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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 11th Mar 2018, 16:33
  #61 (permalink)  
 
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Originally Posted by [email protected] View Post
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.
No Crab. You're talking about the ''last hole in the swiss cheese'', the last factor that caused the accident, not the root cause.

Why do you think they redesigned the base after this accident? Surely if it was only the landing pilots fault, this would be unnecessary! Then you'd give the pilot some additional training, and all chances of this happening again would be gone!

I ask you: Would we have this thread if the base had looked like it does today?

There is a good reason that the NTSB have 4 recommendations, all related to the AC governing heliport design in this report.

I'm sure you have lots of SOP's and know them all by heart, but do you know WHY you have them?

You're right about ASSUME though... but that would not happen if the ramp looked like it does now, then there would not be a need of assuming anything.
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Old 11th Mar 2018, 16:42
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As I stated above, if you collide with something while you are moving and the object you hit is stationary it is pretty much your fault. The root cause is always that you failed to see and avoid. You should try and not depend on others to always do what is expected to the extent that is humanly possible. Do not confuse what I'm saying with the fact that any or all of us might have had the same outcome causing those of us watching to say " yeah, that could have happened to anyone because they were set up by factors beyond their control". Yes, the scenario was beyond expectations of the pilot but that is why we drill and drill and pay big bucks for SMS programs that all have the same risk assessment matrix in them. If they had such a program and did an internal audit on ramp procedures perhaps the poor selection of how they parked aircraft would have popped and things might have been different. Laugh if you like about the chance that that would actually take place but if we follow our own advice and actually do these things, it might surprise those who are sceptics that it can work. That doesn't change the cause of this accident. The root cause doesn't necessarily go back to the one, two or ten things that might have prevented the accident. The root cause is that thing that actually allowed the rotors to hit. This factor was totally under the pilot's authority to prevent and that was the controlled flight of the aircraft in motion. You might argue the analogy but when you run over your kid's bicycle because they laid it down behind your car in the driveway, it is time to yell at the kid for being dumb. However, in those tragic accidents when it it a toddler that is injured or killed because someone didn't see them...is there really any blame placed on the child?
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Old 11th Mar 2018, 18:56
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Roscoe1 -

Nubian
There is a good reason that the NTSB have 4 recommendations, all related to the AC governing heliport design in this report.
yes, it is because they can do something to remove some of the layers of cheese, but other than taking away the licence of the pilot, they can't remove the root cause.
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Old 11th Mar 2018, 21:18
  #64 (permalink)  
 
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Originally Posted by [email protected] View Post
Roscoe1 -

Nubian yes, it is because they can do something to remove some of the layers of cheese, but other than taking away the licence of the pilot, they can't remove the root cause.
Hehe, nothing beats good ol British arrogance! Pick and choose... Why don't you answer my question?

So you remove the landing pilot's license (your root cause) and this would never happen again?? Right....
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Old 11th Mar 2018, 21:31
  #65 (permalink)  
 
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Nubian

Are you from this planet ? She hit the other aircraft there is no more to be said as to whose fault it is. so what you are saying is I am driving down the road, someone stops at traffic lights and I
hit the back of them and it is the traffic lights fault
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Old 11th Mar 2018, 22:05
  #66 (permalink)  
 
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so what you are saying is I am driving down the road, someone stops at traffic lights and I hit the back of them and it is the traffic lights fault
No, your fault.
But if the other guy intentionally stops where he is not supposed to, where he is not expected to be, i.e. in the middle of the road behind a blind corner in poor visability, then it's not solely your fault, is it?
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Old 11th Mar 2018, 22:46
  #67 (permalink)  
 
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Originally Posted by Hughes500 View Post
Nubian

Are you from this planet ? She hit the other aircraft there is no more to be said as to whose fault it is. so what you are saying is I am driving down the road, someone stops at traffic lights and I
hit the back of them and it is the traffic lights fault
I just recognise yet another that has to use dubious scenarios because he does not understanding why accidents happens!

Of course the landing helicopter is at fault, but you folks fail to understand WHY it happened and what could prevent it, which is quite shocking! At least the NTSB and the Pasadena police got it.

All talks about driving into bridge supports and rear ending others in traffic, is just plain bollocks, and show that you have no understanding of how to prevent accidents or understand why they happen.

With your simple way of thinking, no measures will ever need to be put in place to prevent similar accidents from happening again, as it was just this ''dense'' pilots stupid fault.... full stop! Remove the pilot, and all is fine....


Hughes500,
I asked Crab a simple question above, which he very elegantly skipped, so lets see if you can answer it! Would we have this thread if the heliport looked like it does now, after the recommended changes??
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Old 11th Mar 2018, 23:19
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Nubian - that accident could occur anywhere when one pilot lands too close to another aircraft, regardless of what marks are on the ground.

How many accidents have been caused when pilots got their aircraft too close to other aircraft, hangars, lights, wires etc etc etc? And then who was at fault, the person who built the hangar????

Yes, the pad at Passadena has been remodelled but another pilot could still show a lack of judgement by landing too close to a helo that isn't parked in the right place (or even one that was)

You can address design of a helipad, address local procedures and rebrief people, you can add comms systems, you can change everything to try and make sure that particular accident can't ever happen again - right up to the point where a pilot makes a misjudgment/mistake/error - then who will you blame?

If you want to go into the minutiae of why she made that error then you might be far closer to preventing similar accidents - the design of the helicopter windscreens and wipers, stop and go lights on the dispersal to give landing clearance, what safety seminars she had been to, what her mental condition was (family problems or similar causing distraction from the job) - the list is endless.

There will have been many, many factors that could be considered contributory but only one as the main cause - landing the aircraft too close (for whatever reason you choose to pick) to the other one - that's it, pure and simple.

If the second aircraft hadn't been there at all and she had tried to land on the normal square but drifted left and hit the fuel tanks, would you blame the installation of the fuel tanks or poor piloting?

really not sure why you think 'British arrogance' is a factor or is it my fault she crashed?
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Old 11th Mar 2018, 23:33
  #69 (permalink)  
 
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Ok, revoking, suspending or any other certificate punishment is not even close to being warranted because even though the root cause was the action of this pilot, there were some pretty compelling reasons why this was going to happen to someone. It was only partly to do with the attentiveness of the pilot and punishing this person is flat out wrong unless she was doing something so egregious that firing her was the only safe option and that would require a history of incidents and remedial training. In this case I can say with 100% certainty that she will be more careful than most when approaching an LZ. If this person had a good record then punishment is not as smart as some extra training and if you do that, whamo you have a better employee than if you took on an unknown quantity or someone with less experience.
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Old 11th Mar 2018, 23:40
  #70 (permalink)  
 
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Its time we face reality. Sixteen thousand hours is obviously not enough to be a safe and competent pilot. Commercial pilot minimums must be raised to at least 20,000. Then and only then will we finally get pilots who will stop doing stupid irresponsible things!
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Old 12th Mar 2018, 01:17
  #71 (permalink)  
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Originally Posted by roscoe1 View Post
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?
A root cause is either a 'Process', a 'Responsibility' or a 'Resource' failure and once determine by analysis should be corrected so it cannot reoccur.

What appears to have happened here could happen again.
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Old 12th Mar 2018, 08:38
  #72 (permalink)  
 
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ZFT - by those terms, this was a responsibility and, other than grounding the pilot (which wouldn't prevent other pilots making similar mistakes)how would you suggest this is 'corrected'?
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Old 12th Mar 2018, 08:39
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Nubian
It makes didley squat difference the redesign of the pad if a pilot decides to land too close too something. The locations of the pads are obviously a factor, where people had put the other machine was a factor, as was the rain. The root cause was the pilot. If the root cause was the size of the facility then they would have had accidents every time. I would agree that no risk assessment was obviously done when the pads were designed.
Lets be frank the pilot assumed that everything was ok, obviously not. although why the pilot's would accept a 2 ft clearance on such a facility is unbelievable. I think the expression what could possibly go wrong comes to mind, oh yes it did
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Old 12th Mar 2018, 09:36
  #74 (permalink)  
 
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There are ICAO rules for the design of heliports (ICAO-Annex-14-V2). These rules are designed to put in place the first barrier to an undesirable event. In this case, TLOF and taxiway markings that conform to the largest aircraft for which the facility is designed to accommodate.

Looking at the pad from the images available its does not look like the safe distances have ever been properly laid out.

If this is the case, pilots get into the habit of landing on many, many occasions where nothing goes wrong. However, "Risky Shift" is now in play. Caused not only by the assumed inaccurate layout but also those occasions where the safety distances provided are further eroded by poor placement and inaccurate landings. Habit.......leads to complacency.

However, I agree with Crab and Hughes500. Despite all the efforts that should be made to provide safety distances, markings etc, the ultimate responsibility for the flight trajectory always remains with the pilot!

If you have not read ICAO-Annex 14 V2, and you are routinely making decisions as to how close you can land to objects, fuel installations, other aircraft etc! now would be a good time to refresh.

A few years back, operating in NW Oz, I faced a similar problems with a bunch of pilots willing and ready to take considerable risks while manoeuvring in the ground taxi in very large helicopters. They were all good professional pilots but in my opinion, were suffering from a severe dose of "Risky Shift". I was not fully able to solve this problem despite being in a supervisory position due to the ingrained and learned behaviours of the crews. Incredulously, several years prior to my experiences, there had been a helicopter collision on the same manoeuvring area due to the same factors present.

Sometimes, we as pilots are our own worst enemies in our pursuit of expedience.

I do not agree that the problem gets solved by punishment. However, with 16K in the logbook its hard to explain why "Risk Aversion" has not fully set in for the individual. Therefore it would be safe to assume, that despite the "Risky Shift" factors in play, the final act of the pilot in question has to be considered as "completely inappropriate to the conditions", and as such, search for underlying causes of distraction in the personal closet of the pilot.

Finally, to consider that "Rain" and "Visibility" etc was a factor, we are ignoring the principle that when operating in such conditions, additional margins of safety need to be applied. This again sits with the judgement of the pilot.

Clearly to me, judgement was impaired by "Risky Shift", ..........and some other factor(s). Determining what those other factors were, and addressing them, is important IF that pilot is to return to service.

However, if this pilot were to fly tomorrow, I suspect her personal safe distances she is prepared to accept have somewhat increased exponentially. She is highly unlikely to make this mistake again.
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Old 12th Mar 2018, 09:44
  #75 (permalink)  
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Originally Posted by [email protected] View Post
ZFT - by those terms, this was a responsibility and, other than grounding the pilot (which wouldn't prevent other pilots making similar mistakes)how would you suggest this is 'corrected'?
I don't have all the facts to do a root cause analysis but as you correctly state, grounding the pilot would not prevent a similar occurrence, however from what little we do know, I would suggest it was more a process issue with the incorrect positioning of the 'on ground' machine and if there were procedures in place to ensure correct positioning every time, then this thread would not be running?
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Old 12th Mar 2018, 09:56
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To add some colour to my last post, the minimum safe distance between helicopters operating on adjacent TLOFs is 1/2 the width of the largest helicopter in play. Assuming the discs of these helicopters is around 10m, that would mean at least 5m between rotor tips.
Now in a dynamic situation we cannot expect the pilot to accurately judge 5m. However, in the video it looks to me like the landing helicopter actual descended "through the rotor tips" of the stationary running helicopter. That is clearly not 5m or anything like. WHY? because poor knowledge has led to risky shift which has been in play for a prolonged period where nothing has ever gone wrong.

Compliance is the first building block of Flight Safety. Had that pilot known on that day that the minimum distance should have been 5m, this accident would almost certainly not have happened.

(Note I am guessing the rotor diameter cos I am too lazy to look it up, however, if its 4, 5, 6 or even 7m I think you can get the principle I am applying).

Concepts such as risky shift, learned behaviours and poor compliance are symptomatic of Company Culture. If I have learned anything in my time in aviation its that of all things that may need to be changed, the hardest of them to change is Company Culture.
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Old 12th Mar 2018, 10:02
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I have both owned and commercially flown helicopters. I have also worked on offshore oil rigs for many years. From time to time some industry operators run safety oriented seminars and training courses, usually presented by specialist companies.

One of the recurring facts to emerge from most of these seminars is how people's "perception" can and does vary from what is actually being evaluated, and how it can and does lead to disaster. Simply put, what we sometimes conclude as being a fact, may be what we are expecting it to be, rather than what it actually is.

This "perception" is more likely to occur with things that we are very familiar with and have used or done many times before. It is an unconscious reaction that happens automatically, more so if there are other factors that are demanding our immediate attention.

In this case we have a 16,000-hour pilot that is obviously skilled, probably well trained and definitely familiar with her surroundings and normal procedures. Something that she has probably done hundreds, if not thousands of times previously.

It is nothing to do with the weather, or the other helicopter. I am sure that she would have been aware of the parked helicopter, just as she was aware of the weather conditions. She may have been focusing on the weather, but the other helicopter was "just there", as it probably had been many times before. Her perception of it would not have led her to even consider that it may have been parked in the wrong place, or that it could possibly be a hazard.

It is one of the traits of being a human being. We are not machines that can be programmed, no matter how well trained we may be.

Last edited by Old Farang; 12th Mar 2018 at 12:22. Reason: correct typo
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Old 12th Mar 2018, 14:29
  #78 (permalink)  
 
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I can't believe we are arguing over this - scary to be honest.
ONE reason for this accident and one only:

HUMAN FACTORS.

Isn't there anything to distract us from continuing with this thread.

Dumb ass police pilot - not looking where they are going - simples.
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Old 12th Mar 2018, 15:13
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Originally Posted by 2016parks View Post
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?
Over here in EASA land you are, at least I was defnitely made aware of my(!) duty to consider my hazard-radius with repect to nearby "obstacles". Actual "Eangagement" isn't the issue, meaning, I must not park too close to some light aircraft as my downwash might dislodge it let alone turn it upside down. Down to the point that a doofus who parked his plank too close to me, effectively has me grounded, as firing of my ship in a "now you'll learn aber not parking near a helo" attitude will definitely case me being liable for takeoff down-wash to his plank, even if he parked it after I landed. My option is only to scare up the ignorant and make him move his plane, an maybe complaint about him at authorities in repeat instances.

Basically there is not one single valid excuse for crashing into a stationary object, being it a wrongly parked car, a parked helo with rotors turning and lights flashing or fuel shack. In my book the one operating the moving object pays in full, always.

But back OT, I think that type of accident can bite anyone, even very famous and skilled pilots occasionally **** up :
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Old 12th Mar 2018, 16:17
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Well that's clearly the fault of the person who built the hangar...............
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