Black Rock lighthouse and the island it stands on were not included in a navigational database used by helicopter R116 and there is no assurance that a similar accident could not happen again, writes Joyce Fegan.
Graham Liddy, retired head of engineering at the Air Accident Investigation Unit (AAIU), now working as an aviation safety consultant has warned that if there was one obstacle missing off the database used by the Irish Coast Guard helicopter there could be more.
At the time of the fatal crash on March 14, which claimed the lives of Captain Dara Fitzpatrick and Captain Mark Duffy and its crew members Ciarán Smith and Paul Ormsby who are still missing, the helicopter was using an Enhanced Ground Proximity Warning System. This is installed with a terrain and obstacle database.
“If there is one error there could be more. All of the Enhanced Ground Proximity Warning System databases for Ireland need to be reviewed, audited and certified,” he told the Irish Examiner.
“At this point, nobody can give a categoric assurance that there aren’t other missing obstacles in the database,” he said.
In a preliminary report into the Mayo accident by the AAIU, there is a statement from Honeywell, the manufacturer of the Enhanced Ground Proximity Warning System confirming that the island and lighthouse were missing from the database of terrain and obstacles.
“The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in our terrain database,” read the Honeywell statement.
Honeywell said that they use multiple data sources, both authoritative, from the Government and from non-authoritative sources, using “public and private data”.
The preliminary report made two interim safety recommendations.
One recommends that CHC Ireland, which provides search and rescue services for the Irish Coast Guard under a government contract, review and re-evaluates “all route guides in use by its search and rescue helicopters in Ireland”.
The other one is in relation to locator beacons on the lifejackets worn by R116’s four crew members.
A statement issued by CHC Ireland last night said it noted the safety recommendations made by the AAIU.
“We note the safety recommendations made. A review of all route guides in use is well underway as part of our own internal action.
“It is worth stressing that this is an initial report and it does not identify the root cause of this tragic accident. Speculation as to the root cause is unhelpful to the process and potentially hurtful to the families and friends of those involved,” read the statement.
Also included in the preliminary report published by the AAIU was an extract from R116’s voice recorder.
Twenty seconds before impact an aural alarm sounded in the cockpit calling out “altitude”.
This was followed by a crew member identifying an island, about 13 seconds before initial impact.
Captain Fitzpatrick was then instructed to “come right”.
Captain Duffy then confirmed that the heading had been “selected”.
This was followed by the words: “Come right now, come right, COME RIGHT.”
Shortly after this Captain Duffy is heard uttering two expletives. The final words recorded in the craft were also by Captain Duffy, who said: “We’re gone.”
Captain Fitzpatrick’s sister Niamh posted a tribute by the Irish Coast Guard on her social media yesterday afternoon.
“Today marks one month since the tragic loss of Irish Coast Guard helicopter Rescue 116 off the Co Mayo coast. The search continues for missing crewmen Paul Ormsby and Ciarán Smith.
“Go mairidís beo. We will not leave you, you are not alone, help is on its way. Hold hope,” read the Irish Coast Guard tribute on Facebook.
Black Rock lighthouse and island not on warning system
Black Rock lighthouse and the island it stood on were not on the ground warning system used by Irish Coast Guard helicopter R116.
“We’re gone” were the final words heard by the cockpit voice recorder on the night of the fatal crash
This is revealed in a preliminary report by the Air Accident Investigation Unit into the R116 accident in Co Mayo on March 14, which claimed the lives of Captain Dara Fitzpatrick and Captain Mark Duffy.
Crew members Ciarán Smith and Paul Ormsby are still missing.
Another key fact from the report shows that in the final seconds before the crash, the helicopter “pitched up rapidly, impacted with terrain at the western end of Black Rock, and departed from controlled flight.”
Twenty seconds before impact, an aural alarm sounded in the cockpit calling out “altitude”.
This was followed by a crew member identifying an island, approximately 13 seconds before initial impact.
Captain Fitzpatrick was then instructed to “come right”.
Captain Duffy then confirmed that the heading had been “selected”.
This was followed by the words: “Come right now, come right, come right.”
Shortly after this, Captain Duffy is heard uttering two expletives.
The final words recorded in the craft were also by Captain Duffy, who said: “We’re gone.”
An issue identified in the investigation is that the island of Black Rock and its lighthouse were not on the Enhanced Ground Proximity Warning System used by the R116.
An Enhanced Ground Proximity Warning System is designed to decrease instances of “controlled flight into terrain by increasing pilot situational awareness,” according to the report.
Its computer provides “terrain alerting” using look-ahead algorithms specifically developed for helicopter operations.
The Air Accident Investigation Unit spoke with the manufacturer (Honeywell) of the Enhanced Ground Proximity Warning System on board R116 and confirmed that neither the lighthouse nor the island were in its obstacle or terrain database.
“The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in our terrain database,” read the Honeywell statement.
Honeywell said that they use multiple data sources, both authoritative, from the Government and from non-authoritative sources, using “public and private data”.
The preliminary report made two interim safety recommendations.
It recommended a review and reevaluation of “all route guides in use by its search and rescue 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 Enhanced Ground Proximity Warning System database terrain and obstacle limitations.”
It also made a recommendation in relation to the locator beacons on the lifejackets worn by R116’s crew.
Graham Liddy, retired head of engineering at the Air Accident Investigation Unit, now working as an aviation safety consultant, said that if there was one obstacle missing off the database there could be others.
“If there is one error there could be more.
“All of the Enhanced Ground Proximity Warning System databases for Ireland need to be reviewed, audited, and certified,” he told the Irish Examiner.
“At this point, nobody can give a categoric assurance that there aren’t other missing obstacles in the database,” he added.
Captain Fitzpatrick’s sister Niamh, posted a tribute by the Irish Coast Guard, on her social media yesterday.
“Today marks one month since the tragic loss of Irish Coast Guard helicopter Rescue 116 off the Co Mayo coast. The search continues for missing crewmen Paul Ormsby and Ciarán Smith.
“Go Mairidís Beo. We will not leave you, you are not alone, help is on its way. Hold hope,” read the tribute on Facebook.
Transcript of the last 100 seconds from R116 and key facts of the incident
This is an extract of one minute and 40 seconds approximately of relevant data from the cockpit voice recorder, from the period immediately prior to the accident.
Co-pilot (Captain Mark Duffy):
Ok so small target at six miles eleven o’clock. Large out to the right there.
Commander (Captain Dara Fitzpatrick):
Eh just a small little island …
Rear crew channel (Ciaran Smith or Paul Ormsby):
K…looking at an island just in, directly ahead of us now guys, you want to come right.
Commander (Captain Fitzpatrick):
OK, come right just confirm?
Rear crew channel (Ciaran Smith or Paul Ormsby):
About… twenty degrees right yeah.
Commander (Captain Fitzpatrick):
OK come right…select heading.
Co-pilot (Captain Duffy):
Roger…Heading selected.
Rear crew channel (Ciaran Smith or Paul Ormsby):
Come right now, come right, COME RIGHT.
Co-pilot (Captain Duffy):
[Expletive] OOOHHHH [Expletive].Co-pilot (Captain Duffy):
We’re gone.
Key Fact of Mission and Crash:
At approximately 21.39 hrs on March 13, the captain of a fishing vessel contacted Malin Head Marine Rescue Sub-Centre to notify them of a medical emergency on board due to an injury to a crewman.
The nearest Irish Coast Guard SAR helicopter to the fishing vessel was located at Sligo Airport.
At approximately 22.10 hrs, Malin Head Marine Rescue Sub-Centre called the duty pilot of R116 at Dublin for top cover for R118’s medevac tasking, and R116 accepted the mission.
At 23.03 hrs, R116 departed Dublin Airport for Sligo Airport, but it indicated to Dublin air traffic control that it was routing to either Sligo or Blacksod, and would decide which location to use while en route.
At approximately 23.20 hrs, the R116 requested a routing to Blacksod from Dublin air traffic control, to refuel.
R116 was communicating with Dublin and Shannon air traffic control.
R116 continued at 4,000ft, and at 00.34hrs (March 14) the crew informed Shannon that they were commencing descent to refuel at Blacksod.
The helicopter descended to the west to a radio altitude of 2,400ft. Thereafter, the descent was continued in a westerly direction. The helicopter then turned onto a northwesterly heading and continued descending to 200 ft radio altitude and 80 knots indicated air speed.
The helicopter then commenced a left turn onto a south-easterly heading. During this time the helicopter speed was manually selected to 75 knots.
Flight data showed the helicopter was in stable level flight at 200ft radio altitude, 75 kts indicated airspeed, helicopter heading 120 degrees magnetic (approximately) on a track towards waypoint BLKMO.
In the final seconds, the helicopter pitched up rapidly, impacted with terrain at the western end of Black Rock and departed from controlled flight.
The last Shannon air traffic control radar return for R116 was at 00.46 hrs.
R116 was using an enhanced ground proximity warning system to navigate terrain.
The manufacturer of this tool told the Air Accident Investigation Unit that neither Black Rock island nor lighthouse was on their terrain database.
The first indication that R116 may be missing was at 01.06 hrs, when the helicopter crew did not answer radio calls to their call-sign.
At 01.08 hrs, the Blacksod lighthouse advised that they had no contact with R116.
At 02.13 hrs, R118 advised that they were on scene and commencing a search.
At 02.16 hrs, R118 advised that a casualty and debris were sighted in the water south-east of Black Rock. Shortly thereafter, Captain Fitzpatrick was recovered from the water by the Achill all-weather lifeboat.
