Helicopter down in Afghanistan

[Duncan D'Sorderlee]

BBC reporting that 2 RAF pers killed in helicopter crash.

RIP

Duncs:ok:

[NavyNav2]

Reporting Puma Mk2 - not thought to be as result of 'enemy action'.

[CoffmanStarter]

Thoughts go out to all the family and friends involved ... Sad day.

[oldbeefer]

As an ex member of 230 and Flt Cdr of 33, thoughts go to all concerned.

[H-why]

RIP Guys

Lets hope that there is no over-reaction to this from their command and the investigation is truely impartial. Having worked with a number of them over the years, the Puma force is very different beast to 8-10 years ago when they had a poor safety record - the last thing they need is a witch hunt!

Stay Strong SHF!!

[hot_spud]

A dark day for all. RIP guys.

[jayteeto]

Not again, :-(

[pedroalpha]

Loyalty.
I had two tours on 33 in the best of days on the HC1. So sad.

[Tiger_mate]

BBC News:

Five people, including two RAF personnel, have been killed in a helicopter crash in Afghanistan.

The Puma Mk2 helicopter crashed as it was landing at Nato's Resolute Support mission headquarters, Kabul. NATO has not released the nationalities of the other victims or the five left injured.

RIP

[ORAC]

Five people, including two RAF personnel, have been killed in a helicopter crash in Afghanistan.

The Puma Mk2 helicopter crashed as it was landing at Nato's Resolute Support mission headquarters, Kabul. Nato has not released the nationalities of the other victims or the five left injured. A Ministry of Defence spokesman said the crash was "an accident and not the result of insurgent activity".

The families of the British victims have been informed, the MoD said. They have asked for a period of grace before their names are released.......

The two RAF personnel were from 230 and 33 squadrons, both of which are based at RAF Benson, Oxfordshire, the MoD spokesman said. He added: "The helicopter crashed while landing at the headquarters of Resolute Support: the Nato train, advise and assist mission in Afghanistan. The incident is currently under investigation but we can confirm that it was an accident and not the result of insurgent activity."

BBC defence correspondent Jonathan Beale said: "The BBC understands the RAF Puma that crashed in Kabul had been transferring Nato military personnel..... The cause of the crash is still being investigated but an observation balloon became untethered and landed in the Resolute Support base in Kabul."

[jayteeto]

BBC reporting an observation balloon became detached during the incident, is that a thinly veiled hint?

[barnstormer1968]

RIP to all, and thoughts and prayers for surviving family members.

I always feel there is something especially harsh and unfair about fatalities that occur after the cessation of official hostilities. Perhaps they seem even more of a waste and senseless.

[thing]

RIP guys. I would agree with Barnstormer's comments.

[cooheed]

Another sad day. RIP guys and thoughts to the families :(

[ShyTorque]

230 was my old squadron, too, albeit over thirty years since. A tragically sad day, my condolences to those directly affected.

[chevvron]

Why do Sky News persist in showing a Merlin landing when covering this report?

[Stitchbitch]

Loyalty. RIP.

[strake]

British press now increasingly reporting on the balloon as being part of the incident. Guardian quotes ' a severed balloon..'

The balloon was severed from its mooring in the incident, he said, without providing further details.

An Aghan security guard who witnessed the incident told Associated Press that the helicopter appeared to strike the balloon as it landed at the Nato base.

Najibullah, the Afghan security guard who witnessed the incident, said the helicopter “hit the cable of the security balloon over the base. It seemed like the cable was turned around the helicopter rotor,” he said.

[SiClick]

A sad day indeed, condolences to all those affected.

[Top Bunk Tester]

BBC now reporting the names of the front end that sadly lost their lives, RIP Fellas

Per Ardua Ad Astra

[SimonK]

https://www.gov.uk/government/fatalities/flight-lieutenants-alan-scott-and-geraint-roberts-have-died

RIP chaps. Top blokes both of you.

[llamaman]

A sad day, too many fine people in the Puma force taken over the years. My thoughts are with their families and colleagues.

[Door Slider]

BBC now reporting the names of the front end that sadly lost their lives, RIP Fellas

Just for accuracy, one was front end, the other was the crewman.

[Tiger_mate]

I had the pleasure of teaching Roly through basic flying training; and later mentoring him to achieve his CFS A2 pass at his first attempt.

Roly balanced a sucessful career with the needs of family life in a way that many cannot. Direct and honest with a dry sense of humour and a wire locked smile. Today is a terrible day, and my heartfelt condolances are extended to his wife and children. Fiercely proud of his Welsh roots; he was the only student to ever say "Thankyou". When told in response that CFS teaching had claimed that thankyous never came; his immediate response was that his mother would kick his arse if he didnt. ...... and now in the finest traditions of military aviation; I am off to the bar whereupon I will drink to his memory. The good die young is again proven. RIP

[Evalu8ter]

TM,
You've captured the essence of Roly in that post. A good bloke and a damn fine aviator. I'll be raising a glass at 2200 for him tonight, and ask those that can to join me in a simple toast to Roly, Alan and the other casualties of this tragic accident.

No one could put so many different inflections on the word 'sir' to get his underlying point across........rest easy buddy.

[higthepig]

Echo what Tiger_mate said, RIP Roly.
Condolences to all those involved in this sad incident.

[Chinny Crewman]

Summed up perfectly.

[JointShiteFighter]

RIP guys. :-(

[XW420]

Spot on TM. RIP lads On a lighter note, it is good to see things have moved on from the 70s when anyone on 230 would not even sit at the same table as 33, let alone get into the same airframe!

[back end o' the bus]

Roly mate, you were always larger than life and now a true legend.
Real shocker to lose someone of your ability and character. Sad day mate
All clear above. Cuts.:ugh:

[Hubstrasse]

Sadly, being one of the now many intimately familiar with the aftermath of such incidents I wish to commend Simon Paterson on his mettle with such a difficult announcement. I realise much will have evolved in our turbulent Forces, but I sincerely hope the good people of any colour suit have the resources to provide the necessary support to all concerned. Today, tomorrow, the day it's needed. It will be.

Tigers and Stags, look after yourselves,

H

[Tiger Tales]

Pleased to report that we (Puma Force & other SH mates) gathered en masse last night and toasted the lads in the traditional way. They would have approved.

Thoughts are with Roly and Scotty's family right now as they are with our boys and girls still away getting on with the task in hand.

Also to the families of the coalition personnel that also tragically lost their lives as well as a speedy recovery to those who are still in hospital.

LOYALTY
KITA CHARI JUAH

[Hueymeister]

Tiger Tales:

Glad to hear you toasted the guys in a suitable fashion:}. I remember the smash up in the OM and Sgts Mess in Aldergrove after the Bessbrook incident. I'll never forget that night..especially as TCW puked all over me...:}

Simon: Great job on the news; that's how real leaders of men (and women) should act and lead. Well done sir.

[Hueymeister]

Any news on the condition of the other front-ender?

[wokkamate]

Any news on the condition of the other front-ender?

I was wondering about that myself.... There has been no info at all about the other front-enders condition, or who it was. Here's hoping they are (relatively) ok!

[Topsy Turvey]

The MoD does not release the names of injured service personnel, or report on their condition. They will respect their privacy. I hope they are recovering so MoD does not have to release their name.

The 2 aircrew killed were brought home earlier today.

Bodies of RAF airmen Geraint Roberts and Alan Scott repatriated - BBC News (http://www.bbc.co.uk/news/uk-england-oxfordshire-34581760)

TT

[sadhatmo]

What do you say that has not already been said. Thoughts and prayers are with you guys, RIP.

[ShyTorque]

Spot on TM. RIP lads On a lighter note, it is good to see things have moved on from the 70s when anyone on 230 would not even sit at the same table as 33, let alone get into the same airframe!

You're forgetting Op Agila, then?

RIP also to Flt Lt Archie Cook (33 Sqn), Flt Lt Mike Smith and MALM Bob Hodges, both of 230 Sqn.

All killed on Ops on 27 Dec 1979, Rhodesia, in the same airframe :sad:

[Tiger Tales]

A very fitting and moving repatriation ceremony took place this afternoon with Scotty and Roly passing through the Memorial Garden at Carterton flanked by a huge contingent of military personnel and civilians paying their combined respect.
They are home and can finally stand down and rest in peace.

LOYALTY
KITA CHARI JAUH

[Distant Voice]

It was reported in 2013 that, "Wire strike is Cdr JHC's (ODH)'s second highest Air Safety risk". Was this Puma fitted with Wire Strike Protection (first mentioned in PART report in 1995), or was the essential modification delayed in the same way as CWS for Tornado? Did the ODH sign off to say that the risk of Wire Strike was ALARP?

DV

[triboy]

It was reported in 2013 that, "Wire strike is Cdr JHC's (ODH)'s second highest Air Safety risk". Was this Puma fitted with Wire Strike Protection (first mentioned in PART report in 1995), or was the essential modification delayed in the same way as CWS for Tornado? Did the ODH sign off to say that the risk of Wire Strike was ALARP?

DV

I suppose ALARP is a question of the cost of technology and the benefit it provides. Most cutters are designed to cut horizontal wires as that is the most likely threat. They are of course a mitigation to an event that has already occurred. Wire avoidance is mainly based on mapping that has known telegraph/power cables. For local temporary vertical wires not on maps you are looking at a forward looking sensor that is expensive to integrate, low TRL and maybe only DAL C and therefore doesn't greatly change the risk calculations?

[tucumseh]

An excellent reply triboy.

Wire avoidance is mainly based on mapping that has known telegraph/power cables.

My take on what Distant Voice is referring to, is the general process by which MoD decides a risk is ALARP, and continues to be so. My own experience of wire avoidance is of a very short period in 1986, when the laser based detection system was first offered in response to an RAF requirement (so far, so good - this shows a major part of the process was working). It was, rightly, not the solution at that time, mainly because the kit was quite large; but in terms of distance/wire thickness, it far exceeded the RAF spec. In project management terms, the basic technology was mature, but the system integration level lagged a little. That is normal, you need a customer to come along, thus firming up the direction the design takes. In this case, for example, the warning was on a PC in a lab, but in the aircraft it was to be on the HUD.

But, and this is what DV is (I think) getting at, the obvious next step in 1986 was to consider an R&D programme with an aim of getting the SIRL to the next level. (Wasn't called SIRL then, but there was an equivalent process set out by the Chief Scientific Advisor). But nothing was done and, I assume, the Risk Registers in DEC (!! discuss) show little or no progress (as suggested in 2013 - see DV's post); whereas the underlying technology has moved on in leaps and bounds. The Safety Management System demands continuous assessment (and improvement). MoD's failure to meet this obligation lies beneath many accidents. With MoD's withdrawal, the team just applied the science to another customer's requirement, which happened to be Air Traffic Control and missile launching. About 8 years ago they were all made redundant and MoD probably doesn't even realise it owns the Intellectual Property Rights. This is a recurring theme. In 2006, the Nimrod IPT issued an Invitation to Tender to undertake a 3 year R&D programme into mitigating a safety critical risk, not knowing the aircraft office next door had had the solution in service since 1996, to a far better spec than Nimrod sought; and had then improved it in 2001. The old 1996 kit could have just been handed to Nimrod, if that's all they wanted. These are Organisational failures which accident investigations are required to assess, but seldom do. In other words, we never learn, unless you ignore orders.

[Distant Voice]

The Service Inquiry report, published on 15th Dec 2016, cites the following as one of the main causes of the Puma accident in Afghanistan on 11th Oct 2015.

The Panel assessed that a loss of situation awareness was caused by the discussion regarding ground features and resulted in the loss of visual contact with the formation leader. Subsequently, and in attempting to regain sight of the lead aircraft, there was a resultant reduction in awareness regarding the PTDS.

Loss of situation awareness was, according to the Coroner, one of the main causes of the loss of Lynx helicopter a year earlier. Puma and Lynx helicopters were not fitted with collision warning systems at the time of their respective accidents. In both cases pilots were on visual look out for the other aircraft they were flying with. Collision was the top risk according to the Duty Holder, Major General Felton, but still he signed off to say the risk was tolerable and ALARP. He needs to justify this at the inquest.

'The safety statement in effect in May 2015 was that made at the 4th Puma 2 Puma Air System Safety Working Group on 4 February 2015, i.e. “Having reviewed the Equipment Safety Case, Hazard Log, Release to Service, Statement of Operating Intent and Usage, Air Safety Risk Registers and all governance issues, as Operating Duty Holder, I am content that all the Risks to Life on the Puma HC Mk2 are at least Tolerable and As Low As Reasonably Practicable' .

Also, Puma was not fitted with 'cable cutting' equipment at the time. Wire strike was another high risk according to the Duty Holder, but signed off as tolerable and ALARP.

DV

[Just This Once...]

I've sat at many such events to hear the ALARP turned on its head - '...we are operating the platform so it must be ALARP'. Another one is '...it was ALARP at the last meeting and nothing has changed with the aircraft configuration so it must still be ALARP....'.

[Distant Voice]

Just This Once: One 2* Duty Holder claimed that the risk was ALARP(Temporal) because the required equipment would be fitted in three years time.

DV

[Could be the last?]

The comments reported on wrt the issues and perspective of ALARP appear to be centred around the current airframe. However, if technology, which is maturing, but not actively being explored or acknowledged by the MOD, then the statement itself would not stand scrutiny......?

With reference to the report itself, and looking at the devastation suffered in the cabin, it will be interesting to see what efforts are being put into improving the crash worthiness of seating for pax and the third member of the crew?

Moreover, considering that the 'bench style' seating used in the rear of 4-T trucks and other similar vehicles, was replaced post a number of RTAs in the 90's, I would now expect to see a similar change or at least an investigation into better seating as the ac has an OSD of beyond 2025!

Finally, I appreciate the forces incurred in the ac impact (15-30g) maybe significantly greater than a RTA, and the reduction in the 'survivable space' may not be fully mitigated by a redesign of the seating, but surely this is the opportunity to give those that travel in the rear of the ac something more effective for a heavy landing etc. Or will there be another slant on the use of ALARP and the SI's recommendations be ignored?

[Evalu8ter]

I'm not sure cutters would have helped here. Reading the report suggests the HP made a late, and instinctive, break to try to avoid the wire which placed the wire through the disc and, ultimately, over the boom where it fatally weakened the TRDS. WSPS are normally designed to cut horizontal wires you haven't seen. The key here is SA. The wirestrike risk was, likely, considered adequately mitigated by HLS maps,briefing, lookout and the obstructions tablet (which it seems the crews didn't use in congested areas....). The loss of SA degraded the lookout with aggravating factors (distraction, low arousal task, cockpit frames, Day HUD etc) leading to the holes lining up. It was not their day. The fact that anyone survived such an impact should be somewhat encouraging - but something better can always be found. There are plenty of active wire/obstacle warning systems out there, fully mature, in production and fitted to civ and mil aircraft - MoD considers an advisory only tablet (the database of which is out of date the moment 'save' is pressed...it doesn't take long to put up an aerial or string a wire...), route study, HLS books and lookout to be effective mitigation. Perhaps it's time to look at it again?

[Distant Voice]

Puma inquest is due to start today in Oxford. I hope it gets well reported.

DV

[downsizer]

Puma inquest is due to start today in Oxford. I hope it gets well reported.

DV

I can't be the only one whose heart skipped a beat when I saw this thread. Surely you could have started a new one to stop people thinking it was a new accident...

[TorqueOfTheDevil]

I can't be the only one whose heart skipped a beat when I saw this thread. Surely you could have started a new one to stop people thinking it was a new accident...

+1. All it would take is the date to be included in the thread title.

[Distant Voice]

Downsizer and TOTD; If you click on the thread title you will see that it was opened on 11th Oct 2015, and there are three pages of postings. Clearly not new.

DV

[downsizer]

Indeed, but when you just see that thread when you open the mil forum page you don't see it is from Oct 15.

[Old-Duffer]

I have compiled and published a number of books which list the RAFs aircraft losses between VE-Day and 2009 (9000+ aircraft/6000+ fatal casualties) and I try to keep the record up to date, in case there is ever a requirement to extend the coverage.

As regards the aircraft subject to this Thread, I know the names of the RAF crew and the two USAF personnel who were killed but have been unable to find the identity of the French civilian contractor, who was the fifth fatal casualty.

Please does anybody know and please will they PM me with the info?

Old Duffer

[Distant Voice]

Gordon Emin, aged 44.

DV

[Old-Duffer]

Thank you DV.

The next one which is proving more difficult are the two scientists involved in an RAE Puma in France several years ago but I'm still digging with that one.

Grateful for your prompt help.

Old Duffer

[Distant Voice]

The narrative verdict by the coroner is wrong, as it places most of the blame on the aircrew. On the balance of probability the evidence suggests that the crew were fixated on locating the other aircraft, not the football pitch.

Coroner Rules Afghan Helicopter Crash "Was An Avoidable Accident" (http://www.forces.net/news/tri-service/coroner-rules-afghan-helicopter-crash-was-avoidable-accident)

The Service Inquiry report, published on 15th Dec 2016, cites the following as one of the main causes of the Puma accident in Afghanistan on 11th Oct 2015.

"The Panel assessed that a loss of situation awareness was caused by the discussion regarding ground features and resulted in the loss of visual contact with the formation leader. Subsequently, and in attempting to regain sight of the lead aircraft, there was a resultant reduction in awareness regarding the PTDS."

Loss of situation awareness was, according to the Coroner, one of the main causes of the loss of Lynx helicopter a year earlier. Puma and Lynx helicopters were not fitted with collision warning systems at the time of their respective accidents. In both cases pilots were on visual look out for the other aircraft they were flying with. Collision was the top risk according to the Duty Holder, Major General Felton, but still he signed off to say the risk was tolerable and ALARP. Wire strike was the second highest risk.

In March 2016, MoD confirmed that the installation of a Wire Strike Protection System and a CWS were in the process of being installed in the Puma Mk2 helicopter. But these facts to not appear to get mentioned at the inquest.

DV

[Bing]

Collision was the top risk according to the Duty Holder, Major General Felton, but still he signed off to say the risk was tolerable and ALARP.

Because with a program in place to fit a Traffic Awareness System to the Puma there was nothing more that could practicably be done. There was presumably no way to speed up the installation of the equipment without incurring excessive cost and/or grounding the Puma fleet. If you incur excessive cost by speeding up one programme you'll invariably have to cut back another one, e.g. Chinook TAS, and if you ground the fleet waiting for mods to be fitted you'd never have anything flying.

[Distant Voice]

Because with a program in place to fit a Traffic Awareness System to the Puma there was nothing more that could practicably be done.

You could stop flying in pairs. The risk was not ALARP. According to HSE and Lord Cullen, "An intention to reduce a risk ALARP, even if the required action is clearly documented and in hand, does not mean that the risk has been reduced ALARP. A risk is reduced ALARP only when the necessary control measures are in place"

Unfortunately, Duty Holders seen to thing that there is such a thing as ALARP (temporal), and there isn't.

DV

[Bing]

You could stop flying in pairs.

You could stop flying, that would remove the risk completely. Your solution doesn't actually remove the risk of MAC either, it does lose the benefit of mutual cover in a potentially hostile environment though.
The HSE may say that, but they don't provide the regulation that aviation operates under, civilian or military. They were very clear on that when I asked them for some advice.

[tucumseh]

A difficulty certainly arises if the modification is considered "essential" to safety (e.g. to mitigate a Class A risk) as the regs say "to be embodied irrespective of delay, scrap or downtime involved". The fact that the risk of collision and death was predicted, and ultimately occurred, seals it. So, who above General Felton signed to say it would be borne?

[Distant Voice]

Bing, you are correct, the hazard/risk remains but you can reduce the probability of it occurring, passing it up the line to the next DH level does not eliminate the risk either. You are also correct that the HSE is not the military regulatory body, but the MAA constantly make reference to their 'Reducing Risks' documentation. The risk boundaries set in RA1210 are lifted from the HSE documentation. The MAA and Duty Holders can not 'cherry-pick' in order to get the answer they want.

The following is an extract from the MoD Helicopter Safety Enhancement Programme, dated Sept 2013;

"Operating Risks are owned and managed by the Duty Holder who is personally and legally responsible for ensuring that the Risk to Life (RtL) emanating from activities associated with their generation and sustainment of force elements is at least Tolerable and As Low As Reasonably Practicable (ALARP). If an identified Risk to Life (RtL) is not demonstrably at least Tolerable or ALARP then those activities should not continue". (Please note it says 'is', not can be, or will be at some time in the future)

RA 1210 makes it clear that Duty Holders are legally accountable for safe operations and are expected to defend the validity of their ALARP safety statement in a court of law in the event of an accident. That has never happened.

DV

[Distant Voice]

A difficulty certainly arises if the modification is considered "essential" to safety (e.g. to mitigate a Class A risk) as the regs say "to be embodied irrespective of delay, scrap or downtime involved". The fact that the risk of collision and death was predicted, and ultimately occurred, seals it. So, who above General Felton signed to say it would be borne?

I suspect that there are people in the MAA/MoD who would have had the Concorde fleet back in the air, a few weeks after the Paris crash, simply because there was a repair scheme in the pipeline.

DV

[Bing]

The risk boundaries set in RA1210 are lifted from the HSE documentation.

That's the bit I asked the HSE about, their response was that it was nothing to do with them. They have incidentally been removed from the latest version of RA1210 not that that has any bearing on this accident.

The fact that the risk of collision and death was predicted, and ultimately occurred, seals it.

Well no, they hit a tethered ballon which wouldn't have been detected even if they had had a TAS system fitted as they don't, to my knowledge, have a transponder. It's also not classified as a Mid-Air Collision as collisions with objects on or connected to the ground aren't included in that risk. It actually falls under CFIT.

[tucumseh]

Bing, I was referring to the general risk and mitigation, which is the theme of DV's posts on this subject. The original mitigation for avoiding collision with, or controlled flight into, a cable, didn't need a transponder. I've posted before that the technology was ready, but system integration was not, so the decision was correct at the time. But over 30 years have passed, the kit was ready shortly thereafter, so there was no reason not to revisit. Instead, the general risk was allowed to drift on, based on a decision that was no longer valid.

Thanks for the CFIT clarification. If I ever knew that, I'd forgotten!

[Bing]

Bing, I was referring to the general risk and mitigation, which is the theme of DV's posts on this subject. The original mitigation for avoiding collision with, or controlled flight into, a cable, didn't need a transponder. I've posted before that the technology was ready, but system integration was not, so the decision was correct at the time. But over 30 years have passed, the kit was ready shortly thereafter, so there was no reason not to revisit. Instead, the general risk was allowed to drift on, based on a decision that was no longer valid.

Thanks for the CFIT clarification. If I ever knew that, I'd forgotten!

The issue may then be that no one in a position to do anything about it is aware that the kit exists.

[tucumseh]

Bing, that's what the continuous assessment obligation is for. But, yes, MoD's corporate knowledge has long since gone and decamped to pprune.

[Distant Voice]

That's the bit I asked the HSE about, their response was that it was nothing to do with them. They have incidentally been removed from the latest version of RA1210 not that that has any bearing on this accident.

I had noticed that, so DHs have no idea where the boundaries sit? The latest definition of tolerable, lifted from a general statement in the HSE R2P2 document, states "a willingness by society as a whole to live with a risk so as to secure certain benefits and in the confidence that the risk is one that is worth taking and that it is being properly controlled". How does a Duty Holder know what society as a whole is thinking. This is something that needs to be agreed in court in order to be legal.

Well no, they hit a tethered ballon which wouldn't have been detected even if they had had a TAS system fitted as they don't, to my knowledge, have a transponder. It's also not classified as a Mid-Air Collision as collisions with objects on or connected to the ground aren't included in that risk. It actually falls under CFIT.

The TAS would have alerted the pilot of the doomed Puma as to the location of the other craft, and improved his situation awareness. As I stated in my earlier post the fixation was with locating the second Puma not the football pitch, which had been overshot may times, and therefore not a big issue. I note that you talk about TAS, what happened to the original fit of TCAS, as installed in the Bond Super Puma?

You are correct to point out that this was a CFIT, but I can find no reference to that in the SI report (but could be wrong). Having said that I should point out that the MAA Bowtie for CFIT indicates wire-cutters as one of the recovery controls. Whether they would have been effective or not with a banking helicopter we will never know. However, this recovery control was not fitted.

DV

[Bing]

I had noticed that, so DHs have no idea where the boundaries sit?

They probably have a better idea than they did before.
Under the old scheme you had to consider deaths per thousand of the population at risk per year. Which you averaged over a five year period. This works fine for any large industry with many thousands of people involved. However for your typical military aircraft the population at risk is normally in the low hundreds, if you're lucky. This meant any accident that caused death of a first party made the airframe intolerable for the next five years as you'd have to multiply the small population and the fatalities by whatever factor was required to reach 1000.
At the same time a logical reading of the 3rd party tolerability boundary, 1 death per million of the population at risk per year, meant you could happily kill 60 civilians a year and remain tolerable.
So as guidance it was notably unhelpful. Ultimately I'd suggest DHs consider any deaths intolerable in the current climate and are working to remove the risk as well as they can with the levers available to them.

The TAS would have alerted the pilot of the doomed Puma as to the location of the other craft, and improved his situation awareness.

I'd agree with that but I don't know that that would definitely have prevented the accident if the crew had been heads in looking at the TAS they may not have seen the balloon at all.

I note that you talk about TAS, what happened to the original fit of TCAS, as installed in the Bond Super Puma?

I don't know that TCAS was ever considered. For aircraft that spend a lot of time at low level it doesn't really give you anything extra as the RAs are suppressed below a certain height.

Whether they would have been effective or not with a banking helicopter we will never know.

They would not have worked in this situation as at no time did the cable cross part of the airframe where they would have been located, ie the nose. The rotor took the cable to the tailboom avoiding the fuselage completely. What I found interesting is that other helicopters have hit balloon tethers with the rotor disc and not suffered any notable damage.

[Aynayda Pizaqvick]

I'm not sure TCAS would have been much use in this scenario; my experience of using it in formation at low level is that it just warns you continuously that your play mate is there, so gets turned off by the number 2. Even if it was fitted and on, I'm not sure it would have provided the fidelity in sufficient time to prevent this accident.

[Distant Voice]

They probably have a better idea than they did before.
Under the old scheme you had to consider deaths per thousand of the population at risk per year. Which you averaged over a five year period. This works fine for any large industry with many thousands of people involved. However for your typical military aircraft the population at risk is normally in the low hundreds, if you're lucky. This meant any accident that caused death of a first party made the airframe intolerable for the next five years as you'd have to multiply the small population and the fatalities by whatever factor was required to reach 1000.
At the same time a logical reading of the 3rd party tolerability boundary, 1 death per million of the population at risk per year, meant you could happily kill 60 civilians a year and remain tolerable.

Not sure how DHs will have a better idea without guidelines as to what is tolerable. As I said before what is quoted in Issue 4 of RA 1210 is just a general statement lifted from HSE (R2P2). Also, not sure where the five year average came from as there is no mention of it in the HSE documentation. I suspect it is (was) a fudge in order to make the boundary data fit the needs of the day.

Your statement also exposes another flaw in the risk to life process, namely it can only be regarded as a risk to life if a death has already occurred; it is reactive rather than proactive. Risk assessment must be about determining the potential of gaining or losing something of value. In his comments to the the Tornado SI Air Marshal Garwood said, "bad luck has to be part of the explanation.......a few few feet difference in altitude of one aircraft would have created a near miss rather than this tragic accident". So would this near miss have been regard as a risk to life, or not. For me the risk to life occurred before the collision event, not after it. In my book every Class A/B near miss, confirmed by the AIRPROX body, is a risk to life (not machine)

I don't know that TCAS was ever considered. For aircraft that spend a lot of time at low level it doesn't really give you anything extra as the RAs are suppressed below a certain height.

The following is an extract from the MoD Helicopter Safety Enhancement Programme, dated Sept 2013,

"The UK MOD is actively considering installing systems on the majority of the helicopter fleet. For most types the decision in the short term is to fit a non-integrated system, most likely to be a TAS type unit. For the larger platforms (Chinook, Merlin and Puma) the fitment of fully integrated TCAS II systems is being considered."

We can continue to debate what the outcomes could have been with and without certain items of equipment, but the facts remain the same,

(1) The risks of collision and wire strike were the No.1 and No.2 Air Safety risk according to the Cdr JHC (ODH).
(2) The risks, at the time of the accident, were neither tolerable nor ALARP.
(3) The ODH had signed off to say they were.

According to RA1210, by reference,”The Health and Safety Executive is responsible for making adequate arrangements for enforcement. In fulfilment of its duty the Executive provides guidance to its regulatory staff who have to judge whether measures put in place or proposed, by those who are under a duty to control and reduce risks "as low as is reasonably practicable" (ALARP), are acceptable.
The principles and guidelines set out [in HSE documentation]are based on what the courts have decided is required of duty-holders, and are intended to help HSE regulatory staff reach decisions about the control of risks and make clear what they should expect from duty-holders. Ultimately, it is for the courts to decide whether or not duty-holders have complied with the law.”

The final paragraph is very important and is the reason why it is covered in MAA RA1210. So far the MAA/MoD have avoided having the regulation tested in court.

DV

[Bing]

Not sure how DHs will have a better idea without guidelines as to what is tolerable.

Ahh, you have reminded me of another quirk with the previous edition of RA1210. It had Tolerable as defined by the unhelpful deaths per 1000 population at risk per year and Tolerable in the sense of accepting the level of risk of doing something for the operational benefit doing it brings. E.g. it's tolerable to practice IMC flying by having one of the pilots external vision obscured as you gain the benefit of being able to fly on instruments in actual IMC. The DHs still understand what is tolerable in that sense, what they don't have to do is produce some dubious maths to meet an arbitrary limit that doesn't really tell you anything.

namely it can only be regarded as a risk to life if a death has already occurred

Not so, and if that's the impression I gave then I apologise, there are plenty of risks to life that haven't caused a death. Additionally the MAA Hazard Risk Matrix includes minor and major injury so you can have risk to life that you don't think will ever cause a death.

For the larger platforms (Chinook, Merlin and Puma) the fitment of fully integrated TCAS II systems is being considered.

In that case I'd assume the additional features of TCAS II weren't considered advantages for a support helicopter as they typically operate below the level where RAs are suppressed. But that's supposition on my part.

(1) The risks of collision and wire strike were the No.1 and No.2 Air Safety risk according to the Cdr JHC (ODH).

You'd need to look at the detail behind the headline titles to determine what that meant though. I.e. Wire Strike was likely to be concerned with horizontally strung power and telephone lines. MAC was probably concerned with hitting other aircraft in flight. The actual risk experienced fell under CFIT, and without knowing what the detail behind that was you can't jump to your next point.

(2) The risks, at the time of the accident, were neither tolerable nor ALARP.

That's not a fact, that's your opinion until it's tested in court. Just because an accident happens doesn't mean the risk wasn't ALARP, it's As Low As Reasonable Practicable, not As Low As Possible.

[tucumseh]

That's not a fact, that's your opinion until it's tested in court.

MoD likes to say this, knowing very well that the CPS and HSE - and Crown Office in Scotland - run a mile whenever asked to consider prosecution. For example, in the 2011 Red Arrows case (XX177), and despite MoD openly admitting imprisonable offences, both CPS and HSE announced there was no evidence of wrongdoing. After a full confession? This leaves it to the families to re-mortgage properties or take out loans to fund legal assistance. Even then, few engage with expert witnesses who actually understand the issues. On the rare occasions they have, MoD's so called experts have been utterly destroyed in court. (Nimrod XV230 and C130 XV179 are the obvious ones). There's a reason why Star-ranking officers and officials don't appear as witnesses. They'd have to lie, or accuse their subordinates of lying.

MoD also forgets its own teaching. This activity (risk/hazard mitigation) is not presumed safe (innocent) until proven unsafe (guilty). The Safety Management System and its outputs must prove the system or aircraft is safe before Service use; including risks to be ALARP and tolerable. There is a different starting point to the legal process.

[Distant Voice]

The MAA needs to go back to basics; air safety within the MoD was not invented by Haddon-Cave. Adequate regulations were in force long before that, they simply weren’t followed. Unfortunately, since his review the MAA has tried to reinvent the wheel and in many areas has come up with a square one. It still turns, but not as good as the previous round one.

Let’s revisit BP 1201 and the guidelines set out there. Where the risk matrix (probability against severity) is used to define whether a risk is intolerable, tolerable or broadly acceptable and not which level of Duty Holder holds the risk. Passing the risk to a higher level does not eliminate or mitigate the risk. On the subject of risk severity, why was it necessary to change the criteria for category levels so that, for example, Remote went from ‘Unlikely to occur during the operational life of a particular fleet’ to ‘Likely to occur one or more times in 10 years’; the latter being more in line with Occasional or Probable under BP 1201? Of course it did allow a Class A risk to become a Class B risk, overnight, and lowered the standards.

Let’s accept that safe means that a risk is broadly acceptable, or tolerable and ALARP, and by ALARP I mean the legal interpretation set out by HSE and not ALARP (temporal). According to the narrative verdict handed out at the Nimrod inquest ALARP is a current requirement, not a future one. That is why Andrew Walker called for the grounding of the Nimrod fleet, because the fuel system was not ALARP.

Having legally accountable Duty Holders, is a good outcome from H-C, but they need tighter guidelines to work with; remember most of them have only done the 2 day course. As it stands at present I believe that the TOLERABLE and ALARP standard set out by the MAA is so subjective that Duty Holders choose to state whether it is or isn't depending on how they feel. As yet not one of them has been held accountable after three major accidents.

DV

[Chugalug2]

DV:-
I believe that the TOLERABLE and ALARP standard set out by the MAA is so subjective that Duty Holders choose to state whether it is or isn't depending on how they feel.

And therein lies the rub. Civilian operators would long ago have had strap hanging passengers, a la train commuters, if they were free to regulate themselves. No doubt it would have been justified by some acronym or other and dressed up with fanciful and dubious statistics. It wouldn't matter much what people thought anyway as they would be their own judge and jury. That is exactly the case with the MOD and its "independent" Regulator the MAA (and its "independent" Investigator the MilAAIB, or whatever it's called this week).

Grounding, or "pausing" fleets (the Hawk T2's now?) is not the answer. The answer to all these airworthiness related fatal air accidents, whether actual or potential, is a truly independent Regulator and Investigator of the operator (the MOD) and of each other. Unless and until that happens avoidable military airworthiness related air accidents will go on happening relentlessly.

Self Regulation Doesn't Work and in Aviation It Kills!

[Distant Voice]

Grounding, or "pausing" fleets (the Hawk T2's now?) is not the answer. The answer to all these airworthiness related fatal air accidents, whether actual or potential, is a truly independent Regulator and Investigator of the operator (the MOD) and of each other. Unless and until that happens avoidable military airworthiness related air accidents will go on happening relentlessly.

I mentioned Mr Andrew Walker's recommendation simply to illustrate the importance of ALARP. He viewed it as a now requirement, not something that can be put off.

Mr Walker also recommended, "that consideration be given to civil aircraft investigation replacing the Board of Inquiry system for investigating the loss of military aircraft.":ugh:

DV

[Chugalug2]

Indeed DV, it took a 700 year old institution to tell one which has yet to make its first century, "There is something wrong with your bloody aircraft". It has yet to recognise that fact and to take the necessary remedial action.

As tuc continually reminds us, rearranging the deck chairs by rewriting the regs is not the answer. All that is required is to implement the old ones, but that would require admitting why they were scrapped in the first place, and who it was who scrapped them. The RAF can go on protecting the VSOs responsible, or it can move towards regaining its airworthiness. It can't do both.