Ed Helicopter Crashes into Glasgow Pub

Wasn't there a crash where all three pilots ignored visual and verbal warnings, because they were focused on a warning lamp that had blown, and didn't notice that the autopilot had been disengaged? It's possible to concentrate on one thing so much that you just don't notice something that would appear to be un-ignorable. Of course, pilot training should aim to overcome this, but it can clearly happen.


Eastern Airlines flight 401.
 
Wasn't there a crash where all three pilots ignored visual and verbal warnings, because they were focused on a warning lamp that had blown, and didn't notice that the autopilot had been disengaged? It's possible to concentrate on one thing so much that you just don't notice something that would appear to be un-ignorable. Of course, pilot training should aim to overcome this, but it can clearly happen.


There was - it was near Miami, if memory serves me correctly.

But in that instance, the aircraft essentially drifted into the ground without any of the flight crew ever noticing, since they were incorrectly preoccupied with the light bulb for the landing gear. There have been other similar accidents - usually at night or in heavy cloud/fog, where pilots fail to monitor their speed, altitude and vertical speed properly, and consequently fail to understand that the aircraft is heading towards the ground.

In the Glasgow incident, however, this wasn't the issue. At the very least, the pilot would have been 100% aware that his engines had failed and that his aircraft was falling from the sky. What's more, he would have had plenty of visual cues from the lights of Glasgow to add to the inevitable falling sensation he would have been experiencing. And therefore there's no reason why he might have overlooked the necessity of performing an engine-failure hard landing. It's one of the most basic and essential emergency drills that are taught to helicopter pilots.

As I said, it's possible that he might have frozen in fear, or panicked and flustered, once the engines cut out and the aircraft started falling. But notwithstanding the fact that such a response would have meant that he was either an extremely poorly-trained or extremely unfit-for-purpose helicopter pilot, it also doesn't explain his apparent inaction upon hearing the low-fuel-in-supply tank warnings.

After all, the onset of these warnings would have given him ample time to have diagnosed and fixed the problem. He could have kept the aircraft flying normally, monitoring his instruments, while calmly going through the checklist. And frankly, even before reaching for the checklist, his automatic first reaction should have been to a) check all his fuel gauges, then b) to check all his fuel pump switches - which were right above his head in plain view.

All of this, coupled with the fact that he made no radio calls throughout the entire incident, mean that it's very hard to believe that he was either distracted or incompetent to such a degree (or, for that matter, falsely overconfident in his own ability to solve the problem). Bear in mind that after he got the warnings, he would have been able to track the remaining fuel in the supply tanks, so even if he thought he'd applied a "fix", he'd have been able to see constantly that his "fix" wasn't working. Why wouldn't he then have radioed that he had a problem and then set down safely on a green space? Would he really have been so hubristic as to think that he could "wing" it and fly back to base, in the hope that the supply tanks would give him just enough fuel to make it back?

In my opinion, none of it makes any sense unless you start to think in terms of something more than pilot error or incompetence. In particular, how could the pilot have failed to notice that the transfer pumps were switched off, and how could he have failed to even attempt (apparently) a controlled hard landing once the flameouts happened? Doesn't make sense. Unless.....
 
In my opinion, none of it makes any sense unless you start to think in terms of something more than pilot error or incompetence. In particular, how could the pilot have failed to notice that the transfer pumps were switched off, and how could he have failed to even attempt (apparently) a controlled hard landing once the flameouts happened? Doesn't make sense. Unless.....

No idea what the "Unless....." would be about but, the pilot was no rookie. 646 hrs in-type and you tend to have a good idea what's going on.

For me, I'm thinking it was something medical they've missed or simply can't detect.
 
Those switches would not be easy to miss assuming the lighting system worked.

ETA: BUT, I cannot see the valid flight condition that would require the prime pumps on but the transfer pumps off? Any pilots care to discuss this? Perhaps there ought to be a block guard on this whole block?
 
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From the report:

It was found that the main fuel tank contained 76 kg
of fuel, whilst the No 1 supply tank (left) contained 0.4 kg of fuel and the No 2 supply tank
(right) was empty.
more:
The Warning Unit has provided information on the order in which warnings were triggered
during the flight but not when they occurred. The unit recorded the normal warnings
associated with starting the helicopter, followed by a warning free status. It subsequently
recorded intermittent LOW FUEL 1 warnings for the left fuel supply tank, then a permanent
LOW FUEL 2 warning for the right fuel supply tank. This was followed by a further
temporary LOW FUEL 1 warning, before it became permanent for the remainder of the
flight. These LOW FUEL warnings are triggered by thermal sensors in the supply tanks.

For this helicopter build configuration, they indicate when there is approximately 32 kg and
28 kg of fuel remaining in the left and right supply tanks, respectively. On receipt of these
warnings, the manufacturer’s flight manual for the helicopter instructs the pilot to ‘LAND
WITHIN 10 MINUTES’.
An alarm gong was also recorded followed by intermittent warnings relating to low rotor
rpm. The penultimate warning recorded related to the battery discharging, which occurs
when there is insufficient engine-driven generator power. The last warning related to an
autopilot system failure. Investigation into the possible causes for the individual warnings
is continuing.



This is what I expected as most likely. Much of the discussion surrounded which tank that 76kg of fuel was found in. Now they have released it with additional info it greatly clears up this unkown. Secondary was the warning system and contents indication system.

Given the additional info in the report...one conclusion still seems most likely....unfortunately.:(
 
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From the report:


more:




This is what I expected as most likely. Much of the discussion surrounded which tank that 76kg of fuel was found in. Now they have released it with additional info. Secondary was the warning system and contents indication system.

Given the additional info in the report...one conclusion still seems most likely....unfortunately.:(

Unless he was cycling those switches because he thought they were not functioning and the flameout happened while they were cycled off?
 
From the report:


more:




This is what I expected as most likely. Much of the discussion surrounded which tank that 76kg of fuel was found in. Now they have released it with additional info. Secondary was the warning system and contents indication system.

Given the additional info in the report...one conclusion still seems most likely....unfortunately.:(


Yes.

Unfortunately, it's very difficult to understand why, upon hearing/seeing these warnings, the pilot didn't put the aircraft down on some green space (as per the required procedure), given that he self-evidently failed to fix the problem.

I find it hard to believe, for example, that he decided that a) he couldn't fix the problem (especially as the easy and obvious solution was right above his head), but then b) decided to "wing it" anyhow and head back to base, with his fingers crossed that the supply tanks would not dry up before he reached base. And all this without a whisper on the radio about the situation.

And then, once the fuel DID run out, it looks like the pilot again did more-or-less nothing, in contrast to the actions that would have been drilled into him time and again during initial and refresher training. And again, not a squeak over the radio.

It's more than baffling. I'm afraid the only explanation that makes any sense to me is that the pilot somehow acted intentionally in some or all of the actions he took (and failed to take), in the full knowledge of the expected ultimate outcome. If it can be adequately explained otherwise, I'd be more than happy to be shown to be wrong. I hope that's the case, I really do.
 
Unless he was cycling those switches because he thought they were not functioning and the flameout happened while they were cycled off?


But if he had got to the stage where he was cycling the switches, while the alarms must already have been operating for a significant time, then it's virtually impossible to understand why a) he hadn't already radioed that he had an unfixable fuel supply problem, and b) he hadn't already taken the mandated decision to put the aircraft down safely while he still had adequate residual fuel in the supply tanks.
 
Unless he was cycling those switches because he thought they were not functioning and the flameout happened while they were cycled off?
This would be something he would report.

The fact he says nothing is baffling. This is a case where a CVR would have been nice.
 
Those switches would not be easy to miss assuming the lighting system worked.

ETA: BUT, I cannot see the valid flight condition that would require the prime pumps on but the transfer pumps off? Any pilots care to discuss this? Perhaps there ought to be a block guard on this whole block?


From what I remember of some discussion elsewhere....the transfer pumps are shut off during certain flight parameters under certain conditions because they will be unable to transfer fuel in the main tank under low fuel conditions. IIRC in a hover some amount of fuel (close to the 76kg) becomes unusable. At this point the transfer pumps are called out to be switched off as not to overheat. Once fwd flight is attained, which changes aircraft attitude, the pumps can be turned on again and the unusable fuel again becomes usable.
 
No idea what the "Unless....." would be about but, the pilot was no rookie. 646 hrs in-type and you tend to have a good idea what's going on.

For me, I'm thinking it was something medical they've missed or simply can't detect.


If he had been medically incapacitated, the helicopter would surely have quickly fallen out of control - it requires constant pilot input to maintain level flight.

And then there's the timing issue. I'd be more inclined to consider this as an option if the entire incident was of short duration. But here, the whole incident lasted several minutes, from the first low-fuel alarms to the moment of impact. It's surely inconceivable that the pilot had some sort of medical emergency prior to (or shortly after) the onset of the incident, and yet the aircraft remained in controlled steady flight right up to the moment where the engines flamed out?

Even if a medical incapacity had happened only very shortly before the flame out and uncontrolled descent, one would still need to explain the pilot's actions (and inactions) in the several prior minutes after the first low-fuel alarms started. So I'd suggest that any way you try to work it, it's difficult to explain the whole incident in terms of a medical incapacitation of some sort.
 
Yes.



And then, once the fuel DID run out, it looks like the pilot again did more-or-less nothing, in contrast to the actions that would have been drilled into him time and again during initial and refresher training. And again, not a squeak over the radio.

It's more than baffling. I'm afraid the only explanation that makes any sense to me is that the pilot somehow acted intentionally in some or all of the actions he took (and failed to take), in the full knowledge of the expected ultimate outcome. If it can be adequately explained otherwise, I'd be more than happy to be shown to be wrong. I hope that's the case, I really do.


I would still attribute this incident to just plain old human error. I doubt its intentional.

I dont like the fuel switch configuration with the manual transfer pumps, what becomes unusable fuel and when, minimum fuel requirements, requirements for pilots to switch between one configuration and another for hover or fwd flight and only during very low fuel loads. I am actually surprised this hasnt happened much sooner. I have worked on many different aircraft types and I cant recall any that have such a precarious fuel system where the pilot must manage fuel in such a way towards the low end of usable fuel. I am sure there are contributing factors we will never know about.

So IMO its just pilot error on the flame out. And once the flame out occurred it again simply becomes pilot error regarding the execution of a proper autorotation for a safe landing. So as is usually the case accidents are a series of events....in this case two critical events.



Now the above is STILL speculation as the report still leaves out some information such as system failures that are unknown that could be contributing and they stop short of stating final conclusions.
 
If he had been medically incapacitated, the helicopter would surely have quickly fallen out of control - it requires constant pilot input to maintain level flight.


He could have been suffering from some form of subtle incapacitation that allowed him to physically fly the helicopter, but caused his judgment to be seriously impaired. I can't find any information about autopsy results online.
 
So it appears that the most likely interpretation of what we see here so far is that while hovering he was entered a low fuel condition for tank #1. Because he was hovering he switched off the transfer pump for pump #1 because of his low fuel condition. He then was surprised by a low fuel on #2, and switched that off as well. Told the guys that he had to go home now, and started off home. Once he had attitude for 105 kts he should have switched the transfer pumps back on, but did not. As he now had attitude to get fuel to the pumps, the pumps*should have been on. And likely he was flying with the assumption that they were.

Pilots manipulating fuel controls while in flight seems to be an activity fraught with peril. I see it in a lot of accident reports.
 
Pilots manipulating fuel controls while in flight seems to be an activity fraught with peril. I see it in a lot of accident reports.

Seem to remember that did in John Denver (not that his fuel system was quite as fancy-- it involved a pair of vice grips!)
 
Seem to remember that did in John Denver (not that his fuel system was quite as fancy-- it involved a pair of vice grips!)


I've always been a tremendous fan of his :cry1; I've read the NTSB report several times. The vise grips were an attempted and unsuccessful fix to extend the reach of the fuel-selector handle, which had been relocated by the (experimental) aircraft's builder to a position above the pilot's shoulder. Apparently JD inadvertently applied hard rudder while twisting in his seat in an attempt to manipulate the handle, causing the plane to depart controlled flight and crash.
 
He could have been suffering from some form of subtle incapacitation that allowed him to physically fly the helicopter, but caused his judgment to be seriously impaired. I can't find any information about autopsy results online.


Perhaps - but one of the few things that produces these sorts of limited judgement-related symptoms is hypoxia/anoxia, which can be ruled out in this case owing to the low altitude of the helicopter.

I agree however that it is at least a possibility on paper. But I think it's difficult to think of any medical condition which meets these narrow criteria. I guess intoxication of some sort might be a possibility (although this would almost certainly affect motor activity if it was at a level to cause such judgemental defects). But again, I'd imagine that this can be discounted from the autopsy evidence - as far as I know, the pilot's body was recovered intact from the wreckage within several hours of the crash, and it would therefore have been a simple procedure to carry out a full toxicological study on his blood (which would certainly have been done as part of the autopsy).

All that being said, I think you're right to suggest we can't rule it out completely just yet. I'd just suggest that it's fairly unlikely to be a significant contributory factor, based on what we know right now.
 
Not going there.

Carry on discussing the helicopter crash. Knock yourself out. How long have you had your pilot's licence for, by the way?

Rolfe.


That's fine by me - it's the subject of this thread after all.

In answer to your question, I held a PPL for six years in my late teens and early 20s, but I let it lapse owing to the hassle (and cost at that point) of completing the necessary yearly maintenance flight hours. And my father was an RAF fast jet pilot and sat on several RAF boards of inquiry into fatal military accidents. And a few of my father's friends, one of whom I would also count as a friend of mine, are members of the AAIB (he's not investigating this particular case though). I've only ever flown a helicopter once though, purely as a first-time student.

Does that answer your question? I appreciate the sarcasm inherent in the question though :)

Anyhow, what's your view on the most logical and reasonable explanation to fit the currently-known evidence in this case - given that this evidence appears to be broad, reliable, objective, well-sourced and well-supported? Do you think, for example, that the pilot made a series of errors which started with a failure to respond appropriately to the low-fuel alarms, and which culminated in his failure to conduct a controlled autorotation hard landing once the engines had flamed out? And if so, what would you make of his failure to make any radio contact throughout the entire incident (which must have lasted at least several minutes from start to finish)?

These are all relevant, reasonable questions. It's hard to find reasonable answers to them at the moment, without at least considering the almost-unthinkable. But that's a very long way indeed from saying that the ONLY explanation is deliberate pilot action/inaction - and it's even further away from seeking to condemn or vilify the pilot.
 
I would still attribute this incident to just plain old human error. I doubt its intentional.

I dont like the fuel switch configuration with the manual transfer pumps, what becomes unusable fuel and when, minimum fuel requirements, requirements for pilots to switch between one configuration and another for hover or fwd flight and only during very low fuel loads. I am actually surprised this hasnt happened much sooner. I have worked on many different aircraft types and I cant recall any that have such a precarious fuel system where the pilot must manage fuel in such a way towards the low end of usable fuel. I am sure there are contributing factors we will never know about.

So IMO its just pilot error on the flame out. And once the flame out occurred it again simply becomes pilot error regarding the execution of a proper autorotation for a safe landing. So as is usually the case accidents are a series of events....in this case two critical events.



Now the above is STILL speculation as the report still leaves out some information such as system failures that are unknown that could be contributing and they stop short of stating final conclusions.


This may indeed help to explain how the fuel transfer pump switches found themselves in the "off" position at some point during the flight.

But surely, once the "low fuel" alarms started sounding, the instinctive response by the pilot (not to mention the standard written procedure) would have been to follow a train of thought along the following lines: "Hmm, the supply tanks are low on fuel. Now, these tanks are supplied by the main tank. So how much fuel do I have in the main tank? More than enough. OK. So, how come there's plenty of fuel in the main tank but very little in the supply tanks? Why is the fuel not getting from the main tank into the supply tanks? Ah wait, it's the fuel transfer pumps that move the fuel in this way. I'd better look up and check whether those pumps are on or off. Oh Jeez, they're off. I'll turn them on again. Ah, that's better, the supply tanks are now replenishing fine from the main tank. Crisis over."

So even if the fuel transfer pumps had previously been switched off for a legitimate reason, why on earth wouldn't the pilot have checked the switches once the "low fuel" warnings started (and kept going and going and going)? And then, once the alarms had been going for some minutes, why didn't the pilot declare himself baffled (assuming that he didn't look up and check the switches) and make an emergency landing in any case?

I simply find it very hard to understand how and why the pilot would have kept flying - seemingly en route to base - with those alarms going off, his supply tank gauges running to zero, and with him self-evidently having been unable to identify or fix the cause of the growing emergency. And all that without even making a radio call to inform the tower/control of his situation.
 
If he had been medically incapacitated, the helicopter would surely have quickly fallen out of control - it requires constant pilot input to maintain level flight.

Even if a medical incapacity had happened only very shortly before the flame out and uncontrolled descent, one would still need to explain the pilot's actions (and inactions) in the several prior minutes after the first low-fuel alarms started. So I'd suggest that any way you try to work it, it's difficult to explain the whole incident in terms of a medical incapacitation of some sort.

Medical incapacity is a possible explanation. It is conceivable that epilepsy was the cause.

I have developed it in the last three years. It does not necessarily start with a mammoth fit. In my case, and with the benefit of hindsight, it started with a couple of “time outs”. In one case I was driving along a route I had travelled maybe a couple of hundred times before: I suddenly realised that I had overshot a turning. The second time I was walking along a road, again one I had walked along many times before, and realised that I wasn't where I should be. Each incident lasted a few seconds, but the first could have led to a serious accident – fortunately it didn't. In neither case was there any prior suggestion that it might happen.

It's difficult to describe the the feeling. It's not the “deep in thought” one, where you know where you have been but haven't been paying attention. It's a complete blank – how did I get here? It's “I shouldn't have got here". Anyone who has been there will recognise it immediately: it won't make sense to anyone who hasn't.
 

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