Super Puma down central North Sea Feb 2009
Flyer43,
I couldn't agree more; however the company that promotes a 'just culture' not only has blame free reporting but has to use those reports to improve SOPs.
It would appear from a reading of Part OR from EASA (the Implementing Rules on Organisations) and the associated guidance, that risk assessment (hazard analysis) is expected to be part both of the provision and the amendment of SOPs.
One of the better parts of this thread - now that the apparent narrative of the accident has been seen - is the healthy dialogue on the necessity for appropriate SOPs; more in fact, that these SOPs need to take advantage of the specialist equipment that is fitted to modern helicopters. This would indicate that not only should there be observance of the rules (by crews and in SOPs) but there should be generic SOPs and within each SOP subsets for each type of aircraft.
The one thing that has disappointed is the production of an increasing list of accidents that have occurred offshore. As can be seen from the previous analysis of accidents in the GOM and lately those for HEMS, it is just not enough to group them as happening 'offshore' or 'overwater' or 'at night', it is neccessary to dig down and find common elements so that the causal chain can be broken at as many links as possible.
It appears to me that it might also be necessary to bring under the microscope the role of crew members; certainly with the last two accidents the instability of the flight path that led to unease - expressed by the handling pilots - should probably have led to a go-around (or an earlier go-around). Perhaps one of the first things that has to be considered is the removal of the stigma that is attached to the go-around manoeuvre. Whilst this is being considered, the very issue of stability of flight path (or conversely what is considered to be instability) will need to be discussed and defined.
None of this needs to be done in a hurry but clearly it does need to be done.
Jim
I couldn't agree more; however the company that promotes a 'just culture' not only has blame free reporting but has to use those reports to improve SOPs.
It would appear from a reading of Part OR from EASA (the Implementing Rules on Organisations) and the associated guidance, that risk assessment (hazard analysis) is expected to be part both of the provision and the amendment of SOPs.
One of the better parts of this thread - now that the apparent narrative of the accident has been seen - is the healthy dialogue on the necessity for appropriate SOPs; more in fact, that these SOPs need to take advantage of the specialist equipment that is fitted to modern helicopters. This would indicate that not only should there be observance of the rules (by crews and in SOPs) but there should be generic SOPs and within each SOP subsets for each type of aircraft.
The one thing that has disappointed is the production of an increasing list of accidents that have occurred offshore. As can be seen from the previous analysis of accidents in the GOM and lately those for HEMS, it is just not enough to group them as happening 'offshore' or 'overwater' or 'at night', it is neccessary to dig down and find common elements so that the causal chain can be broken at as many links as possible.
It appears to me that it might also be necessary to bring under the microscope the role of crew members; certainly with the last two accidents the instability of the flight path that led to unease - expressed by the handling pilots - should probably have led to a go-around (or an earlier go-around). Perhaps one of the first things that has to be considered is the removal of the stigma that is attached to the go-around manoeuvre. Whilst this is being considered, the very issue of stability of flight path (or conversely what is considered to be instability) will need to be discussed and defined.
None of this needs to be done in a hurry but clearly it does need to be done.
Jim
In the Canadian bush, it is quite common to sometimes sometimes overshoot an approach when things don't "feel" quite right. We teach it, encourage it, expect it.
I do find it both odd and counterproductive that in the offshore world an overshoot for whatever reason demands an incident report to be completed. I've got examples of offshore pilots that having had the professionalism and good judgment to overshoot an approach to a rig then as a consequence found themselves on the carpet in front of their Chief Pilot, with their Command status in jeopardy, just for doing the obvious safe thing. The stigma is very much there.
Same with the stigma for an IFR missed approach. Some companies demand a complete report. The weather at a location, whether a rig offshore or some isolated land location with an IFR approach is going to be uncertain at best. The IFR Approach procedure is independent of guessed or reported weather. All a weather report gives you is a probability of whether or not you will be able to land. It guarantees nothing. You fly the approach to the MAP and if you can see what you need to proceed visual and land you do, and if you can't you don't. Operationally, you save everyone's time and money if you don't launch without a reasonable expectation to land. Sometimes the customer will pay you just to have a look - his money his call, and there is nothing dangerous about it if you follow procedure. This over-reliance on accurate weather reporting coupled with the perceived reprimand of pilots that miss or overshoot an approach is a flawed attitude.
I do find it both odd and counterproductive that in the offshore world an overshoot for whatever reason demands an incident report to be completed. I've got examples of offshore pilots that having had the professionalism and good judgment to overshoot an approach to a rig then as a consequence found themselves on the carpet in front of their Chief Pilot, with their Command status in jeopardy, just for doing the obvious safe thing. The stigma is very much there.
Same with the stigma for an IFR missed approach. Some companies demand a complete report. The weather at a location, whether a rig offshore or some isolated land location with an IFR approach is going to be uncertain at best. The IFR Approach procedure is independent of guessed or reported weather. All a weather report gives you is a probability of whether or not you will be able to land. It guarantees nothing. You fly the approach to the MAP and if you can see what you need to proceed visual and land you do, and if you can't you don't. Operationally, you save everyone's time and money if you don't launch without a reasonable expectation to land. Sometimes the customer will pay you just to have a look - his money his call, and there is nothing dangerous about it if you follow procedure. This over-reliance on accurate weather reporting coupled with the perceived reprimand of pilots that miss or overshoot an approach is a flawed attitude.
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Afterthoughts.........
It seems we so often ponder the sight at the accident scene the following morning when, with the weather fine and the sun shining on the smoking hole in the ground (metaphorically speaking), we say to ourselves..........
"Why was it so depserately urgent that the passengers were delivered THAT day, at THAT time". Now they are all gonners (or nearly so in this case) it seems entirely reasonable for the crew to have said "bugger it, it's too difficult, they can go tomorrow".
How cruel our world is when you are a professional if you 'get the job done' and 'second rate' if you call it a day.
There is such a thing as trying TOO hard........ isn't there?
G
"Why was it so depserately urgent that the passengers were delivered THAT day, at THAT time". Now they are all gonners (or nearly so in this case) it seems entirely reasonable for the crew to have said "bugger it, it's too difficult, they can go tomorrow".
How cruel our world is when you are a professional if you 'get the job done' and 'second rate' if you call it a day.
There is such a thing as trying TOO hard........ isn't there?
G
I read thru this document and found some of the comments within to be interesting thoughts that lend themselves to what JimL and a lot of other experienced North Sea folks are saying.
What struck me was the comment about a leveling off of the rate of improvement in the accident rate over the past Ten Years or so.
If one accepts there have been advances in avionics, auto pilots, training simulators and the like......there has to be an explanation for the leveling off in safety stats.
Are we not saying the same thing in this thread but not yet put into short concise statements what that holdup is caused by?
One particular quote struck me as being very astute and has some direct bearing upon our discussion.
Highlighting is mine and not in the report....
http://www.etsc.eu/documents/bri_air3.pdf
Anyone care to start the "Bullet List" and set forth what they see to be the "links" in our chain we seem to have stretched out so far?
What struck me was the comment about a leveling off of the rate of improvement in the accident rate over the past Ten Years or so.
If one accepts there have been advances in avionics, auto pilots, training simulators and the like......there has to be an explanation for the leveling off in safety stats.
Are we not saying the same thing in this thread but not yet put into short concise statements what that holdup is caused by?
One particular quote struck me as being very astute and has some direct bearing upon our discussion.
Highlighting is mine and not in the report....
Airlines and regulatory authorities have the major
responsibility for running the aviation system and any report that appears to
demand change is either implicitly or explicitly critical of some equipment or
procedure that has already been approved, licensed, or authorised by those bodies.
Thus to implement change, these organisations have first to accept the notion that their previous rules or procedures were capable of improvement and may even have been wrong. Furthermore, it appears to be human nature for the messenger to be blamed for the message, and it is very tempting for operators and regulators to form negative views of the reporting system simply because the messages that it conveys can be uncomfortable to them.
responsibility for running the aviation system and any report that appears to
demand change is either implicitly or explicitly critical of some equipment or
procedure that has already been approved, licensed, or authorised by those bodies.
Thus to implement change, these organisations have first to accept the notion that their previous rules or procedures were capable of improvement and may even have been wrong. Furthermore, it appears to be human nature for the messenger to be blamed for the message, and it is very tempting for operators and regulators to form negative views of the reporting system simply because the messages that it conveys can be uncomfortable to them.
Anyone care to start the "Bullet List" and set forth what they see to be the "links" in our chain we seem to have stretched out so far?
"Why was it so depserately urgent that the passengers were delivered THAT day, at THAT time". Now they are all gonners (or nearly so in this case) it seems entirely reasonable for the crew to have said "bugger it, it's too difficult, they can go tomorrow".
How cruel our world is when you are a professional if you 'get the job done' and 'second rate' if you call it a day.
There is such a thing as trying TOO hard........ isn't there?
How cruel our world is when you are a professional if you 'get the job done' and 'second rate' if you call it a day.
There is such a thing as trying TOO hard........ isn't there?
My only point is this. Management and/or Commercial pressure are often blamed for these mistakes. Just pause a moment and ask yourself whether it's actually self-generated.
I am at the bottom rung of the ladder so I would imagine the cheese holes are either larger or more aligned than most?
I have just over 2 years NS offshore experience and have been lucky enough to have had two very patient TRE's and some great night line taining captains train me for the night offshore landings.
The fact that they were patient, took time to point out some 'gotcha's' etc, still doesn't make someone like myself feel 100% confident of the whole night deck landing scenario. I imagine it will take time to gain the experience required but we just don't get the amount of night deck landing experience in the SNS as some people think.
I have been taught, set up your gate every time. Don't worry about the fact the experienced Commander sitting next to me might be thinking "jeez what a slow coach" etc, but do everything at my own pace. This I will do and i'll be the first person to speak up if I feel i've been unduly pressurised into hurrying.
Why not, for every night approach, ensure that gate is fixed, pretty much as has been mentioned above.
ie, 1nm, 500', 80kts (or sensible for a/c type) and if references aren't correct, throw the approach away
and either start again or go home. Is it really that important to put lives at risk when conditions aren't suitable?
How about this? :- Low time co-jo, High time very experienced commander is PF, Goes something like "I'll land this one, ok so it's not normal to do this, but ****, we were doing this 20 years ago, don't worry, I got it."
Low time co-jo sits there uncomfortable but......!
Discussing this issue with a colleague earlier tonight, (whilst offshore night flying!!), we agreed there is a lack of the whole night offshore training, for whatever reasons. I'm sure we all agree on some of the reasons why
that may be. Unfortunately, my first winter offshore, I and a few colleagues were prevented from flying offshore at night so it's taken time to get to this point in time.
Having a little bit more experience on type, and due to company/customer requirements for night deck qualified pilots, i'm now signed off but getting nowhere near enough night flying to feel totally comfortable yet.
No doubt it'll come with time but if anyone (non offshore pilot etc) thinks the whole offshore night flying thing must be relatively straight forward just because you have multi crew and an all singing and dancing a/c, then I suggest they think again. Initially it's like learning to fly all over again, and, it gave me a new found respect for all of those pilots already doing this type of flying.
Fly safe.
I have just over 2 years NS offshore experience and have been lucky enough to have had two very patient TRE's and some great night line taining captains train me for the night offshore landings.
The fact that they were patient, took time to point out some 'gotcha's' etc, still doesn't make someone like myself feel 100% confident of the whole night deck landing scenario. I imagine it will take time to gain the experience required but we just don't get the amount of night deck landing experience in the SNS as some people think.
I have been taught, set up your gate every time. Don't worry about the fact the experienced Commander sitting next to me might be thinking "jeez what a slow coach" etc, but do everything at my own pace. This I will do and i'll be the first person to speak up if I feel i've been unduly pressurised into hurrying.
Why not, for every night approach, ensure that gate is fixed, pretty much as has been mentioned above.
ie, 1nm, 500', 80kts (or sensible for a/c type) and if references aren't correct, throw the approach away
and either start again or go home. Is it really that important to put lives at risk when conditions aren't suitable?
How about this? :- Low time co-jo, High time very experienced commander is PF, Goes something like "I'll land this one, ok so it's not normal to do this, but ****, we were doing this 20 years ago, don't worry, I got it."
Low time co-jo sits there uncomfortable but......!
Discussing this issue with a colleague earlier tonight, (whilst offshore night flying!!), we agreed there is a lack of the whole night offshore training, for whatever reasons. I'm sure we all agree on some of the reasons why
that may be. Unfortunately, my first winter offshore, I and a few colleagues were prevented from flying offshore at night so it's taken time to get to this point in time.
Having a little bit more experience on type, and due to company/customer requirements for night deck qualified pilots, i'm now signed off but getting nowhere near enough night flying to feel totally comfortable yet.
No doubt it'll come with time but if anyone (non offshore pilot etc) thinks the whole offshore night flying thing must be relatively straight forward just because you have multi crew and an all singing and dancing a/c, then I suggest they think again. Initially it's like learning to fly all over again, and, it gave me a new found respect for all of those pilots already doing this type of flying.
Fly safe.
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Did hear a rumour today that Bond was starting >another< new offshore company ( Not BAS or Bond Offshore ) to bid for offshore contracts ?
Was this decided before this incident or after ?
Was this decided before this incident or after ?
Helideck lighting
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Helideck Lights
djfandango,
Regardless of what CAP437 says, there are many helidecks in the North Sea still sporting the 'old' white/yellowish lights. I'm not sure what percentage of decks have the 'new' green ones, but it is nowhere near high enough yet. Re-fitting all the remaining decks with green lighting will have a cost of course and I'm sure we are all well aware of how poor the oil companies are at the moment. Perhaps if the price of a barrel reaches $150, they may put a little profit aside and complete the changes. I say $150/barrel as last year's high of $145 obviously didn't produce enough spare cash to do the job.
bondu
Regardless of what CAP437 says, there are many helidecks in the North Sea still sporting the 'old' white/yellowish lights. I'm not sure what percentage of decks have the 'new' green ones, but it is nowhere near high enough yet. Re-fitting all the remaining decks with green lighting will have a cost of course and I'm sure we are all well aware of how poor the oil companies are at the moment. Perhaps if the price of a barrel reaches $150, they may put a little profit aside and complete the changes. I say $150/barrel as last year's high of $145 obviously didn't produce enough spare cash to do the job.
bondu
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Helideck Lights
Bondu,
Regardless of how much spare cash the oil companies might have, the simple fact is that a date was set by which time decks had to be changed to the new standard. Give somebody a choice and they will generally take the cheaper option until the last minute!
Regardless of how much spare cash the oil companies might have, the simple fact is that a date was set by which time decks had to be changed to the new standard. Give somebody a choice and they will generally take the cheaper option until the last minute!
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OK, so it looks like a number of them are a bit later than the plan, and these decks should indeed be recategorised. However, how many of you know of flights that have continued to non-conformal decks, at night?
The standards are there for a reason. The longer anybody continues to accept them "cos it's always been like that" then more accidents are inevitable.
Although it is the responsibility of the company that owns or operates the offshore installation to install equipment etc which conforms to the requirements, it is also up to the helicopter operators to ensure that they stop using helidecks that do not conform, or place appropriate restrictions on flights to/from them.
The standards are there for a reason. The longer anybody continues to accept them "cos it's always been like that" then more accidents are inevitable.
Although it is the responsibility of the company that owns or operates the offshore installation to install equipment etc which conforms to the requirements, it is also up to the helicopter operators to ensure that they stop using helidecks that do not conform, or place appropriate restrictions on flights to/from them.
You ever sat in a Safety Meeting with your bosses and tell them to close helidecks to use because of problems?
Talk about dropping a Baby Ruth in a swimming pool!
Talk about dropping a Baby Ruth in a swimming pool!
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Closing Helidecks
SAS
Been there, done that for various reasons and got several T-shirts, both as pilot and auditor/inspector.
As you say, it can be a bit like throwing Baby Ruth in the Swimming Pool, but it sure gets their attention and things happen quite quickly afterwards to rectify the situation.
Been there, done that for various reasons and got several T-shirts, both as pilot and auditor/inspector.
As you say, it can be a bit like throwing Baby Ruth in the Swimming Pool, but it sure gets their attention and things happen quite quickly afterwards to rectify the situation.
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SAS
At least 1 deck has been reclassified Day VFR and at least one operator has written to its clients' advising them of the rule change which came into effect on 1 Jan 09. I am sure that the other two operators are doing likewise.
Hopefully crews are informing their operator of decks with dodgy lighting and not just accepting it.
At least 1 deck has been reclassified Day VFR and at least one operator has written to its clients' advising them of the rule change which came into effect on 1 Jan 09. I am sure that the other two operators are doing likewise.
Hopefully crews are informing their operator of decks with dodgy lighting and not just accepting it.
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HUET Preparation
As a HUET trainer I am interested in the actions of PAX and crew following this ditching. Essentially PAX are taught to follow crew directions, but they are also taught to don hoods and deploy EBS after a ditching in preparation for possible capsize. Is anyone able to provide detail on this at the moment?
Thanks
Thanks
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It could get a bit noisy with 19 beacons in a small area bleating away. At least one of them should be working well enough for the SAR folks to locate them it would seem. Do the rafts carry Epirbs in addition to the Adelt?
Crab,
Does your electronic suite cope with multiple Epirbs or will it process the strongest signal only?
Crab,
Does your electronic suite cope with multiple Epirbs or will it process the strongest signal only?
Sasless - I think electronic suite is rather overstating the homers on the Mk3/3A Sea King
but it will pick up all the 121.5 beacons and try to move the one homing needle as much as it can whilst the audio will be a very confusing mass of beeps.
We did a SAREX for an up and coming captain this week where we had 3 beacons going as he did an IMC homing and the indications were interesting to say the least. If all the beacons are in the same place it is easier than if they are spread out.
More modern homers will show you the relative positions of the beacons on a screen but I don't know how many they can process at once.
but it will pick up all the 121.5 beacons and try to move the one homing needle as much as it can whilst the audio will be a very confusing mass of beeps. We did a SAREX for an up and coming captain this week where we had 3 beacons going as he did an IMC homing and the indications were interesting to say the least. If all the beacons are in the same place it is easier than if they are spread out.
More modern homers will show you the relative positions of the beacons on a screen but I don't know how many they can process at once.