Heli ditch North Sea G-REDL: NOT condolences
Safety Recommendation 2011-036
It is recommended that the European Aviation Safety Agency (EASA) re-evaluate the continued airworthiness of the main rotor gearbox fitted to the AS332 L2 and EC225 helicopters to ensure that it satisfies the requirements of Certification Specification (CS) 29.571 and EASA Notice of Proposed Amendment 2010-06.
It is recommended that the European Aviation Safety Agency (EASA) re-evaluate the continued airworthiness of the main rotor gearbox fitted to the AS332 L2 and EC225 helicopters to ensure that it satisfies the requirements of Certification Specification (CS) 29.571 and EASA Notice of Proposed Amendment 2010-06.
What reaction has that provoked? Would EASA remove the Airworthiness Certification of the MGB and force Eurocopter to redesign that component, to include the cockpit warning systems for chip detectors in the Epicyclic module and improve the oil system to better expose oil borne chips to those new detection systems?
It sounds like this situation is not all that different than the Sikorsky S-92 gearbox problems....different symptoms but pretty much a common problem in that the certification standards left users vulnerable to fatal flaws
It sounds like this situation is not all that different than the Sikorsky S-92 gearbox problems....different symptoms but pretty much a common problem in that the certification standards left users vulnerable to fatal flaws
In terms of the epicyclic chip detector on the L2, it would seem fairly easy to install a cockpit warning light, as there is in the 225, since most of the infrastructure is already there.
By contrast, the basis for the S92's gearbox certification to the standard in force at the time of original certification, seems hard to justify.
HC
Edited to say - cross posted with SM
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I am reluctant to post here. Been on the L2 and now the smaller versions. I do not critisize, point finger or wanna upset anyone here. Yes, EC could have designed a even better gearbox that took more than the current fleet hours before this tragedy occured and yes the certification for gearboxes could have been more stringent. If this is referred to a court regarding the engineering action taken or not taken it will make the current sickness in aviation worse! All humans make errors-engineers, pilots, designers, etc. That is why we have systems. My issue is that in one of my fields which is training I more and more see the sickness from all trades of "as long as i can't be blamed"! This results in no decision making, accountability etc and all due possible future prosecution. So we end up in meeting after meeting after meeting resulting in commercial/HR/safety/who ever joining before a decision is made and if ever made it is vague and non-committal. Been there and done that in the offshore industry where a simple decision can have a huge commercial consequence-the question comes back to why is that enforced and allowed to be enforced down to the engineer and/or pilot who has to go to court for their decision when we are no longer in a culture of decisions without meetings. The fact that the gearbox had so many chips is maybe what made the engineer decide what is one more chip-complacency? Human nature? This is a system failure as more than 1 engineer is normally involved in HUMS, chip warnings, correspondence with a OEM etc so who exactly is to blame? How do we select? Blame EC? Blame Bond? Blame the last signature? I dont know Bond procedures but normally a team is involved.
I learned to respect chip warnings. I learned to forget the old school thought of if no part number it is ok to continue. I learned that what becomes the usual will lead to disaster. I learned to respect epicyclics and why EC made that top chip detector on the 350 engineer only territory! I learned to know my type and my types don't have chip warnings unless something is seriously wrong!!!!
I learned to respect chip warnings. I learned to forget the old school thought of if no part number it is ok to continue. I learned that what becomes the usual will lead to disaster. I learned to respect epicyclics and why EC made that top chip detector on the 350 engineer only territory! I learned to know my type and my types don't have chip warnings unless something is seriously wrong!!!!
HC,
The common denominator in the EC/SK MGB issues is the Certifying Authority for each type signed off on the aircraft design. Neither EC or SK could have put the aircraft into production without those approvals.
I am not defending SK or impugning EC when I challenge the criteria used to approve both of the Gearbox designs....but I am definitely challenging the criteria and process that let both be certified.
Then in a similar view....I challenge the systems that allowed each of the accidents to occur. That cuts across multi-national and multi-operator actions and in-actions....and accuses the helicopter Industry (including certifying authorities) of failing itself in the manner in which business is being done currently.
The question I posed...."cancelling the Type Certificate or Approval of the Gearbox" is valid. I know the Rule is as you state...."certified to the standard then existing"...but at some point does not new data and circumstances demand rethinking that Rule and existing Certifications?
If we accept the AAIB findings but do not require EC to make the needed improvements....are we not ensuring another tragedy at some point in the future? The same goes for SK and the Canadian Investigation.
Do you want to climb into an aircraft with the same deficencies as discovered by the AAIB investigation or the Canadian investigation into the 92 crash and do so because they are both legally certified by the government authority?
Of course not.....otherwise why even investigate an accident at all.
Once we identify "bad" designs, bad engineering, inadequate procedures and policies....certainly corrective actions must be demanded.
How we accomplish that is the question....but what is the answer?
The common denominator in the EC/SK MGB issues is the Certifying Authority for each type signed off on the aircraft design. Neither EC or SK could have put the aircraft into production without those approvals.
I am not defending SK or impugning EC when I challenge the criteria used to approve both of the Gearbox designs....but I am definitely challenging the criteria and process that let both be certified.
Then in a similar view....I challenge the systems that allowed each of the accidents to occur. That cuts across multi-national and multi-operator actions and in-actions....and accuses the helicopter Industry (including certifying authorities) of failing itself in the manner in which business is being done currently.
The question I posed...."cancelling the Type Certificate or Approval of the Gearbox" is valid. I know the Rule is as you state...."certified to the standard then existing"...but at some point does not new data and circumstances demand rethinking that Rule and existing Certifications?
If we accept the AAIB findings but do not require EC to make the needed improvements....are we not ensuring another tragedy at some point in the future? The same goes for SK and the Canadian Investigation.
Do you want to climb into an aircraft with the same deficencies as discovered by the AAIB investigation or the Canadian investigation into the 92 crash and do so because they are both legally certified by the government authority?
Of course not.....otherwise why even investigate an accident at all.
Once we identify "bad" designs, bad engineering, inadequate procedures and policies....certainly corrective actions must be demanded.
How we accomplish that is the question....but what is the answer?
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The common denominator in the EC/SK MGB issues is the Certifying Authority for each type signed off on the aircraft design.
Though only one Certifying Authority also promotes the industry it regulates. The FAA.
The question I posed...."cancelling the Type Certificate or Approval of the Gearbox" is valid. I know the Rule is as you state...."certified to the standard then existing"...but at some point does not new data and circumstances demand rethinking that Rule and existing Certifications?
If we accept the AAIB findings but do not require EC to make the needed improvements....are we not ensuring another tragedy at some point in the future? The same goes for SK and the Canadian Investigation.
Do you want to climb into an aircraft with the same deficencies as discovered by the AAIB investigation or the Canadian investigation into the 92 crash and do so because they are both legally certified by the government authority?
If we accept the AAIB findings but do not require EC to make the needed improvements....are we not ensuring another tragedy at some point in the future? The same goes for SK and the Canadian Investigation.
Do you want to climb into an aircraft with the same deficencies as discovered by the AAIB investigation or the Canadian investigation into the 92 crash and do so because they are both legally certified by the government authority?
In an ideal world that might work, but in the current world it would just mean that we take the safest option - ie never fly again.
The certification rules can never require a 100% guarantee that a part cannot fail to cause a catastrophy - only that it is "extremely remote" etc so I am afraid there will always be accidents, just like thousand of times more people will die on the roads, from cancer etc. We are kidding ourselves if we think we should have a society where untimely death is an impossibility.
Of course we should do what we can to reduce such events to "as low as reasonably practicable" but to go any lower starves the human race of any progress or production.
It has to be said that in both of the accidents cropping up in this thread, the accident could probably have been avoided if the existing systems and procedures had been followed correctly, ie as intended by the author. In the case of the L2 by following the correct maintenance procedure, and in the case of the 92 by the crew following the emergency checklist.
It is when you look at the reasons why these actions did not take place correctly, that it gets interesting. It is very hard to pin down onto 1 person (and who would want to do that anyway) since the failings are intrinsic to our current society's values and ways of behaving.
Just like pilots, helicopters invent new ways to crash from time to time. The certification rules help for those accidents we have already thought of (especially if they are properly followed and enforced) but there will always be new accidents (until we invent anti-gravity!), our only realistic goal is to try to prevent the most obvious, predictable and stupid ones!
HC
HC,
You read more into my comment than perhaps you should. I am not saying each time there is an accident, the Type Certificate should be yanked....just when there is discovered clear evidence the existing design is proven to be deficient even if "properly certified" at the time of the issuance of the Type Certificate.
If the standards under which the Type Certificate was issued are insufficient there is no reason why the Certificate should stand.
The critics of the 92 Gearbox are saying exactly the same thing I am....but using different words. They question the criteria and submissions by Sikorsky in meeting the FAA's requirements. Yet....the 92 received its Type Certificate and maintains it yet today despite the events that led up to the Newfoundland crash.
We can agree, I think, that just because a Type Certificate is issued it does not become etched in stone and cannot be withdrawn.
The problem with that, is it will require Certifying Authorities to admit publically they made a mistake by issuing the Type Certiicate in the first place. They may have met the letter of their rules and requirements but at the same time have been in error by missing some critical flaw in the design or method of acheiving approval.
Government never wants to admit a mistake....even when it is patently clear to everyone involved.
You read more into my comment than perhaps you should. I am not saying each time there is an accident, the Type Certificate should be yanked....just when there is discovered clear evidence the existing design is proven to be deficient even if "properly certified" at the time of the issuance of the Type Certificate.
If the standards under which the Type Certificate was issued are insufficient there is no reason why the Certificate should stand.
The critics of the 92 Gearbox are saying exactly the same thing I am....but using different words. They question the criteria and submissions by Sikorsky in meeting the FAA's requirements. Yet....the 92 received its Type Certificate and maintains it yet today despite the events that led up to the Newfoundland crash.
We can agree, I think, that just because a Type Certificate is issued it does not become etched in stone and cannot be withdrawn.
The problem with that, is it will require Certifying Authorities to admit publically they made a mistake by issuing the Type Certiicate in the first place. They may have met the letter of their rules and requirements but at the same time have been in error by missing some critical flaw in the design or method of acheiving approval.
Government never wants to admit a mistake....even when it is patently clear to everyone involved.
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Government never wants to admit a mistake....even when it is patently clear to everyone involved.
If we don't learn from our mistakes we will never move forward. It won't bring back our lost colleagues but at least they won't have died completely in vain.
People need to be held accountable and we need to move on. We should learn from our mistakes otherwise they will happen again.
If legal action is the only way these days we can painfully slowly move design/operational issues forward then the world is truly a very sad place. Whatever happened to pride in building the best machines possible and with enough inherent safety factors & procedures to allow a solid reputation to be established?
Do we need to start enforcing more independent audits to ensure standards & procedures are maintained, IMO this is definitely something that should be looked at. Who audits the auditors?
IMO it's all about cost-effectiveness and the inherent compromise on safety, not enough due diligence by all disciplines.
It's also about all involved in this industry to stand up and voice their concerns collectively so that everybody in the industry is informed of the issues. Reports such as the TSB and AAIB should be the official ammunition to expedite pro-active solutions/improvements. Governments and their regulating bodies need to get with the programme and not just look for more votes at the next election as we have here in Canada right now.
They say that there is no price on safety, I say that's a load of bollocks, there's a price on everything, even people's lives...that's where the as low as reasonably practicable statement comes from, not just from the bounds of current technology.
As technology moves forward so should engineering safety design, not the opposite...
Safe flying
Max
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AAIB Formal Report published 10-Apr-2012
CROWN OFFICE Website.
G-REDL FAI: 6 January 2014
"February 2013 – Contact with Sheriff Principal of Grampian Highland and Islands identifies 28 October 2013 as the date to hold FAI in the council Chambers fixed for the hearing of the FAI. Responsibility for the date and venue of the FAI rests with the Sheriff Principal.
However in June SCS advised they were unable to source suitable accommodation in Aberdeen for an FAI of this magnitude at that time. A new date has now been scheduled for the FAI of 6 January 2014 and it will take place in Aberdeen."
G-REDL FAI: 6 January 2014
"February 2013 – Contact with Sheriff Principal of Grampian Highland and Islands identifies 28 October 2013 as the date to hold FAI in the council Chambers fixed for the hearing of the FAI. Responsibility for the date and venue of the FAI rests with the Sheriff Principal.
However in June SCS advised they were unable to source suitable accommodation in Aberdeen for an FAI of this magnitude at that time. A new date has now been scheduled for the FAI of 6 January 2014 and it will take place in Aberdeen."
Yes there is a summary in the P&J each day. Nothing too startling yet. The lawyer for the victims families wanted to "fishing trip" by asking to see all tech logs for all Bond's helis but it was declined. I wouldn't like to be the Bond engineers having to account for their decisions.
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STV news have reported on it most days as well.
Engineering 'anomaly' reported in 2009 helicopter crash inquiry | Aberdeen & North | News | STV
There are related articles underneath where anyone can catch up with what happened during the first week.
Apparently due to last 6 weeks.
Engineering 'anomaly' reported in 2009 helicopter crash inquiry | Aberdeen & North | News | STV
There are related articles underneath where anyone can catch up with what happened during the first week.
Apparently due to last 6 weeks.
A few words about FAI.
Here is where the determination will eventually appear.
Sheriff Court
This is the guy that will write it.
http://img.thesun.co.uk/aidemitlum/a...80_619259a.jpg
Known for his abilityto get into the detail. Originally a corporate and commercial solicitor. Sheriff Principal in the North since June 2012.
The investigation is a Crown Office one. Here is what they have to say about their role.
Our role in Investigating Deaths
The principal players in the Inquiry are the Sheriff, the Procurator fiscal and the Interested Parties. The PF has a lot of control over the format of the Inquiry because the results of the COPFS investigation dictate it. Though the role of the Interested Parties is in some ways limited, any of them may end up uncovering important matters not revealed by the COPFS.
The Sheriff will write the Determination which provides the information required by the Act. It is important to realise that the information in the Determination is restricted to tightly defined results. Much more than this will come out during the course of the presentation of evidence at the FAI.
Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976
6 Sheriff’s determination etc.
(1)
(a) where and when the death and any accident resulting in the death took place;
(b) the cause or causes of such death and any accident resulting in the death;
(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;
(d) the defects, if any, in any system of working which contributed to the death or any accident resulting in the death; and
(e) any other facts which are relevant to the circumstances of the death.
Here is where the determination will eventually appear.
Sheriff Court
This is the guy that will write it.
http://img.thesun.co.uk/aidemitlum/a...80_619259a.jpg
Known for his abilityto get into the detail. Originally a corporate and commercial solicitor. Sheriff Principal in the North since June 2012.
The investigation is a Crown Office one. Here is what they have to say about their role.
Our role in Investigating Deaths
The principal players in the Inquiry are the Sheriff, the Procurator fiscal and the Interested Parties. The PF has a lot of control over the format of the Inquiry because the results of the COPFS investigation dictate it. Though the role of the Interested Parties is in some ways limited, any of them may end up uncovering important matters not revealed by the COPFS.
The Sheriff will write the Determination which provides the information required by the Act. It is important to realise that the information in the Determination is restricted to tightly defined results. Much more than this will come out during the course of the presentation of evidence at the FAI.
Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976
6 Sheriff’s determination etc.
(1)
(a) where and when the death and any accident resulting in the death took place;
(b) the cause or causes of such death and any accident resulting in the death;
(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;
(d) the defects, if any, in any system of working which contributed to the death or any accident resulting in the death; and
(e) any other facts which are relevant to the circumstances of the death.
And the point of all this is?
Reading from here:-
Super Puma G-REDL 2009 Investigation timeline
which contains:-
2 November 2012 – Final CAA Report in which they confirm that they had carried out an investigation and the available evidence was insufficient to support a prosecution.
19 December 2012 – Meeting involving Grampian Police, COPFSCrown Office and Procurator Fiscal Service and CAA to discuss the Report.
January 2013 – Crown Counsel consider HSD report. Crown Counsel Instruct that there are to be no criminal proceedings.
So what is the point of this FAI?? Surely it would just be easier to publish the relevant points that led them to the decision they took in Jan 13.
Super Puma G-REDL 2009 Investigation timeline
which contains:-
2 November 2012 – Final CAA Report in which they confirm that they had carried out an investigation and the available evidence was insufficient to support a prosecution.
19 December 2012 – Meeting involving Grampian Police, COPFSCrown Office and Procurator Fiscal Service and CAA to discuss the Report.
January 2013 – Crown Counsel consider HSD report. Crown Counsel Instruct that there are to be no criminal proceedings.
So what is the point of this FAI?? Surely it would just be easier to publish the relevant points that led them to the decision they took in Jan 13.
The Inquiry will record, in the form of the Determination, the details of how a person died and anything that could have been done to prevent the death.
The transcript, which is not normally publicly available, may underpin further work in relation to the same event.
Interested Parties may be represented at the Inquiry and often play an important part in the examination of evidence.
I hear you Jim but surely digging out the facts of this matter just forms part of the decision making process for making a prosecution or not, beyond which why kick that off in 2014 for an accident that happened in 2009?
Pitts, normally you just want to change to entire way the helicopter industry functions. But now you have moved up to wanting to change the way the Scottish legal system works! I think you may have a problem making your wishes come true!
Anway, there is considerable support for your point about why it has taken so long to convene the FAI, but that is just the way it is. It is not a recent decision, there was always going to be an FAI - it is required under Scottish law - only the timing was in doubt.
As to the previous decisions not to prosecute, they were of course made by parties who were close to the events, or based on their reports, and perhaps might be considered to be not totally impartial as a result. Whereas the FAI should be totally impartial with no internal axe to grind. It will be a good thing, albeit rather late as you and others have said.
Anway, there is considerable support for your point about why it has taken so long to convene the FAI, but that is just the way it is. It is not a recent decision, there was always going to be an FAI - it is required under Scottish law - only the timing was in doubt.
As to the previous decisions not to prosecute, they were of course made by parties who were close to the events, or based on their reports, and perhaps might be considered to be not totally impartial as a result. Whereas the FAI should be totally impartial with no internal axe to grind. It will be a good thing, albeit rather late as you and others have said.