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Exactly Crab, all far too slow.
But although all the chat about NVGs, IR and radar is certainly interesting, it just need not have been a critical issue, because the aircraft should never have been where it was – 10 miles from (and beyond) the destination at 200ft on a misty, low cloud night. And to have intended to transit like this for 10 miles was just so unnecessary. Why on earth did this crew not just do a let down from the north east to a point say 2nm north east of Blacksod, in the middle of a 4nm wide and 5 nm long bay – and one surrounded by low elevation terrain? They would have been nicely into wind with a ground speed of 60 knots or so and would have got visual with the Blacksod lighthouse and even scattered housing by 300ft I’m pretty sure. And by all means use the radar and IR to verify their position, but with it only being important for a mile or two - not 10. Again, can anyone say how the sister S92 R118 from Sligo got into Blacksod to refuel? Many must know. But I can’t believe it was the way R116 tried to. |
Rotorspeed - exactly the problem we have all grappled with - you have a very capable helicopter yet you choose to follow a legacy procedure from S-61 days instead of a far more efficient in-aircraft letdown far closer to the intended landing point.
I get the idea of using the PM to make inputs to the AFCS but, as 212man states, how does that work when he is supposed to be monitoring? Some confusion arises when you ask the PM to select an autopilot function - ALTA, HDG, TAS - good CRM but does it cross the boundary of PF/PM? Personally I don't have a problem with it but I don't do commercial SAR. |
Originally Posted by llamaman
(Post 11017668)
I'm not entirely convinced by that argument Scattercat. You best derive Situational Awareness from your most effective inputs at that time. It could be naked eye, or it might be the sensor that's currently working best for you (or a blended solution). All this has to be underpinned by good CRM and appropriate procedures otherwise you are permanently on the back foot.
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ECA criticism
Very strong criticism from the European Cockpit Association. From an article in today’s Times...
ECA President, Captain Otjan de Bruijn, said that it is “an extremely long delay for publishing a report” and that during these 4 years “possible safety-critical flaws have remained unaddressed - something we are quite alarmed about.......any deficiencies that have been identified in the accident investigation must be made public, out in the open so that they can be fixed swiftly”. This next bit is particularly damning..... “We are not aware of any other similar cases across Europe of a re-examination of the technical work of an independent technically qualified organisation by a body with limited expertise in aviation accident investigations. This rare procedure(the appointment of a review board) could be a slippery slope allowing for undue influence over the investigation process and its findings, and clearly has resulted in an unhelpful delay in publication of the report”. |
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It's been 4.5 years since the crash and over 20 months since the draft was circulated privately and then the unprecedented challenge and review system was begun.
Will this report ever see the light of day? It's a smack in the face to any sort of real fact finding safety system. |
Brexit and/or Covid covers most things here at the moment.
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Too many parties have a vested interest in this report never seeing the light of day I am lead to believe. All very 3rd world and the aviation community is the poorer for that.
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It will make a great topic for review at the Operators own safety conference?
Safety & Quality Summit | CHC |
It is the race to the bottom as far as safety is concerned - we all know aviation is expensive and safe aviation is even more so but when money, reputations and the threat of litigation cloud the waters of an investigation - you have to ask of the operators and the Irish Govt - Why didn't you just do it properly instead of trying to save a few quid/euros?
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Would a FOI request to the relevant department not force the issue? It does seem like there is an attempt at deflecting blame/litigation at this point. Experts can be found and data can be analysed via this thing called the internet these days. The crash and physical investigation would have been completed back in 2017. The initial report was written end of 2019. The conflict of interest arose in 2020 but the data is available to be analysed at home/online.
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https://www.independent.ie/irish-new...-40875247.html
Review into R116 crash report ongoing one year after it startedA member of the Irish Coast Guard looks out towards a misty Achill as the search continues for Rescue 116 along Blacksod coastline, Co Mayo, in 2017. Photo: Steve Humphreys Catherine FeganSeptember 22 2021 02:30 AM A review into a report on the Rescue 116 helicopter crash is still continuing, more than a year after the process was formally announced. Four Irish Coast Guard crew members died when the helicopter crashed into Blackrock Island, off the north Mayo coast in 2017. After an extensive and lengthy inquiry, the Air Accident Investigation Unit’s (AAIU) draft final report was issued to interested parties in September 2019. In March last year, a review board was established to examine certain findings following a request from one of the parties subject to the investigation.The process results from a claim by the party in question that the findings reflected adversely on their reputation.It is the first time that a review has been carried out into an AAIU inquiry. The Review Board, chaired by Senior Counsel Patrick McCann, has been established in line with Regulation 16 of Air Navigation Regulations 2009. The regulations provide that on completion of the re-examination, the Chairperson of the Review Board makes a report to the Minister for Transport. It is understood that the Minister has not received the report from Mr McCann to date. Last October it emerged that a key member of the team reviewing the report resigned due to a conflict of interest. The resignation of Phillip Hanson, a senior manager at the UK Coastguard, and the technical expert on the two-man review team, came after Mr Hanson disclosed that he had a personal connection with a senior manager at the helicopter operator, CHC. That manager was due to give evidence on behalf of CHC to the review board. This week, a spokesperson for the Department of Transport said the review was entirely independent and that it was a matter for the chairman to determine how the process would be carried out and how long it would take to complete. The bodies of Captain Dara Fitzpatrick and Captain Mark Duffy were recovered in the days following the tragedy. The remains of their colleagues, winch operator Paul Ormsby and winch man Ciarán Smith, remain lost at sea. Their helicopter had been dispatched to provide assistance to another helicopter, Rescue 118, that was retrieving an injured fisherman from a trawler in the Atlantic.The inquest into the deaths of the crew cannot be finalised until the AAIU report is published The law governing air accident investigations allows any person or organisation to seek a re-examination of “any findings and conclusions” that appear to “reflect adversely” on their reputation. However, this is the first time for an AAIU report to be referred to a review board in the AAIU’s 25-year history, during which it has carried out nearly 1,000 investigations. AAIU inquiries are protected by highly restrictive legislation that makes it a criminal offence to reveal details prior to official publication of an air accident investigation report. |
I can't post any links but there was a number of articles posted last week, looks like the report should be published shortly.
""The 333-page AAIU draft report took more than two years to compile and was completed in late 2019. Publication, which was delayed until the Review Board completed its work, is expected shortly, once the AAIU has incorporated changes recommended by the Review Board." |
The final report is due to be published tomorrow. The RTE Prime Time current affairs programme this evening gave a preview, with errors in multiple mapping systems highlighted. This was presented as meaning that the absence of the island and lighthouse from multiple sources reinforced a belief by the crew that there were no obstacles in their path. Deficiencies in the helicopter operator's safety management systems and the regulator's oversight of same also appear to be covered in the report.
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R116 report to question whether mission was necessary https://www.rte.ie/news/primetime/20...gation-report/ |
LATEST Actions of crew who died in R116 helicopter tragedy were not a factor in cras
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Final Report: Accident involving a Sikorsky S-92A Helicopter, registration EI-ICR, at Black Rock, Co. Mayo, Ireland, on 14 March 2017. Report No: 2021-008 SYNOPSIS A Sikorsky S-92A helicopter, registration EI-ICR (call sign Rescue 116), which was being operated by a private operator on behalf of the Irish Coast Guard (IRCG), was en route from Dublin, on Ireland’s east coast, to Blacksod, Co. Mayo, on Ireland’s west coast. The Flight Crew’s intention was to refuel at Blacksod before proceeding, as tasked, to provide Top Cover for another of the Operator’s helicopters, which had been tasked to airlift a casualty from a fishing vessel, situated approximately 140 nautical miles off the west coast of Ireland. At 00.46 hrs, on 14 March 2017, while positioning for an approach to Blacksod from the west, the Helicopter, which was flying at 200 feet above the sea, collided with terrain at the western end of Black Rock, departed from controlled flight, and impacted with the sea. During the immediate search and rescue response, the Commander was found in the sea to the south-east of Black Rock and was later pronounced dead. Subsequently, the main wreckage of the Helicopter was found close to the south-eastern tip of Black Rock, on the seabed at a depth of approximately 40 metres. The deceased Co-pilot was located within the cockpit section of the wreckage and was recovered by naval service divers. Extensive surface and underwater searches were conducted; however, the two Rear Crew members were not located and remain lost at sea. Forty two Safety Recommendations are made as a result of this Investigation. |
Ploughing through it now. It would be interesting to know how much attention the investigators gave to the postings here. E.g. I see this topic being directly referenced https://www.pprune.org/rotorheads/592162-sar-s-92-missing-ireland.html#post9744317
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Despite all the contributory factors, there is no doubt in my mind that, had they been wearing NVG, they would not have hit the island.
With NVG, the pilots would have seen the terrain (Dara herself mentioned being visual with the sea surface and that was unaided night vision) and made the avoiding turn early - and probably manually - rather than utilising the heading bug on the AP after confirming with the rearcrew about the need to change course. That was a delay that cost them their lives. |
Originally Posted by [email protected]
(Post 11137806)
Despite all the contributory factors, there is no doubt in my mind that, had they been wearing NVG, they would not have hit the island.
With NVG, the pilots would have seen the terrain (Dara herself mentioned being visual with the sea surface and that was unaided night vision) and made the avoiding turn early - and probably manually - rather than utilising the heading bug on the AP after confirming with the rearcrew about the need to change course. That was a delay that cost them their lives. |
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