Reply to Cazatou
I would have hoped that you might have had an opinion as to the possible relevance of the Airworthiness questions even if you did not feel qualified to comment on them. The pilot concerned with the initial PTIT problem in NI was Lt Kingston not Flt Lt Tapper – when Tapper had the same problem the next day (the sortie before the accident) he was assured by the ground crew that it was just a gauge problem, and, possibly wrongly, he did not pursue the problem further – was this a major servicing error in the light of events?
From your comments you may have been closely involved, in which case I have to respect your opinion, but I base my comments on the BOI being biased towards aircrew error by the almost total lack of a credible engineering investigation of the issues involved (including in the review process) and the Board’s own opening statement:
“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.”
I am disappointed that you ignored the fundamental question, namely:
“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?”
The Glen Ogle accident involved a Tornado crashing inverted at high speed after the pilot had made control inputs that led directly to the accident. Nobody knew why the pilot made these inputs. There had been no conversation between pilot and navigator for the 20 seconds prior to the crash and the navigator was absolved from any blame. To refresh your memory further I can offer the following BoI extracts:
EXTRACT FROM BOI PROCEEDINGS INTO THE CRASH OF TORNADO GR1A
ZG708 IN GLEN OGLE PERTHIRE ON 1 SEPTEMBER 1994 (Full document with some deletions placed in House of Commons Library)
HYPOTHETICAL RECONSTRUCTION OF EVENTS IMMEDIATELY PRIOR TO
THE CRASH
45. Evidence from BAE Warton confirms the integrity of the ADR and shows the aircraft to have been flying in full CSAS with SPILS selected when it crashed. Moreover, the BAE report also states that the roll and pitch demands immediately prior to the loss of the aircraft were the result of pilot inputs. The Board considered that the most likely explanation for Flt Lt XXXXX pitch, roll and throttle demands was that they represented a response to a startling event, such as a sudden encounter with a large bird. The extreme nature of the control inputs also suggests a very startled reaction. While the above explanation might account for the reaction it does not fully explain why Flt Lt XXXXX decided to roll further right when already at a high angle of bank. However, an unconsidered, ie inappropriate, response would become more likely if Flt Lt XXXXX was distracted in the seconds leading up to the startling event.
47. Having made the roll, pitch, throttle and finally, slat demands in response to a startling event, evidence from the BAE model indicates that the aircraft was not recoverable soon after the pilot rolled right and applied additional aft stick. Notwithstanding this evidence, Flt Lt XXXXX quickly found himself in an extremely unusual position, possibly combined with a degree of misorientation. He may have been incapable of correctly recovering the aircraft in the time available.
CONSIDERATION OF HUMAN FAILINGS
53. The Board have been unable to determine positively the cause of - the accident. Notwithstanding this fact, the Board concluded that there was little doubt that the control inputs immediately prior to the crash had been made, either voluntarily or otherwise, by the aircraft pilot, Flt Lt XXXXX. Moreover, the Board concluded that Flt Lt XXXXX control inputs, once made, had led rapidly to the aircraft being placed in an irrecoverable position from which it subsequently crashed.
54. Flt Lt XXXXX flying record is excellent and the Board have discovered no evidence which suggests that Flt Lt XXXXX was indulging in in-disciplined or reckless behaviour. However, since Flt Lt XXXXX control inputs led directly to the loss of the aircraft, the Board concluded that Flt Lt XXXXX"s actions constituted an ERROR OF JUDGEMENT and therefore the Board recommends that he be absolved from blame.
Remarks of Station Commander/Commanding Officer
1 I am satisfied that the Board has carried out a thorough investigation into this mysterious and tragic accident. I agree the findings, with one important exception. I accept that, of the choices that they considered, the Board has selected the most plausible reconstruction of events leading to the accident. However, it is only a hypothetical reconstruction which is necessarily heavily caveated and which cannot positively exclude alternative explanations. The fact remains that, albeit for understandable reasons, the Board has been unable to establish beyond doubt what caused ZG 708 to manoeuvre in such a way that it crashed.
2. The term "error of judgement" involves a finding of an honest mistake accompanied with no lack of zeal where a person, through no fault of his own, and whilst exercising the degree of skill which could reasonably be expected, makes an inappropriate response. Given that we do not know exactly what happened in this case, I find it unwise to find that Flt Lt XXXXX made an Error of Judgement. I believe that it would be unwise to draw any conclusions as to human failings because there is too much scope for conjecture. I do not accept, therefore, therefore, the Board's conclusion that Flt Lt XXXXX made an Error of Judgement:. I recommend that there should be no finding regarding human failings.
19 Dec 94 Stn Cdr
PART 4 REMARKS BY AIR OFFICER COMMANDING
1. I am satisfied that the investigation into this most bewildering accident has been commendably thorough. It is unfortunate that,, in spite of their exhaustive efforts, the Board have been unable to determine a definite cause of the accident; nevertheless, a critical examination of the evidence has eliminated a large number of possible causes. Moreover, overwhelming evidence indicates that the aircraft responded both directly and appropriately, to control inputs, either voluntary or otherwise, which were initiated by the pilot and led ultimately to the loss of the aircraft. The Board's dilemma has been an inability to determine why the pilot might have initiated the control inputs; however, they have established beyond reasonable doubt that the pilot manoeuvred the aircraft in a way which led to the crash.
2. It is difficult to comprehend why such an uncomplicated sortie should end so catastrophically. The sortie profile was well within the capability of the crew, and it was flown in a serviceable aircraft and conducted in good low-flying weather conditions. During their investigation, the Board discounted many potential causes. On the basis of the available evidence, particularly that of the Accident Data Recorder (ADR), I accept the Board's conclusion that the aircraft crashed as a direct result of control inputs which manoeuvred it into a perilous attitude with respect to the ground. In assessing why the aircraft should have been manoeuvred in such a manner the Board cited 3 probable causes: an unconsidered response to a "startling event", a control restriction, and medical incapacitation. There was no evidence of a control restriction. Medical incapacitation, -although it could not be discounted, was statistically very unlikely. Therefore, on the evidence available, I agree with the Board that Flt Lt XXXXX unconsidered response to a "startling event" is the most plausible cause. It would not be unreasonable to suppose that the late sighting of a large bird might have prompted him to initiate a rapid roll away from the hazard, and this manoeuvre would cause him instinctively to select full power. Even so, he should have had the necessary degree of skill to fly the manoeuvre safely. In view of Flt Lt XXXXX limited experience on the Tornado GR1, it is however possible that his inappropriate reaction, coupled with a degree of misorientation, could have resulted in the aircraft being placed in a situation from which he was unable to effect a safe recovery.
3. I now turn to the consideration of Human Failings. The Board is not required to establish beyond all doubt what caused the accident. Where an Inquiry has identified that Human Failings were either a cause of, or a contributory factor to, an accident, these failings must be considered carefully and categorized properly. Although often difficult, the question of Human Failings must always be answered. I am unable to accept the Station Commander's view that it would be unwise to draw any conclusions as to Human Failings. In the "startling event" scenario, it is possible that, having been faced with a split second decision to take avoiding action, Flt Lt XXXXX may have made an inappropriate response; I consider that this would constitute an Error of Judgement. Whilst, the Board concluded unequivocally at paras 53-54 that Flt Lt XXXXX control inputs led directly to the loss of the aircraft and constituted An Error of Judgement, they could not ascertain absolutely why he initiated the control inputs. The possibility of either a control restriction or medical incapacitation could not be entirely ruled out. I, therefore, consider that Flt Lt XXXXX Error of Judgement should be qualified as having been the most likely cause of the accident, rather than the definitive cause. Regardless of the circumstances of this particular accident, I agree that Flt Lt XXXXX should be absolved from blame.
AVM
3 Mar 95 AOC I Gp
PART 5 REMARKS OF AOCinC
1. Notwithstanding a thorough investigation and. the availability of evidence revealing the precise activities of the crew up to the point of impact, there is no explanation for the final manoeuvre flown by Fit Lt XXXXX. Bewildering is the only description of these inconclusive circumstances, and I find the hypothetical reconstruction offered by the Board of limited usefulness.
2. In my experience a startled pilot either "snatches" at the controls or, more likely, does nothing; he is not inclined to fly what in this instance resembled the "break" manoeuvre, with rapid but coordinated and simultaneous control inputs and, most unusually, unaccompanied by any word of warning to his navigator. (I disagree with the AOC's assertion that the selection of full power instinctively accompanies rapid roll inputs; it is a conscious selection). But why Fit Lt XXXXX entered such a "break" we shall never know and here I note the important evidence of the Principal Psychologist regarding the incredible nature of the notion of suicide. It is therefore because there is no scope for conjecture (and not too much scope, as the Station Commander, believes) that I find any consideration of human failings to be academic and fruitless. Despite the wealth of detailed evidence, we are confounded and under these particular circumstances I consider it is futile to indulge in hypothesis.
Dictated by AOCinC, STC
and signed in his absence
18 Apr 95
So in the case of the Tornado the system knew exactly what had happened but not why and the Reviewing Officers’ comments on this are, in my view, quite amazing. In the case of the Chinook we do not know either what happened or why it happened, but the system is quite happy to continue to accuse two dead pilots of a major criminal offence on the basis of hypotheses (not just my view - see the HofL comments). Perhaps you could give me your views on the consistency of RAF justice at the time.