THE PRELIMINARY REPORT into the final moments of Rescue 116 has been released this evening by the Air Accident Investigation Unit Ireland.
Coast Guard helicopter Rescue 116 disappeared off the north coast of Mayo after providing communications cover for a medical rescue in March of this year.
The report finds that the Rescue 116 hit Black Rock island, where some of the helicopter debris was found.
It also found that the island wasn’t registered on the crew’s internal mapping system:
In relation to Black Rock and its Lighthouse, the EGPWS manufacturer informed the Investigation that “The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in our terrain database.”
“The Rescue 116 recording contains no reference by the crew to the presence of a lighthouse or terrain at Black Rock during their briefing for APBSS.”
A rear crew member of Rescue 116 identified an island approximately 13 seconds prior to the initial impact with terrain, according to the report.
Although the report states at the start that it “does not contain analysis or conclusions”, it does make two ‘interim recommendations’ based on its findings:
CHC Ireland should review/re-evaluate 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 EGPWS database terrain and obstacle limitations.
It also said RFD Beaufort Ltd should “review the viability of the installation provisions and instructions for locator beacons on Mk 44 lifejackets”.
Black box voice recorder
The last moments recorded by the black box recorder listed in the report were:
Rear Crew Channel: “K… looking at an island just in, directly ahead of us now guys, you want to come right [Commander’s Name]”
Commander: “OK, come right just confirm?”
Rear Crew Channel: “About… twenty degrees right yeah.”
Commander: “OK Come Right… select heading.”
Co-pilot: “Roger… Heading selected.”
Rear Crew Channel: “Come right now. come right. COME RIGHT.”
Smoke in baggage.
Co-pilot: “[Expletive] OOOHHHH [Expletive].”
Co-pilot “We’re gone.”
The helicopter
The report says that the helicopter “rapidly pitched nose up” during the two seconds prior to the initial impact.
Following the initial impact, the data indicates that the helicopter climbed while experiencing large changes in pitch, roll and yaw angles.
The report lists the timeline of events through referencing the Cockpit Voice Recorder (CVR or black box), the log of what controls were used or triggered during the flight, and external evidence such as mapping systems, weather reports and flight safety features.
Among a list of bullet pointed events that lead to the impact, the report says that the crew were “mission-focused and considered” with minimal extraneous conversation.
It also says that both the pilot and co-pilot had commented that it had been a while since either of them had been to Blacksod.
The pilot briefed the crew on the plan for arrival at the lighthouse.
Wreckage
Debris from the helicopter was found on Black Rock Island, the report found:
The horizontal stabiliser was found on the rock, adjacent to an outhouse which was close to the lighthouse. Tiles on the roof of the outhouse exhibited damage, consistent with being struck by falling debris.
Fractured sections of the Intermediate Gear Box (IGB) centre housing, including the oil level sensor and a portion of the chip detector, as well as the IGB fairing which was broken into four distinct pieces, were found on the rock.
Among the items found on the seabed were:
The cabin floor/lower fuselage had separated from the lower fuselage aft of the nose landing gear area and was lying forward of its normal location.
The right hand Main Landing Gear and its sponson had separated from the fuselage. The assembly was found on the sea bed adjacent to the main wreckage.
The winch operator’s control console was lying close to the cabin floor section.
The Sikorsky S-92A helicopter’s safety features and mechanics are listed (which includes emergency exits and flotation devices).
It found that all four lighthouses in the area “were operational over the period of interest” (Eagle Island, Blacksod, Black Rock and Achillbeg).
According to Met Éireann, visibility was 2-3km and weather that evening for “all Irish coastal waters and the Irish Sea contained occasional light rain or drizzle and patchy mist and fog.”
Investigators say that the final report will be published in due course.
The investigation will consider a number of 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 Air Accident Investigations Unit’s preliminary report on the incident is available to read in full here.
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