Pilot error 'led to Puma crash' in Iraq

[stickmonkeytamer]

BBC News - Pilot error 'led to Puma crash' (http://news.bbc.co.uk/1/hi/uk/8403606.stm)

A helicopter crash in Iraq which killed two SAS soldiers in 2007 was primarily caused by pilot error, a coroner has ruled at an inquest into their deaths.

However Herefordshire coroner David Halpern also criticised the Ministry of Defence for "indefensible procedural and maintenance errors".

Sgt John Battersby, 31, of Lancashire, and Cpl Lee Fitzsimmons, 26, from Peterborough, died in the crash.

Two other servicemen were seriously injured in the incident in Baghdad.

Mr Halpern also said a lack of equipment contributed to the men's deaths.

Cpl Fitzsimmons' mother, Jacqui Auty, told the hearing: "When our sons lay their lives on the line for the greater good, I think they deserve better than this."

The crash happened during a mission to find and capture insurgents believed to be responsible for a bombing campaign.

[Mick Strigg]

Oh no! Not that term "Pilot Error" again?

How can he say that? The Coroner is not allowed to apportion blame and pointing out that an error was made by the pilot clearly points the finger at him! Furthermore, what Human Factors lead the pilot to make the error?

The Barristers at this inquest need shooting for allowing the Coroner to say this in his verdict.

[Captain_djaffar]

Coroner ruled pilot error in an air crash investigation?

makes me remember last audit where the lady cleaner was asked how she found our IT network infrastructure.

'good... good, as long as i dont have to clean them'

[Mick Strigg]

downsizer, please "get your coat"!

[Tappers Dad]

downsizer
Yes there is an airworthiness issue here:
The inquest heard that the anti-spill valves, which are operated by gravity, had not been checked or maintained for decades and were not listed on the aircraft's maintenance checklist. :ugh:

Summing up the evidence, the coroner said: "They should have been part of a risk assessment and appropriate maintenance schedule. :ugh:

"It was said by the pilot of the Puma that he would have considered the craft to be un-airworthy if he had known that it had an inoperative anti-spill valve.

In order to mitigate the risk of fire and explosion I would imagine that the MOD/RAF quoted the anti-spill valve, so the fact it was inoperative and hadn't been checked for 30 yrs would mean it was not airworthy.IMHO

[Occasional Aviator]

Sorry, but I'm not entirely convinced by It was said by the pilot of the Puma that he would have considered the craft to be un-airworthy if he had known that it had an inoperative anti-spill valve.

Given the operational imperative and the pressure on crews to deliver in this environment, I don't think this statement can be anything other thna speculation at best, and clutching at straws at worst.

Clearly this was not a causal factor in the crash, but a contributory factor to the consequences. Yes, it is wrong that the documentation did not reflect the state of the aircraft and that the chacks hadn't been done - but I think these are probably indicators of problems rather than problems themselves. I feel very sorry for these crews, who are doing their utmost to deliver but on a shoestring in terms of both equipment and training - and that probably goes for the engineers too. I would be looking not at the pilots but at the hierarchy that put so much pressure on the force.

[heights good]

Chaps,
Please have a think before posting, as usual the media has given a headline to explain an investigation that has went on for 2 years. It isn't that clear cut and hindsight is always 20/20 vision.

I know the circumstances and why things happened as they did I also know the deep and lasting effect it has had on the individuals concerned.

The media need to sell newspapers, mundane and boring stories dont sell its that simple.

HG

[ShyTorque]

Having flown the Puma for three tours, I would say that this was an accident that could have happened in any type of helicopter.

"Brownout" i.e. loss of visual references due to the downwash lifting the dust is a known hazard when operating in a dry environment like this but operational risks do have to be taken.

It's easy for the coroner to criticise the pilot from a non-expert point of view, but even a successful desert landing is only a couple of seconds from brownout, as the downwash catches up with the airframe. If the aircraft can't immediately be landed at zero speed, e.g due to uneven ground, it's all too easy for this to occur.

[Dundiggin']

Having completed lots of Puma tours I know not or should I say, I remember not where the spill valves are. Are these in the fuel jettison lines from the collective fuel tanks?

[ShyTorque]

No, I think they are the valves in the fuel vent lines.

[cazatou]

2 experienced Puma Pilots at posts 10 & 11 have difficulty recalling where the valves are.

What experience has the Coroner had of operating a Military Aircraft in a War Zone with the added pressures placed on the crews operating in such an environment? Has the Coroner ever even flown an aircraft of any sort?

If he has not, then how can the Coroner (without any experience of aviation -let alone the Puma Helicopter) decide what was (or was not) a contributory factor in the crash under combat conditions?

Mind you - he has got his name in the Papers.

[ShyTorque]

Cazatou, One reason I can't be sure is that I never heard the precise term "anti-spill valves" before, that's why I can't be certain where they are.

However, I do recall that the fuel tank vent lines are plumbed to cross over to the opposite side of the airframe, so that if the aircraft rolls onto its side, fuel shouldn't drain out directly from the vents. The vent outlets are visible on the airframe.

Also, it's nearly sixteen years since I flew the type and the aircraft underwent an update after I moved on. Valves may have been fitted during that update; I don't know.

[4Greens]

Just as a reminder, modern accident investigation organisations only come up with contributory factors. They are not listed in any order of importance as this is only misleading.

[trochoid]

The tank vent lines do route over the cabin roof to the opposite side of the airframe and are fitted with "NRVs". In addition the tank compartments are vented. If the fuel tanks are ruptured (highly likely in a crash where the aircraft ends up on its side) then fuel will probably end up out of the bag and in the tank bay and then overboard. With a high C of G and a narrow undercarriage, most Puma accidents end up on their side. Most Chinook accidents stay the right way up and generally just rip the wheels off, hence it's good safety record.

[Two's in]

Cheese Holes 101:

1. The crash was probably caused by adverse environmental/operating conditions exceeding the pilots ability to maintain effective control of the aircraft.

2. The incapacitation of the pax was caused by an inadequate/inappropriate restraint system during operations.

3. The fire was caused by the failure of a device only intended for use following a rollover and hence never used or apparently tested.

4. The deaths of the pax was a combination of 2 and 3.

Pax restraint on Ops is always a bone of contention, nobody expects to be fully strapped in when they are expecting to be leaping out at any moment. A fully functional restraint system for fully fitted troops has yet to be devised. This is an operational risk.

The spill valve check was either a scheduled maint check or not - if it had been checked previously and been found serviceable it was an equipment failure, if it hadn't been checked, but should have been according to the servicing schedule, it was a failure of the maintenance organisation.

This appears to be a classic case where operational pressures conspired to place the crew and pax in a situation that ended tragically. The aircraft handling in the operating conditions, the pax restraints, the spill valve and the fire all taken as single events probably would not have been fatal, but on the day where the professional ethos of getting the job done placed these events into an inescapable series of disasters, a tragedy ensued.

So once again, a layman with a bully pulpit thinks its his duty to publicly "name and shame" those whose professionalism and committment to public duty is beyond compare. On the day it all went wrong, but nobody conspired to set those events in motion, neither the pilot, the engineers, the designers, or the RAF. By all means let's learn from this but get off the "conspiracy of incompetence" hobby horse.

[Diablo Rouge]

Could it be that the fuel in question is from an onboard auxilary tank? That might account for the term 'non spill', whereas I am only familiar with Non-Return Valve (Eu) or Check Valve (US) for such things. I thought that the accident in which 2 troops were killed also killed the Crewman, or am I getting more than one accident confused.

It is a bit unfair to impose 'responsibility' of an engineering aspect onto the aircrew for an accident that appears to be covered by 'Normal Operating Hazard' and therefore considered risk by the service. Are we alone these days when things end up in a Coroners Court? Should we be covered by individual insurance for Legal Liability? I would not like to see my family go through the treadmill should I be involved in such an occurance and not live to defend myself.

[Alber Ratman]

I am pretty sure that the crashworty fuel system modifications were incorporated in the late 80s, having been a JT on the MU team that did the modifications. The systems have never been fitted for 30 years..

The system itself was very simple as been stated, but there is no satisfactory way of testing such systems without ripping all the components out. I cannot see why the cornoner can make the statement that he has on maintenance errors like he has. He says that a valve might not have worked. I think it was more likely that the tanks or anti spill lines were damaged being the source of the fuel IMHO.

TD, this accident bears little relation to XV230, so please don't speculate that it does.

[ShyTorque]

Could it be that the fuel in question is from an onboard auxilary tank?

Unless the ferry tanks have changed since my time on type there was no spill valve fitted to them. They were single skinned tanks with a simple tap feeding directly into a main fuel tank.

[Linedog]

So, you talk shyte on here as well as on e-goat?

[Diablo Rouge]

Shy-Tq The ones to which you refer are history. Were they ex-Andover? I have seen a black box shaped thing which appears quite large compared to the old ones. No idea if they were ever fitted in Iraq as there must be a significant weight penalty with them, but it could be the answer. That there was never an accident / major spillage or fire at least with the old ones is luck not judgement.

Of course this could be a complete Red Herring and may have nothing at all to do with this sad incident. But thats rumour for you.

[ShyTorque]

Linedog, So, you talk shyte on here as well as on e-goat?

Aimed at me, I presume? If so, you are as un-informed as me; I have nothing to do with "e-goat".

Diablo, I'm very glad to hear the old ferry tanks have been dispensed with. They were damned dangerous and were known to split their seams all by themselves, in the cruise. At one time they were fitted forward right as standard role (12 seat plus ferry, IIRC) and we hated them.

[jayteeto]

Never a spillage with the old ones?? How about being at 10,000ft DA above a foreign country not normally associated with the RAF?? The tank vent had not been unplugged and it burst open. I can confirm that you can open the doors both sides and use your hands to 'slosh' gallons and gallons of fuel overboard. I was drenched from head to foot in AVTUR. The nav leg was very very very interesting without all that fuel available and a lot of very hostile jungle below................ :eek:

[Thud_and_Blunder]

Diablo Rouge,

It sounds like you are describing the change in the Chinook fleet's ferry tanks (swap from ex-Andover cylindrical things to black, cuboid, 2.4t Robertson's in the late 90s), rather than anything that happened in the Puma fleet.

[Occasional Aviator]

Thud,

the Puma CAFTS (Crashworthy Auxiliary Fuel Tank System) is a smaller version of the Robertson tank fitted to the Chinook. They were introduced just before 2000, but held up due to some concerns over the strength of the floor attachment points. Don't know what their status is now, but I'm as certain as a very certain person that they have nothing to do with this.

ShyTorque - just to be a pedant, it would have been 10-seat (not 12) plus ferry!

[Fareastdriver]

Four tanks in pairs facing fore and aft. The facing end angled slightly down where the fuel outlets were. Secured to the floor by means of twist fittings. They were in the two tank configuration, forward only, when they burst and sent a wall of flame through the cockpit between the pilot and crewman when XW 203 crashed in 1974. It blew most of the cockpit out and then the flame was sucked back into the cabin as the roof opened up. Both of the crew stepped out of the front with minor burns. Anybody in the back would have been fried.

[BobHead]

Am I missing the point about these valves? They are only suppose to work and come into action as the A/C turns up side down(rolls over) after it has impacted with the ground. The two troopers were not strapped in because they never are just prior to disembarkation on OPs. As has been stated common practice known to all.

If I have read the reports correctly one was dead before the valves were required to operate and the other was going no where. If they had worked he would have needed evacuation and early medical treatment.

So the question is why did the A/C hit the ground in the first place. It seems to me that the Coroner has got the cause of the crash correct i.e. Pilot Error in a "Brown Out" was responsible for one death the second death could be debatable but with out the pilots actions in this case, the valves would not have been needed and the Pilots, Engineers, RAF, MOD would have all of happily flown on until the Puma was scrapped none the wiser or interested.

BobH

[heights good]

Gentlemen, you are all speculating, please stop taking a soundbite from the media and trying to dissect what you can from it. The circumstances are not clear cut or indeed as simple as is being potrayed from the articles published.

If you have not read the incident signal or were not there on the fateful evening then you are not really in a position to comment with any authority. Doing so is only causing upset and hurt for those involved.

Please think before posting guys.

HG

[ShyTorque]

Gentlemen, you are all speculating,

HG,

Well, I for one, was actually sticking up for the pilot! :rolleyes:

[Occasional Aviator]

Thanks HG, we needed that!

[doubledolphins]

Back in the mid 80's I watched as a Bristow's (Super?) Puma turned on it's side at Aberdeen. (No, not from spotter's corner but rather too close for comfort from the light aircraft park adjacent to the runway.) It did not catch fire and every one climbed out. Are the fuel systems the same?

[tonkaplonka]

The fuel system on the Puma and Super Puma are pretty much the same. The vent system is identical, as are the anti-spill valves.
I served in Iraq at the secret airbase with the Puma fleet and I am now a type rated engineer on civilian Super Pumas.
I do recall in 2007 having to service these valves and I have also serviced them on Super Pumas more recently.
They are not an NRV as such but a ball that rolls in to a slot when the aircraft tips over stopping fuel from spilling out of the vent lines.
I do have a diagram from my type course notes as the the new EC225 has the same system( If it's not broken, why fix it)

[Romeo Oscar Golf]

Heights Good I can appreciate your protectiveness and probably many others would share your concern for any "upset and hurt to those involved" but I cannot understand it. I have read the (redacted) Boards of Inquiry concerning the accident (its freely available on the web) and whether you agree or not the findings have been established. They are (briefly) summed up in Hansard as follows The board concluded that the main cause of the accident was controlled flight into terrain, brought about by the handling pilot’s disorientation due to the use of an incorrect technique for a dust take off. A number of contributory and aggravating factors were also identified.
Where exactly is the speculation?

[lsh]

Its the first I have heard about an "anti-spill valve" too!
The black "slab" style of tank referred to above is now fitted, saw one a few weeks back.
The old ones were lethal: we smelt fuel, looked back, one metre head of fuel spraying into cabin!
Opened the valve to "dump" it into the main tanks, IMC, diverted into Yeovilton at 5pm Friday, quite unpleasant with the vapours too.
It was after the 1974 accident in field --? (I can see it but not put a number to it!) that the helicopter force was issued with nomex.
lsh

[MightyGem]

The board concluded that the main cause of the accident was controlled flight into terrain, brought about by the handling pilot’s disorientation ,
Hmm...is one actually in control of the aircraft when disorientated?

[4Greens]

As I have said before it is no longer appopriate in ''modern'' accident investigation to talk about main causes, primary causes or any thing of that ilk. There should just be a number of contributory causes and lessons can be learned from that.

[Tiger_mate]

As I have said before it is no longer appopriate in ''modern'' accident investigation to talk about main causes, primary causes or any thing of that ilk. There should just be a number of contributory causes and lessons can be learned from that.

Ideology that is unsustainable. Take the USAF B52 crash commanded by an experienced and very autocratic Captain. He who listens to no-one and kills people in turn must be accountable on an individual basis. Not suggesting for one minute that such analogy is appropriate to the subject of this particular thread.

[The Old Fat One]

Both Tiger_Mate & 4Greens are right in equal measure. Rarely is an accident caused by a single failure of person or machine, but in order to learn the appropriate lessons we must correctly identify the main causes.

The B52 accident was not just attributable to the poor flying discipline of the pilot in command, but also to a shockingly inefficient supervisory chain which failed to act on multiple red flags raised by many people.

Equally, trying to disguise human error by attempting to reduce all accidents to design flaws and irrelevant maintenance issues will do nothing to reduce accident rates and in many cases would simply serve to obscure the true cause and therefore dilute the lesson that needs to be learnt.

Personally, I think the industry, both military and commercial, has a pretty good track record of identifying problems, highlighting lessons and communicating them to the people that matter - pilots and engineers. A lot of what gets highlighted in the media is just noise.

[4Greens]

Design flaws and poor maintenance are a result of human error as well.

[Mmmmnice]

Kick me roundly if I need it, but doesn't staying upright obviate the whole fuel spill valves issue?

[TorqueOfTheDevil]

is one actually in control of the aircraft when disorientated?

Maybe not in control but still in command...at least that's how the BOI might see it.

[heights good]

The redacted version does cloud the waters on a few very key points. Its not as clear cut as the redacted version makes out.

HG