SAR S-92 Missing Ireland

[drugsdontwork]

I don't think any of those statements are true.

That doesn't really surprise me.

[[email protected]]

Well perhaps you would like to qualify some of your assertions since your earlier posts imply you are a SAR pilot with both SK and S92 experience.

[drugsdontwork]

Well perhaps you would like to qualify some of your assertions since your earlier posts imply you are a SAR pilot with both SK and S92 experience.

Yes, I am a current SAR S92 pilot so am familiar with the specific systems. Unlike you. Yes, I have Mk3 RAF SAR experience. Like you. But no, I don't wish to engage in a pointless slanging match of the type you frequently engage in on here. I have expressed an opinion, I consider it valid, you clearly don't. It's a familiar story to many.

[[email protected]]

So, instead of providing valuable information from a current operator's perspective, you want to flounce off because I had the temerity to disagree with your opinion.

You have seen plenty of opinions on here, many made with little or no knowledge of SAR so instead of sniping at me why don't you back up your opinion with reasons for it - yours should be far more accurate based on your experience so why not share it.

Everyone wants to know the answer to Sasless' point 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.

For example, how do your SOPS differ and how would you have done the letdown?

[Thomas coupling]

I found in all the time I spent @ 200' in amber, gusting red conditions, we the crew were constantly restless, looking for anything untoward. Even way offshore where maps weren't needed, we worshipped radar in case we flew over large tankers (and today - god forbid wind farms).
We never flew a straight line for more than a couple of miles, we simply altyered heading just enough to check the arc ahead was clear.
We had to maintain 200' because of our SOP's but if ever in doubt, would always climb to nose bleed height @ 500'.
I would like to make one observation though, based on thousands of SAR hrs offshore - human factors was key. A strong captain and a weak co-pilot were always compensated for by a strong navigator in the back, who monitored the front seat.
Perhaps, just perhaps, in answer to SAS's question it was down to complacency.... I hope it was quick.:hmm:

[albatross]

My question is this: Re APBSS chart.
An actual route map should have tracks, distances and min alts between waypoints should it not?
An approach plate, if there was one, should be even more detailed and in an entirely different format.
Is this just a map included in the report to aid in orientation for those reading it?
The reason I ask is that the numbering of waypoints is neither in order nor does the numbering cover all waypoints.

[drugsdontwork]

So, instead of providing valuable information from a current operator's perspective, you want to flounce off because I had the temerity to disagree with your opinion.

You have seen plenty of opinions on here, many made with little or no knowledge of SAR so instead of sniping at me why don't you back up your opinion with reasons for it - yours should be far more accurate based on your experience so why not share it.

Everyone wants to know the answer to Sasless' point

For example, how do your SOPS differ and how would you have done the letdown?

I'm not flouncing off. I just don't want an inappropriate argument given the tragic subject matter. I gave my opinion. They knew they were flying over islands at 200' as the rad alt warner went off. They were in FMS route guidance, not heading which would be more appropriate if they were concerned they may hit a radar contact. The warning of an island ahead seen on FLIR did not elicit (initially) a major response. The radar was I think at 10nm range scale, not perhaps a scale I would have if I was dodging close in around targets I was concerned about. Given these facts (I only scan read the report so apologies if any are incorrect) it looks as though they were under the impression that the route the FMS was driving them along was a safe low level route. It's much more likely than obscured waypoints, radar malfunctioning etc. Just my opinion.

RIP.

[SASless]

Drugs,

Since you are currently flying SAR on the S-92.....which is what I am taking from your post....you should be in a perfect position to pass on valuable information to those of us that do not fly the 92, have not flown SAR, who have not flown into Blacksod, and thereby provide an insight into what might have happened that dark, rainy, nasty night.

Punt posted two graphics, one being the CHC Route Guide graphic bearing several waypoints bearing various labels.

BLKSD Blacksod

BLKMO Blackrock

BKSDA

BKSDB

BKSDC

Earlier posts have shown the Track of R-116 from the transit across Ireland to the point it turned back from open water and began its fatal track back towards Blacksod and its impact with Blackrock.

The weather reports for the time period show a ceiling that varies from about 200-300 feet to almost a 1000 feet and visibilities that range from about 2 km to 7 km with rain, drizzle, mist, and fog being reported.

R-118 appears to have landed at Blacksod by using a different approach than did R-116....and did so perhaps twice or more.

Any explanation/guesses why two crews used different approaches that night?

Is there capability within the 92 SAR FMS that would allow for an IMC automated approach to Blacksod directly or from either BKSDB or BKSDC and not require an Open Water Approach then a Ten Mile transit at 200 Feet AGL?

Any idea why Blackrock's Identifier used BLKMO rather than say something like BLKRK (which might trigger recognition that the waypoint was exactly the Lighthouse at Blackrock and not some nearby point in space?

Care to describe the Training Curriculum your Operation uses re gaining full use of all the capabilities of the S-92 SAR Modes?

Does the S-92 SAR FMS have the ability to fix a point by means of the FLIR, GPS, Radar....then fly an automated approach to a hover either over or very close by that "Hooked" point?

Why would the ICG/CHC not have on file, surveyed and checked canned IMC Approach Procedures for known preplanned landing sites such as Blacksod?

[[email protected]]

Drugs, all you say makes sense - what is difficult to understand is that they acknowledged the little islands out of hand, without really questioning why they hadn't seen them on radar before they overflew them. That should have been the first alarm bell that their route wasn't as safe as they had assumed.

If it had prompted them to check the radar more closely and expanded the scale, should the return of Blackrock have been visible even if it was partially obscured by the FMS WP marker?

Clearly they weren't expecting to have to manoeuvre, hence the FMS route guidance, but would you expect a slightly quicker response in the cockpit to a concerned call about terrain from the back?

[louisnewmark]

DDW, I am in total agreement with you. Don't worry about the flak. It seems very likely to me that the crew expected the obstruction to be low enough for them not to bump into it - although I'm not sure why they chose to overfly rocks instead of going round contacts by using HDG - and the stated use of the 10nm range scale suggests to me that they weren't expecting a close-in conflict. I would definitely be using a closer range scale if I knew I was approaching something that I needed to avoid. 10nm suggests to me that the PM wanted to have the Blacksod HLS waypoint and local topography in view, rather than concentrating on the close-in picture. This is one reason why I await the detailed report witn great interest.

SASless etc, please don't be offended if posters choose not to divulge or discuss their respective operators' procedures on this forum; while it might make the usual suspects splutter with online indignation, it really isn't the done thing. Rest assured, though, that those operators will be contemplating their own procedures quite deeply as a direct result of this initial report...which, I expect, was the whole point of publishing it.

[louisnewmark]

Crab - reaction to crew: I think that is a key point. The PF's reaction was (in hindsight) inappropriately slow, and the last chance of preventing the accident appears to have been missed. Big learning point, that one. Also I'm not convinced that they didn't see the islands and rocks on radar; they could have seen them but still dismissed them as a threat.

[G0ULI]

It is worth noting that there was terrain on the mainland coast at 2000 feet plus. With the 10nm range scale, this should have been painting a good view of the coastline on the radar screen. Perhaps the main concern was avoiding getting too close to really high ground during the approach?

[drugsdontwork]

Drugs, all you say makes sense - what is difficult to understand is that they acknowledged the little islands out of hand, without really questioning why they hadn't seen them on radar before they overflew them. That should have been the first alarm bell that their route wasn't as safe as they had assumed.

If it had prompted them to check the radar more closely and expanded the scale, should the return of Blackrock have been visible even if it was partially obscured by the FMS WP marker?

Clearly they weren't expecting to have to manoeuvre, hence the FMS route guidance, but would you expect a slightly quicker response in the cockpit to a concerned call about terrain from the back?

What makes you think they hadn't seen them? I'm pretty sure they had seen them, they were an experienced and capable crew. They just thought the route was safe and that they were low lying islands.

[drugsdontwork]

DDW, I am in total agreement with you. Don't worry about the flak. It seems very likely to me that the crew expected the obstruction to be low enough for them not to bump into it - although I'm not sure why they chose to overfly rocks instead of going round contacts by using HDG - and the stated use of the 10nm range scale suggests to me that they weren't expecting a clise-in conflict. I would definitely be using a closer range scale if I knew I was approaching something that I needed to avoid. 10nm suggests to me that the PM wanted to have the Blacksod HLS waypoint and local topography in view, rather than concentrating on the close-in picture. This is one reason why I await the detailed report witn great interest.

SASless etc, please don't be offended if posters choose not to divulge or discuss their respective operators' procedures on this forum; while it might make the usual suspects splutter with online indignation, it really isn't the done thing. Rest assured, though, that those operators will be contemplating their own procedures quite deeply as a direct result of this initial report...which, I expect, was the whole point of publishing it.

Like what he said 👍🏻

[SASless]

The absolute pity is it takes a tragedy such as this for the collective silence to be broken.

[sycamore]

I asked a few questions,back on p61 ,#1215,but not much response until `rotorspeed` triggered the answer about MAPS.Paper charts of the area concerned.They show the lighthouses/obstructions in the area of interest and their heights .Why were they not in the database?
Why is `Google Earth so wrong with it`s height for Blackrock,..?

About Lesson 1 in basic map-reading tells you about heights of obstacles/hills/mountains/powerlines/windfarms(now).
Radar lesson 1 should tell you about it`s good points,and bad points,limitations and use of scale/shadows.

I dont` always agree with T-C but in this case I see it as a case of` we go to `Blacksod,refuel,and act as topcover for R118`,if they go u/s we may go to the F/V and do the pick-up`.Did the crew actually brief..? was it observed/heard/recorded by anyone else,for posterity..? if not ,why not..? should all briefings b/f by SAR .crews be recorded...? if not ,why not...?

If I had been asked to do it in a S-K,I`d have let down east of Achill island,under radar,2-4 miles range,to 500 ft,then stepped down to 300ft,then 200 to creep in to BLKSD ,in a -61 or a -92.

If one had been diligent before fliight and read all the notes,on p2 of the APBSS,then surely you would have highlighted `Blkrock`...? if one was going to go and do that approach pattern..? It is also marked on the MAP,,,the paper one...!!!!FFFS

This also leads me to enquire of NATS as to why maps of the UK do not show heights of Lighthouses in UK waters....answer is...? dunno,`Charting ` at NATS cannot give an answer,but will consider it....

So,I think that there was a consideration by the crew that `this was an `easy trip`,but possibly the rear crew were not fully`in the picture`,or maybe didn`t have maps/charts of that area.....

point of interest..T-C,when did you go thru RNEFTS,,,,?

[dClbydalpha]

What makes you think they hadn't seen them? ...

For me, a 300ft island 700m long by 450m wide would be giving a strong, distinctive return. Enough that it should have challenged the crew's mind's eye view of the situation.

My impression is that they expected a small low lying island ... and they identified it, incorrectly. The presence of a larger contact might have been compelling.

Rather than look to identifying the cause, I prefer to look at what could have prevented it. I think that a clearer closer radar range scale would be one of them.

DDW can you answer whether the S92 allows an altitude constraint to be entered against a WP or leg in the FMS database?

[DOUBLE BOGEY]

There appears to be a suggestion that the crew were led to believe the rock they flew towards was 'not very high" and therefore they did not bother to set the radar or avoid the rock. So far, the Swiss cheese barriers removed mostly by the crew seem to be,

1. Crew unfamiliar or not recent in the local area.
2. Despite 1 above, it is clear a very inadequate pre flight and en route brief ensued which failed to capture the lump of rock on the route they programmed into the FMS.
3. Truly **** cockpit briefing material (however, was not the co-pilot also the unit CP. If so is he not responsible for cockpit resources like this)
4. A failure to invest in the inherent safety benefits of a CDFA.
5. Incredulous acceptance of flying over radar targets at 200 feet in dark poor WX.
6. Failure to utilise FLIR image in the cockpit.
7. Failure to mandate HDG mode when it is the most appropriate mode during a RADAR letdown where the whole point is to avoid the blobs that appear by turning.
8. Overly complex crew SOPS whereby the PF seemed unable to make an immediate heading change in response to the rear crew call.
9. INAPPROPRIATE response to RADALT warnings.

I may not have captured them all but sadly, like it or hate it, this crew seriously underperformed and the cockpit briefing material just led them to the rock.

[[email protected]]

What makes you think they hadn't seen them? I'm pretty sure they had seen them, they were an experienced and capable crew. They just thought the route was safe and that they were low lying islands. Mainly because they weren't mentioned before they got over them and because the reaction seemed from the transcript to be one of surprise.

And I'm sure their SOPs would also advocate not to overfly radar contacts at low level unless you can visually ID them. Remember, no NVD on this aircraft.

DB, you are pre-empting the investigation with a guilty charge based on limited information - not really fair?

[Geoffersincornwall]

DB - Remember the Zotov Error Map. There's plenty to put into the mix besides a list of the crew's apparent (we don't know everything yet) shortcomings.

Read David Beaty's book The Naked Pilot. There you will learn that the tragic story of the Comet jetliner had its origins in a political/commercial decision not to build a prototype and not to conduct full developmental flight trials. This fact did not prevent the demotion of a Captain who had the misfortune to be in charge of the first Comet to crash whilst taking off from Rome because the performance related problems were kept secret by the makers, the government and the accident investigators (The NAA in those days).

I suggest some patience is appropriate whilst we take in the significance of this tragedy. When we have the full report we can measure how honestly it addresses the shortcomings that are apparent today. Somebody or some body turned down the request for NVG. Any recommendations that emerge from the accident report are awaited with interest.

[learner001]

Having read the whole thread and the preliminary safety report, published 13 April 2017 by the AAIU, No: 2017-006, State File No: IRL00917016, I keep trying to imagine what made this unfortunate crew (RIP) believe that there would be no conflicting obstacles along their route part in the vicinity of BLKMO waypoint!

In some posts, it was mentioned that the crew may have been aware of the island(s) in the vicinity of BLKMO waypoint. I don't know. If not, by the "Altitude!, Altitude!" alert, at least they eventually became aware, that (provided that it would not be a false alert) there should be 'something' in the vicinity of BLKMO waypoint. What they obviously were certainly not aware of (=because of what?=) is, that the elevation of another 'something' in that same vicinity of BLKMO waypoint is that tall.

Of course, to come closer to acceptable assumptions, we also have to go to the earlier stages of the flight. We want to know all about the training, SOPs, preparation and resources, technical and non-technical skills, operational culture, equipment, and dig even further into the past, the involved organisation(s) and so on... And I am sure, quite some things will turn up...

Besides all that, for a moment I like to look just at the possible 'mindset' of the crew at that particular stage of flight, just under one minute/one-and-a-half miles, before waypoint BLKMO. And how it had come to that 'mindset' in order to (re)act as was done after the "Altitude!, Altitude!" alert and the 'Turn advise' . . .

On their easterly course towards Blackrock, the crews 'mindset' appears to have been that, for now, they were on a relatively safe route. And that they had done all the necessary preparation to commence a further approach to Blacksod from the BLKMO waypoint via BKSDA waypoint. Apparently believing, closely around and including Blackrock, somewhere in the vicinity of BLKMO waypoint, (the islands) heights/elevations being of negligent value, relative to their own chosen height/altitude . . .

Because of that 'mindset', they may have been more focusing now of what was going to come in another six or seven miles ahead. 5 miles after BLKMO waypoint. Something, which in their minds may have appeared relatively more challenging:

Roughly six or seven miles ahead, about a mile before BKSDA waypoint, they would have to enter a bay, having to pass safely through the entrance of a (in the general, 'broader world' picture, probably more obvious than the smaller seeming 'little world' in the Blackrock vicinity) relatively narrow, imaginary (if I may call it that) 'safe corridor' of some 3.5 nautical miles wide (1.75 miles either side), where their actual height of 180-200' would indeed be of concern, relative to the closest initial terrain confinements of this corridor. (North around 148' Duvillaun More Island. And South beginning more than 400' and much higher behind that.) Thereafter they would have to stay clear of coastal terrain and obstacles and possible navigating vessels in the bay . . . (Of course, I realise that clearing vessels should apply as well to the further away from shore stages of the route. But also that may likely be subject to another sort of 'mindset')

It appears to me that along the leg towards BLKMO waypoint the above may have 'grown' a 'mindset'. And ultimately may 'have become and may have been' the eventual 'mindset' for that stage of flight, appearing to come forth by just a very few real 'on the scene' observations that are known to us from the report. Which, of course, are just a tiny little part of a much greater sequence of events and circumstances:

- The choice of NAV mode by PF. (Which was apparently not challenged by PM.)

- The 10 miles range choice of PF of the radar, appearing as a belief of no need for a closer picture. (Which apparently was also not challenged by PM.)

- The first and only radar target call by PM appears to be for two targets, at 6 miles only. In relation to track and heading, the "Ok, so, small target at 6 miles, 11 o'clock" appearing to point to the Duvillaun More Island, the North confinement of the 'safe corridor'. The other "Large to the right there" appearing to indicate the South confinement of the 'safe corridor'. Both radar targets are beyond Blackrock. No mention, indication or remark that anything closer would appear or be searched for. (The "1.3 miles to run to Blackmo..." remark appears to be based on waypoint/nav indications.)

- No SOP (re-)action on the "Altitude, Altitude!" alert by PF nor PM, other than PF just mentioning the remark, in the 'greater-more-miles-mind-set' (10nm): "just a small little island, that is BLMO itself", moments after the beginning and just before the ending of this "Altitude!, Altitude!" alert. When they apparently were right over the Northern island (± 0.6 miles from BKLMO waypoint) of the Carrickduff and Carrickad islands. It appears to be indicating a belief that they would now more or less be in very close proximity of that mentioned "small little island", that would lie somewhere about half a mile down there in the vicinity of the BLKMO waypoint, triggering the alert. The 'mindset' possibly now appearing to preclude another more conscious possibility at such short range. And I think, way deep inside, that I may know what that feels like. And also no challenge by PM. (I can not really believe that the "small little island" remark was the PF response to the 6 nm radar target call of the PM.)

- The initial non-(re)action at all from PF/PM on the initial 'Turn advice' from the rear crew.


It is very sad that this obviously dedicated crew of four appear to have been provided on a mission, to be in possession of all the hard- and software sophistication that you may ever dream of, but for one simple basic navigation tool: a proper basic and uncluttered paper pilots flying map . . . In many organisations, a well-known hint as being the 'top of . . .'

In the meantime, during my writing, a number of posts have come up. So, repeat may be in the above. Sorry for that . . .

With respect, RIP, learner . . .

[gulliBell]

..DB, you are pre-empting the investigation with a guilty charge based on limited information - not really fair?

From what I've read in the preliminary accident report, and digesting the volume of opinion contained in this discussion, to me it looks like a bad plan from the outset that was poorly executed. Whatever the mitigating factors, the PIC is ultimately responsible for the safety of the aircraft and the outcome of the mission.

[louisnewmark]

Learner001: definitely no need to apologise for any part of your post; I think it's quite insightful and more than a few readers are likely to be in agreement.

[DOUBLE BOGEY]

DB, you are pre-empting the investigation with a guilty charge based on limited information - not really fair?

CRAB, this is not a court room. Its a discussion forum. From the information available, what I have posted is my personal opinion of how a perfectly serviceable all weather helicopter flying, what should be, a simple task of letting down over the ocean, flew straight into a obstacle 10 x the dimensions (not height) of the average O&G installation.

Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.

Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.

A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.

I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.

I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.

DB

[SASless]

Excellent post by Learner!

[rotorspeed]

DB

Have to say I think your summary was refreshingly clear, rationale and objective. Regretfully for the crew, I totally agree with you. We should use this to remind us all that we could be capable of multiple errors that could have devastating consequences. And that if we hide from the harsh truth of the vital importance of our own actions and judgement as pilots, we risk not taking enough personal responsibility for the safety of our aircraft.

[megan]

like it or hate it, this crew seriously underperformedWhat I hate DB is the arrogance of your assertion. Are you saying you would not have circumed to whatever insidiousness it was that lead this unfortunate crew into whatever the trap was. It would be a little trite to say that every accident is caused by an under performing crew. Remember swiss cheese when you point the finger of blame at any crew member. I've always had the view that there but for the grace of God..... I hope good fortune continues to smile upon you DB, and the future doesn't require you to eat humble pie

[Search&Rescue]

CRAB, this is not a court room. Its a discussion forum. From the information available, what I have posted is my personal opinion of how a perfectly serviceable all weather helicopter flying, what should be, a simple task of letting down over the ocean, flew straight into a obstacle 10 x the dimensions (not height) of the average O&G installation.

Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.

Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.

A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.

I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.

I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.

DB

DB,

I am just curious and always willing to learn more... Could you please describe an ad-hoc CDFA the crew could have done instead of a traditional ARA and continued safely to Blacksod.

[gulliBell]

What I hate DB is the arrogance of your assertion...

I'm open to reading the views of everybody here. As somebody who works for a Part 145 training organization who's job it is to access crew competency, and without knowing the wider background of all the circumstances, I don't see anything redeeming for this flight crew in the transcript of that CVR. Both on what was said, and what was not said. Instead, if the same sortie had been flown in the simulator on their annual competency check, it would probably be an automatic fail for the PIC. Which by definition, is an under-performing crew. But to be fair I would need to hear the transcript of the whole of the flight to make any definitive assessment, and also without the benefit of observing what went on, I remain open minded on that question.

[megan]

gulliBell, I hate to tell you, but along with me and a number of others, you used to be part of under performing crews, operating quite illegally.

[gulliBell]

gulliBell, I hate to tell you, but along with me and a number of others, you used to be part of under performing crews, operating quite illegally.

For sure, no doubt about that...

[SASless]

Some of us lived long enough to move on to other endeavors!

This Crew had a lot of help in not surviving.

At some point it was bound to happen to a Crew.....it just happened to be this Crew this time.

Share the blame as there is plenty to go around!

[puntosaurus]

CRAB, this is not a court room. Its a discussion forum. From the information available, what I have posted is my personal opinion of how a perfectly serviceable all weather helicopter flying, what should be, a simple task of letting down over the ocean, flew straight into a obstacle 10 x the dimensions (not height) of the average O&G installation.

Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.

Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.

A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.

I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.

I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.

DB
It's interesting how pilots from different working environments can see this stuff.

From my own point of view as an onshore corporate person, descending to 200ft 10 miles short of the destination is a suckers move.

DB as a O&G man, you are presumably used to flying on well established routes to known obstacles over water often in ****ty weather.

For SAR people descending to 200ft over water in the middle of nowhere and creeping in marginal weather is their raison d'etre.

You can see how armed with what looks like a planned approach chart the SAR culture and SOPs could collide with what appears like commonsense to other groups. Nevertheless I do detect a certain discomfort from the SAR community on this thread about the overall plan for this approach.

[G0ULI]

From an outsiders point of view, descending to 200 feet in limited visibility and proceeding at 75 knots does not constitute my definition of creeping towards a destination, especially in the knowledge that obstacles above the minimum safe altitude might be in the vicinity. The crew clearly cannot have had any idea what they were flying towards.

[[email protected]]

Yes, there were clearly some errors made by the crew but until we have the full picture, ie the full report, it is both unfair and unprofessional to put the blame directly on them when there is no information that can be offered in their defence - that will reside in the report as mitigating/causal factors.

We should not - armed with only some pieces of information, 20/20 hindsight and often no experience in the role - act as judge and jury.

Ask questions and consider the conditions, equipment and operating procedures by all means - we are all learning from that - but bluntly voicing what can only be an opinion (sometimes clouded by pre-conceptions and learned bias) is simply unhelpful and not very respectful.

[SASless]

Crab is right on this one!

The Crew made some errors....yes!

WHY the Crew made the errors is what tells the tale.

Who else made errors that set the Crew up for failure is also part of the story.

Let's just hope we do not get a Readers Digest Version of the Story!

[louisnewmark]

Yep, I completely agree with Crab's last post. The crew made some errors - some fundamental, some minor, doubtless some as yet unreported - but certainly wouldn't have done so either deliberately or negligently. The issue that is much more important than listing those errors is, as SASless says, understanding WHY the crew made them but didn't realise.

[Ed Winchester]

Get off the moral outrage bus. From the Snowdonia thread:

Before they identified the people involved, I had in my mind (when they said businessman) someone in their mid-fifties with a PPL and his own helicopter as someone who might think taking that route with such a poor forecast and few options would be an acceptable course of action.

Sadly I seem to have been proven right and it looks (with a very small percentage of another cause) like another CFIT in poor weather in a private helicopter....How may more before people take notice and learn from others mistakes???

Surely "bluntly voicing what can only be an opinion (sometimes clouded by pre-conceptions and learned bias)" was simply unhelpful and not very respectful on that thread, Crab?

And that was within the first two days of the accident. The hypocrisy would be staggering if it wasn't so predictable.

This accident, tragic as it is, also looks like a "CFIT in poor weather".

[[email protected]]

Two things to consider - one is that I didn't declare the possible reason as a fact and secondly the S-92 crew deserve some professional respect.


This accident, tragic as it is, also looks like a "CFIT in poor weather". yes it clearly is but the question is why?

[megan]

Posts #1549 & #1550 :ok:I don't see anything redeeming for this flight crew in the transcript of that CVR. Both on what was said, and what was not said. Instead, if the same sortie had been flown in the simulator on their annual competency check, it would probably be an automatic fail for the PIC. Which by definition, is an under-performing crewAn appalling statement from a sim instructor if you don't mind me saying so gulliBell. No one has invented a new way of having an accident, and this one will be a repeat of others that have gone before. I do love the hubris being shown by some, the most dangerous to be partnered with.looks like a "CFIT in poor weather"Not only looks like, it was, and the devil is in the detail, of which we know nought at this stage.

[llamaman]

It always amazes me how quickly (supposedly professional) pilots on this forum are so quick to engage in mud-slinging and massaging their own egos. This is not about casting blame, nor is it necessary about pin-pointing exactly the cause.

It's about learning from a terrible tragedy and trying to evolve in the right direction as the aviation community. Their families and colleagues would expect no less.

[SASless]

This is not about casting blame, nor is it necessary about pin-pointing exactly the cause.

It's about learning from a terrible tragedy and trying to evolve in the right direction as the aviation community. Their families and colleagues would expect no less


In order to learn do we not have to first understand what happened and to do that we have to figure out the causes that led to the tragedy?

Every single one of us could wind up as the topic of discussion in a Thread such as this one..... as long as we go flying....that is the first thing we have to accept.

If you don't get that....then you must get yourself a copy of Ernie Gann's "Fate is the Hunter" and read it very carefully and contemplate what he talks about in that Classic.


“Anyone can do the job when things are going right. In this business we play for keeps.”

Ernest Gann "Fate is the Hunter"

[DOUBLE BOGEY]

Megan, I am saying I would NOT have succumbed to the same fate as this crew!

16k hours and 27 years over the ocean HAS taught me one or 2 things. The first, and most important, would be to have a damn good RADAR image at 200 feet AND to not fly over red blobs AND to crap my pants if the RADALT went off AND after it did, to react ASAP if a guy in the back with a A FLIR told me shortly thereafter to TURN.

A CDFA is an easily deployable procedure you can place over any target or waypoint. Before anyone try's to claim "SAR can't do this"......that's exactly what the TRANS DOWN program provides.

[justanotherflyer]

Instead, if the same sortie had been flown in the simulator on their annual competency check, it would probably be an automatic fail for the PIC.

Or alternatively, if flown in exact detail, it might have brought to light some of the latent threats, be they operational, procedural, technological, cultural, skill-based or otherwise, which ultimately converged to enable this awful tragedy.

[SASless]

DB,

Any reason one could not use BKSDC for such a waypoint and approach from overhead Belmullet at or above MSA?

Punt's post 1509 has the graphic.

[llamaman]

In order to learn do we not have to first understand what happened and to do that we have to figure out the causes that led to the tragedy?

Every single one of us could wind up as the topic of discussion in a Thread such as this one..... as long as we go flying....that is the first thing we have to accept.

If you don't get that....then you must get yourself a copy of Ernie Gann's "Fate is the Hunter" and read it very carefully and contemplate what he talks about in that Classic.

I'm not suggesting we don't look for the causes, merely that the natural human reaction to want to pin blame on someone or something is not an appropriate response in this instance.

Trust me, on more than one occasion me and my crew could have been the unfortunate topic of conversation on this forum.

I do get it and I have read Gann (amongst many others). My point is that this was a very complex scenario involving a myriad of factors that might feasibly never be 100% 'solved'. I'm coming from a perspective of understanding versus blame. I get that this ethos is not for everyone.

[Search&Rescue]

Megan, I am saying I would NOT have succumbed to the same fate as this crew!

16k hours and 27 years over the ocean HAS taught me one or 2 things. The first, and most important, would be to have a damn good RADAR image at 200 feet AND to not fly over red blobs AND to crap my pants if the RADALT went off AND after it did, to react ASAP if a guy in the back with a A FLIR told me shortly thereafter to TURN.

A CDFA is an easily deployable procedure you can place over any target or waypoint. Before anyone try's to claim "SAR can't do this"......that's exactly what the TRANS DOWN program provides.

Point taken DB. I didn't realise that you had renamed "Trans down/Trans down to Hov" to CDFA. But what kind of MAP would you recommend in this case when flying/approaching to Blacksod?

[SASless]

Exactly as I see it as well.

I was not singling you out in my post....that was just a statement of how I see things.

There is a passage in Gann's book where he lists a tally of Crews killed in all kinds of crashes during the early days of the US Airline Industry.....making the point that our real nemesis is "Fate" (as he calls it...) and that sometimes skill, knowledge, experience, education, training, just isn't enough.

I suppose over time we have learned lessons and have a better understanding of how these sad events occur....and are better at using technology to assist in the examination of those causes but in the end...there is a factor over which none of us have any control.

SAR flying for civilian pilots has got to be among the most challenging flying there is as they tend to find themselves being called out in weather that most of us are able to avoid sticking our noses into and go places that do not have any infrastructure to assist in their mission.

Oil and Gas offshore flying has become pretty routine anymore after its Cowboy Days early on. EMS flying has also gone through a couple of tough periods but seems to be doing better. Forestry work has improved and Fire Fighting is getting much safer.

Perhaps this tragedy will see SAR units taking a very critical look at how they are doing business and look for improvements.

[gulliBell]

Posts #1549 & #1550 :ok:An appalling statement from a sim instructor if you don't mind me saying so gulliBell...

In the context of what I said, I stand by it. You can crash the sim doing malfunctions during the training phase of re-currency any number of times and all is good, just hit the reset button and try again. But during a check-ride, where we don't normally throw in malfunctions, except for an OEI missed, busting a minima, aircraft limitation, or flying into something, ordinarily scores the PIC a fail. That must be the outcome based on the widely accepted training competency criteria.

[gulliBell]

Or alternatively, if flown in exact detail, it might have brought to light some of the latent threats, be they operational, procedural, technological, cultural, skill-based or otherwise, which ultimately converged to enable this awful tragedy.

Yes, I agree.

[llamaman]

Exactly as I see it as well.

I was not singling you out in my post....that was just a statement of how I see things.

There is a passage in Gann's book where he lists a tally of Crews killed in all kinds of crashes during the early days of the US Airline Industry.....making the point that our real nemesis is "Fate" (as he calls it...) and that sometimes skill, knowledge, experience, education, training, just isn't enough.

I suppose over time we have learned lessons and have a better understanding of how these sad events occur....and are better at using technology to assist in the examination of those causes but in the end...there is a factor over which none of us have any control.

SAR flying for civilian pilots has got to be among the most challenging flying there is as they tend to find themselves being called out in weather that most of us are able to avoid sticking our noses into and go places that do not have any infrastructure to assist in their mission.

Oil and Gas offshore flying has become pretty routine anymore after its Cowboy Days early on. EMS flying has also gone through a couple of tough periods but seems to be doing better. Forestry work has improved and Fire Fighting is getting much safer.

Perhaps this tragedy will see SAR units taking a very critical look at how they are doing business and look for improvements.

Your last paragraph could be a fitting response to this entire thread.

I'm not totally convinced by the 'fate' argument as I feel that this is another aviation tragedy that could have been avoided. Fate implies the unavoidable.

Yes, the SAR regime is a highly demanding and niche area of aviation. Now is the time for improvement of safety margins via thorough external scrutiny.

[rotorspeed]

What is the UK SAR safety record over say the last 25 years? Do those working within it feel particularly vulnerable with current practices, equipment and systems? Who externally would be competent to carry out an effective and valid review?

[Search&Rescue]

What is the UK SAR safety record over say the last 25 years? Do those working within it feel particularly vulnerable with current practices, equipment and systems? Who externally would be competent to carry out an effective and valid review?

IMHO the SAR Aviation Communities are doing an OUTSTANDING job all over the world in order to Save Others! All the Crews are usually very dedicated and professional. If you consider them flying AWSAR day/night even in 0/0 weather conditions at low level, there haven't been that many major incidents or accidents during last 10 years, or? So, let's wait for the Final Accident Report before starting wild speculations and blaming SAR Communities for poor practices!

[holdatcharlie]

Hi. First let me state I am not a pilot. I am just an interested observer with a life long fascination with flying.

Much has been said about the shortcomings of this crews briefing. And we know that the two people in the front seats were unfamiliar with this part of the coast and particularly the approach to Blacksod. So my question is: what could/should they have done to acquire more information about the let down and potential dangers on the run-in before they arrived? We know they made repeated unsuccessful attempts to contact 116 who would have been the obvious ones to provide local knowledge and specific advice on the approach. No ATC was available to them at that time in the morning. Would there have been any personnel at Blacksod? Or what about the coastguard or their controlling ops? Both of which would have had access to local charts? Flying 'under the duvet' in the dark in an unfamiliar and inhospitable coastline I think I would want to be as prepared as I could be. Someone mentioned mindset, I think in those conditions an 'open mind' i.e. hyper alert was what was needed.

Or could there have been misplaced pride or , dare I say, stubbornness that this was not a particularly hazardous mission by their standards and they shouldn't need any outside assistance. I only say this because my wife often accuses me of that! After all their very job entailed them doing the impossible and so often they were the only help around and on their own.

Apologies if these questions seem naive. Don't flame me!

[[email protected]]

Perhaps it should be understood that SAR can be done very differently depending on requirements, equipment, environment and particularly culture before tarring all SAR operators with the same brush.

UK SAR has an excellent safety record but how things are done in UK compared to EIRE will not be identical - different ethos, different companies providing the crews, different operational tempo and different equipment levels.

I know that this accident will have been the subject of crewroom discussion and training team focus in the UK and probably across the world and if that adjusts small areas of operation to remove even one hole in the cheese then it will be a good thing.

However, the idea that this will lead to a root and branch review of how SAR is done is fantasy unless you just don't want people to get rescued.

Dedicated SAR crews have worked for years to identify and minimise risk wherever possible but the fact remains that the places you are asked to go when the job phone rings are often hazardous and the time pressures, when people are relying on you to save their lives, don't go away.

[SASless]

No one has suggested the UK or Irish Coast Guaed has done a poor job or has a bad safety record.

That being said...is there room for improvement, benefit to taking a fresh view at practices, and generally taking a look for potential problems?

If the immediate knee jerk reaction is to say "NO!".....I submit there is a problem.

[gulliBell]

..Much has been said about the shortcomings of this crews briefing.

...what could/should they have done to acquire more information about the let down and potential dangers on the run-in before they arrived?

...Both of which would have had access to local charts?

...Flying 'under the duvet' in the dark in an unfamiliar and inhospitable coastline I think I would want to be as prepared as I could be.


1. Nobody outside the investigation team has heard the crew briefing, so whether there were shortcomings in the brief nobody here can say.

2. Two points. One is a systematic process of continuous improvement, if there were deficiencies in the operational route guide (or anything else) they should have been identified and amended long ago. The operator QA systems are primarily responsible for this. The other aspect, we don't know anything of the pre-flight planning that was undertaken on this sortie. This is something that the investigation no doubt will review in time.

3. The published aeronautical charts, together with the route guide, should have been sufficient for planning purposes without reverting to other map sources. The WAC chart and operator route guide map both had Blackrock lighthouse spot height indicated.

4. Yes, exactly. Does the contracted "scramble" time to be airborne on this SAR contract give the crews enough time to flight plan before departure? If not, did they have enough resources on-board the aircraft to flight plan adequately during the one hour transit to the search area? I guess both of these questions will also be of interest to the investigation.

[rotorspeed]

I suspect a significant factor here with regard to SAR ops will turn out to be R116's crew's familiarity with the type of mission they were scrambled to. Those aircraft on the west coast are a lot more active than those on the east - not surprisingly. The busiest is R115 at Shannon, which in 2014 completed 310 missions whilst R118 at Sligo wasn't far behind on 277. In contrast R117 at Waterford completed 187 and R116 at Dublin just 130 - the same (131) as in 2003, when - and this is interesting - just 13 missions were at night, compared to 57 for Shannon. And from R116's Dublin base, it's likely few of those were off the much less familiar and hostile west coast.

So we have a picture here whereby R116 may only have flown 3 or 4 night missions over to the west coast - and off it - in the last year. Which fits with their stated lack of familiarity with Blacksod. Perhaps someone with more knowledge can provide a more accurate estimate?

Of course this means flight planning needed to be even more carefully done, and charts and route guides appropriately clear, for rare and challenging missions to be flown safely.

Does anyone know why R115 from Shannon was not available to provide top cover that night? They would doubtless have been far more familiar with Blacksod and its approach.

[[email protected]]

4. Yes, exactly. Does the contracted "scramble" time to be airborne on this SAR contract give the crews enough time to flight plan before departure? If not, did they have enough resources on-board the aircraft to flight plan adequately during the one hour transit to the search area? I guess both of these questions will also be of interest to the investigation. I presume their callout time to airborne time is the same as UK which will be 45 mins .

Even if it is an hour, it should be remembered that they will have had to come in from home as I believe this is the norm there if they live close enough to the base.

They will at least not have to have dealt with sleep inertia as the callout was relatively early.

As to adequate flight planning - usually on a scramble you have enough time for the co-pilot to look at a map along with the rearcrew whilst the pilot gets the aircraft going and then, if the weather isn't a major factor, much of the detail can be fleshed out en route - often because you get scrambled with scant information which is updated on the way.

The cruise period should have allowed enough time to discuss the letdown so we will have to wait for the full CVR transcript (if we ever see it) and the final report to know.

I don't think there is any kneejerk 'NO' to suggestions of review but, as mentioned previously, continuous review is a fact of life in modern aviation - it is just a question of how urgently recommendations are turned into action and that often depends on money and ethos.

[atakacs]

Ok complete ignorant here regarding SAR - hope will not be tossed under the bus outright :rolleyes:

Following this thread for a few weeks now I am still wondering about the 200ft zero vis flying. Is there something technical or procedural into it ? I know the ocean is a big place but there might be quite a few things 200ft above water (such as large marine vessels, offshore windmills, etc)... I am sure they thought that it was perfectly safe but is there any fundamental reason not to elect to fly somewhat higher ?

[G0ULI]

The cloud base was recorded as being around 300 feet that night, so a descent to 200 feet to gain sight of the surface was made. The terrain around the coast rises to over 2,000 feet in places, so descending over water presents the safest option, although not without a degree of risk, as you have pointed out.

Had the weather conditions been better, perhaps an approach would have been conducted from 500 feet, or Black Rock lighthouse would have been clearly visible. We almost certainly wouldn't be having this thread discussion.

[rotorspeed]

Gouli
What exactly do you mean when you talk about an approach being conducted "from 500ft"?

[G0ULI]

rotorspeed

Poor choice of terminology, nothing more, nothing less. I think the meaning is perfectly clear. The choice of route and the height at which it was flown was primarily dictated by the prevailing weather at the time. Flying the same route at 500 feet would clear the Black Rock lighthouse.

[megan]

Nobody outside the investigation team has heard the crew briefing, so whether there were shortcomings in the brief nobody here can sayThat's what I would expect from a sim instructor and aviator, not,I don't see anything redeeming for this flight crew in the transcript of that CVR. Both on what was said, and what was not said

[gulliBell]

That's what I would expect from a sim instructor and aviator, not,

So what is it that you have an issue with? I'm not following your selective snippets of forum posting. My point is, and remains, a transcript of the approach brief was not published in the preliminary report, so we don't know what was said, and so there is nothing further to say about it. The extract of the CVR transcript that was published, to me said a lot by what was not said. Too much silence. Silence in any language is bad CRM.

[[email protected]]

Rotorspeed - I think your post about numbers of callouts, East coast operational tempo and lack of recent familiarity is very valid and these will turn out to be important factors in their decision making process.

[DOUBLE BOGEY]

Megan an Gullibell. I think you should put your handbags down now. Unless you want to share with the group why you seem to dislike each other!

[DOUBLE BOGEY]

CRAB I hear your concerns but for me, this is a simple case of a very badly executed approach.

ALL safe IMC approaches contain the same 3 elements. A defined horizontal profile, a defined vertical profile (both designed to clear obstacles by the minimum criteria) and a point in space to aim for (DH, DA, MDH/MDH+MAPT.

It is now mandated that for NPAs the Operator shall specify a Constant Descent Final Approach, (CDFA) the principle being to stabilise the Descent AND to minimise the risks of unnecessary time spent tracking towards the MAPT at low height. Certainly ARAs in EASA land follow this principle.

In this case, from the information on the chart we have seen, this approach does not appear to include these essential elements.

Some have intimated in their posts, because it routes directly over the Blackrock, that the approach was not designed to be flown in IMC. If this is true then for what possible purpose was the approach even documented. Noise abatement??? Because if you are VMC you do not need to follow all those waypoints to get to Blacksod.

The changes that need to be considered are first and foremost, the assessment, design and approval of ALL approaches in IMC to required SAR operational sites.

The clear distinction between when an IFR approach is deployed to a fixed, known location such as Blacksod AND when a RADAR letdown is deployed.

Mandating CDFAs for all descents below MSA.

What also stands out in this thread is the intimation that SAR is different from all other operations and is therefore either immune to some risks or incapable of complying with some basic principles.

However, the hazards and risks associated with the action of descending from MSA to a point in space where flight can continue by visual references, is identical for all operations.

Given the extra equipment, extra crew, significant training budget/opportunities afforded to CIVSAR and the considerable standby time available to hone the paperwork and procedures; compared to all other operations, this accident should never have occurred and is incomprehensible.

What may lie at the heart of this is the culture of SAR operations and CIVSAR Crews.

[smcc63]

In accordance with the provisions of Annex 131 to the Convention on International Civil Aviation, Regulation (EU) No 996/20102 and Statutory Instrument No. 460 of 20093,

"investigations are in no case concerned with apportioning blame or liability."


They are independent of, separate from and without prejudice to any judicial or administrative proceedings to apportion blame or liability. The sole objective of this safety investigation and Final Report is the prevention of accidents and incidents.

Accordingly, it is inappropriate that AAIU Reports should be used to assign fault or blame or determine liability, since neither the safety investigation nor the reporting process has been undertaken for that purpose.

[The SAR RC]

Too much time watching telly in the crewroom? Is that what you think DB?

For years, the relative lack of training hours in civsar compared to the military has been the subject of discussion on pprune. How much time do you think can be devoted to radar letdowns in rocky coastlines when the vast majority of training time is spent trying to find a vessel that is motoring in a direction that will give you sufficient performance to live winch? Then you also have cliffs, wet winching, drums etc, day and night. Radar practice takes a lot of time out of a limited training budget.

[JB-123]

DB - You are incorrect re CDFA- they only apply to Aeroplanes NOT helicopters
Although it is recommended that helicopters should fly a nominal GP

[Search&Rescue]

CRAB I hear your concerns but for me, this is a simple case of a very badly executed approach.

ALL safe IMC approaches contain the same 3 elements. A defined horizontal profile, a defined vertical profile (both designed to clear obstacles by the minimum criteria) and a point in space to aim for (DH, DA, MDH/MDH+MAPT.

It is now mandated that for NPAs the Operator shall specify a Constant Descent Final Approach, (CDFA) the principle being to stabilise the Descent AND to minimise the risks of unnecessary time spent tracking towards the MAPT at low height. Certainly ARAs in EASA land follow this principle.

In this case, from the information on the chart we have seen, this approach does not appear to include these essential elements.

Some have intimated in their posts, because it routes directly over the Blackrock, that the approach was not designed to be flown in IMC. If this is true then for what possible purpose was the approach even documented. Noise abatement??? Because if you are VMC you do not need to follow all those waypoints to get to Blacksod.

The changes that need to be considered are first and foremost, the assessment, design and approval of ALL approaches in IMC to required SAR operational sites.

The clear distinction between when an IFR approach is deployed to a fixed, known location such as Blacksod AND when a RADAR letdown is deployed.

Mandating CDFAs for all descents below MSA.

What also stands out in this thread is the intimation that SAR is different from all other operations and is therefore either immune to some risks or incapable of complying with some basic principles.

However, the hazards and risks associated with the action of descending from MSA to a point in space where flight can continue by visual references, is identical for all operations.

Given the extra equipment, extra crew, significant training budget/opportunities afforded to CIVSAR and the considerable standby time available to hone the paperwork and procedures; compared to all other operations, this accident should never have occurred and is incomprehensible.

What may lie at the heart of this is the culture of SAR operations and CIVSAR Crews.

DB,

I think you should put your handbag down as well! You seem to be Mr. Perfect, who shows quite arrogant attitude towards SAR Operators and CIVSAR Crews without knowing their current practices!

[[email protected]]

DB - the reasoning for CDFA for FW is that there are less trim and attitude changes required compared to having to level off at MDA/H and then reconfigure for landing if you get visual.

Being able to come in at MDA/H in a helicopter is often the difference between getting in and not since a small gap in the cloudbase can give you the required references to convert to visual approach and land.

For exactly the same reasons, SAR approaches do not need to be CDFA, although the transdown to 200' or whatever is selected is, in essence, exactly that.

If you get visual before 200' you have the option of converting to visual flight, if you don't, you can continue in at 200' until you get visual with the target/coast whatever you are letting down to.

200' gives a good compromise between getting visual beneath the cloud and keeping clear of most obstacles (buoys, small rocks small vessels etc) and gives a good radar picture as well. In addition, you have at least some height to play with in the event of a malfunction.

Try to understand that your offshore procedures do not give the operational flexibility required for SAR.

[puntosaurus]

I think DB is making an important point here, and it's one I tried to make in #1547 also. Although Corporate, O&G, and SAR have very different ways of doing their specific thing, some operations (eg. visiting an onshore fuelling site) are identical in whichever field you are operating in. The SOPs ought to recognise that.

[[email protected]]

So how would O&G or corporate crews conduct an IMC letdown to Blacksod at night with a 300' cloudbase?

[obnoxio f*ckwit]

It is now mandated that for NPAs the Operator shall specify a Constant Descent Final Approach, (CDFA) the principle being to stabilise the Descent AND to minimise the risks of unnecessary time spent tracking towards the MAPT at low height. Certainly ARAs in EASA land follow this principle.

As said above, not mandated for RW. Also, ARAs are not flown as a CDFA. A "CDFA" is flown like a Precision Approach to a Decision Altitude/Height (actually a DDA, to allow a margin such that the MDA/H is not infringed on go around) not a Missed Approach Point. SPA.HOFO specifically talks about planning the approach so that the "levelling" is not done at the same time as other manoeuvres.

In order to follow the guideline that the procedure should not generate an unacceptably high workload for the flight crew, the required actions of levelling at MDH, changing heading at the offset initiation point (OIP), and turning away at MAPt should not be planned to occur at the same NM time from the destination

The vertical profile diagrams also show a definite level segment.

ARAs as currently flown most certainly fit with your statement that:

ALL safe IMC approaches contain the same 3 elements. A defined horizontal profile, a defined vertical profile (both designed to clear obstacles by the minimum criteria) and a point in space to aim for (DH, DA, MDH/MDH+MAPT.

but they are not CDFAs as defined, which is where your use of the term is maybe confusing other posters.

[sycamore]

Questions for S92 operatorsor others; is it possible to fly a parallel offset track/descent profile ie 1/4/,1/2 nm left or right of a canned procedure..?

Is the radar `stabilised` once the tilt has been set manually ,during a descent/transition -down` to look at the same `picture,whilst taking account of changes in aircraft pitch attitudes...? or is that still manual..?

[puntosaurus]

So how would O&G or corporate crews conduct an IMC letdown to Blacksod at night with a 300' cloudbase?

With an appropriate approach profile to a suitably placed MAPt, according to minima appropriate for the role, equipment fit, and training of the crew. Subject (if applicable) to availability of suitable pre-planned weather alternates.

The point is that nobody outside the SAR world (and at least some within it, it seems) would even consider the approach profile taken by this flight, and if they had been given the APBSS chart they would have stored it in the VFR section of their flight bag if not the round file next to their desk. But because they could, they did.

[Geoffersincornwall]

Ponto
I believe the night minima is normally 300 feet above deck height. If the cloudbase was 300 feet then you would need to conduct the standard MAP at 0.75nm based on the radar image of the target.

G.

[puntosaurus]

But Blacksod isn't a deck (I don't think), or a distressed ship, or a man overboard, and that's the point.

[SASless]

Blacksod is not an oil rig or platform.

It it an on shore landing site that is used frequently as a fueling point by CHC Irish Coast Guard Crews.....often while SAR Operations are on-going.

The Operator knows landings there will be necessary during adverse weather and at night or both.

Commonsense alone....tells us there should be Weather Minima set forth for flight operations even for SAR Operations and a formal Approach Procedure should be documented for use by CHC crews that adheres to the policies and procedures set forth in SOP's and the AOC.

Even SAR Ops have real weather limits as at some point the aircraft has to be able to carry out the Task and safely return.

[Geoffersincornwall]

Ponto - Crab

Crab asked the question and Ponto tried to answer but the point I was making was that an O & G crew would NOT be able to descent below a 300 feet base because the normal night minima would be something greater than 300 feet. Typically 350+ feet.

G

[[email protected]]

Hence my point about ARA procedures not being flexible enough for SAR Ops - under those conditions they wouldn't have been able to make an approach at all.

Yes, it is a refuelling base but they were still on a SARop with mission to support (or even replace) R118.

However, rather than assume SAR profiles are not safe, concentrate on what they did fly which was not a SAR profile letdown to Blacksod but a strange company procedure 10 miles away from where they needed to be.

[rotorspeed]

Had this APBSS approach not existed, any views on what sort of approach are they likely to have made to Blacksod?

[puntosaurus]

Crab & Geoffers. Doh ! I'm not making a point about what an O&G crew would do on an ARA approach to a hypothetical deck, or whether such a crew could get in on that night.

Like SASless I'm talking about what ANY crew (corporate, O&G, SAR) OUGHT to be doing when making an approach to a well surveyed and much used onshore site (Blacksod).

Just because SAR crews CAN make approaches like this crew, and on many occasions I'm sure HAVE to, doesn't mean they SHOULD or should have to when making fuels stops onshore. Flexibility can be provided by adjusting minima for the role if required.

And I'm not making competitive points about SAR vs O&G vs Corporate either. Corporate are quite capable of flying perfectly serviceable helicopters into cranes and O&G can drop perfectly serviceable helicopters into the drink off well designed approaches.

[holdatcharlie]

If Blacksod is used so regularly by SAR crews, presumably in all conditions, why were the hazards and shortcomings of the questionable 'standard' procedure that this crew was using not highlighted and amended a long time ago?

[[email protected]]

Punto - I think the fact that they hit a rock they didn't know was there calls into question the 'well-surveyed' element and I'm not sure how often Blacksod does get used, especially by East coast crews.

However, I fully take your point about the conduct of the approach, but until we know what the CVR says, we won't know why they chose this approach or elected to letdown to 200' so early in the procedure.

There were many more options available to them since the S92 is such a capable machine, the SAR type letdown isn't inherently dangerous but what it appears they did doesn't follow what I would call normal SAR protocols.

If the rock hadn't been there, they would still have been faced with a 10-mile transit at 200' in the dark, downwind with any go-around being towards land - not my favourite sort of option.

[jimf671]

... If the rock hadn't been there, they would still have been faced with a 10-mile transit at 200' in the dark, downwind with any go-around being towards land - not my favourite sort of option.

It does get you thinking about why that approach was even documented for these aircraft.

More detail of the combination of contract requirements and regulatory regime would help us to form a better picture of what guided their choices. Currently, most of us can only guess at what their options were.

[DOUBLE BOGEY]

CRAB, I think you are correct. What this crew seemed to have done did not conform to any kind of sensible solution for Blacksod and certainly not what I understand to be a SAR letdown.

Obnoxious fwit, I agree, using the EXACT definition of a CDFA does not suit ARA, or indeed a SAR approach. However, apart from the FW desire to descend to an apparent DA on an NPA, the underlying principles of CDFA add significant safety benefits. Nonetheleast of which is the REQUIREMENT to define both horizontal and vertical profiles.

Searchandrescue, I hope I am PERFECT if your implication is to not be so ends up like the subject of this thread.

Like Punto and other posters have said. For a fixed regular refuelling point you would have expected a properly constructed approach.

CRAB the minima for an ARA at night is a mitigation of risk, commensurate with the requirement to slow down from Vy speed stable to effect the final landing in the reduced visual cues available in the dark. SAR crews could well go lower, commensurate with the mitigations of the task. However, discarding all the good stuff currently in a well organised ARA just because the published O&G minima is too high would be a mistake. Having said that. I know that your Radar letdown follows a structured descent, not normally ending up tracking 10 nms at 200 feet.

[Search&Rescue]

[QUOTE=jimf671;9757064]It does get you thinking about why that approach was even documented for these aircraft.

I am not familiar with the whole Company Route Guidance information and only accident investigators have access to Crew Briefing CVR-material concerning this flight/approach, but...

If the crew had passed Blackrock at "safe altitude" or avoided it laterally, they most likely could have flown rest of the route with LNAV/FMS coupled; all the way to Blacksod. I am pretty sure that this aircraft is capable to follow the routing (within RFM speed limitations of course)... even the tight left turn north east of Blacksod at BLSDC waypoint. So, I think the approach routing is not a problem for this aircraft!

[llamaman]

It seems that people are getting bogged down with the intricacies of the approach this crew elected to fly.

The fact remains that, with the latitude of operational flexibility that SAR crews are allowed, occasionally poor decisions are made. Mostly, they don't culminate with loss of life. In this case the priority of the investigation is to establish whether this was simply poor decision making or whether there are wider cultural/organisational issues.

Without a doubt there will be some very worthwhile lessons to be learned. Regardless of which aviation world you inhabit.

[SASless]

S&R,

Aircraft only do what they are told to do by Humans.

That shall always be the Achilles Heel of automation.

[Search&Rescue]

S&R,

Aircraft only do what they are told to do by Humans.

That shall always be the Achilles Heel of automation.

I TOTALLY AGREE!:ok:

My earlier post was only a reply to Jimf671.

[rotorspeed]

S&R - my view (and I think that of some others) is that this APBSS routing was not created for these SAR aircraft as an approach to Blacksod, but is just a long established old VFR route between two lighthouses, Blacksod and Blackrock. Which is why it has route direction arrows each way and no vertical profile info. As I think ? Crab/DB/Punto said, it makes no sense as a VFR approach to go 10 miles further west than necessary, and it cannot be an IFR approach without a vertical profile. I suspect its use was just because it existed and then it was melded with a standard SAR let down to 200ft without enough thought, aggravated by the crew's local unfamiliarity and rushing to launch.

[G0ULI]

If the route was already preprogrammed into the FMS as a result of previous taskings or appeared as a selectable option...

Hey, someone else has already worked out a routing previously, we'll just follow that. Must be okay, it's stored in the FMS.

Can it really have been as simple as that?

It could have appeared as a simple, safe option to a crew unfamiliar with the area operating in pretty poor weather conditions. Why reinvent the wheel when someone else has apparently already done all the hard work?

Descend to gain sight of the surface over open water, select the route and concentrate on the rest of the mission. An expectation that the route was "safe" because someone must have flown it before, would certainly go a long way to explaining the apparent initial confusion and lack of urgency in changing course in response to the FLIR operator warning of an obstruction ahead.

A land based analogy could easily be drawn with professional lorry drivers blindly following sat nav directions and colliding with low bridges or other hazards when it should be obvious that the route is unsuitable.

[Scattercat]

If the route was already preprogrammed into the FMS as a result of previous taskings or appeared as a selectable option...

Hey, someone else has already worked out a routing previously, we'll just follow that. Must be okay, it's stored in the FMS.

Can it really have been as simple as that?

It could have appeared as a simple, safe option to a crew unfamiliar with the area operating in pretty poor weather conditions. Why reinvent the wheel when someone else has apparently already done all the hard work?

Descend to gain sight of the surface over open water, select the route and concentrate on the rest of the mission. An expectation that the route was "safe" because someone must have flown it before, would certainly go a long way to explaining the apparent initial confusion and lack of urgency in changing course in response to the FLIR operator warning of an obstruction ahead.

A land based analogy could easily be drawn with professional lorry drivers blindly following sat nav directions and colliding with low bridges or other hazards when it should be obvious that the route is unsuitable.

GOULI, I really hope not. The ONLY time I put my & my crew's life in the hands of an IMC procedure, is when I know that it has been designed to a prescribed set of approved criteria, with all of the quality controls that go with that. I find it barely believable that a highly respected crew such as this would do otherwise .... I hope I'm not proven wrong.

[ZFT]

If the route was already preprogrammed into the FMS as a result of previous taskings or appeared as a selectable option...

Hey, someone else has already worked out a routing previously, we'll just follow that. Must be okay, it's stored in the FMS.

Can it really have been as simple as that?

It could have appeared as a simple, safe option to a crew unfamiliar with the area operating in pretty poor weather conditions. Why reinvent the wheel when someone else has apparently already done all the hard work?

Descend to gain sight of the surface over open water, select the route and concentrate on the rest of the mission. An expectation that the route was "safe" because someone must have flown it before, would certainly go a long way to explaining the apparent initial confusion and lack of urgency in changing course in response to the FLIR operator warning of an obstruction ahead.

A land based analogy could easily be drawn with professional lorry drivers blindly following sat nav directions and colliding with low bridges or other hazards when it should be obvious that the route is unsuitable.

Would not a previous route entry be in volotile memory? ( usual caveat.I have no knowledge of RW systems or operations).

[RL77CHC]

Here's the Airborne Radar Approach plate we use when flying offshore to rigs and ships in our S92's, S76C++'s and AW139's. We have to use the radar to reference all distances on the final approach. Our MSA offshore is 1500'. You can join the final approach by flying overhead the station at 1500', flying an arc onto final or doing a straight in approach. On a straight in final approach, be it 6 miles or 20 miles, we must ensure we have no radar targets on our approach path and that it's clear of targets 1 mile either side of track. We can descend down to 1000' Radalt if the aforementioned conditions are met. At 6 miles back we can descend down to 600' Radalt and at 4 miles back we are good to descend to our MDA of 300' Radalt at night and 200' Radalt in the day. It doesn't matter if we are IMC or VMC, we still descend down to our minimums after 4 miles. There's the standard offset of 10 degrees at 1.5 miles and then a further 30 degrees and climb at the MAP of 0.8 miles if we aren't visual. Copilots and Captains use the Radar in GMAP 2 and constantly adjust the tilt and variable gain for the best picture. The radar range is brought down from 10 miles to 1.5 miles incrementally on the final approach as the helicopter gets closer. If any target appears in front of the helicopter or within the 1 mile boundary either side of track the Flight Crew initiates an immediate climb at takeoff power to 1500'. Happened to one of our crews just last week when a supply boat came into the 1 mile zone on a 10 mile straight in approach at night in IMC conditions. There's no chance of flying into a rig, vessel or rock using this approach unless the radar is not being used correctly.

[[email protected]]

And if you try to overlay that procedure on Blacksod, especially with Westerly wind, it just doesn't work - hence the need for a SAR type letdown rather than an ARA.

[G0ULI]

RL77CHC

Thank you for the information and pictures. I note that the first graphic displays a circle at the top containing a reference to MSA information being displayed on Page 2. That is extremely relevant to earlier posts where many posters were absolutely insistent that all approach plates contained all relevant information on a single page. The information referring to the height of Black Rock Lighthouse was also apparently contained on a second page according to information contained in the preliminary report.

That certainly helps develop my mental picture of what could have happened. It will be interesting to see if this forms a significant part of the final investigation report.

[SASless]

Crab,

What if you use one of the SAR modes to make an approach to BKSDC (or some similar point convenient to Blacksod) using a northeasterly heading along the long axis of the inlet?

One could incorporate Blackrock as an IAP at which descent from the MSA could be initiated....that would have been pretty much a crosswind approach and a final turn at "C" for the run-in to Blacksod.

No one seems willing to discuss what options are available to a CHC SAR crew flying the 92 with its first rate Avionics!

I have opined that this flight was operating using old fashioned techniques. If some knowledgeable person can point out the fallacy of my thinking on this Ui am quite willing to listen to what they have to say.

Absent that input....I am going to stick with my thoughts.

The other Crew (118) appears to have done something different on two occasions that night than did 116.

We don't know what it was as it was not set forth by the preliminary report.

We do not know what the weather was for 118 on the approaches and landings either.

My basic question is simple....Do the CHC Crews by SOP routinely use the full capability of the S-92SAR Avionics available to the Crews?

Or....as a matter of policy....or lack of policy....generally use legacy techniques relying upon less than full utilization of the aircraft's capability?

Basically.....are they still using S-61 techniques when there are newer and better 92 techniques available?

[[email protected]]

What if you use one of the SAR modes to make an approach to BKSDC using a northeasterly heading along the long axis of the inlet?

One could incorporate Blackrock as an IAP at which descent from the MSA could be initiated....that would have been pretty much a crosswind approach and a final turn at "C" for the run-in to Blacksod As I understand the S92 AFCS capabilities you can press a button to mark a target at height and it will fly a fully coupled approach to that point to a pre-determined height (very probably 200') so as long as you were positioned somewhere a couple of miles from Blacksod to give adequate coastal clearance, you don't have to go all the way to Balckrock at all.

[SASless]

PHI and the FAA worked together with Sikorsky to approve a very similar Approach to oil rigs and platforms in the Gulf of Mexico for PHI's fleet of 92's so it appears even the non-SAR 92's have that ability.

PHI began use of the Automated Approach capability in 2013.

Even EASA approved the Procedure in June 2015.

http://www.prnewswire.com/news-releases/easa-certifies-sikorsky-s-92-rig-approach-300098781.html

[puntosaurus]

And if you try to overlay that procedure on Blacksod, especially with Westerly wind, it just doesn't work - hence the need for a SAR type letdown rather than an ARA.
Those aren't the only two alternatives.

[tistisnot]

But talk of an ARA approach here is nonsense, otherwise they would have reached a decision range, having already instigated an offset, after which they must be visual to be able to continue towards the rig. They were not visual with this waypoint. Never overfly the blob if not visual.

[212man]

I'm sure Approach To a Point would have been a credible AFCS option. The RFM only allows IMC let downs over water, but I think a suitable initial approach direction from the SE and reasonably low IAS would have allowed its use.
The Approach to Point (ATPT) mode performs an automatic approach to a hover over a pilot selected target. The position of the target is the next waypoint in the FMS flight plan or as designated by the slew controller. To designate a waypoint, use the slew controller to position the cursor over the desired point on either NAV page and press the middle button on the slew
controller. This will put a green square and an “X” over the hooked waypoint. Subsequently, pushing the ATPT button on the MSP will initiate an approach to the hooked waypoint. The ATPT always performs a “direct to” approach and does not turn the aircraft into the wind. The pilot may choose to set an FMS waypoint prior to and down wind from the final waypoint.

http://i202.photobucket.com/albums/aa50/S92ctc/ATPT_1.jpg

When the mode is armed, the aircraft initiates an immediate turn towards the target, engages IAS and RALT, defines an approach line, and determines if there is sufficient distance between the aircraft and target to accomplish the approach. If the approach is engaged and the aircraft is too close to the target for the ATPT profile, the Flight Control Computer (FCC) will disengage ATPT. IAS and RALT will remain engaged and the aircraft will continue toward the target so that the pilot can initiate a MOT over the spot or fly the approach manually. If the distance to the target permits, the aircraft will intercept the approach line and perform a decelerating descent to arrive
at a hover over the designated coordinates.

If below the approach line when initiated, the aircraft will maintain the present altitude until it intercepts the approach line. The aircraft will maintain the present airspeed until the system commands a 1.8 knots per second deceleration to intercept the approach line at the proper speed.

If above the approach line when initiated, the aircraft will descend to intercept the line. The maximum rate of descent while intercepting the approach line is 750 FPM when above 500 feet and 500 FPM when below 500 feet. If the aircraft cannot finish the initial descent before the deceleration is scheduled to begin, the system will discontinue the approach and engage IAS and RALT.

During the “on the line” approach, the aircraft will decelerate at a nominal 1.8 knots per second and descend at 200 FPM. Above 100 feet, the maximum allowable descent rate is 400 FPM. Below 100 feet, the maximum allowable descent rate is 200 FPM. The approach will not continue if the aircraft is too close to the target to slow down or too high to descend in time. If the approach discontinues during the “on the line” portion, IAS (above 50 KIAS) or VHLD (below 50 KIAS) and RALT will automatically engage.

The ATPT will terminate in a hover over the designated coordinates. The system will initially transition to VHLD when within short range of the coordinates, and then to PHLD when directly over the coordinates in a stable hover. RALT will engage when the aircraft reaches the selected hover height. The default hover reference is 50 feet and can be adjusted from 50 to 150 feet via the HVR RA selection on either DCP.

[jimf671]

....as a matter of policy....or lack of policy....generally use legacy techniques relying upon less than full utilization of the aircraft's capability? ...

This why I am concerned about the contract requirements and the specialist regulatory requirement for SAR in this territory. SAR is national and not EASA. There should be defined circumstances when SAR flight and related regulations apply. Did they apply in the case of this phase of this flight and what were they?

[Emerald Islander]

If the route was already preprogrammed into the FMS as a result of previous taskings or appeared as a selectable option...

Hey, someone else has already worked out a routing previously, we'll just follow that. Must be okay, it's stored in the FMS.

Can it really have been as simple as that?

It could have appeared as a simple, safe option to a crew unfamiliar with the area operating in pretty poor weather conditions. Why reinvent the wheel when someone else has apparently already done all the hard work?

Descend to gain sight of the surface over open water, select the route and concentrate on the rest of the mission. An expectation that the route was "safe" because someone must have flown it before, would certainly go a long way to explaining the apparent initial confusion and lack of urgency in changing course in response to the FLIR operator warning of an obstruction ahead.

A land based analogy could easily be drawn with professional lorry drivers blindly following sat nav directions and colliding with low bridges or other hazards when it should be obvious that the route is unsuitable.

I think G0ULI is on the right track.

After R116 returned from its top cover on the 8th, having earlier departed Blacksod , the aircraft underwent a 50 hour maintenance inspection.

It made only a single one hour flight in the East Coast area before the fatal flight.

There is a high probability the waypoints were still in the Euronav system as a recorded previous flight.

On the 8th the AIS shows R116 approached Blacksod via BKSDB and BKSDC however it departed Blacksod via BKSDA and BLKMO. (Their westerly track to the FV went about 400m south of Black Rock so BLKMO must lie along this).

(Note Sligo R118 never adhered to any of these formal approach/departure routes either on the 8th or 13/14th)

So for the R116 crew uncertain of the approach its a simple matter to reverse the previous course to arrive at Blacksod.

All GPS and mapping systems use the same SRTM derived terrain elevation models and will either show mainland only and no islands or will show Black Rock at 50ft.

Lighthouses do not appear in the IAA AIP or Notams so would not be displayed as an obstacle in the GPS. They do appear on the marine charts.
Black Rock was equipped with an AIS beacon but would only show location not height.

The Euronav uses a raster (scanned picture) of the 06 Edition 2013 ICAO VFR Chart 1:250000. On the 1:500000 version the 6 deg isogonal line cuts through the third digit of the lighthouses height value making 282 appear as 28ft. Its likely but needs to be verified that the 1:250000 version has the same defect and also the defect text of obscuring the 206ft height of Duvillaun More which would have alerted them to terrain en-route. In the Euronav vector terrain derived from SRTM can overlaid over the raster chart.

As many here have stated the crew appeared to believe that Black Rock Mayo was a 28ft small island near waypoint BLKMO and were confident that there were no obstacles or terrain in their path and anyway their GPS TAWS and EGPWS and Radar would alert them.




EI

[puntosaurus]

I've been scratching my head for weeks now wondering what BLKMO stands for, and I think you've just cracked it. It's BLacKrock MayO.

[SASless]

Best analysis so far.....and very scary.

If this turns out to be the basic scenario then it is heartbreaking.

Part of my routine coming on-shift at an EMS base in Texas was to take the Waypoint List out to the aircraft and manually check each Waypoint that was entered into the memory....to ensure each matched the Base Record.

When I encountered one that was not on the list I deleted it.

A Paramedic saw me doing that and raised hell when I deleted a former Paramedic's house Waypoint from the memory. He refused to consider my advice to him.....that he get it blessed by the GPS Waypoint God and have it added to the approved list and I would be glad to re-enter it.

We had a process we used to confirm the accuracy of each Waypoint entered and maintained a record for each one that had not just the Identifier and Coordinates but other information as well to include the Elevation of the Waypoint, location description in general wording, and also references to other Navaids such as VOR's, DME's, and NDB's. That way there was no confusion and at any time the information entered could be confirmed as accurate.

[ZFD]

http://aerossurance.com/helicopters/easa-part-dat-providers/

[Mark Six]

From the accident report:
The Commander programmed the “APBSS (Blacksod South) Route” (See Figure No.4 above) into the FMS during the cruise and the Co-pilot confirmed that the route matched the Operator's Route Guide.
So they obviously didn't just blithely pull up the waypoints left in the FMS database from a previous task, they deliberately selected a saved route and checked it against the route guide.

[wiggy]

From the accident report:
The Commander programmed the “APBSS (Blacksod South) Route” (See Figure No.4 above) into the FMS during the cruise and the Co-pilot confirmed that the route matched the Operator's Route Guide.
So they obviously didn't just blithely pull up the waypoints left in the FMS database from a previous task, they deliberately selected a saved route and checked it against the route guide.


Fixed wing FMS user here somewhat confused . We don't have the ability to look back into the memory (volatile or not) and use a route Bloggs built umpteen days ago, we can however select company approved routes (dep/arr page). I had begin to assume the accident crew had used a company generated route extracted from the database- presumably that was not the case?

[puntosaurus]

And since the accident report refers to earlier CVR conversations about how long it was since this crew had been to Blacksod, I think it's unlikely that the accident crew were there on 8th.

[Lonewolf_50]

I've been scratching my head for weeks now wondering what BLKMO stands for, and I think you've just cracked it. It's BLacKrock MayO. The mayo goes on your BLT. :p

Lighthouses do not appear in the IAA AIP or Notams so would not be displayed as an obstacle in the GPS. They do appear on the marine charts.
Black Rock was equipped with an AIS beacon but would only show location not height. As a career maritime sort, this is a salient point. Well pointed out.

[cncpc]

I've been scratching my head for weeks now wondering what BLKMO stands for, and I think you've just cracked it. It's BLacKrock MayO.

I think that is because there is another Blackrock light, I believe in Sligo. So to differentiate. Is there a BLKSO?

[[email protected]]

EASA Decisions on Management of Aeronautical Databases / Part-DAT - Aerossurance (http://aerossurance.com/helicopters/easa-part-dat-providers/)
I have reposted ZFDs link as it highlights the database issue

[puntosaurus]

cncpc. You're absolutely right ! I googled Blackrock before I posted that, but couldn't find anything else, but looking at the map there are four lighthouses in Sligo Bay and one of them is called Black Rock.

[GKaplan]

Fixed wing FMS user here somewhat confused . We don't have the ability to look back into the memory (volatile or not) and use a route Bloggs built umpteen days ago, we can however select company approved routes (dep/arr page). I had begin to assume the accident crew had used a company generated route extracted from the database- presumably that was not the case?

The S92 has the option to pick up a 'crew' route: you get two different pages in the FMS, 'user routes' and 'company routes'. The former can be modified/deleted at will, not the latter (just like you can save 'user waypoints' for repeated use).


The Commander programmed the “APBSS (Blacksod South) Route” (See Figure No.4 above) into the FMS during the cruise and the Co-pilot confirmed that the route matched the Operator's Route Guide.
So they obviously didn't just blithely pull up the waypoints left in the FMS database from a previous task, they deliberately selected a saved route and checked it against the route guide.

It all depends on what the first sentence really mean:
1- pilot selects APBSS from the 'user routes' page.
2- pilot selects it from the 'company routes' page.
3- pilot enters every waypoint in turn directly.

[wiggy]

GKaplan

The S92 has the option to pick up a 'crew' route: you get two different pages in the FMS, 'user routes' and 'company routes'. The former can be modified/deleted at will, not the latter (just like you can save 'user waypoints' for repeated use).

Ah interesting, many thanks for clarifying that.

Rgds

Wiggy

[learner001]

Some operators implemented the following as SOP:

"Before first flight - Delete all user waypoints and all user routes from memory..."

Kind regards, learner . . .

[212man]

Some operators implemented the following as SOP:

"Before first flight - Delete all user waypoints and all user routes from memory..."

Kind regards, learner . . .

It is also possible with the FMS fitted to the S-92 (UNS-1) to automatically delete all User waypoints/routes on power down. That was how I had ours set up in my previous role, so that only Company waypoints and Routes (plus, the Jepp NAV Database) remained - neither of which are modifiable. This meant that the User database remained solely for tactical use during a specific flight.

[learner001]

It is also possible with the FMS fitted to the S-92 (UNS-1) to automatically delete all User waypoints/routes on power down. That was how I had ours set up in my previous role, so that only Company waypoints and Routes (plus, the Jepp NAV Database) remained - neither of which are modifiable. This meant that the User database remained solely for tactical use during a specific flight.

The SOP was implemented to avoid mishaps operating a fleet of 'mixed' manual/automatic deletion, (de)pending modification . . .

[212man]

The SOP was implemented to avoid mishaps operating a fleet of 'mixed' manual/automatic deletion, (de)pending modification . . .

is that a question or a statement? I'm quite familiar with why we implemented the procedure (which occurs automatically once set up in the menu) - I instigated it!

[learner001]

is that a question or a statement? I'm quite familiar with why we implemented the procedure (which occurs automatically once set up in the menu) - I instigated it!

212man, It is a statement!

The SOP was implemented because only part of the fleet was set up for the 'auto delete'!

I was talking about the situation where nav units (that were randomly set up or not set up for 'auto delete') were: (a) to be set up by the supplier on request of the operator or (b) to be modified by the operator nav-ops for the automatic deletion set up. Which, in my recollection, was/is not modifiable by the flight crew by means of the menu.

We probably have similar reasons for the auto delete. Amongst others: Without positively identifying the origins, some crew were activating waypoints/routes, inserted by a previous crew, that had utilised (with their reasoning!) some convenient, nice sounding, user-invented, questionable, random, identifiers. Previous crews sometimes inserting less precise coordinates, or even totally different coordinates for equally sounding identifiers.

Kind regards, learner . . .

[DOUBLE BOGEY]

However the route was generated and whatever it flew them towards there is still the issue of accepting flight over a RADAR return at very low height above the ocean.

Surely the Golden Rule is we shalt not fly over ANYTHING unless we have visual contact with it prior to DR. As such any target in front of us becomes the intermediate destination and the MDH/MDA and DR rules should apply. Or go round it leaving the required safety margin.

The CVR is confusing and not at all clear that they "see" Blackrock" on the RADAR before the impact. Unless I have mistaken this.

[learner001]

DB

So far, (correct me if I am wrong) all I have found is one occasion, calling out two separate radar targets, which was done by the PM, as reflected in my post #1535:

- The first and only radar target call by PM appears to be for two targets, at 6 miles only. In relation to track and heading, the "Ok, so, small target at 6 miles, 11 o'clock" appearing to point to the Duvillaun More Island, the North confinement of the 'safe corridor'. The other "Large to the right there" appearing to indicate the South confinement of the 'safe corridor'. Both radar targets are beyond Blackrock. No mention, indication or remark that anything closer would appear or be searched for. (The "1.3 miles to run to Blackmo..." remark appears to be based on waypoint/nav indications.)

Kind regards, learner . . .

[212man]

They are beyond Blackrock

Can you explain?

[learner001]

212man

Ok, I Understand the confusion.

The radar targets are beyond Blackrock . . .

Changed that in the previous post #1641, as well as in #1535 . . .

Thanks for the heads up . . .

[dClbydalpha]

EASA Decisions on Management of Aeronautical Databases / Part-DAT - Aerossurance (http://aerossurance.com/helicopters/easa-part-dat-providers/)
I have reposted ZFDs link as it highlights the database issue

I'm struggling to see how 76/200A relates to the accident chain. Is there a suspicion that the data load to the FMS was corrupt?

On the FMS topic, there appears to be a number of users here, can any one answer whether the particular FMS allows altitude constraints for a WP or leg?

[[email protected]]

I'm struggling to see how 76/200A relates to the accident chain. Is there a suspicion that the data load to the FMS was corrupt? well, since they mention this accident specifically and then go on to wash their hands of any responsibility for the accuracy of such databases, it sounds like someone is making sure they aren't to blame should it turn out the database was flawed and was a significant contributory cause.

[212man]

I'm struggling to see how 76/200A relates to the accident chain. Is there a suspicion that the data load to the FMS was corrupt?

On the FMS topic, there appears to be a number of users here, can any one answer whether the particular FMS allows altitude constraints for a WP or leg?
Yes it can but the AFCS has no VNAV function so any adherance is to the crew. The PFD and FMS display guidance though.

[Geoffersincornwall]

Crab - Mr Zotov rears his head!!

G

[learner001]

However the route was generated and whatever it flew them towards there is still the issue of accepting flight over a RADAR return at very low height above the ocean.

Surely the Golden Rule is we shalt not fly over ANYTHING unless we have visual contact with it prior to DR. As such any target in front of us becomes the intermediate destination and the MDH/MDA and DR rules should apply. Or go round it leaving the required safety margin.

The CVR is confusing and not at all clear that they "see" Blackrock" on the RADAR before the impact. Unless I have mistaken this.

DB

As noted in #1535 and #1641, in addition to the, so far, one and only known 'radar target presence call' by the PM, mentioning the two targets beyond Blackrock, I have not found any other 'radar target presence calls' in the CVR transcript that could be indicating that the crew would have been "seeing" Blackrock on the radar at any stage during approximately the last minute of the flight.

I realise that some may think, I may be going a bit too deep now at this stage, in which case I apologise for that. But, triggered by and in response to your post I wanted to sort out something that is going through my head for quite a while now: "So far", from the above, I thus assumed that there would be NO more (when looking for obvious) indications possible that could indicate that Blackrock may have been "seen" on the radar by the crew.

However, the absence of (obvious) indications that Blackrock has been "seen" on the radar by the crew does not necessarily preclude or rule out that Blackrock may well have been "seen" ON the RADAR by one or maybe both pilots.

The following may also explain two other possibilities where the:"just a small little island, that is BLMO itself" remark may have originated from.


Whether valid or not, we may not exclude and must consider also other than CVR possibilities, possibly indicating that Blackrock may have been seen on the radar: = Seeing the 'Blackrock radar targets presence' indicated or pointed out by unmistakable, noticeable or even just mere gesture(s) of either crew member. =


Subsequently, (possibly, if not for the "Altitude! Altitude!" alert or, perhaps even combined with that alert) at least one of these 'gesture occurrences', if there had been any:

(a) may have been triggering the: "just a small little island, that is BLMO itself" remark, as a response by the PF to a gesture of the PNF towards the radar.

or

(b) may have been accompanied by the: "just a small little island, that is BLMO itself" remark, which remark in that case could be considered as a spontaneous 'radar target presence call', by the PF who at the same time was doing the gesturing towards the radar.


In other words:

Equivalent to and instead of 'voicing' a 'radar target presence call', the PM may have drawn the PF's attention, whilst only pointing with a finger to a target on the radar screen. Which, instead of (or perhaps in combination with) the "Altitude! Altitude!" alert, may have triggered the: "just a small little island, that is BLMO itself" remark by the PF as a response.

Even so, also the PF, may have been glancing from a distance on the PM's radar screen or even may have been bending over towards the PM's radar screen, every once in a while, and may also have been pointing to a target on the radar screen, spontaneously, as the equivalent of a 'radar target presence call' (so, not triggered by a 'radar target presence call' from the PM) whilst accompanying this gesture with the remark: "just a small little island, that is BLMO itself". (Again, instead of, or in combination with the "Altitude! Altitude!" alert.)

If either case would have occurred, Blackrock was "seen" as a valid target, but also here the actual elevation had then apparently not been appreciated.

Kind regards, learner . . .

[llamaman]

Interesting to see your thoughts Learner. Often, it's the subtle nuances of body language and gestures that reveal what's truly going on. This is where the investigation will have to make some assumptions and might struggle to conclude exactly what happened.

[rotorspeed]

Full respect for your depth and open-minded consideration Learner, but surely the concept of the flight crew relying on a gesture/s to signal something as fundamental as a radar return that could be an island, when at 200ft at night, is getting beyond the bounds of credibility? Given also that two other crew are in the back and supposed to be part of the team, surely too such an approach would be well outside SOPs, convention and common sense? The FLIR operator, who we think was the only one to detect Blackrock island (what should have been) early enough, clearly would have benefitted from being aware of any flight crew recognition of such a radar return - which would have presumably needed to be by voice.

[helimutt]

Full respect for your depth and open-minded consideration Leaner, but surely the concept of the flight crew relying on a gesture/s to signal something as fundamental as a radar return that could be an island, when at 200ft at night, is getting beyond the bounds of credibility?

Up until this accident, i'd have thought it would be beyond the bounds of credibility that a fully equipped, (apparently fully serviceable) SAR S92 could fly into an island at night, but unfortunately this is what happened. The investigators will no doubt have their hands full with this one, as will the operating company.

:sad:

[ZFD]

Both FAA and EASA recognise the import of database integrity.
The following excerpt is an insight on the basic criterion.
"These Conditions establish:
(a) The procedure for the issuance of a letter of acceptance (LOA) for organisations that translate, format and/or integrate information that originates from State aeronautical information services (e.g. AIP) into electronic databases for airborne navigation systems.
(b) The rights and obligations of the applicant for, and holders of, such letters of acceptance.
A.132. Definitions
(a) Navigation Database - Data (such as navigation information, flight planning waypoints, airways, navigation facilities, SID, STAR) that is stored electronically in a system that supports an airborne navigation application.
(b) Data Service Provider – An organisation (not including the State AIP provider), which collects, originates or processes aeronautical data and provides a navigation database in a generic format (such as ARINC 424). Such organisations are eligible for a Type 1 LOA under these Conditions (see Guidance Para 5.7) showing that the generic database has been formatted under controlled conditions.
(c) Data Application Integrator - An organisation that incorporates either State AIP data or a generic database into a format compatible with specific target airborne navigation equipment with a defined intended function. Such organisations require an interface with the equipment design organisation, and are eligible for a Type 2 LOA under these Conditions (see Guidance Para 5.7). This provides a list of equipment models and part numbers where compatibility has been demonstrated to the Agency, permitting the supply of navigation databases directly to end users/operators.
(d) Data Quality Requirements - A specification of the characteristics of data to ensure that data is compatible with its intended use."

https://www.easa.europa.eu/system/files/dfu/rule_Op_01_05_Nav_database_supp_doc.pdf

[dClbydalpha]

well, since they mention this accident specifically and then go on to wash their hands of any responsibility for the accuracy of such databases, it sounds like someone is making sure they aren't to blame should it turn out the database was flawed and was a significant contributory cause.

ED76 and DO200A in my experience ensure the integrity not the veracity of the data. Therefore for a company route, the data would still have to be ensured by the operator. As for the terrain data it comes from a government authorised source. The procedures, to my eye, allow an operator to use processed databases without having to independently verify them.

Thanks 212man, I'll be interested whether the "company route" in the FMS made use of altitude constraints even if it was only a reminder on the control and display unit.

[G0ULI]

The investigators have the ability to superimpose the CVR data over an accurate map of the aircraft's position, height and heading. They may be able to achieve a better understanding of exactly what was being referred to, being in possession of far more information than is contained in the preliminary report.

Replicating the path of the accident flight with a similarly equipped helicopter and recording the cockpit displays, should reveal any shortcomings in the navigational or radar displays.

I can't help feeling that modern navigation equipment is perhaps too accurate and is capable of luring pilots into a false sense of security. The old hard learned lessons about flying to a position that is known to be offset from a waypoint to a certain extent appear to have been forgotten. Of course there is no need given GPS positioning to a couple of metres, except when that waypoint is a lighthouse above your current altitude. The apparent failure of the navigation system to be able to distinctly highlight the danger presented by Black Rock is inexcusable. The information may have been there on the screen, but it should not have needed to be interpreted in order to appreciate its significance.

[gulliBell]

....it currently looks like a combination of minor operating errors and/or oversights that led to this accident.

Or situational awareness breakdown, for reasons yet to be determined.

[G0ULI]

gulliBell

I re-edited the last paragraph as you were posting, but totally agree with your comment.

[ZFT]

Both FAA and EASA recognise the import of database integrity.
The following excerpt is an insight on the basic criterion.
"These Conditions establish:
(a) The procedure for the issuance of a letter of acceptance (LOA) for organisations that translate, format and/or integrate information that originates from State aeronautical information services (e.g. AIP) into electronic databases for airborne navigation systems.
(b) The rights and obligations of the applicant for, and holders of, such letters of acceptance.
A.132. Definitions
(a) Navigation Database - Data (such as navigation information, flight planning waypoints, airways, navigation facilities, SID, STAR) that is stored electronically in a system that supports an airborne navigation application.
(b) Data Service Provider – An organisation (not including the State AIP provider), which collects, originates or processes aeronautical data and provides a navigation database in a generic format (such as ARINC 424). Such organisations are eligible for a Type 1 LOA under these Conditions (see Guidance Para 5.7) showing that the generic database has been formatted under controlled conditions.
(c) Data Application Integrator - An organisation that incorporates either State AIP data or a generic database into a format compatible with specific target airborne navigation equipment with a defined intended function. Such organisations require an interface with the equipment design organisation, and are eligible for a Type 2 LOA under these Conditions (see Guidance Para 5.7). This provides a list of equipment models and part numbers where compatibility has been demonstrated to the Agency, permitting the supply of navigation databases directly to end users/operators.
(d) Data Quality Requirements - A specification of the characteristics of data to ensure that data is compatible with its intended use."

https://www.easa.europa.eu/system/files/dfu/rule_Op_01_05_Nav_database_supp_doc.pdf

However, they have both (knowingly) ignored the lack of regulatory requirements of EGPWS/TAWS updating until now! (Honeywell even still state their is no regulatory requirement to update on their EGPWS DB website).

[rotorspeed]

A lot of risk factors have been identified:

· Insufficiently clear APBSS approach guidance chart
· Assumption that existence of APBSS in FMS database meant it was safe at 200ft
· Lack of total clarity of Blackrock height on 1:500,000 VFR chart
· Blackrock in some databases not others, at varying heights
· Blackrock not in EGPWS database
· Probably poor radar operating technique so Blackrock, a 300ft high 700ft wide island, was not seen
· Too slow reaction by crew to FLIR operator warning of Blackrock
· And no doubt several others

BUT.... the existence of all these risk factors would not have mattered at all if the aircraft had been at a sensible height, not 200ft.

To me the main cause of this accident was the crew’s decision to descend to 200ft for a 12 mile transit (including approach to Blackrock) to Blacksod. It should be obvious that the chance of hitting something in poor vis/IMC increases the lower you go, the longer you do it. 10 miles at 200ft is going to carry 10 times the risk of hitting something as 1 mile at 200ft – which should have been all that was necessary for this approach. They could have even used the APBSS route guidance, which at sensible heights would have fine, with a let-down to 200ft to say BKSDB.

The world is too big and changing too fast for any nav databases to be 100% reliable everywhere. Just look at the rash of emerging wind turbines across northern Europe! Approval and verification processes understandably take time and mean databases will lag.

To opt for a flight profile of massively increased danger - and then having to totally rely on a multiple crew trying to use complex systems properly, (eg radar open to misinterpretation) and fallible databases and EGPWS, to keep safe, is just nuts.

Don’t get me wrong – all the risk factors identified need addressing as soon as possible. But to me the immediate safety actions should be reviewing the approach profiles, particularly vertical, that crews use in situations like this. Clearly if you’re looking for a bloke on a surfboard (and great job btw, SAR Prestwick) flying at 200ft is perfect. But not for 10 miles for an approach at night to a refuelling base. And the needing to be 200ft to be VMC just doesn’t add up here – (a) I don’t think many of us think they were, and (b) the chances were always going to be high of areas of further reduced cloud-base – what were they going to do then? Descend further? Climb into it and go IMC? Turn back?

Clearly the crew chose to use this approach type. Following the investigation, it will be very interesting to see what light is shed on just why.

[DOUBLE BOGEY]

Rotorspeed I agree with you 100%. If you choose to fly very low, at night, over the inky black sea and possibly in and out of clouds WITHOUT a rock solid plan to avoid the obstacles (which you must assume will be there). FOR NO GOOD REASON, its just Russian roulette.

[SASless]

How do we know they did not have a rock solid plan to avoid obstacles (including Blackrock that was at least 82 feet ABOVE their chosen height)?

What if they did.....but something intervened to undermine their Plan?

We do not know what their Plan was as there is insufficient data in the public domain to make that determination.

Plainly, something happened as they were killed when the aircraft impacted terrain despite there being some warning....as noted by the CVR Transcript.

The key to the puzzle will be in ascertaining why the Crew chose such a height despite the known obstacle provided by Blackrock....and then when warned of the proximity of Blackrock by the FLIR Operator....did not take IMMEDIATE Action to avoid the terrain in front of them.

I would think a review of the Unit SOP's, Crew Briefs for this incident, and a review of other Crew Briefs/Practices by this Crew in particular and the Operation Crews in general will shed a lot of light on how business is done during similar weather/night approaches.

Again, legacy practices , SOP's, and incorporation of new technology issues should be carefully considered.

[DOUBLE BOGEY]

SAS, may I be so bold as to suggest you have missed the salient point.......why 200 feet so far from the destination?

Also the P1 must have had some idea what was around the aircraft to support the comment that was made when they had the RADALT alerts.

To be fair to crew at this stage we should assume they did not actually fly over any red blobs at 200 feet, despite the RADALT warnings. They do not make a clear mention of the red blob that should have been painting for Black Rock.

I guess for me the Map and EGPW Database is way down the list because the regulations clearly state it shall not be used for terrain avoidance.

To place waypoints over an obstacle(s) and then make a route out of it, it begs the question for what purpose exactly was the route intended to serve? A letdown, by any sense of the word, implies you cannot see the ground sufficiently to fly by visual means. It would therefore need to have both horizontal and vertical profiles clearly defined. I have not seen the full procedure for this approach so I do not know if this information is prescribed.

It is a terrible event and likely to have some serious repercussions in the industry about how data is interpreted and the formal priorities that should be given to the systems available in the cockpit.

If memory serves me correctly there was an FSI released by the same Operator just a few years back that demanded crews prioritise the FMS Waypoint ICON in favour of the RADAR return. Needless to say the boys and girls in the cockpit laughed it into extinction but not without some resistance from above.

This could be an example of what goes wrong when assumptions are made and poor cockpit paperwork is generated by desk jockeys and the weight and volume of garbage in the cockpit creates so much white noise that the wood cannot be seen from the trees.

[puntosaurus]

That's interesting, so the crew can choose the priorities in the overlay system ?

[DOUBLE BOGEY]

You know someone once told me that when a pilot gets borne he is issued with 2 buckets. One is full of LUCK and the other is empty but marked "EXPERIENCE". The trick they said was to try and fill up the bucket of EXPERIENCE before the bucket of LUCK ran out.

I got borne in the Army. With a little more than 300 hours in my logbook and the ink still wet, I found myself tasked to fly a General from Soest to Rheindahlen along the affectionately termed "IF Corridor". To achieve this we had a MINITANS Doppler driven NAVAID which liked to **** itself occasionally especially in clouds. (Great). However, being well trained in the basics one had a back-up plan! DR (Dead Reckoning). So when the TANS went AWOL you could probably, fair wind and all that, end up within a howitzers range opf the intended destination. Thank God Laarbruck and Bruggen could "Catch" you at the other end with a nicely timed GCA. However, situated along the corridor, close to it, was Dusseldorf. ZE Germans liked to mess you about. Turn Left, Turn Right, Decend, Climb, etc, all of which we could do cos we was properly trained by the Green Machine! All this in a Whistling Chicken Leg (Gazelle) with no SAS let alone AFCS (which was at the time just a mere twinkling in Aerospatiale's eye).

However, then comes the hideous phrase "Cleared to continue with your own navigation"!. Quick look at Mr TANS and realise he has gone on holiday just when I need him. Holy Moly what do I do next!. Captain Manwaring might not panic but his bucket of Experience had a lot more in it than mine! Suddenly an Angel appears (well a Big hole in the clouds) and I look down and see Rheindahlen. Collective dumped, arse eating the seat cushion, dirty dive through the hole and land.

Siting in the seat gently perspiring I sense a deficit in my LUCK bucket and a small addition to my EXPERIENCE Bucket. This lasts but a few moments until the General (who up to now has been oblivious to the mortal danger) leans forward and says "5 Minutes Late, What's your name Soldier"

I resisted the urge to say "Its printed on my chest you Dork!" as such things usually ends ones career.

Fast forward to 1990. I become a sweaty heaving civilian! Sumburgh, 2 x S61s in the fleet fitted with the dreaded Bog-Roil/Knitting Needle NAVAID (Decca moving map) (Moving haha, hah). Aided and abetted with a Black&White Radar Stormscope thingy smack in the middle of the instrument console.

Sumburgh had no ILS back then and getting home in the fog/low cloud was a simple case of local knowledge matching the shape of the coastline against the RADAR return and slithering along the NDB needle and the Bog Roll wobbling on top of the console hopefully confirming that we were not doing something stupid. (Providing of course it didn't eject the bog roll down the centre aisle of the passenger cabin).

My bucket of experience actually felt like it had something in after that and the bucket of luck was stabilising under the steady guidance of the Sumburgh Old and Bold.

And here we are today. The MINITANS has gone to the great NAVAID repository in the Sky and the Bog Roll....well I hope someone wiped their arse on it before it was finally retired. The knitting needle should really have been used to poke our F***ink eyes out so we were stopped forever from doing dumb things! However this was not to be.

Replacing all those Heath Robinson solutions in favour of Glass Cockpits, Moving Maps (that actually move), FLIRS, Colour RADARS, Terrain Databases and the Great God of the Sky...GPS and in theory our buckets of LUCK should be protected somewhat allowing our buckets of experience to grow steadily until we achieve the status of LEGEND (Like SAS or CRAB) no irony intended and said from the heart boys!.

Of all the challenges we faced in the past, the future does not seemed to have learned very much.

However, I remember back to those days in Sumburgh sat next to a crusty old Captain who had long favoured the Times Crossword over filling in his Logbook, peering over his bifocals at my truly ****e performance and saying...."Keep trying Laddy. One day it will be all right". And the thing is that my bucket of luck was in their care until the day came when I could get it right.

Those old agades:

1.Runway Behind you!
2. Fuel in the Bowser!
3. Death and WRACs! (oops that's not politically correct anymore is it).

For the sake of sanity and in no small measure, to look after our personal buckets of LUCK lets add another one;

4. DONT FLY OVER RED BLOBS (below MSA).

[RotorheadS92]

So how would O&G or corporate crews conduct an IMC letdown to Blacksod at night with a 300' cloudbase?

I fly an S92 for O&G. We would not have been permitted to fly an IMC letdown or any type of IAP to Black sod or Black Rock. In order to fly any type of offshore procedure (such as HEDA, OSAP, ARA) we are required to be at least 5nm offshore from any land. We could base a procedure 5nm offshore from Black Rock, but would then be required to meet VFR minimums in VMC towards Black Sod for a landing. While we could have descended to 200', at the end of the IAP we then be required to proceed under visual conditions. Problem would have been that with a 300 OVC at night, we would not have had legal VFR minimums or legal VMC conditions and so would have had to do a missed approach. We are not SAR, so this reflects what an O&G aircraft would do.

[SASless]

DB.....you Dog, you!

61, two pilots, all that lovely kit.....an aotopilot of sorts as I recall....sheer luxury! When we was Young Lads we used to dream of having someone to hold our hands!

Now in the S-58T and Wessex fleets....with no autopilot and the same kit you mention that I remember so fondly.....we held our own hands being single pilot!

I suffered with that same Decca (Mk 19 was it?) and the wonderful scroll map stuck together with cellotape with the adhesive properties of Post-It Glue....that ran away every time there was a hint of static in the air....or you really....really needed it ! That was along about 1979 that I was getting the same trade of luck for experience.....that you were getting yours in the 1990's speaks of how technology change has improved over the years.

But....your point is taken...the more things change the more they stay the same!

Usually if we flew into something in those days we had a lot of help doing it by the absence of help in not doing it.

Today, perhaps we have too much help out of complexity and systemic errors.....and we still run into things we should not.

Managing all this fancy kit and seeing it is being fed accurate data and being given correct inputs is where the rub comes.

Every one of us can fall prey to undesired outcomes.

Hopefully, we will see some positive improvements out of this tragedy!

[DOUBLE BOGEY]

SAS our bog roll also had that strange crispy cellotape holding it together. The same quality and texture as Army bog roll used to be. Maybe we should start a new thread titled:

"And suddenly, an Angel appeared" An ode to the Bucket of Luck!

Whatcha think?

[SASless]

My Guardian Angels earned their pay and probably deserved Hazardous Duty and Overtime Incentive pay as they certainly earned it!

[[email protected]]

Perhaps one reason we got away with all that stuff was because we were pilots first and systems managers second - I'm not so sure that balance hasn't moved out of kilter in recent years with ever cleverer equipment, reduced training hours and tighter budgets.

[llamaman]

Perhaps one reason we got away with all that stuff was because we were pilots first and systems managers second - I'm not so sure that balance hasn't moved out of kilter in recent years with ever cleverer equipment, reduced training hours and tighter budgets.

I'm not convinced the accident rate stats back-up the rose-tinted spectacle view Crab. There's plenty of evidence to show that a lot of aviators didn't 'get away with all that stuff' in the past.

One of the reasons this incident stands out is the very low numbers of fatalities amongst SAR crews (in the UK anyway) in recent years. Thats not to say that there haven't been plenty of occasions when the 'holes' very nearly lined up.

[[email protected]]

I'm not convinced the accident rate stats back-up the rose-tinted spectacle view Crab. There's plenty of evidence to show that a lot of aviators didn't 'get away with all that stuff' in the past.
there is also plenty of evidence that many did and filled their bucket of experience before they emptied their bucket of luck.

A lack of skill in those days was quickly apparent - these days the automation does so much that good systems managers can get through without good handling skills. Look at the airlines where pilots often have to hire light aircraft themselves to keep their hand-flying skills up to scratch - that was from a senior ex-BA training captain!

[llamaman]

And therein lies the rub. We're at a really tricky stage in the evolution of aviation - getting the optimum blend of automation and manual skills is a huge challenge. There have now been a number of recent high-profile incidents where automation (and semi-automation) have been a significant factor. What is really hard to quantify is the number of incidents that have been avoided through effective use of exactly the same systems.

It's so easy to point the finger of blame directly at the crew in this instance. I suspect cultural and systemic factors will have played a big part in this one.

Simply improving basic handling skills is not the solution and over-simplifies the issue. A holistic approach is required where designers, regulators, operators and crews all have a meaningful input into improving safety margins.

This will no doubt involve painful self-reflection for helicopter SAR in Ireland. Unfortunately, like most complex socio-technical systems, it takes failure to stimulate progress.

[DOUBLE BOGEY]

To address the balance somewhat. I am a big fan of automation! However, it's use has to be developed over concrete foundations and not sand!

Also the SOPS and the regulations are important to a point. However, never let a **** procedure stand in the path of sound airmanship.

[[email protected]]

It's not that I believe handling skills are the simple solution - it is the lack of need for those handling skills, as automation has improved, that makes us lazy and over-reliant on the automation to always 'do the right thing'.

Unfortunately, the automation so regularly does the right thing that we stop questioning it and it takes a major deviation before we wake up and realise our magenta line/heading bug/route steer is taking us to the wrong place.

So perhaps, whilst a great deal of training is used to master and manage the automation to get the best out of it, a certain amount should be spent on recognising and dealing with the insidious nature of its failures.

[SASless]

It is the human interface module that seems to be the weak link in this automation thing unless you are riding in one of those Airbus contraptions unlike a Boeing Product that prefers Humans to be the Master over the machine.

Boeing sees a need for the Monkey Skilled Pilot when all else goes pear shaped.

[dClbydalpha]

DB I agree totally, technology and automation will continue to develop. There needs to be significant work done on establishing the rule-set for "safe" automation. Automation in my opinion needs to be immersive or transparent i.e. the pilot should have full intuitive understanding of what the automation is doing or should have no need to understand in order to resolve any situation. Over the last couple of decades we appear to have reached a point between the two which is worse. This results in the pilot being suddenly required to take full control of the situation without the situational or state awareness built by being connected to the actions that led up to that scenario. Massive increase in workload while simultaneously being robbed of the automation that could reduce the workload.

Strangely enough it seems more important to consider the human factors the more we automate things.

[jimf671]

I'm not convinced the accident rate stats back-up the rose-tinted spectacle view Crab. ... ...


The numbers back you up llamaman.

In recent years we have spent a lot of time on pprune discussing accidents with new-ish large rotorcraft types (92 & 225) whose forty-odd total fatalities across 12+ years of service are a small fraction of the fatalities in some older types. Since the 1960s when this size of rotorcraft began to emerge, probably between five and ten thousand people have died in them. Many of those didn't make the papers and only a small fraction have been discussed in depth on the internet.

[gulliBell]

...Unfortunately, like most complex socio-technical systems, it takes failure to stimulate progress.

So true. Without the Apollo 1 failure NASA probably wouldn't have made it to the moon by the end of the decade, if ever.

[DOUBLE BOGEY]

Ah Gullibell........did they make it to the Moon?

[SASless]

Nah.....twas filmed in the wilds of Nevada at a place called Groom Lake.;)

[[email protected]]

The numbers back you up llamaman.
In recent years we have spent a lot of time on PPRuNe discussing accidents with new-ish large rotorcraft types (92 & 225) whose forty-odd total fatalities across 12+ years of service are a small fraction of the fatalities in some older types. Since the 1960s when this size of rotorcraft began to emerge, probably between five and ten thousand people have died in them. Many of those didn't make the papers and only a small fraction have been discussed in depth on the internet. but trying to compare aviation in the 60s and 70s to today is like trying to compare motor racing then and now.

The number of fatalities has drastically reduced because the accident rates forced improvements in safety - it has nothing to do with handling skills or lack thereof, modern F1 drivers and incredibly skilled but they crash less and survive more when they do because of safety improvements in construction and engineering. The same applies to aviation so a simple stats analysis of numbers of crashes or lives lost isn't really valid.

As with motorsport, aviation is on a journey to constantly improve performance and efficiency whilst making the whole process safer.

As we have discussed, automation (and our reliance upon it) has to be introduced, administered and monitored wisely.

[puntosaurus]

I'd be very surprised if inappropriate use of automation finds its way close to the top of the causes of this accident.

Either you as an operator or you as a crew know that a 10mile cruise at 200ft in bad weather downwind to a fixed land base is a bad idea or you don't. How you then handle that cruise is a bit of a secondary issue.

I wonder how many other lessons need to be relearned the hard way ?

[SASless]

Crab,

I agree with all that but your penultimate paragraph identifies a problem.....the individual Pilot and Crew Member along with everyone in the process....and Operator and Authority must also see that there are no pauses, detours, or stays to that journey towards improvement.

I would suggest we might be seeing some systemic failure on display here that caught some folks out one dark night that caused them to pay a terrible price for that.

Formula One cars fail to win races unless all the bits and pieces come together to provide the driver a Ride that will afford him a chance to win if his performance is up to the task.

[[email protected]]

I'd be very surprised if inappropriate use of automation finds its way close to the top of the causes of this accident.no, but the slavish following of the FMS to the detriment of basic airmanship might.

[puntosaurus]

Absolutely, that was my point.

Although to be fair, the slavish following of the FMS wasn't nearly as damaging as the decision to do it at 200ft.

[BluSdUp]

As i have been freighting tourists and Hen-parties across Europe the last week, I have just read and not posted on this thread.

I must say the latest comments has been more productive, safety vise.

I compare this one to the FMS Cali accident and the New Zealand DC10 Antartic CFIT.

Basically modern equipment trusted and directly drilling a hole into the Swiss cheese.

I fly with the children of the magenta line and I am there to remind them that the basics are King , Always !

There is many contributing factors as in most CFIT, but some of the modern Duhikkies are at times counter productive.

I was just out fishing and a Norwegian SeaKing passed over my row boat.
The best SAR crew in the world the RNoAF , soon getting new and modern equipment.
I am going to miss that distinct sound.

Anyway, I hope they keep a healthy combination of old , trusted procedures and new and helpful ones. I am trust they will.

This Company and Crew has indeed shown us not to blindly trust modern equipment and at the same time disregard basics .

[Thunderbirdsix]

Great result by Rescue 118 who carried out the rescue while Rescue 115 flew top cover


Irish Coast Guard helicopter airlifts injured sailor from British Navy submarine | BreakingNews.ie (http://www.breakingnews.ie/ireland/irish-coast-guard-helicopter-airlifts-injured-sailor-from-british-navy-submarine-788946.html)

[dClbydalpha]

...
I was just out fishing and a Norwegian SeaKing passed over my row boat.
The best SAR crew in the world the RNoAF , soon getting new and modern equipment.
I am going to miss that distinct sound.

Anyway, I hope they keep a healthy combination of old , trusted procedures and new and helpful ones. I am trust they will.
...

I am sure 330 SKV have the expertise to make the most of their new aircraft with all its latest technology.

[Jemy]

Just a personal note. If there is to be a memorial service I would be much obliged if someone would PM me details as I may miss any announcement as I'm no longer in the ROI. I worked with a couple of the crew some years ago and would very much like to pay my respects.

[malabo]

Irish S-92 Accident Report Paints Picture of Confusion | Business Aviation News: Aviation International News (http://www.ainonline.com/aviation-news/business-aviation/2017-06-09/irish-s-92-accident-report-paints-picture-confusion)

AIN on-line article by Mark Huber misleadingly titled "Irish S-92 Accident Report Paints Picture of Confusion". There was no confusion. Every crew member thought the aircraft flightpath was following the absolute correct procedure, nothing was challenged. Even the rear crew penultimate suggestion to "come right" was met with deliberate and paced response from both pilots.

[helicrazi]

Irish S-92 Accident Report Paints Picture of Confusion | Business Aviation News: Aviation International News (http://www.ainonline.com/aviation-news/business-aviation/2017-06-09/irish-s-92-accident-report-paints-picture-confusion)

AIN on-line article by Mark Huber misleadingly titled "Irish S-92 Accident Report Paints Picture of Confusion". There was no confusion. Every crew member thought the aircraft flightpath was following the absolute correct procedure, nothing was challenged. Even the rear crew penultimate suggestion to "come right" was met with deliberate and paced response from both pilots.

I think the confusion is exactly HOW they thought they were absolutely correct...

[gulliBell]

A lot of pilots here, presumably with various degrees of experience in various roles, have read the CVR transcript and have arrived at various understandings of what was meant by what was said. This is the problem. I recall very early in the discussion here, it was reported, I think in the context of what is good CRM, that an ex-military pilot was overheard to say, when I press the mic I just want everybody to understand what I say.
I think @helicrazi has made an astute observation that confusion is exactly how they thought they were absolutely correct.

[SASless]

Is there a difference between "Why" and "How" when it comes to the "confused" situational awareness?

[Twist & Shout]

How do you overcome the "incorrect certainty" about a situation?

Potentially, an experienced pilot says something like "nothing higher than 30' here" (after misreading a 300' spot height)

I've been in many situations where something like this has been accepted as fact, and everything is predicated/explained based on an "incorrect certainty" (many not in aviation)

It might seem a farcical/extreme example but I can easily imagine the "certainty" of there being "nothing higher than 30'" resulting in a comment to "write up the faulty rad alt" when it trips unexpectedly for e.g.

Sure in hindsight it's obvious, but at the time, it can be anything but.

In a two crew situation, I feel it's not viable to check/question every statement.

Trying to explain myself:

After start, for a mission requiring 100% fuel. Add in nighttime and a little perceived time pressure.

"We have full fuel right?"
"I topped it to the bottom of the filler, dribbled it in until another drop wouldn't fit, waited for it to settle, dribbled a few drops more till it over flowed. It's full!"

The fuel status might now be beyond doubt, and any anomalies explained away as indication problems.

A fuel leak, or fueling WEX, and now sitting in WXE, are mentally discounted (especially if WXE is coincidentally filled to 90%)

How do we combat this type of error?

[dClbydalpha]

I think it's important to make a distinction between confusion and incorrect SA.

Confusion is a lack of understanding or lack of confidence in the information presented. This crew showed no sign of questioning that accompanies confusion. Compare this with the transcript of AF447, where everyone is trying to grasp what is going on.

I am convinced that this crew started the last phase of the flight with a clear, albeit incorrect, mental picture of what was ahead and how they would deal with it. Nothing in that aircraft, crew, training, procedure or technology was compelling enough to cause a re-assessment of that mental picture. In fact, it appears that most cues were readily incorporated into the existing SA. Until the moment that something untoward was seen on the electroptics.

[[email protected]]

Yes, it's like making the ground fit the map in the early stages of getting lost and until something so obviously wrong appears, it is too easy to convince yourself all is well and just as you planned it.

[jimcarler]

I think it's important to make a distinction between confusion and incorrect SA.

Confusion is a lack of understanding or lack of confidence in the information presented. This crew showed no sign of questioning that accompanies confusion. Compare this with the transcript of AF447, where everyone is trying to grasp what is going on.

I am convinced that this crew started the last phase of the flight with a clear, albeit incorrect, mental picture of what was ahead and how they would deal with it. Nothing in that aircraft, crew, training, procedure or technology was compelling enough to cause a re-assessment of that mental picture. In fact, it appears that most cues were readily incorporated into the existing SA. Until the moment that something untoward was seen on the electroptics.

This is on the money. Easy to remain confident in the SA now as generally it is very good. Unfortunately, mistakes are only really identified after they have caused major damage.

[SASless]

This gets back to my question about "How" and "Why".

"How" is the triggering event....and "Why" is what set it all up for the "How" to happen.....as I see it.

[G0ULI]

The how is easy, the aircraft was flying below MSA for the area.

The why, is because the crew hadn't got a clue they were below MSA due to inadequacies in the charts they were using.

They knew perfectly well where they were, the chart displayed just didn't show them to be in any danger. That led to confusion when an obstruction was identified ahead, because the chart would be expected to show anything large or tall enough to cause danger to the aircraft.

It really doesn't have to be any more complicated than that.

[helonorth]

The how is easy, the aircraft was flying below MSA for the area.

The why, is because the crew hadn't got a clue they were below MSA due to inadequacies in the charts they were using.

They knew perfectly well where they were, the chart displayed just didn't show them to be in any danger. That led to confusion when an obstruction was identified ahead, because the chart would be expected to show anything large or tall enough to cause danger to the aircraft.

It really doesn't have to be any more complicated than that.

You're no fun.

[jeepys]

Gouli,
at 200ft you know you are below msa!

[jetfour]

(Posted in error)

[My names Turkish]

FWIW:

Reconstruction shows R116 crew almost avoided disaster - Independent.ie (http://www.independent.ie/irish-news/reconstruction-shows-r116-crew-almost-avoided-disaster-35739877.html)

[henra]

Gouli,
at 200ft you know you are below msa!



No you don't know if your (electronic) maps don't show any obstacles higher than 30ft. In hindsight obviously we know better.
It is sad to see how a combination of inexact information and certain logic in the equipment that by itself would not cause a big risk/problem (280ft high obstacle in open sea not shown in EGPWS database, not or only partly shown in moving map, depending on mode, EGPWS inhibition in low altitude mode, deactivated clutter suppression, in exactly this combination lining up for a perfect disaster) still makes such a scenario possible even in such a modern machine. Very enlightening regarding unwanted consequences of features.


Why they cruised at 200ft for such an extended period of time will probably remain a mystery, though.

[Fareastdriver]

Has anybody on this thread got any information as to how the search for the two missing crew is going.

[jeepys]

Henry,

I don't know what rules you work to but I have always known msa to be 1000 ft about highest object. At 200 ft you are therefore obviously below msa regardless of what your paper or electronic map says.

Offshore MSA is 1000ft or 1500ft in areas of wind turbines.

[Twist & Shout]

Why they cruised at 200ft for such an extended period of time will probably remain a mystery, though.

No mystery. If the cloud base was around 300'.
One scenario is that they "let down" over the ocean. Got clear of cloud. Then followed a route (clear of cloud, but in the dark?) at a height they thought they were safe at.

Any mystery in my mind is why they thought the route was safe at 200'.
The tragedy in my mind is all the safety back stops not working, especially EGWPS.

[jeepys]

I may have missed it in the previous pages but has there been any info on the vertical path of this procedure?

[Geoffersincornwall]

Jeepys - We are talking SAR here and there are different rules for them that take into account their mission, the training and the equipment on board. Read the previous posts and you will get the picture.

G

[RVDT]

"Dive and drive" is the term you may be looking for.

It has its uses but........................

[jeepys]

Geoffrey,

Well aware of that but I thought they were following a company let down route?

[Democritus]

Geoffrey,

Well aware of that but I thought they were following a company let down route?

Jeepsys - this has all been discussed in depth in previous pages if you care to look. It just needs a bit of effort but to help you - the AAIU Preliminary Report on this accident is referenced in post 840 on page 42 of this thread. On page 17 of the report, para 3.5.8, the Operator's Route Guide is displayed. Read the report and this thread from thereon in and your queries will be answered.

[jeepys]

Democritus,
Seen that thanks but where is page two of the route guide giving other info?
Is there info on that page that gives advisory heights etc?

[Twist & Shout]

For the jeep seats:
As stated further up this page. They "let down" over the sea. A common, and safe practice.
They were using a company VFR route guide. To get to the refueling destination.
Not a "let down route". No vertical guidance. Spot heights were included on the second page.

This is only my understanding from reading the report, with both eyes open, some experience, and a healthy interest.

[jeepys]

Yes so the second page is pretty important for any height/vertical guidance or spot heights

[sycamore]

Why fly around with the gear down over the sea,with at least 10+ miles to land...?

[helicrazi]

Why fly around with the gear down over the sea,with at least 10+ miles to land...?

Nice to get the 'before landing checks' done before decending so low in bad weather, also depending on what was going on in their mental model they may have been planning on coming in slower and lower, so prevents the landing gear warning

[Tezzer 007]

Yes so the second page is pretty important for any height/vertical guidance or spot heights
I posted earlier, Irish Aviation Authority VFR maps use a red circle as the symbol for a lighthouse​. You can see Black Rock and Blacksod lighthouses and their heights marked on the company map (282 and 43)

[[email protected]]

I posted earlier, Irish Aviation Authority VFR maps use a red circle as the symbol for a lighthouse​.Ah yes, that well-known international symbol for a lighthouse.................not!

[BluSdUp]

I just pulled out my Dads old ICAO 1:500 000 VFR chart to check how a lighthouse is marked.:
It is with a black dot, no elevation or height and Feiestein Light ( WestSW of SVG for example)
And in the margin a fine drawing of the lighthouse with 112 on top of it.

Probably a fine thing for Mr VFR on one of his trips to Stavanger for coffee and waffels, but rather crude even if at scale 1:250 000 for any low level night stuff.
Anyway, if the chart had used the ICAO Annex 4 black dot with Blackrock Light printed next to it, we would perhaps not have had this exchange.

[ZFD]

State safety plan 2017;

"In common with the practice in many States, an Irish hel- icopter operator may be involved in both civil aviation activities (eg CAT/HEMS) and state functions (eg SAR). Whereas the IAA has safety oversight of the civil aviation operations, the oversight of state functions rests with the Department of Transport Tourism and Sport. "


https://www.iaa.ie/docs/default-source/default-document-library/iaa-state-safety-report-2017-2020.pdf?sfvrsn=0

This is interesting, especially considering the following;

"The IAA maintains an Aviation Rescue Co-ordination Centre (ARCC) at Shannon Airport and an Aviation Rescue Sub-Centre (ARSC) at Dublin Airport. The Safety Regulation Division of the IAA is the body responsible for the regulation and oversight of aircraft operations, including aeronautical Search and Rescue, within the State."

http://www.dttas.ie/sites/default/files/publications/maritime/english/irish-national-maritime-search-and-rescue-sar-framework/sar-framework.pdf

So, when the music stops, who is left holding the parcel, unfortunately it is the crew of R116 and their colleagues who are and have to deal with a politically and commercially driven environment.

My highest respect to all working in this vacuum.

[llamaman]

All gone very quiet - any update on the two missing crew?

[Just a spotter]

RTÉ's flag ship current affairs programme "Prime Time" has tonight (13th July) carried a report claiming that Sligo based SAR pilots had back in 2013 informed CHC of issues with the information regarding Blackrock Island in the oboard maps.

https://www.rte.ie/news/ireland/2017/0713/890122-blackrock-island/

JAS

[pfm1000]

The TV report is here: https://www.rte.ie/player/ie/show/prime-time-extras-30003379/10750839/

[EESDL]

Doesn't CHC hold an annual 'global' safety seminar, accompanied with a lot of PR bolleux?
They would have surely practiced what they preached and ensured feedback/compliance/ closing the loop.........and would have ran that particular issue up the flag pole to signal action and further ownership of the challenge before going forward......

I think it's about time CHC cease the annual farce of their safety seminar until they actually 'practice what they preach'.......

[SASless]

Lots of shoulder shrugging going on....as forecast.:(

[malabo]

Management/regulatory cockup of the grandest scale. Mystery now is that nobody in either the IAA or operator management team has been sacked. No comfort from all the good advice post incident, I'd want the competence on my team to foresee issues Before they turned into an accident. Quite a number of contributors to this thread have correctly been puzzled that the operation lacked any sophistication or depth of foresight by either the regulator or operator management. Either group could benefit from recruiting from that pool.

[Twist & Shout]

Meanwhile, some "safety manager" is trying to dream up an acronym for the next "safety system".

[[email protected]]

It just makes me wonder why on earth they weren't glued to the radar if they knew they couldn't rely on EGPWS.

[Tezzer 007]

I just pulled out my Dads old ICAO 1:500 000 VFR chart to check how a lighthouse is marked.:
It is with a black dot, no elevation or height and Feiestein Light ( WestSW of SVG for example)
And in the margin a fine drawing of the lighthouse with 112 on top of it.

Probably a fine thing for Mr VFR on one of his trips to Stavanger for coffee and waffels, but rather crude even if at scale 1:250 000 for any low level night stuff.
Anyway, if the chart had used the ICAO Annex 4 black dot with Blackrock Light printed next to it, we would perhaps not have had this exchange.

The RTE programme last night showed a revised map issued by the IAA last month (June 2017) of Skellig Michael (of Star Wars fame) another island. On the old map it had the red circle symbol (for a lighthouse) with 174 next to it. No frequency info. There was no height given for the island itself. Only that of the light. 174 appeared in a white rectangle too.
The new map has a blue circle (revised lighthouse symbol?) with text alongside giving a description of the lighthouse (174/frequency etc) but crucially now has the height of the island (712) marked by a smaller black circle. 712 also is now in the white rectangle.

[Red5ive]

Rescue 116 crash: Pilots’ group raised concerns over IAA
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-crash-pilots-group-raised-concerns-over-iaa-1.3154213

[Red5ive]

Latest search for Rescue 116 winch crew is stood downhttps://www.irishtimes.com/news/ireland/irish-news/latest-search-for-rescue-116-winch-crew-is-stood-down-1.3166797 (25/7/16)

Search for R116 crew continues off Blackrock Island https://www.rte.ie/news/regional/2017/0724/892614-r116-mayo-coastguard/ (24/7/16)

Search for missing Rescue 116 airmen continues 130 days onhttps://www.irishtimes.com/news/ireland/irish-news/search-for-missing-rescue-116-airmen-continues-130-days-on-1.3164084 (23/7/16)

Further searches take place off Blackrock Island for Rescue 116 crew https://www.rte.ie/news/2017/0722/892165-search/ (22/7/16)

Rescue 116: Donegal trawler resumes search around Blackrock island
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-donegal-trawler-resumes-search-around-blackrock-island-1.3158095 (17/7/16)

Donegal trawler continues fresh search for Rescue 116 airmen
https://www.irishtimes.com/news/ireland/irish-news/donegal-trawler-continues-fresh-search-for-rescue-116-airmen-1.3156664 (16/7/16)

[FADEC1]

Meanwhile, some "safety manager" is trying to dream up an acronym for the next "safety system".

You are so "on the money" it's not even funny. It is my view as a lifetime helicopter community member that too many private equity firms have taken over aviation companies, with a exit strategy already in place with the intent of turning a quick profit by getting rid of assets and replacing them with rolls of lean tape. After getting their foot in the door, they have systematically ensured jobs for their friends at the expense of experienced helicopter staff. The financial losses seen at these once large companies seems to show that they really don't know what they're doing. They conveniently blame oil prices for their problems. Somebody in university obviously forgot to tell them about having eggs in the same basket. While they were studying how to crunch numbers and play Chapter 11 games, we were all helping to build these companies to the point where these vultures took notice.
They do not know or understand what safety in aviation means. Yet some of them sponsor real Safety & Quality Summits with real speakers. If it's true that this unfortunate accident was the result of out-dated software and that it was brought up time and time again internally, than the ones responsible for choosing more lean tape instead of software updates should be forced to meet the families and explain it to them. Then they should be banned from stepping into any aviation company, for life. Of course I'm assuming that someone chose lean tape over software updates and I may be totally off-course. I would lean more towards a total lack of understanding of the helicopter business and what we call safety. I have seen a shift through the years and it is not good. The village idiots are definitely in charge now and they hold MBA's and more! They're not smart enough to know any better, but they can tell you how to lean a production plant in a heart beat. None of us work for production plants. Scary times! Good thing I'm retiring soon!

[Just a spotter]

It's being reported that a helmet and lifejacket found on the coast on Saturday belonged to winchman Ciarán Smith.

From The Irish Times, 2nd Oct 2017

https://www.irishtimes.com/news/ireland/irish-news/rescue-116-helmet-and-lifejacket-found-belonged-to-ciar%C3%A1n-smith-1.3241642

JAS

[Red5ive]

Truly shocking!!!!!!!

Ongoing safety concerns for search and rescue helicopter services

RTÉ’s Prime Time also reported that a few weeks before the R116 crash, Coast Guard pilots began testing a new electronic mapping system which was uploaded on to a mini iPad and strapped to the pilots' knee boards.

Both pilots on R116 took these iPads on board on the night of the crash off the Co Mayo coast.

The map that was used was not approved for use as a navigation tool as it was still on trial.

It showed Black Rock Island at 46ft, however, it is 282ft at its highest point.


RTÉ’s Prime Time has learned that the search and rescue teams had been complaining about poor quality maps and navigation equipment for months before the crash.

In September 2016, a flight safety meeting attended by R116 winch man Paul Ormsby, discussed feedback on their new Operations Manual.

The manual warned that the moving map system on board the helicopters should not be used for primary navigation "as it provides insufficient detail and is not kept up to date".


https://www.rte.ie/news/ireland/2017/1026/915302-rescue-116/

https://twitter.com/KatieGHannon

RTE Primetime - report should appear here soon
https://www.rte.ie/news/player/prime-time/

Rescue 116: HSA investigation opens possibility of prosecutions

Faulty locator beacons in crew’s life jackets highlighted five years ago, RTÉ reports https://www.irishtimes.com/news/ireland/irish-news/rescue-116-hsa-investigation-opens-possibility-of-prosecutions-1.3270581

[[email protected]]

It certainly goes a long way towards answering the many questions we had.

[Red5ive]

As mentioned above

Thu 26 Oct 2017

Rescue 116 | Prime Time

Katie Hannon reveals the continuing safety concerns for Ireland's Search and Rescue Helicopters services, some of which were raised as far back as five years ago. https://www.rte.ie/player/ie/show/prime-time-extras-30003379/10794966/

Duration = 24 minutes

(might need an Irish proxy)

[jimjim1]

https://www.rte.ie/player/ie/show/pr...3379/10794966/

(might need an Irish proxy)

It was available to me in UK.

This is an excellent documentary that reports several apparently disturbing issues surrounding this crash.

[HeliboyDreamer]

This is an excellent documentary that reports several apparently disturbing issues surrounding this crash.

Indeed, I was surprised to see that neither Department of Tranport nor Irish Aviation Authority would take responsiblity to oversee safety in Irish SAR.

[coyote_ie]

Am I missing something, the primetime report showed on the 1;250,000 map clearly indicated Blackrock as 282ft! The crew were using unapproved iPads? I wonder if they'd used paper charts & radar the outcome would have been very different. I'm sure the AAIU report will clear all of this up, we'll finally know for fact what the crew did and of course did not brief.

[jeepys]

At that altitude over water the radar should always be the primary tool anyway. Mapping systems are generally 'not to be used for primary navigation'.
It doesn't help with the IAA not taking a leading role in the SAR approach.

[Red5ive]

Am I missing something, the primetime report showed on the 1;250,000 map clearly indicated Blackrock as 282ft! The crew were using unapproved iPads? I wonder if they'd used paper charts & radar the outcome would have been very different. I'm sure the AAIU report will clear all of this up, we'll finally know for fact what the crew did and of course did not brief.

Bringing the iPads looks like a symptom of distrust in on board systems.

@14.42 in the Prime Time report there is an image of a Safety Meeting report. In the last sentence, the fact that Bristow crew's have a good moving map system is mentioned.

3457

[rotorspeed]

Have to say, if the crew knew of concerns on accuracy of charts and mapping systems it's even more surprising they chose a 10nm approach path at 200ft at night. Minimising low altitude transit would seem to be even more prudent to me. Radar may have supposed to be the primary navigation at such a time but clearly that had big risks too.

[coyote_ie]

Bringing the iPads looks like a symptom of distrust in on board systems.

@14.42 in the Prime Time report there is an image of a Safety Meeting report. In the last sentence, the fact that Bristow crew's have a good moving map system is mentioned.

3457

Saw that but point still stands, what was wrong with their 1;250,000 Map? from what I can see from the report, nothing as it had the correct spot height for Blackrock!

[Same again]

what was wrong with their 1;250,000 Map?

It was probably still sealed in the map case. The iPad is King these days.

[tistisnot]

Embrace technology ...... or not.

The map probably sits on a computer somewhere waiting to be printed. Why not offer the map in digital format so that it can be found on the Ipad - like the approach charts -available clear, crisp and highly zoomable for detail.

If Google can produce street names, why can HMG not overlay their map and quickly discover which islands are missing. The tedious updating system would become much quicker, though the state would no doubt need still to produce AIP style coordinates of heights, obstacles, lighthouses etc. Which makes one immediately question how the EGPWS terrain database might differ from the map. Good old adage ..... Garbage In, Garbage Out.

Oh, and you could place all the company's manuals there as well - saving 30 lbs of paper stuffed in a bag. How nice if the OEM's played ball and produced a decent digital flight manual; speedily accessed using .pdf search function.

Philistines .......

[Sevarg]

All very good till the batteries go flat!!

[Musician]

All very good till the batteries go flat!!

You need an USB charger upgrade for your aircraft. :p

[[email protected]]

The Digital Vertical Obstruction File (DVOF) is produced by OS for UK and available (at a cost) but I doubt if Eire is covered by it.

The technology is out there but someone has to pay for the data.

[Flying Bull]

You need an USB charger upgrade for your aircraft. :p

Well, in modern helicopters thatˋs included
Holder for Tablet PC
NOTE Due to the restricted field of view the Tablet PC provision should be placed in the stow position if no tablet PC is installed
Power can be applied to the USB port on the side of the instrument panel when Non-essential bus is powered. A switch is located in the overhead console....

[tistisnot]

Thanks Flying Bull .... ignore the cynics and detractors ..... some crew and some regulators - unbelievers! Follow the chord, kill the heretic

[Hedski]

The question has never been answered and the CVR transcript does not appear to reveal why a descent to such a low level was made so far from the target HLS given the SAR AFCS has preset programmes to descend from 2400’ to preset hover height as low as 50’? This was used in anger so often and trained for almost daily at the UKSAR bases where the airframe in question served for 6 years. Were lessons such as this from UKSAR ignored? Is there a ‘we know what we’re doing’ or ‘we know better’ attitude given apparent screen setup, use of and navigation by rearcrew almost non existent until too late a stage contrary to known best practise in UKSAR given that was the ideal place to draw relevant experience from? CRM questions arise from the transcript but also what about SOP’s for provision of top cover and appropriate fuelling, again a practise UKSAR conducted successfully post RAF Nimrod retirement. It appears the mapping issue is clouding what actually may be the real hazards involved in low level IMC offshore operations and best practises.

[212man]

The question has never been answered and the CVR transcript does not appear to reveal why a descent to such a low level was made so far from the target HLS given the SAR AFCS has preset programmes to descend from 2400’ to preset hover height as low as 50’? This was used in anger so often and trained for almost daily at the UKSAR bases where the airframe in question served for 6 years. Were lessons such as this from UKSAR ignored? Is there a ‘we know what we’re doing’ or ‘we know better’ attitude given apparent screen setup, use of and navigation by rearcrew almost non existent until too late a stage contrary to known best practise in UKSAR given that was the ideal place to draw relevant experience from? CRM questions arise from the transcript but also what about SOP’s for provision of top cover and appropriate fuelling, again a practise UKSAR conducted successfully post RAF Nimrod retirement. It appears the mapping issue is clouding what actually may be the real hazards involved in low level IMC offshore operations and best practises.

I think they call it "legacy practices".....

[[email protected]]

A friend of mine went from UKSAR to ICG on 61 then 92 - the 'we know better' attitude was apparently difficult to overcome - typical was the reluctance to push for NVG.

[tistisnot]

212, I understand your desire for best practice but for whatever reason the crew elected to transit at 200' probably on the presumption that the lighthouse was at 47' - crucial in their decision making / risk assessment as no-one challenged it. Offshore radar procedures are quite simple - never overfly the blob unless you are visual or at MSA otherwise turn to avoid. EGPWS is useless as a last barrier of defence without the correct mapping data.

[212man]

212, I understand your desire for best practice but for whatever reason the crew elected to transit at 200' probably on the presumption that the lighthouse was at 47' - crucial in their decision making / risk assessment as no-one challenged it. Offshore radar procedures are quite simple - never overfly the blob unless you are visual or at MSA otherwise turn to avoid. EGPWS is useless as a last barrier of defence without the correct mapping data.
I think you misunderstood me - I was implying a fact, not a 'best practice'.

[JohnDixson]

212, how high are the newer container ships seen in European coastal waters?

[gasax]

The OOCL Hong Kong currently the largest of the 20,000TEU ships has an air draft of 239 ft.

[[email protected]]

RAF SAR SOP was 'never overfly a radar contact below 1000'

[Fareastdriver]

In the early eighties when there was a bit of a slump in the oil industry there were a few semisub oil rigs stacked in Aberdeen harbour. I was a single pilot (at that time) S76A pilot at Aberdeen.

I was called in to to do a crew changeover on one of those semis in the harbour. The Haar was established so as soon as you left the coast it went into fog. A weather check with the rig said fog. Give it a go, said the company; if you can't find it then come back but we will still charge the rig.

I launched and called up for the beacon. It came up solid as a rock so I carried out a low level rig radar approach. I knew the rig from before so I used 200ft as a decision height and eventually arrived on finals. At 200ft I was passing through the tops of the fog with the needle at 12 o'clock and the rig welded to the radar. I saw nothing as I passed over it; there being no requirement to turn left at 3/4 mile in those days.

I returned to Aberdeen and shut down. As I got out the passengers told me that they had seen the derrick top flash by the rotor tips on the starboard side.

What had happened was that the semisub had floated itself so it was a 100 ft. higher than when it was working which was the only time I had flown to it before. Fortunately I was a an ace pilot because the position of their beacon was above the radio shack and because I had gone precisely over it the orientation of the rig caused my rotor to miss the derrick. Slightly off line to the right and Fareastdriver wouldn't be here.

That was over thirty years ago but stand back for the armchair experts to analyse what I did wrong. Times have changed since then; that job would not have been offered now but it was all part of (lucky) experience.

[satsuma]

Is there a ‘we know what we’re doing’ or ‘we know better’ attitude

It sounds like you already know the answer to that question!

The revelations from RTE are all very interesting but the number one question that remains is 'Why did the island not appear as a contact on the radar?' Everything else merely amounts to contributory and aggravating factors. It's all about the radar. How many radar approaches were individual ICG pilots required to conduct per quarter?

[SASless]

....for whatever reason the crew elected to transit at 200' probably on the presumption that the lighthouse was at 47' - crucial in their decision making / risk assessment as no-one challenged it.


Even if the Lighthouse had been at 47 Feet AGL....a night transit over water in bad vis....using 153 feet (plus or minus Altimeter error, Radalt instrument error, Auto Pilot/Pilot height holding error) seems a bit bold.

[puntosaurus]

The revelations from RTE are all very interesting but the number one question that remains is 'Why did the island not appear as a contact on the radar?' Everything else merely amounts to contributory and aggravating factors. It's all about the radar. How many radar approaches were individual ICG pilots required to conduct per quarter?

There were some very interesting posts a few hundred pages back about what the screen might have looked like with a waypoint symbol overlaid on the radar picture.

[Misformonkey]

The Digital Vertical Obstruction File (DVOF) is produced by OS for UK and available (at a cost) but I doubt if Eire is covered by it.

The technology is out there but someone has to pay for the data.
I think it's available via the CAA for interested parties?

[satsuma]

There were some very interesting posts a few hundred pages back about what the screen might have looked like with a waypoint symbol overlaid on the radar picture.

Yes, so the question remains. How much radar training do the Irish pilots do per quarter?

To correct my previous post, it's not all about the radar. It's also about the lack of NVG, and what appears to have been a reluctance to build them in to the operation. Why would that be?