SAR S-92 Missing Ireland
Would that not point to SOP's needing revision?
And maybe more importantly, when the guy in the back tells you you're flying towards a rock, you take immediate avoiding action rather than engaging in an elaborate two crew pas de deux.
4th interim statement from last Friday
Ridiculous - presumably this has all got caught up in legal wrangling so that nobody gets any closure.
could have just used the aircraft's far higher capabilities instead
Safety working groups have focused on accident causes—such as controlled flight into terrain, loss of control because of crew interaction or mismanagement in the cockpit, or aircraft system failures and reliability— and identified means to mitigate them. Among the mitigations is the development of standardized procedures on the use of aircraft systems automation as defined in the flight crew operating manuals (FCOM) drafted by the OEMs. Such documents, though standard in the fixed-wing world, are relatively new to the helicopter industry, which had allowed operators to develop their own procedures. This led to some misuse of automation that resulted in safety incidents. Many of the large and medium helicopters used by the offshore industry have now had FCOMs written for them, in part thanks to the efforts of HeliOffshore.
“A lot of what we’ve done over the years has been replicating the practices that have made the airline industry so safe,” Cramp says.
“A lot of what we’ve done over the years has been replicating the practices that have made the airline industry so safe,” Cramp says.
Last edited by megan; 19th Mar 2021 at 07:03.
That link doesn't seem to work Megan.
Airline work is very predictable with risk mitigated to the lowest level - as you would expect as a passenger - they can have standard procedures for pretty much everything, they take off, they climb, they cruise, they let down and they land, not much more too it.
Many pax carrying helicopter operations work the same way for the same reasons.
SAR is different, unpredictable, dynamic in nature and often involves flight in hazardous regimes and conditions. That doesn't mean the crews shouldn't apply SOPs and they certainly should know how to effectively manage their automation.
I'm sure there are some things in this accident you can blame the company ethos and training for but this wasn't a newbie crew - I haven't read their SOPs for poor weather/night letdowns over the sea but I would hope it includes having the radar on a screen in the front as well as the back.
We also come back to the lack of NVG - unforgiveable in my view for modern SAR - but correct use of the kit on the aircraft would have saved the day, as would prompt response to the warning from the cabin.
An airline pilot would be castigated for grabbing the controls and hauling the aircraft into a turn but that is what was needed with this late spot - they were slaves to the automation in this case and it cost them their lives.
Airline work is very predictable with risk mitigated to the lowest level - as you would expect as a passenger - they can have standard procedures for pretty much everything, they take off, they climb, they cruise, they let down and they land, not much more too it.
Many pax carrying helicopter operations work the same way for the same reasons.
SAR is different, unpredictable, dynamic in nature and often involves flight in hazardous regimes and conditions. That doesn't mean the crews shouldn't apply SOPs and they certainly should know how to effectively manage their automation.
I'm sure there are some things in this accident you can blame the company ethos and training for but this wasn't a newbie crew - I haven't read their SOPs for poor weather/night letdowns over the sea but I would hope it includes having the radar on a screen in the front as well as the back.
We also come back to the lack of NVG - unforgiveable in my view for modern SAR - but correct use of the kit on the aircraft would have saved the day, as would prompt response to the warning from the cabin.
An airline pilot would be castigated for grabbing the controls and hauling the aircraft into a turn but that is what was needed with this late spot - they were slaves to the automation in this case and it cost them their lives.
They had TAWS but ISTR from the report that the configuration they had (wheels down I think) effectively muted a TAWS mode that might have saved them.
The other crucial issue is that if the rock isn't in the TAWS database, it won't warn you of it.
The other crucial issue is that if the rock isn't in the TAWS database, it won't warn you of it.
The other crucial issue is that if the rock isn't in the TAWS database, it won't warn you of it
In pre-TAWS days pilots looked out the window when operating below LSALT in VMC to avoid flying into anything. It should be the same today. No hand-cuffs or handrails needed, only basic airmanship.
We also come back to the lack of NVG - unforgiveable in my view for modern SAR - but correct use of the kit on the aircraft would have saved the day, as would prompt response to the warning from the cabin
High Definition Electro-Optic and Infrared (EO/IR) Camera System Thehelicopter is equipped with Wescam MX-15i EO/IR Camera System with integrated Spectrolab Nightsun XP searchlight system. Electro-optic and infrared imagery can be viewed at the Winch Operator’s station in the cabin and can also be selected for viewing in the cockpit if the pilots require it. The Avalex AVR-8240-XM digital video recorder provides the capability of recording video from the EO/IR camera and is installed in the SAR Operator’s console.
That link doesn't seem to work
Long-Term Contracting Could Help Offshore Industry Renew Fleets
Tony Osborne March 15, 2021Shell’s arrangement with PHI and Airbus to use the H160 in the Gulf of Mexico is a significant endorsement of Airbus’ newest medium helicopter. Oil and gas support was one of the key target missions for the aircraft during development.New approaches to longer-term contracting could be a bellwether for accelerating the introduction of new technology and new fleets to the offshore helicopter industry.
New fleets of helicopters are not at the top of the priority list for offshore helicopter operators today. More than five years of low oil prices have burdened them with a surplus of helicopters and leases that have tipped some of the biggest operators into bankruptcy.
- H160 will begin offshore duties in Gulf of Mexico this year
- HeliOffshore has developed guidance for operators in the wind farm support business
The upcoming introduction of Airbus’ new H160 twin-engine helicopter to the Gulf of Mexico appears to buck the trend. Petroleum Helicopters Inc. (PHI) is due to debut one H160 on route-proving flights this year, and another three will join the fleet in 2022, when they will operate on behalf of Shell.
The H160’s entry into the oil and gas market is the result of a joint initiative between the OEM, PHI and Shell to bring in a new platform with enhanced safety features, lower operating and maintenance costs, and a reduced carbon footprint.
Most crucially, however, the aircraft will be introduced on a 10-year-long contract, rather than traditional 3-5-year-long deals, Tony Cramp, vice president of aircraft at Shell tells Aviation Week. “You will not find many 10-year contracts for [offshore helicopters] at the moment,” Cramp explains.
“Longer-term contracts provide the stability for the operators to obtain better credit rates for themselves,” he says. “And that is a key element of how we have been able to take this on. That probably needs to be a feature going forward, to enable operators to bring in new technology.”
Types such as the H160, Bell’s Model 525 Relentless and Sikorsky’s S-92A+/B and super-mediums like Airbus’ H175 and Leonardo’s AW189 are part of a new generation of rotorcraft within the industry that should further enhance offshore flight safety.
The Bell 525 brings with it fly-by-wire flight controls, the H160 introduces a vortex-ring-state warning system and a recovery device that returns the helicopter to stable-level flight, and Sikorsky is planning to introduce new main gearboxes and additional automation in the cockpit of the upgraded S-92.
Such technologies can reduce pilot workload and address some of the primary causes of accidents offshore.
But new fleets of helicopters are not cheap. Until sustained growth supports investment or until new initiatives, such as the one for the H160, gain momentum, the industry will continue tightening cooperation, sharing data and working on incremental steps to bolster flight safety through organizations such as industry safety body HeliOffshore and the International Association of Oil & Gas Producers (IOGP).
After a series of fatal accidents in the North Sea between 2009 and 2016 shook the industry, safety performance is now “heading in the right direction,” says Cramp, who is also chairman of the IOGP Aviation Committee.
“More and more companies and operators are adopting the best practices, and what’s important for the operators is that the contracts that we give them require and pay for these processes,” Cramp says. “We’ve got to incentivize the practices and make sure they’re resourced properly, throughout the industry, to be effective.
“Money is tight right now . . . and that has been exacerbated through the events of the last year,” Cramp notes. “So the ability to pay for improved safety is obviously challenged at every point, and we have to be very careful about making the business case for each of these.”
Safety working groups have focused on accident causes—such as controlled flight into terrain, loss of control because of crew interaction or mismanagement in the cockpit, or aircraft system failures and reliability— and identified means to mitigate them. Among the mitigations is the development of standardized procedures on the use of aircraft systems automation as defined in the flight crew operating manuals (FCOM) drafted by the OEMs. Such documents, though standard in the fixed-wing world, are relatively new to the helicopter industry, which had allowed operators to develop their own procedures. This led to some misuse of automation that resulted in safety incidents. Many of the large and medium helicopters used by the offshore industry have now had FCOMs written for them, in part thanks to the efforts of HeliOffshore.
Work has also led to a bespoke rotary-wing terrain awareness and warning system (TAWS), which now equips Leonardo’s AW139 and will soon be used on other types.
Both FCOMs and the new helicopter TAWS (HTAWS) are deemed minimum requirements in new IOGP guidance, published in late 2020, on aviation standards for energy companies. IOGP Report 690: Offshore Helicopter Recommended Practices also calls for the use of safety management systems and states that offshore helicopters should have cameras in the cockpit and on the tail as well as obstacle warning systems and that aircraft should be certified to the most recent standards.
“A lot of what we’ve done over the years has been replicating the practices that have made the airline industry so safe,” Cramp says.
Although data suggests a recent positive trend in safety performance, the industry cannot “rest on its laurels,” says Tim Rolfe, CEO of HeliOffshore. He says work needs to be done to better understand how the implementing of new processes and procedures affects overall safety. “How do we make sure that recommended practices are effectively incorporated into the aviation system?” Rolfe asks. “That needs to be done deliberately. It is easy to assume that these things will happen either voluntarily or just as a factor of time, but actually we want to be a little bit more deliberate than that.”
Beyond developing FCOMs and HTAWs, HeliOffshore’s work groups are creating a series of “leading indicators” to understand safety performance better. They are also using a methodology called human hazard analysis (HHA) to ensure that the design of technical systems does not provoke errors during maintenance, with a particular focus on the elimination of catastrophic system failures.
“This is a real game changer for the helicopter industry,” Rolfe says. “But while we are talking about HHA at a design level, you can apply the same philosophy to cockpit design or extend further to pilot training.”
Other areas of work for Heli-Offshore include preparation for the introduction of fly-by-wire platforms such as the Bell 525, which the OEM hopes to introduce into the market this year, and looking at how the new era of electric vertical-take-off-and-landing (eVTOL) aircraft could also influence offshore operations.
“We’ve got to keep our eye on the emerging technology, making sure that all operators within the aviation system are appropriately trained and supported to manage operations safely, particularly where manned and unmanned aircraft share the same airspace,” Rolfe says.
In the UK, several offshore operators are already supporting—or aiming to expand in—the offshore windfarm sector. CHC Group has bagged contracts to support construction of windfarms off Scotland. Babcock has been using small helicopters to hoist down engineers to wind turbines since 2011. And Bristow has described getting into the windfarm support market as a “strategic priority.”
Analysis by Air & Sea Analytics suggests the offshore windfarm helicopter fleet will expand to about 126 aircraft by 2030 from 27 aircraft today, but the task, particularly that of winching down engineers, will be limited to small and medium-size rotorcraft such as the Airbus H145 and Leonardo AW169.
Recognizing the shift toward wind farm operations, HeliOffshore has worked to develop a series of recommended practices for safe helicopter operations. Working in conjunction with the G+ Global Offshore Wind Health and Safety Organization, it has drafted a document that provides guidance for aircraft operations, performance, equipment and procedures.
Despite the rush toward a net-zero carbon-emission world, demand is unlikely to let up for offshore helicopter operations. The big energy companies are using oil and gas revenues to fund their energy transition. There is, however, less focus on going farther offshore; instead, energy companies are looking to explore within existing fields and using new technologies to extract reserves that previous technology could not reach. And they will need helicopters to help decommission platforms some day.
"Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying together."
This is not unusual in small two crew operations. Good CRM training should render this quote as immaterial to the incident, however, that is assuming good CRM practices were evident in this case which I am not entirely sure were. Apart from the other pilot, there are also two tech crew members that all play a pivotal part in the CRM mix.
This is not unusual in small two crew operations. Good CRM training should render this quote as immaterial to the incident, however, that is assuming good CRM practices were evident in this case which I am not entirely sure were. Apart from the other pilot, there are also two tech crew members that all play a pivotal part in the CRM mix.
The rock wasn't in the data base, the prelim report discusses at some length.
They were at 200', weather forecast 300 - 400' overcast, vis 2 - 3 km with mist and drizzle.
I'm not familiar with all this high tech stuff crab, the following is what the aircraft was fitted with, is it comparable to NVG?
There is no doubt in my mind that they wouldn't have hit the rock if they had been equipped with NVG.
Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying together.
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It is important to remember that ultimately responsibility for this avoidable accident is going to come down to the actions of individual persons, be they flight crew, operations personnel, or people in management positions. And from currently available information it is very hard to see how the flight crew of R116 are not going to be primarily culpable.
The first choice the commander made was to use the APBSS approach to Blacksod, and one has to ask why. What sort of approach was it? What was it for? If it was intended as an IMC let down procedure, what was the MDH and where? The information in the Preliminary Report didn’t make any reference to any such information. Before departure from Dublin the crew clearly should have established what the nature of this approach was and whether it was suitable for their approach to Blacksod that night. The forecast weather was poor – they should have been expecting the 300-400ft cloud base and 2-3km visibility it probably was. And at night. The APBSS approach chart had 282 by the first BLKMO (Blackrock) waypoint, and the approach accompanying notes identified Blackrock lighthouse with a height of 310’. The lack of a database entry is a red herring – the world is too big and too prone to change at low level, whether with wind turbines, vessel masts or anything else up to 500ft, for databases to be relied on outside IFR approaches. As it said on the tin.
So how could the crew of R116 have thought it was a good plan to let down to 200ft in those conditions and head towards this first waypoint, level at 200ft? And even more bizarrely, when this point was 10 nm from their destination? The commander’s understanding of the terrain seems inadequate – she knew there was an island there as she commented on it when the crew got an altitude alert 26 seconds before impact. However the rocks they were flying over that triggered the alert were not Blackrock, but some lesser rocks 0.65nm before. So it seems she knew that BLKMO was not just a point in space, but an island landmark, presumably of - to her - unknown height, yet she still planned to fly over it at night in pretty much IMC conditions at 200ft….. It seems that had the flight crew read the approach notes, they would have realised that the island BLKMO had a height of 310’ Or 282’ had they interpreted the chart number as a height - which surely any sensible person would have done, certainly until proved otherwise.
Admittedly it also appears that the approach information was not sufficiently clear and comprehensive, which was largely an operators’ responsibility. But why descend to 200ft? Was it because the APP1 mode on the AFCS they had available did this by default? Did they follow a poor procedure not designed for the task that night with a recognised AFCS mode without adequate thought and consideration? Seems likely to me.
As several have said too, the other major pilot error was the reaction to the recognition by the rear crew member of Blackrock island, by maybe radar or IR, and instruction to avoid. Transiting at 200ft above the sea on a misty night over known rocks should have had the crew on high alert, yet the whole process of observation, identification, course change instruction and implementation was far too slow and vague. From the avoid instruction, to hitting Blackrock. took 13 seconds. Allowing say 3 seconds pilot reaction time, that gives 10 seconds to effect immediate emergency avoiding action. The fastest way to do that would have been to uncouple and instantly either climb at say 1500ft /min, or bank at say 30 degrees. But it took a fatal 10 seconds of questioning and double checking before the heading bug was turned and the aircraft reacted, and by that time it was all over. With a climb at 1500ft/min they would have cleared Blackrock by 150ft if they’d gone straight over it. Or missed it with an immediate turn. Or a combination of both.
Something that I have never seen discussed is just how the Sligo primary mission S92 approached Blacksod for fuel, an hour or so before. It had the same operator and same aircraft. One assumes that whatever they did worked fine, in which case why did R116 not do the same thing? Or even discuss the approach with R118 before they set off, if R116 was not familiar?
Overall, there will always be situations, in SAR surely more than anything else, when SOPs will not cover the task in hand, or be appropriate, or things will just go wrong for all sorts of reasons. And in these cases we need crews to be able to think intelligently and make sensible decisions that are likely to involve basic flying skills that we learn in our early training, whether VMC or IMC. It is important this is realised, pilots preserve these skills and are open minded to implement them when necessary. And – yet again – not just follow the magenta line.
The first choice the commander made was to use the APBSS approach to Blacksod, and one has to ask why. What sort of approach was it? What was it for? If it was intended as an IMC let down procedure, what was the MDH and where? The information in the Preliminary Report didn’t make any reference to any such information. Before departure from Dublin the crew clearly should have established what the nature of this approach was and whether it was suitable for their approach to Blacksod that night. The forecast weather was poor – they should have been expecting the 300-400ft cloud base and 2-3km visibility it probably was. And at night. The APBSS approach chart had 282 by the first BLKMO (Blackrock) waypoint, and the approach accompanying notes identified Blackrock lighthouse with a height of 310’. The lack of a database entry is a red herring – the world is too big and too prone to change at low level, whether with wind turbines, vessel masts or anything else up to 500ft, for databases to be relied on outside IFR approaches. As it said on the tin.
So how could the crew of R116 have thought it was a good plan to let down to 200ft in those conditions and head towards this first waypoint, level at 200ft? And even more bizarrely, when this point was 10 nm from their destination? The commander’s understanding of the terrain seems inadequate – she knew there was an island there as she commented on it when the crew got an altitude alert 26 seconds before impact. However the rocks they were flying over that triggered the alert were not Blackrock, but some lesser rocks 0.65nm before. So it seems she knew that BLKMO was not just a point in space, but an island landmark, presumably of - to her - unknown height, yet she still planned to fly over it at night in pretty much IMC conditions at 200ft….. It seems that had the flight crew read the approach notes, they would have realised that the island BLKMO had a height of 310’ Or 282’ had they interpreted the chart number as a height - which surely any sensible person would have done, certainly until proved otherwise.
Admittedly it also appears that the approach information was not sufficiently clear and comprehensive, which was largely an operators’ responsibility. But why descend to 200ft? Was it because the APP1 mode on the AFCS they had available did this by default? Did they follow a poor procedure not designed for the task that night with a recognised AFCS mode without adequate thought and consideration? Seems likely to me.
As several have said too, the other major pilot error was the reaction to the recognition by the rear crew member of Blackrock island, by maybe radar or IR, and instruction to avoid. Transiting at 200ft above the sea on a misty night over known rocks should have had the crew on high alert, yet the whole process of observation, identification, course change instruction and implementation was far too slow and vague. From the avoid instruction, to hitting Blackrock. took 13 seconds. Allowing say 3 seconds pilot reaction time, that gives 10 seconds to effect immediate emergency avoiding action. The fastest way to do that would have been to uncouple and instantly either climb at say 1500ft /min, or bank at say 30 degrees. But it took a fatal 10 seconds of questioning and double checking before the heading bug was turned and the aircraft reacted, and by that time it was all over. With a climb at 1500ft/min they would have cleared Blackrock by 150ft if they’d gone straight over it. Or missed it with an immediate turn. Or a combination of both.
Something that I have never seen discussed is just how the Sligo primary mission S92 approached Blacksod for fuel, an hour or so before. It had the same operator and same aircraft. One assumes that whatever they did worked fine, in which case why did R116 not do the same thing? Or even discuss the approach with R118 before they set off, if R116 was not familiar?
Overall, there will always be situations, in SAR surely more than anything else, when SOPs will not cover the task in hand, or be appropriate, or things will just go wrong for all sorts of reasons. And in these cases we need crews to be able to think intelligently and make sensible decisions that are likely to involve basic flying skills that we learn in our early training, whether VMC or IMC. It is important this is realised, pilots preserve these skills and are open minded to implement them when necessary. And – yet again – not just follow the magenta line.
And – yet again – not just follow the magenta line.
"Just learned today that the co-pilot was in fact the Chief Pilot. Wonder what, if any, human factors may have played a role. Have seen the problems in the past of two captains, two check and trainers, chief pilot as co-pilot flying together."
This is not unusual in small two crew operations. Good CRM training should render this quote as immaterial to the incident, however, that is assuming good CRM practices were evident in this case which I am not entirely sure were. Apart from the other pilot, there are also two tech crew members that all play a pivotal part in the CRM mix.
This is not unusual in small two crew operations. Good CRM training should render this quote as immaterial to the incident, however, that is assuming good CRM practices were evident in this case which I am not entirely sure were. Apart from the other pilot, there are also two tech crew members that all play a pivotal part in the CRM mix.
I think they just took the easy option - a company let down procedure which was a legacy from the S61 days - perhaps because they were at a low arousal as they weren't on an actual rescue themselves.
Having chosen the easy option, they then didn't execute it well.
Having chosen the easy option, they then didn't execute it well.
As has been mentioned before why was the aircraft so low so far from final destination. All modern 4 axis sar autopilots are designed to avoid such a scenario.
Does this reflect poor SOP’s?
These aircraft came from the company’s U.K. contract prior to Bristow takeover.
Was there not training and appropriate sharing of information or mentoring?
If there was how was it received or was there complete dismissal and a ‘know it all’ cavalier attitude?
Why have some ex U.K. sar or ex raf crew joined and promptly left again since?
Is it true to read from the transcript that Irish rear crew do not participate anywhere near as much in the flying role outside of on scene evolutions than U.K. or Scandinavian counterparts?
Do Irish crews train appropriately in low level IF, rear crew conned approaches to targets, Flir led transits?
Generally what are standards for CRM? Is a sub 90 minute lecture to 20 people from an off duty ryanair pilot enough as has been mentioned previously?
According to their company press releases their new manager of crew training is a candidate with no civilian or s92 experience and no all weather sar such as would be required. Though is it the aviation authority who have clearly washed their hands from the morning after this accident took place who approved such an appointment?
Overall will anything change or have changed?
Will there be any admission of errors other than blame on the crew in question?
Are relevant government departments or the contracting agency aware of potential shortcomings and their avoid-ability if true?
Does this reflect poor SOP’s?
These aircraft came from the company’s U.K. contract prior to Bristow takeover.
Was there not training and appropriate sharing of information or mentoring?
If there was how was it received or was there complete dismissal and a ‘know it all’ cavalier attitude?
Why have some ex U.K. sar or ex raf crew joined and promptly left again since?
Is it true to read from the transcript that Irish rear crew do not participate anywhere near as much in the flying role outside of on scene evolutions than U.K. or Scandinavian counterparts?
Do Irish crews train appropriately in low level IF, rear crew conned approaches to targets, Flir led transits?
Generally what are standards for CRM? Is a sub 90 minute lecture to 20 people from an off duty ryanair pilot enough as has been mentioned previously?
According to their company press releases their new manager of crew training is a candidate with no civilian or s92 experience and no all weather sar such as would be required. Though is it the aviation authority who have clearly washed their hands from the morning after this accident took place who approved such an appointment?
Overall will anything change or have changed?
Will there be any admission of errors other than blame on the crew in question?
Are relevant government departments or the contracting agency aware of potential shortcomings and their avoid-ability if true?
Lots of questions Northernstar - a journo looking for a story?
it was dark
The APBSS approach chart had 282 by the first BLKMO (Blackrock) waypoint, and the approach accompanying notes identified Blackrock lighthouse with a height of 310’
they obviously didn't see the loom of the light.