Chinook - Still Hitting Back 3 (Merged)

[John Blakeley]

What Would You Have Done

I must support Brian Dixon’s comments above – I was once SEngO on ACM Wratten’s Phantom Sqn (23 Sqn) and found him a great boss to work for. I did not work for him later in his career and cannot therefore say whether some of the comments I have seen on this site are justified or not. However, this does not stop me believing that his and the then AVM Day’s decision to find gross negligence was an incorrect one – indeed I have actually written to Sir William and told him that I believe he made an error of judgement – as Brian says none of us are infallible.

Cazatou asks “what would you have done” and in terms of the last 60 seconds of flight he knows that nobody can answer that since we do not know what was happening and never will until time travel comes along. And this is surely the whole point – because none of us know the pilots should not have been found grossly negligent – this is the error of judgement by the Reviewing Officers, and it has probably had the opposite effect to what they hoped for, as far from “putting the issue behind the RAF” it has caused a much wider issue now relating to the whole introduction to service of the Chinook Mk 2 and duty of care exercised by the RAF to be called into question.

I am sure that for sound operational reasons the RAF had to go against the published Boscombe Down advice, which was “unable to Recommend CA Release for the Chinook Mk 2 aircraft” and insist on taking the Chinook 2 into service – and many of you will know that an Interim CA RTS was issued in November 2003 – the Board confirms that the aircraft was indeed being operated within these limits on that fateful flight, and I am not aware that anyone is questioning the RAF’s judgement in making the decision to bring the Chinook Mk 2 into service. However, this judgement carried flight safety risks, albeit reduced as far as possible by flight restrictions, and it may be (for we will never know) that these risks culminated in 29 deaths on the Mull of Kintyre in June 1994.

I have not seen the equivalent RAF RTS but, having gone against Boscombe Down advice, one has to assume, with the flight limitations that we know existed, that the RAF was operating to the equivalent of what JSP 318B then defined as either Reduced Operating Standards or Military Operating Standards. These were defined as;

 ROS – a lower standard than NOS, used where the urgency of the mission justifies a reduction of the safety margins. Use of the ROS involves higher than normal risk. Authority to use the ROS is restricted. The authority required, guidance on the risk involved, and related operating techniques will be specified in the ODM.

 MOS – a lower standard than ROS, used where the urgency of the mission justifies a further reduction of the safety margins. Use of the MOS involves a higher risk than that for ROS. Authority to use the MOS is restricted. The authority required, guidance on the risk involved, and related operating techniques will be specified in the ODM.

Let me turn Catazou’s question round and go back to basics (and also point out that I don’t know all the answers either!):

 Would you have introduced the Chinook Mk 2 into service without an ADR and CVR to save money even though every other aircraft coming into service at that time was being fitted with this equipment?

 Would you have gone against the “expert” operational advice to bring the aircraft into service with very significant known operating problems eg engine fail captions that may or may not be spurious, engine run-ups and run downs, etc etc, to meet operational requirements?

 Would you have allocated an aircraft type with all of these known problems to a non-operational VIP flight, and against the specific request of the Aldergrove detachment commander?

 Even if all you had available was a Mk2 would you have allocated ZD 576 with its defect history (largely unresolved at the time of the accident) and knowing that it had suffered an in-service defect that was one of 4 being used by Boscombe to justify stopping flight trials, for this mission.

 Knowing the defect history of the aircraft would you have let some illegal maintenance be carried out on the “problem” engine system at Aldergrove without investigating further (and remember even the BOI confirmed that the aircraft had an incipient electrical fault in its No 1 Engine System when it took off for Inverness).

 Would you have held a Board of Inquiry that basically assumed aircrew error from the start, that did not look at the introduction to service and airworthiness issues to see if they could have contributed to the accident and did not follow up the technical evidence it found? In my view on the engineering side, and in the subsequent review procedures, the Board was both inadequate and biased, but even then I would have to say that they made a good decision in only going for a balance of probabilities verdict.

 Knowing all these other issues in even more detail nearly a year later would you have found the pilots guilty of the criminal charge of “Gross Negligence” against your own rules – rules that were there to protect dead aircrew from such a charge in the absence of being able to defend themselves?

 Would you consider whether there was an inconsistency of RAF justice when comparing the verdict on the Chinook with that on the Tornado crash in Glen Ogle in September 1994?

These questions do not have any relationship to, or call into account, either Sir John’s or Sir William’s previous service records and integrity, but that record does not mean that their decisions on ZD 576 are above question, or even, in my view and that of many others, including all of the independent inquiries, correct!

JB

PS Have got an ex Lightning Pilot for lunch today - hope he's not too tough as he has to be old!

[cazatou]

John Blakeley,

Firstly, Sir, I spent many (happy?) flying hours whilst on SORF at Manby doing spin refresher training with Lightning Pilots (in a vain attempt to stop them "tent pegging" around the countryside). I guess that makes me old as well.

I cannot comment on your first 2 points as those decisions rested with the Air Staffs at MOD level. As regards points 3 & 4 it was my understanding that the decision to use the Chinook was taken by the Air Tasking cell as the Puma alternative would have required the use of 2 "assets" and reduced tasking flexibility. It is a long time ago now, but I understood that ZD576 was the only servicable Chinook in Theatre.

The "unofficial" servicing carried out between sorties was, I understood, carried out at the request of the Aircraft Captain. That, however, does not excuse the failure to comply with the rules.

I am not, nor ever was, qualified to comment on the engineering aspects regarding the introduction to service and airworthiness of the aircraft during that introduction.

I would not agree, however, that the BOI basically assumed Aircrew Error. It was my view at the time that the BOI was being "Staffed" that the Board went out of their way NOT to question some of the decisions made by the Pilots regarding the sortie.

Finally, could you give me a hint regarding the "Glen Ogle" Tornado - my recollection is that we had at least 2 filing cabinets full of ongoing Tornado BOI's and at this distance it is difficult to recall them all by location.

[cazatou]

Tandemrotor,

The chart, of which a copy was left for the Duty Auth, was prepared by Lt K on the assumption that the days tasking would require the use of both crews.

This chart was "adopted" by Flt Lts Tapper & Cook (or so I was informed).

[Tandemrotor]

Oh I see.

So you are making the assumption that, the 'spare' chart they left on the Duty Auth's desk, (very possibly the one prepared the previous day by Lt K) somehow represented their pre-flight planning.

That's a pretty big assumption wouldn't you say???

Of course, as you well know, the reason they left a chart at all, (of course they had no requirement to) was a conscientous attempt to satisfy the duty auth who, as you also well know, through no fault of the crew, was not at his desk!

Doesn't quite seem to tie in with your 'laisser faire' allegation does it?

Would you care to debate in detail, a little more of that, factually sparse, allegation?

[cazatou]

Tandemrotor,

I would never dream, as a purely fixed wing Pilot (well apart from one trip with Buck Rowlands - an excellant Instructor; but he failed miserably to teach me to land vertically!!) to even consider such a thing.

However, it was not my assumption but that of the BOI; of course if you know better and can prove that the BOI was wrong then you will have my full support. I would,however, suggest that the length of time since the accident, coupled
with the numerous (one might even say fatuous) accounts of the accident that have appeared in the National Media suggest that a realistic viewpoint is unlikely.

[John Blakeley]

Wrong Date

With apologies, post 2072 is of course incorrect - the CA Release at Issue 1 was dated November 1993 and at the time of the accident it incorporated AL1 dated Mar 1994.

JB

[cazatou]

Tandemrotor,

The reference to the chart left behind for the Duty Auth implied that they had done what they could do in respect of the requirements of ASI's within the constraints of Operations within the Province.

If you are saying that they were intending to do something different then NOW is the time to say so.

OVER TO YOU!!

[jayteeto]

Let me make one thing ABSOLUTELY clear. The first time I spoke to Jon about this sortie was in Aldergrove flight planning. The map was on the table and he was planning. That is why I spoke to him about this great jolly he was going on and where golf was mentioned. Later in the crewroom my other comments were valid. Please do not suggest that they did not plan, that is a blatent lie............

[Ginseng]

cazatou

You say that it was the BOIs assumption that this chart represented the crew's planning, and then challenge your opponent to prove that assumption wrong. Forgive me, but if this was an assumption, then it is no more an established fact than much of the other "evidence" here. If you are right, then the BoI had no business making assumptions on such an important point, and no one needs to prove them wrong to advance the case.

Forgive me again, but I have found both the content and tone of many of your recent posts increasingly bizarre.

There may well have been human error, or not, in this accident. None of us know, or will ever know. We should all understand, however, that there are insufficient grounds here to support manslaughter charges against the crew, which in effect is what the reviewing officers comments amounted to.

Regards

Ginseng

[Tandemrotor]

cazatou, you are absolutely correct that the BOI appear to have 'assumed' that Flt Lt Tapper left photocopies of HIS maps with the DAO's assistant "as a record of the route to be flown"

But since we don't know what maps or charts, were being used by the crew during the flight, how do we judge whether the BOI's assumption; that the photocopy of Lt K's chart left behind was the prime navigation document, is correct??

jayteeto is an eyewitness to the fact that the crew conducted their own independent planning!

Is your, and the BOI's assumption, beyond doubt?

Or even the balance of probability??

As far as crew duty considerations are concerned, I know you will agree with the BOI that:

The Board concluded that at the time of the accident crew duty time limitations had not been exceeded and that fatigue was unlikely to have played a part in the accident

So I assume your ONLY point is, in a circumstantial way, to imply that the crew were operating under some kind of time pressure??

Which to be fair is also the BOI's hypothesis.

However, I would respectfully suggest, the difference between your position, and that of Wg Cdr Pulford and his 2 colleagues, is that they accept the weakness of the factual evidence available, when compared to the standard of proof required. Which is precisely why they felt unable to satisfy that standard.

Do I need to remind you again, what that standard is?

Over to you my friend.

[Whooper 5]

I planned this trip with Jon 7-14 days before the event. Simple. Could not be easier.

W 5

[ShyTorque]

"Quote:
The Board concluded that at the time of the accident crew duty time limitations had not been exceeded and that fatigue was unlikely to have played a part in the accident"

This was, after all, an operational environment.

The 14 hour crew duty times limits laid down are not absolute. In other words, going beyond them does not guarantee an accident nor should it be be deemed negligence. I speak from personal operational experience, not from some shiny-arsed, idealistic, fixed wing, never flown SH, never been in theatre viewpoint.

[walter kennedy]

Whooper 5
Why is there any doubt as to their intentions?
Is there not a procedure for leaving their latest flight plan for the record?
If so, why has it not come to light?

Do you recall the detail of their intentions in the vicinity of the Mull?

[Arkroyal]

cazatou K52

Your evasive answers to John Blakely's excellent post do you no favours.

You feel unable to comment on engineering matters as beyond your ken, but are more than happy to comment on support helicopter operational procedures which are equally foreign to you.

The reasons for this accident are many and complex, and also mostly unknown.

You can't simply cherry-pick the ones which suit your argument and ignore the rest.

How you can postulate the trivial matter of Jon's avoidance of breakfast as worthy of inclusion in an argument to support the finding of gross negligence, yet ignore the Chinook Mk2's known technical failings in the counter argument amazes me.

Get your blinkers off and look at the big picture.

[John Blakeley]

Reply to Cazatou

I would have hoped that you might have had an opinion as to the possible relevance of the Airworthiness questions even if you did not feel qualified to comment on them. The pilot concerned with the initial PTIT problem in NI was Lt Kingston not Flt Lt Tapper – when Tapper had the same problem the next day (the sortie before the accident) he was assured by the ground crew that it was just a gauge problem, and, possibly wrongly, he did not pursue the problem further – was this a major servicing error in the light of events?

From your comments you may have been closely involved, in which case I have to respect your opinion, but I base my comments on the BOI being biased towards aircrew error by the almost total lack of a credible engineering investigation of the issues involved (including in the review process) and the Board’s own opening statement:

“Nevertheless, there was sufficient evidence to eliminate as possible causes: major technical malfunction or structural failure of the aircraft prior to impact; …… Therefore the Inquiry focused on the crew’s handling and operation of the aircraft.”

I am disappointed that you ignored the fundamental question, namely:

“Knowing all these other issues in even more detail nearly a year later would you have found the pilots guilty of the criminal charge of “Gross Negligence” against your own rules – rules that were there to protect dead aircrew from such a charge in the absence of being able to defend themselves?”

The Glen Ogle accident involved a Tornado crashing inverted at high speed after the pilot had made control inputs that led directly to the accident. Nobody knew why the pilot made these inputs. There had been no conversation between pilot and navigator for the 20 seconds prior to the crash and the navigator was absolved from any blame. To refresh your memory further I can offer the following BoI extracts:

EXTRACT FROM BOI PROCEEDINGS INTO THE CRASH OF TORNADO GR1A
ZG708 IN GLEN OGLE PERTHIRE ON 1 SEPTEMBER 1994 (Full document with some deletions placed in House of Commons Library)

HYPOTHETICAL RECONSTRUCTION OF EVENTS IMMEDIATELY PRIOR TO
THE CRASH

45. Evidence from BAE Warton confirms the integrity of the ADR and shows the aircraft to have been flying in full CSAS with SPILS selected when it crashed. Moreover, the BAE report also states that the roll and pitch demands immediately prior to the loss of the aircraft were the result of pilot inputs. The Board considered that the most likely explanation for Flt Lt XXXXX pitch, roll and throttle demands was that they represented a response to a startling event, such as a sudden encounter with a large bird. The extreme nature of the control inputs also suggests a very startled reaction. While the above explanation might account for the reaction it does not fully explain why Flt Lt XXXXX decided to roll further right when already at a high angle of bank. However, an unconsidered, ie inappropriate, response would become more likely if Flt Lt XXXXX was distracted in the seconds leading up to the startling event.

47. Having made the roll, pitch, throttle and finally, slat demands in response to a startling event, evidence from the BAE model indicates that the aircraft was not recoverable soon after the pilot rolled right and applied additional aft stick. Notwithstanding this evidence, Flt Lt XXXXX quickly found himself in an extremely unusual position, possibly combined with a degree of misorientation. He may have been incapable of correctly recovering the aircraft in the time available.

CONSIDERATION OF HUMAN FAILINGS

53. The Board have been unable to determine positively the cause of - the accident. Notwithstanding this fact, the Board concluded that there was little doubt that the control inputs immediately prior to the crash had been made, either voluntarily or otherwise, by the aircraft pilot, Flt Lt XXXXX. Moreover, the Board concluded that Flt Lt XXXXX control inputs, once made, had led rapidly to the aircraft being placed in an irrecoverable position from which it subsequently crashed.

54. Flt Lt XXXXX flying record is excellent and the Board have discovered no evidence which suggests that Flt Lt XXXXX was indulging in in-disciplined or reckless behaviour. However, since Flt Lt XXXXX control inputs led directly to the loss of the aircraft, the Board concluded that Flt Lt XXXXX"s actions constituted an ERROR OF JUDGEMENT and therefore the Board recommends that he be absolved from blame.

Remarks of Station Commander/Commanding Officer


1 I am satisfied that the Board has carried out a thorough investigation into this mysterious and tragic accident. I agree the findings, with one important exception. I accept that, of the choices that they considered, the Board has selected the most plausible reconstruction of events leading to the accident. However, it is only a hypothetical reconstruction which is necessarily heavily caveated and which cannot positively exclude alternative explanations. The fact remains that, albeit for understandable reasons, the Board has been unable to establish beyond doubt what caused ZG 708 to manoeuvre in such a way that it crashed.

2. The term "error of judgement" involves a finding of an honest mistake accompanied with no lack of zeal where a person, through no fault of his own, and whilst exercising the degree of skill which could reasonably be expected, makes an inappropriate response. Given that we do not know exactly what happened in this case, I find it unwise to find that Flt Lt XXXXX made an Error of Judgement. I believe that it would be unwise to draw any conclusions as to human failings because there is too much scope for conjecture. I do not accept, therefore, therefore, the Board's conclusion that Flt Lt XXXXX made an Error of Judgement:. I recommend that there should be no finding regarding human failings.

19 Dec 94 Stn Cdr


PART 4 REMARKS BY AIR OFFICER COMMANDING

1. I am satisfied that the investigation into this most bewildering accident has been commendably thorough. It is unfortunate that,, in spite of their exhaustive efforts, the Board have been unable to determine a definite cause of the accident; nevertheless, a critical examination of the evidence has eliminated a large number of possible causes. Moreover, overwhelming evidence indicates that the aircraft responded both directly and appropriately, to control inputs, either voluntary or otherwise, which were initiated by the pilot and led ultimately to the loss of the aircraft. The Board's dilemma has been an inability to determine why the pilot might have initiated the control inputs; however, they have established beyond reasonable doubt that the pilot manoeuvred the aircraft in a way which led to the crash.

2. It is difficult to comprehend why such an uncomplicated sortie should end so catastrophically. The sortie profile was well within the capability of the crew, and it was flown in a serviceable aircraft and conducted in good low-flying weather conditions. During their investigation, the Board discounted many potential causes. On the basis of the available evidence, particularly that of the Accident Data Recorder (ADR), I accept the Board's conclusion that the aircraft crashed as a direct result of control inputs which manoeuvred it into a perilous attitude with respect to the ground. In assessing why the aircraft should have been manoeuvred in such a manner the Board cited 3 probable causes: an unconsidered response to a "startling event", a control restriction, and medical incapacitation. There was no evidence of a control restriction. Medical incapacitation, -although it could not be discounted, was statistically very unlikely. Therefore, on the evidence available, I agree with the Board that Flt Lt XXXXX unconsidered response to a "startling event" is the most plausible cause. It would not be unreasonable to suppose that the late sighting of a large bird might have prompted him to initiate a rapid roll away from the hazard, and this manoeuvre would cause him instinctively to select full power. Even so, he should have had the necessary degree of skill to fly the manoeuvre safely. In view of Flt Lt XXXXX limited experience on the Tornado GR1, it is however possible that his inappropriate reaction, coupled with a degree of misorientation, could have resulted in the aircraft being placed in a situation from which he was unable to effect a safe recovery.

3. I now turn to the consideration of Human Failings. The Board is not required to establish beyond all doubt what caused the accident. Where an Inquiry has identified that Human Failings were either a cause of, or a contributory factor to, an accident, these failings must be considered carefully and categorized properly. Although often difficult, the question of Human Failings must always be answered. I am unable to accept the Station Commander's view that it would be unwise to draw any conclusions as to Human Failings. In the "startling event" scenario, it is possible that, having been faced with a split second decision to take avoiding action, Flt Lt XXXXX may have made an inappropriate response; I consider that this would constitute an Error of Judgement. Whilst, the Board concluded unequivocally at paras 53-54 that Flt Lt XXXXX control inputs led directly to the loss of the aircraft and constituted An Error of Judgement, they could not ascertain absolutely why he initiated the control inputs. The possibility of either a control restriction or medical incapacitation could not be entirely ruled out. I, therefore, consider that Flt Lt XXXXX Error of Judgement should be qualified as having been the most likely cause of the accident, rather than the definitive cause. Regardless of the circumstances of this particular accident, I agree that Flt Lt XXXXX should be absolved from blame.

AVM
3 Mar 95 AOC I Gp


PART 5 REMARKS OF AOCinC

1. Notwithstanding a thorough investigation and. the availability of evidence revealing the precise activities of the crew up to the point of impact, there is no explanation for the final manoeuvre flown by Fit Lt XXXXX. Bewildering is the only description of these inconclusive circumstances, and I find the hypothetical reconstruction offered by the Board of limited usefulness.

2. In my experience a startled pilot either "snatches" at the controls or, more likely, does nothing; he is not inclined to fly what in this instance resembled the "break" manoeuvre, with rapid but coordinated and simultaneous control inputs and, most unusually, unaccompanied by any word of warning to his navigator. (I disagree with the AOC's assertion that the selection of full power instinctively accompanies rapid roll inputs; it is a conscious selection). But why Fit Lt XXXXX entered such a "break" we shall never know and here I note the important evidence of the Principal Psychologist regarding the incredible nature of the notion of suicide. It is therefore because there is no scope for conjecture (and not too much scope, as the Station Commander, believes) that I find any consideration of human failings to be academic and fruitless. Despite the wealth of detailed evidence, we are confounded and under these particular circumstances I consider it is futile to indulge in hypothesis.


Dictated by AOCinC, STC
and signed in his absence
18 Apr 95

So in the case of the Tornado the system knew exactly what had happened but not why and the Reviewing Officers’ comments on this are, in my view, quite amazing. In the case of the Chinook we do not know either what happened or why it happened, but the system is quite happy to continue to accuse two dead pilots of a major criminal offence on the basis of hypotheses (not just my view - see the HofL comments). Perhaps you could give me your views on the consistency of RAF justice at the time.

[Tandemrotor]

Hi Ark

Just a quick one:

The BOI actually said:

The Board were unable to establish whether breakfast was taken by Flt Lt TAPPER.

Only people like cazatou K52 seek to extend absence of evidence, as evidence of absence.

It is a tactic they are obliged to adopt in many areas, and that characterises their arguments, because the evidence available cannot satisfy the standard required!

Smearing the crew, in a non-factual way, is their only alternative to rational debate.

A debate they lose every time! Need I list the examples??

[Twinact]

the Chinook Mk2's known technical failings

So many hide behind the claimed 'technical failings' of the aircraft, using it as smoke screen to confuse the arguement. I have asked on a number of occasions if it was so bad, what has been done to rectify them? Nothing has changed on the aircraft since then and many of the contributors to this thread have flown many hours in the Chinook know that.

John Blakeley has listed many engineering/airworthiness failings in the Chinook HC Mk2 - surely if these are to be believed we should be supporting a campagin to ground the current fleet.

[Brian Dixon]

Following on from John Blakeley's post:
What is also worth noting is that the AOC signed the Tornado BoI on 3 March 95 and the Chinook BoI on 20 March. The AOCinC signed (in his absence) the Tornado BoI on 18 Apr 95 and the Chinook BoI on 3 Apr 95.
So, both BoIs must have been on, or around their respective desks at the same time.
Why then, the completely different approach to the BoIs, bearing in mind the evidence available for both tragic situations?
My best, as always.
Brian
"Justice hs no expiry date" - John Cook

[John Blakeley]

Twin Act

I think you have started another red herring - things had changed by the time the Stn Cdr wrote his comments on ZD576 - there is as far as I know a full CA Release so the aircraft can operate to Normal Operating Standards (NOS) with the safety that this implies - certainly if it is still on ROS or MOS your comment would be a good one. The campaign is to clear the unjust finding that the pilots of ZD 576 were criminals not to try to put right any remaining problems with the Chinook fleet, especially as one major remaining problem, the Chinook Mk 3, has effectively grounded itself!

JB

[Twinact]

A red herring? Perhaps I didn't explain myself clearly, I'm refering to the mechanics of the aircraft: the FADEC, flight controls, engines, flight instruments. These have remained unchanged since Day One, apart from Block 1 upgrade to FADEC. That is my point.

The Release to Service is just a bit of paper that limits the use of the aircraft by aircrew. The full RTS still includes many Service Deviations which I believe you refer to as ROS/MOS.

I don't understand how the Mk 3 grounded itself?

I have to say, this is the first time I've heard Jon and Rick referred to as criminals.