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How can this happen - controller partly blamed (merged)

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How can this happen - controller partly blamed (merged)

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Old 8th Feb 2006, 02:06
  #21 (permalink)  
 
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Rule One in aviation = Don't crash
Rule two = see rule one.

I wholeheartedly recommend that you read the referenced thread. If you believe in the conditions of "reasonable doubt" then this whole event is nothing more than a very sad accident. I was an expert witness in this case, I too thought when I first encountered the evidence that it was a straight descent into terrain, but having studied all (and I do mean all) the evidence that there is another possible scenario. Especially when one of the highlights of my 4 days in the witness stand was the Gp Capt prosecutor asking me:
"well Mr X if it wasn't for the eye witnesses, nobody actually saw the aircraft".

Brilliant, abso-fkin-lutely brilliant.

Maybe its a sign of the times, but when I was learning to be a pilot I was always taught to look after myself, trust no one, never assume, check and be well prepared. Why is someone else always responsible these days???

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Old 8th Feb 2006, 02:50
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the reconvened RAF Board of Inquiry conclude the crash happened partly because the pilots accepted an air traffic control instruction that was clearly unsafe.
Clear to whom....the controller...the pilots? Or some fecker who had naught to do but spend weeks mulling over things in the quiet of an office with lots of tea and biscuits?

If it is that "clear"....what happened?
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Old 8th Feb 2006, 08:01
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The F15 accident

In support of Tarnished:

The full findings of the Board of Inquiry can be found on the MOD UK website. I have only had a very brief read and will reply more thoroughly after a proper look at the full report.
In essence, it would appear that the full reporting chain still believe the F15s followed a straight line descent in IMC into the ground. To support their theory, they believe that the eyewitnesses saw Tornados (AXIS formation) and not the F15s. This despite the leader of AXIS formation stating at the Court Martial that the flight was flying in loose trail and not in close formation as the eyewitnesses reported the F15s. The F15s crashed in very close formation. Further to that, AXIS formation landed 30 minutes before the estimated time of the crash.

If the new BoI has persuaded the leader of AXIS formation to change his recollection of their route on the day to coincide with eye witness positions then surely perjury will have been committed? The original verbal testimony of the route was given under oath at the GCM and a map of the route was presented as an exhibit (I have a copy of that map). The only other aircraft in the area that day were the F15s. The eyewitnesses could not have seen the Tornados on the route given in evidence.

One of the crassest questions asked by the chief prosecutor (and there were quite a few) at the GCM was : " If you take away the eyewitnesses, there is no evidence that the aircraft were seen to the east of Ben McDui, isn't that true?"

The original BoI was accused of fudging evidence to fit their theory of the cause of the accident; I hope this latest saga is not a repeat performance. The RAF seems to find eyewitnesses very inconvenient !! The subject aircraft overflew 2 of the eyewitnesses at something like 250' in close formation, they then overflew another eyewitness in a matter of seconds having altered heading. I would suggest that fast jets in loose trail almost constitute 2 sightings, not one.


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Old 8th Feb 2006, 08:35
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Another thread on this

There is another thread on this called 'How Can This Happen' (perhaps the moderators can put these together). I have posted quite a few questions on the other site and now that there are people reading this one, who know more about what happened, perhaps they can read those questions and answer them.

It seems to me that the BoI are questioning the phraseology used. If there is a fault in the phraseology, then in the interests of safety, this has to be addressed. If Mr Doleman can get off his train of thought that we are all trying to sling mud at his friend (which I, for one, am not) and get onto the subject of safety, we might all learn something useful.
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Old 8th Feb 2006, 08:46
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A few more quetsions for DD

[quote=DICK DOLEMAN] >The original BoI was accused of fudging evidence to fit their theory of the cause of the accident; <

Who accused them? Was this and official accusation? Were any charges brought? Was the accusation proved (legally) justified? How come we didn't hear the fallout of such an event?

I thought that the original BoI was halted because the CM was convened. You're now implying something different. Were the members of this BoI the same as the original board?
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Old 8th Feb 2006, 08:48
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Dick Doleman please read this thread

DD I'd be interested in your answers to the questions that I've posed on this thead.
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Old 8th Feb 2006, 11:09
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For those wishing to see the BoI report, it is at:
http://www.mod.uk/DefenceInternet/Ab...tMarch2001.htm

NB - Some rather large .pdfs to download!

I note in Part 2 of the BoI report:

23. Three of the witnesses were positive that they had seen twin-tailed ac, not Tornado ac. The board judged that, if they were correct, then the F-15C formation would have had to have avoided the imminent collision with terrain indicated by the last radar plot.

But how do they know whether the F-15C formation leader would have actually been able to see this terrain in such white-out conditions. I thus find the later comment:

In conclusion, the Board judged that, despite their certainty that they had seen twin-tailed ac, the eyewitnesses had been mistaken as to the type of the ac, possibly due to a factor such as the angle of view, the proximity of the ac to eachother, the prevailing light conditions and changes in aspect as the ac flew past whilst manoeuvring.

to be somewhat surprising, given that the 3 witnesses were so 'positive'..

Mods - please merge the threads.

Last edited by BEagle; 8th Feb 2006 at 11:27.
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Old 8th Feb 2006, 13:47
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BEagle

This comment by the board is most surprising:
23. Three of the witnesses were positive that they had seen twin-tailed ac, not Tornado ac. The board judged that, if they were correct, then the F-15C formation would have had to have avoided the imminent collision with terrain indicated by the last radar plot
None of the eye-witnesses were anywhere near the last radar plot. They were between 6km and 8km to the east and south east of the crash site. This evidence was crucial in supporting the defence theory that the F15s were already engaged in low flying prior to the accident and were last seen on a westerly heading towards the area of the crash site.
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Old 8th Feb 2006, 13:57
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Old 8th Feb 2006, 14:46
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Thread merge would be good.

To answer Speedpigs question, only one in 10 of all F-15s (all USAF fast jets??) is/was fitted with an FDR, if it has a serial number ending in a zero, it has a FDR.

Not a lot of people know that.

Sadly neither of these aircraft had one fitted.

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Old 8th Feb 2006, 15:13
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PAMCC,

I believe the ATC world has learnt a lot from this already. Certainly now you would never be let down anywhere dodgy under RIS without the obligatory reminder that "you are responsible for terrain clearance" or whatever the phrase is. I believe that a number of guidelines were brought in pretty quickly after the accident.
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Old 8th Feb 2006, 16:24
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Phraseology + altimeters

That's good to know. Is RIS also terminated when A/c go low level? Surely these a/c would have decended out of radar cover. So I couldn't figure why the RIS wasn't terminated.

Something else that puzzles me.
In the original thread about the CM there was information about the pressure setting for the area and it seemed that if the a/c were on regional and at 4,000ft indicated, they would not have hit the mountain due to the difference between the regional and the actual.

Many words have been written about the theory that these a/c had descended below 4,000ft. So...........was there no readable/useable information recovered from the wreckage to confirm what was on the altimeters? Was it too badly damaged?
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Old 8th Feb 2006, 20:22
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A thought provoking thread! However, a few misconceptions about RIS. Terrain clearance remains the responsibility of the aircrew under both RIS and RAS. Furthermore under a RIS you can be cleared to a height/altitude below the radar vector chart, under a RAS you can't. I've never managed to understand why that is. Surely the only difference between a RIS and a RAS is the avoiding action given from other traffic, but I digress.

The time consuming blah about '...resposible for terrain avoidance ..' has, I believe, thankfully been removed from the book. Certainly I've not heard ATC use it for a few months.

As regards the low-level abort, it is still taught during flying training. If a student is unable to fly a safe abort he will not pass his Instrument Rating. The BIG proplem is knowing when to initiate it, not how!

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Old 8th Feb 2006, 22:17
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Smile

H Peacock. Just wanted to clarify a few points!
Radar Advisory Service is where the aircraft recieve warnings and avoiding action information from other aircraft. The pilot is not obliged to take that action. They certainly cannot be cleared to below a radar vector chart. To do so would relegate them to FIS.
Radar Information Service is where the pilot recieves information only on other aircraft and takes his own avoiding action. Again, they cannot be cleared under the RVC as this would take them down to a FIS.

and no, '...responsible for own terrain clearance...' has most certainly not been taken out of the book and should be given everytime by ATC especially in Class G airspace.

hope that clarifies that!
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Old 9th Feb 2006, 01:48
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The BOI Report is at http://www.mod.uk/DefenceInternet/AboutDefence/CorporatePublications/Reports/OtherPublications/BOI/BoiReportIntoF15AccidentMarch2001.htm

I've followed this tragic accident, and its aftermath, with more than passing interest.

This is not the first time military aircraft have descended into high ground in northern
Scotland while in receipt of some form of ATC service.

There was a similar accident in January 1966, when a Canberra from 2TAF crashed into high ground west of Inverness, on descent to become "VMC below', to enter Tain Range.

If memory serves me correctly, in the
Canberra accident, the aircraft was in receipt of what used to be called 'Limited Radar Advisory Service' (LRAS); and was cleared by ATC to an altitude below that of the local safety height, while heading west along the Moray Firth towards high ground.

In those days, ATC was provided via Moray Radar/Approach based at Lossie using the S264 and CPN4 radars; the former for area/approach and director, the latter for GCA finals. The S264 incorporated both primary and secondary radars, had a max range, I think of 160 nm, and a very good anti clutter/weather filter. If one deselected the MTI, Ben Macdui,
Ben Nevis and various other peaks stood out like canine testicles. In the idiom of the day, the term ‘cumuli granites’ comes to mind.

As in the F15 accident, both Canberra crew members were killed instantly. Similarly, it took some days to locate the wreckage and bodies due to adverse weather.


The RN controller involved was court martialled. I understand he was “dismissed his ship” and never controlled aircraft again.

I believe that disciplinary proceedings were also taken against Squadron staff at RAF Bruggen. I'm not sure what the outcome was but involvement in same isn't likely to be career enhancing.

One of the procedural changes adopted by RN ATC (Moray Radar/Approach) at Lossie after this accident was to tell pilots on VFR descent into LFAs 14 & 15 under LRAS that they were responsible for terrain clearance, they were descending towards high ground; that if they became IMC, they were to climb immediately to FL .... ( a quadrantal level based on the lowest safe altitude within 100nm of Lossie, calculated on the current Regional Pressure Setting and displayed in bold font on the tote board above the controller's display); and to contact Moray Radar/Approach ASAP on … (freq).

And all 2TAF descents into Tain Range from VMC on top were via a GCA into Lossie with overshoot across the Moray Firth.

"Plus ca change, plus c'est la meme chose"!

In the BOI Report, there’s some reference to what, on any version of the facts, must be a Heath Robinson means of communication between Leuchars and Lossie ATC. Even in the 1960s, there was direct ATC land line comms between controllers (and to Highland Radar at Buchan, too) to facilitate ATC/ADIZ/QRA/MDA responsibilities and radar handovers via GEOREF i.a.w a SOP. The vision of using an ordinary telephone in 2001 to effect a radar handover via an assistant simply beggars belief.


And there’s the hoary old chestnut about the permissive nature of the drafting of orders. Is the RAF using public servants to draft orders these days? As Grampaw Pettibone used to say: “Holy snapping ducks*hit, it don’t take no Einstein to know that an order that’s capable of more than one interpretation ain’t worth the paper it’s printed on”.

Also in the Report, both the AOCIC and the AOC note that while responsibility for terrain clearance must remain with aircrew, air traffic controllers "must be responsible for the accuracy and the safety of their instructions". If so, is this responsibility made clear to controllers from ab initio days?


And if the AOCIC is correct in saying that this is a duty of care issue (and I think he is), then, in the absence of any Crown immunity, the question arises as to what civil liability is imposed on both the controller and his employer, vicariously, if that duty is breached. Or is the controller solely liable if he is on a frolic of his own? Never mind the "it's not in my duty statement" cry (whatever that might mean), did he know, or ought to have known, that the altitude that he approved descent to (4000ft), was below the height of high ground in the vicinity of the aircrafts' track?

Which in turn leads to the questions (relevantly in the F15 matter) of what duty of care supervisors have towards ATC staff, and staff to supervisors, where an individual is not completely fit for duty due to circumstances beyond their control.


On reading the BOI Report, it’s not clear to me if these issues are to be addressed. IMHO, they should; and all concerned need to know what their responsibilities are.

Succinctly put: a SNAFU with unnecessary loss of life, career/reputation and aircraft that shouldn't have happened if the lessons of history had been applied.

Last edited by Argus; 9th Feb 2006 at 05:06.
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Old 9th Feb 2006, 02:05
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This seems to be another case of finding a verdict for the verdict's sake without adressing the issues. For example, how 'au fait' were the US pilots with UK procedures and terminology. I know they were based in the UK, but from my experience of the US use of the UKLFS I'm not convinced in this case they had a full understanding of their own terrain clearance responsibilies. Under US procedures there isn't a Radar Information Service as such - so did the pilots understand what they were getting? There has been more than one incident in the past where confusion between systems has been a factor.
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Old 9th Feb 2006, 02:19
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I did not read the entire thing yet but what I did read makes me think going IMC under RAF radar control might be a dodgy thing.

From what I read, discounting how much was blacked out, I see an image of a guy who had suffered some sort of personal tragedy prior to the day in question. His co-workers asked him how he felt...for some good reason. His supervisor had not gotten around to verifying that he was fit. He admittedly had not signed off or read all of the memo's as required. He lost situational awareness (at best) and gave a clearance that placed the aircraft below the height of the mountain they hit while using it as a checkpoint in discussing handover to the next controller. The changeover was effected by a speed dial setup and not a direct line....required the assignment of the trade off to be decided before the handoff could occur. He had been asked for a descent clearance to by a non-standard terminology. He knew the aircraft were above or in cloud thus could not see terrain. He mishandled the radar by offsetting it vice extending the range setting. He was handling one other aircraft was it or was it a second aircraft was on the frequency. Anyway...he was not exactly swamped with business.

There is a lot of discussion about the whys and wherefores that deal with the very limited effect each variance from established procedure had on the fatal crash that killed two pilots but it does not consider the perception that can be formed by assessing the cumulative effect of so many deviations from procedure and plain old commonsense. I see a sloppy operation that failed to accomplish their mission, that being the safe control of air traffic.

The emphasis on the request for Minimum Vector Altitude is misplaced. The emphasis should be simply on why the aircraft were cleared towards the mountain whose height exceeded the altitude they were cleared down to by the controller....all the time he knew they were headed for that location as evidenced by the discussion he had requesting the handover.

One can say the pilots are responsible for terrain clearance....and they are. One cannot evade responsiblity for a controller giving a descent clearance that is lower than the terrain along which the aircraft will be flying. Pilots must be able to rely upon ATC to ensure terrain clearance is considered anytime an ATC clearance is given. Why else is it called a "Clearance".
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Old 9th Feb 2006, 07:31
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Seems to me this was a case of aircrew not aware of MSA, loss of situational awareness. It's a planning issue. As I understand it, they were not in controlled airspace and should not have put themselves in a position where they relied solely on ATC.
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Old 9th Feb 2006, 08:35
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Angrel.
Having spoken to a competent 'air tafffickker' yesterday on the subject of radar-to-visuals (nothing to do with the F15 CFIT), he assured me that an aircraft could be cleared to a lower height on a RIS than a RAS. This was because on a RIS we can be cleared below the radar vector chart. Surely this is why you can get a RIS as soon as getting airborne but before you are high enough for a RAS? I'll double check with my contact, but this does concur with my understanding that you'll always get lower on a RIS!

As regards the 'blah' about terrain clearance, this has gone from ATC phraseology where I work, maybe a local procedure. Do I really need constantly telling something that is SOP? I think not.

H Peacock.
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Old 9th Feb 2006, 09:06
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Cleared? I think not

You cannot be 'Cleared' to do anything on a RIS. It stands for Radar INFORMATION service. If you have an ATCO telling you this they ought to be sent back to training !!! Equally any pilot who doesn't understand ATSORA.

I hope ATCOs are still using the phraseology about terrain clearance. It could save them their licence/a long CM, if, God forbid, something else like the tragic F15 accident happens.
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