2007 Puma Crash, Enquiry and Inquest (Merged)

[Cows getting bigger]

What and why are senior offs writing to each other?

In senior-officer-speak they are probably saying "F***, this is bad".

Put yourself in Joe Public's position. Coroner says that sqn management was slack, incomplete paperwork (CR/LCR?), sqn cdr since retired (not an accusation on my behalf, just repeating a previous statement), audio tape of chaps larking about with 8 troops down the back, anecdotal evidence from another SH crew, BOI not touching the accident with a very-long-thing choosing to hand over to the police.

Regardless of the hard, incontrovertible facts, all of the above isn't exactly a glowing indictment. Any curved ball about Puma anticipators etc is likely to be completely lost in the overwhelming noise.

[Jackonicko]

Torque,

I would, of course, agree that we "should not shy away from a frank discussion as to how it went so wrong on this occasion."

I would suggest that doing so in the full glare of my industry may not be entirely productive - less specialised journos will be looking for scandal, and there may be a temptation for some to go for 'ar.se covering' rather than a proper investigation.

I'd also repeat my unease at hysteria, involving the Police and the CPS, and my distaste at some of the mud-slinging.

There can be a fine line between "spirit and personal pride in one's own expertise" and "showing off", and even "pushing the limits" to get the job done.

While this crew may have crossed that line fairly spectacularly, I'm sure that many of us (when young and foolish) have at least come close to doing so, and to see them being so roundly condemned by their fellow professionals is unedifying.

[flipster]

In the sky news clip, it definitely sounds as if the engine/rotor speed reduces quite quickly. For sure, the AAIB will have been able to fathom out from this if there were any engine problems but, I believe, that it has been reported that there were no engine failures - which is not necessariliy the same thing.

[cazatou]

flipster

It is normal practice in the case of a Fatal Accident for the findings of the BOI to be held in abeyance prior to the judgement of the Coroners Court. This is done so as not to predjudice any subsequent Legal Proceedings.

It may, therefore, be some time before the BOI into this tragedy is completed and published if it is decided that there should be Legal Proceedings in respect of the actions (or inactions) of any of the surviving Crew or others who may have been involved prior to or during the events which resulted in the crash.

[Pheasant]

Caz,

It is normal practice in the case of a Fatal Accident for the findings of the BOI to be held in abeyance prior to the judgement of the Coroners Court. This is done so as not to predjudice any subsequent Legal Proceedings.

Not sure about this one. RN BOIs (before the advent of SIs) were published within about 6 weeks of commencement, the Technical Investigation took longer but was not dependant on the date of the Inquest, which can be some years after the event. The BOI is used to determine the most likely cause of the accident, the inquest attempts to determine the cause of death.

Pheasant

[cazatou]

Pheasant

I based that statement on my experience as Flight Safety 1 at HQ 1 GP which unfortunately involved more that one fatal crash. The BOI is an administrative document and is not part of any subsequent Legal Proceedings which may possibly follow an investigation into an aircraft mishap resulting in such an Inquiry. A separate Summary of Evidence would have to be taken.

[flipster]

So, in that case, the Coroner does not have any sort of accident investigation report on which to help him find out what happened?

Normally, the AAIB would have been asked by the BOI/SI to carry out a full field/ technical investigation of the crash-site and I am sure they have already. But the AAIB only do the technical side of things for the RAF, so who has been/will be conducting the all-important 'operational' reports involving supervision, medical, meteorolgical and human-factors (including psychological and fatigue issues) aspects?

I am sure that these reports would be a great help to Mr Fell, as such reports will help pinpoint the causes of the crash and more importantly, prevent future recurrences of this type of accident. In fact, I would go as far to say that without such reports, completed by accident-investigation personnel, the Coroner's Inquest is most severely hampered.

I am sure someone can let us know who has done this research for the Coroner?

[teeteringhead]

One certainly hopes that Mr Fell is exaggerating when he says there was no record at all of the crew's combat status (CR/LCR or whatever).

Wot? None at all? No logbook entry (subject or checker), no sortie report in trg folder, no entry in F5000 series, no archive photo of "wailing wall" ...... as an erstwhile SH Sqn QHI I find that very difficult to believe .....

..... but if true ........

[vecvechookattack]

Did the AAIB conduct an investigation ? I understood it was the Royal Navy that conducted it? Not sure though...Stand to be corrected

[seafuryfan]

'Coroner sorry for "Sloppy" remark'

BBC NEWS | UK | England | North Yorkshire | Coroner sorry for 'sloppy' remark

[Cows getting bigger]

Is that the same Dixon who was OC 27? If so, I remember the said individual trying to overtake Shaggy, his formation lead, in a certain disturbance in order to be first crossing the start line. Old Shaggy wasn't a happy bunny(ette). Pity really - we'd f***ed up and crossed the line before all of them a few minutes earlier.

Serious hat on, I think this one still has a long way to go. Terribly sad.

[cazatou]

flipster

If the AAIB conducted the investigation then that would be available to the Coroner. What would NOT be available - in the case of an RAF BOI -is the report of the Board to the Command chain because that could form the basis of any further investigation which could result in Formal Disciplinary Action or Courts Martial.

That having been said, Witnesses who gave evidence to the BOI would also be liable to give evidence to the Coroner. It is an area of Legal Proceedings which makes those who practice it quite wealthy at public expense.

[Wrathmonk]

The report in question (albeit "redacted") that Mr Fell may be talking about can be found here. I suspect Paragraph 5.12 might be what he was getting at.

I know it has been posted before but I couldn't find the post/link!

[Biggles225]

Flipster

Im old and well out of date, but the sounds in the report didnt seem to be 'engine problems' noises, they sounded to me like retreating blade stall.
Im prepared to be wrong. (As usual).

[tucumseh]

Caz

Witnesses who gave evidence to the BOI would also be liable to give evidence to the Coroner

Quite right in all that you say.

The area that concerns me is those witnesses whose written evidence, intended for the BoI, is withheld from said BoI, the Coroner and families; thus denying the BoI the opportunity to make recommendations to prevent recurrence, obstructing the Coroner in the execution of his duties and denying families the truth.

Sorry, slightly off topic - I'm thinking about two fatal accidents in 2003.

[vecvechookattack]

If the AAIB conducted the investigation

I'm not sure that the AAIB have conducted an investigation. It was the Royal Navy who conducted the investigation. The aircraft is currently at Yeovilton.

[jayteeto]

Retreating blade stall?? What does that sound like?? I may be wrong in my assumption, I accept that, but that sound on the tape was a very familiar one. As a QHI on Puma, part of the course was to demonstrate (at height) rotor Nr droop. It sounded a bit like the recording.........

[vecvechookattack]

If the NR was drooping was that as a result of them yanking in an armpit full of lever in order to arrest a decent?

[flipster]

Vec - it mat be that the RN Flight Safety Accident Investigation Centre (RNFSAIC) carried out the technical report (they are very well-trained, professional accident investigators - trained in the same way as AAIB) however, as the AAIB cannot deploy to the dustbox, the RNFSAIC normally carry out the field/tech reports for BoI/SIs abroad. In the UK, on the other hand, the AAIB usually gets invited by the RAF to carry out these investigations (as we don't have the expertise), so I would be surprised to hear that the RNFSAIC did it. That said, I believe that the RNFSAIC now have an 'ops inspector', so it is possible! That, at least, would mean that someone professional and out of the RAF chain of command had carried out the investigation - which would greatly help the Coroner. If, however, the ops investigations have not yet been done, I can't see how the Inquest can come to a logical conclusion. I guess we'll have to wait and see.

Wrathmk - nope - that report is pretty damning but it is neither the technical/enineering report, nor the ops report I would expect to be carried out for an aircraft accident by the AAIB/RNFSAIC in accordance with ICAO Annex 13 and associated protocols.

Caz - thanks for that. As you know, the AAIB do not have primacy in the overall investigation of RAF accidents - that is kept within the Service. So, the AAIB do the technical side of RAF accidents and do not complete the 'operations' reports - these are left to "complete novices" (in terms of accident investigations) - in the shape of the unfortunate BoI members. As for formal administrative action, as I think it is called now, then that will have to wait a while. When it happens, then it will probably be very messy, one way or another; certainly as it seems right now. Of course, we could all be jumping to conclusions - if this accident has been thoroughly investigated by the AAIB or RNFSAIC, then the truth will out, as these organisations do not have a political axe to grind and will be dispassionate in their reporting - with a view to preventing recurrence.

However, I am glad the BoI/SI is not yet complete as it woukd only muddy the waters - as Tuc mentions, BoIs do not look at all the slices of cheese, never mind all the holes therein. In fact, I would be happy for the RNFSAIC/AAIB to have primacy in all military accidents and do away with BoIs/SIs for aircraft accidents in toto, as the latter have passed their sell-by date.

Biggles Vec JT2 - While it looks bleak for the pilots right now, it may be that Nr droop and/or the lack of anticipators may be involved (or contributed in some way), as mentioned by others. If so, then it will not have escaped the notice of the AAIB/RNFSAIC that these problems have been raised, time and time again after past Puma accidents but yet nothing has been done to fix the problem; maybe the Puma MLU and engine upgrade is long, long overdue? Who was in charge of this? Of course, it may be that the drooping sound was indeed a last minute attempt to avoid terra firma - I am sure the AAIB/RNFSAIC will be able to work it out wrt the CVR, crash site and witness reports. I am not sure that further speculation on this is possible or wise until then.

Kind regards and symapthy for the families and those left injured

flipster

PS Caz, hope you are doing ok?

[Wrathmonk]

Flipster

Sorry - I think we may be at cross purposes here. I agree totally that the report at my link is

neither the technical/enineering report, nor the ops report I would expect to be carried out for an aircraft accident by the AAIB/RNFSAIC in accordance with ICAO Annex 13 and associated protocols

I posted the link in reference to the comments by Mr Fell about the squadron being a "sloppy outfit" and more in support/explanation of seafuryfan's post and link.

As I understand it, none of the reports you mention above would be "open source" yet as the 'formal' BoI is suspended/still in progress but stand ready to be corrected!