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Police helicopter crashes onto Glasgow pub

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Police helicopter crashes onto Glasgow pub

Old 21st Feb 2014, 21:05
  #2321 (permalink)  
 
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This afternoon has seen some utter shite posted on this thread!
Completely agree Sid... It seems to me the same non helicopter pilots ask a specific 135 technical question, are given an answer, ignore the answer then ask the same crap over and over...

Pump switches again...

Yes, all 4 look the same but when you switch on a prime pump PRIME PUMP comes up on the CAD. When you switch off an XFER pump F PUMP FWD/AFT comes up on the CAD, even I can tell the difference... (as I can read English, just about) and despite earlier suppositions, pilots do tend to look at, and read any amber cautions on the CAD. Therefore, what could cause a switch mix up to go unnoticed, a CAD fault perhaps??? If not a CAD fault then perhaps the prime pumps were on for a reason!

Out of interest, from an earlier discussion, do any 135 pilots here routinely fly with the prime pumps on all the time? I don't know of anyone who does.

Last edited by Bladecrack; 22nd Feb 2014 at 08:38.
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Old 21st Feb 2014, 21:27
  #2322 (permalink)  
 
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Silsoe,

You have brought the discussion back to highlight the key point from the report - this ongoing investigation into issues with the displays.
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Old 22nd Feb 2014, 01:34
  #2323 (permalink)  
 
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An awful lot of dancing around the big elephant in the room.

If you have a mind to fly close to the endurance limit it might be worth making sure you know how the fuel system works, what the lights mean and what the switches all do.

Flying on with RED low fuel lights is madness.

How often are EC135 pilots flying into these low fuel states??
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Old 22nd Feb 2014, 03:03
  #2324 (permalink)  

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OK, lets put some perspective on this.

This vid shows what you are presented with as soon as you switch on the Prime Pumps.
In addition to the Master Caution light in front of the pilot, you get the CAD cautions of PRIME PUMP, the flashing bars and the audio.
(please ignore the warning lights as the ac was shutdown)



This is a snapshot taken from the TFO's viewpoint.
You can see the Master Caution light, the CAD indications of the PRIME PUMP cautions, the bars, and they will also get the audio.



Finally for this post, this is the CAD after the PRIME PUMP caution has been acknowledged.
This is what the CAD would normally be indicating in the situation of;
Transfer Pumps off and Prime Pumps on.




As you can see, there's a lot going on that has to be 'ignored' by each member of the crew.
Still convinced that all was indicating as it should?
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Old 22nd Feb 2014, 06:30
  #2325 (permalink)  
 
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Having read the report, it is clear that 76 KGS was remaining in the main tank and both supply tanks were effectively empty.

This situation is entirely commensurate with the finding that both transfer pumps were switched off.

The LOW FUEL warnings generated by the thermistors in the supply tanks and recorded by the VMS also support the first two findings.

Safety needs to be assured and it is clear to me that this helicopter fuel system was not operated correctly to the point that the systems gave more than adequate warning of impending doom. In addition the pilot operated below the published MLA and, at face value, appears unaware that his airmanship would have led him to carefully manage his fuel, based on his airborne time, if he had a full and complete understanding of his fuel system.

The EC135 has a long and faithful service record in HEMS and Police roles. I see nothing in the AAIB report that in any way tarnishes that record.

Flight Safety principles demand that we accept the most probable causes unearthed during AAIB investigations. Flailing around tryin to grasp at straws in an effort to avoid the bleeding obvious serves no man. It is misleading, unhelpful and deflects the necessary attention that all emergency service pilots should pay to their fuel management towards the end of a long task.

I did not know this pilot but I do know that none of us are immune from such circumstances that he found himself in that night.

The remaining fuel never made it to the engines cos the pumps needed to make it happen we're selected OFF. The pilot had a few more chances to get it right and switch them back on again as the warning lights began to illuminate. Finally a chance to survive if the correct response to double OEI is deployed. SID I know this is deeply unpalatable to you but I think you should breath out and face the facts and findings detailed in the AAIB report and see them for what they actually represent.
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Old 22nd Feb 2014, 07:01
  #2326 (permalink)  
 
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Human beings use five senses to assess what's going on. Sight, sound, smell, taste, and touch.

Sight (displays, warnings, red lights, etc) Sound (alarms, bells, engine making funny noises or worse, no noise at all). Smell (if you smell smoke you really have a problem). Taste? (nausea can overwhelm everything else)

And last, but not least, when all else fails, touch. I fly much better without gloves on, and reach without looking for the trim, the airbrake lever, the stick, etc. I have read on previous posts that the controls in helicopters have been differentiated in texture to avoid confusion.

Can anyone tell me please, do helicopter pilots wear gloves?
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Old 22nd Feb 2014, 07:45
  #2327 (permalink)  
 
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This is what the CAD would normally be indicating in the situation of;
Transfer Pumps off and Prime Pumps on.




As you can see, there's a lot going on that has to be 'ignored' by each member of the crew.
Still convinced that all was indicating as it should?
I'd say way too much amber text for a normal situation. With the pump switches set correctly for cruise, there'd be only the green pitot msg, right?

Is what you are getting at, that the only explanation would be total failure of the CAD, e.g. black screen, because noone in his right mind would have ignored/continued flying with that much yellow in the CAD?
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Old 22nd Feb 2014, 08:04
  #2328 (permalink)  
 
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DB - what exactly were the circumstances? Has the Pilot and crew really ignored all warnings - if they were visible to them? I just wish to understand a bit more if there could have been 'understandable' - not looking for 'acceptable' - reasons for such a handling of the situation. As I know from own mistakes and 'bad days' there often is. I learn best from understanding a situation and not just being told 'right' or 'wrong'. Fuel taken out of the heli was not significantly below MLA, heliport was some 1:30 minutes away. Did the pilot know the exact kg's in the tank - if CAD was working which is a big ?; so according his calcs he might have landed just at the margin - on a day with absolutely no weather restrictions.
I didn't 'know' the Pilot but I met him very briefly as a real person in real life. To know a bit more and get to understand a possible reason for the events and how they relate to this tragic outcome makes this so unreal event with a real person (not only one!) a lot more digestable for me. Same may apply for others? Some people like close relatives could stay sort of paralysed for life if they don't get real answers to what has happened. Big thank you to Sid and Art from my side.
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Old 22nd Feb 2014, 08:45
  #2329 (permalink)  
 
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Well said DB.
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Old 22nd Feb 2014, 08:57
  #2330 (permalink)  
 
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Originally Posted by SilsoeSid
As you can see, there's a lot going on that has to be 'ignored' by each member of the crew.
Were the other crew members qualified to comment? Would a police observer question the actions of a very experienced pilot?
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Old 22nd Feb 2014, 09:11
  #2331 (permalink)  
 
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Too much amber text?

It shows four legitimate warnings, and perhaps a needless statement of the state of the pitot heater.

Prime pumps on is unusual, main tank pumps off is unusual, but it's not impossible you'd want it that way - so they're cautions. Neither are red warnings. If a pump had failed, then it would probably be right to note it in red.

Too many cautions? Well there is the screens and screens of ECAM factor to consider from QF32 for example, but the unusual settings need to be noted somewhere, and if everything is normal there should be no mention: perhaps pitot heater off should be an amber and pitot heater/pitot failed as a red, rather than normal as green?
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Old 22nd Feb 2014, 09:14
  #2332 (permalink)  
 
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Do ec135 pilots wear gloves? - think the real issue is how all this information from the 5 senses is processed with about 100 billions of neurons. If these neurons get conflicting or for them irrational information, they start to have a big battle who is right or wrong. Which part of the brain will dominate in the decision making (if there is any and not only confusion)? What information stored (knowledge, training, experience) will be used? very basic survival instincts could dominate (fight, flight, freeze). In serious stress situations people, also very experienced pilots, can react very differently to what would seem normal or appropriate for an outsider not understanding the whole situation the person and his cognitive system is confronted with.
The cognitive system could be also affected by underlying factors such as a simple infection of a vital part of the cognitive system. That could be a gland for example. Very often these infections are not discovered. Or a tick bite and then Lyme disease. Very often not tested. If the body is fighting such a problem, perhaps already over a long period, the reaction to immediate serious stress might be different as it used to be in normal 'healthy' conditions. Human factor is not always human error. The factors for the 'errors' are not clear but some indications are already pointed out.
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Old 22nd Feb 2014, 09:15
  #2333 (permalink)  

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SID I know this is deeply unpalatable to you but I think you should breath out and face the facts and findings detailed in the AAIB report and see them for what they actually represent.
DB, I am only presenting things that 'should' have been going on and what 'may' have been presented 'if' the CAD had failed.

Nothing you have said is unpalatable to me as if is clear that the prime pumps were switched on, that would have give the warning shown, which for some reason wasn't actioned or there wasn't time to action. It is also clear that regardless of the switch positions, there wasn't enough fuel in the ac to get back to base with the 85kgs required.

I know exactly what your and those that support you so strongly are saying, but imho it's not as simple as you present it. As I said at the beginning of this post, I am showing the cockpit as best I can to you and those that may need to see for yourselves what cautions were, or should have been illuminating.

Tonight I'll try and show the same pictures/vid with the CAD off.
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Old 22nd Feb 2014, 09:21
  #2334 (permalink)  

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Vendee;
Were the other crew members qualified to comment? Would a police observer question the actions of a very experienced pilot?
Absolutely!

I didn't know the observers personally, but I'm sure that every qualified police observer would say something about what was going on. I know ours would. This is actively encouraged throughout their training, currencies and checks, despite what anyone may think about the single pilot aircraft and operations etc.

Every person qualified to fly in an operational police aircraft is current with CRM training and these warnings and cautions simply wouldn't be ignored.
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Old 22nd Feb 2014, 10:01
  #2335 (permalink)  
 
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Of course what is ( also ) not known ( and may never be ),
is precisely WHEN those prime Pumps were switched on and the XFER pumps switched off.

In the case of losing both engines without warning ( e.g if there was a false reading on the CAD ),
could it be that an attempt was being made to relight the engines, with use of the Prime pumps - as you would if starting up on the Ground ?

Would that be a more likely scenario than a pilot inadvertently operating the wrong switches - switches that they are very familiar with ??

Nail
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Old 22nd Feb 2014, 10:03
  #2336 (permalink)  
 
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Sid, thanks for the pictures.

As you know, I do have a problem with the expectations of the TFOs regarding their involvement in aviation matters. You describe them as 'qualified police observers'. I know exactly what you mean. They have qualified in their role as observers.

But they have absolutely no aviation qualification whatsoever. Yes they may (or may not) have absorbed technical information, and may even have the knowledge to ask sensible questions. But they are absolutely not qualified aviators! The system is absolutely designed to give specific individuals 'partitioned' responsibilities! It's supposed to be safer when police officers do the police work in the company of a professional aviator who is the final arbiter of all things aviation! That makes it different, and supposedly safer than the US for example?

Let me put it another way. IF (a big if!) all indications were operating perfectly prior to the aircraft running out of fuel, how much responsibility for the tragedy could you ascribe to the TFOs?

My personal view is, non whatsoever. Simple! Exactly as it should be!

If you want a second qualified aviator in that aircraft, then you pay for a second pilot. Or you accept that one individual soaks up all the pressure! To attempt to blur the lines is just fudging the issue, placing too much expectation/burden on unqualified people! Fudging happens in other areas of police aviation too! In terms of flight safety, blurring and fudging, are not good bedfellows!

Now, we have no idea yet what the precise situation was here, and we won't for some time. But if anyone wishes to understand how a police helicopter's fuel system can be mishandled to cause a double engine failure and autorotation, then there is an example from Christmas Day 2001 involving G-DPPH. You can google the AAIB report and see how the AAIB regards TFOs, and how the pilot explained the situation to them.

Last edited by Tandemrotor; 22nd Feb 2014 at 10:25.
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Old 22nd Feb 2014, 10:11
  #2337 (permalink)  
 
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SS, to me that display of `Prime on,transfer OFF` is confusing in relation to the fuel system as the fuel system is showing opposed selections ,in the same colour /format.Since the prime pumps are only used to start,they should go `green`,then out when `off`. Likewise,the transfer pumps,green when `on`,amber when failed/not immersed/out when `off`.Otherwise it is `Illogical Captain`(Spock).....
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Old 22nd Feb 2014, 10:29
  #2338 (permalink)  
 
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Whilst I can understand why DB says what he says, I think it is still premature to dump this on the pilot.
The following illustrates my reasoning for this.
Even if the aircraft hadnt crashed, it would have arrived back at base below MLA, leading to grief of some form for the pilot. Yet he accepted not one but two additional taskings on his way back from Dalkeith. Logic would suggest that the only explanations for this would be:
a) pilot incompetence - a non starter in this instance.
b) Pilot taking leave of his senses - ditto
c) Pilot misled regarding actual fuel contents
As would be apparent from my earlier posts, I am convinced that c) is the explanation, and that the fuel probe fault is the culprit.
Why were the transfer pumps off? they had been switched off earlier in the flight as the warnings had begun to appear more frequently as the main tank approached empty. We all know that they should have been switched back on, so why didnt he? Possibly because the fuel gauges still showed the supply tanks to have plenty fuel (erroneously). He would expect to have to play tunes on the transfer pumps later to top up the supply tanks, but that did not appear to be necessary at this point. (side comment, why can the transfer pumps not be automated??) .
No amber fuel contents warning, due to fuel probe fault. Red warnings appear very near home, but contents gauges still showing fuel in the supply tanks (erroneously) and fuel in the main tank (correctly). All of his thinking during the mission had been conditioned by the gauged contents, and he had made several decisions based on them. He was convinced they had enough fuel.
Pilot faced with a choice of which inputs to believe, elects to believe gauges rather than lights, carries on as normal. Engine flameout, supply tank still showing adequate fuel, suspects engine pump, swithces prime pumps on.
Clearly speculation on my part, but does seem to join quite a few of the dots together in a way which puts the pilots actions in a different light
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Old 22nd Feb 2014, 10:38
  #2339 (permalink)  
 
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wording: qualified to comment is not the same as qualified in actively taking part of aviation, but any comment could of course influence the PIC's decisions. A bit generalised but from my experience Glasgow cops are certainly not shy, rather the opposite. The ones I got to know don't deal precisely according rules and regs as Glasgow isn't really a rule and regs culture and place (as most places down in Englandshire..), perhaps more a who shouts the loudest environment. David Trail didn't seem to be like that though.
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Old 22nd Feb 2014, 10:42
  #2340 (permalink)  

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Tr,
As you know, I do have a problem with the expectations of the TFOs regarding their involvement in aviation matters. You describe them as 'qualified police observers'. I know exactly what you mean. They have qualified in their role as observers.

But they have absolutely no aviation qualification whatsoever. Yes they may (or may not) have absorbed technical information, and may even have the knowledge to ask sensible questions. But they are absolutely not qualified aviators! The system is absolutely designed to give specific individuals 'partitioned' responsibilities!
How much of a qualified aviator was/is an Army Aircrewman, an RAF Navigator or RN Aircrewman? Come to think of it, what about an airgunner/doorgunner winch-person or dope on a rope?

By the way, amongst the police observers out there, we have a mixture of PPL(A ) & (H), RAF VGS instructors, ex Army Aircrewmen etc. To top this part of the post off, at our unit we even have an ATPL(A) qualified on 737's.

As for your comment about how much responsibility the TFO's had in this tragedy, as in every part of aviation, the ultimate responsibility is the Captains regardless of anyone else's qualifications. To go back to another of your posts, how much responsibility would your qualified CRM'd aviation aware air steward have if an Airbus went down
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