Will Other Controversial BOI's Be Reviewed?

[A2QFI]

After the success of the mission for justice in connection with the MoK Chinook incident will there be requests for reviews of the findings of other contentious BOIs?

I am thinking of a Valiant crash many years ago which was attributed to aircrew error but could have been a structural failure and I am sure there are other suspect findings.

http://www.pprune.org/military-aircrew/267929-valiant-crash-wittering-august-1960-a.html?highlight=valiant+spanhoe

[Old-Duffer]

A2QFI

I spend a good deal of time researching and writing accounts of aircraft accidents and losses. I have often been asked about reopening enquiries because, with greater awareness and more reluctance to accept the initial findings, people want to look again at the verdicts.

As a general rule, the longer ago the accident, less information remains from the initial investigations. There is no certainty that the BofI papers have survived and the background documentation and suchlike is very likely to have been destroyed. Given that the Valiant accident to which you refer is now more then fifty years ago and the aircraft went out of service five years later, it is probable that little original information remains, although of course some has been posted in your offering above.

The rules under which an accident was investigated in - say - 1960, are very different to the current process.

May I suggest that many who contributed to the original enquiry will be dead or quite elderly and their testimony unreliable.

To whom would you address a request to reopen a BoI? What would be the basis of your request? What is the new and compelling evidence that would convince a hard pressed MOD to reconsider the earlier findings? How and who would convene the review and who would actually agree to pay for it? Can the mores of 1960 really be translated into 2011? Whilst intending no disrespect, we have had politicians in the recent past apologising for events which happened a century ago, something which is meaningless in my view.

I have also tried, when asked, to differentiate between phrases such as 'negligence' and 'errors of judgement'. The meanings of these words have changed with time.

Finally, I try to steer people away from getting too deeply involved in trying to clear (perhaps for example) their father's name. It can be and has proved for some, to be an exceptionally distressing experience, I know of no single case where a military verdict has been overturned (ignore ZD576 for the moment). The Vulcan at Heathrow in Oct 56 is an example where after many years it became apparent that the aircraft had possibly been 'talked into the ground' but I don't recall that 'Podge' Howard was ever formally exonerated. On the civil side, the Munich aircrash went on for many years as to whether it was slush on the runway or ice on the wings which was the cause and by time the result was changed, the aircraft's captain was a broken man who had lost his flying career, became a chicken farmer and died young.

Finally, there is the size of the problem. Since VE-Day, the RAF has lost about 9400 aircraft and had over 6000 fatal casualties. Stoically, it was accepted as de riguer that if another definite cause could not be found, it must be the pilot's fault. Where would one start?

Sorry if this seems unhelpful and pessimistic but I actually think it's a realistic assessment.

Old Duffer

[micksmith]

Old Duffer, while I've no doubt the thrust of your argument is correct, and you clearly know far too much about this for me to even think of gainsaying you, you say that in the past:

Stoically, it was accepted as de riguer that if another definite cause could not be found, it must be the pilot's fault.

I thought one of the main arguments being made by the campaigners in the Chinook campaign was that when it was impossible to know what caused the crash, it was the practice not to blame dead pilots who were unable to defend themselves. Was this an incorrect claim or did it change at some point?

[Brian 48nav]

I'm intrigued by the figure you quote of 9400 aircraft lost! Are you able to break it down by major losses?

For example (and I'm just making these up); 500 Meteors,500 Canberras etc.

On the subject of the Vulcan surely the crew were operating to a set Break-Off Height and if it was say 200' then if they were not visual with the lights/runway then they should have initiated an overshoot. LHR wx on the day was given as w/v calm,1100yds vis,scattered down to 300' and 7 oktas at 700' (from 50yrs of Heathrow ATC).

I have no axe to grind either way, being equally proud of my 8years service as a Herc' nav and my time as a civilian ATCO, 14 of which were at LHR.

I have also held a PAR rating, a requirement at Boscombe where the ATC was provided by CAA until 1992. You can not talk an aircraft into the ground, unless his BOH/DH is 0'!!

In my experience it was not unusual for the MOD to try to put blame on civilian ATCOs - a good mate was blamed for an airmiss involving a Royal and a BA747, when quite clearly the Andover had bust its level due to inadequate monitoring by the 'professionals' and it was only the good words by the BA skipper that made 'the powers that be' see sense.

I've always believed that the Vulcan crash was caused by press-on itis by Broadhurst. Why men of Air Rank are allowed anywhere near the controls of an aircraft has always mystified me.

[Carol Johnson]

I am the daughter of one of the crew killed in the 1960's valiant crash. The paper work has survived, all 130 odd pages or so. It is the children who carry the pain of findings blaming their father(s) and although I am not in that situation as my father was the AEO I do think it is important to review the past, in cases where there may be some doubt. Having said that I accept that offical reviews may not be possible and indeed may be very stressful, but threads such as this allow for discussion that, when positively presented, can be of great comfort to those children. It is through the PPRuNE site that the children of the valiant crash have made contact which in itself has been a very positive experience. We lost our fathers and have been able to share the despair that caused. I didn't know my father and am now able to acknowledge him, honour his memory and understand that he gave his life for his country. I believe discussions on this thread are important in helping us accept and understand what may or did happen. I therefore thank those who contribute in a positive manner.

[A2QFI]

I started a thread years ago as I was staggered by the losses, just after the WW2.

http://www.pprune.org/military-aircrew/70987-meteor-accident-statistics.html

[A2QFI]

If there is the will to investigate and correct errors the money can be found!

The Saville report's numbers are their own indictment – 434 days in session, 12 years from inception to publication, a £191m budget, tens of millions of words and finally a retail price of £572. It is not surprising that many observers and even some of those involved wonder whether, whatever its findings, the Bloody Sunday inquiry could really have been worth it. This is the wrong conclusion. The power to hold the state to account is precious beyond price.

This was to investigate 14 deaths - about the numbers of one Shackleton crew!

[Old-Duffer]

Ladies and Gentlemen,

I shall try to respond in a single post to the comments which followed my Post No: 2 above.

First, ‘pilot error’ as a finding was frequently used where no other cause could be found but the concept of ‘error’ was not generally taken to imply negligence but could suggest a lack of skill or whatever. It’s use may not have been officially condoned but the mores of the ‘50s required a rather ‘tidy’ finish to these things, although we would probably use ‘not positively determined’ now.

Second, the losses of aircraft by number and the casualties involved can be easily found on the RAF Museum website, the ‘RAF History’, Historical Society Journals’ and finally ‘Journal 37 – Flight Safety’. The book ‘Broken Wings’ published by Air Britain is also a valuable source. I have details of most of these accidents but to analyse them by type etc would take a bit of time.

Three, I referred to the Vulcan crash at Heathrow, as an illustration that only occasionally are accident investigations reopened. This one wasn’t so much reopened as it had a researchers’ devilling into the findings and offering a reasoned possibility that the original findings were wrong.

As to reopening a specific accident investigation, I remain convinced that there is a need to produce new and compelling evidence, before an enquiry would be reconvened. I also believe that there is an inertia in MOD which would defeat all but the most persistent campaigners. Reference to the Saville Enquiry is, if I may be so bold, a red herring. Saville was part of the ‘peace process’ and was politically motivated at the highest level. Money and time were no object and the reaction of republicans to its publication makes one wonder why anybody bothered. Had all the squaddies involved simply said: ‘Sorry, my Lord, it’s too long ago and my memory is so vague, I can’t even remember which riot this was’, the whole thing would have been stopped dead in its tracks.

However, I digress.

In conclusion, whilst one might wish to find out as much as possible about how and why an accident happened, there can be unintended consequences, such as a feeling of bitterness by (say) the families of some crew against the kith and kin of the pilot or resentment between the families of a dead crew member against a survivor. There is also often a good deal of raw emotion generated and everybody reacts differently and sometimes unpredictably.

Old Duffer

[Fitter2]

May I suggest that a far more useful campaign, to avoid future discussions about individual events which have not yet occured, is one to restore the integrity of the RAF airworthiness system, and to have an independant accident investigation process.

[flipster]

I don't think that every enquiry need be reopened but I would heartily back a campaign to have all fatal accident/BoI reports prior to 1997 amended to 'cause not positively determined'. Obviously, this would only apply in cases where the pilot or crew could not plead their case (eg the aformentioned Valiant). I am sure that the MoK sets a precedent that could back such a camapign'

The application the burden of proof of ' with absolutely no doubt whatsoever' would in most cases, allow the 'exoneration' of crews that paid the ulimate sacrifice for their country - whatever the definition of 'pilot error', 'error of judgement' and apportionment of blame etc.

BTW -I also wholeheartedly agree with Fitter!

[green granite]

Has there been any progress in the Malcolm Williams BOI comments by his Group Captain?

[Carol Johnson]

What you suggest sounds like an excellent solution, given the immense difficulties involved in reviewing something that happened so long ago and the use of terminology that has changed over the years. If there is any doubt as to the cause of an accident, that happened years ago, then it seems fit to look at changing the wording to that which is used today rather than to say pilot error for example, although with the valiant more than error was assigned. How would one request such a change?

[Old-Duffer]

Carol Johnson,

I realise your interest and focus on the Valiant crash but my comments above are valid.

You will need to be able to offer new and compelling evidence, as to why the original BoI finding was inaccurate or otherwise flawed.

I then suggest you write to the Secretary of State for Defence and summarise why this enquiry needs to be reopened. As you are in Australia, I suggest that you need a 'champion' in UK who can muster an interest from (perhaps) the local MP for Spanhoe. If you have any close relatives of your father or mother living in UK and who are prepared to lobby for a review of this accident, that might also help.

I am sure other ppruners will jump into this Thread and offer their advice and I am sorry if what leaves my computer as what I believe is realistic, arrives at your computer and seems negative.

Old Duffer

[Airborne Aircrew]

As I pointed out in the Chinook thread, I think it is imperative for everyone to understand that "Pilot/Aircrew Error" should not be seen as pejorative. Every single pilot or Aircrew has made multiple errors in their flying career. Each error had consequences and some generated BOI's when no injuries resulted from the incident. In some cases the error caused fatalities but they remain just that, errors. There should be no "blame" or feelings of shame regardless of the consequences of the error.

[RIHoward]

Most of the post war crashes were in my view down to the change to new materials like DTD683 and the design strategy used by UK/US A/c designers, that of 'safe-life'. These shortcomings were finally nailed down in 1956 with a paper in the Journal of the Institute of Metals (http://zkt.blackfish.org.uk/XD864/JIM_1790_17-23.pdf) by a group of Birmingham metallurgists and in a talk given to the RAeS by a Lockheed engineer http://www.flightglobal.com/ (http://www.flightglobal.com/pdfarchive/view/1956/1956%20-%200396.html), the former condemning the materials and the latter condemning the design strategy and the materials. A double whammy.

The Meteor crashes and the infamous dive of death can be attributable to an error in the design of the tail structure where failure due to fatigue in the rivet holes holding the skin to the airframe would mean a dramatic reduction in the structural strength of the tail, leading to failure of the tail and uncontrollable dives.

There is a book "Arms Economics and British Strategy" by Emeritus Professor of History George Pedden at Sterling University that has a quote on Chp 6 page 284 from a memo sent by Chancellor Macmillan in 1955-56 to PM Eden

"... When the story of the aeroplanes finally comes out, it will be the greatest tragedy, if not scandal in our history"


That's quite a thing to say in a private memo, I think it is time for the "story of the aeroplanes" to come out, the crews that lost their lives in these incidents deserve the truth being told. They lost their lives largely because of the failure of the A/c industry to build safe A/c due to the huge political pressures being placed upon them, in a similar way to the causes of the 1957 Winscale fire .

The loss of life in RAF crews during the early post war period is staggering with losses reaching a high of over 300 killed in 1954. Post 1956 when the problems with both the materials and design strategy were acknowledged the numbers begin to drop. While it's difficult to say exactly why the numbers begin to fall clearly the revelations of 1956 played a role, all safe-life designs were either rebuilt or scrapped starting in 1956, The Valiant being the single exception to this scrap or rebuild strategy.

http://zkt.blackfish.org.uk/XD864/images/RAF-noncombat-losses.jpg


Thanks to John Blakeley for the data from "Broken Wings" (I think) There is a graph with a similar profile taken from Flight Magazine in the 1970's when there was a campaign to get the MOD/RAF to just release the figures. You can see the effects of the post war demob and then a steady climb to '54-'55. There was a reduction in flying hours in an effort to stem the tide, but it was the change to safer materials and a new 'fail-safe' design philosophy that really made the difference.

So while I agree with Duffer that it would be unlikely for there to be a review of XD864 (the AIB are still passing the buck even 50 years down the line and won't even comment on the BoI's findings), the "story of the aeroplanes" should be told warts and all. The truth is that up to 1956 all UK and US A/c designs were inherently unsafe if they used the new alloys (like DTD683) and were designed to the so called 'safe life' strategy.

[teeteringhead]

But the graph would say more if adjusted for flying hours. The RAF used to record accident rates per x flying hours, and then classify the result because it was relatively easy to solve for x.

Does anyone (Old Duffer?) have adjusted figures; if so, does the graph show a different shape? My feeling is that the "rate adjusted" figure would be higher for longer, certainly well into the 1960s - as an example, IIRC we lost a higher proportion of Lightnings than the Germans did F-104s.

[as ever, I stand to be corrected]

[RIHoward]

Here's the rate adjusted graph from Flight Magazine, I'm sorry I didn't post it with the other one I've only just managed to find it in my "filing system". And sorry for not having the publication date, but I think it was the late '70's.

http://zkt.blackfish.org.uk/XD864/images/RAF_rates.jpg

Your conjecture about its shape is correct, I think.

[Chainkicker]

Publication date should be post 89 surely? Bit of a blip during the Falklands. Perhaps that was the Chinnies on the AC?

[RIHoward]

Thanks Doh! :\

[Henry09]

RIHoward

A very very funny Doh! moment, however, brilliant graphs and info, thanks for posting.

Carol

Good luck!

[Old-Duffer]

Thanks for posting the graphs and the comments thereto.

Of course to be even more accurately portrayed, one then needs to split the graphs into the aircraft role and analyse the stage of flight in which the accident took place.

In earlier times, many aircraft were declared write-offs because the type was approaching the end of its service life and there were stocks of aircraft which could easily be pressed into use. For an extreme example, I found a Tempest which was struck off charge following an engine failure because it wasn't even worth while doing an engine change. Although a slight red herring, at the other extreme, many will remember the pile of charred metal which was Hurricane LF363 - look at her now!

Although big aircraft did not crash often, when they did they had the opportunity to kill a large number of people (Hastings at Abingdon, Herc off Pisa, and two Shacks in a - possible - mid air). Fighters, GA types and trainers have always contributed large numbers of aircraft to the accident stats and this for fairly obvious reasons.

I have always had a concern about the retention of currency amongst aircrew as flying hours are cut and restrictions on what can be practised and where. Simulators are fine for procedural work but I ask the question; 'do they provide the sort of extraneous pressures one encounters during a real live practice and hence are they a totally realistic substitute'? Presumably, somebody is keeping a close eye on - for example - young pilots who are obliged to be away from their 'desks' because of other commitments:hmm::(

Apologies as this Thread has drifted rather more than the originators would have wished.

Finally, the accident stats broken down by aircraft lost and casualties sustained can be found in the RAF Historical Society section of the RAF Museum website and then look for the flight safety seminar.

Old Duffer (late walking the dogs this morning 'cause of posting this)

[dalek]

I was airborne in the same stream when the C130 was lost off Pisa.
It was still dark and flying at 500ft over the sea we unexpectedly encountered two to three eighths of stratus. Before we considered abort, and after only a couple of seconds the cloud cleared.
It is believed the C130 crew just pushed and flew straight in.
As far as I remember though, they were never blamed? No ADR / CVR so who knows what really happened?

[Brian 48nav]

Dalek, I was the nav in the 5th aircraft in the stream of 6, the last 3 as you may recall did not get airborne due to late arrival of their Italian paras.

I do not recall any cloud at all, but I think there was a hint of sea fog drifting in at that ungodly hour.

We took off on RW04(?) and made a right turn onto the initial track of about 240, not left as that would have taken us over city. As soon as we were established on track and with the first turning point, an island,rock solid on my CCWR, I stood up to lean on the back of the co's seat when there was this big red flash in our 11o'clock. Geoff, my skipper screamed someone has flown into a hill, negative I said there's the nearest rock 20 miles ahead on the radar.

No 4 saw it too and made a report to the streamleader, and subsequent radio check revealed No 3 missing.

I'm still in touch with the nav from No4 and the skipper from No6, and saw my skipper in France in 2006.

Memory does play tricks (in fact I witnessed a road accident last week and only 6 days later I'm thinking which was first the bang or the sight of the collision between the 2 cars),another frequent poster on pprune has said that the Andover weather ship said wx was unsuitable. There was no Andover involvement on that detachment to Pisa in Nov '71.

We the crews involved had our theory as to what had happened, and the idiotic idea to have the most difficult sortie, ie night 9 ship formation, as the first of the detachment, instead of a gentle build up starting with day singletons leading in to day 3 ships,must have had quite a role in what happened!

Waffle over, back as OD said to the original thread intention.

BW

[flipster]

Where there is no clear, unambiguos evidence of negligence or blame, all Boards of Inquiry that instead found the pilots/crew blameworthy, should also be set aside. I would support such a campaign.
However, AA is right, in more-recent years (1980-97) - when blame could still be attached via negligence there is, however, no blame though 'error of judgment'/'no lack of zeal' etc. So maybe not all 'pilot error' accidents would be absolved.
More clarification on definition of negligence/human factors (aircrew), human failings etc is required before 1980ish.

[RIHoward]

The Tench Report gives details of procedures for BoIs, published in 1987 the regulations at that time were the 1956 regs Tench gives a summary in his report. Before '56 I guess QRs etc will be available at Kew or AHB

The Tench Report. (http://zkt.blackfish.org.uk/XD864/Tench_Report.pdf)

This damning report should add weight to any campaign I think.

[John Blakeley]

The loss of Tornado F3 ZH558 near Akrotiri on 1 Jul 1994 should , in my view, certainly be looked at again - the time frame of the investigation and RO's comments closely parallel those of the Mull. The main BoI and AOC 11 Gp all decided that there should be no findings of negligence - quoting the rules of AP 3207 - quoting the same rule, and without apparently needing any legal advice from DLS the AOCinC decided that he had "no doubt whatsoever" that the crew were negligent. So one man's opinion (for that is all it can be) overules everybody else - is that how the BoI process was meant to work?

Given the Mull ruling on burden of proof I would imagine the families concerned would be in a good position to require MOD to clear the crew's names should they wish to pursue this.

JB

[Old-Duffer]

Presumably there must be ADR traces and CVR transcripts, which would have informed both the BoI and the CinCs deliberations. One assumes the CinC made the reasons for his decision clear in his findings and, if so, what were they?

For one of the crew, this was their second major accident. Might this, coupled with the previous BoI, have influenced the CinCs findings?

Is there compelling evidence to suggest that the CinCs findings were unreasonable? Presumably he concluded that there was no doubt else why would he have ruled as such?

It would be interesting to see the timelines for the progress of the two BoIs through the system.

Old Duffer

[John Blakeley]

OD,

The point is surely not whether the CinC thought his findings to be reasonable - you have to assume he did, as he presumably also did for the Mull. The point is whether he could meet the burden of proof requirements of 3207 - the BoI and AOC did not think so - so should deceased aircrew be found guilty of negligence by one man's opinion - for that is all it can be unless there is clear evidnece of legal advice being taken (and even that apparently wasn't too reliable in the case of the Mull) - even if he is sitting at the top of tree! For the Mull a learned judge (and indeed learned judges before him) found that the burden of proof had not been met (nothing to do with whether they knew anything about the operation of RAF aircraft, but everything to do with the law and justice) - is the Akrotiri finding any different?

JB

[Old-Duffer]

JB,

Then one needs to look at what the CinC wrote and determine whether the evidence on which he based his findings meets the test.

If he states the basis of his findings and these do not satisfy the test then his findings were wrong but if they do, he was within his rights.

The issue is also one of case law. The law may be written and on the (MOD equivalent) of the Statute Book but it is only by the outcome of trials and a judge's ruling that the legal precedent is established. If this BoI went to the CinC after the Mull BoI, perhaps he believed that he was in a position to make a finding which met the requirements and his decision did not require further legal interpretation/advice.

Perhaps things would have been less confused if, having made a change to the burden of proof, a JAG should have been appointed to advise BoIs or the deceased personnel should have been represented legally and in absentium. After all, it was because deceased personnel could not have any means of defence that the rules were changed in the first place but the changes were not complete by failing to cover the legal representation of dead people.

It would be interesting to know what direction was given to BoI advisers, what guidance was given to Defence Aviation Safety staff and how were the changes to the law represented to those officers responsible for convening and reviewing boards of inquiry.

It is also interesting that, despite various enquiries into the Mull accident, none of the legal bodies involved compelled the MOD to accept their judgements. It seems rather sloppy that, for example, a Scottish Fatal Accident Enquiry proves to be toothless.

Given that Cameron stated in a letter that he would exonerate the Mull crew when he came to power and I told him, Dr Fox and Gerald Howarth that they could not do so on a whim and that without a fresh review such a gesture would be pointless, we now have an accident which has no finding substituted for the one which was overturned. An equally messy situation.

OD

[kiwibrit]

Surely the real point is whether further public money and time should be consumed on BOIs of incidents long ago. BoIs were conducted and reviewed in good faith. Where blame was determined, it was effectively a matter of opinion, albeit based on evidence available - unless a court martial made a guilty finding based on evidence placed before the court. Clearly where those who would have been at risk of a CM were deceased, no court martial occurred. Under the presumption of innocence we have in UK law, it follows that those deceased were innocent. I really can see no benefit in going over old ground.

Surely, the MOD is stretched enough as it is trying to run our Forces without adding a string of old BOIs to re-investigate.

[p beech]

Seems to me that the destructive impact on the reputation of aircrew, who have lost their lives in the service of their country, by the attribution of blame and/or negligence can be fully appreciated only by their close relatives. And to suggest that a review of those BOI's which have resulted in such verdicts should be decided on the costs involved is at best disrespectful.
Iago got it right ( Othello,act 3 ,scene 3)
Regarding the Valiant crash in August 1960 there was a clear malfunction with the aircraft which nobody disputed regarding the nosewheel which failed to retract and the AIB found no explanation for this .
The political atmosphere at that time was quite tense due to the U2/Gary Powers incident a few months earlier and this atmosphere is well ilustrated by reference to the UN clash between MacMillan and Kruschev in September 1960 and the shoe banging exhibition by Kruschev at the UN in October 1960.Both of these incidences can be seen on the internet.

[Courtney Mil]

The loss of Tornado F3 ZH558 near Akrotiri on 1 Jul 1994 should , in my view, certainly be looked at again - the time frame of the investigation and RO's comments closely parallel those of the Mull.

I'm very interested in this one, John, and thank you for raising it. I was the crew's flight commander at the time and had the horror of identifying their bodies. The background is very complicated and steeped in politics. It is an incident that haunts me today. I'm sure you will understand that there is much that cannot be divulged here. I would be interrested in your thoughts. Especially as to why. I made only a very brief reference to it in my journal at the time (edited before I put it in the public domain).

ZH558 Crash (http://www.projectoceanvision.com/vox-10.htm#ZH558)

More generally, I could not agree more about certain AOC's over-ruling/ignoring BoIs' findings. My last job in the RAF was as President on one. Fortunately, I won that one, although I don't think that man concerned ever knew at what cost.

Harrier BOI (http://www.projectoceanvision.com/vox-13.htm#boi)

I'm sure many here will be very familiar with both. But how much do we all really know?

Courtney

[p beech]

The reasons given for the revisions to the regulations ,incuding upgrading the standard of proof, for BOI's for accidents in which the crew died are also valid reasons for reviewing other relevant accidents when negligence/blame was attributed ; summarised in the Philip report as to meet '' generally accepted standards of justice and fairness''.
Regarding the Valiant crash in August 1960 surely the evidence of the widespread cracks in the wingspars ,which was exposed by the comprehensive inspections of the Valiant fleet in 1964,(leading to the withdrawal from service of the entire fleet in Jan.1965,) together with the writings of Morgan,Jones and Brookes is compelling?

[JFZ90]

I'm very interested in this one, John, and thank you for raising it. I was the crew's flight commander at the time and had the horror of identifying their bodies. The background is very complicated and steeped in politics. It is an incident that haunts me today. I'm sure you will understand that there is much that cannot be divulged here. I would be interrested in your thoughts. Especially as to why. I made only a very brief reference to it in my journal at the time (edited before I put it in the public domain).

ZH558 Crash

Hi Courtney, is the BoI available for this incident? I didn't manage to google it.

EDIT - just found this..... http://www.ukserials.com/pdflosses/maas_19940708_zh558.pdf

Reading your website (which I think is rather good) one is left jumping to certain conclusions as to what may have happened - late night party / early sortie? Is this the intent? I will edit if this is inappropriate, but it is the impression given I think.

[MightyGem]

From Courtney's Journal:
We reported our progress to the AOC, who shouted and ranted at us. I especially 'enjoyed' a 45 minute, one-way telephone conversation that I had with my AOC one afternoon. Not only was he kind enough to tell me what findings we were supposed to come up with
This, along with other references in this topic to similar occurrences, beggars belief. How can they do this. All credit to CM for refusing to be lead, but how many others have heeded the "advice" given?

CM, I've booked marked your journal for further reading. Looks very interesting.

[NutLoose]

Sad fact is as I see it a BOI is set up for one reason and one reason only, to find the truth as to what happened to help prevent it happening again and possibly save some poor soul losing their lives........ When politics get into it and higher ranked officers attempt to alter the findings for what ever reasoning that lesson is lost, the pressure to come to a set finding, even if the incorrect one simply buries the truth and leaves the possibility of it happening again, that is why the Civil AIB works so well, it is independent from the airlines or manufacturers etc and works to find the truth.
Additionally they and I don't mean this badly a service board are simply not someone placed in a position that they are not 100% qualified to judge on, such as proffessional accident investigators.... You wouldn't if getting court marshalled take the court appointment officer to defend you (if you had any sense) you would use a proffessional lawyer.... The same should cover BOI's it needs an independent and qualified inspector.

[tucumseh]

Courtney

Thank you for your posts. These “chats” with AOCs are your equivalent of the ones I had with my 2 Stars, when instructed to commit fraud by making false declarations about airworthiness and financial probity. They are closely related because, as Nut Loose says, their intent was to conceal the truth thereby placing aircrew at risk. I suspect if we drew up lists of names there would be much commonality!
Well done indeed.

[BEagle]

With the availability of Internet to disseminate information very rapidly, 'they' were paranoid about truth leaking out onto sites such as PPRuNe....

However, there are a few 'mates in confidence' rumours about the probable cause of at least 2 'unexplained' CFIT fatal accidents. One concerned a Hunter T7 near Shawbury in the early 1970s and the other a Tornado GR1A in Scotland in 1994....

[Algy]

Very late to this thread, but the link to the Flight International article (written by the recently lamented Gainesy) cited earlier is here (http://www.flightglobal.com/pdfarchive/view/1990/1990%20-%200900.html) (over two pages which have to be selected separately).

More to the point, for those not familiar, the entire pre-internet contents of Flight, back to 1909, are available in searchable .pdf at Aviation History - Browse the History of Flight from 1909 (http://www.flightglobal.com/pdfarchive/index.html)

When I was at Flight we commissioned the creation of this archive by scanning every issue of the magazine - many of which exist only as a single hard copy - with optical character recognition. The search functionality works astonishingly well and it is very easy to have a couple of hours sucked out of your day once you start playing around with it. Uncle Roger from the glory days of the 70s and 80s is particularly seductive.

[Chugalug2]

NutLoose:
Sad fact is as I see it a BOI is set up for one reason and one reason only, to find the truth as to what happened to help prevent it happening again and possibly save some poor soul losing their lives........ When politics get into it and higher ranked officers attempt to alter the findings for what ever reasoning that lesson is lost, the pressure to come to a set finding, even if the incorrect one simply buries the truth and leaves the possibility of it happening again, that is why the Civil AIB works so well, it is independent from the airlines or manufacturers etc and works to find the truth.
Hammer, nail, head! Going over old suspect BoI's may save tarnished reputations it is true, but the essential dynamic is to ensure that future Military Air Accident Investigations are not thus suspect. As NutLoose so correctly points out that cannot be unless they are carried out by a body that is completely separate and independent of the operator (the MOD) and of the Authority (the MAA, ie....the MOD!). That is the real message of Mull and, no matter how many "independent" inquiries and "independent" bodies within the MOD are established, that remains the message. Unless and until we have an independent MAA and MAAIB, separate and independent of the MOD and of each other, avoidable military air accidents will go on killing with monotonous and depressing frequency.
Self Regulation Doesn't Work and in Aviation it Kills!

[Hipper]

In 1960 I think BoI reports were 'Secret' and not released to the public for thirty years. Perhaps snippets were published in newspapers - I don't know.The Valiant Spanhoe crash (XD864) warranted only four column inches of basic information in next day's Telegraph - I don't know which page - and less in The Times.

Today we expect all the information to be available to us.

For these reasons, I can't help thinking that the older reports are more likely to be free of outside interference because they were in house - only those that need to know would see them. Today I would have thought the writers of these reports have to keep one eye on public opinion/political implications etc..

I also get the impression that earlier we were acceptiong of blame being placed on the foot soldiers (pilots, train drivers etc.) whereas today we are more likely to look at them as victims of a weak system and put blame on leaders, directors and so on.

[Courtney Mil]

Thanks for the kind words and PMs, guys. I have to say, I've been increasingly shocked by the things being revealed here. It was always my impression that some of the BoI outcomes were wrong (putting it mildly), but really didn't realise how corrupt and rotten so many findings were (alledgedly, obviously).


Tuc,

Nicely put!


MG,

Thank you for your impression of the quote from my journal. Actually, it wasn't my intention to imply that the boys were partying every night so I'm very glad you brought that to my attention. I've added a note to it accordingly. Of course the boys always have a few beers in Cyprus, but I'm glad to say it's much more restrained than it was two or three decades ago.


Both of Stu's accident summaries, if anyone was still looking:

ZE858 BoI summary (http://www.projectoceanvision.com/vox/ZE858-crash.pdf)

ZH558 BoI summary


Courtney

[Carol Johnson]

It is with great, great sadness I write this post. My mother Jeanette Hyde passed away on Tuesday 31st July 2012. She was married to my father Roy Harvey Johsnon who died in the Valiant crash in 1960. I have spent the recent few years finding out about my dad and grieving and came through that. The sadness of very painful loss is now back. My mother suffered so much after that crash and I now realise that my brother and I shared some of that pain throughout our lives so far. Even though it was a long time ago it has always been with us. I hope with all my heart that life goes on in some way and that my mother is at peace with those she loved and with those who loved her.

[TorqueOfTheDevil]

Carol,

Very sad news - sincere condolences to you and your family.

[Chugalug2]

Carol, I am very sorry to hear of your sad loss. Your story is very pertinent to this thread, for it reminds us all of the real cost of fatal aircraft accidents, which is to the loved ones left behind to grieve for what amounts to a life sentence.
If it is of any consolation at all, you should know that there are many here who firmly want to see UK Military Airworthiness and Air Accident Investigation reformed, so that avoidable aircraft accidents are properly investigated to ensure that they are then avoided thereafter. While the MAA and the MAAIB are neither independent of the MOD nor of each other that cannot be relied upon.
It has only been with the help and support of devastated families that we have been encouraged to keep persevering. Our creed is simple and self explanatory:-
Self Regulation Doesn't Work and in Aviation it Kills.

[SOSL]

I know, and respect, many of the guys (M & F) who were drafted into the UK MOD, MAA and the MAAIB.

They are good operators, engineers and other branches - they believe in the supremacy of flight safety and they are trying their best.

But I'm not sure they have complete buy-in from the very top.

It's de-rigeur to blame politicians; sometimes I wonder about our Air Marshals, Generals and Admirals.

Carol, I'm sorry if my post doesn't give you much comfort.

Rgds SOS

[tucumseh]

First of all, my sincere condolences. I may be a civvy, but I knew some who died unnecessarily in airworthiness related accidents. It is very sad.



The failures that led to the MAA being formed could not be influenced by (Service) maintainers or operators. Few, if any, have the necessary training to simply step into the MAA and understand, never mind correct, what went wrong.


Few have any experience of working in a system where VSOs dictate, under threat of disciplinary action, that ATTAINING and MAINTAINING airworthiness should be IGNORED. Their experience is primarily in one small part of the latter (1st/2nd Line). The failures that caused or contributed to Nimrod, Tornado/Patriot, Chinook, Sea King and C130 were all made in the attaining domain; primarily during major upgrades. What would have prevented these failures? Adherence to mandated regulations. From what I read the MAA are focusing almost entirely on one small part of maintaining.

In each case, the recommendations made by the Boards of Inquiry came as no surprise whatsoever to staffs taught how to attain airworthiness. In many cases, the proof is here on pprune, in the posts preceding the BoI reports. In each case there is a written record of senior staffs being advised to implement mandated regulations directly related to subsequent recommendations. In each case the BoI (and Haddon-Cave and Philip reports) can be summarised as "Implement your mandated regulations".

Until that simple truth is acknowledged, little will improve. MoD will not acknowledge it, because doing so directly implicates retired VSOs and senior Civil Servants. They will continue to lie to Ministers (not that Ministers bother about such things). This is where pprune plays a vital role, by naming those who Haddon-Cave refused to, despite being given irrefutable evidence. In this sense, he is part of the problem, not the solution.

It only needs one BoI to be reconvened. I believe, for example, this would require the President / ROs to state they were misled, by omission or commission. I know of two such Presidents / Senior ROs who have been approached recently and presented with such evidence. Disgracefully, each declined to comment, although one expressed himself satisfied that the direct cause of one accident (a Tornado crash) had been mitigated - but only after 20 years had passed since the original mistake. He was content that the systemic failure remained unaddressed in that period, despite VSOs being formally notified on numerous occasions. At first he was up for it. But when he saw the evidence proving his senior colleagues had condoned the aircraft being functionally unsafe, he closed ranks again.

A personal note, which is worth considering. The formal Ministerial and MoD position, conveyed to my MP, is that I remain the only person (in MoD) who believes the airworthiness regulations should be implemented properly. They refuse to withdraw this (written) claim, first made in 2003, even post Haddon-Cave/Philip and the formation of the MAA. I dare say the head of MAA disagrees, but he won't say so; each time I seek a retraction Ministers are advised the ruling should stand (and questions on airworthiness are now directed at the MAA). But this is the point I'm making. Keeping this opinion private to avoid conflict with VSOs and Ministers goes against everything the MAA is meant to stand for. If the MAA were truly independent, he wouldn't have to worry about this.

(Edited to clarify a point. The 2003 statement was made to justify a ruling that the Chief of Defence Procurement was right to uphold disciplinary action against me when I refused to obey an order to make a false declaration that the airworthiness regs had been implemented, when the person issuing the order (and myself, who had the signature) knew they had not. CDP also ruled that it was not an offence to issue such an order. This remains MoD's official position. I issued directions that the aircraft be made safe. The officer issuing the (il)legal order countermanded me, and the resulting lack of functional safety was cited in a subsequent Board of Inquiry report. Hence my "attitude" on here!).

[Rigga]

My condolences to Carol and her family for their loss.

I admit to not knowing how the previous MOD airworthiness systems did or did not work. But the new MAA have a real dilemma in picking which end of their huge problem to sort out first - the chicken or the egg.

Unfortunately it appears that the egg is the easiest to correct first and (doubly unfortunately) they have laid another egg in trying to correct the first.

In their attempt to take charge of their situation they have merely set some new rules in place...no training, familiarisation visits, guidance or enforcement - just new rules.

Oh well. At least someone is enjoying debating them and writing them - cos no-one appears to be reading them!

[corporal punishment]

tucumseh,

Perhaps the answer to your point is that the MAA is independent but those who work in and lead it are not.

[Something witty]

Regarding the Vulcan loss at Heathrow on talkdown refered to much earlier, I recall reading that aside from a talkdown issue it was also partly attributed to the lack of a Pressure Error Correction (correct FW terminology? I use a Helicopter Type Allowance) for the Vulcan's Bar Alt - although hardly the certain truth, ;) pprune supplies the following:

http://www.pprune.org/aviation-history-nostalgia/111797-did-you-fly-vulcan-merged-59.html

Thanks AvroLincoln. According to the BoI report, about 7sec before the Vulcan hit the ground,the GCA controller told Podge Howard that he was 80ft above the glidepath. Even after XA 897 struck the ground, the talkdown continued as if the approach had been normal. The BoI concluded that 'the failure to warn the captain that he was going below the glidepath was the principal cause of the accident.' A subsequent Boscombe study of Vulcan altimerer errors revealed that the large delta wing area, plus friction with the altimeter, amounted to a total possible error of 200ft. As Heathrow 10 Left was 80ft above sea leave, even with 300ft indicated on his altimeter Podge Howard was already among the weeds.

[tucumseh]

tucumseh,

Perhaps the answer to your point is that the MAA is independent but those who work in and lead it are not.

I think I know what you're getting at, but the fact is that if the MAA is headed by senior officers whose career path is determined by the very people who are hostile to what the MAA is trying to achieve, then that degree of influence means there is no independence.

As Rigga says, they have chosen the path of least resistance. As there has been robust resistance to airworthiness since it was run down by (primarily) the RAF Chief Engineer in the early 90s, then it cannot possibly be addressing the failures.

The basic problem is, I believe, the MAA was established to clear the Haddon-Cave recommendations, thinking this would resolve "airworthiness". But H-C's report is fatally flawed, because he declined to publish the historical evidence detailing the depth and breadth of the problems. He blamed the wrong people, while protecting, in fact praising, those who were on record as disagreeing with the concept of airworthiness.

When asked to distil this down to one point, I always say this. H-C blamed Gp Capt Baber (Nimrod ITPL) for the poor management of the Safety Case task he let on BAeS. While partly true, he completely, and quite deliberately, missed the point that the regulations require continuous tasking on BAeS, and Baber should have inherited a valid Safety Case. The very fact he had to let a task on BAeS reveals long term systemic failures. That would have been Baber's defence; and MoD, the Provost Marshall, Thames Valley Police, the H&SE and CPS all played a blinder in conspiring to not bring charges. Thus protecting the guilty.

Allied to this, General Cowan was criticised for implementing 20% cuts over a 4 year period. A five year old can tell you that 28% per year, for 3 successive years (1991-94), is infinitely worse. Especially when it targets airworthiness, whereas Cowan's 5% p/a barely touched it. Why did H-C not mention this? (All the evidence was provided to him). Again, to protect the same guilty people.

The two are related because, when ordering the 28% cuts, the RAF Chief Engineer's department specifically directed that Safety Cases should not be maintained.

The MAA should be acknowledging these facts and addressing them. But to do so would upset the cadre of retired VSOs, who very obviously still dictate matters to their successors; especially the Directorate of Air Staffs. Instead, by re-writing the regs they are implying they were wrong and the cause of the failures. Wrong. Demonstrably, if implemented they would have prevented (at least) Nimrod, Chinook, Tornado, Sea King and C130.

What is the tangible output of the process of "attaining airworthiness"? The Master Airworthiness Reference, the Release to Service, which reflects the Build Standard of the aircraft; and aircraft built and maintainable to that BS. The RTSs of all the above cases exhibit multiple failures to implement regs. The Chinook HC Mk2 RTS of Nov 1993 - June 1994 is typical. There are over 50 major non-compliances with mandated regs, any one of which should have prevented it being signed. So why did ACAS sign it? It is THE BIG QUESTION which has never been asked of him, in the same way Haddon-Cave avoided the big issues.

[Chugalug2]

Carol, I hope that you can see here some of the determination to expose the corrupt morass that now envelops UK Military Flight Safety. In this one thread alone we have those, like yourself that have witnessed the devastating effects that fatal aircraft accidents leave behind them. We have those, like tucumseh, that have been directly persecuted for simply trying to do their job, which was to carry out the mandated airworthiness regulations to ensure that UK Military Aircraft can carry out their most basic function, to stay in the sky! We have many others who have come to realise that those set in command above them far from leading have reneged on their duty of care over those that they command, have issued illegal orders to subvert the Airworthiness Regulations, and have directly suborned them themselves by issuing Release to Service to knowingly unairworthy aircraft.
As tuc says, no-one in authority wishes to heed the evidence laid before them. Because that is the case no reform can take place. Because that is the case avoidable aircraft accidents will go on happening. Because that is the case Servicemen and women will die needlessly. That is a stupid and senseless situation. Every Air Marshal acquainted with this stupidity who does not seek to end it becomes part of the problem, part of the cover-up. Somewhere there is the man or woman who will finally seek to end it. High time they stepped forward!
Self Regulation Doesn't Work, and in Aviation it Kills!
Set the MAA and MAAIB free of the MOD and of each other.

[LyndaV]

Carol, although we have spoken privately I wanted to post my sincere condolences to you and you family for the loss of your Mum. She was so very kind to me at the memorial service for the crew of XD864. Be brave, she would be extremely proud of you.

Chugalug2 - we have suspected a cover up for many years and the points made in your posts simply confirm that this is still the case. Tragically there will be many more families condemned to serve what you very rightly call a life sentence before someone somewhere stands up and puts an end to the current shameful situation.

[Chugalug2]

LyndaV, welcome to the thread (and indeed to PPRuNe!). Would that it were in happier circumstances. No doubt you are familiar with this site:-
XD864 (http://zkt.blackfish.org.uk/XD864/index.html)
but others such as I will be struck with the similarities revealed between the BoIs of Chinook HC2 ZD576 and Valiant BK1 XD864. Technical evidence at the crash site (a fractured centre plane spar in the case of XD864) and previously known problems experienced in operation ignored in favour of a case against Captain and Crew produced by insinuation and sweeping statements. It's deja-vu all over again, Brian!
Of all the places that this allegedly overconfident Captain elects to crash his allegedly airworthy aircraft, he chooses a disused airfield finishing up just off its runway 14! Black eye or feather in cap? I know what looks more appropriate to me.

[LyndaV]

Chugalug2 - I am indeed familiar with the XD864 website, the BOI and every piece of information I could find about the incident.

Whilst I remember punching the air in a most unladylike manner when the Chinook result came through I had not appreciated the similarities between the two BOIs. Frankly one BOI report was enough sad reading for me.

I wholeheartedly agree with your final 3 sentences and having stood at the crash site on more than one occasion it seems obvious that the captain was trying to get down on Spanhoe. I know what I believe.

Good luck with your campaign.

[Chugalug2]

LyndaV, thank you for your encouragement. As I said above, it is the support of the families that is the essential ingredient if we are ever going to get UK Military Airworthiness Provision and Air Accident Investigation reformed. To be honest with you the similarities between the Valiant and Chinook BoIs was as much a revelation to me as they were to you, but they merely reflect the pattern of many UK Military Fatal Air Accidents reviewed in this Forum. Poor investigation, interference from above, suppression of vital evidence, and downright lying from the highest levels, characterises most of them in full or in part. It is axiomatic in Aviation that the Operator, the Regulator, and the Investigator be independent and separate of each other. What happened with XD864 from initial Release to Service to the smouldering wreckage at Spanhoe and the subsequent BoI report is a classic example of what happens when they are but one and the same.
Self Regulation Doesn't Work and in Aviation it Kills

[LyndaV]

Chugalug2 I have PM'd you.

[dervish]

Chugalug2, that was a bloody good effort even if it didn’t pan out. Well spotted. I don’t think it thread drift as that ASaC collision is crying out for the BoI to be reconvened. If a BoI starts with the premise that the aircraft were serviceable, but it emerges they were not (especially in areas the BoI cited as contributory factors), then the BoI itself should be asking for a review. The evidence withheld from it was significant. Not least the IPT immediately blaming a civil servant, but withholding this when the CS produced evidence he’d been told to leave the aircraft unsafe. MoD reverted to this argument after the Inquest, when the CS was no longer in a position to defend himself, and still maintains it. This background detail of organizational faults may not change the conclusions pertaining to the final moments (which I think are pretty well accurate except for the confusion caused by HMS Liverpool’s Lynx, which MoD lied about) but it should make interesting reading for the MAA who are trying to avoid recurrence in the MoD as a whole. But from what I read here they don't want to know.


Does anyone know if the MAA has, for want of a better term, a “cold case” section which reviews old BoIs? It would be an easy way to quickly learn from past mistakes. It also strikes me there is a lot of expertise here on pprune that has immediately spotted the underlying causes on the likes of Nimrod, C130 and Chinook. Why have MoD’s investigators seemingly missed all this? This can’t be coincidence surely? In each case the BoI dwelt on the final moments but didn’t look at underlying causes. In each case the true cause was revealed on pprune. MoD’s role seems to be to denigrate that expertise, but at the cost of human life. So MoD become part of the problem, while doing its best to avoid the solution. Which I guess is what most of your posts are saying!

Keep up the good work.

[Heathrow Harry]

It took years for the Commercial sector to get around to investigating air incidents properly (and even now you get accusations of hidden/altered evidence)

The military SO's hate the idea that any decision they make /made will be questioned - they see it as the slippery slope to non-obedience. Combine this with the UK Civil Service mania for secrecy and never attributing blame for any past decision and we are left with a poisonous mix

Regrettably I think a constant series of re-visited BOI's will be a running sore for everyone - better to have some outside agency to have the power to revisit old accidents and publish the historic facts

[dervish]

Heathrow Harry

I agree. Your final point is what Chugalug2 has been pressing for and seems the only way to get round the entrenched views and behavior of the senior officers and politicians.

[Chugalug2]

Dervish, thank you for your kind words. The wise words of tucumseh resound in my ears always, "If you wish to discover the truth then look for the lies". Fortunately for us the MOD lies like a cheap Changi watch (a 60's phrase less I confuse or enrage present day users of that facility).
As to the BoI, any re-visiting needs to zoom in on the airworthiness of the two aircraft and in particular on the replacement of their anti-collision lights with HISL's before release to the Navy. That was done in flagrant breach of the Airworthiness Regulations and resulted in crews switching off the forward lights to avoid cockpit glare in conditions of poor vis such as existed that day. As with other BoIs this was skirted around with an ad-hoc trial by the investigating board sufficing to say that the HISLs were not the major issue in a mid-air collision that was all about seeing and being seen! There is a pattern here I'm afraid that begins with deliberate suborning of the Regulations and ends with a BoI that finds aircrew to be the sole cause of an accident. At least this BoI didn't go that far, but neither did they seek to investigate the fitting of such dysfunctional Hi Vis lighting. Most accidents work to the Swiss Cheese model. I suspect that this was yet another one where the holes in the slices all obligingly lined up.
When you say:
MoD become part of the problem, while doing its best to avoid the solution. Which I guess is what most of your posts are saying!
you've said it all really.

HH:
Regrettably I think a constant series of re-visited BOI's will be a running sore for everyone - better to have some outside agency to have the power to revisit old accidents and publish the historic facts
and there's no reason why that body should not be an MAAIB, but one independent of the MOD and of the MAA.

[Heathrow Harry]

I was thinking more of a "Truth & Reconciliation Commission" TBHrather than some eternal committee spending years on each case

[Chugalug2]

If the BoI were to be revisited it would surely be to do the job that should have been done at the start, ie to find out the most probable cause(s) of the crash. If that were to rehabilitate the reputations of Captain and Crew, all well and good. If it were to decide that it was a technical failure due to the aircraft's lack of airworthiness, then it needs to discover if that was known of at the time. If it was then it shares that quality with the Chinook HC2's RTS in 1993/4 and a number of other types as well.
Here would be the nub of the issue, that the Regulator (the MOD) allowed the Operator (the MOD's subsidiary, the RAF) to knowingly operate the aircraft in that state but for the Investigator (the MOD's subsidiary, the RAF) to conceal the fact in its report on the subsequent fatal air accident.
Truth & Reconciliation? How would that work with the bereaved then? Flagrantly subverting and suborning the UK Military Airworthiness Regulations is a legal issue not a moral one and should be dealt with as such.

[dalek]

Keep up the good work Chug.
It has been known for some time that the Valiant and Buccaneer had major structural weaknesses. Therefore any BOI involving these aircraft should automatically be reviewed.
Pressure forced the Mull accident to be subject to independent scrutiny. Why not others?

I remember years ago, a BOI stated that that the probable cause of a Buccaneer accident was the pilot carrying out an "aggressive" manoeuvre too close to the sea.
I seem to remember the pilot was an American Exchange Officer, so the MOD lacked the b*lls to go for Negligence or Aircrew Error.
Subsequently discovered that the wing probably fell off in a turn.

[A2QFI]

Wing(s) fell off one after take-off at Laabruch, early 70s. Might have been disorientation and overstress -I don't recall the finding of the BOI.

[Art Field]

A factor which needs to be remembered when recalling aircraft accidents of the now distant past is ignorance, ignorance of the effect of metal fatigue on both engines and airframes, ignorance of airframe design and its effect on handling, incapability, at the time, of the teaching techniques to adequately train the crews to cope with the emergencies which they would have met with. Even as late as 1961 Meteor pilots were being killed carrying out practice assymetric training as had so many twin engine aviators before and far more than real assymetric had claimed. I was at Strubby at that time and remember it seem to have been my fault that the Meatbox needed such careful handling, could not the rudder have not been made bigger? Even the Mighty V's with their sophisticated simulators insisted on flight practice of all emergencies but no-one though up a spar failure as happened to the Valiant in 64.

Although the system in those days should perhaps have stopped and thought more about what it was doing, it was the way it was and with a few exceptions nothing but sorrow can be gained by raking up old sores.

[Old-Duffer]

My initial post on this Thread was No: 2 and I have thought long and hard as to whether I should now return to the Lists.

I remain convinced that nobody in the MOD has an inclination to return to these accidents. It may be remembered that Mr A Blair - a former prime minister - issued a blanket 'apology' for all those executed in the 1st war for 'cowardice'. In fact this included a number of people who had murdered their colleagues or other people and the apology for those who had been wrongly served by the system was hence diluted.

We must allow that times change and what was taboo 50 years ago is now accepted as normal, however unjust or distressing this may continue to be to those most closely affected.

No change of heart, apology or any sort of 'forgiveness' will redress the years of hurt and distress felt by the families and friends who feel their loved ones were harshly treated.

Let the families take comfort that THEY know that their loved ones would have always acted properly and whilst they may have misjudged a situation, they did not do so deliberately or with negligence.

Please let the matter rest, no apology from a politician is worth anything and the loved ones, now lost, would not have wished the lives of those they held most dear to be blighted for evermore.

We have but one life and it is no rehearsal - live it and rejoice every minute of it - the chance will not come again and your lost loved would not wish you to grieve for them but to make the most of what you have.

I make no apologies for this; I have seen too much to convince me that not moving on is counter productive.

Old Duffer

[tucumseh]

Old Duffer


Well said, but I'm afraid the problem is we are not just trying to right past wrongs, but prevent recurrence; which is the aim of BoIs. If it were as simple the former, in a mellow moment I would perhaps agree with you.


Perhaps it is just my make up, but I cannot abide the thought of those who knowingly ran down the airworthiness system, at the cost of great many lives, sitting with their feet up (or playing tennis or swanning about in his yacht, in two notable cases) while their successors spend an inordinate amount of time and money actively protecting them. Nor can I tolerate the very same people blaming innocents when every scrap of evidence points to those who sit in judgement of themselves, and continue to brief Ministers that it is acceptable to discipline staffs who simply seek to follow the same Minister’s mandated regulations. (An utterly bizarre situation, which no Minister has the balls to correct).




(Art Field)


Regarding fatigue and past regulations, these links may interest you (courtesy of another ppruner)


1956 | 0396 | Flight Archive (http://www.flightglobal.com/pdfarchive/view/1956/1956%20-%200396.html)

(http://www.flightglobal.com/pdfarchive/view/1956/1956%20-%200396.html)
http://zkt.blackfish.org.uk/XD864/JIM_1790_17-23.pdf

(http://zkt.blackfish.org.uk/XD864/JIM_1790_17-23.pdf)
It baselines the time when realisation dawned in one important aspect, discussed here. Before that time, thinking was flawed but one must accept aircraft built to these old standards were, at the time, thought airworthy. Anything built to these standards after that was not. These “errors” were, I believe, genuine. “An error does not become a mistake unless you refuse to fix it”. (JFK)

When the RAF Chief Engineer decided to run down the airworthiness system over 20 years ago, this was not a genuine error; it was a deliberate, conscious act aimed at saving money; something he (and others) would be praised for (and indeed were, by Haddon-Cave). What makes their actions infinitely worse is their reaction against those who sought to maintain safety standards – something that continues to this day, despite the existence of the MAA. (Or perhaps with the MAA’s blessing, given they know of this situation and do nothing about it). The inevitable outcome, which very senior officers were advised of when this policy was promulgated, took a few years to manifest itself, due to (a) the natural time lag and (b) a small number of MoD staff who disobeyed direct orders to make aircraft unsafe. Chinook ZD576 was the high profile example. Many others have followed, all avoidable, and all traceable to the decision to save money at the expense of safety. Why did they need to save money? Because the same people had wasted astronomical sums in the first place.



These more recent accidents (not as good word, there was nothing “accidental” about the decision to make aircraft unsafe) are in a quite different category to those of the 50s. There is a huge difference between implementing flawed regulations in good faith, and directing that perfectly good regulations should be completely ignored. This is the nettle the MAA refuse to grasp.



Read the above links. The second relates to fatigue in an alloy to D.T.D 683, which was used, for example, in main spars. This lesson was duly learnt, and by the time MoD was teaching me (to CAA standards as well as MoD standards) this alloy wasn’t even mentioned. I still have my basic training notes and it isn’t in CAA BL/2-2 Issue 5 of 15.12.65. Within 7 years it had been expunged from the specs. Contrast this with the formal advice to AMSO in January 1988, which was only heeded, eventually, when Haddon-Cave repeated it in late 2009. And Haddon-Cave would still be an anonymous QC (albeit one who sits on RAES committees with the above VSOs – which probably explains a lot) if it were not for a few good men who stood against MoD. You don’t always need to correct history, but you do need to understand it to prevent recurrence.