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AS332L2 Ditching off Shetland: 23rd August 2013

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AS332L2 Ditching off Shetland: 23rd August 2013

Old 15th Mar 2016, 08:03
  #2461 (permalink)  
 
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BBC reporting that the report is finally going to be released:


AAIB report due on Shetland Super Puma helicopter crash - BBC News
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Old 15th Mar 2016, 08:56
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It says "due to be released" - no-one could dispute that.

And that it will be published "later". Not "later today"! But let's hope that is what they mean. As it stands the news item is meaningless
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Old 15th Mar 2016, 09:03
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Originally Posted by HeliComparator View Post
It says "due to be released" - no-one could dispute that.

And that it will be published "later". Not "later today"! But let's hope that is what they mean. As it stands the news item is meaningless
STV News reports "Later on Tuesday"
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Old 15th Mar 2016, 14:21
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https://www.gov.uk/government/news/a...23-august-2013
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Old 20th Mar 2016, 14:52
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Why an ILS at 80 knots. It's a hangover from the days when a VNE of 90-95 knots was the norm. On every ILS there is at least 6,000 ft. of concrete at the other end so what is there to slow up for.

!20 over 80 equals 2/3rds the drift, windshear effects and most importantly, less time to screw the approach up. I started my ILS career strapped to 70 tons of aluminium and I had far less trouble at 145 than trying to fly it at 80 knots.

If a 737-200 with the same decision height can come out of cloud at minimums, line it up and carry out a crosswind landing whilst staring through two letterboxes why can't a helicopter do the same with wide angle windows and no crosswind problems.

Should this approach have been flown with a target speed of 120 knots this accident would not have happened.
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Old 20th Mar 2016, 16:17
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Fareastdriver,

RWY 09/27 EGPB 3871 ft long so a bit below your 6000 ft and RWY 09 they flew is LOC only so higher MDA than would be on ILS.

Following our stabilised approach procedures we can slow down to not below Vy on approach in bad weather but in deciding the speed, consideration must be given to the headwind component, increased drift angle in a crosswind and handling qualities.
This reduced speed is to assist in gaining the required visual references for landing.

Higher target speed might have prevented the accident but it all boils down to monitoring whatever you nominate as your approach speed, not?

Regards,
Finalchecksplease
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Old 20th Mar 2016, 22:24
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RWY 09/27 EGPB 3871 ft long so a bit below your 6000 ft and RWY 09 they flew is LOC only so higher MDA
So a 332L2 coming out of cloud with 125 knots at MDA wouldn't be able to stop with ground distance plus 3.781ft. of concrete.

There is a different feel at 120 compared with 80. I used to open my window on finals offshore because I then had an instant Audio ASI. The same technique when looking over the side of the cockpit in a Tiger Moth. Even with the windows closed you will notice an unexpected change of performance.

You notice when it goes quiet. You pay more attention to how the aircraft feels when doing anything and if it doesn't feel or sound right there is something going wrong.

Kept me alive for forty-eight years.
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Old 20th Mar 2016, 22:54
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So a 332L2 coming out of cloud with 125 knots at MDA wouldn't be able to stop with ground distance plus 3.781ft. of concrete.
Never said you couldn't but I wouldn't have done the approach at 125 knots either.

Do the same "crack the window open" on finals offshore, one of the "old" Brent 212 shuttle pilots thought me that when I was a young co-jo and I still use it today
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Old 20th Mar 2016, 23:26
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Going slower, you obviously have more time to see a light in marginal conditions on the approach. Rather do 80kts in a helicopter than 155kts in a Lightning.
Far East Driver, today we can't open the window as the flight manual prohibits it, well in a 76 or 92, unless you can lock the stupid little window open (and most people don't have the lock).
Also the days of hearing what the aircraft is doing? Forget it, we are now in an airline type cockpit with most of the noise coming from air cooling fans for the electronics and EFIS.

Last edited by TroyTempest; 20th Mar 2016 at 23:40. Reason: English Electric Lightning approach speed ��
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Old 21st Mar 2016, 00:07
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Surely of more concern is the 'if we aren't clear of cloud at the published minima we'll just land anyway' mentality - which the co-pilot didn't challenge. That didn't go very well at the Cork (fixed wing) crash either, as I recall. Or the one with the Polish president on.
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Old 21st Mar 2016, 23:36
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I agree that excessive speed reduction down to say Vy can be counterproductive and is not something I did, though I know lots of other people who did. However if there isn't much crosswind it is probably no big deal. The issues here however are that making a big speed change halfway down the approach thus totally destabilising it was not contrary to the stabilised approach policy in force at the time. Huh, some "stabilised approach" policy!


Also very relevant is the lack of appreciation not just of this crew, but from the sound of it lots of other crews, of the inappropriateness and danger of using VS mode without IAS mode when the speed is back near Vy or in fact I'd say below about 110kts.


Bottom line is that for the want of a button press (IAS mode, either with or without VS mode) the accident would not have occurred.
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Old 22nd Mar 2016, 10:09
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Bottom line is that for the want of a button press (IAS mode, either with or without VS mode) the accident would not have occurred
Yes, I agree entirely. The report is astonishing.
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Old 22nd Mar 2016, 12:12
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212

That's a very good description. its almost unbelievable actually.

Some of the recommendations seem a little academic, cameras on passengers for example?
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Old 22nd Mar 2016, 13:39
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I'm not sure it's that astonishing if you mean the crew error. Pilots make errors, get over it!


What we need is error tolerance built in, such as clearly defined procedures whereby both pilots know exactly what is expected to transpire, and using the automation to its best advantage so the pilots can focus on the "big picture".
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Old 22nd Mar 2016, 22:51
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So what then......

Originally Posted by HeliComparator View Post
I'm not sure it's that astonishing if you mean the crew error. Pilots make errors, get over it!


What we need is error tolerance built in, such as clearly defined procedures whereby both pilots know exactly what is expected to transpire, and using the automation to its best advantage so the pilots can focus on the "big picture".
Please - let's leave automation out of this.
This is not an automation issue.
This crash was caused by 2 pilots not carrying out their duties.
Pressing the IAS button would have reduced the required monitoring to a degree but not the duties of the crew.

Not sure about anyone else but if I know weather is 'doggers' I tend to pay that bit more attention during the approach???
So, if the crew were not monitoring the flight - I would be interested to know what were they doing?
I am fully aware pilots make mistakes (even monkeys fall out of trees!) but this 'error' appeared to extend for majority of the important part of the approach, starting with a woefully inadequate brief considering the known conditions.
There was an interesting line which confirmed that 'non-operational' crew discussion had been omitted from the report........
Shame as we might have learnt something.

Like most reports - the reader is often baffled as to why the crew reacted/behaved in a certain way. Please do not think that having the OEM prescribe how to use their aircraft will reduce accidents - fixed-wing have had such manuals for a while and still fall out of the sky due to all manner of automation-related reasons.
Very sad account with such a tragic outcome.
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Old 22nd Mar 2016, 23:29
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Automation is of course not the cause of the accident, but the accident is a good demo of why good automation and it's correct use enhances safety. The captain was very experienced and had a good record, and yet he made the fundamental mistake of failing to look at his airspeed for a long time, just at a time where his choices had made airspeed monitoring especially important. Classic human frailty. Like it or not, if he had engaged IAS mode which, one would have though, would be normal practice for flying an approach in marginal weather, the accident would not have happened.

The passengers wouldn't care why the accident wouldn't have happened, they just didn't want it to happen, and so foolish ideas that we should fly these sorts of things manually in order to maintain our skills, would be ridiculed and rightly so. Bottom line is that humans make mistakes, automation helps to reduce the impact of such mistakes. But only if it is used sensibly.

Let's hope that the 4 lives at least have a legacy of demonstrating to all other pilots why using a vertical mode on the cyclic near Vy is such a foolish thing to do.
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Old 23rd Mar 2016, 08:39
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We can be our own worst enemies....

.... when we train and rehearse scenarios that we use on a frequent basis. The fourth phase in the classic four-stage learning model (see below) leaves us exposed to the vagaries of 'unconscious competence'. This is clearly demonstrated when we drive our well worn route to work and upon arrival cannot remember vital details of the journey.

The role of the PM is critical in this respect but in the helicopter world we do not appear to take this role as seriously as we should.

In the FW (airline) world the LPC/OPC examiner will occupy the PF seat for a portion of the flight and 'seed' it with errors requiring intervention by the PM. That then leads to an assessment of his capabilities in the PM role. Does anyone in the RW world use such a system?

The four stages of learning -

1. UNCONSCIOUS INCOMPETENCE - The subject is not aware that he/she needs the knowledge/skill on offer or believes that in his/her case it is unnecessary.
2. CONSCIOUS INCOMPETENCE - The subject now recognises that the skill/knowledge is indeed required and sets about acquiring/understanding it.
3. CONSCIOUS COMPETENCE - The subject now knows what to do and how to do it and carefully applies that knowledge/skill.
4. UNCONSCIOUS COMPETENCE - The skill/knowledge is so well practiced that the task can be accomplished without conscious thought or monitoring.

Last edited by Geoffersincornwall; 23rd Mar 2016 at 10:50.
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Old 23rd Mar 2016, 09:28
  #2478 (permalink)  
 
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HC
Which one of the 'mistakes' do we put down to 'human fraility' - all of them?
Will the aftermath ensure that MPs ( co-pilot in this case) who will not say "boo to a ghost" are seriously reminded of their responsibilities or shown the door? Huge company culture scenario?
I 'killed' a v experienced instructor in the sim by deliberately crashing on approach to a rig - TWICE - and after him being reminded of his responsibilities before the exercise even began!
I am pretty sure this mistake would not have happened if the approach was able to be flown 'single-pilot'. Completely different mindset and not relying on loosely adhered too multi-pilot procedures.
Complacency due to routine/boredom/ego/over-familiarity - more human frailties - all we need to do now is take the human element out of it .............
Humans are not meant to fly but we insist on it and still pay 'lip service' to critical elements.
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Old 23rd Mar 2016, 12:35
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EESDL


It's stating the obvious to say that the approach wasn't flown properly and that even in the absence of a better method of carring out the approach, it shouldn't have ended badly if either of the pilots had been alert to critical deviations. But the accident did play out as it did. And it isn't the first of it kind. So you have to look both at and beyond the failings of that crew in that situation.


Using VS rather than IAS for a single cue descent is something that I often see (where 4-axis is not available), and is in some company cultures the preferred method. I am personally leery of it because it is less intuitive with basic flying sklls (using PWR to manage ROD). Learning and culture...


Allowing yourself an approach below minima and acquiesence by the left seat? Culture? Probably not the only person on the forum who can think of examples like that.


No clear breifing and conducting the approach according to it? Culture.


Across companies it's pretty clear that rotary is still working its way towards standardisation and real MCC.


I agree with you that the accident probably wouldn't have happened if flown single pilot because the PF would not have been so complacent and taken the same risks.


Single cue descents need particular care and monitoring: It isn't an automated approach or a hands-flown approach, but a mix of both. In an age of automation, using less of the AFCS than you can, may well cause an expectation gap in the cockpit: How aware was the PM of what he should be expecting to see as the captain reduced speed? Neither pilot seemed to have any seat-of-the-pants awareness as they began to fall behind the power curve. Suggests to me that they were both off the page when the method required them to be absolutely on it.




TT
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Old 12th Jun 2019, 12:42
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FAI to be held. https://www.bbc.co.uk/news/uk-scotla...tland-48607634
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