REVIEW OF UK CONFIDENTIAL HUMAN FACTORS INCIDENT REPORTING PROGRAMME (CHIRP) DATA FOR THE JAA/FAA ROTORCRAFT HUMAN FACTORS STUDY GROUP (RHFSG). 1. Introduction CHIRP is a charitable trust located at Farnborough in the UK that provides a means for pilots, engineers, air traffic controllers and cabin attendants to report human factors related incidents in confidence. Details of the scheme are given in Annex 1 to this report. The reports contained in the data base cannot always be fully validated and there is no practical way of establishing the extent to which individual reports have been validated. Data from this source must therefore be treated as anecdotal evidence. In addition, there is no practical means of associating the reports with flight hours or sectors so no rate information can be derived. Objective data on the human factors aspects of accidents and incidents is rarely available, however, so most information in this field is of an anecdotal nature. The CHIRP data is therefore considered to be valuable and helpful despite its limitations. 2. Top Level Analysis The CHIRP data base was interrogated on 06 November 2003 in support of the RHFSG exercise. The total number of reports on the system at that time was 4018, which were distributed amongst the four categories of air transport (AIR), engineering (ENG), general aviation (GA) and cabin issues (CABIN) as follows: AIR (operational from 01 December 1982) ENG (operational from 17 June 1997) GA (operational from 13 November 1996) CABIN (operational from 05 February 1998) = 3059 = 315 = 425 = 219 Since no more detailed categorisation of the data is performed by CHIRP, further breakdown has to be performed by conducting word searches. All four categories were filtered using the word “helicopter” and the following numbers of reports identified: AIR ENG GA CABIN HELICOPTER HELICOPTER HELICOPTER HELICOPTER = 200 =7 = 37 =2 In view of its size, the Air section of the data base was also filtered using the words “North Sea”, “rotor” and “helideck” and the following numbers of reports identified: AIR AIR AIR NORTH SEA = 79 ROTOR = 51 HELIDECK = 21 It is quite possible that further word searches may have identified additional, relevant reports. The numbers likely to be involved are, however, considered to be insignificant. 3. Detailed Analysis 3.1 General All 397 reports identified were individually reviewed, and duplicates eliminated along with reports covering matters not relevant to the study. Reports of a general nature not directly related to an incident were also removed. The remaining 72 reports were then categorised according to whether they addressed maintenance or design issues, and allocated to a category in the RHFSG scheme of 28 April 2004 (see Annex 2). Although not always explicitly stated, it was possible to confidently assign all but one of the reports to the small (<3175kg) and large (>3175kg) helicopter weight classes. The ‘doubtful’ report (no. 2038) was assigned to the large helicopter class, giving a total of 15 small helicopter reports and 57 large. In common with incident reports where the information available is limited and the full context sometimes unknown, it can be difficult to be certain of the precise nature of the problem. In addition, trying to fit the reports to a fixed classification scheme will often result in compromises; sometimes a suitable category does not exist, and at other times the data appears to cover more than one category. For the purposes of the RHFSG exercise, the reports were allocated to the issues established in the RHFSG scheme wherever it was considered reasonable. Where more than one issue was covered, the report was allocated to what was considered to be the primary issue, and any secondary issue(s) not otherwise highlighted were noted in Annex 2 and Annex 3 for information. The 72 reports reviewed are reproduced in Annex 3 to this report. Each entry comprises the CHIRP reference number, the section of the data base and keyword used to filter the data, the classifications allocated, and the verbatim text of the report as it appears on the CHIRP data base. 3.2 Maintenance and design issues Of the 72 reports reviewed, 44 were considered to be fully relevant and 28 potentially relevant. These were divided into maintenance and design issues by weight class as indicated in the following tables: Small helicopters (<3175kg): Maintenance Design Relevant () 2 8 Potentially relevant (?) 1 6 Irrelevant (x) 12 1 Total Potentially relevant (?) 0 22 Irrelevant (x) 55 0 Total 15 15 Large helicopters (>3175kg): Maintenance Design Relevant () 2 35 57 57 Design issues clearly dominate the CHIRP reports for both small and large helicopters and the reasons for this are revealed in Section 3.3 below. 3.3 RHFSG classification 3.3.1 General: The RHFSG classification system comprises four sections: 1. 2. 3. 4. Operational issues identified from fixed-wing experience. Issues identified from fixed-wing experience (NPA 25-310). Known rotorcraft specific HF issues. Other issues arising from data analysis. Each section contains a number of issues against which the reports are compared. An entry is then made against each issue in each section to which one or more reports were allocated according to the following scheme: Class 1 – Issue identified as a causal factor in a fatal accident. Class 2 – Over 10% of HF issues attributed to this cause. Class 3 – Other HF causal factors. NB: Possibly because the general aviation section of CHIRP has been running for only about one third the time of the air transport section, the number of reports relating to small helicopters are quite low. In order to avoid undue emphasis being accorded to individual small helicopter reports, the percentages for both the small and large helicopter categories have been calculated using the total number of relevant reports (72). 3.3.2 Class 1 issues By definition, CHIRP reports would not normally be expected to relate to fatal accidents since these will usually be comprehensively covered by a full accident report. Two reports (1113 and 1164) however, do relate to the same problem that had been the cause of a fatal accident and the corresponding issue (1.14 – misuse of adjacent controls) is therefore set to Class 1 for small helicopters. 3.3.3 Class 2 issues: In the context of this report, Class 2 has been allocated to the three issues covered by 10% or more of the 72 CHIRP reports reviewed. All three issues qualify for the Class 2 rating for large helicopters only. The three issues are: 3.2 Flight deck environment – 19 reports (26.4%) 2.4 Human error with no associated technical failure – 9 reports (12.5%) 3.1 Low visibility rig approaches – 8 reports (11.1%) Flight deck environment issues (3.2) are clearly the most prominent in the CHIRP database by a significant margin, and are predominantly related to offshore commercial helicopter operations. Review of the corresponding reports reveals sub-issues of: immersion suits; lack of air conditioning; noise; vibration; lack of sun visors; lack of heaters; uncomfortable seats; poor air quality. Whereas these issues may individually appear relatively innocuous, when coupled with long duty periods they can easily lead to excessive fatigue and hence human error. There are also reports of one crew member waking up to find the other asleep. One solution might be to improve the flight deck environment; another approach may be to reduce the maximum allowable duty time. The reports allocated to the “human error with no technical failure” category cover a range of problems. In six of the nine reports (253, 526, 552, 563, 625, 968), however, the issues of flight crew fatigue and crew duty time are mentioned. Since there is good evidence to suggest that these issues are linked to flight deck environment, there is a case for including these six reports in the flight deck environment category, further increasing its importance. The relatively high incidence of reports relating to low visibility rig approaches or airborne radar approaches (ARAs) suggests this to be an area of particular concern to pilots involved in offshore commercial helicopter operations. Six of the eight reports on the subject were associated with incidents; two related to inadvertent loss of height (342 & 2207), two related to near misses with the platform (496 & 610), one concerned loss of sight of the platform and a late go-around (675), and one concerned the loss of the platform target on the radar display (631). Although this is an operational issue, it should be borne in mind that the only practical solution lies in the development of appropriate airworthiness requirements. A robust technical solution to the conduct of low visibility rig approaches is required. The UK CAA has already recognised that the aircraft’s weather radar is neither designed nor certificated for the purpose for which it is being used in this instance. 3.3.4 Class 3 issues: Class 3 has been allocated to the remaining issues covered by the CHIRP reports as indicated in Annex 2. Review of the CHIRP reports prior to the establishment of the RHFSG classification scheme had identified human-machine interface (HMI) issues as a significant concern. Fifteen (20.8%) reports were considered relevant and one (1.4%) potentially relevant as shown in the following table. RHFSG classification RHFSG class CHIRP report numbers <3175kg 1.6 1.7 1.14 1.15 2.2 2.4 3.17 3.19 3 3 1 3 3 2 3 3 240 (?) 1581 1113, 1164 1067 No. of reports Total number of reports in classification % of classification related to HMI issues 1 3 2 3 1 2 2 2 1 3 2 3 1 12 2 3 100% 100% 100% 100% 100% 17% 100% 67% >3175kg 684, 953 799, 801 537 625, 800 720, 1490 1594, 2250 It is noted that the HMI related reports account for 100% of the reports in six of the eight RHFSG classifications concerned, and most of the reports in a seventh. Effectively spreading the HMI issues across a number of (mostly class 3) classifications appears to have diluted the importance of this issue, and it is recommended that it be considered a high priority issue. It should also be noted that the associated CHIRP reports are quite evenly shared between the small and large helicopter categories, suggesting that this issue is not confined to offshore commercial helicopter operations. 3.3.5 Other Issues: Four of the 72 reports could not sensibly be allocated to any of the RHFSG categories. Of these, one related to duty hours (480), one to the burden of regulation (1532), one to check list deficiencies (1935), and one to pilot training matters (2106). 4. Conclusions In the context of the RHFSG exercise, the CHIRP data is considered to represent a valid input as anecdotal evidence. In terms of the RHFSG criteria, the following four issues were ranked as either Class 1 or Class 2, and therefore represent areas of major concern: 1.14 - Misuse of adjacent controls. 3.2 2.4 3.1 - Flight deck environment. - Human error with no associated technical failure. - Low visibility rig approaches. Two thirds of the reports allocated to issue 2.4 are considered to be related to flight deck environment through flight crew fatigue. In addition, HMI issues (potentially including RHFSG classification issues 1.6, 1.7, 1.14, 1.15, 2.2, 2.4, 3.17 and 3.19) collectively accounted for 22.2% of the CHIRP reports and should therefore also be considered a major area of concern. D A Howson UK CAA Research Management Dept [email protected] Annex 1 THE UK CONFIDENTIAL HUMAN FACTORS INCIDENT REPORTING PROGRAMME INTRODUCTION Although accident/incident rates in commercial air transport operations have reduced to an extremely low level, the number of accidents with Human Factors causes has not declined at the same rate and thus has become the dominant cause in major accidents. Incident reporting programmes have proved to be valuable tools in the identification of safety related issues and the definition of corrective actions. In the specific case of incidents involving human error, the availability of an independent, voluntary, confidential reporting medium has provided valuable additional information to that available through formal or mandatory reporting systems. THE CHIRP CHARITABLE TRUST The UK Confidential Human Factors Incident Reporting Programme, more commonly known by the acronym CHIRP, has been operating since 1982. In 1996 following a comprehensive independent review by the Guild of Air Pilots and Air Navigators (GAPAN), the Programme was restructured to enable it to make a more effective contribution to the resolution of important safety related issues in the UK air transport industry. CHIRP was established in its present form, as a charitable company limited by guarantee, on 1 November 1996. This corporate structure was selected in order to provide a totally independent organisation, with management and fiscal responsibilities held by an independent Board of Trustees. The Programme is funded by the Civil Aviation Authority, which in turn is funded by the air transport industry. The current Board of Trustees comprises 12 independent members and the Chief Medical Officer of the Civil Aviation Authority, who is appointed on an ex-officio basis. The Chairman is Professor Tony Nicholson, an acknowledged specialist in Aviation Medicine, and formerly Commandant of the Royal Air Force School of Aviation Medicine. The remaining Trustees are: Captain Stephen Bligh Chief Executive MCA Mr Rupert Britton Secretary/Legal Adviser CAA Captain Clive Elton Independent Captain Chris Hodgkinson GAPAN Captain John Hughes Independent Dr Simon Janvrin Chief Medical Officer CAA Captain Jock Lowe Independent Rear Admiral Stephen Meyer Chief Inspector MAIB Air Cdre Rick Peacock-Edwards Independent Mr John Saull Independent Mr Ken Smart Chief Inspector AAIB Mr Philip Wake The Nautical Institute The Trustees together with 16 nominees from the principal air transport interests in the UK comprise the Air Transport Advisory Board. Current nominees are: Ms P Barltrop Captain D Chapman Captain A Davis Captain W Epton Mr C Hague Captain D Harrison Air Cdre A Hudson Mr P Jones Mr J McKenna Mr M Newman British Airways Engineering Head Flight Ops Department CAA (SRG) British Helicopter Advisory Board General Aviation Mfrs & Traders Assoc Society of British Aerospace Companies British Air Line Pilots Association Director Defence Aviation Safety Centre NATS ATO Policy & Performance Chief Surveyor CAA (SRG) Assoc Licensed Aircraft Engineers Captain E Paintin UK Flight Safety Committee Mr M Pardoe UK Operators Technical Group Captain R Screen Flight Operations Liaison Group Captain T Sindall Independent Mr R Trott Guild of Air Traffic Control Officers Mr I Weston Safety Investigation Data CAA (SRG) The role of the Advisory Board is to provide counsel on the most appropriate way in which specific issues might be resolved and to advise the Trustees on the performance of the Programme. The composition of the Board is reviewed regularly to ensure that the membership is appropriate to the scope of the Programme. Advisory Board members act as individual expert advisers and not as representatives of their sponsoring organisations. Information is provided to the Advisory Board on a confidential basis and all means of identifying the individual reporter are removed from reports prior to any discussion. CHIRP employs a permanent staff of four under the management of a full-time Director, Mr Peter Tait. The organisation is located on the QinetiQ (formerly DERA) Site at Farnborough. THE PROGRAMME CHIRP currently receives confidential incident reports from professionally licensed pilots, air traffic controllers, licensed engineers and approved maintenance organisations employed within the UK air transport industry. The Programme has been extended to General Aviation and is also being made available to Design and Production organisations. With effect from July 2001, the Programme was extended to Cabin Crew members. A Cabin Crew Advisory Board has been formed to assist in this initiative. On being received, reports are validated as far as is possible and reviewed with the objective of making the information as widely available as possible whilst maintaining the confidentiality of the source. Anonymous reports are not normally acted upon as they cannot be validated. When appropriate, report information is discussed with relevant agencies with the aim of finding a resolution. Only depersonalised data are used in discussions with third party organisations and the confidentiality of the reporter is assured in any contact with an external organisation. No personal details are retained from reports received. After ensuring that the report contains all relevant information, all personal details are returned to the reporter with an acknowledgement letter. Each report is allocated a unique reference identification. After the return of personal details, CHIRP is unable subsequently to contact the reporter. The reporter may, if he/she wishes, contact the CHIRP office for additional information by using the report reference identification. A newsletter FEEDBACK, covering current topics from disidentified reports and including new report forms, is sent four times a year to all commercially licensed pilots, air traffic controllers and engineering personnel, a circulation of around 30,000. Some reports are disidentified further (e.g. time and place, company, reporter's gender) before being published in FEEDBACK, or making any data available to other agencies. FEEDBACK maintains an awareness of Human Factors issues among the flying, air traffic controller and aircraft maintenance communities and provides a forum for discussion. Two separate newssheets, entitled GA FEEDBACK and CABIN CREW FEEDBACK and containing reports of particular interest to light aircraft operations/leisure flying and cabin crew are distributed to both communities. Depersonalised data are recorded in a secure database at Farnborough for analysis of key topics and trends. Disidentified data are made available to other safety systems and professional bodies. For more information on the Programme, contact: CHIRP, Building Y20E, Room G15, Cody Technology Park, Ively Road Farnborough, GU14 0LX. Tel: +44 (0)1252 395013; Fax: +44 (0)1252 394290; e-mail: [email protected] or www.chirp.co.uk Annex 2 RHFSG CLASSIFICATION SCHEME Key to Colour Coding Class 1 – Issue identified as a causal factor in a fatal accident. Class 2 – Over 10% of HF issues attributed to this cause. Class 3 – Other HF causal factors. 1. OPERATIONAL ISSUES IDENTIFIED FROM FIXED-WING EXPERIENCE UKCHIRP Index Issue <3175kg Priority 1 >3175kg % 2 Absence of Reaction or inadequate reaction Procedural Non-compliance 3 Limitations Non-compliances 4 Pilot fighting against automation 5 Wrong data entry 6 Rotor speed management 1.4 7 Error prone equipment 1.4 8 Poor mastering of novel systems by lack of extra training Fuel management 9 10 11 Snow ingestion, Ice and consequences of icing awareness Information integrity 12 Language 13 Flight below Minimum altitude 14 Misuse of adjacent controls 2.8 15 Standardisation issues 1.4 16 Take off/Approach configuration 17 Take off/Approach data 18 Wrong take off/approach path Priority % 2.8 2.8 2. ISSUES IDENTIFIED FROM FIXED-WING EXPERIENCE (NPA 25-310) UKCHIRP Index Issue <3175kg Priority >3175kg % Priority % 1 Crew awareness 1.4 2 1.4 6 Technical failures that rely on human intervention Human error that relies on technical protection system. Human error with no associated technical failure. Vulnerability of the design to misselection Poor visibility 7 Excessive workload 8 The potential to correct errors 9 New technology 10 Human error resulting in a latent condition which is subsequently combined with a technical failure. Vulnerability to accidental damage 3 4 5 11 12 13 Inconsistent/ambiguous maintenance data and procedures. Task complexity. 14 Accessibility provisions 15 Incorrect fluids 16 Materials & Fabrication methods. 17 Fasteners/Bolts/Latches 18 Protection of structure 19 Control Systems, general (e.g. misassembly, jamming) 2.8 12.5 See 1.14 1.4 4.2 1.4 1.4 1.4 2.8 1.4 3. KNOWN ROTORCRAFT SPECIFIC HF ISSUES UKCHIRP Index Issue <3175kg Priority 1 Low Visibility Rig Approaches 2 Flight Deck Environment 3 Crew Seat Design 4 Locking of Crew Seats 5 Labelling Terminology 6 Document Stowage 7 Collective Control 8 Pilot’s View 9 Windscreen Wipers 10 Engine Malfunction Indication 11 Fuel Gauges 12 Low Fuel, Oil, Hyd. Fluid Warning 13 ‘Brakes On’ Indication 14 ‘Gear Up’ Warning 15 Rainwater Leaks 16 Pilot Intervention Time 17 Tailrotor failure/loss of effectiveness >3175kg % Priority % 11.1 1.4 26.4 1.4 See 2.6 See 1.9 Secondary issue in report 2478 Secondary issue in report 625 See 1.1 2.8 18 See 2.6 19 HMI with new flight deck technology. 20 Wire Strikes 21 Difficulty performing secondary tasks. 22 The need for autorotative guidance 23 Enhanced HQs 24 Wind assessment 4.2 Secondary issue in report 2041 1.4 4. OTHER ISSUES ARISING FROM DATA ANALYSIS UKCHIRP Index Issue <3175kg Priority 1 2 Tolerance to variations in engine-off landing profile Loss of control/over control 3 Passenger awareness 4 T/R protection 5 Initial maintenance schedule 6 Emergency egress capability 7 Accessibility of controls 8 Human physical characteristics 9 Unintentional interference 10 Engine Event monitoring 11 Crashworthiness 12 Fuel tank vent tubes 13 Hoist standards 14 15 16 17 18 >3175kg % 1.4 Priority % Annex 3 CHIRP DATA Key: Wt. class Maint./ Desn. S = <3175kg, L = >3175kg = relevant, ? = potentially relevant, x = irrelevant Report No. Key Words Wt. class Maint. Desn. RHFSG classification Text 16 [GA] HELICOPTER S x 2.14 Accessibility provisions. DCJ 15th March 1999 This Report Submitted to CAA SDAU with Defective Parts During annual inspection, front landing gear dampers required replacement due low deflation. On removal of damper from lower fitting, severe exfoliation corrosion was found on damper attachment lug of undercarriage bracing strut P/No 269A 3120. The lug failed completely during further inspection. Investigation of the other three damper lower attachments revealed the same condition. Failure to detect this defect could result in a rollover during ground operation. 1. This area is difficult to inspect with the damper installed 2. There is no special maintenance call-up for this area 3. Why did I not notice this defect before? 4. I have proposed a repetitive calendar-based inspection to CAA SDAU 34 [AIR] HELICOPTER S x ? 2.6 (3.18) Pilot view & visual cueing 5. This defect, I have since discovered, affects older types of this helicopter, typically 20 years plus, but could apply to the whole fleet in time. DISIDENT PW The incident was none other than allowing myself to fly into thick cloud inadvertently. environment. 55 [AIR] HELICOPTER S ? ? 2.17 Fasteners/ bolts/ latches. In conditions of High Pressure haze in the area, the forward and diagonal visibility slowly deteriorated as I progressed west. There was no clear point at which I could say I am below limits. As I descended in height from 2000' AGL to 1000' TO 500' and the visibility continued to deteriorate I failed to make a decision to turn back, land or divert. At a point where the visibility was down to about 800-1000 metres in haze/mist I slid imperceptibly into cloud. Realising the danger I reverted to instruments (Thank God the Army had given me 20 hrs instrument flying and a White rating) - I successfully completed a talk down approach to an airfield which was closed due to fog. Moral of the story: 1. Stop BEFORE reaching the point of no return. 2. Know that clouds cannot be seen in mist/haze. 3. Instrument flying training is crucial EVEN in VFR rated aircraft/helicopters - It saved my skin. (The only valuable thing I learnt out of this incident - which shook me rigid!, was that I learnt my limits, and learnt the real dangers. of mist/haze, at a time when my experience was limited.) DISIDENT PW A very simple incident of which I am still by no means certain in my own mind. I had flown down to the destination on a navigator training SCT trip. On arriving at the destination I shut the helicopter down and carried out a 'turn around' servicing. As I completed the servicing a car appeared to drive my navigator and myself to lunch and after collecting my bag from the cockpit I drove off. Three hours later I returned rather later than planned and had to hurry in order to make a take off time to get back to Base. I carried out a quick walk round, signed for the turn round and started up. Ten minutes into the twenty minute flight to the to the en route destination we felt a sudden shake of the aircraft, exactly similar to a shake I had felt during an occasion ten years ago when I had flown through the slipstream of a Phantom; I turned through 360 degrees to try to see the other aircraft but failed to spot anything. However, I did spot the chimneys of a power station 1000' below me and thought that we must have flown through a localised thermal. On landing at the en route airfield we discovered that half the port rotor gear box cowling was missing. I was certain when I took off that all the cowlings were fastened, but obviously I was far less certain afterwards. Equally I can't say I HADN'T locked all the catches. All I can say is that: 1. I could easily have been interrupted by the driver just as I came to the two crucial catches and may easily have started the checks again immediately after them in the sequence. 2. I hurried the walk-round because I knew I had done the servicing. Therefore I reduced the normal double check of ground 125 193 [AIR] HELICOPTER [AIR] HELICOPTER L L x x ? 3.2 Flight deck environment. 3.2 Flight deck environment. crew, then pilot, to one action. 3. In our hurry to make the take off I started up while my navigator was still telephoning, thus not making use of a possible independent check. It is still possible it was a mechanical failure, but I trust it will not be a mechanical failure that I have again. DISIDENT PW Had a meal when en-route. Sun bright - wore dark glasses. Co-pilot handling a/c. FELL ASLEEP - WOKE - LOOKED GUILTILY AT CO-PILOT. HE TOO WAS IN THE MIDST OF A LONG BLINK. It is possible we were both asleep at the same time for a few minutes. No deviation from flight path. NO NAV ERRORS. 3.20 into flight. Scheduled departure time 0730. I normally get up 2 hours before take off. I drive 35 mins to work. I usually arrive at work 1.10 mins before scheduled departure time. I usually have a cup of tea and some toast for breakfast. I know this is not an abnormal situation but I feel it worth mentioning because of the on going nature of the problem as the route is very busy and the low sun problem significant particularly in summer when we can get above the weather/ice. Also the cockpit in all helicopters is very hot, as the design required all round visibility results in a large green house. DISIDENT PW After completing round trip of 5hrs 05mins completely without incident, both captain and co-pilot felt absolutely knackered- both had flown approx 150hrs on similar routes in past two months which is not excessive by any standard currently likely to be recognised. However the excessive noise in the cockpit, the appalling vibrations and the noisy radio/intercom combine with the wearing of a survival suit to produce an accident waiting to happen. Whilst no accident happened on this trip, it is disappointing to realise that with the industry in the financial state that is, the chances of any improvement in ANY of the factors I have mentioned is very slight. I believe that the stresses of long distance flying in helicopters are not understood or recognised. These stresses are mental, not physical, and are by nature cumulative. The North Sea is singularly unforgiving, and with the extra variables of long flights, a high degree of professionalism and alertness is needed. Our aircraft certainly doesn't help. Quite a few crews get very tired. I don't know if this is the sort of information you want, but it may throw a little background light on our sort of operations. The problems are mechanical, but they cause mental stress which is both tiring and dangerous. 219 222 [GA] HELICOPTER [ENG] HELICOPTER S L x 3.2 Flight deck environment. 2.19 Control systems, general (e.g. missassembly, PCT/17.04.02 I flew my helicopter to a large country property that is owned by a friend. I landed at around 1600hrs on a late December day. As this was the first time I had landed at this site, I had a good look around so as to determine my take-off route. The best way out was to the North with a paddock running for about 100 metres before meeting a 1 metre fence. About 250 metres past the fence there was several acres of dense woodland. After our meeting and a couple of cups of coffee I returned to my helicopter about 1½ hours later. Despite it now being night the visibility was good with a clear night and still air. I had landed in a couple of inches of snow and about 50 metres from a lake. As I sat in the cockpit I noticed a slight mist appearing along the lower edge of the front screen. A check of the O.A.T. showed just above freezing. Part of the preflight checklist requires that the bleed air heat/demist is selected OFF for take off. This is to maximise engine power and minimise T.O.T. (Turbine Outlet Temperature). The misting in the cockpit, which I assumed was from my breath, was still showing along the lower screen but did not present a flight hazard at this time. Right, I am now ready to go. Landing Lights on, a cheery wave to my friend and up in to a high hover to check VSI (Vertical Speed Indicator) and DI (Direction Indicator) response. Everything looking good, a peddle turn to put me onto a North heading for departure and away I go. To my horror within five seconds the entire screen froze over like a white blanket and I was quite literally flying blind. At the point of 'white out' I estimate my height as about 20 ft and forward airspeed around 40kts. There was absolutely no possibility of carrying out a safe landing so a continued take off was the only option. An immediate check of the VSI (Vertical Speed Indicator) showed a positive rate of climb and the I.A.S. (Indicated Air Speed) was good. I waited until I passed through 500 ft before fixing the collective with the friction and then reaching up and turning on the bleed air de-mist. This system is very efficient and within seconds the screen was clear and the rest of the journey was completed without further incident. I am not sure whether the screen froze up on the inside due to condensation from my breath or whether it froze up on the outside. The helicopter was parked near to a lake in near freezing conditions and there is a chance that moisture formed on the outside surfaces. Quite frankly, if I am confronted with a similar set of weather conditions on take off again I will select heating ON and accept a small reduction in power and increase in TOT. DCJ 12th February 2002 Please find enclosed 2 CHIRP reports. (see E 221) I would like to ask that they are not used in entirety and specifics are not quoted as I would easily be identifiable. jamming). These two reports highlight the HR/HF problems caused by impractical, inappropriate, antique, uneducated and just plain bad management practices in maintenance. Hope they will be of some use and add to the body of evidence (even if only statistical) to re-enforce the message that these things should be taken seriously. Regards The company I work for was recently reprimanded by the CAA following an incident with Human Factors implications. Engineers were being pulled from hangar maintenance work to do outdoor and other Line tasks. The hangar checks they were doing were being carried out in unfavourable and unsuitable Line hangar conditions, rather than the more suitable Heavy maintenance hangar. An aircraft is due a major check. In accord with the criticisms levelled by the CAA after the last incident, it has been brought in to the Heavy maintenance hangar. Personnel from the Line maintenance have been designated to work on this aircraft with no interruptions allowed for ad-hoc line tasks. So far so good. Because they are dedicating men to work on this aircraft, Line maintenance manpower has been depleted. So what have the Line supervisors been told to do if they are running short of manpower? They are instructed to now take Heavy maintenance personnel onto the Line to cover manpower shortages. The situation is also subject to inter-departmental politics and suchlike, but in essence they don't seem to realise that they have not sorted out the problem at all, just shifted things around. 11/2/02 Follow-up telephone call:The incident that the CAA was concerned with was when two tail rotor cables on an S 61 helicopter broke during transition to a helideck. The cables had been inadvertently crossed; a duplicate inspection had failed to detect the miss-assembly. The LAEs were reprimanded for the failure. However, the CAA criticised the Company for switching staff back and forward 240 [GA] HELICOPTER S x ? 1.6 Rotor speed management. between Line and Hangar work and between shifts. They also criticised the Company's lack of insight to Human Factors considerations. The CAA have also obliged the Company to implement two year refresher courses for Engineering staff, including HF training. There is insufficient manpower for the work to be done; additional training has added to the problems. There is difficulty in taking annual leave due to this shortage. PCT 4 July2002 I had already flown the aircraft twice that day, once on a short trip from AAA to BBB, and then on a series of joyrides lasting approximately an hour. The aircraft had been shut down after both flights. I prepared for the return flight to AAA, and the start-up proceeded normally until the last few moments. I finished all Vital Actions prior to putting the checklist away, put the checklist away, finished the last few items, and started to increase the RPM to 104% - the normal operating RPM. Prior to this point the RPM is set at 75%. At the same time as opening the throttle, I switched the governor on. I was momentarily distracted, and the next time I looked at the RPM gauge both the engine and rotor RPM gauges had exceeded the upper red line that is they were both in excess of 116%. I wound RPM down to approximately 90% and checked the governor was on. I do not remember clearly if I switched the governor back on or whether it was still on. I then shut the aircraft down and went to seek advice from home base. Since then I have become aware that I'm not the only person to overspeed an R22 and not understand exactly how it happened. The advice I have received has been inconsistent, with various reasons given for doing things differently to the POH checklist. The last items on the POH "Starting Engine and Run-up" checklist for the R22 (POI-I pages 4-7) are: Cyclic/Collective Friction Governor RPM Lift collective slightly OFF ON 102% - 104% Horn light at 97% Now, that last but one item is a bit ambiguous. I have also spoken with a helicopter pilot who runs R22 safety courses, and have been given the following advice. 1. Do all the mag checks and needle splits at 75% - my understanding is that this is for noise reduction. 2. When ready, at 75% turn the governor on. Roll on throttle, ensuring the governor captures at 80%. RELEASE BUT GUARD the throttle until RPM stabilises at 104% if it runs away upwards, you can catch it before it goes BEYOND LIMITS. 3. At 104%, roll off a bit of throttle and ensure the governor takes RPM back to 104% - at this point I suppose you could also do the RPM horn check. 4. Roll on a SMALL amount of throttle - 1 or 2% - to ensure the governor brings the RPM back down. POI-I allows momentary transgressions into the red band. After that, you're all ready to fly. Why has this been promoted as the way to do it, and what other considerations are there? Firstly, you're not doing two things at once, i.e. switching the governor on AND rolling on throttle, so you can monitor RPM rise. Secondly, this is a critical phase - you're just about to go flying - so unnecessary distractions should have been sorted out before now. Total concentration on getting to operating RPM then lifting safely is crucial. One of the problems with the governor is that is has made the pilot less aware of the RPM because it is assumed that the governor will maintain 104% automatically. It will for most of the time, but it's not infallible- Remember that the RPM gauge is a PRIMARY instrument. Look after the RPM and everything else will look after itself. Some of the previous advice I had received is that people switched on the governor at 90% to avoid the governor making large throttle changes and overstressing the drive train, or to avoid the aircraft spinning on a slick or icy ramp when the tail rotor is not effective at low RRPM. The advice is that normally the MP doesn't need to be controlled to avoid overstressing the drive train, but a slick/icy ramp may need the throttle guarding to prevent a spin. 253 [AIR] NORTH SEA L x ? 2.4 Human error with no associated technical failure. END On the day in question this crew (myself and co-pilot) were scheduled for a morning flight to the Brae Field (141 n.miles N East of Aberdeen.) This flight took 3 hrs 40 minutes and on completion we were rescheduled for a second flight to the Brae. This was in a different aircraft so entailing complete re-planning for a take off as soon as possible. This flight took 4 hrs. Because of deteriorating weather conditions our return to Aberdeen necessitated on ILS approach and although it is company policy for the co-pilot to fly such an 277 [GA] HELICOPTER S ? 2.17 Fasteners/ bolts/ latches. approach in those conditions I elected to fly the approach myself. The co-pilot was very experienced and had flown the approach on the earlier flight so it was my 'turn'. At approximately 350 feet on the approach (DH 210') the co-pilot stated that he was visual with the lights and added 'slightly to the left'. At that point I turned 10 degrees right. At that stage the co-pilot said "I have control", took control, turned left and landed, not without some difficulty, especially at keeping the lights in view. If weather conditions had been a little worse we would have had to overshoot. When the co-pilot took control I realized that my brain had "frozen" and I was not able to correlate the visual signs from the ILS and what the co-pilot was saying. In commenting on the above I would point out that in the previous 32 days I had flown 100hrs 25minutes, the first time I had flown at such a rate. With the present financial climate in the North Sea all the signs are that this situation (i.e. high rates of flying) are likely to continue. 21st November 2002 +++ Helicopter G XXXX recently flown to AAA Airfield. On approach pedals felt odd, very difficult to land. On inspection, (after four attempts) found that tail rotor blade bolts were unmatched. (+++ use two sizes that cannot be mixed as there is a large mass difference). A blade had been replaced by a facility at BBB. Surprised that the tail rotor and gearbox was still attached. 317 [AIR] HELICOPTER L x ? 3.2 Flight deck environment. Helicopter grounded by independent engineer. DISIDENT PW I am writing in the hope of your assistance in countering what for many pilots is a very unpleasant problem. Namely passenger smoking. In the S6l in particular, but also in most other helicopter types, the airflow is from the pax cabin into the cockpit. Also, in the S6l in particular, but also in most other types, one is not permitted to separate pax cabin from cockpit, because it is considered this could prevent the pilots assisting pax following e.g. a ditching. (NB. usually a cabin attendant is not carried.) The result of this is that one is regularly fumigated/ kippered by the Cherry Briars, Havannas etc. of those in the back. This does nothing for one's alertness/general performance during the flight, and often results in an acrid dry throat/nose, plus catarrh, post flight. The following would seem to be the answer:- 1. Open cockpit windows. This though on a S61 has the effect of increasing the forward airflow into the cockpit. 2. Use the ventilator fan. On most occasions this just isn't up to as many as 19 pax all smoking. 3. Put on No Smoking sign. The Company (mine) is 342 [AIR] HELICOPTER L x 3.1 Low visibility rig approaches. 416 [AIR] HELICOPTER L x 3.2 Flight deck environment. against this for fear of offending the clients. The pax regard the right to smoke throughout the flight as virtually divine! (and do not always obey notices). The answer, for my money, is for the C.A.A. to legislate forthwith against smoking in all aircraft, where pax cabin and cockpit are inter- connected. Can you lobby for this? DISIDENT PW The type of approach being made was a radar/NDB approach. The weather reported by the installation was 300 feet cloudbase and about 3/4 NM visibility, wind calm. The sea was as calm as a millpond and the surface like a mirror. Other helicopters had already made successful approaches and landings in the same vicinity.On reaching our mimimum descent height we could see the surface,but forward visibility was nil as we were still marginally inside the cloudbase. Knowing that if we overshot on the approach we would have to go to our diversion, I told the copilot that I was resetting my radio altimeter warning light "bug" 50 feet lower and continuing to descend. Almost immediately there- after we saw the installation about 1/2 mile ahead in haze with no dis- cernible horizon. I ceased to scan the instruments for a few seconds while looking at the installation to assess how best to make a landing. Shortly the copilot warned me that we had descended below 50 feet and I am still shocked at how quickly I descended so low without perceiving it. DISIDENT PW I read your Helicopter reports about people snoozing with interest. It was my habit, and also many other rig pilots at that time to take a quiet cat-nap during low activity periods. On this occasion we had just done our rig crew change, refuelled, and were inbound to an en route stop before the final sector to base. We were at 500 ft "below", drizzle, squalls etc. - normal weather! The Co-Pilot and myself alternated flying and had finished the excellent meal supplied by the rig. I made sure the Co-Pilot knew he was in control and had my 10 min cat-nap. When I awoke the Co was fast asleep! Mercifully the aircraft was at 400 ft on course, Automatic Flight Control System engaged (but no height hold). Over the years I have heard a number of similar hair raising stories. It amazes me that no one has flown into the sea yet. (To be both asleep unintentionally is even worse and not unknown.) This particular Co-Pilot was one of a number who had consistently been doing 80-90 hours a month. Anyone doing this amount of Helicopter flying continuously becomes entirely automatic in action and only half with us. I think mainly due to consistent high vibration and noise, the fatigue factor in flying Helicopters, especially on longer trips (excess 5 hours) would appear to be much greater than comparative modern fixed wing/jet aircraft, and apparently is not appreciated by a large number of people in the Aviation field. Though I have no axe to grind here as I no longer do this form of Aviation, I feel the Helicopter maximum and accumulated permitted hours should be reviewed in kind (i.e. specially for Helicopters) and new legislation should be introduced to reduce the 480 [AIR] HELICOPTER L x ? Other. 486 [AIR] ROTOR L x ? 3.2 Flight deck environment. maximum to a realistic 60-70 hours a month. (60 Accumulative - 70 monthly maximum). RS I must say - with a personal hat on - how I totally agree with the comments on page 6 of Feedback 7 under "Background" in respect of the last two paragraphs. The short term effects of high density duty - especially in helicopters - are just not appreciated. As an example, yesterday I left home at 0610A, reported at 0645A for an 0800A departure from my base for a 2 hour flight direct to a rig 100 nm to the SE. We needed to be at FL 55 to talk to Border Radar so that we had some chance of avoiding RAF exercise aircraft. Temperature at FL 55 was -2 degrees C and we were IMC so we had icing to contend with. Just 8 minutes out from the rig, having planned a direct return flight to base, the pax load was increased to the maximum capacity. Furious flight planning followed which resulted in a decision to tech. stop in Newcastle. A nearly maximum weight take off was made with the wind curling through the oil rig derrick and once the tension of that had gone, we made a blind climb to FL65 in IMC through the Exercise area so we could file a revised Flight Plan with London Information. Border Radar eventually came into range after 20 minutes and to quote them we became the jam in the sandwich between 15 eastbound fighters and 6 westbound fighters - all at unknown altitudes - and within 4 miles of our position. A poor weather ILS was carried out into Newcastle, both crew then unloaded the baggage compartments - North Sea helicopter pilots you will note hump freight and baggage, whilst fixed wing airline pilots hump the hosties!! Eight passengers then decided to leave the flight as they lived nearer to Newcastle than Aberdeen, but did this without a word to the crew or handling agent. That hassle sorted, we took off for Aberdeen, arriving at 1400A. Post Flight paper work completed, into the office to sort out my mail and that of my boss as he is on leave, ring the CAA to sort out a problem and by 1630A start feeling sleepy so I go home. Only a nine and three quarter hour duty day with 5.35 flying, but by 1900A I was asleep at home in front of the television. Previous day was 8 hours in the office after 2 days off, with a full 8 hours of sleep prior to the flight, so in theory there should have been no problem with fatigue. We also fly to a rig which is well North of the Magnus platform. This is an 0915A to 1500A flight, invariably routing through Sumburgh at least on one of the sectors. We find that after three days of a combination of these flights, the crews are just plain tired. So much for 28 day limitation protection. RS In the cruise VMC on top in bright sunshine blade flash through the front rotor system onto the flight deck caused an increasing feeling of unease and tension. After about 45 minutes I left the flight deck and obtained a baseball cap from my Nav bag and returned to the flight deck, the symptoms immediately began to subside and 496 [AIR] HELICOPTER L x 3.1 Low visibility rig approaches. disappeared totally within 10 minutes. This problem has occurred before when I didn't have a cap available and the problem continued until I either descended below cloud or completed the flight. RS I was the captain of a helicopter flight to an offshore oil platform. The weather forecast indicated the presence of low stratus and shortly before we arrived the oil platform went into fog. I elected to conduct a NDB plus Weather/Mapping radar approach to the destination. Now, my co-pilot was relatively new to the North Sea and having demonstrated the approved approach technique to him in VMC just two days prior, I was determined to show him that in the real situation I followed the exact same procedure and resisted the temptation to "grobble" in visually at low speed. With the copilot handling the controls and flying on instruments and myself monitoring the profile, we descended to the MDA of 170' radar altimeter at approximately one and a half NM and continued the run in to Decision Range of 0.5NM. The aircraft was flown at the approach speed of 75 kts and the approach was into the light wind reported at 10 kts. I could see the surface but there was no horizon and forward visability very poor. I was conscious of a nagging doubt about the procedure which I had demonstrated so confidently in VMC. How much off the nose should I put the radar blip? Too little and the oil platform, a large 300' to 400' high structure would be right in front and above us at less than half a NM while we closed at 60 kts ground speed. Too much offset and I would pass abeam the platform by such a distance that I could not hope to see it. The radar painted the target only every 5 secs and as the platform's blip approached the bottom of the screen I wondered if there was a blank space in the radar display into which the blip could disappear without ever getting to the declared minimum range, in which case each successive sweep would just shave off the leading edge of the blip so that it never got any closer. However, the approach continued normally and I wanted to demonstrate the importance of adhering to approach procedures. At the minumum range of 0.5 NM, the offshore structure was not in sight and I called for the turning missed approach procedure to be executed. As we turned away and climbed I was shaken to see the oil platform in a twenty degree bank suddenly appear in the 1 o'clock, hurtle down the starboard side and be passed before I could even squeak. In retrospect I think that this experience warranted an MOR as it indicated that the procedure might be unsatisfactory and the limits too low. However, it is worth noting that in my company the pilots do not have direct access to the relevant MOR forms. Another factor which might bear investigation is that there appears to be no provision in the aircraft maintenance schedules for calibration of the all important airborne radar. 499 501 [AIR] HELICOPTER [AIR] HELICOPTER L S x x ? 3.2 Flight deck environment. 2.4 Human error with no associated technical failure. RS THE HELICOPTER PILOT AND THE LADY DOCTOR. The weather was beginning to get warmer and my problem was this itching in a place one cannot scratch in public. Eventually it became obvious that only a visit to the doctor's would help. Now my doctor is youngish, blonde, not unattractive and a lady. So there I was trying to explain that my situpon was sore and irritating me. "Can you tell me EXACTLY what the matter is?" was the question. After some more mumbled explanation came the dreaded words: "You had better take your trousers off and lie on the couch. " Lying there gritting my teeth I heard the verdict: " Yes heat and perspiration can cause this and you are quite hairy. " I sprang to the defence of a family characteristic and explained that it was this rubberised garment I wore that caused me to get so hot. Did I detect a raised eyebrow - a slightly quizzical look in those blue eyes? I went on hastily to tell how helicopters had a disconcerting habit of, infrequent though not unknown, choosing to flutter down towards the sea and that the North Sea in particular is not very hospitable. As the unnecessary loss of a pilot annoys the company accountants and proves to be most unpopular with the families we are therefore required to wear what is colloquially called a "goonsuit" in an attempt to overcome the problems created by this irksome trait. All this produced a response that I should try to wear something cooler. So here is a plea from an overheated helicopter pilot who is clothed in too much rubber during long, hot and uncomfortable flights. Please Feedback help to save us from these embarrassing itches and concentrate on the job in hand! Use your influence with the manufacturers of immersion suits to make them improve their materials and produce clothing that we can wear in comfort. RS We taxied from the hangar to a parking spot 100m away to carry out the normal engine power check prior to the first flight of the day. This aircraft has two "motorcycle" twist grip throttles alongside each other and to carry out the check each throttle is retarded in turn, power is applied and readings taken to check power is above the minimum specified. As I approached the spot, I rolled the No.2 Engine throttle back against the ground idle spot - something I would usually not do until I was fully stopped on the spot. I then applied the brakes, turned off the landing lights, and then attempted to close the No.2 Engine throttle again. Of course it would not move as it was already closed against the idle stop. Having failed to recognise this I asked the Co-Pilot - a new Captain - to try his No.2 throttle. He did not recognise the throttle was closed either. Convinced we had a stuck throttle I radioed for an engineer to come to the aircraft but luckily before he left the hangar I realised what I had done. The reasons for all this? - because it was the third early morning start out of the past 503 [AIR] HELICOPTER L x ? 2.1 Crew awareness. 526 [AIR] HELICOPTER L x ? 2.4 Human error with no associated technical failure. 537 [AIR] HELIDECK L 2.2 Technical failures that rely on human intervention. four days - up at 0455 local, in work at 0545, man up at 0630 for 0700 departure. Nothing unusual in this if you fly a long range North Sea helicopter. CAP371 just does not cater for the shattering tiredness one feels after three days of early morning flights to the northern East Shetland Basin and back - seven and twenty eight day restrictions do nothing to protect the pilot against cumulative short term fatigue. RS In the previous 6 days before this incident and on the day in question I had completed 68 hours duty and 40 hours flying hours. This incident occurred on the 2nd flight of the day which totalled seven and a half hours flying and twelve hours duty. Whilst planning our route back to Aberdeen from the oil rig I failed to notice that on our intended track, which was to be direct to Scotstown Head NDB, lay the West Shetland island of Foula which rises some 1500ft on its West side. Because we never fly overland and often fly inbound at 1500ft I chose this height as our transit height. On a suggestion from the P2 we climbed to 2500ft en-route in order to improve our communication with Sumburgh. We would not otherwise have climbed and since we were IMC all the way would have probably flown into the cliffs on Foula. There have been many occasions when I have not been able to concentrate towards the end of a twelve hour duty because of both fatigue and discomfort. I do not believe the FTLB has any idea of the scope and nature of present day UK Offshore Helicopter flying. RS Accepted marshalling instructions to park between two other company helicopters which allowed for very little clearance. My fault entirely in accepting instructions although I believe fatigue was a major contributory cause. I had flown 99 hours in 28 days and 105 in the calendar month. Prior to the day's flying I had seriously considered whether I was fatigued sufficiently to endanger the flight. I can honestly say no. However what is apparent following similar decisions to fly under these circumstances (i.e. high monthly hours) is that after about 30 minutes into the flight the cumulative effect of a high "28 day" total really hits you and then I do become excessively fatigued. With reference to Feedback No.8 "The Sleep Spot" I personally would never consider taking a "nap" in a helicopter regardless of the type of operation and particularly at 500'!! I don't know anyone who would. RS Weather...Excellent. Duty hours...Plenty in hand. Tired/Worried...Not at all. The A/C was landed on the station to drop two pax and some boxes. One box had been left behind, unmanifested but the station had been told to expect it. As is normal the deck scheduler approached the A/C when the "anti-coll" light was switched off, opened the right side sliding door, handed me a return manifest (freight 552 [AIR] NORTH SEA L x ? 2.4 Human error with no associated technical failure. only) and continued with his business of off-loading the pax and freight. I worked out the new take-off weight and prepared the sector weight chit watching the scheduler as he passed in front of the A/C and went to the left-hand cabin door, opened it and was obviously looking for something. As all was nearly complete I started to prepare for take-off as he closed the left door, came round the front again and taking the sector weight chit from me moved off towards the exit stairs. The next action was to sort out communications with the cabin as one of the two men I had dropped had been wearing the headset on the way out. This took a short while as the passenger was not English but did speak it. So off we go; throttles open from idle, pre take-off checks (incl C.W.P. clear, anti-coll on, flot gear on, all clear around, radio call "seven on board", where did the scheduler go? Obviously fed-up with waiting for me to sort out the comms and continued below (funny not like him), another good look around and gentle lift-off to hover, something catches my eye on right side!! Scheduler and helper kneeling-down on helideck!! re land on, both clear, thumbs up and continue flight. What the hell was he doing there? Simple he'd gone back to have another look for that box. Well why no warning light on the C.W.P.? Equally simple system u/s! The door lock light operates if either cabin door or the tail boom compartment door is open and the actual functioning is rarely checked as the compartment is usually opened after the cabin doors and closed before them. So what do we have? My fault partly as despite having had two looks around and done all my checks I should have insisted on seeing the final "thumbs-up" from him at deck edge. His fault partly for having gone back without making his intentions clear and today when all this happens together the one system which would have shown me all was not ready was u/s. Who said sod's law? Despite it all and notwithstanding that we are tightening-up a few procedures how about a few more thoughts. What about a separate (duplex) warning for all doors and compartments? A friend's new Honda 5 door has a very natty diagram showing whatever is open; what about it on a $2m helicopter? Then how about a bit of rig design which ensures that the exit line/stairs are in the normal field of view not 130 degrees behind the fwd/aft centreline of the a/c. (They might also have access to the fire gear then as well that could be useful). I believe the plan is also to get headsets for these guys now so that should fill in any remaining gaps, let's hope they don't go u/s or cause any mis-understandings on our one frequency. Meanwhile let's hope this will cause my contemporaries, should they be in the same situation, to think again and check again. RS FLIGHT TIME LIMITATIONS; S61 AIRCREW. "The following flying hours were achieved on 2 consecutive days; 8.4 hours day flying (including 4 hours Instrument Flying) and 8.5 hours day; 0.5 hours night flying. Despite being fit and well rested before both periods of duty I experienced unreasonable fatigue during the second day after the cumulative total of about 14 hours flying. Experience in Scandinavia has shown me that a 2 day limit of 14 hours is much more realistic. The present limit in UK for S61 aircrew of 9 hours per day which can accumulate at that rate per day subject to crew duty time limitations is a flight Safety hazard." The above is a copy of my company incident report rendered last month; their replies follow. Fleet Manager: This is the first written report of the problem which is causing concern throughout the Fleet - as evidenced by a growing number of verbal reports from pilots. The common theme is that, due to the cumulative effects of fatigue, individuals find themselves making an increasing number of mistakes. I am seriously concerned that unless the pressure of work is relieved, a serious misjudgement with possible fatal consequences, is inevitable. The situation is ripe for it; particularly with the onset of worsening weather conditions. Flight Manager is urgently requested to review the situation. God forbid that we find ourselves in an "I told you so " position. Flight Manager: Aircrew are still being recruited and trained, with establishments continually being reviewed. It is not Company policy to condone such high levels of productivity in the long term, however the company must reserve its rights to operate within our approved flight time and duty hours limitations scheme. Perhaps the CAA might care to address the problem and amend CAP 371. ................. All highly laudible? I have enclosed a copy of my logbook for that period. It illustrates the intensity of my flying over the relatively short period of 8 days (and that included one Day Off). Regrettably, by the start of my second flight on 7th October unknowingly I had exceeded the 100 hour 28 day limit (but not the duty time limit). Operations maintain the crew duty times in this company and are supposed to warn aircrew when approaching limits........ No excuse for me though. Let this not cloud the real issue since this only became relevant near the end of the work period under discussion. My main point is that the present 9 hours per day flying time limit is in itself possibly too high but in any case is dangerously high when used accumulatively. It is worthy of note that all of the flying was carried out in "normal working hours ", mainly in daylight and not in extreme weather. I find it difficult to be specific on the subject of fatigue itself other than that of feeling rather weary. It was only when I read back ATC clearances incorrectly and miss-set engines during routine power checks that my poor performance was obvious. I have more than a decade of experience on the S61 on North Sea Operations including 6 years with a Norwegian Company. In Norway we reported frequently for duty at 0300 local for extensive flights many of which included three hours or more of inter rig shuttling. However, their flying hour limitations were as follows. We felt that these limits were realistic. 1 Day ...... 9 hours 2 Days...... 14 hours 7 Days...... 35 hours In my present Company, in the UK Sector, commercial awareness caused me to continue flying when I was in the fatigue bracket. Even as I type this report on a November evening I was to have flown eight and a half hours today and am scheduled to fly a similar amount tomorrow. Competition on the North Sea is fierce and we aircrew have to play our part. Can I.A.M. put more pressure on the CAA to change the present legislation as soon as possible? How about a Trial change? Or do we have to wait for an accident as referred to by our Fleet Manager. 562 [AIR] HELICOPTER L x 3.2 Flight deck environment. 563 [AIR] HELICOPTER L x ? 2.4 Human error with no associated technical failure. ATTACHED:- Pilot's Log Sheets (2). RS Every day I drive to work in my 4 year old Ford Escort which is blissfully comfortable, with a seat that slides, tilts, pitches etc. - a noise level that is remarkably low heating and ventilation readily to hand etc. etc. Although not a new latest model it FEELS GOOD to drive. On arrival at work I climb into a helicopter (worth about 3 million pounds) and am subjected to appalling noise levels - even allowing for the use of a good headset AND earplugs, very aggravating levels of vibration, an excruciatingly uncomfortable seat, a cockpit heater that works flat out or not at all - etc. etc. The list goes on and on. Why has the situation been allowed to come about? I would suggest that the fundamental reason is that the helicopter manufacturers have not HAD to pay much attention to this aspect of helicopter design, as the person who is responsible for buying the machine is seldom the person who flies it. This is directly contrary to the situation as applied to the motor industry - in order to sell the machine one has to take care of the comfort needs of the driver. How can this situation be resolved? As you chaps at CHIRP might carry a bit of clout with The Helicopter manufacturers perhaps you could send copies of letters like this to Augusta, Bell, Westland etc. (Sent a letter to Westland myself - didn't even get an answer). RS The point I want to make is that 3 round trips out of Aberdeen each averaging two and a half to three hours is too much for one day, no matter how many days rest were allowed previously. And when such busy days are normal up to 3 times a week for many North Sea pilots, then the potential for human error to cause a catastrophic incident is far too high. The specific occurrence which I am reporting exemplifies the kind of mistakes which I know other pilots are sometimes making at the end of a long day. On the seventh and last deck landing of the day and the fifth night deck landing, I closed the airstair door after embarking passengers. I checked that the door handle 593 [AIR] NORTH SEA L x 3.2 Flight deck environment. 610 [AIR] HELICOPTER L x 3.1 Low visibility rig was fully moved to the left, pushed hard against the door and looked to ensure that the latches were in position. I should have used a torch to look at the latches, but thought I could see them well enough with available cabin light. En route back to Aberdeen, while conducting cruise checks, the other pilot noticed that the airstair door warning light was illuminated. This light must have been "on " while the pre take-off checks were executed, but obviously both pilots failed to notice it at that stage. Appropriate action was taken to secure the door and the flight was completed without further incident. The latches were incorrectly positioned. At the time of the failure to notice the warning light, both pilots had already completed ten duty hours, seven and a half flying hours, three hours in poor-weather-IMC, one and three quarters night hours and nine sectors. On completion of the day, both pilots had worked eleven and a half hours and flown eight and a half hours. This is by no means exceptional. I believe that the Flight Time Limitations Board has a criterion that pilots should not expect to fly seven or more hours per day on more than four days per year. Well, I have far exceeded that in 1985, while many of my colleagues make my experiences seem like a holiday. I know that there is a shortage of helicopter pilots and that my employers are struggling to make a profit, but lives are at stake. Please limit daily flying and duty hours. RS This report is not of a particular incident but to highlight a continuing and perennial problem for North Sea S61 crews, i.e. flying without a cabin heater. Having just had my first experience of this winter, the only thing I can be sure of is that it probably won't be the last. Although wearing thermal socks under my immersion suit, and cape leather flying gloves, it didn't take long for hands and feet to feel cold, although the flight lasted less than two hours. However 2 hours at a temperature barely above freezing is no joke. The company's attitude is that crews should " dress for the occasion ". Bodily warmth is not a problem it is the extremities, and I believe that thermal socks and gloves are the best one can do. There is no doubt that crew performance deteriorates markedly in extremes of temperature at either end of the scale. Pilots think that flying over the North Sea in winter without cabin heating is a flight safety hazard, but the company certainly expects it of us. I would like to see serviceable cabin heating on the Minimum Equipment List. Can't the CAA make it mandatory by issuing a Notice to AOC Holders on North Sea Operations. What do CAA Flight Operations think of the situation, are they aware of it and do they condone it? Let's hear what Medical Branch/I.A.M. have to say on the subject too, if they care to comment. RS I was giving retraining to experienced North Sea Helicopter Captain. Although platform was giving very poor visibility I decided to make an approach approaches. 625 [AIR] NORTH SEA L x 2.4 Human error with no associated technical failure. 3.14 Gear up warning. (NDB/RADAR) down to .45NM @ 150' (other Captain handling) to give him experience. I pointed out to him the fact that provided the approach pattern was followed to the letter there was no problem and when/if we overshot we would divert to Unst. Approach was flown " perfectly " but I was slightly alarmed to see a platform light pass quite close underneath and to one side in the fog during overshoot. Procedure has now been modified. RS Although I am outside N.Sea work now, I am amazed that fatigue continues to be a cause of concern, evident from CHIRPS and from talking to pilots still engaged in offshore work. The unspoken near accident occurrences seem to be on the increase, nobody has apparently learnt any lessons - but I did! A typical winter's night on the North Sea, the third rotation of the day, a "short" trip to get us back to base within statutory limits, no hot food since breakfast (0730L), the heater went u/s, having flown 5.45 hours just a "little bit tired", we began to feel the cold, we were requested to make a change to our pre-planned route, the last 2 stops being rigs without fuel, a quick discussion ensued and we both reckoned we would be still OK to do the job without refuelling after the last 2 stops and get back to base "in time". Our freight load had been miss-calculated, in fact weighing three times more than we had been told, another calculation well within WAT limit and because of the increased loading time, therefore another fuel calculation, but happily still OK to crack on without picking up any more fuel. Still no heater and feeling "cooler", but lo' and behold hot food for two! All loaded, no passengers, Captain's turn for take-off and the leg to the next rig, all checks carried out properly, there was enough time for me to have my meal before the next stop - or at least part of it. The Captain then volunteers to carry out the prelanding checks himself and do the radio calls - "thank you very much". While eating this meal, and keeping an eye outside (as this was the busiest time of day for the in field shuttle aircraft), I made a mental note that one of the "shuttlers" was heading for the semi-sub anchored beside our destination rig, and having some problems raising them for landing clearance, a quick call in between time from the Captain of our aircraft secured our landing clearance; I had noticed that one of the ADF's was tuned to a BBC broadcast, which had not been tuned in by myself. About three miles from the rig, I put aside my meal tray in preparation for landing and to man the Speed Select Levers, I picked up the check list, the Captain preempted what I was about to do and in as many words said don't bother I've done them, OK fine. The in field shuttler was still calling his destination and not getting any reply, as he was progressively getting closer his calls were becoming more frequent, and I calculated he would be landing roughly at the same time as we would be, nothing unusual in that. On the final stages of our approach, the last 50 feet or so, the shuttle aircraft eventually got through to his destination, almost simultaneously I heard our destination calling us, but because of all the other chatter, what he said was unintelligible, as our aircraft settled to land, saying all clear on this side, I noticed our aircraft begin to sink through its normal landing height (i.e. wheels down on the deck height) - i.e. gulp, no wheels down! We both realized this at the same split second, he (The Captain) raised the aircraft into a higher hover, and our hands met on the gear down lever! Once landed safely, we glanced at each other, words were not necessary! What our "desk" was trying to tell us, was that our gear was up, but because of all the radio interference (and from the BBC) he could not get through. This incident occurred during a 9.00 hour flying day, of which 9.30 was rotorsrunning. Too cold, too much flying, too much rotor running time, too much willingness to help the customer, too many duty hours, too much trust, too many mistakes, too much asked of the crews. At the time we were working seven day weeks. 631 [AIR] HELIDECK L x 3.1 Low visibility rig approaches. I'm sure this is just one of the many incidents that has happened, but has remained unreported fully. RS We were making a rig Radar/NDB approach to a semi-submersible. The rig had been in fog that morning, but prior to our departure, the fog had lifted into low stratus and was beginning to disperse. Since the wind direction was such that the helideck would be on our starboard side, I elected to fly the approach and have the co-pilot carry out the landing. By 150 feet on Radalt we were down to 70 knots IAS and running in to a decision range of 0.5 n.m., visual with the surface. Shortly after the co-pilot called "One mile", I briefly looked across at the Radar screen and saw the return at 0.7 n.m. On looking back at the Radalt, I found that the height had increased by about 25 feet, as I'd inadvertently allowed the nose to come up a few degrees. At the same time, the co-pilot called that he had lost Radar contact with the rig. Believing that this might be due to the increased nose-up attitude, I quickly adjusted the tilt of the antenna down a few degrees, convinced that the rig would reappear at just over half a mile. It did not. I called "Overshooting" and commenced a climbing turn away from 652 [AIR] HELICOPTER L x 2.6 (3.18) Pilot view & visual cueing environment. the location. Several seconds later, the co-pilot called that he was visual with the derrick out to the left, through the broken stratus. The distance was difficult to estimate, but the rig looked too close for comfort. RS I was the Captain of a helicopter which had departed from Aberdeen on a June morning, and after landing on an offshore platform, we were estimating Aberdeen approximately 3 hours later. The North Sea was that day affected by haar (sea fog) and while still some distance from Aberdeen, we copied the ATIS which was reporting fog. As we were radar vectored to the ILS for runway 17, the RVR was consistently reported to be below 600 metres. The ILS was going to be flown using raw data displayed on an HSI with a Glide slope at the side. Now, my company, in common with some other helicopter operators is in receipt of a special dispensation from the CAA which takes account of "the unique characteristics of the helicopter" and permits ILS approaches in RVRs as low as 300 metres. I continued with the approach and briefed my co-pilot; he was to fly the ILS, reducing his airspeed to a bare 70 knots at Decision Height, where he would level the aircraft and fly a level section for 15 seconds, while maintaining the Localiser (not easy where the beam is so narrow). It would be my duty to monitor his handling and to seek visual reference prior to taking control for landing. The procedure developed as briefed and whilst flying level at the OCL I was able to see some Approach Lighting - just. I advised my co-pilot: "I can see........the lights.........I have control" I assumed control of the aircraft, but no sooner had I done so than we over-flew the runway threshold and there were no more High Intensity Approach Lights to be seen, in fact there was nothing to be seen at all! "......No I can't! - You have control!! - Overshoot!!" and I threw it all back to the co-pilot, who, bless him, picked up his instrument scan and we climbed away. On the next attempt, the RVR was considerably better and we completed a normal landing. 672 [AIR] HELICOPTER L x 3.2 Flight deck environment. I have since wondered which of "the unique characteristics of the helicopter" were being taken advantage of. RS There are a number of problems relating to North Sea helicopter flying - which are perhaps emphasized by the fact that a lot of the passengers arrive by jet airliner and an hour later they are crammed into a helicopter. For the crews who exchange the comfort of their (5 year old) cars for the comfort of a cockpit of a 3M pound helicopter the contrast is similarly striking. The passengers do not like or expect to find freight lashed to the floor - or underneath their seats. They do not like sitting in front of freight - however secure it may look - nor do they like seats being folded up against emergency exits - they like every exit to be available. Sometimes the protests from the passengers forces freight to be offloaded. Generally it is best to fly freight and passengers separately so that the cabin is either in the freight role with appropriate seats up against the cabin wall OR in the passenger role with all seats down and secured properly to the floor. Best of all would be, if some helicopters were employed permanently in the freight role - say some S61Ns - which are ideally suited to this task. In regard to the cockpit environment, firstly I enclose a local newspaper showing that a number of pilots feel that the situation can be improved easily. In the road transport World there are regulations governing the noise and comfort levels in long distance lorries. It would be helpful if similar standards could be drawn up for long distance helicopters. Please bear in mind that lorry drivers can wear light clothing and do not wear a heavy lifejacket. I have ceased to be surprised that at the end of a six hour flight over the North Sea that the accuracy of flying both by myself and my co-pilots is not as good as I would like. Nor am I surprised that crews fall asleep easily; a doctor during a health monitoring sortie recently on my co-pilot was fast asleep on the inbound leg when we got to 30 miles. On long legs I invent activity - like reading through the check lists - the ops manual - the Aerad in order to keep my brain alert - it works for me. Overleaf I have listed some of the main problems with brief details of rectification. NORTH SEA HELICOPTER ENVIRONMENT - COCKPIT. PROBLEM POSSIBLE RECTIFICATION Airframe vibration - Fit either Manufacturers "longflight" seats (research has shown that or design seats which absorb vibration - as exposure to low frequency are fitted to lorries and coaches. sound is damaging to internal organs). Direct sunlight. Fit moveable shaded sun visors - as fitted to lorries and coaches. Dehydration - arising from Fit 2x1 litre water bottles within reach of hot cockpits + wearing crew. Contents to be changed before each survival suits + lifejackets sortie. Rigs often unable/unwilling to provide for six + hours continuously. "orange squash". Poor ventilation/heat stress. Fit small fans with small rubber blades directional - on cockpit coaming - to blow cool air on face/torso - particularly helpful when "cooking" on the ground prior to startup/takeoff. 675 [AIR] HELIDECK L x 3.1 Low visibility rig approaches. Very high noise levels 120db+. Supply best available - noise attenuating headsets/light weight helmets/visors. Over long flight concentration lapses and prolonged exposure causes high tone deafness - and loss of licence. RS The "TOO CLOSE FOR COMFORT" article in the number 10 issue of Feedback prompts me to write to you about an experience I had during an approach to an offshore oil platform. I was the Commander of the helicopter and my co-pilot was also an experienced North Sea Captain. This particular day the weather forecast indicated deteriorating visibility but we were carrying plenty of fuel and it did not give us any cause for concern. When we made radio contact with the platform we discovered that the weather was in fact much worse than intial reports had indicated. The cloud base was estimated as 500ft with visibility at 1-2 NM and signs of fog patches forming. I elected to carry out a radar/NDB approach. From the wind direction we had been given it was clear that my co-pilot would have to carry out the actual landing so I flew the procedure while he kept visual lookout. We descended towards the platform and found the cloudbase to be 300ft and not very well defined, but we did establish good visual contact with the sea surface and the descent was continued. The forward visibility was about 1 NM but less than that in patches. My co-pilot read off the ranges to go from the radar and at .75 NM announced that he could see the outline of the platform. At .5 NM he had firm contact and I handed over control to him for the landing. On looking up to get my own visual bearings I was a little unnerved to see how close we were to such a large structure, a feeling I had experienced before. The helideck was at a height of 230ft above the sea surface so it was obviously necessary to climb to get on to it. Imagine our horror when on initiating this manoeuvre the platform promptly disappeared from view. I ordered an immediate overshoot at maximum power. I found my hands instinctively going to the controls and I had to force myself to allow my perfectly competent co-pilot to continue handling the aircraft while I carried out the checks and monitored the flying. How close did we get to the platform? I hate to think! 684 [AIR] HELICOPTER L x 1.7 Error prone equipment. 1.15 Standardisatio n issues. After we had settled down at a safe height and discussed the problem I chose to make another approach but this time we would not descend below the height of the helideck. When we made visual contact from that approach we knew that we could carry out the landing without having to climb and that is what we did, this time without frightening ourselves. RS Had just completed some short inter-platform flights and had just landed to refuel prior to next sector. Normal procedure is to pull the Radio altimeter C.B. when hot refuelling to eliminate radhaz which is the top collared one on a vertical C.B. panel behind the co-pilot's seat. This particular A/C in the fleet had been modified and the radalt C.B. had been moved to another position. The top collared C.B. was now the captain's artificial horizon C.B.! Yes, I pulled it. Pre take-off checks, yes, I missed it. Although the little fail flag must have been showing, the horizon was still indicating sensibly. After take-off, it was not until I started turning that I noticed the fail flag. The obvious answer is more care during pre take-off checks which I fully accept. However some design aspects could be utilized to help the pilot notice fail flags more quickly when the workload is high. 1) A "No Flags" check is not possible on this aircraft as two glideslope flags are always in view on the HSI and ADI even when an ILS frequency is not tuned. The original spec of the aircraft ex factory was such that no flags showed on the flight instruments unless a selected aid was not functioning. As the default position of the G/S flags is "full fly down" when the HSI beam bar is being driven by the ANAV system, the CAA insisted that the G/S flag be visible when ANAV was selected on the HSI. A better solution would be to cause the G/S flag to default to "full fly up". 2) The ADI fail flag appears at the top of the instrument next to the Angle of Bank indicator. In wings level flight, (which normally includes the first portion of the take-off) the Angle of Bank portion of the ADI is 720 [AIR] ROTOR S x 3.17 Tail rotor failure/ loss of effectiveness. 738 [AIR] HELICOPTER L x 3.2 Flight deck environment. not scanned as rapidly as the centre of the instrument. 3) The flag itself is not that big and is striped red and black. Nature has proved that stripes offer very good camouflage. A solid red flag which covers more of the instrument would be much more noticeable. 4) As to cockpit ergonomics, well that's a different matter. The helicopter industry is at least 10 years behind our fixed wing cousins in this field. RS Tail-rotor/crop contact on pulling up at end of swathe, resulting in drive-shaft failure and loss of control at apex of turn onto the next run, aggravated by probable unduly low airspeed (see below), unawareness of initial impact and lack of any immediate warning symptoms thereafter. The machine in question had a couple of minor faults not amenable to rectification at that particular stage of the operation. Namely:(a) boom pressure-gauge mounted too low, hence obscured by rudder pedals unless pilot raised on very thick cushion, thus appreciably modifying his attitude perception, especially of a tail-low condition, and ... (b) unreliable ASI tending to fluctuate and under-read, thus tempting the pilot to ignore low IAS associated with a semi-flared profile, whilst groundspeed remained deceptively high. It is assumed that these false indications, combined with external factors (tailwind component of nearly 10 knots, undulating ground, tall obstructions ahead) caused the basic error of judgement, despite something of the order of 100,000 such turns executed in the past without a sign of tail-strike proneness. NB. It is noteworthy that a previous accident in which I was involved, although completely different in nature and origin, nevertheless does resemble this one in principle in that it is thought to have arisen through a number of secondary and apparently disparate causes (i.e. simplistic so-called "rogue blade" theory found to be erroneous, but the actual collective instability encountered could be attributed rather to vibrations from brunelling of rotor grip, loose engine mount, etc., identifiable in toto only after disassembley of the damaged aircraft). MORAL Keep an intelligent watch for those small points - they can sometimes add up to catastrophe! RS It was a fine, clear day, with a bright sun. Outbound I had the sun abeam me (the co-pilot was in shadow). The angle of sun was such that I was constantly conscious of its presence out of the corner of my eye, and there was a flickering effect caused by the rotor-blade shadows that was very discomforting. By the time we arrived at the platform I had a severe headache, which I consider was caused by this effect. I was given 2 paracetamol by the rig medical attendant, before flying back. However, on the return the sun was about 15 degrees off the nose. It shone straight into my eyes (and those of my co-pilot this time), and even sunglasses were ineffective. Vision in that sector was impossible, compounded by a brilliant reflection off the sea. Even instrument reading was difficult. The discomfort level in our survival suits and life-jackets (worn to conform to the oil company's commercial requirement) was high, even though the OAT was only 10 degrees C at most. Opening the flight deck windows helped ease discomfort, but caused a lot of distracting noise (in addition to the already high ambient levels). By the time I arrived back, I was feeling quite unwell. 760 [AIR] HELICOPTER L x 3.1 Low visibility rig approaches. The helicopters have no sun-visors, in spite of being requested several times by crew members who regularly experience these problems. The "soft hat" suggested by a correspondent in a recent Feedback would not have been a solution to either the outbound or inbound situation. RS Reference your note regarding my CHIRP. I agree the decision range for a radar approach has recently been increased from one half NM to three quarters NM. However the instance I outlined in my report occurred at between one NM and three quarters NM indicated radar range and we almost hit the rig. So the simple answer to your question is yes such near misses will still occur. To be honest it is a miracle that a helicopter has not hit a rig using this procedure. I suppose we must be thankful for small mercies. Personally I feel approval of this procedure by the CAA was an act of gross criminal negligence and that they should be taken to task over it. The lives of thousands of people have been put in serious jeopardy by sheer complacency. It is ridiculous, even now, that the procedure is still being used because the Flight Manual supplements state categorically that the Wx radar MUST NOT be used for collision avoidance. The radar accuracies are not published, they are not calibrated and the manufacturers do not know how accurate they are because they were not designed for collision avoidance in the first place. The procedure has been flown down to minima which equate to minima for precisionapproaches to land airfields. Now I ask you what self respecting authority would allow you to carry out an ILS using uncalibrated ground or airborne equipment. Well that is what has been and still is happening in the offshore helicopter industry. As you will have gathered I feel pretty strongly about this subject but there are numerous other areas eg offshore alternates, Low Vis ILS etc. which have been approved along similar lines to radar approaches i.e. unscientifically by pressure on the CAA from sharp helicopter operators who can gain a commercial advantage with reduced minima or being able to carry less fuel therefore more payload. Unfortunately this commercial advantage is short lived as all the others apply for and generally get the reduced minima etc. This leads to a downward spiral and gradually erodes safety margins until they become unacceptably low. The North Sea has reached this state and something has to be done soon. The responsibility lies fairly and squarely on the shoulders of the CAA. If they continue to shirk their responsibility I dread to think what the consequences will be. 797 [AIR] NORTH SEA L x ? 2.13 Task complexity. N.B. SEE REPORT NO. 750 RS WEATHER IMC.MIX ST,SC FROM 1500FT TO 6000 FT + PRECIPITATION, [RAIN,HAIL & SNOW] This report does not really concern one particular flight, (though I shall use the one above as an example). I think the time has come to express concern over legislation concerning flight in icing conditions on the North Sea. My own career on the North Sea spans only 3 years and the AS332 is the only type for which I am rated. However in the space of 3 short years there have been well over a dozen changes to the AS332 icing limitations. The original Flight Manual Supplement was OK once you had MEMORIZED the available flight ENVELOPES and how they differed with regard to items of equipment being available or not. Since then there have been amendments, changes, new FM Supplements, Ops Circulars etc. dispensed like confetti. To summarize a FEW :- The flight envelopes were altered, then the icing clearance was withdrawn, then it was back with changes regarding ice detection equipment, then the Circulars started; regarding what specific temperatures to avoid, which part of stratiform cloud to avoid, the need for the air below 500ft, limitations for onshore approaches if this, that and the other conditions existed, a new set of departure limitations and so it goes on. The most recent being the CAA imposed circular on engine icing. This involves avoiding certain temperature/precipitation combinations, unless there is air +3 degrees C or above at MSA, in which case we can fly in the prohibited areas for an ACCUMULATED ten minutes. So wherein lies the problem? 1) The average pilot is now suffering from brain failure, trying to remember which bits of all the various legislation is still in force and which bits have been scrapped. 2) We are all only too aware of the penalties for "breaking the law". However, many items are vague and some of us feel that it is inevitable someone will get CAUGHT OUT eventually. 3) The whole system is creating a complete lack of confidence in the compilation of safe and effective legislation. The N.Sea operators between them have nearly 150,000 hours of AS332 experience - how much longer do we have to put up with "stop-gap" measures? I think that cultivating this attitude within pilots is basically unsafe! 4) The recent engine icing limitations are forcing pilots into either :- (a) Known icing conditions where build-ups can be reliably measured e.g. on the day in question, pilots were searching for an altitude between cloud layers or over the tops - a position where they would not have flown prior to this limitation. (b) Low level flying, either to avoid the temp/precipitation combinations or to dissipate ice build-ups. On 15/2/87 the temp at 500ft was +2 degrees C and isolated showers were around. The legislation calls for +3 degrees C at this altitude if flight in icing (for 10 mins) has been encountered. Some pilots therefore "had" to divert to comply with the law, whilst the rest of us let common sense prevail and pressed on - at what cost to our licences if we are caught and at what cost to our jobs if we comply? (c) The chances of not being able to recover into Aberdeen IFR in bad weather and having to resort to use of the "Low Level Route" - not exactly an improvement in safety when a perfectly serviceable ILS is available. 799 [AIR] HELICOPTER L x 1.15 Standarisation issues. So what do we do? Introduce FULL anti-icing equipment as a mandatory requirement I suppose. Meantime let's have some common sense to bolster people's confidence. RS Here is a CHIRP about a problem that I had with my altimeter. Generally, setting the correct pressure is just awkward and slower than such a simple task ought to be. However, this incident demonstrated to me that, when combined with "a bit of pressure", the "awful" altimeters are liable to force an error. There is an ongoing problem with altimeters as fitted to N.Sea helicopters. On several days in 1985, the pressures were lower than 950mb and it was discovered that many of the sub scales would not go low enough, as the altimeter did not conform to the British standard. At first it was proposed that in those circumstances, pilots should set (Pressure Setting + 33mb) and remember that their altimeters would then read 1000ft high. Fortunately this was thrown out. The alternative of British altimeter was deemed too expensive, so the third solution of modification was adopted. The first modification involved a new sub scale with graduations at 2mb intervals, but this produced lots of setting errors. The second modification is another new sub scale plus a change in gearing, but the figures and graduations are so small that combined with the vibration they are too difficult to see. Added to this is the problem that the combinations of; direction of scale; direction of movement of scale; direction of adjusting knob; are all completely random. It's entirely possible that a pilot will use one particular type of altimeter for several flights, so as to condition his actions. Then on the next flight he may find himself using a similar looking altimeter which operates in a different sense. 800 [AIR] HELICOPTER L x 2.4 Human error with no associated technical failure. 1.15 Standarisation issues. With your reputation in the field of Human Factors, do you think that you could persuade the CAA Airworthiness Division and the Helicopter Operators to improve the situation. My employers, B----- Helicopters,LD do not like their employees filing MORs or CHIRPs. RS I was the Captain and handling pilot of an AS332, on a public transport flight. We were tracking some 170 degrees M to the (ADN) VOR at some 4000ft, which put us just above a layer of Sc that was expected to give moderate icing. We intended to carry out an IFR approach to runway 17 at (Aberdeen), but because of the icing considerations we were cleared under radar control, to remain above cloud until within 10nm DME. We had requested radar vectors to the ILS, but were told by ATC that this was not available, as the ILS was radiating for runway 35 while a flight checking aircraft carried out calibration runs. Consequently, I requested a radar approach to runway 17. After passing 10 DME, we descended to 3000ft on QNH 1027mb, and approach checks were completed with a brief for the SRA to runway 17. I was some 5nm north of the VOR at 3000ft, and encountering moderate icing, when the radar controller asked if we were established on the localiser. The non-handling pilot replied that we were not using the ILS as we understood that it was not available. To this the controller replied that it had just become available, and that we should report established on the localiser and also descend to 2000ft on QFE of 1020mb. (We were now quite close to the VOR and at 3000ft on 1027mb, were probably above the glidepath.) This change of plan was somewhat unexpected. My co-pilot quickly tuned and identified the 2 ILS receivers, while I set the QFE and promptly commenced the descent to 2000ft QFE. During the descent, I checked the ident code, selected the ILS on the HSI, set the QDM of the centre line and altered heading to establish on the localiser. I also got the approach plate out of the book and quoted the minima and salient points of the ILS procedure, in a rather hurried brief. At 2000ft, my co-pilot said, "You've gone below 2000ft!". I replied that I had not, but then saw that my altimeter was set on 1030mb and not the correct QFE of 1020mb. Now, this incident was not terribly life threatening in itself, for we came clear of the cloud at about the same time as the mistake was noticed, and even then we were only 100ft below the cleared altitude. But what concerns me is, how did I come to set completely the wrong pressure setting, so as to descend below the cleared altitude? There are clear parallels to be drawn between this minor incident and the loss of GBDAN at Tenerife in 1980 :a) The unexpected change of plan. b) The difficulty in executing the new procedure. c) The flurry of activity required to comply with the ATC instructions. However, this does not explain why the wrong datum pressure was set, after all, altimeter pressure settings are constantly being changed without error. Consider the attached diagrams of the altimeters, drawn to actual size. The altimeters are viewed from a distance of some 50cm, while the instrument panel is acknowledged to suffer from shake. In the AS332 fleet of many aircraft, the individual helicopters are fitted with altimeters of types "A" & "C" or "B" & "C". As the pilots fly from either seat, according to crewing requirements and convenience, a pilot may find himself using an instrument of type "A", "B", or "C". These altimeters are superficially similar, but the sub scales and the mode of changing the datum pressure setting are all different. It seems now, that most of my colleagues have difficulty in seeing and setting the correct pressures. 801 [AIR] HELICOPTER L x 1.15 Standarisation issues. Whatever happened to the altimeters with veeder counters for the pressure setting, that we used to have 20 years ago? APPENDED: DRAWING OF ALTIMETERS, TYPES A, B & C. (SCALE - FULL SIZE). RS There are THREE different types of altimeters on Bristow Tiger Helicopters namely :DRAWING APPENDED SHOWING 3 ALTIMETERS WITH SUBSCALE SETTING KNOBS. PROBLEMS 1. Almost impossible to read sub scale especially in dark + vibration. 2. No two altimeters necessarily work in same way in the same cockpit. REQUEST : Standardisation of altimeters. N.B. One upon a time we had altimeters which worked in natural sense and had large analogue display of pressure setting - but not now! 827 [AIR] HELICOPTER L x ? 3.2 Flight deck environment. Other. 876 [AIR] HELICOPTER L x 3.2 Flight deck environment. viz : small sketch appended. RS PW/FP At Aberdeen, helicopters generally commence their take off from halfway down runway 35/17, entering at Holding Points Charlie and India. I always WINCE at the instruction to, "Line up after the departing (or landing) ________". A helicopter lining up in the path of a fixed wing aircraft seems to be an accident just waiting to happen. The practice is not new, but most recently, I had just changed to tower frequency as my helicopter arrived at Holding Point Charlie, when I was instructed to, "Line up after the departing 748". It was raining at the time, the visibility was not too good and my cockpit windows were misting up. As I acknowledged the ATC instruction, a 332 crossed my nose on take off. I had to think for a moment; I was to line up after a departing aircraft and one had just departed, but it was a 332 and not a 748. With a bit of window rubbing and peering, I saw a fixed wing begin its roll from the full length - yes, line up after THAT one. Am I the only person who's heard what happened at Los Rodeos? It is said that if enough monkeys are given typewriters, then in time one of them will write Hamlet. We are not monkeys, but consider our "Hamlet" :- 1) An aircraft using the full length of the runway. 2) A helicopter intending to enter the runway near the mid point. 3) An instruction for the helicopter to line up. 4) An additional, optional and conditional instruction not to carry out instruction 3) immediately. 5) The helicopter crew seeing an aircraft coming down the runway. Items 1), 2) & 3) will produce an incident while items 4) & 5) should prevent its occurrence. The example related above shows how weak items 4) & 5) are. "Oh come!" I hear someone say, "That's as likely as a 7000 ton ferry sinking because nobody closed its doors". RS NOT DIS-IDENT. Thank you for your telecomm re fatigue amongst helicopter crews etc. I don't think I am the best person because I might just go over the top in any discussion - which would be counter productive. I am presently still on the mend following an airworthiness problem in June when the main spar in the stabilizer of a 332L gave way in flight causing handling problems and requiring a high speed runon landing out with the flight manual clearance. Only two years ago a control rod in the tail rotor broke - causing me to force land the 332L in a farmer's field. A year before that I experienced a problem in the transmission which shut down an engine during a vertical take off. In all three cases passengers were on board. So if I were to appear before a board in London we may end with the 332L being grounded rather than having its airworthiness reviewed by the CAA and DGAC (French CAA) as is presently happening following several airworthiness problems this year alone. I have passed on your requirement for someone to represent North Sea helicopter pilots so somebody may get in touch with you. However for most pilots the review of helicopter pilot fatigue has come too late. There is a rapid turnover of pilots in the North Sea, with all pilots under 30, half the pilots aged 30-40 and a quarter of pilots 40-50 now leaving for fixed wing flying. Our former colleagues now in Dan Air, Brymon and others have told us that they happily fly longer trips because the working environment both in the air and on the ground is so much better, let alone the better prospects, cheaper holidays, safer aircraft etc. How I wish I were thirty and fancy free! Having flown fixed wing myself I would say the the North Sea helicopter working environment is primitive in the extreme - mostly because the machines are derivations of military vehicles. The main concern is for the comfort of the passengers - and the working environment for the crew has been a matter of supreme indifference for the manufacturer, the Oil Company, the helicopter operator and the CAA. For most pilots the effects of high noise levels (120db+), poor sound insulating headsets, high levels of airframe vibration, lack of sun vizors, poor levels of ventilation and heating, incorrect, repeat incorrect seats in the 332L plus wearing a rubber immersion suit, boots and bulky lifejacket, means that those who can leave the industry do so - and accept an initial 50% drop in pay in order to get a foothold in fixed wing flying. The operational problems which continue to cause anguish and hence fatigue for the crews on the 332L are the lack of screen demisting and windscreen wipers on the MAIN central windscreens. This makes decisions very difficult when arriving at decision height off an ILS in precipitation - misted up inside covered in rain/slush/snow outside! The operators wish to lower decision heights to 150 feet for slow speed helicopters - even if the crew can't see out of the main windscreen! Mind you it works well in the simulator! I think if the Chairman of the Board considering crew fatigue were to come to Aberdeen and fly in the jump seat of a 332L for the permitted 9 hours per day, 30 hours per week, 100 hours per month I think we might see some change - if only we might need a new Chairman. It has been put to me that the 332L is a young man's helicopter. However all the young men are leaving - voting with their feet? Is this significant? The problems about helicopter cockpit environment and associated pilot fatigue and linking pilot error accidents + incidents needs to be solved now as all operators are now experiencing a crisis on many levels with so many pilots leaving the North Sea for fixed wing flying. The requirement for helicopter pilots is now exceeding availability and those presently remaining are individually carrying more load which results in more leaving the industry for fixed wing or becoming medically grounded with stress/fatigue related problems - (the CAA will have the figures). Perhaps now that the Oil Companies cannot get the helicopter support that they have been used to we might see some improvements. Please keep pushing gently on our behalf. It is in everyone's interest to get the modifications done - the correct equipment installed and the best operating systems worked out. The present level of safety on the North Sea - is not good enough - this week 3 Chinooks go up for sale as passengers will no longer fly in them). There is a long way to go before we get close to fixed wing standards. 898 [AIR] HELICOPTER L x ? 2.7 Excessive workload. ATTACHED: AIRCRAFT INCIDENT REPORT DD 26.06.87 RS Recently a number of Oil Company executives expressed concern that during December a Sikorsky S-76 had struck the sea during a night inter-rig shuttle flight in the AUK-FULMAR offshore oil field. Further checking with several sources at Aberdeen airfield suggested that: a) The handling pilot (the captain) had blacked out for some seconds allowing the helicopter to descend to strike the sea. b) The non-handling pilot (the co-pilot) was busy with paperwork and therefore not monitoring the flying and reacted only on the impact. c) The Automatic Voice Alerting Device (AVAD) which calls "100 feet" during every descent was de-activated with circuit-breaker having been pulled prior to the incident. d) The Captain was subsequently checked at Farnborough and under stress showed symptoms of blacking out. At the time of the incident the captain was on his 14th day of duty offshore. Should the above be found to be substantially correct the following suggestions are proposed for consideration by the CAA and the Dept of Energy prior to drawing to the notice of AOC holders - as a matter of urgency:a) The radio altimeter bugs which control the AVAD "Check Height" warning to be set to "guard" 200 feet by day and 500 feet by night for transit flying below 1000 feet and inter rig shuttle flying. b) Reference by the non handling pilot to check lists, planning boards, manifests or documents should only be done when the helicopter is above the appropriate check height, established in level flight with no bank applied. For shuttle flying all paperwork should be completed while on deck. c) When the handling pilot wishes to descend below the check height he alerts the non-handling pilot who puts away all documentation and then concentrates on monitoring the flying until touchdown, making the standard calls of "40kts" and "safety pitch" at the appropriate times. d) If while monitoring the descent and approach the non handling pilot sees excessive bank, excessive rate of descent or excessive closing speed with an installation he is to advise the handling pilot, and ensure a positive reply. Further degradation of the situation should require a "missed approach" to be called and in extremis control should be taken over to the extent of avoiding impact with the sea or part of an offshore installation. Pilot incapacitation in whole or part i.e. black out, strokes, heart failure or disorientation can occur at any time and if not adequately guarded against will lead to an unnecessary and completely avoidable accident. Partial incapacitation is difficult to detect in a dark cockpit. e) The practice of oil companies to task the helicopter crew with sorting out manifests, bundles of newspapers, small parcels and letters in the cockpit during inter rig shuttle flights should cease. On landing at an installation the pilot should only be handed the manifests for the destinations in sealed envelopes with the destination clearly marked on each, and a separate envelope marked "pilot", with a copy of the manifests of passengers names and weight of the freight + baggage. All items of freight, post, document bags should be stowed either in the cabin or in the baggage bay - not given to the pilots to sort out and stow somewhere in the cockpit. f) It should be brought to the attention of helicopter crews that the deliberate disabling of a protective device such as the AVAD should be considered as a dereliction of duty. 908 [AIR] HELICOPTER L x 3.2 Flight deck environment. 1.15 Standarisation issues. ATTACHED: Newspaper article titled "Safety checks for North Sea Helicopters". RS If helicopter pilots are not paid more and given better working conditions they are going to leave the offshore industry in droves for better paid jobs in the fixed wing sector. A survey conducted by the North Sea Pilot's Association (NSPA) allowed the 247 pilots who replied to a questionnaire to express their views. Of those who responded 55% said that they were considering leaving, most of them to fixed wing jobs. This could present operators and the oil companies that they support with a grave shortage at a time when many are reporting an upturn in exploration activity. Whatever the unpredictable oil business does it looks as if UK North Sea operators are going to be drained of pilots. The price per barrel will only dictate how hard the shortage hits and how soon. North Sea pilots feel that they are overworked and underpaid and many believe that they are flying substandard equipment in what are acknowledged to be among the most hostile conditions anywhere. A 50 hour week is quite normal as is nine hours or more in the seat per day. A high proportion (66%) of replying pilots believe that their flight time and duty hour limitations should be reduced but see little chance of this happening as the volume of offshore work increases. This is producing concern for safety because of fatigue. "Take care, do not not fly if you are too fatigued. A five second nap on the ILS at the end of your ninth hour in the seat can be fatal", is a quote from the NSPA report. The seats themselves are often orthopaedic nightmares. The proportion of people dissatisfied with their normal crew seating was found quoted as 67%. Exceptions to this were British International Helicopters' and Bond Helicopters' AS332 Super Pumas, whose seating most pilots were satisfied with. A further complaint was the lack of standardisation in cockpit layouts. All the large fleets suffered from this and many pilots consider it to be dangerous. Instruments and warning lights were found to be obscured by parts of the aircraft or the pilot's body. These included primary flight instruments, under-carriage panels and warning panels. The problem was found on most types, says the NSPA. On the subject of emergency and survival equipment and training, the NSPA survey found that 101 pilots, 43% of those who replied, were unhappy with standards and training levels. A high proportion of pilots considered their immersion suits to be illfitting and uncomfortable and 85% did not know whether their suits were watertight. Some actually knew of suits that were not watertight. The full inventory of complaints is too long to reproduce here but it paints a very disturbing picture. 953 [AIR] ROTOR L x 1.7 Error prone equipment. Other. Pilots have been unhappy with their lot for a long time but now that they are in short supply they can do something about it. Many are doing so and voting with their feet. To paraphrase a well known industry figure, "If pilots don't want to fly helicopters they can go and do something else". RS During six years flying the SK61N I had two in flight emergencies. On both occasions I was able to respond quickly and correctly as I regularly trained on the B.A.H. simulator and I found that its realism matched the emergency. On one occasion with an engine malfunction just before LDP onto a rig a wrong diagnosis could have had serious consequences. During a recent check on the Bristow's AS332L simulator I was handling pilot and commander during a procedural approach. I heard a high frequency warning with no other cues. I thought that it was an engine fire and expected the co-pilot to carry out the initial actions only calling on me to confirm the identity of the engine controls before he operated them. In fact he advised me of an engine shut down. On the debrief I was told that I had had a runaway up followed by a rotor overspeed and 957 [AIR] HELICOPTER L x 3.2 Flight deck environment. engine shutdown. Two points come out of this:1. Both the fire warning and rotor overspeed warnings on the AS332L are high frequency beeping tones that can be mis identified in an emergency. All audio warnings should be distinctly different. 2. For a simulator to be of value it must be fully representative of the aircraft. In this case an engine run away up should have been associated with an increase of both engine and rotor RPM noise before the rotor overspeed warning sounded. The resultant increase of torque would also have caused an increase in yaw and a change in the rate of climb/descent. A simulator that does not represent the aircraft fully is potentially dangerous. I had learnt to respond to in flight emergencies based on their simulated presentation. I now have to hesitate as I can no longer trust that my initial response will be correct as part of my training is done on a simulator that only partially represents the real aircraft. RS Many thanks for your letter of 11th May. I confirm that I have no objection to the information appearing as a report in the next Feedback. I am pleased, that following the splashdown of an S-76 near a platform in recent months there has been a safety circular produced outlining the vital necessity of not switching off the warning devices and not attending to paperwork and monitoring the handling pilot below 500ft above the sea. The enclosed is relevant. As you may be aware there is growing commercial pressure on the pilot flying hour fatigue limits - especially the 30 hours flying over a 7 day period. Because of the expansion of business coupled with the drift to fixed wing of the younger pilots i.e. age less than 40, because of poor cockpit working environment (noise vibration + poor ventilation) there is a growing shortage of qualified pilots. You will not be surprised to learn that absolutely nothing has been done about it. The correct vibration absorbing ergonomic manufacturers - seat has yet to be fitted. Sun visors as fitted to all cars/lorries/aeroplanes are not fitted. The ventilation system - to provide cooling air for pilots who are now required by law to wear survival suits at all times is not improved. The pilots who wish to wear noise attenuating (40db+) lightweight helmets and visors are informed that the passengers might object. Apparently it's "macho" to wear a headset on a civil registered helicopter even if it is a derivative of the military PUMA helicopter. The military worldwide provide lightweight helmets to all their helicopter crews - because the machine is noisy. You can see in another industry how ferry boats have frequently sailed with their 968 [AIR] NORTH SEA L x ? 2.4 Human error with no associated technical failure. 982 [AIR] HELICOPTER L x 3.2 Flight deck environment. bow doors open - for lack of warning lights - which are not fitted until it is proved necessary! After two days off at home I went to bed at 2230 and got up at 0500 for an 0600 report for a flight from Aberdeen to the East Shetland Basin. Departed Aberdeen at 0650. All the Scottish Island Diversion Airfields were taffing mist and low cloud with prob 30 tempos of fog. It was not possible to carry fuel for a Norwegian diversion due wind direction. As the actual for Sumburgh was VFR I elected to carry extra holding fuel to cover the period of the prob 30 tempos and refuel at Sumburgh. On first receiving the Sumburgh ATIS it was found to be in fog which was worse than the TAF had indicated. Air Traffic advised us that no improvement was expected so I returned to Aberdeen. The flight was replanned via Kirkwal so that on a second flight more time would be available at Sumburgh where there was by now an improvement although still not to the weather indicated by the basic TAF. On arriving at Kirkwal the weather had deteriorated to below minima but an approach ban did not exist. As another aircraft was on finals we did not know until at the overhead whether we would be cleared straight outbound in the procedure or to enter the hold. The cockpit workload was also quite high due to having a co-pilot who was new to the North Sea although otherwise very experienced. We were cleared straight outbound but I found difficulty in following the track bar on the HSI not surprising as the co-pilot noticed I was still trying to fly the reciprocal of the inbound QDR on the R NAV. I had failed to select the VOR on the track bar. We returned to the VOR for a second approach that went very much better but I found great difficulty in maintaining the instrument scan during the latter part of the approach although this was not a factor in the need for a go round and a second return to Aberdeen. On returning I realised that although I had only done 4 hours flying at the time I felt completely washed out and think that my mis-selection of the track bar and poor instrument flying was caused by feeling so tired - whatever the flight crew limitations I always find early starts even after an uninterrupted night's sleep cause me to be sufficiently tired to degrade my performance. RS You may know that the CAA have recently ruled that all N. Sea helicopter pilots will now wear immersion suits at all times when flying over the North Sea. Although this has been expected, some operators have done nothing to improve ventilation or seats in helicopters where the cockpit temperature is 20 degrees centigrade plus. You may be aware that there is a growing shortage of helicopter pilots - now reaching the stage that there is extreme difficulty in meeting the essential tasking let alone taking profitable ad hoc work that arises from time to time. The main causes of the shortage is the demand from the fixed wing world - with BA recruiting up to age 39 - and the noisy uncomfortable, poorly ventilated cockpits on current North Sea helicopter types quite apart from safety aspects. I would be grateful for any moves to improve the cockpit environment - particularly the AS332L, the main workhorse. The areas of most use would be 1. to fit the correct manufacturers pilot's seat with the correct lumbar support and sufficient fore and aft movement. 2. the fitting of sun visors. 3. the fitting of ventilation fans to provide cooling air at face level. 4. the issue of high noise attenuating headsets such as the PELTOR. 5. the reducing of the monthly and yearly maximum flying hours to take account of the high fatigue loading - which is all unnecessary - that presently exists on N. Sea helicopters. As changes will affect all operators they cannot - but probably will anyway - complain that "they" are being adversely affected. The destruction of the PIPER ALPHA oil production platform and the loss of an S-61 through engine bay fire (ditched - burnt out - and then rolled over and sank) and the ditching of a NORWEGIAN AS332L through delamination of a metal plate on the leading edge of a blade all within the space of 10 days has done little for the confidence in the safety of the North Sea Oil Industry. Whilst we do welcome members of the Government at the memorial service at Aberdeen yesterday - we do note one oil analyst who says that the PIPER ALPHA was an accident waiting to happen - in an industry where Government both profits and directs but takes no responsibility. 1035 [AIR] HELICOPTER L x 3.2 Flight deck environment. Please help to improve things for those who intend to remain in the industry. RS I do appreciate your letter in view of the circumstances. Take it easy - as far as you can - don't rush back to work - sit back and enjoy reading "Flight" from the front page to the back in that order. The "Chirp" system is doing wonders for Air Traffic - 600M pounds is promised to be spent in providing an up to date system for the UK - after all the publicity. Perhaps we should have built London's third airport on reclaimed land in the Thames estuary as was mooted over twenty years ago. The battle for improving helicopter cockpit environment continues - now that the middle cut of N.Sea helicopters are leaving for fixed wing cockpits around the world. At Aberdeen we are requesting pilots to work on their days off to keep the programme going - even the supervisors are flying - so the situation must be getting desperate! On the personal level I've switched from the noisy AS332L cockpit to the less noisy Sikorsky S61. I'm also using a PELTOR headset which is excellent in keeping out background noise. The Company is still charging 25 pounds to people who wish to use one - instead of issuing them free like immersion suits and life jackets. We've 1039 [AIR] HELICOPTER L x ? 3.2 Flight deck environment. 1052 [AIR] HELICOPTER L x ? 2.6 (3.18) Pilot view & visual cueing environment. got to have them so why not provide them? Every other helicopter operator does. This attitude results in some pilots having the PELTOR wishing to keep the intercom and radio volumes down and perhaps the other pilot without the PELTOR needing the volumes up to exceed the background perceived noise level. No wonder we are looking forward to the reduction in flight and duty hours next year - as we are already up to the legal limit in many cases. How the Company will cope when flying hours are reduced to 700 per year - will be very interesting - they will probably ask for and get a dispensation to operate at the old limit until they are able to recruit enough pilots! On the Oil Company side of things the merger of Britoil and BP has resulted in yet one more oil company giving up offshore diversion i.e. having just enough fuel on board to reach the rig and the alternate being another rig close by. This system of fuel planning only allows for the loss of power from one engine. If you have an airworthiness problem and have to land on at speed to retain control - as has happened to me twice - in two years - the availability of a rig or a runway is important. Only one oil company still uses offshore diversion - there used to be at least six. Things are slowly improving as management begin to admit that they now "know about" the problems, get well soon - we need you. RS Although not specifically a CHIRP this item is one that is causing serious concern among helicopter pilots who have no practical avenue through which to make representation without commercial detriment to their companies. At the moment once a week engine turbines are washed using commercial washing additives. After the wash the engine is dried by running it for 4mins and during this period the heater which runs from the engine compressor has to be purged of the washing fluid. This fills the cockpit and cabin with toxic smoke and a number of pilots have subsequently complained of poor health. Even after the purge period when the heater is next used in flight the aircraft is filled with the odour of the burnt additive. It is felt that these fumes are toxic and harmful to health. RS I was dismayed to read in Feedback 18 the Risky Shift article. I retired from flying nearly three years ago and felt that adherance to the rules was being more carefully observed as the Helicopter companies have shown themelves to be quite unmerciless if a pilot is caught breaking them. It seems that there are still some pilots who are prepared to risk their jobs for a few moments of bravado - and risk. Although my experience occurred some years ago it seems that it is still relevant. Flying from Aberdeen, the rig was reporting 200 feet cloudbase and half a mile visibility. I was copilot having about 50 hours on type. Previously I was a senior captain and IRE on another helicopter type and had around 4000 hours. The seniority rules of the company prevented my obtaining a command. My captain was a well-experienced ex-military helicopter pilot. We commenced an en-route let down to 200 feet, the Captain flying while I called altitudes and watched the radar. At 200 feet we were IMC so we set the radar altimeter for 100 feet. At 100 feet we had intermittent surface contact and no forward visibility. We descended further and the Captain slowed the aircraft to compensate for the reduced forward vision. At about 60 feet, we were progressing at 50-60 knots, in sight of the surface, no discernable forward visibility but with a few hundred yards slant range visibilty. I continued to monitor the radar when I noticed that we were descending below 50 feet at 400 FPM, with zero airspeed! I glanced across at the Captain and saw from his erratic movements that he had lost control while trying to keep a visual reference. I came on the controls with a firm "I have it". I applied power, dropped the nose and called for the undercarriage to be raised and for the overshoot checks. He complied without question but he was a little reluctant to accept that we had been about six seconds from backing into the water. Had I simply called "Overshoot", I feel that valuable seconds would have been lost while the Captain re-orientated himself. I still wonder what might have happened had I been much less experienced. Would the Captain have taken the risk in the first place? Would I have identified the situation so readily? Would I have taken control from the Captain? 1067 [AIR] HELICOPTER S x 1.15 Standarisation issues. 1.14 Misuse of adjacent controls. There should never be the need for these questions to be asked, let alone answered if we keep to the procedures. No one likes to hear from a radio operator that XY has just landed when you have just overshot but swallowed pride is good for your health. RS With a greater than normal degree of domestic and work worries I arrived at the Airfield to begin an unfamiliar task. I was being pressed by Ops to leave, while trying to obtain a briefing from my Observer when I was informed of the need to ground run the aircraft before departure. The helicopter had a totally different panel and switch layout to the aircraft that I usually fly although it was the same type. After a normal start I decided to switch off the Control Boost to immobilize the controls as the run was to last for 5 minutes to check for leaks on newly installed components. I switched off what I thought was the CONTROL BOOST - moments later the engine stopped. I had switched off the FUEL VALVE by mistake! 1113 [AIR] HELICOPTER S x 1.14 Misuse of adjacent controls. 1119 [AIR] HELICOPTER L x ? 3.2 Flight deck environment. While realizing that most of the faults lay with myself, I did point out the need for standardization within the Company Fleet, but that costs money, so ...... PW CHIRP FEEDBACK ISSUE 19 APRIL 1989 (PAGE 3) I should like to add my own comments to the "My Mistake" article in the above issue of Feedback. About 3 years ago, in Nigeria, I was lucky enough not to be on board a Bell 206 helicopter which crashed when the Check Captain turned off the fuel valve in mistake for the boost switch. The Check Captain was killed. I feel that Bell Helicopters should be forced to either modify the switch positions or introduce a guard to the fuel valve to prevent inadvertent operation. At the time of the Nigerian accident I wrote to Bell, the CAA and the Nigerian CAA expressing my concern, obviously the same thing still happens!! (I am of course assuming that the incident related in Feedback occurred on a Bell 206). Let's have some action before someone else dies! PW I was rostered for 5 consecutive days starting between 0600 0700 local. Temperatures were high, reaching 23 degrees C on the ground and usually around 15 degrees C in the air. The heat from the mid-summer sun was intense, wind light and sea temperature 12-14 degrees C. The contracts for all my flights required me to wear an immersion suit at all times. Most days two sorties of about 3 hours each were flown, with insufficient time to make it worthwhile removing the suit between flights. I was therefore actually wearing the suit for up to 8 hours a day. By the end of the period I was shattered, and in retrospect should probably have refused to fly on the last day. My suit is the full neck seal type which can not be unzipped or ventilated in flight. Cockpit ventilation can not cope with the effect of the sun (no sun visors), while use of the main vent and opening the windows also causes a marked rise in noise level. The reason for wearing the suits is to enable the pilots to assist the passengers in the water in the event of a ditching. I believe that first principles should apply, and that the primary duty of the crew is to prevent a ditching. In my opinion the enforced wearing of immersion suits in unsuitable conditions degrades the alertness and performance of most pilots to a significant degree. The CAA have already laid down conditions for the wearing of immersion suits. The removal of the Helicopter Commander's discretion outside these rules by use of commercial pressure is incongruous. Refusal to wear a suit puts at risk the individual's job or the Company's contract. Common sense seems to have gone out of the window. Only intervention by the 1126 [AIR] HELIDECK L x 3.1 Low visibility rig approaches. CAA to regulate the wearing of suits or reducing duty times in hot weather seems to offer any solution. PW Whilst planning an 0645 Local flight to a platform in the Northern North Sea the area forecast had been compiled the previous evening, no TAF or ACTUAL was available for the closest and usual diversion. There was an ACTUAL available for airfields close by but no TAF. The Sea Area TAF and area forecast gave low cloud mist and drizzle with a low probability of fog. As the En Route Airfield TAF + ACTUAL were reasonable I elected to update the MET on arrival. On departure 0815L the platform was giving 8K 8/8 above 1000ft. A gut feeling made me increase the fuel above the minimum which gave an airfield diversion from the En Route and a little spare on the legs out and back to the platform. On arrival at the En Route the closest diversion TAF + ACTUAL, another TAF and update from the platform were available. As the land was covered in cloud over the hills with a 160 degree wind and the usual diversion temp + dewpoint both +12 I elected to take the TAF with a pinch of salt luckily the other airfield was OK. But the platform was now giving 1NM viz 8/400. When we got VHF contact th ey gave 1-3/4NM 8/300. But they had a casivac who required emergency surgery. Before the approach I asked the standby boat to check the WX 3/4 mile with cloud just clear of the helideck (HT 200ft). I monitored the copilot on the approach. At 2NM and 250ft I could clearly see the surface. Always a good sign. At one and a half NM and 200ft (MDH) I could see the surface but we were still in the base of cloud. Descended to 150ft and gained forward viz at 1NM. At 3/4NM (MAP) no contact with platform but I was satisfied that with the ground speed we were flying there was sufficient visual distance for a manoeuvre to clear it. Below 3/4NM the radar distance became impossible to judge but we became visual with the support vessel and then the platform at I guess 600 metres with the deck in the cloud base. Care was needed in avoiding re-entering IMC. The casualty was successfully taken to hospital. At no time during the approach did I feel that we were taking an undue risk. With the power being used we were well inside single engine power except possible for the actually moving onto the helideck. But this is not unusual during a rig landing. Throughout the approach the co-pilot flew accurately and all aids and instruments cross checked correctly. Despite the TAF the Area remained in fog for the majority of the day. Although in this case the need to carry out the casivac was relevant a number of points are worthy of thought: 1. It is not sensible to plan flights on a regular basis without all the necessary Met data being available and current. As happens at present. 2. The North Sea operation relies heavily on the quality of Met forecasting and its method of dissemination for the whole area including the island and coastal airfields. Both these often, and particularly early in the morning and at weekends, leave a lot to be desired. 3. I have flown in both crew positions in similar conditions before in the full knowledge that we have been below published minima but the pressure to continue when in contact 1130 [AIR] HELIDECK L x 2.6 (3.8) Pilot’s view. 1164 [AIR] HELICOPTER S x 1.14 Misuse of adjacent controls. with the surface with forward visibility towards an installation where a refuel is possible is great when compared to a diversion on minimum fuel to alternate that may be unfamiliar and affected by the same weather system as the installation. Changing the minima (i.e. the MDH for this approach had been 150ft for a period a few years ago) only increases the pressure on the crew as they consciously break the rules more readily. 4. In my experience crews tend to make the same judgement as to what conditions to continue the contact phase of flights in and use similar criteria to achieve this. Safety would be increased if the cockpit workload during this phase of flight was reduced by the statutory provision of technological aids. Reply to our note rcvd 27.09.89 says "I am old, and thick skinned enough not to care too much if you transmit it on BBC1!" REPORT SENT TO CAPT RAMSDALE HD FLT OPS DEPT 2 REPLY DD 12.10.89 RCVD 12.10.89 ATTACHED FP PW On approach to land at a drilling rig at night in good VMC, but no other visual reference, other than the lit drill rig. The approach was conducted using the standard daytime technique, put the rig in the bottom of the windscreen, and use an altitude, airspeed countdown (i.e. 60kts 500ft, 50kts 400ft, etc) until good helideck visuals can be obtained and the landing made purely by visual reference. This approach however did not work out correctly and I found myself getting too low too early. The descent was held at 200ft Rad Alt, - until a good visual landing could be made. I was quite concerned at this incident as several months earlier another S76 had in a similar situation contacted the water at night, but was able to lift off and land on the rig, the cause of the incident was undetermined. Several days later I was able to re simulate the incident during daytime, and my determination of the cause is as follows:- During Oil Support daytime operations the S76 usually carried a considerable load of passengers. The nose of the S76 (which is quite long for a helicopter) is considerably lower than when unladen (as was the case in both incidents). When laden the previous mentioned technique is a good method for approach, due to the poor forward and down visibility of the S76. Using the same technique unladen (aft C of G), if the sight picture is maintained and close attention is not paid to altitude the aircraft will descend into the water some 3-400 metres short of the rig. The shortcomings of this technique have probably not come to light, as in conditions of good external reference curving approaches or flatter approaches are usually made to touchdown. Although this incident occurred in some time ago this report was prompted due similar incidents. I am attempting to have the Captain of the aircraft that contacted the water also submit a report. PW CHIRP ISSUE 20 PAGE 6 Thank you for printing my letter and CAA reply in the above issue, by the way please note address as above for future correspondence. I am of course aware of the AD issued by the CAA to reposition the hydraulic switch and paint the fuel valve switch red etc., but am still of the opinion that a potential 1469 [AIR] HELICOPTER L x 3.6 Document stowage. 2.19 Control systems, general (e.g. missassembly, jamming). 1490 [AIR] HELICOPTER S x 3.17 Tail rotor failure/ loss of effectiveness. flight safety hazard exists in the Bell 206 Helicopter. The fuel valve and hydraulic valve switches are of identical design and operation and both switches are used during operation of the helicopter. The hydraulic switch is used during run-up to test the controls, and the fuel valve is operated during pre-flight checks to operate the fuel/sediment system. The fact that both switches are used and that they are still easily accessible from the pilots seat means that one day someone will operate the wrong switch again. Painting the fuel valve red is OK, but what if it is night? There is no separate lighting arrangement for this switch. I consider, as a regular Bell 206 pilot, that the fuel valve switch should either be re-located to some safer, less accessible position, e.g. overhead switch panel, or have a guard fitted so that at least two separate movements of the hand must be made to operate it. Over to you. LR Despite numerous requests to the company, the type of helicopter I and other colleagues operate over the North Sea still has no acceptable level of cockpit stowage for the ever increasing multitude of documentation we are expected to carry. Nav. logs, checklists, tech. logs, mainifests, Aerads, route guides etc. etc. all compete for floor space with pilot's feet, full and empty polystyrene coffee cups etc., not to mention the controls of the aircraft. What a ridiculous situation for an aircraft that has been in operation for over a decade. PERSONAL EXPERIENCE REPORT ON ACCIDENT, FIRE AND EVACUATION FROM A HELICOPTER AT A MIDDLE EAST AIRPORT IN 1990 GENERAL An official report on the accident was produced that covers the usual ground with particular emphasis on the technical investigation. The conclusion was that a seizure of the tail rotor pitch control rod thrust bearing torqued the normally non-rotating pitch control rod which is directly attached to the servo piston rod. This caused the servo control rod to shear at the stirrup assembly. This situation resulted in loss of feedback to the servo making pilot rudder pedal input ineffective. The common stop lever on the servo became free allowing the full servo pressure to drive the servo piston rod to either full extension or retraction, exceeding control rigging limits. It chose full retraction, driving the tail rotor blades beyond minimum pitch compounding normal torque reaction. Manufacturers aerodynamics department simulation of this condition shows a violent rotational speed of between 180 degrees and 200 degrees per second. A lot of what I consider to be important detail and personal survival aspects are not covered in the report, hence this paper. My memories of the circumstances related in the report were elicited whilst I was under heavy morphine sedation and my only retrospective reaction is that I was able to produce any coherent answers at all! However, I have no quarrel with its substance. SITUATION IMMEDIATELY PRIOR TO OCCURRENCE A normal, single-pilot operation start up and ground tax preceded a proposed standard Easterly departure from the taxiway parallel to the runway in use 08. W/V was 070/10. I was being held by ATC at the hover and had turned abeam the wind in order to keep an eye on arriving and departing scheduled traffic. So I was heading roughly North when the failure occurred. Hovering cross-wind required some right pedal input, feet on the pedals overriding the autopilot heading hold. This pedal position might have some bearing on the direction that the servo rod chose to travel when "freed". There was never at any time any abnormal vibration, noise or binding in the tail rotor control. TIME OF OCCURRENCE At what I presume to be the instant of the failure the aircraft gave a gentle kick to the left which I made to correct with a further right pedal input, presuming it to be a wind variation. I recall that the small input had no effect - setting my own alarm bells ringing. As I began to feed in an inordinate amount of pedal I recognised that I had no longer any yaw control. I called to the crewman in the left seat in no uncertain terms that we had a major tail rotor problem! (Company policy was to permit Crewmen to act as pilot's helpers, when operating single pilot, and to occupy the left hand seat if there were no passengers carried. They were never permitted to touch primary controls). The divergence to the left immediately became a violent "kick" and from this moment onwards I seemed to be able to comprehend details in a strangely detached manner. I was aware that I had a tail rotor control failure and although the action I intended taking, reducing collective pitch and stop-cocking both engines, would not have had quite the desired effect due to the unusual nature of the failure I was not to know this at the time. Simultaneously the task of "flying the aircraft" was to deal with the violent ROLL to the RIGHT whilst accelerating in yaw to the LEFT. This yaw/roll coupling is easily demonstrated on the Puma and indeed a demonstration of this quirk should form part of any type conversion. But in this instance the yaw control having gone beyond the stops, the "roll under" was formidable, requiring full left cyclic against the stop to prevent the helicopter rolling right over into the tarmac. I checked down on the collective lever to reduce torque, but from the hover height of 15 feet there was little leeway and I can recall bumping a main gear on the ground. I had never come across an emergency situation before that I could not sort out. After some 25 years flying lots of different helicopters and coping with tail rotor drive and control failures on the simulator I was confident that I could salvage something! IMMEDIATELY THEREAFTER I think that I had the situation "stabilised" for a brief period in the violent rotation in that I was able to remove my hand from the collective lever to try to reach for the roof mounted fuel shut-off levers to secure the engines. However, in the initial surge in yaw and roll I had been thrown to the right hand side of the cockpit. It may be that the fuel shut-offs were physically beyond my reach but I have this nightmarish recollection of sparing a second with my left hand away from the collective to make a grab for the levers only to find that my hand met empty air as the levers apparently slid sideways out of reach possibly due to the considerable rotational G forces. We did not wear flight helmets unless operating as rear crew and my lightweight headset left my head at an early stage of the proceedings. It was now apparent that although I was "stabilised" in a violent left yaw I could do no more than keep the aircraft in intermittent contact with the ground whilst still trying to grab the fuel levers. I was unable to distinguish external visual detail, only dark ground and light sky. I felt I might be drifting off the taxiway and was rapidly becoming disorientated. I determined to try to lower the aircraft onto the ground in a forlorn hope that I might be able to use the shearing action of the undercarriage to slow the rotation somewhat, but being aware of the high C of G of this helicopter I had little hope of staying upright. I recall the right main gear, I think, bouncing on the surface. When it touched the next time I checked down on lever hoping to "anchor" the leg to the ground, but by this time I was completely disorientated and as I lowered the lever further the fuselage never levelled itself about the right leg but continued to roll right until the main blades hit the tarmac and disintegrated. The aircraft actually rolled onto its side relatively gently initially but the noise was ear-shattering! It was only as the stubs of the blades hit the tarmac that the ride got really rough. At about this time the main gear box shifted and the engine high speed inputs disconnected allowing the engine to run away up and burst their turbines. The noise was quite unbelievable. I was still rotating with my face a few inches from the tarmac through the open side window. The aircraft eventually came to rest and the appalling noise stopped. I can recall being amazed that the helicopter had held together so well. "AFTER IMPACT" My next recollection is of a period of quiet where not very much happened at all. It was a time of collecting wits and the full enormity of the situation gradually dawned. The unthinkable had happened and I had crashed and probably badly damaged an aircraft, something that had formed the substance of nightmares for me since I had started flying. The overwhelming physical sensation was of being totally disorientated, from whirling like a dervish to total stillness and relative silence seemingly in an instant. At this time I most definitely underwent an "out of body" experience. I saw myself and the situation seemingly from a point above and some distance away from the cockpit. It required a very considerable mental effort to reestablish myself "within" myself. I had a major mental struggle to re-orientate. My dizziness was a problem and visual inputs were still trying to slide out of view sideways. I also had a problem with convincing myself that I was not sitting upright as I would normally be at the conclusion of flight! I remember I found that if I kept my vision close inside the cockpit and fought to ignore the spinning sensation and sliding vision I was able to make some sense of the situation and convince myself that I was lying on my right side. I cannot help but conclude that the experience and mental discipline required to overcome the "leans" encountered in instrument flight stood me in awfully good stead helping me to cope with my situation. The first problem was to find my harness release box, which I eventually did up by my right shoulder. I had "submarined" through the harness and my lower torso was lying on the right hand side of the aircraft from the front part of the door down into the "chin" window. I had to have several attempts at releasing the harness. The first try released only the shoulder straps and a fair amount of frenzied twisting was required to get the box to release the lap strap. I had to concentrate then to kneel up and locate the fuel-shut offs, booster pumps, electrical gang bar etc. for the "After Impact" drills. I recall this required a great deal of mental effort as a form of lethargy was trying to take over in some way. I had a major problem with kneeling/crouching on the door which was "down" to slide myself "up" to the overhead panel which appeared close in front of my face instead of over my head! I "logicked" that by reaching directly to my left that I would find the shutoffs at the "front" of the panel which I did and secured them. I knew that I needed to reach the forward interseat console for the booster pumps. I was unable to do this as it became apparent that a major restriction to movement in the cockpit was the inert body of my Crewman hanging in his harness "above" me. I had my back to him, so to speak, and his bulk prevented me from turning fully. I cannot recall if we communicated at all at this time. FIRE IN THE COCKPIT The realisation now dawned fully that we were on fire. It had been in the back of my mind for some time but somehow it was not a top priority item. I must have had visual and olfactory cues. I gave up on the "overhead" panel switchery although I recall that a number of warning lights were illuminated. The gang bar must have been only six inches from my nose. I do recall thinking that I might have a few moments to press the engine fire extinguishers, but I further remember the sinking feeling when I realised that I had wasted precious time looking for them on the overhead panel when they were actually on the instrument panel, NOT the overhead panel as they are in the later marks which we cross-operated. I became fully convinced that we were on fire when I began to get burned on my right hand side face, shoulder, back and upper arm. We habitually wore a polyester/cotton, shorted sleeved flying suit and desert boots. Cape leather gloves (as per military issue) were available. I had not worn them since leaving the RAF years before. I recall becoming seriously concerned about making an exit from the aircraft at this point. Looking to my right into the cabin I was able to make out that it was well alight. The cabin doors were both gone but there was a fierce draught blowing smoke and flame into the cockpit through the passageway which was now in length horizontal rather than the normal vertical. It acted as a kind of funnel and the flame rapidly increased in intensity. The aircraft had come to rest tail into wind, fuel from the ruptured over-wheel sponson tanks (almost the full fuel load) and the under floor internals had spread onto the tarmac which was afire and this was causing the fierce channelling of smoke and flame into the cockpit. I sank back down out of the direct draught of the fire behind the bulkhead, but the flame and smoke increased in volume, now directed onto the body of my crewman. I should mention that he was a man of formidable build about eighteen to twenty stone and not terribly fit. It is normal in that country to indicate affluence and success in life by becoming corpulent and unfortunately he had followed this custom. EXIT I recall seeing the crewman stir, possibly making an effort to find his harness release. He was clearly still only partly conscious and his movements were ineffectual. This was taking place above my head and it was obvious that my only escape route through the left hand (uppermost) cockpit door was blocked. The cockpit was now filled with dense smoke, I could see very little and was inhaling bad air. It was unlikely that the Crewman would be able to release his harness and escape himself. I was now unable to see or reach him, and there was a very real chance should he be able to release himself that he would fall to the bottom of the cockpit pinning me beneath him. At this stage, crouched on the bottom of the cockpit, things began to look really bleak and panic definitely set in. I attempted to kick out the armoured windscreen panel which was the closest. I paid for this with a badly strained groin which made itself evident later in hospital. On examining the wreck some months later there is evidence that I did manage to kick the screen almost completely through, but even had I succeeded it is doubtful that I could have squeezed through the empty frame. A part of my mind recognised that I had allowed a panic reaction to get hold and that unless it was quelled it would lead down the road to destruction. I recall this realisation quite vividly. In the past I had been very fortunate to undergo the Long Fire Officers course in the RAF some twenty five years previously. This course included "hands on" crash rescue from blazing aircraft, admittedly wearing the full protective clothing and propelled by the scruff of the neck into the flames by a beefy Flight Sergeant! The experience (which we carried out half a dozen times) was invaluable in experiencing the intense noise, almost complete lack of visual cues in the dense smoke and, of course, the considerable heat. In the cockpit I remember being able to get myself under control realising that "I had been here before"! I concluded that kicking out the windscreen was futile and that by lying on the door and reaching down to the chin window beyond the pedals, I could probably kick that out. This I managed to do. I was aware that the tarmac was on fire close to the aircraft and that I would have to crawl through it. I also recalled that in a burning fuel spill in a reasonable wind the flame tends to stay fairly low, knee to waist height, so my chances of subsequently getting to my feet would be fair. Outside the transparencies were completely black, so I had no idea whether there might be wreckage in my way. I expected that the tail boom would probably have been severed and could be an obstacle to a blind exit. I withdrew my legs, turned around and crawled down into the nose of the aircraft, over the pedals, into a very confined space. I can remember the mental effort required to put my right hand and arm down onto the burning tarmac to take my weight as I extricated myself, but I had decided on this course of action at whatever cost. From putting my head outside the aircraft I was completely blind. In fact I closed my eyes and this probably saved them from more serious injury. Again I recalled the experience of feeling my way through a smoke-filled house on the fire course, where eyesight is largely useless. I extracted myself and making sure that I kept my back in contact with the outside of the nose of the aircraft, I stood upright getting the back of my flying suit slightly caught up on the pitot head assembly. I took this to be a good sign that I was facing the right way! From this moment I was fairly sure I would make it. I remember pausing with my hands behind me on the aircraft nose to ensure that I was balanced then with something of an effort I set off walking blindly directly forwards. I knew I must not run in case I met some obstacle that would cause me to fall into the flame. Unfortunately, with the following wind I had chosen a direction that gave me the longest path through the fire, but I did veer slightly left, emerging from the smoke at an angle to the aircraft according to eyewitnesses. Luckily, there was no significant wreckage ahead of me, the tail boom had stayed on the aircraft, being only slightly damaged and upwind of the fire, so making the subsequent technical investigation a lot easier! As I emerged from the smoke I was aware that my clothing was on fire around the legs and was able to beat out what I could and rip off the material where I could not. I asked the first person on the scene, a good friend who had come running over from another helicopter, if I was on fire behind where I could not see and how bad did it look? He looked badly shocked, so I assumed that I did not look too good. I told him that the crewman was still in the aircraft and can remember hearing the fuel tanks explode and knowing from that moment that he would not be able to get out alive. SUBSEQUENTLY At no time during what I have related did I feel any pain whatsoever. The pain began during the Landrover journey to the nearest hospital. The burn injuries to both hands, arms and legs, right face, neck, shoulder, and back began to hurt, I estimate, about five minutes after leaving the aircraft. Throughout the accident, apart from the onset of panic, I retained a surprisingly clear perception of events and detail around me, even to recognising the onset of shock on the journey to hospital. The sight of the injuries to my hands and arms did cause me some mental distress. At the casualty entrance there was a lot of indecision as to whether to put me on a stretcher which was nowhere to be found. I can recall being irritated and getting the driver to open the Landrover door and the door of casualty, so I was able to walk into the hospital unaided, thus probably saving considerable time! I was subsequently stabilised at a military hospital then transferred to the local burns unit then to UK and East Grinstead, sixteen days after the accident. Meshed split skin grafts were carried out on my right hand and arm and left lower leg, some failed and were re-grafted in a second operation. A further operation adding full thickness grafts between the fingers and releasing webbing carried out in 1991 was not quite as successful. Further surgery on the right hand may be required in the future. Apart from scarring I have regained full use of my legs, left hand and arm, but have suffered considerable loss of movement of the fingers of the right hand. My Pilot's Licences were withdrawn in 1991. The mental stresses that accompany severe burn injuries I (and my family) have found to be as much a problem as the burns themselves. Never having experienced any mental problems before, I have found them hard to come to terms with. I would have gained considerably through being allowed to return to work as soon as my surgeon felt I was fit enough. Being around familiar places and amongst my friends would have helped a lot, even if it was only answering a telephone! As it was I was stuck in UK and for probably political reasons was not allowed to return immediately to the Middle East although I had been exonerated from any fault in the accident. I came to terms very early on with the loss of my crewman. I think it was as early as the moments after leaving the aircraft when I heard the further explosions. I am also aware that even if I could have stood the flame exposure I possibly could not have freed him with his full, considerable weight on the release mechanism and had I succeeded I would have been unable to support him. Lifting a man of his bulk though an overhead, untested emergency exit in the prevailing conditions would have been impossible and undoubtedly both of us would have perished. CLOTHING I was wearing Desert boots which apart from badly melted soles protected my feet completely. Fairly bulky ankle socks of polyester cotton saved my legs up to normal sock height. I wear a beard and although I lost a great part of it, it did afford some facial protection. Although the flying suit was short sleeved and of polyester cotton it resisted the flame surprisingly well becoming "glazed" and rigid in the worst places. However, the flesh beneath this damage was injured. OTHER ITEMS Another point that may be of interest is that my wristwatch (I wear it on the right wrist) protected an area of my wrist sufficiently large to enable a band of normal flesh to remain. This avoided scar contractures crossing that joint and most certainly helped to assist in mobilising the limb and hand. The watch is of the black plastic resin type and although badly scorched and partially melted resisted the flames well enough. When I flew this type of helicopter in the RAF I remember that the type of harness in use had a negative "G" strap which was attached to the front of the seat pan and came up between the legs to fasten into the bottom of the QRB. This arrangement would undoubtedly have prevented the "submarining" which I encountered in the accident. In a separate, earlier accident when another similar helicopter rolled onto its port side, the engineer in the RH seat had found it very difficult to release with his weight suspended in it. The company have subsequently changed all helicopter harness to the type normally fitted to the later marks. CONCLUSIONS The report reached a number of conclusions regarding the technical aspects of the accident:1. The failure of the single bearing in the control system which lead to catastrophic failure suggests that the tail rotor servo design needs review for possible retrofit modification to make it fail safe. 2. A safe hard life in both flying hours and calendar period needs to be assigned to the bearing, not "on condition" or 3000 hours. 3. The aircraft fuel vent system had no non-return valve mechanism in the vent lines, so as the aircraft was lying on its side fuel ran out of the vents and fed the fire on the ground around the aircraft. The later marks have such a system. 4. The type certification for these helicopters had remained unchanged for twenty years and needed a review as far as crash-worthy systems, now available as an option, were concerned. It was recommended that the type certification requirements be upgraded to make this type of fuel system mandatory. My own conclusions, apart from the obvious one that I was extremely lucky to survive the accident are:1. This type of failure is uncontrollable. The company simulated the same failure on the simulator for later marks during normal yearly training. Even with two pilot operation, it was not possible to catch the initial swing in time, and the simulator is not able to reproduce the sustained "G" forces involved. 2. I had over the past twenty years or so, considered what detailed action I would take if I had been placed in a number of emergency situations such as tail rotor control/drive failure and how I would expect myself to react. 3. It might have given me a number of sleepless nights, and you may feel that I have a rather pessimistic nature, but I consider this exercise in self- analysis helped considerably in coping with the awful realization that the appalling event had actually occurred and that I should get on and do something about it! I have discovered since that the majority of pilots I spoke with about this type of scenario have never felt the need nor inclination to carry out such an analysis. 4. The disorientation experienced following the rapid rotation in such an accident as this is formidable. I can only say that the mental discipline and considerable effort required to overcome the "leans" and disregard some sensory inputs is precisely the same as I required to cope with the dizziness. Perhaps the several pints of high octane adrenalin in my bloodstream at the time helped! 5. I have no answer to the problem of sensory deprivation within an aircraft (or any other) fire. My previous experience in aircraft and domestic fire situations was of incalculable value. Lacking that, I am uncertain what the outcome might have been. I am at a loss as to how this lifesaving information/experience might be passed on, unless by others reading of this type of experience. 6. Burns and other non-incapacitating injuries (I did some hefty damage to the knuckles of my right hand) can seemingly be ignored to a large extent in the heat of the moment (excuse pun). I felt no pain from the injuries until some time after leaving the aircraft. Or perhaps I have simply forgotten. 7. The mental problems following such an accident should not be underrated, even with the injuries I suffered. It could have been much worse all round. 8. Fear can paralyse the mind. My experience agrees completely with that. It is as well to recognise that you will be in fear of your life in such a situation. You should expect this and try to imagine how you might cope with it. AVIATION EXPERIENCE I submit the following extracts from my CV as regards aviation experience for any comparisons you may wish to draw. ______ Note by CHIRP "THIS CHAP HAD BEEN FLYING HELICOPTERS, BOTH MILITARY AND CIVIL, FOR ABOUT 30 YEARS BEFORE THE ACCIDENT. HE HAD BEEN RATED AS EXCEPTIONAL IN ABILITY AND WAS A FLYING INSTRUCTOR AND EXAMINER." 1532 [AIR] HELICOPTER L x ? Other. Should you wish to use any of this information for publication, please contact me beforehand as the matter is the subject of legal proceedings. I should be happy to speak further on any aspects of the matter in the interests of helping to enhance flight safety and crash survival. PW My concern addresses the growing problem of CAA control of flight operations over the years. Commercial pressures have led to increased strain on aircrew who operate for long hours, become tired and have to worry not only about flying but also redundancy. 1581 [AIR] ROTOR S x 1.7 Error prone equipment. Contrary to what CAA say and what some people believe, it is the CAA's attitude towards flying operations in the commercial world which is directly contributing to crew fatigue and unnecessary bureaucratic requirements which cost a lot of money and significantly affect (adversely) company operations, particularly in relatively small helicopter units. Why must unnecessary documents be carried on helicopters where weight is critical when they can be inspected at base? Why create Performance A figures which are so complicated as to make practical flying impossible? Why inflict flying patterns on light single and twin helios so as to make operations so cumbersome and costly as to kill the cost effectiveness of helicopters as a means of transport without adding one jot to flight safety? The answer: because CAA officials must do so to justify their jobs. There can be no other reason, in view of the adverse effect on flight safety. PW This report concerns the poor visual presentation of the combined Engine/Rotor tachometer. This was a revision flight for PPL H student who has approx 35 hours on this R22 and was his first flight day after a few days break. I had demonstrated an into wind Quick Stop and handed control to my student for him to practise this manoeuvre. During the flare stage, due to the severity of the flare the collective lever was lowered almost fully to maintain constant height, and a split needle condition existed, although not seen on the TACHO. The oil pressure low warning light and the Alternator warning light illuminated. I told my student that the engine had stopped, took control and performed an engine off landing. At no time did either of us notice a change in noise level NOR and more importantly notice where the engine tacho needle was. This awful gauge has three distinct problems, firstly it is unlike any other engine/rotor tacho secondly the clutter of coloured arcs "hide" the position of the needles when glanced at momentarily and lastly the needles are too thin. My observation is that this gauge design is fundamentally flawed by bad design which then puts the onus on the pilot to study the gauge for the information whereby the information should be obvious upon a millisecond glance. I am used to the presentation offered by the Bell 47, Hughes 300, Enstrom F28/280 and Hiller models which DO indicate clearly a "split needle" condition. The two warning lights functioned extremely well and both of us noticed those. Although instrument design may not be part of your responsibilities I do believe the Human Factor interaction here is. May I suggest a solution. [sketch appended here showing needle/s as presently presented versus suggested presentation] 1594 [AIR] NORTH SEA L x 3.19 HMI with new flight deck technology. simplified diagram PW I was called late in the day to complete a flight that required three stops as well as a refuelling stop. The weather was not too bad for the North Sea and I was crewed with a co-pilot unfamiliar with type. Our aircraft was fitted with a newer generation of Area Navigation Computer. I had used it on a number of occasions before with little difficulty, albeit infrequently. It would be the co-pilot's second flight to the area of operation. There was little time to spare to complete the round trip before base airfield closed. From the outset the Nav computer decided that this was the night that it was going to play up. Attempting to update the Decca, VOR/DME, and DR positions as well as generating and inserting new waypoints mostly with little success soon caused excessive cockpit workload. Being aware of the danger of spending too much time head down playing with this techno-box I regularly crosschecked my navigation using raw data as well as having a general check around the cockpit. The wind given by the Nav computer was twice that planned and although I doubted its accuracy I had to take cognizance of the fact that it may be correct or partly correct. This could have made the round trip impossible before base airfield closed. I was having great difficulty correctly operating the Nav computer as I was carrying out functions that I had either not had to do before or the complexity of the operating functions caused me to repeatedly make mistakes. I was not helped by the logic of this system being different for each function than its generic predecessor. The copilot was making a good job of reading snippets of wisdom from the instruction book that came with this technological masterpiece that is about as user friendly as shiney cardboard in the carzey! After one and a quarter hours we arrived at the refuelling stop I had finally revised all my knowledge on the Nav computer and all the errors and warnings were gone, all three positions in its little brain were the same. It was just a shame that someone had moved the refuelling stop 9 miles SSE! I could therefore not rely upon it for either navigation or flight planning nor did I know whether it was u/s or whether I was. During the sector there had been no requirement for any load reconciliation, flight or fuel planning nor any supervision of the co-pilot in these tasks. If I were to reinitialize the Nav computer at the refuelling stop I would not know whether it was functioning correctly until after I was airborne on the next sector where the workload was going to be very high and by which time was effectively committed to attempting to complete the round trip, and still with some real doubt about the wind strength. I reluctantly decided that it was imprudent to proceed beyond the refuelling stop, and on doing the descent checks found that for the preceeding one and a quarter hours the engine anti-icing had been off!! 1702 [AIR] HELICOPTER L x ? 3.2 Flight deck environment. We all spend a great deal of trouble in identifying human factors problems, carrying out cockpit resource training and trying to be safety conscious in carrying out all aspects of our various tasks in aviation. This Area Nav Computer requires the detailed knowledge of an instruction book of 100+ pages and a cockpit check list of half that size. There is no logical or progressive system for its use and it requires a different sequence of actions to use its various sub-functions none of which are self evident in use. The question is, has the techno-pratt who designed this made a positive contribution to flight safety? PW SUBJECT QUESTION DOES INHALATION OF TURBINE EXHAUST FUMES CAUSE TIREDNESS OR ANY OTHER KNOWN LONG TERM HEALTH RISK. I have never been able to satisfactorily explain why I am so tired after a duty period. Most of us have to take to our beds to recover. I sleep well, exercise regularly am experienced in the job which is not too demanding. We fly many sectors in a shift. Average sector 15 mins average number of sectors 20. Each time we land and disembark passengers we get exhaust fumes in the cockpit. We try to minimise this because of the discomfort to eyes and breathing but it is always there. Is there any health risk? 1716 1935 [AIR] NORTH SEA [AIR] HELIDECK L L x x ? ? 2.4 Human error with no associated technical failure. Other. ATTACHED: PILOT DUTY ROSTER FOR DECEMBER 1994 - S61N HELICOPTER PILOTS - reporters duties highlighted. (OPERATION OFFSHORE OIL SUPPORT IN THE FAR EAST) PW I was called in whilst on standby to take an ad hoc flight to the Northern North Sea. By the time I arrived at work the flight was closed with a full load. With the co-pilot I planned fuel minimums based on a refuel at an airfield both ways to give the max payloads. As I was taking a full load out and the Wx at Base required holding fuel I did not anticipate returning direct. Whilst outbound I checked the RNAV TAS computation and it was correct. Having refuelled and called the rig log they requested we offer a return payload without a refuelling stop - a rather unusual request - I calculated the fuel requirement based on the RNAV then the co-pilot calculated the payload. We both watched each other in our tasks. The return time was one and a half hours. The alarm bells should have rung instantly but we were both pleased to be on a one stop back to Base on a Friday night. Luckily the load given allowed us oodles of extra fuel - it was only when in the cruise returning to Base that I realised that a GPS of 176kts were needed to make Base in an hour and a half. Check RNAV TAS should have been 130kts - showed 159kts! - I feel a little silly as I am always trying to instill the need to cross check for gross error and never to rely on fuel planning based only on the RNAV which always tells porky pies! DWB 9 Sept 1996 This is public knowledge so confidentiality need not be maintained but you may find the Human Factors aspects "interesting" What it does not explain is that the company emergency check list was wrong omitting the final item of undercarriage selector "down" after it has been manually pumped into the kneeling position. I learnt about flying from that. (or my excuses for parking a Puma in the low profile position). Good VMC airborne in the cruise 2000", xxxxxxxx Warning light illuminated with ""SERVO"" on 32 Alpha. Shortly followed by ""LH LEV"". I saw that colleague was hands on and I anticipated a total loss of the L/H system. Colleague suggested a suitable diversion and I agreed. I dialled up 129.7 but could get no answer from the Platform (although we had stopped there before). I advised ABZ INFO of our failure and intentions. I QSY'd back to 130.875 but could not raise the Platform. Back to 129.7, still no answer from the Platform. Meanwhile I am monitoring the Hydraulic PX. Both L/H and AUX in the green and xxxx happily flying AP out. I did not declare an emergency as we were flying in VMC and there were no signs of fire, I knew I would raise the Platform somehow as there was lots of traffic around. Finally I called a Second aircraft on the AAA Monitor and asked him to raise the Platform on marine. Back in the cockpit the L/H Hydraulic and AUX PX went to zero. It all went just like the SIM very reassuring. So: I picked up the emergency checklist and using the thumb index managed to open it at "Double Transformer/Rectifier Failure". Re-selected and started reading, as one does at the top left of page "R/H .. " etc. Finally I found "Complete loss of L/H pressure" and carried out the checks by the book. Down to "Land as soon as possible" at this point there is a line across the page so I put the checklist down. Its a lot easier to pump the gear down in the aircraft than the SIM. I turned off the AUX pump as required although it was not on the checklist. By this time we are on finals for the Platform, we had spoken to them, the deck crew are on their way up and it's time for me to give my final excuses for the possible wobbly landing to the PAX. It was a superb landing! It was reassuring as we landed to see the standby boat all prepared, fast rescue boat and scramble nets deployed. We shutdown, off loaded the PAX, phoned base and climbed up to see where all the oil was leaking from. I found a little disc of metal that had been blown (fractured) out of a union. I contacted engineering to advise the details of the failure and organised the deck crew to manhandle the aircraft to the edge of the deck. Colleague and I were quite pleased with ourselves, we decided that we were both more than happy with the way we had handled the situation I had even managed to work the GPS to get us to the Platform (not that we needed it!) While we waited for the cavalry (An S76 full of engineers) we cleaned up all the oil, had lunch and promised the OIM we would be off his deck in a few hours. The engineers arrived, replaced the union, replaced the hydraulic pump and told us that as well as the union having failed there was also damage to the hydraulic pack indicating there had been an overpressure. Both my colleague and I were concerned that the amount of overpressure that blew a solid union apart could also have done other damage. FLASH BACK - Back to the first start up of the day, as Colleague turned the first booster pump on we both heard/felt a clunk which we knew was not a booster pump! Back to the Platform. The engineers have fixed it, so I supervised the deck crew in manhandling the aircraft lock to the centre of the helideck. I saw XXX in P2 seat and asked him to move to the P1 seat so he could operate the toe brakes. He did this by shuffling his body across the cockpit as the deck crew were milling around lay the cockpit doors. Once into wind on the helideck it was time for a one minute ground run. The nose wheel was off centre and we used external power. I did the walk round while XXX did the cockpit checks. Then I got in, checked with XXX that he had done the checks and I did a visual look round the cockpit. Whilst I did the control check I noticed that the external power was off so we got it turned on. When it came on, there was a solid "clunk" and we delayed the start for a few moments whilst we discussed it. Remember we had just had a hydraulic failure in flight plus a "clunk" before start at base. As there was nothing apparently wrong we decided to continue with the ground run. Yes we are in the kneeling position - so what? I had done a start in this position before (once upon a time someone inadvertently lowered one down overnight on the DB102 and I started it for them). On type conversion we had taxied and shut the aircraft down kneeling and been told that it could be treated as normal. Technical training was that all the logic circuits still recognise the ground condition whilst kneeling so I am happy to start amber/green/amber. FLASH BACK- Back in February, I am P1 in the SIM, the P2 is doing P1 under instruction, I'm "H" he is "NH", rig radar with an undercarriage fault. Out of the corner of my eye I notice that he keeps screwing it up by pumping the gear down with I selected down, I did not allow myself to be to distracted whilst as "H" but 3 times said "put the gear up, read the checklist and start again! " Now I know that the circumstances were different but the impression left on my mind was that it was normal to select "up" to pump the gear "down". (It is French, after all!). As I pressed the starter button the external power dropped off line and as usual all the warning lights dimmed. I did notice that the amber/green/amber undercarriage lights were either so dim I could not see them or were out. Eyes now returned to the hydraulic PX coming up. We ran at flight idle for about one minute with all indications normal except no undercarriage indications but also no ""L/G SIG"" or ""L/G CONT"". But the aircraft was stable in the kneeling position. We shutdown with no problem got out and had a chat with engineers about everything that had happened. Everything "on top" was okay so it was decided to go for a 10 minute ground run. We intended to lift into the hover to return the gear to the normal position during this run. XXX got in whilst I did another walk round. The aircraft was in the same configuration as during the previous ground run so I felt happy to start it again... I started #1 up to flight idle, all T+P's okay. Nothing abnormal. Started #2. Just as I was advancing the SSL for the final push into the flight idle gate the aircraft started to move forward and down. My only thought was to let it sink under control so it stayed upright and to stop the rotors as quickly as possible. There was a lot of grinding, grating and crunching noises as it went down but no panic! After we had shutdown and my colleague had left the cockpit I noticed that the emergency undercarriage handle had been returned to the "normal" condition. My first thought was that this was the sole reason for the undercarriage retracting. My colleague had pushed it down as he had shuffled his body across the cockpit! So what had gone wrong. The FDR shows the undercarriage logic put it back into flight before I shutdown on the initial landing and the rest you know but.... XXX and I were in a confident mood, we were pleased with the way we handled the hydraulic failure and the resultant sorting things out....were we to hasty? Over confident? I was quite happy to start in the kneeling position - the Guru of the Puma (now not with us) told me it was okay. I was perhaps overconfident having done it before - a little bravado perhaps! I was happy with the position of the undercarriage selector and emergency handle after I had done the checks - it was okay on the LOFT exercise and in accordance with the checks! We were both very concerned about what had caused the hydraulic failure even though it had been fixed, were we distracted? I am more than happy to allow the P2 to do the cockpit checks - he after all trusts me to do the walk round - it was for a ground run after all. Were we both complacent? When the undercarriage indicator lights went out during the first start had they just dimmed with the external power dropping? By the time I knew they were out we were at flight/idle with everything okay. The second start was only a repeat of the first nothing had changed so there was no need to do all the nine yards The rest is history 2038 [AIR] HELICOPTER ? (L) x ? 3.23 Enhanced HQs. Now over to the reader - at what stage would you have a smelt a rat and been alerted to the fact that something was amiss? That is a question I can not answer for you, as we obviously were not. With hindsight, the first stage should have been the BEFORE START checks. I should have been more conscious that being in the kneeling position needed extra thought. Before the second start I knew the undercarriage indicator lights were out and accepted that the aircraft logic circuits would not allow the gear to come up...... Oh and the big ""clunk"" before the first start......(I now believe it was the nose wheel actuator unlocking!) DWB 10 June 1997 Re: FEEDBACK 42 - ATCO Familiarisation Could ATC's please be made aware of how helicopters are flown. Many, probably most, helicopters are flown single crew. Helicopters require both hands (and both feet) to manoeuvre in the hover and during T/O and landing. I almost always receive critical information such as runway, W/V, QF8, QNH, Transponder Code, Altitude, Frequency Heading, other traffic in multiples during taxi or T/O. It matters little whether one is operating at a major international airport or at a small grass strip, controllers simply don't realise that the pilot must either memorise all the information given or land to write it down, the latter rarely being practical. I don't believe this is particularly dangerous for typical rotary wing operations but there are, quite clearly circumstances where safety could be compromised. 2041 [AIR] HELICOPTER S x 4.2 Loss of control/ over control. 3.23 Enhanced HQs. 2.6 (3.18) Pilot view & visual cueing environment. Helicopters are tricky little devils to fly so, ATC's please give us rotary pilots a break and be aware that we need both hands unless we are on the ground or well clear of it. DWB 10 June 1997/PCT 17 June 1997 It was a clear night when I finally left AAA, a light wind and about 30km visibility. I was in a twin engined helicopter, certified as single pilot IFR and had a current instrument rating, approximately 5000hrs in helicopters of which 900 were on type. My destination was a private landing site which I had only been to once before, but BBB (International airport) was nearby and available if required. The Met Office had issued a Fog warning, valid from the early hours until late morning the next day so I was not too concerned as I departed on a direct track for my landing site at around 2000hrs. I climbed to 2000ft to enjoy the tremendous view and felt relaxed under a RIS enjoying the fact that I was the only aircraft talking to them at that time. After 15 minutes clouds began to appear below me, but I was not yet concerned as I could still see the lights below, through and around the clouds. A few minutes later it was solid cover and I was flying VMC on top. It became clear that my landing site was going to be overcast possibly in mist. Well that was still OK, I had people on the ground with crossed headlights and data from my previous trip had allowed me to work out the difference between QFE and QNH, best approach headings etc. I also had a Radar Altimeter and sophisticated GPS which one could couple to the Autopilot, or just use on the HSI. My escape routes were worked out, BBB was nearby and AAA was in the clear, I'd give it a go. I changed frequency to BBB and was positively identified and given a RIS. I informed BBB of my intentions and set myself up for the first approach, Radar Altimeter 'bugged' to 500ft. At 500ft there was no ground contact, so I went around setting the 'bug' now for 300ft and commenced another approach. All was well, heading, rate of descent, distance to run. I reached 300ft and had not broken cloud although I could see dark patches of ground through what was obviously a thickening mist. I had just decided to go around when the crossed headlights appeared 500m away in my two o'clock. I immediately lowered the collective, flared and commenced a turn to the right applying right pedal.. My eyes were glued to the lights and it was then that they disappeared. At this time I was probably below 300ft at about 50kts, in a turn with a rate of descent with no references whatsoever. I knew I was in big trouble. I transferred back onto instruments and simultaneously raised the collective as high as it would go, and rolled back the bank, expecting the ground to hit me any second. After the second or two it took me to assess the instruments I was confused. The ROD had descreased and was showing a proper response to the applied power by beginning to show a healthy ROC of 1000ft/min, but the AI was showing a wild oscillation in roll of about 20 degrees left then right and in pitch 15 degrees nose up and down, but most alarming was the DI which was spinning so fast that I could not tell which direction, let alone read the headings. Airspeed was zero. I corrected the AI to 'wings level' re-checking the rate climb. I was still IMC and extremely scared. The yaw pedals were useless as the Tail Rotor has clearly 'Broken Away' I had no idea which way I was rotating. I had enough height (1200ft) now to do something about the Airspeed and lowered the collective a little and pushed the nose gently forward. After what seemed an age the ASI began to indicate, the rotating began to slow and eventually stop. I found myself IMC at 1500ft straight and level at about 110kts. With immense relief I commenced a climb to VMC on top and broke cloud at 1800ft. The stars were very bright, but I had a further horrible moment when it appeared the moon was overtaking me and for a moment I thought I was travelling backwards. I suspected that my inner ear was still adjusting. BBB gave me a vectored ILS pronouncing clear skies and greater than 10km visibility. The aircraft remained there overnight and I took a taxi home. 2080 [AIR] HELICOPTER S x ? 2.4 Human error with no associated technical I confessed to an Engineer that I may have 'overtorqued' the main rotor head and it was inspected the next day before I flew it home. I hadn't. The 'overtorque pop-out' was still in place. DWB/PCT 3 Sept 1997 In response to the latest CHIRP, I enclose my offering. There is much more I could say, but I have tried to restrict it to a) first hand experience, and failure. b) the absence of guidelines for non visual approaches to rotary landing sites. The commercial pressure/management coercion written about by your other helicopter correspondent is valid enough but I would add pilot peer pressure ("he could not get in, but I did"). It is only because there are no rules that this can flourish. I am happy to discuss and elaborate this in person, as I am for my letter to be published if it is considered to be helpful. Report: FB43 - Disorientation - An Alarming Experience The 'Alarming Experience' in the latest CHIRP was such a riveting read it has galvanised me into writing to you. The writer's candour is commendable, but has your comment not rather missed the point? Surely the burning issue ought to be how it can be possible for a helicopter to be in the descent at 300 feet from the ground in IMC at night? This would be below minima at many airfields served by recognised navaids and runway lighting? The commercial pressure/management coercion described by your other helicopter correspondent (FB43 Commander's Decision) is valid enough, but I would add pilot peer pressure ("he could not get in, but I did"). It is only because there are no rules that this can flourish. Far be it for me to point a finger. As a co-pilot I have personally overflown a turreted five-storey castle at 500 feet AGL and not seen it until alighting on the croquet lawn. I have also descended at 200 feet AGL in fog before overshooting a manor house. The aircraft's GPS (Global Positioning System) was inoperative at the time, so the Captain used a hand-held GPS receiver resting on the door pull. My first touchdown there was in sunshine; I noted the fine trees sheltering the house and paddocks and could not help wondering! Lastly, on a rainy night on finals to another castle, I found myself discerning individual leaves on trees from my door window. The ancient pile was comprehensively floodlit, but intermittently obscured by pockets of post cold front fracto-stratus. Realising in a flash that just one more in front of us would doom us to destruction, I called "####, Pull Up, Pull Up" as calmly as I could. To his great credit he did, immediately and with full power. Some weeks later in daylight I looked back along our flight path that night. Only the crowns of the deciduous trees were visible across the park's skyline. In between, and the closer they were, the more of them could be seen, were stately cedars. We had been descending over rising ground - even something the best radar altimeter cannot show. In transit outside CAS the principle of terrain clearance in IMC is plain enough. Anything you might otherwise bump into has been cleared by a minimum of 1,000 feet. Similarly, there is no ambiguity about a non-visual runway approach. Every possible permutation of obstacle hazard, landing direction, navaid visible, even aircraft handling characteristics has been computed to promulgate landing minima. Compliance with these is not optional and is equally obligatory to helicopters. But if descending without visual references to an area not designated for the purpose of take-off or landing, just how low is a helicopter allowed to fly? There is no definitive answer, and I am profoundly convinced it is time there was. Only a short time ago a DIY IMC let-down was confined to what used to be called 'cloudbreakers'. The old RNAV's performance, prone to lane jumping and flashing its orange warning light at exactly the wrong moment, was sufficient to deter most from attempting anything more ambitious. Since the Gulf War though, GPS has made such improvements in reliability, presentation and even flight control integration in some equipment that, for the most understandable reasons, and in a vacuum of defining parameters, pilots are doing everything they possibly can to accommodate client requirements. This has created the potential for a highly dangerous grey area. At the moment, anything goes because regulation has not kept pace with the enhanced technology fitted to IFR onshore helicopters. 2106 [AIR] HELICOPTER L x Other. 3.23 Enhanced HQs. Within the last year the fatality record of British registered aircraft in this category is very sobering. As winter draws near a rigorous scrutiny and reappraisal of non-visual approaches to helicopter sites, in theory and practice, by the appropriate regulatory authority would, I suggest, be most timely. DWB 8 Dec 1997 During two instrument approaches with an ab-initio co-pilot who had just been released to line flying as handling pilot I had to take control. Before doing so I had been acting as a talking instrument panel to do all I could to help him stay within acceptable parameters. It would be too easy for me to write a report on him and walk away. With many years on type (AS332L) I see this is a repeated problem when new pilots arrive on the fleet. I know that the learning curve is so steep and so long that it can be months before new co-pilots are not working on the brink of overload all the 2207 [AIR] HELIDECK L x 3.1 Low visibility rig approaches. time. To expect a trainee to go from flying say an R22 on sunny days in South England to operating IFR in the hostile environment of the North Sea is expecting too much for the average pilot. A helicopter is unstable and the AP fitted has poor authority, the co-pilot only has an air speed and altitude hold that are of little use on an ILS. It is a very demanding task for an experienced helicopter pilot to fly an uncoupled ILS in moderate to severe turbulence on this type. Soon the problem is going to get worse as all new pilots will have to be instrument rated and not just pass a company base check. This will only make the learning process longer before the trainee can have a stable period to consolidate his limited experience. In the meantime I hope this individual will come good before his overload overloads his Captain with consequential disastrous results. PCT 110198 We are tasked to fly a relatively short offshore passenger sector at night. The weather at ### (point of departure) was clear but the weather at the ### (destination rig) was reported as "not good". There are no trained met observers on ### (destination rig). The transit flight was normal, we planned a rig radar approach starting our descent into wind at 4nm from 1200ft. The helideck orientation dictated a Left Hand Seat landing. As Captain (RHS) I flew the approach intending to hand-over to the co-pilot for the actual landing. The approach proceeded as expected. The weather was not good, low cloudbase and fog patches. At our MDH of 300ft (night) we were in the bottom of broken cloud. At decision point of 0.75 nm, 300ft offset from our approach track by 15 deg the copilot indicated he had lights visual and to continue. I descended a further 50' to 250' and at approx 1000 meters the co-pilot indicated he was happy to take control of the landing. As soon as control was transferred, I called height and airspeed continually. I could see the lights of the rig in my peripheral vision and at approx 800m and 250ft with 50kts IAS I glanced up at the rig. As I looked down the AVAD 100' warning activated and the rad alt showed us descending through 100'. Corrective action had been instigated by the co-pilot, the AVAD warning was verbally acknowledged by us both. I continued calling height and airspeed, the a/c levelled at 50ft and 45kts. There was more power available and I called for it to be applied. The a/c climbed away and at 250ft 60kts we were 300m from the rig, the helideck was clearly visible the windsock on the nearest crane confirmed the wind (Southerly 15kts) which gave us an unobstructed landing. We continued the approach and the landing phase was normal and smoothly flown. Discussing the incident after the flight, the co-pilot felt he had inadvertently descended too low because of the visual cues he was getting from the platform lights. I will add that in addition the safety vessel that was in close proximity to the platform was more brightly illuminated (it was a supply vessel equipped with floodlights) and was rising and falling in the swell. I felt this incident would not have occurred if I had flown the a/c on instruments monitored by the co-pilot until we were much closer to the platform with the helideck clearly visible before handing over to the landing pilot as an S.O.P or if the a/c had been fitted with rad alt height hold. 2250 [AIR] HELICOPTER L x 3.19 HMI with new flight deck technology. I wonder how many others have found themselves in a similar situation on a night approach to a rig in bad weather who also have had a "fortunate outcome". DWB 4 April 1999 I was line training a P2 on his 2nd N.Sea flight shortly after lifting from the Rig we were advised that we may be required to divert to a nearby Rig (for a CASEVAC) which was on contract to Shell for whom we do not fly. I had a locally produced A4 map giving rig positions but this is not for planning purposes so I needed to load the position of the Rig into the area nav - this has a world wide base but all the N.Sea waypoints rigs platforms are in the limited non protected supplementary data base. It has a left and right screen operated by 2 concentric rotary knobs and a cursor selector. To enter the Rig I first looked up the company nomenclature 'HRND', selected 'SUP' with outer knob then 'CURSOR' then scrolling through the alphabet 4 plus times moving the cursor from space to space 'HRND' was not in the 'SUP' (supplementary data base) to enter the Lat and Long requires 18 scrolls through the alpha/numerics plus cursor moves. Having written the Lat and Long I got the co-pilot to cross check it and pressed 'ENT' - BOTHER it wasn't accepted - I realised that whilst carrying out the above I had also been diverting my attention to monitor my PO's flying, so I did the whole data entry again - same result. Due to the fact that the SUP data base was full I needed to remove a waypoint to make space. This required the selection of 'OTHERS' on the other screen and then scroll through all the 100 plus waypoints to find one that can be removed. Having done that it was back to the procedure for entering 'HRND'. Once I had done this I found we had flown 32 miles! Time to do some fuel calculations. I was flying inbound to AB2 passing a nearby platform also operated by Shell. I was reaching the point where I did not have fuel to return to 'HRND' and hold a land div. I suggested that I wait on the platform while they get a decision as to whether I was required to return to 'HRND' and I could take on fuel to cover all contingencies. By the time they came back with agreement I was well past the platform - I instructed the P2 to make a 180 while I went to put the platform in the active route. Until a year ago we flew regularly to this platform so I knew it was 'BUNA' or 'BUNNA' in the data base. I selected both these but neither were successful - I checked the nomenclature, it should have been 'BUNA'. I was not inclined to clear out another waypoint and go through another period of knob twiddling. Using mental or common sense plus the aircraft radar managed to find the platform lurking behind a shower! - the rest of the flight was a breeze and the casualty safely delivered to hospital but no thanks to the Nav Aid. The points are: 1. The method of operation is unwieldy - after having it on the fleet for 3 years all crews still have problems using it to a greater or lesser degree - it is not intuitive in use. 2. The N.Sea waypoints - platforms, reporting points, HMRs etc. are not in a fixed data base. 3. The supplementary waypoint data base is not large enough to hold all N.Sea requirements bearing in mind we need all the continental route structure for divs. 4. The size of the writing is meant for a fixed wing panel which is closer than the centre consul mid position in a 2 crew helicopter. This is a particular problem for older crew with glasses. 2271 [AIR] NORTH SEA L x ? 3.19 HMI with new flight deck technology. I question how this situation which has real human factors safety aspects is allowed to continue. The cockpit workload pressure caused by an unsuitable area nav causes real dangers for the unwary! JAN 26 Aug 1999 As a line training Capt I was approached by a colleague from another fleet for advice/confirmation of his decision. He had been offered an aircraft for service that had just returned to the North Sea from an onshore dry lease. It was fitted with a Racal R Nav 2 area navigation system which in this installation has inputs from VOR/DME or Decca as well as a Dead Reckoning computer. He had a flight to an area well outside VOR/DME range and where the Decca chain is no longer available. As the flight included 2 x shut downs the DR function would become inaccurate. The Company had provided a hand held GPS brand new and still in its wrapping which clearly the crew had no time to learn how to use. In the prevailing conditions we agreed the flight could be safely carried out. However, when the aircraft was put on the flying program the night before and the hand held GPS bought the Company did not know that the weather would allow the flight to be 2478 [AIR] HELICOPTER L x 2.4 Human error with no associated technical failure. carried out safely. As the North Sea is Class G(?) airspace and the MEL (Minimum Equipment List) states that an area nav system is not required this potentially serious encroachment on safety is legal. Any reasonably experienced North Sea pilot can find their way to and from a rig without an area nav BUT they cannot maintain the track structure, or maintain traffic separation for the descent/climb out phase of flights. As it's legal the company will continue to cut costs in a nav equipment! PCT 21 Sep 00 It was my first flight with a Captain to clear him to fly a helicopter with which he was not familiar following a merger of two companies. I was therefore being particularly alert in my actions. We were required to pick up passengers rotors running by taxiing to a "hot spot". The empty spot was between two other A/C already loading rotors running. Once on the spot I clearly called "brakes on please". There was an equally clear reply "the brakes are on". We then allowed the ground staff and pax under the rotor disc while we carried out a number of "head down" tasks in the cockpit. These are tasks which had not been done by the crew prior to the merger. On completing the Before Departure checks it was found that the brakes were NOT on the co-pilot had inadvertently selected the nose wheel lock! We had sat sandwiched between two A/C all rotors running loading pax on a sloping apron and the company refuses to use chocks during hot spotting. I believe I had been as responsible as I could be in having the parking brake applied. The parking brakes/nosewheel lock are not clearly visible from the P1 seat particularly, as they are often obscured by documents / plates / manifests etc.