Pasadena Police - two OH-58s make contact
No pilot should be expected to 'know' the dimensions used in the design of a heliport; just as no pilot should be expected to ‘know’ exactly where the extremities of the helicopter are in space.
Heliports should be designed within criteria established by the appropriate authority – based upon the ‘Design Helicopter’ (an aggregate of measurements within which all helicopters, for which the heliport is designed, can be contained). The heliport should be marked with, and have promulgated, its ‘Design D’ and ‘Maximum Mass’.
Each of the defined areas (FATO, TLOF, Stand, Taxiway) should have visual cues (aiming points, touchdown and positioning markers, lead-in-lines, centre-lines) that ensure that a pilot observing the markings will be clear of all obstacles (including other helicopters in adjacent areas) by a safe margin. Normal errors of positioning should be accounted for within the design.
This was an ‘Organisational Accident’ (Reason 1997) because none of the above criteria was met and normal standards for design and marking (Annex 14 or AC 150-5390 2C) had not been used in the design of the heliport.
The accident investigation exists to establish all the elements that led up to, and resulted in, the accident, and publish recommendations that will prevent a further occurrence – in essence a barrier for each of the causal links.
It is not established to attribute blame – unlike PPRune!
Jim
Heliports should be designed within criteria established by the appropriate authority – based upon the ‘Design Helicopter’ (an aggregate of measurements within which all helicopters, for which the heliport is designed, can be contained). The heliport should be marked with, and have promulgated, its ‘Design D’ and ‘Maximum Mass’.
Each of the defined areas (FATO, TLOF, Stand, Taxiway) should have visual cues (aiming points, touchdown and positioning markers, lead-in-lines, centre-lines) that ensure that a pilot observing the markings will be clear of all obstacles (including other helicopters in adjacent areas) by a safe margin. Normal errors of positioning should be accounted for within the design.
This was an ‘Organisational Accident’ (Reason 1997) because none of the above criteria was met and normal standards for design and marking (Annex 14 or AC 150-5390 2C) had not been used in the design of the heliport.
The accident investigation exists to establish all the elements that led up to, and resulted in, the accident, and publish recommendations that will prevent a further occurrence – in essence a barrier for each of the causal links.
It is not established to attribute blame – unlike PPRune!
Jim
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The 40-year old pilot of N96BM held a commercial pilot certificate with a rating for rotorcraft-helicopter issued in August of 2010. ... The pilot's estimated total time was 13,065 hours .... The pilot had been assigned to the Pasadena PD Air Operations Division since 2005; 2 years as a pilot and 5 years as a TFO.]
Reason for accident found: fatigue
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The 40-year old pilot of N96BM held a commercial pilot certificate with a rating for rotorcraft-helicopter issued in August of 2010. ... The pilot's estimated total time was 13,065 hours .... The pilot had been assigned to the Pasadena PD Air Operations Division since 2005; 2 years as a pilot and 5 years as a TFO.]
13,065 hours in 7.5 years??? That would be 1.742 hours per year
Reason for accident found: fatigue
13,065 hours in 7.5 years??? That would be 1.742 hours per year
Reason for accident found: fatigue
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8760 hours in a year so 1742 hours a year is not excessive in my view. Average office worker is putting in 2080 hours a year based on an 8 hour day 5 days a week. Long haul truckers are legally allowed to drive 10 hours a day.
Roybert
While I fully understand the responsibility is always on the pilot flying, the spotting crew did her no favors.
If Mrs. SanDiego89 trips on the stairs due a misplaced toy, our forum would deem her at fault for poor navigation, poor risk assessment, conditioned response, and complacency, but you can damn sure bet the kids are going to get yelled at!
If Mrs. SanDiego89 trips on the stairs due a misplaced toy, our forum would deem her at fault for poor navigation, poor risk assessment, conditioned response, and complacency, but you can damn sure bet the kids are going to get yelled at!
Actually they can drive 11 hours a day in the US except interstate California where they are restricted to 10 hours.
FMCSA Hours of service summary
FMCSA Hours of service summary
SD89,
That is because as humans, nothing is ever entirely our fault. Life would be so much better if the word "but" never came after "yes," . In this case the accident was caused by the moving pilot. The conversation should not be a "yes, but" conversation it should be a "yes, this was my fault. May we please do what we can to see it doesn't happen again? Landing on adjacent pads always demands caution. Why was my normal level of caution not sufficient in this case?" One thing I can't understand is why nobody involved in parking aircraft didn't look at what they were routinely doing and point out it was not a good sop for the obvious reason. Having said that, what they did is still not the cause of the accident. Had the second ship already landed and then they rolled out the other one and rolled it into the moving blades, then it would have been the fault of the ground handlers.
That is because as humans, nothing is ever entirely our fault. Life would be so much better if the word "but" never came after "yes," . In this case the accident was caused by the moving pilot. The conversation should not be a "yes, but" conversation it should be a "yes, this was my fault. May we please do what we can to see it doesn't happen again? Landing on adjacent pads always demands caution. Why was my normal level of caution not sufficient in this case?" One thing I can't understand is why nobody involved in parking aircraft didn't look at what they were routinely doing and point out it was not a good sop for the obvious reason. Having said that, what they did is still not the cause of the accident. Had the second ship already landed and then they rolled out the other one and rolled it into the moving blades, then it would have been the fault of the ground handlers.
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It's been twenty years since I've been in a cockpit. So you can discount everything I say. Flying hours is the time spent on the controls only and not in flight planning. And if you can't handle flying for 5 hours a day then you need to look for a new career.
No pilot should be expected to 'know' the dimensions used in the design of a heliport; just as no pilot should be expected to ‘know’ exactly where the extremities of the helicopter are in space.
Heliports should be designed within criteria established by the appropriate authority – based upon the ‘Design Helicopter’ (an aggregate of measurements within which all helicopters, for which the heliport is designed, can be contained). The heliport should be marked with, and have promulgated, its ‘Design D’ and ‘Maximum Mass’.
Each of the defined areas (FATO, TLOF, Stand, Taxiway) should have visual cues (aiming points, touchdown and positioning markers, lead-in-lines, centre-lines) that ensure that a pilot observing the markings will be clear of all obstacles (including other helicopters in adjacent areas) by a safe margin. Normal errors of positioning should be accounted for within the design.
This was an ‘Organisational Accident’ (Reason 1997) because none of the above criteria was met and normal standards for design and marking (Annex 14 or AC 150-5390 2C) had not been used in the design of the heliport.
The accident investigation exists to establish all the elements that led up to, and resulted in, the accident, and publish recommendations that will prevent a further occurrence – in essence a barrier for each of the causal links.
It is not established to attribute blame – unlike PPRuNe!
Heliports should be designed within criteria established by the appropriate authority – based upon the ‘Design Helicopter’ (an aggregate of measurements within which all helicopters, for which the heliport is designed, can be contained). The heliport should be marked with, and have promulgated, its ‘Design D’ and ‘Maximum Mass’.
Each of the defined areas (FATO, TLOF, Stand, Taxiway) should have visual cues (aiming points, touchdown and positioning markers, lead-in-lines, centre-lines) that ensure that a pilot observing the markings will be clear of all obstacles (including other helicopters in adjacent areas) by a safe margin. Normal errors of positioning should be accounted for within the design.
This was an ‘Organisational Accident’ (Reason 1997) because none of the above criteria was met and normal standards for design and marking (Annex 14 or AC 150-5390 2C) had not been used in the design of the heliport.
The accident investigation exists to establish all the elements that led up to, and resulted in, the accident, and publish recommendations that will prevent a further occurrence – in essence a barrier for each of the causal links.
It is not established to attribute blame – unlike PPRuNe!
You could class it as an organisational accident IF it happened immediately after they changed from 300s to 58s and didn't remark the landing pads. That would be reasonable mitigation for the pilot who would have expectations that the new aircraft were introduced into a 'safe' working environment.
However, it is quite clear that they were operating for some time in this condition and had probably had the discussion about it in safety meetings eg Hey, we still haven't changed the pad layout and these helos are much bigger than the last ones'.
Call it laziness, lack of awareness or whatever you want but the reason that accident happened was poor piloting.
If you want real safety as opposed to paper safety, we need to get away from the culture of 'making excuses' for an accident which is clearly someone's fault (for whatever reason.)
However, it is quite clear that they were operating for some time in this condition and had probably had the discussion about it in safety meetings eg Hey, we still haven't changed the pad layout and these helos are much bigger than the last ones'.
Call it laziness, lack of awareness or whatever you want but the reason that accident happened was poor piloting.
If you want real safety as opposed to paper safety, we need to get away from the culture of 'making excuses' for an accident which is clearly someone's fault (for whatever reason.)
Megan,
Don't tell me you're just another lemming in that whatever the NTSB or our AAIB says - goes. They, too are human (remember that argument about human error - well it exists inside even the most illustrious departments).
I would be only too happy to tell the NTSB that this conclusion is suspect, in the least and for the following reason:
Markings are 'guidelines'. They are not compulsory or legal.
Here's the interesting bit: Assuming the NTSB advice is compelling - how does a visiting aircraft, unfamiliar with the venue, fit into this organisational problem?
Does the visiting pilot assume that if he/she bumps into anything of their own volition - it's partly the organisation that is to blame? Of course not. YOU as a pilot are expected to navigate around obstructions and land on a spot that is free from harm. The markings on the helipad are very nice and no doubt very clear, but if a visiting pilot assesses there is something not quite right with the spacing and his/her SPATIAL AWARENESS, then FFS......they make adjustments. IF that adjustment (trying to avoid bumping into other objects) is defective and they do hit something, does one genuinely believe they are only partly to blame because surrounding arrangements were not what they should have been?
If I clip another car in the shopping mall car park because it wasn't perfectly inside its parking slot - can I genuinely accept only 90% of the blame?
This accident couldn't have been more black and white. Pilot brings cab number 2 home. Parks cab 2 on top of cab 1 because they didn't adjust accordingly.
Please let's not make more of this than what it is. A simple mistake by a simple pilot.
Don't tell me you're just another lemming in that whatever the NTSB or our AAIB says - goes. They, too are human (remember that argument about human error - well it exists inside even the most illustrious departments).
I would be only too happy to tell the NTSB that this conclusion is suspect, in the least and for the following reason:
Markings are 'guidelines'. They are not compulsory or legal.
Here's the interesting bit: Assuming the NTSB advice is compelling - how does a visiting aircraft, unfamiliar with the venue, fit into this organisational problem?
Does the visiting pilot assume that if he/she bumps into anything of their own volition - it's partly the organisation that is to blame? Of course not. YOU as a pilot are expected to navigate around obstructions and land on a spot that is free from harm. The markings on the helipad are very nice and no doubt very clear, but if a visiting pilot assesses there is something not quite right with the spacing and his/her SPATIAL AWARENESS, then FFS......they make adjustments. IF that adjustment (trying to avoid bumping into other objects) is defective and they do hit something, does one genuinely believe they are only partly to blame because surrounding arrangements were not what they should have been?
If I clip another car in the shopping mall car park because it wasn't perfectly inside its parking slot - can I genuinely accept only 90% of the blame?
This accident couldn't have been more black and white. Pilot brings cab number 2 home. Parks cab 2 on top of cab 1 because they didn't adjust accordingly.
Please let's not make more of this than what it is. A simple mistake by a simple pilot.
TomCoupling,
Right on, Bob's your uncle, absolument,however you want to put it. Even the NTSB can be overly sympathetic when there are ways that culprets may be construed as victims for reasons that swirl around an accident. I'm not saying there were no mitigating factors, just that only one person could determine whether this accident happened or not and they could do that by doing perhaps the most important thing a VFR pilot has to do while flying and that is of course to see and avoid. That sometimes isn't enough even for the most vigilant among us. They don't have to fly straight or smooth; those are not life or death. The final report may and should have the mitigating factors listed but the cause was controlled flight into a stationary object (stationary even though the blades were turning). It doesn't mean she is a bad pilot. That may only be judged by a career wide view by people who are peers. It just means they had a split second lapse ( or a bit longer) and there but for the grace go most of us.
I caused an accident many years ago that had the potential to be the textbook example of a certain type of aviation accident. Multiple people could have been killed. We were all lucky that day and barely a drop of blood was spilled. There was much mechanical damage. In the end I knew I had trusted certain things to be true which it turned out were not, due to others shortcuts. Their shortcuts were not used as my excuses as much as I would have loved to defer the blame. Sometimes we goof. My life would have been very different if there had been injuries and almost unbearable if I had caused a death. The pilot in this accident should go to sleep every night with a smile that everyone walked away.
Right on, Bob's your uncle, absolument,however you want to put it. Even the NTSB can be overly sympathetic when there are ways that culprets may be construed as victims for reasons that swirl around an accident. I'm not saying there were no mitigating factors, just that only one person could determine whether this accident happened or not and they could do that by doing perhaps the most important thing a VFR pilot has to do while flying and that is of course to see and avoid. That sometimes isn't enough even for the most vigilant among us. They don't have to fly straight or smooth; those are not life or death. The final report may and should have the mitigating factors listed but the cause was controlled flight into a stationary object (stationary even though the blades were turning). It doesn't mean she is a bad pilot. That may only be judged by a career wide view by people who are peers. It just means they had a split second lapse ( or a bit longer) and there but for the grace go most of us.
I caused an accident many years ago that had the potential to be the textbook example of a certain type of aviation accident. Multiple people could have been killed. We were all lucky that day and barely a drop of blood was spilled. There was much mechanical damage. In the end I knew I had trusted certain things to be true which it turned out were not, due to others shortcuts. Their shortcuts were not used as my excuses as much as I would have loved to defer the blame. Sometimes we goof. My life would have been very different if there had been injuries and almost unbearable if I had caused a death. The pilot in this accident should go to sleep every night with a smile that everyone walked away.
