FAI into Clutha crash opens
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
Finally, I rather dispute the Sheriff’s point about the types of pump. Surely it wouldn’t be a big deal to say (for UK aircraft at least) only the Fuchs pumps may be installed and hence there would be no need to ever fiddle with the switches. Routinely switching off the transfer pumps is surely at the heart of this accident. Or am I missing something?
Join Date: Aug 2000
Location: Liverpool based Geordie, so calm down, calm down kidda!!
Age: 60
Posts: 2,051
Likes: 0
Received 17 Likes
on
6 Posts
No, you aren’t missing anything. I was receiving various cautions and warnings that my indications disagreed with. I will admit, I WAS confused, my quote in the cockpit was “I’m not sure what it is yet, but something is up with the fuel system”. The red warnings sealed the deal. Without a CVR we will never know
When the EC155 entered service in Nigeria a crew experienced an engine flame out. One of the jet pumps in the LH Fuel group was blocked by debris and the main tank exhausted. They too were confused as the total quantities appeared normal but the LH Red Fuel Low caption was illuminated.
...and to confuse things further: in my last job I was on task (in a CPDS P2) when the red FUEL warning (with gong) illuminated on one side. We packed in the task, started the clock (we observed the CDS P1 "only 8 minutes" across our small fleet) and turned for an (RN satellite) airfield not a million miles away. Reviewing the actions, I noted that the main tank was still delivering fuel, that both supply tanks were still indicating full and that there were no other indications of low fuel in the supply. I elected to knock the speed back to a figure using power below that required for OEI and turn for base, figuring that if - as I suspected - it was an erroneous warning, then only one engine would be affected and I could fly a single-engine approach. After approximately 15 minutes we flew a twin-engine approach back into home base.
Sure enough, the pump unit had a faulty thermistor so the moral is that even the usually-reliable component of the EC135 fuel indication system can have its off-days. Dave and jay were right to be confused - only jay made the safe call and is here to tell us about it.
I was disciplined for not following unit SOPs by putting the aircraft down within the specified time with a warning light illuminated, which I accepted as not everyone is inclined to analyse what the aircraft is doing versus what the indications are reading - can't go setting bad examples by using aircraft knowledge/ reasoning/ initiative.
Sure enough, the pump unit had a faulty thermistor so the moral is that even the usually-reliable component of the EC135 fuel indication system can have its off-days. Dave and jay were right to be confused - only jay made the safe call and is here to tell us about it.
I was disciplined for not following unit SOPs by putting the aircraft down within the specified time with a warning light illuminated, which I accepted as not everyone is inclined to analyse what the aircraft is doing versus what the indications are reading - can't go setting bad examples by using aircraft knowledge/ reasoning/ initiative.
Last edited by Thud_and_Blunder; 31st Oct 2019 at 12:26. Reason: gongs don't illuminate - edited
Join Date: Dec 2006
Location: UK and MALTA
Age: 61
Posts: 1,297
Likes: 0
Received 18 Likes
on
4 Posts
I agree that there is more to this than a straightforward pilot error - that system was far from Murphy proof.
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.
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.
Join Date: Dec 2006
Location: UK and MALTA
Age: 61
Posts: 1,297
Likes: 0
Received 18 Likes
on
4 Posts
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
In Dave's defence, I feel for him to ignore the warnings like he did there must have been a clear mitigation in his assessment to do so. I therefore conclude in my own mind, he saw plenty of fuel indicating in the Supply Tanks....just as Jayteeto did. It is very easy to criticise but the hooded horseman of habit, gossip, routine "getting away with it" all probably coalesced that night to a horrific ending.
The Sherriff has it right and he is only supposed to deliver the facts. It is for the industry to try and work out the response. Note he also recommends a warning light system for the FUEL XFR lights, I am assuming in addition to the CAD notifications.
Just a numbered other
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.
DV
DV
The FAI is there to determine cause of death. That broad remit includes who’s at fault, surely?
Tragically, we have all learned a little more about what we do, why we do it and how we do it. Because of illness my FAI evidence boiled down to a local interview and a few emails but, even though it was fairly light, I have now experienced much more about aircraft related failures than I need. Lets stay as safe as we can.
This Inquiry is conducted in accordance with the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016. Similar to its predecessor of 1976, this Act has very specific requirements for the outcome of the Inquiry as presented in the Sheriff's determination. At Section 26, sub-section (2), these are as follows.
The circumstances referred to in subsection (1)(a) are -
(a) when and where the death occurred,
(b) when and where any accident resulting in the death occurred,
(c) the cause or causes of the death,
(d) the cause or causes of any accident resulting in the death,
(e) any precautions which -
. (i) could reasonably have been taken, and
. (ii) had they been taken, might realistically have resulted in the death, or any accident resulting in the death, being avoided,
(f) any defects in any system of working which contributed to the death or any accident resulting in the death,. (ii) had they been taken, might realistically have resulted in the death, or any accident resulting in the death, being avoided,
(g) any other facts which are relevant to the circumstances of the death.
Double Bogey,
I suspect you are wrong about the relatives wanting to sue anyone. They will have been compensated, at least in the financial sense, some time ago by the various insurers. In any event, the pilot was acting in the course of his employment, and any claims would fall to be met by his employer or their insurers.
Having followed this closely from the outset, I think what the Sheriff has concluded is correct. However, the question which continues to niggle me is why did such an experienced pilot elect to take this risk, which in turn brings me to the question what were the last taskings about. Why did he orbit two motorway junctions? What did the tasking ask him to look for? Was it an emergency, was life at risk? I have absolutely no idea, but the answers to these questions would surely have had a bearing on the pilots likely frame of mind when deciding to take the risk which he did.
I suspect you are wrong about the relatives wanting to sue anyone. They will have been compensated, at least in the financial sense, some time ago by the various insurers. In any event, the pilot was acting in the course of his employment, and any claims would fall to be met by his employer or their insurers.
Having followed this closely from the outset, I think what the Sheriff has concluded is correct. However, the question which continues to niggle me is why did such an experienced pilot elect to take this risk, which in turn brings me to the question what were the last taskings about. Why did he orbit two motorway junctions? What did the tasking ask him to look for? Was it an emergency, was life at risk? I have absolutely no idea, but the answers to these questions would surely have had a bearing on the pilots likely frame of mind when deciding to take the risk which he did.
Join Date: Aug 2000
Location: Liverpool based Geordie, so calm down, calm down kidda!!
Age: 60
Posts: 2,051
Likes: 0
Received 17 Likes
on
6 Posts
He wouldn’t have “took the risk” like you think. He wouldn’t have thought “I’ve only got a few minutes but I’ll give it a go”, that’s not what people are concluding.
what the conclusion is talking about is that he believed the indications to be false, hence he continued to fly. The task is irrelevant here. The sheriff agreed with many of us that he believed (wrongly) that he had loads of fuel. Trust me, my first reaction was exactly that.
what the conclusion is talking about is that he believed the indications to be false, hence he continued to fly. The task is irrelevant here. The sheriff agreed with many of us that he believed (wrongly) that he had loads of fuel. Trust me, my first reaction was exactly that.
Jayteto,
this may sound like a semantic point, but it isn’t. I don’t doubt the pilot thought the warning lights were wrong, ( I said as much on the original thread) but he didn’t know that they were By accepting the tasking, he took the risk. Full stop.
I remain puzzled by why the nature of the tasking remains a mystery, as I believe it could materially mitigate the assessment of the pilots actions.
this may sound like a semantic point, but it isn’t. I don’t doubt the pilot thought the warning lights were wrong, ( I said as much on the original thread) but he didn’t know that they were By accepting the tasking, he took the risk. Full stop.
I remain puzzled by why the nature of the tasking remains a mystery, as I believe it could materially mitigate the assessment of the pilots actions.
STATEMENT BY DR LUCY THOMAS, FIANCÉE OF PILOT DAVID TRAILL Following the determination of the Fatal Accident Inquiry into the Clutha helicopter crash, Dr Lucy Thomas, fiancée of pilot David Traill, has issued the following statement.
"For almost six years I have remained silent in order to protect my privacy. However, such is my strength of feeling since the Sheriff Principal's Determination on the Fatal Accident Inquiry into the Clutha helicopter crash, I feel compelled to make this statement.
"I am overwhelmed by the support that I have received from so many people, many of whom don't know me and didn't know Dave. I am eternally grateful for this.
"It is my understanding that due to misleading information from the aircraft fuel gauge and display system, Dave had only moments to make decisions and carry out tasks in an attempt to respond to this issue. It is also my understanding that he should have had a significantly longer timescale in which to do so before the helicopter would lose both engines. The manufacturer's aircraft maintenance manual incorrectly recorded that the flameout time between engines was three to four minutes. This was incorrect information. The correct time available should have been in excess of 1 minute but due to the design of the fuel tanks allowing for fuel from one tank to slop over into another, he had only 32 seconds. That 32 seconds ended in tragedy and the loss of his and nine other valuable lives. This has devastated the lives of all who surround them and impacted on so many more.
"In my opinion, the Sheriff Principal's determination does no justice to the memories of Gary Arthur, Tony Collins, Joe Cusker, Colin Gibson, Robert Jenkins, John McGarrigle, Samuel McGhee, Kirsty Nelis, Mark O'Prey, and to the memory and reputation of Dave Traill; it insults the intelligence of those who know of the evidence presented at the Inquiry and are aware of the content of the initial AAIB report.
"Disbelief has been expressed by many family members of those who died and by members of the public at the conclusion drawn by Sheriff Principal Turnbull, who incredulously stated that Dave consciously took risks which caused the accident. This expression of disbelief speaks volumes and means much more to me than the opinion of the Sheriff Principal.
"I find it distressing and incomprehensible that given months, not moments, to consider the facts, the Sheriff Principal has come to this conclusion. He chose not to concentrate on the fact that the EC135 model of helicopter has a history of faults with the caution advisory display, specifically a history of erroneous or spurious fuel indications, amongst other technical problems such as contamination of the fuel tanks, issues still never fully resolved by the manufacturer. Instead, the Sheriff Principal has opted to sully the distinguished reputation of a pilot with an exemplary record who was renowned for his sense of responsibility and his regard for the safety of his crew.
"The opportunity for closure and maybe some peace for so many people has been denied.
"I once again request privacy and respect from the media."
ENDS
Dr Thomas will be making no further comment.
"For almost six years I have remained silent in order to protect my privacy. However, such is my strength of feeling since the Sheriff Principal's Determination on the Fatal Accident Inquiry into the Clutha helicopter crash, I feel compelled to make this statement.
"I am overwhelmed by the support that I have received from so many people, many of whom don't know me and didn't know Dave. I am eternally grateful for this.
"It is my understanding that due to misleading information from the aircraft fuel gauge and display system, Dave had only moments to make decisions and carry out tasks in an attempt to respond to this issue. It is also my understanding that he should have had a significantly longer timescale in which to do so before the helicopter would lose both engines. The manufacturer's aircraft maintenance manual incorrectly recorded that the flameout time between engines was three to four minutes. This was incorrect information. The correct time available should have been in excess of 1 minute but due to the design of the fuel tanks allowing for fuel from one tank to slop over into another, he had only 32 seconds. That 32 seconds ended in tragedy and the loss of his and nine other valuable lives. This has devastated the lives of all who surround them and impacted on so many more.
"In my opinion, the Sheriff Principal's determination does no justice to the memories of Gary Arthur, Tony Collins, Joe Cusker, Colin Gibson, Robert Jenkins, John McGarrigle, Samuel McGhee, Kirsty Nelis, Mark O'Prey, and to the memory and reputation of Dave Traill; it insults the intelligence of those who know of the evidence presented at the Inquiry and are aware of the content of the initial AAIB report.
"Disbelief has been expressed by many family members of those who died and by members of the public at the conclusion drawn by Sheriff Principal Turnbull, who incredulously stated that Dave consciously took risks which caused the accident. This expression of disbelief speaks volumes and means much more to me than the opinion of the Sheriff Principal.
"I find it distressing and incomprehensible that given months, not moments, to consider the facts, the Sheriff Principal has come to this conclusion. He chose not to concentrate on the fact that the EC135 model of helicopter has a history of faults with the caution advisory display, specifically a history of erroneous or spurious fuel indications, amongst other technical problems such as contamination of the fuel tanks, issues still never fully resolved by the manufacturer. Instead, the Sheriff Principal has opted to sully the distinguished reputation of a pilot with an exemplary record who was renowned for his sense of responsibility and his regard for the safety of his crew.
"The opportunity for closure and maybe some peace for so many people has been denied.
"I once again request privacy and respect from the media."
ENDS
Dr Thomas will be making no further comment.
Yes it must be horrible for her. I know what the sherif meant when he said “took a risk” and in the full context of the report it is not outwith the bounds of a reasonable phrase, but unfortunately it translates badly into press headlines, and that certainly does no justice to DT.
As a result of the FAI, those of us that understand the general issues I think now have a much better understanding of why it happened. Well I do, anyway. It would be nice if Dr Thomas understood that people in the industry don’t share the simplistic “took a risk” view that is published in the tabloids,
As a result of the FAI, those of us that understand the general issues I think now have a much better understanding of why it happened. Well I do, anyway. It would be nice if Dr Thomas understood that people in the industry don’t share the simplistic “took a risk” view that is published in the tabloids,
The biggest question for me, which does not seem to have been fully addressed, is the unsuccessful autorotation. Flaming-out both engines due to fuel starvation is one thing, but an accomplished pilot losing NR so catastrophically has me baffled.
Join Date: Nov 2000
Location: White Waltham, Prestwick & Calgary
Age: 72
Posts: 4,144
Likes: 0
Received 29 Likes
on
14 Posts
There is a world of difference between a real one (been there, done that) and practising, which is generally not done in twins*, and practice, especially when you do not expect it, and especially when you expect one engine to flame out after another over a rather longer timescale than is shown here. With modern helicopters having lighter blades, it would not be hard to lose NR.
*At least the 355 has a single engined equivalent to practice on.
I've not flown the type in question, but it seems to me that it has a similar quirk to the 206L where you can have much less fuel available that is indicated, and that doesn't even have a computer.
*At least the 355 has a single engined equivalent to practice on.
I've not flown the type in question, but it seems to me that it has a similar quirk to the 206L where you can have much less fuel available that is indicated, and that doesn't even have a computer.
Hi all,
I can understand Daves Finace - she's emotional involved.
Have more than 1.300 h under NVG - similar tasks - landed more than once with only fuel in the support tanks....
And there is more to the situation - there are more crew members involved - talking to each other, interrupting actions/thoughts, possible putting further pressure on or influencing the decision making....
(What is the employer saying, if you land in a field and order a fuel truck?)
So I think, I have also an general understanding for Daves situation.
Who thinks, it could´t happen to him should take some simulator sessions with an instructor putting pressure on....
Still - as nearly always - it is up to the pilot in command to make the decisions - and get blamed, if it was the wrong one.
What I learned from experience but also from this crash is - better safe than sorry - play it safe - if in doubt, expect the worst scenario.
We have a short reminder, which helps in the process, called
"FORDEC"
F-acts - what happened, what information do I have (cautions, indications i.e.)
O-ptions - which do I have - i.e. engine restart? land? where? continue?
R-isks - to the options I have evaluated
D-ecison
E-xecute - the decision
C-heck - wether my decision is working as planed - otherwise start from the top again.
By now I´m much more willing to say no / cancelling or delaying a mission - interrupting for refuel - without feeling bad - cause I know, what can happen, if someone lets the pressure influence the flight.
If this accident and the discussions leads to more safe decisions - it wasn´t worthless.
To the question about the autorotation - 30isch seconds between failure of the first and the second engine isn´t really much time, especially, if you haven´t expected the failure of the first engine at this time.
So while getting the picture of what happened and dealing with that emergency, the second done failed on Dave.
I´m not really surprised, that the Nr decayed during the autorotation.
Still - also something to learn for Eurocopter/Airbus pilots - if you expect an engine failure due to fuel starvation / and possible the failure of the second one, why not switch the Shed bus to on?
No harm done, if you don´t need it but time and hands of the controls saved in case of - a point for the O-ptions, when the Fuel lights come on.
I can understand Daves Finace - she's emotional involved.
Have more than 1.300 h under NVG - similar tasks - landed more than once with only fuel in the support tanks....
And there is more to the situation - there are more crew members involved - talking to each other, interrupting actions/thoughts, possible putting further pressure on or influencing the decision making....
(What is the employer saying, if you land in a field and order a fuel truck?)
So I think, I have also an general understanding for Daves situation.
Who thinks, it could´t happen to him should take some simulator sessions with an instructor putting pressure on....
Still - as nearly always - it is up to the pilot in command to make the decisions - and get blamed, if it was the wrong one.
What I learned from experience but also from this crash is - better safe than sorry - play it safe - if in doubt, expect the worst scenario.
We have a short reminder, which helps in the process, called
"FORDEC"
F-acts - what happened, what information do I have (cautions, indications i.e.)
O-ptions - which do I have - i.e. engine restart? land? where? continue?
R-isks - to the options I have evaluated
D-ecison
E-xecute - the decision
C-heck - wether my decision is working as planed - otherwise start from the top again.
By now I´m much more willing to say no / cancelling or delaying a mission - interrupting for refuel - without feeling bad - cause I know, what can happen, if someone lets the pressure influence the flight.
If this accident and the discussions leads to more safe decisions - it wasn´t worthless.
To the question about the autorotation - 30isch seconds between failure of the first and the second engine isn´t really much time, especially, if you haven´t expected the failure of the first engine at this time.
So while getting the picture of what happened and dealing with that emergency, the second done failed on Dave.
I´m not really surprised, that the Nr decayed during the autorotation.
Still - also something to learn for Eurocopter/Airbus pilots - if you expect an engine failure due to fuel starvation / and possible the failure of the second one, why not switch the Shed bus to on?
No harm done, if you don´t need it but time and hands of the controls saved in case of - a point for the O-ptions, when the Fuel lights come on.
I find it distressing and incomprehensible that given months, not moments, to consider the facts, the Sheriff Principal has come to this conclusion. He chose not to concentrate on the fact that the EC135 model of helicopter has a history of faults with the caution advisory display, specifically a history of erroneous or spurious fuel indications, amongst other technical problems such as contamination of the fuel tanks, issues still never fully resolved by the manufacturer.
I have never flown the type involved, but bearing in mind the above - and assuming that any pilot of the type is aware of these facts - would it not be prudent to fly with the maxim "if in doubt chicken out"?
I have never flown the type involved, but bearing in mind the above - and assuming that any pilot of the type is aware of these facts - would it not be prudent to fly with the maxim "if in doubt chicken out"?