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AS332L2 Ditching off Shetland: 23rd August 2013

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AS332L2 Ditching off Shetland: 23rd August 2013

Old 27th Oct 2013, 13:34
  #2021 (permalink)  
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About how many Super Puma pilots would CHC have in the NS?
About 4 in the last 12 months.
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Old 27th Oct 2013, 13:55
  #2022 (permalink)  
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With respect to this thread and the subject in hand, you should all be aware that the views expressed here are being read and noted. As far as 26500lbs' post is concerned, and specifically HF (not just in the North Sea but from the Cougar 851 report and the accident in the Far East - i.e. other offshore provinces), there is a culture issue. it would appear that we have an insidious problem that has been allowed to develop because it was not recognised that the introduction of automation would also necessitate a change in our operating procedures and CRM (culture). This is extremely well illustrated by the subject of this thread - the L2 accident at Sumburgh.

We pick up the accident as soon as the choice was made to fly the LOC/DME; this NPA does not have a step-down profile and is therefore a good candidate for a stabilised approach (not CDFA because there was no procedure and the helicopter was not equipped for it). With a stabilised approach even if it was elected to fly in 3 axis mode either the V/S or the A/S mode could have been engaged with the other set as a monitored parameter (i.e. a constant).

To make this a 'monitored-stabilised' approach the PF would have had to decide, from the information provided in the ROD panel, the V/S and the A/S. If this had been done, both pilots would have been oriented to the key constants, and any adjustment that had to be made would have been with respect to the gradient provided by the check heights at the DME check points and applied to the non-coupled constant. The PM would have been completely oriented to the key parameters to monitor and the bounds of the trajectory within which the approach should be conducted. Any departure from the bounds, so established, would have required a challenge from the PM and an adequate response from the PF.

However, if you carefully consider the AAIB report you will see that this was far from a stabilised approach because to fix the V/S (couple) you also have to establish and maintain a reference A/S. This cannot be done on a decelerative approach!

The PF opted for a three axis approach with the V/S coupled but, in the brief, indicated that there would be a reduction of speed to 80kts. Coupling the V/S and flying a stable approach can only be achieved by having a constant A/S; if a decelerative approach is chosen then the required V/S to achieve the notional trajectory will also be a variable.

The effect of this can be seen on the descent below the notional glide when the A/S was reduced (with the V/S coupled).

My point is that in order for the PM to function as a key member of the crew in the monitoring role, he/she must know the boundaries of normality; in the accident, those boundaries were not known because the trajectory was not fixed. In consequence, the PM could not report on a diversion from the V/S or the A/S (and in fact also did not report on the check heights at the DME points - clearly there were too many variables).

It is not known whether the CHC SOPs specify the required regime for a NPA however,an approach flown in accordance with an SOP should indicate the mode of flight, the key constants and the variables. If any of the non-coupled constants tend to the limit, the PM can make the appropriate calls and the PF the necessary response, or, failing that, the PM can take the appropriate action. Without a deterministic approach (SOPs) the crew cannot act as a team - with the inevitable results that we have seen.

Not operating in this manner indicates that we have not yet embraced the cultural changes, associated with automation, that are required in training, operating, and crew resource management. These changes are a necessity that were identified in fixed-wing when similar incidents/accidents occurred at the time of the introduction of the glass cockpit.

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Old 27th Oct 2013, 14:10
  #2023 (permalink)  
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Excellent post Mars. There is one limitation to the logic though and it was seen in the Cougar 851 incident. A situation arose whereby the co-pilot felt unable or incapable of taking control from a captain who had lost control. I sympathise with cougar and am sure it is not a problem unique to their operation for all the reasons I stated in a previous post.
When a multi-pilot helicopter is limited to certain phases whereby only one pilot can control the aircraft there is a new crm issue. This is the case for example when landing an S92 on a helideck. The PM has little or no visual cues to the deck and cannot land if needs be. Therefore when the captain is the PM and the co-pilot is new/inexperienced/tired/stressed/confused/incapacitated there is a crm problem. The same is of course true the other way around - when a co-pilot does not speak up when the experienced captain is PF and loses orientation for whatever reason. For that critical phase of flight the captain is entirely dependent on trusting the other guy and is effectively somewhat out of the loop by definition. How does this manifest itself during line training of a brand new pilot who can be expected to make mistakes? We are relying on a deal of luck and therefore by the same rationale must know that we cannot be lucky all the time. Again a cultural issue? Are all our captains suitable for role or are they just highest on a seniority list?

Last edited by 26500lbs; 27th Oct 2013 at 14:23.
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Old 27th Oct 2013, 14:35
  #2024 (permalink)  
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I find the approach to safety on the NS frustrating.

I don't think that the industry is capable of regulating itself. Too many accountants and not enough real helicopter professionals in management?

1 Bond ETAP ditching - training and operations SOP issue, a sophisticated autopilot which the pilots didn't know how to use properly.
2 Bond L2 - Failure of Maintenance and OEM to intervene in time
3 Bond EC225 MGB - OEM issue but Maintenance and HUMS download should have caught this
4 CHC EC225 MGB - failed to learn the lessons of #3, how obvious can it be?
5 CHC 332L2 - Training and SOP issue? A less sophisticated autopilot not used to its potential?

The OEMs continue to field aircraft and operators and pilots continue to accept some aircraft with known problems (EC225 MGB) covered with a band aid solution. "New shafts" they say but only when your current MGB goes in for overhaul. It could be 3 years before all MGBs are so fitted. Acceptable? ALARP?

How long will it be before the repetitive NDI at 8 hour intervals requiring entry into the MGB and the disconnection of a major control linkage causes another accident? Is such frequent inspection really necessary? If so, should the aircraft type not remain grounded?

The Helicopter industry doesn't want intervention from the regulator (CAA)
The Pilot Unions haven't a clue, and a mooted enquiry by MPs is ridiculed.

The answer is not a self serving closed shop review of the industry by the industry for the industry, an industry in which trust is evaporating.

It's about time that the UK Government ordered a top to bottom enquiry using a group of real safety professionals to show the industry the huge holes in the Swiss Cheese. Its 2 months since 4 people lost their lives, not much to change anything has happened, oh, I forgot about the letters from the CEOs telling everyone they will improve, together!
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Old 27th Oct 2013, 14:47
  #2025 (permalink)  
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Are all our captains suitable for role or are they just highest on a seniority list?
as I keep being told, that is exactly how the civil aviation world likes to work - time in the company not ability or experience.
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Old 27th Oct 2013, 14:53
  #2026 (permalink)  
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Mars, whilst generally agreeing with your post, I think we have to be careful not to drop everything at the door of automation. That is only one element. The issues surrounding monitoring and the need for stabilised approach with parameters clearly defined so as to empower PM to intervene sooner rather than later, apply just as much without automation as with it.

In Bristow it has long been required to be speed stable by 1000' above the airfield during an IFR approach. Perhaps 1000' is too low, but at least we had a policy. I wonder what CHC's policy on stabilised approaches is? The trouble is we have yet to silence the roar from those who maintain that "its a helicopter, not an aeroplane" and want to be able to be fully flexible with speed.

I suspect that if we looked at the Ops Mans of the main players, there would be large differences in such policies between them. Surely this is not how it should be?
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Old 27th Oct 2013, 15:11
  #2027 (permalink)  
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Any change in culture would have to embrace a level of knowledge of the automation that is not being demonstrated at the moment - that in itself requires a change in our training practices away from number of hours to one of demonstration of competence. Perhaps the level of knowledge should associated with a mental map of the working of automation and not necessarily with a mechanical function of keystroke provision. If a situation is observed that is out of the normal, it is far more likely that it can be addressed if the overall logic is understood.

The Cougar 851 incident was complex because the report appears to throw doubt on: the competence of the P1; his level of understanding of the automation; and the confidence/competence level of the P2. Not exactly a happy state of affairs. (Unfortunately a similar situation obtained when the oil filter studs failed in a previous accident.)

With respect to your points on the logic of my argument: it has long been accepted by the airlines that a monitored approach always sees the less experience crew member as the PF. Thus, any required action following an inadequate response to a challenge would always be taken by the more experienced PM.

As for offshore landings; yes, we are in a situation where, because we need to have risk-assessed landing profiles (which does not apply equally to take-off) the PM on an approach cannot see the helideck cues. However, the same logic applies; all crew members must demonstrate competence for deck landings - this might be achieved (as it is) by limiting the scope of inexperienced crew members to those situations where skills have been seen to be adequate. If one of the limits of the landing profile are exceeded, or it can be seen that it might be exceeded, the PM should (gently) challenge; if the inexperience crew member is not in a position to correct the exceedence, then there is little alternative to the PM calling for a go-around and returning to base. This is also a cultural issue but one that has to be adopted if it is considered that we have to have continuation training on the job (as we probably do).

The issue of an inexperienced crew member not being in a position, mentally or physically, to take control following subtle incapacitation is one of training and/or culture and has to be thought through in detail.

We can only operate safely if we adopt the correct stance to all of these issues. The first barrier that we face is to convince the regulator, operator, pilot and customer that we have to have cultural change. My view is that we are in a unique position to do this.

If one thing is becoming clearer to us each day it is that without a change of culture from the top, we will not be able to address the HF issues and put in place a ‘change management’ process that not only could have dealt with the immediate problem, but would also be able to see the next one coming – they are not exactly ‘black swan’ events.

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Old 27th Oct 2013, 15:18
  #2028 (permalink)  
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I suspect that if we looked at the Ops Mans of the main players, there would be large differences in such policies between them. Surely this is not how it should be?
Here's a stabilised approach OMA extract from a non-major..... Stabilised Approaches General
XYZ adopts a stabilised approach policy. The policy includes the following guidelines which are sub-divided for clarity and reflect the different criteria and risk factors associated with the different types of operations that are conducted. In other words, one blanket set of criteria is inappropriate. Common Criteria
The following requirements must be met for all approaches:
(a) The aircraft is on the correct flight path.
(b) Only small changes in heading roll and pitch attitude are required to maintain the correct flight path, and the rate of power application is normal. Any period in excess of 3 seconds with the collective position at MPOG must be considered unstable and immediate corrective action shall be made. Similarly, any period where the Nr rises above the Np, shall be considered unstable.
(c) The aircraft is in the correct landing configuration.
(d) The rate of descent is no greater than 650 feet per minute. If an approach requires a rate greater than 650 feet per minute, a special briefing shall be conducted. If a rate of descent exceeding 650 ft/min develops the PF will state his awareness of it and his intentions.
(e) All briefings and checklists have been conducted.
(f) Unique approach procedures (or abnormal conditions) requiring a deviation from the relevant elements of a stabilised approach require a specific briefing.
Onshore IFR Approaches - Specific Criteria
(a) All flights shall be stabilised by 1000 feet above landing elevation in IMC and by 500 feet above landing elevation in VMC.
(b) ILS and RNAV LNAV/VNAV approaches must be flown within one dot deviation of the glide slope and localiser, and Non Precision Approaches flown within 5° of the Final Approach Track.
(c) For Non Precision Approaches (NPAs) the company adopts the Continuous Descent Final Approach (CDFA) concept, and therefore requires that the approach be flown from the FMS using the Flight Director P-ILS function.
(d) An approach that becomes unstabilised below 500 feet above the landing elevation in IMC or below 250 feet above the landing elevation in VMC, requires an immediate go-around. Simi- larly, any approach being conducted visually (including the final stages of an approach initially flown in IMC) that subsequently results in loss of the required visual references shall be imme- diately discontinued. Onshore VFR Approaches - Specific Criteria
The aircraft should be wings level and aligned with the runway by 300 ft AAL by day, and 500 ft by night. Offshore IFR Approaches - Specific Criteria
For ARA's the aircraft is to be wings level and on the landing heading prior to descending below MDH. Offshore VFR Day Approaches - Specific Criteria
Where the sector distance is less than or equal to 2nm, transit height is to be not less than 300 ft ASL. Sectors in excess of 2nm shall be flown at not less than 500 ft ASL above landing elevation. En-route descents shall initially terminate at not below 500 ft ASL. Regardless of the initial sector length and arrival height, the aircraft shall be wings level and on the final approach track/heading by 300 ft ASL. Offshore VMC Night Approaches - Specific Criteria
Offshore arrivals and approaches in VMC shall be flown coupled to the flight director until the visual descent gate is established. The normal shuttle and circuit height will be 1000 ft ASL. Short sectors and circuits may be flown at 500 ft ASL if specifically briefed and adequate justification given. The aircraft shall be wings level and on the final approach track and at 500 ft ASL by not less than 1nm. The normal visual approach gate shall be 500 ft ASL, 55 KIAS and 0.6nm from the destination. With some minor variations for deck height, this will give approximately a 7-8° glidepath with good deck ovality and will reduce the time flown uncoupled to a minimum.

CAUTION: Avoid excessively long continuous descents to a deck, particularly from an en-route descent. The likelihood of the approach becoming unstable and the difficulty in accurately assessing closure rates and sight picture variation will increase markedly. Pilot Monitoring (PM) Responsibilities
It is imperative that the Pilot Monitoring informs the Pilot Flying (PF) when any of the above parameters are being approached, and that once reached, or exceeded, unequivocal instruction is given to conduct a missed approach if the response by the PF to the PM's advice is considered unsatis- factory. This is particularly critical when in IMC, at night or in a degraded visual environment (DVE.)

Regardless of the defined parameters stated, some degree of common-sense must also be applied along with sound CRM. The primary aim of the policy is to prevent CFIT and this underlying intent should be borne in mind at all times. There may be occasions where discussion is all that is required whereas there may also be occasions where physical intervention is necessary. XYZ does not regard missed approaches as negative events.

Last edited by 212man; 27th Oct 2013 at 15:22.
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Old 27th Oct 2013, 15:24
  #2029 (permalink)  
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HC is absolutely correct that the issue is not just one of automation.

As part of this process of self-examination, all organisations/parties should take the opportunity to look at themselves to see how they might have to change.

I would have thought that the ABC review (the one being conducted by the operators) would have this as their first priority. They should perhaps open their OMs to a central review process to see whether they have adequate SOPs to address the current situation.

The issue of the provision of SOPs is not one of showing compliance with the rules - although that comes into it as the ETAP ditching established; but to provide a regime in which the crew members can each play their part because it is well defined.

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Old 27th Oct 2013, 15:52
  #2030 (permalink)  
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Mars et al

It all begins at the beginning - the TR course. All license related courses are designed around the LST. The traditional TR course focusses on how to fly the helicopter, handling exercises take priority.

If the course is designed for experienced professional twin turbine rated pilots with a current IR (and they normally are) then why do we allocate a huge chunk of the course to handling? When you rent a car and pitch up at the collection point you have little idea what vehicle the hire company will give you but do you spend even 30 minutes studying the hand book when they give you the keys - hell no. You get in and learn about its handling as you progress. What you don't know and will need to read up on is the entertainment system and the satnav.

The critical elements of the latest breed of helicopters are their systems and without a really good, and I mean REALLY GOOD idea of how they work and how to work them you will never be able to cope when the chips are down.

Of all the hundreds of candidates I have seen in last seven years teaching TRs and CT courses I can count the number that arrived with a written copy of their SOPs on one hand - yes one hand. When asked if their company uses SOPs some would say "yes of course". When asked if I might see a copy the reply was invariably "well they're not written down". Ladies and gentlemen, if your SOPs are not written down then they are NOT SOPs. They are one man's version of the SOPs.

Back to the regulators - you guys are so far behind it's painful to contemplate.


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Old 27th Oct 2013, 16:15
  #2031 (permalink)  
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Jim Lovell's contribution

This just appeared on the online version of the Daily Telegraph

Apollo 13 should be a lasting reminder to astronauts and airline pilots of the dangers of relying on automated systems, the commander of the ill-fated mission has claimed.

Capt Jim Lovell said it was basic flying skills that allowed him and his crew to navigate their way back to Earth after an oxygen tank exploded during their voyage to the moon in 1970.

Recent air disasters such as Air France flight 447, lost over the Atlantic in 2009, and the Asiana Airlines plane which crash landed in San Francisco this summer indicate that pilots have become too reliant on autopilot, he added.

Capt Lovell's return to Earth on Apollo 13 was perhaps the most dramatic and courageous episode in the Apollo era of the 1960s and 70s.

Related Articles

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27 Oct 2013

Apollo 13 commander: bring back Moon missions
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Stranded in space with limited power and oxygen, The US team embarked on a daring escape manoeuvre that involved catapulting themselves around the moon and using their lunar module as a lifeboat to carry them home.

At a crucial point before they re-entered Earth's atmosphere, the crew had to adjust their craft's trajectory manually, using no more than a wristwatch and the position of the Earth in their window for navigation.

Astonishingly, Capt Lovell and his colleagues Jack Swigert and Fred Haise were able to steer the module in the right direction and splashed into the Pacific Ocean on April 17.

"I had a lot of automatic things on Apollo 13," Capt Lovell said before receiving the Guild of Air Pilots and Air Navigators’ award of honour at a ceremony in London last week.

"I had a guidance system, I had a computer - even though it was rudimentary at that time, it was a good computer. I lost all that. Didn't have the power to keep it going."

He told The Telegraph that recent air disasters had convinced him that automation has "taken (away) part of the ability of the pilot to control the aeroplane".

"I think that aviators these days have to go back and to and do a lot of hand flying really to be the final judge of controlling the aeroplane," he said.

"There was the example of the Air France plane that was lost. They were on autopilot and the autopilot stalled the aeroplane."

He also highlighted the examples of Asiana Airlines Flight 214 which slammed into tarmac at San Francisco International Airport on July 6 this year, killing three passengers and injuring more than 180.

An official hearing is due in December but some reports suggested an automated device which controlled the plane's speed may have malfunctioned.

(Any complaints about copyright and I'll pull this reply.)

One might observe that had the pilots concerned in these incidents and possibly many more fully understood their AP systems then maybe they would not have suffered in the way they did.


Last edited by Geoffersincornwall; 27th Oct 2013 at 16:18.
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Old 27th Oct 2013, 16:24
  #2032 (permalink)  
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terminus mo

The Pilot Unions haven't a clue, and a mooted enquiry by MPs is ridiculed
BALPA have asked for an independent inquiry because it believes that 'self regulation' is not the way forward. As for the inquiry that the Transport Select Committee is about to carry out, will it look at the UK government's position/input into the North Sea oil industry? I suggest not - the only time the government is interested is if the tax revenue stream is threatened. Likewise, will the inquiry by the three helicopter operators really look at their own positions? Again, perhaps not as deep as they should.
Only a completely independent inquiry with a wide remit will do the job.

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Old 27th Oct 2013, 18:09
  #2033 (permalink)  
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as I keep being told, that is exactly how the civil aviation world likes to work - time in the company not ability or experience.
Crab, it isn't like that at all the companies and I can assure you, some of the command courses are far tougher than an op captain check on SAR. People do fail them and there are career SFOs. Now, can you stop turning this into "my dad is bigger than yours" and let the thread discuss what really matters. Please return to your duties my good man!
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Old 27th Oct 2013, 19:48
  #2034 (permalink)  
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Not sure how I was turning this thread away from what really matters since there seems to be a raft of issues which various contributors feel is the 'bottom line' here. if you can identify the crucial element then please crack on

PS as you know the mil SAR pilots are trained to be captains right from the beginning of their flying training so a separate command course isn't required - the op captaincy check is only a confirmation and is the gift of the Sqn Cdr. I would hope that a dedicated command course is tough, especially when you have (as 26500 has alluded to) such a variety of experience and training routes to get from PPLH to ATPLH and NS captain.

Last edited by [email protected]; 28th Oct 2013 at 07:10.
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Old 29th Oct 2013, 10:42
  #2035 (permalink)  
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Re: Jim Lovell's contribution

The comment on the AF447 accident are inconsistent with those expressed in the long-running AF447 threads,
as noted in : http://www.pprune.org/8122343-post525.html

To paraphrase the comments in that post:
Whether or not you understand and agree with [the need for more hand flying], the opinion [Jim Lovell] expresses
[that the autopilot stalled the aeroplane] is simply wrong. A pity, because we need respected personalities to raise
the profile of current discussions on the pros and cons of automation.

Regards, Peter
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Old 29th Oct 2013, 11:17
  #2036 (permalink)  
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Good point Peter. Jim Lovell's remark is absolutely at odds with the accident report.

The crew thought the computers were still flying the plane and could get them out of trouble. But they weren't, and the crew's unwitting manual inputs thinking the automatics would calculate a best response caused the plane to stay stalled.

In that case, not just an over-reliance on automatics was a contributing factor, but a lack of understanding of them.


Last edited by Torquetalk; 29th Oct 2013 at 11:50.
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Old 29th Oct 2013, 12:54
  #2037 (permalink)  
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Jm Lovell

As I said at the bottom of the page. Had that crew and the many other crews who have been victims of their own ignorance, it would have helped them no end if they had been taught how to work their AP systems and then been mentored after the course to ensure proper understanding of 'real world' events.

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Old 29th Oct 2013, 16:52
  #2038 (permalink)  
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the crucial element is the brain – even a crab could have one. As ignorance has been mentioned, it is created in the human brain. People are not ignorant by nature, rather the opposite. From the very early upbringing and development of cognitive functioning, a brain adapts to the environment and adjusts the thinking patterns accordingly.

However I keep being told that ignorance is sometimes called a rather typical British attitude. All the recent accidents in the UK NS sector seem to include some sort of ignorance. Is it really just luck the Norwegians did not have such a chain of accidents? In the wider picture there might simply be a bit of a greater cultural issue. Human structures in Scandinavia seem less hierarchic and the seniors are far less autocratic. It would be interesting to research the effect of such a difference in culture on cognitive performance during complex tasks like NS helicopter operations.

So just keep calm and carry on?
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Old 29th Oct 2013, 20:23
  #2039 (permalink)  
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Originally Posted by xlsky View Post
the crucial element is the brain – even a crab could have one.
Wot, our crab do you mean, surely not! (only joking, we all know crab has one, the only question is in which bit of the human anatomy does it reside).

Sorry crab, I don't really have a downer on you, just couldnt resist!

Last edited by HeliComparator; 29th Oct 2013 at 20:24.
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Old 30th Oct 2013, 01:50
  #2040 (permalink)  
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Be careful. Try reading the Noggie MORs before you spout forth. If, of course, you are allowed to see them!!!

A miss maybe a good as a mile on any other world but ours.

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