The Irish Coast Guard crew of Rescue 116 were using a pre-programmed navigational route which appeared to be deficient in information when their helicopter crashed into Blackrock island off the north Mayo coast just over a month ago, the Air Accident Investigation Unit (AAIU) has found.
A preliminary report by the AAIU into the crash, which claimed the lives of Capt Dara Fitzpatrick (45), co-pilot Capt Mark Duffy (51), winch operator Paul Ormsby (53) and winchman Ciaran Smith (38), has found that the helicopter “pitched up rapidly” and collided with the western end of the island in its final seconds.
The Dublin-based Sikorsky S-92, which had been tasked to provide “top cover” to its Sligo counterpart in a medical evacuation, had flown west of the Mayo coast to turn and make an approach into Blacksod lighthouse when it collided with Blackrock lighthouse 13km to the west.
Capt Fitzpatrick and Capt Duffy were the first confirmed casualties, and searches are continuing for the two winch crew, who are still missing.
The preliminary report has found that the pilots were relying on a programmed navigational route for Blacksod, which should have assisted their approach and should have warned them of Blackrock island to the west.
Visibility was down to two to three km in mist and drizzle with southwest winds of 20 knots, gusting 30-35 knots and rough seas.
Warning system
A separate enhanced ground proximity warning system (EGPWS), which is not to be relied on for navigation but does provide an alert in an emergency, did not have co-ordinates for Blackrock programmed into it.
The failure of this system is the last link in a chain of events which led to the fatal crash, and which the AAIU aims to address in its final report.
The 38-page preliminary report notes that the cockpit voice recorder recorded Capt Fitzpatrick “commenting to the other crew members on a number of occasions that it had been a substantial period of time since she had previously landed in Blacksod”.
“On one occasion the commander asked the co-pilot when he had last been into Blacksod and he indicated that he had not been there recently,”the report says.
The helicopter began a descent from its cruising altitude of 4,000 ft, was at 200 ft radio altitude, and 75 knots indicated airspeed, and heading towards Blackrock island when it pitched up.
The report says the cockpit voice recorder indicates the co-pilot was using the weather radar to identify terrain features.
The radar altimeter called out “altitude, altitude” some 26 seconds prior to initial impact, and the pilot identified this as a small island below the helicopter.
Last words
One of the winch crew in the rear also identified an island approximately 13 seconds prior to the initial impact with terrain, and interjected “come right” with”increasing urgency”.
The last words recorded were from co-pilot Capt Mark Duffy who said “we’re gone”.
The preliminary report recommends that CHC Ireland, which is contracted by the Irish Coast Guard, should “review/re-evaluate all route guides in use by its search and rescue helicopters in Ireland” .
It also says that the manufacturer of satellite locator beacons on lifejackets used by the search and rescue air crew should review the viability of the installation provisions and instructions.
The beacon had been installed in the same pouch as the GPS antenna, as per a service bulletin issued by the lifejacket manufacturer.
However, the report notes the beacon manufacturer recommended a minimum separation distance of 30 centimetres between it and the antenna to ensure the beacons functioned.
