AS332L2 Ditching off Shetland: 23rd August 2013
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Seat changes
Why only the EC225? The seats in Bristow 225s are different to those in CHCs - don't know how Bond configure theirs.
So, will they also look at the seating in the L2s? And the 332L 'classics'?
bondu
So, will they also look at the seating in the L2s? And the 332L 'classics'?
bondu
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If the co-pilots in the company you work for aren't capable of intervening if things start to go wrong then the CRM training is insufficient or the type of co-pilot the company is recruiting is may be of the wrong type!
one co-pilot with minimum legal requirements, CRM and no experience will not act as an experienced co-pilot.
Call it as you like, on-job training or experience, the co-pilot willl be the product of the captains he flies with. CRM should work on both pilots. Crew Resource management Course continues in the cockpit. The captain himself will lead a new co-pilot to higher standards.
Last edited by vaibronco; 23rd Sep 2013 at 21:36.
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95 pages now...no suggestion there was any technical malfunction..the same helicopters are still flying so what is the conclusion?
Not a word from the crew on how the accident happened despite the fatalities.
The elephant is still in the room but being ignored.
Not a word from the crew on how the accident happened despite the fatalities.
The elephant is still in the room but being ignored.
Last edited by Ye Olde Pilot; 23rd Sep 2013 at 22:11.
As there were four Fatalities....there are two places the Pilots are going to speak....with the AAIB and in Court....ably assisted by Legal Counsel at both places I should think.
That Elephant shall remain in the Tent until the Tent is taken down and packed away till its next use....which the way things are going shall not be all that long.
That Elephant shall remain in the Tent until the Tent is taken down and packed away till its next use....which the way things are going shall not be all that long.
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I think by now all of us can guess the AAIB report.
The helicopter type was cleared to fly again very soon following the accident.
Which points the finger one way.
CFIT. Pilot Error as the tabloids would put it.
The helicopter type was cleared to fly again very soon following the accident.
Which points the finger one way.
CFIT. Pilot Error as the tabloids would put it.
Last edited by Ye Olde Pilot; 23rd Sep 2013 at 22:21.
vaibronco
Where did I say this? Don't put words into my "mouth" Read a post properly before making wild assumptions
I did say
Which tends to put forward the theory that Captains aren't always right.
Wrong - the co-pilot is a product of the company recruitment policy as well as the training departments CRM philosophy. An indiviual Captain should have no bearing on this.
I see from your profile that you are not a current NS pilot so your inaccuracies about NS ops may be excused but if you can't post accurately then don't bother posting
HF
Interesting: you assume that the captain is never wrong.
I did say
or at least when they flew with me I always encouraged them to question any "odd" decisions I made.
the co-pilot will be the product of the captains he flies with.
I see from your profile that you are not a current NS pilot so your inaccuracies about NS ops may be excused but if you can't post accurately then don't bother posting
HF
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YOP. You are at it again!!
We do not use the term "Pilot Error" anymore as it allows systemic failures to be ignored. The pilots are the last link in a very long chain of events that eventually lead to an incident or accident.
Headlining an event as "Pilot Error" neatly gets all the backsliding, penny pinching, ignorant management failings of the hook and allows them to lie dormant until the next poor sap comes along to complete the same chain.
YOP, "Yeh One-dimensional Pilot" methinks!
Hopefully the AAIB, CAA and maybe the Operator will not be as blinkered as you.
DB
We do not use the term "Pilot Error" anymore as it allows systemic failures to be ignored. The pilots are the last link in a very long chain of events that eventually lead to an incident or accident.
Headlining an event as "Pilot Error" neatly gets all the backsliding, penny pinching, ignorant management failings of the hook and allows them to lie dormant until the next poor sap comes along to complete the same chain.
YOP, "Yeh One-dimensional Pilot" methinks!
Hopefully the AAIB, CAA and maybe the Operator will not be as blinkered as you.
DB
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I think they refer more to newly built aircraft from now on, rather than refitting the aircraft already flying.
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the co-pilot is a product of the company recruitment policy as well as the training departments CRM philosophy
An individual Captain should have no bearing on this.
I see from your profile that you are not a current NS pilot so your inaccuracies about NS ops may be excused but if you can't post accurately then don't bother posting
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Funny how it's pilot error when some American slams a cheap and nasty 350 or 206 into a hill on EMS, or in the GOM, but as soon as an Englishman runs a twin ifr capable helicopter into a building, or two pilots manage to run a perfectly capable twin, ifr, no expense spared helicopter into the drink, it becomes systemic failure....
Someone has their blinkers on.
And no I don't fly in America, in the GOM, or EMS, just looking in from the outside.
Someone has their blinkers on.
And no I don't fly in America, in the GOM, or EMS, just looking in from the outside.
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It's strange how in the aviation community, people (and especially managers with no knowledge of aviation, only financing it or supposedly managing the 'sharp end personnel ) have only in fairly recent years come to realise what human factors engineers have known for years.
As far back as 1947 Fitts and Jones studied the behavious of pilots in the cockpit and showed how systematic failures in interpreting instruments and operating controls produced misassessments and actions not as intended.
There's a lot of interesting in this paper published a few years ago by Ohio State University:
http://csel.eng.ohio-state.edu/woods..._hand_chap.pdf
) have only in fairly recent years come to realise what human factors engineers have known for years.As far back as 1947 Fitts and Jones studied the behavious of pilots in the cockpit and showed how systematic failures in interpreting instruments and operating controls produced misassessments and actions not as intended.
The implicit assumption was that the person closest to the failure was the cause. Investigators saw that the aircraft was in principle flyable and that other pilots were able to fly such aircraft successfully. They could show how the necessary data were available for the pilot to correctly identify the actual situation and act in an appropriate way. Since the pilot was the human closest to the accident who could have acted differently, it seemed obvious to conclude that the pilot was the cause of the failure.
Fitts and his colleague empirically looked for factors that could have influenced the performance of the pilots. They found that, given the design of the displays and layout of the controls, people relatively often misread instruments or operated the wrong control, especially when task demands were high. The misreadings and misoperations were design-induced in the sense that researchers could link properties of interface design to these erroneous actions and assessments. In other words, the “errors” were not random events, rather they resulted from understandable, regular, and predictable aspects of the design of the tools practitioners used.
The researchers found that misreadings and misoperations occurred, but did not always lead to accidents due to two factors. First, pilots often detected these errors before negative consequences occurred. Second, the misreadings and misoperations alone did not lead directly to an accident . Disaster or near misses usually occurred only when these errors occurred in combination with other factors or other circumstances.
In the end, the constructive solution was not to conclude that pilots err, but rather to nderstand principles and techniques for the design of visual displays and control layout. Changing the artifacts used by pilots changed the demands
Fitts and his colleague empirically looked for factors that could have influenced the performance of the pilots. They found that, given the design of the displays and layout of the controls, people relatively often misread instruments or operated the wrong control, especially when task demands were high. The misreadings and misoperations were design-induced in the sense that researchers could link properties of interface design to these erroneous actions and assessments. In other words, the “errors” were not random events, rather they resulted from understandable, regular, and predictable aspects of the design of the tools practitioners used.
The researchers found that misreadings and misoperations occurred, but did not always lead to accidents due to two factors. First, pilots often detected these errors before negative consequences occurred. Second, the misreadings and misoperations alone did not lead directly to an accident . Disaster or near misses usually occurred only when these errors occurred in combination with other factors or other circumstances.
In the end, the constructive solution was not to conclude that pilots err, but rather to nderstand principles and techniques for the design of visual displays and control layout. Changing the artifacts used by pilots changed the demands
http://csel.eng.ohio-state.edu/woods..._hand_chap.pdf
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SuperF thanks for your totally pointless post.
I stand by my post however, regardless of creed, colour or Country.
What exactly is your position.......or are you too busy gobbling off to actually have one!!
DB
I stand by my post however, regardless of creed, colour or Country.
What exactly is your position.......or are you too busy gobbling off to actually have one!!
DB
SuperF
Surely that is an American problem - if you want to call it pilot error then it is up to you. If those accidents happened in the UK then the AIB would investigate and look at the chain of events that led to the accident - just because the pilot is at the end of the chain doesn't mean it is the pilot's fault.
HF
Funny how it's pilot error when some American slams a cheap and nasty 350 or 206 into a hill on EMS, or in the GOM,
HF
There's a lot of interesting in this paper published a few years ago by Ohio State University:
http://csel.eng.ohio-state.edu/woods..._hand_chap.pdf
http://csel.eng.ohio-state.edu/woods..._hand_chap.pdf
Early Episodes of “Human Error”
Consider these episodes where some stakeholders reacted to failure by
attributing the cause to “human error,” but where more careful examination
showed how a combnation of factors created the conditions for failure.1
Consider these episodes where some stakeholders reacted to failure by
attributing the cause to “human error,” but where more careful examination
showed how a combnation of factors created the conditions for failure.1
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PILOT ERROR???????????
DB
Well said . I personally feel this terminology of so called pilot error should be done away with. Why we don't we use terms like management error or company error. Why should the pilot be the only one to face the hangmans noose . In classrooms we all talk of flight safety as a chain with many links . Yet , when an accident takes place our vocabularies get limited to pilot error or technical error.
Well said . I personally feel this terminology of so called pilot error should be done away with. Why we don't we use terms like management error or company error. Why should the pilot be the only one to face the hangmans noose . In classrooms we all talk of flight safety as a chain with many links . Yet , when an accident takes place our vocabularies get limited to pilot error or technical error.
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If those accidents happened in the UK then the AIB would investigate and look at the chain of events that led to the accident - just because the pilot is at the end of the chain doesn't mean it is the pilot's fault.
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Humming frog
That is just the attitude that I'm talking about, "Surely that is an American problem"...
Doesn't seem to stop anyone else around the world having the same accidents, it's just as soon as it happens in the UK, you guys all go on the defense and personally attack anyone that disagrees with you.
Nothing is an individual country or industry segment problem. Every accident affects every one of us that is in, or wants to be in this industry. A single engine accident in the USA ripples through the entire helicopter community, like it or not, what they do affects us, what you do affects us, and what we do affects you.
Sorry, but everyone makes errors every single day, the idea is to ensure that those errors don't do harm or kill someone, and where possible minimize or eliminate those errors. We see that with two pilot, twin, ifr machines flying in the NS, as that is how they can reduce the risk, but the guy that made the error at the end of the day, put the machine in the drink, into the hill, or upside down in the trees.
To call it Pilot Error, certainly focuses the pilots mind, and he has a great influence on safety in this industry, calling it system failure or management failure lets it get washed over, and not hurt anyone's feelings....
That is just the attitude that I'm talking about, "Surely that is an American problem"...
Doesn't seem to stop anyone else around the world having the same accidents, it's just as soon as it happens in the UK, you guys all go on the defense and personally attack anyone that disagrees with you.
Nothing is an individual country or industry segment problem. Every accident affects every one of us that is in, or wants to be in this industry. A single engine accident in the USA ripples through the entire helicopter community, like it or not, what they do affects us, what you do affects us, and what we do affects you.
Sorry, but everyone makes errors every single day, the idea is to ensure that those errors don't do harm or kill someone, and where possible minimize or eliminate those errors. We see that with two pilot, twin, ifr machines flying in the NS, as that is how they can reduce the risk, but the guy that made the error at the end of the day, put the machine in the drink, into the hill, or upside down in the trees.
To call it Pilot Error, certainly focuses the pilots mind, and he has a great influence on safety in this industry, calling it system failure or management failure lets it get washed over, and not hurt anyone's feelings....
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SuperF - nice post and I agree with you. We should not ignore errors made by the crew of course as long as we are determined to understand how these errors have happened.
In the worst case it may be that a pilot is just not skilful enough, or deliberatley transgressed from the rules, but we tend to assume that in CAT, a trained and checked pilot has demonstrated sufficient skills and discipline to do the tasks he is doing.
Deconstructing complex events is our best way of trying to identify why a crew made a particular error. This can only happen in a "No Blame" culture and this should be the default status of such investigations as we assume the crew did not want the event to occur to them.
With this approach it allows the investigators, even when a Pilot has maybe been transgressing rules deliberately, to widen the net and look at "culture" that has allowed him to believe what he is doing is acceptable. The internal military inquiry into the Australian Army Blackhawks crashes is a good example of this approach.
In my experience as a pilot, instructor/examiner and regulator, we can change the rules, we can change procedure, we can even change the pilot. However, the hardest thing to change is culture!!
I am not sure Hummingfrog meant to isolate our US brethren with his comments but I agree with you SuperF, they are not appropriate.
DB
In the worst case it may be that a pilot is just not skilful enough, or deliberatley transgressed from the rules, but we tend to assume that in CAT, a trained and checked pilot has demonstrated sufficient skills and discipline to do the tasks he is doing.
Deconstructing complex events is our best way of trying to identify why a crew made a particular error. This can only happen in a "No Blame" culture and this should be the default status of such investigations as we assume the crew did not want the event to occur to them.
With this approach it allows the investigators, even when a Pilot has maybe been transgressing rules deliberately, to widen the net and look at "culture" that has allowed him to believe what he is doing is acceptable. The internal military inquiry into the Australian Army Blackhawks crashes is a good example of this approach.
In my experience as a pilot, instructor/examiner and regulator, we can change the rules, we can change procedure, we can even change the pilot. However, the hardest thing to change is culture!!
I am not sure Hummingfrog meant to isolate our US brethren with his comments but I agree with you SuperF, they are not appropriate.
DB
SuperF
The reason why "pilot error" is not used as a catch all reason for an accident in the UK is to get to the bottom of the reasons for the accident.
Yes sometimes the reason is pilot error and it won't be washed over but as you must know there are nearly always other reasons for the accident - they may be minor but we can all learn from them.
Calling the accident cause as purely pilot error can let off those in the management chain who could be contributing to the accident.
An example of this is the CAA - they mandate absolute limits for flying hours over defined periods - be it day, week, month or year. This is to try and prevent fatigue. The companies however look at these MAXIMUM hours limits as targets. What does the CAA do about this - nothing. Does it audit and look closely at which companies always fly their crews to 95%+ of the maximum - I doubt it. Why do the companies fly their crews to the maximum - money - profit!! Could this lead to accidents - maybe - will the CAA be criticised? I doubt it but they are in the chain!!
The examples you chose could be pure pilot error.
Could also have a strong management cause. For instance if the guy who put the a/c into the hill or upside down into the trees was an EMS pilot on a day VFR contract who didn't have an IR yet felt pressured by the company to get the job done. If he gave in to those pressures, then yes he was at fault for flying in weather not suitable for his qualifications, but if he feared for his job because the management expected him to get the job done then management has to accept a fair amount of blame for the accident.
The Swiss Cheese theory is nearly always present in every accident.
HF
As DB said I didn't mean to isolate the US - it was just a comment that if the US tries to blame pilots rather than look at the whole picture then that is wrong - the UK has moved away from that but if the pilot was to blame then it will come out in the investigation.
To call it Pilot Error, certainly focuses the pilots mind, and he has a great influence on safety in this industry, calling it system failure or management failure lets it get washed over, and not hurt anyone's feelings....
Yes sometimes the reason is pilot error and it won't be washed over but as you must know there are nearly always other reasons for the accident - they may be minor but we can all learn from them.
Calling the accident cause as purely pilot error can let off those in the management chain who could be contributing to the accident.
An example of this is the CAA - they mandate absolute limits for flying hours over defined periods - be it day, week, month or year. This is to try and prevent fatigue. The companies however look at these MAXIMUM hours limits as targets. What does the CAA do about this - nothing. Does it audit and look closely at which companies always fly their crews to 95%+ of the maximum - I doubt it. Why do the companies fly their crews to the maximum - money - profit!! Could this lead to accidents - maybe - will the CAA be criticised? I doubt it but they are in the chain!!
The examples you chose could be pure pilot error.
but the guy that made the error at the end of the day, put the machine in the drink, into the hill, or upside down in the trees.
The Swiss Cheese theory is nearly always present in every accident.
HF
As DB said I didn't mean to isolate the US - it was just a comment that if the US tries to blame pilots rather than look at the whole picture then that is wrong - the UK has moved away from that but if the pilot was to blame then it will come out in the investigation.
Last edited by Hummingfrog; 25th Sep 2013 at 06:47.