SAR S-92 Missing Ireland
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You're not living up to your name O&W.
The chart doesn't show Blackrock at 282'. It shows a waypoint called BLKMO with a caption next to it of 282 with no clue as to its relevance. Is it waypoint 282 in the operators manual ? Is it the depth of the sea at this point ? Is it the QDM from some unspecified navaid on the mainland ?
The island would indeed have been visible on radar and on the EO/IR display if that was available in the cockpit, and for that mistake and the few seconds pause whilst they assimilated the rear crew's input this crew paid with their lives.
However the people that put them in this situation by promulgating a thoroughly misleading chart, and the people that validated a flawed terrain database have yet to be held accountable for their role in this accident. And I'm willing to bet that their punishment will be less severe.
The chart doesn't show Blackrock at 282'. It shows a waypoint called BLKMO with a caption next to it of 282 with no clue as to its relevance. Is it waypoint 282 in the operators manual ? Is it the depth of the sea at this point ? Is it the QDM from some unspecified navaid on the mainland ?
The island would indeed have been visible on radar and on the EO/IR display if that was available in the cockpit, and for that mistake and the few seconds pause whilst they assimilated the rear crew's input this crew paid with their lives.
However the people that put them in this situation by promulgating a thoroughly misleading chart, and the people that validated a flawed terrain database have yet to be held accountable for their role in this accident. And I'm willing to bet that their punishment will be less severe.
Last edited by puntosaurus; 14th Apr 2017 at 03:35.
Puntosaurus, you and others appear to be blaming the operator for providing an inadequate chart (Route Guide) for the ABPSS route, however you are overlooking the fact that:
"The Route Guide includes an associated separate page of text setting out, inter alia, waypoint designations and coordinates, hazards and obstacles and other general comments. This page identified a lighthouse at Black Rock with an associated height of 310’."
Clearly the information regarding Blackrock was available and should have been read in association with the first page showing the routing. I would have also expected some altitude guidance such as "Do not descend below 500' until east of Blackrock", however only lateral guidance seems to have been provided on the Route Guide.
"The Route Guide includes an associated separate page of text setting out, inter alia, waypoint designations and coordinates, hazards and obstacles and other general comments. This page identified a lighthouse at Black Rock with an associated height of 310’."
Clearly the information regarding Blackrock was available and should have been read in association with the first page showing the routing. I would have also expected some altitude guidance such as "Do not descend below 500' until east of Blackrock", however only lateral guidance seems to have been provided on the Route Guide.
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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? AFCS, a rad alt coupled mode and A/S 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.
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.
The short time period from the the crewman calling an obstacle to impact (9 seconds) was insufficient for her to adjust her SA from believing that the small island that had, in her view of the local area, moved from behind to in front of the aircraft and was much higher than expected. This is not a condemnation of her, rather my view that once they were at that point, it takes time for that profound a recalibration of SA. Even the crewman's initial statement seems to be not yet fully aware of the danger for a few seconds....
HeliComparator:
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.
Al-Bert
Unless things have changed in the last 18 years since I was there in a Seaking there are no plates or IFR procedures to remote sites such as Blacksod. We would, if IMC, have carried out a radar letdown overwater on our search radar, possibly but unusually to full FCS hover, and then radar guided hover taxy if still v low viz but in sight of the surface, to the LS. I assume S92 operators have similar company procedures?
puntosaurus:
Sasless. Well I agree that there were lots of other mechanisms already in the cockpit that could have alerted the crew to the presence of the island, and one more (Txpndr) might have helped. But the fundamental problem appears to be that the crew clearly didn't know that BLKMO was above a large island, rather than a small rock (Carrick something or other) barely exposed at low tide.
If your IP is just a Lat/Long in the FMC, why on earth place it over the highest point around. The purpose of a letdown over water is surely to keep you away from the hard stuff until you are ready for it.
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.
If your IP is just a Lat/Long in the FMC, why on earth place it over the highest point around. The purpose of a letdown over water is surely to keep you away from the hard stuff until you are ready for it.
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.
I would first investigate whether this 'route/procedure' predates the 92 and was faithfully copied on, with easily identifiable points from days before FMC guided 4-axis autopilots. Then the choosing of an easily identified visual waypoint clear of higher terrain makes sense to aid visual guidance into the bay.
As has been said, I think some systemic errors and traps will be found that set this crew up to be caught by a combination of poor weather and unfamiliar operating location. The difference between success and failure will be a hair's breadth...
Something we all work hard at trying to see in advance every day.
This was an absolute tragedy
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Mark Six. I'm not overlooking anything. The crew made mistakes, but the purpose of the accident investigation is to make sure that all contributing factors are brought out.
A very wise CRM instructor and training captain from a major airline that I came across recently, said that if 20% of people who came up in front of him were failing correctly to interpret an SOP, then the SOP was probably wrong.
That's my only point here.
A very wise CRM instructor and training captain from a major airline that I came across recently, said that if 20% of people who came up in front of him were failing correctly to interpret an SOP, then the SOP was probably wrong.
That's my only point here.
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Mark Six. I'm not overlooking anything. The crew made mistakes, but the purpose of the accident investigation is to make sure that all contributing factors are brought out.
A very wise CRM instructor and training captain from a major airline that I came across recently, said that if 20% of people who came up in front of him were failing correctly to interpret an SOP, then the SOP was probably wrong.
That's my only point here.
A very wise CRM instructor and training captain from a major airline that I came across recently, said that if 20% of people who came up in front of him were failing correctly to interpret an SOP, then the SOP was probably wrong.
That's my only point here.
Credit to the Irish accident investigators in the AAIU. For a preliminary report, this was an detailed and very professionally prepared presentation of all of the information available. It will already be useful to many operators and pilots in examining whether their operations may have similar issues that have not been caught yet.
Swiss cheese? I'm seeing mainly holes and not much cheese. And an awkward transition from a military/marine mindset to a civilian commercial one. Look at the struggle that experienced, offshore pilots posting here have trying to understand what t'hell the crew was doing as a supposed "SOP" procedure.
Systemic, crew is not at fault. Tough day for management, that were not able to foresee the flaws in their operational system - the responsibility of both the SMS system to successfully risk assess and operations to provide operational expertise in a predictive way, not after the fact like the AAIU has to do now. Other operators fly SAR in that area, I wonder if they shared the same SOPs or if their different management expertise was ahead of the game.
Systemic, crew is not at fault. Tough day for management, that were not able to foresee the flaws in their operational system - the responsibility of both the SMS system to successfully risk assess and operations to provide operational expertise in a predictive way, not after the fact like the AAIU has to do now. Other operators fly SAR in that area, I wonder if they shared the same SOPs or if their different management expertise was ahead of the game.
Good question. I don't understand why you'd want to be at 200' at an IAF on the 1st of a 7 leg procedure to the destination, especially when the commencement of leg1 has a spot elevation of 282'. They had 10 miles to go at 75kts, call it 1.5nm/min with tail wind, equals about 6.5 minutes to run. If they were at 2000' (instead of 200') at the IAF then 300 ft/min from there would be a comfortable vertical profile. The PROC should have a minimum descent altitude for each segment, and to me 2000' looks like a good altitude to be at at the IAF. Was the vertical profile written on the chart?
Last edited by gulliBell; 14th Apr 2017 at 08:53.
One can point to a fundamental error by the crew in not noticing the rock - it was on the charts albeit well disguised - however looking at the whole picture I think it was an entirely predictable error. When there is only one slice of cheese between safety and an accident, the hole will be found fairly often even though (or especially when) it is caused by crew error. Adequate flight safety is only ensured when there are several slices of cheese whose holes don't normally line up - and even then it can happen. This operation had too low a safety margin / too few levels of safety for routine stuff, and we have unfortunately seen the consequences. I wonder who provided operational oversight? It was definitely an accident waiting to happen.
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I can't believe the procedure didn't have:
(1) A minimum (not below) altitude for each segment; and
(2) A CDFA angle to follow, with a distance/altitude scale.
With P-ILS capablility of the S-92A, it seems bizarre.
(1) A minimum (not below) altitude for each segment; and
(2) A CDFA angle to follow, with a distance/altitude scale.
With P-ILS capablility of the S-92A, it seems bizarre.
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Airborn radar approches has been used for a very long time and would have been safe approaching Blacksod. The focus would have been 100% on the radar if doing an ARA.
Unfortunally it seams the crew where lead into false safety following a company route that was not quality assured and risked assesed. A big responsibility lies on all parts of management and training...
Unfortunally it seams the crew where lead into false safety following a company route that was not quality assured and risked assesed. A big responsibility lies on all parts of management and training...
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Listening to RTE radio this morning and it was stated that the light on Black Rock takes 26 seconds to complete a turn so it was clearly not pointing at them when this happened
I don't think we can comment on the design of the approach without seeing the accompanying text which is briefly referred to in the report section 3.5.8. The red highlighted numerics on the chart obviously refers to notes in the unseen text describing the significant obstacles, of which Blackrock was included. I would have thought that as part of the approach brief, they would have gone through the accompanying text in some detail. If they had done so, they must have been aware of the presence of a 310' high obstacle on the approach path.
We should also remember that the chart does not describe an IFR cloud break procedure. It seems to be just "route guidance" to aid what should be a visual section of the flight. I suspect that elsewhere in the company Ops manual there would have been an offshore cloud break procedure to get them VMC below cloud. This procedure should also detail the minimum visibility (which is of course almost impossible to determine at night) and cloud base to allow continued visual flight at low level. The limits for a SAR mission may be significantly lower than for "routine" ops but we have to remember that this particular flight was not for a SAR operation. It was just to provide an extra communications link at this stage.
It's easy to be clinically analytical about this subject and forget that humans were involved in this tragedy. I have a huge respect for those who, on a daily basis, put themselves into potentially very hazardous conditions to help protect life. RIP.
We should also remember that the chart does not describe an IFR cloud break procedure. It seems to be just "route guidance" to aid what should be a visual section of the flight. I suspect that elsewhere in the company Ops manual there would have been an offshore cloud break procedure to get them VMC below cloud. This procedure should also detail the minimum visibility (which is of course almost impossible to determine at night) and cloud base to allow continued visual flight at low level. The limits for a SAR mission may be significantly lower than for "routine" ops but we have to remember that this particular flight was not for a SAR operation. It was just to provide an extra communications link at this stage.
It's easy to be clinically analytical about this subject and forget that humans were involved in this tragedy. I have a huge respect for those who, on a daily basis, put themselves into potentially very hazardous conditions to help protect life. RIP.
Last edited by roundwego; 14th Apr 2017 at 09:57.
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I don't think we can comment on the design of the approach without seeing the accompanying text which is briefly referred to in the report section 3.5.8. The red highlighted numerics on the chart obviously refers to notes in the unseen text describing the significant obstacles, of which Blackrock was included. I would have thought that as part of the approach brief, they would have gone through the accompanying text in some detail. If they had done so, they must have been aware of the presence of a 310' high obstacle on the approach path.
We should also remember that the chart does not describe an IFR cloud break procedure. It seems to be just "route guidance" to aid what should be a visual section of the flight. I suspect that elsewhere in the company Ops manual there would have been an offshore cloud break procedure to get them VMC below cloud.
We should also remember that the chart does not describe an IFR cloud break procedure. It seems to be just "route guidance" to aid what should be a visual section of the flight. I suspect that elsewhere in the company Ops manual there would have been an offshore cloud break procedure to get them VMC below cloud.
The sad fact is its not clear enough and not noticed by the crew....easy to say otherwise now...
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Makes for pretty grim reading.
It's interesting reading the different interpretations of the CHC route in to Blacksod from various sides - some interpreting it as a full IAP (which it is clearly not), others as a visual approach guide, which I don't really think it is either.
Either way, and wherever the truth lies, it's certainly taught me a valuable lesson regarding any assumption of any kind of obstacle clearance or guaranteed safe tracks using company 'homebrew' procedures.
It's interesting reading the different interpretations of the CHC route in to Blacksod from various sides - some interpreting it as a full IAP (which it is clearly not), others as a visual approach guide, which I don't really think it is either.
Either way, and wherever the truth lies, it's certainly taught me a valuable lesson regarding any assumption of any kind of obstacle clearance or guaranteed safe tracks using company 'homebrew' procedures.
Agree completely with roundwego. You can't look at one page of that particular route guide in isolation from the rest of the information on the second page. Furthermore the crew would have been very familiar with the use of company route guides and would (should) have known of the necessity to read the complete document, the significance of spot heights, and the strengths and limitations of the guide. Without knowing the company SOP with regard to route guides it is premature to apportion "blame" to the route designer or management. For all we know that route may have been restricted to particular weather minima, minimum altitudes, speeds, etc. It certainly doesn't look like it's meant to be used as an instrument approach plate.
