AAIB Report A109E accident at Vauxhall, and Inquest Verdict

[Bravo73]

Originally Posted by cave dweller

The only person interviewed at the heliport as far as I understand, was the duty datco on the morning in question. This is only my third ever post and all three including this one was on the same subject.I posted this descrepency back in january 2013 when it was first posted that the client had stated that he had called Battersea to see if we were open. My answer then and my answer now is the same, no call was ever received.

That's all well and good but I seem to recall asking you the same question back when you first posted - have you reported this to the AAIB?

You can't be expecting their investigators to be reading these posts, surely?

[cave dweller]

AAIB report

Most of the posts at that time suggested not to speculate and to wait untill the official report came out, thats exactly what I have done.

[Bronx]

cave dweller

The only person interviewed at the heliport as far as I understand, was the duty datco on the morning in question.

So why did the duty datco confirm that the client called?
What reason might he have to lie to the AAIB?
Maybe he took the call himself?

Most of the posts at that time suggested not to speculate and to wait untill the official report came out, thats exactly what I have done.

That means not speculating on the internet.
It doesn't mean don't give the AAIB information that might help the investigation!

Whatever, it doesn't change anything because the client, for his own reasons, told the pilot Battersea was open and ATC confirmed it was.

2.3.1 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.

The pilot had already told the client he was "hdg back to Redhill" and changed his mind only after the client said Battersea was open and ATC confirmed it was

If the client had left it as 'no flight' the pilot would have kept to his plan to return to Redhill - and two men would still be alive.

[Bravo73]

Originally Posted by cave dweller

Most of the posts at that time suggested not to speculate and to wait untill the official report came out, thats exactly what I have done.

Hang on a minute. By your own admission, you are a witness to the events. And your account differs to the official report of the events. Your account could have a bearing on that report.

And you don't seem to think that you should report this to the AAIB? Are you for real???

[cave dweller]

AAIB report

It may well have been the case that the client had called the DATCO at the time. I am not privvy to what he had said in his report. The DATCO at the time would have not had authority to declare open before 0800. The DATCO did indeed call me to see if we could open to accept the flight , but as I understood it, it was a request from radar in the seconds before impact and that was when he, the DATCO asked me if we could open and accept him. We were not open prior to that communication with the DATCO.

[cave dweller]

AAIB report

I have only just read the report about an hour ago , so did not know what was in the report

[Bronx]

The DATCO at the time would have not had authority to declare open before 0800.

The pilot was cleared by ATC to contact London Heliport. His response to this transmission ended at 0759:22 hrs - just 38 seconds before 0800.
Maybe the DATCO assumed it would have been 0800 by the time he landed?
Not unreasonable.
Anyway, all that doesn't matter now.


What can be done to dissuade pilots from getting themselves into the position this pilot did?
What can be done to help pilots not get into that position?
It's an industry problem around the world and it ain't gonna go away on its own.
Is there a will in the industry to do anything about it?

Maybe not?
Maybe it's the elephant in the room nobody wants to talk about?

[satsuma]

Despite being urged by his client twice not to fly due to poor visibility, Cpt Barnes told him by text message: “I’m coming anyway..."

Possibly the most revealing words in the report. I'm prepared to bet that the pilots who crashed the Haughey Air helicopter in Norfolk thought or said something along the lines of 'We're going anyway' as well.

Is it me or do helicopter operators appear to be more afflicted by commercial pressures than their fixed wing counterparts? Is it because their clients, whether rich businessmen, toffs or oil companies are rolling in it and keep the operators in a state of perpetual fear of losing their business?

[chopjock]

I'm thinking perhaps the pilot would have been visual with the surface for the turn to Battersea, saw that he was higher than the top of the building so no problem, (didn't see the crane going up the other side), held the angle of bank in and through that soft cloud that was above the building and didn't expect a jib arm hidden in the cloud.
My opinion it was simply bad luck, should not have gone through the cloud, but bad luck all the same. (How many of us fly a 180 through a cloud and expect nothing in there?)
His experience should have won the day. Dam crane was the problem.

[Boudreaux Bob]

My opinion it was simply bad luck, should not have gone through the cloud, but bad luck all the same.

VFR/SVFR were the Rules he was supposed to be operating under.

When you fly through Cloud under those Rules you eliminate "Luck" and introduce "Fate".

I would suggest you read the visibility requirements for VFR and SVFR.....then reconsider your "Opinion".

The AAIB Report and all the comments that have been made about this sad event really boil down to a single very simple truth.

The aircraft was being operated in a manner that did not allow for avoidance of obstructions while operating under Visual Flight Rules.

That was the Pilot's own doing, everything else is secondary.

Count all the different times he could have said "No!" and could have done so quite reasonably.

That is the one thing that needs to be learned from Tragedies like this. A single word with two Letters is so hard for helicopter pilots to say.....even though it is begged sometimes.

The AAIB should examine that fatal flaw so many of us have. We all have it to some degree. Some of us have survived despite failing to find the ability to say that one single word at the appropriate time.

Usually one really good Scare and we seem to find it much easier if we are around afterwards.

[Harry O]

Barnsey was the best pilot I knew.
I bet most aviators on here have encountered cloud at some stage in their lives, and have usually done a 180 to remain clear. Pete was IFR rated so he had the experience to fly in cloud.
London has numerous cranes going up. I think the problem with the obstructions in London is nobody is controlling them enough.
No cranes should be erected without the CAA being involved from the start, and ATC should be made aware of every one in their area (each day). Part of a hand over brief to each controller for that patch. Not just the Notams.
Do ATC have any crane obstacle markers on their screens for the London area for low level ops?
If the cranes are close to heliports such as Battersea, ATC should look at altering the heights allowed within ATC zones.
The crane type involved is becoming more common and they are almost invisible against the tower blocks in London.

Just noted the BB comment, and all I can say is weather changes...

[Sir Niall Dementia]

Harry O;


Read the London area NOTAMs for any day of the week, then fly over and look out of the window. There are thousands of cranes, and hundreds of NOTAMS. It would be impossible to do anything like you suggest. Just to add confusion the NOTAMs are not in any decent order with some showing LHR airspace, some LCY and some just a London Lat/Long.


The number of crane NOTAMs now is ridiculous and really deserves a section just to itself.


SND

[SilsoeSid]

To accompany the simple 2 letter word that Bob mentioned earlier, there is also a simple TLA that would also apply here ... 'CRM'.

[Boudreaux Bob]

Harry,

We all make mistakes, aviation has always been that way and always shall.

Accepting that fact shows no disrespect of anyone and we should always seek to learn from those sad times we lose one of our own.

I can assure you if it had ever happened to me I would hope there would have been a very honest and candid discussion of what happened.

If that were not done I would see it as opportunity lost that might just prevent someone else from falling into the same trap I did.

In this tragedy, some decisions were made that led to a very bad ending.

I would submit that flying in Cloud over downtown London at very low altitude while supposed to be VFR demands some cold hard consideration.

It may not be what you wish to see but the professional in you should accept the importance and propriety of that being done.

[DOUBLE BOGEY]

I agree with Bob. We have to be honest regardless of what we thought of Pete. In my view this flight was pushing the limits of feasibility before take-off and reading the reports, the numerous risks involved were simply not in balance with the nature of the flight. It was a simple private charter.

Flying in cloud in such circumstances is not compliant with the IFR.

[CAAAD]

I am a bit surprised that in a high workload environment such as seems to have been the case, single pilot, poor visibility, and so on, the pilot was texting. Although I may be a bit old fashioned and naive.

But it does beg the question - Is this a common practise in the rotorcraft fraternity?

[ShyTorque]

I am a bit surprised that in a high workload environment such as seems to have been the case, single pilot, poor visibility, and so on, the pilot was texting. Although I may be a bit old fashioned and naive.

But it does beg the question - Is this a common practise in the rotorcraft fraternity?

Not with me it's not. I have difficulty texting on the ground, let alone in the air.

[Flying Lawyer]

CAAAD

I am a bit surprised that in a high workload environment such as seems to have been the case, single pilot, poor visibility, and so on, the pilot was texting.

The texts sent/received in flight were whilst the pilot was in VMC above the cloud:

0747 Pilot to Witness A: VFR on top at 1500 feet
0748 Witness A to Pilot: But can you land?
0751 Pilot to Witness A: No hole hdg back to red
0753 Witness A to Pilot: Ok
0753 Pilot to Client: Over Elstree no holes I’m afraid hdg back to Redhill least we tried chat in 10

(The pilot obtained clearance to Redhill and, at 0753, ATC asked: “Rocket 2 do you have VMC or would you like an IFR transit?”
The pilot replied: “I have good VMC on top here, that’s fine, Rocket 2”.)

0755 Client to Pilot: Battersea is open
0755 Pilot to Operator: Can’t get in Elstree hdg back assume clear still
0755 Operator to Pilot: Yes it’s fine still here. (This text was not read.)

The last read and sent text messages were approximately four minutes before the collision with the crane:

At 0756, following the message from the client telling him Battersea was open, the pilot asked ATC to confirm.
It was only after ATC confirmed that it was, that he subsequently descended - while waiting to be cleared to Battersea.

He was using the radio to talk to ATC until a few seconds before impact.
The AAIB considered it unlikely that he was distracted at the same time by composing a text message.

I agree, and would go further: I regard it as extremely unlikely.
Firstly because there is not a shred of evidence that he was and, secondly, because the available evidence suggests that he wasn't.


FL

[terminus mos]

Texting while driving is illegal, has been proven to cause distraction and accidents and is a stupid thing to do.

Texting while flying as Captain of an aircraft under VFR or Special VFR or IFR and in marginal weather is crazy, regardless of whether it was a contributory factor at the actual time of the accident or not.

The pilot went against all CRM / ADM learning I have ever seen, he placed undue commercial and operational pressure on himself, there was plenty of opportunity to break this unfortunate chain which he didn't take.

[Bronx]

He wasn't in marginal weather when he sent/read texts.
He was above it in clear blue skies.

he placed undue commercial and operational pressure on himself

I don't think it was self-imposed pressure but, whether it was or wasn't, it still raises questions about why he felt the need to do it.

It's not the first time it's happened and it won't be the last unless the industry is prepared to face up to the direct and indirect pressures on corporate/freelancer helicopter pilots and think of some way of doing something about it.

He was a very experienced pilot, and from what I read on the original thread, well respected by his peers but he still felt he had to try to get the job done. Why did he feel that?

Instead of just dismissing it as yet another 'one off' we need to look more deeply into the pressures that cause this sort of thing to happen time and time again in the corporate world and try to do change the culture that leads to it.
The culture sure ain't gonna change on its own.