Pilot criticised over Puma crash

[toptobottom]

Click Here (http://news.bbc.co.uk/1/hi/england/north_yorkshire/8325588.stm)

[B.U.D.G.I.E]

has the AAIB report been released yet????

[windowseatplease]

Do the AAIB issue reports on military accidents? I didn't think they did. I thought it was all 'handled' internally by the military.

[SHortshaft]

In the 35 years since I left the Puma fleet nothing much seems to have changed except that we are now using CVRs and mobile phones to record the activities of those with 'cowboy traits'.

'When will they ever learn, when will they ever learn?'

My condolences to the families left behind; my disappointment I reserve for 'the leaders' of the helicopter force. Surely they must understand that the carpet is no longer big enough to sweep these issues under it anymore.

[MBJ]

I wonder what height this crew were authorised down to? As I remember it, before any sortie, let alone a low-level one there was a senior member of a Squadron who would "authorise" the flight - a system that was supposed to ensure appropriate briefing and suitability of the pilots concerned for the job in hand.

In the CVR replays it was evident that the AVAD was giving a warning of low height. What is this set at? In the civvy world this is usually 100ft and was devised and mandated to prevent "Controlled flight into terrain or water" as a result of the Scillies CFIW 30 years ago. Not much use in a tactical military support helicopter, which you would expect, operationally, to be at about 20-50ft AGL.

I can't believe the coroner's report that said the "pilot was not trained" for this type of sortie. He was 28 and on a front line military support squadron, if he wasn't trained he wouldn't have been there. Perhaps the sub-text was he wasn't very well trained?.. or out of practice?.. or he wasn't competent at what he was doing?.. or he ignored his authorisation?

[jayteeto]

Low height is a variable setting made by the crew up to 2000ft on some aircraft, 500ft on others. From this we can be 'certain' only that he was below 2000' and maybe below 500'.

[Whirlygig]

coroner's report that said the "pilot was not trained" for this type of sortie.I suspect that it's terminology. After all, if the flights are supposed to be authorised by a senior officer, then it must be assumed that there would be occasions when authorisation would not be given, i.e. the experience of the pilot is not sufficient for the task e.g. would require further training ergo, "not trained" (in layman's terms).

More like he wasn't current.

Cheers

Whirls

[ShyTorque]

I doubt that he wasn't "current", Whirls.

Military currency isn't the same as civvie rules; or at least wasn't in my years of flying and instructing on the Puma. There is a mandatory monthly training requirement for basic skills exercises (BSE), tactical support training (TST) and instrument flying (IF), which in my day took priority over tasking.

[Evalu8ter]

The pilot was flying under designated powers of auth. In other words, a supervisor was not available to deploy on the "det" and the captain was given temporary powers of auth by a senior supervisor at Benson.

I was lucky enough to have a number of experienced SH navs on the Sqn when I was a junior shag - therefore although I would go on such mini-dets as captain, I was left in no doubt by the Sqn staff who was in charge of the det and who would authorise every sortie. This was an effective check and balance allowing me to accrue captaincy experience with a supervisory hand on my collar. Shame that the SH nav is almost extinct.

[John R81]

Times newspaper report here RAF under fire over 'Top Gun' Puma crash that killed three servicemen - Times Online (http://www.timesonline.co.uk/tol/news/uk/article6890873.ece)

John

[windowseatplease]

Just looks like showing off and hot-dogging that went wrong, like the Mcrae crash.

[BoeingMEL]

.........those were my thoughts exactly as soon as I read the report. Showing off with aircraft, cars and fire-arms continues to kill many innocents. Tragic, sad and inexcusable. Let's hope that management structure at Benson really has been sorted.... and that lessons are learned by all our armed forces. bm

[timex]

I'm not making excuses for what happened in this incident, but before blaming the Forces for all of this you should look at the Govt's part in this. War on 2 fronts, massive overstretch and guys leaving, consequently loads of experienced guys have gone.

[Hedge36]

And that has what, exactly, to do with some numbskull hotdogging his aircraft to the point of killing his crew and destroying a good airframe?

Zip. That's what.

[Bronx]

Hedge36

And that has what, exactly, to do with some numbskull hotdogging his aircraft to the point of killing his crew and destroying a good airframe?


A lot.

Because the coroner made lots of wild wide ranging criicisms of the RAF in general not just the pilot who died. The dead young pilot you see fit to call a numbskull.

There but for the grace of God.
He did something stupid and it went badly wrong.
Maybe you never did anything stupid when you were young. :rolleyes:

[4ftHover]

Lets hope that every new pilot that joins the RAF learns from the mistakes seen here.

Our choice of vehicle is very unforgiving at times.

:sad:

[[email protected]]

Most of us in the military have done our share of wazzing and zooming in the past and lived to tell the tale - why? - because we left ourselves some margin for error and knew when to knock it off.

Unfortunately, some young men will always think they are better at things than they really are and believe themselves to be gods of aviation - you could call it the Top Gun syndrome. The same attitude kills lots of young people in cars every year but shouldn't kill people in military aircraft because the training and supervision should prevent a pilot who is incapable of exercising judgement and self-monitoring from being in charge of an aircraft.

There were lots of other factors in this tragic accident and lots of opportunities for any of the crew or pax to prevent it but it still comes down to the numbskull with his hands on the controls trying to perform manoeuvres he was not skilled enough for and which were wholly inappropriate for the task in hand.

[idle stop]

This was tragic, and we must be sympathetic to the families of those who have lost loved ones, and to those whose lives have been blighted by this avoidable event.
From the reported ages of the 3 crewmembers, it would seem that they were all of a similar experience level. There is potentially a systemic flaw here. Even in the mid-late 70s when I was on the Puma fleet (and then, mostly single pilot ops, except for NI) a junior pilot would not normally be crewed with a 'junior' crewman. And this was before anybody had thought of a formal concept of CRM. If the jp started to step off the line, the experienced crewman would exert his influence: regardless of the rank gradient. It doesn't always work: I can think of another avoidable tragic low-flying Puma accident where it should have.
Incidentally, the training progression then for pilots was:
OCU: 30 hrs (35 for a first-tourist straight from AFTS) out after 6 weeks with D cat/Limited Combat Ready.
Squadron: Initial check, then 3 months of flying on tasking with a QHI/LTC; after 3 months, allowed off on simple tasks (like the Catterick one) as Pi/c, but with a SP as Det Cdr and Authoriser. After 6 months on the squadron re-cat to C/CR (the 'working standard') and, of course, still learning. With luck and a bit of hard work, one could aspire to becoming a 'B' cat.
It is unfortunate that the Press has not taken the trouble to find out about the current training process and presented the pilot as being on his 'first flight without an instructor'.
Lastly, I think it inexcusable that the audio-visual material of the final moments of the flight was released to public broadcast. This was, in my opinion, an abominable lapse of taste and judgement by those concerned with its publication. It should be pointed out to HM Coroners, senior Service personnel, and to the Press and Broadcasting authorities, that this material is analagous to the CVR data, which, if my memory serves correctly, has confidentiality protected by one of the Ottawa Conventions.
I am sure that all the potential systemic flaws in this accident will have been looked at and mitigated well before the Coroner's findings. Quite simply, this accident was a rare lapse of professionalism: it is a sad and severe blow to a truly professional, hard working, and overstretched Support Helicopter force.

[212man]

Lastly, I think it inexcusable that the audio-visual material of the final moments of the flight was released to public broadcast. This was, in my opinion, an abominable lapse of taste and judgement by those concerned with its publication.

My thoughts entirely. The only good thing about it is that there was a CVR in the first place - clearly the Mull Chinook lessons (in respect of data recording) have been taken on board!

[SafetyCase]

:ouch:
Most of us in the military have done our share of wazzing and zooming in the past and lived to tell the tale - why? - because we left ourselves some margin for error and knew when to knock it off.

Unfortunately, some young men will always think they are better at things than they really are and believe themselves to be gods of aviation - you could call it the Top Gun syndrome. The same attitude kills lots of young people in cars every year but shouldn't kill people in military aircraft because the training and supervision should prevent a pilot who is incapable of exercising judgement and self-monitoring from being in charge of an aircraft.

There were lots of other factors in this tragic accident and lots of opportunities for any of the crew or pax to prevent it but it still comes down to the numbskull with his hands on the controls trying to perform manoeuvres he was not skilled enough for and which were wholly inappropriate for the task in hand.


Crab: you just don't get it, do you. I see very clearly that you have been protected for far too many years in your company on the old philosophy on blame allocation

In a more modern way of approaching accidents than you are demonstrating, you don't stop asking the question "why" until you get no further. but in this case the "whys" might hurt your beloved RAF, doesn't it? The fact of the matter is that the management of the RAF let this accident happen, without doing anything to stop unacceptable behaviour. Policy, selection, training, monitoring, assessments, briefings, debriefings, etc. - the tools were there. Why do I say let happen? - read James Reason's writings on Organizational Accidents.

Your references to "Top Gun" is totally uncalled for unless you are meaning the movie.
I was trained by the USN Fighter Weapons School and I take offence that you even think for a minute that the attitude demonstrated by those in the Puma represent anything even close to what Top Gun stands for.

An old friend of mine once said, and now it is part of his company thinking (not my company):

• All accidents are preventable
• Management is the art of control
• Accidents are examples of a loss of control
• Accidents are a failure of management
• Management must do what is reasonably practicable to prevent accidents.

Did the Squadron/Wing/Base/RAF do everything that was reasonable practicable to prevent this tragedy? I think not. The squadron management did not have any control at all. They just sent the lads out on their own for them to show off and have some fun, didn't they? (without actually saying so)

So these young tigers went out to have some fun,impressing their Army passengers and onlookers on the ground. Did the squadron issue any limitations regarding this crew on this flight as it was the first non-instructor flight??. I don't think so.

In my eyes all this makes the RAF as an institution liable for the tragedy, and should be accountable for it. There is a legal term called "Corporate Liability" Look it up, might surprise you. Accident investigation boards all over the world are now focusing much more on company management and even board of directors than they did before.

It became painfully relevant after the offshore Piper Alpha tragedy. But the RAF and others are putting this accident away as "pilot error" and that it will not happen again. BS.

I understand that some of the management of the squadron/wing/ base have retired and joined the civvy market? I hope they wake up to the real world. RAF management training, even at lower levels, leaves a lot to be desired, doesn't it?

And on a personal note: the CVR recording should never ever have been released. Who the h*** authorised that???
I would think that the great RAF would have control over something as simple as that. Or not??

[Dantruck]

Not. You answer your own question, SafetyCase.

This all comes from a Coroner's Inquest. What makes you think the release of evidence (the CVR recordings in this case) required by a Coroner needs to be authorised for release by those that hold it. Even the military are accountable to one of the oldest legal offices in the world, old chap. Or are you suggesting they should have smothered it?... No, surely not.

Once in the hands of the Coroner it, and all the other evidence 'heard' at the inquest, is in the public domain. Inquests are generally open to the public.

The editorial decision to broadcast any or all of the evidence is another question altogether, but in this case I see relatively little harm in doing so. The plus side of doing so with the CVR recordings was, to best explain to the public what happened, ie: that the pilot was wazzing about when he should not have been. There is a clear public interest here: That was the their expensive hardware that got trashed at a time when helicopters are in short supply in a real war and they, the public, are paying for the clean-up. Also, civil action may follow from civilian family members and that may be fuelled in the first instance by public money in the form of Legal Aid.


Dan

[Vie sans frontieres]

Safety Case

Seeing as you've edited your most recent post twice already, you couldn't just edit the whole lot could you?

There's no need to have a pop at Crab just because everyone else does. What he wrote seemed quite balanced really. It'll probably be open season on him when the SAR-H contract winner is announced. Cut the man some slack - what he wrote wasn't inflammatory in any way.

[SafetyCase]

Yes I edit my posts all the time as English is not my first language. Hope you can bear with me,
I guess that your language being french(?) is better than mine.

I totally disagree with you
CVR should never ever be released like in this case.
I think that CVR recordings are privileged information, not necessary to distribute freely. How you think the families feel? And one more thing maybe more important than you think: the recording does not help the investigation at all. It is published only to keep the interest up.

[SafetyCase]

I have the greatest respect for Crab. However, we all need to be able to take a little bit of flak now and then. And I think Crab can take care of himself without your help.
And SAR H was not what we were discussing, was it??

[SafetyCase]

Not. You answer your own question, SafetyCase.

This all comes from a Coroner's Inquest. What makes you think the release of evidence (the CVR recordings in this case) required by a Coroner needs to be authorised for release by those that hold it. Even the military are accountable to one of the oldest legal offices in the world, old chap. Or are you suggesting they should have smothered it?... No, surely not.

Once in the hands of the Coroner it, and all the other evidence 'heard' at the inquest, is in the public domain. Inquests are generally open to the public.

The editorial decision to broadcast any or all of the evidence is another question altogether, but in this case I see relatively little harm in doing so. The plus side of doing so with the CVR recordings was, to best explain to the public what happened, ie: that the pilot was wazzing about when he should not have been. There is a clear public interest here: That was the their expensive hardware that got trashed at a time when helicopters are in short supply in a real war and they, the public, are paying for the clean-up. Also, civil action may follow from civilian family members and that may be fuelled in the first instance by public money in the form of Legal Aid.


Dan

You are not not a person who makes his living by flying are you?

Have you ever heard about the Flight Safety Foundation??

Have you ever heard about IFALPA??

Do you know about EASA and FDM??


I thought so

Have a read on what they think about CVR porn

CVR should never be released to the press!
Actually there are countries that protect this information by law, but I guess you don't agree with that.

[scottishbeefer]

While it might sound slightly distasteful on the telly, I think being able to hear the CVR in this case could actually be a deterrent to the next young'un. A stark reminder that all banter is evidence in the subsequent enquiry.

Seems to me that a disproportionate number of Pumas crash compared to the rest of the helo force. Their tasking doesn't seem any more arduous than the rest so what's the problem? An engrained culture of cowboyism? How are 60(R) streaming the pilots into the Puma force? Haven't they just finished a close look at Puma SF ops?

This kid was flying like an idiot - no question. But - it's hard to believe the Sqn/Station exec's hadn't engaged in the same bufoonery at some point earlier in their careers and therefore armed with this knowledge could have helped nip this sort of thing in the bud as the culture has surely moved on these days - we just can't tolerate this kind of flying. The pilot was ultimately responsible for his actions (he certainly paid for them - along with the rest) but the leadership is almost certainly just as much to blame.

[SafetyCase]

Really - I think is disgusting for TV or radio to transmit the last words of people about to die.
It is all about selling more news.
And the terrible thing: did it help to find the cause? NO

[InTgreen]

Guys,

I'm not saying that there are not lessons to learn from this tradegy.

However hard you try, however many rules you have in place, if someone doesn't keep a good lookout/ignores proceedure/shows off/ignores authorisations - a crash can result. (I am not saying the Puma crash was caused by ANY of the above!)

It is all to easy to jump and say 'Things must change so this can never happen again!' BUT Gents, just adding to the rules is not always the safest way forward. Making sure that the risks are reduced to As low as reasonably practicable- through orders/education/authorisations is the perfect ideal to which we should all aspire. It still needs the man in the seat to follow them, and use sound airmanship and judgement.

[[email protected]]

Safety Case - the fact that the people in the USN Fighter Weapons School feel the need to refer to it as Top Gun is exactly the attitude I mean - the 'I'm better than you' arrogance requires a level of egotism that is not healthy in a cockpit but is common place in the military - unfortunately.

Since this supreme self-belief is not only condoned but encouraged by the upper echelons it is not surprising that some pilots will take it to the limit and venture beyond theirs.

I am certainly not going to defend the RAF in this tragic case, many events had conspired to leave the Puma force with a high dilution of experience and a catch 22 situation where new boys couldn't be trained up enough to do the operational tasking because the rest were working too hard on Ops to spare hours or people.

So some inexperienced guys were left in UK to do noddy tasking, unfortunately with inadequate supervision. It all comes down to poor leadership and a system that promotes the wrong people who seem
incapable of leading by good example.

I do believe that if the release of the CVR tapes helps the other junior pilots out there to realise what is and isn't acceptable and prevents another sensless loss of life then it will have been justified. It's not nice for the families but I expect they wish someone had played the crew a similar tape at some point in their training.

[MBJ]

I've just been looking through my first logbook. On an average month in a peacetime Navy, on my first operational Squadron I was averaging 20-25 hours a month. In one sample month those hours comprised Winching, Close and Tactical formation flying, troop lifts, confined area work, low-level Navexs, Parachute dropping, Night load lifting, Night Navexs, Instrument flying and Tactical 2" RP firing. Most flights were two-pilot plus crewman. I was P1 about 40% of the time by this stage.

The point is I was 22 years old with 400 hours total time. In the RN we got responsibility early, having been properly assessed by the senior guys, and then got on with it.

Now, I'm sure that defence expenditure cutbacks contribute to a lack of good quality training time but I believe that the RAF have never delegated responsibility to their younger pilots effectively and Senior Officers tended to hide behind rulebooks to protect their backs on the slippery promotion ladder. (Incidentally, one of the finest pilots I have known was a grizzled, grumpy old Crab on exchange to us)

If this pilot was a habitual hot-dogger, who failed to spot it and act on it? If he wasn't up to standard why was he self-authorising? Are RAF crewman encouraged to comment during training-flight debriefs? Which half-wit considered playing the "Top Gun" soundtrack through the intercom was ever a good idea?

[SafetyCase]

Safety Case - the fact that the people in the USN Fighter Weapons School feel the need to refer to it as Top Gun is exactly the attitude I mean - the 'I'm better than you' arrogance requires a level of egotism that is not healthy in a cockpit but is common place in the military - unfortunately.

Sorry, but that is not my experience with the USN Fighter Weapons School. Their emphasis on safety and professionalism was very real. But maybe you have different experiences with them.

You might have noticed that I have not said a bad word of any pilot or crewmember during this discussion.
What I am concerned about is the apparent lack of operational management control and oversight in the RAF. Crab has repeatedly bashed away at the management of a certain company that is tendering for the UK SAR contract (without bringing that issue into this thread) so I think it is only fair to point at the total lack of leadership and operational control that was demonstrated during this accident. I am sorry I used the term "Corporate Liability" in an earlier post. what I meant was "Corporate Killing" Yes, it is a legal term, google it. And this is what this case is about in my opinion.

Could this happen in a civilian company? Certainly, however, I don't think so if we are talking about a professional offshore operator, with FDM (HOMP) and proper safety culture, policies, training, hands-on monitoring etc. There are many opportunities for those who would like to break or bend the rules in these companies too: test flights, ferry flights, training flights etc.

So some inexperienced guys were left in UK to do noddy tasking, unfortunately with inadequate supervision. It all comes down to poor leadership and a system that promotes the wrong people who seem incapable of leading by good example.
You are most likely right on this

I do believe that if the release of the CVR tapes helps the other junior pilots out there to realise what is and isn't acceptable and prevents another sensless loss of life then it will have been justified. It's not nice for the families but I expect they wish someone had played the crew a similar tape at some point in their training
I strongly disagree that it was right to release the recording to the public and the tabloid press for entertainment purposes, that is what it really is. The recording was not crucial in establishing the causes of this accident.
In cases like this, the public does not have the right to know. As I said in an earlier post, information gathered by an investigation body is privileged information in certain countries, Denmark for one.
Release for internal use only? Yes, that would have been acceptable.

I have seen pictures of the results of accidents during my accident/incident investigation training. Would I release these to the public? Hardly.
Almost the same thing isn't it?

[Dantruck]

Oh SafetyCase...where do I begin with you?

Am I a person who makes his living by flying?...not now, but in the past, yes. Why do you ask? Is that relevant? Perhaps by not being an aviator I am able to consider the issues with more objectivity than you seem to be able to muster this fine morning.

As you ask, mostly I make my living by gathering facts and knowledge, assembling them into reasoned argument that can be supported by evidence, and then I publish. If I am publishing an opinion I try to build a foundation of evidence around that opinion to support its bearing.

Have I heard of FSP, IFALPA et al?..yes, more than you know. It is not clear how you know, or think you know, that I have not. Please do not try to put words into my mouth, or try to guess what I agree with. If you want to know, simply ask. It is far more polite, not to mention successful.:ok:

Above all, calm down chap. You really should not dismiss the views of others like Crab so glibly, especially when you do not know who they are, and particularly when most of the others in here do. Therein lies the potential for face, egg and a combination of the two.:uhoh:

That CVR recordings should never be released to the media is OPINION.
That CVR recordings assist the public’s understanding of this particular case is FACT.
I see no gain in confusing the two, as you repeatedly insist on doing. :ugh:

As for ‘CVR porn,’ as you call it, the organizations you refer to tend to agree with me...that gratuitous publication serves no purpose and can be upsetting to some, while selective publication is sometimes justified to serve a greater good. Don’t generalize.:=

As I have said, I think broadcasting this particular tape for a specific and helpful purpose (public explanation, in this case) was justifiable. Gratuitous publication is wrong in my book, you will be glad to hear, but that is not what is happening in this case. That is what you fail to recognize.:ugh:

I commend your grasp of English, it being your second language, and all. I myself am struggling miserably to learn German, but I have found the trick is to get yourself a German girlfriend:E. And do keep on editing as much as you like, I say. Editing is a good thing. Don’t let anyone tell you otherwise.:ok:

Dan:ok:

[Snarlie]

The question is `Cowboy Outfit` or one rotten apple. Perhaps now is a good moment to reconsider the re-allocation of responsibility for all flying operations within the MOD to the two services best suited to the modern requirement, namely the Royal Naval Air Service and the Army Air Corps. The arguments are compelling.

[SafetyCase]

Dantruck:

As for ‘CVR porn,’ as you call it, the organizations you refer to tend to agree with me...that gratuitous publication serves no purpose and can be upsetting to some, while selective publication is sometimes justified to serve a greater good. Don’t generalize


The organizations agree? Don't think so. Read this from IFALPA:

IFALPA deplores the use of Cockpit Voice Recordings for entertainment

CHERTSEY 8 December: The International Federation of Air Line Pilots’ Associations (IFALPA) is outraged to learn that once again the Cockpit Voice Recordings (CVR) of aircraft involved in a fatal accident have been leaked and are being used by a media provider for public entertainment.
CVRs are intended for one purpose, to help investigators determine the factors that led to an accident with the aim of preventing an accident of the same type in the future. This idea is enshrined in the international principles set down in ICAO Annex 13 which states in Attachment E (Chapter 3.4) “Safety information should not be used in a way different
from the purposes for which it was collected”.
Publishing the content of CVRs outside the context of an Accident Investigation report does nothing to improve air safety. Accordingly, IFALPA calls on States to institute legislation which will prevent publication of the actual recordings of CVRs in the public domain.

And I do not put Crab down, I have respect for his opinions, but I do reserve the right to discuss, even if the words can seem harsh at times.

[Dantruck]

Yes...IFALPA is specifically talking about use for entertainment purposes, as you will see if you actually stop and read it.

I said: "the organizations you refer to tend to agree with me...that gratuitous publication serves no purpose and can be upsetting..." You are pushing at an open door my friend.

However, all this is not the same as my "...selective publication sometimes justified to serve a greater good" is it?:rolleyes:

Show me that clipping and I might change my mind.
Dan

[oldbeefer]

Snarlie - you imply the other two services have unblemished records and act in a disciplined way at all times? After 40 yrs of working with all three, I beg to differ!

[DOUBLE BOGEY]

I think the CVR porn issue is mute. It was used as evidence and therefore in the public domain. If you fly like a dough bag and stuff it in without just cause I think you deserve all you get.

Why should we be above the law and when paid by the tax payer - not accountable to him. The public and the family deserve to know what happened on that flight....and sadly the press sensationalism is probably the only way to change some die-hard attitudes in the military management.

If you have an accident or serious whoopsie expect the CVR to be played!!! If it contains clear statements of intent to endanger other people, as this one did (lets scare the *** out of this taxi driver)) I would expect to see a custodial sentence.

[SafetyCase]

DB
Are you actually saying that all information gathered by f.ex the AAIB after an accident is public property for all to see?
Would you accept that a transcript of an interview of you, or maybe a recording of that interview should be published by the BBC?
This is the direction some of you are going.
There are good reasons for Denmark, Norway and other countries to prohibit the use of information gathered by an investigation body to be used for any other purpose than establishing the cause of an accident and preventing new accidents. The main one is to ensure that the reporters can be assured of some kind of protection. If not, there will be a marked drop in reporting, and this is not what we want.
Please read the ICAO Annex 13, it is available on the internet.

[Fly_For_Fun]

It is sad and a tragic shame that people have lost their lives, my thoughts are with the family and friends of those who have perished.

I do, however, agree with Crab, and others, that a safety margin imposed by oneself for when one runs out of talent is the saviour of many a "young gun".It is a shame that this particular pilot failed to apply the "10% for the wife and kids" maxim, another tried and tested safety system.
He made the decisions on that day and flew the aircraft in such a way as to lead to the demise of innocent people including crew members, who though complicit in what went on, were not in command.
A no blame culture is all well and good, but responsibility has to be taken by someone and the buck stops with the person holding the cyclic.

[SafetyCase]

All in all, I agree with most of what you are saying.
I am not advocating a "no blame" culture at all, what I would like to see in any company, RAF included, is a "just and learning" culture. To put the cause of this accident on the shoulders of the crew only, and to use the recording of the CVR to support this really upsets me. That will not facilitate the learning which this institution obviously needs. The crew should not have been put in the situation where they thought it was all right to do what they did during this flight. They should have been told in very clear terms, long before the accident, that this kind of flying leads to severe consequences. This is about Squadron Safety Culture.
There seems to have been a serious flaw in the safety culture in that squadron or wing or station. I don't know where the root cause lies, but it there is certainly a serious problem there..

[InTgreen]

Safety Case, do you honestly think that the guys in the cockpit that day 'thought it was alright to do what they did'? From listening to the tapes, they KNEW what they were doing was wrong fella. They knew it and carried on regardless. That is the real shame of this whole accident.

[k12479]

Safetycase, what is the relevence of the opinion of "The International Federation of Air Line Pilots’ Associations (IFALPA)" or what the "international principles set down in ICAO Annex 13" may say? This comes under military aviation not civil and, as Dantruck says, there is a public interest - they paid for the helicopter & the pilot.

[DOUBLE BOGEY]

Are you really trying to say that the crew do not have the responsibility for the safety of the Pax and AC.

Any pilot who needs to be told that unimitaged, dangerous and reckless wazzing is not allowed should never be permitted access to a flying machine.

I do not accept that the culture in the RAF would support the behaviour of this pilot (though being ex Army it is tempting to do so) but I do think that the key to this issue lies in the outcome of the coroners case.

LACK OF ADEQUATE SUPERVISION such that the tendencies of individual crews to be reckless are identified before they cause harm.

Ultimatley we sign the tech log and take control of the helicopter. What we choose to do with it once out of sight of the Chief Pilots office is what seperates the the Professional from the Unprofessional.

Whilst there may be some supervision issues that need addressing (and I am sure the will) the prime causal factor of this accident was a nut loose on the end of the cyclic.

Taking unecessary risks alone is bad enough. Taking unecessary risks with the lives of our passengers without their consent is criminal.

Those poor passengers would have enjoyed the flight right up until impact because they would have placed their 100% trust in the guy flying. The fact that he not only proved himself not worthy of that trust, but worse, left a damning and detailed legacy on the CVR just makes the thing a whole lot worse.

CVR data is there to assist the investigators as to the cause of the accident. If you have nothing to hide you should have nothing to fear. It has nothing to do with reporting incidents.

In this extreme case I think the release of the recordings can only benefit anyone else with similar disregard for airmanship and safety who might otherwise continue to rip the ring out of their aircraft and any trusting soul fool enough to cross their path.

It is better out. Better for the families who have suffered and better for the greater good of helicopter aviation.

This guy has embarrassed us all. But he may also have saved the next sap from making similar stupid mistakes. If the recording was not released, occupying the publics conciousness and ours albeit for 15 minutes, the impact of the accident would have been lost.

Every cloud has a silver lining!!

[HillerBee]

Why is the co-pilot free of blame?

[DOUBLE BOGEY]

My understanding is that there was no co-pilot. Only a Loadmaster.

[SafetyCase]

Safety Case, do you honestly think that the guys in the cockpit that day 'thought it was alright to do what they did'? From listening to the tapes, they KNEW what they were doing was wrong fella. They knew it and carried on regardless. That is the real shame of this whole accident.

Are you really trying to say that the crew do not have the responsibility for the safety of the Pax and AC.

Any pilot who needs to be told that unimitaged, dangerous and reckless wazzing is not allowed should never be permitted access to a flying machine.

I do not accept that the culture in the RAF would support the behaviour of this pilot (though being ex Army it is tempting to do so) but I do think that the key to this issue lies in the outcome of the coroners case


No, I do not say that the crew did not have any reponsibility for the safety of the passengers and aircraft. They were the trigger that resulted in the accident. If this did not have this terrible outcome, they should have been sacked. That said, so should their managers.
Whether the crew thought it was allright to do what they did - I don't know.
My issue is that there seems to be (or was) a culture within the RAF that allows this kind of behaviour. This factor was one of the precursors to this accident. We all know that an accident is the result of many factors, and without this factor, the accident would most likely not have happened. Going after only the crew in this case, would not have prevented future mishaps. The latent problem would still be present.

I agree with most of what DB says, but I still am strongly against releasing CVR evidence to the public. I think his union agrees with me. It serves only to hide some of the important factors of this tragedy (maybe that is why it was released), and for some of the press, it is entertainment designed to sell.

[SafetyCase]

Safetycase, what is the relevence of the opinion of "The International Federation of Air Line Pilots’ Associations (IFALPA)" or what the "international principles set down in ICAO Annex 13" may say? This comes under military aviation not civil and, as Dantruck says, there is a public interest - they paid for the helicopter & the pilot.
You are right, this was a military accident and the civilian rules do not apply. The military is probably very competent in investigating accidents, but it leaves a lot to be desired on how to deal with the press and the public.
To stray off track for a moment: when I attended the accident investigation course at the University of Southern California a while back, one of my fellow students was from the British Armed Forces

The policy (or opinion as you say) of the IFALPA is designed to prevent re-occurrence of accidents, same as ICAO.
There are public interests in civilian accidents too, people have paid money for tickets, and oil companies have paid large sums of money for operators to transport their employees to their workplaces. You and I are paying for that in the end, when filling up our cars or motorbikes.
However, in the civilian world, most have recognized the importance of information protection, in order not to stop the flow of crucial safety information from pilots, engineers etc. Without that flow, safety will be compromised. There are very valid reasons why some states and companies have a confidential reporting system, and that FDM data is de-identified.