Hughes 300 Crash. AAIB Report - Is there something fishy going on

[Hoverman]

It's now almost three years since Dennis Kenyon's son and two others were sadly killed when a clevis lug on their Hughes 300 failed in flight.
And it's a year since the draft AAIB Report was sent out to the people involved inviting their comments. (People involved are given draft reports in confidence and have 28 days to comment before the final report is made public.)
So what's happened since?
Nothing.
A year later and the final report still hasn't been published
Why? What's the hold-up?

I was told at the time by a very reliable source that the only "interested party" which wouldn't accept the AAIB findings and safety recommendations was the CAA. The AAIB was very critical of failures by the CAA which contributed to the accident, that the CAA didn't like it one little bit and were trying to influence the AAIB to take the criticisms out of the report.

What's going on?
There should be no cover-up where flight safety is concerned.

[Helo]

I've been wondering the same thing for many months now. Back in January this year I emailed the AAIB and for what it's worth, I got this response ...

Unfortunatelly the investigation into the G-ZAPS accident is still
incomplete. It has been a complex investigation which is nearly
ready for publication but there has been a great deal of legal
activity and legal interest in it. You may be aware of a Crown Court case which centres on this accident and this has had a severe knock-on effect on our work.

We hope to publish our report by April
--
J J Barnett
Principal Inspector of Air Accidents

So ... Crown Court or CAA problem - take your pick? I'll check in with JJ Barnett again and report back ...

Helo

[Heliport]

Crown Court or CAA problem?
Well, it's definitely not the Court holding things up. The trial finished before Easter 2002. The engineer has served the sentence he got for the ANO breaches he'd always admitted, and has been released from prison.

I've been told the engineer and the bereaved families accepted the AAIB findings and safety recommendations and the only interested party which wouldn't accept the AAIB criticisms and safety recommendations were the CAA.

Last I heard, quite recently, was that the CAA were still trying to get criticisms of their systems and procedures removed and the AAIB were sticking to their guns. Good for them. We have to have confidence and faith in the integrity of the AAIB - they help to keep us alive.

Meanwhile, the poor families can't begin to start putting this behind them. They just have to wait, and are forbidden from talking to anyone about what's in the draft report.

As Hoverman says, there should be no cover-up where flight safety is concerned.
Question is what can we do about it?

Any ideas?

[Thomas coupling]

Write to your MP:)

[QDMQDMQDM]

This is a very useful resource in these situations:

www.faxyourmp.com

I've used it a couple of times and have actually had a response from my MP.

QDM

[Alty Meter]

Looks like the answers are Yes it's very fishy, and Yes the CAA's up to no good.

Why don't you Heli pilots rally round and help Dennis Kenyon by writing a quick letter to the AAIB.
On this sort of thing, I understand a quick letter to MPs does work.

[Helo]

Just a quick update to let you all know that I still haven't had a reply to my email of 10 days ago, which I sent on to J J Barnett, the Principal Inspector of Air Accidents.

Will let you know if anything changes ...

Helo :confused:

[Alty Meter]

And talking about letters to MP's, I've just seen this thread. Click here. (http://www.pprune.org/forums/showthread.php?threadid=72140&referrerid=28147)

I know the issue affects us truckdrivers more directly than you free spirits, but worth a read and a quick post all the same.
You need to read to the end.

[Fair Flair]

So just what is going on?

If there is a reason why the final report cannot be published then shouldn't the interested parties, and the wider audience in the aviation industry, be told just what that is?

And shouldn't there be some time limit on how long this situation can continue? If there is no date in the near future when we will be able to see the final report, then I think the AAIB should take the bull by the horns and publish the interim report. After all, this issue goes beyond the obvious concerns of the bereaved families, and has much wider implications for the aviation industry.

So for the sake of the grieving parents, who are entitled to a public acknowledgement of just how and why their children came to die in such tragic circumstances, and for those of us who wish to ensure that proper and effective measures are taken so that a similar accident can NEVER happen again, then I believe the AAIB
should publish the report in its existing format, so that we can all analyse the evidence and make up our own minds as to where the problem lies.

Then we can really make our MP's work by ensuring that each and every recommendation in the report is fully implemented, no matter whose responsibility it is.

No parent should ever bury their child. No engineer should ever do what Paul Kenward did. No-one responsible for air safety should rest until they are certain that every possible action has been taken to prevent this terrible tragedy from happening again.

So, whatever, or whoever, is delaying this report, think on, get on, so that the bereaved families can begin to move on.

[Tail Bloater]

In most respects the CAA looks after our interests as best they can within the boundaries of their Charter and I think you must agree they do a good job. Where they let themselves down very badly is on such sensitive humanitarian grounds They find it almost impossible to admit to mistakes (wishing to be superhuman on all things) and we have no recourse to their actions, other than an uphill struggle by way of MPs and other with influence.
To admit to mistakes is not admitting to liability. Not admitting to mistakes is erring on the criminal. Public bodies are responsible to us.
So dear CAA, come clean and get this sorted asap

[Hoverman]

I agree 100% with the main thrust of your excellent post Bloater, except for one small part. I most definately do not agree "they do a good job."
They're not known as the Campaign Against Aviation for nothing.

[Thomas coupling]

Bloater:

The CAA as a bureaucratic dinosaur leaves a lot to be desired. As individuals they come across as fairly decent human beings doing a difficult job;) , but as a whole, it is in urgent need of a major overhaul. The CAA (in my opinion) is there to answer to the whim of the big fish (like BA, BAA) et al, I would suggest:eek: :eek:
On a second note, they are NOT a public body, they answer to the government but they also service private industry and make a profit from them too. They have a chairman who is supposed to be impartial! They are in a very invidious position.

Too many funny hand shakes/old boy networking going on for my liking...and this example emphasises it.

[Flying Lawyer]

I have seen a copy of the draft report which was issued in December 2001.
Under the Regulations, draft reports are provided in confidence. I am not permitted to reveal the contents, nor am I permitted to confirm or deny what has been said in earlier posts on this thread.
In answer to the questions about timetable/time limits, I've paraphrased the relevant regulations to make them a little easier to understand.

Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996.

Regulation 12: Report and Representations thereon
If the report is "likely to affect adversely the reputation of any person" the AAIB shall:
* provide a Notice (incl. a copy of the report/safety recommendations) to that person,
* consider any representations which may be made,
* make such changes to the report as it thinks fit after considering of the representations. (In this context, 'person' includes company, body etc.)
Any representations must be in writing and served on the investigating Inspector within 28 days of service of the Notice. However, the Chief Inspector has power to extend the period of 28 days.
NB: Representations may be made about findings and 'adverse comments' as well as safety recommendations which the AAIB proposes to make.

Regulation 13: Publication of Reports
The Chief Inspector must publish the report "in the shortest time possible" and, if possible, within 12 months of the date of the accident or serious incident.
The AAIB has a high workload, and carries out its investigations extremely thoroughly, as anyone who has read a full AAIB report will know. In many cases, it cannot complete an investigation and make appropriate recommendations within 12 months.

Regulation 14: Safety recommendations
The report is sent to the undertakings or national aviation authorities concerned, and they "shall, without delay
take that recommendation into consideration and, where appropriate, act upon it."
However, the aviation authority does not have to implement the AAIB's safety recommendations. It's not unusual for the CAA to decline to implement the AAIB's safety recommendations.

Like others, I've heard rumours, but I don't know the reason for the delay in publishing the final report. If it's any comfort, I have the utmost respect for the AAIB, and have never failed to be impressed by the professionalism, integrity and independence of every investigator with whom I've dealt over the years.
I've often heard it said the AAIB and CAA are 'in each other's pockets' or words to that effect. That is not true. They are not only separate by legislation, but have a totally different ethos. Although the AAIB has a lower profile, the contribution it makes to flight safety in the UK (and elsewhere) is enormous.
The AAIB is under a duty to consider representations, but I'd be extremely surprised if anyone persuaded the AAIB to remove any adverse comments which it considered were valid.

NB: I'm not disagreeing with those who've suggested making some enquiries about when the final report will be published.

Tudor Owen

[Hoverman]

Isn't it unbelievable that the CAA can ignore AAIB safety recommendations?
But, it means the CAA can't be worried about safety recommendations because they can just decide not to implement them.
So, they must want "adverse" comments about their procedures removed.

Isn't the answer for us to email the AAIB?

I've just sent mine. If anyone wants to copy it, feel free.

To the Principal Inspector of Air Accidents
AAIB

Re Crash of Hughes 269 G-ZAPS, March 2000

Please could you tell me why the Report into the above accident has not yet been published when the draft report was issued for representations by interested parties almost a year ago?

AAIB email address is: [email protected]

C'mon chaps. It will only take a few minutes of your time and it's a chance to help one of our own, Dennis Kenyon who lost his son.

[Helo]

The Principal Inspector is Jeremy Barnett. His email address is ...

[email protected]

... and he still hasn't replied to my email of the November 8th.

Could be on holiday, I suppose, so I'll give him the benefit of the doubt at the moment.

Helo

[Genghis the Engineer]

Firstly a disclaimer, I know nothing of the accident in question, I don't work for AAIB or CAA, and have not met any of the people affected by this tragic accident.

However, I work closely with CAA and AAIB, and have participated in half a dozen accident investigations.

It isn't unusual for AAIB to take several years to put out a report if they are still unsure that they have really got to the bottom of the accident. Another example is the PA28R that broke up in the air about 2 years ago, killing 4 people. In high profile cases, it is common for an interim report to be issue (such as was the case with the Hunsden F2a fatality about 4 years ago, that was about 2 years before the full report was published).

With regard to the CAA; the two organisations are jealously independent of each other. In fact I know of CAA surveyors who are quite bitter about recommendations that have been made by AAIB. As to ignoring AAIB recommendations, everybody has that privilege, but few should do so without ensuring that they are on INCREDIBLY safe ground. This applies to the CAA as much as it does to anybody else.

I think that people are right to nudge AAIB - they are very able people but still human and this may simply be an oversight, but if you get a firm holding answer, my feeling is that there will be a very good reason. It is likely that as well as Flying Lawyer, the affected family will have seen a draft of the report, and (please be careful chaps) it may possibly be concerns on their part that have delayed the final publication.

G

[Heliport]

Genghis

It's the families of the deceased who are anxious to have the report published as soon as possible to prevent the same thing happening to anybody else. They are not responsible for the delay.

Although I agree with the comments you've made about AAIB investigations in general, in this case the AAIB had no difficulty at all in 'getting to the bottom of the accident', mainly because the engineer responsible went to them and told them the whole story of what had happened.
The draft report wasn't an interim, it was a draft of the final report the AAIB proposed to publish, including their safety recommendations.

I won't reveal my sources, but they are reliable.

[Genghis the Engineer]

I wouldn't wish to doubt you Heliport, my point was primarily a general one. It is important in any accident to get the report out as quickly as is commensurate with thoroughness. It does sometimes occur that new facts appear late in the day, although in such a case one hopes that the Inspector responsible would have informed the family what and why. In my experience they don't generally fail to do so, although they may not inform the rest of the world.

G

[Hoverman]

Genghis
I agree the AAIB would tell the families of the deceased if there were any new facts which had emerged late.
I think we can rule that possibility out. They hadn't been told anything like that when I started this thread. I don't know if there's been any new facts discovered since then, but it seems very unlikely. The investigation was concluded over a year ago.

The engineer accepted all the criticisms of him - he gave them the information.
The pilot did nothing wrong.
The manufacturer did nothing wrong.

That's why my money is still on the CAA trying to have things which show them in a bad light taken out.

[Fair Flair]

Thanks for the email addresses. I've just sent a message through to Mr Barnet.

I would urge others to follow this course of action. Perhaps this will help the AAIB in their quest to bring this report to its final conclusion.

[Genghis the Engineer]

I'm afraid that many years of dealing with British aviation authorities tends to make me believe much more consistently in the cock-up theory than the conspiracy.

G

[Heliport]

Genghis
You could be right. But I suspect that some contributors to this thread know more about what was in the confidential draft report than they're letting on.

The helicopter world is a small one. ;)

[Fair Flair]

Thanks to the Flying Lawyer for providing the info on the Civil Aviation Regulations.

Presumably Regulation 12 is covered in the draft report, and although a little late, Regulation 13 has been adhered to. So that seems to leave only Regulation 14 as the bone of contention, which many of the above correspondents have been suggesting.

Maybe its time to get the media involved, after all this has a high 'human interest' factor, which would make good copy.

[Genghis the Engineer]

FF, I'd recommend not doing so until they've had every opportunity from polite requests to make a response. Getting the press involved in that way is a last resort and will lose any goodwell you have have started with.

Heliport, I'm sure they do, but I've seen no sign that anybody who has knowledge, feels there's a good reason for the delay. Hence my favouring the "cock-up" theory.

G

[Hoverman]

Fair Flair
Thanks for your support
Reg 12 has been complied with.
Reg 13 hasn't yet if I've understood it properly. I think 'publish' means formally publish the report, not just sending out a draft report to limited numbers in confidential conditions.
Reg 14 is the sticking point.

Genghis
Shame you can't read between the lines, but thanks all the same for your support for the idea of emailing the AAIB to ask when the report will be published.

[Fair Flair]

I have received a response to my email from Jeremy Barnett.

He says that responsibility for publication of the report has been passed to Mr Ken Smart, Chief Inspector of Air Accidents. Apparently Mr Smart will respond to me soon, but no timescales were given.

Ghengis - despite your reservations about contacting the media, I think we are running out of options. Unless someone with appropriate authority/knowledge can tell us why the report is delayed, and provide us with timescales of when it will be placed in the public domain, I can't think of any reasonable situation that explains the failure to publish.

To me, that means there is a possible compromise of safety issues, and that can 't be right.

[Genghis the Engineer]

I was reading between the lines, just couldn't see anything.

I think if it's in the hands of Ken Smart you'll hear quickly and he'll say something meaningful - that has certainly always been my impression of the man.

G

[Hoverman]

"I was reading between the lines, just couldn't see anything." :rolleyes:
Old proverb "There are none so blind as those who will not see."

Genghis
I don't know what your motive is for undermining this attempt to help a fellow pilot but what I've said on this thread is NOT guesswork and it's NOT speculation.
I know it's not just a cock-up.
I know the delay is caused by the CAA objecting to the report being published as per its draft form and trying to get it changed.
I know there's a big battle been going on between the CAA and the AAIB.
I know the CAA were worried about repercssions from the beginning.
I know the CAA was so concerned they had their own lawyers and an outside solicitor at Paul Kenward's trial because they were worried about what might come out.
I know that unless the AAIB safety recommendations are put into effect an accident like this could happen again with more people killed.
And my opinion is that saving other people from being killed is more important than the pride of the CAA.

If you don't know the facts and you're not CAA or ex-CAA please stop making silly uninformed comments. This is a serious matter. I believe the AAIB are straight and will dig their heels in for what's right but someone could be killed until the safety changes are made.

[Genghis the Engineer]

I am not trying to undermine anything or anybody, I was offering an opinion on general procedure having worked in the field, nothing more or less. I do know Ken Smart as a very professional man who cares deeply about safety and openness, which is why I said what I did in my last post.

I can't stop you going to the press, I am merely saying that I'd treat that as an absolute last resort because once you have, nobody is likely to tell you anything directly, and the intrusion of the press may further delay reporting. Your MP would be a much more sensible route because parliamentarians have a direct route to ask such questions, can't be ignored and have to be told the truth.

I have lost 4 friends or colleagues to separate air accidents - one of whom's aircraft is still in the Hangar at Farnborough, and care as deeply as anybody about safety. I have worked on 6 fatal accident investigations. Feel free to disagree with me, but I'd appreciate it if you didn't accuse me of undermining what I fully appreciate are your genuine attempts to improve air safety.

G

[Heliport]

Genghis
I thought it was only a matter of time before somebody reacted to your posts, and I'm pleased Hoverman has done so in a restrained manner - more in frustration than anger I think.
For someone who said "I know nothing of the accident in question, I don't work for AAIB or CAA, and have not met any of the people affected by this tragic accident.", you've been remarkably reluctant to accept what people who do know say.

First you suggested that concerns on the part of the families might be holding things up. Possible, but unlikely in view of what Hoverman had already said. When it was pointed out the families were very anxious to have the report published, you suggested a second possibility - 'new facts arising at a late stage'.

When it was pointed out that the families had not been given any explanation of that sort, you put forward your 'cock-up' theory.
I'm still trying to work out the logic of saying "I've seen no sign that anybody who has knowledge, feels there's a good reason for the delay. Hence my favouring the "cock-up" theory." Isn't the point that people with "knowledge" say there is a bad reason?

You say that you did read between the lines but didn't see anything. I don't doubt what you say, but you must be the only one.

You say you were offering an opinion on "general procedure", but this is not a "general" situation. Those who do know what's been going on say the draft report is critical of the CAA, the recommendations relate to the CAA, and it's the CAA that's holding things up.

One thing has been very clear throughout this thread. Everyone trusts and respects the AAIB for it's independence, integrity and the excellent work it does. It's a reputation which must make the CAA just a little envious. :)

BTW, for what it's worth, I agree the MP route is probably more effective than the Press. I suspect emails from Rotorheads contributors will also help to keep up the pressure.

[Genghis the Engineer]

All things considered, I think it is better that I decline to post further on this topic. I sincerely hope that it is resolved sooner rather than later, and that despite specific objections to what I have said, my comments have been of some use.

G

[Fair Flair]

I've had a reply from Ken Smart, Chief Inspector of Air Accidents.

He says that the representation stage is now complete, and the report will be published very early in the New Year. He confirms that the bereaved families will receive a copy of the report in advance of the publication date.

[Hoverman]

Fantastic news! :) :) :)
The families will be pleased to get the report, and I hope they won't be disappointed when they read it.

Have the AAIB stuck to their guns?
Have the CAA achieved anything after almost a year of "representations"?

Watch this space!!

[Heliport]

Thank you to everyone who supported Hoverman's campaign by emailing the AAIB.

The Report into this accident is of importance not only to the families, but to anyone who flies an unmodified Hughes 300

Heliport

[Fair Flair]

Its absolutely right that the report will be of great interest and importance to a wider audience than the bereaved families, and a number of correspondents have made that point in their comments.

Unfortunately there is nothing that can change for those who have been bereaved, but I'm sure that they would take some small comfort in knowing that what happened to their loved ones would not be allowed to occur ever again.

Maybe I'm being naive, but I hope that whatever it takes to get to that situation will be implemented as a result of the AAIB investigation. Otherwise, presumably its just a matter of time until the next accident, and who will be able to come up with the answers then?

[Lu Zuckerman]

The adversarial relationship between the AAIB and the CAA exists between the FAA and the NTSB in the states. I was personally told the following by a senior NTSB investigator. In respect to an unnamed aircraft that had exhibited a very bad catastrophic safety record. The NTSB recommended the grounding of the fleet. The FAA refused. The investigator went on to say that if this aircraft type exhibited one more catastrophic failure they, the NTSB, would ram it down the throats of the FAA and force the repeal of the aircraft’s’ certification. Since that time there have been 6 or 7 such accidents and the FAA refuses to do anything about it. How would it be if the CAA were the certifying authority and the AAIB investigated all of the accidents?

[Flying Lawyer]

The AAIB has provided advance copies of its (final) Report to the parties involved. It will be published this Friday 21st Feb.

I've heard (unconfirmed) that the CAA will publish a statement the same day.

Tudor Owen