Flight crew incomplete monitoring the norm, crash inquiry is told

Incomplete monitoring of instruments by flight crew is “the norm” among pilots due to how the human brain works, an inquiry into a fatal helicopter ditching that claimed four lives has heard.

Steve Jar vis, an expert on human factors in the aviation industry, said the monitoring of instruments by flight crew had arisen as an issue in many helicopter crashes, but normally the resilience of the system helped protect the aircraft.

Two crew and 12 passengers on the Sup er Puma L2 survived when it ditched on its approach to Sumburgh Airport in Shetland at 6:17pm on 23 August 2013.

But Sarah Darnley, 45, from Elgin, Mo ray; Gary Mccrossan, 59, from Inverness; Duncan Munro ,46, from Bishop Auckland, Count y Durham, and George Allison, 57, from Winchester, Hampshire, all died in the incident.

Mr Jar vis said pilots could suffer from “vigilance decrement ”, which is when it becomes harder for them to remain vigilant over time when monitoring instruments. The research scientist said it could also be difficult for them to maintain attention when looking at autopilot.

An AAIB report published in 2016 found the pilots failed to properly monitor the flight instruments and failed to notice their speed was decreasing until it was too late to avoid the Super Puma plunging into the sea.

Sheriff principal Derek Pyle, who is hearing the fatal accident inquiry( F AI) asked: “What we are talking about is incomplete monitoring, are we not?”

Mr Jarvis replied: “I suppose we are, but what I’m suggesting and what I’ve seen in my research is that incomplete monitoring is actually the norm and the resilience of the system is what happens most of the time and that protects it.

“It’s not because the pilots are just getting degraded or anything. It’ s because deep inside the human brain things are happening which we have not really fully understood at this point and the aviation industry has been really good at making systems resilient enough to deal with that, but until we get an even better understanding that next tiny step probably won’t happen.”

Martin Richardson QC, who is leading the inquiry for the Crown, asked Mr Jar vis: “Should the issue of monitoring by the flight crew at Sumburgh be seen as an isolated incident?” Mr Jar vis replied: “No. One reason is that for many accidents and incidents monitoring has come up as an issue.” He said it was important to understand why pilots do not notice things.