AS332L2 Ditching off Shetland: 23rd August 2013
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Actually the most common form of safety culture in international companies these days is the Just Culture model. SKYbrary has a good definition:
There is a rumour that the Managing Director of one large company operating in the NS is trying to scrap the just culture in favour of a blame culture 
One key to the successful implementation of safety regulation is to attain a “just culture” reporting environment within aviation organisations, regulators and investigation authorities. This effective reporting culture depends on how those organisations handle blame and punishment.
Only a very small proportion of human actions that are unsafe are deliberate (e.g. criminal activity, substance abuse, use of controlled substances, reckless noncompliance, sabotage, etc.) and as such deserve sanctions of appropriate severity. A blanket amnesty on all unsafe acts would lack credibility in the eyes of employees and could be seen to oppose natural justice. A “no-blame” culture per se is therefore neither feasible nor desirable.
What is needed is a “just culture”, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information - but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.
There is a need to learn from accidents and incidents through safety investigation so as to take appropriate action to prevent the repetition of such events. In addition, it is important that even apparently minor occurrences are investigated, in order to prevent catalysts for major accidents. Safety analysis and investigation is a necessary and effective means of improving safety, by learning the appropriate lessons from safety occurrences and adopting preventative actions. It is therefore important that an environment exists where occurrences are reported, the necessary processes are in place for investigation and for the development of necessary preventative actions such as re-training, improved supervision etc.
Only a very small proportion of human actions that are unsafe are deliberate (e.g. criminal activity, substance abuse, use of controlled substances, reckless noncompliance, sabotage, etc.) and as such deserve sanctions of appropriate severity. A blanket amnesty on all unsafe acts would lack credibility in the eyes of employees and could be seen to oppose natural justice. A “no-blame” culture per se is therefore neither feasible nor desirable.
What is needed is a “just culture”, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information - but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.
There is a need to learn from accidents and incidents through safety investigation so as to take appropriate action to prevent the repetition of such events. In addition, it is important that even apparently minor occurrences are investigated, in order to prevent catalysts for major accidents. Safety analysis and investigation is a necessary and effective means of improving safety, by learning the appropriate lessons from safety occurrences and adopting preventative actions. It is therefore important that an environment exists where occurrences are reported, the necessary processes are in place for investigation and for the development of necessary preventative actions such as re-training, improved supervision etc.
Well, I can completely assure you that it isn't Bristow and if anyone says it is, then it is unsubstantiated rumour. We have enough pilots high enough up the greasy pole, who would let we mushrooms know p.d.q. if this were true.
So who's going to eliminate one of the remaining two and satisfy our curiosity?
So who's going to eliminate one of the remaining two and satisfy our curiosity?
Last edited by Colibri49; 25th Sep 2013 at 22:00.
it is unsubstantiated rumour
BBC News - Survivor tells of Super Puma crash ahead of CAA Norway talks
Mr Nugent told BBC Scotland: "There was a hell of a noise and twisting in the fuselage.
"We realised there was something really wrong with the helicopter.
"About four seconds later we were hitting the surface of the water hard. Water was rushing into the fuselage. We had crashed."
He said he managed to escape after trying to help colleagues, but was now struggling to go near helicopters.
Mr Nugent told BBC Scotland: "There was a hell of a noise and twisting in the fuselage.
"We realised there was something really wrong with the helicopter.
"About four seconds later we were hitting the surface of the water hard. Water was rushing into the fuselage. We had crashed."
He said he managed to escape after trying to help colleagues, but was now struggling to go near helicopters.
New AAIB bulletin out with FDR plot. As we suspected, unfortunately. It is amazing how long they went without noticing the airspeed decay. The report doesn't mention any particular distractions so its a bit hard to get away from pilot error, but of course the foundations were laid earlier with decisions to:
Have the captain as PF
Fly the approach 3 axis
Intentionally destabilise the approach by reducing to 80kts late in the approach.
I wonder if any of those choices were contrary to their Ops Manual?
Also, not using ALT.A seems odd, but not contributory.
Have the captain as PF
Fly the approach 3 axis
Intentionally destabilise the approach by reducing to 80kts late in the approach.
I wonder if any of those choices were contrary to their Ops Manual?
Also, not using ALT.A seems odd, but not contributory.
Special Bulletin S7/2013 out now: http://www.aaib.gov.uk/cms_resources...2%20G-WNSB.pdf
Did neither Pilot raise the Collective upon realizing there was an airspeed problem as they approached the Minimum Altitude?
Were there any comments, declarations, or calls reporting taking such action or having taken such action?
Why were they so blind in failing to monitor the Airspeed and ROD as they were in the portion of the approach where they would have been either about to or were in the process of leveling off from the descent to Minimum Altitude?
There is far more to this than is being reported by the AAIB at this time in my view.
Again, they are begging more questions than they are answering.
Why not hold off and make a much more detailed report of their findings?
Were there any comments, declarations, or calls reporting taking such action or having taken such action?
Why were they so blind in failing to monitor the Airspeed and ROD as they were in the portion of the approach where they would have been either about to or were in the process of leveling off from the descent to Minimum Altitude?
There is far more to this than is being reported by the AAIB at this time in my view.
Again, they are begging more questions than they are answering.
Why not hold off and make a much more detailed report of their findings?
SAS, did you read the report? Yes there were calls, yes the collective was raised but too little too late, until right at the end when it was fully raised.
Unfortunately I don't think there is that much more to it than meets the eye. My supposition is that Copilot was looking out. Captain was looking out too because he wanted to get in and was aware of the lack of copilot's experience, and no-one was looking at the instruments properly (they were looking at the altitude, but not the airspeed).
The only thing that doesn't meet the eye is the company training and operational culture that got them there - to what extent that is a factor is unknown at this time and will probably remain so.
Unfortunately I don't think there is that much more to it than meets the eye. My supposition is that Copilot was looking out. Captain was looking out too because he wanted to get in and was aware of the lack of copilot's experience, and no-one was looking at the instruments properly (they were looking at the altitude, but not the airspeed).
The only thing that doesn't meet the eye is the company training and operational culture that got them there - to what extent that is a factor is unknown at this time and will probably remain so.
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The torque set on the approach seems surprisingly low to me - is the 24% that it was increased to at 80kts, having previously been just 18%, anywhere near what the crew might have expected would maintain an 80kt 500ft/min approach profile?
Very sadly for the crew, there seems to be no information coming from either this report, or any reported comments from them on the accident, that looks like this was anything other than simple (two) pilot error from a bizzarely very poorly monitored approach. For their sakes I had hoped there might at least been distraction from dealing with some warning captions or other cockpit distraction.
Very sadly for the crew, there seems to be no information coming from either this report, or any reported comments from them on the accident, that looks like this was anything other than simple (two) pilot error from a bizzarely very poorly monitored approach. For their sakes I had hoped there might at least been distraction from dealing with some warning captions or other cockpit distraction.
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It's the same old sad story of pilots flying routine boring legs missing the big picture when it all goes wrong. The Air France accident is classic.
If I may just point to Vertical Freedoms postings on here he is flying at the margins of the helicopters ability and extreme altitude and weather as a single pilot he must be waiting for an challenge every flight.
How two well qualified North Sea pilots lost the plot here poses major questions.
BBC News - Shetland helicopter crash: Pilots 'failed to spot reduced airspeed'
Four people lost their lives here.
If I may just point to Vertical Freedoms postings on here he is flying at the margins of the helicopters ability and extreme altitude and weather as a single pilot he must be waiting for an challenge every flight.
How two well qualified North Sea pilots lost the plot here poses major questions.
BBC News - Shetland helicopter crash: Pilots 'failed to spot reduced airspeed'
Four people lost their lives here.
Last edited by Ye Olde Pilot; 18th Oct 2013 at 17:51.
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The only thing that doesn't meet the eye is the company training and operational culture that got them there - to what extent that is a factor is unknown at this time and will probably remain so.
. Are you really telling me this could never happen in Bristow????? Careful how you answer
Im sure it could, but if it did it would contravene some Ops Man SOPs. My point was not to hit CHC in particular, rather to desperately look for some alleviation from just blaming the pilots. Just because I suggest there might be some corporate fault in CHC in no way means that I think no corporate fault exists in Bristow! I am not that stupid!
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Autopilot should never be used n a ship in close quarters, narrow channels, entering and exiting port..
Is it common practice to relay on automation when coming into land or is that classed as being lazy getting complacent.
'further enhanced the guidance to support the full use of automation as the default'
Why would they state this, surely there is no substitute for being in full manual control?
Is it common practice to relay on automation when coming into land or is that classed as being lazy getting complacent.
'further enhanced the guidance to support the full use of automation as the default'
Why would they state this, surely there is no substitute for being in full manual control?
That is what the report says, however....
VRS requires very low airspeed whereas they seemed to have 20-30kts, and VRS results in a rate of descent of maybe 6000'/min not responding to collective, whereas they had 1800.
Perhaps they were on the cusp of developing VRS but I think it was mostly low airspeed and high rate of descent with insufficient power to arrest it in time. Although it doesn't really matter either way.
Anyway "it" wasn't caused by any of the above, "it" was caused by prolonged inattention to the airspeed having previously intentionally destabilised the approach by substantially reducing power to slow down.
VRS requires very low airspeed whereas they seemed to have 20-30kts, and VRS results in a rate of descent of maybe 6000'/min not responding to collective, whereas they had 1800.
Perhaps they were on the cusp of developing VRS but I think it was mostly low airspeed and high rate of descent with insufficient power to arrest it in time. Although it doesn't really matter either way.
Anyway "it" wasn't caused by any of the above, "it" was caused by prolonged inattention to the airspeed having previously intentionally destabilised the approach by substantially reducing power to slow down.
Last edited by HeliComparator; 18th Oct 2013 at 19:37.
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VRS is a symptom not the cause. It is dangerous 3 axis autopilot modes. You could have the same accident tomorrow in an A109. If you lower the lever and ddon't pay attention to the speed with alt or vs engaged you will lose control. You need height to recover. The AFCS is dangerous if you don't know about this. If they had had the apm2010 afcs we have it would not have happened. Speed would have fallen to 40kts and stopped. The vertical would have then increased until the ground protection in the system had levelled them out. Crap afcs is your cause. Pilots complain
Last edited by GipsyMagpie; 18th Oct 2013 at 20:12. Reason: Edited to reflect AFCS type
Well not quite, had it been a 225 the IAS mode would have engaged at ~65 kts and raised the collective to maintain 65 kts and the preset Rod, then levelled at 150' still maintaining 65kts.
Great to see VRS appearing in a report - that'll help. How about simple exponential V/S development as a function of a non-linear power demand?