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

skallywag

Deleted User wrote: »

They were relying fully on their navigation system, which needed to be fully accurate if it was to be safe.

This is a misconception.

EGPWS is a navigation aid and not a navigation system. Anyone who has flown a whirlybird will tell you the same. You never use it as your single source of truth for navigation.

Irish Steve

It's probably worth mentioning at this point that R116 was very much not a standard commercial flight, where the concepts of VFR and IFR operations are rigidly defined, as a SAR operation, the crew of R116 would have spent a very high percentage of their time operating at very low level, in often marginal VFR conditions, as their objective would have been to see and identify items of interest on the surface of the (usually) water below them.
While they would have been proficient at operating under IFR conditions, especially when transiting to and from search areas, the very nature of their operation would have been to visually acquire their intended target, as it would be very rare indeed for them to be able to find their objective in any other way, so it would have been very much standard operating procedure to operate below cloud VFR when over water.

Irish Steve

Irish Steve wrote: »

It's probably worth mentioning at this point that R116 was very much not a standard commercial flight, where the concepts of VFR and IFR operations are rigidly defined, as a SAR operation, the crew of R116 would have spent a very high percentage of their time operating at very low level, in often marginal VFR conditions, as their objective would have been to see and identify items of interest on the surface of the (usually) water below them.
While they would have been proficient at operating under IFR conditions, especially when transiting to and from search areas, the very nature of their operation would have been to visually acquire their intended target, as it would be very rare indeed for them to be able to find their objective in any other way, so it would have been very much standard operating procedure to operate below cloud VFR when over water.

Maybe some of the recommendations concern in what sectors of these flights should the general rules be more flexible and when should they be strictly adhered too, to mitigate the risks to crew.

Candamir

Irish Steve wrote: »

It's probably worth mentioning at this point that R116 was very much not a standard commercial flight, where the concepts of VFR and IFR operations are rigidly defined, as a SAR operation, the crew of R116 would have spent a very high percentage of their time operating at very low level, in often marginal VFR conditions, as their objective would have been to see and identify items of interest on the surface of the (usually) water below them.
While they would have been proficient at operating under IFR conditions, especially when transiting to and from search areas, the very nature of their operation would have been to visually acquire their intended target, as it would be very rare indeed for them to be able to find their objective in any other way, so it would have been very much standard operating procedure to operate below cloud VFR when over water.

I was under the impression that the concept of VFR and IFR was rigidly defined in law, not commerce.

skallywag

skallywag wrote: »

This is a misconception.

EGPWS is a navigation aid and not a navigation system. Anyone who has flown a whirlybird will tell you the same. You never use it as your single source of truth for navigation.

Yes, I would have thought that indeed. My only whirlybirding were two very enjoyable lessons on a Robinson 22.

I think some of the frustration with the shutting down of a certain trajectory of analysis earlier in this thread comes from the fact that this is a fairly specialised forum generally inhabited by knowledgeable posters, not some salaciously titled thread on After Hours.

A poster here recently said that this is Ireland and no one is allowed to blame the crew, I'd say it's more a case of no one wants to speak ill of the deceased. However it's worth bearing in mind that engineers, software programmers and project managers should not have aspersions cast on their professionalism without evidence either.

In the end, it will most likely be distilled down to a general fudge about how the government didn't give enough funding and it will be left at that.

When all else fails, we can always blame the government .

Steve

Candamir wrote: »

I was under the impression that the concept of VFR and IFR was rigidly defined in law, not commerce.

I suspect that military and / or SAR operations are not bound by this.

faoiarvok

Candamir wrote: »

I was under the impression that the concept of VFR and IFR was rigidly defined in law, not commerce.

“Concept” may not have been a great choice of word for Irish Steve to use, but SAR are exempt from the usual VMC minima and lots of the other laws that normally go along with their chosen flight rules. The nature and stakes of the flying they do obviously demand this flexibility.

smurfjed

However it's worth bearing in mind that engineers, software programmers and project managers should not have aspersions cast on their professionalism without evidence either.

I would guess that the Helicopter Flight Manual would have some statements similar this to provide legal protection for the equipment manufacturer.

Its also worth noting that the widow of Kobe Bryant has filed a “wrongful death” lawsuit against the operator of his helicopter. I fully expect the same to happen in this case.

Means Of Escape

[Deleted User] wrote: »

Maybe some of the recommendations concern in what sectors of these flights should the general rules be more flexible and when should they be strictly adhered too, to mitigate the risks to crew.

Minimum approach height of 1000 feet over water with zero rule flexibility may be a recommendation .

smurfjed

Means Of Escape wrote: »

Minimum approach height of 1000 feet over water with zero rule flexibility may be a recommendation .

That defeats the purpose of their mission.

L1011

Means Of Escape wrote: »

Minimum approach height of 1000 feet over water with zero rule flexibility may be a recommendation .

You're still thread banned - and always will be. Week off.

Candamir

faoiarvok wrote: »

“Concept” may not have been a great choice of word for Irish Steve to use, but SAR are exempt from the usual VMC minima and lots of the other laws that normally go along with their chosen flight rules. The nature and stakes of the flying they do obviously demand this flexibility.

Yes of course, but this accident occurred during a ‘routine’ refuelling stop. Might be worth considering if operating outside the rules is appropriate in the non rescue part of the mission. Another one for the AAIU.

faoiarvok

Candamir wrote: »

Yes of course, but this accident occurred during a ‘routine’ refuelling stop. Might be worth considering if operating outside the rules is appropriate in the non rescue part of the mission. Another one for the AAIU.

If it’s a rescue mission, I don’t think there is a "non rescue" part of the mission. If you can’t get fuel, you may not be able to complete the mission. Should be left up to commander and crew IMO, but I don’t make these decisions.

smurfjed

smurfjed wrote: »

also worth noting that the widow of Kobe Bryant has filed a “wrongful death” lawsuit against the operator of his helicopter. I fully expect the same to happen in this case.

The 'operator' in this case being who exactly though?

smurfjed

Island Express Helicopters.

plodder

skallywag wrote:

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

Are you saying they are one of the parties that requested this review?

An RTE report at the time seemed to suggest that it was only CHC who were challenging it. Though that wasn't confirmed for definite either.

Nijmegen

faoiarvok wrote: »

If it’s a rescue mission, I don’t think there is a "non rescue" part of the mission. If you can’t get fuel, you may not be able to complete the mission. Should be left up to commander and crew IMO, but I don’t make these decisions.

I would say (if, if, if this is a part of the report that will be a major point of discussion) that different phases of a mission can be classified. Heading to refuel is a different phase to performing a low altitude search, for example, and perhaps you could justify hard rules about gaining altitude to set off on that phase of the mission. As I mentioned above, I wonder what the advantages of a long, low approach are. Fuel consumption (in gaining and losing altitude) and time are obviously material factors. But were they urgent material factors? Or perhaps was it more convenient to keep low and fly in on the (not unfair even if tragically incorrect) assumption there's nothing going to be in the way as far as you are aware.

faoiarvok

Nijmegen wrote: »

I would say (if, if, if this is a part of the report that will be a major point of discussion) that different phases of a mission can be classified. Heading to refuel is a different phase to performing a low altitude search, for example, and perhaps you could justify hard rules about gaining altitude to set off on that phase of the mission.

The only phase I’d differentiate in terms of stakes is RTB after dropping off a casualty or standing down from a mission. Refuelling to head out to a long range search is every bit as important as actually flying the search. There’s no point heading out if you have to turn around as soon as you get there.

Nijmegen wrote: »

As I mentioned above, I wonder what the advantages of a long, low approach are. Fuel consumption (in gaining and losing altitude) and time are obviously material factors. But were they urgent material factors? Or perhaps was it more convenient to keep low and fly in on the (not unfair even if tragically incorrect) assumption there's nothing going to be in the way as far as you are aware.

The advantage of a long low route into Blacksod is to be below the cloud and visual with any terrain on the way in. I’d guess that’s why they were conducting the cloud break well out from the mainland, in the mistaken assumption that that would be the safest place to descend below cloud, yes.

Irish Steve

Another very significant factor that will have influenced their course was that the approach procedure for Blacksod started directly over Blackrock. That certainly will have been a part of the things that contributed to the sceenario.

plodder

Nijmegen wrote: »

I would say (if, if, if this is a part of the report that will be a major point of discussion) that different phases of a mission can be classified. Heading to refuel is a different phase to performing a low altitude search, for example, and perhaps you could justify hard rules about gaining altitude to set off on that phase of the mission. As I mentioned above, I wonder what the advantages of a long, low approach are. Fuel consumption (in gaining and losing altitude) and time are obviously material factors. But were they urgent material factors? Or perhaps was it more convenient to keep low and fly in on the (not unfair even if tragically incorrect) assumption there's nothing going to be in the way as far as you are aware.

One thing that stood out for me in the interim report was how plans change in this environment. You could be heading in one direction and en-route plans change to go somewhere else. There has to be a considerable degree of flexibility with hard rules in that environment. But, I'd agree that shouldn't stop you from breaking an overall mission down into stages and analysing the various aspects of them.

Gadgetman496

Review board to examine R116 crash report

One of the parties subject to investigation sought a re-examination, after informing the Minister of their belief that some of the draft findings and conclusions reflected adversely on their reputation. This has delayed the final publication of the report.

https://www.rte.ie/news/connacht/2020/0311/1121693-review-r116-report/

Steve

Gadgetman496 wrote: »

Review board to examine R116 crash report



https://www.rte.ie/news/connacht/2020/0311/1121693-review-r116-report/

I've read most of the AAIU reports, it's an interest of mine.

I've never considered them in any way biased or lacking in transparency.

This stinks, and it it doesn't surprise me that Ross, who was resoundingly voted out yet still holds power over this is involved. :mad:

AlekSmart

One of the parties subject to investigation sought a re-examination, after informing the Minister of their belief that some of the draft findings and conclusions reflected adversely on their reputation. This has delayed the final publication of the report.

Odd indeed.

So the draft report prepared after due process by the AAIB is now hostage to a percieved 'reputation' ?

Surely the relevant Minister should have simply assured himself of the AAIB Investigation's throroughness and professionalism,and proceeded with the publication ?

How can alleged post report 'reputational' damage make any difference to the conclusions of a properly executed Report ?

Means Of Escape

AlekSmart wrote: »

Odd indeed.

So the draft report prepared after due process by the AAIB is now hostage to a percieved 'reputation' ?

Surely the relevant Minister should have simply assured himself of the AAIB Investigation's throroughness and professionalism,and proceeded with the publication ?

How can alleged post report 'reputational' damage make any difference to the conclusions of a properly executed Report ?

It’s hinging on how the CFIT occurred and the events leading up to it regarding actions and decisions made .
A number of legal actions will probably take place be they based on operation policies of the company,the loss of the leased craft supplied by Waypoint Leasing and it’s crew or inefficiencies in the equipment used ,all determined by this final report

selectamatic

Steve wrote: »

I've read most of the AAIU reports, it's an interest of mine.

I've never considered them in any way biased or lacking in transparency.

This stinks, and it it doesn't surprise me that Ross, who was resoundingly voted out yet still holds power over this is involved. :mad:

"The Minister for Transport Shane Ross has announced that certain findings made by the Air Accident Investigation Unit (AAIU) will be re-examined, at the request of one of the parties subject to the investigation."

To me that reads like Shane Ross is simply announcing what is currently happening, as he is obliged to do as caretaker minister for transport.

I am no fan of his and I was in fact delighted when he wasn't re-elected but to imply he's "involved" in this delay is pretty disingenuous when none of us know which party subject to the investigation is aggrieved by the findings.

Means Of Escape

selectamatic wrote: »

"The Minister for Transport Shane Ross has announced that certain findings made by the Air Accident Investigation Unit (AAIU) will be re-examined, at the request of one of the parties subject to the investigation."

To me that reads like Shane Ross is simply announcing what is currently happening, as he is obliged to do as caretaker minister for transport.

I am no fan of his and I was in fact delighted when he wasn't re-elected but to imply he's "involved" in this delay is pretty disingenuous when none of us know which party subject to the investigation is aggrieved by the findings.

Agreed. All parties involved in this sorry saga are entitled to rebut findings of the report. This does not mean suppression of the reported facts from the document that all parties have already seen and made note of with their respective legal teams
There is massive fallout pending from this incident and therefore depite the investigators not blaming any party there will be ramifications for the parties mentioned based on their findings .

L1011

Means Of Escape wrote: »

Agreed. All parties involved in this sorry saga are entitled to rebut findings of the report. This does not mean suppression of the reported facts from the document that all parties have already seen and made note of with their respective legal teams
There is massive fallout pending from this incident and therefore depite the investigators not blaming any party there will be ramifications for the parties mentioned based on their findings .

When are you going to finally understand what a thread ban is? You cannot post in this thread, ever again.

Two weeks off this time.

MoeJay

This review provision would seem to fly directly in the face of ICAO Annex 13....

Steve

selectamatic wrote: »

"The Minister for Transport Shane Ross has announced that certain findings made by the Air Accident Investigation Unit (AAIU) will be re-examined, at the request of one of the parties subject to the investigation."

To me that reads like Shane Ross is simply announcing what is currently happening, as he is obliged to do as caretaker minister for transport.

Did you read the article?

One of the parties subject to investigation sought a re-examination, after informing the Minister of their belief that some of the draft findings and conclusions reflected adversely on their reputation. This has delayed the final publication of the report.

After reviewing a written request for the AAIU report to be re-examined, Minister Ross has now established a review board to carry out that task.

Nothing above suggests he is simply announcing something not under his control.

selectamatic

Steve wrote: »

Did you read the article?



Nothing above suggests he is simply announcing something not under his control.

Ya I've read the article I wouldn't be in the habit of commenting on things I don't have an interest in.

A party subject of the investigation expressed concerns and these concerns are being heard and a review is taking place.

Is Shane Ross going to carry out the review personally or something? Because if he isn't, he isn't really "involved" as your post open endedly suggested. Allowing a review board the opportunity to examine the report is most likely a base covering exercise as it's highly likely legal cases surrounding this incident are imminent once the report is published.

More to the point the AAIU aren't going to change anything significant in their report regardless of who reviews it anyways so to me this feels like a can kicking exercise or an exercise in denial by whichever party raised the concerns. Either way it's most likely no harm to hear and assess the validity of these concerns before the report is published.

Having Shane Ross as the focus of your anger/frustration seems misplaced to me.

Steve

I have the greatest respect for the AAIU and their ability to conduct impartial and factual investigations and to make their findings public.

It is, however, abhorrent to me that a 'politician' (I care not who it is) can interfere with their investigation and / or influence what findings they publish because they were lobbied by a commercial interest.


What if the first 737 MAX had failed on our soil and the AAIU were gagged by a politician because of 'commercial interests'?

faoiarvok

selectamatic wrote: »

Ya I've read the article I wouldn't be in the habit of commenting on things I don't have an interest in.

A party subject of the investigation expressed concerns and these concerns are being heard and a review is taking place.

Is Shane Ross going to carry out the review personally or something? Because if he isn't, he isn't really "involved" as your post open endedly suggested. Allowing a review board the opportunity to examine the report is most likely a base covering exercise as it's highly likely legal cases surrounding this incident are imminent once the report is published.

More to the point the AAIU aren't going to change anything significant in their report regardless of who reviews it anyways so to me this feels like a can kicking exercise or an exercise in denial by whichever party raised the concerns. Either way it's most likely no harm to hear and assess the validity of these concerns before the report is published.

Having Shane Ross as the focus of your anger/frustration seems misplaced to me.

The Minister is literally the only person empowered to establish a review board, so it was his decision.

sasta le

So the families are holding this back?

skallywag

Without wanting to get into a discussion at this stage (there will be plenty of time for that once the report finally sees the light of day), it would appear that a family member of one of the crew is not happy with certain content in the report.

plodder

Gadgetman496 wrote: »

Review board to examine R116 crash report

One of the parties subject to investigation sought a re-examination, after informing the Minister of their belief that some of the draft findings and conclusions reflected adversely on their reputation. This has delayed the final publication of the report.

https://www.rte.ie/news/connacht/2020/0311/1121693-review-r116-report/

Does the wording in that report not suggest that it's not the families, as the families are not parties "subject to investigation"?

Actually, the press release from the DOT is worded more carefully than that RTE report, and it could be a relative of one of the crew that requested it.

https://www.gov.ie/en/news/803d53-establishment-of-a-review-board-to-re-examine-certain-findings-of-th/

Nforce

from AAIU 3rd Interim Statement as released today http://www.aaiu.ie/

As per International Convention, EU Regulation and national legislation relating to accident
investigation, it is required that, if the final report into an air accident investigation cannot
be made public within 12 months, the Air Accident Investigation Unit shall release an
Interim Statement at least at each anniversary of the accident or serious incident, detailing
the progress of the investigation and any safety issues raised.
On 13 September 2019, as required by SI 460 of 2009, a Draft Final Report was issued in
confidence to interested parties. Comments on that Draft Final Report were to be sent to
the Investigation on or before 11 November 2019. During the Draft Final Report comments
process, one party invoked Regulation 15 of SI 460 of 2009 and sent a ‘notice of reexamination’ regarding certain findings and a conclusion in the Draft Final Report to the
Minister for Transport, Tourism and Sport. On 23 December 2019, the Minister informed
the Chief Inspector of Air Accidents that, in accordance with Regulation 16 of SI 460 of
2009, he was appointing a Review Board to carry out the re-examination requested. On 9
March 2020, the AAIU was advised by the Department of Transport, Tourism and Sport,
that a Review Board has been established under SI 460 of 2009 for the re-examination of
specific findings of the Draft Final Report into the accident to R116. The Investigation
advised all interested parties, on 9 March 2020, of the Departmental contact details for
information relating to the re-examination.
The Investigation has complied with Regulation 12 (1) (b) of SI 460 regarding consideration
of all comments received in response to the Draft Final Report, and awaits further details
of the re-examination.
-

selectamatic

Steve wrote: »

It is, however, abhorrent to me that a 'politician' (I care not who it is) can interfere with their investigation and / or influence what findings they publish because they were lobbied by a commercial interest.

Is it published anywhere that it's a commercial interest who has invoked Regulation 15 of SI 460 of 2009?

As I've said before your anger is misplaced.

You should be abhorred at the interested party not a politician who's merely following protocol.

faoiarvok

selectamatic wrote: »

Is it published anywhere that it's a commercial interest who has invoked Regulation 15 of SI 460 of 2009?

As I've said before your anger is misplaced.

You should be abhorred at the interested party not a politician who's merely following protocol.

What protocol would that be?

The statutory instrument says the Minister “may” establish a review board. The decision is entirely his.

After a (admittedly very quick) search the only other case I can find of an interested party requesting a re-examination was in the 2009 crash of an Air Corps PC9. In that case, the Minister (Varadkar at the time) chose not to establish a review board.

It seems to me that there’s a process for someone connected to the report to ask for a review. So, that’s happened. Let the process work through. The AAIU report will be published in due course. There are safeguards and mechanisms to make sure it doesn’t “disappear”.

The AAIU and its staff, especially the Chief Inspector, have a (well deserved) world renowned competence, plus a track record of first class investigations. To suggest that the report could somehow be buried would, I am sure, be such an anathema to them that it would not happen, whatever the supposed “pressure”. With the emphasis on “supposed”.

This accident was undoubtedly a tragedy. The most important outcome is that lessons are learnt and that a similar tragedy does not happen again - here in Ireland or elsewhere.

selectamatic

faoiarvok wrote: »

What protocol would that be?

The statutory instrument says the Minister “may” establish a review board. The decision is entirely his.

After a (admittedly very quick) search the only other case I can find of an interested party requesting a re-examination was in the 2009 crash of an Air Corps PC9. In that case, the Minister (Varadkar at the time) chose not to establish a review board.

True it is "may" but in such a high profile incident isn't it best to err on the side of caution.

It's almost guaranteed that there will be legal proceedings after the report is published. So no harm in making sure all findings are copper fastened and will stand up to any and all legal proceedings.

As I've already stated the AAIU aren't going to change anything significant and blaming the minister is a futile exercise.

MoeJay

If a report can be reviewed under a decision by the minister of the day (who is a political appointee) under some woolly legal term, the investigator in charge isn’t really in charge, are they...

Investigators should be free from any such legal constraint, just as Annex 13 says (and apparently as Ireland signed up to, in full)

martyc5674

Slightly off topic. But what is the purpose of top cover in a rescue situation such as this?

Esel

Better communications (longer range), afaik.

Coil Kilcrea

martyc5674 wrote: »

Slightly off topic. But what is the purpose of top cover in a rescue situation such as this?

To provide long range oversight, support and communication to SAR assets, mainly helicopters, on rescue missions far out to sea. Normally, a long range fixed wing aircraft e.g Hercules, P8, Casa.

In this tragedy, the Air Corp were not able to provide such cover due to maintenance.

Other posters will explain much better but that’s the gist of it.

Irish Steve

martyc5674 wrote: »

Slightly off topic. But what is the purpose of top cover in a rescue situation such as this?

VHF radios have a relatively limited range, especially when operating at very low level, which will be the case when performing a rescue. Given the nature of the tasks they perform, it is deemed appropriate to have another aircraft or helicopter within radio range of the rescue aircraft, which will be operating at a higher level and also able to communicate with shore based services.

The top cover aircraft, because of the additional height, will have a much better range for the radio, and can act as a relay to shore based services in the event of a problem or the rescue aircraft needing additional information from the coastguard services or other support agencies.

Normally, this sort of operation is better performed by a fixed wing aircraft, as the operating cost is usually lower, and are most likely to have better endurance and performance than a helicopter, but on this occasion, it would seem that there was no fix wing aircraft available to provide the service.

Steve

martyc5674 wrote: »

Slightly off topic. But what is the purpose of top cover in a rescue situation such as this?

Esel wrote: »

Better communications (longer range), afaik.

More like 'any communications'. Frequencies used are line of sight dependent so at low altitude there is a blackout unless they can be relayed by the higher 'top cover' craft.

BarryD2

I’d be thinking that the unhappy party may be a commercial entity and perhaps a supplier of terrain data necessary for what appears to have been a primary navigation system??

Negative_G

Coil Kilcrea wrote: »

In this tragedy, the Air Corp were not able to provide such cover due to maintenance.

This is incorrect.

Prior to this accident, the Air Corps had stood down its 24/7 fixed wing standby aircraft due to lack of technical personnel, lack of ATC and lack of pilot and rear crew. The situation remains the same today.

On the night of the accident a request was made to the Air Corps for Top Cover which could not be met due to unavailability as no standby crew or aircraft were in place.

This has been reported multiple times in the media since the accident.

It keeps being forgotten but the SLA that CHC (Not the Irish Coast Guard) signed up to was that fixed wing Top Cover would be available on an "as available" basis. Someone, somewhere along the line, while negotiating the €500million euro contract, decided that having another helicopter providing Top Cover would be sufficient for long range taskings. I can only speculate that acquiring a dedicated CHC fixed wing asset would have either increased the proposed tender cost or ate into the profit margins and that some form of risk was assessed which fed into the decision.

Negative_G

Irish Steve wrote: »

VHF radios have a relatively limited range, especially when operating at very low level, which will be the case when performing a rescue. Given the nature of the tasks they perform, it is deemed appropriate to have another aircraft or helicopter within radio range of the rescue aircraft, which will be operating at a higher level and also able to communicate with shore based services.

The top cover aircraft, because of the additional height, will have a much better range for the radio, and can act as a relay to shore based services in the event of a problem or the rescue aircraft needing additional information from the coastguard services or other support agencies.

Normally, this sort of operation is better performed by a fixed wing aircraft, as the operating cost is usually lower, and are most likely to have better endurance and performance than a helicopter, but on this occasion, it would seem that there was no fix wing aircraft available to provide the service.

You're completely forgetting that the S92s have advanced avionics and satellite suites in addition to HF radios which can be used for communication.

A significant advantage of having a MPA aircraft on site is that it can get to the vessel quicker and can provide real time 'steers' to the helicopter maximising its time on station to do what it needs to do.

What you also fail to mention is that in the event of a ditching or mechanic failure, a FW asset can drop flares and life rafts to immediately assist in the rescue of crew.

Communications is a side show for the most part thanks to HF & SATCOM.