SAR S-92 Missing Ireland

[[email protected]]

So, instead of providing valuable information from a current operator's perspective, you want to flounce off because I had the temerity to disagree with your opinion.

You have seen plenty of opinions on here, many made with little or no knowledge of SAR so instead of sniping at me why don't you back up your opinion with reasons for it - yours should be far more accurate based on your experience so why not share it.

Everyone wants to know the answer to Sasless' point

Four very professional SAR Crew Members apparently flew a serviceable and very well equipped Aircraft into terrain at night in very bad weather. Most of us look to this crew and think how it could have been anyone of us that came up short that night.....and naturally realizing that provokes a lot of questions as it should.

For example, how do your SOPS differ and how would you have done the letdown?

[Thomas coupling]

I found in all the time I spent @ 200' in amber, gusting red conditions, we the crew were constantly restless, looking for anything untoward. Even way offshore where maps weren't needed, we worshipped radar in case we flew over large tankers (and today - god forbid wind farms).
We never flew a straight line for more than a couple of miles, we simply altyered heading just enough to check the arc ahead was clear.
We had to maintain 200' because of our SOP's but if ever in doubt, would always climb to nose bleed height @ 500'.
I would like to make one observation though, based on thousands of SAR hrs offshore - human factors was key. A strong captain and a weak co-pilot were always compensated for by a strong navigator in the back, who monitored the front seat.
Perhaps, just perhaps, in answer to SAS's question it was down to complacency.... I hope it was quick.

[albatross]

My question is this: Re APBSS chart.
An actual route map should have tracks, distances and min alts between waypoints should it not?
An approach plate, if there was one, should be even more detailed and in an entirely different format.
Is this just a map included in the report to aid in orientation for those reading it?
The reason I ask is that the numbering of waypoints is neither in order nor does the numbering cover all waypoints.

[drugsdontwork]

Originally Posted by [email protected]

So, instead of providing valuable information from a current operator's perspective, you want to flounce off because I had the temerity to disagree with your opinion.

You have seen plenty of opinions on here, many made with little or no knowledge of SAR so instead of sniping at me why don't you back up your opinion with reasons for it - yours should be far more accurate based on your experience so why not share it.

Everyone wants to know the answer to Sasless' point

For example, how do your SOPS differ and how would you have done the letdown?

I'm not flouncing off. I just don't want an inappropriate argument given the tragic subject matter. I gave my opinion. They knew they were flying over islands at 200' as the rad alt warner went off. They were in FMS route guidance, not heading which would be more appropriate if they were concerned they may hit a radar contact. The warning of an island ahead seen on FLIR did not elicit (initially) a major response. The radar was I think at 10nm range scale, not perhaps a scale I would have if I was dodging close in around targets I was concerned about. Given these facts (I only scan read the report so apologies if any are incorrect) it looks as though they were under the impression that the route the FMS was driving them along was a safe low level route. It's much more likely than obscured waypoints, radar malfunctioning etc. Just my opinion.

RIP.

[SASless]

Drugs,

Since you are currently flying SAR on the S-92.....which is what I am taking from your post....you should be in a perfect position to pass on valuable information to those of us that do not fly the 92, have not flown SAR, who have not flown into Blacksod, and thereby provide an insight into what might have happened that dark, rainy, nasty night.

Punt posted two graphics, one being the CHC Route Guide graphic bearing several waypoints bearing various labels.

BLKSD Blacksod

BLKMO Blackrock

BKSDA

BKSDB

BKSDC

Earlier posts have shown the Track of R-116 from the transit across Ireland to the point it turned back from open water and began its fatal track back towards Blacksod and its impact with Blackrock.

The weather reports for the time period show a ceiling that varies from about 200-300 feet to almost a 1000 feet and visibilities that range from about 2 km to 7 km with rain, drizzle, mist, and fog being reported.

R-118 appears to have landed at Blacksod by using a different approach than did R-116....and did so perhaps twice or more.

Any explanation/guesses why two crews used different approaches that night?

Is there capability within the 92 SAR FMS that would allow for an IMC automated approach to Blacksod directly or from either BKSDB or BKSDC and not require an Open Water Approach then a Ten Mile transit at 200 Feet AGL?

Any idea why Blackrock's Identifier used BLKMO rather than say something like BLKRK (which might trigger recognition that the waypoint was exactly the Lighthouse at Blackrock and not some nearby point in space?

Care to describe the Training Curriculum your Operation uses re gaining full use of all the capabilities of the S-92 SAR Modes?

Does the S-92 SAR FMS have the ability to fix a point by means of the FLIR, GPS, Radar....then fly an automated approach to a hover either over or very close by that "Hooked" point?

Why would the ICG/CHC not have on file, surveyed and checked canned IMC Approach Procedures for known preplanned landing sites such as Blacksod?

[[email protected]]

Drugs, all you say makes sense - what is difficult to understand is that they acknowledged the little islands out of hand, without really questioning why they hadn't seen them on radar before they overflew them. That should have been the first alarm bell that their route wasn't as safe as they had assumed.

If it had prompted them to check the radar more closely and expanded the scale, should the return of Blackrock have been visible even if it was partially obscured by the FMS WP marker?

Clearly they weren't expecting to have to manoeuvre, hence the FMS route guidance, but would you expect a slightly quicker response in the cockpit to a concerned call about terrain from the back?

[louisnewmark]

DDW, I am in total agreement with you. Don't worry about the flak. It seems very likely to me that the crew expected the obstruction to be low enough for them not to bump into it - although I'm not sure why they chose to overfly rocks instead of going round contacts by using HDG - and the stated use of the 10nm range scale suggests to me that they weren't expecting a close-in conflict. I would definitely be using a closer range scale if I knew I was approaching something that I needed to avoid. 10nm suggests to me that the PM wanted to have the Blacksod HLS waypoint and local topography in view, rather than concentrating on the close-in picture. This is one reason why I await the detailed report witn great interest.

SASless etc, please don't be offended if posters choose not to divulge or discuss their respective operators' procedures on this forum; while it might make the usual suspects splutter with online indignation, it really isn't the done thing. Rest assured, though, that those operators will be contemplating their own procedures quite deeply as a direct result of this initial report...which, I expect, was the whole point of publishing it.

[louisnewmark]

Crab - reaction to crew: I think that is a key point. The PF's reaction was (in hindsight) inappropriately slow, and the last chance of preventing the accident appears to have been missed. Big learning point, that one. Also I'm not convinced that they didn't see the islands and rocks on radar; they could have seen them but still dismissed them as a threat.

[G0ULI]

It is worth noting that there was terrain on the mainland coast at 2000 feet plus. With the 10nm range scale, this should have been painting a good view of the coastline on the radar screen. Perhaps the main concern was avoiding getting too close to really high ground during the approach?

[drugsdontwork]

Originally Posted by [email protected]

Drugs, all you say makes sense - what is difficult to understand is that they acknowledged the little islands out of hand, without really questioning why they hadn't seen them on radar before they overflew them. That should have been the first alarm bell that their route wasn't as safe as they had assumed.

If it had prompted them to check the radar more closely and expanded the scale, should the return of Blackrock have been visible even if it was partially obscured by the FMS WP marker?

Clearly they weren't expecting to have to manoeuvre, hence the FMS route guidance, but would you expect a slightly quicker response in the cockpit to a concerned call about terrain from the back?

What makes you think they hadn't seen them? I'm pretty sure they had seen them, they were an experienced and capable crew. They just thought the route was safe and that they were low lying islands.

[drugsdontwork]

Originally Posted by louisnewmark

DDW, I am in total agreement with you. Don't worry about the flak. It seems very likely to me that the crew expected the obstruction to be low enough for them not to bump into it - although I'm not sure why they chose to overfly rocks instead of going round contacts by using HDG - and the stated use of the 10nm range scale suggests to me that they weren't expecting a clise-in conflict. I would definitely be using a closer range scale if I knew I was approaching something that I needed to avoid. 10nm suggests to me that the PM wanted to have the Blacksod HLS waypoint and local topography in view, rather than concentrating on the close-in picture. This is one reason why I await the detailed report witn great interest.

SASless etc, please don't be offended if posters choose not to divulge or discuss their respective operators' procedures on this forum; while it might make the usual suspects splutter with online indignation, it really isn't the done thing. Rest assured, though, that those operators will be contemplating their own procedures quite deeply as a direct result of this initial report...which, I expect, was the whole point of publishing it.

Like what he said 👍🏻

[SASless]

The absolute pity is it takes a tragedy such as this for the collective silence to be broken.

[sycamore]

I asked a few questions,back on p61 ,#1215,but not much response until `rotorspeed` triggered the answer about MAPS.Paper charts of the area concerned.They show the lighthouses/obstructions in the area of interest and their heights .Why were they not in the database?
Why is `Google Earth so wrong with it`s height for Blackrock,..?

About Lesson 1 in basic map-reading tells you about heights of obstacles/hills/mountains/powerlines/windfarms(now).
Radar lesson 1 should tell you about it`s good points,and bad points,limitations and use of scale/shadows.

I dont` always agree with T-C but in this case I see it as a case of` we go to `Blacksod,refuel,and act as topcover for R118`,if they go u/s we may go to the F/V and do the pick-up`.Did the crew actually brief..? was it observed/heard/recorded by anyone else,for posterity..? if not ,why not..? should all briefings b/f by SAR .crews be recorded...? if not ,why not...?

If I had been asked to do it in a S-K,I`d have let down east of Achill island,under radar,2-4 miles range,to 500 ft,then stepped down to 300ft,then 200 to creep in to BLKSD ,in a -61 or a -92.

If one had been diligent before fliight and read all the notes,on p2 of the APBSS,then surely you would have highlighted `Blkrock`...? if one was going to go and do that approach pattern..? It is also marked on the MAP,,,the paper one...!!!!FFFS

This also leads me to enquire of NATS as to why maps of the UK do not show heights of Lighthouses in UK waters....answer is...? dunno,`Charting ` at NATS cannot give an answer,but will consider it....

So,I think that there was a consideration by the crew that `this was an `easy trip`,but possibly the rear crew were not fully`in the picture`,or maybe didn`t have maps/charts of that area.....

point of interest..T-C,when did you go thru RNEFTS,,,,?

[dClbydalpha]

Originally Posted by drugsdontwork

What makes you think they hadn't seen them? ...

For me, a 300ft island 700m long by 450m wide would be giving a strong, distinctive return. Enough that it should have challenged the crew's mind's eye view of the situation.

My impression is that they expected a small low lying island ... and they identified it, incorrectly. The presence of a larger contact might have been compelling.

Rather than look to identifying the cause, I prefer to look at what could have prevented it. I think that a clearer closer radar range scale would be one of them.

DDW can you answer whether the S92 allows an altitude constraint to be entered against a WP or leg in the FMS database?

[DOUBLE BOGEY]

There appears to be a suggestion that the crew were led to believe the rock they flew towards was 'not very high" and therefore they did not bother to set the radar or avoid the rock. So far, the Swiss cheese barriers removed mostly by the crew seem to be,

1. Crew unfamiliar or not recent in the local area.
2. Despite 1 above, it is clear a very inadequate pre flight and en route brief ensued which failed to capture the lump of rock on the route they programmed into the FMS.
3. Truly !!!! cockpit briefing material (however, was not the co-pilot also the unit CP. If so is he not responsible for cockpit resources like this)
4. A failure to invest in the inherent safety benefits of a CDFA.
5. Incredulous acceptance of flying over radar targets at 200 feet in dark poor WX.
6. Failure to utilise FLIR image in the cockpit.
7. Failure to mandate HDG mode when it is the most appropriate mode during a RADAR letdown where the whole point is to avoid the blobs that appear by turning.
8. Overly complex crew SOPS whereby the PF seemed unable to make an immediate heading change in response to the rear crew call.
9. INAPPROPRIATE response to RADALT warnings.

I may not have captured them all but sadly, like it or hate it, this crew seriously underperformed and the cockpit briefing material just led them to the rock.

[[email protected]]

What makes you think they hadn't seen them? I'm pretty sure they had seen them, they were an experienced and capable crew. They just thought the route was safe and that they were low lying islands.

Mainly because they weren't mentioned before they got over them and because the reaction seemed from the transcript to be one of surprise.

And I'm sure their SOPs would also advocate not to overfly radar contacts at low level unless you can visually ID them. Remember, no NVD on this aircraft.

DB, you are pre-empting the investigation with a guilty charge based on limited information - not really fair?

[Geoffersincornwall]

DB - Remember the Zotov Error Map. There's plenty to put into the mix besides a list of the crew's apparent (we don't know everything yet) shortcomings.

Read David Beaty's book The Naked Pilot. There you will learn that the tragic story of the Comet jetliner had its origins in a political/commercial decision not to build a prototype and not to conduct full developmental flight trials. This fact did not prevent the demotion of a Captain who had the misfortune to be in charge of the first Comet to crash whilst taking off from Rome because the performance related problems were kept secret by the makers, the government and the accident investigators (The NAA in those days).

I suggest some patience is appropriate whilst we take in the significance of this tragedy. When we have the full report we can measure how honestly it addresses the shortcomings that are apparent today. Somebody or some body turned down the request for NVG. Any recommendations that emerge from the accident report are awaited with interest.

[learner001]

Having read the whole thread and the preliminary safety report, published 13 April 2017 by the AAIU, No: 2017-006, State File No: IRL00917016, I keep trying to imagine what made this unfortunate crew (RIP) believe that there would be no conflicting obstacles along their route part in the vicinity of BLKMO waypoint!

In some posts, it was mentioned that the crew may have been aware of the island(s) in the vicinity of BLKMO waypoint. I don't know. If not, by the "Altitude!, Altitude!" alert, at least they eventually became aware, that (provided that it would not be a false alert) there should be 'something' in the vicinity of BLKMO waypoint. What they obviously were certainly not aware of (=because of what?=) is, that the elevation of another 'something' in that same vicinity of BLKMO waypoint is that tall.

Of course, to come closer to acceptable assumptions, we also have to go to the earlier stages of the flight. We want to know all about the training, SOPs, preparation and resources, technical and non-technical skills, operational culture, equipment, and dig even further into the past, the involved organisation(s) and so on... And I am sure, quite some things will turn up...

Besides all that, for a moment I like to look just at the possible 'mindset' of the crew at that particular stage of flight, just under one minute/one-and-a-half miles, before waypoint BLKMO. And how it had come to that 'mindset' in order to (re)act as was done after the "Altitude!, Altitude!" alert and the 'Turn advise' . . .

On their easterly course towards Blackrock, the crews 'mindset' appears to have been that, for now, they were on a relatively safe route. And that they had done all the necessary preparation to commence a further approach to Blacksod from the BLKMO waypoint via BKSDA waypoint. Apparently believing, closely around and including Blackrock, somewhere in the vicinity of BLKMO waypoint, (the islands) heights/elevations being of negligent value, relative to their own chosen height/altitude . . .

Because of that 'mindset', they may have been more focusing now of what was going to come in another six or seven miles ahead. 5 miles after BLKMO waypoint. Something, which in their minds may have appeared relatively more challenging:

Roughly six or seven miles ahead, about a mile before BKSDA waypoint, they would have to enter a bay, having to pass safely through the entrance of a (in the general, 'broader world' picture, probably more obvious than the smaller seeming 'little world' in the Blackrock vicinity) relatively narrow, imaginary (if I may call it that) 'safe corridor' of some 3.5 nautical miles wide (1.75 miles either side), where their actual height of 180-200' would indeed be of concern, relative to the closest initial terrain confinements of this corridor. (North around 148' Duvillaun More Island. And South beginning more than 400' and much higher behind that.) Thereafter they would have to stay clear of coastal terrain and obstacles and possible navigating vessels in the bay . . . (Of course, I realise that clearing vessels should apply as well to the further away from shore stages of the route. But also that may likely be subject to another sort of 'mindset')

It appears to me that along the leg towards BLKMO waypoint the above may have 'grown' a 'mindset'. And ultimately may 'have become and may have been' the eventual 'mindset' for that stage of flight, appearing to come forth by just a very few real 'on the scene' observations that are known to us from the report. Which, of course, are just a tiny little part of a much greater sequence of events and circumstances:

- The choice of NAV mode by PF. (Which was apparently not challenged by PM.)

- The 10 miles range choice of PF of the radar, appearing as a belief of no need for a closer picture. (Which apparently was also not challenged by PM.)

- The first and only radar target call by PM appears to be for two targets, at 6 miles only. In relation to track and heading, the "Ok, so, small target at 6 miles, 11 o'clock" appearing to point to the Duvillaun More Island, the North confinement of the 'safe corridor'. The other "Large to the right there" appearing to indicate the South confinement of the 'safe corridor'. Both radar targets are beyond Blackrock. No mention, indication or remark that anything closer would appear or be searched for. (The "1.3 miles to run to Blackmo..." remark appears to be based on waypoint/nav indications.)

- No SOP (re-)action on the "Altitude, Altitude!" alert by PF nor PM, other than PF just mentioning the remark, in the 'greater-more-miles-mind-set' (10nm): "just a small little island, that is BLMO itself", moments after the beginning and just before the ending of this "Altitude!, Altitude!" alert. When they apparently were right over the Northern island (± 0.6 miles from BKLMO waypoint) of the Carrickduff and Carrickad islands. It appears to be indicating a belief that they would now more or less be in very close proximity of that mentioned "small little island", that would lie somewhere about half a mile down there in the vicinity of the BLKMO waypoint, triggering the alert. The 'mindset' possibly now appearing to preclude another more conscious possibility at such short range. And I think, way deep inside, that I may know what that feels like. And also no challenge by PM. (I can not really believe that the "small little island" remark was the PF response to the 6 nm radar target call of the PM.)

- The initial non-(re)action at all from PF/PM on the initial 'Turn advice' from the rear crew.


It is very sad that this obviously dedicated crew of four appear to have been provided on a mission, to be in possession of all the hard- and software sophistication that you may ever dream of, but for one simple basic navigation tool: a proper basic and uncluttered paper pilots flying map . . . In many organisations, a well-known hint as being the 'top of . . .'

In the meantime, during my writing, a number of posts have come up. So, repeat may be in the above. Sorry for that . . .

With respect, RIP, learner . . .

[gulliBell]

Originally Posted by [email protected]

..DB, you are pre-empting the investigation with a guilty charge based on limited information - not really fair?

From what I've read in the preliminary accident report, and digesting the volume of opinion contained in this discussion, to me it looks like a bad plan from the outset that was poorly executed. Whatever the mitigating factors, the PIC is ultimately responsible for the safety of the aircraft and the outcome of the mission.

[louisnewmark]

Learner001: definitely no need to apologise for any part of your post; I think it's quite insightful and more than a few readers are likely to be in agreement.