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SAR S-92 Missing Ireland

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SAR S-92 Missing Ireland

Old 15th Apr 2017, 22:24
  #1021 (permalink)  
 
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Originally Posted by gulliBell View Post
I don't know what the route was, because the CVR transcript of the approach brief wasn't in the report.
I meant what do you infer the "route" to be that relates to that particular "plate" in the guide.

Is it not from Blackrock pad to Blacksod pad?

If so, is that not a procedure in which running into Blackrock from the west is not something that would even be contemplated?

Not arguing, I find your input very informed and helpful.
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Old 15th Apr 2017, 22:55
  #1022 (permalink)  
 
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Originally Posted by gulliBell View Post
Why would it appear in the Operator S92 flight documents as a VFR approach/departure procedure if the S92 is too big to operate from Blackrock helipad? It might be a weird depiction of an IMC let-down procedure, depends on what the accompanying notes on page 2 says.
It doesn't look like it is designed for the purpose of landing at Blackrock. Merely that Blackrock is the start/end point for the procedure.

Whether the procedure the crew elected to fly was appropriate will be assessed in the full report. Likewise, the genesis of such a procedure will be analysed.

Tragic though this incident was I believe this an opportunity to take a holistic view of the way SAR Ops are tasked and conducted. For a long time the status quo has been for an 'RCC' (or equivalent) to receive a request for assistance and task an asset accordingly. In my opinion this can sometimes be an overly simplistic process with tasking decisions often being made by non-aviators. Clearly, the aircraft captain has a veto on any tasking but human nature makes it very hard to say no; all rescue organisations by their very nature are 'can do'. The methodology of SAR tasking has not changed in decades. It is rooted in an era when 'jobs' were generally more simplistic in their nature (range, weather conditions etc.). In this case a crew on the East coast of Ireland were woken in the early hours of the morning to top-cover a rescue in the Atlantic via a let-down to an austere refuel site in poor conditions.

If this hadn't been a scramble I wander how much time the average crew would have put in to planning and briefing a similar profile? My point is that a lot is expected of SAR crews and this is an opportunity (in Eire at least) to improve safety margins.
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Old 15th Apr 2017, 22:55
  #1023 (permalink)  
 
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Is it not from Blackrock pad to Blacksod pad?
No, I think that it is a legacy procedure going from an obvious local feature (Blackrock) to the intended LS of Blacksod. There is no reason to think of Blackrock as a LS or helipad because it is no use in any way shape or form to a SAR helicopter - the idea that it is a route from one LS to another I think is nonsense.

Trouble is, in the middle of the night when you are tasked to the area and need to get to the refuel site, it is too easy to pull out the company letdown chart and follow it without thinking about what you are actually doing.

I think there are a lot of questions to be asked about the company procedures in Ireland and I would be surprised if in UK Bristow and HMCG are not taking a long look at their procedures to ensure they are squeaky clean and appropriate to the terrain.
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Old 15th Apr 2017, 23:16
  #1024 (permalink)  
 
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Earilier I posted very similar thoughts re a Bottom Up review of not only this flight but the entire Irish Helicopter SAR Operation much as was done a few years back for the U.K. Offshore Oil Helicopter Industry following a crash.

From a very distant perspective.....it is overdue.

A great deal is asked of SAR crews and they deserve all the help they can get in making their work as safe as possible considering the conditions in which they so often find themselves flying!

UK SAR might take this opportunity to ask themselves some hard questions as well.
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Old 15th Apr 2017, 23:19
  #1025 (permalink)  
 
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Question: Report says R116 was on a heading 120 degrees magnetic, what would the course over the ground have been taking tailwind correction into account ??
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Old 15th Apr 2017, 23:21
  #1026 (permalink)  
 
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Originally Posted by cncpc View Post
......Just above, someone in the know of the history suggests it does come from a previous operators procedure in supply maintenance flights. There was a poster on here who used to fly the B-105 into Black Rock, perhaps he can shed some light.........
Sorry, my experience there was 45 years ago so is not really valid as so much will have changed in the years since then. From my distant memory I had a line check on all Irish lighthouse pads and then got on with it. It was single pilot day only VMC work.
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Old 15th Apr 2017, 23:22
  #1027 (permalink)  
 
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EXACTLY

Originally Posted by llamaman View Post
To my mind that 'Operator's Route Guide' illustrated in the report looks very much like a VFR approach/departure chart. Not an instrument let-down procedure. Any thoughts?
When I flew for Okanagan (precursor company to CHC) in the 70's and 80's we had proper company IFR approach charts that met regulatory standards. I very much doubt this was ever intended to be an IFR approach.
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Old 15th Apr 2017, 23:49
  #1028 (permalink)  
 
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Lamaman
For a long time the status quo has been for an 'RCC' (or equivalent) to receive a request for assistance and task an asset accordingly. In my opinion this can sometimes be an overly simplistic process with tasking decisions often being made by non-aviators.
WRONG! Back in the not so distant past UK RCC Controllers were all aviators, of one brevet or another and sometimes with RAF MRT experience too.
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Old 15th Apr 2017, 23:54
  #1029 (permalink)  
 
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Originally Posted by Al-bert View Post
Lamaman

WRONG! Back in the not so distant past UK RCC Controllers were all aviators, of one brevet or another and sometimes with RAF MRT experience too.
Al-bert. I'm aware of that (albeit UK-specific). If you note the tense you'll see that my comment regarding non-aviators refers to the present and not the past.
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Old 16th Apr 2017, 00:24
  #1030 (permalink)  
 
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I'm sorry Llamaman, that wasn't clear to me. I assumed the second sentence was linked to the first - for a long time the status quo etc! My bad, as magenta kids no doubt say
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Old 16th Apr 2017, 00:26
  #1031 (permalink)  
 
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Originally Posted by [email protected] View Post
There is no reason to think of Blackrock as a LS or helipad because it is no use in any way shape or form to a SAR helicopter - the idea that it is a route from one LS to another I think is nonsense.
I don't think it's nonsense and some others on here don't. I don't know how describing what is almost perfectly obvious as "nonsense" contributes to understanding this accident, particularly when a theory of mistaking a VFR transit route for a "letdown" procedure does contribute to that understanding.

The accident report does contribute as well. It says that this approach was conducted in two phases. An APP1 letdown to 200 feet. Then proceeding at 200 feet to hook into the first point in the Blacksod South Arrival. Believing that it is "nonsense" that the "route" is a VFR transit route based on a departure off Blackrock sets the table for this tragedy.

Both helipads at each terminus of the route carry special pink circle markings that other waypoints do not. They carry their elevation, which other waypoints do not.

Blackrock Light is in fact an LS. The Blacksod lightkeeper is responsible for the Blackrock Light. He has to go there from Blacksod pad to Blackrock pad. Right now, that is the situation. It was the situation at the time of this accident and for a long time before. Because helicopter is the only way to connect between the two, it hardly nonsense that there is a route between them and that is published in a route guide.

A helicopter landed there to bring in the AAIU investigators in this incident.

If some people, including very experienced helicopter pilots on this forum, can't agree that this is just a VFR transit layout for pad to pad flights, then it isn't difficult to see how this crew, unfamiliar with the area, and in the dark of night and weather, didn't understand that this route meant for a helicopter taking off from Blackrock and bringing maintenance people back to Blacksod, or vice versa, can't be patched into at 200 feet.

Maybe someone said "Hey, this isn't an IFR approach" and someone else said "Nonsense".
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Old 16th Apr 2017, 00:46
  #1032 (permalink)  
 
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Originally Posted by SASless View Post
Earilier I posted very similar thoughts re a Bottom Up review of not only this flight but the entire Irish Helicopter SAR Operation much as was done a few years back for the U.K. Offshore Oil Helicopter Industry following a crash.
So far nothing from the minister in charge or his dept .....

The thing is CHC operates in both regions, so you would think they have learnt and applied lessons from UK tragedies....
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Old 16th Apr 2017, 01:22
  #1033 (permalink)  
 
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Originally Posted by ODEN View Post
Yes it is for SAR, dont mix SAR with CAT.
Every country have its own regulation.
Be that as it may, the point is that terrain ID (when operating near terrain) should be via the terrain overlay and not weather RADAR (which is only used offshore for ID-ing non-terrain obstacles and targets, boats/rigs and the like) in this case.

Therefore, the LOW ALT selection is not a good choice at night/IMC for this approach. Not that this would have helped them with the terrain not being in the database.

In the end they shouldn't have been at that altitude. Simply, the chart should have had much more info, especially segment 'not below' altitudes and vertical guidance (as a minimum). However, other holes in the reason model's swiss cheese lined up for this to happen (no terrain in database and selection of LOW ALT).
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Old 16th Apr 2017, 01:24
  #1034 (permalink)  
 
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Originally Posted by bigglesbutler View Post
Not sure if it has changed in the uk but when I left I found that 30nm restriction was only in australia.

Si
I thought it was brought across from the UK, initially. But I may be wrong.
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Old 16th Apr 2017, 01:56
  #1035 (permalink)  
 
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Approved IFR approaches

You all need Approved IFR approaches.
What you are doing now is pure madness.
The last days discussions scares the bejezzs out of me.
What you do over open water, I would do any day at flap 10 and 165kts down to 200 feet to get visual. If anyone let me into one of those new 737 800 Poseidons ! Perfectly safe.
But to apply the same heading for shore or over land requires a proper tested and approved IFR approach.
Make it happen, it is only money.
Good Luck

Last edited by BluSdUp; 16th Apr 2017 at 02:27.
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Old 16th Apr 2017, 02:20
  #1036 (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, 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.

Totally, totally agree.....good summation. I think many of the respondents so far are dooming our industry to disappear further and further down the spiral of the gordian knot of over regulation.... in the endeavour of removing responsibility from those positions ie Captains who are getting paid (or should be getting paid) to do so.

RG
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Old 16th Apr 2017, 02:41
  #1037 (permalink)  
 
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I respectfully suggest we save that innovative thinking for those occasions that require it. When a bit of that old fashioned prior planning makes sense....and actually promotes safety then we should take advantage of it.

Look us in the Eye and deny having canned Approach procedures for landing sites that are known well known in advance....exactly like Blacksod with it being a re-fueling point.....would not greatly enhance safety.

I doubt you can....or will.

No doubt a knee jerk reaction that leads to invalid restrictions and Rules that do nothing to improve safety is a bad thing but well thought out effective changes can only help prevent future accidents and loss of lives.

Change for change sake is not what is being suggested but rather realistic improvements.
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Old 16th Apr 2017, 02:54
  #1038 (permalink)  
 
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Originally Posted by cncpc View Post
If some people, including very experienced helicopter pilots on this forum, can't agree that this is just a VFR transit layout for pad to pad flights, then it isn't difficult to see how this crew, unfamiliar with the area, and in the dark of night and weather, didn't understand that this route meant for a helicopter taking off from Blackrock and bringing maintenance people back to Blacksod, or vice versa, can't be patched into at 200 feet.
I think you may be right in what you are saying about the route guide. It seems to answer a lot of questions as to why they ended up where they did.

Please excuse me if my questions sound silly but, as they were flying from the east coast, would there have been an option to enter "approach Blacksod east" and, if so, would that still have brought them out beyond Blackrock?

Also, the following is the conversation that some people are referring to when they say Capt. Fitzpatrick thought they were already at Blackrock when they were overflying the smaller islands near Blackrock:

Co-pilot : Ok so small target at six miles eleven o'clock Large out to the right there.
Commander: Just a small little island....that's BLMO itself.

To me it actually looks like the commander is responding to both parts of the statement as there is a pause within her answer - the small target is "just a small little island" and then possibly pointed to Blackrock as the large target.

Perhaps they did see a flash from the lighthouse in the distance just at that point in time and flew towards it without, as seems to be now apparent, knowing the height?
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Old 16th Apr 2017, 05:51
  #1039 (permalink)  
 
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We know what their heading was in the last seconds but their path across the ground may have brought them along the edge of the light's red sector. So what would they have seen and what would they have taken from that? Every 500m at 80 knots they should see a flash of white or red. Was the cloud base really 300 to 400 feet or was it below 282 feet?
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Old 16th Apr 2017, 07:23
  #1040 (permalink)  
 
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Originally Posted by agirl View Post
I think you may be right in what you are saying about the route guide. It seems to answer a lot of questions as to why they ended up where they did.

Please excuse me if my questions sound silly but, as they were flying from the east coast, would there have been an option to enter "approach Blacksod east" and, if so, would that still have brought them out beyond Blackrock?

Also, the following is the conversation that some people are referring to when they say Capt. Fitzpatrick thought they were already at Blackrock when they were overflying the smaller islands near Blackrock:

Co-pilot : Ok so small target at six miles eleven o'clock Large out to the right there.
Commander: Just a small little island....that's BLMO itself.

To me it actually looks like the commander is responding to both parts of the statement as there is a pause within her answer - the small target is "just a small little island" and then possibly pointed to Blackrock as the large target.

Perhaps they did see a flash from the lighthouse in the distance just at that point in time and flew towards it without, as seems to be now apparent, knowing the height?
A girl...

It is a complex question on why they "...ended up where they did". I think that what some of us think about this "route" answers the question of why in hell a letdown procedure was "designed" around a 300 foot rock. It wasn't.

If the pilots of R116 though it was, something is badly wrong. However, there are some very qualified SAR people on this forum, and it seems that generally, a letdown out there doesn't need a procedure, it is something that the crew and aircraft can accomplish routinely. I think they just push a button with APP1 on it.

Once that is done, and they are at 200 feet, and they think they are on a procedure in which BLKMO is next, they are doomed unless the system gives them adequate warning of what is out there that they are unaware of and they can recover from the brink.

I don't know the answer to your question of Blackrock East. I expect Blackrock is a VFR only approach, while Blacksod obviously can be approached IFR in some fashion. My experience of autopilot coupled navs is that you set your destination and once nearby you call up the available approaches and activate one and the autopilot begins to fly that. I don't know how the S-92 system works, and most importantly I don't know if these homemade approaches become canned, i.e. programmed into the FMS.

However that may have come to be, it is clear that neither Captain Fitzpatrick or Capt. Duffy were aware of a 300 foot rock in what they were doing. It seems they were discovering things as they went, but as others have pointed out, some things said by Capt. Fitzpatrick don't make sense. Neither does the 200 foot altitude.

My background is in fixed wing supervisory management, safety systems, and some crash investigation supporting litigation counsel and testifying, including one accident in Ireland involving the IAA. I'm more a questions than answers person at this stage, but maybe somebody else here can answer your questions.

Back in the mid 90's I was having a pint with an Aer Lingus 747 captain in Willy Ryan's there by the Phoenix Park entrance and we were talking about competition for Aer Lingus and Ryanair. At some point he said, "Padraig, aviation over here is really a cottage industry."

I know that that cottage industry has a fine safety record, yet this accident has some features, such as this "approach" and two helicopters on the same mission not knowing where the other is, that indicate the CHC at least isn't running the tightest of operations. The questions being asked by the other lads are valid questions.

Last edited by cncpc; 16th Apr 2017 at 07:45.
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