AAIB Report A109E accident at Vauxhall, and Inquest Verdict
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Would any action or report have been taken or made if he had not hit the crane?
Mickjoebill,
I think you might have steered this conversation in the right direction,finally.
Single pilot operations typically are unsupervised and unchallenged.If Pete had made it that day,it would be unlikely that ,other than he himself, anyone else would have got to know about how close the call was. Seen it here dozens of times.All of us have had our "never doing that again!" moments,but does that a safer operation or a safer pilot make? After all, asking a pilot to voluntarily reveal his close shaves because he pushed the limits is akin to asking a motorist who jumps a red light to stop at the next police station and turn himself in.Never going to happen. We remain human. And, there is the rub.How do operators, gently and in a non punitive way, make pilots reveal their screw ups ? Not by regulation.It has to be by building trust and constant reinforcement of that trust.
Is that possible? I don't know but I am sure it is worth a try.
Alt3
Mickjoebill,
I think you might have steered this conversation in the right direction,finally.
Single pilot operations typically are unsupervised and unchallenged.If Pete had made it that day,it would be unlikely that ,other than he himself, anyone else would have got to know about how close the call was. Seen it here dozens of times.All of us have had our "never doing that again!" moments,but does that a safer operation or a safer pilot make? After all, asking a pilot to voluntarily reveal his close shaves because he pushed the limits is akin to asking a motorist who jumps a red light to stop at the next police station and turn himself in.Never going to happen. We remain human. And, there is the rub.How do operators, gently and in a non punitive way, make pilots reveal their screw ups ? Not by regulation.It has to be by building trust and constant reinforcement of that trust.
Is that possible? I don't know but I am sure it is worth a try.
Alt3
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BB - that's a bit disappointing - I thought you might have been able combine the facts provided in the report with your no doubt extensive flying experience to come up with a hypothesis or two to explain the actions that immediately lead to the impact.
Which brings me back to my earlier generalisations comment, and limitations of their value. Saying "fly safer, or "fly by the rules" is valid and reasonable, but of limited value in focussing pilots' minds on risk areas. There can be further benefit in really trying to understand what actually caused the critical error in any given accident. Take the Sumburgh Super Puma crash - what actually caused two pilots to fail to monitor speed anmd height during an approach and hit the sea? Here is not the place to answer that of course.
Which brings me back to my earlier generalisations comment, and limitations of their value. Saying "fly safer, or "fly by the rules" is valid and reasonable, but of limited value in focussing pilots' minds on risk areas. There can be further benefit in really trying to understand what actually caused the critical error in any given accident. Take the Sumburgh Super Puma crash - what actually caused two pilots to fail to monitor speed anmd height during an approach and hit the sea? Here is not the place to answer that of course.
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Rotor,
Let me put it this way for you.
As I was not there and thus have no knowledge of what he was actually seeing weather wise, and not knowing what he was thinking, it is of not much use for me to speculate about that.
That being said, there is no way in Hell I would have done what he did which was to enter Cloud, Fog, or whatever it was that prevented him from seeing where he was going. That is what is baffling about all of this as it just plain does not make any kind of sense at all that he would have done what he did.
One just does not do that kind of thing in the location and weather he was at that day.
Gordy uses a very good saying....."Ass, Tin, Ticket!".
When you get into a real Pickle you save your Ass, try to keep from harming the Helicopter, and ignore the Legal Rules even if it means losing your license for a while.
If I had dropped down to the River looking for a way to slide into the Heliport and then found myself with no where to go....I would have hover mosey'ed along the River until I found a way out and suffered the consequences of my actions. I would never punch into a Cloud or Fog Bank thinking it a wise or safe thing to do.
Let me put it this way for you.
As I was not there and thus have no knowledge of what he was actually seeing weather wise, and not knowing what he was thinking, it is of not much use for me to speculate about that.
That being said, there is no way in Hell I would have done what he did which was to enter Cloud, Fog, or whatever it was that prevented him from seeing where he was going. That is what is baffling about all of this as it just plain does not make any kind of sense at all that he would have done what he did.
One just does not do that kind of thing in the location and weather he was at that day.
Gordy uses a very good saying....."Ass, Tin, Ticket!".
When you get into a real Pickle you save your Ass, try to keep from harming the Helicopter, and ignore the Legal Rules even if it means losing your license for a while.
If I had dropped down to the River looking for a way to slide into the Heliport and then found myself with no where to go....I would have hover mosey'ed along the River until I found a way out and suffered the consequences of my actions. I would never punch into a Cloud or Fog Bank thinking it a wise or safe thing to do.
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I asked my original question about texting because it seemed to be an unnecessary distraction.
I studied the AAIB report a bit further, and found a meticulous investigation, but a disappointing set of Recommendations, often the case in my experience.
There seems to be a general feeling on the forum that the pilot was not acting in a professional manner, despite his experience and general competency.
The AAIB have chosen to ignore behavioural issues completely in favour of plodding obstacle rule making improvements and so on.
This could have been an excellent opportunity to have made an attempt to get to grips with what appears to be a significant industry wide problem, but the AAIB have rather let us down.
I studied the AAIB report a bit further, and found a meticulous investigation, but a disappointing set of Recommendations, often the case in my experience.
There seems to be a general feeling on the forum that the pilot was not acting in a professional manner, despite his experience and general competency.
The AAIB have chosen to ignore behavioural issues completely in favour of plodding obstacle rule making improvements and so on.
This could have been an excellent opportunity to have made an attempt to get to grips with what appears to be a significant industry wide problem, but the AAIB have rather let us down.
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Hoping to satisfy the Holy Trinity by stating both rotary and fixed qualifications, and having 'pushed the boundaries' more than a few times - cutting through the crap here:--
Surely the lesson is that if you are going for a bit of skoshie as Mr Hanna used to call it, don't do it
a) Below the level of nearby obstructions
b) Over built-up areas, so far less chance of taking an unfortunate bystander with you?
This does not just apply to rotary!
Surely the lesson is that if you are going for a bit of skoshie as Mr Hanna used to call it, don't do it
a) Below the level of nearby obstructions
b) Over built-up areas, so far less chance of taking an unfortunate bystander with you?
This does not just apply to rotary!
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CAAAD
I disagree with you about the AAIB's recommendations concerning obstacles (and think they should have gone further in some respects) but I agree entirely with you that they should have looked more closely into the factors which regularly lead to such accidents. In particular, but not exhaustively, the matters mentioned by puntosaurus very early in the thread.
TC
I disagree, for the reasons already suggested by others.
That is the same customer/principal who AFTER being told by the pilot at 0753: "Over Elstree no holes I’m afraid hdg back to Redhill least we tried chat in 10" then sent him a text two minutes later saying: "Battersea is open." The AAIB concluded, correctly in my opinion, that it was likely that the customer's message led to the pilot (wrongly) deciding to divert to Battersea instead of continuing in VMC to to Redhill.
Report 2.3.2:
For the avoidance of any misunderstanding, I am not defending his decision to do so.
For some reason, you believe that those who disagree with your approach either haven’t been listening to you or don’t understand. I suspect most posters agree with most of what you've said about this accident. However, not everyone agrees that the factors which led to it are as simple and straightforward as you and some others believe. There are other factors which need to be considered and addressed. (I'm not referring to "subliminal psychoanalytical, interdevelopmental breakdown.")
There have been differences of opinion regarding texting while flying in VMC but everyone appears to be agreed that the pilot exercised poor judgment when he left VMC and, as ShyTorque said earlier, made the fatal mistake of descending into fog lifting into low cloud. Those, such as Piltdown Man, who have argued that there should be more careful examination of the factors which may have led this pilot to do what he did (and many other pilots before him to make similar poor judgments) have been wrongly accused failing to understand and by one poster of 'defending' the pilot. They have done neither.
John R81
I agree.
FL
I disagree with you about the AAIB's recommendations concerning obstacles (and think they should have gone further in some respects) but I agree entirely with you that they should have looked more closely into the factors which regularly lead to such accidents. In particular, but not exhaustively, the matters mentioned by puntosaurus very early in the thread.
TC
He was not (repeat) under any time, financial pressure to get to his destination.
He had been told by the customer to forget it.
He had already decided to press on AFTER his principal had told him not to bother.
He had already decided to press on AFTER his principal had told him not to bother.
Report 2.3.2:
The flying time from Redhill Aerodrome to overhead London Heliport is short, so the operational advantage of waiting at the heliport rather than the aerodrome is not obvious. The pilot might have thought that the client intended to drive to the heliport and that to position the helicopter there in advance of the client’s arrival would be advantageous from a commercial perspective. This seemed likely given that the pilot appeared to decide to divert to the heliport immediately after he learned from the client that it was open.
For some reason, you believe that those who disagree with your approach either haven’t been listening to you or don’t understand. I suspect most posters agree with most of what you've said about this accident. However, not everyone agrees that the factors which led to it are as simple and straightforward as you and some others believe. There are other factors which need to be considered and addressed. (I'm not referring to "subliminal psychoanalytical, interdevelopmental breakdown.")
There have been differences of opinion regarding texting while flying in VMC but everyone appears to be agreed that the pilot exercised poor judgment when he left VMC and, as ShyTorque said earlier, made the fatal mistake of descending into fog lifting into low cloud. Those, such as Piltdown Man, who have argued that there should be more careful examination of the factors which may have led this pilot to do what he did (and many other pilots before him to make similar poor judgments) have been wrongly accused failing to understand and by one poster of 'defending' the pilot. They have done neither.
John R81
To me that facts that led to him dropping down through the sucker-hole are interesting in that they led to that decision. Part of the investigation and something to learn from for sure, but separate from what happened down below cloud.
FL
Last edited by Flying Lawyer; 12th Sep 2014 at 23:04.
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FL,
Did the AAIB determine what the Client meant when he reported the Heliport "Open"? Did the Client know for a fact the weather was above Minimums for Operations at the Heliport or was it a blanket reference meaning only the "Opening Time" was at hand?
Likewise, when ATC told the Pilot the Heliport was "Open", did that tell the Pilot the Weather was satisfactory for VFR Operations into the Heliport?
How is Ceiling/Visibility measured at the Heliport and reported to Inbound Traffic?
Must Inbound Traffic remain clear of the Heliport until given permission to enter?
Is it ATC that issues that clearance or someone at the Heliport?
Did the AAIB determine what the Client meant when he reported the Heliport "Open"? Did the Client know for a fact the weather was above Minimums for Operations at the Heliport or was it a blanket reference meaning only the "Opening Time" was at hand?
Likewise, when ATC told the Pilot the Heliport was "Open", did that tell the Pilot the Weather was satisfactory for VFR Operations into the Heliport?
How is Ceiling/Visibility measured at the Heliport and reported to Inbound Traffic?
Must Inbound Traffic remain clear of the Heliport until given permission to enter?
Is it ATC that issues that clearance or someone at the Heliport?
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Bob
I have already quoted what the AAIB said about Client's final text.
I have no reason to believe that the client knew anything about the Minimums for Operations at the Heliport. That was not the AAIB's point; nor is it mine.
No, it was not "a blanket reference meaning only the "Opening Time" was at hand."
Re your other questions:
The communications regarding diverting to Battersea are fully set out in the report. Again for the avoidance of any misunderstanding, I am not criticising ATC.
I am not trying to defend either the pilot's decision to descend or his actions thereafter.
I am interested in the factors which led to his decision to descend because that is the area which in my opinion has never been sufficiently explored and might have potential for improving flight safety. Perhaps it won't, but IMHO it's worth trying.
I have already quoted what the AAIB said about Client's final text.
I have no reason to believe that the client knew anything about the Minimums for Operations at the Heliport. That was not the AAIB's point; nor is it mine.
No, it was not "a blanket reference meaning only the "Opening Time" was at hand."
Re your other questions:
The communications regarding diverting to Battersea are fully set out in the report. Again for the avoidance of any misunderstanding, I am not criticising ATC.
I am not trying to defend either the pilot's decision to descend or his actions thereafter.
I am interested in the factors which led to his decision to descend because that is the area which in my opinion has never been sufficiently explored and might have potential for improving flight safety. Perhaps it won't, but IMHO it's worth trying.
Last edited by Flying Lawyer; 12th Sep 2014 at 23:44.
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FL,
I was not being critical of your posts, just wanting to make sure of what the facts and situation was re those issues. You know I very much consider you to be One to listen to closely.
The Rules, ATC, Weather, Client, Operator, and every other factor can conspire (even unknowingly) to create a Mine Field for us but it is up to us to tread safely and not step squarely on top of those we can see.
In this particular case, there is only one way the Finger can point in that regard.
That being said, I fully agree with your desire to see a much broader review of all those factors and influences that played a role in this and other similar accidents such as the 139 Crash and the Glasgow Police Crash.
All three of these tragedies have some related factors that need examination.
I was not being critical of your posts, just wanting to make sure of what the facts and situation was re those issues. You know I very much consider you to be One to listen to closely.
The Rules, ATC, Weather, Client, Operator, and every other factor can conspire (even unknowingly) to create a Mine Field for us but it is up to us to tread safely and not step squarely on top of those we can see.
In this particular case, there is only one way the Finger can point in that regard.
That being said, I fully agree with your desire to see a much broader review of all those factors and influences that played a role in this and other similar accidents such as the 139 Crash and the Glasgow Police Crash.
All three of these tragedies have some related factors that need examination.
Avoid imitations
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I'll say it again.....in aviation, sometimes the most difficult thing is knowing when to say "NO!", and of course, also having the strength of character to say it.
The saying "Ass, tin, ticket" is a good mantra, but it also needs suffixing with the word "Job".
Human nature means that pilots will continue to learn the hard way.
The saying "Ass, tin, ticket" is a good mantra, but it also needs suffixing with the word "Job".
Human nature means that pilots will continue to learn the hard way.
Would it make any difference to this discussion if there were links to a video and still photos showing a pilot flying reasonably but breaking regulations for HEMS flying, on 2 different jobs?
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Breaking exactly what regulations? Flying single crew VFR in cloud = zero vis! next to tall buildings, means a lot closer than 500ft? Above London? Tokyo? NY city? Thank god I live in a bungalow. On the countryside.
Last edited by rantanplane; 13th Sep 2014 at 19:15.
Per Ardua ad Astraeus
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.........if only he had turned left from the right bank.......................
I recall someone asking on the previous thread about an assessment of forward speed - the AAIB makes no mention I could find. Did anyone do the maths from the radar plots?
I recall someone asking on the previous thread about an assessment of forward speed - the AAIB makes no mention I could find. Did anyone do the maths from the radar plots?
Purveyor of Egg Liqueur to Lucifer
Garmin 430 Terrain feature
http://www.aaib.gov.uk/cms_resources...4%20G-CRST.pdf
Page 13
All well and good, but does anyone know when the terrain feature was added to the 430?
From what I can see with the paperwork I have here, any units pre 2007 didn't have the terrain feature.
Page 13
1.6.3 GPS devices
The helicopter was fitted with two panel-mounted GPS units, a Bendix King
KMD 150 and Garmin 430, both of which have a colour moving-map display.
The Garmin 430 can provide navigation, communications, and terrain and
obstacle warning functionality. There are two memory card slots provided to
allow the integration of database information. Typically one would be used for
navigation data and the other to provide terrain and obstacle information. Each
card can be accessed from a quick-release slot on the front of the device.
1.6.3.1 Terrain and obstacle warning
If a valid database and three dimensional position fix is available, the Garmin
430 will be able to display terrain and obstacles relative to the helicopter
altitude and position. For obstacle avoidance, the display features a number of
different symbols representing the different levels of alert and types of obstacle
In addition, the device can use flight path data to trigger an alert in respect
of terrain or obstacles which may present a hazard. If an alert is triggered,
the ‘TERRAIN’ page provides a flashing ‘TERRAIN’ annunciation8 in the lower
left-hand corner ‘annunciator field’ (Figure 7). There is an option to inhibit this
annunciation although the symbols in Figure 6 will still be available. When
activated, this will be displayed on the ‘annunciator field’ as ‘TER INHB’.
1.6.3.2 Database update
The GPS units fitted to G-CRST were destroyed in the post-impact fire and it
was not possible to determine their database revision status at the time of the
accident. The terrain and obstacle database to which the GPS manufacturer
refers on its website is available on a subscription basis and updated on a
56‑day cycle.
Operators can download database updates and transfer the data to GPS units
in individual aircraft. As the GPS unit is a customer option rather than standard
equipment, updates are not a scheduled maintenance requirement in the
helicopter manufacturer’s maintenance planning document and, in the case
of G-CRST, were not logged by the maintenance provider as a maintenance
action. The operator stated that it updated GPS databases annually in March
and had not updated the database in G‑CRST because it received the aircraft
in May 2012.
The helicopter was fitted with two panel-mounted GPS units, a Bendix King
KMD 150 and Garmin 430, both of which have a colour moving-map display.
The Garmin 430 can provide navigation, communications, and terrain and
obstacle warning functionality. There are two memory card slots provided to
allow the integration of database information. Typically one would be used for
navigation data and the other to provide terrain and obstacle information. Each
card can be accessed from a quick-release slot on the front of the device.
1.6.3.1 Terrain and obstacle warning
If a valid database and three dimensional position fix is available, the Garmin
430 will be able to display terrain and obstacles relative to the helicopter
altitude and position. For obstacle avoidance, the display features a number of
different symbols representing the different levels of alert and types of obstacle
In addition, the device can use flight path data to trigger an alert in respect
of terrain or obstacles which may present a hazard. If an alert is triggered,
the ‘TERRAIN’ page provides a flashing ‘TERRAIN’ annunciation8 in the lower
left-hand corner ‘annunciator field’ (Figure 7). There is an option to inhibit this
annunciation although the symbols in Figure 6 will still be available. When
activated, this will be displayed on the ‘annunciator field’ as ‘TER INHB’.
1.6.3.2 Database update
The GPS units fitted to G-CRST were destroyed in the post-impact fire and it
was not possible to determine their database revision status at the time of the
accident. The terrain and obstacle database to which the GPS manufacturer
refers on its website is available on a subscription basis and updated on a
56‑day cycle.
Operators can download database updates and transfer the data to GPS units
in individual aircraft. As the GPS unit is a customer option rather than standard
equipment, updates are not a scheduled maintenance requirement in the
helicopter manufacturer’s maintenance planning document and, in the case
of G-CRST, were not logged by the maintenance provider as a maintenance
action. The operator stated that it updated GPS databases annually in March
and had not updated the database in G‑CRST because it received the aircraft
in May 2012.
From what I can see with the paperwork I have here, any units pre 2007 didn't have the terrain feature.
The accident helicopter was serial number 11017 and was manufactured by
Agusta in 1998. At the last log book entry prior to the accident, the airframe
had accumulated 2,304.5 flight hours since new. The engines were original to
the airframe and had the same number of hours since new. The helicopter had
previously been operated in the UK on the USA register but was transferred to
the UK register in 2007 as G-WRBI.
Agusta in 1998. At the last log book entry prior to the accident, the airframe
had accumulated 2,304.5 flight hours since new. The engines were original to
the airframe and had the same number of hours since new. The helicopter had
previously been operated in the UK on the USA register but was transferred to
the UK register in 2007 as G-WRBI.
Saw this on Facebook this Morning......
Helicopter pilot who crashed in central London felt 'pressure' to fly despite bad weather - Telegraph
Helicopter pilot who crashed in central London felt 'pressure' to fly despite bad weather - Telegraph
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This is the most relevant section of that report for me...
"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”. "
It clearly shows he changed his mind, probably due to being pressured, “coming anyway will land in a field if I have to”. and this is the start of a very bad day.
"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”. "
It clearly shows he changed his mind, probably due to being pressured, “coming anyway will land in a field if I have to”. and this is the start of a very bad day.
I learned a long time ago that "Weather Checks" are done from the Ground.....either it is good enough or it is not. I know of very few fatalities inside a Tea Room.
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?