AAIB Report A109E accident at Vauxhall, and Inquest Verdict
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Vauxhall jury findings
"Mr Barnes, a pilot of 24 years, was under great commercial pressure to satisfy an important client that morning when he made the flawed decision to fly, which was "neither safe nor appropriate", the inquest heard. "
Full report:
Vauxhall helicopter crash deaths 'accidental' jury finds - BBC News
Full report:
Vauxhall helicopter crash deaths 'accidental' jury finds - BBC News
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The key lesson is very clear, if a little harsh:
You are the captain
Your are responsible for the safety of the aircraft, crew, passengers and folk on the ground
It is your decision - alone - whether to light the burners and lift
"Commercial pressure" does not change anything of YOUR responsibility. If you can't stand up to the nasty rich man and take both the decisions and the responsibility for those decisions, then you should not be in the captain's seat. Take the fancy-dress cabbage off your shoulder, stop masquerading as a "captain", and get out of the seat before you kill yourself and others.
You are the captain
Your are responsible for the safety of the aircraft, crew, passengers and folk on the ground
It is your decision - alone - whether to light the burners and lift
"Commercial pressure" does not change anything of YOUR responsibility. If you can't stand up to the nasty rich man and take both the decisions and the responsibility for those decisions, then you should not be in the captain's seat. Take the fancy-dress cabbage off your shoulder, stop masquerading as a "captain", and get out of the seat before you kill yourself and others.
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John R81
Your proposition is broadly correct, despite the childish language in your final paragraph .
It's also very easy for a PPL to say.
To their great credit, the jury didn't adopt such a simplistic approach.
They identified a very real problem - which sooner or later, preferably sooner, needs to be addressed.
We all know in broad terms what happened. Much more important is why it happens and what can be done to reduce the risk of it happening again. Until those issues are addressed, such accidents will continue.
The pilot's decision is, of course, final.
In practice, as history shows, it is not as simple as that.
(I note also that the jury clearly didn't accept the client's version of events.)
SASless
I can imagine Pete saying that but, having known him for many years and having flown with him several times, I have no doubt whatsoever that he didn't mean it literally. I believe it was part of his 'client PR' - to ensure the client understood that he was doing his best.
07:53 Pilot to Client: "Hdg back to Redhill least we tried chat in 10"
(He had abandoned his attempt to collect the client and was returning to base. He had already told another witness this two minutes earlier at 07:51)
Then came:
07:55 Client to Pilot: "Battersea is open."
If only that message had not been sent ......
Your proposition is broadly correct, despite the childish language in your final paragraph .
It's also very easy for a PPL to say.
To their great credit, the jury didn't adopt such a simplistic approach.
They identified a very real problem - which sooner or later, preferably sooner, needs to be addressed.
We all know in broad terms what happened. Much more important is why it happens and what can be done to reduce the risk of it happening again. Until those issues are addressed, such accidents will continue.
The pilot's decision is, of course, final.
In practice, as history shows, it is not as simple as that.
(I note also that the jury clearly didn't accept the client's version of events.)
SASless
As I ponder all of this....the question that is begged....is why the reference to "landing in a field"?
07:53 Pilot to Client: "Hdg back to Redhill least we tried chat in 10"
(He had abandoned his attempt to collect the client and was returning to base. He had already told another witness this two minutes earlier at 07:51)
Then came:
07:55 Client to Pilot: "Battersea is open."
If only that message had not been sent ......
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Client pressure is addressed.....Weekly by Ops staff and pilots.
Ironically I've said 'no' twice in the past seven days to people that gave evidence at that inquest 😢. A 'no' fully supported by my CP and Ops.
I was one of several that cancelled flights that morning. Pete was a friend, but the buck 'stops' with us as individuals and an industry.
This industry doesn't need tighter/more rules. It needs the white knuckle companies that SND describes addressed. It needs more CPs like/with the oversight attitude of SND (albeit the Planet isn't really big enough for two of him 😉
.
Yes, it would have been better if the final sms hadn't been sent. Equally we wouldn't be discussing this if nobody 'had tried'.
Ironically I've said 'no' twice in the past seven days to people that gave evidence at that inquest 😢. A 'no' fully supported by my CP and Ops.
I was one of several that cancelled flights that morning. Pete was a friend, but the buck 'stops' with us as individuals and an industry.
This industry doesn't need tighter/more rules. It needs the white knuckle companies that SND describes addressed. It needs more CPs like/with the oversight attitude of SND (albeit the Planet isn't really big enough for two of him 😉
. Yes, it would have been better if the final sms hadn't been sent. Equally we wouldn't be discussing this if nobody 'had tried'.
Yes, it would have been better if the final sms hadn't been sent.
Your proposition is broadly correct, despite the childish language in your final paragraph .
It's also very easy for a PPL to say.
To their great credit, the jury didn't adopt such a simplistic approach.
They identified a very real problem - which sooner or later, preferably sooner, needs to be addressed.
We all know in broad terms what happened. Much more important is why it happens and what can be done to reduce the risk of it happening again. Until those issues are addressed, such accidents will continue.
The pilot's decision is, of course, final.
In practice, as history shows, it is not as simple as that.
(I note also that the jury clearly didn't accept the client's version of events.)
It's also very easy for a PPL to say.
To their great credit, the jury didn't adopt such a simplistic approach.
They identified a very real problem - which sooner or later, preferably sooner, needs to be addressed.
We all know in broad terms what happened. Much more important is why it happens and what can be done to reduce the risk of it happening again. Until those issues are addressed, such accidents will continue.
The pilot's decision is, of course, final.
In practice, as history shows, it is not as simple as that.
(I note also that the jury clearly didn't accept the client's version of events.)
In the UK we have arguably the most mature aviation structures in terms of regulatory, industry and aeronautics. From the CAA, AAIB, RAeS, BHA, The Honourable Company of Air Pilots etc. Not only do these groups have huge experience as a whole and individually but a great many have members that crossover. The point being that if we wanted to resolve this issue we could do.
The CAA has broadened the scope of its response to SR2014-35 to a "broader and deeper review of IFR flying outside of controlled airspace". It was due for completion Oct 1. One assumes that part of that review could go some way to have given a more formalised structure to contain client pressures?
The inquest heard this:-
The inquest was told that in the weeks prior to the accident, Mr Caring had argued with another pilot from RotorMotion, either over a diverted flight or his perceived general attitude.
It was then decided that only Mr Barnes or owner and chief pilot Philip Amadeus would fly him in future.
This would have put a certain "commercial pressure" on Mr Barnes, Ms Smith conceded.
It was then decided that only Mr Barnes or owner and chief pilot Philip Amadeus would fly him in future.
This would have put a certain "commercial pressure" on Mr Barnes, Ms Smith conceded.
Yet where are Amadeus's ownership of the issues and view on the flight on that day? Given he was also the owner/director of the company. Whilst perhaps no actual rules get broken but it just feels shabby as it seems the company let PB dangle.
One very easy way to get a solution to this is make any communication to aviation businesses, (be that pilot/customer to pilot, pilot/customer to ops) such as this on recorded telephone lines. Beyond that it wouldn't be difficult to make sure any customers with a high % of total company revenue are controlled. There should be no space for the "I'll leave it up to you".
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One very easy way to get a solution to this is make any communication to aviation businesses, (be that pilot/customer to pilot, pilot/customer to ops) such as this on recorded telephone lines.
There should be no space for the "I'll leave it up to you".
There should be no space for the "I'll leave it up to you".
The CAA has broadened the scope of its response to SR2014-35 to a "broader and deeper review of IFR flying outside of controlled airspace". It was due for completion Oct 1.
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Unfortunately Pete was under a lot of pressure that day but I feel the majority was self induced.
The client hit the nail on the head when he said "Maybe part of the fault is that we became too friendly and he thought he would be letting me down." Anyone who knew Pete would understand this but it does not justify the outcome.
I will wait with interest to see what pressures were involved in the Norfolk accident, lets see if that can of worms is fully opened.
The client hit the nail on the head when he said "Maybe part of the fault is that we became too friendly and he thought he would be letting me down." Anyone who knew Pete would understand this but it does not justify the outcome.
I will wait with interest to see what pressures were involved in the Norfolk accident, lets see if that can of worms is fully opened.
Are the Chief Pilots/Managing Directors of helicopter companies, and private owners without a CPL/ATPL who employ a pilot(s), ever vetted by the CAA to assess their attitudes to rules and flight safety? If not perhaps they should be ......
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My language in last post was carefully chosen, and I stick to it. Childish? perhaps, from your viewpoint; but a clear statement of how I personally feel towards anyone who will not stand-up to "pressure" when it is their clear responsibility to do so.
Easy for PPL to say? Well.....
Aviation is not the only profession in which clients might want to do things that are close to the line, on the line, or even over the line. For a self-employed person (I am - a large professional partnership) there is financial pressure not to lose the client, and for employees in some businesses there can be management pressure not to disappoint the client on pain of perhaps loosing their job. So I simply don't see this question being any different in the field of commercial aviation. In my own field, junior employees with poor judgement don't get promoted to be seniors employees. Senior employees who have not actually displayed positive good judgement don't get to be admitted as Partners.
The captain has responsibility for the flight. Take that responsibility or don't be captain. Yes, it's simplistic but it will prevent further deaths.
Easy for PPL to say? Well.....
Aviation is not the only profession in which clients might want to do things that are close to the line, on the line, or even over the line. For a self-employed person (I am - a large professional partnership) there is financial pressure not to lose the client, and for employees in some businesses there can be management pressure not to disappoint the client on pain of perhaps loosing their job. So I simply don't see this question being any different in the field of commercial aviation. In my own field, junior employees with poor judgement don't get promoted to be seniors employees. Senior employees who have not actually displayed positive good judgement don't get to be admitted as Partners.
The captain has responsibility for the flight. Take that responsibility or don't be captain. Yes, it's simplistic but it will prevent further deaths.
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^^
I completely agree with this and I was in professional aviation for 27 years, including 3 years in a flight authorization role.
Latterly I have been a director in two other industries, the current one of which is subject to every bit as much "compliance" as aviation. The mistake that is made is to view aviation as something special and John R81 does us a favour when he points out the human failings do not recognize the "specialness" (for want of a better word) of any given profession.
Certain professions confer certain absolute responsibilities - as Truman famously put it "the buck stops here". Aircraft Captain is one such, however simplistic that might appear. I am of course well aware of the myriad complexities of Human Factors (as I said - three years in flight authorisation - ie I authorised the captains). The whole point of any training/authorisation process is to ensure that on the day the captain makes the right call.
Sometimes they don't. And from that we should all learn. Blaming the client, or the director is not learning.
It's denial.
I completely agree with this and I was in professional aviation for 27 years, including 3 years in a flight authorization role.
Latterly I have been a director in two other industries, the current one of which is subject to every bit as much "compliance" as aviation. The mistake that is made is to view aviation as something special and John R81 does us a favour when he points out the human failings do not recognize the "specialness" (for want of a better word) of any given profession.
Certain professions confer certain absolute responsibilities - as Truman famously put it "the buck stops here". Aircraft Captain is one such, however simplistic that might appear. I am of course well aware of the myriad complexities of Human Factors (as I said - three years in flight authorisation - ie I authorised the captains). The whole point of any training/authorisation process is to ensure that on the day the captain makes the right call.
Sometimes they don't. And from that we should all learn. Blaming the client, or the director is not learning.
It's denial.
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We all know in broad terms what happened. Much more important is why it happens and what can be done to reduce the risk of it happening again. Until those issues are addressed, such accidents will continue.
I think Nick Lappos was beginning to explore the right track with his atttempt to bring landing aids and lightweight instrumentation to the mainstream helicopter world. If you updated his work to include current technology for synthetic landing aids you'd really be getting somewhere. But even then the fixed wing world manages its fair share of cock-ups even with their runway to runway IAP driven approach to IFR.
If you then extended this idea to a drone like world (think "minority report") where the normal operation of a flight was entirely automated, then I think you'd really be getting somewhere. You could then either relax and accept that the only problems now would be unmanaged system failures, or put a pilot in there with strict instructions not to touch the controls unless something went wrong.
On second thoughts, scratch that second idea.
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Couldn't resist posting this little extract of ALL the serious incidents from the Docklands Light Railway Wikipedia entry since its inception in 1987.
Overrun of station buffers
The original Island Gardens DLR station at the end of a viaduct
On 10 March 1987, before the system opened, a test train crashed through buffer stops at the original high-level Island Gardens terminus and was left hanging from the end of the elevated track. The accident was caused by unauthorised tests being run before accident-preventing modifications had been installed. The train was being driven manually at the time.
Collision at West India Quay bridge
On 22 April 1991, two trains collided at a junction on the West India Quay bridge during morning rush hour, requiring a shutdown of the system and evacuation of passengers by ladder.[117][118] One train was travelling automatically, while the other was under manual control.
South Quay bombing
On 9 February 1996, the Provisional Irish Republican Army blew up a lorry under a bridge near South Quay,[120] killing two people and injuring many others.[121] The blast caused £85 million of damage and marked an end to the IRA ceasefire. Significant disruption was caused and a train was stranded at Island Gardens, unable to move until the track was rebuilt.
Overrun of station buffers
The original Island Gardens DLR station at the end of a viaduct
On 10 March 1987, before the system opened, a test train crashed through buffer stops at the original high-level Island Gardens terminus and was left hanging from the end of the elevated track. The accident was caused by unauthorised tests being run before accident-preventing modifications had been installed. The train was being driven manually at the time.
Collision at West India Quay bridge
On 22 April 1991, two trains collided at a junction on the West India Quay bridge during morning rush hour, requiring a shutdown of the system and evacuation of passengers by ladder.[117][118] One train was travelling automatically, while the other was under manual control.
South Quay bombing
On 9 February 1996, the Provisional Irish Republican Army blew up a lorry under a bridge near South Quay,[120] killing two people and injuring many others.[121] The blast caused £85 million of damage and marked an end to the IRA ceasefire. Significant disruption was caused and a train was stranded at Island Gardens, unable to move until the track was rebuilt.
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The bit that got Pete (and has got many others before) is that he forgot that his prime role was that of safety mechanism. We've all been there, being too closely linked to business imperatives. In its simplest form it is the chief pilot questioning why a standard route took 0.6 instead of 0.5.
This morning is an example. Wx is crap and the forecast told us that yesterday. So, why are punters still hanging around on a 'maybe'? There are many operators who will stare at an optimistic PROB 30 TEMPO and encourage their pilots to launch into the ether. The problem with that is the business pressure has now been put fair-and-square on the pilot. It takes a strong operator to make the sensible decision before the problem even reaches the pilot; many prefer to hide behind their ops manuals.
This morning is an example. Wx is crap and the forecast told us that yesterday. So, why are punters still hanging around on a 'maybe'? There are many operators who will stare at an optimistic PROB 30 TEMPO and encourage their pilots to launch into the ether. The problem with that is the business pressure has now been put fair-and-square on the pilot. It takes a strong operator to make the sensible decision before the problem even reaches the pilot; many prefer to hide behind their ops manuals.
R81 - well said overall. I say overall, because the act of turning your client down could mean losing your job and that puts an enormous amount of pressure on LESSER men/women, I would suggest.
I'm not saying it's an easy decision, I'm saying perhaps the solution is to pick your employment carefully perhaps.
My biggest beef - having experienced it countless times (and the ops director for MCAlpine Helicopters/Premier was notorious for saying this when he was in the game years ago - is that the threat by these people on their pilots generates rule breakers and ultimately professionals who go 'rogue'. It is these pilots who will do it if another won't and it is they I wish to pass this message:
You are letting yourself down and your profession down every time you accept a borderline job, simply to keep your job. Plan ahead and the next time you apply for a corporate job - check out the client - it's a two way interview you know.
Even more reason to do this if you have a partner / kids FFS.
I'm not saying it's an easy decision, I'm saying perhaps the solution is to pick your employment carefully perhaps.
My biggest beef - having experienced it countless times (and the ops director for MCAlpine Helicopters/Premier was notorious for saying this when he was in the game years ago - is that the threat by these people on their pilots generates rule breakers and ultimately professionals who go 'rogue'. It is these pilots who will do it if another won't and it is they I wish to pass this message:
You are letting yourself down and your profession down every time you accept a borderline job, simply to keep your job. Plan ahead and the next time you apply for a corporate job - check out the client - it's a two way interview you know.
Even more reason to do this if you have a partner / kids FFS.
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R81 - well said overall. I say overall, because the act of turning your client down could mean losing your job and that puts an enormous amount of pressure on LESSER men/women, I would suggest.
Disclaimer...this advice applies specifically to the UK, although it will apply equally in most other Western jurisdictions.
It is unlikely you would lose your job for doing your job correctly for two reasons:
1. Even in aviation, most people who get to own/run companies are not actually dumb, however much they give the impression that they might be. People who own/run companies are well aware that good staff are - literally - worth their weight in gold and they will look after them as such...even if they don't get along.
2. Assuming your employee has worked for you for two years, if you fire them without good reason, and without following employment protocols, you are bringing a sh1tstorm down on your company. Any employee in the UK that allows themselves to be fired without cause and does not head straight for the nearest employment lawyer is basically ****ing nuts.
For most human beings firing someone is extremely traumatic (trust me...been there, done that). I am an occasional business mentor and one of the commonest failings in business is directors/owners NOT firing people that it is glaringly obvious they should.
So don't be scared of ghosts under the bed...they are usually not there.
Getting all legal because you are not employeed will really depend upon how your services are being engaged in the first place. If you want to specifically relate it to this accident I doubt that PB was an employee of Rotormotion UK in a PAYE sense, meaning there are few (if in fact any) employment laws that would protect.
Given his piloting services were used elsewhere that would be an expensive way to be employeed for a variety of reasons. That said his logbook hours suggest his ability was such that he didn't need to worry about that too much.
What we are all missing when we talk of this pressure is that it isn't recognised to a level that requires any action because there was no safety recommendation in this regard and so if the inquest concludes client pressure was fundamentally the cause of this accident it differs from the AAIB.
Given his piloting services were used elsewhere that would be an expensive way to be employeed for a variety of reasons. That said his logbook hours suggest his ability was such that he didn't need to worry about that too much.
What we are all missing when we talk of this pressure is that it isn't recognised to a level that requires any action because there was no safety recommendation in this regard and so if the inquest concludes client pressure was fundamentally the cause of this accident it differs from the AAIB.
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Freelance pilots (as many helicopter pilots are in the UK) are not well placed to take legal action if their work from a particular source dries up.
Their 'employer' in many instances is the company they have set up for the tax advantages.
Pitts
Not recognised to a level that requires any action in the opinion of the AAIB doesn't mean the problem doesn't exist.
I concede it's arguable that the very small number of incidents/fatalities is insufficient to justify any action, and that the solution isn't immediately obvious - at least to me.
Their 'employer' in many instances is the company they have set up for the tax advantages.
Pitts
Not recognised to a level that requires any action in the opinion of the AAIB doesn't mean the problem doesn't exist.
I concede it's arguable that the very small number of incidents/fatalities is insufficient to justify any action, and that the solution isn't immediately obvious - at least to me.
Yeah agree with all of that although isn't it surprising that the commercial elements, as they may have related to the decision to fly, were not fully investigated (or at least not reported) especially since the body of work done took circa 20 months.
When you reflect upon the conversation about PB transferring to biz jets, that the client had interest in the same, that there had been recent issues to a degree that only PB and the owner of RMUK were to fly this client. The lack of detail that relates to the process of decision making specifically with this flight, including the pre flight conversation with the CP, especially as it is specifically referred to in the ops manual and is no doubt required by the ultimate owner of the machine and its insurance.
We don't find any of that a concern or a need to improve?
It's barely believable that the investigation can go into so much detail about the physical structure that ultimately ended the flight whilst skimming across the human factors that put the machine in the air in the first place.
The lack of an AAIB safety recommendation may not mean that further issues do not exist but having one at least puts it squarely on the table and communication of response and follow up actions are visible.
When you reflect upon the conversation about PB transferring to biz jets, that the client had interest in the same, that there had been recent issues to a degree that only PB and the owner of RMUK were to fly this client. The lack of detail that relates to the process of decision making specifically with this flight, including the pre flight conversation with the CP, especially as it is specifically referred to in the ops manual and is no doubt required by the ultimate owner of the machine and its insurance.
We don't find any of that a concern or a need to improve?
It's barely believable that the investigation can go into so much detail about the physical structure that ultimately ended the flight whilst skimming across the human factors that put the machine in the air in the first place.
The lack of an AAIB safety recommendation may not mean that further issues do not exist but having one at least puts it squarely on the table and communication of response and follow up actions are visible.