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G-LAWX S92 Incident AAIB

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G-LAWX S92 Incident AAIB

Old 13th Oct 2021, 09:03
  #161 (permalink)  
Join Date: Oct 2021
Location: UK
Posts: 1
I have been a regular visitor to PPRuNe as a guest for quite some time and I have been entertained and educated in equal measures over the years, but it is only today that I have actually registered to enable me to post a response to this thread which I have been reading with interest since this unfortunate incident happened.

Who cannot be moved by Dr SM’s soul searching and apparent words of wisdom to help us all learn from this unfortunate incident? I have experience of corporate aviation and I can empathise with what the good Doctor says as a pilot – especially with regards to the making a night approach to an off-airfield site – I have done more than my fair share of them and it is rarely a relaxing experience.

However, what has driven me to register and exercise the right to comment on this thread, as Dr SM has invited us to do, is that if we are going to have an open and honest discussion about this matter than we should do this in full visibility of all of the information. I know Dr SM well and he knows me, unfortunately our relationship has not been harmonious.

There is no doubt that Dr SM is a charming character, there are many that have been seduced by his silver tongue and even I have been tempted to rush out and stock up on his own unique brand of aviation inspired Snake Oil. However I feel that I must also mention that I am involved in legal proceedings with a company (over which he presides) during which I will aver that I have suffered significant financial lose for making protected disclosures around matters concerning MCC. A ‘whistleblowing’ claim as it is known.

MCC is at the heart of my legal dispute and I believe that is also at the heart of this incident. The AAIB report itself is long, technical and complex and I expect there are few of us that have the time or inclination to read it all again so perhaps I can urge you to re-read Dr SM’s recent post on this thread and consider it from a slightly different perspective.

Firstly he mentions the CAA and the owners office and heaps praise on them for their attitude towards a Just Culture (I can tell you at this point that the HR Manager for the company that Dr SM presides over had previously informed me that she had never heard of a Just Culture). I support these comments from Dr SM. He does not extend the same praise to the AAIB who have carried out a thoroughly professional and detailed report and are perhaps, the one organisation that have genuinely attempted to ensure that lessons are learnt. In the execution of this process, they have been critical of his actions and the organisational structure of the company which he oversees. He describes them as ‘painting a picture’, perhaps inviting us to believe that this was the artist impression of what happened rather than a full and detailed report on what actually happened based on hard and unequivocal data that has not the benefit if any ‘spin’ applied to the narrative?

He then takes us inside the cockpit and starts by making the broad point that to err is human. Who can deny that this is true but then he goes on to infer that we must be cautious of being too critical because of commercial pressure (of which he seems to infer that that he was a victim of such pressure even if the pressure wasn’t direct pressure) and that night off airfield landings are a particular hazard and only those who have experienced them can truly understand? Is this the equivalent of the Hollywood portrayal of the Vietnam veteran being probed about his actions who dismisses the questions with the response ‘You weren’t there man’?

He then goes on state that if we think that we, as pilots that train in the simulator, will take that training to the real world and do as we do in the simulator then we are ‘deluded’. What does this tell us about his own personal attitude to training? Can we draw anything from this as to what value he places on such training? Does he believe that TRE’s knowingly sign pilots’ licences secure in the knowledge that if they get a ‘real’ emergency they can only be expected to remember 20% of what they have been taught? Is it fair for him to assume that because his own performance was found lacking, in the same situation everybody else’s would be as well? He talks about the emergency developing as quickly as failing off a cliff. Let us remember that this was not a catastrophic gearbox failure, this was a planned approach into a site that he was very familiar with in a perfectly serviceable airframe fitted with all the bells and whistles and with the benefit of a highly experienced pilot by his side.

Dr SM seems to be asking as to be guided by him on our views and opinions as he has experienced this first-hand and we haven’t. Whilst it is true that none of us were there, wouldn’t the debate more constructive if he centred it around why he was? Surely this was never meant to be a night landing, it was planned to be a day VFR approach and the AAIB report seems to infer that the weather wasn’t even suitable for this.

The report doesn’t shy away from the fact that the dangers associated with attempting the flight were known by Dr SM prior to take–off; “We are really up against it”. I would also make the point that any decisions that were made, were made by Dr SM and Dr SM alone. My reading of the report is that the cockpit gradient was completely wrong and if I am correct in this where should the blame sit? With the F/O or the Commander? Did the F/O not attempt to air some concerns and offer alternative and safer options that fell on deaf ears? When the wheel really came off would it be true to say it that there was very little acceptance that the other half of the team may have had a view and would be able to make a valuable contribution?

It seems to me that there is a strong possibility that Dr SM was of the view that he, and he only, knew what was best. He adds drama with comments alluding to the fact that unless he did something in the next three seconds they would all perish. The counter to this is that if he had listened to the F/O he wouldn’t have been in that situation and had he allowed the F/O to take control, the F/O would have most likely calmly pressed the go-round button and engaged the autopilot to get the helicopter safely climbing away back to Birmingham to position for an ILS and avoid any endangering of life or overtorque of the aircraft. Interestingly Dr SM generally talks in the singular when discussing the incident as if the F/O wasn’t there.

Dr SM then discusses how he considered resignation. He claims that this was at the forefront of his mind and states that he did not do this to protect the jobs of others that work in the company. Let’s consider this for a second or two. The Company has been around for over 40 years and is owned by Lux Aviation and yet Dr SM seems to believe that without him at the helm the company would fail and employees would lose their jobs. What does this tell us about his ego? Would it be fair to say that during the incident it appeared that he felt that he and he alone knew what was best for the flight and now he alone knows what’s best for the company? What does this say about his view of MCC procedures?

What I can tell you is that 6 weeks after the incident I sent an email concerning a company pilot who was transferring to a MP operation within the company and required an initial MP type rating which concluded with the following paragraph “However, whilst not wanting to interfere with the way Fairoaks works, I have been puzzled by the amount of time we have spent trying to prove that an MCC Course is not required. Given that all of his previous MP experience was almost 20 years ago, my recommendation from a risk mitigation point of view, would be that he completed an MCC Course prior to doing the 10 hours MP training or we complete the combined initial MP/MCC course where he is schooled in the (company name) MP SOP’s simulating (company name) operations. This appears to be an opportunity to get things right and provide the best possible training. It is my personal view that a lot of onshore operators have made a mess of the transition to MP operations and end up paying for two pilots but not receiving the safety benefits of a well organised and well trained for MP operation with robust SOP’s and experience and training that is relevant to their operation” To the best of my knowledge the pilot concerned never completed the MCC training. This is why I have an open mind about the rumours that are circulating concerning the aircraft continuing to operate in poor weather.

Dr SM has indicated that the focus should be on making things safer (on this matter at least we whole heartedly agree). If we are to focus on this then I believe we should be looking at all of the issues that surround this subject both pre and post incident. For those of you that are interested the legal aspects of my dispute with Dr SM’s company will be decided at Bristol Employment Tribunal from the 21st to the 24th of February next year. Employment Tribunals are public which means that the press and members of the public are welcome to attend and listen to the evidence heard and the judgments delivered. Given what Dr SM has said in his post, I hope that he will stand by his words and he and his legal team will not oppose this incident being discussed under oath as I believe that MCC training is at the heart of my claim and indeed this incident. I also hope that certain documents that I have requested regarding this matter – such as the internal company report relating to this incident will be released – up until now there has been a reluctance to do this.

Last edited by DickieB; 14th Oct 2021 at 09:13.
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Old 14th Oct 2021, 08:02
  #162 (permalink)  
Join Date: Mar 2008
Posts: 42
G-LAWX S92 Incident Discussion

A very thought provking responce by Dickie B and for me the following is particulary cogent.

‘’ My reading of the report is that the cockpit gradient was completely wrong and if I am correct in this where should the blame sit? With the F/O or the Commander? Did the F/O not attempt to air some concerns and offer alternative and safer options that fell on deaf ears? When the wheel really came off would it be true to say it that there was very little acceptance that the other half of the team may have had a view and would be able to make a valuable contribution

I retired from flying some years ago but during my spell as CP of a corporate S76 operation I included the following in our corporate operations manual to ensure the Pilot Monitoring (called co pilot in the old days and another captain but sat in the left seat) was fully empowerd and briefed prior to any approach.

‘’ duties, responsibilities and calls to be made by the co pilot including actions he should take in the event of failure of the handling pilot to adhere to minimum altitudes/heights, RVR’s, approach bans and descent below MDA/DA.

The form of words for the briefing should be along the lines of:

‘ In the event of descent below minimum specified Altitude/Height or continued approach below specified RVR/MDA/DA without the required visual references you are to verbally warm me by calling ‘Go Around I say again Go Around’. In the event of non immediate corrective/overshoot action by me you are to take control with the words’’ I have control’’ and take overshoot action’

It's not perfect but at least it addressed a serious issue at a critical time.

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Old 14th Oct 2021, 13:06
  #163 (permalink)  
Join Date: Jan 2006
Location: EU
Posts: 484
Whilst Dr SM’s contrition is laudable, I welcome the shift that the last couple of posts has brought. The previous very mild criticisms that had been made were heavily criticized by some willing to accept DrSMs humility and contrition at face value when, in detail, his post was threadbare in any examination of why the flight was executed so badly. It is all very well reaching the conclusion that you should heed your doubts whilst still on the ground, but this glosses over why, once airborne, a lack of protocols and MCC & CRM nearly resulted in a fatality with two pilots and such a capable aircraft.

The lack of procedural definition, including at which points a missed approach would be initiated and how this would be done is a glaring deficiency. And the second poorly planned approach after the first went dangerously wrong, and following an overtorque, was a stunnigly bad decision and insufficiently challenged. Honourable mention should also go to hand flying an S92 because you are a bit out of practice in deteriorating light and marginal weather conditions. That isn’t just a bad decision; it is a failure to understand that important levels of protection are being removed for the wrong reasons at the wrong time.

Was the flight dangerous? Yes, but only because the crew made a series of very poor active and passive decisions. This event did not just involve one bad decision or error of judgement; it was replete with them.

It is also not unfair or unreasonable to question why someone in DrSMs position could conduct a flight like this and there to have been so few protections to have stopped him doing so when he failed to apply long established industry standards. Were they lacking in the operation, or simply ignored because that is just stuff on paper?

Last edited by Torquetalk; 14th Oct 2021 at 13:17.
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Old 14th Oct 2021, 21:10
  #164 (permalink)  
Join Date: Oct 2015
Location: swansea
Posts: 31
Question him, then. He does offer for anyone to do so if they wish but said he would not respond further to the thread. Alternatively, if you just want to keep villifying someone on a forum where you feel anonymous, then carry on, but you will not learn anything. Which is, after all, what you are asking to do.
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Old 15th Oct 2021, 00:10
  #165 (permalink)  
Join Date: Mar 2005
Location: N/A
Posts: 4,098
Question him, then. He does offer for anyone to do so if they wish
I'm afraid I don't see where he made the offer.
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Old 15th Oct 2021, 03:16
  #166 (permalink)  
Join Date: Jan 2006
Location: EU
Posts: 484
Originally Posted by Heathcliff View Post
Question him, then. He does offer for anyone to do so if they wish but said he would not respond further to the thread. Alternatively, if you just want to keep villifying someone on a forum where you feel anonymous, then carry on, but you will not learn anything. Which is, after all, what you are asking to do.
Heathcliff, I would say that your continued readiness to defend DrSM and attempts to shut up those offering critical comment on the flight is not actually in the interests of flight safety or learning lessons. There is, in fact, much to learn from what happened (in the report) and the point is to learn it through discussion and applying the lessons into practice and not have to learn it the hard way. The fact that these are acutally lessons that should have already been learnt and involve mistakes that need not be repeated, especially by someone teaching the subject, is a perfectly reasonable criticism which an apology does not nullify. If those charged with teaching and implementation of good practice don't actually do it, there is not much reason to be optimistic about future flight safety.
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Old 15th Oct 2021, 06:39
  #167 (permalink)  
Join Date: Nov 2002
Location: UK
Posts: 26
I have been critical of the Commanders action in previous posts. Having read Dr SM's post in detail my views have changed very little. He is insistent that the CAA followed a Just Culture which lead to their decision not to revoke his licence or apply any punitive actions. He says that this is because they accepted the information he gave them but also says he isn't going to share the details with us of what he told them. He says that the CAA understood. It is almost as if he wants us to believe that there is more to the story which the CAA know and the AAIB don't.
Way too much smoke and mirrors for me, if Dr SM is genuinely interested in being open and honest and making things safer then don't say your piece and then say you are not going to respond further on this forum. There have been some excellent questions asked over the last few posts - if he wants to assist with safety, come back and answer them so we can all learn from his mistakes. I hadn't considered the issue of the internal report before but it is an interesting one - as AM and SM he was marking his own homework. Why doesn't he share with us how he marked himself?
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Old 15th Oct 2021, 06:59
  #168 (permalink)  
Join Date: Oct 2015
Location: swansea
Posts: 31
Originally Posted by megan View Post
I'm afraid I don't see where he made the offer.
Ah, maybe I misread it: " I have no issues talking about it with anyone who genuinely wants to learn something about avoiding this again." Maybe that wasn't meant for posters on here as I thought - hence my ONE attempt to steer the questioning to where I thought it would be answered - although I thought DrSM was referring to his course too.

I'm not convinced the ire expressed by some repeatedly against one individual is entirely about flight safety, and I certainly don't see how posting that on here improves it when no public discourse will be entered into whereby lessons could be learned, but in my mostly silent years on here I've noticed that's the lifeblood of this forum. I suspect I have become too old for the internet! I shall retire forthwith as I seem no better at it than anyone else. Godspeed.

Last edited by Heathcliff; 15th Oct 2021 at 07:47.
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Old 16th Oct 2021, 17:15
  #169 (permalink)  
Join Date: Nov 2002
Location: UK
Posts: 26
Heathcliff, I have been one of those that have been critical of the conduct of the flight so I suspect that your comment is made (at least partially) at me.
You are probably correct that there are two points here - one is expressing ire and the other is learning to prevent reoccurrence. As far as flight safety is concerned there have been some excellent points raised as to where it all went wrong however it appears that there are no new lessons to be learnt here so the real question, which remains unanswered is - why did it all go so badly wrong? By this I mean why were the SOP's so poor and why weren't those that were there not adhered to? Why did Dr SM chose to push on and on and on, ignoring all wisdom and common sense even once the aircraft has almost impacted the ground? I guess the only person who can really answer this question is Dr SM but he has chosen not to engage and help us with this bar telling us to be cautious without explaining why he himself wasn't.
The other point is expressing ire. When incidents like this occur (thankfully they are rare), personally I am both relieved that the result was not far worse but frustrated (and yes probably angry) that behaviour like this is tolerated within our industry. I am not without fault and I have done things which, with the benefit of hindsight, I would do differently, but for me - this lack of adherence to any kind established procedures is reckless and it damages the reputation of the whole industry. It is akin to the driver that cuts you up on the motorway doing 120mph - I believe it to be unnecessary and dangerous so I don't shed a tear when such drivers are banned but I do get frustrated if they are caught but not punished.
To put this is perspective, have a read of this article.
Personally I believe that the gentlemen concerned (Mr Voice) was reckless and it was good that some kind of punitive action followed. I assume that DrSM also felt that the action was reckless as I would imagine it would have been impossible to secure a conviction without a statement from him as the pilot. So I wonder what the view from fellow readers is with regards to whether there is any comparison (in terms of endangering the helicopter) with the way Mr Voice acted when he chose to shine his torch and the way that Dr SM acted when he chose to operate the helicopter in the way that he did?

Last edited by Undecided; 16th Oct 2021 at 20:36.
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