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AS332L2 Ditching off Shetland: 23rd August 2013

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AS332L2 Ditching off Shetland: 23rd August 2013

Old 21st Oct 2020, 07:25
  #2541 (permalink)  
 
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Let's use the AAIB report to look at that - how a 10,000 hour commander and a 3000 hour co pilot flew the aircraft (perfectly serviceable) into the sea.
The co-pilot provided information to the investigation on the day following the accident and during subsequent interviews. He had a good recollection of most events, but did not have a complete picture of what had occurred during the latter stages of the approach.He stated, at interview, that he had been relying on the commander’s greater experience and had therefore not challenged his comments during the approach briefing. The co-pilot stated that he had accepted the helicopter’s deviation below the published vertical profile during the latter stages of the approach because this was allowed and he had seen other approaches flown in this way. He commented that during the final approach he had noticed the commander looking up at some stage, perhaps seeking external visual reference.
So a bit of a cockpit gradient - stuff you learn about in CRM, HF and MCC training.

Attention. The analysis of crew tasks does not provide evidence that either crew member’s attention was focussed on the airspeed or aircraft pitch (paragraph 32). The Commander was also observed by the Co-Pilot to glance outside the cockpit. If the airspeed and aircraft pitch was outside the Commander and Co-Pilot’s attentional focus it is unlikely that a change in these items would be detected.
poor instrument scan - highlighted in other places in the report. Not something you would expect from an experienced commander.

The crew were using non-standard terminology for their SOP communications which increases the likelihood of miscommunication. It is recommended that the norms Air Accident Report: 1/2016 G-WNSB EW/C2013/08/03 © Crown Copyright 2016 Appendix I (cont) Appendix I 246 associated with SOP calls are identified to determine the extent of the risk and actions put in place to address.
so although the SOPs are not good, they weren't following them anyway.

First AVAD alert. At approximately twelve seconds before impact and at a height of 300ft, the crew were alerted by the Automatic Voice Alarm Device (AVAD) stating “CHECK HEIGHT”. The Commander acknowledged the AVAD alert by stating “Checking the height”. It was, therefore, possible the Commander’s attention was then directed to the altimeter. 300ft is a MDA, where it would be anticipated that vertical descent profile would be levelled off. However, there was no evidence of G-WNSB slowing down or levelling, up to or after the 300ft MDA. There are many reasons why this may have occurred, however there was no evidence to indicate why this may have happened in this instance.
now we are in the realms of basic instrument flying procedures.

The investigation identified the following causal factors in the accident:

● The helicopter’s flight instruments were not monitored effectively during the latter stages of the non-precision instrument approach. This allowed the helicopter to enter a critically low energy state, from which recovery was not possible.

● Visual references had not been acquired by the Minimum Descent Altitude (MDA) and no effective action was taken to level the helicopter, as required by the operator’s procedure for an instrument approach.

The following contributory factors were identified:

● The operator’s SOP for this type of approach was not clearly defined and the pilots had not developed a shared, unambiguous understanding of how the approach was to be flown.

● The operator’s SOPs at the time did not optimise the use of the helicopter’s automated systems during a Non-Precision Approach.

● The decision to fly a 3-axes with V/S mode, decelerating approach in marginal weather conditions did not make optimum use of the helicopter’s automated systems and required closer monitoring of the instruments by the crew.

● Despite the poorer than forecast weather conditions at Sumburgh Airport, the commander had not altered his expectation of being able to land from a Non-Precision Approach.
the contributory factors are just that and smack of complacency with a routine task - the causal factors are just poor piloting.

You can defend them as much as you like HC, personally I feel very sorry for them, they will have to live with the consequences of their failures as a crew for the rest of their lives.

And, while it might surprise you that the MAA is as pink and fluffy as the CAA when it comes to not apportioning blame - this crew failed to do their job properly.

The aircraft was serviceable, the AP did exactly what is was asked to do, there was no other emergency or reasonable distractor to divert them from their task of either landing or going around at MDA/MAP.

You can call it what you like - but this was negligent operation of an aircraft.
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Old 21st Oct 2020, 07:52
  #2542 (permalink)  
 
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Originally Posted by [email protected]
Let's use the AAIB report to look at that - how a 10,000 hour commander and a 3000 hour co pilot flew the aircraft (perfectly serviceable) into the sea.


So a bit of a cockpit gradient - stuff you learn about in CRM, HF and MCC training.

poor instrument scan - highlighted in other places in the report. Not something you would expect from an experienced commander.

so although the SOPs are not good, they weren't following them anyway.

now we are in the realms of basic instrument flying procedures.
the contributory factors are just that and smack of complacency with a routine task - the causal factors are just poor piloting.

You can defend them as much as you like HC, personally I feel very sorry for them, they will have to live with the consequences of their failures as a crew for the rest of their lives.

And, while it might surprise you that the MAA is as pink and fluffy as the CAA when it comes to not apportioning blame - this crew failed to do their job properly.

The aircraft was serviceable, the AP did exactly what is was asked to do, there was no other emergency or reasonable distractor to divert them from their task of either landing or going around at MDA/MAP.

You can call it what you like - but this was negligent operation of an aircraft.
But you still haven’t addressed the question of why those mistakes were made. As I mentioned earlier, not addressing that question is what kept accident rates high in the early days of commercial air transport. There was an accident, the pilots were at fault. End of. And then the same accident would happen sometime later. Pilots at fault. End of. Rinse and repeat.

Eventually (and many years ago for most people) it was worked out that this wasn’t a good way to carry on. One needed to examine why accidents happened, not just how they happened, if one wanted to improve flight safety.

Put it another way, by all accounts these pilots were pretty average in their apparent competence and diligence, right up to the moment they crashed. This despite 6 monthly checks lasting several hours, and, in the case of the copilot, a lot of time recently spent on training for the aircraft type and the role.

A layman looking at that information would surely say “well they seemed competent, they had all that training and checking, and yet the two of them jointly made fundamental errors that killed 4 people. If nothing changes, how can I have any confidence that the same, or similar, accident won’t happen again?“

Only someone totally entrenched in the status quo would fail to see that,
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Old 21st Oct 2020, 11:49
  #2543 (permalink)  
 
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Kind of wish I hadn’t posted now. I agree I hope the crew do not read this stuff. They did not intend to end up where they did and I would prefer to let the official bodies find out why rather than trawl through this guff. Crab you are obviously the fount of all rotary wisdom but your posts are just a bit vomit inducing as you have obviously never made a mistake.
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Old 21st Oct 2020, 11:53
  #2544 (permalink)  
 
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But this wasn't the early days of commercial transport - this was 2013 after many decades of operation in the N Sea and elsewhere and pretty much all the lessons should have been learned by then.


HC, ISTR that you were a senior trainer - I don't know with which company - so why do you think two pilots made such glaring, yet BASIC, errors on a simple instrument approach? And if you were aware of similar shortcomings, what did you do about it?


You have said they had adequate training and checks so what was the problem? A cultural issue perhaps? Pilots regarding themselves as superior because of the salaries they were able to demand?


If you discount mechanical failure, disorientation, fatigue or major distraction you are left with a crew underperforming for no reason unless they were complacent or there was a major personality clash in the cockpit.


A supposedly competent and capable crew flew into the water because they didn't do their job properly - only someone who can't stand to hear the truth would fail to see that. You can't fix the problem unless you acknowledge there is one.

Olster - I have made many mistakes and put my hand up when I did so. I have also attended too many flight safety courses where accidents like this are dissected and discussed in order to determine why crews make such mistakes - there are often linked events (the holes in the Swiss cheese) that combine to create an unfortunate scenario that encourages human errors - I don't see any in this case except the failure to follow basic procedures.

As much as HC bangs on about finding the reasons for the accident - neither the AAIB or the Inquiry have found anything except pilot error - sometimes the blame really does lie with the pilots.
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Old 21st Oct 2020, 12:04
  #2545 (permalink)  
 
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Ok Crab fair point. As an amateur heli pilot and a retired commercial pilot my view is always that wilful negligence apart no pilot sets out to make mistakes that end in catastrophe. I have a son going into offshore heli flying and I guess we are a little bit sensitive but reassure ourselves that the operational standards are indeed very high.My comments about the co pilot were made as I am desperately sorry for what happened on his behalf and he is indeed a gent; I did note that he was commended by the enquiry for his management of the aftermath. In aviation sh1t really can happen.
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Old 21st Oct 2020, 12:11
  #2546 (permalink)  
 
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In aviation sh1t really can happen.
that is the truth and I do feel genuinely sorry for the crew, a colleague of mine made a mistake many years ago and killed 2 people, one of them from our own Sqn, and has had to live with that ever since. he has never hidden from the fact that it was his fault.
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Old 21st Oct 2020, 12:14
  #2547 (permalink)  
 
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● The operator’s SOP for this type of approach was not clearly defined and the pilots had not developed a shared, unambiguous understanding of how the approach was to be flown.

● The operator’s SOPs at the time did not optimise the use of the helicopter’s automated systems during a Non-Precision Approach.

CRAB - in your haste to crucify the crew you are missing these two elements of the findings!!

The performance of the crew in this instance can be easily inferred from the rest of the report. However, nothing is ever as simple as "Pilot Error" unless the man on the sticks shouts "Geronimo" and pushes the cyclic forward to hit the sea.
SOPs, Limitations and Automation Management have to be defined holistically to ensure that on those days where any one of us may be underperforming, we may stand a chance of getting away with a howler with little more than a bruised ego.
It is this "Holistic" approach to systems and procedures management that is the issue here. After this accident a lot of good quality progress was made by all the major players in this area. In the defence of the Operators, some of the vital information necessary to determine solid procedures for the management of automation was missing in the OEMs available data. Much of this has now been addressed.
CRAB the reason why other posters object to your one dimensional response to this accident is because much of the progress that has been made since would not have been possible if we all took your view.
In the black and white pages of an AAIB report ity is oh so easy to see the mistakes others make. Its a little harder to soul search and ask if it could have happened to you. However, in doing so you stand a chance of unlocking the mysteries that surround accidents and make real progress. It is for this reason that when I am asked what the number one quality of an Instructor should be, I reply, empathy! Without it we are blinded by ego and prejudice.

DB


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Old 21st Oct 2020, 13:15
  #2548 (permalink)  
 
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Originally Posted by [email protected]

1/ pretty much all the lessons should have been learned by then.

2/ HC, ISTR that you were a senior trainer - I don't know with which company - so why do you think two pilots made such glaring, yet BASIC, errors on a simple instrument approach? And if you were aware of similar shortcomings, what did you do about it?

3/ You have said they had adequate training and checks so what was the problem? A cultural issue perhaps? Pilots regarding themselves as superior because of the salaries they were able to demand?


4/ As much as HC bangs on about finding the reasons for the accident - neither the AAIB or the Inquiry have found anything except pilot error - sometimes the blame really does lie with the pilots.
1/ it will be a sad day when we think we know it all and all lessons have been learnt. For starters, that can’t possibly be the case until there have been no accidents in aviation for several years.

2/ Not the same company as I worked for so I can’t comment on their training or procedures, but the AAIB did in the bullet points referred to by DB. Clearly I couldn’t have done anything about it even if I was aware. But as also indicated earlier, one of the problems is that unlike the airlines, there is (or was) no standard way to operate. It was left to individuals like me, with no specific training on how to create operational procedures, to make it up as we went along. And in doing so one obviously tends to have “baggage” from experience on previous types.
We only had one L2, for which I wrote the OMB. To be honest I doubt it specifically said “don’t use VS mode near Vy unless you have IAS engaged”. In part, because it seems obvious to me and you can’t include every possible minutia in a part B. But clearly, it wasn’t obvious to numerous pilots who according to AAIB routinely flew non precision approaches coupled to VS and not to IAS. It was SOP to climb out in IAS mode set to something like Vy+20 and accept whatever VS you got, because to climb out in VS mode clearly invited falling off the back of the drag curve.

3. I did not say they had adequate training and checking, I said they had extensive training and checking. Due to the archaic attitudes of the regulator, much of this time was spent doing pointless stuff and not enough time spent doing relevant stuff. For example, one could do an entire type rating and operator conversion in the aircraft and never be exposed to acting as PM during an onshore instrument approach. How can that be adequate? And this is the main thrust of my argument, that training, especially in those days, was very formulaic, very focussed on PF role and not orientated to the actual job. With increasing use of simulators these days I think there is much more exposure to PM role but from a regulatory point of view it is still optional. During an OPC or LPC there is no requirement to demonstrate competence in PM role. It all goes back to the good old days when the captain was there to fly the aircraft and the copilot was there to shut up and make the coffee. The regulator hasn’t really moved on from then.

4. The AAIB are not particularly clever when it comes to that sort of thing. Indeed I had sight of the draft report and had to send an extensive note to them correcting the many mistakes they had made in describing how the L2 autopilot system worked, amongst other points.
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Old 21st Oct 2020, 17:35
  #2549 (permalink)  
 
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We are still only talking about 2013 - only 7 years ago in the familiar environment of the N Sea.

Can you really be serious that training, checking and SOPs were still inadequate to prevent this accident only 7 years ago?

If that were really the case there would have been far more incidents and accidents since IMC approaches are normal fare for aviation in those parts.

That hasn't happened - or has been well covered up - so you can only draw the conclusion that, whilst not perfect, the training, checking and SOPs were adequate for the vast majority of pilots on the vast majority of days.

There was nothing special to differentiate this flight from thousands of others - EXCEPT they crashed by the simple action of failing to notice the IAS on an instrument approach - not 10 or 20 kts missed and a correction made, but all the way to below 30 and VRS.

Do explain how that is not negligent.

I'm not trying to crucify them - I don't know them nor the pax that died but I know where my sympathies lie in this sad case.
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Old 21st Oct 2020, 18:10
  #2550 (permalink)  
 
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Originally Posted by [email protected]
We are still only talking about 2013 - only 7 years ago in the familiar environment of the N Sea.

Can you really be serious that training, checking and SOPs were still inadequate to prevent this accident only 7 years ago?

If that were really the case there would have been far more incidents and accidents since IMC approaches are normal fare for aviation in those parts.

That hasn't happened - or has been well covered up - so you can only draw the conclusion that, whilst not perfect, the training, checking and SOPs were adequate for the vast majority of pilots on the vast majority of days.

There was nothing special to differentiate this flight from thousands of others - EXCEPT they crashed by the simple action of failing to notice the IAS on an instrument approach - not 10 or 20 kts missed and a correction made, but all the way to below 30 and VRS.

Do explain how that is not negligent.

I'm not trying to crucify them - I don't know them nor the pax that died but I know where my sympathies lie in this sad case.
I do find it worrying that you have any involvement in training, you don’t seem to grasp the very basics of flight safety.

Firstly it is surely blatantly obvious to nearly everyone that the training, checking and SOPs were inadequate to prevent this accident. Otherwise, it wouldn’t have happened. To put it politely, “Duh!”.

Secondly you appear to have some fantasy that these things are black and white, or “binary” in modern parlance. Either something is safe, or something isn’t safe, adequate or inadequate. No middle ground. Which I find amazing and scary.

With the training regime extant at the time, people were accustomed to flying an onshore NPA in various different ways with various different upper mode engagements. There was no standardisation simply because there was no laid down standard to adhere to. Yes Ok nearly everyone coped with that, but being accustomed to using VS mode during an NPA with speed reduction was an accident waiting to happen. So not surprisingly it eventually did happen when the cheese holes lined up, especially when there was no proper stabilised approach policy either.

Of course they made a mistake and failed to control and monitor the speed. But we need to bear in mind that humans (of which group most pilots are allegedly a member) make mistakes. They do, so get over it! (Apart from you, obviously). Because we know that humans make mistakes we need to design error-tolerant procedures so that when they do make a mistake, and they will, it isn’t catastrophic.

Hmmm, let me think how could we make flying a NPA error tolerant in terms of airspeed control? Oooh, I know, let’s make the pilots use IAS mode! There, the problem is solved in an instant and the accident won’t happen again. Quite easy really, wasn’t it! Just a pity the company’s SOPs didn’t require that and lots of people were in the habit of not doing so. That cost 4 lives.
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Old 21st Oct 2020, 19:06
  #2551 (permalink)  
 
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Crab is right. There needs to be a system of Consequence Management within every operator's SMS to manage human factors like this, otherwise there will be mayhem. Shell Aircraft will have drilled this into CHC in recent years Bristow was first, NHV are getting educated now and soon it will be Babcocks turn.
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Old 21st Oct 2020, 19:36
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Originally Posted by Shell Management
Crab is right. There needs to be a system of Consequence Management within every operator's SMS to manage human factors like this, otherwise there will be mayhem. Shell Aircraft will have drilled this into CHC in recent years Bristow was first, NHV are getting educated now and soon it will be Babcocks turn.
Surely you are setting bait with that comment
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Old 21st Oct 2020, 19:51
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Originally Posted by HeliComparator
Just a pity the company’s SOPs didn’t require that and lots of people were in the habit of not doing so. That cost 4 lives.
From the summary: "insufficient collective pitch control input was applied by the commander to maintain the approach profile and the target approach airspeed of 80 kt. This resulted in insufficient engine power being provided and the helicopter’s airspeed reduced continuously during the final approach."

Yes, the SOPs sound daft but that should have been a red flag to any competent pilot and additional focus should have been used in the cockpit to work around it until common sense prevailed and led to a change. In the meantime, during a mechanical failure-free NPA, it was the PF who failed to lift up on the collective, and the PM who failed to monitor and register the decreasing airspeed.

FWIW I'm with Crab on this one to a certain extent. Given the plethora of good pilots willing to fly there, if a pilot is lucky enough to hold a seat in the north sea they should be exceptional at their job. A PF not flying properly, and a PM not monitoring properly isn't something that can be glossed over because the SOPs were back-to-front.
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Old 21st Oct 2020, 21:02
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Originally Posted by Shell Management
Crab is right. There needs to be a system of Consequence Management within every operator's SMS to manage human factors like this, otherwise there will be mayhem. Shell Aircraft will have drilled this into CHC in recent years Bristow was first, NHV are getting educated now and soon it will be Babcocks turn.
Response written and then deleted.

Can someone else make him stop!
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Old 21st Oct 2020, 21:07
  #2555 (permalink)  
 
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I do find it worrying that you have any involvement in training, you don’t seem to grasp the very basics of flight safety.

Firstly it is surely blatantly obvious to nearly everyone that the training, checking and SOPs were inadequate to prevent this accident. Otherwise, it wouldn’t have happened. To put it politely, “Duh!”.

Secondly you appear to have some fantasy that these things are black and white, or “binary” in modern parlance. Either something is safe, or something isn’t safe, adequate or inadequate. No middle ground. Which I find amazing and scary.

With the training regime extant at the time, people were accustomed to flying an onshore NPA in various different ways with various different upper mode engagements. There was no standardisation simply because there was no laid down standard to adhere to. Yes Ok nearly everyone coped with that, but being accustomed to using VS mode during an NPA with speed reduction was an accident waiting to happen. So not surprisingly it eventually did happen when the cheese holes lined up, especially when there was no proper stabilised approach policy either.

Of course they made a mistake and failed to control and monitor the speed. But we need to bear in mind that humans (of which group most pilots are allegedly a member) make mistakes. They do, so get over it! (Apart from you, obviously). Because we know that humans make mistakes we need to design error-tolerant procedures so that when they do make a mistake, and they will, it isn’t catastrophic.

Hmmm, let me think how could we make flying a NPA error tolerant in terms of airspeed control? Oooh, I know, let’s make the pilots use IAS mode! There, the problem is solved in an instant and the accident won’t happen again. Quite easy really, wasn’t it! Just a pity the company’s SOPs didn’t require that and lots of people were in the habit of not doing so. That cost 4 lives.
HC your tiresome and bigoted attacks on me with your very anti-military standpoint don't do you any favours and certainly don't make any case for changing my mind about this accident.
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Old 21st Oct 2020, 21:18
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Originally Posted by [email protected]
HC your tiresome and bigoted attacks on me with your very anti-military standpoint don't do you any favours and certainly don't make any case for changing my mind about this accident.
Oh I know there is no hope of that! But you are not the only person reading.

HELLOelloello IS THERE ANYBODY THEREerer?

Ok, maybe you are the only other person reading after all.
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Old 21st Oct 2020, 21:22
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Originally Posted by ApolloHeli
From the summary: "insufficient collective pitch control input was applied by the commander to maintain the approach profile and the target approach airspeed of 80 kt. This resulted in insufficient engine power being provided and the helicopter’s airspeed reduced continuously during the final approach."

Yes, the SOPs sound daft but that should have been a red flag to any competent pilot and additional focus should have been used in the cockpit to work around it until common sense prevailed and led to a change. In the meantime, during a mechanical failure-free NPA, it was the PF who failed to lift up on the collective, and the PM who failed to monitor and register the decreasing airspeed.

FWIW I'm with Crab on this one to a certain extent. Given the plethora of good pilots willing to fly there, if a pilot is lucky enough to hold a seat in the north sea they should be exceptional at their job. A PF not flying properly, and a PM not monitoring properly isn't something that can be glossed over because the SOPs were back-to-front.
Well I’m sure your passengers will be delighted to hear that it couldn’t possibly happen to you.
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Old 21st Oct 2020, 22:32
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Originally Posted by HeliComparator
Well I’m sure your passengers will be delighted to hear that it couldn’t possibly happen to you.
So, hypothetically, if a crew crashed the heli in the sim during a routine NPA without any systems emergencies, should the examiner say "oh well, the SOPs are backwards and pilots make mistakes, so no biggie, you pass"? This same situation, but in a simulator without consequences, or if one of the pilots on board had been competent in their role as a professional pilot and prevented the crash, the pilot(s) at fault for cocking up the flight would be put under the microscope without hesitation.

I don't think that because now that 4 or 5 people died as a result of this crash, we should pan out and find a bigger fish to paint the blame on, and ignore the fact that the crew did not do their job. If you believe that not all the blame falls on the crew, that is perfectly reasonable and supported by the facts of the report (reminder to readers that reports do not apportion blame - our individual interpretations of those facts do), but to say that the crew were victims of some bigger systematic failure that placed them into an inevitable accident when they were in fact the last line of defence from stopping the helicopter from flying into the water, I find highly questionable. The helicopter functioned exactly as described on the tin. The crew however, did not.

As always, this is simply my opinion, through my interpretation of the facts.
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Old 22nd Oct 2020, 05:17
  #2559 (permalink)  
 
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Ah DB, still HCs attack poodle.

News flash - NS pilots are not superior beings, they make mistakes like all other pilots and when they make those mistakes, they should own them - that is the way to learn from them not shot-gunning the blame around to preserve reputation.

Now I'm pretty sure the crew involved have done that and are rebuilding their lives, it's just the outraged ex-NS mob who seem to have a problem with it.

Not sure where apolloheli said it could never happen to him - just seems like a reflex lashing out in the playground.

Last edited by [email protected]; 22nd Oct 2020 at 10:38.
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Old 22nd Oct 2020, 19:49
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Originally Posted by [email protected]
We are still only talking about 2013 - only 7 years ago in the familiar environment of the N Sea.

Can you really be serious that training, checking and SOPs were still inadequate to prevent this accident only 7 years ago?

If that were really the case there would have been far more incidents and accidents since IMC approaches are normal fare for aviation in those parts.
There is a very thin line between a normal flight and a disaster, as pilots we SHOULD all know this. When we move away from SOPs in the cockpit or when the SOPs are flawed this line becomes thinner (not to mention the many other reasons). What I'm saying here is as pilots we get away with it, when we are close to disaster and we don't even know it. Which leads to us thinking if there hasn't been an accident for a while then its all working fine.

This is why there should be endeavours to find out why it happened and then to mitigate. Why do experts make mistakes? I think its a good question.

Crab, the OP manuals I work are updated once a year, sometimes two with many smaller directives in-between. We are constantly improving, learning, moving forward to keep safety at the forefront. I suspect CHCs ops manuals are nearly unrecognisable now than before this accident.

Flying is not that black and white.

Last edited by HeliMannUK; 22nd Oct 2020 at 20:01.
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