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June AAIB - wrong deck landing

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June AAIB - wrong deck landing

Old 9th Jun 2016, 09:39
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June AAIB - wrong deck landing

I see there is a report on a wrong deck landing (out of Aberdeen) in this month's AAIB report. I have to say that, bearing in mind the large amount of time it takes to get important reports out, one wonders whether the AAIB should be bothering itself with such trivia? Political pressure? One is hard pushed to consider the event an "accident" although I'm sure the weasel words of aviation legislation probably does encompass it. Yes oil companies love to rant and wail about such things but in reality it is almost certainly only a big deal in someone's mind, and an excuse to have a go at a contractor.


Of course the event would have been avoided had they religiously set the FMS to the next waypoint to be landed at, something we did as a matter of course in Bristow because we all know how easy it is to get sucked into thinking a destination is the destination when in fact it isn't. And that really is all there is to be said about it.


However if one is going to go to the trouble of writing a detailed report, one might as well consider all the contributory factors and not just pick the ones to suit. So in fact the crew error was compounded by the incessant waffling on the radio, miscommunication, mistakes and changes of mind by the oil company's personnel. But of course although that is mentioned, it doesn't form part of the reason why the "accident" happened according to the report, but in reality it was of course a large part of the reason. "Accidents" rarely occur from one cause in isolation and usually the accident could have been prevented by removing just one of the several contributory causes.


But of course such an argument wouldn't serve the political aims of the report. Disturb the status quo? Not a chance!
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Old 9th Jun 2016, 09:49
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So in fact the crew error was compounded by the incessant waffling on the radio, miscommunication, mistakes and changes of mind by the oil company's personnel. But of course although that is mentioned, it doesn't form part of the reason why the "accident" happened according to the report, but in reality it was of course a large part of the reason.
The problem with your attitude HC is that you regard an offshore flight as a flying exercise. But actually, the flight is required to do a job. The requirements of that job change from time to time. Imagine if fixed wing pilots landed at the wrong airport. Its the same thing. If a Pilot can't land on the correct deck and reasonably adapt to the needs of the job, then they should question their career choice or consider retirement. Oh, sorry, you did retire already.
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Old 9th Jun 2016, 10:24
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https://www.gov.uk/aaib-reports/aaib...y-s-92a-g-vinl
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Old 9th Jun 2016, 10:31
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Originally Posted by terminus mos View Post
The problem with your attitude HC is that you regard an offshore flight as a flying exercise. But actually, the flight is required to do a job. The requirements of that job change from time to time. Imagine if fixed wing pilots landed at the wrong airport. Its the same thing. If a Pilot can't land on the correct deck and reasonably adapt to the needs of the job, then they should question their career choice or consider retirement. Oh, sorry, you did retire already.
Terminus mos,

TBF I think HC has a point.

This wasn't an accident as such so while I think it should be a reportable event I don't think it merits a full field investigation.

Perhaps the procedure should be similar to that in a non commercial transport flight i.e. that the operator is required to submit a report. If that had been the case and the operator had adapted procedures to prevent a recurrence all the AAIB would have had to do would be to read, discuss and if satisfied accept the report. The exact same outcome as the full field investigation.

It is different from a fixed wing event in that given that the crews are routinely liasing with each other and that there is a much lower volume of arrivals and departures at much lower speeds the chances of a real "accident" were relatively low.
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Old 9th Jun 2016, 10:40
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Originally Posted by terminus mos View Post
Imagine if fixed wing pilots landed at the wrong airport. Its the same thing.
Imagine if fixed wing pilots routinely had destination changes mid-way through their flight and had to sort out loads of radio waffle from ground ops about their next payload.

It doesn't happen, which is why FW rarely lands at the wrong airport. So thank you for reinforcing my point!

Yes there is a job to be done, however when things go wrong all aspects should be looked at rather than just blaming the pilots. The processes surrounding passing route and load changes to crew in flight is necessary but currently a long way from optimal.

So is it your contention that the oil companies have no duty to minimise distraction to the pilots in flight? If so, you are part of the problem. A big part.

Of course not all the blame for unnecessary workload lies with the oil companies. In the UK we have ridiculous arse covering radio waffle with ATC. No only have they invented a whole layer of complexity to do with ATSOCAS which no other country seems to need, but for the sole benefit of ATC there is endless reading out and reading back of types of service and their limitations which sometimes go in for several sentences. All completely pointless and having no bearing on the flight, just arse covering in case someone at NATS might get sued. Have a listen to the offshore frequencies sometime and work out how much of the comms is useful or has any bearing on the safe conduct of the flight. About 50% or less, I'd say.
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Old 9th Jun 2016, 10:41
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Perhaps the procedure should be similar to that in a non commercial transport flight i.e. that the operator is required to submit a report. If that had been the case and the operator had adapted procedures to prevent a recurrence all the AAIB would have had to do would be to read, discuss and if satisfied accept the report.
They did....
Information Source: Aircraft Accident Report Form submitted by the
pilot
I do understand how wrong deck landings can occur in particular circumstances, but I'm having a hard time reconciling some aspects of this one including:
  • 180 degrees in the wrong direction
  • Half the sector length
  • A jack up rig helideck versus a platform!


Both pilots had their Navigation Displays (ND) selected to ‘sector’, as normal when operating
offshore, resulting in the Buzzard waypoint being outside the 40° arc displayed either side
of the helicopter’s heading
Well, there's a clue then.....

The commander would have preferred
to have been the Pilot Monitoring (PM) for this short multi-sector route: operating the radio,
completing the associated payload information and navigating in this busy, high workload
offshore environment.
High workload? I think that's stretching it a bit. What's to stop him taking control on finals? In multi sector environments like the SNS, Nigeria Eket field, or Brunei there are often multiple control handovers required.

Edit:
There's another one in the same bulletin - much more understandable: https://assets.publishing.service.go...CHBY_06-16.pdf

Last edited by 212man; 9th Jun 2016 at 10:52.
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Old 9th Jun 2016, 10:57
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Accident? Don't think so...

I think you all need to re-read the full Bulletin report:


1. It is not an accident report, but an INCIDENT report as clearly stated on the top left hand corner of the Synopsis Page.
2. It is not published in isolation; page 47 of the SAME report is about G-CHBY, an AW139 from Humberside having a Wrong Deck landing too... proof that this is not an isolated incident and by companies engaging with the Investigation authorities we can all try and learn from these unfortunate occurrences as a community.


We all know that Wrong Deck Landings are happening throughout the world and for once I enjoyed reading these reports to help recognise a potential situation which could lead to me making the same mistake. I will certainly be checking and double checking in the future!

Last edited by RWing; 9th Jun 2016 at 11:46.
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Old 9th Jun 2016, 11:36
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Just reinforces sad fact that previous 'wrong deck' lessons had failed to be learnt and the phrase - 'experienced offshore captain' - could be mis-interpreted.
Have to agree with others that this was not a 'busy' sector when compared to other areas and maybe indications that crew 'holding on too tight' - or minds elsewhere........
How did the trigger word 'accident' find its' way into dialogue?
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Old 9th Jun 2016, 12:00
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I haven't flown off-shore since 1999, back then we were under strict instruction that both pilots should identify the installation, and state aloud the name they were reading from the nameplate, or deck.

In the late 80's to mid 90's there were several wrong deck landings, the crews were subjected to the usual ritual humiliation by management and colleagues, and the oil companies complained vociferously, and we all learned lessons and waited for the next incident. Reading these two reports makes me wonder if any of those lessons have sunk in, or if they have just been forgotten.

SND
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Old 9th Jun 2016, 12:19
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In the late 80's to mid 90's there were several wrong deck landings
I recall a senior captain also managed to land at the wrong golf course, having previously announced loudly in the flight planning room that anybody landing on the wrong deck should consider resigning.....
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Old 9th Jun 2016, 12:34
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212man

I had forgotten him! His "error" wouldn't have been so bad if the audience had been different.

SND
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Old 9th Jun 2016, 14:00
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In the UK we have ridiculous arse covering radio waffle with ATC. No only have they invented a whole layer of complexity to do with ATSOCAS which no other country seems to need, but for the sole benefit of ATC there is endless reading out and reading back of types of service and their limitations which sometimes go in for several sentences. All completely pointless and having no bearing on the flight, just arse covering in case someone at NATS might get sued. Have a listen to the offshore frequencies sometime and work out how much of the comms is useful or has any bearing on the safe conduct of the flight. About 50% or less, I'd say.
Glad I am not the only one. They seem to be able to successfully provide information to a maximum of about 3 aircraft at any one time.

Its always a joy to get out of the place. Have to say that of all the European countries Germany is the complete opposite. Virtual silence until needed.

If they do clean it up which would be highly improbable they should do the Coast Guard as well while they are at it - banal dribble.
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Old 9th Jun 2016, 14:06
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Originally Posted by RWing View Post
I think you all need to re-read the full Bulletin report:


1. It is not an accident report, but an INCIDENT report as clearly stated on the top left hand corner of the Synopsis Page.
2. It is not published in isolation; page 47 of the SAME report is about G-CHBY, an AW139 from Humberside having a Wrong Deck landing too... proof that this is not an isolated incident and by companies engaging with the Investigation authorities we can all try and learn from these unfortunate occurrences as a community.


We all know that Wrong Deck Landings are happening throughout the world and for once I enjoyed reading these reports to help recognise a potential situation which could lead to me making the same mistake. I will certainly be checking and double checking in the future!
Interesting that you felt the need to create a new forum persona just to post that! Anyway I am all for investigating incidents with the hope of trying to reduce recurrence. But in this case, there has been no significant investigation of all the circumstances, just a "blame the pilots" subtext and not questioning how much of the rest of the circumstance was avoidable. A good opportunity missed but let's face it, AAIB are not best placed to investigate this sort of thing since they have no idea of the environment and clearly don't have the time to find out.
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Old 9th Jun 2016, 14:08
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@SND I suggest that is because the main lesson learnt was that the pilot screwed up and that is the end of the matter. No lessons learnt about distractions during critical phases of flight ie during shuttles.
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Old 9th Jun 2016, 14:34
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Originally Posted by HeliComparator View Post
Interesting that you felt the need to create a new forum persona just to post that! Anyway I am all for investigating incidents with the hope of trying to reduce recurrence. But in this case, there has been no significant investigation of all the circumstances, just a "blame the pilots" subtext and not questioning how much of the rest of the circumstance was avoidable. A good opportunity missed but let's face it, AAIB are not best placed to investigate this sort of thing since they have no idea of the environment and clearly don't have the time to find out.
Sorry, been a long-time reader but not a poster. I suppose I have a lot of time on my hands due to not flying much at the moment for various reasons... read into that as much as you wish...


I totally agree with you HC; I have a feeling there was more to these events and I wonder if the company investigation reports go into more detail? I certainly hope they do.


My personal feeling is that we will still see more Wrong Deck Landings in the future... watch this space...
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Old 9th Jun 2016, 14:39
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I also heard reports of another Wrong Deck Landing which happened West of Shetland as well... I just don't think this problem is going away anytime soon.
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Old 9th Jun 2016, 16:11
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Helicomparator
.........something we did as a matter of course in Bristow because we all know how easy it is to get sucked into thinking a destination is the destination when in fact it isn't. .......

Remember the S61 and the need to re-slave the main compass after take-off? And there was me remembering the Bristow S61 who took off from ESB on its way to Sumburgh, slaved it 180 degrees out, no gross error check against an NDB, standby compass, or the BBC, or the Sun even, and ended up landing in Bergen. Never mind wrong deck - wrong country!!

We all got it wrong sometime.... But generally managed to get away with it.
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Old 9th Jun 2016, 18:29
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I agree with HC that there is a lot more to these events than just the pilot screwing up. Of course, the reason this appeared in the AAIB bulletin is because of the open and honest reporting culture we have built on the NS. We are under the microscope and it would be great if all players were as open and honest about their failings and mistakes. I hope that the current climate and the attitude that the likes of TM displays doesn't take us back to the bad old days.
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Old 9th Jun 2016, 19:41
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Hi Steve

When I mentioned what we did in Bristow it was of course latterly, perhaps only in this decade, due to lessons learnt from wrong deck landings in the past. So I was not implying that Bristow had never had a wrong deck landing or other major cockup such as you mention. We have had loads!

I had one myself in the early 80s as a year 1 copilot on the S61. We had to fly to a semi sub under tow, weather was not too good. And of course navigating by a Decca roll.

So we arrived in the vicinity of where we thought the rig would be (projecting forward its previously reported position using track, speed and time) and there was a radar return. We descended through cloud and became VMC at maybe 500' with the rig under tow in front of us. We called them up, they answered, and we landed. Then we got the call with the different voice "would the aircraft just landed on our heli deck unannounced kindly identify itself?" Oops! Wrong rig. The correct rig, also under tow, was a couple of miles away. It was what Kevin would have described as "SO UNFAIR!" But of course in those days it wasn't a big deal, we just got a bit of a muttering from the chief pilot on return and heard nothing more about it.

That was the moment that I realised that when you look at a rig, press transmit to get deck availability, get a reply, it is a very alluring and powerful indicator to the psyche that the rig you are looking at is the correct one.

But that was then, and now we have Gps- powered FMS and (since the demise of the Trimble) easy entry of waypoints. There seems less excuse now but nevertheless it happens. And so any report worth it's salt would investigate why the crew didn't put the "To" waypoint in. Was it a one off? If so, why? Was it a company culture thing? And in the case of the 139, having the destination waypoint in, why didn't they use the information? We have no idea. All we know is that the pilots screwed up. Not in the slightest bit useful.
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