No one did.

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

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

.... what Woolf said
 

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.

Well said Woolf!

Nothing wrong with "CHECK HEIGHT".

Just answering gulliBell's question about the S92 :)

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.

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).

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.

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?

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?

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

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.

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.

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.

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

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.

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.

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.

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'.

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.