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Pasadena Police - two OH-58s make contact

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Pasadena Police - two OH-58s make contact

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Old 10th Mar 2018, 18:03
  #41 (permalink)  
 
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That could quite easily been prevented by having someone on the ground to meet the helicopter as it landed......he/ she could have used dayglo or illuminated batons. They could be called marshallers. Or is that a bit difficult?
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Old 10th Mar 2018, 18:49
  #42 (permalink)  
 
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It seems the Passadena police learned quite a lot from this accident as their dispersal is much bigger and very differently marked - I assume they now have comms as well.

We trust that the painted markers are correct. We trust that the other machines will stay away from us. We trust that the landing instructions are correct. We trust that ATC is doing its job correctly. We trust that the other pilots are as smart as us. The entire scenario is built on trust. If we cannot trust, what do we do?
we never assume and always check as much as we can, never being afraid to ask questions whether it is of ATC or other pilots.

Blind trust is like expecting everyone else on the roads to drive perfectly all the time and we all know that doesn't happen.

If something is within your control - like checking the proximity of another aircraft, why not be sure rather than just 'trusting'.

The Flight Safety poster - ASSUME makes an ASS out of U and Me - seems appropriate.
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Old 10th Mar 2018, 19:36
  #43 (permalink)  
 
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Originally Posted by [email protected] View Post
If you are expecting to launch immediately and the other aircraft isn't expected back until later then why be pedantic and take more time over exact positioning of the aircraft?
That's why:
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Old 10th Mar 2018, 20:01
  #44 (permalink)  
 
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Originally Posted by ZFT View Post
That's not a root cause
Perhaps I wasn't clear enough. The root cause was that the pilot didn't take enough care in picking a landing spot because they were complacent about using the painted marks, or simply didn't take enough time to see what they were looking at. If you think that wasn't the root cause what would you suggest? Surely not that the stationary ship was poorly positioned?
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Old 10th Mar 2018, 20:26
  #45 (permalink)  
 
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I think it's a bit like someone parking his car on a railroad crossing, assuming that he will be long gone by the time the train arrives or that the train driver will see him in time and avoid collision.

Sure, the arriving pilot messed up big time. I wouldn't give her much more than 50% of the blame though. The guys on the ground acted extremely negligent as well.
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Old 10th Mar 2018, 20:42
  #46 (permalink)  
 
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Originally Posted by SASless View Post
The Police Chief....said there were some "Lessons learned"....would one of them be hiring Professional Pilots and not putting experienced police officers through a very brief training course and making them Pilots be the wiser option?
The pilot has 16,000 hours. It wasn't just some cop they pulled off the street and threw a few hundred flight hrs at.
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Old 10th Mar 2018, 20:45
  #47 (permalink)  
 
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Originally Posted by whoknows idont View Post
I think it's a bit like someone parking his car on a railroad crossing, assuming that he will be long gone by the time the train arrives or that the train driver will see him in time and avoid collision.

Sure, the arriving pilot messed up big time. I wouldn't give her much more than 50% of the blame though. The guys on the ground acted extremely negligent as well.
Semantics always get in the way. Here is what I mean by root cause. Simply by parking an aircraft in the wrong place does not cause an accident. Arriving at the pad and hitting a parked aircraft....that causes an accident. There are many things that may make an accident more likley given normal human behaviour but there can only be one root cause by definition. I prefer to think of tap roots, one big root cause, rather than a dendritic mesh calling each factor a minor root clause. That allows us to focus on the action that caused the accident. If you choose to not blame the pilot because of the error someone else made by parking in the wrong place that is fine by me, but the root cause remains the same. It is always the pilot's responsibility to see and avoid obstacles, even if they are in unexpected places.
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Old 10th Mar 2018, 21:08
  #48 (permalink)  
 
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Originally Posted by roscoe1 View Post
Semantics always get in the way. Here is what I mean by root cause. Simply by parking an aircraft in the wrong place does not cause an accident. Arriving at the pad and hitting a parked aircraft....that causes an accident. There are many things that may make an accident more likley given normal human behaviour but there can only be one root cause by definition. I prefer to think of tap roots, one big root cause, rather than a dendritic mesh calling each factor a minor root clause. That allows us to focus on the action that caused the accident. If you choose to not blame the pilot because of the error someone else made by parking in the wrong place that is fine by me, but the root cause remains the same. It is always the pilot's responsibility to see and avoid obstacles, even if they are in unexpected places.
If this had been an open ramp at an airport it wouldn't have happened. If the weather hadn't reduced the pilots ability to judge her distance this wouldn't have happened.

If I couldn't tell my distance from another chopper when landing on marked company pads, I'd of done what she did and focused on the markings which are supposed to keep us appart, and crashed too.

If it was just an open ramp at the airport I'd of just set it down anywhere, no harm no foul.

The root cause was one pilot not parking where they should have combined with bad weather and another pilot trusting the safety measures which were in place, not realizing that they weren't.

Sure, she should have just set it down, and is partially to blame, but who can honestly say given the same scenario they would have done it differently?

You're coming home to a familiar company pad, the other chopper is running up, I think its safe to assume that most of us wouldn't even think that that other chopper wasn't where it should be.
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Old 10th Mar 2018, 23:56
  #49 (permalink)  
 
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"faith is nothing without doubt" Never trust anyone in this job ! Always be aware....
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Old 11th Mar 2018, 07:54
  #50 (permalink)  
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A root cause is an initiating cause of either a condition or a causal chain that leads to an outcome or effect of interest. The term denotes the earliest, most basic, 'deepest', cause for a given behavior; most often a fault.
The "earliest, most basic cause" was not parking the departure helicopter on the correct location.

If that helicopter on the ground was in the correct location, irrespective of the reason for being on the tarmac, that collision would not have happened.
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Old 11th Mar 2018, 08:16
  #51 (permalink)  
 
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The "earliest, most basic cause" was not parking the departure helicopter on the correct location.
No, that is a strong contributory factor but the primary cause is that she landed too close (and with very good sight of) the other running helicopter.

If that square had been contaminated and was unusable due to a fuel or oil spill that the arriving pilot didn't know about and the aircraft had been positioned in the same way - but for a clearly good reason - then would you still blame 50% on the positioning crew? Of course not - it is down to the landing pilot to keep clear.

Whoknowsidont - sometimes operational urgency means getting things done as expeditiously as possible.
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Old 11th Mar 2018, 09:45
  #52 (permalink)  
 
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It saddens me but I have to agree with Crab in this occasion ;-)
There could have been many reasons for the aircraft not to have used the box. The position of the chopper did not cause the crash - the landing helicopter caused the crash.
The parking position was a contributory factor, just as the reduced visibility due to the rain - but such factors did not cause the crash.
Such factors should not be regarded as ‘semantics’ but essential in an effective investigation.
Having lights on the parking box might have given a visual clue to the landing pilot that the parking was not as expected but that was not the cause - the cause was the landing pilot manoeuvring the chopper into the parked aircraft.
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Old 11th Mar 2018, 11:35
  #53 (permalink)  
 
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Originally Posted by [email protected] View Post
No, that is a strong contributory factor but the primary cause is that she landed too close (and with very good sight of) the other running helicopter.
Crab,

What you are referring to is the result of several factors, not root cause. Flying your helicopter into another one sitting on the ground is a result of several factors, and when analysing this you can identify the root cause, which the collision it self is not.
The root cause was what the police has taken action on after this happened and changed, and that was the marginal clearance between the two pads, which has been a latent problem for a long time.

The crew parking the helicopter incorrectly was a contributing factor. The complacency (easy to get after 22years) of the landing pilot being used to land on its marked pad, and never seen helicopters parked outside their designated pad in 22 years and 16000+ hours. The SOP's, rain, end of shift, training, habits, pilots nearsightedness, etc. All contributing factors.
Take away the marginal clearance of the 2 pads, and we would not have this thread.

From the NTSB report, the helicopters would have less than 2 feet tip separation when running and parked on it's markers, as the rotor diameter of the OH58 is 35 feet and the free space between the two pads center was 37 feet. Would be ok for one helicopter rotors running at a time, but very close and no room for errors with 2 rotors running.
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Old 11th Mar 2018, 12:00
  #54 (permalink)  
 
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John Eacott, the incident to which you refer was in late 1985.

https://www.atsb.gov.au/publications...aair198503546/
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Old 11th Mar 2018, 12:20
  #55 (permalink)  
 
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Originally Posted by [email protected] View Post
If that square had been contaminated and was unusable due to a fuel or oil spill that the arriving pilot didn't know about and the aircraft had been positioned in the same way - but for a clearly good reason - then would you still blame 50% on the positioning crew?
Yes, I would. You either put an aircraft on a pad or you don't. Never put it next to one with too little clearance and then start up. Especially if you know that one a/c is still out there yet to return to base. That is just sheer negligence. If one hasn't been usable, use the other one and make sure the one not usable is marked in a way and let arriving aircraft know via radio. Place someone on the ground watching out, marshalling the arriving aircraft.

The Flight Safety poster - ASSUME makes an ASS out of U and Me - seems appropriate.
I'm with you; both the arriving pilot as well as the guys on the ground made a lot of unsafe assumptions that display a drastic lack of safety culture.

From the report:
The pilot stated that he placed the helicopter on the outside of Pad 1; he knew they would be off the ground in a couple of minutes or he would be up on radios. The pilot stated that his thought process was that, when he was up on radios he would check the weather, and request the pilot of N911FA start toward the priority call.
That sort of complacency directly led to this accident. Yes, physically one airframe was moving and the other was not. Regardless of the verbatim definition of a root cause, for me there is clearly two main reasons for this accident to have happened. The pilot on the ground was obviously aware of the lack of physical clearance.
Everyone involved in aviation has to make sure to contribute a hole-free slice of swiss cheese. The goal must always be not to let complacency, assumptions, operational urgency or any other reasons get in the way of a safety based thought process.

Also I would give a good chunk of blame to the operation as apparently there were no clear procedures established and the design of the pad was questionable at best.
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Old 11th Mar 2018, 12:24
  #56 (permalink)  
 
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Nubian, if I drive my car into a bridge support that is just clear of the road (but was compliant with all the building regulations at the time it was built) is it the fault of the builder?

No, of course not, it is my fault because I misjudged the clearance (for whatever contributory reasons, rain, confusing road markings, not paying attention) - that is the root cause of the accident.

As with the helicopter, the second aircraft could have been parked there all day long without being the cause of an accident - the mishap only occurred with the introduction of the landing helicopter.

The primary and root cause was the pilot of the landing helicopter landing too close to the running one - she made a misjudgment, just as if she had taxied into the side of a hangar or a lighting stanchion.
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Old 11th Mar 2018, 12:32
  #57 (permalink)  
 
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100% agree with Crab on this one...
You are landing a helicopter beside another, which is running, all your focus has to be on clearance from that aircraft.
If in doubt just land on the grass, and wait till they have departed...
Sorry, but this is all pretty basic.
Good news is, no one got seriously hurt... except for the Kiowas...
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Old 11th Mar 2018, 12:35
  #58 (permalink)  
 
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Rubbish!

If you are so dense to not be able to process a flashing strobe light, rotating rotor blades, and the position of the other helicopter on a pad you have used for YEARS...then you certainly have a very real problem with cognitive awareness.

There is a hanger building and fuel system for visual reference as well.

The arriving crew had multiple opportunities to figure out the situation.

Yes...I have flown OH-58’s in those conditions and have operated from aprons very similar to the one in question and have spotted aircraft on the MARKED spots.

No matter the departing crew parked the aircraft improperly...the handling pilot of the landing aircraft owns this one!



Originally Posted by r22butters View Post
If this had been an open ramp at an airport it wouldn't have happened. If the weather hadn't reduced the pilots ability to judge her distance this wouldn't have happened.

If I couldn't tell my distance from another chopper when landing on marked company pads, I'd of done what she did and focused on the markings which are supposed to keep us appart, and crashed too.

If it was just an open ramp at the airport I'd of just set it down anywhere, no harm no foul.

The root cause was one pilot not parking where they should have combined with bad weather and another pilot trusting the safety measures which were in place, not realizing that they weren't.

Sure, she should have just set it down, and is partially to blame, but who can honestly say given the same scenario they would have done it differently?

You're coming home to a familiar company pad, the other chopper is running up, I think its safe to assume that most of us wouldn't even think that that other chopper wasn't where it should be.
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Old 11th Mar 2018, 13:46
  #59 (permalink)  
 
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Is one taught to land/park far enough away from other aircraft so that if both aircraft start their rotors, there will be no engagement?
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Old 11th Mar 2018, 14:28
  #60 (permalink)  
 
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This reminds me of an accident that happened in the early 80's in BC. At the companies main base the ramp space was limited and spots to land to be able to reach the fuel hose were also limited. A 206 was wheeled out of the hangar after maintenance and left there unattended with the blades fore and aft but not tied down. A company pilot came in and landed beside the parked 206 and was doing his cool down at ground idle when a newly hired apprentice seen that the parked 206's blades were not tied down. Having been told that it is not good to ever leave a 206 outside without the blades tied down......you can see where this is going.

Yes, he went and retrieved the tie down from the a/c, hooked the forward blade and proceeded, to the dismay of the pilot in the still at ground idle 206, to walk the blade around to tie it down. Luckily no one was injured in the ensuing catastrophe.

So, what was the root cause here? There were many factors that lead to this accident and breaking any one link in the chain could have prevented it, but IMHO the ROOT cause was either the small available ramp space or the limited length of the fuel hose.
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