SAR S-92 Missing Ireland

[gulliBell]

Originally Posted by smcc63

The pilot in command is acknowledging an "altitude "aural alert

This conclusion is ambiguous if based just on reading the CVR transcript alone. As discussed before, listening to the recording was required to come to this conclusion.

[gulliBell]

Originally Posted by dClbydalpha

In this case once the initial mental picture of the scenario was created, all that additional SA just provided confirmation. What was required was something to look wrong. EGPWS could have done that, with a significantly red blob of terrain. NVDs could also have done that with a looming piece of land.

They had FLIR and the pilots were told of the obstacle ahead 15 seconds before impact. If the EGPWS had painted a red blob in-front of them, would they have reacted any differently from basically being told by the radar operator there is a red blob ahead? If the FLIR didn't look wrong enough, and the radar didn't look wrong enough, would a little blob of red on the EGPWS and an aural terrain warning have triggered immediate avoiding action?

[gulliBell]

Originally Posted by puntosaurus

..Crab. Sudden Twang refers to posts where he/she has asked about where the crew received their training on the S92..

I heard from somebody who used to work at Flight Safety that the crew did their S92 training at Flight Safety (Stavanger perhaps?).

[gulliBell]

Originally Posted by palacio802

..I think that at night, even with NVG you should keep 500' except when in final approach (being this approach to a helipad or a vessel). I don't think NVG gives you much clues when flying over the sea (this is my experience).

How effective would NVG be in this environment i..e over water, under cloud? If they didn't see the lighthouse from 1.3nm away tends to suggest they weren't looking outside, would they have been looking outside if they had NVG?

[jimf671]

In a coastal environment in conditions under cloud where the naked eye just sees a wall of blackness you can see coastlines, islands, unlit buildings, vessels. That would usually be the case even on the same night that NVG would fail in the bottom of a tight valley inland.

[sunnywa]

I have been following this thread and have learnt a lot about radar theory and EGPWS use, so I thank you fellow pilots out there for teaching me some new tricks. If I can maybe raise a few points ( I am a SAR pilot with similar systems in my aircraft type):


1. Many posts have been critical of the descent profile and why they made such a long flight at 200ft. I suspect that because the APBSS approach is not an IFR procedure, the crew realised they would have to get visual below the cloud (300-400ft) to then track toward Blacksod via the APBSS guidance (I would love to know the purpose of the APBSS, VFR vs IFR, what is it there for?). To do this descent, many operators have a 'no closer' clause in their OM so I would think they have to descend clear of all land (looking at the map, it might be 5-10nm) to get visual below cloud before they then would be allowed to turn back towards their fuelling point. If they were any higher, they would have been IMC and since there appears to be no IFR arrival plate to Blacksod, then this would not have been feasible.
2. NVG would have definitely been a final safety feature as they (I believe) would have seen the large rock ahead of them. I have flown a lot of NVG over water and even on the darkest nights, the contrast should have alerted a scanning pilot as to their danger.
3. Some people have mentioned lack of talk on the CVR as complacency. I don't believe this for a second as this crew were at low level, in the dark and in an unfamiliar area. I bet their arousal level was through the roof.


I look at this sad and preventable accident and see much to learn on a personal and organisational level. I am not going to armchair quarterback the crew as I am honest enough to think that some of the decisions made would have been the same if I was in the aircraft. I think the basic problem was the crew did not realise the BLKMO was 300ft high and for some inexplicable reason, they did not see it on radar. If only Blacksod had an IFR RNAV approach, this accident would not have been occurred and four fine persons would still be doing the job they loved.

[Scattercat]

Originally Posted by sunnywa

I have been following this thread and have learnt a lot about radar theory and EGPWS use, so I thank you fellow pilots out there for teaching me some new tricks. If I can maybe raise a few points ( I am a SAR pilot with similar systems in my aircraft type):


1. Many posts have been critical of the descent profile and why they made such a long flight at 200ft. I suspect that because the APBSS approach is not an IFR procedure, the crew realised they would have to get visual below the cloud (300-400ft) to then track toward Blacksod via the APBSS guidance (I would love to know the purpose of the APBSS, VFR vs IFR, what is it there for?). To do this descent, many operators have a 'no closer' clause in their OM so I would think they have to descend clear of all land (looking at the map, it might be 5-10nm) to get visual below cloud before they then would be allowed to turn back towards their fuelling point. If they were any higher, they would have been IMC and since there appears to be no IFR arrival plate to Blacksod, then this would not have been feasible.
2. NVG would have definitely been a final safety feature as they (I believe) would have seen the large rock ahead of them. I have flown a lot of NVG over water and even on the darkest nights, the contrast should have alerted a scanning pilot as to their danger.
3. Some people have mentioned lack of talk on the CVR as complacency. I don't believe this for a second as this crew were at low level, in the dark and in an unfamiliar area. I bet their arousal level was through the roof.


I look at this sad and preventable accident and see much to learn on a personal and organisational level. I am not going to armchair quarterback the crew as I am honest enough to think that some of the decisions made would have been the same if I was in the aircraft. I think the basic problem was the crew did not realise the BLKMO was 300ft high and for some inexplicable reason, they did not see it on radar. If only Blacksod had an IFR RNAV approach, this accident would not have been occurred and four fine persons would still be doing the job they loved.

I too have been closely following and have learnt from this sad thread.

1) In my operating area (Australia), regulations are very specific with regard to the way we must operate in IMC (IFR) and VMC (VFR). If you can't maintain visual reference with the ground or water, navigate visually, maintain aircraft attitude visually, you are operating in IMC. When operating under the IFR, I can ONLY descend below MSA when following a prescribed, approved, promulgated procedure. This may include a company procedure that has been formally designed and has been approved by the regulator.
To my mind, this route, was never an IFR procedure and was never intended as such. Remember that they descended to 200' & hit Blackrock BEFORE the start of this route. It seems to me that for whatever reason, this crew has paid the ultimate price for placing their lives in the hands of a "procedure" that was not fit for the purpose it was used for.

2) NVG would most likely have enabled visual flight & would have almost certainly allowed the crew to have picked up the light, if not the island itself, as they approached Blackrock. I currently spend quite a lot of my time below 200' at night over-water in low visibility conditions and appreciate the level of SA they can provide in concert with radar, FLIR, LNAV, Searchlight etc.

3) Low level, low visibility navigation must employ all available resources, from Mk 1 eyeball (looking out the bl**dy window), to all the bells & whistles available in a modern, 4 crew, SAR configured aircraft.

I for one, try to put myself in the position of this crew, as I know I can & do make errors, & ask myself what I can learn to be safer in the future.

[oleary]

Scattercat

Well said, mate.

[DOUBLE BOGEY]

Scatter Cat and Sunnywa. Your posts are honest and loyal to the SAR community which I respect a lot.

a lot of confusing and sometimes conflicting information on this thread. However we know that descending below MSA over the sea, can only ever be safely done with an ACCURATE RADAR IMAGE. FLIR and NVG add value but the RADAR and the RADALT are priority.

I have operated under 2 assumptions for 30 years, 1. that the radar locks out at 0.5 Nm and 2. You need to start the RADAR with as full and cluttered an image as you can tune in, and then back it off for clarity. This may not have been the correct scientific approach.

This crew were monitoring the radar. The CVR has calls accordingly. Something went tragically wrong with the WX radar setup, serviceability or software.

While in the SAR community there will be options now to recommend NVGs IFR letdowns etc, taking into account all possible safety systems, for the O&G community, they continue to do this kind of letdown in solid IMC (ARA) with ONLY the RADAR to rely on.

In older aircraft I have flown where the RADAR has its own "Telly" not much went wrong. It either worked or it didn't. However in modern multidisplay overlay technologies I have experienced a few kinds of software glitches which I am ashamed to say, fixed by some reconfiguration and rarely reported.

If this terrible event was caused by a faulty radar image or overlay problem we as a community need to start accurately documenting the insidious issues with overlay technology.

[gulliBell]

The accident aircraft seemed to be operating in some quasi-interim flight category, negotiating a phase between IFR and VFR. They certainly weren't on an IFR procedure, no IFR procedure starts at 200'. And they had switched on low altitude mode which is a VFR only mode, so that is a conscious decision that transition from IFR to VFR had occurred. But they weren't VFR otherwise they would have seen the lighthouse 1.3nm directly in-front of them. If VFR somebody has to be looking outside.

Do all the modern tools in these advanced SAR helicopters lull a crew into a false security? I dare say, if they were in a lesser equipped aircraft maybe this accident would have never happened. Or, if this was just a scenario given to them for a check-ride in a simulator, instead of an operational mission, whether they would have done the same thing with the examiner watching them?

I agree with Scattercat. Follow the IFR until you can see where you are going and maintain obstacle clearance by visual reference, no matter how much modern equipment you have that might tempt you to do otherwise. If you are VFR, it shouldn't be of much consequence that a lighthouse isn't in your terrain/obstacle database.

[DOUBLE BOGEY]

Gullibell, the mission of SAR is to letdown over the ocean, acquire the target and save people. What they were doing may not have been the Ideal approach certainly the vertical profile, but in principle it is the bread and butter of SAR and for that matter, an ARA. In this respect we all operate with the RADAR and the RADALT. They were using both. The key to understanding how the missed they rock lies with the RADAR. FLIR on their MFDs may have helped as might NVG. However as an ARA can quite legitimately get you to 200 feet and still be in solid IMC, only the RADAR can keep you safe, or so we have all assumed.

Knowing exactly how the RADAR was tuned and what procedures there were in place to achieve this is core to the interests of all of us flying over the oceans doing Letdowns or ARAs.

In most Organisations the tuning of the Radar is informally taught during line training, legacy driven, and on this hill of hindsight may well be inadequate.

For all persons in a supervisory role in the SAR and O&G I would recommend this issue alone is rapidly addressed and the training formalised to standardise to an ideal setup for each individual type of equipment. overlay issues must be addressed.

The IFR /VFR arguments are a red herring when taken in the wider context of the average mission profile, that is, to descend in IMC to a target.

[helicrazi]

So, correct me if I'm wrong, or point out what I'm misunderstanding,

The radar must have been set up correctly based upon,

1. The gain picking up a large target at 6 miles, assuming it was land. Gain adjusted correctly for land.

2. The tilt picking up the same target, too low it wouldn't have seen out to 6 miles, too high, it would have looked over it, as it picked one up at 6 miles then the tilt should have captures the more immediate target?

[[email protected]]

In most Organisations the tuning of the Radar is informally taught during line training, legacy driven, and on this hill of hindsight may well be inadequate.

that is a most telling statement DB - especially given your previous statement

However as an ARA can quite legitimately get you to 200 feet and still be in solid IMC, only the RADAR can keep you safe, or so we have all assumed.

perhaps the attitude to training for the radar has slipped across from oil and gas to SAR.

We come back to replacing a dedicated and fully trained radar operator with a co-pilot - cheaper but clearly far less effective.

As for NVG - everyone who uses them properly knows that the higher you go the less effective they are - lower is better with goggles hence 200' as a common figure.

[helicrazi]

Originally Posted by [email protected]

that is a most telling statement DB - especially given your previous statement perhaps the attitude to training for the radar has slipped across from oil and gas to SAR.

We come back to replacing a dedicated and fully trained radar operator with a co-pilot - cheaper but clearly far less effective.

As for NVG - everyone who uses them properly knows that the higher you go the less effective they are - lower is better with goggles hence 200' as a common figure.

The co-pilot will help you out of a disorientation though

[coyote_ie]

[QUOTE=Woolf;9741140]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 crewmember’s responsibility to monitor and constantly verbally update the obstacle situation as seen on the radar. Although I know nothing of CHC’s procedures I would assume that this is SOP, especially for SAR.

Very good point.

[Scattercat]

Originally Posted by DOUBLE BOGEY

The IFR /VFR arguments are a red herring when taken in the wider context of the average mission profile, that is, to descend in IMC to a target.

My comments above are more concerned with IMC / VMC conditions & the "how to" rather than the rules governing such. Yes, the correct use of the radar, should form a very important part of the picture, but it should be cross-checked with all other available data sources. The advent of reliable, GPS based navigation systems, allows for RNAV only IMC letdowns, which should then complement radar return information. I would be concerned if, during an ARA, the rig GPS location was not where the radar was painting a target, & visa versa.

[[email protected]]

The co-pilot will help you out of a disorientation though

yes, one of his primary duties is to monitor the handling pilot - instead we get him heads down playing with the radar!

[helicrazi]

Originally Posted by [email protected]

yes, one of his primary duties is to monitor the handling pilot - instead we get him heads down playing with the radar!

A good PM will know when to divert attention and 'play with the radar' usually when the aircraft is in a safe configuration, i.e. fully coupled and no inputs being made. Anyhow, you make a good point, PM cant be 100% monitoring as there are other duties.

[cncpc]

Originally Posted by gulliBell

How effective would NVG be in this environment i..e over water, under cloud? If they didn't see the lighthouse from 1.3nm away tends to suggest they weren't looking outside, would they have been looking outside if they had NVG?

We don't really know what the cloud base was at, or what level of cloud coverage there was, or how thick the bottom layer was. It was a full moon that night. The presumed weather is based on a aftercast shown in the weather section of the prelim report. Ceiling 300-400 feet. It is possible, or certain, that the light was in deep enough cloud that the crew couldn't see it.

It is known that an hour and a half after the accident R118 was on scene, in search mode, and found wreckage and a survivor floating in the water. Presumably in the same conditions that the accident occured in. Close in to Blackrock. Whatever systems they used to accomplish this did work for them. It's been overlooked in all of this, but that was an outstanding bit of SAR work.

[DOUBLE BOGEY]

CRAB as often is the case, you totally miss a point while you concentrate on scoring points.

O&G pilots fly ARAs to 200 feet using, these days, a CDFA type profile. They are taught to NEVER fly over a red blob unless at 1500 feet. The DR is 0.75 Nm (to cope with separation during a go-around and in recognition that the RADAR is not very good inside 1/2nm.

They will never have Rear Crew, FLIR or NVGs. We need to learn what this crew did and why they did it:

1. Did they really choose to fly over red blobs at 200 feet with the RADALT complaining?
2. Did they see Blackrock on the RADAR and choose to fly over it.?

Or, was the RADAR picture crap due to tuning, setup, malfunctions etc.

Whatever the case SETUP and PROTOCOLS concerning the RADAR almost certainly IS the FINAL HOLE in a pretty porous Swiss cheese that night.

The other holes variously:

1. Recency (as admitted on the CVR)
2. Route Familiarity (as admitted on the CVR)
3. Lack of CDFA procedures (dirty dive too early)
4. !!!!ty manuals with poor labelling (heights on charts not properly displayed).
5. Poorly designed SOP for the AHCAS setup. (No FLIR selected in cockpit)
6. A really badly designed letdown procedure masquerading as a route ( or vice versa) that, and get this clear, routes the bloody helicopter over terrain when surrounding it is many square miles of open ocean. Absolutely no excuse or reason for this. Since the days of DECCA we can fly to points in space, clear of obstacless waypoints and use the surround terrain on the edges of the radar as validation. Flying over the terrain to validate the waypoint is a joke for a crew and machine designed to find a dinghy in the vastness of the ocean.