AAIB Bulletin: Morecambe Bay
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Accident report
Regulated Safety
Just because it's legal doesn't necessarily mean it is safe of course.
If you have flown a helicopter for a while you instinctively know a certain cyclic displacement will give you a certain pitch rate to achieve a certain change in pitch angle.
I notice that there is no mention of the possibility of refraction due to rain on the windscreen which is well known phenomena. How experienced either pilot was of it is a possible factor that will probably never be known.
Something obviously caught out 2 experienced pilots who had done this type of thing on many occasions before.
(Courtesy Transport Canada)
(Courtesy FAA)
It would appear that the LHS pilot was confused or uncertain about something.
If both pilots were tricked by this phenomena, it is a possibility that the commander in the RHS assumed from the last visual cues he had that they were a lot higher or nose high which could explain the excessive nose down pitch angle.
My personal opinion is that the reason for this accident is more simple than the "findings and contributory factors" that are in the conclusions in the report.
End my 2p.
If you have flown a helicopter for a while you instinctively know a certain cyclic displacement will give you a certain pitch rate to achieve a certain change in pitch angle.
I notice that there is no mention of the possibility of refraction due to rain on the windscreen which is well known phenomena. How experienced either pilot was of it is a possible factor that will probably never be known.
Something obviously caught out 2 experienced pilots who had done this type of thing on many occasions before.
An error in vision can occur when flying in rain. The presence of rain on the windscreen, in addition to causing poor visibility, introduces a refraction error. This error is because of two things: firstly, the reduced transparency of the rain-covered windscreen causes the eye to see a horizon below the true one (because of the eye response to the relative brightness of the upper bright part and the lower dark part); and secondly, the shape and pattern of the ripples formed on the windscreen, particularly on sloping ones, which cause objects to appear lower. The error may be present as a result of one or other of the two causes, or of both, in which case it is cumulative and is of the order of about 5∞ in angle. Therefore, a hilltop or peak 1/2 NM ahead of an aircraft could appear to be approximately 260 ft lower, (230 ft lower at 1/2 SM) than it actually is.
Pilots should remember this additional hazard when flying in conditions of low visibility in rain and should maintain sufficient altitude and take other precautions, as necessary, to allow for the presence of this error. Also, pilots should ensure proper terrain clearance during enroute flight and on final approach to landing.
Pilots should remember this additional hazard when flying in conditions of low visibility in rain and should maintain sufficient altitude and take other precautions, as necessary, to allow for the presence of this error. Also, pilots should ensure proper terrain clearance during enroute flight and on final approach to landing.
FAR AIM
8-1-5. Illusions in Flight
(e) Atmospheric illusions. Rain on the windscreen can create the illusion of greater height, and atmospheric haze the illusion of being at a greater distance from the runway. The pilot who does not recognize these illusions will fly a lower approach. Penetration of fog can create the illusion of pitching up. The pilot who does not recognize this illusion will steepen the approach, often quite abruptly.
8-1-5. Illusions in Flight
(e) Atmospheric illusions. Rain on the windscreen can create the illusion of greater height, and atmospheric haze the illusion of being at a greater distance from the runway. The pilot who does not recognize these illusions will fly a lower approach. Penetration of fog can create the illusion of pitching up. The pilot who does not recognize this illusion will steepen the approach, often quite abruptly.
It would appear that the LHS pilot was confused or uncertain about something.
If both pilots were tricked by this phenomena, it is a possibility that the commander in the RHS assumed from the last visual cues he had that they were a lot higher or nose high which could explain the excessive nose down pitch angle.
My personal opinion is that the reason for this accident is more simple than the "findings and contributory factors" that are in the conclusions in the report.
End my 2p.
Wowzer - where do I start? Its late, so I will start with the easiest out of RVDT punto and mutt and the funny german-sounding one - that's RVDT
Clearly you are not a night offshore pilot - if you were you would realise that as soon as you are into go-around mode, there is no point in looking out of the window - there is nothing to see. Its straight onto instruments. Hopefully not too much rain on the instruments... Yes you might have a point in the bit where the co-pilot was finding difficulty with visual reference, but that is not what caused the crash. The crash was (best guess) caused by the captain's failure to believe what the instruments were telling him.
This is where I move my disagreement onto Buitenzorg - yes the sim is not a great help in training to judge a night offshore approach, but it is a great help in training the other pilot in how and when to take control, and how to execute a go-around on instruments following loss of visual reference, pref. by using the go-around function that would set a sensible pitch attitude to climb away. You are also clearly not an night offshore pilot (in Europe at least) because if you were you would know that from each installation you must have an onshore alternate, therefore they would have had onshore IFR fuel regardless of whether they were flying IFR approaches or night VFR ones. Your comments about the benefits of starting from an instrument approach are based on ignorance of the procedures and environment. You should stick to pontificating about the third interest in your public profile.
Finally punto - you clearly don't know what you are talking about since you seem to be a fixed wing pilot (probably with a type rating on MS flight sim).
None of the above-mentioned gets the point that its not like an airfield approach where you fly the ILS and just keep going below 200' / DH / MDH til you get to the runway.
Lets make no mistake, these guys were very experienced, not stupid and doing their best. Those that haven't flown offshore at night will not realise that there are nights and there are nights. Many nights there is a moon / stars, lights from other installations etc. Those nights where there is absolutely no visual reference once past the installation are in a different league. Only pilots disciplined in instrument flight will survive, and a great training aid in this area is the simulator, despite any limitations it might have for night visual approaches to a rig.
HC
If both pilots were tricked by this phenomena, it is a possibility that the commander in the RHS assumed from the last visual cues he had that they were a lot higher or nose high which could explain the excessive nose down pitch angle.
This is where I move my disagreement onto Buitenzorg - yes the sim is not a great help in training to judge a night offshore approach, but it is a great help in training the other pilot in how and when to take control, and how to execute a go-around on instruments following loss of visual reference, pref. by using the go-around function that would set a sensible pitch attitude to climb away. You are also clearly not an night offshore pilot (in Europe at least) because if you were you would know that from each installation you must have an onshore alternate, therefore they would have had onshore IFR fuel regardless of whether they were flying IFR approaches or night VFR ones. Your comments about the benefits of starting from an instrument approach are based on ignorance of the procedures and environment. You should stick to pontificating about the third interest in your public profile.
Finally punto - you clearly don't know what you are talking about since you seem to be a fixed wing pilot (probably with a type rating on MS flight sim).
None of the above-mentioned gets the point that its not like an airfield approach where you fly the ILS and just keep going below 200' / DH / MDH til you get to the runway.
Lets make no mistake, these guys were very experienced, not stupid and doing their best. Those that haven't flown offshore at night will not realise that there are nights and there are nights. Many nights there is a moon / stars, lights from other installations etc. Those nights where there is absolutely no visual reference once past the installation are in a different league. Only pilots disciplined in instrument flight will survive, and a great training aid in this area is the simulator, despite any limitations it might have for night visual approaches to a rig.
HC
Last edited by HeliComparator; 17th Oct 2008 at 23:17. Reason: to increase criticism of the funny german-sounding one
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Only just saw HeliComparator's reply.
The IFR fuel requirements are the reason we don't file IFR on our off-shore flights (you are correct, not in Europe). Since none of our off-shore platforms have fuel we have to file to return to base (which would be our on-shore alternate for any of the off-shore sectors) plus for an on-shore alternate to our base. Plus of course holding etc. Our usual loads have us going out at close to max weight on VFR flight plans so carrying IFR fuel would make a serious dent in our ability to carry payload and/or make long (multi-sector) flights. The weather tends to be good, allowing us to fly VFR so much of the time that delaying/cancelling the flight program due to IFR conditions is not a problem.
Also, if every approach had been flown as an IAP rather than visual on the mishap flight, that would have added substantially to the flight time, probably 4 mins. per sector on average (if the IAP were to have been flown into the prevailing wind, our company SOP for ARAs). On an 8-sector flight with 7 off-shore approaches that's about 30 mins extra. Extra fuel, less payload. Same fuel, fewer sectors.
With my limited night off-shore experience I have concluded that never was a truer word written than
and indeed that's how we do our night flights, with the PNF remaining on instruments, constantly monitoring and giving verbal cues to the PF, and ready to take the controls for a go-around on instruments. I also agree that
I maintain however, that the aim of this training and discipline should be to position the aircraft at a point, height and airspeed, that will allow a controlled visual descent to the deck (or go-around) and that this point, height and airspeed should be the same every time.
The IFR fuel requirements are the reason we don't file IFR on our off-shore flights (you are correct, not in Europe). Since none of our off-shore platforms have fuel we have to file to return to base (which would be our on-shore alternate for any of the off-shore sectors) plus for an on-shore alternate to our base. Plus of course holding etc. Our usual loads have us going out at close to max weight on VFR flight plans so carrying IFR fuel would make a serious dent in our ability to carry payload and/or make long (multi-sector) flights. The weather tends to be good, allowing us to fly VFR so much of the time that delaying/cancelling the flight program due to IFR conditions is not a problem.
Also, if every approach had been flown as an IAP rather than visual on the mishap flight, that would have added substantially to the flight time, probably 4 mins. per sector on average (if the IAP were to have been flown into the prevailing wind, our company SOP for ARAs). On an 8-sector flight with 7 off-shore approaches that's about 30 mins extra. Extra fuel, less payload. Same fuel, fewer sectors.
With my limited night off-shore experience I have concluded that never was a truer word written than
Only pilots disciplined in instrument flight will survive
a great training aid in this area is the simulator, despite any limitations it might have for night visual approaches to a rig
Buitzenorg, we are getting a bit closer!
However looking at the traces (bearing in mind they start not long before the go-around) I would not say that the approach was unstable. The speed is fairly steady around 50kts or so and the pitch attitude is not eg excessively nose up. Its clear that there is some over-controlling and that presumably is due to disorientation.
The procedure we follow for a night visual approach is to stabilise at a briefed speed and height (min 50kts IAS and deck height + 200'), run in steady and level at that, then lower the collective to make the final approach once the site picture (= helideck ovality) is right. By briefing a tight speed and height, PNF is empowered to prompt/take control if the parameters are deviated from. Its not clear from the report whether CHC have the same policy and whether or not it was adhered to.
In any event, I maintain that we all have off days, we have all become disorientated at night for no obvious reason. That should be a survivable provided we go-around in good time, as was done here. The go-around should have been survivable, that it was not is hard to understand but I can only think it was a failure to fully transfer to instruments and use the AFCS upper modes to their best advantage. That does not mean that Capt was an idiot, but perhaps his company or base culture was not optimised. I have no doubt that appropriate Sim training would have helped.
I also strongly maintain that had the approach started from an instrument approach (terminating at 0.75nm and deck height + 50' or 300') it would have been harder since the heli would have been unnecessarily low and far out (= flat with poor site picture references).
HC
However looking at the traces (bearing in mind they start not long before the go-around) I would not say that the approach was unstable. The speed is fairly steady around 50kts or so and the pitch attitude is not eg excessively nose up. Its clear that there is some over-controlling and that presumably is due to disorientation.
The procedure we follow for a night visual approach is to stabilise at a briefed speed and height (min 50kts IAS and deck height + 200'), run in steady and level at that, then lower the collective to make the final approach once the site picture (= helideck ovality) is right. By briefing a tight speed and height, PNF is empowered to prompt/take control if the parameters are deviated from. Its not clear from the report whether CHC have the same policy and whether or not it was adhered to.
In any event, I maintain that we all have off days, we have all become disorientated at night for no obvious reason. That should be a survivable provided we go-around in good time, as was done here. The go-around should have been survivable, that it was not is hard to understand but I can only think it was a failure to fully transfer to instruments and use the AFCS upper modes to their best advantage. That does not mean that Capt was an idiot, but perhaps his company or base culture was not optimised. I have no doubt that appropriate Sim training would have helped.
I also strongly maintain that had the approach started from an instrument approach (terminating at 0.75nm and deck height + 50' or 300') it would have been harder since the heli would have been unnecessarily low and far out (= flat with poor site picture references).
HC
HC,
Clearly, you have no idea what I do. And I can confirm with you that I am not an offshore night pilot because I choose not to be.
I do operate offshore but my employer listens to me when I tell him we shouldn't do it at night! Yes we do have all the bells and whistles.
Now this is the bit of your statement that I have trouble with -
An experienced offshore captain? Why?
If he didn't believe his instruments, what made him disbelieve them all of a sudden after all these years? What was tying the CP in knots? Why didn't the captain (PNF) call to go around earlier?
My guess is a sucker punch got the pair of them. Sensory illusions in one of it's numerous flavours. They thought they were "visual", but obviously the "visual" was flawed, i.e. due to some phenomena, and the report does state that it would be "challenging".
Remember the ANZ DC-10 that hit Mt Erebus. Visibilty was over 300 miles at the time, it was daylight. The aircraft was "visual" when it hit the mountain. They were not IMC, they just couldn't see it.
In this situation my claim is the cues are not sufficient to be operating VFR (although granted they may be MOST of the time) and you are too slow to be IFR for all the other reasons already stated. What is Vmin IFR on a 365?
What are the criteria and where do they come from that determines that it is "visual" apart from the jockeys in the front seat?
Let me see now -
Dark - check.
No horizon - check.
No approach slope guidance - check.
(Possible) Rain on windscreen causing sensory illusion to both pilots - check.
(Possible) Aircraft below Vmin IFR - check.
Self assessment by crew of "visual" conditions - check.
Of note is that ALL the sensors, electronic or human, are in the aircraft. Nothing independent from the surface! Nothing to tell you in real time that it is possibly not going as well as expected or perceived.
This is possibly responsible for a large majority of preventable offshore accidents to date. Read the Night Flying post. Somewhere the ducks don't line up!
How much is at stake here? What would it take to install either electronic or visual slope guidance on the deck if you want to be responsible about doing this stuff? It would appear so far that it is beyond human intelligence.
It is already accepted that it is not really visual flight as you have somebody backing you up on instruments, although possibly at a speed at which you technically cannot fly IFR.
Let the hellfire and brimstone begin, justify as you see fit, but the numbers won't go away.
HC - can't you feel that bean in your ear? In your own words no less!
Excuse me? What did you say?
Clearly, you have no idea what I do. And I can confirm with you that I am not an offshore night pilot because I choose not to be.
I do operate offshore but my employer listens to me when I tell him we shouldn't do it at night! Yes we do have all the bells and whistles.
Now this is the bit of your statement that I have trouble with -
The crash was (best guess) caused by the captain's failure to believe what the instruments were telling him.
If he didn't believe his instruments, what made him disbelieve them all of a sudden after all these years? What was tying the CP in knots? Why didn't the captain (PNF) call to go around earlier?
My guess is a sucker punch got the pair of them. Sensory illusions in one of it's numerous flavours. They thought they were "visual", but obviously the "visual" was flawed, i.e. due to some phenomena, and the report does state that it would be "challenging".
Remember the ANZ DC-10 that hit Mt Erebus. Visibilty was over 300 miles at the time, it was daylight. The aircraft was "visual" when it hit the mountain. They were not IMC, they just couldn't see it.
In this situation my claim is the cues are not sufficient to be operating VFR (although granted they may be MOST of the time) and you are too slow to be IFR for all the other reasons already stated. What is Vmin IFR on a 365?
What are the criteria and where do they come from that determines that it is "visual" apart from the jockeys in the front seat?
Let me see now -
Dark - check.
No horizon - check.
No approach slope guidance - check.
(Possible) Rain on windscreen causing sensory illusion to both pilots - check.
(Possible) Aircraft below Vmin IFR - check.
Self assessment by crew of "visual" conditions - check.
Of note is that ALL the sensors, electronic or human, are in the aircraft. Nothing independent from the surface! Nothing to tell you in real time that it is possibly not going as well as expected or perceived.
This is possibly responsible for a large majority of preventable offshore accidents to date. Read the Night Flying post. Somewhere the ducks don't line up!
How much is at stake here? What would it take to install either electronic or visual slope guidance on the deck if you want to be responsible about doing this stuff? It would appear so far that it is beyond human intelligence.
It is already accepted that it is not really visual flight as you have somebody backing you up on instruments, although possibly at a speed at which you technically cannot fly IFR.
Let the hellfire and brimstone begin, justify as you see fit, but the numbers won't go away.
HC - can't you feel that bean in your ear? In your own words no less!
In any event, I maintain that we all have off days, we have all become disorientated at night for no obvious reason.
Last edited by RVDT; 18th Oct 2008 at 01:42.
RVDT
In some ways you are right, if we followed your lead and refused to fly at night it would be safer. It would also be safer if we refused to fly when it was a bit cloudy/foggy/windy. It would be even safer if we just locked the hangar door and went home.
You may be able to get your job done by day VFR, but if your job was to fly oil workers out to N Sea installations from Aberdeen in winter where it doesn't get light until 09:30 and its dark again by 15:30 - and when it is daylight you sometimes don't get to see much ground/sea - you would have a serious problem getting your work done. You could argue that the oil companies should pay for enough aircraft and crews to get the job done in daylight, but an alternative strategy is to accept the increased hazard of night flying and have extra training and equipment to level the risk back to another operation's daytime flying. The latter is the chosen strategy whether its right or wrong.
Once again I discount your point about poor visual references because once the go-around was initiated and the rig passed, its unlikely that there were any visual references with which to get confused. More likely a dose of the leans (very powerful disorientator - has to be experienced to be appreciated) possibly as a result of the unusual attitude moments earlier, caused his brain to believe that everything was fine attitude-wise and no need to stare at the instruments too much when there is a co-pilot to be comforted for his loss of confidence.
Yes, this is why we have 2 pilots, why we have aircraft with fancy autopilots, AVAD and why we should practice having to take control in the sim.
HC
In some ways you are right, if we followed your lead and refused to fly at night it would be safer. It would also be safer if we refused to fly when it was a bit cloudy/foggy/windy. It would be even safer if we just locked the hangar door and went home.
You may be able to get your job done by day VFR, but if your job was to fly oil workers out to N Sea installations from Aberdeen in winter where it doesn't get light until 09:30 and its dark again by 15:30 - and when it is daylight you sometimes don't get to see much ground/sea - you would have a serious problem getting your work done. You could argue that the oil companies should pay for enough aircraft and crews to get the job done in daylight, but an alternative strategy is to accept the increased hazard of night flying and have extra training and equipment to level the risk back to another operation's daytime flying. The latter is the chosen strategy whether its right or wrong.
Once again I discount your point about poor visual references because once the go-around was initiated and the rig passed, its unlikely that there were any visual references with which to get confused. More likely a dose of the leans (very powerful disorientator - has to be experienced to be appreciated) possibly as a result of the unusual attitude moments earlier, caused his brain to believe that everything was fine attitude-wise and no need to stare at the instruments too much when there is a co-pilot to be comforted for his loss of confidence.
In any event, I maintain that we all have off days, we have all become disorientated at night for no obvious reason.
HC
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HC.
Leaving aside the personal abuse, the central issue here that we all need to wrestle with is how two thoroughly experienced pilots in a perfectly well equipped machine managed to kill themselves and their passengers. This is precisely the sort of accident where we have to learn something, because there are no other factors to discount.
Some very experienced people, including Nick & Shawn are leaning to the conclusion that attempting to fly this sort of an approach visually IS the problem, no matter how experienced you are.
Now you obviously believe differently
Now with a single button press I was able to ascertain your qualifications (a courtesy you might choose to afford me), and clearly your view deserves respect. But I would (again respectfully) suggest that after this accident, the burden of proof lies with your side of the argument. And the proof won't emerge from a slanging match on PPRUNE, it will come from thorough research into approach aids and design for offshore platforms.
As you yourself have observed:
So once in a blue moon BOTH pilots can have off days, or much more worrying, they can have on days and still be fooled by what they see. Only two guys know what they saw and felt that night, and the tragedy is that they are not here to tell us about it. However those who are here and do have relevant experience (RVDT, Double Bogey) all testify as to how close to the edge this sort of an approach is.
Until a sim is invented that can generate all the illusions that could ever exist, there is a risk. And all the sim work in the world will not help if you are simming an approach which is fundamentally unsafe.
Leaving aside the personal abuse, the central issue here that we all need to wrestle with is how two thoroughly experienced pilots in a perfectly well equipped machine managed to kill themselves and their passengers. This is precisely the sort of accident where we have to learn something, because there are no other factors to discount.
Some very experienced people, including Nick & Shawn are leaning to the conclusion that attempting to fly this sort of an approach visually IS the problem, no matter how experienced you are.
Now you obviously believe differently
None of the above-mentioned gets the point that its not like an airfield approach where you fly the ILS and just keep going below 200' / DH / MDH til you get to the runway.
The type of approach shown in the link is along the same lines as the type of approach mentioned in the report. It wouldn't have helped in this case - in fact maybe made it worse - its harder to transition from an instrument approach that leaves you at 50' above deck height at 0.75 or even 0.5 nm (very flat), to a visual rig landing, than it is to fly the whole approach visually.
The type of approach shown in the link is along the same lines as the type of approach mentioned in the report. It wouldn't have helped in this case - in fact maybe made it worse - its harder to transition from an instrument approach that leaves you at 50' above deck height at 0.75 or even 0.5 nm (very flat), to a visual rig landing, than it is to fly the whole approach visually.
As you yourself have observed:
In any event, I maintain that we all have off days, we have all become disorientated at night for no obvious reason.
Until a sim is invented that can generate all the illusions that could ever exist, there is a risk. And all the sim work in the world will not help if you are simming an approach which is fundamentally unsafe.
Last edited by puntosaurus; 18th Oct 2008 at 05:23.
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No matter what both pilots see through the windscreen it is the duty of the pilot not flying to monitor the instruments and take action should a deviation from a safe profile occur. Action could be a gentle verbal prompt up to taking control and carrying out a go around. As has been said, this lesson is best learned in the simulator not from the death of colleagues. Any bean counter who has turned down simulator training for pilots expected to operate in conditions such as those described in this accident report needs to be prosecuted.
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night flying
Out of all the flight enviroments we deal with in the North Sea, i find the night time offshore approach and landing the most challenging. I think i find it challenging for two main reasons.
1. It is the only type of flying that i have ever done, where the crew is neither flying fully on instruments nor fully visually. Even on an onshore IFR approach to minimums, there is one defined moment where the flight stops being instrument and becomes visual (if not you go around). The HP has a well defined role of staying on instruments, while the NHP has a well defined role of looking out the window to become visual, and then take controls for the final visual segment resulting in the safe landing. The challenge with offshore night time, especailly when cloud is added and no help is to be gained from moonlight, is that there is no such clear boundary between visual reference and instrument reference. The HP is regularly switching between the two to acheive the approach. The NHP is spending more time monitoring the instruments, but will also be glancing out side as the rig becomes more visual to monitor the approach path. If at the very end of the approach the HP is unhappy and decides to go around, he maintians control, and rapidly goes from looking outside at the rig, to going fully IFR and setting his pitch power etc for the go round.
2. The second reason is amount and frequency of training and practice. I get 2 base checks a year - very comprehensive checks of emergency procedures and instrument procedures. I feel very comfortable with these. With the instrument procedures we can easily and regularly practice them flying the line. With offshore night flying we (and by we i mean all offshore pilots in line with the aviation authority regulations) get to demonstrate one night flight, which may have only one night rig landing, per year.
I honestly don't know how to train better for this constant switching between instrument and visual flying, as we have no training devices that enable this to occur. I feel however that if this issue could be dealt with, and we trained as regularly in this grey area of partial visual and partial instrument flying, as we did in the fully instrument enviroment of base checks then that would be of great benefit.
Andy
1. It is the only type of flying that i have ever done, where the crew is neither flying fully on instruments nor fully visually. Even on an onshore IFR approach to minimums, there is one defined moment where the flight stops being instrument and becomes visual (if not you go around). The HP has a well defined role of staying on instruments, while the NHP has a well defined role of looking out the window to become visual, and then take controls for the final visual segment resulting in the safe landing. The challenge with offshore night time, especailly when cloud is added and no help is to be gained from moonlight, is that there is no such clear boundary between visual reference and instrument reference. The HP is regularly switching between the two to acheive the approach. The NHP is spending more time monitoring the instruments, but will also be glancing out side as the rig becomes more visual to monitor the approach path. If at the very end of the approach the HP is unhappy and decides to go around, he maintians control, and rapidly goes from looking outside at the rig, to going fully IFR and setting his pitch power etc for the go round.
2. The second reason is amount and frequency of training and practice. I get 2 base checks a year - very comprehensive checks of emergency procedures and instrument procedures. I feel very comfortable with these. With the instrument procedures we can easily and regularly practice them flying the line. With offshore night flying we (and by we i mean all offshore pilots in line with the aviation authority regulations) get to demonstrate one night flight, which may have only one night rig landing, per year.
I honestly don't know how to train better for this constant switching between instrument and visual flying, as we have no training devices that enable this to occur. I feel however that if this issue could be dealt with, and we trained as regularly in this grey area of partial visual and partial instrument flying, as we did in the fully instrument enviroment of base checks then that would be of great benefit.
Andy
Last edited by AndyJB32; 18th Oct 2008 at 07:11.
Having read through the report, I too am a bit disappointed with the conclusions, none of which are really going to stop this sort of accident happening again. Very little questioning of the requirement to fly at night, nor of the proceedures used to try to ensure safe flight.
I find HC's responses accurate but slightly aggressive in tone. We all have our opinions here, and all are valid - As mentioned above, we had two pilots here who weren't cutting corners, were clearly aware of the visual problems they were about to encounter and were experienced in the type of flying. I was surprised by how many night decks they both had. I imagine that on the North Sea, I probably don't personally fly more than 30 night decks in a year, so if they can get it wrong, I'm quite sure I, and most other North Sea pilots can as well.
I know some pilots fly an ILS with the 'Intention' of going around. I'm sure we all should be doing that, and if cloud base is quoted as below 400ft, I do. In that way we are mentally prepared, ready and are expecting to initiate the go-around actions at DH. If as usual, you get visual, then you have to convert your approach and landing to VFR, a process made much easier by the new generation of aircraft that will fly you to a safe position and allow you to get your bearings.
Perhaps we should fly night approaches in the same way. The Non-Handling pilot should be ready and expecting to Go-Around unless all the pieces come together and he hears that call 'Landing' or 'Committed'. I know this is how we theoretically all fly, but I think from experience we tend to 'brief to a landing' being the expected ultimate conclusion. I don't think enough pilots brief and are mentally prepared for that go-around.
I also think there seems to be too much personal pride involved. As I think we mentioned in the Night Flying post, I don't know of many Go-Arounds at night even though I'm sure I've been in many situations where we really weren't best placed to make the approach. It seems the Co-Pilot here was feeling a professional pride in making the approach and maybe even worse, was focused on that failure, having had to hand the controls over. I always stress the point during all night approaches including me as the handling pilot, "Anything you don't like, be prepared to take control and we'll fly away and we'll try again" but I'll be making sure in future briefs, we talk about what to be looking for in terms of the (fairly obvious) rates of climb and attitude. - Sadly we don't all have a Go-Around button !!
I find HC's responses accurate but slightly aggressive in tone. We all have our opinions here, and all are valid - As mentioned above, we had two pilots here who weren't cutting corners, were clearly aware of the visual problems they were about to encounter and were experienced in the type of flying. I was surprised by how many night decks they both had. I imagine that on the North Sea, I probably don't personally fly more than 30 night decks in a year, so if they can get it wrong, I'm quite sure I, and most other North Sea pilots can as well.
I know some pilots fly an ILS with the 'Intention' of going around. I'm sure we all should be doing that, and if cloud base is quoted as below 400ft, I do. In that way we are mentally prepared, ready and are expecting to initiate the go-around actions at DH. If as usual, you get visual, then you have to convert your approach and landing to VFR, a process made much easier by the new generation of aircraft that will fly you to a safe position and allow you to get your bearings.
Perhaps we should fly night approaches in the same way. The Non-Handling pilot should be ready and expecting to Go-Around unless all the pieces come together and he hears that call 'Landing' or 'Committed'. I know this is how we theoretically all fly, but I think from experience we tend to 'brief to a landing' being the expected ultimate conclusion. I don't think enough pilots brief and are mentally prepared for that go-around.
I also think there seems to be too much personal pride involved. As I think we mentioned in the Night Flying post, I don't know of many Go-Arounds at night even though I'm sure I've been in many situations where we really weren't best placed to make the approach. It seems the Co-Pilot here was feeling a professional pride in making the approach and maybe even worse, was focused on that failure, having had to hand the controls over. I always stress the point during all night approaches including me as the handling pilot, "Anything you don't like, be prepared to take control and we'll fly away and we'll try again" but I'll be making sure in future briefs, we talk about what to be looking for in terms of the (fairly obvious) rates of climb and attitude. - Sadly we don't all have a Go-Around button !!
punto
It was not my intention to issue personal abuse, however it was my intention to discredit your view by pointing out that you have absolutely no experience of the environment we are discussing. I know this is Pprune but remember we are discussing the death of 2 of our fellow pilots here, and whilst I didn't know them personally many readers did. Now that I have checked your button, my belief that your view in support of Buitzenorg's rather nasty post was based only on ignorance, seems to have been correct.
Reading more courteously what you say this time, night offshore approaches are not going to be stopped nor is there going to be a magic final approach button, and nor is the design of rigs going to significantly change for the better (certainly not the existing ones).
If you look at the history of the N Sea I think the last time there was this type of accident was over 20 years ago. Bearing in mind how much flying is done, that is not a horrendous accident rate (though still too high). If you bear in mind that, despite what you say Simulator training is very good for an unexpected tranfer to instrument flight from low height and speed, and no simulator training was being carried out, this is surely a basic step that can be taken to reduce the liklihood of this recurring (and should have been taken before the horse bolted).
Andy - I totally agree that there is too much training time spent with onshore stuff with engine failures etc, and not enough with offshore stuff. This is in part because its not feasible to safety train for this sort of thing offshore in the aircraft. The Authority has some blame here - now that simulators are available (except for my fleet!) their use should be mandated. At the moment they are sort of mandated for the LPC but there is no requirement to go offshore in them. The CAA are starting to push this a bit but they should push harder! Bean counters only respond to must-haves, not to nice-to-haves.
Special
Guilty, but I found it offensive when people like Buitzenorg were using words like "this accident was set up by a sloppily-set-up approach". The pilots can't stand up for themselves, someone else has to.
Totally agree about practicing go-arounds and the pride factor, though in this case the co-pilot did admit that he was having problems and gave control to Capt. I remember an offshore night approach I flew in light winds many years ago, totally cocked it up and was going much too fast, but pride made me just go for 20 deg nose up to slow down (and it was a night line check!). Afterwards I decreed never to do that again but go-around!
HC
Leaving aside the personal abuse
Reading more courteously what you say this time, night offshore approaches are not going to be stopped nor is there going to be a magic final approach button, and nor is the design of rigs going to significantly change for the better (certainly not the existing ones).
If you look at the history of the N Sea I think the last time there was this type of accident was over 20 years ago. Bearing in mind how much flying is done, that is not a horrendous accident rate (though still too high). If you bear in mind that, despite what you say Simulator training is very good for an unexpected tranfer to instrument flight from low height and speed, and no simulator training was being carried out, this is surely a basic step that can be taken to reduce the liklihood of this recurring (and should have been taken before the horse bolted).
Andy - I totally agree that there is too much training time spent with onshore stuff with engine failures etc, and not enough with offshore stuff. This is in part because its not feasible to safety train for this sort of thing offshore in the aircraft. The Authority has some blame here - now that simulators are available (except for my fleet!) their use should be mandated. At the moment they are sort of mandated for the LPC but there is no requirement to go offshore in them. The CAA are starting to push this a bit but they should push harder! Bean counters only respond to must-haves, not to nice-to-haves.
Special
I find HC's responses ... slightly aggressive in tone.
Totally agree about practicing go-arounds and the pride factor, though in this case the co-pilot did admit that he was having problems and gave control to Capt. I remember an offshore night approach I flew in light winds many years ago, totally cocked it up and was going much too fast, but pride made me just go for 20 deg nose up to slow down (and it was a night line check!). Afterwards I decreed never to do that again but go-around!
HC
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sims
HC, i realise sims have great benefit, but still they can't replicate the constant switch and monitoring between visual and instrument conditions - i think this is the real challenge of the offshore night approach, and the one that is very limited in the available training aids we have.
andy
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Ultimately what caused this aircraft to crash was the commander's inability to establish a climb in the go-around. So why? Clearly the HP co-pilot got disorientated and within a few seconds the acft was 38 deg nose down and banking 38 deg right. The NHP commander then took over and acted quickly - within a second - to now establish a modest 7 deg left bank, which was not wings level, but not a problem, and hugely reduce the nose down pitch from 38 deg to 13 deg pitch down. This though was a big problem. The acft was still descending fast and just continued to do so until it hit the water.
Interestingly, after this initial attempted attitude correction by the commander, he did not input much more. He even asked his co-pilot if he was ok. Doesn't sound like someone wrestling to get an acft attitude he was happy with.
Could it have been because he actually thought he'd done the right thing? I see the OM states that any night go-around should be undertaken on instruments (obviously) and that Tq should go to 100%, wings level and pitch 5 - 10 deg nose down. Well, Tq was circa 100%, wings were not far off level, and the pitch set was only 3 degrees outside the prescribed range, at 13 compared with 5 - 10 deg. Pre-attitude correction the VSI was at 2000ft/min descent; following it the commander might have noticed it swinging back in right direction towards 1300ft/min. We all know there is lag - could he have thought in the second or so that he scanned the VSI it was indicating appropriately?
Of course there were other indications that a good scan should have picked up, like the critically decreasing height, increasing air speed and later, increasing V/S to 1700ft/min down. Big mistake, sure, and one that a commander should not have made. But did he think he'd done, pretty much, the right thing to establish a go-around?
Would seem the OM IMC go-around procedure might need reviewing. I'm sure it's based on sound principles but it would appear it doesn't accommodate correction from such a big (38 deg down) unusual attitude at low level.
Moving on to how the disorientation happened in the first place, from the fact that the height was varying from 500 to 270 ft several miles out I was surprised that the A/P did not continue to be coupled, with say a planned HDG and VS profile, until a decision point close to the rig. This would have reduced HP workload, and enabled an expected image of the platform to be seen on the approach when visibility allowed. The pilots would have known that the visual picture they met over the duration of the VMC approach was with the acft stable and helped their orientation when uncoupling to flare and land. The OM does not apparently make any reference to use of coupling on approaches.
Now I've never flown rigs or the AS365, so I may have got this wrong or missed something. But I have down plenty of SPIFR let downs at night in poor weather. And know it's not easy when you revert to instruments to go-around at low level.
Interestingly, after this initial attempted attitude correction by the commander, he did not input much more. He even asked his co-pilot if he was ok. Doesn't sound like someone wrestling to get an acft attitude he was happy with.
Could it have been because he actually thought he'd done the right thing? I see the OM states that any night go-around should be undertaken on instruments (obviously) and that Tq should go to 100%, wings level and pitch 5 - 10 deg nose down. Well, Tq was circa 100%, wings were not far off level, and the pitch set was only 3 degrees outside the prescribed range, at 13 compared with 5 - 10 deg. Pre-attitude correction the VSI was at 2000ft/min descent; following it the commander might have noticed it swinging back in right direction towards 1300ft/min. We all know there is lag - could he have thought in the second or so that he scanned the VSI it was indicating appropriately?
Of course there were other indications that a good scan should have picked up, like the critically decreasing height, increasing air speed and later, increasing V/S to 1700ft/min down. Big mistake, sure, and one that a commander should not have made. But did he think he'd done, pretty much, the right thing to establish a go-around?
Would seem the OM IMC go-around procedure might need reviewing. I'm sure it's based on sound principles but it would appear it doesn't accommodate correction from such a big (38 deg down) unusual attitude at low level.
Moving on to how the disorientation happened in the first place, from the fact that the height was varying from 500 to 270 ft several miles out I was surprised that the A/P did not continue to be coupled, with say a planned HDG and VS profile, until a decision point close to the rig. This would have reduced HP workload, and enabled an expected image of the platform to be seen on the approach when visibility allowed. The pilots would have known that the visual picture they met over the duration of the VMC approach was with the acft stable and helped their orientation when uncoupling to flare and land. The OM does not apparently make any reference to use of coupling on approaches.
Now I've never flown rigs or the AS365, so I may have got this wrong or missed something. But I have down plenty of SPIFR let downs at night in poor weather. And know it's not easy when you revert to instruments to go-around at low level.
Andy - I agree, the part visual part instrument flight is difficult to replicate in a Sim but in my opinion this accident was not caused by the loss of control of the co-pilot whilst trying to fly visually - these things happen and should not be terminal. It was after the capt took control and flew the go-around and, it seems, did not interpret his instruments correctly. That can be well-replicated in a Sim.
rotorspeed - I agree that the company procedure (assuming they were following it) in terms of use of the autopilot upper modes does not seem to be optimal. One problem here is that the manufacturer gives no guidance on the best way to use the autopilot. Bottom line is that if the capt had pressed the go-around button under his left thumb then let go, we would almost certainly not be having this discussion. I have to be careful here because I have never flown a 365 and it could be that the autopilot doesn't work very well, but certainly on the newer types it should be SOP to maximise use of the automation in these circumstances (and it is on my fleet!)
HC
rotorspeed - I agree that the company procedure (assuming they were following it) in terms of use of the autopilot upper modes does not seem to be optimal. One problem here is that the manufacturer gives no guidance on the best way to use the autopilot. Bottom line is that if the capt had pressed the go-around button under his left thumb then let go, we would almost certainly not be having this discussion. I have to be careful here because I have never flown a 365 and it could be that the autopilot doesn't work very well, but certainly on the newer types it should be SOP to maximise use of the automation in these circumstances (and it is on my fleet!)
HC
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The procedure we follow for a night visual approach is to stabilise at a briefed speed and height (min 50kts IAS and deck height + 200'), run in steady and level at that, then lower the collective to make the final approach once the site picture (= helideck ovality) is right. By briefing a tight speed and height, PNF is empowered to prompt/take control if the parameters are deviated from. Its not clear from the report whether CHC have the same policy and whether or not it was adhered to.
HC,
I agree with you. In a nutshell, that has been the procedure for many years. It was alomst the night offshore version of the old monitored ILS low viz approach into ABZ.
The element that appears to be missing from this particular approach is the briefing of tight speed and height / ROD. In fact, it seems that there was inadequate monitoring of the approach by the PNF. Had it have been better monitored, the PNF may have called a GA sooner and have been more easily able to assimilate what was happening to take control while still on instruments.
Paperwork perhaps?
HC,
I agree with you. In a nutshell, that has been the procedure for many years. It was alomst the night offshore version of the old monitored ILS low viz approach into ABZ.
The element that appears to be missing from this particular approach is the briefing of tight speed and height / ROD. In fact, it seems that there was inadequate monitoring of the approach by the PNF. Had it have been better monitored, the PNF may have called a GA sooner and have been more easily able to assimilate what was happening to take control while still on instruments.
Paperwork perhaps?
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Leading Edge;
There was a CHC/Scotia/BIH FSI a number of years ago that ordered no paperwork to be done while at low level, on approach, or shuttling. Paperwork was to be done in the cruise or on deck.
VH
There was a CHC/Scotia/BIH FSI a number of years ago that ordered no paperwork to be done while at low level, on approach, or shuttling. Paperwork was to be done in the cruise or on deck.
VH