A long-awaited report into the crash of Irish Coast Guard helicopter Rescue 116 that killed all four crew members has criticised several navigational issues that contributed to the crash.
The final Air Accident Investigation Unit report, published on Friday, made a number of criticisms about the Irish Coast Guard, and the private company operating the helicopter.
Capt Dara Fitzpatrick, Capt Mark Duffy and winch team Paul Ormsby and Ciarán Smith died when their Sikorsky S-92 helicopter crashed at Blackrock island, 13km west of Blacksod, Co Mayo, in March 2017.
The helicopter was being operated by a company called CHC Ireland on behalf of the Irish Coast Guard.
The crew had been tasked to provide top cover for another helicopter, which was to airlift a casualty from a fishing boat 225km (140 miles) off the west coast late at night.
The report states that while 200 feet above the sea, Rescue 116 struck the western end of Blackrock island and then hit the sea.
The report said there were a number of factors that likely prevented the flight crew detecting Blackrock in time to avoid the land, such as issues with databases and charts available.
The crew were “unaware” the helicopter was heading for the 86m (282ft) island, with the mission taking place at night in poor weather.
The ordnance survey imagery available “did not show Black Rock, but instead showed open water at Black Rock”, the report said.
It added the Rescue 116 crew were from the east coast and would not have had the same level of local knowledge and familiarity as a crew operating on the west coast.
The situation was “compounded by darkness and poor weather,” and the crew’s night vision may have been “compromised” by the helicopters’ lights.
The report found the operator’s testing of routes used by crews was not “formalised, standardised, controlled or periodic”, and the design and review of routes “were capable of improvement in the interests of air safety”.
It stressed the importance of “effective oversight” of rescue services, and that “helicopters only launch when absolutely necessary”.
Both flight crew members had “commented adversely about the quality of cockpit lighting,” it said.
Blackrock island “was not identified on radar”, and was not on databases used by the crew, it added.
The report said the Irish Coast Guard “did not have a formal risk assessment process for helicopter missions”.
The operator’s manuals “were inconsistent in some areas and did not provide sufficient detail of processes and procedures for the discharge of some safety-critical functions”, it said.
Neither the Department of Transport nor the Coast Guard had “aviation expertise”, which raised questions around contracting and auditing helicopter operations.
The report said the Coast Guard “appears not to have appreciated the severity” of some issues raised in past audits and did not have a safety management system in place at the time.
Although the commander did manage to leave the helicopter after the crash and inflate her lifejacket, she would have been submerged 10m underwater. The cold water, darkness and shock likely acted against her survival, it said.
Training provided to flight crews around the route guide and electronic flight management system “was not formal, standardised and was insufficient” to address “inherent problems”, it said.
The report said the safety investigation was not concerned with “apportioning blame or liability”.
Not mapped
The report found pilots had raised concerns that Blackrock island was not mapped onto a warning system that alerted crews to nearby terrain, nearly four years prior to the Rescue 116 crash.
Blackrock island was not on the crew’s Enhanced Ground Proximity Warning System (EGPWS) database, which alerts pilots if an aircraft is in danger of hitting land.
The report said the omission of the island from the database “had been noticed in 2013”.
An email from 2013 suggested that a note be added to systems that Blackrock island and lighthouse were not on the terrain database. The report found this email “was not acted on”.
“There was no evidence that any of the eight people who were made aware by email that the EGPWS manufacturer had been contacted about adding lighthouses, followed up on the matter,” it said.
As the island was not on the database it was a “latent hazard” for pilots, the report said.
In the 26th June 2013 email, a pilot said he had noticed Blackrock lighthouse was not shown on the terrain warning system, which was an “obvious hazard”.
In another email two days later a pilot emailed the EGPWS manufacturer, informing them that “a few islands and lighthouses” did not appear on the database and asking if it was possible to have them included.
The manufacturer replied that a “problem report” would be opened into the matter.
The manufacturer later told the investigation that it had not been provided with “specific actionable data on what islands and lighthouses to add”, and the matter was closed in March 2015 with no action taken.
The pilot who raised the concerns had copied eight CHC personnel on the email seeking to have local lighthouses added onto the EGPWS database.
“The investigation was provided with no evidence that any of those eight personnel reverted to the pilot to enquire about progress on the issue,” the report said.
The report recommended CHC should review its guidance and training procedures around the use of the terrain warning system, to ensure crews were aware of its limitations.
The investigation also found there was a reluctance among staff to file safety reports on an internal system. This was due to a “fear of being criticised,” or in other cases because they felt “they would simply be closed without appropriate action being taken”.
Discrepancies
The 350-page report also details discrepancies in the descriptions of the initial injury on a fishing boat the rescue crews were tasked to respond to.
At 9.40pm the Malin Head Marine Rescue Sub Centre, Co Donegal, received a call from the captain of a fishing boat, as a crew member had lost “the top half of their thumb” in an accident. The report notes “there was no discussion regarding bleeding at this time”.
Shortly afterwards, an officer at the marine centre called the commander of Rescue 118, who was told the man on board had lost his thumb “and he’s obviously bleeding quite badly there so what I’d like to do is task you to that”.
Meanwhile, the captain of the fishing boat was given medical advice for how to treat the thumb while waiting for the man to be airlifted.
The Marine Rescue centre alerted counterparts in Dublin, and Rescue 116 was tasked to fly out and provide top cover for the airlift operation.
The Department of Transport has said it fully accepts the recommendations of the report, and “will continue to evaluate the findings of the report in the coming weeks”.
Minister for Transport Eamon Ryan described the crash as a “tragic accident that claimed the lives of four individuals who were dedicated to saving the lives of others”.
The publication of the report was a “key step in ensuring that such accidents are prevented in the future”, he said.
The Irish Air Line Pilots’ Association said the report showed the loss of life was “preventable”, and highlighted “regulatory and systemic issues” that put the crew in danger.
The statement said the helicopter crew were “exemplary in the performance of their assigned task,” while operating “offshore in challenging conditions”.
