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

NH2013 · 09-09-2020 4:20pm

I don't believe it was a family member in this case, and was it infact the IAA that took issue with it and how their regulatory oversight was criticised in the report.

This is where the issue arises in running the review as typically it would be up to the IAA themselves to organise such a review, but there's now a significant conflict of interest there.

That is certainly what I understand anyways from what I've heard.

I also believe that this the first time an AAIU report has actually ever been formally called into question, typically their reports are always accepted as published first time.

09-09-2020 4:40pm

NH2013 wrote: »

I don't believe it was a family member in this case, and was it infact the IAA that took issue with it and how their regulatory oversight was criticised in the report.

This is where the issue arises in running the review as typically it would be up to the IAA themselves to organise such a review, but there's now a significant conflict of interest there.

That is certainly what I understand anyways from what I've heard.

Aha! Interesting!

skallywag · 09-09-2020 5:53pm

NH2013 wrote: »

I don't believe it was a family member in this case, and was it infact the IAA that took issue with it and how their regulatory oversight was criticised in the report.

Good point, and perhaps it is also a factor.

It is certainly the case though that family members of the crew have taken issue with the report.

smurfjed · 09-09-2020 7:10pm

The purpose of these reports is to analyse the facts based on the information available, if those facts point to a failure in a procedure or process, then this information needs to be disseminated to other operators to prevent a reoccurrence.

Unfortunately in this world of ours, if there is any indication of a failure on the part of a human, you can expect his/her estate to be sued. This has previously happened in the Cork crash and the Aer Corp crash.

irishgeo · 09-09-2020 11:07pm

NH2013 wrote: »

I don't believe it was a family member in this case, and was it infact the IAA that took issue with it and how their regulatory oversight was criticised in the report.

This is where the issue arises in running the review as typically it would be up to the IAA themselves to organise such a review, but there's now a significant conflict of interest there.

That is certainly what I understand anyways from what I've heard.

I also believe that this the first time an AAIU report has actually ever been formally called into question, typically their reports are always accepted as published first time.

Can't we just get another country accident investigation team to do the review? Crash investigators are often invited in to other countries to investigate crashes.

Turbulent Bill · 09-09-2020 11:58pm

smurfjed wrote: »

The purpose of these reports is to analyse the facts based on the information available, if those facts point to a failure in a procedure or process, then this information needs to be disseminated to other operators to prevent a reoccurrence.

Exactly. Often the immediate cause of an accident is just a symptom of a more systemic issue, such as a process gap. It's much more important to understand that than the final action involved in a crash.

Stovepipe · 11-09-2020 10:11am

When you think of the number of organisations and groups connected to this event, by default, there's no wonder it's a convoluted affair. You have CHC, the families, the IAA, Sikorsky, the manufacturers of all the subsystems, the Ordnance Survey and as a consequence, the Air Corps and the State. A lot of the arms of the State are involved so naturally some people have kept a very close eye on this event since the tragedy itself. The potential results have wider implications. This has so much in common to the crash of DH 248 and it shook the daylights out of the Air Corps and created quite a stir in Irish aviation's upper circles and this has the potential to do the same.

Dwarf.Shortage · 11-09-2020 10:18am

Stovepipe wrote: »

When you think of the number of organisations and groups connected to this event, by default, there's no wonder it's a convoluted affair. You have CHC, the families, the IAA, Sikorsky, the manufacturers of all the subsystems, the Ordnance Survey and as a consequence, the Air Corps and the State. A lot of the arms of the State are involved so naturally some people have kept a very close eye on this event since the tragedy itself. The potential results have wider implications. This has so much in common to the crash of DH 248 and it shook the daylights out of the Air Corps and created quite a stir in Irish aviation's upper circles and this has the potential to do the same.

Would every crash not have the same, or very similar, set of stakeholders?

Every aircraft that ever came down had an owner, an operator, suppliers of subsystems, the crew had families etc.

Stovepipe · 11-09-2020 10:43am

Not necessarily. Most Irish events, be they fatal or not, minor or major, don't involve so many arms of the State. It's usually the airline or operator, the manufacturer (quite often as little more than a courtesy if the aircraft is involved but not at fault) and maybe the IAA as operator of the airspace and the national radar and even a minor involvement of the Met Office for an aftercast of the weather. This event has cast a wider net.

smurfjed · 11-09-2020 10:46am

Looking at this from a purely technical point of view, Why are any ‘arms of the state’ involved at all?

cml387 · 11-09-2020 10:47am

Dwarf.Shortage wrote: »

Would every crash not have the same, or very similar, set of stakeholders?

Every aircraft that ever came down had an owner, an operator, suppliers of subsystems, the crew had families etc.

As Stovepipe says, plus the fact it was such a high profile accident and there will be considerable media interest when the report comes out.

Stovepipe · 11-09-2020 10:57am

@smurfjed, the State's airspace, an aircraft operating on behalf of the State, bearing the national flag, flown by people mostly trained in the State, paid for by the State's money, under a radar screen provided by the State, operated by the State's employees. They'd have to be involved. If this had been a minor accident, whereby a guy ran his Cessna into a hedge and injured only his pride, they'd still be involved. It's not like in America where accident investigation is devolved down to very local official level. Ireland's investigation system is designed to deliberately involve as many State agencies as possible, such as the Gardai, Fire Brigade, Health Service, IAA, Dept of Defence, Air Corps,etc,etc.

11-09-2020 11:05am

Stovepipe wrote: »

Not necessarily. Most Irish events, be they fatal or not, minor or major, don't involve so many arms of the State. It's usually the airline or operator, the manufacturer (quite often as little more than a courtesy if the aircraft is involved but not at fault) and maybe the IAA as operator of the airspace and the national radar and even a minor involvement of the Met Office for an aftercast of the weather. This event has cast a wider net.

The IAA is also involved as it is not only the Air Navigation Services Provider (ANSP, or what we used to call Air Traffic Control back in simpler times) but also the Safety Regulator. This dual remit is unusual in Europe, albeit it used to be the norm 30 or so years ago. Most European countries have split these functions. It’s the FAA model, too.

Govt policy is to split the two functions and that is in train. I expect it is the safety regulatory side that is a party to the report, rather than the ANSP

11-09-2020 1:20pm

Stovepipe wrote: »

When you think of the number of organisations and groups connected to this event, by default, there's no wonder it's a convoluted affair. You have CHC, the families, the IAA, Sikorsky, the manufacturers of all the subsystems, the Ordnance Survey and as a consequence, the Air Corps and the State. A lot of the arms of the State are involved so naturally some people have kept a very close eye on this event since the tragedy itself. The potential results have wider implications. This has so much in common to the crash of DH 248 and it shook the daylights out of the Air Corps and created quite a stir in Irish aviation's upper circles and this has the potential to do the same.

I remember the night of DH248, was in the fog on the south coast with my mother when curiously she said a couple of hours before "some stupid little aircraft is going to take off in this fog". I was caught driving, had to slow to a crawl. Pressure on rescue missions can be great in these conditions.

Storm 10 · 25-09-2020 9:46pm

Sister of a crewmember of Rescue 116 will be on the Late Late show tonight

Roger_007 · 26-09-2020 12:09am

Storm 10 wrote: »

Sister of a crewmember of Rescue 116 will be on the Late Late show tonight

Really good interview.
I was afraid that they would stray into the circumstances of the accident. That would have been wrong at the present stage of the investigation. I’m glad they didn’t go there.

TomOnBoard · 26-09-2020 1:29am

Roger_007 wrote: »

Really good interview.
I was afraid that they would stray into the circumstances of the accident. That would have been wrong at the present stage of the investigation. I’m glad they didn’t go there.

A good interview by Tubbs.. well handled
.. no undue interference in the crash. Simply looked at the human aspect of how does one sister deal with the death of her sibling in a widely reported public service accident...

26-09-2020 1:11pm

TomOnBoard wrote: »

A good interview by Tubbs.. well handled
.. no undue interference in the crash. Simply looked at the human aspect of how does one sister deal with the death of her sibling in a widely reported public service accident...

They were legally precluded from going there. Niamh is very le do headed and safe for RTÉ to interview, to remind the nation about the tragedy.

skallywag · 26-09-2020 2:53pm

I do not think that RTE were ever going to go anywhere near the details of the accident.

It will be interesting to see how the details eventually get treated by the media when the report is finally released.

29-09-2020 8:46pm

skallywag wrote: »

I do not think that RTE were ever going to go anywhere near the details of the accident.

It will be interesting to see how the details eventually get treated by the media when the report is finally released.

Ray Darcy tried to broach the subject with Niamh, but she just said "it's ongoing, Ray". When the report is finally out the media will no doubt be all over it for years to come, it will be the subject to of many documentaries, indeed decades to come.

29-09-2020 9:08pm

I understand there is a review process, but what I can’t fathom is why it is taking so long to complete. COVID-19 is no excuse, in my view.

Valuable information and learning from this tragic accident must be published. Learning from accidents informs future improvements and is a very well established practice

29-09-2020 9:18pm

[Deleted User] wrote: »

I understand there is a review process, but what I can’t fathom is why it is taking so long to complete. COVID-19 is no excuse, in my view.

Valuable information and learning from this tragic accident must be published. Learning from accidents informs future improvements and is a very well established practice

The preliminary report made the necessary immediate key recommendations for safety improvements.

http://www.aaiu.ie/sites/default/files/report-attachments/REPORT%202017-006%20PRELIMINARY.pdf

Safety Recommendation No. 1
CHC Ireland should review/re-evaluate all route guides in use by its SAR helicopters in Ireland, with a view to enhancing the information provided on obstacle heights and positions, terrain clearance, vertical profile, the positions of waypoints in relation to obstacles and EGPWS database terrain and obstacle limitations.
(IRLD2017005)

Safety Recommendation No. 2
RFD Beaufort Ltd should review the viability of the installation provisions and instructions for locator beacons on Mk 44 lifejackets and if necessary amend or update these provisions and instructions taking into consideration the beacon manufacturer’s recommendations for effective operation.
(IRLD2017006)

I had a re-read of the preliminary report and came to this understanding:
Basically the findings there were that an approach had been programmed into the flight management system that brought the helicopter directly into Blackrock Island because the data in the system did not feature the existence of it at all. By coincidence the flight crew were not familiar with the area, having not made that approach in quite some time (maybe years) so they did not appreciate either the existence of the obstacle.

When the rapidly closing obstacle was spotted by one of the rear crew through their camera (used to spot rescue situations) he shouted to the crew, but it was too late for successful evasive action. Evasive action was commenced but seemed to result in the tail striking land, losing use of horizontal stabiliser. Travelling forward beyond the island, the helicopter entered water. Potential rescue was hampered by deficiencies in locator beacons on the life jackets.

Tragic accidents are nearly always a combination of everything all going wrong together in the same instance.

kippy · 29-09-2020 10:10pm

[Deleted User] wrote: »

I understand there is a review process, but what I can’t fathom is why it is taking so long to complete. COVID-19 is no excuse, in my view.

Valuable information and learning from this tragic accident must be published. Learning from accidents informs future improvements and is a very well established practice

Don't worry. The important learnings have been published publicly and I dare say anything else privately to the relevant parties.

cml387 · 29-09-2020 10:11pm

I have recently watched two documentaries about the Air New Zealand crash at Mount Erebus, and the political storm that ensued.

It struck me that at the heart of this crash is a similar issue,a flight crew mislead by inadequate or misleading navigation aids.

In the end,after all ANZ's despicable attempts to put all the blame on the crew were laid bare, their chief pilot clung to the principle that ultimately it is the responsibility of the pilot to safely navigate the aircraft and that (in this case),he, Capt Collins should have independently verified his position and not depended on the INS to navigate safely.

I wonder is a similar argument taking pace at the heart of this accident and that it would be convenient for some in authority to push the blame back from them to the aircrew.

Stovepipe · 30-09-2020 10:28am

See Mull of Kintyre incident and the subsequent inquiry and political and military ****storm it caused afterwards. The Nimrod crash was another one. The old tradition of not blaming the dead because they are not around to explain themselves went out the window.

jmayo · 02-10-2020 5:38pm

cml387 wrote: »

I have recently watched two documentaries about the Air New Zealand crash at Mount Erebus, and the political storm that ensued.

It struck me that at the heart of this crash is a similar issue,a flight crew mislead by inadequate or misleading navigation aids.

In the end,after all ANZ's despicable attempts to put all the blame on the crew were laid bare, their chief pilot clung to the principle that ultimately it is the responsibility of the pilot to safely navigate the aircraft and that (in this case),he, Capt Collins should have independently verified his position and not depended on the INS to navigate safely.

I wonder is a similar argument taking pace at the heart of this accident and that it would be convenient for some in authority to push the blame back from them to the aircrew.

I would actually argue the opposite.

This report has taken way too long and someone or someones put a stop to it late last year because they didn't like the findings.

That someone or someones can include relatives of the pilots.

Call me cynical, or perhaps around long enough to know the way Ireland works, but after this interview I now actually expect the report to be out soon.

02-10-2020 6:46pm

jmayo wrote: »

I would actually argue the opposite.

This report has taken way too long and someone or someones put a stop to it late last year because they didn't like the findings.

That someone or someones can include relatives of the pilots.

Call me cynical, or perhaps around long enough to know the way Ireland works, but after this interview I now actually expect the report to be out soon.

I don't know how a new review report could materially change the findings of the previous Final Report, unless new factors were uncovered. Reports don't go out to assign blame, but findings can conclude that routines that were in practice in flight operations were insufficient to maintain safety, that oversight of the operation was lacking in some respect, etc. It has already been definitely found that navigation data was dangerously inaccurate for SAR helicopter operations. It was known that the crew were not very familiar with the base and it's approaches, for whatever reason. The authorities oversight of operation and the operation itself are the two main elements in question, whatever the findings turn out to be.

I can't see how non-expert relatives could have any influence over factors uncovered which might relate to flight crew performance, simply because (presumably) they are not sufficiently knowledgeable in that sphere. They might, however, raise an eyebrow if the state authorities appear to them to have been left off the hook.

As somebody posted earlier it is perhaps more likely that the CAA is kicking up about too much blame being focussed on them when, *maybe*, in their view the pilots should have been familiar enough with the approach terrain (due to insufficient routine daylight practices) to realise the number of hazards present OR not to have already reported on data inaccuracies uncovered during previous flight operations.

There might have not been enough working/operational time available to crews carry out regular daylight practices to keep familiarity with all approaches they might have to use, which could possibly be a factor.

Could be other factors altogether, but findings are quite likely to include some of the aforementioned.

newcavanman · 02-10-2020 7:33pm

jmayo wrote: »

I would actually argue the opposite.

This report has taken way too long and someone or someones put a stop to it late last year because they didn't like the findings.

That someone or someones can include relatives of the pilots.

Call me cynical, or perhaps around long enough to know the way Ireland works, but after this interview I now actually expect the report to be out soon.

I think its very unusual that three and a half years after the crash we still havent got a final report . You would have to think, that perhaps certain people dont want it to ever to be published

EchoIndia · 02-10-2020 9:30pm

newcavanman wrote: »

I think its very unusual that three and a half years after the crash we still havent got a final report . You would have to think, that perhaps certain people dont want it to ever to be published

What people? This is a report carried out in a western democracy by an agency attached to a Government Department. It would be untenable in this day and age for it not to be published just because it might be uncomfortable for some people or organisations. A fairly standard statement at the front of each AAIU report reads

"This safety investigation is exclusively of a technical nature and the Final Report reflects the determination of the AAIU regarding the circumstances of this occurrence and its probable causes.

In accordance with the provisions of Annex 131 to the Convention on International Civil Aviation, Regulation (EU) No 996/20102 of the European Parliament and the Council, and Statutory Instrument No. 460 of 20093, safety investigations are in no case concerned with apportioning blame or liability. They are independent of, separate from and without prejudice to any judicial or administrative proceedings to apportion blame or liability. The sole objective of this safety investigation and Final Report is the prevention of accidents and incidents.

Accordingly, it is inappropriate that AAIU Reports should be used to assign fault or blame or determine liability, since neither the safety investigation nor the reporting process has been undertaken for that purpose."

selectamatic · 02-10-2020 11:01pm

A mod on here alluded to it being a commercial interest that's holding up the show.

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

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