Concerns were raised about a small island not appearing on a warning system that alerted pilots to dangerous terrain nearly four years before Rescue 116 helicopter crashed into it, killing all four crew, a report has said.
Capt Dara Fitzpatrick, Capt Mark Duffy and winch team Paul Ormsby and Ciarán Smith died when the Irish Coast Guard Sikorsky helicopter crashed at Blackrock island, 13km west of Blacksod, Co Mayo, in March 2017, as it was travelling to help airlift an injured fisherman off a boat.
An Air Accident Investigation Unit (AAIU) report found a number of navigation system issues contributed to the helicopter crashing. The report is critical of safety failures at the Irish Coast Guard, and CHC Ireland, the company which operates search-and-rescue helicopters.
The 350-page report states Rescue 116 was en route to Blacksod refuelling station when it struck the western end of Blackrock island and then crashed into the sea.
The investigation found the crew had been “unaware” the helicopter was heading straight for the island, with the mission taking place at night in poor weather.
It also said the island did not appear on the helicopter’s Enhanced Ground Proximity Warning System (EGPWS), which alerts pilots if an aircraft is in danger of hitting land.
Concerns about Blackrock not being mapped had been raised by a pilot who had identified the omission and suggested those using the system should be warned, but the report said this “was not acted on”.
‘Obvious hazard’
In an email to colleagues dated June 26th, 2013, the pilot said he had noticed the lighthouse on Blackrock island was not showing up on the warning system, which was an “obvious hazard”.
Two days later, the report says, a pilot emailed the manufacturer of the system, informing them that “a few islands and lighthouses” were not included in its database and asked if it was possible to have them added. The report did not say if this was the same pilot or a colleague.
The manufacturer replied stating it would examine the matter. The manufacturer later told investigators that it could not find any evidence it had been provided with “specific actionable data on what islands and lighthouses to add”, and the matter was closed in March 2015 with no action taken.
The pilot who raised the concerns had copied eight CHC staff on the email.
“There was no evidence that any of the eight people who were made aware by email that the EGPWS manufacturer had been contacted about adding lighthouses followed up on the matter,” the report said.
In a statement, the family of Capt Fitzpatrick said the four crew who died were “badly let down” by the air rescue service, with the AAIU report highlighting “many failings”. The family called for all the report’s recommendations to be implemented “urgently”.
Both the Department of Transport, which oversees the Coast Guard, and CHC Ireland have committed to implement the range of reforms recommended in the AAIU report.
The proposed changes include a series of reviews of training and operating procedures, particularly around flight routes taken by pilots and warning systems.
