SAR S-92 Missing Ireland

[Hedski]

Very little of actual significance or meaning. A TRE maintaining low level IF currency by conducting a few rate 1 turns at 500’ for less than 30 seconds just to tick the box tells how much interest there actually is. What about all that well used and demonstrated technology proven in UKSAR on the moving map screen in the main cabin including sea charts and overlaid AIS data for ships. Not much use of that either.

[satsuma]

Very little of actual significance or meaning. A TRE maintaining low level IF currency by conducting a few rate 1 turns at 500’ for less than 30 seconds just to tick the box tells how much interest there actually is. What about all that well used and demonstrated technology proven in UKSAR on the moving map screen in the main cabin including sea charts and overlaid AIS data for ships. Not much use of that either.

That's astonishing. Is this lack of proper training and the willingness to simply box tick where RTE will be focusing the next strand of their investigation or are the Irish public being fed the side of the story that disenchanted employees (with actors' voices) want them to hear?

[Hedski]

Maybe. Certainly it’s an avenue that deflects away from potential problems and further prevents an inward focus..... Currency is a minimum, not confidence inspiring in such a role if perhaps treated as box ticking exercise unless of course there is no inputus to improve amongst a feeling of knowing it all.

[jeepys]

Does anyone know how many hours per month are allocated to training in the contract?

[satsuma]

amongst a feeling of knowing it all.

You don't need to be an aviator to know where that leads.

[Hedski]

Does anyone know how many hours per month are allocated to training in the contract?

Unknown but unlike UKSAR tasking hours reduce training allocation. Maybe hours are precious overall if annual CRM courses last as little as 90 minutes delivered by an off duty ryanair captain apparently with little interactive exercises or case studies. Not like any CRM course I’ve been on, even those I’ve been less than impressed with.

[[email protected]]

Unknown but unlike UKSAR tasking hours reduce training allocationHedski, is that actually the case?

If so it is a major change of position from what Bristow were stating pre-contract when they were asked about training hours.

They were quite adamant that trg could be conducted on ops and count towards the required hours/stats.

Much of my concern and criticism of the contractorisation was founded on their poor attitude to trg hours so maybe the reality of SAR skills trg has been acknowledged by the management.

The ICG attitude is exactly why I railed against commercial SAR for UK.

[jeepys]

Crab,
Are you saying stats cannot be gained during ops?
As far as I am aware the UKSar training hours allocation is working fine.

[Hedski]

UKSAR retains training hours allocation regardless of ops. Ireland the contrary. Currency can include operational evolutions in both places.

[[email protected]]

Are you saying stats cannot be gained during ops?Jeepys - no that would clearly be silly.

Hedski - if that is the case then they have been re-educated in management since their original statements regarding training.

When questioned about the reduced hours available for trg (1.5 hrs per shift vs SARF 4 hrs per shift) they clearly stated that trg could be claimed on ops - they probably meant stats as in a deck or a radar letdown but they clearly believed MilSAR did far too much trg and was therefore too expensive.

Accidents like the ICG tragedy would seem to prove otherwise. Pay lipservice to trg and eventually get bitten.

[[email protected]]

The trouble is keeping people honest.

if you are on a job where the letdown and winching are demanding/tricky/challenging then it is valid to claim those as trg stats (but not hours) since you were doing the job for real.

However, if the job was easy peasy in simple conditions, it is disingenuous (but probably legal) to claim those stats against your training. The whole point of training is to make it challenging so that your skills are honed ready for the difficult rescue.

Otherwise you are in the same boat as the 5 mins under the hood doing clearing turns as radar trg brigade.

'Train hard - fight easy' is an old adage but very appropriate to SARops.

[Hedski]

Sounds like train hard fight easy was not the daily mantra. Especially when you discover that the low hills behind the ‘Fr Ted house’ from the 90’s tv series are considered a valid area to conduct mountain flying training according to operations manuals (highest point 1129ft). Or conducting deck winching currency, day or night, to static tankers at anchor in estuaries. But relevant is the LLIF question, also radar letdowns and transits such as that which was central to this accident. How often, what rearcrew involvement if any given most are not trained as navigators at odds with UKSAR, plus the CRM question given evidence from the transcript of the PF also programming the FMS which is an instant red flag from any offshore or SAR operator elsewhere.

[[email protected]]

Sounds very much like the 'box-ticking, make the stats look good' approach with little oversight or quality assurance.

[NumptyAussie]

https://www.independent.ie/business/irish/r116-accident-could-hit-our-profits-warns-firm-behind-rescue-service-36441005.html

[[email protected]]

As the old saying goes - 'If you think flight safety is expensive, try having an accident and see what happens'.

[Just a spotter]

It's being reported by RTÉ that the AAIU is still working on the report into the loss of Rescue 116 and that the final version won't be published before March.

The Air Accident Investigation Unit says the extent of the inquiry into the fatal crash of Coast Guard Rescue Helicopter 116 means a final report on the matter will not be completed by the first anniversary of the incident.

https://www.rte.ie/news/ireland/2018/0130/937082-r116-crash-report/

JAS

[Cows getting bigger]

As the old saying goes - 'If you think flight safety is expensive, try having an accident and see what happens'.

So true. :D

[NumptyAussie]

How quickly a year passes....

[Thomas coupling]

If I read the above link correctly, it suggests that the IAA produced a database with certain terrain elements msssing in it? Did I just read that correctly?

It later emerged that the island was not included on the helicopter's onboard warning system due to missing navigational data on maps published by the Irish Aviation Authority.

So isn't it the IAA that are going to get the full weight of the law thrown at them for the cause of this accident and not CHC?

I must be missing the point here.................................

[dClbydalpha]

If I read the above link correctly, it suggests that the IAA produced a database with certain terrain elements msssing in it? Did I just read that correctly?



So isn't it the IAA that are going to get the full weight of the law thrown at them for the cause of this accident and not CHC?

I must be missing the point here.................................

The terrain data within something like an EGPWS is not usually produced or even endorsed by the national charting agencies. The systems themselves are usually advisory only.
The data within them is subject to the limitations of the data gathering, reducing and storage algorithms.
I feel the quoted statement is therefore a little misleading.

[Thomas coupling]

I would hope so.

Because if the IAA are anything like our CAA, they will absolve themselves of all responsibility and distance themselves from any incriminations.

[212man]

I think it's misleading as, although the IAA ay be responsible for the aeronautical information on their charts, the actual topographical map will have come from Ordinance Survey Ireland. Where the digital database for the EGPWS comes from is unclear but, given that it will be the same as the Fixed Wing variants it is not a huge surprise that it does not have the level of detail that would include rocks in the sea. The greatest acuity is in the vicinity of airports.

[norunway]

http://www.aaiu.ie/sites/default/files/report-attachments/Interim%20Statement_2.pdf

[Aquila1]

Why is Blackrock island STILL missing from ordnance survey Ireland topographical data a year later?? You can see this on the geohive website.

The Island is accurately charted on old maps from centuries ago. But not on current maps from OSI. It's a bizarre situation and even more bizarre that it doesn't appear to have been rectified.

Obviously there were many factors to this accident but I am surprised that the interim report makes hardly any mention of the charting issues.

[Davey Emcee]

https://www.irishexaminer.com/ireland/rescue-116-items-recovered-from-the-atlantic-472822.html

[Flying Bull]

https://www.irishexaminer.com/ireland/rescue-116-items-recovered-from-the-atlantic-472822.html

Please check the link, my browser denies opening it...
Txs





Fixed

Senior Pilot

[NumptyAussie]

Almost 2 years now...

[SASless]

The Link worked for me just now....

[Red5ive]

Just noticed a minor update on March 1st.


Air Accident Investigation Unit Ireland

Interim Statement --- 1 March 2019

Investigation into Accident involving S92A helicopter EI-ICR (R116)Black Rock, Co. Mayo on 14 March 2017As per International Convention, EU Regulation and domestic Law relating to accident investigation, it is required that, if the final report into an air accident investigation cannot be made public within 12 months, the Air Accident Investigation Unit shall release an Interim Statement at least at each anniversary of the accident or serious incident, detailing the progress of the investigation and any safety issued raised. Work on the preparation of a Draft Report is at an advanced stage.

Rather than preparing another detailed Interim Statement, which would detract from the ongoing work of preparing the Draft Report, the Investigation is focussing its efforts on finalising the Draft Report. Once finalised, the Draft Report will be circulated, in confidence, to interested parties as soon as possible.

Accordingly, a detailed Interim Statement is not being issued on the occasion of the second anniversary of this accident.

-END-

Second Interim Statement: Accident Sikorsky S-92A, registration (EI-ICR) at Black Rock Co. Mayo, 14 March 2017 at 00.46 hrs | AAIU.ie (http://www.aaiu.ie/node/1309)

[[email protected]]

So a second interim statement saying that there won't be a second interim statement...................

[EESDL]

So it’s like being compliant right up to the point when you choose not to be - kind of defeats the whole point of the process.......

[OvertHawk]

The AAIU is a small organisation that will have been stretched to its limits with this inquiry, although I know they will have given it their all.

It seems like what they've chosen to do is entirely sensible and justifiable, particularly if producing another interim bulletin would delay the final report.

[[email protected]]

Heard a rumour that Irish SAR are looking for a quick-fix for NVG training - be interesting to see if they can find anyone with the requisite experience of recent SAR NVG and S92 time..

A few years ago a sadly departed colleague with plenty of NVG experience and instructional time was passed over to introduce NVG to Irish SAR because they wanted someone Irish to do it rather than someone who was qualified - hope they don't repeat that process.

[Hot_LZ]

They’ve just had a very experienced S92 NVGI join and leave in a blink...

LZ

[Sumpor Stylee]

How recent would NVG experience need to be to be acceptable to instruct in civ sar world? I know unless in date you can’t be an IRI or TRI so would NVGI require currency? How recently experienced are those on offer or this person who didn’t hang around? The accident report will doubtless be damning, how well are they risk assessing NVG intro given the mess made of S92 intro and apparent contempt for the advice given and offered by experienced S92 SAR personnel to those who at the time were new to type?

[[email protected]]

And are they just going to get a box-ticking basic NVG qualification or will they get someone who has actual SAR training and Ops experience??

[Sumpor Stylee]

Box ticking was the order of the day for S92 intro wasn’t it? Mentioned here before that CRM was also a box ticking exercise as were some currency items. So probably given those responsible are all still in post.

[BluSdUp]

,, " they wanted someone Irish to do it rather than someone who was qualified."
That sentence might get me in trouble.
But thanks anyway.

Regards
Cpt B

[[email protected]]

BSU - should have clarified that the Irish guys put forward for the post had no instructional qualifications nor experience - they had just been in the company for longer - it wasn't a sneakily disguised Irish joke.:ok:

[[email protected]]

I hear that the Irish CG has signed up for some NVG training - at last - but have the possible providers got any depth of NVG experience, especially in SAR NVG Ops?

Outside of present UK SAR, I know where all the depth of experience lies in that field but that doesn't seem to be where the contract is going.

This is a rumour network after all....

[norunway]

I hear that the Irish CG has signed up for some NVG training - at last - but have the possible providers got any depth of NVG experience, especially in SAR NVG Ops?

Outside of present UK SAR, I know where all the depth of experience lies in that field but that doesn't seem to be where the contract is going.

This is a rumour network after all....

Crab, your right it’s not going to any of the experienced NVG providers.

[coyote_ie]

Crab, your right it’s not going to any of the experienced NVG providers.



Any idea who was awarded the contact? or at least what their background is.....

[[email protected]]

Helioperations I believe.

[Northernstar]

So has this company any previous NVG training delivery? How many NVG experienced instructors do they have? Doesn’t look like many on their website. Was there a tender process, if not why not? Does another company not hold a contract for all SAR training globally for CHC?

[[email protected]]

You would have thought asking Bristow would have been a logical choice since they have all the current SAR NVG experience on the same aircraft type.

[Northernstar]

Hang on. Isn’t this the CHC Ireland who didn’t listen to the training and standards dept of CHC U.K. SAR when they got 92’s from there? And lack of lessons learned contributed to the source of this thread or so people have asserted and discussed at length. Would they be smart enough to ask for help with this? Sounds like they have but maybe kept it quiet hence there’s an apparent award to someone seemingly not experienced in the relevant area, has to be an inside job or sly envelope somewhere. Isn’t the chief pilot of helioperations on their website a former CHC employee? Was he CHC Ireland before that?

[Hot_LZ]

Well sounds like the NVG training has already slipped into 2020.

LZ

[Spanish Waltzer]

Is this why helioperations have just bought 16 old uk mil seakings? Taking over Ireland SAR again while training the crews to use NVG��

[212man]

Isn’t the chief pilot of helioperations on their website a former CHC employee? Was he CHC Ireland before that?

He was CHC in between Bristow (where he started) but was continuously in Stornoway for years I think.

[minigundiplomat]

He was CHC in between Bristow (where he started) but was continuously in Stornoway for years I think.

Ah yes, he of 'meatgate' fame.

[CHARLIEOSCAR]

Ah yes, he of 'meatgate' fame.

'Meatgate' :O

I did feel for them guys at the time.

[P3 Bellows]

I believe that CHC Ireland did have an ex-Bristow NVGI about a year ago but in-house politics got in the way and he left. I think he rejoined Bristow.

[Northernstar]

So to put it back on thread post crash March 2017 the lessons aren’t being learned even before the AAIU report is published, however damning it may turn out to be.

[finalchecksplease]

He was CHC in between Bristow (where he started) but was continuously in Stornoway for years I think.


Not Stornoway but Sumburgh AFAIK

[Northernstar]

If there’s a delay in training what’s the reason for it? Have they worked out that the provider is not all it’s been cracked up to be? Or are there more technical issues? Maybe the rumoured imminent publishing of the AAIB report has something to do with it. Who’s taking the fall etc. Wonder how crews will react to it.

[Franks Town]

Sunday Times Irish addition reporting that fatigue , poor management safety culture ,chart errors and dysfunctional over sight by the Irish Aviation Authority all contributed to the crash . Article is in the front page with expanded coverage in page 21.

[Davey Emcee]

Reform is still needed nearly three years after Rescue 116 crash, warns pilots' group (https://www.thejournal.ie/rescue-116-irish-coast-guard-4949932-Dec2019/)


THE FACTORS THAT led to a fatal helicopter crash off the Mayo coast in 2017 still exist, an organisation representing pilots in Ireland has claimed.

The Irish Air Line Pilots’ Association said it is concerned an accident could happen again if the causes contributing to the crash are not comprehensively addressed.

Four members of the Irish Coast Guard air crew died in the Rescue 116 crash (https://www.thejournal.ie/rescue-116-rocks-at-black-rock-3298196-Mar2017/) in March 2017.

Captain Dara Fitzpatrick, 45, Captain Mark Duffy, 51, and winchmen Paul Ormsby, 53, and Ciaran Smith, 38, all died when their Sikorsky S-92 helicopter crashed into Blackrock island off the coast of Mayo.

It is understood that inaccurate charts and risk of fatigue were among some of the contributing factors in the tragic crash.

The Air Accident Investigation Unit is due to publish a report in the coming months.

The pilot union Irish Air Line Pilots’ Association has urged the Irish Government to make changes to the state regulator, the Irish Aviation Authority (IAA).

Irish Air Line Pilots’ Association president Captain Evan Cullen claimed there are serious issues with the corporate structure of the IAA.

“The IAA is an outlier in terms of its corporate structure,” he said.

“One of the things that makes it unique is that it has the safety regulatory function. But it also has a commercial agenda under its air navigation service provider function.

“In all other western jurisdictions those two are absolutely separate.

“In Ireland we’ve combined the two, so therefore the organisation has its safety mandate as a regulatory oversight and it also makes money out of the same entities that it tries to regulate.

“Certainly there’s a paradox and that’s not sustainable.”

He said that the IAA is not subject to any ombudsman, nor the Auditor General and the group is not subject to respond to requests under the Freedom of Information Act.

He added that the reasons behind the crash “are still out there”.

Capt Cullen said the organisation has raised concerns about the regulator on many occasions since 2003.

“Everything from flight time limitations to tiredness, and obviously the navigational inaccuracies, and security issues which are separate to safety,” he added.

Irish Air Line Pilots’ Association has raised many issues with the IAA in letters seen by the PA news agency.

“The issues raised are quite diverse and what’s been obvious over the years is that the IAA are judging the concerns raised by the source, rather than the actual subject,” Capt Cullen added.

“One of the things that will come out which has already been highlighted in the interim report is that the maps and charts are inaccurate, which was a contributing factor to the accident.

“Other pilots have reported that there were inaccuracies in the maps.

“There were two reports, in 2013 and 2015, that stated the maps were inaccurate and nothing was done about it.”

He has called for the Government to separate the safety regulatory department from the commercial part of the IAA.

Capt Cullen also said that pilots have expressed dissatisfaction in the way the IAA receives and investigates pilots’ complaints.

“Pilots have said they’ve made fatigue reports that have not been acted on and they made technical reports that have not been acted on,” he also claimed.

He said that many pilots who have flagged issues are not made aware if the issue has been investigated or whether it has been addressed.

It also emerged that the Department of Transport failed to appoint an individual to examine the safety and technical performance of the IAA for a long period.

“We discovered that this process had not been done between 2004 and 2014. Even though the law says it has to be done every three years,” he added.

The IAA and Department of Transport did not respond to requests for comment.

[Northernstar]

All those issues are just red herrings surely when people are raising or have raised concerns about culture, standards, training, unwillingness to listen/arrogance, even the possible CRM breakdown evident from how little interaction there was by the transcripts published. Or lack of rear crew involvement when they had tools at their disposal. Could it be a union just making noise claiming to be acting in the interests of its membership?

[[email protected]]

I hope the union keeps making noise so it forces those with entrenched positions within the SAR service provider to re-examine how they do business, why they are so resistant to change and why it is taking so long to rectify a simple matter like NVG training.

[Northernstar]

Did they not start NVG training in simulator? And who is the training provider? Are the Irish coast guard even aware of all this?

[Hot_LZ]

I find it quite ironic that IALPA stand shouting about the lack of change from the regulator when they themselves (and their membership) block a lot of the initiatives that have tried to be implemented since the crash.

A very broken train set that unfortunately IMHO won’t be transparently identified and acted on in the report.

LZ

[norunway]

I find it quite ironic that IALPA stand shouting about the lack of change from the regulator when they themselves (and their membership) block a lot of the initiatives that have tried to be implemented since the crash.

A very broken train set that unfortunately IMHO won’t be transparently identified and acted on in the report.

LZ

What initiatives have been blocked by IALPA & IALPA Membership since the crash.

[Northernstar]

Brining in relevant qualified expertise from UKSAR?

[norunway]

Brining in relevant qualified expertise from UKSAR?

Northernstar - seeing as you have all the facts on that, would you care to explain.

[Northernstar]

It’s been reported on her openly that an NVG instructor with relevant experience was recruited and promptly left again rather rapidly. In fact it’s a very widely known fact in UKSAR and Aberdeen.

[norunway]

It’s been reported on her openly that an NVG instructor with relevant experience was recruited and promptly left again rather rapidly. In fact it’s a very widely known fact in UKSAR and Aberdeen.

GB is obviously not telling the full story to you boys as to why he left so promptly, and has instead decided to put a spin on it.
Reported on here - it is a rumour network.

[Northernstar]

Do you have the full story then? Are you an IALPA rep?

[norunway]

Do you have the full story then? Are you an IALPA rep?

Are you an NVGI instructor with an axe to grind?

[Davey Emcee]

Last edited by Senior Pilot (https://www.pprune.org/posthistory.php?p=10650320); 31st Dec 2019 at 02:13. Reason: Add quote: this helps Rotorheads know what you're posting about!

It was about SAR S-92 Missing Ireland.

[[email protected]]

Norunway - since it sounds like you are on the inside of Irish SAR, are you able to detail what changes have been made in light of this accident and what progress is being made with the introduction of NVG?

[NumptyAussie]

A serious question as an outsider.
What difference would NVG have made to driving a S-92 into a lighthouse at night, a structure whose sole purpose is to warn seafarers that there is a a bit of land that is a hazard to navigation?
Thanks

[[email protected]]

Because you can see it - even if the light isn't working.

Primarily because you are flying visually and using the nav kit and AFCS to take you where you can see.

Instead, they appear to have been flying in an IFR manner with minimal lookout and concentrating on the screens. Even that would have been safer if they had used the radar as their primary terrain avoidance and had the FLIR facing forward as a backup.

[Northernstar]

Exactly. So what’s being discussed here re NVG is relevant to the accident discussion. Also the question of who has or is providing whatever training is ongoing, now rumoured halted but unknown why, has relevance to culture, lack of oversight, safety etc.

Now that Norunway has revealed he’s on the inside of Irish SAR would he like to answer the question re NVG and his assertion about why a highly experienced SAR captain and NVG instructor left? Given he decided to state the persons initials openly.

Also why did an ex navy S92 SAR TRE leave Irish SAR for a contractor organisation flying SeaKings? He did also have NVG experience although being over 15 years ago that’s academic anyway as you couldn’t teach peers with such a lack of recency.

[sycamore]

Nav.database was incorrect as well,..?

[EESDL]

Still strange why they descended so early if they weren’t aware of the lighthouse. Scud-running usually only brings trouble - especially if you’re still flying as if IFR.
’contributory factors’ in an accident report always irks me.
Yes, some important stuff in there but nothing that should not have been completed/aware before the flight. Whilst responsibilities for such ‘errors’ can be directed throughout the Irish SAR establishment, basic flying /navigation / CRM skills were not evident.
Despite the number of individuals on board there appears never to have been a functioning crew onboard.
I wonder how many previous ‘near misses’ were overlooked.
tragedy.

[[email protected]]

Nav.database was incorrect as well,..? certainly an issue but relying on an old S-61 procedure that doesn't seem to have been checked or updated for years is just poor airmanship when you have such a well-equipped aircraft.

[212man]

Nav.database was incorrect as well,..?
Where do you see that? Are you referring to the EGPWS or the FMS?

[SASless]

.... relying on an old S-61 procedure that doesn't seem to have been checked or updated for years is just poor airmanship when you have such a well-equipped aircraft.

Crew failure..... or Management/Flight Safety/Training failure?

Who....by name and position.....ignored the Iceberg and ordered full speed ahead?

Please do not point a single finger at the Crew without including everyone that assisted in setting up the environment that led to this tragedy....that would be very unfair and narrow minded.

[Northernstar]

Exactly. Culture and training are central to how crews operate in a large multinational company such as CHC or Bristow. Rearcrew lack of involvement won’t be their decision alone, they will act professionally according to their training, or lack thereof.

[India Four Two]

When previously reading about this accident, I had assumed that the helipad at Black Rock was near sea level.

After careful reading of the Preliminary Report, I see that the Route Guidance map shows the pad elevation as 262’ and the adjacent lighthouse at 310’. What would induce them to fly at 200’ towards a landing site adjacent to an obstacle that was 110’ above them?


https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/750x810/f0e4d88e_0135_4e95_a879_bb3d8fb3f7ed_8b09a80c0949832da54c5ef 44341169079b5b2e6.jpeg
https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/750x563/9821cde0_7f60_4957_a3dd_fa34ea69b6f9_6051a3440678b21ff97aee6 a2366c06627ac6bb2.jpeg
https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/750x534/eea10730_686d_4985_ac0b_99d530264b16_a1418af2aac8b04922d5f56 1470cc20fed13b702.jpeg

[Apate]

Now that Norunway has revealed he’s on the inside of Irish SAR would he like to answer the question re NVG and his assertion about why a highly experienced SAR captain and NVG instructor left? Given he decided to state the persons initials openly.

Also why did an ex navy S92 SAR TRE leave Irish SAR for a contractor organisation flying SeaKings? He did also have NVG experience although being over 15 years ago that’s academic anyway as you couldn’t teach peers with such a lack of recency.

Perhaps we should be asking why Northernstar has such strong views about this incident, yet has few posts elsewhere. What is his agenda?

[212man]

When previously reading about this accident, I had assumed that the helipad at Black Rock was near sea level.

After careful reading of the Preliminary Report, I see that the Route Guidance map shows the pad elevation as 262’ and the adjacent lighthouse at 310’. What would induce them to fly at 200’ towards a landing site adjacent to an obstacle that was 110’ above them?


https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/750x810/f0e4d88e_0135_4e95_a879_bb3d8fb3f7ed_8b09a80c0949832da54c5ef 44341169079b5b2e6.jpeg
https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/750x563/9821cde0_7f60_4957_a3dd_fa34ea69b6f9_6051a3440678b21ff97aee6 a2366c06627ac6bb2.jpeg
https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/750x534/eea10730_686d_4985_ac0b_99d530264b16_a1418af2aac8b04922d5f56 1470cc20fed13b702.jpeg




Blackrock was not their intended landing site!

[rotorspeed]

Indeed, Blacksod, 10nm east, was. But the question still remains as to why the crew thought being at 200ft in poor vis at night, for a 10nm approach to Blacksod, was the best method.

[funfinn2000]

Why would it take this long for a final report? Politics?

almost 3 years since this tragic event that shook many around the world. It’s seems bizarre to have to wait this long.

[[email protected]]

Indeed, Blacksod, 10nm east, was. But the question still remains as to why the crew thought being at 200ft in poor vis at night, for a 10nm approach to Blacksod, was the best method. Absolutely - that was my point about the lazy use of an old S-61 procedure which they weren't really familiar with but followed, apparently without thinking, when a simple self-positioning radar letdown, much closer to Blacksod would have been far easier and safer.

[Red5ive]

The publication of an Air Accident Investigation Unit (AAIU) report into the 2017 crash of Irish Coast Guard Rescue 116 helicopter has been delayed pending a new review.

The AAIU circulated a 333-page draft final report in November and was expected to publish its final report on the accident this month.


https://www.rte.ie/news/ireland/2020/0109/1105424-r116-helicopter-crash/

[Steepclimb]

It's been said that the stakeholder who objected to some of the conclusions represents family members. Understandable but unfortunate.

[BluSdUp]

It is interesting reading the January RTE article.
As I understand it AAIU has no less then 73 findings and are now finally ready to publish the report.
A report we are all looking forward to so we can learn from this tragic accident.
But somehow one of the stakeholders see fit to drag this out more.
Tragic!

[[email protected]]

Sort of understandable if the report is critical of the crew members who aren't here to defend themselves.

[malabo]

The crew knew there was a blob in front of them yet did not take timely action to avoid it, so yes, in my world, that falls on the captain’s broad shoulders. Same responsibility as if they were to deviate from an SOP because of an on-the-spot assessment - like Sully did.

Anyway, lots of blame to go around, especially management. Crew selection, command assessment, SOP’s appropriate for avionics and location....looking forward to the report. Though I think ppruner’s work will be cut out for them to assign the correct weigh of each finding to the tragedy.

[megan]

The crew knewI would humbly suggest that you have no idea what the crew knew.

[SASless]

Lads....this article quotes the Accident Investigation.

It seems to be a nice summary of the findings to include quoting the CVR record of the conversations between the Crew.

Take a minute to read it then go back to your Saber crossing!


https://www.ainonline.com/aviation-news/business-aviation/2017-05-16/irish-s-92-accident-report-paints-picture-confusion

[[email protected]]

An indication of the problems with being over-reliant on the autopilot and insistence upon using its modes to alter the course of the aircraft - the delay between asking for HDG mode to be selected and it actually happening was too long for the situation they were in. The cyclic still works and a prompt right turn would have saved them.

There are more CRM and procedural issues involved with this tragedy but we can wait for the report to analyse those.

[megan]

Not a nice summary at all SAS, this is a summary. Captain, Co-pilot, Backseat. Timing in seconds. When is it they become aware of the "blob" and its significance? 28.261 or 59.005?

Sabres holstered.

28.261 OK so small target at six miles eleven o’clock Large out to the right there ehm

31.234 Roger

31.533

33.58 Eh just a small little island…that's BLMO itself

36.184 ""

46.767 K...looking at an island just in, directly ahead of us now guys, you want to come right [Commander’s Name]

50.417 ""

50.862 OK, come right just confirm?

51.81 About..

52.035 twenty degrees right yeah

52.888 ""

53.404 OK Come Right...select heading

54.416 ""

55.231 Select

55.38 Roger

55.691 heading

56.164 Heading selected

57.231 ""

57.691 Come right now come right COME RIGHT

59.005 ""

59.893 [Expletive]

60.73 OOOHHHH

61.198 [Expletive]

62.557 We’re gone

8.588 seconds between the first backseat advise and the ultimate come right command.Please do not point a single finger at the Crew without including everyone that assisted in setting up the environment that led to this tragedy....that would be very unfair and narrow minded:ok::D

[SASless]

I see it as being 46.7 when the Back Seater clearly calls it and directs a turn.

There seems to be some mis-identification by the Pilots.

With the comment about two targets...with one being to the right...and the back seater calling for a right turn....I can imagine (assume...guess) that complicated the thinking by the Pilots.

We have to remember there were three inputs to the situation....what the Pilots were seeing and what the Back Seater was seeing....with the Pilots having to fly the aircraft (even if just pushing buttons for the Autopilot).

The Captain had to process all of this....and make the decisions as to what needed to be done.

It was a very dark night....with a low ceiling....which did not help.

Before being too critical of the Crew....put yourself into their shoes and think about what they were dealing with that night.

There are legitimate questions that can and should be asked.....but we have to recall that it is a far different situation when you are doing it....rather than sitting at your computer and discussing it after the fact.

We are all human....and last time I checked there are no Super Humans amongst us.

[Flying Bull]

Doesn’t sound to good :-(

Easy to point fingers - but we‘re all only humans

As always, main point is, you need to be ahead of your aircraft, where am I, whats next - when and how to execute it and what’s after that?
Any uncertainty- reduce pressure (speed) and get ahead again.

What I recognized is, that quite a lot of pilots only turn right/left to avoid traffic- even so we have the ability to play with altitude (no option with low ceiling so).

Hope, that pilots remember this accident and take their time to get ahead again instead of pressing on

[llamaman]

It's far too simplistic to boil this down to the last 20 seconds or so where things rapidly went wrong. No doubt there were many layers of failure starting way before the incident and permeating through all levels of the organisation. I suspect one of the reasons the report has taken so long (too long) is the complex interactions between the multiple failures that conspired to end with the loss of an experienced SAR crew and highly capable modern helicopter.

[SASless]

We might remember all the Stake Holders who get to challenge the Findings before the Report is published.....that puts into motion a process where covering one's hind end becomes both possible and convenient.

[megan]

There seems to be some mis-identification by the PilotsThat pertains to a question I have SAS. The co-pilot calls a small radar target at six miles eleven o'çlock and a large to the right, with no range to the latter, was it six miles as well? What intrigues me is that at the speed they were doing, 75 KASI, from the time of the radar call to crash would indicate a distance of point six of a mile, or there abouts. Miss call of the range?

[[email protected]]

There were many slices of swiss cheese where the holes shouldn't have aligned but that last one was the operating crew, presumably following their SOPs (Ops manual).

It was, in the final analysis, a relatively straightforward night letdown over water in a very capable helicopter and they hit the only high ground for several miles in any direction.

£40K worth of NVG would have saved a £30+ Million helicopter and 4 lives.......................

[SASless]

Crab is right on that....nothing beats being able to see in the dark as compared to not being able to see in the darkl

The ability to see "white" light sources, no matter now small, at great distances is amazing.

Even the ability to see unlighted objects is astounding!

[megan]

crab, I have absolutely no idea of system capabilities, but the aircraft had High Definition Electro-Optic and Infrared (EO/IR) Camera System, and the front seat crew were able to view if selected. Would NVG be more capable?

[Search&Rescue]

crab, I have absolutely no idea of system capabilities, but the aircraft had High Definition Electro-Optic and Infrared (EO/IR) Camera System, and the front seat crew were able to view if selected. Would NVG be more capable?

NVG will be more capable and more useful... both pilots can e.g.
https://cimg2.ibsrv.net/gimg/pprune.org-vbulletin/2000x1504/193aa8fd_6c7a_49c6_b0dd_ac2949a03e3a_7606c35d4beb0dd0462c094 89fdcc1b527fa5430.jpeg
https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/2000x1504/83610e4d_ca88_40a8_9dfc_1443b5701889_6fa80ad4c7f30e536ebf7e0 41c20337f93e98f8e.jpeg
scan different directions and the view is not restricted to aircraft heading or to that direction which the camera is pointing...

[Search&Rescue]

I agree and share your thoughts Crab, but I think that the ”radar set up” was also one key factor in order to avoid this sad accident...

I’d like visualize my thoughts with some hypotetic radar pictures (taken from AW139). Btw. The red radar echo is a faulty echo from radar radome,
which seems to be at approximately 0,4 NM distance with WX mode.

If the radar was on 10 NM scale/WX mode it will be almost impossible to detect the targets, when they appear closer than 0,5 NM.

[SASless]

Seeing visible light sources is where NVG's really perform.

I have watched Airliner Strobe and Landing lights for aircraft landing at Atlanta.....from Augusta......about 150 miles away on a clear night.

Star gazing from the helipad at a remote site was breath taking.

Something as small as a cigarette shows up like a beacon.

If the Light House light was working that night....it would have been a very bright point of light and very easy to see if the aircraft was clear of cloud.

[[email protected]]

Beat me to it S&R:ok:.

Megan, the best solution is for the front crew to be on NVG and have a radar picture on an MFD and for the rearcrew to monitor radar and FLIR on their screen - that way all the bases are covered and with some overlap.

FLIR is excellent but relies on thermal contrast to detect things - it doesn't work in fog or cloud and rain degrades the picture too (the moisture tends to attenuate much of the thermal energy and greatly reduces contrast.) You also get periods of thermal washout/crossover when the background is radiating the same energy as objects in the foreground.

[Search&Rescue]

https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/640x480/163f65c7_23ab_4ad8_84c0_f2be0154ff5e_15d56edfd4b10b396a52dbb aa1e054eed333e0f5.jpeg
5 NM scale
https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/640x480/9e46e229_629a_42f1_9722_a94b066f98ed_e0e0559bcc197737262b237 e2b3e6fb327468e07.jpeg
2,5 NM scale
https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/640x480/027e2735_3048_4448_aebc_ea0b2b3f8661_9439e9ddf273ec45b62981e d2f1fb07cca1a6013.jpeg
1,0 NM scale
https://cimg2.ibsrv.net/gimg/pprune.org-vbulletin/640x480/bf5b5465_d7d7_43f0_a33f_71e4f117216b_6cd2a86e0ed0304f854b99e ff050e149320df55f.jpeg
0,5 NM scale

[[email protected]]

S&R - very good point re the radar scale.

[SASless]

Which Mode would you have the Radar set to for detecting terrain/obstacles ahead of you?

[Search&Rescue]

Which Mode would you have the Radar set to for detecting terrain/obstacles ahead of you?

GMAP2 (and WX/RCT for weather scanning). It will be quite easy to toggle between the modes, if you are using Autotilt e.g. with
WX PRIMUS P701 Radar...

[MightyGem]

Seeing visible light sources is where NVG's really perform.

https://www.youtube.com/watch?v=WkwptuBAt6Y

[BluSdUp]

Sort of understandable if the report is critical of the crew members who aren't here to defend themselves.
Sorry Crab, I disagree.
Some 70% plus of accidents are caused by crew, CFIT even higher.
It is urgent to get this report out as it will also reveal a large amount of recommendations for this specific company and Irish SAR and IAA, I suspect.
I do feel for the Crew and the relatives, but that is no excuse for us to enter year 4 without a final report.
Regards
Cpt B

[[email protected]]

Sorry Crab, I disagree.
Some 70% plus of accidents are caused by crew, CFIT even higher.
It is urgent to get this report out as it will also reveal a large amount of recommendations for this specific company and Irish SAR and IAA, I suspect.
I do feel for the Crew and the relatives, but that is no excuse for us to enter year 4 without a final report.
Regards
Cpt B
I wasn't suggesting they should be protected from criticism but their families would be considered stakeholders so naturally they would try to limit such criticism from the final report.

[SASless]

The" criticism" of the crew should be fair, based upon straight facts, and carefully consider the related factors and actions/in-actions of other persons, agencies, and authorities.

They are not to be the scapegoats in this tragedy.

[Franks Town]

The sister of the Aircraft Commander is about to release a book dealing with her grief post the accident.
Available online for March 1st .Just before the 3rd anniversary. Tell Me the Truth About LossA Psychologist's Personal Story of Loss, Grief and Finding Hope.

[Red5ive]

Review board to examine R116 crash report

A review board has been established to examine the draft final report into a Coast Guard helicopter crash three years ago.The Minister for Transport Shane Ross has announced that certain findings made by the Air Accident Investigation Unit (AAIU) will be re-examined, at the request of one of the parties subject to the investigation.

The Review Board will be chaired by Senior Counsel Patrick McCann who will be assisted by an independent Expert Member. The Review Board will be entirely independent in its work in accordance with the relevant legislation.

https://www.rte.ie/news/connacht/2020/0311/1121693-review-r116-report/

https://www.gov.ie/en/news/803d53-establishment-of-a-review-board-to-re-examine-certain-findings-of-th/

https://www.irishtimes.com/news/ireland/irish-news/rescue-116-crash-report-findings-to-be-re-examined-1.4200241

[Just a spotter]

3rd anniversary of the loss of 4 crew aboard R116

https://www.thejournal.ie/rescue-116-crash-irish-coast-guard-5046281-Mar2020/

JAS

[airsound]

I thought the rather lovely Coastguard R116 heart would look better the right way up.... RIP

https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/323x276/r116heart_3591df098e3a0626146b25fd5ba9c535a470b43f.png

airsound

[LZ4]

R116 accident review faces new delay after UK expert resigns

www.rte.ie/news/ireland/2020/1008/1170350-r116-review/

[Northernstar]

4 years tonight. Still no report. Still no accountability. Families still demanding answers.

[[email protected]]

Disgraceful

[gulliBell]

4 years tonight. Still no report. Still no accountability. Families still demanding answers.
Wasn't the report delayed because the family didn't like the answers?

[212man]

Wasn't the report delayed because the family didn't like the answers?
Probably. Doesn’t matter how much window dressing you use around company SMS, training, maps, EGPWS database etc etc, when a crew flies a serviceable aircraft into a large rock, in VMC, that is detectable on radar, it’s unlikely the findings will come out in their favour

[megan]

it’s unlikely the findings will come out in their favourThe vast majority of accidents come about because of decisions made in the cockpit, the question is why they made those decisions, if we just hang it on the crew we learn nothing. Management prefers that all fingers point to the crew.

[[email protected]]

Management prefers that all fingers point to the crew. But sometimes that is the cause, despite mitigating circumstances - poor decision making.

[megan]

As I hinted crab, why the poor decision? No one, at least very few, set out to screw the pooch.

[SpyPilot]

Would the NTSB Final Report on N76EX being released some 54 weeks post crash be an unfair comparison?

[[email protected]]

Feeling too comfortable following a legacy procedure instead of using the aircraft's actual capability perhaps Megan - you can ask why as much as you like but in the final analysis, as 212 man says, they flew into a rock that they shouldn't have at an altitude they had no necessity to be at at that point.

Standard Operating Procedures are 'handrails not handcuffs' as our SAR Standards use to say - you get paid the money to keep the aircraft and crew safe as your primary objective.

[jimf671]

... ... when a crew flies a serviceable aircraft into a large rock, in VMC, that is detectable on radar, it’s unlikely the findings will come out in their favour

That is certainly true.

What is also true is that there are elements of this that go all the way up through CHC management to the Coastguard and to Ministers. Wasn't there a minister a few years back bragging to the Brits about how cheap the Irish service was. In part, it was cheap because the technical requirements were the same rubbish that the Brits had been using in their inadequate contracts for 40 years and had now abandoned. CHC need to keep their people safe and legal no matter what the contract says and there may be questions to answer there. In the next two years, new contracts will evolve on both sides of the Irish Sea and let's hope both achieve the highest standards.

But yes, aircraft, large rock, pretty clear.

[212man]

The vast majority of accidents come about because of decisions made in the cockpit, the question is why they made those decisions, if we just hang it on the crew we learn nothing. Management prefers that all fingers point to the crew.

Megan, I fully understand that and I have been formally trained in air accident investigation at a well known institution. However, I have also spent enough time in cockpits, and simulator instructor operating stations, to know that at some point there is a limit to how diluted and shared the accountabilities can be made, in some incidents.

[megan]

Feeling too comfortable following a legacy procedure instead of using the aircraft's actual capability perhapsWould that not point to SOP's needing revision?

[[email protected]]

Would that not point to SOP's needing revision? Yes of course and that is one of the many mitigating factors in this accident but you had an experienced crew that knew they were using an old S61 procedure when they could have just used the aircraft's far higher capabilities instead. A radar letdown over the sea to position to a coastal site isn't difficult, especially with all the sensors and a very capable autopilot.

[Wide Mouth Frog]

And maybe more importantly, when the guy in the back tells you you're flying towards a rock, you take immediate avoiding action rather than engaging in an elaborate two crew pas de deux.

[Watson1963]

Fourth Interim Statement: Accident Sikorsky S-92A, registration (EI-ICR) at Black Rock Co. Mayo, 14 March 2017 at 00.46 hrs | AAIU.ie (http://www.aaiu.ie/node/1513)

[[email protected]]

Ridiculous - presumably this has all got caught up in legal wrangling so that nobody gets any closure.

[megan]

could have just used the aircraft's far higher capabilities insteadcrab, an article quoting a mate of 212man, it will be an interesting report to see if it may come under the misuse of automation or lack of standardised procedures procedures ie SOP's as I previously mentioned. It seems the helo industry has been slow to learn from the airline industry if Cramp's last statement in the quote is any indication. The airlines consider SOP to be handcuffs and and on board systems will snitch if you transgress, surely SAR can go about its business with handcuffs rather than handrails. I appreciate you have to hang it out further and take a bigger bite of the cherry than other operators, but without guidance and leaving it up to the crew on the day to determine limits one should not be surprised when thinks & things go pear shaped. As I understand it airlines even dictate what the PF & PM have up on their screens for the particular stage of flight - T/O, cruise, landing. Wonder if that could be a possible issue with this accident, and would a TAWS have provided last chance warning?Safety working groups have focused on accident causes—such as controlled flight into terrain, loss of control because of crew interaction or mismanagement in the cockpit, or aircraft system failures and reliability— and identified means to mitigate them. Among the mitigations is the development of standardized procedures on the use of aircraft systems automation as defined in the flight crew operating manuals (FCOM) drafted by the OEMs. Such documents, though standard in the fixed-wing world, are relatively new to the helicopter industry, which had allowed operators to develop their own procedures. This led to some misuse of automation that resulted in safety incidents. Many of the large and medium helicopters used by the offshore industry have now had FCOMs written for them, in part thanks to the efforts of HeliOffshore.

“A lot of what we’ve done over the years has been replicating the practices that have made the airline industry so safe,” Cramp says.

https://aviationweek.com/forum/aerospace-defense/long-term-contracting-could-help-offshore-industry-renew-fleets?utm_rid=CPEN1000000180327&utm_campaign=27517&utm_medium=email&elq2=04b7788e3dbe48f4966f2293489d2236

[[email protected]]

That link doesn't seem to work Megan.

Airline work is very predictable with risk mitigated to the lowest level - as you would expect as a passenger - they can have standard procedures for pretty much everything, they take off, they climb, they cruise, they let down and they land, not much more too it.

Many pax carrying helicopter operations work the same way for the same reasons.

SAR is different, unpredictable, dynamic in nature and often involves flight in hazardous regimes and conditions. That doesn't mean the crews shouldn't apply SOPs and they certainly should know how to effectively manage their automation.

I'm sure there are some things in this accident you can blame the company ethos and training for but this wasn't a newbie crew - I haven't read their SOPs for poor weather/night letdowns over the sea but I would hope it includes having the radar on a screen in the front as well as the back.

We also come back to the lack of NVG - unforgiveable in my view for modern SAR - but correct use of the kit on the aircraft would have saved the day, as would prompt response to the warning from the cabin.

An airline pilot would be castigated for grabbing the controls and hauling the aircraft into a turn but that is what was needed with this late spot - they were slaves to the automation in this case and it cost them their lives.

[gulliBell]

...Wonder if that could be a possible issue with this accident, and would a TAWS have provided last chance warning?

In pre-TAWS days pilots looked out the window when operating below LSALT in VMC to avoid flying into anything. It should be the same today. No hand-cuffs or handrails needed, only basic airmanship.

[[email protected]]

They had TAWS but ISTR from the report that the configuration they had (wheels down I think) effectively muted a TAWS mode that might have saved them.

The other crucial issue is that if the rock isn't in the TAWS database, it won't warn you of it.

[megan]

The other crucial issue is that if the rock isn't in the TAWS database, it won't warn you of itThe rock wasn't in the data base, the prelim report discusses at some length.In pre-TAWS days pilots looked out the window when operating below LSALT in VMC to avoid flying into anything. It should be the same today. No hand-cuffs or handrails needed, only basic airmanship.They were at 200', weather forecast 300 - 400' overcast, vis 2 - 3 km with mist and drizzle. The rock was known locally to be prone to being shrouded in mist.We also come back to the lack of NVG - unforgiveable in my view for modern SAR - but correct use of the kit on the aircraft would have saved the day, as would prompt response to the warning from the cabinI'm not familiar with all this high tech stuff crab, the following is what the aircraft was fitted with, is it comparable to NVG?High Definition Electro-Optic and Infrared (EO/IR) Camera System Thehelicopter is equipped with Wescam MX-15i EO/IR Camera System with integrated Spectrolab Nightsun XP searchlight system. Electro-optic and infrared imagery can be viewed at the Winch Operator’s station in the cabin and can also be selected for viewing in the cockpit if the pilots require it. The Avalex AVR-8240-XM digital video recorder provides the capability of recording video from the EO/IR camera and is installed in the SAR Operator’s console.That link doesn't seem to workWorks here crab, even by copy and paste. Here it is.Long-Term Contracting Could Help Offshore Industry Renew FleetsTony Osborne March 15, 2021

Shell’s arrangement with PHI and Airbus to use the H160 in the Gulf of Mexico is a significant endorsement of Airbus’ newest medium helicopter. Oil and gas support was one of the key target missions for the aircraft during development.New approaches to longer-term contracting could be a bellwether for accelerating the introduction of new technology and new fleets to the offshore helicopter industry.

New fleets of helicopters are not at the top of the priority list for offshore helicopter operators today. More than five years of low oil prices have burdened them with a surplus of helicopters and leases that have tipped some of the biggest operators into bankruptcy.


H160 will begin offshore duties in Gulf of Mexico this year
HeliOffshore has developed guidance for operators in the wind farm support business

The pandemic has not helped either. Although offshore operations have not been ravaged as badly as the commercial airline industry has, demand for flights has fallen. Operations have been running at 75-80% of what they were in 2019 due to reduced crew sizes on offshore platforms.

The upcoming introduction of Airbus’ new H160 twin-engine helicopter to the Gulf of Mexico appears to buck the trend. Petroleum Helicopters Inc. (PHI) is due to debut one H160 on route-proving flights this year, and another three will join the fleet in 2022, when they will operate on behalf of Shell.

The H160’s entry into the oil and gas market is the result of a joint initiative between the OEM, PHI and Shell to bring in a new platform with enhanced safety features, lower operating and maintenance costs, and a reduced carbon footprint.

Most crucially, however, the aircraft will be introduced on a 10-year-long contract, rather than traditional 3-5-year-long deals, Tony Cramp, vice president of aircraft at Shell tells Aviation Week. “You will not find many 10-year contracts for [offshore helicopters] at the moment,” Cramp explains.

“Longer-term contracts provide the stability for the operators to obtain better credit rates for themselves,” he says. “And that is a key element of how we have been able to take this on. That probably needs to be a feature going forward, to enable operators to bring in new technology.”

Types such as the H160, Bell’s Model 525 Relentless and Sikorsky’s S-92A+/B and super-mediums like Airbus’ H175 and Leonardo’s AW189 are part of a new generation of rotorcraft within the industry that should further enhance offshore flight safety.

The Bell 525 brings with it fly-by-wire flight controls, the H160 introduces a vortex-ring-state warning system and a recovery device that returns the helicopter to stable-level flight, and Sikorsky is planning to introduce new main gearboxes and additional automation in the cockpit of the upgraded S-92.

Such technologies can reduce pilot workload and address some of the primary causes of accidents offshore.

But new fleets of helicopters are not cheap. Until sustained growth supports investment or until new initiatives, such as the one for the H160, gain momentum, the industry will continue tightening cooperation, sharing data and working on incremental steps to bolster flight safety through organizations such as industry safety body HeliOffshore and the International Association of Oil & Gas Producers (IOGP).

After a series of fatal accidents in the North Sea between 2009 and 2016 shook the industry, safety performance is now “heading in the right direction,” says Cramp, who is also chairman of the IOGP Aviation Committee.

“More and more companies and operators are adopting the best practices, and what’s important for the operators is that the contracts that we give them require and pay for these processes,” Cramp says. “We’ve got to incentivize the practices and make sure they’re resourced properly, throughout the industry, to be effective.

“Money is tight right now . . . and that has been exacerbated through the events of the last year,” Cramp notes. “So the ability to pay for improved safety is obviously challenged at every point, and we have to be very careful about making the business case for each of these.”

Safety working groups have focused on accident causes—such as controlled flight into terrain, loss of control because of crew interaction or mismanagement in the cockpit, or aircraft system failures and reliability— and identified means to mitigate them. Among the mitigations is the development of standardized procedures on the use of aircraft systems automation as defined in the flight crew operating manuals (FCOM) drafted by the OEMs. Such documents, though standard in the fixed-wing world, are relatively new to the helicopter industry, which had allowed operators to develop their own procedures. This led to some misuse of automation that resulted in safety incidents. Many of the large and medium helicopters used by the offshore industry have now had FCOMs written for them, in part thanks to the efforts of HeliOffshore.

Work has also led to a bespoke rotary-wing terrain awareness and warning system (TAWS), which now equips Leonardo’s AW139 and will soon be used on other types.

Both FCOMs and the new helicopter TAWS (HTAWS) are deemed minimum requirements in new IOGP guidance, published in late 2020, on aviation standards for energy companies. IOGP Report 690: Offshore Helicopter Recommended Practices also calls for the use of safety management systems and states that offshore helicopters should have cameras in the cockpit and on the tail as well as obstacle warning systems and that aircraft should be certified to the most recent standards.

“A lot of what we’ve done over the years has been replicating the practices that have made the airline industry so safe,” Cramp says.

Although data suggests a recent positive trend in safety performance, the industry cannot “rest on its laurels,” says Tim Rolfe, CEO of HeliOffshore. He says work needs to be done to better understand how the implementing of new processes and procedures affects overall safety. “How do we make sure that recommended practices are effectively incorporated into the aviation system?” Rolfe asks. “That needs to be done deliberately. It is easy to assume that these things will happen either voluntarily or just as a factor of time, but actually we want to be a little bit more deliberate than that.”

Beyond developing FCOMs and HTAWs, HeliOffshore’s work groups are creating a series of “leading indicators” to understand safety performance better. They are also using a methodology called human hazard analysis (HHA) to ensure that the design of technical systems does not provoke errors during maintenance, with a particular focus on the elimination of catastrophic system failures.

“This is a real game changer for the helicopter industry,” Rolfe says. “But while we are talking about HHA at a design level, you can apply the same philosophy to cockpit design or extend further to pilot training.”

Other areas of work for Heli-Offshore include preparation for the introduction of fly-by-wire platforms such as the Bell 525, which the OEM hopes to introduce into the market this year, and looking at how the new era of electric vertical-take-off-and-landing (eVTOL) aircraft could also influence offshore operations.

“We’ve got to keep our eye on the emerging technology, making sure that all operators within the aviation system are appropriately trained and supported to manage operations safely, particularly where manned and unmanned aircraft share the same airspace,” Rolfe says.

In the UK, several offshore operators are already supporting—or aiming to expand in—the offshore windfarm sector. CHC Group has bagged contracts to support construction of windfarms off Scotland. Babcock has been using small helicopters to hoist down engineers to wind turbines since 2011. And Bristow has described getting into the windfarm support market as a “strategic priority.”

Analysis by Air & Sea Analytics suggests the offshore windfarm helicopter fleet will expand to about 126 aircraft by 2030 from 27 aircraft today, but the task, particularly that of winching down engineers, will be limited to small and medium-size rotorcraft such as the Airbus H145 and Leonardo AW169.

Recognizing the shift toward wind farm operations, HeliOffshore has worked to develop a series of recommended practices for safe helicopter operations. Working in conjunction with the G+ Global Offshore Wind Health and Safety Organization, it has drafted a document that provides guidance for aircraft operations, performance, equipment and procedures.

Despite the rush toward a net-zero carbon-emission world, demand is unlikely to let up for offshore helicopter operations. The big energy companies are using oil and gas revenues to fund their energy transition. There is, however, less focus on going farther offshore; instead, energy companies are looking to explore within existing fields and using new technologies to extract reserves that previous technology could not reach. And they will need helicopters to help decommission platforms some day.Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying together.

[jeepys]

"Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying together."

This is not unusual in small two crew operations. Good CRM training should render this quote as immaterial to the incident, however, that is assuming good CRM practices were evident in this case which I am not entirely sure were. Apart from the other pilot, there are also two tech crew members that all play a pivotal part in the CRM mix.

[[email protected]]

The rock wasn't in the data base, the prelim report discusses at some length. that was exactly my point.

They were at 200', weather forecast 300 - 400' overcast, vis 2 - 3 km with mist and drizzle. it was dark!

I'm not familiar with all this high tech stuff crab, the following is what the aircraft was fitted with, is it comparable to NVG? Infra-red doesn't see through cloud, and rain washes the temperature differential away. They should have had IR and NVG - when flying at night without NVG in those conditions there is little point looking out of the window - with NVG's on you will be scanning ahead visually as well has having IR and radar to back you up.

There is no doubt in my mind that they wouldn't have hit the rock if they had been equipped with NVG.

Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying together. I agree that this was probably part of the CRM issue.

[rotorspeed]

It is important to remember that ultimately responsibility for this avoidable accident is going to come down to the actions of individual persons, be they flight crew, operations personnel, or people in management positions. And from currently available information it is very hard to see how the flight crew of R116 (x-apple-data-detectors://0) are not going to be primarily culpable.

The first choice the commander made was to use the APBSS approach to Blacksod, and one has to ask why. What sort of approach was it? What was it for? If it was intended as an IMC let down procedure, what was the MDH and where? The information in the Preliminary Report didn’t make any reference to any such information. Before departure from Dublin the crew clearly should have established what the nature of this approach was and whether it was suitable for their approach to Blacksod that night. The forecast weather was poor – they should have been expecting the 300-400ft cloud base and 2-3km visibility it probably was. And at night. The APBSS approach chart had 282 by the first BLKMO (Blackrock) waypoint, and the approach accompanying notes identified Blackrock lighthouse with a height of 310’. The lack of a database entry is a red herring – the world is too big and too prone to change at low level, whether with wind turbines, vessel masts or anything else up to 500ft, for databases to be relied on outside IFR approaches. As it said on the tin.

So how could the crew of R116 have thought it was a good plan to let down to 200ft in those conditions and head towards this first waypoint, level at 200ft? And even more bizarrely, when this point was 10 nm from their destination? The commander’s understanding of the terrain seems inadequate – she knew there was an island there as she commented on it when the crew got an altitude alert 26 seconds before impact. However the rocks they were flying over that triggered the alert were not Blackrock, but some lesser rocks 0.65nm before. So it seems she knew that BLKMO was not just a point in space, but an island landmark, presumably of - to her - unknown height, yet she still planned to fly over it at night in pretty much IMC conditions at 200ft….. It seems that had the flight crew read the approach notes, they would have realised that the island BLKMO had a height of 310’ Or 282’ had they interpreted the chart number as a height - which surely any sensible person would have done, certainly until proved otherwise.

Admittedly it also appears that the approach information was not sufficiently clear and comprehensive, which was largely an operators’ responsibility. But why descend to 200ft? Was it because the APP1 mode on the AFCS they had available did this by default? Did they follow a poor procedure not designed for the task that night with a recognised AFCS mode without adequate thought and consideration? Seems likely to me.

As several have said too, the other major pilot error was the reaction to the recognition by the rear crew member of Blackrock island, by maybe radar or IR, and instruction to avoid. Transiting at 200ft above the sea on a misty night over known rocks should have had the crew on high alert, yet the whole process of observation, identification, course change instruction and implementation was far too slow and vague. From the avoid instruction, to hitting Blackrock. took 13 seconds. Allowing say 3 seconds pilot reaction time, that gives 10 seconds to effect immediate emergency avoiding action. The fastest way to do that would have been to uncouple and instantly either climb at say 1500ft /min, or bank at say 30 degrees. But it took a fatal 10 seconds of questioning and double checking before the heading bug was turned and the aircraft reacted, and by that time it was all over. With a climb at 1500ft/min they would have cleared Blackrock by 150ft if they’d gone straight over it. Or missed it with an immediate turn. Or a combination of both.

Something that I have never seen discussed is just how the Sligo primary mission S92 approached Blacksod for fuel, an hour or so before. It had the same operator and same aircraft. One assumes that whatever they did worked fine, in which case why did R116 not do the same thing? Or even discuss the approach with R118 before they set off, if R116 was not familiar?

Overall, there will always be situations, in SAR surely more than anything else, when SOPs will not cover the task in hand, or be appropriate, or things will just go wrong for all sorts of reasons. And in these cases we need crews to be able to think intelligently and make sensible decisions that are likely to involve basic flying skills that we learn in our early training, whether VMC or IMC. It is important this is realised, pilots preserve these skills and are open minded to implement them when necessary. And – yet again – not just follow the magenta line.

[212man]

And – yet again – not just follow the magenta line.

I don't want to get into a full blown automation conversation, but I did point out a potentially salient fact pretty early on on the subject of 'magenta'. Black rock was a waypoint, so would have been displayed as a magenta 'star' shape on the route, on the navigation display, with its name alongside. If the crew had the Wx RADAR in mapping mode, the return for the rock would also have been magenta. If the range selected was large enough to include Blacksod (the destination), there is a very good chance that the radar return would have been small and therefore masked within the star shape. If the range had been scaled down the radar return would have been larger and would have 'grown' outside the confines of the star. So, questions around the use of Wx Radar are likely to be far more relevant than what was in the EGPWS database - which is largely a red herring, as rotorspeed implies.

[Franks Town]

"Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying together."

This is not unusual in small two crew operations. Good CRM training should render this quote as immaterial to the incident, however, that is assuming good CRM practices were evident in this case which I am not entirely sure were. Apart from the other pilot, there are also two tech crew members that all play a pivotal part in the CRM mix.
Sorry Jeepys that's incorrect. The co pilot was a line Captain and was never a Chief Pilot. The PIC on the night was an ex Chief Pilot of another base and the roster writer for all SAR pilots in Ireland.

[[email protected]]

I think they just took the easy option - a company let down procedure which was a legacy from the S61 days - perhaps because they were at a low arousal as they weren't on an actual rescue themselves.

Having chosen the easy option, they then didn't execute it well.

[Northernstar]

As has been mentioned before why was the aircraft so low so far from final destination. All modern 4 axis sar autopilots are designed to avoid such a scenario.
Does this reflect poor SOP’s?
These aircraft came from the company’s U.K. contract prior to Bristow takeover.
Was there not training and appropriate sharing of information or mentoring?
If there was how was it received or was there complete dismissal and a ‘know it all’ cavalier attitude?
Why have some ex U.K. sar or ex raf crew joined and promptly left again since?
Is it true to read from the transcript that Irish rear crew do not participate anywhere near as much in the flying role outside of on scene evolutions than U.K. or Scandinavian counterparts?
Do Irish crews train appropriately in low level IF, rear crew conned approaches to targets, Flir led transits?
Generally what are standards for CRM? Is a sub 90 minute lecture to 20 people from an off duty ryanair pilot enough as has been mentioned previously?
According to their company press releases their new manager of crew training is a candidate with no civilian or s92 experience and no all weather sar such as would be required. Though is it the aviation authority who have clearly washed their hands from the morning after this accident took place who approved such an appointment?
Overall will anything change or have changed?
Will there be any admission of errors other than blame on the crew in question?
Are relevant government departments or the contracting agency aware of potential shortcomings and their avoid-ability if true?

[[email protected]]

Lots of questions Northernstar - a journo looking for a story?

[megan]

it was darkFailed to mention that salient point, given the weather though I think it could be rather moot, they obviously didn't see the loom of the light.The APBSS approach chart had 282 by the first BLKMO (Blackrock) waypoint, and the approach accompanying notes identified Blackrock lighthouse with a height of 310’The discrepancy would be explained by the lighthouse data which gives 282' as the height of the focal point of the light itself, while 310' would be the the top of the light house.

[[email protected]]

they obviously didn't see the loom of the light. Had they been wearing NVG, even in that weather, they would have seen it.

[Franks Town]

[QUOTE=jeepys;11013142]"Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying ]


That’s incorrect . The co pilot on the night was not the chief pilot of the Dublin base and never was. The PIC however was a former chief pilot of a different base and at the time the roster writer for all pilot rosters in Ireland .

As for CRM issues the only indication that there may have been a n issue is a quote from the 30 day interim report stating all comms from the crew where mission focused. I’ve never been in a SAR job where all comms revolved around the mission . Especially at that time of night.


Also the familiars did not initiate the review of the draft report CHC did.

[gulliBell]

And given they couldn't see where they were going suggests they shouldn't have been there in the first place. If you don't have the required visual reference for VMC you are IMC and follow the IFR procedures.

[havick]

[QUOTE=jeepys;11013142]"Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying ]


That’s incorrect . The co pilot on the night was not the chief pilot of the Dublin base and never was. The PIC however was a former chief pilot of a different base and at the time the roster writer for all pilot rosters in Ireland .

As for CRM issues the only indication that there may have been a n issue is a quote from the 30 day interim report stating all comms from the crew where mission focused. I’ve never been in a SAR job where all comms revolved around the mission . Especially at that time of night.


Also the familiars did not initiate the review of the draft report CHC did.

Is the CP of a base just a badge of honor thing or is it a regulatory position holder?

[Scattercat]

Had they been wearing NVG, even in that weather, they would have seen it.
Exactly Crab. I still struggle to understand how this organisation allowed this technology and capability to go unused.
Does anyone know if they are using NVG now?

[Northernstar]

Also if they are or have attempted to use NVG who delivered the training course and was there a competition? In a previous post it was mentioned how a sar captain was recruited from UKSAR for just such a function and promptly left again. Why so?

[[email protected]]

A chum of mine was working for them for quite a few years on S61 and then S92 - an ex mil NVG instructor who wasn't selected to train crews because he wasn't Irish, they wanted to keep it in-house despite not having the experience to do so.

This was over 10 years ago and since then they haven't managed to introduce what is very basic technology by modern standards. I don't know if it is the Irish CG, the IAA or CHC who have dragged their heels but someone has questions to answer sending crews out for night SAR without NVG.

I hope they have them now.

[jeepys]

A chum of mine was working for them for quite a few years on S61 and then S92 - an ex mil NVG instructor who wasn't selected to train crews because he wasn't Irish, they wanted to keep it in-house despite not having the experience to do so.

This was over 10 years ago and since then they haven't managed to introduce what is very basic technology by modern standards. I don't know if it is the Irish CG, the IAA or CHC who have dragged their heels but someone has questions to answer sending crews out for night SAR without NVG.

I hope they have them now.

One would expect that lack of NVG's would have been an early finding in this investigation and therefore implementation of this would have been an urgent if not at the very least sensible thing to do. I do hope they are NVG now as there is no excuse after four years on.

[jimf671]

... ... who wasn't selected to train crews because he wasn't Irish, ... ... ..

The way it used to be done was slipping Ordinary pass in Gaeilge into the job spec. Allegedly.

[Hot_LZ]

I believe they have nothing more than a threadbare NVG capability. By this I mean a few of the aircrew at 1 base. It may have expanded since I was last informed.

LZ

[megan]

Had they been wearing NVG, even in that weather, they would have seen itNot sure how you can be so certain in your judgement crab with the islands reputation for being shrouded in mist, all I would say is NVG may have helped. Mist means the vis is greater than 1 km, the presence of drizzle in a weather forecast usually indicates significantly reduced visibility, how much reduced in this case we have no idea. I know from vast experience that weather reports when trying to operate in VMC are a crutch you shouldn't rely upon implicitly, nor when legally in the clouds for that matter. Bow to your experience in using the things crab, been reading on the NVG limitations,Pilots wearing NVGs may be able to see through some areas of low density particles such as thin fog, light rain, low density smoke, dust and pollution (Joint Aviation Authorities 2003). Flying in these conditions may reduce the usable energy available to the NVG and decrease the quality of the image (RTCA 2001b). These conditions will affect the contrast of the image. The risk that low density particles pose to an operation can be reduced by training pilots to recognise changes in the NVG image, ensuring thorough weather briefings before flight with an emphasis on NVG effects, ensuring pilots are aware of weather patterns in the flying area, and ensuring pilots occasionally scan the outside scene unaided (RTCA 2001b).http://www.atsb.gov.au/media/36432/Night_vision_goggles.pdf

Over and out, waiting for the report.

[[email protected]]

Megan, it certainly wouldn't have been a great goggle picture in those conditions but even in very low light levels they are far better than the human eye and, with a visibility of 1 km, they most certainly would have seen the rock and definitely seen the lighthouse beam.

Like many ex-mil people, I have used NVG in ridiculously low light levels - sometimes referred to as 'Red Illum' - and they still work and you would always want them instead of the naked eye.

I have also used them extensively over the sea and coast in similar and far worse weather to the accident crew and, only if you completely enter cloud, do you not need your goggles.

When worn correctly, you are able to look under the goggles to see your instruments, including MFDs with map, weather and radar information and then lookout through the goggles - best of both worlds and exactly how they should have been operating that night.

You can read all you like in a report but the only way to really appreciate NVG is to use them.

[megan]

Back to be a pest crab, and hopefully learn some thing about these new age gizmos.

The aircraft was fitted with a Wescam MX-15i EO/IR Camera System. Would NVG's provide greater capability, and in what way? Would use of the Wescam provide adequate warning given the forecast weather, if not, why not?

Thanks crab.

[[email protected]]

No problem Megan - in that scenario you would hopefully have the camera facing forward and being monitored - I would have to re-read the report but ISTR that is where the rearcrew warning about the rock came from, they were monitoring the IR picture in the cabin.

The IR picture in rain suffers because of thermal washout - it relies on the thermal contrast of emissions between different surfaces - the rock and the sea for example - to detect shapes and this is affected by rain and cloud.

NVG is different, it need light to amplify and produce an image on the screen in the goggles, so as long is there is some light, you will get a picture even if it is very speckly and low contrast.

This crew had radar, which it would seem they didn't have optimised for the scenario, IR which I think did detect the rock very late but didn't have NVG which in the described conditions would have forced them to lookout because they were wearing them and detected the rock and light house.

[[email protected]]

Megan, to elaborate further - the sensor on the IR element of the camera is cooled to around -200 deg C and is very sensitive to received emissions in the appropriate band.

The level of radiated emission of an object is the total of what it transmits, what it reflects and what passes through it which is why it is too simplistic to talk about the temperature of an object.

If the total emissivity of foreground and background objects is the same then you can't tell one from the other - this is called thermal crossover and can really hamper searches.

Rain and the moisture in clouds attenuate the amount of radiation travelling from the object to the sensor so degrading the picture by reducing contrast.

Hope that helps.

[Scattercat]

Back to be a pest crab, and hopefully learn some thing about these new age gizmos.

The aircraft was fitted with a Wescam MX-15i EO/IR Camera System. Would NVG's provide greater capability, and in what way? Would use of the Wescam provide adequate warning given the forecast weather, if not, why not?

Thanks crab.

I'd add further, that from a human factors perspective, we build a much better picture (situational awareness) from what we see directly with our eyes, as opposed to what and how we interpret images or information on a screen. Hence, even in these poor visibility conditions, viewed through NVG's they would have received and processed a much clearer and quicker picture of their situation. Low level, low visibility flying requires the use of all available inputs from Mk 1 eyeballs, navigation instruments, radar & of course, other crewmembers.

[[email protected]]

Good points Scattercat :ok:

[llamaman]

I'd add further, that from a human factors perspective, we build a much better picture (situational awareness) from what we see directly with our eyes, as opposed to what and how we interpret images or information on a screen. Hence, even in these poor visibility conditions, viewed through NVG's they would have received and processed a much clearer and quicker picture of their situation. Low level, low visibility flying requires the use of all available inputs from Mk 1 eyeballs, navigation instruments, radar & of course, other crewmembers.

I'm not entirely convinced by that argument Scattercat. You best derive Situational Awareness from your most effective inputs at that time. It could be naked eye, or it might be the sensor that's currently working best for you (or a blended solution). All this has to be underpinned by good CRM and appropriate procedures otherwise you are permanently on the back foot.

[albatross]

How about the old ARA rule of thumb “Don’t overfly at less than 1500’ any radar target you have not positively identified.”

[[email protected]]

How about the old ARA rule of thumb “Don’t overfly at less than 1500’ any radar target you have not positively identified.” we used 1000' in the UKSAR force but if you haven't seen the contact, you can't apply that rule.

The problem wasn't only that they didn't detect the threat until very late but that the reaction was so slow - it was done like a routine turn at a WP - the PF acknowledges that a turn is required, then asks the PNF to adjust the heading bug, then the heading bug gets moved and finally the aircraft starts to turn.

Use the automation by all means but be prepared to take immediate action when it is - as it was in this case - required.

[212man]

then asks the PNF to adjust the heading bug, then the heading bug gets moved and finally the aircraft starts to turn.

in itself a bizarre SOP some operators have adopted. PF is PF - whether they fly using the automation or manually. Getting the PM to make control inputs means they are no longer ...... PM!

[rotorspeed]

Exactly Crab, all far too slow.

But although all the chat about NVGs, IR and radar is certainly interesting, it just need not have been a critical issue, because the aircraft should never have been where it was – 10 miles from (and beyond) the destination at 200ft on a misty, low cloud night. And to have intended to transit like this for 10 miles was just so unnecessary. Why on earth did this crew not just do a let down from the north east to a point say 2nm north east of Blacksod, in the middle of a 4nm wide and 5 nm long bay – and one surrounded by low elevation terrain? They would have been nicely into wind with a ground speed of 60 knots or so and would have got visual with the Blacksod lighthouse and even scattered housing by 300ft I’m pretty sure. And by all means use the radar and IR to verify their position, but with it only being important for a mile or two - not 10.

Again, can anyone say how the sister S92 R118 from Sligo got into Blacksod to refuel? Many must know. But I can’t believe it was the way R116 tried to.

[[email protected]]

Rotorspeed - exactly the problem we have all grappled with - you have a very capable helicopter yet you choose to follow a legacy procedure from S-61 days instead of a far more efficient in-aircraft letdown far closer to the intended landing point.

I get the idea of using the PM to make inputs to the AFCS but, as 212man states, how does that work when he is supposed to be monitoring? Some confusion arises when you ask the PM to select an autopilot function - ALTA, HDG, TAS - good CRM but does it cross the boundary of PF/PM?

Personally I don't have a problem with it but I don't do commercial SAR.

[Scattercat]

I'm not entirely convinced by that argument Scattercat. You best derive Situational Awareness from your most effective inputs at that time. It could be naked eye, or it might be the sensor that's currently working best for you (or a blended solution). All this has to be underpinned by good CRM and appropriate procedures otherwise you are permanently on the back foot.
I think we're saying the same thing Ilamaman :ok:

[Nebuchadnezzar]

Very strong criticism from the European Cockpit Association. From an article in today’s Times...

ECA President, Captain Otjan de Bruijn, said that it is “an extremely long delay for publishing a report” and that during these 4 years “possible safety-critical flaws have remained unaddressed - something we are quite alarmed about.......any deficiencies that have been identified in the accident investigation must be made public, out in the open so that they can be fixed swiftly”.

This next bit is particularly damning.....

“We are not aware of any other similar cases across Europe of a re-examination of the technical work of an independent technically qualified organisation by a body with limited expertise in aviation accident investigations.

This rare procedure(the appointment of a review board) could be a slippery slope allowing for undue influence over the investigation process and its findings, and clearly has resulted in an unhelpful delay in publication of the report”.

[jimf671]

Recent podcast.
https://shows.acast.com/squawk7000/episodes/chc-helicopter-in-ireland

No mention of goggles.

[BoeingDriver99]

It's been 4.5 years since the crash and over 20 months since the draft was circulated privately and then the unprecedented challenge and review system was begun.

Will this report ever see the light of day? It's a smack in the face to any sort of real fact finding safety system.

[Davey Emcee]

Brexit and/or Covid covers most things here at the moment.

[P3 Bellows]

Too many parties have a vested interest in this report never seeing the light of day I am lead to believe. All very 3rd world and the aviation community is the poorer for that.

[rotor-rooter]

It will make a great topic for review at the Operators own safety conference?
Safety & Quality Summit | CHC (http://www.chcheli.com/SafetySummit)

[[email protected]]

It is the race to the bottom as far as safety is concerned - we all know aviation is expensive and safe aviation is even more so but when money, reputations and the threat of litigation cloud the waters of an investigation - you have to ask of the operators and the Irish Govt - Why didn't you just do it properly instead of trying to save a few quid/euros?

[BoeingDriver99]

Would a FOI request to the relevant department not force the issue? It does seem like there is an attempt at deflecting blame/litigation at this point. Experts can be found and data can be analysed via this thing called the internet these days. The crash and physical investigation would have been completed back in 2017. The initial report was written end of 2019. The conflict of interest arose in 2020 but the data is available to be analysed at home/online.

[Cyclic Hotline]

https://www.independent.ie/irish-news/news/review-into-r116-crash-report-ongoing-one-year-after-it-started-40875247.htmlReview into R116 crash report ongoing one year after it startedA member of the Irish Coast Guard looks out towards a misty Achill as the search continues for Rescue 116 along Blacksod coastline, Co Mayo, in 2017. Photo: Steve Humphreys Catherine Fegan (https://www.independent.ie/opinion/independent-journalists/catherine-fegan/)

September 22 2021 02:30 AM

A review into a report on the Rescue 116 helicopter crash is still continuing, more than a year after the process was formally announced. Four Irish Coast Guard crew members died when the helicopter crashed into Blackrock Island, off the north Mayo coast in 2017.

After an extensive and lengthy inquiry, the Air Accident Investigation Unit’s (AAIU) draft final report was issued to interested parties in September 2019. In March last year, a review board was established to examine certain findings following a request from one of the parties subject to the investigation.The process results from a claim by the party in question that the findings reflected adversely on their reputation.It is the first time that a review has been carried out into an AAIU inquiry.

The Review Board, chaired by Senior Counsel Patrick McCann, has been established in line with Regulation 16 of Air Navigation Regulations 2009. The regulations provide that on completion of the re-examination, the Chairperson of the Review Board makes a report to the Minister for Transport. It is understood that the Minister has not received the report from Mr McCann to date. Last October it emerged that a key member of the team reviewing the report resigned due to a conflict of interest. The resignation of Phillip Hanson, a senior manager at the UK Coastguard, and the technical expert on the two-man review team, came after Mr Hanson disclosed that he had a personal connection with a senior manager at the helicopter operator, CHC. That manager was due to give evidence on behalf of CHC to the review board.

This week, a spokesperson for the Department of Transport said the review was entirely independent and that it was a matter for the chairman to determine how the process would be carried out and how long it would take to complete. The bodies of Captain Dara Fitzpatrick and Captain Mark Duffy were recovered in the days following the tragedy. The remains of their colleagues, winch operator Paul Ormsby and winch man Ciarán Smith, remain lost at sea. Their helicopter had been dispatched to provide assistance to another helicopter, Rescue 118, that was retrieving an injured fisherman from a trawler in the Atlantic.The inquest into the deaths of the crew cannot be finalised until the AAIU report is published

The law governing air accident investigations allows any person or organisation to seek a re-examination of “any findings and conclusions” that appear to “reflect adversely” on their reputation. However, this is the first time for an AAIU report to be referred to a review board in the AAIU’s 25-year history, during which it has carried out nearly 1,000 investigations. AAIU inquiries are protected by highly restrictive legislation that makes it a criminal offence to reveal details prior to official publication of an air accident investigation report.

[LightOnSkids]

I can't post any links but there was a number of articles posted last week, looks like the report should be published shortly.

""The 333-page AAIU draft report took more than two years to compile and was completed in late 2019. Publication, which was delayed until the Review Board completed its work, is expected shortly, once the AAIU has incorporated changes recommended by the Review Board."

[Liffy 1M]

The final report is due to be published tomorrow. The RTE Prime Time current affairs programme this evening gave a preview, with errors in multiple mapping systems highlighted. This was presented as meaning that the absence of the island and lighthouse from multiple sources reinforced a belief by the crew that there were no obstacles in their path. Deficiencies in the helicopter operator's safety management systems and the regulator's oversight of same also appear to be covered in the report.

[Red5ive]

R116 report to question whether mission was necessary
https://www.rte.ie/news/primetime/2021/1104/1257995-r116-air-accident-investigation-report/

[Davey Emcee]

R116 helicopter: Actions of crew who died in R116 helicopter tragedy were not a factor in crash, air accident inquiry finds - Independent.ie (https://www.independent.ie/news/actions-of-crew-who-died-in-r116-helicopter-tragedy-were-not-a-factor-in-crash-air-accident-inquiry-finds-41019502.html)

[Red5ive]

Final Report: Accident involving a Sikorsky S-92A Helicopter, registration EI-ICR, at Black Rock, Co. Mayo, Ireland, on 14 March 2017. Report No: 2021-008
SYNOPSIS

A Sikorsky S-92A helicopter, registration EI-ICR (call sign Rescue 116), which was being operated by a private operator on behalf of the Irish Coast Guard (IRCG), was en route from Dublin, on Ireland’s east coast, to Blacksod, Co. Mayo, on Ireland’s west coast. The Flight Crew’s intention was to refuel at Blacksod before proceeding, as tasked, to provide Top Cover for another of the Operator’s helicopters, which had been tasked to airlift a casualty from a fishing vessel, situated approximately 140 nautical miles off the west coast of Ireland. At 00.46 hrs, on 14 March 2017, while positioning for an approach to Blacksod from the west, the Helicopter, which was flying at 200 feet above the sea, collided with terrain at the western end of Black Rock, departed from controlled flight, and impacted with the sea.

During the immediate search and rescue response, the Commander was found in the sea to the south-east of Black Rock and was later pronounced dead. Subsequently, the main wreckage of the Helicopter was found close to the south-eastern tip of Black Rock, on the seabed at a depth of approximately 40 metres. The deceased Co-pilot was located within the cockpit section of the wreckage and was recovered by naval service divers. Extensive surface and underwater searches were conducted; however, the two Rear Crew members were not located and remain lost at sea.

Forty two Safety Recommendations are made as a result of this Investigation.

Final Report: Accident involving a Sikorsky S-92A Helicopter, registration EI-ICR, at Black Rock, Co. Mayo, Ireland, on 14 March 2017. Report No: 2021-008 | AAIU.ie (http://www.aaiu.ie/node/1551)

[212man]

Ploughing through it now. It would be interesting to know how much attention the investigators gave to the postings here. E.g. I see this topic being directly referenced https://www.pprune.org/showthread.php?p=9744317

[[email protected]]

Despite all the contributory factors, there is no doubt in my mind that, had they been wearing NVG, they would not have hit the island.

With NVG, the pilots would have seen the terrain (Dara herself mentioned being visual with the sea surface and that was unaided night vision) and made the avoiding turn early - and probably manually - rather than utilising the heading bug on the AP after confirming with the rearcrew about the need to change course. That was a delay that cost them their lives.

[NumptyAussie]

Despite all the contributory factors, there is no doubt in my mind that, had they been wearing NVG, they would not have hit the island.

With NVG, the pilots would have seen the terrain (Dara herself mentioned being visual with the sea surface and that was unaided night vision) and made the avoiding turn early - and probably manually - rather than utilising the heading bug on the AP after confirming with the rearcrew about the need to change course. That was a delay that cost them their lives.

Serious question Crab, would a Pilot use NVG in proximity to a lighthouse?

[[email protected]]

Serious question Crab, would a Pilot use NVG in proximity to a lighthouse? Yes, of course. You just wouldn't stare directly at the light (which wouldn't be on all the time anyway)

[[email protected]]

There is an automatic gain control on the NVG tubes which effectively does the same as increasing or decreasing the ISO on your camera - when it is really dark, the gain control goes to max to amplify as much light as possible but you then get unwanted 'noise' speckling, honeycombing etc.

In a bright light, the gain control does the opposite - partly to prevent damage to the tubes - but you only have about a 40 degree field of view so you can look slightly away from the light source and keep a good picture.

[snakepit]

Despite all the contributory factors, there is no doubt in my mind that, had they been wearing NVG, they would not have hit the island.

With NVG, the pilots would have seen the terrain (Dara herself mentioned being visual with the sea surface and that was unaided night vision) and made the avoiding turn early - and probably manually - rather than utilising the heading bug on the AP after confirming with the rearcrew about the need to change course. That was a delay that cost them their lives.

I think that’s just too simplistic a statement Carb. I agree that had they been using NVGs the ‘might’ have seen the island but you cannot say that they ‘would’ have seen the island.

The reality is, and as the report finds, the crew were essentially set up to fail by an insurmountable (for them, on that night) series of systemic failures. Even NVGs might have made no difference at all because as a crew they were trucking along at 200’ in the belief that they had Company proven safe lateral and vertical clearance. Any crew that believes they are currently safe will by human nature be less aroused and therefore less diligent. In this scenario even with NVGs it’s likely there lookout on that stormy night would have been sub optimal; just like the sub optimal use of radar ranging and any of the many other factors that might just have saved their lives but they failed to do with the required diligence. All because they were misled by those many systemic failures into believing they were safe when they were anything but.

[megan]

Only part way through the report, but I get the impression that no real detailed approach brief was made, had attention been paid to the route guide all the information was there, on the map Blackrock 282', in the notes Blackrock 310'. Unfamiliarity played a role, Captain had not been there for 15 years and Co-pilot not for some time, all the more reason for attention to the route guide. Then again there is operating at an unsocial hour and attendant human factors. NVGs may have been nice, but they were not relevant to the accident in my view.

Most interested in seeing what crab has to say, being in the business.

[Northskycop]

I respectfully have to say that NVG's would probably have saved their lives, especially of we are saying Dara saw the sea surface with the naked eye. With over four years of using white phosphor NVG's, I cannot understand any SAR operation in the world now not using NVG's as standard. They seem to be reliant on the FLIR, and when all said and done, the information was there from an operator who clearly could see what was ahead, as he said there was an Island and move right. We operate the FLIR in support of NVG's on night ops. The fact there is NO reference to NVG's in the report and recommendations surprises me. And the fact the Coast Guard have had a program running for 11 years, and now still only one aircraft operating them.

[Northskycop]

I think that’s just too simplistic a statement Carb. I agree that had they been using NVGs the ‘might’ have seen the island but you cannot say that they ‘would’ have seen the island.

The reality is, and as the report finds, the crew were essentially set up to fail by an insurmountable (for them, on that night) series of systemic failures. Even NVGs might have made no difference at all because as a crew they were trucking along at 200’ in the belief that they had Company proven safe lateral and vertical clearance. Any crew that believes they are currently safe will by human nature be less aroused and therefore less diligent. In this scenario even with NVGs it’s likely there lookout on that stormy night would have been sub optimal; just like the sub optimal use of radar ranging and any of the many other factors that might just have saved their lives but they failed to do with the required diligence. All because they were misled by those many systemic failures into believing they were safe when they were anything but.
​​​​​​Why do you say 'might' as opposed to what is the actuality - I am sure with my NVG experience, that a 250' high chunk of rock will be glaringly obvious - but you would have to be looking out of the window and heads not totally into instruments which requires some skill. NVG's are an aid, yes I understand that, and there are many cautions about their use as we know. But they are game changers to most night operations

[llamaman]

NVGs might have saved them but there were so many other systemic and behavioural failures which are highlighted by the report. I agree that any SAR helicopter Operator routinely exposing their crews to the low-level environment in poor weather should equip and train for NVG use as a duty of care. They are not a panacea though; twice in my flying career I came extremely close to flying into obstructions (which had been recce'd during the day, and were accurately plotted) whilst wearing NVGs at low level. It's a high workload environment that demands currency, competency and procedures which are as safe as is reasonably possible. Sadly, this report confirms that this wasn't the case.

[[email protected]]

I stand by my assertion that they would not have hit the island had they been equipped with NVG.

When you do a night letdown over water wearing NVG you are mentally prepared for the visual environment - when you are relying on radar and AFCS procedures only, then you are in a different (almost IFR) mindset.

Having used the AFCS to get down to low level, they would have been using NVG as primary collision avoidance and FLIR and radar as secondary.

They would have seen the island in that case.

[llamaman]

Having done SAR radar/NVG letdowns I'm convinced that a crew using the procedures and training I was exposed to in all probability would not have flown in to a large piece of rock. These guys may have been saved by NVG but it's impossible to make that assumption. I still feel that procedural/behavioural influences were a big factor as was automation bias. If you're confident the kit and the procedure is sound (as they were) then you're way less likely to be expecting a nasty surprise. NVGs may, or may not, have been their saviour.

[Koalatiger]

Reading the report it does not say anything about why they did not use the marine charts?
Over water, outside the coastline, surely they are the most detailed maps around?
Why using on shore maps....or am I missing something.

[Johnthemidjit]

Reading the report it does not say anything about why they did not use the marine charts?
Over water, outside the coastline, surely they are the most detailed maps around?
Why using on shore maps....or am I missing something.

Probally because they were in a helicopter…. Not a boat !

[Franks Town]

The family of both pilots have released statements and in the case of the pilot in commander have given a radio interview . Obviously their views would differ from the comments here as they are more personal . However even the family’s of the pilots have different views . One more defensive than the other perhaps .

https://www.rte.ie/radio/radio1/clips/22026455/

Captain Fitzpatrick’s father on a national radio station .

captain Fitzpatrick’s family statement released on Twitter

blob:https://www.pprune.org/cc6b67d7-81de-4d67-89cc-f8e12ce3ab6f



Captain Mark Duffy’s wife’s statement in a national news paper.

https://www.independent.ie/irish-news/widow-of-rescue-116-crew-member-pays-tribute-to-team-who-perished-as-report-into-helicopter-report-to-be-released-41019248.html

[Koalatiger]

Probally because they were in a helicopter…. Not a boat !

…well, why would you have the marine charts loaded in the tough-book if not utilizing them when needed. Flying at 200 feet over water they seam to be the most sensible charts to look at to determine your location and any islands in your way. The report does not say anything about it…

[Northskycop]

…well, why would you have the marine charts loaded in the tough-book if not utilizing them when needed. Flying at 200 feet over water they seam to be the most sensible charts to look at to determine your location and any islands in your way. The report does not say anything about it…
I'm not aware of any crews using marine charts as routine. As said above, they are not in a boat and would not be looking for marine obstructions. And the toughbook was in the back. There is a back scandal in all this that the Irish Coast Guard NVG project started in 2010. Yet only one aircraft operating now in 2021.

This from early October 2021, Afloat Article."
A delay in using night vision goggles purchased by the State for Irish Coast Guard search and rescue helicopter crews has been criticised in the Comptroller and Auditor General’s (C&AG) annual report. Although over 4.3 million euro was paid by the Department of Transport to CHC Ireland in 2013 to ensure night vision imaging systems (NVIS) capability, only one of four search and rescue bases had been approved for this as of June 2021, the C&AG’s report for 2020 states.

The C&AG notes that a March 2010 report, which was prepared before the tender process for the Irish Coast Guard search and rescue (SAR) helicopter contract, had recommended helicopters be fitted with an NVIS system.

That 2010 report also recommended that night vision goggles and crew training should be provided when funding became available.

“In 2013, the Department of Transport paid €4.305 million to the company providing SAR in Ireland to ensure the five helicopters used for the service are equipped with NVIS capability,” the C&AG states.

“ Another €527,000 was paid in 2015 for 24 sets of night-vision goggles,” it says, and an initial payment of €1.714 million was made in 2018 for training that began in November 2019.

“The night vision goggles would remain the property of the Coast Guard and, on expiry of the current contract, the goggles would continue to be available for use by SAR crew,”the C&AG says.

It notes the department expects the training to be completed by 2022. Sligo is the only SAR base so far approved for NVIS capability by the Irish Aviation Authority (IAA).

The C&AG notes that it will be “some time before all the bases are operating in the same way”.

The Department of Transport told the C&AG that visual reference to the pilots’ outside world is essential for safe and effective flight.

During daylight hours, the pilot relies heavily on the out-the-windshield view of the airspace and terrain for situational awareness, it explained.

“ During night flying, the pilot can improve the out-of-the-windshield view with the use of a NVIS. Overall, NVIS as an additional aid to navigation and search, in suitably equipped aircraft using appropriately trained crews enhances operational effectiveness and safety for both SAR and helicopter emergency medical service (HEMS) operations,” the department said.

It said that NVIS have been shown to pick up small lights, such as lights on lifejackets, hand-held torches and distant vehicles at much greater ranges than the naked eye.

“ When operating overland, NVIS assist the crew in navigating, seeing and avoiding terrain and obstructions as well as being able to identify survivors earlier than with the naked eye,”the department said, and can increase the crew’s overall search capability as NVIS enhances visibility.

The department said that NVIS can provide a “back-up to the forward-looking infrared system (FLIR) if the FLIR suffers an unserviceability in-flight”.

It said that NVIS can assist in identifying suitable landing sites more easily under SAR flight rules. This will also enable the helicopters to access the offshore islands that are without aviation infrastructure such as Inishbofin for medical evacuations under SAR flight rules.

It said that during night-time commercial air transport operations (i.e. HEMS incidents), landing is only permitted at company approved surveyed sites, but NVIS has the potential to remove this restriction and allow crews to land safely at sites which have not been surveyed.

“Overall, the use of night vision aid technology increases night-time situational awareness for pilots and technical crew,”the department said.

It also said that use of night vision goggles “markedly decreases the possibility of collisions with terrain or manmade obstruction”.

In its response to questions raised by the C&AG, the department’s accounting officer said that “of necessity, the implementation of the NVIS has been done on a phased basis”.

“Clearly, training can only take place when the helicopters are correctly equipped and goggles are available to use. Regrettably, the timelines have been far longer than original anticipated,” the department said.

It said the Irish Coast Guard had “consistently pressed the company to deliver the training as quickly as possible, to explore all possible options and to engage with the IAA throughout to determine whether certain elements could be accelerated, all with due regard to safety and to ensuring that the core SAR availability was unaffected”.

It also said that re-fitting the helicopters to make them compatible with NVIS operations “does not confer a competitive advantage to the company” in bidding for the new SAR contract.

The C&AG said that “ significant payments were made from voted funds as long ago as 2013, and the planned capability has not yet been delivered across the service”.

“On that basis, I am not persuaded that good value for money for the taxpayer has been achieved from this expenditure,” he said.

Oireachtas Committee of Public Accounts chairman Brian Stanley welcomed the report and noted it highlighted the “wastage of public money” associated with night vision capability within the Irish Coast Guard.

[gulliBell]

I will never comprehend how anybody at anytime ever thought it a good idea to be stooging around at 200 feet in the pitch black of night when you can't see anything ahead of you, let alone a lighthouse sitting on a great big rock in the middle of the sea flashing its light in your direction every 12 seconds. To my way of thinking, in undertaking such an activity, chances are eventually you're going to fly into something. And all for the reason of a situation where a doctor at a hospital on the other end of the radio has diagnosed, wrap it in a bandage and give him a panadol. I wonder in this instance what the outcome for the patient fisherman was, whether the severed thumb was re-attached, or the doctor was right (likely couldn't be saved).

[blind pew]

Generally do not have enough terrain detail to be of any use as I discovered pre GPS days doing a booze run to Calais where the tide speed matches the boat speed but was at 90 degrees to heading and with a lack of navigation bouys within visual range I resorted to a Michelin map book to identify our position approaching the coast.
On another angle the Irish pilot's Union chairman appeared on the news with a scathing attack on the regulator..no surprise there then.

[Koalatiger]

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/480x405/a6028d8e_6780_409a_8637_c4f2ae8ff046_9f424ea21f87481db53ec0c 5f5e0dd967f83e005.jpeg

[[email protected]]

These guys may have been saved by NVG but it's impossible to make that assumption. If you were doing this letdown during daytime in the same weather (300-500' cloudbase and 2 nm vis) you would be looking out of the window once below cloud at 200'.

If you were doing this letdown in the same weather at night using NVG, you would be looking out of the window once at 200' - with 2nm vis, how would you not see a nearly 300' high lump of rock with a lighthouse on it?

I still feel that procedural/behavioural influences were a big factor as was automation bias. Absolutely right - because they had no NVG and the procedural let down was all they had. Could that have been executed better? Possibly.

[RVDT]

Koalatiger said - Why using on shore maps....or am I missing something.

Elevation maybe?

[blind pew]

IIRC the road maps from the 80s had contours and spot heights...identifying the coast using the high cliffs of Cap grise Nez to the South of Calais gave me a rough position and the direction of the dredged channel Bouy. The marine charts I used only had the odd church spire.

[Koalatiger]

11138453]Koalatiger said -

Elevation maybe?

Irrelevant if there are no island on the map (as in this case) situated in the water offshore. On shore maps do not have that requirement and don't have to because its is for navigation on shore. For navigation off shore and along a coast or approaching a coastline, marine maps have all islands and hence corresponds to your radar picture. Flying/relying on a route and checking it against not accurate maps is two big holes (giving false security) in this tragic accident.
When you are that low you need to fly and navigate like a boat to stay safe.

[[email protected]]

Koalatiger - when I was doing UK SAR, we carried maritime charts but they sat in a nav bag and were seldom referred to.

That was mainly because we knew our local areas - especially the lighthouses - and we had Admiralty charts in our operations room at the SAR flight.

I used to ask pilots questions about the charts during check rides.

Unfortunately, in a modern digital cockpit, any mapping will be electronic and few would see the need for including digitised maritime charts.

Coupled with that, they were operating away from their normal area and so were not as au fait with the letdown area as they might have been.

[Koalatiger]

Koalatiger - when I was doing UK SAR, we carried maritime charts but they sat in a nav bag and were seldom referred to.

That was mainly because we knew our local areas - especially the lighthouses - and we had Admiralty charts in our operations room at the SAR flight.

I used to ask pilots questions about the charts during check rides.

Unfortunately, in a modern digital cockpit, any mapping will be electronic and few would see the need for including digitised maritime charts.

Coupled with that, they were operating away from their normal area and so were not as au fait with the letdown area as they might have been.


Well that is about to change I guess. It does not matter what the maps are called, accurate maps are the key, I think we all can agree on that.
The fact is that the maps being used for navigation/situation awareness did not have the lighthouse/island on it.

[Aucky]

A ‘Honeywell Primus 701A’ weather radar system was fitted. This system is a high resolution, fully stabilised, high power, digital radar, designed for high resolution weather detection and terrain mapping. The radar manufacturers’ manual includes the following warning:

‘THE SYSTEMS PERFORM ONLY THE FUNCTIONS OF WEATHER DETECTION OR MAPPING. IT SHOULD NOT BE USED OR RELIED UPON FOR PROXIMITY WARNING OR ANTI-COLLISION PROTECTION’.

Are the implications of this statement more wide reaching than SAR? As someone who has never flown offshore ARAs, is the weather radar performing a purely ‘terrain mapping’ function during an ARA, i.e. confirmatory position information for the rig location, rather than proximity warning or anti-collision protection? I had always assumed, perhaps incorrectly, that it was used to ensure the path was clear on final approach track to the decision point (and thereby performing an anti-collision function), and also was also used to provide essential proximity information on which the decision point was based.

[[email protected]]

The fact is that the maps being used for navigation/situation awareness did not have the lighthouse/island on it. yes, it is all about the accuracy of the database - using a generic aviation one doesn't seem to be the way forward for SAR - I don't know what UK SAR uses now.

[Red5ive]

Just for the record:

Statement on the publication of AAIU’s Final Report into R116 air accidentMinister Eamon Ryan T.D. and Minister of State Hildegarde Naughton T.D. acknowledge and appreciate the completion of the investigation into the R116 air accident. The accident claimed the lives of R116 crew members Dara Fitzpatrick, Mark Duffy, Ciarán Smith and Paul Ormsby in March 2017 and today marks the publication of the final report into this investigation by the Air Accident Investigation Unit.

The Department of Transport fully accepts the recommendations contained within the report and will continue to evaluate the findings of the report in the coming weeks.

Since receiving the draft Final Report in September 2019, the Department of Transport has undertaken a significant programme of change across key areas to take account of issues raised and recommendations addressed to the Minister of Transport.

Commenting on the publication of the AAIU R116 report Minister Ryan said:

“This was a tragic accident that claimed the lives of four individuals who were dedicated to saving the lives of others. I would like to again convey my condolences to the families and loved ones of the R116’s crew at this time. The completion of the investigation and the publication of the report is a key step in ensuring that such accidents are prevented in the future. I wish to acknowledge the investigative work that has been done by the AAIU that has culminated in this report. This is clearly reflected in the level of detail and wide-ranging nature of the report, with safety recommendations that cover all aspects of SAR aviation, both nationally and internationally.”

Minister of State Hildegarde Naughton added: “I would like to take this opportunity to again express my sincere condolences to the families and loved ones of the four members of R116’s crew, and to all who were affected by the accident. I understand that today’s publication of the AAIU’s Final Report will be a difficult time for all involved. I note the final report contains several safety recommendations addressed to the Department of Transport and I look forward to seeing all necessary work, much of which is already commenced, completed as soon as practicable. My door, and the doors of the Department, remain open to the families of the R116 Crew for any assistance that may be required going forward.”

Ministers propose to seek time in Dáil Eireann to allow for Statements on the matter.



https://www.gov.ie/ga/preasraitis/854f8-statement-on-the-publication-of-aaius-final-report-into-r116-air-accident/



Have CHC issued a statement?

[jimf671]

I have had a look at the mapping aspects of this matter.

OSI land mapping, of the kind one would expect for land SAR, does NOT include Black Rock. The nearest sheet stops at the western tip of the nearest mainland. I downloaded the digital version of the OSI mapping and although a detached piece of OSI's grid appears in the ocean where one would expect Black Rock to be, no land is shown at that location. I have established that this is not a historical omission caused by the previous rulers of Ireland since the OSGB maps held by the National Library of Scotland, and probably from surveys before 1913 but revised in the 1940s, DO include Black Rock, although not in great detail and probably without a spot height, although the NLS copy is not very legible in this respect.

None of the secondary mapping providers, such as Open Street map, show useful detail for Black Rock even though some show the buildings and helipad.

Worryingly, I also found an online map by SWC maps, that displayed a respresentation of Black Rock blessed with only a 10m contour line for height information. So there is information out there in the wild representing Black Rock as being between 10m and 20m in maximum height above the sea.

Contrast this with the situation in a neighbouring territory. Alisa Craig is an island that, just like Black Rock, is less than 10NM off the coast. Even secondary mapping like Open Street Map shows the spot height for the highest point on the island. The normal OSGB mapping that one would expect to use for land SAR shows information from a full survey with 10m contours and spot heights.

Similarly, considering an uninhabited and unexploited island, more than 30NM west of inhabited land, thus one that might be considered far less significant than Black Rock, Stac an Armin (extreme fragment of St Kilda), appears on OSGB mapping (including Landranger sheet 18 and digital versions) with 10m contours and a spot height and on Open Street Map with a spot height.

I note that the OSI website is illustrated with more than one image of surveyors working on rugged coastlines with boats. One might hope that these recent photographs have been made possible by a realisation that there are consequences to dismissing even one square metres of Irish land when one's reputation and sales are based on a centimetre-accurate mapping service.

[[email protected]]

Clearly other countries Ordnance Survey mapping isn't up to the same standard as the UKs.

[Hot_LZ]

Maritime Mapping.

It’s relevance has been discussed above with some dismissing its importance for SAR operations. These are commonly used in UKSAR and have done since the beginning of the current contract. When conducting maritime and littoral let downs either IMC or on NVG, the front end are using aeronautical charts and the back end are following up with a combination of aeronautical and maritime digital mapping. Contacts on radar/FLIR are cross checked with the charts in order to identify buoys and low laying terrain.

LZ

[megan]

because they had no NVG and the procedural let down was all they had. Could that have been executed better? PossiblyAll they had to do was follow the route guide and they would have been home safe and sound, NVGs only become a feature of debate because they weren't following the route guide ie descended below the notated altitude of 310', Black Rock gets a mention under Hazards, being number one on the list. A pertinent approach brief using the route guide, rather than the one given, would have flagged what they were about to execute and the hazards thereto.At 00.10 hrs, the Commander briefed the Co-pilot on the approach into Blacksod:
‘I think we just go straight over and when we're happy enough to step it down em down below two four we'll do the approach one all the way down, let it just fly the route, get the speed back until we’re comfortable and literally just let it fly all the way round em if we're happy with the visuals on the first run-in it'll be on my side so it’ll be my landing. We’ll go in, if not we'll just do a circuit all the way around and eh we'll make sure it’s on a two four zero heading’The let-down procedure was briefed by the Commander, with all timings and acknowledgements by the Co-pilot presented in square brackets, as follows:
‘[Commander at 00.30:01 hrs] okay let-down procedure, can I wait until we're abeam this alpha position [an apparent reference to waypoint BKSDA] here [Co-pilot acknowledged at 00.30:05 hrs: okay] [Commander at 00.30:06 hrs] and then we're going to, I'm going to select alt pre down to two thousand and four hundred feet, [Co-pilot acknowledged at 00.30:09 hrs: roger] [Commander at 00.30:10 hrs] if you're happy we're clear of everything [Co-pilot acknowledged at 00.30:11 hrs: understood] [Commander at 00.30:12 hrs] I’m going to do an approach one all the way down to two hundred feet, eighty knots, [Co-pilot acknowledged at 00.30:15 hrs: yes] [Commander at 00.30:16 hrs] eh, it might be slightly past M O [an apparent reference to waypoint BLKMO] at that moment so we'll see what, how we are height wise at that moment, so I think we'll just eh take a heading, continue on past there go back around and the aim is just to follow the route all the way round em and eh [Co-pilot acknowledged at 00.30:27 hrs: roger understood] [Commander at 00.30:29 hrs] getting the speed back as much as we're comfortable, we're aware we're going to have a pretty high ground speed on the way in. [Co-pilot acknowledged at 00.30:34 hrs: Okay]’


https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/730x663/c_39581823a3b93cbe12de103bbbf265a3e1ce3821.png

Having just finished reading the report there is much to cogitate upon, what I've written above re brief is merely one element in the mix of organisational failures, still would have saved the day though, length of time they had been awake would explain why anyone would be off their game.

[[email protected]]

length of time they had been awake would explain why anyone would be off their game Agree completely. The nature of fatigue is insidious and often difficult to recognise in yourself, especially in the wee small hours.

The nature of SAR is unpredictable and managing fatigue is essential - I always tried to have a nap in the afternoon if possible which helped enormously when the phone rang late in the evening or overnight, and yes, people did take the p*ss out of me for doing it but it worked for me.

[[email protected]]

At 00.45 hrs, the Co-pilot announced ‘okay so small targets at six miles at 11 o'clock … large out to the right there’. This was followed approximately 20 seconds later by an Auto Callout ‘Altitude, Altitude’, which the Commander said was ‘just a small little island that's B L M O itself’. that was the point when action should have been taken - they didn't see the little island until they overflew it which should have raised their hackles and got them to turn or climb and reassess the letdown profile.

They had nearly 10 miles to run before they were even abeam Blacksod so they didn't need to be at 200'.

I know it is easy to be wise with 20/20 hindsight but that was not a great let down route into the refuel site.

[torqueshow]

Are the implications of this statement more wide reaching than SAR? As someone who has never flown offshore ARAs, is the weather radar performing a purely ‘terrain mapping’ function during an ARA, i.e. confirmatory position information for the rig location, rather than proximity warning or anti-collision protection? I had always assumed, perhaps incorrectly, that it was used to ensure the path was clear on final approach track to the decision point (and thereby performing an anti-collision function), and also was also used to provide essential proximity information on which the decision point was based.

You’re correct in that is exactly how it is used during an offshore ARA. I would (cynically) say that the wording of the limitations of the Honeywell radar is more of a liability-covering legalese.

That being said the phrases “proximity warning” and “ant collision protection” are quite vague. On approach to a rig using the radar, it is used to determine floating obstacles such as standby vessels or other boats in the desired approach path and the range to those obstacles and the destination. Whiles this provides proximity information, it doesn’t provide a proximity “warning”, neither is that information considered particularly accurate below 0.5nm. Anti-collision protection falls under much the same logic I would think.

In my anecdotal experience, the GMAP terrain modes of the radar weren’t particularly more effective than fiddling with the gain and tilt of the normal Wx mode

[rotorspeed]

Apart a host of other issues, the Conclusions section of this report highlights that Black Rock was not in the EGPWS database, on the 1:250,000 aeronautical chart, Euronav imagery or Toughbook. As others have commented on. So mapping was not 100% reliable. But is that really surprising? Would anyone sensible assume that every one of Ireland’s no doubt hundreds of small islands is accurately recorded? Accurately enough to be confident bowling along at night in IMC conditions at 200ft for a planned 10 miles? Just nuts, as I know Crab and gulli agree.

There is a far simpler check that could and should have been done if this highly risky approach was going to be followed – just look at Google Earth. In the corporate world I operate in, whenever I’m going somewhere new I (and I’m sure many others) look at the approach and landing site on Google Earth. Together of course with charts. But photos don’t lie. A 15 second look at the APBSS approach on Google Earth would have made Black Rock glaringly obvious. And there’s even a photo to click on that shows it to be a bloody great lump of rock, about 300ft high! Even if the elevation cursor only shows it as 11m – not that you’d ever rely on that. But amongst the 37 Safety Recommendations not one says do a check on Google Earth!

Sometimes I feel that the world of aviation is so bogged down in a lifetime’s reading of documents and procedures that the obvious is missed.

[megan]

bowling along at night in IMC conditions at 200ft for a planned 10 miles? Just nuts, as I know Crab and gulli agreeIt needs to be looked at in overall context, had they been on a task to rescue some one from a boat in close proximity to Black Rock they would still have been operating at 200', and below, but they wouldn't have the radar return from the island covered by route data, as was the case.There is a far simpler check that could and should have been done if this highly risky approach was going to be followed – just look at Google EarthAbsolutely nothing wrong with the belt and braces approach, but they already had the requisite information in the cockpit - the route guide, a pity the information wasn't presented in the style of an approach plate, with a profile view annotated with altitudes.

Checking Google Earth - The contract requirement was to be airborne 45 minutes after call out, they were 8 minutes late in meeting that requirement, so I doubt a lack of thoroughness in preparation was a factor. They originally were not going to Black Rock in any event, it was a diversion decision made in flight, I doubt Google would have been able to be accessed from the aircraft.

[gulliBell]

...Would anyone sensible assume that every one of Ireland’s no doubt hundreds of small islands is accurately recorded? Accurately enough to be confident bowling along at night in IMC conditions at 200ft for a planned 10 miles? Just nuts, as I know Crab and gulli agree..

Even with a perfect set of surveyed maps it's still nuts to go barrelling along at 1.5 nm/minute at night in the pitch dark at 200' when you can barely even make out the water below you, even in a capable SAR helicopter. Especially when your task at that point is just to top up on fuel. I don't see that route maps or aeronautical charts or NVG or EGPW navdata or toughbooks or anything else had anything to do with it. They are all just excuses after-the-fact. You play the cards you are dealt with. Despite all those things that went against them, for the life of me I find it difficult to believe that nobody "stepped back" and thought for a minute there must be a better way to do what they were doing.

[megan]

I find it difficult to believe that nobody "stepped back" and thought for a minute there must be a better way to do what they were doing.What might you suggest was a "better" way, keep in mind they were not supposed to be at 200'?

[Torquetalk]

What might you suggest was a "better" way, keep in mind they were not supposed to be at 200'?

One that didn’t involve using an object of undefined height as a turning WYPT, descending behind it, down to 200ft, then flying at it with a 40kt tailwind at night in 2-3km visibility in rain with an incorrectly set-up WX radar.

The FMS could have been used to set up any number of interceptions for a downwind leg or base leg; cross-checking on the WX radar that the sector is free. The bay was otherwise almost entirely free of obstacles so why on earth did they fly out to the island anyway, as there were other POS RNAV WYPTS that could have been used to join the route? And why did nobody ask “how high is Black Rock?” And look at the chart to check. Even with the incorrect information on the chart, 200ft was always going to lead to a collision with the plan to fly over at that height..

From the moment the rear crewman called the object and suggested coming right (2nd call), they had about 12 seconds to impact. But the crew remained in a SA fog until the very last seconds.

[Fostex]

I am still disturbed by the 'CRM dance' of the PF asking the PM for a course correction when a trusted crew member in the back has identified terrain ahead. Fair enough they are following their SOPs for operating under AP when flying what they think is a safe approach. However as soon as un-identified terrain is sighted ahead then it might be a big clue that the approach/let down is no longer safe. The winch man in the back seeing a big rock/lighthouse ahead is analogous to a terrain command from the GPWS and surely at that point the AP should be disconnected immediately and avoiding action taken?

Caveat, I am fixed wing pilot but shocked that the crew acted in this way. Multiple calls and 12 seconds from sighting terrain until hitting it. Very sad.

[rotorspeed]

Megan - a far better way to do it would have been simply to do a let down from the NE to a point say 2nm NE of Blacksod. They would have been into wind, so with a G/S of circa 40kts, and around 2nm away from any other land. They would almost certainly have seen Blacksod lighthouse flashing at 300ft and positioned in. It would also been a lot faster and burst less fuel.

And anyhow, how did R118 get into Blacksod? That clearly worked. Does anyone know if that info is buried in the 350 pages of the report? Did R116 crew establish how R118 were planning on approaching? Would have been wise.

Fostex - yes, the slowness of the response to the report of land ahead steer right was dreadful. An immediate action of uncoupling and doing a rapid climbing turn would have unquestionably saved the day. Or even not uncoupling but just doing it, not querying it. How much was tiredness or just inadequate competence from the crew I don't know, but decision making just was not good enough.

I will try and read the report in full.

[llamaman]

"Fostex - yes, the slowness of the response to the report of land ahead steer right was dreadful. An immediate action of uncoupling and doing a rapid climbing turn would have unquestionably saved the day. Or even not uncoupling but just doing it, not querying it."

I couldn't agree more. Our SOP for a late sighting of an obstruction (with risk of collision) whilst at low level on NVG was a call of "Up, up, up" from any crew member which would initiate an immediate low level abort, without question. It absolutely saved me and my crew's life on one occasion when a crew member in the jump seat saw a significant mast in our flight path which hadn't been seen by either pilot.

[gulliBell]

What might you suggest was a "better" way, keep in mind they were not supposed to be at 200'?

A better way would have been for any one of four people on board to say "this is not a good idea". I'm bewildered why nobody said so. I'm left to wonder if they had a newly minted 200 hour co-pilot on board who didn't have an ounce of operational experience, but had a bit of gumption, would have piped up and said so. I always fall back to what Marty used to say when I was a newly minted 200 hour co-pilot when contemplating a course of action to complete a task...."what would they say at the subsequent inquiry". Well, at this subsequent inquiry there was quite a bit to say.

[megan]

A better way would have been for any one of four people on board to say "this is not a good idea". I'm bewildered why nobody said so. I'm left to wonder if they had a newly minted 200 hour co-pilot on board who didn't have an ounce of operational experience, but had a bit of gumption, would have piped up and said soOn what grounds would either of the two back seaters say "this is not a good idea", the two front seaters were quite happy with what they were doing. We have a tendency to accept that those in a position of power know what they are doing. If you recall we carried a chart in the cockpit detailing the CDP for take off, trouble was it was all bollox and if things turned to worms on a take off I may have been attending your funeral, no pilot ever detected that the information had been pulled out of some ones backside, took years to get the info corrected. How did you plan for a shore based alternate on all your flights? Supplement in the flight manual from the Authority demanded one, as did the ops manual. Did you put in an incident report as the Authority demanded when required to shut down off shore because every thing on shore was clagged? Did any co-pilot coming into the organisation ever question how things were done? Not to my knowledge, though some captains did, but they soon fell into line. Had you had an engine failure coming off Mackerel with 600 lb of gas and been told home and ESL clagged, what then? Normalisation of deviance.

I'm pretty sure I know of the incident of which you speak, not much Marty hasn't told me, tooling about in fog, some thing done by all, but the organisation was not one to address issues other than giving the individual lowest on the totem pole a good kicking, I can give you a copy of a letter received by one (TE) who was a mere bystander to an incident that management had been told was going to occur if they didn't get their act in order. In typical management cowardice the lowest on the totem pole was given the task of penning the letter, BM. Remember taking a bunch of overseas VIPs offshore and one saying "I thought this was a VFR operation", yer, right, typical management completely out of the loop as to what goes on at the coal face because the budget is sacrosanct when it comes to spending money on infrastructure.

[TeeS]

I can’t help but think the primary (out of many) causes of this horrendous incident is that it was not clear to anyone what the ‘Route APBSS (Blacksod South) actually was! I assume when the route was first produced pre 1999 it was meant as a visual low-level route (not a low-level IMC route!) for an S61 or similar, equipped with something like Decca based RNAV 1 or RNAV 2 which (as the report mentions) required an overfly of the start point (BKLMO) to confirm the navigation accuracy. I assume this would have started with an offshore let-down to a suitable height to gain visual references.
Back then, this was probably a sensible solution as there were no other real options for an instrument approach. What I can’t understand, and what to me is unforgivable, is that 18 years later, the Authorities have still not insisted that the ONLY acceptable method for general aviation helicopters (including SAR helicopters flying to/from regular use sites) to descend below MSA from IMC is via a properly designed and published instrument/PinS procedure.

From what I can see (I do not have access to the terrain or obstacle data for Ireland), you could easily have PinS approaches and departures both to/from the North East and West South/West which would have been more efficient and safer!

Out of interest, I drew the route on a Google Earth image (attached) with the RNP 0.3 (CAT H) waypoint fix tolerance areas (for anyone not into PBN, 0.3NM either side of track [that’s your RNP 0.3 so 95% of the time the GNSS says you are over the waypoint you should be in the pink rectangle] and 0.24NM before and after the waypoint). Also shown are the area semi-width areas in amber for a helicopter flying a route 1.45NM each side of track and in green for an aircraft on a STAR, SID, Initial Segment, Intermediate Segment or Missed Approach 1.15NM.

If drawn as a procedure, the route looks pretty flyable at MSA until BKSDB where the combination of establishing back on track after the turn and then turn anticipation for a rather interesting 148 degree turn at BKSDC is probably not doable in a distance of only 3.2NM.

Cheers
TeeS
https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/2000x1124/blackrock_screenshot_4a370ef73faa74b86f79d3cd40e830fef9ba501 8.png

[gulliBell]

On what grounds would either of the two back seaters say "this is not a good idea"....

I did quite a bit of SP flying with a crewman in the back. They sure would let it be known if they thought Plan A was not a good idea.

[gulliBell]

...What I can’t understand, and what to me is unforgivable, is that 18 years later, the Authorities have still not insisted that the ONLY acceptable method for general aviation helicopters (including SAR helicopters flying to/from regular use sites) to descend below MSA from IMC is via a properly designed and published instrument/PinS procedure.


Well yeah. And also. It's very naughty (i.e. illegal) on an ILS approach not having the landing runway threshold in sight at the DH yet continue flying straight and level at 200' until you eventually see the runway and land. But it's seemingly OK to basically do that at night when stooging around the boonies at 200' when not on any IMC procedure and you can't even see 200' ahead of you. I kinda have a bit of difficulty trying to rationalize that.

[megan]

They sure would let it be known if they thought Plan A was not a good ideaAs these chaps would have as well I'm sure.

[megan]

But it's seemingly OK to basically do that at night when stooging around the boonies at 200' when not on any IMC procedure and you can't even see 200' ahead of you. I kinda have a bit of difficulty trying to rationalize that.From the report.On the night of the accident, R116 was tasked by MRCC Dublin to provide Top Cover for R118 and was using a ‘Rescue’ call sign; the IAA informed the Investigation that based on these two factors the flight was considered to be a SAR flight and, at the Commander’s discretion, could avail of the alleviations/exemptions contained in the National SAR Approval.

The CVR indicates that the Commander’s decision to go to Blacksod for fuel rather than Sligo was based on a concern to save thirty minutes flight time following R118 out, and also on the return journey; furthermore, the Commander received a report ‘conditions good at Blacksod’. The CVR indicates that the Commander later noted that reports from Blacksod indicated a cloud base as low as 300 ft and APP1 was used to bring the Helicopter down to 200 ft over open water before turning inbound to follow the APBSS route. This flight profile was in accordance with OMF which allows a minimum height of 200 ft with the helicopter’s collective axis coupled to RALT, and an absolute minimum of 50 ft helicopter hover with collective coupled to an AFCS SAR mode height hold.

However, OMF also requires visibility sufficient for the requirements of the task and to satisfy any OMB requirements for system modes being used. Although not a system mode requirement, OMB says ‘DVE is defined as visibility less than 4000 metres or no distinct natural horizon. Circuits shall be flown at 500 feet with reference to the RADALT with speed at least VY. Once established on the final approach track inside 2 nm at 500 feet, couple or remain coupled to RALT, HDG and IAS and beep down to 300 feet (or deck elevation plus 50 feet, whichever is the higher), to be level by around 1 nm to run.’

The Crew completed DVE Approach checks, indicating that they expected that they would be operating in DVE conditions. However, in descending to 200 ft, whilst it allowed the Crew to obtain COCISS conditions (clear of cloud, in sight of the surface), it eroded a safety barrier – height above the surface – without a definite improvement in terms of horizontal visibility. Furthermore, at 9 NM from Blacksod and 200 ft above sea level, operating just below the cloud base, at night, there were no external visual cues available (e.g. identifiable light sources or discernible features), to allow the Crew to assess horizontal/forward visibility.

[sycamore]

I find it a bit disconcerting that the briefing for the descent/approach was not more `formalised` ,ie everyone on the same `Hymn-Sheet`, front and rear crew ,copies of the `route` and noting all the heights..nothing seemed to be mentioned.Consider also that the W/Op had been on the crew of R116 doing a similar sortie on 8 March just a few days earlier,and had `that big rock` pointed out by that crew`s W/Man,when it had been overflown on the departure from BLKSD at 900FT,as that crew initially decided on a flyover at 500ft,but then decided 900ft would be better.
I would have thought that on return there would have been crew-room chat/discussions about a sortie into an unfamiliar `patch`,and the procedures.
For ref; page 66,p 1.8.7,;8/3/17. of the Report....

[[email protected]]

They could still have used their 'legacy S61' approach quite safely but kept at 2400' until BLKMO, descended to 1000' by BKSDA then 200' by BKSDB - that would have kept them clear of terrain and allowed them to get beneath the cloudbase by the time there might have been something (lights etc) to see to assess the weather/vis before a simple left turn into BLKSD into wind once abeam and visual.

Yes, it was 01:00 and they had been up for a while but this was an experienced crew who seemed happy to 'do it they way we have always done it' rather than utilise the capabilities of the aircraft.

The profile they flew would have been safe using NVG - not ideal but safe enough - but unaided at night over the sea is IMC and you wouldn't dream of being below SALT unless you were on an approach (internal or external aids) to your LS.

[TeeS]

I don't disagree with you Crab and if a SAR crew were responding to a vessel in the bay there, I realise that is the sort of process they would follow; however, in the absence of the 'low level route' I think it was unlikely that a crew would fly over an unexpected radar return at low level and I also suspect that the crew's arousal level would be higher in that situation than if they were following a known/reported route and missed one key piece of information, which is something we are all capable of doing.

My point is that Blacksod is a refuel point and as such is expected to be used on a regular basis, so there is no excuse for having to fly an ad-hoc IFR approach into it. The Authorities should be driving this forward for all operations where at the moment routine ad-hoc approaches are flown to regularly used sites, that includes corporate, SAR and HEMS in some areas.
Cheers
TeeS

[[email protected]]

TeeS - I agree and it highlights the complacency of the regulator and the operator in failing to ensure best practice.

[HissingSyd]

there might have been something (lights etc) to see to assess the weather/vis

This is something that has bugged me from the very beginning and rather pushes the question of NVG to one side.

They were flying straight towards a lighthouse flashing every 12 sec - an intense source - which they neither saw nor caught the loom of.

To me this implies that the visibility at that position and height was far worse that the reports and may have been only a few metres. The lamp was only 82 feet above them.

Both as a pilot who once spent a fair amount of time flying around at 200 feet over the sea in some appalling weather, and as a ship's navigating officer, I am mightily puzzled.

[212man]

Both as a pilot who once spent a fair amount of time flying around at 200 feet over the sea in some appalling weather, and as a ship's navigating officer, I am mightily puzzled.

I am too and the report doesn't really explain it, despite all the analysis!

[ChristopherRobin]

This is something that has bugged me from the very beginning and rather pushes the question of NVG to one side.

They were flying straight towards a lighthouse flashing every 12 sec - an intense source - which they neither saw nor caught the loom of.

To me this implies that the visibility at that position and height was far worse that the reports and may have been only a few metres. The lamp was only 82 feet above them.

Both as a pilot who once spent a fair amount of time flying around at 200 feet over the sea in some appalling weather, and as a ship's navigating officer, I am mightily puzzled.

It bothered me too, however read Appendix W in the technical appendices document (page 103) and it goes into why this would be so in some detail (pencil beam, optimised for shipping). Also, but not in the report to my knowledge, the moon (above clouds, so no idea how visible it was) was on the direct reciprocal of their final track, i.e. behind the lighthouse.

[HissingSyd]

It bothered me too, however read Appendix W in the technical appendices document (page 103)

Thanks for pointing me to that. It does strike a memory of loosing a light when getting close inshore. However, I also remember how much the loom could be seen in poor visibility and for much longer than the flash, if less intense.

[[email protected]]

I think the answer is that if you are not looking out of the window - because you are not expecting to see anything and you are heads in with FMS/radar etc - you won't see the lighthouse flash perhaps two or 3 times in that short period before you hit it.

Perhaps the weather was worse than expected and the lighthouse was in cloud - wearing NVG would have made that immediately obvious as you got to 200' in the letdown.

[ChristopherRobin]

Thanks for pointing me to that. It does strike a memory of loosing a light when getting close inshore. However, I also remember how much the loom could be seen in poor visibility and for much longer than the flash, if less intense.
I agree, although an additional factor is that the drift angle was 12˚L due to the wind from the rear right, so any light would have been offset to the left and not dead ahead. Ultimately, a contributory factor at best. CRM doesn't seem to be a major focus of the report especially around the approach briefing—unusual.

[Rotorbody]

My memory is of a ‘legacy’ route, initially created by Irish Helicopters to be used by the Bo105 servicing the Irish Lights contract. It’s purpose was to provide a ‘safe’ route between Blacksod and Blackrock Island, intended to be used for transit between both locations in poor weather conditions, subject to Day VFR regulations. At the time, flights at night could not be operated under VFR.

The ‘plate’ showed a magnetic track/reciprocal track and distance between each point on the route overlaid on the appropriate section of a VFR navigation chart. Each reference point was abeam an identifiable land feature. It pre-dated GPS and was flown on a time elapsed / dead reckoning basis. It was operated single pilot and without incident over the years although each pilot would have been very familiar with both the route and the topography of the area. It was never intended for navigation west of Blackrock Island.

Let us all remember that 4 people needlessly lost their lives in this accident. If it serves only 1 purpose, that is, if it causes you to examine more closely, to question and re-evaluate EVERY approach you consider making in ‘undetermined and unknown’ areas / conditions, then their sacrifice will not have been in vain.

[Davey Emcee]

Minister urged to accept all recommendations from R116 helicopter crash report (breakingnews.ie) (https://www.breakingnews.ie/ireland/minister-urged-to-accept-all-recommendations-from-r116-helicopter-crash-report-1215228.html)