Bristow S76 Ditched in Nigeria today Feb 3 2016

[gulliBell]

I tell all my trainees "not all malfunctions are in the emergency checklist". It is very important to have good systems knowledge to understand why the emergency checklist says what it says, because when following the checklist hasn't worked, or if the problem is not mentioned in the checklist, to have an idea what corrective action in response to a malfunction might be appropriate. So many times I see trainees following a checklist procedure that they have no idea what they are doing, or why, and that is a big problem because they might be on the wrong checklist procedure and not realize it, or they will have no idea whether what they are about to try is sensible in the circumstances, or what they should do if what they have tried doesn't work.

Sikorsky are not going to write in a checklist "if the helicopter goes wildly out of control immediately switch off a hydraulic system, and if that doesn't work, switch off the other one". This is what I would do if faced with this situation. I wouldn't even check if a servo light or master caution light or any other warning light is on, and I wouldn't even get out the checklist. Sometimes prioritization of common sense needs to over-ride strict compliance with procedure.

There have been times I see trainees become so confused when following a checklist procedure I end up taking it off them and say solve the problem without a checklist. The outcome is usually a better one compared with what they were doing before.

And as for my earlier comments about CVR/FDR, I have never seen anything in any regulator approved operator in-flight checklist about a pilot needing to do anything about these. Not in the S76, or any medium-twin Bell helicopter. I do know that passenger seats have been permanently removed from aircraft to bypass the CVR/FDR requirement, and I do know that HUMS has been removed from aircraft when it was not a contract requirement.

Reliance on automation in helicopter cockpits over the years seems to have reduced pilot capacity for doing the basic piloting stuff when something goes wrong.

[industry insider]

Sikorsky are not going to write in a checklist "if the helicopter goes wildly out of control immediately switch off a hydraulic system, and if that doesn't work, switch off the other one". This is what I would do if faced with this situation.

I had an excellent Training Captain during my conversion, in ground school, I was taught to turn off each hyd system in turn if I ever experienced any hint of control issues. I was also taught the importance of the after start / pre flight hyd check. But that was a long time ago.

[gulliBell]

90% of the recurrent trainees I see don't do the after start hydraulic check properly, which makes me wonder why they were never taught properly from the outset, or since.

[Geoffersincornwall]

A couple of points:-

1. Can you simulate this malfunction (servo block) in the simulator? If so is it included in the TR and practiced in the recurrent training?

2. In my AW139 I have about 300 possible malfunctions that the displays will bring to the attention of the pilots via the Crew Alerting System (CAS) or the PFD. To imagine that the pilot can work out what to do in every case courtesy of his (Ground School acquired) technical knowledge is, I think, wishful thinking. The situation means that they have little choice but to track down the relevant passage in the Quick Reference Handbook (QRH) and read it then do what it says. Often there will be a lack of explanation that helps the pilot to understand why he should take the action described in the QRH. One lives in hope that these knowledge gaps will be filled by the much anticipated FCOM. I hear that the FCOM for the S76D has been published - does this contain any revelations about hydraulic malfunctions?

G.

[gulliBell]

The malfunctions in the simulator are as per straight out of the RFM, and that doesn't include un-commanded extension/retraction of a servo piston. If there was demand from clients to practise this malfunction then a case could be made to the simulator manufacturer to update the software to do this (= expensive!). I don't know how close the motion simulation would be able to get, it would be a pretty wild ride I expect.

[Copterline 103]

@gulliBell
90% of the recurrent trainees I see don't do the after start hydraulic check properly, which makes me wonder why they were never taught properly from the outset, or since.

I fully agree with this but my experience tells me that the 99 % of the S76 pilots and instructors don't understand what they are checking. All our pilots have been type trained by a simulator company in Florida. Each crew member has had recurrent flight training in sim twice per year (6 months interval). This simulator training organization never pointed out how to do Stick Jump test properly (during the type rating course or during the 6 months recurrent flight training).

The Stick Jump Test is the hydraulic check of S76. The aim of the check is to verify that both hydraulic systems (HYD1 and HYD2) work well and at the same time as the HYD1 or HYD2 is OFF line that the Servo Actuators are checked by one servo channel one by one. This is commonly known, understood and performed.

My opinion is that these 99 % of the pilots and instructors are forgetting to do or they don't know how to do the stick jump part of the test. The stick jump test's idea is to verify that the power of the Hydraulic System 1 and 2 and the power the Servo Actuator's channel #1 and #2 are on an equal level. To make this verification during the check the pilot must keep the control stick moving at the same time when he or she switches over HYD #1 OFF to HYD #2 ON or reverse. If during this cross over (together with the moving flight controls) from #1 to #2 or from #2 to #1 the stick should not make a jump. If the jump occurs it is an indication that the powers between the hydraulic systems are different or if the hydraulic power is equal between systems HYD1 and HYD2 then this is an indication that there is a difference between one or more of the three Servo Actuator's channel #1 and #2.

The common mistake during the test is that the pilot will stop the control stick movement at time when the pilot makes the HYD1/2 cross over (switch off and switch on). When the stick doesn't be on move at time of switching over from HYD1 to HYD2, can't any stick jumps be detected.

The most likely the Stick Jump is caused by the increased Servo Actuator's internal leakage rate. This is the way find out a development that is a flight safety issue. This Stick Jump can't be identified in a case where the leakage rate has decreased parallel during the time on both channels #1 and #2. Even the power of the Servo Actuator power is poor (less that minimum acceptable) but if the both channel's leakage rates are on an equal level, no Stick Jumps exists. This is a scenario where you could have unairworthy Servo Actuator installed but you are not able to pick it up by the Stick Jump Test, even the test is performed properly and within timely manner.

I have seen some endurance and continuity test reports which are proving that this is a kind of development that doesn't have to be developed in hours; this could develop within seconds.

I hope that some of the pilots and instructors will take into account the above, in their daily duties. I would like to receive some comments from the S76 line pilots and the line instructors are these things mention above something new for them? Please show up to the Forum.

[Copterline 103]

@gulliBell
Sikorsky are not going to write in a checklist "if the helicopter goes wildly out of control immediately switch off a hydraulic system, and if that doesn't work, switch off the other one".

Now we are closing the topic. How does the S76 helicopter fly? Now I don't mean the situation when the helicopter becomes suddenly unflyable. There should not be any malfunction identified which is not covered by the abnormal or an emergency check list. This is a basic certification requirement.

@gulliBell
This is what I would do if faced with this situation. I wouldn't even check if a servo light or master caution light or any other warning light is on, and I wouldn't even get out the checklist. Sometimes prioritization of common sense needs to over-ride strict compliance with procedure.

My understanding is that the commercial and the modern helicopter operation are based of the law, rules and the good industrial practices. The offshore operation under IFR is a multi crew operation where the crew coordination and cooperation is the ground for the safe, reliable and efficient operation.

It is very difficult to understand the attitude that if something catastrophically happens? The sole crew member will start to solve the emergencies by his intuition without identification, verification before acting. How is the crew coordination taken care of in this kind of cockpit culture? How this kind of operation culture been descript on the Flight Operation Manuals and how has this kind of operation been taken care of by the recurrent flight training?

This is an issue which also belongs in the category; I don't believe that this kind of operation culture can exist in any offshore flight operation organization.

As an examiner I should fail you due to bad attitude, lack of CRM, lack of crew coordination and due to non-compliance of RFM's emergency check lists.

[Copterline 103]

@gulliBell
The malfunctions in the simulator are as per straight out of the RFM, and that doesn't include un-commanded extension/retraction of a servo piston. If there was demand from clients to practise this malfunction then a case could be made to the simulator manufacturer to update the software to do this (= expensive!). I don't know how close the motion simulation would be able to get, it would be a pretty wild ride I expect

My opinion is that these malfunctions should be included to the RFM and also should be trained during recurrent simulator training to the flight crews "SWITCH OFF HYD1" if it doesn't recover the controllability "TRY TO SWITCH OFF HYD2" and hope that the recovery could be achieved.

SIK has this software already in GenHel simulator so it should be very easy to be updated to the all S76 full motion simulators.

[gulliBell]

The thing is, as we saw in the Copterline accident, if the servo goes to full extension/retraction the ride will be so wild and disorientating for all concerned that normal CRM will probably be thrown out the window as well. If one of the pilots has the presence of mind to switch off a servo, and then the other one if that didn't work, might actually save the day for them. Attempting to run a challenge/response emergency checklist by the book, when one pilot head is probably crunched hard up against a windshield pillar, and the other pilot head probably stretched on its neck not far away from the same windshield pillar also, and their adrenaline level and heart rates are immediately shot through the roof, to expect a vanilla dose of by-the-book CRM in these circumstances is fanciful.

One of the 2 pilots needs to have the presence of mind to take decisive action. The action needs to be announced, if possible; the circumstances do not lend themselves to a timely discussion of the matter.

I consistently see problematic CRM in a normal environment when there are relatively minor malfunctions to contend with, let alone when the helicopter is playing rollercoaster and trying to throw you out the door. This is the reality I'm afraid. An action taken that is not by the book but which saves the aircraft is a better outcome than a crew following a checklist perfectly all the way to the scene of the accident.

[Copterline 103]

@gulliBell
An action taken that is not by the book but which saves the aircraft is a better outcome than a crew following a checklist perfectly all the way to the scene of the accident

I fully agree about this with you but if the crew has the knowledge that the Emergency Check list has an item if helicopter will suddenly become unflyable without any cautions and warnings. The crew should memorize by heart that "SWITCH OF HYD1" and is doesn't make recovery "TRY TO SWITCH OFF HYD2" in a situation where the helicopter caution system is not capable to announce any caution or warnings.

My point is that this should be in the RFM, Emergency check lists and have to be just one of the emergency events that will be trained regularly by the full motion sim recurrent session for all the S76 pilots.

[Geoffersincornwall]

I can just imagine the guys back at the Sikorsky factory trying to get their heads around this. The system was designed and built by the previous generation of engineer/designers so in theory the current generation bear no guilt - if there is guilt to be borne. But would they be wise to come forward and admit that the hydraulic system has a fundamental design flaw? Can you imagine the fall-out that would accompany such an admission?

Can I ask you (Copterline) what Sikorsky have replied to your assertions?

Aye
G.

[Copterline 103]

@Geoffersincornwall
I can just imagine the guys back at the Sikorsky factory trying to get their heads around this. The system was designed and built by the previous generation of engineer/designers so in theory the current generation bear no guilt - if there is guilt to be borne. But would they be wise to come forward and admit that the hydraulic system has a fundamental design flaw? Can you imagine the fall-out that would accompany such an admission?

Can I ask you (Copterline) what Sikorsky have replied to your assertions?

Aye
G.

My case is still pending. The counter party is nowadays Lockheed Martin.

[Geoffersincornwall]

Copterline - has any kind of SB been issued on the subject of correctly carrying out the stick-jump test?

[Copterline 103]

@Geoffersincornwall
Copterline - has any kind of SB been issued on the subject of correctly carrying out the stick-jump test?

No SB's or no RFM updates!

[gulliBell]

The hydraulic interlock and stick jump test is in the RFM, it's always been there.

[John Eacott]

Originally Posted by Copterline 103

Maybe I'm slow and not as smart. Just a humble TRI/TRE deeply involved in the issue during the last couple decades and so far I have done quite well.

In professional Forum I appreciate to discuss in professional manner. My main concern is flight safety, noting more nothing less.

My apologies, but your previous posts had given me that impression. I see from subsequent posts that you have some pilot's knowledge.

gullBell, you are quite right. The 'stick jump' check has been around since the A model, and is well explained in the Flight Safety training manual from the early 1980s.

[JohnDixson]

Stick Jump Check

Goes back to the S-58.

Best,
John

[pilonrock]

Well

Had aa channel or 2 drop out on a SPZ 7000 on a A model in IMC with 8 pax on board. On a few different occasions .It was a little wiggly and took some passing control back and fourth as the leans began to step in but it was not uncontrollable. Interestingly enough the A model didn't have an AP and we spent the better part of our days on the dials in IMC. Never had to land until we " practically" had to.

This automation business is great when it works, but there is still a requirement to fly the helicopter - it's what pilots do!!! It's important that any pilot who has such a big responsibility in a larger transport category helicopter has a great deal of hands on flying experience several 1000 hrs and has faced many non scripted emergencies, under different meteorological conditions and operating theatres . Then and only then should they be permitted by industry to fly the big stuff.

I guess at the end of the day the mystery will be solved. Still no new ASB's ADs or out from The authorities on this issue.... Hmmm.

I am thankful though that no one died! Certainly seen too much of that over several decades.

Stay safe over there!

[[email protected]]

Well nothing much seems to have happened on this thread in the week I have been away skiing apart from some ramblings about hyd failures that may or may not exist.

It is reminiscent of the Wessex and Sea King drill of 'If in doubt, primaries out' since switching hyd 2 off with a hyd 1 jack hardover could cause a rapid attitude change that might not be controllable.

However, what has been suggested so far has been at odds with the Nigeria 'ditching' since whatever the problem was, it didn't make the aircraft unflyable as they made a controlled water 'landing' rather than crashing into the sea.

[industry insider]

Not surprising Crab.

As I said many posts ago, this was a simple autopilot issue which was mis interpreted by the crew. The fact that Bristow has sent all of its BHNL S-76 crews to the simulator for "additional training" alludes to the fact that "additional training" should prevent a recurrence in BHNL's view.