A warning system that increases pilot ‘situational awareness’ did not include Black Rock and its lighthouse or the terrain of the island in its database, according to the preliminary report of the Air Accident Investigation Unit into the crash of Irish Coast Guard helicopter R116 (March 15) that claimed the lives of Captain Dara Fitzpatrick, co-pilot Capt Mark Duffy, winch operator Paul Ormsby and winchman Ciaran Smith.
ILV Granuaile supports the ROV and divers during search operations of R116 at Blackrock island
A digital map that allows the pilot to view a representation of terrain and obstacles ahead is included in the Enhanced Ground Proximity Warning System (EGPWS), ‘provided these are contained in the database’.
EGPWS manufacturer, Honeywell, informed the Investigation that compliant processes include the ‘integration and validation’ of multiple public and private data sources, furnished by customers, governments and private industry. It added however: ‘Honeywell’s selected terrain and obstacle source data do not include Black Rock.’
And while the island is present in alternate data sets, ‘the actual altitude of Black Rock is considerably higher than what is indicated in these alternate data sets.’ They confirmed the obstacle data for ‘the Ireland region’ is sourced from their ‘Type 1 LOA supplier’. This data ‘does not include obstacles on Black Rock’ Honeywell told the Investigation.
The EGPWS also includes basic modes that prevent descent into level or evenly sloping terrain. Enhanced or ‘look ahead’ modes are based on Global Positioning System (GPS) position compared to terrain and obstacle databases. ‘Look ahead’ modes are intended to prevent the aircraft from running into ‘sharply rising terrain or man-made obstacles’, the report notes.
While the Investigation is still at a preliminary stage, it has made two interim safety recommendations. It notes that as the flight crew has been using an operator-specific route guide it would be appropriate that the operator should review all such route guides.
‘CHC Ireland 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 Investigation also notes ‘a matter of concern’ relating to the installation of the locator beacon in the lifejackets worn by the pilots, which ‘appeared’ to be in accordance with a Service Bulletin issued by the lifejacket manufacturer RFD Beaufort Ltd.
‘This shows the GPS antenna in the same pouch as the beacon. However, the beacon manufacturer’s publications recommend a minimum separation between beacon and GPS antenna of 30 centimetres (cm).’
The AAIU has recommended that the manufacturer ‘should review the viability of the installation provisions and instructions for locator beacons on Mk44 lifejackets and if necessary amend or update these provisions and instructions taking into consideration the beacon manufacturer’s recommendations for effective operation’.
R116 had responded to a call to provide ‘top cover’ for a medical evacuation of an injured fisherman from a fishing vessel, 141 nm off the Co Mayo coast. The Air Corps could not respond to the mission request as they had no availability until 08.00 hrs.
The first indication that R116 could be missing was at 01.06 hrs on March 14 when the helicopter crew did not answer radio calls to their call-sign.
In the final seconds, R116 ‘pitched up rapidly’, impacted with terrain at the western end of the Black Rock and departed from controlled flight.
An extract of ‘relevant data’ from the recovered Control Voice Recorder notes the last words of co-pilot Capt Mark Duffy: “We’re gone.”
The Final Report of the AAIU will consider 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 report notes: ‘The sole purpose of this investigation is to prevent aviation accidents and serious incidents. It is not the purpose of any such investigation and the association investigation report to apportion blame or liability. A safety recommendation shall in no case create a presumption of blame or liability for an occurrence.’
Irish Coast Guard
The Coast Guard has reiterated its sympathy to the families of Paul, Dara Mark and Ciaran.
“It remains a matter of huge regret that Paul and Ciaran’s bodies have not yet been recovered and everybody is acutely aware of the upcoming memorial services for Paul and Ciaran,” remarked Gerard O’Flynn Search and Rescue Operations manager
Gerard O’Flynn thanked the families for taking the decision to proceed with the ceremonies in these most difficult circumstances. He also asked everybody to be mindful of the sense of loss and bewilderment being experienced not alone by their families but also by their colleagues in CHC Ireland who continue to provide day and night helicopter search and rescue services in addition to aero medical support to the HSE/National Ambulance Service.
He thanked the many Statutory and Voluntary organisations that participate in the search off Blacksod, a Search that extended from South of Achill to North of Donegal Bay.
“Despite the tragedy of the situation, the level of cooperation and coordination between a multiplicity of groups in what was an unprecedented search was hugely impressive.
The local community in the Blacksod area deserve special mention for the support they provided over several weeks to the many searchers and most importantly to the families of Paul, Ciaran, Dara and Mark”.
He also thanked the many people who made donations of food and money to the local community organisers.
“Nobody expects the rescuers to become the casualties and it was indicative that so many organisations who benefited from Coast Guard service made such a huge effort to support the search”.
Ar dheis Dé go raibh a n-anamacha
‘The RNLI stands with our colleagues in the Irish Coast Guard as they deal with their terrible loss. The search for the crewmembers involved six RNLI lifeboats with volunteer lifeboat crews travelling from across the country to support their colleagues.
Lifeboat stations lowered their station flag to half-mast or opened Books of Condolence as marks of respect. RNLI lifeboats work hand- in-hand with Irish Coast Guard helicopters; their presence providing an additional asset to work alongside our volunteers and offering much needed cover and support in the most challenging of callouts.
The crews train alongside each other year-round and share valuable knowledge and experience that undoubtedly has saved many lives. Our thoughts remain with the families and colleagues of Rescue 116 and we will continue to keep them in our thoughts.
Irish Fish Producers Organisation: Francis O’Donnell
We take much for granted in 2017 having reached an era of near instant communication.
Machines and communication routes don’t work on their own. Hard working, family-orientated and ordinary decent people make these systems work and in particular when it comes to the safety at sea for all marine users. We often forget those very people have family like you and I, friends like you and I.
On March 14, Capt Mark Duffy; Capt Dara Fitzpatrick and colleagues Ciaran Smith and PaulOrmsby left their Dublin base by helicopter to carry out support for what we have come to consider as a routine rescue of a fishermen injured on a fishing vessel, one hundred and fifty miles off the west coast of Ireland.
We all go about our day-to-day business, not thinking that at some point, someone somewhere will get into a tricky or life threatening situation. We make that phone call for help, knowing that the most professional and hard-working people will start an operation with the sole focus of bringing that person back safe. Their DNA is unique; it comprises putting their own lives at risk to save others without giving it a second thought.
They wouldn’t have it any other way. They are special people, gifted by an unequalled lack of selfishness.
Very sadly on this occasion the rescuers got into difficulty. Recovering the entire crew is now the primary objective with the secondary objective of trying to understand what actually caused the accident. We owe our very deep gratitude to all of the crew of rescue helicopter 116; to all of their colleagues and to all the rescue services in general.
This accident has brought into sharp focus — as it has done many times in the past— for Ireland’s fishing industry the pain experienced by families and loved ones when people are tragically lost while doing their job. Behind the person there is a whole world that collapses suddenly in situations like this, there is debris everywhere.
The Irish fishing industry is extremely privileged to have such brilliant people across all of the rescue services, available to them 24/7. Many give their time on a voluntary basis while others are full-time employees. Either way, they provide a professional service and never wane in their commitment to bring injured people or those who have been tragically lost, back to their loved ones.
Capt Mark Duffy; Capt Dara Fitzpatrick; winch men Ciaran Smith and Paul Ormsby, were some of the top life savers in Ireland and it is certainly poignant that they lost their lives doing what they loved the most — helping others.
On behalf of my own organisation and the Irish fishing industry I offer our sincere condolences to their respective families, friends and colleagues in what is a very painful time for them.
LAST: Caitlin Ui Aodha
I again send our deepest sympathies to the comrades, friends, and especially the families who so tragically lost their loved ones in Rescue 116 on March 14. We think especially this weekend of the families of Ciaran Smith and Paul Ormsby, as the Smith family celebrate Mass in memory of Ciaran and his comrades.
LAST (Lost at Sea Tragedy) had been in contact with the families over the last few weeks of the search, when we saw one of the biggest searches by fishing vessels ever undertaken, along the west and northwest coast.
Thanks to the hard work and dedication of Eamonn Dixon, and the local fishermen of Belmullet – Shaun Curran our vice chair in Killybegs and Jerry Hassett; on the second weekend over 100 divers were organised and coordinated by John Carney.
Indeed, once the appeal went out, boats, divers and hillwalkers arrived from all around the island. In true form, local fishermen and divers expressed their desire to carry out these searches — and they did so until all avenues were exhausted, and were privileged to be allowed to give their time and efforts in the hope of recovery that would have brought some comfort to the families.
Fishermen appreciate the work and time that the rescue services put in to help them in their time of peril. This tragedy rang a very sad and sombre note to all sea-going people: that those who go to our rescue do so at the risk to their own lives. So it was with deepest sadness that despite all efforts, the sea still refuses to give up their bodies.
As too many around the coast know – there is scarcely a greater pain for families than to lose someone so tragically, itself horrendous, but not to recover their bodies and return them home, even more so.
As an island people we once again showed our true nature. The effort by local men, women and children who got up every day to make tea, soup, lit candles and pray has to be commended.
I was asked in March if I would like to chair LAST, and I am so grateful to give back to our fishing families and local communities who were so helpful and supportive in our difficult weeks of the search for the crew of the TitBonhomme.
It is our aim in LAST to have a committee in every harbour, to assist those who need it – be that fishermen, their families, those involved in aquaculture, or as we recently saw, those who make work to keep us safe, in any way we possibly can — be it as big or small as a cup of tea, to light a candle, or hold a hand.
These things are just as important to families who find themselves faced with such sudden loss. Families need support in those difficult times – a time that is made harder by logistics that mean they are often only afforded very limited information during an ongoing search, and then, very unfortunately, are left to face very publicly, snippets of information that should never be in wider circulation than is necessary – most certainly not as soundbites for the media.
Is this necessary? Who does that serve?
We greatly appreciate the work of our rescue services, Coastguard, RNLI, navy and Gardaí. Without local people to assist however, providing food and shelter and especially local fishermen, whose local knowledge is invaluable, these searches would be a lot more difficult. LAST was in a position to help financially and this was crucial too.
LAST will hold a meeting in Galway on June 10 and we would like to see as many people there as possible, so we can make a plan about how to move this forward.
Along with Eamon Dixon, and fishermen from all over the west and northwest coast who joined in the search, and many others, I left Belmullet with a very sad heart. But now is the time to drive this forward; we need to be in a position to assist each other should such a tragic event arise again.
We know only too well that sadly it will, somewhere around the coast.
Marine Institute: Dr Peter Heffernan
It was such a terrible tragedy to lose the crew of Rescue R116 who saved the lives of so many people responding routinely to accidents and emergencies, sometimes in very dangerous conditions and our thoughts and sympathies are with the families, friends and colleagues of the crew of Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciaran Smith.
Marine Institute staff assisted with the search operation over three weeks at Blacksod, alongside a large team of people, agencies and volunteers. Together with so many others, we did what we could to help, and we feel privileged to have been able to play our part in the huge search and recovery effort and to try to bring some closure to the family and friends of the crew.
Initially we deployed the national research vessel, RV Celtic Voyager to Blacksod to begin the seabed mapping and scanning, to aid the search and recovery operation, and later deployed our remotely operated submarine, ROV Holland I, which was fitted with specialist equipment and video cameras, and formed an important part of the search.
Our INFOMAR team — a joint seabed mapping programme with the Geological Survey Ireland — played a key role in scanning and mapping the seabed to identify target search areas and to facilitate the safe operation of the ROV Holland I and the navy and Garda dive team operations throughout the duration of the search operation. Our ocean modelling team also provided the Coast Guard with predictive models incorporating wind and tides to assist with search areas.
The effort coordinated by Marine Institute included support from INFOMAR colleagues at the Geological Survey of Ireland (DCCAE) who deployed their shallow-water mapping vessel RV Geo, and P&O Maritime who operate our research vessels and expertly pilot the ROV Holland I. These teams formed part of a much wider group including the Coast Guard, RNLI and Civil Defence volunteers and Defence Forces assets including naval divers, ships and Air Corps.
The operation showed the real value of inter-agency cooperation, as well as the importance of having specialist national marine research infrastructure available and experienced people to bring their expertise and skills to meet the challenges of this type of mission.