SAR S-92 Missing Ireland
From HC;
"Automation may cause accidents, but far more accidents are caused by humans flying without automation. The trick is to train to use it correctly and appropriately, not to rip it out and hand fly everything."
Totally agree. Modern APs and FMS are fantastic aids to aviation. If utilised correctly (and training is key) they massively offload pilot capacity and allow for far safer operation of aircraft than in the past.
For those dismissing automation I'd be interested to hear what your experience of 'manual' vs 'automated' aircraft is? To say that automation has no place in SAR operations is ludicrous. I suspect that those of us who have operated a cross-section of aircraft across different generations of automation will generally extol its virtues. More often than not it is not automation that causes such accidents but a systemic failure in which numerous factors combine to engineer a disastrous consequence.
"Automation may cause accidents, but far more accidents are caused by humans flying without automation. The trick is to train to use it correctly and appropriately, not to rip it out and hand fly everything."
Totally agree. Modern APs and FMS are fantastic aids to aviation. If utilised correctly (and training is key) they massively offload pilot capacity and allow for far safer operation of aircraft than in the past.
For those dismissing automation I'd be interested to hear what your experience of 'manual' vs 'automated' aircraft is? To say that automation has no place in SAR operations is ludicrous. I suspect that those of us who have operated a cross-section of aircraft across different generations of automation will generally extol its virtues. More often than not it is not automation that causes such accidents but a systemic failure in which numerous factors combine to engineer a disastrous consequence.
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On the subject of NVG, if they were in limited visibility, would the NVG have helped? I am asking as I am not sure having very limited experience of NVG.
Maybe the FLIR picture being displayed on the Pilots MFDs would have been the best chance of "seeing" the rock and taking the necessary avoiding action by reference to the picture in front of the crew. The FLIR can be overlaid in a 225 but I am not sure if this is possible in the 92.
Its very hard to imagine flying over a red blob on the RADAR screen at 200 feet above the sea regardless of what the mental model was in the crews minds. I wonder if their radar software had a momentary glitch which does happen with overlay technology.
From what has been reported it would seem a very strange procedure to be so low, so far away, from the intended destination.
Llamaman, I think the underlying point about automation in this event is knowing when to use it and when to "take-control" to make a rapid avoiding manoeuvre. The aim of the automation being deployed successfully is to ensure you do not have to take such evasive action. Making sure the automation is taking you on a flight path trajectory that is free from obstructions. I would suggest that in the final moments for this poor crew, the startle effect caused by the increasing urgency of the rear crew call for evasive action and maybe the limited time between receiving he call and reacting to it, defeated them. In any case the act of "gripping it and ripping it" 200 feet above the sea at night is going to be problematic when done in such urgent circumstances.
It routes us back to the underlying cause being a failure to assess the flight trajectory correctly before plugging in the RADALT Height Hold and HDG holds. This is I believe, is what needs to be addressed. How did this failure occur, Was it lack of knowledge, Lack of Information, Lack of safe Procedures or simply a massive error on the part of two experienced flight crew.
The procedure should be safe and take the aircraft to the minima, free from all obstacles. The FLIR, NVG, RADAR, whilst essential to assure safety of the procedure, are in essence superfluous to requirements if the procedure is safe, safely flown and the correct minima observed.
Gullibel, automation is only as good as the training the crews receive to use it. Your job in the FFS is to teach them that. If you feel like "ripping it out" you need to look inward!
Maybe the FLIR picture being displayed on the Pilots MFDs would have been the best chance of "seeing" the rock and taking the necessary avoiding action by reference to the picture in front of the crew. The FLIR can be overlaid in a 225 but I am not sure if this is possible in the 92.
Its very hard to imagine flying over a red blob on the RADAR screen at 200 feet above the sea regardless of what the mental model was in the crews minds. I wonder if their radar software had a momentary glitch which does happen with overlay technology.
From what has been reported it would seem a very strange procedure to be so low, so far away, from the intended destination.
Llamaman, I think the underlying point about automation in this event is knowing when to use it and when to "take-control" to make a rapid avoiding manoeuvre. The aim of the automation being deployed successfully is to ensure you do not have to take such evasive action. Making sure the automation is taking you on a flight path trajectory that is free from obstructions. I would suggest that in the final moments for this poor crew, the startle effect caused by the increasing urgency of the rear crew call for evasive action and maybe the limited time between receiving he call and reacting to it, defeated them. In any case the act of "gripping it and ripping it" 200 feet above the sea at night is going to be problematic when done in such urgent circumstances.
It routes us back to the underlying cause being a failure to assess the flight trajectory correctly before plugging in the RADALT Height Hold and HDG holds. This is I believe, is what needs to be addressed. How did this failure occur, Was it lack of knowledge, Lack of Information, Lack of safe Procedures or simply a massive error on the part of two experienced flight crew.
The procedure should be safe and take the aircraft to the minima, free from all obstacles. The FLIR, NVG, RADAR, whilst essential to assure safety of the procedure, are in essence superfluous to requirements if the procedure is safe, safely flown and the correct minima observed.
Gullibel, automation is only as good as the training the crews receive to use it. Your job in the FFS is to teach them that. If you feel like "ripping it out" you need to look inward!
Last edited by DOUBLE BOGEY; 14th Apr 2017 at 13:19.
Crab@
What would you say was the minimum height one could safely use NVG at night over water? What other factors do you consider? Thanks
If they had been wearing NVG, they would have seen the big rock ahead
I can tell you this for sure. What I see when teaching in a Level D FFS helicopter simulator, irrespective of the level of experience of the crews, far more accidents happen when automation is involved, than without. To the extent that I feel like ripping out the automation and have the trainees hand fly everything. Logic tells you that automation must be safer. In the training environment, I don't see it.
Of course the opposite case sometimes applies, I feel like ripping out the controls and stowing them in the boot and have the automation do all of the flying. But, generally speaking, the outcomes are consistently better without reliance on automation. Assuming of course the basic IFR skills of being able to fly a heading, airspeed, altitude etc accurately are there; which sadly, often they are not.
Of course the opposite case sometimes applies, I feel like ripping out the controls and stowing them in the boot and have the automation do all of the flying. But, generally speaking, the outcomes are consistently better without reliance on automation. Assuming of course the basic IFR skills of being able to fly a heading, airspeed, altitude etc accurately are there; which sadly, often they are not.
But I also think your view might be clouded by the narrow type of flying (ie training and testing, lots of emergencies etc, most of the time "abormal operations"). As opposed to the real world where virtually all the time flying is routine, arousal levels low, unexpected sudden changes of plan are rare.
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Reading the AAIB report it states that the FLIR Image CAN be selected not the MFDS in the Cockpit. Anyone know if there would be a reason not to do this for a low altitude flight with rocks in the vicinity?
I've been contemplating the FDR data:
1. The heading trace shows a constant heading in the six seconds before impact (i.e. no lateral avoiding action was happening).
2. At impact, an instantaneous rapid heading change to the right, followed by various rates of right rotation for the remainder of the recording (which you'd expect when the TR ceased to function).
3. The pitch trace shows abrupt aft cyclic flare simultaneously with large collective increase (about 1.5 seconds before impact), rapid NR droop initially, followed by reducing collective and the aircraft climbing slowly at 60kts.
4. NR recovers as engine power increase/collective decrease until point of impact when NR goes slightly high (which you'd expect at the instant the load of the TR is removed).
5. The aircraft continued to climb slowly after impact until the last data point (the last recorded altitude point was about 450').
6. The engines remained at a high/intermediate power setting after impact until the last data point.
1. The heading trace shows a constant heading in the six seconds before impact (i.e. no lateral avoiding action was happening).
2. At impact, an instantaneous rapid heading change to the right, followed by various rates of right rotation for the remainder of the recording (which you'd expect when the TR ceased to function).
3. The pitch trace shows abrupt aft cyclic flare simultaneously with large collective increase (about 1.5 seconds before impact), rapid NR droop initially, followed by reducing collective and the aircraft climbing slowly at 60kts.
4. NR recovers as engine power increase/collective decrease until point of impact when NR goes slightly high (which you'd expect at the instant the load of the TR is removed).
5. The aircraft continued to climb slowly after impact until the last data point (the last recorded altitude point was about 450').
6. The engines remained at a high/intermediate power setting after impact until the last data point.
Last edited by gulliBell; 14th Apr 2017 at 13:55.
I'm guessing here, but if they had NVG they probably wouldn't have flown the approach they flew. But if they did have NVG and flew the same approach, and I'm guessing again, the outcome would have been the same. The crew in the back could see in front of the aircraft using FLIR, which can image in complete darkness. The cockpit crew would have been looking inside underneath NVG, one flying the other monitoring, knowing the crew in the back could see out the front. In complete darkness the FLIR gives you a better image than NVG, but with very limited depth. NVG provides some depth of view (i.e. 2 tubes providing a stereo image), but out at sea at night under cloud the FLIR they had would provide a much better image than the NVG they didn't have.
Originally Posted by [email protected]
HC - by 'cock-up' do you mean using the rock as a WP?
One of the problems with learning from this sort of accident, is that we all smugly say to ourselves (privately) that it could never happen to us. Bit like the Clutha bar accident in Glasgow. But nevertheless, these sort of accidents continue to happen, especially when there are not many safety layers to breach. People tend to believe that only other people make stupid human factors mistakes.
Not exactly, I mean putting the aircraft on a flight path where a terrain collision was going to occur (unless last moment emergency evasive manoeuvre can save it). So not so much using the rock as a waypoint, rather flying at a rock elevation ~300' whilst being at 200'.
I think legacy procedures may be a factor here - there is no need to let down such a long way out, especially not to 200'.
Since they didn't have NVG, there would be far more tendency to stay 'heads in' even at 200' whereas an NVG-equipped crew would transfer to 'visual' flight, backed up with the AP and sensors, as soon as they got below the cloud.
They must have been VMC below because the FLIR could see the rock - contrary to some opinions, FLIR cannot see through cloud and is very poor when there is little thermal contrast between the objects it is looking at.
The 'heads-in' mindset leads to careful changes of attitude and heading because it is treated like IMC (which it effectively is) hence the slow reaction to the heading request and the use of the HDG function of the AP rather than the flying controls, which would have been much quicker.
The primary fault seems to be the procedure and its design but there are so many contributory factors here that could have been removed from the equation.
Such overwater letdowns are very procedural in nature and can vary in difficulty depending on the weather and proximity to obstacles - I believe they were adequately trained to use the automation in these conditions but somewhere the basics of looking out the window (or the electronic version of checking the radar picture) were lost.
Did the training for the crew include the fact that at 80 kts with the gear down, the GPWS look-ahead distance was restricted to 10'?? And which genius thought that was a good idea for a SAR helicopter?
Someone correct me if I am wrong.....but did not the Chief Investigator of this Accident work at the same Operation in the past?
If he did....what positions did he have while employed?
If so....what effect does that have on the investigation?
If he did....what positions did he have while employed?
If so....what effect does that have on the investigation?
If indeed that's what happened - we don't know for certain that the warnins were visible and even if they were, the guy seemed pretty competent and if he can do it, so can we all, especially if we adopt the "it couldn't happen to me" attitude. You are rather making my point for me!
Thank you Coyote and Skadi!
Any thoughts on why the defined track goes over the top of Black Rock? Would it not have been more sensible for the inbound track to have been more from the south west passing half way between Black Rock and Saddle Head.
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I don't think he flew for CHC. He flew SAR in the Dauphin for the Irish Aer Corps.
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I think as was said earlier, before the days of GPS it was common to base routes on things rather than imaginary points in space. It would be interesting to know when that procedure was created, and when it was last significantly revised.
The question about that absent data lies with the Operator as the system has the ability for User additions to the Database. The data on Blackrock should have been there no doubt.....but there are limitations to any system when it comes to the areas the systems memory will be programmed to cover. In all likelihood the database area of coverage did not anticipate low level flight operations near Blackrock such as the ICG performs.
The Operator could have ensured all potential landing sites or areas of operation were in fact properly contained in the database.
Had the Operator surveyed,checked, and documented formal IMC Point-in-Space Approaches to every known location IMC Approaches would be conducted....and incorporated the advanced capabilities of the S-92 SAR Avionics System then this particular tragedy would have been avoided.
The aircraft can safely terminate at a hover over a pre-determined point without the Crew seeing the surface and both track, height, and angle of approach be safely controlled by the aircraft systems.
Had that been done....the Crew would have been assured of terrain clearance and enjoyed much greater Situational Awareness and not been down at 200 feet at Ten Miles from the Landing Point. Had the Crew had NVG's.....it is very likely the Flight Crew could have seen the Light or Light House and Blackrock itself and afford them the ability to avoid the collision with terrain.
One Man's Opinion here.....this Crew were handed a Time Bomb by Management, Training, and Safety. The Operator failed to change from old ways and failed to embrace new technology that requires a change of Mindset and Safety Culture.
If there is any good that can come from the loss of four very experienced, professional, and dedicated people who lived to save others.....hopefully this tragedy shall result in a serious over haul of the SAR Operation and its Safety Standards. We owe that to those lost while helping others!
The Operator could have ensured all potential landing sites or areas of operation were in fact properly contained in the database.
Had the Operator surveyed,checked, and documented formal IMC Point-in-Space Approaches to every known location IMC Approaches would be conducted....and incorporated the advanced capabilities of the S-92 SAR Avionics System then this particular tragedy would have been avoided.
The aircraft can safely terminate at a hover over a pre-determined point without the Crew seeing the surface and both track, height, and angle of approach be safely controlled by the aircraft systems.
Had that been done....the Crew would have been assured of terrain clearance and enjoyed much greater Situational Awareness and not been down at 200 feet at Ten Miles from the Landing Point. Had the Crew had NVG's.....it is very likely the Flight Crew could have seen the Light or Light House and Blackrock itself and afford them the ability to avoid the collision with terrain.
One Man's Opinion here.....this Crew were handed a Time Bomb by Management, Training, and Safety. The Operator failed to change from old ways and failed to embrace new technology that requires a change of Mindset and Safety Culture.
If there is any good that can come from the loss of four very experienced, professional, and dedicated people who lived to save others.....hopefully this tragedy shall result in a serious over haul of the SAR Operation and its Safety Standards. We owe that to those lost while helping others!