Yak 52 down Nr Boscombe 8/7/2016

[NutLoose]

Though it happened two days ago it appears that it was being used by ETPS and I am surprised it hasn't been mentioned, hence this post.
Sadly one has died


Yak 52 down nr Salisbury. 1 fatality (http://forum.keypublishing.com/showthread.php?139374-Yak-52-down-nr-Salisbury-1-fatality&p=2324438#post2324438)

RIP and thoughts are with the family and friends at this time.

Only thing at Boscombe a little out of the ordinary at the minute is a YAK-52, G-YAKB, which is working with ETPS. It is blue and yellow though, not silver.

Plane flying round Boscombe today ? FighterControl ? Home to the Military Aviation Enthusiast (http://www.fightercontrol.co.uk/forum/viewtopic.php?f=41&p=829177)


..

[farsouth]

Two threads already running on it - one in "Accidents and close calls", one in "Private flying"

[Selatar]

Per Ardua. So very sad.

RIP fella

[Willard Whyte]

The poor chap who died was a very experienced serving pilot in the RAF. Spent many enjoyable hours flying with him around the world, including an impromptu light aircraft vs. car 'Top Gear' challenge between San Diego and 'Vegas a few years ago. A good friend who'll be missed by all who knew him and flew with him. Had a few glasses of our favourite 'detachment wine' in his honour on Saturday night. RIP mate.

[Lima Juliet]

Yes, RIP to a great pilot, captain, skier, hockey player, keen GA/glider pilot and Cambridge graduate. Outstanding individuals like him are only made once in a while and he is a great loss to his family, friends and his country.

I have deliberately not mentioned his name until it has been formally released. I know that tributes have been flooding in via private social media and email all weekend.

Ad Astra old chum. :(

[Mandator]

Official obit and valediction on the MOD website:

RAF Pays Tribute to Pilot Killed In Civilian Air Accident (http://www.raf.mod.uk/news/archive/raf-pays-tribute-to-pilot-killed-in-civilian-air-accident-11072016)

[MSOCS]

Shocked, hugely saddened and devastated for his family and all his many, many friends.

RIP mate. A tiny consolation is that you died in the pursuit of your passion, but you'll be sorely missed my friend.

Per Ardua old boy.

[Miles Magister]

Very sad to hear the news. A nice guy, good pilot and one of the best senior students CUAS has had. Very sadly from the same CUAS course as Kev Whyman.
Best wishes to all left behind

MM

[UAV689]

A top top man in every sense. Will be sorely missed and all my thoughts are with his poor family. Am shocked to say the least, he was one of the nicest, most welcoming, inclusive aviators I have had the pleasure of meeting.

[iRaven]

RIP Alex. A top aviator, skier and such fun to be around. You lived up to the 8 Sqn motto:

USPIAM ET PASSIM - EVerywhere Unbounded

My condolences to your family...

:sad:

[Stitchbitch]

Ah bugger. Alex was a great bloke, always had time for a chat with the squips.. Thoughts are with the family at this difficult time. :(

[Just This Once...]

First met Alex at CUAS in '94 where, to my mind, he had the correct focus on flying and having a good time; regrettably his college tutors didn't share this enthusiasm.

The T&E world brought us together again and he had lost none of the humour or talent and I always enjoyed flying with him.

I am gutted by his loss and the Service will be a poorer place without him. My thoughts are with his family.

[ShyTorque]

Tragic to read.

The second RAF loss in small civilian aircraft of late. I lost a serving RAF colleague in a accident in a small SEP and another ex-RAF one, too.

Just goes to show that small aircraft can bite just as hard as large military ones.

[Mystic Greg]

The world was a better, more fun place for Alex's presence. RIP, and condolences to his family.

[Big Sand]

May I add my sincere condolences to this very very sad loss. First met Alex as he had flown the Bulldog on the CUAS and he kindly later invited me to display at the Bulldog at Waddington 2006. Loved life loved flying. Wishing strength to all his nearest and dearest. A gentleman aviator that will be sadly missed.

[Willard Whyte]

I know this isn't the place to post detailed information, Alex's funeral will take place next Friday, July 29th.

[Lima Juliet]

A fine tribute today to a great man, father, test pilot and husband. Holding up traffic in central London for his funeral was exactly the sort of thing that tickled his humour. As was the 6-ship of RAF be-medalled No 1 wearing RAF officers on 'Boris Bikes' riding to his wake at the RAF Club as they had missed the bus from St Clement Danes!

Per Ardua Ad Astra, Alex, old chum...

[airsound]

The report of the Service Inquiry into this accident has just been released.
https://www.gov.uk/government/publications/service-inquiry-into-the-aircraft-accident-involving-yak52-g-yakb-on-8-july-2016
This is the military inquiry - the AAIB Investigation is still listed as 'under investigation'.

A sobering read.

[Two's in]

Literally breathtaking. If you step back far enough, you begin to see a very worrying picture of Airworthiness post-Haddon Cave. This report contains pages and pages of descriptions about risks, ALARP, insurances, Government Contracting and Sub-Contracting arrangements, operational pressures, AWC Audits and a whole host of "protections". But despite all that guff, a service pilot got airborne in an aircraft that had fundamental serviceability issues with a non-service pilot whose qualifications were never fully established by the Board. When the aircraft developed problems maintaining power, the most basic of airmanship principles appear not to have been applied in recovering to a forced landing, resulting in the tragic loss of life.

My point is quite simple, have we become lost in our own Byzantine safety culture to the detriment of applying the most basic supervision and airmanship principles?

[BEagle]

b. The minima for renewal of a SEP (Land) type rating was either a Skills Test or 12 flying hours in the 12 months before renewal date plus one hour of flight with an instructor.
- Renewal was required every 2 years
- An Fl rating had to be renewed every 3 yrs by completing '2 out of 3' of the following: attending a seminar, 50 hr instructional time or a Skills Test.

I count at least 9 errors of fact in that paragraph alone....

The minimum for revalidation of an SEP (Land) Class Rating is either a Proficiency Check, or 12 hrs PIC in the 12 months before expiry plus a total of an hour of refresher flying with an instructor.
- Revalidation is required every 2 years
- An FI certificate has to revalidated every 3 years by completing '2 out of 3 ' of the following: attending an FI refresher seminar, 50 hr of instructional time or an Assessment of Competence. An Assessment of Competence is mandatory at least every 6 years.

:rolleyes:

[mabmac]

I count at least 9 errors of fact in that paragraph alone....

The minimum for revalidation of an SEP (Land) Class Rating is either a Proficiency Check, or 12 hrs PIC in the 12 months before expiry plus a total of an hour of refresher flying with an instructor.
- Revalidation is required every 2 years
- An FI certificate has to revalidated every 3 years by completing '2 out of 3 ' of the following: attending an FI refresher seminar, 50 hr of instructional time or an Assessment of Competence. An Assessment of Competence is mandatory at least every 6 years.

:rolleyes:
To be precise, the revalidation of an SEP (Land) Class rating does not require 12 hrs PIC but either a Proficiency Check or 12 hrs flight time including 6 hrs PIC, 12 take-offs and landings and a training flight of at least 1 hour (or a maximum of three totalling 1 hour) with the same flight instructor or class rating instructor.

[Sideshow Bob]

high spirits,

I guess the thing to remember here is that the AAIB have primacy over this accident not the DAIB. There was some errors in military supervision which contributed to the accident; however, I would think that the AAIB's focus will be on how this un-airworthy aircraft was being used for demonstration flying with more than a minimum crew for commercial purposes breaching Article 23 of the ANO.

[BEagle]

You are correct about the 12 hrs flight time including 6 hrs PIC minimum - my late night error!

However, a training flight of at least 1 hour (or a maximum of three totalling 1 hour) with the same flight instructor or class rating instructor.
has now been amended by Commission Regulation (EU) 2015/445 of 17 March 2015; the hour if refresher flying no longer needs to be a gained in a maximum of three flights with the same instructor.

Anyway, the report should really have been 100% correct to establish whether the PIC had a valid SEP Class Rating and Instructor Certificate.

Nevertheless, the report makes shocking reading concerning flying supervision, aeroplane maintenance records, ANO compliance, pilot qualifications, pilot recency etc. etc.....

The engine hadn't received any overhaul in 24 years, no-one seemed to have checked or replenished the oil that day, many of the engine instruments were unserviceable as were the artificial horizons and altimeters...

Does the RAF still have a Flying Supervisors' Course? If so, this accident should be used as an example for FSC students.

[Chugalug2]

I'm having trouble opening Airsound's link, which produces mainly blacked out pages interspersed with occasional readable ones. Is this a problem at my end or simply security redaction?

As I understand it this was a civilian registered aircraft, hence subject to the civilian regulator rather than the MAA, and subject to AAIB investigation primarily. Is that correct?

The aircraft was being operated for Boscombe Down and included a Service pilot, hence this SI. Is that correct?

As to airworthiness, it has been said repeatedly on this forum, "Implement the Regs". No amount of huffing and puffing, or creating new "independent" authorities will gainsay that. The UK military air fleet is riddled with unairworthiness because that simple requirement was not adhered to.

[Davef68]

I'm having trouble opening Airsound's link, which produces mainly blacked out pages interspersed with occasional readable ones. Is this a problem at my end or simply security redaction?




Sounds like at your end - I've seen that when there is an incompatability between the PDF and the reader you are using (Usually, but not always, the version of Adobe Reader).

Yes to your other questions - Civil aircraft, operated at/for ETPS, incident involved the death of a service pilot.

[Chugalug2]

Many thanks Daveof68. I'll check out my adobe reader. Thanks also for the confirmation of my queries. If the MOD tries making hay out of poor civilian airworthiness, then the words glasshouses and stones come to mind.

[Just This Once...]

Years ago we had numerous aircraft types of various vintages and design concepts owned and maintained by the UK test pilot organisations. Other nations did likewise and with mutual cooperation across nations this gave an extensive list of aircraft for test pilots to fly inside the military domain.

Costs money though.

Much cheaper to contract to one company (who prefers collecting and storing documents, rather than reviewing them), who contracts another, who contracts yet another, who then hires an aircraft from an individual who operates on a PtF, complete with an installed engine that has never been overhauled in its 24 years of service. For safety, just add a PIC with little currency or experience on type, no supervision, questionable ability, a cavalier attitude to rules and regulations, doubtful airmanship and a madcap scheme to hand a forced landing to the front seat occupant (even if not qualified and on his first trip) as he doubted his own ability to execute one from the rear seat.

Seems a perfect mix to conduct extended envelope spinning, both erect or inverted and expanded envelope flying. Best not worry the aircraft & airworthiness owner though, the PIC can just send a quick email to state that it would just be gentle and benign flying.

I had known Alex for 20 years and flown with him in a number of aircraft types. He deserved better than this.

[Cows getting bigger]

Lordy lord. There is so much wrong here. Headlines:

Confusion over DH responsibilities
Process 'holes' - numerous
Contractural weaknesses/ignorance
Sub-Sub-Sub- contracting (nothing new there)
Civilian Airworthiness (not just MoD/QinetiQ oversight)
Permit to Fly rather than CofA - no exemption from CAA to undertake specified activity (breech of ANO)
Ignorance within QinetiQ regarding PtF vs. CofA
Aircraft/pilot Insurance
A 24 year-old engine that had never been overhauled
Rear seat PIC did not have engine MAP or serviceable RPM gauge.
Numerous other unserviceable instruments
Questionable (by MoD standards) pilot currency/competency.
Inadequate pre-flight crew brief
Incorrect ARTM (Aviation Task Risk Matrix)
Shortened timeline - rushing

We've now arrived at the aircraft!

One other morsel:

The PIC was sitting on a high visibility jacket that had been borrowed from the Contractor as a booster cushion

FFS.

We need to ask ourselves why this could happen under the gaze of the world's premier Test Pilot School

[Martin the Martian]

Blimey. Talk about a damning report. As stated, all under the gaze of ETPS.

[Cows getting bigger]

Sorry, round 2.

I don't normally get annoyed by stuff like this; I try to take an objective stance. BUT - this is shambolic. This reads like a flying club/group hidden in the wilderness. In fact, I'm probably doing flying clubs a disservice. ETPS military personnel shouldn't have even walked within 50ft of that aircraft, never mind fly in it.

[DaveUnwin]

If the name of the organisation that was supposed to be providing supervision and oversight had been redacted we'd all have assumed this was either the world's worst flying club or a real banana republic Micky Mouse airforce operating that Yak. The Empire Test Pilots School? Really?

[Hueymeister]

I'd known Alex since we were Air Cadets together..

I shared some of my EFB work with him and sought advice on getting stuff into the cockpit. A more enquiring and professional mind I have yet to meet.

The report is a truly scary read and I feel that he was let down by a series of safety checks that should have stopped that aircraft ever getting to the QE course.:sad::(

[Tay Cough]

There are also a number of very good and well cared for Yak-52s out there as well as the world's most experienced Yak-52 instructor (ex-DOSAAF) who is based in the UK.

I have no doubt one could have been made available to ETPS with all the Is dotted and Ts crossed if they had asked around.

[Chris Kebab]

That SI is an absolutely shocking read and, as Beagle states, ought to become the starting point on any course discussing how a flying organisation ought not to be run. It is probably one of the most startling for many years.

QinetiQ should never have let that aircraft get airborne from Boscombe Down with either a military or civilian member of ETPS (which, as I understand it, they now own) on-board, looks a real dereliction of their airworthiness and safety responsibilities. QinetiQ - a supposed world class organisation, I just hope they have been able to acknowledge and rectify their failings.

And where was the AWC is all of this with regards the much vaunted MAA DH process? Surely they retained primacy with regards the duty of care to a serving Flt Lt while flying on duty, or did they? What oversight/assurance were they providing to serving ETPS military aircrew on a day-to-day basis while flying on behalf of QinetiQ? Personally I couldn't untangle the division of responsibility between the AWC and QinetiQ in this report with regards a serving military pilot, flying a CAA regulated aircraft, in an MOD funded, privately owned, flying organisation - or is that just me? Who is the dog and who is the tail in this QinetiQ/AWC arrangement?

Suspect the fallout from this could run and run - and that's even before the AAIB present their report. As others have said the good Flt Lt was seriously let down - in my opinion by both QinetiQ and the AWC - and he did deserve a lot better; RIP.

[Just This Once...]

Tay - No real chance of getting all the dots and crosses sorted as all UK Yak-52s are only on a PtF - this was commented on in the report.

[Momoe]

In reply to Just this Once

The Yak-52 being on a PtF is irrelevant, it's either airworthy or it's not - in this case NOT airworthy. I've seen enough PtF aircraft and flown some and being on a PtF is not an excuse for poor maintenance/adherence to AD's.

Agree with the other posters that this is banana republic territory.

This was an accident waiting to happen compounded by what appears to be a level of complacency that beggars belief.

[Just This Once...]

No, it is relevant as the PtF is linked to the incomplete airworthiness chain, oversight and design support. As a result the burden of airworthiness passes directly to the owner and the residual risk is mitigated by the restrictions stipulated in the PtF (e.g. prohibition on revenue earning flights, limited POB etc). Airworthiness and serviceability are different things, albeit intertwined.

[gasax]

I read through the report and could not help but wonder how military airworthiness processes are hopelessly wrapped up in paperwork - with no proper linkage to the real world.

The risk assessment would have stopped the engine stopping? The reason the engine actually stopped (operation or fault not even established - FFS?) not established. Lots of indignation about a Ptf - when military aircraft do not actually meet civilian standards anyhow..... and so do not have a C of A (and when they are supposed to the standards are not met anyhow - anyone for gliding?)

The limits for spinning breached on multiple occasions and none of these military trained and experienced pilots thought to even mention it?

Little or no sortie briefing, little or no checking the aircraft is even ready.

Everything passed over to a contracting company who themselves obviously had a similar level of non-competence.

Yes it is a shambles - but one created and perpetuated by the military processes and plain lack of competence, discipline and organisation within it

[Cows getting bigger]

The risk assessment would have stopped the engine stopping?

The risk assessment would have stopped the aircraft from flying. It would have ensure the crew restraints were satisfactory. It would have ensured the appropriate insurance. It would have identified that the Yak 52 was not fit for purpose.

The risk assessment would have stopped the accident.

[jonw66]

Agree Cows but it should never have got anywhere near a risk assessment the aircraft was unserviceable.
I read it this morning when airsound posted the link and still cannot believe the complacency.
Would be interesting to hear Engines thoughts as a senior engineer.
Best
John

[Tay Cough]

Tay - No real chance of getting all the dots and crosses sorted as all UK Yak-52s are only on a PtF - this was commented on in the report.

I don't wish to get into a tit-for-tat. It would be inappropriate on a thread of this nature. Exemptions are granted, subject to certain criteria being met. For example, it is possible to pay for training in a Spitfire in the UK. All civilian Spitfires are PtF.

[jonw66]

If I was in the fortunate position to have a jolly in a Spitfire for £3000 I would expect someone of Cliff Spinks reputation to be sat in the front seat and John Romain saying the aircraft is serviceable.
A world away from this mess.

[tucumseh]

Besides the airworthiness and serviceability aspects... As someone who experienced the protracted nonsense of simple Boscombe Down tasking moving to "soft-charging", "hard-charging" and then full QinetiQ ownership, what this report emphasises is the associated fragmentation and compartmentalisation this process caused. Frankly, Boscombe staff didn't know if they were full-bored or countersunk; and the report reeks of it. The only beneficiaries were those who suddenly found themselves multi-millionaires by virtue of the position they held in DERA at the time.

This has resulted in an over-complexity of what was already a bit of a minefield. Not unlike what the MAA have created in the regulatory domain - 7 years after creation they have yet to address Haddon-Cave's central point. Failure (in fact, flat refusal) to implement perfectly good regulations. Here, the problem is failing to implement what are now labyrinthine regulations (some forced by the above sell off), with numerous examples cited of people thinking others were responsible for critical activities. We've been there before, one recent example being no one knowing who was responsible for the Hawk safety cases (Red Arrows XX177).

[woptb]

Agreed,without compliance all is window dressing ie pi55ing in the wind!

[Wander00]

A minor point but just read the original RAF announcement -implication throughout that this was a "civil" not Service aviation accident - brilliant bit of PR, but quite a way from the real story

[tucumseh]

"ETPS should have access to aircrew publications in English".

25 years after Director Flight Safety noted MoD were using captured Argentinian pubs to service Chinooks.

[Chugalug2]

The regulatory arrangements for ensuring that this aircraft was both airworthy and serviceable rests with the Civlian regulator, whether devolved or no. The regulatory arrangements for ensuring the military regulations are implemented and complied with by ETPS (or any other unit) rests with the MAA.

When Regulation is done on the cheap people die. When regulation is compromised by protecting VSO reputations people die. At least the AAIB can and will produce an objectively neutral report when published. Does this SI do likewise?

Self Regulation Does Not Work, and in Aviation It Kills!

[pulse1]

One of the report recommendations 1.4.39 b) says:

"Put in place robust measures to ensure that all ETPS personnel understand reporting requirements, when operating both ETPS fleet and third party aircraft, in order to ensure that all relevant occurrences are reported ."

Am I the only one around here who finds it highly disturbing that, of 2 ETPS tutors and several Students who flew in it, not one reported any of the obvious faults with this aircraft. What does this tell us about the airmanship of modern RAF pilots? Do they really have to be told this kind of stuff?

Having run a PtF aircraft for 10 years in a group with 2 ex RAF fast jet pilots I am afraid that it doesn't totally surprise me.

[gasax]

The risk assessment -ATRM has no reference to airworthiness - and that is so completely symptomatic of the paper cave that military airworthiness seems to have driven itself into.

Safety case where the data bears no relevance to the actual situation, safety case where the operational staff have no input. Pilots who routinely breach limits and do not report and an institutional approach which is about trying to absolve the regulating authority from responsibility?

Difficult to imagine things being anymore screwed up!

Or are all RAF missions undertaken in aircraft riddled with faults, where the brief is routinely ignored and there is a pile of irrelevant paper?

[Bob Viking]

Pulse1.

I guess life would be so much simpler and safer if we were all as awesome as you. I don't know you from Adam but from your one post I have just read I'm not sure we would get along very well.

BV

[AutoBit]

Pulse 1

What a totally unnecessary and unwarranted comment. Did you actually read the report? It's quite clear what happened at ETPS, and whilst it's deeply disturbing I would venture two points.

1. The normalisation of deviance can happen in ANY organisation
2. If you bothered to read the comments before your post you'll see that every military pilot (indeed every pilot) has raised an eyebrow to this.

[dervish]

BV

Nothing Pulse1 or anyone here says can be worse than the SI!

[Chugalug2]

Pulse 1 raises an important point. Of course there are shortcomings at a local level, there were local shortcomings also in the Red Arrows tragedy that killed Flt Lt Cunningham, and in the many other airworthiness related fatal accidents featured in this forum. That is the point, when you deal a fatal blow to an Air Safety System the damage is done from top to bottom of the organisation, whether it be the issue of illegal RTS's or the lack of proper practice as here.

That fatal blow was delivered some thirty years ago, and UK Military Air Safety is still dysfunctional because of it; despite BoI's and SI's reporting on airworthiness related fatal air accidents one after the other, despite Judicial Reviews, despite the formation of the "independent" MAA, and despite VSO findings being overturned. Why? Because even now the reputations of certain old men are deemed more important than young servicemen's and women's lives. There can be no reform of UK Military Air Regulation or Air Accident Investigation until the real reasons for the systemic dysfunction of UK Military Air Safety is admitted to. Doing that requires a stop to the cover up and naming those VSO's who were responsible, and time is of the essence.

Until that happens airworthiness related fatal air accident threads will be a continuing and tragic feature of this forum.

Self Regulation Does Not Work and in Aviation it Kills!

[Basil]

A brief scan suggests that many of the Swiss cheese holes were already lined up; a couple more and . . . .

[silverfoxx]

Am I the only one around here who finds it highly disturbing that, of 2 ETPS tutors and several Students who flew in it, not one reported any of the obvious faults with this aircraft. What does this tell us about the airmanship of modern RAF pilots? Do they really have to be told this kind of stuff?

ETPS tutors are not exclusively RAF and the students come from over 6 different nations.

It's a bit of an assumption to relate this to what you perceive to be a lack of airmanship of RAF pilots.

[dervish]

Unlike a few recent posters I hope the DSA realises that the report is merely an adjunct to others stretching back many years. As Basil says, the holes were already lined up, which means previous reports had been taken in isolation.

[BEagle]

With so many unserviceabilities, let alone anything else, surely whoever runs ETPS these days should have told the aircraft owner to "Get this lousy piece of Commie crap off my airfield NOW - and don't come back until it's fixed"?

[tucumseh]

Beagle

I agree, but as it was sub-sub-sub-contracted, it's unlikely anyone at ETPS knew who the owner was. The more obvious clue was non-English pubs, which the report implies is all they had for about 7 years. I recall many decades ago an Admiral (FOSNI) quietly asking why I was in the close vicinity of, never mind attempting to repair, a Gazelle clutch when the drawings were in French. Even though the drawings he was looking at were for a Lynx TRGB, his point was made.

[airsound]

Beags & Tuc

The SI says (para 1.3.7)QinetiQ contracted the service through a Framework Agreement with a third party, Command Pilot Training (CPT) Ltd.... CPT Ltd further sub-contracted the service to the PIC, who sourced G-YAKB from its private owner. According to the CAA's GINFO, that owner is Martin Jeffery Gadsby, and his address is given.



PS Ever thought of the Diplomatic Service as a career, Beags?

[BEagle]

Surely someone at ETPS knows how to establish who owns a civil registered aircraft? Or haven't they even heard of G-INFO?

Any how, whichever military person runs ETPS these days (assuming there is someone) should have told KwintyKwoo that the lousy piece of Commie crap was unfit for purpose, get rid of it and pursue the sub-sub-sub-sub contractors for frustration of contract whilst finding another more suitable aircraft.

Diplomatic Service? That would have meant dealing with cocktail party civil serpents and their brown envelope contacts, so no thanks!

[ORAC]

https://www.theguardian.com/uk-news/2017/aug/05/test-pilot-death-raf-mod-report-alex-parr

A damning report into the death of one of the RAF’s top test pilots said the aircraft he crashed in had “significant equipment defects” before it took off. Flt Lt Alex Jay Parr, a 40-year-old father of three, died in July 2016 when a Yak-52 he was piloting suffered engine failure and crash-landed on farmland. Parr was thrown from the plane and his body was found several feet from the wreckage.

A report by the Ministry of Defence has strongly criticised the RAF and the defence firm Qinetiq for a string of failings which contributed to the accident. These include the fact the plane, used in instruction flights to train test pilots, took off with broken flight instruments, out-of-date parachutes and worn-out seat harness straps. A separate inquiry by the Air Accident Investigation Branch is being carried out, but MoD investigators discovered that the aircraft, built in Romania in 1993, did not have an engine overhaul in 24 subsequent years of flying.

The plane took off from an airfield at Boscombe Down, Wiltshire, in July last year. The military base, operated by Qinetiq on behalf of the MoD, is the home of Empire Test Pilot School, where elite pilots from Britain and the rest of the world, including the US, are trained to become test pilots. Several Nasa astronauts have honed their skills at the school. It is widely regarded as one of the world’s leading flight schools and the report will be a deep embarrassment to the MoD.

Air Marshal Richard Garwood, head of the Defence Safety Agency, last year told MPs on the parliamentary defence committee investigating the safety of military training, that the MoD and the RAF in particular, had “far better [safety] processes in place” since a 2006 incident in which a Nimrod aircraft exploded over Afghanistan killing 14 crew members. An inquiry into the Nimrod explosion later found “systemic failings” by defence officials and manufacturers were compounded by the MoD sacrificing safety to cut costs.

The report into Parr’s death concludes there was a failure to carry out due diligence to ensure a safe flight, that there was inadequate supervision, a lack of risk assessment and that the plane took off with “significant defect failures” including no gyro compasses, a broken altimeter, and failed engine gauges. “These failures would have denied the crew critical information during the emergency and likely caused distraction and confusion,” says the MoD report.

Investigators said parachutes on the aircraft “appeared out of date”, seat harness straps were “significantly weakened” and the pilot was not wearing a helmet.mThe plane was privately owned but sub-contracted to defence contractor Quinetiq. A second pilot, who survived the crash, was “inadequately prepared” for the training flight, having only logged one hour in the aircraft in the previous 12 months, investigators said.

“Overall, no stakeholder grasped the reality of a sub-sub-contractor operating a borrowed airplane. This led directly to [training school] personnel flying in an aircraft that was unfit for purpose and operating in contravention of the Air Navigation Order,” the report says.

Before the crash, the aircraft had been operating training flights at MoD Boscombe Down for a week “without either the aircrew, engineers or supervision picking up on what was clearly an unprofessional and deteriorating situation. We need to ask ourselves why this could happen under the gaze of the world’s premier test pilot school”.

Air Chief Marshal Sir Stuart Peach, describing Flt Lt Parr’s death as a tragedy, paid tribute to him as an “outstanding husband, father, Royal Air Force officer, pilot, test pilot and friend. Clever, witty and warm, he will be missed by many.”

[Chugalug2]

Air Marshal Richard Garwood, head of the Defence Safety Agency, last year told MPs on the parliamentary defence committee investigating the safety of military training, that the MoD and the RAF in particular, had “far better [safety] processes in place” since a 2006 incident in which a Nimrod aircraft exploded over Afghanistan killing 14 crew members.
Pure hubris, given that maintaining a Safety Case, or even providing for one prior to Release to Service into the RAF, is clearly no longer official MOD policy.

[MPN11]

Please excuse my intervention into what is clearly NOT my field, but having spent the last hour or so reading the SI [and comprehending much of it] I find the whole sad saga deeply depressing.

Setting aside the numerous failings, including unreported instrument failures and inadequate checks [excuse my loose terminology] ... has the system now submerged itself in so much convoluted paperwork and 'yuck-speak' that simple common-sense been removed from the equation?

Ignoring numerous other factors, with several cockpit instruments u/s I cannot understand why anyone at ETPS considered the aircraft fit to fly, let alone continue operating it for a week without anyone seemingly bothering to snag it. I wouldn't really want to drive a car in that state.

[Heathrow Harry]

looked like a classic "familiarity breeds contempt " case ie if it had suddenly turned up like that no-one would have touched it but it had been there for ages and people just accepted the gradual deterioration in the aircraft

But it was only there for a week... what were they thinking of?

[Above The Clouds]

That report is a damming indictment to all parties and persons involved.

[SWBKCB]

That report is a damming indictment to all parties and persons involved.

isn't that the problem - too many people involved and too much "shared" responsibility?

[tucumseh]

the MoD and the RAF in particular, had “far better [safety] processes in place” since a 2006 incident in which a Nimrod aircraft exploded over Afghanistan killing 14 crew members.

This ludicrous nonsense proves an oft-made point. The evidence to Haddon-Cave was that the regulations were not implemented. He accepted this. Government accepted it. The MAA was established to correct it. It has yet to start, preferring to write new regulations and processes; and still allow project offices to treat them as optional.

[MPN11]

tecumseh ... I guess that's my simplistic, non-aviator, point. Generating even more mountains of paper, processes, Regulations and MBA-speak scribble doesn't help anyone if people don't THINK!

In my ATCO days, as Supervisor, Training Officer or Local Examiner, I expected people to think. Yes, obviously comply with the rules, but also exercise their brains occasionally. When, for example, examining someone on Director for a Certificate of Competency endorsement, I would sometimes lean over and put their radar display on standby (obviously watching proceedings on the adjacent display). Many of them would just freeze, without thinking of all the other resources available to them.

If people don't THINK, and instead just try occasionally to wade through 183kg of regulations and forms, we do the people a disservice. Our Danny42C had to think, in his flying and ATC careers, without innumerable volumes of bumf... and he functioned effectively, without sitting on the output of several hundred MBA's worth of incomprehensible typescript..

[Green Flash]

If they really want to use basic airframes they should have borrowed the BBMF's Chippy; at least it will be thoroughly, comprehensively and professionaly well-spannered and documented, etc etc

[MPN11]

If they really want to use basic airframes they should have borrowed the BBMF's Chippy; at least it will be thoroughly, comprehensively and professionaly well-spannered and documented, etc etc
But, in the ETPS context, not an unusual/unfamiliar type?

[Martin the Martian]

The Chipmunk has been out of regular RAF/FAA/AAC service now for about 20 years, so it would count as an unfamiliar type now, I would have thought.

[biscuit74]

A dreadful accident and what seems to be an appalling series of oversights with some quite absurd convolutions discussed in that SI.

My basic safety thought - What happened to the KISS principle, chaps?

(And so well said 'MPN 11' - It's important that people THINK!)

[tucumseh]

MPN11

Agreed.

The MAA won't admit why it is writing these new regs. It is because MoD has been dumbed down. To someone of my age and background, understanding and implementing them was something you did in the 4 or 5 grades before you became a project manager. Today, most skip those grades, and there is no one left to train them when parachuted into the minefield. Industry and MoD's technical authors realised this many years ago, and started having to rethink how they wrote publications. They could no longer assume the previous levels of competence.

One aspect of this case proves my point. The report recommends aircraft publications should be in English, not Russian. In 1992, the RAF Director of Flight Safety recommended they be in English, not Argentinian. 25 years!

[airpolice]

I am only halfway through the report, but I keep wondering... if the YAK52 is such a good tool for the job, why didn't QQ just buy one, get it airworthy, and charge accordingly?

[TheChitterneFlyer]

I am only halfway through the report, but I keep wondering... if the YAK52 is such a good tool for the job, why didn't QQ just buy one, get it airworthy, and charge accordingly?


Because it would then become a 'familiar' type on the QinetiQ books! Maybe the Harvard switch positions should have had the facility to be changed over to Cyrillic (I'm being ironic). I know, the Harvard has now been sold and there's no chance of QinetiQ buying a Chippy or a Yak.

[airpolice]

1.6.7 The organisational aspects of this accident demonstrated that the lessons identified by previous internal audits and formal staff assurance reports had not been learnt.

No **** Sherlock.

[TorqueOfTheDevil]

Air Chief Marshal Sir Stuart Peach, describing Flt Lt Parr’s death as an avoidable tragedy, paid tribute to him as an “outstanding husband, father, Royal Air Force officer, pilot, test pilot and friend. Clever, witty and warm, he was let down by the system and will be missed by many.”


The full text of the Air Chief Marshal's statement - presumably?

[MOA]

Whilst not wishing to say 'I told you so', this breakdown in oversight and assurance was highlighted as a risk when D Flying was subsumed into the MAA and effectively broken up.

Many a meeting were held with the Ops 2* and the 3* Head and also rigorously documented, but the MAA hierarchy did not believe it to be an issue.

Had D Fg still been in existence, would the accident have happened? One cannot say for sure. However, I strongly believe the numerous swiss cheese holes would not have had the ability to line up/been there in the first place.

Crawling back to a happier place as this break up of Flt Test oversight back in 2011/12 got me going then and appears to have done it again...