QinetiQ ETPS YAK crash 2016

[Chris Kebab]

Notice that the inquest into Alex Parr's death has started, will be very interesting to see how deep the Coroner wishes to dig on this one https://www.bbc.co.uk/news/uk-england-wiltshire-46431120

The SI made for very, very uncomfortable reading https://www.gov.uk/government/publications/service-inquiry-into-the-aircraft-accident-involving-yak52-g-yakb-on-8-july-2016

[Lima Juliet]

Yes, a real tragedy felt across many fleet cadres, and a Alex was a good pal of mine.

As ever lots of things that should never have happened, but did. I also find it amazing that lots of very experienced pilots flew this aircraft, which was discovered afterwards to have significant defects, and none of them objected to it. The aged seat straps that undoubtedly made Alex’s survival of the forced landing unsurvivable is one such fault - what is so surprising, that none of the experienced pilots raised concern over the condition of those straps or indeed of the other faults the aircraft was carrying. As they were test pilots or student test pilots then I find that fact quite startling. I will watch the inquest with great interest (and much sadness).

[tucumseh]

The SI made for very, very uncomfortable reading

Indeed. Manuals in Russian, despite Director of Flight Safety warnings to Chief Engineer and ACAS about others being in Spanish. At least we have (or had) Spanish airmen doing ab initio training to call on.

[6f1]

Any more news on the findings of this inquest?

[Onceapilot]

From the BBC,

"A coroner will highlight concerns to the Civil Aviation Authority over the death of an RAF test pilot.

Flt Lt Alex Parr, 40, died when a Yak-52 civilian aircraft suffered engine failure and crashed during an emergency landing in Wiltshire in July 2016.

An inquest jury at Wiltshire and Swindon Coroner's Court in Salisbury returned a narrative conclusion.

It said the choice of landing strip "probably contributed" to his death.

Flt Lt Parr, a tutor at the Empire Test Pilots' School at Boscombe Down, was thrown clear after impact close to Dinton airfield on 8 July 2016.

Wiltshire and Swindon Coroner David Ridley said he would be writing a report to the Civil Aviation Authority highlighting his concerns about issues raised during an inquiry by the Air Accidents Investigation Branch (AAIB).

The 10-day inquest heard civilian pilot John Calverley, 62, who was commanding the flight, was taking Fl Lt Parr on a demonstration flight.

Fuel starvation was the most likely cause of the engine failure.

Initially Mr Calverley chose a wheat field for the forced landing but as they made the approach he took over the controls and chose an airstrip instead.

A post-mortem examination concluded the Cambridge University graduate and father-of-three from Marlborough died from multiple traumatic injuries.

The AAIB carried out extensive testing of the engine but could not conclusively establish what caused the loss of power.

Some RAF crew had noticed problems with the "unserviceability" of some instruments on the Yak-52 days before the fatal crash but had not reported it to their superiors.

The AAIB said essential instruments were working and it would not have affected the decision to use the plane.

Following the crash, the Yak-52 has been removed from the test pilots' course syllabus."

[6f1]

Onceapilot

Thanks for the update.

Very poor airmanship from the PIC by not following basic rules,a very sad outcome.

[Franek Grabowski]

Yak-52 is a pretty reliable aircraft, so I guess problem was elsewhere.

[kenparry]

Yak-52 is a pretty reliable aircraft, so I guess problem was elsewhere.

Your opinion is not supported by the facts established by th investigation

[Chris Kebab]

Looks like the Coroner kept his scrutiny to simply the technical issues relevent to the crash and appears not to to have explored some of the other serious underlying aspects raised in the SI.

Have only access to the BBC reporting but I'm surprised the apparent ineffectiveness of the whole QinetiQ and AWC governance regime didn't get mentioned nor the whole byzantine muddle that seems to exist in this (seemingly quite dysfunctional) joint CAA/MAA, civilian/serviceman environment.

QinetiQ, the owners of ETPS, seem to have done well keeping their name out of the headlines here and I imagine there was a huge corporate sigh of relief at the Coroner's findings. Let's hope QinetiQ (and the AWC for that matter) have learned from this totally avoidable accident and are now doing the decent thing in supporting the family of the dead military pilot.

[[email protected]]

This accident is used as a case study at MAA CoAST on the Fg Sups Course (and probably other courses) - ridiculous litany of errors.

[Franek Grabowski]

Your opinion is not supported by the facts established by th investigation
As far as I can see, there were maintenance problems. Yaks and other Soviet origin aircraft are still flying around. They are very robust and reliable, but the economy is a problem.

[orca]

If you look at para 1.4.243 of the inquiry it’ll tell you that the Yak-52 had a questionable reliability record.

[Two's in]

Along with the myriad of failures in this chain (well documented in the Inquiry) there is the underlying and historical problem that "elite" flying units can often develop a sense of immortality along with an attitude that "checks and balances are for the little people". When this attitude is endemic within the organisation, smaller problems go unnoticed until sadly, more serious issues start to occur. Historically the Red Arrows and C-130 AB/SF Support have had well publicized examples where basic safety principles have been compromised or breached leading to tragedies. It should be obvious that specialist or non-standard flying operations require the same, if not more, scrutiny than regular operations in terms of supervision and control.

[Franek Grabowski]

If you look at para 1.4.243 of the inquiry it’ll tell you that the Yak-52 had a questionable reliability record.
The stats do not tell anything about actual reasons of incidents.

[LOMCEVAK]

Onceapilot

Thanks for the update.

Very poor airmanship from the PIC by not following basic rules, a very sad outcome.

Specifically what are you referring to with 'poor airmanship'? What 'basic rules' were not followed?

For everyone, I suggest that you read the AAIB report to try to understand why this accident occurred. The SI delved into far-reaching aspects that had no impact on this accident; discussion regarding QinetiQ/MOD relationship should be in a separate thread. I challenge anyone to look at the SI recommendations and say which one(s) would have prevented the accident when the facts are considered. The Inquest was to ascertain why Alex died and, therefore, aspects addressed in the SI report that were not relevant to this were excluded by the Coroner.

When an engine failure occurs, there are usually several options which the pilot may choose. During a forced landing pattern, sometimes the options change and further decisions have to be made and the pattern modified. It is only with hindsight that we can tell whether the option that was followed was the best one. I wish that a full transcript of the safety pilot's evidence as a witness at the Inquest could be published here. He was very open, honest, humble and helpful under some extremely forceful questioning. And yes, I was there that day and heard it. For the pilots reading this, have you never flown a PFL that has not worked? I am sure that we all have. Therefore, what is the justification for the critical comments above? This pilot has previously suffered three engine failure in a Yak52 and had landed successfully from them all. This time, sadly the pattern that he flew ended up with a tragic accident and he is the first to admit it.

For those who are critical here, it is a shame that you were not at the Inquest to hear the evidence that was given to put this into context. My thoughts are with Alex's family and also with the safety pilot who will have to live with this for the rest of his days.

[6f1]

LOMCEVAK

Aviate,Navigate comunicate.

Aviate get the aircraft to the best gliding speed,navigate,pick a field and try to land into wind,communicate i.e. Mayday.

[1] The aircraft did not land into wind not always possible [ pick a field early.]

{2}Don't change fields at the last minute.

The SI should not have been excluded.
1.4.192. The decision to abandon the original forced landing and attempt to land on the strip would have resulted in a downwind landing leading to longer float and ground run than an into wind landing. The difference between the resulting ground speeds of an into wind and out of wind landing would have been double the surface wind , or 28 kts. The impact of the aircraft alongside the strip, manoeuvring at low speed indicates that the landing on the strip was probably attempted from a starting point where the available energy (a combination of height and speed) was insufficient for it to be successful. Notwithstanding insufficient information to determine the aircraft's flight path exactly, it was probable that the accident crew had a window of opportunity to reverse the decision to land on the strip by rolling wings level, maintaining glide speed and landing. This would probably have resulted in a wings level and successful Forced Landing. In deciding to attempt to land on the strip,at the point that they did , the accident crew reduced the probability of a successful forced landing.

The AAIB report states

This late decision, and the subsequent manoeuvres in the attempt to reach the strip, ultimately resulted in an unsuccessful forced landing and the aircraft struck the ground in a steeply left banked attitude.

Most wing level forced landings in this type of aircraft you normally walk away from.

I hope this explains my comments!

[Just This Once...]

For everyone, I suggest that you read the AAIB report to try to understand why this accident occurred. The SI delved into far-reaching aspects that had no impact on this accident; discussion regarding QinetiQ/MOD relationship should be in a separate thread. I challenge anyone to look at the SI recommendations and say which one(s) would have prevented the accident when the facts are considered. The Inquest was to ascertain why Alex died and, therefore, aspects addressed in the SI report that were not relevant to this were excluded by the Coroner.


No doubt you have more insight than I and my experience of this type is limited to just 1 flight at BDN too long ago, but your view does look rather charitable when held against information in the public domain. Again, you probably have more insight so these are strictly my own views.

We fly single engine piston aircraft with the knowledge that the safety net is nothing more than airspeed, groundspeed, attitude and a reasonably forgiving surface. An engine failure does not make for a catastrophic accident, but is an unforgiving environment. We expect the average pilot on the average day to achieve an average outcome, with only the randomness of surface obstacles to ruin our day.

It was not unreasonable for the SI to wonder why, in relatively benign conditions, that the aircraft impacted the ground, with bank and pointing downwind. So, did the PIC have the training, currency, recency and professionalism to be able to perform to the level assumed?

The SI did seem to offer an evidence-based opinion that the PIC failed to meet the standard in all 4 areas. Worryingly there also appeared to be a number of incidents during the accident week of flying indiscipline, rule breaking and an apparent indifference to safety.

This could have equally have been an accident report where the outcome was triggered by entering an inverted spin at well-below the minimum entry height. Much as it pains me to raise any flag against any fellow aviator from afar, but the PIC's communications to the owner regarding the sortie profiles vs those he actually flew could not have been wider from the mark. Clearly the SI felt the need to explore the personal integrity of a civilian aviator who had suffered serious personal injury and the harrowing loss of a crew member. That must have been an especially difficult task for all concerned.

[orca]

LOMCEVAK,

I’ve PM-ed you about another matter.

Specifically ref your point about which of the SI recommendations would have prevented the accident.

As I’m sure you’re aware the SI concluded that the causal factor (the only one that removal in isolation would have prevented the accident) - was a failed force landing following engine failure.

I only say this as your challenge is therefore one you cannot lose as the SI did not make any recommendations (that I can spot) specifically targeting the causal factor.

Not meant to be pedantic or escalatory - merely an observation about what the SI actually said with the nomenclature available to them.

[andrewn]

This debate is missing the point. Much like the Shoreham Hunter tragedy, where the focus was very much on the guy at the controls.

The root cause for this one appears to lie more in systemic and long term failures of governance, including lack of clear ownership of risk and persistent under resourcing.

One of those occurrences where the holes in the cheese were always going to line up one day, sadly.

[Fortissimo]

There is an article here https://www.ukfsc.co.uk/wp-content/uploads/2018/06/FOCUS-105.pdf (the editorial) that talks about Coroners and their investigations where a competent agency like the AAIB has already produced a report into an accident. Coroners are supposed to accept the ‘expert’ reports unless they are clearly flawed or incomplete. Guess the SI would fall into the same category.

[LOMCEVAK]

6f1,
My previous comments related to your choice or words. The PIC made errors of judgement; don't we all to a greater or lesser extent? I would not classify this as 'poor airmanship' but, perhaps, that is the semantics of a generalised expression. A forced landing requires far more than 'following basic rules'. It is a procedure with respect to airspeed and high and low key heights but it requires considerable judgement. There is generic best practise but, even in this modern age, it can never be flown by simply following rules. All of the relevant items from the SI report were well covered by the AAIB report, and the coroner, in accordance with normal practice at such inquests, used the latter.

Just This Once,
Your comments on ".. flying indiscipline, rule breaking .." are an interpretation of events that occurred. Be careful of condemning people in such a manner unless you really know what happened. Similarly, ".. an apparent indifference to safety". I can assure you that none of the aircrew at ETPS were indifferent to safety. Every day, everyone went to work and tried to perform their job as safely as possible with every intention of going home that evening having not broken any aeroplanes or people. Circumstances may have made that difficult but everyone was very safety conscious. This was just one tragic accident and the first fatality at ETPS since 1981 (and that was due to an aircraft malfunction and a medical issue post ejection). I would argue that safety had been maintained there because of the people, not despite them. In the circumstances, it is inappropriate for me to expand any further.

Orca,
Valid observation - thanks.

Rgds

L

[Just This Once...]

I am not sure how you read my comments as applying to ETPS, but that was not my intent.

[[email protected]]

Wasn't the lack of sucess of the forced landing due to the fact that it should be flown from the front seat (where I believe the civilian pilot had flown his previously succesful ones) but that was occupied by the ETPS student with no time on type?

So either front seat with the view but no time on type or rear seat with the experience but no clear view - not much of a choice....

Couple that with some non-functioning instruments and you have something of a recipe for disaster.

[212man]

was occupied by the ETPS student with no time on type?
I'm not sure I would characterise him as a 'student' - he was the TP Tutor doing his own QE exercise as part of his CPD.

[[email protected]]

Thanks 212 - I had forgotten what post he held and assumed he was an ETPS student. Still a very avoidable accident.