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

@wintergirl
The report isn't actually pointing any fingers as its not designed to "blame", its designed to present facts.

duskyjoe wrote: »

I agree, appears to be a classic " Swiss cheese model" CFIT. All the holes just lined up. Why also did the craft descend to 150RA with 13nm track miles to run to blacksod? Many many unanswered questions.

Because the flight plan in use said to do so.

Because the flight plan in use said to do so.

What flight plan are you talking about?

smurfjed wrote: »

What flight plan are you talking about?

The company mandated flight route they were using its in the report. although the flight height is specified as pointed out above. Could the flight level be determined by the cloud base and be vfr.

irishgeo wrote: »

The company mandated flight route they were using its in the report. although the flight height is specified as pointed out above. Could the flight level be determined by the cloud base and be vfr.

no indication that heights were contained in briefings associated with the approach selected, other then a mention in the report that the associated briefing page contained pertinent ( my phrase) information about Blackrock

The report identifies a lack of topographical data about Blackrock Island on R116’s enhanced ground proximity warning system (EGPWS) as a factor in the disaster that unfolded.
The system alerts pilots, repeatedly and with greater stridency if they fail to react to the initial warning, if the ground on their flight path ahead is higher than the altitude at which they are flying. However, it is not a navigational tool.
Once initial reports had ruled out mechanical failure, it seemed apparent that the disaster was a so-called Cfit crash – a “controlled flight into terrain” impact.
Cfit is the acronym used to describe the phenomenon of an airworthy aircraft being flown, unintentionally, into an object that destroys it – the ground, a mountain or water.
“People are understandably blaming it on the EGPWS manufacturer,” said one pilot. But that’s not accurate. EGPWS is a last-resort crash prevention tool and is not used for routine navigation.

Source Irish Times

The last paragraph is quite pertinent

Wintergirl wrote: »

Unfortuneatly we don't understand how the CFIT occurred but we can certainly understand why it might have occurred.

We have seen the chart the crew were using but we haven't seen the accompanying information sheet that went with it.We know the pilots didn't realise Black Rock was there but we don't know how its existence wasn't apparent.We would need to be in Dublin Airport when the call came in and see what the preparation for the flight involved.We do know neither pilot was familiar with the area which makes it even more important that the information that accompanied the chart was read.Why wasn't this sheet in the official report, the map wasn't a complete piece of information without the sheet that explained the symbols.

I really don't know how anyone could post that operational error appears to be the main issue here.What does operational error mean.

Just to be clear

The report stated that two sources of information pertinent to Blackrock were present ( a) Briefing note page accompanying the Operator route page and (b) details of the island were present on certain map pages accessible to the crew ( i.e. this data was onboard

The presence of the " briefing note " in the report , or not , is unlikely to add anything new in that regard

Unfortuneatly we don't understand how the CFIT occurred but we can certainly understand why it might have occurred.

Actually the opposite is true, we understand how it occurred, i.e. a helicopter descended under command to 200 feet and then , under command , turned onto a heading , that caused it to collide with an object that was higher then its flight altitude.

what we dont know is "why it occurred." , i.e. why the crew took the decisions they did.

Cloudio9 wrote: »

It doesn't make sense to me that it's inhibited when flying at 80 knots in a helicopter. It's not going to land at 80 knots.

Any database of terrain obstructions can never be relied upon to save your life, No database will ever be complete or upto date and hence a 100% reliance would be a fatal activity. Crew of all sorts of electronically navigated vessels are lost from such simple "over" reliance. the fact that 99.9% of the time it works , does not then justify the reliance of the .1% of times that it fails.


The focus on the EGPWNS is understandable and the " omission " provides a " hook' for the ill-educated in these matters to latch onto.

There is commentary elsewhere and also in the report that that terrain warning system is severely limited when the low altitude option is enabled and the landing gear is extended . Educated Suggestion elsewhere have suggested lookahead is limited to 10 feet

As has been said by several the issue of the terrain warning system is peripheral to the central issue

it should also be pointed out that the crew where notified of the " terrain " , 15-18 seconds before the final moments

Wintergirl wrote: »

Isn't it clear though that the crew took the decisions they did because they didn't know Black Rock was there.If they knew Black Rock was in their path they would have taken completely different decisions.

clearly , this is the case, any other conclusion would be bizarre

We can understand why this might have occurred, the middle of the night and rushing to an emergency in an area they weren't familiar with

.

No we cannot extend that logic, that is merely speculation , the essence of the crew training and the systems onboard, is that they should be able to navigate such paths with safety , we do not know the reasons they took the decisions that then fatally imperilled them

We aren't sure though how it occurred when the last link in the chain let them down, i.e. the ground warning system, how come this didn't alert them to the danger.Why wasn't it in the database.

Again this is not the kernel of the issue. No sane crew would simply fly at an obstruction and then rely on a dubious database system to save them. These databases exist where a crew is flying in an unpredictable pattern often typically of an actually SAR , where the helicopter flight path may be dictated by issues other then a preplanned flight path. This was clearly not a SAR operation


equally they are " aids" , not crutches


so, the issue is that , given the known information onboard about blackrock, why was the aircraft flown at it , at 200 feet . Thats the crucial remaining question not that the warning system failed them

BoatMad wrote: »

Any database of terrain obstructions can never be relied upon to save your life, No database will ever be complete or upto date and hence a 100% reliance would be a fatal activity. Crew of all sorts of electronically navigated vessels are lost from such simple "over" reliance. the fact that 99.9% of the time it works , does not then justify the reliance of the .1% of times that it fails.


The focus on the EGPWNS is understandable and the " omission " provides a " hook' for the ill-educated in these matters to latch onto.

There is commentary elsewhere and also in the report that that terrain warning system is severely limited when the low altitude option is enabled and the landing gear is extended . Educated Suggestion elsewhere have suggested lookahead is limited to 10 feet

As has been said by several the issue of the terrain warning system is peripheral to the central issue

it should also be pointed out that the crew where notified of the " terrain " , 15-18 seconds before the final moments

I think you misunderstand me. My point is it doesn't make sense (to me) from a system design perspective that it is inhibited when the helicopter is flying at 80 knots because landing gear extended or not, this is a VTOL aircraft and is unlikely (or never?) going to be landing at 80 knots.

BoatMad wrote: »

The whole basis of databased warnings systems ( i.e. systems that do not detect or attempt to detect whats really out there) is that they are an " aid ". The disclaimers associated with these systems are enough to show you that , irrespective , these systems are not a " backup" to unwise decisions . (NOTE, I am not saying such a decision occurred in this case ) .

The system is inhibited significantly when the " low altitude " option is enabled, that was made clear by the report . Th reasons for that decision are again not pertinent here ( that is a design decision )

to exactly what extent is unclear, nor is it in any way deductible that any such warning if it did exist would have saved the aircraft

Again , its not really germane to what happened

I think we'll leave it there. You insist on attempting to school me in a pompous, condescending manner on points I didn't make.

Helis typically fly a similar final approach to fixed wing - the VTOL would only be in the last few feet - you might consider it to be the equivalent to fixed wing flare. Many of the EGPWS modes are inhibited to avoid nuisance warnings in a phase where it is deliberately flying close to terrain.

BoatMad wrote: »

it should also be pointed out that the crew where notified of the " terrain " , 15-18 seconds before the final moments

Where did you get the 15-18 seconds? And do you mean before impact?

Gaoth Laidir wrote: »

I think the full transcript is important, not only for the conversation, but also for the "other sources" of audio that occured (automated callouts, "loud noise" (which probably gives us time of impact (02.02:59.983), etc.). These extra data are important pieces in the jigsaw.

I think the full CVR transcript will be more important in terms of the decision making process that led to the let down.