The EGPWS database didn’t include Black Rock, and the


EuroNav 5 moving map ended just to the east, showing BLKMO against a blank blue background. The radar, set to the high- sensitivity terrain-mapping mode, showed both the terrain and the aircraft’s routing in magenta, obscuring the obstruction beneath the waypoint symbol. There is no evidence that any member of the crew either saw the beacon of the Black Rock light or expected to. The FLIR relies on temperature differences relative to the background that had diminished many hours after sunset. By the time the winchman identified Black Rock in the FLIR, the helicopter was a scant 0.3 nm away and closing at 90 kt., leaving just 12 seconds in which to avoid the collision. The crew followed their employer’s standard procedures, which


called for heading or altitude changes below 500 ft. to be requested by the pilot flying and performed by the pilot monitoring while continuing to fly coupled. The final pitch and roll inputs sug- gest the pilot might have responded to the winchman’s urgent warnings just a moment too late.


The Takeaway Prudent operators protect their crews with multiple layers of equipment and procedures, minimizing the risk of single-point


failures, lapses in memory, or errors in judgment. The record shows that the crew of Rescue 116 was disciplined, professional, and thorough, flying the mission by the book. They completed the correct checklists at the appropriate times, confirmed their position and scanned for obstacles before descending, conducted a detailed landing-site briefing to deter- mine the airspeed and altitude necessary for a successful go-around if one engine failed, and repeatedly cross-checked the fuel on board against that required to divert if they couldn’t get into Blacksod.


But as the investigation concluded, they probably believed that the design of the APBSS arrival route “would provide adequate ter- rain separation if the FMS was used to follow the route, and that obstacles only need be considered if going off the route.” The AAIU’s final report includes extensive comments on organi-


zational flaws at multiple levels, from the operator’s informal pro- cedure for establishing and proving routes to the Irish Coast Guard’s lack of a safety management system. But most immedi- ately, it was the highly unlikely convergence of missing data, incomplete charts, indistinguishable colors, and an obstruction noted only in comments difficult to read in the “atrocious” cockpit lighting that sent R116 flying straight and level toward a tall black rock in a pitch-black night.


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MARCH 2022 ROTOR 65


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