SAR S-92 Missing Ireland
Crew was trained, experienced and qualified. Aircraft was equipped for the task. I don't buy the "there but for the grace of god, everyone messes up sometime, etc" arguments. Operations procedures are meant to be boilerplate, to tolerate the "human errors" that can creep in. "It's 1am and we're all a little tired, lets double check all the FMS entries and get all the gear front and back working for us" - it is called threat and error management. I don't doubt that all other civilian SAR operations have had to stand in front of their CEO's and assure them that this would not have happened in their organization. The "system", from the IAA on down, simply cannot tolerate any kind of unaddressed risk. The "swiss cheese" model is an explanation of operations management failure to address all risk, and falls under the responsibility of the company SMS system and S&Q that is charged with auditing effectiveness of the current and anticipating the worst in the future.
To land at Blacksod on that night you had to get under the weather. If that was the plan at the outset then they could have dropped out just west of Fahy Lough, nice 10x2nm corridor. From the radio transmissions it sounds more uncertain, they may have gone out a ways to try contact 118 before deciding to come back for a refuel. Pprune will know soon enough, some may know already.
Us Canadians can't seem to fly without a map Garmin on the panel, but the 92 had lots of mapping capability. Rear crew with their detailed maps showing own position and communicating to the front. EGPWS will paint shorelines and obstacles, so will radar, RadAlts plus GPS altitude if required, user waypoints can be defined as airports and will show up on the flightplan screen (almost Garmin-like), and finally the iPads with any number of apps that map. JeppFD strangely enough shows Blackrock but with an elevation of only 46' - anybody else confirm?
To land at Blacksod on that night you had to get under the weather. If that was the plan at the outset then they could have dropped out just west of Fahy Lough, nice 10x2nm corridor. From the radio transmissions it sounds more uncertain, they may have gone out a ways to try contact 118 before deciding to come back for a refuel. Pprune will know soon enough, some may know already.
Us Canadians can't seem to fly without a map Garmin on the panel, but the 92 had lots of mapping capability. Rear crew with their detailed maps showing own position and communicating to the front. EGPWS will paint shorelines and obstacles, so will radar, RadAlts plus GPS altitude if required, user waypoints can be defined as airports and will show up on the flightplan screen (almost Garmin-like), and finally the iPads with any number of apps that map. JeppFD strangely enough shows Blackrock but with an elevation of only 46' - anybody else confirm?
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Prayers and reflection as Rescue 116 wreckage located
I've been lurking here from a distance, I've old ties with this outfit.
My take is they had problems and were trying to ground at Blackrock.
Nothing else makes sense.
My take is they had problems and were trying to ground at Blackrock.
Nothing else makes sense.
The considerable effort required to launch the SAR effort in this instance for a fisherman at sea with a non-life threatening thumb injury is difficult for me to comprehend also.
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For those commenting on the ATC 0000Z recording posted above, note that there was one further call with R116 made on the next tape (from 0030Z) which you can get here. Skip to about 4:30 in the recording.
"Shannon, Rescue 116"
"Rescue 116, Shannon go"
"Passing 4000 feet now in the descent making our way to Blacksod for refuel, Rescue 116"
"Copy ... <inaudible>"
"Shannon, Rescue 116"
"Rescue 116, Shannon go"
"Passing 4000 feet now in the descent making our way to Blacksod for refuel, Rescue 116"
"Copy ... <inaudible>"
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Anyway, we will find out soon enough what went wrong.
SAR is challanging and the margins are sometimes very small and I hope crews all over the world get all the training and resources they need to do a safe and good job as possible.
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My take is they had problems and were trying to ground at Blackrock.
...and if they had an immediate dire and urgent problem with an intent of a forced landing on Blackrock, with 4 crew who would all have access to the outside world on the radio, you'd think one of them wouldn't be able to get a RT call out.
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I think all of this will be answered with the recorders. There are very many possibilities, from a "simple" human error cfit, to a loss of tail rotor and fast yawning situation for a number of seconds before impact, restricting rear crew abilities to transmit a radio call-especially if they were unrestrained at the time. Also the large rock and low (decreasing) altitude, a rear crew transmission on fm (antenna on bottom of fuselage?) may not have been picked up if there was only one attempt. Recorders will (hopefully)show what happened in detail.
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R116 was tracking directly to Blackrock for the last 100nm after it left Dublin, and indeed passed by Blacksod about 4nm south, still maintaining a direct track to Blackrock, then went close by Blackrock and then turned back and approached it again. It is clear R116 was consistently aiming for what we know was Blackrock.
This does not therefore look like a late change of plan to land at Blackrock following some kind of emergency.
The question is why was the acft aiming for Blackrock. One reason is that they were deliberately using it as an approach point to get visual for a VFR transit to Blacksod. But this makes little sense - why go 10nm further to let down right over a 300ft rock rather than let down over the sea just south of your prob max 100ft elevation Blacksod destination, also having a lighthouse? A second reason could be that they deliberately intended to land at Blackrock and take stock. This makes no sense either - why would you opt for a hazardous uninhabited rock with a probably too small helipad and no fuel? And anyway, you have just told Shannon you are landing at Blacksod.
The third reason is of course that they thought they were actually going to Blacksod the whole time, hence the direct track, call to Shannon, second approach, and descent to a height that would have been fine for Blacksod. But then the huge mystery is how could such a fundamental navigation error have been made, and continue to be made, by a clearly very experienced crew? FMS mis-programming would be the obvious answer for the initial mistake - and indeed Blackrock and Blacksod are, and sound, very similar. And if you actually lived in a place called Blackrock, that name would be much more familiar, particularly late at night when you're tired and rushing...... But even if this happened it is still hard to see how such an experienced crew in presumably such a well equipped modern acft with moving maps visible to both crew and cabin would not have picked up this error in good time.
This does not therefore look like a late change of plan to land at Blackrock following some kind of emergency.
The question is why was the acft aiming for Blackrock. One reason is that they were deliberately using it as an approach point to get visual for a VFR transit to Blacksod. But this makes little sense - why go 10nm further to let down right over a 300ft rock rather than let down over the sea just south of your prob max 100ft elevation Blacksod destination, also having a lighthouse? A second reason could be that they deliberately intended to land at Blackrock and take stock. This makes no sense either - why would you opt for a hazardous uninhabited rock with a probably too small helipad and no fuel? And anyway, you have just told Shannon you are landing at Blacksod.
The third reason is of course that they thought they were actually going to Blacksod the whole time, hence the direct track, call to Shannon, second approach, and descent to a height that would have been fine for Blacksod. But then the huge mystery is how could such a fundamental navigation error have been made, and continue to be made, by a clearly very experienced crew? FMS mis-programming would be the obvious answer for the initial mistake - and indeed Blackrock and Blacksod are, and sound, very similar. And if you actually lived in a place called Blackrock, that name would be much more familiar, particularly late at night when you're tired and rushing...... But even if this happened it is still hard to see how such an experienced crew in presumably such a well equipped modern acft with moving maps visible to both crew and cabin would not have picked up this error in good time.
Regarding reason 3...fundamental navigation error...I'm no expert in the human factors area, but I've got a hunch that a highly experienced crew is equally prone to making a data input error, and not noticing it, as a novice crew. I don't think experience is any protection against data input errors, and what follows thereafter, simply because that is the way humans are built. We have become accustomed to the computer being infallible and lulling us into a false sense of security against our own fallibility.
Regarding reason 3...fundamental navigation error...I'm no expert in the human factors area, but I've got a hunch that a highly experienced crew is equally prone to making a data input error, and not noticing it, as a novice crew. I don't think experience is any protection against data input errors, and what follows thereafter, simply because that is the way humans are built. We have become accustomed to the computer being infallible and lulling us into a false sense of security against our own fallibility.
But if it was a data entry error, in their minds they were still heading to Blacksod and their mental picture would have been the approach to blacksod, then the approach they flew would have made no sense? heading to the north abeam overland to approach again over land? Surely it would have been a let down and a run in over the sea without an overfly? especially to such a low landing site? heading off overland first to approach backsod makes little sense to me in poor weather
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Did the S92 in question have systems to automatically deploy both the floats and ELT in the advert of entering the water? My apoligies if this has been asked previously.
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R116 was tracking directly to Blackrock for the last 100nm after it left Dublin, and indeed passed by Blacksod about 4nm south, still maintaining a direct track to Blackrock, then went close by Blackrock and then turned back and approached it again. It is clear R116 was consistently aiming for what we know was Blackrock.
Unlikely to be heading for the boat since R118 was doing that plus they had already declared they were refuelling at Blacksod before comtinuing on any tasking.
If they had no NVD it is more likely they were using a legacy profile from S61 days to get to Blacksod - if this meant using Blackrock as a visual marker to confirm they were clear of any other terrain then it sort of makes sense but still doesn't explain how they came to hit the rock.
If they had no NVD it is more likely they were using a legacy profile from S61 days to get to Blacksod - if this meant using Blackrock as a visual marker to confirm they were clear of any other terrain then it sort of makes sense but still doesn't explain how they came to hit the rock.
It must be my simplistic brain, but why wouldn't you just set up a way point out in sea and track in, rather than heading for a bit of rock miles away to potentially get visible with said bit of rock, only to lose it behind you as you head for land, possible losing both landmark references, at least with letting down offshore using radar and taws you can track in direct as required at low level?