Helicopter crash off the coast of Newfoundland - 18 aboard, March 2009
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What is the intent of putting in place Regulations like FAR29 (specifically Section 29.927) that set minimum standards other than to ensure a certain (sometimes critical in the case of MGB) redundancy is there when needed ? Surely we aren’t saying well it’s there because it says so on this piece of paper, but don’t expect to ever depend on it if you really need it ?
Is not one of the reasons these types of aircraft are chosen for offshore transportation in the first place that that they do offer that additional critical redundancy according to their FAR29 Certification, so if something bad happens really fast (e.g. you lose your MGB oil in a matter of minutes), there is that built-in additional time to get the aircraft down in a controlled manner.
From the time the crew first notices a loss of MGB lubricant, the aircraft, as Certified to FAR29.927, is to be capable of 30 minutes continued flight – it’s a design requirement, a testing requirement, and a FAR29 Certification requirement for any failure which results in loss of MGB lubricant. Aren’t these minimum standards, i.e. there may possibly even be inherent benefits over and above, but no failure below ?
I won’t second guess the flight crew’s actions relating to this tragic event and that will be determined by professional investigators who have first hand access to the many pertinent sources of information, but whatever happened after they first noticed loss of lubricant, should there have been more time available to them due to the built-in additional redundancy for the MGB as specified by the FAR29 Regulation ?
What types of redundancy systems are installed on these aircraft that protects the MGB against any of these failures ?
Are these systems designed to address multiple failure modes and are they standard equipment on all helicopters working offshore (albeit with a weight and $ cost) ?
Why only 30 minutes of continued flight – is that acceptable for hostile offshore flight times of over an hour to destination with no alternate ?
Surely the Regulations have not fallen that far behind current technology that we may be trading off potential critical redundancy for the sake of only having to meet minimum requirements which were introduced over 20 years ago ?
In an (offshore oil) industry that is cash rich, that continuously advances new technologies and has lobbying power like no other, things such as outdated regulations or a hands-off mentality are not issues that cannot be addressed ?
Lots of questions, and probably hundreds more out there – hope there are lots of answers that can help to make flying offshore safer for everybody.
Is not one of the reasons these types of aircraft are chosen for offshore transportation in the first place that that they do offer that additional critical redundancy according to their FAR29 Certification, so if something bad happens really fast (e.g. you lose your MGB oil in a matter of minutes), there is that built-in additional time to get the aircraft down in a controlled manner.
From the time the crew first notices a loss of MGB lubricant, the aircraft, as Certified to FAR29.927, is to be capable of 30 minutes continued flight – it’s a design requirement, a testing requirement, and a FAR29 Certification requirement for any failure which results in loss of MGB lubricant. Aren’t these minimum standards, i.e. there may possibly even be inherent benefits over and above, but no failure below ?
I won’t second guess the flight crew’s actions relating to this tragic event and that will be determined by professional investigators who have first hand access to the many pertinent sources of information, but whatever happened after they first noticed loss of lubricant, should there have been more time available to them due to the built-in additional redundancy for the MGB as specified by the FAR29 Regulation ?
What types of redundancy systems are installed on these aircraft that protects the MGB against any of these failures ?
Are these systems designed to address multiple failure modes and are they standard equipment on all helicopters working offshore (albeit with a weight and $ cost) ?
Why only 30 minutes of continued flight – is that acceptable for hostile offshore flight times of over an hour to destination with no alternate ?
Surely the Regulations have not fallen that far behind current technology that we may be trading off potential critical redundancy for the sake of only having to meet minimum requirements which were introduced over 20 years ago ?
In an (offshore oil) industry that is cash rich, that continuously advances new technologies and has lobbying power like no other, things such as outdated regulations or a hands-off mentality are not issues that cannot be addressed ?
Lots of questions, and probably hundreds more out there – hope there are lots of answers that can help to make flying offshore safer for everybody.
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S-92 gear box repairs
Found this on the Sikorsky website, sorry if it's been posted previously.
Sikorsky Aerospace Services and VIHAG Announce Agreement for S-92®*Helicopter Gearbox Repair and Overhaul
The press release says in part:
I guess Cougar and VIHAG will be getting up to speed on the S-92 gearboxes faster than they originally thought.
Sikorsky Aerospace Services and VIHAG Announce Agreement for S-92®*Helicopter Gearbox Repair and Overhaul
The press release says in part:
February 24, 2009
ANAHEIM, California - Sikorsky Aerospace Services, at Heli-Expo today announced the signing of an agreement with VIH Aviation Group (VIHAG) to authorize VIHAG's ability to repair and overhaul S-92® helicopter gearboxes. Sikorsky Aerospace Services is the aftermarket business of Sikorsky Aircraft Corp., a subsidiary of United Technologies Corp. (NYSE:UTX).
ANAHEIM, California - Sikorsky Aerospace Services, at Heli-Expo today announced the signing of an agreement with VIH Aviation Group (VIHAG) to authorize VIHAG's ability to repair and overhaul S-92® helicopter gearboxes. Sikorsky Aerospace Services is the aftermarket business of Sikorsky Aircraft Corp., a subsidiary of United Technologies Corp. (NYSE:UTX).
The VIH Aviation Group of companies has operations in Canada, the U.S. and other countries ranging from Taiwan to Peru. VIHAG is Canada's oldest privately owned helicopter business, and includes several helicopter operating companies as well as an aviation technical services company and regional fixed base operator companies. VIHAG subsidiary Cougar Helicopters is an acknowledged leader in all-weather, instrument flight rules (IFR) Offshore and IFR Search and Rescue services; while VIH also operates a fleet of visual flight rules (VFR) helicopters in a variety of tasks, including specialized helicopter services such as aerial crane construction, heli-logging, disaster relief, exploration, forestry and personnel transport.
I have been thinking today.....a scary thing for me to do some of you might agree.
My pondering got around to the concepts of Pilot Error, Crew Error, Operational Error, and humans making errors in general as they relate to aviation.
This accident cannot be attributed to Pilot Error in the least.
The Crew was confronted with a serious mechanical problem and as it turned out....it was in fact a serious mechanical failure. That in itself rules out Pilot Error as the aircraft was lost to a mechanical failure.
The Crew were presented with unusual indications initially and those were indication abnormalities. There were no signs of smoke, fumes, fire, vapor trails, grinding noises, or other physically viewable signs of a problem. All they could see were the unusual indications of warning lights, caution lights and gauge indications.
The Crew sought and got technical assistance from their Operations. There was a back and forth discussion of some sort regarding the indications, possible causes, and options to be considered in the wake of those indications.
Thus the Crew did not act independently. That rules out Cockpit Error in my view. The Crew exercised good CRM as evidenced by taking action to descend then report the problem. It appears they consulted their Emergency Checklist, and at least initiated the proper response as indicated by the immediate descent and reduction in airspeed. They sought the counsel of their Operations and Engineering staff who provided what guidance they thought right.
That brings us to Operational Error.
If we define this to be a systemic error and not a Pilot or Crew Error and one that involves other individuals from the system including Engineering and Flight Operations then perhaps this is the category we should begin to call this accident.
Plainly Human Error played a role....a very large role in this accident.
The substantial risk of the failure of the Oil Filter Bowl retention studs was under estimated by a host of people and organizations. Perhaps the Emergency Procedures in place at the time did not adequately address the situation the crew encountered and management decisions did not effectively deal with the situation before the flight and during the actual emergency itself. If the crew had not made contact with their Operations Office, would they have been more likely to have landed the aircraft and thus avoided the result of that effort to continue flying?
Others have mentioned the NASA experiences with the loss of two Shuttles and the near loss of a third. We could add the loss of three astronauts in a launch pad fire when the capsule used an oxygen enriched atmosphere.
Was this crew not in the same situation as the astronauts aboard the shuttles? Were they not as much Victims as were the passengers?
They were professionals in the true sense of the word.
My pondering got around to the concepts of Pilot Error, Crew Error, Operational Error, and humans making errors in general as they relate to aviation.
This accident cannot be attributed to Pilot Error in the least.
The Crew was confronted with a serious mechanical problem and as it turned out....it was in fact a serious mechanical failure. That in itself rules out Pilot Error as the aircraft was lost to a mechanical failure.
The Crew were presented with unusual indications initially and those were indication abnormalities. There were no signs of smoke, fumes, fire, vapor trails, grinding noises, or other physically viewable signs of a problem. All they could see were the unusual indications of warning lights, caution lights and gauge indications.
The Crew sought and got technical assistance from their Operations. There was a back and forth discussion of some sort regarding the indications, possible causes, and options to be considered in the wake of those indications.
Thus the Crew did not act independently. That rules out Cockpit Error in my view. The Crew exercised good CRM as evidenced by taking action to descend then report the problem. It appears they consulted their Emergency Checklist, and at least initiated the proper response as indicated by the immediate descent and reduction in airspeed. They sought the counsel of their Operations and Engineering staff who provided what guidance they thought right.
That brings us to Operational Error.
If we define this to be a systemic error and not a Pilot or Crew Error and one that involves other individuals from the system including Engineering and Flight Operations then perhaps this is the category we should begin to call this accident.
Plainly Human Error played a role....a very large role in this accident.
The substantial risk of the failure of the Oil Filter Bowl retention studs was under estimated by a host of people and organizations. Perhaps the Emergency Procedures in place at the time did not adequately address the situation the crew encountered and management decisions did not effectively deal with the situation before the flight and during the actual emergency itself. If the crew had not made contact with their Operations Office, would they have been more likely to have landed the aircraft and thus avoided the result of that effort to continue flying?
Others have mentioned the NASA experiences with the loss of two Shuttles and the near loss of a third. We could add the loss of three astronauts in a launch pad fire when the capsule used an oxygen enriched atmosphere.
Was this crew not in the same situation as the astronauts aboard the shuttles? Were they not as much Victims as were the passengers?
They were professionals in the true sense of the word.
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SAS Let me play devil's advocate for a second,
If an aircraft manufacturer says do XYZ if ABC happens
AND
An aircraft operator does not do such XYZ, regardless of reasoning
Surely this will be deemed as "contributory negligence "
and therefore Pilot Error
Just looking at it as the Lawyers for the insurance companies will!!
Chester
If an aircraft manufacturer says do XYZ if ABC happens
AND
An aircraft operator does not do such XYZ, regardless of reasoning
Surely this will be deemed as "contributory negligence "
and therefore Pilot Error
Just looking at it as the Lawyers for the insurance companies will!!
Chester
chester2005 SAS Let me play devil's advocate for a second,
If an aircraft manufacturer says do XYZ if ABC happens
AND
An aircraft operator does not do such XYZ, regardless of reasoning
Surely this will be deemed as "contributory negligence "
and therefore Pilot Error
Just looking at it as the Lawyers for the insurance companies will!!
Chester
If an aircraft manufacturer says do XYZ if ABC happens
AND
An aircraft operator does not do such XYZ, regardless of reasoning
Surely this will be deemed as "contributory negligence "
and therefore Pilot Error
Just looking at it as the Lawyers for the insurance companies will!!
Chester
Just came to my mind that a long time ago when discussing run-dry(or other kind of tests) info, I recall someone arguing that info is better not to be known, I thought that was stupid but today I'm not so sure...
Regards
Aser
Chester,
Read the post carefully.
Pilot Error is when you the pilot kill a perfectly good aircraft.....one that is completely serviceable.
Cockpit Error means you contributed to the outcome by making a mistake (and I construe that to mean independently of outside involvement).
Operational Error....means you had outside help in making the error.
Human Errors are normal....they happen every day on every flight. They don't necessarily have a bad outcome. Ever miss a radio call and have to be spoke to a second time before you hear the call? Ever dial up a wrong frequency and catch yourself? Ever punch the wrong start button and think what a buffoon you are?
The Human Errors I see in this Cougar thing are some that did not get caught and wound up with a bad outcome.
The investigation should dig into every one of them along with coming up with the technical description of what broke on the aircraft and merely detailing the direct immediate actions of the crew.
Every factor that can be identified as a contributing factor should be examined to determine how it occurred and how it can be prevented from occurring again. The key is fixing what is broke before it can strke down another crew and load of passengers.
Look at the Night Offshore Approach thread.....and DB's effort to improve night flying techniques and procedures industry wide. That is the exact right response to the Bond CFIT accident. He has us all re-thinking our mindset re night flying offshore. That is a good thing!
Let's do the same with the Cougar tragedy so we can keep something like this happening again.
We need to rethink our attitudes towards gearbox failures, certification tests and standards, communication of defect reports and ensuring proper action is taken in a most timely manner. We need to review industry wide the way we train pilots, formulate emergency procedures, structure response plans, and monitor engineering standards for effective levels of safety review.
What if we find out Cougar had those very steel studs on the shelf in anticipation of an upcoming scheduled inspection and all this could have been prevented by merely installing them upon receipt? That is the kind of review we are talking about.....looking at every facet of this accident to see how the Human decision making process allowed this to happen.
This is not finger pointing....or laying blame....just being honest with ourselves on how we really do business and comparing it to how we should be doing business.
I did not know any of these folks but I have known way too many of them in the past and that is what makes me speak out as I do when these things happen.
Read the post carefully.
Pilot Error is when you the pilot kill a perfectly good aircraft.....one that is completely serviceable.
Cockpit Error means you contributed to the outcome by making a mistake (and I construe that to mean independently of outside involvement).
Operational Error....means you had outside help in making the error.
Human Errors are normal....they happen every day on every flight. They don't necessarily have a bad outcome. Ever miss a radio call and have to be spoke to a second time before you hear the call? Ever dial up a wrong frequency and catch yourself? Ever punch the wrong start button and think what a buffoon you are?
The Human Errors I see in this Cougar thing are some that did not get caught and wound up with a bad outcome.
The investigation should dig into every one of them along with coming up with the technical description of what broke on the aircraft and merely detailing the direct immediate actions of the crew.
Every factor that can be identified as a contributing factor should be examined to determine how it occurred and how it can be prevented from occurring again. The key is fixing what is broke before it can strke down another crew and load of passengers.
Look at the Night Offshore Approach thread.....and DB's effort to improve night flying techniques and procedures industry wide. That is the exact right response to the Bond CFIT accident. He has us all re-thinking our mindset re night flying offshore. That is a good thing!
Let's do the same with the Cougar tragedy so we can keep something like this happening again.
We need to rethink our attitudes towards gearbox failures, certification tests and standards, communication of defect reports and ensuring proper action is taken in a most timely manner. We need to review industry wide the way we train pilots, formulate emergency procedures, structure response plans, and monitor engineering standards for effective levels of safety review.
What if we find out Cougar had those very steel studs on the shelf in anticipation of an upcoming scheduled inspection and all this could have been prevented by merely installing them upon receipt? That is the kind of review we are talking about.....looking at every facet of this accident to see how the Human decision making process allowed this to happen.
This is not finger pointing....or laying blame....just being honest with ourselves on how we really do business and comparing it to how we should be doing business.
I did not know any of these folks but I have known way too many of them in the past and that is what makes me speak out as I do when these things happen.
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SAS I can't disagree with you on the points you raise but i am quite pragmatic and maybe a little cynical and i did say i was only playing devil's advocate.
The possibility remains that because the pilots did not follow the manufacturer's recommendations regarding this type of event i'm reasonably confident that with the right lawyer "spin" the crew will be blamed for this, at least in some way.
I don't agree with it but i am a realist and i'll be surprised if any opportunity is not fully exploited to lessen the bad PR effect this incident has on the manufacturer.
But as i said SAS i agree with you and your cause.
Chester
The possibility remains that because the pilots did not follow the manufacturer's recommendations regarding this type of event i'm reasonably confident that with the right lawyer "spin" the crew will be blamed for this, at least in some way.
I don't agree with it but i am a realist and i'll be surprised if any opportunity is not fully exploited to lessen the bad PR effect this incident has on the manufacturer.
But as i said SAS i agree with you and your cause.
Chester
Good post SASless.
But...the lawyers will ask:
"...given the same aircraft fault, was there any way a crew could have operated this aircraft to avoid the catastophic crash?"
It may not be pilot error per se.
And IF there was an "ideal sequence of events" that could have been carried out by a crew in order to avoid the eventual crash, it comes down to the degree by which this operating crew deviated from the "ideal sequence of events".
If the majority of reasonable pilots would have largely mirrored the actions of the crash crew, they should be vindicated. If the majority of resonable pilots would have done something differently, then there may be a case to answer.
It's a tough one, but ultimately the aim should be not punishment of crews, but improvement in the way things are done.
But...the lawyers will ask:
"...given the same aircraft fault, was there any way a crew could have operated this aircraft to avoid the catastophic crash?"
It may not be pilot error per se.
And IF there was an "ideal sequence of events" that could have been carried out by a crew in order to avoid the eventual crash, it comes down to the degree by which this operating crew deviated from the "ideal sequence of events".
If the majority of reasonable pilots would have largely mirrored the actions of the crash crew, they should be vindicated. If the majority of resonable pilots would have done something differently, then there may be a case to answer.
It's a tough one, but ultimately the aim should be not punishment of crews, but improvement in the way things are done.
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Run Dry Testing
If I understand things correctly the test is carried out by running an otherwise perfect MGB on the test-bed with a fully functioning lubrication system and then stopping everything whilst the oil is drained. The test is then re-started with representative loads equal to something close to normal flight.
It is important to understand that this test is therefore one designed to experiment with a MGB that has simply lost all the oil and is otherwise undamaged.
When contructing training scenarios in the simulator I try to add a realsitic context, one that recreates the real world where you the pilot DO NOT KNOW WHAT IS GOING ON BACK THERE. You have a MGB with sensors and these, plus your eyes and ears are what guides your response.
If I have learnt anything over the years it's that the RFM is written by experts but is not read by the aircraft. The experts largely second-guess the failure modes expected based on their experience and their knowledge of the system design. There will always be failure modes that were not thought of by the experts and we, the trainers, must teach a more generic approach to this possibility thereby extracting, in the process, the very best CRM from the trainees. At the very least you come away from such exercises with an greater understanding of where the Emergency Checklist stands in the scheme of things.
Malfunctions and failures cannot be ordered up like a 'Burger-Meal-Suoer-Size-To-Go'. Many many malfunctions that I have experienced or read about are NOT per the text-book, were never contemplated.
Knowing that and with a streak of self preservation the obvious course of action if anything threatens your ability to stay airborne is to get on the surface. If the waters are rough and colour your decision making then we MUST look at THIS aspect of the equation and ask ourselves if we have it right yet. Was the survival equipment as good as it can reasonably be expected to be. Was the aircraft flying over a sea-state beyond the certification standards? How can we make a controlled landing on the water in adverse conditions as safe as possible so that the obvious decision to 'land immediately' can be taken without, or at least with as little fear as possible.
I bet the clothing worn underneath survival suits will henceforth be appropriate if it wasn't before and if it wasn't adequate why was that situation allowed to be?
I attended a Shell sponsored safety seminar many years back at which the head of IFALPA said "Ladies and gentlemen - we need accidents.......". He went on to explain that managements the world over only focus their attention and often only allocate additional resources when they are in that post-accident traumatised state. We may need that attention, may need those resources if we find there are things that need fixing, things that need further research or equipment that has to be bought. I hope that between them those associated with this unfortunate accident can find the resources to make improvements to the aircraft, to the safety equipment and to the protocols and procedures related to avoiding a repetition in the future.
G
It is important to understand that this test is therefore one designed to experiment with a MGB that has simply lost all the oil and is otherwise undamaged.
When contructing training scenarios in the simulator I try to add a realsitic context, one that recreates the real world where you the pilot DO NOT KNOW WHAT IS GOING ON BACK THERE. You have a MGB with sensors and these, plus your eyes and ears are what guides your response.
If I have learnt anything over the years it's that the RFM is written by experts but is not read by the aircraft. The experts largely second-guess the failure modes expected based on their experience and their knowledge of the system design. There will always be failure modes that were not thought of by the experts and we, the trainers, must teach a more generic approach to this possibility thereby extracting, in the process, the very best CRM from the trainees. At the very least you come away from such exercises with an greater understanding of where the Emergency Checklist stands in the scheme of things.
Malfunctions and failures cannot be ordered up like a 'Burger-Meal-Suoer-Size-To-Go'. Many many malfunctions that I have experienced or read about are NOT per the text-book, were never contemplated.
Knowing that and with a streak of self preservation the obvious course of action if anything threatens your ability to stay airborne is to get on the surface. If the waters are rough and colour your decision making then we MUST look at THIS aspect of the equation and ask ourselves if we have it right yet. Was the survival equipment as good as it can reasonably be expected to be. Was the aircraft flying over a sea-state beyond the certification standards? How can we make a controlled landing on the water in adverse conditions as safe as possible so that the obvious decision to 'land immediately' can be taken without, or at least with as little fear as possible.
I bet the clothing worn underneath survival suits will henceforth be appropriate if it wasn't before and if it wasn't adequate why was that situation allowed to be?
I attended a Shell sponsored safety seminar many years back at which the head of IFALPA said "Ladies and gentlemen - we need accidents.......". He went on to explain that managements the world over only focus their attention and often only allocate additional resources when they are in that post-accident traumatised state. We may need that attention, may need those resources if we find there are things that need fixing, things that need further research or equipment that has to be bought. I hope that between them those associated with this unfortunate accident can find the resources to make improvements to the aircraft, to the safety equipment and to the protocols and procedures related to avoiding a repetition in the future.
G
If I understand things correctly the test is carried out by running an otherwise perfect MGB on the test-bed with a fully functioning lubrication system and then stopping everything whilst the oil is drained. The test is then re-started with representative loads equal to something close to normal flight.
(1) Section 29.927(c) prescribes a test which is intended to demonstrate that no hazardous failure or malfunction will occur in the event of a major rotor drive system lubrication failure. The lubrication failure should not impair the ability of the crew to continue safe operation of Category A rotorcraft for at least 30 minutes after perception of the failure by the flight crew. For Category B rotorcraft, safe operation under autorotative conditions should continue for at least 15 minutes. Near the completion of the lubrication failure test, an input torque should be applied for 15 seconds to simulate a minimum power landing following autorotation. Some damage to rotor drive system components is acceptable after completion of the lubrication system testing. The lubrication system failure modes of interest are usually limited to failure of bearings, gears, splines, clutches, etc., of pressure lubricated transmissions and/or gearboxes. A bench test (transmission test rig) is commonly used to demonstrate compliance with this
rule. Since this is a test of the capability of the residual oil in the ransmission to provide limited lubrication, a critical entry condition for the test should be established. The transmission lubricating oil should be drained while the transmission is operating at maximum normal speed and nominal cruise torque (reacted as appropriate at the main mast and tail rotor output quills). A vertical load should be applied at the mast, equal to the gross weight of the rotorcraft at 1g, and the lubricant should be at the maximum temperature limit. Upon illumination of the low oil pressure warning required by § 29.1305, reduce the input torque for Category A rotorcraft to the minimum torque necessary to sustain flight at the maximum gross weight and the most efficient flight conditions. To complete the test, apply an input torque to the transmission for approximately 25 seconds to simulate an autorotation. The last 10 seconds (of the 25 seconds) should be at the torque required for a minimum power landing. A successful demonstration may involve limited damage to the transmission, provided it is determined that the autorotative capabilities of the rotorcraft were not significantly impaired. For Category B rotorcraft, upon illumination of the low oil pressure warning light, reduce the input torque to simulate an autorotation and continue transmission operation for 15 minutes. To complete the test, apply an input torque to the transmission for approximately 15 seconds to simulate a minimum power anding. A successful demonstration may involve limited damage to the transmission provided it is determined that the autorotative capabilities of the rotorcraft were not significantly impaired. If compliance with Category A requirements is demonstrated, Category B requirements will have been met.
rule. Since this is a test of the capability of the residual oil in the ransmission to provide limited lubrication, a critical entry condition for the test should be established. The transmission lubricating oil should be drained while the transmission is operating at maximum normal speed and nominal cruise torque (reacted as appropriate at the main mast and tail rotor output quills). A vertical load should be applied at the mast, equal to the gross weight of the rotorcraft at 1g, and the lubricant should be at the maximum temperature limit. Upon illumination of the low oil pressure warning required by § 29.1305, reduce the input torque for Category A rotorcraft to the minimum torque necessary to sustain flight at the maximum gross weight and the most efficient flight conditions. To complete the test, apply an input torque to the transmission for approximately 25 seconds to simulate an autorotation. The last 10 seconds (of the 25 seconds) should be at the torque required for a minimum power landing. A successful demonstration may involve limited damage to the transmission, provided it is determined that the autorotative capabilities of the rotorcraft were not significantly impaired. For Category B rotorcraft, upon illumination of the low oil pressure warning light, reduce the input torque to simulate an autorotation and continue transmission operation for 15 minutes. To complete the test, apply an input torque to the transmission for approximately 15 seconds to simulate a minimum power anding. A successful demonstration may involve limited damage to the transmission provided it is determined that the autorotative capabilities of the rotorcraft were not significantly impaired. If compliance with Category A requirements is demonstrated, Category B requirements will have been met.
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Many thanks for adding that detail. Fascinating as it may be the point I was making is that the test seeks to second guess the failure mode which, as we can see does not entertain any other internal damage or maybe oil contamination that may shorten bearing life or vibration which may exacerbate the possibility of gear teeth fracture.
I'm not trying to create an inventory of failure modes but simply saying that we as flight crew are not well placed to understand the exact nature of a failure when we are given some simple information via Ts and Ps and possibly accelerometers and chip detectors.
My gut feel is that we should find somewhere to put down anytime we doubt the airworthiness of the machine. This would typically be because of a fire hazard, hydraulic problems or transmission problems. Clearly we don't want to throw the aircraft into the water at the first sign of a malfunction because the chances of it ever flying again are slim but that said I would rather be embarrassed than dead. The SAR 332L2 in NL last year (or was it the year before?) is a case in point. Who cares about the airframe when everybody gets back alive. If a bunch of machines end up in Davy Jones's Locker then maybe the insurance companies will have something to say about it and we will be forced to improve things. What worries me is the angst caused by the survivability issues surrounding a ditching. We somehow have to make it a more attractive option. I can’t imagine that the Canadian crew of this S92a would have turned down the safety of a Liferaft if they had considered it a safer option.
G.
I'm not trying to create an inventory of failure modes but simply saying that we as flight crew are not well placed to understand the exact nature of a failure when we are given some simple information via Ts and Ps and possibly accelerometers and chip detectors.
My gut feel is that we should find somewhere to put down anytime we doubt the airworthiness of the machine. This would typically be because of a fire hazard, hydraulic problems or transmission problems. Clearly we don't want to throw the aircraft into the water at the first sign of a malfunction because the chances of it ever flying again are slim but that said I would rather be embarrassed than dead. The SAR 332L2 in NL last year (or was it the year before?) is a case in point. Who cares about the airframe when everybody gets back alive. If a bunch of machines end up in Davy Jones's Locker then maybe the insurance companies will have something to say about it and we will be forced to improve things. What worries me is the angst caused by the survivability issues surrounding a ditching. We somehow have to make it a more attractive option. I can’t imagine that the Canadian crew of this S92a would have turned down the safety of a Liferaft if they had considered it a safer option.
G.
Is it not the case however that the S-92 was never proven to meet these requirements ? I'm sure that was the original plan, but when testing proved that it didn't meet the spec, they were able to certify the aircraft without the dry running ability under the 'Unless such failures are extremely remote" loophole.
So whilst these definitions are clear and seemingly well thought out, the S-92 was able to get certified without meeting them.
So whilst these definitions are clear and seemingly well thought out, the S-92 was able to get certified without meeting them.
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They are saying he has "turned the corner" and has had surgery for broken vertibrais in his back. From the news story on the link he has spoken to family and doctors and will hopefully be fit for interview at the end of the week but is still fighting serious injuries.
NST
Sole survivor may soon provide chopper crash answers: RCMP
NST
Sole survivor may soon provide chopper crash answers: RCMP
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Differences in training
It has occurred to me, and was the subject of a recent discussion I had with a recently retired jet fighter pilot, that our civilian training lacks something, which I think must be core in military training: The concept that the flying machine is paid for, who cares, save the people. This closely corresponds to; okay, I was flying one second ago, now I'm riding, I don't like it - eject! And you're out of there...
During a discussion on another thread, I offered that I doubt that I could get my head around the concept of the ballistic parachutes found on a few GA airplanes, and when to use it. Nothing in my training has ever addressed the concept of "give up flying now, and pull this handle". I've always been trained, and practiced, making the best of things, and aiming for a suitable landing area, and trying to save everything. The spectre of being harder to insure as a pilot in the future plays into this.
The difference being the concept of "save youself, forget the machine" Civilian operators really don't highlight this as much as the military - cost of crew training relative to cost of machine, I suppose. It was a shock for me a year ago, during specialized marine training, while standing at the dock, to be told by the instructor "drive it like you stole it, you don't have to pay for it, no matter what happens". You don't ever hear that on a civilian flight line! The training environment was much more relaxed, and I didn't ding the boat!
Our industry will help itself, if we draw together the currently distant elements of a machine which will really tell the pilots "okay, this is it, I'm drawing my last breath one way or the other, save yourselves now"; and pilot training which includes more reassurance that when you get that message, the boss, and insurance company, agree that the flight crew are no longer resonsible for the machine - only the people - do what you've gotta do!
In today's information age, why don't pilots have a suscinct summary of a lot of information? Instead of a chip light, and a low pressure indication, and a high oil temp indication, why does the pilot not get a message (like the soft voiced british lady some where in the spacecraft of all of those Sci-Fi movies), which urgently says: "Land now regardless of the surface under you. I'm watching 10 chip sensors, 8 temperatures, 4 pressures, 2 smoke detectors, and three torques in the main rotor transmission. 82% of the indications are outside the prescribed limits, and you should expect that the rotor will not be turning 115 seconds from now. Land now regardless of the surface under you." Once that message was written on the EFIS, and spoken to the CVR, the pilots would know that they were off the hook for the machine.
Our industry needs to take the pressure off the pilot for deciding that a flight must end before they planned it to, and include the concept that "abandon flight " is also worthy of pride.
Pilot DAR
During a discussion on another thread, I offered that I doubt that I could get my head around the concept of the ballistic parachutes found on a few GA airplanes, and when to use it. Nothing in my training has ever addressed the concept of "give up flying now, and pull this handle". I've always been trained, and practiced, making the best of things, and aiming for a suitable landing area, and trying to save everything. The spectre of being harder to insure as a pilot in the future plays into this.
The difference being the concept of "save youself, forget the machine" Civilian operators really don't highlight this as much as the military - cost of crew training relative to cost of machine, I suppose. It was a shock for me a year ago, during specialized marine training, while standing at the dock, to be told by the instructor "drive it like you stole it, you don't have to pay for it, no matter what happens". You don't ever hear that on a civilian flight line! The training environment was much more relaxed, and I didn't ding the boat!
Our industry will help itself, if we draw together the currently distant elements of a machine which will really tell the pilots "okay, this is it, I'm drawing my last breath one way or the other, save yourselves now"; and pilot training which includes more reassurance that when you get that message, the boss, and insurance company, agree that the flight crew are no longer resonsible for the machine - only the people - do what you've gotta do!
In today's information age, why don't pilots have a suscinct summary of a lot of information? Instead of a chip light, and a low pressure indication, and a high oil temp indication, why does the pilot not get a message (like the soft voiced british lady some where in the spacecraft of all of those Sci-Fi movies), which urgently says: "Land now regardless of the surface under you. I'm watching 10 chip sensors, 8 temperatures, 4 pressures, 2 smoke detectors, and three torques in the main rotor transmission. 82% of the indications are outside the prescribed limits, and you should expect that the rotor will not be turning 115 seconds from now. Land now regardless of the surface under you." Once that message was written on the EFIS, and spoken to the CVR, the pilots would know that they were off the hook for the machine.
Our industry needs to take the pressure off the pilot for deciding that a flight must end before they planned it to, and include the concept that "abandon flight " is also worthy of pride.
Pilot DAR
As an back in my younger days on the Chinook in Uncle's Army....I had the good fortune to have been around some old helicopter pilots. One of the things we espoused was the aircraft was merely a re-usable container much akin to a metal shipping container that engines or other large components arrived in from the depot.
We taught the contents of that expendable container was what was important....and not the container.
As a civilian pilot it is the same.
Either the owner has insurance or he best have some deep pockets as the concept is the same. The boss fellah can buy you another helicopter but he cannot replace your life and limbs.
The only concern you should have for the aircraft is not using it up for no good reason.....but when you need to....save your hide first and worry about the helicopter after the fact.
We taught the contents of that expendable container was what was important....and not the container.
As a civilian pilot it is the same.
Either the owner has insurance or he best have some deep pockets as the concept is the same. The boss fellah can buy you another helicopter but he cannot replace your life and limbs.
The only concern you should have for the aircraft is not using it up for no good reason.....but when you need to....save your hide first and worry about the helicopter after the fact.
Join Date: Mar 2005
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I was always told " any landing/ditching you can walk away from is a good one, If the aircraft can be reused as well it's a great one!!!"
If we all practised it to the letter there would probably be less machines to fly but more pilots and pax alive.
Chester
If we all practised it to the letter there would probably be less machines to fly but more pilots and pax alive.
Chester
I’m not sure that it serves any useful purpose trying to pin the tail on the donkey in seeking a single cause to this accident. Perhaps we should move away from the use of human error and towards the less pointed human factors. The primary cause of this accident appears to be a mechanical failure; to establish all secondary causes requires that we look back and try to understand why the previous incident did not ‘raise the hackles’ and why it was felt that there was ‘room to manoeuvre’ after the first stud failure last year.
It is clear that the precursors to this accident had already been seen; on July 3rd last year malabo hinted at a transmission problem in Australia; Heli-kiwi then indicated a failure of oil filter studs; Malabo and Heli-kiwi traded quips until, after being pressed by NorthSeaTiger, Heli-kiwi gave us the essential information
Following this report, the thread meandered on but was more engaged by the incident of a pump failure than the fact that we had seen an extremely serious incident caused by a major failure of the MGB assembly.
Within hours, it was known that all MGB oil had been lost through the filter bowl assembly. Shortly after that, it was also known that this was caused by the failure of the titanium studs. As was pointed out in an earlier post, we now had a failure mode which had not been considered during certification. In fact it must have been known quite soon after the inspection that, without a change of material for the studs, another failure was foreseeable with a likelihood of reasonably probable. Such a conclusion (if recognised, and it is not clear that it was) should have triggered a hazard analysis which should have impacted, in turn, the manufacturer, the regulator and the operator.
The manufacturer and the regulator should have conducted an assessment of whether the aircraft should be grounded until the titanium studs were replaced, against the likelihood of another failure. The fact that the aircraft was not grounded and, in the letter to operators in January, it was still not felt necessary permitting, instead, another 1250hrs or 12 months for replacement is not easily understood (in hindsight). Even with a 30 minute run-dry capability this would appear too relaxed. However, having made those decisions, all operators should have been brought into the decision making process because it was them, and their customers, who were now to take the front-line risk.
At the very least, the results of the investigation of the Broome incident should have been promulgated to all operators so that they could educate/inform their pilots, so that the likelihood and consequence of such a failure would be foremost in the minds. More, the whole notion of a 30 minute run-dry time for gearbox should have been debunked and the necessity, regardless of environment, of a ‘land immediately’ in any case of a loss of oil pressure reiterated. In view of the fact that data had been collected during the Broome incident, it would also have been possible to put the sequence of events and cockpit indications into a file, and distributed for the purpose of demonstrating the symptoms and indications.
This leads to the questions:
(1) Was the probability of another stud failure established?
(2) Was the probability of this event put to the regulator?
(3) Did the regulator accept that nothing need be done until the new stud had been sourced?
(4) When the new stud was sourced, was the rectification interval accepted by the regulator?
(5) Were the operators informed of the Broome event and the probability of another until such time as the studs had been replaced?
(6) If the operators were made aware of the situation, did they risk assess their procedures with the aim of minimising the consequences of a failure?
(7) were the operational and training departments aware of the probability of failures and did they place appropriate focus on the required actions?
The main difference between the first incident and the Cougar accident is the action of the crew following the manifestation of the same emergency. We can only speculate on why there were differences in reaction but it is probable that it was due to the operational environment: in Australia, the aircraft had coasted in and was over land; in Canada, the aircraft was over Sea State 5 and a water temperature of just above zero. Regardless of this, had the sequence of actions shown above been put into place, this accident might have been another (however, more serious) incident.
Anyone who reads this (and the S92) thread now knows that ‘land immediately’ provides no leeway. It should never have been in doubt; it might not have been if we had learnt the lessons from the Broome incident and paid less heed to those for whom such rules/procedures are seen as a challenge to their intellect.
It is clear that the precursors to this accident had already been seen; on July 3rd last year malabo hinted at a transmission problem in Australia; Heli-kiwi then indicated a failure of oil filter studs; Malabo and Heli-kiwi traded quips until, after being pressed by NorthSeaTiger, Heli-kiwi gave us the essential information
Day before yesterday an S92 was onroute to Broome on a return flight from an offshore rig when a main Txmsm low oil pressure was noted, shortly afterwards remaining oil pressure ceased completely and a fairly rapid decent was carried out. From time of intial low px indication at 6000ft to touchdown was 8 minutes. The oil filter housing which apparently has 3 studs fastening it to the txmsn was hanging on by one which hadn't broken and most of the oil had been pumped out.
Within hours, it was known that all MGB oil had been lost through the filter bowl assembly. Shortly after that, it was also known that this was caused by the failure of the titanium studs. As was pointed out in an earlier post, we now had a failure mode which had not been considered during certification. In fact it must have been known quite soon after the inspection that, without a change of material for the studs, another failure was foreseeable with a likelihood of reasonably probable. Such a conclusion (if recognised, and it is not clear that it was) should have triggered a hazard analysis which should have impacted, in turn, the manufacturer, the regulator and the operator.
The manufacturer and the regulator should have conducted an assessment of whether the aircraft should be grounded until the titanium studs were replaced, against the likelihood of another failure. The fact that the aircraft was not grounded and, in the letter to operators in January, it was still not felt necessary permitting, instead, another 1250hrs or 12 months for replacement is not easily understood (in hindsight). Even with a 30 minute run-dry capability this would appear too relaxed. However, having made those decisions, all operators should have been brought into the decision making process because it was them, and their customers, who were now to take the front-line risk.
At the very least, the results of the investigation of the Broome incident should have been promulgated to all operators so that they could educate/inform their pilots, so that the likelihood and consequence of such a failure would be foremost in the minds. More, the whole notion of a 30 minute run-dry time for gearbox should have been debunked and the necessity, regardless of environment, of a ‘land immediately’ in any case of a loss of oil pressure reiterated. In view of the fact that data had been collected during the Broome incident, it would also have been possible to put the sequence of events and cockpit indications into a file, and distributed for the purpose of demonstrating the symptoms and indications.
This leads to the questions:
(1) Was the probability of another stud failure established?
(2) Was the probability of this event put to the regulator?
(3) Did the regulator accept that nothing need be done until the new stud had been sourced?
(4) When the new stud was sourced, was the rectification interval accepted by the regulator?
(5) Were the operators informed of the Broome event and the probability of another until such time as the studs had been replaced?
(6) If the operators were made aware of the situation, did they risk assess their procedures with the aim of minimising the consequences of a failure?
(7) were the operational and training departments aware of the probability of failures and did they place appropriate focus on the required actions?
The main difference between the first incident and the Cougar accident is the action of the crew following the manifestation of the same emergency. We can only speculate on why there were differences in reaction but it is probable that it was due to the operational environment: in Australia, the aircraft had coasted in and was over land; in Canada, the aircraft was over Sea State 5 and a water temperature of just above zero. Regardless of this, had the sequence of actions shown above been put into place, this accident might have been another (however, more serious) incident.
Anyone who reads this (and the S92) thread now knows that ‘land immediately’ provides no leeway. It should never have been in doubt; it might not have been if we had learnt the lessons from the Broome incident and paid less heed to those for whom such rules/procedures are seen as a challenge to their intellect.