Chinook - Still Hitting Back 3 (Merged)

[John Blakeley]

What the Yachtsman Really Said

Caz,

Dalek has really made the major point, but I should remind you of what Mr Holbrook really said when he was questioned properly as opposed to his evidence to, and its apparently superficial analysis by the BoI. The HofL took some time over this and this is what they said:

Weather
63. The state of the weather was crucial to the conclusions of the investigating board and of the two Air Marshals. Two witnesses gave oral evidence to the Board as to weather. First Mr Murchie, a keeper at the lighthouse, spoke of visibility there being some 15-20 metres, but 400-500 metres to the north. The Board asked him no further questions about weather. The second was Mr Holbrook, the yachtsman, whose initial statement to the Strathclyde Police contained an expression of opinion "that the helicopter pilot would have been in a position to clearly see the local land mass". In his statement to the Board Mr Holbrook said that the aircraft was well below cloud level and visibility was about a mile limited by haze. At the time he was about two nautical miles south west of the lighthouse. He was asked three questions by the Board of which one was relevant to weather, namely whether he could see the physical features of the cliff on the Mull. To this he replied "no".
64. When he gave evidence at the FAI Mr Holbrook expressed the opinion that the pilot could have seen "the location of the Mull lighthouse" and described the low cloud as "hugging the Mull" (Sheriff's determination, p 110 of HL Paper 25(ii)). He was criticised by the Ministry of Defence for having given different versions of his account to the Board and the FAI. In these circumstances we invited him to give evidence, an invitation which he willingly accepted.
65. Mr Holbrook's evidence to us began with a statement which he had asked leave to make (Q 594). He explained that the low cloud clung to the contours of the high ground so that the location of the Mull massif itself was not in doubt from sea level. He considered that the crew of the aircraft when he saw it could determine without ambiguity where the Mull was and could see the cliffs, beach and lower perimeter walls of the lighthouse complex.
66. Mr Holbrook reaffirmed that when he saw the aircraft he could not see the physical features of the Mull but he went on to explain that he was able to see the location of the lighthouse complex because the buildings and the white perimeter wall showed up as a colour change against the background of the land mass (QQ 594, 602). The top of the lighthouse was in cloud as the cloud level moved up and down (Q 606). Mr Holbrook went on to explain that the cloud was following the contours of the land and was very localised (Q 615). He also remarked, as he had done before the Board, that the helicopter was in sunlight as it passed (Q 619). At that time the aircraft was about two miles to the south west of the lighthouse. He expressed the opinion that the aircraft was flying at a height of between 200 and 400 ft and that the crew would have been better able to see the position of the lighthouse than he was at sea level with a certain amount of spray (QQ 610-13). He estimated the speed of the aircraft to be 60-80 knots but did not feel confident enough to be dogmatic as he had not previously seen a Chinook in flight. However, it was his impression that the aircraft was travelling sufficiently slowly to be involved in a search and rescue operation (Q 639).
67. We do not consider that Mr Holbrook changed his evidence between his appearances before the Board and the FAI, rather that when he was subjected to professional examination and cross-examination at the FAI and to our questioning he was able to expand upon the rather brief evidence which he had given to the Board. We had no hesitation in accepting him as a reliable and convincing witness.
68. In his statement to the police and in his evidence to us Mr Holbrook referred to the fact that the trawlers round which he was manoeuvring appeared to be Scottish as one of them had St Andrew's cross painted on the superstructure (Q 630). When Wing Commander (now Group Captain) Pulford gave evidence to us he was asked whether the Board sought evidence from any of the fishing vessels referred to by Mr Holbrook. He replied that they had tracked down the fishing vessels to Northern Ireland and the RUC could neither find anybody who had seen the aircraft nor trace some of the boats (Q 11).
69. It is perhaps surprising in view of Mr Holbrook's statement to the Strathclyde Police about the trawler with St Andrew's cross on the superstructure that that force were not asked to pursue the matter. It is perhaps even more surprising that the Board asked Mr Holbrook only one question in relation to weather and used the answer as a component in the construction of a theory as to the probable course adopted by the pilots.
70. Mr Holbrook explained to us that he had repeatedly but unsuccessfully asked to see photographs of a Chinook at different heights and ranges, in order the better to estimate the height and speed of the aircraft when he saw it. He clearly felt that he would have been in a better position to assist the Board had he been furnished with such information. We do not know why the Board did not accede to his request or afford him the opportunity of seeing a Chinook in flight.
71. The statements taken by Strathclyde Police which dealt with weather were all from persons on the Mull at or above the height of the lighthouse and did not therefore throw light on the extent to which the land mass could be seen from an aircraft approaching from seaward. These persons all spoke of being enveloped in cloud to a greater or lesser degree.

You are finding Gross Negligence based on something even the BoI appeared to accept that they never intended to do (and incidentally the major non sequitur in the BoI's findings). They planned to stay VFR and had every intention of staying VFR - even MoD has now confirmed in writing that having changed the waypoint in VFR (and with a new course which would have kept them VFR) they would have expected the crew to immediately change course. If they had intended to climb over the Mull and then selected "an inappropriate rate of climb" as per the BoI conclusion what is your explanation (speculation?) for them making the waypoint change? How do you know the aircraft was serviceable at the waypoint change? There was no ADR/CVR and at low level any distress call they may have had time to make would not necessarily have been heard in that area. The AAIB report did not guarantee the aircraft was serviceable - indeed they could not dismiss the possibility of a control restriction, and would not anyway have been able to find any evidence of a major distraction such as a false engine fail caption (part of the RTS but conveniently not mentioned by the BoI). The aircraft would certainly have failed any proper airworthiness assessment for its suitability for such a passenger flight! You are fond of selective quotations - here are a few from Stn Cdr Odiham's comments:

The Board then opine, in making this profile dovetail with other evidence, that the crew, faced with the expected deteriorating weather, consciously elected to make a climb on track over high ground and in doing so used a speed and power combination that is unrecognisable as a Chinook technique. I find this difficult to believe; such actions would go against all the crew’s instincts and training. Moreover it is the very antithesis of the professionalism and careful planning that had gone before. Even taking into account the factors which the Board feel could have deceived the crew into believing a high speed cruise climb would have given them sufficient clearance over the Mull I, and the few, senior Chinook operators that I felt able to consult, find this suggestion incredible.

Aircraft -Speed. Although not stated as such, the implication in the Board's findings is that the transit speed approaching the Mull of Kintyre was unusually high. I doubt this. An assessment based on a time/distance calculation, shows that the average groundspeed from take off to impact was, depending on the parameters used, in the range 135-155 kts which, when corrected for the forecast wind, gives an IAS of between 115-135 kts. In practice, I believe the crew adopted a cruise IAS of 135 kts, which is both range speed and is commonly accepted as the maximum speed for passenger comforts. However, the Board suggest that as the Mk I Chinook experienced high vibration levels above 135 kts, which are not so pronounced in the Mk II, the crew were seduced into accepting a higher speed than that and, as they were unfamiliar with flying at such speeds, this caused them to miscalculate the gradient of the climb that would be achieved. Again I believe this stretches credibility too far. I do not believe even the most junior crew would have selected a cruise climb technique that close to the Mull whatever the cruise speed. They would only have entertained such a profile by starting the climb well clear of the high ground and probably as they coasted out from Northern Ireland. The Board tacitly acknowledges this in para 44, where they accept that the crew’s general NVG training, enhanced by the specialist SF Flight training package, is such that "it (is) most likely that the crew would have adopted (the technique of a cyclic flare and max power climb) in the event of inadvertently entering cloud whilst aware they were directly approaching, and close to, high ground.

Whilst tackling this issue the Board were unable to totally discount the following factors:

a. Spatial disorientation or visual illusion.

b. An unregistered technical malfunction.

c. Human factors.

Human factors.

Any of these, or a combination of them, could, in my view, have sufficiently distracted the crew from the task of turning away from the Mull to cause them both to inadvertently enter cloud and then to fail to take the correct procedure for an emergency climb in a timely manner. The Board consider engine control system malfunctions and it is particularly relevant to note that at this stage of the Chinook Mk II's service spurious ENG FAIL captions, lasting on average 7-8 seconds, were an increasingly frequent occurrence. These are now well understood but at the time they were not. Had such an indication occurred it would have caused crew considerable concern particularly as they were over the water with no obvious area for an emergency landing. Such a warning would also have required an urgent and very careful check of engine instruments and FRCs. (The FRCs of the time were of course incomplete and not easy to use - one of the facts that the BoI did acknowledge.)

So bearing in mind that none of us can say what the cause of the accident was with "no doubt whatsover" and that even the Reviewing officers accept that their verdict contains a degree (I would say major element) of speculation what is it that you KNOW that makes you so certain without any doubts whatsoever that these pilots made such a grossly negligent decision? Please tell us - without relying on speculation to get there!

JB