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SAR S-92 Missing Ireland

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SAR S-92 Missing Ireland

Old 15th Apr 2017, 10:43
  #961 (permalink)  
 
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Originally Posted by Triskelle View Post

...However, without resort to the separate page of text, the map from the Route Guide in Figure 4 shows a spot height of 282 ft at BLKMO, which is presumably the terrain height of Black Rock (not including the height of the lighthouse)?
The height of the light is 282 feet above the local high water mark. Add a few feet to get the top of the light house.
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Old 15th Apr 2017, 10:52
  #962 (permalink)  
 
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Excuse my ignorance, but in the most sophisticated helicopters in the civilian world, why aren't all known planned landing sites such as Blacksod provided with GPS approaches with a vertical profile akin to that of an ILS, flown (in the case of SAR) to a very low-minima using auto hover if required? They take very little time to develop, and the cost would be negligable on a £500m contract. I get the necessity for ARA let downs to unknown rescue locations, but routine landings for fuel? I'd argue that the risk philosophy should be closer to that used in HEMS. At adhoc HEMS operating sites, rarely used more than once, the risk permitted is at it's highest in order to facilitate getting the job done. However at hospitals, and hems operating bases, refuel locations etc, used regularly there should be less alleviation as they are planned landing sites, used at a higher frequency, that can be known to the operator, thus procedures can be put in place and followed.

The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling. A paper chart, or an iPad and Runway HD would have improved their SA, over all the kit & radar in an S92? Are we saying there is no simple moving map with an OS layer, or chart in the cockpit?
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Old 15th Apr 2017, 10:58
  #963 (permalink)  
 
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Sectio 3.5.8 operators route guide

Originally Posted by puntosaurus View Post
You're not living up to your name O&W.

The chart doesn't show Blackrock at 282'. It shows a waypoint called BLKMO with a caption next to it of 282 with no clue as to its relevance. Is it waypoint 282 in the operators manual ? Is it the depth of the sea at this point ? Is it the QDM from some unspecified navaid on the mainland ?

The island would indeed have been visible on radar and on the EO/IR display if that was available in the cockpit, and for that mistake and the few seconds pause whilst they assimilated the rear crew's input this crew paid with their lives.

However the people that put them in this situation by promulgating a thoroughly misleading chart, and the people that validated a flawed terrain database have yet to be held accountable for their role in this accident. And I'm willing to bet that their punishment will be less severe.
Has anyone read section 3.5.8 of the report? I think it's quite relevant, it clearly states that a page of text accompanied the flight route and included information about blackrock and the lighthouse height amsl. Raises some questions?.
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Old 15th Apr 2017, 11:48
  #964 (permalink)  
 
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Low Level Over Water Flight

Although there are a number of quite significant contributory factors, I think the main point here is that regardless of whether a published procedure is followed or not, any low-level flight over water in IMC, at night or in marginal conditions MUST use the radar as the PRIMARY navigation aid. If a radar return cannot be positively, visually identified it MUST NOT be overflown. Besides islands there are plenty of moving marine obstacles that can easily reach 300ft or more which would not be on any map, chart or in any database. Whether radar guidance is achieved from front or back seats is a matter of procedure but it would be a designated crewmemberís responsibility to monitor and constantly verbally update the obstacle situation as seen on the radar. Although I know nothing of CHCís procedures I would assume that this is SOP, especially for SAR.

Everyone makes mistakes, Iíve made plenty and seen very capable colleagues do the same. Most of the time some procedure, mechanism or technology prevents a tragic outcome, sadly not so on this occasion. Iím sure there is much to learn here.
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Old 15th Apr 2017, 12:20
  #965 (permalink)  
 
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Originally Posted by pegasusflash View Post
Has anyone read section 3.5.8 of the report? I think it's quite relevant, it clearly states that a page of text accompanied the flight route and included information about blackrock and the lighthouse height amsl. Raises some questions?.
I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish.
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Old 15th Apr 2017, 12:31
  #966 (permalink)  
 
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Would a single Page Approach Plate for a checked and tested "standard" Approach for Blacksod have been much better?

One that incorporates the full capability of the Avionics fit be far better?

One that would ensure Terrain Clearance?
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Old 15th Apr 2017, 12:34
  #967 (permalink)  
 
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Originally Posted by SASless View Post
Would a single Page Approach Plate for a checked and tested "standard" Approach for Blacksod have been much better?
Yes. And I'm absolutely staggered that what was published got past a Chief Pilot and operational review.
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Old 15th Apr 2017, 12:40
  #968 (permalink)  
 
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Originally Posted by SARWannabe View Post
...The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling...
I always use the paper chart for flight planning, never what's in a terrain database.
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Old 15th Apr 2017, 12:46
  #969 (permalink)  
 
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Originally Posted by Woolf View Post
..I think the main point here is that regardless of whether a published procedure is followed or not, any low-level flight over water in IMC, at night or in marginal conditions MUST use the radar as the PRIMARY navigation aid..
Agreed. And an operational radar should not be an MEL item for this role. And thorough training should be provided in its use, both initially, and recurrently. There is a good Honeywell training video on the use of weather radar, that should be mandatory viewing for any pilot who uses a radar.

Again, in the simulator we can throw in any sort of weather conditions. The number of pilots I've seen fumble with the weather radar and just blast through dangerous weather suggests its proper use is not widely understood or practised.

If nothing else on that helicopter worked for them, that radar should have been able to save the day for them.

Last edited by gulliBell; 15th Apr 2017 at 12:58.
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Old 15th Apr 2017, 12:53
  #970 (permalink)  
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No idea on rotary wing operation, but in FW there is no regulatory requirement to even update the latest version of the EGPWS database!

Unlike FMS updates which are mandated, EGPWS database revisions are left up to the operator to determine (within their CMS) how they are addressed.
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Old 15th Apr 2017, 12:55
  #971 (permalink)  
 
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I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish.
Agree gulliBell, Actually I would like to see the route guide plate for Blacksod arrivals, even if ts only a VFR one. It would surely have the lowest safe marked on it in each sector? Surely Blacksod could have had a simple GPS approach rather than having to use SAR autopilot modes?
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Old 15th Apr 2017, 12:57
  #972 (permalink)  
 
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but since you would have to let down over the water anyway, why wouldn't you use the SAR autopilot modes?
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Old 15th Apr 2017, 13:09
  #973 (permalink)  
 
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Insider.

You do understand the full capability of the SAR modes on the S-92 don't you?

Why in the world would you want to revert to old techniques using lesser capability?


Take note of the Sikorsky/PHI FMS Offshore Rig Approach in use in the Gulf of Mexico using far less capability than the SAR modes....then rethink what you are suggesting.
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Old 15th Apr 2017, 13:17
  #974 (permalink)  
 
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Originally Posted by C195 View Post
..Making a low level transit in marginal weather must also be deemed more risky than descending closer to the landing site. Was this the standard way of making this type of approach when IMC?
I've never seen an approach that started so far out at such a low level. And I've never seen an approach plate that didn't give the pilot all the critical information needed on a single page, with both lateral and vertical navigation, and spot heights of all obstacles in proximity of the flight path.
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Old 15th Apr 2017, 13:42
  #975 (permalink)  
 
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You do understand the full capability of the SAR modes on the S-92 don't you?
Of course but it was the use of the SAR modes down to 200' to the west of Blackrock that caused the problem.

Had an "old" technique been used, we would not be having this discussion. SAR modes are for SAR, not routine landings for a fuel stop when there was no urgency. As gulliBell says, why start an approach at 200' essentially IFR (night) with miles and miles to run at 75 knots?

Its the "new" techniques that lead to a false sense of security. I always sought to minimise my time over the sea at at 200' as I am sure you did SAS.
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Old 15th Apr 2017, 13:59
  #976 (permalink)  
 
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Originally Posted by [email protected] View Post
... ...

Because in civilian SAR, the rearcrew are not flightcrew (no licences) they are not allowed to be responsible for the navigation of the aircraft - this is such a waste of crew resources simply because civil aviation regards anyone not in the cockpit as cabin crew.

... ...
This is an area for which there has been some discussion in the UK and possibly elsewhere. Ideally, regulators will get a grip on this and the role of "SAR Technical Crew" can develop from 'trolley dolly in a dry suit' status to a licensed aviation trade encompassing what advanced SAR rear crew in various territories have learned across several decades of operation.



"If you think education is expensive, try ignorance."
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Old 15th Apr 2017, 14:07
  #977 (permalink)  
 
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Originally Posted by industry insider View Post
...Surely Blacksod could have had a simple GPS approach rather than having to use SAR autopilot modes?
The approach they were using was simple, al-be-it for that nasty left turn on to the final course, and it didn't need any automation to fly it safely. All that was needed was to arrive at the IAF (BLKMO) at a height where a constant descent rate of 450ft/min would put you on the final segment (BKSDC) at 200 ft/75kts, and to monitor the radar so that the horizontal navigation made sense with what the GPS was telling you. 3000' at BLKMO would have worked nicely. The numbers can be crunched in your head, it doesn't need an FMS to work it out. And at that height you could still talk to everybody you needed to talk to, with no need to give a landing report whilst still 6+ minutes out.

Last edited by gulliBell; 15th Apr 2017 at 14:23.
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Old 15th Apr 2017, 14:10
  #978 (permalink)  
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Originally Posted by SARWannabe View Post
Excuse my ignorance, but in the most sophisticated helicopters in the civilian world, why aren't all known planned landing sites such as Blacksod provided with GPS approaches with a vertical profile akin to that of an ILS, flown (in the case of SAR) to a very low-minima using auto hover if required? They take very little time to develop, and the cost would be negligable on a £500m contract. I get the necessity for ARA let downs to unknown rescue locations, but routine landings for fuel? I'd argue that the risk philosophy should be closer to that used in HEMS. At adhoc HEMS operating sites, rarely used more than once, the risk permitted is at it's highest in order to facilitate getting the job done. However at hospitals, and hems operating bases, refuel locations etc, used regularly there should be less alleviation as they are planned landing sites, used at a higher frequency, that can be known to the operator, thus procedures can be put in place and followed.

The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling. A paper chart, or an iPad and Runway HD would have improved their SA, over all the kit & radar in an S92? Are we saying there is no simple moving map with an OS layer, or chart in the cockpit?
I didn't want to get shouted at for saying the same thing but as an outsider this also surprises me.

I get the general point of radar let downs and pseudo ILS AFCS coupled approaches but to a refuelling site would it be really that difficult to chart a GPS/RNAV approach or even better yet an ANP-AR approach? Sometimes innovation in aviation seems choked by bureaucracy and pointless regulation and hangs on to legacy procedures far too long.

It seems very sad that the minimum speed for EGPWS to be "armed", for want of a better word, was not specified as an SOP for all approaches. I gather that it may not have made a diiference here as there are questions as to wether Blackrock was in the database or not but, it would seem a sensible SOP to arise out of this event.
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Old 15th Apr 2017, 14:10
  #979 (permalink)  
 
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Bklmo

Originally Posted by gulliBell View Post
Isn't the light beam columnated? The light wouldn't go up into the cloud, it's angled down towards the surface. And at one flash every 12 seconds, they might not have been below cloud for long enough before hitting the rock for the light to be visible to them. But yes, from 500' up even if you were in cloud, you'd expect to see the light, or the clouds light up around you, every 12 seconds from a few miles out.

The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself". This call came 15 seconds after the co-pilot reported 1.3 miles to BLKMO. This I just don't understand, it's evidence of a breakdown in SA. I mean, when you've just been told BLKMO is 1.3 miles in front of you (according to GPS), and there is a radar target 6 miles ahead of you, how could that radar target possibly be BKLMO? What that target probably was is Duvillaun More, which you'd expect to be at 11 o-clock on radar because the next segment takes you to the right of it. And the co-pilot should have identified the radar target as a possible obstacle on the next segment by looking at the map, and he didn't question the pilot when it should have been obvious that a radar target 6 miles in-front of you couldn't possibly be a GPS waypoint only 1 mile in-front of you. And another thing I don't understand, when the co-pilot reported 1.3 miles to BLKMO, there MUST have been a big red target directly in front of him on the radar (assuming the radar was set to 10nm arc and 1.3nm is still in the detectable range). Also, the crewman told the pilot the island was visible directly ahead 15 seconds before impact, and to come right. In the 6 seconds before hitting the rock the FDR shows they were not making any heading change to ensure lateral separation.

From 200' above the surface and at 3nm range, a 300' island in-front of you would probably indicate on the radar screen as an obvious red blob with little depth, probably with no other colours evident, probably with some sea clutter either side of it, with a great big arc of black for miles and miles behind it. And as you got closer to the target the red blob would be getting bigger and bigger, and the black arc behind it would stay just as black. That great big arc of black behind a red radar return should attract your attention, because that black area with no radar returns is potentially dangerous. It's dangerous of course because a big island in-front of you has bounced all the radar energy back to you, and nothing behind it can be detected. If it was only a small island with little elevation the radar image would be completely different, you should see sea clutter returns only a short distance behind the red return. I've got a hunch the radar was painting a good picture of what was in-front of them for the last 6nm, but there was no proper interpretation of what the radar was telling them.

I know it's easy to be critical from armchair comfort with the benefit of time and hind-sight and the rest of it, but the brutal reality of it is, I don't see much PIC stuff going on. The pilot said virtually nothing of substance through the whole of the end of CVR transcript, when the aircraft was getting in an imminent state of peril. And the bit the pilot did say about BLKMO was obviously wrong but it wasn't corrected by the co-pilot. Blackrock must have been detectable on the radar directly in-front of the aircraft for the whole of the track inbound to BKLMO, and it should have been identified and reported as a hazard to the pilot, but it wasn't. The warning from the rear crew about the rock in-front of them either wasn't made forcefully enough, or wasn't acted on quickly enough (no avoiding action was being taken in the 6 seconds before impact). My reading of that little bit of CVR transcript is not enough of substance was being said amongst the crew. My flight instructor used to say "silence is bad CRM" - for me, and again this is being said from the comfort of my armchair, there is just too much silence on that CVR transcript.
Re:The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself"
the commander was acknowledging an aural altitude warning when she made this comment
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Old 15th Apr 2017, 14:13
  #980 (permalink)  
 
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You miss the point entirely although you ask the right question!

If the SAR modes can safely deliver you directlyto the helipad in a stabilized hover if asked to do so...why not ask it to do so...or at least to a point very close to the helipad?


As Blacksod, like other known deliberate Landing Sites used by the Operator, did not have a documented IMC approach procedure, one that assured track and vertical guidance guaranteeing Terrain clearance....one has to ask...."Why?".

Why did the Crew choose a point Ten Miles from the Helipad instead of a point very close to Blacksod itself?

Had that IMC approach existed and been used....this Crew would not have been at 200 feet and ten miles out to sea heading ashore as they were when they hit Blackrock.






Originally Posted by industry insider View Post
Of course but it was the use of the SAR modes down to 200' to the west of Blackrock that caused the problem.

Had an "old" technique been used, we would not be having this discussion. SAR modes are for SAR, not routine landings for a fuel stop when there was no urgency. As gulliBell says, why start an approach at 200' essentially IFR (night) with miles and miles to run at 75 knots?

Its the "new" techniques that lead to a false sense of security. I always sought to minimise my time over the sea at at 200' as I am sure you did SAS.
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