How can this happen - controller partly blamed (merged)

[PICKS135]

http://news.bbc.co.uk/1/hi/scotland/4686602.stm

Surely if your not guilty at a court martial, then you arent to blame !!

[BEagle]

What utter nonsense.

Clearly the F-15 pilots were inadequately prepared to fly in the UK ATC environment - it was entirely up to their unit 'indoctrination' to ensure that they understood UK terminology and ATC service levels. That the lead pilot requested the 'minimum vectoring altitude' shows that he had no idea of UK terminology.....

The Court Martial which cleared the ATCO was told that the lead F-15 pilot was entirely to blame for his CFIT accident.

The ATCO in question should insist that it is made abundantly clear that no blame whatsoever should be attached to him.

This is worthy of another Chinook/Mull of Kintyre level of outrage from serving RAF personnel...

[PAMCC]

Surely this is a case of the horse going before the cart The Courts Mashall shouldn't have taken place until after the RAF Enquiry was complete. That way all the information would have been available.

The BBC report also seems to imply that the Courts Marshall cleared him of total blame; in other words that he wasn't solely to blame, but leaving the door open for the official RAF enquiry to find him partially to blame for giving an unsafe clearance.

Seems he had a 'lucky' escape at the CM, if it had come after the official enquiry he might now be facing very serious charges. Or does double jeopardy not come into play here?

[rudekid]

Beagle

I try hard to bite my tongue at the drivel you normally spout. However on this occasion...

This is worthy of nothing like the level of disgust felt around the service at the dreadful Mull of Kintyre saga.

Read some information on the case, read some information on the BoI and then see if your opinions are still the same.

Lots of people at fault, lots of issues raised. Blame? Not on any single person. And rightly so.

Sad facts: Two dead aircrew. RIP.

[Speedpig]

A spokesman for the Ministry of Defence said it was not the role of a Board of Inquiry to apportion blame, and it marked the closure of an unfortunate incident for the RAF

The purpose, surely is to estsablish facts and prevent it happening again?
Sadly the crews can't comment. Do F15s carry FDRs?

Please don't lambast me for lack of knowledge, I'm merely an interested civilian.

[JTIDS]

If the RAF enquiry is in the standard format of an accident report, then it would not lay the blame with any one, it would instead list the various contributory factors which lead to the accident. This has been the case I believe ever since after the Mull of Kintyre accident report. This would tie in with the quote in the report:-

"A spokesman for the Ministry of Defence said it was not the role of a Board of Inquiry to apportion blame, and it marked the closure of an unfortunate incident for the RAF."

It would therefore seem that this is another piece of badly written reporting by the BBC, reopening wounds best left alone.

Edited because my grammar is appalling.

[LTNman]

http://news.bbc.co.uk/1/hi/scotland/4686602.stm

A crash which killed two fighter pilots in the Cairngorms has been partly blamed on a military air traffic controller, BBC Scotland has learned.
The official RAF inquiry reached its conclusion even though the controller was cleared of causing the deaths by an earlier RAF court martial.

Two US pilots from Suffolk died when their F-15 jets crashed into Ben Macdui on a low flying exercise in 2001.

The report concludes they accepted an unsafe air traffic control instruction.

The deaths of Lieutenant Colonel Kenneth Hyvonen and Captain Kirk Jones, who were based at RAF Lakenheath, have been scrutinised several times.

The original RAF Board of Inquiry was suspended pending the court martial of Malcolm Williams, the air traffic controller at RAF Leuchars who gave flight descent information to the two US planes shortly before they crashed.

The RAF court martial cleared Flt Lt Williams of causing the deaths of the two pilots.



A US Air Force inquiry then concluded the American pilots made the first mistake, following confusion about terminology with the RAF controller.

Now the findings of the reconvened RAF Board of Inquiry conclude the crash happened partly because the pilots accepted an air traffic control instruction that was clearly unsafe.

A spokesman for the Ministry of Defence said it was not the role of a Board of Inquiry to apportion blame, and it marked the closure of an unfortunate incident for the RAF.

The F-15 pilots were flying in variable cloud on a low altitude training mission and were lost from radar during an air traffic control handover on 26 March, 2001.

Lieutenant Colonel Hyvonen, 40, and Captain Jones, 27, were killed instantly when their aircraft crashed while on a low flying exercise from RAF Lakenheath.

[chevvron]

Is this bad reporting, or do the BoI really believe that he gave an INSTRUCTION when providiing RIS?

[EXATCO]

A detailed account of the Courts Martial is at: http://www.pprune.org/forums/showthread.php?t=61388&highlight=F15+Court

The whole sad and sorry story seems to whiff of the foulest sort of politics. I wonder if the BoI ignored eyewitness accounts etc. in the same way as the Prosecution appeared to have done!

[PAMCC]

JTIDS are you suggesting that this shouldn't have been reported? Or are you suggesting that the report didn't say that the pilots accepted an unsafe clearance and that the media have got that wrong? There seems to be the suggestion of both, in your last posting.

Any of us who have been around avaiation for a while know that most accidents are caused by a catalogue of events. It seems that this is the case here. If the board state that the clearance was unsafe, then that is the conclusion of the board. The board isn't apportioning blame just stating the facts. This fact, was a contributary factor to the accident and must be recognised by all concerned.

In the interest of safety and to ensure that another tragic event like this does not happen again, it is necessary for all concerned to be aware, take this on board and ensure that any clearnce given and received is clearly understood by all parties.

[BEagle]

By flying below safety altitude in IMC without positive radar control, the flight leader displayed woeful situational awareness and, as a result, caused the controlled flight into terrain of both himself and his wingman.

This was not helped by his lack of understanding of UK ATC procedures, and the confusion he caused to the ATCO providing the Radar Information Service by his incorrect use of domestic US terminology.

All RAF pilots of my era were taught low level weather aborts during their basic Jet Provost low level navigation training. Quite why this experienced pilot was so unaware of the immediate terrain and yet pressed on with his exercise will probably never be fully established.

The CM cleared the ATCO of any blame and costs were awarded against the Crown. One hopes that the ATCO's QC will go into battle once more to demand both a retraction and an unequivocal apology.

Is the report available in the public domain yet? The US press are reporting: 'The report concluded that "the controller's actions were not the cause of the accident, though they made it very likely to occur." '

[The Gorilla]

In no way shape or form can this be equated with the Mull of Kintyre travesty!
:mad:

[L J R]

Gorilla,

I repect your right to an opinion. I just disagree with it.

[JTIDS]

PAMACC, I am agreeing with pretty much what you say. What I was trying to say that the BBC report seemed to be trying to create controversy where there was none. However I have just re-read my posting and realised the possible area of confusion.

[Pierre Argh]

they accepted an unsafe air traffic control instruction Some have questioned this choice of words? From what I recall of the accident (not first-hand, but read on this forum and in other more "official" sources)... On request from the formation leader for descent, the Controller allocated a level that did not provide terrain clearance... the fact that the pilots, under RIS, had responsible for terrain clearance and that the allocated level was above the mountain top so could not have directly caused the death of the pilots... even the not guilty decision (which incidently I do support) does not diminish from the fact IMHO it was still an unsafe instruction?

[PAMCC]

JTIDS, the media always have a habit of trying to create controversy. Thank you for your reply though :)

I hope, that sensible people will think that the Board's report raises interesting saftey issues. I am curious to know why they say that the phraseology used by the ATCO was constributary to the accident. If, it was indeed, contributary, then we should all be asking this question and a resolution made to ensure that better phraseology is used in the future. This has got to be worthy of discussion on this thread.

Can anyone tell me what the exact phraseology was? Is there a transcript available anywhere?

[SixDelta]

Had he "issued a clearance" (under a RIS i understand) to descend to an altitude below MSA for the area?

Presumably this is why we are now constantly reminded that we are responsible for our own terrain clearance when in reciept of such a service now...

[SASless]

All RAF pilots of my era were taught low level weather aborts during their basic Jet Provost low level navigation training. Quite why this experienced pilot was so unaware of the immediate terrain and yet pressed on with his exercise will probably never be fully established.

Beags....has an RAF crew smacked rock since you were first trained on Boxkites in the RAF? Seems to me we have had a long ongoing discussion about at least one crew in a Chinook.

Try to answer your own question....why did the two pilots find themselves flying lower than the rock? Reckon they may have had some help in making that mistake? It does not have to be intentional help....it does not have to be direct help....but two good men died for some bad reason.

It seems very odd to hold a court martial while a BOI is on-going. They are two indepenent inquiries and have completely different purposes, however they are about the very same set of facts and thus cannot be separated.

My view would be the court martial was hurried up and the BOI was suspended so that political face could be saved. No one on the RAF side wanted to confronted with any responsibliity for two USAF aircraft and pilots being lost.....no matter how tangentially involved.

I see it as being a very transparant method of shielding the home team while leaving the visitors out on the limb.

That the USAF pilots made a mistake....or a series of mistakes but the bottom line....any vector given by radar to an aircraft has to take into account the minimum safe altitude for the area being flown. The terminology difference should not have rendered that mandate invalid.

The controller if confused...and aware of being confused...should have announced his uncertainty and suggested a climb to altitude while things got sorted out. I would suggest if the pilots had sensed any uncertainty, in all liklihood they would have asked for the climb clearance or one would hope anyway.

The thrust of the BOI should be to accurately layout the facts....assess them for factors that led to the disaster and fairly descibed what those factors were without regard to who winds up with egg on their face.

The inclusion of the court martial smacks of some self serving interest by the Airships in this matter and not a seeking of justice for either the pilots or the controller.

The Chinook thread is yet another indicator of how good men can be let down by the system.

[Brit55]

It is indeed SixDelta,

although I have to say that it took me a while to get used to!

"You are identified RIS blah blah. You are responsible for terrain avoidance."

No Sh*t..!

[PAMCC]

Issues as to the ATCO being confused with respect to the terminology used, are, in my opinion exactly why the safety issues from the BoI should be being addressed. An ATCO of his apparent long standing and capability (and I'm going on what all his friends and collegues wrote on this forum leading up to the CM) should not have been confused. So why did this happen and why did he feel unable to advise the pilot that this was the case?

The results of the CM are known and unarguable.

However there are lessons to be learnt here. I have not had any replies as to the exact phraseology used. What happened to the good old phrase "at your discretion' or "unable to give descent below Minimum safe Altitude"? Were these phrases used or weren't they? If they were then how could the BoI have considered the phraseology used to be unsafe?

It also seems that the ATCO was well aware that the aircraft intended to descend to 4000ft and that the aircarft disappeared from radar, but that this was not due to the crash. I read from this, that this descent took the aircraft out of known radar coverage. Is that correct? If so what happened to that good old phrase "you are (going) out of radar coverage, Radar Information Service Terminated".

All of the above are little alert messages to the pilot that he is now doing entirely his own thing and if they had been used, would have absolutely and fully exonerated the ATCO.

So someone out there please tell me. Are military controllers no longer taught the above phraseology? Has it changed? Did they ever use it? Was it used in this case? From what we are learning from the BoI, it seems the latter is unlikely.

So I say once again. We all have a lot to learn on the issue of safety here. What is likely to be done about it? Has any of it already been addressed?

[Tarnished]

Rule One in aviation = Don't crash
Rule two = see rule one.

I wholeheartedly recommend that you read the referenced thread. If you believe in the conditions of "reasonable doubt" then this whole event is nothing more than a very sad accident. I was an expert witness in this case, I too thought when I first encountered the evidence that it was a straight descent into terrain, but having studied all (and I do mean all) the evidence that there is another possible scenario. Especially when one of the highlights of my 4 days in the witness stand was the Gp Capt prosecutor asking me:
"well Mr X if it wasn't for the eye witnesses, nobody actually saw the aircraft".

Brilliant, abso-fkin-lutely brilliant.

Maybe its a sign of the times, but when I was learning to be a pilot I was always taught to look after myself, trust no one, never assume, check and be well prepared. Why is someone else always responsible these days???

Tarnished

[SASless]

the reconvened RAF Board of Inquiry conclude the crash happened partly because the pilots accepted an air traffic control instruction that was clearly unsafe.

Clear to whom....the controller...the pilots? Or some fecker who had naught to do but spend weeks mulling over things in the quiet of an office with lots of tea and biscuits?

If it is that "clear"....what happened?

[DICK DOLEMAN]

In support of Tarnished:

The full findings of the Board of Inquiry can be found on the MOD UK website. I have only had a very brief read and will reply more thoroughly after a proper look at the full report.
In essence, it would appear that the full reporting chain still believe the F15s followed a straight line descent in IMC into the ground. To support their theory, they believe that the eyewitnesses saw Tornados (AXIS formation) and not the F15s. This despite the leader of AXIS formation stating at the Court Martial that the flight was flying in loose trail and not in close formation as the eyewitnesses reported the F15s. The F15s crashed in very close formation. Further to that, AXIS formation landed 30 minutes before the estimated time of the crash.

If the new BoI has persuaded the leader of AXIS formation to change his recollection of their route on the day to coincide with eye witness positions then surely perjury will have been committed? The original verbal testimony of the route was given under oath at the GCM and a map of the route was presented as an exhibit (I have a copy of that map). The only other aircraft in the area that day were the F15s. The eyewitnesses could not have seen the Tornados on the route given in evidence.

One of the crassest questions asked by the chief prosecutor (and there were quite a few) at the GCM was : " If you take away the eyewitnesses, there is no evidence that the aircraft were seen to the east of Ben McDui, isn't that true?"

The original BoI was accused of fudging evidence to fit their theory of the cause of the accident; I hope this latest saga is not a repeat performance. The RAF seems to find eyewitnesses very inconvenient !! The subject aircraft overflew 2 of the eyewitnesses at something like 250' in close formation, they then overflew another eyewitness in a matter of seconds having altered heading. I would suggest that fast jets in loose trail almost constitute 2 sightings, not one.


DICK DOLEMAN is online now Edit/Delete Message

[PAMCC]

There is another thread on this called 'How Can This Happen' (perhaps the moderators can put these together). I have posted quite a few questions on the other site and now that there are people reading this one, who know more about what happened, perhaps they can read those questions and answer them.

It seems to me that the BoI are questioning the phraseology used. If there is a fault in the phraseology, then in the interests of safety, this has to be addressed. If Mr Doleman can get off his train of thought that we are all trying to sling mud at his friend (which I, for one, am not) and get onto the subject of safety, we might all learn something useful.

[PAMCC]

[quote=DICK DOLEMAN] >The original BoI was accused of fudging evidence to fit their theory of the cause of the accident; <

Who accused them? Was this and official accusation? Were any charges brought? Was the accusation proved (legally) justified? How come we didn't hear the fallout of such an event?

I thought that the original BoI was halted because the CM was convened. You're now implying something different. Were the members of this BoI the same as the original board?

[PAMCC]

DD I'd be interested in your answers to the questions that I've posed on this thead.

[BEagle]

For those wishing to see the BoI report, it is at:
http://www.mod.uk/DefenceInternet/AboutDefence/CorporatePublications/Reports/OtherPublications/BOI/BoiReportIntoF15AccidentMarch2001.htm

NB - Some rather large .pdfs to download!

I note in Part 2 of the BoI report:

23. Three of the witnesses were positive that they had seen twin-tailed ac, not Tornado ac. The board judged that, if they were correct, then the F-15C formation would have had to have avoided the imminent collision with terrain indicated by the last radar plot.

But how do they know whether the F-15C formation leader would have actually been able to see this terrain in such white-out conditions. I thus find the later comment:

In conclusion, the Board judged that, despite their certainty that they had seen twin-tailed ac, the eyewitnesses had been mistaken as to the type of the ac, possibly due to a factor such as the angle of view, the proximity of the ac to eachother, the prevailing light conditions and changes in aspect as the ac flew past whilst manoeuvring.

to be somewhat surprising, given that the 3 witnesses were so 'positive'..

Mods - please merge the threads.

[DICK DOLEMAN]

This comment by the board is most surprising:
23. Three of the witnesses were positive that they had seen twin-tailed ac, not Tornado ac. The board judged that, if they were correct, then the F-15C formation would have had to have avoided the imminent collision with terrain indicated by the last radar plot
None of the eye-witnesses were anywhere near the last radar plot. They were between 6km and 8km to the east and south east of the crash site. This evidence was crucial in supporting the defence theory that the F15s were already engaged in low flying prior to the accident and were last seen on a westerly heading towards the area of the crash site.

[DICK DOLEMAN]

Check your PMs

[Tarnished]

Thread merge would be good.

To answer Speedpigs question, only one in 10 of all F-15s (all USAF fast jets??) is/was fitted with an FDR, if it has a serial number ending in a zero, it has a FDR.

Not a lot of people know that.

Sadly neither of these aircraft had one fitted.

Tarnished

[PPRuNeUser0211]

PAMCC,

I believe the ATC world has learnt a lot from this already. Certainly now you would never be let down anywhere dodgy under RIS without the obligatory reminder that "you are responsible for terrain clearance" or whatever the phrase is. I believe that a number of guidelines were brought in pretty quickly after the accident.

[PAMCC]

That's good to know. Is RIS also terminated when A/c go low level? Surely these a/c would have decended out of radar cover. So I couldn't figure why the RIS wasn't terminated.

Something else that puzzles me.
In the original thread about the CM there was information about the pressure setting for the area and it seemed that if the a/c were on regional and at 4,000ft indicated, they would not have hit the mountain due to the difference between the regional and the actual.

Many words have been written about the theory that these a/c had descended below 4,000ft. So...........was there no readable/useable information recovered from the wreckage to confirm what was on the altimeters? Was it too badly damaged?

[H Peacock]

A thought provoking thread! However, a few misconceptions about RIS. Terrain clearance remains the responsibility of the aircrew under both RIS and RAS. Furthermore under a RIS you can be cleared to a height/altitude below the radar vector chart, under a RAS you can't. I've never managed to understand why that is. Surely the only difference between a RIS and a RAS is the avoiding action given from other traffic, but I digress.

The time consuming blah about '...resposible for terrain avoidance ..' has, I believe, thankfully been removed from the book. Certainly I've not heard ATC use it for a few months.

As regards the low-level abort, it is still taught during flying training. If a student is unable to fly a safe abort he will not pass his Instrument Rating. The BIG proplem is knowing when to initiate it, not how!

H Peacock

[Angrel]

H Peacock. Just wanted to clarify a few points!
Radar Advisory Service is where the aircraft recieve warnings and avoiding action information from other aircraft. The pilot is not obliged to take that action. They certainly cannot be cleared to below a radar vector chart. To do so would relegate them to FIS.
Radar Information Service is where the pilot recieves information only on other aircraft and takes his own avoiding action. Again, they cannot be cleared under the RVC as this would take them down to a FIS.

and no, '...responsible for own terrain clearance...' has most certainly not been taken out of the book and should be given everytime by ATC especially in Class G airspace.

hope that clarifies that!

[Argus]

The BOI Report is at http://www.mod.uk/DefenceInternet/AboutDefence/CorporatePublications/Reports/OtherPublications/BOI/BoiReportIntoF15AccidentMarch2001.htm (http://www.mod.uk/DefenceInternet/AboutDefence/CorporatePublications/Reports/OtherPublications/BOI/BoiReportIntoF15AccidentMarch2001.htm)

I've followed this tragic accident, and its aftermath, with more than passing interest.

This is not the first time military aircraft have descended into high ground in northern Scotland while in receipt of some form of ATC service.

There was a similar accident in January 1966, when a Canberra from 2TAF crashed into high ground west of Inverness, on descent to become "VMC below', to enter Tain Range.

If memory serves me correctly, in the Canberra accident, the aircraft was in receipt of what used to be called 'Limited Radar Advisory Service' (LRAS); and was cleared by ATC to an altitude below that of the local safety height, while heading west along the Moray Firth towards high ground.

In those days, ATC was provided via Moray Radar/Approach based at Lossie using the S264 and CPN4 radars; the former for area/approach and director, the latter for GCA finals. The S264 incorporated both primary and secondary radars, had a max range, I think of 160 nm, and a very good anti clutter/weather filter. If one deselected the MTI, Ben Macdui, Ben Nevis and various other peaks stood out like canine testicles. In the idiom of the day, the term ‘cumuli granites’ comes to mind.

As in the F15 accident, both Canberra crew members were killed instantly. Similarly, it took some days to locate the wreckage and bodies due to adverse weather.

The RN controller involved was court martialled. I understand he was “dismissed his ship” and never controlled aircraft again.

I believe that disciplinary proceedings were also taken against Squadron staff at RAF Bruggen. I'm not sure what the outcome was but involvement in same isn't likely to be career enhancing.

One of the procedural changes adopted by RN ATC (Moray Radar/Approach) at Lossie after this accident was to tell pilots on VFR descent into LFAs 14 & 15 under LRAS that they were responsible for terrain clearance, they were descending towards high ground; that if they became IMC, they were to climb immediately to FL .... ( a quadrantal level based on the lowest safe altitude within 100nm of Lossie, calculated on the current Regional Pressure Setting and displayed in bold font on the tote board above the controller's display); and to contact Moray Radar/Approach ASAP on … (freq).

And all 2TAF descents into Tain Range from VMC on top were via a GCA into Lossie with overshoot across the Moray Firth.

"Plus ca change, plus c'est la meme chose"!

In the BOI Report, there’s some reference to what, on any version of the facts, must be a Heath Robinson means of communication between Leuchars and Lossie ATC. Even in the 1960s, there was direct ATC land line comms between controllers (and to Highland Radar at Buchan, too) to facilitate ATC/ADIZ/QRA/MDA responsibilities and radar handovers via GEOREF i.a.w a SOP. The vision of using an ordinary telephone in 2001 to effect a radar handover via an assistant simply beggars belief.

And there’s the hoary old chestnut about the permissive nature of the drafting of orders. Is the RAF using public servants to draft orders these days? As Grampaw Pettibone used to say: “Holy snapping ducks*hit, it don’t take no Einstein to know that an order that’s capable of more than one interpretation ain’t worth the paper it’s printed on”.

Also in the Report, both the AOCIC and the AOC note that while responsibility for terrain clearance must remain with aircrew, air traffic controllers "must be responsible for the accuracy and the safety of their instructions". If so, is this responsibility made clear to controllers from ab initio days?

And if the AOCIC is correct in saying that this is a duty of care issue (and I think he is), then, in the absence of any Crown immunity, the question arises as to what civil liability is imposed on both the controller and his employer, vicariously, if that duty is breached. Or is the controller solely liable if he is on a frolic of his own? Never mind the "it's not in my duty statement" cry (whatever that might mean), did he know, or ought to have known, that the altitude that he approved descent to (4000ft), was below the height of high ground in the vicinity of the aircrafts' track?

Which in turn leads to the questions (relevantly in the F15 matter) of what duty of care supervisors have towards ATC staff, and staff to supervisors, where an individual is not completely fit for duty due to circumstances beyond their control.


On reading the BOI Report, it’s not clear to me if these issues are to be addressed. IMHO, they should; and all concerned need to know what their responsibilities are.

Succinctly put: a SNAFU with unnecessary loss of life, career/reputation and aircraft that shouldn't have happened if the lessons of history had been applied.

[Dan Winterland]

This seems to be another case of finding a verdict for the verdict's sake without adressing the issues. For example, how 'au fait' were the US pilots with UK procedures and terminology. I know they were based in the UK, but from my experience of the US use of the UKLFS I'm not convinced in this case they had a full understanding of their own terrain clearance responsibilies. Under US procedures there isn't a Radar Information Service as such - so did the pilots understand what they were getting? There has been more than one incident in the past where confusion between systems has been a factor.

[SASless]

I did not read the entire thing yet but what I did read makes me think going IMC under RAF radar control might be a dodgy thing.

From what I read, discounting how much was blacked out, I see an image of a guy who had suffered some sort of personal tragedy prior to the day in question. His co-workers asked him how he felt...for some good reason. His supervisor had not gotten around to verifying that he was fit. He admittedly had not signed off or read all of the memo's as required. He lost situational awareness (at best) and gave a clearance that placed the aircraft below the height of the mountain they hit while using it as a checkpoint in discussing handover to the next controller. The changeover was effected by a speed dial setup and not a direct line....required the assignment of the trade off to be decided before the handoff could occur. He had been asked for a descent clearance to by a non-standard terminology. He knew the aircraft were above or in cloud thus could not see terrain. He mishandled the radar by offsetting it vice extending the range setting. He was handling one other aircraft was it or was it a second aircraft was on the frequency. Anyway...he was not exactly swamped with business.

There is a lot of discussion about the whys and wherefores that deal with the very limited effect each variance from established procedure had on the fatal crash that killed two pilots but it does not consider the perception that can be formed by assessing the cumulative effect of so many deviations from procedure and plain old commonsense. I see a sloppy operation that failed to accomplish their mission, that being the safe control of air traffic.

The emphasis on the request for Minimum Vector Altitude is misplaced. The emphasis should be simply on why the aircraft were cleared towards the mountain whose height exceeded the altitude they were cleared down to by the controller....all the time he knew they were headed for that location as evidenced by the discussion he had requesting the handover.

One can say the pilots are responsible for terrain clearance....and they are. One cannot evade responsiblity for a controller giving a descent clearance that is lower than the terrain along which the aircraft will be flying. Pilots must be able to rely upon ATC to ensure terrain clearance is considered anytime an ATC clearance is given. Why else is it called a "Clearance".

[ShyTorque]

Seems to me this was a case of aircrew not aware of MSA, loss of situational awareness. It's a planning issue. As I understand it, they were not in controlled airspace and should not have put themselves in a position where they relied solely on ATC.

[H Peacock]

Angrel.
Having spoken to a competent 'air tafffickker' yesterday on the subject of radar-to-visuals (nothing to do with the F15 CFIT), he assured me that an aircraft could be cleared to a lower height on a RIS than a RAS. This was because on a RIS we can be cleared below the radar vector chart. Surely this is why you can get a RIS as soon as getting airborne but before you are high enough for a RAS? I'll double check with my contact, but this does concur with my understanding that you'll always get lower on a RIS!

As regards the 'blah' about terrain clearance, this has gone from ATC phraseology where I work, maybe a local procedure. Do I really need constantly telling something that is SOP? I think not.

H Peacock.

[PAMCC]

You cannot be 'Cleared' to do anything on a RIS. It stands for Radar INFORMATION service. If you have an ATCO telling you this they ought to be sent back to training !!! Equally any pilot who doesn't understand ATSORA.

I hope ATCOs are still using the phraseology about terrain clearance. It could save them their licence/a long CM, if, God forbid, something else like the tragic F15 accident happens.

[SASless]

Shy,

The RAF BOI disagees with you...they clearly stated the Planning was more than adequate. The knee board data recovered at the crash scene showed 5700 feet for a MSA and met all USAF standards.

The key is the difference between US and UK procedures for ATC requirements when giving clearances.

In the US ATC controllers are required to consider MSA's when issuing vectors/clearances. In the UK...controllers until this accident had no requirement to do so so. Recall also, the pilot asked for the minimum vectoring altitude from the controller...and was assigned 4000 feet. He queried that and it was confirmed. As the BOI reported...that seems to confirm the pilot accepted the altitude assuming it was the minimum altitude for vectors at that distance and location. The procedural differences between the US and the UK are the key in that situation. As is the pilots appearing to have not been adequately trained to know the lower standard of service provided by the UK ATC system in RIS/RAS control as compared to the US method.

Unless the rules have changed to make that a requirement then I find that a bit off putting. Think about it the next time you receive a clearance while flying under RIS/RAS coverage and you get a descent/altitude clearance of any kind.

Which system has the higher standard for safety in this regard....the US or the UK system?

[ShyTorque]

"The key is the difference between US and UK procedures for ATC requirements when giving clearances."

I agree, that's what I meant when I said it's a planning issue. If I was flying in a different country, I would be expected to know the differences, especially if based there. Perhaps in this case training issues, as you say, were also a factor.

Being UK trained, I consider MSA every time ATC give me a descent and have had cause to query it on more than one occasion.

Why did the pilots accept the clearance and descend if they knew it would put them IMC below MSA in mountainous terrain?

[H Peacock]

Surely, even under a RIS, if ATC tell me to turn/climb/decend then that is a clearance to do as told is it not? I accept you may have reason for not doing as asked and would duly inform ATC, but are saying that an instruction to turn/climb/decend is not a clearance to do as asked/told?

I have most definitely been cleared to land/roll/overshoot when under a RIS (internal aids or GCA), honest!

H Peacock

[PAMCC]

Weren't you cleared to land/roll/go around by the tower?

If so, you weren't under a RIS as Tower controllers don't have radar, or at least not radar that is calibrated to give a radar service. They are however, allowed to give a clearance to use the runway and can pass that clearance to a 2nd controller to pass on to you if they don't need to talk to you for any other reason.

So if you were given the above instruction by APC or anyone else it would have been at the behest of the Tower controller and the clearance would have only pertained to the runway and it's useage and doesn't form part of the RIS you are/were receiving.

It's quite a different scenario to en-route flying.

[PAMCC]

H Peacock
Sorry I didn't answer the other question.

If you are in Class G airspace under a RIS, ATC shouldn't be telling you to climb/descend/turn. They should be giving you information on known traffic, it is then up you, the pilot to climb/descend/turn as you think fit.

It's a popular misconception.............recently under a RIS, in Class G, I was with a pilot , who was told to 'hold' over a specific town. Had he so wished, he could have told Controller 'No I won't, I intend to carry on'. However, as we were close to a commercial airfield and commercial flights were on frequency also in Class G, it seemed pertinent to do as requested.

When under a RIS you are being given information on 'known a/c', it is up to you to see the rest of the picture and act accordingly. Hence, you're responsible for separation and terrain clearance. That's because the controller cannot do these for you as he/she hasn't got the full picture to do so.

Might I politely suggest a good, long, hard read of ATSORA? It was written to help clarify to ATC and pilots exactly what service was being given and what contract of service is offered and accepted between each. It was also supposed to standardise procedures so that both Civil and military ATCOs/pilots knew what was going on. I will be sad to learn it, if this is no longer the case.

[SASless]

A fair discussion of the points raised by this very accident.....


http://www.pprune.org/forums/showthread.php?threadid=185767&action=download

Deliverance....you stated your opinon....now explain how you arrived at that? Compare and contrast the three organizations and show us where they part company and how the UK system is the best of the the three. Also....are you talking military or civilian or both when you say that?

Is is they always start the conversation with "Pass your message... or rely upon QFE altimeter settings....variable transistion altitudes....treat airways as controlled airspace"....why the advantage over other systems?

[Argus]

Including:Bottom line, under the heading of Duty of Care a controller should not give an instruction or advice that they know might endanger the aircraft, irrespective of service and class of airspace, unless given with a clear caveat.

[US Herk]

Familiarity with UK procedures by US crews stationed here is a constant challenge. There is no OAT equivalent in the states & no direct correlations for RAS/RIS - this is hard to get one's head around when first landing on island here & is a continual education process.

As a gross generalisation, the under-educated typically believe any radar service is the same as in the states where the controller, while vectoring you, has responsibility for terrain clearance. Whilst ultimately, the pilot is always responsible for everything even in the States, a great deal of trust is placed with US ATC controllers.

The Eagles in question, bet their life on an assumption. That they were wrong is tragic, not stupid. We owe it to them to not repeat their mistake.

I don't much care for witch hunts - it serves little purpose. Whether he is culpable or not, that controller will live with doubts that he himself must deal with - even if found in the clear & had done everything by the book. Punishing him is nothing more than leadership through liability control...

[Argus]

Mike Jenvey

Of course the pilot in command has the ultimate responsibility. But that's not the issue I was querying. The issue is: what is a controller's duty of care when giving an instruction or clearance; and, if there is a duty, does a breach of it give rise to an action in negligence against the individual concerned and his employer?

I'm curious as to why the first BOI was aborted, and a GCM convened. Oz practice is to hold the BOI first. When what are called "potentially affected persons" (PAPs) are identified, they are afforded legal representation at public expense (unlike the UK process) at the BOI by military (usually reserve) lawyers. The disciplinary/administrative processes usually flow from the BOI recommendations, which are then considered by the convening authority, who decides what further action to take.

The current BOI in Sydney into the loss of a RAN S61 plus nine lives on Nias Island, Indonesia, in April 2005 is an example on point. The proceedings so far have identified what appears to be the immediate mechanical cause of the accident. But there's also been evidence that suggests systemic failures, in this case deficiencies in the Navy's maintenance training, communication and supply processes, including what senior officers knew or didn't know (the SGT Schultz defence, beloved of politicians, of "I know nothing because I wasn't told"). Difference is that the RAN BOI has yet to make any findings on which disciplinary action might be taken, whereas the RAF decided to interrupt the BOI and go ahead with the Court Martial.

The F15 case is fascinating. Was there a political imperative to find a scapegoat? Is this what caused the original BOI to be halted and replaced by a GCM? Or did some one form a view (wrongly as it turned out) that there was sufficient evidence to obtain a conviction, and decide to terminate the BOI?

In all of this, the RAF controller was the fall guy. Both pilots were dead. He certainly had a case to answer, but the GCM acquitted him of all charges.

Nevertheless, according to the BOI Report, it seems he issued an unsafe descent 'clearance' that took both aircraft below the height of a mountain peak close to the aircraft's planned track. Should he have known where Ben Macdui was relative to the aircraft's track? Was the high ground shown on the radar display? Should he have known that that what he was doing was inherrently unsafe? Or was he reckless as to his actions? Or did he think he had no liability because RIS placed the terrain clearance onus on the pilot? Or was his personal situation such that either he, or his supervisor, should have concluded that he was unfit for duty that day? Would a 'reasonable' RAF air traffic controller behaved in the same way?

Does this mean that the RAF can have another go at him by way of administrative action to the lower civil standard of 'on the balance of probabilities'?

Also, he's a senior FLTLT with significant ATC experience. Is there a greater duty on him than, say, some one fresh out of the ATC School, to apply his knowledge and expertise?

And what liability/duty of care does the RAF have in employing an individual air trafficker in a responsible position when it knew or ought to have known it was possible he would be distracted because of his personal situation?

And what about the NOK of the two pilots? Are they entitled to compensation from the UK Government (as the employer of the controller) and the individual or his insurer for what happened?

What disturbs me is that we went through all of this in 1966. It seems we've learnt nothing from what happened then, and repeated the same ATC mistakes with the same fatal consequences. When the RN left Lossie in 1972, it seems to have taken with it the corporate ATC memory of the previous decade.

[SID East]

Further to some of the previous points / clarifications made; you CAN be descended below the RVC or ASA on a RIS so long as vectors are not applied below these levels. In addition pilots are to be reminded of their responsibilities for terrain clearance when proceeding below these levels.
RAS is only available above the RVC and never below it. I could quote the JSP of WK but I shall refrain from doing so. Sorry Angrel but H Peacock has it!

Also it has been mentioned ad-nausea about the fact that as controllers we do have to remind pilots of responsibility for terrain clearance being theirs and I have seen similar comments on numerous ATCEB reports in the "aircrew comment" section.

As a JATCC Student at Shawbury some years ago various changes in policy (some quite literally on a weekly basis) were hurried onto the course to address the issue resulting from Ben Macdui of which this was one. The instructors were often as frustrated as we were at times but I think now we have a steady state in this respect.

One thing that sticks with me now is the advice I have received from instructors and controllers alike "get it on the tape" "limit everything you possibly can", "protect your back". As a result we have a more defensive Mil ATC Service. Controllers will continue to state responsibilities to pilots as it is in their best interests to do so.

I alluded to this on a thread last year entitled "Fear Factor in ATC training". A fellow course mate had a Tristar crash into high ground (in the simulator!) as a result of his actions. He walked away from the Sim having been told he just could have killed 250 people - withdrawal from the course followed not long after. The F15 CM looming was also a significant factor in a number of withdrawals at this time (unofficially).

I met someone else (pilot) whom Cat 5'd a Firefly on his or her first ever solo. The pilot was counselled, given lots of support and went on to become a front line pilot. At this stage of Flying Trg he was not compared to someone crashing a Tristar and potentially killing 250 people.

Given the comparison, and that ATC normally live through their operational errors (pilots are not always so lucky), is it any wonder where the defensive nature comes from? That said we all want to provide the best service we can - we are good like that!

I would be interested to hear from anyone controlling pre Ben Macdui as to what the RVC was used for exactly and how. I've heard that it was a lot different to the current system, given the changes in procedures adopted after 2001.

[Siddeous]

It seems to me that with all this focus on "is the controller to blame" most people are overlooking two important pieces of the puzzle. Firstly and most importantly is the eyewitness account of the jets manouvering at low level from a dependable witness who knew the difference between a Tornado and an F15, and the 1 hour time difference between the two formations. Such a crucuial piece of evidence that seems to be totally discounted by the BOI in their quest for a scapegoat. Secondly the fact that the aircraft altimeters recovered from the crash site showed they had descended through 4000', albeit by a small margin. Surely though if they had been aware of the high ground and had already questioned the descent they would have made sure they stayed at or slightly above that level.

I find it amazing that the station commander writes that pilots are rightly responsible for the safety of their aircraft, but air traffic must take some responsibility for the incident and the aircraft hitting the ground (well thats how i read it) Which is it to be? If air traffic are to take responsibility for these things like terrain avoidance, then they should have ultimate control over aircraft in all situations to avoid this happening again. That of course prohibits the pilots operational freedom.

I am sure every air traffiker takes their duty of care very very importantly. I am also sure that air traffic controllers are there to stop aircraft bumping into each other in the air. Descending to low level must surely be the pilots responsibility, after all the controller only has a map much the same as a pilot. They can't look out of that cockpit to make sure your safe.

Just my humble opinions

[PAMCC]

SID East

I take that you're not suggesting that this descent is a 'Cleared' descent. i.e. still up to the pilot and not initiated by the controller. I think that this is maybe where the confusion exists with H Peacock. He thinks he's being 'cleared'. Whereas, in a RIS, the contract between controller and pilot is, very basically:
'you can descend at you own discretion and I will continue to give you a RIS, i.e. Whilst in radar cover, I have you identified, I will continue to give you an information on known traffic, and I will pass useful and pertinent information but I am not controlling you. All decisions on maneouvres are yours. Separation from other aircraft and the ground is your responsibility.'

I'm not suggesting that any of his should enter the phraseology, just that this is what the contract between the two actually is and what should be understood by both in a RIS. :)

[PAMCC]

Argus

I've been told that the BoI was halted and CM initiated because the Procurator Fiscal was going to start civil proceedings and the RAF wanted their guy in a military court. This isn't verified though.


There are two other threads running on this. One in this forum and another in the ATC forum. Can the moderators merge them possibly?

[SID East]

No was not suggesting a "cleared" descent I agree with you totally, if the pilot wants further descent - at their discretion it is.
Sorry if that didn't come across in my post, I see how I could have been misinterpreted. I was trying to highlight that legally they can be allowed to descend below the RVC levels on a RIS.
Obviously as a controller you wouldn't want to be specifying heights to descend to in this situation, I had a maritime training aircraft yesterday under a RIS descending low level over the sea - reminded the pilot of his responsibility for terrain avoidance when he approached the RVC levels and continued to offer the service (no vectors) until he disappeared from radar i.e. like the situation you stated.
Take it easy
:ok:

[BEagle]

PAMCC - my experience of the knowledge of the limitations of RIS/RAS etc as understood by many military pilots is that they do not have a particularly good understanding of the rules of ATSORA.

Which have been around for years now.....

At a MEASC meeting many years ago, I commented that the average level of knowledge of the regulations pertaining to the sub-division of UK airspace displayed by graduates of the Tucano/Jetstream course was generally worse than that required even for PPL Air Law.

At a Bulldog standards session at Topcliffe, one of the prospective A2 candidates admitted he'd never heard of Class B airspace. Perhaps understandable, given his RW background - he'd probably never ever been anywhere near Class B airspace. But where did such a gap in his professional knolwedge stem from in the first place?

Under no circumstances can any mandatory instructions be issued under a RIS; in fact there isn't even any legal requirement for pilots flying under a RAS outside Controlled Airspace even to follow RAS instructions...

Claerly it is time to harmonise all civil/military terminology, with the only specific military difference being those associated with the role (e.g. visual run in and break).

And what, pray, is an 'Air Defence Advisory Service'? Is it RIS, RAS or something else?

[H Peacock]

PAMCC. I've just read your latest words but still maintain that, under a RIS, you can be given instructions.

Hope this is not too long-winded, but from descending through FL245 until landing from an ILS last week I was under a RIS throughout. I was asked to descend to various FLs, turn onto various hdgs, set QFE, descend to a height, do some checks, tell him when I was established on the localiser and then that I was on the g-slope with the gear. It was then that talkdown cleared me to land - still under a RIS. During this recovery I had one call albout another ac, but the majority of the R/T calls were instructions from ATC which I acknowledged before executing.

I don't think I'm being too pedantic here, but surley this amounts to being 'cleared' to follow each instruction, albeit I didn't ever have to.


H Peacock

[PAMCC]

SID East

Thanks, I was sure that was what you meant, but wanted to make sure that anyone else reading this, had it clarified as well.

I noted your mention of fear during ATC training...............I'm a civil ATCO (but have worked at a couple of joint units, hence the interest in Military controlling). Way, way back when I did my course, on the very first day, our course manager entered the classroom, introduced himself and said:

'Only one third of you will reach the end of the course, the rest will be 'chopped''

Nice way to start.........We didn't want to believe him, but he was absolutely correct. Only one third graduated. I think the odds are better these days :)

Keep safe!:ok:

[PAMCC]

Beagle
I entirly agree with you about standardisation, but wasn't this exactly what ATSORA was supposed to do?

H Peacock
Sorry, but, yes, you are being pedantic. You are not being CLEARED. Read what I have written about the contract between pilot and ATCO re a RIS. I don't think I can write this any clearer. It disturbs me that as a pilot you STILL think you are being cleared :confused: Other than the landing clearance ( a runway is sacrosanct to the runway controller), you are being given help to get you to your required point. All vectors and descent information will be with regard to known traffic. Separation from other aircarft and the ground is still ALL your responsibility. If you are being given a RIS you are outside regulated airspace. That means that, the controller may not be aware of all the traffic in that airspace or, it's intentions. This is why you cannot be 'Cleared' to do anything. You would be asking far too much of ATCOs if you wanted cast iron clearances when they don't know everything that may be out there, or you when you may be flying where radar cover has limitations.

Apart from the stated clearances wrt to runways. You can only be CLEARED to do a maneouvre in controlled airpsace or given a clearance to enter or cross it, at which time you will be receiving a RCS.

One of the reasons that ATSORA was introduced was that increased radar cover around the country, along with the fact that so many a/c were carrying transponders, meant that a better service could be achieved outside regulated airspace than a FIS. Before introduction, there were many incidents because, using the new coverage, controllers were being occasionally misunderstood when they passed information to pilots. Pilots were sometimes under the misaprehension that they were being 'controlled'. ATSORA was supposed to clarify the situation and encourage all pilots to use an Air Tarffic Service whenever possible, to give a safer flying environment all round. It seems that the importance of this, needs further highlighting.

Also sorry to be long winded. However, I am deeply concerned that pilots are once again misunderstaning the limtations of the service they are receiving. I urge you, once again, for your own safety and that of others to have a good, long read of ATSORA.:)

[PPRuNe Radar]

It might be different in military procedures, but ATSORA has been changed to ATSOCA in the civil world for 4 or 5 years or more. Just to add my own little bit of pedantry ;)

[PAMCC]

Sorry my error, often typing in a hurry. I don't think you were being pedantic, just pointing out my mistake:)

However, the rules that I have mentioned still apply and I'm concerned that some don't seem to know the conditions of the contract that they are entering into. I think that some of the questions posed on this thread have safty implications and my typing error should not detract from those or from what I have written whilst trying to clarify the situation.

Time I went to enjoy my time off and get some fresh air.........I've written more than enough on this subject.

[BEagle]

I was using the original term!

There are still inconsistencies, e.g. 'Overshoot' and 'Go around' as well as weak RT standards - mainly on the part of the aircrew.

Most of the differences are not in the en-route part of a flight, but in the terminal and visual circuit environment.

There is a DAP ATSOCA workshop coming up soon - which will be most interesting, I think.

And by the way, the 'Yellow Book' FIH has a very clear, unambiguous section on UK Air Traffic Services.....

[US Herk]

As a spam flying over here - always trying to comply with the UK rules & instructing our younger crews on some of the differences between US & UK ATC - where might I find a copy of the ATSOCA??

We carry RAF FLIP products, maintain UK AIP, & part of our indoctrination is specifically going over RAS/RIS/FIS and other equally challenging things for us Yanks, but more source documentation & less word of mouth is always helpful!:ok:

In fact, I'm scheduled to give a brief to our flying squadron in the next few weeks covering exactly these topics + UKLFS - whilst I feel I have an above average (for a Yank) insight into said topics having been fortunate enough to be on exchange with the RAF previously, I do not consider myself an expert. We have, in the past, coordinated for ATCOs to brief us & will continue to do so getting the expert info to the crews - I'm just a poor fill-in this time around! :O

[BARNWOOD]

I seek advice from only those that have an in depth knowledge of UK Board Of Inquiry procedures and any related legal matters. The following extracts are taken from the recent BOI report on the F15 accident in the Cairngorms on 26th March 2001. The subject aircraft were under Radar Information Service (RIS)

Station Commander on Cause :

I did not find the arguments over "instructions" wholly germane to the question. I accept that the the "instruction" from air traffic to the formation was not an order but it was reasonable to assume that the crews would comply with the "advice" given and doing so placed the aircraft and crews in an unsafe situation. I am therefore content that the Board's determination of the cause of the accident is soundly based. Indeed, I would go further and suggest that the word "potentially" should be deleted from the Cause, as the "instruction" given was clearly unsafe

Comments by the Air Officer Commanding:


A BOI does not apportion blame and I note that none has been apportioned in this case

and later,

I support the Board's analysis of causes and factors other than finding myself in agreement with the Stn Cdr that the cause of the accident was that the formation accepted an unsafe ATC instruction rather than one that was potentially unsafe.

Comments by Commander in Chief


I am therefore in no doubt that the Air Traffic descent information " BITE 21 descend initially 4000ft on the Portree 29.62" was unsafe, and I agree with my Stn Cdr and AOC 3Gp that the word "potentially" be removed from the Board's Cause for the accident


All the above suggest that they are 'blaming' the controller concerned and that appears to be outside the remit of the BOI procedure and I assume these gentleman would be considered part of that whole procedure. If my assumption is correct, then they may have negligently exceeded their authority and opened up a possible claim under 'vicarious liability'.

Any help (from any source) would be appreciated, as I am tabling some questions for my MP on this BOI report.
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[DICK DOLEMAN]

The Support Group response to the BoI report can be found on this Forum under the title above. Many thanks

[FCWhippingBoy]

Not wishing to be embroilled in any arguments, and only because, as a Fighter Controllers' Assistant, I'm curious as to procedures used outside of the Fighter Control world, do normal (for want of a better phrase!) Air Traffic Controllers limit their service depending on radar coverage?

Certainly, when controlling a/c, and particularly overland, the controllers I work with apply a FIS height depending on radar coverage/operating area ...

"You are identified Radar Information Service, limited below Xft, Flight Information Service below Xft. You are responsible for terrain avoidance. Acknowledge" (or words to that effect!)

I realise the aircraft in this incident may have been within the coverage of the radar in use, as mention has been made of "last radar plots", but I'm just curious, purely for my own knowledge.

Regards,
FCWB

[ExGrunt]

Argus said:
I'm curious as to why the first BOI was aborted, and a GCM convened.
The rules in the UK are different. This change was brought in by the Armed Forces Act 2001:
38 In section 135 of the Air Force Act 1955 (c. 19) (boards of inquiry), for subsection (5) there is substituted-
"(5) Evidence given before a board of inquiry convened-
(a) under this section,
(b) under section 135 of the Army Act 1955, or
(c) under the Queen's Regulations for the Royal Navy,
shall not be admissible against any person in proceedings before a court-martial, commanding officer or appropriate superior authority, other than proceedings for an offence against section 70 of this Act where the corresponding civil offence is perjury."

If the RAF had waited for the BoI most of the prosecution evidence used in the GCM would have been inadmissable.

[Argus]

ExGrunt

No, the Antipodean rules are the same. In Oz, any statement or disclosure made in the course of giving evidence to a BOI is not admissible against that witness in any civil or criminal proceedings in any Federal, State or Territory court or before a Service Tribunal except in proceedings by way of a prosecution for giving false testimony at the BOI.

Problem here is that administrative action (eg show cause why one should not be discharged) isn't subject to this provision.

[Tigs2]

There are so many Human Factors issues in this case and it appears they(The System) have not even tried to address them. Keep your chin up Spot, there are many people rooting for you!
Tigs