The crash of Rescue 111: ‘The worst silence I ever heard in all my life’

[Davey Emcee]

The crash of Rescue 111: ‘The worst silence I ever heard in all my life’ (irishtimes.com) (https://www.irishtimes.com/life-and-style/people/the-crash-of-rescue-111-the-worst-silence-i-ever-heard-in-all-my-life-1.4762896)

[[email protected]]

What a waste of 4 lives.

Crap weather - who would launch in a helicopter to try and find a boat lost in thick fog?

They didn't need to be launched anyway as the boat had been found.

Poor fuel planning and diversion awareness.

Amateurs doing SAR.

[gulliBell]

The thing is, when you read that story, as you continue to read you just know the inevitable outcome.

[[email protected]]

Sadly, it is a well known accident as it had been used as a cautionary tale in UK Milsar for many years.

[212man]

If they’d turned off the landing/search light and flown it coupled to 70 ft on the ILS, there’s probably a good chance they could have got in on a third attempt - after flying the first two to normal minima.

[500 Fan]

Amateurs doing SAR.

Is it the Coastguard dispatcher that you are referring to as an "amateur" or the four deceased crew members?

500 Fan.

[malabo]

Some similarities with the more recent S92 tragedy. Where was the operational control and standards? With the boats in heavy fog, why attempt a beach cloud break when there is a perfectly good ILS nearby that can be flown at 60 knots to impact on a flat unobstructed surface?

Thanks 212man, my pet peeve on night ILS in fog or blowing snow is pilots wanting the landing light on because the checklist says so. Probably the same guys that would overshoot at DH despite there being no other better options.

[[email protected]]

Is it the Coastguard dispatcher that you are referring to as an "amateur" or the four deceased crew members? All of them and I don't speak ill of the dead lightly.

[[email protected]]

212man, the only Dauphin I have flown was the N3 and, although it only had a 3-axis autopilot, would fly a coupled ILS to level off at 60' down the runway - did theirs have the same capability?

[ShyTorque]

A low experience crew in a new, unfamiliar type of helicopter coupled with weather that was probably close to, or beyond even IFR limits. I doubt they had yet learned to take full advantage of the IFR capabilities of the aircraft in any case.

In the past I had to reluctantly turn down a small number of mission requests because I was experienced enough to know that they couldn’t be safely flown due to weather. In one particular instance I was seriously taken to task over my decision. A very senior police officer try to make a big deal out of it and made threats about my continued employment. He apparently then tried to call out two other helicopter units including RAFSAR who also refused to launch, for exactly the same reasons (heavy snow, strong winds and fog). On that occasion the allegedly missing people were not actually in distress at all and didn’t need rescuing, they had planned and were equipped to stay out overnight if needed and returned home unaware.

[212man]

212man, the only Dauphin I have flown was the N3 and, although it only had a 3-axis autopilot, would fly a coupled ILS to level off at 60' down the runway - did theirs have the same capability?
Had 4-axis.

[donner89]

A low experience crew in a new, unfamiliar type of helicopter coupled with weather that was probably close to, or beyond even IFR limits. I doubt they had yet learned to take full advantage of the IFR capabilities

Hardly a new type Shy. Introduced to the fleet in 1986. Accident occurred in 1999. There was a considerable media circus surrounding the launch of the 24hr SAR that day. That would certainly have influenced the decision making of the crew, to decline a flight on the first night…

[megan]

Formal report, still reading to form a view rather than a knee jerk response.

http://www.aaiu.ie/sites/default/files/report-attachments/13091-REPORT_2000_011-0.PDF

[ShyTorque]

Hardly a new type Shy. Introduced to the fleet in 1986. Accident occurred in 1999. There was a considerable media circus surrounding the launch of the 24hr SAR that day. That would certainly have influenced the decision making of the crew, to decline a flight on the first night…

I meant it was new to the crew!

[megan]

There was a considerable media circus surrounding the launch of the 24hr SAR that day. That would certainly have influenced the decision making of the crew, to decline a flight on the first nightA quick skim of the report addresses this and comes to the conclusion that all the media hoopla would have had the effect of compelling them to accept the task. Rather than speaking ill of the dead I wish crab would address the report and give us the benefit of his SAR experience by commenting on the facts. Trashing the crew brings no lessons learnt to the table. Sorry.

[Declan275]

212man, the only Dauphin I have flown was the N3 and, although it only had a 3-axis autopilot, would fly a coupled ILS to level off at 60' down the runway - did theirs have the same capability?

The DH had a very advanced avionics kit for it’s day including a 4 axis autopilot with a Sar modes such as auto hover , trans up, trans down etc. It was actually very good when it all worked. It was however obsolescent at the time of the accident. Re: the 70/70 apch, it was not practiced and was not as straight forward as just letting an AW139 for example, continue down to ALVL on an ILS with an automatic change of coupled modes.

The pilots had nearly 600hrs and 390hrs on type and both had over 2000hrs total. The monthly training requirements for an AC SAR crew at the time more than covered IFR requirements and currency on type.

[gulliBell]

...The pilots had nearly 600hrs and 390hrs on type and both had over 2000hrs total.

Once the fog was so thick you couldn't even see your hand in-front of your face, once the fuel situation did not allow for a diversion no amount of experience would save you from an unfortunate outcome. Experience should be relied on not to get yourself into that dire situation in the first place, rather than be relied upon to get yourself out of the dire situation you got yourself into.

[Declan275]

[QUOTE=Experience should be relied on not to get yourself into that dire situation in the first place, rather than be relied upon to get yourself out of the dire situation you got yourself into.[/QUOTE]

Agreed, I was referring to the comment that the aircraft was new to them or the Air Corps. It had been in service since the mid eighties and would have been very much a known quantity both organisationally and to the crew. There had been a daytime SAR operation in Waterford for years, it was the night element at that base and the location/type mix that was new.

[[email protected]]

A quick skim of the report addresses this and comes to the conclusion that all the media hoopla would have had the effect of compelling them to accept the task. Rather than speaking ill of the dead I wish crab would address the report and give us the benefit of his SAR experience by commenting on the facts. Trashing the crew brings no lessons learnt to the table. Sorry.
To start at the beginning of the analysis - this was not a life-saving mission, they casualty vessel was lost and the only medical issue was seasickness.

They were initially called out and then stood down - they did not need to launch.

Having made the decision to launch in pi** poor weather, they did not seem to have made any plan for diversion or considered diversion fuel planning.

Not taking extra fuel on a poor weather search was a major error - always plan for the worst and fuel jettison was possible.

Leaving scene should have happened earlier - the casualty vessel was under tow and close to the harbour.

Having gone around from the first ILS and seeing nothing of the airfield was the time to think about diverting.

Having gone around from the second (probably much lower) the consideration of a trans down to the airfield should have been made.

Electing to make a downwind approach to the coast with no viable escape route was, as it proved, asking for trouble.

An approach on a Northerly heading, to the hover in the bay would have allowed subsequent slow speed manoeuvring to the coast - it would have given a more credible left turn into wind and out of the bay as an escape route.

Long crew duty day with no rest periods, non SAR-Squadron pilots (the unit QM and a QHI) flying more than one type, P1 with limited experience of the area.

Ultimately the Captain is responsible for the safe conduct of the flight and must consider variables such as weather, fuel, possible diversion etc.

The P2 and rearcrew are part of the crew and on SAR should have an equal voice regarding the conduct of mission planning and execution - without CVR we won't know anything about that unfortunately.

The mission was launched 'to let them have some practice' by the tasking authority despite the first decision to be to stand them down - that shows how little the flight needed to happen.

[gulliBell]

...The P2 and rearcrew are part of the crew and on SAR should have an equal voice regarding the conduct of mission planning and execution - without CVR we won't know anything about that unfortunately..
The time for talking was before they launched in the first place. Had there been a pragmatic and sensible and open and inclusive discussion/appreciation at that stage they would have turned the bus around and gone home. Given that discussion didn't happen, chances are it probably wouldn't have happened in flight either. Or if it did, would have been about as useful as the discussion wasn't in the Rescue 116 accident.

[[email protected]]

Gullibell - true but it would seem the decision to cancel stand down and launch instead was between the Captain and the tasking authority - however, I would still expect him to consult the crew in light of the weather and lack of urgency of the task.

Perhaps the 'can-do' attitude of the crew, mentioned early in the report was a factor in launching with no need.

[500 Fan]

Trashing the crew brings no lessons learnt to the table.

Agree with this sentiment.

500 Fan.

[[email protected]]

Agree with this sentiment. perhaps that sentiment is why they never addressed the issues and Irish SAR continued to struggle for many years.

Yes, there are a lot of contributory factors to do with experience dilution, organisational structure (the IAAC didn't have a Flight Safety setup at all) and the overly lengthy report goes into them all in great detail and only points out the crews failings in vague terms. The problem is that it allows each party the ability to offset their share of the blame with the others and the effect of any major causes is lost in the noise.

I spent a lot of time professionally, teaching and mentoring junior SAR pilots and Captains for the very good reason that if you make crap choices or fail to plan properly for a SAROp, you can get quickly caught out and end up in trouble. The first rule of first aid is not to become a casualty yourself and the same applies to SAR.

If you don't find fault with poor decisions made by the crew, how are you ever going to stop the next crew doing something similar when the pressure is on?

[MightyGem]

In one particular instance I was seriously taken to task over my decision. A very senior police officer try to make a big deal out of it and made threats about my continued employ
Very strange. In my 17 years flying for the Police, I turned down many tasks due to weather and was never questioned over my decision.

[megan]

I spent a lot of time professionally, teaching and mentoring junior SAR pilots and Captains for the very good reason that if you make crap choices or fail to plan properly for a SAROp, you can get quickly caught out and end up in trouble. The first rule of first aid is not to become a casualty yourself and the same applies to SARYour final sentence is true of any operation crab, not just SAR. Spent nearly three decades flying for an oil company owned and operated off shore operation and the operation paid no attention to rules or regs, and the aircrew to a man, including check and training, happily accepted the status quo, me included until the lights turned on in the final few years, the phrase "Normalisation of Deviance" covers the scenario at work. One of the check and trainers later went on to be the organisations regulatory overseer (FOI - Flight Operations Inspector), didn't change anything, nor did it change anything when the regulatory head office learnt of how operations were conducted

[gulliBell]

...Spent nearly three decades flying for an oil company owned and operated off shore operation and the operation paid no attention to rules or regs.

Not-with-standing, they must have been doing something right because you don't operate in that harsh offshore environment for 30+ years without a single accident relying on pure luck alone. I mean, it's basically the same operating environment as the North Sea, and in the North Sea how many aircraft have been lost and passengers killed over the same period? Plenty, I bet.

[speedrestriction]

Amateurs doing SAR.

Wrong - it was worse. Professionals doing SAR without the right training and organisational safety systems in place and not adequately overseen by a regulator. The crew paid the price for a defective system.

The Irish Air Corps were chronically underfunded in the late nineties. I have no idea about now but back then it was not unusual for flying hours on some fleets to be heavily restricted for budgetary reasons - money being conserved to make sure the maritime patrol and government jet could stay flying until the end of the financial year.

[[email protected]]

The crew paid the price for a defective system Agreed but it was the crew that decided to launch in poor weather with no diversion - even a just-out-of-training student pilot could have made the decision not to go just looking at the weather.

When you know you are part of a creaking system, that is the time to be more careful not less - look after number 1!

Professionals doing SAR without the right training and organisational systems are, by definition, amateurs.

[Sir Korsky]

Crab's commentary is the brutal truth, wherever it tends to fall on your emotional scale.

[Two's in]

Back to an earlier comment made by crab, the nature of accident reports now almost demands the listing of the myriad of secondary or tertiary factors. This is not necessarily a bad thing, but it carries the risk of diluting or obfuscating the primary causes - certainly to the uninformed or ill-informed. Sometimes there is a very obvious cause and effect linkage, but not always. In this case, simply taking off in those weather and light conditions set in motion a series of events that led to the almost inevitable and tragic outcome. The decision whether or not to lift is fundamental tenet of captaincy and airmanship, commercial or operational pressures don't suddenly increase your flying ability or improve the weather, but they do undermine your ability to make logical and safe decisions.

[megan]

Not-with-standing, they must have been doing something right because you don't operate in that harsh offshore environment for 30+ years without a single accident relying on pure luck aloneYou'd make a good manager Gulli, that was the exact excuse management made for not complying with rules and regs, we've never had an accident, but it was only through pure luck and some skillful flying that avoided any crunched metal, all major incidents occurred in benign circumstances. Personally I had absolute faith in our maintenance, top notch. There were some major lapses in maintenance of course, it happens in all systems, such as powder found coming out from the elastomerics on the four main blades, bearings had not been installed during a rebuild, errors/incidents occurred, but in the system that prevailed you never heard of what went on unless you were personally involved. Perhaps you can tell of your interview you mentioned in a post here a short time ago, I have an idea, but not with any surety.

You'll remember the take off charts where you extracted whether you could meet cat A or B, the figures were bollox and not one pilot was aware over the years that was so, until changed at the behest of one pilot after years of agitation. Figures were such that in some areas where you thought you had cat A capability if put to the test you were going to find yourself in deep do do.

How did you go about ensuring you had an alternate for offshore operations as required by the CASA supplement in the flight manual and the Ops Manual? I could go on.

You'll remember the following, why didn't you comply?


https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/2000x1282/ab202_f2abdc9286e735a5802fbff68fb3f1ceae2547f2.jpg

[gulliBell]

...You'll remember the following, why didn't you comply?

The pilot is always going to be the poor bunny who gets stood in front of the firing squad after an accident, because surely after every accident the subsequent inquiry will find he failed to comply with the FOM in some way. And if the same pilot religiously followed the requirements of the FOM and parked the bus a few times because of it then management is not going to be happy about it and he risks being marched out the door with a don't come back Monday letter. That is the reality of the situation, it's a no win.
Some of the FOM I worked under in PNG were so ridiculously onerous there was no way to comply and get the job done. Such as requiring a 10% power margin for all external load jobs, for example. They are written by people who like a lot of words, who like big thick manuals, who have no practical insight to the needless complexities of their own making, etc. When I started agitating about making changes to manuals because what was written was stupid and stopping me from getting the job done it was viewed by management as being a trouble maker. I was happy to do all the legwork to make the changes, but treading on the toes of those in the company who were responsible for producing these rubbish operational documents seriously upsets the apple cart.
In the operation you referred to for sure there were incidents where luck was shining on them. Plenty of other examples. An S76 out of maintenance arriving at Tuna with no oil in the TRGB. But fundamentally I think the operation had such a good safety record for the reasons you mentioned, plus the pilots were all competent and operationally astute. Although I do remember a few closed door Monday morning parades in MM's office after he found out about the occasional weekend shenanigans, stories which had become highly embellished I point out, which might have stretched operational flexibility a bit too far. Especially if a company aircraft had been observed on the Tuna via Sperm Whale Head low level route.

[[email protected]]

To continue from Two's in's post - I have seen the accident investigation system go from blaming the pilot to not blaming anyone and both are counter-productive to Flight Safety.

Blaming the pilot was often an easy way out for management (MoD for instance) to prevent organisational, supervisory, engineering or budgetary causes from being highlighted.

Not blaming anyone affords the same people the same opportunities but by obfuscation in a deluge of extraneous data instead of misdirection using a scapegoat.

Why? Because admitting fault means losing jobs, funding, credibility or, most importantly, money.