Sea King Accident 22 March 2003; Collision between XV650 and XV704 [Archive]

Chugalug2

14th Nov 2009, 21:31

Having had one thread pulled by the OP and a further one enquiring after it locked by the Mods in the past week or so, I hope that this is third time lucky. I do not intend to pull this one so it will whither only from lack of interest or Mod action.
The following is a piece in the Sunday Times 15 Nov 09 by their Defence Correspondent Mick Smith:
Sea Kings incident: Military aircraft accident summary, Board of Inquiry report and letters - Times Online (http://www.timesonline.co.uk/tol/news/uk/article6917084.ece)
Sea Kings incident: Military aircraft accident summary, Board of Inquiry report and letters
The Board of Inquiry report into the loss of the two Sea Kings is heavily redacted throughout. The redactions include the references to the problems with the high intensity strobe lights (HISL), even though this is not a secret piece of equipment. The references to the lights being unfit for purpose as fitted on the helicopter and the breach of airworthiness regulations are at paragraphs 100-102, and the conclusion with regard to that problem is at paragraph 141, with a recommendation to replace the forward strobe light with an anti-collision light immediately at paragraph 146.

The Military Aircraft Accident Summary, which is undated and is not redacted, notes in paragraph 14 that the strobe lights were switched off making it difficult to see the other helicopter and assess the distance between them.

The first letter is from the former civil servant to his MP and was passed to Bob Ainsworth, now defence secretary, but then armed forces minister, in September last year. Headed "Military Airworthiness", it repeatedly points out the problems with airworthiness on both the Nimrod and Sea King fleets and the implications for military airworthiness as a whole. It also shows that Ainsworth has been misled by his officials over the board of inquiry into the loss of the two Sea Kings. It is dated 9 September 2008, more than a year before last month's publication of the Haddon-Cave review of the loss of an RAF Nimrod which condemned military airworthiness as a whole

The second letter from the civil servant to his MP, dated 15 March this year, and also passed to Ainsworth, refers to the attempt to force the former civil servant to make a false declaration that the Sea Kings with the forward strobe light as fitted was airworthy. It also refers to the way in which the breach of airworthiness regulations and the correspondence and reports referring to it, were not revealed to either the board of inquiry or the inquest.

Wholigan

14th Nov 2009, 22:12

Having had one thread pulled by the OP and a further one enquiring after it locked by the Mods in the past week or so, I hope that this is third time lucky

As you say, the first thread on this subject (started by Sun Who) was deleted by the thread starter.

A "further one enquiring after it" was "locked by the mods" because the question had been answered and no other questions had been asked! Incidentally, this thread was started by flipster.

I can find no record back over the past week or so of a thread started by you about the Sea King accident. Can you give me more information on it?

Mick Smith

14th Nov 2009, 22:59

Here's the article (http://www.timesonline.co.uk/tol/news/uk/article6917482.ece) that goes with those interesting docs, Chugalug

The mother of a Royal Navy officer killed when two Sea King helicopters collided during the invasion of Iraq has called for an inquest to be reopened after it emerged the Ministry of Defence withheld vital evidence from the original hearing.

Ann Lawrence, whose son Marc, 26, was one of seven men killed in the mid-air crash, said the inquest in January had been told the helicopters were safe, but it was now clear that they had serious problems with their lights.

"If the risk of similar accidents is to be reduced, the truth must be heard and the record put straight,” said Lawrence, 60, from Westgate, Kent. “The reputations of our boys must not be damaged in order for others to protect their own.”

The two Sea King Mk 7 helicopters collided over the northern Persian Gulf in the early hours of March 22, 2003.

The helicopters’ anti-collision lights had been replaced by high-intensity strobe lights (HISL), but these were switched off because they reflected off the surface of the sea, interfering with the pilots’ vision.

A former civil servant at the MoD told The Sunday Times earlier this month that he repeatedly attempted to prevent the lights being fitted without proper testing or trials, but was overruled by his superiors.

Documents withheld from the inquest and the victims' families relate to breaches of airworthiness regulations before, during and after the fitting of the strobe lights in place of the anti-collision lights.

Both the board of inquiry report into the collision and the military air accident summary cited the fact that the lights were switched off as a factor in the pilots’ apparent failure to see each other.

The board of inquiry said the strobe light installation was “not fit for purpose” and did not comply with the MoD's airworthiness regulations.

Correspondence between Bob Ainsworth, the defence secretary, and the former civil servant - via his MP - suggest the minister was also misled by his own officials over the issue.

Ainsworth told the whistleblower's MP in June 2008 that “no reference to any system being ‘unfit for purpose’ can be found" in the board of inquiry report.

The documents that were not passed to the coroner include details of how the former civil servant, then working on the Sea King Mk 7 programme, tried to ensure the lights were safe.

The strobe lights were fitted to predecessor aircraft but there was no evidence that they had been tested or trialled in accordance with MoD regulations.

When the former civil servant discovered this in May 2000, he demanded that the lights should not be fitted until fully checked by Westland, the helicopter manufacturer, and any problems corrected.

The whistleblower, however, was overruled. Six months later he pointed out that Westland still had concerns over the way in which the lights were being fitted and called for a full test schedule, but he was ignored again.

The former civil servant subsequently moved to another MoD programme but following the board of inquiry into the crash he wrote a full report detailing his efforts to prevent the lights being fitted without trials. Neither this nor any of the other documents relating to the failure to observe airworthiness regulations were passed to lawyers representing the Sea King crash families.

In a letter sent to Ainsworth via his MP in March this year, the whistleblower said: “These are very serious issues. Failure to pass on key evidence, especially when directly related to board of inquiry criticisms, is, I believe, a failure of duty of care amounting to gross negligence."

Shawn Williams, a solicitor representing several victims' families, said: "They believe that significant evidence was not placed before the coroner.

“We need to establish why and how this occurred so appropriate action can be taken. The purpose is to establish a legal basis for reopening the inquest. We will leave no stone unturned in doing so."

Lawrence said: “They said the aircraft was airworthy but at no time was the question of the lights raised. Indeed, it was said the aircraft had been shown to be safe.

“The obvious intention was to make clear that no further discussion about the aircraft’s safety was necessary. It is now all too clear this was not the case."

The MoD declined to comment.

Chugalug2

15th Nov 2009, 07:48

Mick, thanks for that. I'm off to get the Sunday Times now to get the real McCoy (hint and plug there, did you see?).
Wholigan:
I can find no record back over the past week or so of a thread started by you about the Sea King accident. Can you give me more information on it?
I meant that it was the third attempt at a thread re the Sea King accident, not mine alone. Sorry for not expressing myself better. The point I was trying to make was that a lot of effort had been made by members posting about this accident only to have it all scrapped by the OP. Not questioning his right to do so, nor of the second thread being locked off, merely trying to reassure those posting on this one that it will stay as far as I am concerned. Hope that answers your question and once again apologies for any confusion.

flipster

15th Nov 2009, 16:52

Reconvene the Inquest? Perhaps they should also reconvene the BOI as there are a few unanswered questions thrown up by the RNFSAIC report that could do with answering and clarification?

Anyway, how come the BOI completed before the RNFSAIC had done their stuff? Seems a bit odd to me! Perhaps that is way it was done in 2003? I'm not sure, however, that is what the present regs (those pertaining to SIs) indicate.

Furthermore, HQ Fleet should look hard at the FACT that the concept of use and operation of HISL on the Mk7 did not, categorically, comply with the airworthness regs - (the BoI was spot-on in that respect) - ie if you have to switch HISL off because it distracts the pilots, then it is not 'fit for purpose' - because your 'last line of defence' is now compromised.

MoD were being disingenuous at the Inquest, when they implied that HISL was 'airworthy'. Of course, as a stand-alone piece of kit, HISL probably meets the airwothiness regs but it is the actual concept of use within a specific environment that renders the HISL 'non-compliant' - the original Mk7 Service Deviation proves that conclusively. I am afraid to disappoint some posters, this is a fact and is written in black and white. Yes, you may have for years, 'got away' with switching off HISL quite safely - that doesn't make that a correct action but you probably weren't to know. The engineers did but, sadly, they were over-ruled.

For sure, there were other factors involved in this accident that may have saved them but ultimately, the loss of the crews of XV704 and 650 are testimony to that fact their last lines of defence did not defend them when they needed them.

Now, I don't think anyone will benefit from a 'blame and shame game'. however, the MoD must come clean, apologise to the families and the engineers at MoD and Westlands who were ignored......and fix the system, so that this is not repeated.

Add to this, the fact that many marks now use HISL and NVG - perhaps this needs proper assessment and trialling in representative environments - as proposed many years ago by the same experienced airworthiness engineers? Has this been done, I wonder?

bast0n

15th Nov 2009, 16:54

Am I missing something here?

Both aircraft and ship using serviceable radars - and still they collide?

Where do the anti-cols/strobes come into the equation?

Please enlighten me. I have read all the threads and am still mysified.

flipster

15th Nov 2009, 17:11

Baston,

Neither ac nor ship radars would have given a complete picture and ATCers were out of the loop as both pilots had called a positive 'visual' while at LL over sea.

Quite why they remained on a collision course, no-one will ever know but the BoI highlighted the confusing and disorientating lighting configuration produced by an ac with its fwd HISL 'off', the tail HISL 'on' (but dimmer and partly occluded by sets of rotors) and the nav lights flashing bright. If both crews were 'visual' and yet took evasive action only at the last minute then it is highly likely that they may have been disorientated and confused as to the relative movement, closure and speed of eachother.

Mick Smith

15th Nov 2009, 17:49

This is what the BoI said:

It is considered by the Board that the [forward HISL] is not fit for purpose and non-compliant with the requirement in DEF STAN 00970 Vol 2 para 2.1 (Enc. 42), in that the [redaction] it should be located so that the emitted light shall not be detrimental to the crew's vision.

102. However, this situation raises a dilemma. The conspicuity of each aircraft was significantly degraded from some angles without a [redaction] Thus, in trying to maximize their ability to see out of their cockpit each crew was at the same time ensuring that their own aircraft was more difficult to see from the most dangerous direction - directly ahead.

The BoI is, as Flipster points out, clearly referring to it being unfit for purpose as fitted, and in the specific conditions. It also said it should be replaced immediately, which it of course hasn't been because to have done that would have been to accept that it was never properly trialled and tested.

I wonder what the BoI would have said if they had seen the paperwork that shows that an engineer fought hard to have it properly trialled and tested - trials and tests that would have presumably shown up a problem highlighted by both the BoI and the subsequent MAAS as a factor in the collision - but was overruled by people who did not have the qualifications to make that judgement?

How on earth can anyone defend the fact that neither the BoI nor the Inquest saw that paperwork?

bast0n

15th Nov 2009, 19:35

Flipster

and the nav lights flashing bright

I would have thought that this is all the crews would have needed to avoid collision. Pre anti coll/strobes that is all anyone had.

I still seem to be missing something.....................

Help please.

flipster

15th Nov 2009, 20:49

Bast

Read para 103 of the BoI.

In sum, as I see it, both ac had declared themselves visual (and therefore denied themselves ship-provided or self-provided radar avoidance) but the dark, the wx and the poor exterior lighting of BOTH ac conspired to impair the crews' ability to assess their visual picture and spatial orientation (as shown in the BoI trial) and, therefore, to keep clear.

What is not mentioned is that the crews may well have been unaware of the degraded nature of their own lighting - this ac was a new mark on its first deployment, with new lights and it may be that they had not often met head on before, if at all.

Of course, acceptance of radar separation, a height split, different routings or delayed arrival/deps etc would have kept them apart and then, the fact the HISL arrangement was poor would have been irrelevant.

Unfortunately, nature is not like that and it will, at sometime, expose any of our weaknesses; it did so on this occasion.

Have a read, if you will.

BTW - I would also say that a helo's nav lights are much closer together (on the side of the ac, or on the wheel sponons - as on SK) and so can't give the same head-on aspect and cues as an FW ac with nav lights on the wing-tips. The wooded, occluded and dim nature of the rear HISL could only have added to the confusion about distance/closure. Baston, you have a point though; perhaps they would have been better off with both HISLs off? Unfortunately, a trial that would have discovered this was denied to the engineering project office (by a non-engineer), so we just don't know.

Two's in

16th Nov 2009, 02:16

Don't let me put words in bast0n's mouth, but there appear to be two seperate but linked events here:

(1) The undue haste with which the HISL mod was released to service.

(2) The collision between the two aircraft at night.

Our current propensity to line up the "holes in the cheese" seems to conveniently overlook some fundamental principles of airmanship that have been taught since (night) flying began. If these two aircraft had been oblivious of each other's presence and had the mid-air, then the HISL condition would obviously be a significant factor. Given the mutual awareness of the respective aircraft, the need to formate at night and the near head-on closure angles, then the HISL's condition is contributory but not necessarily causative.

Vertical separation, radar assist, pre-briefed joining patterns and use of nav lights were all tools and techniques that would or could have prevented this tragic accident. To focus on the HISL mod to the exclusion of questioning the execution of basic airmanship skills is not likely to reveal all the lessons that could be (re)learned here.

bast0n

16th Nov 2009, 08:01

Two's in

You have said it in one and I am grateful for the "words in my mouth".

The blindingly obvious seems to be being pushed out of the way in favour of blaming someone for introducing HISLs in a dodgy fashion.

Thanks.

Mick Strigg

16th Nov 2009, 08:18

bast0n

16th Nov 2009, 09:09

Mick

I won't spoil your fun with facts this time guys; enjoy yourselves!

I wish you would as I am genuinely mistified. Perhaps I have missed something in the past on previous threads?

Mid air collisions are an interest of mine having attended one betwen two Seakings south of the Isle of White in the 70's and having had one myself - Wessex/SeaHarrier - and no it wasn't my fault.............:ok:

Mick Smith

16th Nov 2009, 10:33

Oh no, not again! I thought that we had buried this subject, but no, it is once more resurrected so that the "mind's made up" brigade can, once more, get on on their soap-boxes and spout on.

I won't spoil your fun with facts this time guys; enjoy yourselves!

Like Bast0n, I wish you would.

You were asked for the facts on the last thread but either didn't have time or couldnt be bothered to give them before the thread was removed by the originator and the subject in your terms "buried". So let me specify again what I would like to know. I appreciate you might not have answers to all these questions but if that is the case, I have to wonder why you can take the attitude quoted above.

The BoI said the problems with HISL were a factor in the collision, particularly pointing to the fact that switching it off limited the crews' ability to see the other aircraft "from the most dangerous direction - directly ahead". It also said that "the ASaC Mk 7 radar was unable to paint primary radar return of another aircraft when in the mode employed for recovery to and departure from the ship".

You and others used the last thread to dismiss this as an issue, also dismissing the BoI's assessment that it was to all intents and purposes a head-on collision.

1) Was this because - as you seem to suggest - the BoI's assessment had been overturned by another body, and did that body make a written report to that effect?

2) Since that report would have been overturning a key assessment of a document of public record, was it also made a public record?

Two's In. The HISL as fitted was not released "with undue haste", it was released without the proper checks to see if it passed the military's own airworthiness regulations. It was found not to do so after a mid-air collision in which seven people died.

3) Was the BoI told that, in May 2000, the engineer managing the Sea King Mk7 programme had refused to agree "read across" of HISL from a previous mark because there was no evidence of any trials or tests. But was overruled by a senior official without the necessary qualifications to make that judgement.

4) Was the BoI told that the design authority had declined to back the replacement of the anti-collision lights with HISL?

5) Why was the inquest not told about the fully documented "facts" in questions 3 and 4?

barnstormer1968

16th Nov 2009, 11:24

Mike Smith

4) Was the BoI told that the design authority had declined to back the replacement of the anti-collision lights with HISL?

5) Why was the inquest not told about the fully documented "facts" in questions 3 and 4?.

I would not want to second guess these above questions of yours, so can I ask if you are asking whether the BOI had info withheld from it, or rather did not ask the questions (but should have)?

I am merely trying to understand whether certain posters are alluding to a cover up of facts, or merely an incompetent BOI. Neither are the ideal situation, but one of them is a more sinister situation

flipster

16th Nov 2009, 11:39

Baston

I am sure that your collision wasn't your fault....but even it was, you are around to argue your case. Sadly, as I am sure you are well aware, that is not the position of the crews of XV704 and 650. What would have happened if you had not survived? The chances are that someone, somewhere would have held you to blame, even partly, in absentia?

In this case, as there was no real CVR/ADR, we are all mystified as to why the 2 ac did not avoid eachother - both having called 'visual'. Yes, there is a possibility of a c0ck-up but since the crews can't defend themselves, you cannot say that for certain - just like the Mull Chinook. What you can do, however, is to discover the probable contributory factors and fully address them so as to prevent recurrence - this is the whole idea of accident investigation, is it not? Or have I missed something?

So, in this case, you would need to address all the contributory issues recommended by the BoI and RNFSAIC - there were a few!

That is what MoD and Fleet have done....mainly - except that they decided, for reasons best known unto themselves, that the SK7 HISL was airworthy - however, they DID rescind the Service Deviation - mea culpa? Sadly, as I said, the light itself is probably ok but its concept of use is plainly not compliant with the def stan - this is in black and white and the BoI were quite right to say so. Why this was not followed up in the Inquest (and by the BoI) owes more to disingenuity and side-stepping by MoD; perhaps HM Coroner and the families may even have been purposefully misled?

What is obvious here, to someone with an ounce of common-sense, is that the procedure around the introduction and fitment of this system was done poorly - and against engineering advice, for no other reason than cost or incompetence. Furthermore, this is an issue that has cropped up in a number of other accidents - inter alia - Nimrod and Herc (both admitted by MoD). The Haddon-Cave Report backs this up still further to include some big industry names.

I agree that the Sea King HISL is probably not the sole cause of this accident but the disorientation caused by 'one-on, one-off' lighting system, is certainly a key element but a better lighting system could have prevented the accident. Also, if nothing else, this highlights some really poor management in MoD - which remains uncorrected and unaddressed. How many other latent failures like this are waiting out there?

Also, this accident shows that the engineers who recommended the proper processes and trailling (and who were initially hounded by certain parts of MoD procurement system) should recieve a full, written and public apology.

Anyway, to correct some of the less-considered comments - we are NOT trying to blame anyone - there is little mileage in the blame game, as prevention of recurrence is not helped in any way by that approach - why can't some posters grasp that? (Its all rather sad, really). The only caveat I would add to that is that, should there be any evidence of unmitigated willful neglect and/or criminal incompetence, higher-authorities are bound to consider taking matters further. That is not my preferred choice as it happens but, sometimes, this is only way that big organisations take note of the safety ethos and processes.

Perhaps that is why the Haddon-Cave Report has it sights set on the wider military airworthiness system but I am convinced that some people in the MoD and industry are still in denial. That needs to change and the whole mil airworthiness system needs a complete overhaul.

Whether the MoD riposte to the H-C report will acheive that remains to be seen - whether UK PLC (Mil) can afford to do so is also in question. One thing that is 'a given' is that we can no longer send our sons and daughters into a distant 'peace-keeping' conflict with equipment that does the enemy's job for him. I hope you might at least agree with that final statement?

Kind regards

flipster

Mick Smith

16th Nov 2009, 11:46

Barnstormer
I don't have any reason to think the BoI was incompetent. What I can say is that the facts - and they are documented facts - that I was alluding to were definitely not passed to the inquest. This was clearly illegal if done deliberately and the fact that they are not mentioned in the BoI report tends to support other evidence that the full facts surrounding this issue were also withheld from the BoI.

Separately, I have tried twice now to get the ppruners who dismiss the relevance of the BoI report assessments I referred to in my last post to say if this is a result of a subsequent report that overruled the BoI - in which case their arguments would of course be perfectly reasonable - or just considered opinion within the wardroom or the IPT. I'm hoping for greater success this time round.

flipster

16th Nov 2009, 12:04

Mick

As I understand it, the RNFSAIC report is not 'senior' to the BOI. Depending on who you ask, either the RNFSAIC support the BOI to come to their conclusions or that the RNFSAIC report directly to Fleet. But either way, it should not be possible for the reports to conflict greatly with eachother - at least not without the reconvening of the BOI and/or written clarification by Fleet.

Interestingly, the quote I see on the Sea King BOI is that they believe that RNFSAIC were there to help them

para 5

" The RNFSAIC was tasked to conduct an accident investigation in support (my emphasis) of the BOI....."

This equates with the current regs regarding accident investigations and Service Inquiries (what were BOIs), JSP832, where it states

"Service Inquiries for aviation occurrences are supported (my emphasis again) by specialist investigations conducted by RNFSAIC for RN aircraft and in-theatre RAF aircraft, AIEFSO for Army aircraft and the AAIB for MAFTR and out-of-theatre RAF aircraft."

Therefore, if there are discrepancies between BOI and the later RNFSAIC (eg the discussion about 'playmates' and also autokinesis wrt disorientation by the HISLs), then perhaps it is only right to ask for clarification by the BOI and or Fleet.

flipster

[email protected]

16th Nov 2009, 12:14

Two's in - :ok::ok::ok: I tried to get the same points across on the previous threads but the 'HISLs were to blame' camp won't see that argument.

Mick Strigg

16th Nov 2009, 12:25

Crab,

Perhaps the "Minds made up" brigade live in the "HISLs were to blame" camp! :yuk:

bast0n

16th Nov 2009, 13:14

Flipster

Your posts have been very enlightening - thank you.

I agree with the view that apportioning blame achieves almost nothing. The desire to find out what happened - as far as is possible - is so much more productive, specially if we can all learn from the evidence, and dare I say it, conjecture.

PS Flipster - the Wessex FAW 1 did a good job, and over a pub as well..........:)

Mick Smith

16th Nov 2009, 13:46

Crab
Two's in - I tried to get the same points across on the previous threads but the 'HISLs were to blame' camp won't see that argument.

Mick Strigg
Crab,
Perhaps the "Minds made up" brigade live in the "HISLs were to blame" camp!

I am not aware of a "HISLs were to blame camp".

Any chance that either of you might answer the questions, rather than throwing pathetic little darts at the board?

nigegilb

16th Nov 2009, 16:43

Mick Sm, no chance of that, you are p****ing in the wind.

Interestingly I was chatting with an ex RN Sea King pilot the other day, he was saying that in his time the RNFSAIC had "allegedly", on occasion, been known to protect the careers of high flying officers with their "helpful" contributions to BoIs when, how can one say it, when one had clearly fcuked up somewhat.

I guess it has always gone on to some extent, but I wouldn't be in a rush to place the findings of RNSAIC, or members of the Admiralty above those from a BoI.

What interested me from yesterday's article was the complete lack of comment from the MoD. Most unusual, I suggest we keep pushing on a half open door.

Until the children answer your excellent questions Mick Sm, I also suggest we ignore them.

Pheasant

16th Nov 2009, 17:54

in his time the RNFSAIC had "allegedly", on occasion, been known to protect the careers of high flying officers with their "helpful" contributions to BoIs when, how can one say it, when one had clearly fcuked up somewhat.

Under the RN system of BOIs/Tech Investigations I simply cannot see this sort of thing happening. In the case of the current discussion if the evidence of "covered up" HISLs issues had been available to the BOI/AI guys it would have been included in their reports. The FAA has absolutely no interest in anything but the facts and truth so that accidents can be understood and lessons identified and learned.

nigegilb

16th Nov 2009, 18:33

Pheasant, perhaps you can cast some light as to why neither BoI or RNFSAIC appeared to have read any of the reports concerning the Safety Engineer's refusal to grant read across for the HISL's to be installed on SK MK7?

And his resolute position to insist on functional safety trials?

Or the refusal of Westland to have anything to do with the outrageous breach of airworthiness regulations?

We are all ears?

Mick Smith

16th Nov 2009, 22:34

Nige,
if the RNFSAIC appears not to have read the documentation re the engineer's refusal to read across, isnt it more likely that it simply wasnt told about it either? Or am I missing something?

Mick Smith

17th Nov 2009, 10:39

This is a message to all the members of what might be called the "you dont care about the facts" camp. Pprune is full of attacks on hacks for not caring about the facts. I have asked repeatedly about the facts. You havent answered the questions. You insist these facts exist and are confirmed facts without ever explaining the authority for gainsaying the BoI. So I am going to give you yet another chance to answer the following questions:

You and others used the last thread to dismiss this as an issue, also dismissing the BoI's assessment that it was to all intents and purposes a head-on collision.

1) Was this because - as you seem to suggest - the BoI's assessment had been overturned by another body, and did that body make a written report to that effect?

2) Since that report would have been overturning a key assessment of a document of public record, was it also made a public record?

3) Was the BoI told that, in May 2000, the engineer managing the Sea King Mk7 programme had refused to agree "read across" of the HISL installation from a previous mark because there was no evidence of any trials or tests, but was overruled by a senior official without the necessary qualifications to make that judgement?

4) Was the BoI told that the design authority had declined to back the replacement of the anti-collision lights with HISL?

5) Why was the inquest not told about the fully documented "facts" in questions 3 and 4?

It would be really good if someone had the balls to actually answer the questions.

dervish

17th Nov 2009, 11:15

I posted to the old thread that it was well known at the time the IPT denied any knowledge of HISL when an investigation was launched into the Board’s statement that the installation was unfit for purpose.

This Parliamentary answer was also posted;

Mr. Bob Ainsworth [holding answer 26 March 2008]: High Intensity Strobe Lighting (HISL) was progressively fitted to all Marks of the UK MOD Sea King fleet between 1983 and 2001:

Mark 3—Rear Light introduced in 1983; Forward Light introduced in 1985.
Mark 3a—1996 (fitted when the aircraft was introduced to service).
Mark 2—1997 (all Mark 2 aircraft have subsequently been converted to the Mark 7 standard).
Mark 4—2001
Mark 5—1998
Mark 6—1998
Mark 7—2000

Could someone explain the MoD system which permits seven marks of Seaking to be fitted with a system since 1983, yet the IPT can claim ignorance 21 years later? Is this related to the Gray and Nimrod reports which both emphasize the MoD airworthiness system is in disarray?

nigegilb

17th Nov 2009, 12:15

Thanks Dervish, most useful. This is being looked into at a legal level at the moment.

nunquamparatus

17th Nov 2009, 16:24

Guys,

Whilst I am aware that for some (namely the families of the aviators who perished) this is still and will ever remain an incredibly painful subject. I knew all of the 849 Sqdn guys (standfast Lt Adams USN) and their death hit me, and many other that knew them, extremely hard. Before people start using Haddon-Cave as a drum to beat and resurrect this incident and attack UK MoD to, in some cathartic way, find someone to blame, let's re-cap:

1. The accident occured at night, at Low Level (due to Airspace Control Measures - ie hard-ceiling above) in an extremely pressurised environment.

2. The ATCO made the correct call, in sufficient time to both aircraft - on an unbeliveably busy circuit. The two SKs collided despite this call.

Would NVG and/or different lighting have made a difference? Perhaps, maybe probably. Would the ATCO have done something made more calls if he knew the aircraft were going to collide? OF COURSE - WOULDN'T WE ALL. But there were no NVG for the ASAC community, they were not trained. It was not deemed to be a requirement at the time. We can all find reasons why this should not have happened - but it comes down to this. It was a tragic accident - utterly awful and the loss of life was and will always be unbearable to those who mourn them. Everything that happened after the moment of impact can now be questioned in hindsight - up to the moment the two aircraft collided, the pilots were in charge of their destiny (to a degree I accept).

Before I am criticised for, in some way, defending the UK MoD policy of ill-equipping our forces - don't go there. I lost friends - people I lived with, spent quality time with, flew with. DO NOT think I wouldn't change anything to have them all back. Aviation, especially military aviation, is a dangerous business. Aircrew operate near and sometimes beyond the edge of the envelope of safety, dependent upon operational necessity. When we lose people through accidents it is only right that we look inwards and try to ensure that it never happens again, for whatever reason. But you cannot change what has happened and to argue that HISL or NVG would have stopped this happening is an exercise in futility and an insult to the seven men who perished on that night, going out to do their job - a job they all signed up for - despite knowing the inherent risks.

flipster

17th Nov 2009, 17:01

Nunc

An emotive post and many here respect and sympathise with you and, of course, the families.

Having said that, would it be possible for you to clarify your position wrt

Would NVG and/or different lighting have made a difference? Perhaps, maybe probably.

and

to argue that HISL or NVG would have stopped this happening is an exercise in futility and an insult....

Of course nothing is guaranteed, but to me, the 2 phrases are not mutally compatible, I'm afraid.

For the record, I do happen to believe that effective ACL/HISLs would have prevented this accident - along with a number of other actions, of course (eg Radar Vectors/Alt split etc) and HISLs are not the b-all and end-all - but they do highlight failings in MoD that remain uncorrected to this day.

Nonetheless, I fully agree that this was 'an accident' and a very sad one indeed. However, it can be argued that there is no such thing a 'just an accident' - just unfoseen and unpredicted events - either through things such as lack of information, use of that information or even complacency (and not necessarily by the final operators).

Unfortunately, the fact that there are laid down regulations in the Defence Standards and JSPs indicates that such accidents may have happened before - hence why switching off lights was/is frowned upon by the Def Stans. So, this accident could be construed as a 'predictable outcome' of not having good enough external lighting.

However, the intent of most people here to is prevent recurrence (I would hope) - in my case, to help ensure the airworthiness system (that was meant to prevent such 'predictable' accidents) is, once again, robustly enforced. Indoubtedly, doing this will go some way to preventing recurrence. Having lost a number of colleagues to 'preventable' accidents, I don't believe that aiming to stop any replay of those losses, is in way an insult to the fallen. The less greiving families, the better, I hope you would agree?

sympathetically,

flipster

Mick Smith

17th Nov 2009, 18:24

Nunc
Thanks for your very moving post. As someone else out there has already said, there are two issues here, one of which you deal with.

I certainly dont blame anyone out there that night for what happened, nor would I ever seek to.

The issue that is driving my questions is not ambiguous or difficult to understand fully, as the moments that led up to the collision will inevitably remain. The issue is very clear.

It is the process in which one man sought to ensure that the regulations applying to airworthiness with regard to the fitting of HISL to the Mk7 were properly followed, and was repeatedly overruled by someone who did not have the qualifications to do so.

The documentation relating to that was not given to the board of inquiry and it was not given to the inquest. That first act breached service rules. The second was illegal. All the evidence suggests the information was withheld deliberately, and not just by one person, by a number of people acting in concert.

I'm not trying to blame anyone for the collision. I am blaming someone for forcing through a piece of equipment that was not properly tested and trialled, and a number of people for illegally seeking to prevent evidence of that action being made available to the bodies trying to work out what happened that night.

It is of course true that this raises legitimate questions over the effect on the collision. If an official body, working on expert testimony decides that the failure to carry out the proper airworthiness procedures could not have had any impact, so be it.

But both the board of inquiry and the inquest should have been given that information so they could make that judgement and if they had been given the information, and used it in coming to their decisions, whatever they decided, I suspect this thread would not exist.

I'm sorry if it inevitably brings back bad memories for those relatives who do not want to revisit the situation or the colleagues of the crews.

nigegilb

17th Nov 2009, 19:33

Nunc, I too am sorry for your loss.

Mick Smith's post and Flip's highlight what went so badly wrong regarding airworthiness and what is hoped to be achieved in the bigger picture by highlighting Sea King mid-air collision now.

If I was the Coroner I would be hopping mad if there was evidence from a prime witness of;

a. Collusion

b. Willful failure to implement airworthiness regulations.

At the very least, I would move to ensure that I heard the new evidence from the witness. The only way this can happen is to re-convene either the BoI then the Inquest, or simply re-convene the Inquest.

Many of us have conflicting views on this collision. The most important views are those of the Coroner and the BoI. If they are going to be prevented from seeing this this evidence then one can state categorically that justice will not have seen to have been done. And the families might be condemned to live with the element of blame lingering in the air unnecessarily.

I fully expect to see some developments in the coming days and weeks.

tucumseh

18th Nov 2009, 06:15

Flipster #17

That is what MoD and Fleet have done....mainly - except that they decided, for reasons best known unto themselves, that the SK7 HISL was airworthy - however, they DID rescind the Service Deviation - mea culpa? Sadly, as I said, the light itself is probably ok but its concept of use is plainly not compliant with the def stan - this is in black and white and the BoI were quite right to say so. Why this was not followed up in the Inquest (and by the BoI) owes more to disingenuity and side-stepping by MoD; perhaps HM Coroner and the families may even have been purposefully misled?
I think this is a significant area given the similarities it highlights with the Mull of Kintyre accident; that staffs at a certain level are allowed to stand as judge and jury in their own case.

To summarise the above posts;

The BoI criticised the HISL installation design (a Naval Service Modification, not an Aircraft Design Authority Modification) and the way crews were instructed in its use (the Service Deviation).

2 years later the RNFSAIC contradicted parts of the BoI report, partly in disagreement and partly because they used forensic tools to properly analyse the mission tape. This last is critical because it completely alters the tone of the BoI report which, we now know, wrongly infers mild panic in the cockpits.

Both reports went up to FLEET who, along with the IPT, decided the HISL design was ok (note, HISL units, not the HISL installation design and use). The significance here, in addition to Flip’s “side-stepping”, is that the BoI criticised functional safety (although didn’t use those words), but FLEET and the IPT only commented on the physical safety of the discrete HISL unit.

It seems clear the trial conducted by the BoI (whose actions I suggest were exemplary) was almost certainly the only comprehensive trial conducted thus far to assess the functional safety of a HISL installation.

Whether or not this was deliberately disingenuous is not for me to say, but it is clearly in the interests of both that the confusion be perpetuated and the real issues hidden – as it seems they were from both the BoI and Coroner. Why? Possibly because (a) the IPT is responsible for tasking and approving the HISL installation design, and (b) FLEET are the signatory to Category 1 Service Deviations?

This conflict of interests should be declared, although I confess I don’t know enough to say who would resolve the conflict. But it does seem odd that the BoI did not reconvene to assess the RNFSAIC report. Anyone reading just their report gets entirely the wrong picture.

Chugalug2

18th Nov 2009, 09:11

Nunquamparatus, I too am sorry for your loss and the pain that revisiting it causes you. Like others have said the doing of it is not simply gratuitous. The purpose of Airworthiness Regulation and Accident Investigation is to avoid future avoidable accidents and the needless loss of life. Your sentiments, or similar, were expressed by ex colleagues of those who perished in the Hercules, the Nimrod and the Chinook tragedies. The Military Aviation world is a surprisingly close knit one, and like any family it resents intrusions into its private grief. Like other ex-serving members I have experienced that and can empathise with your feelings. But serving or retired we are or were all professionals and it is as professionals that we post here for a purpose, that is to avoid future avoidable accidents. We cannot do that if Airworthiness Regulations are not properly enforced or Aircraft Accidents are not effectively Investigated.
You posted:
The ATCO made the correct call, in sufficient time to both aircraft - on an unbeliveably busy circuit. The two SKs collided despite this call.
I had not realised that the frequency being used was incredibly busy. Does this not make the claim that it was not being recorded on Ark Royal all the more strange, indeed as a mere ex light blue I might say incredible? If you had told me that a major fleet unit did not routinely record and preserve as a matter of course all transmissions made in the launching and recovery of its aircraft I would find it unbelievable. Upon reflection I still do. Am I wrong? By the way, when you say that the ATCO "made the correct call" how do you know? How does anyone know if the recording does not exist? I'm not saying he didn't but simply asking; how do we know?

scottishbeefer

18th Nov 2009, 18:37

My chats with the other 849 boys who were there that night led me to believe the air was carrying a lot of sand that night. In those conditions (like being in cloud) it don't matter none if you're on anti-cols/HISLs or whatever, the reflection from the sand caused by the lower light is at best distracting, at worst blinding - so you're likely to turn 'em off. Hence the possibility of bumping into your oppo increases a lot. I'd have done the same I hasten to add.

At night I routinely turn off my lower strobe (especially on NVG) if it's wet/cloudy, as the risk/benefit of distraction/collision vs easier flying usually weighs up in favour of selecting "OFF".

You can argue about which lighting set-up is better/airworthy until the cows come home to roost, but the simple fact is, most of us in that position would have had a light off. As eluded to in earlier posts, this was one of those tragic accidents - but no more than that. I'm certain the RN have examined how to launch/recover cabs with slightly more coordination (although I'm not aware of the actual outcome there) but the bottom line is that looking at lighting is a hiding to nothing here.

SB

tucumseh

19th Nov 2009, 06:30

You can argue about which lighting set-up is better/airworthy until the cows come home to roost, but the simple fact is, most of us in that position would have had a light off. As eluded to in earlier posts, this was one of those tragic accidents - but no more than that. As you say, it seems obvious there are occasions when the light(s) must be off. The point made by the BoI was that, because other defences in depth (against the risk of collision) were missing, the final defence (lights) became even more crucial. This was exacerbated by the remaining light being "dim" and "wooded", leading to disorientation. These are the BoI's words, not mine.

If the BoI are to be criticised it is that they don't spell out all these issues, or explore the background. They came to the logical conclusion that the HISL installation, as fitted and used within that aircraft and system of systems, was unfit for purpose. Compare their trials results with the requirements of Def Stan 00-970 (which they quoted verbatim), and they could come to no other conclsuion. Perhaps, if the other defences had been available, they would not have been so hard on HISL, but the fact remains they were missing and that should have flagged serious problems in the Safety Case (which one assumes was updated when HISL was introduced into the AEW Mk2 in 1997?).

I see this problem all the time in procurement. In the same way the report is written with a target audience in mind, whom the Board assume understand implicitly the background detail, so too are airworthiness standards written for the use of staff who understand each nuance from long experience. But, that experience, competence and corporate knowledge (all crucial components of airworthiness) are missing (see Gray and Haddon-Cave), the position today being inexperienced staffs are taught Def Stans are not mandatory; so they routinely ignore them. The problem is, they are not taught the next sentence; that if you ignore one standard you MUST invoke another.

So, when you say;

I'm certain the RN have examined how to launch/recover cabs with slightly more coordination.
is this not an implicit acknowledgment that the regulations governing interoperability and systems of systems integration were, it appears, not followed? (I'm sure you are correct!). It is an obvious area to investigate on a programme that changed the designation to ASaC Mk7. One obvious reason for doing that is change of use and function, so it would make sense to investigate the impact of that change with those who use it. For example, ships, to ensure their procedures are still suitable for the new aircraft and the way it must operate. The regulations demand it. The BoI does explore this, but much is redacted. But their conclusions make it clear that there were serious failings in this area.

So, in answer to a previous question, yes, in my opinion this case is entirely linked to the Gray and Haddon-Cave reports.