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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 13th Aug 2013, 13:13
  #81 (permalink)  
 
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I was the Captain of the SAR Seaking on that dreadful day. We were on standby in the crewroom when the scramble buzzer sounded. We rushed to the Ops room to see what was happening to be told the Chinook had crashed - I could see where as a pall of smoke could be seen through the ops window.

We arrived at the scene to find just burning wreckage. The rearcrew volunteered to leave the Seaking and enter the debris field in the hope of finding somebody.

The MPA fire crews made a vain effort to reach the crash site but became bogged down so we moved as many firemen and portable fire bottles to the crash site as we could..

It was a very sad and emotional day as 78 Sqn was a small tight unit with lots of banter between the Seaking and Chinook flights.

The most emotional part was standing in the Tristar hangar with the Flag drapped coffins while one of the 78 Sqn Chinook crew played the last post just before the coffins were carried to the Tristar for the journey home. I found it very difficult not to breakdown.

May they all be remembered.

HF
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Old 13th Aug 2013, 13:15
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SASLess

I'm afraid I must rely on Rigga's recall (whom I know, and trust implicitly) when he said (above);

And, through an assumed lack of drawing control, transferred the same problem to Almondbank, UK.
Almondbank was (is) the 3rd line repair facility for Chinook transmissions, from about 1983-on. This doesn't mean they repaired or had even seen the transmission components from the 1989 aircraft. In common with many Chinook components tasked to NARO (Naval Aircraft Repair Organisation) - ignore "Naval", in this context it is all Rotary Wing - there was a complete lack of supporting documentation. On the face of it, one could criticise the London office responsible for ensuring the correct resources were in place before declaring a 3rd line capability, but one must also take into consideration the solid evidence that, as late as 1999, maintained technical publications, drawings and their configuration control were still absolutely verboten and largely unfunded. I can assure you from personal experience that when Chinook was being introduced to service any such tasking at 3rd line received little or no support and staff were told to DIY. Having to reverse engineer and develop your own test procedures was quite common. In some cases, no test rigs were provided (a repair is not complete until verified) and those supplied for other aircraft were adapted locally. This was also a complaint from the AAIB during their 1994 investigations into ZD576. The CHART report of Aug 1992 re-enforces all this.


Hope this helps.
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Old 13th Aug 2013, 13:57
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Tuc,

Good men died because of all that.....and no one has gone to Prison?

Words fail me.

Dare I ask......have the problems been corrected so that the spares system is providing air worthy parts and procedures to the Engineers? Is the Training system doing its job to provide fully qualified Engineers?

Last edited by SASless; 13th Aug 2013 at 14:00.
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Old 13th Aug 2013, 14:09
  #84 (permalink)  
 
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Thrust Bearings:
There was no reference in the Aft Transmission Build Manuals/Drawings about which way around the Input Thrust Bearings should be installed. (IIRC it should have been to hide the Ser No's from view) although Boeing had experienced some failures previously and attributed them to that reason.
It is thought that some "old sweats" at Almondbank recognised the issue, figured out the requirement, and jotted down a note to put them the right way around, which they did perhaps for years. Then somebody else was given the job and did not read that particular "hint". The Bearings were installed with no particular favourite setting.
It was a complete fluke that both aircraft flew on consecutive days, 8000 miles apart, as the boxes had been built some time apart. And it was also a complete fluke that no-one was hurt significantly.
From memory, only those two Xmsn's and one other had the bearings incorrectly set. (I may be wrong - it's been a while)
In Almondbank's defence Quality Assurance was in its infancy then and this sort of (one-for-the-notebook) attitude was rife - I did it myself; I saw it happen around me; and learned from it.
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Old 13th Aug 2013, 14:33
  #85 (permalink)  
 
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"Dare I ask......have the problems been corrected so that the spares system is providing air worthy parts and procedures to the Engineers? Is the Training system doing its job to provide fully qualified Engineers?"

Spares:
In short: Mainly...yes.

Not necessarily limited to the helicopter fleets; but there is no money in MOD now - and U/S parts are often "retained" as possible future repairable resources -and probably without repair requests to justify keeping them there.
My concern, when I worked for an MOD contract, was that the Cat4/5 U/S parts were retained too close to flight line units that might see them, pick them out of their Bins and use them again.

Training:
In Short: Mainly...yes.

Current training for new guys gives the right information and practices. But as soon as they get to real "Lines" they are re-trained into "How we do it here".
My theory is that those at the Line have not been re-trained with the right information, because of Ops driven requirements, and have spent the last 10-15 years doing it the War Ops way.
I hope that, when the War finishes, the right way will slowly dawn on those riding on the seats and they will want this form of life preservation back under control.
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Old 13th Aug 2013, 14:50
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Sounds like lots of "money" laying around in the form of rebuildable spares that might be sold to BV, Columbia, or other Operators of the Chinook.

A smart Contractor might find a way to work a deal with several Operators and provide a centralized pool of spares.....so that each Operator does not have to maintain as large a pool of spares individually.

Someone at Columbia needs to be working this angle as they have all of the Engineering expertise and infrastructure that would be needed.

However....I can see one really huge problem.....the NIH Rule would be firmly applied by the RAF Airships.
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Old 13th Aug 2013, 16:33
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SASLess,
Not just the NIH rule but the increasing reliance upon (some might call subservience to) Boeing under the TLCS contract...
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Old 13th Aug 2013, 18:18
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It is thought that some "old sweats" at Almondbank recognised the issue, figured out the requirement, and jotted down a note to put them the right way around, which they did perhaps for years.
While past my time, I have no reason to doubt this. What I'd add is this. The proper thing to do is raise a MF765 Unsatisfactory Feature Report on the relevant documentation and drawings. The complete and utter failure of this system to support all lines of servicing was what red flagged the fact Chinook Mk2 could not possibly be airworthy during the ZD576 inquiries. It was noted in 1985 by RAF Support Command, and then regularly by various MoD departments for the next 28 years. As no answer to the MF765 would be forthcoming, one would resort to a QC5 Query Note if anyone was willing to put their name to it.


I've said many times, but it is always worth repeating, in the period 1991-93 AMSO/RAF Chief Engineer set about slashing the necessary funding to the tune of 28% per year, and in 1992 directives were issued that MF765s (and 760s) would NOT be progressed. The mandated procedures are laid down in a single Def Stan, which was cancelled some years ago and not one complete copy remains in MoD. As Rigga says, this bred generations who repaired/tested equipment to handwritten notes, not Aircraft Technical Pubs. Like him, I've had to do this myself. In the case of Chinook, I've been in the position of having developed some of the unofficial tests myself and, to this day, I suspect the only description of some test rigs and their circuit diagrams are in my handwriting. I've still got the original notes. Senior staffs certainly weren't going to waste money on irrelevancies such as test specs and maintenance contracts.

And no, the guilty have not been imprisoned, nor stripped of their knighthoods or CBs.
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Old 13th Aug 2013, 18:43
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I do apologise. The 1985 notification was not from RAFSC, but OC Eng at RAF Odiham, by letter ODI/774/1/Eng dated 25th June 1985.

The main concerns expressed therein relate to an aircraft being inadvertently de-modified and an incorrect standard of thrust lever being fitted, because the relevant modifications were not in the APs. It describes this as a "Flight Safety Hazard". It finishes "Why are amendments available to Boeing Vertol in October 1984 still not available to the RAF". Pretty damn good question in my opinion.

In 2007 the Minister for the Armed Forces replied to an MP that none of the above was true.

This complaint was flagged in the CHART report of August 1992 by Inspector fo Flight Safety as unresolved. In March 1999 the Chief of Defence Procurement confirmed to the Public Accounts Committee it was still unresolved. ("Confirmed" is perhaps the wrong word. "Boast" would be more appropriate, given his stated objections to maintaining airworthiness and fitness for purpose). All relevant papers were submitted to Lord Philip.
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Old 13th Aug 2013, 19:55
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Interesting about the spares, several airlines tend to have pool expensive items such as engines etc, or used to, then if they were needed could utilise them.

I am surprised similar couldn't be or isn't done with the Services, I realise a there will be differences between models, but a lot will be common, it would make sense and be cheaper if say the RAF held XYX part, the USA ABC, Holland EFG, etc so when in theatre or say Europe you are cutting down your actual stock holding.

I take it one of the problems with the amount of U/S spares is down to the culture the RAF now operates under, gone are the bays that could overhaul and rebuild components, gone are the likes of the Station Welder that could repair parts like exhausts etc? While nice shiny parts straight out of Boeing might be nice, in a major war if the factory ever got taken out you would be stuffed, as the facility to support parts locally at the front end is no longer there..


..

Last edited by NutLoose; 13th Aug 2013 at 19:58.
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Old 14th Aug 2013, 05:51
  #91 (permalink)  
 
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Nutloose

To be fair, this would be fiendishly difficult. Especially if THE key player, the Aircraft Design Authority, is not too concerned about maintaining Configuration Control. And at an equipment level there are very good reasons, many dictated to MoD by the likes of the Home Office, for the UK having different kit to anyone else. (Secure Comms being the obvious one). Every user would have to buy in to this process, which for most of the life of (UK) Chinook would exclude the RAF. Without it, the risk of fitting incorrect parts would be immense, as seen in the above example. And there would be so many exemptions/exclusions, we’d still have to retain our existing supply organisation.

Who would manage it, or be its champion, in MoD? Remember, while undergoing Transition To War in late 1990/early 1991, our supply organisation (AMSO) was actively scrapping War Reserves and ensuring what remained were not maintained serviceable. That mindset is a huge barrier. At a lower level, the experience required, and need to retain it, is simply not catered for by our Personnel policies.

At a political level, who would sign up to the list of allies in this “club”? For example, Argentina is in the Lynx club, which has (had?) an international user group. I recall over 20 years ago this degenerated into an annual bunfight as to where the next meeting would be, participants being more interested in jollies to foreign lands. That’s an interesting question – to what degree did the UK contribute to Argentina’s capability through this pact? The answer is quite a bit, because we were the major user and led the way on most aircraft and equipment modifications, which everyone else simply adopted. Honourable exception – The Netherlands.

However, your question is timely, because the proposed GOCO initiative (sic) offers an opportunity to look at this again, assuming MoD does the sensible thing and sticks with Bernard Gray’s confirmation that he’ll use extant policy and engage Design Authorities. But even this no brainer looks in danger, given the list of consultancies that have expressed an interest. If a non-DA GOCO contractor tried to do this, the likes of Boeing would have them for breakfast.


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Old 14th Aug 2013, 07:18
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Can I just say that, as an ex driver airframe, I find this interchange between engineers (past and present?) both instructive and encouraging. Despite the depressing testimony given here of deliberate obstruction and neglect to the extent of Gross Negligence by RAF VSO's, at least these posters are willing to face up to this scandal and call a spade a spade.

In contrast, on another thread, others (of the two winged variety?) talk of "usual suspects" and wish to reserve this forum to serving personnel, leaving we has-beens to gossip amongst ourselves elsewhere. I suspect that they will do the gossiping and little else.

The foundation on which the RAF was built was its engineers, and their foundation were the SNCO's. The engineers alone are the ones that need to regain the standards that preceded the malevolent destruction of Flight Safety procedures described by tuc. It would seem that none of the RAF leadership has a clue and that the MAA is merely the straw man that its designers set out to create.

As tuc says, no-one has been brought to book over this massive hit on UK Airpower, indeed the guilty have been actively protected by their successors, to the extent even of staking out junior scapegoats.

This may all be seen as airing our dirty washing in public, and that we should all join in the cover-up. You only have to remember those who have died thus far in airworthiness related air accidents to realise what a false prospectus that is.

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Old 14th Aug 2013, 12:58
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Well said Chug2. I've noticed the penny has dropped with a lot of posters but there are too many who criticise and openly doubt the messenger but never offer an alternative. I notice they don't criticise Odiham's OC Eng for saying exactly the same thing. The Mull and Nimrod threads were the same, with the usual suspects only interested in hiding the facts. What a non-surprise when it turned out one was a 3 Star rent a mouth. I came to the conclusion long ago it is a RAF / Civvy thing. They just don't like the idea of a civvy actually knowing what he's talking about, but can't see how bloody stupid they look criticising someone who wants to keep them safe.
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Old 14th Aug 2013, 16:12
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TRAVILAD

Check your PM's

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Old 14th Aug 2013, 17:10
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""Why are amendments available to Boeing Vertol in October 1984 still not available to the RAF."

The same for Puma.
In the late 80's we (Odi-Trans Bay) were getting a huge back-log of Puma Blade Sleeve work (Norway's cold, you know?) and approached Bristow directly - going behind the EA's back - to find how they coped with cold climes in the North Sea.
Bristow had swapped Araldite Resin sealing for the Blade Sleeves for more durable PRC in the 1970's and the Aerospatiale manuals had the Mod added.
We then put in an Amendment request to the EA and got some dosh for our troubles.

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Old 14th Aug 2013, 18:47
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Thanks for that tucumseh,

I realise a lot of equipment would be user specific that is why I was suggesting spares such as transmission items, rotor blades, wheels, windscreens, doors, panels, uc legs etc, those items that are common to the majority of fleets but expensive and those items likely to be damaged.... For want of a better word it would be like a Boeing Vertol fwd supply depot paid for, operated and maintained by the Countries operating the aircraft in Europe or theater. That way you are reducing your stock holding whilst increasing the availability and amount of stock..

I am totally shocked that the RAF do not appear to be subscribing to manufacturer service bulletiens, AD's and current manuals, Civi wise you would be grounded. It's a recipe for disaster and those withholding them for any reason, financial or otherwise, are nothing more than common murders if someone dies because of it..... I AM accountable Civi wise if anything happens, it's about time that was carried over into the military hierarchy who are responsible.

Last edited by NutLoose; 14th Aug 2013 at 20:58.
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Old 15th Aug 2013, 08:07
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Rigga

A familiar story. If you want to read about the restrictions your Puma EAs were under at this time, read the Chinook Airworthiness Review Team (CHART) report of August 1992, which covered Puma and Wessex as well. It becomes obvious where the root problem lay.

A separate Puma report (PART) was prepared in 1996, which referred back to criticisms in previous ARTs. In paras 197/198 the Inspector of Flight Safety noted the 1992 reports had;

"recognised that there was a gap in the present orders and procedures concerning the amendment of Air Publications".

The "gap" was that the airworthiness regulations were not implemented due to lack of funding and the consequent reduction of trained staffs, as they had nothing to do so had found other jobs.

He went on;

"The problem lay with the question of what the tradesmen did in the meantime. Were they to work to and sign for an activity which was known to be wrong or did they work outside the content of the maintenance document and thus be hostage to fortune should a problem occur?"


And so on. Excellent, and honest. IFS proposes a temporary solution - Local Approved Amendments to drawings and documentation, which Rigga referred to earlier. Trouble is, this "temporary" arrangement had already been common practice for over a decade and continues. And, without access to the Design Authority, and his approval, the Safety Case is progressively compromised. Funding is also required to regress and update.

This report, like its predecessors, was submitted direct to Assistant Chief of the Air Staff and the Chief Engineer. In the period 1991-96 the latter post was held by one man - ACM M Alcock. He has stated publicly that he implemented the recommendations of these ARTs. The PART (above ) of 1996 clearly asserts that previous recommendations in Chinook, Puma, Wessex, Hercules and Tornado ARTs were NOT implemented, so IFS repeats them. The evidence is on IFS's side.

Of course, this doesn't mean Alcock was to blame; clearly he wasn't because he says so. But his official response to the 1992 reports is recorded for posterity - a further 28% cut in relevant funding and, in December 1992, civilian staffs threatened with dismissal by his immediate subordinate (DGSM) for repeating the recommendations of the Inspector of Flight Safety.
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Old 15th Aug 2013, 16:19
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Just out of curiosity, having read all the horror stories about RAF Chinook support, was there no 'sister design firm' set up to support the aircraft as the UK Design Authority? In the case of the RAF and RN Phantoms, HSA Brough, (later BAE Systems) were given that role (and very interesting it was too). However I can't remember getting a lot of in service support information from McDonnell Douglas or feedback through them from other F4 customers.
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Old 15th Aug 2013, 17:32
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The term is "Design Custodian" - whereby they hold a set of secondary masters, maintain the Build Standard (main output - the Safety Case), but have an ongoing contractual relationship with the Design Authority which is directed by MoD.

The situation has changed over time, but for most of my career Boeing flatly refused to act as a sub-contractor or secondary party to anyone, and MoD permitted this. In practice, MoD's position would be dictated at a political level.

In contrast, Westland had no such hang ups, and nor would they be permitted any. This worked both ways for them. They didn't operate on a level playing field, but it gained them much work as a sub (or even sub-sub) contractor. However, it also meant they were associated with, but not responsible for, many projects that went wrong. Puma Nav Update is the one they always harped on about to me. Sea King ASaC Mk7 is another. In both cases they hauled the Prime (and MoD) out of the mire big style. In both cases, I think you'll find MoD didn't include the aircraft/airframe work in the tender, so Westland didn't bid. But after the event, whoever "won" the bid was awarded the aircraft work without having to demonstrate competence. It usually starts with the Service stating they'll modify the aircraft themsleves, so PE/DPA/DE&S aren't given the necessary funding. This is a common weakness in MoD and explains delays to many aircraft upgrade programmes. Not thread drift by any means, especially on Chinook! But at the the end of the day it is the Prime who writes the press release and Westland were never mentioned. The "Wasteland" nonsense you hear is just that - utter rubbish. Any mistakes they've made are more than offset by the help they've given us. Without them, both the above programmes would be "another Chinook Mk3" and Boscombe wouldn't have enough hangarage to store the aircraft.
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Old 15th Aug 2013, 20:31
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I can totally agree with Boeings stance, they are the design authority for the Chinook, to circumnavigate that both undermines their authority and then allows things to be embodied on the aircraft that they have no say or control over.. And let's face it, that would have been know when purchased.

Having said that at contracts being signed the MOD accepted that Boeing were the design authority, they are the people they should be working with on all aspects of Airworthiness, to simply say "ouch we are not paying that' would get your EASA Approvals withdrawn in the Civil world...

One does wonder the legal ramifications if a Chinook crew is killed due to MOD negligence under failing to comply with Airworthiness requirements laid down by the manufacturer.

Incidentally wasn't one of the major advantages of the Jaguar that the design authority had transferred to the MOD, thus allowing upgrades to be carried out both cheaply and quickly?


..

Last edited by NutLoose; 15th Aug 2013 at 20:33.
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