Friday 15 December 2017

Rescue 116: Aviation expert Kevin Byrne on the questions that still need to be answered

Air accident experts need time and space to finish the investigation and come up with recommendations

Two of the crew of Rescue 116: (left to right) Dara Fitzpatrick and Ciaran Smith
Two of the crew of Rescue 116: (left to right) Dara Fitzpatrick and Ciaran Smith

Kevin Byrne

There is one small branch of the civil service which has been serving the aviation community in Ireland for many years and which conducts its business in many ways "under the radar", to use an aviation analogy.

I refer to the Air Accident Investigation Unit of the Department of Transport, Sport and Tourism, led by Jurgen White.

Crash scene: A naval vessel passes Blackrock lighthouse during the search for Rescue 116. According to the crash investigation’s initial findings, the rocky outcrop and lighthouse did not exist in the helicopter’s flight safety software Picture: Keith Heneghan
Crash scene: A naval vessel passes Blackrock lighthouse during the search for Rescue 116. According to the crash investigation’s initial findings, the rocky outcrop and lighthouse did not exist in the helicopter’s flight safety software Picture: Keith Heneghan

In the normal course of events, it conducts its aeronautical detective business outside the glare of publicity and without undue haste.

The close-knit staff comprises highly experienced pilots and engineers from the military and civilian aviation community.

In the normal way, most of the Irish public would not follow any particular investigation but the sudden loss of Rescue 116 off the west coast changed that perception.

The publication of the interim report into this accident has surprised the general reader in that they see the transcript of the crew's final words as being insensitive to the families who lost loved ones, more poignant as two members remain lost at sea.

This is normal practice in all parts of the global aviation community and it is worth emphasising why such investigations are conducted in the first place; the facts of air accidents are discerned solely to understand what went wrong in order to prevent a repetition. Blame is never apportioned, as chief investigator Jurgen White has emphasised on many previous occasions.

As a former decorated Air Corps Search and Rescue pilot (he holds the Distinguished Service Medal), he appreciates the need for answers in this unprecedented helicopter accident.

The Sikorsky S-92A is one of the world's most sophisticated SAR helicopters and with less than 4,900 hours on the airframe and being about 10 years old, there were many service years left in the accident aircraft.

With hundreds of this model in service in many parts of the globe, there was an imperative to discover if any type of mechanical failure led to this tragedy. A clear statement to the negative was issued relatively quickly after the Flight Data Recorder was recovered from the sea bed and analysed by experts.

Rescue 116 had a warning system for low altitude but that did not include information for the terrain around Black Rock island
Rescue 116 had a warning system for low altitude but that did not include information for the terrain around Black Rock island

In essence, other factors were in play. We must concentrate, then, on what has been released in the public domain, and especially on the two safety recommendations released last Thursday night.

The first one is stark and simplistic in some ways: it suggests that CHC Ireland should review and re-evaluate all route guides in use by its SAR helicopters in Ireland.

What does this mean? The helicopter was descending from its cruising altitude of 4,000ft so that it could land and refuel at Blacksod, which is basically a landing pad for helicopters.

It is not an airport, has no radar or air traffic controllers or equipment and so a controlled "transdown" is made via autopilot over the sea.

The S-92's Honeywell Enhanced Ground Proximity Warning System (EGPWS) had modified software for search and rescue duties. Therefore, the pilots placed implicit trust in it as it had proven itself on many previous missions and training flights.

They did not expect to meet a rocky outcrop with a lighthouse in their path and by the time the rear crew member alerted them using an infra-red screen, it was too late to avoid a collision.

Remarkably, during the course of the inquiry, the manufacturer admitted: "The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in our terrain database." In other words, the very object with which R116 collided did not exist as far as the software was concerned, which is a serious anomaly in aviation terms and needs to be explained.

Furthermore, it begs a question or two in respect of other features around our rugged Irish coastlines: what other geographical features have been excluded from essential software programmes? And why?

Two of the crew of Rescue 116: (left to right) Dara Fitzpatrick and Ciaran Smith
Two of the crew of Rescue 116: (left to right) Dara Fitzpatrick and Ciaran Smith

The fact that both pilots had no recent experience of landing at Blacksod is of no great importance, as the nature of SAR flying means that flexibility and routine changes of plan are the general norm.

This aspect of aviation is far removed from the conventional commercial flying along established airways to well-lit, well-equipped full service airports. Yet the SAR aircrews would have it no other way; they are a very special, almost renegade bunch.

The operator, in this case CHC Ireland, has a huge responsibility and desire to make their operation as safe as practicable as possible. Its flight planning department will have provided route planning guides for low level flights, both by day and night, which provide the greatest efficiency and the least risk but, by its very nature, search and rescue can be a perilous business. In so many cases the weather can be marginal, the distance from land may be great and the vessel in distress may be without power or navigational ability. In many cases, the information available to the crew members before departure may be of little planning value. They often plan for the worst and are rarely disappointed!

Let us examine the second recommendation which advises the manufacturer of the lifejackets to review the installation provisions and instructions for locator beacons on their lifejackets. What does this mean? Should any of the crew members enter the water for any reason, the lifejacket should inflate automatically and at the same time the Electronic Locating Transmitter (ELT) broadcasts its position so that any rescue agency can home in on the signal and effect a rescue.

In the case of R116, none of the four lifejackets worn by the crew activated the fitted ELT when they entered the sea, possibly because the distance between the recommended minimum separation between beacon and GPS antenna of 30cm was not applied. They were wearing the GPS antenna in the same pouch as the beacon, which appeared to be in accordance with a picture contained in a Service Bulletin issued by the lifejacket manufacturer showing them in this configuration. There is a confusion, to say the least, about the information given by the manufacturer, RFD Beaufort Ltd, a world leader in safety and survival equipment.

The case of R116 brings back memories of the loss of the Air Corps' Dauphin helicopter 248 in Tramore in 1999, in which four crew members also lost their lives. This kind of sacrifice and that of R116 illustrates all too clearly why the investigation of the AAIU must, and will, draw to its natural conclusion over the coming months outside the immediate glare of publicity.

Only when the final questions are answered and the complete list of recommendations are published will we know exactly what happened to the last flight of R116 and, more importantly, why.

Kevin Byrne, Lt Col (retired) Lecturer in aviation, DCU

Sunday Independent

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