selected,” but less than one second later, the winchman urged, “Come right now … come right … COME RIGHT!” The helicopter pitched up and rolled right, hit the


western end of Black Rock (also known as Blackrock Island), and crashed into the sea. At 1:08 am, Blacksod Lighthouse staff asked the


Exhaustive examination of the wreckage identified a series of oversights that allowed an


experienced crew to remain unaware of the hazard that lay ahead.


Malin MRSC if they could determine the whereabouts of R116. At 1:13, Malin relayed a MAYDAY call to all sta- tions. After hoisting aboard the injured sailor from the fishing vessel, R118 flew to Black Rock to initiate a search. They arrived at 2:10 and almost immediately saw strobes in the water, a life raft, and an apparent casualty the winchman was unable to recover in rough seas. The Achill Island lifeboat reached the scene and pulled the captain from the water at 2:37. She was unresponsive and couldn’t be revived. The body of the copilot, still strapped into his seat, was subse- quently recovered


from the wreckage by naval divers. Despite extensive searches both underwater and along the shore, the remains of the two rear crewmen have not been found.


The Investigation Several pieces of debris, including fragments of the intermediate gearbox fairing and casing, most of the hor- izontal stabilizer, fragments of a wheel rim, and several tail-rotor blade tips were found in the vicinity of Black Rock Lighthouse and the adjacent helipad. Floating wreckage included the center portion of the right spon- son containing the right fuel tank, fragments of the shat- tered left sponson, the cargo hatch, main ramp, and forward-sliding cabin door. The approximate location of the MPFR’s underwater locator beacon was determined the day after the acci- dent. One week later, on Mar. 22, a submersible remotely operated vehicle (ROV) found the main wreck- age on the ocean floor at a depth of 40 m (131 ft.) and compiled a detailed photographic and videographic sur- vey. Irish Naval Service divers recovered the MPFR and the memory card from the aircraft’s health and usage monitoring system (HUMS). Most of the wreckage was brought to the surface in April in a series of operations by heavy-lifting vessels, during which the cockpit sepa- rated from the major portion of the fuselage. Additional


64 ROTOR MARCH 2022


ROV dives on Jul. 22 retrieved the FLIR system’s control panel, including the digital video recorder (DVR). Despite the units’ extended immersion in salt water,


data from the MPFR, HUMS, and DVR were eventually downloaded with the assistance of laboratories in the United Kingdom and the United States. The DVR proved to have been set to “Play” rather than “Record” and captured no images during the accident flight. The MPFR, however, recorded the communications and flight data that investigators used to reconstruct the acci- dent narrative. Exhaustive examination of the wreckage disclosed no


evidence of failure of any powerplant, rotor, flight con- trol, or avionics component before impact. Instead, the AAIU’s admirably detailed report identified a series of oversights, both organizational and individual, that allowed an expert and experienced crew to remain unaware of the hazard that lay ahead. The operator’s arrival routes were “base-centric,” not only in the sense that crews were most familiar with the arrival routes in their usual operational areas, but also in that each base was considered responsible for defining and revising the routes it “owned.” Yet, no formal pro- cess had been established for validating or approving these routes or conducting test flights under different weather conditions using different combinations of fly- over and flyby waypoints. Neither R116 pilot was familiar with the APBSS route. While still in cruise flight at 4,000 ft., the captain remarked, “God, I’d say I haven’t been in Blacksod in about 15 years,” and the copilot agreed: “No, not recently; been awhile.” More than half an hour later, as they briefed the


winchman (responsible for monitoring the FLIR) on the approach course, the captain acknowledged that “it’s been donkey’s years since I’ve been in here.” The operator provided the AAIU with a copy of the


approach route. Black Rock wasn’t shown on the visual depiction, apparently obscured by the symbol for the BLKMO waypoint, though the height of the obstruction was noted in the comments. No minimum crossing alti- tude was suggested. Each pilot briefed the approach route separately, but the MPFR didn’t record either pilot mentioning the 282-ft. pinnacle at the initial fix. The voice circuits of the MPFR did record the captain complaining that the “bloody lights in this thing drive me mad,” and the copilot agreeing, “Yeah, eh, they’re atro- cious,” which the AAIU suggested hindered their reading of the comments on the approach. They selected a later waypoint for flyby or “smart turn” anticipation but kept BKMO as an overfly waypoint.


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