Chinook - Still Hitting Back 3 (Merged)
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I'm afraid that the longer this has gone on the more and more pointlessly over-analytical it has become. Gross negligence seems a bit unfair but let's face it, the aircraft in question was not found to be unserviceable prior to the crash so what do you expect the establishment to say?
Yes, the crew were making do with less than ideal circumstances (chopping and changing between the Mk.1 & Mk2, crew duty issues, restrictive icing clearance etc) but hey, when are circumstances 100% ideal on SH? Rarely, I can tell you. Improvise, adapt, overcome. That's what they'd been taught and that's what they were doing. If they weren't happy they wouldn't have got airborne in the frst place.
No-one seems to countenance the thought that the crew, like countless SH crews before them, might have just been 'cuffing it' on a low-arousal task. Dissecting every last detail of what was a routine flight is wholly counter-productive because a crew will often make things up as they go along. Yes, there'll be a broad plan to get from A to B but the finer detail often changes for any number of reasons ranging from the trivial to the safety-critical. With this in mind, over-analysing the minutiae of the crew's actions just seems desperate.
Nothing will be proven, whether it's regarding waypoints, rotor overspeeds, spurious captions or whatever. As admirable as the campaigners intentions are, you just appear to be grasping at straws and are clearly fighting a losing battle. Sorry if the truth hurts.
Yes, the crew were making do with less than ideal circumstances (chopping and changing between the Mk.1 & Mk2, crew duty issues, restrictive icing clearance etc) but hey, when are circumstances 100% ideal on SH? Rarely, I can tell you. Improvise, adapt, overcome. That's what they'd been taught and that's what they were doing. If they weren't happy they wouldn't have got airborne in the frst place.
No-one seems to countenance the thought that the crew, like countless SH crews before them, might have just been 'cuffing it' on a low-arousal task. Dissecting every last detail of what was a routine flight is wholly counter-productive because a crew will often make things up as they go along. Yes, there'll be a broad plan to get from A to B but the finer detail often changes for any number of reasons ranging from the trivial to the safety-critical. With this in mind, over-analysing the minutiae of the crew's actions just seems desperate.
Nothing will be proven, whether it's regarding waypoints, rotor overspeeds, spurious captions or whatever. As admirable as the campaigners intentions are, you just appear to be grasping at straws and are clearly fighting a losing battle. Sorry if the truth hurts.
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Nothing will be proven,
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Was it serviceable?
VSF
Shy Torque has pointed out the purpose of this thread and I agree with him and indeed some of your comments since any attempt to define the cause of this accident is impossible - but then you don't find people guilty of Gross Negligence on this basis either. In the search for the truth that you claim to have found, you state that the aircraft was not found to be unserviceable prior to the crash - it was, of course not proven to be seviceable either - read the full AAIB conclusions. Of course if the BOI does not get given all of the relevant evidence relating to serviceability, aka in this case airworthiness, they may not look as widely as you might expect them to. We have not yet seen any evidence that this letter was shown to them, the Sherriff's FAI, or the other committees that have investigated this tragic accident - indeed I sometimes wonder if even the Reviewing Officers knew of its existence. This input from the Flight Clearance Authority is hardly grasping at straws - did you include it in your search for the truth? The bits in bold are my input.
File Ref: ADD/308/04 dated 6 June 1994
CHINOOK MC MK 2 - CA RELEASE TRIALS References:
A. A&AEE Letter Report TM 2210 - Chinook HC Mk 2 - Interim CA Release Recommendations.
1. You will be aware that at Reference A we were unable to recommend CA Release for the Chinook HC Mk 2 aircraft due to unquantifiable risks associated with the unverifiable nature of the FADEC software. However, we offered advice and proposed limitations aimed at minimising any risk associated with unpredictable FADEC software behaviour in the event that it became operationally necessary to use the aircraft prior to verified software becoming available. This advice assumed that the reliability and integrity of the hardware in the engine control system was adequate, as appeared to be the case from rig, bench, Service experience and integrity studies.
2. Since the introduction of the HC Mk 2 into Service in Oct 93, we are aware of at least 15 engine related incidents in a total of 1258 flying hours; this excludes those incidents that occurred during tests associated with the overspeed limiter checks. Of the 15 incidents, 4 are- considered to have particularly serious implications and are discussed below:
a. RAF Odiham Incident Signal DTG 081730Z MAR 94. ZA 704 - No 2 Engine flamed out after FADEC Reversionary Switch selected during pre-flight checks on the ground. No fault found.
b. RAF Odiham Incident Signal DTG 281232Z AFR 94. ZA 681 - No 1 Engine rapidly shut down after FADEC Reversionary Switch selected during pre-flight checks on the ground. No fault found.
c. RAF Laarbruch Incident signal DTG 1309232 MAY 94. ZA 671 – Nr rose rapidly to exceed 120% after both FADEC Reversionary Switches were selected during pre-flight checks. No fault found, but forward and aft rotor head tie bars were found to be distorted, indicating that the overspeed limiter system had failed to function.
d. RAF Odiham Incident Signal DTG 191545Z MAY 94. ZD 576 Emergency Power Caption illuminated twice in flight and once on the ground. PDT of No 1 Engine reached 950°C. No fault found, but blueing and minor cracking evident on blade tips of turbine nozzle assembly stators.
3. Three of the above incidents occurred on the ground during FADEC Reversionary lane checks, and there is in place a restriction on the manual selection of Reversionary mode in flight. However, we no longer consider this to be an adequate safeguard against the possibility of a potentially serious in-flight incident. The Reversionary mode is a vital safety feature in a full authority digital system and as such has to perform in a reliable and effective manner. At some stage we must expect a primary lane failure in flight which will result in the automatic selection of "Reversionary Mode" but experience to date suggests that the basic requisites of that system may not be met.
4. Whilst we are aware of the very considerable steps you are taking to determine the causes of these incidents and of the ongoing investigations involving a report from HSDE, the Textron 'White Paper', the EDS Scicon verification study and the T55 software block change proposals, I have to state that the serious, frequent and unexplained incidents to which I have alluded, have eroded what confidence we had in the Chinook HC Mk 2 engine management system. This unease has grown despite our meeting on 25 May. The unquantifiable risks identified at the Interim CA Release stage may not in themselves have changed but some have become more clearly defined by events, to an extent where we now consider the consequences of the risks and the probability of an occurrence to be unacceptable.
5. As a result of our concerns for the flight safety of the aircraft, I have regretfully taken the decision to suspend Chinook HC Mk 2 flight trials until such time as we are satisfied with the explanations for, and solutions to, the above incidents. Furthermore, we strongly recommend that you make our concerns known to the RAF in order that they may consider their, own position.
6. Please be assured that this decision has been taken in complete isolation from the tragic accident that occurred on the Mull of Kintyre on 2 June, and that we remain committed to pursuing the outstanding CA Release trials as soon as our flight safety concerns are overcome. In the meantime, we will of course continue to provide you with whatever advice and assistance we can in your deliberations and to help bring the outstanding investigations and studies to a satisfactory conclusion.
JB
Shy Torque has pointed out the purpose of this thread and I agree with him and indeed some of your comments since any attempt to define the cause of this accident is impossible - but then you don't find people guilty of Gross Negligence on this basis either. In the search for the truth that you claim to have found, you state that the aircraft was not found to be unserviceable prior to the crash - it was, of course not proven to be seviceable either - read the full AAIB conclusions. Of course if the BOI does not get given all of the relevant evidence relating to serviceability, aka in this case airworthiness, they may not look as widely as you might expect them to. We have not yet seen any evidence that this letter was shown to them, the Sherriff's FAI, or the other committees that have investigated this tragic accident - indeed I sometimes wonder if even the Reviewing Officers knew of its existence. This input from the Flight Clearance Authority is hardly grasping at straws - did you include it in your search for the truth? The bits in bold are my input.
File Ref: ADD/308/04 dated 6 June 1994
CHINOOK MC MK 2 - CA RELEASE TRIALS References:
A. A&AEE Letter Report TM 2210 - Chinook HC Mk 2 - Interim CA Release Recommendations.
1. You will be aware that at Reference A we were unable to recommend CA Release for the Chinook HC Mk 2 aircraft due to unquantifiable risks associated with the unverifiable nature of the FADEC software. However, we offered advice and proposed limitations aimed at minimising any risk associated with unpredictable FADEC software behaviour in the event that it became operationally necessary to use the aircraft prior to verified software becoming available. This advice assumed that the reliability and integrity of the hardware in the engine control system was adequate, as appeared to be the case from rig, bench, Service experience and integrity studies.
2. Since the introduction of the HC Mk 2 into Service in Oct 93, we are aware of at least 15 engine related incidents in a total of 1258 flying hours; this excludes those incidents that occurred during tests associated with the overspeed limiter checks. Of the 15 incidents, 4 are- considered to have particularly serious implications and are discussed below:
a. RAF Odiham Incident Signal DTG 081730Z MAR 94. ZA 704 - No 2 Engine flamed out after FADEC Reversionary Switch selected during pre-flight checks on the ground. No fault found.
b. RAF Odiham Incident Signal DTG 281232Z AFR 94. ZA 681 - No 1 Engine rapidly shut down after FADEC Reversionary Switch selected during pre-flight checks on the ground. No fault found.
c. RAF Laarbruch Incident signal DTG 1309232 MAY 94. ZA 671 – Nr rose rapidly to exceed 120% after both FADEC Reversionary Switches were selected during pre-flight checks. No fault found, but forward and aft rotor head tie bars were found to be distorted, indicating that the overspeed limiter system had failed to function.
d. RAF Odiham Incident Signal DTG 191545Z MAY 94. ZD 576 Emergency Power Caption illuminated twice in flight and once on the ground. PDT of No 1 Engine reached 950°C. No fault found, but blueing and minor cracking evident on blade tips of turbine nozzle assembly stators.
3. Three of the above incidents occurred on the ground during FADEC Reversionary lane checks, and there is in place a restriction on the manual selection of Reversionary mode in flight. However, we no longer consider this to be an adequate safeguard against the possibility of a potentially serious in-flight incident. The Reversionary mode is a vital safety feature in a full authority digital system and as such has to perform in a reliable and effective manner. At some stage we must expect a primary lane failure in flight which will result in the automatic selection of "Reversionary Mode" but experience to date suggests that the basic requisites of that system may not be met.
4. Whilst we are aware of the very considerable steps you are taking to determine the causes of these incidents and of the ongoing investigations involving a report from HSDE, the Textron 'White Paper', the EDS Scicon verification study and the T55 software block change proposals, I have to state that the serious, frequent and unexplained incidents to which I have alluded, have eroded what confidence we had in the Chinook HC Mk 2 engine management system. This unease has grown despite our meeting on 25 May. The unquantifiable risks identified at the Interim CA Release stage may not in themselves have changed but some have become more clearly defined by events, to an extent where we now consider the consequences of the risks and the probability of an occurrence to be unacceptable.
5. As a result of our concerns for the flight safety of the aircraft, I have regretfully taken the decision to suspend Chinook HC Mk 2 flight trials until such time as we are satisfied with the explanations for, and solutions to, the above incidents. Furthermore, we strongly recommend that you make our concerns known to the RAF in order that they may consider their, own position.
6. Please be assured that this decision has been taken in complete isolation from the tragic accident that occurred on the Mull of Kintyre on 2 June, and that we remain committed to pursuing the outstanding CA Release trials as soon as our flight safety concerns are overcome. In the meantime, we will of course continue to provide you with whatever advice and assistance we can in your deliberations and to help bring the outstanding investigations and studies to a satisfactory conclusion.
JB
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you state that the aircraft was not found to be unserviceable prior to the crash - it was, of course not proven to be seviceable either
Just because there had been a few FADEC issues in the weeks that preceded the crash doesn't mean there were at the time. As it stands, even the layman can see that without concrete evidence, your arguments are pretty thin and that you're grasping at straws in the forlorn hope that someone will reverse previous decisions. Face facts, it's not going to happen. Not on the off chance that something might not have been working.
VSF,
To select some words from your last two posts:
"Nothing will be proven"
"It can't be proven"
"It's pretty unlikely"
"...might....."
"....seems...."
So you are content with the verdict based on "absolutely no doubt whatsoever " are you? If you are, why? The words above are hardly indicative of hard evidence are they?
To select some words from your last two posts:
"Nothing will be proven"
"It can't be proven"
"It's pretty unlikely"
"...might....."
"....seems...."
So you are content with the verdict based on "absolutely no doubt whatsoever " are you? If you are, why? The words above are hardly indicative of hard evidence are they?
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VSF,
Unlike you I am not making any claims to know the truth - I like everyone else, including yourself despite your claim to know "the truth hurts", will never know what went wrong. I was merely pointing out a few factual areas which one might have expected a full BoI and review procedure to have covered - there are many others including such "minor" distractions as false engine fail warnings lasting up to 12 seconds, etc, etc which were part of the RTS at the time. You do not find Gross Negligence, the civilian equivalent being manslaughter, without knowing and having 100% confidence in the facts!
It seems to me that you are the one here who is grasping at straws - and at least I write my comments under my own name.
JB
Unlike you I am not making any claims to know the truth - I like everyone else, including yourself despite your claim to know "the truth hurts", will never know what went wrong. I was merely pointing out a few factual areas which one might have expected a full BoI and review procedure to have covered - there are many others including such "minor" distractions as false engine fail warnings lasting up to 12 seconds, etc, etc which were part of the RTS at the time. You do not find Gross Negligence, the civilian equivalent being manslaughter, without knowing and having 100% confidence in the facts!
It seems to me that you are the one here who is grasping at straws - and at least I write my comments under my own name.
JB
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I'll put forward my stance once more.
There are those who are happy to see aircrew accused of manslaughter without firm evidence. And those who are most definitely not.
There are those who are happy to see aircrew accused of manslaughter without firm evidence. And those who are most definitely not.
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VSF, maybe the chaps were playing stone, scissors, paper in the cockpit or, at very least, 'cuffing it'. But the big point is that the burden of proof does not lie with the crew, it lies with those who level the accusation of gross negligence. This is not about proving what did or did not happen, this is about the MOD proving their case against their own clear and unequivocal criteria.
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The bottom line is that an apparently serviceable aircraft was flown into terrain. In the absence of any evidence of unserviceability to that particular aircraft at that time, what do you expect the AOCs to say? What choice did they have? Years of conjecture about things that might have occurred has achieved precious little because that's exactly what it is - conjecture. Draw a line under it. Please. For the sake of the other 27 families if nothing else.
vsf, can you be serious? I cannot imagine that anyone could be a troll on this thread, but what on earth possesses you to post here (for the first time?) such incendiary rubbish and at this time of year in particular? Now I realise that you are a serving helicopter pilot and I am not and never was, but your illogical contribution seems to owe little or nothing to your professional status so I will rush in and no doubt prove the proverb correct:
The discussion has concerned (well recently) not the serviceability but the airworthiness, and it would be an understatement to rephrase your post to "an apparently unairworthy aircraft", to say the least.
Well, personally if they had merely endorsed the original BoI finding I would be satisfied, but evidently they weren't.
Not to make the outrageous finding that they did, for a start.
Couldn't agree more, and yet Messrs W & D still felt able to produce their "guilty unless proved innocent" finding on just that basis.
You forgot to mention moving on and smelling coffee!
Why would they draw any comfort from their loved ones having died because of the alleged pilots' gross negligence? Why would it be more hurtful to be told that the cause was unknown, or even possibly that it was due to the aircraft's unairworthiness? I only raise these points because you have. Is it not better not to speak on other peoples behalf, when we have no idea of what they truly think, or do you anyway?
Finally may I add that I understand from your previous posts on other threads that you are presently an SAR pilot. If I have that wrong I apologise, but in any case may I say how much those who carry out such important and hazardous work are admired, especially when the rest of us enjoy the company of friends and family at this time of year. To all of you that serve and protect us, whether on duty now or hopefully also with your own loved ones, a very sincere thank you from an old BOF!
apparently serviceable aircraft
what do you expect the AOCs to say?
What choice did they have?
Years of conjecture about things that might have occurred has achieved precious little because that's exactly what it is - conjecture
Draw a line under it.
For the sake of the other 27 families if nothing else
Finally may I add that I understand from your previous posts on other threads that you are presently an SAR pilot. If I have that wrong I apologise, but in any case may I say how much those who carry out such important and hazardous work are admired, especially when the rest of us enjoy the company of friends and family at this time of year. To all of you that serve and protect us, whether on duty now or hopefully also with your own loved ones, a very sincere thank you from an old BOF!
What choice did they have?
As for the supposed serviceability of the aircraft, that is pure speculation especially given the evidence of trend failures previously posted by JB. Were these trends investigated? Or was the 1991 savings measure to curtail such investigations, thus compromising airworthiness, a factor? I can only speak from personal experience, but recall we were instructed to cancel all such tasks on the Design Authorities. I know the reaction of “my” contractors – “You’re ###### mad. The airworthiness system will never recover”.
And then 2 years later Safety Cases became compulsory. But if you’ve allowed a 2-3 year gap in the audit trail, and will not fund retrospective corrective action, then any Safety Case for legacy equipment is by definition flawed as you are forced to make the sweeping, and completely unverifiable, statement that the aircraft/equipment is deemed safe at the effective date of the legislation.
How much of this was discussed at the various inquiries?
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Chugalug2, you need to calm down mate.
If I crash and burn in '09 and my family start a 'aircraft not airworthy' campaign (that seems to be the done thing these days) I'll be back to haunt them until they stop.
Rather like proving anything you want with statistics, if you really wanted to, you could probably find enough evidence to declare every aircraft type on the inventory non-airworthy. But the guys and girls across all three services just get on with it; that's what they're paid to do. If one of the four guys wasn't happy with the aircraft on 2 Jun 94, they wouldn't have got airborne in the first place. That's an incontrovertible fact.
If I crash and burn in '09 and my family start a 'aircraft not airworthy' campaign (that seems to be the done thing these days) I'll be back to haunt them until they stop.
Rather like proving anything you want with statistics, if you really wanted to, you could probably find enough evidence to declare every aircraft type on the inventory non-airworthy. But the guys and girls across all three services just get on with it; that's what they're paid to do. If one of the four guys wasn't happy with the aircraft on 2 Jun 94, they wouldn't have got airborne in the first place. That's an incontrovertible fact.
Please don't worry on my behalf, Vsf, I am very calm. What your supernatural intentions are for your family are of course your concern and presumably theirs. Your glib attitude to airworthiness as being "proving anything you want with statistics" ties in very neatly with the contempt held for it by the MOD. The only difference being of course that the MOD is the Authority for UK Military Airworthiness provision, and you are not. I am very well aware that it is the job of "the guys and girls across all three services just get on with it", I used to be such a guy. It is also the job of the MOD to ensure that the aircraft that they "just get on with it" in are airworthy. It did so in my day, but they have not it seems for the past twenty years or so. As to:
That is plain tosh and you know it. So the gross negligence was signing the F700 now was it? It seems to move further and further away from the accident site. In that we agree at least, but keep moving for we have further to go yet both in space and time. There was gross negligence all right but by others, and much further up the food chain.
If one of the four guys wasn't happy with the aircraft on 2 Jun 94, they wouldn't have got airborne in the first place. That's an incontrovertible fact.
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Tosh?
No it isn't. It's a fundamental principle. If you're not happy you don't get airborne in the first place.
Regular contributors to these pages may find it hard to believe, but my thoughts on this entire issue are not uncommon throughout the aviation world. It just seems taboo to dare to suggest that the guys could've b0llocksed it up. Every time this campaign takes it a stage further and it receives yet more national press coverage, old wounds are re-opened for the other bereaved families. When's it going to end? The MoD aren't for changing, surely you must all realise that by now.
No it isn't. It's a fundamental principle. If you're not happy you don't get airborne in the first place.
Regular contributors to these pages may find it hard to believe, but my thoughts on this entire issue are not uncommon throughout the aviation world. It just seems taboo to dare to suggest that the guys could've b0llocksed it up. Every time this campaign takes it a stage further and it receives yet more national press coverage, old wounds are re-opened for the other bereaved families. When's it going to end? The MoD aren't for changing, surely you must all realise that by now.
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I think VSF has worded rather well a critique of your strategy that probably many looking at this tragedy would agree with.
If you add that the a/c had got within 650 yards of the nearest shore at the point where they discarded waypoint A (and about 750 from that fog station, for those interested) and thus appeared to have been in control at least until that point and yet were still at high speed and seemed to make a deliberate turn to the right (into danger) onto a track which they held until 4 secs before impact at which point the a/c appeared to have responded correctly to the control positions found THEN you perhaps should consider approaches other than “airworthiness”.
While some would say it can happen to the best, I personally cannot believe the coincidence of them having a bad day, with their experience and local knowledge in this area, just when they have the particular VIPs on board.
My own analysis of the available data suggests that they were paying particular attention to navigation and that they had a purpose for approaching a known LZ closely.
Whether they were misled by a third party or simply misjudged their approach does not really matter if you are interested in just clearing their names – any such activity would reduce any mistake on their part to an error of judgment if that and together with that such an activity has not been disclosed surely throws out the original verdict of gross negligence.
If you add that the a/c had got within 650 yards of the nearest shore at the point where they discarded waypoint A (and about 750 from that fog station, for those interested) and thus appeared to have been in control at least until that point and yet were still at high speed and seemed to make a deliberate turn to the right (into danger) onto a track which they held until 4 secs before impact at which point the a/c appeared to have responded correctly to the control positions found THEN you perhaps should consider approaches other than “airworthiness”.
While some would say it can happen to the best, I personally cannot believe the coincidence of them having a bad day, with their experience and local knowledge in this area, just when they have the particular VIPs on board.
My own analysis of the available data suggests that they were paying particular attention to navigation and that they had a purpose for approaching a known LZ closely.
Whether they were misled by a third party or simply misjudged their approach does not really matter if you are interested in just clearing their names – any such activity would reduce any mistake on their part to an error of judgment if that and together with that such an activity has not been disclosed surely throws out the original verdict of gross negligence.
BEagle:
Point taken Beegs, in which case let us refer to the ultimate authority, none other than Wiki itself (OK peeps, joke!) where they say:
Anyone disagree with that? Or with this; an aircraft may be serviceable yet unairworthy, but an unserviceable aircraft is always unairworthy?
Methinks the distinction between serviceability and airworthiness is lost on some?
Airworthiness is defined in JSP553 Military Airworthiness Regulations (2006) Edition 1 Change 5 as:
The ability of an aircraft or other airborne equipment or system to operate without significant hazard to aircrew, ground crew, passengers (where relevant) or to the general public over which such airborne systems are flown
This definition applies equally to civil and military aircraft.
The ability of an aircraft or other airborne equipment or system to operate without significant hazard to aircrew, ground crew, passengers (where relevant) or to the general public over which such airborne systems are flown
This definition applies equally to civil and military aircraft.