I agree SASless, I have seen some woeful use of automation over the years. Correct use of automation should be an integral part of a type rating. We don’t want to lose hand flying skills as is happening in the airline world but having just got way out of shape and massively over-torqued the only sensible option in this incident was to engage the autopilot and then start working as a crew as to what they were going to do next. I am still completely mystified as to why a 6000 hour plus pilot would chose not to (or didn’t have the knowledge how to) engage simple altitude hold and heading hold modes. I can’t imagine how frustrating that must have been for the co-pilot with the poor manual flying skills being displayed by the Commander.

I presume you mean “automation”…..but then again, maybe not; I’ve seen a few “automatons” in the cockpit in my time, too.

Corrected! But me too.

Thankfully, they do now have a more enlightened staff when it comes to the rotary world and due to the efforts of certain individuals, the tide seems to be turning. There is some way to go with regard to other operational issues, but as I come to the twilight of my career, that is unlikely to happen in my time in the cockpit.

Proper understanding of automation is essential. I’m certainly not against the view of manually flying in IMC for the purposes of maintaining a perishable skill, however once presented with the evidence that your manual flying is of a detriment to the flight then it’s time to leave it to the autopilot. Personally I think I would have been so spooked by the initial incident that I wouldn’t hesitate to let the automation do it for me, instant stress reliever.

Indeed. I can’t imagine there are many pilots out there who are not 100% behind this comment. This was a very strange (and probably the least safe) decision in a stream of questionable decisions. I can’t help but think that the CAA must be left in a difficult position now with regards to the AM position. It's one thing saying the right thing to pass an audit but when you are presented with concrete evidence of not doing the right thing - are they able to turn a blind eye?

Food for thought....taken from the US FAA discussing Helicopter IFR Operations.

There are sections of the document that could be used to compare the actions of the Pilots in this incident and the Bryant tragedy, the OZ Huey crash...or every other CFIT crash....no matter what jurisdiction they occurred within.

Helicopter flying in marginal weather shall always be fraught with risk.....managing that risk is the key.




https://www.faa.gov/regulations_poli..._Chapter_7.pdf

[QUOTE=SASless;11067530]Food for thought....taken from the US FAA discussing Helicopter IFR Operations.

There are sections of the document that could be used to compare the actions of the Pilots in this incident and the Bryant tragedy, the OZ Huey crash...or every other CFIT crash....no matter what jurisdiction they occurred within.

Helicopter flying in marginal weather shall always be fraught with risk.....managing that risk is the key.



I had not seen this document before and it contains some great advice. However, as you allude to, it does seem that some pilots are incapable of taking such advice no matter where they come from or their experience level. Perhaps it’s time to rethink safety and rather than introduce more regulation that produces an increased admin burden on those that already comply, we simple identify those that are prone to taking risks and non compliance and stop them flying. This is what the motor industry does either through licence suspension or increased insurance premiums so it is not financially viable to drive.

I’ve always said that VFR is safe. IFR is safe. It’s in between the two that is the tricky part. The main thing is to make a safe plan of how to do it and how to escape - and stick to it.

That's right. Everything you need to know about it is written in the RFM and the AP manual, both of which are required to be carried in the aircraft. How it is that pilots arrive on annual recurrent simulator courses without knowing the system basics, or having a thorough functional knowledge of system operation, or knowing system operating limitations for that matter, when it is well documented in publications carried in the aircraft is an eternal mystery to me.

Gulli.....you ask a. question that you very well know the answer.

Because t hey do not use that equipment on a daily basis, have no intention of using it, and therefore perceive there is not need to know anything about it.

That they are being flat assed stupid for all of t hat alludes them.

Far too often...we read of them in the newspapers and folks wonder how it could be they are no longer with us.

Every time those of that mindset crash in a simulator.....that should be a jolt to their sense of complacency they live in.....but they laugh it off and think the Sim is just a big ol' video game.

Many times I stopped the training after the first flight.....sent them to the classroom and turned on the video of "THEIR" performance in the cockpit.....then went for coffee while they watched "Their"" performance that resulted in what would surely have been a fatal accident.

Most times that was all that was needed to change their view about the seriousness of Simulator Training.

If I. did not see visible signs of a reawakening of the two....we did a step by step analysis of what they had done to kill themselves and every time we had to do that....I had their full and undivided attention afterwards.

Then it seemed the Sim sessions went a lot better.

It was. not "me" that made the difference....it was the accumulated experience of the Sim Instructors over the many Years that was analyzed and adopted into a program designed to expose trainees to procedures, techniques, and various ways of enhancing the safe operation of the aircraft....all of which were gleaned from earlier Trainees as well as the Instructors.

That is one example of going outside your own Operation to. look for new and/or better ways of doing what you do in your Operation.

:Lots of folks around the World are flying. Helicopters....we can and should learn from all of them as best we can.

One thing for sure is no one Operator or Authority has the monopoly on how to do this helicopter flying thing in a safe and efficient way.....as sometimes there are several right ways to do the same task....picking the best way is the key.

If you hold a ATPL....you are supposed to be a Professional....and that requires continuing study, learning in your Profession, meeting high standards of Professionalism.....and of course mentoring those who are new to the Profession.

I learned a lot while teaching in the Simulator....as lots of very good people passed through the school and they were a knowlege source that bore listening to when doing your instructing.

There were also some that Gulli describes that did not want to be there and resisted the opportunity to learn....and sadly even displayed a patently bad attitude of refusing to entertain the notion the Sim Training was of any value to them.....and it was them that needed that training the most.



“No matter how much experience you have, there’s always something new you can learn and room for improvement.”
― Roy T. Bennett, The Light in the Heart

Interesting post SASless. Seems there are a few in the industry who just refuse to learn and looks like the industry doesn’t intend to do anything about it. Sad state of affairs really. Seems that even politicians have more honour - Matt Hancock quoted as saying - Those of us who make the rules have to stick by them and that’s why I have to resign.

Report published: link to report on G-LAWX

Post #34 - it was published mid-June...

Sorry - it was on August 2021's list...

Yes, they seem to ‘re-publish’ bigger reports with the end of month summaries now. Trying to ensure it gets seen I suppose..

Ironic or good value for money?
https://www.cranfield.ac.uk/courses/...ety-management

I can recommend that course, certainly worth your time!

I alluded to that in post 43

Can’t comment on the course as I have never completed it however, if my 30 minutes on Google has given me the correct information than is this the biggest case of ‘do what I say not what I do’ in the history of aviation?

Thanks 212man, I see that now. Took me a while to join the dots. It really does beggar belief.

It is an insult to the industry

Flight beyond sight, I couldn’t agree more!

I completely agree. I thought it was bad but it appears it is much worse than first meets the eye. It looks as though we have a Commander who is also the MD, Accountable Manager and Safety Manager whose actions lead to a serviceable helicopter coming within 28' of impacting the ground.
On the information presented the individual suffers no sanction from the Company or Regulator and continues to lecture on Aviation Safety Management at an international recognised university.

You raise some excellent points highrpm. Given the points you raise I simply don't understand why Cranfield continue to allow the individual concerned to be part of their academic staff.

ICAO Annex 13:
I would suggest taking part in that particular Cranfield course before crucifying both a person and his relationship with the university. I did that module before this particular incident but it would not surprise me if the topic will be discussed during the upcoming version of the course.

Surely if you don’t practice what you preach you have to be held accountable for your actions? I’m not a great fan of politicians but generally they fall on their swords when they are busted breaking the rules. Why is it acceptable for a senior manager and pilot who held the very rules which he preached with such disregard himself to be allowed to reach atonement by lecturing other people on why they must follow the rules?
I’m aware of other pilots in the same regulatory regime who have had their collars felt for minor airspace infringements. Will they be absolved from any punitive action if they are paid to lecture us on why we shouldn’t bust airspace? Probably not.

Trust me, this is covered in that particular course.
I don't know if we can call him a public figure, he hasn't been on Strictly Come Dancing yet AFAIK. But seriously, is there such a thing as 'more accountable'? You either are or you're not. In this situation the aircraft commander is the person who is accountable when a flight doesn't go as planned, and an accountable manager is where the buck stops when the situation warrants the attention of any kind of authority. We tend to hold persons in positions such as these to certain higher standards, but is that fair? I mentioned in an earlier post that even though someone has lots of titles on his or her business card, when it's your behind on that flight deck seat you're just another pilot stuck with the same limited information that any pilot has and having to take the same split-second decisions that every other pilot will have to make on a day to day basis. And that process is just as liable to include errors of any kind as any other process that includes humans. I would even go so far as to state that having an extra responsibility within a company can make the process of taking those decisions even more daunting as you can't push the job of explaining everything to the client/boss/authorities towards someone else.
I agree, but as you already mentioned, it depends on the size of the organisation. Yet, this is something that the company has already addressed, see 'Safety Actions' on page 64 of the report.
We're linking two different topics here as the outcome of this particular safety investigation and the subjects taught in a particular Cranfield course are not in itself connected to each other. Having said that, based on my participation in that course a few years ago I would say that the role of leadership and the structure of the SMS system are very much part of the course, were discussed extensively and I was under the impression that no subject was taboo. The lecturers (it wasn't just one person lecturing during those five days) were all very open in discussing incidents and accidents that were relevant to the subject at hand and personal experiences were very much a part of those stories. Because of this I would not be surprised if the G-LAWX incident under discussion here will be addressed during that course, but the only way to find out is to go there and take part in the course.
You don't go into lecturing to reach any kind of atonement. Also, does that mean that a lecturer cannot make any mistakes, and is not allowed to have made any mistakes at any point in the past? I'm playing devil's advocate here but in my personal opinion, someone who does know what it is like to be involved in a sticky situation may well be the better lecturer on that subject. Also, please do not forget that it takes a brave person to stand up in front of a group of professionals and admit that you have done the unthinkable at some point in the past. The whole culture that we are trying to achieve within aviation is one where we can have adult conversations about these topics, where we can admit that yes, we have perhaps erred at some point in the past and where we can take this experience and learn from it so that it doesn't happen again. I don't see where doing this in front of a classroom instead of within the company is in any way wrong.

Jhieminga - I don't disagree with the underlying sentiments of your post however I hope that you can understand the issue regarding a 'Just Culture' in that this individual was involved in a serious incident as outlined in the AAIB report. We have all done things which we regret and would have done differently and sharing those experiences so that others can learn should be commended however I suggest that you have another read of this report. The Commander claims that he did not engage the autopilot as he was aware of skill fade and wanted to practice his manual flying skills even though any sane person would say that that was not the time for IF practice. He also goes on to state that he was aware of the overtorque and used that as the justification for the second ill advised approach when the reports mention that at some point prior to this they were visual with the ground (so could have landed in the nearest suitable field or returned to Birmingham to shot an ILS.)

[QUOTE=Undecided;11110568]…his job was to protect his pilots from commercial pressure yet it is clear that he succumbed to it on the day of the incident and therefore it is most likely that this was not a one off.]

Particularly this. It is a near certain thing that the way the decisions got made followed a pattern. In this event, even the first approach which should have chastened the Commander into a rethink was not enough to break it. Absolutely shocking. And that the PM did not put in a robust challenge speaks volumes about the real culture irrespective of what is on paper.

The main point to come out of this is how pressure to get the job done can sometimes overcome common sense and good judgment. It’s easy to smugly pour scorn on this from an armchair but I’ve always said that the most difficult thing about corporate rotary is when to take stock and say no!

That comment holds true for SAR and, I suspect, HEMS as well.

This is the sort of incident that is dissected well on military (and I'm sure civilian) Flight Safety courses - too much focus on achieving the task, poor weather, adverse cockpit gradient and a breakdown in CRM - leading to poor decision making - all ingredients we have seen so often in so many accidents.

Such dissections allow you to measure yourself against the decisions made - you can ask yourself how far down that same path would you have gone before you said no. If you get to the end and still don't see a problem - then you are the problem!

I agree, having done both.
However, having the man who pays your salary (and who can dismiss you from your hard earned job with a wave of his hand) sitting behind you in the cabin adds a certain extra pressure.

I've never forgotten the story of one pilot who landed on the aircraft owner's lawn on his first day in the job, but slightly in the wrong place. He hadn't been briefed on the correct place. He was told he was incompetent and never to return.

ShyTorque and Crab, I completely agree with your points which is why this particularly incident is so shocking. As we are agreed that the hardest part of the job is knowing when to say no, those pilots that work for a management company/AOC need as much support and back up from their superiors as possible. This is the whole point of having a management structure and a SMS structure to identify these hazards and mitigate the risks. We are all aware that feeling pressurized to operate below legal limits or those limits that the pilot feels comfortable with (whichever is higher) is a fast way to yet another high-profile accident.

Undecided,
I'm making a general comment based on my own experiences. I don't know the pilot concerned and would never make a personal and public attack based on what appears to be hearsay.

I’m making my comments based on factual information that is contained in the report. I believe these matters should be discussed in forums such as this in a genuine attempt to make our industry safer and trying to understand why accidents and incidents such as this keep happening. It seems clear that a management structure and mature SMS system did nothing to prevent this incident.

Undecided - I agree, you can tick all the SMS boxes you want on paper but when someone wilfully disregards the protocols - as we saw also with the Kobe Bryant crash - the result is almost inevitable.

I find it difficult to understand how Cranfield allow him to lecture on safety when he appears to have a total disregard for it other than in an academic way.

Perhaps this is intellectual arrogance at its worst, someone who knows all the reasons for safety protocols but believes himself to be above them.

But not here:

Please note that I haven’t defended the pilot involved. As I said, I don’t know him and have no reason to defend him. However, I have read the report and it’s obvious a lot of errors of judgement were made and things could have gone even more badly wrong, thank goodness they did not.

On a public forum such as this, further accusations against an individual based on hearsay (as in outside of the published report in this case) may require the individual making them to justify themselves in a court of law. The forum rules are quite clear on this; although it’s an anonymous place on the face of it, the owners of the website may be obliged to pass on details of any of us and will do so if required to do so in a legal situation. I have no desire to get involved in such an issue - having very recently seen the price lawyers charge these days I value my house too much. Having been a member of this forum since 1995, I tread the line carefully.

P.S. I hold absolutely no clout over the actions of the CAA!

Hi SAS, indeed twas me..........the odd thing was I met a lot of resistance amongst my very close training colleagues. Some of which simply could not make the adjustment that the Pilot Monitoring really has an Executive role to play in these types of approaches and the role of the Advanced cockpit and Automation could play. Lots of agreement and support form the Regulator and the wider Rotorheads community. I have to say it did not make me too popular with my own Company Training colleagues, many of which I felt understood more after the following spate of NS HF/Automation cock-ups. Looking back, the helicopters we began to operate were far more advanced than our thinking, strategy and understanding at the time. This led to very poor training responses which at the time were best characterised by an over reliance on manual handling skills. Most of the TR course for complex heavies still treat the automation like an afterthought rather than integrating the concepts right from the get-go. In my later role for the OEM we had one operator using EC225 and L2 with dual rated pilots. There risk assessment and analysis led them to conclude that "If the L2 doesn't have that feature we will not use it on the EC225", effectively reducing the 225 to an L2! As [pilots, trainers and managers we are the most influential players in our expert field! When we fail to analysis/adjust/mandate effectively it leads to horror shows like this one. Fear is the great moderator and a pilot without fear due to lack of understanding of the dangers he is about to experience is the most at risk.

Safety Officers, Risk Assessors and Nominated Post holders need a healthy active imagination in order to identify hazards and risk and mitigate effectively. Sadly, the modern SMSA, in my opinion, is an overly complicated and huge administrative burden on Operators that its true value and effectiveness is often lost in the ether.

Good to see you back in the Fray SAS long may it continue.

DB.