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

ProfessorPlum · 14-04-2017 01:45AM

Irish Steve wrote: »

And unfortunately, we have no way to know why that page was not referred to in their briefing, and it's also interesting that AAIU did not include that information in their report. I would want a lot more detail before I would be prepared to commit to flying that approach. we also do not have the information that's in their navigation system, I would expect that to have altitude at the waypoints.

We are unfortunately reduced to reading between the lines in some areas, or speculating, and I'm not going there, we may get some more detail in the final report, I suspect that AAIU are still working very hard to firm up on some of the issues that are only at present highlighted by this interim report

The report doesn't say that that page wasn't refered to in their briefing. It says that there was no mention of an obstacle at Blackrock. It seems there was an error of omission in the planing of the approach and a breakdown in situational awareness. What the reasons were for this are unclear. Hopefully the AAIU will be able to come up with some answers over the coming months.

emo72 · 14-04-2017 01:45AM

What does "smoke in baggage" mean? It's from the journal article this evening

wotswattage · 14-04-2017 01:47AM

Roger_007 wrote: »

So, how come they were flying at an altitude of 200ft at the start of their approach. That makes no sense.

Junkyard Tom wrote: »

Is it unusual?

I guess that's the question nobody here can answer without the full report, is it normal/common to descend to 200ft before the first waypoint or is it intended to start from a height and only descend to the 200ft mark towards the end of the sequence of approach waypoints??

Irish Steve · 14-04-2017 01:49AM

ProfessorPlum wrote: »

The report doesn't say that that page wasn't refered to in their briefing. It says that there was no mention of an obstacle at Blackrock. It seems there was an error of omission in the planing of the approach and a breakdown in situational awareness. What the reasons were for this are unclear. Hopefully the AAIU will be able to come up with some answers over the coming months.

Fair comment, and yes the final report will be a very thought provoking read, and may well yet surprise us with some of the findings.

Roger_007 · 14-04-2017 01:55AM

Steve wrote: »

The report says nothing of the sort and to be honest I am getting really ticked off with this ill informed response.

Please explain how you came to this conclusion and why you should not be banned from this forum for ignoring all the previous warnings.

I came to my conclusions from reading the report. I am simply offering the possibility that there may have been an error by the crew in the instructions they fed in to the flight management system.
I know that this may be regarded as speculation, but the facts that are known so far offer no other explanation.

PS.......I do not intend to make any further posts on this matter.

Irish Steve · 14-04-2017 02:05AM

emo72 wrote: »

What does "smoke in baggage" mean? It's from the journal article this evening

It will be a sensor warning, but as the airframe had suffered catastrophic damage as a result of contact with Blackrock, it can be discounted as an alarm caused by damaged or broken wiring in that area of the airframe.

TomOnBoard · 14-04-2017 02:24AM

faoiarvok wrote: »

The vertical descent here serves a different purpose to an ILS approach or similar. The descent is being conducted in order to break through the clouds and gain visual reference for the rest of the flight. The descent was done well out from Blacksod in order to come to a low level over water that was unfortunately misunderstood to be obstacle and terrain free. The rest of the flight to Blacksod was intended to be carried out at this altitude, with the surface in sight, and with enough visibility to see and avoid terrain.

Nutshell!

And to add to that misunderstanding (for whatever reason), two separate systems that might have provided useful warnings of an impending obstacle did not contain data upon which they could act.

duskyjoe · 14-04-2017 02:50AM

Enough has been said, kudos to mods regulating full time.
God bless the crew members poor souls, an utter heart breaking tragedy. I felt genuinely ill when I read the initial report today. So did my colleagues.
If true I find it shocking Blackrock was not in the EPGWS data base.

BoatMad · 14-04-2017 02:55AM

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.

Yes but it was up to the captain to decide the point and method of the letdown, the mode selected is a SAR mode

BoatMad · 14-04-2017 03:18AM

rwaldron21 wrote: »

So Enhanced Ground Positioning Warning System did not have the "lighthouse obstacle" included in an obstacle database and the "terrain of the island" was not listed on the terrain database.

How on earth, in this day and age, can such obstacles not exist on these systems.

Makes me wonder how many more Obstacles are missing........

I have sailed very highly automated yachts and motor boats , with full integrated autopilot , Ais and APRA auto target tracking , with auto route inspection software , full authority autopilots etc

I have seen first hand what such over reliance on technology can bring , virtually to the point where navigators refuse the evidence of their own eyes.

Several very stark issues are clear , even if all the answers aren't

(A) the stupidity of an approach , ( the preprogrammed operators route ) that passed over a 300 foot island , while there was open sea to the north and south. The blame here's lies with chc

(B) the acknowledged lack of local knowledge admitted to by both pilots

(C) Blackrock was marked on the gps maps at certain zoom levels , the route was not checked to confirm this , at no point ( seemingly ) did the pilots realise the island lay under the pregrogramned approach route

(D) no clear reason has been advanced why a SAR orientated letdown to 200 feet was enacted so far away from the LZ. Clearly the testimony of Rescue 118 which is the local crew is needed to confirm what the appropriate letdown procedure was applczble to the " approach to Blacksod south " , because clearly the one used on that night was not the correct one.

(D) the lack of Blackrock of n the terrain database is inexplicable , but the fact remains that any blind allegiance to automated database ( i.e. prestored) avoidance systems will get you killed.

I personally , feel the accident was due to a massive loss of situational awareness , the pilots simply never realised the island was undernesth them.

The remaining question still remains , this was confirmed to be an operational lighouse , the helicopter actually hit the outbuildings of the lighthouse . How did the lack of situational awareness extend to not seeing a great big light in front of you. This I find hard to understand.

BoatMad · 14-04-2017 03:30AM

Roger_007 wrote: »

I came to my conclusions from reading the report. I am simply offering the possibility that there may have been an error by the crew in the instructions they fed in to the flight management system.
I know that this may be regarded as speculation, but the facts that are known so far offer no other explanation.

PS.......I do not intend to make any further posts on this matter.

There is compelling evidence that the route chosen was the appropriate ( if badly preprogrammed ) operator standard approach. the tradgy was the waypoints took them over Blackrock ( it could be speculated that this was deliberate to provide visual confirmation of the route )

The issue was the decision to perform a letdown to 200 feet by a crew that had no awareness that a 300 foot island lay on the approach despite the fact, that as I understand it , the plates and maps had that information contained within them , even if the terrain warning system did not. That resulting lack of situational awareness was the ultimate cause of the accident.

the result makes for very sobering reading in relation to the issues of our dependence on automated nav aids.

ChikiChiki · 14-04-2017 04:12AM

Dwarf.Shortage wrote: »

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.

That was one factor that jumped out at me aswell from the report. If there was more urgency in the initial request to turn right from the back it may well have been avoided. Between the confirmation request and heading change valuable time was lost. Perhaps it will lead to a new communication procedure.

We have lost a great team who have served the country well.

RIP to the crew.

BoatMad · 14-04-2017 04:29AM

ChikiChiki wrote: »

That was one factor that jumped out at me aswell from the report. If there was more urgency in the initial request to turn right from the back it may well have been avoided. Between the confirmation request and heading change valuable time was lost. Perhaps it will lead to a new communication procedure.

We have lost a great team who have served the country well.

RIP to the crew.

Approx 14 seconds elapsed from the point the crew member begin speaking the initial warming of the island to the impact. Approx 3 seconds after the change route was programmed the helicopter impacted. Looking at the cyclic logs it's clear the helicopter had not even begun the manoeuvre.

What I cannot explain , is that after performing the letdown to 200 feet , the helicopter was 1.5 nautical miles away from Blackrock ( or more correctly the waypoint , which was just to the west of the lsland ) it began a slow programmed turn to the approach the way point , hence for well over 3/4 of that distance , ( 40-50secs), the helicopter was flying directly towards a working lighthouse, at very low altitude yet no one commented on the light !! ( which they didn't expect to be there )

What's further inexplicable is that the commander knew of the existence of the two very small islands 0.65nm west of Blackrock , yet seemingly had no situational awareness of Blackrock itself , very very strange indeed.

TomOnBoard · 14-04-2017 07:28AM

Just in relation to the ongoing recovery operation, I note a few areas in the AAIU report that may be of relevance.

The report is very detailed for this stage of the investigation. It states how all 4 crew members were seated and what kind of restraints were used. It itemises parts of the wreckage that were found and gives an indication of their location. It indicates that the cabin floor and lower fuselage separated from the more substantial entirety of the cockpit, cabin ceiling, gearbox and engines. This separation took place aft of the front landing gear.

While the cockpit remained largely intact when found on the seabed, much of the cabin/fuselage seems to have been damaged, with a number of items on the left side of the aircraft being specifically mentioned as shattered, honeycombed, broken etc. while items on the right side, although separated from the fuselage were found largely intact.

In all the items mentioned as having been located, no mention is made of the 2 seats with their 4-point safety harnesses of the winch crew. The operators console was found near the wreckage on the sea bed as were the winch mechanism, a litter structure and utility seating. I believe the silence in respect of those 2 seats is significant, and as we know that at least the Operator was in his position as demonstrated by the call outs to turn right, it is reasonable to conclude that he was strapped in his seat at the time. It is also reasonable to conclude that as both men and their seats are missing and their location suffered catastrophic structural damage at some point between the crash and the wreckage coming to rest on the seabed, they are (or were) still in their seats in the vicinity of the crash site.

And those seats have not been found.

Gaoth Laidir · 14-04-2017 07:34AM

The TRA that had been set up around Blackrock has finally been lifted.

arubex · 14-04-2017 07:40AM

Razor44 wrote: »

The call out from the rear crew of 'island ahead come right' was met with a call for clarification (correctly).

I hope the final report investigates whether the rear crew in CHC operations feel empowered in terms of input to flight direction. Why wasn't there an 'immediate turn right 20' or 'immediate stop' command available and trained?

That call and the subsequent nine-second dialogue reminded me of the cockpit management issues that many airlines experienced in the 1980s / 90s when the less-senior crew had to 'make a case' to the pilot-in-command as to an action they were recommending.

The S-92 simulators that I've researched this morning are flightdeck-crew only. I think that's an oversight, the entire crew should be trained together because when things go bad it's the entire crew that needs to work together.

ironclaw · 14-04-2017 08:23AM

Section 5.3 ... Automatic Identification System (AIS)
.... Various agencies such as the Health Service Executive (HSE) are also provided with this data.

Curious to know if anyone knows, why would the HSE want AIS data?

TomOnBoard · 14-04-2017 08:27AM

ironclaw wrote: »

Curious to know if anyone knows, why would the HSE want AIS data?

So that it can track incoming HEMS missions to ensure everyone is ready to receive the emergency when it arrives?

Dubh Linn · 14-04-2017 08:31AM

Do you have a link for the PDF version of the report?

ironclaw · 14-04-2017 08:39AM

Dubh Linn wrote: »

Do you have a link for the PDF version of the report?

https://static.rasset.ie/documents/news/preliminary-report-2017-006.pdf

14-04-2017 08:41AM

Has it been confirmed that the lighthouse was actually working that night? It seems very strange that nobody mentions the light or refers to the island as i assume it should have been visible for quite some time...

TomOnBoard · 14-04-2017 08:43AM

Deleted User wrote: »

Has it been confirmed that the lighthouse was actually working that night? It seems very strange that nobody mentions the light or refers to the island as i assume it should have been visible for quite some time...

Confirmed in the report.

The Hill Billy · 14-04-2017 08:44AM

Dubh Linn wrote: »

Oh for Christ's sake, can you please just give me a link for a PDF of the bloody report! I'm not exactly asking ye to stick burning needles in your eyes!

Admin Note: Banned for 3 days. When you come back, act a bit more civil to other posters.

tHB

irishgeo · 14-04-2017 08:45AM

[Deleted User] wrote: »

Has it been confirmed that the lighthouse was actually working that night? It seems very strange that nobody mentions the light or refers to the island as i assume it should have been visible for quite some time...

It was working. But with low cloud maybe they didn't see it or it was between flashes. The helicopter moves alot faster than the ships it was designed for.

shamrock55 · 14-04-2017 08:48AM

Excuse my ignorance here but would the pilots or crew not have seen the island when they approached it themselves without the need for this tech,or are these helicopters flown by looking at screens?

ED E · 14-04-2017 08:52AM

shamrock55 wrote: »

Excuse my ignorance here but would the pilots or crew not have seen the island when they approached it themselves without the need for this tech,or are these helicopters flown by looking at screens?

Middle of the night, see very little out the window.

DOCARCH · 14-04-2017 08:54AM

ED E wrote: »

Middle of the night, see very little out the window.

And....the clue is in the name....Blackrock.

kerry cow · 14-04-2017 08:58AM

DOCARCH wrote:

And....the clue is in the name....Blackrock.

Ya Blackrock with a lighthouse on top !!!!!

shamrock55 · 14-04-2017 08:59AM

Fair enough,i actually thought the incident took place early morning (dawn) and that visability was quite good,i was wrong obviously

sword1 · 14-04-2017 08:59AM

It can be hard to judge how far away a lighthouse is, remember the speed the helicopter was travelling at it could seem that the light was a few miles further away if he was not expecting it to be there. I presume the rock should show on their radar though and if you had a light and a target and were paying full attention it should have been apparent. Unfortunately it looks like a combination of over reliance on the electronic s and not being fully attentive to all the available information and what was outside the window. In the situation of going straight ahead surely the pilot should see any obstacles first and not the crew behind. From the transcript it seems he was not aware of it even when it was pointed out

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

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