AW139 Crash in Bahamas - 7 Killed

[gulliBell]

Originally Posted by Arcal76

..How an owner is able to trust his pilot anymore?

That is what a Part 141 Training Organization with Level D full flight simulators are for.

[[email protected]]

Gulli, that is what Non-PC Plod is saying - the mandatory training doesn't seem to confer quality, just acknowledges that some training has been done.

[gulliBell]

I'd be very surprised, assuming what I read in the CVR transcripts as being indicative of the level of proficiency, that that crew would pass the most superficial of recurrent sim checks when assessed against the practical test standards. Certificate of attendance maybe, but not certificate of competency.

[Torquetalk]

Originally Posted by gulliBell

I'd be very surprised, assuming what I read in the CVR transcripts as being indicative of the level of proficiency, that that crew would pass the most superficial of recurrent sim checks when assessed against the practical test standards. Certificate of attendance maybe, but not certificate of competency.

Not sure Gulli. If a sim check is imminent, crews (quite rightly) go through the procedures and are mentally prepared. especially if given LOFT exercises to carry out.

But these guys were not prepared and had no standards or procedures to define their flight, which cased them to lose control in a woefully predictable way.

They were also flying privately and not subject to anything other than a type rating requirement and air law. Between that and what happened there is a big a black hole as the one they managed to fly into.


Crab

Unlike the Norfolk accident, they were not in fog. No need for a mil style IR departure. They could have conducted a perfectly normal pad departure and lived. By the time the aircraft went IMC, it would have been stable and would have flown perfectly well with or without George.

[helonorth]

Originally Posted by megan

I don't see that as much of an issue, legalities aside, EMS guys do it all the time.

Not over water they don't and not without NVG's!

[[email protected]]

Torquetalk - but an unlit helipad at night without NVG is hardly any different to a take off in fog - you still can't see where you are going and need to be fully on instruments from the start of the departure.

[malabo]

The human performance factual report is an interesting read, describes the training received. Both pilots paired together for initial and recurrent training at NETC. Came as a complete surprise having read the CVR transcript first.

Departing from that helipad, with aircraft lighting (if they could find them all) and the ambient cultural lighting should have been easy. Did it all the time EMS with the 222 (UT with no stab) and later on offshore, but you have to able to accurately control the helicopter and read the attitude instruments. Like Crab says, no biggie if you know what to expect and have done it a time or two before.

I see Talbot was part of the investigation team from Leonardo, met him when he was doing icing trials on the 139 in Alaska. Sharp guy.

I've flown helicopter Caribbean - Florida a few times. Totally wallpapered with permits, flight plans, customs notifications - all due to my healthy respect for foreign authorities and especially the US CBP. But they sound like they flew regularly to the "island" and back without any notification to any authority. The flight plan discussion only came up for the return flight due to some realization of an ADIZ penetration concern and an ambulance call out.

[sprag47]

I remember last year on this thread and many were offering theories such as windshield bird strike, T/R separation with subsequent tail boom separation, even the possibility that the owner was at the controls. A few of us figured it was UFIT
given the early morning hour, an emergency trip, and the final departure point location and conditions. As others have noted, the crew was way behind the aircraft beginning with pitch-pull in Florida. They may as well have been in a Bell 47 for all the good the systems in the AW139 did them. A tragic, easily preventable accident...and we’ll see this happen again and again in the future I’m afraid.

[Torquetalk]

Originally Posted by [email protected]

Torquetalk - but an unlit helipad at night without NVG is hardly any different to a take off in fog - you still can't see where you are going and need to be fully on instruments from the start of the departure.

Using the search light they should have been able to spot the pad up to a sensible TDP. And don’t forget they had those golf cart lights, no doubt with oil drums in the back for redundancy. But agree that from TDP that was an instrument dep.

Even the basic elements of a AW139 vertical take-off should have worked out, darkness or not, fog or not. Appropriate power, appropriate attitudes were all that were needed. If you are going to do a lot of stuff In haste and ignore a few rules along the way, no need to throw the book out of the window...

[ApolloHeli]

Just gonna mention it here because it hasn't been pointed out before, but a key reason for the altitude loss after departure was that the collective FTR was engaged whilst the ALTA was coupled, meaning that their initially selected V/S of 1000fpm was replaced by a 'standard' value of 100fpm. Therefore, as they were rocketing up with more than 100fpm, and with the cyclic FTR still engaged (apparently no human interaction with the collective at the point), the autopilot reduced collective position to attain the 100fpm V/S. Despite all the other reasons and possible contributory factors mentioned above, I still find it a shame that the collective FTR was activated for the few seconds that the AP was coupled. Had that not happened, it is entirely possible they would have gotten away with it. A real Swiss cheese event.

[[email protected]]

I don't know about a swiss cheese event - when two people with no CRM skills and a limited knowledge of the AP functions are let loose it's a matter of when, not if, there is going to be an accident.

They were undone by a combination of poor CRM, poor handling and management skills and poor awareness of the risky profile (until the last 10 seconds!)

[ApolloHeli]

Originally Posted by [email protected]

I don't know about a swiss cheese event - when two people with no CRM skills and a limited knowledge of the AP functions are let loose it's a matter of when, not if, there is going to be an accident.

They were undone by a combination of poor CRM, poor handling and management skills and poor awareness of the risky profile (until the last 10 seconds!)

I mean "Swiss cheese" in the sense that it is possible that the single occurrence of activating the collective FTR could have been the difference between meeting the water at 150kts and maintaining enough collective to remain clear of it until the aircraft was stabilised and clear of danger given their attitude after activation of the AP upper modes. A single factor such as that could have been the difference between this thread and nothing worth reporting on at all.

I agree with you on all other factors though (and I find it very intriguing that the SIC was apparently aware of the G-LBAL incident but didn't realise the parallels until 10 seconds before impact - I do wonder what it would've taken for him to realise the similarities sooner and possibly avert the tragedy altogether). At the end of the day I do believe they were capable of getting off the ground cleanly, but that would have required max 5 minutes' worth of briefing and planning on the ground at the island which clearly was not done. As was mentioned above - agreeing on a defined departure profile, and under which circumstances the PM would assume control to prevent a loss of control would have been sufficient. We can all agree that the CVR shows no evidence of this (as far as I can interpret).

[rotorspeed]

This was no Swiss cheese - as in a sequence of broadly reasonable actions extraordinarily lined up to exploit the unlikely weaknesses in each to cause an accident. There was major incompetence at most stages, not least because neither crew could read their own perfectly serviceable EADI display to realise they were in an arcing descent into the sea - regardless of the upper mode setting failures - and suitably react.

[sprag47]

Originally Posted by rotorspeed

This was no Swiss cheese - as in a sequence of broadly reasonable actions extraordinarily lined up to exploit the unlikely weaknesses in each to cause an accident. There was major incompetence at most stages, not least because neither crew could read their own perfectly serviceable EADI display to realise they were in an arcing descent into the sea - regardless of the upper mode setting failures - and suitably react.

Exactly. Apparently no basic instrument competence. And Lindbergh flew across the North Atlantic at night on needle, ball, and airspeed....

[XV666]

Originally Posted by sprag47

Exactly. Apparently no basic instrument competence. And Lindbergh flew across the North Atlantic at night on needle, ball, and airspeed....

Agree that the competence of this crew was sadly lacking in both CRM and Instrument skills.

I’d also point out to the North American poster that Alcock & Brown preceded Lindbergh by eight years, without any gyro instruments at all. Some lost skills somewhere?

[sprag47]

Originally Posted by heli

Agree that the competence of this crew was sadly lacking in both CRM and Instrument skills.

I’d also point out to the North American poster that Alcock & Brown preceded Lindbergh by eight years, without any gyro instruments at all. Some lost skills somewhere?

And this Yank salutes Alcock and Brown!

[Arcal76]

I missed the human factor report initially.
So, those guys did the ground training but did not do the the initial SIM training, just some flight with an Agusta pilot???
I don't really understand that ! when you switch to a complicated aircraft, the SIM is essential. Of course, their level was low, it is not possible to get a good level and see all procedures by just flying the aircraft.
And if you go to the SIM after that, you gone be way behind. It make no sense to me except they saved time and money.
What is even worst, the SIC was qualified and should have take control and did not do anything when he was coaching during the first leg.
They were both weak because this lack of SIM training was essentiel.

[Nescafe]

It’s very sad to reflect that if they had simply pressed the CAT A button they could have just followed the guide bars to safely depart and climb away. The fact that they didn’t know where the landing light was would indicate that they probably didn’t even know about the function that would have saved their lives.

[[email protected]]

It’s very sad to reflect that if they had simply pressed the CAT A button they could have just followed the guide bars to safely depart and climb away.

they would still have had to hand fly the aircraft for the departure though - something the PF singularly failed to do. The push to 10 degrees nose down at TDP could have been disorientating in the dark too.

[Nescafe]

they would still have had to hand fly the aircraft for the departure though - something the PF singularly failed to do. The push to 10 degrees nose down at TDP could have been disorientating in the dark too.

All true, but the first thing I was taught when flying instruments, was trust your instruments! Those purple lines would have almost certainly saved this crew and GLBAL.