SAR S-92 Missing Ireland
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Remember this one in China? I can't find an AAIB report, I am not sure that one was ever done. Captain was A.L-T, a true gent.
It doesn't add anything material here but it does illustrate the difficulty of assessing terrain on a weather radar, even if its your primary means.
G-TIGN Accident Details On 22/05/1989
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Date 22/05/1989
Registration G-TIGN
Aircraft registration | UK Civil Aviation Authority
https://www.google.com/search?q=G-TIGN
Aircraft Type AS332
Manufacturer Eurocopter
Fatal Yes
Narrative A/C FLEW INTO A HILLSIDE IN BAD WEATHER & BURNT OUT. 3 FATALITIES.
Details A/C WAS LIMITED TO VFR FLT ONLY, IN ACCORDANCE WITH OPS MANUAL, DUE U/S AREA NAV. IT WAS OPERATING WITH A CREW OF TWO PILOTS (1 BRITISH, 1 CHINESE) PLUS INTERPRETER. WHILE RETURNING FROM AN OFFSHORE OIL PLATFORM IN POOR WEATHER AND USING RETURNS FROM LAND ON THE WEATHER RADAR, DESCENDING FROM 2000FT TO MAINTAIN VMC, THE A/C STRUCK STEEPLY SLOPING GROUND AT ABOUT 600FT & CAUGHT FIRE KILLING ALL 3 OCCUPANTS. INVSTGN BY CHINESE AUTHORITIES WITH AAIB PARTICIPATION. CAA CLOSURE: FULL REPORT NOT PUBLISHED BY CHINESE AUTHORITY. OPR HAS AMENDED OPERATIONS MANUAL. NO FURTHER CAA ACTION APPROPRIATE.
It doesn't add anything material here but it does illustrate the difficulty of assessing terrain on a weather radar, even if its your primary means.
G-TIGN Accident Details On 22/05/1989
Skip Navigation Links
Date 22/05/1989
Registration G-TIGN
Aircraft registration | UK Civil Aviation Authority
https://www.google.com/search?q=G-TIGN
Aircraft Type AS332
Manufacturer Eurocopter
Fatal Yes
Narrative A/C FLEW INTO A HILLSIDE IN BAD WEATHER & BURNT OUT. 3 FATALITIES.
Details A/C WAS LIMITED TO VFR FLT ONLY, IN ACCORDANCE WITH OPS MANUAL, DUE U/S AREA NAV. IT WAS OPERATING WITH A CREW OF TWO PILOTS (1 BRITISH, 1 CHINESE) PLUS INTERPRETER. WHILE RETURNING FROM AN OFFSHORE OIL PLATFORM IN POOR WEATHER AND USING RETURNS FROM LAND ON THE WEATHER RADAR, DESCENDING FROM 2000FT TO MAINTAIN VMC, THE A/C STRUCK STEEPLY SLOPING GROUND AT ABOUT 600FT & CAUGHT FIRE KILLING ALL 3 OCCUPANTS. INVSTGN BY CHINESE AUTHORITIES WITH AAIB PARTICIPATION. CAA CLOSURE: FULL REPORT NOT PUBLISHED BY CHINESE AUTHORITY. OPR HAS AMENDED OPERATIONS MANUAL. NO FURTHER CAA ACTION APPROPRIATE.
I put forward this theory in post #143
The cockpit transcript was depressingly similar. The captain advised the co-pilot (pf) to turn around. As he was Chinese without Level 4 in English this was relayed by the interpreter. He queried the heading and this also went back and forth through the interpreter. When it was resolved he commenced the turn but half way round the helicopter struck the top of the hill killing all three.
The radar was found to be 5 degrees nose up which would have masked the coast close up in front of them.
The cockpit transcript was depressingly similar. The captain advised the co-pilot (pf) to turn around. As he was Chinese without Level 4 in English this was relayed by the interpreter. He queried the heading and this also went back and forth through the interpreter. When it was resolved he commenced the turn but half way round the helicopter struck the top of the hill killing all three.
The radar was found to be 5 degrees nose up which would have masked the coast close up in front of them.
Incorrect gain or tilt can make surface targets or islands invincible.
ukv1145 - understood, thanks
Newer used a Wx-only radar, but I have used and am using Wx+SAR-radars( including Primus 701A wich I think is used in the S92 SAR?)
In my opinion these radars will detect and show small islands and rock regardless of mode and that they are safe and for awoiding terrain when flying over sea. Of course, as with all equipment, you need to be trained with to use it and I think we can safely assume that this crew was trained.
Earlier days of SAR only had the SAR/Wx-radar to rely on, combined with paper maps/sea carts for close-to-land operations, at least where I come from. In my world the radar picture superseeds moving map if seing ground/osbtacle on the radar( of course you should use all system that adds on SA).
I would absolutely think that the radar could be trusted, and that the radar should have been one of the first slice of the swiss cheese. The EGPWS should be one of the last. Said to see that it did not do the work this time.
So, between a regulator that refused to permit use of NVD and an operator who didn't update or check the database or review the letdown procedures, there seems to be room for a few lawsuits.............
Well here we are 56 pages on. Would you Rotorhead chaps/esses please indulge me because, in a sense, I was there at Page Zero having visited Malin Head, as a tourist, earlier that day and noted the Coastguard HQ. Whilst I was tucked up in a hotel bed outside London/Derry Dara and Mark and their crewmates were outbound "to the rescue". When I awoke the accident had happened - so why, apart from that co-incidence of geography, do I feel so affected and why this post?
Ans: Many many years ago I was rescued, severely hypothermic, from the freezing 'oggin, at night, by an SAR Heli crew (for those who might wish to guess which incident 'twas in Europe but not UK).
Recently retired after 15,000+ fixed-wing professional flying hours you will understand why the SAR community has throughout retained a special place in my heart.
I also have a contribution to make in the understanding of how this seems to have come about - in the interest, as always, of learning lessons and sadly, in this case, pointing out one that does not seem to have been learnt by the Operator. Do you Rotorheady peeps remember 'Impact Erebus'? The Air NZ DC10 that CFITed into the Antarctic in late 1979. The proximate cause was Sector White Out but the single largest contributing factor was the fact that the Airline's Flight Planning Dept. had changed the stored Flight Plan in the FMS the day before (non-trivially, they moved the inbound track 27nm East!) and NOT TOLD the Crew. The latter carried out a conscientious brief based, unknowingly, on the wrong data - Ringing any bells here? It did with me within 24 hrs and 50+ pages ago and I trust you will agree worth sharing. Keep safe guys and girls, and Thanks again tb
Ans: Many many years ago I was rescued, severely hypothermic, from the freezing 'oggin, at night, by an SAR Heli crew (for those who might wish to guess which incident 'twas in Europe but not UK).
Recently retired after 15,000+ fixed-wing professional flying hours you will understand why the SAR community has throughout retained a special place in my heart.
I also have a contribution to make in the understanding of how this seems to have come about - in the interest, as always, of learning lessons and sadly, in this case, pointing out one that does not seem to have been learnt by the Operator. Do you Rotorheady peeps remember 'Impact Erebus'? The Air NZ DC10 that CFITed into the Antarctic in late 1979. The proximate cause was Sector White Out but the single largest contributing factor was the fact that the Airline's Flight Planning Dept. had changed the stored Flight Plan in the FMS the day before (non-trivially, they moved the inbound track 27nm East!) and NOT TOLD the Crew. The latter carried out a conscientious brief based, unknowingly, on the wrong data - Ringing any bells here? It did with me within 24 hrs and 50+ pages ago and I trust you will agree worth sharing. Keep safe guys and girls, and Thanks again tb
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There is clearly a great deal of S92 SAR expertise following this thread. The co-pilot, who was monitoring the radar, called a "small target at 6 miles at 11 o'clock" when they were 1 mile west of Blackrock. Do others agree this could have been Duvillaun More island? Followed by "Large out to the right there, ehm" - pretty vague. Achill Island maybe, assuming the lack of distance and bearing meant it was not too relevant? Hard to believe such a casual comment would be so vague if it was Blackrock a mile away - and anyway, that would have been ahead, not to the right.
What do the radar experts think about the notion that Duvillaun and Achill were seen, but not, apparently Blackrock? Are there radar modes and settings that could explain that?
Given that the captain was targeting 200ft before turning back east for BLKMO, assuming say a 70kt GS and the APP1 500ft/min descent, I make that passing Blackrock eastbound at about 1000ft. And again, it seems this wasn't seen on radar either, though perhaps to be more expected as still 700ft below.
It appears it was the FLIR operator that picked up Blackrock. The time from the rear crew observation to the impact was about 13 secs, so that would mean it was seen at 550m range, assuming 90kts GS. Again do our S92 experts agree with that, and what might that tell us about visibility and IMC/VMC? What range does FLIR have in clear air and cloud?
Apologies if some of this has been answered before - a lot of ground has been covered!
What do the radar experts think about the notion that Duvillaun and Achill were seen, but not, apparently Blackrock? Are there radar modes and settings that could explain that?
Given that the captain was targeting 200ft before turning back east for BLKMO, assuming say a 70kt GS and the APP1 500ft/min descent, I make that passing Blackrock eastbound at about 1000ft. And again, it seems this wasn't seen on radar either, though perhaps to be more expected as still 700ft below.
It appears it was the FLIR operator that picked up Blackrock. The time from the rear crew observation to the impact was about 13 secs, so that would mean it was seen at 550m range, assuming 90kts GS. Again do our S92 experts agree with that, and what might that tell us about visibility and IMC/VMC? What range does FLIR have in clear air and cloud?
Apologies if some of this has been answered before - a lot of ground has been covered!
Sorry to all you current guys who love the complexity of all the Gucci modes, bells and whistles that the S-92 enjoys, and you guys well versed in procedures and plates for everything. All those 'advantages' were directly responsible for this CFIT. It simply would not, indeed could not, have happened to a simple 'steam age' Sea King. KISS seems appropriate - so much has been lost for such little gain it seems. I wonder, has any SAR job been done with an S-92 that wouldn't have been done by a Sea King? 
ps: like P3, genuinely interested!
ps: like P3, genuinely interested!
Last edited by Al-bert; 17th Apr 2017 at 10:47. Reason: add ps
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I believe that if they had mandated and flown a stabilised approached to a an MAPT for BLACKSOD this accident could not have happened. The vertical profile designed such that all obstacles are cleared in the entire FATO.
Amateur Letdown procedures such as this one, or, the mistaken belief that "because we are SAR, the rules and conventions need not apply" lead to events like this.
The considerations of safety offered by the FLIR, RADAR, MOVING MAP, NVG are just that. Only considerations to add value. However, the letdown profile should be designed such that reliance on these systems alone, the ensure separation, is the first hole in the swiss cheese.
Offshore ARAs and SAR Let-downs mid-ocean, ultimately rely on the WX RADAR for final separation but the vertical and horizontal profiles are now mandated to ensure the best possible performance from the RADAR.
What astounds me here is why, with FLIR available on the MFDs, this was not selected to supplement the RADAR return on the other MFD.
I suspect this accident will focus on the performance and robustness of the EGPWS database, which in my view would be a mistake. EGPWS will only ever be the "Virtual World". The RADAR and the FLIR offering information about the "Real" world.
Using NVG to navigate and avoid obstacles this far away from the TLOF is surely a last resort. I appreciate NVGs would add value during the final landing phase but this far out, just a distraction for the 2 available all-weather - primary sources of the Real world, RADAR and FLIR.
Amateur Letdown procedures such as this one, or, the mistaken belief that "because we are SAR, the rules and conventions need not apply" lead to events like this.
The considerations of safety offered by the FLIR, RADAR, MOVING MAP, NVG are just that. Only considerations to add value. However, the letdown profile should be designed such that reliance on these systems alone, the ensure separation, is the first hole in the swiss cheese.
Offshore ARAs and SAR Let-downs mid-ocean, ultimately rely on the WX RADAR for final separation but the vertical and horizontal profiles are now mandated to ensure the best possible performance from the RADAR.
What astounds me here is why, with FLIR available on the MFDs, this was not selected to supplement the RADAR return on the other MFD.
I suspect this accident will focus on the performance and robustness of the EGPWS database, which in my view would be a mistake. EGPWS will only ever be the "Virtual World". The RADAR and the FLIR offering information about the "Real" world.
Using NVG to navigate and avoid obstacles this far away from the TLOF is surely a last resort. I appreciate NVGs would add value during the final landing phase but this far out, just a distraction for the 2 available all-weather - primary sources of the Real world, RADAR and FLIR.
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I think the absence of NVD is a bit of a red herring considering the helicopter was fitted with FLIR equipment. If lifting a casualty from a vessel, it would be normal to illuminate the lifting area with deck lighting. For sea and cliff rescue, there is a searchlight. NVD is more likely to be a hinderance than a help in most rescue operations since the pilot(s) should be positioning according to the directions from the winchman.
All the equipment in the world is not going to help if the crew are provided with less than complete navigation information, a flawed approach procedure, and fail to recognise and react promptly when there are several indications that they are flying into danger.
In this instance there was a self confirmatory bias at work where the crew were clearly not entirely sure of their position, hadn't flown in the area for ages, and were drawn into the trap of assuming that various rocks and islets that they spotted indicated that they were more or less on track and on course. The FLIR equipment did give advanced warning of the obstruction ahead but they simply did not appreciate the danger because it didn't fit with their situational map, a trap most pilots will have fallen into at one time or another.
A tragic accident that this experienced crew could and should have been capable of avoiding, despite the flawed navigation data and a completely unsuitable approach plan given the weather conditions at the time.
All the equipment in the world is not going to help if the crew are provided with less than complete navigation information, a flawed approach procedure, and fail to recognise and react promptly when there are several indications that they are flying into danger.
In this instance there was a self confirmatory bias at work where the crew were clearly not entirely sure of their position, hadn't flown in the area for ages, and were drawn into the trap of assuming that various rocks and islets that they spotted indicated that they were more or less on track and on course. The FLIR equipment did give advanced warning of the obstruction ahead but they simply did not appreciate the danger because it didn't fit with their situational map, a trap most pilots will have fallen into at one time or another.
A tragic accident that this experienced crew could and should have been capable of avoiding, despite the flawed navigation data and a completely unsuitable approach plan given the weather conditions at the time.
Sorry to all you current guys who love the complexity of all the Gucci modes, bells and whistles that the S-92 enjoys, and you guys well versed in procedures and plates for everything. All those 'advantages' were directly responsible for this CFIT. It simply would not, indeed could not, have happened to a simple 'steam age' Sea King.
I would dispute that: on 21st March 1974 054 from 824NAS flew into a 220ft high cliff on the Lizard Peninsular when positioning at night at 200ft radalt hold (due to doppler plot slippage was the BOI finding). Why the radar failed to give an indication that all was not well was never established, all four on board were killed.
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We did, however, have a running commentary from the FLIR operator when he was operating the FLIR and we always acted upon any doubt expressed by any crew member. This was Maritime SAR in a rocky environment.
As an offshore pilot, I have used and use the radar as my primary means to remain clear of solid stuff when below MSA over water. Moving map and GPS/FMS are fancy calculators, the radar gives me a fix. Because it is a wx radar, I play with the tilt to see if there is anything missed on the previous sweep. It does not have an " ideal" setting, not even on mapping mode. I do not overfly anything I have not visually (mk1 eyeball) identified beforehand, as it has been pointed out by other contributors that sometimes stuff sails in the way that is high enough to seriously ruin your day.
I am old enough to have worked with just a monochrome radar and decca; anything later I consider a bonus. A MPP is still only " most probable" according to the calculator; reality may differ.
A tragic accident and I write this with the full benefit of hindsight.
Al-Bert,
Why would an Approach Plate for a preplanned IMC Procedure that had been surveyed, trained for, checked, and used incorporating the Gucci abilities of the FMS and other equipment cause an accident like this?
I submit the absence of that is the main contributing cause of this accident.
Times change as does technology....and we should change with it.
Eacott Reminded you that Steam Age 61's had their bad days and you then admitted post one such bad day....changes in the way business was done was effected.
So why not do the same after this one?
Why would an Approach Plate for a preplanned IMC Procedure that had been surveyed, trained for, checked, and used incorporating the Gucci abilities of the FMS and other equipment cause an accident like this?
I submit the absence of that is the main contributing cause of this accident.
Times change as does technology....and we should change with it.
Eacott Reminded you that Steam Age 61's had their bad days and you then admitted post one such bad day....changes in the way business was done was effected.
So why not do the same after this one?
John - ref below
"I would dispute that: on 21st March 1974 054 from 824NAS flew into a 220ft high cliff on the Lizard Peninsular when positioning at night at 200ft radalt hold (due to doppler plot slippage was the BOI finding). Why the radar failed to give an indication that all was not well was never established, all four on board were killed."
Was it not something to do with MTI that meant the land did not show on the screen?
"I would dispute that: on 21st March 1974 054 from 824NAS flew into a 220ft high cliff on the Lizard Peninsular when positioning at night at 200ft radalt hold (due to doppler plot slippage was the BOI finding). Why the radar failed to give an indication that all was not well was never established, all four on board were killed."
Was it not something to do with MTI that meant the land did not show on the screen?
I think the absence of NVD is a bit of a red herring considering the helicopter was fitted with FLIR equipment. If lifting a casualty from a vessel, it would be normal to illuminate the lifting area with deck lighting. For sea and cliff rescue, there is a searchlight. NVD is more likely to be a hinderance than a help in most rescue operations since the pilot(s) should be positioning according to the directions from the winchman.
DB - the best 'real world' view is out of the front window and with NVG on they would have seen the rock long before it became an issue.
Rotorspeed - as previously mentioned, FLIR does not look through cloud since it relies on the thermal differences between the objects it is looking at - in cloud the water droplets attenuate almost all the thermal energy and make everything look uniform.
P3 Bellows - it was mentioned earlier ISTR that the IAA wouldn't allow civilian use of NVD - a bit behind the times really since just about everyone else does it now.
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CHC
Multi pilot
Hi Tech
Questions over SOPs/OM
Loss of SA Not noticing.
Questions of briefing for the let down.
A/C serviceable
CFIT low level or LOCFIT
All apply to G WNSB also.
Multi pilot
Hi Tech
Questions over SOPs/OM
Loss of SA Not noticing.
Questions of briefing for the let down.
A/C serviceable
CFIT low level or LOCFIT
All apply to G WNSB also.