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Originally Posted by Triskelle
(Post 9741063)
...However, without resort to the separate page of text, the map from the Route Guide in Figure 4 shows a spot height of 282 ft at BLKMO, which is presumably the terrain height of Black Rock (not including the height of the lighthouse)? |
Excuse my ignorance, but in the most sophisticated helicopters in the civilian world, why aren't all known planned landing sites such as Blacksod provided with GPS approaches with a vertical profile akin to that of an ILS, flown (in the case of SAR) to a very low-minima using auto hover if required? They take very little time to develop, and the cost would be negligable on a £500m contract. I get the necessity for ARA let downs to unknown rescue locations, but routine landings for fuel? I'd argue that the risk philosophy should be closer to that used in HEMS. At adhoc HEMS operating sites, rarely used more than once, the risk permitted is at it's highest in order to facilitate getting the job done. However at hospitals, and hems operating bases, refuel locations etc, used regularly there should be less alleviation as they are planned landing sites, used at a higher frequency, that can be known to the operator, thus procedures can be put in place and followed.
The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling. A paper chart, or an iPad and Runway HD would have improved their SA, over all the kit & radar in an S92? Are we saying there is no simple moving map with an OS layer, or chart in the cockpit? |
Sectio 3.5.8 operators route guide
Originally Posted by puntosaurus
(Post 9739658)
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. |
Low Level Over Water Flight
Although there are a number of quite significant contributory factors, I think the main point here is that regardless of whether a published procedure is followed or not, any low-level flight over water in IMC, at night or in marginal conditions MUST use the radar as the PRIMARY navigation aid. If a radar return cannot be positively, visually identified it MUST NOT be overflown. Besides islands there are plenty of moving marine obstacles that can easily reach 300ft or more which would not be on any map, chart or in any database. Whether radar guidance is achieved from front or back seats is a matter of procedure but it would be a designated crewmember’s responsibility to monitor and constantly verbally update the obstacle situation as seen on the radar. Although I know nothing of CHC’s procedures I would assume that this is SOP, especially for SAR.
Everyone makes mistakes, I’ve made plenty and seen very capable colleagues do the same. Most of the time some procedure, mechanism or technology prevents a tragic outcome, sadly not so on this occasion. I’m sure there is much to learn here. |
Originally Posted by pegasusflash
(Post 9741090)
Has anyone read section 3.5.8 of the report? I think it's quite relevant, it clearly states that a page of text accompanied the flight route and included information about blackrock and the lighthouse height amsl. Raises some questions?.
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Would a single Page Approach Plate for a checked and tested "standard" Approach for Blacksod have been much better?
One that incorporates the full capability of the Avionics fit be far better? One that would ensure Terrain Clearance? |
Originally Posted by SASless
(Post 9741179)
Would a single Page Approach Plate for a checked and tested "standard" Approach for Blacksod have been much better?
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Originally Posted by SARWannabe
(Post 9741085)
...The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling...
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Originally Posted by Woolf
(Post 9741140)
..I think the main point here is that regardless of whether a published procedure is followed or not, any low-level flight over water in IMC, at night or in marginal conditions MUST use the radar as the PRIMARY navigation aid..
Again, in the simulator we can throw in any sort of weather conditions. The number of pilots I've seen fumble with the weather radar and just blast through dangerous weather suggests its proper use is not widely understood or practised. If nothing else on that helicopter worked for them, that radar should have been able to save the day for them. |
No idea on rotary wing operation, but in FW there is no regulatory requirement to even update the latest version of the EGPWS database!
Unlike FMS updates which are mandated, EGPWS database revisions are left up to the operator to determine (within their CMS) how they are addressed. |
I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish. |
but since you would have to let down over the water anyway, why wouldn't you use the SAR autopilot modes?
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Insider.
You do understand the full capability of the SAR modes on the S-92 don't you? Why in the world would you want to revert to old techniques using lesser capability? Take note of the Sikorsky/PHI FMS Offshore Rig Approach in use in the Gulf of Mexico using far less capability than the SAR modes....then rethink what you are suggesting. |
Originally Posted by C195
(Post 9741197)
..Making a low level transit in marginal weather must also be deemed more risky than descending closer to the landing site. Was this the standard way of making this type of approach when IMC?
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You do understand the full capability of the SAR modes on the S-92 don't you? Had an "old" technique been used, we would not be having this discussion. SAR modes are for SAR, not routine landings for a fuel stop when there was no urgency. As gulliBell says, why start an approach at 200' essentially IFR (night) with miles and miles to run at 75 knots? Its the "new" techniques that lead to a false sense of security. I always sought to minimise my time over the sea at at 200' as I am sure you did SAS. |
Originally Posted by [email protected]
(Post 9740864)
... ...
Because in civilian SAR, the rearcrew are not flightcrew (no licences) they are not allowed to be responsible for the navigation of the aircraft - this is such a waste of crew resources simply because civil aviation regards anyone not in the cockpit as cabin crew. ... ... "If you think education is expensive, try ignorance." |
Originally Posted by industry insider
(Post 9741202)
...Surely Blacksod could have had a simple GPS approach rather than having to use SAR autopilot modes?
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Originally Posted by SARWannabe
(Post 9741085)
Excuse my ignorance, but in the most sophisticated helicopters in the civilian world, why aren't all known planned landing sites such as Blacksod provided with GPS approaches with a vertical profile akin to that of an ILS, flown (in the case of SAR) to a very low-minima using auto hover if required? They take very little time to develop, and the cost would be negligable on a £500m contract. I get the necessity for ARA let downs to unknown rescue locations, but routine landings for fuel? I'd argue that the risk philosophy should be closer to that used in HEMS. At adhoc HEMS operating sites, rarely used more than once, the risk permitted is at it's highest in order to facilitate getting the job done. However at hospitals, and hems operating bases, refuel locations etc, used regularly there should be less alleviation as they are planned landing sites, used at a higher frequency, that can be known to the operator, thus procedures can be put in place and followed.
The fact that the obstacle and island weren't in the terrain database, so close to a company approved route, is simply mind boggling. A paper chart, or an iPad and Runway HD would have improved their SA, over all the kit & radar in an S92? Are we saying there is no simple moving map with an OS layer, or chart in the cockpit? I get the general point of radar let downs and pseudo ILS AFCS coupled approaches but to a refuelling site would it be really that difficult to chart a GPS/RNAV approach or even better yet an ANP-AR approach? Sometimes innovation in aviation seems choked by bureaucracy and pointless regulation and hangs on to legacy procedures far too long. It seems very sad that the minimum speed for EGPWS to be "armed", for want of a better word, was not specified as an SOP for all approaches. I gather that it may not have made a diiference here as there are questions as to wether Blackrock was in the database or not but, it would seem a sensible SOP to arise out of this event. |
Bklmo
Originally Posted by gulliBell
(Post 9740747)
Isn't the light beam columnated? The light wouldn't go up into the cloud, it's angled down towards the surface. And at one flash every 12 seconds, they might not have been below cloud for long enough before hitting the rock for the light to be visible to them. But yes, from 500' up even if you were in cloud, you'd expect to see the light, or the clouds light up around you, every 12 seconds from a few miles out.
The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself". This call came 15 seconds after the co-pilot reported 1.3 miles to BLKMO. This I just don't understand, it's evidence of a breakdown in SA. I mean, when you've just been told BLKMO is 1.3 miles in front of you (according to GPS), and there is a radar target 6 miles ahead of you, how could that radar target possibly be BKLMO? What that target probably was is Duvillaun More, which you'd expect to be at 11 o-clock on radar because the next segment takes you to the right of it. And the co-pilot should have identified the radar target as a possible obstacle on the next segment by looking at the map, and he didn't question the pilot when it should have been obvious that a radar target 6 miles in-front of you couldn't possibly be a GPS waypoint only 1 mile in-front of you. And another thing I don't understand, when the co-pilot reported 1.3 miles to BLKMO, there MUST have been a big red target directly in front of him on the radar (assuming the radar was set to 10nm arc and 1.3nm is still in the detectable range). Also, the crewman told the pilot the island was visible directly ahead 15 seconds before impact, and to come right. In the 6 seconds before hitting the rock the FDR shows they were not making any heading change to ensure lateral separation. From 200' above the surface and at 3nm range, a 300' island in-front of you would probably indicate on the radar screen as an obvious red blob with little depth, probably with no other colours evident, probably with some sea clutter either side of it, with a great big arc of black for miles and miles behind it. And as you got closer to the target the red blob would be getting bigger and bigger, and the black arc behind it would stay just as black. That great big arc of black behind a red radar return should attract your attention, because that black area with no radar returns is potentially dangerous. It's dangerous of course because a big island in-front of you has bounced all the radar energy back to you, and nothing behind it can be detected. If it was only a small island with little elevation the radar image would be completely different, you should see sea clutter returns only a short distance behind the red return. I've got a hunch the radar was painting a good picture of what was in-front of them for the last 6nm, but there was no proper interpretation of what the radar was telling them. I know it's easy to be critical from armchair comfort with the benefit of time and hind-sight and the rest of it, but the brutal reality of it is, I don't see much PIC stuff going on. The pilot said virtually nothing of substance through the whole of the end of CVR transcript, when the aircraft was getting in an imminent state of peril. And the bit the pilot did say about BLKMO was obviously wrong but it wasn't corrected by the co-pilot. Blackrock must have been detectable on the radar directly in-front of the aircraft for the whole of the track inbound to BKLMO, and it should have been identified and reported as a hazard to the pilot, but it wasn't. The warning from the rear crew about the rock in-front of them either wasn't made forcefully enough, or wasn't acted on quickly enough (no avoiding action was being taken in the 6 seconds before impact). My reading of that little bit of CVR transcript is not enough of substance was being said amongst the crew. My flight instructor used to say "silence is bad CRM" - for me, and again this is being said from the comfort of my armchair, there is just too much silence on that CVR transcript. the commander was acknowledging an aural altitude warning when she made this comment |
You miss the point entirely although you ask the right question!
If the SAR modes can safely deliver you directlyto the helipad in a stabilized hover if asked to do so...why not ask it to do so...or at least to a point very close to the helipad? As Blacksod, like other known deliberate Landing Sites used by the Operator, did not have a documented IMC approach procedure, one that assured track and vertical guidance guaranteeing Terrain clearance....one has to ask...."Why?". Why did the Crew choose a point Ten Miles from the Helipad instead of a point very close to Blacksod itself? Had that IMC approach existed and been used....this Crew would not have been at 200 feet and ten miles out to sea heading ashore as they were when they hit Blackrock.
Originally Posted by industry insider
(Post 9741251)
Of course but it was the use of the SAR modes down to 200' to the west of Blackrock that caused the problem.
Had an "old" technique been used, we would not be having this discussion. SAR modes are for SAR, not routine landings for a fuel stop when there was no urgency. As gulliBell says, why start an approach at 200' essentially IFR (night) with miles and miles to run at 75 knots? Its the "new" techniques that lead to a false sense of security. I always sought to minimise my time over the sea at at 200' as I am sure you did SAS. |
Jim - who is going to drive it forward? The CAA chap who spent a day at Chiv looking at this before the civSAR went ahead was himself a 'trolley dolly' with no conception of what went in in a SAR helo.
The operators won't push it because they would have to pay more for licensed rear crew. Perhaps this is why it had only been 'discussed' with no move forward for many years. |
had that IMC approach existed and been used....this Crew would not have been at 200 feet and ten miles out to sea heading ashore as they were when they hit Blackrock |
Re "small little island "
The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself"
This was not a reply to co-pilot it was an acknowledgement of an aural altitude warning, see CVR timeline |
Originally Posted by smcc63
(Post 9741304)
The co-pilot did have a target on radar, he reported "target at 6 miles 11 o'clock Large" and the pilot replied "just a small little island, that's BLMO itself"
This was not a reply to co-pilot it was an acknowledgement of an aural altitude warning, see CVR timeline The amount of 'waffle' on here is mind boggling. The co-pilot had A target on the radar at 6 miles. Which was probably the mainland. NOT Blackrock |
Originally Posted by smcc63
(Post 9741282)
the commander was acknowledging an aural altitude warning when she made this comment
And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning, which is referenced to height and not barometric altitude. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned barometric altitude. |
It is clear the captain did know that BLKMO was not just a waypoint over the sea but an island, because when the CVR picks up the ALTITUDE call out, she says: "Eh just a small little island.... that's BLMO itself" So the question is how did she know it was an island, and what information about its height did she have? Did she have good enough information, but had misinterpreted it? She clearly did not realise it was 300ft high.
Furthermore I find it very surprising that you'd track over what you knew was an island at night at 200ft at all - and if you did, you would surely have made a comment in advance to the crew to expect an ALTITUDE alert - and what clearance on the radalt to expect, as it was so little. But why would you not just climb to add some clearance for good measure? There was no reason not to. What little CVR talk there is gives me the impression this crew were not completely sure of the terrain ahead and were relying significantly on radar and possibly EGPWS to provide information to keep them safe. As is clear from a considerable number of the 980 posts on this thread, both radar and EGPWS have their complexities, that mean that one has to be very knowledgable about them in order to be able to 100% rely on them to be able to avoid obstacles flying at 200ft at night. Which brings us back to the madness of this approach - it must surely have been totally unnecessary to carry it out at 200ft from so far out, over known islands at night. Getting into Blacksod safely in the prevailing weather should not have been a particularly difficult task for this helicopter. Basic flight planning with identification of a sensible let-down path and monitoring position with nothing more detailed than a 1:500,000 moving map was all that was required. And they had this and much more. It should not have absolutely needed a formal approach (though admittedly very advantageous) or more equipment on the aircraft. It seems to me that a danger of too much external control with SOPs and sophisticated aircraft equipment to rely on, is that, whilst having clear and obvious benefits that we need, risk is increased in one way by reducing the amount of original thinking and decision making pilots undertake. So they can easily get worse at it, as probably happened here. |
Surely with the data now in hand it will be helpfull if they fly a SAR 92 over the exact same path, with the same cockpit setup on a VMC day and verify exactly what the crew would have seen in the cockpit and also in the back.
Perhaps this has already been done. Such a sad event. |
Originally Posted by gulliBell
(Post 9741330)
OK, I see. I was anticipating discussion of the radar target identified by the co-pilot, I thought the pilot was responding to that, in addition to the initial acknowledgement. Regarding the automated aural ALTITUDE alert, what normally is the SOP crew response for that? I would have thought a formal acknowledgement of that warning would be required, such as "copied, altitude 200, no further descent" and then the co-pilot responding "no further descent", something like that, rather than what was said.
And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned altitude. |
Originally Posted by rotorspeed
(Post 9741332)
It is clear the captain did know that BLKMO was not just a waypoint over the sea but an island...
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Originally Posted by [email protected]
(Post 9741287)
Jim - who is going to drive it forward? The CAA chap who spent a day at Chiv looking at this before the civSAR went ahead was himself a 'trolley dolly' with no conception of what went in in a SAR helo.
The operators won't push it because they would have to pay more for licensed rear crew. Perhaps this is why it had only been 'discussed' with no move forward for many years. There are numerous problems with giving this some momentum. As you say, the operators would have to pay more. In fact, my first words to the previous director of Bristow UK SAR on first meeting her were "Are you sure you're paying your rear-crew enough?" She didn't get it. And she didn't have the background that would have enabled her to 'get it'. MR aren't license holders or AOC holders and so we have no direct leverage (UK, Eire and elsewhere same situation) which leaves us with the political route which is tortuous and slow. Your old mates are little help since many of them were leaving anyway and the SAR operators pay them a lot more than shelf stackers or security guards and let them do a job they love for a lot more years: happy happy. What comes after them is a big worry. I'd say to the regulators, "Would you like to be a world-leading aviation regulator in the field of SAR or are you happy to wait for the accidents?" (Time on the wire is not the same as air miles.) :E |
Originally Posted by gulliBell
(Post 9741351)
It's not clear to me. I put myself in the co-pilot seat and I still think the pilot is referencing the island comment to my radar target call, and the ALTITUDE warning was either missed, or it was not responded to in a formal sense required by an SOP. You can't be responding to a system generated warning in the way it was responded to because that has resulted in ambiguity. The comment might have been in relation to the warning, or it might have been in response to the co-pilot radar target call. Hence why a system generated warning must always be responded to in an SOP'd formal way, by both pilots.
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Originally Posted by smcc63
(Post 9741366)
It's all open to interpretation of course..
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Originally Posted by gulliBell
(Post 9741389)
Wearing my co-pilot hat, having read the transcript, I believe it's more likely the ALTITUDE alert was missed by both pilots. I say that because there was no SOP-like response to the ALTITUDE alert by either crew, and Captains don't intentionally fly over islands in an unfamiliar area at night at 200', and if they were to do so, the co-pilot would challenge this course of action.
I'm sure a more comprehensive conclusion can be arrived at post final AAIU report |
Originally Posted by gulliBell
(Post 9741330)
And my other question, I'm not familiar with a radalt triggering ALTITUDE warning, normally I expect radalt to trigger a MINIMA warning, which is referenced to height and not barometric altitude. Is this just an S92 configuration thing? MINIMA seems to me to be the proper warning, as that is self evident not to descend any further. ALTITUDE could just mean you've strayed plus or minus whatever tolerance away from an assigned barometric altitude.
When the a/c descends below the RADALT bug, you get an "ALTITUDE, ALTITUDE" aural alert. Yes even though it's a height it is referring to; I suppose an alert "Height, Height" doesn't do as well phonetically! |
I spend much of my life floating around at or below safety altitude (Navaid calibration and procedure validation). I'm struggling to understand why anyone would knowingly design a letdown which incorporates the only highpoint within a number of miles. For sure, we're talking different environment, but the old adage sticks - "Pilots will eventually find ways to do something wrong".
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CVR
Re aural altitude alert:
As per AAIU report: The Commander had the moving map displayed on her MFD and the Co-pilot had weather radar displayed on his MFD. The CVR recordings indicated that the Co-pilot was using the weather radar to identify terrain features. The Rad Alt provided a callout of “ALTITUDE, ALTITUDE” 26 seconds prior to the initial impact. The Commander identified the reason for the aural alert as a small island below the helicopter which she said was “just a small little island... that’s B L M O itself”. At the time of the aural alert FDR data placed the Helicopter in the vicinity of an outcrop of two rocks, Carrickduff and Carrickad, which are located approximately 0.65 nm to the west of the Black Rock. |
Altitude alert
Re altitude aural alert, above Carickduff,see location on google maps at this address 9C6F3M96+J4
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Originally Posted by gulliBell
(Post 9741161)
I'd like to read that page of text before I condemn the APBSS route guide map as utter rubbish.
With respect, there is an obvious inference to be made. Accepting that, it seems to be perfectly fine. It can't be adapted for something else than it was intended without careful considerations of other factors. Editing for further response to GulliBell and SASless below. If it is used for what it actually was intended to be used for, I don't dispute its approval by the Chief pilot or other company operations people. It's fine for that. The problem starts when "IAP" is imagined to attach to BLKMO. That's not approved. I expect that CHC will tell the investigators, or they already know, that the "route" this applies to is from the helipad at Black Rock to the helipad at Blacksod. Or in reverse. A route, after all, is from A to B. |
What is the history of that Route Guide?
When was it created, what technology was it based upon, how is it updated, how is the data checked for accuracy? Why was the current format chosen and has there been consideration in changing it to incorporate technology changes? |
Originally Posted by SASless
(Post 9741460)
What is the history of that Route Guide?
When was it created, what technology was it based upon, how is it updated, how is the data checked for accuracy? Why was the current format chosen and has there been consideration in changing it to incorporate technology changes? |
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