SAR S-92 Missing Ireland
Just for my education, why was such a large piece of rock not visible on the weather radar? Surely the SOP for such a let-down is to have the radar set up in a mode which highlights such obstructions?
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Oden,
They did have an NVD - the EO/IR being used by the rearcrew. He clearly saw the obstruction and kept calling for a turn....
I presume that the EO diisplay wasn't (or couldn't be) selected on one of the cockpit MFDs? Not sure NVGs would have helped, they may well have been 'flipped up' at that stage of flight - overwater, AP modes engaged and a procedure in the FMS.
They did have an NVD - the EO/IR being used by the rearcrew. He clearly saw the obstruction and kept calling for a turn....
I presume that the EO diisplay wasn't (or couldn't be) selected on one of the cockpit MFDs? Not sure NVGs would have helped, they may well have been 'flipped up' at that stage of flight - overwater, AP modes engaged and a procedure in the FMS.
cnpc. Whoever drew up the approach knew the island was 282ft high, because he or she wrote it on the plate.
oden. The guys in the back knew they were headed for the island because they were looking at an image of it on a display. Presumably the crew were not looking at that display.
oden. The guys in the back knew they were headed for the island because they were looking at an image of it on a display. Presumably the crew were not looking at that display.
The exact information in relation to Black Rock and Lighthouse varied from none, to detailed, depending on the selected map/chart.
How did R118 get into Blacksod? Same approach?\\
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They weren't going to Blackrock, they were going to BLKMO in the FMC, as commanded by the loading of the APBSS (AProach to BlackSod South) approach. The commander called it BLKMO when she misidentified it. The earlier crew being based on the west of Ireland presumably knew that BLKMO was Blackrock and that is was a large island, and presumably stayed higher later.
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I'm surprised this approach didn't have any heights specified. Is that normal for this SAR operation? What's the point of an approach, clearly intended for IMC let downs, without associated heights? But even so, I still cannot see any reason why you'd descend to 200ft so far out, even if you knew it was flat sea. Could this be a case of being sucked into to using too much automation (i.e. APP1) without thinking enough about the logic of its use right then?
As I tried to say earlier, in my view it points to the flawed culture in SAR of always trying to get low / VFR as soon as possible. In my experience SAR pilots are far happier flying around at 200' VFR below cloud in the crud, rather than being at MSA IFR in cloud. Of course getting "down and dirty" asap can sometimes be the right thing to do, but not always. It surely can't be right to need to descend to 200' so far from the destination during an instrument letdown.
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5.1.2 Data Recovery
Electrical testing revealed short circuits which necessitated additional measures to recover the CVR and FDR recordings.
These measures included desoldering individual memory devices and reinstalling them on a functional memory board provided by the manufacturer of the MPFR
Electrical testing revealed short circuits which necessitated additional measures to recover the CVR and FDR recordings.
These measures included desoldering individual memory devices and reinstalling them on a functional memory board provided by the manufacturer of the MPFR
Bit lucky twice.
They weren't going to Blackrock, they were going to BLKMO in the FMC, as commanded by the loading of the APBSS (AProach to BlackSod South) approach. The commander called it BLKMO when she misidentified it. The earlier crew being based on the west of Ireland presumably knew that BLKMO was Blackrock and that is was a large island, and presumably stayed higher later.
It surely can't be right to need to descend to 200' so far from the destination during an instrument letdown.
Can't help but ask the obvious, they hit a building meters from a confirmed operational lighthouse?
If they were low enough to collide with something, surely they should have seen the light?
If they were low enough to collide with something, surely they should have seen the light?
As I tried to say earlier, in my view it points to the flawed culture in SAR of always trying to get low / VFR as soon as possible. In my experience SAR pilots are far happier flying around at 200' VFR below cloud in the crud, rather than being at MSA IFR in cloud. Of course getting "down and dirty" asap can sometimes be the right thing to do, but not always. It surely can't be right to need to descend to 200' so far from the destination during an instrument letdown.
In the APP1 mode that they were in, when they were at 200' ASL on final approach and stable, pitch is maintaining altitude, and power is maintaining airspeed. Correct? So the autopilot was driving the pitch axis to maintain height, correct? What was driving the power, was this being controlled manually by the pilot, or automatically by the AFCS? If the power was being manipulated manually, and the speed got too slow, I assume at some point the AFCS will pitch up abruptly (when it gets on the back side of the power curve) trying to maintain the selected height? I'm not familiar with S92, but this behaviour has all the attributes of S76. A pitch mode being used to maintain height, but not enough power being applied to maintain speed after levelling off. Especially after a low power descent, levelling off, but not applying power. The airspeed will very slowly bleed off, which might not be noticed by the crew, until it gets to a point where AFCS commands abrupt pitch up, airspeed rapidly decreases, and then things are out of control.
Am I right in saying that the aircraft was out of control before it hit the rocks, because insufficient power was applied for the flight mode they were in? And if they didn't hit the rocks the result would have been the same? We demonstrate this in the simulator, once that rapid pitch up occurs, without immediate corrective action, the aircraft will just fall out of the sky and you need more than 200' to recover the situation. I've seen experienced crews make this mistake; it happens in 2 different manoeuvres. Single engine missed approach using vertical speed mode to climb, but not applying enough power, and low power descent using ALT PRE, capturing the new height but not applying power.
EDIT: OK, answers to these questions were covered in the report. Pitch is being used to control speed, power is being used to control altitude.
Am I right in saying that the aircraft was out of control before it hit the rocks, because insufficient power was applied for the flight mode they were in? And if they didn't hit the rocks the result would have been the same? We demonstrate this in the simulator, once that rapid pitch up occurs, without immediate corrective action, the aircraft will just fall out of the sky and you need more than 200' to recover the situation. I've seen experienced crews make this mistake; it happens in 2 different manoeuvres. Single engine missed approach using vertical speed mode to climb, but not applying enough power, and low power descent using ALT PRE, capturing the new height but not applying power.
EDIT: OK, answers to these questions were covered in the report. Pitch is being used to control speed, power is being used to control altitude.
Last edited by gulliBell; 14th Apr 2017 at 06:03.
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My reading of the report is they did not impact the building, they impacted rock at the western end of the island. Debris from that collision landed on the building and damaged the roof tiles. Had the aircraft hit the building there would be far more damage than just to roof tiles.
It seems from the preliminary report the light for some reason was not visible to any of the crew or there surely would have been some comment made on it.I have flown quite a bit with Irish SAR crews and having now read that report I find that quite strange. With respect,and in a professional manner, they talk about everything of relevance that they observe during a flight. That the front nor rear crew did not observe and report any lighthouse causes me to believe it was not visible for some reason. I know it is stated the light was "on" by the automated system, but how accurate that is to the actual state of the light is unproveable.
It seems from the preliminary report the light for some reason was not visible to any of the crew or there surely would have been some comment made on it.I have flown quite a bit with Irish SAR crews and having now read that report I find that quite strange. With respect,and in a professional manner, they talk about everything of relevance that they observe during a flight. That the front nor rear crew did not observe and report any lighthouse causes me to believe it was not visible for some reason. I know it is stated the light was "on" by the automated system, but how accurate that is to the actual state of the light is unproveable.
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Madness!
Whoever approved this operation is a criminal!
Words fail!
As if heli flight was not risky enough, we start doing THIS!
With those " charts"! Utter madness!
Whoever approved this operation is a criminal!
Words fail!
As if heli flight was not risky enough, we start doing THIS!
With those " charts"! Utter madness!
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I find it staggering that an operation such as this does not have helmet mounted NVG's. If I want to I can go to a local flight school and fly a 300C to get NVG current and yet an aircraft used in such a hostile environment doesn't have them.
Why the heck do people flip up goggles when in proximity to the ground? The whole point is that you use them to see the ground. There's no point being on goggles when you're IMC at 4000' msl. Had one of the pilots been on goggles they would have been able to see the light from the lighthouse from a considerable distance away, even through mist and drizzle. Unless the light itself was an LED type that the wavelength of the light cannot be 'seen' by goggles.
A terrible waste of life.
I presume that the EO diisplay wasn't (or couldn't be) selected on one of the
cockpit MFDs? Not sure NVGs would have helped, they may well have been 'flipped up' at that stage of flight - overwater, AP modes engaged and a procedure in the FMS.
cockpit MFDs? Not sure NVGs would have helped, they may well have been 'flipped up' at that stage of flight - overwater, AP modes engaged and a procedure in the FMS.
A terrible waste of life.
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BluSdUp. That's the swiss cheese I'm afraid, and I'm glad to see that the Irish Accident Investigation Crew have latched on to it. There were things that could have saved this operation, and the rear crew so nearly saved the day, but ultimately the operator let them down by not giving them clear and unambiguous documentation to allow them to do their job.
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Maybe we should stop beating round the bush.
The operators let down procedure clearly shows Black Rock at 282'
It would have also been visible on Radar and would have been a waypoint in the system. There is no reason not to know that there was a big lump of rock with a light on it that was 282' AMSL. It is the start point of a company procedure not the point to be at 200'.
This is all very sad, who knows if the pilot had reacted immediately when the Winch Operator first called for a right turn would it have been enough; rather than the PF questioning the turn request.
The operators let down procedure clearly shows Black Rock at 282'
It would have also been visible on Radar and would have been a waypoint in the system. There is no reason not to know that there was a big lump of rock with a light on it that was 282' AMSL. It is the start point of a company procedure not the point to be at 200'.
This is all very sad, who knows if the pilot had reacted immediately when the Winch Operator first called for a right turn would it have been enough; rather than the PF questioning the turn request.
Last edited by Older and Wiser; 14th Apr 2017 at 03:11.
My reading of the report is they did not impact the building, they impacted rock at the western end of the island. Debris from that collision landed on the building and damaged the roof tiles. Had the aircraft hit the building there would be far more damage than just to roof tiles.
It seems from the preliminary report the light for some reason was not visible to any of the crew or there surely would have been some comment made on it.I have flown quite a bit with Irish SAR crews and having now read that report I find that quite strange. With respect,and in a professional manner, they talk about everything of relevance that they observe during a flight. That the front nor rear crew did not observe and report any lighthouse causes me to believe it was not visible for some reason. I know it is stated the light was "on" by the automated system, but how accurate that is to the actual state of the light is unproveable.
It seems from the preliminary report the light for some reason was not visible to any of the crew or there surely would have been some comment made on it.I have flown quite a bit with Irish SAR crews and having now read that report I find that quite strange. With respect,and in a professional manner, they talk about everything of relevance that they observe during a flight. That the front nor rear crew did not observe and report any lighthouse causes me to believe it was not visible for some reason. I know it is stated the light was "on" by the automated system, but how accurate that is to the actual state of the light is unproveable.