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

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Comments

  • #3392
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    Gaoth Laidir wrote: »
    Where did you get the 15-18 seconds? And do you mean before impact?

    The first call from the crewmen, came approx 15 seconds before the initial impact , it was clear that that call was not handled with sufficient alacrity that the situation warranted ( for whatever reason , as thats not clear )


  • #3393
    Gaoth Laidir
    Registered Users, Registered Users 2 Posts: 8,262 ✭✭✭Gaoth Laidir


    BoatMad wrote: »
    The first call from the crewmen, came approx 15 seconds before the initial impact , it was clear that that call was not handled with sufficient alacrity that the situation warranted ( for whatever reason , as thats not clear )

    It came 13 seconds before impact (2.02:46 and 2.02:59). Actually, he STARTED saying it at 02.02:46 and finished it at 2.02:50, so the crew really had only 9 seconds to act


  • #3394
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


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

    Yes, indeed, however I suspect that it will not illustrate the decision any mor then has been alluded to in the preliminary report.

    Actually solving this accident may in fact prove to be very difficult outside of " informed " speculation and Occams razor


  • #3395
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    Gaoth Laidir wrote: »
    It came 13 seconds before impact (2.02:46 and 2.02:59). Actually, he STARTED saying it at 02.02:46 and finished it at 2.02:50, so the crew really had only 9 seconds to act

    The point I was making was the island WAS detected


  • #3396
    Gaoth Laidir
    Registered Users, Registered Users 2 Posts: 8,262 ✭✭✭Gaoth Laidir


    BoatMad wrote: »
    The point I was making was the island WAS detected

    Everyone knows that, it's never been in dispute. You were saying it was detected sooner than it actually was.


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  • #3397
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    Gaoth Laidir wrote: »
    Everyone knows that, it's never been in dispute. You were saying it was detected sooner than it actually was.

    Its important not to take my comment out of context

    I was commenting on the issue of whether the EGPWS issue was germane to the accident

    i contended
    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


    what I was alluding to was the point that the EGPWS warning might have been as near useless as the crewman one.

    This is because the primary reason for the accident is really the belief in the pilots that the route taken and the altitude taken was safe and that no obstruction was expected in the place where it occurred.

    The issue that has to be examined , is why the pilots formed that view , given ( in theory ) the sources of information available to them.


  • #3398
    Steve
    Registered Users, Registered Users 2 Posts: 22,575 ✭✭✭✭Steve


    BoatMad wrote: »
    The point I was making was the island WAS detected
    We all know that. We all accept that. Why are you pressing this point?

    They initiated a heading change on the autopilot which would have resulted in a standard rate 3 deg/sec turn, we now know this wasn't sufficient.


  • #3399
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    Steve wrote: »
    We all know that. We all accept that. Why are you pressing this point?

    They initiated a heading change on the autopilot which would have resulted in a standard rate 3 deg/sec turn, we now know this wasn't sufficient.

    I was addressing the issue that a poster was bringing up , that the accident was the result of the lack of terrain warning from the EGPWS, and the fact that this " simplistic conclusion " has been grabbed by the press , yet largely discounted by professional commentary ( I provided a source )

    There is clear indication from the FDR that no actual turn had began before impact. Its clear that the pilots still did not appreciate the enormity of what was about to happen. The continued evidence is that the pilots had no reason to believe an obstruction of the nature that was encountered was immediately in front of them, or on the route at all . The " whys " of that are the key issue remaining


  • #3400
    Tenger
    Moderators, Motoring & Transport Moderators Posts: 10,129 Mod ✭✭✭✭Tenger


    BoatMad wrote: »
    .................
    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
    My understanding of this was that the terrain warning was caused by the smaller islands that the S92 passing over at this point, not a warning of the island ahead of it.


  • #3401
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    Tenger wrote: »
    My understanding of this was that the terrain warning was caused by the smaller islands that the S92 passing over at this point, not a warning of the island ahead of it.

    I was referring to the EGPWS, the terrain warning was from the radio altimeter system.

    There is no evidence presented that any EGPWS warnings were presented at any time for any obstacle , suggesting that the reports that its effect was "muted" as a result of option selections was correct


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  • #3402
    smurfjed
    Registered Users, Registered Users 2 Posts: 10,801 ✭✭✭✭smurfjed


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

    They were faced with a night approach into a landing site that was unfamiliar to them, they elected to use one of the S92's SAR modes to descend to 200 feet prior to following a guidance path to landing, to me this is extremely logical and demonstrates caution.
    [font=Open Sans, Arial, Helvetica, sans-serif]I doubt that we will ever know why the height of the rock wasn't evident to them as it was "apparently" available from at least two sources.[/font]


  • #3403
    Gaoth Laidir
    Registered Users, Registered Users 2 Posts: 8,262 ✭✭✭Gaoth Laidir


    BoatMad wrote: »
    Its important not to take my comment out of context

    I was commenting on the issue of whether the EGPWS issue was germane to the accident


    what I was alluding to was the point that the EGPWS warning might have been as near useless as the crewman one.

    This is because the primary reason for the accident is really the belief in the pilots that the route taken and the altitude taken was safe and that no obstruction was expected in the place where it occurred.

    The issue that has to be examined , is why the pilots formed that view , given ( in theory ) the sources of information available to them.

    You said they knew about Blackrock ahead 15-18 seconds before "final moments" (impact?). The CVR says it was 13 seconds. All I asked was where you got the 15-18 seconds. What I got in response has been long-winded ramblings that have avoided answering my question.


  • #3404
    duskyjoe
    Closed Accounts Posts: 643 ✭✭✭duskyjoe


    irishgeo wrote: »
    Because the flight plan in use said to do so.
    No it didn't.


  • #3405
    Gaoth Laidir
    Registered Users, Registered Users 2 Posts: 8,262 ✭✭✭Gaoth Laidir


    So what's the status on that APBSS route now? Is it still in use?


  • #3406
    homerjay2005
    Registered Users, Registered Users 2 Posts: 29,346 ✭✭✭✭homerjay2005


    very basic question here - how come this issue with the routes, never discovered before or more importantly, in daylight? surely in recent months, there was a need to refuel in blacksod, so how come a near miss wasnt recorded then?

    it was said in a previous post before that the other crews (115, 118) came in along the coast. so why was this route used on this particular night? and surely, somebody somewhere should have copped a potential issue with blackrock.


  • #3407
    robyntmorton
    Registered Users, Registered Users 2 Posts: 4,263 ✭✭✭robyntmorton


    In all honesty, we don't know why this particular approach, on this night, with this crew went wrong. All we know is that it did, even though they were positioning for the standard company APBSS approach.

    Chances are (but I can't say for certain) in response to the AAIU interim safety recommendation, CHC crews have had the APBSS approach removed from their procedures, and would be told to use the northerly APBSN approach instead.


  • #3408
    TheChizler
    Registered Users, Registered Users 2 Posts: 9,539 ✭✭✭TheChizler


    homerjay2005 wrote: »
    very basic question here - how come this issue with the routes, never discovered before or more importantly, in daylight? surely in recent months, there was a need to refuel in blacksod, so how come a near miss wasnt recorded then?
    It's possible cloud cover was never that low when that route was flown before, or it was in daylight and the island was spotted from miles away so they just went around/over it.


  • #3409
    smurfjed
    Registered Users, Registered Users 2 Posts: 10,801 ✭✭✭✭smurfjed


    There is a suggestion on another forum that the company route was designed for DECCA navigation equipped aircraft where the crew had to have waypoints that were visually identifiable, so a lot of the routes would have included land masses.  
    Sometimes in life we omit the things that are most obvious, we know that something is there/done a certain way, and therefore believe that everyone knew that information.


  • #3410
    Wintergirl
    Banned (with Prison Access) Posts: 19 ✭Wintergirl


    But the crew had a map with the figure of 282 marked on it beside a red dot.

    Why did they fly at 200ft when clearly something marked 282 was in their way.

    Did they know the height of Blacksod, it was marked with a figure too,43, so if they knew the height of Blacksod they should have known the height of Black Rock in relation to that.


  • #3411
    plodder
    Registered Users, Registered Users 2 Posts: 8,044 ✭✭✭plodder


    Wintergirl wrote: »
    But the crew had a map with the figure of 282 marked on it beside a red dot.

    Why did they fly at 200ft when clearly something marked 282 was in their way.

    Did they know the height of Blacksod, it was marked with a figure too,43, so if they knew the height of Blacksod they should have known the height of Black Rock in relation to that.
    I wonder how significant it was that they initially were heading to Sligo and en route decided to switch to Blacksod. So, replanning their arrival at Blacksod may have been done while making their extensive efforts to establish radio comms with R118. How easy would it be to overlook the 282 on the map in that situation? It isn't all that obvious. In fact, it's partly obscured and certainly could be more obvious. The waypoint labels stand out more than the critical safety information relating to the obstacle. Though the question clearly depends on the associated text in the guide, which we haven't seen yet.

    “Fanaticism is always a sign of repressed doubt” - Carl Jung



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  • #3412
    Wintergirl
    Banned (with Prison Access) Posts: 19 ✭Wintergirl


    Who is responsible for the training and upskilling of the pilots.


    If you by mistake overlooked the 282 does that mean then you overlooked the 43 at Blacksod too.You would surely need to know the exact height of somewhere you intended to land.


  • #3413
    plodder
    Registered Users, Registered Users 2 Posts: 8,044 ✭✭✭plodder


    Wintergirl wrote: »
    If you by mistake overlooked the 282 does that mean then you overlooked the 43 at Blacksod too.You would surely need to know the exact height of somewhere you intended to land.
    Total amateur speculation on my part. But, it seems logical to me that you would pay a lot more attention to the details of the destination, and you wouldn't take that information just off a map. You might be more likely to take the waypoint details just from the map though.

    “Fanaticism is always a sign of repressed doubt” - Carl Jung



  • #3414
    jimmycrackcorm
    Registered Users, Registered Users 2 Posts: 14,353 ✭✭✭✭jimmycrackcorm


    BoatMad wrote:
    This is because the primary reason for the accident is really the belief in the pilots that the route taken and the altitude taken was safe and that no obstruction was expected in the place where it occurred.

    This would explain the lack of action to the terrain warning followed by the lack of 'slamming on the brakes' so to speak when the crew warning to come right was given. (Notwithstanding that slamming on the brakes hasn't prevented a car crash once when I was driving).

    Given the nature of SAR, surely the terrain warning must come up fairly often so as to be nonchalant to a degree?


  • #3415
    Wintergirl
    Banned (with Prison Access) Posts: 19 ✭Wintergirl


    But surely if you are highly trained you wouldn't just take waypoint details off a map without knowing what a figure beside a waypoint meant.

    You aren't going to get to your destination if you hit something on the way so it seems obvious to me that you should be familiar with everything on the way to that destination particularly when you aren't familiar with the area and you are flying at night time.

    Do the winch men have access to the maps with the waypoints on them.


  • #3416
    smurfjed
    Registered Users, Registered Users 2 Posts: 10,801 ✭✭✭✭smurfjed


    But the crew had a map with the figure of 282 marked on it beside a red dot.

    Why did they fly at 200ft when clearly something marked 282 was in their way.
    Was this a fact or an assumption? 
    I could say welcome to the world of advanced cockpits, why would you want to use paper maps?


  • #3417
    Storm 10
    Registered Users, Registered Users 2 Posts: 6,092 ✭✭✭Storm 10


    Bit off topic but Rescue 117 is on the way home after doing a medical transfer from Dublin to London, surely this should be done by the Air Corps and not take a Rescue Helicopter off station.


  • #3418
    Wintergirl
    Banned (with Prison Access) Posts: 19 ✭Wintergirl


    Its all utterly bewildering and incomprehensible.The AAIU have all the time in the world to explain to the experts and the general public what happened.

    The final report will be very interesting.


  • #3419
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    Gaoth Laidir wrote: »
    You said they knew about Blackrock ahead 15-18 seconds before "final moments" (impact?). The CVR says it was 13 seconds. All I asked was where you got the 15-18 seconds. What I got in response has been long-winded ramblings that have avoided answering my question.

    I was merely typing from memory. I was addressing a different issue , I was not commenting at that point on reaction times etc. You persist in following this single issue when is not pertinent


  • #3420
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    smurfjed wrote: »
    Was this a fact or an assumption? 
    I could say welcome to the world of advanced cockpits, why would you want to use paper maps?

    I'll Leave out a long winded CV. But let me explain a key issue that arises where vector maps and relatively small screen LCD map displays are in use.

    Because screen space is limited unlike a full sized paper map/chart , vector maps remove detail at higher levels of zoom , typically omitting things like small Islands etc ,

    hence when used to preview a intended course , it requires quite laborious route previewing , zooming in and out , firstly to get a mental picture of the whole route and then to zoom in so that the relevant local detail occurred. The problem is that under task pressure these can be omitted , in fact you almost need to " know" the obstructions ate there to then seek them out at certain zooms levels.

    Issues also arise where raster scanned charts /maps are used , where " maplets " containing data must be actively retrieved , this is further compounded with " quilting " errors and issues that resulted from raster maps , which are essentially scanned data being switched together. From individual maps to create larger maps


    I have seen near misses and close encounters ( not in aircraft ) where lower levels of zooms were not accessed and " assumptions " were made.

    Latest generation software , especially in the Non controlled equipment fit areas , is now trying to analyse operator selected routes and warn operators of proximity to dangers. However this in itself introduces another risk of " automation complacency ".

    I've been on the bridge of the QM2, state of the art systems arguably more capable then any helicopter , even there with larger electronic displays , sitting on a chart table was a full scale admiralty paper chart.

    This is because route investigation is simply easier on a 4 foot by 3 foot detailed chart then zooming around on a 10 " LCD screen.
    Of course this approach is not practical in the confined cockpit of a helicopter. But automation contains significant risk factors.

    Now , I cannot determine what the Crew of 116 accessed or didn't access in order to investigate the APBBS route. , but the report makes it clear that details of the island were available on the mapping system on certain pages , it's also clear from the report that however the crew where not expecting the obstruction to be on the route selected at the altitude used. .


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  • #3421
    BoatMad
    Registered Users, Registered Users 2 Posts: 10,506 ✭✭✭✭BoatMad


    TomOnBoard wrote: »
    Or private air ambo if Aer Corps not available?

    Especially relevant in the context of:

    1. The fleet is already down 20% of its capability and
    2. Each aircraft must now have a 16 man-hour intervention after every 10 hours of operation to check the tail rotor assembly in accordance with air worthiness safety instructions.

    Has the helicopter not been replaced. ?


This discussion has been closed.
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