Chinook - Still Hitting Back 3 (Merged)

[Tandemrotor]

endplay

Oh that it were 2 living pilots. An inquiry could have listened to their version of events, and made a fair and just finding.

Sadly the two gentlemen in this case are denied the opportunity of presenting their defence, and no lasting record of any of their words or actions survived.

Only a record of the airworthiness of this machine survives. The truly appalling extent of even that, being concealed for over a decade!

Concealed by the very same organisation that found the pilots guilty in the first place!

Let right be done.

[endplay]

Tandemrotor, (or anyone else)

I naturally take your point about being able to question living pilots and perhaps that part of my query deserved such a response. I would, however, like to know if a breach of VFR/IFR is grounds for a determination of gross negligence. My personal view is that if you can't ask why they did this then you can't assume but as a non flier I don't have that knowledge. The case for clearing the pilots seems to be based on the letter of the law so if the law says that a breach is GN then that is what it is. If not then the decision is no more than an opinion and its validity is as open to question as any expressed in this forum or elsewhere.

Not looking for a fight just clarification.

[Tandemrotor]

endplay

I can only offer a personal opinion. Although I have been intimately familiar with the case, I cannot claim to speak on behalf of the campaign group, who have settled on this strategy. Their view may be very different.

There is a sense in which your question regarding IFR/VFR is irrelevant to this case.

The simple facts regarding the weather are that: Everybody standing on the land mass of the Mull of Kintyre was in cloud. This very localised hill fog surrounding the Mull was visible from the coast of Northern Ireland. Clear conditions prevailed to a position, undetermined but, extremely close to the Mull Lighthouse.

Whilst it is possible, though not provable that ZD576 impacted the hillside in cloud. This simple assumption does NOTHING to help us understand what the pilots could see, nor what was happening, in the moments leading up to that impact.

The tiny snippets of disjointed information available, simply aren't robust enough!

THAT is why your question regarding IFR/VFR simply won't help us to progress.

As far as I understand it the focus on the RAF's requirement of 'Absolutely no doubt whatsoever' is simply the 'key' to help unlock this unwarranted opprobrium.

Firstly because it is simple to demonstrate that the Wg Cdr who conducted the investigation, ALSO had a duty to find negligence where the weight of evidence demanded it. He knew the evidence perhaps better than anyone, and he made no such finding.

And secondly, because the tidal wave of evidence coming to light about the appalling state of this aircraft. at that time, means ANY reasonable person, could not find the pilots guilty of ANYTHING. Not even on a balance of probability. As demonstrated by EVERY SINGLE SUBSEQUENT INDEPENDENT INQUIRY! (and there have been many!)

Let right be done.

[John Purdey]

Chinook

Tandemrotor. Irrelevant or not, it would be interesting to see your answer to Endplay's question. Regards. JP

[meadowbank]

KG86

You mentioned:

But, in all my Chinook experience, I have never heard of another such event.

I am surprised that you have not heard of the US Army Chinook's UFCM in June 1997 when one of their acft failed to respond to a control input, rolled in the opposite direction and eventually rolled through 180 degrees before control (of sorts) was regained. In the process, the Chinook descended from its cruise height of 1100 ft to 250 ft, following which the crew landed (untidily) asap. Despite extensive engineering efforts, no fault was ever found with the acft. Hardly surprising, therefore, that if no fault was found on an intact acft, it is unlikely that a similar technical fault would have been found within thenwreckage of ZD576.

I also have a document listing 35 separate UFCM events between 1994 and 1999.

[Tandemrotor]

John Purdey

It would also be interesting to hear your answer to my question, asked some days ago, in post 3816.

Here it is again, incase you missed it:

Quote:
6. RWTS has carefully monitored the progress of this trial and has put tremendous effort into ensuring that it progresses safely to provide timely CA release recommendations. These recommendations with respect to FADEC have, to date, been ignored. Until RWTS is provided with a clear, unequivocal and realistic explanation of the faults described at references B through H, with corrective action, further Chinook HC2 flying shall not be authorised. A statement of 'No Fault Found' will no longer satisfy this requirement.

7. As a trials organisation, A&AEE has always been keenly aware of the risks associated with operating the Chinook HC2 and has tailored sortie profiles accordingly. Crews of the RAF have no such luxury and are likely at higher risk than the A&AEE crews. As such, RWTS deem it imperative that, in the strongest possible terms, the RAF should be provided with a recommendation to cease Chinook HC2 operations until the conditions established in paragraph 6 are satisfied
May I just ask cazatou (K52), and john purdey: Was this aircraft fit for purpose?

"May I just ask cazatou (K52), and john purdey: Was this aircraft fit for purpose?"

Any chance?

Regards, TR

[Seldomfitforpurpose]

TR,

For all the obvious reasons I seriously doubt you will ever receive an answer to that question from either of those two chaps

[John Purdey]

Chinook

Tandemrotor. Apologies for not replying to your much earlier question, I must have been away, which was "May I just ask cazatou (K52), and john purdey: Was this aircraft fit for purpose?"
If we assume, purely for the purposes of this discussion, that the a/c was not fit for purpose, then please say exactly what mods were incorporated after the accident to so successfully prevent a repetition over the past 15 years.

Now please answer Endgame. Regards. JP

[NigelOnDraft]

endplay

Is a breach of VFR and IFR gross negligence and had the crash not happened would such a finding against 2 living pilots have been disputed?

Contrary to some of the above posters, I think you ask a good, and relevant question

I will state some personal opinions that may or may not be relevant to this accident, but might help you with your question:

Is a breach of VFR ... gross negligence

I doubt there is a pilot flying who has not at some point "breached VFR" Most of the breaches will have been unintentional, and a good % the pilot was never aware of it. VFR in these circumstances requires pilot assessment of Met Vis and Cloud(base). There is no "dial" indicating these values... and over the sea, approaching some visible land, you might deduce the visibility as well above legal, but fail to spot the mist over another portion of land

Is a breach of ... IFR gross negligence

Of course, if you are now not VFR then you are IFR and new rules apply... and it cannot become another case of "gross negligence" when you are unable to correct this instantly (it requires a climb to SA).

I would probably accept

An intentional, and sustained, breach of VFR and IFR, is gross negligence, if the appropriate actions are not carried out

I'm ex-RAF FW (FJ), and from very early days we were taught (and I later taught) the "Low Level Abort". The Low Level Abort is used when the pilot asseses is he no longer "VFR", or is unable to maintain VFR. It involves a rapid climb to/above SA, and it is presumed IFR will be encountered in this process. It will therefore, by definition, include

...a breach of VFR and IFR

until you reach SA. I doubt there is a (ex-)serving FJ pilot who has never carried out a genuine, unforeseen, LL Abort. Were we all "negligent"? Let alone "grossly negligent"

I would therefore say,

...and had the crash not happened would such a finding against 2 living pilots have been disputed?

the answer is yes - the mere fact of having been in breach of VFR and IFR is accepted as a possibility and appropriate actions prescribed.

The key statement you identified

...and at this time they were in breach of both VFR and IFR. For that reason, the pilots were considered by the ROs to have been grossly negligent ...

I disagree with since it misses whether the pilots were aware they were in breach, and to muddy the waters, the extent to which they were in breach of VFR. To be judged "grossly negligent" I believe it would need to be shown they were 100% aware they were not VFR (and for it to be "grossly" probably well below VFR) AND the appropriate actions were not taken, once this awareness occurred, in a reasonable timescale. Or put another way... IMHO to be grossly negligent it needs to be shown that they knew they were IFR and failed to take (and were able to take) appropriate actions (whatever the RW equivalent of the LL Abort is).

Just my 2ps worth
NoD

[Chugalug2]

John Purdey:

If we assume, purely for the purposes of this discussion, that the a/c was not fit for purpose, then please say exactly what mods were incorporated after the accident to so successfully prevent a repetition over the past 15 years.

Again a fair question and one that deserves an answer, just as BD's ultimatum surely required one:

Until RWTS is provided with a clear, unequivocal and realistic explanation of the faults described at references B through H, with corrective action, further Chinook HC2 flying shall not be authorised.

Someone, somewhere, must be able to answer either or both. Indeed I would be greatly surprised if the latter was not swiftly though discreetly resolved as a direct result of BD's statement and this accident, which occurred by dreadful coincidence on the same day I believe. Anyone?
The state of UK Military Airworthiness provision has been shown to have been under prolonged and deliberate attack by the very Authority charged with providing it, ie the MOD. Are we to assume that they made an exception to this fleet, or has it been simply lucky since this accident?

[tucumseh]

JP

If we assume, purely for the purposes of this discussion, that the a/c was not fit for purpose, then please say exactly what mods were incorporated after the accident to so successfully prevent a repetition over the past 15 years.

I’m afraid, John, you’re sounding suspiciously like one of the lackeys who drafts Ministerial replies whose sole aim is to compartmentalise the issues as a damage limitation exercise, but actually cause more harm by hiding the wider picture. MoD has consistently sought to retrospectively justify its (in)action PRIOR to the accident by referring the events AFTER it. As I quoted earlier;


“It has never happened before” is not valid evidence on its own, that a particular event will not happen”.


These rules require a proactive approach to safety management. Contrary to what MoD thinks acceptable, Safety Management should not be based on “Do nothing, let’s wait 15 years and see if we have an accident”. The Chinook is but one aircraft type whose airworthiness is supposed to be maintained under these rules. If you ask “What fatal crashes have, according to the Boards of Inquiry or Inquests, been caused by or contributed to by failure to implement mandated airworthiness regulations?”, then you get a truer picture – Nimrod, Sea King, Tornado/Patriot, Hercules…….. I’m not familiar with the recent Puma case, but I see MoD took a hammering again last week from the Wiltshire Coroner.

This kind of duplicity and inconsistency is becoming the norm from MoD. Its stance is ludicrous, and flies in the face of its own regulations. Hutton was like a rabbit in the headlights when interviewed by Mr Snow – possibly because he realised just what utter rubbish he had been advised to say, including the inference that serviceability and airworthiness are one and the same. His argument wouldn't last 10 seconds in court.


Similarly, the suggestion that modifications would prevent further accidents shows a very narrow understanding of MoD’s legal obligation under JSP553 Chapter 5 (maintaining airworthiness in-service) and the various procedural Defence Standards one follows to ensure compliance. Draw up a list of what contributes to airworthiness (it’s very long) and then ask if each has been carried out properly PRIOR to the accident. Then add another 4 or 5 columns for the other aircraft I mentioned. You’ll see a startling commonality emerge, which immediately elevates the matter beyond Chinook (or whatever aircraft), narrowing down the list of those responsible. One or two failures may not in themselves cause a problem, but the cumulative effect of multiple failures is there for all to see.


You may or may not agree with MoD’s view that “minor” transgressions such as not properly reporting faults are acceptable (noted in the BoI report). Again, MoD seeks to isolate and ignores what happened beforehand, or on other aircraft and equipment. If one minor fault wasn’t reported, that may be acceptable if the rest of the fault reporting, investigation and corrective action system was funded and functioning (which is one small component of maintaining airworthiness). But it wasn’t – a deliberate act to save money, which had the effect of contributing to the cumulative effect and increasing the probability of an event occurring. Instead of criticising the dead pilots for not reporting a fault (for example) why not expand the scope of the report by also saying “Even if they did report it, a Director and a Director General, in MoD(PE) and AMSO respectively, had 2 years earlier decided to slash funding and stop fault investigations”. Better still, just list the numerous audit reports which criticise MoD's failure in this respect and ask what action was taken. (MoD can't say, because it doesn't bother keeping such records, even though the reports' recommendations impact on their core business. How's that for contempt?). Then ask if the repeated failure to have faults investigated or corrective action taken in any way influenced air or ground crew actions, and caused a degree of laxity. (Human factors, another component of airworthiness). Yes, failure to report is wrong, but is the failure to ensure the aircraft was airworthy not a greater offence?

In which case, there would seem to be a prima facie case against those who knowingly compromised airworthiness across all fleets in the preceding years; and, even worse, those who have continued with this policy since knowing the damage it has caused. I deliberately say “policy” because they were advised of the risk and took a deliberate decision, when they had the option to comply with the regs.

[John Purdey]

Chinook

Tucumseh. Thanks for the lecture, now please answer the question. JP

[Tandemrotor]

John Purdey

You are very good at asking questions, but extremely bad at answering them.

Can't you manage an answer for me? Or will it be just another question?

Regards TR

[tucumseh]

John


No apologies for the “lecture”, sometimes it’s necessary to have a refresher course on the facts. God knows, MoD don’t admit to them.

please say exactly what mods were incorporated after the accident to so successfully prevent a repetition over the past 15 years.

Why not ask the MoD? When the design of the Mk2 and its equipment came Under Ministry Control, the regulations state the aircraft technical publications (for both aircraft and equipment) MUST be up to date. (There is a very detailed checklist that must get all its boxes ticked, or it shouldn’t happen. Tech Pubs is just one item in 4 pages. Remarkably, the list concentrates on airworthiness components). In simple terms, and assuming MoD can demonstrate, as it is required to do, compliance with the above, you can ask the question two ways;

• Ask for a copy of all amendments to all Topic 2s since it came UMC.
• Ask for a copy of all HQ Mod Committee decisions.

To avoid wasting your time, I can tell you MoD won’t be able to answer properly. Firstly, the pubs were not up to date (as widely noted in Mull papers). Secondly, the same financial cuts stopped ATPs being routinely amended. Thirdly, you’ll be hard pressed to find someone who remembers HQMCs, never mind has the historical information (i.e. audit trail). But here’s a starter for ten - ask to see Directorate of Military Aircraft Projects (D/MAP) secretariat records. They should be at Wyton now.

For the hell of it, I’d ask a better series of questions.

• Following said financial cuts, how many Fault Investigation requests (MF760A) were refused?
• How many of these 760s would have resulted in a modification?
• How many were safety related?
• If/when funding re-instated, was retrospective action taken to assess rejected MF760s?
• Of those MF760s that did result in a modification, how many were not reflected in the respective ATPs, or did not result in drawing amendments, resulting in Maintainers not actually knowing what the build standard was meant to be?

I recall NARO pointing out one time that a common LRU, destined for Chinook, had over 60 DA modifications missing from its Topic 2. That's a hell of a quandry for the QA guy. The workshop knows of 60 missing mods in one box, but doesn't know what their classification is so can't make a judgement on which ones are crucial to its functionality, reliability, interchangeability or safety.



The importance of these questions is that the Aircraft Safety Case MUST reflect the current Design Authority Build Standard (not the in use standard, which usually lags). Can MoD demonstrate, as it is required to do, that this is the case? If not, how on earth can it demonstrate compliance with JSP553? It can't.

And just to be cheeky……. What action was taken against the staff who (a) permitted and encouraged these failures of mandated airworthiness process, and (b) raised concerns about it? Actually, I can answer that. (a) None. (b) Disciplinary action.

[ShyTorque]

I have a question, too, to refresh my memory.

Brian, It came to light well after the accident that the MOD were suing Boeing over the problems with the FADEC software.

If known, can you remind me of the date of their initial action in this respect, compared to the date of the letter from the head of the Boscombe Down test pilots, urging the type be grounded, and the accident itself?

Thanks.

[Tandemrotor]

John Purdey

After the excellent response from tucmseh, it looks like it's over to you.

If you could also fit in an answer to my post from some days ago now, I would appreciate it.

Any thoughts?

Best regards, TR

[John Purdey]

Chinook

Tucumseh. It really will not do to drown us in paper references. Please say exactly what mods to this Mk of a/c were incorporated that have for 15 years prevented a repeat of this accident. Is that so difficult?

Tandemrotor. I must have missed something. I thought I answered your question by my 3861,did I not? Regards as always JP

[tucumseh]

It really will not do to drown us in paper references. Please say exactly what mods to this Mk of a/c were incorporated that have for 15 years prevented a repeat of this accident. Is that so difficult?

John

With all due respect, if MoD actually had all the "paper references" (i.e. an audit trail) perhaps we wouldn't be at this current impasse!

Your question is both ludicrous and irrelevant. Nevertheless, I've told you why MoD would have difficulty answering it, never mind anyone here. Ask them. I'm as interested in their answer as you, but perhaps for different reasons.

[Chugalug2]

JP, as one who called for your question to be answered, it seems to me that it was answered in spades by tucumseh. It's over to you now as Tandemrotor says. Or don't you do answers?

[Seldomfitforpurpose]

Chug,
JP's last post says

"Tandemrotor. I must have missed something. I thought I answered your question by my 3861,did I not? Regards as always JP"

But as post 3861 appears to be a post from Shy Torque then it would seem the answer to your question is No...............