04-12-2025, 07:26 PM
(This post was last modified: 04-13-2025, 06:53 AM by Kharon.
Edit Reason: Missed a bit out - bladder pressure.
)
Should have turned left at Albuquerque.
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Nearly made that left at Alboquirky – nearly....thought about it – but Nah...
ATSB 1- “At 1356:06, as XKQ climbed while tracking approximately south, and XH9 descended while tracking approximately east-south-east, the helicopters collided. The height of the collision was estimated to be 39.6 m (130 ft) above ground level, and around 155 m west-north west of the heliport.”
ATSB 2- “Evidence existed that the pilot experienced stress a week before the accident. The pilot’s family members recalled the pilot worked long hours, had many work responsibilities, and had reported being under a lot of pressure at work, and provided verifiable examples of the demands the operator placed upon the pilot. Email, telephone billing records and other information showed the pilot often worked outside of their rostered hours.”
ATSB 3- “The ACAS systems that XH9 and XKQ were fitted with did not announce traffic to the pilot below 380 ft (XH9) or 400 ft (XKQ). That meant any company traffic on approach or departure would not be provided to the pilot unless the pilot referred to a visual display.” NO COMMENT!@#
The ATSB have, IMO, not done too bad a job of this 'investigation'. The sheer volume of 'Safety Issues' underscore their concerns; and. the 'findings' carry some serious items for consideration. Well done, even if slightly over cooked. However, having spent some time with the report now there are a couple of items which, again, IMO, could have been exploited. But that would then become 'opinion' rather than report; so no points deducted for that. However: for consideration -
ATSB 2 : No surprise; a GA pilot often working outside of roster hours. No one minds the odd call after hours. Mostly 'management' pilots will grab a coffee and re-work a section of a manual or procedure, a one off, during a day off, or an idle hour; no biggy. However. When there is a company 'need' for revision after audit, or a new type coming on line, or new procedures etc. Well, sometimes the workload becomes fatiguing, can even generate some resentment. There exists a 'real' human factor here which demands some serious consideration, for some very real reasons. Bear in mind that the 'words' drafted into 'operational documents' carry a very real 'legal' liability', the average Mutt drafting 'stuff' to go into a SMS or Ops Manual is trading in good faith. As the ATSB report clearly demonstrates, that which is written (for the guidance of wise men and the obedience of fools) can, and most likely will become 'evidence'. Pressure – you bet.
While on the subject of 'pressure' there is one particle which rings a small bell. The day was, for the company huge in terms of 'revenue'. Always desperately needed and with a huge crowd queued up for a five minute 'thrill' it was important to work the ass very hard, to gather in the money harvest. I wonder at the 'fatigue' score, I wonder at the hydration levels and the blood sugar. Hot, sweaty, busy as hell – break from duty; food eaten and digested; rushed procedures loading (why were the pilots loading passengers?). It begs questions of the residual 'operational' capability of the flight crews. Just saying – but I've been there, seen that in action. Fatigued and stressed before the operation; flogged during; far from lunch and air conditioned break. Being 'good lads' and liking their job, the extra mile was run. I've no idea if this was a factor; but, I'd have liked the ATSB to have at least nodded to the 'human factors' involved. Odds on bet in my book....
Item last: Take a moment to consider this picture :-
![[Image: AO-2023-001-Figure%20%284%29.png?itok=uWe8RsmS]](https://www.atsb.gov.au/sites/default/files/styles/wide/public/2025-04/AO-2023-001-Figure%20%284%29.png?itok=uWe8RsmS)
Then, place yourself in the Right seat of either Chopper, both making left turns - as ATSB proved; you cannot see a bloody seagull coming at you from the 'blind side'. Why not change the route to accommodate this glaring safety oversight? Why not ONE WAY circuits, take the conflict points away? Where was the much vaunted (and advertised and exaggerated) CASA operational oversight? Carefully not referenced, new operation, new type - I wonder why?
My apologies for 'banging on' but IMO, this event was completely avoidable and yet it tragically highlights so much of what is 'missing' in the current 'safety' thinking. Only my humble etc; and, happy to stand corrected, but, bring your best game with you. I'm cranky (ish)...
That's me done; my glass is empty, bladder full (to screaming) – time to find my boots (pup likes to hide 'em) and amble off into a lovely late summer night, watch the Flying foxes, find a log and sit a while; maybe even have an illicit smoke (or two)..
Selah...
-
Nearly made that left at Alboquirky – nearly....thought about it – but Nah...
ATSB 1- “At 1356:06, as XKQ climbed while tracking approximately south, and XH9 descended while tracking approximately east-south-east, the helicopters collided. The height of the collision was estimated to be 39.6 m (130 ft) above ground level, and around 155 m west-north west of the heliport.”
ATSB 2- “Evidence existed that the pilot experienced stress a week before the accident. The pilot’s family members recalled the pilot worked long hours, had many work responsibilities, and had reported being under a lot of pressure at work, and provided verifiable examples of the demands the operator placed upon the pilot. Email, telephone billing records and other information showed the pilot often worked outside of their rostered hours.”
ATSB 3- “The ACAS systems that XH9 and XKQ were fitted with did not announce traffic to the pilot below 380 ft (XH9) or 400 ft (XKQ). That meant any company traffic on approach or departure would not be provided to the pilot unless the pilot referred to a visual display.” NO COMMENT!@#
The ATSB have, IMO, not done too bad a job of this 'investigation'. The sheer volume of 'Safety Issues' underscore their concerns; and. the 'findings' carry some serious items for consideration. Well done, even if slightly over cooked. However, having spent some time with the report now there are a couple of items which, again, IMO, could have been exploited. But that would then become 'opinion' rather than report; so no points deducted for that. However: for consideration -
ATSB 2 : No surprise; a GA pilot often working outside of roster hours. No one minds the odd call after hours. Mostly 'management' pilots will grab a coffee and re-work a section of a manual or procedure, a one off, during a day off, or an idle hour; no biggy. However. When there is a company 'need' for revision after audit, or a new type coming on line, or new procedures etc. Well, sometimes the workload becomes fatiguing, can even generate some resentment. There exists a 'real' human factor here which demands some serious consideration, for some very real reasons. Bear in mind that the 'words' drafted into 'operational documents' carry a very real 'legal' liability', the average Mutt drafting 'stuff' to go into a SMS or Ops Manual is trading in good faith. As the ATSB report clearly demonstrates, that which is written (for the guidance of wise men and the obedience of fools) can, and most likely will become 'evidence'. Pressure – you bet.
While on the subject of 'pressure' there is one particle which rings a small bell. The day was, for the company huge in terms of 'revenue'. Always desperately needed and with a huge crowd queued up for a five minute 'thrill' it was important to work the ass very hard, to gather in the money harvest. I wonder at the 'fatigue' score, I wonder at the hydration levels and the blood sugar. Hot, sweaty, busy as hell – break from duty; food eaten and digested; rushed procedures loading (why were the pilots loading passengers?). It begs questions of the residual 'operational' capability of the flight crews. Just saying – but I've been there, seen that in action. Fatigued and stressed before the operation; flogged during; far from lunch and air conditioned break. Being 'good lads' and liking their job, the extra mile was run. I've no idea if this was a factor; but, I'd have liked the ATSB to have at least nodded to the 'human factors' involved. Odds on bet in my book....
Item last: Take a moment to consider this picture :-
Then, place yourself in the Right seat of either Chopper, both making left turns - as ATSB proved; you cannot see a bloody seagull coming at you from the 'blind side'. Why not change the route to accommodate this glaring safety oversight? Why not ONE WAY circuits, take the conflict points away? Where was the much vaunted (and advertised and exaggerated) CASA operational oversight? Carefully not referenced, new operation, new type - I wonder why?
My apologies for 'banging on' but IMO, this event was completely avoidable and yet it tragically highlights so much of what is 'missing' in the current 'safety' thinking. Only my humble etc; and, happy to stand corrected, but, bring your best game with you. I'm cranky (ish)...
That's me done; my glass is empty, bladder full (to screaming) – time to find my boots (pup likes to hide 'em) and amble off into a lovely late summer night, watch the Flying foxes, find a log and sit a while; maybe even have an illicit smoke (or two)..
Selah...