Police helicopter crashes onto Glasgow pub: final AAIB report
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DrinkGirls,
How does fuel get into the supply tanks during fuelling?
In your picture, it implies that once the main tank is above the "fence" fuel spills into the supplies, it doesn't.
Hi Chopjok,
not quite sure about the 135 - but in the BK117 you switch the transferpumps on, to get the feeder tanks filled.....
Wich you seldom need, cause you normaly land with them filled....
not quite sure about the 135 - but in the BK117 you switch the transferpumps on, to get the feeder tanks filled.....
Wich you seldom need, cause you normaly land with them filled....
Hi chopjock
The refuelling point is into the main tank. This will fill the main tank until it reaches the level of the two pipes that connect the main tank to each of the supply tanks; at this point, fuel will 'overflow' into the supply tanks and fill them. The exceptions to this are:
1) If the battery is on and transfer pumps are selected on, the FWD transfer pump will be filling both supply tanks during the refuel
2) If the battery is on, shed bus switch is activated or ground power is applied and transfer pumps are selected on, then both transfer pumps will be filling both supply tanks during the refuel
Ignore any mention of a 'fence' in this process - the fence exists between the two supply tanks and happens to be at approximately the level of the two connecting 'overflow' pipes.
Cheers
TeeS
The refuelling point is into the main tank. This will fill the main tank until it reaches the level of the two pipes that connect the main tank to each of the supply tanks; at this point, fuel will 'overflow' into the supply tanks and fill them. The exceptions to this are:
1) If the battery is on and transfer pumps are selected on, the FWD transfer pump will be filling both supply tanks during the refuel
2) If the battery is on, shed bus switch is activated or ground power is applied and transfer pumps are selected on, then both transfer pumps will be filling both supply tanks during the refuel
Ignore any mention of a 'fence' in this process - the fence exists between the two supply tanks and happens to be at approximately the level of the two connecting 'overflow' pipes.
Cheers
TeeS
Information Notice AHD EC135 IN 2693-I-28
Starts at page 111 in the report pretty much explains it.
With respect to your dialogue it pretty much covers it.
Starts at page 111 in the report pretty much explains it.
With respect to your dialogue it pretty much covers it.
It is frustrating, just like a certain chinook thread.
Someone flies beyond their ultimate endurance as quantified by consumption over time and even when faced with a drawn-out barrage of low fuel indications carries on tasking and falls out of the sky in a failed attempt to achieve the most fundamental of a helicopter pilot's emergency manoeuvres; autorotation. This is, by anyone's standards utterly inexplicable yet it happened.
And everyone who knew him said "he was such a brilliant pilot he couldn't possibly have done this..."
Someone flies VFR into fog, returns towards base and while apparently texting (!) on his phone in IMC in controlled airspace while under SVFR tries to carry out an unplanned diversion into somewhere without visual contact and hits a crane...This is, by anyone's standards utterly inexplicable yet it happened.
And everyone who knew him said "he was such a brilliant pilot he couldn't possibly have done this..."
A mil heavy flies in marginal VMC into a mountain that they knew was there and was planned into their nav kit (the rights and wrongs of whether another type should have been used is irrelevant) This is what happened. This is, by anyone's standards utterly inexplicable yet it happened.
And everyone who knew him said "he was such a brilliant pilot he couldn't possibly have done this..."
A superbly IFR equipped 2 pilot corporate twin ploughs onto the ground 600m from it's take off point in 20m vis. Thew crew apparently couldn't perform a towering IFR departure - had never been taught??? The company involved already had similar previous. This is, by anyone's standards utterly inexplicable yet it happened.
And everyone who knew him said, "he was such a brilliant pilot he couldn't possibly have done this..."
How many other cases can we provide to support this theory?
How many pilots have shut down the wrong engine, and all their colleagues indignantly cry,
"he was such a brilliant pilot he couldn't possibly have done this..."
How did 3 Korean pilots inc. at least one line trainer drag the keel of a 777 over the round-down and damn near scribble 300 people? This is, by anyone's standards utterly inexplicable yet it happened.
"they were such experienced pilots they couldn't possibly have done this..."
A Hawker Hunter ploughs into a main road after a manoeuvre involving a bizarre cranked half cuban entry into a loop or somesuch,
And all who knew him protested "he was such a brilliant pilot he couldn't possibly have done this..."
The Display Safety Officer at a show at Duxford, .... He'd just briefed everyone else not to do it, then promptly did it himself. This is, by anyone's standards utterly inexplicable yet it happened.
And everyone who knew him said "he was such a brilliant pilot he couldn't possibly have done this..." But he had.
And a dozen or more others.
Yet in each case they did do it, and in each case without the tiniest shred of evidence - evidence mind you, not emotion, evidence - or even a credible theory - to suggest anything but pure pilot error.
Isn't it about time we grew up enough to accept that even the best of pilots can and occasionally do make the daftest seeming mistakes? It may hurt us, by association, to admit this as it infers fallibility in the rest of us which is never a comfortable admission, but the reality is that this simply is the case in a surprising number of accidents.
Every time there is an accident it seems that max effort is put into "proving"the pilot - that infallible God-like being made in the image of the rest of us, could not possibly have had anything to do with it even when it is abundantly clear that there is no shred of evidence for anything else.
I do not accept legal quibbles re "proof beyond reasonable doubt" which in today's wacky logic means "proof beyond any other statistical possibilty" which isn't the same thing, is reason to deny the likelyhood of the cause - to do so is to bury our heads in the sand and deny the possibility of human error which is repeatedly proven to be by far the most likely cause.
From a position of both logic and such evidence as we have from previous events where no other feasible cause is found it seems obvious beyond reasonable doubt that the rational thing is to question the pilots's actions or inactions.
In this particular case there is apparently no suggestion of malfunctions (as opposed to design errors) within the fuel warning nor any other system system so what explanation can there be except that the pilot, for some unknown reason, continued the flight beyond any reasonable rationale.
We'll never know that rationale, we probably could not even know it had a flight data/voice recorder been fitted but even when every helo, glider and microlight is encumbered with one with one I think we can be assured that every now and again someone is going to fly into predicted cumulo granitus, blindly clobber a construction crane or just try to fly for an hour on fifty nine minutes of fuel in the hope that - well - what?? We'll never know, except that he did.... It's simply human nature. And a mystery. Mandatory recorders will almost certainly reinforce the fact that many, if not most accidents are not related to technical malfunctions at all and though in some cases we'll gain clues from what is said or recorded we'll still be totally flummoxed by the greater proportion.
I don't think we advance the science of air safety by resolutely denying the likelihood of pilot error simply because he "was a good bloke" and we think him to be a "good pair of hands" and therefore incapable of error - or rather that in the reflected limelight we prefer to think ourselves as infallible as we wish him to have been...
It's a bit of a generalisation but statistically a pretty sound assertion that if it looks like a duck, flies like a duck, quacks like a duck than it probably is a duck and thus most likely didn't fly into the ground in vmc by virtue of some inexplicable and unreproduceable avionics failure or fuel system design fault.
A desire to absolve fellow pilots of responsibility for an accident is all very commendable but when blindly continued - as so often happens - in defiance of all evidence it begins to look like no more than tribalism, self indulgence or nepotism. Or a kind of transferred self-denial. And that is a blinker that Aviation Safety could do without.
Doubtless I will be flamed into ashes now for daring to say such heretical things, this concept will not be to everyone's taste, but can you fault the general logic?
Last edited by Wageslave; 29th Oct 2015 at 03:00.
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Wageslave
You make a good point. The AAIB reports tend to focus on the mechanics of flight and problems with the aircraft, rather than the pilot. Where no mechanical issues are found, then it is put down to pilot error. But, there is seldom any detailed analysis or report about the personality of the pilot, relationship problems, and other issues that may have influenced his or her behaviour at the time of the accident. At best we get, the pilot was well rested having flown x number of hours y days before the accident flight and had a class 1 medical. No drugs or alcohol were found in the body. Often the reason for this is cited as not wishing to intrude, embarrass or further distress grieving relatives. The German Wings crash was a notable exception to this general rule.
A common factor in many accident flights is that pilots are (or feel) pressured into making a flight when their own best judgement should be screaming NO! If the man with the money says fly, you fly. Good well paid flying jobs are hard to come by.
You make a good point. The AAIB reports tend to focus on the mechanics of flight and problems with the aircraft, rather than the pilot. Where no mechanical issues are found, then it is put down to pilot error. But, there is seldom any detailed analysis or report about the personality of the pilot, relationship problems, and other issues that may have influenced his or her behaviour at the time of the accident. At best we get, the pilot was well rested having flown x number of hours y days before the accident flight and had a class 1 medical. No drugs or alcohol were found in the body. Often the reason for this is cited as not wishing to intrude, embarrass or further distress grieving relatives. The German Wings crash was a notable exception to this general rule.
A common factor in many accident flights is that pilots are (or feel) pressured into making a flight when their own best judgement should be screaming NO! If the man with the money says fly, you fly. Good well paid flying jobs are hard to come by.
The Boss Man saying "FLY!" was undoubtably a big factor in two of the scenarios I mentioned, but I feel that this accident went deeper than that.
What on earth makes someone carry on flying with the whole warning panel is screaming "low fuel" and the stopwatch is backing that up?
Was it "Oh, we'll just squeeze it back home, it'll be OK and we'll keep shtumm" or simply shocked denial of all the evidence and suppression of the facts, or some sort of fear-induced bravado? Maybe even simple flat denial. Panic perhaps? Low fuel! Sheeeet! and perhaps continue the motor task but freeze mentally? We can't afford to reject any of these possibilities.
Lack of rest, family troubles or the Boss saying "Fly!" are all stressors and decision making influences but I feel that something much deeper, much more fundamental to the task occurred, something more akin to target fixation perhaps. A Professional pilot on a complex mission in challenging conditions getting so wrapped up in the task that he allows the tactical situation to overwhelm his judgement? This is far beyond mere fatigue or boss-induced stress, this is a kind of hypnosis or tactical tunnel vision that obscures the rest of his judgement? I don't know, I just can't see a scenario that is remotely familiar to me that could explain it, and lets face it, the engineers can't explain it so like it or not it is most likely to be down to something on these lines..
Look how those A300 pilots flew repeated approaches to Mogadishu last week and finally ran out of fuel downwind - it's not as if they didn't see it coming with each successive go-around, but something gripped their minds so comprehensively that they finally launched into the luft with only enough fuel for half a circuit. How could that be? Yet they did it. Their broad tactical view had somehow been compressed into looking down a toilet paper tube, and ultimately down one with a plug in it. Yet they still flew on imagining a picture it couldn't possibly have shown them. They were far from the first, and they certainly won't be the last. CRM doesn't begin to explain how this sort of thing happens despite it being a recognised cause of accidents. Why is that? It is clearly a not infrequent occurrence.
We'll never know but I'd bet Clutha was sometjhing similar. I'll be looking to the psychologists rather than engineers for an answer to this accident now, and I'm not holding my breath.
I'm just so sorry the relatives were mislead into expecting that the AAIB report would provide definitive answers when it was pretty clear from the start that it could not. I hope and pray they are not similarly deceived by the media over the equally fallible powers of the Fatal Accident Enquiry which, in the absence of any new facts, has no more hope of providing an answer.
What on earth makes someone carry on flying with the whole warning panel is screaming "low fuel" and the stopwatch is backing that up?
Was it "Oh, we'll just squeeze it back home, it'll be OK and we'll keep shtumm" or simply shocked denial of all the evidence and suppression of the facts, or some sort of fear-induced bravado? Maybe even simple flat denial. Panic perhaps? Low fuel! Sheeeet! and perhaps continue the motor task but freeze mentally? We can't afford to reject any of these possibilities.
Lack of rest, family troubles or the Boss saying "Fly!" are all stressors and decision making influences but I feel that something much deeper, much more fundamental to the task occurred, something more akin to target fixation perhaps. A Professional pilot on a complex mission in challenging conditions getting so wrapped up in the task that he allows the tactical situation to overwhelm his judgement? This is far beyond mere fatigue or boss-induced stress, this is a kind of hypnosis or tactical tunnel vision that obscures the rest of his judgement? I don't know, I just can't see a scenario that is remotely familiar to me that could explain it, and lets face it, the engineers can't explain it so like it or not it is most likely to be down to something on these lines..
Look how those A300 pilots flew repeated approaches to Mogadishu last week and finally ran out of fuel downwind - it's not as if they didn't see it coming with each successive go-around, but something gripped their minds so comprehensively that they finally launched into the luft with only enough fuel for half a circuit. How could that be? Yet they did it. Their broad tactical view had somehow been compressed into looking down a toilet paper tube, and ultimately down one with a plug in it. Yet they still flew on imagining a picture it couldn't possibly have shown them. They were far from the first, and they certainly won't be the last. CRM doesn't begin to explain how this sort of thing happens despite it being a recognised cause of accidents. Why is that? It is clearly a not infrequent occurrence.
We'll never know but I'd bet Clutha was sometjhing similar. I'll be looking to the psychologists rather than engineers for an answer to this accident now, and I'm not holding my breath.
I'm just so sorry the relatives were mislead into expecting that the AAIB report would provide definitive answers when it was pretty clear from the start that it could not. I hope and pray they are not similarly deceived by the media over the equally fallible powers of the Fatal Accident Enquiry which, in the absence of any new facts, has no more hope of providing an answer.
Last edited by Wageslave; 29th Oct 2015 at 02:40.
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Wageslave;
Well written, and saying what I believe so many are thinking. You have concerns about being flamed, you shouldn't. I don't believe anyone can argue such concise and well thought out posts.
SND
Well written, and saying what I believe so many are thinking. You have concerns about being flamed, you shouldn't. I don't believe anyone can argue such concise and well thought out posts.
SND
Avoid imitations
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Although I see the point of view put forward by "wageslave", I would never agree to the principle of every aircraft being fitted with a CVR.
Why not? Because not all aircraft are used for public transport and as a general principle, I'm against a surveillance society.
Why not? Because not all aircraft are used for public transport and as a general principle, I'm against a surveillance society.
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The whole premise of twin engine operations is based on probability. The probability of the first engine failing (P1) for whatever reason (fuel starvation etc), and the second engine failing (P2) on any given sortie is deemed to be so infinitesimally small (P1xP2) that the operation of twin engine craft are seen as a better option than single engine in many applications.
The trouble with this theory is that this incident has proved this isn't so and that once the pilot places the craft into a certain configuration (xfer switches off), for whatever reason, and leaves them off when they need to be back on (for whatever reason) after a certain period of time, P1 will become 1 (certainty), but worse, P2 will also become 1.
The fact that millions of hours have been accumulated in this type with no incident is irrelevant, when you are dealing with low probabilities, you have to wait millions of hours for something to happen. It seems a weak design to have something that needs to be in the correct position for continued and safe flight, out of direct line of sight, unlit and next to other switches of a similar look and feel.
If it really is impossible to design a pump that is able to be put in an automatic mode and we are stuck with xfer switches that are dependant on pilot management, they should at the very least be in direct line of sight and even better, positioned right below the relevant captions in the WU.
The trouble with this theory is that this incident has proved this isn't so and that once the pilot places the craft into a certain configuration (xfer switches off), for whatever reason, and leaves them off when they need to be back on (for whatever reason) after a certain period of time, P1 will become 1 (certainty), but worse, P2 will also become 1.
The fact that millions of hours have been accumulated in this type with no incident is irrelevant, when you are dealing with low probabilities, you have to wait millions of hours for something to happen. It seems a weak design to have something that needs to be in the correct position for continued and safe flight, out of direct line of sight, unlit and next to other switches of a similar look and feel.
If it really is impossible to design a pump that is able to be put in an automatic mode and we are stuck with xfer switches that are dependant on pilot management, they should at the very least be in direct line of sight and even better, positioned right below the relevant captions in the WU.
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ShyTorque
CVR's have nothing to do with with big brother watching, if they help investigators identify root cause of an accident why would you not want them? This current thread is a prime example of an accident that will leave loads of unanswered questions, speculation and second guesses.
It will not provide closure to those affected by the accident and it will not help the industry's ability to improve operational or emergency procedures, or pilot training.
There has been a lot of comments on this thread, some I agree with and some i think are pure fantasy and made with little knowledge. Wageslave pretty much summed it up. There are facts and they are unanswerable questions
CVR's have nothing to do with with big brother watching, if they help investigators identify root cause of an accident why would you not want them? This current thread is a prime example of an accident that will leave loads of unanswered questions, speculation and second guesses.
It will not provide closure to those affected by the accident and it will not help the industry's ability to improve operational or emergency procedures, or pilot training.
There has been a lot of comments on this thread, some I agree with and some i think are pure fantasy and made with little knowledge. Wageslave pretty much summed it up. There are facts and they are unanswerable questions
skyrangerpro: If it really is impossible to design a pump that is able to be put in an automatic mode and we are stuck with xfer switches that are dependant on pilot management, they should at the very least be in direct line of sight and even better, positioned right below the relevant captions in the WU.
N.B. Said company owns multiple BOs and one EC135, so they should know.
Anyone here knowledgable about types of EC135 transfer pumps?
Last edited by Reely340; 29th Oct 2015 at 12:00.
There is hope, at last:
And of course where there is light there has to be shadow:
Both quotes taken from Final Clutha crash report leaves many questions unanswered | Vertical Magazine - The Pulse of the Helicopter Industry
The manufacturer is also developing fuel quantity sensors that are less susceptible to water contamination, expected to be available in the fourth quarter of 2016. For the next update to the EC135, scheduled for certification next year, Airbus Helicopters is simplifying operation of the fuel transfer pumps to remain ON at all times during flight without dry-run indication warnings, reflecting the improved dry-run capabilities of new-generation pumps.
And of course where there is light there has to be shadow:
However, this change is not proposed for the current EC135 fleet, as the existing fuel pump caution signal does not differentiate between a dry-running pump and pump blockage.
Both quotes taken from Final Clutha crash report leaves many questions unanswered | Vertical Magazine - The Pulse of the Helicopter Industry
Dry running pumps have been available for years. Jet pumps (venturi fuel driven pumps) as used in the AS365/EC155 and others. In this case having Jet pumps in the main tanks would mean that the pilot had no need to worry about pumps running dry. As long as the boost pumps (replacing prime pumps) in the supply tank were operating then fuel would transfer.
I remember an engineer friend of mine discussing the unecessary complications built into modern design. He described a modern system to regulate water flow and level, describing level sensors and controlled valves. He concluded with of course you could always use a ballcock!!!
I remember an engineer friend of mine discussing the unecessary complications built into modern design. He described a modern system to regulate water flow and level, describing level sensors and controlled valves. He concluded with of course you could always use a ballcock!!!
Why not? Because not all aircraft are used for public transport and as a general principle, I'm against a surveillance society.
Public Transport or not....some very innocent people died as a result of this crash.
How many have to die before your desire for privacy is trumped?
By Wageslave:
"I'll be looking to the psychologists rather than engineers for an answer to this accident now, and I'm not holding my breath".
Good posts, Wageslave, and I think you are right not to hold your breath.
AAIB is a largely engineering led organisation and, I understand, do not have any Human Factors specialists on the team.
MrsY is a Human Factors specialist involved in accident investigation and was shocked by the lack of Human Factors knowledge/ experience/ interest after meeting with AAIB personnel.
"I'll be looking to the psychologists rather than engineers for an answer to this accident now, and I'm not holding my breath".
Good posts, Wageslave, and I think you are right not to hold your breath.
AAIB is a largely engineering led organisation and, I understand, do not have any Human Factors specialists on the team.
MrsY is a Human Factors specialist involved in accident investigation and was shocked by the lack of Human Factors knowledge/ experience/ interest after meeting with AAIB personnel.
Avoid imitations
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SAS,
There are many car accidents, far more than those in aircraft, which injure and kill members of the public, thousands of them. So, are you prepared to have a CVR in your private car?
Your private boat? People have boating accidents, some fatal.
In your private house? There are huge numbers of fatal accidents in the home.
Where do I draw the line?
CVRs in all PT aircraft, by all means, but not in all aircraft. In any case, the use of them in private aircraft would be totally unregulated, and regulations regarding their usage unenforcable.
I once worked for a non AOC operator who had a CVR retro-fitted. No big deal until we discovered he was regularly reviewing the aircraft CVR tapes. Nothing to do with accident prevention. He wanted to weed out those speaking against the company.
Helicomparator,
Excellent point. I think the USA should review its gun laws first...many lives to be saved there, too. How many have to die before "the right to carry" is trumped?
There are many car accidents, far more than those in aircraft, which injure and kill members of the public, thousands of them. So, are you prepared to have a CVR in your private car?
Your private boat? People have boating accidents, some fatal.
In your private house? There are huge numbers of fatal accidents in the home.
Where do I draw the line?
CVRs in all PT aircraft, by all means, but not in all aircraft. In any case, the use of them in private aircraft would be totally unregulated, and regulations regarding their usage unenforcable.
I once worked for a non AOC operator who had a CVR retro-fitted. No big deal until we discovered he was regularly reviewing the aircraft CVR tapes. Nothing to do with accident prevention. He wanted to weed out those speaking against the company.
Helicomparator,
Probably not as many as had to die to achieve the personal freedoms and privacy we enjoy these days.