7. Board of Inquiry Procedures.
The terms of reference for a BoI state that the process is not to apportion blame. We assume that the Station Commander Leuchars, AOC 3Gp and the CinC are considered to be part of this process. If that is the case, then they we believe they may have exceeded their remit by making the following comments which we construe as apportioning 'blame'. The controller concerned is mentioned by name in parts of both the Station Commander's and CinC.
Station Commander on Cause:
I did not find the arguments over "instructions" wholly germane to the question. I accept that the "instruction" from air traffic to the formation was not an order but it was reasonable to assume that the crews would comply with the "advice" given and doing so placed the aircraft and crews in an unsafe situation. I am therefore content that the Board's determination of the cause of the accident is soundly based. Indeed, I would go further and suggest that the word "potentially" should be deleted from the Cause, as the "instruction" given was clearly unsafe.
Comments by the Air Officer Commanding:
A BOI does not apportion blame and I note that none has been apportioned in this case
and later,
I support the Board's analysis of causes and factors other than finding myself in agreement with the Stn Cdr that the cause of the accident was that the formation accepted an unsafe ATC instruction rather than one that was potentially unsafe.
Comments by Commander in Chief
I am therefore in no doubt that the Air Traffic descent information " BITE 21 descend initially 4000ft on the Portree 29.62" was unsafe, and I agree with my Stn Cdr and AOC 3Gp that the word "potentially" be removed from the Board's Cause for the accident.
8. BoI Conclusions.
We are of the opinion that the BoI conclusion was formed very early on in the process and that a disproportionate credence was afforded to the favourable evidence. Evidence contrary to their conclusion was either discredited or discarded. Their report lacks the balance that would suggest a fair investigation. We cannot understand how the BoI can come to a conclusion as to the most likely cause of this accident without proving the balance of probability. As an example of their approach, they say in their Summary of Causes and Factors at page 2-31 para 49c that one of the contributory factors was:
The Pilot's lack of situational awareness with regards to his position relative to high ground.
This is an assumption, not a fact. Where is the proof to warrant this statement ? It is not in this report.
9. Summary.
We can find no evidence to support the BoI's conclusion that:
This accident occurred because the formation accepted a potentially unsafe ATC instruction and descended without sufficient references to avoid hitting high ground.
Although we can see the BoI's line of enquiry linking the crash site and a very close last radar sighting, it is inexcusable, without an established time of impact, to discount very credible eyewitness reports that demonstrated a very definite flight path and formation flown by the F15s that could not be associated with the Tornados in the area earlier and which had landed some 30 minutes prior to the estimated time of the crash. The compelling evidence, from known weather conditions and tape transcript information suggests that the aircraft descended in VMC conditions; they never reported that they were IMC. In support of their theory, the Board insinuates a lack of professional navigational skills by the flight leader that does not accord with his proven experience and ability. The subsequent eyewitness statements indicate that BITE 21 flight had made a successful transition into LFA 14 before crashing, in probable whiteout conditions, close to Ben MacDui, possibly while trying to regain their pre-planned route. The report by this BoI was sometimes factually incorrect and contrary to evidence in the USAF report or to that given under oath at the GCM. Their investigation lacked balance and failed to provide a satisfactory balance of probability to support their theory as to the cause of the crash. Furthermore, we believe that the higher authority has exceeded the remit given to the BoI procedure, by apportioning blame. This occurred when the actions of the Air Traffic Controller were highlighted as a contributory cause. We shall be lodging an appeal against these findings.
Dick Doleman
GCM Defence Support Group
12 Feb 2006