Chinook - Still Hitting Back 3 (Merged)

[Tandemrotor]

There was NO paperwork

Ah indeed. So was the case involving a fatal Chinook crash in the Falklands in the mid eighties, killing yet more of my friends!

Deep servicing of an HC1 had involved removal, and replacement of the aft pylon (a fairly major piece of engineering endeavour??)

NO supporting paperwork was raised. Who even knows if any suitable protocol was followed? Nontheless, the first time it moved into forward flight, all aboard perished. Including some of Valkyrie's colleagues; engineers accompanying the first test flight.

Just to remind those unfamiliar: The a/c was seen flying in glorious weather at approximately 500', when it very slowly entered a vertical dive from which it never recovered. Impacting the ground at extremely high speed (and with one of it's occupants attempting to leave beforehand!) the only radio call transmitted was the middle portion of the phrase; "******* hell"

It's not just pilots that cause accidents my friend!

BTW

The aircraft in question was not cleared to transit at that altitude

Please enlighten us with your familiarity with this case.

Or accept you are utterly ignorant of the FACTS and are simply bumping your gums!

[tucumseh]

Caz

We sat in those cockpits for 10-15 minutes and then we both unstrapped, got out and said to the groundcrew "How the **** do you turn these radios on?" It took 30 mins before they found someone who knew!!

Tandemrotor

NO supporting paperwork was raised. Who even knows if any suitable protocol was followed?

These are depressingly familiar statements to anyone remotely familiar with Mull, Nimrod, Hercules, Sea King, Tornado etc. They represent major failings in the airworthiness system. I wish I’d a fiver for every time someone has said “Ditch training” or ”Don’t bother modifying (or even buying) the simulator” as a means of “saving” money. They think it’s clever and, worse, are praised. If you ignore either, the aircraft or equipment should never be offered to the RTSA, never mind actually released to service. First came across this on Harrier in the mid-80s. Pilots got in, said WTF, and got out.

But, as ever, instead of going into denial, MoD should also study examples where such failings didn’t occur and ask why.

[cazatou]

tucumseh

In the case of the JP's we had just flown Leeming - Aldergrove and were quite content to return as the weather was more than adequate for a VFR transit if necessary. In the other case the aircraft had been fully certified by the CAA and had just been modified with the addition of some military radio and navigation aids; again the weather was benign. In neither case would I have had any hesitation in declining to fly the aircraft if the weather conditions had been marginal. There are, however, occasions when the Aircraft Captain has to bite the bullet and say "No" - irrespective of the rank or status of the passengers.

[tucumseh]

Caz


Thanks. Understood.

There are, however, occasions when the Aircraft Captain has to bite the bullet and say "No" - irrespective of the rank or status of the passengers.

Agreed.

However, I’d say that to make such an informed decision, one must be first of all informed. A common factor in all the examples I quoted is that the various problems/risks were known by a few, but not conveyed to the aircrew. Again, that is a serious, and systemic, breakdown of the Airworthiness and Safety Management Systems. As reiterated by Coroner Masters a week or so ago.

[cazatou]

tucumseh

I would not disagree;there are times, however, when fault detection and analysis are only paid lip service to - irrespective of the experience of the Aircrew.

Back in 1991 I can remember an Andover which had been left at Brize with a control restriction. No fault was found - therefore I and another very experienced (ex TQF) Captain went to do an Air Test on the aircraft. No fault was experienced in level flight, however a distinct obstruction was evident if even the slightest combination of "roll and pull" was attempted.

We returned to Brize where the Engineers were inclined to disbelieve us - so I played the trump card detailed in GASO's and impounded the aircraft. This, of course, had to be reported to Group HQ who did not seem best pleased. The engineers put the aircraft up on jacks and found the fault within 2 hours. It took another 2 days to rectify it.

I wonder how many Aircrew have read that paragraph regarding "Impounding an aircraft".

[Chugalug2]

Caz, fascinating as your personal aviation anecdotes always are, I don't quite see the relevance to this thread of your last one. Are you saying that this captain knew of an identifiable fault on this aircraft prior to departure but, unlike you, was unable to say "NO"? Or perhaps you mean that the disquiet alone that existed about the HC2 at the time, despite it being cleared by the Airworthiness Authority with restrictions into Squadron service, should have caused the captain to say "NO"? If that is the case should not every other captain on the fleet have said "NO" on every other occasion? Would you have said "NO" if such a captain for merely feeling disquiet? Does not such a situation reflect poorly on the Airworthiness Authority especially given that BD had grounded their fleet the day prior to this accident?
By the way, I think that many captains have enjoyed the thrill of saying "NO" to senior officers, I know I have. But Mrs T? Now that's something else...respect!

[cazatou]

Chugalug 2

Apologies for the delay - weather - something beyond my control.

Regarding the "impounding" of an aircraft; as far as I am aware AT NO TIME did any Chinook HC2 Pilot institute this procedure in regard to control or other problems - yet the procedure was there to be used if the situation demanded. Did they read GASO's - or just sign for them?

Regarding Boscombe Down "grounding its fleet"; the trials underway at BD were suspended because BD could not validate the data obtained using its preferred method of validation and a Meeting was called to establish a way forward for the trials.The aircraft were not "grounded" - they just did not fly because the trials had been suspended.

On a lighter note; I always felt that Lady Thatcher (as she now is) was the perfect VIP passenger. One always got a written "Thank you" following a flight and she did throw an excellent Cocktail Party - the surroundings were pretty impressive too!!

[meadowbank]

Valkyriejmp

The aircraft in question was not cleared to transit at that altitude and collided with the first bit of solid object after crossing the sea.

To what transit altitude are you referring?
The crew set out to transit under VFR to Inverness, and the Flight Authorisation Sheet will have included a mimimum altitude for the transit (I'm not a rotary pilot, but let's say 100 ft). The aircraft was seen shortly before the crash by the yachtsman, whose evidence indicated that ZD576 was probably at a few hundred feet above the water - perhaps you can explain what the aircraft wasn't cleared to be doing in this context?
Yes, the aircraft collided with the Mull, but that is not per se an indication of 'Negligence' or even 'Aircrew Error' and there are several possible causes of the impact which cannot be ruled out, meaning that 'Negligence' would be very tough to prove 'Beyond Reasonable Doubt', let alone the 'Beyond any doubt whatsoever' that the (ex) Air Marshals claim to have satisfied and for which the 5 members of the House of Lords' Select Committee who, let's face it, ultimately have every motive for finding in favour of the Establishment, failed to find any grounds.

[Chugalug2]

Sorry Caz, still not getting what you're driving at here. I'm fairly sure that if anyone had "impounded" a Chinook per GASOs we'd have heard about it by now, so lets agree to accept that hasn't happened pending evidence to the contrary. So what? I don't even see that as implying any ignorance of your "trump card", merely that the solid grounds for doing so, ie a control restriction as you instanced etc, were not present. The grounds for BD suspending, grounding, impounding, call it what you will (it still quacks so effectively is a duck), were there but only to their skilled eyes, ie as you say software discrepancies. If they were not prepared to continue with their trials which presumably involved more than software evaluation, and given that their rules allow for greater risk taking than RAF squadron peacetime operating, one has to query why the latter was not suspended as well.
As for your lighter note I suspect that you were yet another to fall under the allure of that femme fatale and her shapely ankles!

[cazatou]

Chugalug 2

If you want a male candidate for "Perfect Passenger" then it would have been
the Labour Minister Roy Mason at the NI Office - he gave memorable Cocktail Parties too!!

Re Chinook,

People have been complaining for years on this thread about "known defects" for which there was no rectification programme; yet there was no record of multiple Incident Reports detailing system failures.

After the penultimate sortie the crew "mentioned" an avionics snag to the groundcrew who "re-seated" the avionics box in question. No paperwork was raised. Who knows what other potential or actual faults were dealt with in this way on that Detatchment; thereby leaving no written evidence of any such problem.

[tucumseh]

People have been complaining for years on this thread about "known defects" for which there was no rectification programme; yet there was no record of multiple Incident Reports detailing system failures

.


It is a well documented fact that, in the previous few years (early 90s), the RAF had systematically cut the funding for conducting, inter alia, Fault Investigations (which is effectively what you speak of). And if you have no MF761 to underpin the requirement for a rectification programme, then the latter is seldom, if ever, approved. Engineering Authorities (as they were called then) were “advised” by Suppliers (who, when AMSO was formed, had gained control of funding designed to maintain airworthiness) not to bother requesting investigations, to save up MF760s and submit omnibus MF760As; in an effort to save money. The natural outcome was delay and often, at unit level, cessation of raising MF760s, it being deemed a waste of time as no visible action was being taken. (MF760/A/1 – Narrative Fault Report / Fault Investigation Request / Fault Investigation Report respectively).

As little money was being spent on investigations, requests for re-instatement of funding fell on deaf Supplier ears, who responded with the ludicrous argument “You never spent any last year (as none was released!) so you don’t need any next year”. Another cracker was “Reliability improves with age, the kit is old, so it shouldn’t fail. The MF760s must be wrong”. If I recall, that was severe cracking in gearboxes. And thus, a crucial part of the Airworthiness Regs (JSP 553 Ch. 5 Maintaining Airworthiness) could not be complied with. The situation became progressively worse. At first (1990-ish) money would be released eventually if the problem was safety related; in time the policy became “no safety tasks to be undertaken”. Suppliers / non-engineers being permitted to make engineering decisions has been a problem more or less ever since, although funding has improved somewhat since the Suppliers lost total control. But, not sufficiently to take retrospective action, so there remain huge gaps in the airworthiness audit trails. This is not only my view, but was later re-iterated by the House of Commons Defence Committee and the Public Accounts Committee. Their reports are open source. It has also been mentioned during recent Inquests.

When considering Mull (or any other accident), please consider what happened in the preceding years. Don’t be fooled by the MoD argument that everything is ok now, so it can’t have been a problem 15 years ago. I think this important perspective is missing from much of the debate.

[Chugalug2]

Tuc, you do well to remind us of the early corrupting of the Flight Safety system by those often referred to as "bean counters", for it was those very people assiduously simply "doing their job" that started the whole inevitable slide from proper Airworthiness provision to the fatal accidents which brought with them the pain and anguish visited on so many. Were not the restrictions on Engineering reporting that you describe also levelled on Aircrew reporting, ie a big reduction in the processing of Incident Reports (F765B in my day) called for? With the Airworthiness Authority (the MOD) presiding over such a sabotaging of RAF Flight Safety little wonder that many of those at the work face did what was expected of them and simply stopped reporting. Result? The virtuous loop of incident, diagnosed fault, report, statistical assessment, preventative mod, enhanced safety, was broken. After that you just have to wait. The rest is now tragic history. Whether or not that ticking bomb led to this accident I don't know, nor I would suggest does anyone else. There were, we are told, concerns at Squadron level over the airworthiness of the HC2, a concern echoed in the Nimrod and Hercules fleets over deficiencies that did indeed lead to fatal accidents. Time now for the Airworthiness of the HC2 prior to this accident to be fully discussed.

[cazatou]

Chugalug2 & Tucumseh

I totally refute any suggestion that there was an orchestrated campaign to reduce incident reporting in the years prior to this accident. Moreover, in view of the fact that my final tour was in Flight Safety at HQ 1Gp, I take it as a deliberate slur on my character and integrity that you insinuate that this was the case and that, by implication, I was involved in such a campaign.

There was, in fact, a campaign to encourage personnel to submit such reports even if they considered the incident to be trivial.

[tucumseh]

Caz


I’m sure you’ll be pleased to know that the “orchestrated campaign” was in fact initiated by those, like you, who held positions of responsibility for safety and airworthiness – in our case those with airworthiness and technical approval delegation. Our aim was to have the policies and practices I spoke of overturned. I’m sure you would have joined us.

Luckily, we were supported by an independent audit instigated by the EAC and another carried out by MoD’s own Internal Audit team. They conducted their business in the face of very high level opposition, in particular the 2* responsible for maintaining airworthiness, who had publicly threatened his technical staff with dismissal for daring to insist on meeting their legal obligations (to PUS and SoS). A similar stance was later adopted by his opposite number in PE, who was responsible for Chinook (post Mull). But, credit where it’s due, many of his junior officers, mainly Wg Cdrs, expressed their deep concern and supported us jumped-up civvies. I’m sure you know what it’s like – the lunacy of one or two men at the top does not constitute an orchestrated campaign, but those below must immediately make career decisions. Some chose their career, others chose airworthiness and safety. That is why the situation is variable across aircraft and equipment fleets, and why MoD will always be able to cite success stories.

As I said, there was only partial success and the inevitable outcome is recorded in various BoI reports, Audit reports and Committee proceedings.

[BEagle]

Well, I submitted a fair number of IRs for all the engine failures and bits not working correctly I experienced in 5000 hrs on the Vickers FunBus and I don't recall any directive being issued to restrict or persuade against submitting such IRs.


I was, however, rather disappointed at the lack of follow-up action to such IRs at times.

As en ex-FSO, I agree with cazatou - at least in the (then) 1 Gp and also in Learning Command, there were no attempts to stifle honest reporting. The only disincentive being the likes of Ba$tard Bill who wanted IRs to lead to disciplinary action......... So at one stage, a 'grown up' was required to 'approve' IRs in case they might 'embarrass the squadron'. Yes, there really were people so inadequately testiculated that they would try to sanitise the truth to protect their careers .

[tucumseh]

Thanks Beagle.

If you refer to my earlier post, I mentioned that the instruction was to EAs, the 2nd link in the chain, to encourage them to save up narrative reports and/or reject more. The initial narrative reports continued, although I noted a reduction in these because, as you say, units perceived a lack of follow up action - action which is mandated by the regs even if it is just informing the originator that nothing is being done. (The failure of process noted during the recent C130 inquest). Crucially, the regs demand this decision be made by a suitable competent person.

The actual edict went something like "A MF760/A costs £xxk to process, cut back because we seldom get free rectification so there is no point in conducting an investigation". In other words, we don't care a toss if the fault is real, or the effect it's having, we're only interested if there's a chance of designer liability. Of course, only a complete idiot would think of it this way. Not least because MoD can seldom demonstrate they have complied with servicing instructions etc, so they haven't a leg to stand on. Crucially (in the case of a number of accidents discussed here) if MoD have introduced a Service Engineered Modification without following the mandated regs (which is most of the time) then all the DA has to say is you've altered the product without referring to us, we're not liable. Read any warranty and it says the same. But, in my opinion, this does not mean you don't investigate faults (or incidents).

There are two important points here. First, forget the detail of whether it is a 760, 765 or whatever. The procedural Def Stan lists them all, and tells you what to do with each, but the overarching subject is maintaining airworthiness (and hence safety). The policy directive compromised this and the HCDC & PAC reports I mentioned note the inevitable outcome. Second, and I detest this one, the faceless wonders who didn’t have to actually sign for airworthiness passed the buck to the EAs who, at that time, were normally senior NCOs or junior civvies. It was they who were put under pressure to reject reports or not submit requests for further action. Very few would grab the phone to call a senior and complain. The reaction to those who did was immediate – normally a Gp Capt phoning your boss and demanding disciplinary action. (In my case, my boss refused, and the AVM himself traveled 250 miles to carpet me and threaten dismissal. He didn’t even stop for lunch. Started at 0900 and “did” 8 of us before leaving at 1700. He started with the most senior, and each one had to remain and watch the next. By the time the last one was taken (me) 7 of my colleagues were sat up against a wall. And the fact there were 8 of us means there are plenty witnesses). When your other colleagues see this happening, what do you think the natural reaction is? Head down, cite the policy directive and don’t bother investigating faults, incidents or maintaining airworthiness in general.

There you go. RAF “man management” policy, December 1992, and how it affected airworthiness. I won’t say any more. There is no need.

[cazatou]

tucumseh

Thank you for that clarifcation.

BEagle

Thank you for the support. I agree with you that there were people who saw a path to promotion in "coming down hard" on personnel who suffered major incidents/accidents - an attitude which is counter - productive as it deters people from reporting incidents and thus increasing the chance of a accident. One also had to contend with the BOI Presidents who came to an instant decision regarding "negligence", and manipulated the BOI so that "inconvenient" testimony/evidence was brushed aside or ignored.

The Courts Martial system now has a cadre of Permanent Presidents - I see no reason why the BOI system should not follow that example.

[Chugalug2]

Caz, the corrupting effects of which I wrote were effected at a far higher level than that of Group FSO's. Having said that I was unaware that you personally were at Group then as an FSO. As tuc says the attempts were resisted by good men and women up and down the chain, but nevertheless the corrosive effect of such pressure would have had a debilitating effect on Flight Safety in the RAF generally. As to my contribution, it has been my understanding that the attempts to reduce the narrative reports extended across the system ie involving reports from both engineers and aircrew. I have heard of this before and believed it to be the case. However I take note of your comments and Beag's to the contrary, and am willing to edit out my "belief" to that effect in my post if there are no other recollections in support of that. This is not about individuals, other than the people who initiated such attempts to shut down the system, but of the Flight Safety system itself.

[ShyTorque]

The aircraft were not "grounded" - they just did not fly because the trials had been suspended.

Cazatou (aka K52),

You have obviously forgotten something. The Boscombe trials aircraft needed maintenance and the Handling Sqn pilots refused to fly it to Odiham (just 31 nautical miles away) where said maintenance was to be carried out!

The RAF Odiham unit maintenance test pilot was eventually transported to Boscombe Down to recover the aircraft. If I'm not mistaken, this was in Sqn Ldr Burke's evidence (the unit test pilot himself) as given during the House of Lords' Inquiry.

The pilots responsible for the introduction of the aircraft to squadron service had lost confidence in the safety of the aircraft. They were not in an operatiional environment and had the backing of their immediate superior officers, unlike the unfortunate squadron pilots who were ordered to carry on regardless despite the request for a Mk 1 from the captain. Had they been made aware of the full facts those squadron pilots involved in this accident might have also seen fit to say no too and this accident would then never have happened.

[cazatou]

Shy Torque

Having done a tour on Handling Sqn at Boscombe Down I can assure you that it is a :




GROUND TOUR





It would not be surprising, therefore, that Handling Sqn Pilots refused to fly the aircraft. In my tour I flew a total of 12hrs 50mins as 2nd pilot over a period of 2 years.