Police helicopter crashes onto Glasgow pub: final AAIB report
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MORs
For those pedantic personnel on this forum, I probably should have said that I wished I had submitted a Voluntary MOR. A MOR would be any incident which endangers or which if not corrected, would endanger an aircraft, its occupants or any other person. So in my case, my correctly functioning fuel system gave me a flashing FUEL caution, which I acknowledged, saw that my supply tanks had lowered, then looked at my switches and switched them on, nothing dangerous there. I had cautions and indications which validated that something was wrong and thus I corrected it.
However, had I the knowledge that GXMII had suffered a similar fault to GNWEM (which I am shocked at!!!) and (I believe GSPAO had) then I would have been within my rights to submit a MOR, as now my situation with 2 transfer pumps off, would go dangerously unnoticed. SO, please submit a voluntary MOR whenever you have any doubt about something - the experts will sift it and link it together because they may have seen other reported events - I did not.
I'm really surprised that the result of GXMII didn't result in INs distributed to the whole community and the changing of the wording of the fuel cautions. Its worrying to conclude then, that it might have only been GNWEM, combined with the accident that caused such action to be carried out.
Anyway, is there anyone else who believes that the flight tests could have been more thorough? 200kgs, similar CofG, what attitude for a F PUMP FWD?
However, had I the knowledge that GXMII had suffered a similar fault to GNWEM (which I am shocked at!!!) and (I believe GSPAO had) then I would have been within my rights to submit a MOR, as now my situation with 2 transfer pumps off, would go dangerously unnoticed. SO, please submit a voluntary MOR whenever you have any doubt about something - the experts will sift it and link it together because they may have seen other reported events - I did not.
I'm really surprised that the result of GXMII didn't result in INs distributed to the whole community and the changing of the wording of the fuel cautions. Its worrying to conclude then, that it might have only been GNWEM, combined with the accident that caused such action to be carried out.
Anyway, is there anyone else who believes that the flight tests could have been more thorough? 200kgs, similar CofG, what attitude for a F PUMP FWD?
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Transfer Pump System - some points
It is quite clear to me also, that some pilots may have been doing work arounds to the dry running pumps. If I start by admitting that I have left a dry running pump on for a minute or two knowing that it would subsequently become immersed - as I might forget to switch it back on. The Police role in particular has hover, low speed, or forward flight periods, sometimes changing between these stages many times. If you have announced to your crew when F PUMP AFT or FWD has come on, that you will leave it on as you know you will be moving to another attitude shortly, then that firstly is good CRM, but is a work around of a imperfect system. You do that work around as you might forget to switch that pump on again. So really, again, we should be submitting voluntary MORs or at least reporting such work arounds to our operators, so that they can take the issue further.
Have a think about the aircraft you fly, if you are doing anything to make up for an imperfect system, then report it.
I'm a huge fan of EC now AH Products, and I know their engineers can make it even better.
Anyway, let me be clear, the GSPAO scenario was a very simple one, it had a hover portion at Dalkeith where I believe the F PUMP FWD ran dry, followed by a transit back where the F PUMP AFT ran dry. But also had a fault similar to GNWEM, I believe.
Interestingly, thanks to INs published after GNWEM/GSPAO, we know about spill over from Supply tanks to the main, so why now is there not an action - prior to landing to ensure that BOTH Transfer pumps are switched on, to ensure every last drop of fuel which is the main tank is being transferred in to the supply tanks - by the way an automatic system would sort this problem too.
Have a think about the aircraft you fly, if you are doing anything to make up for an imperfect system, then report it.
I'm a huge fan of EC now AH Products, and I know their engineers can make it even better.
Anyway, let me be clear, the GSPAO scenario was a very simple one, it had a hover portion at Dalkeith where I believe the F PUMP FWD ran dry, followed by a transit back where the F PUMP AFT ran dry. But also had a fault similar to GNWEM, I believe.
Interestingly, thanks to INs published after GNWEM/GSPAO, we know about spill over from Supply tanks to the main, so why now is there not an action - prior to landing to ensure that BOTH Transfer pumps are switched on, to ensure every last drop of fuel which is the main tank is being transferred in to the supply tanks - by the way an automatic system would sort this problem too.
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Its unusally quiet on this forum
Together, I as a pilot having had experiences relevant to this accident, and others as pilots (some having experiences prior to mine and GSPAO which are directly relevant), engineers, operators, manufacturers and the final AAIB team, have all failed this crew. We are collectively to blame.
Put you MORs in whether mandatory or not (voluntary) and sort out the aircraft you fly in!
If you think your issue will be ridiculed, as some do on this forum, well, they are the sad ones, not you, keep saying it.
Fly safe everyone, and lets help each other!
Put you MORs in whether mandatory or not (voluntary) and sort out the aircraft you fly in!
If you think your issue will be ridiculed, as some do on this forum, well, they are the sad ones, not you, keep saying it.
Fly safe everyone, and lets help each other!
Purveyor of Egg Liqueur to Lucifer
Of course there is one circumstance when the warning panel could possibly not be seen, even if the panel was lit up like the proverbial Christmas tree ..... VNe flap.
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I had the very same thought SS. I remember our old T1 having the Velcro replaced on the Vne flap after it kept falling down in flight. Might well have been down anyway after the impact,
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SID and Pieced8, let's not forget the basic airmanship process of fuel endurance at the start of the sortie, THE FLIGHT TIME UNDERTAKEN, the pumps being inappropriately managed, followed by multiple warnings acknowledged and cancelled by the pilot leading ultimately to a poorly executed auto EOL.
if we should learn anything it is this:
Knowledge is power! The power to act correctly! Knowledge that despite any contents indications to the contrary, a fuel backstop WARNING, independent and robust, should be taken at face value as described in the RFM procedures. Thinking one knows better, acting on hearsay or past experience, does not cut it. Knowledge, training and discipline. These are the three things that stand out to me as the key learning points.
Alternatively we can immerse ourselves in multiple conspiracy theories and learn nothing!
if we should learn anything it is this:
Knowledge is power! The power to act correctly! Knowledge that despite any contents indications to the contrary, a fuel backstop WARNING, independent and robust, should be taken at face value as described in the RFM procedures. Thinking one knows better, acting on hearsay or past experience, does not cut it. Knowledge, training and discipline. These are the three things that stand out to me as the key learning points.
Alternatively we can immerse ourselves in multiple conspiracy theories and learn nothing!
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The point at which I believe the LOW FUEL Warnings were dismissed
No Conspiracy theories from me.....if you truly know this aircraft, there is only one possibility:
I simply believe that if the pilot was presented with correct fuel indications, ie lowering supply tank levels along with an associated FUEL caution, he quite simply would have done as I said I did previously, looked up and put his Transfer pumps on. It would all make total sense to him.
However, I believe he must have had the GNWEM/GXMII fuel sensor fault. Remember that this previously unknown fault (or simply not distributed to the pilot community!!!!!) doesn't show up a blank indication in a fuel tank, or FUEL QTY FAIL or FUEL DEGRADE cautions. It looks normal, as the supply tanks are showing full whilst in reality, they are insidiously emptying.
So at the exact time of being presented LOW FUEL Warnings, the pilot may have simply dismissed the warnings as they were contrary to his normal graphic indications of full supply tanks. He probably may not have even physically checked his transfer pumps were on - why would he, as the supply tanks couldn't be full without the Transfer pumps being on, could they.......or so he believed at the time being unaware of the GNWEM/GXMII fault.
At the exact time of the LOW FUEL Warnings, the GSPAO fuel indications (full supply tanks and fuel in the main) could have appeared normal having been indicating only 26 Kgs or 7.8 Mins of flying time more than he should of at that point, remembering that on previous flights, he may have been getting 5 - 10 minutes more endurance if flying conservatively (although I admit their profiles don't fall in to this category). So it is not a fuel difference which would instantly raise alarm bells in this fuel sensor fault mode.
Once the warnings were dismissed, some normal but distracting tasking follows, and you would probably need at least 5 if not 10 more minutes of flying to see a noticeable difference of fuel readings, or as in this case actually notice that they haven't changed at all. That was 5-10 minutes which they didn't have of course!
So yes we can all look at the end fuel state and say that he should have known that this was not possible to have 76 kgs in the main, but the fuel indications are not far from normal at the exact point of when he DISMISSED (NOT IGNORED!!) the Low Fuel warnings.
Yes the pilot made some errors, as I have too, but I remain convinced that if we as an Aviation community had worked better together, then we could have prevented this event from happening.
I'm am still shocked that I trained in 2010 and was at no time then or subsequently informed of the GXMII incident. This is a complete failing at all levels.
I simply believe that if the pilot was presented with correct fuel indications, ie lowering supply tank levels along with an associated FUEL caution, he quite simply would have done as I said I did previously, looked up and put his Transfer pumps on. It would all make total sense to him.
However, I believe he must have had the GNWEM/GXMII fuel sensor fault. Remember that this previously unknown fault (or simply not distributed to the pilot community!!!!!) doesn't show up a blank indication in a fuel tank, or FUEL QTY FAIL or FUEL DEGRADE cautions. It looks normal, as the supply tanks are showing full whilst in reality, they are insidiously emptying.
So at the exact time of being presented LOW FUEL Warnings, the pilot may have simply dismissed the warnings as they were contrary to his normal graphic indications of full supply tanks. He probably may not have even physically checked his transfer pumps were on - why would he, as the supply tanks couldn't be full without the Transfer pumps being on, could they.......or so he believed at the time being unaware of the GNWEM/GXMII fault.
At the exact time of the LOW FUEL Warnings, the GSPAO fuel indications (full supply tanks and fuel in the main) could have appeared normal having been indicating only 26 Kgs or 7.8 Mins of flying time more than he should of at that point, remembering that on previous flights, he may have been getting 5 - 10 minutes more endurance if flying conservatively (although I admit their profiles don't fall in to this category). So it is not a fuel difference which would instantly raise alarm bells in this fuel sensor fault mode.
Once the warnings were dismissed, some normal but distracting tasking follows, and you would probably need at least 5 if not 10 more minutes of flying to see a noticeable difference of fuel readings, or as in this case actually notice that they haven't changed at all. That was 5-10 minutes which they didn't have of course!
So yes we can all look at the end fuel state and say that he should have known that this was not possible to have 76 kgs in the main, but the fuel indications are not far from normal at the exact point of when he DISMISSED (NOT IGNORED!!) the Low Fuel warnings.
Yes the pilot made some errors, as I have too, but I remain convinced that if we as an Aviation community had worked better together, then we could have prevented this event from happening.
I'm am still shocked that I trained in 2010 and was at no time then or subsequently informed of the GXMII incident. This is a complete failing at all levels.
Last edited by 8Pieced; 7th Nov 2015 at 10:13. Reason: added word all to last sentence
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Double Bogey, I'm sure that you have read this thread and realise that everything that I have posted here is a fact.
(I had a longer reply to your post, however 8 has beaten me to it.
)
Bearing in mind the tone of your first sentence, can you please tell me/us; on the night of 29 Nov 2013, what was the MLA for SPOA?
(I had a longer reply to your post, however 8 has beaten me to it.
)Bearing in mind the tone of your first sentence, can you please tell me/us; on the night of 29 Nov 2013, what was the MLA for SPOA?
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Double Bogey, I'm sure that you have read this thread and realise that everything that I have posted here is a fact.
(I had a longer reply to your post, however 8 has beaten me to it. )
Bearing in mind the tone of your first sentence, can you please tell me/us; on the night of 29 Nov 2013, what was the MLA for SPOA?
(I had a longer reply to your post, however 8 has beaten me to it.
)Bearing in mind the tone of your first sentence, can you please tell me/us; on the night of 29 Nov 2013, what was the MLA for SPOA?
DV
I'd be a bit concerned if I was Airbus Helicopters as most of what has been discussed on this thread points very firmly to the conlcusion that the EC135 fuel system was not fit for purpose.
I'd be a bit concerned if I was Airbus Helicopters as most of what has been discussed on this thread points very firmly to the conlcusion that the EC135 fuel system was not fit for purpose.
Adding a Copilot attending to those switches and acknowledging them captions, it'd be a very safe aircraft
Calm down, calm down. The reason there are "issues" with fuel management on these aircraft on this forum is because they are POLICE aircraft. A VERY different beast to the one the Ec135 was really designed for which is ViP cruise.
The nose up attitude afforded by police Ec135's is way different to one bought by - for instance a current owner - Abramovich. For his pilots it is NOT a problem.
The nose up attitude afforded by police Ec135's is way different to one bought by - for instance a current owner - Abramovich. For his pilots it is NOT a problem.
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Let me rephrase that question put to DB;
Bearing in mind the tone of your first sentence, can you please tell me/us; on the night of 29 Nov 2013, what was the operators MLA for SPOA?
Bearing in mind the tone of your first sentence, can you please tell me/us; on the night of 29 Nov 2013, what was the operators MLA for SPOA?
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Hi SID, it's a matter of perspective. The MLA is a secondary issue to the circumstances where the flight time expended almost certainly warrants careful supervision of the pesky pumps.......or do you think otherwise?
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DB, please answer the question.
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I'd take 80kgs of fuel and my usual 2 Police crew any day over 2 Pilots
2 Pilots would be a poor reaction to this incident. I don't think people realise just how good these Police crews are. Spot on at Nav, understanding RT, reading checklists, practiced in emergency scenarios at every shift briefing, basic systems knowledge, Notams, Weather, conducting the police mission too. They are the mission commander and pilot is the driver. Any pilot who doesn't fully utilise the crew to assist in their duties does so at their own peril. If my crew isn't happy we go home. It is not certain that a 2nd pilot on board would have stopped this happening.
I fly also multi crew for an Offshore Company and I can see why their particular operation justifies 2 pilots.
I fly also multi crew for an Offshore Company and I can see why their particular operation justifies 2 pilots.
Last edited by 8Pieced; 7th Nov 2015 at 22:13. Reason: Added 80kgs of fuel to title, last about about mult crew
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Sid, 20 minutes fuel at cruise consumption.
What was the company policy on the night of 29 November 2013 in respect of the fuel state at which the aircraft should not land below?