'We're gone': Last words heard from R116 as it 'pitched up rapidly'

An initial report into the Rescue 116 helicopter crash says it "pitched up rapidly" in its final seconds, and reveals the final words from the cockpit were from co-pilot Mark Duffy who said: "We're gone."

The report also found that Black Rock and its lighthouse were not included in the on-board obstacle database and the terrain of the island was not included in the on-board terrain database.

The information has come from the Air Accident Investigation Unit which is analysing data recovered from the blackbox flight recorder.

The bodies of Captain Dara Fitzpatrick and Captain Mark Duffy have been recovered. However, Paul Ormsby and Ciarán Smith are still missing almost a month after the helicopter went down.

The report sets out the timeline of events leading up to the crash, and provides information on flight recordings in which the crew's comments in the final moments were captured.

The four crew of Rescue 116 helicopter.

Timeline (extracts from the Air Accident Investigation Unit report):

  • At approximately 21.39 on March 13, the captain of a fishing vessel contacted Malin Head Marine Rescue Sub Centre to notify them of a medical emergency on board due to an injury to a crewman.
  • The nearest Irish Coast Guard SAR helicopter to the fishing vessel was located at Sligo Airport; its crew were on a 45-minute response time to launch.
  • At approximately 21.42 hrs the Malin Head Marine Rescue Sub Centre (MRSC) contacted the Sligo SAR crew duty pilot. MRSC Malin provided the Duty Pilot with the details of the mission tasking, including the weather conditions and the nature of the medical emergency. The Sligo Duty Pilot accepted the tasking.
  • At 21.55 hrs, MRSC Malin established a 3-way call/phone-patch with the captain of the fishing vessel and a doctor from the contracted medical service at Cork. After discussing the extent of the injuries, the doctor asked MRSC Malin “is he [the injured seaman] going to be medevaced11?” MRSC Malin advised that he was.
  • At 22.03 hrs MRSC Malin contacted the Air Corps to pass details of the mission request and the Air Corps undertook to review it and respond. At 22.06 hrs the Air Corps Duty Officer telephoned MRSC Malin to advise that they had no availability until 8am.
  • At approximately 22.10 hrs, MRCC called the Duty Pilot of R116 at Dublin for Top Cover for R118’s medevac tasking, and R116 accepted the mission.
  • At 23.03 hrs, R116 departed Dublin Airport with a crew of four on board; two flight crew, a winch operator and a winchman (Captain Dara Fitzpatrick and Captain Mark Duffy; Paul Ormsby and Ciarán Smith;
  • R116 departed for Sligo Airport, but they indicated to Dublin air traffic control that they were routing to either Sligo or Blacksod, and would decide which location to use while en route. At approximately 23.20 hrs, the R116 requested a routing to Blacksod from Dublin air traffic control, to refuel.
  • R116 continued at 4,000 ft, and when south abeam waypoint BKSDA12 the crew informed Shannon at 00.34 hrs (14 March 2017) that they were commencing descent to refuel at Blacksod. The helicopter descended to the west to a radio altitude of 2,400 ft. Thereafter, the descent was continued in a westerly direction. As the helicopter approached the waypoint BLKMO13 from the east, the helicopter then turned onto a north westerly heading (293 degrees magnetic) and continued descending to 200 ft radio altitude and 80 Knots Indicated Air Speed (KIAS).
  • The helicopter then commenced a left turn onto a south easterly heading. During this time the helicopter speed was manually selected to 75 kts. The Commander then requested a “direct to BLKMO” selection on the helicopter’s Flight Management System (FMS). Flight Data Recorder (FDR) data indicates that the helicopter commenced a left turn towards BLKMO. [NOTE: BLKMO is a geographic point on the Operator’s Route Guide at which the arrival into Blacksod was to commence; it is close to Black Rock.]
  • Flight data recorded on the Health and Usage Monitoring System (HUMS) card and the FDR, showed that the helicopter was in stable level flight at 200 ft Radio Altitude, 75 kts Indicated Airspeed, helicopter heading 120 degrees magnetic (approximately) on a track towards waypoint BLKMO. In the final seconds, the helicopter pitched up rapidly, impacted with terrain at the western end of Black Rock and departed from controlled flight.
  • The last Shannon ATC radar return for R116 was at 00.46 hrs. The first indication that R116 may be missing was at 01.06 hrs, when the helicopter crew did not answer radio calls to their call-sign.
  • At 01.08 hrs, the Blacksod lighthouse advised that they had no contact with R116. At 01.13 hrs MRSC Malin broadcast (relayed) a MAYDAY on Marine Channel 16 to the Achill and Ballyglass Lifeboats, which were then tasked. At 02.13 hrs, R118 advised that they were on scene and commencing a search.
  • At 02.16 hrs, R118 advised that a casualty and debris were sighted in the water southeast of Black Rock. Shortly thereafter, the Commander Dara Fitzpatrick was recovered from the water by the Achill all-weather lifeboat. The Co-pilot Mark Duffy was subsequently located within the cockpit during Remotely Operated Vehicle (ROV) under water searches and was later recovered by divers from the Irish Naval Service. The two rear crew members remain missing, despite extensive surface and sea bed searches.

Wreckage/debris was identified on the rock following an aerial search. Examination of this wreckage revealed evidence of contact with terrain; this wreckage came mainly from the tail rotor and intermediate gear box areas.

A review of the communications data showed that Commander for the mission Dara Fitzpatrick was seated in the right hand side cockpit seat and was the pilot flying. The other pilot (Mark Duffy), seated in the left hand side cockpit seat, was also a qualified helicopter commander; he was the co-pilot ("pilot monitoring") for the flight.

The report adds: "Crew communications were mission-focused and considered, with minimal extraneous conversation."

Crew's comments recorded before impact

The audio files recorded Commander Dara 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 she asked the co-pilot when he had last been into Blacksod and he indicated that he had not been there recently.

A rear crew member identified an island, probably through the use of the on-board camera, about 13 seconds prior to the initial impact with terrain. He said: “Looking at an island just in, directly ahead of us now guys, you want to come right [Commander’s Name]”.

In response to a query “OK, come right just confirm?” from the Commander, the rear crew member said “twenty degrees right yeah”, and a heading change was initiated using heading mode. The rear crew member then interjected, with increasing urgency, “Come right now come right COME RIGHT”.

The helicopter rapidly pitched nose up during the two seconds prior to the initial impact. Following the initial impact, the data indicates that the helicopter climbed while experiencing large changes in pitch, roll and yaw angles.

The last audible words recorded were those of the co-pilot Mark Duffy: "We’re gone."

An extract from the voice recordings included in the report.

The recorded data indicates that the flight crew was using an operator-specific route guide. The initial report published this evening recommends a review of the Operator’s Route Guides is warranted.

Specifically: "CHC Ireland [which provides search and rescue (SAR) services for the Coast Guard under a €500m government contract] 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."

A second recommendation is 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.

On-board data

The helicopter was equipped with an Enhanced Ground Proximity Warning System (EGPWS), which provides visual and aural alerts when there are obstacles ahead.

The report says the "look-ahead modes are intended to prevent the aircraft from running into sharply rising terrain or man-made obstacles. The EGPWS also provides a digital terrain map that allows the pilot to view a representation of terrain and obstacles ahead, provided these are contained in the databases...If the EGPWS detects that the helicopter is, or will come into, conflict with database terrain or obstacle(s), it will provide a combination of annunciator lights, colour display(s) and aural alerts to the pilot".

In relation to Black Rock and its Lighthouse the EGPWS manufacturer informed the investigation that “The lighthouse obstacle is not in the obstacle database and the terrain of the island is not in (the) terrain database.”

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