Analysis of Helicopter Accident Offshore-04 Nov 15.
Dauphin Helicopter was involved in an accident while operating a night training flight on 4th November 2015 from WIS platform to a rig.
The flight was a training flight with an examiner occupying the left hand side seat and the trainee (pilot under check) was occupying the right hand side seat.
Examiner had 27 years of flying experience with almost 19588 hrs. of flying mainly in offshore operations. Pilot under check had 6700 hrs of total flying experience with 4115 hrs on type. He had about 190 hrs of night flying and had flown by night almost one year before and was due for Night flying check.
On 04 Nov 15, the helicopter planned night training flying and took off from WIS helipad at 1910 hrs. At the time of take-off, the weather information (winds) communicated to the flight crew was 015°/10 knots.
The helicopter made an approach to land on Ron Tappmeyer but as the helicopter was high on approach, it made a go around and banked to the left. Simultaneously it descended and few seconds later the helicopter crashed into the sea. Both the crew suffered fatal injuries.
The position of Ron tappmeyer was to the south extremity of the South field with no other rigs nearby to provide ambient lighting. As per the AIS and FDR the tail wind approach was made with speed of approximately 79 kts. This high speed approach would have caused an abrupt loss of visual reference.
The pilot on controls was flying during night after break of nearly a year. The fact that it was a dark phase of moon made this even more challenging. Some amount of dusk flying on instruments would have prepared the pilot flying for undertaking the night flying profile/ maneuvers. As soon as he got airborne and set course for Ron tappmeyer, the pilot flying has probably entered conditions ideal for black hole phenomenon because of loss of horizon as is corroborated by CVR replay. Under such conditions he was not aware about the direction he was proceeding to i.e. up or down / turning right or left. The pilot flying probably continued to fly visually instead of getting on to instruments. Therefore on initiating the go around after realizing that he was high he entered into spatial disorientation extremely quickly. The instructor was not disoriented and was aware that the helicopter was low. He had cautioned, (though delayed), the pilot flying twice. He however did not realize that the pilot flying was in total state of spatial disorientation and was unable to react to his caution. Nor did he take over Controls.
Offshore training is being carried out without a written programme. There is no procedure or control on conduct of training and PIC is left to decide all aspects of the flight. In this particular flight the marine radio officer/ AME were not aware of the flight profile. As per the CVR the radio officer enquired about the flight profile when flight crew was preparing to start up. Further as one of the crew had a break in night currency it would have been Prudent to carry out some amount (0:15 minutes) of dusk flying prior to night flying including a few approach/ landing at WIS platform before proceeding to Ron tappmeyer.
As per the CVR, the helidecks selected for night training were rig Ron tappmeyer and floater vessel Samudra Sevak. These were not ideal platform for initial night training due to poor surrounding ambient lighting and Sevak being a floater is an unstable deck.
The committee was not provided any other requirement either from DGCA or from ONGC wherein requirement of helidecks safety audit/ surveillance/ inspection are laid down. The committee during course of investigation visited SLQ and EE production platform to which Ron tappmeyer was attached on the night of accident. The condition of the both the helidecks surfaces were found rusted with rust flakes coming out at a number of places. The matter was discussed with DGM (Aviation safety) who, as per him carries out inspection of helidecks for their condition and safe operation of helicopters, though there is no system/ procedure developed for the purpose. Pawan Hans also have not carried out any inspection/ audit of the helidecks, though it should have been carried out under SMS. The system of HAC is not effective as there was no close loop mechanism for taking action on the hazards raised. From the regulatory point of view there are no laid down requirements of periodicity of the safety audits of helidecks or system of action taken reports to ensure compliance on the deterioration observed on the safety standards. There is an urgent need to have formal regulation on the subject, similar to CAP 437 with inbuilt check & balance provisions between the helicopter operators and the installation (rigs etc.) owners.
It was observed that normal check list was not carried out by following challenge and response procedure.
The CVR readout brings out a lack of adherence to standardized checks and procedures and communication protocol between the crew. While the pilot on controls decided to go around, both pilots, perhaps, continued to fly VFR. Pilot monitoring displayed lack of situational awareness by not taking over controls. The crew thereby failed to engage in the important process of CRM.
The SMS manual has not been revised since initial issue in 2014, inspite of the fact that various changes in organisation setup have taken place. Neither there was any Risk Assessment carried out for any of these changes. Safety Communication through meetings, seminars and bulletin etc along with Safety Training has been stated as a major way to achieve the goal of Safety Promotion. No safety circular or bulletin has however been issued during last 2 years. Safety training is required to be provided to all staff with refresher each year, but it was found that even initial training has not been completed for all the employees as mentioned in the Manual.
The SMS Manual further requires that the Flight Safety Document system shall be reviewed at least once a year but it was not carried out even once. It was informed that for a period of almost a year prior to the accident, actions such as review of Flight Safety Manual, Safety Management System Manual and record keeping on key performance indicators, training of PHL executives, pilots, AMEs and other staff were not conducted though it was required as per regulations. There was no key performance indicator specific to the offshore operations.
The Helicopter Underwater Escape Training (HUET) for the PIC was not current on the date of accident. As per the existing SOP, in addition to the standard Night Flying Procedures, before landing on a Rig/Floater, a dummy circuit must be carried out and pilot monitoring must call out bank during turns; and
speed & ROD during approach. The emergency floatation gear switch was not armed as the crew was not planning to carry out ditching so the floatation gears have not inflated.
The training manual available with the WR was not having any date of issue though it was approved by the DGCA in as it is condition. In WR the same flight crew personnel (DGM Level) was holding the posts of DGM Training and DGM Ops. The SMS manual though accepted by DGCA does not contain ‗How to
do‘ the various functions mentioned therein. The Manual just remains a document without performance of any function at working level. There is no SOP for carrying out night offshore training. There are some references in the SOP issued for Night Ambulance Operation. There is no document indicating procedure of taking weather (off shore) and transmitting the same to flight crew. The flight crew operating in offshore is not provided with accurate information on the
visibility, cloud ceiling and cloud base. Earlier Committees of Inquiry have recommended ―establishment of strong safety department‖ but it was observed that the operator has not established the safety department in true letter and spirit. It is still continuing on ad-hoc basis and full fledged department is yet to be
Paras 3 & 4 of Subpart D – Special Helicopter Operations under PART 2 – OPERATIONS of CAR – Section 8, Series ‘H’ Part I on Commercial Helicopter Operations regarding flight rules, night offshore operations and corresponding training / recency requirements are ambiguous. The cross-country requirement of ―route flying check sortie by night‖ in Para 4.5 (Page 4-B-3) of DGCA CAR Section 8, Series H, Part I is not being complied by offshore operators as required.
There is no documented safety system or procedure with ONGC to ensure Safety Assurance particularly for helidecks audits, certification
and periodic inspections.
No specific training for handling communication and traffic of helicopters is given to the marine radio officers.
The training records of the flight crew is just a record keeping exercise without any system or procedure in place to review the observation of the instructor / examiner for monitoring the progress of the flight crew. There is no system to identify the observations made by the SFIs in their reports and depute the crew members accordingly for the various special operations being conducted by PHL. Flight Plans are filed with Bombay FIC only for flights taking off/landing
back at Juhu from Bombay High. The major portion of Bombay High Oil field is class G airspace and no flight plans are filed for flights within this region.
The Marine Radio officers provide information of position of Helicopters and Transmit wind direction/velocity to the flight crew. They are neither authorised nor competent to ensure requisite separation between the helicopters
The deficiency existing on the Helidecks were reported by the operator however no closed loop system exists to make these good in a timely effective manner.
DGM (AS) ONGC is supposed to carry out all the proactive safety oversight activities including inspection of flight decks and physical inspection of helicopters but is not trained on any of the aspects.
Many recommendations made by the earlier courts / committees of inquiry having operational safety implications are yet to be implemented by the Operator in true spirit. Even the actions taken on the recommendations have withered away with passage of time due complacency and non-supervision. Due to non-availability of senior level operational personnel and adhocism, there is no supervision of operational activity. The Operator positions a helicopter in Bombay High for the purposes of night medevac, however no SOP has been developed for undertaking night offshore operations at helidecks, particularly in the absence of night landing aids.
The pilot on controls was flying during dark phase of moon at night after break of nearly a year.
Some amount of dusk flying on instruments would have prepared the pilot flying for undertaking the night flying profile/ maneuvers. Before the descent and until the autopilot disconnection, the recorded parameters were nominal.
The helicopter made a tail wind approach with speed of approximately 79 kts for Ron tappmeyer which is to the south extremity of the South field with no other rigs nearby to provide ambient lighting which caused an abrupt loss of visual reference. During the descent and before the helicopter started to turn left, the
parameters were consistent with a standard approach procedure associated with a speed decrease by pushing slightly down the collective stick and nose up the helicopter.
The left turn was 50 seconds long with slight variations in roll attitude. The lateral acceleration remains between -0.03 and +0.09. The corrections did not lead to a roll attitude less than 12° to left After the Autopilot disconnection, the pilot was ―hands on and the attitude of the helicopter was consistent with the inputs on the flight commands.
No specific pilot inputs were recorded, except actions on the collective pitch in the last second of the recording. The pilot flying has probably entered conditions ideal for black hole phenomenon because of loss of horizon wherein he was not aware about the direction he was proceeding to i.e. up or down / turning
right or left.
The pilot flying probably continued to fly visually instead of getting on to instruments, therefore on initiating the go around after realizing that he was high he entered into spatial disorientation extremely quickly.
The instructor cautioned, (though delayed), the pilot flying twice but did not realize that the pilot flying was in total state of spatial disorientation and was unable to react to his caution. The PIC did not take over controls when the helicopter descended below critical height.
No warnings were recorded in the flight data during the flight of the event.
The helicopter impacted into the sea at high velocity, as
- The pilot on controls, who had a long break in night offshore flying, got into complete spatial disorientation, as a result of black hole phenomenon, while approaching a helideck at high speed in tail winds on a dark night, and
- The PIC did not take over controls when the helicopter descended below critical height.
Analysis by ASMSI
The main cause of the accident was Spatial Disorientation, loss of Situational Awareness and consequent Controlled Flight Into Terrain.
- Knowledge about Spatial Disorientation.
- Alertness, Vigilance.
- Pre Flight Planning, Preparation and Briefing.
- Adherence to SOP’s.
- Lack of Safety and Professional Culture in the Organisation.
Due to high level of experience of the Instructor (almost 20000 Hrs), most of which was in Offshore Operations, there appears to be sense of complacency on the part of the Instructor.
The Instructor was aware that the Helicopter was losing height and bank angle was increasing since he cautioned the Trainee Pilot about the same twice. However, for reasons unknown, he did not take over control and allowed the helicopter to impact sea. May be by the time he realized the situation, the Helicopter was almost nearing point of impact and even if he tried to take over control, it was too late.
Although the Pilot under training was also well experienced yet he had not flown by night since last one year. Hence, it was his night currency flight with the Instructor. One year is a long time and the Instructor should have done the training by night on shore before proceeding to Offshore on Helidecks which were suitable. However, the Instructor decided to undertake the training on the helideck which was more challenging than the other helidecks in the vicinity, which could have been selected.
The approach was made in tail winds and the approach was overshooting due to which, the Trainee Pilot decided to go around.
The Instructor appeared to be quite relaxed with the knowledge that he was flying with a well experienced Pilot of same age as him. Hence, although the Instructor twice cautioned the pilot about loss of height and increasing angle of bank yet he was not assertive enough to tell the Trainee Pilot to take corrective action and even failed to take over the controls in time to prevent the accident.
It appears that there was lack of proper preflight briefing, planning, and preparation, assessment of risk factors and sense of complacency seem to prevail.
Keeping in mind the fact that the Instructor was highly experienced in offshore flying including night operations, none of the Supervisor (that is Head of Training and Head of Operations) felt the need to involve in the planning and briefing of the Crew for the Flight.
There were no proper SOP’s and Training Manual also had not been prepared in a professional manner.
The Coordination between the Crew, AME and the Helideck Flight Operations staff was lacking to such an extent that the AME and Helideck Flight Operations staff was not even aware of the planned training flight before the Helicopter asked for startup.
The Operator does not seem to have learnt any lessons from the past accidents and the action on the recommendations of the Inquiry Team on the past accidents had not been implemented.
The Safety Culture of the Operator was lacking which is clearly evident in improper implementation of SMS, casual approach towards preparation and implementation of SOP’s, Training Manual, absence of CRM and absence of supervision, coordination and monitoring.
- No amount of experience is enough to operate safely unless the Pilots properly Plan, Prepare for the Flight, conduct extensive Pre Flight, Descent and Approach briefing, carry out risk assessment, have good knowledge about helicopter, its systems, Emergencies, Procedures, enroute and approach charts, remain alert vigilant particularly during critical phases of the Flight and not be complacent at any stage, particularly during high risk operations, like night flying offshore.
- More the experience, more the chances of complacency setting in and this aspect must be kept in mind by experienced pilots.
- The Instructor or the Co Pilot should be fully alert and involved during the flight particularly when the flight operations are demanding and they should take over controls in time since any delay can be dangerous.
- Spatial Disorientation (SD) is one of the most important factor while flying offshore since chances of SD are quite high while flying over sea even during day time and the probability factor of SD multiplies with bad weather and night offshore operations. This aspect must be adequately emphasized during Pre Flight briefing.
- It is essential to keep in mind the long gap between the night currency and any other currency and the Instructor must take the training more seriously rather than going through the motions.
- Experience of the Instructor and the Pilot under Training should not influence the mind of the Supervisors and the Pilots, to take the training in a casual manner.
- Pre Flight briefing, Pre Descent and Approach Briefing are essential requirement for better Situational Awareness (SA) and the Instructor/Captain should conduct the same with seriousness it deserves.
- The Operator must take adequate steps to improve its Safety Culture through Proactive Hazard Identification, sincere implementation of SMS,proper development and periodic review of SOP’s, Manuals, involvement of Top Management including Head Training,Operations,Flight and Maintenance Safety.
- Adequate emphasis must be given on Simulator and Ground training. The objective should be on quality of training rather than tick the box syndrome which prevails among most of the Operators and Pilots. Remember the purpose of any training is to promote safety and efficiency of the Operations and as such, the training must be taken seriously.
- There should be proper coordination and briefing about the conduct of Operations/Training between the Operator, Pilots, AME’s and the Helideck Operations Staff.
- The periodic Audit of the Helidecks must be carried out as per CAP 437 provisions and the hazards observed must be disseminated to all the Operators, Pilots and the Hiring Agency. The Hiring Agency should respond on priority, to ensure that the Helidecks meet the standards and observation by the Operator/Pilots are attended in time.
- The recommendations on the past accidents/incidents must be implemented by the Operator without any delay and the accountability of the Accountable Executive must be duly emphasised and enforced.