© TOM MOLONEY
ACCIDENT RECOVERY
By David Jack Kenny
Black Night at Black Rock
An unlikely confluence of circumstances causes a well-trained crew to perish during a rescue operation.
O
PERATORS WHO CONDUCT high-consequence flights under difficult conditions have learned
to construct multitiered systems of risk management: redundant equipment, sophisticated automation, multiple sources of flight-critical information, rigorous adher- ence to standardized procedures, and a constant cycle of review and improvement. The various tiers vastly reduce the
chance that any single error, omission, or failure will put aircraft and crew in jeopardy. Yet, it seems impossible to eliminate risk altogether. Exactly the wrong confluence of overlooked information, mistaken assumptions, and an inhospitable environ- ment can still yield tragic consequences.
The Mission At 9:39 pm on Mar. 13, 2017, the captain of a fishing vessel about 140 nautical miles (nm) west of the Irish coast contacted the Marine Rescue Sub Centre (MRSC) in Malin Head, Ireland, to report that a crew member had suffered the traumatic ampu- tation of most of one thumb. After consul- tation with medical staff, the MRSC decided to request helicopter evacuation of the injured sailor.
Under contract with the Irish Coast Guard, Sikorsky S-92A helicopters are oper- ated from four search-and-rescue (SAR) bases around the country: Dublin on the east coast under the designation “Rescue 116” or R116; Shannon and Sligo on the west (R115 and R118, respectively); and Waterford on the southern coast (R117). All are qualified for helicopter emergency medical services as well as SAR missions, including offshore rescues in degraded visual environments (DVE). Sligo was the base nearest to the vessel’s location, and
The accident aircraft, photographed on May 14, 2016.
the R118 SAR duty pilot accepted the mission. The commander of R116 had gone
home for the evening when the Dublin Marine Rescue Coordination Centre con- tacted her to request that her crew fly “top cover” on the rescue flight, following R118 to the scene after a delay to provide assis- tance in the event of difficulty with the extraction or an in-flight emergency. While driving back to the airport, the commander called the Sligo base to coordi- nate plans, speaking to R118’s winch oper- ator. He suggested they could refuel at the helipad adjacent to Blacksod Lighthouse, the westernmost fuel stop available along their route. After reaching the base, how- ever, she commented that she expected the weather to be too low to get into Blacksod and planned to refuel at Sligo instead. The four-person crew boarded, and
900 L (238 gal.) of fuel were added to bring the total load to 5,000 lb. R116’s
multipurpose flight recorder (MPFR) regis- tered the engine start at 10:55 pm.
The Crew Both pilots held European Union airline transport licenses issued by the Irish Aviation Authority with S-92A type ratings. Both had qualified to fly as captains. On this flight, the 45-year-old mission commander was the pilot flying. Since beginning her training in 1990, she’d logged 5,292 hours of flight time. She earned her instrument and multi-engine ratings in 1993 and all-weather SAR qualification the fol- lowing year. She flew the Sikorsky S-61N for 19
years, upgrading to captain in 2000. In 2013, she transferred from Waterford to Dublin and completed transition training to the S-92A. Her 825 hours in that model included 725 as pilot-in-command (PIC). The 51-year-old copilot began learning to fly helicopters in 1996 and got his first pro- fessional job in 1999, flying the Bell 206 in
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