Fatigue theory over Islander air rescue deaths
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Fatigue theory over Islander air rescue deaths
The investigation identified the following causal factors:
1. The pilot allowed the aircraft to descend below the minimum altitude for the aircraft’s position on the approach procedure, and this descent probably continued unchecked until the aircraft flew into the sea.
2. A combination of fatigue, workload and lack of recent flying practise probably contributed to the pilot’s reduced performance.
3. The pilot may have been subject to an undetermined influence such as disorientation, distraction or a subtle incapacitation, which affected his ability to safely control the aircraft’s flightpath.
AAIB Report here;
http://www.aaib.dft.gov.uk/sites/aai...06__g_bomg.cfm
1. The pilot allowed the aircraft to descend below the minimum altitude for the aircraft’s position on the approach procedure, and this descent probably continued unchecked until the aircraft flew into the sea.
2. A combination of fatigue, workload and lack of recent flying practise probably contributed to the pilot’s reduced performance.
3. The pilot may have been subject to an undetermined influence such as disorientation, distraction or a subtle incapacitation, which affected his ability to safely control the aircraft’s flightpath.
AAIB Report here;
http://www.aaib.dft.gov.uk/sites/aai...06__g_bomg.cfm
I admit, I haven't read the report but I am surprised why he would be 'fatigued' and have 'workload', when he had 'lack of recent flying practise'?
Doesn't make sense.
Doesn't make sense.
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BN2 Accident off Machrihanish, 15th March 2005
Mr Bernoulli, lack of recent experience would lead to a higher workload, however that link is no more than a casual factor here, the increased workload was due to a Single Pilot IFR flight at night in very poor weather conditions. If you have never operated in these conditions, well I have, and can assure you a 'high workload' is a realistic description.
If you read the report those points will become clear.
The report makes very sober reading, especially to one who knew the Pilot. I do not agree with the whole report but on balance perhaps it is not too far from what actually happened that fateful night. The linking of the Liverpool accident is probably relevant, however this accident http://www.aaib.dft.gov.uk/sites/aai...pdf_501869.pdf is probably more relevant.
On an aside, Loganair have lost 3 hulls in the last 10 years, 5 aircrew killed in these accidents, makes you think....
If you read the report those points will become clear.
The report makes very sober reading, especially to one who knew the Pilot. I do not agree with the whole report but on balance perhaps it is not too far from what actually happened that fateful night. The linking of the Liverpool accident is probably relevant, however this accident http://www.aaib.dft.gov.uk/sites/aai...pdf_501869.pdf is probably more relevant.
On an aside, Loganair have lost 3 hulls in the last 10 years, 5 aircrew killed in these accidents, makes you think....
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No one would seriously suggest that the BN2 crashes were in any way linked to the SD 360 accident but they may be indicative of of a company culture. As anyone who has operated the BN2 Air ambulance will admit there but for the grace of God................I think we can all see the truth in the the detailed analysis, it was a f**king hard job, limited resources and very difficult operating situations, eat your heart out routine operations with computer generated weather,notams and all the rest, these guys operated with minimum information and maximum commitment. God bless you Alan and Guy you were doing a job you believed in.
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BN2
'Meeb', don't quite get your point that you don't agree with the report's findings ! What is it you don't agree with ?
This was a routine amb. flight to Cal and as such would have been the most frequently operated flight of the Western Isles,as indeed it still is today albeit by a different operator.
Those in the know will realise that it would not have been a difficult approach in the weather conditions of that evening and it would be bread and butter for any of the Loganair Amb. pilots .
For any one who has done that approach especially at night will know just how difficult it is to attain any kind of visual reference during both the outbound and base turn segments of the approach due to the approach being over the sea.In my opinion the pilot may have tried to convert to a visual approach during the turn and lost sight again of visual references.In this case it becomes very similar to the G-BEDZ accident in Tingwall,Shetland several years ago !
As someone else said.......'There but for the grace of God'......
B.
This was a routine amb. flight to Cal and as such would have been the most frequently operated flight of the Western Isles,as indeed it still is today albeit by a different operator.
Those in the know will realise that it would not have been a difficult approach in the weather conditions of that evening and it would be bread and butter for any of the Loganair Amb. pilots .
For any one who has done that approach especially at night will know just how difficult it is to attain any kind of visual reference during both the outbound and base turn segments of the approach due to the approach being over the sea.In my opinion the pilot may have tried to convert to a visual approach during the turn and lost sight again of visual references.In this case it becomes very similar to the G-BEDZ accident in Tingwall,Shetland several years ago !
As someone else said.......'There but for the grace of God'......
B.
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bral and waaf, thank you for your comments. The reason for my last statement was merely because it was a statement of fact! I cannot think of any airline in the UK who has lost 3 hulls in the last 10 years, thats why I said it must make one think... surely? Safety culture, well, that opens a whole new can of worms and after the MT accident there was a changing of the guard, so maybe, but if so, it leaves many more questions...
bilderberger, you really need to read my post a little more carefully...
I did not say I don't agree with the reports findings, I said I did not agree with the whole report, a significant error on your behalf.
Then you mention that this accident had similarities to the accident to G-BEDZ, which I had already stated in my post, did you even bother to read my post at all...?? If you had, you might have seen that I was alluding to the same conclusion, but with a very different prognosis.
then...
I do not agree with that at all! The weather conditions were not suitable for a visual approach, the weather conditions were rapidly deteriorating with lowering cloud base and reducing visibilty. The report states that the Pilot would be in a situation of high workload, increased somewhat by the weather, and because it was in darkness, therefore difficult.
Machrihanish is not in the Western Isles, it is on the Kintyre Peninsula which is a region of the mainland of Scotland. It is a long road journey to get to a fully equiped hospital and so the air ambulance is frequently used.
I agree it is a common destination for air ambulance flights, but to suggest that this, or indeed any mission to a remote airfield in poor weather was routine, is simply not true, and confirms your lack of knowledge on this subject.
When I operated the BN2 on air ambulance missions no flight was ever routine... how ridiculous to even say such a thing, especially when a fine gentleman and aviator lost his life during this mercy mission.
People like you who pontificate on PPRuNe about things you know nothing about really p*ss me off....
bilderberger, you really need to read my post a little more carefully...
'Meeb', don't quite get your point that you don't agree with the report's findings !
Then you mention that this accident had similarities to the accident to G-BEDZ, which I had already stated in my post, did you even bother to read my post at all...??
If you had, you might have seen that I was alluding to the same conclusion, but with a very different prognosis.
Those in the know will realise that it would not have been a difficult approach in the weather conditions of that evening
In my opinion the pilot may have tried to convert to a visual approach during the turn and lost sight again of visual references
Machrihanish is not in the Western Isles, it is on the Kintyre Peninsula which is a region of the mainland of Scotland. It is a long road journey to get to a fully equiped hospital and so the air ambulance is frequently used.
I agree it is a common destination for air ambulance flights, but to suggest that this, or indeed any mission to a remote airfield in poor weather was routine, is simply not true, and confirms your lack of knowledge on this subject.
When I operated the BN2 on air ambulance missions no flight was ever routine... how ridiculous to even say such a thing, especially when a fine gentleman and aviator lost his life during this mercy mission.
People like you who pontificate on PPRuNe about things you know nothing about really p*ss me off....
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Islander.
Meeb,
Thank you for that !
There are lots of you here who are instant experts !
I'll say it again........It is not and never has been a 'difficult approach' as you call it !
It's a straightforward procedure turn at a dme dist. to intercept a radial inbound.
Also what is is you don't 'agree' with in the AAIB report ?
God,you've got a brass neck !
B.
Thank you for that !
There are lots of you here who are instant experts !
I'll say it again........It is not and never has been a 'difficult approach' as you call it !
It's a straightforward procedure turn at a dme dist. to intercept a radial inbound.
Also what is is you don't 'agree' with in the AAIB report ?
God,you've got a brass neck !
B.
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It is not and never has been a 'difficult approach' as you call it !
What I said was:
The report states that the Pilot would be in a situation of high workload, increased somewhat by the weather, and because it was in darkness, therefore difficult.
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The then operator of the Scottish Air Ambulance always found it difficult to recruit people to the Islander operation largely due to the pathetic rates of pay which didn't reflect the necessity for superior basic flying skills and to compensate for the fact the fact that flying the Islander wasn't the ideal path to the left or right seat of a shiny jet.
The operation was always treated too casually although it generated proportionally more(?) incidents over the years than any other UK (or European ?) civil operation. IMHO there is no way that the pilot should have been allowed to operate after 30+ days off and a quick circuit. As it was I don't suppose he had a choice.
The operation was always treated too casually although it generated proportionally more(?) incidents over the years than any other UK (or European ?) civil operation. IMHO there is no way that the pilot should have been allowed to operate after 30+ days off and a quick circuit. As it was I don't suppose he had a choice.
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Nowt personal
I don't know the guys involved. I have no axe to grind. I did spend 5 years flying the BN2 for Logy, and I'm afraid I would have to say Machrihanish was very routine. It was a very very common callout, and a simple procedure. Now if you know the job, you know about night Barras, night Islays, or night Orkneys or Shetland (Foula omigod!!!!!) where things were very different. Just like pickups from, say Dundee or Perth in the middle of the night and a long haaul down to BHX or CAM to get to a transplant hospital. Single pilot all that way, and back, IFR/IMC, hmmmm, not a career choice, and hence the turnover. I'm not trying to judge anything, just to agree that to lose three hulls with those fatalities HAS to say something about the operator, and possibly its oversight of training and experience on the job.
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Ironically this operator was mentioned in the House of Commons Transport Commitee report on the work of the CAA. Read appendix 39 of the report.
Report available here http://www.publications.parliament.u...an/809/809.pdf
Report available here http://www.publications.parliament.u...an/809/809.pdf
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That was a well judged post Cornflake. I flew the BN2 for LC as well and remember at least 3 hull losses and I don't know how many lives also numerous "dings and scratches". I remember one period when we seemed to feature almost monthly in the accident digests. The question is.. Where was the CAA in all of this.
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Transport Committe Report
I've just followed the link to that Transport Committee report, that appendix is rather interesting reading. I'm glad I don't work for LC anymore, but I'm astonished that they got away with that one. Not much justice there, and as for overuling Huz - no wonder he left. You would think things like this could not happen, I also note the references to Scotty, can't say I'm surprised there, I'll just bet he 'couldn't recollect!"
It all goes to show you can't trust anyone but yourself.
However, with ref the fatal accident discussed in this thread, the VOR and the flightpath make rather interesting reading - objectively speaking - as does the track of the procedure.
It all goes to show you can't trust anyone but yourself.However, with ref the fatal accident discussed in this thread, the VOR and the flightpath make rather interesting reading - objectively speaking - as does the track of the procedure.
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I've just followed the link to that Transport Committee report, that appendix is rather interesting reading. I'm glad I don't work for LC anymore
I like the bit where it says
There had been no AAIB investigation because this occurrence had not been reported to them
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Anyone help out here.. ?
Although I can get to the Face page of the report, when trying to access any of the sub categories the whole thing jams up... Having spent a few years driving turbo-props around up there I have the greatest respect for anyone flying BN2's around single crew on short notice medivac ops 12 months of the year...
Would be intersted to know what sort of experience level the pilot had.. and was icing firmly discounted as a possible contributing factor in the report ?
Although I can get to the Face page of the report, when trying to access any of the sub categories the whole thing jams up... Having spent a few years driving turbo-props around up there I have the greatest respect for anyone flying BN2's around single crew on short notice medivac ops 12 months of the year...
Would be intersted to know what sort of experience level the pilot had.. and was icing firmly discounted as a possible contributing factor in the report ?
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The report makes for some sober reading.
As an ex-LC amb pilot, I was once in a similiar position. I came back off leave to find myself out of 28 day currency/recency. I advised Ops and was told to come in slighty early for my afternoon airport standby and get myself current again. I told them that I would fly over to Cumbernauld, do a couple of circuits than come back to GLA for an ILS. This was agreed to without hestitation.
To be out of currency at the start of night standby is not smart. Generally you only got called out from night standby if there was an element of urgency about it and that puts pressure on you. To have to get current first probably put him in the position of doing the dead minimum. One visual night circuit at GLA in heavy rain is not enough to get happy again after 32 days without flying. Add the fact that he had been up 17 hours at the start of the approach and you have someone not able to give of their best. Add some serious IMC (low cloud) and things are stacking up.
I shall take his death (and that of his crew, the paramedic) as a reminder about the effects of fatigue. Sad though.
As an ex-LC amb pilot, I was once in a similiar position. I came back off leave to find myself out of 28 day currency/recency. I advised Ops and was told to come in slighty early for my afternoon airport standby and get myself current again. I told them that I would fly over to Cumbernauld, do a couple of circuits than come back to GLA for an ILS. This was agreed to without hestitation.
To be out of currency at the start of night standby is not smart. Generally you only got called out from night standby if there was an element of urgency about it and that puts pressure on you. To have to get current first probably put him in the position of doing the dead minimum. One visual night circuit at GLA in heavy rain is not enough to get happy again after 32 days without flying. Add the fact that he had been up 17 hours at the start of the approach and you have someone not able to give of their best. Add some serious IMC (low cloud) and things are stacking up.
I shall take his death (and that of his crew, the paramedic) as a reminder about the effects of fatigue. Sad though.
Last edited by Mr Moustache; 12th Nov 2006 at 13:04. Reason: spelling!