FAI into Clutha crash opens

[OvertHawk]

Originally Posted by [email protected]

Big Frank's link has some worrying comments about how an experienced engineer who raises concerns about engineering workload at Glasgow, is ignored by his line manager and his action in reporting his concerns dismissed as 'unprofessional'..

Even if it was considered that what he wrote and how he wrote it was "unprofessional", any line manager who read such a thing should be asking themselves "How tired, stressed and desperate does Bloggs have to be to write something like that?" Even if they do not consider that the point he raises is a valid concern the manner in which he is speaking is indicative of a significant Human Factors problem that should have been raising flags.

[jayteeto]

BigFrank has posted a link to the reviews so far. I would recommend reading these reviews as they clear up some points that people have been raising over what was and wasn’t attempted

[Fortyodd2]

There is also a Twitter feed from BBC Journalist Paul O’Hare

https://mobile.twitter.com/pohareBBC

Most but not all days are covered.

[skyrangerpro]

https://www.scotsman.com/news/inquir...raft-1-4925316

[GC47G]

Just read Big Franks post which is not good reading , but applying Occam’s razor , the lights are not on the panel for decoration and auriols for something to listen , it’s worrying this is going to head the total wrong way down the path looking for the answer , For me light comes on manage it.......

[sadgit]

For the record; DT had an excellent knowledge of the fuel system and had carried out auto’s with both engines at GI.

[toptobottom]

Originally Posted by high spirits

Toptobottom post #73
I flew with DT(as did many on this forum). He would never entertain deliberately crashing a helicopter and I never witnessed an argument with anyone he operated with.

I know this is a rumour forum, but that’s quite frankly out of order..... please stop.

high spirits - when the inexplicable occurs and all rational circumstances and behaviour have been thoroughly investigated, it's normal to start looking at seemingly ridiculous reasons, however unpalatable they may be. By all accounts DT was an excellent pilot, but he was still human and humans (as we see with alarmingly increased frequency) have a habit of appearing to behave perfectly 'normally', while harbouring psychological issues that only surface when it's too late to prevent tragedy. If we ignored certain avenues just because "I knew him and he would never do that", we're denying that unknown mental health issues exist and can manifest themselves in unpredictable behaviour. Sorry if you're offended, but it's a possibility that cannot be ignored, just because you never witnessed an argument between him and his colleagues.

[DOUBLE BOGEY]

TOPTOBOTTOM, There is some merit in what you post. We had a very strange set of circumstances surrounding a well respected and seemingly stable colleague who decided one day that life was just too much for him! Inexplicable.!
However, in this case I believe there is sufficient evidence (or lack of) to see DT being led down the garden path by the indications in front of him. Having said that, someone most probably switched both transfer pumps OFF during the flight!! In the end, that will most probably prove to be the root cause of this tragedy. It is no surprise that the current recommendation on seeing or hearing any fuel warning is to check the TFR pumps switches and CBs. It is simple fuel system. However, like most simple systems a "simple" simplex mistake can be catastrophic.
For these reasons I don't buy into the psychobabble theories.

Amber PUMP cautions = Pumps OFF = Supply Tanks Draining + Faulty Contents indications + Poor Confidence in the warning & cautions systems = No appropriate response from Pilot = 2 x Flameout = pressurised auto = uncontrolled descent.

It could be that the supply tanks indicated FULL throughout. It could be that despite the "Memory" in the CAD that neither the Visual or Aural warnings manifested themselves properly in the cockpit. However, for all that to happen the Transfer Pumps HAD to be switched OFF!. In my view this is the only tangible and relevant piece of information that current EC135 pilots needs to assimilate. If you leave the TRFR pumps OFF, the supply tanks will eventually run dry.

The sideshows of maintenance histories, anecdotal events of a similar nature, training, system design are all for the Sherriff to digest and decide upon.

[jayteeto]

Toptobottom. Your logic says that in this case, you must consider the unthinkable. You chose your unthinkable theories with no evidence whatsoever. So let’s show how ridiculous that is. I can offer some theories with real evidence in this situation.
What about Dave having a dashing ‘tash? Maybe he was a secret Village People fan? Maybe he couldn’t cope with being gay?
Dave visited Moscow a few years ago, maybe someone was about to oust him as a spy?
These two scenarios are ridiculous, however they meet your standards of evidence, ie “think the unthinkable”.

Come on man! His family and friends read what is said here. He can’t defend himself. Show at least a little bit of respect........

[OvertHawk]

Toptobottom

Sometimes the unthinkable does need to be thought. But after an exhaustive investigation by the AAIB (during which they will have considered the unthinkable, the thinkable and everything in between) they have come up with a number of facts and conclusions, none of which include the scenario you suggest.

To make this suggestion, in disregard of the investigation findings and with no evidence whatsoever to support your accusation (and much to disprove it) is scurrilous, ignorant and dishonourable.

OH

[BigFrank]

Airbus: lack of priority for safety issues

That certainly seems to be a rational conclusion given that the latest evidence, link below, says that it took them over a decade to come up with a solution for what seems to this layman to be a major safety issue of which they had been clearly informed .

Apparently that is the view too of a witness from a British helicopter operating company who stated that the attitude of Airbus appeared to be:

, " ...[Y]ou use your design department rather than us using ours to come up with a solution...."

Scottish Review: Maurice Smith

[MightyGem]

From the Scottish Review:

Ms Shelagh McCall QC, representing Captain Traill's partner Dr Lucy Thomas, raised the possibility that the pilot may have been flying using 'visual contact' (VFR) rather than his night-time instruments, and therefore believed he would have enough fuel to land. 'If the pilot had thought he was operating on VFR and had 65kg in the tank, they would not have needed a Mayday,' she suggested. 'Correct,' said Mr Stobo(director of operations at Babcock mission critical services).

Well that's two people who have no idea what they are talking about.

[GC47G]

MightyGem , Agreed 1000% on that

[GC47G]

Sorry , but that theory doesn’t fit with endurance / distance covered with the tasks they covered ?....

[BigFrank]

Latest report on Scottish Review website

Scottish Review: Maurice Smith


(The FAI has, it reports, been put on ice till at least the beginning of July; though I presume that the timing of the next report mentioned in the text as early August is due to non-publication of the "magazine" in the month of July.)

More to the point, the brief report does seem to repeat/ reinforce previous testimony about a known degree of unreliability of warning lights.

And about a failure to address the problem?

[Flying Bull]

Originally Posted by Cleavage

Does anyone recall (or have access to) what the required drill was for both a F PUMP FWD and a F PUMP AFT prior to Rev 12 (Jan 2014) of the Airbus Emergency Check List?

There's no mention of that drill in the AAIB report Appendix A, but it lists the drills separately. Does anyone know if it existed prior to the accident?

Actioning the drills separately could leave both pumps selected off if the main tank contents are 'low'.

if 2000 is early enough
FLIGHT MANUAL EC 135 T1 (CPDS)
Emergency and Malfunction Procedures
3 - 20
CAUTION INDICATIONS
F PUMP AFT
(MISC)
Conditions/Indications
Failure of aft fuel transfer pump, or dry run.
Procedure
1. Fuel level in the main tank – Check
If main tank fuel quantity is sufficient to keep both fuel pumps wet:
2. FUEL PUMP XFER-A sw – Check ON
3. XFER-A PUMP circuit breaker – Check in
If F PUMP AFT indication remains on:
4. FUEL PUMP XFER-A sw – OFF
If main tank fuel quantity is low:
2. FUEL PUMP XFER-A sw OFF
NOTE EEach fuel transfer pump is capable of feeding more fuel than both engines will
consume.
EIn hover flight conditions the unusable fuel can be up to 71 kg. The quantity of
unusable fuel can be reduced to 7.5 kg when flying with 80 KIAS or more.

FLIGHT MANUAL EC 135 T1 (CPDS)
Emergency and Malfunction Procedures
3 - 21
CAUTION INDICATIONS
F PUMP FWD
(MISC)
Conditions/Indications
Failure of forward fuel transfer pump, or dry run.
Procedure
1. Fuel level in the main tank – Check
If main tank fuel quantity is sufficient to keep both fuel pumps wet:
2. FUEL PUMP XFER-F sw – Check ON
3. XFER-F PUMP circuit breaker – Check in
If F PUMP FWD indication remains on:
4. FUEL PUMP XFER-F sw – OFF
If main tank fuel quantity is low:
2. FUEL PUMP XFER-F sw OFF
NOTE EEach fuel transfer pump is capable of feeding more fuel than both engines will
consume.
EIn forward flight conditions the unusable fuel can be up to 59 kg. The quantity
of unusable fuel can be reduced to 3.6 kg when flying with 80 KIAS or less.

[MightyGem]

Does anyone recall (or have access to) what the required drill was for both a F PUMP FWD and a F PUMP AFT prior to Rev 12 (Jan 2014) of the Airbus Emergency Check List?

There was no drill for the FAILURE of BOTH Transfer Pumps before the Main Tank was empty, if that is what you mean.

Having noticed this, not log after we got our 135, I can recall taking off with both pumps switched OFF(on purpose) to see what would happen. In the cruise, the contents of the Main Tank reduced as the fuel went through the "overflow"(correct term forgotten) into the Supply Tanks for a while, but at around 250kgs indicated in the Main Tank, the Supply Tank contents started to reduce, with the Main Tank contents staying the same.

So, if BOTH Transfer Pumps failed below 250kgs in the Main Tank, you would only have the contents of the Supply Tanks for use.

[MightyGem]

No, the only time that it should occur is when the main tank has run dry.

[Flying Bull]

Originally Posted by Cleavage

I guess "should" being the operative word.
If you were in the hover or at a low speed surely the remaining fuel in the tank would be aft, leaving the forward pump uncovered, and resulting in the F PUMP FWD being selected off. As the pitch goes down to increase speed, surely the fuel moving forward would now uncover the aft pump, resulting in the F PUMP AFT being selected off. If there was no drill for captions on both fuel pumps and neither of the individual drills tells you that one of those should be turned back on, isn't there a chance that they can both remain off with some fuel still in the main tank?? If its compounded by the reported fuel sensor problems, surely there's a chance of both fuel pumps being off and believing the fuel is in the supply tanks?

Thats why you need a rating for flying helicopters, where in the theorie part - which requires a test to pass - things like the fuel system are covered.
(Tanks, capacity, pumps, usage i.e.)
When someone gets captions about the fuelstate, pilots normaly get realy sensitive, checking the fuel state and how much fuel is in which tank, knowing, that there might be unusable fuel, depending on which pump isn´t working.
Knowing, that the engines take their fuel from the feeder tanks does mean, that they are the tanks I focus on.
If fuel isn´t transfering from the main tank, I do something about it or make decisions to asure a safe landing.
We wont get an answer, why this time the obvious wasn´t done or which assumptions led to continuing the flight, despite the warnings.
But I won´t blame it on the general fueltank/pump setup, which is used in hundreds or even thousands of helicopters worldwide.
(Bo105, BK117 all variants, EC135, EC155) and except from an autorotation, where the crew covered the warning lights with duct tape, I don´t recal incidents which are related to the general setup.

[GC47G]

Inquiry back in session today .......