Ireland Coast Guard Rescue 116 Crash Report
Air Accident Investigation Unit (AAIU) Preliminary Report Accident of Irish Coast Guard S-92A EI-ICR determined it struck terrain that wasn’t in its enhanced ground proximity warning system (EGPWS) database
AAIU, April 13, 2017 - The Irish Coast Guard S-92 EI-ICR rescue helicopter operated by CHC Ireland that crashed on March 14 was commencing an approach to refuel when it struck terrain that wasn’t in its enhanced ground proximity warning system (EGPWS) database, according the Air Accident Investigation Unit (AAIU) preliminary report.
Rescue 116 departed Dublin shortly after 11PM headeding west across Ireland for Sligo Airport where the crew planned to refuel before continuing offshore.
En route to Sligo, however, the crew requested a routing change from Dublin Air Traffic Control to instead refuel farther west at Blacksod Lighthouse.
When the aircraft was just past Blacksod, the flight crew commenced a descent, continuing west in order to follow a route that had been pre-established as “Approach Blacksod South” or APBSS.
The flight crew programmed the route into their flight management system selecting the automatic flight control system’s SAR “Approach 1” mode, which automatically transitions the aircraft down to 200 feet above the water at an airspeed of 80 knots.
Once established at a lower altitude, the flight crew programmed a direct course to the waypoint BLKMO to commence the arrival route to Blacksod.
Cockpit voice recordings indicated that approaching Black Rock were using weather radar to identify terrain features ahead. Approximately 26 seconds prior to the initial impact, the radar altimeter provided a callout of “Altitude, Altitude”.
Although the lighthouse at Black Rock was determined to have been functioning at the time of the crash, the low meteorological visibility and ceilings would have greatly reduced its luminous range.
The AAIU has made an interim safety recommendation to CHC Ireland that it “should review/re-evaluate all route guides in use by its SAR 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.”
The report includes the last two minutes of the Cockpit Voice Recorder (CVR) transcript.
Complete report PDF
"Rescue 116" CVR Transcript Publication is Unnecessary and Harmful, Says Pilot Community
April 19, 2017 - International Federation of Air Line Pilots’ Associations (IFALPA) MONTREAL & BRUSSELS - Last Friday, the Irish Air Accident Investigation Unit (AAIU) published the last two minutes of the Cockpit Voice Recorder (CVR) transcript of a fatal helicopter accident (CHC Sikorsky S-92 "Rescue 116"), which occurred at Black Rock, on the west coast of Ireland, on the 14th of March 2017. That same day, this transcript filled newspapers and websites, including the front page of the Irish Times.
The International Federation of Air Line Pilots’ Associations (IFALPA) and the European Cockpit Association (ECA) strongly condemn this publication as unwarranted, unacceptable, counterproductive to flight safety, and a breach of both ICAO Annex 13 Standards and EU Regulation 996/2010.
Not only does the publication contravene the internationally agreed principles of accident investigation confidentiality, set out in ICAO Annex 13 and EU Accident Investigation Regulation 996/2010, but it unnecessarily adds to the burden of the victims' families, and is also a breach of trust to all those involved in commercial aviation.
There is absolutely no justification for - or benefit from - publishing specifically the last two minutes of this flight, other than feeding a thirst for sensationalism.
Indeed, according to ICAO Annex 13 paragraph 5.12 and the EU Regulation 996/2010 Article 14 (paragraph 1) the State conducting the investigation of an accident shall not make CVR recordings and any transcripts from such recordings available for purposes other than accident or incident investigation. Such recordings shall be included in the Final Report or its appendices only when pertinent to the analysis of the accident. Annex 13 goes on to state that "parts of the records not relevant to the analysis shall not be disclosed." No benefit has been noted in the report to justify the Irish investigation body’s decision to disclose CVR data.
In this early stage of the technical investigation, many critical questions remain to be answered. IFALPA and ECA call for adherence to the proper accident investigation process and expect a comprehensive and accurate analysis of events based on the highest professional standards. IFALPA and ECA remain fully committed to enhancing aviation safety and our organisations’ resources are at the disposal of the Accident Investigation Agencies to achieve this aim.
Sikorsky S-92A EI-ICR ( Garda Cósta na hÉireann )