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

Irish Steve

selectamatic wrote: »

A mod on here alluded to it being a commercial interest that's holding up the show.

Can you clarify? Not all people with moderator in their name are moderators here, so in that case, they are posting as a private individual, not a moderator of this forum.

selectamatic

Irish Steve wrote: »

Can you clarify? Not all people with moderator in their name are moderators here, so in that case, they are posting as a private individual, not a moderator of this forum.

Apologies Irish Steve I mistakenly always thought I was replying to you when I found myself much to my own disbelief defending Shane Ross a few months ago on here :pac:

I see now it was a different poster.

Steve wrote: »

I have the greatest respect for the AAIU and their ability to conduct impartial and factual investigations and to make their findings public.

It is, however, abhorrent to me that a 'politician' (I care not who it is) can interfere with their investigation and / or influence what findings they publish because they were lobbied by a commercial interest.


What if the first 737 MAX had failed on our soil and the AAIU were gagged by a politician because of 'commercial interests'?

selectamatic wrote: »

Is it published anywhere that it's a commercial interest who has invoked Regulation 15 of SI 460 of 2009?

As I've said before your anger is misplaced.

You should be abhorred at the interested party not a politician who's merely following protocol.

Irish Steve

selectamatic wrote: »

Apologies Irish Steve I mistakenly always thought I was replying to you when I found myself much to my own disbelief defending Shane Ross a few months ago on here :pac:

I see now it was a different poster.

Thanks, sorry for stirring the pot slightly, this has been a difficult and at times almost impossible thread to manage, so we're perhaps more sensitive if things start going into controversial areas.

Above picture is of Black Rock Lighthouse. The Interim Report states that helicopter tail came into contact with an outhouse roof close to the lighthouse. Outhouses are visible above.

From Preliminary Report:

6.2 Debris found on Black Rock
The horizontal stabiliser was found on the rock, adjacent to an outhouse which was close to the lighthouse. Tiles on the roof of the outhouse exhibited damage, consistent with being struck by falling debris.
The horizontal stabiliser exhibited significant damage and distress, with damage to the graphite tip and leading edge; it separated from the tail rotor pylon at the root. The trailing edge of the root (approximately 20 inches in length) separate from the main structure. A piece of a leading edge erosion strip from one of the tail rotor blades, one and a half inches in length, which was recovered on the rock, was found to fit into a gouge in the horizontal stabilizer mounting structure. The underside of the mounting structure was scraped and distorted.
Fractured sections of the Intermediate Gear Box (IGB) centre housing, including the oil level sensor and a portion of the chip detector, as well as the IGB fairing which was broken into four distinct pieces, were found on the rock.
Also recovered from the rock were fractured sections of tail rotor blade; each section was less than two inches long. Two tail rotor control cable pulleys were also recovered, one of which was found on the platform at the top of the lighthouse. In addition, fractured pieces of a wheel rim were recovered close to the helipad.

3.5.8 Operator’s Route Guide
Figure No.4 shows the Operator’s Route Guide for Blacksod (designated ‘APBSS16 (Blacksod South) Route’) which the Crew of R116 was using at the time of the accident. The Route Guide includes an associated separate page of text setting out, inter alia, waypoint designations and coordinates, hazards and obstacles and other general comments. This page identified a lighthouse at Black Rock with an associated height of 310’.
Figure No. 4: Operator’s Route Guide for APBSS
16 APBSS: The Operator informed the Investigation that APBSS stands for ‘Approach Blacksod

The obstacle was actually in the operator's route guide with the obstacle featured. If so, why was the routing designed directly over a known obstacle, unless the altitude was intended to be much higher than the one selected on or pre-programmed in FMS. How/when was the route guide referenced by those flying it, I wonder. There seems to have been a conflict between the dataset used by the flight computer and the hard copy data available to crew. This factor is likely to have been addressed in the Final Report which is under review.

I am wondering if the lighthouse light was visible to crew that night, and if not, why not. It is there as a marker to make the obstacle visible to shipping, and not intended for helicopter navigation. I don't know anything about flying SAR choppers in autopilot approach mode, but there must be an explanation why the flashing light was not seen as the aircraft was making a trajectory towards it. I'm sure the explanation is clear-cut if I understood it, or maybe it is not practice to scan out ahead through the window in darkness.

irishgeo

Deleted User wrote: »

Above picture is of Black Rock Lighthouse. The Interim Report states that helicopter tail came into contact with an outhouse roof close to the lighthouse. Outhouses are visible above.

From Preliminary Report:





The obstacle was actually in the operator's route guide with the obstacle featured. If so, why was the routing designed directly over a known obstacle, unless the altitude was intended to be much higher than the one selected on or pre-programmed in FMS. How/when was the route guide referenced by those flying it, I wonder. There seems to have been a conflict between the dataset used by the flight computer and the hard copy data available to crew. This factor is likely to have been addressed in the Final Report which is under review.

I am wondering if the lighthouse light was visible to crew that night, and if not, why not. It is there as a marker to make the obstacle visible to shipping, and not intended for helicopter navigation. I don't know anything about flying SAR choppers in autopilot approach mode, but there must be an explanation why the flashing light was not seen as the aircraft was making a trajectory towards it. I'm sure the explanation is clear-cut if I understood it, or maybe it is not practice to scan out ahead through the window in darkness.

The weather reports states

Weather Mist and drizzle
Cloud Overcast with a cloud base of 300-400 ft

So the cloud base might have been below the height of the lighthouse .

The report also states

The helicopter descended initially to 2,400 ft, whereupon the Commander selected
the APP1 mode to establish the helicopter at 200 ft AMSL and 80 kts. Thereafter,
the airspeed was manually adjusted to 75 kts due to the Commander’s stated
expectation of tailwinds on the easterly leg of the arrival.

I think the key to why the report has been delayed and a review requested could be around the following extract from the preliminary report regarding the helicopter’s Enhanced Ground Proximity Warning System (EGPWS), which also has a digital terrain map that allows the pilot to see terrain and obstacles

In relation to Black Rock and its Lighthouse the EGPWS manufacturer informed the Investigation that “The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in our terrain database.” Honeywell (the manufacturer) explained to the Investigation that:

“Honeywell’s DO-200A compliant processes include the integration and validation of multiple data sources, both authoritative (Government and Type 1 LOA suppliers) and non-authoritative (public and private data). Typical terrain data sources include remote sensor data (e.g., SRTM, ASTER) as well as topographical map digitized data. Obstacle data sources include Government AIP data, supplied by our Type 1 LOA supplier, as well as non-authoritative data furnished by customers, governments and private industry. Honeywell’s selected terrain and obstacle source data do not include Black Rock.”

“Honeywell’s terrain data is sourced from our supplier [named supplier]. It is a digitized topographic map derived data set. It does not include Black Rock. We have looked at alternate sources, including SRTM and ASTER. While Black Rock is present in these alternate data sets, the actual altitude of Black Rock is considerably higher than what is indicated in these alternate data sets. Our obstacle data for the Ireland region is sourced from our Type 1 LOA supplier, [named supplier]. This data is originated by the [named source], and does not include obstacles on Black Rock.”

The Investigation is continuing to engage with Honeywell and other parties/agencies to reach a full understanding of this issue.

It’s probably around who provided the data.

Profile of Black Rock Island and Lighthouse with blunt outline of outhouse (mentioned as a contact/debris point from tail rotor area) visible just below and to right of tower. The helicopter was approaching to right of picture. Bear in mind the aircraft was approaching from below the top of the island.

From my very limited experience of lessons on the tiny Robinson 22, which is always hand flown, if I want to slow right down or stop forward trajectory I ease the cyclic stick back towards me. On the Robbie I only do that if I am hovering a few high in ground effect as it isn't capable if a high hover like a big machine (the Robbie will lose rpm, stall and fall to ground), so I only do that in real life if I'm approaching to land. As I pull back on the cyclic (and I do that ever so gently) the main rotor tilts its blades "backwards" to pull aircraft to a stop. If I pull back far enough it will actually start travelling backwards. The profile of the aircraft will will Bose high, tail low, if you can picture it.

However if I'm in a big powerful helicopter I can stop it in a hover, but of course if it's travelling at speed it has some momentum to lose. If I see a big object suddenly looming out of nowhere right in front of me I want to stop the forward motion as much as possible if it is not possible to dodge it sideways. In a sudden situation like that I will end up nose higher than tail. If I want to turn, say right, to avoid the object I pull cyclic stick to right, similar to you stock in fixed wing, as well as co-ordinating my turn by a nice easy push on the right pedal. All these manoeuvres alone are easy to do with cyclic and pedals, I dare say even easier In one way than with fixed wing as choppers are direct, precise and satisfactory in response.

Another way to avoid an object I'm fast encroaching in is to climb attempt to climb over it. Add in the collective, the climb and descent control, and you need a bit more coordination. Not difficult aloft, once you don't pull up the collective sharply and stall the aircraft by losing rotor rpm, which you always keep an eye on. Forward airspeed in likes of Robinson 22 is a factor in preventing stalls when out of ground effect. I don't know the variables of how the big choppers behave in sudden upward grasp of the collective for an attempted quick climb. Anyway if I am confronting a big unexpected lighthouse I might rapidly attempt to lose speed by pulling back cyclic as well as pulling up the collective. As an observer you would likely see my aircraft in a scooping motion as forward speed is rapidly lost, the tail dipping, nose up, and aircraft rising over obstacle. My tail could quite easily hit an object close below if I wasn't lucky to pull it off. At same time I might have commenced a turning manoeuvre, maybe with tail swinging left if I turned right and vice versa. Once I'm near terrain that I've managed to avoid head-on collision with, in a helicopter the tail behind me is liable to get hit once I'm close enough to terrain as it dips down.

[Deleted User]

[Deleted User] wrote: »

I think the key to why the report has been delayed and a review requested could be around the following extract from the preliminary report regarding the helicopter’s Enhanced Ground Proximity Warning System (EGPWS), which also has a digital terrain map that allows the pilot to see terrain and obstacles.
It’s probably around who provided the data.

Most definitely the route followed on that night was one provided in the on board computers, and that data was incorrect. That has now been corrected for operations since the preliminary report. The practice of following computer systems alone would likely be also addressed by the investigation, as it is by all other aircraft investigations.

In the midst of active search and rescue missions pilots are going to be in new territories a good bit the time, and should be able to fully rely on the data on board the computers to carry out searches in the dark. There is always an added element of risk to SAR because of some rapid changes in terrain, weather encountered etc. The area where the rescue happens is the one where most of the danger ought to lie.

However, in the case of this tragedy, it was during a routine approach for a fuel pick-up. I don't know how many refuelling bases are used by the operation, but I can't think there are that very many. Between the refuelling points, the operations bases and licensed airports that might be used by them on occasion In Ireland, is a reasonably limited number of set approaches. Why *one* of them *on this night only* (after brought the aircraft into conflict with terrain, would be made apparent to some extent in the report.

It's often two and sometimes a multitude of coinciding factors that causes an accident that goes into the annals of history. In many reports it is apparent that, sadly, an accident was "waiting to happen", as in Murphy's Law. Reports have enhanced air safety to the extent that we can confidently fly with huge margins if safety in most parts of the world.

Yes, it’s James Reason’s Swiss Cheese model always at play.

irishgeo

irishgeo wrote: »

The weather reports states



So the cloud base might have been below the height of the lighthouse .

The report also states

Yes, it could indeed have been engulfed in cloud and the flashing light not able to penetrate the horizontal thickness. The factor that hid the obstacle from view until a rear crew member got a glimpse of it through his equipment, and of course his command to pull right was based on what he could view from his particular position. Without further details don't know whether that might have been helpful In the evasion manoeuvre or inadvertently brought it further conflict in the event. All that would just explain the final moments of the flight.

This crude photoshop mix I've done on the iPhone is my creation of what I imagine the close-in of the aircraft upon terrain looked like.

skallywag

Deleted User wrote: »

I think the key to why the report has been delayed and a review requested could be around the following extract from the preliminary report regarding the helicopter’s Enhanced Ground Proximity Warning System (EGPWS), which also has a digital terrain map that allows the pilot to see terrain and obstacles

If it turns out that the crew were relying on EGPWS to navigate then of course the incorrect / missing data was a serious contributor to the accident. That said, if the crew were really relying on EGPWS as a primary navigation tool, then serious questions are clearly going to be asked.

skallywag

skallywag wrote: »

If it turns out that the crew were relying on EGPWS to navigate then of course the incorrect / missing data was a serious contributor to the accident. That said, if the crew were really relying on EGPWS as a primary navigation tool, then serious questions are clearly going to be asked.

I suppose in the extremely poor visibility that particular night they were reliant on on the EPGWS, and it's missing data was of course the immediate cause of the accident happening in this instance. They chose to be entirely reliant on the system without sufficient knowledge (the terrain data in the brain) of the approach and its hazards.

The fact that the Way Point BLKMO (a GPS location) coincided with an isolated high obstacle, meant that it was a tragedy waiting to happen at any time low pilots unfamiliar with it might use it for an approach below 800ft in poor visibility. It is pretty far west of Blacksod refuelling point, and the sea routing was chosen to avoid the mountainous terrain to the east. This Way Point (& maybe others) is now known to be unsuitable for use by SAR aircraft.

The missing data is obviously the primary factor in the the tragedy. If all crews were substantially familiar with the terrain of all routine approaches, the accident might not have occurred, as a different altitude might have been chosen. I wouldn't have a clue about the feasibility of having all crews this familiar with all approaches or always referencing the operations manual which did contain the data; I imagine this was addressed somewhere in the draft final report.

ProfessorPlum

Deleted User wrote: »

I suppose in the extremely poor visibility that particular night they were reliant on on the EPGWS, and it's missing data was of course the immediate cause of the accident happening in this instance. They chose to be entirely reliant on the system without sufficient knowledge (the terrain data in the brain) of the approach and its hazards.

EGPWS is not a navigation tool.

skallywag

Deleted User wrote: »

The missing data is obviously the primary factor in the the tragedy

I would rephrase that somewhat myself. If they were really reliant on EGPWS for navigation that night, then yes, the fact that the data was incorrect was certainly a factor in the tragedy, but the 'primary factor' itself would be the fact that EGPWS was being used to navigate in the first place.

I do not wish to get into any speculation here, etc. but I have a feeling that the crew's level of reliance on EGPWS will be a key factor in the final report.

ProfessorPlum

ProfessorPlum wrote: »

EGPWS is not a navigation tool.

It was partially reliant on the nav data, was it not? Or am I mistaken? And if they thought they had a free run in over the water because of absence of obstacle indicators in their onscreen nav charts, then it seemed the way to go. When the island did start appearing it was said to be "only a little island" and presumed to have no significant height because the nav system "allowed" the approach to be chosen at low altitude over it.

I know the Operations Manual did include the obstacle and its elevation, but this was not referred to in this occasion. That would presumably be a hard copy book carried on board the helicopter, available for reference by pilots, if I'm presuming correctly. In the cockpit environment would there be a question of ability to refer to the manual due to lighting, I wonder. I haven't a clue about cockpit area lighting inside such helicopters although I would have thought a torch would be a solution.

skallywag

skallywag wrote: »

I would rephrase that somewhat myself. If they were really reliant on EGPWS for navigation that night, then yes, the fact that the data was incorrect was certainly a factor in the tragedy, but the 'primary factor' itself would be the fact that EGPWS was being used to navigate in the first place.

I do not wish to get into any speculation here, etc. but I have a feeling that the crew's level of reliance on EGPWS will be a key factor in the final report.

That's kind of in my mind too, from day 1 of when facts first emerged. But what I didn't and still don't know is if this is a standard practice in these operations, outside of Ireland etc. Only the final report will elucidate that.

ProfessorPlum

Deleted User wrote: »

It was partially reliant on the nav data, was it not? Or am I mistaken? And if they thought they had a free run in over the water because of absence of obstacle indicators in their onscreen nav charts, then it seemed the way to go. When the island did start appearing it was said to be "only a little island" and presumed to have no significant height because the nav system "allowed" the approach to be chosen at low altitude over it.

I know the Operations Manual did include the obstacle and its elevation, but this was not referred to in this occasion. That would presumably be a hard copy book carried on board the helicopter, available for reference by pilots, if I'm presuming correctly. In the cockpit environment would there be a question of ability to refer to the manual due to lighting, I wonder. I haven't a clue about cockpit area lighting inside such helicopters although I would have thought a torch would be a solution.

I’ll preface by saying I know almost nothing about SAR OPS, and I don’t know how the crew was navigating. But it remains that EGPWS is not means of primary navigation, it’s not authorised to be used that way.


“The agency [EASA] is looking into this subject to identify needs for corrective actions or room for improvements, notwithstanding that, according to the flight manual of S-92, ‘navigation must not be predicated upon the use of [EGPWS] information’,” it says.

It adds that in order to be included in a terrain database, obstacles must have a minimum height of 30m.“

https://www.flightglobal.com/easa-examines-helicopter-terrain-awareness-database-gaps/123942.article?adredir=1

Reading between the lines of this article, it may be that EGPWS is in fact used for nav.

What I cannot understand that Blacksod is a routine refuelling stop for SARs off the west coast. It was always the preflight plan to refuel there (iirc) Why is there not a procedure for safely letting down? R116 can not be the first CHC heli to refuel there in similar weather conditions. How is it that no other crew recognised that the terrain at Blackrock was not included in the database, if that route was a usual one for making the stop?

Hopefully the full report won’t be too much longer. May the crew RIP.

Irish Steve

A very significant factor that emerged when they started issuing corrections is that the obstacle location and height information on the prime data provided by the IAA was wrong, and by implication, any data issued to manufacturers of GPWS systems and the like was also going to have those same errors in it. As for the exact reasons for those issues, I suspect it may have been a subject that had to be explored in a lot more depth during the finalisation of the report.

It is a fundamental aspect of the events, but until the full and final report is released, it's not appropriate to comment further.

skallywag

ProfessorPlum wrote: »

...But it remains that EGPWS is not means of primary navigation, it’s not authorised to be used that way....

This point hits the nail on the head.

Honeywell do not sell this technology as a 'navigation tool'. If someone is using EGPWS to navigate, then they are making a very serious mistake.

I do not accept the point that extremely poor weather may have made the crew reliant on EGPWS.

skallywag

skallywag wrote: »

This point hits the nail on the head.

Honeywell do not sell this technology as a 'navigation tool'. If someone is using EGPWS to navigate, then they are making a very serious mistake.

I do not accept the point that extremely poor weather may have made the crew reliant on EGPWS.

Thanks to responses here I've now done some further online reading into this system (including a Flight international article from 2002) and from all of this I see where this all comes together. I await the report, and RIP to the flight & winch crew.

I had a lovely close-up of a rescue practice once on board a boat in Svålbard, when I was standing on the deck shred a crew member was winched down. A memorable moment, and I always admire the courage of these people who deserve to operate in the best safety conditions possible.

lucernarian

Irish Steve wrote: »

Thanks, sorry for stirring the pot slightly, this has been a difficult and at times almost impossible thread to manage, so we're perhaps more sensitive if things start going into controversial areas.

I want to call out the high quality and consistent modding that characterises Aviation. One of the best forums on Boards. Thanks for your efforts.

FFVII

lucernarian wrote: »

I want to call out the high quality and consistent modding that characterises Aviation. One of the best forums on Boards. Thanks for your efforts.

.

Storm 10

Further delay in the report

R116 accident review faces delay after expert resigns
http://www.rte.ie/news/ireland/2020/1008/1170350-r116-review/

CHC looks like a company with enormous worldwide tentacles that has provided services to other major helicopter companies:

https://en.wikipedia.org/wiki/CHC_Helicopter

Afaics, this one will hang there indefinitely.

lintdrummer

Storm 10 wrote: »

Further delay in the report

R116 accident review faces delay after expert resigns
http://www.rte.ie/news/ireland/2020/1008/1170350-r116-review/

Interesting that that report explicitly names CHC as the probable reason for the review in the first place, there's been a lot of speculation here as to who had objected.

jetfiremuck

Are we to believe that Hansen only realized conflict recently and resigned......really!. So has he corrupted the process now, wherin he was central to the investigation with first hand access to information. Fox in the hen house

lintdrummer

lintdrummer wrote: »

Interesting that that report explicitly names CHC as the probable reason for the review in the first place, there's been a lot of speculation here as to who had objected.

The sheer magnitude of that company and our aviation legislation make resolution of report a very awkward process. It seems there are few people expert enough in the world who have not had a connection with it, and the RTE report say the crews' families will not allow the report be reviewed by anyone other than a rarity who is without any links to CHC. It's a stalemate.

cml387

Is there a case for an expert from a military SAR, e.g. the RAF?

cml387

cml387 wrote: »

Is there a case for an expert from a military SAR, e.g. the RAF?

I was wondering the same thing. It’s clearly a niche expertise.