RadAlts for altitude control. Thus we ponced around using a regional QNH setting in the same airspace as opposing traffic did using a more accurate method of determining height although our reference datum was different from theirs.
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What I find amazing is that GOM operators fly approximately 400,000 hours a year, 300,000 in single engine helicopters. Given engine[only] failure rates of 1 per 100,000; that assures that at least 3 single engine aircraft a year will be bobbing around on their floats.
To answer your question
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To avoid confusion, let me restate my observation:
Any endevor where crews of 5,000 hour people with 20 years experience regularly produce an accident rate 20 times higher than commercial airlines needs serious attention to all aspects. If you had an elevator with that track record, you'd take the stairs. If you had canned goods that harmed you that often, the Government would drive you out of business.
When you get to the point where "Blame" is how you characterize the way to solve the problem, you are doomed to fail. The "Right Stuff" is a term coined by Tom Wolf to describe the rationalization that test pilots use to decide how the job itself was not dangerous, it was those only those fools who lacked the "right stuff" that died.
Forget blaming the crew, start finding out how to better the system. When pilots just harumph and say "pilot error" they HELP the operators and regulators perpetuate the system we have, and they prevent any improvements beyond more training and more rules (with the same accident rate). When we pilots EXPECT perfection from ourselves to succeed then we help perpetuate the system that we have.
Go ahead, say "Pilot Error" and think that solves the problem. It only explains the crash, with the same accuracy and precision as if you had said "hydrodynamic impact forces".
The fellow in a hot air balloon call down to an old geezer, "Where am I?" he asked. The geezer answered, "You're in a b'loon, ya damn fool!" Same precision and accuracy, but no solution to the problem at all.
Gentlemen, solve the problem, do not jump into the same old rut.
Any endevor where crews of 5,000 hour people with 20 years experience regularly produce an accident rate 20 times higher than commercial airlines needs serious attention to all aspects. If you had an elevator with that track record, you'd take the stairs. If you had canned goods that harmed you that often, the Government would drive you out of business.
When you get to the point where "Blame" is how you characterize the way to solve the problem, you are doomed to fail. The "Right Stuff" is a term coined by Tom Wolf to describe the rationalization that test pilots use to decide how the job itself was not dangerous, it was those only those fools who lacked the "right stuff" that died.
Forget blaming the crew, start finding out how to better the system. When pilots just harumph and say "pilot error" they HELP the operators and regulators perpetuate the system we have, and they prevent any improvements beyond more training and more rules (with the same accident rate). When we pilots EXPECT perfection from ourselves to succeed then we help perpetuate the system that we have.
Go ahead, say "Pilot Error" and think that solves the problem. It only explains the crash, with the same accuracy and precision as if you had said "hydrodynamic impact forces".
The fellow in a hot air balloon call down to an old geezer, "Where am I?" he asked. The geezer answered, "You're in a b'loon, ya damn fool!" Same precision and accuracy, but no solution to the problem at all.
Gentlemen, solve the problem, do not jump into the same old rut.
Thread Starter
Any endevor where crews of 5,000 hour people with 20 years experience regularly produce an accident rate 20 times higher than commercial airlines needs serious attention to all aspects. If you had an elevator with that track record, you'd take the stairs. If you had canned goods that harmed you that often, the Government would drive you out of business.
IHL points out a mindset and way of doing business that confirms part of the mindset that suggests the helicopter industry in the GOM still suffers from the Bob Suggs School of Management attitude.
Bladebanger's post suggests some of our bad habits have spread to Oz.
As long as the helicopter industry has a hire and fire mentality, Nick...things are not going to change. Try to stand up to yer boss fellah and tell him how to run his private railroad and see how long you last.
As one of our posters has said...."One becomes 'known" in the industry.". That same poster also said folks that were Gypsies were not good candidates for hire.
I would suggest Nick, that is the part of the industry that needs changing....the old Bobby Suggs bunch that refuse to accept the fact "people" are the key to success of a business and not just the senior management pukes.
Has the FAA ever taken certificate action against an operator in the GOM or the EMS industry? Ever...at any time?
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It is not a management problem, nor is it a pilot problem. Read the posts above, PILOTS get out the rubber stamp, put the accident in the right bin, and then go about their business as if they solved the cause.
The problem I am discussing is that the entire industry is shackled by its inability to seek technical solutions to technical problems.
I am in the business of building stuff, so when a problem is found, we FIX it. If my company lost 2% of its products coming down the assembly line due to a single cause, and we had tried unsuccessfully for years to train that problem out or the workforce, we would do something ELSE to FIX the problem.
Most management wouldn't fail to fix the problem, it is the pilots who I place most of the burden on, since they do not even ask for the fixes. Look at the series of posts on pprune where I perposely ask for safety improvement ideas, and every dumb bastard asks for more OEI safety, in spite of the fact that it is CFIT that gets us. Only when pilots connect the dots will there be solutions, but pilots are so busy believing they are infallable that they REFUSE to consider solutions where they are helped in their job. Otherwise, we would be screaming for helo airways, helo approaches, EGPWS and many other similar technical solutions.
The problem I am discussing is that the entire industry is shackled by its inability to seek technical solutions to technical problems.
I am in the business of building stuff, so when a problem is found, we FIX it. If my company lost 2% of its products coming down the assembly line due to a single cause, and we had tried unsuccessfully for years to train that problem out or the workforce, we would do something ELSE to FIX the problem.
Most management wouldn't fail to fix the problem, it is the pilots who I place most of the burden on, since they do not even ask for the fixes. Look at the series of posts on pprune where I perposely ask for safety improvement ideas, and every dumb bastard asks for more OEI safety, in spite of the fact that it is CFIT that gets us. Only when pilots connect the dots will there be solutions, but pilots are so busy believing they are infallable that they REFUSE to consider solutions where they are helped in their job. Otherwise, we would be screaming for helo airways, helo approaches, EGPWS and many other similar technical solutions.
Thread Starter
Nick,
Why would Sikorsky build a 76 and not make a RadAlt a basic instrument package item?
Immediate answer will be....ah..it is a customer option.
Next question....why would an operator buy a 76 and not install a RadAlt?
Are you telling us the pilots driving the thing don't ask for the RadAlt?
If the pilot's ask for equipment and the operator does not install it....then what Nick? Strike action or something?
Sounds like you are on the side that thinks accidents are "pilot error" even if only through acquiesence as a subset of the aviation population.
Why would Sikorsky build a 76 and not make a RadAlt a basic instrument package item?
Immediate answer will be....ah..it is a customer option.
Next question....why would an operator buy a 76 and not install a RadAlt?
Are you telling us the pilots driving the thing don't ask for the RadAlt?
If the pilot's ask for equipment and the operator does not install it....then what Nick? Strike action or something?
Sounds like you are on the side that thinks accidents are "pilot error" even if only through acquiesence as a subset of the aviation population.
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nick Lappos
I'm with you, may i remind people that it is not all that long ago that a certain RPT F/W perambulated for a lengthy time in an unstable state, prior to a bad time and it turned out to be nothing more than a patch over the static vents which played havoc with all of the aneroids.
I wouldn't go too hard on the drivers, especially if they were in a basic machine,--- dark night --- all that! ASI, -- yeah but -- weaving a bit -- but maybe ok, VSI not moving, both alt's not moving!!
I wouldn't go too hard on the drivers, especially if they were in a basic machine,--- dark night --- all that! ASI, -- yeah but -- weaving a bit -- but maybe ok, VSI not moving, both alt's not moving!!
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SASless,
To my knowledge, NO S76 was ever delivered without a rad alt, it is part of the baseline cockpit, paid with the sales price, and it would cost more to take it out for 1 operator! The rad alt has settable low altitude warning lights. The one reported here might have been modified in the field. I also find it interesting that instead of discussing the point, you try lamely to attack me or the company I worked for as if that explains the problem! Sad try. What about the basic point I make?
topendtorque,
I have no idea what you are saying, is it that you speculate that all 5 altimeters in the aircraft were stuck? Not likely. You say I should not be so hard on the drivers, which means you completely miss my point. I am not hard on those pilots in the aircraft, I am being hard on those pilots on the ground at pprune and elsewhere who decide as long as it is "pilot error" the solution is found and the problem goes away.
We must all work to make BETTER helos and better airspace systems, so that we can eliminate all pilot error accidents at the source (i.e. improve the difficult task) and not at the convenient end point (the dead pilot).
To my knowledge, NO S76 was ever delivered without a rad alt, it is part of the baseline cockpit, paid with the sales price, and it would cost more to take it out for 1 operator! The rad alt has settable low altitude warning lights. The one reported here might have been modified in the field. I also find it interesting that instead of discussing the point, you try lamely to attack me or the company I worked for as if that explains the problem! Sad try. What about the basic point I make?
topendtorque,
I have no idea what you are saying, is it that you speculate that all 5 altimeters in the aircraft were stuck? Not likely. You say I should not be so hard on the drivers, which means you completely miss my point. I am not hard on those pilots in the aircraft, I am being hard on those pilots on the ground at pprune and elsewhere who decide as long as it is "pilot error" the solution is found and the problem goes away.
We must all work to make BETTER helos and better airspace systems, so that we can eliminate all pilot error accidents at the source (i.e. improve the difficult task) and not at the convenient end point (the dead pilot).
Last edited by NickLappos; 9th Mar 2006 at 14:39.
Thread Starter
Nick,
This time you are wrong on at least two counts.
The Air Log machines that first got delivered were "green" and had only the basic flight instruments and a standby attitude indicator. The completions were done at Heli-Dyne in Ft. Worth and IFR kit was installed there. Air Log pilots had to fly the aircraft without SAS or a proper set of instruments when the company ran into a backlog at the Heli-Dyne completion center.
This was in the days when Sikorsky was selling the 76 with the organic in-house SAS system and Air Log wanted the Sperry system. You do remember the phase I, II, and III SAS system configurations.
The aircraft were sold that way at the request of the customer.
Vice what you suggest, I am not "attacking" Sikorsky or you. Simple fact remains that manufacturers will sell the aircraft as the customer demands. From what you have reported in the past, Sikorsky has taken steps to add some items as basic standard fit and thus customers have to buy the kit.
The Sperry system far exceeded the in-house system in function and thus was the preferred SAS/Autopilot system.
This time you are wrong on at least two counts.
The Air Log machines that first got delivered were "green" and had only the basic flight instruments and a standby attitude indicator. The completions were done at Heli-Dyne in Ft. Worth and IFR kit was installed there. Air Log pilots had to fly the aircraft without SAS or a proper set of instruments when the company ran into a backlog at the Heli-Dyne completion center.
This was in the days when Sikorsky was selling the 76 with the organic in-house SAS system and Air Log wanted the Sperry system. You do remember the phase I, II, and III SAS system configurations.
The aircraft were sold that way at the request of the customer.
Vice what you suggest, I am not "attacking" Sikorsky or you. Simple fact remains that manufacturers will sell the aircraft as the customer demands. From what you have reported in the past, Sikorsky has taken steps to add some items as basic standard fit and thus customers have to buy the kit.
The Sperry system far exceeded the in-house system in function and thus was the preferred SAS/Autopilot system.