EC155 incident, SNS, 6 Nov 2013
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I wanted to ad something about the notion of "Flying Through" the AFCS.
I think it is vital tha the pilot understands exactly what flight path he has ordered from the AFCS whenever he presses an interface button. The GA mode of the EC225/175 is a classic example of this as it delivers something different depending on current IAS and how many engines are working.
If the pilot truly understands the shape and parameters of the impending flight path he should ensure, before deploying it, that the Earth will not get in the way of that flight path.
Flying Through a commanded flight path is a misleading statement a d can lead to serious attitude changes which in themselves can contribute to a cluster-f*ck along the flight path.
Why? Because there are essentially two fly through conditions possible. The first, and in my view the only acceptable one, is to assist the AFCS in achieved an IAS/VS/ALT datum with an appropriate control input. This may be done because the pilot believes the the AFCS is not reacting quick enough because of course it is limited in its immediate authority and rates in which it can modify attitude. However, if the pilot uses this option believing it is vital, he has either already chosen an unsafe flight path from the AFCS or he is simply not patient enough to let the AFCS do its clever work. For this scenario Training and Experience are key to overcoming this.
The second fly through involves the pilot trying to force the aircraft beyond IAS/VS/ALT datums he may have already commanded from the AFCS. Usually this occurs because he did not understand the shape and nature of the flight path he ordered from the AFCS or, as appears in this case, his monitoring skills are so poor he cannot believe that the AFCS is delivering the correct algorithm.
In this situation a modern digital AFCS will take the attitude to its authorised limits to fight the pilot inputs once controls are released.
HC - pressing the Trim Releases is a very dangerous practice especially during a night rig departure and in my view should only be done in an extreme situation. Where the required rate of attitude change to avoid impact demands it. Once the trim is pressed on the cyclic all notion of stability is lost.
Training pilots to use a modern AFCS takes patience, skill and knowledge from the Instructor. But more than this, it takes time! Most Type Rating Courses used by industry do not include any dedicated training on the AFCS. By that I mean real time board briefs and dedicated time just accessing AP functions with the sole remit to fully understanding each mode.
For the GA system of the EC225 this mode requires 2 hours classroom and 4 hours PF/PNF split, of dedicated SIM time. There is no way a pilot has a hope of understanding how it works without this. Thereafter, for the rest of the course, the GA needs to be integrated so the pilot understands how the flight path shape it delivers can be deployed to enhance the safety of his operations especially when close the the surface.
I think it is vital tha the pilot understands exactly what flight path he has ordered from the AFCS whenever he presses an interface button. The GA mode of the EC225/175 is a classic example of this as it delivers something different depending on current IAS and how many engines are working.
If the pilot truly understands the shape and parameters of the impending flight path he should ensure, before deploying it, that the Earth will not get in the way of that flight path.
Flying Through a commanded flight path is a misleading statement a d can lead to serious attitude changes which in themselves can contribute to a cluster-f*ck along the flight path.
Why? Because there are essentially two fly through conditions possible. The first, and in my view the only acceptable one, is to assist the AFCS in achieved an IAS/VS/ALT datum with an appropriate control input. This may be done because the pilot believes the the AFCS is not reacting quick enough because of course it is limited in its immediate authority and rates in which it can modify attitude. However, if the pilot uses this option believing it is vital, he has either already chosen an unsafe flight path from the AFCS or he is simply not patient enough to let the AFCS do its clever work. For this scenario Training and Experience are key to overcoming this.
The second fly through involves the pilot trying to force the aircraft beyond IAS/VS/ALT datums he may have already commanded from the AFCS. Usually this occurs because he did not understand the shape and nature of the flight path he ordered from the AFCS or, as appears in this case, his monitoring skills are so poor he cannot believe that the AFCS is delivering the correct algorithm.
In this situation a modern digital AFCS will take the attitude to its authorised limits to fight the pilot inputs once controls are released.
HC - pressing the Trim Releases is a very dangerous practice especially during a night rig departure and in my view should only be done in an extreme situation. Where the required rate of attitude change to avoid impact demands it. Once the trim is pressed on the cyclic all notion of stability is lost.
Training pilots to use a modern AFCS takes patience, skill and knowledge from the Instructor. But more than this, it takes time! Most Type Rating Courses used by industry do not include any dedicated training on the AFCS. By that I mean real time board briefs and dedicated time just accessing AP functions with the sole remit to fully understanding each mode.
For the GA system of the EC225 this mode requires 2 hours classroom and 4 hours PF/PNF split, of dedicated SIM time. There is no way a pilot has a hope of understanding how it works without this. Thereafter, for the rest of the course, the GA needs to be integrated so the pilot understands how the flight path shape it delivers can be deployed to enhance the safety of his operations especially when close the the surface.
DB I can agree with much of what you say, except for the trim release issue. However let's not distract this thread getting bogged down in an argument where both of us are intransigent.
The concepts that were discussed at the conference embrace a lot of what is being said here by 'pilot and apprentice' and HeliComparator' in the sense that knowledge and experience is built up during scenario-based training sessions. 'Resilience' keeps its dictionary meaning and only the method for achieving it is described. In the extracts below it states how 'resilience' is developed. Rather than paraphrase, here are several quotes from the Evidence Based Training implementation guide:
You will notice the use of the word 'facilitate' in the text and this is further explained as follows:
To see how this might change the approach from more traditional methods, here are some elements so that you can see the difference in approach between instructing and facilitating:
Jim
Scenario-based training phase
This phase forms the largest phase in the EBT program, and is designed to focus on the development of resilience through exposure to situations that develop and sustain a high level of competency. This includes training to mitigate the most critical risks identified for the aircraft generation. The phase will include the management of specific threats and errors in a real time line-orientated environment. The scenarios will include critical systemic and environmental threats, in addition to building effective crew interaction to identify and correct errors. A portion of the phase will also be directed towards the management of critical aircraft system malfunctions. For this program to be fully effective, it is important to recognize that these predetermined scenarios are simply a means to develop competency, and not an end, or “tick box” exercises in themselves.
This phase forms the largest phase in the EBT program, and is designed to focus on the development of resilience through exposure to situations that develop and sustain a high level of competency. This includes training to mitigate the most critical risks identified for the aircraft generation. The phase will include the management of specific threats and errors in a real time line-orientated environment. The scenarios will include critical systemic and environmental threats, in addition to building effective crew interaction to identify and correct errors. A portion of the phase will also be directed towards the management of critical aircraft system malfunctions. For this program to be fully effective, it is important to recognize that these predetermined scenarios are simply a means to develop competency, and not an end, or “tick box” exercises in themselves.
EBT is about assisting pilots improve from a minimum standard of performance, measured across a very restricted and predictable regime of checking, to a higher standard of performance across a very wide spectrum of activities, under training that facilitates improvement and stretching of competence capability. It is in these “expert” and “beyond expert” areas that we build resilience to deal with unforeseen events, and engender the confidence in and to deal competently with challenges encountered in flight operations.
Good facilitation will invoke a thought process, which may elicit a suggested alternative behavior from the person himself or herself, which of course does not question their values and has a more positive effect. The technique of facilitation allows this process to occur, although it is not just for the poor performer or for the development of attitudes. Facilitation can also be used to reinforce effective behavior because it gives people an understanding of why they are good, which encourages their continued development. Furthermore, it can be used in the development of skills and knowledge, because it is an effective tool for allowing self-analysis and in depth thought, which is an easier way for people to learn, as there is less recourse to memory techniques. The skills of self-analysis are not only of benefit in the training session, but can also be continually used for self-development on the line...
Although instructors have used facilitation techniques within their instruction style naturally for many years, instructors traditionally are focused on just the basics of explaining, demonstrating and, finally, checking that the task is being done in accordance with a standard. However artfully employing the technique of facilitation means that students are given the opportunity to discover what they are doing and the effect it has on others and the task, so that they can make the decision themselves to alter their behavior or even reinforce any positive behavior. This process should be made as easy as possible.
Although instructors have used facilitation techniques within their instruction style naturally for many years, instructors traditionally are focused on just the basics of explaining, demonstrating and, finally, checking that the task is being done in accordance with a standard. However artfully employing the technique of facilitation means that students are given the opportunity to discover what they are doing and the effect it has on others and the task, so that they can make the decision themselves to alter their behavior or even reinforce any positive behavior. This process should be made as easy as possible.
What do the words instructing/facilitating imply: [instructing] telling, showing; [facilitating] enabling the trainee to find the answer by himself.
What is the aim: [instructing] transfer knowledge and develop skills; [facilitating] gain insight/self analysis to enable an attitude change.
Who knows the subject: [instructing] instructor; [facilitating] both instructor and trainee.
Who has the experience: [instructing] instructor; [facilitating] both instructor and trainee.
What is the relationship: [instructing] authoritarian; [facilitating] equal.
Who sets the agenda: [instructing] instructor; [facilitating] both instructor and trainee.
One of the slides that raised eyebrows and a ripple of amusement at the conference contained this description of the necessary qualities of a facilitating trainer:What is the aim: [instructing] transfer knowledge and develop skills; [facilitating] gain insight/self analysis to enable an attitude change.
Who knows the subject: [instructing] instructor; [facilitating] both instructor and trainee.
Who has the experience: [instructing] instructor; [facilitating] both instructor and trainee.
What is the relationship: [instructing] authoritarian; [facilitating] equal.
Who sets the agenda: [instructing] instructor; [facilitating] both instructor and trainee.
Is patient and has a positive attitude;
Shows humility and admits mistakes;
Encourages and is honest;
Is non-judgemental and shows empathy;
Is supportive, respectful and honest;
Has good knowledge.
All qualities that I recognise in HC and many other trainers who are active on this forum.Shows humility and admits mistakes;
Encourages and is honest;
Is non-judgemental and shows empathy;
Is supportive, respectful and honest;
Has good knowledge.
Jim
Hmmmm, must be my non-evil twin! Anyway, what I didn't get out of the conference was a snappy understanding of the difference between ATQP and EBT. There were presentations on each, but seemingly no link. Are they mutually exclusive, the same thing by a different name, mutually compatible, or what?
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New crap
I have recently(the last two years) changed type from an old and reliable heavy machine to a new 'bells and whistles' heavy machine. As is normal, I am responsible for the lives of others when I operate this machine.
I have read the report and the above posts by wise instructors. Apart from disorientation I see very few similarities between this incident and the BLUN accident.
I am not sure whether I am a magenta person or somebody with no grass roots skills or what. I really do not believe that 'bush flying' or manual handling practice would help at all. I do not remember the single engine helicopters I flew having so little power that at max t/o weight you would have to dive to get going. The thousands of 'simple autopilot' hours I have flown have been relatively incident free(long may it continue).
What I can say is I do not properly understand the autopilot yet, even though I have had many hours in a simulator and in the machine and I am very keen to learn every trick. The manufacturer's instructions are poor at best. The English on the said instructions, their format and incompleteness make them some of the worst Flight Manual instructions I have ever read. Not only this but no computer based training exists for the fancy autopilot for me to exercise my old fashioned keenness to learn. It should. I could be more familiar with an A320 autopilot using a cheap off the shelf sim than I am with the autopilot I have to use professionally. Even a procedural trainer would do. The impression I have is that nobody, even the company that produced the machine, fully understand it yet. Maybe I am wrong and somebody out there understands it but certainly nobody has been able to come up with adequate instructions or training packages.
IMHO it is bad training, maybe lack of instructor experience or knowledge and rushed out, poorly supported equipment that is the underlying problem here.....and elsewhere.
I have read the report and the above posts by wise instructors. Apart from disorientation I see very few similarities between this incident and the BLUN accident.
I am not sure whether I am a magenta person or somebody with no grass roots skills or what. I really do not believe that 'bush flying' or manual handling practice would help at all. I do not remember the single engine helicopters I flew having so little power that at max t/o weight you would have to dive to get going. The thousands of 'simple autopilot' hours I have flown have been relatively incident free(long may it continue).
What I can say is I do not properly understand the autopilot yet, even though I have had many hours in a simulator and in the machine and I am very keen to learn every trick. The manufacturer's instructions are poor at best. The English on the said instructions, their format and incompleteness make them some of the worst Flight Manual instructions I have ever read. Not only this but no computer based training exists for the fancy autopilot for me to exercise my old fashioned keenness to learn. It should. I could be more familiar with an A320 autopilot using a cheap off the shelf sim than I am with the autopilot I have to use professionally. Even a procedural trainer would do. The impression I have is that nobody, even the company that produced the machine, fully understand it yet. Maybe I am wrong and somebody out there understands it but certainly nobody has been able to come up with adequate instructions or training packages.
IMHO it is bad training, maybe lack of instructor experience or knowledge and rushed out, poorly supported equipment that is the underlying problem here.....and elsewhere.
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Hompy, for myself I'll say that I see no indication of a lack of manual skills in this incident. They knew enough to feel the a/c was too heavy, dealt with it appropriately. They were able to clear the faults with the autopilot and make sound judgements on serviceability. Once disoriented they recovered the a/c, got everyone home, and self reported. There is lots to commend.
My comments were directed at the automatic action of using the GA button (standard) on a non standard departure. Why? They already suspected AP faults. A more conservative approach to the AP, or a better understanding of how it would react to a non standard flight regime for engagement of the GA, and there would have been no incident.
Personally I don't like the idea of flying 'through' the autopilot unless one is absolutely 100% certain why it is doing what it is doing and why it needs help. Otherwise, let it fly or fly yourself. Remember the old "you have control" "I have control" from flight training. I personally use the same logic with George!!
This crew may or may not fit the profile I have been talking about. They certainly tried to get back 'on the rails' as soon as they could (AP usage on departure). It is too bad that no one noticed an a/c so far overweight until a full weight night departure, but this crew may have been on their first shift in the airframe. We don't know.
IMHO, just by the tone and content of your post, you are one of the ones who will be just fine. You are asking the questions and you are concerned about the answer.
If you had said "I know what buttons to push to get the job done for now, that's good enough" then I would be worried.
My comments were directed at the automatic action of using the GA button (standard) on a non standard departure. Why? They already suspected AP faults. A more conservative approach to the AP, or a better understanding of how it would react to a non standard flight regime for engagement of the GA, and there would have been no incident.
Personally I don't like the idea of flying 'through' the autopilot unless one is absolutely 100% certain why it is doing what it is doing and why it needs help. Otherwise, let it fly or fly yourself. Remember the old "you have control" "I have control" from flight training. I personally use the same logic with George!!
This crew may or may not fit the profile I have been talking about. They certainly tried to get back 'on the rails' as soon as they could (AP usage on departure). It is too bad that no one noticed an a/c so far overweight until a full weight night departure, but this crew may have been on their first shift in the airframe. We don't know.
IMHO, just by the tone and content of your post, you are one of the ones who will be just fine. You are asking the questions and you are concerned about the answer.
If you had said "I know what buttons to push to get the job done for now, that's good enough" then I would be worried.
Sound judgements on serviceability!!!!!!
We know the weight of the aircraft and load, it won't go up.
Offload a passenger and it still won't go up .
Offload another passenger now she fly.
How about shut down, get engineering input and if deemed safe make a non revenue flight back with another aircraft going out to pick up the pax.
This aircraft had an inaccurate fuel system and an inaccurate weight and balance schedule.
We know the weight of the aircraft and load, it won't go up.
Offload a passenger and it still won't go up .
Offload another passenger now she fly.
How about shut down, get engineering input and if deemed safe make a non revenue flight back with another aircraft going out to pick up the pax.
This aircraft had an inaccurate fuel system and an inaccurate weight and balance schedule.
P&A on the subject of flying through the AP I'm sure it depends on the model. On the 225, and therefore I'm hoping on the 155 as well, as soon as you "fly through" on an axis, the AP knows it and gives up trying to carry out the upper mode function on that axis until such time as you stop overriding, at which point it smoothly takes up doing what you asked it to do in the first place, PROVIDED the cyclic and collective are in trim when you release control. If the they are not in trim when you let go, the controls jump to the trimmed position, the aircraft will lurch and whilst eventually the AP will resume the correct attitude, in the mean time the attitude will be wrong. That is why it is ESSENTIAL to depress the cyclic trim release especially, when releasing control back to the AP. I say the cyclic control especially, because in general one doesn't fly against the collective spring trim, it is too powerful to do that comfortably.
If you think about it, when flying through the basic AP you are overriding the AP's basic attitude hold, and when you let go that attitude is resumed. It's just the same flying through GA except in that case the underlying mode is "flying up and away" rather than holding some attitude you had previously selected. So when you let go, it just wants to fly up and away, which is usually a good thing when you are near the ground on departure.
If you fly against the trims so as to change eg airspeed significantly, the cyclic is no longer in trim and you must retrim it by pressing the cyclic trim release before letting go. On the 225 with its very light cyclic, the sudden removal of the spring forces tends to cause a slight lurch which is offensive if one takes pride in smooth flight. This therefore is one of the reasons why it is better to press the cyclic trim release the whole time one is "flying through" safe in the knowledge that you can let go at any time, there won't be a lurch, and the AP will smoothly resume doing what is expected of it. The other reason is that, again in the case of the 225, the AP mode when flying against the trims is not quite the same as that when pressing the trim release. Despite protestations from DB the latter case is more stable. Anyway, what is the point in having a trim system if one is intentionally going to fly out of trim?
It's not mentioned in the report, but if the pilot overrode on cyclic whilst the airspeed was changing significantly (thus requiring a new trimmed position at the end of the override) but didn't trim release, instead letting go, it is no wonder the attitude got a bit out of hand. This is absolutely the wrong thing to do, but most likely has never been properly taught to the pilot. If it is anything like the EC225, there is only 1 FDR parameter for each axis, covering both the override detection and the trim release, so it was probably not possible to determine whether the trim release was pressed or the pilot was just flying out of trim. Again, if like the EC225, that FDR parameter is a bit flaky anyway!
In this incident case as mentioned, a good deal of the problem seems to have been taking control only of the cyclic and not of the collective. If it had been me flying, (presuming I had got myself into their situation) I would have depressed both cyclic and collective trim releases which says unequivocally to the AP "I have control", selected a sensible attitude and power, released everything and then watched it fly away.
So, as I said originally, it's a pity the report doesn't cover use of the trim release since it is a fundamental and critical issue.
If you think about it, when flying through the basic AP you are overriding the AP's basic attitude hold, and when you let go that attitude is resumed. It's just the same flying through GA except in that case the underlying mode is "flying up and away" rather than holding some attitude you had previously selected. So when you let go, it just wants to fly up and away, which is usually a good thing when you are near the ground on departure.
If you fly against the trims so as to change eg airspeed significantly, the cyclic is no longer in trim and you must retrim it by pressing the cyclic trim release before letting go. On the 225 with its very light cyclic, the sudden removal of the spring forces tends to cause a slight lurch which is offensive if one takes pride in smooth flight. This therefore is one of the reasons why it is better to press the cyclic trim release the whole time one is "flying through" safe in the knowledge that you can let go at any time, there won't be a lurch, and the AP will smoothly resume doing what is expected of it. The other reason is that, again in the case of the 225, the AP mode when flying against the trims is not quite the same as that when pressing the trim release. Despite protestations from DB the latter case is more stable. Anyway, what is the point in having a trim system if one is intentionally going to fly out of trim?
It's not mentioned in the report, but if the pilot overrode on cyclic whilst the airspeed was changing significantly (thus requiring a new trimmed position at the end of the override) but didn't trim release, instead letting go, it is no wonder the attitude got a bit out of hand. This is absolutely the wrong thing to do, but most likely has never been properly taught to the pilot. If it is anything like the EC225, there is only 1 FDR parameter for each axis, covering both the override detection and the trim release, so it was probably not possible to determine whether the trim release was pressed or the pilot was just flying out of trim. Again, if like the EC225, that FDR parameter is a bit flaky anyway!
In this incident case as mentioned, a good deal of the problem seems to have been taking control only of the cyclic and not of the collective. If it had been me flying, (presuming I had got myself into their situation) I would have depressed both cyclic and collective trim releases which says unequivocally to the AP "I have control", selected a sensible attitude and power, released everything and then watched it fly away.
So, as I said originally, it's a pity the report doesn't cover use of the trim release since it is a fundamental and critical issue.
Last edited by HeliComparator; 12th Jul 2014 at 22:11.
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Hompy, for myself I'll say that I see no indication of a lack of manual skills in this incident. They knew enough to feel the a/c was too heavy, dealt with it appropriately.
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Sound judgements on serviceability!!!!!!
We know the weight of the aircraft and load, it won't go up.
Offload a passenger and it still won't go up .
Offload another passenger now she fly.
How about shut down, get engineering input and if deemed safe make a non revenue flight back with another aircraft going out to pick up the pax.
This aircraft had an inaccurate fuel system and an inaccurate weight and balance schedule.
We know the weight of the aircraft and load, it won't go up.
Offload a passenger and it still won't go up .
Offload another passenger now she fly.
How about shut down, get engineering input and if deemed safe make a non revenue flight back with another aircraft going out to pick up the pax.
This aircraft had an inaccurate fuel system and an inaccurate weight and balance schedule.
The SNS may be great, but in the places I've worked the load presented is often...optimistic shall we say....and they recognized an issue with weight. It did go up, but not as spritely as they liked so they lightened the load. It could have been an issue with wind, turbulence, temperature just as well. They also could have shut down and demanded a re-weigh of all pax and cargo. This seldom wins friends, and dropping a couple pax is a quick easy fix.
THESE things happen all day, every day, all over the world.
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I am not sure about that. Allowing any aircraft with passengers on board to get to 36 degrees nose down on a rig take off day or night to me shows a big lack of manual skill. A simple pull max power, 5-10 degrees nose down, hold the attitude and count to 10 would ensure a safer take off than the gyrations seen here.
All the manual skills in the world won't save you once you are already disoriented. Choosing a non-standard departure, then hitting the GA early, and finally getting surprised; all that caused the disorientation. The gyrations resulted from the disorientation.
I see no reason, based on this report, to believe that he would have had any trouble if he had just flown the departure himself. But I also think his choice to depart so aggressively at night is odd. Again, without information on this company's performance planning, it is hard to judge how a 155 would normally perform.
This is why IIMC is a killer. If you no longer know which way is up, and you don't trust George, all the hot $hit hands and feet in the world won't help.
HC, I could discuss the trim release, etc in the 76 vs the 225 but neither of us know if it has anything to do with the 155. From your descriptions it appears the 76 and 225 have very important, if subtle, differences.
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The Legendary Oil Patch Weight Scales and Clock will get you every time if you let them.
Bubba, who would make two of me, carrying a back pack, briefcase, dragging a Duffel Bag as big has he is, and a two Bears straining to pick up a 40 pound Tool Box....for a combined weight of 290 pounds for example.
Or the ol', two minute delay, the Pax is on his way up the helideck steps right now!
Oh yes, perfection in motion out there isn't it?
THESE things happen all day, every day, all over the world.
Or the ol', two minute delay, the Pax is on his way up the helideck steps right now!
Oh yes, perfection in motion out there isn't it?
Firstly, the answer HC's question on the link between ATQP (AQP in the US) and EBT - with respect to Europe (I'm sure how this fits in the US or elsewhere). My first admission is that I am not the expert in these subjects but I am relying on discussions with Keith Dyce of British Airways and Mike Varney of Airbus, who are.
ATQP came first and was addressed at tailoring 'operational' training so that it would more align with the issues that were being experienced by the operators. In general, that meant a move away from the tick-box elements that were enshrined in Operational Regulations. However, it addresses only operational training and the requirement to provide licence proficiency checks (LPC) and Type Ratings in accordance with FLC regulations remain.
The EBT programme resulted from an analysis of data collected over a long period - using a number of reporting and survey systems (including LOSA, FDM, ASRs and accident and incident reports - the evidence part of the acronym). EBT also continues the ICAO initiative to establish competence based training; this has led to the construction of the eight ICAO competencies (nine for Airbus who – rightly according to attendees at this conference – include ‘knowledge’). It is considered that the achievement of these competencies, and eventually resilience, depends on facilitation rather than instruction.
The EBT programme uses the results from the data collection to establish a baseline programme (which is defined in the documentation) - which now includes both operational and licence compliance. The enhanced programme, permits further tailoring of the programme to be achieved using the operator's own LOSA, FDM, ASRs and training reports. This dynamic system allows training to be modified as part of the constant improvement cycle.
EBT is now moving into a phase where the Type Rating will also be part of the EBT culture. Something that has to be achieved if the commercial world wishes to have an integrated system of training (Type Rating, Licence Proficiency and Operational Conversion and Training) that is based upon their own procedures and the perceived risks - in their operational environment.
This rather long monologue is intended to show that ATQP is a half-way house to EBT.
Just a couple of other points with respect to this incident:
With respect to Hompy's points; at the conference the complexity of autopilots was discussed and Herve Jammayrac, in his presentation, agreed that they were too complex and the interface had to be simplified. My findings from the conference were: "Autopilot are increasingly omnipotent and few pilots understand them – there is a need for pilots to have access to conceptual models that they can gain, and retain, a mental picture of what is happening within the system". This of course has to be achieved as an addition to the changes in training that are also required.
As was indicated before (and in the report) there were complicated faults with the controls with respect to the autopilot that took some time to resolve. However my earlier point still applies; if it has taken three resets to clear a fault which indicates a problem with the collective channel, a more prudent pilot might have taken that as a given and not engaged the GA function.
The aircraft weighed substantially more that the documentation implied; the system of mass control on the North Sea is reasonable (not more than that I would suggest) and the fact that a decent hover, at the restricted mass, could not be achieved confounded both pilots. The decision to drop passengers was a brave one (and to do it twice showed real initiative); the exaggerated pitch attitude change at the rotation point - with a known heavy aircraft - was not appropriate; it is no surprise that the aircraft took some time to arrive at a point where a climb was possible.
All of this re-emphasises my point that the level of knowledge amongst offshore pilots needs to be examined and the system (in the type rating as well as in operational conversion and training) needs review. One of my observations from the conference was:
"Necessary changes required in piloting skills when converting from flying with basic instruments and stabilisation, to managing the on-board systems, had not been fully recognised and implemented; there was ample evidence that the necessity for managed transition had not been understood (by regulators or operators) or put in place."
Jim
ATQP came first and was addressed at tailoring 'operational' training so that it would more align with the issues that were being experienced by the operators. In general, that meant a move away from the tick-box elements that were enshrined in Operational Regulations. However, it addresses only operational training and the requirement to provide licence proficiency checks (LPC) and Type Ratings in accordance with FLC regulations remain.
The EBT programme resulted from an analysis of data collected over a long period - using a number of reporting and survey systems (including LOSA, FDM, ASRs and accident and incident reports - the evidence part of the acronym). EBT also continues the ICAO initiative to establish competence based training; this has led to the construction of the eight ICAO competencies (nine for Airbus who – rightly according to attendees at this conference – include ‘knowledge’). It is considered that the achievement of these competencies, and eventually resilience, depends on facilitation rather than instruction.
The EBT programme uses the results from the data collection to establish a baseline programme (which is defined in the documentation) - which now includes both operational and licence compliance. The enhanced programme, permits further tailoring of the programme to be achieved using the operator's own LOSA, FDM, ASRs and training reports. This dynamic system allows training to be modified as part of the constant improvement cycle.
EBT is now moving into a phase where the Type Rating will also be part of the EBT culture. Something that has to be achieved if the commercial world wishes to have an integrated system of training (Type Rating, Licence Proficiency and Operational Conversion and Training) that is based upon their own procedures and the perceived risks - in their operational environment.
This rather long monologue is intended to show that ATQP is a half-way house to EBT.
Just a couple of other points with respect to this incident:
With respect to Hompy's points; at the conference the complexity of autopilots was discussed and Herve Jammayrac, in his presentation, agreed that they were too complex and the interface had to be simplified. My findings from the conference were: "Autopilot are increasingly omnipotent and few pilots understand them – there is a need for pilots to have access to conceptual models that they can gain, and retain, a mental picture of what is happening within the system". This of course has to be achieved as an addition to the changes in training that are also required.
As was indicated before (and in the report) there were complicated faults with the controls with respect to the autopilot that took some time to resolve. However my earlier point still applies; if it has taken three resets to clear a fault which indicates a problem with the collective channel, a more prudent pilot might have taken that as a given and not engaged the GA function.
The aircraft weighed substantially more that the documentation implied; the system of mass control on the North Sea is reasonable (not more than that I would suggest) and the fact that a decent hover, at the restricted mass, could not be achieved confounded both pilots. The decision to drop passengers was a brave one (and to do it twice showed real initiative); the exaggerated pitch attitude change at the rotation point - with a known heavy aircraft - was not appropriate; it is no surprise that the aircraft took some time to arrive at a point where a climb was possible.
All of this re-emphasises my point that the level of knowledge amongst offshore pilots needs to be examined and the system (in the type rating as well as in operational conversion and training) needs review. One of my observations from the conference was:
"Necessary changes required in piloting skills when converting from flying with basic instruments and stabilisation, to managing the on-board systems, had not been fully recognised and implemented; there was ample evidence that the necessity for managed transition had not been understood (by regulators or operators) or put in place."
Jim
Last edited by JimL; 13th Jul 2014 at 10:54.
Thanks Jim. Regarding integrated training, this was of course how we did it in the "good old days" - it was only with the advent of JAR that they were split into licence training / testing and Operational training /testing. Are we following a circular path?
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Hompy,
I once worked for a builder of helicopters that had English as a second language (no...not an American firm but one on the eastern side of the Saltwater Divide) and saw how the Technical Writers went about their business creating Tech Manuals for an American Aircraft built under license.
Their effort could be described as a simple translation of US Army Manuals into their native language then later doing a second translation into ordinary English.
The comparison of the original Text in the US Army Manual to the related section of the Non-Army English version yielded an impression there were two entirely different aircraft being discussed.
When one considers the fact that most of the Tech Writers are just that and not Design Engineers or Test Pilots tasked with collateral duties of creating the Tech Manuals (including the Pilot's Handbook or whatever passes for such), it is not surprising there is a gap between what is printed and what should be printed.
Compound that by injecting a translation from their "First Language" to multiple other languages and you can see the challenge that process becomes.
Trying to provide a "complete" description of a complex system such as modern AFCS/FMS Autopilot systems are these days is a very challenging task that in my not so humble opinion is not ever bound to be completely successful.
Why a computer based software program cannot be developed is a good question. I would submit simple "Cost" being the biggest obstacle. The integration that would take is a daunting task especially when considering the Manufactuer's cannot produce a paper and text Manual that adequately describes all the variations of the Autopilot system.
Likewise to develop a Systems Trainer that can duplicate all the functions and map-functions of the AFCS system would be a very expensive proposition to develop, field, maintain, and use for instruction.
When the limited fleet size for particular helicopters is considered it just is not economically feasible.
I once worked for a builder of helicopters that had English as a second language (no...not an American firm but one on the eastern side of the Saltwater Divide) and saw how the Technical Writers went about their business creating Tech Manuals for an American Aircraft built under license.
Their effort could be described as a simple translation of US Army Manuals into their native language then later doing a second translation into ordinary English.
The comparison of the original Text in the US Army Manual to the related section of the Non-Army English version yielded an impression there were two entirely different aircraft being discussed.
When one considers the fact that most of the Tech Writers are just that and not Design Engineers or Test Pilots tasked with collateral duties of creating the Tech Manuals (including the Pilot's Handbook or whatever passes for such), it is not surprising there is a gap between what is printed and what should be printed.
Compound that by injecting a translation from their "First Language" to multiple other languages and you can see the challenge that process becomes.
Trying to provide a "complete" description of a complex system such as modern AFCS/FMS Autopilot systems are these days is a very challenging task that in my not so humble opinion is not ever bound to be completely successful.
Why a computer based software program cannot be developed is a good question. I would submit simple "Cost" being the biggest obstacle. The integration that would take is a daunting task especially when considering the Manufactuer's cannot produce a paper and text Manual that adequately describes all the variations of the Autopilot system.
Likewise to develop a Systems Trainer that can duplicate all the functions and map-functions of the AFCS system would be a very expensive proposition to develop, field, maintain, and use for instruction.
When the limited fleet size for particular helicopters is considered it just is not economically feasible.
I'm sorry Bob - I don't buy that! I prefer the description of the necessity for good mental models from Don Norman's book - The Design of Everyday Things.
I really don't need the designer to tell me how he designed it - or show me the algorithms or circuit boards; what I need is an effective 'mental model' that permits me to work out what I need to do when encountering a situation I have not seen, or been briefed about, before (resilience). My guess is the crew of the EC155 did not see the relevance of their three resets to the collective channel and their selecting of the Go Around mode.
In the event there was no effect but the seeds of doubt over the functioning of the autopilot, sown on the deck of the Clipper, clouded their judgement (as did the destruction of their mental model of the take-off profile caused by the incorrect mass) and resulted in them flying through the autopilot modes.
Clearly there is an issue evidenced by the discussion between Double Bogey and HeliComparator - both of whom have a well-above-average understanding of the workings of the EC225 autopilot.
If you have several hours to spare, sit yourself down with the S92 RFM and try to work out the trim system. Note particularly the change of control over the commanded/reference vertical speed between the 'two cue coupled' and 'three cue coupled' vertical speed mode.
Jim
The design model is the designer's conceptual model. The user's model is the mental model developed through interaction with the system. The system image results from the physical structure that has been built (including documentation, instructions, and labels). The designer expects the user's model to be identical to the design model. But the designer doesn't talk directly with the user—all communication takes place through the system image. If the system image does not make the design model clear and consistent, then the user will end up with the wrong mental model. (From Norman, 1086.)
A good conceptual model allows us to predict the effects of our actions. Without a good model we operate by rote, blindly; we do operations as we were told to do them; we can't fully appreciate why, what effects to expect, or what to do if things go wrong. As long as things work properly, we can manage. When things go wrong, however, or when we come upon a novel situation, then we need a deeper understanding, a good model.
In the event there was no effect but the seeds of doubt over the functioning of the autopilot, sown on the deck of the Clipper, clouded their judgement (as did the destruction of their mental model of the take-off profile caused by the incorrect mass) and resulted in them flying through the autopilot modes.
Clearly there is an issue evidenced by the discussion between Double Bogey and HeliComparator - both of whom have a well-above-average understanding of the workings of the EC225 autopilot.
If you have several hours to spare, sit yourself down with the S92 RFM and try to work out the trim system. Note particularly the change of control over the commanded/reference vertical speed between the 'two cue coupled' and 'three cue coupled' vertical speed mode.
Jim
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Jim,
You miss the point I was making. It is not the "Designer" telling the "User" how he designed it...how the electronic boards work...or the inner workings of the algorithms....but how the System is supposed to function AT THE USER's Level.
If the Designer, in this case Air Bus, cannot provide a proper User Manual and Factory Training Course then therein lies a huge problem.
At some point, there has to be a foundation whereby a proper knowledge of how the particular AFCS system operates in both Normal and Abnormal modes. If the builder cannot do that then who can?
Someone has to be the Subject Matter expert. Who would you nominate if not the Builder?
Do you think "language" itself and its usage not influence all of this?
"Resilience" seems to be a new buzz word created by someone to foster some notion things have changed since the advent of Aviation where the Pilot has to understand how the systems function on his aircraft and thus be able to understand what to do when they fail for some reason.
The Cornerstone of all this is the Pilot being able to have a source of education/training to adequately prepare him for those situations.
What has changed is the complexity of systems which makes that all the more difficult and challenging.
The basic problem is the same as ever.
The techniques we must adopt to address this complexity will be different but so have our efforts in the past.
When all these fancy Bells and Whistles quit working, Pilots will have to revert to what they have always done in the past, adapt, improvise, and overcome.
That is where you fancy concept of "Resilience" kicks in.
I call it "fly the helicopter".
You can argue all you want about what it takes to do that but that is the task in its most basic concept.
You miss the point I was making. It is not the "Designer" telling the "User" how he designed it...how the electronic boards work...or the inner workings of the algorithms....but how the System is supposed to function AT THE USER's Level.
If the Designer, in this case Air Bus, cannot provide a proper User Manual and Factory Training Course then therein lies a huge problem.
At some point, there has to be a foundation whereby a proper knowledge of how the particular AFCS system operates in both Normal and Abnormal modes. If the builder cannot do that then who can?
Someone has to be the Subject Matter expert. Who would you nominate if not the Builder?
Do you think "language" itself and its usage not influence all of this?
"Resilience" seems to be a new buzz word created by someone to foster some notion things have changed since the advent of Aviation where the Pilot has to understand how the systems function on his aircraft and thus be able to understand what to do when they fail for some reason.
The Cornerstone of all this is the Pilot being able to have a source of education/training to adequately prepare him for those situations.
What has changed is the complexity of systems which makes that all the more difficult and challenging.
The basic problem is the same as ever.
The techniques we must adopt to address this complexity will be different but so have our efforts in the past.
When all these fancy Bells and Whistles quit working, Pilots will have to revert to what they have always done in the past, adapt, improvise, and overcome.
That is where you fancy concept of "Resilience" kicks in.
I call it "fly the helicopter".
You can argue all you want about what it takes to do that but that is the task in its most basic concept.
Last edited by Boudreaux Bob; 13th Jul 2014 at 15:10.
A bit of Luddite-ism creeping in there Bob! How do you propose to "fly the helicopter" when they become fully FBW? Even now, you are surely not proposing to fully disengage the autopilot and fly without stability at all? No, these days one is inevitably having to interact with the electronics at some level, it is just a matter of choosing the right level, and there no doubt resilience helps. With DB and I not even being able to agree on the use of the trim release, how can we possibly be expected to agree on the vastly more complex issues of the automation? (Although to be fair, we mostly do!).
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HC.....can you fly a helicopter by pushing buttons, twisting knobs in addition to or in lieu of moving Sticks?
What part of adapt, improvise, and overcome eludes you?
In the end no matter how you slice it, Pilots have to "fly the machine". If you want to be a nit picker and question every single word and ignore the context and concept then who needs to rethink their position here?
It does not matter if it is FBW, push pull tubes, or cables and pulley's....when it is your Ass sat in the Seat you are going to have to find a way to control the aircraft.
Your knowledge of the systems is the starting point is it not?
In this case "Ignorance" will kill you. You have said that before when suggesting some folks do not understand how their AFCS works and as a result do not know how to properly utilize all of its capabilities.
What is different between what I am saying and your position in the past?
As to this "Luddite" thing, am I not espousing saving the machinery which is quite contrary to what the Luddites were all about?
What part of adapt, improvise, and overcome eludes you?
In the end no matter how you slice it, Pilots have to "fly the machine". If you want to be a nit picker and question every single word and ignore the context and concept then who needs to rethink their position here?
It does not matter if it is FBW, push pull tubes, or cables and pulley's....when it is your Ass sat in the Seat you are going to have to find a way to control the aircraft.
Your knowledge of the systems is the starting point is it not?
In this case "Ignorance" will kill you. You have said that before when suggesting some folks do not understand how their AFCS works and as a result do not know how to properly utilize all of its capabilities.
What is different between what I am saying and your position in the past?
As to this "Luddite" thing, am I not espousing saving the machinery which is quite contrary to what the Luddites were all about?