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-   -   Police helicopter crashes onto Glasgow pub: final AAIB report (https://www.pprune.org/rotorheads/569553-police-helicopter-crashes-onto-glasgow-pub-final-aaib-report.html)

SASless 29th Oct 2015 14:19

If an Oil Company can require CVR's why should the Police not be able to do the same thing?

Even BALPA is backing down from their stance on releasing CVR Recordings it would appear from recent news.

Why the concern over a lack of privacy at your work place?

It is not your home, your car, your girlfriend's flat, it is your place of work.

If you had a CVR....would you do anything any different than you do right now?

ShyTorque 29th Oct 2015 14:21

So you think we should just rollover in total surrender?

SASless 29th Oct 2015 14:30

I have flown many helicopters with CVR's and have absolutely no concern about them being used.

Perhaps, I know when to make snarky comments about my employer and realize the Cockpit is not the place to do that.

I damn sure know that is not the place when there is a CVR.

Yet, If I stick to the business of flying the aircraft in compliance to all the Rules, Regulations, SOP's, Checklists and the like then I am quite happy for the Boss Fellah to check up on me. If I get out of step for some reason i am quite comfy explaining why I did what I did.

If I snuffed it in a crash I would want the CVR to clear me of any intentional misconduct and prove me to be as much a Victim as my passengers.

I bet if you asked Dave's Family and Friends....they would tell you they would like to know the answers to the many questions still remaining about how this Tragedy occurred....having a CVR probably would provide many of those answers.



On a lighter note.....


Borrowing a post from Ericferret in the Military Aviation Forum about the lack of Commonsense in the US Military.....


Currently North Sea helicopter crews are wearing bright orange emmersion suits with reflective strips. To go out to the aircraft they have to wear a high viz. No hope whatsoever for the survival of the human race with this level of idiocy.

Shy.....Yes.....I think you lot have rolled over and surrendered.

Thomas coupling 29th Oct 2015 15:53

Wageslave, I don't think everybody is skirting around the real cause of this accident. I for one (and before the results came out) felt that even if there was a technical hitch with the fuel system on this a/c, the pilot had mishandled the subsequent EOL.
Since the report, I have re-inforced these views.

I am onboard with your views.

To ERR is to be human and people need to understand that occasionally the soft fleshy bit at the front of the aircraft - malfunctions, just like inanimate parts do.

CVR and FDR's have been long overdue in the police world. We talked about them in the late 90's. The CAA should have mandated them over a decade ago.
I FULLY expect there to be a statement shortly in this regard.
Either black boxes or twin pilot. For police ops.

ericferret 29th Oct 2015 16:27

and Air Ambulance?

FH1100 Pilot 29th Oct 2015 17:39

Now that the AAIB report is out and digested, and the goofy fuel system of the EC-135 has been explained, we've come to a point where we have a pretty clear idea of *what* happened, if not the *why* of it. And I don't think we'll ever know exactly.

But I have an idea!

First of all, I think the pilot was intentionally flying the main tank down to zero, using the fuel in the supply tanks as his reserve. "Legal" or not, within SOP or not, that's what he was doing. He was really close to the base, and I'm sure (conjecture here) that one way or the other he was landing as soon as that particular task was complete. And 78kg was probably "close enough" to his required reserve to be acceptable.

Heck, I've done that in a 105, albeit inadvertently: On a long flight I misjudged the fuel required and ran that dang Main down to zero knowing I had twenty minutes in the Supplies. We were close to our fuel stop, but even so when I saw that supply tank needle start to move down I was one tense piloto. The mechanic who was flying in with me from offshore was not a happy camper.

So what caused the EC-135 pilot to shut *both* transfer pumps off? Well, it has to do with these "rigid-rotor" helicopters: The cabin attitude between hover and cruise changes a lot! And we know that the fuel in the main tank moves around a lot between cruise attitude and hover attitude. The fore and aft transfer pumps become uncovered...then they get covered again. Speed up to cruise...slow to loiter...speed back up to cruise...etc. At low fuel levels, in forward flight the aft transfer might be sucking air. Come to a hover and the forward transfer pump unports.

These were not long legs from one tasking to the next. Perhaps Dave just got tired of the captions coming on and off and just said, "Screw it," and turned both transfer pumps off, intending to turn them back on before the supply tanks got "too" low. My guess is that when he finally did reach up to turn the transfer pumps back on he inadvertently got the "primes" instead. Hey, it's dark, and they're right next to each other. Who among us has never hit the wrong switch at night? My hand ain't up.

I'll bet that first engine failure caught him completely by surprise. Below 1,000 feet there's not a lot you can do, troubleshooting-wise: Pitch for best single-engine speed and set OEI power. By the time it was all sinking in, that second engine quit. "What the...?" He did the best he could, I'm sure. But he didn't have much time. It was all over eight seconds after the second engine quit. Not a whole lot of time.

Although I've voiced my educated guess, I cannot think of a single genuine reason a pilot might want to shut *both* transfer pumps off in flight. That is probably the biggest unanswerable question of this accident. But hey, we're all humans here.

So in the end, I guess I agree with Reely340 and others. The transfer pumps in the EC135 ought to have an "auto" setting that will take their operation away from the pilot.

Sky Sports 29th Oct 2015 18:40

"transfer pumps in the EC135 ought to have an "auto" setting"
 
I'm only playing devils advocate here, but here we go anyway.

There is a train of thought that suggests pilots should have things to do, should be kept busy, to concentrate the mind. Automation can be a wonderful thing in other walks of life, but in aviation it can lead to inactivity and a loss of concentration and system status.

Yes, the transfer pumps could be automated on the 135, giving the pilot less to do, but what then? If we stick with the 135 he/she could find themselves with enough time on their hands to start messing around with twist grips/training switches and knacker two engines.

On one of the early 135's, the NHP with nothing to do wondered how much effort was needed to press the fuel shut-off button. You guessed it. He pressed the button and one engine spooled down in flight.

The switches were modified with the cross shaped metal guards. This lead to another pilot in a boring cruise to wondering if he could get a pen between the guard squares. You guessed it. He could and the engine spooled down. That's why the latest mod is a Perspex guard.

Away from the 135, the classic example is Air France flight 447. A trans-atlantic flight that was so automated that the aircrew only had about 3 minutes of work at each end of the flight. And we know what happened to that.

So while we all like to do less for the same money, in some cases there is a really good reason to keep people busy.

ShyTorque 29th Oct 2015 18:59


I bet if you asked Dave's Family and Friends....they would tell you they would like to know the answers to the many questions still remaining about how this Tragedy occurred....having a CVR probably would provide many of those answers.
SASless, Davy Traill was one of my ex RAF colleagues.

Anyway, I'd agree with your quote above. It was a public transport flight. I wrote that I would not be happy about CVRs on every aircraft. Had you read my initial post on this (#195) properly and in context, you would have already realised that I have no objections to CVRs on PT aircraft.

ShyTorque 29th Oct 2015 19:03

Sky Sports


So while we all like to do less for the same money, in some cases there is a really good reason to keep people busy.
There is always something job related to occupy police pilots on task! And there is only one pilot.

nigelh 29th Oct 2015 19:06

If you are all so worried about privacy then why not have the recorder sealed and only the AAIB can open it in the event of an accident ?? That way we can all continue having a crafty cigarette and slagging the boss off without worry ??

[email protected] 29th Oct 2015 19:07

I think a police pilot, at night with busy tasking and limited endurance, has quite enough to do without fannying around with fuel transfer pumps.

A better design in the first place would have removed the dick-dance required to manage the fuel system

However, following on from wageslave's comments - there is an adage in the instructional world that 'it's the good student that will be the one who tries to kill you'.

Everyone runs out of capacity and talent at sometime and the better skilled and more competent often get themselves into stickier positions before that happens.

Unfortunately, running out of talent for someone who has some is frequently a 'cliff-edge' event rather than a gradual decline, especially if their perception is that they are operating inside their comfort-zone.

MichiScholz 29th Oct 2015 19:25

Even when there are thousand of flight hours logged with this type of helicopter, from my point of view it must be said, that there could be a better design of the essential fuel system.

1) placement of prime pump switches right beneath the transfer pumps. The prime pumps are only needed during startup as far as I know, so why not placing them riight beneath the fadec switches, or integrate them in the fadec startup logic?

2) Unreliable display of FUEL quantity in the supply tanks. At least the fuel low is now independent from the sensors. Fuel low - land as soon as possible!

3) Expecting 4 minutes on fuel starvation get cut down to a few seconds, I think only a few, maybe nobody can handle such an emergency during night, but maybe this scenario should be trained in a simulator.

Wageslave 29th Oct 2015 22:36

The big question, surely is CVR or FDR, or both?

I can see no rational objection to either on moral or ethical grounds. I've flown many thousands of hours with both and never gave it a moment's thought. If you don't trust the management then erase the CVR after landing as you are entitled to do.

But surely a CVR is of limited use at best i the single pilot environment unless pilots are given to talking to themselves whereas a FDR is far more valuable.

What is also certain is that the feelings of relatives should play no part whatsoever in the decision to fit, these must be for air safety reasons and air safety reasons alone. We cannot allow monitoring to become established in the name of 3rd party emotions or we'll be heading down a very dark and hazardous one-way street.

3rd party emotions are already becoming far too big a factor in the media over this particular accident and the sooner it is made clear that the AAIB report has no remit to answer there the better. This isn't being harsh, it is a necessity to keep professional rand safety requirements quite separate from personal feelings and inappropriate expectations. They do not make a useful mix, quite the contrary. Vide the distasteful hue and cry about the Shoreham Hunter pilot "still walking around" "without having been grilled by the police yet", a quote that chills me to the bone in it's unjust and aspiring vindictiveness and implied accusation.
Accident investigations are the strict and sole purview of cold, analytical enquiry and emotions must never be brought into it.

megan 30th Oct 2015 01:44


Perhaps Dave just got tired of the captions coming on and off and just said, "Screw it," and turned both transfer pumps off, intending to turn them back on before the supply tanks got "too" low. My guess is that when he finally did reach up to turn the transfer pumps back on he inadvertently got the "primes" instead. Hey, it's dark, and they're right next to each other. Who among us has never hit the wrong switch at night? My hand ain't up.
The most succinct piece of reasoning on the thread explaining the possible "why". As you suggest, been done before. Aircraft ditched following a bolter on a carrier because the flaps were raised rather than the gear. Handles next to each other. Fuel low lights came on shortly after night take off. Fuel dump turned on rather than landing light off. Switches next to each other. Ergonomics.

DrinkGirls 30th Oct 2015 10:20

A couple of points:

1. Its not a dick dance to manage the system. Even when extremely busy, you should be regularly scanning Ts+Ps. With this system, if you forget to switch the tx pumps back on, you get LOADS of information to remind you that you have forgot, AGES before it becomes a safety issue. (unless of course your supply tanks are showing permanent full).

2. Some are saying that they should look to see the history of landing fuel states. If they show regularly landing near to limits, something should be raised.
WHY???
Those limits are imposed by the authority to ensure a safe operation, a safety allowance is given in case of error or delay. If a unit regularly lands just above minimum fuel limits, they should be congratulated on being safe.
If the limits are not safe, the authority should change the limits. This is just like the military....... Boss says be there for 0800, SNCO says be there for 0750, JNCO says be there for 0745, erk gets there at 0740 'just to be sure'.

3. Despite people assuming that we are trying to say Dave wasn't at fault, I don't see anyone trying to excuse the ignoring of red fuel captions. The only thing that I am trying to say is that all may not be as black and white as we think. To EC135 operators, sit in the cockpit and imagine those supply tanks are nearing zero indicated. Not partially depleted, but actually NEARING ZERO. Even imagine that you are a serious risk taker....... Your TFO says "Dave, lets do one last quick important task before RTB". With 2 red lights and virtually empty supply tanks, I do not think that even Johnny Knoxville would seriously attempt that. So, despite him being at fault, SOMETHING caused/fooled/pushed him into continuing to fly............

Do I think Dave was at fault? Sadly, yes.
Do I think something distracted him? Almost certain of it
Do I know what? No, but the fuel gauges showing full are favourite
Should he have coped with that if it were true? Yes he should, but it didnt help
Would a CVR have helped? A no brainer, they should be in NOW

andyy 30th Oct 2015 10:42

A CVR will help in the subsequent accident investigation, but how about trying to reduce the chances of that accident happening by designing aircraft that,

Dont have a "goofy" fuel system (to quote someone in a post above).

Dont have important switches next to each other so its easy to switch the wrong one off.

Dont give false senses of security from gauge readings.

As someone else has said, Its ergonomics, and it still seems to be sadly lacking.:ugh:

Humans make mistakes, dont do the logical or sensible things, push on when they shouldnt - but the chances of that happening will be reduced if the aircraft has been designed well in the first place, and CVR isnt a piece of good design, its an aid to finding out what was badly designed and what procedures were ignored in the first place.

Wageslave 30th Oct 2015 10:44

A CVR would probably have told us nothing about this event except for timing of audio warnings.

We risk barking up the wrong tree here. Surely what really is needed is a FDR, not a voice recorder. Sure, while you're at it add the audio side, but it is systems data that would tell you the most in a silent single (non vocalised) pilot operation.

SilsoeSid 30th Oct 2015 10:47

Well said Drinkgirls :D

SilsoeSid 30th Oct 2015 10:56


My guess is that when he finally did reach up to turn the transfer pumps back on he inadvertently got the "primes" instead. Hey, it's dark, and they're right next to each other.
One would only say that if one didn''t know what would happen should the prime pumps be inadvertantly switched on.....

Video;



Perhaps there's a reason why the system is designed such that the cautions light up, the CAD bars flash and Master Caution illuminates when you put the prime pumps on.

[email protected] 30th Oct 2015 14:54


A CVR would probably have told us nothing about this event except for timing of audio warnings.
Except we would know what passed between the crew which could have been vitally important.

Presumably the FAI will include transcripts of the Airwave tasking and explain what would have been so important that an aircraft on fuel minimas had to be used.


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