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AAIB report - comments included in the newsletter of a London firm of lawyers. They concentrate on the recommendations of AAIB.
new email1 I find the recommendations to the DOT most interesting: * Implement a mechanism, compliant with Regulation (EU) 73/2010 and UK law, for the formal reporting and management of obstacle data, including a reporting requirement for newly permitted developments; * Implement measures that enable the CAA to assess, before planning permission is granted, the potential implications of new obstacles for airspace arrangements and procedures; and, * Remind the relevant authorities to notify the CAA: (i) where planning permission for developments which include obstacles is granted; (ii) about obstacles not previously notified; and, (iii) about obstacles previously notified that no longer exist. * (A similar recommendation applies to the Scottish Government reminding the relevant Scottish planning bodies) The second of these addresses something that I did find rather odd - current law requires CAA to consider only the approach / departure LHR and LCY when considering planning applications for tall buildings in that area, not the Battersea Heliport or H4. |
Alouette 3: Beautifully said. Absolutely spot on.
Piltdown man: You aren't listening. I did NOT say he was a rotten apple, or a bad pilot. He was in fact an unassuming, considerate, very professional guy. BUT - on that day and at that time, he dropped his guard. Please try to understand this. Using your comparisons: driving: Formula 1 drivers are the best of the bunch - you don't get better, yet they make mistakes and they are catastrophic. It has nothing to do with subliminal psychoanalytical, interdevelopmental breakdown or any other human factor gobbledy gook. The bloke messed up for 0.025 of a second and it cost him his life. Sh*t happens - we are not automatons. Get used to it and move onto something useful elsewhere in the industry where you can improve on. RiP and all that.................:zzz:. |
John R81
The Aviation Accident Investigation Branch (AAIB) released a report on Tuesday, following a fatal helicopter incident near Vauxhall Bridge, London, in January of last year. I've not bothered reading beyond that point. |
As usual, there have been a lot of generalisations made about the flight and pilot, most of which do not actually help identify exactly why Pete Barnes hit the crane. And as with all accidents, the exact, ultimate cause is important and often not focussed on enough, I feel.
Ironically I think he hit the crane because (at this point) he was trying to comply with the rules - or at least to the greatest extent he could. The pilot had made a fairly tight right hand turn over Chelsea Bridge, hand flown, at a fairly steady altitude, so was almost certainly visual here. He then descended quickly to 570ft as he was proceeding east, again almost certainly to maintain VMC with a lowering cloud base as he went east. At this point, given clearance to turn west for Battersea Heliport, I'd guess that he knew turning right over the river at 500ft, whilst perfectly safe, would put him blatantly and obviously in breach of Rule 5, so he chose to climb as high as he could whilst being able to see the ground, which he surely could, given the images showing the silhouette of the aircraft from the base of the tower. Tragically in so doing the very reduced forward visibility meant he did not see the crane boom - which frankly was hard to see against the background in good visibility. So I suspect that (ultimately) pressure to comply with the rules contributed to this accident. Though admittedly he would probably not have been in that situation if he'd fully complied with the rules from the outset. |
Rotorspeed - haven't you been listening?
Look - 'most' pilots scud run especially if they operate within the confines of flying lanes as Peter did and especially if they know that the weather limits are borderline. Most clouds you penetrate during scud running are full of air! One or two are NOT. Guess what - There was NO pressure to comply with the rules, he had already decided to press on AFTER his principal had told him not to bother. He continued because he was complacent with his performance. Please try to understand this. He was pushing his luck cloud hopping and ran out of it. |
To be fair, if he hadn't been IMC while under SVFR/ VFR, he probably would have seen the crane and hopefully avoided it.
He sounds like a nice guy from what I've read but he broke rules and it killed him. The rules exist as a result of many accidents over the years. They get refined when things happen. For me, there are no extra take aways from someone breaking the rules which were put in place to help him. He broke them, he died. Sad yes but true. Marking cranes would not have helped this crash as he was supposed to be VFR anyway (key point being 'visual'). What can the CAA realistically do, approve cranes during housing development? Lets be clear here, over London, people should expect cranes, tall buildings and other aircraft, this isn't remote northern Scotland, it's the capital. |
TC - actually I have been listening and I agree with much of what you say. However you please listen and understand why I am saying - and that's that people, as you are here - tend to generalise and not look at the exact cause of an accident. I stand by my comments. Why do you think he hit that crane? Do you agree with my analysis? If not, where is it flawed? Or do you really think he was just randomly in and out of cloud and could have hit various buildings at odd times?
Don't think that I am trying to say Pete wasn't to blame. He was. But looking at detail is interesting. If he had not hit that crane he would have almost certainly landed at Battersea with no problem and the flight would have attracted no attention. |
"Why do you think he hit that crane?"
Because the crane, like him, was in cloud and he didn't see it. The crane was entitled to be there in the cloud - he wasn't. |
Or do you really think he was just randomly in and out of cloud and could have hit various buildings at odd times? |
If he had not hit that crane he would have almost certainly landed at Battersea with no problem and the flight would have attracted no attention. Are you suggesting that except for Fate sticking a Thumb in his Eye it would have been acceptable for him to have done as he did? TC, I have a very huge problem with your comment: "Look - 'most' pilots scud run especially if they operate within the confines of flying lanes as Peter did and especially if they know that the weather limits are borderline. Most clouds you penetrate during scud running are full of air! One or two are NOT. Guess what - " As a very experienced Rudscunner.....One NEVER punches into Cloud....NEVER! The beauty of the helicopter is that it can fly very slowly....and is very agile especially at slow speeds. One maintains visual contact with the Ground at all times and One maintains forward Visibility and flies at a Speed that allows you to avoid obstacles and terrain AT ALL TIMES. One varies Speed based upon the distance and clarity of Visibility you have. Otherwise, you are going to spear that Mountain Goat with your Pitot Tube one day. One does not EVER Scud Run at Night....if one wishes to live long enough to make other mistakes in life. All you Youngsters out there reading this. You can "Scud Run" but you have to do it in a "Safe" manner. Finding a way to do it both "Safe" and "Legal" is the hard part. Which should tell you that "Scud Running" is not an approved practice. Not being "Approved" connotes it should not be done to begin with. |
If he had not hit that crane he would have almost certainly landed at Battersea with no problem and the flight would have attracted no attention. 1.17.7 The Operator’s Operations Manual Part A of the Operator’s Operations Manual detailed the responsibilities and duties of the Chief Pilot (who was also the Flight Safety Officer), the duty Operations Manager and the pilots operating flights. There was no flight‑by‑flight requirement for the various post holders to engage with pilots in the decision whether or not to operate a flight and there was no formal pre-flight risk assessment process. However, it was expected that pilots would liaise with duty personnel or the Chief Pilot as required in fulfilling their responsibility to ensure the safe operation of the helicopter. |
even if there wouldn't be any cranes, or high rise buildings, penetrating clouds in a tight airspace above a populated area, all under VFR rules, is nothing but gross negligence.
if this penetrating thru clouds is a tolerated way of operating, one day there might be an other aircraft in just the same cloud doing just the same mistake Get f***ing real! :ugh: What is the overall sum of this insurance case going to be? Is this in any relation to the need of operation as conducted? We are all paying for it, and some people not only with money but a lot more. |
TC - my own view is that you're not right on that, but I accept you could be. You however (I assume) don't think my theory could possibly be true - I generally agree with your posts but that seems a bit arrogant to me.
Don't get out of hand folks, I'm in no way condoning the pilot's actions here, but just trying to consider what actually caused him to hit the crane, as a technical point. Clearly whatever he was doing he shouldn't have been doing it, but I don't think he was being quite as reckless as some here would have. |
Rotorspeed,
If you were to omit the part about "trying to comply with the Rules" part of your post....you have offered the most logical explanation of why this happened. I would bet consideration of complying with any Rule was the last thing in Barnes' mind at the time. He was concentrating on getting into the heliport despite some very bad weather conditions. |
To me that facts that led to him dropping down through the sucker-hole are interesting in that they led to that decision. Part of the investigation and something to learn from for sure, but separate from what happened down below cloud.
Once through the cloud layer to go into Battersea there are probably three competing pressures; at this point I discount the pressures (self-imposed?) from above the cloud to do the best job he could for the client. Once heading down through the cloud-hole he was concentrating on putting the machine down at Battersea. The first pressure he faced when he popped-out VFR below is noise abatement. Weather so bad, why not hover over the river and get cleared in? Not ideal from a power point of view, but solo in that machine? No problem! There is a circuit pattern at Battersea designed in part for noise abatement and hovering over the river whilst waiting for clearance would be legal (rules of flight) but generate complaints for Battersea. Safe, but very unpopular. Did it even come into his mind? Perhaps a low-hour pilot would think this way, but then a low-hour would not have been there. So he flew the circuit After that, as said already, he has pressures to remain +500ft from anything and to stay VFR. My guess is he was trying to do both which led to a climb and ..... he broke the 500ft rule. |
Whilst the crane is getting a lot of attention, the core question is what led him to fly within 105 feet of a prominant building?
Was it solely down to poor vis? Police and HEMS helicopters aside, how often do helicopters fly within 100ft of buildings over London? Would any action or report have been taken or made if he had not hit the crane? Mickjoebill |
Lol
My post was on for 20 seconds, I realised my mistake and deleted it. Do you have notifications every time a post is made? |
BB - what suggestions would have as to why he climbed 200ft before starting his right 180 if it wasn't to try and comply with the rules and be less obvious? If he simply wanted to widen the turn I think he would have done this over lower buildings to the north of the river.
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Sid,
of course I do, that's how you stay on top of the banter. Bear in mind that the delete key is not the same as a magic buttton. AP |
Rotor,
I have no suggestions on what he did or why he did it as my Crystal Ball is in for routine maintenance. All I can do is consider what happened. He hit a Crane in Cloud. Everything after that is pretty much ordinary supposition beyond the information noted by the AAIB Report. There is an old Greek Saying that fits your question. "I should smell my hand and know what he was thinking?" Barnes did not record his thoughts for consideration by the rest of us. |
Would any action or report have been taken or made if he had not hit the crane?
Mickjoebill, I think you might have steered this conversation in the right direction,finally. Single pilot operations typically are unsupervised and unchallenged.If Pete had made it that day,it would be unlikely that ,other than he himself, anyone else would have got to know about how close the call was. Seen it here dozens of times.All of us have had our "never doing that again!" moments,but does that a safer operation or a safer pilot make? After all, asking a pilot to voluntarily reveal his close shaves because he pushed the limits is akin to asking a motorist who jumps a red light to stop at the next police station and turn himself in.Never going to happen. We remain human. And, there is the rub.How do operators, gently and in a non punitive way, make pilots reveal their screw ups ? Not by regulation.It has to be by building trust and constant reinforcement of that trust. Is that possible? I don't know but I am sure it is worth a try. Alt3 |
BB - that's a bit disappointing - I thought you might have been able combine the facts provided in the report with your no doubt extensive flying experience to come up with a hypothesis or two to explain the actions that immediately lead to the impact.
Which brings me back to my earlier generalisations comment, and limitations of their value. Saying "fly safer, or "fly by the rules" is valid and reasonable, but of limited value in focussing pilots' minds on risk areas. There can be further benefit in really trying to understand what actually caused the critical error in any given accident. Take the Sumburgh Super Puma crash - what actually caused two pilots to fail to monitor speed anmd height during an approach and hit the sea? Here is not the place to answer that of course. |
Rotor,
Let me put it this way for you. As I was not there and thus have no knowledge of what he was actually seeing weather wise, and not knowing what he was thinking, it is of not much use for me to speculate about that. That being said, there is no way in Hell I would have done what he did which was to enter Cloud, Fog, or whatever it was that prevented him from seeing where he was going. That is what is baffling about all of this as it just plain does not make any kind of sense at all that he would have done what he did. One just does not do that kind of thing in the location and weather he was at that day. Gordy uses a very good saying....."Ass, Tin, Ticket!". When you get into a real Pickle you save your Ass, try to keep from harming the Helicopter, and ignore the Legal Rules even if it means losing your license for a while. If I had dropped down to the River looking for a way to slide into the Heliport and then found myself with no where to go....I would have hover mosey'ed along the River until I found a way out and suffered the consequences of my actions. I would never punch into a Cloud or Fog Bank thinking it a wise or safe thing to do. |
BB: I see I am out of your peanut gallery now...heh heh...:D
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I asked my original question about texting because it seemed to be an unnecessary distraction.
I studied the AAIB report a bit further, and found a meticulous investigation, but a disappointing set of Recommendations, often the case in my experience. There seems to be a general feeling on the forum that the pilot was not acting in a professional manner, despite his experience and general competency. The AAIB have chosen to ignore behavioural issues completely in favour of plodding obstacle rule making improvements and so on. This could have been an excellent opportunity to have made an attempt to get to grips with what appears to be a significant industry wide problem, but the AAIB have rather let us down. |
Hoping to satisfy the Holy Trinity by stating both rotary and fixed qualifications, and having 'pushed the boundaries' more than a few times - cutting through the crap here:--
Surely the lesson is that if you are going for a bit of skoshie as Mr Hanna used to call it, don't do it a) Below the level of nearby obstructions b) Over built-up areas, so far less chance of taking an unfortunate bystander with you? This does not just apply to rotary! |
CAAAD
I disagree with you about the AAIB's recommendations concerning obstacles (and think they should have gone further in some respects) but I agree entirely with you that they should have looked more closely into the factors which regularly lead to such accidents. In particular, but not exhaustively, the matters mentioned by puntosaurus very early in the thread. TC 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 had already decided to press on AFTER his principal had told him not to bother. Report 2.3.2: The flying time from Redhill Aerodrome to overhead London Heliport is short, so the operational advantage of waiting at the heliport rather than the aerodrome is not obvious. The pilot might have thought that the client intended to drive to the heliport and that to position the helicopter there in advance of the client’s arrival would be advantageous from a commercial perspective. This seemed likely given that the pilot appeared to decide to divert to the heliport immediately after he learned from the client that it was open. For some reason, you believe that those who disagree with your approach either haven’t been listening to you or don’t understand. I suspect most posters agree with most of what you've said about this accident. However, not everyone agrees that the factors which led to it are as simple and straightforward as you and some others believe. There are other factors which need to be considered and addressed. (I'm not referring to "subliminal psychoanalytical, interdevelopmental breakdown.") There have been differences of opinion regarding texting while flying in VMC but everyone appears to be agreed that the pilot exercised poor judgment when he left VMC and, as ShyTorque said earlier, made the fatal mistake of descending into fog lifting into low cloud. Those, such as Piltdown Man, who have argued that there should be more careful examination of the factors which may have led this pilot to do what he did (and many other pilots before him to make similar poor judgments) have been wrongly accused failing to understand and by one poster of 'defending' the pilot. They have done neither. John R81 To me that facts that led to him dropping down through the sucker-hole are interesting in that they led to that decision. Part of the investigation and something to learn from for sure, but separate from what happened down below cloud. FL |
FL,
Did the AAIB determine what the Client meant when he reported the Heliport "Open"? Did the Client know for a fact the weather was above Minimums for Operations at the Heliport or was it a blanket reference meaning only the "Opening Time" was at hand? Likewise, when ATC told the Pilot the Heliport was "Open", did that tell the Pilot the Weather was satisfactory for VFR Operations into the Heliport? How is Ceiling/Visibility measured at the Heliport and reported to Inbound Traffic? Must Inbound Traffic remain clear of the Heliport until given permission to enter? Is it ATC that issues that clearance or someone at the Heliport? |
Bob
I have already quoted what the AAIB said about Client's final text. I have no reason to believe that the client knew anything about the Minimums for Operations at the Heliport. That was not the AAIB's point; nor is it mine. No, it was not "a blanket reference meaning only the "Opening Time" was at hand." Re your other questions: The communications regarding diverting to Battersea are fully set out in the report. Again for the avoidance of any misunderstanding, I am not criticising ATC. I am not trying to defend either the pilot's decision to descend or his actions thereafter. I am interested in the factors which led to his decision to descend because that is the area which in my opinion has never been sufficiently explored and might have potential for improving flight safety. Perhaps it won't, but IMHO it's worth trying. |
FL,
I was not being critical of your posts, just wanting to make sure of what the facts and situation was re those issues. You know I very much consider you to be One to listen to closely. The Rules, ATC, Weather, Client, Operator, and every other factor can conspire (even unknowingly) to create a Mine Field for us but it is up to us to tread safely and not step squarely on top of those we can see. In this particular case, there is only one way the Finger can point in that regard. That being said, I fully agree with your desire to see a much broader review of all those factors and influences that played a role in this and other similar accidents such as the 139 Crash and the Glasgow Police Crash. All three of these tragedies have some related factors that need examination. |
I'll say it again.....in aviation, sometimes the most difficult thing is knowing when to say "NO!", and of course, also having the strength of character to say it.
The saying "Ass, tin, ticket" is a good mantra, but it also needs suffixing with the word "Job". Human nature means that pilots will continue to learn the hard way. |
Would it make any difference to this discussion if there were links to a video and still photos showing a pilot flying reasonably but breaking regulations for HEMS flying, on 2 different jobs?
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Breaking exactly what regulations? Flying single crew VFR in cloud = zero vis! next to tall buildings, means a lot closer than 500ft? Above London? Tokyo? NY city? Thank god I live in a bungalow. On the countryside.
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.........if only he had turned left from the right bank.......................
I recall someone asking on the previous thread about an assessment of forward speed - the AAIB makes no mention I could find. Did anyone do the maths from the radar plots? |
Garmin 430 Terrain feature
http://www.aaib.gov.uk/cms_resources...4%20G-CRST.pdf
Page 13 1.6.3 GPS devices The helicopter was fitted with two panel-mounted GPS units, a Bendix King KMD 150 and Garmin 430, both of which have a colour moving-map display. The Garmin 430 can provide navigation, communications, and terrain and obstacle warning functionality. There are two memory card slots provided to allow the integration of database information. Typically one would be used for navigation data and the other to provide terrain and obstacle information. Each card can be accessed from a quick-release slot on the front of the device. 1.6.3.1 Terrain and obstacle warning If a valid database and three dimensional position fix is available, the Garmin 430 will be able to display terrain and obstacles relative to the helicopter altitude and position. For obstacle avoidance, the display features a number of different symbols representing the different levels of alert and types of obstacle In addition, the device can use flight path data to trigger an alert in respect of terrain or obstacles which may present a hazard. If an alert is triggered, the ‘TERRAIN’ page provides a flashing ‘TERRAIN’ annunciation8 in the lower left-hand corner ‘annunciator field’ (Figure 7). There is an option to inhibit this annunciation although the symbols in Figure 6 will still be available. When activated, this will be displayed on the ‘annunciator field’ as ‘TER INHB’. 1.6.3.2 Database update The GPS units fitted to G-CRST were destroyed in the post-impact fire and it was not possible to determine their database revision status at the time of the accident. The terrain and obstacle database to which the GPS manufacturer refers on its website is available on a subscription basis and updated on a 56‑day cycle. Operators can download database updates and transfer the data to GPS units in individual aircraft. As the GPS unit is a customer option rather than standard equipment, updates are not a scheduled maintenance requirement in the helicopter manufacturer’s maintenance planning document and, in the case of G-CRST, were not logged by the maintenance provider as a maintenance action. The operator stated that it updated GPS databases annually in March and had not updated the database in G‑CRST because it received the aircraft in May 2012. From what I can see with the paperwork I have here, any units pre 2007 didn't have the terrain feature. The accident helicopter was serial number 11017 and was manufactured by Agusta in 1998. At the last log book entry prior to the accident, the airframe had accumulated 2,304.5 flight hours since new. The engines were original to the airframe and had the same number of hours since new. The helicopter had previously been operated in the UK on the USA register but was transferred to the UK register in 2007 as G-WRBI. |
Saw this on Facebook this Morning......
Helicopter pilot who crashed in central London felt 'pressure' to fly despite bad weather - Telegraph |
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This is the most relevant section of that report for me...
"It is clear from text message records and witness evidence that the pilot knew before flight that there was fog at Elstree Aerodrome. In a telephone conversation with a colleague at 0649 hrs, he said he was going to cancel the flight because of the weather despite feeling under pressure to continue with it. At 0706 hrs, he reportedly told Witness A that he intended to fly over Elstree to check the weather for himself and, at 0729 hrs, he sent a text to the client saying that he would be “coming anyway will land in a field if I have to”. " It clearly shows he changed his mind, probably due to being pressured, “coming anyway will land in a field if I have to”. and this is the start of a very bad day. |
I learned a long time ago that "Weather Checks" are done from the Ground.....either it is good enough or it is not. I know of very few fatalities inside a Tea Room.
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Re: some of the comments attributed to Tinkler-Rose and Ms Smith. Any view as to why none of this was reflected in the AAIB report?
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