AS332L2 Ditching off Shetland: 23rd August 2013
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If you read this quote from a survivor of G-BEON
And the survivors of the AS332L2 statements they are similar.
Langley-Williams told The Times (20 July 1983, p. 28 & 18 July 1983, p. 26): "It was very quick. I bumped forwards and hit my head on the seat in front." She asked Smith, "'What the hell is going on?'" The response was one word, by which time the passengers were chest-deep in seawater. "I closed my mouth and took a deep breath and by then I was under water." The seat had twisted on impact, tightening the seatbelt. "I realised I had not got an awful lot of breath left." She released the belt, opened the door and floated to the surface.
Cause:
A report investigating the incident was concluded twenty months later, in February 1985, finding the cause to be 'pilot error'. The official report concluded that the accident was caused by the pilot not observing and correcting an unintentional descent before the helicopter collided with the sea during an attempt to fly at 250 feet using visual clues in poor and deceptive visibility over a calm sea.
The report also added that the following were contributory factors:
inadequate flight instrument monitoring due to flying in visibility conditions unsuited to visual flight.
lack of audio height warning equipment.
Safety recommendations
The Accident Investigation Branch made eight recommendations:
The weather minima for helicopter flight in visual flight rules and the related crew instrument monitoring procedures should be removed.
Radio Altimeters, with both audio and visual decision height warning, would be fitted to all helicopters operating offshore as a matter of urgency.
Consideration should be given to the development of a ground proximity warning system for helicopters.
The moving of the radio altimeter indicators to within the pilot's field of head-up vision should be examined.
Helicopters used for public transport should be fitted with an automatically deployable survival radio beacon.
Consideration should be given to pilots of helicopters used for public transport to wear lifejackets with dual frequency personal locator beacons.
The use of QFE by the company on low level approaches to St Mary's aerodrome and the minimum RVR should be reviewed.
The requirements concerning the strength of helicopter passenger and cabin attendant seats be reviewed.
A report investigating the incident was concluded twenty months later, in February 1985, finding the cause to be 'pilot error'. The official report concluded that the accident was caused by the pilot not observing and correcting an unintentional descent before the helicopter collided with the sea during an attempt to fly at 250 feet using visual clues in poor and deceptive visibility over a calm sea.
The report also added that the following were contributory factors:
inadequate flight instrument monitoring due to flying in visibility conditions unsuited to visual flight.
lack of audio height warning equipment.
Safety recommendations
The Accident Investigation Branch made eight recommendations:
The weather minima for helicopter flight in visual flight rules and the related crew instrument monitoring procedures should be removed.
Radio Altimeters, with both audio and visual decision height warning, would be fitted to all helicopters operating offshore as a matter of urgency.
Consideration should be given to the development of a ground proximity warning system for helicopters.
The moving of the radio altimeter indicators to within the pilot's field of head-up vision should be examined.
Helicopters used for public transport should be fitted with an automatically deployable survival radio beacon.
Consideration should be given to pilots of helicopters used for public transport to wear lifejackets with dual frequency personal locator beacons.
The use of QFE by the company on low level approaches to St Mary's aerodrome and the minimum RVR should be reviewed.
The requirements concerning the strength of helicopter passenger and cabin attendant seats be reviewed.
Last edited by Ye Olde Pilot; 30th Aug 2013 at 21:58.
Re post 896
The threshold of 09 at Sumburgh is on the beach; no lead in lights or other early visual aids. As it is an over the sea, localiser only approach with no obstacles in the undershoot my preference is to get near MDA early, level on the AP and bleep down. There is not a standard lighting system so normal procedures are not the best.
FWIW, 25yrs on SP, 225 the best yet; it's a real pilots a/c with a brilliant AP.
Re. EFIS. My scan was poor on an analogue cockpit, my instrument flying improved wonderfully when I converted to L2 in '99.
FWIW, 25yrs on SP, 225 the best yet; it's a real pilots a/c with a brilliant AP.
Re. EFIS. My scan was poor on an analogue cockpit, my instrument flying improved wonderfully when I converted to L2 in '99.
Ye Olde Pilot
No I'm not suggesting that at all. They might both have made preliminary statements with their legal representatives present, after both agreeing a common position for the sake of enabling investigative processes to proceed.
There but for fortune go all of us and I very much doubt that most of us would be obstructive if we found ourselves in a similar position. There would be no point, because the truth always comes out in cases like this.
No, neither does my last sentence imply that they or any of us would seek to hide the truth if we thought that we could get away with it. Lives were lost and I'm confident that their instinct would be to help the survivors and bereaved to understand.
I have a very high regard for the personal integrity of our colleagues.
No I'm not suggesting that at all. They might both have made preliminary statements with their legal representatives present, after both agreeing a common position for the sake of enabling investigative processes to proceed.
There but for fortune go all of us and I very much doubt that most of us would be obstructive if we found ourselves in a similar position. There would be no point, because the truth always comes out in cases like this.
No, neither does my last sentence imply that they or any of us would seek to hide the truth if we thought that we could get away with it. Lives were lost and I'm confident that their instinct would be to help the survivors and bereaved to understand.
I have a very high regard for the personal integrity of our colleagues.
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YEO and others. I know the Commander of this flight well and he is honest as the day is long. Straight down the middle and a very good pilot.
We do not yet know what happened only that the Authority has stated it is not technical.
Whatever happened it was certainly not deliberate.that is called "An accident" knowing the man and the standards of that Company I doubt they would have deliberately flown an unauthorised approach.
Wait fr the report.
We do not yet know what happened only that the Authority has stated it is not technical.
Whatever happened it was certainly not deliberate.that is called "An accident" knowing the man and the standards of that Company I doubt they would have deliberately flown an unauthorised approach.
Wait fr the report.
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Of course none of us would have made a mistake with 20/20 hindsight but it's a sobering thought that what we think is routine can often bite when we least expect it.
The next day or two will reveal the truth.
There has to be a corporate role in this accident.
The next day or two will reveal the truth.
There has to be a corporate role in this accident.
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Radalt settings
Can someone tell me what the rad alt setting policy is for precision and non-precision approaches in CHC?
I believe that Bond bug NHP to zero on precision approaches. Is this correct? What is their policy for non-precision approach?
And offshore ARA too, please.
I believe that Bond bug NHP to zero on precision approaches. Is this correct? What is their policy for non-precision approach?
And offshore ARA too, please.
RJC your question is aimed at CHC so I can't answer it, but I can say this:
Depending on the variant and the operator, there are differences in the way the pilot and copilot radalt bugs work regarding the AVAD callout. On the L2, for everyone, the "check height" occurs on descending below the 1st bug, so the setting of the second bug is superfluous in this respect. For the 225, those for Bond and CHC are likewise. For Bristow, we requested a similar setup to the 332L, where you get the "soft" warning light /caption on descending below the 1st bug, and the harder "check height" on descending below the second.
Depending on the variant and the operator, there are differences in the way the pilot and copilot radalt bugs work regarding the AVAD callout. On the L2, for everyone, the "check height" occurs on descending below the 1st bug, so the setting of the second bug is superfluous in this respect. For the 225, those for Bond and CHC are likewise. For Bristow, we requested a similar setup to the 332L, where you get the "soft" warning light /caption on descending below the 1st bug, and the harder "check height" on descending below the second.
Agreed. Flying in the back of an L2 is a horrible claustrophobic experience. It's just about tolerable if the flight isn't very full, however when every seat is taken it's a very uncomfortable experience, physically and mentally. Not withstanding the spate of recent incidents this is the main reason why it is so unpopular.
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Of course none of us would have made a mistake with 20/20 hindsight but it's a sobering thought that what we think is routine can often bite when we least expect it.
The bereaved, the survivors, the pilots, the company and all directly involved should be treated at this stage with the sympathy and understanding befitting their horrible loss and shock. There's no place for mud slinging.
The next day or two will reveal the truth.
There has to be a corporate role in this accident.
The report(s) will be cool, thorough and factual. Whatever the findings, it would serve all best to view them as resolution and opportunity to improve rather than to blame.
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The report(s) will be cool, thorough and factual. Whatever the findings, it would serve all best to view them as resolution and opportunity to improve rather than to blame.
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Why are peope blaming the pilots before the preliminary report is out ?.
"No technical failure" leaves several other possibilities open including lack of fuel, bird strikes, incapacitation, etc etc.
Please stop jumping to conclusions - they are almost always wrong and there is seldom a simple single cause.
"No technical failure" leaves several other possibilities open including lack of fuel, bird strikes, incapacitation, etc etc.
Please stop jumping to conclusions - they are almost always wrong and there is seldom a simple single cause.
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Zotov Error Maps
Does anyone know if the AAIB, or any other similar organisation, makes use of the investigation tool known as the 'Zotov Error Map'?
The ZEM plots the contributions made by other (and all, hopefully) agencies to a particular accident using a graphic based on a non-liner time-line.
Thus it is possible to include a decision made some considerable time before the accident by authorities, companies or individuals and include them in the overall assessment of causal factors.
David Beaty in his book 'The Naked Pilot' pointed us away from the simplistic diagnostic 'Pilot Error' and the ZEM can take that one step further. I am familiar with at least one (UK) fatal accident in which the ZEM would have implicated powerful groups but who in reality escaped inclusion in the post-accident narrative in a way that reflected their true contribution to events.
For those looking for simplistic solutions to this SP L2 incident they will be there for the taking but if we are to fully understand the nature of the holes that appeared in the Swiss cheese on this occasion we need a more mature and sophisticated approach. An approach that can hold powerful groups to task about any contribution to an accident they may have made, no matter how small, no matter how embarrassing.
Time will tell.
G.
PS - Emil Zotov is a Russian born New Zealand based accident investigator. His ZEM has been included in several safety conferences I have been privileged to attend but I have not encountered it in mainstream conversations about accident investigation.
The ZEM plots the contributions made by other (and all, hopefully) agencies to a particular accident using a graphic based on a non-liner time-line.
Thus it is possible to include a decision made some considerable time before the accident by authorities, companies or individuals and include them in the overall assessment of causal factors.
David Beaty in his book 'The Naked Pilot' pointed us away from the simplistic diagnostic 'Pilot Error' and the ZEM can take that one step further. I am familiar with at least one (UK) fatal accident in which the ZEM would have implicated powerful groups but who in reality escaped inclusion in the post-accident narrative in a way that reflected their true contribution to events.
For those looking for simplistic solutions to this SP L2 incident they will be there for the taking but if we are to fully understand the nature of the holes that appeared in the Swiss cheese on this occasion we need a more mature and sophisticated approach. An approach that can hold powerful groups to task about any contribution to an accident they may have made, no matter how small, no matter how embarrassing.
Time will tell.
G.
PS - Emil Zotov is a Russian born New Zealand based accident investigator. His ZEM has been included in several safety conferences I have been privileged to attend but I have not encountered it in mainstream conversations about accident investigation.
Last edited by Geoffersincornwall; 31st Aug 2013 at 02:19. Reason: PS included and text refined
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Ye Olde Pilot:
This is not a condolences thread. That is elsewhere.
I, and others, will continue to discuss the technical aspects of our work and how they may or may not relate to this particular accident as we see fit.
I, for one, speak about my own accident, and the ones where I have lost close personal friends, just as I do this one.
HC: As much as I agree with the sentiment, and especially the soothing effects of a good G&T, I have refrained as much as possible from saying similar things. For all that we have been trying to have a rational debate about the accident, potential causes, and ways to improve what we do, there has been a witch-hunt going on here as well. Now that the 332 family has been burned at the stake and proven not a witch, the villagers are looking for new targets. We need to show we are better than that.
YOP:
Every preconception you make confirms why the real investigators need to do their jobs.
Amen brother!
And I second that!
It's alright to be defensive for the crew but four people lost their lives.
Passengers trust and put their lives in the operators of offshore helicopter
operators and the management.
In this case it went wrong for reasons we have yet to establish.
In the meantime the funerals are taking place.
Perhaps better to have sympathy for families that lost loved ones instead of
worrying about the flight deck crew who have not had the decency to emerge
with their lives intact but concerned about careers.
No spirit of Sully here.
Passengers trust and put their lives in the operators of offshore helicopter
operators and the management.
In this case it went wrong for reasons we have yet to establish.
In the meantime the funerals are taking place.
Perhaps better to have sympathy for families that lost loved ones instead of
worrying about the flight deck crew who have not had the decency to emerge
with their lives intact but concerned about careers.
No spirit of Sully here.
I, and others, will continue to discuss the technical aspects of our work and how they may or may not relate to this particular accident as we see fit.
I, for one, speak about my own accident, and the ones where I have lost close personal friends, just as I do this one.
HC: As much as I agree with the sentiment, and especially the soothing effects of a good G&T, I have refrained as much as possible from saying similar things. For all that we have been trying to have a rational debate about the accident, potential causes, and ways to improve what we do, there has been a witch-hunt going on here as well. Now that the 332 family has been burned at the stake and proven not a witch, the villagers are looking for new targets. We need to show we are better than that.
YOP:
There has to be a corporate role in this accident.
The report(s) will be cool, thorough and factual. Whatever the findings, it would serve all best to view them as resolution and opportunity to improve rather than to blame.
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Does anyone know if the AAIB, or any other similar organisation, makes use of the investigation tool known as the 'Zotov Error Map'?
Any accident report worthy of the name will look into ALL the factors that may have contributed - whether they be corporate governance, training, maintenance etc etc.
Why are peope blaming the pilots before the preliminary report is out ?
Emphasis mine. Like the crash crew arriving at the scene and asking the pilot "what happened?", and receiving the reply "no idea, I just got here myself."
The Domino Effect - Helicopters Magazine
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pilot and apprentice
Many years ago during Canadian Arctic operations we did a lot of night flying so we got pretty good at recognizing the dangers of the "both pilots looking out the window, nobody minding AS/VSI/RADALT" scenario.
But I especially remember a particular night approach (rare on the East Coast) to the Rowan Gorilla off Sable Island with 214ST CF-VZO. We got too low on the approach and despite SOP calls the flying pilot (not me) did not correct. The AS decayed, VSI pegged down and we almost went into the water. In hindsight, I still find it difficult to believe that 2 very experienced IFR captains could screw it up that badly.
My condolences to all involved in this tragedy.
But I especially remember a particular night approach (rare on the East Coast) to the Rowan Gorilla off Sable Island with 214ST CF-VZO. We got too low on the approach and despite SOP calls the flying pilot (not me) did not correct. The AS decayed, VSI pegged down and we almost went into the water. In hindsight, I still find it difficult to believe that 2 very experienced IFR captains could screw it up that badly.
My condolences to all involved in this tragedy.
Last edited by oleary; 31st Aug 2013 at 06:45.
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Brian
James Reason - Yes he certainly expounded on that subject but I don't recall him presenting it in graphical format. If I was able to draw one for you you would immediately see how powerful the ZEM is in bringing the whole thing together in one digestible format.
Dr Steve Walters was the man who sold me on it and he has written a few papers on the subject. He made a powerful case using a fixed wing accident in NZ that involved, I believe, a DH6.
G.
Dr Steve Walters was the man who sold me on it and he has written a few papers on the subject. He made a powerful case using a fixed wing accident in NZ that involved, I believe, a DH6.
G.
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Reduce the numbers
Now that the 332 family has been burned at the stake and proven not a witch
Flying in the back of an L2 is a horrible claustrophobic experience. It's just about tolerable if the flight isn't very full, however when every seat is taken it's a very uncomfortable experience, physically and mentally.
The nervousness among oil workers about flying and speaking openly about their concerns was highlighted in some of the media interviews during the aftermath of last week's accident.
"The EC225 is a flying death trap," one oil worker with 20 years' experience told the BBC. "The internal layout means [passengers] in the back … are so close that your knees are interlocked with the passenger sitting opposite you."
"The EC225 is a flying death trap," one oil worker with 20 years' experience told the BBC. "The internal layout means [passengers] in the back … are so close that your knees are interlocked with the passenger sitting opposite you."
Last edited by satsuma; 31st Aug 2013 at 05:46.