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

BoatMad · 14-04-2017 07:32PM

Cloudio9 wrote: »

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

thats clear, cant see much use off a warning when you are over the obstruction !!!, its rather like by depth sounder telling me it has zero feet under me. ( I simultaneously know this !)

BoatMad · 14-04-2017 07:37PM

Cianmcliam wrote: »

I would think so, it sounds like the commander knew about the two smaller rocks either through the EGPWS or the moving map. If neither had Blackrock then it would seem the course change called out would not have seemed urgent. 'Island ahead' could indicate a fairly flat piece of land.

I don't think either could be blamed. The winchman may have thought the helicopters systems would be indicating the island before he felt it necessary to call it out, the pilot would have probably assumed there was no urgency as there was nothing showing on the displays.

The indication from elsewhere is that EGPWS would not have added anything as, with gear down and the low alt mode engaged its almost effectively disabled , Since the report gives indications of the EGPWS voice announcements, and these didnt happen, we can deduce that it was not a EGPWS announcement that triggered her comment . I suggest it was the RA warning of a sudden decrease in RA altitude

I would further suggest , that given my knowledge of vector and raster based mapping ( I write software in this area ) , had the commander the map set to a zoom factor that clearly identified the same islets , she would have equally seen blackrock unless it was zoomed in so extensively that the scale was so large as to leave the island off the screen and I think thats improbable

Growler!!! · 14-04-2017 07:40PM

BoatMad wrote: »

Cloudio9 wrote: »

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

thats clear, cant see much use off a warning when you are over the obstruction !!!, its rather like by depth sounder telling me it has zero feet under me. ( I simultaneously know this !)

The "Altitude Altitude" alert call out came from the RA which was set to 180ft. If the heli was in a hover it would let the pilot know that they had descended below the set Altitude. It is not for obstacle or obstruction avoidance unlike the EGPWS.

faoiarvok · 14-04-2017 07:41PM

SimonTemplar wrote: »

Thanks. But why did they wish to be below cloud cover. They were heading inland to refuel not searching the sea. What benefit did being below cloud cover offer them when it was pitch dark and they were already flying by instruments anyway?

Genuinely curious about this.

They can't land at Blacksod by instrument reference, as there are no instrument approaches or radio navigation aids there for that purpose. They must use Visual Flight Rules to get there, which requires them to have line of sight to the surface.

As there is terrain all around their route in to Blacksod, it seems they probably wanted to get down under the clouds that far out in an area which they believed to be free of high terrain and obstacles in order to keep themselves safe for the rest of the route in to Blacksod.

In essence, the low altitude was being flown to allow the crew see and avoid terrain. While it obviously contributed to the opposite situation in this case, on a different route, in different weather conditions, or on a different day, this strategy would arguably be the safest course of action and is probably something the crew have been doing for many years in order to protect themselves and their passengers. Such a tragic coincidence of factors to have it go wrong for them this time.

Cloudio9 · 14-04-2017 07:41PM

BoatMad wrote: »

I would further suggest , that given my knowledge of vector and raster based mapping ( I write software in this area ) , had the commander the map set to a zoom factor that clearly identified the same islets , she would have equally seen blackrock unless it was zoomed in so extensively that the scale was so large as to leave the island off the screen and I think thats improbable

I've seen a comment from a pilot expressing surprise that the islets that are little more than rocks are displayed on certain maps but Blackrock isn't.

BoatMad · 14-04-2017 07:46PM

Cloudio9 wrote: »

I've seen a comment from a pilot expressing surprise that the islets that are little more than rocks are displayed on certain maps but Blackrock isn't.

The report clearly says that the maps contain pages that range from zero detail of blackrock to extensive detail of Blackrock , this would be consistent with the " paged zoom" effect on vector maps, i.e. higher zoom remove detail

SO lets remove the issue that the island was not on the maps, it was not in the EGPWS database , but thats a different matter entirely

siobhan08 · 14-04-2017 07:52PM

SimonTemplar wrote: »

Thanks. But why did they wish to be below cloud cover. They were heading inland to refuel not searching the sea. What benefit did being below cloud cover offer them when it was pitch dark and they were already flying by instruments anyway?

Genuinely curious about this.

My understanding of reading the thread and listening to the experts on the radio that they broke the cloud cover so they would have a clear run into Blacksod as opposed to breaking cloud over terrain and then having to navigate around potential obstacles on landing.

The expert on the Pat Kenny show was a former Air Corps L Colonel and he said that if you were to approach Dublin Airport with all the well lit runway, air traffic control etc and it would usually be a 10-mile approach. Blacksod wouldn't have any of that so they have to "stage down" by transitioning down gradually from above the cloud cover to below the cloud and "walk your way at a low speed so you can visually acquire" information to safely make the landing. The transitioning down to a low altitude allows you to see the ground ie the sea in the case and then the land

You can listen to him explain things here http://www.newstalk.com/listen_back/13240/35317/14th_April_2017_-_The_Pat_Kenny_Show_Part_1/

BoatMad · 14-04-2017 07:54PM

faoiarvok wrote: »

They can't land at Blacksod by instrument reference, as there are no instrument approaches or radio navigation aids there for that purpose. They must use Visual Flight Rules to get there, which requires them to have line of sight to the surface.

As there is terrain all around their route in to Blacksod, it seems they probably wanted to get down under the clouds that far out in an area which they believed to be free of high terrain and obstacles in order to keep themselves safe for the rest of the route in to Blacksod.

In essence, the low altitude was being flown to allow the crew see and avoid terrain. While it obviously contributed to the opposite situation in this cause, on a different route, in different weather conditions, on a different day, this approach would arguably be the safest course of action and is probably something the crew have been doing for many years in order to protect themselves and their passengers. Such a tragic coincidence of factors to have it go wrong for them this time.

It has been commented elsewhere that AIS tracks of Rescue 115 and 118 do not typically use this approach as they approach blacksod flying along the coast line, presumably using it as a VFR reference

Hence we can deduce that this is not a common approach path ( stand to be corrected on this )

In essence, the low altitude was being flown to allow the crew see and avoid terrain

while this is true, clearly at night in mist and drizzle , VFR is really a form of instrument landing

what you say may or may not be true, but the issue remains , why did a competent crew flying a mechanical perfect helicopter equipped with state of the art equipment, fly into an island that was clearly positioned in the path of a low level documented preprogrammed approach path .

The obvious conclusion is , The crew did not know that island was in such a position to cause the issue it did for the SOP they followed. any other conclusion would suggest wilfulness.

The question that remains is simply: why did they not know

Growler!!! · 14-04-2017 07:56PM

BoatMad wrote: »

it was not in the EGPWS database , but thats a different matter entirely

Was it not in the database because it wasn't considered an enroute obstacle to aviation? Do the other islets show up on the 2 different scale VFR charts?

14-04-2017 07:57PM

Cloudio9 wrote: »

I've seen a comment from a pilot expressing surprise that the islets that are little more than rocks are displayed on certain maps but Blackrock isn't.

The report has a section that deals specifically with Blackrock and Honeywell and lack of data associated. Remember this is only a month after the incident, the supplier of the data upwards through Honeywell and CHC will each be followed up to determine why certain data was not included and why this was overlooked.

Yes that'll certainly be something that will have to be answered during the investigation. How can you include the smaller one but not the bigger one and how were you not aware before that this was missing and at what point was this removed from the database. The list of questions in relation to this is lengthy.

BoatMad · 14-04-2017 07:58PM

The expert on the Pat Kenny show was a former Air Corps L Colonel and he said that if you were to approach Dublin Airport with all the well lit runway, air traffic control etc and it would usually be a 10-mile approach. Blacksod wouldn't have any of that so they have to "stage down" by transitioning down gradually from above the cloud cover to below the cloud and "walk your way at a low speed so you can visually acquire" information to safely make the landing. The transitioning down to a low altitude allows you to see the ground ie the see in the case and then the land

would experts regard 80 kts as " low speed " ? This is 92 miles an hour ?

if as you suggest they can see the " sea" , they clearly would see a 200 foot tall island . The scenario depicted in the report clearly suggests they did not see the terrain until very late in the day. I could just about understand this SOP in daylight in that situation around blackrock , at night and it mist and drizzle it seems incomphrensible unless you either have detailed local knowledge or access to other knowledge that indicates the route is clear

TomOnBoard · 14-04-2017 07:59PM

BoatMad wrote: »

The report clearly says that the maps contain pages that range from zero detail of blackrock to extensive detail of Blackrock , this would be consistent with the " paged zoom" effect on vector maps, i.e. higher zoom remove detail

SO lets remove the issue that the island was not on the maps, it was not in the EGPWS database , but thats a different matter entirely

No, let's not remove the issue! Let's leave something for the Investigation to deal with as it outlines in its Section 9:

9 FURTHER INVESTIGATION

The Investigation is ongoing and a formal, ICAO Annex 13, Final Report will be published in due course. The Investigation will consider a number of factors including organisation and management of the mission, the Operatorâ€™s procedures and guidance, helicopter systems, navigation, mapping & charting, human performance, aircraft performance, survival aspects, ergonomics, oversight, risk management and a deeper analysis of the recorded data and recovered wreckage.

14-04-2017 08:01PM

What the report doesn't indicate is what other company procedural approaches to Blacksod they have, this one is specifically the SOUTH one. Is there another one that the local crews use to arrive in from the north along the west of the coastline ?

BoatMad · 14-04-2017 08:05PM

Deleted User wrote: »

The report has a section that deals specifically with Blackrock and Honeywell and lack of data associated. Remember this is only a month after the incident, the supplier of the data upwards through Honeywell and CHC will each be followed up to determine why certain data was not included and why this was overlooked.

Yes that'll certainly be something that will have to be answered during the investigation. How can you include the smaller one but not the bigger one and how were you not aware before that this was missing and at what point was this removed from the database. The list of questions in relation to this is lengthy.

its important not to get different aircraft system mixed up

The Moving maps contained information on blackrock

The EGPWS database did not have data that could have been used to warn the pilots of a terrain feature that was dangerous.

However its clear from the report and from other expert commentary that the EGPWS system is considerably muted when the low alt mode is engaged and the gear is down, in essence it is " disabled " as the system think you are landing. There is no indication in the report that the EGPWS system could have " saved the day " , presumably this will be investigated further. But I personally dont think its the issue at hand. Getting yourself into a dangerous situation in the first place so that an emergency warning system has to extract you from it , it not something I believe a crew of that calibre would find themselves in the first place.

BoatMad · 14-04-2017 08:06PM

Deleted User wrote: »

What the report doesn't indicate is what other company procedural approaches to Blacksod they have, this one is specifically the SOUTH one. Is there another one that the local crews use to arrive in from the north along the west of the coastline ?

no doubt we will know in time, but a commentator elsewhere has pointed out that Rescue 115 and 118 use a coastal north south approach ( based on his viewing of AIS data) , since that is the direction they would approach Blacksod

siobhan08 · 14-04-2017 08:07PM

BoatMad wrote: »

would experts regard 80 kts as " low speed " ? This is 92 miles an hour ?

if as you suggest they can see the " sea" , they clearly would see a 200 foot tall island . The scenario depicted in the report clearly suggests they did not see the terrain until very late in the day. I could just about understand this SOP in daylight in that situation around blackrock , at night and it mist and drizzle it seems incomphrensible unless you either have detailed local knowledge or access to other knowledge that indicates the route is clear

I've not suggested anything I was quoting from the interview on the Pat Kenny Show as I have stated before I would be an aviation novice. I would suggest listening to it, It made things easier for a novice like me to kind of understand what happened.

BoatMad · 14-04-2017 08:10PM

TomOnBoard wrote: »

No, let's not remove the issue! Let's leave something for the Investigation to deal with as it outlines in its Section 9:

9 FURTHER INVESTIGATION

The Investigation is ongoing and a formal, ICAO Annex 13, Final Report will be published in due course. The Investigation will consider a number of factors including organisation and management of the mission, the Operatorâ€™s procedures and guidance, helicopter systems, navigation, mapping & charting, human performance, aircraft performance, survival aspects, ergonomics, oversight, risk management and a deeper analysis of the recorded data and recovered wreckage.

I am not for a minute saying that the mapping was fit for purpose or not, I am merely correcting posters that are mixing up the EGPWS database and the moving maps system and claiming that the mapping systems contained no reference to Blackrock

the report clearly says

"
The helicopter was equipped with a EuroAvionics EuroNav 5 moving map display which had a number of maps/charts available for selection. The exact information in relation to Black Rock and Lighthouse varied from none, to detailed, depending on the selected map/chart."

BoatMad · 14-04-2017 08:11PM

siobhan08 wrote: »

I've not suggested anything I was quoting from the interview on the Pat Kenny Show as I have stated before I would be an aviation novice. I would suggest listening to it, It made things easier for a novice like me to kind of understand what happened.

there has been considerable commentary on PPPuNe from a large collection of pilots many with SAR experience as to the SOP issues around APP1 , its not as simple as presented ( it would seem ) and of course what you hear on a radio show tends to simplified to the point of near nonsense

14-04-2017 08:13PM

BoatMad wrote: »

would experts regard 80 kts as " low speed " ? This is 92 miles an hour ?

if as you suggest they can see the " sea" , they clearly would see a 200 foot tall island . The scenario depicted in the report clearly suggests they did not see the terrain until very late in the day. I could just about understand this SOP in daylight in that situation around blackrock , at night and it mist and drizzle it seems incomphrensible unless you either have detailed local knowledge or access to other knowledge that indicates the route is clear

Yes experts including the inbuilt autopilot speeds for APP1 indicate a speed of approx 80kts for this procedure. So yes 80 kts is a low speed.

You keep missing others valid points, the helicopter was operating in a reasonably low visibility situation with viz at 2-3km in mist and cloud base at 300ft approx they were about 100ft (30m) below this but cloud has a tendency to extend a small bit below this and viz is not constant it can get thicker and thinner. The aircraft is fitted with LED lights. They will have had constant bright red flashing lights, white strobes and landing lights on. These will have been lighting up the clouds and mist which will have been interfering with their night vision. Hence the reason why the co pilot was observing the weather radar and the rear crew were observing the FLIR imagery. It would have been difficult for the crew to have spotted a rock in this situation even with a lighthouse beam. I'll be honest it would have been difficult in the circumstances to distinguish between a lighthouse and the white strobes.

I imagine all will be covered at length in the final report.

TomOnBoard · 14-04-2017 08:17PM

BoatMad wrote: »

The Moving maps contained information on blackrock

Unless you have insider knowledge, you can't possibly know more than the investigators. They say this (mapping & charting) is still the subject of ongoing investigation.

BoatMad · 14-04-2017 08:18PM

Deleted User wrote: »

Yes experts including the inbuilt autopilot speeds for APP1 indicate a speed of approx 80kts for this procedure. So yes 80 kts is a low speed.

You keep missing others valid points, the helicopter was operating in a reasonably low visibility situation with viz at 2-3km in mist and cloud base at 300ft approx they were about 100ft (30m) below this but cloud has a tendency to extend a small bit below this and viz is not constant it can get thicker and thinner. The aircraft is fitted with LED lights. They will have had constant bright red flashing lights, white strobes and landing lights on. These will have been lighting up the clouds and mist which will have been interfering with their night vision. Hence the reason why the co pilot was observing the weather radar and the rear crew were observing the FLIR imagery. It would have been difficult for the crew to have spotted a rock in this situation even with a lighthouse beam. I'll be honest it would have been difficult in the circumstances to distinguish between a lighthouse and the white strobes.

I imagine all will be covered at length in the final report.

I dont dispute this , clearly they did not identify visually an island they obviously did not expect to be in the flight path they have chosen, until it was too late. Whether they saw the lighthouse or not is not really the issue ( I was merely commenting that I find it hard to understand , especially as the report seems to suggest they are using FLIR, ( its speculates on that point ) that they would not have seen the light with a FLIR device.

However the key question is not any of this , the key question is , did the crew know in advance the island was on the flight path ( or potentially on the flight path ) and if not , why not ?

BoatMad · 14-04-2017 08:19PM

TomOnBoard wrote: »

Unless you have insider knowledge, you can't possibly know more than the investigators. They say this (mapping & charting) is still the subject of ongoing investigation.

the report contain this piece of text

"
The helicopter was equipped with a EuroAvionics EuroNav 5 moving map display which had a number of maps/charts available for selection. The exact information in relation to Black Rock and Lighthouse varied from none, to detailed, depending on the selected map/chart."

do you wish to dispute this

the comment you refer to is a general issue because this is a preliminary report , but based on the comment it has made to date, it was clear that both the briefing notes and the mapping systems contained data on blackrock. of course it could be that such information was badly presented, badly accessed or badly understood or any combination or none . but the basic fact remains , that the aircraft contained systems that had knowledge of the obstruction

TomOnBoard · 14-04-2017 08:22PM

BoatMad wrote: »

I am not for a minute saying that the mapping was fit for purpose or not, I am merely correcting posters that are mixing up the EGPWS database and the moving maps system and claiming that the mapping systems contained no reference to Blackrock

the report clearly says

"
The helicopter was equipped with a EuroAvionics EuroNav 5 moving map display which had a number of maps/charts available for selection. The exact information in relation to Black Rock and Lighthouse varied from none, to detailed, depending on the selected map/chart."

And goes on to say "The full colour EuroNav System features selectable map illustrations. Either vector or scanned raster maps can be displayed"

You cannot possibly know what map had been selected, and therefore can also not possibly know whether Blackrock was on the Commander's map display or not.

faoiarvok · 14-04-2017 08:26PM

BoatMad wrote: »

Hence we can deduce that this is not a common approach path ( stand to be corrected on this )

Bad phrasing on my part, I said "this approach" to mean more like "this strategy" of conducting the cloud break early. Will edit now to clarify that.

BoatMad wrote: »

while this is true, clearly at night in mist and drizzle , VFR is really a form of instrument landing

No, it's either VFR or it's not, even with SAR exemptions from some VFR requirements.

BoatMad · 14-04-2017 08:31PM

TomOnBoard wrote: »

And goes on to say "The full colour EuroNav System features selectable map illustrations. Either vector or scanned raster maps can be displayed"

You cannot possibly know what map had been selected, and therefore can also not possibly know whether Blackrock was on the Commander's map display or not.

sheesh, of course not and its unlikely the FDR will contain that data either.

I dont know if you have ever used nautical charting system based around vector and or raster mapping ( The subject is complex)
Any user ofd such systems, will be aware off zoom detail , the possibility of data being obscured by other data , the fact that vector systems hide data at certain zoom levels, that fact that multiple maps may be available covering the same area, the issue of map quilting etc . Aircraft moving maps use the same technology .( in fact the companies are the same )

So you are correct that I cannot know at the precise time what the commander was displaying

thats not really the issue.

The issue is did the commander know that the information was there to be found and did she know in advance of arriving at a low level in the vicinity of a significant danger that the island was there in the first place. and if not why not was that a system failure . a SOP failure, a crew prep failure, etc etc .

BoatMad · 14-04-2017 08:35PM

faoiarvok wrote: »

Bad phrasing on my part, I said "this approach" to mean more like "this strategy" of conducting the cloud break early. Will edit now to clarify that.

The cloud break strategy in itself was performed correctly ( it seems ) over open water. The issue was the use of a " company approach route" that passed virtually over blackrock at an altitude that presented a mortal danger

No, it's either VFR or it's not, even with SAR exemptions from some VFR requirements.

I cannot comment here , merely that the conditions suggested that an instrument aided approach was the only practical mechanism. It was clear that the Heli was flying a preprogrammed waypoint to waypoint route under a flight management system , while being held in an autopilot controlled flight envelope .

Irish Steve · 14-04-2017 08:42PM

The unanswered questions for me at the moment, which I hope the full report will discuss in a lot more detail are

When was the Blacksod South approach designed, and for what aircraft type?

If not specifically designed for the S92, had it been updated to take account of the much higher capability of the S92 when compared to the S61 and/or other earlier less capable aircraft?.

Was the procedure designed by CHC, or was is provided to them by a third party, and if a third party, who?

Are any other helicopter operators ( Irish Lights, Air Corps to name 2) using similar charts and procedures that may be incomplete or inaccurate?

What vertical profile information is contained in the page that's mentioned but not included in the interim report?

The crew appear to have been correctly executing the approach to Blacksod, based on the information that we have at present, but there are some areas where we do not have complete information, probably because AAIU do not yet have complete information. Hopefully, the final report will clarify some or all of these issues.

To add some other information that's relevant to the discussion, the S92 has on board equipment that enables it to enter any position and then fly a controlled approach to that point, with transition to a hover if required over that point, as low as 50 Ft above it, which in the SAR mode is absolutely appropriate to making contact with a trawler or similar to recover a casualty.

On that basis, it should have been possible to design an approach profile for the S92 that provided a completely controlled descent clear of any terrain conflicts, to break cloud as part of the approach into Blacksod, which would then allow for a visual landing. The horizontal part of the existing procedure is very much oriented towards that, with the final path into Blacksod being into the prevailing wind direction, and the missed approach path taking them clear of terrain and back to the start point, which is the sort of procedure that's appropriate for things like separation from other air traffic and the like. What we don't have (yet) is the vertical profile information that would be part of a "Normal" approach profile.

The AAIU interim report is an excellent document that deals in a sensitive and appropriate way with difficult issues, and they have given us a lot of clear information about what really happened to R116. All we can hope for is that as they dig deeper into all the information they have, asking the sort of questions I have asked above, they can work out the WHY of the event, in a non judgemental way, so that everybody can learn from this awful event, and do everything possible to make sure there is never a repeat.

TomOnBoard · 14-04-2017 08:44PM

BoatMad wrote: »

the report contain this piece of text

"
The helicopter was equipped with a EuroAvionics EuroNav 5 moving map display which had a number of maps/charts available for selection. The exact information in relation to Black Rock and Lighthouse varied from none, to detailed, depending on the selected map/chart."

do you wish to dispute this

the comment you refer to is a general issue because this is a preliminary report , but based on the comment it has made to date, it was clear that both the briefing notes and the mapping systems contained data on blackrock. of course it could be that such information was badly presented, badly accessed or badly understood or any combination or none . but the basic fact remains , that the aircraft contained systems that had knowledge of the obstruction

Are you challenging me to a duel? If so, I get to choose weapons...

Means Of Escape · 14-04-2017 08:49PM

siobhan08 wrote: »

My understanding of reading the thread and listening to the experts on the radio that they broke the cloud cover so they would have a clear run into Blacksod as opposed to breaking cloud over terrain and then having to navigate around potential obstacles on landing.

The expert on the Pat Kenny show was a former Air Corps L Colonel and he said that if you were to approach Dublin Airport with all the well lit runway, air traffic control etc and it would usually be a 10-mile approach. Blacksod wouldn't have any of that so they have to "stage down" by transitioning down gradually from above the cloud cover to below the cloud and "walk your way at a low speed so you can visually acquire" information to safely make the landing. The transitioning down to a low altitude allows you to see the ground ie the sea in the case and then the land

You can listen to him explain things here http://www.newstalk.com/listen_back/13240/35317/14th_April_2017_-_The_Pat_Kenny_Show_Part_1/

Flying over the sea and night is like white out(Flying over snow)
Impossible to determine where the sky starts and the water ends leading to SD therefore a reliance on your instruments is vital which the commander correctly did
JFK Jnr crash an example of this .

BoatMad · 14-04-2017 08:50PM

TomOnBoard wrote: »

Are you challenging me to a duel? If so, I get to choose weapons...

:D:D:D

no merely that I presume you except the preliminary reports comments on the existing mapping system as it pertains to data about blackrock

I have engaged in no speculation about the quality , ease of access or crew knowledge of such mapping systems such that they could retrieve data pertaining to blackrock in advance of actually arriving in its vicinity.

I have merely pointed out that the report says that two sources of information pertaining to blackrock were available to the crew, The approach path briefing notes and the data contained in the Mapping systems .

This leads to the question , did they know , and if not , why not.

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

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