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Norways first AW101 on its side

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Norways first AW101 on its side

Old 8th Dec 2017, 22:45
  #81 (permalink)  
 
Join Date: Dec 2015
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The 612 variant of the AW101 uses a variety of sources to assess the on ground condition: WOW status, collective position, engine torque, Nr and airspeed. Once the ground condition is established, the control gains of the pitch roll and yaw axes are reduced by 50% to avoid ground resonance when on the ground or during take-off or landing.
Ex Machina is offline  
Old 19th Dec 2017, 03:19
  #82 (permalink)  
 
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Any new information?

Notwithstanding all of the good information above, is there anything new and reasonably reliable on this event? I imagine that as accident investigations go this has to be a relatively easy one. New aircraft mostly in one piece, no fire, no fatalities or serious injuries (as far as I know), no weather or other aircraft involved, likley had a FDR and CVR and aircraft at home base, all make life easier for investigators. I would imagine there might have been factory reps on site.
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Old 19th Dec 2017, 08:29
  #83 (permalink)  
 
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I am sure those that need to know...know

those that don't will have to wait until a formal statement is made

(although Norwegian AW101s have been seen flying in Yeovil since the incident....)

DM
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Old 19th Dec 2017, 09:20
  #84 (permalink)  
 
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Essentially shorthand for pilot error then......
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Old 23rd Dec 2017, 17:59
  #85 (permalink)  
 
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Any news?

I was just a trip across the fjord to Stavanger today and enjoying a windy ferry crossing. Remembering when Sleipner sunk and when Alexander Kielland flipped over, and how the great 330 Sq saved a lot of lives.
Today we had another storm with a name, Birk , I think.

The other day I talked with an old mechanic from the PBY Catalina. Interesting chap. Like a cat , used most of his nine lives.

The 330Sq first flew out of Island in 1941 and is Norways oldest operational squadron.

Anyone knows if the factory pilots was involved in this or was it my local heros !
Anyway
Lets bring on the new bird.
Looking forward to see and hear it, I can "ident" a Seaking by the sound.
And the fact they are out when the rest of us are cancelling the trip to the woodshed until the weather gets better.

A merry Xmas to all and especially You SAR folks
Cpt B
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Old 23rd Dec 2017, 21:18
  #86 (permalink)  
 
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Originally Posted by BluSdUp View Post

A merry Xmas to all and especially You SAR folks
Cpt B
All the best wishes for a quiet Christmas to the Boys and Girls of 330 Sqn.
Safe flying.
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Old 15th Jan 2019, 17:57
  #87 (permalink)  
 
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The final report on the accident from the Armed forces accident investigation commission (SHF) was published recently.
It lists 12 safety recommendations and 8 measures that has already been implemented.
The complete report is available on their web page here (Complete report in Norwegian only)

This is the published English summary:

On November 24th 2017, a Norwegian AW101-612 rescue helicopter rolled over during start-up. The helicopter was the first AW101 Norway had received and was operated by the unit OT&E AW101. Two pilots were seated in the helicopter when it rolled onto its right side outside an Air Force hangar at Sola air base. No one was injured in the incident, but the helicopter suffered comprehensive damage.

The incident happened during ground run of the helicopter’s engines following a compressor wash. The investigation has shown that the collective was in a higher position than usual when the rotor was accelerated. Thus, the rotor blades were at an angle of attack capable of producing a significant amount of lift. Because the rotor was accelerated using two engines rather than one, it achieved full rotational speed. The combined forces from the main rotor and the tail rotor, were sufficient to make the helicopter roll over.

Over time, ambitious timelines in the project for acquisition of new rescue helicopters, combined with delays in the development of the helicopter, had created a situation of persistent time pressure for all parties involved. The time pressure and the ongoing development of the helicopter, training aids and documentation, caused challenges in regards to the training that pilots and other personnel from OT&E AW101 received from the provider. Combined with the fact that several of the pilots did not have the experience and continuity that the training program was based on, this led to known and unknown shortcomings in the pilots’ skills and competencies after completing training. The constant demand for progress, negatively affected quality assurance in various parts of the organisation, and contributed to elevated and unidentified operational risk.

No sudden or unknown technical malfunction contributed to the incident. A number of human and organisational factors contributed to the incident developing without anyone identifying or correcting the deviations. Among these were shortcomings in the crew’s system knowledge and experience with the AW101-612, insufficient risk awareness, deviations from the checklist, shortcomings in the training received, and imprecise checklist wording.

After the incident, the Air Force cancelled operations with AW101 in Norway until further notice, and initiated an additional training program for OT&E AW101 personnel. Changes were made to how the unit was organised, including adding two new crews. Planned, complementary training was given by the helicopter provider to compensate for known training deltas. The Air Force took measures to clarify and strengthen the role of the Air Force part of the project organisation in shielding, supporting and supervising the activity of OT&E AW101. The Inspectorate of Air Operations gave increased priority to AW101 by increasing staffing in the helicopter department and performing inspections of OT&E AW101.

The accident investigation board has compiled a list of safety issues related to the incident and to the broader organisation involved in acquisition and operations of the AW101, and give recommendations that may help improve safety in the Armed Forces. Several of the recommendations have already been addressed by the measures listed in the previous paragraph. For some recommendations, there is still reason to consider additional measures. This includes, but is not limited to, quality assurance of the technical documentation of the helicopter, and the role of the defence sector in the project board.
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Old 15th Jan 2019, 19:22
  #88 (permalink)  
 
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There is mention of the helicopter experience of personnel in key project positions. It also notes that such OT&E units do not carry experience on the next OT&E task but are formed anew for specific aircraft OT&E tasks.

Are there any Norwegian speakers out there who can dig out more of the highlights?
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Old 15th Jan 2019, 21:29
  #89 (permalink)  
 
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But a fundamental element of starting the rotors on any helicopter is to ensure the lever is down.
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Old 15th Jan 2019, 22:19
  #90 (permalink)  
 
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Yes, but sometimes it isn't. I'm sure some of us on here have discovered that.
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Old 15th Jan 2019, 23:26
  #91 (permalink)  
 
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Fundamentally it stated that in skipping the AFCS Check (since they were not going to fly) they also skipped the flight controls position check. This likely led them to advance throttles (flick the knob) to Flight on engines 2 and 3, the collective was at 45%, or 7 degrees of pitch, the cyclic was not centered and the machine lifted onto its side. Very generalized.

It also stated that the Check list states that due to elastomerics in the rotor head the collective will be partially up, and to NOT attempt to lower until there is hydraulic pressure.

Cheers
W.
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Old 16th Jan 2019, 07:02
  #92 (permalink)  
 
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On Airbus aircraft with elastomeric heads you can overcome them and latch the lever down without hydraulic power but they aren't as big as the 101 or it might just be design differences.

Given the checks that they skipped and the relative unfamiliarity with the correct lever position combined with poor training continuity, all the holes in the swiss cheese lined up again.
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Old 16th Jan 2019, 13:24
  #93 (permalink)  
 
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It also stated that the Check list states that due to elastomerics in the rotor head the collective will be partially up, and to NOT attempt to lower until there is hydraulic pressure.
The S92 is the same. Here's the note I wrote in our Ops Manual Pt B 12 years ago.......

Prior to rotor engagement, the collective will rest in a midrange position. Monitor collective position during initial rotor engagement. As Nr increases through approximately 20% and hydraulic pressure increases, the CM2 shall depress the collective trim switch and move the collective to the full down position.. Avoid using the collective trim switch until hydraulic pressure builds.
(CM2 is the RHS pilot)

On top of that, with CT-7 engines (not sure if this variant is CT-7 or RTM 322) you can do the entire engine rinse and dry procedure without engaging the rotor!

Pity the same lessons have to be relearned!
212man is online now  
Old 16th Jan 2019, 18:52
  #94 (permalink)  
 
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On that 101 they would have had No1 engine in Accessory drive and full flight control hydraulics available before the AFCS check or rotor start. The FRCs do not state that the AFCS check is 'before flight only', they are after No1 starting and before any rotor start, there is no implication they can be skipped. The flight displays have a real time indication of control positions to the pilot so no need to rely on 'feel' either, so no excuses just bad airmanship.

I understand that one of the pilots had flown the aircraft from the UK so hardly unfamiliar, I am sure that LH would not have 'signed him off' as competent if the training pilots felt otherwise.

DM
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Old 16th Jan 2019, 19:09
  #95 (permalink)  
 
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@Dangermouse, there is a whole series of pages in the report on the psychology of what was done and not done, but it is too long for me to translate.

@Crab, there was mentioning that the instructors had told the pilots that it wasn't necessary to have the hand on the collective during the accelerating of the rotor. The AW101-612 has a force trim release on the collective, so this is considered "why" neither pilot had their hands on the collective lever, so this is why they did not. It ALSO stated in the checklist to NOT ATTEMPT to lower the collective until hydraulic pressure was coming up, preceded with a CAUTION.

Other than that, the report also notes that with the limited experience on type (26.2 and 13.1 respectively in the aircraft, and 60ish in the sim), rush during training had many of them hot-switch rather than do full starts etc., it (the report) questioned why they didn't do a full start checklist, as there would have been training value for both of them.

The report also states that the AFCS checks often failed if completed before rotors turning so they would have waited until after Rotors Turning to complete. Unfortunately the "Full, Free and Clear" check of all flight controls is after the caption AFCS CHECKS, hence they didn't complete them, thus missing the non-centered controls.... That are prominently displayed on the PFD...

Last edited by Winnie; 16th Jan 2019 at 19:39. Reason: Ambiguous statements...
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Old 16th Jan 2019, 19:36
  #96 (permalink)  
 
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Originally Posted by Winnie View Post
@Crab, there was mentioning that the instructors had told the pilots that it wasn't necessary to have the hand on the collective during the starting sequence, so this is why they did not...
I thought it said that PM did have his hand on the collective. The issue being not noticing that it was already high.
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Old 16th Jan 2019, 20:02
  #97 (permalink)  
 
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It does, but there are a lot of factors involved, so my paragraphs of paraphrasing isn't really enough, but I can't be bothered to translate 64 pages from Norwegian to English... Too lazy.
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Old 16th Jan 2019, 20:19
  #98 (permalink)  
 
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Lots of dithering back and forth about all of this....but perhaps we should consider the concept that if you need a Checklist to start up an aircraft correctly then perhaps you are in the wrong business.

Checklists are supposed to be "Aids" or "Guides" and not replace good old fashioned airmanship....a notion that means you know your aircraft, its systems, and how to properly operate the aircraft.

Lord sakes....how old fashioned are we to think one would know the proper position of the flight controls before rotating blades and why ever would we think one of the two pilots would have their grubby mitts on the those flight controls.

How novel is it to think one. of the things you might consider checking is the actual position of the flight controls?

If you have a Force Trim/Mag Brake and associated Trim Release Switch for the Collective...that one would think to click the switch to ensure the mag brake is set to the physical position of the collective?

If you have a Fllght Control position display on the PFD and still have not tweaked to an unusual Collective or Cyclic position....and have not put your mitts on those flight controls....and you do skip over the Checklist entry that would have told you to check the Flight Controls.....well....I think you are really in the wrong business.

This is just another helicopter and the basic methods and practices do transfer over to new and different types even though there are technical differences in how they are applied....but the concepts are the same.
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Old 16th Jan 2019, 20:37
  #99 (permalink)  
 
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As now expected google translate declined to translate the report.

"The page you requested was too large to translate."

However, why not split the file up into pieces and translate them individually and then re-assemble the file - bound to be a web site for that.

https://www.onlinedoctranslator.com/en

I have translated it and uploaded it to google drive.
The document linked below was created by the above random website and security concerns may apply. I am reading it, you need to choose

https://drive.google.com/open?id=1Dl...qKFsSoAR3RdFjV

Let me know if link is not working for you.

Original
https://www.regjeringen.no/contentas...4.nov.2017.pdf

Last edited by jimjim1; 16th Jan 2019 at 20:57. Reason: small adjustments for clarity
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Old 16th Jan 2019, 20:49
  #100 (permalink)  
 
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@Sasless, I agree mostly, however, there is blame to be put on multiple organizations in this case, including the Norwegian Air Force AND Leonardo Helicopters... Lack of training from one, or rather lack of relevant training, lack of knowledge between different variants etc from LH. Lack of continuity of flying from the Air Force, some of the OT&E pilots had not really flown in a year. or more... But read through the whole thing that jimjim1 posted. it may give some clarity. But blaming the crew alone for this fu$kup is a little rich.

We all make mistakes, just try to minimize the impact of such mistakes...
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