Rescue 116: Family of Dara Fitzpatrick say crew was 'badly let down'

Rescue 116: Family of Dara Fitzpatrick say crew was 'badly let down'

Captain Dara Fitzpatrick, Captain Mark Duffy, and winch men Ciarán Smith and Paul Ormsby all lost their lives on March 14, 2017. The Air Accident Investigation Unit (AAIU) found that the helicopter’s crew was unaware there was a 282ft obstacle on their flight path as they flew along a pre-programmed route that night.

The final investigation into the Rescue 116 crash that killed four people has found that there were “serious and important weaknesses” in aspects of the flight operator’s safety management system.

It found that the helicopter’s crew was unaware there was a 282ft obstacle on their flight path as they flew along a pre-programmed route on the night of the crash in March 2017.

The report also found that the crew was unable to accurately assess horizontal visibility at night under cloud, and also highlighted the poor weather that night as contributing to the crash.

The Air Accident Investigation Unit (AAIU) published its final report into the incident this morning. All four crew members on board were killed when the Rescue 116 helicopter crashed in the early hours of March 14, 2017.

Captain Dara Fitzpatrick, chief pilot Mark Duffy, winch operator Paul Ormsby and winchman Ciarán Smith were en route from Dublin to Blacksod in Co. Mayo to refuel when the incident occurred.

The bodies of Ms Fitzpatrick and Mr Duffy were discovered after the crash, but Mr Ormsby and Mr Smith were never recovered.

The 350-page report follows a lengthy investigation by the AAIU, and the organisation makes 42 safety recommendations on foot of its probe into the crash.

It said its investigation was solely focused on improving flight safety and nothing within the report should be interpreted as “a criticism of any individual or organisation”.

It found that CHC Ireland, which operated the helicopter on behalf of the Irish Coast Guard, did not have formalised, standardised, controlled or periodic measures in the testing of routes in its flight management system route guide.

The training provided to flight crews on the use of routes in the paper flight management system route guide was not “formal, standardised and was insufficient to address inherent problems with the [route guide] and the risk of automation bias”.

The report identified “serious and important weaknesses” in aspects of the operators safety management system, including in relation to safety reporting.

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

Reacting to the report this morning, 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.

“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.”

Responding to the report today, the family of Dara Fitzpatrick said they believed that Dara and her fellow crew members were “badly let down” by operator CHC for “not providing them with the safe operating procedures and training that they were entitled to expect''.

The family said there was an expectation on the operator of the search and rescue service to minimise the risk to the crew by aiming to remove risk and providing crews with safety procedures on which they can rely.

“Unfortunately, this was not done on this occasion,” the family said.

“We hope that the AAIU final report and the review board report will ensure that those responsible for this operation, both directly and at a supervisory level, urgently implement the necessary changes, and that in future they pay attention to the feedback that they get from flight crew as to any inadequacies and hazards in the operation, so that such an accident will never happen again, that no one else will needlessly lose their lives, and that no other families will have to endure the devastating loss that we endure with the untimely death of our beautiful Dara.”

In a statement, CHC Ireland said that it is committed to implementing the appropriate safety recommendations in the final report.

It said the report is “clear that the organisation of Search and Rescue in Ireland involves many stakeholders including the Irish Aviation Authority, the Irish Coast Guard and the European Aviation Safety Agency.”

“CHC Ireland will ensure that it collaborates with all the relevant stakeholders to address the recommendations,” it said. “The most important thing is that we collectively ensure that all areas identified for further strengthening are actioned.” 

The company also expressed its deepest sympathies to the families and friends of the four crew members.

The Irish Air Line Pilots Association (IALPA) said the report shows that the loss of life was “as needless as it was preventable”.

It said that the crew were “let down by a regulatory system which left them ill-equipped to do the vital work that same system tasked them with”.

IALPA added: “This tragic and unnecessary loss of life must not be allowed to happen again. IALPA is calling on the Government and Minister for Transport to institute an immediate review of the failures identified in this report, and to bring forward concrete proposals to address each and every identified failure immediately."

Timeline of R116 crash 

This is the timeline supplied in the AAIU investigation’s final report into the R116 tragedy. R116 was tasked with providing support to their counterparts R118, who were responding to a callout from a fishing vessel. After setting off from Dublin, the crew were going to refuel at Blacksod before lifting off again.

13 March 2017 

9.39pm - The captain of a fishing vessel contacted the Malin Head Marine Rescue Sub Centre (MRSC Malin) to seek medical advice because a crewman on board had suffered an injury.

9.42pm - MRSC Malin contacted the Sligo Search and Rescue duty pilot, and tasked the Sligo-based helicopter R118 with airlifting the injured crewman to hospital.

10.10pm - The MRCC in Dublin alerted the R116 crew via radio to provide top cover - or support - for R118.

10.55pm - The helicopter engines for R116 were started and commenced take-off at Dublin airport. It departed at 11.02pm.

11.11pm - R116 made contact with R118 via radio. R118 informed R116 that it was about to land in Blacksod and that it would contact R116 when it was on the ground in Blacksod. Two minutes later, R116 tracked towards Sligo.

11.20pm - Having cross checked their calculations, the flight crew determined to route to Blacksod, instead of Sligo, for the purpose of uplifting fuel.

11.33pm - R116 climbed from 3,000ft to 4,000ft. Once it reached 4,000ft, the commander said she would select the pre-programmed route in the helicopter’s flight management system.

14 March 2017 

00.04am - R116 passed over Knock Airport. The rear crew made contact with Blacksod helipad to request information on the wind, cloud base and visibility. Several minutes later, a further request was made for wind direction, speed and visibility.

00.28am - R116 crossed the Mayo coast and flew out over Blacksod Bay. Shortly after this, inter-crew communications confirmed that the helicopter was over the water.

00.34am - R116 passed a navigational waypoint, and began to descend. The co-pilot informed Shannon Area Control Centre that it was in descent and were making their way to Blacksod for refuelling. Shannon acknowledged and asked R116 to report back when airborn again.

00.43am - the helicopter was turning back towards the earlier waypoint and commenced its “before landing” checklist. During this time, the Co-pilot stated: “Starting to get ground coming in there at just over eight miles in the ten o'clock position.” 00.45am - The co-pilot said ‘okay so small targets at six miles at 11 o'clock … large out to the right there’. This was followed approximately 20 seconds later by an Auto Callout ‘Altitude, Altitude’, which the Commander said was ‘just a small little island that's B L M O itself’.

00.46am - Just before 00.46am, the winchman said: ‘Looking at an island just eh directly ahead of us now guys… you wanna come right’. The commander asked for confirmation of the required turn and she instructed the co-pilot to select heading mode, which the co-pilot acknowledged and actioned. Within one second of this acknowledgement, the winchman said “come right now, come right, come right”.

00.46.08am - The helicopter pitched up rapidly and rolled to the right. It collided with terrain at the western end of Black Rock and then impacted with the sea. The main wreckage came to rest on the seabed to the east of Black Rock, at a depth of 40metres.

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