SAR S-92 Missing Ireland

[gulliBell]

We teach the PM selects the required heading, whether the chart calls for it, or the PF calls for it...I don't like it that way whilst in coupled flight, but I "don't" see it as an error should the PF make the heading bug changes during a check flight. My thinking of it is I don't like to change the fundamentals of what I'm used to for single pilot IFR, that is, the PF does the flying and there is no ambiguity as to who is responsible for what. But for 2-crew, as long as there is consistency for the various actions between the crew, and it has been briefed beforehand, or the responsibilities are otherwise previously well established by operator SOP.

If I understand it, there is a single channel of the CVR that records the microphone input from both rear crew, so who said what in that channel of the CVR transcript I don't know. Can somebody from the SAR community clarify the respective roles of each of the two rear crew during this phase of flight, and what equipment was available at each crew station? I'm only used to having one crewman bark at me should there be any need for barking, and if a bark is required, it's usually very loud and clear.

Also, the CVR transcript indicates an ELT ping was transmitted on impact with the rock. Do we know if this was detected by a satellite? And also, some comment on the pros/cons of having a Captain assigned to a co-pilot role. I think there is potential for some dysfunction in a crew when there is no cockpit gradient, and I know myself I tend to be slightly less vigilant as a co-pilot if I'm playing co-pilot to another Captain. And the Captain tends to be less vigilant if he's got another Captain playing co-pilot. The whole nature of the cockpit is different with two Captains flying together. Might this explain why there wasn't much communication between the pilots?

[G0ULI]

Many years ago when ships carried radio officers, it was my habit after the last watch of the day to go on the blacked out bridge and chat with the navigation officers over a cuppa. Invariably the radar screen would be misadjusted, with the sensitivity and brightnesss turned down. I would reset the display only to be faced with complaints from the navigation officer that looking at the radar screen set correctly destroyed his night vision. Their preferred setting was to have no clutter at all visible and large targets barely showing on the screen. It kept the brightness down but meant that small vessels such as fishing boats would go completely unnoticed unless their navigation lights were spotted.

Moving on several decades. Helicopter flying in the dark, crew wanting to keep their night vision as sharp as possible for a forthcoming landing, all the instrument lighting turned down as low as it will go. It seems a similar situation to what I experienced years ago but in a different environment. Everything could have been working just fine, but to see fine detail on a radar display, you need the brightness turned up more than is compatible with maintaining good night vision. I know there are night display modes that are supposed to help with this problem, but established habits are hard to break. None of the navigation officers I worked with could avoid tweeking the radar display after I had set it up correctly.

Just another one of those human factors that could be relevant.

[puntosaurus]

That is a very valid question.

With the radar set to 10 NM range on the PM's (copilot) NAV screen in this case, the waypoint symbol for "BLKMO" would hide the radar return from Blackrock. If using 5 NM, or even better 2.5 NM range, the return from Blackrock would be relatively larger than the waypoint symbol, and hence get your attention.

I tried this a couple of days ago (in the S92 with the Primus 701A radar) using an oil rig as "Blackrock". With 10 NM range, GMAP2, optimal gain and tilt, and at a distance of 1-2 NM from the oil rig it was very difficult to actually spot the return because of the waypoint symbol. Blackrock might have given a slightly larger return than an oil rig though.

The more I think about it, the more I think overlay technology for radar wherever radar is the primary mechanism for obstacle avoidance ought to be officially SOP'd out of existence as of right now. And given the inherent weaknesses of SOPs as quoted by TREs on this and other threads then I think a technology solution (dedicated screen?) may be required.

[[email protected]]

DB - you highlighted the poor training of radar set up and usage in your industry - it had to come from somewhere and O&G are the ones who pioneered ARAs.

MilSAR had a dedicated radar operator who has been replaced, in the O&G format, by the co-pilot in CivSAR, this is not points-scoring, this is highlighting cheap practices adopted into roles that need dedicated expertise.

[gulliBell]

Pilots needs to be competent at operating the equipment they are provided with, particularly really important stuff like a radar. In 24 years of flying weather radar equipped helicopters I have never received any structured, formal training in the use of the radar, apart from watching a Honeywell radar training video, once. I don't even think we have radar questions in our recurrent exam question bank, and radar is not taught during initial type technical ground school. If this is widely common in the industry it needs to change. Maybe there should be a radar exam, much like a basic gas turbine exam before you're allowed to fly a turbine helicopter, with a logbook certification required.

[palacio802]

gullibell, my experience is more or less the same. In my squadron there was an A-4 sheet with instructions explaining the basic functions and little more. Some pilots never used tilt control, for instance.

And reading some civilian transport accident reports, in commercial airlines is the same. Pilots do not master the use of weather radar because there is not an specific training course about it.

To add something to the debate, I think that the primary source for VFR navigation when you are not familiar with the area in which the flight is conducted, should be a VFR CHART. I mean, a paper chart or a digital moving map. Radar and EGPWS are important tools for navigation, but a good map in a correct scale is paramount.

[puntosaurus]

DB - you highlighted the poor training of radar set up and usage in your industry - it had to come from somewhere and O&G are the ones who pioneered ARAs.

MilSAR had a dedicated radar operator who has been replaced, in the O&G format, by the co-pilot in CivSAR, this is not points-scoring, this is highlighting cheap practices adopted into roles that need dedicated expertise.

I don't think this is a matter of being cheap, it looks like a matter of inexperience in the SAR world. The CivSAR machine in question appears to have had both the staff and the equipment to operate as you suggest, but it looks like the operator lacked the experience to put those tools to good use, and the crew were not adequately prepared to deal with their input.

[birmingham]

I have been following this thread and have learnt a lot about radar theory and EGPWS use, so I thank you fellow pilots out there for teaching me some new tricks. If I can maybe raise a few points ( I am a SAR pilot with similar systems in my aircraft type):


1. Many posts have been critical of the descent profile and why they made such a long flight at 200ft. I suspect that because the APBSS approach is not an IFR procedure, the crew realised they would have to get visual below the cloud (300-400ft) to then track toward Blacksod via the APBSS guidance (I would love to know the purpose of the APBSS, VFR vs IFR, what is it there for?). To do this descent, many operators have a 'no closer' clause in their OM so I would think they have to descend clear of all land (looking at the map, it might be 5-10nm) to get visual below cloud before they then would be allowed to turn back towards their fuelling point. If they were any higher, they would have been IMC and since there appears to be no IFR arrival plate to Blacksod, then this would not have been feasible.
2. NVG would have definitely been a final safety feature as they (I believe) would have seen the large rock ahead of them. I have flown a lot of NVG over water and even on the darkest nights, the contrast should have alerted a scanning pilot as to their danger.
3. Some people have mentioned lack of talk on the CVR as complacency. I don't believe this for a second as this crew were at low level, in the dark and in an unfamiliar area. I bet their arousal level was through the roof.


I look at this sad and preventable accident and see much to learn on a personal and organisational level. I am not going to armchair quarterback the crew as I am honest enough to think that some of the decisions made would have been the same if I was in the aircraft. I think the basic problem was the crew did not realise the BLKMO was 300ft high and for some inexplicable reason, they did not see it on radar. If only Blacksod had an IFR RNAV approach, this accident would not have been occurred and four fine persons would still be doing the job they loved.

For me that about sums this up

[SASless]

The USCG tests Mariners for Radar Endorsements for those Licences......and that is for vessels moving a lot slower that are in contact with water!



Pilots needs to be competent at operating the equipment they are provided with, particularly really important stuff like a radar. In 24 years of flying weather radar equipped helicopters I have never received any structured, formal training in the use of the radar, apart from watching a Honeywell radar training video, once. I don't even think we have radar questions in our recurrent exam question bank, and radar is not taught during initial type technical ground school. If this is widely common in the industry it needs to change. Maybe there should be a radar exam, much like a basic gas turbine exam before you're allowed to fly a turbine helicopter, with a logbook certification required.

[gulliBell]

..To add something to the debate, I think that the primary source for VFR navigation when you are not familiar with the area in which the flight is conducted, should be a VFR CHART. I mean, a paper chart or a digital moving map. Radar and EGPWS are important tools for navigation, but a good map in a correct scale is paramount.

For years the training pipeline has been producing VFR pilots who are very weak at DR map to ground navigation. Map reading skills have been degraded by GPS. I think a CPL-H candidate should do their cross country flight test without a GPS. And afterwards, they should occasionally turn off their GPS and practice getting from A to B with just a VFR chart. And IFR crews aren't immune from these things either (I've seen an ATPL Captain + CPL Co-pilot crew get seriously lost in the traffic pattern at a major International airport with a 7000' long runway, and they had no idea how to get "unlost").

[[email protected]]

I don't think this is a matter of being cheap, it looks like a matter of inexperience in the SAR world. The CivSAR machine in question appears to have had both the staff and the equipment to operate as you suggest, but it looks like the operator lacked the experience to put those tools to good use, and the crew were not adequately prepared to deal with their input. Punto - the problem is that even with well trained ex-mil radar operators, the civil system won't allow those without flight crew licences to be responsible for the navigation of the aircraft.

So, even if the rear crew are trained to use the radar ( and they do have the screens in the cabin to do so) they can't 'control' the aircraft in the same way as a mil Radop would have done in the Sea King.

Personally I see this as a retrograde step that pushes workload to the front of the aircraft in poor weather or at night when it could be managed much better using more of the crew.

Perhaps it is something that could be addressed through the AOC to give derogations from the 'normal rules'.

However, I wouldn't be surprised to find that some CivSAR crews do operate the 'old-fashioned' way because they have ex-mil Radops with a great deal of skill and knowledge in manipulating the radar.

[IRCG SMC WHITEY]

Need help from you guys!!
The distance between the Rocks (when RADALT callout was triggered) & Blackrock is approx. 1250 metres. Time elapsed from RADALT callout being triggered & time of impact is 28 seconds. That equates to 44.64 mr/sec..160.71 KM/hr ...or 86.7Knots
Does this mean tailwind was 11kts ???
I have't been at the controls of an aeroplane since 1994. Forgotten most theory !!!

[puntosaurus]

This overlay issue is bigger than just radar. I was in a 169 recently and the factory educated pilots 'discovered' that transponder returns are only displayed on the MFD in RA mode. In TA mode which is much more common for that helicopter operation, no returns are displayed.

Their training included a reasonable slug of time in a Virtual Interactive Procedure Trainer which is supposed to get you used to the controls and displays at lower cost than the full sim. Seems like there ought to be a lot more canned scenarios to display the quirks of the system.

However the problem is that nobody seems to be able to forsee the quirks until there is an accident to point them out.

[SASless]

Although a slightly different situation....the concept of marrying up data from different sources is the same. During periods of foggy weather producing visibility not much greater than the length of my 41 foot sailboat ... overlaying the Radar display onto the Chart plotter (moving map driven by the GPS) was very effective in navigating in the waters I called home.

The auto pilot was in Heading mode ...the chart plotter told me where the Markers, Buoys, and known obstructions were supposed to be ... and the Radar showed where they actually were along with other Vessels that were in my area. Add in AIS data being tagged to the Vessel Returns and getting around was easy and safe.

Buoys have a habit of being moved by storms or by the Coast a Guard as the channel shifts due to storms and erosion so GPS alone cannot be relied upon ...thus making the use of Radar so important. Determining the reason for the Variance is the problem as you might not know the cause of the Return not being where at the Map depicted location ...and there is nothing showing on the Radar at the GPS designated location.

Even Oil Rigs move about with delayed notice to air crews sometimes!

Resolving ambiguity can be an issue while using this new hi-tech equipment.

The Nav system could carry out a pre-planned Route with up to 99 Waypoints in the Nav Mode.

Point being ... technology properly used can very much enhance Situational awareness!

Even the Fog Horn on the boat was automated.....leaving a hand free that otherwise would have been ringing a Bell!

The Radar had to be properly adjusted to obtain the most accurate Returns as it had multiple modes that included both surface Returns and Weather modes just as Aviation Radars do.






My comments above are more concerned with IMC / VMC conditions & the "how to" rather than the rules governing such. Yes, the correct use of the radar, should form a very important part of the picture, but it should be cross-checked with all other available data sources. The advent of reliable, GPS based navigation systems, allows for RNAV only IMC letdowns, which should then complement radar return information. I would be concerned if, during an ARA, the rig GPS location was not where the radar was painting a target, & visa versa.

[puntosaurus]

Need help from you guys!!
The distance between the Rocks (when RADALT callout was triggered) & Blackrock is approx. 1250 metres. Time elapsed from RADALT callout being triggered & time of impact is 28 seconds. That equates to 44.64 mr/sec..160.71 KM/hr ...or 86.7Knots
Does this mean tailwind was 11kts ???
I have't been at the controls of an aeroplane since 1994. Forgotten most theory !!!

Possibly, but the co-pilot called BLKMO at 1.3nm 15s earlier and 45s before impact. That would have given them 104kt over the ground by my reckoning.

[puntosaurus]

Punto - the problem is that even with well trained ex-mil radar operators, the civil system won't allow those without flight crew licences to be responsible for the navigation of the aircraft.

So, even if the rear crew are trained to use the radar ( and they do have the screens in the cabin to do so) they can't 'control' the aircraft in the same way as a mil Radop would have done in the Sea King.

Personally I see this as a retrograde step that pushes workload to the front of the aircraft in poor weather or at night when it could be managed much better using more of the crew.

Perhaps it is something that could be addressed through the AOC to give derogations from the 'normal rules'.

However, I wouldn't be surprised to find that some CivSAR crews do operate the 'old-fashioned' way because they have ex-mil Radops with a great deal of skill and knowledge in manipulating the radar.

Well HEMS are allowed to have technical crew members, so I don't see why SAR can't.

PS. I just looked through PART-OPS and it looks like there is no SAR Special Approval (SPA), and only an indirect reference under Specialised Operations (SPO-HEC Human External Cargo). So it wouldn't surprise me if SAR operators had HEMS approvals already.

[IRCG SMC WHITEY]

Thanks Puntosaurus.
Further query distances on radar is it calibrated in nautical miles or statute mile??

[212man]

Thanks Puntosaurus.
Further query distances on radar is it calibrated in nautical miles or statute mile??

Nautical miles

[jimf671]

Well HEMS are allowed to have technical crew members, so I don't see why SAR can't.

PS. I just looked through PART-OPS and it looks like there is no SAR Special Approval (SPA), and only an indirect reference under Specialised Operations (SPO-HEC Human External Cargo). So it wouldn't surprise me if SAR operators had HEMS approvals already.


Is anyone able to give a basic overview of the Irish SAR regulatory regime? Particularly regarding rear-crew.


I'm familiar with the UK situation and Crab and I are amongst those who believe there are missed opportunities there regarding the skills of 'SAR Technical Crew'. The same seems to be true about a number of territories. An opportunity exists for a regulator to grow a great big pair and make a world-leading move toward SAR Technical Crew being a licensed aviation trade.

[puntosaurus]

If I'm right, then with Ireland being a member of EASA, an Irish SAR operator will come under PART-OPS and have an EASA AOC with a SPA-HEMS and SPO-HEC approval (and possibly a few others as well) issued by the local competent authority (in this case the IAA). In that case you don't need a regulator to strap on a pair, just an operator. And all they need to do is describe the role of the technical crew member appropriately and make sure he/she is trained and checked in their ability to discharge the role.

PS Guys are we absolutely sure that the rear crew are not already technical crew members ? I can't imagine that the winchman is not, given that he must be interacting with the crew during winching operations ?

[cncpc]

Need help from you guys!!
The distance between the Rocks (when RADALT callout was triggered) & Blackrock is approx. 1250 metres. Time elapsed from RADALT callout being triggered & time of impact is 28 seconds. That equates to 44.64 mr/sec..160.71 KM/hr ...or 86.7Knots
Does this mean tailwind was 11kts ???
I have't been at the controls of an aeroplane since 1994. Forgotten most theory !!!

There are some numbers in the report that don't quite add up, but not significant to understanding this.

[rjsquirrel]

There are some numbers in there that don't quite add up, but not significant to understanding this.

They add up quite nicely. It has been previously posted that the surface winds were 220 deg at 19 to 21 knots. (Bellmullet 220 at 19Kt, Mace Haed at 230 at 21kt), just about right to create the ground speed as calculated.

[cncpc]

They add up quite nicely. It has been previously posted that the surface winds were 220 deg at 19 to 21 knots. (Bellmullet 220 at 19Kt, Mace Haed at 230 at 21kt), just about right to create the ground speed as calculated.

I wasn't referring specifically to the groundspeed issue or to the numbers in that poster's calculations.

[[email protected]]

PS Guys are we absolutely sure that the rear crew are not already technical crew members ? I can't imagine that the winchman is not, given that he must be interacting with the crew during winching operations ? Punto, yes they are technical crew members but that, as I understand it, isn't the same as being allowed to be responsible for the navigation of the aircraft because they aren't licensed in the same way as a pilot or flight engineer.

However, that conveniently ignores the fact that when the winch operator is using the aux hover trim (or whatever it is called in the S92), he is flying the aircraft - perhaps because the pilot can over-ride him it doesn't count?

It also ignores the responsibility for tip and tail clearances when winching where, if he/she makes a mistake, it can be disastrous.

[puntosaurus]

Well I can absolutely assure you that PART-OPS-SPA-HEMS can be interpreted to allow the technical crewmember to do all of things you need them to do, provided that the role is described in the operations manual and that the training and checking required for the role is also set out in Part D.

[BigFrank]

On RTE Radio Good Morning Ireland programme this morning (= Today on BBC Radio 4) there was a discussion of the accident.

Two separate elements were discussed:

i) The failure to follow appropriate protocols in releasing transcripts from the cockpit. This was the "official" basis for the interview, it seems.

ii) However, at the end of the interview, the President of the Irish Airline Pilots Association appeared to make some trenchant criticisms of the reliability of the information being provided by the systems to the crew.

Criticisms which the interviewer, pressed for time by an editor no doubt, failed to pursue.

http://www.rte.ie/radio1/morning-ireland/#2463200


The item is number 9 or 10 in the running list when you scroll down.

[louisnewmark]

Those who are arguing for a dedicated radar operator are - or rather were - very capable military SAR operators. Unfortunately, they also have no experience of genuine SAR in a modern civilian setup, so are arguing with knowledge of only one side of the coin. It also is simply not true that tech crew cannot provide navigational guidance to pilots; that is exactly what happened pre-NVG at night at low level using the FLIR. Unhelpful, provocative and outdated. It certainly adds nothing constructive to the analysis of this incident, IMHO.

[dervish]

louisnewmark

The extensive debate and arguments over how radars work and are used tend to support any call for dedicated operators. Too much compromise evident in this accident. Just my opinion.

[[email protected]]

It also is simply not true that tech crew cannot provide navigational guidance to pilots; that is exactly what happened pre-NVG at night at low level using the FLIR. Unhelpful, provocative and outdated. Louis, the key word you used is guidance, they do not control the letdown in the same way as a military radop would and the responsibility for terrain clearance remains with the pilots whereas that role was held by the Radop.

I have plenty of friends and ex-colleagues in the new SAR service so I am not talking from a position of complete ignorance - I have flown the 139 in the SAR fit and had to approve certain letdown profiles being taught to other nation's students. The rear crew could observe, monitor and assist but the responsibility remained with the co-pilot.

As I said earlier, I suspect that some SAR rearcrew play a much more 'traditional' role in any radar letdowns.

[cncpc]

louisnewmark

The extensive debate and arguments over how radars work and are used tend to support any call for dedicated operators. Too much compromise evident in this accident. Just my opinion.

Radar is for the purpose of avoiding objects at the same height as you are flying at, or near to it as to be a danger.

A properly designed IFR approach achieves the same thing, much simpler, and you know that an organized system with several layers of oversight is protecting you, your crew, and your aircraft.

It seems extraordinary that people are running around in the ocean, with rocks and ships in that ocean, in the dark and poor vis, thinking they might run into something and relying entirely on a technology which can generate so many posts about how it can't work properly sometimes.

I know that it can resolve to that in SAR ops where there is a real rescue in play. This aircraft was simply going into a refuel site, often used.

[jimf671]

As a Search And Rescue operation, this is a state activity and not EASA.

IAIP-O-76

" ... the European Aviation Safety Agency (EASA) has deemed that the requirements of the ‘Basic Regulation’ shall not apply to the conduct of Search and Rescue operations and that such operations are to be classified as a ‘State’ activity which is to be regulated by the National Aviation Authority."

" ... operations carried out for the purpose of Search and Rescue by a commercial operator shall be deemed to be for the purpose of Commercial Air Transport and therefore subject to the operator being the holder of an Irish National Search and Rescue Approval (SAR APP)."

[puntosaurus]

Well let's see if any Irish regulatory hounds can inform us more, but by deeming Commercial SAR as CAT they are putting themselves under PART-OPS, and PART-OPS is as I described. I would hazard a guess that Irish National Search and Rescue Approval (SAR APP) is a process for ensuring that all the requisite PART-OPS approvals are in place.

[jimf671]

The relevant Irish document does not appear to have escaped into the wild (and I know a few foot-soldiers in Ireland who would dearly like to understand more about this) but here is a definition from the UK's CAP 999.

"SAR Technical Crew
A member of the SAR crew (e.g. winch operator, winchman) other than flight crew who is assigned to a helicopter SAR flight for the purpose of operating specific aircraft and role equipment, assisting the flight crew during the mission and attending to any person in need of medical assistance."

Since the UK SAR contract spec, and state of regulatory development, is quite advanced we might expect that an Irish definition would be either similar or less advanced.

Anyway, nothing there about navigation or obstructions or, as Crab has pointed out, flying the aircraft using hover trim, often when the aircraft is as close as it should ever be to rocky obstructions.

[puntosaurus]

Aha ! From CAP 999
Search and Rescue is a State activity and therefore not regulated under EU law;
it is consequently regulated by National Aviation Authorities (NAAs). In the UK,
operation of civil helicopters for SAR is considered to be for the purposes of
Public Transport (PT) and therefore subject to Article 12 of the Air Navigation
Order (ANO) 2009 requiring a national Air Operator's Certificate (AOC).
So let's see what the Irish regulatory hounds can dig up from their version.

PS If the Irish version has that same definition, I think I would consider it OK for technical crew members to do what you want. The radar, FLIR, and hover trim are aircraft/role equipment, and what could be better assistance to the flight crew than warning them about imminent terrain or using the hover trim to finesse the winching operation.

[cncpc]

Is there a possibility that one of the back crew members was in the door and eyeballed the rock and that led to the turn suggestion, or do we know for a fact that something on the FLIR gear led to this?

Or are both strapped in and looking at screens at this stage?

[jimf671]

I don't know what an Irish SAR APP says but I do know that the way things are run there makes interoperability with SAR partners that little bit more difficult. This is the sort of thing that held back UK CivSAR for 40 years and finally got sorted just in the final weeks before the current contract started in 2015.

Another matter that might be relevant is the tasking responsibility and how that dovetails into the regulatory regime. It appears to still be the case that tasking is the responsibility of the Irish Coastguard and not the IAA at ARCC Shannon. (MoU 2010?)

In the UK context, when ARCC task an aircraft it is not longer CAT but becomes SAR flight and different rules of flight apply.

Does that distinction exist in Irish SAR Ops? How is it triggered? Was R116's top cover task SAR flight? Were they CAT or were they free to operate under a SAR regulatory regime?

[G0ULI]

It is precisely these discussions about regulations, individual crew members responsibilities and operating procedures that convinces me that SAR should be conducted by the military. It is a flight crew on board the aircraft that need to act together as a unified team. How they divide up the tasks to get the job done safely should be up to individual crews, not some regulatory body determining strict limits on what each crew member is allowed to do. Mixing and matching crew members all trained to the same standards in their own management limited role benefits only management and bean counters. It does not enhance flight safety or result in crews that operate with complete trust in one another and knowledge of each others strengths and weaknesses. Would this accident have happened if the aircraft was being operated by the military? I am inclined to think not.

[switch_on_lofty]

Gouli: In military ops crew roles are defined. There isn't mixing and matching of roles, for instance a Seaking Observer/Radar Op can't do the co-pilots or winchman's job just because someone is more senior or less experienced.
Mil aviators are just as used to working with different crew members as civ ones. Obviously the smaller the community the more you get to know people but it's really a lot more standard than you've inferred here.
I believe that the map shown could be interpreted as an IFR let down / company route when it's not intended as such but maritime helicopter operators are used to letting down in such situations over water, using the radar as the primary tool. In my experience this has been done by a trained radar operator who monitors the descent and other PM duties as normal. Not sure I'd feel that comfortable with a pilot with no training on radars (as has been inferred by some) doing that function.

[jeepys]

Gouli,

When did you last fly SAR?

Of course the military don't crash, do they!

[SASless]

The Military had Radar Operators in the Cabin due to the fact they had a huge ol' Radar on top of the aircraft for various uses other than SAR. The SAR thing was not the original primary mission of the Sea King.

I am sure Crab, Al-bert, Mars, and others well versed in the many Roles the Sea King was tasked with in its military roles can explain to us.

In the Civil 61/92 SAR machines there is no Radar Operator in the Cabin due to there being no need for one as the Radar display is in the Cockpit.

Rather than debating what could be.....perhaps sticking to what is....will be of better use in the discussion of the causes of this tragic accident.

[G0ULI]

Okay, point taken. I spent most of my working career in small dedicated groups where we all had overlapping areas of expertise and no one got upset if someone commented and/or took over because you were cocking it up for some reason. It was expected that you all looked out for each other. Times have clearly changed and the corporate model rules.

[Search&Rescue]

It is precisely these discussions about regulations, individual crew members responsibilities and operating procedures that convinces me that SAR should be conducted by the military. It is a flight crew on board the aircraft that need to act together as a unified team. How they divide up the tasks to get the job done safely should be up to individual crews, not some regulatory body determining strict limits on what each crew member is allowed to do. Mixing and matching crew members all trained to the same standards in their own management limited role benefits only management and bean counters. It does not enhance flight safety or result in crews that operate with complete trust in one another and knowledge of each others strengths and weaknesses. Would this accident have happened if the aircraft was being operated by the military? I am inclined to think not.

Unbelievable comment! You gotta to be kidding us...

[SASless]

A "For What It Is Worth" comment.....how does the US Coast Guard or US Air Force crewing, crew duties, and aircraft equipment compare to the RAF SAR/ICG/UK SAR Operations?

The JayHawks and PaveHawks are very similar to the 92's....and the old H-3's/CH-53's would have similarities to the SeaKings and S-61's.

If we did a genuine compare and contrast would we not see some blending of all the various cultures over time as Technology improved, Aircraft design and capability changed, and Operational Experience was gained?

Point being.....isn't there more than one right answer to most questions?

[G0ULI]

Perhaps if I were to suggest that SAR should not be a commercial operation subject to cost constraints that could limit crew training, that might be more acceptable?

Yes, I know the military have their problems too, but they would appear to have greater freedom to operate without having to account for every penny.

[Red5ive]

Yes, I know the military have their problems too, but they would appear to have greater freedom to operate without having to account for every penny.

You do realise the the Aer Corps lost four crew and a Dauphin in 1999!

[jeepys]

I am not sure how many training hours the Irish CG contract includes but with the UK civvy SAR contract there is a heap of hours for training. 50 per month to be precise.
Having a private operator run the country's SAR does not mean it's going to be sub standard because of penny pinching.

Gouli, are you saying the Irish Air Corps would do a better job?

[jimf671]

... the military have their problems too, but they would appear to have greater freedom to operate without having to account for every penny.



I didn't know you were such a wit Gouli!

[oleary]

yes, one of his primary duties is to monitor the handling pilot - instead we get him heads down playing with the radar!

..... the PF should be "playing with radar"? How do you do an ARA?

[oleary]

louisnewmark

The extensive debate and arguments over how radars work and are used tend to support any call for dedicated operators. Too much compromise evident in this accident. Just my opinion.

..... how have we managed to use the same radar, for 50 years, with a two-pilot crew, in the same weather conditions, during O&G operations?

[tistisnot]

Because you never intended to overfly the rig; you used the lowest ( approx 2.5 nm) scale and you made a decision at 150' and 0.5 nm or 200' and 0.75nm having already made an offset to avoid the blob. If you got an automated AVAD (yes the boringly simple one) call-out, and not visual with the destination, it was further offset, pull power and climb to MSA. eGPWS was designed to avoid terrain and published obstacles for onshore work ...... database, loss of situational awareness, confirmation bias

[Older and Wiser]

Well I can absolutely assure you that PART-OPS-SPA-HEMS can be interpreted to allow the technical crewmember to do all of things you need them to do, provided that the role is described in the operations manual and that the training and checking required for the role is also set out in Part D.

Punto I beleive you are conflating regulations. Operating equipment is different to being responsible for primary navigation. Primary Navigation is, under EASA, FAA & CASA, to the best of my knowledge, solely in the hands of a licensed Pilot.
All SAR Rearcrew are Technical crew and just like their HEMS Counterparts they can operate radios, FLIR and "assist" the pilot with navigation.
As such, as is the case on UK SAR Helicopters and MoD Falkland Contract SAR Helicopters, the Technical Crew cannot operate the RADAR and give positive navigation commands to the Pilots. However the latter 2 services operating the AW189 do have a view of the Radar Return on the Technical Crew Mission Computer but, because of the EASA Regs the OE cannot fit the controls of the radar in the Cabin so they only have sight of what the pilots have set up whether it is a good set up or bad.
Some pilots will listen to advice from Technical Crew who have many years of being Radar Operators on Military SAR on how to get the best from the radar - many others will not. Some Technical Crew in the Civilian world do not have that experience.

[DOUBLE BOGEY]

Are some of the posters really trying to punt, that despite two licensed trained pilots in a third generation cockpit, the answer lies in allowing the guy in the back to drive the helicopter by verbal commands to avoid, what was effectively a rock that had been in the same place for millions of years?

Despite RADAR, FLIR, MOVING MAP, FMS WAYPOINT, GPS SUPER ACCURACY, this crew flew into a 300 foot high rock in what was effectively, the middle of the Ocean. If the only way to stop tha happening is to have "A man in the back" god help us all!

[Search&Rescue]

Are some of the posters really trying to punt, that despite two licensed trained pilots in a third generation cockpit, the answer lies in allowing the guy in the back to drive the helicopter by verbal commands to avoid, what was effectively a rock that had been in the same place for millions of years?

Despite RADAR, FLIR, MOVING MAP, FMS WAYPOINT, GPS SUPER ACCURACY, this crew flew into a 300 foot high rock in what was effectively, the middle of the Ocean. If the only way to stop tha happening is to have "A man in the back" god help us all!

Totally agree! Thanks DB!

But I have to add that NVG makes a huge difference! I have been flying my first 25 SAR years (A412, AS332L1, S76C++) without and last 2 years (AW139) with NVG and I can only confirm that it will be "a whole different ball game" concerning flight safety!

[DOUBLE BOGEY]

You know a lot of accusations of systemic failures and management penny pinching that could have contributed to this accident. However, route guides and cockpit procedures are firmly in the domain of Pilots and Managing pilots. CHC senior management must be holding their heads in their hands and really questioning how this accident can happen, compared to a routine ARA in O&G. How, on the other S92 thread, two apparently highly experienced pilots can fly straight into the oil rig in 8/8s blue.

As a pilot community it is us who should hang our heads in shame. We are supposed to be the experts. We are not doing very well at the moment. Repeated bleats about money, contracts, regulations are a crass distraction from the demonstrated incompetence in these two events.

As a professional body we should look inward, at every level. Training, chief pilots, procedures and basic skill sets.

My good mate says flying a helicopters is really only about two requirements, try not to run out of fuel and don't bump into anything along the way.

Take London Crane, Glasgow Clutha, Italy SAR, Turkish Radio Mast, LBAL, Blacksod, Brazil Nosewheel crash, Brazil Oil Rig, Sumburgh L2 and tell me where we can lay fault anywhere but at our own feet.

[Geoffersincornwall]

Back in 1975 a Bristow S61 lifted off from the Beryl platform (SE of Shetland) with the intention of joining the 110 radial inbound to Sumburgh. Unfortunately, the pilot had a brain-fart and turned on to the 110 radial. Neither pilot recognised their error until the radar revealed an unrecognised coastline. They just made it to Bergen.

This confirms a propensity of human beings - to make mistakes and not realise it until it's too late. This wasn't a unique event, Ireland wasn't a unique event. Such mistakes are likely to continue but that should not prevent us trying to instil appropriate SOP's via quality training - in FSTD's of course. The need for regular effective renewal of skills was a subject I presented at an RAeS conference a while back (Automation ? Will Evidence Based Training Deliver a More Competent Helicopter Pilot? ? Sim Trainer (http://simtrainer.co.uk/automation-will-evidence-based-training-deliver-a-more-competent-helicopter-pilot/)). The notion that recurrent training is like an annual 'inoculation' and that mere attendance will insulate the crew against errors is an indication that the point has been missed. A six-month recurrent programme is the minimum to be effective and a three-month cycle would be better.

As FSTD's become more common and more available I would hope that we introduce more effective recurrent programmes that focus on RAISING standards not just maintaining them.

G.

[[email protected]]

I am not sure how many training hours the Irish CG contract includes but with the UK civvy SAR contract there is a heap of hours for training. 50 per month to be precise. compared to the 120 hours per month that the RAF SAR Force had.............and, as discussed, newer technology requires more training not less.

However, I believe the UKSAR are using a bit more than 50 a month.

[DOUBLE BOGEY]

Geoffers, agree 100%. Also in tha training we need to be ready to "Bin" the incompetent tossers who latterly tend to launch official complaints against Instructors and Examiners, for what in majority of cases, seems to be and accepted practice to mask unsuitability at the most basic levels.

Also spineless middle management pilots who accept the "Yes" men over the "No" men and who in themselves, so inexperienced, that they cannot cope with the demands of the older, wiser more experienced crews.

Bring back the days when the CP was truly the "Senior" pilot.

Training needs addressing. People who crash in the simulator..............what are they capable of in the real Helicopter!

[rotorspeed]

Sunnywa seems to have the most logical explanation regarding why the APP1 approach was used to 200ft then the APBSS route guide towards Blacksod. In summary the crew knew (a) APBSS was probably VFR, (b) the cloudbase was around 300ft hence the need for a 200ft VFR transit, (c) that their SOPs mandated any over sea IMC let down had to be well away from the coast and (d) that as there was no IFR arrival plate this was their only option.

Of the many issues, firstly what SOPs do apply to the ICG SAR for IMC let downs? If there is no IFR arrival plate (which presumably for most of their non airport destinations there isn't), exactly what are the crew permitted to do? Presumably creating their own safe let down procedure is not a permitted option?

[[email protected]]

DB - it's a dark and ****ty night, 200' cloudbase, strong winds, limited vis due to the heavy rain and there is a vessel aground on rocks (coastal location) with life seriously in danger and the conditions preclude lifeboat rescue.

It is an unfamiliar area and you are scrambled to the job - you have to get down from the cruise and get to the job - you are obviously relying heavily on the radar.

Not only do you have to let down to a safe area but then you need the radar to close to the coast until you get visual.

Would you rather have a well-trained radar operator whose ONLY job is to conduct that letdown safely, using all the skills and experience gained from training and being regularly examined in this discipline OR would you rather rely on the co-pilot who might have been up to speed when he did his type and role training but hasn't really got the best out of the radar and hasn't done a letdown in really poor weather for quite a while (for training or for real). Oh, and he is listening to 3 different radios, monitoring your flying and managing the FMS.

Tell me which one you think is safer and which you would prefer - I think my choice in the matter is self-evident.

ARAs are not SAR letdowns.

[Al-bert]

Geoffers, agree 100%. Also in tha training we need to be ready to "Bin" the incompetent tossers who latterly tend to launch official complaints against Instructors and Examiners, for what in majority of cases, seems to be and accepted practice to mask unsuitability at the most basic levels.

Also spineless middle management pilots who accept the "Yes" men over the "No" men and who in themselves, so inexperienced, that they cannot cope with the demands of the older, wiser more experienced crews.

Bring back the days when the CP was truly the "Senior" pilot.

Training needs addressing. People who crash in the simulator..............what are they capable of in the real Helicopter!

Careful DB, you're beginning to sound like me :=:ok:

[Geoffersincornwall]

Crab - Sad fact, use of Radar, Taws, TCAS not included in basic TR course as they are 'customer specific options'. Before you ask I guess the vast majority of aircraft built have those 'options' on board. Training for this equipment is the responsibility of the owner/operator.

I think we have to accept that SAR involves the occasional need to venture into areas that are not entirely regulated so then the crew must fall back on their skill and experience. They have their own special versions of what are referred to as 'Black Swan Events.


G.

[tistisnot]

Regrettably crews are guilty of not using the Safety and Quality System to effect change. It is seen as cumbersome. Surely it is high time we adopted a rotary form of LOSA; to allow experienced and trained company pilots to monitor crews anonymously with a view to providing real evidence of both good and poor PDM, TEM in light of the quality of and adherence to company SOP's with a view to demanding that Safety & Quality force Operational Management to change or amend where necessary. The selected LOSA pilots will also have received plenty of cockpit feedback on poor or lacking procedures, training, roles, charts etc or even heaven forbid heard suggestions for safer alternatives.

LOFT in the simulator only partially covers this. And in the aircraft of today ... a jump seat is not necessarily / easily available for the task but as DB states .... it is we, the pilots and trainers, who need to recognize and amend our ways - by listening to and watching each other.

[DOUBLE BOGEY]

DB - it's a dark and ****ty night, 200' cloudbase, strong winds, limited vis due to the heavy rain and there is a vessel aground on rocks (coastal location) with life seriously in danger and the conditions preclude lifeboat rescue.

It is an unfamiliar area and you are scrambled to the job - you have to get down from the cruise and get to the job - you are obviously relying heavily on the radar.

Not only do you have to let down to a safe area but then you need the radar to close to the coast until you get visual.

Would you rather have a well-trained radar operator whose ONLY job is to conduct that letdown safely, using all the skills and experience gained from training and being regularly examined in this discipline OR would you rather rely on the co-pilot who might have been up to speed when he did his type and role training but hasn't really got the best out of the radar and hasn't done a letdown in really poor weather for quite a while (for training or for real). Oh, and he is listening to 3 different radios, monitoring your flying and managing the FMS.

Tell me which one you think is safer and which you would prefer - I think my choice in the matter is self-evident.

ARAs are not SAR letdowns.

CRAB - In a modern third generation cockpit, I would rather be looking at the RADAR screen myself and not reliant on the Co-pilot or anyone else for that matter, regardless of me being PF or PNF. Most especially at 200 feet on a dark and stormy night.

In a modern MFD cockpit, the requirement for the PNF to "direct" the PF is extent. Sure the calls should come, but they are supplementary to the PFs ability and requirement to avoid red blobs on the MFD in front of him.

You cannot confuse the basic requirements of the procedure they were flying with a rescue mission.

I recognise, having done it, that in older types the scan required precludes the PF from really concentrating on the RADAR. Althopugh having flown those types I have always checked the screen as much as my scan would allow.

I agree 100% that in SAR, a rear RADAR Operator is a huge bonus when off route letting down in nager to an incident.

However, this accident has nothing whatsoever to do with that. This accident started in the planning room, when, as both pilots were "unfamiliar" with the procedure they were required to do, so evidently failed to capture the height of Blackrock and the implications of it along the route they were about to fly. Which in itself presents a wider question. If Black sod was a regular known and required refuelling stop WHY were this crew so unfamiliar with the area/procedure/hazards.

Not too long ago a good friend of mine, a TRE/LTC, decided to take a refuel in Sumburgh to familiarise the co-pilot he was Line Training with the airfield. He did not need to stop for fuel but as he was passing he took advantage to get the co-pilot familiar with an airfield which would become a regular alternate/fuel stop for the rest of his NS career.

On RTB he was torn a sizeable new one by the Pilot management for making this decision and slightly delaying a flight/causing a bit of expenditure. Policy stated was such Line Training adventures were unacceptable. And yet the regulations demand familiarisation training.

These are the insidious problems that afflict the modern commercial helicopter operation.

Looking at the Blacksod area in general, it would be placed in my view, as a "Difficult"/ "Hazardous" approach with no ground based NAVAIDS for positioning and a high reliance on GPS/RADAR and the Vertical Profile to ensure safe operations. This does not mean it cannot be done safely. It just places a premium on data, briefing and training.

In this case, the data was poor, the briefing seemed to consist of an admission of unfamiliarity and the training....well I guess that one is answered already.

In the fixed wing world they grade aerodromes in degree of difficulty and the pre-requisites to operate to/from a particular aerodrome are proportionate to that difficulty.

I watched with a degree of fascination when flying NS. co-pilots opting for SAR work. Co-pilots that I would put in the "Low Ability" category. No-one intervened. They got there. Some of them a few short years later were Commanding a SAR machine.

SAR demands high quality, reasonably experienced flight crew. Where experience is lacking, selection, quality and maturity should fill the gap. Much as how the Military machine works.

There is much to point the finger at in this accident. However, the more we become aware of what happened the harder it is not to focus on the competence and skills of that crew.

I really want there to be something wrong with the RADAR. However, the Commanders attitude to the red blobs they overflew and the RADALT warnings they were receiving paints a very poor picture of complacency and discipline. As a professional body we must not be afraid of accepting that in the end, maybe we were just not good enough!

[offtrack]

DB - it's a dark and ****ty night, 200' cloudbase, strong winds, limited vis due to the heavy rain and there is a vessel aground on rocks (coastal location) with life seriously in danger and the conditions preclude lifeboat rescue.

It is an unfamiliar area and you are scrambled to the job - you have to get down from the cruise and get to the job - you are obviously relying heavily on the radar.

Not only do you have to let down to a safe area but then you need the radar to close to the coast until you get visual.

Would you rather have a well-trained radar operator whose ONLY job is to conduct that letdown safely, using all the skills and experience gained from training and being regularly examined in this discipline OR would you rather rely on the co-pilot who might have been up to speed when he did his type and role training but hasn't really got the best out of the radar and hasn't done a letdown in really poor weather for quite a while (for training or for real). Oh, and he is listening to 3 different radios, monitoring your flying and managing the FMS.

Tell me which one you think is safer and which you would prefer - I think my choice in the matter is self-evident.

ARAs are not SAR letdowns.


I know for sure which I would prefer, as a commander manage the flight myself, and let the copilot do the hands on flying. Because it's much safer and more efficient that way.

And when on the site, transfer of controls before hoisting. Or maybe not, if the copilot has better visual references from the left seat.

[Mark Six]

A full time radar operator to operate a simple piece of machinery on the off chance that once a year you just might encounter the scenario you suggested Crab? Seriously? Or how about the Australian SAR/EMS model flying modern aircraft with all the same equipment as R116 but operating single pilot with an aircrewman in the LHS?

[G0ULI]

The military accept that there is an attrition rate inherent in operating in hazardous conditions. They train to reduce the risks to acceptable or tolerable levels. Many if not most SAR flights involve some degree of hazard that would normally be avoided, otherwise a rescue flight would not be required in the first place. What exactly is the acceptable attrition rate for civilian search and rescue flights?

[gulliBell]

..Training needs addressing. People who crash in the simulator..............what are they capable of in the real Helicopter!

You might be surprised at the number of weather related crashes in the simulator when there is no technical malfunction that needs dealing with...actually, I probably see more of these CFIT crashes than crashes that are the result of improper handling. In other words, crews are crashing the simulator simply because of bad weather about as often as they crash the simulator because of poor technique in response to technical malfunctions. Demonstration by the instructor, and repetition and practice of the malfunction by the trainee, usually results in improvement to an acceptable standard. There is time allocated in the training budget for this. But I haven't yet worked out how to prevent crews from having CFIT events, the causes are so deeply entrenched that it is a waste of simulator time trying.

[HughMartin]

Training needs addressing. People who crash in the simulator..............what are they capable of in the real Helicopter!

The handling qualities, control feel and visuals on the simulators I was exposed to left a lot to be desired. Some of them should not have been certified.

I have circa 20,000 hours under my belt and used to regularly crash the simulator trying to demonstrate my competence landing or taking off from an offshore helideck. I never crashed and burned in my 20,000 hours and estimated 30,000 take off and landings in real aircraft.

When the simulator started doing its own thing and not doing what it should do, I used to take my hands off the controls, cross my arms and announce "Brace Brace Brace", much to the irritation of the instructor.

[DOUBLE BOGEY]

Hugh I guess I am referring to crashes in open flight like CFIT etc. The spatial limitations caused by the visual systems when trying to do a pin point manoeuvre where the lack of vertical image is obviously a problem.

It is for that reason that initial deck certification for O&G has to be done on the real aircraft to a real deck. Long may that requirement remain in place.

I accept I used a broad brush! Sorry for that.

[gulliBell]

The handling qualities, control feel and visuals on the simulators I was exposed to left a lot to be desired. Some of them should not have been certified...

The simulators now are quite good, but depth perception of blended projected visuals on to a curved screen requires some adjustment of technique. An initial trainee can do all of their training on the simulator and then be certified to fly the real helicopter with no additional training required. But I suspect flying the real helicopter for the first time after initial training on the simulator will feel about as wobbly as the simulator feels the first time you fly it after years of flying a real helicopter.

The simulators are quite realistic and provide a valuable training tool as part of a wider training curriculum.

[palacio802]

Hugh I guess I am referring to crashes in open flight like CFIT etc. The spatial limitations caused by the visual systems when trying to do a pin point manoeuvre where the lack of vertical image is obviously a problem.

It is for that reason that initial deck certification for O&G has to be done on the real aircraft to a real deck. Long may that requirement remain in place.

I accept I used a broad brush! Sorry for that.

The 'experience' in most flight simulators is really disgusting and not in correspondence with the available technology and the prices per hour. But this is another topic...

[gulliBell]

...and not in correspondence with the available technology and the prices per hour...

There is a huge cast working behind the scenes to keep the simulators going, and the parts needed to maintain them are the exact same pricey parts that go into a real helicopter. Plus the initial outlay to buy the simulator is much the same as what a new real helicopter costs, sometimes more. Which takes up a big chunk of the price per hour. Where the economics of the simulator really shine is when you crash them, much much cheaper than crashing the real thing.

[palacio802]

There is a huge cast working behind the scenes to keep the simulators going, and the parts needed to maintain them are the exact same pricey parts that go into a real helicopter. Plus the initial outlay to buy the simulator is much the same as what a new real helicopter costs, sometimes more. Which takes up a big chunk of the price per hour. Where the economics of the simulator really shine is when you crash them, much much cheaper than crashing the real thing.

Yes, I know. The same excuses for years, hehehe. But then, I go home and see the visuals of a 2004' flight simulator running in an old PC and I think: "jesus, they are laughing at us!".

[Lonewolf_50]

Perhaps if I were to suggest that SAR should not be a commercial operation subject to cost constraints that could limit crew training, that might be more acceptable?

Yes, I know the military have their problems too, but they would appear to have greater freedom to operate without having to account for every penny. G0ULI: from that I take it that you have not been in the military. (At least not recently, and not in military aviation).

In the past quarter of a century, at least, a significant sea change in military operations that I was familiar with was the vibrant cost consciousness of everything we did, which was a marked change from the 80's and before. (The end of the Cold War and the major draw downs of the mid 90's was where I started to see this). This was in a comparatively well funded military. For smaller services, and for nations with much smaller budgets as a whole, that pinch is going to be felt more keenly.

Not to put too fine a point on it, but in the early 00's a standard military function -- station pilots flying SAR with UH-1N's, for Naval Air Stations all over our country -- was quite simply cancelled without replacement. Someone ran a cost benefit and decided to dump the flying billets and that core capability. (Let the Coast Guard handle it, they said ...) There was some talk about trying to contract it out as well ... this, in the best funded Navy in the world.

I completely "get" why some SAR requirements are contracted out to civilian operators in various places. Governments are under a lot more public scrutiny for dollars spent, and it's the dollars anyone cares about until a fatal accident crops up. (The points in previous pages about training noted, and my head nodded on each post that brought that up. Training costs money).

If this accident can act as an impetus to improve systems training for the expensive kit, perhaps there's a silver lining to the cloud.
The military accept that there is an attrition rate inherent in operating in hazardous conditions. They train to reduce the risks to acceptable or tolerable levels. Many if not most SAR flights involve some degree of hazard that would normally be avoided, otherwise a rescue flight would not be required in the first place. The military no longer "accept" that in the year 2017. The military do indeed train to reduce risk to acceptable levels for military missions. You will still see training mission accidents; I refer you to the recent Black Hawk that crashed on a golf course in Maryland.
What exactly is the acceptable attrition rate for civilian search and rescue flights? No way am I jumping on that grenade.


My maritime flying (military) and SAR experience included the radar only being usable by the operator in the back (SH-2F) and the ability for either front or back seat to operate the radar (SH-60B). Being able to use a modern radar effectively while also keeping your copilot/PM/PNF duties on task is a matter of training. And practice. (See comments by DB a while back regarding recency).

Crab and DB (http://www.pprune.org/rotorheads/592162-sar-s-92-missing-ireland-66.html#post9746282) have had a good back and forth on some of the issues, so nothing further on that.


As to radar sensitivity and tweaking: G0ULI, you remind me of my early days of the non digital radars (we had the LN-66, which was an adapted maritime radar, IIRC Marconi) and getting the clutter/gain/scale etc just right. Likewise with ship board radars when I was on the bridge. I had a bit of a learning curve when the APS-124 and all digital tools confronted me in the Seahawk. Had to learn a new way of tweaking the radar. I will venture a guess that getting it "just right" is still as much art as science on a given day. Therefore, practice.

[SASless]

Lone....the answer to that last question shall begin to be answered by what actions are taken in response to the ICG Crash!

[gulliBell]

...But then, I go home and see the visuals of a 2004' flight simulator running in an old PC and I think: "jesus, they are laughing at us!".

Project that 2004 flight simulator image onto an enormous 220x80degree screen and see how good the resolution is. But yeah, it doesn't take much computing power to run the simulator, actually I think the whole show runs on a Windows XP computer (which is probably the cheapest part of the whole system).

[louisnewmark]

I consider myself (and my employer considers me) to be a well-trained radar operator who routinely carries out radar approaches to moving shipping, fixed offshore structures, coastal locations and in confined coastal inlets etc. These approaches are almost always carried out in simulated IMC, and occasionally actual IMC, to minimum radar range. They are NOT simply oil-&-gas-style ARAs. Twice a year I practice radar approaches in assessed LOFT scenarios in the simulator.

I also consider myself (and my employer considers me) to be a well-trained SAR pilot who routinely flies radar approaches etc etc. I am ably assisted by moving maps with AIS and radar overlays, EGPWS, NVIS, very helpful SAR autopilot modes which greatly reduce the old-school manual flying burden, another equally-competent pilot/radar operator and a pair of well-trained and competent tech crew who can also overlay AIS and radar onto their moving map to oversee my efforts and chip in when necessary.

Those who know, know. Those who don't often either presume that their non-SAR techniques are used in SAR or, more regrettably, shout ever louder either to get a bite or to convince the uninitiated that they really do know. The danger of this latter approach is that the uninitiated might take the shouted ballcocks to be gospel truth, and if one of the uninitiated happens to be a lurking journo then a huge amount of avoidable hassle can ensue. As I said, those who know, know.

For what it's worth (and of course I may be wrong), I think it's probable that the accident radar was set up and being operated correctly for the conditions, and that overflight of the radar return at BLKMO was deliberate in the belief that it represented low-lying rocks that were not a threat. I also think that, in this case, release of the CVR transcript has been extremely useful as it will have spurred some vigorous discussions in every SAR crewroom and management office in both the UK and Eire, leading to positive safety outcomes well in advance of the full report's publication. I'm sure that this was the intent of the AAIU team - well done to them.

There are lots of learning points already arising from this accident but the big 'take-home' lesson is this: never, ever overfly a radar contact in IMC below MSA. Simple.

[SASless]

Sim training is as good as those setting the rules allow it.

I watched a well known Northsea Operator with Operations around the World refuse to embrace Sim Training until forced to by the customer, then they flew crews halfway around the World to Texas with the Sim training within a couple of hours of their arrival, then insisted the training secnnario's have nothing to do with the area in which the crews actually flew, dictated what training was done, AND which instructors could do the training.

That the Sim school dealt with customers from all points of the Globe and by being at the Factory where the aircraft was designed and produced thus having access to expert technical advice and historical data.....the Operator insisted it knew better on all issues.

The laugh is I endured the farce the Sim Training we got and being close friends with several of the Instructors we still found ways to derive benefit by being there. Later I was an instructor there and conducted training for many of the Pilots from my former employer.

I did Recuse myself when tasked to do the training on a former house mate and training captain/ops manager/type captain....as I knew I could not be objective on his evaluation knowing of his incompetence and bad attitude.

I did ride along during his Sim Training under the guise of evaluating the instructor. It was actually to be a witness as we assumed he would fail to meet the standard and would try to blame the instructor.

He did not let us down...and his fellow trainee being the Senior Training Captain in the Company got to see for himself what happened and had a good laugh at seeing an attitude adjustment happen in real time.

Sim training is only as good as it is allowed to be.

It is a Sim.....and not the real aircraft....so it is more procedures and concepts that the Sim is best suited to provide and those strengths should be made best use of during training.

[palacio802]

Lonewolf, attrition level is something still present in (NATO) military operations. This has not changed because it is something inherent to the military. You could be tasked even for a suicide mision if the command decides it.

In the day to day life of military units the approach is as follows. They use risk matrices to determine the level of command required to give the green light. The more the risk level, the higher the level of the authority that can approve it. But no mission is theoretically "forbidden". The attrition level is something more implicit but still present.

Of course you train as much as you can in order to reduce the level of risk in any situation but accepting that any level of risk is acceptable if the president gives the order to go.

[DOUBLE BOGEY]

Those who know, know. Those who don't often either presume that their non-SAR techniques are used in SAR or, more regrettably, shout ever louder either to get a bite or to convince the uninitiated that they really do know.

There are lots of learning points already arising from this accident but the big 'take-home' lesson is this: never, ever overfly a radar contact in IMC below MSA. Simple.

LOUISENEWMARK

Those who don't know don't know either. NEVER EVER OVERFLY A RADAR CONTACT - this is not a SAR Technique. Its basic common sense!

But many thanks for clearing up several pages of the bleeding obvious with a totally pointless, holier than thou, "we are so so special"....post.

[louisnewmark]

DB, I absolutely agree that it's basic common sense and any of my colleagues would agree - yet, for perhaps a number of reasons, it seems to have happened here.

Apologies if my previous post seems to be of the "we are so special" variety; I'm certainly not and wouldn't want anyone to believe that I thought that way, but my point was that the training that my colleagues and I receive is rather better than certain posters on here would like to think (or like others to think). Yes, there's the bleeding obvious, but there's also an inordinate amount of spurious nonsense!

[DOUBLE BOGEY]

Loiusenewmark. Thanks for your gracious post and maybe I was a bit quick to fire off. I agree with all you say and you are, in my opinion, 100% correct about flying over the Red Blobs.
Like I have said repeatedly on this thread. I have a huge respect for the SAR Community and would much prefer this to have been caused by something other than the crew. However, it seems, from what we have learned in the AAIB report that this is not the case.

I just cant get my head around the 200 feet thing and the lack of real response when the RADALT began to kick off. On one hand, it implies they studied the guides and decided that the rocks were nothing and therefore not a problem to fly over. (albeit this being a crass departure from conventional wisdom in any circumstance). However, if they had done the study then surely they would have realised the height of Blackrock.

I understand your commitment and appreciation of your training. However, training without underlying competence, discipline and sensible procedures (who steers the helicopter) amounts to not much at all. It seems on that on this day, for reasons we will probably never know, a whole lot of cheese holes lined up to supplement what was essentially an underlying poor practice of probably routinely accepting overflight of RADAR targets at daft heights.

I also cant understand that if the rear crew called for a change of heading why the PF just did not do it rather than asking the PNF to make this change. Is this normal? PF should control the trajectory of the helicopter at all times.

We have this a lot with automation philosophies and how organisations chose to set out their stall. I believe that the PNF can make preselection's, but only the PF should control the final trajectory, ie engagements or datum changes. The alternative is effectively 2 x pilots trying to fly the helicopter at the same time which is OK if they both remain in the loop but sucks a lot when one of them drops out of the loop....like appeared to happen here.

If the PF had immediately changed the heading instead of asking for that change, the outcome may well have been a couple of pairs of brown trousers and beer tab for the rear crewman. As it was the outcome was somewhat less positive. This delay lies at the heart and soul of automation philosophy and setting out habits (SOPs) that work in extremis and in your favour rather than act like a ticking time bomb to catch you out when you least expect it.

[louisnewmark]

Lots of good points, DB, but it seems to me that there were a lot of other factors contributing to the crew's apparent loss of SA. For example, a) nobody is at their sharpest at 2:00am, b) they flew a recognised company route that I presume was intended for use in poor weather and, surely, nobody would approve or continue to accept such a route that overflies a 280 ft rock, c) for some reason it seems possible that they believed the rocks to be low, and so were happy to overfly them, d) they were unfamiliar with the local topography. Points c) and d) may have reinforced their reliance on point b).

Forgive me if you know the next bit, but here goes: the aircraft's roll channel would have been coupled to the nav kit to follow the route. When initially alerted to the need for a heading change the PF followed the usual multi-pilot procedure by asking the PM to select the roll channel into 'heading' mode so that the PF could then manually select the heading bug, and hence the aircraft, to the desired heading. That's absolutely fine and safe in normal fully-coupled circumstances but, in this case, neither pilot appears to have appreciated the urgency. Instead of overriding the autopilot by manually moving the controls to change the aircraft's flightpath rapidly, as would probably have been appropriate, the pilots used up valuable time by following automation SOPs. By the time the urgency was emphasised it was too late to avoid the island.

It seems that the pilots were complying with the tech crewman's direction, but in an inappropriate (with hindsight) manner. SOP techniques in non-SOP circumstances.

[Geoffersincornwall]

DB - I have been watching pilots perform in the 139 sim for more than 10 years and I can tell you that if you want to guarantee misselection of AP modes under IMC conditions in an MP environment then get the PF to make them. If the PIC wants to effectively manage the situational awareness then I suggest he act as PM. That way he gets to be a more effective manager of the situation and make the AP selections whilst vetting all that the PF does.

We have just written the 139 FCOM for offshore and so this is a very active area of discussion.

G

PS - I wouldn't rule out the flat cross-cockpit gradient as a factor. BTW you can move the HDG bug using cyclic trim in the 139 so maybe a better system than that on the S92.

[louisnewmark]

Geoffers - cyclic trim controls the hdg bug (in HDG mode) in the S-92 also. I think that's what the PF intended to use.

PS - Very good point about the flat cross-cockpit gradient.

[Red5ive]

Rescue 116 crash: New search for missing crew

Army personnel and Garda experts to take part in two-day mission on Blackrock Island
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-crash-new-search-for-missing-crew-1.3054295

[cncpc]

I just cant get my head around the 200 feet thing and the lack of real response when the RADALT began to kick off. On one hand, it implies they studied the guides and decided that the rocks were nothing and therefore not a problem to fly over. (albeit this being a crass departure from conventional wisdom in any circumstance). However, if they had done the study then surely they would have realised the height of Blackrock.



The RADALT warning came when they passed over the Carraigs. The captain knew what they were. She didn't know that from the guide "plate" because that doesn't have them. She is looking at a moving map which does. The RADALT doesn't only give the warning, it displays what the new radar altitude is. Somewhat less than it was. For a moment, and then goes back to 180 or 200, whatever it was set at.

At the warning point, and given she has correctly analyzed the reason, what would you have her do? You say crew error, so at this point, what does she do?

She incorrectly assumed that was BLKMO, which doesn't jive with the distance to waypoint info. If she is looking at a map which shows the two little Carraigs, surely that map has Blackrock as well, although as the report says, depending which map is up on the display, it may contain anywheres from no to the correct information re the altitude of Blackrock.

The Carraigs didn't show on radar, so not a big deal if they were overflown. Blackrock may or may not have shown on radar, and the large target may have been the Achill coast about 3 miles away. The crewman saw an island. It wasn't a radar return. What should she have done?

BLKMO: A geographic point on the Operator’s Route Guide at which the arrival into Blacksod was to commence; it is close to Black Rock.

[Tezzer 007]

The PO said they were 1.3 miles from BLKMO.
He then said "small target six miles at eleven o'clock".
Then "Large, out to the right there"
PF replied "A small little island... that's BLMO itself".
So her BLMO comment cannot refer to the six mile target,as 1.3 had already been given as distance.
So she either pointed at something they had visual on. Or she pointed at his radar display or her own map display. What she pointed at could be the "Large, out to the right" what she thought was BLKMO.
Then the guy in the back said "Come right"
She asked for confirmation. She thought BLKMO was to the right.
I think it could have been Achill that was mistaken for Black Rock, as Black Rock was, of course, right in front of them.

[DOUBLE BOGEY]

Cnpc, for a start, the moving map, the paper map and the EGPWS do not matter once you are 200 feet in the dark over the sea.

All the matters is the RADAR, followed by RADALT. FLIR would help. NVG they did not have.

So you ask me the question. I answer. I would have the PF flying AND fully controlling the helicopter. I would have the RADAR image on the PF and PNF MFD.

It the Radar was correctly tuned. PF sees target. PF announces target and makes a correction to the trajectory. PNF concurs. The simplest, quickest smartest way to operate a third genearation helicopter at night. In addition the Commander would be PNF and the Co-0pilor PF.

I absolutely vehemently disagree that the PNF should have any control of the aircrafts trajectory UNLESS the PF becomes disorientated. It's f****ing madness to have the aircraft and AP modes being controlled by two people. PNF pre-selects, PF checks and Authorises. Once the mode is engaged PF drives the helicopter by knobs or trim switches, or if warranted, flys through. PF totally responsible for the aircrafts trajectory, coupled or uncoupled. PNF monitoring the trajectory and the FMA indications.

It's gobsmacking what people have just posted about automation. Surely even the most mentally deficient can understand that pissing about with silly over complex INAPPROPRIATE AUTOMATION SOPS almost certainly was the last hole in this Swiss cheese.

Geoffers, all I can say is you are not taking your guys in the right direction. Please re think it through. If you PF is miselecting then more training required. But you cannot have the Helicopter trajectory shared between two people.

[SASless]

DB is right....one Pilot "drives"...the other monitors and assists!

[cncpc]

Cnpc, for a start, the moving map, the paper map and the EGPWS do not matter once you are 200 feet in the dark over the sea.

All the matters is the RADAR, followed by RADALT. FLIR would help. NVG they did not have.

So you ask me the question. I answer. I would have the PF flying AND fully controlling the helicopter. I would have the RADAR image on the PF and PNF MFD.

It the Radar was correctly tuned. PF sees target. PF announces target and makes a correction to the trajectory. PNF concurs. The simplest, quickest smartest way to operate a third genearation helicopter at night. In addition the Commander would be PNF and the Co-0pilor PF.

I absolutely vehemently disagree that the PNF should have any control of the aircrafts trajectory UNLESS the PF becomes disorientated. It's f****ing madness to have the aircraft and AP modes being controlled by two people. PNF pre-selects, PF checks and Authorises. Once the mode is engaged PF drives the helicopter by knobs or trim switches, or if warranted, flys through. PF totally responsible for the aircrafts trajectory, coupled or uncoupled. PNF monitoring the trajectory and the FMA indications.

It's gobsmacking what people have just posted about automation. Surely even the most mentally deficient can understand that pissing about with silly over complex INAPPROPRIATE AUTOMATION SOPS almost certainly was the last hole in this Swiss cheese.

Geoffers, all I can say is you are not taking your guys in the right direction. Please re think it through. If you PF is miselecting then more training required. But you cannot have the Helicopter trajectory shared between two people.

Thanks, DB. You make your points well.

I wasn't so much challenging what you had said prior, because my own comments can be taken as a crew error view as well. I was actually asking what you would do, in the right seat, when the guy in the back says there is an island directly ahead. Is it too late by then, or is there some act of command and aviating that could have saved those people. When they have arrived at that awful point, when procedure and systems have failed them, and they are at 200 feet with an island directly ahead.

The bit about BLKMO comes from the accident report. They consider that drawing to be an arrival, and for some reason they seem to say that BLKMO is not the helipad. That it actually may be over the ocean.

[Geoffersincornwall]

SAS & DB - You misquote me, I never said that the PM is in charge of the trajectory. I said the PIC is in charge of the whole caboodle and to have the best chance of managing the operation he delegates the flying to the P2. The PF calls the trajectory and the AP modes and the PM (PIC) selects them. He has the brain-space to observe what is happening and veto anything he doesn't like.

With the spectrum of abilities we see on a daily basis, you really don't want the guy on instruments taking his attention away to do the AP selections. Remember that the AP panel is in the middle of the interseat console on the 139.

You may be using your own skills as a reference for the rest of the pilot population. If you read the piece on the end of the link I posted earlier you will see that less than 50% of those we see can be considered to be 'competent'.

G

[Red5ive]

The bit about BLKMO comes from the accident report. They consider that drawing to be an arrival, and for some reason they seem to say that BLKMO is not the helipad. That it actually may be over the ocean.

Could that be referring to a waypoint near Blackrock.

On the Newstalk clip (http://www.pprune.org/9740703-post962.html)I posted, the expert seemed to infer it was a waypoint (at 10m20s).

[Red5ive]

On RTE Radio Good Morning Ireland programme this morning (= Today on BBC Radio 4) there was a discussion of the accident.

Two separate elements were discussed:

i) The failure to follow appropriate protocols in releasing transcripts from the cockpit. This was the "official" basis for the interview, it seems.

ii) However, at the end of the interview, the President of the Irish Airline Pilots Association appeared to make some trenchant criticisms of the reliability of the information being provided by the systems to the crew.

Criticisms which the interviewer, pressed for time by an editor no doubt, failed to pursue.

Morning Ireland - RTÉ Radio 1 (http://www.rte.ie/radio1/morning-ireland/#2463200)


The item is number 9 or 10 in the running list when you scroll down.

mp3
http://podcast.rasset.ie/podcasts/audio/2017/0419/20170419_rteradio1-morningireland-pilotgroup_c21160962_21161053_232_/20170419_rteradio1-morningireland-pilotgroup_c21160962_21161053_232_.mp3

[212man]

SAS & DB - You misquote me, I never said that the PM is in charge of the trajectory. I said the PIC is in charge of the whole caboodle and to have the best chance of managing the operation he delegates the flying to the P2. The PF calls the trajectory and the AP modes and the PM (PIC) selects them. He has the brain-space to observe what is happening and veto anything he doesn't like.

With the spectrum of abilities we see on a daily basis, you really don't want the guy on instruments taking his attention away to do the AP selections. Remember that the AP panel is in the middle of the interseat console on the 139.

You may be using your own skills as a reference for the rest of the pilot population. If you read the piece on the end of the link I posted earlier you will see that less than 50% of those we see can be considered to be 'competent'.

G
No, no, no. PF controls flight path - PM monitors.

[cncpc]

Could that be referring to a waypoint near Blackrock.

On the Newstalk clip (http://www.pprune.org/9740703-post962.html)I posted the expert seemed to infer it was a waypoint (at 10m20s).

In the scenario I subscribe to and which is sort of generally accepted, that route was originally drawn up as a service/transit route between the two helipads. Support for that seemed to be that these waypoints had a pink circle under them, and numbers believed to be either the elevation of the pads or the the obstacle height of the lighthouse.

The wording in the report may be just poor wording, but it could mean that the waypoint is not co-located with the helipad, or even the island. Just near it, i.e. over open water. If that is the case, it opens another hole in the cheese. Nobody knows what page 2 says in that APBSS thing. It may have heights associated with each waypoint, or it may tell you that there is a 310 foot lighthouse "near" the waypoint.

Support for it being the helipad comes from the fact if you fly to BLKMO at 200 feet in cloud or darkness, you will hit the rock perfectly in line with the helipad. Whatever the case, its confusing enough that even the investigators cannot describe it in an unambiguous way.

[Geoffersincornwall]

212 - That's what I said - PF controls trajectory and calls the AP modes. My advice is that the PF is the copilot whilst the PIC remains as PM and can exercise his PIC responsibilities more effectively. This closely follows the principles of a 'monitored approach' favoured by many when the chips are down and the weather marginal.

G.

[cncpc]

Red5ive...

That newstalk interview was painful. The "expert" obviously isn't keeping in touch with this thread.

E.g. he says they couldn't see the light because they were too high and the light had a roof.

[SASless]

You may be using your own skills as a reference for the rest of the pilot population. If you read the piece on the end of the link I posted earlier you will see that less than 50% of those we see can be considered to be 'competent'.



Let me get this straight....If I am the "Driver", "Handling Pilot", "Pilot Handling", "the Guy with his Mitts on the Sticks".....are you suggesting I have to rely upon the other guy up front to mash a button to select a Mode....turn a Heading Knob....or reset a Bug?

Is that what you are saying?

All this while the Autopilot System is controlling the machine for me in response to my inputs?

[Red5ive]

What a ridiculous statement for a regulator to make!

The Irish Aviation Authority (https://www.irishtimes.com/search/search-7.1213540?tag_organisation=Irish%20Aviation%20Authority&article=true) declined to comment when asked if it was responsible for approving operator route guides and other databases.
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-families-should-be-fully-involved-in-review-says-lawyer-1.3055789

[G0ULI]

I would think it was much more likely that they couldn't directly see the light because the cliffs above them at their 200 foot flight level cut off the beam. I note that the aircraft would have been presenting a port side nav light towards the lighthouse. Is it possible that the aircraft navigation lights and anti collision beacon reflecting against low clouds could potentially mask the lighthouse red and white lights? I am making the assumption that they would be illuminated flying at low level on an intended approach.

Rereading the report, it looks like the crew didn't look at the page two notes of the approach pattern and were completely unaware that they were below MSA approaching Black Rock. That document and the way the route was presented is absolutely damning as the initiator of all that followed.

Many thanks to the contributors over the last few pages for your insightful and thought provoking posts. Much appreciated.

[smcc63]

I would think it was much more likely that they couldn't directly see the light because the cliffs above them at their 200 foot flight level cut off the beam. I note that the aircraft would have been presenting a port side nav light towards the lighthouse. Is it possible that the aircraft navigation lights and anti collision beacon reflecting against low clouds could potentially mask the lighthouse red and white lights? I am making the assumption that they would be illuminated flying at low level on an intended approach.

Rereading the report, it looks like the crew didn't look at the page two notes of the approach pattern and were completely unaware that they were below MSA approaching Black Rock. That document and the way the route was presented is absolutely damning as the initiator of all that followed.

Many thanks to the contributors over the last few pages for your insightful and thought provoking posts. Much appreciated.

Absolutely agree,,"that document" initiated a series of events that led to complacency and ultimately a tragic outcome

[sunnywa]

For what it is worth, I believe Goffers is more correct in the crew set up. In our SAR Cab, the PIC is the PM(PNF) and the co-pilot is the pilot flying. However, in reality using the 4 axis autopilot, the PF is monitoring the flight path and the system to make sure it doesn't throw a wobbly and the PIC/PM is the person who is monitoring the radar for clearances, if needed, telling the PF that he is about to turn the heading bug (and does alter the heading) (to avoid something or track somewhere), keep SA on the job, put in the search pattern, activate it etc, control the SAR modes (APP1,2 MOT etc). In effect, the PIC is controlling the flight path and keeping a better SA to complete the job with the PF is sitting there scanning to make sure what the PM says is going to happen is happening in a safe manner. The PF is doing nothing but scan. With NVG, they also scan (minimally) outside.


DB, if you want me as the PIC to be the PF and control the aircraft, while keep SA on everything, sneak a peek at the radar to make sure nothing is happening, then you are giving the PIC about 90% of the workload in this ****ty environment. I personally think that is too much, and, while this was not a factor in this accident, now put in an inexperienced (but competent) co-pilot.
Preparing to receive........:ouch:

[gulliBell]

...if you want me as the PIC to be the PF and control the aircraft, while keep SA on everything, sneak a peek at the radar to make sure nothing is happening, then you are giving the PIC about 90% of the workload in this ****ty environment. I personally think that is too much, and, while this was not a factor in this accident, now put in an inexperienced (but competent) co-pilot.
Preparing to receive........:ouch:

How do the SAR pilots flying AW139 in Australia manage to do it all single-pilot? They do single pilot IFR and at night, don't they?

[cncpc]

Absolutely agree,,"that document" initiated a series of events that led to complacency and ultimately a tragic outcome

Not sure it led to complacency. For now, it is at the core of issues as most see it here. The investigation may identify what issues led to this failing to provide a safe procedure when it was selected in combination with APP1. All is well if there is a 400 foot ceiling.

Nothing unusual about the IAA refusing to answer questions. Pretty standard. Same with CHC. Lawsuits are surely coming from the families. There is a Brit lawyer from a big firm already on it.

I know what purports to be an IFR approach like that might be has to be regulator approved and published through the regulator in most first world countries. I can't imagine this was formally approved.

[sunnywa]

Night overwater SAR is a two pilot plus two crew job in Aust. Overland can be 1 pilot spifr.

[louisnewmark]

"My advice is that the PF is the copilot whilst the PIC remains as PM and can exercise his PIC responsibilities more effectively. This closely follows the principles of a 'monitored approach' favoured by many when the chips are down and the weather marginal."

Geoffers, I absolutely agree with you here.

[Mark Six]

Night overwater SAR is a two pilot plus two crew job in Aust. Overland can be 1 pilot spifr.

Oh really?! I didn't get the memo. Maybe that's the case where you work but you obviously don't know what's going on in the rest of the country. Co-pilot on RAAF SAR??

[Geoffersincornwall]

BTW, the Epic system allows one pilot to monitor Radar on his MFD and TAWS on his HSI whilst the other has TAWS on his MFD and radar on the HSI. Radar image needs to be optimised for the altitude (tilt) and sea conditions (gain) and that means that changes may be needed to the IAS/Altitude change. These changes have to be carried out by the PM.

This is essentially what the 139 FCOM says and that was the product of a lot of experienced offshore people at the factory and validated by those in industry.

Ultimately you have to write your SOP's and stand by them..... or not!

G.

[Nigel Osborn]

Unless it's changed in the last few years, the RAAF SAR helicopter has a co-pilot.

[DOUBLE BOGEY]

PIC is PM, CO-pilot is PF. Absolutley agree. Geoffers, I take your point for an AC with the AP mode selection panel on the inter console. Ergonomically that may make sense for PF to call for and PM to push the button. On AC where the PF has the AP controls in front of him. The situation is changed, for the better in my view.

However I see no merit in the PM changing the trajectory, i.e. Turning an active heading bug. This is PFs role 100 % with PM monitoring.

On an AC where the RADAR image can be displayed on an MFD in front of PF, with no loss of primary flight display, it's the quickest reaction to target avoidance.

Bear in mind, in these modern AC the AP is doing the actual flying. The PF ideally controlling the AP in response to his SA, whether visual IMC or negotiating a RADAR target.

Sunnywa, you state as PIC you should not be monitoring 90% absolutley agree with you. YOU SHOULD BE MONITORING 100% and another 50% capacity in addition for constant contingency planning. If the PIC cannot cope with this workload he's in the wrong job.

[DOUBLE BOGEY]

Geoffers, principles are just that. However, at 200 feet tracking towards the coast BOTH PILOTS SHOULD have the RADAR image on their respective mission screens. TAWS is the virtual world, database driven and as we see from this accident not fit for purpose in terrain avoidance. Setting up the MFDs must be logical and responsive the the mission and phase of flight.

Moving map and TAWS are advisory systems. The RADAR is the ONLY tool able to see solid objects in front of the helicopter. It's madness not to have that vital, critical and accurate information right in front of the pilot driving the helicopter, AND the pilot monitoring the flight path, WHENEVER below MSA over the ocean.

[Mark Six]

Unless it's changed in the last few years, the RAAF SAR helicopter has a co-pilot.

It hasn't changed. RAAF SAR co-pilot was my guess as to the position currently occupied by Sunnywa.

[sonas]

Have any of you thought about the family reading this forum? Yes fully understand the technical aspect of it and learning points that have arisen. However, who should have done this and who should have done that doesn't help the relatives and friends.Think it's time to put a sock in it.

[Frying Pan]

Sonas, I do not agree with your statement, but I will defend the right for you to say it. No disrespect intended.

This is a forum site. Enough said......or not.

[rotorspeed]

The associated notes to the APBSS chart are clearly going to be critical - what did they say, and were they read. Given that these were standard notes presumably available to all flight crew and others across a four base IRCG SAR operation over the last 5 years, and are also considered likely to be legacy notes created many years ago and therefore used by quite a few other pilots, I assume there are quite a few reading this thread who know exactly what these notes say. And what they were intended for. Anyone care to comment?

[DOUBLE BOGEY]

Sonas, This is a website forum for Professional pilots to discuss whatever issues they see fit. No-one wants to upset relatives but we do a serious job of work and some, not all, of this forum is provided by pilots and crew who never want this kind of accident to happen again. Sure the official reports and investigations run their course but that should not inhibit us from talking about the issues and provoking each others thoughts with one aim in mind. To help us not to make the same mistakes as others, no mater if they are perceived or not.

You have you opinion and it is right and proper you should air it freely.

Gods forbid If I am ever a subject of one of these threads feel free to tear my performance apart. If it helps someone else then maybe some good comes of it!

[S76Heavy]

Having flown stuff that now sits in museums, I was slowly introduced to increasing levels of automation. So far, the automation is still "dumb" in that it does everything you tell it to, very smoothly but with a profound lack of SA. You as the pilot will have to provide the SA.
Which is why I hardly ever use NAV mode. The AP will happily fly me into a rock of a thunderstorm blindly following the signals it is designed to follow. Whenever there might be a need to adjust track for avoidance purpuses, HDG is my preferred mode as it only takes a simple turn of the knob or a flick to the coolie hat to move into the desired direction, usually away from potential trouble. Especially low level I want to have full and immediate control over where we are going. And when there is doubt, there is no doubt: Go around and try again. Better to arrive a bit late in this life than much too early in the next one..

[Search&Rescue]

PIC is PM, CO-pilot is PF. Absolutley agree. Geoffers, I take your point for an AC with the AP mode selection panel on the inter console. Ergonomically that may make sense for PF to call for and PM to push the button. On AC where the PF has the AP controls in front of him. The situation is changed, for the better in my view.

However I see no merit in the PM changing the trajectory, i.e. Turning an active heading bug. This is PFs role 100 % with PM monitoring.

On an AC where the RADAR image can be displayed on an MFD in front of PF, with no loss of primary flight display, it's the quickest reaction to target avoidance.

Bear in mind, in these modern AC the AP is doing the actual flying. The PF ideally controlling the AP in response to his SA, whether visual IMC or negotiating a RADAR target.

Sunnywa, you state as PIC you should not be monitoring 90% absolutley agree with you. YOU SHOULD BE MONITORING 100% and another 50% capacity in addition for constant contingency planning. If the PIC cannot cope with this workload he's in the wrong job.

I generally agree... but IMHO both pilots (PIC/COP) should be able to fly (act as a PF) an ARA to a minima and initiate a go-around if needed... same applies with cruise/low level flight... It is not that difficult to fly a modern SAR helicopter if you have got a proper training and you are "current" (you have practised ARA's / SAR missions recently)... I mean, most of the SAR operators have "all the bells and whistles" in the helicopters and the pilots usually
fly 3 cue / 4 axis coupled with the SAR modes when the visibility is poor... they can reduce the groundspeed e.g. to10 kts, if downwind is less than 10 kts ;) if needed in order to change the course and avoid the obstacle. I consider an ARA as a quite simple/basic task... You just follow the SOP's and respect your minima!
Btw. our company SAR ARA minima is 0,2 nm/100ft AGL (day/night).

[gulliBell]

...For what it's worth (and of course I may be wrong), I think it's probable that the accident radar was set up and being operated correctly for the conditions, and that overflight of the radar return at BLKMO was deliberate in the belief that it represented low-lying rocks that were not a threat..

This aspect is absolutely critical to unravel. Does the Primus radar system store information in non-volatile memory that can be downloaded for review, particularly the tilt and gain settings, and maybe the images that were being rendered? Whilst the radar may have been set up correctly, or not, I doubt the images were being interpreted correctly. With appropriate tweaking of the gain/tilt, low lying rocks will be surrounded by sea clutter returns, whereas a big cliff in-front of you may have sea clutter in-front of it, but will have no sea clutter behind it. You should never fly into a big black void behind a red (weather) or magenta (ground map) return because that area is potentially very hazardous.

[gulliBell]

Unless it's changed in the last few years, the RAAF SAR helicopter has a co-pilot.

The RAAF SAR aircraft are single pilot capable, right? As far as I know they are fitted with the Honeywell SPZ-7600 autopilot system with SAR option, which is certified for single pilot MOT operation, right? I suspect the co-pilot is required by the client, not by the configuration and equipment in the helicopter? Unless on NVG at night. I'm trying to contemplate the step up from that simple installation to that which was fitted to the accident aircraft, which I'm to understand is considerably more capable. The difficulty I'm grappling with is capability, how it is that increasingly capable aircraft are showing up in accidents more than less capable aircraft. Or so it seems. As capability increases it seems that life for the pilots is being made more difficult, not less. Or is automation making life too easy for the pilots and they aren't remaining alert enough to keep up with situational awareness?

My opinion on which pilot should be monitoring and which should be flying during any particular stage of flight should entirely be the prerogative of the PIC, and not enshrined in SOP in any way. There's no way to sugar-coat it, but the PIC is ultimately responsible for the safe operation of the aircraft, and the final disposition of it.

[llamaman]

My opinion on which pilot should be monitoring and which should be flying during any particular stage of flight should entirely be the prerogative of the PIC, and not enshrined in SOP in any way. There's no way to sugar-coat it, but the PIC is ultimately responsible for the safe operation of the aircraft, and the final disposition of it.

Beat me to it. It's staggering that Captains in civilian SAR are paid what they are yet seem to be hamstrung by procedures (often driven by the level/capability of modern automation and commercial pressures).

Surely the responsibility for safety of the aircraft/crew is that of the Captain? They should be empowered with the flexibility to achieve that in the most appropriate manner. The entire crew should be trained to a standard that best supports that.

Its called captaincy, airmanship and crew resource management.

[Search&Rescue]

My opinion on which pilot should be monitoring and which should be flying during any particular stage of flight should entirely be the prerogative of the PIC, and not enshrined in SOP in any way. There's no way to sugar-coat it, but the PIC is ultimately responsible for the safe operation of the aircraft, and the final disposition of it.

Well said gulliBell! :ok:

[palacio802]

Have any of you thought about the family reading this forum? Yes fully understand the technical aspect of it and learning points that have arisen. However, who should have done this and who should have done that doesn't help the relatives and friends.Think it's time to put a sock in it.

My ex-squadron left two helicopters between 2014 and 2015. Seven crewmembers died in the two accidents. I knew all of them. When I read the investigation report of the first one, I couldn't believe it. Some relevant information regarding the pilots was not in the report. I guess nobody told to the investigators in order not to hurt the families. The outcome of this is a "wrong" and not conclusive report. And families still claiming for an answer and in an spiral of conspiracy theories and self-destruction.

Putting shocks doesn't help at the long term. This is my opinion. And sorry for my English. :(

[Red5ive]

No sign of missing R116 crew men after detailed search of Blackrock Island
https://www.rte.ie/news/connacht/2017/0421/869367-rescue-116-search/

[SASless]

Pilot's prerogative.....why not?

Just remember there needs to be some SOP's that grant flexibility but also provide some structure so everyone is on the same page and each knows what the other is supposed to be doing with the idea of making sure nothing gets overlooked or there be confusion as to who is supposed to be doing a particular task.

Anyone remember that infamous BA Memorandum about Change of Duties during a Missed Approach.....the one written Tongue in Cheek but very clearly pointed out how confusing some things can be?

You 92 Drivers out there....two FMS control Pads....one for each Pilot...one by the Left Knee of the Right Seat Pilot and the other by the Right Knee of the Left Seat Pilot?

Is there not a Collective Switch that affords either pilot the ability to change Heading settings?

What about a Cyclic Button (Coolie Hat)....is there one of those?

Just how many ways are there of altering the "Heading" or "Course Flown" by a Pilot flying a 92?

[rotorspeed]

gullibell/llamaman

Good to see a bit of common sense amidst all this esoteric stuff on radar operation and crew responsibilities.

What stands out from all this is that we have the nonsense of a crew probably thinking they needed to descend to the highly risky height of 200ft at night to nominally be VFR according to SOPs (or maybe just did so because it was normal SAR technique) and then clout a 300ft rock - because of course it was night and they weren't VFR at all. There was full cloud cover and there was poor vis. All this debate about radar technique (which shouldn't have been essential if they were VFR) just proves that the risks of mis-interpretation and misuse were far greater than the risk of hitting anything descending in IMC with a normal profile, navigating with reference to GPS, planned by looking at VFR charts before they departed (which presumably didn't happen) to give maximum clearance to charted and known obstacles. And if they knew they weren't going to be VFR why on earth descend to 200ft? Just do a normal IMC let down profile, to keep as high as possible for as long as possible.

I may turn out to be wrong, but I'm pretty sure this accident need never had happened if the crew had not been hamstrung with SOPs and just used their intelligence to perform a sensible let down procedure for what was after all just a refuel to a well established base. And if regulations didn't allow it they should be changed. They weren't searching for a life raft in the dark ocean for goodness sake.

I feel some posting here can't see the wood for the trees. I'm the first to admit, I've no SAR Experience so welcome any alternative views from those that do.

[Geoffersincornwall]

rotorspeed

Have you ever flown in an operation that can deliver a different copilot every day? If so you will know and understand the value of SOP's. There will always be enough slack in the system to allow some discretion for the PIC, especially in the SAR world.

G

[A Real Pin]

More than 100 divers in sub-sea search for helicopter crew
Survey thought to be largest dive exercise of its type in efforts to find R116 winch crew missing for six weeks

More than 100 divers in sub-sea search for helicopter crew (http://www.irishtimes.com/news/ireland/irish-news/more-than-100-divers-in-sub-sea-search-for-helicopter-crew-1.3057128?utm_content=sf-man)

[Pltnorway]

Pilot's prerogative.....why not?

Is there not a Collective Switch that affords either pilot the ability to change Heading settings?

What about a Cyclic Button (Coolie Hat)....is there one of those?

Just how many ways are there of altering the "Heading" or "Course Flown" by a Pilot flying a 92?

As long as HDG is coupled to the flight director, heading may be altered by rotating a knob on the RIC - a small panel on the pedestal, and by pressing either cyclic coolie hat. At low speeds in SAR mode, heading is altered by pressing a switch on either collective.

[Pltnorway]

Example of S92 MFD NAV screen.
Radar 10NM range, GMAP2, manual gain, slightly tilted down, a/c height 500 feet, oil rig target at just under 2NM, about 15 degrees offset, active waypoint symbol overlapping the radar return.

https://preview.ibb.co/dyh4MQ/IMG_4907.jpg

[megan]

The RAAF SAR aircraft are single pilot capable, right?Was always a two pilot affair as far as I'm aware. SOP when you were in that neck of the woods was copilot flew from RHS as PF, PIC in the left as PM conducting the orchestra. Single pilot capable though I think.

[rotorspeed]

Geoffers

No I haven't! Don't get me wrong, I fully recognise the importance of SOPs, but I'm just trying to think of some reason as to why the flight crew opted for a much hazardous approach than necessary. It is obvious the risk of obstacles - and uncharted ones - is always going to be greater the lower you are, and the longer you're there. It's clear you've loads of experience - any ideas on why they did?

[gulliBell]

Example of S92 MFD NAV screen.
Radar 10NM range, GMAP2, manual gain, slightly tilted down, a/c height 500 feet, oil rig target at just under 2NM, about 15 degrees offset, active waypoint symbol overlapping the radar return.


A good example of correctly tuned radar. The point I was making earlier about interpretation of the radar information is clearly shown, with sea clutter appearing behind the target in-front of you. If the oil rig was instead a 500' cliff there would be a very deep arc absent of sea clutter behind the target, which should flag a big warning in the pilot SA loop.

The radar on the accident aircraft, if correctly operated and interpreted, should have provided a warning sign of what was ahead even if the active waypoint marker sat directly on top of the Blackrock radar return. If they send an S92 out to re-fly the accident mission profile I'd like to see what the radar image looks like.

[gulliBell]

As long as HDG is coupled to the flight director, heading may be altered by rotating a knob on the RIC - a small panel on the pedestal, and by pressing either cyclic coolie hat. At low speeds in SAR mode, heading is altered by pressing a switch on either collective.

What rate does it turn you at, 6 degrees/sec?

[helonorth]

gullibell/llamaman





I feel some posting here can't see the wood for the trees.

They were flying too low.

[louisnewmark]

"As long as HDG is coupled to the flight director, heading may be altered by rotating a knob on the RIC - a small panel on the pedestal, and by pressing either cyclic coolie hat. At low speeds in SAR mode, heading is altered by pressing a switch on either collective."

Of course, the pilot could also simply move the controls in the traditional manner in order to override the autopilot - which, if the PF had fully appreciated the proximity of the rock and the tech crewman's urgency, would probably have been a more appropriate course of action.

[[email protected]]

The picture of the MFD NAV screen does seem to point at why they didn't notice the rock - it's all very well to say they should have noticed the absence of returns beyond the rock but you are asking them to notice something is missing from a display which is far easier said than done.

The 3rd generation helicopter seems to have a problem of too much information and perhaps the SOP should be to have the simple radar picture on the MFD without the FMS overlay.

[smcc63]

Re HDG change

See page 13 paragraph 4 of AAIU report

[dClbydalpha]

Thanks Pltnorway for that informative illustration. It shows my initial concern that priority given to the symbol, along with the outline needed to distinguish it, hides the return at that display range.

It is important to understand such limitations when setting the MFD for a particular task.

[gulliBell]

... it's all very well to say they should have noticed the absence of returns beyond the rock but you are asking them to notice something is missing from a display which is far easier said than done..

No, it's easy to do, and it's essential knowledge which must be applied for proper use of the radar. I never paid any attention to this aspect of using the radar until I watched the Honeywell weather radar training video, which was a great resource for understanding what the radar was telling you.

[[email protected]]

It probably is easy when it is the only thing you have to do. When you are multi-tasking then you will tend to react to the information that is presented to you rather than try to interpret what isn't being shown to you.

[S3R]

Can anyone post a link to this Honeywell weather radar training video? Apologies if done already.

[llamaman]

It probably is easy when it is the only thing you have to do. When you are multi-tasking then you will tend to react to the information that is presented to you rather than try to interpret what isn't being shown to you.

I'm guessing by your logic Crab that all multi-crew aircraft should still have dedicated flight engineers and navigators?

[[email protected]]

Hardly, I'm just suggesting that vital information (which that radar picture is in those circumstances) should be absolutely clear rather than having extra information overlaid on top of it.

I don't have a problem with new technology (not that those MFDs are) but there is a temptation to put lots of information on the screen just because you can rather than because it is needed.

When not in critical stages of flight then have as much junk as you want on the screen but at 200' in the dark have a clear and well presented radar picture since it is the only thing that can stop you bumping in to things.

[llamaman]

Fair comment. Any system is only as good as the operator; and the operator is only as good as his/her training and currency allow them to be.

[dClbydalpha]

... (not that those MFDs are) ...

Can you please elaborate on the quote Crab.

I think the temptation is to put too much on one display, rather than have to change between different formats.

[gulliBell]

Can anyone post a link to this Honeywell weather radar training video? Apologies if done already.

There are lots of weather radar training videos on YouTube, for example:

https://youtu.be/xmRYNIghm9M

[[email protected]]

dclbydalpha - I just meant that MFDs are not new technology and I agree that it is too easy to have too much information on one scree.

[industry insider]

It would be interesting to see what the display looks like on. 2.5nm setting. Maybe the Black Rock return would have been be bigger than the BLKMO overlay and more visible to the crew?

[dClbydalpha]

Thanks Crab ... I was reading too much into it.

While the flexibility offered by multiple MFDs is great, it does mean that the crew have to consider their setup for each phase and for each crew role. Perhaps rather than be "information" orientated display menu options should be "task" or "role" orientated at the first level.

[Search&Rescue]

It would be interesting to see what the display looks like on. 2.5nm setting. Maybe the Black Rock return would have been be bigger than the BLKMO overlay and more visible to the crew?

Absolutely! Concerning Radar, the scale, tilt and gain settings are the key issues when flying at low level in poor VMC or IMC weather conditions...

[ZFD]

Looking at Icao annex 13 and EASA Reg 996/2010, as professional aviator, the use of CVR/FDR, in the interim report, raises serious questions on how the actual just culture / non punitive concept for the utilisation of these systems was envisaged.
The caveat envisaged in Art 14 of the regulations must not used lightly, in prior cases for both fixed wing and helicopter, we have seen data being used well outside the boundaries of agreed protocols.
We all need to discuss the broader implications and trends, both planning / operationally / commercially and most important legally.

Even the AAIU website states this protocol.

http://www.aaiu.ie/guidance-documentation

"RECORDERS
The AAIU will retrieve the Cockpit Voice Recorder (CVR), the Flight Data Recorder (FDR) and any other recorded information that is available and pertinent to the operation of the flight. Once within the jurisdiction of the AAIU, the recorded material will be confidential to the investigation, however, the affected flight crew may, under the supervision of the AAIU, listen to the CVR."

http://www.skybrary.aero/index.php/Regulation_996/2010_on_the_investigation_and_prevention_of_accidents_and_in cidents_in_civil_aviation


"Protection of Sensitive Safety Information
Article 14 of the Regulation establishes a list of records that shall not be made available or used for purposes other than safety investigation, such as:
identity of persons who have given evidence;
opinions and notes of investigators;
draft reports;
FDR data;
cockpit voice and image recordings, and their transcripts;
written or electronic recordings and transcriptions of recordings from air traffic control units;
occurrence reports filed under Directive 2003/42/EC, etc.
However, it is recognised that the administration of justice or the competent authority in a EU Member State may decide on the disclosure of records according to national law. Member States are invited to limit the cases in which such a decision of disclosure may be taken.
Communication of Information
Article 15 of the Regulation stipulates that:
the anonymity of those involved in an accident or incident shall be protected;
information, deemed relevant to the prevention of accidents and incident, shall be communicated to aircraft (and equipment) manufacturers, maintenance organisations, aircraft operators and training organisations;
EASA and national civil aviation authorities receive relevant factual information obtained during the safety investigation, except information referred to in Article 14(1);
victims and their relatives or their associations or public are appropriately informed without compromising the objectives of the safety investigation."

[Emerald Islander]

Hi, I'm a long term reader but first time poster. I've been enthralled by the depth of knowledge of the posters. Like most, I cant understand how the event took place. It makes no sense.

Why didn't they route to Sligo ? They must have known the Blacksod weather from the ground staff by the time they reached Knock.

The requirement to use of Blacksod for this mission is questionable. The FV was only 195nm from Sligo. The S92 was claimed by IRCG to have a range of 800nm with 2 aux tanks, or is this fiction. Could any S92 operator comment.

Also how difficult is it for the PIC in the right hand seat to program the single FMS CDU located on the left seat co-plot side of the center console.

How would they have planned the flight. Would they use charts or is everything in the FMS.and the map display and Ipads these days.

thanks

EI

[S3R]

There are lots of weather radar training videos on YouTube, for example:

https://youtu.be/xmRYNIghm9M

Thanks for the link GB - but you had specifically mentioned a Honeywell training video. Is this training video you refer to on the internet or something in house? Thanks

[G0ULI]

ZFD

The regulations regarding the use of CVR and FDR equipment were framed around a need to secure agreement from pilot's unions to allow such equipment to be fitted and used.

Under British law and perhaps the law of other nations, the deceased technically have no rights. You cannot commit slander or libel against someone who is dead, for example. Also the laws protecting personal privacy no longer apply. There are some caveats however where the deceased may have living relatives who would be affected by any such revelations, because naturally they are still subject to the protections the law allows. It is a rather grey area at times.

In this particular incident, we have a bit of a nonsense where the crew are identified in the popular press, but the accident report goes to great lengths to avoid mentioning or identifying any of the crew members, when this information is already in the public domain. That is completely in accordance with the regulations and quite correct for the accident investigators to do so.

The CVR transcript excerpts in this incident are extremely relevant in helping to come to certain conclusions as to how and why this accident happened. They give a very clear indication as to what was going on in the aircraft as it neared Black Rock and in combination with other information relating to the navigation data the crew were using, it is possible to formulate procedures to ensure that such an accident does not happen again.

At the very least it is a wake up call to all operators to check the accuracy and appropriateness of the navigation data and let down approach charts in use.

National governments are given the ultimate decision over whether it is appropriate to use or release CVR data, and such is the importance of the circumstances under which this accident happened, the Irish government have clearly decided it is appropriate.

Certain weaknesses have been identified in which the way that radar data is presented on MFD screens and the possibility that vital information can be suppressed or overwritten has been highlighted as a potential problem.

The purpose of air accident reports is to prevent a recurrance of a similar accident. If it saves just a single life, then this report has done its job regardless of pilots personal sensitivities over the use of CVR or FDR data.

[G0ULI]

Emerald Islander

If you care to read through the thread, there are many contributions from people who are or were involved in SAR that explain the how and why it might have happened.

Essentially the crew were mislead by an approach chart that did not highlight the danger presented by Black Rock. Radar information that might have revealed the hazard at an earlier stage appears to have been overwritten by other data on the multi function display. Basically, they didn't see Black Rock or appreciate the danger it presented until it was too late.

Personally I believe that the crew probably regarded this as nothing more than a bit of a mundane training mission to the West Coast from Dublin. Their job was to act as a radio relay for another aircraft further out in the Atlantic. No real excitement to be had and the weather was fairly horrible with cloud almost down to sea level. Early hours of the morning, no one was right on top of their game. So the little hints that things weren't quite going to plan got missed. Simple as that really.

The helicopter was equipped with everything needed to allow safe flight in pretty much any conditions, so bad weather in and of itself would not cause the crew any problems.

Read through the whole thread and the accident report and come to your own conclusions.

[gulliBell]

CVR Transcript

The extract of the CVR transcript that was published in the preliminary accident report was done so in accordance with protocols, yes? The protocols protect cockpit voice recordings and their transcripts not relevant to the safety investigation from being published; I assume therefore the stuff considered relevant can be published. Which is why only the context of the recording from the initiation of the flight, up to the safety relevant part, was summarized, and everything after that, which was safety relevant, was published. I thought a transcript of the approach brief may also have been relevant to safety investigation, but this was not published.

[gulliBell]

..Essentially the crew were mislead by an approach chart that did not highlight the danger presented by Black Rock. Radar information that might have revealed the hazard at an earlier stage appears to have been overwritten by other data on the multi function display...


Essentially the crew were mislead, by their own assumption, by an approach chart that was not an approach chart applicable for what they were doing. The approach chart they were using was a route guide intended for visual manoeuvre, not an approach chart with vertical and lateral profiles that would establish them clear of obstacles for when they were not visual. As far as we know, the danger of Blackrock was not specifically highlighted in the route guide, other than its spot height appearing on the chart.

[G0ULI]

gulliBell

I agree that more specific detail of the approach brief would have been useful. It is possible that there were deficiencies in the approach brief, which could imply the assignment of blame if mentioned. For example we know that the height of Black Rock is mentioned on page 2 of the approach document, but did the crew read that? It also appears on the chart, but was possibly covered by other data on the MFD. Certainly the radar display appears as if it was compromised by other overlaid data.

We have identified an inadequate approach plate, flawed let down procedures, radar display being compromised by overlay data, do we really need to go much further than that?

Sorry our posts crossed, but I think we are in agreement.

[gulliBell]

When I'm doing IFR checks on crews in the simulator, I can be 95% assured of the final outcome just by listening to the crew approach brief. Which is why a transcript of the crew brief in this instance might provide some additional insight, but I suspect we won't see any more transcripts of the CVR recording appearing in the final report.

[cncpc]

Emerald Islander

Simple as that really.



With respect, no, not as simple as that.

[gulliBell]

With respect, no, not as simple as that.

The "what happened" is very simple, you can boil it down to a single sentence. They flew into a lighthouse outpost at night they didn't know was there.

The "why it happened" has no simple explanation. That will take many pages of detailed analysis covering all technical, operational, historical, and human factors aspects. They AAIB did a good job of the preliminary report. The final report is likely to be a very substantial document and will uncover the "why it happened" question.

[cncpc]

I was referring to GOULI's analysis summary, some of which you have already correctly commented on.

Referring to that drawing as an "...approach plate" perpetuates the myth that took the crew in to the trap. An approach plate is taken to mean a drawing and annotations that appears on a single page and contains every bit of information necessary to safely accomplish an approach to a landing area in instrument conditions. It describes a rule bound process to complete a thoroughly validated procedure to land in conditions of no or uncertain visibility down to DH or MAP. There is no page 2. You pull the page from your chart book, put it into the clip, and brief it and fly it. I have never done an approach briefing before the approach chart was in the yoke clip and on both sides. There was not a second page ever discussed in any briefing. Or is it displayed electronically? Whatever, if it is an approach plate, everything you need to know is on that one piece of paper.

GOULI makes a good point about not only the radar return, but the spot height on the drawing being obscured by the waypoint symbol. From that, we are assuming that this chart was on the PF's MFD. No paper chart. The report says this "approach" was selected in the FMS. Does that result in the chart coming onto the MFD, or both MFD's for the briefing? If it's all canned and activated after the letdown, then it automatically shows the waypoint symbol as the goto waypoint.

The letdown procedure was not flawed. It was completed a few miles from Blackrock. The flaw was in the belief that once completed, the hookup to BLKMO and on to Blacksod could be accomplished at 200 feet. The procedure was meant for a helicopter starting from the pad at Blackrock. It would have been easily adaptable to an IFR procedure with vertical guidance added. But it wasn't. It does seem to be the only option for an IFR approach to Blacksod, but this crew was in a VFR procedure.

The root cause of this accident may well be found to lie in CHC and how any document in the route guide comes into existence and placed in an aircraft where crews may rely on it, and how in Ireland, such a document does not require regulator approval. If it does, and was approved, then that becomes a root cause question.

It takes less than four hours to draw up a proper approach chart for Blacksod. The IAF is BKSDA, the PT is right at 2000, down to 1000, down to 200, set an MDA and a MAP by Blacksod, and lay out the missed. Check the sector clearances on the way in all the way to the edges, fly it, publish it.

This thread never happens.

[Mark Six]

Well said cncpc. Was about to submit an almost identical post to yours.

[gulliBell]

Yes, well said, and I agree with all of it. An IFR qualified pilot would have instantly recognized the route guide was not an approach procedure for use under IMC, and they wouldn't have been suckered into using it until VMC was established. The crew were clearly operating in VFR mode, in the mistaken belief they were VMC, when in actual fact the visibility was much less than that required for VMC. They didn't know, but should have known, BLKMO had a lighthouse parked on it, whatever height it was, because they should have been expecting to see it from 5nm to confirm that VMC prevailed. I don't know on what basis they formed the opinion they were VMC and clear to proceed on the route guide.

[[email protected]]

The irony is that an ad-hoc SAR letdown to a rescue in the vicinity of Blacksod would have been completed much nearer to the intended destination, would not have required an extensive crew brief or the use of approach plates and would have been much safer.

Back to the company procedures that were not fit for purpose......

[cncpc]

The irony is that an ad-hoc SAR letdown to a rescue in the vicinity of Blacksod would have been completed much nearer to the intended destination, would not have required an extensive crew brief or the use of approach plates and would have been much safer.

Back to the company procedures that were not fit for purpose......

Wouldn't you think that was what R118 actually did 90 minutes later, Crab?

[Search&Rescue]

The irony is that an ad-hoc SAR letdown to a rescue in the vicinity of Blacksod would have been completed much nearer to the intended destination, would not have required an extensive crew brief or the use of approach plates and would have been much safer.

Back to the company procedures that were not fit for purpose......

I agree that ad-hoc SAR ARA letdown is sometimes the simpliest way to reach the destination, but here... with all respect Crab, we can't blame the routing that much... I can only refer the Preliminary Report 3.5.8. Operator's Route Guide. If the pilots read and understood the guidance and had flown the vertical profile accordingly, there shouldn't have been problems. Operator's Route Guide gives the hight of Blackrock 310 ft. It is on pilot's discretion how (at what altitude/height) he/she is going to pass the waypoint BLKMO (it could have been 1300ft or even 2000ft AGL). Now, for some reason R116 had already descended to 200 ft RHT (AGL) when they still were west of the BLKMO waypoint... (Of course we don't know for sure, what kind of approach briefing they had in cockpit... VMC or IMC?)

[rotorspeed]

cncpc
And what R118 did about 1hr 45mins earlier too. Same operator so same systems and approach information presumably?

[[email protected]]

cnpc and rotorspeed - yes and perhaps they flew a different approach because they were more familiar with the area and possibly knew the company approach had flaws in it.

It is possible 118 flew the same company arrival when they went for their refuel but I suspect they flew a much quicker SAR approach when they were tasked to search for 116.

[Emerald Islander]

AIS track for the 8th and 13/14th show R118 approached directly to BKSDC then on to BLKSD .

Returning from the FV at approx 02:10 on the 14th it routed directly to BLKMO then commenced SAR sweep to the south.

At approx 03:30 it headed north up past the Iniskea Islands turned East across the peninsula to BKSDC. then BLKSD.

R116 on the 8th abeam Slevemore turned north and tracked to BKSDC.then BLKSD.

Talk on another forum is of a APBSN North approach.

The AAIU report states " The Commander programmed the “APBSS (Blacksod South) Route”...into the FMS ".

One of my questions was to S92 pilots, how easy/difficult is this as PIC if the only CDU is on the co-pilots side?

[212man]

It's a myth to say that all IFR approach plates are always on a single sheet.

[SASless]

It's a myth to say that all IFR approach plates are always on a single sheet.






A fellow named Jeppensen showed us the way!

Ever use his?

[212man]

A fellow named Jeppensen showed us the way!

Ever use his?
Yes - including some on two pages! Hence my remark.

[SASless]

Must be very rare.....as I have never seen one or used one.

Point here is the absence of any such "Plate" or Pre-planned IMC Approach for Blacksod....that if available and used.....would probably have prevented this tragedy.

Care to post an example of what you speak about?

[Pltnorway]

Referring to that drawing as an "...approach plate" perpetuates the myth that took the crew in to the trap. An approach plate is taken to mean a drawing and annotations that appears on a single page and contains every bit of information necessary to safely accomplish an approach to a landing area in instrument conditions. It describes a rule bound process to complete a thoroughly validated procedure to land in conditions of no or uncertain visibility down to DH or MAP. There is no page 2. You pull the page from your chart book, put it into the clip, and brief it and fly it. I have never done an approach briefing before the approach chart was in the yoke clip and on both sides. There was not a second page ever discussed in any briefing. Or is it displayed electronically? Whatever, if it is an approach plate, everything you need to know is on that one piece of paper.
Incorrect. On some Jeppesen approach plates, the copter minimas are on found on plate 10-9Y.


GOULI makes a good point about not only the radar return, but the spot height on the drawing being obscured by the waypoint symbol. From that, we are assuming that this chart was on the PF's MFD. No paper chart. The report says this "approach" was selected in the FMS. Does that result in the chart coming onto the MFD, or both MFD's for the briefing? If it's all canned and activated after the letdown, then it automatically shows the waypoint symbol as the goto waypoint.
No it does not. It simply means that by selecting the APBSS approach on the FMS, the corresponding waypoints will be added to the flight plan of the FMS. The preliminary report even refers to the operators route guide, and the second text page. It is a paper chart.


The letdown procedure was not flawed. It was completed a few miles from Blackrock. The flaw was in the belief that once completed, the hookup to BLKMO and on to Blacksod could be accomplished at 200 feet. The procedure was meant for a helicopter starting from the pad at Blackrock. It would have been easily adaptable to an IFR procedure with vertical guidance added. But it wasn't. It does seem to be the only option for an IFR approach to Blacksod, but this crew was in a VFR procedure.

You are making an assumption here. My assumption would definitely not be like yours. This is not a route from one helipad to another. It is a VFR arrival route from off the coast to Blacksod.

[SASless]

VFR....VMC......what was the situation that night for the route R-116 was trying to fly when it impacted Blackrock?

Was the aircraft VMC or IMC?

Was the operation (Offshore of Blackrock to Blacksod) being done VMC or IMC?

What were the conditions when R-118 made an approach and landing to refuel at Blacksod?

What were the conditions upon their return to search for R-116?

What did 118 do that 116 did not that allowed them to both Refuel and then later conduct a Search.....and complete both evolutions safely?

[cncpc]

cnpc and rotorspeed - yes and perhaps they flew a different approach because they were more familiar with the area and possibly knew the company approach had flaws in it.

It is possible 118 flew the same company arrival when they went for their refuel but I suspect they flew a much quicker SAR approach when they were tasked to search for 116.

Emerald Islander confirms your view of what likely happened, Crab.

First time in, entered that procedure at BKSDC.

[cncpc]

VFR....VMC......what was the situation that night for the route R-116 was trying to fly when it impacted Blackrock?

Was the aircraft VMC or IMC?

Was the operation (Offshore of Blackrock to Blacksod) being done VMC or IMC?



They must have believed they were VMC.

There are a couple of townlands, Glosh and Nakil, along a road running north south about 2.5 miles west of Blacksod up on a rise of land up to 150 feet ASL. About 50 or 60 houses. It may be that these were visible in the turn back eastbound, confirming that they were VMC, at least at that point. That high land would have obscured Blacksod light.

The report says they were on the warm side of a cold front running northeast to southwest and located at the time off the northern tip of Ireland.

[Tezzer 007]

Essentially the crew were mislead, by their own assumption, by an approach chart that was not an approach chart applicable for what they were doing. The approach chart they were using was a route guide intended for visual manoeuvre, not an approach chart with vertical and lateral profiles that would establish them clear of obstacles for when they were not visual. As far as we know, the danger of Blackrock was not specifically highlighted in the route guide, other than its spot height appearing on the chart.

Irish Aviation Authority use a red circle as the symbol for a lighthouse (with no text). The CAA use a blue circle with l'hse next to it.
So the red circle with 282 next to it was, in theory, all that was needed.

[BluSdUp]

I grew up with Jeppy plates and like them, now we have some other jazz that I that is not so good.
Anyway , Jeppesen flew mail routes in the States in the 30s and his fellow aviators saw him updating his personal notes in the bar and they liked it.
So he started compiling info and selling his notes for 10 dollar . The rest is history.

Having watched this thread I think the process is the same. Except Jeppesen knew what he was doing.
It has been pointed out before. Forget about the small idiotic details.The big picture is that there should be APPROVED IFR APPROACHES to these few places in Ireland.
The authorities and companies incompetence killed this crew.
Never mind that they were a mess.

75kts with a tailwind at 200 feet possibly IMC at night for a long distance heading for the coast.
Madness.

[SASless]

They must have believed they were VMC.

There are a couple of townlands, Glosh and Nakil, along a road running north south about 2.5 miles west of Blacksod up on a rise of land up to 150 feet ASL. About 50 or 60 houses. It may be that these were visible in the turn back eastbound, confirming that they were VMC, at least at that point. That high land would have obscured Blacksod light.

The report says they were on the warm side of a cold front running northeast to southwest and located at the time off the northern tip of Ireland.



But no mention by the Crew of seeing any lights.

[llamaman]

It has been pointed out before. Forget about the small idiotic details.The big picture is that there should be APPROVED IFR APPROACHES to these few places in Ireland.
The authorities and companies incompetence killed this crew.

Sometimes it's the 'small idiotic details' that add up to create the big incident. It's overly simplistic to cast blame purely at the authorities and the company. I'm sure that issues will be found in areas across the board in this one.

If you view it as a systemic failure whereby the system incorporates all elements (including the crew) then that might help. It's all too tempting in such circumstances to look to blame an individual/individuals or organisation. It's rarely that simple.

One of the principles of SAR is that crews (unlike in commercial air transport) do not need to rely on 'approved IFR approaches' to get where they need to be going. This however relies on adequate training and sensible regulation/operating procedures. I feel that these areas will be of most interest to the investigators.

[rotorspeed]

When there is a SAR task at night and the cloudbase is say lower than 500ft, can SAR crews perform the mission, and if so how, given there will be no published IFR approach to their target?

[Red5ive]

Underwater searches fail to show up any trace of missing crew men
https://www.rte.ie/news/2017/0423/869693-search-blackrock-island/

search for airmen brings 180 divers to crash site
https://www.irishtimes.com/news/ireland/irish-news/phenomenal-search-for-airmen-brings-180-divers-to-crash-site-1.3058178

[[email protected]]

Yes of course they can - SAR wouldn't be much use if the limit was a 500' cloudbase.

Go back to the early pages of the thread where I described how a SAR letdown is done. It can be done in zero visibility if required but only over water, not over land. Coastal counts as over water because that is where you let down and then close with the coast.

[Geoffersincornwall]

Dmitri Victorovitch Zotov is the NZ based air accident investigator who created the eponymous 'Zotov Error Map', (ZEM).

This fascinating technique creates multiple timelines that track back from the moment an accident occurs. Each timeline represents the contribution made to the history of the accident and includes the crew, operator, manufacturer, national aviation authority, repair station, equipment suppliers, training organisations ... everyone who made the smallest contribution even if this was many years before the accident.

I learned about the ZEM thanks to working with an expert in SMS, Dr Steve Walters. I hope this technique is used by the accident investigators looking into this case because clearly there are issues about decisions taken by those other than the crew that appear to have had a material effect on the way this flight was conducted.

David Beaty's book 'The Naked Pilot' should be compulsory reading for all those assigned to the task of Pilot in Command. It will alert them to the tendency to find a convenient scapegoat in the pilot, especially if he or she is no longer around to defend their actions. Zotov helped the accident investigators by allowing everyone involved to be included in the analysis.

G.

[cncpc]

But no mention by the Crew of seeing any lights.

No, no mention.

It's an assumption that the ceiling was a stratified uniform layer, but it may not have been. If they did see lights, it may have been before the CVR part released. If they expected to see them, they they may not have remarked when they did. Isn't the curvature of the earth rule 12 miles =1000 foot lower?

Or they may have seen nothing.

[cncpc]

Dmitri Victorovitch Zotov is the NZ based air accident investigator who created the eponymous 'Zotov Error Map', (ZEM).

This fascinating technique creates multiple timelines that track back from the moment an accident occurs. Each timeline represents the contribution made to the history of the accident and includes the crew, operator, manufacturer, national aviation authority, repair station, equipment suppliers, training organisations ... everyone who made the smallest contribution even if this was many years before the accident.

I learned about the ZEM thanks to working with an expert in SMS, Dr Steve Walters. I hope this technique is used by the accident investigators looking into this case because clearly there are issues about decisions taken by those other than the crew that appear to have had a material effect on the way this flight was conducted.

David Beaty's book 'The Naked Pilot' should be compulsory reading for all those assigned to the task of Pilot in Command. It will alert them to the tendency to find a convenient scapegoat in the pilot, especially if he or she is no longer around to defend their actions. Zotov helped the accident investigators by allowing everyone involved to be included in the analysis.

G.

That is an excellent approach, but in order to be fully developed, it requires access to rather masssive amounts of information. Practically, only a national investigative agency would have the power and resources to do it. I have heard that the Canadian TSB does use timeline animation in some investigations however, but how many objects/layers are involved isn't known.

Unless one is predisposed to a bias towards the crew in this one, it is going to be difficult to hang this one the crew. Although, if they had a number of options, the choice of this one was very unfortunate. R118 utilized different options.

[rotorspeed]

Crab
Of course it was a somewhat rhetorical question - I would have been very surprised if a SAR approach couldn't have been made with a 500ft or less cloudbase.

But perhaps you could be slightly more helpful - what sort of vis and cloudbase limits apply for a SAR over-sea let down? And what distance from land is required?

[BluSdUp]

SAR overwater letdowns are safe, as I understand.
Problem here is modern equipment paired with homemade charts, SOP etc.
Lots of details indeed, but no quality control or watertight or foolproof procedure towards LAND.

What I suggest is a few IFR charts to fuel bases and hospitals in Ireland.
I suppose most hospitals can be reached IFR by doing an ILS to airport then a short VMC segment to pad at hospital ?

With regards to IFR over land , I fail to see the principle difference between fixed wing and helicopter ( SAR or not).

I would think SAR is exiting enough as it is ,never mind shooting dodgy homemade approaches were proper and safe ones should be made by the State, that you contract for.

[Red5ive]

I would think SAR is exiting enough as it is ,never mind shooting dodgy homemade approaches were proper and safe ones should be made by the State, that you contract for.

Would be interesting to compare with what the Irish Aer Corps use.

Also strong odds AAIU Chief flew a similar route as Aer Corps pilot.

[cncpc]

What I suggest is a few IFR charts to fuel bases and hospitals in Ireland.
I suppose most hospitals can be reached IFR by doing an ILS to airport then a short VMC segment to pad at hospital ?

With regards to IFR over land , I fail to see the principle difference between fixed wing and helicopter ( SAR or not).

I would think SAR is exiting enough as it is ,never mind shooting dodgy homemade approaches were proper and safe ones should be made by the State, that you contract for.

I think the approaches differ in several ways. Because of the limited range of helicopters, I expect that alternates are fewer than for fixed wing. The missed may be structured differently. In some machines, it seems the approach can be vertical to a spot and crawl forward. Helicopters generally have more options. In most cases, it would be ground in sight, rather than runway in sight, at DH or MAP. Landing at an airport is likely not much different.

It's more likely in this type of work, with the experience and expertise of CHC, that they would do ad hoc or restricted approaches. The state should certainly be the approving authority, though.

All of what we are talking about is your routine landing spots, no?

[gulliBell]

..Unless one is predisposed to a bias towards the crew in this one, it is going to be difficult to hang this one the crew...

Isn't it the case that once they have exposed themselves to low altitude mode the onus is entirely on the PIC to see and avoid obstacles? If so, and not-withstanding all those other factors which might get pinned on the operator or elsewhere, the core issue does seem to me the aircraft was operating in conditions which did not allow them to see and avoid obstacles in the flight path.

[RotorheadS92]

Does anyone know what the company or regulatory VFR minimums were for this flight? The transitional flight from Black Rock to Black Sod is not an IFR procedure and so would require VFR minimums be met, including having visual surface reference requirements. I'm thinking with an overcast of 300-400', that it is unlikely VFR minimums were achieved and that a missed approach from the IFR letdown procedure would have been required.

[cncpc]

Isn't it the case that once they have exposed themselves to low altitude mode the onus is entirely on the PIC to see and avoid obstacles? If so, and not-withstanding all those other factors which might get pinned on the operator or elsewhere, the core issue does seem to me the aircraft was operating in conditions which did not allow them to see and avoid obstacles in the flight path.

The operative presumption was that there are no obstacles at 200 over the sea. Because if there are obstacles, if you presume they are there, and its dark, then you should be higher than any obstacle anywheres near your path. If you are using the radar to look for something you concede might be out there on a simple approach to a fuel area, then you shouldn't be at 200 feet. You are right that the choice of 200 feet is entirely the pilot's. What is in question is how she came to believe that was a safe choice. Because 500 feet was surely a safe choice.

[gulliBell]

..What is in question is how she came to believe that was a safe choice..

Yes. And again that comes down to the thoroughness of the pre-flight planning, and the in-flight execution, which is the responsibility of the PIC.

[Search&Rescue]

The operative presumption was that there are no obstacles at 200 over the sea. Because if there are obstacles, if you presume they are there, and its dark, then you should be higher than any obstacle anywheres near your path. If you are using the radar to look for something you concede might be out there on a simple approach to a fuel area, then you shouldn't be at 200 feet. You are right that the choice of 200 feet is entirely the pilot's. What is in question is how she came to believe that was a safe choice. Because 500 feet was surely a safe choice.

If the SAR helicopter is cruising offshore / in archipelago at 200 ft AGL (9 nm from the landing site) in poor night VMC/IMC wx conditions, there is usually no one warning the crew about e.g. drifting or moving targets. For that reason the pilots should monitor/compare moving map and radar picture all the time
and be prepared to avoid the obstacles on route with a heading change.

[[email protected]]

Rotorspeed - as I said, the SAR letdowns can be conducted in zero vis/fog/in cloud, however you want to define it - that is the whole point of having a fully automatic letdown capability in a SAR helicopter.

For those FW orientated, think of it as a Cat III autoland that you can do anywhere over the sea providing you are using the radar correctly.

As to min distance from the land - we used to use about 0.5nm as an absolute minimum for the let down and we could close to around 75m in the coupled hover from there.

Although FAA rules permit otherwise, you are not VMC/VFR over the water at night even when you are completely clear of cloud.

[cncpc]

Although FAA rules permit otherwise, you are not VMC/VFR over the water at night even when you are completely clear of cloud.

Is that because other jurisdictions, i.e. UK and Ireland, require all night flight to be IFR, or is that just an over water rule.

There is legal night VFR in Canada and US, I think France and Portugal, too.

I've done a lot of night VFR. It's really IFR, or you're best to treat it that way. In remote areas, i.e. ocean, you can't really see things below an overcast, or sometimes not much even with a clear moonless sky. Full moon, yes, you can land at a strip with a full moon and no lights.

So you say that this was 100% an IFR flight because it was night?

200 feet doesn't seem right.

[Non-PC Plod]

Is that because other jurisdictions, i.e. UK and Ireland, require all night flight to be IFR, or is that just an over water rule.

There is legal night VFR in Canada and US, I think France and Portugal, too.

I've done a lot of night VFR. It's really IFR, or you're best to treat it that way. In remote areas, i.e. ocean, you can't really see things below an overcast, or sometimes not much even with a clear moonless sky. Full moon, yes, you can land at a strip with a full moon and no lights.

So you say that this was 100% an IFR flight because it was night?

200 feet doesn't seem right.

To be VFR, you need to be VMC. If you are not in sight of the surface, and you have no visible horizon, as is often the case over the sea at night, you cannot be VFR.

[handysnaks]

cncpc:

In the UK, we 'now' have night VFR as well.

[rotorspeed]

Thanks Crab, appreciate your very helpful response, which confirms that SAR let downs can be in 0/0 conditions and 0.5nm offshore was your minimum. Presumably the S92 is even better equipped than the aircraft you were flying, so limits are not likely to be more restricting. So it certainly seems for this SAR crew, a task that requires a let down with say a 200ft cloudbase and 2000m vis, 2 miles offshore would be pretty straightforward stuff.

Given that, it seems extraordinary that approaching this refuelling stop at Blacksod was not a very straightforward task. Better weather, 5 miles of open sea south and 4 miles east, a sea level target with a big flashing light on top.

There's lots of finger pointing at a poor APBSS and this clearly had its inadequacies as the AAIU made Safety Recommendation 1 ref CHC route guides to essentially highlight obstacle risk and limitations of EGPWS. But then the APBSS (probably) included no transit heights which was therefore at the judgement of the flight crew. It was after all only described as a "route guidance". The associated notes and CVR briefings will add much needed clarity in due course.

Some have said it was negligent for there not to have been an IFR let down procedure for Blacksod. But whilst it would have been helpful, we come back to the point that these SAR crews are presumably spending much of their time making let downs that are far trickier - it is bread and butter to them - and they are highly skilled and trained to do it safely.

Ironically I'm sure it would have been far safer if this APBSS approach had never existed and the crew had had to make their own approach. It's existence probably lulled them into assuming it was a clear VFR route in so a standard 200ft transit was ok. Still doesn't quite add up with why the captain flew over what she said was a "small little island... that's BLMO (sic) itself". Odd thing to do at 200ft at night in poor vis. Maybe she thought BLKMO was more like 28ft than 282ft.

[Mars]

It is a pointless exercise trying to ascertain whether this operation was conducted under VFR because, unlike IFR, there is no firm basis for establishing compliance without reference to: the State's regulations; any alleviation/mitigation that applies to CIVSAR; the requirements of the SAR OM; and, the company safety culture under which the rule set is applied.

That is why in an earlier post, the comment was made that 'culture of SAR in the civil era needs a review'.

It is quite inappropriate to quote other State's operational regulations in this discussion because they are not universally grounded. The ICAO Annex 2 Standard states:
CHAPTER 4. VISUAL FLIGHT RULES

4.3 VFR flights between sunset and sunrise, or such other
period between sunset and sunrise as may be prescribed by the
appropriate ATS authority, shall be operated in accordance
with the conditions prescribed by such authority.

Each State provides basic rules and layers them for types of operation. For example:
§ 91.155 Basic VFR weather minimums.

(1) Helicopter. A helicopter may be operated
clear of clouds if operated at a
speed that allows the pilot adequate
opportunity to see any air traffic or obstruction in time to avoid a collision.

...and the layering:
§ 135.207 VFR: Helicopter surface reference
requirements.

No person may operate a helicopter
under VFR unless that person has visual
surface reference or, at night, visual
surface light reference, sufficient
to safely control the helicopter.

Very few States make a requirement for 'reference to a horizon' or 'minimum visual cue environment' - because it is extremely difficult to 'justify'/'show compliance' with such requirements.

With respect to this accident, it appears that the APBSS chart, in the absence of vertical and visibility limits, is based upon those that apply to CAT - i.e. formerly JAR-OPS and then EASA OPS (as stated in my previous post).

The US regulation does appears to provide a basic (and sensible) objective that should have been met:
A helicopter may be operated clear of clouds if operated at a speed that allows the pilot adequate opportunity to see any air traffic or obstruction in time to avoid a collision.

However, there has to be a judgement on whether the 'see and avoid' condition applies to the more esoteric 'sense and avoid'. Clearly whilst flight over open seas in the presence of unexpected ships is relatively simple to address, the conditions (and probable assumptions) under which APBSS was flown, raises doubt.

[gulliBell]

...Still doesn't quite add up with why the captain flew over what she said was a "small little island... that's BLMO (sic) itself". Odd thing to do at 200ft at night in poor vis. Maybe she thought BLKMO was more like 28ft than 282ft.

When the PIC said that the BLKMO waypoint was still 1nm ahead, so this might bring a conclusion that the waypoint and the geographical feature were understood not to be co-located.
Yes, odd thing to do at 200ft at night in poor viz. What is more odd is that the other three people on board must have agreed with the plan without realizing the danger, or suggesting an alternative. Presumably in SAR a broad outline of the plan is discussed among the crew, a course of action is agreed, and then carried out. Rather than the PIC decree a plan and everybody else just obeys without giving it much of a 2nd thought. Again, we need to revert to earlier inter-crew discussion which we're not privy to.

[rotorspeed]

gulliBell

You could be right ref that the PIC thought the feature and waypoint were not co-located, but I'm not so sure. They were actually over the rocks that triggered the ALTITUDE alert just 0.65nm before Blackrock, not 1nm. Might not sound much different, but if the PIC's map scale was set so that the whole route into Blacksod was showing (or even much of it) I think it could have looked close enough for her to think those rocks and BLKMO were the same. Of course many of us are looking carefully at the fine detail now, but if we assume the crew weren't aware of the major hazard of this approach, given they had 10nm to run they might not have zoomed the map in to see fine detail until nearing Blacksod.

[SASless]

Some care are must be exercised when quoting US FAR's re night VFR.

Part 91 applies to Non-Air Taxi Operations and Part 135 applies to Air Taxi Operations.

The Surface Light Reference applies to Paert 135 .

VFR weather Minima are visibility and ceiling....with Clear of Cloud applying to Rotocraft in uncontrolled airspace.

That there is no visible horizon or surface light reference does not enter into determining VFR.

Under the FAR's one can be in a situation where you are VFR but must control the aircraft solely by reference to instruments (Part 91).

Until a Victim is aboard the aircraft it may be operated Part 91 rather than Part 135......as many HEMEs Operator did for years......with dozens of fatal crashes to prove it.

[RotorheadS92]

What are VFR night minimums required of this operation, the most restrictive of regulation, Operation Specifcation or by the operator? For example if the night VFR minimum for ceiling was 1000ft, then the IFR approach should have terminated at 1000' if VMC was not achieved and a MAP initiated. What is the sense of going to 200RA when the VFR minimum is much higher, and VFR is necessary for the 10nm flight from Black Rock to Black Sod?

I've been reading a lot of very good posts concerning the EGPWS and radar usage, but think the fact that VFR minimums and therefore proper VMC may not have been achieved, was a major contributing factor.

[switch_on_lofty]

RotorheadS92: You have to appreciate that the questions that you ask are not really relevant. If you can operate IMC low over the sea (as you can when doing SAR in a helicopter) then there is effectively no appropriate VMC minima. At night over the sea you can't really be VMC in the same way you are overland with lit towns etc. It can just be inky blackness all around you.
However as others have said VMC helicopters is COCISS, and as the back seaters could see the rocks on the camera that means that they were VMC, but given that you can be VMC and still not see anything it's not really relevant.

[[email protected]]

You won't get 'proper' VMC at night over the water with a 300' cloudbase but the SAR AOC will permit exactly that configuration because it has to in order to get jobs done.

The whole point of a SAR helicopter with a complex AFCS and its own radar is that it can safely letdown IMC below 1000' - but ONLY over water.

They were using the helicopter for what it was designed for but ended up at 200' too early in the procedure for the obstacle environment. Had the rock not been there, they would have flown in at 200' using the AFCS modes with the Rad alt coupled all the way to Blacksod - not VMC, not IFR but technically, because they had no NVG, still IMC.

[xny556]

Does Eire have in its Civil Aviation Law and Regulations any provision that allows a pilot to "break the rules" in order to save and/or protect life?

New Zealand does.

[G0ULI]

Just a point of speculation, but if the aircraft had been a hundred yards or so left or right of the course they tracked, there is a distinct possibility that they would have passed Black Rock in complete ignorance of the danger it represented.

Would a report even have been submitted, or would some later incident have been needed to highlight the problems uncovered by this investigation? I have a deep suspicion that there are a whole load of undiscovered gotchas just waiting out there to catch out the unwary.

Despite all the planning and preparation possible, flight safety is built on the misfortunes of those who preceded us into the air. I can't see that changing any time soon.

[G0ULI]

xny556

Sad to say, unthinking (or intentional) heroism has no place in corporate culture. You do it by the book. The rules are in place to guarantee the best possibility of a successful outcome without unduly risking the rescuers.

Break the rules and get away with it, you might be hailed as a hero and get a medal, if public acclaim prevents you from getting the sack first. Failure is not an option unless strictly within the rules!

Been there, done that. Got the scars to prove it.

[jeepys]

Gouli,

Heroism has no place in the corporate culture as some will take risks in pursuit of heroism which can end in a nice story if all goes well or end in disaster if not.
The crew have to decide whether taking a risk is worth it. Would you break the rules if someone's life depended on it, quite possibly, but would you do the same if it was just a broken arm, I would hope not.
With all that said there were no rules broken here.

[SASless]

if the aircraft had been a hundred yards or so left or right of the course they tracked, there is a distinct possibility that they would have passed Black Rock in complete ignorance of the danger it represented.


That is a bit harsh.....but had the Aircraft not hit the Rock and been destroyed....there would be no report and we would not be having this discussion.

Had the evasive maneuver been successful....there would probably have been an Incident Report of some kind and in all likelihood some soul searching by the Crew about how close they came to disaster.

We cannot think about what might have been.....as that is too late now.

Seeing a very honest inquiry into this tragedy that results in some serious Lessons Learned that work towards preventing similar events in the future is what matters now.

Otherwise....four very good People died for no good outcome.

We owe it to them to see that Review takes place.

[[email protected]]

Sasless - :ok:

[Al-bert]

Sasless - :ok:

Seconded :ok:

[RotorheadS92]

Some care are must be exercised when quoting US FAR's re night VFR.


Until a Victim is aboard the aircraft it may be operated Part 91 rather than Part 135......as many HEMEs Operator did for years......with dozens of fatal crashes to prove it.

Not true anymore. All flight with medical crew on board are considered part 135.

https://www.federalregister.gov/documents/2014/02/21/2014-03689/helicopter-air-ambulance-commercial-helicopter-and-part-91-helicopter-operations

[SASless]

What provoked the change?

The many fatal crashes I noted in my post!

There were other changes that the FAA and EMS industry had to adopt after the NTSB and Media exposed the unsafe practices and patent violations of Part 135 by many EMS Operators.

Read the text you quoted....it clearly used the past tense.....but you missed that I guess!

[jimf671]

So does anyone have the detail of the Irish regulatory framework for SAR helicopters?

Where are the definitions of SAR flight, the triggers for implementation, the revised minima and so on?

[justanotherflyer]

Does Eire have in its Civil Aviation Law and Regulations any provision that allows a pilot to "break the rules" in order to save and/or protect life?

New Zealand does.

IAA (Rules of the Air (https://www.iaa.ie/publications/docs/default-source/publications/legislation/statutory-instruments-(orders)/irish-aviation-authority-(rules-of-the-air)-order)) Order, 2004.

Sec.17
Nothing in this Order shall be construed as preventing a departure from a provision of this Order including the Rules in the Schedule to this Order to such extent as may be necessary to avoid immediate danger.

[Apate]

So does anyone have the detail of the Irish regulatory framework for SAR helicopters?

Where are the definitions of SAR flight, the triggers for implementation, the revised minima and so on?

No doubt in the OMA of the only AOC holder conducting SAR in Ireland.

I don't think they have any obligation to make anything public, but stand to be corrected.

[Emerald Islander]

[QUOTE=SASless;9749960]
"Was the aircraft VMC or IMC?
Was the operation (Ofshore of Blackrock to Blacksod) being done VMC or IMC?
What were the conditions when R-118 made an approach and landing to refuel at Blacksod?"

Belmullet Automatic Weather Station: 10 miles North of Blacksod,

1323 Vis 3.9 km Cloud 180m 8/8 Mist

1400 Vis 2.5 km Cloud 120m 8/8 Rain showers

1401 Vis 3.0 km Cloud 90m 8/8 Rain showers

1402 Vis 7.0 km Cloud 90m 3/8-900m 8/8 Rain

1403 Vis 4.7 km Cloud 1000m 8/8 Mist

[SASless]

Elevation at Belmullet given as being 16.4 Feet.

Even at the best Visibility reported....of 7.0 km....I would have to assume there was no other surface lighting visible to the crew of 116 other than that of Blackrock.....assuming it was clear of Cloud.

[cncpc]

Elevation at Belmullet given as being 16.4 Feet.

Even at the best Visibility reported....of 7.0 km....I would have to assume there was no other surface lighting visible to the crew of 116 other than that of Blackrock.....assuming it was clear of Cloud.

Other than vessels, if there were any, no other surface lighting visible at a best viz of 7 km., or even higher ground near Blacksod light, certainly not Blacksod light. High ground intervenes.

Isn't it inconceivable that they could see the light and still hit the rock?

Can anyone venture an opinion of what happens to a stratified layer over ocean when a rock intrudes to 300 feet, and there are 20 knot gusting winds coming up the sides of the rock. The orographic effect needs a higher rise than that to be significant, or...? More of a mariner than aviator question, but can the weather be different in the area of the rock than it is a mile away over flat ocean?

How much cloud depth, i.e. ceiling lower than the light itself, will result in the light not being visible?

[gulliBell]

..How much cloud depth, i.e. ceiling lower than the light itself, will result in the light not being visible?

The light wouldn't be visible unless you were looking outside and saw it. They weren't expecting to see a lighthouse, and presumably the only person looking outside was the FLIR operator, who just happened to notice the rock, but with no mention of a lighthouse being planted on top of it. The cloud could be a pea-souper fog down to surface level and you should still be able to see the lighthouse light from a mile away through the fog and pitch blackness of the night.

[cncpc]

The light wouldn't be visible unless you were looking outside and saw it. They weren't expecting to see a lighthouse, and presumably the only person looking outside was the FLIR operator, who just happened to notice the rock, but with no mention of a lighthouse being planted on top of it. The cloud could be a pea-souper fog down to surface level and you should still be able to see the lighthouse light from a mile away through the fog and pitch blackness of the night.

A lighthouse doesn't shine through fog. That's why they are located with foghorns.

[gulliBell]

A lighthouse doesn't shine through fog. That's why they are located with foghorns.

I've done enough flying around at night in the gloop in the vicinity of lighthouses to have a reasonable hunch that they should have seen the lighthouse light from about 1nm, if they were looking for it.

[Georg1na]

CNPC said "A lighthouse doesn't shine through fog."


Perhaps not in Canada but the loom of a light even in the worst conditions can be seen at night from a considerable distance .


PS - but only if someone is looking out of the window................

[blind pew]

Cnpc...it can be very different a hundred meters away.
I've flown the mountains and cliffs in Ireland for twenty plus years...Initially in gliders and now paragliders.
The Dublin and Ulster gliding clubs run an expedition to Kerry in autumn.
I considered bailing out when ridge soaring east of mount Brandon when I was engulfed in orographic cloud...a sort of flash over effect. Unfortunately I had installed an ex RAF horizon with an inverta which wasn't the fastest gyroscope to erect. I used my gps to escape.
Another wave flight I decided to jump over the northern end of mount Brandon with an orographic cloud base of 1,000ft. The mountain is 3,000 ft plus.
I tracked around 12km along the face and about 1 km out to sea...the lift closer in was so strong that I was close to VNE even at 1 km.
After one pass the mountain and sea completely disappeared as an embedded storm passed through...
Because Ireland is stuck out into the Atlantic the weather changes extremely quickly and sometimes visciously.
As to the flow around and behind the light house it could be anything...I be seen a viscous cloud similar to a microburst impacting a road in the lee of one of the Canaries...The flow around cone shaped mountains isn't nice although I have managed to soar a couple and somewhere there is a video of flows around cones.

[cncpc]

Cnpc...it can be very different a hundred meters away.
I've flown the mountains and cliffs in Ireland for twenty plus years...Initially in gliders and now paragliders.
The Dublin and Ulster gliding clubs run an expedition to Kerry in autumn.
I considered bailing out when ridge soaring east of mount Brandon when I was engulfed in orographic cloud...a sort of flash over effect. Unfortunately I had installed an ex RAF horizon with an inverta which wasn't the fastest gyroscope to erect. I used my gps to escape.
Another wave flight I decided to jump over the northern end of mount Brandon with an orographic cloud base of 1,000ft. The mountain is 3,000 ft plus.
I tracked around 12km along the face and about 1 km out to sea...the lift closer in was so strong that I was close to VNE even at 1 km.
After one pass the mountain and sea completely disappeared as an embedded storm passed through...
Because Ireland is stuck out into the Atlantic the weather changes extremely quickly and sometimes visciously.
As to the flow around and behind the light house it could be anything...I be seen a viscous cloud similar to a microburst impacting a road in the lee of one of the Canaries...The flow around cone shaped mountains isn't nice although I have managed to soar a couple and somewhere there is a video of flows around cones.

Thanks, BP.

Assuming they were proceeding in low vis under a stratus layer with a base below the light, if the layer might have been disrupted in the immediate area of the rock with that southwest wind being forced up the cliff. And, if that might have given a glimpse of the light, or might have been what allowed the crewman to see the "island" at the last moment.

I think the aircraft would have been on the windward side in this scenario.

Anybody know if there is a recording of the IR camera gear?

[albatross]

Are we now dancing around the maypole for the second or third time with folks posting questions that have already been asked and answered?
Understanding of course that many questions can not be answered because there are facts not in evidence.
Therefore there is a lot of, as usual in tragic cases like this, a lot of rumours, innuendos and hearsay.

[[email protected]]

Albatross - yes, I think we have got to the 'FFS read the thread' stage and the 'are there any more pointless questions' level - the discussion about the visibility of the lighthouse is so irrelevant to the actual causes of this accident it beggars belief.

[SASless]

If I have read posts in this Thread correctly....118 started their first approach to Blacksod at a point much closer to Blacksod and well away from Blackrock itself.

If they in fact used SAR Modes to make an automated approach to that Waypoint then found their way to Blacksod that was just a Kilometer or two (just guessing here on the distance) then I see them doing what I would think far safer and much more in line with "modern" thinking rather than a let down in open water to find the surface then run Ten Miles at 200 feet to Blacksod as 116 did.

Visibility is an issue, whether they could see the Blackrock Light definitely is an issue.

We know they did not grasp the danger they were in re Blackrock due to its elevation and their height above the surface.

Hopefully, analysis of the full CVR will offer up the explanation for so many of the questions being discussed.

Four very professional SAR Crew Members apparently flew a serviceable and very well equipped Aircraft into terrain at night in very bad weather. Most of us look to this crew and think how it could have been anyone of us that came up short that night.....and naturally realizing that provokes a lot of questions as it should.

[megan]

Re sighting of light in fog.

St. Catherine's Lighthouse (Isle of Wight) was originally constructed as a forty metre high tower, but subsequently reduced to twenty seven metres in 1875 because of difficulty sighting the light in fog. Is currently the third most powerful light maintained by Trinity.

Mariners use the following tables

Meteorological Optical Range Table
Code No.XXXWeatherXXXXXXXXXXXXXXDistance
0XXXXXXXXDense fogXXXXXXXXXXXXXLess than 50
1XXXXXXXXThick fogXXXXXXXXXXXXXf50 - 200 yards
2XXXXXXXXModerateXXXXXXXXXXXXf200 - 500 yards
3XXXXXXXXLight fogXXXXXXXXXXXXX500 - 1000 yards
4XXXXXXXXThin fog XXXXXXXXXXXXXX.5 - 1.0 nm
5XXXXXXXXHaze XXXXXXXXXXXXXXXX1.0 - 2.0 nm
6XXXXXXXXLight HazeXXXXXXXXXXXX2.0 - 5.5 nm
7XXXXXXXXClearXXXXXXXXXXXXXXXX5.5 - 11.0 nm
8XXXXXXXXVery ClearXXXXXXXXXXXX11.0 - 27.0 nm
9XXXXXXXXExceptionally ClearXXOver 27.0

Personally I don't see how they could have seen the light if you plot on the following chart.

[Freewheel]

Four very professional SAR Crew Members apparently flew a serviceable and very well equipped Aircraft into terrain at night in very bad weather. Most of us look to this crew and think how it could have been anyone of us that came up short that night.....and naturally realizing that provokes a lot of questions as it should.


SAS, if you don't mind, that quote will appear in my training notes.

[[email protected]]

Visibility is an issue, whether they could see the Blackrock Light definitely is an issue. As I have tried to explain, a letdown of this sort using the SAR modes to 200' without the aid of NVGs, is an instrument procedure. How often do you look out of the window when you are flying IMC?

The lighthouse may or may not have shone in their direction during the crucial period before the crash but they weren't expecting it to be there and therefore were not looking for it. Instead, they were doing as trained and monitoring the MFDs, albeit with the possibility of a radar contact obscured by WP data.

They may also have had their landing lamps on which would produce many reflections but all they were expecting outside is sea, sea and more sea since they were a long way from the coast and Blacksod.

The lighthouse beam is irrelevant in all aspects other than it might have been the last thing to save them - if they had been looking for it.

The fact is the rock became visible to the FLIR operator in time to avoid it but that didn't happen due to procedural focus by the flight crew.

Concentrate on why that happened rather than obsessing about the lighthouse visibility.

[rotorspeed]

Agree Crab - lighthouse is almost incidental.

Back to the beginning of events, and basic procedure, would the Dublin SAR base have included a 250k or 500k VFR chart of Ireland pinned on the wall? Does SAR flight planning include looking at relevant hard copy charts? And would it have been expected that a crew would look at any likely approach - in this case APBSS - with reference to a VFR chart?

[SASless]

The other question that I have is when did the Approach transition from Being IMC to VMC.....or did it at all?

As there was no mention of the Blackrock Light being seen....I am of the opinion the crew was IMC until very shortly before impact with Terrain.

In my opinion....the descent to 200 feet headed away from land while over open water is where visual contact with the surface was planned. Then it was supposed to bea VMC transit to Blackrock picking up increasing visual cues along the way in the form of surface lights.

We have to consider what cues would have been visible to a Crew who DID NOT HAVE NIGHT VISION DEVICES beyond the FLIR which was in operation and being used (but in what Mode remains unknown to us).

It was damned dark that night....the Crew were still using. MK I Eyeballs to see.

Just what could they be expected to see?

What should they have seen if VMC?

The Blackrock Light is not incidental if one assumes the Crew thought themselves VMC....but were not.

Is there anyone here that would cruise at 200 feet AGL while IMC for Ten Miles knowing there was any obstruction along the flight path?

[[email protected]]

Don't confuse the IMC/VMC flight with being in cloud or clear of cloud.

They would have been in cloud until about 300' based on the met reports so by the time they were at 200' they should have been clear of cloud.

Did that make any difference to what they could see - even if they had been looking out (which I very much doubt for reasons previously mentioned)?

It was very dark, over the sea with a low cloudbase and no cultural lighting - that is IMC in anyone's book if you don't have NVG.

Is there anyone here that would cruise at 200 feet AGL while IMC for Ten Miles knowing there was any obstruction along the flight path? yes, if it was necessary and the radar operator was up to the job.

It wasn't necessary to get so low so early in order to get to Blacksod - why they chose to do that is a big question and the answer is probably in SOPs and culture inherited from previous types.

[SASless]

Agreed....but if it as you say about SOP's and inherited practices....why the difference in the way 118 successfully found Blacksod a couple of times that night as compared to how 116 tried but failed?

[birmingham]

Agreed....but if it as you say about SOP's and inherited practices....why the difference in the way 118 successfully found Blacksod a couple of times that night as compared to how 116 tried but failed?

It is certainly very perplexing.

The crew were experienced and presumably had flown this approach on a number of occasions.

If Blackrock was a waypoint on the let down to Blacksod if they had been visual (which they clearly weren't) they would have been looking for it and/or seen the lighthouse beacon.

If they were IMC they would presumably have been aware that the hazard wasn't in the database from previous trips.

Even when the winchman saw it on the IR after an audible terrain warning there was no real urgency that suggested an imminent threat.

Hard to comprehend if you don't routinely fly for miles at 200' at night

Hard to understand and very sad.

[[email protected]]

Without knowing the relative experience levels of the two crews that is a difficult question to answer.

[puntosaurus]

Agree Crab - lighthouse is almost incidental.

Back to the beginning of events, and basic procedure, would the Dublin SAR base have included a 250k or 500k VFR chart of Ireland pinned on the wall? Does SAR flight planning include looking at relevant hard copy charts? And would it have been expected that a crew would look at any likely approach - in this case APBSS - with reference to a VFR chart?

Here's the 1:500 VFR chart for reference (top right). Interestingly, the caption for the red/orange circles in the legend is "Lighthouses - Elevations in italic numerals". I think we've found the origin of the orange circles on the APBSS chart, and I wonder if the APBSS chart started out as a scan of the 1:250 chart bounded by the 54N parallel and the 10W meridian. Has anyone got a copy they could post ? It's also interesting that the numbers next to the lighthouses are in unboldened black type and italic whereas the spot heights on land are in bold and normal type with a black spot adjacent. Also the heights of the obstacles on the chart are in red.

http://i1205.photobucket.com/albums/bb433/wraycp/CCF27042017-page-001.jpg

And here's the APBSS chart for comparison. Interestingly again, the caption Blackrock isn't very closely associated with the obstacle.

http://i1205.photobucket.com/albums/bb433/wraycp/APBSS.png

[drugsdontwork]

It isn't hard to understand. They knew the islands were there. For whatever reason they thought their route was safe at 200'. Explains why they didn't abort when the rad alt went off, explains why they were in FMS guidance not heading hold, and explains the lack of urgency when the technical crew warned of Blackrock.

[Fareastdriver]

Being brought up navigating with a compass, map and stopwatch if your destination is a red blob with 43 written on the side then another waypoint with a red blob and 282 written beside it is 282 ft. high.

[[email protected]]

It isn't hard to understand. They knew the islands were there. For whatever reason they thought their route was safe at 200'. Explains why they didn't abort when the rad alt went off, explains why they were in FMS guidance not heading hold, and explains the lack of urgency when the technical crew warned of Blackrock. I don't think any of those statements are true.

[G0ULI]

On both of the examples shown, the final digit of the height shown for Black Rock is overshadowed by other markings and could easily have been read as 28 rather than 282. I believe this has already been commented on in an earlier posting as a possibility.

It is often the most mundane things that catch you out and easy to miss an overshadowed digit if you aren't specifically looking for it, especially with other displays and instruments demanding attention.

[llamaman]

I'd be interested to see the procedure in it's entirety (including any notes). To my mind the route diagram is very 'back of a fag packet' for what they were trying to achieve in those conditions.