AAIB Bulletin: Morecambe Bay
 

The AAIB has issued a preliminary report of the investigation into the cause of the SA-365N Dauphin 2 crash in Morecambe Bay on 27 December.


AAIB Bulletin S1/2007 Special



FL

Can I ask that amateur crash investigators don't start putting their theories onto this board. Let the AIB finish their deliberations so we get the true picture.

HF

A Dauphin Pilot

It makes for very scary reading!

Hummingfrog: I agreed with your comment, initially, then thought...hang on , if a discussion on this topic becomes "taboo", you might as well go and delete most of all the other threads on pprune. The flyBe GPWS incident is a good example. I've read enough on that thread to make me think twice on travelling with flyBe and am glad I did. I can make my own decision about the credibility of a post - a stupid theory based on little facts can be easily distinguised from an informed debate about an incident. Saying that, the media should not be given fuel to speculate - but they'll likely to find stuff out before anyone hits a key on PPRuNE anyway.

I can't help but be intrigued by this crash, and being a fixed wing pilot, I'm fustrated by lack of knowledge about rotary wing oil rig ops to even begin formulating a "best guess". I would be interested in hearing views on this one to be honest.

One of the reasons why some people here do not appreciate speculation is that a lot of the hypotheses could centre around pilot error.

If it is later found not to be pilot error though, the pilots could still be tarred with that as a reason for the accident. One only has to consider those poor bloody Chinook pilots and the effort that has gone into clearing their names.

That might be an extreme (and not entirely apposite) example but, as the rotary world is so small and many pilots on here know each other, it could be considered insensitive to discuss pilot error without having any hard evidence with which to back it up.

Secondly, when there are so many theories being bandied around, it is hard to distinguish fact from fiction.

I’m with Hummingfrog on this one. It is one matter to discuss something once the final report is out but another altogether when it's just a preliminary.

Cheers

Whirls

Fair shout.

Didn't realise the rotary world was so small to be honest.

It's small! If you read the original thread about the accident, you'll see how many of the guys here knew and respected the pilot.

Cheers

Whirls

Just like to add my wholehearted agreement with Hummingfrog. Conversation about an accident is one thing but as has already been mentioned speculation without all the facts is undisirable and can be upsetting to friends and family.
This from a previous accident where those speculating know not what occured.

I would also add that the Captain of the 365 was a very experienced and professional Guy and will be sorely missed by all who knew him.
And "that there but for the grace of God"

Non-rhetorical question: What is the point of releasing this preliminary report? It just seems to provide fuel for conjecture. Can anyone enlighten me, please? I'm a bit puzzled... :confused:

Why the bulletin?
 

Bulletins are routine now. They are preliminary factual reports. They contain facts as established from the FDR/CVR and leave it at that. Lots of "what happened", but no "why it happened", because the latter will not be established for some time yet.

Why post them? It's an insult to the aviation community's - and the public's - intelligence to withhold facts from them once the facts are established. It's the truth, even if it's not the whole truth. Truth, even part of it, tends to limit speculation; but nothing - even silence - will ever stop it.

I'm with StarbucksOne: "If a discussion on this topic becomes "taboo", you might as well go and delete most of all the other threads on pprune. The flyBe GPWS incident is a good example. I've read enough on that thread to make me think twice on travelling with flyBe and am glad I did. I can make my own decision about the credibility of a post."

Fair point. I'd not really thought of it like that.

"Facts" they may be but the context and derivation of those "Facts" is subject to debate. That is the crux of the problem in such debates as go on at places like pprune and pub bars in the wake of events such as this.

I would assume a Special Bulletin could/might contain more specific "facts" if something had been found to report and thus would provide better service to those who read the thing.

That was not the case here. The Bulletin merely set forth the status of the investigation to date thus providing an opportunity for conjecture about the cause. It would seem to me, mere conjecture serves no good at this point.

I understand the sensitivities. I knew one of them. But certain facts have been established by the AAIB. There is no evidence of mechanical failure. There maybe some additional contributing factors but The liklihood of finding that evidence is probably slim.

There isn't much more to speculate on is there? This accident has the hallmarks of other accidents or near acidents.

Those of us with thousands of hours of offshore flying, especially in the dark UK winter have all been in a similar situation, it just that we had a different outcome.

Sad business.

SASless,

Respectfully, I suggest you find a quiet moment to sit down and read the report again. What has been found has been reported, without making it gory.

I remember a time on Pprune when Pprune meant just that....
professional pilots rumour network.
The professionalism in us catered for the standard of the discussion and the moderators moved in when it got 'out of hand' (on those rare occasions).
It now seems (to me) that more and more (recent) members are fighting shy of discussing these rumours, or chewing over what has been / has not been disclosed.
It's as if the nanny state is pervading the very existence of free speech. I feel we are quietly sinking under a morass of political correctness; insidious malaise rather than refreshing discourse. Fear of "the fear of upsetting anything or anyone":mad:
Look back over similar instances like this thread, why don't you?
If you were at work or in the bar, you'd chat about this....why not here also - a dedicated vehicle for such issues.

Provided one delivers a constructive opinion devoid of libel or harrassment, what harm does it do?

Are we all going to end up checking our "six" all the time? This isn't Russia for goodness sake:E

It won't resolve the issue, it won't (if handled correctly) upset friends and relatives - if we debate it healthily, it will simply define us for what we are: inquisitive, curious creatures. Nothing more, nothing less.

A fair point well made TC, but the freedom to swing my arm ends where your nose begins!

We may have a right to discuss such matters but we also have a responsibility to have some regard to others.

In a court of law (don't shoot me FL!!) a similar debate could be held as sub judice, and for good reason. Some of the ramblings that I have previously read regarding accidents and incidents could be tantamount to tabloid speculation and, at worst, scaremongering.

Cheers

Whirls

I think I've been in aviation a lot longer than most of you - conjecture re accidents has been around for as long as accidents themselves. I concur with TC. The mouse button will allow you to avoid this thread Whirly but if you venture in your brain will allow you to discount what you don't agree with - threatening TC with violence is most un-PC!!
GAGS
E86

Whirls,
Whilst I take your point regarding sub judice I would say that the two cannot be compared.

In a court of law the guilt or innocence of the accused is being decided by 'twelve good men and true'. These are selected at random from the populous and therefore no expectation of expertise lies upon them.

The AAIB are experts and therefore, one would hope, not susceptible to influence from conjecture, speculation or hearsay from outside sources such as PPRUNE.

Having said all that I choose to withold any such opinion because I am no expert myself and would not wish to either show my ignorance or inadvertently cause alarm or distress to anyone by doing so.

My thoughts are still with the families of those who perished.

LM

I'll propose that as a community, we pilots take more comfort in "pilot action" errors. That includes the pilots not handling an otherwise controllable mechanical/electrical malfunction. To hope to find an accident is the result of factors beyond a pilot's control is just too pessimistic to contemplate. As long as we can hope for "pilot error" then there's a chance that in the same situation the next pilot could have done something better, and perhaps can prepare for it in the meantime. If the accident was due to something the pilot was not able to control, then all the training and experience in the world counts for naught, and we are all doomed to the shadow of an occupation that could snuf our lives arbitrarily and randomly.
From the preliminary report, we know the aircraft had some dramatic attitude excursions from the normal profile in the final few seconds. I doubt most pilots have ever seen anything like 38 degrees nose down, unless they flew Apaches or Lynx in a past life. It is a preliminay report, with more information to come, so we can be patient. For myself I'm going to give it a try in a simulator where I get a second chance. Staying with the facts, does anybody know what kind of autopilot/flight director system this aircraft had and what modes would likely have been engaged by CHC in their standard offshore procedures. Information for the sim experience only, no speculation on what the crew may have been doing, which no doubt will be in the AAIB final report.
malabo

malabo,
 

I am thinking the same. I was a broblem with Pitch-lanes from autopilot in a past. It is funny feeling for take-off or landing when pitch lanes drops off. Other thing is Trim feel. It is very easy to cut it off inadvertentally or maybe jump it over from checklist. This is not a speculation for this accident but it happens to me and our crews in VFR- inland ambulance flights. I can immagine how surprising it might be over the dark sea...

Hostile

I think the main purpose of publishing the preliminary report is to reduce speculation and rumourmongering by stating what happened and eliminating certain causes - the main one being major structural or component failure.
This is done partly to keep all the other 365 crews and pax happy that there is not a serious fault with the aircraft so that they can keep flying it without fear. If you were Eurocopter, you would want to show as quickly as possible that your aircraft is safe and I suspect that some pressure is applied from industry onto the CAA in these cases.
There are some other safety equipment issues that could have been included in the preliminary report but I will wait for the full report before discussing them.

:rolleyes: It's an expression luv! :rolleyes: The whole point of the expression is that it means I DON'T have the freedom if it means trampling over someone else's freedoms.

My concern, as I mentioned before, is that if there is any mud-slinging (as sometimes these things can degenerate), then mud sticks and I don't think it's unreasonable to wait for a final report to prevent such rumour-mongering. If a couple of people ask one to refrain from something, then I would respect their wishes. That's not necessarily being PC, it's being polite!

Cheers

Whirls (with an "S")

I'm with TC (an a few others whose names I've forgotten already) on this.

Let's be realistic. You will NOT stop people wondering what happened. And it's normal for them to share those speculations with fellow aviators. So they'll post them. Now, look back at other threads where this has happened. The original speculating would probably have been long forgotten. But what usually happens is that someone says the post shouldn't have been made, someone else argues for free speech, a third person wades in and demands that all speculation stop, the next one flames the previous poster for telling him what to do or not do, etc etc etc.

Suddenly one speculation becomes an all-out argument! And for what? Because the original post might be wrong? Because one person might have suggested a pilot made a mistake when he didn't?

We've had the pilot from a recent accident come on PPRuNe and explain what he thought happened. We've had relatives and friends come on and thank people for their condolences, and for caring enough to post at all. But as I recall, we haven't actually had anyone - except other PPRuNers - complain about people speculating in a perfectly human fashion as to what happened.

Live and let live might not be perfect, but it's better than any of the alternatives. :ok:

Cheers,

Whirly (with a "Y")

speculation
 

It's no doubt inevitable that some people will post speculatve theories, and some people will argue for the benifit of these posts. However, the AAIB report makes it clear that the initial report now published only shows the facts as they have been found so far. It makes clear that not only may these facts be corrected and altered before the final report comes out, it also states that no analysis has been done on the information found so far.
I think if the AAIB are waiting before they come to any conclusions, it may be worthwhile if we consider doing the same.

I am an Offshore Pilot currently flying heavy helicopters. The question whether a Pilot is respected or not by his peers has no bearing on my desire to understand what happended on this flight.

I do not like the thought that this accident could be attributable to pilot/crew error but if that is what the AAIB ultimatley determine then we accept it and try to learn from it. My responsibilities as a proffessional aviator to my crew and passengers requires me to keep an open mind and strip away the emotion from the incident.

It would help if we could read a thread without all the "Holier than thou sh*te" complicating the messages!

We have been here before with the Brent Spar accident!!

I think that is the key issue here. Speculation, provided a good degree of thought is applied before posting, should not be discouraged. Much can be learned by all from "healthy" discussions and debates on all manner of topics.
As has been pointed out on this thread, the helicopter world is a very small one and it is inevitable that crew involved in any accident will likely be well known to many of us on this forum. As long as we all remember that, particularly when responding to threads such as this one (although it has wandered way off the initial post), then others should not take offence. Surely, the real intent of this site, outside of the rumour mongering, is to improve our understanding of the profession or passtime that we are all engaged in and so help prevent further accidents.

I agree DOUBLE BOGEY. Keep to what we know, make our discussion beneficial to all, especially those of us who may find ourselves in very similar positions sometime. ie night, over ocean, etc etc.
To go out on a limb here, has anyone had very similar experience which could provide 'sensible' insight into this tragic accident. Maybe even to start a new thread with a title such as 'Things that could go wrong in certain ops'. It may help us inexperienced guys with a little knowledge from the old and wrinklies.:E
As posted previously, we hate to think our fellow aviatiors may have gotten things wrong but, if it's a case of pilot error or mechanical / instrument failure etc, then I know what I prefer the outcome to be, even if others disagree.

A question for offshore dauphin pilots,

1. How come the AAIB report makes no mention of AVAD calls on the CVR for 100 feet (pre-set) and 50 feet (the later being the standard for a rig landing).

Or is the AVAD suspended during rig approaches?

Hi Folks

Media making further assumptions, headlines reported as if definitive.
NW Evening Mail -
Mechanical failure ruled out in fatal chopper crash
Published on 30/01/2007
http://www.nwemail.co.uk/news/viewar...aspx?id=460867

HTH
ATB
Paul

I too am concerned that we seem to fear above all else the conclusion of Pilot Error. I believe that this is still the final conclusion in many aircraft accidents and incidents, and I assume that none of us can honestly claim to have never made a mistake, and I would consider that I personally have made and observed mistakes that have genuinely frightened me and could have had disasterous consequences. You learn from them, you discuss them openly, just to put that experience to someone else so that they may never get themselves into that situation, or may better get out of it.

I further agree with a point made by Malamo, that I almost hope for that conclusion - The thought that an aircraft suffered a terminal fault that was impossible to recover from, is something that keeps me awake at night !

Nobody is doubting the experience and professionalism of this crew and I've heard nothing but positive comments about both pilots. Whilst I didn't know them, its clear they were a good crew. I, like most of us, have no firm idea what caused this crash so I won't try to speculate, but if it ultimately turns out to be pilot error, few of us would be criticising the crew - I will maybe be able to read the report having learned something, but certainly I'll be thinking 'There but for the grace of God go I .....'

AVAD
 

DB: I wondered the same as you did. It would have been helpful to know from this bulletin whether the AVAD call occurred or not. I'm not a chopper pilot, but I thought the AVAD 100ft call was "hard wired" and not cancellable. Does anyone know if that rule is suspended on final approach and if so how?

DB, "50 ft for rig landings": whose SOP is that????

radalt
 

the 100 foot to go call cannot be cancelled.
Offshore sop bug setting is 200 foot set before landing for visual approaches.

AVAD
 

IIRC the AVAD "100 feet" warning does not operate if the ROD is over a certain figure - I think it might be 1500fpm. This is to avoid distracting the crew when crossing an elevated deck edge for instance. The last recorded ROD was 1400fpm.

Wiz

IIRC its supressed when rod (calculated by rate of change of radalt) is over 5000'/min. If it was 1500'/min it wouldn't be much use!

HC

I am wondering if it was not mechanical failure could it have been a gyro related issue, I should say now I have never flown the 365, but I have experienced and am familiar with gryo related problems in the SK, which can be quite insidious initially and then deteriorate quickly.

Such a problem can affect both the attitude information supplied to the crew and obviously the stabilisation system. A problem of that nature relatively close to the surface at night with poor to nil visual cues/horizon would be a nightmare to deal with.:(

I would suggest that following tragic accidents the time between the loss of a friend(s) and the report of the cause(s) being released is best used remembering the good times had with that person(s) no longer with us ......Speculation...rumours..guesses or whatever you want to call them serve no purpose in written form other than to revive moments of sadness for those that knew them...

Yes Prune is a rumour network...rumour about things that dont affect others emotionally..

I may be wrong but just my view on dignity and human respect for others:ok:

Bug setting for night is 300', 200' for day and on short finals the AVAD can be cancelled but not the light. For us at least!

I once flew for an operator whose AVAD could not be cancelled, after carrying out 30+ landings during the day you start to filter out the call so it becomes no longer an alert but just another annoying noise.

When you can cancel it it is so unusual to hear it, that on activation you react immediately. However if it is cancelled on finals and a go around is made the gear is not retracted or a landing is made (activation of the weight on wheels switch) I don't think the AVAD will activate and give an alert if you go below the bug set height. This might account for the absence of comment in the report.

Perhaps the more technical minded will confirm this or put me right.

I was quite upset after reading the report. Could it possibly be that depite all the training and the many years practice the gremlins that haunt those dark nights can conspire to snatch your life away as punishment for just a moment's lack of concentration. I know that once or twice they have scared the **** out of me and I know that others have had their own scary moments where disorientation or loss of concentration have resulted in a 'near-miss' or, in one case, a nasty, pointless CFIT.


Unlike Melabo I do hope that there was a mechanical failure of some kind for
otherwise it means that I have to be sure to be 110% on top of the entire flight even if that last shuttle comes at the end of a maxed-out Duty Period when I'm feeling like ****e. I knew I worked in an unforgiving world but having to perform to the highest levels without respite is something I wish I could do but I know that I can't.


I still hope that the 10% of the aircraft yet unrecovered may yield important data. If not then I have to come to terms with what may be unrealistic expectations of our ability to perform at the required levels without ever making any mistakes. Maybe routine night flying needs to be reviewed and maybe technologies such as NVGs need to be revisited for use in cruise flight.

G

:( :confused: :\

I generally refrain from posting my opinion or theories in matters like these. However, in view of the press's reaction to the initial report I would like members of the discussion panel to reflect on two fairly recent previous accidents.

Firstly, the S-76 lost in unusual circumstances where it spiralled out of control into the Bering sea, causing a loss of 14 lives. That could have easily been seen as pilot error and the argument still goes on.

Secondly, the original UK A109 crash landing that was put down to pilot error until a second one went down some time afterwards in almost identical circumstances and was found to be caused by an incorrectly fitted control item, a non rotating star scissor link. The first accident evidence (wreckage) was re-examined and the same evidence was there. Verdict changed.