AS332L2 Ditching off Shetland: 23rd August 2013
Avoid imitations
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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.
SASless wrote
....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.
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.
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.
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.
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.
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.
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.
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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SAS
So just to be clear, from your previous post, can you confirm that you believe management deficiencies will turn out to have a "huge role" in the Sumburgh crash?
And any particular reason why you didn't respond to the questions I asked you in post 2281?
So just to be clear, from your previous post, can you confirm that you believe management deficiencies will turn out to have a "huge role" in the Sumburgh crash?
And any particular reason why you didn't respond to the questions I asked you in post 2281?
I see post 2281 belonging to Biggles.....perhaps you might repeat the question as I do not see your post.
As "Management" can have different meanings at different times...I will say "Yes"....as I include Training Captains, Check Captains, Sim Instructors, Safety Managers and the like in "Management".
As to "Huge"....that is your choice of wording.
Significant....yes, notable......yes, will they be called out by the AAIB....who knows at this point!
As "Management" can have different meanings at different times...I will say "Yes"....as I include Training Captains, Check Captains, Sim Instructors, Safety Managers and the like in "Management".
As to "Huge"....that is your choice of wording.
Significant....yes, notable......yes, will they be called out by the AAIB....who knows at this point!
As "Management" can have different meanings at different times..
A very vague description of Management with weasel words
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SAS
My post 2281 related to your post on the Air Methods accident and was:
"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? "
No SAS, "huge" was your wording actually. Read you own post again - para 2 under Humm.
Quite right, industry insider! SAS, I think you know that most people will assume you mean the company business managers when you say "management". And if not, and you mean training captains and check captains, why not be a bit more specific and say so? Or perhaps you would rather responsibility was heaped on corporate management - in fact I do find that tends to be your style. If flight crew don't believe they are trained to fly a task they shouldn't do it - and surely they should be able to be judge that. Do you think that the Sumburgh crew were not confident they were sufficiently trained to fly the NPA safely? I very much doubt it.
My post 2281 related to your post on the Air Methods accident and was:
"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? "
No SAS, "huge" was your wording actually. Read you own post again - para 2 under Humm.
Quite right, industry insider! SAS, I think you know that most people will assume you mean the company business managers when you say "management". And if not, and you mean training captains and check captains, why not be a bit more specific and say so? Or perhaps you would rather responsibility was heaped on corporate management - in fact I do find that tends to be your style. If flight crew don't believe they are trained to fly a task they shouldn't do it - and surely they should be able to be judge that. Do you think that the Sumburgh crew were not confident they were sufficiently trained to fly the NPA safely? I very much doubt it.
I don' guess you two would consider non-standard cockpits to be a Management issue or concern?
Would you consider having one guy fulfill the Base Manager, Base Training Captain, and Base Safety Officer tasks as being good thinking by Management as well?
Do you reckon the Corporate Check Pilot arriving on site then watching the Duty Crew launch in the Spare Aircraft after doing a Bag Swap from the Duty Aircraft...into IMC Conditions in a mountainous area in an aircraft they were not familiar with (and having significantly different equipment) not a Management Concern?
Would you consider the Corporate Mantra of anytime, anywhere, any weather (contingent to FAA OpSpecs minima)....but ignoring the actual practice of most of their IFR crews avoiding flying in actual IMC whenever possible a Management issue?
If you disagree with the notion Management (at all levels/functions) does not play a role in the environment Flight Crews find themselves operating in....then just say so. But....you are already aware most others disagree with that view.
You certainly are free to disagree.....but at least offer up some corroboration of your own views.
Answer some of your own questions.....why did they parallel the course and not track the course? What would explain that?
I presented an explanation for the lack of DME information....did you not read that? If they did not use the DME "Hold" function they would not have had any DME readout to see.....if you recall how that system works in a Sperry Cockpit.
If they did not use that function.....why not? Did they train that way? Did they not understand how that function worked....did they not understand how that particular piece of equipment worked on the Spare Aircraft?
Did the Check Pilot do an Orientation Briefing on the Spare Aircraft before the Crew launched in it?
You have a lot of questions you could be asking or is it you just want to disagreeable?
Would you consider having one guy fulfill the Base Manager, Base Training Captain, and Base Safety Officer tasks as being good thinking by Management as well?
Do you reckon the Corporate Check Pilot arriving on site then watching the Duty Crew launch in the Spare Aircraft after doing a Bag Swap from the Duty Aircraft...into IMC Conditions in a mountainous area in an aircraft they were not familiar with (and having significantly different equipment) not a Management Concern?
Would you consider the Corporate Mantra of anytime, anywhere, any weather (contingent to FAA OpSpecs minima)....but ignoring the actual practice of most of their IFR crews avoiding flying in actual IMC whenever possible a Management issue?
If you disagree with the notion Management (at all levels/functions) does not play a role in the environment Flight Crews find themselves operating in....then just say so. But....you are already aware most others disagree with that view.
You certainly are free to disagree.....but at least offer up some corroboration of your own views.
Answer some of your own questions.....why did they parallel the course and not track the course? What would explain that?
I presented an explanation for the lack of DME information....did you not read that? If they did not use the DME "Hold" function they would not have had any DME readout to see.....if you recall how that system works in a Sperry Cockpit.
If they did not use that function.....why not? Did they train that way? Did they not understand how that function worked....did they not understand how that particular piece of equipment worked on the Spare Aircraft?
Did the Check Pilot do an Orientation Briefing on the Spare Aircraft before the Crew launched in it?
You have a lot of questions you could be asking or is it you just want to disagreeable?
SAS, I wasn't even considering your unrelated onshore EMS Bell 412 accident in the USA. I haven't studied it, read of it, and I am not interested in it. This thread is about an AS332L2 fatal accident in Sumburgh UK at the end of an offshore flight.
I don't think its appropriate or relevant to drag up any old CFIT accident on the other side of the world and start pontificating about management. The AAIB won't even think about or consider this Bell 412 USA accident.
If disagreeing with you and wanting to stick to relevance is "disagreeable" to you, so be it.
I don't think its appropriate or relevant to drag up any old CFIT accident on the other side of the world and start pontificating about management. The AAIB won't even think about or consider this Bell 412 USA accident.
If disagreeing with you and wanting to stick to relevance is "disagreeable" to you, so be it.
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Last week the FAA issued a report on “Operational Use of Flight Path Management Systems”.
http://www.skybrary.aero/bookshelf/books/2501.pdf
A small (informal) helicopter group has been looking at that report and their view of it, and its relevance, is as follows:
“The report is comprehensive and appears to cover and summarise most of the issues that we have addressed over a short period of discussion. However, when the report is being read, it is difficult not to fall into the trap of confirmatory bias.
The comparisons between the population examined in the report and our industry is not just one of scale it is also a matter of (lack of) parallel experiences, foreshortened timescales, and variance in operations (for example, we might perhaps require less emphasis on manual skills). We benefit from the application of automation, but this comes at a price because we have not had time to adapt our thinking and processes to, what is, a revolutionary approach to operations. Only in the offshore industry - and probably only in deep-water operations - is there a move to comprehensively re-equip with equipment that has cockpit integration/automation approaching the complexity of the population in this report. Fortunately, this is one of the few corners of our industry that does have the ability to move as one and make necessary changes. Perhaps we might be the exemplar in any changes that are made and this needs to be conveyed to other parts of our industry.
Compared to the airline industry, which is largely homogeneous, we are a collection of very small operators who, for understandable reasons, are more interested in competition than cooperation. For that reason, we do not have the clout to force a change in design (even the authors of the report are only recommending that the process 'takes account of' human-centric design - they make few recommendations for concrete changes in regulations). Nevertheless, because we are a small industry, it is possible to engender the required change in the culture of oversight, training and operations (in a reasonable time scale) although deciding what constitutes 'required change' is going to be the first and most difficult step.
It is accepted that, although changes (of various magnitudes) are necessary in design, certification, training requirements, training regimes, operating procedures, crew cooperation etc., the process of change must be owned at the highest level and be applied and driven from the top. Hence there is a need to ask questions about required changes in:
1. the system;
2. the regulator;
3. the regulations; and
4. oversight.
It needs to be understood that the system should include a version of the ‘plan/do/monitor/adjust’ improvement cycle as part of the State Safety Programme (SSP) – as does the operators SMS. We can continue to discuss how the recommendations of the report are applied to our industry but, in the final analysis, unless the solution at all levels contains a version of this process, it will not be enduring.”
Mars
http://www.skybrary.aero/bookshelf/books/2501.pdf
A small (informal) helicopter group has been looking at that report and their view of it, and its relevance, is as follows:
“The report is comprehensive and appears to cover and summarise most of the issues that we have addressed over a short period of discussion. However, when the report is being read, it is difficult not to fall into the trap of confirmatory bias.
The comparisons between the population examined in the report and our industry is not just one of scale it is also a matter of (lack of) parallel experiences, foreshortened timescales, and variance in operations (for example, we might perhaps require less emphasis on manual skills). We benefit from the application of automation, but this comes at a price because we have not had time to adapt our thinking and processes to, what is, a revolutionary approach to operations. Only in the offshore industry - and probably only in deep-water operations - is there a move to comprehensively re-equip with equipment that has cockpit integration/automation approaching the complexity of the population in this report. Fortunately, this is one of the few corners of our industry that does have the ability to move as one and make necessary changes. Perhaps we might be the exemplar in any changes that are made and this needs to be conveyed to other parts of our industry.
Compared to the airline industry, which is largely homogeneous, we are a collection of very small operators who, for understandable reasons, are more interested in competition than cooperation. For that reason, we do not have the clout to force a change in design (even the authors of the report are only recommending that the process 'takes account of' human-centric design - they make few recommendations for concrete changes in regulations). Nevertheless, because we are a small industry, it is possible to engender the required change in the culture of oversight, training and operations (in a reasonable time scale) although deciding what constitutes 'required change' is going to be the first and most difficult step.
It is accepted that, although changes (of various magnitudes) are necessary in design, certification, training requirements, training regimes, operating procedures, crew cooperation etc., the process of change must be owned at the highest level and be applied and driven from the top. Hence there is a need to ask questions about required changes in:
1. the system;
2. the regulator;
3. the regulations; and
4. oversight.
It needs to be understood that the system should include a version of the ‘plan/do/monitor/adjust’ improvement cycle as part of the State Safety Programme (SSP) – as does the operators SMS. We can continue to discuss how the recommendations of the report are applied to our industry but, in the final analysis, unless the solution at all levels contains a version of this process, it will not be enduring.”
Mars
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AS 332 L2 thread gone AWOL?
The Sumburgh thread seems to have gone missing - possibly a formatting error somewhere? The most recent couple of pages of entries appear to be imaccessible. Any chance one of the 'deities' could take a look (and then delete this?)?
It appears from the graphs at the end of the AAIB report that the HP must have sub-consciously moved the collective down every time he got a height check (and was always above the nominal glidepath) - the graph shows clear steps of reducing Tq and lever position during the approach.
This would account for the cyclic program reducing the speed to keep the desired RoD which eventually resulted in the high nose up, low speed condition (despite speed calls at 80 kts and 35 kts) that finally led to the VRS.
As I said before - it is so counter-intuitive to have a configuration where cyclic controls RoD and lever controls speed - how did anyone think that was a good idea?
This would account for the cyclic program reducing the speed to keep the desired RoD which eventually resulted in the high nose up, low speed condition (despite speed calls at 80 kts and 35 kts) that finally led to the VRS.
As I said before - it is so counter-intuitive to have a configuration where cyclic controls RoD and lever controls speed - how did anyone think that was a good idea?
As I said before - it is so counter-intuitive to have a configuration where cyclic controls RoD and lever controls speed - how did anyone think that was a good idea?
Quote:
As I said before - it is so counter-intuitive to have a configuration where cyclic controls RoD and lever controls speed - how did anyone think that was a good idea?
Chances are one of the test pilots at EC could explain that, since I expect they were involved in the development process.
As I said before - it is so counter-intuitive to have a configuration where cyclic controls RoD and lever controls speed - how did anyone think that was a good idea?
Chances are one of the test pilots at EC could explain that, since I expect they were involved in the development process.
As I said before - it is so counter-intuitive to have a configuration where cyclic controls RoD and lever controls speed - how did anyone think that was a good idea?
Originally Posted by [email protected]
As I said before - it is so counter-intuitive to have a configuration where cyclic controls RoD and lever controls speed - how did anyone think that was a good idea?
To me, engaging a vertical mode on cyclic and controlling speed with collective is just as intuitive as the other way round, under the appropriate conditions. It is just a matter of selecting the optimal way of doing it for the circumstances. A pilot who can't cope with that shouldn't be flying.
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212man,
I worked on a 3-axis A/P that was fitted both to the Alouette III and the 212... but that goes back to the mid-seventies, so I reckon I'd better stay out of the discussion !
I worked on a 3-axis A/P that was fitted both to the Alouette III and the 212... but that goes back to the mid-seventies, so I reckon I'd better stay out of the discussion !