2007 Puma Crash, Enquiry and Inquest (Merged)

[flipster]

Indeed the Royal Naval Flight Safety Accident Investigation Centre (RNFSAIC) could perform the military role in concert with the AAIB - these professionals work closely together and are similiarly trained, so interoperability is not a problem - and they will deploy! Put them together as a joint unit, outwith the MoD's chain of command and you could have a professional accident investigation unit that LEADS the investigation from a dispassionate and objective viewpoint - rather than the purely 'technical advice' the AAIB/RNFSAIC presently provide to BsOI/SIs (whose members are untrained accident investigators). Rather sadly, this way forward was recommended by the Tench Report in 1986 (!) but it was 'buried' by the MoD for reasons unknown. Goodness knows how many lives and aircraft have been lost because of this MoD failure.

Implementation of the airworthiness regs is another subject, though closely linked. Chug is right, the MoD continue to prove that self-regulation has failed. It is now time that this function is removed from the MoD's grasp.

[Pheasant]

The RNFSAIC works independently of the chain of command whilst it is conducting an investigation. Their reports stand for themselves and are never altered or amended. The role of the RN BOI is to determine the "events leading up to the accident", draw conclusions and make recommendations. Again whilst appointed by the chain of command they acted in an independent way. The key is the difference in philosophy between the RN and RAF. IMHO the RN chain of command have always been able to stand back and not second guess BOIs, and accept their findings. If they (the CoC) have disagreed with the BOI then it was always stated in a seperate document and the BOI report remained uninfluenced and untouched. The RN do not conduct formal oral briefings of the CoC (where influence may be brought to bear one might think) during the BOI but they do keep the CoC informed of key issues that affect airworthiness or safety. The RN system is excellent and has withstood many an investigation and inquest.

I noted that the RN BOI/RNFSAIC teams gained significant praise from both the coroner and families during the PORTLAND inquest.

[colonel cluster]

Tar, Brush....

Chug, you seem intent to talk about indenpendence, and BOIs etc, in the context of the MOD, but as pointed out above, the Services work differently, with the RN and AAC having a separate Acc Investigation function, outwith the HQ. Perhaps before pushing for an external solution, we should look at where better practice may be found internally.

Don't tar the whole MOD by how the RAF do business.

[Gnd]

Get the RN, AAC and RAF to do each others with 1 internal SME to advise - would get better results as indipendant and the RN and AAC would get off easily - Synic - no way!!!

[Chugalug2]

CC:

Don't tar the whole MOD by how the RAF do business.

I tar the whole MOD by the way that the MOD itself does business, CC, ie its business of Military Airworthiness Regulation. Should you demure from that proposition I would refer you to the revelations in the Chinook, Nimrod and Hercules Accident threads on this very forum, as well as comments made by sundry Coroners, FAI's and Parliamentary Committees. It is nothing short of a national scandal. As regards MI's other than by the RAF my only observation is that pride comes before a fall and of course my irritating mantra;
Self Regulation does not work and in Aviation it Kills!

[SiClick]

There is no reason why the AAIB could not have their role modified to include deployments to military accidents in theatre. Its just not a part of their current role.
A significant number of the AAIB are ex-military anyway!

[vecvechookattack]

There is no reason why the AAIB could not have their role modified to include deployments to military accidents in theatre. Its just not a part of their current role

There is a reason. They won't go. Who is going to drag them out there?

Self Regulation does not work and in Aviation it Kills

Complete rubbish. Self regulation doesnt work if you are weak and feeble. Otherwise it works fine.

[Chugalug2]

Vecvec:

Complete rubbish. Self regulation doesnt work if you are weak and feeble. Otherwise it works fine.

That may well be vecvec, but is it not a gamble that every time there is an accident those involved in the aftermath to ensure that it can never happen again are "otherwise" in your own words? In Civil Aviation no such assumption is made, either in Regulation or in Investigation. Is your case that those in Civil Aviation must be assumed to be "weak and feeble" whereas in Naval Aviation (in your case) they most certainly are not? Self Regulation is the British disease and has served us ill. One only has to think of the many "weak and feeble" MP's now helping with enquiries into their expenses.

[vecvechookattack]

The mistake you are making is to compare Civil and Military aviation. Civil airlines have 1 priority and that is to make money. Whilst making money they will state that they are commited to the safety and security of the crew and passengers. Military aviation has 1 priority and that is to kill the enemy. Whilst killing the enemy we may crash and kill some of our crews. That is accepted. It is accepted by the public but more importantly it is accepted by the crews. That is why the AAIB will not go into harms way and that is why the RNFSAIC will go into harms way.

[Chugalug2]

Vecvec:

Military aviation has 1 priority and that is to kill the enemy. Whilst killing the enemy we may crash and kill some of our crews. That is accepted.

If that were all that is being discussed here we would be on common ground, vecvec. Of 60 lives lost in 5 aircraft; Chinook (29), 2 Sea Kings (7), Hercules (10) and Nimrod (14), the only enemy presence was possibly as insignificant as one AK47 round (into the Hercules unprotected fuel tank). Each of those accidents had significant Airworthiness issues that were discounted or ignored by their respective BoI's. Whether or not they were the basic cause, a contributory cause, or incidental to the accident is not the point. Those issues would have been investigated by professional accident investigators at the time rather than being addressed long after the event thanks to external pressure or to still be the subject of rancour.

[Pheasant]

Chug,

Each of those accidents had significant Airworthiness issues that were discounted or ignored by their respective BoI's.

In the case of the Seaking accident I am intrigued by your assertion above. What were the "significant airworthiness" issues that were discounted, please justify your statement.


I am also struggling to recall an RN air accident where airworthiness or the Military Airworthiness regime run by the RN was in any way a significant factor in the accident. The vast majority were either unpredicted mechanical failure or some form aircrew issue/unknown cause. None were due to the process of airworthiness from my recall - of course there are always lessons that can be learned to improve the process. Once again we all need to be careful to speak of the Service that appears to have a problem, not colour all of the Services by saying there is a general problem. The RN system has been tested on many occasions and is robust and has oft been quoted as best practice.

[Chugalug2]

Pheasant, the last thing I want to get involved in here is a willy waiving contest and general yah-boo about "your lot sucks whilst ours is great". I find your statement:

I am also struggling to recall an RN air accident where airworthiness or the Military Airworthiness regime run by the RN was in any way a significant factor in the accident.

to be rather confusing. It is my understanding that all UK military aircraft are essentially subject to the same Airworthiness regime, ie the MOD's, hence no single service can be exempt from deficiencies in that regime. The MOD has many deficiencies in its Airworthiness regime!
As to the Sea King accident, I understand it involved two Sea King aircraft of the same Mk. being involved in an almost head on mid-air collision in hazy conditions. I also understand that the fitting of the forward HISL's on that Mk was such that pilots could be dazzled by them in such hazy conditions. Thus it is probable that neither aircraft was operating its forward HISL at the time of this accident. That would seem to constitute a "significant factor" in my book, but one which the BoI discounted by performing its own ad hoc trials and thus finding that it was not significant after all!

[vecvechookattack]

You have to remember that at the time of the Sk accident both crews were fighting and attempting to kill the enemy.....


as were the crew of the Chinook......and the Hercules...and the Nimrod....

[Chugalug2]

Vecvec, I have said before I have no issue with your statement. I may be a civvie, indeed an even more despicable genre, a retired civvie, but I have served and know full well that the job of HM Forces is to confront and destroy Her Majesty's enemies when so ordered! But, with respect, what has that got to do with the price of fish? No enemy was present or party to any of these accidents other than the Hercules, and even then was only successful in all probability due to a significant Airworthiness deficiency of the type. I know that the pedants will cavil at that last sentence but a Military Transport aircraft should have basic fuel tank protection from small arms fire IMHO. That may constitute "fitness for purpose" rather than Airworthiness, so let us call it "Military Airworthiness" and not split hairs! In all other cases I maintain that there was an Airworthiness deficiency no matter what, and that it was significant in all probability, but not according to that BoI.

[PTT]

Close presence of the enemy is irrelevant. The aircraft were, in some way, contributing to the effort to kill the enemy. As such the risks were accepted as a necessary part of the wider whole.

[Chugalug2]

Ah, so you are saying that these Airworthiness shortcomings, of unpredictable power excursions caused by defective FADEC coding, of flight control jamming, of fuel lines routed through bays containing ignition sources, of fuel tanks with no ESF or purging fit, of Anti Collision lights that needed to be turned off in the very conditions when they were most needed, were all known risks and deemed acceptable due to Operational imperatives, PTT? Known and accepted by whom might I ask? The operating crews, their subordinate commanders, the CoC, or simply the people in Main Building who were keeping their fingers crossed? As they were all in contravention of the MOD's own Airworthiness Regulations, could you tell me the purpose of such Regulations if they are to be so flouted? In one case far from operating against the enemy, close or otherwise, the aircraft was being used for ferrying VIP's around the UK. Was that risk accepted? If so by whom and why?

[KG86]

Gentlemen, gentlemen.... This thread is not about airworthiness; it is about a tragic, avoidable accident which has sullied the reputation of the RAF.

If you want a general debate on airworthiness, can I suggest you take it elsewhere. You have already subverted the Mull thread. Please don't do the same to this one.

[PTT]

Ah, so you are saying that these Airworthiness shortcomings, of unpredictable power excursions caused by defective FADEC coding, of flight control jamming, of fuel lines routed through bays containing ignition sources, of fuel tanks with no ESF or purging fit, of Anti Collision lights that needed to be turned off in the very conditions when they were most needed, were all known risks and deemed acceptable due to Operational imperatives, PTT?

No, I'm saying that your contention that "no enemy was present or party to any of these accidents other than the Hercules" is irrelevant.

Although it was a very longwinded and entertaining strawman you managed to build

[Chugalug2]

KG86, it is ironic that you make my point better than I could myself, which is that this very tragic and avoidable accident may well sully the reputation of the RAF if it is not properly investigated, as with the examples I list above. The Airworthiness of the Puma is an issue as has already been posted in this thread by those far more knowledgeable than I. Simply because the CVR contains seemingly damning evidence against members of the crew does not mean that issue and its possible bearing on this tragedy should not be fully and transparently investigated. Will it be? The precedents do not inspire confidence. You may think that a finding of Gross Negligence by the pilot(s) might sully the RAF's reputation. History shows that it is the preferred option when airworthiness deficiencies might prove even more embarrassing if "found"! I find it interesting that you think I have subverted the Mull thread. OK to post as long as one doesn't make waves, eh? I am not even a messenger to shoot, merely someone who is shocked by the attitude to Flight Safety extant in the RAF and MOD today.
PTT, Rather than being entertained by me could you please try to take on board what I am saying? Military Air Accident Investigation by the RAF is compromised, BoI/MI findings are not objective and the causes of accidents are often undetected, uncorrected and thus avoidable accidents are not avoided. I propose that such investigation be therefore removed from the RAF to an MAAIB. To those who maintain that the FAA and AAC do not have such a problem I say think on. How can any investigation carried out by serving officers be truly independent of the CoC? This is not a diatribe against any individual but against a system that is a contradiction of itself. I say again,
Self Regulation does not work and in Aviation it Kills!

[[email protected]]

And the whole purpose of Flight Safety in the military was 'not to do the enemy's job for them' - if you send people out in non-airworthy aircraft or make them operate in relatively low-threat environments with no lights which leads to loss of life with no enemy in sight, something must be seriously skewed in your perspective of how to do military airpower.

If the RN's 'best practise' is the SK crash then you can keep it - opposite ways, same height, no lights, no NVG - absolute genius