Chinook - Still Hitting Back 3 (Merged)
Cazatou:
Have you missed post #4080 by tucumseh? It was addressed to you Sir, and I for one should very much like to know your response to it. Given your preoccupation with the importance of obeying orders regarding the eating of breakfast (with no proof that it wasn’t), could you please comment on the order given by an RAF AVM, on pain of dismissal and instanced by tuc, that his subordinates should ignore their mandated obligations regarding airworthiness and compound that by then lying in a cover up. In the light of later fatal airworthiness related accidents (including this one?) was this not potential manslaughter? Were you not in Group Flight Safety at this time? What could you achieve if identified airworthiness shortcomings shown up by the Flight Safety process could not be put right because of the obstruction caused by such orders? Were you aware of such orders? Were they not illegal orders that all military recruits are taught should not be obeyed but reported?
Have you missed post #4080 by tucumseh? It was addressed to you Sir, and I for one should very much like to know your response to it. Given your preoccupation with the importance of obeying orders regarding the eating of breakfast (with no proof that it wasn’t), could you please comment on the order given by an RAF AVM, on pain of dismissal and instanced by tuc, that his subordinates should ignore their mandated obligations regarding airworthiness and compound that by then lying in a cover up. In the light of later fatal airworthiness related accidents (including this one?) was this not potential manslaughter? Were you not in Group Flight Safety at this time? What could you achieve if identified airworthiness shortcomings shown up by the Flight Safety process could not be put right because of the obstruction caused by such orders? Were you aware of such orders? Were they not illegal orders that all military recruits are taught should not be obeyed but reported?
Last edited by Chugalug2; 13th Mar 2009 at 11:31. Reason: Words, dear boy, words!
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"The Catering arrangements are just one example"
You mean the ones that were approved at station level, funded by the catering section and audited by command accounts year on year........
You mean the ones that were approved at station level, funded by the catering section and audited by command accounts year on year........
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Chugalug2
Re your last Post.
1. I have read the assertions of Tucumseh but I have not seen any evidence to that effect. I do not say that he is making it up - I do not know.
2. What I do know is that no fault was found by the AAIB following the crash of ZD576 that could have caused the crash.
3. I am not aware of any major modification or rectification programme to correct any shortcomings found by the AAIB which contributed to the crash.
4. I have not read or heard of any similar Chinook accident in the nearly 15 years since this tragedy.
5. I am aware of the blatent disregard of Standing Orders and Instructions by the 2 Pilots of the aircraft for which (as the outgoing and incoming Detatchment Commanders) they must equally share the blame.
Re your last Post.
1. I have read the assertions of Tucumseh but I have not seen any evidence to that effect. I do not say that he is making it up - I do not know.
2. What I do know is that no fault was found by the AAIB following the crash of ZD576 that could have caused the crash.
3. I am not aware of any major modification or rectification programme to correct any shortcomings found by the AAIB which contributed to the crash.
4. I have not read or heard of any similar Chinook accident in the nearly 15 years since this tragedy.
5. I am aware of the blatent disregard of Standing Orders and Instructions by the 2 Pilots of the aircraft for which (as the outgoing and incoming Detatchment Commanders) they must equally share the blame.
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Gentlemen,
A quick request for help - is there available anywhere online a copy of the actual (presumably detacted) written BOI paperwork? I have tried to search but to no avail.
I am after a copy of the 'full TORs' for this Inquiry - normally noted after the composition of the Board - they are normally quite generic - although I would have been interested to have been a fly on the wall in Jon Day's office when they met!! Nonetheless, my research will have no bearing on the case - I am just interested to see how the TORs for the members differ from today's SIs.
Thanks awfully
flipster
A quick request for help - is there available anywhere online a copy of the actual (presumably detacted) written BOI paperwork? I have tried to search but to no avail.
I am after a copy of the 'full TORs' for this Inquiry - normally noted after the composition of the Board - they are normally quite generic - although I would have been interested to have been a fly on the wall in Jon Day's office when they met!! Nonetheless, my research will have no bearing on the case - I am just interested to see how the TORs for the members differ from today's SIs.
Thanks awfully
flipster
Cazatou:
You see, I’ve covered everyone of the points that you raised. Not to your satisfaction though, I’ll grant. Now please reciprocate by answering directly the points made by tucumseh and repeated in my post. Should that AVM’s order have been obeyed? Was it illegal?
- I asked for your comments on tucumseh’s post, that is of its contents not of evidence to authenticate it. You have not done so yet.
- “No fault found” does not mean no fault around.
- And the inference being?
- Thank God!
- Your awareness does not constitute proof, cazatou (thank God!)
You see, I’ve covered everyone of the points that you raised. Not to your satisfaction though, I’ll grant. Now please reciprocate by answering directly the points made by tucumseh and repeated in my post. Should that AVM’s order have been obeyed? Was it illegal?
Chug, it’s ok, we know the MoD’s view, and that of their apologists.
Caz has a point; I only have contemporaneous notes of that December 1992 incident, although there are 9 other witnesses – 2 Air Cdre’s (one of whom looked extremely nervous and didn’t want to be there) and 7 other civvys, all senior to me and, as far as I know, still alive. I never really got a word in, as they all erupted and gave the AVM an earful. My annual report mentions the incident though, in a supportive way.
However, the subsequent audit reports that supported me are available in the official record, as is the reason why they were initiated – to prove the AVM wrong. The 1* who initiated the main audit (i.e. stood against his immediate boss on my behalf) is still serving. (Thanks MW, you know who you are).
But of course that’s the least of it, because a host of other senior staffs have kept faith with the AVM’s ruling, and continue to have top level support.
That’s why people have died. It's also why MoD wastes countless millions each year, so is unable to afford the various components of airworthiness that have been ruled optional or unaffordable.
PS I can confirm the AVM and his 1* bagmen had breakfast, lunch and dinner that day.
Caz has a point; I only have contemporaneous notes of that December 1992 incident, although there are 9 other witnesses – 2 Air Cdre’s (one of whom looked extremely nervous and didn’t want to be there) and 7 other civvys, all senior to me and, as far as I know, still alive. I never really got a word in, as they all erupted and gave the AVM an earful. My annual report mentions the incident though, in a supportive way.
However, the subsequent audit reports that supported me are available in the official record, as is the reason why they were initiated – to prove the AVM wrong. The 1* who initiated the main audit (i.e. stood against his immediate boss on my behalf) is still serving. (Thanks MW, you know who you are).
But of course that’s the least of it, because a host of other senior staffs have kept faith with the AVM’s ruling, and continue to have top level support.
That’s why people have died. It's also why MoD wastes countless millions each year, so is unable to afford the various components of airworthiness that have been ruled optional or unaffordable.
PS I can confirm the AVM and his 1* bagmen had breakfast, lunch and dinner that day.
Oh, and for the benefit of aircrew here, as I ignored the order to not make the aircraft safe (issued, I believe, when the aircrews were still in sickbay) there is of course a record of the resultant modification I approved and the urgent embodiment programme I initiated. Just a bit of minor detail.
Thanks tuc! Seems to me that caz's point re proof is a variable one. When "assertions" are made by Senior Air Officers without proof they are to be taken as gospel, but when "assertions" from others, such as yourself, are made against Senior Air Officers they are to be ignored. All are equal in the sight of RAF due process, but some are much more equal than others methinks!
Is breakfast finished yet?
Is breakfast finished yet?
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Chugalug2
The "Air Officers" put their names to the decisions they made and to the documents that support those decisions. Those Air Officers were the Chief of the Air Staff, the Air Officer Commanding in Chief Strike Command and the Air Officer Commanding No 1 Group. They supported the finding of negligence by the Officer Commanding RAF Odiham in respect of Flt Lt Tapper and extended that finding to Flt Lt Cook.
Who is tucumseh, what is his identifiable expertise and can he prove the authenticity of the statements he has made and provide the documentation to back it up?.
All I have seen is a great deal of assertion without any evidence. The warning on PPrune regarding people not being who they purport to be springs to mind. ( Before anyone leaps in to level that accusation against me - I am sure that Brian would confirm that he has had my details for the past 10 years).
He may well be genuine - but if he is then why is he feeding little pieces of information one at a time on this thread. If he genuinely believes that what he is posting is the unadulterated truth - that the crew and passengers of ZD 576 were needlessly sacrificed because of poor engineering management - then why has he not gone to the Civil Authorities (particularly the Police) and/or the media to expose the "cover-up" which he drip feeds to an audience on this thread which is willing to believe any statement which puts those who had the duty to adjudicate in this sorry tale in a bad light.
PS. Has anyone asked Lt K what was the turning point he planned on the Mull - the Lighthouse or the Landing site?
The "Air Officers" put their names to the decisions they made and to the documents that support those decisions. Those Air Officers were the Chief of the Air Staff, the Air Officer Commanding in Chief Strike Command and the Air Officer Commanding No 1 Group. They supported the finding of negligence by the Officer Commanding RAF Odiham in respect of Flt Lt Tapper and extended that finding to Flt Lt Cook.
Who is tucumseh, what is his identifiable expertise and can he prove the authenticity of the statements he has made and provide the documentation to back it up?.
All I have seen is a great deal of assertion without any evidence. The warning on PPrune regarding people not being who they purport to be springs to mind. ( Before anyone leaps in to level that accusation against me - I am sure that Brian would confirm that he has had my details for the past 10 years).
He may well be genuine - but if he is then why is he feeding little pieces of information one at a time on this thread. If he genuinely believes that what he is posting is the unadulterated truth - that the crew and passengers of ZD 576 were needlessly sacrificed because of poor engineering management - then why has he not gone to the Civil Authorities (particularly the Police) and/or the media to expose the "cover-up" which he drip feeds to an audience on this thread which is willing to believe any statement which puts those who had the duty to adjudicate in this sorry tale in a bad light.
PS. Has anyone asked Lt K what was the turning point he planned on the Mull - the Lighthouse or the Landing site?
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Pulse,
Like JP, Caz cannot answer any of the real questions on here, the questions are easy but the answers are hard to admit to, hence the politic we have to read from folk fearful of a proper debate.
Like JP, Caz cannot answer any of the real questions on here, the questions are easy but the answers are hard to admit to, hence the politic we have to read from folk fearful of a proper debate.
Caz
I’m sure you are aware that if anyone placed in the position I describe wishes to complain or bring it to the attention of higher authority, the process involved is one of escalation; not running to the Police or press.
That process has been followed, but is not yet exhausted. (We have recourse to the Cabinet Secretary). What I describe has been consistently ruled as admissible behaviour. Bear in mind that, until about 2003, the MoD rules permitted the “accused” to judge his own case. The rules changed but only in minor detail. Ones immediate line manager is not allowed to judge himself now, but if the order came from anywhere above that, they are still allowed. So, you have a ludicrous situation whereby a officer is permitted to say “Yes, I told him to (e.g. commit an offence), but I’m allowed to, even though the regs say I’m not” and that is accepted by the complete MoD hierarchy.
I have a different opinion, which I am entitled to. Pprune is not a court of law and I am under no obligation to provide anyone here with evidence. However, if I chose to, the burden of proof would be far less than that required when condemning the pilots. If MoD thought for one minute they could prove me wrong, then I’m sure they’d come knocking. They don’t, because the evidence I cite exists, and MoD has happily placed its rulings in writing. Yes, I express a certain frustration here, but I try to do it constructively by drawing the linkages to the cause of accidents, with a view to preventing it happening again. I also do it because people I knew have died. MoD doesn’t want to go there but, increasingly, they are being exposed in courts of law.
I must say I like your summary – “needlessly sacrificed because of poor engineering management”. Needlessly certainly, sacrificed is perhaps too strong, but poor engineering management is a simple statement of fact, reiterated and emphasised by recent Coroners’ rulings. However, I would say that the reputations of the pilots have been deliberately sacrificed, and in doing so those responsible have been exposed as cowards.
Talking of burden of proof, I read your post carefully and the emphasis seems to have changed somewhat. I find it interesting that CAS, CinC and AOC were merely "putting their names" to support the Odiham Staish that Tapper was negligent and then simply extended that to Cook! A new slant, but I admit I’m not overly familiar with the RAF process so perhaps others will confirm this is not rewriting history.
Regards
I’m sure you are aware that if anyone placed in the position I describe wishes to complain or bring it to the attention of higher authority, the process involved is one of escalation; not running to the Police or press.
That process has been followed, but is not yet exhausted. (We have recourse to the Cabinet Secretary). What I describe has been consistently ruled as admissible behaviour. Bear in mind that, until about 2003, the MoD rules permitted the “accused” to judge his own case. The rules changed but only in minor detail. Ones immediate line manager is not allowed to judge himself now, but if the order came from anywhere above that, they are still allowed. So, you have a ludicrous situation whereby a officer is permitted to say “Yes, I told him to (e.g. commit an offence), but I’m allowed to, even though the regs say I’m not” and that is accepted by the complete MoD hierarchy.
I have a different opinion, which I am entitled to. Pprune is not a court of law and I am under no obligation to provide anyone here with evidence. However, if I chose to, the burden of proof would be far less than that required when condemning the pilots. If MoD thought for one minute they could prove me wrong, then I’m sure they’d come knocking. They don’t, because the evidence I cite exists, and MoD has happily placed its rulings in writing. Yes, I express a certain frustration here, but I try to do it constructively by drawing the linkages to the cause of accidents, with a view to preventing it happening again. I also do it because people I knew have died. MoD doesn’t want to go there but, increasingly, they are being exposed in courts of law.
I must say I like your summary – “needlessly sacrificed because of poor engineering management”. Needlessly certainly, sacrificed is perhaps too strong, but poor engineering management is a simple statement of fact, reiterated and emphasised by recent Coroners’ rulings. However, I would say that the reputations of the pilots have been deliberately sacrificed, and in doing so those responsible have been exposed as cowards.
Talking of burden of proof, I read your post carefully and the emphasis seems to have changed somewhat. I find it interesting that CAS, CinC and AOC were merely "putting their names" to support the Odiham Staish that Tapper was negligent and then simply extended that to Cook! A new slant, but I admit I’m not overly familiar with the RAF process so perhaps others will confirm this is not rewriting history.
Regards
In all this to-ing and fro-ing as to what might have changed on the fleet since this incident a couple of thoughts occur to me.
We know for an absolute fact that the US undemanded departure from flight did take place and, thankfully, all lived to tell the tale. So......
Has it ever happened since in their fleet?
As there was no cause found, did they carry out any mods to the aircraft as a result to try and prevent further occurences?
If they did modify the aircraft were those mods flowed across the Atlantic to the RAF Fleet?
The US response to this may help answer the questions being asked by JP and others.
We know for an absolute fact that the US undemanded departure from flight did take place and, thankfully, all lived to tell the tale. So......
Has it ever happened since in their fleet?
As there was no cause found, did they carry out any mods to the aircraft as a result to try and prevent further occurences?
If they did modify the aircraft were those mods flowed across the Atlantic to the RAF Fleet?
The US response to this may help answer the questions being asked by JP and others.
cazatou:
I'm pleased to see that tucumseh has chosen to reply to your post about him, personally. Far better that he should rather than have others speak for him. Having said that I will now contradict that last statement by embarrassing him dreadfully! Tuc was already posting on this forum long before I started doing so. In particular he was contributing to the curiously named "parliamentary questions" thread re Hercules ESF of Nigegilb. I hope that he will forgive me if I say that I then found his posts heavy going, strewn as they were with the technical acronyms of the MOD. I found though that if one kept attempting to understand them they were dynamite, already pointing up the labyrinthine machinations that had prevented that essential protection in a vulnerable tactical transport for some 40 years. The fact that I had flown it in blissful ignorance of having lacked that protection (in the late 60's/early 70s) made me both angry at the waste of lives that it lead to and implicated in the ignorance that allowed those in the know to sit on it. I'm sure that nigegilb would agree that the eventual long fought for success of his campaign to get ESF fitted was greatly helped by tuc's revelations of how fitness for purpose and airworthiness were so heavily compromised by an MOD bent on cashing in its "Peace Dividends". As soon as one battle was won, the next commenced, ie the Nimrod Inquest. Again tuc revealed the reality behind the beguiling assurances of MOD statements. Again he was attacked on this forum by those whose philosophy appears to be "my system, right or wrong". Again the culpability of the airworthiness authority in not enforcing its own regulations was displayed and this time formally declared and admitted to. Again I doubt if the outcome would have been the same without tuc. So now we come to Mull. Again we are told that there are no airworthiness factors to this tragedy despite more apparent shortcomings than were first realised in the two previous threads. It is clear to me that a pattern has long since emerged, the common denominator of which is the deliberate unpicking of UK military airworthiness provision at the behest of senior air officers in order to placate their political masters' demands for more and more cutbacks. As tuc says this has already cost many lives and I fear will cost many more before things are put right. It is my belief that UK Military Airworthiness provision must be removed from the MOD ASAP and put in the charge of an independent Military Airworthiness Authority. Such a body will have its work cut out to arrest and reverse this scandalous state of affairs and we will see more avoidable accidents such as this one before it can succeed. All the more reason it should start without any unnecessary delay.
I'm pleased to see that tucumseh has chosen to reply to your post about him, personally. Far better that he should rather than have others speak for him. Having said that I will now contradict that last statement by embarrassing him dreadfully! Tuc was already posting on this forum long before I started doing so. In particular he was contributing to the curiously named "parliamentary questions" thread re Hercules ESF of Nigegilb. I hope that he will forgive me if I say that I then found his posts heavy going, strewn as they were with the technical acronyms of the MOD. I found though that if one kept attempting to understand them they were dynamite, already pointing up the labyrinthine machinations that had prevented that essential protection in a vulnerable tactical transport for some 40 years. The fact that I had flown it in blissful ignorance of having lacked that protection (in the late 60's/early 70s) made me both angry at the waste of lives that it lead to and implicated in the ignorance that allowed those in the know to sit on it. I'm sure that nigegilb would agree that the eventual long fought for success of his campaign to get ESF fitted was greatly helped by tuc's revelations of how fitness for purpose and airworthiness were so heavily compromised by an MOD bent on cashing in its "Peace Dividends". As soon as one battle was won, the next commenced, ie the Nimrod Inquest. Again tuc revealed the reality behind the beguiling assurances of MOD statements. Again he was attacked on this forum by those whose philosophy appears to be "my system, right or wrong". Again the culpability of the airworthiness authority in not enforcing its own regulations was displayed and this time formally declared and admitted to. Again I doubt if the outcome would have been the same without tuc. So now we come to Mull. Again we are told that there are no airworthiness factors to this tragedy despite more apparent shortcomings than were first realised in the two previous threads. It is clear to me that a pattern has long since emerged, the common denominator of which is the deliberate unpicking of UK military airworthiness provision at the behest of senior air officers in order to placate their political masters' demands for more and more cutbacks. As tuc says this has already cost many lives and I fear will cost many more before things are put right. It is my belief that UK Military Airworthiness provision must be removed from the MOD ASAP and put in the charge of an independent Military Airworthiness Authority. Such a body will have its work cut out to arrest and reverse this scandalous state of affairs and we will see more avoidable accidents such as this one before it can succeed. All the more reason it should start without any unnecessary delay.
Last edited by Chugalug2; 14th Mar 2009 at 13:04.
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Chug and Tuc
Well said.
I am now more 'pro' your idea of an independent mil AW body than I was - but I would also add a 'military branch' of the AAIB and do away with BOIs and SIs entirely. It would be fascinating to see if a modern investiagtion, using the complete data, evidence and statements, with more appropriate and thorough investigative practices would come to the same assessment of this accident? I doubt it.
Flip
ps IS the original BOI report available anywhere?
Well said.
I am now more 'pro' your idea of an independent mil AW body than I was - but I would also add a 'military branch' of the AAIB and do away with BOIs and SIs entirely. It would be fascinating to see if a modern investiagtion, using the complete data, evidence and statements, with more appropriate and thorough investigative practices would come to the same assessment of this accident? I doubt it.
Flip
ps IS the original BOI report available anywhere?
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UFCM
short&shapeless
Not a complete answer to your questions, but the following are references which are, or were, in the public domain:
House of Lords debates
Monday, 5 March 2001
The honourable Member for Tatton, in a debate in the other place on 27th June, reported that according to the Ministry of Defence there were 6 UFCMs involving Chinooks in 1994, five in 1995, six in 1996, five in 1997, seven in 1998 and six in 1999. That is 35 incidents in all, in six of which the cause was never found.
(This list is available in detail somewhere, but I cannot locate it at the moment - TheAerosco)
Written answers
Tuesday, 30 October 2001
The table lists the incidents of uncommanded flying control movements in Chinook helicopters since 1 January 1999 and their determined causes.
Uncommanded flying control movements in Chinook aircraft since 1999
Date Tail number Cause
1999
12 March ZA712 Faulty AFCS
17 March ZA718 Faulty DASH actuator and directional gyro
20 April ZD983 Directional gyro out of tolerance
29 April ZH775 Faulty AFCS and directional gyro
14 June ZA718 Faulty directional gyro
29 July ZA718 Faulty AFCS and directional gyro
29 October ZA711 Faulty directional gyro
18 November ZA711 Faulty directional gyro
2000
6 January ZA714 Faulty AFCS
6 January ZA718 Faulty AFCS
11 February ZA682 Faulty vertical gyro
4 April ZA682 Faulty DASH actuator gear assembly
5 April ZA679 Faulty DASH actuator
5 April ZA684 Faulty directional gyro connector
30 May ZA710 Faulty AFCS
24 July ZA679 Faulty AFCS and DASH actuator
5 August ZA674 Faulty cables to AFCS
9 November ZA671 Faulty vertical gyro
12 November ZA671 Faulty AFCS
2001
17 January ZH777 Units replaced following pitch oscillations
1 March ZA709 Faulty directional gyro
1 May ZA674 Faulty directional gyro
24 May ZA680 Faulty lower control actuators
5 July ZD981 Faulty attitude indicator
Extract from US Army "Flightfax" December 1998
A look at the issues
Uncommanded flight-control inputs
The May 1998 issue of Flightfax contained the
first-person accounts of the crew of a CH-47 that did a barrel roll. As a result of that
incident, Aviation Safety Action Message CH-47-98-ASAM-01 (151327Z Oct 98) requested
information from users on uncommanded control inputs. Input from users confirmed
that this was not the only incident of uncommanded flight-control input experienced
in the CH-47 community in the last several years.
According to the Analytical Investigation Branch
at Corpus Christi Army Depot, 21 activities
responded to the ASAM, reporting 27 AFCS/electrical malfunctions,
4 hydraulic-related malfunctions,
4 unknown causes,
and 3 suspected ice-and-water contamination incidents.
Following are some examples.
1. While in cruise flight at 10,000 feet msl and 126
KIAS, the aircraft experienced an uncommanded pitch
down of 20 to 25 degrees. When the PC applied aft
cyclic, the aircraft pitched up then down before the
PC regained control. The aircraft lost 500 to 1,000
feet of altitude during the sequence. When there
were no additional problems, the crew elected to
continue flight to their destination; they flew another
2 hours without further incident. It was later
determined that the incident was caused by failure of
the pitch axis portion of the AFCS. It is suspected
that, during the sequence, excessive control inputs
led to excessive flapping and lead-lag,
resulting in failure of the
shock-absorber mounts.
2. During flight-control check, the crew
experienced control binding, with the cyclic limited
to 4 inches forward movement and 1.5 inches lateral
movement. The crew chief stated that the forward
head was moving while the aft head was stationary.
Pressure was in normal ranges, and the problem
persisted for 5 minutes. The situation could not be
duplicated by maintenance, but an actuator problem
was suspected.
Update
Last year, a CH-47 miraculously returned to a
wheels-down attitude at 250 feet agl after rolling
360 degrees in flight. The Army Safety Center, the
CCAD Investigative Analysis Unit, AMCOM, and
Boeing continue to monitor and evaluate all CH-47
flight-control anomalies to determine the cause of
the incident. Following is a recap of ongoing actions:
1. AMCOM’s Systems Engineering Department
and CH-47 PEO/PM are currently preparing an ASAM
that addresses findings, recommendations, and
corrective actions developed to date.
2. A dehydrator will be issued in the near future
to remove contaminants from flight hydraulic
systems.
3. All chrome-plated aluminum end caps on
servo-cylinders will be removed and replaced with
chrome-plated stainless-steel end caps.
4. Several operational controls will be
implemented to enhance early detection of flight-
control lockup.
5. By-the-book maintenance is being emphasized.
For example, mechanics must ensure that all
hydraulic lines or components are capped and
plugged as soon they are disconnected; all
previously used or leftover hydraulic containers
must be disposed of; and all hydraulic components
received from the supply system must be drained
properly.
—MSG Ruben Burgos, Aviation Systems & Investigation Division,
DSN 558-3703 (334-255-3703),
Extract from US Army "Flightfax" October 2000
Uncommanded flight-control inputs:
This is an ongoing issue within the
community that has yet to be resolved. Investigations have
been conducted, but none have turned up conclusive evidence
of the cause of any of the reported incidents. ASAM
CH-47-97-ASAM-01 (151327Z Oct 97) and CH-47-99-ASAM-02
(161228Z Feb 99) have been issued to address suspected
causes, and to ensure the proper operation of the aircraft
systems. Units should comply with the published
messages, and conduct all maintenance procedures by
the book. If any flight control anomalies are experienced they
should be documented thoroughly and reported
through unit safety and maintenance channels.
Hydraulic System purification:
Historically the CH-47 flight control systems
have never been serviced or the filters changed unless there
was a maintenance problem requiring action. The fact that
the systems were never serviced was highlighted during
the investigations that tried to determine the cause of the
uncommanded flight-control inputs reported from the field.
CH-47-99-ASAM-02 (161228Z Feb 99) requires the
purification of all aircraft flight and utility systems, and
CH-47-00-ASAM-03 (012043Z Jun 00) details the sampling
and reporting procedures. This purification and reporting is
designed to: remove contaminantes (water,
particulates, air, solvents), improve system performance,
extend fluid life, and establish a baseline for future
investigations.
Not a complete answer to your questions, but the following are references which are, or were, in the public domain:
House of Lords debates
Monday, 5 March 2001
The honourable Member for Tatton, in a debate in the other place on 27th June, reported that according to the Ministry of Defence there were 6 UFCMs involving Chinooks in 1994, five in 1995, six in 1996, five in 1997, seven in 1998 and six in 1999. That is 35 incidents in all, in six of which the cause was never found.
(This list is available in detail somewhere, but I cannot locate it at the moment - TheAerosco)
Written answers
Tuesday, 30 October 2001
The table lists the incidents of uncommanded flying control movements in Chinook helicopters since 1 January 1999 and their determined causes.
Uncommanded flying control movements in Chinook aircraft since 1999
Date Tail number Cause
1999
12 March ZA712 Faulty AFCS
17 March ZA718 Faulty DASH actuator and directional gyro
20 April ZD983 Directional gyro out of tolerance
29 April ZH775 Faulty AFCS and directional gyro
14 June ZA718 Faulty directional gyro
29 July ZA718 Faulty AFCS and directional gyro
29 October ZA711 Faulty directional gyro
18 November ZA711 Faulty directional gyro
2000
6 January ZA714 Faulty AFCS
6 January ZA718 Faulty AFCS
11 February ZA682 Faulty vertical gyro
4 April ZA682 Faulty DASH actuator gear assembly
5 April ZA679 Faulty DASH actuator
5 April ZA684 Faulty directional gyro connector
30 May ZA710 Faulty AFCS
24 July ZA679 Faulty AFCS and DASH actuator
5 August ZA674 Faulty cables to AFCS
9 November ZA671 Faulty vertical gyro
12 November ZA671 Faulty AFCS
2001
17 January ZH777 Units replaced following pitch oscillations
1 March ZA709 Faulty directional gyro
1 May ZA674 Faulty directional gyro
24 May ZA680 Faulty lower control actuators
5 July ZD981 Faulty attitude indicator
Extract from US Army "Flightfax" December 1998
A look at the issues
Uncommanded flight-control inputs
The May 1998 issue of Flightfax contained the
first-person accounts of the crew of a CH-47 that did a barrel roll. As a result of that
incident, Aviation Safety Action Message CH-47-98-ASAM-01 (151327Z Oct 98) requested
information from users on uncommanded control inputs. Input from users confirmed
that this was not the only incident of uncommanded flight-control input experienced
in the CH-47 community in the last several years.
According to the Analytical Investigation Branch
at Corpus Christi Army Depot, 21 activities
responded to the ASAM, reporting 27 AFCS/electrical malfunctions,
4 hydraulic-related malfunctions,
4 unknown causes,
and 3 suspected ice-and-water contamination incidents.
Following are some examples.
1. While in cruise flight at 10,000 feet msl and 126
KIAS, the aircraft experienced an uncommanded pitch
down of 20 to 25 degrees. When the PC applied aft
cyclic, the aircraft pitched up then down before the
PC regained control. The aircraft lost 500 to 1,000
feet of altitude during the sequence. When there
were no additional problems, the crew elected to
continue flight to their destination; they flew another
2 hours without further incident. It was later
determined that the incident was caused by failure of
the pitch axis portion of the AFCS. It is suspected
that, during the sequence, excessive control inputs
led to excessive flapping and lead-lag,
resulting in failure of the
shock-absorber mounts.
2. During flight-control check, the crew
experienced control binding, with the cyclic limited
to 4 inches forward movement and 1.5 inches lateral
movement. The crew chief stated that the forward
head was moving while the aft head was stationary.
Pressure was in normal ranges, and the problem
persisted for 5 minutes. The situation could not be
duplicated by maintenance, but an actuator problem
was suspected.
Update
Last year, a CH-47 miraculously returned to a
wheels-down attitude at 250 feet agl after rolling
360 degrees in flight. The Army Safety Center, the
CCAD Investigative Analysis Unit, AMCOM, and
Boeing continue to monitor and evaluate all CH-47
flight-control anomalies to determine the cause of
the incident. Following is a recap of ongoing actions:
1. AMCOM’s Systems Engineering Department
and CH-47 PEO/PM are currently preparing an ASAM
that addresses findings, recommendations, and
corrective actions developed to date.
2. A dehydrator will be issued in the near future
to remove contaminants from flight hydraulic
systems.
3. All chrome-plated aluminum end caps on
servo-cylinders will be removed and replaced with
chrome-plated stainless-steel end caps.
4. Several operational controls will be
implemented to enhance early detection of flight-
control lockup.
5. By-the-book maintenance is being emphasized.
For example, mechanics must ensure that all
hydraulic lines or components are capped and
plugged as soon they are disconnected; all
previously used or leftover hydraulic containers
must be disposed of; and all hydraulic components
received from the supply system must be drained
properly.
—MSG Ruben Burgos, Aviation Systems & Investigation Division,
DSN 558-3703 (334-255-3703),
Extract from US Army "Flightfax" October 2000
Uncommanded flight-control inputs:
This is an ongoing issue within the
community that has yet to be resolved. Investigations have
been conducted, but none have turned up conclusive evidence
of the cause of any of the reported incidents. ASAM
CH-47-97-ASAM-01 (151327Z Oct 97) and CH-47-99-ASAM-02
(161228Z Feb 99) have been issued to address suspected
causes, and to ensure the proper operation of the aircraft
systems. Units should comply with the published
messages, and conduct all maintenance procedures by
the book. If any flight control anomalies are experienced they
should be documented thoroughly and reported
through unit safety and maintenance channels.
Hydraulic System purification:
Historically the CH-47 flight control systems
have never been serviced or the filters changed unless there
was a maintenance problem requiring action. The fact that
the systems were never serviced was highlighted during
the investigations that tried to determine the cause of the
uncommanded flight-control inputs reported from the field.
CH-47-99-ASAM-02 (161228Z Feb 99) requires the
purification of all aircraft flight and utility systems, and
CH-47-00-ASAM-03 (012043Z Jun 00) details the sampling
and reporting procedures. This purification and reporting is
designed to: remove contaminantes (water,
particulates, air, solvents), improve system performance,
extend fluid life, and establish a baseline for future
investigations.
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Pulse 1
Apologies fo the delay.
Yes, I believe that Sqn Ldr Burke believed 100% that the evidence he gave was accurate.
That does not mean that it was correct or had any bearing on the crash of ZD576; as anybody who has had to sift through conflicting witness statements regarding an incident or accident (Military or Civil) will confirm.
Apologies fo the delay.
Yes, I believe that Sqn Ldr Burke believed 100% that the evidence he gave was accurate.
That does not mean that it was correct or had any bearing on the crash of ZD576; as anybody who has had to sift through conflicting witness statements regarding an incident or accident (Military or Civil) will confirm.
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Caz
As an impartial but interested observer (retired from a different fleet), I don't really understand why you and so many others, are so blinkered to the possibility that the 'official view' (both then and now) does not meet the burden of proof required to tarnish for ever the name of Flt Lts Tapper and Cook. I think the time has come to move on; why cannot you and the others (and the Gov't) see that? What drives you to such stubborness?
In the first instance, you persist with the notion that not having breakfast indicates that Flt Lt Tapper was a persistant breaker of GASOs ASIs etc and, even if this was the case, this does not PROVE that he was negligent in flying that particular sortie, nor does it prove how it was flown. I cannot see there to be a credible link here; it sounds as if you are clutching at straws a little. Perhaps it is time to put that one to bed?
Additionally, you and others dismiss entirely the possibility, however unlikely, of a number of potential aggravating factors - admittedly they are difficult to prove but they also difficult to disprove. It has been pointed out that neither you, nor anyone else alive, really knows what happened that day. Ergo, one fails to see how the burden of proof for gross negligence is satisfied.
For example, you dismiss out of hand the observations of S/L Burke - what gives you the right so to do? It seems as if he could be an expert witness to whom we all should listen? Why do you think his evidence/opinion should be totally discounted?
Also, you are sceptical of assertions of Tucumseh (whom I know to be highly knowledgable in the fields of airworthiness and procurement) that:
a. If the ac was being operated in such a way as described (a local engineering instruction to carry out a maintenance procedure in the air, by non-engineers - to check the integrity of the DECU connectors every 15 mins), then de facto, the ac was not airworthy - as mandated and defined by JSP 553 and a whole host of Def Stans.
b. If the MoD cannot disprove this (which it seems impossible to do), then a cold audit trail in the Safety Cases and Hazard Logs etc at the IPT is a smoking gun that points directly to the MoD failing to maintain the build standard/airworthiness of the ac. If the ac was serviceable but not actually airworthy however, it doesn't actually make the MoD totally blameworthy but it surely absolves the crew to absolute guilt?
Furthermore, as a fairly seasoned operator at LL in the hills of Scotland, I fail to see how just because you cannot see the hill tops, you are somehow negligent by maintaining 'VMC below'. It is also apparent that there is some confusion as to how bad was the actual weather at the time. I suggest this undermines somewhat your 'black and white' approach to "could he or could he not see the Mull?" Again, no-one is ever going to be sure what was visible out of the office window or why he manoeuvred as he did. Who knows if the pilot wasn't distracted by a fly, an itch, something in his eye, a minor cockpit indication, or even a transitory engine malfunction at this time? We JUST DON'T KNOW for sure.
It is also apparent that there is some confusion as to the speed and ROC of the ac as the crew penetrated cloud, as they eventually did do - even Boeing's best guess seems like a stab in the dark. Helos do not zoom climb like jets, as you well know - but this is a fact that may have been lost on some? That is even before the possibilities of engine/control trouble. I find it strange, if not astounding, to note that the assertion that the E5 fault had no relevance. Unfortunately, I am not qualified to say for sure - other than to say that if this was found to have been indicated as relevant in another ac incident, then it would be a brave or foolish person to totally discount the possibility of the fault having some bearing on this accident.
Ultimately, I appreciate that back in the 1990s, it was more likely that QR1269 etc would rear its ugly head. But when we look back now, it is incredible to believe that some people cannot see that the findings of the senior officers might have been flawed, even if they might have been understandable at the time from their POV. Fortunately, we have evolved since then, have we not? Professor Reason's swiss cheese theory is widely accepted everywhere - even in the military where it is often quoted in FS training courses. While the crew may have made a slip, a lapse or even an error of judgement, it is very hard to argue that they definitely made a negligent violation - given the information available to the senior officers even then. Its not like they flew upside down under a bridge in the full view of CinCStrike?
I cannot believe that in hindsight, one is not able to see the 'big holes in the slices of cheese' that failed to protect Flt Lts Tapper and Cook from perhaps the most human of errors. If you search through modern investigative checklists - there are a whole host of possible influences that were not, in all probability, covered by the BOI; most probably for the simple fact that they were neither instructed nor expected to follow such lines of inquiry. Even these days, the instructions/TORs given to BOI/SIs come from the very people who might have a bearing on the organisational factors surrounding the case ie the AOC. (That is one reason why I believe the days of BOIs/SIs are numbered; they just don't reflect current 'best practice'.)
In those days, some people may have felt comfortable with findings of gross negligence (strangely the BOI itself did not) but I would hope that such people can now see that this is certainly no longer 'best practice' and in almost every case known to aviation, it is not acceptable to blame solely the 'local causes'; the organisation always has its own part to play. Sadly, this was outside the remit of the BOI in 1994. In fact, blame is no longer to the aim of modern investigations - it is to prevent recurrence. A distinction apparently lost to some.
Almost 15 years has passed and it is now time to right the wrongs of history, the families of the crew and of those who perished deserve their peace. Messrs Crawford, Day and Wratten did what they thought was right.....as seemed acceptable in those days. I don't blame them. Now, however, I would like to think that men of such intellect can see that their perspective was based on an out-dated methodology and logic, which is no longer credible. I doubt if anyone wants protracted legal/parliamentary debates; just the acceptance that, in hindsight, no-one will ever know for certain what happened that day and it is meet and right to let the ghosts of Mull sleep easy by dropping the claims that the crew were grossly negligent.
Flipster
As an impartial but interested observer (retired from a different fleet), I don't really understand why you and so many others, are so blinkered to the possibility that the 'official view' (both then and now) does not meet the burden of proof required to tarnish for ever the name of Flt Lts Tapper and Cook. I think the time has come to move on; why cannot you and the others (and the Gov't) see that? What drives you to such stubborness?
In the first instance, you persist with the notion that not having breakfast indicates that Flt Lt Tapper was a persistant breaker of GASOs ASIs etc and, even if this was the case, this does not PROVE that he was negligent in flying that particular sortie, nor does it prove how it was flown. I cannot see there to be a credible link here; it sounds as if you are clutching at straws a little. Perhaps it is time to put that one to bed?
Additionally, you and others dismiss entirely the possibility, however unlikely, of a number of potential aggravating factors - admittedly they are difficult to prove but they also difficult to disprove. It has been pointed out that neither you, nor anyone else alive, really knows what happened that day. Ergo, one fails to see how the burden of proof for gross negligence is satisfied.
For example, you dismiss out of hand the observations of S/L Burke - what gives you the right so to do? It seems as if he could be an expert witness to whom we all should listen? Why do you think his evidence/opinion should be totally discounted?
Also, you are sceptical of assertions of Tucumseh (whom I know to be highly knowledgable in the fields of airworthiness and procurement) that:
a. If the ac was being operated in such a way as described (a local engineering instruction to carry out a maintenance procedure in the air, by non-engineers - to check the integrity of the DECU connectors every 15 mins), then de facto, the ac was not airworthy - as mandated and defined by JSP 553 and a whole host of Def Stans.
b. If the MoD cannot disprove this (which it seems impossible to do), then a cold audit trail in the Safety Cases and Hazard Logs etc at the IPT is a smoking gun that points directly to the MoD failing to maintain the build standard/airworthiness of the ac. If the ac was serviceable but not actually airworthy however, it doesn't actually make the MoD totally blameworthy but it surely absolves the crew to absolute guilt?
Furthermore, as a fairly seasoned operator at LL in the hills of Scotland, I fail to see how just because you cannot see the hill tops, you are somehow negligent by maintaining 'VMC below'. It is also apparent that there is some confusion as to how bad was the actual weather at the time. I suggest this undermines somewhat your 'black and white' approach to "could he or could he not see the Mull?" Again, no-one is ever going to be sure what was visible out of the office window or why he manoeuvred as he did. Who knows if the pilot wasn't distracted by a fly, an itch, something in his eye, a minor cockpit indication, or even a transitory engine malfunction at this time? We JUST DON'T KNOW for sure.
It is also apparent that there is some confusion as to the speed and ROC of the ac as the crew penetrated cloud, as they eventually did do - even Boeing's best guess seems like a stab in the dark. Helos do not zoom climb like jets, as you well know - but this is a fact that may have been lost on some? That is even before the possibilities of engine/control trouble. I find it strange, if not astounding, to note that the assertion that the E5 fault had no relevance. Unfortunately, I am not qualified to say for sure - other than to say that if this was found to have been indicated as relevant in another ac incident, then it would be a brave or foolish person to totally discount the possibility of the fault having some bearing on this accident.
Ultimately, I appreciate that back in the 1990s, it was more likely that QR1269 etc would rear its ugly head. But when we look back now, it is incredible to believe that some people cannot see that the findings of the senior officers might have been flawed, even if they might have been understandable at the time from their POV. Fortunately, we have evolved since then, have we not? Professor Reason's swiss cheese theory is widely accepted everywhere - even in the military where it is often quoted in FS training courses. While the crew may have made a slip, a lapse or even an error of judgement, it is very hard to argue that they definitely made a negligent violation - given the information available to the senior officers even then. Its not like they flew upside down under a bridge in the full view of CinCStrike?
I cannot believe that in hindsight, one is not able to see the 'big holes in the slices of cheese' that failed to protect Flt Lts Tapper and Cook from perhaps the most human of errors. If you search through modern investigative checklists - there are a whole host of possible influences that were not, in all probability, covered by the BOI; most probably for the simple fact that they were neither instructed nor expected to follow such lines of inquiry. Even these days, the instructions/TORs given to BOI/SIs come from the very people who might have a bearing on the organisational factors surrounding the case ie the AOC. (That is one reason why I believe the days of BOIs/SIs are numbered; they just don't reflect current 'best practice'.)
In those days, some people may have felt comfortable with findings of gross negligence (strangely the BOI itself did not) but I would hope that such people can now see that this is certainly no longer 'best practice' and in almost every case known to aviation, it is not acceptable to blame solely the 'local causes'; the organisation always has its own part to play. Sadly, this was outside the remit of the BOI in 1994. In fact, blame is no longer to the aim of modern investigations - it is to prevent recurrence. A distinction apparently lost to some.
Almost 15 years has passed and it is now time to right the wrongs of history, the families of the crew and of those who perished deserve their peace. Messrs Crawford, Day and Wratten did what they thought was right.....as seemed acceptable in those days. I don't blame them. Now, however, I would like to think that men of such intellect can see that their perspective was based on an out-dated methodology and logic, which is no longer credible. I doubt if anyone wants protracted legal/parliamentary debates; just the acceptance that, in hindsight, no-one will ever know for certain what happened that day and it is meet and right to let the ghosts of Mull sleep easy by dropping the claims that the crew were grossly negligent.
Flipster