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-   -   SAR S-92 Missing Ireland (https://www.pprune.org/rotorheads/592162-sar-s-92-missing-ireland.html)

cncpc 15th Apr 2017 18:11


Originally Posted by Cows getting bigger (Post 9741444)
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.

No one did.

Dublinboy 15th Apr 2017 18:11

Hi probably out of my league here but been following the thread..this was so tragic and I'm like every one else just wondering how? From my limited experience ppl fixed wing .I have to ask the question if the chart provided as shown in the report shows the spot elevation as 282 at blckmo had the crew access to this prior or during the flight or just totally misread it?..it was there to be seen but maybe they had no access to it? Seems very strange ...also I think some else already mentioned it looks to me like it was intended only for the lighthouse to lighthouse route guide and It was never intended to be used outside the range that it covers

Al-bert 15th Apr 2017 18:16

GKaplan

I suppose an alert "Height, Height" doesn't do as well phonetically!
what's wrong with 'CHECK HEIGHT' 'CHECK HEIGHT' for radalt bug? Always grabbed my attention!

oleary 15th Apr 2017 18:32

.... what Woolf said
 

Originally Posted by Woolf (Post 9741140)
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 crewmemberís responsibility to monitor and constantly verbally update the obstacle situation as seen on the radar. Although I know nothing of CHCís procedures I would assume that this is SOP, especially for SAR.

Everyone makes mistakes, Iíve 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. Iím sure there is much to learn here.

For donkey's years we did exactly what Woolf describes but in two-crew cockpits (non SAR) using much more primitive equipment - because it worked.

Search&Rescue 15th Apr 2017 18:34


Originally Posted by Woolf (Post 9741140)
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 crewmemberís responsibility to monitor and constantly verbally update the obstacle situation as seen on the radar. Although I know nothing of CHCís procedures I would assume that this is SOP, especially for SAR.

Everyone makes mistakes, Iíve 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. Iím sure there is much to learn here.

Well said Woolf!

GKaplan 15th Apr 2017 19:08


Originally Posted by Al-bert (Post 9741484)
GKaplan

what's wrong with 'CHECK HEIGHT' 'CHECK HEIGHT' for radalt bug? Always grabbed my attention!

Nothing wrong with "CHECK HEIGHT".

Just answering gulliBell's question about the S92 :)

catch21 15th Apr 2017 20:00

Regarding section 3.5.8 of the report, Operator's Route Guide, I would suggest two things:

APBSS, as shown, is a two-way route between Black Rock and Blacksod helipads because leg 5, BLKSD -> BKSDB is shown as an outbound leg from Blacksod, and legs 2/6 & 1/7 (BKSDB <-> BKSDA & BKSDA <-> BLKMO) are shown as two-way legs to and from Black Rock.

Also that footnote 16 on the same page, APBSS: The Operator informed the Investigation that APBSS stands for 'Approach Blacksod South' is very much worthy of further scrutiny.

Twenty2B 15th Apr 2017 20:57

Way points and rocks
 
Notwithstanding all the factors involved here, my intuition says that it's not sensible to set large obstacles as way points in an otherwise empty sea. I recall a Greek ferry disaster where prominent rocks near a port where used as a waypoint, the autopilot performing a fantastic job of guiding the vessel to that very point (with equally tragic consequences).

MagentaL 15th Apr 2017 21:00

Why would the operator provide their S92 crews with a route between two helipads, one of which is unsuitable for an S92, and then call the route 'Approach Blacksod South'. It seems to me it was most definitely intended as an approach route to Blacksod.

llamaman 15th Apr 2017 21:24


Originally Posted by catch21 (Post 9741569)
Regarding section 3.5.8 of the report, Operator's Route Guide, I would suggest two things:

APBSS, as shown, is a two-way route between Black Rock and Blacksod helipads because leg 5, BLKSD -> BKSDB is shown as an outbound leg from Blacksod, and legs 2/6 & 1/7 (BKSDB <-> BKSDA & BKSDA <-> BLKMO) are shown as two-way legs to and from Black Rock.

Also that footnote 16 on the same page, APBSS: The Operator informed the Investigation that APBSS stands for 'Approach Blacksod South' is very much worthy of further scrutiny.

To my mind that 'Operator's Route Guide' illustrated in the report looks very much like a VFR approach/departure chart. Not an instrument let-down procedure. Any thoughts?

SASless 15th Apr 2017 21:26

Greek Ferries run at the same height as those Rocks......Helicopters oddly enough are supposed to operate well above the Rocks. Point taken but Instrument Approaches ashore seem to work fine if that basic rule is followed.

What would be an acceptable offset from the hard bits?

How would you choose where to locate that Offset Point?

gulliBell 15th Apr 2017 21:26


Originally Posted by cncpc (Post 9741458)
As a starting point, what do you infer the "route" to be?

I don't know what the route was, because the CVR transcript of the approach brief wasn't in the report.

gulliBell 15th Apr 2017 21:40


Originally Posted by GKaplan (Post 9741405)
Barometric altitude bug: when the a/c descends below the preset altitude you get a "MINIMUMS, MINIMUMS" aural alert. I suppose that makes sense as the minimums used for normal instrument approaches are altitudes (DA, MDA).

When the a/c descends below the RADALT bug, you get an "ALTITUDE, ALTITUDE" aural alert.

This is the behaviour in the S92? What I'm familiar with, in a non-SAR Honeywell cockpit, when you arrive at, descend below, or climb above a preset altitude you just get a single beep and a visual warning. When you descend below a bugged radalt height you just get a light on the analog radalt display with no aural warning, or when you descend towards a set DH, which is referenced to the radalt (and not barometric altitude), you get MINIMA MINIMA aural warning, and a visual warning.

G0ULI 15th Apr 2017 21:41

Having read all the posts and the accident report, two things seem to point towards a crew that were perhaps a bit too relaxed and complacent. Mention is made that there was very little conversation being carried on in the aircraft other than for operational reasons and secondly the pilot taking four seconds to question the instructions from the rear crew member warning of an obstruction ahead, then using the autopilot heading change to alter course.

I appreciate that scud running at 200 feet in the dark is no place to be suddenly taking manual control and flying a violent evasive manoeuvre without warning.

But I am struck by how laid back the crew were, especially considering that neither pilot had operated into that area for some time and there is no mention in the report of briefing for possible hazards on the approach or a missed approach procedure. That would surely have been mentioned even at this early stage of the investigation.

Do we end up with a fully fitted out SAR helicopter involved in CFIT due to complacency, or is there some deeper fault with the system that goes beyond having maps that showed different and insufficient details of hazards depending on the scale selected.

gulliBell 15th Apr 2017 21:44


Originally Posted by llamaman (Post 9741634)
To my mind that 'Operator's Route Guide' illustrated in the report looks very much like a VFR approach/departure chart. Not an IMC let-down procedure. Any thoughts?

Why would it appear in the Operator S92 flight documents as a VFR approach/departure procedure if the S92 is too big to operate from Blackrock helipad? It might be a weird depiction of an IMC let-down procedure, depends on what the accompanying notes on page 2 says.

gulliBell 15th Apr 2017 21:59


Originally Posted by G0ULI (Post 9741655)
...and secondly the pilot taking four seconds to question the instructions from the rear crew member warning of an obstruction ahead, then using the autopilot heading change to alter course.

This is the classic characterisation of a "magenta pilot" (refer to a few pages earlier in that AA training video).


Originally Posted by G0ULI (Post 9741655)
I appreciate that scud running at 200 feet in the dark is no place to be suddenly taking manual control and flying a violent evasive manoeuvre without warning.
.

A manually flown, immediate and affirmative evasive manoeuvre was required by either pilot in this instance the moment the rear crew obstacle warning was understood. Instead of 6+ seconds flying straight and level on an autopilot HDG coupled mode at a rock. The CRM evident in issuing the warning, and then responding to it, was too complacent. I think in Human Factors training they call this a "laissez faire" type crew.

IRCG SMC WHITEY 15th Apr 2017 22:00

The more I look at the Operator's Route Guide, it looks like it may have been "adapted" from a CIL plate for supply/maintainence purposes.
The rocks bearing 280 degrees 1.32km, from Blackrock Lighthouse, are known as Carrickaduff, the northwesterly (145mrs long, height unknown) one is the bulkier of the two.

cncpc 15th Apr 2017 22:13


Originally Posted by llamaman (Post 9741634)
To my mind that 'Operator's Route Guide' illustrated in the report looks very much like a VFR approach/departure chart. Not an instrument let-down procedure. Any thoughts?

Those are my thoughts. Other than it is based on an aircraft departing the Black Rock helipad.

Just above, someone in the know of the history suggests it does come from a previous operators procedure in supply maintenance flights. There was a poster on here who used to fly the B-105 into Black Rock, perhaps he can shed some light.

There was a post above challenging the point to point mostly VFR nature of this route because if an S92 can't go there, why is it in the guide for that aircraft? I've never seen a route guide that was aircraft specific, rather than company specific, but...could be.

Mark Six 15th Apr 2017 22:14

Several posters keep insisting the Route Guide was some kind of woefully inadequate IMC letdown procedure or instrument approach plate. I believe you're giving it a status it doesn't deserve, and then criticising the designer, management, etc based on your own misinterpretation of its purpose. The IMC letdown had already been achieved prior to commencing the route shown on the diagram. No doubt the company has night/IMC overwater letdown procedures which presumably is what the crew followed prior to routing towards Blackrock. According to the report,

"The Commander's stated intent was to complete the APP1 procedure prior to turning east towards waypoint BLKMO to commence the arrival route to Blacksod Lighthouse."
The APP1 procedure was the descent to 200'.

SASless 15th Apr 2017 22:22

We also have pondered why being at 200 feet AGL with 10 Miles to run to Blacksod, with no NVG's in very marginal weather at Night was thought safer than utilizing the full capabilities of the aircraft to complete a pre-planned, surveyed, trained, and checked IMC procedure.

That...is a very fair question to ask Management.


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