Hearing into fatal 2013 Super Puma crash to begin in January

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CharlieOneSix
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Hearing into fatal 2013 Super Puma crash to begin in January

#1 Post by CharlieOneSix » Fri Dec 06, 2019 3:16 pm

wnsb.jpg
.
This is not going to be pretty when the FAI verdict is given.

Fatal Accident Inquiry date fixed

AAIB Report 1/2016
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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#2 Post by Boac » Fri Dec 06, 2019 3:18 pm

35kts!!

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#3 Post by Fox3WheresMyBanana » Fri Dec 06, 2019 3:57 pm

That's neither pilot looking at the airspeed for 36 seconds.
Sounds like they are both assuming they are in an IAS hold mode. Maybe the co-assumes the Captain switched to IAS hold at 2.4DME from his comment. Maybe the co-, given his recent training background, is assuming there'll be an over-ride at 65kts decreasing as per the EC225.
I've never used autopilot for approaches. The Tornado F3 had an ILS mode but it was only used once on the OCU for a demo. I am struggling to see the benefit of an autopilot for approaches, given we know humans are less good at monitoring automatics than flying manually, that pilots need the handling practice for if they do have to take over, and that the fuel burn advantage of autopilot is likely minimal for the approach. Fly manually from when one "has the glide, ready to slide" as the Yanks say.

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#4 Post by Boac » Fri Dec 06, 2019 4:12 pm

Given the 'normal' Sumburgh wind, they would pretty much be going BACK up the GP at 35kts IAS!

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#5 Post by FD2 » Sat Dec 07, 2019 10:12 am

If I'm reading the report correctly, they had levelled at MDA and I suspect there were two pairs of eyes looking out for the runway. I wonder how often they practised coupled approaches. As you say C16, it's not looking good for the FAI.

The Sperry system we had in the KLM S76B was amazing and would fly you down the ILS and up the centreline at 50ft if it was allowed to, which we did sometimes in VMC as a confidence booster. We tried to alternate manual approaches with coupled ones, but I know that if I was out of options because of a bad TAF or emergency then I would have allowed the autopilot to fly the approach, if necessary to below minima, with only one pair of eyes outside at DH.

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#6 Post by Boac » Sat Dec 07, 2019 10:41 am

Does Fig12 not show they were already decelerating well above MDA and levelled 100 below MDA?

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#7 Post by CharlieOneSix » Sat Dec 07, 2019 12:42 pm

Boac - yes, it would appear to show that. Our Bell 214ST's were capable of a 3-axis coupled ILS. In respect of an ILS approach, like most crews if the weather was not critical I would fly a uncoupled ILS to keep my hand in for the day when the automatics went tits up. Our 214ST autopilots were 3-axis not 4-axis, so the collective lever had to be manually flown in a coupled ILS. If the weather was very near limits then I always used a coupled ILS approach. For the non-helo types, with 3-axis you controlled airspeed on the ILS by use of the collective whilst the autopilot controlled localiser and glideslope maintenance with pitch and roll commands to the cyclic. At first sight using collective for airspeed control is not intuitive.

On a non-precision approach such as on 09 at Sumburgh my preference in marginal weather was to fly the whole approach coupled to the localiser and airspeed coupled rather than vertical speed as the accident aircraft did. 80kts would be a reasonable speed approaching minima so in the event of a go-around you are already above best rate of climb speed - one less thing to think about achieving as the power comes on.

I've never flown the 332L2 so can't comment on their systems.

Maybe things are different from when I retired 20 years ago but prior to then on an IMC Base Check or I/R Renewal on my last type the trainers almost never examined you on how you managed a fully coupled approach. We had no simulator so the examiner was in the co-pilot's seat and the emphasis was on how you coped with a manual ILS, VOR or NDB approach with probably a fire on one engine just as you started the final approach, followed by perhaps a combination of stabilisation failure in the roll channel plus fly-by-wire elevator failure and all the while the examiner in the co-pilot's seat acting dumb but competent in doing what you asked him to.
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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#8 Post by FD2 » Sat Dec 07, 2019 10:06 pm

Boac - it looks as though they never actually levelled at 300 ft but did briefly level at 200 ft at 85 second point. From passing through MDA 300 ft at about 78 seconds to impact at about 92 seconds took all of 12 - 14 seconds.

Should the CP have been more forceful, or had he not noticed what was happening because he was looking out? Should the autopilot have been disconnected and a go around initiated or were the airspeed and descent parameters too advanced for that? Many questions we can only speculate on in comfort, but as C16 says, it doesn't look good for the FAI, from this very thorough report.

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#9 Post by CharlieOneSix » Mon Aug 24, 2020 10:41 pm

The Fatal Accident Enquiry finally starts - remotely - next week, the 7th anniversary of the tragedy being yesterday. BBC News -24/8/20. Personally I fail to see what it will achieve. The professionals at the AAIB determined what happened and how the four died. How this will result in any further closure for the families is beyond me - it can only be stressful for them all these years later.

The Scottish Government determines a FAI thus:
A Fatal Accident Inquiry is a public examination of the circumstances of a death conducted before a sheriff. The procurator fiscal is responsible for presenting the evidence. Other interested parties, including nearest relatives, employers or organisations such as the Scottish Prison Service (SPS) are also entitled to lead evidence.

The purpose of an inquiry is to establish the circumstances of the death, and to consider what steps (if any) might be taken to prevent other deaths in similar circumstances. The sheriff's role is to establish the facts surrounding the death, rather than to apportion blame or to find fault. The FAI is a forward looking vehicle – it is a fact-finding procedure rather than fault‑finding. It is not to establish civil or criminal liability.
So what does it achieve over and above what the AAIB determined?
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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#10 Post by Undried Plum » Tue Aug 25, 2020 6:47 am

CharlieOneSix wrote:
Mon Aug 24, 2020 10:41 pm
The Fatal Accident Enquiry finally starts - remotely - next week, the 7th anniversary of the tragedy being yesterday. BBC News -24/8/20. Personally I fail to see what it will achieve. The professionals at the AAIB determined what happened and how the four died. How this will result in any further closure for the families is beyond me - it can only be stressful for them all these years later.

The Scottish Government determines a FAI thus:
A Fatal Accident Inquiry is a public examination of the circumstances of a death conducted before a sheriff. The procurator fiscal is responsible for presenting the evidence. Other interested parties, including nearest relatives, employers or organisations such as the Scottish Prison Service (SPS) are also entitled to lead evidence.

The purpose of an inquiry is to establish the circumstances of the death, and to consider what steps (if any) might be taken to prevent other deaths in similar circumstances. The sheriff's role is to establish the facts surrounding the death, rather than to apportion blame or to find fault. The FAI is a forward looking vehicle – it is a fact-finding procedure rather than fault‑finding. It is not to establish civil or criminal liability.
So what does it achieve over and above what the AAIB determined?
Phat phees for phucking lawyers.

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#11 Post by FD2 » Wed Aug 26, 2020 11:25 pm

Not being in touch with the world of offshore flying for over 14 years now, it would be of interest to find out what the CAA has instructed the offshore companies about practising coupled approaches. We had to fly the ILS manually in the older S76A+ I flew in Bristow for 6 or 7 years (apart from the ex-BCal aircraft C16 mentions) because it was hands and feet on and no autopilot anyway, but the 4-axis Sperry fit in the KLM S76B was a delight and we were obliged to fly coupled approaches most of the time - only having a bit of fun handling the aircraft for real occasionally to keep our hand in. The aircraft was a lot more accurate than most of us anyway, or maybe me anyway, but for the newbies on the machine the various modes available could be confusing.

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#12 Post by CharlieOneSix » Sat Sep 12, 2020 1:23 pm

Apart from acknowledgment of the quick action of the co-pilot in arming the floats just before the helicopter hit the water, the crew are being hammered in the Fatal Accident Enquiry. There is no doubt that the crew's actions were responsible for the tragedy but it does make me wonder why as professional aircrew we never had professional liability insurance. I don't know of anyone who had that kind of insurance. It seems to be aimed at those who have a direct relationship with their client, ie the employer in the case of pilots. Like many others I was a BALPA member for many years and that goes some way to protecting the member against a legal claim but at that time BALPA members were in a minority.

I remember the case many years ago when a Bristow 212 on a SAR mission flew into the water north of Shetland and there were fatalities to the medical staff onboard. At the Inquiry the pilot - not a BALPA member - started a conversation with the lawyer representing Bristow. The pilot was shocked when the lawyer said "I'm sorry, Capt X, but I'm here to represent the Company, not you". A salutary lesson.
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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#13 Post by Undried Plum » Sat Sep 12, 2020 3:10 pm

It's called "Master Servant relationship" in Law.

The Master is responsible for the actions and inactions of the Servant.

An employee pilot of an Air Transport aircraft would be crazy to take out personal liability insurance. The suing of the deepest pockets, and all that.

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#14 Post by CharlieOneSix » Sat Sep 12, 2020 8:29 pm

Thanks for that UP - makes a lot of sense.
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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#15 Post by CharlieOneSix » Fri Sep 25, 2020 11:02 pm

From the BBC News website about the conclusion of the Fatal Accident Inquiry:
Shetland Super Puma crash: 'Pilot error main cause' of helicopter hitting the sea
What a surprise - we knew that when the AAIB report came out. In this case a FAI was an incredible waste of money. I thought the term 'pilot error' had been done away with in official circles and replaced with 'human factors'. Obviously not.
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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#16 Post by FD2 » Sat Sep 26, 2020 12:27 am

Martin Richardson for the Crown made the submission that "the Crown position is the principal cause was pilot error". What happened leading up to the accident was never in doubt, so here we are seven years later holding an inquiry into something the AAIB had already determined. He may well be very familiar with modern aviation psychology etc for all we know, but I doubt it. ;)))

Sheriff Principal Pyle said it was a "dreadful" accident which had a dreadful effect. He said blame was not a matter he was required to determine.

So what was the point of the FAI and the costs involved? In four weeks the Sherriff will make his 'determination' but the press has already told us what the cause was.

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Re: Hearing into fatal 2013 Super Puma crash to begin in January

#17 Post by CharlieOneSix » Sat Sep 26, 2020 5:14 pm

I suppose once the Rail Accident Investigation Branch (RAIB) complete their investigation into the fatal derailment near us there will be the usual calls for yet another Fatal Accident Inquiry. That of course will come to the same conclusion as the RAIB but it will have kept the pockets of a multitude of lawyers nicely topped up at the taxpayers’ expense.
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