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

Steve · 14-04-2017 11:28PM

smurfjed wrote: »

@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.

OK, I understand what you are saying in terms of "children of the magenta line, maybe I don't fully understand what an FMS course change means then, in my mind this would mean they changed the autopilot heading bug which would mean a standard rate turn to the new heading.
Is that wrong?

Steve · 14-04-2017 11:32PM

Irish Steve wrote: »

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

OK, am I confusing the term FMS with FMC which is used for lateral navigation? I thought FMS included the autopilot. I apologise if I got that wrong.

smurfjed · 14-04-2017 11:37PM

Is that wrong?

Yes.
The FMS obviously had the company route programmed into it, when they selected DIRECT TO, it brought them to the start of that route, it would have automatically followed the planned route with the required course headings. The idea of making a FMS course change would entail dropping the name of the starting of the change into the scratch pad, changing the course and adding a distance then bringing that back into the route and executing it. Easy to do but time consuming.
Heading changing would involve the heading knob and selecting a Heading mode for the autopilot rather than the FMS navigation mode. Simple to do and fast.

14-04-2017 11:39PM

Steve wrote: »

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.

Post edited for clarity. Please see my original post.

Gaoth Laidir · 14-04-2017 11:42PM

smurfjed wrote: »

Yes.
The FMS obviously had the company route programmed into it, when they selected DIRECT TO, it brought them to the start of that route, it would have automatically followed the planned route with the required course headings. The idea of making a FMS course change would entail dropping the name of the starting of the change into the scratch pad, changing the course and adding a distance then bringing that back into the route and executing it. Easy to do but time consuming.
Heading changing would involve the heading knob and selecting a Heading mode for the autopilot rather than the FMS navigation mode. Simple to do and fast.

So if the autopilot was flying the standard route that was set up in the system, how did that route take it on a direct collision course with Blackrock?

Means Of Escape · 14-04-2017 11:44PM

Irish Steve wrote: »

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

I respectfully disagree and cannot see any advantage of flying at 200 feet

There are however numerous reasons why over 500 feet is far more advantageous the most obvious one is control and clearance in the event of a mechanical failure .

If it is accepted that this was CFIT then the altitude of the helicopter is the key reason for the crash as the incomplete data onboard would be irrelevant

It has yet to be established as to why 116 was flying so low be it protocol or a crew decision and I am in no doubt that approaches at 200 feet at night outside of a mile from destination will be reviewed

Gaoth Laidir · 14-04-2017 11:46PM

Means Of Escape wrote: »

I respectfully disagree and cannot see any advantage of flying at 200 feet

There are however numerous reasons why over 500 feet is far more advantageous the most obvious one is control and clearance in the event of a mechanical failure .

If it is accepted that this was CFIT then the altitude of the helicopter is the key reason for the crash as the incomplete data onboard would be irrelevant

It has yet to be established as to why 116 was flying so low be it protocol or a crew decision and I am in no doubt that approaches at 200 feet at night outside of a mile from destination will be reviewed

Under 500 feet. The Lambay transit route is max 500 ft.

smurfjed · 14-04-2017 11:49PM

how did that route take it on a direct collision course with Blackrock?

I would hazard a guess that it was designed as a VFR arrival route with fixed locations for less capable helicopters.

oppenheimer1 · 14-04-2017 11:50PM

Gaoth Laidir wrote: »

Under 500 feet. The Lambay transit route is max 500 ft.

There are only a handful of locations that intersect with airport corridors where an altitude ceiling would apply no?

Irish Steve · 14-04-2017 11:55PM

Gaoth Laidir wrote: »

So if the autopilot was flying the standard route that was set up in the system, how did that route take it on a direct collision course with Blackrock?

If I understand it correctly, the FMS was navigating them from the point west of Blackrock on to the approach route to Blacksod, which starts at BLKMO, so when they entered "direct to BLKMO", and that resulted in the course that took them to the collision with Blackrock.

We don't yet have the exact coordinates of BLKMO, which is unhelpful, a suggestion I have seen elsewhere has been made that the origins of the Blacksod South approach comes from a route that would be used in VFR as part of the resupply process for the Blackrock lighthouse by Irish Lights, but we have no way to confirm or deny that possibility. It has also been suggested that BLKMO has the same coordinates as the landing pad on Blackrock, if that is the case, then the failure to have an adequate terrain clearance at that point is a major issue that will have to be clarified in the final more detailed report by AAIU

TomOnBoard · 15-04-2017 12:06AM

Steve wrote: »

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.

I note the Mod note, and agree with the comment.

However, there is a related matter that emanates from the report's statement that " the two cockpit side jettisonable window hatches were found in close proximity to the main wreckage". Given that a) "the cockpit area was repasonably intact", and b) opening the hatch required the use of a handle that had to be turned from the inside,

Does this throw some light in the context of Capt Fitzpatrick's exit from the aircraft after the crash?

Steve · 15-04-2017 12:12AM

TomOnBoard wrote: »

Does this throw some light in the context of Capt Fitzpatrick's exit from the aircraft after the crash?

I see where you are going with this, but I think we are getting into speculation again and not in a good way. I really think we should leave that lie until there is more information.

Irish Steve · 15-04-2017 12:24AM

TomOnBoard wrote: »

I note the Mod note, and agree with the comment.

However, there is a related matter that emanates from the report's statement that " the two cockpit side jettisonable window hatches were found in close proximity to the main wreckage". Given that a) "the cockpit area was repasonably intact", and b) opening the hatch required the use of a handle that had to be turned from the inside,

Does this throw some light in the context of Capt Fitzpatrick's exit from the aircraft after the crash?

At this stage, we have no way to know exactly what happened between the collision with the island, and the eventual resting place underwater, the only comment in the interim report is that the aircraft "departed from controlled flight". We may get more information when the moment by moment data from the FDR has been analysed in minute detail, but that process will be happening for some time to come, and was unlikely to have been available in time for the publication of the report.

Reasonably intact is also subjective, distortions as a result of the initial impact, possible short term aerodynamic overloads due to the damage, and the impact with the water surface all have the potential to have caused the release of the windows without any human intervention, so it will be impossible to state with any certainty what the sequence of events was during the final seconds of the flight. With this many variables, it is unlikely that we will get any clarity of how Cpt Fitzpatrick came to be in the water and separated from the aircraft, and at this time, it would be both unreasonable and inappropriate for people outside of a very small group to be given specific details of any post mortem examination results that might shed some light on this aspect of the event.

allthedoyles · 15-04-2017 12:57AM

<SNIP>

comparing a driver in a road crash to the crew in incident is bizarre.
Don't post here like that again or you will be banned for trolling A&A

ProfessorPlum · 15-04-2017 09:50AM

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.

While it is absolutely necessary and appropriate to practice the kind of flying that SAR crews will do on a daily basis, it would be reasonable to question the appropriateness to practice this kind of flying in the circumstances - at night, in very marginal weather conditions, and both pilots unfamiliar with the area and the procedure. It would be interesting to see what CHC SOPs have to say, if anything, on the matter. I'd guess they flew the 'approach' as they did because, for whatever reason, they judged it to be the best option in the circumstance, not because it was an apportunity to practice their flying skills.

adam88 · 15-04-2017 10:27AM

It's been asked here before by another poster but I can't seem to find anyone that has answered it.

In my profession we learn how to prevent future incidents by near misses. These are invaluable in preventing future harm or incident.

If this was accompany approach then surely it had to be noticed this big bloody rock I the middle of the published approach. Why was this noticed or is it a case that a near miss form or similiar was sitting on someone's desk or something.

Irish Steve · 15-04-2017 10:30AM

ProfessorPlum wrote: »

While it is absolutely necessary and appropriate to practice the kind of flying that SAR crews will do on a daily basis, it would be reasonable to question the appropriateness to practice this kind of flying in the circumstances - at night, in very marginal weather conditions, and both pilots unfamiliar with the area and the procedure. It would be interesting to see what CHC SOPs have to say, if anything, on the matter. I'd guess they flew the 'approach' as they did because, for whatever reason, they judged it to be the best option in the circumstance, not because it was an apportunity to practice their flying skills.

And you've just effectively hit the point of the fundamental difference between airline flying and SAR. The SAR crews can be called on at very short notice to do exactly what you've described, in weather conditions that most people wouldn't go walking in, and in an area that they don't have detailed knowledge or experience of, and they have to have the skills and capability to make informed decisions about where it is or is not safe to operate. We don't have the full details of the Blacksod South approach, but a company approved and provided approach procedure should have all the appropriate checks to ensure that if flown in accordance with the procedure, it is safe, and for reasons as yet unexplained, on this flight, it wasn't.

There have to be serious questions asked, and reported on in the final report, about the nature of the approach procedures, and the terrain information in the database, which is supposedly an enhanced database that is upgraded for SAR purposes, and clearly, the tragic events of R116 have demonstrated in the worst possible way that some of the procedures and on board data were not fit for purpose.

Growler!!! · 15-04-2017 10:41AM

adam88 wrote: »

It's been asked here before by another poster but I can't seem to find anyone that has answered it.

In my profession we learn how to prevent future incidents by near misses. These are invaluable in preventing future harm or incident.

If this was accompany approach then surely it had to be noticed this big bloody rock I the middle of the published approach. Why was this noticed or is it a case that a near miss form or similiar was sitting on someone's desk or something.

I think the Company Approach starts overhead Blackrock island at least that's what it looks like in the report. It mentions 282 which is the elevation of the island itself. I think the question asked before is why was the Company Approach started at a low altitude. Was this the normal SOP or was descent normally initiated much later.

Tenger · 15-04-2017 10:42AM

adam88 wrote: »

..........
In my profession we learn how to prevent future incidents by near misses. These are invaluable in preventing future harm or incident.

If this was accompany approach then surely it had to be noticed this big bloody rock I the middle of the published approach. Why was this noticed or is it a case that a near miss form or similiar was sitting on someone's desk or something.

There is a historical precedent for something like this. On the first and second space shuttle launches, large chunks of insulation broke off and impacted the orbiter. (Requiring spy sats sweeps to examine the orbiter on the 1st flight)
This was seen as quite a worry by certain engineers. However as with any new program more immediate issues took over. By the time the insulation issue was reassessed the attitude was than "everything seems fine here"
Fast forwards 20 years and you have the loss of Columbia due to insulation impact damage on launch.

Could the position of Blackrock along a published company routing be a similar issue. Long established acceptance of less than favourable conditions is permitted/tolerated due to overfamiliarity?

smurfjed · 15-04-2017 10:48AM

about the nature of the approach procedures,

The approach was slow an cautious, but questions will be asked about whey they continued straight and level for 6 seconds after the initial back seat call for a turn.

ProfessorPlum · 15-04-2017 10:53AM

Irish Steve wrote: »

And you've just effectively hit the point of the fundamental difference between airline flying and SAR. The SAR crews can be called on at very short notice to do exactly what you've described, in weather conditions that most people wouldn't go walking in, and in an area that they don't have detailed knowledge or experience of, and they have to have the skills and capability to make informed decisions about where it is or is not safe to operate......

And just as you won't find me practicing a raw data ILS approach in marginal CAT 1 conditions with a limiting cross wind onto a short contaminated runway, I'd argue that the same principal of maintaining some margin of safety apply to all pilots, particularly when 'practicing' skills. Whether SAR or airline, pilots deserve to get home at night and if there is a culture in the SAR community of eroding safety margins - in this case to nothing - particularly in non 'life and death' rescue situations, then that culture needs to be looked at. But back to my original point - I don't think this approach was flown in the manner it was out of practice as you implied. I can only assume it was considered to be the best approach for the circumstance.

Irish Steve · 15-04-2017 11:18AM

ProfessorPlum wrote: »

And just as you won't find me practicing a raw data ILS approach in marginal CAT 1 conditions with a limiting cross wind onto a short contaminated runway, I'd argue that the same principal of maintaining some margin of safety apply to all pilots, particularly when 'practicing' skills. Whether SAR or airline, pilots deserve to get home at night and if there is a culture in the SAR community of eroding safety margins - in this case to nothing - particularly in non 'life and death' rescue situations, then that culture needs to be looked at. But back to my original point - I don't think this approach was flown in the manner it was out of practice as you implied. I can only assume it was considered to be the best approach for the circumstance.

I think we're both on the same page, only looking at it from slightly different perspectives, and yes, you'd be rightly reluctant to fly a marginal approach with added negative factors, but if you had to do it, you would.

The clear impression we have at the moment is that the crew of 116 didn't see any adverse factors to the approach to Blacksod, other than that neither of them had been there for some time.

A long time back in the thread someone posted that they are not "have a go heros", and that culture is not wanted or appropriate, but they are and have to be capable of very rapidly evaluating the risks, and making informed decisions about how they deal with the situation.

This approach should have been completely normal, standard and uneventful, albeit that they hadn't been there in a while, to context that, a diversion to an airport that you've not been to before, but with published procedures would get a higher level of attention than a routine ILS on to 28 at Dublin, and you'd be ultra vigilant all the way to the runway, but if the procedure is there, you'd use it and not expect a nasty surprise on the way down. Based on the (incomplete) information that's been released so far, that's what the crew of 116 were doing.

I won't speculate, until I see the rest of the Blacksod approach information, I can't determine if what the 116 crew did on the night was good, bad, appropriate or plain wrong, and at this stage, AAIU have not made the rest of the approach information available.

AAIU may well not comment on that aspect, as their mandate is not to apportion blame, which is correct.

Final Approach · 15-04-2017 11:24AM

I work in the aviation industry, but nothing in relation to flying aircraft or indeed helicopters. I have have been following this thread with interest, and having read the AAIU preliminary report with regard Rescue 116 yesterday, as well as following some of the associated media articles, I am quite frustrated by one particular statement I read, and would like those in the know to clarify that I am correct in my interpretation.

A popular, and what I would consider normally the most accurate/least sensational newspaper published an article yesterday in relation to the AAIU report, stating that :

"The route guide to Blacksod helicopter pad included Blackrock island as a waypoint on a prescribed approach in from the west. While the island’s height at 282ft is marked, the aeronautical chart depicts it as a red dot without any indication of land mass. In the recorded cockpit conversation, Capt Fitzpatrick believed it to be a small little island”.

Where I have difficulty is that having read the report, my interpretation is that when Capt. Fitzpatrick RIP made this statement, she was in fact flying over Carrickduff and Carrickad, which is where Rescue 116 was pinpointed to have been when she made these comments, and which is what consequently activated the ALTITUDE warning. This was during her approach to Blackrock, but not in any way associated with Blackrock, isn't that the case!?

If so, the newspaper are being utterly misleading in their publication of their mis-interpretation of the report at Capt. Fitzpatricks expense, which is a horrible oversight on their part. If someone could clarify the above I'd apreciate it, as it's frustrating me to the point that I am prepared to write a letter of complaint to the newspaper. Thank you.

Irish Steve · 15-04-2017 11:32AM

Final Approach wrote: »

If someone could clarify the above I'd apreciate it, as it's frustrating me to the point that I am prepared to write a letter of complaint to the newspaper. Thank you.

I think it's fair to say that your interpretation of the report is correct, but until we get to see the detailed final report, we can't be 100% certain, the full report will hopefully contain very detailed maps and representations of the critical stages of the flight, with annotated timings, and ground/height position mapping as well.

Irish Steve · 15-04-2017 11:50AM

smurfjed wrote: »

The approach was slow an cautious, but questions will be asked about whey they continued straight and level for 6 seconds after the initial back seat call for a turn.

We don't have details of what might have changed in those 6 seconds, a reasonable response would be to check the nav displays to see if they were painting anything, and then respond, and there was clearly nothing on the screens that was causing concern, so the natural reaction would be to quickly check in case, and then respond.

You would (correctly) instantly respond to a TCAS alert, but a master caution would be looked at before anything was changed, an alert from the other crew members would not have had the same urgency as an alert from the Monitoring Pilot, even more so as it would have come as a complete surprise.

ProfessorPlum · 15-04-2017 11:50AM

Irish Steve wrote: »

I think we're both on the same page, only looking at it from slightly different perspectives, and yes, you'd be rightly reluctant to fly a marginal approach with added negative factors, but if you had to do it, you would.

The clear impression we have at the moment is that the crew of 116 didn't see any adverse factors to the approach to Blacksod, other than that neither of them had been there for some time.

A long time back in the thread someone posted that they are not "have a go heros", and that culture is not wanted or appropriate, but they are and have to be capable of very rapidly evaluating the risks, and making informed decisions about how they deal with the situation.

This approach should have been completely normal, standard and uneventful, albeit that they hadn't been there in a while, to context that, a diversion to an airport that you've not been to before, but with published procedures would get a higher level of attention than a routine ILS on to 28 at Dublin, and you'd be ultra vigilant all the way to the runway, but if the procedure is there, you'd use it and not expect a nasty surprise on the way down. Based on the (incomplete) information that's been released so far, that's what the crew of 116 were doing.

I won't speculate, until I see the rest of the Blacksod approach information, I can't determine if what the 116 crew did on the night was good, bad, appropriate or plain wrong, and at this stage, AAIU have not made the rest of the approach information available.

AAIU may well not comment on that aspect, as their mandate is not to apportion blame, which is correct.

Of course I'd fly the marginal approach described - if it was the best option open to me! I wouldn't choose it - or choose to downgrade my equipment in those conditions - for the sake of practice.
The question then comes back to Means of Escape's original comment - why chose to fly so low so far out, which erodes an available safety marking for no obvious benefit? I don't believe they were deliberately 'practicing' their low level skills - not in those conditions. Was it then a culture in CHC or in the wider SAR community? Or was it deemed on the night to be the best option, and if so why?

As you said, this was a standard company route, and there should have been no surprises. I would have assumed it would be reasonably familiar to crews - it was one of their regular refuelling locations - apparantly not. Do CHC crews not include as part of their training the more standard stuff - these type of company 'approaches'. Does the lack of training for regular approaches lead to complacency among crews? In other words if these approaches are not deemed necessary to train, are they perceived as so routine that the dangers are over looked or minimised?
I think the AAIU will most definitely comment on the 'good, bad, appropriate or wrong' issue. While the purpose of the investigation is not to appropriate blame, it is certainty to point out any errors in decision making and investigate the reasoning and the culture behind them.

ProfessorPlum · 15-04-2017 12:03PM

smurfjed wrote: »

The approach was slow an cautious, but questions will be asked about whey they continued straight and level for 6 seconds after the initial back seat call for a turn.

I think without the audio of the CVR it's impossible to know how urgent the call for a right turn was. From the transcript, without tone of voice, there doesn't seem a huge amount of urgency about it. It's only the rear crew instruction at 2 seconds before impact (that is transcribed in capitals so I assume that to mean he has raised his voice at this point) that seems urgent. At that point it was already too late.

Cessna_Pilot · 15-04-2017 12:17PM

Irish Steve wrote: »

We don't have details of what might have changed in those 6 seconds, a reasonable response would be to check the nav displays to see if they were painting anything, and then respond, and there was clearly nothing on the screens that was causing concern, so the natural reaction would be to quickly check in case, and then respond.

You would (correctly) instantly respond to a TCAS alert, but a master caution would be looked at before anything was changed, an alert from the other crew members would not have had the same urgency as an alert from the Monitoring Pilot, even more so as it would have come as a complete surprise.

If someone behind me started shouting that there was an obstacle dead ahead in front of me the last place I'd be looking is inside!

smurfjed · 15-04-2017 12:53PM

an alert from the other crew members would not have had the same urgency as an alert from the Monitoring Pilot

I disagree, this was a 4 person crew, not two.

Jacovs · 15-04-2017 01:00PM

Looking at appendix B, page 37, what is the significance of the vertical red line on time stamp 7072 and then the vertical yellow line just after time stamp 7076?
Appendix B is referred to on page 27.

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

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