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

TomOnBoard

There's been an amount of research done on accidents in multiple fields of human endeavour, and possibly more in the aviation industry than anywhere. An article from 2010 (referring to findings presented at a CHC- sponsored safety & quality summit) suggested that “In a preponderance of accidents, pilots and air crew are set up for failure.”

This is not 'passing the buck' for 'pilot error'; rather it is seeing the reality of a complex set of processes for what it is: not one process but many processes that are interlinked in a chain. Most of the time, all is good and we all marvel that such magnificent technological achievements can be designed by humans to do things that seem to defy natural laws of physics. And when all is good, the designers and engineers are fantastic, the pilots wonderful and the crews who soldier at the edge of human endeavour heroic.

However, at some point in the forging of the chain, a bug creeps in which may seem innocuous on its own. And perhaps another one creeps in later on, and another- all tiny and insignificant in their own right but when they all align on a dark night over unknown waters, something happens and all are lost. The fact is the PIC is the last person to have control of the machine at that point and can too easily become the last person standing in a gruesome form of musical chairs. But the long chain of events - many elements of which were put in place weeks, months or even years before the tragedy - simply ends up in a terrible confluence of all the little things aligning and the last person in charge being left without a chair to sit on.

Couple that with decision-making that may have created fertile ground for all the bad things to impact on each other and you have a disaster. I believe that's what happened on 14th March: the end- point in a cascade of errors and accidents that ended in a disaster. I hope the investigators will be able to tease out all the links and go back far enough to identify all the 'little' bugs that crept in, and establish where the decision- making went wrong, so that those particular issues will be removed from future processes in the interests of safety.

While its very clear at this stage that the R116 crew were left with no chairs when the music stopped, we still need to await the final report to understand the totality of what happened. Anyone who believes right now that they know so much about the decision- making that night and the chain of events that preceded it as to be able to 'foretell' the final report of the investigators, needs to consider how their protestations are only demonstrating an omniscience and arrogance that undermines every word they say.

For anyone interested in some reading material around all this:

https://www.helicoptersmagazine.com/procedures/the-domino-effect-2106#sthash.q61eqAiW.dpuf

http://www.asasi.org/papers/2008/Accident%20Data%20and%20the%20Helicopter%20Offshore%20Safety%20Case%20Presented%20by%20Steve%20Walters.pdf

Tenger

BoatMad wrote: »

..................
However the performance of the warning systems ( i.e. the crews use of it and the underlying technology ) is not the key issue

Again the issue is why did a experienced crew select a route with a known obstacle ( i.e. that information was on board the aircraft ) and then fly that route . ..........

You are obviously very experienced in the whole area of naviagtion systems. But over the last while you have been grinding an axe with most people of this thread.
However I dont think anyone is really on the other side of the argument with you in relation to the questions quoted about. Could you try to be a little less forceful about it? Its an anonymous forum, you dont need to prove yourself here.

Henry Ford III

I was walking earlier on a beach in Clare and one of R116's sister 'copters flew low over me headed for the Cliffs of Moher.

It was a very moving moment in my little world.

Coil Kilcrea

Henry Ford III wrote: »

I was walking earlier on a beach in Clare and one of R116's sister 'copters flew low over me headed for the Cliffs of Moher.

It was a very moving moment in my little world.

Now that I can truly understand.

I regularly waved as R116 frequently few by my house. And I'm struck by the fact that I won't see them again. Life goes on but remembering and reflecting, however slight, is significant on a human level.

Means Of Escape

Tenger wrote: »

You are obviously very experienced in the whole area of naviagtion systems. But over the last while you have been grinding an axe with most people of this thread.
However I dont think anyone is really on the other side of the argument with you in relation to the questions quoted about. Could you try to be a little less forceful about it? Its an anonymous forum, you dont need to prove yourself here.

He is totally correct in his statement regardless of the way he presented it

plodder

TomOnBoard wrote: »

For anyone interested in some reading material around all this:

https://www.helicoptersmagazine.com/procedures/the-domino-effect-2106#sthash.q61eqAiW.dpuf

http://www.asasi.org/papers/2008/Accident%20Data%20and%20the%20Helicopter%20Offshore%20Safety%20Case%20Presented%20by%20Steve%20Walters.pdf

The first of those articles is an interesting read, but the second one, my god, I work in software, so I know what a flow chart looks like. But, you can't expect humans to operate according to flowcharts (like those ones).

TomOnBoard

plodder wrote: »

The first of those articles is an interesting read, but the second one, my god, I work in software, so I know what a flow chart looks like. But, you can't expect humans to operate according to flowcharts (like those ones).

I suppose its a bit of a curate's egg. I found parts of it hard to follow, but that's possibly because in its debut performance, it had some skinny aircrafty dude making a presentation and he was just using the slides as backup for what was probably a scintillating presentation. However,there are few of the slides in the presentation that don't contain some very useful thinking (albeit requiring some study). But, if they don't float your boat, that's OK. There's loads of other stuff out there that deal with multi- dimensional causation when it comes to a specific event. These 2 are just 2 I found interesting and shared because of that.

For me the ould flowchart is a great resource to schematically represent complex decision making and process flows. However, I fully agree with your point that no human being should operate according to flowcharts; I know in any area I've ever been involved in, they would only ever be used as 2 dimensional best-case attempts to illustrate/describe such complexities as mentioned. After all, without them, the communication of such complexities are difficult if not impossible in the printed word.

TomOnBoard

Means Of Escape wrote: »

He is totally correct in his statement regardless of the way he presented it

Which one? There were sooooo many!

Means Of Escape

TomOnBoard wrote: »

Which one? There were sooooo many!

Avionics

J Mysterio

Means Of Escape wrote: »

He is totally correct in his statement regardless of the way he presented it

I think said poster has gone to great lengths to post his musings diplomatically, and to contribute. I dont understand why he is being haunted.

Tenger

Means Of Escape wrote: »

He is totally correct in his statement regardless of the way he presented it

I didnt state or imply that s/he was incorrect.
I dont disagree with Boatmad. To be very honest I would not have the expertise to do so. Hence I have not done so. I had not realised the level of tech that modern boats carried, the discussion has been very illuminating on that front. So thanks for that.

My point is that s/he keeps returning to the question of Why? In a manner that seems as if others are ignoring that question.
I too want to know Why?

plodder

BoatMad wrote: »

A bigger issue surrounds the use of the radar ,

On that point, take a look at this post on pprune. It's a photo of an S92 NAV display set up the same way as R116, but with an oil rig 2 miles away. The area of interest of the radar, is not that big. Easy to miss something especially when you have other extraneous information overlaid on it, and your attention might be more focused on what is further out.

Kalyke

I must say I am impressed with the owner/crew/skipper of the Gearadoin (spelling). Their effort, along with many, many more is outstanding.

Gaoth Laidir

plodder wrote: »

On that point, take a look at this post on pprune. It's a photo of an S92 NAV display set up the same way as R116, but with an oil rig 2 miles away. The area of interest of the radar, is not that big. Easy to miss something especially when you have other extraneous information overlaid on it, and your attention might be more focused on what is further out.

The fact that Blackrock is was only about 200 metres wide from the direction they were approaching makes its radar return pretty small I would imagine. From 1 NM away that would subtend and angle of just 6 ° on the screen, which seems not much bigger than the sea clutter returns on that image.

ProfessorPlum

Gaoth Laidir wrote: »

The fact that Blackrock is was only about 200 metres wide from the direction they were approaching makes its radar return pretty small I would imagine. From 1 NM away that would subtend and angle of just 6 ° on the screen, which seems not much bigger than the sea clutter returns on that image.

The give away would be the lack of returns from behind the return - its often more useful than the return itself.

plodder

Gaoth Laidir wrote: »

The fact that Blackrock is was only about 200 metres wide from the direction they were approaching makes its radar return pretty small I would imagine. From 1 NM away that would subtend and angle of just 6 ° on the screen, which seems not much bigger than the sea clutter returns on that image.

and with a way marker overlaid. Presumably, they would have seen better by selecting a shorter range on the radar. That would make the return much larger on the screen. But, would that presuppose knowing that there was something that they needed to be looking out for?

Gaoth Laidir

ProfessorPlum wrote: »

The give away would be the lack of returns from behind the return - its often more useful than the return itself.

Yes but with such a small target the shadow behind it would be minimal and scarcely noticeable, I'd imagine.

Gaoth Laidir

plodder wrote: »

and with a way marker overlaid. Presumably, they would have seen better by selecting a shorter range on the radar. That would make the return much larger on the screen. But, would that presuppose knowing that there was something that they needed to be looking out for?

Which brings us full circle back to the whole talk about the arrival briefing and seeing 282 ft on the chart.

ProfessorPlum

Gaoth Laidir wrote: »

Yes but with such a small target the shadow behind it would be minimal and scarcely noticeable, I'd imagine.

Not quite. The lack of returns will fan out in an arc behind the return, so unless there's nothing else on the screen it would be noticeable as it would be a very well defined arc. I don't use radar for ground mapping, but I'd imagine if you were, you'd be scanning down to include ground clutter, so a lack of ground returns should ring some warning bells.
It'll be interesting to see how the radar was set up and what was likely to be displayed on screen.

plodder

ProfessorPlum wrote: »

Not quite. The lack of returns will fan out in an arc behind the return, so unless there's nothing else on the screen it would be noticeable as it would be a very well defined arc. I don't use radar for ground mapping, but I'd imagine if you were, you'd be scanning down to include ground clutter, so a lack of ground returns should ring some warning bells.
It'll be interesting to see how the radar was set up and what was likely to be displayed on screen.

According to the preliminary report GMAP2 mode, with range set to 10 miles.

Means Of Escape

Tenger wrote: »

I didnt state or imply that s/he was incorrect.
I dont disagree with Boatmad. To be very honest I would not have the expertise to do so. Hence I have not done so. I had not realised the level of tech that modern boats carried, the discussion has been very illuminating on that front. So thanks for that.

My point is that s/he keeps returning to the question of Why? In a manner that seems as if others are ignoring that question.
I too want to know Why?

CFIT
Approach altitude too low for distance from destination
Poor overall knowledge of area /terrain and the obstacles associated with it
Incomplete data in craft system
Delayed response to execute a tactical manoeuvre
Spatial disorientation /spatial awareness resulting in incorrect/delayed action when performed

Far from speculation but certainly debatable at this juncture

Gaoth Laidir

Rescue 116 has just roared overhead here now at 3000 ft and 138 knots. Could hear it coming for over a minute. Quite a sound off it.

Gadgetman496

Sniffer dogs to be used in search for missing Rescue 116 crew.

http://www.rte.ie/news/2017/0428/871204-rescue-116/

icjzfmq7ewon1t

This isn't directly related to rescue 116 so please remove if deemed unsuitable

https://m.soundcloud.com/doc-on-one/a-good-day-at-blackrock

nuac

Avianna Witty Weekend wrote: »

This isn't directly related to rescue 116 so please remove if deemed unsuitable

https://m.soundcloud.com/doc-on-one/a-good-day-at-blackrock

Thanks TW

Played that just now, Beautiful and sad.

Never on BR, but have sailed in the vicinity.

Bad currents around it, and heavy swell. The Atlantic swell is increased by the shallowing and irregular bottom and the constraints of the land. Sad that even an experienced Keeper was caught out by it.

The Light House keeper and their families were heroic. Imagine having to tether your children to iron pegs in the ground!

icjzfmq7ewon1t

Very sad story nicely told. Sounds a very dangerous place. Just imagine having to anchor the children but if they weren't they'd be swept away.
Lighthouse keepers were indeed brave men to work under these conditions.

plodder

There's an interesting post today on pprune, which sounds credible in terms of content. Digital terrain model had Blackrock at 50ft, and a defect in the scanned chart showed it (possibly) at 28ft. The final digit of the 282 is obscured apparently.

zuutroy

plodder wrote: »

There's an interesting post today on pprune, which sounds credible in terms of content. Digital terrain model had Blackrock at 50ft, and a defect in the scanned chart showed it (possibly) at 28ft. The final digit of the 282 is obscured apparently.

plodder

It's debatable I suppose, though that's a photo of a physical chart I presume, rather than the raster version on the aircraft display. So, there could be further degradation in that case. The overprinting of Duvillaun More is particularly bad as well. Either way, imo the quality of the information presentation is not great; same for the charts on the route guide.

Turtwig

If anything surely an obscured "2" would draw your attention to it more. It's perfectly readable imo, at most it would make the viewer double take at the number to determine whether it was "2" or "7"?

Gaoth Laidir

Turtwig wrote: »

If anything surely an obscured "2" would draw your attention to it more. It's perfectly readable imo, at most it would make the viewer double take at the number to determine whether it was "2" or "7"?

There's still no excuse for having text obscured like that, especially the Duvillaun More.

Cloudio9

Turtwig wrote: »

If anything surely an obscured "2" would draw your attention to it more. It's perfectly readable imo, at most it would make the viewer double take at the number to determine whether it was "2" or "7"?

Well with the benefit of hindsight we're all focusing on it. It's far from ideal the way it appears if you're scanning a number of different points on a map.

TomOnBoard

Gaoth Laidir wrote: »

There's still no excuse for having text obscured like that, especially the Duvillaun More.

On any objective assessment, you'd have to say that maps & charts used in navigation by aviators at the 'bleeding edge' of flying activity should be of the highest standard, conforming to a large number of quality criteria, including being crisp and clear, totally informative and without a shred of ambiguity that could lead to bad decisions.

When I saw that Pprune post, I was struck by the story that was being outlined. Doubts about the quality of charting certainly formed in my mind from reading the post, especially as it is intimated that a rasterised version of an unclear/ambiguous chart subsequently may have formed part of the on- board display.

We (the great unwashed) cant know what the crew looked at on that terrible night. However, we know that the AAIU has the CVR as well as SOP packets of charts and other information that will have been used by the crew in flight planning. AAIU will be able to deduce the extent to which all this is of relevance to what happened, and we have to await its deliberations.

However, we (the great unwashed) can say that IF the photo of the chart that was posted is an accurate representation of the standard of charts in use which was then further degraded by the scanning process, serious questions arise.

If the Pprune scenario accurately represents the information available on the night and could have contributed to poor understanding of the threats that were out there, and IF any/all actions were not mitigated by other information, that simply seems dreadful to me.

plodder

Cloudio9 wrote: »

Well with the benefit of hindsight we're all focusing on it. It's far from ideal the way it appears if you're scanning a number of different points on a map.

And we're looking at a paper chart, not at one of the MFD screens on board. A fine detail like that could easily be obscured on a digital display. It depends on the size of the screen, its resolution, the quality of the graphics. Probably the detail would be visible if you have the ability to zoom in, but then you would have to have a reason to zoom in. We'll have to wait to find out what the investigators make of it.

irishgeo

plodder wrote: »

And we're looking at a paper chart, not at one of the MFD screens on board. A fine detail like that could easily be obscured on a digital display. It depends on the size of the screen, its resolution, the quality of the graphics. Probably the detail would be visible if you have the ability to zoom in, but then you would have to have a reason to zoom in. We'll have to wait to find out what the investigators make of it.

wont they able to check it on one of the other choppers screens.

plodder

irishgeo wrote: »

wont they able to check it on one of the other choppers screens.

I guess that is what they will do all right.

ElNino

This is very sad to listen to

BoatMad

plodder wrote: »

And we're looking at a paper chart, not at one of the MFD screens on board. A fine detail like that could easily be obscured on a digital display. It depends on the size of the screen, its resolution, the quality of the graphics. Probably the detail would be visible if you have the ability to zoom in, but then you would have to have a reason to zoom in. We'll have to wait to find out what the investigators make of it.

The aircraft had both vector and raster charts in its electronic mapping. Though I believe the main ones are vector. Hence the scanned image from a paper chart is totally misleading.

Blackrock should and would have given a considerable radar return especially that low , however I suspect from the data in the report, that the range was set too great. Its a mystery however that they did not detect it and it will be interesting to see if the final report provides any clues as to why

CFIT
Approach altitude too low for distance from destination
Poor overall knowledge of area /terrain and the obstacles associated with it
Incomplete data in craft system
Delayed response to execute a tactical manoeuvre
Spatial disorientation /spatial awareness resulting in incorrect/delayed action when performed

Far from speculation but certainly debatable at this juncture

with the exception of point 3 I think we can say yours is a reasonable conclusion
I would argue the aircraft had two sources of information on Blackrock , the only conclusion you can then reach is that neither where investigated sufficiently to trigger concern

note that the altitude decision is entirely rational , given the low cloud , it would make sense to cloudbreak over the open sea and not anywhere near land, This is precisely what they did, its the fact that they didnt "clear" the route that is the issue.

Collie D

I just read this article and the following quote stood out

"In the distance, it was a grateful sound to hear the engines of R116 making its way to us," the D?n Laoghaire Coast Guard wrote on their Facebook page.

D?n Laoghaire Coast Guard thanked everyone who had assisted in the call out. “It was an emotional but thankful sight to see our helicopter, R116 keeping an eye on us.”

Have they re-registered a helicopter or named a new one in memory or something?

kmart6

Posted way back.

faoiarvok

Collie D wrote: »

Have they re-registered a helicopter or named a new one in memory or something?

The helicopters aren't actually named or registered Rescue 11x, that's the callsign used by them when on a rescue mission.

The registrations are
EI-ICG
EI-ICU
EI-ICA
EI-ICR (crashed)
EI-ICD

(Spelling out GUARD, as in Irish Coast Guard)

Growler!!!

Collie D wrote: »

I just read this article and the following quote stood out

"In the distance, it was a grateful sound to hear the engines of R116 making its way to us," the D?n Laoghaire Coast Guard wrote on their Facebook page.

D?n Laoghaire Coast Guard thanked everyone who had assisted in the call out. “It was an emotional but thankful sight to see our helicopter, R116 keeping an eye on us.”

Have they re-registered a helicopter or named a new one in memory or something?

No. Whichever heli was/is assigned to the Dublin base carries the Callsign "Rescue 116" while on a call out. They will use the aircraft reg when out training.

Alun

As an aside, R116 was actually returning from a rescue up north on Slieve Donard at the time, which I just happened to witness first hand from a vantage point not too far away. I was just checking on the Mournes MRT Facebook page to see what the story was, and looked up the track of R116 on Marinetraffic, and wondered why they'd headed to that area on the way back before returning to base. Now I know why!

Psychlops

Airframes have swapped since Saturday,

As it stands:

EI-ICG~Sligo~R118
EI-ICU~Waterford~R117
EI-ICA~Dublin~R116
EI-ICD~Shannon~R115

Gadgetman496

Psychlops wrote: »

Airframes have swapped since Saturday,

As it stands:

EI-ICG~Sligo~R118
EI-ICU~Waterford~R117
EI-ICA~Dublin~R116
EI-ICD~Shannon~R115

So they swapped Dublin with Shannon?

Why would they do that, what purpose would it serve?

Psychlops

Gadgetman496 wrote: »

So they swapped Dublin with Shannon?

Why would they do that, what purpose would it serve?

SNN is where they do major maintenance.

donkey balls

Gadgetman496 wrote: »

So they swapped Dublin with Shannon?

Why would they do that, what purpose would it serve?

I don't know the ins and outs regarding CHC/ICG operations could it be something to do regarding MX of the heli, We use to swop airframes around so that an aircraft due in for MX would swop base and fly to the intended base were the MX be carried out.

Atlantic Dawn

Prime Time on RTE 1 covering R116 now, from the intro it seems to be focusing on lack of accurate map data for crash.

Cloudio9

Looks like CHC are about to get a booting here.

Cloudio9

Katie Hannon is very well researched. Top journalist.