G-LAWX S92 Incident AAIB
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?
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.
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.
Originally Posted by Heathcliff
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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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?
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?
Originally Posted by megan
I'm afraid I don't see where he made the offer.
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.
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.
https://www.dailymail.co.uk/news/art...elicopter.html
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?
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.
https://www.dailymail.co.uk/news/art...elicopter.html
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.
