Commanders: Flying or Monitoring?
At a recent Royal Aeronautical Society Conference, one of the speakers, Colin Milne of BALPA, highlighted that in a number of past UK large helicopter accidents involving Controlled Flight Into Terrain (CFIT) or Loss of Control (LOC) the Commander was the Pilot Flying rather than the Pilot Monitoring.
While there are circumstances where this is appropriate, for example when the wind direction suits a helideck approach flown from the Commander’s position, as the conference summary points out:
…this was contrary to the practice in the airlines where the more experienced pilot assumed the monitoring role – ready to advise corrections or, in extremis, to take control.
This also eliminates any reticence a monitoring pilot may have due to the authority gradient in the cockpit.
The five accidents quoted were:
- G-BEON Sikorsky S-61N, British Airways Helicopters, in the sea near St Mary’s Aerodrome, Isles of Scilly on 16 July 1983, 20 fatalities (AAIB Report) – a routine passenger flight from Penzance to the Isles of Scilly – the only non-oil & gas accident cited
- G-TIGH Aerospatiale AS332L, Bristow Helicopters, the Shell Cormorant Alpha platform, East Shetland Basin on 14 March 1992, 11 fatalities (AAIB Report)
- G-BLUN Aerospatiale SA365N, CHC, near the Centrica North Morecambe gas platform, Morecambe Bay on 27 December 2006, 7 fatalities (AAIB Report) – strictly in this accident control was transferred to the Commander moments before the accident
- G-REDU Eurocopter EC225, Bond Offshore Helicopters, near the BP Eastern Trough Area Project (ETAP) Central Production Facility Platform in the North Sea on 18 February 2009, no fatalities (AAIB Report)
- G-WNSB Eurocopter AS332L2, CHC, 1.5 nm west of Sumburgh Airport, Shetland Islands on 23 August 2013, 4 fatalities (AAIB Special Bulletins)
The first anniversary of the G-WNSB accident is on Saturday 23 August 2014. To mark the anniversary, the UK Oil and Gas Chaplaincy and Step Change in Safety have created a memorial film which includes a short Act of Remembrance. Step Change in Safety’s Les Linklater reflects on that accident here.
Milne also discussed the need for:
- common operating procedures
- understanding the Type Certificate Holder’s design philosophy
- sharing lead customer experiences
- agreeing common procedures
- incorporating those procedures for all training providers
- mandating those procedures.
These are matters currently being examined as part of the Joint Operators Review (JOR), which was discussed at Oil & Gas UK’s recent Aviation Seminar.
In 2013 the RAeS ran a specific conference on monitoring. One account of that is here and another here.
UK CAA have also set up a microsite ‘Making Monitoring Matter’.
Airbus presented their thoughts on monitoring to the European Society of Air Safety Investigators (ESASI) in April 2014.
UPDATE 13 November 2014:
The Flight Safety Foundation (FSF) issued a study A Practical Guide for Improving Flight Path Monitoring, the final report of the Active Pilot Monitoring Working Group. The working group was created to address the issue of aviation incidents with ineffective monitoring as a factor.
Meanwhile the CAA have issued a series of Crew Resource Management (CRM) videos. These include one that features a reconstruction of a helicopter incident where a malfunction forced the crew to divert to an unfamiliar airfield. Autopilot mode confusion during the glideslope capture results in loss of control a breakdown in collective situation awareness.
UPDATE 18 September 2016: AAIB: Human Factors and the Identification of Flight Control Malfunctions
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