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

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Comments

  • Registered Users, Registered Users 2 Posts: 886 ✭✭✭cosanostra


    BoatMad wrote: »
    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

    If they looked out the window they would have seen nothing it was pitch black and foggy, accurate technology would have saved them


  • Registered Users, Registered Users 2 Posts: 1,897 ✭✭✭Means Of Escape


    BoatMad wrote: »
    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.

    Fair enough
    From the report can it be gathered that there are different altitude protocols when approaching a landing site over land as distinct from approaching over sea due to greater number of obstacles over land ?
    No cause for concern being no "known" obstacles approaching Blacksod
    Again flying for a considerable distance at 200 feet over sea at night with very few external visual guides with only instruments to rely on is very risky and doubly so for this unfortunate crew not having the sole obstacle on their systems .


  • Registered Users, Registered Users 2 Posts: 5,133 ✭✭✭TomOnBoard


    I hope this issue of communication between R116 and R118 gets a good deal more attention immediately and doesn't have to await a final report.

    R116 was tasked to provide Top Cover. However, by the time it was up and away, R118 was en route to Blacksod for a refuelling before heading out to the FV location. The report says that 116-118 direct comms was achieved only once, on secure VHF while 118 was at/near Blacksod. According to the report this was around 23:10-23:20, around 15 minutes after 116 left Dublin.

    By the time 116 would have safely arrived at Blacksod and refuelled, it would have been 01:00 ish allowing for a best case scenario, before it left Blacksod to perform its mission of Top Cover provision. At that stage, 118 was more or less on the way back from the operation, based on its arrival at Blackrock to start searching, with the casualty still on board, at 02:13.

    118 was lost to all comms for some time as evidenced by Shannon's efforts to make contact via a Translantic Aircraft (which also failed) together with 116's many attempts as described in the report. Being out of contact for so long seems to need explanation, as does a HEMS mission heading out so far ahead of its Top Cover accompaniment as to make that Top Cover largely redundant, at least from a comms perspective and possibly also from a SaR perspective if 118 itself had gone down.

    The report stressed this matter of communications being on the mind of the 116 crew, and may have been why they were so far out, attempting to make contact before deciding to refuel.

    At least 2 issues arise: a) if Top Cover is needed why would there be such a gap between the HEMS and Top Cover aircraft leaving Black Sod, and b) can satellite comms that deal with the deficiencies of radio be put in place to help plug that particular issue immediately.


  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    cosanostra wrote: »
    If they looked out the window they would have seen nothing it was pitch black and foggy, accurate technology would have saved them

    you have obviously never sailed at night , This is a 16 mile range nautical light flashing every 12 seconds , it would have been clearly visible ahead . to obscure that light would have required dense fog and even then the loom would be detectable.

    Accurate technology doesnt exist , and it never can be relied upon to " save the day ". Its the downfall of the iPhone generation . 99,9% of the time it works, the 0.1% kills you

    All these device are " aids to navigation ". they are fallible

    Note that onboard the crew were confirmed to have access to the briefing pages for the approach , which mentioned the obstacle and moving map pages that equally detailed the obstacle , including its height.

    As machines become more and more automated, humans get more and more complacent , even highly trained professional ones. The " Kit " is so good that we rely on it until the day it kills us.


  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    Fair enough
    From the report can it be gathered that there are different altitude protocols when approaching a landing site over land as distinct from approaching over sea due to greater number of obstacles over land ?

    we cannot determine that, all we know is the stated page contained no altitude information and the" briefing page " mentioned as detailing the obstruction was not copied in the report

    No cause for concern being no "known" obstacles approaching Blacksod

    Both the moving maps on board and the briefing guides too the approached detailed the obstacle that was Blackrock. The map would have needed to be zoomed in to check the course in detail ( this is a very common issues with small sized moving maps) and the briefing notes would have to have been consulted. All we can conclude is that they are not as the crew actions seemed to indicate that they were unaware of its existence
    Again flying for a considerable distance at 200 feet over sea at night with very few external visual guides with only instruments to rely on is very risky and doubly so for this unfortunate crew not having the sole obstacle on their systems .

    Indeed to a non pilot , flying 10 miles at 200 feet would seem foolish , you could gets ships that tall ( or fly into a oil platform being towed or whatever )
    ot having the sole obstacle on their systems

    their map systems have been confirmed to have the obstacle details on it. however the nature of vector maps is that detail is removed at higher levels of zoom, I speculate ( and I accept it is a speculation ) that the crew did nor review the approach route in detail on the mapping system ( there was certainly no mention of such and action )


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  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    The report stressed this matter of communications being on the mind of the 116 crew, and may have been why they were so far out, attempting to make contact before deciding to refuel.

    116 were never " far out ", They initially decided to refuel at Sligo airport and then changed mid flight to Blacksod. The approach to Blacksod was then performed following the companies " route" . ( the issue here is the decision over height )


  • Registered Users, Registered Users 2 Posts: 215 ✭✭Coil Kilcrea


    It's distressing to read through the transcript and the sequence of events. It's difficult to comprehend for many reasons. And frankly, I don't have the words. But I'm struck by the fact that hover capability has to be an advantage in transitioning from IFR to VFR and wonder why not descend over the Blacksod landing pad?

    Possibly a stupid question but it's puzzling me .....R111 also springs to mind where they tried to within a few hundred feet.


  • Registered Users, Registered Users 2 Posts: 1,197 ✭✭✭arubex


    TomOnBoard wrote: »
    and b) can satellite comms that deal with the deficiencies of radio be put in place to help plug that particular issue immediately.

    Any helicopter SATCOM installations I've read about have required supplemental type certs for the installation, due to the need to either integrate with the flight computers ( to acquire data about rotor rotation ) or for antenna installation on the rotor mast.

    It may be that there is no current STC on the S-92 for a suitable SATCOM installation.



    Edit: apparently Honeywell have an STC for the AW139 but the S-92 is 'in progress'. I don't know about other vendors.


  • Registered Users, Registered Users 2 Posts: 1,351 ✭✭✭Cloudio9


    BoatMad wrote: »
    you have obviously never sailed at night , This is a 16 mile range nautical light flashing every 12 seconds , it would have been clearly visible ahead . to obscure that light would have required dense fog and even then the loom would be detectable.

    us.

    The helicopter was below the cloud, the lighthouse was in the cloud (not fog) based on the reported weather. I don't know how light travels through cloud and suggest neither do you as it wouldn't be something you'd encounter in your sailing experience.


  • Registered Users, Registered Users 2 Posts: 5,133 ✭✭✭TomOnBoard


    BoatMad wrote: »
    116 were never " far out ", They initially decided to refuel at Sligo airport and then changed mid flight to Blacksod. The approach to Blacksod was then performed following the companies " route" . ( the issue here is the decision over height )

    My post relates to the inter- communication issues identified in reading the report as well as matters of procedures for tasking that can create such a gap as the relative timelines show.


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  • Registered Users, Registered Users 2 Posts: 1,897 ✭✭✭Means Of Escape


    Bigbok wrote: »
    I fly on the S93 twice a month to the oil rig and I have never been 200ft?if flying between rigs we aren't allowed below 400 or 600 ft?when coming in to land at the heliport in sumbrugh we are well above 600ft until we are literally above our landing area before coming down,so what were they doing 8km out at 200ft???

    BoatMad can clarify that especially to all non pilots (hitting ships ,oil rigs etc)


  • Registered Users, Registered Users 2 Posts: 3,469 ✭✭✭jetfiremuck


    arubex wrote: »
    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.

    A good look and review of CRM (cockpit resource management ) and P.A.C.E (Probing,alerting,challenging,and emergency warning) might be in order for all SRM crews that operate here. Can't hurt anyway.


  • Registered Users, Registered Users 2 Posts: 1,813 ✭✭✭Wesser


    I don't know anything about helicopters.

    Can someone please explain to me, an amateur, why a helicopter would fly f
    so low that it can actually hit a landmass. Surely this is very very low .

    Also can someone please explain to me why it would hit an island which is a TINY speck in a massive ocean is this just a massive unfortunate coincidence.


  • Registered Users, Registered Users 2 Posts: 16,011 ✭✭✭✭Discodog


    Why does a helicopter follow the same approach & decent as a fixed wing?

    Why can't it fly a mile offshore & then decend on the hover? If you are trying to find the cloudbase a slow hover decent seems sensible. If the worst happens you land on the sea.


  • Registered Users, Registered Users 2 Posts: 645 ✭✭✭faoiarvok


    arubex wrote: »
    It may be that there is no current STC on the S-92 for a suitable SATCOM installation.

    A couple of sources reference the S-92s being equipped with satellite comms.

    https://flyinginireland.com/2015/03/irish-coast-guard-enhancing-capabilities/
    http://www.dttas.ie/sites/default/files/publications/maritime/english/irish-coast-guard-publications/s92-compared-s61cr.pdf

    I've read elsewhere from aircrew that satellite comms are often considered to be more pain than they're worth, with long connection delays, numerous dropped connections, long complicated numbers required to dial.


  • Registered Users, Registered Users 2 Posts: 527 ✭✭✭de biz


    The preliminary report confirms that R118 landed at Blacksod at approximately
    22.28 hrs.

    It would be interesting to see the track and vertical profile of their approach path.


  • Registered Users, Registered Users 2 Posts: 72,775 ✭✭✭✭L1011


    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.

    Your posts are full of speculation, so I find it odd that you're calling someone else out on it. Stop the speculation yourself, and use the report function.


  • Registered Users, Registered Users 2 Posts: 8,261 ✭✭✭Gaoth Laidir


    Boatmad, they most likely could not see the light from Blackrock and would not have been looking for it anyway. As I explained last night, flight visibility at that height - just below cloudbase - would have been a lot less than the 3000 m reported at sea level at Belmullet. At that speed they would have covered 500 m between flashes. Flight visibility could have been around that or even less, so there may have been only 1 flash for them to spot. Add in the strobe light from the aircraft itself and the focus on instruments and we can put to bed this discussion on the lighthouse.

    Boating is one thing, flying is a totally different dimension.


  • Registered Users, Registered Users 2 Posts: 5,133 ✭✭✭TomOnBoard


    de biz wrote: »
    The preliminary report confirms that R118 landed at Blacksod at approximately
    22.28 hrs.

    It would be interesting to see the track and vertical profile of their approach path.

    Nope! It left Sligo at 22:28


  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    Wesser wrote: »
    I don't know anything about helicopters.

    Can someone please explain to me, an amateur, why a helicopter would fly f
    so low that it can actually hit a landmass. Surely this is very very low .

    Also can someone please explain to me why it would hit an island which is a TINY speck in a massive ocean is this just a massive unfortunate coincidence.

    The sequence of what happened and the deductions that can be made are clear to see

    (A) The crew departed Dublin , with an initial decision to refuel at Sligo airport
    (B) They decided to change course and land and refuel at blacksod.
    (C) The crew were unfamiliar with the approach to Blacksod having not attempted it for a " long" time
    (D) For whatever reason the crew, clearly did not appraise themselves of the obstructions that existed on the designated approach route that was programmed into the FMS of the Heli , They did have access to that information , but there is clearly no evidence that they didi appraise themselves
    (E) The Autopilot flew the course and then under autopilot began to transition down in steps to the radar altitude 2400 feet, whereupon a SAR mode level down was selected bringing the aircraft to 200 feet and 75knots airspeed ( with and intended 80knts ground speed ) .

    We do not know why such a descent was selected

    (F) The unfortunate occurrence was that the first waypoint on the approach to Blacksod from the south , using the preprogrammed route " The company or operator route " was close to Blackrock island.

    (G) Hence the hellcopter was as a result of a crew decision , now flying low directly towards an obstacle that was higher then it

    (H) A clear loss of situational awareness, meant the flying crew, never until,way too late, that they had put themselves into a dangerous position


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  • Registered Users, Registered Users 2 Posts: 4,112 ✭✭✭selectamatic


    L1011 wrote: »
    Your posts are full of speculation, so I find it odd that you're calling someone else out on it. Stop the speculation yourself, and use the report function.

    I'm failing to see where boatmads posts are "full" of speculation. I think it's pretty obvious he's read the preliminary report at length and has a good understanding of what he's talking about.

    IMO he's been one of the best contributers to this thread.


  • Registered Users, Registered Users 2 Posts: 1,351 ✭✭✭Cloudio9


    Regarding the decision to go to 200ft, 10 miles from the helipad, a number of helicopter pilots on pprune have stated that there is a culture in SAR to get visual as soon as possible even if that is not necessarily the best decision.


  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    Boatmad, they most likely could not see the light from Blackrock and would not have been looking for it anyway. As I explained last night, flight visibility at that height - just below cloudbase - would have been a lot less than the 3000 m reported at sea level at Belmullet. At that speed they would have covered 500 m between flashes. Flight visibility could have been around that or even less, so there may have been only 1 flash for them to spot. Add in the strobe light from the aircraft itself and the focus on instruments and we can put to bed this discussion on the lighthouse.

    Boating is one thing, flying is a totally different dimension.

    sorry , the period of the light is 12s , that is one ( or more flashes ) every 12 seconds, The light is sectored and has a range of 16Nm ( this is the surface range) This is a considerably powerful light compared to surface sea based lights

    They were 1.5 nm away from the lighthouse when the turn began ,and it took over a minute to cover the distance to the lighthouse

    the aspect of the lighthouse would have become visible as the Heli proceeded through its turn , gradually appearing own the left hand side of the aircraft

    They then had anything from 50 seconds where the light would be visible , that upwards of 4 flashes , even if they had 30 seconds they would have seen 2-3 flashes

    To suggest that at 200 feet , which is about 100 feet higher then the bridge of a big cargo vessel , at 1 mile out that a 16nM light was not visible is in my view simply ridiculous


    I would contend and entirely different thing ( and I have witnessed it in boats )

    The pilots were involved with the automation and in completing the turn to the waypoint, Thy had formed an incorrect mental picture of the route ahead to that waypoint. If ( they may not have been looking out the window) or when they saw a brief flash , it was simply ignored because the reality did not match the mental picture and the picture being supplied by the automation

    Ive seen people at sea run into objects that were clearly there , because the automation told them , is was clear.


  • Registered Users, Registered Users 2 Posts: 23,895 ✭✭✭✭mickdw


    Is it a case that if they had initially intended to fly to blacksod that they would have had a briefing on intended approach etc whereas this flight departed heading for sligo meaning the blacksod approach was not understood to the same degree that it might otherwise have been.


  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    L1011 wrote: »
    Your posts are full of speculation, so I find it odd that you're calling someone else out on it. Stop the speculation yourself, and use the report function.

    if you could like to detail any " speculation " that I have referred to , I would be glad to review it. Where I have made a deduction I have always said so.

    I pointed out this particular speculation , because the report did not mention nor was there any indication that the approach to blacksod contained vertical information


  • Registered Users, Registered Users 2 Posts: 1,351 ✭✭✭Cloudio9


    Boatmad you seem to be in denial about the fact that the cloud base was reported as 300ft which is below the lighthouse.


  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    mickdw wrote: »
    Is it a case that if they had initially intended to fly to blacksod that they would have had a briefing on intended approach etc whereas this flight departed heading for sligo meaning the blacksod approach was not understood to the same degree that it might otherwise have been.

    The pilots ( via the CVR) were seen to be discussing that they both had not been to blacksod for a long time.

    Hence it cant be reasonably deduced ( as opposed to speculation ) that they were not familiar with the approach in the same way the local crew of 118 were

    They did have on board information that set out the obstacles on the elected approach route, but again it is a reasonable deduction that they didi not access that information


    The rest seemed to be a standard approach that SAR crews do , but this is based on commentary that is not available directly from the crew, as we have NO idea why the particular decisions to select such an approach and the various flight levels were chosen


  • Registered Users, Registered Users 2 Posts: 72,775 ✭✭✭✭L1011


    BoatMad wrote: »
    if you could like to detail any " speculation " that I have referred to , I would be glad to review it. Where I have made a deduction I have always said so.

    I pointed out this particular speculation , because the report did not mention nor was there any indication that the approach to blacksod contained vertical information

    Deductions are speculation. The majority of your posts today have been reported so it's not like I'm unique in seeing it

    If you must call it "deducing" you can take it as an instruction to stop it too


  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    Cloudio9 wrote: »
    Boatmad you seem to be in denial about the fact that the cloud base was reported as 300ft which is below the lighthouse.

    and you seem to be entirely unaware of the power of a 16NM light especially 1 mile away from it . The loom in the cloud alone would have been extensive

    to suggest it was invisible is ridiculous . it may not have been immediately obvious , but to someone that was aware it should have been there , it would have been most definitely obvious

    Note that the aftercast for blackrock was

    Visibility 2-3 km
    Weather Mist and drizzle
    Cloud Overcast with a cloud base of 300-400 ft

    fog was not mentioned and the cloud base was certainly enough for the light to be visible


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  • Registered Users, Registered Users 2 Posts: 13,702 ✭✭✭✭BoatMad


    L1011 wrote: »
    Deductions are speculation. The majority of your posts today have been reported so it's not like I'm unique in seeing it

    If you must call it "deducing" you can take it as an instruction to stop it too

    what specific speculation are you referring to , I am genuinely perplexed

    deductions are conclusions that are reached on the reasonable basis of the available information

    Speculation is a conclusion based on little or no relevant available information


    for example , we can reasonably deduce that the crew were not aware of the existence of the obstacle of Blackrock island along the line of the intended approach


This discussion has been closed.
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