S92, manoeuvring, near Black Rock Western Ireland,
2017
Summary:
On 14 March 2017, control of a Sikorsky S92A
positioning in very poor visibility at 200 feet over the sea in accordance with
an obstacle-marked FMS ground track in order to refuel at a coastally-located
helipad was lost after it collided with late-sighted terrain ahead before
crashing into the sea killing all on board. The Investigation attributed the
accident to the lack of crew terrain awareness but found a context of
inadequate safety management at the operator, the comprehensively ineffective
regulatory oversight of the operation and confusion as to responsibility for
State oversight of its contract with the operator.
Event Details
When:
14/03/2017
Event Type:
Day/Night:
Night
Flight Conditions:
IMC
Flight Details
Aircraft:
Operator:
Type of Flight:
Public Transport (Non Revenue)
Flight Origin:
Take-off Commenced:
Yes
Flight Airborne:
Yes
Flight Completed:
No
Phase of Flight:
Descent
Location
Approx.:
near Black Rock, western Ireland
General
Tag(s):
Helicopter Involved, Inadequate Aircraft Operator Procedures,
Ineffective Regulatory Oversight
CFIT
Tag(s):
Into terrain
HF
Tag(s):
Manual Handling
LOC
Tag(s):
Unintended transitory terrain contact
EPR
Tag(s):
Uncontrolled Water Impact
Outcome
Damage or injury:
Yes
Aircraft damage:
Hull loss
Non-aircraft damage:
No
Non-occupant Casualties:
No
Occupant Fatalities:
Most or all occupants
Number of Occupant Fatalities:
4
Off Airport Landing:
No
Ditching:
No
Causal Factor Group(s)
Group(s):
Aircraft Operation, Aircraft Technical
Safety Recommendation(s)
Group(s):
Aircraft Operation, Aircraft Airworthiness
Investigation Type
Type:
Independent
Description
On 14 March 2017,
a Dublin-based Sikorsky S92A (EI-ICR) being operated by
CHC Ireland on behalf of the Irish Coast Guard was positioning in night IMC to
assist an offshore casualty recovery operation already under way off the west
coast of Ireland by providing “top cover”. The Captain was aware
that en-route
refuelling would be necessary and decided after takeoff that
uplift at a coastal helipad at Blacksod would be appropriate. Whilst attempting
to navigate to this location at low level in very poor forward visibility,
a late sighting of terrain co-located with the first FMS waypoint
of the intended approach was followed by unsuccessful avoiding action and a collision which
led to a loss of control and the helicopter
impacting the sea surface with fatal injuries sustained by all four occupants.
Investigation
A comprehensive
Investigation was carried out by the Irish AAIU. The ULB signal
from the submerged MPFR, which had equivalent data retention
capability to an FDR and a 2 hour CVR led
to its location the day after the accident and it was subsequently found by an
ROV still attached to its original mountings in the forward left hand
avionics rack. It was recovered by divers ten days after the accident and its
data were successfully downloaded.
The Flight
Crew
The 45 year-old Captain in command
had a total of 5,292 hours flying experience which included 825 hours on type
with approximately 725 of those hours obtained in command on type. The 51
year-old Co-Pilot was also employed as an S92 Captain at the Dublin base and
had a total of 3,435 hours flying experience which included 795 hours on type
with approximately 695 of those hours obtained in command on type.
What Happened
As a result of an
injury to a crew member on board a Fishing Vessel approximately 140 nm west of
Ireland, the Duty SAR crew based at Sligo had been tasked
with airlifting the injured crewman to hospital. The Dublin Airport-based
accident helicopter was then tasked with providing support (‘top cover’) for
the airlift mission. The assigned Co-Pilot was already in the rest room at the
Dublin Base and the Captain in command arrived about half an hour later after telephoning
from her car. Meanwhile, the engineering support team had towed the helicopter
from the hangar to prepare it for refuelling and the two assigned other crew
members had arrived.
All four crew
members gathered in the operations room and one of the Dublin-based engineers
recalled the Captain in command commenting that the weather at a suggested
interim stop, Blacksod, was probably not going to be good enough and that they
would instead route to Sligo. The Sligo SAR base was advised that the Dublin helicopter “would
be coming into Sligo for a rotors-running refuel because the weather at
Blacksod was unsuitable”.
The helicopter
took off from runway 16, established on track to the north and levelled off at
3,000 feet QNH. Nine minutes after takeoff, one of the rear crew contacted the
helicopter conducting the recovery and was advised that they would shortly be
landing at Blacksod and would make contact again once on the ground there. They
described the conditions as they neared the landing as including some low cloud at
about 500 feet whilst inbound on what was subsequently found to have been a
different low level route to the one the Dublin-based helicopter intended to
use.
The flight continued at 3,000 feet
and after determining that there would be a time/fuel advantage in uplifting
fuel at Blacksod rather than Sligo, it was decided they would route to Blacksod
and a slight change of track to the left followed. On ATC instructions, the
flight then transferred to Shannon Information and advised that it was en route
to Blacksod IFR and would be climbing to 4000 feet QNH.
Once the Helicopter was level at
4,000 ft, the Captain in command advised that she was going to select the ‘APBSS’
(Blacksod South) route for an arrival at Blacksod (BLKSD) on the FMS and
descend out to sea before turning around to follow the prescribed inbound route
from waypoint BKLMO via waypoints BKSDA, BKSDB and BKSDC to Blacksod. The
illustration of this route taken from the Route Guide (see below) showed
relevant obstacles in numbered red circles with obstacle one being the 282 feet
high Blackrock which was co-located with the waypoint BLKMO.
Half an hour after passing over
Knock Airport, the waypoint BKSDA on the inbound FMS route was overflown
tracking west northwest and descent from 4000 feet was commenced with ATC
informed accordingly. As 2,400 feet was passed, an automatic SAR helicopter mode
which results in descent from 2,400 feet agl to 200 feet agl unless interrupted
was selected on the AFCS. As the descent continued, a slight right turn was
made to allow descent down to 200 feet prior to making a left turn back to
waypoint BLKMO”.
As this left turn
was commenced with the automatics still engaged by selecting ‘Direct To’ BLKMO,
the Winchman announced that the helicopter was “clear around to the
left” and this was followed approximately 30 seconds later by the
Co-Pilot announcing that they were clear ahead on the EGPWS and
radar. As the turn was continuing at 200 feet, the ‘Before Landing’ Checklist was
commenced and as it was completed, the Captain-in-command was recorded
commenting that she was visual with the sea surface. Soon after,
an Auto Callout “Altitude, Altitude” was annunciated and in
response, she was recorded saying it was “just a small little island
that's BLKMO itself” but after another 20 seconds or so, the Winchman
announced that he was “looking at an island just eh directly ahead of
us now guys…you wanna come right [commander’s name]”. She asked for
confirmation of the required turn, was told 20° right and instructed the
Co-Pilot to select HDG mode which he did as the Winchman called “come
right now, come right, COME RIGHT”.
Shortly after this, FDR data showed
the helicopter pitching up rapidly and rolling to the right following which it
collided with the western end of Black Rock, departed from controlled flight
and fell into the sea. The main wreckage came to rest on the seabed to the east
of Black Rock, at a depth of 40 metres.
Discussion
Various observations were made based
on the factual information gathered and on its wider systemic context which
included, in concise summary, the following:
·
The flight crew did not verbalise the obstacles listed for the chosen
APBSS route and it seems that they believed that its design as one of CHC
Irelands’ ‘Low Level’ routes would, if followed using the FMS, provide adequate
lateral terrain separation.
·
Even though both pilots separately reviewed the APBSS route, neither
noticed the presence of Black Rock as an on track obstacle. The combination of
relatively low flight deck lighting with the use of coloured documents, the
size of font used in some of them, the tabulation of a large amount of
numerically dense information intended to be used in conjunction with charts as
well as the combined portrait/landscape presentation of some routes, including
APBSS was sub optimal.
·
The reason for retaining in unaltered form a longstanding procedure which
used a 282 feet obstacle as the starting point for what the Operator described
as a ‘Low Level’ route, with no vertical profile, could not be determined
because the origins of the route design itself were unknown to the CHC
Ireland.
·
A number of other factors militated against the pilots detecting their
unexpected proximity to Black Rock in time to carry out an effective avoidance
manoeuvre:
o
it was not in the EGPWS database;
o
the BLKMO magenta waypoint symbol and track line on the nav display
probably obscured radar returns from Black Rock which might otherwise have been
detected when set to the 10 nm range;
o
The 1:250,000 Aeronautical Chart Euronav imagery did not extend as far
as Black Rock, and the 1:50,000 Ordnance Survey Ireland imagery in the
Toughbook showed open water at the position where Black Rock was located;
o
CHC Ireland did not have formal processes or procedures to approve
mapping data/imagery for use in its helicopters.
·
The operating environment on the west coast would have been more
challenging than east coast crews were familiar with particularly regarding the
availability of visual cues in the littoral environment. This meant that it
would not have been possible for the Flight Crew to accurately assess forward
horizontal visibility. Since Black Rock was only detected on the helicopter’s
infra red camera when it was approximately 600 metres away, it is likely
horizontal visibility using the naked eye was less than that and the
pilots' night vision may have been compromised by the helicopter’s
external lighting.
·
CHC Ireland stated that the routes provided “were merely there
as a framework on which to build a plan for entry/exit to a number of known
sites”. There was no formal training in their use, no formal procedure for
the design of routes, no formal procedure for how a crew should use a route
guide, routes did not include a vertical profile or, usually, minimum altitudes
for route legs and routes were not available for use in the full flight
simulator.
·
The Route Guide was prefaced with the statement that it was ‘a work in
progress and should be used with the necessary caution until all
routes/waypoints are proven’. There was no defined process for route proving
and in the absence of formal, standardised training, design procedure or
procedure for how a crew should use a route guide, it was unclear what
beliefs/expectations individual pilots may have had regarding routes and how
they could be used. Problems with a number of routes had been identified
through crew safety reporting but these were closed without any check that
routes with problems had actually been corrected.
·
There were wider failings in the CHC Ireland SMS with
procedures not following those documented and/or obviously necessary, risk
assessments being carried out by inadequately trained
personnel, and failure to properly record important safety information.
·
The reliance by CHC Ireland on a secondary duty model to discharge
safety critical tasks meant that matters could arise and be left in abeyance
while personnel were on leave, off-shift or otherwise engaged in their primary
SAR duties.
·
Despite the fact that its published reports and Aeronautical Notice
said that the IAA SAR operations were classified as a ’State’ activity and were
to be regulated by the National Aviation Authority, the IAA subsequently
expressed uncertainty about its mandate to regulate SAR; however, it neither
withdrew nor restricted the Operator’s National SAR Approval.
·
CHC Ireland, the Irish Coast Guard and the Irish Government Department
of Transport, Tourism and Sport all believed that the Irish Aviation Authority
was regulating SAR operations. Audit reports of the Operator’s bases for the
Irish Coast Guard by a consultant did not appear to have been critically
reviewed and the organisation did not have an SMS. Also, the Department of
Transport, Tourism and Sport lacked the technical expertise to effectively
oversee the Irish Aviation Authority.
·
Although it was acknowledged by the Irish Aviation Authority that CHC
Ireland was performing “medium to high risk” operations, the
level of operational safety oversight achieved did not reflect
this.
Overall, the Investigation came to
the conclusion that the collective findings made demonstrated that the accident
was, in effect, what could be fairly described as ‘an organisational accident’.
The particular challenges of contracting and tasking complex operations such as
Search and Rescue require that associated risks are fully understood, that
effective oversight of contracted services can be maintained and that
helicopters only launch when absolutely necessary.
The Probable
Cause of the Accident was formally recorded as “the Helicopter
was manoeuvring at 200 feet asl, 9 nm from the intended landing point, at
night, in poor weather, while the crew was unaware that a 282 feet high
obstacle was on the flight path to the initial route waypoint of one of the
Operator’s pre-programmed FMS routes”.
Twelve Contributory
Factors were also identified as follows:
1. The initial route
waypoint, towards which the Helicopter was navigating, was almost coincident
with the terrain at Black Rock.
2. The activities of
the Operator for the adoption, design and review of its routes in the FMS Route
Guide were capable of improvement in the interests of air safety.
3. The extensive
activity undertaken by the Operator in respect of the testing of routes in the
FMS Route Guide was not formalised, standardised, controlled or periodic.
4. The training
provided 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.
5. The FMS Route
Guide did not generally specify minimum altitudes for route legs.
6. The flight crew
probably believed, as they flew to join it, that the APBSS route (from waypoint
BLKMO to waypoint BLKSD as described in legs 1 to 4 of the narrative and on the
map in FMS Route Guide) provided by design adequate terrain separation from
obstacles.
7. Neither pilot had
recently operated into Blacksod.
8. EGPWS databases
did not indicate the presence of Black Rock, and neither did some ‘Toughbook’
and ‘Euronav’ imagery.
9. It was not
possible for the flight crew to accurately assess horizontal visibility at
night under cloud at 200 feet above sea level and 9 nm from shore over the
Atlantic Ocean.
10. The flight crew
members’ likely hours of wakefulness at the time of the accident were
correlated with increased error rates and judgement lapses.
11. There were serious
and important weaknesses with aspects of the Operator’s SMS including in
relation to safety reporting, safety meetings, its Safety and Quality
Information Database (SQID) and the management of its FMS Route Guide such that
certain risks that could have been mitigated were not.
12. There was
confusion at the State level regarding responsibility for oversight of SAR
operations in Ireland.
A Preliminary
Report published on 13 April 2017 whilst the Investigation was continuing
included two Interim Safety Recommendations as follows:
·
that CHC Ireland should review/re-evaluate all route
guides in use by its SAR helicopters in Ireland, with a view to enhancing the
information provided on obstacle heights and positions, terrain clearance,
vertical profile, the positions of waypoints in relation to obstacles and EGPWS
database terrain and obstacle limitations. [2017-005]
·
that RFD Beaufort Ltd should review the viability of
the installation provisions and instructions for locator beacons on Mk 44
lifejackets and if necessary amend or update these provisions and instructions
taking into consideration the beacon manufacturer’s recommendations for
effective operation. [2017-006]
A First Interim
Statement on the progress of the Investigation published on 16 March 2018
included three more Interim Safety Recommendations as follows:
·
that the Sikorsky Aircraft Corporation should make the
necessary updates/modifications to the S-92A helicopter to ensure that the
latitude and longitude information recorded on the Flight Data Recorder
reflects the most accurate position information available during all flight
regimes and mission profiles. [2018-001]
·
that CHC Ireland, with external input, should conduct a
review of its SMS and ensure that the design of its processes and procedural
adherence are sufficiently robust to maximise the safety dividend; this review
should consider extant risk assessments and a thematic examination of the
corpus of all safety information available to the Operator, both internally and
externally. [2018-002]
·
that the Irish Minister for Transport, Tourism and Sport as
the issuing authority for the Irish National Maritime Search and Rescue
Framework should carry out a thorough review of SAR aviation operations in
Ireland to ensure that there are appropriate processes, resources and personnel
in place to provide effective, continuous, comprehensive and independent
oversight of all aspects of these operations. [2018-003]
A total of
42 Safety Recommendations based on the Findings of the
Investigation were then made at its conclusion as follows:
·
that CHC Ireland should review its guidance, operating
and training procedures in relation to the use of EGPWS in its operations,
ensuring crews are aware of the limitations of the system and that the EGPWS
manufacturer’s guidance on the use of Low Altitude mode is followed. [2021-03]
·
that CHC Ireland should ensure that it has in place
processes to ensure that mapping imagery used in its ‘Euronav’ and ‘Toughbook’
are suitable, current and sufficiently comprehensive for its intended uses, and
that appropriate guidance for the use of such systems is provided in the Operations
Manual. [2021-04]
·
that the Irish Aviation Authority should require
operators who have exemptions from Rules of the Air, to provide a full safety
case, including details of the acceptable navigation data sources to be used,
as part of the exemption application and review processes. [2021-05]
·
that the Irish Aviation Authority should require an
operator that has exemptions from Standard Rules of the Air to state the
minimum height at which each leg of its company routes can be flown. [2021-06]
·
that CHC Ireland should develop and promulgate
procedures/processes for all aspects of Route Guide management including route
design, review, approval, updating, usage, briefing, operational limitations
(to include at a minimum, visibility & altitude limits and Airborne Radar
Approach compatibility), crew training and periodic familiarisation
requirements. [2021-07]
·
that the Irish Minister for Transport should ensure
that the training syllabus for personnel involved in the decisions to launch
SAR helicopter missions includes the following:
o
information regarding the protocols used by other agencies with whom
they work, so that it is clear where responsibilities lie and how to make best
use of each agency’s expertise;
o
recognition of and strategies to address cognitive bias which could
affect decision-making/risk
assessment regarding the initiation and continuation of SAR
missions;
o
the potential for in-flight communications with helicopter crews to
adversely affect crew effectiveness;
o
practical scenario-based exercises. [2021-08]
·
that CHC Ireland should, with input from its parent
company, ensure that its OM Part A assignment and alignment of Nominated
Persons’ responsibilities is appropriately defined; that limitations regarding
assignments are appropriately set out and adhered to; and that appropriate
processes, procedures and training enable staff to discharge assigned
responsibilities in a transparent and auditable manner. [2021-09]
·
that CHC Ireland should, with input from its parent
company, review its organisational structure, secondary duty model, staffing
levels and personnel training, for its operations and support functions, to
ensure that there are sufficient resources available to discharge all necessary
responsibilities, safety management oversight, and the drafting, approval and
management of documentation. [2021-010]
·
that CHC Ireland should consider implementing a LOSA programme
within its SAR operation which can routinely review operational standards for
flight and technical crew, and provide reports on these reviews to the
Accountable Manager for actioning by the relevant function. [2021-011]
·
that CHC Ireland should formalise its monitoring of
all SAR flights to ensure that use of any exemptions allowed under the National
SAR Approval is monitored, that minimum horizontal visibility is always
recorded and that missions and decision-making are routinely reviewed with
crews to maximise safety margins and standardise launch criteria. [2021-12]
·
that the Irish Minister for Transport should implement
a procedure for Irish Coastguard to engage, at an appropriate level, with its
SAR helicopter operator in relation to mission launch concerns in a manner that
minimises any impact on duty crews and avoids creating a perception of
competition or commercial pressure. [2021-13]
·
that CHC Ireland should ensure that appropriate time
is provided within the roster to facilitate staff attendance at safety-related
meetings and that the minutes of all safety related meetings are stored in a
manner that facilitates their incorporation into the knowledge base of safety
information within the company. [2021-14]
·
that CHC Ireland should review its OM Part F
procedures in order to:
o
remove consideration of casualty condition from flight crew
dispatch/continuation criteria for SAR missions;
o
require crews of support SAR helicopters to specifically consider
when/whether it is appropriate to dispatch under SAR criteria;
o
provide specific guidance to crews about the assessment of visibility
under conditions of darkness and or poor weather. [2021-15]
·
that the Irish Minister for Transport should, in
conjunction with the relevant agencies, review processes regarding the
requesting/tasking of ‘Top Cover’ assets, fixed wing or helicopter, and should
ensure that terminology is well defined and consistently used. [2021-16]
·
that the Irish Minister for Transport should ensure
that proposed changes to Irish Coast Guard operating procedures are the subject
of a risk assessment or safety case, that any mitigations required are in place
prior to implementing the changes, and that SOPs are
updated in a timely fashion to reflect any such changes. [2021-17]
·
that CHC Ireland should review its policies, manuals,
training and guidance in relation to the operational use of radar in the SAR
role and ensure that manuals and training accurately reflect the limitations of
the systems used. [2021-018]
·
that CHC Ireland should ensure that rear crew members
receive adequate operational training and periodic, formal training and
rating(s) to operate the ‘Toughbook’, with particular emphasis on approaches
and construction of routes to target areas, the limitations of the databases
and software in use; and that the OM Part F and other documentation for
both systems should be reviewed and updated. [2021-019]
·
that CHC Ireland should review its document management
and updating methodologies and the robustness of its practices to ensure that
current documents are readily apparent, that older revisions are appropriately
archived and that staff members are provided with a uniform method for confirming
the latest revision state of any document. [2021-020]
·
* that CHC Ireland should introduce, and regularly
review, a Helicopter OFDM programme to support its SMS and
personnel in identifying and addressing operating issues and trends to optimise
safety margins within its operation. [2021-21]
·
that the Sikorsky Aircraft Corporation should make the
necessary updates/modifications to the S-92A helicopter, when configured for
SAR operations, to ensure that the active lateral navigation mode information,
including AFCS SAR modes, are recorded on the Flight Data Recorder during
all flight regimes and mission profiles. [2021-22]
·
that the Sikorsky Aircraft Corporation should make the
necessary updates/modifications to the S-92A Helicopter Rotorcraft Flight
Manual Supplement No. 4 Part 2, to include a description of the operational
usage of the AFCS SAR ‘SRCH’ mode. [2021-23]
·
that the Irish Minister for Transport should ensure
that the Irish Coast Guard’s internal processes are sensitive to warnings from
its process auditors, and that mechanisms are in place to ensure that
appropriate and necessary actions are expeditiously implemented in response to
any such warnings. [2021-24]
·
that the Irish Minister for Transport should review
the provision of aviation expertise to the Irish Coast Guard to ensure that it
is effective and structured to support appropriate governance arrangements and
that Irish Coast Guard operating procedures are risk assessed and maintained current. [2021-25]
·
that the Irish Minister for Transport should
ensure that appropriate departmental governance arrangements are in place to
oversee the functioning of the Irish Coast Guard and to ensure that issues
identified are addressed so that the systems in place will be sufficiently
comprehensive and robust. [2021-26]
·
that the Irish Minister for Transport should ensure
that the Irish Coast Guard fully implements a Safety Management System which
encompasses all aspects of its air operations and which includes all stake
holders in those operations. [2021-27]
·
that the Irish Minister for Transport should review
extant service level agreements involving Irish Coast Guard air operations to
ensure that they are suitably robust and complete, and to ensure the viability
of statements of responsibility provided in such service level
agreements. [2021-28]
·
that the Irish Minister for Transport should
periodically review the availability of in-house expertise, to ensure that the
Department retains the necessary technical capabilities to intelligently
oversee and review all activities associated with SAR aviation
operations. [2021-029]
·
that the Irish Aviation Authority should review its
arrangements, guidance and procedures for overseeing civilian operators providing
SAR services within the State, to ensure that they are sufficiently robust and
transparent so that all parties involved have a full understanding of the scope
and limits of their responsibilities and that agency interface arrangements are
designed for optimal clarity and shared understanding. [2021-30]
·
that the Irish Minister for Transport should ensure
that the Department has sufficient specialist aviation expertise to enable it
to discharge effective oversight of the full range of Irish Aviation Authority
activities. [2021-31]
·
that the Irish Minister for Transport should institute
a detailed review of the Irish Aviation Authority’s regulatory and oversight
mechanisms to ensure that they are sufficiently robust and comprehensive and
that interfaces and delineation of responsibilities are clearly defined and
understood by the Irish Aviation Authority and the entities it regulates. [2021-032]
·
that the European
Commission should carry out a review of how SAR is managed
in EU member states with a view to identifying best practice/minimum safety standards
and, as appropriate, promulgating guidance for SAR operations using civil
registered aircraft, which at the moment are excluded from Regulation
(EU) No 2018/1139 so that an appropriate and uniform level of
basic safety will apply in civil SAR operations throughout Europe. [2021-033]
·
that the Irish Minister for Transport should engage
with the European Union Aviation Safety Agency and
the European Commission to ensure that an appropriate SAR regulatory framework,
and associated guidance material are in place whether by opt-in to Regulation
(EU) No 2018/1139, or otherwise. [2021-034]
·
that the Irish Minister for Transport should review
the SAR/Helicopter Emergency Medical Services (HEMS) Decision Tree and all
arrangements regarding the tasking of SAR helicopters to ensure that there is
maximum clarity in the tasking process and that HEMS missions are not conducted
under provisions which should only apply to SAR missions. [2021-035]
·
that the Irish Aviation Authority should ensure that
its review procedures for operators that carry out multiple mission types,
particularly where different regulatory regimes are in place, consider and
address all aspects of mission differentiation, to ensure that operators are
applying full, appropriate regulatory rigour to all flights. [2021-036]
·
that CHC Ireland should review and update its offshore
survival training procedures to ensure that all helicopter crews carry out their
mandatory training wearing the safety clothing and types of equipment that
would be worn during day-to-day operations, and to ensure that the correct
functioning and compatibility of all safety clothing/equipment is verified
during this training. [2021-037]
·
that CHC Ireland should review and update its
procedures relating to the introduction into service of non-mandatory equipment
generally, and safety equipment in particular, to ensure that the procedures
are sufficiently robust to identify and resolve integration issues before
equipment is introduced into operational service. [2021-038]
·
that CHC Ireland should engage with all relevant
parties to conduct an in depth study and review of the cockpit environment of
its S-92A helicopter to ensure that safe operations can be achieved under all
ambient lighting conditions and that all aspects of information presentation
(colour schemes, typography, size, font, surface reflectivity, etc.) used in
the presentation of Route Guides, Landing Site Directories and other
information provided for use by flight crew, are optimised for use in the
cockpit environment. [2021-039]
·
that the European Union Safety Agency should carry out
a safety promotion exercise, in parallel with the development of certification
specifications for human factors in the design of rotorcraft cockpits, to
provide operators of in-service helicopters with a best practice guide to
mitigate the risks associated with human
factors and pilot workload issues. [2021-040]
·
that CHC Ireland should provide explicit guidance in
its Operations Manual on the protocols and briefing requirements for transfer
of PF and PM roles during a mission. [2021-041]
·
hat CHC Ireland should ensure that it has in place
a FRMS based
on scientific principles, which takes advantage of modern techniques such as
bio-mathematical analysis of roster patterns, is known to all its crew members
and encourages the reporting of fatigue related issues. [2021-042]
·
that the Irish Aviation Authority should review the
Operator’s 24-hour SAR shift pattern to ensure that it adequately accounts for
concerns arising from published research on human performance and that the
Operator’s FRMS and SAR variation to Aeronautical Notice O.58 provide
appropriate levels of safety and protection for crews. [2021-043]
·
that CHC Ireland should review its training syllabi
and operations manuals to increase crew awareness of automation and cognitive
bias, and as far as possible to provide strategies for recognising and
combating these threats. [2021-044]
The 464 page Final Report of
the Investigation was published on 5 November 2021.
Related
Articles
·
Controlled
Flight Into Terrain (CFIT)
·
Fatigue
Risk Management System (FRMS)
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