78 Sqn Chinook Crash (20 years ago)
Gentleman Aviator
Crash was only a few weeks after I left MPA (I left 9 May 86)
I was in the gozome Tristar and saw it out the window before we taxied back.And I know I just got back in time for my Anniversary on the 28th. Another reason for getting Timmy back was SOP in case fuel contam had been an issue - so all aircraft grounded until all fuel sources checked (I'd just finished a tour as Hels and CFSO in HQ BFFI).
Avoid imitations
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RIP Steve Newman and his crew.
I spoke to Steve just before he left for his final detachment; he was obviously on the Chinook flight of the OCU, myself on Pumas. He was one of many friends and colleagues killed in flying accidents during the couple of decades I flew in the mob. However, this was the one which made me determined, as the father of three young kids, to do everything I could to avoid a Chinook posting. It had a very poor reputation at the time and this unexplained accident made it worse.
I did manage to avoid it, thankfully.
I know that the crews now love it, but then they did not.
I spoke to Steve just before he left for his final detachment; he was obviously on the Chinook flight of the OCU, myself on Pumas. He was one of many friends and colleagues killed in flying accidents during the couple of decades I flew in the mob. However, this was the one which made me determined, as the father of three young kids, to do everything I could to avoid a Chinook posting. It had a very poor reputation at the time and this unexplained accident made it worse.
I did manage to avoid it, thankfully.
I know that the crews now love it, but then they did not.
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Definitely the 27th Feb 1987.
Sadly I was down there on 78 at the time and knew the guys well. I was on R&R on West Falkland at the time of the crash and was picked up the following morning. The remaining Chinook at the time was called back from task to deal pick up the crash ISO and deal with the post crash work. I take my hat off to the Chinook crew who dealt with this, they flew quite a few hours that day no doubt in shock at what had occurred.
Travilad (Stephen) I knew your dad (Andy) well, we went through Loadie training together at Brize where he was affectionately know as "Pastie" and we were both on 7 Sqn together at the time. I will never forget his Cornish drawl and the laughs we shared and the pranks we played. Andy and I were on the same flight just before the fateful day when we "relocated the infamous Lot 22"
It was a very sombre time down south as we said goodbye to 7 friends. I will always remember Padre Clive Parnell-Hopkinson who was the SH Padre and happened to be there at the time, He ran with the repatriation service, what a gent.
Every 27th Feb I still have a quiet moment remembering these guys and raise a glass in their memory.
Sadly I was down there on 78 at the time and knew the guys well. I was on R&R on West Falkland at the time of the crash and was picked up the following morning. The remaining Chinook at the time was called back from task to deal pick up the crash ISO and deal with the post crash work. I take my hat off to the Chinook crew who dealt with this, they flew quite a few hours that day no doubt in shock at what had occurred.
Travilad (Stephen) I knew your dad (Andy) well, we went through Loadie training together at Brize where he was affectionately know as "Pastie" and we were both on 7 Sqn together at the time. I will never forget his Cornish drawl and the laughs we shared and the pranks we played. Andy and I were on the same flight just before the fateful day when we "relocated the infamous Lot 22"
It was a very sombre time down south as we said goodbye to 7 friends. I will always remember Padre Clive Parnell-Hopkinson who was the SH Padre and happened to be there at the time, He ran with the repatriation service, what a gent.
Every 27th Feb I still have a quiet moment remembering these guys and raise a glass in their memory.
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Certainly not forgotten. I was the co-pilot in the Tristar that day, we stopped at the holding point, I saw the chinook at around 1500ft, looked in to change a radio frequency and when I looked up saw the column of smoke just starting to rise. A very sad day. We didn't consider fuel contamination - probably should have - we went back to the ramp in case we were needed, the next TriStar wouldn't have been in for five days or so.
Last edited by Alex Whittingham; 7th Aug 2013 at 10:10.
Mull of Kintyre Fatal Accident Inquiry (March 1996), Witness J;
"Boeing Vertol have a vested interest in deterring any report which leaves them liable. This company is well funded and has shown a determination in the past to influence the outcome of inquiries. When Wg Cdr M Pledger took command of 78 Sqn in the Falkland Islands in Feb 88 I asked him to brief the Chinook Flight on the findings of the BOI for the fatal crash which killed Flt Lts Moffat, Newman, Sgt Johns and a number of engineering personnel, as this had not then been published. As Chairman of the board of inquiry he briefed 2 findings: the first his own most probable cause (failure of a hydraulic jack due to poor quality control at Boeing Vertol) and then that which would actually be published due to the failure of MOD to face pressure brought to bear by Boeing Vertol (cause unknown)."
Clearly, the BoI had to use the phrase "most probable cause", but anyone reading the AAIB Annex to the BoI report, and in particular the separate report by the AAIB inspector (same one as ZD576), would be left in no doubt why Wg Cdr Pledger came to this conclusion.
Boeing is not alone in that bit of effort.....seems I recall the RAF AirShips do more than some of that too when it comes to Chinook Crashes. Just saying!
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Just to show how much MoD protects Boeing the follow is a reply I received last year regarding loose connectors on the Chinook's DECUs. An SI stated that the issue was the subject of a Boeing Investigation. I asked, what was the outcome? if there was a report, could I have a copy?
"The MOD does hold information related to your request for a copy of the Boeing Report. A Public Interest Test has been conducted which sets out the factors that are weighed for and against release. This concluded that the balance of the public interest lies in withholding the information requested. In summary, it was considered that there is a public interest in providing accountability for decisions taken, illustrating that fair procedures have been undertaken, achieving transparency about issues which may be of interest to the public and bringing to light information which may reassure the public that health and safety factors have been taken into consideration by the MoD. However these were outweighed by factors against disclosure such as the possible prejudice to relations between the UK and the US Governments if such information were to be released. The information requested is covered by the International Traffic in Arms Regulations (ITAR)"
Distant Voice
In 1968, my unit lost a CH-47A model at Diggers Rest FSB near Nui Dat, Vietnam. The Aircraft was carrying an underslung load of 105MM Howitzer Ammo. The aircraft was seen to pitch up....go inverted....and impact the ground with the underslung load landing atop the wreckage which was mostly consumed by fire. There were no survivors.
The Accident investigation had two theories....one was a Separation of the Forward Swash Plate.....the other was FOD in the form of a US Army Mess Hall Plastic Coffee Cup that had become lodged in the Flight Controls in the area of the SAS Closet.
Sadly, when you get that much metal hitting the ground with horrific force followed by a hot burning fire with plenty of jet fuel to feed the blaze....finding the exact cause of the crash becomes problematic especially when there is no CVR or Data Recording system.
The loss of good Men (and now Women) in these tragedies, as sad as they are, are part of the risk we all take when we put on the Wings and go flying.
Accident Boards should restrain themselves to making statements based upon definitive evidence....even if it means there is not "Cause" provable. Improving the Aircraft monitoring systems, engineering procedures, and quality assurance procedures by everyone in in the system from forging or the stock to inserting the last split pin.....should be the goal for us all.
That requires Leadership of the highest order starting at the very Top and working its way down the ladder.
Otherwise....we will keep on losing our friends.
I stood at the point of impact for that aircraft in 1968 and again in 2011....and it wasn't any easier the second time than it was the first.
The Accident investigation had two theories....one was a Separation of the Forward Swash Plate.....the other was FOD in the form of a US Army Mess Hall Plastic Coffee Cup that had become lodged in the Flight Controls in the area of the SAS Closet.
Sadly, when you get that much metal hitting the ground with horrific force followed by a hot burning fire with plenty of jet fuel to feed the blaze....finding the exact cause of the crash becomes problematic especially when there is no CVR or Data Recording system.
The loss of good Men (and now Women) in these tragedies, as sad as they are, are part of the risk we all take when we put on the Wings and go flying.
Accident Boards should restrain themselves to making statements based upon definitive evidence....even if it means there is not "Cause" provable. Improving the Aircraft monitoring systems, engineering procedures, and quality assurance procedures by everyone in in the system from forging or the stock to inserting the last split pin.....should be the goal for us all.
That requires Leadership of the highest order starting at the very Top and working its way down the ladder.
Otherwise....we will keep on losing our friends.
I stood at the point of impact for that aircraft in 1968 and again in 2011....and it wasn't any easier the second time than it was the first.
Although I know how much this will annoy a lot of people, I feel the need to state this reaction...
"Accident Boards should restrain themselves to making statements based upon definitive evidence...."
And therin lies the rub - If any investigative Board is laid open to influence from internal (and indeed, external) politicking there never will be a guarantee of that fully evidential reporting situation.
"Accident Boards should restrain themselves to making statements based upon definitive evidence...."
And therin lies the rub - If any investigative Board is laid open to influence from internal (and indeed, external) politicking there never will be a guarantee of that fully evidential reporting situation.
Sadly.....every Board is subject to both influences.
The extent of those influences is what matters.
The extent of those influences is what matters.
Extracts from AAIB Report
"Evidence of a number of pre-impact defects (in actuators) was found. A number of rig tests were conducted in the assessment of the cause and effect of the defects. Co-operation from Boeing Vertol was generally good, but little in-depth knowledge of the actuators was apparent in the responsible Design Groups.
Forward Swivelling Upper Boost Actuator
No upper roll pin or locking were was present and the clevis attaching rod had not been drilled to accept the pin. These were clearly assembly omissions.
Relatively deep witness marks were found on the rod, indicative of it having been carelessly clamped in a vice or grips prior to final assembly.
Aft Pivoting Upper Boost Actuator
Strip examination revealed that some of the seals in the head housing assembly had been incorrectly installed. One head housing back-up ring on System 1 and two on System 2 were found with bevelled ends crossed over.
In addition, it was found that incorrect back-up rings had been fitted in the 1.5" diameter seal between the piston bearing sleeve and the outer cylinder in both Systems 1 and 2. Continuous back-rings should have been used, but scarf cut rings were fitted.
(This same defect was discovered in the Aft Swivelling Upper Boost Actuator). Additionally, it was found that the outer seal in System 2 between the core of the head housing assembly and the piston assembly was incorrectly assembled and had suffered a gross failure. The inner back-up ring was missing, and the evidence clearly indicated it had not been installed at assembly. A 0.5" circumferential length of the O-Ring and the outer back-up ring was missing, providing a large overboard leakage path for System 2 fluid."
And so on and on, depressingly so. You don't have to be an engineer to grasp something was VERY wrong here. Also, out of interest, very similar language used in the Challenger report.
"Evidence of a number of pre-impact defects (in actuators) was found. A number of rig tests were conducted in the assessment of the cause and effect of the defects. Co-operation from Boeing Vertol was generally good, but little in-depth knowledge of the actuators was apparent in the responsible Design Groups.
Forward Swivelling Upper Boost Actuator
No upper roll pin or locking were was present and the clevis attaching rod had not been drilled to accept the pin. These were clearly assembly omissions.
Relatively deep witness marks were found on the rod, indicative of it having been carelessly clamped in a vice or grips prior to final assembly.
Aft Pivoting Upper Boost Actuator
Strip examination revealed that some of the seals in the head housing assembly had been incorrectly installed. One head housing back-up ring on System 1 and two on System 2 were found with bevelled ends crossed over.
In addition, it was found that incorrect back-up rings had been fitted in the 1.5" diameter seal between the piston bearing sleeve and the outer cylinder in both Systems 1 and 2. Continuous back-rings should have been used, but scarf cut rings were fitted.
(This same defect was discovered in the Aft Swivelling Upper Boost Actuator). Additionally, it was found that the outer seal in System 2 between the core of the head housing assembly and the piston assembly was incorrectly assembled and had suffered a gross failure. The inner back-up ring was missing, and the evidence clearly indicated it had not been installed at assembly. A 0.5" circumferential length of the O-Ring and the outer back-up ring was missing, providing a large overboard leakage path for System 2 fluid."
And so on and on, depressingly so. You don't have to be an engineer to grasp something was VERY wrong here. Also, out of interest, very similar language used in the Challenger report.
Last edited by tucumseh; 7th Aug 2013 at 17:14.
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The sort of thing you would have expected from 1970s British Leyland, not an aircraft manufacturer. You do wonder whether such endemic, corporate negligence could still be pursued.
Tuc,
Following the crash and discovery of the actuator issues....was there a follow-up to determine the source of the problems, whether other Actuators were in such a condition, and were there any other defective Actuators found installed on operational aircraft or in the Spares Inventory?
Following the crash and discovery of the actuator issues....was there a follow-up to determine the source of the problems, whether other Actuators were in such a condition, and were there any other defective Actuators found installed on operational aircraft or in the Spares Inventory?
Last edited by SASless; 7th Aug 2013 at 17:48.
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Don't know about that but I do know that two RAF Chinooks subsequently thrashed themselves to bits on 24 & 25 July 1989 after newly replaced aft drive transmission input thrust bearings failed, these having been fitted the wrong way round during manufacture. Very expensive (both never flew again) but fortunately no loss of life.
My recollection of the HC1s during the 80s were of unreliable aircraft that many were reticent to fly-in.
My recollection of the HC1s during the 80s were of unreliable aircraft that many were reticent to fly-in.
Last edited by Cows getting bigger; 7th Aug 2013 at 18:24.
SASless:-
Then the obvious answer is to remove Boards (ie Air Accident Investigation Boards) from such malevolent influence. In the case of UK Military Aviation that requires that the MAAIB be made independent of, and separate from, the MOD and the MAA (which should also be separated from the MOD).
If that had been the case for this accident then perhaps a cause might have been found, no matter how politically delicate it be. That might then have ensured the airworthiness of the HC1 and that the HC2 was given a legal RTS into the Royal Air Force. That might then have saved many lives....
Sadly, we'll never know because none of the accident investigations including this one were free of such "influences".
Sadly.....every Board is subject to both influences.
The extent of those influences is what matters.
The extent of those influences is what matters.
If that had been the case for this accident then perhaps a cause might have been found, no matter how politically delicate it be. That might then have ensured the airworthiness of the HC1 and that the HC2 was given a legal RTS into the Royal Air Force. That might then have saved many lives....
Sadly, we'll never know because none of the accident investigations including this one were free of such "influences".
Last edited by Chugalug2; 7th Aug 2013 at 19:37.
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Is this the right Sgt Johns in the course photo?
If it is, let me know and I can supply an copy without watermark
If it is, let me know and I can supply an copy without watermark
Last edited by November4; 7th Aug 2013 at 21:53.
SASless
Forgive me if I'm a little tardy with responses at the moment.
The papers I quoted from were obtained during my Mull of Kintyre inquiries because it was patently obvious that the AAIB investigator regarded ZA721 (Feb 87) as the starting point for ZD576 (Jun 94). When you look at the systemic failures there are many common factors.
The answer to your question, in general terms, therefore has to be no, MoD did very little to address these failures. In 1994, and even today, many still existed. You may recall MoD did everything in its power to prevent linkages being drawn to past events, claiming anything that occurred on ZD576 was unique to that aircraft tail number. In fact, almost every failure, fault and defect had a precedent, both in the Chinook Fleet and across MoD.
If MoD simply looked at these and other Chinook actuators, that would be an entirely typical, compartmentalised MoD response. As DV said above, MoD's reaction was entirely focused on protecting relationships between USA/BV and UK/MoD. Aircrew lives are regarded as a minor factor. The evidence of Witness J to the ZD576 FAI (above) was widely ignored, and certainly not followed up, but it is actually fundamental to the whole airworthiness debate, providing an insight into the systemic failures and systematic rundown of the process. It is key evidence that provides a date.
This wasn't the only Freedom of Information request MoD refused to answer. Another, arising from this BoI report, was on Hazard Analysis.
My personal opinion of this has been aired often. MoD investigations never dig and ask the next obvious question. In this case, a thorough overhaul of an obviously unfit for purpose QA/QC system would have provided a fighting chance of preventing recurrence. In Aug 1992 the CHART report by the RAF's own Inspector of Flight Safety cited ZA721 as an airworthiness related accident. That speaks volumes, given the official line was Cause Unknown. Was this an oversight or IFS making a point to the Chief Engineer and ACAS? Given the rest of the report, the latter. MoD's reaction? Withhold CHART from all concerned. My point is that there is a clear and unbroken chain of evidence from these 1980s failures to Haddon-Cave and then Lord Philip.
One small example - in 1998 new Chinooks were being delivered with similar serious assembly defects. At Boscombe a starboard avionics rack (about 6 feet high, 3 feet wide and crammed with black boxes) came loose and fell on a contractor, just after the aircraft had landed upon initial delivery. (On the pan outside RWTS hangar). The fixing bolts had been over-torqued and crushed the honeycomb bulkhead so that something weighing hundreds of pounds was literally hanging by a thread. In control runs, split pins had not been split. One part fell off and hit the pilot on the head as he was walking out the back. It had secondary bonding that consisted of a rolled up ball of 24awg equipment wire stuffed behind Nav systems. Nav problems? Always check bonding first. It matters not that these were not actuator problems - they were serious QC failures and indicative of a very poor ethos. MoD's reaction was exactly the same. Boeing are a protected species and nothing was done, except each defect (not fault) was quietly fixed as and when it was spotted. Except, the problem is that a defect (as opposed to a fault) indicates contractor liability arising from a poor design. That is, we were content to fire fight instead of getting to the root cause.
Haddon-Cave agreed that there were savings at the expense of safety, but what of pandering to a contractor on the basis of preserving relations, but knowing this places aircrew lives at risk? The next question would be who benefited from this.
Tuc,
Following the crash and discovery of the actuator issues....was there a follow-up to determine the source of the problems, whether other Actuators were in such a condition, and were there any other defective Actuators found installed on operational aircraft or in the Spares Inventory?
Following the crash and discovery of the actuator issues....was there a follow-up to determine the source of the problems, whether other Actuators were in such a condition, and were there any other defective Actuators found installed on operational aircraft or in the Spares Inventory?
Forgive me if I'm a little tardy with responses at the moment.
The papers I quoted from were obtained during my Mull of Kintyre inquiries because it was patently obvious that the AAIB investigator regarded ZA721 (Feb 87) as the starting point for ZD576 (Jun 94). When you look at the systemic failures there are many common factors.
The answer to your question, in general terms, therefore has to be no, MoD did very little to address these failures. In 1994, and even today, many still existed. You may recall MoD did everything in its power to prevent linkages being drawn to past events, claiming anything that occurred on ZD576 was unique to that aircraft tail number. In fact, almost every failure, fault and defect had a precedent, both in the Chinook Fleet and across MoD.
If MoD simply looked at these and other Chinook actuators, that would be an entirely typical, compartmentalised MoD response. As DV said above, MoD's reaction was entirely focused on protecting relationships between USA/BV and UK/MoD. Aircrew lives are regarded as a minor factor. The evidence of Witness J to the ZD576 FAI (above) was widely ignored, and certainly not followed up, but it is actually fundamental to the whole airworthiness debate, providing an insight into the systemic failures and systematic rundown of the process. It is key evidence that provides a date.
This wasn't the only Freedom of Information request MoD refused to answer. Another, arising from this BoI report, was on Hazard Analysis.
My personal opinion of this has been aired often. MoD investigations never dig and ask the next obvious question. In this case, a thorough overhaul of an obviously unfit for purpose QA/QC system would have provided a fighting chance of preventing recurrence. In Aug 1992 the CHART report by the RAF's own Inspector of Flight Safety cited ZA721 as an airworthiness related accident. That speaks volumes, given the official line was Cause Unknown. Was this an oversight or IFS making a point to the Chief Engineer and ACAS? Given the rest of the report, the latter. MoD's reaction? Withhold CHART from all concerned. My point is that there is a clear and unbroken chain of evidence from these 1980s failures to Haddon-Cave and then Lord Philip.
One small example - in 1998 new Chinooks were being delivered with similar serious assembly defects. At Boscombe a starboard avionics rack (about 6 feet high, 3 feet wide and crammed with black boxes) came loose and fell on a contractor, just after the aircraft had landed upon initial delivery. (On the pan outside RWTS hangar). The fixing bolts had been over-torqued and crushed the honeycomb bulkhead so that something weighing hundreds of pounds was literally hanging by a thread. In control runs, split pins had not been split. One part fell off and hit the pilot on the head as he was walking out the back. It had secondary bonding that consisted of a rolled up ball of 24awg equipment wire stuffed behind Nav systems. Nav problems? Always check bonding first. It matters not that these were not actuator problems - they were serious QC failures and indicative of a very poor ethos. MoD's reaction was exactly the same. Boeing are a protected species and nothing was done, except each defect (not fault) was quietly fixed as and when it was spotted. Except, the problem is that a defect (as opposed to a fault) indicates contractor liability arising from a poor design. That is, we were content to fire fight instead of getting to the root cause.
Haddon-Cave agreed that there were savings at the expense of safety, but what of pandering to a contractor on the basis of preserving relations, but knowing this places aircrew lives at risk? The next question would be who benefited from this.