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78 Sqn Chinook Crash (20 years ago)

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78 Sqn Chinook Crash (20 years ago)

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Old 8th Aug 2013, 07:12
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Originally Posted by travilad
This is indeed the right Sgt Johns, the tash I am assured was very fashionable back then. I would love a copy if you don't mind.
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Old 8th Aug 2013, 09:11
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Anyone still in touch with Audrey Moffatt, I would like to forward my regards

W
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Old 8th Aug 2013, 12:03
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I believe I said this in the Mull thread but I'll say it again:-

I was in the Swamp, (Crewman's accommodation at Airport Camp), when the phone call came telling us of the crash. I had flown with Steve on many occasions when he was on 33 and he was always a fine pilot and it was always a pleasure to fly with. I knew Andy, (he was also nicknamed "Wally" IIRC), from the Sgt's Mess at Odiham and had flown innumerable Track and Vibros with Dave Chitty and Karl Minshull. I forget the name of the third tech but I believe I had flown Air Tests with him too. It was a very sad day.

There was much speculation about the cause and eventually the rumours all began to fall into line that it was a DASH runaway. It was about this time that a conversation was had where, while no explicit orders were given, it was made quite clear to us that the "possible" cause of the crash was not to be discussed with the families of the victims, period!

Not long after this the HC1 backed into the aircraft steps at an Air Show somewhere in Germany and the fuel tanks failed to separate as they were supposed causing three(?) deaths. I knew the young crewman who was burned to death in that accident too, though not well.

Subsequently I was posted to 240 OCU for conversion to the HC1 and, despite me asking to be sent anywhere but Chinooks on compassionate grounds, (wife had a dangerous heart condition that was worsened by stress), the RAF insisted they wanted me there. I completed the ground phase but refused to board the aircraft for the famil flight on the grounds that the things aren't airworthy and to fly on them risked the life of my wife. Funnily enough the RAF somehow thought I might be a little imbalanced and sent me to a high priced psychiatrist in London only to be told that I am, indeed, perfectly sane. The RAF and I parted ways.

I believe much of what has been said in the Mull thread confirms my thoughts that the airworthiness system in the RAF in the 80's and 90's was broken and, with regard to the Chinook at the time, was quite probably criminal.
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Old 8th Aug 2013, 13:35
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Tuc,

Are you aware of similar issues being experienced by the US Army on their Chinooks during the same time period?

I know of one infamous incident where a candy bar wrapper was found inside a Transmission. The investigation revealed open cases were stored next to an employee break area and that it appeared someone threw the wrapper into the gearbox while it was stashed there during the manufacturing process.


A Power Point Presentation you might find interesting.

http://www.chinook-helicopter.com/ma...SOF_Review.ppt

Last edited by SASless; 8th Aug 2013 at 14:00.
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Old 8th Aug 2013, 14:32
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SASless

Two examples involving the same general design area;


“Safety of Flight Message – All US Army CH-47D, MH-47D and MH-47E Aircraft 6th December 1994


Summary of Problem


A 1992 accident in Alaska was caused by a screw in the Upper Boost Actuator Control Valve failing from Hydrogen Embrittlement. The failed screw restricted the travel of the pilot valve in the actuator resulting in reduced controllability of the aircraft.”

And

Accident involving US Army CH-47D near Tulia, Texas on 11th April 1997.

“During aft swivelling boost removal, maintenance personnel discovered that the plain press bushing.....was not installed. Installation procedures show the requirement for two washer and not the required bushing. Without this bushing installed, uneven loading is placed on the bolt and clevis. Uneven loading and missing bushings have proven in the past to be directly related to fatigue failure.



The upper boost actuators and ILCAs deserve immediate and positive action, since these two areas are CRITICAL TO FLIGHT SAFETY, PERSONNEL SAFETY, AND EQUIPMENT SAFETY.”

(Upper case emphasis in original report).
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Old 8th Aug 2013, 15:22
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Tuc,

I was referring to more substantive complaints....my memory tells me there was an investigation into Boeing's QC/QA performance by the US Army as part of Contract Performance issues. I cannot remember the details or the time period it took place and thus far have not found any information that would report the outcome of the investigation.

It was quite a while ago all this happened.

One Question that is begged.....is how the "Operator" figures into the equation?

If the Tech Manuals are not detailed enough....and there is scant experience amongst the Engineering crews....are we seeing mishaps that occurred due to the lack of "corporate knowledge"?

In the past I criticized the RAF and UK Civvie Operators for refusing to embrace the notion of leaning upon more experienced operators of the Chinook during the early years of the machines introduction into service. Without assessing motive to that failure......I cannot help but wonder if it might have worked out better for all if that had been done with more enthusiasm.

In light of the complaints heard from the UK side of the Pond....about the RAF system of procurement and certification....if compounded by the lack of experience on a particular aircraft design.....even a dull third grader can see plenty of room for errors being made.
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Old 8th Aug 2013, 16:43
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SASLess

I’m not sure what would constitute “more substantive”. You gave me a link to a .ppt presentation on Safety of Flight messages, and I quoted from a real example. Similarly, from the US equivalent of a Board of Inquiry report. From a US viewpoint, these would be “substantive”.

Nevertheless, you ask good questions. As a result of ZA721 (Falklands 1987) the BoI recommended the Hazard Analysis be updated. If you read the comments of the Reviewing Officers, one rather misses the point that the Hazard Analysis already exists. Also, the ROs show no understanding whatsoever of how such a thing would be funded or progressed. And they shared Haddon-Cave’s later ignorance of the fact such contracting must be continuous - that is, you don’t just start a “Hazard Analysis” task when something goes wrong. It is a continuous process designed to stop things going wrong. A few years later the recommendation was rendered academic, as in 1991 the RAF Chief Engineer began his rundown of airworthiness by chopping the funding for such (mandated) contracts.

As you say, this raises the question of how much blame can be apportioned at Operator/Maintainer level, be it US or UK. The ZA721 BoI report makes severe criticism of short 4 month tours of key personnel, pointing out that few were trained for the post they were given. The “solution” was to extend this to 6 month tours, which doesn’t address the basic training. Notably, when all the evidence of equipment failure pointed to Boeing QC problems, 5 RAF Maintenance personnel were named by the BoI. Any reasonable person reading the report would ask why this vindictiveness, when not matched by more robust criticism of, and action against, Boeing. The Senior RO, ACM Sir Peter Harding, comes close to apologising for this, and their time spent under QR 1269 action. Clearly, there was a political imperative, and subsequent papers confirm this.
Years later (1993) when our (UK) Trainers went to Boeing to prepare the Engineering Training syllabus for FADEC in what was to become Mk2, Boeing could offer no help whatsoever, actually expecting OUR staff to train THEM. In 1999, almost 20 years after the UK ISD, our Chief of Defence Procurement admitted to our Public Accounts Committee that basic pre-requisites for airworthiness were STILL not in place.



You may recall this was at a time when RAF maintainers were forced to use captured Argentinian pubs to maintain our Chinooks, as our pubs were not to the required standard. The US Tulia report makes the same criticism, so one cannot point the finger at our (UK) Tech Pubs people; the failure would seem to be earlier in the process at Boeing.

This, indeed, describes a critical lack of Corporate Knowledge. But what caused that? The major cause was the conscious decision of these senior RAF staffs to waste astronomical sums of money, in turn prompting them to make savings at the expense of safety. I cannot comment on what was happening in the US Military, but on Chinook this was clearly compounded by severe shortcomings at Boeing. I can sympathise with Boeing up to a point, as for many years they would be without the necessary funded and mandated contracts from the UK; but that doesn’t excuse the likes of holes not drilled in Actuators, screws not heat treated (or the wrong screws specified), wrongly fitted seals and gross errors in documentation.



We have plenty of dull 3rd graders over here – they’re called VSOs.
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Old 8th Aug 2013, 17:26
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Also over here we have an incredibly meticulous AAIB inspector (Tony Noble) who investigated the engineering aspects of 721 and 576, who's reports (even to me, a non engineer or Chinook operator) seem glaringly obvious that the airframes were not fit to fly.

Were fleetwide inspection carried out following his input? Were other manufacturing faults found? Or did 'politics' rear it's head?

It seems to me Mr Nobles' efforts were ignored.

Oh what a tangled web we weave when first we practice to deceive
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Old 8th Aug 2013, 17:32
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While instructing Libyan Air Force crews on the care, feeding, and operation of the Chinook, done in Italy for Agusta....I had the occasion to be visited by several Agusta Engineers (the kinds that design things....) and some Agusta Techs, and two Quality Control guys just as I was finishing a preflight inspection on Libyan Bird number 2.

They asked if I minded their taking a look at the Synch Shaft and I quite happily granted Permisso.

Out came the Calipers, Micrometers, Yard Sticks and Chalk Lines....followed by a lengthy Chinese Parliament done in Italian complete with lots of Arm waving.

Following a Consensus being found in said meeting.....the Lead Engineer came over and suggested we not fly that day as they had confirmed a Machinist had misread the Blue Prints and had mis-machined the Thomas Couplings.....leaving them a bit short of Spec....literally.

As the Synch Shaft is about the most important gizmo on the Chinook....the significance of one of those couplings failing....does not bear thinking about if one is engaged in flying the Chinook.

Point of all that.....Helicopters are complex machines and ensuring they are safe and reliable is very much a complex process with many potential points of failure.

I flew the Chinook back when it and I were new and the design had a long way to go before maturing to the point the major defects had been worked out. I can tell horror stories of Engine Gear boxes, Push Pull Tube Rod Ends, Rotor Blades rotating in the Cuff, and a few other minor glitches that turned some machines into trash taking the crews with them. But....it is still the best helicopter I ever flew and continues to prove itself a real workhorse.

It sounds as though you folks in the RAF had far more problems than we did particularly in light of how late into the life of the Chinook you folks got involved.

Re Maintenance Manuals.....any particular reason you could not have taken the US Army TM Series of Manuals for the Chinook and modify them for use?

Surely, despite the language difficulties....the content of the Manuals would be useful once translated into "English English".

(Split Pin = Cotter Pin for example)
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Old 8th Aug 2013, 18:19
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"Re Maintenance Manuals.....any particular reason you could not have taken the US Army TM Series of Manuals for the Chinook and modify them for use?

Surely, despite the language difficulties....the content of the Manuals would be useful once translated into "English English"."


Brilliant!

The struggles we had to find info for the Mk1 & 2 - The Mk 1 was backed up by an Argentine MM found in the Falklands and I (well, me and Mel) got a set of US -47D manuals for 18Sqn as Gutersloh closed.

Each was far better than the tripe rolled out as a RAF manual that didn't include Rotor Heads.
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Old 8th Aug 2013, 18:35
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At Agusta....the Manuals they produced were just that....copies of the Army TM series for the "C" Model as what they were building were very pretty renditions of the standard "C" models right down to the same Spec for Avionics, Engines, and equipment.
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Old 8th Aug 2013, 18:35
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an incredibly meticulous AAIB inspector (Tony Noble) who investigated the engineering aspects of 721 and 576
Not Tony Cable?
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Old 8th Aug 2013, 18:56
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A Cotter Pin is something different over here!

The question of Tech Pubs policy was addressed in evidence to Lord Philip. There were two main issues.

First, the Chief Engineer's airworthiness cuts had included a directive in 1992 that Tech Pubs would no longer be routinely maintained. (If I recall, the funding was chopped from 4th Quarter 1991/92-on). That is, they would NOT reflect the In Use Standard. Of course, this meant the specialist staffs at Farnborough (and then Glasgow) would have less to do, and they started shipping out. This was the declared intent of AMSO - precisely the same happened to the specialist airworthiness staffs in london - our funding was chopped, we'd sod all to do (or plenty to do, but denied the wherewithal) and we had to seek other jobs. Tech Pubs was transferred from MoD(PE) to AMSO/CE, which made things even worse.

Secondly, the role of the RAF Handling Squadron at Boscombe changed. Hitherto, they'd been lead on certain pubs, but this was rationalised. I'm more ambivalent about this change - with experienced staffs in post, it was managed well either way. CE denuded the system of the experience, which created problems either way.
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Old 8th Aug 2013, 19:13
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Damn. Thank You, Chinook 240.

Yes Tony Cable.

A 'Noble' man.

Freudian slip...........
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Old 8th Aug 2013, 21:05
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Columbia Helicopters in Oregon seem to have their fleet sorted out and provide the US Army with support.

Sadly, they did lose one in South America about a year ago but considering the kind of work they do and the sheer number of hours they fly per machine monthly....that is no indictment of their system.

Granted their Leadership Tree is much shorter than any Military but Success should be imitated where possible.

Their engineering practices are what I would focus upon to see how they do things.

Has the RAF ever sent someone for a visit with Columbia?

Last edited by SASless; 8th Aug 2013 at 21:51.
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Old 8th Aug 2013, 21:44
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Has the RAF ever sent someone for a visit with Columbia?
Another excellent question.

The issue of "visits" is covered in mandated airworthiness regulations (the ones the Chief Engineer instructed us not to implement from 1992-on, but without which all is lost).

Financial provision must be made for all Design Authorities or Custodians to make annual visits to (in RN terminology) Typed Air Stations. The visit shall address In Service concerns of both Operators and Maintainers. Don't all shout at once if this doesn't happen!

Similarly, the person who makes this financial provision (the nearest thing today is the Requirements Manager, but none do this component of their job) can make provision for visits TO contractors; especially any who can contribute to Operational Effectiveness. In practice, this was managed on an ad hoc basis and would be booked to a suitable contract related to the subject. Each equipment or aircraft PDS contract has a named individual (the Technical Agency) responsible for all airworthiness matters, who would also regard it as his job to help arrange such a thing. Again, the chances of finding anyone in MoD nowadays who does this is next to zero.
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Old 8th Aug 2013, 22:00
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Tuc,

A for what its worth.....during a visit to Hunter AAF for a Unit Reunion....we were escorted by a Chinook Pilot.....a very experienced CW5 who had several combat tours in Iraq and Afghanistan.

When I asked him about his knowledge of the RAF Chinook Operations in Afghanistan.....he said he only knew what he had read in the Newspapers and seen from a distance. He did note that upon the arrival of the RAF in country....his unit contacted the RAF and offered to share "Lessons Learned" data but were quite coldly rebuffed.....and upon receiving that kind of response stepped back and pulled up the lawn chair and water bottle to watch how they got on. His intent was to pass on what the US Army had learned paid for in lives and aircraft and perhaps save the RAF from re-inventing the same old wheel.

I told him I would not find that at all surprising based upon my experiences in the past.
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Old 9th Aug 2013, 05:15
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SASless, I recollect a similar event. Kosovo 1998 - the war bit was over and we were all jostling to relocate assets from Macedonia into Kosovo. One day the RAF Chinook line chief noticed that there were no US Army Chinooks flying. Having checked that it wasn't 4th July, he took a bimble across to the US dispersal only to find out that the entire US fleet had been grounded (can't remember why).

Anyway, a few hectic signals between our ops and the UK resulted in the grounding of our Chinooks and CGB being sent over to Bosnia to provide replacement cover in the mighty Puma.

I never found out why the Americans had grounded the aircraft and we, initially, had decided not to do the same.

PS. I wouldn't necessarily point the finger completely at the RAF - it could have been lack of information from USA. Quite a few years later I was involved in a significant event which occurred due to poor passage of technical information between coalition states.

Last edited by Cows getting bigger; 9th Aug 2013 at 05:17.
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Old 9th Aug 2013, 05:15
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The mention of "visits" may sound a bit faffy, but I always thought them good value. Like many civil servants, industry could quickly lose sight of what and who they were there to support. Nothing bucked them up better than being planted in front of a dozen hairy arsed servicemen (and women) who were moaning and groaning about what was wrong - and had been pre-briefed that these were the guys who could sort it out. It never failed to work. The beancounters viewed this as a waste of money but in my book prioritising and clearing Operational Constraints and Limitations was money in the bank.
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Old 9th Aug 2013, 08:27
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Re Kosovo

Was There, and walk rounds on the plastic persuit ship became a a little more careful because: Memory getting dim but both US and if I recall Dutch chinnys were grounded and thought us 'well'ard' to keep-on-truckin' few inquiries later by the boss (Fat Freddy) Boeing had apparently had a rogue assembly worker putting a rather impotant thrunge bearing in upside down resulting in a loss or two Stateside. Boss decides to cease ops and signals MOD - Rather curt reply received WE TELL YOU when not to fly. Hummmm. after 1 or 2 very benign missions ..........cease CH47 ops check for gear box numbers xxxxxx

Result- Boss furious- operators no (even less)confidence in the system and a big sigh of relief . Yes, one of the contaminated, I think rear pylon gear boxes was fitted to an in-theatre ac and was suspect!
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