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

ectoraige wrote: »

In particular, by a crew unfamiliar with the site. Once familiar with the route it's easier to confirm what you already know e.g. selecting the right mode on the moving display, double-checking the height of the lighthouse.

Thats a key comment , however surely the situation where a " by a crew unfamiliar with the site would seek all means to make themselves familiar and utilise any and all information at their disposal to do so

BoatMad wrote: »

The aftercast describes mist and drizzle with a stated visibility of 2-3 Km ( poor visibility ) , from my experience on ships and yachts , that would not in any way render the light invisible at 1nM ( this is not speculation ) and certainly not invisible at 0.5 nM

You are viewing from sea level. The lights are designed to be focused for sea level & not for aircraft at 200 feet. Plus, if you sail & you know the North West, you will know that visibility can change in an instant as can cloudbase.

For pilots, that are so used to flying at low altitude over the sea, it's understandable that they may have an inclination to try & get below the weather.

ectoraige wrote: »

It would appear so. Also, the APP1 mode is a lower speed, my understanding is it's seen as a 'slow and careful' operational mode, so that may have played into the equation as well.

I am not a heli pilot, but I have friends that are. Their general comment is that high altitude is better then low altitude

a comment from PPPuNe, where there are clearly experienced pilots , suggests that SAR operations tend to favour 200 feet APP1 SAR decent under RA , this is a preprogrammed descent to 200 feet and 80 kts. Its a low and slow ( relatively ) I'm not sure its being characterised as " slow and careful" perhaps you could supply a link to back that up

BoatMad wrote: »

therefore can we agree as to the facts

...

(i) The height of the light is 282 feet above sea level , and flashes a white light with a period of 12seconds , or 5 flashes a minute and the White sector light covers the direction the Aircraft approaches the waypoint ( a red sector was elsewhere ). The white light has a stated range of 20 nM according to the commissioners of irish lights ( the red sector light has a range of 16 Nm ) , these are regarded as nominal ranges in clear conditions

The height of the island is 282 feet, but the lighthouse is listed at 310 feet so with the provided aftercast the light could very well have been within the clouds.

ectoraige wrote: »

The height of the island is 282 feet, but the lighthouse is listed at 310 feet so with the provided aftercast the light could very well have been within the clouds.

The commissioner of Irish lights state the "height of the light " is 86 metres , i.e. 282 feet , That is typically very accurate so that mariners can use triangulation to determine range. We can clearly state the report does not mention any evidence that the crew spotted the light. However it does not at this point put forward a reason for that , merely indicating the data suggesting the light was on and working. a 20 NM light is a very powerful light in comparison to the things you see on cardinal marks etc

ectoraige wrote: »

The height of the island is 282 feet, but the lighthouse is listed at 310 feet so with the provided aftercast the light could very well have been within the clouds.

The heli-pad elevation is 282ft. The aftercast cannot be accurate to more than 100 ft. Either way, see my post above.

Steve wrote: »

The heli-pad elevation is 282ft. The aftercast cannot be accurate to more than 100 ft. Either way, see my post above.

Im sorry , but when the owner of the lights tell me its 86 metres above sea level, thats gospel. These are key facts in worldwide nautical almanacs for decades


"Blackrock Island (54°4′0.67″N 10°19′12.66″W) is a rocky island rising to a height of 70 meters above sea level and located northwest of Achill Island approximately 12 miles west of Blacksod Bay.[3] Typical rainfall is 72 inches per annum, and the island is often shrouded in mist.[4] It is visible from near the Glosh Tower on the Mullet Peninsula, with reference to the other islands in the area, is sometimes described as the "one that looks like a volcano".[5]

There is a small rocky islet 125m to the east with a length of 80m. There are about five rocky islets including Fish Rock, Carrickaduff and Carrackabrown spread 1km to 2km in a generally westwards direction."


The tower height is given as 15metres, but this typically would be the structure without any appendages ( radio masts etc )

BoatMad wrote: »

well heres a confusing bit

"
Co-pilot (PM)
OK so small target at six miles eleven o’clock Large
out to the right there"


can someone care to comment on " large out to the right there "

the commander responded

"Eh just a small little island... that’s B L M O itself"

Target at 11 O'clock at 6 miles is probably Duvillaun More. Blackrock being between him and Duvillaun Mor effectively hiding Blackrock on radar ?

Large target to the right is probably Achill.

One of the things which I wonder about in this discussion and other similar incident related discussions in the past is the ability of people outside the field to accept key features of the culture of air accident investigation. For the most part, the focus is on finding out what the underlying cause of an accident is. There isn't a focus on blame/fault, but a heavy focus on lessons learned.

That, and the fact that there tends to be a public focus on landing on a simple explanation to something which is often not necessarily simple to explain. Not one cause but several, no core cause as one contributing cause being missing - any one - may have led to an entirely different outcome. So when I see clashes in threads like this, it seems to me to be more cultural than anything.

The thing is, carrying out an in-depth investigation into an event without focusing on blame does not mean there is no accountability. The AAIU have made recommendations on foot of this one already and they are only at preliminary report stage.

I wonder sometimes if the world would be much better off with this approach rather than the journalism/news driven need to find a focus point of blame/fault. You can see it in the Indo's headline drawing attention to the last comment in the voice transcript rather than the gaps in coverage in some of the data the crew should be able to rely on. Did it add much to what we knew to focus on that? Did it help?

That's one point.

The other point is this: because this was not a mechanical cause, it brings back into focus the question of the availability of the CASAs and the fact that sometimes they provide top cover and sometimes they do not. I am open to correction but it seems to me that the circumstances under which they are and are not available could be a bit more clearly defined and any lacunae in staffing coverage affecting the AirCorps in general should be looked at anyway.

siobhan08 wrote: »

I'm a complete aviation novice but I kept up to date with the thread and have seen it said multiple times in the thread that they were at 200ft because of the cloud cover being at 300ft.

thats clear , whats not clear is why they choose such a path to transition down to such a low height , 10 miles from the LZ, and equally placing themselves in mortal danger

BoatMad wrote: »

(c) Given that neither of these targets mentioned in the co-pilots weather radar sit rep. refer to the islets mentioned by the commander - why did she comment on them very puzzling

I think her only reason for commenting on them was because they generated an automated "altitude altitude" warning as they passed over them.

Calina wrote: »

The other point is this: because this was not a mechanical cause, it brings back into focus the question of the availability of the CASAs and the fact that sometimes they provide top cover and sometimes they do not. I am open to correction but it seems to me that the circumstances under which they are and are not available could be a bit more clearly defined and any lacunae in staffing coverage affecting the AirCorps in general should be looked at anyway.

Yes. Another item for consideration in the learning process. The list is growing...

Calina wrote: »

One of the things which I wonder about in this discussion and other similar incident related discussions in the past is the ability of people outside the field to accept key features of the culture of air accident investigation. For the most part, the focus is on finding out what the underlying cause of an accident is. There isn't a focus on blame/fault, but a heavy focus on lessons learned.

Correct and that is the key intent of people here, why did actions occur and for what purpose and what did any such actions illustrate deficiencies in systems, crew prep or overall system management. It should be pointed out that in most air accident investigations, where the cause is identified , the investigator will not be slow to illustrate it.

That, and the fact that there tends to be a public focus on landing on a simple explanation to something which is often not necessarily simple to explain. Not one cause but several, no core cause as one contributing cause being missing - any one - may have led to an entirely different outcome. So when I see clashes in threads like this, it seems to me to be more cultural than anything.

we have differences of opinion because not all facts are known , nor will they.

The thing is, carrying out an in-depth investigation into an event without focusing on blame does not mean there is no accountability. The AAIU have made recommendations on foot of this one already and they are only at preliminary report stage.

The recommendation was clearly appropriate because the presence of a significant danger on a preprogrammed approach path is clearly a safety risk. However there could be reasonable explanations as to why waypoints were near identifiable structures , in an era before high accuracy GPS maps.

The issue remains , why did the crew of Rescue 116 not know that blackrock existed on the path they had chosen. That is the key answer that will have to be answered.

I

wonder sometimes if the world would be much better off with this approach rather than the journalism/news driven need to find a focus point of blame/fault. You can see it in the Indo's headline drawing attention to the last comment in the voice transcript rather than the gaps in coverage in some of the data the crew should be able to rely on. Did it add much to what we knew to focus on that? Did it help?

The media seek sensationalism or blame and are notoriously inaccurate , I have not read any media coverage of this event

That's one point.

The other point is this: because this was not a mechanical cause, it brings back into focus the question of the availability of the CASAs and the fact that sometimes they provide top cover and sometimes they do not. I am open to correction but it seems to me that the circumstances under which they are and are not available could be a bit more clearly defined and any lacunae in staffing coverage affecting the AirCorps in general should be looked at anyway.

This is an operational policy issue and is not really germane to the incident, irrespective of the reason, one would expect that an experienced crew flying an exemplary machine fitted with significant automation , following a predetermined landing approach would have safety reached the LZ. It clearly did not .