Evil, the available/released facts would seem to support your statement. However there may be facts as yet undiscovered. Rumsfords Unknown knowns or whatever!
You should realise that the closer people on this thread were to the PIC and/or the type of operation, the harder it is for them to accept the kind of statement you made in post #83. Logic would dictate the story is most likely more complicated than that. I would be mindful of peoples sense of decency and compassion. In particular the Hill of Hindsight is no place to grandstand unless you are of course perfect and without potential fault. For example, despite many years of experience in several different operating environments, I never really digested the difference between thermistor/capacitance detectors and the vital role they play in the indicating, caution and warning systems until this accident brought them to light. I suspect the PIC was similarly indisposed but that is just an opinion. |
What he just said, agreed |
I would also add, that being on the other side of the fence for a while, the OEM took some flack in this accident. However, when you fully understand the design concept of such systems and then listen to the engineers express their surprise at how poor the knowledge and understanding appeared to be, generally, amongst the Pilot community, it can be humbling. To a design engineer, us not understanding why he used thermistors as the backstop warning system, coupled with an apparent failure to follow the FM Procedure when the lights come on is just inexplicable to him.
As a community it is important WE do not seek to blame or achieve the simple satisfaction that comes with abrogated responsibility. In the end, we should always look inward. If it can happen to Dave....it can happen to me. What can I/Should I do about it? The rest is just hot air and conjecture. |
Even more agreed |
Look, we can all be under pressure to continue and get the max out of the aircraft endurance and are often pushed to use the absolute maximum available to get the job done. However, in this case the PIC used all of that and then all of his reserves and ignored the warnings until there was NONE left and the engines flamed out due to fuel starvation. At any time during flight the PIC should know their fuel state and that required to return to base or a safe point of landing with reserves intact, that didn't happen in this case.
|
No it didn’t i wonder why? it would be nice to find out i know, let’s have an inquest to examine ALL the issues genius |
not survivable
Originally Posted by jayteeto
(Post 10459535)
No it didn’t i wonder why? it would be nice to find out i know, let’s have an inquest to examine ALL the issues genius - your job is to fly a type notorious for various fuel level indicator flaws (stories from the fire fighter brigarde about pressure washing engines hot or cold, tiny but effective water droplets in the tank, etc) - your boss tries to stretch a sortie as far as possible, almost bordering on having you cut into your fuel reserve - its pitch dark outside - you constantly have to toggle them dry-run sensitive fuel pumps, due to an inferiour fuel pump type (at least compared to EC135s ancestor BO105, which has a similar tank setup but dry-run capable pumps) - these very important switches are overhead, hence out of sight - you keep acknowledging the "faulty" low fuel warnings, while the main tank gauge indicates "~80kg remaining" (hence you are convinced they are as faulty as you've heard. Nobody told you about the sensor types and their extremely different sensitivity to ingressed water) - while the display still indicates ~80kg of fuel the first engine dies on you - with the home base lighting in sight, you frantically try to prepare for OEO flight, assured that you've got another 1,5 mins till silence, hence can fly home - trying to get home on one engine with still "80 kgs remaining" indicated, the second engine goes silent "prematurely", some 30secs after the first - now the cockpit goes truly black, rad-alt and landing-light gone, thanks to stupid electrical setup - real panic sets in because nobody ever let you practize/demonstrate a "both engines at idle" autorotation, let alone a true EOL (not even in a sim?) - the acoustic environment is waaay different than usual, RRPM indicator is as black as the rest of the cockpit, RRPM hard to tell by ear (wearing a helmet) - between overrevving the MR and trying to arrest a "normal" RRPM, (hard to tell w/o instrument or visible blades) you are trying to pick a landing spot - you end up below the min. end of the "RRPM power off" arc - end of story I don't see how this is survivable for anyone. Who would have taken the time to mentally backtrack all previous actions to find the wrong pumps to be on? So many systems were preceived by the pilot to have failed: - recurring low fuel warnings while 80kg indicated in main tank, although one recalls humbly acting on the illuminating pump dry run indicator lights mutiple times in this very sortie, hence reasoning "it can't be the pumps" - engine starving while 80kg indicated - second engine starving way earlier than stated in the POH There is only one on single contribution of the pilot to this accident: having switched off both transfer pumps and switching on both prime pumps. Anything else is airbus' fault: bad choice of fuel pump type, necessitating unnecessary, error prone pilot work bad choice of fuel sensor type, water-droplet sensitive fuel level sensors are a stupid choice bad choice of emergency electrical power (it costs one(!) diode to fully automatically route battery power to the bus, thereby taking over supply when both generators fail) That accident would never have happened in a BO105: when both engines are running you make sure both transfers pumps are on, switch off the prime pumps and forget about pumps until you land and shutdown. |
Pretty interesting that the finger is being pointed at the manufacturer rather than the pilot that flew the aircraft out of fuel...
|
Originally Posted by Autonomous Collectiv
(Post 10459683)
Pretty interesting that the finger is being pointed at the manufacturer rather than the pilot that flew the aircraft out of fuel...
especially considering the frequently recurring fuel indicator issues of the EC135 fleet ("When the manufacturer tested the fuel sensors that were returned from the worldwide fleet, for repair, it found about 70% had no fault. ") and mixing fuel level indication sensors with very diffent technology (water ingress sensitivity) and the finnincky fuel pump toggle-'em-switches setup, let alone putting misleading instructions in the POH regarding time difference between engine fuel starvation left/right nicely rounded off by an overhead shed-bus switch, that has to be manually addressed to get rad-alt working, right when one has all hands full attempting an autorotation. It's hard to picture a design less fail safe than the EC135 fuel system, which is a shame as the mentioned BO105 already showed how a zero attention fuel system might look like. |
Originally Posted by Autonomous Collectiv
(Post 10459683)
Pretty interesting that the finger is being pointed at the manufacturer rather than the pilot that flew the aircraft out of fuel...
1 Pilot fogot to switch on main pumps after engine start, 2 DIY installed filter glass moved downward during flight, causing the duck tape to block the "low fuel" warning light (the holes in the cheese are aligning) => and at 20 mins past midnight, over the river Elbe in Germany he had one engine die (200ft AGL) and 4(!) seconds later (150ft AGL) the second engine starved of fuel. He did an AR at night into the shallow part of the river. :ok: They got their ankles wet, noone injured, helicopter only slightly damaged. Recommendation by the authority: Change BO105 POH to required all four pumps to be on from before startup. german language report: https://www.bfu-web.de/DE/Publikatio...ublicationFile |
When you are at the limit of endurance (which one assumes you are aware because of the watch/the physical position i.e. on the way home) at the point when the first engine flames out then surely you think fuel ahead of a wider problem?? And if you do think fuel dont all pumps go on by default and if you damage a pump through some dry running then so be it??
i just can not imagine that at this point in his trip fuel state isnt the assumed cause of all the problems and if 80kgs is being indicated at the point of engine flame out its hardly a time to over think things? |
Originally Posted by Pittsextra
(Post 10459876)
When you are at the limit of endurance (which one assumes you are aware because of the watch/the physical position i.e. on the way home) at the point when the first engine flames out then surely you think fuel ahead of a wider problem?? And if you do think fuel dont all pumps go on by default and if you damage a pump through some dry running then so be it??
i just can not imagine that at this point in his trip fuel state isnt the assumed cause of all the problems and if 80kgs is being indicated at the point of engine flame out its hardly a time to over think things? |
Tigerfish Having yourself been in the ops side of the air support unit , can you shed any light on my post on the 10th (post 13 ) regarding refuelling such late at night giving very little places to do so , totally understanding the ops side for the PIC while on duty . So my my question is to you was there any procedure for reporting such occurrences back to the air support unit ,out with the PIC having to lots of paperwork explaining why and how it was addressed from the air support side |
GC47G Sadly I cannot remember the detail now. Its over 20 years since I retired. Our practise re overnight refuelling was this. We had a large capacity mobile bowser at the unit. It was powered by an on board diesel generator. The fuel farm which closed at about 6.00pm would come over last thing before finishing and ensure that our own bowser was fully topped up. Then the aircraft would be refuelled as required during the remainder of the night from our own bowser. Refueling would always be at the direction and supervised by the PIC. At that time all of our observers were long time members of the unit, and well versed in the method of refuelling. They worked very much as a team, which is why I have always pressed for detail of the crews conversation with their control room. I cannot believe that my guys would have just sat there with the warning lights illuminated and said nothing to their C/R. But we've been through this conversation before, and I accept that that avenue was covered.
It seems that there must have been some form of CRM failure. TF |
Originally Posted by n5296s
(Post 10444530)
Seems to me this will forever remain a mystery, in the absence of a CVR. It's beyond comprehension how an experienced and by all accounts excellent pilot could have (a) ignored multiple low fuel warnings (b) forgotten to turn the transfer pumps back on and then (c) when the inevitable happened, failed to enter autorotation, for which you'd expect him to be spring-loaded considering the fuel situation.
It makes me think of some classic rail accidents where the driver's actions are just beyond comprehension: Moorgate in 1975, or Grantham in 1906 (where the driver was seen calmly staring ahead, travelling at full speed into a low speed curve). |
I am with SRP - The only way to understand "pilot error" is to try to understand why the actions taken looked rational to that pilot in those circumstances at that time.
on the subject |
Coverage of Enquiry online by Scottish Review
The on line weekly magazine "Scottish Review" has had a report from the enquiry since it began.
Here is the latest; published this morning. If you look at the sidebar you can find the 3 or 4 previous articles. Scottish Review: Maurice Smith |
Originally Posted by John R81
(Post 10462116)
I am with SRP - The only way to understand "pilot error" is to try to understand why the actions taken looked rational to that pilot in those circumstances at that time.
A very good book on the subject that looks an interesting book, I'm going to read it. Thanks. |
Big Frank's link has some worrying comments about how an experienced engineer who raises concerns about engineering workload at Glasgow, is ignored by his line manager and his action in reporting his concerns dismissed as 'unprofessional'..
|
Yes. Complex long FAI need somebody there listening for the small but important details. The Determination is the final output document, that addresses the specific points in the Act that I posted previously, and is public, but the Transcript is available only to 'Interested Parties' (those legally represented). Even in the Transcript you will miss the emotional impact of some of the points and importance of tiny decisions made along the way: the smaller holes in the cheese.
|
Originally Posted by [email protected]
(Post 10466971)
Big Frank's link has some worrying comments about how an experienced engineer who raises concerns about engineering workload at Glasgow, is ignored by his line manager and his action in reporting his concerns dismissed as 'unprofessional'..
|
BigFrank has posted a link to the reviews so far. I would recommend reading these reviews as they clear up some points that people have been raising over what was and wasn’t attempted |
There is also a Twitter feed from BBC Journalist Paul O’Hare https://mobile.twitter.com/pohareBBC Most but not all days are covered. |
|
Just read Big Franks post which is not good reading , but applying Occam’s razor , the lights are not on the panel for decoration and auriols for something to listen , it’s worrying this is going to head the total wrong way down the path looking for the answer , For me light comes on manage it....... |
For the record; DT had an excellent knowledge of the fuel system and had carried out auto’s with both engines at GI. |
Originally Posted by high spirits
(Post 10469249)
Toptobottom post #73 I flew with DT(as did many on this forum). He would never entertain deliberately crashing a helicopter and I never witnessed an argument with anyone he operated with. I know this is a rumour forum, but that’s quite frankly out of order..... please stop. |
TOPTOBOTTOM, There is some merit in what you post. We had a very strange set of circumstances surrounding a well respected and seemingly stable colleague who decided one day that life was just too much for him! Inexplicable.!
However, in this case I believe there is sufficient evidence (or lack of) to see DT being led down the garden path by the indications in front of him. Having said that, someone most probably switched both transfer pumps OFF during the flight!! In the end, that will most probably prove to be the root cause of this tragedy. It is no surprise that the current recommendation on seeing or hearing any fuel warning is to check the TFR pumps switches and CBs. It is simple fuel system. However, like most simple systems a "simple" simplex mistake can be catastrophic. For these reasons I don't buy into the psychobabble theories. Amber PUMP cautions = Pumps OFF = Supply Tanks Draining + Faulty Contents indications + Poor Confidence in the warning & cautions systems = No appropriate response from Pilot = 2 x Flameout = pressurised auto = uncontrolled descent. It could be that the supply tanks indicated FULL throughout. It could be that despite the "Memory" in the CAD that neither the Visual or Aural warnings manifested themselves properly in the cockpit. However, for all that to happen the Transfer Pumps HAD to be switched OFF!. In my view this is the only tangible and relevant piece of information that current EC135 pilots needs to assimilate. If you leave the TRFR pumps OFF, the supply tanks will eventually run dry. The sideshows of maintenance histories, anecdotal events of a similar nature, training, system design are all for the Sherriff to digest and decide upon. |
Toptobottom. Your logic says that in this case, you must consider the unthinkable. You chose your unthinkable theories with no evidence whatsoever. So let’s show how ridiculous that is. I can offer some theories with real evidence in this situation. What about Dave having a dashing ‘tash? Maybe he was a secret Village People fan? Maybe he couldn’t cope with being gay? Dave visited Moscow a few years ago, maybe someone was about to oust him as a spy? These two scenarios are ridiculous, however they meet your standards of evidence, ie “think the unthinkable”. Come on man! His family and friends read what is said here. He can’t defend himself. Show at least a little bit of respect........ |
Toptobottom
Sometimes the unthinkable does need to be thought. But after an exhaustive investigation by the AAIB (during which they will have considered the unthinkable, the thinkable and everything in between) they have come up with a number of facts and conclusions, none of which include the scenario you suggest. To make this suggestion, in disregard of the investigation findings and with no evidence whatsoever to support your accusation (and much to disprove it) is scurrilous, ignorant and dishonourable. OH |
Airbus: lack of priority for safety issues
That certainly seems to be a rational conclusion given that the latest evidence, link below, says that it took them over a decade to come up with a solution for what seems to this layman to be a major safety issue of which they had been clearly informed .
Apparently that is the view too of a witness from a British helicopter operating company who stated that the attitude of Airbus appeared to be: , " ...[Y]ou use your design department rather than us using ours to come up with a solution...." Scottish Review: Maurice Smith |
From the Scottish Review:
Ms Shelagh McCall QC, representing Captain Traill's partner Dr Lucy Thomas, raised the possibility that the pilot may have been flying using 'visual contact' (VFR) rather than his night-time instruments, and therefore believed he would have enough fuel to land. 'If the pilot had thought he was operating on VFR and had 65kg in the tank, they would not have needed a Mayday,' she suggested. 'Correct,' said Mr Stobo(director of operations at Babcock mission critical services). |
MightyGem , Agreed 1000% on that |
Sorry , but that theory doesn’t fit with endurance / distance covered with the tasks they covered ?.... |
Latest report on Scottish Review website
Scottish Review: Maurice Smith
(The FAI has, it reports, been put on ice till at least the beginning of July; though I presume that the timing of the next report mentioned in the text as early August is due to non-publication of the "magazine" in the month of July.) More to the point, the brief report does seem to repeat/ reinforce previous testimony about a known degree of unreliability of warning lights. And about a failure to address the problem? |
Originally Posted by Cleavage
(Post 10478583)
Does anyone recall (or have access to) what the required drill was for both a F PUMP FWD and a F PUMP AFT prior to Rev 12 (Jan 2014) of the Airbus Emergency Check List?
There's no mention of that drill in the AAIB report Appendix A, but it lists the drills separately. Does anyone know if it existed prior to the accident? Actioning the drills separately could leave both pumps selected off if the main tank contents are 'low'. FLIGHT MANUAL EC 135 T1 (CPDS) Emergency and Malfunction Procedures 3 - 20 CAUTION INDICATIONS F PUMP AFT (MISC) Conditions/Indications Failure of aft fuel transfer pump, or dry run. Procedure 1. Fuel level in the main tank – Check If main tank fuel quantity is sufficient to keep both fuel pumps wet: 2. FUEL PUMP XFER-A sw – Check ON 3. XFER-A PUMP circuit breaker – Check in If F PUMP AFT indication remains on: 4. FUEL PUMP XFER-A sw – OFF If main tank fuel quantity is low: 2. FUEL PUMP XFER-A sw OFF NOTE EEach fuel transfer pump is capable of feeding more fuel than both engines will consume. EIn hover flight conditions the unusable fuel can be up to 71 kg. The quantity of unusable fuel can be reduced to 7.5 kg when flying with 80 KIAS or more. FLIGHT MANUAL EC 135 T1 (CPDS) Emergency and Malfunction Procedures 3 - 21 CAUTION INDICATIONS F PUMP FWD (MISC) Conditions/Indications Failure of forward fuel transfer pump, or dry run. Procedure 1. Fuel level in the main tank – Check If main tank fuel quantity is sufficient to keep both fuel pumps wet: 2. FUEL PUMP XFER-F sw – Check ON 3. XFER-F PUMP circuit breaker – Check in If F PUMP FWD indication remains on: 4. FUEL PUMP XFER-F sw – OFF If main tank fuel quantity is low: 2. FUEL PUMP XFER-F sw OFF NOTE EEach fuel transfer pump is capable of feeding more fuel than both engines will consume. EIn forward flight conditions the unusable fuel can be up to 59 kg. The quantity of unusable fuel can be reduced to 3.6 kg when flying with 80 KIAS or less. |
Does anyone recall (or have access to) what the required drill was for both a F PUMP FWD and a F PUMP AFT prior to Rev 12 (Jan 2014) of the Airbus Emergency Check List? Having noticed this, not log after we got our 135, I can recall taking off with both pumps switched OFF(on purpose) to see what would happen. In the cruise, the contents of the Main Tank reduced as the fuel went through the "overflow"(correct term forgotten) into the Supply Tanks for a while, but at around 250kgs indicated in the Main Tank, the Supply Tank contents started to reduce, with the Main Tank contents staying the same. So, if BOTH Transfer Pumps failed below 250kgs in the Main Tank, you would only have the contents of the Supply Tanks for use. |
No, the only time that it should occur is when the main tank has run dry.
|
Originally Posted by Cleavage
(Post 10481380)
I guess "should" being the operative word.
If you were in the hover or at a low speed surely the remaining fuel in the tank would be aft, leaving the forward pump uncovered, and resulting in the F PUMP FWD being selected off. As the pitch goes down to increase speed, surely the fuel moving forward would now uncover the aft pump, resulting in the F PUMP AFT being selected off. If there was no drill for captions on both fuel pumps and neither of the individual drills tells you that one of those should be turned back on, isn't there a chance that they can both remain off with some fuel still in the main tank?? If its compounded by the reported fuel sensor problems, surely there's a chance of both fuel pumps being off and believing the fuel is in the supply tanks? (Tanks, capacity, pumps, usage i.e.) When someone gets captions about the fuelstate, pilots normaly get realy sensitive, checking the fuel state and how much fuel is in which tank, knowing, that there might be unusable fuel, depending on which pump isn´t working. Knowing, that the engines take their fuel from the feeder tanks does mean, that they are the tanks I focus on. If fuel isn´t transfering from the main tank, I do something about it or make decisions to asure a safe landing. We wont get an answer, why this time the obvious wasn´t done or which assumptions led to continuing the flight, despite the warnings. But I won´t blame it on the general fueltank/pump setup, which is used in hundreds or even thousands of helicopters worldwide. (Bo105, BK117 all variants, EC135, EC155) and except from an autorotation, where the crew covered the warning lights with duct tape, I don´t recal incidents which are related to the general setup. |
Inquiry back in session today ....... |
All times are GMT. The time now is 01:43. |
Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.