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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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Originally Posted by cave dweller
(Post 8648853)
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.
You can't be expecting their investigators to be reading these posts, surely? :confused: |
AAIB report
Most of the posts at that time suggested not to speculate and to wait untill the official report came out, thats exactly what I have done.
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cave dweller
The only person interviewed at the heliport as far as I understand, was the duty datco on the morning in question. What reason might he have to lie to the AAIB? Maybe he took the call himself? Most of the posts at that time suggested not to speculate and to wait untill the official report came out, thats exactly what I have done. It doesn't mean don't give the AAIB information that might help the investigation! Whatever, it doesn't change anything because the client, for his own reasons, told the pilot Battersea was open and ATC confirmed it was. 2.3.1 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. If the client had left it as 'no flight' the pilot would have kept to his plan to return to Redhill - and two men would still be alive. |
Originally Posted by cave dweller
(Post 8648881)
Most of the posts at that time suggested not to speculate and to wait untill the official report came out, thats exactly what I have done.
And you don't seem to think that you should report this to the AAIB? Are you for real??? |
AAIB report
It may well have been the case that the client had called the DATCO at the time. I am not privvy to what he had said in his report. The DATCO at the time would have not had authority to declare open before 0800. The DATCO did indeed call me to see if we could open to accept the flight , but as I understood it, it was a request from radar in the seconds before impact and that was when he, the DATCO asked me if we could open and accept him. We were not open prior to that communication with the DATCO.
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AAIB report
I have only just read the report about an hour ago , so did not know what was in the report
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The DATCO at the time would have not had authority to declare open before 0800. Maybe the DATCO assumed it would have been 0800 by the time he landed? Not unreasonable. Anyway, all that doesn't matter now. What can be done to dissuade pilots from getting themselves into the position this pilot did? What can be done to help pilots not get into that position? It's an industry problem around the world and it ain't gonna go away on its own. Is there a will in the industry to do anything about it? Maybe not? Maybe it's the elephant in the room nobody wants to talk about? |
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..." Is it me or do helicopter operators appear to be more afflicted by commercial pressures than their fixed wing counterparts? Is it because their clients, whether rich businessmen, toffs or oil companies are rolling in it and keep the operators in a state of perpetual fear of losing their business? |
I'm thinking perhaps the pilot would have been visual with the surface for the turn to Battersea, saw that he was higher than the top of the building so no problem, (didn't see the crane going up the other side), held the angle of bank in and through that soft cloud that was above the building and didn't expect a jib arm hidden in the cloud. :eek:
My opinion it was simply bad luck, should not have gone through the cloud, but bad luck all the same. (How many of us fly a 180 through a cloud and expect nothing in there?) His experience should have won the day. Dam crane was the problem. |
My opinion it was simply bad luck, should not have gone through the cloud, but bad luck all the same. When you fly through Cloud under those Rules you eliminate "Luck" and introduce "Fate". I would suggest you read the visibility requirements for VFR and SVFR.....then reconsider your "Opinion". The AAIB Report and all the comments that have been made about this sad event really boil down to a single very simple truth. The aircraft was being operated in a manner that did not allow for avoidance of obstructions while operating under Visual Flight Rules. That was the Pilot's own doing, everything else is secondary. Count all the different times he could have said "No!" and could have done so quite reasonably. That is the one thing that needs to be learned from Tragedies like this. A single word with two Letters is so hard for helicopter pilots to say.....even though it is begged sometimes. The AAIB should examine that fatal flaw so many of us have. We all have it to some degree. Some of us have survived despite failing to find the ability to say that one single word at the appropriate time. Usually one really good Scare and we seem to find it much easier if we are around afterwards. |
Barnsey was the best pilot I knew.
I bet most aviators on here have encountered cloud at some stage in their lives, and have usually done a 180 to remain clear. Pete was IFR rated so he had the experience to fly in cloud. London has numerous cranes going up. I think the problem with the obstructions in London is nobody is controlling them enough. No cranes should be erected without the CAA being involved from the start, and ATC should be made aware of every one in their area (each day). Part of a hand over brief to each controller for that patch. Not just the Notams. Do ATC have any crane obstacle markers on their screens for the London area for low level ops? If the cranes are close to heliports such as Battersea, ATC should look at altering the heights allowed within ATC zones. The crane type involved is becoming more common and they are almost invisible against the tower blocks in London. Just noted the BB comment, and all I can say is weather changes... |
Harry O;
Read the London area NOTAMs for any day of the week, then fly over and look out of the window. There are thousands of cranes, and hundreds of NOTAMS. It would be impossible to do anything like you suggest. Just to add confusion the NOTAMs are not in any decent order with some showing LHR airspace, some LCY and some just a London Lat/Long. The number of crane NOTAMs now is ridiculous and really deserves a section just to itself. SND |
To accompany the simple 2 letter word that Bob mentioned earlier, there is also a simple TLA that would also apply here ... 'CRM'.
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Harry,
We all make mistakes, aviation has always been that way and always shall. Accepting that fact shows no disrespect of anyone and we should always seek to learn from those sad times we lose one of our own. I can assure you if it had ever happened to me I would hope there would have been a very honest and candid discussion of what happened. If that were not done I would see it as opportunity lost that might just prevent someone else from falling into the same trap I did. In this tragedy, some decisions were made that led to a very bad ending. I would submit that flying in Cloud over downtown London at very low altitude while supposed to be VFR demands some cold hard consideration. It may not be what you wish to see but the professional in you should accept the importance and propriety of that being done. |
I agree with Bob. We have to be honest regardless of what we thought of Pete. In my view this flight was pushing the limits of feasibility before take-off and reading the reports, the numerous risks involved were simply not in balance with the nature of the flight. It was a simple private charter.
Flying in cloud in such circumstances is not compliant with the IFR. |
I am a bit surprised that in a high workload environment such as seems to have been the case, single pilot, poor visibility, and so on, the pilot was texting. Although I may be a bit old fashioned and naive.
But it does beg the question - Is this a common practise in the rotorcraft fraternity? |
I am a bit surprised that in a high workload environment such as seems to have been the case, single pilot, poor visibility, and so on, the pilot was texting. Although I may be a bit old fashioned and naive. But it does beg the question - Is this a common practise in the rotorcraft fraternity? |
CAAAD
I am a bit surprised that in a high workload environment such as seems to have been the case, single pilot, poor visibility, and so on, the pilot was texting. 0747 Pilot to Witness A: VFR on top at 1500 feet 0748 Witness A to Pilot: But can you land? 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 (The pilot obtained clearance to Redhill and, at 0753, ATC asked: “Rocket 2 do you have VMC or would you like an IFR transit?” The pilot replied: “I have good VMC on top here, that’s fine, Rocket 2”.) 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. He was using the radio to talk to ATC until a few seconds before impact. The AAIB considered it unlikely that he was distracted at the same time by composing a text message. I agree, and would go further: I regard it as extremely unlikely. Firstly because there is not a shred of evidence that he was and, secondly, because the available evidence suggests that he wasn't. FL |
Texting while driving is illegal, has been proven to cause distraction and accidents and is a stupid thing to do.
Texting while flying as Captain of an aircraft under VFR or Special VFR or IFR and in marginal weather is crazy, regardless of whether it was a contributory factor at the actual time of the accident or not. The pilot went against all CRM / ADM learning I have ever seen, he placed undue commercial and operational pressure on himself, there was plenty of opportunity to break this unfortunate chain which he didn't take. |
He wasn't in marginal weather when he sent/read texts.
He was above it in clear blue skies. he placed undue commercial and operational pressure on himself It's not the first time it's happened and it won't be the last unless the industry is prepared to face up to the direct and indirect pressures on corporate/freelancer helicopter pilots and think of some way of doing something about it. He was a very experienced pilot, and from what I read on the original thread, well respected by his peers but he still felt he had to try to get the job done. Why did he feel that? 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. |
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