Police helicopter crashes onto Glasgow pub
SKadi,
Not just NPAS pilots, it's in the RFM, All pilots operating the 135.
Not just NPAS pilots, it's in the RFM, All pilots operating the 135.
So was this pilot now suddenly faced with a fuel management situation unlike anything previously experienced?
skadi
We have to remember we plan our flights to land before using any of our Reserve Fuel.
Which brings up a question for the NPAS Pilots.
In your flight planning....do you start with a No Use Minimum Fuel Quantity that is in addition to the standard Reserve Fuel.....that being "Minimum In-Flight Fuel" at which point a Precautionary Landing becomes mandatory to prevent running out of Fuel while Airborne?
If so....how much Fuel do you set aside for that?
Which brings up a question for the NPAS Pilots.
In your flight planning....do you start with a No Use Minimum Fuel Quantity that is in addition to the standard Reserve Fuel.....that being "Minimum In-Flight Fuel" at which point a Precautionary Landing becomes mandatory to prevent running out of Fuel while Airborne?
If so....how much Fuel do you set aside for that?
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I am wondering if there is something significant in the fact that the latest AAIB Bulletin makes a point of stating that of the final four tasks G-SPAO completed before the accident, the first was "non urgent", the second was "observation" and the last two were "non-urgent". I am baffled as to why, given such lack of necessity of these tasks, the fuel status was allowed to get so low. Surely any competent pilot has in his mind a background awareness of his endurance and generally monitors this, particularly as limits get closer? And at that time he double checks fuel quantity indications and is on heightened alert for any cautions or warnings. Furthermore if, due to any failures, fuel quantity indications, cautions and warnings didn't all add up, wouldn't you revert to original planned endurance as the reference?
I find it hard to believe running to such low reserves is routine for police helicopter ops, particularly when performing non-urgent tasks.
Of course it might be that the reason none of the above happened properly was also relevant to the reason an autorotation was apparently not entered into, when the (from quite predictable fuel exhaustion) double engine failure occurred.
I find it hard to believe running to such low reserves is routine for police helicopter ops, particularly when performing non-urgent tasks.
Of course it might be that the reason none of the above happened properly was also relevant to the reason an autorotation was apparently not entered into, when the (from quite predictable fuel exhaustion) double engine failure occurred.
AOF, Thanks for your comments. I really am concerned that the extended mission ranges just might be one of the causational factors here!
I have been around the 135 for most of its 10 years and know fairly well what is a typical mission profile for a large proportion of the fleet, And they are not long missions!
Suddenly the rules have changed, and as a result the missions must be getting longer, making fuel management issues much more of a factor than before.
Its just too easy to dismiss that possibility as being one of the factors that made up the chain of events that culminated in >>>>>>>.
TF
I have been around the 135 for most of its 10 years and know fairly well what is a typical mission profile for a large proportion of the fleet, And they are not long missions!
Suddenly the rules have changed, and as a result the missions must be getting longer, making fuel management issues much more of a factor than before.
Its just too easy to dismiss that possibility as being one of the factors that made up the chain of events that culminated in >>>>>>>.
TF
Purveyor of Egg Liqueur to Lucifer
Sasless;
I think the answer to your question is that we have to be on the ground with a minimum of 60kg day / 90kg night. That's one figure called the 'Minimum Landing Allowance'.
(different operators may have different MLA's)
Whether that's in a field or at a refuel facility, simple
"'No Use Minimum Fuel Quantity', 'Standard Reserve Fuel', 'Minimum In-Flight Fuel'"
Whats all that about!
Why use one phrase when you can have three!
Which brings up a question for the NPAS Pilots.
In your flight planning....do you start with a No Use Minimum Fuel Quantity that is in addition to the standard Reserve Fuel.....that being "Minimum In-Flight Fuel" at which point a Precautionary Landing becomes mandatory to prevent running out of Fuel while Airborne?
In your flight planning....do you start with a No Use Minimum Fuel Quantity that is in addition to the standard Reserve Fuel.....that being "Minimum In-Flight Fuel" at which point a Precautionary Landing becomes mandatory to prevent running out of Fuel while Airborne?
(different operators may have different MLA's)
Whether that's in a field or at a refuel facility, simple
"'No Use Minimum Fuel Quantity', 'Standard Reserve Fuel', 'Minimum In-Flight Fuel'"
Whats all that about!Why use one phrase when you can have three!
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90kg at night?
So, either the pilot thought he had more fuel than he actually did (regardless of dispersal within the fuel system) or he was knowingly already breaking one of the rules before the engines failed.
I suppose that brings the investigation back to what the displays were telling him.
So, either the pilot thought he had more fuel than he actually did (regardless of dispersal within the fuel system) or he was knowingly already breaking one of the rules before the engines failed.
I suppose that brings the investigation back to what the displays were telling him.
Sid....no matter you used a fourth name....the concept is the same.
Using your figure of 90 Kgs "Minimum Landing Allowance"....is it safe to say had that mandate to Land upon reaching the MLA Fuel level been complied with, we would not be having this discussion extant?
How far into the Supply Tanks would that be?
Did the aircraft over fly or fly by locations a safe landing could have been made, and should have been made respective to the MLA Fuel Requirement?
Does NPAS take disciplinary action when Pilots land with less than MLA Fuel?
Better question is does NPAS take Disciplinary Action (even unofficial action) if a Pilot makes a precautionary landing due to lack of fuel?
Using your figure of 90 Kgs "Minimum Landing Allowance"....is it safe to say had that mandate to Land upon reaching the MLA Fuel level been complied with, we would not be having this discussion extant?
How far into the Supply Tanks would that be?
Did the aircraft over fly or fly by locations a safe landing could have been made, and should have been made respective to the MLA Fuel Requirement?
Does NPAS take disciplinary action when Pilots land with less than MLA Fuel?
Better question is does NPAS take Disciplinary Action (even unofficial action) if a Pilot makes a precautionary landing due to lack of fuel?
By just screwing up the flare you would probably not be able to effectively stop the rotor prior to impact.
even with a stalled rotor that would take a couple of seconds (somewhere >5s, up to 10s).
Unfortunately it appears something went wrong during entry into AR (delayed for whatever reason to a point where RRPM was so low that recovery was too slow/impossible).
Hence my initial question regarding the error message of the A/P.
Deep, deep back in my mind I had a scenario where the pilot had engaged A/P to allow himself to troubleshoot/anaylse the problem (e.g. the fuel situation) when suddenly the second engine quit. Him having flown that type for quite some time in similar missions would have him not expecting to completely run out of fuel at that flight time. This might have led him to assume some sort of technical problem rather than a straight forward fuel problem.
Regaining situational awareness while under NVG, checking switches on the overhead panel or other things when suddenly it becomes quiet I could imagine would be quite disorienting. I could imagine something like this could slightly delay an entry into AR.
The EC135 has a rather low inertia rotor, so I ssume delaying of entry into AR of much more than 1 or 2s would probably lead to an RRPM in the critical range.
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Here's a real stoopid hypothesis based on my distrust of computers.
Many a time we have seen competent pilots put their faith in what the pretty computer graphic is displaying and initially ignore warning lights and gongs generated from completely separate sensing systems.
Can the main tank qty display get out of calibration and read 0kg left when there is in fact actually 75kg available? Can the main tank qty reading go backwards without a reset after registering a 0kg reading?
Pilot switches off XFER pumps when 0kg/main is shown on the pretty computer graphic unaware that the logic that drives the fuel qty display has gotten all confused and produced an incorrect indication that eventually conflicts with the final safety net of caption and aural alerts.
Pilot knowledge of the separate circuits for fuel captions and aural alerts is probably up to date however familiarity with endurance of the machine compels the pilot to believe that their is fuel available, so pilot makes the assumption that the captions are probably wrong and ignores the FM procedures to land immediately, after all that pretty computer graphic is so convincing, not to mention home base is only a few minutes away.
Unfortunately this hypothesis doesn't explain why after the loss of the first engine the pilot didn't put two and two together and immediately lose all faith in that pretty computer graphic.
This is the bit that is really hard to understand, but we have all heard and read about these kinds of incidents of continuing in the face of multiple warning indications many times before.
Many a time we have seen competent pilots put their faith in what the pretty computer graphic is displaying and initially ignore warning lights and gongs generated from completely separate sensing systems.
Can the main tank qty display get out of calibration and read 0kg left when there is in fact actually 75kg available? Can the main tank qty reading go backwards without a reset after registering a 0kg reading?
Pilot switches off XFER pumps when 0kg/main is shown on the pretty computer graphic unaware that the logic that drives the fuel qty display has gotten all confused and produced an incorrect indication that eventually conflicts with the final safety net of caption and aural alerts.
Pilot knowledge of the separate circuits for fuel captions and aural alerts is probably up to date however familiarity with endurance of the machine compels the pilot to believe that their is fuel available, so pilot makes the assumption that the captions are probably wrong and ignores the FM procedures to land immediately, after all that pretty computer graphic is so convincing, not to mention home base is only a few minutes away.
Unfortunately this hypothesis doesn't explain why after the loss of the first engine the pilot didn't put two and two together and immediately lose all faith in that pretty computer graphic.
This is the bit that is really hard to understand, but we have all heard and read about these kinds of incidents of continuing in the face of multiple warning indications many times before.
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I agree henry, but in my mind the only thing that could have caused an experienced pilot to ignore the final safety net of warning captions and gongs would be conflicting advice from the computer screen which was falsely supported by endurance experience on that type.
More integrity in modern avionics yes but often restricted to operating within known constraints.
More integrity in modern avionics yes but often restricted to operating within known constraints.
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A thought:
A couple of decades ago, when I was flying in a virtually identical role, in a BO105, (very similar fuel system?) of course we also had a MLA/Reserve. I have a vague recollection at that time it was 20kgs per side (I stand to be corrected)
On more than one occasion, whilst involved in important tasking, I offered the observer a choice. Either pull off the developing task and RTB, or continue with the tasking, on the understanding we would have insufficient fuel to RTB and would be landing in a field. (day or night)
On occasion we continued with the important tasking, but with a cast iron bottom line of 20kgs on either side. On reflection, it's possible I was too trusting of the accuracy of the indications available to me.
In my situation, I was able to offer that choice because we always had a duty observer back in our office with a fuel trailer and a Land Rover. We were never more than 60 minutes away from having fuel brought to us! That helped the decision making enormously.
Was such a facility available in Glasgow? Was the tasking important? Was there any pressure to extend the flight to the maximum? The operational radio conversations will undoubtedly provide some kind of insight.
I still find it incredibly difficult to believe that we are dealing here with a pilot who simply mismanaged the fuel system, and subsequent autorotation to the extent being suggested. In fact I won't believe it until I read the AAIB's final report.
Of course I accept that we are all human, and the best of us occasionally perform in ways that are difficult to understand. But I think the pilot concerned will deserve the benefit of the doubt if there is indeed any doubt at all at the end of the AAIB's investigation. I am of course aware that this tragedy has touched many lives, but on top of that, I will feel absolutely gutted for Captain Trail if the accident turns out to have been avoidable.
A couple of decades ago, when I was flying in a virtually identical role, in a BO105, (very similar fuel system?) of course we also had a MLA/Reserve. I have a vague recollection at that time it was 20kgs per side (I stand to be corrected)
On more than one occasion, whilst involved in important tasking, I offered the observer a choice. Either pull off the developing task and RTB, or continue with the tasking, on the understanding we would have insufficient fuel to RTB and would be landing in a field. (day or night)
On occasion we continued with the important tasking, but with a cast iron bottom line of 20kgs on either side. On reflection, it's possible I was too trusting of the accuracy of the indications available to me.
In my situation, I was able to offer that choice because we always had a duty observer back in our office with a fuel trailer and a Land Rover. We were never more than 60 minutes away from having fuel brought to us! That helped the decision making enormously.
Was such a facility available in Glasgow? Was the tasking important? Was there any pressure to extend the flight to the maximum? The operational radio conversations will undoubtedly provide some kind of insight.
I still find it incredibly difficult to believe that we are dealing here with a pilot who simply mismanaged the fuel system, and subsequent autorotation to the extent being suggested. In fact I won't believe it until I read the AAIB's final report.
Of course I accept that we are all human, and the best of us occasionally perform in ways that are difficult to understand. But I think the pilot concerned will deserve the benefit of the doubt if there is indeed any doubt at all at the end of the AAIB's investigation. I am of course aware that this tragedy has touched many lives, but on top of that, I will feel absolutely gutted for Captain Trail if the accident turns out to have been avoidable.
Pardon me.....but the critical fuel level is not the Main Tank but rather is the Supply Tank level.
There are any number of things that can happen to fuel transfer from the Main Tank to the Supply Tanks....but the crucial thing is the amount of fuel actually in the Supply Tanks.
At some point the Supply Tanks will start showing a decrease in quantity as the Transfer of fuel ceases for whatever reason.
Shortly after that happens.....some caution lights illuminate, then some warning lights illuminate, and at various times Warning Horns start sounding.
Add in the Operational Procedure re Minimum Landing Allowance Fuel as reported by Sid.....and one must question the Pilot's Actions.
If the Low Fuel Warnings were occurring prematurely....and there was fuel left in the Main Tank....but the Supply Tanks were showing a decreasing Quantity.....the Landing Criteria was met.....no matter the reason....it was met.
If confronted with multiple indications of decreasing fuel levels in the Supply Tanks..... which confirms a fuel quantity below the MLA Fuel Level for Night Flight.....the correct course of action would have been to carry out a Precautionary Landing.
The Pilot did not land.
Plainly he decided to make for the heliport and did not make it.
How many of us have never done a similar thing?
There are any number of things that can happen to fuel transfer from the Main Tank to the Supply Tanks....but the crucial thing is the amount of fuel actually in the Supply Tanks.
At some point the Supply Tanks will start showing a decrease in quantity as the Transfer of fuel ceases for whatever reason.
Shortly after that happens.....some caution lights illuminate, then some warning lights illuminate, and at various times Warning Horns start sounding.
Add in the Operational Procedure re Minimum Landing Allowance Fuel as reported by Sid.....and one must question the Pilot's Actions.
If the Low Fuel Warnings were occurring prematurely....and there was fuel left in the Main Tank....but the Supply Tanks were showing a decreasing Quantity.....the Landing Criteria was met.....no matter the reason....it was met.
If confronted with multiple indications of decreasing fuel levels in the Supply Tanks..... which confirms a fuel quantity below the MLA Fuel Level for Night Flight.....the correct course of action would have been to carry out a Precautionary Landing.
The Pilot did not land.
Plainly he decided to make for the heliport and did not make it.
How many of us have never done a similar thing?
Purveyor of Egg Liqueur to Lucifer
Sasless;
Just to get the facts right ref NPAS here.
The Scottish aircraft is operated by Bond for the Scottish Police, NPAS is not involved in this incident apart from the cover they provided afterwards.
To your questions -
As can be read on the latest bulletin, that of course you've read as a footnote to page 2, the operators 'Final Reserve Fuel', "being the minimum amount of fuel with which pilots should plan to land with" was 85kg.
Yes it is safe to say that if that was complied with, we would not be having this discussion. (assuming of course all indications were correct)
Landing with 90 kgs would leave both supply tanks full at 47 & 43 kg's respectively. Landing with 85kgs would mean using 5 kgs of the supply tanks fuel.
You can look at google maps as well as the rest of us!
I'm not part of that food chain, however I like to think that we are in a culture that would rather a pilot landed in a field on minimums, than to press on. (especially with the larger areas of cover now required)
Personally I would give the pilot a pat on the back, a well done and a 'now lets have a look at this', than pursue any disciplinary action.
Every day is a learning day!
Just to get the facts right ref NPAS here.
The Scottish aircraft is operated by Bond for the Scottish Police, NPAS is not involved in this incident apart from the cover they provided afterwards.
To your questions -
Using your figure of 90 Kgs "Minimum Landing Allowance"....is it safe to say had that mandate to Land upon reaching the MLA Fuel level been complied with, we would not be having this discussion extant?
Yes it is safe to say that if that was complied with, we would not be having this discussion. (assuming of course all indications were correct)
How far into the Supply Tanks would that be?
Did the aircraft over fly or fly by locations a safe landing could have been made, and should have been made respective to the MLA Fuel Requirement?
Does NPAS take disciplinary action when Pilots land with less than MLA Fuel?
Better question is does NPAS take Disciplinary Action (even unofficial action) if a Pilot makes a precautionary landing due to lack of fuel?
Better question is does NPAS take Disciplinary Action (even unofficial action) if a Pilot makes a precautionary landing due to lack of fuel?
Personally I would give the pilot a pat on the back, a well done and a 'now lets have a look at this', than pursue any disciplinary action.
Every day is a learning day!
Purveyor of Egg Liqueur to Lucifer
Sasless:
Ref your last post, the actions for when the LOW FUEL 1 and/or LOW FUEL 2 warnings with "Gong" come on are;
Fuel Contents…………...Check
If positive indication in min tank
XFER pumps………………...Check ON
Circuit breakers…………..Check IN
If FUEL LOW light remains ON
Bleed air switch…………..Switch OFF (if >5deg C)
LAND WITHIN 10 MINUTES
However, what we have here is; XFER pumps off and PRIME pumps on.
Ref your last post, the actions for when the LOW FUEL 1 and/or LOW FUEL 2 warnings with "Gong" come on are;
Fuel Contents…………...Check
If positive indication in min tank
XFER pumps………………...Check ON
Circuit breakers…………..Check IN
If FUEL LOW light remains ON
Bleed air switch…………..Switch OFF (if >5deg C)
LAND WITHIN 10 MINUTES
However, what we have here is; XFER pumps off and PRIME pumps on.
Purveyor of Egg Liqueur to Lucifer
I'm not saying we're going round and round again, but ….
I learnt a very apt phrase last night while watching an article about a recent Stephen Hawking paper, where apparently it has been reported that he says that "There are no Black Holes"
Here, as well as in the science reporting community, we have a simple hurdle.
In the science community it is the theoretical physics papers, in our case it is the Flight Manuals, AAIB reports, this thread, the 135 thread etc etc; but the phrase is the same;
TL : DR
Too long, didn't read!
Here, as well as in the science reporting community, we have a simple hurdle.
In the science community it is the theoretical physics papers, in our case it is the Flight Manuals, AAIB reports, this thread, the 135 thread etc etc; but the phrase is the same;
TL : DR
Too long, didn't read!
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Switches
Image of switch panel from EC135 Training Manual shows proximity of Prime/Xfer switches. Under googles (and some stress), we might not always check/verify which goes back to HF. At the end of the day even the AAIB will make some assumptions in the absence of FDR/CVR data.
Purveyor of Egg Liqueur to Lucifer
See what I mean
It's been a while since I flew the police EC135 but I recall some aspects of it like it was yesterday:
Every trip I did I leftthe Tx pumps ON throughout the trip. If the captions illuminated during a high nose up as the pumps cavitated - I ignored them because I knew they would go out as they became fully immersed in fuel seconds later.[Otherwise I would be forever switching between ON and OFF during the hover].
Day time - I would invariably and knowingly fly to main tank dry. I would watch the fuel levels in both supply tanks knowing that there is where my MLA was (60kg). I 'think' there is a 3 or 4 lb delta between both supply tanks. I would ALWAYS plan to land on back at base with sufficient fuel to remain above the MLA - just good captaincy. NOT ONCE have I ever gone below MLA - no job is worth it.
Night time - requires a little more caution and more attentio to the fuel flow - leaving sufficent in the main tank and FULL supply tanks to land on @ night MLA. Invariably I would leave quite a lot more than MLA @ night for the wife and kids especially operating where i did in the middle of the boon docks where a forced landing due to low fuel would possibly end up in a world of hurt do to the nature of the ad hoc LZ.
The AAIB tells it as it 'was'. The Tx pumps were off and the Prime pumps were ON.
From now on, this is my perspective on what happened:
He'd left the prime pumps on throughout the sortie.
At some stage in flight, he'd been in the hover and the Tx pumps were flagging up cavitation due to hover attitude. He'd switched them OFF - been distracted after flying out of the hover and failed to turn them back on again.
He was @ 400' [why do people think he was @ 1000'?]. when the first engine failed due to fuel starvation. He was sorting out the lost services due to the engine failure (mainly police equipment) AND he was positioning for a landing @ night low level over a city, 180 degrees out of wind when the second donk stopped UNEXPECTEDLY(in his mind). He continued to manoeuvre for a landing spot whilst milking the Nr and unfortunately allowed it to drop below its recoverable minimum (83% I recall???). Hyds fail at 63% - where there is total loss of aircraft control.
I can't help but think about another issue that is bugging me:
Amongst other a/c types, I come across Chinook pilots in my teachings. My impression from dealing with these guys who fly an a/c where power is on permanent and almost unlimited supply (plus enormous rotor inertia) - EOL's (BOTH engines switched off) is alien to them. I don't mean that from an unprofessional perspective - they simply don't train for it, nor contemplate it as much as others who regard total engine failure as a real possibility. Food for thought perhaps?
My only remaining unanswered question I have in this very sad situation is this:
Why were the RED warning alerts on the CWP not spotted or commented on by ANY of the crew?
Every trip I did I leftthe Tx pumps ON throughout the trip. If the captions illuminated during a high nose up as the pumps cavitated - I ignored them because I knew they would go out as they became fully immersed in fuel seconds later.[Otherwise I would be forever switching between ON and OFF during the hover].
Day time - I would invariably and knowingly fly to main tank dry. I would watch the fuel levels in both supply tanks knowing that there is where my MLA was (60kg). I 'think' there is a 3 or 4 lb delta between both supply tanks. I would ALWAYS plan to land on back at base with sufficient fuel to remain above the MLA - just good captaincy. NOT ONCE have I ever gone below MLA - no job is worth it.
Night time - requires a little more caution and more attentio to the fuel flow - leaving sufficent in the main tank and FULL supply tanks to land on @ night MLA. Invariably I would leave quite a lot more than MLA @ night for the wife and kids especially operating where i did in the middle of the boon docks where a forced landing due to low fuel would possibly end up in a world of hurt do to the nature of the ad hoc LZ.
The AAIB tells it as it 'was'. The Tx pumps were off and the Prime pumps were ON.
From now on, this is my perspective on what happened:
He'd left the prime pumps on throughout the sortie.
At some stage in flight, he'd been in the hover and the Tx pumps were flagging up cavitation due to hover attitude. He'd switched them OFF - been distracted after flying out of the hover and failed to turn them back on again.
He was @ 400' [why do people think he was @ 1000'?]. when the first engine failed due to fuel starvation. He was sorting out the lost services due to the engine failure (mainly police equipment) AND he was positioning for a landing @ night low level over a city, 180 degrees out of wind when the second donk stopped UNEXPECTEDLY(in his mind). He continued to manoeuvre for a landing spot whilst milking the Nr and unfortunately allowed it to drop below its recoverable minimum (83% I recall???). Hyds fail at 63% - where there is total loss of aircraft control.
I can't help but think about another issue that is bugging me:
Amongst other a/c types, I come across Chinook pilots in my teachings. My impression from dealing with these guys who fly an a/c where power is on permanent and almost unlimited supply (plus enormous rotor inertia) - EOL's (BOTH engines switched off) is alien to them. I don't mean that from an unprofessional perspective - they simply don't train for it, nor contemplate it as much as others who regard total engine failure as a real possibility. Food for thought perhaps?
My only remaining unanswered question I have in this very sad situation is this:
Why were the RED warning alerts on the CWP not spotted or commented on by ANY of the crew?