G-LAWX S92 Incident AAIB
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.
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.
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.
ICAO Annex 13:
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.
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.
It is not the purpose of this activity to apportion blame or liability.
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.
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.
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.
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?
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.
[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.
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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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!
I’ve always said that the most difficult thing about corporate rotary is when to take stock and say no!
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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That comment holds true for SAR and, I suspect, HEMS as well.
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.
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.
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.
Last edited by Undecided; 15th Sep 2021 at 06:14.
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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.
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.
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.
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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Please note that I haven’t defended the pilot involved. As I said, I don’t know him and have no reason to defend him. However, I have read the report and it’s obvious a lot of errors of judgement were made and things could have gone even more badly wrong, thank goodness they did not.
On a public forum such as this, further accusations against an individual based on hearsay (as in outside of the published report in this case) may require the individual making them to justify themselves in a court of law. The forum rules are quite clear on this; although it’s an anonymous place on the face of it, the owners of the website may be obliged to pass on details of any of us and will do so if required to do so in a legal situation. I have no desire to get involved in such an issue - having very recently seen the price lawyers charge these days I value my house too much. Having been a member of this forum since 1995, I tread the line carefully.
P.S. I hold absolutely no clout over the actions of the CAA!
On a public forum such as this, further accusations against an individual based on hearsay (as in outside of the published report in this case) may require the individual making them to justify themselves in a court of law. The forum rules are quite clear on this; although it’s an anonymous place on the face of it, the owners of the website may be obliged to pass on details of any of us and will do so if required to do so in a legal situation. I have no desire to get involved in such an issue - having very recently seen the price lawyers charge these days I value my house too much. Having been a member of this forum since 1995, I tread the line carefully.
P.S. I hold absolutely no clout over the actions of the CAA!
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Safety Officers, Risk Assessors and Nominated Post holders need a healthy active imagination in order to identify hazards and risk and mitigate effectively. Sadly, the modern SMSA, in my opinion, is an overly complicated and huge administrative burden on Operators that its true value and effectiveness is often lost in the ether.
Good to see you back in the Fray SAS long may it continue.
DB.