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

Roger_007

It would be a pity it the AAIU became involved in a dispute over their findings. They go to great lengths to establish the facts and their reports are, above all, findings of fact only.
It would be a retrograde step for aviation safety if their reports are to be compromised in any way by the sensitivities of any ‘stakeholder’. If they start down that road where will it end? Will they ever be able to publish a report again without someone external to the AAIU being able to effectively influence its contents.

TomOnBoard

easypazz wrote: »

Post #449 is well worth another read.

Could you link to it pls. I can't go to specific post number on my phone

Gadgetman496

TomOnBoard wrote: »

Could you link to it pls. I can't go to specific post number on my phone

Post #449

NH2013

easypazz wrote: »

Post #449 is well worth another read.

Unfortunately, some of the information contained and assumed at the time that post was written has been proven false over the past two years, in particular the information on instrumentation/charts the crew were provided with.

The final report won’t make for nice reading, especially when you consider the line of work of the crew flying the craft, but ultimately, the report will conclude that the cause of the accident was CFIT.

It will also expose systemic faults that were all contributory, both with the operator CHC and its charts, navigation systems, accuracy of terrain databases installed and safety reporting systems/culture but also with the regulator; the IAA and how it treats smaller operations and it’s oversight of the industry in general.

It does not takeaway though from how the crew that flew that night should be viewed, for their heroism shown over their years service and all the lives that have been saved, by what was well known as an exceptionally profession crew. This report should not be taken to tarnish their reputations, but instead serve to further safety in the field going forward.

Unfortunately a crew that made a mistake on the night in question that cost them their lives but also they were a crew that were let down by the safety nets that were supposed to be in place but were instead absent or did not function as intended.

salonfire

It's madness the official report is delayed due to some sensitivities.

What if another similar accident occurs that could have been prevented based on the AAIB Recommendations?

Very unprofessional on the part of the AAIB.

faoiarvok

salonfire wrote: »

It's madness the official report is delayed due to some sensitivities.

What if another similar accident occurs that could have been prevented based on the AAIB Recommendations?

Very unprofessional on the part of the AAIB.

The AAIB is the UK equivalent. The organisation here is the AAIU.

The review board is allowed for in the legislation which governs the AAIU, and the establishment of a review board is done by the Minister, so this isn’t currently a matter for the AAIU to decide.

Finally, the AAIU already made several Safety Recommendations in the preliminary report, and I believe they are free to issue Safety Recommendations separate from a report if they consider that they require urgent attention, so waiting for a Final Report shouldn’t prevent anyone getting urgent recommendations from the AAIU.

salonfire

salonfire wrote: »

It's madness the official report is delayed due to some sensitivities.

What if another similar accident occurs that could have been prevented based on the AAIB Recommendations?

Very unprofessional on the part of the AAIB.

Nice rant. But you might want to correct your post to A) direct it at the correct agency and apologise to them publicly as you didn’t even get your facts correct before you ranted at the wrong agency.

Stovepipe

let me reiterate; the AAIU is entirely independent and the Minister for Transport respects that, as do all the other State agencies that are involved. They can put out an SR any time they like. Faoiarvok is exactly right. The report will be published when the drafts for examination by interested parties have been returned.

salonfire

faoiarvok wrote: »

Finally, the AAIU already made several Safety Recommendations in the preliminary report, and I believe they are free to issue Safety Recommendations separate from a report if they consider that they require urgent attention, so waiting for a Final Report shouldn’t prevent anyone getting urgent recommendations from the AAIU.

But does the Recommendations in a preliminary report carry the same weight compared to Recommendations in a final Official Report?

I would imagine the companies and businesses involved would pay far greater heed if the Recommendations came from the final report.

Stovepipe

If it's urgent, then companies will have to respond as soon as.

Irish Steve

salonfire wrote: »

But does the Recommendations in a preliminary report carry the same weight compared to Recommendations in a final Official Report?

I would imagine the companies and businesses involved would pay far greater heed if the Recommendations came from the final report.

Recommendations made in an interim report in some respect carry more weight than the final report, in as much as the relevant reporter is saying "We still have work to do on this incident, but we already know that these issues are of significance, so we're reporting them now to make sure that the wider community gets to know about them NOW, rather than in 12 months time.



The Final report may well have more recommendations than an interim, in as much as specific work on aspects of the incident may well uncover wider or deeper issues than were first thought, but the interim recommendations carry every bit as much weight as later recommendations.

LiamaDelta

Caledonia wrote: »

Read back on the early thread. Some posters and in particular a Moderator were very very poor. Like they could not countenance pilot error at all. The more knowledgeable posters were shut down. Very odd.

Personally I think the moderators did a very good job in trying to limit wild speculation and absolute derailment of the thread given the very limited information that was available. Just because some of the initial speculation and conjecture has since been proven factual doesn't mean that it wasn't appropriate to limit the discussion in order to keep it from descending into farce.

Caledonia

It was actually stated what happened couldn’t have happened.

tricky D

Comments on moderation are off topic as per note in post 1 and general boards rules.

prunudo

Any word on when the official report might be released? How long do interested parties have to have their say?

General Disarray

Caledonia wrote: »

Read back on the early thread. Some posters and in particular a Moderator were very very poor. Like they could not countenance pilot error at all. The more knowledgeable posters were shut down. Very odd.

As per the yet (unreleased) official report, a perfectly serviceable aircraft was flown into an obstacle, to which I am apportioning no blame.
So yes, your observations are accurate.

Irish Steve

General Disarray wrote: »

As per the yet (unreleased) official report, a perfectly serviceable aircraft was flown into an obstacle, to which I am apportioning no blame.
So yes, your observations are accurate.

Given the very specific role that the aircraft was purchased and (supposedly) equipped for, it is questionable if it was actually serviceable for the role being performed at the time of the accident.

Yes, it was most likely mechanically serviceable, but as a complete system for a very specialised role, in light of the issues that have emerged, in my view, it was not servicable, due to fundamental errors that the crew may not have been fully aware of.

The paper charts were inaccurate, the database in the on board systems was inaccurate and incomplete, and the approach procedures being used by the operator were flawed. None of those factors can be attributed to the crew that were operating the airframe at the time of the accident, and those flaws were a very significant contributor to the end result.

prunudo

But surely this wasn't the first time that approach was flown. Did other crews flag the issue and management fail address the issue?
All ifs and buts until the report comes out but it seems there may have been failures at a lot of levels.

skallywag

I do not think it is fair to point any fingers at a mod. It is extremely difficult to moderate a thread like this, with emotions flying high, and the mods on this thread have my respect.

That said, this accident has been proven to be CFIT. Without a doubt.

There was no mechanical failure. Whatsover. The crew took decisions which caused the machine to crash.

skallywag

prunudo wrote: »

Any word on when the official report might be released? How long do interested parties have to have their say?

No. Nobody knows right now.

FFVII

skallywag wrote: »

I do not think it is fair to point any fingers at a mod. It is extremely difficult to moderate a thread like this, with emotions flying high, and the mods on this thread have my respect.

That said, this accident has been proven to be CFIT. Without a doubt.

There was no mechanical failure. Whatsover. The crew took decisions which caused the machine to crash.

Come out of it.

I don't read nor know if it even still exists but this thread/forum has had many a feedback thread. You couldn't come in here for a few years it was that bad!!

Probably still the same lads now, I'm on touch so can't see the names. If I get carded for this, nothing changed.

Atlantic Dawn

Nearly 3 years to give a report, wtf like, it wasn't a moon landing that crashed that needed to be documented?

L1011

FFVII wrote: »

Come out of it.

I don't read nor know if it even still exists but this thread/forum has had many a feedback thread. You couldn't come in here for a few years it was that bad!!

Probably still the same lads now, I'm on touch so can't see the names. If I get carded for this, nothing changed.

No, you're getting carded by a mod that wasn't here at the time because you're breaking one of the basic site rules

Steve

prunudo wrote: »

But surely this wasn't the first time that approach was flown. Did other crews flag the issue and management fail address the issue?
All ifs and buts until the report comes out but it seems there may have been failures at a lot of levels.

From my reading of the interim report, the flight crew had not flown this approach previously.

Irish Steve

Atlantic Dawn wrote: »

Nearly 3 years to give a report, wtf like, it wasn't a moon landing that crashed that needed to be documented?

No it wasn't a moon landing, but in terms of the work required for what is a relatively small unit, AAIU have had to do a lot of complex research into areas of flight operations and specialied systems that would be outside of their normal experience, and they will have had to wait for responses to many questions that have been sent to organisations and companies outside of Ireland.

116 was being operated by a very experienced and highly trained crew that would have had probably the highest level of experience and training that was possible, there is no way that the Search and Rescue role can be compared to pretty much any other helicopter operation, and it has almost no relationship to the vast majority of commercial flying that is the normal operation that AAIU are charged with dealing with.

While we don't have the full details of the findings, it has become very clear that there were some massive failings within a number of organisations that resulted in the total failure of the specialised systems that were supposed to give the crew warnings of dangerous situations developing.

AAIU have had to ask a number of organisations some very complex and potentially embarassing questions, and the answers to those questions are likely to have raised an equivalent number of new and equally disturbing questions, which then had to be analysed and quantified.

Rumour has it that there are a significant number of recommendations and findings in the report. We can only hope that the organisations that are implicated in the findings will respond in an appropriate manner.

It has become very clear that at the time of the accident, there was no mechanical or electrical fault with the aircraft that caused the crew problems operating the flight.

What has also become clear is that the specialised systems and procedures that were supposed to provide guidance and warnings to the crew of potential danger were very much flawed, and those flaws resulted in no warnings being given to the crew of the danger in front of them, they were left literally and figuratively in the dark.

We can only hope that the findings of this report will result in far reaching changes to ensure in the future, no SAR crew is ever put in the same situation again.

I would very much hope that when the final report is eventually released, the members of the R116 crew will be truly allowed to Rest In Peace, without their reputations being tarnished by findings of failure by the crew, as it seems clear to me that they were the unfortunate victims of a combination of errors and failings by others outside of their control or influence.

prunudo

Steve wrote: »

From my reading of the interim report, the flight crew had not flown this approach previously.

Yes ,sorry should have been more clear in my post. I meant that surely other crews had flown this approach before and if during daylight hours would have found that there was conflicting information on the charts.

knucklehead6

skallywag wrote: »

There was no mechanical failure. Whatsover. The crew took decisions which caused the machine to crash.

While that may be factually correct, from what I’ve come to understand from what I have heard/read there were systematic failures and no blame can be apportioned to the crew.
Yes, it appears to be a case of Controlled Flight Into Terrain, but aids that should have helped the crew weren’t up to scratch


Not meaning to nitpick but your post does look a little like crew fault. I don’t think this is the case.

Gaoth Laidir

Nobody seems to want to answer that question of previous crews not spotting and reporting the omission in the database. Very quick to jump on some comments, though.

plodder

Gaoth Laidir wrote: »

Nobody seems to want to answer that question of previous crews not spotting and reporting the omission in the database. Very quick to jump on some comments, though.

The only omission I know about is the fact that Blackrock was missing from the EGPWS database. Nobody would have noticed that unless they had flown dangerously close to the rock before.

Don't think anyone can definitively say "no crew fault" either though unless that's in the final report which isn't published yet.

faoiarvok

There seems to be plenty of people who think that “human error” is a conclusion that signals the end of an investigation, and that asking questions beyond that is some sort of exercise in trying to avoid blaming crew members (though of course, as has been explained so many times, the apportionment of blame is not the job of AAIU reports).

That may have been the attitude long ago, but it is no longer. If it were, the civil aviation industry would not be as safe as it is. The idea is to understand WHY humans make particular errors, in order to guard against them in future. This concept dates at least as far back as the Tenerife disaster, where the explanation of “they took off when they weren’t supposed to, the idiots” may have seemed like a conclusion. Instead, the industry and investigators continued to dig deeper, identifying the “asymmetrical cockpit” on board the KLM aircraft, leading to new CRM procedures that make every other flight safer as a result.