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

ProfessorPlum · 18-04-2017 11:15PM

Gaoth Laidir wrote: »

So in the meantime other S92 pilots carry on in the dark (so to speak) regarding the details of the crash. The report is fully factual so calling any part of it premature is wrong imo. It has not stated any cause as yet, just laying out the facts so far. If the conversation in the cockpit sheds light on the events and could go towards improving safety in the near future before the final report then what is the problem? As stated before, there are a lot more pro helicopter pilots over on pprune who find no problem with the report. I would be listening to them first and foremost.

Is there anything specifically in the CVR transcripts that you feel enlightens these S92 pilots? Specifically something that could not have been promulgated in another way?
The AAIU will make safety recommendations if it feels that this is the case - as it has done in the interim report. Neither of the safety recommendations they made were based on the CVR data. If during the course if the investigation they feel a safety recommendation is warranted, they will make it. In the near future. Or in the middle future. Or in the final report. The point is that that point is not now.

TomOnBoard · 19-04-2017 05:35AM

ProfessorPlum wrote: »

Is there anything specifically in the CVR transcripts that you feel enlightens these S92 pilots? Specifically something that could not have been promulgated in another way?
The AAIU will make safety recommendations if it feels that this is the case - as it has done in the interim report. Neither of the safety recommendations they made were based on the CVR data. If during the course if the investigation they feel a safety recommendation is warranted, they will make it. In the near future. Or in the middle future. Or in the final report. The point is that that point is not now.

I think the IALPA are being a bit precious on this.

Firstly, there were 4 people on that aircraft. Only 2 were pilots. Is the IALPA purporting to speak for the winch crew, who appeared to be the only people on board to 'see' the island at 13 seconds before impact and to say so?

I'd like to think that, as a result of the publication of the 2 minutes of CVR, operators and crews in SAR everywhere are asking themselves if they might need to reconsider their SOPs, their training, the role of the two rear crew members, their use of radar, possible over reliance on technology, importance of clear communications and acknowledgements in the cockpit etc. etc. All these things can be gleaned from that last 2 minutes.

All that said, perhaps the last couple of seconds of CVR, containing utterances and sounds that followed the initial collision, did not need publication by the AAIU, as by that time the aircraft was already lost. It's that last couple of seconds that were so awful to read and that fed the salaciousness of the Newspapers.

Gaoth Laidir · 19-04-2017 06:13AM

ProfessorPlum wrote: »

Is there anything specifically in the CVR transcripts that you feel enlightens these S92 pilots? Specifically something that could not have been promulgated in another way?
The AAIU will make safety recommendations if it feels that this is the case - as it has done in the interim report. Neither of the safety recommendations they made were based on the CVR data. If during the course if the investigation they feel a safety recommendation is warranted, they will make it. In the near future. Or in the middle future. Or in the final report. The point is that that point is not now.

They said it "it unnecessarily adds to the burden of the victims' families.. " Do they know that? Have the families said that? Or are they just making the assumption?

They also say it breaches international codes. Well the AAIU say it does't. I'm sure if it does then the AAIU will be hearing about it.

For me, it serves as a wakeup call to all pilots, not just those of S92s. The rapid nature of how the situation unfolded in those last 13 seconds is clearly shown in the recording. Without actually showing it like that I don't believe it would be so clear. The full 2 minutes shows a sterile cockpit, a professional crew, input from the rear crew. I don't see why IALPA would want to hide that from the world. What "confidentiality" are they speaking of? Granted, the rags grab the last words and run with it, but at least this time it's based on fact. Nothing will bring back the crew so the families must already be under maximum grief.

Nekarsulm · 19-04-2017 07:35AM

"I'm not saying it should never be done, but only when it backs up the technically relevant details"

"The databases are corrupted, they're inaccurate, I've seen databases where Blackrock Island is shown at 46 feet height"

"These (CVR) details should not be on the front of newspapers, ---- the relevant technical personell would have been madde aware of them..."

Enda Cullen, on Morning Ireland today.

So it seems that he would rather that any evidence of pilot error is kept from the general public.

TomOnBoard · 19-04-2017 08:24AM

Nekarsulm wrote: »

"I'm not saying it should never be done, but only when it backs up the technically relevant details"

"The databases are corrupted, they're inaccurate, I've seen databases where Blackrock Island is shown at 46 feet height"

"These (CVR) details should not be on the front of newspapers, ---- the relevant technical personell would have been madde aware of them..."

Enda Cullen, on Morning Ireland today.

So it seems that he would rather that any evidence of pilot error is kept from the general public.

He did his cause no favours on the RTE interview and came across as confused in what he was trying to say. He appeared to be doing a 'circle the wagons' exercise for the pilots, pushing the corrupted databases view of the crash. He went from the argument that the publication of any CVR by the AAIU was wrong to one that says 'all 100%' of the 2 minutes should't have been published. Why didn't he just come straight out and say that his problem was with the final few seconds and I'd be able to agree with him. He appeared on a very sticky wicket as he challenged the investigation. Frankly, I can't see him winning a battle with Jurgen White and his people with these tactics.

Tellingly, when pushed by the questioner, he had to explain that, while his statement referred to what the families wanted, not all the families agreed with his position.

Nekarsulm · 19-04-2017 08:34AM

I agree, TOB.
The tabloid Press will do what they usually do, and sensationalize, contort and misrepresent information, to sell papers.
This is not a reason to withhold information from the public arena.
What would be next if you went down this route, Courthouses to be off limits to the Public because some hack writes gutter press type reports for the paper?

Irish Steve · 19-04-2017 08:49AM

I think we should be very careful with the words here. However unpalatable it is, this flight ended as a result of CFIT. What is not clear is the reason for that happening, and at this stage, it is too early to be simplistic and just ascribe it to "pilot error".

What we have from the interim report is the specific detail of a crew that were operating in an appropriate mission focussed manner, and using a procedure that was given to them by the company, and at no point in the interim report is there any comment that they made an error, and the only people who could answer the questions of what they did and why they did is are unfortunately not here to provide the answers, so we are dependent on the AAIU to analyse every piece of information that they can get to try and provide an explanation of the events of the flight.

There are for certain areas where the interim report is lacking in detail. We don't have the specific details of the second page of the approach information, which may contain critical data relating to the execution of that approach, and we don't have the specific details of the CHC standard operating procedure for cloud break approaches. It is possible that the crew made an error in the execution of one of these processes, but at this stage of the investigation, we don't have the detail to be categoric about the cause.

Without those pieces of information, we cannot make an accurate determination of why they ended up colliding with Blackrock, and to be arguing about if this is "pilot error" or not at this stage is not doing anything to assist in determining why this accident happened.

The contributory factors for sure were numerous, and if any of them had been different, the outcome of the flight would have been different. AAIU have made 2 specific safety recommendations, and while that is far from the end of it, the fact that they have made them this early into the investigation has to be seen as a clear indication that they regard them as significant and urgent.

Mebuntu · 19-04-2017 09:03AM

Aah, the IALPA lads. The same lads that over the years have caused untold misery to thousands of Aer Lingus passengers with strikes or threats of strikes, meddling in Ryanair's affairs and issuing reputation damaging statements and, now, having the gall to tell the AAIU how to conduct their business.

Move along people, nothing to see here.

TomOnBoard · 19-04-2017 09:12AM

I don't see anyone arguing here for "pilot error". I do see a pilots union shooting itself in the foot with an ill-considered and poorly thought-out statement that appears to place itself as the representative body of pilots in needless conflict with the investigation. I see the error of that statement being made worse by a cack-handed performance on the national airwaves that only re-in forced the illusion of conflict with the investigation, placed an undue level of importance on database corruption without mentioning all the other possible contributory factors, and having to show that the union was not speaking for all the families despite having previously assumed the mantle of their protectors.

Coil Kilcrea · 19-04-2017 09:26AM

TomOnBoard wrote: »

He did his cause no favours on the RTE interview and came across as confused in what he was trying to say. He appeared to be doing a 'circle the wagons' exercise for the pilots, pushing the corrupted databases view of the crash. He went from the argument that the publication of any CVR by the AAIU was wrong to one that says 'all 100%' of the 2 minutes should't have been published. Why didn't he just come straight out and say that his problem was with the final few seconds and I'd be able to agree with him. He appeared on a very sticky wicket as he challenged the investigation. Frankly, I can't see him winning a battle with Jurgen White and his people with these tactics.

Tellingly, when pushed by the questioner, he had to explain that, while his statement referred to what the families wanted, not all the families agreed with his position.

This was exactly my concern. It sounded like an attempt to manipulate the messaging and did not address the issue properly. Worse, it was a very poor representation on behalf of pilots.

This thread has had many very finely articulated posts by aviators who convey a confidence and deep knowledge of their profession.

Jurgen Whyte and his team won't be bullied, coerced or persuaded to deliver a censored report. They have an important job to do and so far they've impressed. Moreover, their painstaking sensitivity to the family has been apparent from the start.

Finally, what about the two lads in the back of R116? Who speaks for them?

Coil Kilcrea · 19-04-2017 09:28AM

TomOnBoard wrote: »

I don't see anyone arguing here for "pilot error". I do see a pilots union shooting itself in the foot with an ill-considered and poorly thought-out statement that appears to place itself as the representative body of pilots in needless conflict with the investigation. I see the error of that statement being made worse by a cack-handed performance on the national airwaves that only re-in forced the illusion of conflict with the investigation, placed an undue level of importance on database corruption without mentioning all the other possible contributory factors, and having to show that the union was not speaking for all the families despite having previously assumed the mantle of their protectors.

And do we know if IALPA were speaking on behalf of the families? And was it the pilots families or the entire crews families?

Reati · 19-04-2017 12:25PM

ProfessorPlum wrote: »

In the first paragraph of the statement! Did you read it?

Yes I did read it. Did you take time to understand it?

Last Friday, the Irish Air Accident Investigation Unit (AAIU) published the last two minutes of the Cockpit Voice Recorder (CVR) transcript of a fatal helicopter accident (CHC Sikorsky S-92 R116), which occurred at Black Rock, on the west coast of Ireland, on the 14th of March 2017. That same day, this transcript filled newspapers and websites, including the front page of the Irish Times.

That is not condemnation of the media or their actions. It's a statement of fact regarding the media published the words.

The next paragraph continues with condemnation aimed at the AAIU for publishing the CVR claiming they wanted to feed sensationalism.

No mention of the media nor their actions for the rest of the report.

TomOnBoard · 19-04-2017 12:25PM

Coil Kilcrea wrote: »

And do we know if IALPA were speaking on behalf of the families? And was it the pilots families or the entire crews families?

My recollection of the interview this morning (no, I'm not going to download the podcast to re-check) was that the families had been advised of the statements and that not all of them agreed with it. I think that means that IALPA is not speaking on behalf of the families, but that one or some of them, but not all, having seen the statement before its publication, agreed with it.

Means Of Escape · 19-04-2017 02:10PM

selectamatic wrote: »

Quite a few prominent posters basically stating that this accident wouldn't be classed as CFIT and then proceeding to condemn anyone who had the gaul to disagree with them.

Condemn.?
No no no
Ridicule and arrogantly dismiss as armchair investigators
Oh dear

J Mysterio · 19-04-2017 02:15PM

siobhan08 wrote: »

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.

This is something that I heard doctors wanted to be reviewed in a more general sense. For example... If a frail old person is basically dying naturally, and the doctor knows this, he is still obligated by law to perform CPR which could break ribs etc of an old person. It's not right in all circumstances but is done to cover themselves against lawsuits etc.

Means Of Escape · 19-04-2017 07:48PM

They have a point.
Whatever way you roll the dice publishing the final dialogue between pilots for the masses is in effect counterproductive and used for sensationalist fodder
It's been posted here that the final minutes of the recordings are the most important yet others would argue the minutes leading up to the seconds before impact are the most crucial as or gives a clearer picture as to the decisions taken to place the craft in that position
Anyone who has an interest in final transcripts can google them specifically.
It's not well known for example that Pilot Robert of the 2009 Air France crash shouted "this can't be happening " yet anyone who saw the headlines of any paper recently knows MR Duffy's were "we're gone"
I'm sure the family had to be told that this was going to be published and I don't know what their response was .
Rather than splashing it on the papers an approach where one would have to search for the transcript on the AAIU would have been more apt
It was probably suffice for the AAIU to state that it was a CFIT and that the full report will be published at a later date .
Publishing it clearly places the crash on the pilots reaction to the information given from behind to anyone who reads it as the piece that was printed and zero knowledge of aviation
This clearly serves as an injustice to the crew until the full report is made available .

Reati · 19-04-2017 07:57PM

It's the nature of the beast unfortunately, there was a national interest in this and there was no way to publish the transcript without it ending up on all the media (and by God do I use the term loosely).

The only option was not to publish it which runs the risk of the media making up or publishing rumored dialogue or being accused of not being transparent.

TomOnBoard · 19-04-2017 08:39PM

Reati wrote: »

It's the nature of the beast unfortunately, there was a national interest in this and there was no way to publish the transcript without it ending up on all the media (and by God do I use the term loosely).

The only option was not to publish it which runs the risk of the media making up or publishing rumored dialogue or being accused of not being transparent.

You're right for sure in your first point.

On the second point, a judgement was made by the investigators that the last 2 minutes ought to be published. They did that without making any safety recommendations specifically relating to those 2 minutes. The recommendations they did make refer to routing which would have figured on the CVR probably quite early in the flight, and life-jacket beacon/antenna separation matters that obviously would never have featured on the CVR.

I believe they included the 2 minutes in order to educate and inform other S-92 operators and crew in the interests of spurring them to 'consider their positions' and make safety changes, if appropriate on a purely voluntary but informed basis, without waiting for a final report that might or might not make specific recommendations. Its a kind of a "if the cap fits" narrative that I feel is very intelligently included and that may help save other crews from finding themselves in similar tragic circumstances down the line.

That said, I personally would have framed that 2 minutes as something like "last 2 minutes of safety/procedure- relevant conversation from the CVR", and would NOT have published the last couple of seconds following the collision of the tail (or whatever) structure with the island up to the noises heard and alluded to in the transcript. I could see how the most closely involved, whether family or colleagues would have felt that was an undue intrusion, AT THIS STAGE. Clearly it would all have come out at some point, but perhaps that last couple of seconds did not need to come out right now. A year down the road, and maybe people closest to the situation would be better prepared.

However, regardless of the question of whether the last couple of seconds ought to have been published or not, almost a week had passed since the report and ooodles of commentary had resulted from it. And then the IALPA issued its statement. OMG! How to snatch defeat from the jaws of victory!!!

J Mysterio · 19-04-2017 08:55PM

Mostly agree with the above. It read like a stage play in the way it was delivered. The particular details. This after having information slowly released, building a picture over the preceding month or so. It was filmic really and that really added to it being quite emotionally disturbing.

Terrible for the families. They will need a lot of support.

Reati · 19-04-2017 08:56PM

TomOnBoard wrote: »

However, regardless of the question of whether the last couple of seconds ought to have been published or not, almost a week had passed since the report and ooodles of commentary had resulted from it. And then the IALPA issued its statement. OMG! How to snatch defeat from the jaws of victory!!!

Exactly. I've no inside knowledge but this feels like after such large media attention they felt like they were under pressure and needed to make some statement. I doubt this would have happened if the media weren't all over this.

The problem we have is we don't know what or who inside the union was the trigger was to come out with the statement. Could have been the families, could have been pilots, could have been union reps showing top cover for their members.

When the full report comes out will the entire CVR transcript be included?

Nekarsulm · 19-04-2017 09:04PM

I get the distinct impression that a lot of noses in the pilots Union etc. are out of joint because the Investigation team are proving to be independent, and keeping control of the process.
This was the first fact based info revelation, all else before was speculation and Chinese whispers.
All such was stepped on in this forum for the past month, and now that factual initial findings are released, its still criticized.
Hard to win!

Coil Kilcrea · 19-04-2017 09:10PM

Means Of Escape wrote: »

They have a point.
Whatever way you roll the dice publishing the final dialogue between pilots for the masses is in effect counterproductive and used for sensationalist fodder
It's been posted here that the final minutes of the recordings are the most important yet others would argue the minutes leading up to the seconds before impact are the most crucial as or gives a clearer picture as to the decisions taken to place the craft in that position
Anyone who has an interest in final transcripts can google them specifically.
It's not well known for example that Pilot Robert of the 2009 Air France crash shouted "this can't be happening " yet anyone who saw the headlines of any paper recently knows MR Duffy's were "we're gone"
I'm sure the family had to be told that this was going to be published and I don't know what their response was .
Rather than splashing it on the papers an approach where one would have to search for the transcript on the AAIU would have been more apt
It was probably suffice for the AAIU to state that it was a CFIT and that the full report will be published at a later date .
Publishing it clearly places the crash on the pilots reaction to the information given from behind to anyone who reads it as the piece that was printed and zero knowledge of aviation
This clearly serves as an injustice to the crew until the full report is made available .

I think referencing CFIT in itself without context or pending the final report would fuel further speculation and be potentially more damaging to the pilots reputations. Clearly there are many factors that have to be considered and fully explained in the final report. The headline grabbers will grab the headlines anyway and so to my mind, both for learnings and to comprehend the contributory factors, transparency is critically important.

It's a difficult balance for all concerned but I'm not sure IALPA properly articulated their concerns and they certainly didn't hammer the headline writers.

Tenger · 19-04-2017 09:44PM

Means Of Escape wrote: »

Condemn.?
No no no
Ridicule and arrogantly dismiss as armchair investigators
Oh dear

Someone is clearly not happy with the mod instructions repeatedly posted in the thread. (At this point due to the abuse the mod team have received inthread and via PM we arent particularly content either and would have had an easier life if we had just closed the thread weeks ago.)
The mod decisions was taken very early on to prevent mass jumping to conclusions of "it was pilot error leading to CFIT" There were a lot of immediate 'definite statements' being made. The case was being closed almost on day 1.
Statements were made about the high level of the SAR crews, and that the chance of 'pilot error' should be less, not that it was non-existent. Anyone who works in aviation knows the prevalence of human error in any incident.

The issue at the start of the thread was the huge influx of posters asking questions like "did they input Blackrock rather than Blacksod?", "did they get confused in the dark", "why didnt they just land on the island?", The mods had to make a decision on controlling the discussion that was moving very rapidly and was in danger of spiraling out of control. Regardless of your opinion on the decision, the mod decision stands.

At this point in time the prelim report seems to be pointing towards an operational error, rather than pilot error. Further info released and the final report will provide more concrete results.

Any poster who got banned didnt get banned for posting an opinion, they got banned for breach of Boards.ie rules (which every member here has signed up to as it is not a public forum BTW)

I had hoped that we were finished with this types of mod posts in this thread. It has been a mature and somber discussion over the last few days.
So, anyone else who wants to argue in thread, ignore a mod instruction, re-reg just to troll the thread, attack another poster or do any of the other infractable actions is free to work away

delly · 19-04-2017 11:39PM

As someone who is in no way knowledgable regarding the aviation industry, but has a very long standing following of volunteer and rescue services, the level of arguing points by some posters and level of control/direction just compounds the deep sadness of this tragedy even further. It's a case of wanting to metaphorically shake people and ask them do they realise what has happened here, four people have died putting there lives on the line for me and you.

Steve · 20-04-2017 12:12AM

delly wrote: »

As someone who is in no way knowledgable regarding the aviation industry, but has a very long standing following of volunteer and rescue services, the level of arguing points by some posters and level of control/direction just compounds the deep sadness of this tragedy even further. It's a case of wanting to metaphorically shake people and ask them do they realise what has happened here, four people have died putting there lives on the line for me and you.

I agree with your sentiment, however, the focus of this thread must remain on discussion of known facts. We all have the utmost respect for the crew of 116 but we cannot let emotions or blame prematurely bias what we know so far.

smurfjed · 20-04-2017 05:02AM

A

controlled flight into terrain (CFIT, usually pronounced cee-fit) is an accident in which an airworthy aircraft, under pilot control, is unintentionally flown into the ground, a mountain, a body of water or an obstacle.^[1] In a typical CFIT scenario, the crew is unaware of the impending disaster until too late. The term was coined by engineers at Boeing in the late 1970s.

https://en.wikipedia.org/wiki/Controlled_flight_into_terrain
Regardless of the procedures and policies, the final event was an accident in which an airworthy aircraft under pilot control was unintentionally flown into an obstacle.

arubex · 20-04-2017 09:19AM

Tenger wrote: »

At this point in time the prelim report seems to be pointing towards an operational error, rather than pilot error.

Again, moderators should not be using their status to make statements of opinion. Your job is to 'moderate' not to guide the discussion towards the conclusion you prefer. Ideally moderators do not even participate in the subject.

There is no 'pointing' in the preliminary report. It does not provide opinion or probabilities of ultimate cause. It is remarkably neutral given the media environment in which it had to prepared.

Perhaps the best action would be to close this thread until the final report is issued. At this point we're back to personal soapboxing.

Means Of Escape · 20-04-2017 09:40AM

Tenger wrote: »

Someone is clearly not happy with the mod instructions repeatedly posted in the thread. (At this point due to the abuse the mod team have received inthread and via PM we arent particularly content either and would have had an easier life if we had just closed the thread weeks ago.)
The mod decisions was taken very early on to prevent mass jumping to conclusions of "it was pilot error leading to CFIT" There were a lot of immediate 'definite statements' being made. The case was being closed almost on day 1.
Statements were made about the high level of the SAR crews, and that the chance of 'pilot error' should be less, not that it was non-existent. Anyone who works in aviation knows the prevalence of human error in any incident.

The issue at the start of the thread was the huge influx of posters asking questions like "did they input Blackrock rather than Blacksod?", "did they get confused in the dark", "why didnt they just land on the island?", The mods had to make a decision on controlling the discussion that was moving very rapidly and was in danger of spiraling out of control. Regardless of your opinion on the decision, the mod decision stands.

At this point in time the prelim report seems to be pointing towards an operational error, rather than pilot error. Further info released and the final report will provide more concrete results.

Any poster who got banned didnt get banned for posting an opinion, they got banned for breach of Boards.ie rules (which every member here has signed up to as it is not a public forum BTW)

I had hoped that we were finished with this types of mod posts in this thread. It has been a mature and somber discussion over the last few days.
So, anyone else who wants to argue in thread, ignore a mod instruction, re-reg just to troll the thread, attack another poster or do any of the other infractable actions is free to work away

Many people unhappy with the way this thread was moderated and debate suffocated
Your reply to my statement of fact in no way undermines it .

Close the thread and be done with it until the full report is published .

Cloudio9 · 20-04-2017 11:23AM

Tenger wrote: »

At this point in time the prelim report seems to be pointing towards an operational error, rather than pilot error.

It's a lot more nuanced than that I'm afraid.

We know we have operational weaknesses with the approach(es)
We know we have a deficiency in at least one safety system
We know that an obstacle was identified by one of the rear crew yet the aircraft still collided with that obstacle
We know that the pilot monitoring the radar did not identify the obstacle on radar.

Tenger · 20-04-2017 12:35PM

Cloudio9 wrote: »

It's a lot more nuanced than that I'm afraid.....
.......
.......

I would agree. Most accident reports have a myriad of findings and causes.
My statement of 'seems to be.." is merely my quick reading of it.
Smurfjed above posted the technicality of the terminolgy bring used. I wasnt posting my phrase as an opinion, I wasnt trying to push an agenda, regardless of certain opinions.
I was posting a mod post about arguing inthread.
My agenda or opinion would not be in bold.

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

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