R116 Accident AAIU report discussions

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.

A rather simplistic view. Was that the case with both Boeing 747 MCAS accidents?

“Boeing 747 MCAS accidents?” What B747 MCAS accidents ?

Actually as far as I know the first Boeing 737 Max accident may have been prevented if the flight crew of the preceding flight had informed the next crew (the doomed flight) about what happened to them and how they resolved it.

There was a failure of crew documenting events.

And yes it was pure luck they were able to resolve it.

I find it illuminating that when one posts certain hard questions as to the events of the night of 14th March 2017 in Blacksod there are very few respondents.

So where does this go now? Are we looking at civil or criminal cases in the near future. Does someome carry out future inspections/ Audits to see if the reports recomendations are made or does the report sit on a shelf somewhere gathering dust

Was it not the case that the cockpit lighting made it hard to read printed documentation at night, which was why they relied more on the information on the flight displays instead? Or maybe they would rely on the flight displays more if they were understood to be displaying the same information as are on the printed charts?

This all feeds back to the potential for fatigue and taking mental shortcuts when taking in data. Easier to read a line of text than to assimilate and process a chart or table of data, especially when poor lighting conditions makes charts hard to read.

Crew read the notes and probably see it listed as an obstacle on the page (as they made reference to another obstacle listed with it), but not specifically noted in the info on the approach.

Crew is used to a slightly different way of laying out those approach notes where relevant obstacles are noted in the text and the route is planned to avoid obstacles and be fly able at minimums. Crew fail to note the rock as a dangerous obstacle and seem to have made the assumption that, like the east coast plans they were familiar with, the entire route was safe to fly at 200'.

Very much the swiss-cheese model in operation.

Procedures weren't followed properly when deciding to launch a SAR mission in the first place. Malin had decided to launch the OP before even getting the full detail. Even the FV crew weren't looking for it.

There was a complete lack of cohesion or oversight on the approaches that weren't approaches. With differences from base to base and inaccurate information that had been left unverified or unchanged for years. A company decision was obviously take to treat them as "guides" and not approaches to avoid having the responsibility of keeping them current and correct. The complete lack of Vnav info on a route "guide" to be used in poor visibility conditions is both laughable and now tragic.

If the weather in Blacksod had been better when the crew briefed at the base it could well have been a different outcome. It's far easier to take that in in the bright light (and fresher mindset) of the briefing room, rather than in the dark on a late night flight.

The missing data from the EGPWS database was obviously a crucial factor. The fact that it was not dealt with as a matter of urgency because they never had it on the S61 is damning. It takes no consideration for the different ways modern crews use the information at their disposal.

Changing any one of those factors could have changed the outcome, but ultimately the management of the whole CHC operation was exposed as very slapdash and poor, as was the government and coastguard oversight of their contractor.

I'd have to reread to refresh myself, but didn't they find from the review flight that it was not showing up at speeds of 70kts and below due to the reduced envelope, but as R116 was travelling at 77kts it would have shown had it been in the database?

It's also not the first crash on this island (Ireland) from using an unofficial,unapproved procedure. It wouldn't have been impossible to put that let-down approach procedure into a flight simulator and test it there, before using it for real.

The "rock" was already in the OS database/IAA VFR charts and had been for a very long time,plus the procedure was designed to overfly the rock as part of a descending left hand turn,so it had to have been known about. The location of the rock was not a "point in space" like an RNAV entry,but a crucial pivot point about which the second last turn was made, before the straight section/run-in to Blacksod. Whoever designed the procedure was clearly familiar with non-precision approaches.

they are also often tasked with casevac from mountains, Carrauntoohil being a frequent "port of call". It's a lot of helicopter just to lift one person off.

Snickersman on other closed thread "An Inquest jury has ruled that the deaths were "accidental". Not sure about all the legal implications here because the foreman of the jury also said that 'deficiencies in mapping “contributed considerably to this accident”.'

Too bloody right they did.

I am not a pilot, but I knew a man (long dead now) who flew Fairey Swordfish biplanes off aircraft carriers in the second world war. He once remarked, after a famous case when a private plane crashed at night while flying over water, that it was very common for inexperienced pilots in such circumstances to become disoriented. The golden rule, he said, was "you have to trust your instruments"

If that was true flying open-cockpit biplanes in the 1940s, you would imagine it would be even more valid in the 21st century. One would hope that navigation aids might have actually improved with the advances in digital and GPS technology. By that token, if Captain Fitzpatrick, a highly experienced pilot, was concentrating on her instrument panel instead of looking out the window into the gloom, she was only following best practice. If the information being presented to her was faulty, ie if it neglected to mention that she was heading straight for a rocky promontory, then could the crash really be called an accident? Albeit not her fault?

i think this has some room to run. But as I said, I'm not an aviation professional. Or amateur."

I wondered about this too, there was possibly a bit of the 'state washing it's hands' in this verdict. Will we now see a civil case now against the manufacturers of the on board navigation systems and suppliers of data to same?

May they all RIP regardless.

Is that really the case?

"We provide this system at (presumably) huge cost to ultimately the Irish tax payer but we take no responsibility for the omission of natural obstacles from the data on which it is based?"

Seriously???

I could maybe have some sympathy if it was a high-rise hotel that had been thrown up in the year or so since the system was provided to the helicopter operator but a piece of geographical real estate that has been there for centuries? "Well, shucks. Our cartographer must have missed it"

If that is the case then as a taxpayer I'm outraged.

Snickers Man wrote> ...is that really the case?

I believe so.

I remember at the time being sent a link to the actual Honeywell manuals for EGPWS where it very clearly called out that this system must not be used as a primary navigation system. It is intended to be an aid, but not your single source of truth to the 'where am I and what obstacles must I avoid' question. I cannot find the same link on a quick search, but if you do a google for EGPWS documentation I think you will find the wording which I refer to within the Honeywell user manuals.

Some good points from Steve in the post above, particularly on the 500ft topic.

'Meitheal' on RTE1 currently, documentary about the search after the accident and impact on the local community.