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AAIB Report A109E accident at Vauxhall, and Inquest Verdict
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I understand that the AAIB Report will be published tomorrow.
It's been leaked to the press and, as a result, there are news items in today's Telegraph and Daily Mail. Helicopter safety warnings ignored before London crash - Telegraph Development hit by helicopter was so big pilots COULDN'T fly through London without getting dangerously close to it | Mail Online I doubt if the Report will contain any surprises concerning causation but it will be interesting to see what safety recommendations are made - and to read what the professional helicopter pilots here think of them. Too far, just right or not far enough? There's potential for a good informed discussion. I only hope it won't be spoilt (again) by people who've never held a helicopter licence, either professional or private, but that's probably a triumph of hope over experience. FL |
Since these newspaper reports tend to change and/or disappear, this is the Telegraph article:
Warnings of a threat to the safety of helicopters flying above central London were ignored ahead of a crash last year in which two people died, according to a new report. Pilot Pete Barnes, 50 was killed along with Matthew Wood, a pedestrian, when an Agusta 109 helicopter crashed into a crane at St George’s Wharf, Vauxhall, amid heavy fog in January 2013. But an official report into the disaster, to be published this week, reveals that concerns were raised with the Civil Aviation Authority in 2009 about how the development would affect flight paths. The operator of London Heliport warned the CAA that pilots travelling along the south bank at low altitude due to cloudy conditions would be forced to breach rules which ban them coming within 500ft of any buildings. According to a copy of the Air Accident Investigation Branch report, leaked to The Telegraph, the message “does not appear to have led to further discussion or action”. Following the accident NATS, the air traffic controller, ruled that helicopters should no longer be instructed to fly on the south bank at low altitude to avoid coming too close to buildings. “Any pilot routing along the south bank of the river and passing within 500ft vertically of the top of the crane, or the building once the crane is removed, would be in breach” of the rules, the AAIB said in its report. It noted that pilots and not air traffic controllers are responsible for obstacle clearance, but added: “Controllers should not issue clearances which imply permission to breach regulations. According to a copy of the Air Accident Investigation Branch report, leaked to The Telegraph, the message “does not appear to have led to further discussion or action”. Following the accident NATS, the air traffic controller, ruled that helicopters should no longer be instructed to fly on the south bank at low altitude to avoid coming too close to buildings. “Any pilot routing along the south bank of the river and passing within 500ft vertically of the top of the crane, or the building once the crane is removed, would be in breach” of the rules, the AAIB said in its report. It noted that pilots and not air traffic controllers are responsible for obstacle clearance, but added: “Controllers should not issue clearances which imply permission to breach regulations. Despite being urged by his client twice not to fly due to poor visibility, Cpt Barnes told him by text message: “I’m coming anyway will land in a field if I have to.” Unable to land at Elstree, he turned back for Redhill but received another message from Mr Caring telling him London Heliport in Battersea was open, and requested permission to land. Travelling at low altitude on an established flight path along the River Thames, and unable to remain clear of cloud, Capt Barnes made a right turn towards The Tower at St George’s Wharf, one of Europe’s tallest skyscrapers. The report claimed it was most likely obscured by the weather, and the pilot could have been distracted by changing radio frequencies as he approached the site. The helicopter struck the crane’s jib, detaching its rotor blades, after flying within 105ft of the skyscraper. Capt Barnes died as it crashed 700ft to the ground, also killing Mr Wood, 30, and injuring a dozen more people. The report added that the skyscraper was not listed as an obstacle in the helicopter’s navigation system, and that Capt Barnes had not logged onto an online database containing updated flight information for pilots for the past three years. It also noted that there is no effective system for ensuring all potential obstacles for pilots are registered, and the crane had only been added to databases "by coincidence" after being spotted by an off-duty member of staff at the Defence Geographic Centre. The AAIB made a number of recommendations to improve the assessment of obstacles before planning permission is granted, and the reporting of potential hazards to pilots. Spokesmen for the Civil Aviation Authority and the Department for Transport declined to comment before the publication of the report on Tuesday. |
FL,
" Oh Yea of little faith!". Jimmy Durante had the same problem! What we shall read of course is the Government, CAA, NATS, basically all the "Crats" hold no "Responsibility" no matter their involvement, malfeasance, or misfeasance. It noted that pilots and not air traffic controllers are responsible for obstacle clearance, |
AAIB Summary:
At 0820 hrs on 16 January 2013 the Air Accidents Investigation Branch (AAIB) was notified that a helicopter flying over central London had collided with a crane and crashed into the street near Vauxhall Bridge. A team of AAIB inspectors and support staff arrived on the scene at 1130 hrs. The helicopter was flying to the east of London Heliport when it struck the jib of a crane, attached to a building development at St George Wharf, at a height of approximately 700 ft amsl in conditions of reduced meteorological visibility. The pilot, who was the sole occupant of the helicopter, and a pedestrian were fatally injured when the helicopter impacted a building and adjacent roadway. The investigation identified the following causal factors: 1. The pilot turned onto a collision course with the crane attached to the building and was probably unaware of the helicopter’s proximity to the building at the beginning of the turn. 2. The pilot did not see the crane or saw it too late to take effective avoiding action. The investigation identified the following contributory factor: 1. The pilot continued with his intention to land at the London Heliport despite being unable to remain clear of cloud. Ten Safety Recommendations have been made. |
No real answers or surprises really - just lots of 'if only' thoughts at various stages of the report.
God bless. |
http://www.pprune.org/8277778-post7.html
The AAIB will be investigating not only the ultimate cause of the crash but other factors which may have contributed. It was a commercial flight so I suspect those investigations will include looking at (for example) the nature of the operation, management structure, flight ops structure, safety management systems in place (if any), procedure for authorising flights, and freelance pilots self-authorising if that is what happened in this instance. They might even look at the risks inherent in a 'no fly-no pay' system, particularly when combined with self-authorisation, if that was the arrangement here. |
No.
The AAIB does not appear to have investigated those aspects. If it had done so, the list of 'contributory factors' might have been longer than just one item. H. |
What a strange omission. You'd have thought that would be an obvious area to investigate. Then again, I suppose it's possible that they did investigate it and concluded that none of those issues were contributory. Or maybe they did and there was no basis to support a conclusion either way. I guess we'll never know....
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Shame it took fatalities to emphasise the dangers of allowing any number high rise buildings directly on a helicopter route in CAS. I always considered it was a matter of when, rather than if, an accident would occur, especially in that location. It was difficult enough when the Post Office Tower was the dominant obstacle, now it's ridiculous.
On the route poor old Barnesy was given, pilots are being given a clearance to fly at 1400 feet QNH. Any lower and you bust R157, which goes up to 1400 feet. Any higher, and you bust your clearance against head-on inbound ILS traffic to London City airport, which come down to 2,000 feet just north of Vauxhall Bridge. While concentrating on maintaining exactly 1400 feet you can think about not busting the 500 foot rule against these high rises while looking for your reporting point and other traffic on H4. Meanwhile pilots need to carry out cockpit checks and slow down whilst descending into Battersea, of course listening to the many "cautions" routinely issued by ATC about cranes, turbulence, river traffic and birds on the FATO alongside the actual landing clearance. London Heliport itself is surrounded by an increasing number of cranes, some of them overhang the river bank on the approach/climbout area. The river banks are being developed in the immediate vicinity, too (I counted fourteen cranes on a recent visit). Irrespective of the notification of many of the obstacles (I noted how many "new" ones were suddenly notified in very short order after this accident occurred), there are now so many, it's impossible to be totally aware of all of them, especially when the routing you get isn't necessarily the one you request on the R/T on first contact with ATC. I think London Heliport has had its day, for this and other reasons and another landing site is desperately overdue. My solution would be for a new heliport to be built at City Airport (LCY). There is an existing instrument approach there (which would have prevented this accident in the first place) and many of the passengers, who want to go to the city in any case, would be better catered for in that they wouldn't be faced with a 30 minute road journey to get to and from the helicopter. Obviously, there has always been a helicopter ban at LCY, dating back to the days of "Red Ken". I think a review of this policy is now well overdue. |
Shy;
Well said! Combine all that with the fact that there are now so many crane notams that I bet pilots are missing essential items due to the crane stuff being so badly spread out. Much as I love Battersea I am getting very fed up of EGPWS Obstacle warnings drowning out radios, intercom etc from all the cranes/structures in the Battersea circuit. Sadly I doubt Boris will be much more help than Red Ken, its not a vote winner. Dear old Pete, I spoke to him the night before the smash, and a couple of weeks before we talked about a different landing site for London, and about how little chance we had of getting one. SND |
Safety Recommendations
4.7 Recommendation 2014-031: It is recommended that the Civil Aviation Authority review Federal Aviation Regulations Part 135 Rules 135.615, VFR Flight Planning, and 135.617, Pre-flight Risk Analysis, to assess whether their implementation would provide safety benefits for those helicopter operations within the UK for which it is the regulatory authority. From what my British friends tell me about the CAA that will go over like a lead balloon. :) |
Long before I was into aviation I was a qualified Town Planner (dreary jobs, glad to get away).
One of the things that comes out is the lack of joined-up thinking between different government departments. The CAA allocates helicopter route H4 along the Thames, tightly squashed in under the LCY (who were on easterlies that morning, thus making their turn onto finals overhead Vauxhall) 09 approach at under 2,000 feet. Meanwhile another government department, it seems to be the Deputy PM's office this week, happily gives planning permission (because although ostensibly done by local authorities, all the "biggies" come to government attention) for some of the highest structures in the country right on the same route. This one was right on the Battersea approach from H4 at 700 ft. You also have to wonder what the developer was thinking in the first place, putting that up into a known and published helicopter route. But avoiding such issues is what Planning is about. Goodness, it nit-picks over the most trivial details. This was not trivial. The one that has previously concerned me is The Shard at London Bridge. Over 1,000 ft high and again right on H4. Remember that one of the clearances given to this aircraft was to go east in the hold as far as London Bridge. Which is The Shard location. And where a holding aircraft would be doing a 180 degree turn over the river in tricky visibility. |
Interestingly no mention of the "Elephant in the Room" here by contributors.
VFR-IMC anyone? |
A bigger question is why did this guy, who from all accounts was a pretty proficient operator, put himself in the position he did. He was not stupid and background chatter appears to put him in the camp of one of the "good guys". For some reason, he believed it would be worthwhile doing what was he was doing - what was that reason? Was this such regular occurrence he felt comfortable being where he was? Also, was he truly unaware of the buildings along the Thames? ATC were. The CAA were. Until we understand more about the person and the reasons why he was where he was (failing to adhere to Rule 5 is not a cause) we are set for a repeat.
A good report but desperately missing some personal, HF background and analysis. PM |
Discrepensies in AAIB report
Just started reading the AAIB report, and one thing that I can categorically say did not happen, was that the client did not call the Heliport at 0750 to ask if we were open. I was manning the telephones that morning from 0700. I was, at the time the senior person at the heliport and therefore the Aerodrome Authority. I was called by the DATCO, to ask if we could accept the flight, as we were still completing our opening checks. Given my authority and that we were awaiting final checks on fuel, I was satisfied that H2 fire cover was available, and therefore was happy to accept the flight.. That call from the client at 0750 simply did not happen!
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Piltdown Man
A bigger question is why did this guy, who from all accounts was a pretty proficient operator, put himself in the position he did. What can be done to dissuade pilots from getting themselves into that position? What can be done to help them not get into that position? ..... the nature of the operation, management structure, flight ops structure, safety management systems in place (if any), procedure for authorising flights, and freelance pilots self-authorising if that is what happened in this instance. They might even look at the risks inherent in a 'no fly-no pay' system, particularly when combined with self-authorisation, if that was the arrangement here. Freelancers feel even greater pressure, sometimes from clients and sometimes self imposed because no flight = no pay. 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. Why? Trying to keep the client happy? As he told the client at 0753 - "least we tried". No flight, no pay? The weather was OK at base and OK to the north of England where the client wanted to go. If he could just squeeze in to pick up the client? Worth a try? etc You always get the holier than thou types when there's an accident but how many pilots can say hand on heart that they have never ever pushed it? The billionaire businessman client was very quick to tell the press he was happy to call off the trip because of the weather. That looks like the truth so far as it goes, but it's not the whole truth. The client told the AAIB he phoned Battersea Heliport at 0750 to see if was open. Whether he did (as he says) or didn't (as cave dweller says) - Why did he tell the pilot Battersea was open? 1.1.2 Text messages and phone calls 0751 Pilot to Witness A: "No hole hdg back to red" 0753 Witness A to Pilot: "Ok." 0753 Pilot to Client: "Over Elstree no holes I’m afraid hdg back to Redhill least we tried chat in 10" 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." NB. This text was not read. When told the heliport was open, the pilot said that it would be “very useful” if he could proceed there, indicating that he was considering this option. The fact that the helicopter subsequently descended while the pilot was waiting to be cleared to the heliport suggests that his intention was to divert there. A good report but desperately missing some personal, HF background and analysis. They worked out the immediate cause but that wouldn't have been difficult. A high profile accident like this was a perfect opportunity to investigate the contributory causes, to look at the background culture, to draw attention to the pressures faced by corporate and self-employed pilots etc. The opportunity was there but the AAIB didn't take it. Until someone does, accidents of this sort will continue to happen. . |
Originally Posted by cave dweller
(Post 8648784)
Just started reading the AAIB report, and one thing that I can categorically say did not happen, was that the client did not call the Heliport at 0750 to ask if we were open. I was manning the telephones that morning from 0700. I was, at the time the senior person at the heliport and therefore the Aerodrome Authority. I was called by the DATCO, to ask if we could accept the flight, as we were still completing our opening checks. Given my authority and that we were awaiting final checks on fuel, I was satisfied that H2 fire cover was available, and therefore was happy to accept the flight.. That call from the client at 0750 simply did not happen!
(Rather than just tell us on a public rumour forum?) |
Bronx
A high profile accident like this was a perfect opportunity to investigate the contributory causes, to look at the background culture, to draw attention to the pressures faced by corporate and self-employed pilots etc. The opportunity was there but the AAIB didn't take it. Until someone does, accidents of this sort will continue to happen. Hole in One!:D:D:ok: 4.7 Recommendation 2014-031: It is recommended that the Civil Aviation Authority review Federal Aviation Regulations Part 135 Rules 135.615, VFR Flight Planning, and 135.617, Pre-flight Risk Analysis, to assess whether their implementation would provide safety benefits for those helicopter operations within the UK for which it is the regulatory authority. |
AAIB
The only person interviewed at the heliport as far as I understand, was the duty datco on the morning in question. This is only my third ever post and all three including this one was on the same subject.I posted this descrepency back in january 2013 when it was first posted that the client had stated that he had called Battersea to see if we were open. My answer then and my answer now is the same, no call was ever received.
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