Fatal Accident Inquiry - Clutha Police Helicopter Crash

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#21 Post by barkingmad » Wed Oct 30, 2019 1:36 pm

The report is very critical of the decision to keep flying even though apparently the fuel low-level warning lights had illuminated.

I thought that fairly soon after the crash there was doubt cast upon the integrity or reliability of the fuel status warning system(s) on the aircraft type.

Any helo’ aces here able to cast more light on this perception-I look forwards to being corrected.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#22 Post by Undried Plum » Wed Oct 30, 2019 3:06 pm

For the purpose of consideration and discussion I link here to both the FAI Report and to the AAIB Report.

FAI

AAIB

I shall read both documents fully this evening before commenting.

I've attended several FAIs, for various reasons, and I've found the quality of the examination and reporting by Sheriffs to be highly variable. I've seen them vary from risibly incompetent to highly insightful and very intelligent. Not sure where this guy Turnbull fits on that scale.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#23 Post by barkingmad » Wed Oct 30, 2019 9:44 pm

They didn’t star when it came to PanAm103 nor has their legal system shone brightly when it came to re-examining the evidence against Megrahi?

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#24 Post by FD2 » Wed Oct 30, 2019 10:59 pm

Not an ace here, but if the pilot didn't respond to the low fuel warning I suspect that was standard 'practice', because there was an assumption (incorrect in this case) there was enough fuel left to return to base and he wasn't too worried. I know nothing about that aircraft and its fuel system - the closest I have been was watching one hovering over Newcastle one day while pursuing 'scrotes'.
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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#25 Post by barkingmad » Wed Oct 30, 2019 11:33 pm

Since Clutha I get nervous when the fuzz eggbeater hangs around our village oop north.

Anyone recall a report of defective fuel indications on the type, mentioned in the initial stages of the investigation?

And their legal system failed to bring to justice the multiple casualties bin lorry driver who lied to the licensing authorities and his employer. Another swamp requiring draining in addition to Westminster?

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#26 Post by barkingmad » Thu Oct 31, 2019 9:34 am

Is it possible the critical fuel switches were inadvertently knocked off in the impact sequence?

There also appears to be doubt cast on the reliability of the fuel quantity indication sensors and a recommendation that those fitted to the type be changed.

Very easy to dump the blame on dead pilot as an easy way out from technical issues which may have been left unsolved.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#27 Post by Boac » Thu Oct 31, 2019 10:02 am

I recall the AAIB considered he just had not switched them on! If he had, I doubt the engines would have stopped?

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#28 Post by Fox3WheresMyBanana » Thu Oct 31, 2019 10:17 am

Is it possible the critical fuel switches were inadvertently knocked off in the impact sequence?
The impact was assessed at 70G. There are usually witness marks that would indicate displacement during that kind of crash. The positions of surrounding switches would also be considered. It is highly unlikely that they would have been displaced without other evidence, but always possible.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#29 Post by Pontius Navigator » Thu Oct 31, 2019 10:19 am

Are they straight toggle switches or latched (pull and move)?

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#30 Post by Fox3WheresMyBanana » Thu Oct 31, 2019 12:00 pm

The four fuel pump switches are on the overhead panel. All four are simple toggle (p87 of AAIB report).
Probably of more significance is that the two fuel prime pump switches, normally only used for startup, we discovered in the ON position after the crash. The fuel transfer switches, which should have been on, were OFF. The four switches are adjacent, equally spaced, and identically shaped/coloured in the video (See at 1:00, fuel pump switches are third row back).



Personally, I would regard this as poor cockpit design. Firstly, the switches are used in separate phases of flight and so should be at least slightly separated. Secondly, as overhead switches which might need to be used without initially looking, it would be better if they were differently shaped and/or operated differently (e.g. latched).

My guess for the most likely scenario is that the pilot selected the fuel prime switches instead of the fuel transfer switches.
Further reasoning:
1. Given the likelihood of NVG lighting being selected for the benefit of the two observers wearing NVGs, the cockpit lighting would have been dimmer for the pilot, who probably wasn't wearing his NVGs.
2. This one mistake would cause the eventual accident, since the pilot would henceforth be assuming that the engines would keep working until all fuel runs out. I assume that the low fuel warning captions were assumed by the pilot to be misleading indications, given the prior history of these warnings with this model of helicopter.
3. A single error is a more likely cause for the accident given the pilot's very high level of skill and experience.

The AAIB has not put too much on the position of the switches since they may well have been disturbed during recovery operations, which is a valid point.

I would welcome the views of our rotary brethren who are used to working with overhead panels at night. Is this a possible mis-selection?

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#31 Post by barkingmad » Thu Oct 31, 2019 5:56 pm

Reading the injuries of the helo occupants nobody can be certain that flailing limbs and/or publications and/or personal kit not secure could not under any circumstances have moved the critical switches.

I don’t follow all the tech info quoted in the full report and in the absence of a comprehensive DFDR fit and readout I am unsure as to whether some of the onboard systems recording non-volatile memory chips actually show a pre-impact selection to “OFF” of the switches.

In the absence of such hard evidence we’re back in Mull of Kintyre Chinook territory. The possible mis-selection of the switches at night on the O/H panel should be taken as a design flaw waiting for the Tombstone Imperative and should be flagged up as such rather than accusing an apparently competent and capable pilot of deliberately ignoring the fuel “you are about to die” lights.

The indecent haste of those affected to jump to this conclusion is understandable as grieving relatives will do, looking for someone somewhere to blame. However, in a forum such as this I would hope for more forensic and objective opinions as to the cause and less behaving like the Chinook senior orifices’ attitude towards their dead subordinates.

I know sweet F A about the intimate workings of this ‘frame but I’m seriously uncomfortable with the knee-jerk reaction, especially bearing in mind the report’s accounts of erroneous fuel readings, the possibility of water contamination post compressor washing, the recommendation to change the fleet’s fuel qty sensors and the reams of red-bordered checklist pages featuring near the report’s conclusion.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#32 Post by FD2 » Thu Oct 31, 2019 6:19 pm

barking - you are quite right to point out that there shouldn't be any apportionment of blame without direct evidence that he was to blame.There are indeed many ifs and buts here but it is also important to eliminate, or prioritise, those which are highly improbable. The fact that he was a highly experienced pilot does not rule out pilot error, it just makes it less likely,

If there is no obvious cause then there is no obvious cause and direct blame cannot be attributed to him. I agree that the Chinook 'judgments' were wrong in not taking all relevant possibilities into account but the AAIB does not work in the same way as a court martial board and I hope would not be so quick to leap to 'judgment' - just stating the facts as they find them.

fox - I found overhead switches to be a pest at night as I got older, needing glasses for very close things like overhead switches but not for distant viewing. Half lenses were best but required tilting my head very far back to bring overhead switches into focus.
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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#33 Post by Fox3WheresMyBanana » Thu Oct 31, 2019 6:44 pm

The cockpit design is different in philosophy to what I am used to. Many more switches in a fighter like the Tornado are designed to be different in shape/operation so that they can be changed by feel, with a comfirmatory look to follow. Also startup sequence switches would be grouped together so that they can be gangbarred for a rapid start. There appears to be room for the fuel prime switches on the main panel near the engine start switches. Alternatively, the fuel prime switches could be located on the other end of the third overhead row to the fuel transfer switches, separated by the block of lights. This would not disturb the grouping by row, but would massively reduce the chance of a mis-selection. Or the fuel transfer switches could have been mounted on the front panel next to the fuel status display, since their use will be connected to what that display shows. Any of these three changes would seem more logical to me as a pilot, and easier to use, than the arrangement the designers came up with. Since a mis-selection of the fuel prime switches causes no problems, and the mis-selection of the fuel transfer switches does, it would seem preferable to go for the third option as this also makes the position of the switches much more obvious to the pilot. What do the rotary guys think?

Given the main usage of the EC135 appears to be EMS and Police, a rapid start arrangement including option 1. as well would seem like a good idea too.

There appears to be a lot of space on the fuel display. Incorporating red/green blobs indicating the status of the transfer pumps would seem worthy of inclusion.

Not that the Tornado was perfect - the fuel dump indicator lights were low down on the right side panel, and several pilots to my knowledge ended up turning off the dump somewhat later than intended, and major embarrassment was avoid by the skin of the teeth of at least one pilot.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#34 Post by TheGreenGoblin » Thu Oct 31, 2019 10:29 pm

FD2 wrote:
Wed Oct 30, 2019 10:59 pm
Not an ace here, but if the pilot didn't respond to the low fuel warning I suspect that was standard 'practice', because there was an assumption (incorrect in this case) there was enough fuel left to return to base and he wasn't too worried. I know nothing about that aircraft and its fuel system - the closest I have been was watching one hovering over Newcastle one day while pursuing 'scrotes'.
The cry wolf syndrome. Typical of many aircraft where one comes to dismiss erroneous or inaccurate readings and start to trust to one's experience until it all goes terribly wrong one day.

I think you have summed up the essence of this accident right here.
The days run away like wild dogs over the hills.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#35 Post by CharlieOneSix » Thu Oct 31, 2019 11:31 pm

Like FD2 I have no knowledge of the type in the accident. However it reminds me of the accident to an Alidair Viscount which ran out of fuel on final approach to Exeter Airport in 1980.....G-ARBY Accident Report. Another example of unreliable fuel gauges and all the holes lining up to cause an accident.
G-ARBY.jpg
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The helicopter pilots' mantra: If it hasn't gone wrong then it's just about to...

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#36 Post by barkingmad » Fri Nov 01, 2019 7:48 am

And then there was the ATR in the Mediterranean which ran out of fuel near Palermo with fatalities post-ditching after the fuel gauges from a -42 had been fitted to a -72!?

And the flameout and glide of a Canadian aircraft where lbs of fuel were assumed to be kgs and so it goes on.

From the start of my airline flying, and possibly in the wake of the Alidair accident, we were taught to work out a rough literage of uplift versus the expected kilos of gauge increase on turnaround at away destinations and some cross-checked the figures even on ex-base departures. Any significant discrepancy stopped the music until the difference was resolved. I then went on to operate with other airlines whose LTCs and other supervisors questioned the practice and harrumphed with the comment “That’s not our company SOP”! Possibly the fact I could do the calculation using mental arithmetic whilst compensating for warm and/or cheap fuel spooked the aforementioned sky gods. So the “Not invented here” syndrome was evident even in the ‘best’ companies.

Back to the Clutha accident, I’m glad that the O-N community have started to discuss and possibly disagree with the Scottish FAI reports of deliberate malpractice by the dead pilot. I like to think that us professionals can and will rise above such thoughtless and irresponsible reporting and call it out when detected.

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Re: Fatal Accident Inquiry - Clutha Police Helicopter Crash

#37 Post by TheGreenGoblin » Mon Nov 04, 2019 8:23 pm

Helicopter pilot in Clutha crash was not to blame, says fiancee
The fiancee of the pilot blamed for killing 10 people in the Clutha helicopter crash has criticised the findings of the fatal accident inquiry and claimed the sheriff downplayed evidence showing the manufacturer and aircraft were at fault...

Thomas, <<the fiance>> from Lochwinnoch in Renfrewshire, said Turnbull <<the sheriff.. was wrong. She said the sheriff had failed to take proper account of the helicopter’s history of faults with its caution advisory display, of “erroneous or spurious fuel indications” and problems such as fuel tank contamination.

Thomas said his findings insulted the intelligence of those who knew about the aircraft’s history. She said the model’s maintenance manual had wrongly said a flameout time between engines would be about three to four minutes.

In fact, the correct time was more than one minute but, because of the design of the fuel tanks, Traill had only 32 seconds before flameout. In a statement, she said of the victims: “This has devastated the lives of all who surround them and impacted on so many more.”
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