SAR S-92 Missing Ireland
Joined: Jun 2003
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From: Off the Planet
Excluding any loose ends that will be found from the wreckage, the interim report contains most that is required to understand what happened. It is likely that a combination of company organizational issues and SAR culture were the key elements. It resulted in a bad plan that was executed accurately.
Helicomparator makes an interesting point that the culture of SAR in the civil era needs a review; it would benefit from a process similar to that used in CAP 1145.
It is likely that APBSS was a VFR procedure that had been in place for some time. Blackrock is an island that, in VFR, can be seen from a distance; it allows an accurate placing of the aircraft for a series of visual manoeuvres leading to a VFR approach to Blacksod. It is unlikely that it was ever risk assessed for use in weather below VFR limits (cloud base - day 600ft, night 1,200ft; visibility – day 1,500m (800m for short periods), night 5km).
Descent from IMC to VMC/VFR in Class G airspace over the water is permitted in accordance with procedures Approved by the Authority; such a procedure would be permitted only with a serviceable RADAR and to an altitude/height where a continuation of the flight under VFR would be possible. (It is likely that SAR has a derogation from the VFR minima under operational conditions.)
The SOPs of SAR (and additional equipment on board) permit a let-down, and a continuation of flight, over water below normal VFR limits – this would have been standard for the SAR crew. It is likely that this alleviation would extend to the approach and landing at Blacksod (which appears to be the refuelling site of choice).
The linking of the en-route descent (to SAR limits) and the APBSS approach (under SAR limits) from Blackrock to Blacksod does not appear to have been risk assessed when the APBSS procedure was incorporated into the SAR Operations Manual. If it had then there should have been bold warnings on the plate and/or a limitation on height and visibility on the route.
The lack of an instrument approach to Blacksod under conditions where it was a principal SAR refuelling site appears to be an organizational issue.
The lack of adequate notation on the APBSS plate appears to be an organizational issue.
The combination of SAR culture and standard VFR routing to Blackrock/Blacksod increased the probability of an accident. It would appear that, the Captain was unaware of the height of the terrain/obstructions on Blackrock (from the CVR “Eh just a small little island… that’s B L M O itself”). The choice of APBSS routing and SAR limits probably resulted from a misunderstanding that Blackrock posed no threat and was intended to be overflown - from there confirmatory bias was in play.
It was unfortunate that Blackrock was missing from the EGPWS data-base - an issue that now has to be addressed in the provision of the eTOD for EGPWS and synthetic vision systems. The lack of knowledge on the thread about the functioning of EGPWS is a little sad; however, in mitigation, this is a device that does not require anything from the pilot but reaction to the ‘callout’ (questioning the EGPWS would be counterproductive). Had Blackrock been in the data-base, it is likely that it would have been 'called out' in the lookahead function.
This was an unfortunate accident that, hopefully, will result in an examination of civil SAR and leading to a process of improvement.
Helicomparator makes an interesting point that the culture of SAR in the civil era needs a review; it would benefit from a process similar to that used in CAP 1145.
It is likely that APBSS was a VFR procedure that had been in place for some time. Blackrock is an island that, in VFR, can be seen from a distance; it allows an accurate placing of the aircraft for a series of visual manoeuvres leading to a VFR approach to Blacksod. It is unlikely that it was ever risk assessed for use in weather below VFR limits (cloud base - day 600ft, night 1,200ft; visibility – day 1,500m (800m for short periods), night 5km).
Descent from IMC to VMC/VFR in Class G airspace over the water is permitted in accordance with procedures Approved by the Authority; such a procedure would be permitted only with a serviceable RADAR and to an altitude/height where a continuation of the flight under VFR would be possible. (It is likely that SAR has a derogation from the VFR minima under operational conditions.)
The SOPs of SAR (and additional equipment on board) permit a let-down, and a continuation of flight, over water below normal VFR limits – this would have been standard for the SAR crew. It is likely that this alleviation would extend to the approach and landing at Blacksod (which appears to be the refuelling site of choice).
The linking of the en-route descent (to SAR limits) and the APBSS approach (under SAR limits) from Blackrock to Blacksod does not appear to have been risk assessed when the APBSS procedure was incorporated into the SAR Operations Manual. If it had then there should have been bold warnings on the plate and/or a limitation on height and visibility on the route.
The lack of an instrument approach to Blacksod under conditions where it was a principal SAR refuelling site appears to be an organizational issue.
The lack of adequate notation on the APBSS plate appears to be an organizational issue.
The combination of SAR culture and standard VFR routing to Blackrock/Blacksod increased the probability of an accident. It would appear that, the Captain was unaware of the height of the terrain/obstructions on Blackrock (from the CVR “Eh just a small little island… that’s B L M O itself”). The choice of APBSS routing and SAR limits probably resulted from a misunderstanding that Blackrock posed no threat and was intended to be overflown - from there confirmatory bias was in play.
It was unfortunate that Blackrock was missing from the EGPWS data-base - an issue that now has to be addressed in the provision of the eTOD for EGPWS and synthetic vision systems. The lack of knowledge on the thread about the functioning of EGPWS is a little sad; however, in mitigation, this is a device that does not require anything from the pilot but reaction to the ‘callout’ (questioning the EGPWS would be counterproductive). Had Blackrock been in the data-base, it is likely that it would have been 'called out' in the lookahead function.
This was an unfortunate accident that, hopefully, will result in an examination of civil SAR and leading to a process of improvement.
Joined: May 2002
Posts: 2,697
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From: Wanaka, NZ
We know much of what they did, what we don't know is why they did what they did. The approach briefing, which isn't in the CVR transcript, would be useful to understand the options contemplated, and what course of action was decided.
Regarding training. When crews are sent to the simulator for training, the instructors expect the trainees to know how to use the radar, and all those other things. There is no time allocated for teaching these things. In my experience, it is regrettably common to find recurrent trainees with weak knowledge of aircraft limitations let alone the intricacies of how to tune their weather radar. This tells me that thorough on-going structured training at the operator level is lacking. Whether these observations can be applied more widely across the industry, or whether it is limited to our client base, I don't know. I've seen trainees turn on the weather radar and just blast through an active thunderstorm with lighting and maintain course just because ATC gave them a heading to steer. Even cranking up the turbulence level to maximum doesn't cause them to think a different plan might be a better idea. Sometimes pilots can be their own worse enemy.
Regarding training. When crews are sent to the simulator for training, the instructors expect the trainees to know how to use the radar, and all those other things. There is no time allocated for teaching these things. In my experience, it is regrettably common to find recurrent trainees with weak knowledge of aircraft limitations let alone the intricacies of how to tune their weather radar. This tells me that thorough on-going structured training at the operator level is lacking. Whether these observations can be applied more widely across the industry, or whether it is limited to our client base, I don't know. I've seen trainees turn on the weather radar and just blast through an active thunderstorm with lighting and maintain course just because ATC gave them a heading to steer. Even cranking up the turbulence level to maximum doesn't cause them to think a different plan might be a better idea. Sometimes pilots can be their own worse enemy.
Joined: Oct 1999
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From: Den Haag
1. Did they really choose to fly over red blobs at 200 feet with the RADALT complaining?
Joined: Jul 2014
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From: Spain
I agree with most of you guys. Specially with the "holes" listed by double bogey.
But we shouldn't forget that the ultimate cause of the accident is the failure of the crew in changing the heading of the aircraft. They KNEW they had an obstacle just in from of them up to 15 seconds before the crash.
The CVR suggests that the copilot received the command to change the course and used his control knob. But the helicopter didn't change its course, as the graphic shows. Why? Perhaps the AP mode selected. What do you think about this?
But we shouldn't forget that the ultimate cause of the accident is the failure of the crew in changing the heading of the aircraft. They KNEW they had an obstacle just in from of them up to 15 seconds before the crash.
The CVR suggests that the copilot received the command to change the course and used his control knob. But the helicopter didn't change its course, as the graphic shows. Why? Perhaps the AP mode selected. What do you think about this?
Joined: Oct 1999
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From: Den Haag
The CVR suggests that the copilot received the command to change the course and used his control knob. But the helicopter didn't change its course, as the graphic shows. Why? Perhaps the AP mode selected. What do you think about this?
Joined: Jun 2006
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From: Perth, Australia
212 Man
My reading of the transcript is that the PF (PIC) was giving directions to the PM to first select Hdg mode (assume they were in Nav mode tracking DTO BLKMO) then never got around to telling the PM to turn before the Rear Aircrewman started to call urgently. This was the period when a heading change of any type might have worked. The PF did not seem to actually select or turn the heading.
My reading of the transcript is that the PF (PIC) was giving directions to the PM to first select Hdg mode (assume they were in Nav mode tracking DTO BLKMO) then never got around to telling the PM to turn before the Rear Aircrewman started to call urgently. This was the period when a heading change of any type might have worked. The PF did not seem to actually select or turn the heading.
Joined: Oct 1999
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Posts: 7,373
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From: Den Haag
212 Man
My reading of the transcript is that the PF (PIC) was giving directions to the PM to first select Hdg mode (assume they were in Nav mode tracking DTO BLKMO) then never got around to telling the PM to turn before the Rear Aircrewman started to call urgently. This was the period when a heading change of any type might have worked. The PF did not seem to actually select or turn the heading.
My reading of the transcript is that the PF (PIC) was giving directions to the PM to first select Hdg mode (assume they were in Nav mode tracking DTO BLKMO) then never got around to telling the PM to turn before the Rear Aircrewman started to call urgently. This was the period when a heading change of any type might have worked. The PF did not seem to actually select or turn the heading.
Joined: May 2002
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From: Wanaka, NZ
We teach the PM selects the required heading, whether the chart calls for it, or the PF calls for it...I don't like it that way whilst in coupled flight, but I "don't" see it as an error should the PF make the heading bug changes during a check flight. My thinking of it is I don't like to change the fundamentals of what I'm used to for single pilot IFR, that is, the PF does the flying and there is no ambiguity as to who is responsible for what. But for 2-crew, as long as there is consistency for the various actions between the crew, and it has been briefed beforehand, or the responsibilities are otherwise previously well established by operator SOP.
If I understand it, there is a single channel of the CVR that records the microphone input from both rear crew, so who said what in that channel of the CVR transcript I don't know. Can somebody from the SAR community clarify the respective roles of each of the two rear crew during this phase of flight, and what equipment was available at each crew station? I'm only used to having one crewman bark at me should there be any need for barking, and if a bark is required, it's usually very loud and clear.
Also, the CVR transcript indicates an ELT ping was transmitted on impact with the rock. Do we know if this was detected by a satellite? And also, some comment on the pros/cons of having a Captain assigned to a co-pilot role. I think there is potential for some dysfunction in a crew when there is no cockpit gradient, and I know myself I tend to be slightly less vigilant as a co-pilot if I'm playing co-pilot to another Captain. And the Captain tends to be less vigilant if he's got another Captain playing co-pilot. The whole nature of the cockpit is different with two Captains flying together. Might this explain why there wasn't much communication between the pilots?
If I understand it, there is a single channel of the CVR that records the microphone input from both rear crew, so who said what in that channel of the CVR transcript I don't know. Can somebody from the SAR community clarify the respective roles of each of the two rear crew during this phase of flight, and what equipment was available at each crew station? I'm only used to having one crewman bark at me should there be any need for barking, and if a bark is required, it's usually very loud and clear.
Also, the CVR transcript indicates an ELT ping was transmitted on impact with the rock. Do we know if this was detected by a satellite? And also, some comment on the pros/cons of having a Captain assigned to a co-pilot role. I think there is potential for some dysfunction in a crew when there is no cockpit gradient, and I know myself I tend to be slightly less vigilant as a co-pilot if I'm playing co-pilot to another Captain. And the Captain tends to be less vigilant if he's got another Captain playing co-pilot. The whole nature of the cockpit is different with two Captains flying together. Might this explain why there wasn't much communication between the pilots?
Last edited by gulliBell; 19th April 2017 at 11:24.
Joined: Dec 2013
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From: Norfolk
Many years ago when ships carried radio officers, it was my habit after the last watch of the day to go on the blacked out bridge and chat with the navigation officers over a cuppa. Invariably the radar screen would be misadjusted, with the sensitivity and brightnesss turned down. I would reset the display only to be faced with complaints from the navigation officer that looking at the radar screen set correctly destroyed his night vision. Their preferred setting was to have no clutter at all visible and large targets barely showing on the screen. It kept the brightness down but meant that small vessels such as fishing boats would go completely unnoticed unless their navigation lights were spotted.
Moving on several decades. Helicopter flying in the dark, crew wanting to keep their night vision as sharp as possible for a forthcoming landing, all the instrument lighting turned down as low as it will go. It seems a similar situation to what I experienced years ago but in a different environment. Everything could have been working just fine, but to see fine detail on a radar display, you need the brightness turned up more than is compatible with maintaining good night vision. I know there are night display modes that are supposed to help with this problem, but established habits are hard to break. None of the navigation officers I worked with could avoid tweeking the radar display after I had set it up correctly.
Just another one of those human factors that could be relevant.
Moving on several decades. Helicopter flying in the dark, crew wanting to keep their night vision as sharp as possible for a forthcoming landing, all the instrument lighting turned down as low as it will go. It seems a similar situation to what I experienced years ago but in a different environment. Everything could have been working just fine, but to see fine detail on a radar display, you need the brightness turned up more than is compatible with maintaining good night vision. I know there are night display modes that are supposed to help with this problem, but established habits are hard to break. None of the navigation officers I worked with could avoid tweeking the radar display after I had set it up correctly.
Just another one of those human factors that could be relevant.
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That is a very valid question.
With the radar set to 10 NM range on the PM's (copilot) NAV screen in this case, the waypoint symbol for "BLKMO" would hide the radar return from Blackrock. If using 5 NM, or even better 2.5 NM range, the return from Blackrock would be relatively larger than the waypoint symbol, and hence get your attention.
I tried this a couple of days ago (in the S92 with the Primus 701A radar) using an oil rig as "Blackrock". With 10 NM range, GMAP2, optimal gain and tilt, and at a distance of 1-2 NM from the oil rig it was very difficult to actually spot the return because of the waypoint symbol. Blackrock might have given a slightly larger return than an oil rig though.
With the radar set to 10 NM range on the PM's (copilot) NAV screen in this case, the waypoint symbol for "BLKMO" would hide the radar return from Blackrock. If using 5 NM, or even better 2.5 NM range, the return from Blackrock would be relatively larger than the waypoint symbol, and hence get your attention.
I tried this a couple of days ago (in the S92 with the Primus 701A radar) using an oil rig as "Blackrock". With 10 NM range, GMAP2, optimal gain and tilt, and at a distance of 1-2 NM from the oil rig it was very difficult to actually spot the return because of the waypoint symbol. Blackrock might have given a slightly larger return than an oil rig though.
Last edited by puntosaurus; 19th April 2017 at 12:27.
Joined: Apr 2000
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From: EGDC
DB - you highlighted the poor training of radar set up and usage in your industry - it had to come from somewhere and O&G are the ones who pioneered ARAs.
MilSAR had a dedicated radar operator who has been replaced, in the O&G format, by the co-pilot in CivSAR, this is not points-scoring, this is highlighting cheap practices adopted into roles that need dedicated expertise.
MilSAR had a dedicated radar operator who has been replaced, in the O&G format, by the co-pilot in CivSAR, this is not points-scoring, this is highlighting cheap practices adopted into roles that need dedicated expertise.
Joined: May 2002
Posts: 2,697
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From: Wanaka, NZ
Pilots needs to be competent at operating the equipment they are provided with, particularly really important stuff like a radar. In 24 years of flying weather radar equipped helicopters I have never received any structured, formal training in the use of the radar, apart from watching a Honeywell radar training video, once. I don't even think we have radar questions in our recurrent exam question bank, and radar is not taught during initial type technical ground school. If this is widely common in the industry it needs to change. Maybe there should be a radar exam, much like a basic gas turbine exam before you're allowed to fly a turbine helicopter, with a logbook certification required.
Joined: Jul 2014
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From: Spain
gullibell, my experience is more or less the same. In my squadron there was an A-4 sheet with instructions explaining the basic functions and little more. Some pilots never used tilt control, for instance.
And reading some civilian transport accident reports, in commercial airlines is the same. Pilots do not master the use of weather radar because there is not an specific training course about it.
To add something to the debate, I think that the primary source for VFR navigation when you are not familiar with the area in which the flight is conducted, should be a VFR CHART. I mean, a paper chart or a digital moving map. Radar and EGPWS are important tools for navigation, but a good map in a correct scale is paramount.
And reading some civilian transport accident reports, in commercial airlines is the same. Pilots do not master the use of weather radar because there is not an specific training course about it.
To add something to the debate, I think that the primary source for VFR navigation when you are not familiar with the area in which the flight is conducted, should be a VFR CHART. I mean, a paper chart or a digital moving map. Radar and EGPWS are important tools for navigation, but a good map in a correct scale is paramount.
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Originally Posted by [email protected]
DB - you highlighted the poor training of radar set up and usage in your industry - it had to come from somewhere and O&G are the ones who pioneered ARAs.
MilSAR had a dedicated radar operator who has been replaced, in the O&G format, by the co-pilot in CivSAR, this is not points-scoring, this is highlighting cheap practices adopted into roles that need dedicated expertise.
MilSAR had a dedicated radar operator who has been replaced, in the O&G format, by the co-pilot in CivSAR, this is not points-scoring, this is highlighting cheap practices adopted into roles that need dedicated expertise.
Joined: Sep 2007
Posts: 244
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From: Birmingham
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.
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.
Joined: May 2002
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From: Downeast
The USCG tests Mariners for Radar Endorsements for those Licences......and that is for vessels moving a lot slower that are in contact with water!
Pilots needs to be competent at operating the equipment they are provided with, particularly really important stuff like a radar. In 24 years of flying weather radar equipped helicopters I have never received any structured, formal training in the use of the radar, apart from watching a Honeywell radar training video, once. I don't even think we have radar questions in our recurrent exam question bank, and radar is not taught during initial type technical ground school. If this is widely common in the industry it needs to change. Maybe there should be a radar exam, much like a basic gas turbine exam before you're allowed to fly a turbine helicopter, with a logbook certification required.
Joined: May 2002
Posts: 2,697
Likes: 71
From: Wanaka, NZ
..To add something to the debate, I think that the primary source for VFR navigation when you are not familiar with the area in which the flight is conducted, should be a VFR CHART. I mean, a paper chart or a digital moving map. Radar and EGPWS are important tools for navigation, but a good map in a correct scale is paramount.
Last edited by gulliBell; 19th April 2017 at 13:03.
Joined: Apr 2000
Aviation Qualifications: ATP+Mil
Posts: 10,959
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From: EGDC
I don't think this is a matter of being cheap, it looks like a matter of inexperience in the SAR world. The CivSAR machine in question appears to have had both the staff and the equipment to operate as you suggest, but it looks like the operator lacked the experience to put those tools to good use, and the crew were not adequately prepared to deal with their input.
So, even if the rear crew are trained to use the radar ( and they do have the screens in the cabin to do so) they can't 'control' the aircraft in the same way as a mil Radop would have done in the Sea King.
Personally I see this as a retrograde step that pushes workload to the front of the aircraft in poor weather or at night when it could be managed much better using more of the crew.
Perhaps it is something that could be addressed through the AOC to give derogations from the 'normal rules'.
However, I wouldn't be surprised to find that some CivSAR crews do operate the 'old-fashioned' way because they have ex-mil Radops with a great deal of skill and knowledge in manipulating the radar.
Joined: Apr 2014
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From: Co. Kildare
Need help from you guys!!
The distance between the Rocks (when RADALT callout was triggered) & Blackrock is approx. 1250 metres. Time elapsed from RADALT callout being triggered & time of impact is 28 seconds. That equates to 44.64 mr/sec..160.71 KM/hr ...or 86.7Knots
Does this mean tailwind was 11kts ???
I have't been at the controls of an aeroplane since 1994. Forgotten most theory !!!
The distance between the Rocks (when RADALT callout was triggered) & Blackrock is approx. 1250 metres. Time elapsed from RADALT callout being triggered & time of impact is 28 seconds. That equates to 44.64 mr/sec..160.71 KM/hr ...or 86.7Knots
Does this mean tailwind was 11kts ???
I have't been at the controls of an aeroplane since 1994. Forgotten most theory !!!
Guest
Posts: n/a
This overlay issue is bigger than just radar. I was in a 169 recently and the factory educated pilots 'discovered' that transponder returns are only displayed on the MFD in RA mode. In TA mode which is much more common for that helicopter operation, no returns are displayed.
Their training included a reasonable slug of time in a Virtual Interactive Procedure Trainer which is supposed to get you used to the controls and displays at lower cost than the full sim. Seems like there ought to be a lot more canned scenarios to display the quirks of the system.
However the problem is that nobody seems to be able to forsee the quirks until there is an accident to point them out.
Their training included a reasonable slug of time in a Virtual Interactive Procedure Trainer which is supposed to get you used to the controls and displays at lower cost than the full sim. Seems like there ought to be a lot more canned scenarios to display the quirks of the system.
However the problem is that nobody seems to be able to forsee the quirks until there is an accident to point them out.