Missing Twin Squirrel: Wales/Ireland
Yes, that is symptomatic of his attitude to the whole flight it seems.
It seems to be a difference between the professional pilot and the successful businessman/sportsman - when faced with a changing scenario whilst flying, someone who is used to being right (or being told they are right) in their own profession appears to be less likely to change their course of action when conditions change.
I didn't say professional pilots were immune to CFIT but the S92 certainly had mitigating factors and the 139 had severe operator/owner pressure, I'm not sure which 109 you refer to.
The 92 had errors in its navigational database and perhaps a crew that were too comfortable following the magenta line.
The 139 crew should have said no but pushed on using an inappropriate departure technique.
There have been far, far more GA pilots hitting the ground unintentionally over the years and the root cause is often poor weather appreciation and unnecessary risk-taking due to pressonitis.
The 92 had errors in its navigational database and perhaps a crew that were too comfortable following the magenta line.
The 139 crew should have said no but pushed on using an inappropriate departure technique.
There have been far, far more GA pilots hitting the ground unintentionally over the years and the root cause is often poor weather appreciation and unnecessary risk-taking due to pressonitis.
Avoid imitations
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Flown by pilots with professional licences, but not flown in a truly professional manner - there lies the difference.
Last edited by ShyTorque; 9th Mar 2018 at 19:58. Reason: spelling correction..
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Yet another AAIB report which does not really consider the HF elements as follows:
(a) Why did the pilot plan a flight when Shawbury was RADZ 003 and Valley cloud base at 600 ft, was the pilot's thinking that the Rhiongs would be better?
(b) Would a 180 degree turn helped, simply do not enter IMC.
(c) Did the pilot brief the PAX that in the event the weather was bad, they would land at Welshpool, or Liverpool and via taxi and scheduled flight continue to Dublin.
(d) Jut another CFIT of not lossing face in not getting to the destination.
I am sorry if this is not respectfull to the deseased, but perhaps we can learn from this,
(a) Why did the pilot plan a flight when Shawbury was RADZ 003 and Valley cloud base at 600 ft, was the pilot's thinking that the Rhiongs would be better?
(b) Would a 180 degree turn helped, simply do not enter IMC.
(c) Did the pilot brief the PAX that in the event the weather was bad, they would land at Welshpool, or Liverpool and via taxi and scheduled flight continue to Dublin.
(d) Jut another CFIT of not lossing face in not getting to the destination.
I am sorry if this is not respectfull to the deseased, but perhaps we can learn from this,
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I think there have been some very pertinent observations from crab, two's in and others about flight planning in this era of electronic tablet navigation. Scrolling around a map on a screen is no substitute for sitting in front of a real map when you're planning a flight.....you just see so much more.
What I can't understand is this. He got airborne around 10.30, he would have seen the above TAF and METAR for Valley before he got in the aircraft. Why did he think the flight could have been conducted safely in VMC?
I notice he had the weather radar from the Met Office displayed on his ipad......maybe he thought he could dodge the Wx radar returns and remain VMC, but Wx radar from the Met Office shows areas of rain.....it's not a low cloud radar.
Very sad....he even had the autopilot engaged, so when it started looking dicey he could have selected a climb to MSA until over the sea.
TAF EGOV 290747Z 2909/2918 18020KT 8000 BR OVC006 BECMG 2909/2911
OVC007 TEMPO 2909/2918 3000 RADZ BKN003=
OVC007 TEMPO 2909/2918 3000 RADZ BKN003=
METAR COR EGOV 290950Z 16019KT 8000 BR OVC007 11/10 Q1015
BLACKGRN TEMPO 3000 RADZ BKN003 YLO2=
BLACKGRN TEMPO 3000 RADZ BKN003 YLO2=
I notice he had the weather radar from the Met Office displayed on his ipad......maybe he thought he could dodge the Wx radar returns and remain VMC, but Wx radar from the Met Office shows areas of rain.....it's not a low cloud radar.
Very sad....he even had the autopilot engaged, so when it started looking dicey he could have selected a climb to MSA until over the sea.
Originally Posted by [email protected]
I didn't say professional pilots were immune to CFIT but the S92 certainly had mitigating factors and the 139 had severe operator/owner pressure, I'm not sure which 109 you refer to.
The 92 had errors in its navigational database and perhaps a crew that were too comfortable following the magenta line.
The 139 crew should have said no but pushed on using an inappropriate departure technique.
There have been far, far more GA pilots hitting the ground unintentionally over the years and the root cause is often poor weather appreciation and unnecessary risk-taking due to pressonitis.
The 92 had errors in its navigational database and perhaps a crew that were too comfortable following the magenta line.
The 139 crew should have said no but pushed on using an inappropriate departure technique.
There have been far, far more GA pilots hitting the ground unintentionally over the years and the root cause is often poor weather appreciation and unnecessary risk-taking due to pressonitis.
Someone suggested the human factors weren't covered so well and I would think the AAIB might recognise that hasn't been their strongest area as they recruited for that exact role recently.
All that said there is only so many times you can pass essentially the same message, in this case the pilot was experienced and one must surely be generous enough to think that a pilot with 3650hrs can read and understand TAF and METAR and F215 information. Why the obvious wasn't heeded is no clearer here than the fuel situation in Glasgow or the decision making of the 109 pilot who crashed in London or the two crew members of the 139 in Norfolk.
Pressure? I'm sure in most of those, I understand that this pilot was enroute to a wedding and for sure you can well imagine if that was the case it brought pressure.
If he was using an iPad as his primary nav did it freeze giving him a false impression of his position? who knows and one would still be pulled back to the preflight weather info and airmanship around continuation of a VFR flight into IMC.
But all that to one side people err and plenty of "great guys" have been caught out too and paid pilots are not immune.
Pitts - you are completely correct - it is the human element that keeps failing in these (usually) avoidable accidents but I don't know why you think the CAA should have the answers.
There are reams of information about the human psyche, decision making, perceived pressure et al and HF is a required element of all licences - yet the accidents keep happening.
Why do people keep crashing on the roads? Cars are safer yet the frustrations and pressures of real life (plus a lack of awareness in many cases) keep contributing to the death toll.
There are so many reasons that the human being is the weak link in the man/machine interface that even when you think you have educated everyone about everything, something bizarre occurs - who saw the German Wings suicide coming?
As an instructor, I keep finding myself teaching the same stuff, over and over again, using incidents like this one to help other pilots learn from others mistakes.
BUT, however well trained you are, it just takes a bad day with something happening that you didn't want or expect, just to drop your guard enough for those human failings to override that training and start you on the slippery slope to an accident/incident.
If you are lucky, your in-built sense of self-preservation comes to the rescue in time to avert disaster - if not..............
There are reams of information about the human psyche, decision making, perceived pressure et al and HF is a required element of all licences - yet the accidents keep happening.
Why do people keep crashing on the roads? Cars are safer yet the frustrations and pressures of real life (plus a lack of awareness in many cases) keep contributing to the death toll.
There are so many reasons that the human being is the weak link in the man/machine interface that even when you think you have educated everyone about everything, something bizarre occurs - who saw the German Wings suicide coming?
As an instructor, I keep finding myself teaching the same stuff, over and over again, using incidents like this one to help other pilots learn from others mistakes.
BUT, however well trained you are, it just takes a bad day with something happening that you didn't want or expect, just to drop your guard enough for those human failings to override that training and start you on the slippery slope to an accident/incident.
If you are lucky, your in-built sense of self-preservation comes to the rescue in time to avert disaster - if not..............
Hi - I don't think I've mentioned the CAA?
I agree with your last post, my prior point just being everyone can err.
When you instruct you are very close to the coal face in terms of being forced to think about your flying and no doubt your students highlight things that you may not have considered as something that could "err"??
But as a community what is the engagement? Who talks to the 3000hr pilot about best practice or just gives a review? Does his LPC cover things? Possibly but these continued VFR flights into IMC are akin to just not putting enough fuel in the tank. Maybe operation off private type sites should have some buddy system with a phone call to someone who can have the "are you sure..?" comment?
All with its own un-intended consequence and snags.
I agree with your last post, my prior point just being everyone can err.
When you instruct you are very close to the coal face in terms of being forced to think about your flying and no doubt your students highlight things that you may not have considered as something that could "err"??
But as a community what is the engagement? Who talks to the 3000hr pilot about best practice or just gives a review? Does his LPC cover things? Possibly but these continued VFR flights into IMC are akin to just not putting enough fuel in the tank. Maybe operation off private type sites should have some buddy system with a phone call to someone who can have the "are you sure..?" comment?
All with its own un-intended consequence and snags.
Hi - I don't think I've mentioned the CAA?
On your last point, the GA community could learn something from the military where each flight is required to be authorised - it can be self-authorised or more often done by someone else.
The process means you present your plan and someone else casts their eye over it and asks pertinent questions.
In this case, if he had phoned someone and briefly talked through his plan, you would like to think they would have asked questions about the weather and what he would do if it was bad en route.
It may be that he had done this sort of thing many times before and been lucky to get a cloudbreak or weather improvement - this is another classic human failing where the risks become normalised and he assumes he is a better pilot because he got through last time.
I'm not sure which 109 you refer to.
Ah yes and both of those could be classed as Shy Torque described a few posts ago.
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Not forgetting the other A109 that suffered an accident, flown by a PPLH holder in what could be described at best as very marginal VMC. The pilot probably attempted to fly an ILS, for which he was neither qualified or trained. Or another that quite a few of us in the industry know about - another A109S hit the ground and bounced, at night whilst trying to land in low cloud/fog in a remote area; thankfully not too hard a bounce such that the pilot got away with it, but the aircraft didn't fare too well.
People always make mistakes, be it whilst flying, driving, walking or whatever. Increased legislation won't prevent many of them. An AOC holder has a responsibility to monitor the safety of all involved, but that won't ever prevent professional pilots making errors of skill, or judgement of a situation once airborne.
People always make mistakes, be it whilst flying, driving, walking or whatever. Increased legislation won't prevent many of them. An AOC holder has a responsibility to monitor the safety of all involved, but that won't ever prevent professional pilots making errors of skill, or judgement of a situation once airborne.
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In the Vauxhall Bridge accident the pilot was using his mobile phone, yet the AAIB did not really indentify that as a major facitor.
As for military authorisation, that did not make a difference in the CFIT Chinook accident and various other RAF CFIT accidents.
As for military authorisation, that did not make a difference in the CFIT Chinook accident and various other RAF CFIT accidents.
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The Mountains of Mourne accident was inexcusable, in my book. I had flown with that pilot in the past and cannot understand why he failed to fly at MSA.
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The specific cause of this accident seems something of a mystery, ie why did the pilot descend in IMC into high ground. There was no apparent reason to. He had the equipment to know his position with the iPad moving map, the height of the terrain in his path, and his altitude. There was nothing wrong with the aircraft and no reason eg icing to force him down. And he had engaged autopilot modes to enable stable flight in IMC.
The task before him was pretty simple really. Had he just continued on track at the 3000ft he achieved he could have got to his destination. So what went wrong?
Well, we know he was sloppy. His log book was not remotely up to date and he well overloaded a limited power aircraft. We know too that the weather was going to mean he had virtually no chance of achieving this flight according maintaining VMC, as his licence required him too. So what went through his mind pre flight ref weather? One scenario is that he just didn't look carefully enough at the met info. Seems a bit strange to me that the visited pages were rainfall, not TAFs and METARs. I guess it is possible he was clueless enough not to be able to obtain and understand a general weather picture, but after over 3000hrs VFR experience that seems very unlikely.
Another scenario is that he did know the weather was likely to be poor en route but that he was happy (ish) to continue IMC, because he had an autopilot and knew how to push the buttons. And indeed he'd done this before. The AAIB report surprisingly didn't consider this possibility. Though if this was the case why did he descend at all?
If he intended to maintain VMC why climb as high as 3000ft, into an increasing headwind, so early - ie 20 miles before he needed to for terrain clearance? Possibly to get a smoother ride - it was probably fairly bumpy. But I'm not sure this pilot would have thought this way. And if he wanted to maintain VMC, why not descend earlier and faster to maintain VMC, or simply turn back. Two very easy actions.
Another point - I was surprised by the lack of any reference in the report to any RT comms. He was squawking 1177 which would indicate he was talking to London Information. If so, I wonder what he said to them?
The rate of descent from the peak of 3000ft is very interesting and significant to me - it is minimal, at 25ft/min, and is maintained for 15mins. Who ever descends at such a fine rate - and immediately after climbing? Even in a cruise descent to a destination you might choose a VS of say 200ft/min to optimise speed, but not 25ft/min. And I can't believe the cloudbase he was keeping under was reducing so slowly and progressively.
So here's a scenario. The pilot climbs to 3000ft having selected a climb on VS. At 3000ft he turns down the VS to level, but doesn't select ALT. But actually he's selected not 0, but 25ft/min down. He makes both mistakes because he's sloppy. And he doesn't check the altimeter for the same reason.
Now he trundles on at 115kts, passing through and over bits of cloud, until eventually he comes to much more solid cloud ahead. At this point he decides to descend and keep under it. He knows highest ground is 2300ft but as he's at 3000ft he can descend 700ft before he's going to hit anything. And he can see patches of ground well below through gaps in the cloud.
However of course he's not descending from the 3000ft he thinks he's at, but 2700ft. And that 300ft makes a fatal difference. Any thoughts?
An alternative is that his rate of descent rapidly increases when he encounters the forecast mountain wave conditions. Maybe he hasn't deliberately descended faster at all - after all, 185ft/min is still strangely slow to be an effort to maintain VMC - and that this extra modest descent is from downdrafts.
And then finally there is the slightly mysterious reference to "other substances" being found in the pilot's body. Which clearly has the potential for judgment to be even more flawed.
The task before him was pretty simple really. Had he just continued on track at the 3000ft he achieved he could have got to his destination. So what went wrong?
Well, we know he was sloppy. His log book was not remotely up to date and he well overloaded a limited power aircraft. We know too that the weather was going to mean he had virtually no chance of achieving this flight according maintaining VMC, as his licence required him too. So what went through his mind pre flight ref weather? One scenario is that he just didn't look carefully enough at the met info. Seems a bit strange to me that the visited pages were rainfall, not TAFs and METARs. I guess it is possible he was clueless enough not to be able to obtain and understand a general weather picture, but after over 3000hrs VFR experience that seems very unlikely.
Another scenario is that he did know the weather was likely to be poor en route but that he was happy (ish) to continue IMC, because he had an autopilot and knew how to push the buttons. And indeed he'd done this before. The AAIB report surprisingly didn't consider this possibility. Though if this was the case why did he descend at all?
If he intended to maintain VMC why climb as high as 3000ft, into an increasing headwind, so early - ie 20 miles before he needed to for terrain clearance? Possibly to get a smoother ride - it was probably fairly bumpy. But I'm not sure this pilot would have thought this way. And if he wanted to maintain VMC, why not descend earlier and faster to maintain VMC, or simply turn back. Two very easy actions.
Another point - I was surprised by the lack of any reference in the report to any RT comms. He was squawking 1177 which would indicate he was talking to London Information. If so, I wonder what he said to them?
The rate of descent from the peak of 3000ft is very interesting and significant to me - it is minimal, at 25ft/min, and is maintained for 15mins. Who ever descends at such a fine rate - and immediately after climbing? Even in a cruise descent to a destination you might choose a VS of say 200ft/min to optimise speed, but not 25ft/min. And I can't believe the cloudbase he was keeping under was reducing so slowly and progressively.
So here's a scenario. The pilot climbs to 3000ft having selected a climb on VS. At 3000ft he turns down the VS to level, but doesn't select ALT. But actually he's selected not 0, but 25ft/min down. He makes both mistakes because he's sloppy. And he doesn't check the altimeter for the same reason.
Now he trundles on at 115kts, passing through and over bits of cloud, until eventually he comes to much more solid cloud ahead. At this point he decides to descend and keep under it. He knows highest ground is 2300ft but as he's at 3000ft he can descend 700ft before he's going to hit anything. And he can see patches of ground well below through gaps in the cloud.
However of course he's not descending from the 3000ft he thinks he's at, but 2700ft. And that 300ft makes a fatal difference. Any thoughts?
An alternative is that his rate of descent rapidly increases when he encounters the forecast mountain wave conditions. Maybe he hasn't deliberately descended faster at all - after all, 185ft/min is still strangely slow to be an effort to maintain VMC - and that this extra modest descent is from downdrafts.
And then finally there is the slightly mysterious reference to "other substances" being found in the pilot's body. Which clearly has the potential for judgment to be even more flawed.
Anchorhold
I didn't say it was infallible but it is a layer of safety/supervision that doesn't exist in GA.
The Mull crash had a lot more going on than just a simple CFIT - I have seen several military CFIT crashes discussed at length on various mil flight safety courses - including that one - the auth process is a check and balance but ultimately if the captain doesn't comply with his auth there's not much you can do.
Rotorspeed - I think your logic is sound regarding the use of the VS mode but without a CVFDR we won't ever know.
Every pilot should study this accident to try and understand how poor practices can too easily convert a serviceable aircraft and several humans into a scar on a mountainside.
As for military authorisation, that did not make a difference in the CFIT Chinook accident and various other RAF CFIT accidents.
The Mull crash had a lot more going on than just a simple CFIT - I have seen several military CFIT crashes discussed at length on various mil flight safety courses - including that one - the auth process is a check and balance but ultimately if the captain doesn't comply with his auth there's not much you can do.
Rotorspeed - I think your logic is sound regarding the use of the VS mode but without a CVFDR we won't ever know.
Every pilot should study this accident to try and understand how poor practices can too easily convert a serviceable aircraft and several humans into a scar on a mountainside.
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I think pilots in their intial training and recurrent training there needs to be more emphasis on decision making, risk assesment through reading AAIB reports.
As mentioned before I think there is within parts of the rotary community a different attitude to pressing on in poor weather and many fixed wing pilots have a different attitude climb to MSA and or 180 degree turn and request radar, of course the latter is not an option in a valley.
While even the RAF at Valley were probably not flying and this flight was planning to fly go through Snowdonia was a CANP filed, that would be a sensible option. It concerns me that even if the conditions were flyable, that a Hawk or SAR rotary might be coming in the opposite direction.
As mentioned before I think there is within parts of the rotary community a different attitude to pressing on in poor weather and many fixed wing pilots have a different attitude climb to MSA and or 180 degree turn and request radar, of course the latter is not an option in a valley.
While even the RAF at Valley were probably not flying and this flight was planning to fly go through Snowdonia was a CANP filed, that would be a sensible option. It concerns me that even if the conditions were flyable, that a Hawk or SAR rotary might be coming in the opposite direction.
Hawks and SAR rotary have standard routes in, through and out of Snowdonia which are generally at low level.
The route the Squirrel took would have been very unlikely to meet mil traffic - even if he had managed to stay VMC throughout.
CANP is usually used for specific sites - hang-gliding, USL work etc rather than a 'VFR' route.
Agree with your point about different attitudes to pressing on in poor weather RW vs FW.
The route the Squirrel took would have been very unlikely to meet mil traffic - even if he had managed to stay VMC throughout.
CANP is usually used for specific sites - hang-gliding, USL work etc rather than a 'VFR' route.
Agree with your point about different attitudes to pressing on in poor weather RW vs FW.