N72EX (Kobe Bryant) Crash Update-

[[email protected]]

It's an interesting interview and probably describes many small operations where commercial pressure inevitably impacts operational decisions - much like a lot of HEMS operations in the US I would expect. Don't fly, don't get paid - but crashing is a lot more expensive.

[airplanecrazy]

Originally Posted by gulliBell

Umm, not quite. The GA button cancels all other modes, maintains wings level, and commands a rate of climb of 750 fpm. The key point about this behavior is, if you don't have the power required to climb at 750 fpm, in trying to maintain that ROC the autopilot will slowly increase nose up pitch. As the nose is slowly pitched up the airspeed deceases slowly. If you fail to notice this, eventually the aircraft will get your attention with a sudden nose up pitch just before it falls out of the sky with zero airspeed. I've seen this happen during recurrent training, far too many times.

Is the behavior you describe specific to particular SPZ-7000 installations? The SPZ-7000 DAFCS Pilot's manual for the S76 says: "The go-around mode may be engaged by pressing the button on the mode selector or by depressing the go-around switch on the collective. When engaged this mode will cancel all other modes that are engaged. Upon engagement the collective will be commanded to obtain 75 knots or more while the roll axis will return the aircraft to a level roll attitude and will maintain the current aircraft magnetic heading. The pitch axis will be commanded to a positive rate-of-climb of 750 fpm."

[gulliBell]

It behaves as you describe there. However, where many pilots become unstuck is in an OEI go-around. The autopilot does not know you only have one engine available, and you probably don't have enough power (via the collective) to automatically maintain 75 knots. The autopilot will still always pitch for 750 fpm. The end result, if left uncorrected, is the sudden nose up pitch, zero airspeed and falling out of the sky tail first. In a GA let the pilot control the power, and let the autopilot take care of climb rate. For whatever reason doing it this way more often results in better pilot monitoring of the situation and less falling out of the sky tail first.

[airplanecrazy]

Originally Posted by gulliBell

It behaves as you describe there. However, where many pilots become unstuck is in an OEI go-around. The autopilot does not know you only have one engine available, and you probably don't have enough power (via the collective) to automatically maintain 75 knots. The autopilot will still always pitch for 750 fpm. The end result, if left uncorrected, is the sudden nose up pitch, zero airspeed and falling out of the sky tail first. In a GA let the pilot control the power, and let the autopilot take care of climb rate. For whatever reason doing it this way more often results in better pilot monitoring of the situation and less falling out of the sky tail first.

That makes perfect sense. Thanks!

[megan]

The end result, if left uncorrected, is the sudden nose up pitch, zero airspeed and falling out of the sky tail first. In a GA let the pilot control the power, and let the autopilot take care of climb rate

For climbing I never used VS mode because you could find yourself running out of airspeed and falling tail first, only use VS for descent, for climb use IAS. It's going to be a life saver if you're heavy, single engine and you're inattentive, as some FW accident reports spell out even with all engines running using VS for climb they ended up stalling and incurred buffet induced structural damage - bits falling off the airframe.

[gulliBell]

Originally Posted by megan

For climbing I never used VS mode because you could find yourself running out of airspeed and falling tail first, only use VS for descent, for climb use IAS. .

Exactly. But you have a thorough understanding of the system and know exactly what you are doing. The problem arises with pilots who only push the GA button once per year on their annual competency check without knowing exactly what it does, and does not, do. Quite often on those check rides the recurrent trainee gets an engine failure about 3 seconds after they push the GA button on a missed precision approach. The confusion and calamity with the pushing of auto-pilot buttons after that can so easily lead to mayhem and the falling out of the sky tail first. I find successful outcomes are more likely if the pilot just leaves the auto-pilot mode as it is, and manually adjust the power to droop the main rotor speed to 100%. And then leave it there. That is easy, and will see the aircraft safely climbing wings level. Whilst changing the auto-pilot mode from VS to IAS as suggested by megan is very good advice, the execution of that in practice can be very problematic and quickly lead to an unfortunate outcome.

[[email protected]]

The only problem with VS in a descent (not qualified on 76 but other similar aircraft) is that without adequate monitoring of the collective and what power you have set, the AP can reduce speed sufficiently to put you into VRS. That is if you are in 3-axis mode.

[JimEli]

Did the NTSB miss some blame in this accident? Could it have been prevented if the FAA had performed their duties? The FAA was specifically tasked to check for these apparent missing tasks, which seem to have be added with an update to IEH's training manual on March 6, 2020?

Part 135 Helicopter Training and Qualification Program Review and Competency Check Requirements
National Policy Effective Date: 9/22/17, Cancellation Date: 9/22/18
“The objective of the program review is to identify and correct part 135 helicopter training and qualification programs that do not include the required training and checking on (1) procedures for helicopter handling in flat-light, whiteout, and brownout conditions and (2) recovery from inadvertent instrument meteorological conditions (IIMC). In addition, this notice provides guidance to ASIs conducting § 135.293(a) helicopter written or oral tests or § 135.293(b) helicopter competency checks.”

As pilots, the FAA holds our feet to the fire, yet this seems egregious on their part...

[ShyTorque]

Originally Posted by gulliBell

Pressing HDG mode on the flight director was all that was required to keep wings level and redirect some attention to other tasks. Doing so would have helped enormously.

Only if the aircraft heading was the same as the heading bug. Otherwise the aircraft would enter a rate one turn onto the bug heading.

[wrench1]

Originally Posted by JimEli

which seem to have be added with an update to IEH's training manual on March 6, 2020?...

FYI: This issue was discussed during the preliminary investigation stages. Island outsourced their 135 training who provided the required 135 IIMC, etc training procedures and records. As I recall the main issue was that the procedures used had to be also listed in the Island training as well which they revised in March after it was brought up during the investigation. Also keep in mind, Island passed a number of audits to include Chevron where no training short comings were noted. I can't readily find the document that discussed this March revision but it is out there.

[havick]

Originally Posted by ShyTorque

Only if the aircraft heading was the same as the heading bug. Otherwise the aircraft would enter a rate one turn onto the bug heading.

This exact reason is why I got funny looks when I flew jets after helicopters and the other pilot thought I was overly OCD centering the HDG bug.

[megan]

The only problem with VS in a descent (not qualified on 76 but other similar aircraft) is that without adequate monitoring of the collective and what power you have set, the AP can reduce speed sufficiently to put you into VRS. That is if you are in 3-axis mode.

Very true crab, hence why procedures have to be tailored to your operation. In 12,000 hours on the 76 never once used the GA function, we were a VMC operation (cough, cough), never once flew an IMC approach in anger.

[JimEli]

Originally Posted by wrench1

FYI: This issue was discussed during the preliminary investigation stages. Island outsourced their 135 training who provided the required 135 IIMC, etc training procedures and records. As I recall the main issue was that the procedures used had to be also listed in the Island training as well which they revised in March after it was brought up during the investigation. Also keep in mind, Island passed a number of audits to include Chevron where no training short comings were noted. I can't readily find the document that discussed this March revision but it is out there.

In the docket interview with the FAA POI, he characterized the contract training as not part of the operator’s approved training program, stating, “it was never something where, you know, I either approved, accepted, or required it, or, you know, anything to that effect.”
And I would suggest rereading the interview with the FAA POI. Especially when they get to the part about the missing procedures. You know, the point where his appointed representation cuts in to clarify things....

[wrench1]

Originally Posted by JimEli

In the docket interview with the FAA POI, he characterized the contract training as not part of the operator’s approved training program, stating, “it was never something where, you know, I either approved, accepted, or required it, or, you know, anything to that effect.”
And I would suggest rereading the interview with the FAA POI. Especially when they get to the part about the missing procedures. You know, the point where his appointed representation cuts in to clarify things....

And? Don’t quite follow where you’re going with this. Are you saying the FAA missed the inclusion of IIMC procedures in Islands Training manual over a 14 year period and as such Ara didn’t have the proper IIMC training which caused the accident?

Keep in mind, IIMC training wasn't required until a few years after the Island Training Manual was approved and they used a Part 142 provider for most of their required training in that same time frame. But as I mentioned earlier, this has been discussed by the investigators and when the IIMC procedure was found missing in the Island manual (not the Part 142 manual) Island revised their manual to correct the error.

[JimEli]

Originally Posted by wrench1

And? Don’t quite follow where you’re going with this. Are you saying the FAA missed the inclusion of IIMC procedures in Islands Training manual over a 14 year period and as such Ara didn’t have the proper IIMC training which caused the accident?

Keep in mind, IIMC training wasn't required until a few years after the Island Training Manual was approved and they used a Part 142 provider for most of their required training in that same time frame. But as I mentioned earlier, this has been discussed by the investigators and when the IIMC procedure was found missing in the Island manual (not the Part 142 manual) Island revised their manual to correct the error.

No. I'm saying the FAA POI was tasked w/i 60 days of 9/22/17, to "conduct a focused review of the helicopter training and qualification programs for their assigned certificate holders to identify whether the programs include the required training and testing on procedures for aircraft handling in flat-light, whiteout, and brownout conditions and training and checking on recovery from IIMC." It is doubtful this was accomplished, because we know they didn't discover the missing procedures until after the accident.

[wrench1]

Originally Posted by JimEli

No. I'm saying the FAA POI was tasked w/i 60 days of 9/22/17, to "conduct a focused review of the helicopter training and qualification programs for their assigned certificate holders to identify whether the programs include the required training and testing on procedures for aircraft handling in flat-light, whiteout, and brownout conditions and training and checking on recovery from IIMC." It is doubtful this was accomplished, because we know they didn't discover the missing procedures until after the accident.

So you are of the opinion that if the POI conducted that policy review on Euro Safety’s training program, whom Island contracted their training requirements to per 135.324, this would not meet the intent of the 60 day 2017 Policy memo?

[Gordy]

Originally Posted by JimEli

No. I'm saying the FAA POI was tasked w/i 60 days of 9/22/17, to "conduct a focused review of the helicopter training and qualification programs for their assigned certificate holders to identify whether the programs include the required training and testing on procedures for aircraft handling in flat-light, whiteout, and brownout conditions and training and checking on recovery from IIMC." It is doubtful this was accomplished, because we know they didn't discover the missing procedures until after the accident.

It was accomplished satisfactorily, otherwise it would have been noted as a deficiency.

Originally Posted by wrench1

So you are of the opinion that if the POI conducted that policy review on Euro Safety’s training program, whom Island contracted their training requirements to per 135.324, this would not meet the intent of the 60 day 2017 Policy memo?

Island did NOT contract their 135 training to Eurosafety. The Eurosafety training was in addition to the FAA required training as stated by the POI “it was never something where, you know, I either approved, accepted, or required it, or, you know, anything to that effect.”

[wrench1]

Originally Posted by Gordy

Island did NOT contract their 135 training to Eurosafety..”

I'll defer to your local knowledge, but there were several discussions/documents during the initial part of the investigation that did show a contractual agreement with Euro Safety for training. How those discussions turned out I do not know. If I find the documents I'll post them.

[airplanecrazy]

Originally Posted by wrench1

I'll defer to your local knowledge, but there were several discussions/documents during the initial part of the investigation that did show a contractual agreement with Euro Safety for training. How those discussions turned out I do not know. If I find the documents I'll post them.

Not to insert myself into your debate, but I recalled this section of the "OPERATIONAL FACTORS/HUMAN PERFORMANCE" report https://data.ntsb.gov/Docket/Documen...eport-Rel.pdf:

"2.5.4 Additional ground and flight training
According to the director of operations, Island Express contracted with EuroSafety International (EuroSafety) to provide ground and flight training along with flight examinations for the company pilots to prepare for annual FAA proficiency checks. This training was not a part of Island Express’s FAA-approved training program. EuroSafety used company helicopters for the flight training and examinations. According to the EuroSafety S-76 flight instructor, EuroSafety offered an S-76 refresher program that consisted of 2 to 3 days ground training and 2 to 3 flights, depending on the experience of the pilots. EuroSafety did not use an S-76 simulator for training or evaluations. The flight instructor stated that he provided ground training and flight training on inadvertent instrument meteorological conditions (IIMC) avoidance and recovery, to prepare the pilot for FAA check rides that may include those evaluations. A review of Island Express training records revealed the accident pilot’s last EuroSafety training and evaluation occurred on May 8, 2019."

[Gordy]

Originally Posted by airplanecrazy

Not to insert myself into your debate, but I recalled this section of the "OPERATIONAL FACTORS/HUMAN PERFORMANCE" report https://data.ntsb.gov/Docket/Documen...eport-Rel.pdf:

"2.5.4 Additional ground and flight training
According to the director of operations, Island Express contracted with EuroSafety International (EuroSafety) to provide ground and flight training along with flight examinations for the company pilots to prepare for annual FAA proficiency checks. This training was not a part of Island Express’s FAA-approved training program. EuroSafety used company helicopters for the flight training and examinations. According to the EuroSafety S-76 flight instructor, EuroSafety offered an S-76 refresher program that consisted of 2 to 3 days ground training and 2 to 3 flights, depending on the experience of the pilots. EuroSafety did not use an S-76 simulator for training or evaluations. The flight instructor stated that he provided ground training and flight training on inadvertent instrument meteorological conditions (IIMC) avoidance and recovery, to prepare the pilot for FAA check rides that may include those evaluations. A review of Island Express training records revealed the accident pilot’s last EuroSafety training and evaluation occurred on May 8, 2019."

Correct.....