The crash of Rescue 111: ‘The worst silence I ever heard in all my life’
Gullibell - true but it would seem the decision to cancel stand down and launch instead was between the Captain and the tasking authority - however, I would still expect him to consult the crew in light of the weather and lack of urgency of the task.
Perhaps the 'can-do' attitude of the crew, mentioned early in the report was a factor in launching with no need.
Perhaps the 'can-do' attitude of the crew, mentioned early in the report was a factor in launching with no need.
Agree with this sentiment.
Yes, there are a lot of contributory factors to do with experience dilution, organisational structure (the IAAC didn't have a Flight Safety setup at all) and the overly lengthy report goes into them all in great detail and only points out the crews failings in vague terms. The problem is that it allows each party the ability to offset their share of the blame with the others and the effect of any major causes is lost in the noise.
I spent a lot of time professionally, teaching and mentoring junior SAR pilots and Captains for the very good reason that if you make crap choices or fail to plan properly for a SAROp, you can get quickly caught out and end up in trouble. The first rule of first aid is not to become a casualty yourself and the same applies to SAR.
If you don't find fault with poor decisions made by the crew, how are you ever going to stop the next crew doing something similar when the pressure is on?
In one particular instance I was seriously taken to task over my decision. A very senior police officer try to make a big deal out of it and made threats about my continued employ
I spent a lot of time professionally, teaching and mentoring junior SAR pilots and Captains for the very good reason that if you make crap choices or fail to plan properly for a SAROp, you can get quickly caught out and end up in trouble. The first rule of first aid is not to become a casualty yourself and the same applies to SAR
I REALLY SHOULDN'T BE HERE
Originally Posted by [email protected]
Amateurs doing SAR.
The Irish Air Corps were chronically underfunded in the late nineties. I have no idea about now but back then it was not unusual for flying hours on some fleets to be heavily restricted for budgetary reasons - money being conserved to make sure the maritime patrol and government jet could stay flying until the end of the financial year.
The crew paid the price for a defective system
When you know you are part of a creaking system, that is the time to be more careful not less - look after number 1!
Professionals doing SAR without the right training and organisational systems are, by definition, amateurs.
Below the Glidepath - not correcting
Back to an earlier comment made by crab, the nature of accident reports now almost demands the listing of the myriad of secondary or tertiary factors. This is not necessarily a bad thing, but it carries the risk of diluting or obfuscating the primary causes - certainly to the uninformed or ill-informed. Sometimes there is a very obvious cause and effect linkage, but not always. In this case, simply taking off in those weather and light conditions set in motion a series of events that led to the almost inevitable and tragic outcome. The decision whether or not to lift is fundamental tenet of captaincy and airmanship, commercial or operational pressures don't suddenly increase your flying ability or improve the weather, but they do undermine your ability to make logical and safe decisions.
Not-with-standing, they must have been doing something right because you don't operate in that harsh offshore environment for 30+ years without a single accident relying on pure luck alone
You'll remember the take off charts where you extracted whether you could meet cat A or B, the figures were bollox and not one pilot was aware over the years that was so, until changed at the behest of one pilot after years of agitation. Figures were such that in some areas where you thought you had cat A capability if put to the test you were going to find yourself in deep do do.
How did you go about ensuring you had an alternate for offshore operations as required by the CASA supplement in the flight manual and the Ops Manual? I could go on.
You'll remember the following, why didn't you comply?
The pilot is always going to be the poor bunny who gets stood in front of the firing squad after an accident, because surely after every accident the subsequent inquiry will find he failed to comply with the FOM in some way. And if the same pilot religiously followed the requirements of the FOM and parked the bus a few times because of it then management is not going to be happy about it and he risks being marched out the door with a don't come back Monday letter. That is the reality of the situation, it's a no win.
Some of the FOM I worked under in PNG were so ridiculously onerous there was no way to comply and get the job done. Such as requiring a 10% power margin for all external load jobs, for example. They are written by people who like a lot of words, who like big thick manuals, who have no practical insight to the needless complexities of their own making, etc. When I started agitating about making changes to manuals because what was written was stupid and stopping me from getting the job done it was viewed by management as being a trouble maker. I was happy to do all the legwork to make the changes, but treading on the toes of those in the company who were responsible for producing these rubbish operational documents seriously upsets the apple cart.
In the operation you referred to for sure there were incidents where luck was shining on them. Plenty of other examples. An S76 out of maintenance arriving at Tuna with no oil in the TRGB. But fundamentally I think the operation had such a good safety record for the reasons you mentioned, plus the pilots were all competent and operationally astute. Although I do remember a few closed door Monday morning parades in MM's office after he found out about the occasional weekend shenanigans, stories which had become highly embellished I point out, which might have stretched operational flexibility a bit too far. Especially if a company aircraft had been observed on the Tuna via Sperm Whale Head low level route.
Some of the FOM I worked under in PNG were so ridiculously onerous there was no way to comply and get the job done. Such as requiring a 10% power margin for all external load jobs, for example. They are written by people who like a lot of words, who like big thick manuals, who have no practical insight to the needless complexities of their own making, etc. When I started agitating about making changes to manuals because what was written was stupid and stopping me from getting the job done it was viewed by management as being a trouble maker. I was happy to do all the legwork to make the changes, but treading on the toes of those in the company who were responsible for producing these rubbish operational documents seriously upsets the apple cart.
In the operation you referred to for sure there were incidents where luck was shining on them. Plenty of other examples. An S76 out of maintenance arriving at Tuna with no oil in the TRGB. But fundamentally I think the operation had such a good safety record for the reasons you mentioned, plus the pilots were all competent and operationally astute. Although I do remember a few closed door Monday morning parades in MM's office after he found out about the occasional weekend shenanigans, stories which had become highly embellished I point out, which might have stretched operational flexibility a bit too far. Especially if a company aircraft had been observed on the Tuna via Sperm Whale Head low level route.
To continue from Two's in's post - I have seen the accident investigation system go from blaming the pilot to not blaming anyone and both are counter-productive to Flight Safety.
Blaming the pilot was often an easy way out for management (MoD for instance) to prevent organisational, supervisory, engineering or budgetary causes from being highlighted.
Not blaming anyone affords the same people the same opportunities but by obfuscation in a deluge of extraneous data instead of misdirection using a scapegoat.
Why? Because admitting fault means losing jobs, funding, credibility or, most importantly, money.
Blaming the pilot was often an easy way out for management (MoD for instance) to prevent organisational, supervisory, engineering or budgetary causes from being highlighted.
Not blaming anyone affords the same people the same opportunities but by obfuscation in a deluge of extraneous data instead of misdirection using a scapegoat.
Why? Because admitting fault means losing jobs, funding, credibility or, most importantly, money.
