View Full Version : SAR S-92 Missing Ireland
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From the article Fianna Fáil’s Dara Calleary, a Mayo TD, said: “I wonder why, as an island nation, we are contracting out our search-and-rescue, service?”
“Minister we cannot allow our search and rescue to become an issue of profit.”
Very good question.................
Hot_LZ
23rd Nov 2021, 20:41
Probably the same reasons most modern states tend to privatise vs nationalise.
LZ
Yes, trying to move it from the public balance sheet to a private one in order to move the risk away from Govt. It then allows blame and liability to be shifted away from the state if something goes wrong. Seems familiar in this case perhaps?
roundwego
24th Nov 2021, 11:58
Its not so much about shifting liability risk its about shifting financial risk. A privatised service will always work out cheaper. Not necessarily the best. That depends on oversight of the operator.
Not necessarily the best. That depends on oversight of the operator. Agreed, and that appears to have been found wanting in this case.
If everything is owned and regulated by the state, any issues should be quick to address since Govt departments tend not to sue each other.
Introduce a contractor on the other hand and things start to get messy when something bad happens and the reason(s) for it need to be established.
Manchester
24th Nov 2021, 16:08
How can you say that the oversight of the operator was found wanting in this case, and then imply that the operation should be owned and regulated by the very people who failed to handle even the oversight?
You also have a rosy picture of governments: “any issues should be quick to address“?? “quick to address” is simply not in any government’s skill set. Read yesterday’s Times article by the lady brought in from industry to buy covid vaccines so quickly and successfully. Selected excerpts include:
“across government there is a devastating lack of skills and experience in science, industry and manufacturing”
“there are very few people with science or operating backgrounds at all levels of government. This would not matter if we had senior civil servants with scientific and technical understanding, but we don’t”
“The machinery of government is dominated by process rather than outcome causing delay and inertia”
I’ve seen this from all sides and can only applaud her. Government is amateurs avoiding bad news, Industry is people moving quickly to fulfil often weak contracts (in order to win the next one) under often weak oversight.
https://www.thetimes.co.uk/article/kate-bingham-says-britain-is-put-at-risk-by-civil-service-groupthink-xqmhztc6p
Manchester
24th Nov 2021, 17:51
On second thoughts, I withdraw "amateurs" and substitute "generalists", i.e. potentially competent but lacking relevant experience
How can you say that the oversight of the operator was found wanting in this case, and then imply that the operation should be owned and regulated by the very people who failed to handle even the oversight? Because a Govt should ensure its regulators have the requisite skills and experience - that they often don't is a weakness of politicians and the people they select to be those regulators.
Industry didn't exactly cover itself in glory - how many years have CHC failed to introduce NVG when they all knew it was the industry standard.
As for the failings of Govt and the lack of expertise in the civil service - can you guess who has been systematically removing those skills and expertise from them? Oh yes, the Govt who doesn't like to be told No when they try something dodgy or egregious.
NumptyAussie
25th Nov 2021, 10:07
Industry didn't exactly cover itself in glory - how many years have CHC failed to introduce NVG when they all knew it was the industry standard.
Does the contract that CHC signed specify NVG would be used /implemented on the contract?
Does the contract that CHC signed specify NVG would be used /implemented on the contract? I suspect not and that is where the problems between a Govt and its contractors start.
At the point where the need for NVG is recognised - presuming the contract was written without it (unforgiveable in modern SAR) - the contractor says 'It's not in the contract - we need more money to provide that additional service level'.
The Govt has allocated a budget for SAR and it has spent it - not wisely it would seem - and can't lose face handing out extra cash to a contractor as that might set a precedent and/or make them look incompetent or foolish.
Round and round it goes until a fatal accident where both sides can now blame the other.
You only get as much safety as you are prepared to pay for........
Manchester
25th Nov 2021, 10:45
Inaccurate suppositions. Read the report. Get the facts.
Well you must be much cleverer than me Manchester because I can find no mention of the contract regarding aircraft spec and night capability - the only mention I can find of NVG is here
Between June and August 2015 work was carried out on EI-ICR to incorporate Night Vision Imaging System (NVIS)-compatible components into the aircraft. This work was carried out under an amendment (No. 13) to the contract between DTTAS and the Operator. Components were installed as part of a planned adoption of NVGs (Night Vision Goggles) by air crew. The work had the effect of changing the lighting environment within the cockpit to optimise it for use with NVGs, in particular by altering the intensity and tone of cockpit lighting and its colour spectrum. At the time of the accident the use of NVGs by crews had not commenced.
Indicating that a contract amendment was made (so not stipulated in the original) and enough money was found by DTTAS (Dept of Transport) yet it never went operational and it seems therefore that the crews were never trained.
Now there may be many reasons for that (not contained in the report) but the UKSAR S-92s were procured and utilised with NVIS so that rules out a technical issue. Possibilities are reluctance among crews to use NVG (most not ex-mil with any experience of them) or possibly DTTAS balking at the costs of modifying the aircraft, procuring NVG and then the large training bill associated with doing night SAR properly.
An interesting line earlier in the report refers to commercial pressure to get the transition from S61 to S92 completed and the loss of 2 weeks (it calls it ITAR) training. NVG/NVIS come firmly under the ITAR banner so should the service on S-92 actually have started with NVG embodied and crews trained?
As the THE NIMROD REVIEW conducted by Haddon-Cave found, contracting-out of services in safety-critical areas presents particular challenges, which must be recognised and addressed through appropriate structures and arrangements. The Investigation believes that whilst contracting out of aviation support services (including auditing) is a matter for the Department of Transport, it is imperative that the Department has sufficient in-house expertise to allow it to remain an ‘intelligent-customer’. The Minister outlined several measures that have been taken since the accident (Section 1.17.8.2 and Appendix U), including the planned appointment of a full time Aviation Manager.
My ongoing concern with contracting out.
jimf671
25th Nov 2021, 20:29
... ... the large training bill associated with doing night SAR properly. ... ...
A not widely understood factor that looms very large over every activity moving toward NVIS implementation, especially those like SAR having significant regulatory alleviations.
With that factor comes the inevitable question of whether the correct resources are actually available. This may be the part where Ireland has not covered itself in glory.
NumptyAussie
26th Nov 2021, 04:12
An interesting line earlier in the report refers to commercial pressure to get the transition from S61 to S92 completed and the loss of 2 weeks (it calls it ITAR) training. NVG/NVIS come firmly under the ITAR banner so should the service on S-92 actually have started with NVG embodied and crews trained?
The FLIR is ITAR controlled and would have probably required some training in its use.
The FLIR is ITAR controlled and would have probably required some training in its use. Good point - that explains the mention of a lack of training from the manufacturers for the rearcrew later in the report
NumptyAussie
26th Nov 2021, 10:43
Good point - that explains the mention of a lack of training from the manufacturers for the rearcrew later in the report
Somewhat ironic (in its saddest possible meaning,) that the only real night vision enhancement item on board the aircraft, could have saved the crew if there was a more rapid response to a verbal instruction from its operator.
Agreed, The problem with FLIR is that it doesn't see through cloud and rain well and it is difficult to make a weather assessment using FLIR. So if the weather was worse than expected it would have been a late spot (as it appears to have been) of the rock in conditions of poor thermal contrast.
I don't know how much weight their SOPs gave to direction from the cabin on letdowns but I know most pilots I have flown with would have taken immediate hands-on action to the 'Come right' request.
Sumpor Stylee
26th Nov 2021, 21:40
Little weight to LLIF and direction from rear crew in CHCI, and they never did any in their military careers. Not even trained to navigate. Certainly U.K. levels of crew driven letdowns and transits were not practised and not SOP.
172510
27th Nov 2021, 18:11
How can you say that the oversight of the operator was found wanting in this case, and then imply that the operation should be owned and regulated by the very people who failed to handle even the oversight?
:) That's the point
roscoe1
28th Nov 2021, 00:10
With reference to commands from the crew being responded to immediately. Years ago we had aHEMS helipad right next to the airport beacon pole/ tower. Bad idea to begin with but such it was. One day one of the pilots was launching and had started a drift that would certainly have ended in a sad way but for a flight nurse who said one word. That word was "pole!!". They were probably less than a foot away when he responded. The pilot was so shaken by this lapse that he set it back down to regain some composure before moving on. Nobody at that base was into the pilot versus med crew baloney you so often hear about.
mickjoebill
28th Nov 2021, 08:41
In regard to incorporating FLIR into nav, I recall a night flight with a UK police airwing where the crew was given location of the job, which was identified with address and as being near a local power station cooling tower. As we took off the observer, new to the role and to operating FLIR, used FLIR to identify the power station, but was aghast when it became apparent the aircraft was not flying toward it!
A very animated conversation followed. Resolution not helped by having a doc tv crew onboard which was a new experience for the crew. The pilot agreed that the image was the power station but given it was a night flight he said no, he was "sticking to my instruments" and he "had to believe his instruments".
Just as well, as the FLIR had picked up a power station in the next county, rather the one to which they had been dispatched. (another scene to hit the cutting room floor)
Mjb
BoeingDriver99
17th Dec 2021, 07:58
Final report out. Executive summary running to 21 pages, 71 findings and 12 contributory causes.
Concise and clear it is not.
200ft ASL in a dirty Atlantic night, 9nm from touchdown.
212man
17th Dec 2021, 08:25
Final report out. Executive summary running to 21 pages, 71 findings and 12 contributory causes.
Concise and clear it is not.
200ft ASL in a dirty Atlantic night, 9nm from touchdown.
Thanks, but if you go back 5 pages you will see it came out 5th November
Cyclic Hotline
2nd Jun 2022, 13:19
https://www.independent.ie/irish-news/jury-in-r116-helicopter-crash-inquest-return-verdict-of-accidental-death-41714084.htmlBREAKING Jury in R116 helicopter crash inquest return verdict of accidental deathhttps://www.independent.ie/irish-news/1ab63/41714083.ece/AUTOCROP/w620/R116%20victims (https://www.independent.ie/irish-news/jury-in-r116-helicopter-crash-inquest-return-verdict-of-accidental-death-41714084.html#) R116 victims avan Murray (https://www.independent.ie/opinion/independent-journalists/eavan-murray/)June 02 2022 12:51 PM
The jury in the inquest into the Irish Coastguard R116 helicopter crash, which resulted in the deaths of four crew members – the pilot Capt Dara Fitzpatrick, co-pilot Capt Mark Duffy, and winchmen Paul Ormsby and Ciaran Smith – have returned a verdict of accidental death.
The jury retired to consider their verdict on Wednesday evening and resumed Thursday morning.
In her summation of the evidence and guidance to the jury, North Mayo coroner Dr Eleanor Fitzgerald said a finding of accidental death would be akin to a straightforward drowning.
While a finding of death by misadventure was akin to a person swimming while intoxicated and then drowning.
The inquest heard harrowing evidence of R116’s final moments as the crew realised they were within 12 seconds of impacting Blackrock island.
All those on board the Rescue 116 helicopter lost their lives when the aircraft crashed into Blackrock Island at 00.46 on March 14, 2017, off the Mayo coast.
In the immediate aftermath of the tragedy, the body of Captain Dara Fitzpatrick was recovered from the sea, and 12 days later, the remains of Captain Mark Duffy were recovered from the cockpit of the submerged wreckage.
However, the bodies of winch operators Paul Ormsby and Ciarán Smith were never recovered, and their deaths have been recorded as lost at sea.
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The inquest, which was overseen by the Coroner for North Mayo, Dr Eleanor Fitzgerald, heard from 23 witnesses, including the chief air accident investigator who found the tragedy occurred due to a myriad of both operation and human factors.
During the deliberations, the jury sought clarification from the Air Accident Report Investigator Paul Farrell about the conclusions and safety recommendations he found.
Last November, a 350-page Air Accident Investigation Unit (AAIU) report into the tragedy laid out the chain of events that led to the accident.
The report found several issues relating to the navigational aids used by the crew on the night of the accident.
The inquest also heard there were also human factors such as crew fatigue and poor lighting in the cockpit as potential issues which led to the tragedy.
The AAIU made a total of 42 safety recommendations. Nineteen of those were addressed to CHC Ireland; the company contracted to operate air search and rescue (SAR) operations in Ireland.
These included suggestions to carry out a review of navigation aids, enhanced crew training and improved monitoring of missions and decision making.
Other recommendations were made concerning the Department of Transport’s oversight of SAR and Coast Guard operations. The Aviation Authority and the European Commission also advised to take action on foot of the report.
One finding to emerge from the investigation was that R116’s initial intention was to refuel in Sligo rather than Blacksod due to concerns by Capt Fitzpatrick about weather conditions.
However, during the flight from their base in Dublin, Capt Fitzpatrick was assured by her colleagues in R118 that weather conditions in Blacksod were fine, and the aircraft switched course.
The first witness called in person was Mr Ian Scott, the station officer at Malin Head Coastguard station.
Mr Scott defended his decision to task R116 to provide top cover to R118 during a rescue of a fisherman who had amputated his thumb above the knuckle on a trawler 140 nautical miles off the west coast.
Top cover is where a second aircraft attends an incident at least 100 miles off the coast, observing the rescue operation and assisting if required.
The second aircraft also assists with communications between the vessel, rescue aircraft and the dispatcher.
Questions arose as to whether a medical evacuation by R118 of the injured fisherman was required in the first place.
Departing from his witness statement, Mr Ian Scott, a station officer at Malin Head Coast Guard, offered his condolences to the bereaved families.
Mr Scott said he had 42 years of experience and felt the thumb injury received by the fisherman on the trawler was life-threatening as he heard the words “bleeding out”, “blood spurting”, “severe pain”, and “amputation”.
“It is my opinion that man needed off that vessel,” he said.
“I would make the same decision now. I have to make decisions on the information I have.”
Coroner Dr Fitzgerald asked Mr Scott if he believed the injury to the fisherman, who caught his thumb while hauling in a fishing net, was “life and death”.
“It could well have been,” he replied.
Dr Fitzgerald asked if he still believed it was the right decision to evacuate the casualty “even in the middle of the night”?
Mr Scott said the person was bleeding and “If I had left him, he could have died”.
He added that before he tasked R116 to provide top cover, he initially tried the Air Corp and a British Nimrod fixed-wing maritime patrol aircraft, but neither were available.
Mr Scott said he was taken aback to hear subsequently that a doctor whom he consulted with on the night had said in a statement she did not recommend a medical evacuation of the casualty.
“At no time was I told she disagreed with that decision,” Mr Scott said
In her evidence, Dr Mai Nguyen, who was then an Emergency Department Registrar in Cork University Hospital, said when she spoke to Mr Scott, the rescue helicopter had already been dispatched.
Dr Nguyen said from her memory of the incident, she felt at the time the dispatch of the Sligo based R118 Coast Guard helicopter “was probably an excessive thing” but that it was not her call.
“I was a first-year resident I did not have the power to stop a helicopter making that journey.
“I personally felt the injury was minor in nature and wouldn’t have sent the Coastguard out there because the thumb couldn’t have been saved.”
She told the inquest she provided medical advice on how to treat the injured fisherman but also said that given how far the vessel was out to sea, she did not think the thumb could be saved.
The Air Accident Investigation Unit (AAIU) report into the crash found that procedures governing the dispatching of a Coast Guard helicopter were not conducted in sequence.
Mr Scott detailed extensive efforts to contact R116 after he was informed by the lighthouse keeper at Blacksod lighthouse, Vincent Sweeney, that the helicopter did not arrive as scheduled to refuel.
Mr Scott said he was very alarmed to hear at 1.06am on March 14, R116 was missing and uncontactable.
The coroner heard both Mr Scott and Mr Sweeney made extensive efforts to make contact with the helicopter via radio and a satellite phone.
Mr Sweeney, the lighthouse keeper told Dr Fitzgerald he was on duty having been alerted to the injured fisherman at 9.55 pm on March 13, 2017.
He told the inquest that R118 first arrived to refuel and he was informed R116 would follow later in the night.
Mr Sweeney said at 00.26, he spoke with R116 and understood they would be landing shortly.
It was previously established that R116 disappeared from radar at 00.46 am.
Mr Sweeney said he went outside to wait for the helicopter but was unable to see or hear it approaching.
“The longer this went on, the more concerned I became,” he said.
Mr Sweeney also told the inquest that visibility deteriorated rapidly and what was initially “a mist” developed into “a deadly fog”.
“It happened in a matter of minutes,” he said.
Vincent Sweeney estimated visibility at 400-500ft earlier in the night on the night but minutes before R116 was due to land to refuel, visibility “dropped fast”, to the point that “you’d hardly see your arm in front of you”.
The inquest into the deaths opened in April 2018, when preliminary evidence was heard.
Proceedings were adjourned pending the completion of a number of investigations into the crash.
A Garda inquiry was finalised in 2019, resulting in a file being sent to the Director of Public Prosecutions (DPP), which directed no prosecutions.
During a break in the proceedings on Wednesday, Mr Ian Scott, who dispatched R116 on the night of tragedy, approached relatives of the crew, including Capt Dara Fitzpatricks’ mother and said he was so sorry for their loss and he thinks of the tragedy and their loved ones every day.
Mr Scott was warmly embraced by each of the bereaved family members.
BoeingDriver99
2nd Jun 2022, 14:42
I wonder how many amputated thumbs have precipitated death in recent years?
Bizarre to focus on the dispatch of the rescue helicopter rather than the cause of the crash to the top cover one.....I know the launch of one precipitated the launch of the other but in the big scheme of things is very low down on the contributory factors.
I suppose accidental death keeps all parties happy - no blame attached and 'just one of those things'.
malabo
2nd Jun 2022, 20:13
What a crock of ****. Same jury that recently heard the Depp-Heard case I suppose. And I'll take their verdict just as seriously.
BoeingDriver99
2nd Jun 2022, 22:39
If you produce a 350 page report and make 42 safety recommendations then you spread the responsibility sufficiently thinly that no one person or organisation has to do anything at all, there is no accountability and nothing ever changes. Couple that with the rapid, public deification of the crew means that nothing is learned from their needless, preventable deaths.
But sure ‘tis grand.
Fark'n'ell
3rd Jun 2022, 05:33
Mr Scott said he had 42 years of experience and felt the thumb injury received by the fisherman on the trawler was life-threatening as he heard the words “bleeding out”, “blood spurting”, “severe pain”, and “amputation”.
Removed my right thumb at the knucle 30 years ago.Hardly bled and didn't hurt that much.
jimf671
3rd Jun 2022, 14:55
I notice that the Coastguard had been unaware that during the previous seven years the neighbouring SRR (UK) had the same problem regarding top cover as Ireland (due to be fixed in both jurisdictions during coming years by current contract processes).
snakepit
3rd Jun 2022, 18:23
Bizarre to focus on the dispatch of the rescue helicopter rather than the cause of the crash to the top cover one.....I know the launch of one precipitated the launch of the other but in the big scheme of things is very low down on the contributory factors.
I suppose accidental death keeps all parties happy - no blame attached and 'just one of those things'.
When is prune going to give us a ‘like’ button!
SASless
4th Jun 2022, 02:11
I agree about the Like Button...some posts are worthy of public notice of approval.
BoeingDriver99
4th Jun 2022, 02:23
Or "just forty-two of those things" :8
Lude-og
4th Jun 2022, 10:57
Bizarre to focus on the dispatch of the rescue helicopter rather than the cause of the crash to the top cover one.....I know the launch of one precipitated the launch of the other but in the big scheme of things is very low down on the contributory factors.
I suppose accidental death keeps all parties happy - no blame attached and 'just one of those things'.
https://www.citizensinformation.ie/en/death/sudden_or_unexplained_death/inquests.html
Just an FYI about the purpose of a coroner's court (in Ireland, at least) and what they are empowered to determine, from the above link:
"Nobody is found guilty or innocent at an inquest, and no criminal or civil liability is determined. All depositions, post-mortem reports and verdict records are preserved by the Coroner and made available to the public.When the proceedings have been completed, a verdict is provided in relation to the identity of the deceased, and how, when and where the death occurred. The range of verdicts that can be declared by the Coroner or jury include:
Accidental death
Misadventure
Suicide (https://www.citizensinformation.ie/en/death/bereavement_counselling_and_support/support_services_for_those_affected_by_suicide.en.html)
Natural causes
Unlawful killing
Open verdict"
As you mentioned; the launch of one precipitated the launch of the other, but I think the reporting of that portion of the proceedings was a bit more interesting (read: highlighting the possibly questionable decision making process of the dispatcher), as opposed to it being a particular focus of the proceedings.
dervish
6th Jun 2022, 12:56
I find it alarming that they expected to be able to get a Nimrod to assist, six years after they'd left service.
Open verdict would have been a better verdict. It was an accident and they did die but, other than to record how they died, the coroners court is a waste of time - we already knew how but the why was the important part.
206Fan
16th Feb 2023, 05:53
Looks like R118 from Sligo has made the news.
https://www.derryjournal.com/news/irish-coastguard-helicopter-made-emergency-landing-at-derry-after-serious-incident-4026997
It has emerged the Sligo-stationed R118 helicopter – which is a familiar sight over Derry and Donegal where it often responds to emergency incidents – experienced problems on Sunday, February 5.
An Irish Coastguard helicopter had to make an emergency landing at City of Derry Airport after suffering a ‘serious incident’ in flight, it has emerged.
The aircraft was overstressed, lost control and exceeded its maximum airspeed. The UK Civil Aviation Authority has impounded the aircraft to conduct a full investigation.
212man
16th Feb 2023, 10:58
Looks like R118 from Sligo has made the news.
https://www.derryjournal.com/news/irish-coastguard-helicopter-made-emergency-landing-at-derry-after-serious-incident-4026997
Why the UK CAA, and why would they be doing an investigation? Any investigation will be done by the AAIU
SASless
16th Feb 2023, 13:20
Could it be because CHC is the Operator and is a UK based Company that might trigger the CAA's involvement or is that just yet more proof the Media fails to fact check themselves?
JB-123
16th Feb 2023, 13:33
City of Derry is in the UK....
Robbo Jock
16th Feb 2023, 13:37
Derry is Northern Ireland, hence UK. Probably has something to do with it.
212man
16th Feb 2023, 13:39
Thanks I see that now!
albatross
16th Feb 2023, 17:20
Now how do you do get yourself in that situation?
I have a crackpot theory but will wait for the report.
malabo
16th Feb 2023, 20:53
Why in this thread? No relation to the fatal incident from years ago.
Though perhaps an AAIB investigation would actually find something since it would be independent of the local Irish SAR politics.
ApolloHeli
16th Feb 2023, 21:15
Now how do you do get yourself in that situation? ...
Not in any way suggesting it is the cause in this instance, but a friend once encountered +70kts windshear while transiting IMC. Nr overspeed, through Vne, the works... Not something I had considered possible but anecdotally it can happen.
rrekn
17th Feb 2023, 08:59
I heard from one of the lads that this was the usual overdramatised click-bait reporting on behalf of the sensationalised media... Crew encountered some clear air turbulence and made a precautionary landing, engineers did the standard conditional inspections and the aircraft flew out later that day...