29th April

Absence of map data may have contributed to fatal helicopter crash

A warning system that increases pilot ‘situational awareness’ did not include Black Rock and its lighthouse or the terrain of the island in its database, according to the preliminary report of the Air Accident Investigation Unit into the crash of Irish Coast Guard helicopter R116 that claimed the lives of Capt Dara Fitzpatrick, co-pilot Capt Mark Duffy, winch operator Paul Ormsby and winchman Ciaran Smith.

Blackrock Island

Black Rock island and lighthouse. Tiles on the roof of the outhouse exhibit damage 'consistent with being struck by falling debris'

A digital map that allows the pilot to view a representation of terrain and obstacles ahead is included in the Enhanced Ground Proximity Warning System (EGPWS), ‘provided these are contained in the database’.

EGPWS manufacturer, Honeywell, informed the Investigation that compliant processes include the ‘integration and validation’ of multiple public and private data sources, furnished by customers, governments and private industry.

It added however: ‘Honeywell’s selected terrain and obstacle source data do not include Black Rock.’

And while the island is present in alternate data sets, ‘the actual altitude of Black Rock is considerably higher than what is indicated in these alternate data sets.’

They confirmed the obstacle data for ‘the Ireland region’ is sourced from their ‘Type 1 LOA supplier’. This data ‘does not include obstacles on Black Rock’ Honeywell told the Investigation.

The EGPWS also includes basic modes that prevent descent into level or evenly sloping terrain. Enhanced or ‘look ahead’ modes are based on Global Positioning System (GPS) position compared to terrain and obstacle databases. ‘Look ahead’ modes are intended to prevent the aircraft from running into ‘sharply rising terrain or man-made obstacles’, the report notes.

Safety recommendations

While the Investigation is still at a preliminary stage, it has made two interim safety recommendations.

It notes that as the flight crew has been using an Operator-specific route guide it would be appropriate that the Operator should review all such route guides.

‘CHC Ireland should review/re-evaluate all route guides in use by its SAR helicopters in Ireland, with a view to enhancing the information provided on obstacle heights and positions, terrain clearance, vertical profile, the positions of waypoints in relation to obstacles and EGPWS database terrain and obstacle limitations.’

The Investigation also notes ‘a matter of concern’ relating to the installation of the locator beacon in the lifejackets worn by the pilots, which ‘appeared’ to be in accordance with a Service Bulletin issued by the lifejacket manufacturer RFD Beaufort Ltd.

‘This shows the GPS antenna in the same pouch as the beacon. However, the beacon manufacturer’s publications recommend a minimum separation between beacon and GPS antenna of 30 centimetres (cm).’

The AAIU has recommended that the manufacturer ‘should review the viability of the installation provisions and instructions for locator beacons on Mk44 lifejackets and if necessary amend or update these provisions and instructions taking into consideration the beacon manufacturer’s recommendations for effective operation’.

Final flight

R116 had responded to a call to provide ‘top cover’ for a medical evacuation of an injured fisherman from a fishing vessel, 141 nm off the Co Mayo coast. The Air Corps could not respond to the mission request as they had no availability until 08.00 hrs.

The first indication that R116 could be missing was at 01.06 hrs on March 14 when the helicopter crew did not answer radio calls to their call-sign.

In the final seconds, R116 ‘pitched up rapidly’, impacted with terrain at the western end of the Black Rock and departed from controlled flight. An extract of ‘relevant data’ from the recovered Control Voice Recorder notes the last words of co-pilot Capt Mark Duffy: “We’re gone.”

The Final Report of the AAIU will consider factors including organisation and management of the mission; the Operator’s procedures and guidance, helicopter systems; navigation; mapping and charting; human performance; aircraft performance; survival aspects; ergonomics, oversight; risk management and a deeper analysis of the recorded data and recovered wreckage.

The report notes: ‘The sole purpose of this investigation is to prevent aviation accidents and serious incidents. It is not the purpose of any such investigation and the association investigation report to apportion blame or liability. A safety recommendation shall in no case create a presumption of blame or liability for an occurrence.’

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