Fatal Accident Inquiry - Clutha Police Helicopter Crash

[CharlieOneSix]

Announced yesterday:

http://www.bbc.co.uk/news/uk-scotland-glasgow-west-42108923

[FD2]

Nearly 5 years on - I wonder what has suddenly spurred them into action. They know what happened, but they'll never know why it happened as those in the aircraft are dead, so what is the point of holding an inquiry now? My mind isn't closed on the matter, I'm just keen to know what else can be determined from an inquiry.

[CharlieOneSix]

The dates have been announced. The public inquiry will formally begin at Hampden Park on 8 April 2019 - six and a half years after the event. The first preliminary hearing will be held at the stadium on 3 October this year. The Crown Office previously said there there would be no criminal proceedings.

What on earth is this inquiry going to add to the AAIB findings?!

A side issue - there was an S92 which had a nosewheel stuck up when it approached Scatsta some time ago. It had to be released in the hover by an engineer.. The AAIB bulletin is apparently out and there was some idiot offshore union man on local TV yesterday calling for a public inquiry. I'm speechless!

[Fox3WheresMyBanana]

Justice delayed is justice denied.

[FD2]

I think 'idiot' is too kind C16 over the S92 call.

It seems that a public inquiry under the guidance of an aviation expert will be able to shed light on this matter which the AAIB couldn't. More likely waste lots of money and direct loads of it towards a bunch of lawyers. Any idea who's calling for the inquiry?

[CharlieOneSix]

I'm not sure but I think it's more to do with inquiring about the deaths of those in the Clutha rather than those on the helicopter or how the helicopter came to crash there. I still don't see what can be achieved by it. At least, following his demise, we don't have to cringe any more at Jim Ferguson's media inputs about helicopter incidents. Nice guy, I met him many times but his opinions could be way off target.

[Undried Plum]

A Scottish FAI is a totally different animal to an AAIB Investigation.

It has two prime tasks: Cause of Death; and whether and how the accident might have been preventable.

It has some advantages over an AAIB investigation, such as the fact that witnesses are summonsed and required to give evidence under oath on pain of Contempt of Court criminal charges, with a prison sentence being very likely, if they tell porkies or refuse to answer at all.

FAIs are very expensive and the legal establishment, in the form of the Crown Office, tends not to convene them in most fatal accident cases. As for the lengthy delay in setting up an FAI, that's quite common. The AAIB obviously has a time imperative in their work because they may have to make recommendations quite promptly for public safety reasons so they are convened immediately after the event.

I doubt very much that we'll learn anything new in this case though. In particular, I doubt that we'll ever know why the pilot didn't immediately whack the lever down and go into autorotation as soon as power was lost. That apparent inaction is, to me, quite baffling.

[CharlieOneSix]

Thanks for that, Plum. Sadly of course the prime witnesses are no longer with us. I just cannot see what those who were in the Clutha can add to this sad affair - and of course what Joe Public outside the Clutha saw during the incident may be totally inaccurate, especially as it took place at night.

[Undried Plum]

"The helicopter pilots' mantra: If it hasn't gone wrong then it's just about to..."

So apposite; - and so relevant to the mystery bit for me.

Why didn't he do what was so necessary?

I 'get' the bit about his having misread/misinterpreted the fuel state.

I just do not understand why he didn't do the obvious when paraffin no longer gave oomph.

[FD2]

Plum - thanks for the info - yes, it's a mystery alright. Having set the fuel up properly and believing he had enough to return to base it would have caught him entirely by surprise, but he wasn't a novice and should have got the lever down. I know nothing about the 135's fuel system - would both engines have stopped at exactly the same time in the configuration he had at the time?

C16 - I agree that in this case it doesn't seem as though an inquiry can determine any more than the AAIB.

[Undried Plum]

I know nothing of the 135, but the AAIB Report's summary says:

When the helicopter was about 2.7 nm from GCH, the right engine flamed out. Shortly afterwards, the left engine also flamed out.

For the purposes of this discussion, perhaps I should paste a bit more of the AAIB summary:

Fuel in the helicopter’s main fuel tank is pumped by two transfer pumps into a supply tank, which is divided into two cells. Each cell of the supply tank feeds its respective engine. During subsequent examination of the helicopter, 76 kg of fuel was recovered from the main fuel tank. However, the supply tank was found to have been empty at the time of impact. It was deduced from wreckage examination and testing that both fuel transfer pumps in the main tank had been selected off for a sustained period before the accident, leaving the fuel in the main tank, unusable. The low fuel 1 and low fuel 2 warning captions, and their associated audio attention-getters, had been triggered and acknowledged, after which, the flight had continued beyond the 10-minute period specified in the Pilot’s Checklist Emergency and Malfunction Procedures.

Despite extensive analysis of the limited evidence available, it was not possible to determine why both fuel transfer pumps in the main tank remained off during the latter part of the flight, why the helicopter did not land within the time specified following activation of the low fuel warnings and why a MAYDAY call was not received from the pilot. Also, it was not possible to establish why a more successful autorotation and landing was not achieved, albeit in particularly demanding circumstances.

The investigation identified the following causal factors:

73 kg of usable fuel in the main tank became unusable as a result of the fuel transfer pumps being switched off for unknown reasons.
It was calculated that the helicopter did not land within the 10-minute period specified in the Pilot’s Checklist Emergency and Malfunction Procedures, following continuous activation of the low fuel warnings, for unknown reasons.
Both engines flamed out sequentially while the helicopter was airborne, as a result of fuel starvation, due to depletion of the supply tank contents.
A successful autorotation and landing was not achieved, for unknown reasons.
The investigation identified the following contributory factors:

Incorrect management of the fuel system allows useable fuel to remain in the main tank while the contents in the supply tank become depleted.
The RADALT and steerable landing light were unpowered after the second engine flamed out, leading to a loss of height information and reduced visual cues.
Both engines flamed out when the helicopter was flying over a built-up area.

[Undried Plum]

Sorry, I bolloxed up the formatting of that paste and I don't know how to retrospectively edit a post on this forum

[CharlieOneSix]

Plum - look at the top right of one of your recent posts and you will see four icons. The far left one which looks like a pencil is the edit tool. You only have an hour from the time of your post to edit it and then that icon disappears.

[admin]

Thanks for jumping in C16. This one Undried Plum.

edit.jpg (2.43 KiB) Viewed 997 times

Admin

[Undried Plum]

Thanks to whoever it was who sorted out my duff formatting.

"more dual required", as QFIs like to say.


Edited just for the sake of doing so

Further edited just for practice. I think I might be getting the hang of it now.

Back to the topic....

[FD2]

Thanks for the report extract Plum - inexplicable isn't it? Does it mean that they just happened to be near the bar when it happened or were they tasked to check something out? I'll download the AAIB report I think.

[CharlieOneSix]

From memory of reading the AAIB report I think they were on their way back to GCH where even if there had been no fuel mismanagement they would have landed below minimum fuel state.

Re the failure to lower the collective, and regardless of any fuel mismanagement, when he lost one engine I can see the "Oh, *****" bubble. When the second one went I can see the "WTF" bubble whilst he was still sorting out the first failure and he perhaps spent literally three or four seconds taking it in and lost all RRPM before he lowered the collective.

Because of something that happened when I did my S76 conversion in 1980 in Connecticut I can appreciate the slow reaction, fatal in his case but not in mine. We were pounding the training circuit with S/E failure after S/E failure at various stages of flight, when on one circuit Pat, the Sikorsky instructor, chopped both engines together on the downwind leg. It hadn't been in the brief and I reacted slowly assuming initially it was another S/E failure and only checked partially down on the collective. The reality then kicked in. The RRPM did go to 90%, just above minimum (87%?) but I managed to get them back up. It doesn't matter how many hours we have, sometimes we get it wrong - sometimes we get away with it, sometimes we don't. That's not meant to be flippant, just factual.

"Thy rotor rpm is thy staff of life" - the most important of the ten commandments of helicopter flying.

[Boac]

Surely the big question is why did he screw up the fuel transfer? The rest of it merely compounded the up-cock.

[FD2]

You've got a good point there C16. I've had two engine failures, both in twin engined aircraft, and they both happened in a split second. They certainly weren't like the base check sneaky hand slowly pulling back a speed lever, glimpsed out of the corner of one's eye. One was in an S76 which was so light with just two pilots that it was hardly noticeable and the other in a Sea King which ended with us sitting in the Clyde in about 5 seconds from 40ft, so perhaps his slow reactions should be viewed with a little more understanding. The fuel mis-management though, I agree with Boac about being the root cause. Again I don't know what else was going on in the aircraft or in his life at the time so must refrain from armchair judgement.

[TheGreenGoblin]

I see the Clutha crash Court enquiry report has come out...

Fatal accident inquiry in Glasgow finds pilot David Traill ‘consciously took a risk’

The inquiry, roughly equivalent to an inquest, was charged with establishing what caused the fatal crash and how the victims died. It took place in a temporary court at Hampden Park football stadium to accommodate scores of witnesses, aviation experts and family members. Breaks in the hearings were scheduled to fit around football matches and concerts.

An Air Accidents Investigations Branch (AAIB) report published in 2015 found two fuel supply switches were off and the pilot did not follow emergency procedures after a fuel warning in the cockpit.

The Crown Office, Scotland’s prosecution authority, ruled there was not enough evidence to justify criminal proceedings. The police interviewed 2,000 witnesses and amassed 1,400 pieces of evidence for the FAI.