EC155 incident, SNS, 6 Nov 2013
Thread Starter
Join Date: Apr 2001
Location: Sometimes north, sometimes south
Posts: 1,809
Likes: 0
Received 4 Likes
on
1 Post
EC155 incident, SNS, 6 Nov 2013
AAIB report on this incident is now out here. It must fill southern N Sea offshore workers with dread. Two aborted take-offs with a pax offloaded each time, then a mishandled departure leading to both pilots being disoriented and pointing the aircraft at the sea with a 36 degrees nose down pitch attitude and ROD of >3000fpm before arresting the descent at 50ft.
A lot of factors in there but the basic one seems, once again, to be disorientation compounded by pilots struggling to work out what the auto-pilot is trying to do to the aircraft.
All credit to both guys for finally getting themselves out of this very very scary situation but it doesn't exactly instil confidence.
NS
A lot of factors in there but the basic one seems, once again, to be disorientation compounded by pilots struggling to work out what the auto-pilot is trying to do to the aircraft.
All credit to both guys for finally getting themselves out of this very very scary situation but it doesn't exactly instil confidence.
NS
Reliably informed that the operator reported it to their CAA that evening upon hearing of incident, who then requested UK AAIB assistance.
I'd like to work for a company with such an open culture - rather than get the big broom out to find room under the lumpy carpet.......
Night rig departures into nothing but darkness sat in an aircraft back into service after a lease in East Africa - no thanks matey !
I'd like to work for a company with such an open culture - rather than get the big broom out to find room under the lumpy carpet.......
Night rig departures into nothing but darkness sat in an aircraft back into service after a lease in East Africa - no thanks matey !
Firstly before comparisons are once again made between the levels of safety in States around the North Sea, it should be acknowledged that this was not an aircraft on the UK register or operated by a UK AOC holder.
As always with the AAIB this was a good factual report and analysis; those who were at the RAeS conference last week (Technology Friend or Foe - the introduction of automation to offshore operations) would have seen the similarities between this incident and the video clip shown of Cougar 851 in 2011 - albeit with a number of additional issues that had to be taken into consideration by the pilots.
Notwithstanding that the crew was dealt a poor hand by the operator, the 'optimistic trait' of pilots comes to the fore; believing that he had an issue with the autopilot - and specifically the collective channel - the pilot still selected the GA button after take-off. Having done this, the trace indicates that he spent a great deal of time breaking through on the cyclic and the collective controls. In fact the upper modes were working as advertised but the pilots did not trust them; their inputs to the controls acted negatively on the situation.
Does this come into the category of 'automation dependency' or not - it is not clear to me. What is extremely clear is that the conclusions reached at the conference last week about the need for a change of culture and more attention given to the issues of automation are applicable to all operators. What a pity Dancopter (and other non-UK North Sea operators) were not present at the conference; their insight into the effects of the introduction of automation would have been welcome,
Apart from taking note of the actions of the operator, I cannot see any recommendations from the AAIB - anyone else spot them?
Jim
As always with the AAIB this was a good factual report and analysis; those who were at the RAeS conference last week (Technology Friend or Foe - the introduction of automation to offshore operations) would have seen the similarities between this incident and the video clip shown of Cougar 851 in 2011 - albeit with a number of additional issues that had to be taken into consideration by the pilots.
Notwithstanding that the crew was dealt a poor hand by the operator, the 'optimistic trait' of pilots comes to the fore; believing that he had an issue with the autopilot - and specifically the collective channel - the pilot still selected the GA button after take-off. Having done this, the trace indicates that he spent a great deal of time breaking through on the cyclic and the collective controls. In fact the upper modes were working as advertised but the pilots did not trust them; their inputs to the controls acted negatively on the situation.
Does this come into the category of 'automation dependency' or not - it is not clear to me. What is extremely clear is that the conclusions reached at the conference last week about the need for a change of culture and more attention given to the issues of automation are applicable to all operators. What a pity Dancopter (and other non-UK North Sea operators) were not present at the conference; their insight into the effects of the introduction of automation would have been welcome,
Apart from taking note of the actions of the operator, I cannot see any recommendations from the AAIB - anyone else spot them?
Jim
The fact is that I do not understand the mindset; if he had to reset the autopilot three times, why did he then engage the GA mode (a four axis mode). Having engaged the GA, why did he not trust it until it was established that it was not doing what it was expected to do. All this given that there were issues compounding the situation - including an aircraft (which is not the best performer in any case) that weighed more than the documentation indicated.
My guess would be that this serious incident once again shows that the level of understand of a pilot for what is a very complex piece of equipment (and algorithm) is indicative of general knowledge among the pilot work-force. In my view that is not solely the fault of the pilots but of a system of training and operations which has hardly changed since the introduction of these very complex systems in the mid 2000s.
Jim
My guess would be that this serious incident once again shows that the level of understand of a pilot for what is a very complex piece of equipment (and algorithm) is indicative of general knowledge among the pilot work-force. In my view that is not solely the fault of the pilots but of a system of training and operations which has hardly changed since the introduction of these very complex systems in the mid 2000s.
Jim
Join Date: Aug 2001
Location: Cornwall
Age: 75
Posts: 1,307
Likes: 0
Received 0 Likes
on
0 Posts
Flight hours - what use?
What if he had 5000 hours but an analysis revealed that it was 5000 times the same hour - or something close to this.
Mine is not an argument about absolutes but about the wisdom of realising that it is, in the end, competence that delivers satisfaction for operator and customer alike. Their aspirations will not be met unless and until the regulatory system embraces COMPETENCY BASED TRAINING.
This should be supported by a move away from a 'Binary' style of examination in which only two possibilities exist - PASS or FAIL. This system condemns the best pilot in the company to be awarded the same status as the worst and does no favours for the latter who by rights should receive some additional supportive training.
When will we get the message???
G
Mine is not an argument about absolutes but about the wisdom of realising that it is, in the end, competence that delivers satisfaction for operator and customer alike. Their aspirations will not be met unless and until the regulatory system embraces COMPETENCY BASED TRAINING.
This should be supported by a move away from a 'Binary' style of examination in which only two possibilities exist - PASS or FAIL. This system condemns the best pilot in the company to be awarded the same status as the worst and does no favours for the latter who by rights should receive some additional supportive training.
When will we get the message???
G
Thread Starter
Join Date: Apr 2001
Location: Sometimes north, sometimes south
Posts: 1,809
Likes: 0
Received 4 Likes
on
1 Post
Isn't there a more immediate problem? It would be reasonable to conclude from this incident and others before it that there are other helicopter crews flying daily who may be vulnerable to a repeat of this or a similar incident. We can't wait for a revamp of the training system. Surely the CAA needs to take action NOW to review each company's ops management, training, competency etc etc with urgency. Or even place restrictions on night/IFR offshore departures e.g. only using crew with specified levels of experience and currency to fly those trips.
I'd love to know what the eight "long straw holders" on that aircraft now think about their means of transport to work.
I'd love to know what the eight "long straw holders" on that aircraft now think about their means of transport to work.
Join Date: Mar 2005
Location: Holly Beach, Louisiana
Posts: 916
Likes: 0
Received 0 Likes
on
0 Posts
Is there a great difference in experience required for big and not quite big helicopters?
What is the key difference between and 225 and a 155 that would drive a huge difference in Total Flight Hours or whatever criteria is being used today?
If it is mere weight of the aircraft then I would find that a bit odd if the two aircraft had very similar flight control systems.
Liikewise if it were just the number of seats then I would find having a different standard even more problematic.
Time in Type would mean more than Total Time in my view.
That added to Total Offshore Experience should be the more important Skill Set being used to determine PIC requirements in my view.
Who would want to be the guy that has to write the Rule and upset the current Apple Cart?
What is the key difference between and 225 and a 155 that would drive a huge difference in Total Flight Hours or whatever criteria is being used today?
If it is mere weight of the aircraft then I would find that a bit odd if the two aircraft had very similar flight control systems.
Liikewise if it were just the number of seats then I would find having a different standard even more problematic.
Time in Type would mean more than Total Time in my view.
That added to Total Offshore Experience should be the more important Skill Set being used to determine PIC requirements in my view.
Who would want to be the guy that has to write the Rule and upset the current Apple Cart?
Join Date: Oct 2012
Location: Canada
Age: 53
Posts: 215
Likes: 0
Received 0 Likes
on
0 Posts
The fact is that I do not understand the mindset; if he had to reset the autopilot three times, why did he then engage the GA mode (a four axis mode). Having engaged the GA, why did he not trust it until it was established that it was not doing what it was expected to do. All this given that there were issues compounding the situation - including an aircraft (which is not the best performer in any case) that weighed more than the documentation indicated.
My guess would be that this serious incident once again shows that the level of understand of a pilot for what is a very complex piece of equipment (and algorithm) is indicative of general knowledge among the pilot work-force. In my view that is not solely the fault of the pilots but of a system of training and operations which has hardly changed since the introduction of these very complex systems in the mid 2000s.
Jim
My guess would be that this serious incident once again shows that the level of understand of a pilot for what is a very complex piece of equipment (and algorithm) is indicative of general knowledge among the pilot work-force. In my view that is not solely the fault of the pilots but of a system of training and operations which has hardly changed since the introduction of these very complex systems in the mid 2000s.
Jim
I personally see it as indicative of a mindset, a malaise, that is common all over the industry. Moreso in the multi-whatever and IFR environments which I'll clarify later.
As long as the 'plan' is followed, then 99.9% of the crews out there manage just fine. As long as the [CRM jargon def'n] errors have been predicted and a response promulgated then we happily fix it and carry on. The problem is when fluid, unpredicted adaptability is needed. This is where the system produced "Children of the Magenta" fall apart. They will continue to (blindly in my opinion) revert back to the way they have 'always' done it. It is not a concious decision, it is a conditioned response that they have allowed themselves to develop by getting comfortable with the barrage of limits, regulations, SOP's, etc that endeavour to take away our ability to think.
The more constraining the 'rules' (sum total of reg's, limits, SOP's, etc) are then the less likely it is that we are actually thinking about the job. We are just pushing round pegs into round holes and square pegs into square holes. It is a personality thing, IMHO, that determines how an individual responds to this. Some can't stand it and leave, some accept it. I know pilots who try to prevent this malaise by reviewing EOP's each day, or something similar. Well done!
I have my own way to fight my own complacency that has shown me just how deep the ruts in the road are! There are so many things that we do that are standard (little s) that they almost seem to take on a new life as a Standard (big S). Something as simple briefing that I will decouple at altitude in VMC rather than descend to 500' coupled, or to cruise at 6500' versus the 'standard' 2000', can have the other pilot in a state for ages. It is the worst with pilot who came up in the IFR system as cadets and have never had to figure it out themselves. Many can't believe that no SOP prohibits my indiscriminate activities. It has certainly proven to me how many of my fellows don't actually listen to anything in my brief!
Those crews who have spent real time working in the VFR, single, no support environment have had to develop those self-improvement skills because noone was going to hand hold them along. They also pay more attention. I think we need to put more pressure on ourselves (and each other) in the IFR world.
Join Date: Oct 2012
Location: Canada
Age: 53
Posts: 215
Likes: 0
Received 0 Likes
on
0 Posts
Is there a great difference in experience required for big and not quite big helicopters?
What is the key difference between and 225 and a 155 that would drive a huge difference in Total Flight Hours or whatever criteria is being used today?
If it is mere weight of the aircraft then I would find that a bit odd if the two aircraft had very similar flight control systems.
Liikewise if it were just the number of seats then I would find having a different standard even more problematic.
Time in Type would mean more than Total Time in my view.
That added to Total Offshore Experience should be the more important Skill Set being used to determine PIC requirements in my view.
Who would want to be the guy that has to write the Rule and upset the current Apple Cart?
What is the key difference between and 225 and a 155 that would drive a huge difference in Total Flight Hours or whatever criteria is being used today?
If it is mere weight of the aircraft then I would find that a bit odd if the two aircraft had very similar flight control systems.
Liikewise if it were just the number of seats then I would find having a different standard even more problematic.
Time in Type would mean more than Total Time in my view.
That added to Total Offshore Experience should be the more important Skill Set being used to determine PIC requirements in my view.
Who would want to be the guy that has to write the Rule and upset the current Apple Cart?
The offshore world does use a baseline minimum and then there is an ability to use a high time in type, for instance, to offset lesser offshore. Ultimately a tally of hours should be an indication of potential, not a definer of capability.
I'm sure a pilot with 250 hrs total time, but 50 in a 747, would be better qualified than me, with 8000 hrs and 0 in a 747, to do the trans-atlantic hop for LH.
P & A - well said!
Now if we could trim your post down to a couple of words and stick them up in Ops ............
Just arranged something slightly different at work and was amazed with the number of 'thinks bubbles' floating around heads of 'experienced' pilots.....
It is a helicopter!
Now if we could trim your post down to a couple of words and stick them up in Ops ............
Just arranged something slightly different at work and was amazed with the number of 'thinks bubbles' floating around heads of 'experienced' pilots.....
It is a helicopter!
P&A I think the term you are looking for, which was mentioned several times at the conference JimL mentioned, is "Resilience". ie crews need to have some depth of ability so that when things go pear shaped, they can fall back on their underlying knowledge and skill and judgment to recover the situation, rather than flailing around helplessly when "the tramlines" are departed from. It is a great and meritorious buzzword, although I am less certain how we train resilience into crews in the real world.
Regarding this incident, I think we need type rated experience to comment (so that rules me out) from the likes of 212man. But with my EC225 experience I find it unfortunate that no mention is made of the trim release buttons. The EC225 is quite happy when you "fly through" go-around mode or the like, but only if you press the trim releases before expecting the AFCS to resume control. Personally I always fly through with the trim releases pressed, in the case of the EC225 it is much more stable and easier to fly, but nevertheless the majority of my erstwhile colleagues would insist on flying against the spring trims. It was one trait I failed to eradicate before I fell off my perch.
Clearly these guys didn't really understand the implications of flying through on one axis but not the other (ie on the cyclic, whilst allowing the collective to be reduced by the autopilot. Inadequate training and lack of OMB information on standard departure procedures probably lies at the heart of that.
Again, relating to the EC225 and therefore risking being wrong about the EC155, I think it is a great shame that what came out of the incident was a ruling that GA mode shall not be used on departure. That is just saying "we don't really understand how this bit works, we are not competent to use is, therefore we won't use it". Presumably the next step, following a future flight path deviation, will be to disallow use of the autopilot altogether and make the pilots fly with no stability at all, just in case it does something they don't understand?!! Barking!
The GA mode, properly used (EC225 again) is a great safety asset during a difficult departure and it is a retrograde step to disallow its use (as always, unless the EC155 has a particular issue that I don't know about)
Oh and that old chestnut about "manual flying skills" crops up again. One thing I learnt from the conference was that "situational awareness" has many levels. The situation regarding where one is around an IF approach, other traffic, terrain etc. is the top level. But at the opposite end of the scale, the situational awareness of what the current airspeed, flight attitude and altitude etc are. And there are numerous layers in between.
So it is with manual flying skills. "Lets make them fly more manual ILSs" for example, means that the pilots are quite good at flying an immaculate manual ILS. To do that typically means that you get yourself in trim and in general the smaller control inputs you make, the better. So you fly a really smooth ILS with hardly any attitude or power changes, and those you do make are very slow and gentle. But does that really help at all with the incident scenario? I would say not in the slightest.
So let's make them fly manually on departure for longer, until the AFCS upper modes are engaged. Again, the flight path should be well controlled and this is generally achieved by small slow and gentle control inputs with correspondingly well controlled attitude and other flight parameters. Does that help with recovering from the incident scenario? I would say not in the slightest.
What is needed in these cases is the confidence to make significant control inputs to stabilise a situation that is getting out of control. These days, with the passengers breathing down our necks and reporting every bump and bank to their safety reps, ATC reporting any slight deviation from the expected flight path, pilots are herded into a very tight flight profile that is always the same, scared of a ticking off (at a subconscious level) if they have to make sudden control movements and lacking in confidence to handle anything out of the ordinary.
Although the report is not yet out, I wonder if this was the reason why the Sumburgh L2 pilot took 8 seconds to increase the collective from lowish power to takeoff power whilst his helicopter was falling into the sea. The engines spool up in about 2 seconds and had he raised the collective at that speed when he first became aware of the need to increase power, I suspect disaster could have been avoided.
How is such ability and confidence gained? When I was a baby co-pilot I went to Miri (Sarawak, Borneo) on the SA330 and we had an empty sector morning and evening positioning to and from the international airport to the passenger airfield which allowed lots of AP out flying, steep turns, torque turns and other wild flying which these days would be absolutely not allowed. But my flying abilities took a massive turn for the better.
So I would say the current obsession with doing everything on rails and not upsetting the passengers is the reason why pilots these days can sometimes lack the skills - or RESILIENCE - to get themselves out of the poo. Writing a comment about the need for "better manual flying skills" will never be the answer. The culture has to change from a short sighted one of "passenger comfort and perceived safety first" to the big picture of "you have to crack an egg to make an omelette" because for sure, the former strategy isn't working.
Regarding this incident, I think we need type rated experience to comment (so that rules me out) from the likes of 212man. But with my EC225 experience I find it unfortunate that no mention is made of the trim release buttons. The EC225 is quite happy when you "fly through" go-around mode or the like, but only if you press the trim releases before expecting the AFCS to resume control. Personally I always fly through with the trim releases pressed, in the case of the EC225 it is much more stable and easier to fly, but nevertheless the majority of my erstwhile colleagues would insist on flying against the spring trims. It was one trait I failed to eradicate before I fell off my perch.
Clearly these guys didn't really understand the implications of flying through on one axis but not the other (ie on the cyclic, whilst allowing the collective to be reduced by the autopilot. Inadequate training and lack of OMB information on standard departure procedures probably lies at the heart of that.
Again, relating to the EC225 and therefore risking being wrong about the EC155, I think it is a great shame that what came out of the incident was a ruling that GA mode shall not be used on departure. That is just saying "we don't really understand how this bit works, we are not competent to use is, therefore we won't use it". Presumably the next step, following a future flight path deviation, will be to disallow use of the autopilot altogether and make the pilots fly with no stability at all, just in case it does something they don't understand?!! Barking!
The GA mode, properly used (EC225 again) is a great safety asset during a difficult departure and it is a retrograde step to disallow its use (as always, unless the EC155 has a particular issue that I don't know about)
Oh and that old chestnut about "manual flying skills" crops up again. One thing I learnt from the conference was that "situational awareness" has many levels. The situation regarding where one is around an IF approach, other traffic, terrain etc. is the top level. But at the opposite end of the scale, the situational awareness of what the current airspeed, flight attitude and altitude etc are. And there are numerous layers in between.
So it is with manual flying skills. "Lets make them fly more manual ILSs" for example, means that the pilots are quite good at flying an immaculate manual ILS. To do that typically means that you get yourself in trim and in general the smaller control inputs you make, the better. So you fly a really smooth ILS with hardly any attitude or power changes, and those you do make are very slow and gentle. But does that really help at all with the incident scenario? I would say not in the slightest.
So let's make them fly manually on departure for longer, until the AFCS upper modes are engaged. Again, the flight path should be well controlled and this is generally achieved by small slow and gentle control inputs with correspondingly well controlled attitude and other flight parameters. Does that help with recovering from the incident scenario? I would say not in the slightest.
What is needed in these cases is the confidence to make significant control inputs to stabilise a situation that is getting out of control. These days, with the passengers breathing down our necks and reporting every bump and bank to their safety reps, ATC reporting any slight deviation from the expected flight path, pilots are herded into a very tight flight profile that is always the same, scared of a ticking off (at a subconscious level) if they have to make sudden control movements and lacking in confidence to handle anything out of the ordinary.
Although the report is not yet out, I wonder if this was the reason why the Sumburgh L2 pilot took 8 seconds to increase the collective from lowish power to takeoff power whilst his helicopter was falling into the sea. The engines spool up in about 2 seconds and had he raised the collective at that speed when he first became aware of the need to increase power, I suspect disaster could have been avoided.
How is such ability and confidence gained? When I was a baby co-pilot I went to Miri (Sarawak, Borneo) on the SA330 and we had an empty sector morning and evening positioning to and from the international airport to the passenger airfield which allowed lots of AP out flying, steep turns, torque turns and other wild flying which these days would be absolutely not allowed. But my flying abilities took a massive turn for the better.
So I would say the current obsession with doing everything on rails and not upsetting the passengers is the reason why pilots these days can sometimes lack the skills - or RESILIENCE - to get themselves out of the poo. Writing a comment about the need for "better manual flying skills" will never be the answer. The culture has to change from a short sighted one of "passenger comfort and perceived safety first" to the big picture of "you have to crack an egg to make an omelette" because for sure, the former strategy isn't working.
Join Date: May 2012
Location: Aer
Posts: 431
Likes: 0
Received 0 Likes
on
0 Posts
So I would say the current obsession with doing everything on rails and not upsetting the passengers is the reason why pilots these days can sometimes lack the skills - or RESILIENCE - to get themselves out of the poo. Writing a comment about the need for "better manual flying skills" will never be the answer. The culture has to change from a short sighted one of "passenger comfort and safety first" to the big picture of "you have to crack an egg to make an omelette" because for sure, the former strategy isn't working.
TM I added "perceived" to the text you quoted, because of course the ultimate aim is passenger safety, but that is not achieved by appeasing the passengers' view of what is safe and what is not.
These days, one is not allowed to conduct a "flamboyant" departure or arrival offshore without passengers, on the grounds that the deck crew might see it and somehow feel it was "cowboy flying" thus reducing the standing of the Operator in their eyes. This is the sort of level we have descended to (and did so a good few years ago). We are reaping the rewards of that sort of attitude IMO. A badly-run FDM programme also acts as a funnel that ensures pilots never depart from the tramlines even without passengers, and even during training sorties to some extent.
These days, one is not allowed to conduct a "flamboyant" departure or arrival offshore without passengers, on the grounds that the deck crew might see it and somehow feel it was "cowboy flying" thus reducing the standing of the Operator in their eyes. This is the sort of level we have descended to (and did so a good few years ago). We are reaping the rewards of that sort of attitude IMO. A badly-run FDM programme also acts as a funnel that ensures pilots never depart from the tramlines even without passengers, and even during training sorties to some extent.
And experience - not just 10,000 hrs droning over the ocean, but also experience of handling the aircraft in a wide range of flight paths and attitudes including extreme ones. And I don't mean 5 mins spent doing UAs in the Sim - that has very little value IMO. In the real world, the Chimp Brain takes over (see prof Steve Peters writings) and makes us perform badly. The Chimp Brain cannot be tamed in the Sim for it only surfaces when the adrenalin is flowing, and we all know that the Sim is not going to kill us = no adrenalin = no Chimp Brain.
Join Date: Oct 2012
Location: Canada
Age: 53
Posts: 215
Likes: 0
Received 0 Likes
on
0 Posts
P&A I think the term you are looking for, which was mentioned several times at the conference JimL mentioned, is "Resilience". ie crews need to have some depth of ability so that when things go pear shaped, they can fall back on their underlying knowledge and skill and judgment to recover the situation, rather than flailing around helplessly when "the tramlines" are departed from. It is a great and meritorious buzzword, although I am less certain how we train resilience into crews in the real world.
My contention is that we have to stop telling ourselves and each other that this is a training issue. I believe it is a personal responsibility issue.
Perhaps where the training staff can come into play is in giving joe/jill pilot the tools to self-assess. From there, it is up to the individual to want to improve. And frankly, if they don't want to, then I say send them packing.
I have a rant that is screaming to get out, but it will destroy any last vestige of anonymity I have on here, so not today. Suffice to say, I have tilted long and hard at this windmill and a dozen people nearly lost their lives to prove me right. Sad. Sadder still that so little changes.
Join Date: Oct 2012
Location: Canada
Age: 53
Posts: 215
Likes: 0
Received 0 Likes
on
0 Posts
HC: I'll add....when I was working with copilots who wanted to improve but were finding it very difficult in the multi/IFR role, I advised them to resign (or take a leave) and pursue some good old fashioned bush/utility flying. In a JetBox or 350. They took with them a positive attitude toward self improvement and came back a year or two later with a huge improvement in SA, self confidence, and basic skills.
I still advocate this but there are very few takers, if any.
It is worth noting that there is a provision for copilots with Cougar to take just such a LOA, in the process of upgraded to captain, in their collective agreement.
I still advocate this but there are very few takers, if any.
It is worth noting that there is a provision for copilots with Cougar to take just such a LOA, in the process of upgraded to captain, in their collective agreement.