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AS332L2 Ditching off Shetland: 23rd August 2013

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AS332L2 Ditching off Shetland: 23rd August 2013

Old 22nd Nov 2013, 19:20
  #2281 (permalink)  
 
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But gradually they became more accustomed to it, then they loved it, and finally, 6 or so years later, we started to notice signs of automation dependency.
Who taught them automation dependency?
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Old 22nd Nov 2013, 20:31
  #2282 (permalink)  
 
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SAS I don't really get your point. Maybe you used insufficient words?

My post related to the various completely different factors of loss of manual flying skill, lack of knowledge of the full gamut of automation behaviour, and automation dependency. Apart from them all being something to do with flying, there is no significant connection but I perceive that some, including you, don't really "get" that. Next time I shall try to use more words in the hope you will thus finally understand it.
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Old 22nd Nov 2013, 20:32
  #2283 (permalink)  
 
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Fareastdriver - Alas like so many other bad habits, they are self-taught. It is the job of the training system to train for countermeasures to automation dependency.

Last edited by HeliComparator; 23rd Nov 2013 at 08:45.
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Old 26th Nov 2013, 07:43
  #2284 (permalink)  
 
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In previous posts on this thread there were attempts to attribute the cause of the L2 accident too simplistically. A passage from pages 103/4 of the recently issued report "Operational Use of Flight Path Management Systems" puts forward a much more enlightened viewpoint:

Data are collected primarily about “front line” operations. Attempts to diagnose safety-related problems in analyses and investigations are dominated by categorizing events as due to “pilot error” and “controller error,” and the WG found this is no different when addressing flight path management and use of automated systems. The persistence of this attitude reduces the ability to understand the factors that create the conditions for, or lead to, these errors (Woods et al., 2010). One class of latent or underlying factors is that of organizational factors related to organizational culture, including policy, procedures and economic pressures. Another class of latent factors relates to effects of complexity - increases in the degree and kinds of interdependencies across factors (including tighter coupling of systems). Unfortunately, very little information about these classes of latent factors is gathered at all (what is gathered is not done so in a consistent way), and little of the available data is utilized to assess the effects of such factors.
I think that most of us would subscribe to the view that "...organizational culture, including policy, procedures and economic pressures..." were issues that have to be examined when determining how to prevent other such accidents in the future.

Mars
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Old 26th Nov 2013, 09:59
  #2285 (permalink)  
 
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Mars: "I think that most of us would subscribe to the view that "...organizational culture, including policy, procedures and economic pressures..." were issues that have to be examined when determining how to prevent other such accidents in the future".




I'll second that. From my experience preventable accidents are rarely due to one thing only, there are usually other factors in the build up to the actual event.
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Old 26th Nov 2013, 10:37
  #2286 (permalink)  
 
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My best example of what Mars and others rightly suggest is the Air Methods Bell 412 crash at Bluefield, WV several years ago.

The flight was a Two Crew, fully IFR equipped Bell 412, operated on an IFR EMS Operation based at a Hospital. A different Vendor, operating a VFR Single Pilot BK-117 experienced a Fatal Crash several years earlier while operating from that Hospital. The first Crash happened when the aircraft impacted a mountain side near Fancy Gap, VA. That crash prompted the Hospital to upgrade their operation to the Two Pilot IFR Program.

If one does a front-line only review of the accident....it would show the crew never found the Glide Slope on the ILS, reverted to a Localizer Approach, completely missed the Airport and flew into a Mountain several miles beyond the airport.

There would be some question as to how they could have managed that as it would take some really gross incompetence to do that.

Then if you were to take a larger look....as was done....one then sees there was a structural problem.....there was only an Outer Marker Beacin.....not a Locator Outer Marker Beacon.

Then you see, despite the Crew asking to be vectored well outside the Marker, ATC (Radar) turning them inside the Marker.

If you stopped looking at that point....you would then miss the rest of the story.

The aircraft the crew was flying was a "Spare" aircraft flown in that day by the Corporate Check Pilot who was there to do IF Base Checks. The "Spare" aircraft had different Avionics, particularly Area Nav, than did the Base Aircraft.

The Bluefield Flight had been turned down due to weather and the Crew had decided to fly to another location that had suitable weather and do a Public Relations Appearance.

The Captain, was the Base Manager, Safety Officer, and Base Training Pilot.

As the Operator bragged about its IFR capability in its sales and PR....the Crew felt compelled to do the Bluefield Flight after the Corporate Check Pilot had flown in with the Spare Aircraft and the Med Crew had swapped over the Medical Kit.

If you lay out the Accident Chain on this fatal crash that killed four people....the second fatal crash at that one EMS Operation.....it shows a much different situation than if you limited it to what happened from Takeoff to Crash.

I used the crash data to create a Simulator Training Scenario....without telling the Trainee's anything about the flight. I set up the Scenario by suggesting we go someplace none of us had ever gone before....and made a show of flipping through the Approach Plate Booklet and happening upon......Bluefield, WV.

Then I acted as ATC and provided the vectors to place the Trainees in exactly the same location the AM Crew found themselves that day.

Out of a dozen or so such flights in the Sim.....not one crew crashed or came close to hitting anything.

I firmly believe a thorough wide ranging investigation to effectively describe all of the factors that play a role in these tragedies. That is why I suggested a "Shields Down" investigation of this latest crash and the industry itself in light of the past several ditchings and crashes.
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Old 26th Nov 2013, 15:19
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The Captain, was the Base Manager, Safety Officer, and Base Training Pilot.
from that comment it would appear that personality and a conflict of interests was a main causal factor.

What was the co-pilot doing? assuming his boss was too good to get it wrong?

Are there parallels with the Shetland crash? Poor monitoring of the PF by the PNF perhaps?
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Old 26th Nov 2013, 15:26
  #2288 (permalink)  
 
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SASless:
Nice post and great story. One of the important things that would ensure that all your sim 'students' (victims???) would do well was that they should have all been very familiar with the avionics and systems in the simulated helicopter.
One wonders what would happen if they were suddenly presented with an avionics suite they were not completely familiar with....
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Old 26th Nov 2013, 17:40
  #2289 (permalink)  
 
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Shawn

Many years ago I was asked to audit a company that had suffered a fatal CFIT by the management of that company. What I was able to establish was that the 6-8 pilots regularly employed had all completed their 6 monthly IMC Base Checks on the same medium twin helicopter - the one owned by them.

The company routinely operated up to seven different medium twins but whilst they were all the same type each had a different avionics suite and area nav.

So, the only time you were asked to demonstrate your competence was on the same helicopter with very familiar avionics.

The rest of the time you had to struggle with any one of seven alternatives without one single jot of instruction on how the systems worked.

"The handbook is in the door pocket" - sound familiar.

Is it no wonder........

I bet there are charter outfits out there still doing the same.

G.
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Old 26th Nov 2013, 17:45
  #2290 (permalink)  
 
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Crab,

The Captain was a very nice fellow, well liked, experienced, former military pilot. The Co-Pilot was also a Military aviator.....and was active in the National Guard (Territorials).

There was no hint or record of the Captain being anything but professional.

The Crew plainly goofed up.....and in my opinion....their being unfamiliar with the aircraft they were flying that day played a huge role in the chain of events (or chain of Non-Events if you will) that ultimately killed them and their two Medical Crew Members.

Recall the ILS Approach extant the day of the accident did not have a Locator....but just a Marker Beacon.

If my memory serves me right....the Accident Aircraft had a LORAN and the Duty Aircraft had a GPS.....but for sure the Area Nav unit was quite different from the one they were well used to from their regular flying.

There was a DME and VOR at the Airport.

Now ask yourself some questions about how you could fix the location of the AIRPORT if you had dual VOR/ILS Receivers, a DME receiver, an ADF receiver, and an Area NAV?

As there was no Locator....I would have been concerned about being turned in too soon by ATC, EXACTLY as the Crew was. They appeared to trust ATC would do as they asked.

It appears they never saw the Glideslope or never got onto the Glide Slope and seem to have abandoned the ILS and opted to complete a Localizer Only Approach.

It is surmised they confused the Outer Marker for the Middle Marker/Inner Marker due to the reported altitudes that were flown. They hit the mountain that was something like Seven Miles beyond the Airport (if my recollection of the distance is correct.....but it was quite some distance past the airport).

They could have used the "Hold" function to retain the DME readout.
They could have used the Area Nav to fix the Airport.
They could have used the Area Nav to "fix" the Outer Marker (even if not legal).

They did not or they would not have flown the profile they did.

So is that Crew Error, Training related, Management Error, Policy/SOP error?

Did the Federal Air Regulations and the Operator's OpSpec's cause a problem?

Could the company have purchased IFR Certified GPS for all of their Aircraft...should they have Standardized Cockpits in all their aircraft?

Excerpt from the NTSB Report

Aircraft Accidents and Incidents - Bluefield, Virginia 24605 Mercer County Airport Friday, April 22, 1994 14:45 EDT

Last edited by SASless; 26th Nov 2013 at 18:00.
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Old 26th Nov 2013, 20:01
  #2291 (permalink)  
 
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SAS

What do you think the crew would have been looking at displayed on the HSI if they were completing a localiser approach - it seems from the report they were tracking parallel to the localiser 1 mile left? And even if they thought the middle marker was the outer marker, why would they not have seen from the DME readout that this was incorrect?

How could such errors possibly be training, management, policy or SOP errors? Wasn't it just largely basic crew error, with mitigation for poor radar vectors?
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Old 26th Nov 2013, 20:27
  #2292 (permalink)  
 
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Talk about thread drift. An EMS Bell 412 in the US versus the 332L2 in Sumburgh.
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Old 26th Nov 2013, 23:00
  #2293 (permalink)  
 
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Taking the short view again are you II?

Can you not see the correlation between the practice of looking at Accidents as isolated events and not a long list of factors?

Both crews were doing an Instrument Approach....both either were or seemed to be doing a Non-Precision Airport based Approach....both hit the surface despite having autopilots, co-pilots, had passed training and checks, and four people died in each event.

The FAA and NTSB each limited their reviews with the Crew, Aircraft, and ATC....and gave scant mention to anything else.

Is that what you want the CAA and AAIB to do on the Shetlands crash....take the short view as you seem to be a proponent of that by your last post.
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Old 27th Nov 2013, 07:00
  #2294 (permalink)  
 
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Sas, I am sure they were both professionally competent and nice guys who didn't set out to crash that day but doing real IMC IFR does tend to sort the wheat from the chaff.

They clearly didn't brief the MAPt or the MAP and alarm bells should have rung if they were listening to a properly coding ILS but not able to see glideslope indications. Presumably the DME told them directly where the airport was (in terms of distance) and an increasing DME indicates you are going away from the airport.

LORAN has one really useful function - the airport button, that gives you heading and distance to the 20 nearest airports.

Now the suggestion that it is perfectly fine to go IMC in an aircraft you are not familiar with seems to be the point at which most aviators would say no - these guys didn't (military-indoctrinated get the job done attitude?)

Yes, there are, as always, a lot of threads in this accident that could be highlighted in any report but both the aircraft and the airfield were perfectly serviceable - the failures were all human, from getting airborne in the first place in an unfamiliar aircraft to poor IFR procedures and briefing.

You can blame what you like as contributory factors but two experienced guys f*****d up when they shouldn't have - you can't legislate for that.
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Old 27th Nov 2013, 07:20
  #2295 (permalink)  
 
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I think what SASless is alluding to is the role that management can play in forming a link in the accident chain. Failing to provide a common IFR fit across the fleet and always doing the IFR training using one particular a/c being the link in his example.

It does/did happen in the N Sea as well. At the time that DECCA was on its way out and despite having notice that new area nav kit was required nothing was done until the last moment. The end result was that our offshore replacement a/c turned up with a Trimble GPS instead of DECCA. I had no company training on the Trimble, there was just an instruction booklet in the door pocket!!

Fortunately we were a mainly VFR operation which gave me time to study the booklet.

This episode showed how management were not focused on Flight Safety. As far as they were concerned the a/c had a usable GPS it was up to the pilots to learn how to use it!!

HF
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Old 27th Nov 2013, 08:05
  #2296 (permalink)  

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HF, that happened to me; I went to a new job on a new type of aircraft. It was so new that there was no recognised training syllabus for it. It had a nav/ comm system I had not seen before but there were no instruction manuals. I spent three days in the hangar with the GPU connected working it all out.
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Old 27th Nov 2013, 10:34
  #2297 (permalink)  
 
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SASless wrote

Can you not see the correlation between the practice of looking at Accidents as isolated events and not a long list of factors?

Both crews were doing an Instrument Approach....both either were or seemed to be doing a Non-Precision Airport based Approach....both hit the surface despite having autopilots, co-pilots, had passed training and checks, and four people died in each event.

The FAA and NTSB each limited their reviews with the Crew, Aircraft, and ATC....and gave scant mention to anything else.

Is that what you want the CAA and AAIB to do on the Shetlands crash....take the short view as you seem to be a proponent of that by your last post.
....and they were both helicopters!

Firstly, the CAA are the regulator not the investigator. Secondly, their involvement into any North Sea helicopter safety investigation has been ridiculed on this thread. Thirdly, the AAIB is normally very thorough and professional in these investigations, taking the long view and considering all contributory factors. Fourthly, I do not agree that these accidents have much in common. Fifthly, I believe that management has a huge role in the prevention or otherwise of accidents, safety culture does start at the top.

Yes, the NTSB and the FAA limited their views in the Bell 412 case, they can be a little light in their respective analyses as we all know.

The so called "cooperative investigation" between the helicopter operators has so far not amounted to anything more than a nice signed letter. The Shields Down will never happen in my opinion.

Sometimes, I think you post rubbish, just for the sake of posting.
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Old 27th Nov 2013, 13:08
  #2298 (permalink)  
 
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Thumbs up

Industry: Concur.
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Old 27th Nov 2013, 13:09
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II....are you completely secure in thinking the AAIB will chase down every single investigative Lead and look into Operator Training, Checkride, and Management Policies, Standards, and SOP's during the investigation extant? Or do you think they will limit their inquiries into just the events of that day, in that particular aircraft, at that unique location?

If they do the Latter, will you be satisfied they have done an adequate job of finding and identifying the Factors that lead up to the Crew losing control of the aircraft and killing four people in the process?


Crab,

No doubt the Air Methods Crew committed gross errors.....even the FAA Human Factors Division has done a Study of this Accident. I am trying to get a copy of their Power Point Presentation about the Crash. Thus far, I am able to locate one on-line version that is incomplete. When/If I get one from the FAA i shall post it here. There is no evidence available to determine if they had put the DME into "Hold" which would have allowed them to know their distance from the Airport. We have to assume they did not as if they had....and observed the readout increasing rather than decreasing....they would have realized something was quite wrong.

As simple a thing as using a DME "Hold" function is....not doing so is failing to use available "automation" features.....in every sense we are concerned about in the Shetlands Crash. Granted the Shetlands issue is far more complex overall in that we are talking about an AFCS with multiple modes that are capable of flying the aircraft....but the Pilot decision process is the same in both cases. They all had available something they did not use.....or mis-used.


Humm,

I am very much saying Management played a role in the 412 Crash....and said so while working for them at a different location. Pointing some of the factors I saw at play with the CP, GM, and Training Department did not make me very popular despite it being politely done in private.

Management very often does play a huge role that gets left out of most Accident Reports as what they do is not illegal, is not a direct measurable effect necessarily, and escapes examination.

They presumed to know better and were not interested in hearing anything other than how great a job they were doing. A quick review of their Safety Stats would have contradicted that view.

I am sure in the Shetlands event it shall turn out to be very much the same.

Is it not a Management Responsibility to ensure the right equipment is provided, effective training is completed, and Standards are maintained? Part of that is setting up an intern mechanism to seek input from all levels of Staff in an effort to identify problems and ask for suggestions on how to remedy the perceived problems....with a Management Response to any such input.
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Old 27th Nov 2013, 13:39
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Management Impact

SAS, I concur with the direction you have taken with regard to the Shetlands accident explanation ( to come ).
Wanted to offer a comment on your simple, but really on point remark:

"Management very often does play a huge role that gets left out of most Accident Reports as what they do is not illegal, is not a direct measurable effect necessarily, and escapes examination."

Management pressure to press on when the evidence already on hand says " caution ", or to place people in position to accomplish a task when they really don't want to be there, are realities that can exist, with fatal results. There are other versions of people in direct line management doing, or perhaps, not doing something that had a direct bearing on the ensuing accident, and the AAIB/NTSB have no way of learning these details. Hard to criticize in some respects, because these issues can be judgmental/opinion based.

Anyhow, a fertile discussion.
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