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Old 15th Mar 2009, 23:23
  #4080 (permalink)  
flipster
 
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Caz

As an impartial but interested observer (retired from a different fleet), I don't really understand why you and so many others, are so blinkered to the possibility that the 'official view' (both then and now) does not meet the burden of proof required to tarnish for ever the name of Flt Lts Tapper and Cook. I think the time has come to move on; why cannot you and the others (and the Gov't) see that? What drives you to such stubborness?

In the first instance, you persist with the notion that not having breakfast indicates that Flt Lt Tapper was a persistant breaker of GASOs ASIs etc and, even if this was the case, this does not PROVE that he was negligent in flying that particular sortie, nor does it prove how it was flown. I cannot see there to be a credible link here; it sounds as if you are clutching at straws a little. Perhaps it is time to put that one to bed?

Additionally, you and others dismiss entirely the possibility, however unlikely, of a number of potential aggravating factors - admittedly they are difficult to prove but they also difficult to disprove. It has been pointed out that neither you, nor anyone else alive, really knows what happened that day. Ergo, one fails to see how the burden of proof for gross negligence is satisfied.

For example, you dismiss out of hand the observations of S/L Burke - what gives you the right so to do? It seems as if he could be an expert witness to whom we all should listen? Why do you think his evidence/opinion should be totally discounted?

Also, you are sceptical of assertions of Tucumseh (whom I know to be highly knowledgable in the fields of airworthiness and procurement) that:

a. If the ac was being operated in such a way as described (a local engineering instruction to carry out a maintenance procedure in the air, by non-engineers - to check the integrity of the DECU connectors every 15 mins), then de facto, the ac was not airworthy - as mandated and defined by JSP 553 and a whole host of Def Stans.

b. If the MoD cannot disprove this (which it seems impossible to do), then a cold audit trail in the Safety Cases and Hazard Logs etc at the IPT is a smoking gun that points directly to the MoD failing to maintain the build standard/airworthiness of the ac. If the ac was serviceable but not actually airworthy however, it doesn't actually make the MoD totally blameworthy but it surely absolves the crew to absolute guilt?

Furthermore, as a fairly seasoned operator at LL in the hills of Scotland, I fail to see how just because you cannot see the hill tops, you are somehow negligent by maintaining 'VMC below'. It is also apparent that there is some confusion as to how bad was the actual weather at the time. I suggest this undermines somewhat your 'black and white' approach to "could he or could he not see the Mull?" Again, no-one is ever going to be sure what was visible out of the office window or why he manoeuvred as he did. Who knows if the pilot wasn't distracted by a fly, an itch, something in his eye, a minor cockpit indication, or even a transitory engine malfunction at this time? We JUST DON'T KNOW for sure.

It is also apparent that there is some confusion as to the speed and ROC of the ac as the crew penetrated cloud, as they eventually did do - even Boeing's best guess seems like a stab in the dark. Helos do not zoom climb like jets, as you well know - but this is a fact that may have been lost on some? That is even before the possibilities of engine/control trouble. I find it strange, if not astounding, to note that the assertion that the E5 fault had no relevance. Unfortunately, I am not qualified to say for sure - other than to say that if this was found to have been indicated as relevant in another ac incident, then it would be a brave or foolish person to totally discount the possibility of the fault having some bearing on this accident.

Ultimately, I appreciate that back in the 1990s, it was more likely that QR1269 etc would rear its ugly head. But when we look back now, it is incredible to believe that some people cannot see that the findings of the senior officers might have been flawed, even if they might have been understandable at the time from their POV. Fortunately, we have evolved since then, have we not? Professor Reason's swiss cheese theory is widely accepted everywhere - even in the military where it is often quoted in FS training courses. While the crew may have made a slip, a lapse or even an error of judgement, it is very hard to argue that they definitely made a negligent violation - given the information available to the senior officers even then. Its not like they flew upside down under a bridge in the full view of CinCStrike?

I cannot believe that in hindsight, one is not able to see the 'big holes in the slices of cheese' that failed to protect Flt Lts Tapper and Cook from perhaps the most human of errors. If you search through modern investigative checklists - there are a whole host of possible influences that were not, in all probability, covered by the BOI; most probably for the simple fact that they were neither instructed nor expected to follow such lines of inquiry. Even these days, the instructions/TORs given to BOI/SIs come from the very people who might have a bearing on the organisational factors surrounding the case ie the AOC. (That is one reason why I believe the days of BOIs/SIs are numbered; they just don't reflect current 'best practice'.)

In those days, some people may have felt comfortable with findings of gross negligence (strangely the BOI itself did not) but I would hope that such people can now see that this is certainly no longer 'best practice' and in almost every case known to aviation, it is not acceptable to blame solely the 'local causes'; the organisation always has its own part to play. Sadly, this was outside the remit of the BOI in 1994. In fact, blame is no longer to the aim of modern investigations - it is to prevent recurrence. A distinction apparently lost to some.

Almost 15 years has passed and it is now time to right the wrongs of history, the families of the crew and of those who perished deserve their peace. Messrs Crawford, Day and Wratten did what they thought was right.....as seemed acceptable in those days. I don't blame them. Now, however, I would like to think that men of such intellect can see that their perspective was based on an out-dated methodology and logic, which is no longer credible. I doubt if anyone wants protracted legal/parliamentary debates; just the acceptance that, in hindsight, no-one will ever know for certain what happened that day and it is meet and right to let the ghosts of Mull sleep easy by dropping the claims that the crew were grossly negligent.


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