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ASN Wikibase Occurrence # 194177
Last updated: 27 November 2021
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Date:14-MAR-2017
Time:00:46 LT
Type:Silhouette image of generic S92 model; specific model in this crash may look slightly different
Sikorsky S-92A
Owner/operator:CHC Ireland opf Irish Coast Guard
Registration: EI-ICR
MSN: 920051
Fatalities:Fatalities: 4 / Occupants: 4
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:Atlantic, near Blackrock, 10km W of Black Sod, Co Mayo -   Ireland
Phase: Approach
Nature:Ambulance
Departure airport:Dublin Airport (DUB/EIDW)
Destination airport:Black Sod
Investigating agency: AAIU
Narrative:
A Sikorsky S-92A helicopter, registration EI-ICR (call sign Rescue 116), which was being operated by a private operator on behalf of the Irish Coast Guard (IRCG), was en route from Dublin, on Irelandís east coast, to Blacksod, Co. Mayo, on Irelandís west coast. The flight crewís intention was to refuel at Blacksod before proceeding, as tasked, to provide Top Cover for another of the operatorís helicopters, which had been tasked to airlift a casualty from a fishing vessel, situated approximately 140 nautical miles off the west coast of Ireland. 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.
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. The deceased co-pilot was located within the cockpit section of the wreckage and was recovered by naval service divers. Extensive surface and underwater searches were conducted; however, the two rear crew members were not located and remain lost at sea.

Probable Cause
The Helicopter was manoeuvring at 200 ft, 9 NM from the intended landing point, at night, in poor weather, while the Crew was unaware that a 282 ft obstacle was on the flight path to the initial route waypoint of one of the Operatorís pre-programmed FMS routes.

Contributory Cause(s)
1. The initial route waypoint, towards which the Helicopter was navigating, was almost coincident with the terrain at Black Rock.
2. 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.
3. 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.
4. 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.
5. The FMS Route Guide did not generally specify minimum altitudes for route legs.
6. 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.
7. Neither Flight Crew member had operated recently into Blacksod.
8. EGPWS databases did not indicate the presence of Black Rock, and neither did some Toughbook and Euronav imagery.
9. 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.
10. The Flight Crew membersí likely hours of wakefulness at the time of the accident were correlated with increased error rates and judgment lapses.
11. There were serious and important weaknesses with aspects of the Operatorís 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.
12. There was confusion at the State level regarding responsibility for oversight of SAR operations in Ireland.

Sources:

http://www.thejournal.ie/coast-guard-helicopter-3286066-Mar2017/
http://www.thejournal.ie/search-day-three-coast-guard-blacksod-3290667-Mar2017/
http://www.itv.com/news/2017-03-14/irish-coast-guard-helicopter-with-four-crew-on-board-goes-missing/
https://www.edinburghnews.scotsman.com/news/1-dead-in-search-for-irish-coast-guard-helicopter-and-crew-1-4391550
https://www.rte.ie/news/2017/0314/859533-coastguard-mayo-incident/
https://www.rte.ie/news/2017/0316/860130-coastguard-helicopter-search/
https://www.rte.ie/player/us/show/prime-time-extras-30003379/
http://web.archive.org/web/20170410213936/http://campus.ie:80/surviving-college/signal-black-box-rescue-116-detected
http://www.aaiu.ie/node/1053
http://www.dttas.ie/press-releases/2017/coast-guard-statement-incident-involving-coast-guard-sar-helicopter-west-coast
http://www.dttas.ie/press-releases/2017/statement-minister-shane-ross-coast-guard-incident
https://www.independent.ie/irish-news/investigators-focus-on-possible-electrical-failure-in-tragic-rescue-116-crash-35536039.html
https://www.independent.ie/irish-news/divers-expected-to-wait-until-sunday-to-carry-out-search-for-missing-rescue-116-as-funeral-details-for-hero-captn-dara-fitzpatrick-announced-35538451.html
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-crash-search-focuses-around-blackrock-island-1.3012933
https://www.irishtimes.com/news/ireland/irish-news/rescue-116-crash-wreckage-found-at-lighthouse-1.3013844
https://www.irishtimes.com/news/politics/rescue-116-final-crash-report-expected-to-take-some-time-1.3373884
July 2018 : https://www.irishmirror.ie/news/irish-news/coast-guard-helicopter-crash-ireland-12927987
______________________________________________
https://www.marinetraffic.com/en/ais/home/shipid:290916/zoom:8
http://www.aeroboek.nl/S92/920051.HTM
https://afloat.ie/safety/coastguard/item/35297-aaiu-statement-on-investigation-into-the-loss-of-r116 (AAIU 20 March 2017)
https://www.irishtimes.com/news/ireland/irish-news/body-of-captain-mark-duffy-recovered-from-rescue-116-helicopter-wreckage-1.3025220
http://www.aaiu.ie/node/1063 (AAIU statement 1 April 2017)
http://www.aaiu.ie/node/1067 (AAIU preliminary report 13 April 2017)

Accident investigation:
cover
  
Investigating agency: AAIU
Status: Investigation completed
Duration: 4 years and 7 months
Download report: Final report
Location

Media:


Images:

Photo of EI-ICR courtesy AirHistory.net


Bray / Irish Sea [ Off-Airport ]
19 July 2015; (c) Fergal Goodman

Revision history:

Date/timeContributorUpdates
14-Mar-2017 08:15 gerard57 Added
14-Mar-2017 08:28 harro Updated [Aircraft type]
14-Mar-2017 08:34 harro Updated [Location, Departure airport, Destination airport, Source, Damage, Narrative]
14-Mar-2017 08:36 harro Updated [Registration, Nature]
14-Mar-2017 11:54 Anon. Updated [Registration]
14-Mar-2017 14:06 Iceman 29 Updated [Cn, Source]
14-Mar-2017 14:49 Iceman 29 Updated [Source, Embed code, Narrative, Photo, ]
14-Mar-2017 18:27 Iceman 29 Updated [Total fatalities, Other fatalities, Source, Embed code, Narrative]
14-Mar-2017 18:43 ryan Updated [Total fatalities, Source, Embed code, Narrative]
14-Mar-2017 18:44 gerard57 Updated [Total fatalities, Other fatalities, Source, Embed code, Narrative]
14-Mar-2017 19:46 Iceman 29 Updated [Source, Embed code, Narrative]
15-Mar-2017 19:57 Iceman 29 Updated [Source, Embed code, Narrative]
17-Mar-2017 07:07 MarkStep Updated [Source]
17-Mar-2017 07:09 harro Updated [Total fatalities, Narrative]
17-Mar-2017 17:29 Aerossurance Updated [Time, Aircraft type, Registration, Operator, Location, Phase, Departure airport, Destination airport, Narrative]
20-Mar-2017 22:39 Aerossurance Updated [Source, Narrative]
27-Mar-2017 21:40 Iceman 29 Updated [Embed code]
28-Mar-2017 07:40 Chieftain Updated [Source, Embed code, Narrative]
02-Apr-2017 14:59 Aerossurance Updated [Location, Source, Narrative]
13-Apr-2017 22:50 Aerossurance Updated [Source, Narrative]
30-Jan-2018 20:16 Iceman 29 Updated [Source]
30-Jan-2018 20:20 Iceman 29 Updated [Embed code]
16-Jul-2018 11:06 Iceman 29 Updated [Source, Embed code]
05-Nov-2021 11:16 harro Updated [Category]

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