SAR S-92 Missing Ireland
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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 . . .
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 . . .
Last edited by learner001; 3rd May 2017 at 18:48. Reason: "They are beyond Blackrock" changed to:"Both radar targets are beyond Blackrock", after 212man raised confusion in #1642
Originally Posted by [email protected]
..DB, you are pre-empting the investigation with a guilty charge based on limited information - not really fair?
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Originally Posted by [email protected]
DB, you are pre-empting the investigation with a guilty charge based on limited information - not really fair?
Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.
Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.
A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.
I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.
I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.
DB
Excellent post by Learner!
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DB
Have to say I think your summary was refreshingly clear, rationale and objective. Regretfully for the crew, I totally agree with you. We should use this to remind us all that we could be capable of multiple errors that could have devastating consequences. And that if we hide from the harsh truth of the vital importance of our own actions and judgement as pilots, we risk not taking enough personal responsibility for the safety of our aircraft.
Have to say I think your summary was refreshingly clear, rationale and objective. Regretfully for the crew, I totally agree with you. We should use this to remind us all that we could be capable of multiple errors that could have devastating consequences. And that if we hide from the harsh truth of the vital importance of our own actions and judgement as pilots, we risk not taking enough personal responsibility for the safety of our aircraft.
like it or hate it, this crew seriously underperformed
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CRAB, this is not a court room. Its a discussion forum. From the information available, what I have posted is my personal opinion of how a perfectly serviceable all weather helicopter flying, what should be, a simple task of letting down over the ocean, flew straight into a obstacle 10 x the dimensions (not height) of the average O&G installation.
Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.
Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.
A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.
I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.
I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.
DB
Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.
Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.
A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.
I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.
I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.
DB
I am just curious and always willing to learn more... Could you please describe an ad-hoc CDFA the crew could have done instead of a traditional ARA and continued safely to Blacksod.
Last edited by Search&Rescue; 28th Apr 2017 at 12:33.
I'm open to reading the views of everybody here. As somebody who works for a Part 145 training organization who's job it is to access crew competency, and without knowing the wider background of all the circumstances, I don't see anything redeeming for this flight crew in the transcript of that CVR. Both on what was said, and what was not said. Instead, if the same sortie had been flown in the simulator on their annual competency check, it would probably be an automatic fail for the PIC. Which by definition, is an under-performing crew. But to be fair I would need to hear the transcript of the whole of the flight to make any definitive assessment, and also without the benefit of observing what went on, I remain open minded on that question.
Some of us lived long enough to move on to other endeavors!
This Crew had a lot of help in not surviving.
At some point it was bound to happen to a Crew.....it just happened to be this Crew this time.
Share the blame as there is plenty to go around!
This Crew had a lot of help in not surviving.
At some point it was bound to happen to a Crew.....it just happened to be this Crew this time.
Share the blame as there is plenty to go around!
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CRAB, this is not a court room. Its a discussion forum. From the information available, what I have posted is my personal opinion of how a perfectly serviceable all weather helicopter flying, what should be, a simple task of letting down over the ocean, flew straight into a obstacle 10 x the dimensions (not height) of the average O&G installation.
Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.
Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.
A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.
I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.
I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.
DB
Not my place to criticise the crew but I believe we should not be afraid to sense the obvious here.
Take away the FLIR, the Rear Crew, the assumed additional expertise of the SAR crew and you have a Offshore ARA in its basic form.
A waypoint, a Radar Target (or several) and a vertical profile (CDFA). Backed up with a sensible Altitude/RADALT Bug response philosophy. Nothing else really needed and this is done every day by the O&G pilots.
I strongly re-emphasise that the merits of the CDFA (not utilised in this approach) would have saved them. However, I keep forgetting, this is Rotorheads and we don't really like silly, new rules that take away are ability to do exactly what we want when we want to do it.
I started on this thread pushing back against Helicomparitor. Now I am beginning to think, having read and seen all the data, his original point may indeed by valid.
DB
From my own point of view as an onshore corporate person, descending to 200ft 10 miles short of the destination is a suckers move.
DB as a O&G man, you are presumably used to flying on well established routes to known obstacles over water often in ****ty weather.
For SAR people descending to 200ft over water in the middle of nowhere and creeping in marginal weather is their raison d'etre.
You can see how armed with what looks like a planned approach chart the SAR culture and SOPs could collide with what appears like commonsense to other groups. Nevertheless I do detect a certain discomfort from the SAR community on this thread about the overall plan for this approach.
Last edited by puntosaurus; 28th Apr 2017 at 14:06.
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From an outsiders point of view, descending to 200 feet in limited visibility and proceeding at 75 knots does not constitute my definition of creeping towards a destination, especially in the knowledge that obstacles above the minimum safe altitude might be in the vicinity. The crew clearly cannot have had any idea what they were flying towards.
Yes, there were clearly some errors made by the crew but until we have the full picture, ie the full report, it is both unfair and unprofessional to put the blame directly on them when there is no information that can be offered in their defence - that will reside in the report as mitigating/causal factors.
We should not - armed with only some pieces of information, 20/20 hindsight and often no experience in the role - act as judge and jury.
Ask questions and consider the conditions, equipment and operating procedures by all means - we are all learning from that - but bluntly voicing what can only be an opinion (sometimes clouded by pre-conceptions and learned bias) is simply unhelpful and not very respectful.
We should not - armed with only some pieces of information, 20/20 hindsight and often no experience in the role - act as judge and jury.
Ask questions and consider the conditions, equipment and operating procedures by all means - we are all learning from that - but bluntly voicing what can only be an opinion (sometimes clouded by pre-conceptions and learned bias) is simply unhelpful and not very respectful.
Crab is right on this one!
The Crew made some errors....yes!
WHY the Crew made the errors is what tells the tale.
Who else made errors that set the Crew up for failure is also part of the story.
Let's just hope we do not get a Readers Digest Version of the Story!
The Crew made some errors....yes!
WHY the Crew made the errors is what tells the tale.
Who else made errors that set the Crew up for failure is also part of the story.
Let's just hope we do not get a Readers Digest Version of the Story!
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Yep, I completely agree with Crab's last post. The crew made some errors - some fundamental, some minor, doubtless some as yet unreported - but certainly wouldn't have done so either deliberately or negligently. The issue that is much more important than listing those errors is, as SASless says, understanding WHY the crew made them but didn't realise.
Get off the moral outrage bus. From the Snowdonia thread:
Surely "bluntly voicing what can only be an opinion (sometimes clouded by pre-conceptions and learned bias)" was simply unhelpful and not very respectful on that thread, Crab?
And that was within the first two days of the accident. The hypocrisy would be staggering if it wasn't so predictable.
This accident, tragic as it is, also looks like a "CFIT in poor weather".
Originally Posted by [email protected]
Before they identified the people involved, I had in my mind (when they said businessman) someone in their mid-fifties with a PPL and his own helicopter as someone who might think taking that route with such a poor forecast and few options would be an acceptable course of action.
Sadly I seem to have been proven right and it looks (with a very small percentage of another cause) like another CFIT in poor weather in a private helicopter....How may more before people take notice and learn from others mistakes???
Sadly I seem to have been proven right and it looks (with a very small percentage of another cause) like another CFIT in poor weather in a private helicopter....How may more before people take notice and learn from others mistakes???
And that was within the first two days of the accident. The hypocrisy would be staggering if it wasn't so predictable.
This accident, tragic as it is, also looks like a "CFIT in poor weather".
Two things to consider - one is that I didn't declare the possible reason as a fact and secondly the S-92 crew deserve some professional respect.
yes it clearly is but the question is why?
This accident, tragic as it is, also looks like a "CFIT in poor weather".
Posts #1549 & #1550 
An appalling statement from a sim instructor if you don't mind me saying so gulliBell. No one has invented a new way of having an accident, and this one will be a repeat of others that have gone before. I do love the hubris being shown by some, the most dangerous to be partnered with.
Not only looks like, it was, and the devil is in the detail, of which we know nought at this stage.
I don't see anything redeeming for this flight crew in the transcript of that CVR. Both on what was said, and what was not said. Instead, if the same sortie had been flown in the simulator on their annual competency check, it would probably be an automatic fail for the PIC. Which by definition, is an under-performing crew
looks like a "CFIT in poor weather"