Posted on behalf of Dick Doleman and the Support Group.
As many Ppruners will be well aware, the legal proceedings following the F15 accident have now been ongoing, in one form or another, since 2001. The Ppruners response and support for Flt Lt 'Spot' Williams and his family, during the Court Martial, was absolutely fantastic; it was also a great tonic for all of us who were there with him and it helped to give us hope when things looked bleak. We all hoped that the just result of the 'not guilty' verdict would be the end of the matter for Spot and his family. Unfortunately, this doesn't appear to be the case. We feel this Board of Inquiry has come to the wrong conclusion on the cause of accident and has also unjustly apportioned blame to 'Spot'.
Please read the following report which focuses on 'cause'. If you would like to comment, please bear that in mind. Other threads have plenty of discussion on the semantics of RIS and RAS which are not central to our argument in trying to prove that Board of Inquiry has come to the wrong conclusion. Many thanks for your support.
Dick Doleman
Response to the Board of Inquiry Report. F15 Accident. Cairngorms. 26 March 2001
1. Introduction.
This report has been prepared by the support group that attended the entire Court Martial of the controller concerned in this incident. We speak from the knowledge of hearing all the evidence and we have the full findings of the USAF Aircraft Accident Investigation Report dated 15 April 2003. Firstly, we wish to draw your attention to the RAF's decision to release this Board of Inquiry (BoI) report to the press and into the public domain before informing the Air Traffic Controller concerned of their intent; it is a most discourteous to treat an employee in this manner. Secondly, it should be appreciated that the Terms of Reference for a BoI are specific and clearly state that the process is not designed to apportion blame; it is designed to be a process from which lessons can be learnt.
We have now had a chance to read the BoI findings and the comments and recommendations made by higher authority. There can be no objection to the BoI making safety recommendations and we have no wish to demean their work in this regard, however, we take issue with them and the subsequent reporting chain over their conclusion on the likely cause of this tragic accident. We do not believe the cause of this accident was related to any advice passed by the air traffic controller at RAF Leuchars. We remain convinced that this accident was controlled flight into terrain (CFIT), in probable whiteout conditions, while BITE 21 flight (2 x F15 aircraft) was engaged in low flying in Low Flying Area 14 (LFA 14) and possibly trying to regain their pre planned route having been diverted by weather.
2. It is our belief that the BoI has stuck rigidly to the premise that this was a straight line 'Instrument Met Conditions' (IMC) descent into terrain. We dispute this finding. We note that the BoI also had access to the USAF Aircraft Accident Investigation Board Report dated 15 April 2003 and all other relevant documentation available to both the original BoI and the General Courts Martial (GCM). There are several areas in the BoI report which are either contradicted by the USAF report or differ from testimony given under oath at the GCM and we shall now cover these points in the order in which they occur in the BoI report.
3. At page 2-3, para 10, the Board states:
At 1314, the formation reported that they were in cloud at FL60.
The USAF report ('Statement of Opinion' page 23) contradicts this statement. They interpreted Bite21 as saying;
'Bite's in the climb to six thousand' and not 'Bite's in cloud at six thousand'.
This seemingly minor point is actually very important, as, at no time did BITE 21 flight ever report to ATC that they were IMC, or, request a change to Radar Advisory Service (RAS); a request that would have indicated a change of flight conditions. Why did the BoI choose to ignore the USAF interpretation of this transmission or not mention that there was another interpretation of what was said?
4. At page 2-5, para 16, the Board states:
A Tornado formation callsign AXIS, that had transited the area at approximately 1235, reported a very low cloud base with severe whiteout condition.
This is not quite the story told to the GCM. Under oath, the member of AXIS formation told the court that the formation had flown in 'loose trail' along the Dee valley and had encountered severe whiteout conditions necessitating a turn-about just east of Braemar; they reported the visibility as good outside of isolated showers. A 1:50,000 ordnance survey map with their route drawn on it was presented to the GCM as an exhibit (we have a copy of that map). This map shows quite clearly that after the turn-about, the formation backtracked the Dee valley to a point where they then continued northward up the Lairig Ghru passing only some 2kms to the west of Ben MacDui and the crash site. There was no mention of further bad weather or deviations from the Dee valley on that leg of the flight. It seems very strange then that at page 2-6, para 22 of the report, the Board says:
The members of AXIS formation could describe their route towards Braemar where they were forced to turn about onto west due to deteriorating weather and can recall a northward transit up the Lairig Ghru before turning east to route to the north of Ben MacDui. However, they were uncertain of their exact route between Braemar and the Lairig Ghru because of poor weather. The Board found that all the eyewitness statements were consistent with a route that could have been followed by the Tornado formation as they routed between Braemar and the Lairig Ghru.
We find this very strange, because AXIS formation had only just come from that direction. The leg between passing the turn towards the Lairig Ghru and Braemar would have taken just over a minute at 420kts. Surely the weather couldn't have changed significantly in that time and, if it was that bad, why turn back towards it? That the crew might have deviated from the Dee valley but couldn't recall how they then got back to the Lairig Ghru seems inconceivable, particularly as such an event wasn?t mentioned at the GCM. This amendment of east-to-west track conveniently places AXIS flight closer to where the eyewitness reported sightings the F15s but only by forgetting how they might have got there. However, the amended track would have meant AXIS formation turning north up Glen Quoich for some 6km before over-flying the first witness at Dubh Ghleann and then turning west and taking a contour-following route to regain the Lairig Ghru somewhere south of Ben McDui; all of this in weather reported by the BoI as very low cloud base and whiteout conditions. We think AXIS formation would have remembered that particular detour, when flying in loose trail ! It is very important to note that none of the eyewitnesses could have seen AXIS formation if they tracked their original route, following the Dee valley, just as the member of AXIS formation had informed the GCM under oath.
5. The next statement made by the BoI is of equal concern. At page 2-6, para 23, they say:
Three of the witnesses were positive that they had seen twin-tailed ac, not Tornado ac. The Board judged that, if they were correct, then the F15c formation would have had to have avoided the imminent collision with terrain indicated by the last radar plot. The Board believed that this would have required an extreme manoeuvre. Such a manoeuvre would have required a sharp climb that would have undoubtedly have split the formation and, probably, have placed the ac back into radar coverage.
We have read this statement many times. It first struck us that the BoI had invented new eyewitnesses but now we believe this to be a very obscure way of trying to say that the eyewitnesses never saw the F15s. The BoI seem to be following their theory that the F15s never deviated from the track recorded by the radar until impact in IMC. In their view, the only place an eyewitness could have seen F15s would have been close to the last radar contact. That theory being correct, then the aircraft would have suddenly become 'Visual Met Conditions' (VMC) beneath cloud, in close proximity to these (hypothetical) eyewitnesses, and then be seen 'in an extreme manoeuvre' to avoid hitting the ground that they (hypothetically) suddenly saw ahead of them; ergo (in the BoI's view), the eyewitnesses never saw F15s. This seems to be a most unusual way of trying to discount 4 eyewitness and their reported positions (which were not disputed) between 5km and 8km to the south east of the crash site.
At page 2-7, para 23, the Board go on to say:
'In conclusion, the Board judged that, despite their certainty that they had seen twin-tailed ac, the eyewitnesses had been mistaken as to the type of the ac, possibly due to a range of factors such as the angle of view, the proximity of the ac to each other, the prevailing light conditions and changes in aspect as the ac flew past while manoeuvring'
This is a very strange conclusion to make, bearing in mind that the F15s were in close formation, while the member of AXIS formation (Tornado aircraft) reported to the GCM that they were flying in 'loose trail'. There is no mention of the important fact that the Tornados landed some 30 minutes prior to the assumed time of crash. While it is conceded that the time of sighting by all the witnesses were approximations, the margin of estimate of time between all the 4 witness groups was small. It should be appreciated that seeing low flying aircraft flying in 'loose trail' would appear to a casual observer as though he were seeing 2, possibly unrelated, aircraft . None of the eyewitnesses reported such a sighting. Concerning the BoI's inference that eyewitnesses were mistaken in their recognition of twin-tailed aircraft, one eyewitness stated under oath at the GCM that he was adamant that the aircraft he had seen were not Tornados; he had seen many of these in his hill walking experience. Moreover, two of the eyewitnesses were directly over-flown, by their estimate of 40yds; even if this was at 250ft, it was a an extremely close sighting of 2 large aircraft in close formation and could hardly be confused with the sighting of a single Tornado (as it would be seen in 'loose trail'). It is very important to understand that these particular eyewitnesses, standing at a spot height position on the eastern side of Dubh Ghleann, first saw the aircraft as they approached them head-on from the south and their first comment to each other, on seeing the aircraft, was about the twin tails. The aircraft then banked over them, turning from a northerly to a westerly heading, presenting the witnesses with a tail-view aspect. Within a matter of seconds the formation over-flew a solo skier from behind, presenting him, also, with a tail-view aspect.
As a result of the BoI report, the Station Commander, RAF Leuchars
comments at Part 3, page2, para4:
'The Board's consideration of the statements of the eyewitnesses had been thorough and provides a reasonable explanation of what they saw; that, despite remaining discrepancies, there was a high probability that the aircraft reported were Axis formation; Dr .........'s credible evidence concerning the unreliability of eyewitness testimony offers a satisfactory explanation of the remaining discrepancy over the number of tails on the aircraft observed. I did not find the 'Alternative Cause' put forward by Flt Lt ...... persuasive.
We note the Station Commander has used the phrase 'high probability' in referring to the type of aircraft seen; this seems to suggest that there was also a probability that the eyewitnesses had, indeed, seen the F15s as there were no other aircraft in the area that day.
6. Weather Factors and Situational Awareness.
The USAF report (page 14 Summary of Weather sub para C(1) ) states:
Forecast weather for the route of flight was for scattered to broken cloud layers at 2500ft to 8000ft, enabling VFR flight, even though it is likely that the tops of mountains would be obscured. With the weather as forecasted, some manoeuvring would likely be required to avoid clouds and remain VMC.
At the GCM, the crew-member from AXIS formation reported much the same, with scattered showers moving through the area and localised severe whiteout conditions; he reported that visibility was good outside of the showers. In our recollection, there was no mention at the GCM of a very low cloud base that the BoI says AXIS reported to them in para 4 above. The USAF summary was in accord with the information given to the GCM and it was conceded by the USAF aircrew-witness that at Flight Level 80 , BITE 21 flight would have had unlimited visibility and would likely see up to 5/8th of the surface. The BoIs view is somewhat different and neatly fits their theory of straight line descent into terrain.
The BoI state at page 2 '23 , para 46:
The Board was confident that the formation entered cloud shortly after commencing the descent and, having descended through 4000ft, was in the process of levelling off when they impacted the ground.
In their summary, the BoI state on page 2-23, para 46 :
The leader asked for a descent in a position that would take the formation down towards Ben MacDui but it is not clear if he realised this.
We are very surprised by this statement, the BoI seem to question the navigational skills of the leader of BITE 21 formation . The BoI acknowledge that they were in possession of the same documentation and evidence that was presented at the GCM.
The BoI state at page 2-19, para 45b :
The mission was correctly planned with an adequate level of detail present on the Mission Data Card. The weather forecast was fit for low-level and the formation was correctly booked into LFA 14. A topographical map was found at the crash site and the RAA, at 5700ft for the area, was calculated in accordance with the extant USAF regulations. Overall, the Board assessed the sortie as properly planned and therefore rejected planning as a factor.
At page 2-21, para 45f they state:
However, the Board also believed that if the lead pilot had had a fuller situational awareness, he would have realised that the descent was taking the ac directly towards high ground in the vicinity of a peak standing at 4296ft. The Board, therefore, concluded that the lead pilot's lack of situational awareness was a contributory factor in the accident.
At page 2-27, para 47 sub para c(2) they state:
In this accident, the F-15Cs had adequate navigational means to monitor their position and were aware of their RAA, but nevertheless, the aircrew must have lost situational awareness with regards to the exact position of the high ground that they impacted. The Board believed that, had the pilots had knowledge of the minimum heights that ATC could safely descend them down to and had they known exactly where they were in relation to high ground, then they might not have been so trusting of the ATC instruction to descend to 4000ft. In summary, the Board felt that the practicalities of pilots complying with current regulations were not directly a causal factor in the accident, but nevertheless, identified that it is an issue that should be addresses in order to minimise the risk of pilots accepting potentially unsafe ATC descent instructions.
We are not sure what the BoI actually mean in the last sentence of the above para but they do seem to be contradicting themselves before that in their other statements. They are completely intent on discounting the evidence from weather forecasts and R/T tape transcripts that BITE 21 flight were descending in VMC, in order to satisfy their view of the cause of the accident; this is hardly a balanced view. Let us not forget that the lead pilot was very experienced on the F15, with 1,700 hrs on type, and had previously been an Instructor Pilot and Evaluator Pilot on the same type; he would have had immense experience in determining situational awareness from the navigational aids available.
His sortie was correctly planned, he was weather briefed, he was carrying a Low Level map on which he had marked his RAA of 5700ft (the annotation was made close to Ben MacDui). Additionally, he was on his own navigation following his pre-planned route using INS to his next waypoint (Aviemore. W/P 10) which took the flight very close to Ben MacDui. We suggest that the leader of BITE 21 flight knew exactly where he was and that he was flying in the weather conditions he would have expected from his pre-flight brief. During the stage of flight from top of descent, the flight leader should not have been under a particularly heavy workload and we can see no reason why he should have lost 'situational awareness'. Furthermore, there is no evidence for the BoI to conclude that he lost situational awareness. They simply refuse to accept the possibility that, this immensely experienced pilot, passed his RAA of 5700ft because he was in sight of the surface. The theory put before the GCM by the defence QC was, that as the flight approached the Ben MacDui area, their descent into low level on their pre-planned route using INS was blocked by visible cloud. We see no evidence to contradict this theory. This is completely in accord with the USAF Report page 14, para
7,sub para c (1) which we re-state:
Forecast weather for the route of flight was for scattered to broken cloud layers at 2500ft to 8000ft, enabling VFR flight, even though it is likely that the tops of mountains could be obscured. With the weather as forecasted, some manoeuvring would likely be required to avoid clouds and to remain VMC.
We believe that leader then elected to continue descent avoiding this cloud and entered low level and went below radar cover and out of R/T contact. Whilst in low level flight, the leader was attempting to regain his pre-planned route when BITE 21 impacted terrain in probable whiteout conditions that were prevalent throughout the area. It was while trying to reposition to the planned route that the flight was seen by several very credible eyewitnesses. This theory was put forward by a very experienced Test Pilot who had much low level experience, was current on the Typhoon and had completed an exchange tour on the F15.