SAR S-92 Missing Ireland

[9Aplus]

Fully agree with RVDT
Coasts with many islands and rocks can be real challenge to any locator from standard
old 121,5 and on.
Sea environment and high waves is another problem.
On land GSM location from another aircraft can be useful technology.
On sea only sort of permanent tracking network can gain some time to rescue services.
Technologies like FR24, FLARM, OGN in some kind of voluntary networks can bring
some benefits, hopefully.

[dClbydalpha]

We're beginning to mix topics here. There is a difference between.
1) establishing that an aircraft incident has occurred and where.
2) finding an aircraft post incident.
3) finding personnel post incident.

I'll also add AIS is not limited to LOS.

[[email protected]]

I'll also add AIS is not limited to LOS. if it uses the growing number of satellites with a dedeicated AIS receiver, is it not technically S-AIS?

If VHF only then it is definitely LOS.

[dClbydalpha]

if it uses the growing number of satellites with a dedeicated AIS receiver, is it not technically S-AIS?

If VHF only then it is definitely LOS.

Technically all satellite comms involves at least two LOS segments, but generally satcom is considered BLOS.

AIS is VHF, and is relayed through satellites giving the system BLOS capability.

For ships there is no impact on installation, for aircraft the obvious has to be considered.

[Concentric]

For ships there is no impact on installation, for aircraft the obvious has to be considered.
And for remote lighthouses...?

[dClbydalpha]

And for remote lighthouses...?

Whatever is required, but
Would people need to track a lighthouse BLOS?

[satsuma]

I recall many Irish winch crew choosing not to wear their STASS bottles on their life jacket but stowing them close to their work station for use when required.

[IRCG SMC WHITEY]

Any one wishing to check tides for Blacksod Bay should consult the UKHO EasyTide site and navigate your way to Blacksod Bay.
Regarding rapid airspeed change circa impact time, could this be due to helo richocheting off Blackrock and electrics powering down?

[Concentric]

Whatever is required, but
Would people need to track a lighthouse BLOS?
What I was hinting at was that ships use AIS to avoid collisions. The fishing boat with injured crewman had AIS but probably not the fancier systems CHC track their assets with. The S-92 transmitted AIS and as a SAR ac would be expected to have AIS detection in order to help find and identify target vessels.

The Black Rock lighthouse appears on MarineTraffic AIS (see below) giving its height, range and light signature. VHF may not work underwater but it will penetrate rain or low cloud better than 19th century flashing lights. One thing it does not appear to have is a radar beacon (http://www.irishlights.ie/tourism/our-lighthouses/black-rock-(mayo).aspx) whereas Bull Rock (http://www.irishlights.ie/tourism/our-lighthouses/bull-rock.aspx)for example does.

[[email protected]]

Mitchaa - I can't think of a situation when they wouldn't wear their immersion suits, especially at night.

As Satsuma has said , they had a version (I don't know which one) of STASS (Short Term Air Supply System) and will have trained using it in the dunker.

Dclbydaplha - so it is S-AIS:) The original concept of AIS was a LOS collision avoidance IIRC.

[dClbydalpha]

...
Dclbydaplha - so it is S-AIS:) The original concept of AIS was a LOS collision avoidance IIRC.

Depends whether you're on the AIS end or the SAT end 😉.

Your recollection is correct, IIRC it was originally developed for collision avoidance in coastal approaches and in to harbour. Like all technology its use gets extended. I am not aware of any modification required to a ship's AIS for it to be tracked by satellite. Best if it is a Class A unit though.

[dClbydalpha]

Concentric

I don't know the SAR fit for that S92, but I'd be surprised if it didn't include AIS. However whether it would have been selected for display is another matter.

Again, even with a beacon, the crew would have needed to be operating the radar in a beacon mode to benefit.

Not sure what the SOP would have been with regards to those items during such an approach.

[dClbydalpha]

The thing I can't get my head around is either

1) why there was no terrain warning.
2) if there was why it was too late or ignored.

[9Aplus]

My experience out of long time hosting of VHF AIS RX that standard coverage is 40 km between the islands. On open 80-100 km (LOS) for small crafts and in some extra summer propagation cases can go up 1500-1800 km. Location Mediterranean sea.
For low flying objects much better than ADS B or Mode A & C MLAT (have them too)

[212man]

The thing I can't get my head around is either

1) why there was no terrain warning.
2) if there was why it was too late or ignored.
Did you see my comments earlier in the thread, that state that for the Mk XXII EGPWS the look ahead alert envelope shrinks below 100 KIAS and is inhibited below 70 KIAS? I'm not saying that is what happened, but it lends itself as an explanation.

Page 17: http://skybrary.aero/bookshelf/books/3018.pdf

The MK XXII uses turn
rate and direction to predict the aircraft flight path in the turn
and “looks around the corner” for terrain/obstacles. Forward
airspeed will also modify the look-ahead envelope. Below 100
knots, the envelope is reduced until it is completely inhibited at
70 knots or less. The preceeding speeds are for "fast" helicopter
configurations, "slow" configurations use the range 90 knots to
60 knots for envelope reduction

[IRCG SMC WHITEY]

Re SAR fit for Irish CG S92s - they had (2014) Saab R4 AIS at Winch Op position.

[IRCG SMC WHITEY]

The following link may be of interest. Irish Coast uard is part of Dept. of Transport
S-92A Technical Details | DTTAS Department of Transport, Tourism And Sport (http://www.dttas.ie/maritime/english/s-92a-technical-details)

[ukv1145]

Just to note. The R4a is not connected to any on board sensors (ie air data computers) so any speed data is calculated from the AIS internal GPS position changes. The AIS GPS antenna on the S92 is located on the tail pylon.

[[email protected]]

I am not aware of any modification required to a ship's AIS for it to be tracked by satellite. Best if it is a Class A unit though. No, I believe the modifications had to be done to the satellites to allow them to pick up the specific VHF tx from the ships AIS - duplex channels of 87B and 88B I think.

The AIS GPS antenna on the S92 is located on the tail pylon. that will be the GPS Rx but where is the VHF Tx aerial for the AIS?

Great idea to have the EGPWS disabled at 70 kts - just the sort of speed you are doing a trans down to the hover and possibly getting close to obstacles/land.

[dClbydalpha]

212 man. Sorry being a bit sloppy with my terminology. There are a number of conditions under which there is no FLTA protection. Similarly warnings could be inhibited. However the display should have had an unambiguous amber blob of terrain in their flight path. I can't fathom either the absence or misinterpretation of this.

[gulliBell]

...for the Mk XXII EGPWS the look ahead alert envelope shrinks below 100 KIAS and is inhibited below 70 KIAS? I'm not saying that is what happened, but it lends itself as an explanation.


I for one have done a bit of flying around with TAWS + MFD equipped helicopters in VMC and have often wondered why I don't get terrain warnings when I'd expect a warning was appropriate, and why I get warnings which I don't think to be necessary. I have a poor understanding of the logic being used in either case to warn, or not to warn. One of the IFR helicopters I was flying was fitted with the aeroplane version of the TAWS system (because it was cheaper) and that was next to useless in the helicopter operating environment.

I have come to the conclusion the system can't be relied upon 100% of the time, and if you're relying on it not to hit something, that reliance is not totally reliable.

[ukv1145]

No, I believe the modifications had to be done to the satellites to allow them to pick up the specific VHF tx from the ships AIS - duplex channels of 87B and 88B I think.

that will be the GPS Rx but where is the VHF Tx aerial for the AIS?

Great idea to have the EGPWS disabled at 70 kts - just the sort of speed you are doing a trans down to the hover and possibly getting close to obstacles/land.

VHF Tx just forward of the ramp on the belly.

[dClbydalpha]

VHF Tx just forward of the ramp on the belly.

Which is good for operation with satellite tracking in open water as the chances are there will be satellites below you. However not so good in terrain.

[dClbydalpha]

Great idea to have the EGPWS disabled at 70 kts - just the sort of speed you are doing a trans down to the hover and possibly getting close to obstacles/land.

But also the time that you get most irritated by something telling you the fact that you're approaching the ground?

As far as I can tell, the map display should still have had the high terrain marked. If it wasn't i'm interested to know why.

[212man]

As far as I can tell, the map display should still have had the high terrain marked. If it wasn't i'm interested to know why

Yes, it will.

[HeliComparator]

Yes, it will.


But only if selected onto a display, presumably?

[212man]

But only if selected onto a display, presumably?

Yes, but assuming the wx radar is on the NAV MFD it will require the PFD to be set to ARC mode to show EGPWS (or vice versa depending on which requires the greater granularity) . That's how I set it up, but some operators like to revert to HSI mode for that nostalgic feeling of reduced SA.....

[dClbydalpha]

Yes, but assuming the wx radar is on the NAV MFD it will require the PFD to be set to ARC mode to show EGPWS (or vice versa depending on which requires the greater granularity) . That's how I set it up ...

Thanks for the info, from your setup I presume there is no automatic popup with proximity to off airport terrain.

[212man]

Thanks for the info, from your setup I presume there is no automatic popup with proximity to off airport terrain.

There is a pop-up mode which will appear on an MFD with PFD Arc or NAV set and, if none selected as such, will automatically change the display of one MFD according to a priority logic. However, I prefer to have the map there in the first place to avoid pop-ups!

[Loquatious]

The pop up mode is not a separate mode, it merely displays the terrain map when a warning is generated; so it will be suppressed in the same way as described above.

On another note, radar beacons display in the S-92A standard wx mode.

[dClbydalpha]

On another note, radar beacons display in the S-92A standard wx mode.

Does that mean that beacon mode is always on?

[212man]

The pop up mode is not a separate mode, it merely displays the terrain map when a warning is generated; so it will be suppressed in the same way as described above.


Seems a bit pedantic - 'pop up' is a mode of operation of the EGPWS, and is clearly stated as such in the RFM, using that terminology.

[Beluga406]

Wikipedia - List of Light Houses still has Blackrock listed with a tower height of 15 mm/ 49 ft . What do other data bases have the height?

[Democritus]

The Commisioners of Irish Lights who operate the lighthouse state the height of the light as 282 feet MHWS and the height of the tower as 49 feet

[[email protected]]

And isn't 15mm a bit small for a lighthouse?:E

[skadi]

Wikipedia - List of Light Houses still has Blackrock listed with a tower height of 15 mm/ 49 ft . What do other data bases have the height?

... and wikipedia also lists the focal hight, which is imminent for navigational purpose ( distance of visibility ) as 282 ft.

So the top of the lighthouse should be some feet higher...

https://en.wikipedia.org/wiki/Blackrock_Island_(Mayo)

skadi

[IRCG SMC WHITEY]

Whats all the debate about where the top of lighthouse is/is not located!!
R116 didnt collide with it - light is functioning

[Thunderbirdsix]

Massive sea and land search organised for this weekend for the two missing crewmen, hope and pray they find them for their families


Latest: Fleet of trawlers to search for missing Rescue 116 crewmen as wreckage is brought ashore | BreakingNews.ie (http://www.breakingnews.ie/ireland/latest-fleet-of-trawlers-to-search-for-missing-rescue-116-crewmen-as-wreckage-is-brought-ashore-784519.html)

[dClbydalpha]

Whats all the debate about where the top of lighthouse is/is not located!!
R116 didnt collide with it - light is functioning

I suspect it is a debate about whether or not it should be in the obstacle database. 50 ft is usually the cut-off in none urban areas.

[Red5ive]

‘Granuaile’ also back at Irish Coast Guard helicopter crash site
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-submersible-scanning-more-of-blackrock-seabed-in-search-for-airmen-1.3038851

Over 60 boats to take part in search for Rescue 116
https://www.rte.ie/news/2017/0406/865798-coastguard-rescue-116/

https://www.irishtimes.com/news/ireland/irish-news/search-for-rescue-116-air-crew-by-fishing-fleet-planned-at-weekend-1.3037922

[cncpc]

Whats all the debate about where the top of lighthouse is/is not located!!
R116 didnt collide with it - light is functioning

I expect that some people would see it as informative as to what happened.

[triskele]

'Whats all the debate about where the top of lighthouse is/is not located!!
R116 didnt collide with it - light is functioning'
Because there's a huge light on it? Shining in your windscreen? Telling you it is not Blacksod?

[obnoxio f*ckwit]

'Whats all the debate about where the top of lighthouse is/is not located!!
R116 didnt collide with it - light is functioning'
Because there's a huge light on it? Shining in your windscreen? Telling you it is not Blacksod?

Surely Blacksod has a lighthouse too?

[BluSdUp]

Have been following Rotorhead since last spring , mainly the Puma accident in Norway.
I have great respect for what you all do.
Can anyone please tell me when you all started going IMC ( IFR if it was planned and approved)
And then doing Cloudbreak procedure, for a better word outbound, rig ship or wreck?
I am guessing it is something that started in the Northsea Oil industry ca 1970?
Outbound stay VFR find rig, Inbound SVG go IFR and shoot ILS.
Then what?
Did they give NDB,DME on rigs?
OK , so we use WX radar in MAP mode, radio alt, EGPWS. And lastly the LNAV VNAV PATH based on all these sats , vor dme IRS. When, and how.
Basicly looking for a historic timeline for the evolution of North Sea and European SAR IFR approches.
Regards from an Fixed Winnger

[cncpc]

Surely Blacksod has a lighthouse too?

Yes, it does. But if you are at 270 feet, the light would be below you, not above.

[triskele]

'Yes, it does. But if you are at 270 feet, the light would be below you, not above.'
Indeed, but Blacksods' light has a quite different characteristic, so's we simple seafarers can tell the two apart.

[BookwormPete]

120 fishing boats/trawlers from the Irish fishing fleet are undertaking a co-ordinated search for the missing crewmen.

120 boats search for missing Rescue 116 crewmen (http://www.rte.ie/news/ireland/2017/0408/866262-rescue-116-mayo-coast-guard/)

The search line can be seen in real time at www.marinetraffic.com; it should be noted that only vessels exceeding 300 tons are required to carry an AIS transponder so for every vessel you see on their map display there are about 8 others between them.

The sweep, which has been planned by three fishing industry organisations (The Killybegs Fishermen’s Organisation, Irish Fish Producers’ Organisation and Erris Inshore Fishermen’s Association) in response to an appeal by missing crewman Mr Smith’s sister, Orla, set off from the crash location at Blackrock island, 13km west of the north Mayo coast, at first light today. The South Donegal and North Mayo coast has been divided into a number of search areas, each under the direction of an RNLI or Irish Coast Guard asset. The Naval Service ship LÉ Ciara will be on scene ready to assist where required.

[[email protected]]

It's an excellent idea - the local fishermen will know the tides and any local effects far better than the CG computer which will generate a massive potential search area.

[Al-bert]

It's an excellent idea - the local fishermen will know the tides and any local effects far better than the CG computer which will generate a massive potential search area.

:ok: which reminds me of a search in Cardigan bay for an overdue 12' speed boat with three teenagers who'd run out of petrol and drifted 20 odd miles downwind of Borth. The CG computer had a Nimrod searching off the Isle of Man by first light. We ignored the 'plot' and flew direct to where we calculated they'd have drifted to. Picked em up early am. No flares or radio. CG astonished that Nimrod hadn't found them in the dark "but they can find a needle in a haystack" said DC Milford CG! :ugh:

[Red5ive]

Also
A group of over 70 divers who are trained in search and recovery have launched 18 ribs to assist, as part of an agreement between the Irish Underwater Council and Irish Coast Guard.https://www.irishtimes.com/news/ireland/irish-news/rescue-116-over-100-fishing-vessels-search-for-missing-airmen-1.3042247

Great effort to get a little armada out to help.

Strange that the Navy don't have many small ships to help out, like the HMS Ranger (https://twitter.com/HMS_Ranger) that was docked in Cork.

[albatross]

Well done those people.
Thanks.

[BookwormPete]

Also
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-over-100-fishing-vessels-search-for-missing-airmen-1.3042247

Strange that the Navy don't have many small ships to help out, like the HMS Ranger (https://twitter.com/HMS_Ranger) that was docked in Cork.

If HMS Ranger is in Cork I presume she's on a courtesy visit? That's one thing but to have a Royal Navy ship take part in a Coast Guard operation in Irish waters and be under the overall command of an Irish warship would probably require a load of diplomatic wrangling they didn't have time for. I'm sure the Ranger's crew would have been more than willing.

[IRCG SMC WHITEY]

Red5ive & BookwormPete
check marine traffic for HMS Ranger - now making her approach to Dublin currently off Bray Co. Wicklow. I think the reference to her was an example of small type Naval Craft

[Redhawk 83]

Unless I missed it, no one has mentioned jackets inflating upon immersion, only a light illuminating and PLB's activating?

In addition to a water activated PLB (Becker unit comes to mind). Here is a self activating AIS beacon for the vest; of course NOT activating till vest is inflated manually. Does the Irish SAR Aircraft have the SAAB AIS receiver like the UK SAR S92?


http://info.mcmurdogroup.com/rs/boatracs/images/Clipper%20AIS%20MOB%20Rescue%20Case%20Study%202014.pdf

[jimf671]

... would probably require a load of diplomatic wrangling they didn't have time for0 ...

On the other hand, it's SAR, and as Albert reminded us in post 63, "SAR is international". UK SAR aircraft use Blacksod too.

[SASless]

Sadly.....it is a Recovery Operation now.

[[email protected]]

UK SAR aircraft use Blacksod too. Does that still happen/has it happened under the new contract? Now the Irish CG have the same range as UK SAR (and the same aircraft) is there a need for UK assets to go across to W of Ireland or does it become a function of whose SRR the job is in?

[jimf671]

I'm not aware of specific jobs in the last couple of years but then they didn't exactly happen every week!



(Reports show there have been one long distance Atlantic job for each of Stornoway and Newquay since 2015 but a lot further north and south so they do not have a Irish stop as an option.)

[Red5ive]

Just noticed Granuaile left Blackrock and headed to Galway.

A couple of days ago it was said they planned anther 72 hrs more with the ROV at Blackrock. Must have about done that.

[Red5ive]

An extensive search around Blackrock Island off the Co Mayo coast has concluded without finding any trace of two missing Coast Guard crew members.
https://www.rte.ie/news/connacht/2017/0410/866740-rescue-116/

Coast guard scales down search for Rescue 116 crew
https://www.irishtimes.com/news/ireland/irish-news/coast-guard-scales-down-search-for-rescue-116-crew-1.3044058

Must be so hard on the families.

[Red5ive]

Search for missing crew of Rescue 116

The Air Accident Investigation Unit and An Garda Síochána in conjunction with Coast Guard have expressed their sincere appreciation to the Commissioners of Irish Lights (CIL) and Marine Institute who were supported by GSI (Geological Survey Office), for the extensive search conducted in the vicinity of Black Rock lighthouse following the tragic loss of Coast Guard helicopter Rescue 116 on March 14.

The search operation conducted by the Marine Institute's Holland 1 ROV concluded this afternoon when the Granuaile departed Blacksod Bay.

Supt. Tony Healy confirmed that the Garda water unit would conduct diving searches in the vicinity of Blackrock Light as soon as wind and tidal conditions are considered suitable.

He also confirmed that he had requested Coast Guard and Civil Defence volunteers to continue with targeted searches of coastal areas and monitoring of specific areas of interest.

Gerard O'Flynn from the Coast Guard thanked all the statutory and voluntary organisations for their unstinting support over the past four weeks, paying special thanks to Coast Guard, RNLI and Civil Defence volunteers and Defence Forces assets including naval divers, ships and Air Corps. He added that the operation highlighted the value of inter-agency cooperation in meeting challenges of this type.

The Coast Guard also wishes to remind all mariners to keep a good lookout for any material associated with Rescue 116 and to report any findings to Malin Head Coast Guard Coordination Centre.

AGS, AAIU and IRCG reiterated their sympathy to the families of Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciaran Smith and expressed the hope that with the extensive monitoring both at sea and on shore that the remains of Paul and Ciaran would be found.

10/04/2017 - Search for missing crew of Rescue 116 | AAIU.ie (http://www.aaiu.ie/node/1065)

[cncpc]

Have they stopped retreival of the wreckage from around Blackrock as well?

[Red5ive]

Have they stopped retreival of the wreckage from around Blackrock as well?

Looks like it. Granuaile gone and its the only vessel they were using to lift wreckage, but they said they will bring it back if necessary.

The ROV will probably then go back to the Celtic Explorer. They charge €6k a day for it.
https://www.marine.ie/Home/site-area/infrastructure-facilities/research-vessels/vessel-rates?language=en

[Pruneface]

Now that the recovery effort seems to have reached a point where it is winding down except for more targeted searches that will happen when needed, the investigators' preliminary report would seem to be the next milestone that will occur. Is there a legal requirement to produce a preliminary report within 30 days or is that just a guideline? I had expected some outcome from the CVR analysis by now.

[JimJim10]

The Sligo and Shannon aircraft cover the west of Ireland for SAR.Very occasionally you will get UK military helicopters heading out to the Atlantic for "no reason" and stopping by Sligo, Shannon, or Blacksod for fuel. Have not seen it in quite a while though. The Sligo helicopter was called out to a grid reference a good number of years ago to do "nothing really". Was the most interesting job that year iirc. Those "no reasons" really are massive when they surface.



...oops.

Does that still happen/has it happened under the new contract? Now the Irish CG have the same range as UK SAR (and the same aircraft) is there a need for UK assets to go across to W of Ireland or does it become a function of whose SRR the job is in?

[llamaman]

The sooner the AAIU publish something about this the better. The SAR (and wider aviation) community need to know how a modern, fully-serviceable helicopter complete with a highly experienced crew ended up at the bottom of the sea. The fact that the rearcrew are still missing is not only heartbreaking for the families but something from which lessons need to be learned quickly. My gut feeling is that this wasn't straightforward human error but a systemic failure with multiple contributory factors (as is often the case).

[cncpc]

The sooner the AAIU publish something about this the better. The SAR (and wider aviation) community need to know how a modern, fully-serviceable helicopter complete with a highly experienced crew ended up at the bottom of the sea. The fact that the rearcrew are still missing is not only heartbreaking for the families but something from which lessons need to be learned quickly. My gut feeling is that this wasn't straightforward human error but a systemic failure with multiple contributory factors (as is often the case).

Well stated. Particularly in regard to systemic failure and the need to know now what is surely privately known within the system that has failed.

[dClbydalpha]

... need to know how a modern, fully-serviceable helicopter complete with a highly experienced crew ended up at the bottom of the sea ... this wasn't straightforward human error but a systemic failure with multiple contributory factors (as is often the case).

All well said, apologies for cutting the specific quotes out.

One of the purposes of the systems approach is to prevent, as much as is reasonably possible, a simple human error becoming catastrophic. Somewhere in the details, when published, will be some crucial lessons to learn and maybe some assumptions that need to be re-assessed.

[pumaboy]

The sooner the AAIU publish something about this the better. The SAR (and wider aviation) community need to know how a modern, fully-serviceable helicopter complete with a highly experienced crew ended up at the bottom of the sea. The fact that the rearcrew are still missing is not only heartbreaking for the families but something from which lessons need to be learned quickly. My gut feeling is that this wasn't straightforward human error but a systemic failure with multiple contributory factors (as is often the case).
Well writing could not have made it better, there are many questions that have to be answered from all angles, and the fact the rear crew are still missing this is not acceptable and it is not fair for the famillies, they need closure.

[SASless]

Life is not fair....the Sea is a very unforgiving place.

Yes, Closure is good and it tragic the families and friends of the two lost Missing Crewmen are having to go through this but One must be realistic. There has been a tremendous amount of searching going on in a very inhospitable environment.

Fishermen, Sailors, and others who venture out all understand the risks and odds of this happening.

The Accident Report will be written in time and the story will be told.

As for the Missing Crewmembers....there is always hope no matter how slight that they will be found and the family achieve some closure in that regard.

[BluSdUp]

I have asked before and nobody dare touch it.
The elefant in the room if you will,,,,,
Likely occurance:

A gross error in flying a " IFR " approach that was not picked up by existing procedure or common practice !

Why? We shall see.

What I like to know is how is it normally done, what equipment is needed.
What training is done , what standards apply. What is common and what discression does the Crew have? ???

It is hard to compare Heli SAR/NS oil IFR,and Airline but lets try.
After all in BGO , SVG and Aberdeen we are all just a number on the ILS, inbound.
So basics are the same, Me Cat C, You Cat A!

The outbound IFR to VFR transition, is what an old B 737-800 driver is interrested in.
Can anyone enlighten us on this, please?
It is unlikely this senior crew messed it up, if Your procedure is solid.
So, me thinks :the procedure is not good!

So, again : What is the procedure, in detail? Anyone?

With Great Respect
Cpt B

[gulliBell]

The outbound IFR to VFR transition, is what an old B 737-800 driver is interrested in.

It is unlikely this senior crew messed it up, if Your procedure is solid.


There is no magic IFR to VFR transition. Just like in your B737-800, the pilot of an IFR helicopter conforms to a published procedure until visual. If you're not visual at the MAPt you follow the missed approach procedure and either try again, or hold, or go somewhere else.

And as for the other question. A senior crew can mess up, I can assure you of that. We see it quite often in simulator training (but I'm not saying for sure this crew messed up, but it's certainly a possibility).

[GKaplan]

A senior crew can mess up, I can assure you of that.

+1

Remember Tenerife...

[BluSdUp]

Anyone have a link to the plates for Blacksod?

[cncpc]

I have asked before and nobody dare touch it.
The elefant in the room if you will,,,,,
Likely occurance:

A gross error in flying a " IFR " approach that was not picked up by existing procedure or common practice !

Why? We shall see.

What I like to know is how is it normally done, what equipment is needed.
What training is done , what standards apply. What is common and what discression does the Crew have? ???

It is hard to compare Heli SAR/NS oil IFR,and Airline but lets try.
After all in BGO , SVG and Aberdeen we are all just a number on the ILS, inbound.
So basics are the same, Me Cat C, You Cat A!

The outbound IFR to VFR transition, is what an old B 737-800 driver is interrested in.
Can anyone enlighten us on this, please?
It is unlikely this senior crew messed it up, if Your procedure is solid.
So, me thinks :the procedure is not good!

So, again : What is the procedure, in detail? Anyone?

With Great Respect
Cpt B

I do agree with the elephant in the room characterization, but I believe the elephant is systemic before it is crew.

[Al-bert]

Anyone have a link to the plates for Blacksod?

Unless things have changed in the last 18 years since I was there in a Seaking there are no plates or IFR procedures to remote sites such as Blacksod. We would, if IMC, have carried out a radar letdown overwater on our search radar, possibly but unusually to full FCS hover, and then radar guided hover taxy if still v low viz but in sight of the surface, to the LS. I assume S92 operators have similar company procedures?

The following information was published - there may be more these days. Hope that helps. http://www.dttas.ie/sites/default/files/publications/maritime/english/ircg-liaison-agreements-and-mous/2010-03-22-service-level-agreement-ircg-and-cil-2010-signed.pdf

[My names Turkish]

'We're gone' - last words from cockpit of Rescue 116 as report reveals 'rapid pitch up' - Independent.ie (http://www.independent.ie/irish-news/downed-rescue-116-pitched-up-rapidly-in-final-seconds-before-striking-terrain-preliminary-report-reveals-35621566.html)

Not sure where they are getting that info, AAIU page has no preliminary report published yet.

Downed Rescue 116 'pitched up rapidly' in final seconds before striking terrain, preliminary report reveals

A preliminary report into downed Rescue 116 has revealed the coastguard helicopter 'pitched up rapidly' in its final seconds.
The report relied on data recovered from the FLight Data recorder and the Health and Usage Monitoring System (HUMS) card.
"Flight data recorded on the Health and Usage Monitoring System (HUMS) card and the FDR, showed that the helicopter was in stable level flight at 200 ft Radio Altitude, 75 kts Indicated Airspeed, helicopter heading 120 degrees magnetic (approximately) on a track towards waypoint BLKMO. In the final seconds, the helicopter pitched up rapidly,impacted with terrain at the western end of Black Rock and departed from controlled flight", the report states.

More to follow.
Online Editors

[elro]

ACCIDENT: Sikorsky S-92A, EI-ICR, Black Rock, Co. Mayo Ireland 14th March 2017: Report 2017-006 Preliminary | AAIU.ie (http://www.aaiu.ie/node/1067)

[cncpc]

More from that report...

A preliminary report into downed Rescue 116 has revealed the coastguard helicopter 'pitched up rapidly' in its final seconds.The report also revealed that the helicopter's on board warning system did not have data related to Blackrock island.An obstacle data base on their system did not list the lighthouse on Blackrock, and the terrain database did not have information on the terrain on the island.



Audio data revealed Captain Dara Fitzpatrick and co-pilot Mark Duffy had discussed earlier in the flight that it had been a long time since either had visited the island.

[llamaman]

Heartbreaking reading the CVR transcript. One line in the interim report stands out though and probably confirms what most of us were thinking;

"The CVR recording contains no reference by the Crew to the presence of a lighthouse or terrain at Black Rock during their briefing for APBSS.”

I'm somewhat surprised that Blackrock wasn't in the terrain database. For a fleet of helicopters expected to conduct SAROPS anywhere in the Irish SRR (and beyond), often in very poor weather conditions/in the dark, that seems remiss.

[SASless]

Just a question.....what is the feasibility of having had Radar Transponders installed at Light Houses such as Black Rock?

[Al-bert]

Simply and utterly horrendous! RIP guys.

[puntosaurus]

SASless, I think I'd ask that question the other way round.

What is the point in having a procedure encourage helicopters to route to the highest obstacle around when the obstacle has no navaid of any practical use, is miles away from the intended landing spot, and then for good measure leaves out vertical guidance.

[rotorspeed]

Obviously the omission of Blackrock in the EGPWS database is bad, but Blackrock was featured on the more detailed of the 5 charts in the moving map system, which was being displayed on one of the captain's screens. And it is featured with height 282ft on the Operators Route Guide to Blacksod that they were following. So it appears information was there to notify the crew of Blackrock's presence. And indeed the captain had considered an ALTITUDE warning 26 secs before impact as being "a small island" (which it was), so realised they weren't just over flat sea.

But what I really don't understand is why, 10 miles out, the crew had already descended so low as 200ft RA. It seems they had a standard SAR approach mode APP1 selected, which took them down to 200ft, but why? At least so soon?

[puntosaurus]

Well the obvious conclusion is that they didn't realise that Blackrock was such a substantial feature. The Commander herself called one of the smaller islets 0.65nm earlier as being the IP. Why didn't the operational route guide show a green spot under the waypoint. Drawn to scale it would still have been identifiable as a substantial chunk of hard stuff.

[SASless]

Punt,

Slowly.....if Blackrock had been equipped with a Transponder as is generally done with Oil Rigs and Platforms......and you had your Radar appropriately set up.....then that bit of Rock would be very easily identified.

If you had included Blackrock as a Waypoint the GPS would point to it as well.....and with a moving map display there would be a third way of identifying it....and with a Minimum Crossing Altitude/Height....in a preplanned Approach Procedure.....then by adding some Structure to an Arrival to Blacksod.....safety would be enhanced....would it not?

What technical issues (if any) prevent the Irish Light House authorities from installing the Transponder?

[ODEN]

The AAIU should make a safety recommendation that all night SAR operations shall have NVD. This would most probably have saved them...
Hopefully that will be in the future SAR regulation and a conclusion in the final report.

A lot to learn from this accident...the most shocking and biggest Swiss cheese whole is that Blackrock is not in the EGPWS data base....no last defense...

[cncpc]

SASless, I think I'd ask that question the other way round.

What is the point in having a procedure encourage helicopters to route to the highest obstacle around when the obstacle has no navaid of any practical use, is miles away from the intended landing spot, and then for good measure leaves out vertical guidance.

I can't imagine that whoever at CHC drew up this "approach" knew that Blackrock was 310 feet high. He or she must have had the topo that showed it to be 32 feet high.

Sorry, I've now read Rotorspeeds post and see that the height is on the route guide.

[puntosaurus]

Sasless. Well I agree that there were lots of other mechanisms already in the cockpit that could have alerted the crew to the presence of the island, and one more (Txpndr) might have helped. But the fundamental problem appears to be that the crew clearly didn't know that BLKMO was above a large island, rather than a small rock (Carrick something or other) barely exposed at low tide.

If your IP is just a Lat/Long in the FMC, why on earth place it over the highest point around. The purpose of a letdown over water is surely to keep you away from the hard stuff until you are ready for it.

cnpc. Whoever drew up the approach knew the island was 282ft high, because he or she wrote it on the plate.

oden. The guys in the back knew they were headed for the island because they were looking at an image of it on a display. Presumably the crew were not looking at that display.

[cncpc]

P

If you had included Blackrock as a Waypoint the GPS would point to it as well.....and with a moving map display there would be a third way of identifying it....and with a Minimum Crossing Altitude/Height....in a preplanned Approach Procedure.....then by adding some Structure to an Arrival to Blacksod.....safety would be enhanced....would it not?



I think Blackrock was a waypoint.

[llamaman]

Just for my education, why was such a large piece of rock not visible on the weather radar? Surely the SOP for such a let-down is to have the radar set up in a mode which highlights such obstructions?

[Red5ive]

A lot to learn from this accident...the most shocking and biggest Swiss cheese whole is that Blackrock is not in the EGPWS data base....no last defense...

Wonder did any of the crews who use Blacksod regularly ever highlight this?

[Evalu8ter]

Oden,
They did have an NVD - the EO/IR being used by the rearcrew. He clearly saw the obstruction and kept calling for a turn....

I presume that the EO diisplay wasn't (or couldn't be) selected on one of the cockpit MFDs? Not sure NVGs would have helped, they may well have been 'flipped up' at that stage of flight - overwater, AP modes engaged and a procedure in the FMS.

[cncpc]

cnpc. Whoever drew up the approach knew the island was 282ft high, because he or she wrote it on the plate.

oden. The guys in the back knew they were headed for the island because they were looking at an image of it on a display. Presumably the crew were not looking at that display.

I did correct that. The report says this about the maps available in that Euromap system...

The exact information in relation to Black Rock and Lighthouse varied from none, to detailed, depending on the selected map/chart.

So if APP1 descends to 200 feet, and flies towards a 282 foot next waypoint, is the alternative to manually set a higher descent target given that APP1 obviously will have this result? Or are there APP2 options, etc?

How did R118 get into Blacksod? Same approach?\\

[puntosaurus]

They weren't going to Blackrock, they were going to BLKMO in the FMC, as commanded by the loading of the APBSS (AProach to BlackSod South) approach. The commander called it BLKMO when she misidentified it. The earlier crew being based on the west of Ireland presumably knew that BLKMO was Blackrock and that is was a large island, and presumably stayed higher later.

[rotorspeed]

I'm surprised this approach didn't have any heights specified. Is that normal for this SAR operation? What's the point of an approach, clearly intended for IMC let downs, without associated heights? But even so, I still cannot see any reason why you'd descend to 200ft so far out, even if you knew it was flat sea. Could this be a case of being sucked into to using too much automation (i.e. APP1) without thinking enough about the logic of its use right then?

[HeliComparator]

As I tried to say earlier, in my view it points to the flawed culture in SAR of always trying to get low / VFR as soon as possible. In my experience SAR pilots are far happier flying around at 200' VFR below cloud in the crud, rather than being at MSA IFR in cloud. Of course getting "down and dirty" asap can sometimes be the right thing to do, but not always. It surely can't be right to need to descend to 200' so far from the destination during an instrument letdown.

[Red5ive]

5.1.2 Data Recovery

Electrical testing revealed short circuits which necessitated additional measures to recover the CVR and FDR recordings.

These measures included desoldering individual memory devices and reinstalling them on a functional memory board provided by the manufacturer of the MPFR



Every time you subject the memory chips to a heat cycle, there is a chance the data will be corrupted.

Bit lucky twice.

[cncpc]

They weren't going to Blackrock, they were going to BLKMO in the FMC, as commanded by the loading of the APBSS (AProach to BlackSod South) approach. The commander called it BLKMO when she misidentified it. The earlier crew being based on the west of Ireland presumably knew that BLKMO was Blackrock and that is was a large island, and presumably stayed higher later.

Thanks. That makes much sense.

[industry insider]

It surely can't be right to need to descend to 200' so far from the destination during an instrument letdown.

I agree HC, most instrument letdowns have the aircraft at its lowest point close to or at the missed approach point.

[mini]

Can't help but ask the obvious, they hit a building meters from a confirmed operational lighthouse?

If they were low enough to collide with something, surely they should have seen the light?

[jimf671]

As I tried to say earlier, in my view it points to the flawed culture in SAR of always trying to get low / VFR as soon as possible. In my experience SAR pilots are far happier flying around at 200' VFR below cloud in the crud, rather than being at MSA IFR in cloud. Of course getting "down and dirty" asap can sometimes be the right thing to do, but not always. It surely can't be right to need to descend to 200' so far from the destination during an instrument letdown.

I'm seeing something else HC. Land vs Maritime. Different mindset, different mapping priorities. That may be threaded through several of the relevant issues.

[gulliBell]

In the APP1 mode that they were in, when they were at 200' ASL on final approach and stable, pitch is maintaining altitude, and power is maintaining airspeed. Correct? So the autopilot was driving the pitch axis to maintain height, correct? What was driving the power, was this being controlled manually by the pilot, or automatically by the AFCS? If the power was being manipulated manually, and the speed got too slow, I assume at some point the AFCS will pitch up abruptly (when it gets on the back side of the power curve) trying to maintain the selected height? I'm not familiar with S92, but this behaviour has all the attributes of S76. A pitch mode being used to maintain height, but not enough power being applied to maintain speed after levelling off. Especially after a low power descent, levelling off, but not applying power. The airspeed will very slowly bleed off, which might not be noticed by the crew, until it gets to a point where AFCS commands abrupt pitch up, airspeed rapidly decreases, and then things are out of control.

Am I right in saying that the aircraft was out of control before it hit the rocks, because insufficient power was applied for the flight mode they were in? And if they didn't hit the rocks the result would have been the same? We demonstrate this in the simulator, once that rapid pitch up occurs, without immediate corrective action, the aircraft will just fall out of the sky and you need more than 200' to recover the situation. I've seen experienced crews make this mistake; it happens in 2 different manoeuvres. Single engine missed approach using vertical speed mode to climb, but not applying enough power, and low power descent using ALT PRE, capturing the new height but not applying power.

EDIT: OK, answers to these questions were covered in the report. Pitch is being used to control speed, power is being used to control altitude.

[JimJim10]

My reading of the report is they did not impact the building, they impacted rock at the western end of the island. Debris from that collision landed on the building and damaged the roof tiles. Had the aircraft hit the building there would be far more damage than just to roof tiles.


It seems from the preliminary report the light for some reason was not visible to any of the crew or there surely would have been some comment made on it.I have flown quite a bit with Irish SAR crews and having now read that report I find that quite strange. With respect,and in a professional manner, they talk about everything of relevance that they observe during a flight. That the front nor rear crew did not observe and report any lighthouse causes me to believe it was not visible for some reason. I know it is stated the light was "on" by the automated system, but how accurate that is to the actual state of the light is unproveable.Can't help but ask the obvious, they hit a building meters from a confirmed operational lighthouse?

If they were low enough to collide with something, surely they should have seen the light?

[BluSdUp]

Madness!
Whoever approved this operation is a criminal!

Words fail!
As if heli flight was not risky enough, we start doing THIS!
With those " charts"! Utter madness!

[jimf671]

Black Rock (Mayo) (http://www.irishlights.ie/tourism/our-lighthouses/black-rock-(mayo).aspx)

[vaqueroaero]

I find it staggering that an operation such as this does not have helmet mounted NVG's. If I want to I can go to a local flight school and fly a 300C to get NVG current and yet an aircraft used in such a hostile environment doesn't have them.

I presume that the EO diisplay wasn't (or couldn't be) selected on one of the
cockpit MFDs? Not sure NVGs would have helped, they may well have been 'flipped up' at that stage of flight - overwater, AP modes engaged and a procedure in the FMS.

Why the heck do people flip up goggles when in proximity to the ground? The whole point is that you use them to see the ground. There's no point being on goggles when you're IMC at 4000' msl. Had one of the pilots been on goggles they would have been able to see the light from the lighthouse from a considerable distance away, even through mist and drizzle. Unless the light itself was an LED type that the wavelength of the light cannot be 'seen' by goggles.

A terrible waste of life.

[puntosaurus]

BluSdUp. That's the swiss cheese I'm afraid, and I'm glad to see that the Irish Accident Investigation Crew have latched on to it. There were things that could have saved this operation, and the rear crew so nearly saved the day, but ultimately the operator let them down by not giving them clear and unambiguous documentation to allow them to do their job.

[Older and Wiser]

Maybe we should stop beating round the bush.
The operators let down procedure clearly shows Black Rock at 282'
It would have also been visible on Radar and would have been a waypoint in the system. There is no reason not to know that there was a big lump of rock with a light on it that was 282' AMSL. It is the start point of a company procedure not the point to be at 200'.
This is all very sad, who knows if the pilot had reacted immediately when the Winch Operator first called for a right turn would it have been enough; rather than the PF questioning the turn request.

[cncpc]

My reading of the report is they did not impact the building, they impacted rock at the western end of the island. Debris from that collision landed on the building and damaged the roof tiles. Had the aircraft hit the building there would be far more damage than just to roof tiles.


It seems from the preliminary report the light for some reason was not visible to any of the crew or there surely would have been some comment made on it.I have flown quite a bit with Irish SAR crews and having now read that report I find that quite strange. With respect,and in a professional manner, they talk about everything of relevance that they observe during a flight. That the front nor rear crew did not observe and report any lighthouse causes me to believe it was not visible for some reason. I know it is stated the light was "on" by the automated system, but how accurate that is to the actual state of the light is unproveable.

They may have been IMC, or just below the ceiling at 200 feet. I don't know, can you see a lighthouse light through a 100 vertical feet of cloud? I expect they climbed 82 feet to rock top height in their evasive manouevre and certainly would have seen the light then, if not before. Would they have seen it abeam as they went outbound at 2400?

[puntosaurus]

You're not living up to your name O&W.

The chart doesn't show Blackrock at 282'. It shows a waypoint called BLKMO with a caption next to it of 282 with no clue as to its relevance. Is it waypoint 282 in the operators manual ? Is it the depth of the sea at this point ? Is it the QDM from some unspecified navaid on the mainland ?

The island would indeed have been visible on radar and on the EO/IR display if that was available in the cockpit, and for that mistake and the few seconds pause whilst they assimilated the rear crew's input this crew paid with their lives.

However the people that put them in this situation by promulgating a thoroughly misleading chart, and the people that validated a flawed terrain database have yet to be held accountable for their role in this accident. And I'm willing to bet that their punishment will be less severe.

[Mark Six]

Puntosaurus, you and others appear to be blaming the operator for providing an inadequate chart (Route Guide) for the ABPSS route, however you are overlooking the fact that:

"The Route Guide includes an associated separate page of text setting out, inter alia, waypoint designations and coordinates, hazards and obstacles and other general comments. This page identified a lighthouse at Black Rock with an associated height of 310’."

Clearly the information regarding Blackrock was available and should have been read in association with the first page showing the routing. I would have also expected some altitude guidance such as "Do not descend below 500' until east of Blackrock", however only lateral guidance seems to have been provided on the Route Guide.

[pilot and apprentice]

In the APP1 mode that they were in, when they were at 200' ASL on final approach and stable, pitch is maintaining altitude, and power is maintaining airspeed. Correct? So the autopilot was driving the pitch axis to maintain height, correct? What was driving the power, was this being controlled manually by the pilot, or automatically by the AFCS? AFCS, a rad alt coupled mode and A/S If the power was being manipulated manually, and the speed got too slow, I assume at some point the AFCS will pitch up abruptly (when it gets on the back side of the power curve) trying to maintain the selected height? I'm not familiar with S92, but this behaviour has all the attributes of S76. A pitch mode being used to maintain height, but not enough power being applied to maintain speed after levelling off. Especially after a low power descent, levelling off, but not applying power. The airspeed will very slowly bleed off, which might not be noticed by the crew, until it gets to a point where AFCS commands abrupt pitch up, airspeed rapidly decreases, and then things are out of control.

Am I right in saying that the aircraft was out of control before it hit the rocks, because insufficient power was applied for the flight mode they were in? And if they didn't hit the rocks the result would have been the same? We demonstrate this in the simulator, once that rapid pitch up occurs, without immediate corrective action, the aircraft will just fall out of the sky and you need more than 200' to recover the situation. I've seen experienced crews make this mistake; it happens in 2 different manoeuvres. Single engine missed approach using vertical speed mode to climb, but not applying enough power, and low power descent using ALT PRE, capturing the new height but not applying power.

Based on the report, I believe the pitch up was in response to seeing the island at the last moment. Been there, seen that...

The short time period from the the crewman calling an obstacle to impact (9 seconds) was insufficient for her to adjust her SA from believing that the small island that had, in her view of the local area, moved from behind to in front of the aircraft and was much higher than expected. This is not a condemnation of her, rather my view that once they were at that point, it takes time for that profound a recalibration of SA. Even the crewman's initial statement seems to be not yet fully aware of the danger for a few seconds....

HeliComparator:
As I tried to say earlier, in my view it points to the flawed culture in SAR of always trying to get low / VFR as soon as possible. In my experience SAR pilots are far happier flying around at 200' VFR below cloud in the crud, rather than being at MSA IFR in cloud. Of course getting "down and dirty" asap can sometimes be the right thing to do, but not always. It surely can't be right to need to descend to 200' so far from the destination during an instrument letdown.

In this case, looking at the route guide, I would say it is not an instrument letdown. This is not an approach. It is a visual route to be flown to avoid terrain while approaching an off airport destination. As such, reaching and maintaining VMC while still offshore is probably required.

Al-Bert
Unless things have changed in the last 18 years since I was there in a Seaking there are no plates or IFR procedures to remote sites such as Blacksod. We would, if IMC, have carried out a radar letdown overwater on our search radar, possibly but unusually to full FCS hover, and then radar guided hover taxy if still v low viz but in sight of the surface, to the LS. I assume S92 operators have similar company procedures?

This leads to my comments below.

puntosaurus:
Sasless. Well I agree that there were lots of other mechanisms already in the cockpit that could have alerted the crew to the presence of the island, and one more (Txpndr) might have helped. But the fundamental problem appears to be that the crew clearly didn't know that BLKMO was above a large island, rather than a small rock (Carrick something or other) barely exposed at low tide.

If your IP is just a Lat/Long in the FMC, why on earth place it over the highest point around. The purpose of a letdown over water is surely to keep you away from the hard stuff until you are ready for it.

cnpc. Whoever drew up the approach knew the island was 282ft high, because he or she wrote it on the plate.

oden. The guys in the back knew they were headed for the island because they were looking at an image of it on a display. Presumably the crew were not looking at that display.

Again, just my opinion with limited information, but based on experience.

I would first investigate whether this 'route/procedure' predates the 92 and was faithfully copied on, with easily identifiable points from days before FMC guided 4-axis autopilots. Then the choosing of an easily identified visual waypoint clear of higher terrain makes sense to aid visual guidance into the bay.

As has been said, I think some systemic errors and traps will be found that set this crew up to be caught by a combination of poor weather and unfamiliar operating location. The difference between success and failure will be a hair's breadth...

Something we all work hard at trying to see in advance every day.

This was an absolute tragedy

[puntosaurus]

Mark Six. I'm not overlooking anything. The crew made mistakes, but the purpose of the accident investigation is to make sure that all contributing factors are brought out.

A very wise CRM instructor and training captain from a major airline that I came across recently, said that if 20% of people who came up in front of him were failing correctly to interpret an SOP, then the SOP was probably wrong.

That's my only point here.

[pilot and apprentice]

Mark Six. I'm not overlooking anything. The crew made mistakes, but the purpose of the accident investigation is to make sure that all contributing factors are brought out.

A very wise CRM instructor and training captain from a major airline that I came across recently, said that if 20% of people who came up in front of him were failing correctly to interpret an SOP, then the SOP was probably wrong.

That's my only point here.

Good point, well said

[cncpc]

Credit to the Irish accident investigators in the AAIU. For a preliminary report, this was an detailed and very professionally prepared presentation of all of the information available. It will already be useful to many operators and pilots in examining whether their operations may have similar issues that have not been caught yet.

[malabo]

Swiss cheese? I'm seeing mainly holes and not much cheese. And an awkward transition from a military/marine mindset to a civilian commercial one. Look at the struggle that experienced, offshore pilots posting here have trying to understand what t'hell the crew was doing as a supposed "SOP" procedure.

Systemic, crew is not at fault. Tough day for management, that were not able to foresee the flaws in their operational system - the responsibility of both the SMS system to successfully risk assess and operations to provide operational expertise in a predictive way, not after the fact like the AAIU has to do now. Other operators fly SAR in that area, I wonder if they shared the same SOPs or if their different management expertise was ahead of the game.

[gulliBell]

..But what I really don't understand is why, 10 miles out, the crew had already descended so low as 200ft RA. It seems they had a standard SAR approach mode APP1 selected, which took them down to 200ft, but why? At least so soon?

Good question. I don't understand why you'd want to be at 200' at an IAF on the 1st of a 7 leg procedure to the destination, especially when the commencement of leg1 has a spot elevation of 282'. They had 10 miles to go at 75kts, call it 1.5nm/min with tail wind, equals about 6.5 minutes to run. If they were at 2000' (instead of 200') at the IAF then 300 ft/min from there would be a comfortable vertical profile. The PROC should have a minimum descent altitude for each segment, and to me 2000' looks like a good altitude to be at at the IAF. Was the vertical profile written on the chart?

[HeliComparator]

One can point to a fundamental error by the crew in not noticing the rock - it was on the charts albeit well disguised - however looking at the whole picture I think it was an entirely predictable error. When there is only one slice of cheese between safety and an accident, the hole will be found fairly often even though (or especially when) it is caused by crew error. Adequate flight safety is only ensured when there are several slices of cheese whose holes don't normally line up - and even then it can happen. This operation had too low a safety margin / too few levels of safety for routine stuff, and we have unfortunately seen the consequences. I wonder who provided operational oversight? It was definitely an accident waiting to happen.

[LordFlashheart]

I can't believe the procedure didn't have:
(1) A minimum (not below) altitude for each segment; and
(2) A CDFA angle to follow, with a distance/altitude scale.

With P-ILS capablility of the S-92A, it seems bizarre.

[Fareastdriver]

Before this procedure was authorised by the company did anybody fly it? in daylight, VMC, to make sure that the procedure worked.

[ODEN]

Airborn radar approches has been used for a very long time and would have been safe approaching Blacksod. The focus would have been 100% on the radar if doing an ARA.
Unfortunally it seams the crew where lead into false safety following a company route that was not quality assured and risked assesed. A big responsibility lies on all parts of management and training...

[Thunderbirdsix]

Can't help but ask the obvious, they hit a building meters from a confirmed operational lighthouse?

If they were low enough to collide with something, surely they should have seen the light?

Listening to RTE radio this morning and it was stated that the light on Black Rock takes 26 seconds to complete a turn so it was clearly not pointing at them when this happened

[roundwego]

I don't think we can comment on the design of the approach without seeing the accompanying text which is briefly referred to in the report section 3.5.8. The red highlighted numerics on the chart obviously refers to notes in the unseen text describing the significant obstacles, of which Blackrock was included. I would have thought that as part of the approach brief, they would have gone through the accompanying text in some detail. If they had done so, they must have been aware of the presence of a 310' high obstacle on the approach path.

We should also remember that the chart does not describe an IFR cloud break procedure. It seems to be just "route guidance" to aid what should be a visual section of the flight. I suspect that elsewhere in the company Ops manual there would have been an offshore cloud break procedure to get them VMC below cloud. This procedure should also detail the minimum visibility (which is of course almost impossible to determine at night) and cloud base to allow continued visual flight at low level. The limits for a SAR mission may be significantly lower than for "routine" ops but we have to remember that this particular flight was not for a SAR operation. It was just to provide an extra communications link at this stage.

It's easy to be clinically analytical about this subject and forget that humans were involved in this tragedy. I have a huge respect for those who, on a daily basis, put themselves into potentially very hazardous conditions to help protect life. RIP.

[catch21]

Listening to RTE radio this morning and it was stated that the light on Black Rock takes 26 seconds to complete a turn so it was clearly not pointing at them when this happened

Black Rock (Mayo) (http://www.irishlights.ie/tourism/our-lighthouses/black-rock-(mayo).aspx)

According to the link above it is a single flash every 12 seconds.

[Thunderbirdsix]

Black Rock (Mayo) (http://www.irishlights.ie/tourism/our-lighthouses/black-rock-(mayo).aspx)

According to the link above it is a single flash every 12 seconds.

Flashes every 12sec takes 26sec to do a full turn

[ODEN]

I don't think we can comment on the design of the approach without seeing the accompanying text which is briefly referred to in the report section 3.5.8. The red highlighted numerics on the chart obviously refers to notes in the unseen text describing the significant obstacles, of which Blackrock was included. I would have thought that as part of the approach brief, they would have gone through the accompanying text in some detail. If they had done so, they must have been aware of the presence of a 310' high obstacle on the approach path.

We should also remember that the chart does not describe an IFR cloud break procedure. It seems to be just "route guidance" to aid what should be a visual section of the flight. I suspect that elsewhere in the company Ops manual there would have been an offshore cloud break procedure to get them VMC below cloud.

Well thats the hole point.
The sad fact is its not clear enough and not noticed by the crew....easy to say otherwise now...

[Jag Race]

Flashes every 12sec takes 26sec to do a full turn

Shouldn't the time to do a full turn be a multiple of the flash interval?

(That's if it even turns any more. It's solar-powered now).

[FC80]

Makes for pretty grim reading.

It's interesting reading the different interpretations of the CHC route in to Blacksod from various sides - some interpreting it as a full IAP (which it is clearly not), others as a visual approach guide, which I don't really think it is either.

Either way, and wherever the truth lies, it's certainly taught me a valuable lesson regarding any assumption of any kind of obstacle clearance or guaranteed safe tracks using company 'homebrew' procedures.

[Mark Six]

Agree completely with roundwego. You can't look at one page of that particular route guide in isolation from the rest of the information on the second page. Furthermore the crew would have been very familiar with the use of company route guides and would (should) have known of the necessity to read the complete document, the significance of spot heights, and the strengths and limitations of the guide. Without knowing the company SOP with regard to route guides it is premature to apportion "blame" to the route designer or management. For all we know that route may have been restricted to particular weather minima, minimum altitudes, speeds, etc. It certainly doesn't look like it's meant to be used as an instrument approach plate.

[ODEN]

Three why's that need to be asked...

1. Why did they use the company route?
2. Why did the not know about Blackrock and its location?
3. Why did they not have NVD (helmet mounted).?

[HeliComparator]

Three why's that need to be asked...

1. Why did they use the company route?
2. Why did the not know about Blackrock and its location?
3. Why did they not have NVD (helmet mounted).?

4. Why did they not notice a huge blob on the radar (cockpit procedures?)

Just a thought but I wonder how often the flew double-captain. Some captains are pretty bad at doing the copilot role. Of course the most dangerous is two training captains flying together!

[skadi]

An explanation for the missing EGPWS data:
I assume these are based on radar satellite data which results in a 3D model of mother earth. If you look at Blackrock via Google Earth, you will find out that there the elevation is also not more than 12m ( ~39ft ) ...

skadi

[dervish]

Why did they not notice a huge blob on the radar

Completely unfamiliar with the aircraft but the report says it used its Weather Radar in a certain mode, implying a compromise. If it doesn't have a separate search radar, how good is a Weather one at picking up and displaying this?

[llamaman]

Lots of themes to explore here. It so often takes a tragic accident to expose systemic failures and weaknesses in an organisation's culture and operating practices. For those that haven't done it, operating a helicopter and managing a crew at low-level, in the dark, in poor weather and an unfamiliar environment is challenging to say the least. Those that have have all had their sphincter-tightening moments. When I think about it in detail I've had too many 'near-misses' for comfort. One that springs to mind was a very close encounter with a significant mast that was only avoided by a very late call of 'up, up, up' by my sharp co-pilot. And that was on a pre-recce'd low-level route using NVDs and it was a known and accurately marked obstruction!

I guess my point is that with the best will in the world, and multiple safeguards, tragic accidents like this are waiting to happen. Pointing the finger is not helpful; what is required is a very honest and thorough review of every aspect of this accident so that the risk of a similar one happening in the future is removed as far as possible. Only then will the friends, families and colleagues take some comfort in this tragic loss.

[gulliBell]

Completely unfamiliar with the aircraft but the report says it used its Weather Radar in a certain mode, implying a compromise. If it doesn't have a separate search radar, how good is a Weather one at picking up and displaying this?

If I recall from the preliminary report, weather radar was being operated in a ground mapping mode which should have clearly shown ground returns. I think the CVR transcript has the co-pilot mentioning the ground return (Blackrock) as they were turning inbound from the procedure turn.

[gulliBell]

Agree completely with roundwego. You can't look at one page of that particular route guide in isolation from the rest of the information on the second page...

A PROC should be described on a single page, with all the critical information needed to fly it presented in plan and elevation view. I have never seen a PROC spread out over multiple pages.

[JimJim10]

Maybe we should stop beating round the bush.
The operators let down procedure clearly shows Black Rock at 282'
It would have also been visible on Radar and would have been a waypoint in the system. There is no reason not to know that there was a big lump of rock with a light on it that was 282' AMSL. It is the start point of a company procedure not the point to be at 200'.
This is all very sad, who knows if the pilot had reacted immediately when the Winch Operator first called for a right turn would it have been enough; rather than the PF questioning the turn request.

13 seconds between the first (calm) warning of an island and the impact. Heading change completed and confirmed 10secs after this warning. Final shouted warning 3 seconds before impact. Rapid control inputs as that happened. The front crew had no idea what they were reacting to, what actions were required, or how immediately it was required. They reacted as they should to any change in heading without realising the emergency facing them. A fly up command may have been "better" and less confusing to the pilot but we have no right second guessing them.

The flir image would not have given good depth-perception or rate of closure... unlikely that the rear crew realised how close it was either to begin with. Only ten seconds later it was apparant that things were not good.

The world was against them from the start of that 13 seconds unfortunately. They nearly made it. So nearly.

[dervish]

Thanks gulliBell

[[email protected]]

The problem is the managing of the automation - the rearcrew called for the heading change, then the captain asked the co to select the heading so, by the time the heading actually changed it was far too late.

An instant hand-control input to change the heading could have avoided the rock or made the last minute 'f**k me' change of heading sufficient to avoid impact.

There has been much written and said about the 'children of the magenta' and the belief that more automation makes things safer - this accident happened to a perfectly serviceable aircraft with more bells and whistles designed to make the aircraft safer.

[HeliComparator]

The problem is the managing of the automation - the rearcrew called for the heading change, then the captain asked the co to select the heading so, by the time the heading actually changed it was far too late.

An instant hand-control input to change the heading could have avoided the rock or made the last minute 'f**k me' change of heading sufficient to avoid impact.

There has been much written and said about the 'children of the magenta' and the belief that more automation makes things safer - this accident happened to a perfectly serviceable aircraft with more bells and whistles designed to make the aircraft safer.

This is true, but the issue arose only after a major cockup had occurred. I suggest the primary target for any review should be why the cockup occurred, not why the sudden and unexpected need for an evasive change heading (or climb) was executed slower than it could have been.

[gulliBell]

The problem is the managing of the automation...

Exactly. In simulator training, many times I've seen the automation, doing exactly what the crew tells it to do, fly a perfectly serviceable helicopter into the ground whilst the crew watched. When crews are doing "stick and rudder" hand flying, the prevalence of CFIT, in my experience, seems to be far less. The physical interaction of the stick and rudder flying seems to install an additional degree of mental alertness that you just don't see to the same extent when pilots are just monitoring automation. As a teacher it can get frustrating to watch, you feel like ripping out all the automation and have the crews get back to fundamentals and using just the basic set of IFR tools.

[HeliComparator]

Exactly. In simulator training, many times I've seen the automation, doing exactly what the crew tells it to do, fly a perfectly serviceable helicopter into the ground whilst the crew watched. When crews are doing "stick and rudder" hand flying, the prevalence of CFIT, in my experience, seems to be far less. The physical interaction of the stick and rudder flying seems to install an additional degree of mental alertness that you just don't see to the same extent when pilots are just monitoring automation. As a teacher it can get frustrating to watch, you feel like ripping out all the automation and have the crews get back to fundamentals and using just the basic set of IFR tools.

Automation may cause accidents, but far more accidents are caused by humans flying without automation. The trick is to train to use it correctly and appropriately, not to rip it out and hand fly everything.

[[email protected]]

Gullibell - completely agree - over-reliance on the drift diamond or trying to use the heading function of the AP in an NDB hold - proper pilot flying beats them both every time.

HC - by 'cock-up' do you mean using the rock as a WP?

[[email protected]]

jimjimThe flir image would not have given good depth-perception or rate of closure... unlikely that the rear crew realised how close it was either to begin with. Only ten seconds later it was apparant that things were not good.
If they had been wearing NVG, they would have seen the big rock ahead, it should have appeared on the radar picture and the GPWS would have warned them if they had been going faster - lots of holes in the cheese.

[Al-bert]

Automation designed to ease the workload of procedural flying has very little place in SAR, AA or Police work, which is predominantly VFR with IMC outside of controlled airspace. What are 'children of the magenta' btw?

[the coyote]

Al-bert

It refers to a generation of pilots that have grown up using automation.

Youtube: Children of Magenta (https://www.youtube.com/watch?v=pN41LvuSz10)

A presentation well worth watching if you haven't seen it.

[skadi]

What are 'children of the magenta' btw?

Masters of the magenta - the real story - Air Facts Journal (http://airfactsjournal.com/2016/07/masters-of-the-magenta/)

skadi

[rotorspeed]

I'm slightly concerned at the amount of finger pointing already at systemic failure and management responsibility for this. Fundamentally the accident happened because the crew deliberately descended to, and maintained, 200ft at night, in either poor VMC or IMC, and tracked straight towards a 300ft rock that was marked on their more detailed moving map charts and (albeit not ideally) on the approach guidance they were using, and mentioned in the accompanying notes.

There must be a high chance that the crew did not have one of the more detailed charts displayed and had not read the accompanying approach route notes, despite them being unfamiliar with the approach to Blacksod. And when there were warning signs, they were too slow to respond. Whose responsibility can this be, other than the flight crew? It's not as if this was an unplanned, emergency diversion with little time to study - they had been flying en route for an hour an half, presumably with no great crew activity required, before they started descending for Blacksod.

Even before they departed Dublin, surely a major part of their flight planning would have been considering the likelihood of refuelling at either Sligo or Blacksod, and considering how they were going to let down into Blacksod. They presumably had access to charts at Dublin to study ref the Blacksod approach - and certainly my 1:500,000 one shows Blackrock and its height. And then if it was me, (corporate only, admittedly) I would have also looked at Google earth for any further info - where again Blackrock is shown, albeit, as Skadi says, with the wrong elevation - not that you'd take too much heed of this.

Using the approach they chose was clearly a mistake, so why did they? Were they so entrenched in SOPs they just chose one (most common?) that seemed routine, having missed the elevation of waypoint BLKMO and therefore the approach's suitability?

As HC says, is there a too rigid culture in SAR on using early descent to 200ft, regardless of approach purpose? A let-down to re-fuel is very different to let down for actual search and rescue. Given the likely weather (around 2km vis and 300-400ft cloudbase) and the low terrain around Blacksod, something simple like a 500ft/min let down from the west to be at a point say 2 miles south of Blacksod to a MDH of say 200ft would have been safe and probably meant that at that point Blacksod lighthouse would have been visible flashing, to track to. An approach that requires 10nm flying at 200ft at night and in poor vis in sea dotted with islands seems a bad decision.

Surely the crew had enough autonomy to either choose a better SOP - or do what many of us do and plan their own safe let down?

This aircraft had a lot of sophisticated kit on it - but does that lead to over-reliance on it? Eg EGPWS - did they assume this would keep them from hitting anything?

Clearly this is early days and there's still a lot more information and analysis to come before the full report is out. I fully understand flight crew like to protect their own, but ultimately it is important we as pilots recognise the need for us to make our own sensible judgements regardless of others to keep us and our pax alive.

[gulliBell]

Automation may cause accidents, but far more accidents are caused by humans flying without automation. The trick is to train to use it correctly and appropriately, not to rip it out and hand fly everything.

I can tell you this for sure. What I see when teaching in a Level D FFS helicopter simulator, irrespective of the level of experience of the crews, far more accidents happen when automation is involved, than without. To the extent that I feel like ripping out the automation and have the trainees hand fly everything. Logic tells you that automation must be safer. In the training environment, I don't see it.
Of course the opposite case sometimes applies, I feel like ripping out the controls and stowing them in the boot and have the automation do all of the flying. But, generally speaking, the outcomes are consistently better without reliance on automation. Assuming of course the basic IFR skills of being able to fly a heading, airspeed, altitude etc accurately are there; which sadly, often they are not.

[llamaman]

From HC;

"Automation may cause accidents, but far more accidents are caused by humans flying without automation. The trick is to train to use it correctly and appropriately, not to rip it out and hand fly everything."

Totally agree. Modern APs and FMS are fantastic aids to aviation. If utilised correctly (and training is key) they massively offload pilot capacity and allow for far safer operation of aircraft than in the past.

For those dismissing automation I'd be interested to hear what your experience of 'manual' vs 'automated' aircraft is? To say that automation has no place in SAR operations is ludicrous. I suspect that those of us who have operated a cross-section of aircraft across different generations of automation will generally extol its virtues. More often than not it is not automation that causes such accidents but a systemic failure in which numerous factors combine to engineer a disastrous consequence.

[DOUBLE BOGEY]

On the subject of NVG, if they were in limited visibility, would the NVG have helped? I am asking as I am not sure having very limited experience of NVG.

Maybe the FLIR picture being displayed on the Pilots MFDs would have been the best chance of "seeing" the rock and taking the necessary avoiding action by reference to the picture in front of the crew. The FLIR can be overlaid in a 225 but I am not sure if this is possible in the 92.

Its very hard to imagine flying over a red blob on the RADAR screen at 200 feet above the sea regardless of what the mental model was in the crews minds. I wonder if their radar software had a momentary glitch which does happen with overlay technology.

From what has been reported it would seem a very strange procedure to be so low, so far away, from the intended destination.

Llamaman, I think the underlying point about automation in this event is knowing when to use it and when to "take-control" to make a rapid avoiding manoeuvre. The aim of the automation being deployed successfully is to ensure you do not have to take such evasive action. Making sure the automation is taking you on a flight path trajectory that is free from obstructions. I would suggest that in the final moments for this poor crew, the startle effect caused by the increasing urgency of the rear crew call for evasive action and maybe the limited time between receiving he call and reacting to it, defeated them. In any case the act of "gripping it and ripping it" 200 feet above the sea at night is going to be problematic when done in such urgent circumstances.

It routes us back to the underlying cause being a failure to assess the flight trajectory correctly before plugging in the RADALT Height Hold and HDG holds. This is I believe, is what needs to be addressed. How did this failure occur, Was it lack of knowledge, Lack of Information, Lack of safe Procedures or simply a massive error on the part of two experienced flight crew.

The procedure should be safe and take the aircraft to the minima, free from all obstacles. The FLIR, NVG, RADAR, whilst essential to assure safety of the procedure, are in essence superfluous to requirements if the procedure is safe, safely flown and the correct minima observed.

Gullibel, automation is only as good as the training the crews receive to use it. Your job in the FFS is to teach them that. If you feel like "ripping it out" you need to look inward!

[dervish]

Crab@

If they had been wearing NVG, they would have seen the big rock ahead

What would you say was the minimum height one could safely use NVG at night over water? What other factors do you consider? Thanks

[Skylark58]

R118 had already landed at Blacksod to refuel, presumably using the same route guide.Would they have followed the same let down and approach profile as R116?

[HeliComparator]

I can tell you this for sure. What I see when teaching in a Level D FFS helicopter simulator, irrespective of the level of experience of the crews, far more accidents happen when automation is involved, than without. To the extent that I feel like ripping out the automation and have the trainees hand fly everything. Logic tells you that automation must be safer. In the training environment, I don't see it.
Of course the opposite case sometimes applies, I feel like ripping out the controls and stowing them in the boot and have the automation do all of the flying. But, generally speaking, the outcomes are consistently better without reliance on automation. Assuming of course the basic IFR skills of being able to fly a heading, airspeed, altitude etc accurately are there; which sadly, often they are not.

Sounds to me like your crews need better foundation training in how, when, where and why to use automation, when to drop down a level or two, and when to revert to manual!

But I also think your view might be clouded by the narrow type of flying (ie training and testing, lots of emergencies etc, most of the time "abormal operations"). As opposed to the real world where virtually all the time flying is routine, arousal levels low, unexpected sudden changes of plan are rare.

[DOUBLE BOGEY]

Reading the AAIB report it states that the FLIR Image CAN be selected not the MFDS in the Cockpit. Anyone know if there would be a reason not to do this for a low altitude flight with rocks in the vicinity?

[gulliBell]

I've been contemplating the FDR data:

1. The heading trace shows a constant heading in the six seconds before impact (i.e. no lateral avoiding action was happening).
2. At impact, an instantaneous rapid heading change to the right, followed by various rates of right rotation for the remainder of the recording (which you'd expect when the TR ceased to function).
3. The pitch trace shows abrupt aft cyclic flare simultaneously with large collective increase (about 1.5 seconds before impact), rapid NR droop initially, followed by reducing collective and the aircraft climbing slowly at 60kts.
4. NR recovers as engine power increase/collective decrease until point of impact when NR goes slightly high (which you'd expect at the instant the load of the TR is removed).
5. The aircraft continued to climb slowly after impact until the last data point (the last recorded altitude point was about 450').
6. The engines remained at a high/intermediate power setting after impact until the last data point.

[gulliBell]

On the subject of NVG, if they were in limited visibility, would the NVG have helped? I am asking as I am not sure having very limited experience of NVG....


I'm guessing here, but if they had NVG they probably wouldn't have flown the approach they flew. But if they did have NVG and flew the same approach, and I'm guessing again, the outcome would have been the same. The crew in the back could see in front of the aircraft using FLIR, which can image in complete darkness. The cockpit crew would have been looking inside underneath NVG, one flying the other monitoring, knowing the crew in the back could see out the front. In complete darkness the FLIR gives you a better image than NVG, but with very limited depth. NVG provides some depth of view (i.e. 2 tubes providing a stereo image), but out at sea at night under cloud the FLIR they had would provide a much better image than the NVG they didn't have.

[HeliComparator]

HC - by 'cock-up' do you mean using the rock as a WP?

Not exactly, I mean putting the aircraft on a flight path where a terrain collision was going to occur (unless last moment emergency evasive manoeuvre can save it). So not so much using the rock as a waypoint, rather flying at a rock elevation ~300' whilst being at 200'.

One of the problems with learning from this sort of accident, is that we all smugly say to ourselves (privately) that it could never happen to us. Bit like the Clutha bar accident in Glasgow. But nevertheless, these sort of accidents continue to happen, especially when there are not many safety layers to breach. People tend to believe that only other people make stupid human factors mistakes.

[[email protected]]

Not exactly, I mean putting the aircraft on a flight path where a terrain collision was going to occur (unless last moment emergency evasive manoeuvre can save it). So not so much using the rock as a waypoint, rather flying at a rock elevation ~300' whilst being at 200'. and that would appear to be because they didn't realise that the WP they had asked for a 'direct to' was in fact a rock and not just a point in space.

I think legacy procedures may be a factor here - there is no need to let down such a long way out, especially not to 200'.

Since they didn't have NVG, there would be far more tendency to stay 'heads in' even at 200' whereas an NVG-equipped crew would transfer to 'visual' flight, backed up with the AP and sensors, as soon as they got below the cloud.

They must have been VMC below because the FLIR could see the rock - contrary to some opinions, FLIR cannot see through cloud and is very poor when there is little thermal contrast between the objects it is looking at.

The 'heads-in' mindset leads to careful changes of attitude and heading because it is treated like IMC (which it effectively is) hence the slow reaction to the heading request and the use of the HDG function of the AP rather than the flying controls, which would have been much quicker.

The primary fault seems to be the procedure and its design but there are so many contributory factors here that could have been removed from the equation.

Such overwater letdowns are very procedural in nature and can vary in difficulty depending on the weather and proximity to obstacles - I believe they were adequately trained to use the automation in these conditions but somewhere the basics of looking out the window (or the electronic version of checking the radar picture) were lost.

Did the training for the crew include the fact that at 80 kts with the gear down, the GPWS look-ahead distance was restricted to 10'?? And which genius thought that was a good idea for a SAR helicopter?

[llamaman]

I'd be very interested to see a copy of the procedure (and associated notes) they were following. No doubt it will be included in the full incident report.

[SASless]

Someone correct me if I am wrong.....but did not the Chief Investigator of this Accident work at the same Operation in the past?

If he did....what positions did he have while employed?

If so....what effect does that have on the investigation?

[HeliComparator]

I don't think there are many professional pilots here that would ignore 3 low fuel warnings

If indeed that's what happened - we don't know for certain that the warnins were visible and even if they were, the guy seemed pretty competent and if he can do it, so can we all, especially if we adopt the "it couldn't happen to me" attitude. You are rather making my point for me!

[Al-bert]

:ok: Thank you Coyote and Skadi!

[roundwego]

Any thoughts on why the defined track goes over the top of Black Rock? Would it not have been more sensible for the inbound track to have been more from the south west passing half way between Black Rock and Saddle Head.

[Bayerische]

Someone correct me if I am wrong.....but did not the Chief Investigator of this Accident work at the same Operation in the past?

If he did....what positions did he have while employed?

If so....what effect does that have on the investigation?


I don't think he flew for CHC. He flew SAR in the Dauphin for the Irish Aer Corps.

https://ie.linkedin.com/in/jurgen-whyte-3a093ba

[glenbrook]

Time and again, EGPWS breaks the accident chain | Business Aviation News: Aviation International News (http://www.ainonline.com/aviation-news/aviation-international-news/2008-01-22/time-and-again-egpws-breaks-accident-chain)

Not this time :(

[Al-bert]

Bayerische He flew SAR in the Dauphin for the Irish Aer Corps
He was commandant of the Air Corps SAR when I knew him 87-99 ish

[HeliComparator]

Any thoughts on why the defined track goes over the top of Black Rock? Would it not have been more sensible for the inbound track to have been more from the south west passing half way between Black Rock and Saddle Head.

I think as was said earlier, before the days of GPS it was common to base routes on things rather than imaginary points in space. It would be interesting to know when that procedure was created, and when it was last significantly revised.

[SASless]

The question about that absent data lies with the Operator as the system has the ability for User additions to the Database. The data on Blackrock should have been there no doubt.....but there are limitations to any system when it comes to the areas the systems memory will be programmed to cover. In all likelihood the database area of coverage did not anticipate low level flight operations near Blackrock such as the ICG performs.

The Operator could have ensured all potential landing sites or areas of operation were in fact properly contained in the database.

Had the Operator surveyed,checked, and documented formal IMC Point-in-Space Approaches to every known location IMC Approaches would be conducted....and incorporated the advanced capabilities of the S-92 SAR Avionics System then this particular tragedy would have been avoided.

The aircraft can safely terminate at a hover over a pre-determined point without the Crew seeing the surface and both track, height, and angle of approach be safely controlled by the aircraft systems.

Had that been done....the Crew would have been assured of terrain clearance and enjoyed much greater Situational Awareness and not been down at 200 feet at Ten Miles from the Landing Point. Had the Crew had NVG's.....it is very likely the Flight Crew could have seen the Light or Light House and Blackrock itself and afford them the ability to avoid the collision with terrain.

One Man's Opinion here.....this Crew were handed a Time Bomb by Management, Training, and Safety. The Operator failed to change from old ways and failed to embrace new technology that requires a change of Mindset and Safety Culture.

If there is any good that can come from the loss of four very experienced, professional, and dedicated people who lived to save others.....hopefully this tragedy shall result in a serious over haul of the SAR Operation and its Safety Standards. We owe that to those lost while helping others!

Time and again, EGPWS breaks the accident chain | Business Aviation News: Aviation International News (http://www.ainonline.com/aviation-news/aviation-international-news/2008-01-22/time-and-again-egpws-breaks-accident-chain)

Not this time :(

[[email protected]]

In that article in glenbrook's link, the main thing the creator of GPWS acknowledges is the limitations of the database - does that fact get included in any training?

[roundwego]

SASless, you said

The question about that absent data lies with the Operator as the system has the ability for User additions to the Database. The data on Blackrock should have been there no doubt.....but there are limitations to any system when it comes to the areas the systems memory will be programmed to cover. In all likelihood the database area of coverage did not anticipate low level flight operations near Blackrock such as the ICG performs.

Are you sure you are correct in your statement about user data being able to be added to the EGPWS database? My understanding is that any new obstacles etc has to be notified to the equipment manufacturer for inclusion in the very infrequent updates. i don't think it is reasonable to expect the operator to check the whole egpws database for correctness.

I know the egpws database has its origins many years ago when computer memory was expensive and the database had extremely low resolution to keep the file size small. An obstacle such as a radio mast would show up as a 1km square block on the screen and the mast would not necessarily have been in the centre of the square. In fact, if the mast was exactly at the meeting point of 4 blocks on the map grid, it would show up as a 2x2 km block. I am not aware that the database has become higher resolution in recent times. Having said that, there is no excuse for Black Rock not to be in the database.

(I may be incorrect in the size of the egpws map grid blocks because, being an American product, I would have thought the units would have been non metric)

[noooby]

So why did no member of the crew notice a honking great lighthouse shining at them?

Even in IMC, when you get close to it, it will light up the inside of the cloud.

When you're VMC and co-alt, it should be shining right into the cockpit, and those things are BRIGHT!

Lighthouse service says it was on at the time (as in, remotely switched on), but was it actually working? Why would it not have been noticed? The first anyone seems to know of an obstacle (despite the Co-Pilot having Radar displayed in GMAP mode on his MFD), is when the crew in back ask for a right turn.

The 701 radar has pretty good ground mapping. And it will do it to a close enough range that objects don't disappear from the display until you're nearly on top of them (unlike the 660 radar), so why no visual of the light and no radar sighting of a b***dy great rock in front of you?

[noooby]

crab, are crew trained to appreciate that EGPWS is not approved for navigation? Or is that fact passed over and they learn to trust it more than perhaps they should?

Although, with their speed, altitude and the fact that the gear was down, warning and caution messages relayed to the crew would be limited and different to a situation where they were faster with the gear up.

[[email protected]]

crab, are crew trained to appreciate that EGPWS is not approved for navigation? Or is that fact passed over and they learn to trust it more than perhaps they should?
Good question nooby and I think it will come back to the reliance on automation again - we get given the new gucci kit and don't expect it to go wrong.

The main difference between the Mk 3 and the Mk 3A Sea King was the AP - the Mk 3 was single channel, steam driven and it's failure modes could easily put you in the water so the crews watched it like a hawk. The 3A had a duplex digital AFCS which hardly ever went wrong, had benign failure modes and was very good so crews trusted it - sometimes more than they should have.

The S92 is in another dimension as far as capability goes so it is very easy to see how complacency can creep in.

[212man]

SASless, you said



Are you sure you are correct in your statement about user data being able to be added to the EGPWS database? My understanding is that any new obstacles etc has to be notified to the equipment manufacturer for inclusion in the very infrequent updates. i don't think it is reasonable to expect the operator to check the whole egpws database for correctness.

I know the egpws database has its origins many years ago when computer memory was expensive and the database had extremely low resolution to keep the file size small. An obstacle such as a radio mast would show up as a 1km square block on the screen and the mast would not necessarily have been in the centre of the square. In fact, if the mast was exactly at the meeting point of 4 blocks on the map grid, it would show up as a 2x2 km block. I am not aware that the database has become higher resolution in recent times. Having said that, there is no excuse for Black Rock not to be in the database.

(I may be incorrect in the size of the egpws map grid blocks because, being an American product, I would have thought the units would have been non metric)
Yes, and the report states that in the quote from Honeywell. It's done by the operator providing the data to Honeywell and they include it in the update cycle.

[cncpc]

R118 had already landed at Blacksod to refuel, presumably using the same route guide.Would they have followed the same let down and approach profile as R116?

I asked that and another poster pointed out that R118, out of Sligo, was much more familiar with the area and would have known of Blackrock and the need for a higher altitude in that part of the approach.

[roundwego]

Yes, and the report states that in the quote from Honeywell. It's done by the operator providing the data to Honeywell and they include it in the update cycle.

That's what I thought. I read your statement as the operator having the ability to add data directly to the aircraft database without having to involve Honeywell.

I think the discussion about EGPWS is a bit of a red herring as in the described aircraft configuration, no warning would have been given even if Black Rock had been in the database as the system would have assumed the crew were making an approach to land on the helipad - low speed, gear down.

[rotorspeed]

SAS

"One Man's Opinion here.....this Crew were handed a Time Bomb by Management, Training, and Safety. The Operator failed to change from old ways and failed to embrace new technology that requires a change of Mindset and Safety Culture."

That's a pretty damning statement about the management of this SAR operation. All those involved will no doubt have pride and strive to be professional, like the flight crew. What information are you relying upon to conclude that?

[Galwayguy]

Did the crewman, who spotted the Island, give a strong enough warning ? Is there a language protocol that means you are giving an immediate instruction rather than an advisory ?

[roundwego]

Alphanumeric wrote;-

They crashed into the ground as they did not realise the terrain was higher than sea level.

All this talk of databases, waypoints, EGPWS, safety culture, procedures etc does not detract from the fact that there was no proper two-crew approach brief* that discussed the elevation of Blackrock and how the approach was going to be conducted. This is standard offshore 2-crew procedure.

*Just like there was no proper 2-crew departure brief in the G-LBAL accident.

Yet another uneducated conclusion. How do you know there was not a proper two crew approach brief? They both acknowledged they were unfamiliar with the area. The report does indicate there was an approach brief but acknowledges there was no mention of the presence of Black Rock nor the lighthouse. The big question was why? I cannot believe the crew were anything but conscientious in carrying out there task so one can only assume, there was a deficiency in the way the terrain information was presented or the way the procedure was designed. As I mentioned previously, I don't understand why the prescribed track went directly overhead a 300' high lump of granite and brick.

Alphanumeric, to blame the crew in such simplistic terms puts your own professionalism in doubt.

[Thunderbirdsix]

Any time I saw Rescue 115 or 118 head to Blacksod on Marine Traffic they route along the Coast Line, Rescue 115 heads up over Galway Bay to Clifden then along the coast to Blacksod, 118 departs Sligo straight along the coast then down to Blacksod, I guess with 116 coming cross country the first coastline they encounter is Blacksod

[boatmad]

Alphanumeric wrote;-



Yet another uneducated conclusion. How do you know there was not a proper two crew approach brief? They both acknowledged they were unfamiliar with the area. The report does indicate there was an approach brief but acknowledges there was no mention of the presence of Black Rock nor the lighthouse. The big question was why? I cannot believe the crew were anything but conscientious in carrying out there task so one can only assume, there was a deficiency in the way the terrain information was presented or the way the procedure was designed. As I mentioned previously, I don't understand why the prescribed track went directly overhead a 300' high lump of granite and brick.

Alphanumeric, to blame the crew in such simplistic terms puts your own professionalism in doubt.


The report clearly mentions that the approach briefing notes and moving map contained data showing blackrock and its heights etc . It did not contain any comment as to whether the crew accessed such information

[[email protected]]

All this talk of databases, waypoints, EGPWS, safety culture, procedures etc does not detract from the fact that there was no proper two-crew approach brief* that discussed the elevation of Blackrock and how the approach was going to be conducted. This is standard offshore 2-crew procedure. And this was not an approach to Blackrock as a LS - that would have required such a brief - this was part of a letdown to cloudbreak to get to Blacksod.

Therefore all the talk about databases, GPWS and especially the construction of the procedure is absolutely valid.

Do you include a brief during a procedural letdown to a rig on EVERY WP in the FMS? I suspect not - such detail would be confined to the final approach to the LS/rig itself.

[cncpc]

They crashed into the ground as they did not realise the terrain was higher than sea level.

All this talk of databases, waypoints, EGPWS, safety culture, procedures etc does not detract from the fact that there was no proper two-crew approach brief* that discussed the elevation of Blackrock and how the approach was going to be conducted. This is standard offshore 2-crew procedure.

*Just like there was no proper 2-crew departure brief in the G-LBAL accident.

All terrain is higher than sea level.

The accident report distinctly says there was an approach briefing. It can be inferred that the crew was unaware of Blackrock as a piece of terrain at 300 feet. It does seem that Capt. Fitzpatrick was aware of rocks there as she knows why the altitude warning sounds, but she thinks they are over the waypoint. So she knows the waypoint is over "terrain", but obviously doesn't know its height. In fact, even though they are only at 200 feet, she is not concerned by the alerter.

What does APBSS mean at the top of that chart we are considering some kind of buck shee or homemade approach "plate"? On looking at it, it seems that it is more likely a VFR day or night or reduced viz transit route from heliport to heliport as Blackrock and Blacksod are terminus points. There is no real indication that some approach procedure for Blacksod keys on Blackrock or the waypoint.

Inbound to Blackrock from the east, it is clear that the intention is to land at Blackrock heliport. It is a straight in approach with a presumption of VFR conditions or at worst reduced viz. There is no scenario of approaching it from the ocean to the west. That may provide an explanation at least why this seems to be a very inadequate IMC procedure. It wasn't meant to be.

Leaving Blackrock also assumes you are lifting off from the heliport for Blacksod, which does have a bit of an indirect routing. There is no scenario in which you pass over Blackrock.

For whatever that is worth, the question then is whether this "approach" is programmed into the FMS, or whether each waypoint is sequentially selected manually by a Direct To button and the waypoint. The error in that would be assuming it is an IFR approach.

[Search&Rescue]

Noooby

Maybe it was one important detail that most likely they didn't have the radar target (a b***dy great rock) in front of them! I may be wrong, but it is my understanding that the heading was approximately 120 degrees and due to the wind the track was 098 degrees. And if you have 10 NM scale on your radar, it is not always that easy to realise that you are drifting to an obstacle if you are pretty close (e.g. 0,3 nm) with that kind of drift angle... But I agree that the 701 radar is very good for ground mapping...

[Al-bert]

Noooby

Maybe it was one important detail that most likely they didn't have the radar target (a b***dy great rock) in front of them! I may be wrong, but it is my understanding that the heading was approximately 120 degrees and due to the wind the track was 098 degrees. And if you have 10 NM scale on your radar, it is not always that easy to realise that you are drifting to an obstacle if you are pretty close with that kind of drift angle... But I agree that the 701 radar is pretty good for ground mapping...

and 'children of the magenta' deride the Sea King blind arc! :=
Maybe a 'clear blind arc left' might have helped in this case? :(

[[email protected]]

Inbound to Blackrock from the east, it is clear that the intention is to land at Blackrock heliport. It is a straight in approach with a presumption of VFR conditions or at worst reduced viz. There is no scenario of approaching it from the ocean to the west. That may provide an explanation at least why this seems to be a very inadequate IMC procedure. It wasn't meant to be. No, there was never any intent to land at Blackrock - why on earth would there be? Blackrock was 2 things - firstly a WP in the company letdown route to get to Blacksod and secondly a bloody great rock on the way to do so. The fact that they were overlaid on a procedure without any clear indication of the threat is the real issue here.

Al-bert - agreed, you and I both know that it would not have happened in a SK letdown because we had a dedicated radar operator rather than an over-tasked co-pilot to stop us bumping into things.

[Al-bert]

Al-bert - agreed, you and I both know that it would not have happened in a SK letdown because we had a dedicated radar operator rather than an over-tasked co-pilot to stop us bumping into things.

Exactly Crab!

[Democritus]

.....Inbound to Blackrock from the east, it is clear that the intention is to land at Blackrock heliport. .....

That would be quite impossible in a S92 due to its size. I've landed many times on the Blackrock pad, but with a much smaller Bo105 - admittedly the last time was almost 45 years ago - and from photos the pad hasn't increased in size since then.

[cncpc]

No, there was never any intent to land at Blackrock - why on earth would there be? Blackrock was 2 things - firstly a WP in the company letdown route to get to Blacksod and secondly a bloody great rock on the way to do so. The fact that they were overlaid on a procedure without any clear indication of the threat is the real issue here.

Al-bert - agreed, you and I both know that it would not have happened in a SK letdown because we had a dedicated radar operator rather than an over-tasked co-pilot to stop us bumping into things.

Maybe I wasn't clear on that. I was talking about that APBSS generally, the Approach Blacksod South, I turns out is what that stands for. My point was to suggest that it seems to be a transit route from heliport to heliport at each lighthouse. Eastbound off Blacksod, the arrows going the other way lead to the heliport at Blackrock. Conversely, the route seems to be for a machine that has lifted off Blackrock heliport. Which eliminates the possibility of hitting Black Rock.

There is nothing on this "approach" that takes place east of Black Rock. So the part of the flight we know did go east seems to be some letdown procedure APPS1 at the crew's option, following which they would join into a procedure which is based on a helicopter taking off from Blackrock light and going to Blacksod, likely the normal procedure in servicing Blackrock light, which is unmanned.

Someone, perhaps you Crab, has already pointed out that this seems not to be a real IFR approach. Others have said it seems stupid to base a letdown point around a 300 feet rock. It is. But this chart does not show any procedure east of Black Rock.

Is there a APBR? page in the route guide, some approach for Black Rock? Or is it just the reverse of the Black Sod approach, or what seems like it may be the missed for Blacksod.

It is not unusual that this crew is not familiar with Black Rock. They are an S-92 crew in an aircraft that as I understand cannot use Black Rock heliport. So they have never been out there. They haven't even been to Blacksod for quite a while.

If you know Blackrock is 300 feet high, and you know APBSS is a chart limited to use for helicopters transiting between Blackrock and Blacksod, then you aren't considering it an approach for a machine that doesn't initially lift off Blackrock. Sure, it can be used from Black Rock eastbound, but only if you cross BLKMO at say 1500 and step down going through the other fixes to 200 at wherever makes sense to be at that altitude on the final into Blacksod.

I don't see why a flight needs to go that far out, when a Trans Down to VFR at 200 at say BKSDA works better.

[cncpc]

That would be quite impossible in a S92 due to its size. I've landed many times on the Blackrock pad, but with a much smaller Bo105 - admittedly the last time was almost 45 years ago - and from photos the pad hasn't increased in size since then.

Thanks Democritus, for confirming what I said in the post above in response to Crab. I had seen somewhere that you couldn't land an S-92 there as it seems tight to the structure. I never meant to be taken to mean that R116 was attempting to land at Blackrock.

Hopefully I've made my small issue clear about that APBSS being an "approach" only in terms of flight from one helipad to the other. And, that if you know the Black Rock waypoint is also a pad, and that it's 300 feet ASL, you can cook up something which begins at Black Rock, but at a higher altitude. I'd say that is what R118 did earlier, or used only part of the APBSS.

[SASless]

Crab,

But did not that Radar Operator have a Blind Spot looking ahead?

The 92 FLIR Operator identified the Terrain and asked for a Turn.....not the same advanced warning as the Radar Operator might have been able to give for sure.

We can agree that there are some glaring issues that should have been addressed long before this Crew took to the Air....and few of them were under their direct control.

As another ICG S-92 Landed at Blacksod just an hour or so before this Crew crashed.....it will be interesting to hear how they managed not to hit Blackrock in the process.

What did they do....or not do....that lead to their success I wonder?

I would enjoy being on the Accident Board.....and be able to ask so many questions of numerous parties about their actions and in-actions that might have played a role in the Accident Chain for this tragedy!

[Al-bert]

Crab,

But did not that Radar Operator have a Blind Spot looking ahead?



The blind arc was 14 deg either side of dead ahead. It was SOP to regularly 'clear the blind arc' by a brief turn left or right (depending on drift) under the direction of the radar operator. This particular accident, as Crab said, would not have occurred in one of our SKs.

[SASless]

Additionally.....yours was not a dual purpose Weather Radar and probably had much better definition of surface objects too I bet.

[Al-bert]

And being raw radar on the Mk 3 it had Admiralty Charts (including lighthouse characters and elevation) or OS maps overlaid as required.

[The SAR RC]

Non-SAR operators posting on here and questioning the wisdom of this kind of approach need to remember that it should be a simple procedure for a well trained SAR crew. Imagine for one second that Blacksod was not a refuel point but the position of an injured person. Would there have been a procedure? Of course not, they'd have used the kit on board to ease their way in. As it was, they followed and trusted a procedure that it seems like none of them had flown and in doing so, missed the basics, namely checking what's on the radar.

[SASless]

It was not a Survivor....and was a planned destination for refueling.

One that was used by a an earlier flight that same evening.

The Operator had every opportunity to create a known safe IMC procedure for use by Crews....even those un-familar with the site. The Route Guide failed to rise to the level needed to accomplish that.

If it were a Survivor and thus could be anywhere within the Area of Operations then your comment would be valid.....but it was not.

Shortly after the crash, I went to Google Earth and took a gander at the area around Blackrock and Blacksod and noticed two bits of Rock near Blackrock and the thought that went through my mind was that it would be possible for a crew to perhaps over look them or confuse them with Blackrock somehow if the weather precluded visual contact with the Lighthouse illumination.

I do not believe this is the time or place to see a RAF SAR vs Civvie SAR argument be renewed. Pointing out the differences in equipment and procedures is fine....but what is being discussed is how an experienced Crew in a well equipped aircraft came into contact with terrain.

[Red5ive]

RTÉ - Today with Sean O'Rourke

Rescue 116 Preliminary Report
14 April 2017, 13:00

Graham Liddy, Aviation Safety Consultant, (ex AAIU)
Lorna Siggins, Irish Times Marine Correspondentmp3
http://podcast.rasset.ie/podcasts/audio/2017/0414/20170414_rteradio1-seanorourke-rescue116p_c21159706_21159713_232_.mp3

Newstalk - Pat Kenny Show

Understanding the report on the crash of Rescue 116
14 April 2017, 11:32

with the help of with aviation safety expert and former Air Corps Lt Col Kevin Byrne.mp3
https://cdn.radiocms.net/media/001/audio/000029/187834_media_player_audio_file.mp3


Questions to be asked about navigational devices on Rescue 116
- Gerry Byrnehttps://www.irishtimes.com/news/ireland/irish-news/questions-to-be-asked-about-navigational-devices-on-rescue-116-1.3048795


The clip from RTE, Graham Liddy suggests the obstacle data probably came from a state dept, Dept of Transport possibly getting data from OSI (https://www.osi.ie/) and IAA (https://www.iaa.ie/). Where does Honeywell source that data?

Hard to believe anyone has better maps of Ireland than OSI.

[gulliBell]

So why did no member of the crew notice a honking great lighthouse shining at them?
..

Isn't the light beam columnated? The light wouldn't go up into the cloud, it's angled down towards the surface. And at one flash every 12 seconds, they might not have been below cloud for long enough before hitting the rock for the light to be visible to them. But yes, from 500' up even if you were in cloud, you'd expect to see the light, or the clouds light up around you, every 12 seconds from a few miles out.

The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself". This call came 15 seconds after the co-pilot reported 1.3 miles to BLKMO. This I just don't understand, it's evidence of a breakdown in SA. I mean, when you've just been told BLKMO is 1.3 miles in front of you (according to GPS), and there is a radar target 6 miles ahead of you, how could that radar target possibly be BKLMO? What that target probably was is Duvillaun More, which you'd expect to be at 11 o-clock on radar because the next segment takes you to the right of it. And the co-pilot should have identified the radar target as a possible obstacle on the next segment by looking at the map, and he didn't question the pilot when it should have been obvious that a radar target 6 miles in-front of you couldn't possibly be a GPS waypoint only 1 mile in-front of you. And another thing I don't understand, when the co-pilot reported 1.3 miles to BLKMO, there MUST have been a big red target directly in front of him on the radar (assuming the radar was set to 10nm arc and 1.3nm is still in the detectable range). Also, the crewman told the pilot the island was visible directly ahead 15 seconds before impact, and to come right. In the 6 seconds before hitting the rock the FDR shows they were not making any heading change to ensure lateral separation.

From 200' above the surface and at 3nm range, a 300' island in-front of you would probably indicate on the radar screen as an obvious red blob with little depth, probably with no other colours evident, probably with some sea clutter either side of it, with a great big arc of black for miles and miles behind it. And as you got closer to the target the red blob would be getting bigger and bigger, and the black arc behind it would stay just as black. That great big arc of black behind a red radar return should attract your attention, because that black area with no radar returns is potentially dangerous. It's dangerous of course because a big island in-front of you has bounced all the radar energy back to you, and nothing behind it can be detected. If it was only a small island with little elevation the radar image would be completely different, you should see sea clutter returns only a short distance behind the red return. I've got a hunch the radar was painting a good picture of what was in-front of them for the last 6nm, but there was no proper interpretation of what the radar was telling them.

I know it's easy to be critical from armchair comfort with the benefit of time and hind-sight and the rest of it, but the brutal reality of it is, I don't see much PIC stuff going on. The pilot said virtually nothing of substance through the whole of the end of CVR transcript, when the aircraft was getting in an imminent state of peril. And the bit the pilot did say about BLKMO was obviously wrong but it wasn't corrected by the co-pilot. Blackrock must have been detectable on the radar directly in-front of the aircraft for the whole of the track inbound to BKLMO, and it should have been identified and reported as a hazard to the pilot, but it wasn't. The warning from the rear crew about the rock in-front of them either wasn't made forcefully enough, or wasn't acted on quickly enough (no avoiding action was being taken in the 6 seconds before impact). My reading of that little bit of CVR transcript is not enough of substance was being said amongst the crew. My flight instructor used to say "silence is bad CRM" - for me, and again this is being said from the comfort of my armchair, there is just too much silence on that CVR transcript.

[pilot and apprentice]

Isn't the light beam columnated? The light wouldn't go up into the cloud, it's angled down towards the surface. And at one flash every 12 seconds, they might not have been below cloud for long enough before hitting the rock for the light to be visible to them. But yes, from 500' up even if you were in cloud, you'd expect to see the light, or the clouds light up around you, every 12 seconds from a few miles out.

The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself". This call came 15 seconds after the co-pilot reported 1.3 miles to BLKMO. This I just don't understand, it's evidence of a breakdown in SA. I mean, when you've just been told BLKMO is 1.3 miles in front of you (according to GPS), and there is a radar target 6 miles ahead of you, how could that radar target possibly be BKLMO? What that target probably was is Duvillaun More, which you'd expect to be at 11 o-clock on radar because the next segment takes you to the right of it. And the co-pilot should have identified the radar target as a possible obstacle on the next segment by looking at the map, and he didn't question the pilot when it should have been obvious that a radar target 6 miles in-front of you couldn't possibly be a GPS waypoint only 1 mile in-front of you. And another thing I don't understand, when the co-pilot reported 1.3 miles to BLKMO, there MUST have been a big red target directly in front of him on the radar (assuming the radar was set to 10nm arc and 1.3nm is still in the detectable range). Also, the crewman told the pilot the island was visible directly ahead 15 seconds before impact, and to come right. In the 6 seconds before hitting the rock the FDR shows they were not making any heading change to ensure lateral separation.

From 200' above the surface and at 3nm range, a 300' island in-front of you would probably indicate on the radar screen as an obvious red blob with little depth, probably with no other colours evident, probably with some sea clutter either side of it, with a great big arc of black for miles and miles behind it. And as you got closer to the target the red blob would be getting bigger and bigger, and the black arc behind it would stay just as black. That great big arc of black behind a red radar return should attract your attention, because that black area with no radar returns is potentially dangerous. It's dangerous of course because a big island in-front of you has bounced all the radar energy back to you, and nothing behind it can be detected. If it was only a small island with little elevation the radar image would be completely different, you should see sea clutter returns only a short distance behind the red return. I've got a hunch the radar was painting a good picture of what was in-front of them for the last 6nm, but there was no proper interpretation of what the radar was telling them.

I know it's easy to be critical from armchair comfort with the benefit of time and hind-sight and the rest of it, but the brutal reality of it is, I don't see much PIC stuff going on. The pilot said virtually nothing of substance through the whole of the end of CVR transcript, when the aircraft was getting in an imminent state of peril. And the bit the pilot did say about BLKMO was obviously wrong but it wasn't corrected by the co-pilot. Blackrock must have been detectable on the radar directly in-front of the aircraft for the whole of the track inbound to BKLMO, and it should have been identified and reported as a hazard to the pilot, but it wasn't. The warning from the rear crew about the rock in-front of them either wasn't made forcefully enough, or wasn't acted on quickly enough (no avoiding action was being taken in the 6 seconds before impact). My reading of that little bit of CVR transcript is not enough of substance was being said amongst the crew. My flight instructor used to say "silence is bad CRM" - for me, and again this is being said from the comfort of my armchair, there is just too much silence on that CVR transcript.

To add to my last...

There would be no red blob, they were in GMap which gives gives a blue/green/purple palette with less contrast. Pedantic, perhaps, but I am highlighting that so much of the comments are based on a basis of knowledge and experience not directly related to this incident.

Yes, the radar should have been painting a return but I am reminded that radar does not paint vertically. A shoal and a cliff can appear the same and we can easily see what we expect to see...

I do agree that they weren't saying much. 2:46 was the first indication of the island, calmly reported and responded to. But until 10 seconds later, 2 seconds before impact it looks like a typical sterile cockpit in minimum weather.

Most appear not to have actually read the report (not you GulliBell).

The proximate and fatal error was that the crew were unaware the waypoint was also an island. Most of the rest of the errors follow from that clearly flawed mental model of the route.

In the report, it is an assumption that the camera was how the island was seen, not confirmed fact...

And I won't bother to repeat the observations I made previously about my own experience with these routes (not procedures).

I do recognize that the UK seems to have a different practice with regard to IMC letdowns to off airport locations and I don't know if similar practice applies to Ireland. Where I have flown, I would not expect a useful IAP to Blacksod to be approved by the CAA.

[[email protected]]

I do not believe this is the time or place to see a RAF SAR vs Civvie SAR argument be renewed. Pointing out the differences in equipment and procedures is fine....but what is being discussed is how an experienced Crew in a well equipped aircraft came into contact with terrain. the valid point about procedures in this case (without reopening the debate) is that instead of having a dedicated radar operator who controls the letdown (and can have a FLIR picture on one screen and the radar on another) while the copilot concentrates on monitoring the pilot, the AP and the nav - you have instead the co-pilot doing everything whilst the two very capable guys in the back can only interject if they see something on their screens they don't like.

Because in civilian SAR, the rearcrew are not flightcrew (no licences) they are not allowed to be responsible for the navigation of the aircraft - this is such a waste of crew resources simply because civil aviation regards anyone not in the cockpit as cabin crew.

Those rearcrew who are ex-mil will probably still try to take as much of an active part in any letdown because that is the way they are wired - those who have spent their time as 'cabin crew' are perhaps used to being 'ignored' which might explain why the request for heading change was not made more forcefully.

[gulliBell]

...Those rearcrew who are ex-mil will probably still try to take as much of an active part in any letdown because that is the way they are wired..

The ex-mil rear crewman I have had always know the track and distance to the next waypoint, and the minimum height on that sector, and on reaching that waypoint, which direction to turn, and on to what heading. They follow the procedure all the way with their finger on the map. If I deviate from anything they expect, they will bark at me.

[gulliBell]

..Yes, the radar should have been painting a return but I am reminded that radar does not paint vertically. A shoal and a cliff can appear the same and we can easily see what we expect to see...

The radar still provides useful information to determine a shoal from a cliff. With antenna tilt adjustments a shoal will be surrounded by sea clutter, and it will be painted with some depth. A cliff will be painted with virtually no depth, and nothing but black behind it. It's that black area immediately behind a strong return with little depth that should set off alarm bells in the mind. Same applies for weather interpretation.

[LordFlashheart]

Airborn radar approches has been used for a very long time and would have been safe approaching Blacksod. The focus would have been 100% on the radar if doing an ARA.
Unfortunally it seams the crew where lead into false safety following a company route that was not quality assured and risked assesed. A big responsibility lies on all parts of management and training...

ARA's are not approved within 30NM of land. The newer regulations (i.e. CASA exemptions in Australia) are approved within 15NM of terrain. The weather RADAR is only used for target ID as there is no terrain in the area and a RADAR return is the only way to ID the target. So, unfortunately, weather radar is not a great solution for terrain avoidance in this situation, only weather avoidance

[bigglesbutler]

ARA's are not approved within 30NM of land. The newer regulations (i.e. CASA exemptions in Australia) are approved within 15NM of terrain. The weather RADAR is only used for target ID as there is no terrain in the area and a RADAR return is the only way to ID the target. So, unfortunately, weather radar is not a great solution for terrain avoidance in this situation, only weather avoidance

Not sure if it has changed in the uk but when I left I found that 30nm restriction was only in australia.

Si

[ODEN]

ARA's are not approved within 30NM of land. The newer regulations (i.e. CASA exemptions in Australia) are approved within 15NM of terrain. The weather RADAR is only used for target ID as there is no terrain in the area and a RADAR return is the only way to ID the target. So, unfortunately, weather radar is not a great solution for terrain avoidance in this situation, only weather avoidance

Yes it is for SAR, dont mix SAR with CAT.
Every country have its own regulation.

[Max Contingency]

Among the many many learning points here, I would like to propose two more:

Some vertical guidance alongside a company FMS roue that uses islands as waypoints?

Fly all IMC (non navaid) letdowns in Heading or Auto hover mode? These are dynamic procedures and it is easier and quicker to react to shipping, terrain, crew instructions, wind changes, escape headings etc.

[[email protected]]

Max - :ok:

[Triskelle]

The Preliminary Report page 15 states:
In relation to Black Rock and its Lighthouse the EGPWS manufacturer informed the
Investigation that “The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in our terrain database.”
and the Preliminary Report page 17:
Figure No.4 shows the Operator’s Route Guide for Blacksod (designated ‘APBSS16
(Blacksod South) Route’) which the Crew of R116 was using at the time of the accident.
The Route Guide includes an associated separate page of text setting out, inter alia,
waypoint designations and coordinates, hazards and obstacles and other general
comments. This page identified a lighthouse at Black Rock with an associated height of 310’.


However, without resort to the separate page of text, the map from the Route Guide in Figure 4 shows a spot height of 282 ft at BLKMO, which is presumably the terrain height of Black Rock (not including the height of the lighthouse)?


I attended a talk by a Honeywell representative several years ago who suggested CFIT would soon be a thing of the past because the database included every feature and building on the planet.

[gulliBell]

...However, without resort to the separate page of text, the map from the Route Guide in Figure 4 shows a spot height of 282 ft at BLKMO, which is presumably the terrain height of Black Rock (not including the height of the lighthouse)?


The height of the light is 282 feet above the local high water mark. Add a few feet to get the top of the light house.

[SARWannabe]

Excuse my ignorance, but in the most sophisticated helicopters in the civilian world, why aren't all known planned landing sites such as Blacksod provided with GPS approaches with a vertical profile akin to that of an ILS, flown (in the case of SAR) to a very low-minima using auto hover if required? They take very little time to develop, and the cost would be negligable on a £500m contract. I get the necessity for ARA let downs to unknown rescue locations, but routine landings for fuel? I'd argue that the risk philosophy should be closer to that used in HEMS. At adhoc HEMS operating sites, rarely used more than once, the risk permitted is at it's highest in order to facilitate getting the job done. However at hospitals, and hems operating bases, refuel locations etc, used regularly there should be less alleviation as they are planned landing sites, used at a higher frequency, that can be known to the operator, thus procedures can be put in place and followed.

The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling. A paper chart, or an iPad and Runway HD would have improved their SA, over all the kit & radar in an S92? Are we saying there is no simple moving map with an OS layer, or chart in the cockpit?

[pegasusflash]

You're not living up to your name O&W.

The chart doesn't show Blackrock at 282'. It shows a waypoint called BLKMO with a caption next to it of 282 with no clue as to its relevance. Is it waypoint 282 in the operators manual ? Is it the depth of the sea at this point ? Is it the QDM from some unspecified navaid on the mainland ?

The island would indeed have been visible on radar and on the EO/IR display if that was available in the cockpit, and for that mistake and the few seconds pause whilst they assimilated the rear crew's input this crew paid with their lives.

However the people that put them in this situation by promulgating a thoroughly misleading chart, and the people that validated a flawed terrain database have yet to be held accountable for their role in this accident. And I'm willing to bet that their punishment will be less severe.

Has anyone read section 3.5.8 of the report? I think it's quite relevant, it clearly states that a page of text accompanied the flight route and included information about blackrock and the lighthouse height amsl. Raises some questions?.

[Woolf]

Although there are a number of quite significant contributory factors, I think the main point here is that regardless of whether a published procedure is followed or not, any low-level flight over water in IMC, at night or in marginal conditions MUST use the radar as the PRIMARY navigation aid. If a radar return cannot be positively, visually identified it MUST NOT be overflown. Besides islands there are plenty of moving marine obstacles that can easily reach 300ft or more which would not be on any map, chart or in any database. Whether radar guidance is achieved from front or back seats is a matter of procedure but it would be a designated crewmember’s responsibility to monitor and constantly verbally update the obstacle situation as seen on the radar. Although I know nothing of CHC’s procedures I would assume that this is SOP, especially for SAR.

Everyone makes mistakes, I’ve made plenty and seen very capable colleagues do the same. Most of the time some procedure, mechanism or technology prevents a tragic outcome, sadly not so on this occasion. I’m sure there is much to learn here.

[gulliBell]

Has anyone read section 3.5.8 of the report? I think it's quite relevant, it clearly states that a page of text accompanied the flight route and included information about blackrock and the lighthouse height amsl. Raises some questions?.

I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish.

[SASless]

Would a single Page Approach Plate for a checked and tested "standard" Approach for Blacksod have been much better?

One that incorporates the full capability of the Avionics fit be far better?

One that would ensure Terrain Clearance?

[gulliBell]

Would a single Page Approach Plate for a checked and tested "standard" Approach for Blacksod have been much better?


Yes. And I'm absolutely staggered that what was published got past a Chief Pilot and operational review.

[gulliBell]

...The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling...

I always use the paper chart for flight planning, never what's in a terrain database.

[gulliBell]

..I think the main point here is that regardless of whether a published procedure is followed or not, any low-level flight over water in IMC, at night or in marginal conditions MUST use the radar as the PRIMARY navigation aid..

Agreed. And an operational radar should not be an MEL item for this role. And thorough training should be provided in its use, both initially, and recurrently. There is a good Honeywell training video on the use of weather radar, that should be mandatory viewing for any pilot who uses a radar.

Again, in the simulator we can throw in any sort of weather conditions. The number of pilots I've seen fumble with the weather radar and just blast through dangerous weather suggests its proper use is not widely understood or practised.

If nothing else on that helicopter worked for them, that radar should have been able to save the day for them.

[ZFT]

No idea on rotary wing operation, but in FW there is no regulatory requirement to even update the latest version of the EGPWS database!

Unlike FMS updates which are mandated, EGPWS database revisions are left up to the operator to determine (within their CMS) how they are addressed.

[industry insider]

I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish.

Agree gulliBell, Actually I would like to see the route guide plate for Blacksod arrivals, even if ts only a VFR one. It would surely have the lowest safe marked on it in each sector? Surely Blacksod could have had a simple GPS approach rather than having to use SAR autopilot modes?

[[email protected]]

but since you would have to let down over the water anyway, why wouldn't you use the SAR autopilot modes?

[SASless]

Insider.

You do understand the full capability of the SAR modes on the S-92 don't you?

Why in the world would you want to revert to old techniques using lesser capability?


Take note of the Sikorsky/PHI FMS Offshore Rig Approach in use in the Gulf of Mexico using far less capability than the SAR modes....then rethink what you are suggesting.

[gulliBell]

..Making a low level transit in marginal weather must also be deemed more risky than descending closer to the landing site. Was this the standard way of making this type of approach when IMC?


I've never seen an approach that started so far out at such a low level. And I've never seen an approach plate that didn't give the pilot all the critical information needed on a single page, with both lateral and vertical navigation, and spot heights of all obstacles in proximity of the flight path.

[industry insider]

You do understand the full capability of the SAR modes on the S-92 don't you?

Of course but it was the use of the SAR modes down to 200' to the west of Blackrock that caused the problem.

Had an "old" technique been used, we would not be having this discussion. SAR modes are for SAR, not routine landings for a fuel stop when there was no urgency. As gulliBell says, why start an approach at 200' essentially IFR (night) with miles and miles to run at 75 knots?

Its the "new" techniques that lead to a false sense of security. I always sought to minimise my time over the sea at at 200' as I am sure you did SAS.

[jimf671]

... ...

Because in civilian SAR, the rearcrew are not flightcrew (no licences) they are not allowed to be responsible for the navigation of the aircraft - this is such a waste of crew resources simply because civil aviation regards anyone not in the cockpit as cabin crew.

... ...

This is an area for which there has been some discussion in the UK and possibly elsewhere. Ideally, regulators will get a grip on this and the role of "SAR Technical Crew" can develop from 'trolley dolly in a dry suit' status to a licensed aviation trade encompassing what advanced SAR rear crew in various territories have learned across several decades of operation.



"If you think education is expensive, try ignorance."

[gulliBell]

...Surely Blacksod could have had a simple GPS approach rather than having to use SAR autopilot modes?

The approach they were using was simple, al-be-it for that nasty left turn on to the final course, and it didn't need any automation to fly it safely. All that was needed was to arrive at the IAF (BLKMO) at a height where a constant descent rate of 450ft/min would put you on the final segment (BKSDC) at 200 ft/75kts, and to monitor the radar so that the horizontal navigation made sense with what the GPS was telling you. 3000' at BLKMO would have worked nicely. The numbers can be crunched in your head, it doesn't need an FMS to work it out. And at that height you could still talk to everybody you needed to talk to, with no need to give a landing report whilst still 6+ minutes out.

[My names Turkish]

Excuse my ignorance, but in the most sophisticated helicopters in the civilian world, why aren't all known planned landing sites such as Blacksod provided with GPS approaches with a vertical profile akin to that of an ILS, flown (in the case of SAR) to a very low-minima using auto hover if required? They take very little time to develop, and the cost would be negligable on a £500m contract. I get the necessity for ARA let downs to unknown rescue locations, but routine landings for fuel? I'd argue that the risk philosophy should be closer to that used in HEMS. At adhoc HEMS operating sites, rarely used more than once, the risk permitted is at it's highest in order to facilitate getting the job done. However at hospitals, and hems operating bases, refuel locations etc, used regularly there should be less alleviation as they are planned landing sites, used at a higher frequency, that can be known to the operator, thus procedures can be put in place and followed.

The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling. A paper chart, or an iPad and Runway HD would have improved their SA, over all the kit & radar in an S92? Are we saying there is no simple moving map with an OS layer, or chart in the cockpit?

I didn't want to get shouted at for saying the same thing but as an outsider this also surprises me.

I get the general point of radar let downs and pseudo ILS AFCS coupled approaches but to a refuelling site would it be really that difficult to chart a GPS/RNAV approach or even better yet an ANP-AR approach? Sometimes innovation in aviation seems choked by bureaucracy and pointless regulation and hangs on to legacy procedures far too long.

It seems very sad that the minimum speed for EGPWS to be "armed", for want of a better word, was not specified as an SOP for all approaches. I gather that it may not have made a diiference here as there are questions as to wether Blackrock was in the database or not but, it would seem a sensible SOP to arise out of this event.

[smcc63]

Isn't the light beam columnated? The light wouldn't go up into the cloud, it's angled down towards the surface. And at one flash every 12 seconds, they might not have been below cloud for long enough before hitting the rock for the light to be visible to them. But yes, from 500' up even if you were in cloud, you'd expect to see the light, or the clouds light up around you, every 12 seconds from a few miles out.

The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself". This call came 15 seconds after the co-pilot reported 1.3 miles to BLKMO. This I just don't understand, it's evidence of a breakdown in SA. I mean, when you've just been told BLKMO is 1.3 miles in front of you (according to GPS), and there is a radar target 6 miles ahead of you, how could that radar target possibly be BKLMO? What that target probably was is Duvillaun More, which you'd expect to be at 11 o-clock on radar because the next segment takes you to the right of it. And the co-pilot should have identified the radar target as a possible obstacle on the next segment by looking at the map, and he didn't question the pilot when it should have been obvious that a radar target 6 miles in-front of you couldn't possibly be a GPS waypoint only 1 mile in-front of you. And another thing I don't understand, when the co-pilot reported 1.3 miles to BLKMO, there MUST have been a big red target directly in front of him on the radar (assuming the radar was set to 10nm arc and 1.3nm is still in the detectable range). Also, the crewman told the pilot the island was visible directly ahead 15 seconds before impact, and to come right. In the 6 seconds before hitting the rock the FDR shows they were not making any heading change to ensure lateral separation.

From 200' above the surface and at 3nm range, a 300' island in-front of you would probably indicate on the radar screen as an obvious red blob with little depth, probably with no other colours evident, probably with some sea clutter either side of it, with a great big arc of black for miles and miles behind it. And as you got closer to the target the red blob would be getting bigger and bigger, and the black arc behind it would stay just as black. That great big arc of black behind a red radar return should attract your attention, because that black area with no radar returns is potentially dangerous. It's dangerous of course because a big island in-front of you has bounced all the radar energy back to you, and nothing behind it can be detected. If it was only a small island with little elevation the radar image would be completely different, you should see sea clutter returns only a short distance behind the red return. I've got a hunch the radar was painting a good picture of what was in-front of them for the last 6nm, but there was no proper interpretation of what the radar was telling them.

I know it's easy to be critical from armchair comfort with the benefit of time and hind-sight and the rest of it, but the brutal reality of it is, I don't see much PIC stuff going on. The pilot said virtually nothing of substance through the whole of the end of CVR transcript, when the aircraft was getting in an imminent state of peril. And the bit the pilot did say about BLKMO was obviously wrong but it wasn't corrected by the co-pilot. Blackrock must have been detectable on the radar directly in-front of the aircraft for the whole of the track inbound to BKLMO, and it should have been identified and reported as a hazard to the pilot, but it wasn't. The warning from the rear crew about the rock in-front of them either wasn't made forcefully enough, or wasn't acted on quickly enough (no avoiding action was being taken in the 6 seconds before impact). My reading of that little bit of CVR transcript is not enough of substance was being said amongst the crew. My flight instructor used to say "silence is bad CRM" - for me, and again this is being said from the comfort of my armchair, there is just too much silence on that CVR transcript.

Re:The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself"
the commander was acknowledging an aural altitude warning when she made this comment

[SASless]

You miss the point entirely although you ask the right question!

If the SAR modes can safely deliver you directlyto the helipad in a stabilized hover if asked to do so...why not ask it to do so...or at least to a point very close to the helipad?


As Blacksod, like other known deliberate Landing Sites used by the Operator, did not have a documented IMC approach procedure, one that assured track and vertical guidance guaranteeing Terrain clearance....one has to ask...."Why?".

Why did the Crew choose a point Ten Miles from the Helipad instead of a point very close to Blacksod itself?

Had that IMC approach existed and been used....this Crew would not have been at 200 feet and ten miles out to sea heading ashore as they were when they hit Blackrock.






Of course but it was the use of the SAR modes down to 200' to the west of Blackrock that caused the problem.

Had an "old" technique been used, we would not be having this discussion. SAR modes are for SAR, not routine landings for a fuel stop when there was no urgency. As gulliBell says, why start an approach at 200' essentially IFR (night) with miles and miles to run at 75 knots?

Its the "new" techniques that lead to a false sense of security. I always sought to minimise my time over the sea at at 200' as I am sure you did SAS.

[[email protected]]

Jim - who is going to drive it forward? The CAA chap who spent a day at Chiv looking at this before the civSAR went ahead was himself a 'trolley dolly' with no conception of what went in in a SAR helo.

The operators won't push it because they would have to pay more for licensed rear crew.

Perhaps this is why it had only been 'discussed' with no move forward for many years.

[industry insider]

had that IMC approach existed and been used....this Crew would not have been at 200 feet and ten miles out to sea heading ashore as they were when they hit Blackrock

Exactly SAS. It costs relative peanuts to design and approve an IMC/GPS approach for "company" use. Why don't all refuelling sites have one?

[smcc63]

The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself"

This was not a reply to co-pilot it was an acknowledgement of an aural altitude warning, see CVR timeline

[helicrazi]

The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself"

This was not a reply to co-pilot it was an acknowledgement of an aural altitude warning, see CVR timeline


The amount of 'waffle' on here is mind boggling.

The co-pilot had A target on the radar at 6 miles. Which was probably the mainland. NOT Blackrock

[gulliBell]

the commander was acknowledging an aural altitude warning when she made this comment

OK, I see. I was anticipating discussion of the radar target identified by the co-pilot, I thought the pilot was responding to that, in addition to the initial acknowledgement. Regarding the automated aural ALTITUDE alert, what normally is the SOP crew response for that? I would have thought a formal acknowledgement of that warning would be required, such as "height 200, no further descent" and then the co-pilot responding "roger, 200 captured, no further descent", something like that, rather than what was said.

And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning, which is referenced to height and not barometric altitude. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned barometric altitude.

[rotorspeed]

It is clear the captain did know that BLKMO was not just a waypoint over the sea but an island, because when the CVR picks up the ALTITUDE call out, she says: "Eh just a small little island.... that's BLMO itself" So the question is how did she know it was an island, and what information about its height did she have? Did she have good enough information, but had misinterpreted it? She clearly did not realise it was 300ft high.

Furthermore I find it very surprising that you'd track over what you knew was an island at night at 200ft at all - and if you did, you would surely have made a comment in advance to the crew to expect an ALTITUDE alert - and what clearance on the radalt to expect, as it was so little. But why would you not just climb to add some clearance for good measure? There was no reason not to.

What little CVR talk there is gives me the impression this crew were not completely sure of the terrain ahead and were relying significantly on radar and possibly EGPWS to provide information to keep them safe.

As is clear from a considerable number of the 980 posts on this thread, both radar and EGPWS have their complexities, that mean that one has to be very knowledgable about them in order to be able to 100% rely on them to be able to avoid obstacles flying at 200ft at night.

Which brings us back to the madness of this approach - it must surely have been totally unnecessary to carry it out at 200ft from so far out, over known islands at night. Getting into Blacksod safely in the prevailing weather should not have been a particularly difficult task for this helicopter. Basic flight planning with identification of a sensible let-down path and monitoring position with nothing more detailed than a 1:500,000 moving map was all that was required. And they had this and much more.

It should not have absolutely needed a formal approach (though admittedly very advantageous) or more equipment on the aircraft. It seems to me that a danger of too much external control with SOPs and sophisticated aircraft equipment to rely on, is that, whilst having clear and obvious benefits that we need, risk is increased in one way by reducing the amount of original thinking and decision making pilots undertake. So they can easily get worse at it, as probably happened here.

[albatross]

Surely with the data now in hand it will be helpfull if they fly a SAR 92 over the exact same path, with the same cockpit setup on a VMC day and verify exactly what the crew would have seen in the cockpit and also in the back.

Perhaps this has already been done.

Such a sad event.

[smcc63]

OK, I see. I was anticipating discussion of the radar target identified by the co-pilot, I thought the pilot was responding to that, in addition to the initial acknowledgement. Regarding the automated aural ALTITUDE alert, what normally is the SOP crew response for that? I would have thought a formal acknowledgement of that warning would be required, such as "copied, altitude 200, no further descent" and then the co-pilot responding "no further descent", something like that, rather than what was said.

And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned altitude.

Apologies, but my expertise is confined to transcript analysis, anything else I cannot help you with

[gulliBell]

It is clear the captain did know that BLKMO was not just a waypoint over the sea but an island...

It's not clear to me. I put myself in the co-pilot seat and I still think the pilot is referencing the island comment to my radar target call, and the ALTITUDE warning was either missed, or it was not responded to in a formal sense required by an SOP. You can't be responding to a system generated warning in the way it was responded to because that has resulted in ambiguity. The comment might have been in relation to the warning, or it might have been in response to the co-pilot radar target call. Hence why a system generated warning must always be responded to in an SOP'd formal way, by both pilots.

[jimf671]

Jim - who is going to drive it forward? The CAA chap who spent a day at Chiv looking at this before the civSAR went ahead was himself a 'trolley dolly' with no conception of what went in in a SAR helo.

The operators won't push it because they would have to pay more for licensed rear crew.

Perhaps this is why it had only been 'discussed' with no move forward for many years.

Quite.

There are numerous problems with giving this some momentum. As you say, the operators would have to pay more. In fact, my first words to the previous director of Bristow UK SAR on first meeting her were "Are you sure you're paying your rear-crew enough?" She didn't get it. And she didn't have the background that would have enabled her to 'get it'. MR aren't license holders or AOC holders and so we have no direct leverage (UK, Eire and elsewhere same situation) which leaves us with the political route which is tortuous and slow. Your old mates are little help since many of them were leaving anyway and the SAR operators pay them a lot more than shelf stackers or security guards and let them do a job they love for a lot more years: happy happy. What comes after them is a big worry. I'd say to the regulators, "Would you like to be a world-leading aviation regulator in the field of SAR or are you happy to wait for the accidents?"



(Time on the wire is not the same as air miles.) :E

[smcc63]

It's not clear to me. I put myself in the co-pilot seat and I still think the pilot is referencing the island comment to my radar target call, and the ALTITUDE warning was either missed, or it was not responded to in a formal sense required by an SOP. You can't be responding to a system generated warning in the way it was responded to because that has resulted in ambiguity. The comment might have been in relation to the warning, or it might have been in response to the co-pilot radar target call. Hence why a system generated warning must always be responded to in an SOP'd formal way, by both pilots.

It's all open to interpretation of course, but on cvr timeline, six mile target was acknowledged with "Rodger" from pilot, next was aural altitude warning followed by pilots comment "small little island "

[gulliBell]

It's all open to interpretation of course..

Wearing my co-pilot hat, having read the transcript, I believe it's more likely the ALTITUDE alert was missed by both pilots. I say that because there was no SOP-like response to the ALTITUDE alert by either crew, and Captains don't intentionally fly over islands in an unfamiliar area at night at 200', and if they were to do so, the co-pilot would challenge this course of action.

[smcc63]

Wearing my co-pilot hat, having read the transcript, I believe it's more likely the ALTITUDE alert was missed by both pilots. I say that because there was no SOP-like response to the ALTITUDE alert by either crew, and Captains don't intentionally fly over islands in an unfamiliar area at night at 200', and if they were to do so, the co-pilot would challenge this course of action.

Absolutely,and I respect your experience, I think a lot more info could be gleaned from actual audio, i.e. Rate of speech, confidence of annunciation etc.
I'm sure a more comprehensive conclusion can be arrived at post final AAIU report

[GKaplan]

And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning, which is referenced to height and not barometric altitude. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned barometric altitude.

Barometric altitude bug: when the a/c descends below the preset altitude you get a "MINIMUMS, MINIMUMS" aural alert. I suppose that makes sense as the minimums used for normal instrument approaches are altitudes (DA, MDA).

When the a/c descends below the RADALT bug, you get an "ALTITUDE, ALTITUDE" aural alert.
Yes even though it's a height it is referring to; I suppose an alert "Height, Height" doesn't do as well phonetically!

[Cows getting bigger]

I spend much of my life floating around at or below safety altitude (Navaid calibration and procedure validation). I'm struggling to understand why anyone would knowingly design a letdown which incorporates the only highpoint within a number of miles. For sure, we're talking different environment, but the old adage sticks - "Pilots will eventually find ways to do something wrong".

[smcc63]

Re aural altitude alert:
As per AAIU report:

The Commander had the moving map displayed on her MFD and the Co-pilot had weather radar displayed on his MFD.
 The CVR recordings indicated that the Co-pilot was using the weather radar to identify terrain features.
 The Rad Alt provided a callout of “ALTITUDE, ALTITUDE” 26 seconds prior to the initial impact. The Commander identified the reason for the aural alert as a small island below the helicopter which she said was “just a small little island... that’s B L M O itself”. At the time of the aural alert FDR data placed the Helicopter in the vicinity of an outcrop of two rocks, Carrickduff and Carrickad, which are located approximately 0.65 nm to the west of the Black Rock.

[smcc63]

Re altitude aural alert, above Carickduff,see location on google maps at this address 9C6F3M96+J4

[cncpc]

I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish.

As a starting point, what do you infer the "route" to be?

With respect, there is an obvious inference to be made. Accepting that, it seems to be perfectly fine.

It can't be adapted for something else than it was intended without careful considerations of other factors.

Editing for further response to GulliBell and SASless below.

If it is used for what it actually was intended to be used for, I don't dispute its approval by the Chief pilot or other company operations people. It's fine for that. The problem starts when "IAP" is imagined to attach to BLKMO. That's not approved.

I expect that CHC will tell the investigators, or they already know, that the "route" this applies to is from the helipad at Black Rock to the helipad at Blacksod. Or in reverse. A route, after all, is from A to B.

[SASless]

What is the history of that Route Guide?

When was it created, what technology was it based upon, how is it updated, how is the data checked for accuracy?

Why was the current format chosen and has there been consideration in changing it to incorporate technology changes?

[Cows getting bigger]

What is the history of that Route Guide?

When was it created, what technology was it based upon, how is it updated, how is the data checked for accuracy?

Why was the current format chosen and has there been consideration in changing it to incorporate technology changes?

Indeed, things change. I came relatively close to a wind turbine the other day which was on some charts but not others. The 'official' AIP version was lacking!!