AAIB Report A109E accident at Vauxhall, and Inquest Verdict
We are, as pilots, our own worst enemies - we have belief in our own abilities borne out of succeeding through our training and spending years 'getting the job done' and we all believe we are excellent assessors of risk and will always know when to say NO (as Shy observes this is a notoriously difficult word to utter when the pressure is on).
The risk vs reward decision we would make from the ground before the engine is started is vastly different to the one we will make when airborne with a task to complete.
Is there an easy answer? No, but at least recognising that we are the weak link may go some way to making extra allowances for 'the wife and kids' when electing to push on when that little nagging voice in your ear (not her indoors) is telling you to turn round and go home.
This is what all that Human Factors training is supposed to make us understand but self imposed pressure and ego seem to keep us from fully absorbing and applying that training.
When you get to the edge of your capacity and multitasking ability it is much more of a 'cliff-edge' than most would expect and that is where we get overwhelmed by events and make big mistakes.
The risk vs reward decision we would make from the ground before the engine is started is vastly different to the one we will make when airborne with a task to complete.
Is there an easy answer? No, but at least recognising that we are the weak link may go some way to making extra allowances for 'the wife and kids' when electing to push on when that little nagging voice in your ear (not her indoors) is telling you to turn round and go home.
This is what all that Human Factors training is supposed to make us understand but self imposed pressure and ego seem to keep us from fully absorbing and applying that training.
When you get to the edge of your capacity and multitasking ability it is much more of a 'cliff-edge' than most would expect and that is where we get overwhelmed by events and make big mistakes.
coming anyway will land in a field if I have to
I have walked away from an operator who expected wholesale disregard of normal safety protocols . Although it saved my arse from official grief it cost me the job and much worse left him still in the market with his unsuspecting posh and glossily brochured clients just as exposed. I'll make no implication regarding a connection or otherwise with this incident but go figure.
The cowboys and the chancers (for this is what they are) who operate towards such pressures should have no place in the industry, even though it voluntarily costs decent honest pilots their jobs.
Sure, it isn't easy for honest pilots to object to such pressure as I found out, but it does, ultimately leave them alive and free of guilt.
Last edited by Wageslave; 26th Nov 2015 at 21:34.
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Pittsextra;
Re: some of the comments attributed to Tinkler-Rose and Ms Smith. Any view as to why none of this was reflected in the AAIB report?
Re: some of the comments attributed to Tinkler-Rose and Ms Smith. Any view as to why none of this was reflected in the AAIB report?
History of the flight
1.1.2 Text messages and phone calls
At 0649 hrs, the pilot received a call from another pilot who was a colleague from a different helicopter operation. The pilot reportedly told his colleague that the weather was clear at Redhill Aerodrome and at his final destination but he expressed his concern about the weather at Elstree. The pilot told his colleague that he felt under pressure to go ahead with the flight that morning but he had decided to cancel it.
Another pilot (Witness A) was aware of the flights planned by the pilot of G-CRST. He stated to the investigation that the pilot phoned him at 0706 hrs to tell him that the weather at Redhill was clear and that he was going to collect a passenger from Elstree. The pilot said there was fog at Elstree but he was going to fly overhead to see for himself.
At 0718 hrs, the client called the pilot to discuss the weather. The client stated to the investigation that the pilot said he thought the weather might clear earlier than forecast. The client said he would drive to Elstree and call the pilot to keep him advised.
The client reported that, at 0731 hrs, having noticed how poor the weather was during his journey, he called the pilot to suggest that he should not take off until he (the client) had reached Elstree and observed the weather. According to the client, the pilot replied that he was already starting the engines and so the client repeated his suggestion that the pilot should not take off.
1.1.2 Text messages and phone calls
At 0649 hrs, the pilot received a call from another pilot who was a colleague from a different helicopter operation. The pilot reportedly told his colleague that the weather was clear at Redhill Aerodrome and at his final destination but he expressed his concern about the weather at Elstree. The pilot told his colleague that he felt under pressure to go ahead with the flight that morning but he had decided to cancel it.
Another pilot (Witness A) was aware of the flights planned by the pilot of G-CRST. He stated to the investigation that the pilot phoned him at 0706 hrs to tell him that the weather at Redhill was clear and that he was going to collect a passenger from Elstree. The pilot said there was fog at Elstree but he was going to fly overhead to see for himself.
At 0718 hrs, the client called the pilot to discuss the weather. The client stated to the investigation that the pilot said he thought the weather might clear earlier than forecast. The client said he would drive to Elstree and call the pilot to keep him advised.
The client reported that, at 0731 hrs, having noticed how poor the weather was during his journey, he called the pilot to suggest that he should not take off until he (the client) had reached Elstree and observed the weather. According to the client, the pilot replied that he was already starting the engines and so the client repeated his suggestion that the pilot should not take off.
Decision making
2.3.1 The decision to depart from Redhill Aerodrome
It is clear from text message records and witness evidence that the pilot knew before flight that there was fog at Elstree Aerodrome. In a telephone conversation with a colleague at 0649 hrs, he said he was going to cancel the flight because of the weather despite feeling under pressure to continue with it. At 0706 hrs, he reportedly told Witness A that he intended to fly over Elstree to check the weather for himself and, at 0729 hrs, he sent a text to the client saying that he would be “coming anyway will land in a field if I have to”.
The pilot was subject to operational and commercial pressures and was required to consider their associated risks when making the decision to operate the flight. The weather conditions at Redhill Aerodrome had begun to clear (see Figure 10) and the pilot would have been able to return there if the weather at Elstree Aerodrome reflected the forecast. He therefore had a safe contingency plan before departure. However, the weather forecast indicated that a large proportion of the flight was likely to be conducted above the cloud or fog, icing was likely during flight within cloud and there was a low probability of being able to land at Elstree Aerodrome because there was no instrument approach procedure.
2.3.1 The decision to depart from Redhill Aerodrome
It is clear from text message records and witness evidence that the pilot knew before flight that there was fog at Elstree Aerodrome. In a telephone conversation with a colleague at 0649 hrs, he said he was going to cancel the flight because of the weather despite feeling under pressure to continue with it. At 0706 hrs, he reportedly told Witness A that he intended to fly over Elstree to check the weather for himself and, at 0729 hrs, he sent a text to the client saying that he would be “coming anyway will land in a field if I have to”.
The pilot was subject to operational and commercial pressures and was required to consider their associated risks when making the decision to operate the flight. The weather conditions at Redhill Aerodrome had begun to clear (see Figure 10) and the pilot would have been able to return there if the weather at Elstree Aerodrome reflected the forecast. He therefore had a safe contingency plan before departure. However, the weather forecast indicated that a large proportion of the flight was likely to be conducted above the cloud or fog, icing was likely during flight within cloud and there was a low probability of being able to land at Elstree Aerodrome because there was no instrument approach procedure.
As I ponder all of this....the question that is begged....is why the reference to "landing in a field"?
Did Barnes make a practice of off airport landings in the past in order to accommodate his Clients when weather at Airports or other formal landing sites precluded "normal" operations?
Or....did his sense of humor allow for such a comment that at this stage of things come across with far too much significance that is warranted?
With Redhill and other locations in the Clear.....why would he mention the possibility of landing in a field?
Did Barnes make a practice of off airport landings in the past in order to accommodate his Clients when weather at Airports or other formal landing sites precluded "normal" operations?
Or....did his sense of humor allow for such a comment that at this stage of things come across with far too much significance that is warranted?
With Redhill and other locations in the Clear.....why would he mention the possibility of landing in a field?
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A very good question S'less, one that makes me think that the ability to land in a field makes some of us with a certain mindset, depart in weather conditions below that where if the field landing wasn't an option, they wouldn't have taken off in the first place.
Imho, the rotary ability to land 'in a field' and the thought of using it as a considered option if the met's a little dodgy, is nothing more than an empty chamber in the cylinder of the revolver used in the game known as Met Roulette. Unfortunately either side of that particular chamber are the gotchas!
We can get caught out and the forecasts can be wrong, however on this particular day .
Imho, the rotary ability to land 'in a field' and the thought of using it as a considered option if the met's a little dodgy, is nothing more than an empty chamber in the cylinder of the revolver used in the game known as Met Roulette. Unfortunately either side of that particular chamber are the gotchas!
We can get caught out and the forecasts can be wrong, however on this particular day .
Hi Sid - I read that but it seems to me that the comments being attributed to T-Rose this week suggest a greater concern, a longer standing unhappiness that a career change would be of interest, that Rose had told him to bin the flight and that in the weeks prior there were other issues with the same client.
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I know of very few fatalities inside a Tea Room.
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Hi Pitts, I guess the report can only go on the evidence.
Client problems with other pilots and the client only wanting to fly with certain people is information possibly not factual enough to be included in the AAIB report, besides, that is something Mr Caring denies anyway Owner of The Ivy says he did not pressure crash pilot into flying - Telegraph.
Perhaps the client was part of this 'career change' and to let Mr Caring down on that morning may have been seen as jeopardised this new future.
https://www.rt.com/uk/226223-blair-private-jet-donor/
"The luxurious private jet used by former British Prime Minister Tony Blair and dubbed Blair Force One is reportedly owned by one of Britains richest men.
Blair uses the plane, a £30 million Bombardier Global Express jet, which comes with a stateroom, kitchen, lounge and bed, as he travels around the world as a consultant.
The Telegraph revealed the private jet belongs to Richard Caring, whose fortune is estimated at £800 million ($1.2 billion)."
I see what you mean about recent comments and it's interesting to note that the AAIB report mentions, "The pilot told his colleague that he felt under pressure to go ahead with the flight that morning but he had decided to cancel it.". Yet now at the Coroners Court we hear; "he told a colleague he felt under "extreme pressure" to go ahead with the flight despite bad weather."
Maybe the added adjective has something to do with Mr Caring's comment at the CC;
"Mr Caring also criticised previous evidence from an air ambulance colleague of Captain Barnes, Shaun Tinkler-Rose, who suggested Captain Barnes was placed under "pressure" by his client to fly.
Mr Caring described Mr Tinkler-Rose's evidence as "extreme" and added: "I believe Mr Tinkler-Rose is slightly confused in his understanding of the use of commercial helicopters."
He described Mr Tinkler-Rose as a "frustrated pilot," and disputed the notion commercial helicopter clients are "control freaks or people who can't take no for an answer.""
Client problems with other pilots and the client only wanting to fly with certain people is information possibly not factual enough to be included in the AAIB report, besides, that is something Mr Caring denies anyway Owner of The Ivy says he did not pressure crash pilot into flying - Telegraph.
Mr Tinkler-Rose added Mr Barnes had told him he was tired of the pressures of the private helicopter industry and wanted to move into the environment of private jets.
https://www.rt.com/uk/226223-blair-private-jet-donor/
"The luxurious private jet used by former British Prime Minister Tony Blair and dubbed Blair Force One is reportedly owned by one of Britains richest men.
Blair uses the plane, a £30 million Bombardier Global Express jet, which comes with a stateroom, kitchen, lounge and bed, as he travels around the world as a consultant.
The Telegraph revealed the private jet belongs to Richard Caring, whose fortune is estimated at £800 million ($1.2 billion)."
I see what you mean about recent comments and it's interesting to note that the AAIB report mentions, "The pilot told his colleague that he felt under pressure to go ahead with the flight that morning but he had decided to cancel it.". Yet now at the Coroners Court we hear; "he told a colleague he felt under "extreme pressure" to go ahead with the flight despite bad weather."
Maybe the added adjective has something to do with Mr Caring's comment at the CC;
"Mr Caring also criticised previous evidence from an air ambulance colleague of Captain Barnes, Shaun Tinkler-Rose, who suggested Captain Barnes was placed under "pressure" by his client to fly.
Mr Caring described Mr Tinkler-Rose's evidence as "extreme" and added: "I believe Mr Tinkler-Rose is slightly confused in his understanding of the use of commercial helicopters."
He described Mr Tinkler-Rose as a "frustrated pilot," and disputed the notion commercial helicopter clients are "control freaks or people who can't take no for an answer.""
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SASless
In an ideal world weather decisions are indeed made on the ground, but the reality is, particularly in the UK where the nearest met report maybe 50 miles away, going to have a look and seeing if the weather is suitable when at the planned destination is the only - and a sensible - option, providing of course (a) there is a solid alternate if not, with appropriate fuel, and (b) someone is prepared to pay for a possible aborted flight. And fog can be notoriously patchy - from the nearest METARS a site may appear to be surely fogged out, but when there it can be gin clear. This exact scenario was possible for this accident flight. But a good alternate - Redhill - was not used.
In an ideal world weather decisions are indeed made on the ground, but the reality is, particularly in the UK where the nearest met report maybe 50 miles away, going to have a look and seeing if the weather is suitable when at the planned destination is the only - and a sensible - option, providing of course (a) there is a solid alternate if not, with appropriate fuel, and (b) someone is prepared to pay for a possible aborted flight. And fog can be notoriously patchy - from the nearest METARS a site may appear to be surely fogged out, but when there it can be gin clear. This exact scenario was possible for this accident flight. But a good alternate - Redhill - was not used.
Would you really trust a webcam or an automated weather report to make a real-world go-no-go decision if you knew it was marginal? I know I wouldn't.
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yes I do - very often, especially at night, when the number of reporting points is reduced.
I made a linklist of places within my operating area on my homepage, so that I can access the links from PC as well as mobile phone / pad, in case I have to check after an outside landing (i.e. refueling at an closed airport).
With official permission to fly outside normal limitations and often missions which include search for people, who will certainly die, if not found in time, the additional information is very useful.
Also the radarmovies online are very very helpful for timing or routing to get to the mission area or back.
yes I do - very often, especially at night, when the number of reporting points is reduced.
I made a linklist of places within my operating area on my homepage, so that I can access the links from PC as well as mobile phone / pad, in case I have to check after an outside landing (i.e. refueling at an closed airport).
With official permission to fly outside normal limitations and often missions which include search for people, who will certainly die, if not found in time, the additional information is very useful.
Also the radarmovies online are very very helpful for timing or routing to get to the mission area or back.
Automated weather reporting sites are becoming quite common here in the USA.....and are used in preflight planning.
How common are those kinds of facilities in the UK?
Thinking of ASOS, AWOS, and similar units.
https://www.faa.gov/air_traffic/weather/asos/
How common are those kinds of facilities in the UK?
Thinking of ASOS, AWOS, and similar units.
https://www.faa.gov/air_traffic/weather/asos/
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Would you really trust a webcam or an automated weather report to make a real-world go-no-go decision if you knew it was marginal? I know I wouldn't.
My regular operating site's nearest weather station is ten nm away, often with very different met. conditions. With regard to fog being present or not, at the time of your task, the only sure way is to go and have a look for yourself. Five minutes either way can make a lot of difference. Same when operating to early morning off airport destination landing sites. too. It's a regular part of the corporate job. Otherwise, the pax would be flying fixed wing to the nearest airport and driving to the destination and the corporate helicopter business would be no more. Obviously, a suitable alternative/diversion needs to be available and PB did have one.
I don't think PB's decision to go take a look at Elstree was totally flawed except by doing so (in circumstances with a relatively poor chance of success, in view of the initial discussion by phone with the client), he probably put unnecessary personal and commercial pressure on himself.
Once the aircraft had taken off, it began burning fuel and using aircraft hours. Obviously, declaring a "no can do" on the ground, due to weather, is one thing, but to burn fuel and hours and then finish on a "no show" means the difference between making a profit or a loss for the company.
As I said before, the really bad decision was to change from his initial safe plan B, to RTB and instead attempt to get to Battersea in conditions that were only suitable for IFR, when it is a strictly VFR only airport.
Shame that having stated he was unhappy with the pressure of corporate flying, (it sometimes gets all of us that way) he put undue and tragically terminal pressure on himself. Even had he managed to land at Battersea, how he thought he would get away with "altitude busting" right down into R157 is hard to understand unless he thought he was actually flying clear of it, possibly further to the west. I still believe he may have seen a bridge over the Thames through a gap in the low cloud and mistaken it for another. It's an easy mistake to make. Although a regular user of some parts of the Helilanes, I still sometimes have to check the 50,000 chart when given a Thames bridge as part of a short notice or unexpected clearance and at such times the pilot workload can be very high indeed.
The rest of the calculation needs doing too....if you have a result such as in this Tragedy....what is the "Cost" versus "Gain" numbers?
Otherwise, I fully agree with everything you had to say in that post.
We should be like Doctors....and "Do No Harm!".
Otherwise, I fully agree with everything you had to say in that post.
We should be like Doctors....and "Do No Harm!".
Once the aircraft had taken off, it began burning fuel and using aircraft hours. Obviously, declaring a "no can do" on the ground, due to weather, is one thing, but to burn fuel and hours and then finish on a "no show" means the difference between making a profit or a loss for the company.
Weather Cameras are the way of the future, the CAA needs to catch up:
FAA Weather Cameras
Pick a camera and click it---then click an image to see all the info it gives. Try Barrow--way up North.
FAA Weather Cameras
Pick a camera and click it---then click an image to see all the info it gives. Try Barrow--way up North.
Last edited by Gordy; 28th Nov 2015 at 19:10. Reason: added more
Crab, me old chap... suggest you take a look at the METARS for Heathrow, London City, Stansted etc... the word AUTO is the norm for quite a few UK airfields these days!
I don't have a problem with auto reporting but not for a really marginal go/no go unless I have a viable plan B ready to go when it turns out worse than expected.
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Crab, indeed you are very fortunate; the corporate helicopter pilot is often very much on his own in many respects.
If any helicopter task involves marginal wx conditions, especially with regards to fog (as we all know, it's a met man's guess with regards to timings of clearance), it would be a very foolish pilot who takes off without a plan B and IFR fuel reserves.
If any helicopter task involves marginal wx conditions, especially with regards to fog (as we all know, it's a met man's guess with regards to timings of clearance), it would be a very foolish pilot who takes off without a plan B and IFR fuel reserves.
Agreed - but there are clearly those who will still do exactly that - unfortunately we often read about them post event.
Civilian Flying is a whole different way of life than Military flying.
As Shy correctly states....in the Civilian World the Pilot is generally completely on One's own.
No Met Staff, no Engineering Section, No Ops Staff, and no one looking over your Shoulder to approve your decisions.
As Shy correctly states....in the Civilian World the Pilot is generally completely on One's own.
No Met Staff, no Engineering Section, No Ops Staff, and no one looking over your Shoulder to approve your decisions.