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

Wombatman · 14-04-2017 11:24AM

Storm 10 wrote: »

Have listened to Rescue 115 and 118 making approaches to UHG in poor weather, they fly out over the Bay and descend to 200 feet and follow the River Corrib to the hospital

At night? How do they make out the river?

Storm 10 · 14-04-2017 11:27AM

Wombatman wrote: »

At night? How do they make out the river?

They fly low level towards Galway Harbour then follow the River up, the Hospital is to the left of the river.

L1011 · 14-04-2017 11:29AM

There are so many reported posts, nearly all of which break the rules for this thread, that I need to briefly lock it for review and cleanup. There will be cards and bans.

L1011 · 14-04-2017 11:31AM

gctest50 wrote: »

The winchman started playing at navigation and sent them straight into the island.

That helicopter very nearly made it

Climbs at about 1500 feet per minute

Week off for this and other speculation and blaming

L1011 · 14-04-2017 11:40AM

I think I've got the worst of the nonsense removed. Please continue to report posts

Reati · 14-04-2017 11:48AM

Wombatman wrote: »

Any information on the condition and number of warning lights around the lighthouse complex on Blackrock? Surely there were red blinking lights all the way up the tower and around the complex to warn aircraft of a tall structure.

In fairness, if they didn't notice the bright flash of the lighthouse a little red light wouldn't have made much difference in those weather conditions imo

Wombatman · 14-04-2017 11:49AM

gctest50 wrote: »

The Operators Route Guide identifies the lighthouse

Not my question. My question is were there many\adequate warning beacons around the lighthouse\helipad on Blackrock to assist in visual identification?

TomOnBoard · 14-04-2017 11:53AM

Storm 10 wrote: »

They fly low level towards Galway Harbour then follow the River up, the Hospital is to the left of the river.

And a 150 ft high Cathedral is on the right.... Frightening!

Means Of Escape · 14-04-2017 11:59AM

smurfjed wrote: »

Due to overcast CLOUD coverage. As you get closer to your destination you still have to descend but now you are doing in with terrain surrounding you.

200 feet 10 miles out ?

stampydmonkey · 14-04-2017 12:00PM

TomOnBoard wrote: »

And a 150 ft high Cathedral is on the right.... Frightening!

Not of any significance...But it would actually be on the left.

January · 14-04-2017 12:04PM

stampydmonkey wrote: »

Not of any significance...But it would actually be on the left.

Presumably, they fly just past the cathedral in that case and turn left just after it to approach the hospital?

TomOnBoard · 14-04-2017 12:05PM

stampydmonkey wrote: »

Not of any significance...But it would actually be on the left.

So that makes it smaller and somehow less frightening? Not for me, I'm afraid.

Reg'stoy · 14-04-2017 12:13PM

arubex wrote: »

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.

I have been following this thread with interest and as former military rear crew who knew the two Rear crew very well and one of the pilots reasonable well (professionally) I just wanted to step in and put some things to right that seem to be creeping into posters opinions.
Firstly I want to say that CRM (Crew Resource Management) has been industry standard (in heli's) for a number of years now.
All members of this crew were highly experienced and would have worked together regularly as a 'team', all opinions and I mean all opinions are heard and acted upon when given in the aircraft. All members of the crew would have had an input into the brief for the approach to refuel.
All of the crew would have communicated with each other in highly stressful environments and these 'comms' would invariably always be relayed in a calm manner which would belie the situation. Giving patter over a pitching deck has to be done calmly.

To think that one of the rear crew would have felt worried or not been forthright in offering an opinion or instruction (until we know the full story) to me belittles their training and professionalism of all of the crew.

Alun · 14-04-2017 12:19PM

One thing I don't quite understand about all this .. if this was supposedly a standard, pre-programmed approach to Blacksod as the diagram in the report indicates, how is it that the lack of Blackrock on the warning system hasn't been highlighted before, or worse still a similar accident or near miss?

Another thing that strikes me is that they've redacted the name of the terrain data provider ...

This data is originated by the [named source], and does not include obstacles on Black Rock

I'd say that whoever [named source] is, they'll be getting very nervous right now.

Steve · 14-04-2017 12:34PM

Alun wrote: »

One thing I don't quite understand about all this .. if this was supposedly a standard, pre-programmed approach to Blacksod as the diagram in the report indicates, how is it that the lack of Blackrock on the warning system hasn't been highlighted before, or worse still a similar accident or near miss?

They didn't publish the textual part of the approach, it exists, it was mentioned in the report, so we don't know if it included any vertical guidance or MSA information for the waypoints.

It's possible the approach hadn't been flown at night before in these meteorological conditions. I'm sure the AAIU will focus heavily on this in the course of the full investigation.

LeakRate · 14-04-2017 12:39PM

On page 6 of the report it states BLCKMO as a waypoint, at which the approach to Blacksod is to commence. It states that it is close to Blackrock itself.

Also in figure 4 of the report, it states the route guide shown in figure 4 has a seperate page of text setting out hazards and obstacles amoungst other things. I assume the numerical points on the route guide in figure 4 are then referred to on the page of text, which by the looks of it, number 1 refers to blackrock Island itself.
I'm sure this page will be in the final report, will be interesting to see it.

BoatMad · 14-04-2017 12:50PM

UsedToWait wrote: »

I really hope that the families get some comfort from this, weird as it sounds..
To me, as a complete outsider to the aviation world, it seems open and shut.
They were given incorrect/incomplete information to complete the job at hand safely.
RIP

sorry unfortunately not, classic loss of situational awareness due to over reliance on automated aids

its fine for 99.9% off the time, unfortunately the .1% kills you stone dead

Means Of Escape · 14-04-2017 12:52PM

Irish Steve wrote: »

In the light of the (incomplete) information they had available to them, there was no known risk in being at that altitude, and much of their every day activity was carried out at those sorts of levels, so it would not have been unusual or out of the ordinary for them to operate at those sorts of altitudes

Having said that, my anticipation initially, in the absence of information about a standard company approach was that they would have been crossing Blackrock at about 3000 Ft, and then doing the equivalent of an ILS terminating at about 2 miles south of Blacksod, with a visual transition to land.

There are risks flying at low altitude (micro bursts)and any pilot would favour having a better clearance from terrain/sea (than 200ft) to have time to react to an emergency(mechanical failure ) or to make an evasive manoeuvre .
It is beyond comprehension why the protocol set out by the administration allowed/authorised an exceptionally low approach altitude (day or night)this no doubt will be changed immediately

There was a sustained flight at 200 ft very far from the destination and regardless of cloud cover can be deemed as very risky .

Alun · 14-04-2017 12:54PM

On the terrain data front, I can confirm that Blackrock does indeed show up in the SRTM 3 arc sec (approx. 90m) resolution world data set. I use it myself in a couple of PC mapping programs and put in the coords of Blackrock to check. It only shows a max elevation of 15m though due to the averaging nature of such low resolution DEMs but still, it's difficult to see how something like this could be missed.

TomOnBoard · 14-04-2017 12:56PM

Alun wrote: »

I'd say that whoever [named source] is, they'll be getting very nervous right now.

There are many parties with a huge interest in learning from this with a view to making future operations in many other locations safer and preventing similar accidents in the future. I don't see responsible operational entities whose products or services were in use on that flight feeling nervous; rather I see them probably feeling more sadness than nerves and will focus on making whatever changes are needed whether in procedures, equipment or personnel. Granted some legal and commercial divisions may be more nervous, but I think the aviation industry is usually much better at identifying issues and correcting them than most large corporations in other industries.

BoatMad · 14-04-2017 12:59PM

Means Of Escape wrote: »

There are risks flying at low altitude (micro bursts)and any pilot would favour having a better clearance from terrain/sea (than 200ft) to have time to react to an emergency(mechanical failure ) or to make an evasive manoeuvre .
It is beyond comprehension why the protocol set out by the administration allowed/authorised an exceptionally low approach altitude (day or night)this no doubt will be changed immediately

There was a sustained flight at 200 ft very far from the destination and regardless of cloud cover can be deemed as very risky .

I do not believe than the operator route details contains specific flight levels that were tp be maintained at each waypoint, Hence you are speculating here.

Lets be clear, the report said that the pilots did have access to information ( the approach briefing and the Moving maps contained information that described blackrock and reported its height

homerjay2005 · 14-04-2017 01:12PM

this part from the RTE report is very interesting especially that they kept descending as opposed to avoiding.

The first indication of an obstacle comes 26 seconds before the initial impact when an automatic warning system gave a call-out "Altitude, altitude".

Thirteen seconds later one of the crew members in the back of the aircraft identified an island and advised the captain to veer right, away from the island, and in the seconds that followed the helicopter descended and hit into Blackrock.

the fact that it was only the tail that hit the island, means they were only a couple of metres perhaps, from safety. we are talking 1 or 2 seconds could and would have saved their lives.

this is such an avoidable incident, 5 or 6 factors all came together to cause this and it was oh so simple.

wexandproud · 14-04-2017 01:16PM

BoatMad wrote: »

sorry unfortunately not, classic loss of situational awareness due to over reliance on automated aids

its fine for 99.9% off the time, unfortunately the .1% kills you stone dead

this is what i was the point i was trying to make earlier when i asked about using the lighthouse as a reference point . While it does appear that the lighthouse may not have been on their systems it was referred to in the route as a waypoint so people knew it was there.
it reminds me of an old fisherman a few years ago , he said it doesn't matter whats the chart says if someone tells you there is a rock there you better assume its there

BoatMad · 14-04-2017 01:18PM

homerjay2005 wrote: »

this part from the RTE report is very interesting especially that they kept descending as opposed to avoiding.

the fact that it was only the tail that hit the island, means they were only a couple of metres perhaps, from safety. we are talking 1 or 2 seconds could and would have saved their lives.

this is such an avoidable incident, 5 or 6 factors all came together to cause this and it was oh so simple.

typical media inaccuracies, The preliminary report showing the FDR bar altitude shows a contistent 200 foot approach until the impact point

The key point is this , we live increasing in an age where we rely on technology to " save our asses ". 99.9% of the time it works , 0.1% it fails and we die. complacency in the face of increasing " capable " automated technology is a key issue and this is not the first air crash that exhibits it.

Means Of Escape · 14-04-2017 01:19PM

BoatMad wrote: »

I do not believe than the operator route details contains specific flight levels that were tp be maintained at each waypoint, Hence you are speculating here.

Lets be clear, the report said that the pilots did have access to information ( the approach briefing and the Moving maps contained information that described blackrock and reported its height

If it transpires that there are no specific flight levels to be maintained as standard protocol then this level of 200 feet 10 miles out was decided by the crew and the level dictated by cloudcover solely ?

Informed and intelligent theories not speculating .

Reati · 14-04-2017 01:34PM

Reg'stoy wrote: »

All members of this crew were highly experienced and would have worked together regularly as a 'team', all opinions and I mean all opinions are heard and acted upon when given in the aircraft.

Exactly, the pilot listened to the other crew and went to make the course correction once it was confirmed but they didn't have time to complete it.

I wouldn't expect a pilot to suddenly veer right without at least asking for confirmation. Placing oneself in the situation mentally, I can't see what else they could have done (without our benefit of hindsight). They weren't expecting and didn't know there was an object in front of them, when they did it was too late to do anything.

Discodog · 14-04-2017 01:42PM

There must be a way for the rear crew to give an obey instantly commands. To me the transcript reads that the initial turn right sounds like a navigation request rather than an emergency command.

Those extra seconds could of made a big difference.

BoatMad · 14-04-2017 01:46PM

Means Of Escape wrote: »

If it transpires that there are no specific flight levels to be maintained as standard protocol then this level of 200 feet 10 miles out was decided by the crew and the level dictated by cloudcover solely ?

Informed and intelligent theories not speculating .

The fundamental issue was a crew unfamiliar with the approach , did not seemingly appraise themselves of the detail of the approach waypoints and missed a key obstacle . They then transitioned down t0 200 feet and 75 knots and turned to the waypoint all the time remaining unaware till until very near the end that a major obstacle was in front of them .

However the basic fact remains that a lighthouse , confirmed operational , flashes at FL(12) which is a brief flash every 12 seconds, covering the sector they were flying on with a 16 nautical mile range , which they would have clearly seen at 200 feet ( as it would have been 100 feet above them ) directly in their path once the turn was completed, i.e. they were flying directly at it for 40-50 seconds and that this causes " no pause for thought " or even cockpit comment.

My view here is that , having no cause for concern that flight crew were focused on the " computers " and failed to acknowledge what was clearly " out there in front of them " . I have seen exactly the same issues in highly instrumented boats for example.

The lack of terrain warning was neither here nor there.

BoatMad · 14-04-2017 01:49PM

Discodog wrote: »

There must be a way for the rear crew to give an obey instantly commands. To me the transcript reads that the initial turn right sounds like a navigation request rather than an emergency command.

Those extra seconds could of made a big difference.

The issue here is the reports speculates on how the rear crew detected the island , for all we know he could have just seen it with his own eyes

The fundamental problem was that the pilots had lost situational awareness and were simply not mentally attuned to the fact that an island was in their path.

there are serious issues about the ( over) reliance on technology in this accident that are also common with several other air crashes . Its becoming an increasing issue as technology becomes centre stage in all our lives

BoatMad · 14-04-2017 01:53PM

Discodog wrote: »

There must be a way for the rear crew to give an obey instantly commands. To me the transcript reads that the initial turn right sounds like a navigation request rather than an emergency command.

Those extra seconds could of made a big difference.

in fact looking at the approach speed, a call for 20 degrees right turn was too little as the closure continued at 75 knots

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

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