H-C and the Missing Information.
What I find difficult to understand is that H-C spends some 174 pages dealing with the Nimrod safety case, and how people like Baber and Eagles failed to recognise the fact that Dry Bay No.7 did not have fire detection and suppression, and yet the abuse of the STF procedure and in particular this witnesses important statement, gets no mention. In fact H-C has the impertinence to state, "The Inquest produced little factual evidence of value to the Review" This statement indicates a clear violation of the Nimrod safety case; unofficial amendments to RTS document, equipment installed on the galley table, circuit breakers being used as switches etc.
THE CORONER: Did you have any problems with Special Trials Fit in the equipment?
SQN LDR ******: To put it in context, I am a qualified trials officers at the General Duties Air Assistance Course in 1992 and then spent three years from 1992 to 1995 at Boscombe Down as a trials officer doing special trials fix on the Comet aircraft, the laboratory aircraft. So I did have a bit of knowledge of the system and how it should be used and I just wanted to sort of point out as part of this that I thought you were abusing it slightly.
THE CORONER: And why would you [think] it was being abused?
SQN LDR ******: From what I remember of my training, the definition of a special trials fit is a fit that has gone onto the aircraft for the duration of the trial which, in exception
circumstances, could be taken into operational use.
THE CORONER: So, your criticism here is that the special trials fits just stay?
SQN LDR ******: Exactly. I mean, yes, my interpretation would be you had an urgent operation requirement, special trials fit onto an aircraft, take it to theatre, get the job done, bring it back, take the equipment off. Whereas, we were doing go to theatre, take it back, onto a different aircraft, that goes out. So, yes, there were ... and there are reasons behind that why I think it is not quite the way to play business.
THE CORONER: And why do you think it is not quite the way.
SQN LDR ******: Okay, one of the reasons I have a degree in electrical and electronic engineering, so to my mind moving cable harnesses regularly is not good practice.
THE CORONER: Why?
SQN LDR ******: Just potential damage.
THE CORONER: To the harnesses?
SQN LDR ******: To the actual cable harnesses when they are moved from one aircraft to stored, moved back to another aircraft.
THE CORONER: So potential damage to the cabling and constant shorting?
SQN LDR ******: Potentially.
THE CORONER: With a fire?
SQN LDR ******: Potentially.
THE CORONER: Potentially, yes.
MALE SPEAKER: Right, you say specifically, and this was the reason I wished to ask you this question, “we will (inaudible) in writing but before the accident there were three circuit breakers we were meant to pull before taking it and we didn’t”. What did you mean by that?
SQN LDR ******: Okay, what had happened was when we first arrived in theatre, the problem is you do not have ready access to this equipment in the UK. So you often arrive out in theatre to an aircraft that has got, in this case I believe it was four or five separate special trials fits fitted to it and that is the first time you have really got, to get to grips with it again. Somebody at Kinross had tried to be helpful when they produced like a local briefing package where they had in the back of the release to service document for each special trials fit they made, sort of make a waiver of, if you are going to do air to air refuelling you need to pull the circuit breaker or not use this particular item.
THE CORONER: Why do you think that was? Why did they say pull those circuit breakers?
SQN LDR ******: Because of the way it is being fitted to the aircraft, it is another safety break, if you like, just in case. Because they had not had the opportunity to fully embody the equipment onto the aircraft and perhaps test it as thoroughly as it should have been.
THE CORONER: So, (inaudible) if the system is switched off during air to air refuel then chances of any problems associated with electrical shorting or failure in that period are removed?
SQN LDR ******: They should be zero.
THE CORONER: Yes.
MALE SPEAKER: What was it about air to air refuelling in particular that meant that the special trials fit had to be switched off during that process?
SQN LDR ******: Well, as if have just explained, it was because of ... when you have not properly embodied something onto the aeroplane, the big issue for us as the operating crew is that the air to air refuelling checks when you have not embodied it will not reflect what you need to do. Until a piece of equipment is serviced embodiment modification that will include changing all the paperwork that goes with it. So as part of your air to air refuelling checks you would have then been told pull this circuit breaker, pull that circuit breaker, do not use that. What had happened was that was not in the formal checklist so crews had ... as I say, somebody had tried to develop a local checklist that had an error in it and as a result of the accident we had a quick look back to make sure we were doing things properly, and that is when we discovered that error.
THE CORONER: Do you think that error might have had anything to do with what happened to this aircraft?
SQN LDR ******: In reality I do not, but at the time I made this statement obviously, you know, it was fresh after the event and –
THE CORONER: So, fresh out of the event, what made the connection in your mind?
SQN LDR ******: Purely because with my background I was aware of how we were using special trails fits and I wondered if the way we had used them might have been significant.
THE CORONER: So it was just in your mind that there might have been some electrical failure that might have been responsible for the ignition of fuel?
SQN LDR ******: Possibly that. The other aspect was were trying to sort of, you know, put ourselves into that crew’s position in terms of the time line as it was described to us. And one of the things post having done your air to air refuelling is obviously putting circuit breakers back in to get this equipment working again, and potentially that might have been significant.
THE CORONER: Potentially, yes, thank you.
The abuse of the STF system is covered in the CHART report (1992), the HEART report (1997) and the NART report (1998), and yet all follow up documents and MoMs appear to have got lost. I strongly recommened that if anyone from the MAA reads Pprune they should demand that these documents be made available to the new organisation. If we do not know where we have gone wrong in the past (or hide the past), how can the future be any better. Perhaps, one day, H-C will explain why this vital evidence was ignored.
DV.