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G-LAWX S92 Incident AAIB

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G-LAWX S92 Incident AAIB

Old 11th Sep 2021, 17:26
  #101 (permalink)  
 
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Originally Posted by 212man View Post
I alluded to that in post 43
Thanks 212man, I see that now. Took me a while to join the dots. It really does beggar belief.
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Old 12th Sep 2021, 08:11
  #102 (permalink)  
 
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It is an insult to the industry
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Old 12th Sep 2021, 13:25
  #103 (permalink)  
 
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Flight beyond sight, I couldn’t agree more!
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Old 12th Sep 2021, 17:06
  #104 (permalink)  
 
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Originally Posted by flight beyond sight View Post
It is an insult to the industry
I completely agree. I thought it was bad but it appears it is much worse than first meets the eye. It looks as though we have a Commander who is also the MD, Accountable Manager and Safety Manager whose actions lead to a serviceable helicopter coming within 28' of impacting the ground.
On the information presented the individual suffers no sanction from the Company or Regulator and continues to lecture on Aviation Safety Management at an international recognised university.

Last edited by Undecided; 15th Sep 2021 at 08:48.
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Old 12th Sep 2021, 18:42
  #105 (permalink)  
 
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I wonder how many of the billionaire clients, or their entourage who contract these services, are aware of the report’s implications and vote accordingly?

How any mature AOC can have a safety manager who is also the MD/AM who flies the line operationally is beyond me. I’m curious to know whether the Cranfield safety courses learning objective to ‘Critically assess strategies for developing and enhancing safety culture including the role of leadership, structure and reporting systems’ thinks this leadership structure is a good practice.

I’m sure there is a textbook description of a just safety culture in their safety policy but what good are words when the preechings and practice are demonstrably at odds. As this is a rumour network, I’ve heard of at least two other more recent alleged reportable events involving this aircraft where there may have been a reluctance to (or possibly failure to) report due to hierarchical concerns.
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Old 12th Sep 2021, 20:13
  #106 (permalink)  
 
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You raise some excellent points highrpm. Given the points you raise I simply don't understand why Cranfield continue to allow the individual concerned to be part of their academic staff.

Last edited by Undecided; 15th Sep 2021 at 06:06.
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Old 13th Sep 2021, 07:13
  #107 (permalink)  
 
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ICAO Annex 13:
3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents.
It is not the purpose of this activity to apportion blame or liability.
I would suggest taking part in that particular Cranfield course before crucifying both a person and his relationship with the university. I did that module before this particular incident but it would not surprise me if the topic will be discussed during the upcoming version of the course.
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Old 13th Sep 2021, 08:39
  #108 (permalink)  
 
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I have no doubt that the course is excellent, and also no doubt that the lecturers are excellent at imparting well researched data driven knowledge. Having the practical experience of front line pressure is essential in giving them the ability to make the theory relevant to the audience, and to understand that it is one thing to understand the theory, and quite a different skill to apply it daily and effectively in decision making. This in itself should be a key learning point.

I have nothing against the individual. We all learn about human error enough to understand that none of us are immune from making mistakes. If serious, our mistakes are often well documented and scrutinised in forums like this. That is something we all accept each time we commit aviation. The only reason the ‘individual’ is attracting a particular focus upon them-self here is that when you have elevated yourself to being a public figure and authority on safety, as well as a most senior figure in one of the largest onshore operators, people will naturally hold you more accountable to your actions.

Any observation I made is in relation to the safety management system of which they are a part, and in this case responsible for, as this is the system which is designed to add barriers to prevent such occurrences. I strongly believe that in order to generate a healthy safety culture, where the size of the organisation permits, the post-holder of safety manager should not be the flight ops manager, the accountable manager, or the MD/CEO of the company due to the detrimental effect it can have on an open and honest reporting/investigating culture. To me this is even more important if those persons also fly the line. I’m keen to know whether this view is supported in Cranfield’s evidence based teachings on the role of leadership and structure in a mature safety management system. My view, although appearing logical to me, may be unfounded.
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Old 13th Sep 2021, 09:02
  #109 (permalink)  
 
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Surely if you don’t practice what you preach you have to be held accountable for your actions? I’m not a great fan of politicians but generally they fall on their swords when they are busted breaking the rules. Why is it acceptable for a senior manager and pilot who held the very rules which he preached with such disregard himself to be allowed to reach atonement by lecturing other people on why they must follow the rules?
I’m aware of other pilots in the same regulatory regime who have had their collars felt for minor airspace infringements. Will they be absolved from any punitive action if they are paid to lecture us on why we shouldn’t bust airspace? Probably not.

Last edited by Undecided; 15th Sep 2021 at 06:08.
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Old 13th Sep 2021, 13:06
  #110 (permalink)  
 
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Originally Posted by highrpm View Post
...it is one thing to understand the theory, and quite a different skill to apply it daily and effectively in decision making. This in itself should be a key learning point.
Trust me, this is covered in that particular course.
Originally Posted by highrpm View Post
...when you have elevated yourself to being a public figure and authority on safety, as well as a most senior figure in one of the largest onshore operators, people will naturally hold you more accountable to your actions.
I don't know if we can call him a public figure, he hasn't been on Strictly Come Dancing yet AFAIK. But seriously, is there such a thing as 'more accountable'? You either are or you're not. In this situation the aircraft commander is the person who is accountable when a flight doesn't go as planned, and an accountable manager is where the buck stops when the situation warrants the attention of any kind of authority. We tend to hold persons in positions such as these to certain higher standards, but is that fair? I mentioned in an earlier post that even though someone has lots of titles on his or her business card, when it's your behind on that flight deck seat you're just another pilot stuck with the same limited information that any pilot has and having to take the same split-second decisions that every other pilot will have to make on a day to day basis. And that process is just as liable to include errors of any kind as any other process that includes humans. I would even go so far as to state that having an extra responsibility within a company can make the process of taking those decisions even more daunting as you can't push the job of explaining everything to the client/boss/authorities towards someone else.
Originally Posted by highrpm View Post
I strongly believe that in order to generate a healthy safety culture, where the size of the organisation permits, the post-holder of safety manager should not be the flight ops manager, the accountable manager, or the MD/CEO of the company due to the detrimental effect it can have on an open and honest reporting/investigating culture.
I agree, but as you already mentioned, it depends on the size of the organisation. Yet, this is something that the company has already addressed, see 'Safety Actions' on page 64 of the report.
Originally Posted by highrpm View Post
I’m keen to know whether this view is supported in Cranfield’s evidence based teachings on the role of leadership and structure in a mature safety management system.
We're linking two different topics here as the outcome of this particular safety investigation and the subjects taught in a particular Cranfield course are not in itself connected to each other. Having said that, based on my participation in that course a few years ago I would say that the role of leadership and the structure of the SMS system are very much part of the course, were discussed extensively and I was under the impression that no subject was taboo. The lecturers (it wasn't just one person lecturing during those five days) were all very open in discussing incidents and accidents that were relevant to the subject at hand and personal experiences were very much a part of those stories. Because of this I would not be surprised if the G-LAWX incident under discussion here will be addressed during that course, but the only way to find out is to go there and take part in the course.
Originally Posted by Undecided
Why should it be acceptable for a senior manager and pilot who held the very rules which he preached with such disregard himself be allowed to reach atonement by lecturing other people on why they must follow the rules?
You don't go into lecturing to reach any kind of atonement. Also, does that mean that a lecturer cannot make any mistakes, and is not allowed to have made any mistakes at any point in the past? I'm playing devil's advocate here but in my personal opinion, someone who does know what it is like to be involved in a sticky situation may well be the better lecturer on that subject. Also, please do not forget that it takes a brave person to stand up in front of a group of professionals and admit that you have done the unthinkable at some point in the past. The whole culture that we are trying to achieve within aviation is one where we can have adult conversations about these topics, where we can admit that yes, we have perhaps erred at some point in the past and where we can take this experience and learn from it so that it doesn't happen again. I don't see where doing this in front of a classroom instead of within the company is in any way wrong.
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Old 13th Sep 2021, 13:30
  #111 (permalink)  
 
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Jhieminga - I don't disagree with the underlying sentiments of your post however I hope that you can understand the issue regarding a 'Just Culture' in that this individual was involved in a serious incident as outlined in the AAIB report. We have all done things which we regret and would have done differently and sharing those experiences so that others can learn should be commended however I suggest that you have another read of this report. The Commander claims that he did not engage the autopilot as he was aware of skill fade and wanted to practice his manual flying skills even though any sane person would say that that was not the time for IF practice. He also goes on to state that he was aware of the overtorque and used that as the justification for the second ill advised approach when the reports mention that at some point prior to this they were visual with the ground (so could have landed in the nearest suitable field or returned to Birmingham to shot an ILS.)

Last edited by Undecided; 15th Sep 2021 at 06:12.
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Old 13th Sep 2021, 18:04
  #112 (permalink)  
 
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[QUOTE=Undecided;11110568]…his job was to protect his pilots from commercial pressure yet it is clear that he succumbed to it on the day of the incident and therefore it is most likely that this was not a one off.]

Particularly this. It is a near certain thing that the way the decisions got made followed a pattern. In this event, even the first approach which should have chastened the Commander into a rethink was not enough to break it. Absolutely shocking. And that the PM did not put in a robust challenge speaks volumes about the real culture irrespective of what is on paper.
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Old 13th Sep 2021, 19:19
  #113 (permalink)  

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The main point to come out of this is how pressure to get the job done can sometimes overcome common sense and good judgment. It’s easy to smugly pour scorn on this from an armchair but I’ve always said that the most difficult thing about corporate rotary is when to take stock and say no!
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Old 14th Sep 2021, 07:10
  #114 (permalink)  
 
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I’ve always said that the most difficult thing about corporate rotary is when to take stock and say no!
That comment holds true for SAR and, I suspect, HEMS as well.

This is the sort of incident that is dissected well on military (and I'm sure civilian) Flight Safety courses - too much focus on achieving the task, poor weather, adverse cockpit gradient and a breakdown in CRM - leading to poor decision making - all ingredients we have seen so often in so many accidents.

Such dissections allow you to measure yourself against the decisions made - you can ask yourself how far down that same path would you have gone before you said no. If you get to the end and still don't see a problem - then you are the problem!
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Old 14th Sep 2021, 13:05
  #115 (permalink)  

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That comment holds true for SAR and, I suspect, HEMS as well.
I agree, having done both.
However, having the man who pays your salary (and who can dismiss you from your hard earned job with a wave of his hand) sitting behind you in the cabin adds a certain extra pressure.

I've never forgotten the story of one pilot who landed on the aircraft owner's lawn on his first day in the job, but slightly in the wrong place. He hadn't been briefed on the correct place. He was told he was incompetent and never to return.

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Old 14th Sep 2021, 16:05
  #116 (permalink)  
 
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Originally Posted by ShyTorque View Post
I agree, having done both.
However, having the man who pays your salary (and who can dismiss you from your hard earned job with a wave of his hand) sitting behind you in the cabin adds a certain extra pressure.

I've never forgotten the story of one pilot who landed on the aircraft owner's lawn on his first day in the job, but slightly in the wrong place. He hadn't been briefed on the correct place. He was told he was incompetent and never to return.
ShyTorque and Crab, I completely agree with your points which is why this particularly incident is so shocking. As we are agreed that the hardest part of the job is knowing when to say no, those pilots that work for a management company/AOC need as much support and back up from their superiors as possible. This is the whole point of having a management structure and a SMS structure to identify these hazards and mitigate the risks. We are all aware that feeling pressurized to operate below legal limits or those limits that the pilot feels comfortable with (whichever is higher) is a fast way to yet another high-profile accident.


Last edited by Undecided; 15th Sep 2021 at 06:14.
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Old 14th Sep 2021, 16:32
  #117 (permalink)  

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Undecided,
I'm making a general comment based on my own experiences. I don't know the pilot concerned and would never make a personal and public attack based on what appears to be hearsay.
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Old 14th Sep 2021, 16:44
  #118 (permalink)  
 
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Originally Posted by ShyTorque View Post
Undecided,
I'm making a general comment based on my own experiences. I don't know the pilot concerned and would never make a personal and public attack based on what appears to be hearsay.
I’m making my comments based on factual information that is contained in the report. I believe these matters should be discussed in forums such as this in a genuine attempt to make our industry safer and trying to understand why accidents and incidents such as this keep happening. It seems clear that a management structure and mature SMS system did nothing to prevent this incident.
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Old 14th Sep 2021, 17:04
  #119 (permalink)  
 
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Undecided - I agree, you can tick all the SMS boxes you want on paper but when someone wilfully disregards the protocols - as we saw also with the Kobe Bryant crash - the result is almost inevitable.

I find it difficult to understand how Cranfield allow him to lecture on safety when he appears to have a total disregard for it other than in an academic way.

Perhaps this is intellectual arrogance at its worst, someone who knows all the reasons for safety protocols but believes himself to be above them.
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Old 14th Sep 2021, 18:53
  #120 (permalink)  

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Originally Posted by Undecided View Post
I’m making my comments based on factual information that is contained in the report.
But not here:
Originally Posted by Undecided View Post
Other posters have alleged that this was not a one of occurrence and has happened before (and even more shockingly) after the event.
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