Lurking123 is correct to point out that other CFIT accidents did not draw the same responses by staff officers as those produced by Wratten and Day after the Mull crash. For example, Hercules XV193, also from Strike Command, crashed in Scotland in 1993. The BOI could not be sure of the cause as there was no CVR/ADR, nor witnesses to crash itself; any findings were 'conjecture' (MoD's words, not mine). This was a similar scenario to that of ZD576 but the crew of the Herc were, quite rightly, not found to be grossly negligent. However, Tapper and Cook were treated differently....why was this? Why was precedent ignored?
VP
You are quite correct to point out that the immediate root cause of the crash of ZD576 was that they crashed into a hill. However, I think you'll find that the concept of a single 'root cause analysis' is an outdated one.
In many accidents, there are local 'active' failures but also organisational 'latent' errors; this is called the Reason Model and is widely used and forms part of ICAO Annex 13.
Tuc rightly draws our attention to the possible 'latent' failures in the defences and safeguards of the organisation (ie the holes in the layers of swiss cheese). It is certainly possible (Tuc would say probable) that the MoD failed to maintain Airworthiness in the Chinook at this time (local engineering instructions to be performed in the air). This has been shown and admitted to by the MoD in the Nimrod XV230 enquiry - the same Senior Officer that looked after Chinook and the Hercules. One could even argue that airworthiness and possible FADEC failure/glitches are only one of a number other possible latent failures, which were not fully investigated at the time - because the AOC said so and because it was common practice). Instead, the BOI directed their attention to the local 'active' failings by the crew on that day (ie they unintentionally flew into cumulo-granite.... for some reason, which will forever remain unknown).
In 1994, blame was apportioned only if the facts were absolutely incontravertable. Even if that was the case (and I don't believe it was), have we not evolved from the bad old days of 'blame and shame'? Accident investigations in this more enlightened age should consider the Reason Model's 'latent' errors, as well as the unsafe acts that lead, more directly, to an accident. I am not sure that the MoD followed best practice - then in 1994 - nor perhaps, even now.
Sadly, it is understandable why the RAF hierarchy did what they did, especially considering the emotive loss of most of NI's counter-terrorism experts. Inherently, it is more 'psychologically satisfying' (and easier) for the organisation to blame an individual for the last error in the chain but I would argue that to continue doing so shows a lack of clarity in one's logic and reason and also a blinkered approach to the true aim of the investigation - to prevent recurrence.
If the BOI of ZD576 had been allowed/instructed to delve a little deeper than the obvious root cause of the crash, perhaps the crews of Hercules XV179, Nimrod XV230 and Sea Kings XV650 and XV704 would be alive today?
Numerous accidents and incidents such as the Herald of Free Enterprise, Clapham, Chernobyl, Dryden, Erebus et al have cited the pre-disposing conditions of organisational error (eg lack of training, supervision and/or poor risk/resource-management etc) as having made major contributions to the accidents. This modern approach is 'best practice'. Is it not time for the MoD to join the 21st century? Regrettably, they cannot (or will not) because, after an accident, the very people commanding the investigators will themselves come under scrutiny - yet I live in hope that things will change.
JP - I didn't mean to 'stir your sh!t'! I may have hit a nerve but I'm afraid that your answer leaves doesn't really make things any clearer to me. Try asking yourself why would an experienced and most capable pilot fly into a hill? One thing is for sure; it was not on purpose!
Also, your appreciation of low-level and safety altitude confuses me - if an ac is at LL then, by definition, it is below safety altitude - all of the time. There may well be cloud obscuring the high ground; that does not make it illegal (clear of cloud, in sight of the surface = VMC for helos, I think it was then) - in fact, it is 'situation normal' for most LL ops in the UK, as I'm sure you are aware. 150kts (not confirmed) is NOT high speed - it may have been quick for a Chinook, mind you but it is not fast. But if an ac then goes into cloud, the pilot should always try to climb as expeditiously as possible, in a safe direction, up to safety altitude - every single bit of training I ever received or gave in the RAF reinforced this and we have NO reason to believe that the crew of ZD576, nor anyone in the Chinook fleet, would have done differently. (Here, I assume that this was also SOP for the Chinook fleet - if not, then why not?)
If they had flown into cloud that day, it would be reasonable to assume that they would have followed their training - but, if they were in cloud, why didn't they do so? That question is as unfathomable now as it was then but it doesn't necesarily mean they were grossly negligent.
You talk about 'facts', well these are the facts:
The fact is that no-one really knew what the weather was actually like in the area at the time nor when or if ZD576 entered cloud (with due deference to the sailor, his view of the weather and the ac speed is, at best, a guess).
The fact is that no-one can be sure of the goings-on in the cockpit - visual illusions, distractions and a loss of SA come in many shapes and sizes (even fly-shaped!).
The fact is no-one can be totally sure of the integrity and performance of the ac, its systems, nor its powerplant - despite what the manufacturers say.
The fact is that no-one really knows what were the thought-processes of the crew, nor their plan, nor their actions.
The fact is that most of the BOI 'findings', everything talked about in the H of L and almost everything written on this site is conjecture because there was no ADR/CVR.
The fact is that no-one will ever really know what happened that fateful day.
With this as a backdrop, I argue that it was wholly inappropriate for the crew to be found grossly negligent and it is now time to change that ruling.
Please let the crew, the passengers and their families rest in peace.
Last edited by flipster; 26th Mar 2009 at 09:04.