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

BoatMad · 14-04-2017 08:59PM

Irish Steve wrote: »

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.

This is a thoughtful post. But it avoids the difficult question

The suitability of the approach path for the helicopter is not in reality germane. If a professional crew elected to use that approach, one must assume that they had good reason to believe it was suitable even if it was ( or was not ) optimal for the aircraft in question

The investigation has to establish whether they had in the first place made an appropriate choice and if not why not

Secondly having chosen an approach route. The investigation now has to determine why the elected takedown procedure and subsequent approach to the LZ was regarded as appropriate given the physical location of a dangerous obstruction.

IN that regard they will have to consider , the availably of appropriate data and attempt to determine if such data was accessed and then considered , the suitability of the aircraft systems to " aid" the crew in achieving their aim , i.e. to arrive safety at the LZ and the in the process,answer the 64 million dollar question, why did a competent crew , flying a perfectly good aircraft, fly into an island. this isnt about blame, this is about answers

Irish Steve · 14-04-2017 09:01PM

Unlike fixed wing aircraft, using an autoland capability that gets guidance from the ILS, there is no similar system for a helicopter at a site like Blacksod, which has no approach aids of any sort, so they have to land visually.

While in theory they can hover over a point, and descend vertically, that is not the preferred mode of operation, for performance and safety reasons, they are much happier to perform an approach with a horizontal movement as part of the profile, it's less strain on the aircraft, and provides more options in the event of a failure of any of the systems at a critical moment. So, they both want and need to establish a clear visual contact with the landing site with enough time and space to be able to set up a stable and safe approach, albeit that it can be from relatively close to the landing site, both vertically and horizontally.

BoatMad · 14-04-2017 09:04PM

Irish Steve wrote: »

Unlike fixed wing aircraft, using an autoland capability that gets guidance from the ILS, there is no similar system for a helicopter at a site like Blacksod, which has no approach aids of any sort, so they have to land visually.

While in theory they can hover over a point, and descend vertically, that is not the preferred mode of operation, for performance and safety reasons, they are much happier to perform an approach with a horizontal movement as part of the profile, it's less strain on the aircraft, and provides more options in the event of a failure of any of the systems at a critical moment. So, they both want and need to establish a clear visual contact with the landing site with enough time and space to be able to set up a stable and safe approach, albeit that it can be from relatively close to the landing site, both vertically and horizontally.

no one disputes the " intent " of the crew, their bone fides are not in question, what is in debate , is the particular decision tree ( and event cascade) that lead to the particular tragedy in that particular place

14-04-2017 09:10PM

The first question has been answered already, they didn't know otherwise they would at some point have discussed Blackrock the lighthouse and the terrain. The report clearly says they didn't at ANY point mention it during the flight.

That leaves the more important point, why didn't they know either via page 2 or via the nav system (moving map etc).

EGPWS would have been displayed as an overlay on the ND, this when selected would have shown blue for over water and then varying colours from black to red differentiating the height of terrain. If Blackrock wasn't included then the area would just have been blue. With gear down the aural and visual warnings would by my limited understanding have been dumbed down to avoid spurious warnings during low level ops. The EGPWS is important and can't be dismissed as likely this was being used as a reassurance to them when overlaid on the ND with the flights LNAV routing in relation to terrain.

Yes an important question will be, what was the companies SOP in relation to low level ops, EGPWS use, maps displayed etc. It's

BoatMad · 14-04-2017 09:24PM

EGPWS would have been displayed as an overlay on the ND, this when selected would have shown blue for over water and then varying colours from black to red differentiating the height of terrain. If Blackrock wasn't included then the area would just have been blue. With gear down the aural and visual warnings would by my limited understanding have been dumbed down to avoid spurious warnings during low level ops. The EGPWS is important and can't be dismissed as likely this was being used as a reassurance to them when overlaid on the ND with the flights LNAV routing in relation to terrain.

It is stated elsewhere that the Honeywell database specifically states that it does not include all terrain features that might be dangerous ( and I can see any lawyer insisting on it ) , it no more then the GPS chart plotter on my boat contains a text message that says its is merely an " aid to navigation " and cannot be relied upon ( or words to that effect )

I would contend , that outside of a totally unforeseen process, no crew would willingly fly into an area that they were not prepared for and had not prepped for . I can accept that in a SAR operation. situations may present themselves that require " seat of the pants " actions, but I would contend this was not a classic SAR op.

Therefore it is the task of any crew of any vessel or aircraft to undertaken sufficient pre-planing and "research " to ensure that appropriate decisions are taken and known risks are characterised and were possible mitigated. simply blindly trusting the technology is simply not good enough , you must have clear evidence that the technology can be trusted in the first place and in all cases you must ensure that situational awareness is not lost , so that you cannot recover manually .

Equally any technological aid , that is used to provide " reassurance " must be carefully used so as not to become a " crutch " , technology is a product of humans and humans err. CFIT is a cascade of man and machine interaction

This accident causes many questions to be asked, which in time the full report will cover, at both a system level , crew level and technology level.

right now we know its a CFIT , next we hope to determine WHY it was a CFIT

selectamatic · 14-04-2017 09:31PM

Irish Steve wrote: »

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.

This is the one thing I'm having trouble understanding though. If APBSS was undertaken correctly how did r116 crash, surely the first aircraft that used APBSS would have crashed.

Was it not reported that r116 had used APBSS a few weeks prior to the incident albeit obviously with a different crew on that particular instance something had to differ in the approach from the approach used in the night of the accident.

Means Of Escape · 14-04-2017 09:36PM

Irish Steve wrote: »

Unlike fixed wing aircraft, using an autoland capability that gets guidance from the ILS, there is no similar system for a helicopter at a site like Blacksod, which has no approach aids of any sort, so they have to land visually.

While in theory they can hover over a point, and descend vertically, that is not the preferred mode of operation, for performance and safety reasons, they are much happier to perform an approach with a horizontal movement as part of the profile, it's less strain on the aircraft, and provides more options in the event of a failure of any of the systems at a critical moment. So, they both want and need to establish a clear visual contact with the landing site with enough time and space to be able to set up a stable and safe approach, albeit that it can be from relatively close to the landing site, both vertically and horizontally.

It can be argued that flying at 200 feet above water does not allow any room or time to control the craft effectively in the event of a failure of the craft unless it is a catastrophic failure i.e.explosion

There is no advantage of flying so low regardless of cloud cover
The helicopter in question is a very capable machine that due to its role is also very robust pound for pound .

BoatMad · 14-04-2017 09:45PM

selectamatic wrote: »

This is the one thing I'm having trouble understanding though. If APBSS was undertaken correctly how did r116 crash, surely the first aircraft that used APBSS would have crashed.

Was it not reported that r116 had used APBSS a few weeks prior to the incident albeit obviously with a different crew on that particular instance something had to differ in the approach from the approach used in the night of the accident.

we simply are not provided with enough sight of the company route plan to answer that question , what we do know is that the interim report makes no mention of a vertical flight profile and DOES make mention of a briefing notes page that details obstructions including blackrock island.

Hence we do not know is the waypoints were merely 2D navigational waypoints or 3D waypoints

However we do know that the approach plan as presented allowed a degree of local decision making . for example , the plan as presented by the report didnt not contain the Takedown direction , i.e. the crew flew beyond the first waypoint to effect a takedown to VFR , whether there is an SOP to do this is not documented

We then know that a controlled autopilot turn was manually initiated by the crew to bring the helicopter to the initial waypoint "BLKMO" and we know the crew intended to fly onwards to the next one as you would expect "BKSDA",

Again it is not clear that the SOP required a turn to the right or left to approach the initial waypoint nor if such a change would have just avoided blackrock. It may be that wind direction etc and local conditions required that the approach plan be flexible and decided by the crew.

hence was it that the selected approach was " vulnerable " to particular implementations ? , Im sure thats one of the answers the investigation will attempt to answer

Irish Steve · 14-04-2017 09:51PM

Means Of Escape wrote: »

It can be argued that flying at 200 feet above water does not allow any room or time to control the craft effectively in the event of a failure of the craft unless it is a catastrophic failure i.e.explosion

There is no advantage of flying so low regardless of cloud cover
The helicopter in question is a very capable machine that due to its role is also very robust pound for pound .

I guess that I'd have to answer that the reason they do it whenever they can is so that they keep the essential skills that they use on most missions very much active and current, much of what they do on a regular basis requires them to operate at these low levels for prolonged periods of time, often in very difficult weather conditions, and the best way to be good at something is to do it on a regular basis.

Gaoth Laidir · 14-04-2017 10:07PM

I wonder what other rocks/small islands around Ireland are also not on the database...

Ok, Blackrock being right in the thick of a published approach to a refuelling station is a special case, but in a real SAR mission somewhere else, flying a similar low and slow approach to a vessel in IMC, you'd hope that such a situation would not present itself in the future. A major revision of all these things is needed.

BoatMad · 14-04-2017 10:11PM

Gaoth Laidir wrote: »

I wonder what other rocks/small islands around Ireland are also not on the database...

Ok, Blackrock being right in the thick of a published approach to a refuelling station is a special case, but in a real SAR mission somewhere else, flying a similar low and slow approach to a vessel in IMC, you'd hope that such a situation would not present itself in the future. A major revision of all these things is needed.

I suspect that one will never have a situation here EGPWS databases will ever be 100% complete , one must live with the fact these are " aids" not infallible expert systems

Means Of Escape · 14-04-2017 10:23PM

Irish Steve wrote: »

I guess that I'd have to answer that the reason they do it whenever they can is so that they keep the essential skills that they use on most missions very much active and current, much of what they do on a regular basis requires them to operate at these low levels for prolonged periods of time, often in very difficult weather conditions, and the best way to be good at something is to do it on a regular basis.

Fair enough however it is illegal to perform a stall manoeuvre in a light aircraft at 200 feet over a populated area so one has to ask whether flying at this altitude is wise

I would foresee this practice being terminated in the not too distant future for all rescue helicopters with minimum height for all approaches and departures being implemented .

Irish Steve · 14-04-2017 10:40PM

Means Of Escape wrote: »

Fair enough however it is illegal to perform a stall manoeuvre in a light aircraft at 200 feet over a populated area so one has to ask whether flying at this altitude is wise

I would foresee this practice being terminated in the not too distant future for all rescue helicopters with minimum height for all approaches and departures being implemented .

So what do we then do about things like "remain below 500 Ft" as a clearance to leave the zone at Dublin so that there's no conflict with IFR traffic that's at 1500 Ft above them.

200 Ft over a populated area is not the same as 200 Ft over water, even more so if this happens 100 Miles off shore. We don't see it in this country, I've seen plenty of heavy aircraft flying below 500 Ft over land in the UK, the RAF do it all the time, and the size aircraft they do it with can be seriously impressive, and they don't seem to have too many problems with doing it, they do it because they deem it appropriate to the skills required by their pilots.

There's also a significant difference between a light single engine aircraft, and something like the S92, which is multi engine, and certified for flight on one engine in the event of a failure.

We're in danger of drifting off topic here, so I'll leave it there

Gamebred · 14-04-2017 10:44PM

Was there postmortem results on the 2 victims found? any findings on if they were dead on impact? I do hope it was over quick for them.

Steve · 14-04-2017 10:51PM

Gamebred wrote: »

Was there postmortem results on the 2 victims found? any findings on if they were dead on impact? I do hope it was over quick for them.

Nothing in the report, the commander was recovered alive and the co-pilot was recovered from the sea bed.

This has been well covered both here and in mainstream media. Please read up on the subject before asking further questions like this.

irishgeo · 14-04-2017 10:56PM

Steve wrote: »

Nothing in the report, the commander was recovered alive and the co-pilot was recovered from the sea bed.

This has been well covered both here and in mainstream media. Please read up on the subject before asking further questions like this.

The RNLI aren't allowed to declare death. They don't have a doctor on board.

Gamebred · 14-04-2017 11:02PM

Steve wrote: »

Nothing in the report, the commander was recovered alive and the co-pilot was recovered from the sea bed.

This has been well covered both here and in mainstream media. Please read up on the subject before asking further questions like this.

Havent seen any discussion of cause of death, every one presuming it was death on impact i'd be interested to know the details, why was it not part of the report yesterday? will it be a seperate coroners report that will yield final cause?

smurfjed · 14-04-2017 11:03PM

was taken to effect a FMS course change

[font=Open Sans, Arial, Helvetica, sans-serif]Where did you get the idea that they tried to effect a FMS course change?[/font]

14-04-2017 11:06PM

Means Of Escape wrote: »

Fair enough however it is illegal to perform a stall manoeuvre in a light aircraft at 200 feet over a populated area so one has to ask whether flying at this altitude is wise

I would foresee this practice being terminated in the not too distant future for all rescue helicopters with minimum height for all approaches and departures being implemented .

I highly highly doubt that will happen. You have to consider what their role is exactly, rescue. This method is used for approaches to vessels out at sea as well as recovery to base or refuelling area.

The need to constantly practice these skills is a necessity not a nicety.

Steve · 14-04-2017 11:06PM

irishgeo wrote: »

The RNLI aren't allowed to declare death. They don't have a doctor on board.

I don't understand the RNLI reference, Capt. Fitzpatrick died in hospital, not at sea.

Steve · 14-04-2017 11:10PM

Gamebred wrote: »

Havent seen any discussion of cause of death, every one presuming it was death on impact i'd be interested to know the details, why was it not part of the report yesterday? will it be a seperate coroners report that will yield final cause?

The report was a prelim, the final report will have all avenues of investigation documented, including cause of death if relevant.

14-04-2017 11:11PM

Steve wrote: »

I don't understand the RNLI reference, Capt. Fitzpatrick died in hospital, not at sea.

Basically it means that she was probably dead when recovered but couldn't have been technically declared dead until she was with a doctor which was in hospital. Therefore the reports are recovered alive and declared dead at the hospital.

Edit: this is not a statement of fact or knowledge of such it is merely an explanation of a previous point made by another poster. Sorry just for clarity.

Steve · 14-04-2017 11:12PM

smurfjed wrote: »

[font=Open Sans, Arial, Helvetica, sans-serif]Where did you get the idea that they tried to effect a FMS course change?[/font]

The CVR seems to indicate so.

OK Come Right…select
heading

Roger…
Heading selected

faoiarvok · 14-04-2017 11:15PM

Gamebred wrote: »

Havent seen any discussion of cause of death, every one presuming it was death on impact i'd be interested to know the details, why was it not part of the report yesterday? will it be a seperate coroners report that will yield final cause?

Method of injury/death is not a subject to be considered by the AAIU as it is not within their expertise, and frankly, is irrelevant to their investigation, as its purpose to investigate the accident with the goal of preventing a repeat in the future.

siobhan08 · 14-04-2017 11:17PM

Steve wrote: »

I don't understand the RNLI reference, Capt. Fitzpatrick died in hospital, not at sea.

I think she could have been dead when she was recovered personally. Like the previous poster has said the RNLI cannot declare a person dead so would have carried out whatever measures they could to preserve life and transferred her to more advanced medical care.

From my personal experience as a lifeguard our training taught us that even if we think a person is dead we have to carry out any measures that would attempt to preserve life until paramedics arrived. So even if in our hearts we know someone has passed on we have to begin and continue CPR until advanced medical care arrives as we cannot make the declaration of death.

Gamebred · 14-04-2017 11:17PM

faoiarvok wrote: »

Method of injury/death is not a subject to be considered by the AAIU as it is not within their expertise, and frankly, is irrelevant to their investigation, as its purpose to investigate the accident with the goal of preventing a repeat in the future.

Thats what I was wondering, so I presume the family will only find cause of death by a coroners report? im sure they will want to know.

Steve · 14-04-2017 11:17PM

Deleted User wrote: »

Basically it means that she was probably dead when recovered but couldn't have been technically declared dead until she was with a doctor which was in hospital. Therefore the reports are recovered alive and declared dead at the hospital.

I hadn't considered that.

I don't think it is prudent to continue discussion on this matter until there is an official report on it.

Mod note: Out of respect for the crew, any further discussion of this is off limits.

Cloudio9 · 14-04-2017 11:17PM

faoiarvok wrote: »

Method of injury/death is not a subject to be considered by the AAIU as it is not within their expertise, and frankly, is irrelevant to their investigation, as its purpose to investigate the accident with the goal of preventing a repeat in the future.

Maybe in the case of this accident but method of death is often very relevant in investigations.

smurfjed · 14-04-2017 11:24PM

@steve, thats a heading change, not a FMS course change.
We have discussed "children of the magenta line", trying to effect an FMS course change would demonstrate an over reliance on the FMS, making a heading change demonstrates that they weren't reliant on the FMS.

Irish Steve · 14-04-2017 11:25PM

Steve wrote: »

The CVR seems to indicate so.

Splitting hairs, but in the interests of accuracy, the FMS is used to enter the details of where they want to go, but for things like a heading change, that's entered on a section of the autopilot, which is a separate piece of computer hardware that can specifically control things like heading, height, speed and rate of climb/descent, and it can be used to over ride the course that the FMS has calculated

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

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