Helicopter crash off the coast of Newfoundland - 18 aboard, March 2009
JimL,
You are saying exactly what I have been for the past week or so.
My question to you is a bit more direct.
Why is it incumbent for someone outside the "Regulator" supposed to raise an issue.....don't the Regulators have a responsibility to monitor events as they happen and question both operators and manufacturers?
You use the singular...."Regulator" and not the plural....."Regulators".
Why did the situation you so correctly describe escape action by the Australian, American, British, and Canadian Regulators?
Why did this situation get by the Operators?
Why did this situation get by Sikorsky?
Who in the hell is supposed to be looking ahead amongst all those groups?
My answer.....every one of them!
Yet, not one person, regulator, or operator saw need to raise the flag!
There is no excuse for such a thing to happen in this day and time with all the studies, concepts, procedures, reporting venues, and communication capability we have at hand to identify such issues.
What is going to happen now.....the Regulators going to step up to the plate and admit their failure?
Will the Operators step up and admit their failure?
Will Sikorsky own up to its failure?
Or will we see the Regulators point their fingers at someone else, the Operators slink off into the bushes and hire some high dollar lawyers, and Sikorsky do the same?
I suggest there ought to be some Government Employment vacancies crop up very soon for a start. Operators need to do their soul searching as well.
Needless to say....Sikorsky is going to be given lots of assistance in finding their faults in this.
You are saying exactly what I have been for the past week or so.
My question to you is a bit more direct.
Why is it incumbent for someone outside the "Regulator" supposed to raise an issue.....don't the Regulators have a responsibility to monitor events as they happen and question both operators and manufacturers?
You use the singular...."Regulator" and not the plural....."Regulators".
Why did the situation you so correctly describe escape action by the Australian, American, British, and Canadian Regulators?
Why did this situation get by the Operators?
Why did this situation get by Sikorsky?
Who in the hell is supposed to be looking ahead amongst all those groups?
My answer.....every one of them!
Yet, not one person, regulator, or operator saw need to raise the flag!
There is no excuse for such a thing to happen in this day and time with all the studies, concepts, procedures, reporting venues, and communication capability we have at hand to identify such issues.
What is going to happen now.....the Regulators going to step up to the plate and admit their failure?
Will the Operators step up and admit their failure?
Will Sikorsky own up to its failure?
Or will we see the Regulators point their fingers at someone else, the Operators slink off into the bushes and hire some high dollar lawyers, and Sikorsky do the same?
I suggest there ought to be some Government Employment vacancies crop up very soon for a start. Operators need to do their soul searching as well.
Needless to say....Sikorsky is going to be given lots of assistance in finding their faults in this.
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Hi SaSSless
Can’t resist coming back re your post. I have one simple statement that I have used over many years seeing unfortunately continued failings in areas that should have been Red flagged. “Hindsight is a great leveller”
The ownership of this particular failing is as we know complex, will any one entity admit, answer NO, will lessons be learnt and improvements to the system be effective, unfortunately I suspect NO. Will the lobby of big business and company interests continue to have the influence they now have, answer YES.
I stand to be pilloried I know, but after over 40 odd years in the industry and seeing the so called advances in the legislation that supposedly was developed to protect, prevent and safe guard operation of helicopters the crew and passengers from predictable failings, we still see repeated events like the one in question.
At least when I started we knew the risk, the failings and lightly cause of a dramatic and spectacular meeting with our maker.
We did not have the illusion that the system gave a measure of protection; we had no WWW and the unfortunate risk of misinformation that could affect critical decisions. My own indicator was an Itch in by neck and it never let me down.
There are only old aviators; the bold seem to fade away.
Back into retirement.
Outhouse.
Can’t resist coming back re your post. I have one simple statement that I have used over many years seeing unfortunately continued failings in areas that should have been Red flagged. “Hindsight is a great leveller”
The ownership of this particular failing is as we know complex, will any one entity admit, answer NO, will lessons be learnt and improvements to the system be effective, unfortunately I suspect NO. Will the lobby of big business and company interests continue to have the influence they now have, answer YES.
I stand to be pilloried I know, but after over 40 odd years in the industry and seeing the so called advances in the legislation that supposedly was developed to protect, prevent and safe guard operation of helicopters the crew and passengers from predictable failings, we still see repeated events like the one in question.
At least when I started we knew the risk, the failings and lightly cause of a dramatic and spectacular meeting with our maker.
We did not have the illusion that the system gave a measure of protection; we had no WWW and the unfortunate risk of misinformation that could affect critical decisions. My own indicator was an Itch in by neck and it never let me down.
There are only old aviators; the bold seem to fade away.
Back into retirement.
Outhouse.
Last edited by outhouse; 31st Mar 2009 at 15:26.
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Outhouse,
Hopefully, I can put a little reassurance back into "the system" for you...
I am a regulator (though nothing whatever to do with FAA, Sikorsky, or Cougar Helicopters). I am learning from this event, and will do better in the future because of it. It can be hard for a "little guy" to stand up to big business, but at the end of the day, they're asking for my signature on a recommedation for desgin approval, and I'll only sign, when I can see that compliance HAS been demonstrated, as the standard intends. Sometimes the wording of the standards are somewhat ambiguous. "Interpretation" can be a problem, though I cannot imagine how in this case!
As long as each "little guy" in the system does his or her job properly, the system works pretty well. I assure you that as every item of compliance requires the signature of a duly appointed person against it, before approval will be issued.
Everything our industry depends upon people doing their best for the next guy down the line. An "event" can serve well to remind us of how that obligation is so important...
Pilot DAR
Hopefully, I can put a little reassurance back into "the system" for you...
unfortunately I suspect NO. Will the lobby of big business and company interests continue to have the influence they now have, answer YES.
As long as each "little guy" in the system does his or her job properly, the system works pretty well. I assure you that as every item of compliance requires the signature of a duly appointed person against it, before approval will be issued.
Everything our industry depends upon people doing their best for the next guy down the line. An "event" can serve well to remind us of how that obligation is so important...
Pilot DAR
The FAA TCDS (type certificate data sheet) is a good source of performance information and in the case of the S92 there is no mention of a run dry capability. I would have assumed that if so certified then it would have warranted a line.
What it does say is (the capitals are theirs not mine).
THE HELICOPTER MUST BE OPERATED IN ACCORDANCE WITH THE OPERATING LIMITATIONS SPECIFIED IN THE FAA APPROVED ROTORCRAFT FLIGHT MANUAL.
No mention of operating it in accordance with the manufacturers sales blurb.
I am truly grateful that I have never found myself in a similar situation to this. The man who thought of the expression caught betwen a rock and a hard place must have had this crew in mind.
What it does say is (the capitals are theirs not mine).
THE HELICOPTER MUST BE OPERATED IN ACCORDANCE WITH THE OPERATING LIMITATIONS SPECIFIED IN THE FAA APPROVED ROTORCRAFT FLIGHT MANUAL.
No mention of operating it in accordance with the manufacturers sales blurb.
I am truly grateful that I have never found myself in a similar situation to this. The man who thought of the expression caught betwen a rock and a hard place must have had this crew in mind.
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As Outhouse very aptly stated - Hindsight is a wonderful thing.
I was in Aberdeen when the inclined driveshaft hinge pin fell out of TIGD (332L) on short finals for the runway.
The very same failure had happened on at least one 330J Puma and the design on that had been changed - why did the 'bad' design reappear on the newer machine?
As it was the aircraft ended up on it's side but if this had come about earlier in the flight, who knows what the outcome would have been.
I was in Aberdeen when the inclined driveshaft hinge pin fell out of TIGD (332L) on short finals for the runway.
The very same failure had happened on at least one 330J Puma and the design on that had been changed - why did the 'bad' design reappear on the newer machine?
As it was the aircraft ended up on it's side but if this had come about earlier in the flight, who knows what the outcome would have been.
PD good post, glad you will stand up and be counted.
The 30 minute claim?? in the sales literature is very loose wording leaving you to make of it what you will.
.EF reminds us of the TCDS and says no mention of run dry yet there is a caption on sales literature pointing strongly in that direction, it would be in the back of my mind that things were not as bad as they seem.
S25s post
"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. ( there is either a requirement or not ) & as it failed to meet the requirement surely the failure in not a remote possibility
So whilst these definitions are clear and seemingly well thought out, the S-92 was able to get certified without meeting them. ".
The 30 minute claim?? in the sales literature is very loose wording leaving you to make of it what you will.
.EF reminds us of the TCDS and says no mention of run dry yet there is a caption on sales literature pointing strongly in that direction, it would be in the back of my mind that things were not as bad as they seem.
S25s post
"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. ( there is either a requirement or not ) & as it failed to meet the requirement surely the failure in not a remote possibility
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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Perhaps the sales literature was referring to an oil cooler leak that could be isolated with the bypass switch, thus allowing continued operation for at least 30 minutes. A previous post indicated that two and a half hours had elapsed on the test machine, which obviously was not a FAR29 category "A" test. Hence no mention in the FAA TCDS...I'm quite sure that no pilot worth his salt would ever put too much faith in a manufacturer's sales pitch.
From what I've read in previous posts the RFM states land immediately on MGB pressure < 5 psi and that's what should have happened had the guys had enough time to execute that manouvere. I suspect that the MGB temp went to ambient when the guys were dropping to 800 feet as there was no lube oil to wet the sensor, they checked with flight ops and they said "probably a faulty MGB press sensor, bring it back to the hangar", the guys went to 133 knots and didn't know anything else was amiss until the pressure went to zero and the MBG failed along with the inputs for the AC gens, with not enough time to active the APU and/or arm the flotation bags (couldn't happen anyway as they were > 80 knots) hence the FDR/CVR switching off and the flotation bags not being released on water contact. This is only supposition but I can see how this hypothetical sequence of events would make sense.
Robert Decker, the sole survivor of flight 491, is now recuperating at home, and will hopefully shed some light into the actual events of the last few fatal minutes. I'm sure the TSB will glean more data from the remaining avionics components that are still being analysed by the specialists.
From what I've read in previous posts the RFM states land immediately on MGB pressure < 5 psi and that's what should have happened had the guys had enough time to execute that manouvere. I suspect that the MGB temp went to ambient when the guys were dropping to 800 feet as there was no lube oil to wet the sensor, they checked with flight ops and they said "probably a faulty MGB press sensor, bring it back to the hangar", the guys went to 133 knots and didn't know anything else was amiss until the pressure went to zero and the MBG failed along with the inputs for the AC gens, with not enough time to active the APU and/or arm the flotation bags (couldn't happen anyway as they were > 80 knots) hence the FDR/CVR switching off and the flotation bags not being released on water contact. This is only supposition but I can see how this hypothetical sequence of events would make sense.
Robert Decker, the sole survivor of flight 491, is now recuperating at home, and will hopefully shed some light into the actual events of the last few fatal minutes. I'm sure the TSB will glean more data from the remaining avionics components that are still being analysed by the specialists.
I believe this is the up to date Emergency Procedure that would have been reviewed by the Crew and the Cougar Ops folks during the conversation they held by radio during the descent to 800 feet.
I have added the bold print and underlining.
Do you 92 drivers out there concur in this is the procedure you have been taught and are expected to conform to by your operator?
I have added the bold print and underlining.
Do you 92 drivers out there concur in this is the procedure you have been taught and are expected to conform to by your operator?
MAIN GEARBOX OIL SYSTEM FAILURE
Symptom:
MGB OIL PRES or MGB OIL HOT or MGB CHIP or ACC 1 CHIP or ACC 2 CHIP or MGB OIL PRES
GEARBOX OIL PRESSURE aural alert.
Confirming:
NOTE
The confirming steps only apply to low oil pressure or high oil
temperature.
There are no confirming steps for chip indications.
Symptom:
Main gearbox oil pressure is less than 35 psi
or
Main gearbox oil temperature is greater than 130 degrees.
WARNING
BYP must be selected within 5 seconds after the MGB OIL
PRES warning has illuminated to ensure an adequate
quantity of oil remains in the gearbox.
DO NOT activate BYP
if the warning is not illuminated.
CAUTION
When the MGB BYP mode is activated by the crew, the MGB
oil temperature will increase. The temperature is expected to
increase into the red operational range, this indication
should not be considered a secondary indication for
determination of landing immediately.
CAUTION
The main AC generators are cooled by main gearbox oil. Loss
of cooling oil may result in mechanical failure of the generators
and loss of main electrical power.
NOTE
The MGB BYPASS caution will illuminate when BYP is selected. As
the MGB oil pressure stabilizes, the switch should be left in the BYP
position. The MGB BYPASS caution and MGB OIL PRES warning
will remain on until the rotor is shut down after landing.
NOTE
After MGB bypass switch is activated, MGB oil pressure should
stabilize or fluctuate in the range of 5 to 25 psi. Gearbox temperature
will slowly increase into the red zone.
NOTE
Either a massive main gearbox oil leak or the failure of a main gearbox
oil pump may cause the MGB OIL PRES warning light to illuminate.
NOTE
If the MGB OIL PRES warning illuminates, the MGB OIL PRES
caution will not be illuminated.
Action:
1. MGB OIL BYP - Select BYP only if the red MGB OIL PRES warning illuminates.
2. Descend to minimum safe altitude.
3. APU CTRL — ON.
4. APU GEN — ON.
5. Land as soon as possible.
If the MGB OIL PRES warning or the MGB OIL PRES caution and any of the following secondary indications of gearbox
failure are observed:
MGB oil pressure below 5 psi
Smoke or fumes in the cabin
Any subsequent hydraulic system failure
Progressively increasing power required to maintain flight
Unusual vibrations or noises.
6. Land immediately.
Symptom:
MGB OIL PRES or MGB OIL HOT or MGB CHIP or ACC 1 CHIP or ACC 2 CHIP or MGB OIL PRES
GEARBOX OIL PRESSURE aural alert.
Confirming:
NOTE
The confirming steps only apply to low oil pressure or high oil
temperature.
There are no confirming steps for chip indications.
Symptom:
Main gearbox oil pressure is less than 35 psi
or
Main gearbox oil temperature is greater than 130 degrees.
WARNING
BYP must be selected within 5 seconds after the MGB OIL
PRES warning has illuminated to ensure an adequate
quantity of oil remains in the gearbox.
DO NOT activate BYP
if the warning is not illuminated.
CAUTION
When the MGB BYP mode is activated by the crew, the MGB
oil temperature will increase. The temperature is expected to
increase into the red operational range, this indication
should not be considered a secondary indication for
determination of landing immediately.
CAUTION
The main AC generators are cooled by main gearbox oil. Loss
of cooling oil may result in mechanical failure of the generators
and loss of main electrical power.
NOTE
The MGB BYPASS caution will illuminate when BYP is selected. As
the MGB oil pressure stabilizes, the switch should be left in the BYP
position. The MGB BYPASS caution and MGB OIL PRES warning
will remain on until the rotor is shut down after landing.
NOTE
After MGB bypass switch is activated, MGB oil pressure should
stabilize or fluctuate in the range of 5 to 25 psi. Gearbox temperature
will slowly increase into the red zone.
NOTE
Either a massive main gearbox oil leak or the failure of a main gearbox
oil pump may cause the MGB OIL PRES warning light to illuminate.
NOTE
If the MGB OIL PRES warning illuminates, the MGB OIL PRES
caution will not be illuminated.
Action:
1. MGB OIL BYP - Select BYP only if the red MGB OIL PRES warning illuminates.
2. Descend to minimum safe altitude.
3. APU CTRL — ON.
4. APU GEN — ON.
5. Land as soon as possible.
If the MGB OIL PRES warning or the MGB OIL PRES caution and any of the following secondary indications of gearbox
failure are observed:
MGB oil pressure below 5 psi
Smoke or fumes in the cabin
Any subsequent hydraulic system failure
Progressively increasing power required to maintain flight
Unusual vibrations or noises.
6. Land immediately.
That's what the RFM states, so should be what the other operators have as well.
Just one comment on layout - I don't think it is a good idea to have so many notes, comments and warnings before you reach the actual emergency drill. Do the drill, then read the essay! Maybe that will be something Cougar will change in the near future?
VL
Just one comment on layout - I don't think it is a good idea to have so many notes, comments and warnings before you reach the actual emergency drill. Do the drill, then read the essay! Maybe that will be something Cougar will change in the near future?
VL
VL,
that is the RFM I would suggest, not the Cougar Checklist.
Other 92 pilots, note that the 5-25 psi referred to here:
will not be the case for a single pump failure, where 5-7psi can be expected with the current configuration.
that is the RFM I would suggest, not the Cougar Checklist.
Other 92 pilots, note that the 5-25 psi referred to here:
After MGB bypass switch is activated, MGB oil pressure should
stabilize or fluctuate in the range of 5 to 25 psi
stabilize or fluctuate in the range of 5 to 25 psi
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Helicopter design - S92a
Looks like the designer(s) of the MGB and ancilliaries will not be getting an Oscar any day soon. It's interesting that the physical integrity of the AC gens should be dependent on the MGB oil supply.
If one takes the view that 'no oil then no AC is not your biggest problem' then maybe you can hold that up to the certification body as a reasonable analysis but if you then go on to create secondary situations with continued flight being possible with reduced flow then other, nastier, failure modes come into focus.
The only time I have had to deal with a fire in the air was on an S61 when one of the AC gens seized, the quill shaft did not break but instead ripped the AC Gen away from the gearbox and set fire to surrounding trunking and oil soaked cowlings. The only warning we got was an AC gen fail but fortunately we were on final approach when it happened. We ground taxied into dispersal oblivious of the situation until the ground crew started jumping up and down like demented go-go dancers. I hate to think what would have happened if the problem had surfaced on hour earlier over the mountains of Croatia.
Apart from reinforcing my assertion that we should not only teach malfunctions and emergencies according to the RFM but also develop generic solutions for those malfunctions that are not listed therein. We would not have found 'Transmission Deck Fire' in the S61 RFM although maybe after the Lee SAR incident it is now included.
Checklists
The degree to which the S92a checklist is being picked apart by us PPruners is an indication of the extent to which they will be reviewed by the lawyers.
We are faced with a dilemma with checklists insofar as for legal certainty they must derive from the RFM. The basic RFM covers the basic aircraft - no optional equipment is allowed for. To generate a checklist that will work properly with any particular configuration you are left to your own devices to coble together your interpretation of the inputs from maybe up to a dozen RFM Supplements. Where do you stand then? I don't know for sure is the simple answer.
What has worked in the past is that your company Operations Manual (if you are lucky enough to have one) will publish a version of the checklist that you have created and if the OM is then reviewed by the NAA and 'accepted' as meeting their requirements then you are at least in a strong situation.
Ideally the OM will contain the 'Expanded Checklist' with all the notes and cautions but the cockpit checklist needs to be a practical document that contains the minimum information required by a fully trained crew. My experience is that unworkable checklists are set aside in favour of the 'memorised' kind. Emergency Checklists may need some of the notes and cautions but the design and layout - as has been mentioned in a previous post - are critical to the effective use of them. One new type has an Emergency Drill for Hyd Fail with the No. 1 System on the right of the page and the No. 2 on the left of the page. This is completely counter intuitive and I have seen non-English speakers read out the wrong drill (oh dear - I have given the game away!). It's not the only editorial glitch that can add to your problems rather than reduce them but we're working on it.
G.
If one takes the view that 'no oil then no AC is not your biggest problem' then maybe you can hold that up to the certification body as a reasonable analysis but if you then go on to create secondary situations with continued flight being possible with reduced flow then other, nastier, failure modes come into focus.
The only time I have had to deal with a fire in the air was on an S61 when one of the AC gens seized, the quill shaft did not break but instead ripped the AC Gen away from the gearbox and set fire to surrounding trunking and oil soaked cowlings. The only warning we got was an AC gen fail but fortunately we were on final approach when it happened. We ground taxied into dispersal oblivious of the situation until the ground crew started jumping up and down like demented go-go dancers. I hate to think what would have happened if the problem had surfaced on hour earlier over the mountains of Croatia.
Apart from reinforcing my assertion that we should not only teach malfunctions and emergencies according to the RFM but also develop generic solutions for those malfunctions that are not listed therein. We would not have found 'Transmission Deck Fire' in the S61 RFM although maybe after the Lee SAR incident it is now included.
Checklists
The degree to which the S92a checklist is being picked apart by us PPruners is an indication of the extent to which they will be reviewed by the lawyers.
We are faced with a dilemma with checklists insofar as for legal certainty they must derive from the RFM. The basic RFM covers the basic aircraft - no optional equipment is allowed for. To generate a checklist that will work properly with any particular configuration you are left to your own devices to coble together your interpretation of the inputs from maybe up to a dozen RFM Supplements. Where do you stand then? I don't know for sure is the simple answer.
What has worked in the past is that your company Operations Manual (if you are lucky enough to have one) will publish a version of the checklist that you have created and if the OM is then reviewed by the NAA and 'accepted' as meeting their requirements then you are at least in a strong situation.
Ideally the OM will contain the 'Expanded Checklist' with all the notes and cautions but the cockpit checklist needs to be a practical document that contains the minimum information required by a fully trained crew. My experience is that unworkable checklists are set aside in favour of the 'memorised' kind. Emergency Checklists may need some of the notes and cautions but the design and layout - as has been mentioned in a previous post - are critical to the effective use of them. One new type has an Emergency Drill for Hyd Fail with the No. 1 System on the right of the page and the No. 2 on the left of the page. This is completely counter intuitive and I have seen non-English speakers read out the wrong drill (oh dear - I have given the game away!). It's not the only editorial glitch that can add to your problems rather than reduce them but we're working on it.
G.
We would not have found 'Transmission Deck Fire' in the S61 RFM although maybe after the Lee SAR incident it is now included
http://www.aaib.gov.uk/sites/aaib/cm...0%20G-BEID.pdf
For those who are such ardent 61 supporters, and for another taste of life in the 70s and 80s, here's another one that happened 4 months later:
http://www.aaib.gov.uk/sites/aaib/cm...0%20G-BDES.pdf
I think that although both are unrelated failure modes, they illustrate the sorts of timescales we may be faced with in these kinds of emergencies, and that in reality these kinds of failures do not lend themselves well to emergency checklists....
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212
You have hit the nail on the head. If we ONLY cover text book emergencies during sim training we run the risk of creating a generation incapable of thinking outside the box.
Thank God for LOFT where opportunities are available for developing decision making skills in a safe environment.
G
PS. - Have just read a bit of those two accident reports. I feel even more justified in asserting the need for developing CRM skills capable of dealing with these random failures. Case studies such as the two reports 212 has attached to his post are ideal material. I am puzzled by a lack of response to my suggestion that the ocean should be made a place of safe-haven either by lmiting the sea state for normal ops and/or improving the ability to get out of the downed helicopter and into the liferaft.
Thank God for LOFT where opportunities are available for developing decision making skills in a safe environment.
G
PS. - Have just read a bit of those two accident reports. I feel even more justified in asserting the need for developing CRM skills capable of dealing with these random failures. Case studies such as the two reports 212 has attached to his post are ideal material. I am puzzled by a lack of response to my suggestion that the ocean should be made a place of safe-haven either by lmiting the sea state for normal ops and/or improving the ability to get out of the downed helicopter and into the liferaft.
Last edited by Geoffersincornwall; 1st Apr 2009 at 08:04.
Geoff,
With regard to your first point; yes, but not such that existing drills can be seen as flexible.
For your second point; read the following paper which resulted from many years of research into just that subject and which was published because of: (a) the resistance to further modification of the requirements by other Authorities; and (b) the perception that the CAA no longer had the legal competence to propose rule changes and wished to pass its knowledge and recommendations to one that had - i.e. EASA.
http://www.caa.co.uk/docs/33/2005_06.PDF
I had close knowledge of the referenced paper in Appendix F because I Chaired the committee that researched and produced it.
Jim
Jim
With regard to your first point; yes, but not such that existing drills can be seen as flexible.
For your second point; read the following paper which resulted from many years of research into just that subject and which was published because of: (a) the resistance to further modification of the requirements by other Authorities; and (b) the perception that the CAA no longer had the legal competence to propose rule changes and wished to pass its knowledge and recommendations to one that had - i.e. EASA.
http://www.caa.co.uk/docs/33/2005_06.PDF
I had close knowledge of the referenced paper in Appendix F because I Chaired the committee that researched and produced it.
Jim
Jim
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JimL
I take your point vis a vis the established emergency protocols and would not seek to replace them but merely to give them a context. As experience with a new type grows we know that a greater understanding of the machine and its foibles will follow. I have learnt to be sceptical about text book failures and I think it is a healthy scepticism but ignoring the RFM would be throwing the baby out with the bathwater.
Will read your paper as soon as I get a quiet moment.
G
PS - I don't suppose you have an electronic copy of the HARP Report only I wanted to refresh my memory on the paragraph that highlighted the fact that gearboxes were a severe weakpoint of the (then) current designs - just before the authorities went on to certify the Boeing 234 which had 5 gearboxes in a drive train in which the failure of any one would have resulted in the total loss of the aircraft - which happened - killed 40+ people and resulted in the only time people-power has casused the withdrawal of a machine from offshore use....... in UK anyway. Makes you wonder about joined-up regulation doesn't it.
Will read your paper as soon as I get a quiet moment.
G
PS - I don't suppose you have an electronic copy of the HARP Report only I wanted to refresh my memory on the paragraph that highlighted the fact that gearboxes were a severe weakpoint of the (then) current designs - just before the authorities went on to certify the Boeing 234 which had 5 gearboxes in a drive train in which the failure of any one would have resulted in the total loss of the aircraft - which happened - killed 40+ people and resulted in the only time people-power has casused the withdrawal of a machine from offshore use....... in UK anyway. Makes you wonder about joined-up regulation doesn't it.
About the weather minima...
I don't agree but here is it:
Regards
Aser
I don't agree but here is it:
Regulatory authorities
recognise that ditchings and crashes, though rare, do occur from time to time, and for
this reason require operators to provide a comprehensive range of safety equipment,
procedures and training. However, there are occasions when weather conditions in
offshore areas are such that a safe ditching would be impossible, survival time in the
sea would be very much reduced, and rescue would be extremely difficult or
impossible. If the safety provisions are necessary under normal conditions, it is illogical
to permit flights to take place in conditions such that they would be of no avail.
Therefore, it has been argued, flights should be prohibited in conditions that preclude
a safe ditching or would not allow survivors to be rescued.
3 The counter-argument runs as follows. There is an element of risk in all forms of
transport, but it is considered ‘safe’ when the risk is assessed as being at an acceptably
low level; occasional accidents, tragic though they are, do not invalidate this policy
unless they occur at a frequency that discredits the original risk calculations. Fixedwing
public transport flights take place globally over oceanic and mountainous areas
which would not permit a safe ditching or forced landing. Similarly, Group A public
transport helicopters routinely fly without restriction over wooded and hilly terrain, in
cloud, and over countryside covered in dense fog, where a safe autorotational landing
could not be performed. Offshore helicopter operations are not radically different
from other forms of rotary-winged public transport; such extra risks as they do carry
(related to the hostile environment and the repeated exposure of individual
passengers) are already handsomely discounted by the provision of extra safety
equipment and training. Moreover, operations over rough seas are not necessarily
more dangerous than similar flights over land; for example, if the Cormorant Alpha
accident had occurred at an airport, it is most unlikely that anyone would have
survived the impact. It would therefore be perverse to apply any restrictions to
offshore flights that are not applied to other equivalent forms of public transport.
recognise that ditchings and crashes, though rare, do occur from time to time, and for
this reason require operators to provide a comprehensive range of safety equipment,
procedures and training. However, there are occasions when weather conditions in
offshore areas are such that a safe ditching would be impossible, survival time in the
sea would be very much reduced, and rescue would be extremely difficult or
impossible. If the safety provisions are necessary under normal conditions, it is illogical
to permit flights to take place in conditions such that they would be of no avail.
Therefore, it has been argued, flights should be prohibited in conditions that preclude
a safe ditching or would not allow survivors to be rescued.
3 The counter-argument runs as follows. There is an element of risk in all forms of
transport, but it is considered ‘safe’ when the risk is assessed as being at an acceptably
low level; occasional accidents, tragic though they are, do not invalidate this policy
unless they occur at a frequency that discredits the original risk calculations. Fixedwing
public transport flights take place globally over oceanic and mountainous areas
which would not permit a safe ditching or forced landing. Similarly, Group A public
transport helicopters routinely fly without restriction over wooded and hilly terrain, in
cloud, and over countryside covered in dense fog, where a safe autorotational landing
could not be performed. Offshore helicopter operations are not radically different
from other forms of rotary-winged public transport; such extra risks as they do carry
(related to the hostile environment and the repeated exposure of individual
passengers) are already handsomely discounted by the provision of extra safety
equipment and training. Moreover, operations over rough seas are not necessarily
more dangerous than similar flights over land; for example, if the Cormorant Alpha
accident had occurred at an airport, it is most unlikely that anyone would have
survived the impact. It would therefore be perverse to apply any restrictions to
offshore flights that are not applied to other equivalent forms of public transport.
Regards
Aser
Since we have raised several new questions and ideas about how to make things better....lets return to what brought us here at this thread.
We know there was a confirmation by the Crew they were seeing "Zero Oil Pressure" an reported to ATC while on descent to 800 feet.
We know they had a two way conversation with OPS and can only assume they relayed that situation during that conversation.
If we accept the fact they did in fact continue to see "zero" oil pressure we have to question why they did not carry out the actions dictated by the checklist.
"Zero" oil pressure is one of the confirming situations that kicks off the instruction to "Land Immediately".
If the decision was made because of confusing indications....say an oil pressure that was flucuating above 5 PSI then we might suspect they might see a way out of the situation. Given the choice of ditching or continuing to fly I am sure most of us would see any indication above 5 PSI in a postive light and probably discount the fact the majority of the indications were under 5 PSI. That might not be the smart view but when confronted with ditching or not we would probably want to avoid ditching.
If the decision was an improper diagnosis by them or someone in OPS that caused them to continue flight then that would be a tragedy but seems a remote possibility.
If the decision was to avoid ditching due to the sea state and the knowledge of how cold and rough the water was and they accepted they had a very serious gearbox problem but they or someone in OPS decided it was best to try for land then that raises more questions.
We know there was a confirmation by the Crew they were seeing "Zero Oil Pressure" an reported to ATC while on descent to 800 feet.
We know they had a two way conversation with OPS and can only assume they relayed that situation during that conversation.
If we accept the fact they did in fact continue to see "zero" oil pressure we have to question why they did not carry out the actions dictated by the checklist.
"Zero" oil pressure is one of the confirming situations that kicks off the instruction to "Land Immediately".
If the decision was made because of confusing indications....say an oil pressure that was flucuating above 5 PSI then we might suspect they might see a way out of the situation. Given the choice of ditching or continuing to fly I am sure most of us would see any indication above 5 PSI in a postive light and probably discount the fact the majority of the indications were under 5 PSI. That might not be the smart view but when confronted with ditching or not we would probably want to avoid ditching.
If the decision was an improper diagnosis by them or someone in OPS that caused them to continue flight then that would be a tragedy but seems a remote possibility.
If the decision was to avoid ditching due to the sea state and the knowledge of how cold and rough the water was and they accepted they had a very serious gearbox problem but they or someone in OPS decided it was best to try for land then that raises more questions.