Rescue 116 Crash at Blackrock, Co Mayo(Mod note in post 1)

Negative_G

The lack of ownership of this issue is incredible.

Seems to be the case that between CHC, IAA & Honeywell, somebody dropped the ball big time.

The EGPWS issue had been flagged several times previously, and was raised during a meeting where two of the R116 victims were present.

I don't envy the job of the AAIU in investigating and producing this report. Every single word will be scrutinised by the legal eagles and while the purpose of accident reports is only to state facts and not attribute blame, its hard to see how the finger won't be pointed in this instance given what we know already.

There will be substantial legal implications and settlements based on the contents of the eventual report.

Irish Steve

Prime Time have highlighted a number of issues, which could prove to be controversial.

It would seem that CHC had been made aware of shortcomings in the database, as long ago as 2013, and specifically relating to Blackrock. While redacted, there were E-mail exchanges between the Sligo based crew and CHC management raising concerns about Blackrock, and its proximity to the Blacksod approach profile

The report then went on to highlight that under "normal" ICAO considerations, an obstacle below 90 metres would not be reported as an obstacle, but the suggestion was made by Prime Time that the 90 Mtr height criteria changes when an airport or similar is close by, which it clearly was in this case, which should have resulted in the addition of Blackrock into the database.

The IAA have prime responsibility for the database information that is provided to the systems providers, the report mentioned that there have been a number of meetings between CHC and IAA relating to problems with both missing and phantom items in the database, which has resulted in updates.

Specific mention was made this evening to another island off the West Coast, Skellig Michael was apparently in the database, but the only height reported was the height of the lighthouse, at somewhere (I think) around 200 Ft. As a result of representations relatively recently, a NOTAM to advise was issued, and the database and charts have now been updated to reflect that the actual height of the island is actually 715FT.

It would seem that there have been a number of glaring mistakes made by several organisations. If an obstacle below 90 Mtrs is not being included in the database, that (for me) makes that database as provided unsuitable for the very specific (and different) requirements of search and rescue operations, and on that basis, CHC should have been acting in concert with the systems provider to ensure that the very specialised additional requirements of SAR were added to the database to ensure that places like Blackrock were included in the database they were using, even more so given that concerns about Blackrock and it's position in relation to the Blacksod arrival route had been flagged in 2013.

It is totally realistic and appropriate for normal aviation use that objects below a specific height are not required to be present in the database, as no normal aircraft (fixed wing or rotary) should be operating at those levels. Unfortunately, that is very much NOT the case for Search and Rescue, and it is beginning to look very much as if a significant number of potentially dangerous obstacles are not contained within the database that is on the S92 aircraft.

A number of questions were not answered on the basis that the investigation of the R116 accident is ongoing, hopefully the final report from the AAIU will be able to make full reference to the issues that are clearly a massive contributor to the accident that resulted in the loss of R116.

homerjay2005

this is a stand out point for me -

RTPrime Time have revealed there was numerous emails sent between Sligo base Coast Guard pilots and a senior CHC manager regarding Black Rock Island in 2013.
The emails highlighted the absence of Black Rock and stated it was a safety concern as the 282 foot island was on the route approved by the company for approaching the refuelling base at Blacksod Bay from the South.

surely, at least crews were made aware of this? if not, there are even more serious questions here than a software problem.

this also makes an organisation, who have a €500m contract, look like a bunch of complete imbiciles -

The official Aviation Authority aeronautical map had previously indicated that Skellig Michael was just 174 feet.
This was the height of the lighthouse, not the island's highest point.
The Authority alerted pilots immediately and issued a new map last month which increased Skellig Michael to its actual height of 712ft.

if it wasnt so tragic, if would be funny. but its not and its a complete shambles and the families of the victimes, must be really fuming at what was allowed to happen. it was all so avoidable.

lucernarian

The IALPA has released a statement about this, which is very critical of the IAA among others.

The IAA has a responded with a statement that manages to be somewhat patronising, self-congratulatory and unapologetic all at the same time. It's not very classy or impressive on their part.

Edit: included quote

We note IALPA’s view. However, this is not shared by anybody in the industry, specifically the international organisations that continuously audit Ireland’s safety oversight regime.

FrancieBrady

homerjay2005 wrote: »

the families of the victimes, must be really fuming at what was allowed to happen. it was all so avoidable.

'Fuming'? They must be sick to their stomachs and completely bereft at how pointless and avoidable this was.

A genuine tragedy.

Storm 10

It's a terrible tragedy that should never have happened, it beggars belief that those brave Coastguard crews were operating around the Coast in poor weather conditions with equipment that had not been updated with the correct height of offshore obstacles. Thoughts and prayers with the crew and their families.

kippy

This is a disgrace by any standard.

Comhrá

Who'll be first to wheel out the pathetic 'systems failure' excuse?

It should appear some time later today or tomorrow at the latest.

adam88

HAS anyone found out if the height that the chopper was at was the height that the approach should have been at. I understand that they wanted to break cloud over sea and not land but was the approach not a gradual let down. Sorry don't have the lingo

Also had it been the case that it had been Shannon or Sligo then I presumed they'd have known that the rock was in their way. Was it that 116 wasn't aware of it from lack of local knowledge

Atlantic Dawn

Out of interest what costs and work would be involved in adding new hazards to the EGPWS system? It seems a straightforward task yet looks like the companies involved didn't want to complete the task for whatever reason.

smurfjed

The EGPWS issue had been flagged several times previously, and was raised during a meeting where two of the R116 victims were present.

Was this EGPWS issue specific to Blackrock?

Negative_G

smurfjed wrote: »

Was this EGPWS issue specific to Blackrock?

In short, no.

Under an FOI Prime Time discovered that a chain of emails between Sligo pilots and a senior CHC manager specifically referring to the absence of Black Rock from the EGPWS database. These emails were from June/July 2013. A test flight had shown that Blackrock did not exist on the database. This was communicated to management.

There was also an issue of "phantom obstacles" on the east coast. Two of the R116 crew were present at a meeting in Nov 2016 when this was discussed. The prime time report did not refer to Blackrock in this case. The issue was apparently addressed and the minutes indicated that the matter was closed.

Obviously the issue on the east coast was addressed while the lack of Blackrock in the database was not addressed.

I wonder was there any internal safety circular issued by CHC to all pilots and crew at all bases. You would think that such an obstacle, and the lack of it in a EGPWS database on a company approach procedure for Blacksod would have warranted a safety circular while the matter was being addressed.

Tenger

lucernarian wrote: »

The IALPA has released a statement about this, which is very critical of the IAA among others.

The IAA has a responded with a statement that manages to be somewhat patronising, self-congratulatory and unapologetic all at the same time. It's not very classy or impressive on their part.

Thats a pretty disgusting response from the IAA.

Gadgetman496

Fresh searches are to take place off Blackrock Island in Co Mayo this weekend, as the investigation into the crash of a Coast Guard rescue helicopter last March continues.


LINK:

smurfjed

If CHC and the crew knew about the lack of Blackrock in the database, why didn't they have hand drawn approach plates / briefing notes for this refuelling station?

Gaoth Laidir

smurfjed wrote: »

If CHC and the crew knew about the lack of Blackrock in the database, why didn't they have hand drawn approach plates / briefing notes for this refuelling station?

Just what I was about to ask. If a problem/omission is known by some crew, why isn't it made known to all crews?

cabledude

Atlantic Dawn wrote: »

Out of interest what costs and work would be involved in adding new hazards to the EGPWS system? It seems a straightforward task yet looks like the companies involved didn't want to complete the task for whatever reason.

Surely a budget for such upgrades could be found in a contract of 50m per year.

markpb

cabledude wrote: »

Surely a budget for such upgrades could be found in a contract of 50m per year.

People keep mentioned the cost of this contract as if it's colossal money but I'm not sure if any of them (myself included) are clear on what it covers so we're in no position to know how far it goes. €50m per year sounds like a lot to me but I guess if I had to build a multi-million euro hanger at Dublin airport, buy several helicopters at an average price of $200m each, fuel and maintain those helicopters, pay for staff to fly (possibly?) and maintain the helicopters 24/7 and whatever else might be covered by the contract, it might seem like good value.

Storm 10

markpb wrote: »

People keep mentioned the cost of this contract as if it's colossal money but I'm not sure if any of them (myself included) are clear on what it covers so we're in no position to know how far it goes. €50m per year sounds like a lot to me but I guess if I had to build a multi-million euro hanger at Dublin airport, buy several helicopters at an average price of $200m each, fuel and maintain those helicopters, pay for staff to fly (possibly?) and maintain the helicopters 24/7 and whatever else might be covered by the contract, it might seem like good value.

All the flying crews and maintenance crews are employed by CHC

Bazzy

The one thing thats stood out to me about the whole thing is that the professionals Rte news and primetime) keep pointing out that the coast guard is the only one who does this type of flying

It really highlights what they do every time they go out I really hope i'll never need them and I mean that in the best possible way

i hope the search proves successful this weekend

Oscar Bravo

This Saturday a focused site search of Blackrock Island and the surrounding area using local area knowledge mixed with the initial data from the previous search will take place.

The operation is scheduled to run through to Wednesday 19th. Organised by CHC, An Garda Síochána and IRCG will take operational lead, with Belcross Enterprises (Marine contractors) with the Marine Institute in support. This will be a five day trawling campaign using a specially modified fishing net. The net was provided free by Swan Net-Gundry Ltd based out of Killybegs and will be deployed from a medium sized fishing vessel called the MFV Westbound. The use of this vessel will allow the team to operate close to various contours around the island itself to maximise our efforts.

The expected work routine will be based on a 12 – 13 hour day using a trawl, recover, review, trawl cycle. During this period the IRCG will increase their shore patrols with R115 and R118 assisting those searches periodically over the five days the exact timings for this will be confirmed through IRCG planning. The ILV GRANUAILE is scheduled to arrive in Blacksod on the 22nd/23rd of July to initiate another round of ROV work.

Roger_007

I find it very curious that RTE are doing this investigation now, before the final report from the air accident investigation body has been issued. How do they know that the issues raised will not form part of the final report. It seems to me that it is a deliberate attempt to pre-judge the outcome and do the usual 'blame the authorities' game.
It is up to the official investigating body to identify what the contributory factors to this accident were and where mistakes were made which can be avoided in the future.
There is a tendency by most posters on this thread to try to pin blame everyone and anyone except the crew. No blame should be pinned on anyone until the final report is published.

Steve

Bazzy wrote: »

The one thing thats stood out to me about the whole thing is that the professionals Rte news and primetime) keep pointing out that the coast guard is the only one who does this type of flying

Yea and no, CIL do regular flights to refuel and maintain the lighthouse. I assume it's done in daylight VFR conditions tho.

Roger_007 wrote: »

No blame should be pinned on anyone until the final report is published.

+1

byhookorbycrook

Scary to hear that Skellig data was wrong too .

Steve

byhookorbycrook wrote: »

Scary to hear that Skellig data was wrong too .

Not sure what to make of that news tbh.

The GPWS supplier makes databases for commercial aviation. anything below MSA is at the captains discretion and risk so obstacles that are not in a 'normal' flightpath / approach are not included. Understandable, they cannot be expected to map every pylon, hill and wind turbine on the planet, that's what MSA is for.

The lat / long / altitude of the light was correctly reported and I suspect it was taken from an admiralty chart.

Bazzy

Steve wrote: »

Yea and no, CIL do regular flights to refuel and maintain the lighthouse. I assume it's done in daylight VFR conditions tho.



+1

Point taken but i'd imagine this would be planned maintenance and could be rescheduled if conditions didn't suit. i'm not taking from their work in reality Lighthouses save lives

Irish Steve

Steve wrote: »

Not sure what to make of that news tbh.

The GPWS supplier makes databases for commercial aviation. anything below MSA is at the captains discretion and risk so obstacles that are not in a 'normal' flightpath / approach are not included. Understandable, they cannot be expected to map every pylon, hill and wind turbine on the planet, that's what MSA is for.

The lat / long / altitude of the light was correctly reported and I suspect it was taken from an admiralty chart.

Very true, but the issue that's becoming clearer is that the information that was provided to the S92's is (bluntly) not fit for purpose, in that it does not contain accurate information.

The SAR operation is unique in terms of the manner in which it operates, unlike almost any other branch of aviation, the crews that fly SAR operations are routinely asked to operate at levels and in places that would be deemed dangerous (and possibly illegal) for most flight operations, and on many occasions, they do so in weather conditions that would encourage most other flyers to stay on the ground. That they have done so for so many years with so few accidents is testimony to their skills and dedication.

On that basis, to then discover that the information in their support systems relating to places like Blackrock and Skellig Michael is incomplete or inaccurate, in that the elevation contained in their system was massively understating the actual height of the obstacle, or was not even reporting the presence of the obstacle is a serious indictment of a massive failing by CHC to ensure that the data being used by their operation was both accurate and complete, and also fit for purpose, and this is perhaps the most critical part of the scenario, that it contains ALL of the obstacles that may present a risk to the operation of the SAR service.

If that means that CHC have to commission a custom made EGPWS database that contains a much larger data content than the "standard" general aviation database used for commercial operations, the nature of the SAR task absolutely justifies that being provided to them, a combination of data from the Ordnance Survey database, NASA and even possibly Google maps should mean that it is possible to produce a comprehensive database that does contain the critical obstacle data that is essential to the safe operation of SAR services around the coast.

In the grand scale of things, they do not need a whole world database to the level of precision that is needed for operations around Ireland, they need a relatively small geographic area updated to ensure that it contains a complete mapping of all of the potential obstacles that could prove a risk factor to successful operation at the levels they routinely operate at when performing their tasked missions.

I don't see the RTE reporting as being an attempt to allocate blame, they are trying to determine why R116 was lost, and to try and ensure that there cannot be a repeat of the accident that led to the loss of the aircraft and crew. What is thought provoking is that the RTE investigation is bringing into the open and public domain shortcomings and omissions, and failures of response relating to the content and accuracy of the on board systems being used by R116, and their searching has also exposed the fact that CHC were made aware of issues relating to Blackrock in 2013.

We can only trust that the AAIU have also become aware of the same information, and that their final report will reflect on those findings, and make recommendations that will ensure that there cannot be a repeat of this sort of accident in future operations.

Gaoth Laidir

Irish Steve wrote: »

I don't see the RTE reporting as being an attempt to allocate blame, they are trying to determine why R116 was lost, and to try and ensure that there cannot be a repeat of the accident that led to the loss of the aircraft and crew.

But that is precisely the job of the AAIU. I thought that all such investigatoon/speculation by anyone other than them was taboo.

Irish Steve

Gaoth Laidir wrote: »

But that is precisely the job of the AAIU. I thought that all such investigatoon/speculation by anyone other than them was taboo.

RTE mentioned that some of the people they contacted were not prepared to respond to their requests as they are involved in the AAIU investigation.

What's more worrying is that they are not as such speculating, they are revealing specific shortcomings in the data being used to provide critical information to the flight crews, and their investigations are revealing that CHC management were made aware of at least some of the issues some 4 years ago as part of the acceptance trials of the S92.

In theory, AAIU have access to the same information, but nothing can be assumed, we have no way to know if someone somewhere has provided information to RTE that has not been revealed elsewhere, which RTE have then used to process specific Freedom of Information requests in order to gain official confirmation of the truth, accuracy or otherwise of the information that is in their possession.

The FOI requests have provided information that they believe is of interest to the public, so they have chosen to report it, which is part of their remit and responsibility as a broadcaster.

boredbaby

I find this extract from the user manual of the Honeywell EGPWS that was fitted to R116 intetesting:

"CAUTION: The pilot must maintain visual contact with all terrain and obstacles at all times when using the Low Altitude mode. The Low Altitude mode must not be engaged during IFR conditions. The “look down” angle is reduced with “Low Altitude” engaged. Warning time is greatly reduced.”

Now, the AAIU preliminary report states that the crew had selected 'Low Altitude' mode on their EGPWS during the approach procedure, despite not being visual with the terrain in front of them.

Given this scenario, would the EGPWS, now in this mode with a "greatly reduced warning time" have given sufficient notice to take evasive action even if Blackrock Island/Lighthouse had been present in the terrain database?

The pilots were given 13 secs advance notice by a member of the rear crew to alter course prior to impact, and unfortunately failed to do so in time, resulting in impact.

I wonder if EGPWS in 'Low Altitude' mode would have done any better?