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SAR S-92 Missing Ireland

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SAR S-92 Missing Ireland

Old 14th Apr 2017, 11:19
  #881 (permalink)  
 
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Three why's that need to be asked...

1. Why did they use the company route?
2. Why did the not know about Blackrock and its location?
3. Why did they not have NVD (helmet mounted).?
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Old 14th Apr 2017, 11:24
  #882 (permalink)  
 
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Originally Posted by ODEN View Post
Three why's that need to be asked...

1. Why did they use the company route?
2. Why did the not know about Blackrock and its location?
3. Why did they not have NVD (helmet mounted).?
4. Why did they not notice a huge blob on the radar (cockpit procedures?)

Just a thought but I wonder how often the flew double-captain. Some captains are pretty bad at doing the copilot role. Of course the most dangerous is two training captains flying together!
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Old 14th Apr 2017, 11:29
  #883 (permalink)  
 
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An explanation for the missing EGPWS data:
I assume these are based on radar satellite data which results in a 3D model of mother earth. If you look at Blackrock via Google Earth, you will find out that there the elevation is also not more than 12m ( ~39ft ) ...

skadi
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Old 14th Apr 2017, 12:06
  #884 (permalink)  
 
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Why did they not notice a huge blob on the radar
Completely unfamiliar with the aircraft but the report says it used its Weather Radar in a certain mode, implying a compromise. If it doesn't have a separate search radar, how good is a Weather one at picking up and displaying this?
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Old 14th Apr 2017, 12:26
  #885 (permalink)  
 
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Lots of themes to explore here. It so often takes a tragic accident to expose systemic failures and weaknesses in an organisation's culture and operating practices. For those that haven't done it, operating a helicopter and managing a crew at low-level, in the dark, in poor weather and an unfamiliar environment is challenging to say the least. Those that have have all had their sphincter-tightening moments. When I think about it in detail I've had too many 'near-misses' for comfort. One that springs to mind was a very close encounter with a significant mast that was only avoided by a very late call of 'up, up, up' by my sharp co-pilot. And that was on a pre-recce'd low-level route using NVDs and it was a known and accurately marked obstruction!

I guess my point is that with the best will in the world, and multiple safeguards, tragic accidents like this are waiting to happen. Pointing the finger is not helpful; what is required is a very honest and thorough review of every aspect of this accident so that the risk of a similar one happening in the future is removed as far as possible. Only then will the friends, families and colleagues take some comfort in this tragic loss.
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Old 14th Apr 2017, 12:31
  #886 (permalink)  
 
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Originally Posted by dervish View Post
Completely unfamiliar with the aircraft but the report says it used its Weather Radar in a certain mode, implying a compromise. If it doesn't have a separate search radar, how good is a Weather one at picking up and displaying this?
If I recall from the preliminary report, weather radar was being operated in a ground mapping mode which should have clearly shown ground returns. I think the CVR transcript has the co-pilot mentioning the ground return (Blackrock) as they were turning inbound from the procedure turn.
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Old 14th Apr 2017, 12:35
  #887 (permalink)  
 
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Originally Posted by Mark Six View Post
Agree completely with roundwego. You can't look at one page of that particular route guide in isolation from the rest of the information on the second page...
A PROC should be described on a single page, with all the critical information needed to fly it presented in plan and elevation view. I have never seen a PROC spread out over multiple pages.
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Old 14th Apr 2017, 12:37
  #888 (permalink)  
 
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Originally Posted by Older and Wiser View Post
Maybe we should stop beating round the bush.
The operators let down procedure clearly shows Black Rock at 282'
It would have also been visible on Radar and would have been a waypoint in the system. There is no reason not to know that there was a big lump of rock with a light on it that was 282' AMSL. It is the start point of a company procedure not the point to be at 200'.
This is all very sad, who knows if the pilot had reacted immediately when the Winch Operator first called for a right turn would it have been enough; rather than the PF questioning the turn request.
13 seconds between the first (calm) warning of an island and the impact. Heading change completed and confirmed 10secs after this warning. Final shouted warning 3 seconds before impact. Rapid control inputs as that happened. The front crew had no idea what they were reacting to, what actions were required, or how immediately it was required. They reacted as they should to any change in heading without realising the emergency facing them. A fly up command may have been "better" and less confusing to the pilot but we have no right second guessing them.

The flir image would not have given good depth-perception or rate of closure... unlikely that the rear crew realised how close it was either to begin with. Only ten seconds later it was apparant that things were not good.

The world was against them from the start of that 13 seconds unfortunately. They nearly made it. So nearly.
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Old 14th Apr 2017, 12:57
  #889 (permalink)  
 
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Thanks gulliBell
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Old 14th Apr 2017, 12:58
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The problem is the managing of the automation - the rearcrew called for the heading change, then the captain asked the co to select the heading so, by the time the heading actually changed it was far too late.

An instant hand-control input to change the heading could have avoided the rock or made the last minute 'f**k me' change of heading sufficient to avoid impact.

There has been much written and said about the 'children of the magenta' and the belief that more automation makes things safer - this accident happened to a perfectly serviceable aircraft with more bells and whistles designed to make the aircraft safer.
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Old 14th Apr 2017, 13:15
  #891 (permalink)  
 
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Originally Posted by [email protected] View Post
The problem is the managing of the automation - the rearcrew called for the heading change, then the captain asked the co to select the heading so, by the time the heading actually changed it was far too late.

An instant hand-control input to change the heading could have avoided the rock or made the last minute 'f**k me' change of heading sufficient to avoid impact.

There has been much written and said about the 'children of the magenta' and the belief that more automation makes things safer - this accident happened to a perfectly serviceable aircraft with more bells and whistles designed to make the aircraft safer.
This is true, but the issue arose only after a major cockup had occurred. I suggest the primary target for any review should be why the cockup occurred, not why the sudden and unexpected need for an evasive change heading (or climb) was executed slower than it could have been.
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Old 14th Apr 2017, 13:21
  #892 (permalink)  
 
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Originally Posted by [email protected] View Post
The problem is the managing of the automation...
Exactly. In simulator training, many times I've seen the automation, doing exactly what the crew tells it to do, fly a perfectly serviceable helicopter into the ground whilst the crew watched. When crews are doing "stick and rudder" hand flying, the prevalence of CFIT, in my experience, seems to be far less. The physical interaction of the stick and rudder flying seems to install an additional degree of mental alertness that you just don't see to the same extent when pilots are just monitoring automation. As a teacher it can get frustrating to watch, you feel like ripping out all the automation and have the crews get back to fundamentals and using just the basic set of IFR tools.
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Old 14th Apr 2017, 13:25
  #893 (permalink)  
 
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Originally Posted by gulliBell View Post
Exactly. In simulator training, many times I've seen the automation, doing exactly what the crew tells it to do, fly a perfectly serviceable helicopter into the ground whilst the crew watched. When crews are doing "stick and rudder" hand flying, the prevalence of CFIT, in my experience, seems to be far less. The physical interaction of the stick and rudder flying seems to install an additional degree of mental alertness that you just don't see to the same extent when pilots are just monitoring automation. As a teacher it can get frustrating to watch, you feel like ripping out all the automation and have the crews get back to fundamentals and using just the basic set of IFR tools.
Automation may cause accidents, but far more accidents are caused by humans flying without automation. The trick is to train to use it correctly and appropriately, not to rip it out and hand fly everything.
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Old 14th Apr 2017, 13:25
  #894 (permalink)  
 
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Gullibell - completely agree - over-reliance on the drift diamond or trying to use the heading function of the AP in an NDB hold - proper pilot flying beats them both every time.

HC - by 'cock-up' do you mean using the rock as a WP?
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Old 14th Apr 2017, 13:28
  #895 (permalink)  
 
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jimjim
The flir image would not have given good depth-perception or rate of closure... unlikely that the rear crew realised how close it was either to begin with. Only ten seconds later it was apparant that things were not good.
If they had been wearing NVG, they would have seen the big rock ahead, it should have appeared on the radar picture and the GPWS would have warned them if they had been going faster - lots of holes in the cheese.
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Old 14th Apr 2017, 13:28
  #896 (permalink)  
 
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Automation designed to ease the workload of procedural flying has very little place in SAR, AA or Police work, which is predominantly VFR with IMC outside of controlled airspace. What are 'children of the magenta' btw?
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Old 14th Apr 2017, 13:42
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Al-bert

It refers to a generation of pilots that have grown up using automation.

Youtube: Children of Magenta

A presentation well worth watching if you haven't seen it.
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Old 14th Apr 2017, 13:43
  #898 (permalink)  
 
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Originally Posted by Al-bert View Post
What are 'children of the magenta' btw?
Masters of the magenta - the real story - Air Facts Journal

skadi
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Old 14th Apr 2017, 13:50
  #899 (permalink)  
 
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I'm slightly concerned at the amount of finger pointing already at systemic failure and management responsibility for this. Fundamentally the accident happened because the crew deliberately descended to, and maintained, 200ft at night, in either poor VMC or IMC, and tracked straight towards a 300ft rock that was marked on their more detailed moving map charts and (albeit not ideally) on the approach guidance they were using, and mentioned in the accompanying notes.

There must be a high chance that the crew did not have one of the more detailed charts displayed and had not read the accompanying approach route notes, despite them being unfamiliar with the approach to Blacksod. And when there were warning signs, they were too slow to respond. Whose responsibility can this be, other than the flight crew? It's not as if this was an unplanned, emergency diversion with little time to study - they had been flying en route for an hour an half, presumably with no great crew activity required, before they started descending for Blacksod.

Even before they departed Dublin, surely a major part of their flight planning would have been considering the likelihood of refuelling at either Sligo or Blacksod, and considering how they were going to let down into Blacksod. They presumably had access to charts at Dublin to study ref the Blacksod approach - and certainly my 1:500,000 one shows Blackrock and its height. And then if it was me, (corporate only, admittedly) I would have also looked at Google earth for any further info - where again Blackrock is shown, albeit, as Skadi says, with the wrong elevation - not that you'd take too much heed of this.

Using the approach they chose was clearly a mistake, so why did they? Were they so entrenched in SOPs they just chose one (most common?) that seemed routine, having missed the elevation of waypoint BLKMO and therefore the approach's suitability?

As HC says, is there a too rigid culture in SAR on using early descent to 200ft, regardless of approach purpose? A let-down to re-fuel is very different to let down for actual search and rescue. Given the likely weather (around 2km vis and 300-400ft cloudbase) and the low terrain around Blacksod, something simple like a 500ft/min let down from the west to be at a point say 2 miles south of Blacksod to a MDH of say 200ft would have been safe and probably meant that at that point Blacksod lighthouse would have been visible flashing, to track to. An approach that requires 10nm flying at 200ft at night and in poor vis in sea dotted with islands seems a bad decision.

Surely the crew had enough autonomy to either choose a better SOP - or do what many of us do and plan their own safe let down?

This aircraft had a lot of sophisticated kit on it - but does that lead to over-reliance on it? Eg EGPWS - did they assume this would keep them from hitting anything?

Clearly this is early days and there's still a lot more information and analysis to come before the full report is out. I fully understand flight crew like to protect their own, but ultimately it is important we as pilots recognise the need for us to make our own sensible judgements regardless of others to keep us and our pax alive.
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Old 14th Apr 2017, 13:50
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Originally Posted by HeliComparator View Post
Automation may cause accidents, but far more accidents are caused by humans flying without automation. The trick is to train to use it correctly and appropriately, not to rip it out and hand fly everything.
I can tell you this for sure. What I see when teaching in a Level D FFS helicopter simulator, irrespective of the level of experience of the crews, far more accidents happen when automation is involved, than without. To the extent that I feel like ripping out the automation and have the trainees hand fly everything. Logic tells you that automation must be safer. In the training environment, I don't see it.
Of course the opposite case sometimes applies, I feel like ripping out the controls and stowing them in the boot and have the automation do all of the flying. But, generally speaking, the outcomes are consistently better without reliance on automation. Assuming of course the basic IFR skills of being able to fly a heading, airspeed, altitude etc accurately are there; which sadly, often they are not.
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