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R116 crew had 13 seconds to avoid Blackrock island

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CRASH SCENE The crew of Rescue 116 made a desperate last minute attempt to avoid crashing into Blackrock Island.  Pic: Keith Heneghan/Phocus

Anton McNulty


THE crew of Rescue 116 had just 13 seconds to avoid a collision with Blackrock Island which was not included on the database of their warning system.
A 39-page preliminary report into the accident published last week found Captain Dara Fitzpatrick, the senior pilot of R116, made a desperate last second attempt to avoid a collision with the island but was unable to do so.
The report found that the crew were using the Operator’s Route Guide for landing into Blacksod and Blackrock Island was on their flight path. However, they were unaware of the island’s presence as the warning system to avoid crashes into terrain did not have Blackrock Island on its database.
The recording of the crew taken from data recorder on R116 showed that their first indication of Blackrock was just 13 seconds before the fatal impact when a rear crew member identified an island, probably through the use of the infrared camera.
He said; “looking at an island just in, directly ahead of us now guys, you want to come right [Commander’s Name]”.
In response to this, Commander Fitzpatrick asked “OK, come right just confirm?” and the rear crew member responded “twenty degrees right yeah”. The rear crew member then interjected, with increasing urgency, “Come right now come right COME RIGHT”.
In the final seconds, the helicopter pitched up rapidly but impacted with terrain at the western end of Blackrock. The last words from the helicopter were ‘We’re gone’ which were uttered from co-pilot, Captain Mark Duffy, just as R116 struck the island and crashed into the sea.
The last contact with R116 was at 12.46am on March 14 and the first indication it was missing was at 1.06am. At 1.08am, the Blacksod lighthouse advised that they had no contact with R116 and at 1.13am, Malin Head Marine Rescue Sub Centre issued a May Day which launched the extensive search which is still ongoing.
Commander Fitzpatrick was found shortly after the accident by the Achill lifeboat but died soon afterwards while the body of Captain Duffy was recovered from the cockpit on March 26. The bodies of the remaining two crewmen, Ciarán Smith and Paul Ormsby have yet to be recovered despite an extensive shore, sea surface and underwater search.
The report which was carried out by the Air Accident Collision Unit confirmed earlier reports that Blackrock which has an elevation of 282 ft and contains a lighthouse was not featured on the helicopter’s Enhanced Ground Proximity Warning System (EGPWS).
The EGPWS also provides a digital terrain map that allows the pilot to view a representation of terrain and obstacles ahead, provided these are contained in the databases.
In relation to Blackrock and its lighthouse, the EGPWS manufacturer informed the investigation team. “The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in our terrain database.”
Recommendations
The Air Accident Collision Unit recommended that CHC Ireland, who operate the search and rescue helicopters on behalf of the Irish Coast Guard, 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 crew of Dublin-based R116 had been dispatched to provide top-cover for the Sligo-based R118 which was involved in a medical evacuation of a fishing vessel 141 nautical miles west of the Mayo coast.
They were returning to Blacksod lighthouse to refuel when the disaster struck. The report also indicated that the Dublin-based crew spoke of their lack of knowledge of the terrain around Blacksod.
Capt Fitzpatrick was recorded commenting to the other crew members on a number of occasions that it had been a substantial period of time since she had previously landed in Blacksod. On one occasion she asked the Co-pilot when he had last been into Blacksod and he indicated that he had not been there recently.
Before the impact, the flight data recorded showed that the helicopter was in a stable level flight at 200ft and travelling at a speed of 75 knots.
The Commissioners of Irish Lights conducted a review of all data for the light houses at Blackrock, Blacksod, Eagle Island and Achillbeg for the night of the accident. It concluded that the four lighthouses in the vicinity of the R116 accident location were operational over the period of interest.
Following the accident, debris from the helicopter was found on Blackrock, floating in the sea to the east of the rock and washed up on the shoreline of counties Mayo and Donegal. The main wreckage was found by locating the acoustic beacon attached to the Multi-Purpose Flight Recorder, which was located in 40m of water off the southeast side of Blackrock.
The report found that based on damage patterns examined during the wreckage layout and observations carried out from the ROV surveys, ‘it appears that the helicopter was in a nose high attitude when it impacted with Blackrock’.
The secondary safety recommendation was made to the manufacturer of the lifejackets after the investigation identified a matter of concern relating to the installation of the locator beacons in the lifejackets worn by the crew.
“RFD Beaufort Ltd [manufacturer] should review the viability of the installation provisions and instructions for locator beacons on Mk 44 lifejackets and if necessary amend or update these provisions and instructions taking into consideration the beacon manufacturer’s recommendations for effective operation,” the safety recommendation read.

Ceremony
Over the weekend, the crew of Rescue 116 were remembered in an emotional wreath-laying ceremony during which four flares were set off - one for each lost hero.
More than 800 people attended the event for the victims of the tragedy, including Captain Dara Fitzpatrick’s sister, Niamh.
The commemoration, organised by the RNLI lifeboat service off Dunmore East, Co Waterford, also included rescue workers from across the country.

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