Irish Examiner view: Bitter lessons from crash at Blackrock

The Air Accident Investigation Unit’s report proves to be dispiriting reading and provides chilling feedback
Irish Examiner view: Bitter lessons from crash at Blackrock

Captain Dara Fitzpatrick, Captain Mark Duffy, and winch men Ciarán Smith and Paul Ormsby all lost their lives on March 14, 2017.

The day after four brave members of the Irish Coast Guard lost their lives off Mayo, and while the search for survivors was under way, we reflected on the great risks that rescue crews take to save others from hazardous circumstances.

This is indeed the kindness of strangers “expressed with an extraordinarily selfless generosity... allied to exceptional courage”.

The Air Accident Investigation Unit’s 350-page report into those tragic and, it now seems, avoidable events of March 14, 2017, proves to be dispiriting reading for the bereaved families and provides chilling feedback for CHC Ireland, the British Columbia-headquartered company that has the State contract to operate Ireland’s search and rescue helicopters.

The report found that Blackrock Island, the location of the crash, “was not identified on radar” and was not on the terrain databases used by the crew in a mission that was “compounded by darkness and poor weather”. There were “serious and important weaknesses” in aspects of the flight operator’s safety management system, the report concludes, addressing 19 of its 42 recommendations to CHC Ireland.

Difficulties are identified with CHC’s internal reporting procedures, reticence by some staff to file reports for fear of being criticised, lack of follow-up, and a preference by some to resolve issues informally.

Investigators were told that issues had been raised over perceived overt commercial pressure being placed on duty crew, on “risk fatigue management” and, although this is difficult to comprehend, problems with the quality and adequacy of the cockpit moving map system. Some map images were described as “completely blurred and unreadable”, while it was also described as unsuitable for UK airspace when paper charts had to be used instead.

Complaints raised in 2013

Some of the complaints were raised in 2013, nearly four years before disaster befell flight R116.

There appears to have been scope for misunderstanding in the varying responsibilities allocated to the Irish Aviation Authority (IAA) and the Irish Coast Guard.

The IAA approved CHC to conduct search and rescue missions, as well as helicopter emergency medical services. However, it told the investigation that operational search and rescue flights, under a rescue call sign, were subject to oversight by the coast guard.

The Irish Coast Guard said it did not have aviation expertise available on its staff, but had contracted an external consultancy to provide it with expertise, advice and auditing of the operator’s bases. That contract expired in January 2017 and had not been renewed at the time of the crash.

With some of the origins of this catastrophe being sown within a multidisciplinary, part private, part public blue-light service, it is hard to refute the conclusions of the bereaved families, including those of Captain Dara Fitzpatrick, who say that the crew, directed over unfamiliar terrain, were “badly let down”. That fatal night, when R116 was unaware there was a 282ft obstacle in its pre-programmed route, will haunt many for years to come.

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