R116 Accident AAIU report discussions

There was a project in CHC to do exactly that, the report highlighted it and stated on pg66

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In July 2013, there was a proposal to record all routes that had been test flown; to update the index page on the Route Guide to state whether or not a route had been test flown; and to add a notice to the index page stating that ‘No crews are allowed to use routes at night or in poor visibility unless indicated here that they have test flown’. Emails also suggested that a list of all routes in each area [Base] was to be developed and displayed on the Ops Room wall, along the lines of; ‘Route’, ‘Date Test Flown’, ‘By Whom’ and any ‘Comments’. The Operator’s Safety and Quality Integrated Database (SQID) system (Section 1.17.4.2) had the potential to provide a means to record and track the actions associated with the Route proving task. The Investigation notes that the associated email chain involved several pilots, including a Post-Holder; however, SQID was neither used nor suggested for this purpose. 

Whilst the emails reviewed seem to indicate committed efforts by a number of persons at all bases, there was no one individual/Post-Holder responsible for driving the project and none of those involved had been trained for this type of work. Four years after the Route Guide transposition, the document still contained the warnings ‘It is a work in progress and should be used with the necessary caution until all routes/waypoints are proven ... Again it is a work in progress so if you have any comments/suggestions, please revert’.

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I believe there was time.

The flying pilots were warned of an obstacle up ahead and told to go right. A new heading was entered into flight computer but they hit before this took effect.

If the flying pilot was made aware that this was a life or death situation, surely she had the option to manually take control and take the chopper high and wide on full power.

The entry of a revised heading into flight computer tells me that no emergency action was taken. No extra power put in etc.

Still working my way through the report.

I would say a pilot is used to trusting their instruments and automation above anything else. It's not up to the rear crew to fly or navigate the aircraft and perhaps easy to see why their input might be seen as lower priority than information (even if wrong) on the cockpit displays.

42 safety recommendations points to there being many factors in many organisations that need to be addressed. Don't think other AAIU reports have come near that number.

Avoiding action was advised and taken within seconds of the obstacle being identified.

The pilot + co-pilot were flying on instruments. Where do you fly towards on full power when you can't see what you are trying to avoid? You could just as easily be powering blind into the obstacle faster and harder.

A helicopter weighing between 8 and 12 tonnes, and travelling at 166 kmh doesn't turn on the spot either. There's considerable inertia to overcome and a flight envelope to consider.

Blackrock was only visible to the rear crew member on the forward looking infra red thermal imaging camera. This would have had very much restricted field of view, contrast, visual acuity and depth perception compared to normal daylight human vision. Given the limitations of FLIR the immediate criticality of the situation may not have been aparent until it was too late.

Add the perception - response time, time to communicate the hazard and corrective action to the pilot + co-pilot, time for the pilot + co-pilot to apply that corrective action (whether through instrument settings or switching to manual flight control) and the time for the helicopter to respond to that corrective action and you run out of time very quickly. The collision makes it self evident that in the circumstances, there wasn't time.

No matter what way you look at the crew and their degree of tiredness or otherwise, this was fundamentally a failure of navigation techniques. To be flying at low level in the dark in reduced visibility in an area with features that were unmapped or poorly mapped on their flight navigation systems was inherently risky. And that's all there is really to it.

Who was responsible? The crew themselves for not realising the limitations of the system they were operating, the protocols and flight paths they were following or the agencies/ companies responsible for the data on their system? Seems to be a bit of all three. But you'd have to think that if this substantial feature had been properly represented on the EGPWS database, that the accident would have been avoided. They'd have had plenty of warning.

There has been a lot of discussion about what obstacles were in, (or not in), what database. This is being homed in on by the media as being the main cause of the accident. I think from reading the report that this conclusion is incorrect.

Section 2.2.8 of the report states:-

“At 00.43 hrs, the Commander commented ‘okay again just got the surface visual there anyway which is good [...]’. This indicates that the Commander had visual contact with the surface at that time. However, the assessment of horizontal visibility requires, by definition, that a known feature at a known distance can be seen. But, when operating at 200 ft, approximately 9 NM from shore, over the Atlantic Ocean, at night, in poor weather, there was no known, or discernible, feature to be seen. Furthermore, none of the potential sources of ambient light mentioned in OMF, ‘moon light, light from coastal towns, light from adjacent vessels / installations or indeed flares deployed by top cover aircraft’ would have been available to the Crew. Accordingly, horizontal visibility could not be determined, and consequently it was not possible for the Flight Crew to know that they had ‘visibility sufficient to allow safe aircraft manoeuvre at selected airspeed / groundspeed’, as required in OMF. In effect, the Crew was in a situation where they could not see whether there was an obstacle in their path. “

I think that there is no doubt that, in the opinion of the investigators, the aircraft was being flown in an unsafe manner at the time, given the visibility conditions prevailing. They stated in their conclusions that there errors and lapses of judgement on the part of the flight crew but you have to trawl through the report to find what exactly they were referring to.

In aviation safety there should no room for fudging the truth, even when it hurts. There is a long and honourable record of air accident investigators being absolutely honest about the causes of accidents. It is what makes aviation so safe these days.

R118 refuelled in Blacksod shortly before. Same operator, Same aircraft, Same weather.Their approach was sucessfull.

Report never mentions reviewing what they did differently or if they too came close to cfit.

Does any one here know what were the legal objections to the initial draft report, by whome?

What was omitted from the final published report?

The report actually does mention that R118 made a different approach to Blacksod, from a different direction than what R116 attempted. That's presumably because they arrived from a different direction, from Sligo. It's in a reference note on the bottom of page 14:

The fact that they descended so early is puzzling to me. As a fixed wing pilot, a cloud break procedure is normally carried out so that you have a continuous descent which reaches it's lowest point a short distance from the landing runway. The report mentions that they used an autopilot function to carry out the descent to 200ft but that this was completed way out at the start of the approach. Now, maybe that's appropriate to do at sea when you're searching for a vessel, but I can't see the logic on an approach to a landing site.

From what I have heard in the past I would not read too much into the training that they carry out.

Flying around the Wicklow mountains on a sunny day doesn't prepare anyone for West of Ireland on a wet miserable night.

There are still a lot of unanswered questions and absolving the pilots of any contribution in the case of CFIT doesn't do anyone any favours.

The best pilots, the best crews in the world make mistakes and it is when that lines up with other failings that serious accidents occur.

From what I have seen, one consensus amongst some pilots (SAR experienced ones included) is that NVG would have prevented this and that then raises huge questions as to why money was put aside years ago for SAR (Coast Guard) to purchase NVG equipment and the only base to have implemented any of it seems to be Sligo.

Now I am not sure if this has changed recently or not, but jaysus in this day and age why does it take years to do any fooking thing in this country.

This was exactly my point in my first para! Maybe you articulated it better. Also that airline pilots do considerably more than 4 hours training every 6 months. But training is appropriate to the type and scope of operations - it's not comparable.

Ah, come on Steve, read what I wrote! The report, page 146 or anywhere else, doesn't mention training in the airline environment, which is where I pointed out that you were wrong.

Also, I said 'might only get a call every couple of weeks', which is perfectly correct, and the reason why there is a need for more training flights as the number of actual missions would not be sufficient to keep everyones skills current. I didn't say that they only fly every couple of weeks.