The accident of Rescue 116 is tragic in many ways. On a dark and rainy night, the helicopter and its crew were on a mission to assist in airlifting an injured seaman off a fishing vessel when they collided with terrain. Once again, we go beyond the immediate and obvious reasons for the accident and take a long, hard look at the organisational factors, including the overall safety management. Why wasn't any terrain shown on the crew's maps? Why didn't the EGPWS any warnings? And why was Rescue 116 called out to assist in the first place?