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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)

[email protected] 26th Nov 2015 18:19

We are, as pilots, our own worst enemies - we have belief in our own abilities borne out of succeeding through our training and spending years 'getting the job done' and we all believe we are excellent assessors of risk and will always know when to say NO (as Shy observes this is a notoriously difficult word to utter when the pressure is on).

The risk vs reward decision we would make from the ground before the engine is started is vastly different to the one we will make when airborne with a task to complete.

Is there an easy answer? No, but at least recognising that we are the weak link may go some way to making extra allowances for 'the wife and kids' when electing to push on when that little nagging voice in your ear (not her indoors) is telling you to turn round and go home.

This is what all that Human Factors training is supposed to make us understand but self imposed pressure and ego seem to keep us from fully absorbing and applying that training.

When you get to the edge of your capacity and multitasking ability it is much more of a 'cliff-edge' than most would expect and that is where we get overwhelmed by events and make big mistakes.

Wageslave 26th Nov 2015 21:18


coming anyway will land in a field if I have to
What, beyond this astonishingly reckless statement do we need to know to determine the ultimate cause of the accident?

I have walked away from an operator who expected wholesale disregard of normal safety protocols . Although it saved my arse from official grief it cost me the job and much worse left him still in the market with his unsuspecting posh and glossily brochured clients just as exposed. I'll make no implication regarding a connection or otherwise with this incident but go figure.
The cowboys and the chancers (for this is what they are) who operate towards such pressures should have no place in the industry, even though it voluntarily costs decent honest pilots their jobs.
Sure, it isn't easy for honest pilots to object to such pressure as I found out, but it does, ultimately leave them alive and free of guilt.

SilsoeSid 27th Nov 2015 12:33


Pittsextra;
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?
If one was to read the report, page 8;


History of the flight
1.1.2 Text messages and phone calls

At 0649 hrs, the pilot received a call from another pilot who was a colleague from a different helicopter operation. The pilot reportedly told his colleague that the weather was clear at Redhill Aerodrome and at his final destination but he expressed his concern about the weather at Elstree. The pilot told his colleague that he felt under pressure to go ahead with the flight that morning but he had decided to cancel it.

Another pilot (Witness A) was aware of the flights planned by the pilot of G-CRST. He stated to the investigation that the pilot phoned him at 0706 hrs to tell him that the weather at Redhill was clear and that he was going to collect a passenger from Elstree. The pilot said there was fog at Elstree but he was going to fly overhead to see for himself.

At 0718 hrs, the client called the pilot to discuss the weather. The client stated to the investigation that the pilot said he thought the weather might clear earlier than forecast. The client said he would drive to Elstree and call the pilot to keep him advised.

The client reported that, at 0731 hrs, having noticed how poor the weather was during his journey, he called the pilot to suggest that he should not take off until he (the client) had reached Elstree and observed the weather. According to the client, the pilot replied that he was already starting the engines and so the client repeated his suggestion that the pilot should not take off.
page 48


Decision making
2.3.1 The decision to depart from Redhill Aerodrome

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”.

The pilot was subject to operational and commercial pressures and was required to consider their associated risks when making the decision to operate the flight. The weather conditions at Redhill Aerodrome had begun to clear (see Figure 10) and the pilot would have been able to return there if the weather at Elstree Aerodrome reflected the forecast. He therefore had a safe contingency plan before departure. However, the weather forecast indicated that a large proportion of the flight was likely to be conducted above the cloud or fog, icing was likely during flight within cloud and there was a low probability of being able to land at Elstree Aerodrome because there was no instrument approach procedure.
https://assets.digital.cabinet-offic...014_G-CRST.pdf

SASless 27th Nov 2015 13:12

As I ponder all of this....the question that is begged....is why the reference to "landing in a field"?

Did Barnes make a practice of off airport landings in the past in order to accommodate his Clients when weather at Airports or other formal landing sites precluded "normal" operations?

Or....did his sense of humor allow for such a comment that at this stage of things come across with far too much significance that is warranted?

With Redhill and other locations in the Clear.....why would he mention the possibility of landing in a field?

SilsoeSid 27th Nov 2015 15:27

A very good question S'less, one that makes me think that the ability to land in a field makes some of us with a certain mindset, depart in weather conditions below that where if the field landing wasn't an option, they wouldn't have taken off in the first place.

Imho, the rotary ability to land 'in a field' and the thought of using it as a considered option if the met's a little dodgy, is nothing more than an empty chamber in the cylinder of the revolver used in the game known as Met Roulette. Unfortunately either side of that particular chamber are the gotchas!

We can get caught out and the forecasts can be wrong, however on this particular day ….

Pittsextra 27th Nov 2015 15:38

Hi Sid - I read that but it seems to me that the comments being attributed to T-Rose this week suggest a greater concern, a longer standing unhappiness that a career change would be of interest, that Rose had told him to bin the flight and that in the weeks prior there were other issues with the same client.

ShyTorque 27th Nov 2015 16:13


I know of very few fatalities inside a Tea Room.
Very true. Unfortunately, that's sometimes where the pilot learns his services are no longer required.

SilsoeSid 27th Nov 2015 16:25

Hi Pitts, I guess the report can only go on the evidence.

Client problems with other pilots and the client only wanting to fly with certain people is information possibly not factual enough to be included in the AAIB report, besides, that is something Mr Caring denies anyway Owner of The Ivy says he did not pressure crash pilot into flying - Telegraph.


Mr Tinkler-Rose added Mr Barnes had told him he was tired of the pressures of the private helicopter industry and wanted to move into the environment of private jets.
Perhaps the client was part of this 'career change' and to let Mr Caring down on that morning may have been seen as jeopardised this new future.

https://www.rt.com/uk/226223-blair-private-jet-donor/

"The luxurious private jet used by former British Prime Minister Tony Blair and dubbed ‘Blair Force One’ is reportedly owned by one of Britain’s richest men.
Blair uses the plane, a £30 million Bombardier Global Express jet, which comes with a stateroom, kitchen, lounge and bed, as he travels around the world as a consultant.
The Telegraph revealed the private jet belongs to Richard Caring, whose fortune is estimated at £800 million ($1.2 billion)."



I see what you mean about recent comments and it's interesting to note that the AAIB report mentions, "The pilot told his colleague that he felt under pressure to go ahead with the flight that morning but he had decided to cancel it.". Yet now at the Coroners Court we hear; "he told a colleague he felt under "extreme pressure" to go ahead with the flight despite bad weather."

Maybe the added adjective has something to do with Mr Caring's comment at the CC;

"Mr Caring also criticised previous evidence from an air ambulance colleague of Captain Barnes, Shaun Tinkler-Rose, who suggested Captain Barnes was placed under "pressure" by his client to fly.
Mr Caring described Mr Tinkler-Rose's evidence as "extreme" and added: "I believe Mr Tinkler-Rose is slightly confused in his understanding of the use of commercial helicopters."
He described Mr Tinkler-Rose as a "frustrated pilot," and disputed the notion commercial helicopter clients are "control freaks or people who can't take no for an answer."
"

rotorspeed 27th Nov 2015 16:36

SASless

In an ideal world weather decisions are indeed made on the ground, but the reality is, particularly in the UK where the nearest met report maybe 50 miles away, going to have a look and seeing if the weather is suitable when at the planned destination is the only - and a sensible - option, providing of course (a) there is a solid alternate if not, with appropriate fuel, and (b) someone is prepared to pay for a possible aborted flight. And fog can be notoriously patchy - from the nearest METARS a site may appear to be surely fogged out, but when there it can be gin clear. This exact scenario was possible for this accident flight. But a good alternate - Redhill - was not used.

Flying Bull 28th Nov 2015 16:56

@rotorspeed,

with thousands of webcams, even smal airports with automatic weather (and often webcams) one isn´t limitted to the view official met-reports....

[email protected] 28th Nov 2015 16:58

Would you really trust a webcam or an automated weather report to make a real-world go-no-go decision if you knew it was marginal? I know I wouldn't.

Flying Bull 28th Nov 2015 17:23

@ [email protected]

yes I do - very often, especially at night, when the number of reporting points is reduced.
I made a linklist of places within my operating area on my homepage, so that I can access the links from PC as well as mobile phone / pad, in case I have to check after an outside landing (i.e. refueling at an closed airport).
With official permission to fly outside normal limitations and often missions which include search for people, who will certainly die, if not found in time, the additional information is very useful.
Also the radarmovies online are very very helpful for timing or routing to get to the mission area or back.

SASless 28th Nov 2015 18:20

Automated weather reporting sites are becoming quite common here in the USA.....and are used in preflight planning.

How common are those kinds of facilities in the UK?

Thinking of ASOS, AWOS, and similar units.

https://www.faa.gov/air_traffic/weather/asos/

ShyTorque 28th Nov 2015 18:43


Would you really trust a webcam or an automated weather report to make a real-world go-no-go decision if you knew it was marginal? I know I wouldn't.
Crab, me old chap... suggest you take a look at the METARS for Heathrow, London City, Stansted etc... the word AUTO is the norm for quite a few UK airfields these days!

My regular operating site's nearest weather station is ten nm away, often with very different met. conditions. With regard to fog being present or not, at the time of your task, the only sure way is to go and have a look for yourself. Five minutes either way can make a lot of difference. Same when operating to early morning off airport destination landing sites. too. It's a regular part of the corporate job. Otherwise, the pax would be flying fixed wing to the nearest airport and driving to the destination and the corporate helicopter business would be no more. Obviously, a suitable alternative/diversion needs to be available and PB did have one.

I don't think PB's decision to go take a look at Elstree was totally flawed except by doing so (in circumstances with a relatively poor chance of success, in view of the initial discussion by phone with the client), he probably put unnecessary personal and commercial pressure on himself.

Once the aircraft had taken off, it began burning fuel and using aircraft hours. Obviously, declaring a "no can do" on the ground, due to weather, is one thing, but to burn fuel and hours and then finish on a "no show" means the difference between making a profit or a loss for the company.

As I said before, the really bad decision was to change from his initial safe plan B, to RTB and instead attempt to get to Battersea in conditions that were only suitable for IFR, when it is a strictly VFR only airport.

Shame that having stated he was unhappy with the pressure of corporate flying, (it sometimes gets all of us that way) he put undue and tragically terminal pressure on himself. Even had he managed to land at Battersea, how he thought he would get away with "altitude busting" right down into R157 is hard to understand unless he thought he was actually flying clear of it, possibly further to the west. I still believe he may have seen a bridge over the Thames through a gap in the low cloud and mistaken it for another. It's an easy mistake to make. Although a regular user of some parts of the Helilanes, I still sometimes have to check the 50,000 chart when given a Thames bridge as part of a short notice or unexpected clearance and at such times the pilot workload can be very high indeed.

SASless 28th Nov 2015 18:59

The rest of the calculation needs doing too....if you have a result such as in this Tragedy....what is the "Cost" versus "Gain" numbers?

Otherwise, I fully agree with everything you had to say in that post.

We should be like Doctors....and "Do No Harm!".


Once the aircraft had taken off, it began burning fuel and using aircraft hours. Obviously, declaring a "no can do" on the ground, due to weather, is one thing, but to burn fuel and hours and then finish on a "no show" means the difference between making a profit or a loss for the company.

Gordy 28th Nov 2015 19:08

Weather Cameras are the way of the future, the CAA needs to catch up:

FAA Weather Cameras

Pick a camera and click it---then click an image to see all the info it gives. Try Barrow--way up North.

[email protected] 29th Nov 2015 10:07


Crab, me old chap... suggest you take a look at the METARS for Heathrow, London City, Stansted etc... the word AUTO is the norm for quite a few UK airfields these days!
Maybe I'm just lucky having access to MOMIDS and a met man/girl to talk to.

I don't have a problem with auto reporting but not for a really marginal go/no go unless I have a viable plan B ready to go when it turns out worse than expected.

ShyTorque 29th Nov 2015 10:15

Crab, indeed you are very fortunate; the corporate helicopter pilot is often very much on his own in many respects.

If any helicopter task involves marginal wx conditions, especially with regards to fog (as we all know, it's a met man's guess with regards to timings of clearance), it would be a very foolish pilot who takes off without a plan B and IFR fuel reserves.

[email protected] 29th Nov 2015 10:18

Agreed - but there are clearly those who will still do exactly that - unfortunately we often read about them post event.

SASless 29th Nov 2015 11:11

Civilian Flying is a whole different way of life than Military flying.

As Shy correctly states....in the Civilian World the Pilot is generally completely on One's own.

No Met Staff, no Engineering Section, No Ops Staff, and no one looking over your Shoulder to approve your decisions.

ShyTorque 29th Nov 2015 12:05

SAS, that's correct.

There's no authorisation oversight, no ops staff, so no-one to book your airfield slot clearances or find suitable off airport landing sites (and gain the CAA permssions where needed), arrange aircraft hangarage, your overnight accommodation, transport to and from it .... Then the check A, oil replens etc are all done by you because the engineers don't get to see the aircraft for weeks...it goes on. Of course, as an added bonus, the pilot gets to carry the passenger's luggage.

ANOrak 29th Nov 2015 16:49


.....unless he thought he was actually flying clear of it, possibly further to the west. I still believe he may have seen a bridge over the Thames through a gap in the low cloud and mistaken it for another. It's an easy mistake to make.
I think Shy has hit the nail on the head and, knowing the area well and having had the privilege of knowing Pete, I believe that this was the real cause of this tragic accident.

[email protected] 29th Nov 2015 16:54

SAS, unlike a lot of military flying, SAR aircraft launch all hours of the day and night with minimal planning time, sketchy details of the job, next to no idea what weather they will find on scene and often in the sorts of weather that most other sensible people don't go flying in at all.

By comparison - a civilian corporate pilot seems to have it quite easy:ok:

500e 29th Nov 2015 16:57

Duck Crab Incoming:eek:

Torquetalk 29th Nov 2015 17:37

Damn Crab, you really are trolling for bites with that one.


I haven't done SAR, but have done HEMS where the criteria you list are met. Have also worked in the single pilot charter environment. There is simply no comparison as far as workload goes, either on or off the job. The lack of team (crew) on the job, and the lack of team (back office support) in the SP corporate world means the workload is simply immense.




TT

Flying Bull 29th Nov 2015 17:45

Even SAR-pilots should - and actually say no.

Hard decissions, cause you know, somebody is going to die - but better somebody else, I don´t know, than the crew and me.....

We have limits - which protect the younger ones cause they can say no below these limits without any query.

The older ones often fly below these limits - but only, as long as the whole crew is "happy" with that.
Every crewmember is entiteld to cancel the mission, if excecuted below the limits - no discussion after that.

Had some interesting outside landings, twice the helicopter had to stay there for about a week, cause the weather prohibited any returnflight...
Nice service of some locals with tea and accommodation (the rest of the first night) included.....

ShyTorque 29th Nov 2015 18:43


By comparison - a civilian corporate pilot seems to have it quite easy:ok:
Having done both (which I know Crab hasn't, so he's not yet fully completed his civvie apprenticeship :E), plus military, HEMS and Police, I quickly found the SPIFR corporate world can be the most demanding. Not always, but often, for a number of reasons, the airborne workoad can be extremely high.

SAR pilots have usually got very little to do except drink tea ( ;) ) and always more than one other person in the aircraft to help them once airborne, let alone that well established base organisation to help prep the helicopter and pull it out of the hangar before you even came on shift.

In the corporate world, there is often only one shift. And you're often on it. 24/7.

On SAR, you don't have the person who directly pays your salary sitting in the back, always there to make your day by interrupting you with further demands and suggestion at the most critical of moments, such as the second you initiate an IMC go-around from minima. Try doing your daily job with the equivalent of the chief of the air staff in the cabin, always ready to press the "bing bong" button...

Also, it is always a bonus to be able to use a "Rescue" callsign.
Try getting any priority from ATC units when you're only allowed to use the aircraft reg. as your callsign. Like it or not, you're at the bottom of the pecking order with the puddle jumpers. :ouch:

Speaking of puddle "jumping", the worst job of the day is lying in one after last landing to fit the towing arm because it's nearly midnight and everyone else has gone home.

Having written this, I'm thinking I'd now like to go back to SAR for a rest. :ok:

[email protected] 29th Nov 2015 18:55

Yes, SAR is just sooooo easy - just remind me how far out to sea with nowhere to land or refuel do corporate pilots fly (day or night), and I must have forgotten the workload involved in night mountains in the snow and wind, hovertaxying in near zero vis with cumulogranitas all around.

Oh and then there is no pressure at all trying to get to a hospital as fast as possible in shi*e weather with guys giving CPR to the casualty(ies)in the back.

And I must be mis-remembering hovering downwind with no references with 250' of cable out and 2 pink bodies dangling on the end - it must be so much more difficult to negotiate a helilanes clearance with a nice air trafficker to get to Battersea during the day.

I presently train pilots up for the SPIFR role and it really isn't rocket science:ok:

Perhaps if the corporate world is so difficult and demanding with so much pressure, the pilots should choose to say no more often:)

jellycopter 29th Nov 2015 19:38

OK Crab, you've obviously got the biggest Willy on this forum.

SASless 29th Nov 2015 20:29

Back to Neutral Corners fellas....both jobs have their unique demands.

Both have different setups and ways of doing things.

Crab will in time fully understand what we refer to when we talk of doing things alone....and not just the in-flight SPIFR thing....that is but one part of the job.

EMS pilots know that feeling of looking over their shoulder as their Crew pull every trick they have out of the Bag to save some poor Sod who is having a bad day.

Most places I worked that could be several times a day/night thing for them every shift they work.

We all have flown in crappy weather, a lot of us have done the winching in bad weather thing or done Lifts with folks dangling below us.

Going offshore to the very limits of your fuel endurance is not that uncommon as you try to offer the Customer the max number of seats....which is not much different than SAR as I know very few SAR Pilots who go beyond their fuel limit and cause themselves to have to land in the Oggin.

Crab might just accept that when a Civilian Contractor replaces the Military on some Contracted Task we always do so with fewer aircraft, fewer Staff, and with a higher rate of utilization. That is why we make money doing it.

ShyTorque 29th Nov 2015 20:49


Damn Crab, you really are trolling for bites with that one.
The fish are not biting - but they're jumping in the boat... ;)

JerryG 29th Nov 2015 21:00

Give it a break Crab.
I've done both jobs to the max.
SAR takes good airmanship but Corporate involves MUCH harder decisions, believe me.

[email protected] 29th Nov 2015 21:04


I've done both jobs to the max.
Oh dear - now who's got his willy out??:E

ShyTorque 29th Nov 2015 22:49


Perhaps if the corporate world is so difficult and demanding with so much pressure, the pilots should choose to say no more often:)
Some of us do. The real skill is when you can say no and keep your job.

Two's in 29th Nov 2015 23:38

Despite the humor of the dick-dance, you are all saying the same thing. Whatever the job entails, the critical component will be the Captaincy decisions that allow you to complete the mission safely. The corporate world has the added fun of trying to keep your job (by keeping your bosses happy) but it all counts for nothing if you kill yourself or your passengers through inadequate or poor decision making (i.e. Basic Captaincy).

This incident illustrated tragically (again) that accidents are no respecter of experience, on the day, the only decision that counts is the last one you made, regardless of how many hours you have under your belt.

Sir Korsky 30th Nov 2015 02:05


SAR pilots have usually got very little to do except drink tea
Don't forget ' and do some pruuning ' Shy.

I had a situation this week where the weather was SOP borderline and the temps made IFR not an option. I told the pax you may not get to your off airport LZ but we'll do our best. He agreed to continue. We did some dog legging to circumnavigate the bad stuff to stay VFR. It was night time, raining and miserable. We used IAS mode to slow things way down when required - a very important step. Don't charge around when things get murky. On many occasions I asked the SIC if he was happy to continue. We got the customer to his destination and he was happy. We added an extra 10 minutes or so to the trip, but I couldn't care less. We had abort plans set at every step and we weren't afraid to cut our losses and divert. Sticking to your guns is a critical part of decision making and I'm not the gambling type.

Thomas coupling 30th Nov 2015 11:35

Anorak:


Quote:
.....unless he thought he was actually flying clear of it, possibly further to the west. I still believe he may have seen a bridge over the Thames through a gap in the low cloud and mistaken it for another. It's an easy mistake to make.
I think Shy has hit the nail on the head and, knowing the area well and having had the privilege of knowing Pete, I believe that this was the real cause of this tragic accident.
As much as we all loved him. He had cause to "drop the ball" for a second or two and it was all over. More weight to the statistic that 72% of all UK (global?) accidents are pilot induced.

Crab: I think one of the biggest differences between Corporate pressure and SAR pressure is that the former drags on continuously - way before and beyond the actual trip. The latter arrives in a lorry load - minutes before the trip and ends, seconds after you coast in and are visual with the airfield.
It is the constant drip drip drip of pressure that causes even the best (like this crash) to drop their guard for a few seconds.

For corporate drivers, the pressure starts as soon as the alarm clock goes off.

JerryG 30th Nov 2015 16:42


He had cause to "drop the ball" for a second or two and it was all over.
Hear hear TC. Let those amongst us who are without sin cast the first stone.

Thomas coupling 30th Nov 2015 18:31

Jerry - do you honestly think it was anything else?

SASless 30th Nov 2015 18:42

Twas more than a few Seconds I would suggest....there was a long string of Uh-Oh's!

Way back for instance when the Client called and said the weather too bad...scrub the flight.....for starters.


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