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Twitter/Irish Coast Guard

Rescue 116 crash: Investigators seek review of all Irish search and rescue operations

Four Irish Coast Guard crew were killed in the tragedy. The latest interim report has been published.

A REPORT BY air accident investigators into the Rescue 116 tragedy has recommended that a “thorough review” should be carried out into all air search and rescue operations in Ireland.

The report was published today – just days after the first anniversary of the crash that claimed the lives of four Irish Coast Guard crew, marked by a ceremony at Blacksod in Co Mayo.

Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby all lost their lives after Irish Coast Guard helicopter Rescue 116 went down off the Mayo coast last year.

A preliminary report previously published by AAIU found that Rescue 116 hit Black Rock island before crashing.

It also found that the island wasn’t registered on the crew’s internal mapping system.

An interim report by the Air Accident Investigation Unit Ireland (AAIU) has made three further recommendations today.

Regarding overall search operations it says:

The Minister for Transport, Tourism and Sport, as the issuing authority for the Irish National Maritime Search and Rescue Framework, should carry out a thorough review of search and rescue aviation operations in Ireland to ensure that there are appropriate processes, resources and personnel in place to provide effective, continuous, comprehensive and independent oversight of all aspects of these operations.

Accuracy

This latest report identifies a problem with the “coarseness of the latitude and longitude position information recorded” on the flight data recorder.

It makes the following recommendation to the aircraft manufacturer, Sikorsky:

The Sikorsky Aircraft Corporation should make the necessary updates/modifications to the S-92A helicopter to ensure that the latitude and longitude information recorded on the Flight Data Recorder reflects the most accurate position information available during all flight regimes and mission profiles.

Investigators said that helicopter service company CHCI should conduct a review of its safety management system (SMS):

CHCI, with external input, should conduct a review of its SMS and ensure that the design of its processes and procedural adherence are sufficiently robust to maximise the safety dividend; this review should consider extant risk assessments and a thematic examination of the corpus of all safety information available to the Operator, both internally and externally.

The investigators said that a digital video recorder capable of recording infrared images was recovered from the seabed, but no data was recovered from it.

Examination of the helicopter wreckage is ongoing, meanwhile:

This examination is to enable the Investigation to develop the best possible understanding of the flight dynamics and structural disruption sequence associated with the accident.
A large number of items, some of which were related to the accident helicopter, have been recovered sporadically from both sea and shoreline over the period since the accident.
All recovered items were secured by An Garda Síochána at Belmullet Garda Station and are subject to consideration by the Investigation.

The investigation is ongoing and a final report will be published in due course, the latest report says.

- With reporting by Daragh Brophy

Read: ‘Forever remembered for the sacrifice they made’: Rescue 116 crew honoured in Mayo >

Read: Coast Guard says it’s mindful of ‘devastating pain and loss’ felt by families of Rescue 116 crew >

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12 Comments
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    Mute Denis McClean
    Favourite Denis McClean
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    Mar 16th 2018, 1:10 PM

    Multiple carts before horses and fields with open gates come to mind.

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    Mute Paul O Faolain
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    Mar 16th 2018, 1:47 PM

    Was it pilot error or something else,does anyone know the answer

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    Mute Nauris Serna
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    Mar 16th 2018, 2:11 PM

    @Paul O Faolain: Ad with most accidents, it’s a sequence of events that led to it. Also, worth noting, that the purpose of the investigation is to prevent a repeat, rather than put a blame or liability on somebody.

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    Mute Crocodylus Pontifex
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    Mar 16th 2018, 2:53 PM

    @Paul O Faolain: The investigation is ongoing. There is a requirement to publish a report 1 year after the event if the case is still open which is what today’s update is about. A lot of things had to line up for this tragedy to happen so there will be no clear and simple answer.

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    Mute Hugh Legat
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    Mar 16th 2018, 3:39 PM

    Investigation ongoing. I would like to know is it correct the pilot repeatedly ignored radar alarms of an “imminent collision” take evasive action! It doesn’t matter it wasn’t on her chart.

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    Mute Ohhh_reeally
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    Mar 16th 2018, 4:01 PM

    @Hugh Legat: good man Hugh, “you’d like to know”. Do you mind me asking why you’d like to know? What use will the information be to you once you have it?

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    Mute pat winters
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    Mar 16th 2018, 5:10 PM

    @Hugh Legat: A lot of reading but avoiding the proverbial elephant (lighthouse) in the room. A lighthouse is a tower, building, or other type of structure designed to emit light from a system of lamps and lenses and to serve as a navigational aid for maritime pilots at sea or on inland waterways. Lighthouses mark dangerous coastlines, hazardous shoals, reefs, and safe entries to harbors; they also assist in aerial navigation.

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    Mute EUGENE 70 percent
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    Mar 16th 2018, 10:35 PM

    @Hugh Legat: is it the ground proximity warning system that gives the warning you refer to.

    Because an earlier finding was that Blackrock was not on whatever mapping the ground proximity warning uses.

    I see on RTE that the investigation is continuing and that warning systems are one of the things that will continue to be looked at.

    Best wait for the FINAL report before rushing to assume the pilot ignored warmings.

    Quite striking in my eyes to see a reccomendation for review of SYSTEMS and how the SAR operations operate “if it was as simple as a pilot ignoring a warning”.

    Can’t help but suspect that theres a POSSIBILITY that investigators see wider system flaws as at the very least a POTENTIAL contributory factor in the crash.

    They aren’t making recommendations for fun. They are likely making them because the investigation is uncovering things pointing them to a NEED for one.

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    Mute Quentin Moriarty
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    Mar 17th 2018, 9:09 AM

    @Ohhh_reeally: landing gear down 9 miles out
    Legat has a point

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    Mute Quentin Moriarty
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    Mar 16th 2018, 5:32 PM

    Altitude approach protocols a priority

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    Mute Martin Dale
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    Mar 16th 2018, 3:37 PM

    Proper order

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    Mute Neuville-Kepler62F
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    Mar 17th 2018, 6:24 PM

    “Professional” Pilot error is never a root cause of air accidents when viewed from an engineering perspective. It is a systems or process error. This is the second helicopter crash after Tramore. The root cause of both must be identified.

    Even at speed a good on board radar system will give ample advanced warning of impending collision and should intervene in aircraft flight to avoid it.

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