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-   -   AAIB Report A109E accident at Vauxhall, and Inquest Verdict (https://www.pprune.org/rotorheads/547226-aaib-report-a109e-accident-vauxhall-inquest-verdict.html)

chopjock 11th Sep 2014 09:20

t mos

Texting while driving is illegal, has been proven to cause distraction and accidents and is a stupid thing to do
Why do you think that is? Obstacles on the surface perhaps?
Texting in the air during light work load on top with nothing to hit is hardly crazy now is it?

terminus mos 11th Sep 2014 09:24


He wasn't in marginal weather when he sent/read texts.
He was above it in clear blue skies.
I am not getting into a pissing contest with you, texting while flying in command of a single pilot aircraft at any time or in any weather is worthy of a Darwin award.


Instead of just dismissing it as yet another 'one off' we need to look more deeply into the pressures that cause this sort of thing to happen time and time again in the corporate world and try to do change the culture that leads to it.
The culture sure ain't gonna change on its own.
Easily identifiable cultural problem, its called a day rate

Chopjock


Texting in the air during light work load on top with nothing to hit is hardly crazy now is it?
Yes, I think it is absolutely crazy. He was in command of an aircraft, not the marketing department. Texting in this case simply applied more pressure which built to the point of making a fatal error.

Pittsextra 11th Sep 2014 09:50


Easily identifiable cultural problem, its called a day rate
Absolutely, and not hard to work out the pressure given:-

Flying experience*: Total all types: 10,234 hours
Total on type: Not known
Last 90 days: 30 hours
Last 28 days: 9 hours

Last 24 hours: 0 hours

rotorspeed 11th Sep 2014 09:57

terminus nos

Your assertion that texting when single pilot in any aircraft at any time is worthy of a Darwin award is utterly ridiculous - and unfairly damning of Pete Barnes. Pete may have made fatal mistakes here, but texting was not one.

His texts were made when he was VMC on top, no doubt A/P coupled. They were brief and pertinent too - this wasn't just idle banter. The ability to text can actuually be a safety aid - sometimes by informing people on the ground of certain things stress can be reduced and flights made more efficient.

Please explain why sending a brief text is any more distracting than, for example, re-programming a route in the GPS, looking at a chart or approach plate and setting up an ILS with frequency selection with navaid identification etc. All quite accepted distractions from simply looking out of the screen or at the panel monitoring instruments and any warnings - the serious of which tend to be audio anyway in the A109.

terminus mos 11th Sep 2014 10:31


Please explain why sending a brief text is any more distracting than, for example, re-programming a route in the GPS, looking at a chart or approach plate and setting up an ILS with frequency selection with navaid identification etc. All quite accepted distractions from simply looking out of the screen or at the panel monitoring instruments and any warnings - the serious of which tend to be audio anyway in the A109.
Because all of the things that you mention are directly connected with the conduct of the flight, physically and mentally. In this case, the Commander of the aircraft's mind was on how to deal with his customer when it should have been on selecting Redhill in the GPS, climbing to 2400" and heading about 210 degrees.

rotorspeed 11th Sep 2014 10:50

tn

Do you ever use a phone when driving - hands free of course?

satsuma 11th Sep 2014 10:52

EASA put it so much better than the rest of us. For commercial air transport at least (and you'd think the guidance would be sensible across all forms of flying): https://www.caa.co.uk/docs/33/Inform...ice2014022.pdf

The operator shall not permit any person to use a portable electronic device (PED) on board an aircraft that could adversely affect the performance of the aircraft’s systems and equipment, and shall take all reasonable measures to prevent such use.
This means that there is per se no ban on the use of PEDs. However, the operator is required to demonstrate that radio frequency emissions from PEDs do not pose a risk to aircraft systems and equipment and that all hazards are mitigated before allowing the use of PEDs on board.


They are, I should point out, specifically talking about non-transmitting PEDs, where less stringent rules apply. If the operator had carried out a demonstration similar to that highlighted in bold and proven that texts could not have an adverse effect on aircraft systems, at least the only question that remains is the issue of distraction from the primary flying task.

Thomas coupling 11th Sep 2014 11:12

This is an opportunity to call a spade a spade.
The pilot [RiP] was over confident with his skill set that day. No-ONE else should or could be blamed in any shape way or form.

This pilot thought he was above the laws of nature and the industry when he had decided (in himself) that he was going to press on. This wasn't a "press on itis" it was a cold calculated ecsiion to take on the elements to achieve his target.

As 'nice' as he was, as charismatic as he was - he genuinely felt that he was capable of making the venue - against all odds and advice offered to him.

A MASSIVE breakdown in CRM and a very very bad advert to all other wannabee pilots out there that the highest echelons of the professional commercial world - is flawed.

Learn from this - all you who replace his ilk and never ever think or believe you are above it all.
A sad day for our profession. One that we should be ashamed of. :=

Piltdown Man 11th Sep 2014 11:14

Judgmental opinions arising from 20-20 hindsight are worthless. We need to know why, not just what. And while we are at it, we should also ditch the focus on the texting stuff and instead bundle it with operating electronic devices. There are more distracting FMS and RNAV systems than mobile phones, yet they appear to be acceptable to use. Also, we must accept that legislation, more stringent SOP's, additional regulations will not necessarily improve safety.

Bronx's last post may lead us in the right direction. For example, I hadn't realised that 10,000 hour pilots in charge of highly sophisticated and very expensive helicopters weren't always paid a salary. I'm also no wiser in understanding how charter contracts work when a job can not be executed, either because of poor weather or technical malfunctions. Who gets paid what etc.

Only if we can see things through Peter Barnes' eyes as he saw them will we be able to prevent the next person from seeing what he did, resulting in a similar outcome.

PM

Thomas coupling 11th Sep 2014 11:21

PM: You are not listening are you. Try not to look for something that is not there. I'm sure like me, you have been in those circumstances where you are 'up against' it (weather in this case) and have done it time and time again and believe it'll work out OK again....It didn't: Quell Surprise. Live with it......he didn't.

satsuma 11th Sep 2014 11:23


we should also ditch the focus on the texting stuff
Does it not reveal though a mindset that only some of the rules apply? Like VFR weather limits for example. :hmm: Throw in a bucketload of commercial pressure and what have you got? Something to do with holes in cheese.

rotorspeed 11th Sep 2014 12:09

Texting, briefly, in the quiet cruise is just not a distraction risk and focus on it should indeed be ditched. The reality is commercial pressure exists in every part of aviation apart from pleasure flying, but of course we just deal with it. For those that don't do corporate flying just consider how useful it is for those that do to be able to - occasionally - communicate with pax, ground ops, wife etc with a message when plans change. So you've set off for a pick up 150nm away and pax cancels - what do you do? Carry on and only find out when you arrive? Ask ATC etc to relay a message? Or receive a quick text saying job cancelled? Sensibly I'm sure, the latter happens much of the time. Saving a load of money on a wasted flying that no-one wants to pay for in the process. How should pilots communicate when plans change?

alouette3 11th Sep 2014 12:17

I am amazed at the tiptoeing going on around here.With the exception of TC,everybody here seems to want to give the pilot a get -out- of -jail -free card.
Fact of the matter is that Peter Barnes might have been God's gift to aviation but,at the end, he was human just like the rest of us.He was afflicted with the very human pressure of making a buck ---or not. He displayed all the Hazardous Attitudes,in spades, and, at the end of a very illustrious career, made a cold calculated decision which cost him his life.There is no getting around all these facts and we will be better served as an industry if we don't.The time for mourning and paying respects is over.The time to learn lessons is here and if we keep trying to blame ATC,Cranes,Culture and what have you,we will have another one of these in short order.
By the way, it is never okay to text or pull out a laptop to check scheduling when you are entrusted with a multi- million dollar asset.I seem to recall a fellow EMS pilot texting and running out of fuel and the group here was quick to condemn. I also recall an airliner that overshot Minneapolis because the pilots were busy with a laptop going over schedules.The former is dead and the latter are without a job.So ,if you call yourself a professional, do not even debate the VFR okay to text/IFR not okay to text issue.It is unbecoming.Ask yourself, where do we draw the line? If it is VFR On Top and I am on autopilot, is it okay to pull out my smart phone and catch up on the latest episode of House Of Cards?
Alt 3.

SilsoeSid 11th Sep 2014 12:49


The reality is commercial pressure exists in every part of aviation apart from pleasure flying...
Simply not true!

cockney steve 11th Sep 2014 13:10

Firstly, I'm not a pilot....but before you reject my post :ooh:

AIUI, the route was "follow the river" had ther been water visible on both sides of the Aircraft, it would not have encountered land-based objects.
Please tell me why i'm wrong.
EDIT.- I accept there are bridges crossing, but clearance should be adequate for any legally-conducted transit.

Boudreaux Bob 11th Sep 2014 13:17

The discussion can drift around to all sorts of esoteric issues it wants.

But the simple truth is this was a CFIT event.

It occurred in Daylight over a very large Metropolitan area on a route well known by the Pilot.

The Pilot had elected to divert from his planned route and proceed to a landing site for which he did not have the Reported Weather.

The aircraft was being operated under either VFR or SVFR Rules which require adherence to a certain Minimum Visibility.

The Aircraft was observed to be "in Cloud" at the time of the collision with the Crane.

Even when asked by ATC....the Pilot had reported having "Good" Weather (meaning within VFR/SVFR limits).

The Aircraft was at or below the Minimum Altitude/Height Above Ground permissible by Rule.

At no point had the Pilot reported being IMC, requested an IFR Clearance, or was able to conduct an IFR Approach Procedure for his intended landing site.

I don't care if he was texting on two phones....and doing an Irish Jig while listening to BBC. He plainly was not flying the aircraft in any acceptable manner for the conditions extant.

He was required by his VFR and/or SVFR Clearance to maintain forward visibility and height above ground to facilitate avoiding any obstructions on his Flight Path.

As he was in Cloud he failed to do right.

Blame the Crane, ATC, NATS, God, the Devil, Fate, Luck or whatever.....the PILOT was at the Controls and making the Decisions.

He Failed in several ways.

Sadly, he died and destroyed a perfectly good Helicopter and Crane along with some Vehicles on the Ground.

What is unforgivable, is he killed an innocent person on the ground as well as injuring several others.

He was not a "great" pilot......not by a long shot.

He may have been your Friend but if you are honest with yourself, you will accept even Friends can do harm to others.

rotorspeed 11th Sep 2014 13:29

Silsoe - commercial pressure does exist everywhere, though not where you're perhaps thinking of - with pilots during a job. Pilot salaries, conditions, training, aircraft, equipment etc will all be moaned about by pilots at some point, and are examples of the reality of the constraints of commercial pressure in aviation.

Fair post, BB.

ShyTorque 11th Sep 2014 13:36


At no point had the Pilot reported being IMC, requested an IFR Clearance, or was able to conduct an IFR Approach Procedure for his intended landing site.
Just to clarify that point. There is no IFR approach at London Heliport. It appears that there was no need for him to have asked for an IFR clearance in transit because the conditions did not require one, bearing in mind that the previous plan was to return to Redhill. The fatal mistake was to descend into fog lifting into low cloud. It may have been that the pilot misidentified another bridge along the Thames for Vauxhall bridge, easily done in marginal visibility.

For an experienced helicopter pilot, VFR is easy. IFR is also relatively easy. It's the bit in between that catches people out, as appears to have been the case here.

Boudreaux Bob 11th Sep 2014 13:44

Clarify as you wish.

He was in Cloud.

It was Controlled Airspace was it not?

You are exactly correct there was no Instrument Approach.

He was no longer VMC, VFR, or SVFR.

He had obtained a VFR/SVFR Clearance.

He was not complying with the Requirements of either of those Clearances.

In the UK, can you fly IMC in Controlled Airspace without a IFR Clearance?

ELondonPax 11th Sep 2014 13:46

I am not a pilot, but an interested observer. To those so keen to defend the use of a mobile phone whilst flying, consider this.
In the UK. A car/lorry driver using equipment that isn’t hands free is subject to prosecution. A commercial bus or train driver who did this on duty would be subject to instant dismissal, as well as prosecution, even if the event happened on a totally deserted road/track at 0600 on a clear summer Sunday morning. Could you explain why such rules about mobiles exist in other safety critical transport modes but should not apply to helicopter pilots?

As for “Texting in the air during light work load” Flying over one of the most densely populated areas of Europe, with complex air traffic restrictions. That’s a “light workload” situation?

SilsoeSid 11th Sep 2014 13:52

rotorspeed;

Silsoe - commercial pressure does exist everywhere, though not where you're perhaps thinking of - with pilots during a job. Pilot salaries, conditions, training, aircraft, equipment etc will all be moaned about by pilots at some point, and are examples of the reality of the constraints of commercial pressure in aviation.
:confused: It was you that said "The reality is commercial pressure exists in every part of aviation apart from pleasure flying,"

I am saying that it exists in every part of aviation, including pleasure/private flying.

airpolice 11th Sep 2014 14:04

Steve, you should read the report. It will greatly assist your participation in this debate.

The route, going West, is follow the North bank, not the river.

Eastbound is follow the South bank.

That's to limit the opportunity for a head on.



2.5.2 Flights on the helicopter routes
Reciprocal traffic on the helicopter routes is deemed separated when westbound traffic routes along the north bank of the River Thames and eastbound traffic routes along the south bank. Rule 5 applies, so any pilot routing along the south bank of the river and passing within 500 ft vertically of the top of the crane (whose elevation the associated NOTAM stated was 770 ft amsl), or the building (elevation 607 ft amsl) once the crane is removed, would be in breach of the ANO.

The building at St George Wharf has therefore increased the local minimum allowable altitude along the south bank to 1,100 ft (based on the building). It has consequently had the effect of preventing two-way traffic on H4 when London City Airport is using Runway 09 (when traffic on H4 is limited to 1,000 ft amsl) or when the cloud base is below 1,200 ft.

airpolice 11th Sep 2014 14:15

Rotrospeed wrote :


Texting, briefly, in the quiet cruise is just not a distraction risk and focus on it should indeed be ditched.
I think we need to accept the huge difference between using a panel mounted device like a Garmin GPS/Radio, and holding an iPhone in your hand.

You are not going to drop the Garmin.


As for commercial pressure in all aviation, that's true. Even weekend warriors are not immune to the cost of going around and spending another chunk of money so they are faced with a desire/hint/suggestion that pressing on is much cheaper/better.

As always, its about making the right decisions, in time.

We all know the right thing to do, it's actually doing it that sets some people apart.

When you start getting multiple points wrong, that's when it becomes hairy.

ShyTorque 11th Sep 2014 14:29


Clarify as you wish.

He was in Cloud.
It was Controlled Airspace was it not?
You are exactly correct there was no Instrument Approach.
He was no longer VMC, VFR, or SVFR.
He had obtained a VFR/SVFR Clearance.
He was not complying with the Requirements of either of those Clearances.

In the UK, can you fly IMC in Controlled Airspace without a IFR Clearance?
BB, I was attempting to clarify your point about the pilot not requesting an IFR clearance and / or an IFR approach. I wasn't disagreeing with your post in its entirety.

The answer to your question is obviously a resounding NO, nor was I attempting to intimate otherwise.

rotorspeed 11th Sep 2014 14:50

Silsoe - ok, and agree actually! Sorry to misinterpret but your post wasn't clear!

Bronx 11th Sep 2014 17:19

terminus mos


I am not getting into a pissing contest with you,
What a curious response. :confused:


texting while flying in command of a single pilot aircraft at any time or in any weather is worthy of a Darwin award.
Fine. That's your opinion, but it's not what you said.



When the texts were first mentioned in the original thread a lot of people assumed the pilot was texting while he was scud-running and some people even assumed he was texting when he hit the crane. It's clear from the report that he wasn't.

He shouldn't have been scud-running at all but if the guy is gonna be criticized then let him be criticized for what he did not what he didn't.

alouette3 11th Sep 2014 17:54

Bronx,

He shouldn't have been scud-running at all but if the guy is gonna be criticized then let him be criticized for what he did not what he didn't.

He is being criticized for texting.Period.It was obviously a high workload situation and he shouldn't have been doing that.Before or after or during scud running.

I suppose you belong to the texting,PS/X Box generation that doesn't seem to understand the risks and who believes in the myth of multitasking.
Alt3.

RVDT 11th Sep 2014 18:16

Hmmmm.................


ShyTorque 11th Sep 2014 18:29

The answer only 15? I counted many more.There were only two figures not wearing white. One of the people passing the basketballs and the gorilla.

Or are we only supposed to count those wearing white shirts?

Boudreaux Bob 11th Sep 2014 19:11

A3....one should not "assume". You know what happens when one does that without substantial basis or logic on one's side.:=

Bronx 11th Sep 2014 19:18

Alt3

I don't call VMC on top a high workload situation.
He had been given clearance back to base and was on his way there until he got the Battersea is open message.


I suppose you belong to the texting,PS/X Box generation that doesn't seem to understand the risks and who believes in the myth of multitasking.
You suppose far too much.
BTW, I don't but it gave my grandkids a good laugh.

The myth of multitasking? :confused:
Helicopter pilots have been multitasking since before they invented the word.
Fly yes, operate no.


Piltdown Man

I'm also no wiser in understanding how charter contracts work when a job can not be executed, either because of poor weather or technical malfunctions. Who gets paid what etc.
Nobody.
No fly = no pay.

rantanplane 11th Sep 2014 19:36

The place I learned flying its spelt "arse+you+me"

Boudreaux Bob 11th Sep 2014 20:38


0755 Client to Pilot: Battersea is open
0755 Pilot to Operator: Can’t get in Elstree hdg back assume clear still
0755 Operator to Pilot: Yes it’s fine still here. (This text was not read.)

The last read and sent text messages were approximately four minutes before the collision with the crane:

At 0756, following the message from the client telling him Battersea was open, the pilot asked ATC to confirm.
It was only after ATC confirmed that it was, that he subsequently descended - while waiting to be cleared to Battersea.
Can we fairly state that had the Pilot not been texting, he would not have been told about Battersea and would not have asked ATC about Battersea, as he clearly indicated he had over flown Elstree and could not find a way down and was returning to Redhill?

If we can, then I would suggest that in that case, Texting caused him to divert from his best decision of all that Day, and thus Texting would have been the Trigger that got pulled on the Gun.

Heliport 11th Sep 2014 21:04

alouette3

I am amazed at the tiptoeing going on around here.With the exception of TC,everybody here seems to want to give the pilot a get -out- of -jail -free card.
Who? :confused:
People have expressed different opinions about texting but no-one has tried to defend what the pilot did.

if we keep trying to blame ATC,Cranes,Culture and what have you,we will have another one of these in short order.
If we keep focusing only upon what the pilot did and don't bother to explore the factors that led, or might have led, him to do it we will have another one of these in short order.
Who's blaming ATC?
The AAIB are concerned about the proliferation of very tall cranes along the river. Are they wrong?
If you think there's no culture problem you are either very much mistaken or it's very different in your part of the world.

We all know what the pilot did, he pushed his luck/tempted fate in poor visibility, but as Piltdown Man and others have said in different ways 'We need to know why, not just what.'

TC

PM: You are not listening are you. Try not to look for something that is not there.
He is listening. He just doesn't agree with you.

With genuine respect for your very long experience as both a Navy and ASU pilot, saying 'Don't be over confident', 'Learn from this' etc, whilst obviously sound advice, is too simplistic. People have been saying 'Learn from this' for years and yet these accidents still happen.
Is it not even worth considering whether there are other factors (in addition to over confidence/a belief that it won't happen to them) that lead pilots to do it?
And, if there are, trying to remove or reduce the effect of those factors?


H.

Thomas coupling 11th Sep 2014 21:26

Heliport: Sometimes one can genuinely not see the wood etc.................
Perhaps you haven't been in situations like this often enough to realise nearly ALL commercial pilots push the limits for absolutely no reason at all other than they have seen it, done it, been there so many times, so one more 'time' shouldn't make a difference. He was not (repeat) under any time, financial pressure to get to his destination. He had been told by the customer to forget it. He wasn't lost, in fact he was fiddling with his damn phone minutes before so he was obviously "comfortable" with his SA.
And that was the problem...he was: COMPLACENT.
Intermittent VMC, cloud hpping/dodging ....call it what you like.
He carried on as if it was a minor blip on his radar.
Sometimes HELIPORT you have to debrief your fellow pilots and tell it as it is.
This is as straight forward a case of unprofessional flying as one could get. Don't look for anything else here, other than CRM....because it was sorely missing.
Please don't wrap this in various layers of aviation gobbledy gook to get others to think "society is to blame". They aren't, the environment wasn't, ATC weren't. HE WAS. K.I.S.S.:*

alouette3 11th Sep 2014 22:06

Bronx,

I don't call VMC on top a high workload situation.
Single pilot, trying to make it to a heliport,possibly in and out of clouds ,over a large metropolitan city riddled with cranes,changing decisions based on client input,talking to ATC.If that is not a high workload situation I don't know what is.
The myth of multitasking? :confused:
Helicopter pilots have been multitasking since before they invented the word.

Okay so I got your age wrong.However, you do need to read a few more books on human factors and the like before you come out here and make a statement like that. Maybe then you can explain better to your grand kids why it is not safe to text and drive or even talk on the cell phone while doing so.
I know why he did the things he did.But, you go ahead and try and find someone else to blame.
Alt3.

alouette3 11th Sep 2014 22:13

Heliport,
Who? :confused:
People have expressed different opinions about texting but no-one has tried to defend what the pilot did.

If you haven't figured that out,you need to go back and read this thread from the beginning.

If you think there's no culture problem you are either very much mistaken or it's very different in your part of the world.
Things are no different in my part of the world.Heaven knows we have our own unique set of cultural issues to deal with.But,when we as a a group try to blame culture for a purely poor CRM and Hazardous Attitudes related accident,just because the pilot was well liked , had 10K hours and was British, we are equally to blame. An experienced pilot commits a rookie mistake and so it is culture.Is that what you want the next generation of pilots to get from this?
I certainly hope not.
Alt3.

SilsoeSid 11th Sep 2014 22:38

This multi tasking malarky that is being thrown around is nothing but a myth. We can do many things at the same time, but we simply cannot multitask to the extent that we believe the term 'multitasking' means, simple.

If we look at this incident in simple chunks, cheese slices if you will, it becomes clearer bit by bit. For starters, as Bob says, it's pretty clear that if the mobile phone texting wasn't going on, Pete would have continued back to Redhill.

Future CRM courses will be pulling this to bits and picking every single one of the multiple times where this incident could have been prevented. Just to make it clear, not everyone of them directly involves Pete.

Yes we can learn from this and learn a lot, however not until people pull their heads out of the sand and realise that CRM involves single piloted aircraft as much as multi piloted aircraft, will we fully appreciate the lessons we are presented with and can learn from. Until then, these mistakes will be repeated.

The days of the term 'Single Pilot CRM' being greeted with contempt, must be relegated to the dim and distant past.

Doesn't this all sound oh so familiar?

http://www.pprune.org/rotorheads/458...ml#post7196857

http://www.pprune.org/rotorheads/446...ml#post6318274

http://www.pprune.org/rotorheads/416...ml#post5721442

Piltdown Man 11th Sep 2014 22:58

So if I understand TC correctly, Peter Barnes was the proverbial "rotten apple". He broke the rules and was complacent and as a result, crashed and died. Obviously he'll never make that mistake again and aviation will be safer without him. Or will it?

The answer is it won't be, because nothing will have been done to prevent others from doing the same. Will more rules and greater punishments change anything? I doubt it. The AAIB described what happened where and it appeared Peter decided to aviate, navigate and communicate all at the same time - but we still don't know why. How many times since this incident have helicopters flown along H4 in marginal conditions? I don't have any numbers, but I'll wager it was more than one. How about using pilots with more experience? So that will be pilots with more than 10,000 hrs. Or will another gadget in the aircraft help? Aren't there enough already? Or is it the environment or system in which they operate at fault?

I'll tell you for free, beating people with a safety stick does little to change the future. Or do we print a notice on the windshield stating "WARNING - Do not be complacent"?

The solution I'm suggesting is that we start by understand the reasons why because it is clear that the rule makers have failed us. You don't think so? Well when you next get in your car, see how many illegal acts are committed around you. You can even include yourself if you like. There'll be speeders, under-takers. mobile phone users, non-seatbelt users, in-insured drivers etc. And each and every one of these acts is illegal, yet the drivers still offend.

So yes TC, Heliport is right, I do listen but don't agree with you. The only way we can lift our game is to work with people and not punish them. Creating and enforcing rules, regulations and by-laws gave improvements in the past, but we have moved on. Let's keep progressing and try not to revert back to our savage past

PM

alouette3 12th Sep 2014 00:53

PM,

The solution I'm suggesting is that we start by understand the reasons why because it is clear that the rule makers have failed us.

What is there to understand? The rules exist and were broken.Plain and simple. No amount of rule making will take away client pressure, economic pressure or self induced pressure.This is especially true in a world of single pilots where there is no one looking over your shoulder and the only one making the decisions is the one least qualified to assess his or her own ability--- the pilot.
No one has failed us. We are our own worst enemy and the only solution is to understand that a 10K pilot was suckered into a situation that killed him. Until we have gadgets that can record a man's final thoughts, we will never know what Peter or any other pilot was thinking in the final moments.We can only surmise ,given the evidence so far, that what he might have been thinking is "I can do this", "It only happens to others" "Done this before can do it again" "Must get the job done" or thoughts along those lines.
Alt3.


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