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

Irish Steve · 13-04-2017 11:16PM

Re the EIS speed issues. Without access to the raw data captured by the system, we cannot exactly map the location of the last report received. It is unfortunately altogether possible, and alluded to in the AAIU report that after the initial impact with the Island, the airframe experienced significant disruptions to integrity and flight path.

We do not know if the speed reported is calculated by the sending system, or extrapolated from the last known position.

Another possible reason is that as a result of the disruption to the flight path, the horizontal speed at the time of that report may well have been 9 Kts, as the aircraft may well have been falling more than it was moving horizontally.

There are also possible discrepancies in the capture and recording of some sources of the data, so while it is indeed a possible anomaly, the fact that AAIU have not commented on it at this time suggests to me that it is not an item of interest or significance.

On that basis, I am going to suggest that this aspect of the speed be dropped, as it is clearly not of interest to the ongoing investigation

L1011 · 13-04-2017 11:17PM

kona wrote: »

Anybody who mentions that again should be banned. It's infuriating.
The only figures that matter are in the report.

Will be banned.

ectoraige · 13-04-2017 11:17PM

TallGlass wrote: »

Out of interest, why is Google maps not used?

I don't think Google strives for the same accuracy, it's designed with different parameters. Sadly, it might have been good enough on the night.

L1011 · 13-04-2017 11:18PM

TallGlass wrote: »

Out of interest, why is Google maps not used?

Because its woefully inaccurate? Of the three* major commercial consumer map vendors it'd be dead last. It is not suitable for any safety critical purposes nor does it intend to be.

*well, four with Apple's horror but that's only available on their kit.

smurfjed · 13-04-2017 11:19PM

Many pages ago, someone stated that a normal approach would be a 3 degree approach, this would ideally have them at an altitude of 3000 feet 10 nms away. While that information is kinda correct for a standard instrument approach, that wasn't the case with this helicopter. From the report they were following a lateral flight profile programmed into the FMS, that procedure (3.58 Operator Route Guide) doesn't show a vertical profile.
Due to the cloud base of 300-400 feet, (4 Weather) and the use of the APP 1 Transition to Low Level, it appears that they elected to descend to 200 feet at position BLKMO to commence the approach with adequate visual reference.
Why was this never seen before, unfortunately maybe no one had encountered such a low cloud base while following this procedure.
The last seconds of the CVR are extremely sad.

uck51js9zml2yt · 13-04-2017 11:19PM

I think the bigger issue is the alleged voice recorder details coming into the public domain.
It appears the winchmen saw Blackrock which wasnt on the map and knew they were gone!

scuby · 13-04-2017 11:19PM

At this stage we should be thinking about the last few seconds of their lives, and what they saw, experienced, rather than trying to get one up on each other..... #heartbroken

ted1 · 13-04-2017 11:20PM

elastico wrote: »

robyntmorton wrote: »

From my reading of the report, we have the how of the accident:

* The aircraft crossed Ireland in a high altitude cruise.
* The aircraft transitioned from cruise to low level flight, stopping at 2,400 ft.
* The SAR APP1 mode was selected, which brings the aircraft to low level operations as per a standard process (to 200ft/80kt)
* We do not know what mode the EGPWS was in, but its low altitude switch was set to ON. This affects warnings issued, to avoid having the alarm sound while in the middle of the job.
* The aircraft was on approach to Blacksod as per a company SOP approach. We do not know whether this is machine flown, or manual via the autopilot systems
* The two pilots had not flown an approach to Blacksod recently
* There were weather issues in the area (mist/drizzle - visibility 2-3km)
* The Health and Usage Monitoring System HUMS recorded no technical anomalies.
* There was no mention of Blackrock in the approach briefing
* At impact -13 seconds the rear seat crew queried the presence of an island ahead, recommending a right turn for avoidance
* The pilot flying requested confirmation of turn
* Rear crew recommended a 20 degree right turn
* This was selected on the autopilot heading dial
* At the same time the rear crew started urgently repeating "come right"
* The aircraft struck the rock in a nose high attitude, and departed from controlled flight

All that tells us is what happened - that it was CIFT. It does not tell us WHY it happened. We do not know whether the crew mis positioned the aircraft at the start of the approach, if there was a slight position error provided to the flight management systems, or a number of factors which contributed to it.

I can only commend the crew, those involved in the rescue effort, and the AAIU for being so thorough in their preliminary report and work so far. We have been given a lot of detail tonight, which will of course require a lot more for the final report.

If it was, this crash would have happened years ago surely?

Is the altitude in the sop adjusted based on cloud cover ?

Gaoth Laidir · 13-04-2017 11:20PM

Steve wrote: »

You are adding nothing to this discussion other than to get peoples backs up.

1 week ban.

Amen to that.

Means Of Escape · 13-04-2017 11:23PM

TomOnBoard wrote: »

The report explains the 200ft question. It was part of the Approach1 pre-programmed option to allow the aircraft change from high altitude/high speed flight to low altitude/ low speed flight. It also governs the speed to 80kts, which was then adjusted manually to 75kts to allow for tailwinds.

That is fine with full external visual aids during light hours however I am sure that this height will be adjusted 5 fold in recommended height approaches after this report .
Given that the crew would have been aware of the island, regardless of it not bring in their software ,one would expect to have a route with a clearance of at least 500 feet above the highest point of a known obstacle even with poor visibility at that higher level .

screamer · 13-04-2017 11:23PM

Awfully sad to hear that they knew they were gone. Awful for their families to know that it gives no comfort not answers. Who maintains the database for the software? Or in this case who didn't?

Dwarf.Shortage · 13-04-2017 11:26PM

The thing that jumps out at me from that report is that all it would've taken to avoid the accident was clearer communication that the 20 degree right turn was urgent. Whether the instruction should have been clearer or the listening better is neither here nor there, how many times a day does everyone miscommunicate ever so slightly?

The grave consequences of a such a simple miscommunication highlight how dangerous this line of work is. As for the last few seconds of audio, extremely difficult to read.

P.lane78 · 13-04-2017 11:29PM

Stupid question from an interested observer why isn't the approach to blacksod from the land side ...is it terrain based

Bussywussy · 13-04-2017 11:30PM

kona wrote: »

Yes really, the software was incorrect, it guided them into a rock.

EGPWS isn't a navigation tool as the WS at the end indicates,the latest software avail was installed,the omission of Blackrock didn't guide them anywhere as EGPWS as I said is a warning system

jimmycrackcorm · 13-04-2017 11:30PM

I'm not sure if I'm interpreting what I'm reading correctly but was the intention to come right by inputting the direction instead of simply manual turning?

ectoraige · 13-04-2017 11:31PM

elastico wrote: »

If it was, this crash would have happened years ago surely?

I think it's the case that the crash could have happened years ago. If crews first flew into Blacksod using that approach in daylight then they would have awareness of the size of Blackrock. If there was a higher cloudbase then perhaps a flight mode other than APP1 would have been used. There are likely other approaches too that may be used. It could even be the case that had the light of the lighthouse been pointing in a different direction the pilots may have spotted it.

TomOnBoard · 13-04-2017 11:31PM

ectoraige wrote: »

elastico, I think you're missing the fact that a waypoint is nothing more than a point on the map, sometimes it corresponds with a feature, sometimes not. BLKMO was the waypoint set, which does in this case correspond with Blackrock, but it was chosen because their route guide said to go to BLKMO to get to Blacksod.

If you asked for directions to a pub and I told you to turn left at a church would that mean you wanted to go to mass?

I think that's the nub of a huge issue here. If your directions say turn left AT the church, but if I drive THROUGH the church, a very different result will occur.

page 5 of the report states that "The Commander then requested a 'direct to BLKMO' selection" on the FMS, thereby inadvertently turning a waypoint into a destination. The EGPWS did not, and terrain mapping systems might not, have Blackrock data within them, thereby rendering their functionality dangerously useless as a means of warning or alerting the crew.

The fact that BLKMO was even on a route as a company supplied route waypoint is astounding, given that it has a height of 282 ft, and a valid approach for that route (Approach1) had a flying height of 200 ft at a speed of 80 kts. Aghast!!!

Dwarf.Shortage · 13-04-2017 11:33PM

TomOnBoard wrote: »

I think that's the nub of a huge issue here. If your directions say turn left AT the church, but if I drive THROUGH the church, a very different result will occur.

page 5 of the report states that "The Commander then requested a 'direct to BLKMO' selection" on the FMS, thereby inadvertently turning a waypoint into a destination. The EGPWS did not, and terrain mapping systems might not, have Blackrock data within them, thereby rendering their functionality dangerously useless as a means of warning or alerting the crew.

The fact that BLKMO was even on a route as a company supplied route waypoint is astounding, given that it has a height of 282 ft, and a valid approach for that route (Approach1) had a flying height of 200 ft at a speed of 80 kts. Aghast!!!

BLKMO is not Blackrock Island, it's nearby but not the island.

Junkyard Tom · 13-04-2017 11:35PM

I presume the families would have been briefed about all this before it went to press?

Damien360 · 13-04-2017 11:35PM

I an a bit confused after reading the report. There is more than one mapping system but it mentions early in the report the option to add custom details. I assume this is for pylons etc for pilots to add. 116 and 118 would have flown there many times with many crews. Did nobody see the error in the maps before or was it too weird an omission to be really noticed.

Very sad reading and the 2 recommendations just seem all too late.

ED E · 13-04-2017 11:35PM

jimmycrackcorm wrote: »

I'm not sure if I'm interpreting what I'm reading correctly but was the intention to come right by inputting the direction instead of simply manual turning?

That's how I read it too. I would guess when flying at night by instruments course is knob controlled by default rather than using the stick.

gctest50 · 13-04-2017 11:36PM

Valentina Savory Pacemaker wrote: »

I think the bigger issue is the alleged voice recorder details coming into the public domain.
It appears the winchmen saw Blackrock which wasnt on the map and knew they were gone!

The winchmen saw it and recommended 20 degree right :

A rear crew member identified an island, probably through the use of the EO/IR camera, approximately 13 seconds prior to the initial impact with terrain.

He said “looking at an island just in, directly ahead of us now guys, you want to come right [Commander’s Name]”.

In response to a query “OK, come right just confirm?”

from the Commander, the rear crew member said “twenty degrees right yeah

Rear Crew

2.02:52.035: twenty degrees right
yeah

kona · 13-04-2017 11:39PM

Bussywussy wrote: »

EGPWS isn't a navigation tool as the WS at the end indicates,the latest software avail was installed,the omission of Blackrock didn't guide them anywhere as EGPWS as I said is a warning system

OK I'll explain this further.

The pilot sets his auto pilot to whatever heading and speed and altitude he likes.
It's dark so he's flying by his instruments. He descends to 200ft at 75 knots and is ticking away nicely. No warnings no nothing the he would expect to hear or see in the event of terrain ahead.

Ticking along nicely, the Winchman sees the rock on his infrared suite and instructs the pilot to change his course 20 degrees to the right.
Unfortunately he's too late.

Now if the software had this information he would have heard "terrain terrain pull up"....and pulled up in time with no fuss.

The pilot relied on his equipment which let him down because the software was wrong and inaccurate. This is what I'm saying.

UsedToWait · 13-04-2017 11:41PM

kona wrote: »

OK I'll explain this further.

The pilot sets his auto pilot to whatever heading and speed and altitude he likes.
It's dark so he's flying by his instruments. He descends to 200ft at 75 knots and is ticking away nicely. No warnings no nothing the he would expect to hear or see in the event of terrain ahead.

Ticking along nicely, the Winchman sees the rock on his infrared suite and instructs the pilot to change his course 20 degrees to the right.
Unfortunately he's too late.

Now if the software had this information he would have heard "terrain terrain pull up".

The pilot relied on his equipment which let him down because the software was wrong and inaccurate. This is what I'm saying.

Excuse my ignorance, but was the helicopter being flown by autopilot when it crashed?

irishgeo · 13-04-2017 11:42PM

Damien360 wrote: »

I an a bit confused after reading the report. There is more than one mapping system but it mentions early in the report the option to add custom details. I assume this is for pylons etc for pilots to add. 116 and 118 would have flown there many times with many crews. Did nobody see the error in the maps before or was it too weird an omission to be really noticed.

Very sad reading and the 2 recommendations just seem all too late.

Maybe the cloud base was never at 300ft before.

P.lane78 · 13-04-2017 11:42PM

Obviously not pre empting the full report, but is this a matter of investigating a fatal conflict between SOP, weather conditions and recent crew familiarity...

Alkers · 13-04-2017 11:43PM

L1011 wrote:

Because its woefully inaccurate? Of the three* major commercial consumer map vendors it'd be dead last. It is not suitable for any safety critical purposes nor does it intend to be.

Interesting that the aaiu themselves use it in the report

kippy · 13-04-2017 11:44PM

Had a read of the report there.
As with a lot of incidents of this nature and as many people have already said on this thread it appears that a number of things went wrong, the ultimate result being fatal for the crew.
Any one change in circumstances at the time and/or different set of variables and this doesn't happen - as had been discussed already. But that unfortunately is the same for many fatal incidents.

There will no doubt be more questions answered in the full report and I don't believe that needless speculation should be started off again. The investigators have made some directives out of this already and there may be more from the full report.

I hope that the two crew who are still missing are found and some closure can be brought to their families.

RIP to all four crew.

Thanks to all who are in the emergency and rescue services who are doing their best for us on a day to day basis.

Reading that report (as well as many similar) really highlights the thin line between life and death.

TomOnBoard · 13-04-2017 11:45PM

Dwarf.Shortage wrote: »

BLKMO is not Blackrock Island, it's nearby but not the island.

Not as I read it. That crosshairs is very much on the island according to the route map in the report.

Irish Steve · 13-04-2017 11:46PM

UsedToWait wrote: »

Excuse my ignorance, but was the helicopter being flown by autopilot when it crashed?

Yes, in that there is less risk of the automation becoming disoriented in mixed instrument/visual conditions, and it allows the pilot to concentrate on the "bigger" picture rather than having to concentrate hard on flying the machine.

Flying a helicopter, especially in the hover, was once described to me as being akin to balancing a tennis ball on the point of a knitting needle. The automatics are very well capable of doing that task very well indeed.

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

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