FAI into Clutha crash opens
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https://www.eveningtimes.co.uk/news/...auge-failures/
AIR ambulance pilots who flew the same type of helicopter as the one which caused the Clutha disaster have told how their fuel gauges failed during flight.
Two airmen giving evidence at the inquiry into the accident, which cost the lives of ten people, spoke of getting faulty readings during flights in an EC-135 helicopter which said fuel tanks were full when they were actually dangerously depleted.
William Bryers, a former flying instructor and John Taylor, now a flight lieutenant with the RAF, were working for the air ambulance service in England when the incidents happened.
Captain Bryers said that the gauge gave an incorrect reading “about 30-35 kilos [of fuel] either way” while it was being flown, depending on the pitch of the aircraft.
Flt Lt Taylor recounted a further incident in the same aircraft where low fuel warnings sounded during a flight, despite gauges showing that both supply tanks were still full.
Both were speaking at the ongoing hearing into the disaster, which is taking place at a temporary court Hampden Park before Sheriff Principle Craig Turnbull.
Ten people died when police helicopter G-SPAO fell from the sky and crashed into the crowded Clutha Vaults pub in Glasgow on 29 November 2013.
The pilot and all passengers aboard the aircraft were among the fatalities. The question of how much fuel the aircraft had and what the crew knew about it has been central to the inquiry.
The problems aboard Captain Byers’ helicopter occurred during three different flights he made on 10 December 2013. The pilot saw changes in fuel levels when transitioning from a ‘take-off and hover’ position to level flight.
He said: “I had never experienced that, and it stood out to me. So I made notes to that.
“When taking off there was around 30 kilos less. Moving forward there was about 30 kilos above.”
He said it was not connected to fuel being burned off while the aircraft was in operation, and that the fluctuations were greater than he had ever experienced before.
The incident was reported to Captain Bryers’ superiors, and noted in a technical log.
Details were also passed on to Flt Lt Taylor, who was flying the helicopter the next day. During a flight to Backpool where the aircraft was to be examined, the gauges failed again.
Despite showing the instruments showing full tanks, fuel pump warning lights were activated in the cockpit, causing confusion among the crew.
Flt Lt Taylor: “If they had both been on I would not have lifted. During the climb both came on. I don’t know which one came on first, but there was not much time between them.
“It took me a few minutes for the light to go on in my head, and I said to the paramedic [onboard] that ‘there’s something not quite right here’.”
The aircraft landed safely at Blackpool with the fuel indicators showing that both supply tanks were full, and that the main tanks also had some fuel left, despite Flt Lt Taylor knowing it had to be empty by this point. By this point red low fuel lights had been activated on the dashboard.
The court also heard that a technical “information notice” was dispatched in March the next year by the helicopter’s manufacturer, which explained that fuel displays could be affected by the pitch of the aircraft and give faulty readings.Flt Lt Taylor said this came as a surprise to the pilots, who were unaware if the aircraft’s fuel supply ‘logic’.
He said: “It was quite a shock to learn that ‘logic’. We did not know our own fuel systems. It was talked about a great deal.”
Pilot David Traill, 51; PC Tony Collins, 43; and PC Kirsty Nelis, 36, died along with seven customers who were in the bar when it was struck by the helicopter - Gary Arthur, 48; Joe Cusker, 59; Colin Gibson, 33; Robert Jenkins, 61; John McGarrigle, 58; Samuel McGhee, 56; and Mark O'Prey, 44.
The Inquiry continues.
Two airmen giving evidence at the inquiry into the accident, which cost the lives of ten people, spoke of getting faulty readings during flights in an EC-135 helicopter which said fuel tanks were full when they were actually dangerously depleted.
William Bryers, a former flying instructor and John Taylor, now a flight lieutenant with the RAF, were working for the air ambulance service in England when the incidents happened.
Captain Bryers said that the gauge gave an incorrect reading “about 30-35 kilos [of fuel] either way” while it was being flown, depending on the pitch of the aircraft.
Flt Lt Taylor recounted a further incident in the same aircraft where low fuel warnings sounded during a flight, despite gauges showing that both supply tanks were still full.
Both were speaking at the ongoing hearing into the disaster, which is taking place at a temporary court Hampden Park before Sheriff Principle Craig Turnbull.
Ten people died when police helicopter G-SPAO fell from the sky and crashed into the crowded Clutha Vaults pub in Glasgow on 29 November 2013.
The pilot and all passengers aboard the aircraft were among the fatalities. The question of how much fuel the aircraft had and what the crew knew about it has been central to the inquiry.
The problems aboard Captain Byers’ helicopter occurred during three different flights he made on 10 December 2013. The pilot saw changes in fuel levels when transitioning from a ‘take-off and hover’ position to level flight.
He said: “I had never experienced that, and it stood out to me. So I made notes to that.
“When taking off there was around 30 kilos less. Moving forward there was about 30 kilos above.”
He said it was not connected to fuel being burned off while the aircraft was in operation, and that the fluctuations were greater than he had ever experienced before.
The incident was reported to Captain Bryers’ superiors, and noted in a technical log.
Details were also passed on to Flt Lt Taylor, who was flying the helicopter the next day. During a flight to Backpool where the aircraft was to be examined, the gauges failed again.
Despite showing the instruments showing full tanks, fuel pump warning lights were activated in the cockpit, causing confusion among the crew.
Flt Lt Taylor: “If they had both been on I would not have lifted. During the climb both came on. I don’t know which one came on first, but there was not much time between them.
“It took me a few minutes for the light to go on in my head, and I said to the paramedic [onboard] that ‘there’s something not quite right here’.”
The aircraft landed safely at Blackpool with the fuel indicators showing that both supply tanks were full, and that the main tanks also had some fuel left, despite Flt Lt Taylor knowing it had to be empty by this point. By this point red low fuel lights had been activated on the dashboard.
The court also heard that a technical “information notice” was dispatched in March the next year by the helicopter’s manufacturer, which explained that fuel displays could be affected by the pitch of the aircraft and give faulty readings.Flt Lt Taylor said this came as a surprise to the pilots, who were unaware if the aircraft’s fuel supply ‘logic’.
He said: “It was quite a shock to learn that ‘logic’. We did not know our own fuel systems. It was talked about a great deal.”
Pilot David Traill, 51; PC Tony Collins, 43; and PC Kirsty Nelis, 36, died along with seven customers who were in the bar when it was struck by the helicopter - Gary Arthur, 48; Joe Cusker, 59; Colin Gibson, 33; Robert Jenkins, 61; John McGarrigle, 58; Samuel McGhee, 56; and Mark O'Prey, 44.
The Inquiry continues.
Last edited by Senior Pilot; 5th Jul 2019 at 01:13. Reason: Add quote: this helps Rotorheads know what you're posting about!
Nothing really new here.
differences in the fuel state depending on attitude is common - but if you understand, that the low fuel warning is independent from the displayed value the necessary actions are straight forward.
i f in doubt, play it save is a good advice in aviation.
differences in the fuel state depending on attitude is common - but if you understand, that the low fuel warning is independent from the displayed value the necessary actions are straight forward.
i f in doubt, play it save is a good advice in aviation.
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Final post on enquiry from Scottish Review
Their correspondent's perception of the main points raised in the final few days of the enquiry.
Scottish Review: Maurice Smith
Scottish Review: Maurice Smith
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The final report has just been published:
https://www.bbc.co.uk/news/uk-scotla...-west-50220838
https://www.bbc.co.uk/news/uk-scotla...-west-50220838
The final report has just been published:
https://www.bbc.co.uk/news/uk-scotla...-west-50220838
https://www.bbc.co.uk/news/uk-scotla...-west-50220838
mjb
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Unnecessrialy complex fuel system, leaving the pilot to do what the aircraft system should do automatically by design.
Unreliable gauges and low level alarms routinely crying WOLF
Pump switches out of view
All waiting for innocent error and then, GOTCHA!
Pilot victim of booby trap, yet blamed.
Thank goodness my fuel gravity from two tanks,on-off, but gotcha flap switch detents back to 'up'
Unreliable gauges and low level alarms routinely crying WOLF
Pump switches out of view
All waiting for innocent error and then, GOTCHA!
Pilot victim of booby trap, yet blamed.
Thank goodness my fuel gravity from two tanks,on-off, but gotcha flap switch detents back to 'up'
Clutha crash: Inquiry says pilot 'took a chance' to ignore fuel warnings
https://www.bbc.com/news/uk-scotland...-west-50220838
BBC saying similar.
https://www.bbc.com/news/uk-scotland...-west-50220838
Clutha crash: Inquiry says pilot 'took a chance' to ignore fuel warnings
https://www.bbc.com/news/uk-scotland...-west-50220838
Interesting to see some of the family support:
Mr O'Prey's father Ian said he was "really angry" at the inquiry's findings and that Capt Traill had been made "a fall guy".
The Clutha's owner, Alan Crossan, also expressed "shock and disappointment" at the report and how "brutal" it had been towards Capt Traill.
The Clutha's owner, Alan Crossan, also expressed "shock and disappointment" at the report and how "brutal" it had been towards Capt Traill.
The problem is that the media and public understanding of what happened and what it 'means' was always going to be different from that of an experienced professional. Understanding the underlying cause and the lessons to be learned doesn't sell papers.
The support being shown by the families towards the pilot is refreshing in many ways but also must be taken in the context of "This is Glasgow". Glasgow is a very egalitarian city. It is the natural response of most people to support the wee guy against the big guy. When the big guy also happens to be the "Polis" then it's a no-brainer. Many people in Glasgow want this to be the police's fault rather than some poor bloke just doing his job.
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AAIB Accident Report - Glasgow City Centre 29/11/2013
I would be interested to know the thoughts of Rotary Pilots who may have questioned some of the reports findings.
in particular I find it interesting that the report questions why ATC heard nothing from the Helicopter minutes and seconds before the impact.
As I recall from my training as a PPL(H) In all instances when airborne it is the practice to 1. Aviate, 2. Navigate and 3. Communicate In that order.
Might this explain the lack of COMM's leading up to the impact?
Also the fact that it appears that the attempt to effect autorotation 3 times on realisation that both engines had flared out the pilot was doing all he could to
limit the risk of injury or death by ditching in the River Clyde. Although the machine was so close to the water, this was also hampered by the fact that the 'steering light' was not switched on
which made it near impossible to gauge height, location and speed. There are some questions raised that cannot be answered but IMHO the pilot at the point of the double flare-out exercised
all his skill to auto the machine into the river to limit the risks of death and injury and he was so very close!
I am asking the question mindful of and with the deepest sympathy and respect to all who suffered in this tragic and heart-breaking event.
in particular I find it interesting that the report questions why ATC heard nothing from the Helicopter minutes and seconds before the impact.
As I recall from my training as a PPL(H) In all instances when airborne it is the practice to 1. Aviate, 2. Navigate and 3. Communicate In that order.
Might this explain the lack of COMM's leading up to the impact?
Also the fact that it appears that the attempt to effect autorotation 3 times on realisation that both engines had flared out the pilot was doing all he could to
limit the risk of injury or death by ditching in the River Clyde. Although the machine was so close to the water, this was also hampered by the fact that the 'steering light' was not switched on
which made it near impossible to gauge height, location and speed. There are some questions raised that cannot be answered but IMHO the pilot at the point of the double flare-out exercised
all his skill to auto the machine into the river to limit the risks of death and injury and he was so very close!
I am asking the question mindful of and with the deepest sympathy and respect to all who suffered in this tragic and heart-breaking event.
Atceng – “low level alarms routinely crying WOLF” Actually not. The Low Fuel sensors have been shown to be the one component that could and can be relied upon – unlike the Fuel Qty sensors which are prone to over reading if/when contaminated.
The Sherriff Principal has it right with his final paragraph:
[515] The central question for the inquiry is why did that happen? The answer is a simple one. Captain Traill ignored the LOW FUEL warnings he received. Had he followed the procedure set down in the Pilot’s Checklist in respect of the LOW FUEL 1 and / or LOW FUEL 2 warnings, the accident would not have happened. Put another way, Captain Traill took a chance that the LOW FUEL warnings he received were erroneous. That was a conscious decision on his part. It was a decision that had fatal consequences for ten people.
The responsibility for the outcome of every flight lies with the aircraft Captain - it's the price of the privilege of the 4 bars on their shoulders.
The Sherriff Principal has it right with his final paragraph:
[515] The central question for the inquiry is why did that happen? The answer is a simple one. Captain Traill ignored the LOW FUEL warnings he received. Had he followed the procedure set down in the Pilot’s Checklist in respect of the LOW FUEL 1 and / or LOW FUEL 2 warnings, the accident would not have happened. Put another way, Captain Traill took a chance that the LOW FUEL warnings he received were erroneous. That was a conscious decision on his part. It was a decision that had fatal consequences for ten people.
The responsibility for the outcome of every flight lies with the aircraft Captain - it's the price of the privilege of the 4 bars on their shoulders.
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I've read the full report (unlike the media, I fear). It is very factual and I believe balanced and reasonable. What the media will not pick up on/report is that the sheriff concluded that the fuel gauges were misreading. He sated this several times. He also said he believed Dave ignored the red captions because the information he was getting from the CAD (no yellow caption) and the indicated fuel contents contradicted what the red captions were saying. I always believed this to be the case and I'm glad the sheriff concluded this from the evidence. What is unpalatable to us but is factually correct is as the sheriff stated (and this is the only thing the press will pick up) if both transfer pumps had not been switched off and the red captions ignored then this accident would not have happened. Thats the fact. The why we will never know.
I've read the full report (unlike the media, I fear). It is very factual and I believe balanced and reasonable. What the media will not pick up on/report is that the sheriff concluded that the fuel gauges were misreading. He sated this several times. He also said he believed Dave ignored the red captions because the information he was getting from the CAD (no yellow caption) and the indicated fuel contents contradicted what the red captions were saying. I always believed this to be the case and I'm glad the sheriff concluded this from the evidence. What is unpalatable to us but is factually correct is as the sheriff stated (and this is the only thing the press will pick up) if both transfer pumps had not been switched off and the red captions ignored then this accident would not have happened. Thats the fact. The why we will never know.
Edit - ah yes I see he is proposing that there was a fuel indication problem, although the primary reason for that conclusion is that it would be incomprehensible for DT to have ignored not only the amber fuel captions but also the red ones. To ignore red ones on their own is certainly more understandable. That said, he seems to have ignored the transfer pump lights.
Last edited by HeliComparator; 30th Oct 2019 at 19:50.
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The Sheriff has clearly implied negligence on the part of the pilot, based on ‘the balance of probabilities’. According to Lord Philip (Mull of Kintyre Review), where aircrew have died and unable to defend themselves the ‘Standard of Proof’ is set higher to the level of ‘Absolutely no doubt whatsoever’ Furthermore, FAI are not set up to assign blame. This FAI fails to comply with these two criteria.
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Helicomparator. I gave 2 days of evidence to the enquiry. About a week after the tragedy I was flying an aircraft that had both red warnings come on in flight. The tanks showed 47/26/43 on the gauges and the amber/yellow fuel warning did not show. I landed very quickly, the tanks were drained and were nearly empty. We nearly repeated the accident. So the sherif WAS talking about this scenario.
ultimately, the conclusion is correct. I was confused but believed the “worst” warning. It appears Dave didn’t.
My argument ALWAYS was that whilst it was pilot error, I believed there were possible mitigating circumstances where Dave was confused by what he saw. I’m glad the sheriff has understood this and accepted that he may have been confused.
For the record, the court was totally fair with me, they gave me a hard time but they were also prepared to listen and consider my answers. Hopefully the families can find some peace now
ultimately, the conclusion is correct. I was confused but believed the “worst” warning. It appears Dave didn’t.
My argument ALWAYS was that whilst it was pilot error, I believed there were possible mitigating circumstances where Dave was confused by what he saw. I’m glad the sheriff has understood this and accepted that he may have been confused.
For the record, the court was totally fair with me, they gave me a hard time but they were also prepared to listen and consider my answers. Hopefully the families can find some peace now