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

1747577798082

Comments

  • Registered Users, Registered Users 2 Posts: 2,984 ✭✭✭Stovepipe


    Well,if the AAIU or an equivalent body, published a report that stated outright that Pilot x or mechanic Y was fully responsible for a crash,then they had better be prepared to stand over it in court, especially if the supposedly blamed person was killed in the crash. Some authorities are prepared to say so but most aren't, because every single report would be contested in court and nothing would be achieved. In some countries, the AAIU is independent of the aviation authority/military/govt but in a lot of cases, they are not and are under political and military pressure to deliver reports that suit certain agendas. In Ireland, the AAIU are independent and it's all the better for our aviation that that is the case. As for blame, there's nothing stopping the IAA from taking action after any report is published,especially if they feel the need to take away a person's license. Nothing prevents families from taking legal action against the airlines or the Air Corps or any pilot or engineer or ATC0. Air accident reports avoid the apportioning of blame,so that the industry can learn from mistakes. It may not be popular or palatable, but it means that people will find out what happened and the manufacturers can make safer aircraft or pilot training might have to be changed or engineers retrained and so on.


  • Registered Users, Registered Users 2 Posts: 8,408 ✭✭✭Gadgetman496


    Stovepipe wrote: »
    Well,if the AAIU or an equivalent body, published a report that stated outright that Pilot x or mechanic Y was fully responsible for a crash,then they had better be prepared to stand over it in court, especially if the supposedly blamed person was killed in the crash. Some authorities are prepared to say so but most aren't, because every single report would be contested in court and nothing would be achieved. In some countries, the AAIU is independent of the aviation authority/military/govt but in a lot of cases, they are not and are under political and military pressure to deliver reports that suit certain agendas. In Ireland, the AAIU are independent and it's all the better for our aviation that that is the case. As for blame, there's nothing stopping the IAA from taking action after any report is published,especially if they feel the need to take away a person's license. Nothing prevents families from taking legal action against the airlines or the Air Corps or any pilot or engineer or ATC0. Air accident reports avoid the apportioning of blame,so that the industry can learn from mistakes. It may not be popular or palatable, but it means that people will find out what happened and the manufacturers can make safer aircraft or pilot training might have to be changed or engineers retrained and so on.


    42eb2b957d.jpeg

    "Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid."



  • Registered Users, Registered Users 2 Posts: 60 ✭✭General Disarray


    The final draft of the report was released by the AAIB. Anyone who is directly referenced/quoted/inferred is automatically reserved a right of reply to any of the statements or findings therein.

    The draft report is provided to these people before official final publication so that they can reply to any of the findings. Any replies will be taken into account before the official final report is released.

    This is all normal procedures inline with ICAO recommendations.

    There's no "conspiracy".


  • Registered Users Posts: 481 ✭✭mr.anonymous


    The AAIU won't apportion blame or liability. But every word of their draft report will be laboured over by a wide range of interested and referenced parties.

    What their final report states could form the basis for millions in lawsuits against the aircraft manufacturer, life jacket manufacturer or other parties.

    I'd imagine the IAA would want any criticism of their oversight sanitised given the extent of what they regulate. This will be the most significant report since the Cork accident report.


  • Registered Users, Registered Users 2 Posts: 60 ✭✭General Disarray


    Having read the final draft report myself, a lot of early posters who were heavily criticised in this thread, will be fully vindicated.


  • Registered Users, Registered Users 2 Posts: 69,560 ✭✭✭✭L1011


    And "I told you so" posts are still not allowed, so drop it.


  • Closed Accounts Posts: 2,346 ✭✭✭easypazz


    Having read the final draft report myself, a lot of early posters who were heavily criticised in this thread, will be fully vindicated.

    Post #449 is well worth another read.


  • Posts: 0 [Deleted User]


    easypazz wrote: »
    Post #449 is well worth another read.

    here here


  • Registered Users, Registered Users 2 Posts: 5,970 ✭✭✭Storm 10




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  • Registered Users, Registered Users 2 Posts: 22,584 ✭✭✭✭Steve


    Total bucket or ' it wasn't me'
    It also emerged that Blackrock island was not included in a database designed to warn the crew they were in danger of hitting land.

    It was designed for CA, nor for SAR.


  • Registered Users, Registered Users 2 Posts: 21,886 ✭✭✭✭Roger_007


    It would be a pity it the AAIU became involved in a dispute over their findings. They go to great lengths to establish the facts and their reports are, above all, findings of fact only.
    It would be a retrograde step for aviation safety if their reports are to be compromised in any way by the sensitivities of any ‘stakeholder’. If they start down that road where will it end? Will they ever be able to publish a report again without someone external to the AAIU being able to effectively influence its contents.


  • Registered Users, Registered Users 2 Posts: 5,121 ✭✭✭TomOnBoard


    easypazz wrote: »
    Post #449 is well worth another read.

    Could you link to it pls. I can't go to specific post number on my phone


  • Registered Users, Registered Users 2 Posts: 8,408 ✭✭✭Gadgetman496


    TomOnBoard wrote: »
    Could you link to it pls. I can't go to specific post number on my phone

    Post #449

    "Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid."



  • Registered Users Posts: 404 ✭✭NH2013


    easypazz wrote: »
    Post #449 is well worth another read.

    Unfortunately, some of the information contained and assumed at the time that post was written has been proven false over the past two years, in particular the information on instrumentation/charts the crew were provided with.

    The final report won’t make for nice reading, especially when you consider the line of work of the crew flying the craft, but ultimately, the report will conclude that the cause of the accident was CFIT.

    It will also expose systemic faults that were all contributory, both with the operator CHC and its charts, navigation systems, accuracy of terrain databases installed and safety reporting systems/culture but also with the regulator; the IAA and how it treats smaller operations and it’s oversight of the industry in general.

    It does not takeaway though from how the crew that flew that night should be viewed, for their heroism shown over their years service and all the lives that have been saved, by what was well known as an exceptionally profession crew. This report should not be taken to tarnish their reputations, but instead serve to further safety in the field going forward.

    Unfortunately a crew that made a mistake on the night in question that cost them their lives but also they were a crew that were let down by the safety nets that were supposed to be in place but were instead absent or did not function as intended.


  • Posts: 0 [Deleted User]


    It's madness the official report is delayed due to some sensitivities.

    What if another similar accident occurs that could have been prevented based on the AAIB Recommendations?

    Very unprofessional on the part of the AAIB.


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  • Registered Users, Registered Users 2 Posts: 645 ✭✭✭faoiarvok


    salonfire wrote: »
    It's madness the official report is delayed due to some sensitivities.

    What if another similar accident occurs that could have been prevented based on the AAIB Recommendations?

    Very unprofessional on the part of the AAIB.

    The AAIB is the UK equivalent. The organisation here is the AAIU.

    The review board is allowed for in the legislation which governs the AAIU, and the establishment of a review board is done by the Minister, so this isn’t currently a matter for the AAIU to decide.

    Finally, the AAIU already made several Safety Recommendations in the preliminary report, and I believe they are free to issue Safety Recommendations separate from a report if they consider that they require urgent attention, so waiting for a Final Report shouldn’t prevent anyone getting urgent recommendations from the AAIU.


  • Posts: 0 [Deleted User]


    salonfire wrote: »
    It's madness the official report is delayed due to some sensitivities.

    What if another similar accident occurs that could have been prevented based on the AAIB Recommendations?

    Very unprofessional on the part of the AAIB.

    Nice rant. But you might want to correct your post to A) direct it at the correct agency and B) apologise to them publicly as you didn’t even get your facts correct before you ranted at the wrong agency.


  • Registered Users, Registered Users 2 Posts: 2,984 ✭✭✭Stovepipe


    let me reiterate; the AAIU is entirely independent and the Minister for Transport respects that, as do all the other State agencies that are involved. They can put out an SR any time they like. Faoiarvok is exactly right. The report will be published when the drafts for examination by interested parties have been returned.


  • Posts: 0 [Deleted User]


    faoiarvok wrote: »
    Finally, the AAIU already made several Safety Recommendations in the preliminary report, and I believe they are free to issue Safety Recommendations separate from a report if they consider that they require urgent attention, so waiting for a Final Report shouldn’t prevent anyone getting urgent recommendations from the AAIU.

    But does the Recommendations in a preliminary report carry the same weight compared to Recommendations in a final Official Report?

    I would imagine the companies and businesses involved would pay far greater heed if the Recommendations came from the final report.


  • Registered Users, Registered Users 2 Posts: 2,984 ✭✭✭Stovepipe


    If it's urgent, then companies will have to respond as soon as.


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  • Moderators, Motoring & Transport Moderators Posts: 6,522 Mod ✭✭✭✭Irish Steve


    salonfire wrote: »
    But does the Recommendations in a preliminary report carry the same weight compared to Recommendations in a final Official Report?

    I would imagine the companies and businesses involved would pay far greater heed if the Recommendations came from the final report.




    Recommendations made in an interim report in some respect carry more weight than the final report, in as much as the relevant reporter is saying "We still have work to do on this incident, but we already know that these issues are of significance, so we're reporting them now to make sure that the wider community gets to know about them NOW, rather than in 12 months time.



    The Final report may well have more recommendations than an interim, in as much as specific work on aspects of the incident may well uncover wider or deeper issues than were first thought, but the interim recommendations carry every bit as much weight as later recommendations.

    Shore, if it was easy, everybody would be doin it.😁



  • Registered Users, Registered Users 2 Posts: 824 ✭✭✭LiamaDelta


    Caledonia wrote: »
    Read back on the early thread. Some posters and in particular a Moderator were very very poor. Like they could not countenance pilot error at all. The more knowledgeable posters were shut down. Very odd.

    Personally I think the moderators did a very good job in trying to limit wild speculation and absolute derailment of the thread given the very limited information that was available. Just because some of the initial speculation and conjecture has since been proven factual doesn't mean that it wasn't appropriate to limit the discussion in order to keep it from descending into farce.


  • Registered Users Posts: 152 ✭✭Caledonia


    It was actually stated what happened couldn’t have happened.


  • Closed Accounts Posts: 9,700 ✭✭✭tricky D


    Comments on moderation are off topic as per note in post 1 and general boards rules.


  • Registered Users, Registered Users 2 Posts: 7,638 ✭✭✭prunudo


    Any word on when the official report might be released? How long do interested parties have to have their say?


  • Registered Users, Registered Users 2 Posts: 60 ✭✭General Disarray


    Caledonia wrote: »
    Read back on the early thread. Some posters and in particular a Moderator were very very poor. Like they could not countenance pilot error at all. The more knowledgeable posters were shut down. Very odd.

    As per the yet (unreleased) official report, a perfectly serviceable aircraft was flown into an obstacle, to which I am apportioning no blame.
    So yes, your observations are accurate.


  • Moderators, Motoring & Transport Moderators Posts: 6,522 Mod ✭✭✭✭Irish Steve


    As per the yet (unreleased) official report, a perfectly serviceable aircraft was flown into an obstacle, to which I am apportioning no blame.
    So yes, your observations are accurate.

    Given the very specific role that the aircraft was purchased and (supposedly) equipped for, it is questionable if it was actually serviceable for the role being performed at the time of the accident.

    Yes, it was most likely mechanically serviceable, but as a complete system for a very specialised role, in light of the issues that have emerged, in my view, it was not servicable, due to fundamental errors that the crew may not have been fully aware of.

    The paper charts were inaccurate, the database in the on board systems was inaccurate and incomplete, and the approach procedures being used by the operator were flawed. None of those factors can be attributed to the crew that were operating the airframe at the time of the accident, and those flaws were a very significant contributor to the end result.

    Shore, if it was easy, everybody would be doin it.😁



  • Registered Users, Registered Users 2 Posts: 7,638 ✭✭✭prunudo


    But surely this wasn't the first time that approach was flown. Did other crews flag the issue and management fail address the issue?
    All ifs and buts until the report comes out but it seems there may have been failures at a lot of levels.


  • Registered Users, Registered Users 2 Posts: 3,008 ✭✭✭skallywag


    I do not think it is fair to point any fingers at a mod. It is extremely difficult to moderate a thread like this, with emotions flying high, and the mods on this thread have my respect.

    That said, this accident has been proven to be CFIT. Without a doubt.

    There was no mechanical failure. Whatsover. The crew took decisions which caused the machine to crash.


  • Registered Users, Registered Users 2 Posts: 3,008 ✭✭✭skallywag


    prunudo wrote: »
    Any word on when the official report might be released? How long do interested parties have to have their say?

    No. Nobody knows right now.


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  • Registered Users Posts: 1,382 ✭✭✭FFVII


    skallywag wrote: »
    I do not think it is fair to point any fingers at a mod. It is extremely difficult to moderate a thread like this, with emotions flying high, and the mods on this thread have my respect.

    That said, this accident has been proven to be CFIT. Without a doubt.

    There was no mechanical failure. Whatsover. The crew took decisions which caused the machine to crash.

    Come out of it.

    I don't read nor know if it even still exists but this thread/forum has had many a feedback thread. You couldn't come in here for a few years it was that bad!!

    Probably still the same lads now, I'm on touch so can't see the names. If I get carded for this, nothing changed.


  • Registered Users, Registered Users 2 Posts: 83,462 ✭✭✭✭Atlantic Dawn
    M


    Nearly 3 years to give a report, wtf like, it wasn't a moon landing that crashed that needed to be documented?


  • Registered Users, Registered Users 2 Posts: 69,560 ✭✭✭✭L1011


    FFVII wrote: »
    Come out of it.

    I don't read nor know if it even still exists but this thread/forum has had many a feedback thread. You couldn't come in here for a few years it was that bad!!

    Probably still the same lads now, I'm on touch so can't see the names. If I get carded for this, nothing changed.

    No, you're getting carded by a mod that wasn't here at the time because you're breaking one of the basic site rules


  • Registered Users, Registered Users 2 Posts: 22,584 ✭✭✭✭Steve


    prunudo wrote: »
    But surely this wasn't the first time that approach was flown. Did other crews flag the issue and management fail address the issue?
    All ifs and buts until the report comes out but it seems there may have been failures at a lot of levels.

    From my reading of the interim report, the flight crew had not flown this approach previously.


  • Moderators, Motoring & Transport Moderators Posts: 6,522 Mod ✭✭✭✭Irish Steve


    Nearly 3 years to give a report, wtf like, it wasn't a moon landing that crashed that needed to be documented?

    No it wasn't a moon landing, but in terms of the work required for what is a relatively small unit, AAIU have had to do a lot of complex research into areas of flight operations and specialied systems that would be outside of their normal experience, and they will have had to wait for responses to many questions that have been sent to organisations and companies outside of Ireland.

    116 was being operated by a very experienced and highly trained crew that would have had probably the highest level of experience and training that was possible, there is no way that the Search and Rescue role can be compared to pretty much any other helicopter operation, and it has almost no relationship to the vast majority of commercial flying that is the normal operation that AAIU are charged with dealing with.

    While we don't have the full details of the findings, it has become very clear that there were some massive failings within a number of organisations that resulted in the total failure of the specialised systems that were supposed to give the crew warnings of dangerous situations developing.

    AAIU have had to ask a number of organisations some very complex and potentially embarassing questions, and the answers to those questions are likely to have raised an equivalent number of new and equally disturbing questions, which then had to be analysed and quantified.

    Rumour has it that there are a significant number of recommendations and findings in the report. We can only hope that the organisations that are implicated in the findings will respond in an appropriate manner.

    It has become very clear that at the time of the accident, there was no mechanical or electrical fault with the aircraft that caused the crew problems operating the flight.

    What has also become clear is that the specialised systems and procedures that were supposed to provide guidance and warnings to the crew of potential danger were very much flawed, and those flaws resulted in no warnings being given to the crew of the danger in front of them, they were left literally and figuratively in the dark.

    We can only hope that the findings of this report will result in far reaching changes to ensure in the future, no SAR crew is ever put in the same situation again.

    I would very much hope that when the final report is eventually released, the members of the R116 crew will be truly allowed to Rest In Peace, without their reputations being tarnished by findings of failure by the crew, as it seems clear to me that they were the unfortunate victims of a combination of errors and failings by others outside of their control or influence.

    Shore, if it was easy, everybody would be doin it.😁



  • Registered Users, Registered Users 2 Posts: 7,638 ✭✭✭prunudo


    Steve wrote: »
    From my reading of the interim report, the flight crew had not flown this approach previously.

    Yes ,sorry should have been more clear in my post. I meant that surely other crews had flown this approach before and if during daylight hours would have found that there was conflicting information on the charts.


  • Registered Users, Registered Users 2 Posts: 6,842 ✭✭✭knucklehead6


    skallywag wrote: »

    There was no mechanical failure. Whatsover. The crew took decisions which caused the machine to crash.


    While that may be factually correct, from what I’ve come to understand from what I have heard/read there were systematic failures and no blame can be apportioned to the crew.
    Yes, it appears to be a case of Controlled Flight Into Terrain, but aids that should have helped the crew weren’t up to scratch


    Not meaning to nitpick but your post does look a little like crew fault. I don’t think this is the case.


  • Registered Users, Registered Users 2 Posts: 8,219 ✭✭✭Gaoth Laidir


    Nobody seems to want to answer that question of previous crews not spotting and reporting the omission in the database. Very quick to jump on some comments, though.


  • Registered Users, Registered Users 2 Posts: 7,404 ✭✭✭plodder


    Nobody seems to want to answer that question of previous crews not spotting and reporting the omission in the database. Very quick to jump on some comments, though.
    The only omission I know about is the fact that Blackrock was missing from the EGPWS database. Nobody would have noticed that unless they had flown dangerously close to the rock before.

    Don't think anyone can definitively say "no crew fault" either though unless that's in the final report which isn't published yet.


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  • Registered Users, Registered Users 2 Posts: 645 ✭✭✭faoiarvok


    There seems to be plenty of people who think that “human error” is a conclusion that signals the end of an investigation, and that asking questions beyond that is some sort of exercise in trying to avoid blaming crew members (though of course, as has been explained so many times, the apportionment of blame is not the job of AAIU reports).

    That may have been the attitude long ago, but it is no longer. If it were, the civil aviation industry would not be as safe as it is. The idea is to understand WHY humans make particular errors, in order to guard against them in future. This concept dates at least as far back as the Tenerife disaster, where the explanation of “they took off when they weren’t supposed to, the idiots” may have seemed like a conclusion. Instead, the industry and investigators continued to dig deeper, identifying the “asymmetrical cockpit” on board the KLM aircraft, leading to new CRM procedures that make every other flight safer as a result.


  • Registered Users, Registered Users 2 Posts: 21,886 ✭✭✭✭Roger_007


    The preliminary report contained all the relevant information about what the aircraft did leading up to the accident. It established that it was flying at an extremely low altitude, in darkness, while still many kilometres from its intended landing point. What the final report will determine is why.
    Although it is not the function of the AAIU to apportion blame to any party, it is their responsibility to describe factually what all the contributory factors were. If that impinges on some sensitivities then that is unfortunate, but necessary. In no way should any report of the AAIU be amended because of pressure from anyone outside the investigating unit and, in particular, there should be no political influence.
    If the rumours that the report is being ‘reviewed’ are true, that would be a very worrying development. It is vital that the integrity and professional reputation of the AAIU is maintained.


  • Moderators, Motoring & Transport Moderators Posts: 6,522 Mod ✭✭✭✭Irish Steve


    plodder wrote: »
    The only omission I know about is the fact that Blackrock was missing from the EGPWS database. Nobody would have noticed that unless they had flown dangerously close to the rock before.

    Blackrock was missing, but there were also some other significant issues with spot heights and precise locations on a number of places being incorrect in both electronic and paper (map) information.

    Some of those errors were corrected very quickly after they were found, but it's not yet clear if all sources have been updated to add or correct the information, and there is doubt about the validity of information in other areas.

    One reason I have heard put forward is that paper based charts are designed for VFR flight, and unless departing or landing, VFR flight is supposed to be carried out above 500FT AMSL, and if predominantely over water, there is no reason to be below 500Ft, so inaccuracies in charts of items below 500FT is not relevant.

    If that is the case, it raises a whole range of very awkward questions about the accuracy and validity of the electronic information contained in the systems that were selected for R116, given that the specific SAR role that the aircraft is performing will require operations over water below 500 Ft on a regular basis.

    Shore, if it was easy, everybody would be doin it.😁



  • Registered Users, Registered Users 2 Posts: 7,404 ✭✭✭plodder


    Blackrock was missing, but there were also some other significant issues with spot heights and precise locations on a number of places being incorrect in both electronic and paper (map) information.
    Yes, I know that. But the post and a previous one seemed to be making the point that if there were omissions and 'conflicting' information then how come no previous crews had pointed this out. I was saying nobody would have noticed the omission.

    Regarding the spot heights on the chart, that wasn't so much a 'conflict' as an ambiguity imo, which someone might have pointed out previously, or might not have. It's easy to imagine situations where other crews would have understood the information on the chart, but someone completely new to the area might not.


  • Posts: 0 [Deleted User]


    One of the questions is why crew decided on a long low approach from some little distance at sea. Obviously their belief was that this approach was safest, free from obstacles and that there was zero chance of encountering any terrain at all at their chosen altitude. They must have been totally unfamiliar with the area during daylight or they would have been aware of the presence that distinct landmark thereabouts.They were relying fully on their navigation system, which needed to be fully accurate if it was to be safe.


  • Registered Users, Registered Users 2 Posts: 3,086 ✭✭✭Nijmegen


    Out of curiosity, are long and low approaches in poor visibility not a bad idea generally? My understanding is that they were flying at 200ft or so when they crashed, and while there's not a lot of moving man made things that height there are a few on the sea plus the chance that your charts are inappropriate / wrong. Yeah there's a one in a million chance that the Allure of the Seas happens to be passing by or your charts are out, but this might be an example of where what can go wrong. I guess another way to look at it someone more educated than me might explain, is what are the advantages of such an approach?


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  • Registered Users, Registered Users 2 Posts: 1,741 ✭✭✭tnegun


    Am probably wrong but I thought they were that low to get below the clouds? The idea being you get close to where you need to be in or above the clouds then fly to a place you know is safe, descend below the clouds and then continue to where you want to be?


  • Posts: 0 [Deleted User]


    I remember when learning to fly in the 80s I had an instructor who sadly later died in a CFIT in Scotland Delivering lobsters from Stornoway to London. He was introducing me to the concept of being caught out flying h into low visibility, so we ascended into cloud. I asked him “Are you satisfied that there isn’t another person practising the exact same thing in this are?” A man with a dry wit he responded “ah well, what you don’t see you don’t miss!”


  • Registered Users, Registered Users 2 Posts: 22,584 ✭✭✭✭Steve


    prunudo wrote: »
    Yes ,sorry should have been more clear in my post. I meant that surely other crews had flown this approach before and if during daylight hours would have found that there was conflicting information on the charts.
    In daylight, they would and should have eyes out, essentially flying VFR so not having to rely on an electronic terrain mapping gps.

    Yes, that could be considered speculation, however it is based on my reading of the interim AAIU report.


  • Registered Users, Registered Users 2 Posts: 3,008 ✭✭✭skallywag


    While that may be factually correct, from what I’ve come to understand from what I have heard/read there were systematic failures and no blame can be apportioned to the crew.

    I certainly would not necessarily agree with that, although do not really want to speculate any further before the final report is eventually published.

    There was indeed a certain amount of over zealous 'this is a SAR crew, so they cannot possibly have made an error' when this thread was in it's infancy, which can subsequently be critiqued based on the interim findings, particularly the CVR data which was released.


  • Registered Users, Registered Users 2 Posts: 3,008 ✭✭✭skallywag


    Nearly 3 years to give a report, wtf like, it wasn't a moon landing that crashed that needed to be documented?

    Some family members are disputing the findings. A draft of the final report was released quite some time ago.


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