2017 Irish Coast Guard Rescue 116 crash

Summary

In the early hours of 14 March 2017, a Sikorsky S-92 helicopter operated by CHC Helicopter under contract to the Irish Coast Guard (call sign Rescue 116) crashed into the sea while supporting a rescue operation off County Mayo, on Ireland's west coast. All four crew members on board, Captain Dara Fitzpatrick, Chief Pilot Mark Duffy, winch operator Paul Ormsby, and winch man Ciarán Smith were killed.[1][2][3][4][5][6][7][8][9]

2017 Irish Coast Guard Rescue 116 crash
EI-ICR, the helicopter involved, photographed in August 2013
Accident
Date14 March 2017
SummaryControlled flight into terrain in poor weather, at night
SiteBlackrock Island, County Mayo, Republic of Ireland
54°04′01″N 10°19′13″W / 54.0669°N 10.3202°W / 54.0669; -10.3202
Aircraft
Aircraft typeSikorsky S-92A
OperatorCHC Helicopter for Irish Coast Guard
Call signRescue 116
RegistrationEI-ICR
Flight originDublin Airport, Republic of Ireland
StopoverBlacksod Lighthouse, Republic of Ireland
Occupants4
Crew4
Fatalities4
Survivors0
2017 Irish Coast Guard Rescue 116 crash is located in island of Ireland
Blackrock island
Blackrock island
Dublin
Dublin
Sligo
Sligo
class=notpageimage|
Location of crash site

The Air Accident Investigation Unit released its final report on 5 November 2021. It concluded that the probable cause was that while the helicopter was flying towards its intended landing spot at 200 ft, at night, in poor weather, the crew was unaware of the presence of a 282-foot obstacle in their flight path.

Events edit

During the evening of 13 March 2017, the Malin Head Coastguard took a call from the captain of a fishing boat 250 kilometres (130 nmi) off the west coast, who reported that one of his crew had suffered an accident in which he had lost part of his thumb. The decision was made to evacuate the casualty to hospital, and two helicopters were despatched for this purpose: Rescue 118 would winch the injured fisherman on board and transport him to land, while Rescue 116 would provide "top cover" support.[10](pp207-211) (In search and rescue opearations, top cover is when a second aircraft is used to relay communications between a rescue aircraft far from land and its co-ordination centre on the shore).[11]

Rescue 118 took off from its base at Sligo at around 10:30 and, after a refuelling stop at Blacksod Lighthouse, proceeded to meet the fishing boat. Rescue 116, based in Dublin, took off just before 11pm, and headed to Blacksod to refuel, a journey of 1¾ hours. Approaching Blacksod over the sea at 200', the crew failed to see Blackrock Island, 9.5nmi west of Blacksod,[10](p230) until it was too late. Despite a last-moment evasive manoeuvre, at 12:46am the helicopter struck the western slope of the island. The collision damaged the tail structure rendering the helicopter uncontrollable, and it tumbled into the sea off the eastern side of Blackrock.[10](pp13-16, 310) The alarm was raised by the crew of the lighthouse when the helicopter failed to arrive as expected, prompting the Marine Rescue Coordination Centre (MRCC) in Dublin to declare an emergency.[10](pp127-129)

Once Rescue 118 had finished winching the injured fisherman on board, it flew to Blacksod where it located the body of R116's captain in the water; the body was retrieved by the RNLI Achill lifeboat.[10](pp127-129) Rescue 115, the Shannon-based Coast Guard helicopter, was dispatched to the area to aid in the search for the other three crew members, along with a CASA CN-235 maritime patrol aircraft from the Irish Air Corps.[12]

On 18 March, the funeral for Captain Dara Fitzpatrick was celebrated, in Glencullen, County Dublin.[13][14][15]

Wreckage recovery and search for the missing edit

The Irish Naval Service offshore patrol vessel Róisín arrived in the search zone at 9:00 am[failed verification] on 14 March.[12] Divers from the Naval Service Diving Section and Garda Water Unit were also sent to the scene. The Naval Service flagship Eithne joined the search effort[16] that afternoon,[failed verification] and both Naval Service vessels continued the search throughout the night and into the next day.[citation needed] Eithne was made on-scene coordinator of the recovery mission. The Marine Institute's RV Celtic Voyager was dispatched on the night of 14 March to search using multibeam echosounders to help locate the wreckage.[17]

The Commissioners of Irish Lights sent the ILV Granuaile, an advanced multifunctional vessel, to the scene. The vessel is equipped with a dynamic positioning system which allows it to operate in difficult sea conditions, cranes capable of hoisting recovered wreckage and a helicopter platform.[18] The Marine Institute's work class ROV Holland one was mobilised onto the Granuaile in Galway harbour.[16] The Geological Survey of Ireland surveyed the underwater region and carried out detailed mapping where the search was focused on to aid diving teams in the recovery of the wreckage.[16] The Navy's Samuel Beckett later joined the recovery efforts and assumed command as the on-scene coordinator.[19]

 
Blackrock

On the afternoon of 15 March, a signal transmitting from the helicopter's multi-purpose flight recorder[a] was detected by a team from the Irish Marine Institute using USBL equipment from a local fishing[citation needed] vessel.[20]: 27 [21] The signal emanated at around 50 metres (55 yd) southeast of Blackrock Island,[22] and on 22 March, the main wreckage of R116 was located on the sea bed at a depth of 40m by the Marine Institute Holland 1 ROV,[21][23][24][25]

Naval Service divers reached the helicopter on 24 March and recovered the flight recorder.[26][19] The black box had some superficial damage, and was flown to the UK Air Accidents Investigation Branch where the data were downloaded.[10](pp75-76) Two days later divers removed the body of co-pilot Mark Duffy from the cockpit and brought it to the surface.[1][27] The funeral for Captain Duffy was celebrated in County Louth on 30 March.[28]

Throughout the recovery attempts weather and sea conditions forced diving to be suspended for long periods for safety reasons. The large sea surface and underwater swells and currents around Blackrock Island made it dangerous for divers to operate and decompress safely from 40m depths. [15] In tandem with wreckage salvage there were extensive aerial, sea and coastline searches.[29]

On the evening of 2 April, the main bulk of the helicopter was raised from the sea and placed aboard the Irish Lights vessel Granuaile. After the lifting of the wreckage, it was confirmed that there was still no sighting of either winch operator Paul Ormsby or winch man Ciáran Smith. [30]

Families of the missing crewman appealed for fishermen and seafarers to join in the search,[31] [32] [33] [34] and on the weekend of 8-9 April 2017 over 110 fishing vessels joined RNLI lifeboats, Irish Coast Guard and others in a co-ordinated sweep of over 8,500 square kilometres from Blacksod to Donegal in one of the largest sea searches in Irish maritime history.[35] Granuaile and its ROV returned to the site in July to make another search of the seabed for the missing crew members, without success.[10](p126-127)

Air Corps resourcing issues edit

The use of Rescue 116 to provide top cover on this mission was a second choice. The Coast Guard had first asked the Defence Forces for the use of one of their CASA CN-235 maritime patrol aircraft to undertake this task. The use of the fixed-wing CN-235 is generally considered preferable in this role because it can reach the scene quicker and remain on station for longer than a helicopter can,[36][37] but on the night of 13-14 March this was not possible because of a staff shortage in experienced and trained personnel which made it unable to operate an "out-of-hours" roster.[38][39] This was the third time in 2017 that a request for top cover was refused due to reduced availability.[40][41]

At 1:45 am, an hour after last contact from Rescue 116, the Coast Guard made an emergency request for assistance to the Air Corps to help search for the missing SAR helicopter. The Air Corps activated its recall plan and 3 hours and 45 minutes after the Coast Guard's initial request for top cover, a CASA CN-235 maritime patrol aircraft was airborne.[36][40]

Since the crash took place, there have remained safety concerns for search and rescue helicopter services in Ireland, with problems including cartographic errors and omissions, problems with the navigational software, inadequate life jackets and a lack of oversight of the Search and Rescue service.[42][needs update]

Investigation edit

The investigation on the accident was conducted by Air Accident Investigation Unit. Two of its investigators arrived in Blacksod on the morning of the accident.[12][10](p7)

On 16 March, AAIU investigators were airlifted onto Blackrock, where they recovered some debris from the helicopter: the horizontal stabiliser, a wheel rim, parts of the intermediate gear box (located at the base of the tail), and small fragments of the tail rotor.[43][20](pp26-27) From the examination of these items AAIU investigators believe that the helicopter had clipped the island close to the lighthouse, and subsequently crashed out of control into the sea.[44] Blackrock was registered in the craft's GPS mapping system but not on EGPWS. (EGPWS) is a legacy capable Class A terrain awareness and warning system (TAWS) designed for digitally equipped aircraft.[45][clarification needed]

The AAIU found no mechanical anomalies from the flight recorder data, and therefore no additional safety actions were required on similar helicopter types.[29][46]

Initially the Air Accident Investigation Unit was due to release an initial version of the final report into the crash in November 2019.[47] But the report was delayed, because it needed to be reviewed, this is the first report to be reviewed in the 25-year history of the AAIU.[47][better source needed]

The AAIU released its final report in November 2021. The investigation found that the probable cause was that the helicopter was flying at 200 ft, from is intended landing spot, on night flight, in poor weather, with the crew unaware of the presence of a 282-foot obstacle (Blackrock and its lighthouse) in their flight path to the initial route waypoint of one of the Operator's pre-programmed FMS routes.

The report also found some contributory factors that are the following:

  • The initial route waypoint, towards which the Helicopter was navigating, was almost coincident with the terrain at Black Rock.
  • The activities of the Operator for the adoption, design and review of its Routes in the FMS Route Guide were capable of improvement in the interests of air safety.
  • The extensive activity undertaken by the Operator in respect of the testing of routes in the FMS Route Guide was not formalised, standardised, controlled or periodic.
  • The Training provided to flight crews on the use of the routes in the (paper) FMS Route Guide, in particular their interface with the electronic flight management systems on multifunction displays in the cockpit, was not formal, standardised and was insufficient to address inherent problems with the FMS Route Guide and the risk of automation bias.
  • The FMS Route Guide did not generally specify minimum altitudes for route legs.
  • The Flight crew probably believed, as they flew to join it, that the APBSS (waypoint BLKMO to BLKSD as described in legs 1 to 4 of narrative and on the map in FMS Route Guide in respect of APBSS) route by design provided adequate terrain separation from obstacles.
  • Neither Flight Crew member had operated recently into Blacksod.
  • EGPWS databases did not indicate the presence of Black Rock, and neither did some toughbook and Euronav imagery.
  • It was not possible for the Flight Crew to accurately assess horizontal visibility at night, under cloud, at 200 ft, 9 NM from shore, over the Atlantic Ocean.
  • The Flight Crew members' likely hours of wakefulness at the time of the accident were correlated with increased error rates and judgment lapses.
  • There were serious and important weaknesses with aspects of the Operator's SMS including in relation to safety reporting, safety meetings, its safety database SQID and the management of FMS Route Guide such that certain risks that could have been mitigated were not.
  • There was confusion at the State level regarding responsibility for oversight of SAR operations in Ireland.[10]

Tributes edit

Just three weeks before its fatal crash, Rescue 116 with the same four crew members appeared briefly in the 1st episode of 3rd season of the Irish TV show Paramedics. A tribute was made by the paramedics involved in that episode.[48]

Notes edit

  1. ^ The multi-purpose flight recorder installed on EI-ICR combines the traditional functions of CVR and FDR in a single unit [10](72–73)

References edit

  1. ^ a b Siggins, Lorna (25 March 2017). "Rescue 116 recovery effort to resume on Sunday". The Irish Times. Archived from the original on 29 September 2021. Retrieved 25 March 2017.
  2. ^ "Body of Rescue 116 crew member brought ashore". RTÉ News. 26 March 2017. Archived from the original on 26 March 2017. Retrieved 26 March 2017.
  3. ^ "Search continues for three members of Coast Guard helicopter crew". The Journal.ie. 14 March 2017. Archived from the original on 15 March 2017. Retrieved 14 March 2017.
  4. ^ "Latest: Capt. Dara Fitzpatrick leaves behind 'heartbroken' family and 3-year-old son; 3 missing crew named". Breaking News IE. 14 March 2017. Archived from the original on 29 September 2021. Retrieved 14 March 2017.
  5. ^ "Search wound down for crew of missing Coast Guard". ITV News. 14 March 2017. Archived from the original on 14 March 2017. Retrieved 14 March 2017.
  6. ^ "Irish coastguard pilot Captain Dara Fitzpatrick dies after crash". BBC News. 14 March 2017. Archived from the original on 28 July 2018. Retrieved 14 March 2017.
  7. ^ McGrath, Graham (14 March 2017). "One found and three crewmen missing in Irish Coast Guard helicopter search". Extra.ie. Archived from the original on 15 March 2017. Retrieved 14 March 2017.
  8. ^ "One dead, three missing in Coast Guard helicopter crash". RTÉ News. 14 March 2017. Archived from the original on 15 March 2017. Retrieved 14 March 2017.
  9. ^ Siggins, Lorna (20 May 2017). "Rescue 116 crew member remembered as 'selfless'". The Irish Times. Archived from the original on 17 October 2017. Retrieved 16 October 2017.
  10. ^ a b c d e f g h i j "Final Report: Accident involving a Sikorsky S-92A Helicopter, registration EI-ICR, at Black Rock, Co. Mayo, Ireland, on 14 March 2017. Report No: 2021-008". Air Accident Investigation Unit. 7 November 2021. Retrieved 2 June 2022.
  11. ^ "Government Learjet sent on first 'top-cover' mission". 10 August 2011. Retrieved 22 August 2022.
  12. ^ a b c Siggins, Lorna; Gleeson, Colin; Pollak, Sorcha (14 March 2017). "Search for Coast Guard crew continues after one death confirmed". The Irish Times. Archived from the original on 18 March 2017. Retrieved 14 March 2017.
  13. ^ "Chopper gives 'top cover' to Capt Dara Fitzpatrick at emotional farewell". irishtimes.com. Archived from the original on 21 March 2017. Retrieved 26 March 2017.
  14. ^ "Mourners gather for funeral of 'talented and generous' hero Coast Guard Captain Dara Fitzpatrick". Irish Independent. 18 March 2017. Archived from the original on 20 March 2017. Retrieved 26 March 2017.
  15. ^ a b "Captain Dara Fitzpatrick remembered at funeral mass". rte.ie. 18 March 2017. Archived from the original on 20 March 2017. Retrieved 26 March 2017.
  16. ^ a b c Siggins, Lorna (20 March 2017). "Rescue 116: Taoiseach meets agencies on board LE Eithne". The Irish Times. Archived from the original on 22 March 2017. Retrieved 24 March 2017.
  17. ^ "Scanning equipment used in search for missing Coast Guard crew". RTÉ News. 15 March 2017. Archived from the original on 15 March 2017. Retrieved 15 March 2017.
  18. ^ "ILV Granuaile". Commissioners of Irish Lights. Archived from the original on 25 March 2017. Retrieved 24 March 2017.
  19. ^ a b Siggins, Lorna (24 March 2017). "Rescue 116 search: Helicopter 'black box' recovered". The Irish Times. Archived from the original on 25 March 2017. Retrieved 24 March 2017.
  20. ^ a b "AAIU Preliminary Report 2017-006 13 April 2017" (PDF). 13 April 2017. Archived (PDF) from the original on 14 April 2017. Retrieved 18 April 2017.
  21. ^ a b "Marine Institute continues to assist Rescue 116 recovery". 10 April 2017. Archived from the original on 24 October 2017. Retrieved 18 April 2017.
  22. ^ Siggins, Lorna (15 March 2017). "Coast Guard helicopter search: Faint 'chirp' from black box located". The Irish Times. Archived from the original on 16 March 2017. Retrieved 16 March 2017.
  23. ^ "AAIU Statement: AAIU Investigation into the loss of R116". Air Accident Investigation Unit. 20 March 2017. Archived from the original on 24 March 2017. Retrieved 23 March 2017.
  24. ^ "22/03/2017: AAIU Statement on R116 Investigation". Air Accident Investigation Unit. 22 March 2017. Archived from the original on 24 March 2017. Retrieved 23 March 2017.
  25. ^ "Wreckage of Rescue 116 found off Mayo coast". RTE News. 23 March 2017. Archived from the original on 23 March 2017. Retrieved 23 March 2017.
  26. ^ "AAIU Statement on R116 Investigation". Air Accident Investigation Unit. Archived from the original on 2 May 2017. Retrieved 24 March 2017.
  27. ^ Siggins, Lorna (26 March 2017). "Naval divers recover body from wreckage of Rescue 116 helicopter". The Irish Times. Archived from the original on 29 September 2021. Retrieved 26 March 2017.
  28. ^ "Funeral of Rescue 116 pilot Captain Mark Duffy takes place". The Irish Times. 30 March 2017. Retrieved 19 February 2024.
  29. ^ a b Siggins, Lorna (1 April 2017). "Rescue 116 crash: 'No mechanical anomalies' in analysis of black box". The Irish Times. Archived from the original on 2 April 2017. Retrieved 1 April 2017.
  30. ^ "No sign of missing crew members as R116 wreckage lifted from sea". RTÉ News. 2 April 2017. Archived from the original on 2 April 2017. Retrieved 3 April 2017.
  31. ^ Schiller, Robin (3 April 2017). "Devastated families of missing Rescue 116 men told 'don't give up hope'". Irish Independent. Archived from the original on 3 April 2017. Retrieved 4 April 2017.
  32. ^ McNulty, Anton (28 March 2017). "R116 extended search to Donegal Bay". Mayo News. Archived from the original on 5 April 2017. Retrieved 4 April 2017.
  33. ^ Schiller, Robin (4 April 2017). "'We need help of fishermen to find missing crew and end our nightmare'". Irish Independent. Archived from the original on 4 April 2017. Retrieved 4 April 2017.
  34. ^ "Sister of Rescue 116 winchman in emotional appeal to Donegal fishing community" (Radio Audio). Highland Radio. 4 April 2017. Archived from the original on 4 April 2017. Retrieved 4 April 2017.
  35. ^ McNulty, Anton (11 April 2017). "Search for missing R116 crew scaled back, but continues". Mayo News. Archived from the original on 13 April 2017. Retrieved 12 April 2017.
  36. ^ a b Murtagh, Peter (17 March 2017). "Staff shortage initially curbed Defence Forces' role in Blacksod emergency". The Irish Times. Archived from the original on 17 March 2017. Retrieved 17 March 2017.
  37. ^ "SLA IRCG DOD" (PDF). Archived (PDF) from the original on 19 March 2017. Retrieved 18 March 2017.
  38. ^ Murphy, Paul (5 November 2021). "R116 report to question whether mission was necessary". RTÉ News. Retrieved 5 November 2021.
  39. ^ Williams, Paul (19 March 2017). "'Crisis' in the Defence Forces means our Air Corps are effectively working 9-to-5". Irish Independent. Archived from the original on 23 March 2017. Retrieved 22 March 2017.
  40. ^ a b McGreevy, Ronan (16 March 2017). "Defence Forces staff shortage led to Rescue 116 being deployed". The Irish Times. Archived from the original on 17 March 2017. Retrieved 17 March 2017.
  41. ^ "Air Corps personnel shortages 'well known' – Taoiseach". RTÉ News. 16 March 2017. Archived from the original on 18 March 2017. Retrieved 17 March 2017.
  42. ^ "Ongoing safety concerns for search and rescue helicopter services". RTÉ.ie. 26 October 2017. Archived from the original on 2 January 2018. Retrieved 1 January 2018.
  43. ^ Siggins, Lorna (17 March 2017). "Coast Guard helicopter wreckage found at lighthouse". The Irish Times. Archived from the original on 17 March 2017. Retrieved 17 March 2017.
  44. ^ "ACCIDENT: Sikorsky S-92A, EI-ICR, Black Rock, Co. Mayo Ireland 14th March 2017: Report 2017-006 Preliminary". Air Accident Investigation Unit. 13 April 2017. Archived from the original on 17 October 2017. Retrieved 16 October 2017.
  45. ^ Ní Aodha, Gráinne (13 April 2017). "'We're gone': Final words of R116 crew released in preliminary report". TheJournal.ie. Archived from the original on 14 April 2017. Retrieved 17 March 2017.
  46. ^ "01/04/2017: AAIU Statement on R116 Investigation". Air Accident Investigation Unit. 1 April 2017. Archived from the original on 3 April 2017. Retrieved 2 April 2017.
  47. ^ a b Murphy, Paul (9 January 2020). "Delay in publication of R116 crash report". RTÉ News. Archived from the original on 28 April 2020. Retrieved 30 April 2020.
  48. ^ "Paramedics – Thursday, 29 March 2018". 3player. Archived from the original on 21 August 2018. Retrieved 21 August 2018.

External links edit

  • Final Report of the AAIU
  • "Rescue 116: Accidental death verdicts in helicopter crash inquest". BBC News. 2 June 2022. Retrieved 26 March 2024.