ZD 576 - A Reminder
I usually try to get Brian Dixon to help post some of the background work I have been doing on the engineering and maintenance aspects of the BoI into the crash of ZD 576, but he is I know very busy, and I thought that I should try and contribute in my own right. Long term PPRuNe users may recall that Brian put a major engineering critique onto the main web site around 18 months ago, and this still stands, with MOD never having responded to it except with the ususal platitude of "no new evidence". Most of the contributors to PPRuNe have, rightly, concentrated on operational matters as befits a professionsl pilots web site (I am afraid that I can only claim a PPL) but interesting, and indeed relevant, as many of these observations are they can do very little to change the mind of an obstinate MOD - especially when they can ignore all the other inputs from the House of Lords down.
Nevertheless we cannot and should not give up the fight, and the latest information we are obtaining under the FOIA shows quite clearly just how "hit and miss" RAF justice in the shape of BOI findings was in the early 90s - thus we need to take every opportunity to keep pressure on the MOD through EDMs, MP's letters etc. I also have no doubt that one area where MOD is vulnerable is that of the "airworthiness" of the Chinook Mk 11 (in terms of its release to service limitations at the time) and the defect history of ZD 576 in particular.
The RAFA Journal Air Mail, which some of you may have seen, recently reviewed the Campbell book Chinook Crash, and this led me to respond to the Editor. However, since with its apolitical policy I am not sure that my letter will get published I thought that it might be worthwhile to publish it on PPRuNE just as reminder of some of the issues involved:
"I was pleased to see that the reviewer of Steuart Campbell’s book “Chinook Crash” rightly raised the point that many people are very unhappy with Reviewing Officers’ verdict, against the findings of the BoI and the two Station Commanders comments before them, of Gross Negligence. As many of your readers will know this represents a finding which is a criminal one of manslaughter or culpable homicide. What your reviewer does not mention is that every independent review of this verdict, including a Scottish Fatal Accident Inquiry and a House of Lords Select Committee, and even, with subsequent public statements, the Prime Minister and Secretary of State for Defence of the time have found “against” the two Air Marshals. At paragraph 174 of their Conclusions the House of Lords Select Committee, having listened to all of the arguments of the two Air Marshals comments:
“In carrying out our terms of reference, we have considered the justification for the Air Marshals' finding of negligence against the pilots of ZD 576 against the applicable standard of proof, which required "absolutely no doubt whatsoever". In the light of all the evidence before us, and having regard to that standard, we unanimously conclude that the reviewing officers were not justified in finding that negligence on the part of the pilots caused the aircraft to crash.”
Despite this MOD steadfastly sticks by this unjust and outrageous verdict, which not only broke the RAF’s rules of the time on finding deceased aircrew negligent but did so without any chance of the “guilty” pilots being able to defend themselves. This is why the Mull of Kintyre Group is still so active now some 11 years after the accident and why the respected and independent legal publication “Juridical Review” in July 2001 commented:
The fundamental role of a RAF board of inquiry should be to determine the cause of an accident without prejudice. Any other function is not part of its remit and accordingly ultra vires. It is increasingly apparent that the present approach of the board of inquiry process and that of objective investigation are irreconcilable. Accordingly the system must be revised to ensure that those officers who control the findings of boards of inquiry should not be those engaged in management and command responsibility for the aircraft and the personnel involved.
Turning to the book itself, unfortunately your reviewer gives credibility to the Campbell book that, having read the first drafts, I would suggest that it should not have – albeit I would accept that in many respects it is a “good read”. In particular your reviewer states “Campbell’s closely argued conclusion shows how the accident occurred.” This is nonsense – like the rest of us Campbell does not know – the aircraft was not fitted with either an Accident Data Recorder or a Cockpit Voice Recorder. Even when finding the pilots guilty of Gross Negligence the AOC in C starts his comments with “Without the irrefutable evidence which is provided by an ADR and a CVR there is inevitably a degree of speculation as to the precise detail of the sequence of events in the minutes and seconds prior to impact.”
A true caveat which he unfortunately he seems to have ignored when he goes on to say:
“I therefore agree with the AOC’s summary, in particular that the actions of the two pilots were the direct cause of this crash. I also conclude that this amounted to gross negligence.”
If Campbell’s theory as to the cause of the accident was correct then it could, depending on other factors, amount to an aircrew error, but not, by the standards of the time, gross negligence. However, Campbell has been very selective in his choice of facts from the BoI proceedings and I would suggest that his theory has no more credibility, and indeed given the facts significantly less credibility, than those of us who believe that there were serious question marks regarding the airworthiness standard of the Chinook Mk 2 fleet at this stage of its release to service, and the pre-crash defect history of ZD 576 in particular. This was an area where the BoI did very little follow-up, and it is interesting that the word airworthiness does not figure anywhere in the BoI proceedings despite the fact that the Chinook Mk2 had effectively been grounded within the flight test organisation at the time of the accident.
The BoI starts with the assertion:
“Nevertheless, there was sufficient evidence to eliminate as possible causes: major technical malfunction or structural failure of the aircraft prior to impact; …… Therefore the Inquiry focused on the crew’s handling and operation of the aircraft.”
Since there is more than enough evidence within the BoI itself to show that this assertion is unsupportable one has to wonder if this was a case of the decision being made very early on to “situate the appreciation” that this had to be an aircrew error accident. The BoI shows quite clearly that the Chinook Mk 2 fleet was suffering a continuing series of problems, any one of which could have caused the pilots of ZD 576 to have been either unable, or so distracted, that they failed to make the turn up the west coast of the Mull. For example a senior OCU instructor in evidence to the BoI comments:
“The unforeseen malfunctions on the Chinook HC2 of a flight critical nature have mainly been associated with the engine system FADEC. They have resulted in undemanded engine shutdown, engine run-up, spurious engine failure captions and misleading and confusing cockpit indications.”
There are literally dozens of other areas where evidence relating to the airworthiness, engineering or maintenance standards of both the fleet and the aircraft are ignored or not followed up. Even on the operational side the “join” where the BoI was told to look again is very obvious. Until now, because they pick and choose the facts that suit them MOD has been able to ignore all criticisms of the judgement – even that of the HoL Select Committee. MOD’s need to keep this as a pilot error accident is clearly paramount because if it were to be found that it was not then Pandora's Box is opened on the whole process of getting the Chinook Mk II into service and the decision to use it for such a passenger flight. Would you climb onto an airliner you knew had such Release To Service limitations; was suffering from a wide range of "flight safety critical" false and real transient problems, and which had just been grounded by the test and certification organisation of the same "airline"? It seems to me that the major failure in the duty of care that the RAF owed these individuals occurred not in the hands of the pilots but when the Mk II was selected for the mission against the advice of the Detachment Commander and in the case of ZD 576 with so many still unresolved defects – Sadly Campbell’s book does not look at these issues in any critical way at all. "
John Blakeley