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R116 Accident AAIU report discussions

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This discussion was created from comments split from: Rescue 116 Crash at Blackrock, Co Mayo(Mod note in post 1).

We've had to do this to avoid some problems that are happening as a result of the migration to Vanilla, the page managment on the old thread is not working correctly, which was making it almost impossible to see what's happening in the thread.

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ProfessorPlum

https://www.boards.ie/discussion/comment/118135833#Comment_118135833

Ah, come on Steve, read what I wrote! The report, page 146 or anywhere else, doesn't mention training in the airline environment, which is where I pointed out that you were wrong.

Also, I said 'might only get a call every couple of weeks', which is perfectly correct, and the reason why there is a need for more training flights as the number of actual missions would not be sufficient to keep everyones skills current. I didn't say that they only fly every couple of weeks.

Irish Steve

https://www.boards.ie/discussion/comment/118135496#Comment_118135496

As I supposedly don't know what I am talking about, perhaps you might like to take a look at page 146 of the full report, and then respond on where that leaves your specious comment about " a call every couple of weeks". Certainly for Shannon and Sligo, in the years that are reported, they were in the air most days on tasking, as well as on training, and they carried out more tasking flights than training, and Dublin and Waterford were active on live taskings on average every other day, alongside their training sorties.

ProfessorPlum

https://www.boards.ie/discussion/comment/118135628#Comment_118135628

This was exactly my point in my first para! Maybe you articulated it better. Also that airline pilots do considerably more than 4 hours training every 6 months. But training is appropriate to the type and scope of operations - it's not comparable.

Stovepipe

https://www.boards.ie/discussion/comment/118135496#Comment_118135496

Training flights are built into the operations of CHC helis,precisely because of the low volume of actual callouts, so the aircrew get day/night training on such things as winching for the rear crew, ILS approaches for the pilots and lifts from different things such as boats,water, hills and so on. You are also forgetting the number of callouts where the casualty is recovered before they get on scene and they are cancelled in mid flight. As for airline pilots,sim training is as tough or as easy as the instructors make it and they do practise for real-world failures such as depressurisations or inflight fires,so training is what is relevant for each type of pilot.

[Deleted User]

What I read seems careful to avoid the apportion of blame to the pilot, while at the same time leaving no real other option for responsibility. Are the publishers being careful not to upset families of the crew by dancing around evidence?

ProfessorPlum

https://www.boards.ie/discussion/comment/118135428#Comment_118135428

Irish Steve is also wrong about training in the airline environment, not to mention the fact that airline pilots get 'hands on' every day they go to work. SARS pilots might only get a call out every couple of weeks or less, so the extra training is necessary to keep skills current.

If CHC were serious about actual training, they would have validated everyone of their letdowns (for fuelling etc), and trained all of their crews on them. It seems 'local knowledge' made the approach to Blacksod survivable for West coast crews, yet was an accident waiting to happen for unfamiliar crews. That's not something a training department would be proud to stand over.

jmayo

https://www.boards.ie/discussion/comment/118132558#Comment_118132558

From what I have heard in the past I would not read too much into the training that they carry out.

Flying around the Wicklow mountains on a sunny day doesn't prepare anyone for West of Ireland on a wet miserable night.

There are still a lot of unanswered questions and absolving the pilots of any contribution in the case of CFIT doesn't do anyone any favours.

The best pilots, the best crews in the world make mistakes and it is when that lines up with other failings that serious accidents occur.

From what I have seen, one consensus amongst some pilots (SAR experienced ones included) is that NVG would have prevented this and that then raises huge questions as to why money was put aside years ago for SAR (Coast Guard) to purchase NVG equipment and the only base to have implemented any of it seems to be Sligo.

Now I am not sure if this has changed recently or not, but jaysus in this day and age why does it take years to do any fooking thing in this country.

Nijmegen

As I mentioned above, I think the very presence of the long and protracted legal involvement in the report leads one to almost cast doubt where perhaps a report that hadn't gone through such a process wouldn't have it, even if the content was broadly the same.

If there are lessons to be learned for future crews, hopefully there's enough reading between the lines for the operational staff to make appropriate changes.

It's clear however that equally, had the feature in the vicinity of a waypoint been better featured on the map... Well, there's a lot of basic improvements to come from this tragedy that will hopefully prevent loss of life in the future.

Thoughts with the families and colleagues, whom I'm sure are feeling quite raw with the report having finally come out. It must be very odd to have the final moments of your loved ones detailed in such a way, but may the memory of their whole lives be a blessing.

Irish Steve

Examining the crew here on sites like this is inappropriate, because there are way too many people who think they have a valid opinion about what happened without having the necessary background, training and experience to be able to draw valid conclusions.

The fact that lawyers have sanitised the findings and recommendations has not changed the clear conclusions that can be drawn from the report.

The average line pilot for an airline spends up to 4 hours every 6 months in a training environment, usually a simulator. In 2015, the Dublin base of R116 flew over 360 training missions, twice as many as actual rescue missions, and they were not time in a simulator. That level of hands on happens to make sure that they are on top of their task.

There may be reasons to criticise the crew, but there are others who are much higher on the list who need to be examined first.

MrMusician18

https://www.boards.ie/discussion/comment/118131697#Comment_118131697

Why shouldn't people examine the role of the crew here? Just because the job is difficult and frequently heroic, doesn't mean that mistakes aren't made and that they cannot be recognised. It's not about blame, it's about facts.

The report is far from clear, it is quite obvious that the conclusions have been washed by the lawyers.

The tendancy in Ireland is to point to State and organisational failings over individual error but an air accident investigation should be above that. It is of no help to bury the flight crews mistakes in the body of the report and and best refer to them cryptically or omit them from the contributory factors especially if important learnings can be taken from them.

Irish Steve

https://www.boards.ie/discussion/comment/118130629#Comment_118130629

R118 came in via a completely different route and profile. it is mentioned in the report, where 116 spoke to 118, and they advised that the cloud over Broadhaven Bay was around 500 Ft, so 118 used a completely different approach route and profile in order to get into Blacksod. 116, in the absence of recent local experience, relied on the company published approach procedures, unaware that the Blacksod south procedure was fundamentally flawed as a result of the absence of clear information about the elevation of Blackrock and its proximity to the entry point of the approach procedure.

We should not be looking at the crews of SAR in this issue, they are (and have proved it more times than any other group) the most highly skilled and capable aviatiors in the industry, the problem areas for me are the issues that AAIU have highlighted with the operator (CHC) and the IAA, who were in a grey area and uncertain about how or even if they should be involved with or exercising any regulatory role in relation to Search and Rescue, and as a result, there were a whole range of glaring omissions and holes in the way that IAA were dealing with critical flight safety issues. CHC have been exposed as severely lacking in the necessary management structure and safety culture to manage and operate a high risk operating environment, and their responses to issues raised on internal systems such as SQID were too often slow, or incomplete, or even totally lacking, which only served to increase the flight safety risks. CHC also demonstrated a mind numbing lack of engagement with the analysis and evaluation of the safety and suitability of mission critical navigation mapping and data base information, and there are a number of significant issues that IAA have to address.

The crew of 116 may well have been at a low ebb as a result of a (questionable) call for service at a late hour. Their rostering system has been called into doubt, as has the dependence of the Coast Guard on the use of helicopters for top cover on long range missions. They responded to a call, and accepted the mission, and were doing their best to fulfill the mission parameters, and as a result of regulatory and management shortcomings, while flying towards a route that should have ensured their safety, they lost their lives.

AAIU have not even come close to assigning any fault to the crew, they have made the largest number of recommendations for actions in one report, and those actions are the responsibility of the managment of the operator and IAA.

We should recognise that the massive time and effort put into the report by a large number of dedicated professionals has produced a clear report that does serve the purpose of ensuring future safe SAR operations, as long as the recommendations that have been made are fully implemented.

skallywag

The fact that the aircraft was been flown at 200ft under such visibility conditions is clearly a key factor in the accident.

Yes, there are of course apparent failings with the mapping, etc. but regardless of any of that, many (and in that I include pilots who have flown S92s in Ireland and also others who were on the hangar floor) are simply asking what were they doing there under those conditions.

Of course the report should not get into finger pointing, but in my reading of it at least it definitely is attributing this fact to the crash, albeit in quite a reading-between-the-lines way.

lintdrummer

https://www.boards.ie/discussion/comment/118130629#Comment_118130629

The report actually does mention that R118 made a different approach to Blacksod, from a different direction than what R116 attempted. That's presumably because they arrived from a different direction, from Sligo. It's in a reference note on the bottom of page 14:

The Investigation was informed that R118 approached Blacksod using the SGLOWBS route (Sligo low level route to Blacksod), which is different to the route R116 intended to use.

https://www.boards.ie/discussion/comment/118130777#Comment_118130777

The fact that they descended so early is puzzling to me. As a fixed wing pilot, a cloud break procedure is normally carried out so that you have a continuous descent which reaches it's lowest point a short distance from the landing runway. The report mentions that they used an autopilot function to carry out the descent to 200ft but that this was completed way out at the start of the approach. Now, maybe that's appropriate to do at sea when you're searching for a vessel, but I can't see the logic on an approach to a landing site.

EchoIndia

https://www.boards.ie/discussion/comment/118130629#Comment_118130629

The report does say that another Dublin crew that operated into Blacksod some days previously did not descend so early, as one of the crew was aware of Black Rock from previous experience in the area. Therefore while the actual route taken by R118 on the night is not mentioned in any detail, it seems likely that relative familiarity played a part in ensuring successful avoidance of known hazards.

Glen Immal

R118 refuelled in Blacksod shortly before. Same operator, Same aircraft, Same weather.Their approach was sucessfull.

Report never mentions reviewing what they did differently or if they too came close to cfit.

Does any one here know what were the legal objections to the initial draft report, by whome?

What was omitted from the final published report?

[Deleted User]

John Fitzpatrick has spoken publicly about the report: Father of crashed helicopter pilot criticises failure to address safety concerns https://jrnl.ie/5594346

Roger_007

There has been a lot of discussion about what obstacles were in, (or not in), what database. This is being homed in on by the media as being the main cause of the accident. I think from reading the report that this conclusion is incorrect.

Section 2.2.8 of the report states:-

“At 00.43 hrs, the Commander commented ‘okay again just got the surface visual there anyway which is good [...]’. This indicates that the Commander had visual contact with the surface at that time. However, the assessment of horizontal visibility requires, by definition, that a known feature at a known distance can be seen. But, when operating at 200 ft, approximately 9 NM from shore, over the Atlantic Ocean, at night, in poor weather, there was no known, or discernible, feature to be seen. Furthermore, none of the potential sources of ambient light mentioned in OMF, ‘moon light, light from coastal towns, light from adjacent vessels / installations or indeed flares deployed by top cover aircraft’ would have been available to the Crew. Accordingly, horizontal visibility could not be determined, and consequently it was not possible for the Flight Crew to know that they had ‘visibility sufficient to allow safe aircraft manoeuvre at selected airspeed / groundspeed’, as required in OMF. In effect, the Crew was in a situation where they could not see whether there was an obstacle in their path. “

I think that there is no doubt that, in the opinion of the investigators, the aircraft was being flown in an unsafe manner at the time, given the visibility conditions prevailing. They stated in their conclusions that there errors and lapses of judgement on the part of the flight crew but you have to trawl through the report to find what exactly they were referring to.

In aviation safety there should no room for fudging the truth, even when it hurts. There is a long and honourable record of air accident investigators being absolutely honest about the causes of accidents. It is what makes aviation so safe these days.

MrMusician18

https://www.boards.ie/discussion/comment/118128080#Comment_118128080

"I didn’t see anywhere in the report that said crew fatigue was a factor."

It's literally there in point 10 of the conclusions under contributory causes. It isn't reading too much into it when it's stated like that, in that part of the report.

10. The Flight Crew members’ likely hours of wakefulness at the time of the accident were correlated with increased error rates and judgment lapses.

Furze99

No matter what way you look at the crew and their degree of tiredness or otherwise, this was fundamentally a failure of navigation techniques. To be flying at low level in the dark in reduced visibility in an area with features that were unmapped or poorly mapped on their flight navigation systems was inherently risky. And that's all there is really to it.

Who was responsible? The crew themselves for not realising the limitations of the system they were operating, the protocols and flight paths they were following or the agencies/ companies responsible for the data on their system? Seems to be a bit of all three. But you'd have to think that if this substantial feature had been properly represented on the EGPWS database, that the accident would have been avoided. They'd have had plenty of warning.

markpb

https://www.boards.ie/discussion/comment/118127836#Comment_118127836

You could be reading too much into it. The crew were fatigued and fatigue is known to cause problems so the investigation unit recommended that crew fatigue should be better managed. I didn’t see anywhere in the report that said crew fatigue was a factor.

FishOnABike

https://www.boards.ie/discussion/comment/118126938#Comment_118126938

Avoiding action was advised and taken within seconds of the obstacle being identified.

The pilot + co-pilot were flying on instruments. Where do you fly towards on full power when you can't see what you are trying to avoid? You could just as easily be powering blind into the obstacle faster and harder.

A helicopter weighing between 8 and 12 tonnes, and travelling at 166 kmh doesn't turn on the spot either. There's considerable inertia to overcome and a flight envelope to consider.

Blackrock was only visible to the rear crew member on the forward looking infra red thermal imaging camera. This would have had very much restricted field of view, contrast, visual acuity and depth perception compared to normal daylight human vision. Given the limitations of FLIR the immediate criticality of the situation may not have been aparent until it was too late.

Add the perception - response time, time to communicate the hazard and corrective action to the pilot + co-pilot, time for the pilot + co-pilot to apply that corrective action (whether through instrument settings or switching to manual flight control) and the time for the helicopter to respond to that corrective action and you run out of time very quickly. The collision makes it self evident that in the circumstances, there wasn't time.

MrMusician18

https://www.boards.ie/discussion/comment/118126646#Comment_118126646

"A good litmus test tends to be if you put another crew into the same situation at the same time, would the outcome have been different."

The problem with the report though, is that it doesn't let us establish that, and that's why this report (or at least it's conclusions) is a failure. By throwing fatigue into the mix, the conclusions suggest crew decision making had a role in the accident (as that is what is impacted by fatigue), but fails to identify what those decisions were.

The fear of apportioning blame shouldn't prevent the reporting of fact. If the decisions of the crew contributed to the accident then it should be stated clearly in the conclusions as well as identifying fatigue. If the decisions of the crew had no role, then fatigue is not a factor and shouldn't be considered a contributing factor, but additional information.

I feel like I'm labouring the point here, but it's important: At the moment we're left with a report that says that there were errors and judgement lapses on behalf of the crew due to tiredness, but nothing on what those were or the role they played in the conclusions. Either they did or they didn't have a role and the report should state it clearly and not have the reader undertake guesswork, or read between the lines.

The report spent far too much time with the lawyers tbh.

mr.anonymous

Still working my way through the report.

I would say a pilot is used to trusting their instruments and automation above anything else. It's not up to the rear crew to fly or navigate the aircraft and perhaps easy to see why their input might be seen as lower priority than information (even if wrong) on the cockpit displays.

42 safety recommendations points to there being many factors in many organisations that need to be addressed. Don't think other AAIU reports have come near that number.

AnRothar

I believe there was time.

160 kmh is 160000 meters per hour.

Divided by 3600 gives a forward speed of 44 meters per second.

550 meters of ground at 44 meters every second is just under 13 seconds.

I am not so sure.

mickdw

https://www.boards.ie/discussion/comment/118124942#Comment_118124942

I believe there was time.

The flying pilots were warned of an obstacle up ahead and told to go right. A new heading was entered into flight computer but they hit before this took effect.

If the flying pilot was made aware that this was a life or death situation, surely she had the option to manually take control and take the chopper high and wide on full power.

The entry of a revised heading into flight computer tells me that no emergency action was taken. No extra power put in etc.

Furze99

https://www.boards.ie/discussion/comment/118123916#Comment_118123916

The Russian data referred to was not physical or digital forms of physical maps. If you ever play games with 3D graphics, you'll see modelling of the ground and so on. These are based on digital models of the landscape, imaginary usually in games. In real life, there are digital models of the land surface. On a planetary wide basis, these were/are measured by the big players - NASA, Russians, Chinese presumably, EU. This type of data was loaded in the R116 navigation system to predict and give warning of heights in the line of flight. It seems that Black Rock was missing in the Russian datasets and possibly also in the NASA datasets, too far off the coast to be included seems to be the reason.

[Deleted User]

I haven’t had the time to read the report as I’ve been extremely distracted, but will settle down to read through it at some stage where I can focus.

Ryaner

https://www.boards.ie/discussion/comment/118123620#Comment_118123620

It is really really important for these reports not to apportion blame, so much so that every report will say so and reference the central guidelines about it. What is important is to identify the root causes so that they can be fixed.

If, and I'm not saying the crew did make a mistake, but if they did, it is very important to establish why they did. A whole lot of accident reports over the years have found crew making mistakes and then identified the organisational issues that actually created them. Crew Resource Management that exists in all modern airlines is one such thing that came out of this way of thinking. A good litmus test tends to be if you put another crew into the same situation at the same time, would the outcome have been different. IMO the answer is we'd have the same outcome.

Ryaner

https://www.boards.ie/discussion/comment/118125999#Comment_118125999

There was a project in CHC to do exactly that, the report highlighted it and stated on pg66

"""

In July 2013, there was a proposal to record all routes that had been test flown; to update the index page on the Route Guide to state whether or not a route had been test flown; and to add a notice to the index page stating that ‘No crews are allowed to use routes at night or in poor visibility unless indicated here that they have test flown’. Emails also suggested that a list of all routes in each area [Base] was to be developed and displayed on the Ops Room wall, along the lines of; ‘Route’, ‘Date Test Flown’, ‘By Whom’ and any ‘Comments’. The Operator’s Safety and Quality Integrated Database (SQID) system (Section 1.17.4.2) had the potential to provide a means to record and track the actions associated with the Route proving task. The Investigation notes that the associated email chain involved several pilots, including a Post-Holder; however, SQID was neither used nor suggested for this purpose.

Whilst the emails reviewed seem to indicate committed efforts by a number of persons at all bases, there was no one individual/Post-Holder responsible for driving the project and none of those involved had been trained for this type of work. Four years after the Route Guide transposition, the document still contained the warnings ‘It is a work in progress and should be used with the necessary caution until all routes/waypoints are proven ... Again it is a work in progress so if you have any comments/suggestions, please revert’.

"""

[Deleted User]

https://www.boards.ie/discussion/comment/118121129#Comment_118121129

This would imply that the crews in general accepted working under uncertain standards in that various notes obstacles may or may not exist, and in-noted obstacles may be present. Why there wasn’t insistence on reconnaissance missions in daylight conditions of good visibility to verify uncertain data in one way puzzles me, but on a human level they were just trying to get on with their very busy jobs.