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SAR S-92 Missing Ireland

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SAR S-92 Missing Ireland

Old 15th Apr 2017, 14:14
  #981 (permalink)  
 
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Jim - who is going to drive it forward? The CAA chap who spent a day at Chiv looking at this before the civSAR went ahead was himself a 'trolley dolly' with no conception of what went in in a SAR helo.

The operators won't push it because they would have to pay more for licensed rear crew.

Perhaps this is why it had only been 'discussed' with no move forward for many years.
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Old 15th Apr 2017, 14:29
  #982 (permalink)  
 
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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
Exactly SAS. It costs relative peanuts to design and approve an IMC/GPS approach for "company" use. Why don't all refuelling sites have one?
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Old 15th Apr 2017, 14:32
  #983 (permalink)  
 
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Re "small little island "

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 was not a reply to co-pilot it was an acknowledgement of an aural altitude warning, see CVR timeline
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Old 15th Apr 2017, 14:49
  #984 (permalink)  
 
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Originally Posted by smcc63 View Post
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 was not a reply to co-pilot it was an acknowledgement of an aural altitude warning, see CVR timeline

The amount of 'waffle' on here is mind boggling.

The co-pilot had A target on the radar at 6 miles. Which was probably the mainland. NOT Blackrock
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Old 15th Apr 2017, 15:04
  #985 (permalink)  
 
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Originally Posted by smcc63 View Post
the commander was acknowledging an aural altitude warning when she made this comment
OK, I see. I was anticipating discussion of the radar target identified by the co-pilot, I thought the pilot was responding to that, in addition to the initial acknowledgement. Regarding the automated aural ALTITUDE alert, what normally is the SOP crew response for that? I would have thought a formal acknowledgement of that warning would be required, such as "height 200, no further descent" and then the co-pilot responding "roger, 200 captured, no further descent", something like that, rather than what was said.

And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning, which is referenced to height and not barometric altitude. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned barometric altitude.

Last edited by gulliBell; 15th Apr 2017 at 15:40.
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Old 15th Apr 2017, 15:06
  #986 (permalink)  
 
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It is clear the captain did know that BLKMO was not just a waypoint over the sea but an island, because when the CVR picks up the ALTITUDE call out, she says: "Eh just a small little island.... that's BLMO itself" So the question is how did she know it was an island, and what information about its height did she have? Did she have good enough information, but had misinterpreted it? She clearly did not realise it was 300ft high.

Furthermore I find it very surprising that you'd track over what you knew was an island at night at 200ft at all - and if you did, you would surely have made a comment in advance to the crew to expect an ALTITUDE alert - and what clearance on the radalt to expect, as it was so little. But why would you not just climb to add some clearance for good measure? There was no reason not to.

What little CVR talk there is gives me the impression this crew were not completely sure of the terrain ahead and were relying significantly on radar and possibly EGPWS to provide information to keep them safe.

As is clear from a considerable number of the 980 posts on this thread, both radar and EGPWS have their complexities, that mean that one has to be very knowledgable about them in order to be able to 100% rely on them to be able to avoid obstacles flying at 200ft at night.

Which brings us back to the madness of this approach - it must surely have been totally unnecessary to carry it out at 200ft from so far out, over known islands at night. Getting into Blacksod safely in the prevailing weather should not have been a particularly difficult task for this helicopter. Basic flight planning with identification of a sensible let-down path and monitoring position with nothing more detailed than a 1:500,000 moving map was all that was required. And they had this and much more.

It should not have absolutely needed a formal approach (though admittedly very advantageous) or more equipment on the aircraft. It seems to me that a danger of too much external control with SOPs and sophisticated aircraft equipment to rely on, is that, whilst having clear and obvious benefits that we need, risk is increased in one way by reducing the amount of original thinking and decision making pilots undertake. So they can easily get worse at it, as probably happened here.
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Old 15th Apr 2017, 15:13
  #987 (permalink)  
 
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Surely with the data now in hand it will be helpfull if they fly a SAR 92 over the exact same path, with the same cockpit setup on a VMC day and verify exactly what the crew would have seen in the cockpit and also in the back.

Perhaps this has already been done.

Such a sad event.
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Old 15th Apr 2017, 15:13
  #988 (permalink)  
 
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Originally Posted by gulliBell View Post
OK, I see. I was anticipating discussion of the radar target identified by the co-pilot, I thought the pilot was responding to that, in addition to the initial acknowledgement. Regarding the automated aural ALTITUDE alert, what normally is the SOP crew response for that? I would have thought a formal acknowledgement of that warning would be required, such as "copied, altitude 200, no further descent" and then the co-pilot responding "no further descent", something like that, rather than what was said.

And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned altitude.
Apologies, but my expertise is confined to transcript analysis, anything else I cannot help you with
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Old 15th Apr 2017, 15:31
  #989 (permalink)  
 
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Originally Posted by rotorspeed View Post
It is clear the captain did know that BLKMO was not just a waypoint over the sea but an island...
It's not clear to me. I put myself in the co-pilot seat and I still think the pilot is referencing the island comment to my radar target call, and the ALTITUDE warning was either missed, or it was not responded to in a formal sense required by an SOP. You can't be responding to a system generated warning in the way it was responded to because that has resulted in ambiguity. The comment might have been in relation to the warning, or it might have been in response to the co-pilot radar target call. Hence why a system generated warning must always be responded to in an SOP'd formal way, by both pilots.
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Old 15th Apr 2017, 15:33
  #990 (permalink)  
 
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Originally Posted by [email protected] View Post
Jim - who is going to drive it forward? The CAA chap who spent a day at Chiv looking at this before the civSAR went ahead was himself a 'trolley dolly' with no conception of what went in in a SAR helo.

The operators won't push it because they would have to pay more for licensed rear crew.

Perhaps this is why it had only been 'discussed' with no move forward for many years.
Quite.

There are numerous problems with giving this some momentum. As you say, the operators would have to pay more. In fact, my first words to the previous director of Bristow UK SAR on first meeting her were "Are you sure you're paying your rear-crew enough?" She didn't get it. And she didn't have the background that would have enabled her to 'get it'. MR aren't license holders or AOC holders and so we have no direct leverage (UK, Eire and elsewhere same situation) which leaves us with the political route which is tortuous and slow. Your old mates are little help since many of them were leaving anyway and the SAR operators pay them a lot more than shelf stackers or security guards and let them do a job they love for a lot more years: happy happy. What comes after them is a big worry. I'd say to the regulators, "Would you like to be a world-leading aviation regulator in the field of SAR or are you happy to wait for the accidents?"



(Time on the wire is not the same as air miles.)
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Old 15th Apr 2017, 15:52
  #991 (permalink)  
 
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Originally Posted by gulliBell View Post
It's not clear to me. I put myself in the co-pilot seat and I still think the pilot is referencing the island comment to my radar target call, and the ALTITUDE warning was either missed, or it was not responded to in a formal sense required by an SOP. You can't be responding to a system generated warning in the way it was responded to because that has resulted in ambiguity. The comment might have been in relation to the warning, or it might have been in response to the co-pilot radar target call. Hence why a system generated warning must always be responded to in an SOP'd formal way, by both pilots.
It's all open to interpretation of course, but on cvr timeline, six mile target was acknowledged with "Rodger" from pilot, next was aural altitude warning followed by pilots comment "small little island "
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Old 15th Apr 2017, 16:14
  #992 (permalink)  
 
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Originally Posted by smcc63 View Post
It's all open to interpretation of course..
Wearing my co-pilot hat, having read the transcript, I believe it's more likely the ALTITUDE alert was missed by both pilots. I say that because there was no SOP-like response to the ALTITUDE alert by either crew, and Captains don't intentionally fly over islands in an unfamiliar area at night at 200', and if they were to do so, the co-pilot would challenge this course of action.
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Old 15th Apr 2017, 16:34
  #993 (permalink)  
 
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Originally Posted by gulliBell View Post
Wearing my co-pilot hat, having read the transcript, I believe it's more likely the ALTITUDE alert was missed by both pilots. I say that because there was no SOP-like response to the ALTITUDE alert by either crew, and Captains don't intentionally fly over islands in an unfamiliar area at night at 200', and if they were to do so, the co-pilot would challenge this course of action.
Absolutely,and I respect your experience, I think a lot more info could be gleaned from actual audio, i.e. Rate of speech, confidence of annunciation etc.
I'm sure a more comprehensive conclusion can be arrived at post final AAIU report
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Old 15th Apr 2017, 16:42
  #994 (permalink)  
 
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Originally Posted by gulliBell View Post
And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning, which is referenced to height and not barometric altitude. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned barometric altitude.
Barometric altitude bug: when the a/c descends below the preset altitude you get a "MINIMUMS, MINIMUMS" aural alert. I suppose that makes sense as the minimums used for normal instrument approaches are altitudes (DA, MDA).

When the a/c descends below the RADALT bug, you get an "ALTITUDE, ALTITUDE" aural alert.
Yes even though it's a height it is referring to; I suppose an alert "Height, Height" doesn't do as well phonetically!
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Old 15th Apr 2017, 17:29
  #995 (permalink)  
 
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I spend much of my life floating around at or below safety altitude (Navaid calibration and procedure validation). I'm struggling to understand why anyone would knowingly design a letdown which incorporates the only highpoint within a number of miles. For sure, we're talking different environment, but the old adage sticks - "Pilots will eventually find ways to do something wrong".
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Old 15th Apr 2017, 17:30
  #996 (permalink)  
 
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CVR

Re aural altitude alert:
As per AAIU report:

The Commander had the moving map displayed on her MFD and the Co-pilot had weather radar displayed on his MFD.
 The CVR recordings indicated that the Co-pilot was using the weather radar to identify terrain features.
 The Rad Alt provided a callout of “ALTITUDE, ALTITUDE” 26 seconds prior to the initial impact. The Commander identified the reason for the aural alert as a small island below the helicopter which she said was “just a small little island... that’s B L M O itself”. At the time of the aural alert FDR data placed the Helicopter in the vicinity of an outcrop of two rocks, Carrickduff and Carrickad, which are located approximately 0.65 nm to the west of the Black Rock.
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Old 15th Apr 2017, 17:37
  #997 (permalink)  
 
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Altitude alert

Re altitude aural alert, above Carickduff,see location on google maps at this address 9C6F3M96+J4
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Old 15th Apr 2017, 17:49
  #998 (permalink)  
 
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Originally Posted by gulliBell View Post
I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish.
As a starting point, what do you infer the "route" to be?

With respect, there is an obvious inference to be made. Accepting that, it seems to be perfectly fine.

It can't be adapted for something else than it was intended without careful considerations of other factors.

Editing for further response to GulliBell and SASless below.

If it is used for what it actually was intended to be used for, I don't dispute its approval by the Chief pilot or other company operations people. It's fine for that. The problem starts when "IAP" is imagined to attach to BLKMO. That's not approved.

I expect that CHC will tell the investigators, or they already know, that the "route" this applies to is from the helipad at Black Rock to the helipad at Blacksod. Or in reverse. A route, after all, is from A to B.

Last edited by cncpc; 15th Apr 2017 at 18:26.
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Old 15th Apr 2017, 17:57
  #999 (permalink)  
 
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What is the history of that Route Guide?

When was it created, what technology was it based upon, how is it updated, how is the data checked for accuracy?

Why was the current format chosen and has there been consideration in changing it to incorporate technology changes?
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Old 15th Apr 2017, 18:00
  #1000 (permalink)  
 
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Originally Posted by SASless View Post
What is the history of that Route Guide?

When was it created, what technology was it based upon, how is it updated, how is the data checked for accuracy?

Why was the current format chosen and has there been consideration in changing it to incorporate technology changes?
Indeed, things change. I came relatively close to a wind turbine the other day which was on some charts but not others. The 'official' AIP version was lacking!!
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