It is important to remember that ultimately responsibility for this avoidable accident is going to come down to the actions of individual persons, be they flight crew, operations personnel, or people in management positions. And from currently available information it is very hard to see how the flight crew of
R116 are not going to be primarily culpable.
The first choice the commander made was to use the APBSS approach to Blacksod, and one has to ask why. What sort of approach was it? What was it for? If it was intended as an IMC let down procedure, what was the MDH and where? The information in the Preliminary Report didn’t make any reference to any such information. Before departure from Dublin the crew clearly should have established what the nature of this approach was and whether it was suitable for their approach to Blacksod that night. The forecast weather was poor – they should have been expecting the 300-400ft cloud base and 2-3km visibility it probably was. And at night. The APBSS approach chart had 282 by the first BLKMO (Blackrock) waypoint, and the approach accompanying notes identified Blackrock lighthouse with a height of 310’. The lack of a database entry is a red herring – the world is too big and too prone to change at low level, whether with wind turbines, vessel masts or anything else up to 500ft, for databases to be relied on outside IFR approaches. As it said on the tin.
So how could the crew of R116 have thought it was a good plan to let down to 200ft in those conditions and head towards this first waypoint, level at 200ft? And even more bizarrely, when this point was 10 nm from their destination? The commander’s understanding of the terrain seems inadequate – she knew there was an island there as she commented on it when the crew got an altitude alert 26 seconds before impact. However the rocks they were flying over that triggered the alert were not Blackrock, but some lesser rocks 0.65nm before. So it seems she knew that BLKMO was not just a point in space, but an island landmark, presumably of - to her - unknown height, yet she still planned to fly over it at night in pretty much IMC conditions at 200ft….. It seems that had the flight crew read the approach notes, they would have realised that the island BLKMO had a height of 310’ Or 282’ had they interpreted the chart number as a height - which surely any sensible person would have done, certainly until proved otherwise.
Admittedly it also appears that the approach information was not sufficiently clear and comprehensive, which was largely an operators’ responsibility. But why descend to 200ft? Was it because the APP1 mode on the AFCS they had available did this by default? Did they follow a poor procedure not designed for the task that night with a recognised AFCS mode without adequate thought and consideration? Seems likely to me.
As several have said too, the other major pilot error was the reaction to the recognition by the rear crew member of Blackrock island, by maybe radar or IR, and instruction to avoid. Transiting at 200ft above the sea on a misty night over known rocks should have had the crew on high alert, yet the whole process of observation, identification, course change instruction and implementation was far too slow and vague. From the avoid instruction, to hitting Blackrock. took 13 seconds. Allowing say 3 seconds pilot reaction time, that gives 10 seconds to effect immediate emergency avoiding action. The fastest way to do that would have been to uncouple and instantly either climb at say 1500ft /min, or bank at say 30 degrees. But it took a fatal 10 seconds of questioning and double checking before the heading bug was turned and the aircraft reacted, and by that time it was all over. With a climb at 1500ft/min they would have cleared Blackrock by 150ft if they’d gone straight over it. Or missed it with an immediate turn. Or a combination of both.
Something that I have never seen discussed is just how the Sligo primary mission S92 approached Blacksod for fuel, an hour or so before. It had the same operator and same aircraft. One assumes that whatever they did worked fine, in which case why did R116 not do the same thing? Or even discuss the approach with R118 before they set off, if R116 was not familiar?
Overall, there will always be situations, in SAR surely more than anything else, when SOPs will not cover the task in hand, or be appropriate, or things will just go wrong for all sorts of reasons. And in these cases we need crews to be able to think intelligently and make sensible decisions that are likely to involve basic flying skills that we learn in our early training, whether VMC or IMC. It is important this is realised, pilots preserve these skills and are open minded to implement them when necessary. And – yet again – not just follow the magenta line.