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Rescue 116: Final report finds 12 contributory factors leading to fatal 2017 crash

Rescue 116 went down in March 2017 with four crew onboard while preparing to refuel at Blacksod, Co Mayo.

The search scene for Rescue 116
The search scene for Rescue 116
Image: Eamonn Farrell via RollingNews.ie

Updated Nov 5th 2021, 10:12 AM

A FINAL REPORT into the Rescue 116 helicopter crash in which four people died during a search and rescue mission has found 12 contributory factors. 

Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby all lost their lives after Irish Coast Guard helicopter Rescue 116 went down on 14 March 2017. 

Rescue 116 crashed after it struck Blackrock Island off the Mayo coast on its way to a refuelling stop at Blacksod. It was due to refuel before taking part in a rescue operation.

The bodies of Ciarán Smith and Paul Ormsby were never recovered.

The Air Accident Investigation Unit (AAIU) has published its final report into the crash today following a lengthy investigation and review. 

The report said the “probable cause” of the crash was poor weather, the helicopter’s altitude and the crew being unaware of  a 282ft obstacle on the flight path to the initial route waypoint of one of the operator’s pre-programmed Flight Management System (FMS) routes.

Contributory causes

The report found 12 contributory causes of the crash. 

This includes “serious and important weaknesses” with how the helicopter operator, CHC Ireland, managed risk mitigation. 

“There were serious and important weaknesses with aspects of the Operator’s [safety management system] including in relation to safety reporting, safety meetings, its safety database SQID and the management of FMS (Flight Management System) Route Guide such that certain risks that could have been mitigated were not,” the report said.

The report has found that the helicopter operator didn’t have “formalised, standardised, controlled or periodic” systems of testing flight routes. 

The activities of the operation 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 report found. 

The report also found that the training given 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.

It also found the FMS route guide did not generally specify minimum altitudes for route legs. 

The report found that the initial route waypoint was almost “coincident” with the terrain at Blackrock Island. Flight databases didn’t indicate the presence of Blackrock and neither did some of its imagery, the report found. 

The flight crew probably believed, as they flew to join it, that the route by design provided adequate terrain separation from obstacles, the report found. 

It said neither flight crew member had operated recently into Blacksod.

It wasn’t possible for the flight crew to accurately assess horizontal visibility at night, under cloud, at 200ft over the Atlantic Ocean, it said.

“The flight crew members’ likely hours of wakefulness at the time of the accident were correlated with increased error rates and judgement lapses,” the report added. 

The report noted elsewhere that the operating manual quoted directly from European Union Aviation Safety Agency (EASA) that “a crew member shall not perform duties in flight if he knows or suspects that he is suffering from fatigue, or feels unfit to the extent that the flight may be in danger”. 

However, it added that in the absence of a fatigue risk management system (FRMS) as required by EASA, and given the operator’s 24-hour roster pattern, “this advice is at odds with the scientific findings that individuals are notoriously poor judges of their own levels of fatigue”. 

It also found there was “confusion at State level” regarding responsibility for oversight of search and rescue operations in Ireland. 

The investigation identified emails from pilots in June 2013 to other personnel, including some involved in Route Guide/Flight Management System updating projects, advising that some obstacles were not show on the ground proximity warning system. One pilot mentioned Black Rock Lighthouse, stating that at 310 feet high it was an “obvious hazard”.

On 28 June 2013 one of the pilots emailed the system’s manufacturer advising that ‘a few Islands and lighthouses locally […] do not appear on the database’. He asked whether it was possible to have these obstructions added to the database.

The manufacturer replied stating that a ‘problem report’ had been opened and that its engineering department may require further information about obstacle locations, but otherwise it would ‘contact you when they have an answer’.

The manufacturer could find no further correspondence after this and the problem report was eventually closed in March 2015, with no action taken by the database group.

A number of safety recommendation were made in the report but the AAIU said they should “in no case create a presumption of blame or liability”.

“The sole objective of this safety investigation and final report is the prevention of accidents and incidents,” the AAIU said. 

‘Deepest sympathy’

In a statement this morning, the helicopter operator, CHC Ireland, has expressed its “deepest sympathy” towards the family and friends of Captain Dara Fitzpatrick, Captain Mark Duffy, winchman Ciarán Smith and winch operator Paul Ormsby.

CHC Ireland said lessons from the report will “undoubtedly” be applied across search and rescue operations in Ireland and throughout the world.

It said it is “committed to implementing the appropriate safety recommendations that are directed towards CHC Ireland in the final report”. 

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Rob Tatten, General Operations Manager and Accountable Manager, CHC Ireland said: “I would firstly like to express our deepest sympathy to the family and friends of our lost colleagues; Ciarán, Dara, Mark and Paul.

“The accident and loss of the crew was a terrible tragedy.

“Their colleagues in Search and Rescue bravely continue to serve the people of Ireland on behalf of the Irish Coast Guard as they have done for over 20 years. Their unwavering commitment to the role that they perform is admirable.

“Our crews continue to fly hundreds of search and rescue missions every year, saving many lives. Our team is justifiably proud of our global safety record and everyone in CHC Ireland is committed to the safe delivery of our service.

“We continue to honour the memories of Ciarán, Dara, Mark and Paul. They will never be forgotten.”

The Department of Transport has said it fully accepts the recommendations contained within the report and will continue to evaluate the findings in the coming weeks. 

“This was a tragic accident that claimed the lives of four individuals who were dedicated to saving the lives of others. I would like to again convey my condolences to the families and loved ones of the R116’s crew at this time,” Minister for Transport Eamon Ryan said. 

“The completion of the investigation and the publication of the report is a key step in ensuring that such accidents are prevented in the future. I wish to acknowledge the investigative work that has been done by the AAIU that has culminated in this report,” Ryan said. 

“This is clearly reflected in the level of detail and wide-ranging nature of the report, with safety recommendations that cover all aspects of SAR aviation, both nationally and internationally.”

‘Badly let down’ 

The family of helicopter pilot Captain Dara Fitzpatrick have said today’s report highlights “many failings” by the operator of the rescue service.

The Fitzpatrick family said today they hope that the report will ensure that those who were responsible for the operation will urgently implement the necessary changes so that such an accident never happens again.

“We believe that Dara and the other crew members of Rescue 116 were badly let down by the Operator CHC not providing them with the safe operating procedures and training that they were entitled to expect,” the Fitzpatrick family said.

While the report identified 12 contributory causes of the crash, the family said there were “many other failings” by the operator that contributed to the accident.

“These include not training the crew on all the specific approaches on simulators and in the aircraft and ensuring that before they were tasked to fly into different landing sites they had prescribed recent experience,” they said.

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