The "probable cause" of the Rescue 116 Irish Coast Guard helicopter crash, which claimed the lives of four air crew off the north Mayo coast in March 2017, has been identified as a combination of poor weather, the helicopter's altitude and the crew being unaware of a 282ft obstacle on the flight path to an initial waypoint in a pre-programmed route guide.
The 350- page final report by the Air Accident Investigation Unit (AAIU) also identifies "serious and important weaknesses" in management of risk mitigation by helicopter operator, CHC Ireland, which holds the Irish Coast Guard search and rescue (SAR) contract.
Four crew Capt Dara Fitzpatrick, Capt Mark Duffy, winch team Paul Ormsby died in the crash at Blackrock island at 0046.08 hours on March 14th 2017.
The bodies of Capt Fitzpatrick and Capt Duffy were recovered, but both Paul Ormsby and Ciaran Smith are still missing despite extensive searches.
The report recalls how R116 was asked to provide top cover for Rescue 118 from Sligo, which had been tasked to airlift a casualty from a fishing vessel, situated approximately 140 nautical miles off the west coast of Ireland.
Black Rock off the Mullet Peninsula in Co Mayo, where the Sikorsky S-92 helicopter went down Credit: CIL
"At 00.46 hrs, on 14 March 2017, while positioning for an approach to Blacksod from the west, the helicopter, which was flying at 200 feet above the sea, collided with terrain at the western end of Black Rock, departed from controlled flight, and impacted with the sea," it says.
"During the immediate search and rescue response, the Commander was found in the sea to the south-east of Black Rock and was later pronounced dead. Subsequently, the main wreckage of the helicopter was found close to the south-eastern tip of Black Rock, on the seabed at a depth of approximately 40 metres," it says.
Capt Fitzpatrick's colleague Capt Duffy died instantly and was located within the cockpit section of the wreckage and was recovered by Naval service divers.
The report has 42 safety recommendations, which Minister for Transport Eamon Ryan says he accepts
The report has 42 safety recommendations, which Minister for Transport Eamon Ryan says he accepts.
The preliminary report published in April 2017 was critical of lack of navigational information for the crew. It highlighted how personal locator beacons in the pilots' lifejackets malfunctioned due to a conflict in fitting instructions.
The final report, which has been delayed in publication by two years after one of the parties sought a review, identifies "confusion at State level" regarding responsibility for oversight of search and rescue operations in Ireland.
It highlights how the Irish Aviation Authority believed Irish Coast Guard to be responsible for search and rescue oversight, when the Irish Coast Guard did not have this expertise.
Rescue helicopter R116
The report found that the initial route waypoint for the approach to Blacksod to refuel was almost "coincident" with the terrain at Blackrock island. Flight databases didn't indicate the presence of Blackrock, and neither did some of its imagery. Lighthouses were not clearly marked in the route guide with a small red dot and an elevation in numerical value.
Route guide hazards and obstacles listed on the route guide title page were identified by white numericals, within red circles, outlined in black.
The report has found that the helicopter operator didn't have "formalised, standardised, controlled or periodic" systems of testing flight routes.
Route guides had not been fully proven and updated, there was an error in the length of one of the route legs for Blacksod helipad which had gone undetected since 1999, and emails provided by CHC Ireland showed that one pilot advised in June 2013 that Blackrock lighthouse was not shown on the emergency ground proximity warning system (EGPWS).
It also found that the flight crew members' likely hours of wakefulness at the time of the accident were correlated with "increased error rates and judgement lapses."
A sleep study of some of the operator's SAR crew members found that they accrued less sleep than the US National Sleep Foundation recommended and that "this may not be enough sleep for optimal operational duty".
The Irish Coast Guard four helicopter bases operate a 24-hour shift – the only emergency service to do so –and it is understood that flight duty time was degraded over the years by the Irish Aviation Authority.
The Department of Transport has stated it fully accepts the recommendations contained within the report and will continue to evaluate the findings in the coming weeks.
"This was a tragic accident that claimed the lives of four individuals who were dedicated to saving the lives of others," Minister for Transport Eamon Ryan said.
He said he would "like to again convey my condolences to the families and loved ones of the R116's crew at this time".
"The completion of the Investigation and the publication of the report is a key step in ensuring that such accidents are prevented in the future. I wish to acknowledge the investigative work that has been done by the AAIU that has culminated in this report," he said.
"This is clearly reflected in the level of detail and wide-ranging nature of the report, with safety recommendations that cover all aspects of SAR aviation, both nationally and internationally," he said.
The AAIU, which states its role is not to apportion blame or liability, said it adopted a revised text after a review, and says the final report includes "substantially the same safety recommendations" as those issued in the draft final report in September 2019.
The report notes that the reasons for selecting a 282 ft obstacle as the starting point for what the Operator described as a 'Low Level' route, with no vertical profile, could not be determined because the origins of the route design itself were unknown to the operator.
"a number of factors militated against the flight crew detecting Black Rock"
It identifies a number of factors that militated against the flight crew detecting Black Rock in time to carry out an effective avoidance manoeuvre.
It says Black Rock was not in the emergency ground positioning warning system (EGPWS) databases.
"The BLKMO magenta waypoint symbol and track line likely obscured radar returns from Black Rock (which might have been detected on the 10 NM range)" and the 1:250,000 Aeronautical Chart, Euronav imagery did not extend as far as Black Rock."
"The 1:50,000 Ordnance Survey Ireland imagery in the Toughbook did not show Black Rock, but instead showed open water at Black Rock," it says.
"Furthermore, the operator did not have formal processes or procedures to approve mapping data/imagery for use in its helicopters," it says.
"The operating environment on the west coast would have been more challenging than east coast crews were familiar with, particularly regarding the availability of visual cues in the littoral environment. This meant that it would not have been possible for the Flight crew to accurately assess their horizontal visibility," it says.
"However, given that Black Rock was only detected on the FLIR camera when the Helicopter was approximately 600 m from it, it seems that the horizontal visibility to the naked eye was probably less than 600 m," it says.
"Furthermore, the Flight crew's night vision may have been compromised due to the helicopter's external lighting. Research indicates that if the Flight crew were awake for the length of time suggested by the Investigation's review (18 hours for the Commander and 17 hours for the Co-pilot), they would have been more prone to errors in judgement and decision-making," it says.
"The tempo of the mission was different to east coast missions, and furthermore, the SAR support nature of the mission was known to be monotonous, increasing the risk of the Crew succumbing to fatigue," it says.
"Routes were generally viewed as base-centric, and a level of local knowledge and familiarity may have been assumed, which was an invalid assumption when an east coast crew was utilising a west coast route, a situation compounded by darkness and poor weather," it says.
"The Operator said that the routes were merely there as a framework on which to build a plan for entry/exit to a number of known sites. However, there was no formal training in the use of routes; there was no formal procedure for how a route was to be designed; there was no formal procedure for how a crew should use a route guide; routes did not include a vertical profile or minimum altitudes generally, for route legs; and routes were not available for use in the simulator," it says.
"The Route Guide was prefaced with the statement that it was 'a work in progress and should be used with the necessary caution until all routes/waypoints are proven'. Therefore, the routes were unproven, and the Operator did not have a defined process for route proving. Consequently, in the absence of formal, standardised training, design procedure or procedure for how a crew should use a route guide, it is unclear what beliefs/expectations individual pilots may have had regarding routes and how they could be used operationally," it says.
"Problems with a number of routes had been identified in the SQID system (the Operator's Safety and Quality Integrated Database), however, the SQID report was closed after personnel were emailed to resolve the matter, but without checking that the routes had actually been updated correctly," it says.
"The closing of SQIDS without checking that effective action had been completed was one of a number of issues identified with the Operator's Safety Management System (SMS). The Investigation also found that safety meetings were not being held as often as called for; minutes were not being uploaded onto SQID; SQID closure was not following the protocols set out in the Safety Management and Compliance Monitoring Manual (SMCMM); the quality of Risk Assessments could be improved," it says.
The report recalls how the helicopter maintained a north-westerly track until it reached 200 ft, at which point the Commander announced that Approach One was complete and that she was '[…] just going to help it round the corner … coming to the left'.
"As the Helicopter commenced the left turn back towards BLKMO, the Winchman announced that the Helicopter was 'clear around to the left'. This was followed approximately 30 seconds later by a further announcement from the Co-pilot that they were 'ah clear ahead on E GYP WIZZ and radar'," it says.
"At 00.43 hrs, as the helicopter was turning back towards BLKMO at 200 ft, the 'Before Landing' checklist was commenced. During this time, the Co-pilot stated: 'starting to get ground coming in there at just over eight miles in the ten o'clock position'. Just as the Commander was completing the final item of the 'Before Landing' checklist, she commented that she was visual with the surface of the sea," it says.
"At 00.45 hrs, the Co-pilot announced 'okay so small targets at six miles at 11 o'clock… large out to the right there'. This was followed approximately 20 seconds later by an Auto Callout' Altitude, Altitude', which the Commander said was 'just a small little island that's B L M O itself'," it says.
"Just prior to 00.46 hrs the Winchman announced 'Looking at an island just eh directly ahead of us now guys…you wanna come right [Commander's name]'. The Commander asked for confirmation of the required turn, and the Winchman replied 'twenty degrees right yeh'," it says.
"The Commander instructed the Co-pilot to select heading (HDG) mode, which the Co-pilot acknowledged and actioned. Within one second of this acknowledgement, the Winchman announced 'come right now, come right, COME RIGHT'. Shortly after this, the helicopter pitched up rapidly and rolled to the right. At 00.46:08 hrs, the helicopter collided with terrain at the western end of Black Rock, departed from controlled flight, and impacted with the sea. The main wreckage of the helicopter came to rest on the seabed to the east of Black Rock, at a depth of 40 metres (m)," it says.
In its conclusions, the report states that there were gaps in the way tasking protocols were followed at MRSC Malin.
It says both flight crew members commented adversely about the quality of cockpit lighting, and neither had been to Blackrock recently.
It says the Commander reviewed the route waypoints with the co-pilot and took '*overfly*' off one waypoint, which the Investigation believes was BKSDC (Blacksod).
It says she did not verbalise the obstacle information from APBSS route into Blacksod, when she briefed the route but it appears that she did read at least some of the information because she was aware of an obstacle to the west of Blacksod when the Co-pilot asked about an escape heading.
It says the co-pilot self-briefed the route and he did not verbalise the obstacle information.
"Radar was operated on the 10 NM range throughout the descent and manoeuvring to commence APBSS," it says.
It says Black Rock was not identified on radar which was likely due to obscuration caused by the magenta BLKMO waypoint marker and the magenta track line to the waypoint marker.
"Black Rock was not in the EGPWS databases. The 1:250,000 Aeronautical Chart, Euronav imagery did not extend as far as Black Rock. The 1:50,000 OSI imagery available on the Toughbook did not show Black Rock Lighthouse or terrain, and appeared to show open water in the vicinity of Black Rock," it says.
"The AIS transponder installed on the helicopter was capable of receiving AIS Aids-to Navigation transmissions; however, the AIS add-on application for the Toughbook mapping software could not display AIS Aids-to-Navigation transmissions," it says.
"The winchman announced that he had detected an island ahead on the EO/IR camera system when the helicopter was about 0.3 NM from it, travelling at a ground speed of 90 kts. The winchman called for a change of heading and the flight crew were in the process of making the change when the urgency of the situation became clear to the winchman," it says.
"There is no indication on the cockpit voice recorder that the flight crew saw Black Rock, although in the final seconds of flight there was a significant, manual input on the Collective Lever, an associated 'droop' in main rotor RPM and a roll to the right," it says.
"the Department of Transport lacked the technical expertise to oversee the IAA"
"The helicopter collided with terrain at the western end of Black Rock, departed from controlled flight and impacted with the sea. At no stage did any member of the crew comment on seeing, or expecting to see, a light from Black Rock Lighthouse," it says.
It says the Department of Transport lacked the technical expertise to oversee the IAA and the Irish Coast Guard did not have a safety management system.
"Numerous areas, across several agencies, are explored in-depth in the Final Report, it says which demonstrate that the accident was, in effect, what expert Professor James Reason termed 'an organisational accident'," it says.
"The Final Report highlights the importance of robust processes in relation to the following areas: Route Guide design, waypoint positioning, and associated training; reporting and correcting of anomalies in EGPWS and charting systems; Fatigue Risk Management Systems; Toughbook usage; en route low altitude operation; and the functionality of emergency equipment," it says
"It is particularly important that an operator involved in Search and Rescue has an effective Safety Management System, which has the potential to improve flight safety by reacting appropriately to safety issues reported, and by proactively reducing risk with the aid of a rigorous risk assessment process, "it says.
The Final Report identifies the importance of the levels of expertise within organisations involved in contracting and tasking complex operations such as Search and Rescue, to ensure that associated risks are understood, that effective oversight of contracted services can be maintained and that helicopters only launch when absolutely necessary.
In a statement, Hermione Duffy, wife of the late Capt Mark Duffy, said her husband had been an excellent pilot and father and, together with his colleagues, shared a deep commitment to his search and rescue role, always taking pride and satisfaction from his work.
Ms Duffy asked people to remember that "four honourable souls lost their precious lives that night in the service of others, and in circumstances which are harrowing and traumatic to read of and which have left wives, children, parents and extended families bereft".
"the loss of four aircrew lives was "as needless as it was preventable"
The Irish Airline Pilots Association (IALPA) said the report shows that the loss of four aircrew lives was "as needless as it was preventable", it says.
The final publication of the Report corresponds with the AAIU Interim and Preliminary reports and "makes it clear that the crew of R116 were exemplary in the performance of their assigned task", IALPA says.
"Their planning, response, teamwork, and communication was exactly what would be expected from such a competent and seasoned crew, on a flight led by such professional pilots," it says.
"They were let down by a regulatory system which left them ill-equipped to do the vital work that same system tasked them with," it says.
"The report outlines a number of regulatory and systemic issues which conspired to put the crew in lethal danger. Prime amongst them was the provision of inaccurate and misleading chart and map data," IALPA says.
"All flight crew rely on the basic assumption that their maps and charts provide accurate data. Few flight crews could be more reliant on that assumption of accurate data than the crew of a rescue helicopter, operating offshore in challenging conditions outside their normal home base, scrambled at short notice to launch a rescue in the middle of the night (00:45 am). They relied on the data production standards of Irish regulation to guarantee them correct information" it says.
"They were let down," IALPA says.
IALPA President Evan Cullen described it as a fundamental betrayal, and said that "as an airline pilot, if I take a flight from Dublin to Rome, I must navigate the Alps, and I expect one of two things from the Swiss authorities; tell me the height of the alps, or tell me they don't know the heights, so I'd better avoid them. The one thing they can't do, under any circumstances, ever, is tell me the wrong height, or tell me the Alps are not there," he said.
"In essence that is what the Irish State did to Dara, Mark, Paul and Ciarán. They approved information which said, 'you are safe', when the absolute opposite was the truth."
IALPA said the report details failures in oversight, equipment requirements and maintenance, and in resourcing for SAR.
"But it is the regulatory failure by the now-defunct Irish Aviation Authority which is central to this accident. They set the standards for equipment, for mapping, and for oversight. They accepted standards which most, if not all, of their European peer authorities, would not," IALPA says.
"This tragic and unnecessary loss of life must not be allowed to happen again. IALPA is calling on the Government and Minister for Transport to institute an immediate review of the failures identified in this report, and to bring forward concrete proposals to address each and every identified failure immediately," it says.
CHC Ireland responds
CHC Ireland said it would like to express its deepest sympathy towards the family and friends of our colleagues; Ciarán, Dara, Mark and Paul", and welcomed the final report.
The company said it acknowledged the work of the AAIU "in producing such a comprehensive review", which is "extremely thorough and will make difficult reading for all those involved".
"These lessons will undoubtedly be applied across Search and Rescue operations in Ireland and throughout the world. We are also grateful for the work of the Chair of the Review Board," CHC Ireland said.
"CHC Ireland continues to advance aviation safety by investing in ongoing employee training and development, working to global standards and engaging with aviation stakeholders. Our commitment is to deliver essential Search and Rescue services to the people of Ireland in a safe and professional manner," it said.
"We are committed to implementing the appropriate Safety Recommendations that are directed towards CHC Ireland in the Final Report. The report is clear that the organisation of Search and Rescue in Ireland involves many stakeholders including the Irish Aviation Authority, the Irish Coast Guard and the European Aviation Safety Agency. CHC Ireland will ensure that it collaborates with all the relevant stakeholders to address the recommendations. The most important thing is that we collectively ensure that all areas identified for further strengthening are actioned," it said.
"We continue to honour the memories of Ciarán, Dara, Mark and Paul. They will never be forgotten"
CHC Ireland general operations manager Rob Tatten referred to the "unwavering commitment" of all those involved in search and rescue.
"Our crews continue to fly hundreds of search and rescue missions every year, saving many lives. Our team is justifiably proud of our global safety record and everyone in CHC Ireland is committed to the safe delivery of our service," he said.
"We continue to honour the memories of Ciarán, Dara, Mark and Paul. They will never be forgotten," Mr Tatten said.
Irish Aviation Authority statement
The Irish Aviation Authority (IAA) issued a statement this evening saying it wished to "take the opportunity to again express our greatest sympathy to the families and friends of the four crew members of the Irish Coast Guard R116, who tragically lost their lives while undertaking a rescue mission on 14 March 2017"
The authority said it welcomed the publication today of the Air Accident Investigation UUnit's (AAIU) comprehensive report into this accident, which we believe will contribute to the prevention of future aviation accidents both in Ireland and indeed globally.
We have reviewed and fully accept the recommendations addressed to the IAA, which have already been implemented or are proceeding to full implementation. We will verify our progress in this regard to the AAIU.
At the time of the R116 accident, the IAA exercised safety oversight of the operator through their Air Operator Certificate and a national Search & Rescue approval. As indicated in the AAIU report, Search & Rescue regulation is not covered by ICAO or EU safety rules. The AAIU has recommended that the EU Commission review Search & Rescue safety standards at European level with a view to developing guidance material, and the IAA supports this recommendation. The IAA continues to work on an on-going basis with the European Commission and EASA in the development of safety rules.
As the aviation regulator for Ireland, the safety of air crew and passengers is our number one priority. We want to restate our commitment to working with all stakeholders to achieve this aim, including the implementation of all safety recommendations in the AAIU report.
The IAA is currently undergoing a programme of institutional restructuring, which will establish a new, single, independent aviation regulator for civil aviation in Ireland. This conforms with best practice for institutional structure and governance for regulators in Europe and globally.
Pilot Dara Fitzpatrick
In a statement the family of pilot Dara Fitzpatrick said they believed that Dara and her fellow crew members were ""adly let down" "by operator CHC Ireland for ""ot providing them with the safe operating procedures and training that they were entitled to expect'"
Family response
The Fitzpatrick family said there was an expectation on the operator of the search and rescue service to minimise the risk to the crew by aiming to remove risk and providing crews with safety procedures on which they can rely.
"Unfortunately, this was not done on this occasion," "the Fitzpatrick family said.
"We hope that the AAIU final report and the review board report will ensure that those responsible for this operation, both directly and at a supervisory level, urgently implement the necessary changes, and that in future they pay attention to the feedback that they get from flight crew as to any inadequacies and hazards in the operation, so that such an accident will never happen again, that no one else will needlessly lose their lives, and that no other families will have to endure the devastating loss that we endure with the untimely death of our beautiful Dara," "the family stated.
