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

Roger_007

The preliminary report contained all the relevant information about what the aircraft did leading up to the accident. It established that it was flying at an extremely low altitude, in darkness, while still many kilometres from its intended landing point. What the final report will determine is why.
Although it is not the function of the AAIU to apportion blame to any party, it is their responsibility to describe factually what all the contributory factors were. If that impinges on some sensitivities then that is unfortunate, but necessary. In no way should any report of the AAIU be amended because of pressure from anyone outside the investigating unit and, in particular, there should be no political influence.
If the rumours that the report is being ‘reviewed’ are true, that would be a very worrying development. It is vital that the integrity and professional reputation of the AAIU is maintained.

Irish Steve

plodder wrote: »

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.

Blackrock was missing, but there were also some other significant issues with spot heights and precise locations on a number of places being incorrect in both electronic and paper (map) information.

Some of those errors were corrected very quickly after they were found, but it's not yet clear if all sources have been updated to add or correct the information, and there is doubt about the validity of information in other areas.

One reason I have heard put forward is that paper based charts are designed for VFR flight, and unless departing or landing, VFR flight is supposed to be carried out above 500FT AMSL, and if predominantely over water, there is no reason to be below 500Ft, so inaccuracies in charts of items below 500FT is not relevant.

If that is the case, it raises a whole range of very awkward questions about the accuracy and validity of the electronic information contained in the systems that were selected for R116, given that the specific SAR role that the aircraft is performing will require operations over water below 500 Ft on a regular basis.

plodder

Irish Steve wrote: »

Blackrock was missing, but there were also some other significant issues with spot heights and precise locations on a number of places being incorrect in both electronic and paper (map) information.

Yes, I know that. But the post and a previous one seemed to be making the point that if there were omissions and 'conflicting' information then how come no previous crews had pointed this out. I was saying nobody would have noticed the omission.

Regarding the spot heights on the chart, that wasn't so much a 'conflict' as an ambiguity imo, which someone might have pointed out previously, or might not have. It's easy to imagine situations where other crews would have understood the information on the chart, but someone completely new to the area might not.

One of the questions is why crew decided on a long low approach from some little distance at sea. Obviously their belief was that this approach was safest, free from obstacles and that there was zero chance of encountering any terrain at all at their chosen altitude. They must have been totally unfamiliar with the area during daylight or they would have been aware of the presence that distinct landmark thereabouts.They were relying fully on their navigation system, which needed to be fully accurate if it was to be safe.

Nijmegen

Out of curiosity, are long and low approaches in poor visibility not a bad idea generally? My understanding is that they were flying at 200ft or so when they crashed, and while there's not a lot of moving man made things that height there are a few on the sea plus the chance that your charts are inappropriate / wrong. Yeah there's a one in a million chance that the Allure of the Seas happens to be passing by or your charts are out, but this might be an example of where what can go wrong. I guess another way to look at it someone more educated than me might explain, is what are the advantages of such an approach?

tnegun

Am probably wrong but I thought they were that low to get below the clouds? The idea being you get close to where you need to be in or above the clouds then fly to a place you know is safe, descend below the clouds and then continue to where you want to be?

I remember when learning to fly in the 80s I had an instructor who sadly later died in a CFIT in Scotland Delivering lobsters from Stornoway to London. He was introducing me to the concept of being caught out flying h into low visibility, so we ascended into cloud. I asked him “Are you satisfied that there isn’t another person practising the exact same thing in this are?” A man with a dry wit he responded “ah well, what you don’t see you don’t miss!”

Steve

prunudo wrote: »

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.

In daylight, they would and should have eyes out, essentially flying VFR so not having to rely on an electronic terrain mapping gps.

Yes, that could be considered speculation, however it is based on my reading of the interim AAIU report.

skallywag

knucklehead6 wrote: »

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.

I certainly would not necessarily agree with that, although do not really want to speculate any further before the final report is eventually published.

There was indeed a certain amount of over zealous 'this is a SAR crew, so they cannot possibly have made an error' when this thread was in it's infancy, which can subsequently be critiqued based on the interim findings, particularly the CVR data which was released.

skallywag

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?

Some family members are disputing the findings. A draft of the final report was released quite some time ago.

skallywag

Deleted User wrote: »

They were relying fully on their navigation system, which needed to be fully accurate if it was to be safe.

This is a misconception.

EGPWS is a navigation aid and not a navigation system. Anyone who has flown a whirlybird will tell you the same. You never use it as your single source of truth for navigation.

Irish Steve

It's probably worth mentioning at this point that R116 was very much not a standard commercial flight, where the concepts of VFR and IFR operations are rigidly defined, as a SAR operation, the crew of R116 would have spent a very high percentage of their time operating at very low level, in often marginal VFR conditions, as their objective would have been to see and identify items of interest on the surface of the (usually) water below them.
While they would have been proficient at operating under IFR conditions, especially when transiting to and from search areas, the very nature of their operation would have been to visually acquire their intended target, as it would be very rare indeed for them to be able to find their objective in any other way, so it would have been very much standard operating procedure to operate below cloud VFR when over water.

Irish Steve

Irish Steve wrote: »

It's probably worth mentioning at this point that R116 was very much not a standard commercial flight, where the concepts of VFR and IFR operations are rigidly defined, as a SAR operation, the crew of R116 would have spent a very high percentage of their time operating at very low level, in often marginal VFR conditions, as their objective would have been to see and identify items of interest on the surface of the (usually) water below them.
While they would have been proficient at operating under IFR conditions, especially when transiting to and from search areas, the very nature of their operation would have been to visually acquire their intended target, as it would be very rare indeed for them to be able to find their objective in any other way, so it would have been very much standard operating procedure to operate below cloud VFR when over water.

Maybe some of the recommendations concern in what sectors of these flights should the general rules be more flexible and when should they be strictly adhered too, to mitigate the risks to crew.

Candamir

Irish Steve wrote: »

It's probably worth mentioning at this point that R116 was very much not a standard commercial flight, where the concepts of VFR and IFR operations are rigidly defined, as a SAR operation, the crew of R116 would have spent a very high percentage of their time operating at very low level, in often marginal VFR conditions, as their objective would have been to see and identify items of interest on the surface of the (usually) water below them.
While they would have been proficient at operating under IFR conditions, especially when transiting to and from search areas, the very nature of their operation would have been to visually acquire their intended target, as it would be very rare indeed for them to be able to find their objective in any other way, so it would have been very much standard operating procedure to operate below cloud VFR when over water.

I was under the impression that the concept of VFR and IFR was rigidly defined in law, not commerce.

skallywag

skallywag wrote: »

This is a misconception.

EGPWS is a navigation aid and not a navigation system. Anyone who has flown a whirlybird will tell you the same. You never use it as your single source of truth for navigation.

Yes, I would have thought that indeed. My only whirlybirding were two very enjoyable lessons on a Robinson 22.

I think some of the frustration with the shutting down of a certain trajectory of analysis earlier in this thread comes from the fact that this is a fairly specialised forum generally inhabited by knowledgeable posters, not some salaciously titled thread on After Hours.

A poster here recently said that this is Ireland and no one is allowed to blame the crew, I'd say it's more a case of no one wants to speak ill of the deceased. However it's worth bearing in mind that engineers, software programmers and project managers should not have aspersions cast on their professionalism without evidence either.

In the end, it will most likely be distilled down to a general fudge about how the government didn't give enough funding and it will be left at that.

When all else fails, we can always blame the government .

Steve

Candamir wrote: »

I was under the impression that the concept of VFR and IFR was rigidly defined in law, not commerce.

I suspect that military and / or SAR operations are not bound by this.

faoiarvok

Candamir wrote: »

I was under the impression that the concept of VFR and IFR was rigidly defined in law, not commerce.

“Concept” may not have been a great choice of word for Irish Steve to use, but SAR are exempt from the usual VMC minima and lots of the other laws that normally go along with their chosen flight rules. The nature and stakes of the flying they do obviously demand this flexibility.

smurfjed

However it's worth bearing in mind that engineers, software programmers and project managers should not have aspersions cast on their professionalism without evidence either.

I would guess that the Helicopter Flight Manual would have some statements similar this to provide legal protection for the equipment manufacturer.

Its also worth noting that the widow of Kobe Bryant has filed a “wrongful death” lawsuit against the operator of his helicopter. I fully expect the same to happen in this case.

Means Of Escape

[Deleted User] wrote: »

Maybe some of the recommendations concern in what sectors of these flights should the general rules be more flexible and when should they be strictly adhered too, to mitigate the risks to crew.

Minimum approach height of 1000 feet over water with zero rule flexibility may be a recommendation .

smurfjed

Means Of Escape wrote: »

Minimum approach height of 1000 feet over water with zero rule flexibility may be a recommendation .

That defeats the purpose of their mission.

L1011

Means Of Escape wrote: »

Minimum approach height of 1000 feet over water with zero rule flexibility may be a recommendation .

You're still thread banned - and always will be. Week off.

Candamir

faoiarvok wrote: »

“Concept” may not have been a great choice of word for Irish Steve to use, but SAR are exempt from the usual VMC minima and lots of the other laws that normally go along with their chosen flight rules. The nature and stakes of the flying they do obviously demand this flexibility.

Yes of course, but this accident occurred during a ‘routine’ refuelling stop. Might be worth considering if operating outside the rules is appropriate in the non rescue part of the mission. Another one for the AAIU.

faoiarvok

Candamir wrote: »

Yes of course, but this accident occurred during a ‘routine’ refuelling stop. Might be worth considering if operating outside the rules is appropriate in the non rescue part of the mission. Another one for the AAIU.

If it’s a rescue mission, I don’t think there is a "non rescue" part of the mission. If you can’t get fuel, you may not be able to complete the mission. Should be left up to commander and crew IMO, but I don’t make these decisions.

smurfjed

smurfjed wrote: »

also worth noting that the widow of Kobe Bryant has filed a “wrongful death” lawsuit against the operator of his helicopter. I fully expect the same to happen in this case.

The 'operator' in this case being who exactly though?

smurfjed

Island Express Helicopters.

plodder

skallywag wrote:

Some family members are disputing the findings. A draft of the final report was released quite some time ago.

Are you saying they are one of the parties that requested this review?

An RTE report at the time seemed to suggest that it was only CHC who were challenging it. Though that wasn't confirmed for definite either.

Nijmegen

faoiarvok wrote: »

If it’s a rescue mission, I don’t think there is a "non rescue" part of the mission. If you can’t get fuel, you may not be able to complete the mission. Should be left up to commander and crew IMO, but I don’t make these decisions.

I would say (if, if, if this is a part of the report that will be a major point of discussion) that different phases of a mission can be classified. Heading to refuel is a different phase to performing a low altitude search, for example, and perhaps you could justify hard rules about gaining altitude to set off on that phase of the mission. As I mentioned above, I wonder what the advantages of a long, low approach are. Fuel consumption (in gaining and losing altitude) and time are obviously material factors. But were they urgent material factors? Or perhaps was it more convenient to keep low and fly in on the (not unfair even if tragically incorrect) assumption there's nothing going to be in the way as far as you are aware.

faoiarvok

Nijmegen wrote: »

I would say (if, if, if this is a part of the report that will be a major point of discussion) that different phases of a mission can be classified. Heading to refuel is a different phase to performing a low altitude search, for example, and perhaps you could justify hard rules about gaining altitude to set off on that phase of the mission.

The only phase I’d differentiate in terms of stakes is RTB after dropping off a casualty or standing down from a mission. Refuelling to head out to a long range search is every bit as important as actually flying the search. There’s no point heading out if you have to turn around as soon as you get there.

Nijmegen wrote: »

As I mentioned above, I wonder what the advantages of a long, low approach are. Fuel consumption (in gaining and losing altitude) and time are obviously material factors. But were they urgent material factors? Or perhaps was it more convenient to keep low and fly in on the (not unfair even if tragically incorrect) assumption there's nothing going to be in the way as far as you are aware.

The advantage of a long low route into Blacksod is to be below the cloud and visual with any terrain on the way in. I’d guess that’s why they were conducting the cloud break well out from the mainland, in the mistaken assumption that that would be the safest place to descend below cloud, yes.

Irish Steve

Another very significant factor that will have influenced their course was that the approach procedure for Blacksod started directly over Blackrock. That certainly will have been a part of the things that contributed to the sceenario.