As I recall, VFR does not allow flying into clouds and that you maintain clearance distances to them as well as constant visual contact with the ground.

That's the point that I was trying to make, if the pilot had been cleared only for a VFR flight, what was he doing flying through the clouds?

John R. Baker, P.E. (ret)
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This forum is an unusual catch all for bad news which engineers might find interesting and enjoy discussing. It should just be the Failures and Disasters Forum.

Not a complaint, just an observation.

I like it. Name it "bad news which engineers might find interesting and enjoy discussing" forum.
Then we could also have a "good news which engineers might find interesting and enjoy discussing" forum.

JohnR,
Lots of wings hanging on St Peter's gates are wondering the same.

I must admit I was flying VFR when an overcast suddenly appeared underneath, except for one hole just large enough for me to spirally descend through and below. Fortunately there was still enough clearance and height of cloud over ground to let me get to the nearest airport under VFR. Water vapor sometimes spontaneously condenses into fog and clouds with minimal temperature change, especially near hills and mountains during high humidity atmospheres. The worst place for that to happen.

Quote (JohnRBaker)

...if the pilot had been cleared only for a VFR flight, what was he doing flying through the clouds?

As I recall this was discussed at least peripherally in the original thread. An affliction sometimes called "get-there-itis".

The problem with sloppy work is that the supply FAR EXCEEDS the demand

JB - I know you like huff post, but that snippet is next to useless.

If you had read the previous thread or the ntsb reports you might understand better.

Here is the summary from the ntsb https://www.ntsb.gov/news/events/Documents/2021-BM...

and the summary from the news release is here. https://www.ntsb.gov/news/press-releases/Pages/NR2...

The flight started under VFR and the company was not allowed to fly on IFR, but during the flight the conditions changed and the pilot decided to continue, climb ( he was apparently cleared for IFR, but may not have been flying that way for a while) into what the aviation boys call "into Instrument Meteorological Conditions" or IMC. You or me would call it "flying into a cloud"... his aim was to break through the low cloud so that the radar from the airport could find him and tell him where to go.

Then with the sudden loss of the true horizon, he seems to have got disorientated and failed to transit to the artificial horizon on his flights controls - which to be fair to his memory is reported as being very difficult to do - thought he was flying level and straight up through the cloud, but was actually in an increasing diving turn to the left which he didn't notice until it was too late and he had a windscreen full of hillside.

The issue is a known one of pressure to complete the flight, either from the client, the company or just his own desire to complete the flight - they call it "plan continuation bias" - and apparently a lack of a pre planned plan B. You can see this happening in so many incidents where people continue to plough on disregarding alarms, not believing what the instruments are telling them, disregarding changing situations and become tunnel vision focussed on reaching the destination / end point.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

The first IFR lesson a student pilot gets is "Always Believe your Instruments". You close your eyes while the instructor nearly does a loop and says open your eyes. You throw up as you try to figure out how you got there by only flying straight and level. If you still don't believe the instruments, he does it again. Hard lesson to forget. However get-there-itis can be quite compelling at times.

Eh, this subforum and the pub have become reminiscent of FB - places for hot air to hear itself talk on everything unrelated to engineering. Getting rid of both would be a huge improvement.

The man was a professional pilot flying a multi-million dollar bird, not your neighbor’s Cessna so no need to continue vilifying.

Or it could be all the more reason. Professionals are supposed to be trustworthy enough not to make amature mistakes.

And, sorry, you are entitled to your opinion, but you also do not have to be here if you'd rather be doing something else.

Amateur mistakes? So you’re continuing to speculate and denigrate the dead?

Quote (what was he doing flying through the clouds?)

I don't think it was a cloud he collided with...

Rather than think climate change and the corona virus as science, think of it as the wrath of God. Feel any better?

-Dik

I've done a bit of flying in a chopper (not a pilot) and I can see how easy it is to get disoriented... he may have made an error at the wrong time... but, occasionally accidents do happen... sorry for all of them...

Rather than think climate change and the corona virus as science, think of it as the wrath of God. Feel any better?

-Dik

The general consensus appears to be that he got caught in the clouds and couldn't find an easy way out. I have no further information. If you do, please share. In any case, I belive a truely professional pilot would most likely say, "The weather looks like a risk that I am not prepared to expose you to and I intend to sit right here until I think it looks better. If you have to be somewhere, I suggest you inquire at the car rental office right over there." Every pilot I know has at one time or another waited many hours, if not several days, for clear enough weather to make a safe flight.

Not saying this happened here, but statistically these weather related accidents happen most often, not to inexperienced pilots, but those with just enough experience to think they have developed excellent flying skills, more than adequate to see them through marginal conditions, not thinking there is a very real possibility the conditions might worsen enroute. They concentrate on the known skill set variables and their known capabilities, but forget to take into account the other uncontrollable variables, which at times can be a bigger advantage than knowing how to fly well in itself. I'm still here.

These Loss of control incidents are not uncommon in fact they are very common. I don't disagree with what you say about what a pilot should say. The air taxi world is cut throat and there will always be anther pilot to take your job.

I think there is a fatality every 45 days in the HEMS rotary air ambulance world in the USA. Most of them due to weather related or at night loss of control.

VFR is a a lot higher work load in my opinion than IFR I haven't flown VFR in 10 years. I am fixed wing though.

CWB1,

It's not clear which poster or post you're referring to. By the time you respond another post may have been made.

I don't disagree about the pub, that's got a bit toxic recently but maybe that matches the mood of the US at the moment.

But this forum I think works very well. The miami bridge thread the combined thought proved found what is generally taken to be the issue after about 4 weeks.

This thread is using, at least from my view, the considered view of the NTSB. I'm not vilifying or denigrating the pilot, but trying to understand what he clearly didn't do correctly otherwise he wouldn't have crashed. Learning from incidents like this help everyone prevent the next one.

Was it a engineering design issue or a human issue? Probably a bit of both, but the pilot gets it 90% of the time.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

At the end of the day, flying skills are only as good as your judgment.

Terrible accident. I'm sure a mistake or mistakes were made by the pilot but I'm sure he thought we was making the right call. I don't think he intended to kill himself that day.

The part that makes me sick is Kobe's widow filing monetary lawsuits. My goodness, how much money does she need? Kobe made more than enough in his life for her to live in luxury for the rest of hers and her children. But then again I'm not a greedy SOB and I almost want to throw up when I see ambulance chaser lawyer commercials on TV.

It's not always about the money, but getting some measure of closure and perceived "justice" in the form of financial punishment of the perceived guilty parties. I think, if prompted, she would agree to donate any money that she actually gets

TTFN (ta ta for now)
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I admire your lack of greed, however consider how you might feel if you were in her shoes, heaven forbid. Anyway, she, as you, I and everyone else, is/are entitled to legally fight for what we think we deserve under those circumstances and I suspect that you know as much about their financial situation as I do, so is there any real traction here.

I saw recent press releases, didn't see any previously unknown information.

My posts reflect my personal views and are not in any way endorsed or approved by any organization I'm professionally affiliated with.

LittleInch, my first post was general comments to no one in particular, my second to 1503. I have always found failure analyses both interesting and educational, and get paid well to do it quite often. Speculation never enters into it. Unfortunately most of what I have seen in recent months in this subforum isnt engineering related so generally wont even bother checking it for new posts. As to this incident, the NTSB couldn't prove that the pilot did ANYTHING wrong. Stating otherwise is defamatory, unethical, and in poor taste. The only lesson here is the one being forcibly ignored - dont gossip bc the mob loves to believe and repeat nonsense.

Quote:

I'm not vilifying or denigrating the pilot, but trying to understand what he clearly didn't do correctly otherwise he wouldn't have crashed.

The pilot did a CFIT while supposedly climbing and with no mechanical or electrical failures; that much we know for sure.

TTFN (ta ta for now)
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What is engineering related is the employment model and commercial pressure that is prevalent in the air taxi world.

There are many proper engineering threads in the forum where there is a web of contracts and sub contracts with external sign offs. And sales team over selling the real capabilities

Just reading the latest output from the Grenfell enquiry. Which reminds me to see what's new in the Miami bridge thread.

Aviation accidents reports only establish what happened and make safety recommendations. They don't as such point the finger of blame. But if there are no technical findings then the finger is firmly pointed towards the pilot/s. And to be honest most of the time it is human performance related.

CWB1, As you must know, failure analysis does not always involve poping rivets and frozen O-rings and rarely enters, for example, roadway accident investigations. Human failure alone can cause accidents. Running red lights, excessive speed and drink driving leave no evidence, other than perhaps skid marks and post mortem blood results. In this case there appears to be a lack of any such physical evidence; no black box; not even any skid marks remain to analyse. As such, we are limited to speculation as our only means to try to explain the results and hopefully learn about what might have happened and prevent similar incidents in future. Of course speculation should be based on experience, limited to realistic, plausible causes and event chains and avoid the "space lasers" theories. So far, I think we are within that box. I to my knowledge, have not made any accusations at all, only pointing out that poor judgement is statistically the most common root cause of these types of accidents and stated what I would have done in a similar situation. And contrary to your accusation, one possibility I mentioned above about how tricky it can be to predict cloud formation in humidity laden atmosphere over hills and mountains (did you bother to read it?) might even explain the results from a more pilot-friendly perspective. Anyway, I'll stick with my plausible explination until evidence to the contrary presents itself, as I belive it is based entirely on my personal experience in similar situations and statistical results of many prior NTSB investigations involving similar circumstances.

CWB1,

I'm interested to work out what exactly you think about crash investigations of this type. This is not simply an "engineering" view of life and in this case nothing broke or failed to work as required, but the helicopter crashed and everyone on board died. So something clearly went wrong. Given the lack of flight and cockpit data recorders - which the NTSB has recommended on a number of occasions and the FAA doesn't agree - a certain level of speculation based on the data that is available is inevitable. That doesn't, IMHO, make such speculation and informed comment "defamatory, unethical, and in poor taste".

I also don't accept that what generally occurs on these threads is "gossip" or "hot air" and equally when incorrect statements appear they are challenged. The start three posts in this update thread might come into this category and they were challenged and links provided to the NTSB actual report to correct them.

This is what the report says about probable cause.

"The National Transportation Safety Board determines that the probable cause of this
accident was the pilot’s decision to continue flight under visual flight rules into instrument
meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control.
Contributing to the accident was the pilot’s likely self-induced pressure and the pilot’s plan
continuation bias, which adversely affected his decision-making, and Island Express Helicopters
Inc.’s inadequate review and oversight of its safety management processes. "

The only really new piece of information not previously available was that the company procedures either didn't require the pilot to update his flight risk analysis form at the point of near departure, which would still have been "low risk", but would have required clearance from the ops director and a plan B being put in place.

I agree that it's always far too easy to point the finger at the poor guy at the pointy end without always showing that the "system" was at fault for allowing the situation to develop.

But if you don't like the forum and don't want to contribute in any way, then this is your choice. You can remove forums from your My forums list.....

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

Quote (Spartan5)

This forum is an unusual catch all for bad news which engineers might find interesting and enjoy discussing. It should just be the Failures and Disasters Forum.

I agree. Just had a related conversation with my Manger a few days ago. He observed that in aviation, no effort is spared to engineer out single point failures that could cause a hull loss. Aviation accidents are typically the result of a chain of events. Most discussions on aviation accidents aren't going to be engineering disasters.

Regarding pilot error, no airplane does much of anything without a pilot. So yeah, the pilot more often than not plays a significant role in all outcomes when it comes to flying, good or bad. One really bad day cancels out all credits earned during the thousands of good days that preceded it.




My posts reflect my personal views and are not in any way endorsed or approved by any organization I'm professionally affiliated with.

I certainly agree with your manager. And in fact most all failures of well engineered systems are caused by more than one individual failure event. But the curious result of that is, that when you do the math backwards, you never get the same number predicted by the formulas used to calculate the forward probability of the chain of multiple component failures. Multiple component failures when back-calculated almost always show a higher probability than what the forward calculation predicts. My personal theory is that, if one component is bad, there is an inherent higher probability that others may also be bad. I suspect that there are linked factors, such as poor maintenance practice is not usually going to be limited to only one component, etc.

Most aircraft do such a good job of flying themselves straight and level, they can do that all by themselves, so when they don't, someone, or some thing is usually making it do something else. Even in a stall, the best way to get most aircraft safely out of it is to adjust to the appropriate power setting, take your hands off the yoke and let the plane fly its own way out. In fact, most aircraft fly themselves so well that any accident is going to be the result of someone, or something trying to make it do otherwise. Of course that is usually going to be someone trying to stop it flying and get back down onto a runway. Although none of this is true for helicopters. They are inherently unstable.

Actually I only disagree slightly with your last point, which implies that a pilot gets credit earned for good days flying that can be drawn upon and used on those bad flying days. My view is, "Pilots don't get no credit! Each flight starts anew with balance of 0.0000". Less than ideal mechanical, or flying conditions, etc. can only push that balance negative.

Someone did a recreation of the flight on Microsoft Flight Sim but removed the weather. It was fascinating to be able to see the pilot disorientation happen. It seems the video has been removed as I can't find it now.

Anyways, to put this bluntly, if the pilot had survived he would have been charged criminally.

It's a bit reminiscent of this story:

"The report found this discussion caused the Captain to experience "clash of motives."[3] On one hand he knew that landing in the reported weather conditions was unsafe.[3] On the other hand, he faced strong motivation to land at Smolensk anyway.[3] He expected a strong negative reaction from the President if he chose to divert the airplane and land at an alternate airport.[3]"

https://en.wikipedia.org/wiki/Smolensk_air_disaste...

To note the comments about aircraft flying themselves do not apply to rotary. They basically have to fly them from the moment they hit the start button to the moment the blades stop moving.

I suspect it all started to go wrong when he had to change frequency. Which requires a hand and looking at something other than the instruments.

Only did a couple of hours in them. But completely different to fixed wing.

I don't think the FAA knows what to do with these FAR135? operations. There will be uproar if they tighten down on them but the accident stats are horrible. Europe the regs are so tight it doubles if not triples the price of a charter. And HEMS also costs 3 times as much.... fraction of the fatality rate per 100 000 hours though.

"Although none of this (ability to fly themselves) is true for helicopters. They are inherently unstable."

They don't need to be moving or off the ground for them to fall over and crash was my point.

Oh, Right. Yes, they do that quite well on their own. Bad pilot not required.

1502-44 Have you any idea what the training and currency requirements are for a Part 135 operators pilots?. They usually give it in these reports in the preamble.

They have been recommending CVR's and FDR's for 30 odd years and its always been successfully been lobbied against.

It was a play on words and helicopter behavior, maybe too convoluted. I meant, "Bad pilot not required" - because helicopters easily crash all by themselves".

I've been in two helicopter "incidents", both in the Colombian Andes, and fortunately, the pilots were extremely skilled, as I believe most are, at least in Colombia. You have to have some faith there. Any bad ones don't survive flying the Andes for very long. All the clouds there can have rock linings. One helicopter experienced a lamination failure in the rotor as we descended into rough winds blowing down the valley, just west of the Eastern Cordillera towards Ocaña and another, the pilot was following the Arauca River, only a few meters above it, in rain and heavy mist, when a river boat awith a very tall mast appeared immediately in front of us.

I don't count one fixed wing "near incident", at least near enough for me. An Air France flight, that went into a mountain in Bogota, because, fortunately, I was on the same flight number, but two months before. I don't like flying anything in the Andes very much at all, but still have faith in the pilots. You have to.

https://ecfr.io/Title-14/Part-135

Other than a couple of landings during thunderstorms where I discovered first-hand what wind-sheer felt like (when you've flown over 5 million miles like me, statistically, stuff like that was bound to happen) the scariest incident was something I didn't know anything about until AFTER I was safely home.

In December 1988, me and a coworker flew to Germany to attend some meetings at Opal in Rüsselsheim. It was the week before Christmas and we had planned to be there for four days (our flight home was already booked). Anyway, after two days we had finished our meetings and if it had been any other time of the year, we might have decided to stick with our original flights, and spend the extra days doing a little sightseeing, however, since it was so close to Christmas, we decided to try and change our flights. At the time I was still working for McDonnell Douglas but the German EDS team was acting as our host for our visits at Opal (a subsidiary of GM). So we asked one of the admins in the EDS office to see if they could change our flights. We had flown from LAX to Frankfort, via Chicago, on American Airlines and they were able to get our return flight changed to the 21st, getting us home two days early.

Anyway, on the morning of the 21st, when we got to the Frankfort airport I mentioned to my coworker, who had never been at the Frankfort airport before this trip, that I was shocked at how lax the security appeared to be. I know it was just a few days before Christmas and people were carrying all sorts of carry-on including wrapped gifts. Now there was still the normal screening, X-raying the carry-ons, but there was very few people being given a second look or their bags, which was usually pretty standard in Frankfort. Also, there were very few heavily armed police walking around, again something that had been common on my previous times in the Frankfort airport.

Anyway, we got on our flight, which was pretty uneventful, making it to Chicago without any problems, as was the case with our flight to LA. Anyway, I caught the shuttle home to Orange County, but I hadn't told my wife that I was coming home early as I was going to surprise her and the kids. But when I walked in she yelled at me for flying home TODAY, of all days, the 21st. When I asked her what the big deal was, she said, didn't you hear the news?

Back then, the LAST place you'd ever hear about an air-crash was while you were on a flight or at an airport (remember, this was before cell-phones). Anyway, December 21, 1988 was the day that Pan Am flight 103 was blown out of the sky over Lockerbie, Scotland. Now if the EDS admin had told us that they couldn't get us on that American Airlines flight, but there was this Pan Am flight to Detroit by way of London, where we could then get a flight to LAX, we probably would have taken it, so as to get home early.

That has always haunted me, but I continued to fly, for another 25+ years, passing through the Frankfort airport many more times, but I have to say, I never saw lax security there again. It was always very visible and in-your-face.

John R. Baker, P.E. (ret)
EX-Product 'Evangelist'
Irvine, CA
Siemens PLM:
UG/NX Museum:

The secret of life is not finding someone to live with
It's finding someone you can't live without

I won't even sit in one these days and that's without out it turning and burning. And teh kids are more than slightly pissed off they can't go on the sight seeing flights in them.

Honestly out of the 17 deaths I have dealt with in my aviation career. Half of them have been burning petrol in fixed wing and the other half are rotary.

They are utterly lethal contraptions.

JohnR, yes count that one. Should I count the one that returned to the Dominican Republic (30m out) because the cargo door opened? Fixed wing.

Right. Frankfurt must be the most heavily armed AP outside an active war zone and maybe inside too. Lots of iron there. But for me not so scarey as others. All their guys are over 14yrs old.

1503-44, I'd vote for that one. While I've never experienced anything quite like that, I've been on more than one flight that had to return to the airport after losing an engine, or at least getting a warning light that there was something wrong with an engine which then had to be shutdown, so I can empathize at least a small amount for what I'm sure you felt at the time.

John R. Baker, P.E. (ret)
EX-Product 'Evangelist'
Irvine, CA
Siemens PLM:
UG/NX Museum:

The secret of life is not finding someone to live with
It's finding someone you can't live without

No doubt human factors are the most difficult to eliminate both in design and failure analysis, that's why they are included in DFMEAs and fishbones alike. Speculation however should never enter engineering nor failure analysis. Literally the first thing tradesmen learn about troubleshooting in trade school and engineers learn in failure analysis courses is not to speculate, just follow the process and facts. Taking shortcuts or making assumptions based on emotion justified as "experience" has been well-documented to be misleading and hugely wasteful of time and resources, unfortunately its very common among those who lack training and real experience. The facts speak for themselves and failure modes (like people) are either guilty, innocent, or suspect. Prove it, disprove it, or draw no conclusion about it. Its unfortunate but we cannot properly analyze every failure in life due to lack of data. However, we can make always make improvements. I have not been involved with aircraft investigations but have with ground vehicles and would never speculate nor offer the suggestive type of report linked above as I cannot afford the professional and legal repercussions of such nonsense. I have no issue with pilot error being included in a report on possible causes, however reading the NTSB report or this thread would have the layman believe the pilot is at fault...yet its possible that he is 100% innocent. Stateside, accusing someone of an act that you know cannot be proven (no matter how probable) is defamation and unethical. There is no exception made for probability because we have the presumption of innocence.

I could venture that "the presumption of innocence" is solely a legal convention that should have no influence on a failure investigation.

These guys are good. They log a lot of hours too. There's more drownings on these islands each Yr than there are death due to traffic accidents. A lot of narrow paths and straight vertical drops into the ocean; no way to climb onto the rocks. One recovery last week, drown trying to save her dog and a rescue of 2 persons 5km from here just a few hours ago.
https://youtu.be/iwTUW0vp5N0

The legal case is just starting in court.

Don't have a clue which way it will go.

As I recall, the majority of US army training fatalities are associated with night flying of helicopters using a single monocular IR viewer ; it is easy to get disoriented if the landscape is not flat . Ditto for flying into or thru clouds.

Latest news on the Kobe Bryant crash is that many more first responders are now thought to have filmed and shared the films of the bodies. Apparently there is a market for that on the dark web, and everyone can be assumed to have access to a smart phone and its video capability.

"...when logic, and proportion, have fallen, sloppy dead..." Grace Slick

The US Army has tried many times to get obstacle avoidance systems for their helos, but they invariably fall below the budget line; it's a 3D world, and looking at it with 2D sensors just doesn't hack it, for safety.

TTFN (ta ta for now)
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Until recently most of the EMS helicopter flights in NZ have been VFR (including night). When they starting getting NVG capability (still VFR night) they started cancelling a lot more night flights as they could see just how bad it actually was. Its not uncommon for the EMS helicopters to land somewhere for a hour or 2 till the weather passes through.

I don't get why he didn't hover for a bit to find another way through the clouds, unless he greatly underestimated how thick the cloud was or it was developing & he didn't break though in the expected time. Its not really like fixed wing where you your best response to unexpected entry into clouds for the non IFR current is to let go of the controls (assuming you are all timed out).

https://losangeles.cbslocal.com/2021/06/22/vanessa...

just an update on the legal stuff