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-   -   FAI into Clutha crash opens (https://www.pprune.org/rotorheads/620287-fai-into-clutha-crash-opens.html)

Fortyodd2 16th Apr 2019 11:17

Delta-Ng. - your last 2 posts - Spot on.

Pittsextra - option B - know what you have to start with and updated / re-assessed as you go.

jeepys 16th Apr 2019 11:31

Pittsextra,

the trouble is fuel flow is not at a constant rate. Demands in S&L flight at 110 kts say could be a chunk less than sitting in the hover. Taking off with an hours worth of fuel, is that at best endurance or highest likely fuel flow required?

Pittsextra 16th Apr 2019 12:41

Well quite but the general point being that with your expected endurance of 1 hour (via one assumes a combo of calculated/finger in the air from experience of your expected mix of best endurance v max fuel flow) if you see a fuel alarm at 50mins then surely your first thought is "oh i hadnt realised id been so greedy with the fuel today" rather than "the alarm is erroneous lets push on".?? Even with the fuel remaining had the aircraft landed successfully at its home goodness knows how these guys are living if landing with so little is standard.

DOUBLE BOGEY 16th Apr 2019 13:29


Originally Posted by Pittsextra (Post 10448795)
Well quite but the general point being that with your expected endurance of 1 hour (via one assumes a combo of calculated/finger in the air from experience of your expected mix of best endurance v max fuel flow) if you see a fuel alarm at 50mins then surely your first thought is "oh i hadnt realised id been so greedy with the fuel today" rather than "the alarm is erroneous lets push on".?? Even with the fuel remaining had the aircraft landed successfully at its home goodness knows how these guys are living if landing with so little is standard.

Landing with so little???? 80kgs is more than the VFR FRF.

Fortyodd2 16th Apr 2019 15:20

FRF / MLA is a limit not a target.

DOUBLE BOGEY 16th Apr 2019 15:46


Originally Posted by Fortyodd2 (Post 10448905)
FRF / MLA is a limit not a target.

Obviously not an Offshore pilot because the FRF is often all that's left unless the air gods have been kind and left a little contingency to sweeten the deal!

Fortyodd2 16th Apr 2019 15:55

Correct, not an Offshore Pilot - and if that's the "Offshore Attitude" to FRF / MLA then glad I stayed clear of it.

DeltaNg 16th Apr 2019 17:08

FRF Should give you 20 minutes at loiter (VFR) and 30 minutes (IFR) and still be able to land safely.

TeeS 16th Apr 2019 17:14


Originally Posted by DeltaNg (Post 10448984)
FRF Should give you 20 minutes at loiter (VFR) and 30 minutes (IFR) and still be able to land safely.

HI Delta
Unless my memory has let me down again, the VFR requirement is based on 20 mins cruise whilst the IFR requirement is 30 mins at holding speed - in the end they tend to produce a similar value.
Cheers
TeeS

DrinkGirls 16th Apr 2019 18:44

It’s so simple you say. Start the clock and you should know what your endurance is?

WRONG

I have got airborne in a helicopter with faulty fuel gauges. They SHOWED 1:30 fuel but were over-reading by 15 minutes worth. In other words the fuel was not there at the start. It got very tense when the other warnings came on.

The only time you can be confident of your contents is when the tank is brimmed full or empty.

If this aircraft had faulty gauges, it could have lifted with god only knows what in the tanks. The stopwatch call would be irrelevant

As I said above, it happened to me

DOUBLE BOGEY 17th Apr 2019 06:32


Originally Posted by Fortyodd2 (Post 10448945)
Correct, not an Offshore Pilot - and if that's the "Offshore Attitude" to FRF / MLA then glad I stayed clear of it.

FortyOdd, I like your feeling towards this and cannot fault you for wanting to avoid being low on fuel. It sucks and always will. However, its not an "Attitude" in HOFO its sometimes a commercial necessity and the Commander needs to be comfortable with it otherwise he can take "Additional Fuel required by the Commander" as is his prerogative under the rules. Majority of HOFO Pilots I have worked with like to take as much fuel as they can get in but sometimes the client wants all the available payload. That's the nature of the job. However, you can bet your pay packet that on those occasions we is watching the fuel gauges with deep suspicion until we land safely. We employ lots of little tricks to justify a little more fuel like planning with winds more punitive than forecast so the system calculates more fuel. It takes a really brave soul to plan minimum wx/absolute minimum fuel without at least a tweak here and their for the "wife and kids". Often this happens subconsciously during the planning. One day the bean counters will eventually stand over our shoulders and the cat will get out of our nav bag. Rue the day!!

Pittsextra 17th Apr 2019 06:48


Originally Posted by DOUBLE BOGEY (Post 10448828)
Landing with so little???? 80kgs is more than the VFR FRF.

Are we not nit picking? Using your 80kgs and the averged 3.3kg/min consumption at the point it fell through a roof, and that roof was a distance away from the planned landing site and absolutely no margin for any precautionary alternative....at night.

You can make general points at the margin but fundementally you know how much fuel has been uplifted and the watch gives you the rest. If your SOPs and crew allow you to operate such that a couple of dozen kgs of fuel make the difference it hardly seems logical that this same crew are not then super attentive to all of the information presented to them around fuel including where that fuel is.
That will not be answered because all are dead but what can be is the acceptance or otherwise of the fuel management process. I doubt very much that a similarly operated aircraft could crash with similarly low levels of fuel remaining as far away from its base today, which suggests SOPs will have been revised, suggesting the process that allowed this situation to occur was flawed.

DeltaNg 17th Apr 2019 22:11

We are not nit picking. FRF figures are guidlines which are determined by Operators and Regulators with safety in mind as a sensible amount of fuel to land with as a minimum.

Fundamentally we all know how much fuel has been uplifted, and everyone who has flown for 20 years commercially is super attentive, but suddenly one day we don't just ignore a whole load of fuel warnings without some other factor in play.

jayteeto 18th Apr 2019 07:42

Delta NG, that last line says it all

AnFI 19th Apr 2019 14:22

"There are many holes in the cheese that needed to line up. Some of them are already there, now, in our own working environments. Finding the holes and plugging them is the mission."
2 layers of cheese with 2 holes each is easy to avoid holes lining up
4 layers with 300 holes each is very difficult.

Tight on fuel to assure engine accountability during takeoff is clearly a false safety trade-off.
Complexity leads to pilot error. Pilot error is about 4/5ths of accidetnts.
Complexity increases the probability of System Failures. About 1/5th of Fatal accidents are system failures.

Engines 1%.
Complexity kills. (to paraphrase Occam: "a helicopter should have a single reliable engine")

There is a level of engine reliability at which the extra risks (of 2 engines) are not worth it.
Anyone got a handle on what that figure is? IS THERE AN EXPERT out there?
Should be easy to calculate. Probably somewhere around the 10^-3 to 10^-6 mark. Trying to improve on that risks shooting one's self it the foot with an overcomplicated gun.

"a pilot who understands the EC135 fuel system should NEVER end up with fuel starvation provided..."
and the number of pilots that don't is? : 1 per 100,000? 1 per 1000? 1 per 10?

DOUBLE BOGEY 20th Apr 2019 06:30

ANFI we all know what your bee in your bonnet is and it has f***k all to do with this accident.
One day you will grow up and realise you live in the real world where problems are real. Not imagined. Not hypothesised. Just real.
DeltaNg summarises this event very well in his last line. I would add, given the nature and background of the pilot that night..........there is most probably more to this story than what the current evidence implies. The subject pilot deserves at least that consideration.
BTW he was 2 minutes from landing at his home base. His calculated FRF would have been intact. If the events had not unfolded as they did it would have been just another professional pilot exploiting his available endurance efficiently to serve the public.
That is what this is about. Complexity and no of engines play no significant part.

DOUBLE BOGEY 20th Apr 2019 06:47

Pitts. UPLIFTED FUEL. In professional aviation we make a big effort to ratify/verify the amount uplifted against the difference on the fuel gauges before and after refuel. But it is meaningless if the gross amount displayed before refuel is already erroneous AND we did not fill and witness to the brim.

Read/listen to what is being written. Anecdotal evidence of fuel indicating in the supply tanks that wasn’t there.

FUEL ENDURANCE - unless you are Stephen Hawkins, mentally calculating the predicted fuel consumption on a Police Ops flight is practically impossible. Hovering, balls-out, loiter type circling and everything in between was taking place on this flight. Other than a vague notion of what could have been used the pilot could easily be 10-20% out. Thus a very heavy reliance on gauge indications is necessary. And that is assuming the value indicated at all stages of flight is correct.

DrinkGirls 20th Apr 2019 07:10

Double Bogey- spot on

For the record, it may not have happened in this case. BUT, if the aircraft had the same fault that happened to the Barton aircraft a few days later and was discovered in a few aircraft in the fleet check, then that’s a game changer. What if the fuel wasn’t ever in the tanks at take off? All the stopwatches in the world wouldn’t have helped.

However, even if the fault had been present, there was enough belt and braces systems to give the pilot the information he needed.

IF HE HAD BEEN TAUGHT AND UNDERSTOOD THE FUEL SYSTEM PROPERLY

Not looking for an excuse, just looking for a reasonable understanding of why Dave might have been confused

DeltaNg 20th Apr 2019 17:39

Unfortunately, like an icicle used as a dagger, hard evidence of the fuel displays status & the water which caused the capacitance probes to fail has long since evaporated.

But I'd like to think others would consider the possibility that the professional pilot perhaps wasn't entirely to blame for this horrific event.

AnFI 20th Apr 2019 18:35


Originally Posted by DeltaNg (Post 10452068)
But I'd like to think others would consider the possibility that the professional pilot perhaps wasn't entirely to blame for this horrific event.


Originally Posted by DrinkGirls (Post 10451733)
However, even if the fault had been present, there was enough belt and braces systems to give the pilot the information he needed.

IF HE HAD BEEN TAUGHT AND UNDERSTOOD THE FUEL SYSTEM PROPERLY

Not looking for an excuse, just looking for a reasonable understanding of why Dave might have been confused

I agree with these 2 sentiments. From them and the pages of educational discussions on the EC135 fuel system, it is clear that it IS complex enough to expect a pilot failure rate. I don't think it's the pilots fault, just the complexity of what is required of him will result in accidents.

DB also 'Fuel Pressure', is a real world cause of accidents. AND "in the real world where problems are real. Not imagined. Not hypothesised. Just real." like this real world multiple fatal accident or Leicester? OR the imaginary world where engine redundancy is an imagined magic cure?

DeltaNg 20th Apr 2019 18:42

I often wonder whether 2 engines have any real tangible benefit in the helicopter world.

For prolonged transits over 'hostile' terrain I can see the rationale - which was originally airline's reasons for having extra engines - but for non-complex operations, there must be statistics that suggest that B206's have done a lot better in some areas ...

Flying Bull 20th Apr 2019 20:14


Originally Posted by DeltaNg (Post 10452121)
I often wonder whether 2 engines have any real tangible benefit in the helicopter world.

For prolonged transits over 'hostile' terrain I can see the rationale - which was originally airline's reasons for having extra engines - but for non-complex operations, there must be statistics that suggest that B206's have done a lot better in some areas ...

Well, the police NRW went for twins after a series singles having problems (crashing)
And even nowadays I d rather have a spare engine operating over congested areas, hovering prolonged times, day and night.
If a donk fails on you it’s just more relaxing having another one keeping you in the air instead of the need to react instantaneously to recover the Nr, getting speed, deciding where to autorotate to (especially at night with NVG).

How many engine failures had I?
One sputtering engine allowing limited power only, on a Bell206 where parts of the compressor housing went through the engine , several times when I tried to increase power - with passengers on board,
One engine to shut down on a Bo105
One engine to shut down on a BK117

The occurrences on the twins were much less stressful, nearly „non events“, except for the paperwork involved...

So ne question for me, what I prefer....

chopjock 20th Apr 2019 21:32


Originally Posted by Flying Bull (Post 10452169)



If a donk fails on you it’s just more relaxing having another one keeping you in the air instead of the need to react instantaneously to recover the Nr, getting speed, deciding where to autorotate to (especially at night with NVG).



That could probably be just what this pilot and many others were thinking too...

megan 20th Apr 2019 23:51


OR the imaginary world where engine redundancy is an imagined magic cure?
You're going to need to justify that comment given the fact that 75.9% of the accidents caused by system failures are as a result of engine failures.

AnFI 21st Apr 2019 10:31


Originally Posted by megan (Post 10452271)
You're going to need to justify that comment given the fact that 75.9% of the accidents caused by system failures are as a result of engine failures.

Good point, I don't recognise those figures though, 'taxonomy'.
It DOES NOT concur with the EASA data analysis, which gives about 10% of the 20% that are system failures.
Are you including engine accidents for twins there?

Distant Voice 26th Apr 2019 10:58


Originally Posted by DrinkGirls (Post 10442802)
anchorhold
The relatives DO need closure. This isn’t endless inquiries, this is THE inquiry. The AAIB report will be part of it. An inquest doesn’t just look at why the helicopter crashed. It looks at post crash responses, lessons to be learned and more importantly, how EACH and every victim died. It looks at many many things other than the accident report. In other words, it’s vital. So, apology accepted.
Now, why don’t we all listen to what is said over the next 6 months, see if we can learn anything new about what happened and let the families have the inquest that they deserve. It’s not all about compensation you know.........

What a pity that the Lord Advocate and the Crown Office of Scotland do not apply the same criteria to the Moray Firth Tornado collision. Are service families second class citizens?

DV

chinook240 26th Apr 2019 15:57

I haven’t seen these posted before but this is the list of issues the FAI will address

SHERIFFDOM OF GLASGOW AND STRATHKELVIN
Court Ref: GLW-B1473-18
CONSOLIDATED LIST OF ISSUES

1. When and where each of the deaths occurred.

2. When and where the aircraft crash occurred.

3. The cause or causes of each of the deaths.

4. The cause or causes of the helicopter crash, including:-

4.1. how fuel was managed on the aircraft and in particular why both
transfer pumps were switched OFF, rendering unusable the
otherwise usable fuel in the main tank;

4.2. whether the Pilot’s Checklist was available to the pilot;

4.3. whether it was within the competence of a helicopter pilot
qualified to fly G-SPAO on police duties to comply with the
requirements of the Pilot’s Checklist;

4.4. at what stage in flight did the LOW FUEL warnings likely occur;

4.5. why, having acknowledged the LOW FUEL warnings, did the pilot
not complete the actions detailed in the Pilot’s Checklist;

4.6. whether the timing and/or the initially intermittent character of the LOW FUEL warnings contributed to the Pilot’s Checklist procedure not being completed;

4.7. whether there have been other instances of LOW FUEL warnings
not being followed;

4.8. whether the pilot believed the fuel transfer pumps were
operating, notwithstanding the LOW FUEL warnings, because he believed he had switched the fuel transfer pumps back ON, and if so whether the design or layout of the switches contributed to such errors occurring;

4.9. whether the pilot believed the transfer pumps were operating, notwithstanding the LOW FUEL warnings, as a result of erroneous fuel indications being displayed on the CAD;

4.10.what the root cause or causes were of any such erroneous fuel indications and whether they were adequately investigated and acted upon prior to the accident;

4.11.whether there was a failure of any part of the CAD prior to the accident;

4.12.what steps were open to a helicopter pilot qualified to fly this helicopter after both engines flamed out;

4.13.whether the designed time-interval between engine flame-outs was compromised by the design of the fuel tank system and, in particular, the undivided volume above the supply tanks, which, depending on the attitude of the helicopter, might have allowed fuel to migrate from one supply tank to another;

4.14.why autorotation, flare recovery and landing were not completed successfully;

4.15.whether the ability to carry out autorotation, flare recovery and landing was compromised by the design of the cockpit layout.

5. The precautions, if any, which could reasonably have been taken, and which, had they been taken, might realistically have resulted in the helicopter crash being avoided, including whether the crash might realistically have been avoided:-

5.1. by including within the fuel contents indication system a caution or warning that both transfer pumps were switched OFF;

5.2. by including within the fuel contents indication system a caution or warning that a fuel pump, having been switched OFF, has since been submerged in fuel;

5.3. by designing the fuel tank system and fuel contents indication system in such a way that the fuel transfer pumps did not require to be switched ON or OFF during flight;

5.4. by including within the fuel contents indication system a caution or warning, in the case of anomalous or implausible combinations of outputs from the sensors;

5.5. by designing the fuel tank system, and in particular the differential capacities of the supply tanks, in such a way as to ensure that the design objective of creating an interval of 3-4 minutes between engine flame-outs, or such other interval of time as would be represented by 4.5kg of fuel, or any other safe interval of time, was achieved;

5.6. by ensuring that power to the RADALT and steerable landing light was automatically maintained in the event of a double engine flame- out.

6. The defects, if any, in any system of working which contributed to the deaths or the accident, including:-

6.1. whether any aspect of the system of maintenance of G-SPAO, including its washing regime, contributed to the contamination of the fuel and/or the fuel tank system with water;

6.2. whether any aspect of the pre-flight check procedures contributed to the accident occurring;

6.3. whether any aspect of the training of pilots, in particular, with regard to fueling, pre-flight checks, the pilot handover procedure, the operation of the fuel contents indication system, erroneous fuel indications, the appropriate response to fuel cautions and warnings, and the execution of an autorotation at night, contributed to the accident occurring;

6.4. whether the practice of the “day-shift” pilot handing the aircraft over already fueled to the “night-shift” pilot contributed to the accident occurring.

7. any other facts which are relevant to the circumstances of the deaths, including:-

7.1. whether, and the extent to which, the Safety Recommendations of the AAIB in their Report 3/2015 have been adopted and implemented;

7.2. whether, and the extent to which, the operator, helicopter manufacturer and engine manufacturer have taken necessary and appropriate safety actions following the accident, including those considered by the AAIB in their Report 3/2015;

7.3. whether, and the extent to which, any recommendations should be made by this Court.



http://www.scotcourts.gov.uk/docs/de...9.pdf?sfvrsn=2

DrinkGirls 26th Apr 2019 18:41

Looks like the investigating officers have been asking the right questions. Hopefully the armchair investigators who had all the answers on Pprune will now realise there are many more issues that need to be addressed before we character assassinate Dave. The conclusion may or may not agree with the original board, however he will be able to rest in peace, knowing that he has been given a more thorough hearing. Everyone involved deserves that.

jimf671 26th Apr 2019 22:42


Originally Posted by DrinkGirls (Post 10456611)
Looks like the investigating officers have been asking the right questions. ,,,,

Yes. These are essentially the sub-sub-sections of section 6. sub-section (1) of the 1976 Act, with (a) and (b) each split into two streams to address the individual deaths and the crash event separately. It fleshes out the statutory purposes of the Inquiry to the next level of detail, almost certainly by the Procurator Fiscal, so that it provides a framework for the PF to present the evidence.

Reely340 27th Apr 2019 10:27

Nice, encompassing questionaire, but there is one important question missing:

4.16 whether the ability to carry out autorotation, flare recovery and landing was compromised by Helicopter Police of Scotland (sp?)
through not providing sufficient opportunities for their pilots to practice real world EOLs in EC135 types, by day and night.

Now, lets see virtual hands from those EC135 drivers on pprune, that actually did practice real EOL in an 135!
And how many of you did practice them at night, w/o rad-alt?

anyone at all?

Flying Bull 27th Apr 2019 11:32


Originally Posted by Reely340 (Post 10457074)

Now, lets see virtual hands from those EC135 drivers on pprune, that actually did practice real EOL in an 135!
And how many of you did practice them at night, w/o rad-alt?

anyone at all?

No need to practice them for real.
But it would enhance the chance to get things right- i.e. switching the EmerShedBus early with the first problems arising, (low fuel warning i.e.), if pilots had a go in a simulator once or twice a year....

Art of flight 28th Apr 2019 14:01

Simulator time. Training budget.
 

Originally Posted by Flying Bull (Post 10457115)


No need to practice them for real.
But it would enhance the chance to get things right- i.e. switching the EmerShedBus early with the first problems arising, (low fuel warning i.e.), if pilots had a go in a simulator once or twice a year....

Certainly saw a night and day different approach to risk management once the police employed us directly. As pilot's provided by a contractor we had the absolute minimum training the employer was mandated to provide. Once we were tupe'd across to direct employment the gravity of responsibility hit home with the police employer and we regular took part in simulator, first aid, fire fighting and dunked training.

toptobottom 29th Apr 2019 08:52

I was flamed for suggesting this earlier, but as it's a rumour site, I'll try again...
Has there been any investigation into the personal relationships between the souls on board? All the points to be covered reflect technical issues - either physical systems, training, compliance, procedural, etc. but what about emotional factors? It wouldn't be the first time an aircraft was deliberately crashed...

Evil Twin 29th Apr 2019 09:32

I fly a 135 most night shifts. I still don't understand why they ran out of fuel. There are so many warnings, notwithstanding basic airmanship that it makes no sense at all. Mission lock possibly coupled with poor CRM is the only conclusion that I can come up with.

RVDT 29th Apr 2019 12:13

toptobottom,

+1

About the only thing that is plausible.

G0ULI 29th Apr 2019 13:19

toptobottom, RVDT,

While personal relationships and personal issues may be relevant, they are unlikely to be considered outside of professional CRM issues aboard the aircraft. If there were known issues prior to the flight, management will be heavily censured and criticised for not doing anything about it. Close or familial relationships are generally forbidden between officers serving together, although it is not unknown for husband and wife to serve at the same station and/or work together in the same vehicle. The problem is that allegations of collusion will be levelled if an account of events by such officers is disputed.

If such matters are considered, it is likely that that part of the FAI will be heard behind closed doors and the conclusions omitted from the final report unless they point directly to being a primary cause of this incident.

jayteeto 29th Apr 2019 19:28

Evil Twin. Luckily for us your narrow minded view is not shared by all

DOUBLE BOGEY 29th Apr 2019 20:05

Evil Twin and RVDT - while I get this is a rumour forum and bearing in mind I did not know the Pilot I am struggling to understand how you can possibly come up with that hypothesis.

DeltaNg 29th Apr 2019 20:25


MightyGem 29th Apr 2019 20:36


Originally Posted by jayteeto (Post 10459137)
Evil Twin. Luckily for us your narrow minded view is not shared by all

Well, it's better than toptobottom's wild theory. :hmm:


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