What Would You Have Done
I must support Brian Dixon’s comments above – I was once SEngO on ACM Wratten’s Phantom Sqn (23 Sqn) and found him a great boss to work for. I did not work for him later in his career and cannot therefore say whether some of the comments I have seen on this site are justified or not. However, this does not stop me believing that his and the then AVM Day’s decision to find gross negligence was an incorrect one – indeed I have actually written to Sir William and told him that I believe he made an error of judgement – as Brian says none of us are infallible.
Cazatou asks “what would you have done” and in terms of the last 60 seconds of flight he knows that nobody can answer that since we do not know what was happening and never will until time travel comes along. And this is surely the whole point – because none of us know the pilots should not have been found grossly negligent – this is the error of judgement by the Reviewing Officers, and it has probably had the opposite effect to what they hoped for, as far from “putting the issue behind the RAF” it has caused a much wider issue now relating to the whole introduction to service of the Chinook Mk 2 and duty of care exercised by the RAF to be called into question.
I am sure that for sound operational reasons the RAF had to go against the published Boscombe Down advice, which was “unable to Recommend CA Release for the Chinook Mk 2 aircraft” and insist on taking the Chinook 2 into service – and many of you will know that an Interim CA RTS was issued in November 2003 – the Board confirms that the aircraft was indeed being operated within these limits on that fateful flight, and I am not aware that anyone is questioning the RAF’s judgement in making the decision to bring the Chinook Mk 2 into service. However, this judgement carried flight safety risks, albeit reduced as far as possible by flight restrictions, and it may be (for we will never know) that these risks culminated in 29 deaths on the Mull of Kintyre in June 1994.
I have not seen the equivalent RAF RTS but, having gone against Boscombe Down advice, one has to assume, with the flight limitations that we know existed, that the RAF was operating to the equivalent of what JSP 318B then defined as either Reduced Operating Standards or Military Operating Standards. These were defined as;
ROS – a lower standard than NOS, used where the urgency of the mission justifies a reduction of the safety margins. Use of the ROS involves higher than normal risk. Authority to use the ROS is restricted. The authority required, guidance on the risk involved, and related operating techniques will be specified in the ODM.
MOS – a lower standard than ROS, used where the urgency of the mission justifies a further reduction of the safety margins. Use of the MOS involves a higher risk than that for ROS. Authority to use the MOS is restricted. The authority required, guidance on the risk involved, and related operating techniques will be specified in the ODM.
Let me turn Catazou’s question round and go back to basics (and also point out that I don’t know all the answers either!):
Would you have introduced the Chinook Mk 2 into service without an ADR and CVR to save money even though every other aircraft coming into service at that time was being fitted with this equipment?
Would you have gone against the “expert” operational advice to bring the aircraft into service with very significant known operating problems eg engine fail captions that may or may not be spurious, engine run-ups and run downs, etc etc, to meet operational requirements?
Would you have allocated an aircraft type with all of these known problems to a non-operational VIP flight, and against the specific request of the Aldergrove detachment commander?
Even if all you had available was a Mk2 would you have allocated ZD 576 with its defect history (largely unresolved at the time of the accident) and knowing that it had suffered an in-service defect that was one of 4 being used by Boscombe to justify stopping flight trials, for this mission.
Knowing the defect history of the aircraft would you have let some illegal maintenance be carried out on the “problem” engine system at Aldergrove without investigating further (and remember even the BOI confirmed that the aircraft had an incipient electrical fault in its No 1 Engine System when it took off for Inverness).
Would you have held a Board of Inquiry that basically assumed aircrew error from the start, that did not look at the introduction to service and airworthiness issues to see if they could have contributed to the accident and did not follow up the technical evidence it found? In my view on the engineering side, and in the subsequent review procedures, the Board was both inadequate and biased, but even then I would have to say that they made a good decision in only going for a balance of probabilities verdict.
Knowing all these other issues in even more detail nearly a year later would you have found the pilots guilty of the criminal charge of “Gross Negligence” against your own rules – rules that were there to protect dead aircrew from such a charge in the absence of being able to defend themselves?
Would you consider whether there was an inconsistency of RAF justice when comparing the verdict on the Chinook with that on the Tornado crash in Glen Ogle in September 1994?
These questions do not have any relationship to, or call into account, either Sir John’s or Sir William’s previous service records and integrity, but that record does not mean that their decisions on ZD 576 are above question, or even, in my view and that of many others, including all of the independent inquiries, correct!
JB
PS Have got an ex Lightning Pilot for lunch today - hope he's not too tough as he has to be old!