R116 Accident AAIU report discussions

Two very noticable things in that article in the way they highlight legal teams involved.

As others have said I always thought Air Accident Reports were just statement of facts.

They never directly apportion fault or blame or determine liability, but if that facts point out dificiencies by any of the parties then it who is to blame is kinda obvious.

So was this review a review of the facts or the way the facts were portrayed in the report ?

I'm in two minds about it. On one hand, it's hard to see how two teams of competing lawyers can actually improve a draft report like this. On the other hand, if only one party to the enquiry has legal representation, then you could imagine a report being made a lot worse, with blame being shifted on to those who aren't represented. So, it's not hard to feel sympathy for the families believing they need to be involved.

"There'll be a lot in it I'd imagine. Aeronautical databases and information, especially about obstacles like Blacksod. CHC's safety."

Suspect you may be close to it there. Wasn't the story at the time that they were flying 'blind' using a 3D navigation system that shows up the shape of the ground in front. And that the Blackrock they crashed into wasn't in the navigation database? Despite being a pretty high & large rocky island with a lighthouse plonked on it.

So who supplied the navigation system, what data was on it and who was responsible for supplying the data?? Some commercial entity or the state? Whose responsibility was it to upgrade it or report errors in the data?

And to what extent the pilots might have been partially to blame for not being aware of the limitations of the system.

Those seemed to be the questions knocking about at the time in various media reports.

Do people not know who the family of one of the crew actually is?

what their previous role was?

forgiving fees?

Just to point out that the mod note from the previous thread holds, as do any threadbans.

The 10,000 posts thing is now old news, but this is the replacement thread. The ban on posts which mean "I Told You So" will be enforced without mercy - and on the current forum software, three infractions means a siteban for a month - so remember this.

Additionally, there is no longer a split between news and discussion threads as there was in the short term after the incident so that instruction can be ignored.

https://en.wikipedia.org/wiki/2017_Irish_Coast_Guard_Rescue_116_crash

The Air Accident Investigation Unit circulated a 333 page draft version of the final report into the crash in November 2019. The report was delayed, prompting a review - the first in the 25 year history of the AAIU

What are the 'normal charts published by the Ordnance Survey'? If you refer to sheet 22 of the OSi Discovery Series, Blackrock island is shown but not in a satisfactory way. As it's too far off the coast, it's portrayed in a small inset map and furthermore with no indication of it's quite substantial height. We are obliged not to speculate but the fact as per that map anyway, is that it is inadequately mapped by the state on this particular publication. Which brings you back to a key question - who supplied the 3D data for the navigation system and who was responsible for correcting errors and omissions in it?

The Ordnance Survey maps the island and those maps are the basis for all VFR charts,as the IAA are required to use the OS for sourcing it's maps. That's an ICAO requirement,even before you get into IFR and EASA. As for correcting errors,that tends to be reliant on the end user spotting errors and then sending that gen back to the OS or the IAA. If an operator buys in third-party nav data to upgrade their flight management systems,then they have a way to send back gen about errors to the creator of that data. Back in the day of manual Jeppesen charts and plates for IFR,you had a method of sending found errors back and it was usually corrected very quickly.

The thing is,blaming the State is a get out of jail card for all parties;the aircrew don't get blamed, the operator doesn't and the AAIU can't assign blame. It is tradition in this part of the world that the dead aircrew don't get blamed, as they are not are around to explain themselves. Look at the Mull of Kintyre Chinook case.

There was a mention of the crash in the Sunday Independent (https://www.independent.ie/irish-news/irish-air-traffic-control-in-crisis-staff-claim-as-they-call-for-transport-minister-eamon-ryan-to-investigate-40865030.html)a few weeks back, in short - the IAA being the regulatory body and the provider of services is an issue. My reading of the article is the IAA called for the review, but it isn't clear.

I'm hearing there may be something about this report on PrimeTime tonight.

No idea how true that is.

Edit to add it may be about the split of the IAA as referenced above.

The interim report has the CVR readout with timescale to the second, if anyone cares to download and read it. The original documents are in the public domain so you don't need to rely on journal.ie.

Yes it is a long time when you consider that the recommendations of the final report may contribute to preventing further accidents.

It wasn't a case of the crew having incorrect charts. I think the suggestion tonight was that the root of the problem was the OSI chart, published by the state, was inadequate. Since all other navigation databases are ultimately using the official charts as reference, then none of the systems which could have drawn the crews attention to the obstacle did.

Seems to have been a systemic failure of the SMS at CHC in that safety reports were not being resolved in a timely manner, if at all. The IAA was not conducting proper oversight to enforce CHCs own procedures.

They had reference documents for each approach and it was listed as an obstacle on the Blacksod approach briefing document. According to Prime Time it was mentioned 4 times in that particular document but there was a perception among the pilots that these reference documents were unreliable and often had misinformation on them. The impression I got was that they were not used much by the crews.

Here it is.

Executive Summary.

Full report.

I've only read the ES so far but the operator do not come out well from this. The reference to fatigue alone is worrying.

"R118 advised MRSC Malin that strobes had been sighted in the water. The Crew of R118 informed the Investigation that shortly thereafter they identified a life raft in the water and that a casualty was floating in the water nearby. The winchman was deployed to recover the casualty. ... The helicopter was re-positioned several times but each time the winchman got close to the casualty, wave action separated them. Achill lifeboat arrived on scene at this time. R118 directed it to the casualty’s location, recovered the winchman and withdrew a short distance so that the lifeboat could attempt to recover the casualty."

Jesus, that must have been heart-breaking for the crew of R118 😟

"To understand why Black Rock had not been included in the EGPWS databases at the time of the accident, the Investigation asked the EGPWS manufacturer about its processes for obtaining topographic data. The EGPWS manufacturer informed the Investigation that data was originally sourced from multiple Russian Military Topographic maps which were processed by its supplier and delivered to the EGPWS manufacturer in Digital Elevation Model (DEM) format covering Ireland."

Looks like the EGPWS terrain data came from Russian sources, OSi here only supplied digital versions of paper maps.

The data could just have easily come from NASA via their SRTM datasets which are in common use.

Maybe the OSI should be supplying digital terrain data for all offshore obstacles within Irish territory.

They could well have used SRTM data also, but the distance between grid points (90m) for the data available for Europe is insufficient to accurately represent small "pointy" objects like Black Rock. I have some experience of using SRTM data in digital mapping applications for hillwalking / mountaineering applications and while it's OK for smoother terrain, it falls short when things get steeper and sharper and as a result of this people in the mountaineering community, specifically the SMC (Scottish Mountaineering Council), produced a corrected version, filling in voids, correcting obvious errors (usually caused by steep cliffs producing unwanted reflections of the radar signal).

I don't know what the grid spacing of this Russian military data is, but the issue is that with small objects like this, you have no idea of where in the grid pattern the peak will fall, if it's slap bang in the middle of four data points the elevation calculated by interpolating between those four points in the DEM will possibly be much lower. As an experiment, I popped the coordinates of Black Rock into one of my mapping programs using an SRTM derived DEM as a waypoint (Black Rock, although it appears on the paper map of the area in an inset, doesn't appear on any of the OSi digital map tiles I have) and hovering over the waypoint I get an elevation of 13m, much lower than what it is in reality.

I would imagine that from the EGPWS manufacturer's POV, they don't want to be dealing with multiple national agencies supplying DTM data and then merging these datasets and ensuring no gaps etc. Much simpler to acquire one large world dataset from the big boys like NASA, Russians and likely China have same sort of data. Would cost have also been a factor?