Thanks Crab ... I was reading too much into it.

While the flexibility offered by multiple MFDs is great, it does mean that the crew have to consider their setup for each phase and for each crew role. Perhaps rather than be "information" orientated display menu options should be "task" or "role" orientated at the first level.

Absolutely! Concerning Radar, the scale, tilt and gain settings are the key issues when flying at low level in poor VMC or IMC weather conditions...

Broader Perspective
 

Looking at Icao annex 13 and EASA Reg 996/2010, as professional aviator, the use of CVR/FDR, in the interim report, raises serious questions on how the actual just culture / non punitive concept for the utilisation of these systems was envisaged.
The caveat envisaged in Art 14 of the regulations must not used lightly, in prior cases for both fixed wing and helicopter, we have seen data being used well outside the boundaries of agreed protocols.
We all need to discuss the broader implications and trends, both planning / operationally / commercially and most important legally.

Even the AAIU website states this protocol.

http://www.aaiu.ie/guidance-documentation

"RECORDERS
The AAIU will retrieve the Cockpit Voice Recorder (CVR), the Flight Data Recorder (FDR) and any other recorded information that is available and pertinent to the operation of the flight. Once within the jurisdiction of the AAIU, the recorded material will be confidential to the investigation, however, the affected flight crew may, under the supervision of the AAIU, listen to the CVR."

http://www.skybrary.aero/index.php/Regulation_996/2010_on_the_investigation_and_prevention_of_accidents_and_in cidents_in_civil_aviation


"Protection of Sensitive Safety Information
Article 14 of the Regulation establishes a list of records that shall not be made available or used for purposes other than safety investigation, such as:
identity of persons who have given evidence;
opinions and notes of investigators;
draft reports;
FDR data;
cockpit voice and image recordings, and their transcripts;
written or electronic recordings and transcriptions of recordings from air traffic control units;
occurrence reports filed under Directive 2003/42/EC, etc.
However, it is recognised that the administration of justice or the competent authority in a EU Member State may decide on the disclosure of records according to national law. Member States are invited to limit the cases in which such a decision of disclosure may be taken.
Communication of Information
Article 15 of the Regulation stipulates that:
the anonymity of those involved in an accident or incident shall be protected;
information, deemed relevant to the prevention of accidents and incident, shall be communicated to aircraft (and equipment) manufacturers, maintenance organisations, aircraft operators and training organisations;
EASA and national civil aviation authorities receive relevant factual information obtained during the safety investigation, except information referred to in Article 14(1);
victims and their relatives or their associations or public are appropriately informed without compromising the objectives of the safety investigation."

Flight Planning and FMS
 

Hi, I'm a long term reader but first time poster. I've been enthralled by the depth of knowledge of the posters. Like most, I cant understand how the event took place. It makes no sense.

Why didn't they route to Sligo ? They must have known the Blacksod weather from the ground staff by the time they reached Knock.

The requirement to use of Blacksod for this mission is questionable. The FV was only 195nm from Sligo. The S92 was claimed by IRCG to have a range of 800nm with 2 aux tanks, or is this fiction. Could any S92 operator comment.

Also how difficult is it for the PIC in the right hand seat to program the single FMS CDU located on the left seat co-plot side of the center console.

How would they have planned the flight. Would they use charts or is everything in the FMS.and the map display and Ipads these days.

thanks

EI

Thanks for the link GB - but you had specifically mentioned a Honeywell training video. Is this training video you refer to on the internet or something in house? Thanks

ZFD

The regulations regarding the use of CVR and FDR equipment were framed around a need to secure agreement from pilot's unions to allow such equipment to be fitted and used.

Under British law and perhaps the law of other nations, the deceased technically have no rights. You cannot commit slander or libel against someone who is dead, for example. Also the laws protecting personal privacy no longer apply. There are some caveats however where the deceased may have living relatives who would be affected by any such revelations, because naturally they are still subject to the protections the law allows. It is a rather grey area at times.

In this particular incident, we have a bit of a nonsense where the crew are identified in the popular press, but the accident report goes to great lengths to avoid mentioning or identifying any of the crew members, when this information is already in the public domain. That is completely in accordance with the regulations and quite correct for the accident investigators to do so.

The CVR transcript excerpts in this incident are extremely relevant in helping to come to certain conclusions as to how and why this accident happened. They give a very clear indication as to what was going on in the aircraft as it neared Black Rock and in combination with other information relating to the navigation data the crew were using, it is possible to formulate procedures to ensure that such an accident does not happen again.

At the very least it is a wake up call to all operators to check the accuracy and appropriateness of the navigation data and let down approach charts in use.

National governments are given the ultimate decision over whether it is appropriate to use or release CVR data, and such is the importance of the circumstances under which this accident happened, the Irish government have clearly decided it is appropriate.

Certain weaknesses have been identified in which the way that radar data is presented on MFD screens and the possibility that vital information can be suppressed or overwritten has been highlighted as a potential problem.

The purpose of air accident reports is to prevent a recurrance of a similar accident. If it saves just a single life, then this report has done its job regardless of pilots personal sensitivities over the use of CVR or FDR data.

Emerald Islander

If you care to read through the thread, there are many contributions from people who are or were involved in SAR that explain the how and why it might have happened.

Essentially the crew were mislead by an approach chart that did not highlight the danger presented by Black Rock. Radar information that might have revealed the hazard at an earlier stage appears to have been overwritten by other data on the multi function display. Basically, they didn't see Black Rock or appreciate the danger it presented until it was too late.

Personally I believe that the crew probably regarded this as nothing more than a bit of a mundane training mission to the West Coast from Dublin. Their job was to act as a radio relay for another aircraft further out in the Atlantic. No real excitement to be had and the weather was fairly horrible with cloud almost down to sea level. Early hours of the morning, no one was right on top of their game. So the little hints that things weren't quite going to plan got missed. Simple as that really.

The helicopter was equipped with everything needed to allow safe flight in pretty much any conditions, so bad weather in and of itself would not cause the crew any problems.

Read through the whole thread and the accident report and come to your own conclusions.

CVR Transcript

The extract of the CVR transcript that was published in the preliminary accident report was done so in accordance with protocols, yes? The protocols protect cockpit voice recordings and their transcripts not relevant to the safety investigation from being published; I assume therefore the stuff considered relevant can be published. Which is why only the context of the recording from the initiation of the flight, up to the safety relevant part, was summarized, and everything after that, which was safety relevant, was published. I thought a transcript of the approach brief may also have been relevant to safety investigation, but this was not published.

Essentially the crew were mislead, by their own assumption, by an approach chart that was not an approach chart applicable for what they were doing. The approach chart they were using was a route guide intended for visual manoeuvre, not an approach chart with vertical and lateral profiles that would establish them clear of obstacles for when they were not visual. As far as we know, the danger of Blackrock was not specifically highlighted in the route guide, other than its spot height appearing on the chart.

gulliBell

I agree that more specific detail of the approach brief would have been useful. It is possible that there were deficiencies in the approach brief, which could imply the assignment of blame if mentioned. For example we know that the height of Black Rock is mentioned on page 2 of the approach document, but did the crew read that? It also appears on the chart, but was possibly covered by other data on the MFD. Certainly the radar display appears as if it was compromised by other overlaid data.

We have identified an inadequate approach plate, flawed let down procedures, radar display being compromised by overlay data, do we really need to go much further than that?

Sorry our posts crossed, but I think we are in agreement.

When I'm doing IFR checks on crews in the simulator, I can be 95% assured of the final outcome just by listening to the crew approach brief. Which is why a transcript of the crew brief in this instance might provide some additional insight, but I suspect we won't see any more transcripts of the CVR recording appearing in the final report.

With respect, no, not as simple as that.

The "what happened" is very simple, you can boil it down to a single sentence. They flew into a lighthouse outpost at night they didn't know was there.

The "why it happened" has no simple explanation. That will take many pages of detailed analysis covering all technical, operational, historical, and human factors aspects. They AAIB did a good job of the preliminary report. The final report is likely to be a very substantial document and will uncover the "why it happened" question.

I was referring to GOULI's analysis summary, some of which you have already correctly commented on.

Referring to that drawing as an "...approach plate" perpetuates the myth that took the crew in to the trap. An approach plate is taken to mean a drawing and annotations that appears on a single page and contains every bit of information necessary to safely accomplish an approach to a landing area in instrument conditions. It describes a rule bound process to complete a thoroughly validated procedure to land in conditions of no or uncertain visibility down to DH or MAP. There is no page 2. You pull the page from your chart book, put it into the clip, and brief it and fly it. I have never done an approach briefing before the approach chart was in the yoke clip and on both sides. There was not a second page ever discussed in any briefing. Or is it displayed electronically? Whatever, if it is an approach plate, everything you need to know is on that one piece of paper.

GOULI makes a good point about not only the radar return, but the spot height on the drawing being obscured by the waypoint symbol. From that, we are assuming that this chart was on the PF's MFD. No paper chart. The report says this "approach" was selected in the FMS. Does that result in the chart coming onto the MFD, or both MFD's for the briefing? If it's all canned and activated after the letdown, then it automatically shows the waypoint symbol as the goto waypoint.

The letdown procedure was not flawed. It was completed a few miles from Blackrock. The flaw was in the belief that once completed, the hookup to BLKMO and on to Blacksod could be accomplished at 200 feet. The procedure was meant for a helicopter starting from the pad at Blackrock. It would have been easily adaptable to an IFR procedure with vertical guidance added. But it wasn't. It does seem to be the only option for an IFR approach to Blacksod, but this crew was in a VFR procedure.

The root cause of this accident may well be found to lie in CHC and how any document in the route guide comes into existence and placed in an aircraft where crews may rely on it, and how in Ireland, such a document does not require regulator approval. If it does, and was approved, then that becomes a root cause question.

It takes less than four hours to draw up a proper approach chart for Blacksod. The IAF is BKSDA, the PT is right at 2000, down to 1000, down to 200, set an MDA and a MAP by Blacksod, and lay out the missed. Check the sector clearances on the way in all the way to the edges, fly it, publish it.

This thread never happens.

Well said cncpc. Was about to submit an almost identical post to yours.

Yes, well said, and I agree with all of it. An IFR qualified pilot would have instantly recognized the route guide was not an approach procedure for use under IMC, and they wouldn't have been suckered into using it until VMC was established. The crew were clearly operating in VFR mode, in the mistaken belief they were VMC, when in actual fact the visibility was much less than that required for VMC. They didn't know, but should have known, BLKMO had a lighthouse parked on it, whatever height it was, because they should have been expecting to see it from 5nm to confirm that VMC prevailed. I don't know on what basis they formed the opinion they were VMC and clear to proceed on the route guide.

The irony is that an ad-hoc SAR letdown to a rescue in the vicinity of Blacksod would have been completed much nearer to the intended destination, would not have required an extensive crew brief or the use of approach plates and would have been much safer.

Back to the company procedures that were not fit for purpose......

Wouldn't you think that was what R118 actually did 90 minutes later, Crab?

I agree that ad-hoc SAR ARA letdown is sometimes the simpliest way to reach the destination, but here... with all respect Crab, we can't blame the routing that much... I can only refer the Preliminary Report 3.5.8. Operator's Route Guide. If the pilots read and understood the guidance and had flown the vertical profile accordingly, there shouldn't have been problems. Operator's Route Guide gives the hight of Blackrock 310 ft. It is on pilot's discretion how (at what altitude/height) he/she is going to pass the waypoint BLKMO (it could have been 1300ft or even 2000ft AGL). Now, for some reason R116 had already descended to 200 ft RHT (AGL) when they still were west of the BLKMO waypoint... (Of course we don't know for sure, what kind of approach briefing they had in cockpit... VMC or IMC?)

cncpc
And what R118 did about 1hr 45mins earlier too. Same operator so same systems and approach information presumably?

cnpc and rotorspeed - yes and perhaps they flew a different approach because they were more familiar with the area and possibly knew the company approach had flaws in it.

It is possible 118 flew the same company arrival when they went for their refuel but I suspect they flew a much quicker SAR approach when they were tasked to search for 116.

AIS track for the 8th and 13/14th show R118 approached directly to BKSDC then on to BLKSD .

Returning from the FV at approx 02:10 on the 14th it routed directly to BLKMO then commenced SAR sweep to the south.

At approx 03:30 it headed north up past the Iniskea Islands turned East across the peninsula to BKSDC. then BLKSD.

R116 on the 8th abeam Slevemore turned north and tracked to BKSDC.then BLKSD.

Talk on another forum is of a APBSN North approach.

The AAIU report states " The Commander programmed the “APBSS (Blacksod South) Route”...into the FMS ".

One of my questions was to S92 pilots, how easy/difficult is this as PIC if the only CDU is on the co-pilots side?

It's a myth to say that all IFR approach plates are always on a single sheet.

A fellow named Jeppensen showed us the way!

Ever use his?

Yes - including some on two pages! Hence my remark.

Must be very rare.....as I have never seen one or used one.

Point here is the absence of any such "Plate" or Pre-planned IMC Approach for Blacksod....that if available and used.....would probably have prevented this tragedy.

Care to post an example of what you speak about?

Incorrect. On some Jeppesen approach plates, the copter minimas are on found on plate 10-9Y.

No it does not. It simply means that by selecting the APBSS approach on the FMS, the corresponding waypoints will be added to the flight plan of the FMS. The preliminary report even refers to the operators route guide, and the second text page. It is a paper chart.

You are making an assumption here. My assumption would definitely not be like yours. This is not a route from one helipad to another. It is a VFR arrival route from off the coast to Blacksod.

VFR....VMC......what was the situation that night for the route R-116 was trying to fly when it impacted Blackrock?

Was the aircraft VMC or IMC?

Was the operation (Offshore of Blackrock to Blacksod) being done VMC or IMC?

What were the conditions when R-118 made an approach and landing to refuel at Blacksod?

What were the conditions upon their return to search for R-116?

What did 118 do that 116 did not that allowed them to both Refuel and then later conduct a Search.....and complete both evolutions safely?

Emerald Islander confirms your view of what likely happened, Crab.

First time in, entered that procedure at BKSDC.

They must have believed they were VMC.

There are a couple of townlands, Glosh and Nakil, along a road running north south about 2.5 miles west of Blacksod up on a rise of land up to 150 feet ASL. About 50 or 60 houses. It may be that these were visible in the turn back eastbound, confirming that they were VMC, at least at that point. That high land would have obscured Blacksod light.

The report says they were on the warm side of a cold front running northeast to southwest and located at the time off the northern tip of Ireland.

Irish Aviation Authority use a red circle as the symbol for a lighthouse (with no text). The CAA use a blue circle with l'hse next to it.
So the red circle with 282 next to it was, in theory, all that was needed.

Jeppesen charts
 

I grew up with Jeppy plates and like them, now we have some other jazz that I that is not so good.
Anyway , Jeppesen flew mail routes in the States in the 30s and his fellow aviators saw him updating his personal notes in the bar and they liked it.
So he started compiling info and selling his notes for 10 dollar . The rest is history.

Having watched this thread I think the process is the same. Except Jeppesen knew what he was doing.
It has been pointed out before. Forget about the small idiotic details.The big picture is that there should be APPROVED IFR APPROACHES to these few places in Ireland.
The authorities and companies incompetence killed this crew.
Never mind that they were a mess.

75kts with a tailwind at 200 feet possibly IMC at night for a long distance heading for the coast.
Madness.

But no mention by the Crew of seeing any lights.

Sometimes it's the 'small idiotic details' that add up to create the big incident. It's overly simplistic to cast blame purely at the authorities and the company. I'm sure that issues will be found in areas across the board in this one.

If you view it as a systemic failure whereby the system incorporates all elements (including the crew) then that might help. It's all too tempting in such circumstances to look to blame an individual/individuals or organisation. It's rarely that simple.

One of the principles of SAR is that crews (unlike in commercial air transport) do not need to rely on 'approved IFR approaches' to get where they need to be going. This however relies on adequate training and sensible regulation/operating procedures. I feel that these areas will be of most interest to the investigators.

When there is a SAR task at night and the cloudbase is say lower than 500ft, can SAR crews perform the mission, and if so how, given there will be no published IFR approach to their target?

https://www.rte.ie/news/2017/0423/86...ckrock-island/

https://www.irishtimes.com/news/irel...site-1.3058178

Yes of course they can - SAR wouldn't be much use if the limit was a 500' cloudbase.

Go back to the early pages of the thread where I described how a SAR letdown is done. It can be done in zero visibility if required but only over water, not over land. Coastal counts as over water because that is where you let down and then close with the coast.

BluSdUp et al
 

Dmitri Victorovitch Zotov is the NZ based air accident investigator who created the eponymous 'Zotov Error Map', (ZEM).

This fascinating technique creates multiple timelines that track back from the moment an accident occurs. Each timeline represents the contribution made to the history of the accident and includes the crew, operator, manufacturer, national aviation authority, repair station, equipment suppliers, training organisations ... everyone who made the smallest contribution even if this was many years before the accident.

I learned about the ZEM thanks to working with an expert in SMS, Dr Steve Walters. I hope this technique is used by the accident investigators looking into this case because clearly there are issues about decisions taken by those other than the crew that appear to have had a material effect on the way this flight was conducted.

David Beaty's book 'The Naked Pilot' should be compulsory reading for all those assigned to the task of Pilot in Command. It will alert them to the tendency to find a convenient scapegoat in the pilot, especially if he or she is no longer around to defend their actions. Zotov helped the accident investigators by allowing everyone involved to be included in the analysis.

G.

No, no mention.

It's an assumption that the ceiling was a stratified uniform layer, but it may not have been. If they did see lights, it may have been before the CVR part released. If they expected to see them, they they may not have remarked when they did. Isn't the curvature of the earth rule 12 miles =1000 foot lower?

Or they may have seen nothing.

That is an excellent approach, but in order to be fully developed, it requires access to rather masssive amounts of information. Practically, only a national investigative agency would have the power and resources to do it. I have heard that the Canadian TSB does use timeline animation in some investigations however, but how many objects/layers are involved isn't known.

Unless one is predisposed to a bias towards the crew in this one, it is going to be difficult to hang this one the crew. Although, if they had a number of options, the choice of this one was very unfortunate. R118 utilized different options.