Bad night at Black Rock

A helicopter was lost and four people died trying to save a fisherman’s thumb.

The crash investigation that followed was one of the most thorough and thorough in Irish and perhaps even European aviation. It has addressed virtually all aspects of helicopter search and rescue (SAR) technology, training, human and survival factors, navigation, operations and regulations and resulted in 42 recommendations. separate security.

It began on the evening of March 13, 2017. R118, a Sikorsky S-92A operated as a search and rescue aircraft for the Irish Coast Guard by CHC Ireland (CHCI), was dispatched to a point 140 nm offshore of Mayo of this country (west) coast at night, in bad weather. The mission: to evacuate a crew member of a 260-foot-long fishing boat who had lost the top of his thumb in an accident. The doctor on board the ship had already stopped the bleeding, administered pain reliever and seen medics ashore who told him there was not much to do and that in all likelihood the appendix would not. could not be saved. This was not a medical emergency and although there was little medical benefit to it, SAR dispatchers still launched the R118 for its high-risk mission. The wisdom of this decision would come under scrutiny in the years to come and in the pages of a comprehensive 348-page final version. accident report published last November by the Irish Aircraft Accident Investigation Unit (AAIU). The 2019 IAAU preliminary report sparked a wave of objections from the CHCI to the point that, for the first time in its history, an IAAU report was subject to reconsideration.

Summarizing its own work on the accident, the IAAU noted that its report “emphasizes the importance of robust processes in the following areas: route guide design, waypoint positioning and associated training; reporting and correcting anomalies in EGPWS [enhanced ground proximity warning system] and mapping systems; fatigue risk management systems; Toughbook [portable computer] use; low-level en-route operation; and the functionality of emergency equipment. It is particularly important that an operator involved in search and rescue has an effective safety management system, which has the potential to improve flight safety by reacting appropriately to reported safety issues and by monitoring safety issues. Proactively reducing risk using a rigorous risk assessment process. The final report identifies the importance of levels of expertise within organizations involved in the procurement and assignment of tasks to complex operations such as search and rescue, to ensure that the associated risks are understood , that effective oversight of contracted services can be maintained and that helicopters only take off when absolutely necessary. Finally, regulatory authorities have a role to play in ensuring the safety of flight operations, including search and rescue activities.

Regarding launching rescue missions only “when absolutely necessary”, the report explained that the national framework for maritime search and rescue provides the criteria for deciding whether to launch a rescue, including that “”[SAR] includes finding and providing assistance to people who are, or are suspected of being, in imminent danger of death. these procedures are considered inappropriate. However, in this case, “officers’ actions should conform as closely as possible to the instructions contained in the framework most relevant to the circumstances and they should keep all other parties involved informed.” “

On the night of the crash, the Irish Air Force indicated that it could not provide customary fixed-wing “top cover” for the mission due to staff availability, so CHCI dispatched a second S-92A. , R116, this one from its base across the country in Dublin, to provide this service. The crew of the R116 had already logged a full day. Aircraft Commander Dara Fitzpatrick had returned home after the day’s flying and retired for the evening when she received the call to return to base, as was Co-pilot Mark Duffy. Winch operator Paul Ormsby and winch Ciaran Smith completed the crew. Fitzpatrick and his crew initially discussed a direct route to Sligo en route to refuel, but later changed that decision in favor of the Blacksod helicopter landing base based on favorable weather reports received en route. . These reports – ceiling of 400 to 500 feet and horizontal visibility of three miles – have been shown to be overly optimistic.

R116 approached Blacksod from the east at 4000 feet, overflown, then began a descent to 200 feet above sea level (ASL) before changing course to rejoin the approach , which required him to pass through Black Rock, an elevated boulder 9nm west of Blacksod Heliport with a lighthouse and helipad at 282 feet ASL, with terrain elevation and a lighthouse listed at 310 feet ASL in the CHCI route guide. On leaving, the R116 would pass north, entering south. During a conversation gleaned from the cockpit voice recorder (CVR), Fitzpatrick and Duffy admitted that they had not flown in this area for some time. Fitzpatrick said it had been almost 15 years. Although Black Rock is a known danger, it was not loaded into the S-92A’s Honeywell EGPWS at the time, although CHCI flight crews noted this omission as early as 2013. Crews with local knowledge more recent ones have made it their duty to cross Black Rock. with a lot of elevation margin, sometimes flying at 900 ASL or more.

The decision to descend to 200 ASL proved fatal, as the crew was probably operating with incomplete information. As the IAAU noted, “The flight crew lowered the helicopter to 200 feet and used the FMS to ‘Direct To’ maneuver the first waypoint, BLKMO, on the APBSS route, unaware that BLKMO was adjacent to a 282-foot obstacle consisting of landforms and a lighthouse.

The multipurpose flight recorder was recovered 10 days after the accident.

Fatigue could also have played a role. At the time of the accident, Aircraft Commander Fitzpatrick had been awake for 6 p.m. and Co-pilot Duffy for 5 p.m. was known to be monotonous, increasing the risk of the crew succumbing to fatigue.

On the inbound course, R116 likely encountered southwest winds of up to 40 knots, near zero forward visibility, and a ceiling of 200 feet or less above grade, according to the subsequent weather observations from Blacksod. The wind was blowing R116 in Black Rock. While the lighthouse beam was active, it was likely obscured by clouds. The reflections from the helicopter’s traffic lights probably added to the problem. There were also issues with the cockpit lighting, modified for the installation of night vision, although the night vision goggles had not yet been provided. The crew regularly took their own flashlights on board to compensate. But the reduced lighting, combined with the hard-to-read font, graphics and colors of the company’s route guide, only added to the stress and confusion. The on-board radar was probably of little value, according to the IAAU. “The radar operated in the 10nm range throughout the descent and maneuvering to start the APBSS [the approach]. The GMAP2 mode on the weather radar uses the color magenta to represent terrain returns — the same color as the active track and waypoint on the S-92A’s navigation screen. Black Rock was not identified on radar, which was likely due to obscuration caused by the magenta BLKMO waypoint marker and the magenta track line to the waypoint marker.

The maps were also not loaded into the “Toughbook” computer used by the crew. The report found that “the 1: 250,000 aeronautical map, Euronav imagery did not extend as far as Black Rock. The 1: 50,000 OSI images available on the Toughbook did not show the Black Rock lighthouse or terrain and appeared to show open water in the vicinity of Black Rock. The AIS transponder installed on the helicopter was capable of receiving AIS navigation aids transmissions; however, the AIS add-on application for the Toughbook mapping software was unable to display AIS aids to navigation transmissions.

Winner Paul Ormsby, who operated the helicopter’s infrared camera, saw the danger when the S-92 was only 0.3 nm or 600 meters from Black Rock and was flying at 90 knots. In the last seconds of the flight, he advised the captain to “turn right”. It took six seconds for the captain to recognize, at which point Ormsby said, “twenty degrees to the right, yes.” Fitzpatrick then advised Duffy, “Okay, go right, select the title, select the title.” Duffy recognized two seconds later, “Roger, heading selected.” Four seconds later Ormsby could see it was too late, begging the pilots to “Come on … come on … come on!” Less than a second later, synthetic voice warnings “altitude, altitude” sounded in the cockpit as the CVR recorded the sounds of impact.

R116 collided with the terrain on the western edge of Black Rock and fell into the sea. The bodies of Ormsby and Smith were never found. Duffy was found strapped to his seat in the main wreckage, submerged 40 meters deep. Fitzpatrick’s personal locator beacon suggests she submerged at least 10 meters before rising to the surface, but likely drowned during the ascent. The IAAU discovered that the probable cause of the accident was as follows: “The helicopter was maneuvering 200 feet, 9 nm from the intended landing point, at night, in bad weather, when the crew did not know. that a 282-foot obstacle was in the flight. path to the original route waypoint of one of the operator’s preprogrammed FMS routes. But he also cited a dozen contributing factors, the main one being: “It was not possible for the flight crew to accurately assess horizontal visibility at night, under cloud, at 200 feet, 9 nm from the shore, over the Atlantic Ocean. ”

The loss of the R116 comes down to a tired flight crew flying in bad weather, at night, in uncharted territory, with incomplete information, on an unnecessary mission.

It was a bad night at Black Rock.