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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 island 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 R116Rescue 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 FitzpatrickPilot 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.

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Minister for Transport Eamon Ryan has said his department will cover “reasonable legal expenses” incurred by the families of the four Rescue 116 air crew who died off North Mayo in relation to a review of the draft final Air Accident Investigation Unit (AAIU) report.

In a statement issued this Thursday evening, Mr Ryan said he had written to the families of the crew of R116 that afternoon.

He said he had “ let them know that the Department of Transport will cover their reasonable legal expenses incurred as a result of the Review into the accident in which their loved ones lost their lives”.

Pilots Dara Fitzpatrick and Mark Duffy and winch team Paul Ormsby and Ciarán Smith died when their Sikorsky S-92 crashed at Blackrock island off north Mayo in the early hours of March 14th, 2017.

The four crew were employed by CHC Ireland which holds the Irish Coast Guard search and rescue contract.

The AAIU issued a preliminary and interim reports, and sent its draft final report to “interested parties” in September 2019 with a 60-day window for submissions and comments.

However, in March 2020, former transport minister permitted the establishment of a review board to examine certain findings in the draft final report before publication, following a request from one of the parties.

A review board, chaired by senior counsel Patrick McCann, was established under Regulation 16 of Air Navigation Regulations 2009.

The Irish Airline Pilots Association and European Cockpit Association were critical of this decision as being against the international norm, which seeks to ensure investigations are published within a timeframe to improve safety.

The AAIU does not apportion blame, and this was the first time its draft final report had been subject to such a review.

Earlier this week, RTÉ Investigates reported that three of the four families were obliged to pay for their own legal representation in the review which had been sought by the air crews’ employer, CHC Ireland, and had incurred substantial costs.

Ryan said that “the chairman of the Review board wrote to me with a recommendation that the reasonable legal costs of the families be covered”.

“I was happy to accept this recommendation and asked my officials to work on a mechanism to resolve the issue,” he said.

“The families of the crew did not ask for the review and were placed in a position of having to contribute to a complex process to ensure their loved ones’ interests were fully represented,”Ryan said.

“While the Department of Transport argued before the review board that it did not have authority to make an order on costs, this was done because of the broader implications that such a ruling might have in future,” he said.

“ This was never intended to imply a reluctance to pay these costs, and the additional stress this may have caused is regretted,” he said.

“In writing to the families, I am also conscious that they will shortly receive the final report of the investigation into the accident, a moment which is bound to be difficult for all concerned,” he said.

“Today we remember the service of pilot Dara Fitzpatrick, co-pilot Mark Duffy, winchman Ciarn Smith and winch operator Paul Ormsby who gave their lives in the courageous pursuit of protecting others,” Ryan said.

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Skerries RNLI’s volunteers launched their inshore lifeboat on Wednesday evening (21 April) as part of a multi-agency response to reports of a swimmer in difficulty near the Martello tower in Balbriggan.

The Atlantic 85 lifeboat Louis Simson was launched within minutes of the crew being paged just before 7pm and proceeded directly to the area indicated.

On arrival the crew found the Dublin-based Irish Coast Guard helicopter Rescue 116 already on scene and winching a man from the water.

The casualty was the lowered onto the beach and into the care of an ambulance crew and members of Dublin Fire Brigade who administered first aid before he was transferred to hospital.

Meanwhile, further reports came in that other swimmers had entered the water to assist the casualty and a subsequent emergency call raised concerns that there may still be someone in the water.

Rescue 116, Skerries RNLI and the Skerries Coast Guard unit coordinated to carry out a search of the immediate area covering the water and the shoreline.

The lifeboat investigated a number of objects at the request of Rescue 116, including a lifebuoy which they recovered into the lifeboat.

When Dublin Coast Guard was satisfied that the area had been thoroughly searched and there were no further swimmers in danger, the lifeboat was stood down and returned to station.

Speaking about the callout, press officer Gerry Canning said: “When a person is in trouble in the water, every second counts. Rescue 116 were on scene very quickly and it was an excellent response from all of the emergency services who worked brilliantly together.

“Our thoughts are with the friends and family of the man taken from the water and we hope he makes a full recovery.”

Published in RNLI Lifeboats

A European pilots’ organisation has expressed alarm at the delay in publishing the final report into the loss of four air crew in the Rescue 116 helicopter crash off the Mayo coast four years ago.

As The Times Ireland edition reports, European Cockpit Association (ECA) president Captain Otjan de Bruijn has also questioned why Ireland had adopted a “rare procedure” where an aviation accident investigation can be re-examined before publication.

An air accident investigation must be published to ensure key safety lessons can be learned “swiftly”, Capt de Bruijn said, and he has urged release of the report “without delay”.

Capt Dara Fitzpatrick, Capt Mark Duffy and winch team Paul Ormsby and Ciarán Smith died after their Irish Coast Guard Sikorsky S-92 helicopter crashed at Blackrock island off the north Mayo coast on March 14th, 2017.

The four Dublin-based helicopter crew were providing “top cover” communication for the medical evacuation of a crewman from a British-registered fishing vessel off the west coast.

The Air Accident Investigation Unit (AAIU) issued a preliminary report and a series of interim reports, and a final draft report was given to families and stakeholders in late 2019, with a 60-day period for submissions.

However, its publication was put on hold by a request in January 2020 by an unidentified stakeholder for a review, which was granted by Ryan’s predecessor, Shane Ross.

The ECA president said that the final report was due in January 2020, and it “is an extremely long delay for publishing a report”

Capt de Bruijn said that during these four years, “possible safety-critical flaws have remained unaddressed – something we are quite alarmed about”.

“Any deficiencies that have been identified in the accident investigation must be made public, out in the open so they can be fixed swiftly. In the interests of passenger safety, we urge the Irish AAIU to release the report without delay,” he said.

“We are not aware of any other similar cases across Europe of a re-examination of the technical work of an independent technically qualified organisation by a body with limited expertise in aviation accident investigations,” Capt de Bruijn said of the review board option.

“This rare procedure could be a slippery slope allowing for undue influence over the investigation process and its findings, and clearly has resulted in an unhelpful delay in the publication of the report,” he said.

“Let us not forget that the final report contains safety-critical recommendations that are valuable – and potentially life-saving – lessons for the aviation system in and beyond Ireland,” he said.

The Irish Airline Pilots Association (IALPA) has already questioned the decision to include a review in the Irish legislation, and said the review “does not comply with the standards and recommended practices laid down by the International Civil Aviation Organisation (ICAO)”.

The Department of Transport said, “the review board is independent in its work in accordance with the 2009 Regulations and the timeframe for the board to carry out the re-examination is a matter for the chairperson to determine”.

Read more in The Times here

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Minister for Transport Eamon Ryan has appointed a new review board into the Air Accident Investigation Unit’s (AAIU) final report on the Rescue 116 helicopter crash.

As The Irish Independent reports today, the review experienced a setback last month when the technical advisor Philip Hanson, an aviation expert with the British Maritime and Coastguard Agency, stood down over a potential conflict of interest.

However, Mr Ryan has established a new board to review aspects of the unpublished AAIU final report into the crash, which claimed the lives of Capt Dara Fitzpatrick, Capt Mark Duffy and winch team Paul Ormsby and Ciarán Smith off the north Mayo coast in March 2017.

The minister has opted to re-appoint senior counsel Patrick McCann as chairman and sole member of the review, following legal advice from the Attorney-General.

Mr McCann was chair of the previous review which was established by former transport minister Shane Ross earlier this year, and Mr Hanson was appointed as technical expert.

In a parliamentary response to Galway West Independent TD Catherine Connolly, the transport minister says the new timeframe for the re-examination of the final report is “ a matter for the chairperson to determine” as the board is “entirely independent in its work”.

Relatives of the four air crew are now waiting over three-and-a-half years for the final report into the Sikorsky S-92 collision, which occurred at Blackrock island, Co Mayo, while the helicopter was approaching Blacksod lighthouse to refuel.

The four Dublin-based crew were providing “top” cover” or support to a medical evacuation off the west coast by the Sligo-based Rescue 118 helicopter.

The bodies of the two winch crew have not been found in spite of extensive searches.

A draft of the final report was given last November to the families of the four crew and stakeholders including their employer, CHC Ireland, with a 60-day period for submissions or comments.

However, its publication had to be put on hold when Mr Ross acceded to a request for a “notice of re-examination” by an unidentified stakeholder.

Under Ireland’s Air Navigation (Notification and Investigation of Accidents, Serious Incidents and Incidents) Regulations 2009, a review can be applied for by an “interested party” in relation to “findings and conclusions that appear to reflect adversely on the person’s reputation”.

A Department of Transport spokeswoman said the minister was notified of Mr Hanson’s alleged conflict of interest on September 22nd. She said Mr Hanson did not receive any payment for his work on the review board over the past six months.

CHC Ireland has declined to say whether it sought the review. It was the first request of its type in the AAIU’s history of undertaking air crash investigations.

The AAIU had ruled out mechanical fault early on, and made recommendations in a preliminary report published a month after the helicopter crash, relating to anomalies in chart information software and a flaw in installation of locator beacons on crew life-jackets.

In its first interim report, the AAIU highlighted failures of oversight for search and rescue by the State.

It also recommended a review of safety management systems by CHC Ireland; and it identified a software issue with data recorded, which was not directly relevant to the cause of the crash.

It recommended a thorough review of search and rescue aviation operations in Ireland, which former minister Mr Ross commissioned.

Read more here

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In the absence of this year’s Bray Air Display due to the coronavirus pandemic, the Irish Coast Guard’s Dublin-based helicopter Rescue 116 conducted a special fly-past to pay tribute to Ireland’s frontline healthcare workers.

The Sikorsky S92 helicopter took to the skies over the Co Wicklow town at 3pm yesterday, Saturday 25 July, on the same afternoon it flew to the rescue of a family of four stranded by the tide at Sandymount.

Rob Tatten, general operations manager of CHC Ireland, which operates the coastguard’s SAR helicopter service, was in attendance to make small presentation to Mr Paul Reid, chief executive of the HSE, and spoke before the event.

He said: “CHC, who operates the helicopter search and rescue contract on behalf of the Irish Coast Guard, has been taking part in the Bray Air Display every year. However due to the pandemic that wasn’t possible this year.

“But with the organisers of the show we said could we do something to recognise the phenomenal work of our fellow frontline healthcare workers, who like us continue to work 24/7, 365 days a year.

“So today, Rescue 116, while out training, will do a fly-past to thank those workers while we also make a short presentation to Paul Reid and other frontline workers to say thank you on behalf of CHC, the Irish Coast Guard, the aviation community and Bray Air Display.”

Published in Coastguard

The Irish Coast Guard’s Dun Laoghaire unit launched to the rescue of a family of four cut off by the tide on Sandymount yesterday afternoon, Saturday 25 July.

Dun Laoghaire Coast Guard were tasked to incident along with the local RNLI’s inshore lifeboat and the Dublin-based coastguard helicopter Rescue 116.

The two adults and two children were retrieved from their sandbank by the helicopter crew, who landed them at a safe spot on land where they wiremen by a coastguard team. All were found to be in good spirts.

Emergency services remind the public if you see anyone in difficulty in or near the water to dial 112/999 immediately and ask for the coastguard.

Published in Rescue

Vertical Magazine has shared video of a roundtable discussion on helicopter rescues from earlier this year, featuring a member of the Rescue 116 crew with the Irish Coast Guard.

Helicopter winchman Derek Everitt was in attendance at the HAI Heli-Expo in Anaheim, California this past January, where he took part in a talk with fellow professionals about their ‘life on the wire’.

He was joined by Montana-based air rescue specialist Wil Milam, fire rescue pilot Tony Webber, Canadian rescuer Rob Munday, Las Vegas police flight instructor Dave Callen and hoist operator and paramedic Jason Connell.

The wide-ranging discussion, which can be seen in the video above, included their most memorable rescues — and some of the biggest mistakes they’ve learned from.

For Everitt, his most memorable “screw-up” was as young crewman with the Air Corps involved an unplanned landing at a mountain crossroads for his pilot to impress a high-ranking friend — with embarrassing results.

Vertical has much more on the story HERE.

Published in Coastguard

Air navigation services run by the Irish Aviation Authority (IAA) have not been adequately resourced and were still suffering from staffing shortages for at least two years after the Rescue 116 helicopter crash, The Sunday Independent reports.

A review for the Department of Transport also calls for a "just culture body" which is "robust" to be implemented as soon as possible to protect pilots and other crew members who make confidential reports on safety concerns.

And it criticises delays in separating the State aviation authority's conflicting functions of safety regulation and commercial operations.

The lack of accurate air navigation charts available to Irish Coast Guard helicopter search and rescue crews was one of the key issues highlighted after the Rescue 116 crash which claimed the lives of Capt Dara Fitzpatrick, Capt Mark Duffy, Paul Ormsby and Ciaran Smith off north Co Mayo on March 14, 2017.

The final report into the crash has still not been published as an unidentified stakeholder has been granted a review of the final draft report by Minister for Transport Shane Ross.

In late 2017, the IAA had invited search and rescue and other pilots to help correct aeronautical charts after it conceded charts published three months after the crash were inaccurate, with lighthouses in wrong locations and obscure symbols.

Although the IAA is responsible for providing aeronautical charts under State safety plans, it has said it does not guarantee their accuracy or completeness and disclaims all liability.

The review of the IAA technical and safety performance by Helios and Egis Avia consultants during the second and third quarters of 2019 found the IAA air navigation division staff were having to work "extended hours", as posts could not be filled after one inspector left and one took maternity leave.

The "slow pace" of separating safety regulation from money-making commercial activities within the IAA and the potential workload increase for IAA staff as a result of Brexit are other issues flagged in the review.

For more, read The Sunday Independent report here

Published in Coastguard
Tagged under

The Irish Coast Guard has issued a statement marking three years since the loss of four crew of the helicopter Rescue 116 off Co Mayo.

Capt Dara Fitzpatrick, Capt Mark Duffy, and winch crew Paul Ormsby and Ciarán Smith died when their Sikorsky S-92 hit Blackrock island off north Mayo in the early hours of 14 March 2017. The bodies of Ormsby and Smith have not been found to date.

The coastguard said: “As our frontline and emergency service workers yet again distinguish themselves during this current crisis, we remember Dara, Mark, Paul and Ciarán who we lost three years ago today. Four of Ireland’s finest stepped out into the darkness to come to the aid of strangers.

“Two brave souls were brought home, two remain lost to the sea, but all four will be forever remembered for the sacrifice they made. Our thoughts today are with the families, friends and colleagues of Dara, Mark, Paul and Ciarán.

“Go Mairidís Beo.”

Last night, Belfast Coastguard paid respects to their colleagues in the Republic, stating: “Three years on the sense of loss and disbelief is still very much real for us all. Tonight especially, we remember the crew and their families.”

And in a touching tribute following a tidal cutoff rescue yesterday (Friday 13 March), the crew of the helicopter now using the Rescue 116 callsign left a special signature of a heart in the sky to remember those lost.

Afloat.ie reported on Thursday (12 March) that a senior counsel has been appointed to chair a review into aspects of the State investigator’s final report on the 2017 helicopter crash.

Published in Coastguard
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