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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Originally Posted by ODEN
(Post 9739406)
A lot to learn from this accident...the most shocking and biggest Swiss cheese whole is that Blackrock is not in the EGPWS data base....no last defense... |
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. |
Originally Posted by puntosaurus
(Post 9739408)
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. 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?\\ |
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?
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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 Bit lucky twice. |
Originally Posted by puntosaurus
(Post 9739445)
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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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? |
Originally Posted by HeliComparator
(Post 9739460)
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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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. |
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.
Originally Posted by mini
(Post 9739524)
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? |
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.
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. A terrible waste of life. |
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. |
Originally Posted by JimJim10
(Post 9739567)
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. |
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. |
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. |
Originally Posted by gulliBell
(Post 9739560)
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. 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. 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 |
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. |
Originally Posted by puntosaurus
(Post 9739678)
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. |
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.
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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. |
Originally Posted by rotorspeed
(Post 9739376)
..But what I really don't understand is why, 10 miles out, the crew had already descended so low as 200ft RA. It seems they had a standard SAR approach mode APP1 selected, which took them down to 200ft, but why? At least so soon? |
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. |
Before this procedure was authorised by the company did anybody fly it? in daylight, VMC, to make sure that the procedure worked.
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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... |
Originally Posted by mini
(Post 9739524)
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? |
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. |
Originally Posted by Thunderbirdsix
(Post 9739887)
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
According to the link above it is a single flash every 12 seconds. |
Originally Posted by catch21
(Post 9739902)
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Originally Posted by roundwego
(Post 9739899)
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. The sad fact is its not clear enough and not noticed by the crew....easy to say otherwise now... |
Originally Posted by Thunderbirdsix
(Post 9739910)
Flashes every 12sec takes 26sec to do a full turn
(That's if it even turns any more. It's solar-powered now). |
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. |
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.
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