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

[email protected] 23rd Apr 2017 08:52

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.

Emerald Islander 23rd Apr 2017 09:50

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?

212man 23rd Apr 2017 10:05

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

SASless 23rd Apr 2017 11:15


Originally Posted by 212man (Post 9749751)
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?

212man 23rd Apr 2017 12:11


Originally Posted by SASless (Post 9749808)
A fellow named Jeppensen showed us the way!

Ever use his?

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

SASless 23rd Apr 2017 12:58

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?

Pltnorway 23rd Apr 2017 14:43


Originally Posted by cncpc (Post 9749482)
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.

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


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.
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.


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.
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.

SASless 23rd Apr 2017 15:03

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?

cncpc 23rd Apr 2017 15:16


Originally Posted by [email protected] (Post 9749689)
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.

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

First time in, entered that procedure at BKSDC.

cncpc 23rd Apr 2017 15:42


Originally Posted by SASless (Post 9749960)
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?

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.

Tezzer 007 23rd Apr 2017 18:59


Originally Posted by gulliBell (Post 9749445)
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.

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.

BluSdUp 23rd Apr 2017 20:20

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.

SASless 23rd Apr 2017 20:27


Originally Posted by cncpc (Post 9749990)
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.



But no mention by the Crew of seeing any lights.

llamaman 23rd Apr 2017 21:04


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.
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.

rotorspeed 23rd Apr 2017 21:06

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?

Red5ive 23rd Apr 2017 21:08


Underwater searches fail to show up any trace of missing crew men
https://www.rte.ie/news/2017/0423/86...ckrock-island/


search for airmen brings 180 divers to crash site
https://www.irishtimes.com/news/irel...site-1.3058178

[email protected] 23rd Apr 2017 21:10

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.

Geoffersincornwall 23rd Apr 2017 21:16

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.

cncpc 23rd Apr 2017 21:17


Originally Posted by SASless (Post 9750210)
But no mention by the Crew of seeing any lights.

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.

cncpc 23rd Apr 2017 21:26


Originally Posted by Geoffersincornwall (Post 9750236)
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.

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.


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