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G-LAWX S92 Incident AAIB

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G-LAWX S92 Incident AAIB

Old 20th Jun 2021, 09:10
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I believe that PiNs approaches would allow the full capabilities of modern helicopters to be used which will have huge safety benefits for the onshore community. However any flying in IMC requires a level of discipline and adherence to rules and procedures. From what I have read in the report this was not present during this flight, some or most of it was IMC given that it was below VMC limits.

I worry that the regulator will cite this as a reason for not implementing PiNs approaches on the basis that we can’t be trusted to follow the rules. It appears that no follow up action has been taken by the regulator and his company bar some minor Ops Manual amendments.

Pilots are often held to account for minor airspace infringements but not the big stuff. As a previous poster commented, luck was on their side that day on a day when luck should not have been needed. If that luck had not been there we would be looking at another Shoreham type accident.

Last edited by Undecided; 15th Sep 2021 at 05:56.
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Old 20th Jun 2021, 09:25
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So you increase the minima to make it safer which means they still can't get the customer into his home site - so what next?

Pilots like these seem happy to break the VFR rules to try and get in - what will stop them ignoring the new safer minima to do the same thing?

Doing something dodgy and getting away with it a few times does not prove its safety or guarantee the next attempt will be successful but that appears to be how some onshore pilots work.

Last edited by [email protected]; 20th Jun 2021 at 10:43.
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Old 20th Jun 2021, 10:06
  #63 (permalink)  
 
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Forgive my naivety -- all I know about the rotary world is derived from enjoying seeing Shawbury's aircraft using one of our fields -- but what kind of corporate client is important enough to generate this sort of decision-making? Why is it so difficult to say "no" to them? Are some clients so exalted that a car pickup from Wellesbourne (or even Birmingham) just wouldn't have been acceptable? Or are there genuine issues such as security, perhaps?

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Old 20th Jun 2021, 11:12
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High net worth clients are mostly accepting of pilot operational decisions. It is when pilots get the false impression that said high net worth clients might not be so accepting of said pilot operational decisions that self-imposed pressure causes prudent sensible decision making to be thrown out the window and the "can do" mentality over-rides everything.
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Old 20th Jun 2021, 13:15
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One legend in his own lunchtime whose body was found circling the sharks near his yacht was well known to put pressure on pilots and engineers. There was also the accident in Norfolk. It really can be that bad at that level, hence my comments about self-esteem above. Corporate pilots need to have a good opinion of themselves, which is rather contrary to the company person suggested by EASA in their KSA 100 exam. It caused quite a stir when I suggested that pilots actually need to be a little anti-authority.

Phil
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Old 20th Jun 2021, 16:14
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When an Authority can say one check ride every six months and you are both current and proficient in IFR/IMC flight....being a bit anti-authority might just save your life.

Just because the Authority says you can....doesn't mean you must or should.


Crab,

With the advent of GPS, FMS systems, Autopilots with four axis capability, RadAlts, TAWS, GPWS.....and FLIR....can you with your SAR experience....envision an IAP for that landing site that if properly surveyed, flight checked, and re-surveyed monthly for changes in the way of obstructions to include checking with the local authority to see if there. have been any Building Permits filed for or approved within the surveyed flight path?

What Minimums would you think workable and safe?

The Operator/Client had gone to the lengths to provide a visual glide slope and landing azimuth device....which shows their intent was to find ways to make their operation safer by seeking some usable technical assistance.

Would not that Point in Space IAP be one such thing that would have worked for them had they had that option?
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Old 21st Jun 2021, 09:53
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Crab,

With the advent of GPS, FMS systems, Autopilots with four axis capability, RadAlts, TAWS, GPWS.....and FLIR....can you with your SAR experience....envision an IAP for that landing site that if properly surveyed, flight checked, and re-surveyed monthly for changes in the way of obstructions to include checking with the local authority to see if there. have been any Building Permits filed for or approved within the surveyed flight path?

What Minimums would you think workable and safe?
Yes, of course you could create a workable instrument approach to the LS - it has the advantage of being on the top of a hill so the obstacle planes would be fairly benign.

However, you still have to revert to visual flight once you get to your minima since you don't have all the advantages of airfield lighting to help you identify the LS in the dark.

With all the caveats you suggest in place, 150' minima above the elevation of the LS would seem reasonable but probably at a low speed of circa 60 kts to enable quick transition from instrument descent into visual approach and landing.

The problem with this flight wasn't the aircraft capability though - it was poor decision making and self-imposed pressure (as we see all too often) - clearly the suggestion to go straight to Wellesbourne would have been the adult decision.

I note they were both ex-Mil and ex-Sea King but don't know which Service they had been in - that may have had a bearing on their decision-making.
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Old 21st Jun 2021, 16:11
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I think what made this particularly vulnerable to making the major error the commander (particularly) did, was that the flight was actually ok - if marginal - for 24 of the 25 miles of the route, over the lower ground that formed all but pretty much the final approach. It was the rapidly rising ground of the sharp 500ft hill, towards the top of which was the LS, that suckered the commander into having a go. Had the LS been on much lower ground just 1.5 nm to the east he would have landed routinely, but trying to get that last mile or so took him in to higher ground surrounded by mist – in the twilight. He didn’t actually descend to end up 28ft above the ground – the ground rose up as he was flying along, fairly level, albeit in far too poor vis for that last mile.

If an alternative LS had been identified and arranged for poor weather use somewhere on this much lower open ground 1.5nm away, it would have been a far more appealing divert option than heading back to Wellesbourne, let alone back Birmingham which had the only instrument approach. And the flight could have been undertaken legally and safely. Given the scale of the operation I would have thought this would not have been too difficult. Maybe for other frequently used LSs on hills with low ground nearby, this would be a wise idea……

I’m certainly not suggesting the crew were not at major fault – just putting some context into how they might have got themselves into the situation.
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Old 22nd Jun 2021, 07:33
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From the report
History of the flight The pilots of the Sikorsky S-92A (S92) had been operating for several days from the landing site (LS) in the northern Cotswolds
They can't cite unfamiliarity with the terrain and local area as an excuse.
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Old 22nd Jun 2021, 08:39
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I agree, yet familiarity may lead to complacency, or at least a slightly lower level of attentiveness towards the risks of this particular combination of rising ground, low visibility and all the other factors. I am not trying to absolve the crew of any blame, but it is very easy to sit here and come up with what should have been done at the time. The crew painted themselves into a corner, were fortunate to come out of it with only some dents in their ego instead of in the airframe, and we've got a good report out of it that should lead to some significant improvements in the industry (hopefully). If you've ever found yourself in a situation that you should have avoided, you know how long you can continue to kick yourself for being so stupid. I suspect that the crew has done enough of that already.
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Old 22nd Jun 2021, 11:15
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Incidents like this one should be analyzed and with the benefit of hind sight....provide a forensic examination of what happened....how it happened...why it happened....and provide Lessons Learned for everyone....the Crew, the Operator, the Client, and every other Pilot and Crew that goes forth doing what we do as Helicopter Pilots.

Otherwise there is no really good outcome to these things.

The Crew are good and decent people....but they as we all are....are Human and thus susceptible to make mistakes as we all do.

I do not look down on them or find them to worthy of being branded for life over this one event....they were trying hard to carry. out their assigned task in marginal weather and approaching darkness.

They made some decisions that I bet you if there was a way to re-wind the Tape and have a Re-Do....they would do things differently.....but that is not real life.

At least they lived to tell the tale....unllike so many others that wound up in a smoking pile of wreckage.

What is interesting to me would be hearing from them about how upon reflection they would do the flight again if they could.

We should learn from our mistakes not be crucified for them.....as long as we make them while trying to do it right.

Sometimes even the most experienced Pilot or Crew is set up for failure by a training deficiency, SOP, or Rule which only comes to light when something like this happens.
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Old 22nd Jun 2021, 12:40
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SASLESS, I agree with your sentiments with regards to the co-pilot but not sure it holds true for the Commander.
For me, the most damning part of the report is the part when, having got horribly out of shape during the first approach and almost hit the ground which culminated in a massive over-torque, he elected to have another go even though they knew the weather was nowhere near suitable. Personally I don’t buy into the ‘we needed to get the aircraft on the ground because of the over-torque’ argument. There is no evidence in the report that this was never discussed as a crew, no checks were run and no emergency call was made. Would we be so dismissive of a driver who was driving at 120mph because his passengers were late and wanted to get home?’

Last edited by Undecided; 15th Sep 2021 at 08:43.
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Old 22nd Jun 2021, 13:09
  #73 (permalink)  
 
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https://www.helicopterinvestor.com/a...-training-457/
I was aware of this already but not sure if it was initiated before or after the incident?
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Old 22nd Jun 2021, 13:17
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Gulli has been telling us of how common it is for Sim Students arriving without full understanding of the avionics onboard the aircraft they fly in the course of their employment.

I saw that in the Sim as well.

I also see a common thread in too many crashes where Pilots refuse to use the full capabilities of the aircraft and insist upon hand flying the machine when they need to reduce their workload.

That is a direct byproduct of the lack of proper training, poor SOP's, and a failed SMS.....which all can be laid at the feet of Management.

Pilots....Line Crews and Training Captains have a role to play in seeking Industry Best Practices for their own Operations and that requires looking outside their own to others to seek those better ways of doing business.

So....a question is why is this "new" training "new" an "unique"?

It is for sure needed and shall prove to be beneficial.
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Old 22nd Jun 2021, 13:39
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212man - given the Company is the same, perhaps it is born of 'lessons learned' or some form of atonement.
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Old 22nd Jun 2021, 14:34
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Originally Posted by 212man
https://www.helicopterinvestor.com/a...-training-457/
I was aware of this already but not sure if it was initiated before or after the incident?
The director’s comments on AFCS authority versus pilot authority aren’t very inspiring.
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Old 22nd Jun 2021, 15:19
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I followed the link reference the automation training being offered. The other articles were about the EC225 receiving certification in Russia which took place in 2015. Therefore it looks like the article pre-dates this incident.

Last edited by Undecided; 15th Sep 2021 at 08:44.
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Old 22nd Jun 2021, 15:34
  #78 (permalink)  

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I also see a common thread in too many crashes where Pilots refuse to use the full capabilities of the aircraft and insist upon hand flying the machine when they need to reduce their workload.

That is a direct byproduct of the lack of proper training, poor SOP's, and a failed SMS.....which all can be laid at the feet of Management.
It's not many years at all since the CAA insisted on hand flown instrument approaches during check-rides, rather than being allowed to "cheat" by using the automatics and coupling it all up.
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Old 22nd Jun 2021, 15:53
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Originally Posted by ShyTorque
It's not many years at all since the CAA insisted on hand flown instrument approaches during check-rides, rather than being allowed to "cheat" by using the automatics and coupling it all up.
Yes - I have commented on that before. At one point, around 2004, the Head of Training relented to lobbying and allowed the use of ALT hold while copying the METAR - I have seen it in the minutes of a TSLG meeting! There were some more enlightened FOTIs, but they were using common sense rather than policy, based on their currency on the EC225 etc. Policy changed once the Head of Training had his 'road to Damascus' moment after being on the S-92 JAA OEB team, and took a 180 degree view on the topic.
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Old 22nd Jun 2021, 18:39
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Shy,,,,,Perhaps the CAA might get out of the Dark Ages and start looking outside of their own small circle for Industry Best Practices THEN issue Mandates and Rules.

Our FAA is just as bad in that regard.....far too often the aircraft designers are far ahead of the technical expertise of the FAA which has an adverse effect on related. outcomes.

I am sure the CAA is no different.

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