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Jul
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2022
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Posted 2 years 151 days ago ago by Admin
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The title of this blog should be “Know your autopilot.” As an ATP examiner having tested and examined pilots from over twenty countries, I have seen my share of pilots miss-handle the autopilot both in the aircraft and in the Level-D flight simulator and get themselves into trouble. What I observed in most cases was the pilot flying would ‘punch off’ the autopilot just when they needed it most, mainly because they were not certain what the autopilot was doing. Whenever they hit the autopilot disconnect button, I called it the “I’m going to kill myself switch” and watch the fun begin.
The following is an accident report where the pilot let his autopilot get the best of him. Let’s use this incident as a learning experience for us all.
Air Ambulance Helicopter Struck Ground During Go-Around after NVIS Inadvertent IMC Entry (Mercy Flight, Bell 429).
At 21:10 Local Time on 6 October 2021, air ambulance Bell 429 of Mercy Flight was damaged near Genesee County Airport, Batavia, New York (midway between Buffalo and Rochester). Neither the pilot nor the three medical personnel onboard were injured. Mercy Flight is a not-for-profit air ambulance operator that has transported 30,000 patients over 40 years.
The Accident Flight
Information released by the US National Transportation Safety Board (NTSB) in their public docket on 4 January 2022 reveals that the aircraft had been tasked to collect a patient and deliver them to Strong Memorial Hospital, Rochester, New York. A short 10 minute third sector was necessary to return to their home base at Batavia-Genesee County Airport.
The pilot had been flying for 30 years, including flying for a Police Department, and most recently had flown for Mercy Flight for 5 years. He had flown 3583 hours in total, 621 on type and 1049 at night. He held an Instrument Rating. His instrument experience consisted of 11 hours actual and 49 simulated. He was working his usual 20:00—08:00 shift and awoken at 17:00 after a “good night’s rest”.
All three sectors were conducted using a Night Vision Imaging System (NVIS) and Night Vision Goggles (NVGs) in what were stated to be Visual Flight Rules (VFR) conditions. The pilot had checked the weather before the first sector but did not recheck at Strong Memorial Hospital “because it was clear”. The automated data at 20:50 for their destination was cloud at 1400 ft. and 10 mile visibility, 10ºC air temperate and a dew point at 9ºC.
As the helicopter neared the airport several occupants noticed “patches of fog” which they discussed over the intercom according to an interview with the pilot. Curiously, the brief narrative in the accident report form appears to contradict that by stating that no one onboard saw “the isolated fog bank” (although could relate to a specific patch of fog).
Once the airport was in sight the pilot terminated the radar service and self-vectored for “a practice RNAV-28 LPV approach, under VFR”. In interview with the FAA the pilot reported that the 4-axis autopilot was coupled and that the “runway and lighting was in sight all the way down the glideslope”. The pilot stated he “did not notice the fog” through the NVGs. The FAA interview states he did not ‘look under’ (i.e. below) the googles and it is surprisingly stated that looking below was “not normal”. This was not apparently challenged by the FAA interviewers.
An FAA interview summary then states:
At about 200 feet, he inadvertently entered a fog bank and lost visual reference to the runway. According to comments by the operator on the accident form, the pilot decided to hand-fly the aircraft “because of the close-proximity to the ground”. However, he attempted a climbing right turn to exit the fog, but forgot to totally de-couple the autopilot. He was able to momentarily climb above the fog, but was fighting the autopilot for control, and the aircraft descended back down into the fog bank, while drifting north.
During the attempted go-around, he made a radio call announcing the loss of visuals. Helicopter did not seem to be climbing as he pulled in collective. He managed to keep the aircraft level, and about 45 seconds later he impacted the ground, bounced, turned to the right and tried to climb, but was unable to and impacted the ground a second time, collapsing the skids.
The terrain was “flat farmland, with a treeline to the west and the airport fence line to the south”. The trees appear only one rotor diameter away from where the aircraft came to rest. The skids were subsequently found to be spread and the fuselage, tail stinger and nose wire cutter had contacted the ground. There was fuselage damaging and cracking evident. The operator, in the recommendation section of the report form, sensibly suggest that the “go-around feature of the autopilot could have been utilized” and ATT (Attitude Retention) mode was also an option.
The title of this blog should be “Know your autopilot.” As an ATP examiner having tested and examined pilots from over twenty countries, I have seen my share of pilots miss-handle the autopilot both in the aircraft and in the Level-D flight simulator and get themselves into trouble. What I observed in most cases was the pilot flying would ‘punch off’ the autopilot just when they needed it most, mainly because they were not certain what the autopilot was doing. Whenever they hit the autopilot disconnect button, I called it the “I’m going to kill myself switch” and watch the fun begin.
The following is an accident report where the pilot let his autopilot get the best of him. Let’s use this incident as a learning experience for us all.
Air Ambulance Helicopter Struck Ground During Go-Around after NVIS Inadvertent IMC Entry (Mercy Flight, Bell 429).
At 21:10 Local Time on 6 October 2021, air ambulance Bell 429 of Mercy Flight was damaged near Genesee County Airport, Batavia, New York (midway between Buffalo and Rochester). Neither the pilot nor the three medical personnel onboard were injured. Mercy Flight is a not-for-profit air ambulance operator that has transported 30,000 patients over 40 years.
The Accident Flight
Information released by the US National Transportation Safety Board (NTSB) in their public docket on 4 January 2022 reveals that the aircraft had been tasked to collect a patient and deliver them to Strong Memorial Hospital, Rochester, New York. A short 10 minute third sector was necessary to return to their home base at Batavia-Genesee County Airport.
The pilot had been flying for 30 years, including flying for a Police Department, and most recently had flown for Mercy Flight for 5 years. He had flown 3583 hours in total, 621 on type and 1049 at night. He held an Instrument Rating. His instrument experience consisted of 11 hours actual and 49 simulated. He was working his usual 20:00—08:00 shift and awoken at 17:00 after a “good night’s rest”.
All three sectors were conducted using a Night Vision Imaging System (NVIS) and Night Vision Goggles (NVGs) in what were stated to be Visual Flight Rules (VFR) conditions. The pilot had checked the weather before the first sector but did not recheck at Strong Memorial Hospital “because it was clear”. The automated data at 20:50 for their destination was cloud at 1400 ft. and 10 mile visibility, 10ºC air temperate and a dew point at 9ºC.
As the helicopter neared the airport several occupants noticed “patches of fog” which they discussed over the intercom according to an interview with the pilot. Curiously, the brief narrative in the accident report form appears to contradict that by stating that no one onboard saw “the isolated fog bank” (although could relate to a specific patch of fog).
Once the airport was in sight the pilot terminated the radar service and self-vectored for “a practice RNAV-28 LPV approach, under VFR”. In interview with the FAA the pilot reported that the 4-axis autopilot was coupled and that the “runway and lighting was in sight all the way down the glideslope”. The pilot stated he “did not notice the fog” through the NVGs. The FAA interview states he did not ‘look under’ (i.e. below) the googles and it is surprisingly stated that looking below was “not normal”. This was not apparently challenged by the FAA interviewers.
An FAA interview summary then states:
At about 200 feet, he inadvertently entered a fog bank and lost visual reference to the runway. According to comments by the operator on the accident form, the pilot decided to hand-fly the aircraft “because of the close-proximity to the ground”. However, he attempted a climbing right turn to exit the fog, but forgot to totally de-couple the autopilot. He was able to momentarily climb above the fog, but was fighting the autopilot for control, and the aircraft descended back down into the fog bank, while drifting north.
During the attempted go-around, he made a radio call announcing the loss of visuals. Helicopter did not seem to be climbing as he pulled in collective. He managed to keep the aircraft level, and about 45 seconds later he impacted the ground, bounced, turned to the right and tried to climb, but was unable to and impacted the ground a second time, collapsing the skids.
The terrain was “flat farmland, with a treeline to the west and the airport fence line to the south”. The trees appear only one rotor diameter away from where the aircraft came to rest. The skids were subsequently found to be spread and the fuselage, tail stinger and nose wire cutter had contacted the ground. There was fuselage damaging and cracking evident. The operator, in the recommendation section of the report form, sensibly suggest that the “go-around feature of the autopilot could have been utilized” and ATT (Attitude Retention) mode was also an option.
In conclusion, the autopilot is without question a valuable tool to aid in your workload when flying either in VMC or IMC conditions. However, if you are not 100% up-to-speed in fully understanding it’s operation then it can become a hindrance and even a danger to the safe operation of your aircraft. So practice using your autopilot often, even in VMC conditions so when the day or night comes when you really need it you will be more than comfortable with its operation.
About Randy:
Randy Mains is an author, public speaker, and a CRM/AMRM consultant who works in the helicopter industry after a long career of aviation adventure. He currently serves as chief CRM/AMRM instructor for Oregon Aero. He may be contacted at [email protected].
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