Aircrew Manual
I am reluctant to enter the debate on yet another topic, but given the posts of W5 and yourself regarding the Aircrew Manual I wondered if the following extract from my full Engineering Assessment of Oct 03 would help shed further light on the topic. The extract relates mainly to the FRCs, where the Board did take some evidence, but as far as I can see no serious attempt was made to assess the rest of the aircrew and engineering publication, despite their key role in the airworthiness chain.
Extract:
One of the concerns in all that has gone on in the various Inquiries since the accident and the many questions in Parliament and elsewhere must be that MOD does not appear to have carried out any form of serious, and independent, internal review of the issues being raised for themselves. Everything in this Review is from public domain information – MOD would have the advantage of having a lot more information to either support or disprove the comments being made. Instead MOD has hidden behind the “flag” of no new evidence (although if they looked they would see plenty of unused evidence), and has continued to ignore or even obfuscate those “facts” and questions that they do not like. A classic example of this relates to the FRCs:
Questioned by the Board Witness 20 was asked:
Question:
“Were these malfunctions covered by drills in the Chinook HC2 Flight Reference Cards (FRC)?”
Reply:
“No, the Chinook HC2 FRC were based primarily on the Chinook D model, which is not fitted with FADEC. Drills relating to FADEC were based on the best information on how the system would respond during certain malfunctions.”
Question:
“Were there any areas where the Chinook HC2 FRC, valid on 2 Jun 94, were confusing?”
Reply:
“Yes, a number of emergency drills, in particular electrical and hydraulic, were poorly laid out and required the crew to be familiar with the drill to avoid confusion. The shortfall in the Chinook HC2 FRC was discussed with crews during their conversion courses.”
In their findings the Board, at paragraph 46c comments:
“The relative inexperience of the crew on the Chinook HC2 could have amplified the degree of distraction created by even a relatively minor technical occurrence. Any distraction could have been further amplified by the poor guidance provided by the Chinook HC2 Flight Reference Cards.”
In their observations at paragraph 70a the Board states:
“The Chinook HC2 FRCs valid at the time of the accident were confusing.”
Despite the fact that the Board has identified the FRCs as an issue (and the place of FRCs in the airworthiness “chain” is a key one) this is not followed up. The “relative inexperience” of the crew raises the issue of why the Chinook HC2 was chosen for such a high profile passenger sortie – this is not followed up at all by the Board. (It is interesting to note that the HC2 was used despite a request from Flt Lt Tapper to retain an extra HC1 in Northern Ireland “because of the limited operational capabilities of the HC2 due to its Controller Aircraft Release” – statement by witness 11). The same witness also confirms that he was happy with Flt Lt Tapper’s ability to operate the HC2 inter alia, “because he knew his way around the Chinook HC2 Flight Reference Cards, which are particularly confusing”. (Hardly a ringing endorsement for the suitability of the HC2 for passenger operations, although further confirmation that Flt Lt Tapper was taking the problems of the HC2 seriously.)
It is also interesting that apart from the FRCs the Board, despite the clear implications of statements such as those from Witness 20, makes no attempt to assess the completeness and effectiveness of the rest of the Aircrew (or Engineering) Publications system – nor did the TORs of the Board ask them to do so.
Of further interest is that MOD officials seem to have deliberately misinformed Ministers, and they in turn Parliament, about the true situation with the FRCs. On 13 June 2000 Mr Brake raised the following written Parliamentary question:
“To ask the Secretary of State for Defence if his Department requires manufacturers to provide complete flight reference cards prior to releasing an aircraft into operational service; if the Chinook Mk 2 had a complete set of flight reference cards at the time of the fatal crash of ZD 576 in June 1994, and if these included drills covering the possibility of FADEC malfunctions. [125300]”
In his reply Mr Spellar said:
“All manufacturers of new Ministry of Defence aircraft are contractually required to provide full aircrew documentation prior to release to operational service. This documentation includes both Aircrew Manual and Flight Reference Cards. The Chinook Mk 2 had a complete set of Flight Reference Cards in June 1994. This contained all the normal and emergency operating drills in force at that time, including drills for a possible FADEC malfunction.”
I am sure that MOD chose its words very carefully and they are probably all in the strictest sense true – however, they do not reflect the Board’s findings and the real situation facing the Chinook HC2 aircrews, and one has to wonder why MOD chose to offer this apparent misinformation.
JB