Police helicopter crashes onto Glasgow pub: final AAIB report
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Afraid I'm with SkySports on this;
How on earth do you accept another job after flying for so much time? Was there a culture of landing below MLA? The police guys on board heard the warnings, the one in front probably saw them. We don't know what conversations took place, and I suspect this is where the AAIB are coming from.
I've flown 135's for ten years (not in a police role) and have always found the CAD really simple, as is fuel planning. During those ten years I've twice had fuel indication snags, both times I've landed knowing that although the supply tank was showing empty, there was fuel as the relevant engine was running, I was well inside my planned endurance and there were no RED FUEL LOW warnings. When the sensor fails in my experience the affected tank goes black if its' a supply tank and gives ratty data if its' the main.
I have (in a different type) found myself really tight on fuel, at night in a hostile environment and I was mighty scared. But, since my earliest instructor banged on at me about fuel guages and the importance of knowing how long your fuel could last my final action before take-off is to hit a stopwatch. Should the indications fail you instantly have a time indication as a final check.
SND
How on earth do you accept another job after flying for so much time? Was there a culture of landing below MLA? The police guys on board heard the warnings, the one in front probably saw them. We don't know what conversations took place, and I suspect this is where the AAIB are coming from.
I've flown 135's for ten years (not in a police role) and have always found the CAD really simple, as is fuel planning. During those ten years I've twice had fuel indication snags, both times I've landed knowing that although the supply tank was showing empty, there was fuel as the relevant engine was running, I was well inside my planned endurance and there were no RED FUEL LOW warnings. When the sensor fails in my experience the affected tank goes black if its' a supply tank and gives ratty data if its' the main.
I have (in a different type) found myself really tight on fuel, at night in a hostile environment and I was mighty scared. But, since my earliest instructor banged on at me about fuel guages and the importance of knowing how long your fuel could last my final action before take-off is to hit a stopwatch. Should the indications fail you instantly have a time indication as a final check.
SND
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In your experience it goes black?
So not much experience of the fault then?
If the sensor fails, it does indeed go black.
However if the sensor is water contaminated, it shows the supply tank to be permanently full.
Listen, no one on this thread seems to doubt that Dave did wrong, even with the possible alternate scenarios on dodgy fuel gauges. My crusade is that IF the gauges fatally confused him, this could happen again. Surely it is better to say, "we don't know if gauges were involved, but there is an element of doubt, let's fix that possibility".
So not much experience of the fault then?
If the sensor fails, it does indeed go black.
However if the sensor is water contaminated, it shows the supply tank to be permanently full.
Listen, no one on this thread seems to doubt that Dave did wrong, even with the possible alternate scenarios on dodgy fuel gauges. My crusade is that IF the gauges fatally confused him, this could happen again. Surely it is better to say, "we don't know if gauges were involved, but there is an element of doubt, let's fix that possibility".
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SND
Of course that would only be of use if full tanks on take off.
my final action before take-off is to hit a stopwatch. Should the indications fail you instantly have a time indication as a final check.
"Listen, no one on this thread seems to doubt that Dave did wrong, even with the possible alternate scenarios on dodgy fuel gauges. My crusade is that IF the gauges fatally confused him, this could happen again. Surely it is better to say, "we don't know if gauges were involved, but there is an element of doubt, let's fix that possibility".
Rakker, your English is better than some I have read on this board
and you make good points. If anything good comes out of this horror let it be lessons learned and changes made. Nothing else can.
Pre departure fuel check
Of course that would only be of use if full tanks on take off
Don't know a pilot who wouldn't monitor the time in flight (chrono etc) against fuel whether you're flying a 747 or something smaller.
Turbines are very easy to monitor as fuel flow is very accurate- having said that, I imagine, that it must be a lot more difficult with helicopters when hovering etc etc as opposed to straight line cruise A to B.
Last edited by Good Business Sense; 25th Oct 2015 at 12:22.
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In many respects, this accident has the same hallmarks as the Mull of Kintyre Chinook. We'll never know what happened, precisely, but there are a large number of things that can be taken on board to reduce the chances of it happening again.
I think I am like most, Dave was one of us, had a similar background and training as most of us, and in all likelihood could very well have been anyone of us except they way things go when it comes to being in the seat that night.
What we are trying to work out is why this happened to Dave as it could have been one of us instead except for Luck, Fate, or sheer happenstance.
I am trying to make sense out of what we know...and trying to put myself in Dave's Shoes that tragic evening.
Everything tells us it should not have happened to him....yet it did.
That is what is frightening about all of this...it could very well have been anyone of us if it could happen to Dave.
I don't know him...doubt I ever met him....but I know in my heart he was a good guy with good training and apparently made some mistakes.
I don't fault him personally and only hope to see it all figured out so we can learn from this sad loss of lives and hopefully prevent future losses to the same causes whatever they turnout to be.
What we are trying to work out is why this happened to Dave as it could have been one of us instead except for Luck, Fate, or sheer happenstance.
I am trying to make sense out of what we know...and trying to put myself in Dave's Shoes that tragic evening.
Everything tells us it should not have happened to him....yet it did.
That is what is frightening about all of this...it could very well have been anyone of us if it could happen to Dave.
I don't know him...doubt I ever met him....but I know in my heart he was a good guy with good training and apparently made some mistakes.
I don't fault him personally and only hope to see it all figured out so we can learn from this sad loss of lives and hopefully prevent future losses to the same causes whatever they turnout to be.
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This may appear to be a daft question to some of you specialist, but why do we have main tank and a co-located split supply tank? Why not have a split main tank with gaps in the baffle feeding the engines?
DV
DV
This may appear to be a daft question to some of you specialist, but why do we have main tank and a co-located split supply tank? Why not have a split main tank with gaps in the baffle feeding the engines?
Whilst it would be possible to have one tank feeding both engines directly, compromises would have to be made to the shape of the tank and the shape of the helicopter to get a reliable supply.
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DrinkGirls;
Just my experience of what happened with supply tank indication failure.
Chopjock;
Fuel pick up is (should be always balanced) against what you had and what the bowser gave you.
SND
Just my experience of what happened with supply tank indication failure.
Chopjock;
Fuel pick up is (should be always balanced) against what you had and what the bowser gave you.
SND
This may appear to be a daft question to some of you specialist, but why do we have main tank and a co-located split supply tank? Why not have a split main tank with gaps in the baffle feeding the engines?
Therefore -
29.903 Engines.
(b) Category A; engine isolation. For each category A rotorcraft, the powerplants must be arranged and isolated from each other to allow operation, in at least one configuration, so that the failure or malfunction of any engine, or the failure of any system that can affect any engine, will not—
(1) Prevent the continued safe operation of the remaining engines; or
(2) Require immediate action, other than normal pilot action with primary flight controls, by any crewmember to maintain safe operation.
(b) Category A; engine isolation. For each category A rotorcraft, the powerplants must be arranged and isolated from each other to allow operation, in at least one configuration, so that the failure or malfunction of any engine, or the failure of any system that can affect any engine, will not—
(1) Prevent the continued safe operation of the remaining engines; or
(2) Require immediate action, other than normal pilot action with primary flight controls, by any crewmember to maintain safe operation.
29.953 Fuel system independence.
(a) For category A rotorcraft—
(1) The fuel system must meet the requirements of §29.903(b); and
(2) Unless other provisions are made to meet paragraph (a)(1) of this section, the fuel system must allow fuel to be supplied to each engine through a system independent of those parts of each system supplying fuel to other engines.
(a) For category A rotorcraft—
(1) The fuel system must meet the requirements of §29.903(b); and
(2) Unless other provisions are made to meet paragraph (a)(1) of this section, the fuel system must allow fuel to be supplied to each engine through a system independent of those parts of each system supplying fuel to other engines.
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it must meet most of the design requirements of Part 29 Cat A as there are no criteria within Part 27.
Perhaps keeping it simpler would be safer.
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Or the designers were just too lazy, like requirng a busy pilot to count the number of times the collective is rasied as on the 350.
Phil
Phil
Is anyone in any doubt any more, why this all went horribly wrong?
Four things are FACT:
1. Fuel switches were in the incorrect position.
2. The 10 minute to land warning was ignored.
3. The pilot was unable to carry out an EOL successfully.
4. The pilot was very very experienced.
On that dark, wet night over Strathclyde all the holes in the swiss cheese - lined up.
NO -ONE is infallible. WE ARE NOT COMPUTERS.
Four things are FACT:
1. Fuel switches were in the incorrect position.
2. The 10 minute to land warning was ignored.
3. The pilot was unable to carry out an EOL successfully.
4. The pilot was very very experienced.
On that dark, wet night over Strathclyde all the holes in the swiss cheese - lined up.
NO -ONE is infallible. WE ARE NOT COMPUTERS.
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Looking at this incident from another direction, every experienced car driver can recall a journey where they started off and arrived at their destination with no recollection of the journey itself due to being distracted by other thoughts.
Is it unreasonable to suggest that a very experienced helicopter pilot might not also be capable of going through the motions of flying a helicopter while not being totally focused on the job?
At the time the supply tank switches were switched off in response to a warning they were running dry, it would appear the pilot was reacting normally. At some point between then and when the low fuel messages appeared, something appears to have distracted the pilot to such an extent, he was effectively just going through the motions. The warnings were acknowledged but not actioned. Only when the first engine flamed out did the pilot snap out of his distracted state and was probably very confused as he struggled to catch up with what the helicopter was doing.
The second engine spooling down would just add to the confusion and possibly utter bewilderment as nothing appeared to be happening as described in the manuals.
So the question is, what event could happen in mid flight that would give rise to such a level of distraction in an experienced pilot? We can say with reasonable certainty that there was no significant equipment failures in the helicopter and it was basically airworthy and with enough fuel to return to base safely, although below the mandated safety limits. So what else could have occured during the trip back from Edinburgh towards Glasgow?
Would anyone on this forum admit to having been flying along in a soporiphic state only to be startled into awareness by the Nr horn sounding, or a sudden engine failure? I can't imagine it hasn't happened before.
Is it unreasonable to suggest that a very experienced helicopter pilot might not also be capable of going through the motions of flying a helicopter while not being totally focused on the job?
At the time the supply tank switches were switched off in response to a warning they were running dry, it would appear the pilot was reacting normally. At some point between then and when the low fuel messages appeared, something appears to have distracted the pilot to such an extent, he was effectively just going through the motions. The warnings were acknowledged but not actioned. Only when the first engine flamed out did the pilot snap out of his distracted state and was probably very confused as he struggled to catch up with what the helicopter was doing.
The second engine spooling down would just add to the confusion and possibly utter bewilderment as nothing appeared to be happening as described in the manuals.
So the question is, what event could happen in mid flight that would give rise to such a level of distraction in an experienced pilot? We can say with reasonable certainty that there was no significant equipment failures in the helicopter and it was basically airworthy and with enough fuel to return to base safely, although below the mandated safety limits. So what else could have occured during the trip back from Edinburgh towards Glasgow?
Would anyone on this forum admit to having been flying along in a soporiphic state only to be startled into awareness by the Nr horn sounding, or a sudden engine failure? I can't imagine it hasn't happened before.
Last edited by G0ULI; 26th Oct 2015 at 00:02. Reason: Added question
I once attended a Training Course where the Conditions White, Green, Yellow, and Red of Pilot Attentiveness was discussed.
It made a lot of sense back then and bears repeating.
White.....you are somewhere warm, cozy, smelling of fine perfume and freshly washed Hair....or whatever equivalence does that for you. Things are safe, your mind is anywhere but in the Cockpit.
Green....you are in the Cockpit, everything is going fine, the weather is great, bags of fuel, things are just going as planned.
Yellow....You are in the Cockpit and sitting a bit more upright than normal...something is not quite right but nothing dire noticed yet.
Red....You are sat straight up....you Heart is over speeding....you stomach is in your throat...butt cheeks clinched tight enough you could trade the Shoulder Harness and Lap Belt for a Trailer Hitch Ball and be firmly fixed to the seat....and lots of stuff is going badly wrong.
Transition from each Condition/Mode should be gradual, unhurried, and planned ahead....the rate of change causes distress the quicker it happens....with a significantly reduced accuracy in reaction time and appropriateness of that reaction.
We should never go more than one Condition per change....and never knowingly operate in either White or Red Modes.
Green is fine....but Yellow is the best.
That means you are awake, thinking, checking what needs to be checked, monitoring what needs monitoring, and making sure your plans are still intact and if not you are aware of it and taking corrective action.
If some thing goes wrong....it will not be a surprise or shock to you...even if you only generate a mere second or two of advance warning.
Get yourself a Yellow Sticker and put it somewhere you will see it in your Cockpit....it works!
It made a lot of sense back then and bears repeating.
White.....you are somewhere warm, cozy, smelling of fine perfume and freshly washed Hair....or whatever equivalence does that for you. Things are safe, your mind is anywhere but in the Cockpit.
Green....you are in the Cockpit, everything is going fine, the weather is great, bags of fuel, things are just going as planned.
Yellow....You are in the Cockpit and sitting a bit more upright than normal...something is not quite right but nothing dire noticed yet.
Red....You are sat straight up....you Heart is over speeding....you stomach is in your throat...butt cheeks clinched tight enough you could trade the Shoulder Harness and Lap Belt for a Trailer Hitch Ball and be firmly fixed to the seat....and lots of stuff is going badly wrong.
Transition from each Condition/Mode should be gradual, unhurried, and planned ahead....the rate of change causes distress the quicker it happens....with a significantly reduced accuracy in reaction time and appropriateness of that reaction.
We should never go more than one Condition per change....and never knowingly operate in either White or Red Modes.
Green is fine....but Yellow is the best.
That means you are awake, thinking, checking what needs to be checked, monitoring what needs monitoring, and making sure your plans are still intact and if not you are aware of it and taking corrective action.
If some thing goes wrong....it will not be a surprise or shock to you...even if you only generate a mere second or two of advance warning.
Get yourself a Yellow Sticker and put it somewhere you will see it in your Cockpit....it works!
Progress. I think about it a lot. Like the transmission in the Sikorsky S-92 with the dual oil pumps that can not independently supply sufficient pressure to preclude an emergency situation if one fails. Now there's some great design progress, eh? 
My experience is not with the EC-135. I flew the old, antique Bo-105. It has a similar fuel tank/supply setup as the EC-135 apparently. You had to turn transfer pumps on to move fuel forward from the main tank to the little supply tanks in which were the "real" fuel pumps that sent it up to the engines. The transfer pumps did not have caution/advisory lights to tell you when they were off. PHI (knowing that we dumb pilots would sooner or later forget them) added white "Transfer Pump OFF" lights to the dash. Turning the pumps on extinguished the lights. The system was not foolproof. The lights were white. On a bright, sunny day they could "disappear" under the glare shield. Ask me how I know. Wait- don't ask.
As SASless says, no self-respecting Bo105 pilot would *ever* deliberately turn the transfer pumps off in flight. If you did, you'd run out of fuel in about twenty minutes (on a good day) when the supply tanks ran dry. Or maybe it was eleven minutes - I don't remember. What I *do* remember is that we never shut the transfers off.
The fuel quantity indicator system in the Bo-105 was stone-simple.
You had a fuel gauge with two needles. One was for the main tank and the other, the supply. Because of where the fuel quantity sensor was located, in forward flight (about 10 degrees nose down) the main tank fuel indicator would show empty even when there was plenty of fuel in it. You did not use the gauge for the main tank in cruise; you used your watch. (For aviation-savvy but non-pilot passengers who were new to the Bolkow, it was kind of scary on a long flight to see the fuel gauge go to zero.) But if you ever saw your supply tank needle coming down, your LZ better be in sight.
I cannot believe that Eurocopter made the EC-135 "better" by requiring the pilot to periodically switch the transfer pumps off and on. That's ridiculous. That's not progress, is it.
Now then... We all know good pilots who've inexplicably come to grief in helicopters. It's hard for us to wrap our heads around it: How someone we know and admire could make such a dumb, fatal mistake? We arrogantly think that *we* ourselves would never do such a thing - so how/why did someone as good as "X" do it? Would a CVR have told us? Not necessarily. Would more training in full-down night EOL's have helped? I doubt it, but YMMV. Once that first engine quit I'll bet it was fair pandemonium in that cockpit, or at least a lot of, "What the hell is going on??" and a lot of cuss words. Things were surely happening fast.
I've said before and I'll say again: Helicopters are very easy to crash. The helicopter does not care how much experience you've got or how good a pilot you are or what your friends think of you. And neither you nor I are immune to making the same kind of fatal mistakes as the ones who've sadly, tragically gone before us. I know how close I've come over the years and I get shivers up and down my spine when I recall them. Grace of God and all that.
Look at those two guys who crashed the AW-139 taking-off in the fog from that rich guy's estate a couple of years ago. Should have been a "simple" vertical take-off through the fog layer. Set the hover attitude and then straight up: easy-peasy. But no, as he pulled pitch the PF started (inadvertently?) pushing forward on the cyclic. Did neither of the *two* pilots onboard see that the nose was going down, down, down? Did neither of them notice that the rate-of-climb indicator wasn't showing a climb? Apparently not. We think they had plenty of time to recognize what was going on, but I'll bet things happened pretty fast for them as well. Two qualified and experienced professional pilots killed everybody onboard that night.
We all make mistakes. Why the pilot of the EC-135 continued to fly beyond 1:30 makes no sense especially when he'd already received low-fuel warnings. "Everybody" knows the -135 doesn't have all that much endurance. He *had* to know he was about empty. And why he was messing around with the transfer pump switches with so little fuel left is extremely puzzling. That the engines ran dry with fuel onboard is simply inconceivable. What was he thinking?? Even a CVR cannot tell us.
There are a lot of unanswered and unanswerable questions. Some accidents are like that. Sometimes you never know. Sometimes all you can do is shake your head, accept that the pilot screwed up and move on with the knowledge that in our world sometimes things just don't make sense.
My experience is not with the EC-135. I flew the old, antique Bo-105. It has a similar fuel tank/supply setup as the EC-135 apparently. You had to turn transfer pumps on to move fuel forward from the main tank to the little supply tanks in which were the "real" fuel pumps that sent it up to the engines. The transfer pumps did not have caution/advisory lights to tell you when they were off. PHI (knowing that we dumb pilots would sooner or later forget them) added white "Transfer Pump OFF" lights to the dash. Turning the pumps on extinguished the lights. The system was not foolproof. The lights were white. On a bright, sunny day they could "disappear" under the glare shield. Ask me how I know. Wait- don't ask.
As SASless says, no self-respecting Bo105 pilot would *ever* deliberately turn the transfer pumps off in flight. If you did, you'd run out of fuel in about twenty minutes (on a good day) when the supply tanks ran dry. Or maybe it was eleven minutes - I don't remember. What I *do* remember is that we never shut the transfers off.
The fuel quantity indicator system in the Bo-105 was stone-simple.
You had a fuel gauge with two needles. One was for the main tank and the other, the supply. Because of where the fuel quantity sensor was located, in forward flight (about 10 degrees nose down) the main tank fuel indicator would show empty even when there was plenty of fuel in it. You did not use the gauge for the main tank in cruise; you used your watch. (For aviation-savvy but non-pilot passengers who were new to the Bolkow, it was kind of scary on a long flight to see the fuel gauge go to zero.) But if you ever saw your supply tank needle coming down, your LZ better be in sight.
I cannot believe that Eurocopter made the EC-135 "better" by requiring the pilot to periodically switch the transfer pumps off and on. That's ridiculous. That's not progress, is it.
Now then... We all know good pilots who've inexplicably come to grief in helicopters. It's hard for us to wrap our heads around it: How someone we know and admire could make such a dumb, fatal mistake? We arrogantly think that *we* ourselves would never do such a thing - so how/why did someone as good as "X" do it? Would a CVR have told us? Not necessarily. Would more training in full-down night EOL's have helped? I doubt it, but YMMV. Once that first engine quit I'll bet it was fair pandemonium in that cockpit, or at least a lot of, "What the hell is going on??" and a lot of cuss words. Things were surely happening fast.
I've said before and I'll say again: Helicopters are very easy to crash. The helicopter does not care how much experience you've got or how good a pilot you are or what your friends think of you. And neither you nor I are immune to making the same kind of fatal mistakes as the ones who've sadly, tragically gone before us. I know how close I've come over the years and I get shivers up and down my spine when I recall them. Grace of God and all that.
Look at those two guys who crashed the AW-139 taking-off in the fog from that rich guy's estate a couple of years ago. Should have been a "simple" vertical take-off through the fog layer. Set the hover attitude and then straight up: easy-peasy. But no, as he pulled pitch the PF started (inadvertently?) pushing forward on the cyclic. Did neither of the *two* pilots onboard see that the nose was going down, down, down? Did neither of them notice that the rate-of-climb indicator wasn't showing a climb? Apparently not. We think they had plenty of time to recognize what was going on, but I'll bet things happened pretty fast for them as well. Two qualified and experienced professional pilots killed everybody onboard that night.
We all make mistakes. Why the pilot of the EC-135 continued to fly beyond 1:30 makes no sense especially when he'd already received low-fuel warnings. "Everybody" knows the -135 doesn't have all that much endurance. He *had* to know he was about empty. And why he was messing around with the transfer pump switches with so little fuel left is extremely puzzling. That the engines ran dry with fuel onboard is simply inconceivable. What was he thinking?? Even a CVR cannot tell us.
There are a lot of unanswered and unanswerable questions. Some accidents are like that. Sometimes you never know. Sometimes all you can do is shake your head, accept that the pilot screwed up and move on with the knowledge that in our world sometimes things just don't make sense.