ON 14 MARCH 2017, the four-person crew of the Rescue 116 helicopter went on its final mission.

More than four years after Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby died in a fatal crash off the Mayo coast, an investigation report has found there were 12 contributory factors in the incident. 

The helicopter was tasked to provide ‘top cover’ to the Sligo rescue helicopter, which was on a long-range rescue mission. R116 crashed after it struck Blackrock Island on its way to refuel at Blacksod. 

A final Air Accident Investigations Unit (AAIU) report, published today, found that the probable cause of the crash was poor weather, the helicopter’s altitude and the crew being unaware of a 282ft obstacle on the flight path as it was not identified on the Flight Management System (FMS).

The 350-page report outlines in detail the events of the hours and minutes leading up to the crash. 

Call to a fishing vessel

9.40pm: The maritime rescue sub-centre (MRSC) at Malin Head in Donegal received a phone call from the captain of a fishing vessel stating that a crew member had sustained an injury. The captain reported that one of the crew had lost ‘the top half of their thumb’.

The captain was told that a helicopter was being alerted, that it would fly to Blacksod and go out from there to the vessel’s location, 140 miles west of Eagle Island, off the north-west Mayo coast.

The commander of the Sligo-based helicopter R118 was contacted and informed that ‘top cover’ would be arranged. In long-distance rescues for rescue helicopters, ‘top cover’ is provided by a second aircraft to ensure communications can be maintained between the rescue crew and the co-ordination centre on land.

9.53pm: The Malin centre called the Dublin co-ordination centre stating that R118 was going to do a long range medical evacuation and asking whether the Dublin helicopter (R116) would be available to provide top cover.

There was a conversation about what would be required and the Dublin centre questioned whether a CASA maritime patrol aircraft from the Irish Air Corps (IAC) could be requested. Malin said it did not know if there would be a CASA aircraft available.

10:02pm: Malin contacted the IAC duty officer to ask about the availability of a CASA. The duty officer called back to advise there was no maritime patrol aircraft available at that time, but that one could be offered at 8am the following morning. Malin MRSC declined the offer and said they would make alternative arrangements.

Malin contacted the Dublin co-ordination centre again to request top cover and discuss the nature of assistance required. There was some discussion around refuelling in Blacksod.

Mission accepted

10:10pm: MRCC Dublin called the Dublin duty pilot of R116 for top cover for R118’s tasking. The Commander for R116, Captain Dara Fitzpatrick, accepted the mission and asked MRCC Dublin to alert the other crew members by TETRA radio call.

10:35pm: After all of the helicopter crew arrived at the Dublin SAR base, they had a meeting in the operations room and just over ten minutes later all four were on board the helicopter.

Before departure Captain Fitzpatrick expressed doubts to MRCC Dublin about the weather at Blacksod and indicated that R116 would route to Sligo instead of the Co Mayo site.

11.06pm: The crews of R116 and R118 had been in regular communication and winch operator Paul Ormsby told Captain Fitzpatrick that R118 was just about to land at Blacksod.

“Oh great, thanks, you might just find out what the conditions are like there as well,” she replied.

He checked and advised her “conditions good at Blacksod”.

Captain Fitzpatrick compared options of going to Sligo or Blacksod in terms of flight time and fuel and asked for a number of books, before deciding they would go to Blacksod.

“We’re not under any pressure so happy enough with that and look if we don’t get in we’ve got plenty of fuel to’; the co-pilot Mark Duffy interjected ‘get us to Sligo’ and she continued ‘get back so I’m just going to give you a direct to em Blacksod now. You’ll get a left turn’.

11:36pm: Captain Fitzpatrick told the crew she was “just going to re-familiarise myself with Blacksod…south”. The report notes that it is likely she was looking at a route index as she indicated she was going to add the route to the helicopter’s automated system.

‘It’s been a while’

11:52pm: Captain Fitzpatrick remarked that she did not believe she had been in Blacksod “in about fifteen years”. Winchman Ciarán Smith replied it had “been a while for me too, alright”. Fitzpatrick asked her co-pilot whether he had been there recently, to which he replied “No, not recently”.

The report states the fact that there was no further conversation on the topic at that time suggested they did not consider that the lack of familiarity was a risk factor that required further discussion.

12:22am: The flight crew discussed staying at a safe altitude until they were clear of land before reducing altitude over what they believed was open water. 

12.24am: Winchman Ciarán Smith remarked that the high ground was “obviously in here somewhere”, to which Captain Fitzpatrick replied “Down here, this is our first point there, we go SDA, that’s kinda when we’re abeam Achill.”

The investigation report notes that Smith was the only member of the crew to raise the issue of high ground/terrain in relation to the automated route and that the flight crew seemed content that it did not warrant detailed consideration.

12.32am: The flight crew briefed for the arrival at the helipad at Blacksod. The investigation report noted that they did not appear to have considered Landing Site Directory obstacles.

Final moments

12:43am: The ‘before landing’ checklist was commenced. During this time co-pilot Mark Duffy stated: ‘starting to get ground coming in there at just over eight miles in the ten o’clock position’. 

Duffy advised that there were “small targets at six miles eleven o’clock, large out there to the right”.

An ‘ALTITUDE ALTITUDE’ warning sounded and Captain Fitzpatrick told the crew “There’s just a small little island that’s BLMO itself”.

Winchman Ciarán Smith alerted the pilots that he was “looking at an island just directly ahead of us now guys”.

“You want to come right,” he told Fitzpatrick.

She asked for confirmation and he replied “twenty degrees right, yeah”. 

Captain Fitzpatrick asked Duffy, the co-pilot, to select heading mode and he confirmed that was done.

Within one second of this acknowledgement, the report notes that winchman Ciarán Smith announced “come right now, come right, COME RIGHT”.

12:46am: The helicopter collided with terrain at the western end of Black Rock, departed from controlled flight, and impacted with the sea.

Several warning alerts could be heard on the recording as the last words – “we’re gone” – came from co-pilot Mark Duffy.

1.08am: Blacksod Lighthouse contacted MRSC Malin head as R116 had not arrived as expected at the helipad.

1.13am: MRSC Malin made a MAYDAY relay to all stations informing them that communucations had been lost with R116 and requested that any vessels with information contact them.