Yes, it is fair to say that the lot of onshore charter pilots is more fraught with cultural pressures and often operationally challenging environments (unofficial weather measurements/assessments; off-field landings; ad hoc flights to new and perhaps unsurveyed environments) than that of offshore peers. But there has to be a line drawn when one or more decision points run up against better judgement. Gratitude for getting the job in critical conditions is perishable (at best); the consequences of a proper cock-up are severe and long-lasting. Ultimately, no one will thank you for killing them.

Well we do have the magnetic North Pole! Santa Claus lives here, not Lapland. Kids can mail letters to him using the Canadian Postal Code H0H 0H0 and they get answered!

If the commander is who I assume him to be from the report description, there is more than a little irony to this event, and potentially salient lessons for all, given his other roles and qualifications.

I think I know what you're trying to say, but to me it also shows how being in that seat and being in command is a great equaliser. At that point everything that's on your business card is suddenly irrelevant and you're just another pilot, having to deal with the situation and the pressures.

Is this the same Company that do the Royal Flights....?

No it isn’t.

FNW, TVM......

It's the same company that the report references as "the operator" in writing, yet names them directly in three of the eight safety recommendations.

I thought I would refresh my knowledge of the operator but reading the website of an operator at a time like this is an extremely strange experience with a whole range of emotions and thoughts. Just the company strapline “As a pilot you cannot buy experience; as our customer, you can” provokes a wide gamut of emotions but mainly sorrow.

Sorrow for those directly involved in this event, sorrow for the other employees in the company, sorrow for those in the industry that do a good job and feel sick to the core when reading of incidents such as 'LBAL, CRST, WIWI, N72EX, but most of all, sorrow that not all in our sector seem to have learnt from the numerous similar accidents that have happened in recent years. Thanks heavens no one lost their lives, but reading the report leaves me feeling almost as sad as if they had.

HS

Once again....we see a Report that read over Tea and Biscuits in the lounge with a soft fire behind the hearth makes one simply wonder how it could happen to such qualified, experienced, and decent people.

But, the other venue....in the hot seat on that miserable day with darkness approaching and a customer that of all appointments is running late.....that Tea is cold and bitter and the biscuits a bit stale.

Why is the hardest word in the Pilot's vocabulary to say....is the word "NO!",

The problem is when the weather is marginal but legal that we too often find ourselves wishing we had held onto discarded options. Most of us survive those less than stellar decisions but sadly too many of us do not survive.

When you see your options slithering away like folks owing you money that see you coming towards them with outstretched hand....perhaps it is time to opt for some fresh hot tea and biscuits and arrange ground transport for the Landed Gentry.

Mucking about in the dark and. murk over uneven terrain in what is arguably a very well kitted out aircraft with just about every kind of Gucci Kit you could reasonably ask for.....and then some....and not just filing IFR and going to the nearest Airfield with an approved IAP just has to make you wonder.

The very good news is no one got hurt, the aircraft was not damaged....some hat sizes got shrunk....and perhaps some real lessons learnt.

A for what it is worth.....an EMS Operator in my hometown lost a Bell 412 in Bluefield, West Virginia one afternoon....killed two pilots and the two Flight Nurses when they flew smack into a very hard mountain on the far side of the Airport while doing an Instrument Approach.

The Captain was the Base Manager, Training Captain, and Safety Officer all at one time. He was a good and decent Man, a well qualified pilot, married with children.

There is some wisdom in spreading the jobs around to different people so there is a widely exposure in the decision making. process....which done properly enhances safety.

We are all human with the vulnerabilities that entails.

Why oh why do we reject the automation and insist upon manipulating the flight controls ourselves when we could be seen as being rather dashing as we push buttons and twist plastic knobs.....and not get ourselves into the pickles we do that a properly managed Autopilot system would not.

Couldn’t agree more. So many lessons to learn from this that it needs to be re-read and digested numerous times. PinS won’t be the answer to everyone’s problems as many corporate variants of 92, 109, 76 aren’t appropriately equipped, and should they exist in the U.K. PinS would be expensive to implement and only useful to well frequented sites which makes up a small proportion of the overall charter market. Is any variant of S92 certified for PinS? However for that portion that does frequent the same landing site time and time again, in a fully RNP APCH certified modern machine like a 145/169, and is willing to invest in approach design and certification, it has to be said that the UK regulator have been far from helpful or progressive in approach. At this time the CAA are processing around 10 RNP approaches a year, mostly to airfields with an ILS. The DfT haven’t been overly forward thinking or helpful either, EGNOS SOL service participation ending in a weeks time. Expect the LPV option for U.K. approaches in your FMS to disappear in the next AIRAC cycle post 25/6/21 (15th July). To me it’s depressing that the technology is there to make life safer, but in the U.K. your hands are tied from using it. In continental Europe on the other hand numerous hospitals have PinS approaches and connecting networks. A real shame.

At least the co-pilot said and did something which may have averted a far less fortunate outcome. Plenty of times whilst I've instructed experienced crews in the simulator the co-pilot said nothing and did nothing and seemed perfectly happy to arrive at the scene of the accident sitting on his hands in silence.

Yes, credit where it's due....

I partly agree, but would also expect the greater knowledge to have led to more informed decision making. Hopefully the lessons learned will add to the quality and authenticity of the courses he teaches.

For clarity - I’m not having a dig

Point in Space approaches have been demonstrated by Sikorsky in the past.

The technology exists and is installed in many helicopters.

Low Level IFR route structure is within the capability of the Industry with the major hurdle being the Authorities around the World that seems to be the hardest nut to crack.

Many EMS operations in the United States have an IAP to the Hospital Landing Pad which are off airport and are such IAP's.

I attended a Safety Seminar in Raleigh, North Carolina at least ten years ago where Nick Lappos talked of that work by Sikorsky using an S-76 to do those Point in Space Approaches.

He was a very strong advocate for the expansion of Helicopter IFR flight in non-traditional IFR environments.....or in plain language....doing Helicopter IFR using the unique ability to land at places other than legacy airport facilities.

That is the hard task...getting the authorities to bless and embrace that change in thinking .

It can be done...and done safely with the right equipment and training, combined with a careful intiial survey of the intended approach and surveillance of that to ensure no changes occur....much as has to be done with current on-airport IAP's..

I’m a great fan of PiNs approaches and I have no doubt that they would bring huge safety benefits if they were embraced by the regulator in the U.K. However aren’t we missing the point here; it seems that (according to the AAIB report) the crew may have breached multiple rules and Company Procedures whilst attempting to carry out a VFR approach in a MP helicopter with what appears to be very poor MCC procedures. .

Some offshore operators mandate procedures for night VGA approaches including the use of automation, based on hard won experience. This seems like a procedure that is crying out for the same.

Was it Double Bogey that was involved in the improvements in Night Offshore Approaches?

One of the regulars was....and my fading memory tells me it might have been he that was involved.

Can you truly regulate a PiNs approach? Night offshore has a certain level of expectation that you are flying into a clear area and the destination will follow given rules, lighting, obstacle clearance etc. The weather radar will pick out other targets.

PiNs into private landing site at night - Doesn't that just give you a better level of comfort until you discover that Vodaphone have put up a new mast or the trees have grown taller over the last 7 years since it was last surveyed?

We do 2D & 3D approaches to low minima in environments that are either strictly regulated and surveyed, or checked on board by means of weather radar in the case of offshore. For ad hoc sites onshore all that is needed are higher minima to take account of near terrain, obstacles and navigation performance. Because no fool is going to fly down blind into an environment that has not been surveyed for currency, where another fool might be flying in conditions unsuitable for VFR flight. Surely.

I believe that PiNs approaches would allow the full capabilities of modern helicopters to be used which will have huge safety benefits for the onshore community. However any flying in IMC requires a level of discipline and adherence to rules and procedures. From what I have read in the report this was not present during this flight, some or most of it was IMC given that it was below VMC limits.

I worry that the regulator will cite this as a reason for not implementing PiNs approaches on the basis that we can’t be trusted to follow the rules. It appears that no follow up action has been taken by the regulator and his company bar some minor Ops Manual amendments.

Pilots are often held to account for minor airspace infringements but not the big stuff. As a previous poster commented, luck was on their side that day on a day when luck should not have been needed. If that luck had not been there we would be looking at another Shoreham type accident.

So you increase the minima to make it safer which means they still can't get the customer into his home site - so what next?

Pilots like these seem happy to break the VFR rules to try and get in - what will stop them ignoring the new safer minima to do the same thing?

Doing something dodgy and getting away with it a few times does not prove its safety or guarantee the next attempt will be successful but that appears to be how some onshore pilots work.

Forgive my naivety -- all I know about the rotary world is derived from enjoying seeing Shawbury's aircraft using one of our fields -- but what kind of corporate client is important enough to generate this sort of decision-making? Why is it so difficult to say "no" to them? Are some clients so exalted that a car pickup from Wellesbourne (or even Birmingham) just wouldn't have been acceptable? Or are there genuine issues such as security, perhaps?

High net worth clients are mostly accepting of pilot operational decisions. It is when pilots get the false impression that said high net worth clients might not be so accepting of said pilot operational decisions that self-imposed pressure causes prudent sensible decision making to be thrown out the window and the "can do" mentality over-rides everything.

One legend in his own lunchtime whose body was found circling the sharks near his yacht was well known to put pressure on pilots and engineers. There was also the accident in Norfolk. It really can be that bad at that level, hence my comments about self-esteem above. Corporate pilots need to have a good opinion of themselves, which is rather contrary to the company person suggested by EASA in their KSA 100 exam. It caused quite a stir when I suggested that pilots actually need to be a little anti-authority.

Phil

When an Authority can say one check ride every six months and you are both current and proficient in IFR/IMC flight....being a bit anti-authority might just save your life.

Just because the Authority says you can....doesn't mean you must or should.


Crab,

With the advent of GPS, FMS systems, Autopilots with four axis capability, RadAlts, TAWS, GPWS.....and FLIR....can you with your SAR experience....envision an IAP for that landing site that if properly surveyed, flight checked, and re-surveyed monthly for changes in the way of obstructions to include checking with the local authority to see if there. have been any Building Permits filed for or approved within the surveyed flight path?

What Minimums would you think workable and safe?

The Operator/Client had gone to the lengths to provide a visual glide slope and landing azimuth device....which shows their intent was to find ways to make their operation safer by seeking some usable technical assistance.

Would not that Point in Space IAP be one such thing that would have worked for them had they had that option?

Yes, of course you could create a workable instrument approach to the LS - it has the advantage of being on the top of a hill so the obstacle planes would be fairly benign.

However, you still have to revert to visual flight once you get to your minima since you don't have all the advantages of airfield lighting to help you identify the LS in the dark.

With all the caveats you suggest in place, 150' minima above the elevation of the LS would seem reasonable but probably at a low speed of circa 60 kts to enable quick transition from instrument descent into visual approach and landing.

The problem with this flight wasn't the aircraft capability though - it was poor decision making and self-imposed pressure (as we see all too often) - clearly the suggestion to go straight to Wellesbourne would have been the adult decision.

I note they were both ex-Mil and ex-Sea King but don't know which Service they had been in - that may have had a bearing on their decision-making.

I think what made this particularly vulnerable to making the major error the commander (particularly) did, was that the flight was actually ok - if marginal - for 24 of the 25 miles of the route, over the lower ground that formed all but pretty much the final approach. It was the rapidly rising ground of the sharp 500ft hill, towards the top of which was the LS, that suckered the commander into having a go. Had the LS been on much lower ground just 1.5 nm to the east he would have landed routinely, but trying to get that last mile or so took him in to higher ground surrounded by mist – in the twilight. He didn’t actually descend to end up 28ft above the ground – the ground rose up as he was flying along, fairly level, albeit in far too poor vis for that last mile.

If an alternative LS had been identified and arranged for poor weather use somewhere on this much lower open ground 1.5nm away, it would have been a far more appealing divert option than heading back to Wellesbourne, let alone back Birmingham which had the only instrument approach. And the flight could have been undertaken legally and safely. Given the scale of the operation I would have thought this would not have been too difficult. Maybe for other frequently used LSs on hills with low ground nearby, this would be a wise idea……

I’m certainly not suggesting the crew were not at major fault – just putting some context into how they might have got themselves into the situation.

From the report They can't cite unfamiliarity with the terrain and local area as an excuse.

I agree, yet familiarity may lead to complacency, or at least a slightly lower level of attentiveness towards the risks of this particular combination of rising ground, low visibility and all the other factors. I am not trying to absolve the crew of any blame, but it is very easy to sit here and come up with what should have been done at the time. The crew painted themselves into a corner, were fortunate to come out of it with only some dents in their ego instead of in the airframe, and we've got a good report out of it that should lead to some significant improvements in the industry (hopefully). If you've ever found yourself in a situation that you should have avoided, you know how long you can continue to kick yourself for being so stupid. I suspect that the crew has done enough of that already.

Incidents like this one should be analyzed and with the benefit of hind sight....provide a forensic examination of what happened....how it happened...why it happened....and provide Lessons Learned for everyone....the Crew, the Operator, the Client, and every other Pilot and Crew that goes forth doing what we do as Helicopter Pilots.

Otherwise there is no really good outcome to these things.

The Crew are good and decent people....but they as we all are....are Human and thus susceptible to make mistakes as we all do.

I do not look down on them or find them to worthy of being branded for life over this one event....they were trying hard to carry. out their assigned task in marginal weather and approaching darkness.

They made some decisions that I bet you if there was a way to re-wind the Tape and have a Re-Do....they would do things differently.....but that is not real life.

At least they lived to tell the tale....unllike so many others that wound up in a smoking pile of wreckage.

What is interesting to me would be hearing from them about how upon reflection they would do the flight again if they could.

We should learn from our mistakes not be crucified for them.....as long as we make them while trying to do it right.

Sometimes even the most experienced Pilot or Crew is set up for failure by a training deficiency, SOP, or Rule which only comes to light when something like this happens.

SASLESS, I agree with your sentiments with regards to the co-pilot but not sure it holds true for the Commander.
For me, the most damning part of the report is the part when, having got horribly out of shape during the first approach and almost hit the ground which culminated in a massive over-torque, he elected to have another go even though they knew the weather was nowhere near suitable. Personally I don’t buy into the ‘we needed to get the aircraft on the ground because of the over-torque’ argument. There is no evidence in the report that this was never discussed as a crew, no checks were run and no emergency call was made. Would we be so dismissive of a driver who was driving at 120mph because his passengers were late and wanted to get home?’

https://www.helicopterinvestor.com/a...-training-457/
I was aware of this already but not sure if it was initiated before or after the incident?

Gulli has been telling us of how common it is for Sim Students arriving without full understanding of the avionics onboard the aircraft they fly in the course of their employment.

I saw that in the Sim as well.

I also see a common thread in too many crashes where Pilots refuse to use the full capabilities of the aircraft and insist upon hand flying the machine when they need to reduce their workload.

That is a direct byproduct of the lack of proper training, poor SOP's, and a failed SMS.....which all can be laid at the feet of Management.

Pilots....Line Crews and Training Captains have a role to play in seeking Industry Best Practices for their own Operations and that requires looking outside their own to others to seek those better ways of doing business.

So....a question is why is this "new" training "new" an "unique"?

It is for sure needed and shall prove to be beneficial.

212man - given the Company is the same, perhaps it is born of 'lessons learned' or some form of atonement.

The director’s comments on AFCS authority versus pilot authority aren’t very inspiring.

I followed the link reference the automation training being offered. The other articles were about the EC225 receiving certification in Russia which took place in 2015. Therefore it looks like the article pre-dates this incident.

It's not many years at all since the CAA insisted on hand flown instrument approaches during check-rides, rather than being allowed to "cheat" by using the automatics and coupling it all up.

Yes - I have commented on that before. At one point, around 2004, the Head of Training relented to lobbying and allowed the use of ALT hold while copying the METAR - I have seen it in the minutes of a TSLG meeting! There were some more enlightened FOTIs, but they were using common sense rather than policy, based on their currency on the EC225 etc. Policy changed once the Head of Training had his 'road to Damascus' moment after being on the S-92 JAA OEB team, and took a 180 degree view on the topic.

Shy,,,,,Perhaps the CAA might get out of the Dark Ages and start looking outside of their own small circle for Industry Best Practices THEN issue Mandates and Rules.

Our FAA is just as bad in that regard.....far too often the aircraft designers are far ahead of the technical expertise of the FAA which has an adverse effect on related. outcomes.

I am sure the CAA is no different.