AAIB Bulletin: Morecambe Bay

[Aser]

HC

now that simulators are available (except for my fleet!)

Happy news for you:
HeliSim inaugurates World's first Eurocopter EC225 Full Flight Simulator
Friday, October 10, 2008 / Eurocopter
Vertical Daily News: HeliSim inaugurates World's first Eurocopter EC225 Full Flight Simulator

Regards
Aser

[HeliComparator]

Aser - Inaugurated, yes. Approved, no. Once it has an approval from the DGAC/CAA we will start to use it, that may be as soon as the end of this month.

HC

[RVDT]

HC,

Wade on in here - http://www.pprune.org/rotorheads/344394-flying-night.html.

[puntosaurus]

What on earth is the matter with you HC ? We're all hurting because these people died, you don't have a monopoly on empathy.

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!)]

That's essentially the point. Why are people flying visual approaches manually to the most challenging of landing sites in marginal weather when there are tools to help ?

[smudge07]

Having read some of the responses on this thread I felt compelled to write.

I find some of the comments difficult to read having known one of the crew, however, it is vital that we learn from accidents such as this and it is important people discuss what the report said and share their own thoughts.

The thread from Rotorspeed, however, is totally unacceptable and insulting to the crew, I just couldn't believe the last paragraph 'Now I've never flown rigs or the AS365, so I may have got this wrong or missed something. But I have done 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'.

With your experience you are in a position to have an opinion, however you are in absolutely NO position to make statements such as: 'Big mistake, sure, and one that a commander should not have made'. You have absolutely no experience in this environment.

In comparison I have years of experience flying offshore and thousands of hours in 365 series. I would not comment on 'SPIFR let downs' as I have little experience there.

I totally agree with HC comments, especially your response to Buitenzorg: 'However the interpreter thereof may well do, or at least be talking out of his ' Couldn't have said it better myself.

More respect everyone please.

Smudge07.

[Chopper Doc Junior]

From reading the report the thing that strikes me is that none of the recommendations seems likely to improve safety. If as the pilots were discussing you have no depth perception due to poor conditions why are they trying to do a visual approach? Or have I missed something here? I cannot see how in similar circumstances this type of accident will not happen again.

[rotorspeed]

Smudge07

Well then, with the benefit of all your 365 offshore experience and this very extensive report, if it wasn't a mistake by the commander that ultimately caused this acft to hit the sea, what was it? In fact much of my post actually concerned me trying to understand why the commander acted as he did.

Or were my comments "totally unacceptable" because part of what I said dared to criticise a pilot who had tragically died? I am very sorry indeed that the pilot and the other passengers died. But although some posts on this forum seem to indicate that we pilots should never be criticised in the event of a fatal accident, I consider that only an objective debate about causes, once the accident report is out, is going to help save lives in the future by helping us all avoid mistakes.

There was no evidence of any mechanical failure with this acft. The weather was poor, but not beyond limits or really bad. There seemed to be no technical emergency the crew were pre-occupied with. Yet this acft crashed. You and no doubt many others are I suspect continuing to perform similar operations, some without much simulator training. Are some offshore passengers at major risk of being victim of a similar accident? If so such operations should surely be suspended immediately.

I put the caveat in about my lack of experience in this environment to allow those like you with all your experience the invitation to use that to tell me why any of my views are invalid. Perhaps now you'd like to be specific about that.

[212man]

A sobering report which should be mandatory reading for al offshore pilots. I would suggest that the parameters recorded in the go-around should be used as the basis for a pre-briefed (to an individual - not the crew) pilot incapacitation 'event' in simulator training.

A couple of things I thought might have had more scrutiny or reference to:

• The visual appearance of the ADI at the point of control handover: It is my belief that at the pitch attitude reached, the ADIs would have been completely black and would not have been easy to interpret (especially in the dark) The use of 'fly up' chevrons as seen on modern EFIS displays might help greatly in these situations
  
  
• The pitch change that was effected (around 25 degess pull up) must have felt quite significant, especially in the dark, and with the likely g forces that would have resulted at the prevailing airspeed (looks close to 2g in the FDR trace). There must be some consideration to the idea that RHS pilot felt he had initiated a significant recovery manouevre, and that the actual degree of pitch change and rate required was likely to be totally unnatural to him. It is likely to have been of the order of 55-60 degrees of pitch change which is practically an aerobatic manouevre! (-38 to +15-20)
  
  
• No discussion was made by the AAIB or CAA as to whether the aircraft could actually have been recovered from this upset. What pitch change and rate of change would have been required, if at all recoverable, given the height and rate of descent that resulted?
  
  
• A brief reference is made to the G/A button (and HC mentions it above.) More information on the envelope within which it can be used might have completed it's reference, with the likely conclusion that it would not have responded quickly enough at the higher speeds, and would not be engageable at the lower speeds
  
  
• I'm surprised the letter from the CAA was published with the name and address of a nominated post holder for another operator. A disidentified letter would have served the intent, without any ability to construe a connection or inference
  
  
• The pathology report states injuries consistent with a high vertical speed and some forward motion. Surely it would be the other way round - I know 2000 ft/min is a high vertical speed, but I'm sure the 126 kts did more harm

Terribly sad, regardless, and we should heed the lessons carefully

[rotorspeed]

212man

Good to see some interesting, specific points raised.

Following on from your point about the possible blackness of the ADI picture, given that the commander had reduced pitch quickly to the 13 deg nose down, any thoughts on why, with a more familiar picture now on the ADI, he did not pull back further on the cyclic over those final 6 seconds? Do you think he could have thought he was around that 5 -10 pitch down attitude that was in the OM for an IMC GA?

Or was the real issue that this was not fundamentally a GA, but a recovery from a (very) unusual attitude at a very low height and that the prescribed GA attitude was not relevant?

[AndyJB32]

Go around function

Just a general post to find out what people feel about using the go around function when offshore.

I realise in certain circumstances it will be benificial, but i'd argue that in the latter part of an approach, if things start to go wrong, that it would have to be used with extreme caution. I've only got a couple of 100 hours in the 365 from about 4 years ago, so i could be wrong here, but.......

when you press the go around function, doesn't the 365 roll wings level and try to attain 75 KIAS through pitch?

In which case, if you're already below 75 KIAS it will demand a pitch down attitude when you are within a couple of hundred feet of the sea. As far as i'm aware, it doesn't adjust power, so you may now be nose down, at a lowish power setting.

Also, if you are already quite close into the rig, and getting disoriented, then rolling wings level may cause you to turn toward the rig, or at least not turn away from the rig, at the same time as you try to sort out a pitch down command.

If the go around button is used, isn't it best to use it from a reasonably stable platform unless you have a lot of height to play with? Maybe start a go around manually, and make sure the aircraft is above 75KIAS and positivley flying away from the structure before thinking of engaging the go round mode.

I'd be interested to know what other people feel.

andy

[902Jon]

I believe the go-around button is designed for use on a coupled instrument approach when your approach speed is probably in the 90 - 120 kts band. It will only change the attitude to obtain 75kts. There is no collective input on the SFIM auto-pilot to add power to make the climb.
IMHO, I dont believe that given the low altitude/extreme unusual attitude, that the go-around button would have made any difference.
Most of us that have flown off-shore at night on inter-platform shuttles will recognise these conditions and will know how quickly you can get into the s***. RIP

[Bravo73]

Flight has an article in this week's edition about the accident and report:

AAIB calls for compulsory helicopter simulator recurrent training in its Morecambe Bay crash report


It is also mentioned in the front page editorial. Unfortunately I can't find a link to that article but 'Learmont's Blog' has a similar theme:

Helicopters need help - Learmount

[[email protected]]

Could a simple angle of approach indicator (as fitted to most grey-funnel liners) help with rig approaches?

It would need to be modified to give the 3 -colour spread of light around 360 degrees to account for different approach paths with different winds but that is not rocket science to achieve.

It could be made small enough to fit in the middle of the HLS so it is underneath the aircraft for landing and therefore out of the way.

That would at least give the HP an idea that his angle of approach was right as all he needs is to stay in the green sector to achieve the desired glidepath. It would also show when the aircraft was coming in too low to start with as only a red light would be visible.

In might not have prevented this terrible accident but it might have alerted both pilots to the fact that the actual flightpath was diverging from the desired one much earlier.

[Shawn Coyle]

Such an approach lighting system existed nearly 20 years ago - called Firefly. Had flashing green for high, green on glidepath, red for low, flashing red for really low. Glidepath azimuth and elevation remotely adjustable from helicopter. Small, battery operable. worked well. Nobody wanted it... Still able to be resurrected. Did AAIB even mention it's possibility?
Anybody wanting more details, PM me.

[rufus.t.firefly]

A similar device was on show at Helitech at Duxford last year - you can guarantee the majority of the energy company managers " if " on site during the show will have just walked straight past it .... it always costs to put your hand in your pocket - mustn't offend the bean counters by investing to make things easier and enhancing safety in the long run

It would be a relatively inexpensive aid to install in the big scheme of things

[[email protected]]

Therefore it behoves the CAA to mandate such equipment for rig ops if they are going to continue to allow them to continue safely at night. Then the bean counters don't get a say - No AAI, no heli ops to rigs at night!

It is a shame there wasn't a recommendation for something simple like this in the report.

[Hummingfrog]

An AAI is not the answer to the problem of night approaches to rig helidecks. The ability to make approaches from any direction within the 210 arc makes it impractical to have a calibrated instrument with enough power and directional coverage that doesn't blind the air or deck crew once on the deck.

The approach to a RN ship's deck is from a set direction so the beam can be aligned and also show green until on the deck as it is mounted above deck level. A centre deck level mounted device would not allow a narrow green beam to show as the helicopter approached the deck - it would show amber.

The answer lies in what is actually happening. Green deck edge lights which greatly improve the acquisition of the deck from amongst the cultural rig lighting. Along with illuminating circle and H with LEDs which is being trialled on the Thames platform. This allows the pilot to fly a sight picture approach from a good range.

HF

[RedWhite&Blue]

Along with illuminating circle and H with LEDs which is being trialled on the Thames platform.

This really does help, but I landed there last night and the deck is back to just green perimeter lights.

It seems that the LED parts of the deck lighting just aren't up to the job. Great shame.

Back to the drawing board then...

Just a thought, imagine a cone of an omni-directional approach path, emanating from the centre of the H, being plotted via a multitude of GPS waypoints and a display in the cockpit to indicate whether you are above, on or below the approach cone. With clever computers and RAIM etc, could it be done? If its only a question of money then please just ask...

[[email protected]]

Hummingfrog - it is the initial part of the approach that needs the AAI - the area where there are no rate of closure cues and only the aspect of the helideck to work from. Once you are close in you would have all the visual references you need so it wouldn't matter that the AAI was in the middle of the deck.

The fact that it would be in the centre of the deck would mean it wouldn't dazzle the aircrew when they were hovering over it and it could be turned off when neccessary to protect the helideck crew.

A 210 degree arc would be very straight forward to achieve with prisms and mirrrors or modern stuff like LEDs. It needs to be simple so it is cheap and straighforward to use and robust enough for the job.

Whatever the solution, is seems clear to an interested observer that some additional approach aid is required to make night rig approaches easier to fly and therefore safer and it needs to be driven by pressure from the operators/crews onto the CAA who must then mandate it for future ops.

[HeliComparator]

Although visual approach path indicators sound like a good idea, because of the requirement for 360 deg visibility in an environment where there is a lot of structure above helideck level, and because we approach not to the helideck but to the comittal point which is out to the side, I don't think its feasible. I say 360 deg (not 210 deg) because we approach into wind, we do not only approach in the 210 deg clear sector. Typically with the wind in an unfortunate direction, we would approach to the comittal point (around 40' above the deck and out to the side, with rotor disc just missing helideck edge, before comitting and moving sideways. Therefore I think the visual approach path indicators would be unseen (when far away) and give false indications (when near - but I would have to check the trigonometry!).

A better solution is first to make the visual approach more specifically briefed and flown (as I mentioned, running in at deck height + 200' and a nominated speed, typically and IAS to give 50kts groundspeed, preferably with ALT and IAS modes engaged). From 200' at a normal approach angle, you are quite close and visual references are reasonable. Visual references are massively improved by the new type of helideck lighting that Humming and RWB mention.

But such is the interest in the oil industry in actually improving safety (rather than talking about it) that I understand it will be many years if ever before all offshore installations are modified with the new lighting. In reality it will probably mostly be only new installations that get it. Yup, its pathetic, we can't even get decent lighting!

HC