helicopter marine pilot transfer (hmpt): lessons from the ... · • visual flight rules vfr –...

Helicopter Marine Pilot Transfer (HMPT):Lessons from the offshore Oil and Gas sectorCameron Ross Head of Aviation

OverviewKey definitions • IOGP – International Association of Oil & Gas Producers.• HeliOffshore – industry association dedicated to safety of offshore operations• Controlled Flight Into Terrain/Water CFIT/CFIW – an airworthy aircraft is unintentionally flown into terrain or water.• Visual Flight Rules VFR – regulations governing flight under weather conditions clear enough for flight crew to use visual reference.• Instrument Flight Rules IFR – regulations governing flight under conditions in which flight using outside visual reference is not safe.• Night VFR – regulations governing flight primarily by outside visual reference performed at night.• BARSOHO – Basic Aviation Risk Standard for Offshore Helicopter Operations – a contractable standard used by the Resource Sector.

220 September 2018

Helicopter marine pilot transfer lessons from the Oil and Gas Industry

OverviewPlan• Review a sample of relevant industry accidents analysed by the offshore oil and gas sector to enhance offshore aviation safety.• Provide summary of controls in place today as a result of offshore oil and gas sector’s quest to learn from events.• Refer to past IOGP study relevant to Helicopter Marine Pilot Transfer.• Introduce the concept of industry ownership of aviation safety as a means of driving standards up.• Introduce actions for the Marine Pilot Community to consider.

320 September 2018Helicopter marine pilot transfer lessons from the Oil and Gas Industry

OverviewPurpose Introduce ‘Chronic Unease’ to the Helicopter Marine Pilot Transfer Community

Chronic Unease:- The experience of constant discomfort and concern about the management of offshore helicopter risk. - Having a healthy scepticism about decisions associated with what we have put in place to manage this risk. - Is it the best we can do? Can we do better to prevent and accident and save lives? - Constantly asking ourselves ”What could possibly go wrong”?


Offshore helicopters in Australia – early industryVH-UTW Barracouta Platform 22 March 1968• Three fatalities, seven injuries.

• Single pilot.

• Single engine.

• Fixed floats.

• No helideck management.

• No industry or regulatory oversight of offshore operation.

• No contract oversight by company.


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Failure of tail rotor pylon VH-UTW Barracouta March 1968: Source DCA Report 1968

25 July 1990 Infrastructure - obstacle strikeG-BEWL S-61N Brent Spar UK North SeaHelicopter was manoeuvring to land on the Brent Spar a permanently moored semi-submersible.

Tail rotor contacted a hand rail attached to the crane structure. The aircraft impacted helideck and spun overboard.

Seven survivors. Six fatalities.

Critical Control Failure: Infrastructure / AircraftIntrusion of the crane structure into the limited obstacle sector.

Helideck markings not drawn to scale, D-value 11% smaller.

Seat design and restraint system.

What the offshore oil and gas sector learned/confirmedGreater adherence to helideck obstacle standards, CAP 437.

Improved seat design and inclusion of upper torso restraint system.


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Brent Spar 25 July 1990: Source AAIB Report 2/92

14 March 1992 Controlled flight into waterG-TIGH AS332 Super Puma Cormorant Alpha UK North SeaHelicopter shuttling from production platform to nearby ‘flotel’.

1950hrs local, darkness, wind 55 knots heavy sea state.

Five survivors. Eleven fatalities (five had survived the initial impact).

Critical Control Failure : PersonnelHuman factors - failure to recognise changing relationship between airspeed and ground speed – turning downwind.

Human factors - fatigue, non-flying workload (administration).

What the offshore oil and gas sector learned/confirmedAmend CAP 437 to standardise Pitch and Roll reporting.

Installation of automatic flotation equipment on aircraft.

Develop adverse weather policy for all operations.

EXIS lighting, Life Jacket crotch straps, HUET, Survival Suits. Externally mounted liferafts.


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Location of Cormorant Alpha: Source AAIB Report 2/93

1992 Blade Strikes - personnel

G-BOND and G-BLEZ UK North Sea18 April 1992 G-BOND S76A+ Seas rough, and large wave hitting stern moved aircraft and exacerbated pitch and roll leading to main rotor strike on Helideck Landing Officer (HLO).

22 Sep 1992 G-BLEZ 365N Dauphin Victor Bravo (fixed) platform SNS. Helideck Deck Assistant (HDA) fatally struck by main rotor blade.

Critical Control Failure : PersonnelHuman factors – failure of flight crew to manually control disc attitude whilst looking outside.

Human factors – use of A4 sized clipboard on right thigh adjacent cyclic control.

What the offshore oil and gas sector learned/confirmedOne member of the flight crew guarding controls (head-up) and not doing paperwork or administration (head-down).

Better two-way radio communication with helideck personnel.


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Crew change: Source HeliOffshore

10 April 1998 Controlled flight into waterVH-WCQ Bell 206B3 Single Pilot MPT 22KM NW Dampier Australia0515 local time in total darkness (zero moon) aircraft flew into ‘mirror-like’ water surface as single pilot was trouble-shooting tail rotor issue.No instrument rating. Flight was conducted under Night VFR.Pilot commenced Night MPT passenger carrying operations one-month prior to the incident.Critical Control Failure : PersonnelHuman factors – failure to visually determine aircraft attitude.Environmental – validity of Night VFR requirements for over-water helicopter operations.What the offshore oil and gas sector learned/confirmedAll black is the same as all white. Instrument rating essential.Two crew a requirement for offshore.Helicopter Terrain Awareness and Warning Systems (HTAWS).


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Dampier - East Intercourse Island

26 December 2000 Suspected Controlled flight into waterN83137 Bell 206B Single Pilot High Island Gulf of Mexico USA2130 local time in total darkness (zero moon) aircraft and single pilot went missing on flight to destination platform during freight flight. No instrument rating. Aircraft not equipped for instrument flight. Flight was conducted under Night VFR. Cloud Base 700 feet. Aircraft and pilot never foundCritical Control Failure : Personnel / AircraftHuman factors – no instrument rating.Aircraft – No satellite flight following. Not certified for instrument flight.What the offshore oil and gas sector learned/confirmedInstrument rating essential.Aircraft equipped for instrument flight.Two crew a requirement for normal and emergency scenarios.Satellite Flight Following.


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Gulf of Mexico (GoM)

8 September 2005 Controlled flight into water

F-GYPH Dauphin 365N3 Single Pilot Le Havre FranceThe aircraft impacted the water in the English Channel 18 km from Le Havre during a night MPT approach to a vessel.

The single pilot was not wearing a survival suit, life jacket nor was he strapped into his seat prior to impact.

Pilot fatally injured and marine pilot passenger not recovered.

Critical Control Failure : PersonnelHuman factors – failure of pilot to adhere to approach procedures.

Human factors – poor decision making with Night VFR

What the offshore oil and gas sector learned/confirmedTwo crew operations to aid in Threat Error Management.

Discipline approach to use of survival equipment.

Establishment and use of Standard Operating Procedures.

Helicopter Terrain Awareness and Warning Systems (HTAWS)


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Accident location and transcript: Source BEA Report f-ph050908

27 December 2006 Controlled flight into water

G-BLUN AS365 Dauphin Morecambe Bay, Irish Sea UKCo-pilot became disorientated during dark night and poor weather.

Request to hand over aircraft to Captain, occurred very late (4 seconds after disorientation) - aircraft was already in an unusual attitude.

Seven fatalities no survivors.

Critical Control Failure : PersonnelHuman factors – failure of crew to identify early onset of spatial disorientation and provide timely take over.

What the offshore oil and gas sector learned/confirmedApproach Monitoring by non-flying pilot.

Helideck lighting green from yellow assists visual cues.

Simulator training for two-crew operations.

Weather observations required from trained observers/equipment.


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G-BLUN Main Rotor Head: Source AAIB Report 7/2008

23 August 2013 Controlled flight into waterG-WNSB AS332L2 Sumburgh Shetland Islands UK North SeaHelicopter was on approach to Sumburgh Airport coupled to the autopilot in 3-axis with vertical speed mode selected.Insufficient collective applied, resulting in decreasing airspeed and onset of high rate of descent. Intervention by crew too late to avoid impact with water. Aircraft rolled inverted.Fourteen survivors. Four fatalities.Critical Control Failure : PersonnelFlight Crew not following procedure or optimal use of automation. What the offshore oil and gas sector learned/confirmedDevelopment of Flight Crew Operating Manuals (FCOM).Helicopter Terrain Awareness Warning Systems (HTAWS).Category A Emergency Breathing Systems.SOPs for automation and 4-axis coupled approaches.External deployment of liferafts.Seating arrangements and window size.


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G-WNSB: Source AAIB Accident Report 1/2016

6 February 2017 Controlled flight into waterN978RH Bell 206B Gulf of Mexico (GoM) Helicopter departed oil tanker, operating night VFR (darkness).Aircraft impacted water at level attitude, likely to entered Instrument Meteorological Conditions (IMC) without pilot being aware. One fatality, two survivors.Critical Control Failure : PersonnelOperating Night VFR in Instrument Meteorological Conditions (IMC).No night flying time.What the offshore oil and gas sector learned/confirmedInstrument procedures required for night offshore flight.Night offshore experience essential.Two crew for night offshore flight.RADALT, TAWS, automatic floats, ADELT, external liferafts.


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N978RH: Source NTSB

IOGP Study - 2008


Source: IOGP Risk management approach to night offshore operations

IOGP Study - 2008



IOGP Study - 2008



Since 2008 offshore industry has added:

HTAWS (enhanced from TAWS with specific offshore modes).

CAT A EBS for hostile environment (includes night).

Seating correlated to window/door size to aid evacuation.

Industry standard for offshore helicopter operations


Source: Flight Safety Foundation

What good looks like in comparable industries


Wind Farm Industry: Source Airbus Two-crew, twin engine, weather radar, float equipped, etc: Source Airbus

And the results?


Considerations for the marine pilot communityWork as an industry to drive standards up• Learn from the past 50-years of offshore oil and gas helicopter accidents.

• Adopt a common industry offshore helicopter standard that becomes referenced contractually. Levels the playing field.

• Follow emerging industries such as offshore wind farms who have adopted offshore oil and gas aviation standards.

Treat flying Night Offshore as an IFR environment • No moon, no stars equals no horizon and no visual surface light reference - does not meet regulatory definition of VFR.

• Accept and understand Night VFR offshore is a contradiction. It does not exist.

Insist on Two-Crew Operations – Day and Night• Adopt actual two-crew operations. Simulator training as a crew. Defined crew procedures driven by disciplined use of SOPs.

• Alternating single pilot by day and two pilot by night falls well short of best practice and has safety implications.

Insist on aircraft meeting all industry standard requirements for offshore helicopters• Manual and automatic deployable floats, HUMS, FDM, HEELS, UTR, HTAWS, Dual Radalt*.* Health and Usage Monitoring Systems/Flight Data Monitoring/Helicopter Emergency Egress Lighting System/Upper Torso Restraint/Helicopter Terrain Awareness and Warning System/Radio Altimeter

Talk about next steps (not if but when) • Category A Emergency Breathing Systems (EBS) and Night Vision Imaging Systems (NVIS).


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