AS332L2 Ditching off Shetland: 23rd August 2013
It’s not just about having good SOPs, it’s about compliance and the cultural acceptance of non compliance. It’s all very well for the company to produce perfect Ops Manuals and perfect training in the simulator but if there is a general acceptance of, and by crews to informally adopt “I know a better way of doing this” routines, it leads to the slippery slope downwards. Compliance requires good, sensible and workable SOPs and good monitoring on a day to day basis. It also requires a high level of training, not just technical but also cultural, to ensure good compliance. The number of organisational changes and economic pressures on some North Sea helicopter operators had caused a degradation of standards and standards monitoring which allowed a significant amount of SOP variations to the point when all the holes lined up and the accident occurred.
Last edited by roundwego; 22nd Oct 2020 at 21:06.
From the Cambridge dictionary
Miriam Webster
Collins
You should be asking the question - why were they negligent? Instead of blaming poor SOPs. Poor SOPS didn't cause them to ignore the IAS. This has the hallmarks of a cultural problem which I sincerely hope has been addressed.
Nuff said
Nuff said
Originally Posted by [email protected]
From the Cambridge dictionary
Miriam Webster
Collins
You should be asking the question - why were they negligent? Instead of blaming poor SOPs. Poor SOPS didn't cause them to ignore the IAS. This has the hallmarks of a cultural problem which I sincerely hope has been addressed.
Nuff said
Miriam Webster
Collins
You should be asking the question - why were they negligent? Instead of blaming poor SOPs. Poor SOPS didn't cause them to ignore the IAS. This has the hallmarks of a cultural problem which I sincerely hope has been addressed.
Nuff said
“Nuff said” demonstrates a completely closed mind and inability to think about the issue from a wider angle.
The word “negligent” is a subjective, opinionated and emotive word which does little to contribute to a considered and intelligent analysis of the causes of this event.
Originally Posted by [email protected]
This has the hallmarks of a cultural problem which I sincerely hope has been addressed.
Saying the crew were negligent doesn't‘ really do much to stop the next badly managed approach. I bet the crew concerned would give their eye teeth to go back and do it differently. And would never do it like that again. But without an analysis of why they did it that way, why the monitoring broke down, why the MCC/CRM was inadequate, the same and other needless events await to befall other crews. The crew know they buggered up. Understanding why is the lesson for all of us.
I cannot tell you how many VS mode descents with the airspeed being flown with the collective I‘ve witnessed. It was certainly the preferred method at one company. This crew were the saps who demonstrated why it isn’t a smart way to fly a helicopter.
Sheriff Principal Derek Pyle said the reason for the error remained unknown - but that there had been "no wilful neglect" by the pilot.
In his findings he said the cause of the accident had been pilot error, but the reasons for this remained unknown."At the end of the day we know that for whatever reason or reasons the commander failed to maintain the target approach speed," he said.
He said one possible reason was in the developing knowledge of the inability of the human brain to monitor flight instruments continuously.
"There was plainly no wilful neglect," he added.
"Rather, there was, as one witness described it, a perfect storm of circumstances which resulted in all the safety barriers in place not preventing - or remedying - his one failure, to maintain the correct speed."
In his findings he said the cause of the accident had been pilot error, but the reasons for this remained unknown."At the end of the day we know that for whatever reason or reasons the commander failed to maintain the target approach speed," he said.
He said one possible reason was in the developing knowledge of the inability of the human brain to monitor flight instruments continuously.
"There was plainly no wilful neglect," he added.
"Rather, there was, as one witness described it, a perfect storm of circumstances which resulted in all the safety barriers in place not preventing - or remedying - his one failure, to maintain the correct speed."
Nuff said” demonstrates a completely closed mind and inability to think about the issue from a wider angle.
The word “negligent” is a subjective, opinionated and emotive word which does little to contribute to a considered and intelligent analysis of the causes of this event.
The word “negligent” is a subjective, opinionated and emotive word which does little to contribute to a considered and intelligent analysis of the causes of this event.
roundwego I assume crab would deem the Sheriff Principal incompetent given his finding.The official accident report addresses human factors in some detail, so I can't understand why crab, with his extensive experience in the industry, fails in his comprehension. The trouble with human factors is it is often difficult to explain exactly the "why". Flight into the water has been a regular event in offshore operations, for various reasons, we had a Puma flown by two check and training captains go into the water on a night VMC approach to a ship, human factors had a big role to play. Interestingly some have not even been the subject of investigation, the Puma in Nigeria which went into the water for example. A lesson foregone.
I've been involved in my own near miss on an approach to a platform in severe clear VMC, all due to human factors, which I won't elaborate on in deference to those involved, and who still don't know how they contributed, it would take volumes to explain.
The sheriff clearly stated “wilful neglect” ie there were no intentional faults.
It is semantics - you don’t require intent to be negligent, you simply need to not take the care and attention required to do the job properly.
Sticking your tailrotor into a bush on takeoff and ruining the aircraft is negligence - you didn’t intend to do it but you could have done more to avoid hitting it.
It is semantics - you don’t require intent to be negligent, you simply need to not take the care and attention required to do the job properly.
Sticking your tailrotor into a bush on takeoff and ruining the aircraft is negligence - you didn’t intend to do it but you could have done more to avoid hitting it.
Wilful neglect would surely lead to criminal proceedings but that isn't the answer here.
The accident has been dissected by both the AAIB and the Sheriff Principal yet no reason can be found for the breakdown in CRM and basic piloting in this case.
Is is a Human Factors issue? Almost certainly but all the usual suspects have been looked at so what is the answer?
The word negligent is hardly subjective as the different dictionary definitions show.
I stand by my original post of negligence (not wilful or intentional) because for whatever reason they failed to do what they were supposed to do despite training, checks and a great deal of experience (especially rom the commander).
Was the commander the issue? Was it a personality clash? Was it too much deference to experience?
If people don't tell the truth then we won't know - pretending they weren't negligent and that there is a mysterious and as yet unknown human factor at work is the decision of the really closed mind.
The accident has been dissected by both the AAIB and the Sheriff Principal yet no reason can be found for the breakdown in CRM and basic piloting in this case.
Is is a Human Factors issue? Almost certainly but all the usual suspects have been looked at so what is the answer?
The word negligent is hardly subjective as the different dictionary definitions show.
I stand by my original post of negligence (not wilful or intentional) because for whatever reason they failed to do what they were supposed to do despite training, checks and a great deal of experience (especially rom the commander).
Was the commander the issue? Was it a personality clash? Was it too much deference to experience?
If people don't tell the truth then we won't know - pretending they weren't negligent and that there is a mysterious and as yet unknown human factor at work is the decision of the really closed mind.
Originally Posted by [email protected]
Wilful neglect would surely lead to criminal proceedings but that isn't the answer here.
The accident has been dissected by both the AAIB and the Sheriff Principal yet no reason can be found for the breakdown in CRM and basic piloting in this case.
Is is a Human Factors issue? Almost certainly but all the usual suspects have been looked at so what is the answer?
The word negligent is hardly subjective as the different dictionary definitions show.
I stand by my original post of negligence (not wilful or intentional) because for whatever reason they failed to do what they were supposed to do despite training, checks and a great deal of experience (especially rom the commander).
Was the commander the issue? Was it a personality clash? Was it too much deference to experience?
If people don't tell the truth then we won't know - pretending they weren't negligent and that there is a mysterious and as yet unknown human factor at work is the decision of the really closed mind.
The accident has been dissected by both the AAIB and the Sheriff Principal yet no reason can be found for the breakdown in CRM and basic piloting in this case.
Is is a Human Factors issue? Almost certainly but all the usual suspects have been looked at so what is the answer?
The word negligent is hardly subjective as the different dictionary definitions show.
I stand by my original post of negligence (not wilful or intentional) because for whatever reason they failed to do what they were supposed to do despite training, checks and a great deal of experience (especially rom the commander).
Was the commander the issue? Was it a personality clash? Was it too much deference to experience?
If people don't tell the truth then we won't know - pretending they weren't negligent and that there is a mysterious and as yet unknown human factor at work is the decision of the really closed mind.
Clearly they were negligent: The PF neglected to maintain safe flight parameters; the PM neglected to monitor those parameters and intervene. Arguably, they neglected to agree and fly one or more methods of flying the approach which would have have been safer, including flying by hand.
But that doesn’t lead anywhere. It is the analysis of how they made the decisions they did which is of interest. That it was a baldy executed approach is obvious. Attributing responsibility to the crew beyond this simply has no value. They clearly did not set out to crash. What was the context in which this was possible tells us much more and will help prevent more “CRM mouth music” as you rightly said.
Last edited by Torquetalk; 23rd Oct 2020 at 07:37.
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CRAB, please explain why, after this accident, the CAA launched an investigation into HOFO procedures AND substantial changes were made to all Operator's SOPs. None-the-least of which was a requirement to properly define automation management procedures. That meant Operator's, for the first time, were require to mandate when and how the automation was utilised for any given approach. In addition, SOPs require very clear Intervention Parameters to be defined and the associated calls/action required of the PM.
This was a case of bolting the door after the horse had done a runner. However, none of this could have been driven if we all sat back and simply blamed the pilot.
Having said this, there is some evidence that laid down procedures were not followed. EG, PF looking up when he should be monitoring the Instruments.
Flying a coupled approach does not require particular handling skills but does require a firm understanding of the automation management, SOPs and the pitfalls of each mode. Transitioning from IMC to VMC and the detection, recognition and acceptance of the required visual references takes experience which is exponential as the conditions approach marginal. For this reason, many HOFO seasoned Commanders would sit the P2 at the sticks (as PF) and monitor the approach themselves as they are then in the ideal position to make the difficult decisions at the bottom and take control for the landing. In addition, one can assume that the Commander's greater handling skillset facilitate an optimum deceleration to land without loosing the references.
This accident highlights many things and CRM deterioration is offered as a complicit factor. However, the decision to be PF or PM in marginal approach conditions sits with the Commander. Maybe this should be mandated to ensure that each approach exploits the optimum experience and skills of each Pilot.
In short, when the PF looks up from the Instruments without the Required References being acquired no one is really flying the helicopter.
When the safety of the approach relies on commons sense and/or best practise and not mandated procedures there will always be an opportunity for the fickle hand of fate to intervene and some poor sap to invent a new wheel (that is subsequently discovered to square).
HOFO flying is boring, repetitious and tedious because it should leave little room for original thought during NORMAL procedures.
Now CRAB, for this accident, if the Automation procedures were not defined or mandated and If the crew duties were left entirely at the discretion of the Commander how can he alone take the full blame for the result?
This was a case of bolting the door after the horse had done a runner. However, none of this could have been driven if we all sat back and simply blamed the pilot.
Having said this, there is some evidence that laid down procedures were not followed. EG, PF looking up when he should be monitoring the Instruments.
Flying a coupled approach does not require particular handling skills but does require a firm understanding of the automation management, SOPs and the pitfalls of each mode. Transitioning from IMC to VMC and the detection, recognition and acceptance of the required visual references takes experience which is exponential as the conditions approach marginal. For this reason, many HOFO seasoned Commanders would sit the P2 at the sticks (as PF) and monitor the approach themselves as they are then in the ideal position to make the difficult decisions at the bottom and take control for the landing. In addition, one can assume that the Commander's greater handling skillset facilitate an optimum deceleration to land without loosing the references.
This accident highlights many things and CRM deterioration is offered as a complicit factor. However, the decision to be PF or PM in marginal approach conditions sits with the Commander. Maybe this should be mandated to ensure that each approach exploits the optimum experience and skills of each Pilot.
In short, when the PF looks up from the Instruments without the Required References being acquired no one is really flying the helicopter.
When the safety of the approach relies on commons sense and/or best practise and not mandated procedures there will always be an opportunity for the fickle hand of fate to intervene and some poor sap to invent a new wheel (that is subsequently discovered to square).
HOFO flying is boring, repetitious and tedious because it should leave little room for original thought during NORMAL procedures.
Now CRAB, for this accident, if the Automation procedures were not defined or mandated and If the crew duties were left entirely at the discretion of the Commander how can he alone take the full blame for the result?
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It has been interesting to read of the recent debate here, which broadly agrees that the crew made the mistake(s) that caused the accident, but differs on who was to mainly to blame. It seems HC leads the lack of adequate SOPs and CRM view so therefore the fault of the operating organisation, and Crab the pilots made errors they never should have view.
I’ve never flown North Sea, or even really any multi crew, but have flown a lot of SP IFR obviously on twins in corporate ops. Skimming through the accident report again, the following seem key points. Firstly there was clearly woefully inadequate monitoring of airspeed by the crew. The need to do this on any approach, IFR or not, is clearly a fundamental piloting skill that you learn before you even go solo when training for your first licence. However as we all know, when IMC with the lack of visual cues, the scan becomes essential to ensure this. I think pretty much all of us agree that coupling to IAS not VS is a far better way to conduct an approach on 3 axis. However using VS is not disastrous – I used to use it, and clearly thousands of IFR approaches have been successfully made using it. What is used should just highlight what is left for the pilots to focus on and monitor. Being basic, with this localiser DME approach using VS, the pilots do not have to really monitor roll/heading or vertical speed, as these were coupled. The one main thing they did have to monitor closely was airspeed, and control it with collective. Even height was secondary, at least in the early stages of the approach, as it should have been more or less right given they started from a set known distance, height and VS – had the airspeed been in the window. So why didn’t the PF do this? Well, amongst the considerable chat between the crew which included bits of briefings, there was no mention at all of the fact that they were doing a VS coupled approach so that monitoring IAS was their number one priority. Of course the PF should have known this – basic stuff – and almost certainly did, but he certainly didn’t seem focussed on it at the critical time. And there was quite a bit of non-pertinent chat before the approach started. I’ll come back to this.
What made the need to monitor IAS carefully far more important than normal was they had not truly established a stabilised approach far enough out. According to the AAIB report, they had. And indeed technically they had, according to the definition. But this is an example of where reliance on the specifics of ever more extensive documentation can be counter-productive, eroding the responsibility for intelligent thought and judgement. When 1000ft at circa 3 miles they were at 108kts – upper end of the SOPs 80kt -120kt window. Right height, right course, right descent rate. But the PF had said that as the weather was on minimums, he would slow the approach to 80kts. So he only had a mile or two to slow a ? 7 tonne helicopter from 108kts to 80kts. Which clearly was going to take a big reduction in torque, which would then have to be partly reapplied to maintain the 80kts. Hardly a stabilised situation. And going to need close monitoring of AIS throughout, until a properly stabilised approach was achieved, belatedly. Surely a 10,500 hour commander with a 3000 co-pilot hour should have known that especially given the marginal weather and desire for a slow approach this should have been set up much earlier, regardless of any SOP detail and compliance?
So why did this occur? Well interestingly the other two localiser 09 approaches the commander made to Sumburgh included in the AAIB report showed similar higher speed at the start of the approach. But the difference here was far better weather – eg 900ft cloudbase – which meant that the commander was under no pressure to slow and not bothered about getting in on around minimums, so got visual still at 110kts ish and slowed much later to land VFR. It seemed that he adopted a similar early approach technique but this time belatedly intended to implement his objective of a 80kt approach, with catastrophic consequences.
The intercom chat between PF and PM to me demonstrated a dangerous blend of awareness of the weather being minimums and being challenging, yet with the slightly nervous banter and bravado of a crew trying to gloss it over and treat it too casually so neither wanted to appear too concerned to the other. I see this as a real hazard of multi crew operations – the obligation to have bandwidth to communicate as well as just concentrate on what matters flying the aircraft safely, with the assumption that the other guy knows what he is doing even if you’re not 100% sure. But then that’s where CRM is so important.
So in summary where am I on responsibility? I have to say much more on crew than operator systems. Sure the systems can improved, no doubt were and will continue to be. But this was not a situation in which a new operating system had resulted in an accident pretty soon after implementation. No doubt thousands of flights and IFR approaches had been previously carried out successfully using the operators systems, many with less experienced crew. I think we all feel for the crew’s angst from this, and also know we all make mistakes. But I also think an important way to minimise this, and hopefully eliminate the big ones, is for us all to understand how much responsibility rests on our own shoulders and not to be too quick to pass the buck to an inadequate environment.
I’ve never flown North Sea, or even really any multi crew, but have flown a lot of SP IFR obviously on twins in corporate ops. Skimming through the accident report again, the following seem key points. Firstly there was clearly woefully inadequate monitoring of airspeed by the crew. The need to do this on any approach, IFR or not, is clearly a fundamental piloting skill that you learn before you even go solo when training for your first licence. However as we all know, when IMC with the lack of visual cues, the scan becomes essential to ensure this. I think pretty much all of us agree that coupling to IAS not VS is a far better way to conduct an approach on 3 axis. However using VS is not disastrous – I used to use it, and clearly thousands of IFR approaches have been successfully made using it. What is used should just highlight what is left for the pilots to focus on and monitor. Being basic, with this localiser DME approach using VS, the pilots do not have to really monitor roll/heading or vertical speed, as these were coupled. The one main thing they did have to monitor closely was airspeed, and control it with collective. Even height was secondary, at least in the early stages of the approach, as it should have been more or less right given they started from a set known distance, height and VS – had the airspeed been in the window. So why didn’t the PF do this? Well, amongst the considerable chat between the crew which included bits of briefings, there was no mention at all of the fact that they were doing a VS coupled approach so that monitoring IAS was their number one priority. Of course the PF should have known this – basic stuff – and almost certainly did, but he certainly didn’t seem focussed on it at the critical time. And there was quite a bit of non-pertinent chat before the approach started. I’ll come back to this.
What made the need to monitor IAS carefully far more important than normal was they had not truly established a stabilised approach far enough out. According to the AAIB report, they had. And indeed technically they had, according to the definition. But this is an example of where reliance on the specifics of ever more extensive documentation can be counter-productive, eroding the responsibility for intelligent thought and judgement. When 1000ft at circa 3 miles they were at 108kts – upper end of the SOPs 80kt -120kt window. Right height, right course, right descent rate. But the PF had said that as the weather was on minimums, he would slow the approach to 80kts. So he only had a mile or two to slow a ? 7 tonne helicopter from 108kts to 80kts. Which clearly was going to take a big reduction in torque, which would then have to be partly reapplied to maintain the 80kts. Hardly a stabilised situation. And going to need close monitoring of AIS throughout, until a properly stabilised approach was achieved, belatedly. Surely a 10,500 hour commander with a 3000 co-pilot hour should have known that especially given the marginal weather and desire for a slow approach this should have been set up much earlier, regardless of any SOP detail and compliance?
So why did this occur? Well interestingly the other two localiser 09 approaches the commander made to Sumburgh included in the AAIB report showed similar higher speed at the start of the approach. But the difference here was far better weather – eg 900ft cloudbase – which meant that the commander was under no pressure to slow and not bothered about getting in on around minimums, so got visual still at 110kts ish and slowed much later to land VFR. It seemed that he adopted a similar early approach technique but this time belatedly intended to implement his objective of a 80kt approach, with catastrophic consequences.
The intercom chat between PF and PM to me demonstrated a dangerous blend of awareness of the weather being minimums and being challenging, yet with the slightly nervous banter and bravado of a crew trying to gloss it over and treat it too casually so neither wanted to appear too concerned to the other. I see this as a real hazard of multi crew operations – the obligation to have bandwidth to communicate as well as just concentrate on what matters flying the aircraft safely, with the assumption that the other guy knows what he is doing even if you’re not 100% sure. But then that’s where CRM is so important.
So in summary where am I on responsibility? I have to say much more on crew than operator systems. Sure the systems can improved, no doubt were and will continue to be. But this was not a situation in which a new operating system had resulted in an accident pretty soon after implementation. No doubt thousands of flights and IFR approaches had been previously carried out successfully using the operators systems, many with less experienced crew. I think we all feel for the crew’s angst from this, and also know we all make mistakes. But I also think an important way to minimise this, and hopefully eliminate the big ones, is for us all to understand how much responsibility rests on our own shoulders and not to be too quick to pass the buck to an inadequate environment.
It has been interesting to read of the recent debate here, which broadly agrees that the crew made the mistake(s) that caused the accident, but differs on who was to mainly to blame. It seems HC leads the lack of adequate SOPs and CRM view so therefore the fault of the operating organisation, and Crab the pilots made errors they never should have view.
I’ve never flown North Sea, or even really any multi crew, but have flown a lot of SP IFR obviously on twins in corporate ops. Skimming through the accident report again, the following seem key points. Firstly there was clearly woefully inadequate monitoring of airspeed by the crew. The need to do this on any approach, IFR or not, is clearly a fundamental piloting skill that you learn before you even go solo when training for your first licence. However as we all know, when IMC with the lack of visual cues, the scan becomes essential to ensure this. I think pretty much all of us agree that coupling to IAS not VS is a far better way to conduct an approach on 3 axis. However using VS is not disastrous – I used to use it, and clearly thousands of IFR approaches have been successfully made using it. What is used should just highlight what is left for the pilots to focus on and monitor. Being basic, with this localiser DME approach using VS, the pilots do not have to really monitor roll/heading or vertical speed, as these were coupled. The one main thing they did have to monitor closely was airspeed, and control it with collective. Even height was secondary, at least in the early stages of the approach, as it should have been more or less right given they started from a set known distance, height and VS – had the airspeed been in the window. So why didn’t the PF do this? Well, amongst the considerable chat between the crew which included bits of briefings, there was no mention at all of the fact that they were doing a VS coupled approach so that monitoring IAS was their number one priority. Of course the PF should have known this – basic stuff – and almost certainly did, but he certainly didn’t seem focussed on it at the critical time. And there was quite a bit of non-pertinent chat before the approach started. I’ll come back to this.
What made the need to monitor IAS carefully far more important than normal was they had not truly established a stabilised approach far enough out. According to the AAIB report, they had. And indeed technically they had, according to the definition. But this is an example of where reliance on the specifics of ever more extensive documentation can be counter-productive, eroding the responsibility for intelligent thought and judgement. When 1000ft at circa 3 miles they were at 108kts – upper end of the SOPs 80kt -120kt window. Right height, right course, right descent rate. But the PF had said that as the weather was on minimums, he would slow the approach to 80kts. So he only had a mile or two to slow a ? 7 tonne helicopter from 108kts to 80kts. Which clearly was going to take a big reduction in torque, which would then have to be partly reapplied to maintain the 80kts. Hardly a stabilised situation. And going to need close monitoring of AIS throughout, until a properly stabilised approach was achieved, belatedly. Surely a 10,500 hour commander with a 3000 co-pilot hour should have known that especially given the marginal weather and desire for a slow approach this should have been set up much earlier, regardless of any SOP detail and compliance?
So why did this occur? Well interestingly the other two localiser 09 approaches the commander made to Sumburgh included in the AAIB report showed similar higher speed at the start of the approach. But the difference here was far better weather – eg 900ft cloudbase – which meant that the commander was under no pressure to slow and not bothered about getting in on around minimums, so got visual still at 110kts ish and slowed much later to land VFR. It seemed that he adopted a similar early approach technique but this time belatedly intended to implement his objective of a 80kt approach, with catastrophic consequences.
The intercom chat between PF and PM to me demonstrated a dangerous blend of awareness of the weather being minimums and being challenging, yet with the slightly nervous banter and bravado of a crew trying to gloss it over and treat it too casually so neither wanted to appear too concerned to the other. I see this as a real hazard of multi crew operations – the obligation to have bandwidth to communicate as well as just concentrate on what matters flying the aircraft safely, with the assumption that the other guy knows what he is doing even if you’re not 100% sure. But then that’s where CRM is so important.
So in summary where am I on responsibility? I have to say much more on crew than operator systems. Sure the systems can improved, no doubt were and will continue to be. But this was not a situation in which a new operating system had resulted in an accident pretty soon after implementation. No doubt thousands of flights and IFR approaches had been previously carried out successfully using the operators systems, many with less experienced crew. I think we all feel for the crew’s angst from this, and also know we all make mistakes. But I also think an important way to minimise this, and hopefully eliminate the big ones, is for us all to understand how much responsibility rests on our own shoulders and not to be too quick to pass the buck to an inadequate environment.
I’ve never flown North Sea, or even really any multi crew, but have flown a lot of SP IFR obviously on twins in corporate ops. Skimming through the accident report again, the following seem key points. Firstly there was clearly woefully inadequate monitoring of airspeed by the crew. The need to do this on any approach, IFR or not, is clearly a fundamental piloting skill that you learn before you even go solo when training for your first licence. However as we all know, when IMC with the lack of visual cues, the scan becomes essential to ensure this. I think pretty much all of us agree that coupling to IAS not VS is a far better way to conduct an approach on 3 axis. However using VS is not disastrous – I used to use it, and clearly thousands of IFR approaches have been successfully made using it. What is used should just highlight what is left for the pilots to focus on and monitor. Being basic, with this localiser DME approach using VS, the pilots do not have to really monitor roll/heading or vertical speed, as these were coupled. The one main thing they did have to monitor closely was airspeed, and control it with collective. Even height was secondary, at least in the early stages of the approach, as it should have been more or less right given they started from a set known distance, height and VS – had the airspeed been in the window. So why didn’t the PF do this? Well, amongst the considerable chat between the crew which included bits of briefings, there was no mention at all of the fact that they were doing a VS coupled approach so that monitoring IAS was their number one priority. Of course the PF should have known this – basic stuff – and almost certainly did, but he certainly didn’t seem focussed on it at the critical time. And there was quite a bit of non-pertinent chat before the approach started. I’ll come back to this.
What made the need to monitor IAS carefully far more important than normal was they had not truly established a stabilised approach far enough out. According to the AAIB report, they had. And indeed technically they had, according to the definition. But this is an example of where reliance on the specifics of ever more extensive documentation can be counter-productive, eroding the responsibility for intelligent thought and judgement. When 1000ft at circa 3 miles they were at 108kts – upper end of the SOPs 80kt -120kt window. Right height, right course, right descent rate. But the PF had said that as the weather was on minimums, he would slow the approach to 80kts. So he only had a mile or two to slow a ? 7 tonne helicopter from 108kts to 80kts. Which clearly was going to take a big reduction in torque, which would then have to be partly reapplied to maintain the 80kts. Hardly a stabilised situation. And going to need close monitoring of AIS throughout, until a properly stabilised approach was achieved, belatedly. Surely a 10,500 hour commander with a 3000 co-pilot hour should have known that especially given the marginal weather and desire for a slow approach this should have been set up much earlier, regardless of any SOP detail and compliance?
So why did this occur? Well interestingly the other two localiser 09 approaches the commander made to Sumburgh included in the AAIB report showed similar higher speed at the start of the approach. But the difference here was far better weather – eg 900ft cloudbase – which meant that the commander was under no pressure to slow and not bothered about getting in on around minimums, so got visual still at 110kts ish and slowed much later to land VFR. It seemed that he adopted a similar early approach technique but this time belatedly intended to implement his objective of a 80kt approach, with catastrophic consequences.
The intercom chat between PF and PM to me demonstrated a dangerous blend of awareness of the weather being minimums and being challenging, yet with the slightly nervous banter and bravado of a crew trying to gloss it over and treat it too casually so neither wanted to appear too concerned to the other. I see this as a real hazard of multi crew operations – the obligation to have bandwidth to communicate as well as just concentrate on what matters flying the aircraft safely, with the assumption that the other guy knows what he is doing even if you’re not 100% sure. But then that’s where CRM is so important.
So in summary where am I on responsibility? I have to say much more on crew than operator systems. Sure the systems can improved, no doubt were and will continue to be. But this was not a situation in which a new operating system had resulted in an accident pretty soon after implementation. No doubt thousands of flights and IFR approaches had been previously carried out successfully using the operators systems, many with less experienced crew. I think we all feel for the crew’s angst from this, and also know we all make mistakes. But I also think an important way to minimise this, and hopefully eliminate the big ones, is for us all to understand how much responsibility rests on our own shoulders and not to be too quick to pass the buck to an inadequate environment.
Yes of course the pilots should have been monitoring the airspeed more closely. But as I have intimated, humans make mistakes and the whole point of SOPs and multi-pilot ops is to reduce the severity of a mistake to the point that it becomes inconsequential. Nor is it “back and white” - yes lots of people including this crew, had made approaches along the same lines without incident. But that doesn’t really matter. The question should be, were the SOPs and MCC reasonably optimal to prevent a mistake from becoming catastrophic - that being the duty of an operator, surely? I suggest the answer is No.
So when the **** hit the fan and the circumstances and mistakes lined up, did the company SOPs help avoid a catastrophe? No.
And what about the training programme. Had the copilot ever had any formal training about the role of PM during an onshore instrument approach? I’m not sure, but I strongly suspect not. This, as I said earlier, due to a regulatory obsession with the PF role despite it being a multi-pilot helicopter. I well remember the standard briefing for many years given by the examiner to a crew undergoing a check in the sim - “The copilot will be competent but without showing any initiative”. What a great way to train for PM role!
And whilst I am on about the regulator, for years the regulator disallowed automation to be used during checks. The autopilot was deemed to be in the mythical state whereby the basic stabilisation, attitude hold, maintaining current heading hold and co-ordinated turn were all functional, but altitude hold, IAS hold, selected heading hold and coupling to nav, ILS, VOR were all deemed inoperative. So all the training was about manual flying, none of it was about correct use of automation. How crazy is that!?
By 2013 in our company, due to a lot of fighting by me and a sensible flight ops inspector, we were eventually allowed to use the automation as intended during checks on the 225 fleet. But it was a major struggle and one which I’m not sure CHC ever fought or won.
So yes the pilots should have monitored airspeed better and should have been coupled to IAS, but their safety net in terms of company SOPs and the culture extant both in the company and the regulator, failed them and their passengers.
Your individual points are all valid of course, but I come to a different overall conclusion.
Yes of course the pilots should have been monitoring the airspeed more closely. But as I have intimated, humans make mistakes and the whole point of SOPs and multi-pilot ops is to reduce the severity of a mistake to the point that it becomes inconsequential. Nor is it “back and white” - yes lots of people including this crew, had made approaches along the same lines without incident. But that doesn’t really matter. The question should be, were the SOPs and MCC reasonably optimal to prevent a mistake from becoming catastrophic - that being the duty of an operator, surely? I suggest the answer is No.
Yes of course the pilots should have been monitoring the airspeed more closely. But as I have intimated, humans make mistakes and the whole point of SOPs and multi-pilot ops is to reduce the severity of a mistake to the point that it becomes inconsequential. Nor is it “back and white” - yes lots of people including this crew, had made approaches along the same lines without incident. But that doesn’t really matter. The question should be, were the SOPs and MCC reasonably optimal to prevent a mistake from becoming catastrophic - that being the duty of an operator, surely? I suggest the answer is No.
If both pilots aren't doing their job, then SOPs are irrelevant. In this case, as recently brought up, the PF wasn't abiding by SOPs anyways as both crew had their heads out of the cockpit simultaneously.
I feel like we all agree that the SOPs could have been better - I'm yet to see someone make a claim to the contrary, but while I believe that the crew's performance on this approach most likely would have led to an accident regardless of the SOPs, I get the impression that you seem to believe that with both crew staring out of window and no eyes on the flight parameters, that a different set of SOPs would have stopped them from hitting the water.
I concede to your point (highlighted in bold), maybe with different automation guidelines they might have been able to pull it out of the bag once the EGPWS starting howling if the IAS had been kept above ETL by virtue of different SOPs, but I believe to say that the crew were simply victims here is going too far. As crab stated, they were negligent. Not wilfully, but negligent in their responsibility as flight crew members nonetheless.
And whilst I am on about the regulator, for years the regulator disallowed automation to be used during checks. The autopilot was deemed to be in the mythical state whereby the basic stabilisation, attitude hold, maintaining current heading hold and co-ordinated turn were all functional, but altitude hold, IAS hold, selected heading hold and coupling to nav, ILS, VOR were all deemed inoperative. So all the training was about manual flying, none of it was about correct use of automation. How crazy is that!?
By 2013 in our company, due to a lot of fighting by me and a sensible flight ops inspector, we were eventually allowed to use the automation as intended during checks on the 225 fleet. But it was a major struggle and one which I’m not sure CHC ever fought or won.
So yes the pilots should have monitored airspeed better and should have been coupled to IAS, but their safety net in terms of company SOPs and the culture extant both in the company and the regulator, failed them and their passengers.
By 2013 in our company, due to a lot of fighting by me and a sensible flight ops inspector, we were eventually allowed to use the automation as intended during checks on the 225 fleet. But it was a major struggle and one which I’m not sure CHC ever fought or won.
So yes the pilots should have monitored airspeed better and should have been coupled to IAS, but their safety net in terms of company SOPs and the culture extant both in the company and the regulator, failed them and their passengers.
At the time of the As332L2 introduction - and even the 225 later - the CAA were in the absolute dark ages when it came to policy on the use of automation and FMS in training and testing for RW aircraft, despite an entirely logical and appropriate attitude for FW for many years. Consequently, the associated SOPs were poorly developed and were not actually used during testing/checking, as the pilots were busy hand flying as if they were in an S61!
I well remember seeing the minutes of a meeting of the CAA Training Standards Liaison (with industry heads of training) Group in 2004, when it was stated that the use of ALT hold could be condoned whilst writing down the ATIS! Can you imagine where BA would have been at that time? They certainly didn't have their B777 pilots hand flying approaches and following green needles.
As HC says, it was the lobbying by him and his company, plus the increased exposure of CAA Ops Inspectors to line flying these newer machines, that led to a change in policy. As a UK TRE, introducing the EC155 into service, I wrote to the CAA Head of Training and Standards around 2002 querying this very subject. To this day, I wish I had printed and framed his response. As we were not actually operating under that regulatory environment I carried on and did what I thought was right - and our actual regulator's inspectors, who had purely FW airlines backgrounds, did not bat an eyelid when observing our simulator sessions. To his credit, a few years later he was on the S92 JOEB, and had a 180 degrees change of view.
That said, I am as bemused as anybody as to how there was such a breakdown in monitoring. Regardless of the IAS, there would have been other cues too - pitch attitude, wind noise, rotor noise, 'seat of the pants' rate of descent increase. All in all, very sad.
So let’s re-run the approach with the same crew, same weather, same monitoring of IAS but with one difference - SOP mandated, and company culture supported, the use of IAS mode during such approaches. The accident would not have happened. I’m not sure how much clearer it could be!
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But HC surely the issue here is not primarily on whether IAS or VS coupling was used - it is that the crew were supposed to be monitoring a parameter and weren’t. With AIS hold, that type of error could have caused them to not monitor VS sufficiently with the result they dived the aircraft into the sea with a grossly excessive ROD and not enough time to recover.
DB
I would think that it was because they were horrified that a licensed, professional crew could make such fundamental errors and needed to find out why this crew did things so badly compared to others. I'm sure the CAA inspector's first thought on this was 'How the f*** did they manage that?'
HC
If your pilots aren't going to follow SOPs anyway, what difference would it make? It was so much more than just the use of VS mode, it was, as rotorspeed highlights, their whole attitude to the approach that was wrong.
You can't absolve them of their responsibility to fly the F'ing aircraft - that doesn't need to be in SOPs, that is a BASIC tenet of airmanship.
Rotorspeed - great post last but one, very reasoned
CRAB, please explain why, after this accident, the CAA launched an investigation into HOFO procedures AND substantial changes were made to all Operator's SOPs.
HC
So let’s re-run the approach with the same crew, same weather, same monitoring of IAS but with one difference - SOP mandated, and company culture supported, the use of IAS mode during such approaches. The accident would not have happened. I’m not sure how much clearer it could be!
You can't absolve them of their responsibility to fly the F'ing aircraft - that doesn't need to be in SOPs, that is a BASIC tenet of airmanship.
Rotorspeed - great post last but one, very reasoned
But HC surely the issue here is not primarily on whether IAS or VS coupling was used - it is that the crew were supposed to be monitoring a parameter and weren’t. With AIS hold, that type of error could have caused them to not monitor VS sufficiently with the result they dived the aircraft into the sea with a grossly excessive ROD and not enough time to recover.
Just like a fixed-wing, IAS is THE most important parameter because with adequate airspeed, the helicopter is easily controllable. With inadequate airspeed, the helicopter is barely controllable as this accident demonstrates. If the collective had been raised at the same altitude as it was raised in this accident, but with plenty of airspeed, the accident wouldn’t have happened.
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Sorry HC but I think you’re being naive here. You can’t just take exactly the same circumstances. It is the principle that matters. The wx could easily have been say 100ft base and 300m vis 1 mile out. Or even on the deck. Without VS monitoring and a high ROD they’d be in the sea. All the time pilots are allowed to be pilots, utilising judgment and skill, there will be the potential for mistakes and accidents if things are not done properly.
Thanks Crab! 👍
Thanks Crab! 👍
It is interesting that no one has mentioned the different ability to recognise changing parameters using vertical strip indicators rather than clock style ones. On a clock style indicator one just has to glance at the position of the needle to recognise a relative value. On a strip indicator, one has to actually read a numeric value and then translate that into a value which is then compared with “normal”. For example, if the 3 o'clock position on a conventional ASI relates to Vy then a glance at the gauge will ring an unconscious bell saying “I am at the point where any reduction in speed will need more power to stop an increase in ROD”. A strip indicator requires one to read a digital value, convert it to an analogue mental model and then compare that with a Flight Manual graph before concluding a consequence.
Which option do you think is the easier processing function?
Which option do you think is the easier processing function?