Chinook - Still Hitting Back 3 (Merged)
Join Date: Sep 2006
Location: NZ
Posts: 308
Likes: 0
Received 0 Likes
on
0 Posts
And to maintain this thread in the complete nonsense it has degenerated into over recent posts; Please do not forget prawn voluvents were served in flight (true) but did both pilots eat the same thing at the same time;? and did this contribute to the incident? For goodness sake please get this thread back onto line and away from this complete rubbish being posted at present!
Join Date: Jul 2002
Location: UK Sometimes
Posts: 1,062
Likes: 0
Received 0 Likes
on
0 Posts
Caz,
In the light of Jayteeto's comments, I really think you should drop the alledged lack of crew breakfast argument - once and for all; to persist would do you no credit.
I note that few 'cognoscenti' seem to have any views on the other points I rasied in post 4109. I freely admit that I may have the wrong end of stick but the stony silence, in itself, speaks volumes. Please enlighten me.
flipster
In the light of Jayteeto's comments, I really think you should drop the alledged lack of crew breakfast argument - once and for all; to persist would do you no credit.
I note that few 'cognoscenti' seem to have any views on the other points I rasied in post 4109. I freely admit that I may have the wrong end of stick but the stony silence, in itself, speaks volumes. Please enlighten me.
flipster
Join Date: Oct 1999
Location: Bedfordshire
Posts: 243
Likes: 0
Received 0 Likes
on
0 Posts
Boslandew
Far from petty points scoring, we now have positive evidence (from Jayteeto) that breakfast was eaten by the crew, thus putting to bed the rather lame notion that the crew was already negligent by having not eaten it.
Perhaps we could now fast forward to the issue of whether or not the crew was negligent to have continued towards the cloud-covered Mull, despite, according to the yachtsman, being in perfectly acceptable VMC over the Sea. JP seems unwilling to discuss this but it is something central to the argument of Messrs Wratten and Day that the crew was grossly negiligent.
Of course, 1 nm would be a bit too close for a fast jet pilot (like AM Wratten) to make a decision to turn up the coast at 420 kts+, but what about in a Chinook at 150 kts G/S?
Far from petty points scoring, we now have positive evidence (from Jayteeto) that breakfast was eaten by the crew, thus putting to bed the rather lame notion that the crew was already negligent by having not eaten it.
Perhaps we could now fast forward to the issue of whether or not the crew was negligent to have continued towards the cloud-covered Mull, despite, according to the yachtsman, being in perfectly acceptable VMC over the Sea. JP seems unwilling to discuss this but it is something central to the argument of Messrs Wratten and Day that the crew was grossly negiligent.
Of course, 1 nm would be a bit too close for a fast jet pilot (like AM Wratten) to make a decision to turn up the coast at 420 kts+, but what about in a Chinook at 150 kts G/S?
Join Date: Mar 2009
Location: London
Posts: 79
Likes: 0
Received 0 Likes
on
0 Posts
VMC or IMC
This is my first day and just registered! Looking round the site I was surprised to see this thread running at full speed after all this time. That said, I was in MOD at the time of the BOI and met the President on several occasions. Most of what we discussed must remain priviledged, but I recall several points that have subsequently been blurred by press and political comment - albeit well intentioned. Equally, several external issues have become involved in the search for the Holy Grail - why did the aircraft crash?
Yes lets get back to basics. 100% of aircraft accidents have a root cause, in this case the aircraft entered IMC below safety height and flew under control into the ground - now termed a CFIT accident. RAF pilots are trained from day one of the dangers of flight in IMC, and the action to be taken in the event that one enters IMC below safety height - climb to safety height. In this case there was no evidence that the aircraft was climbing when it hit the ground - the contrary - the Captain had failed in his primary duty. But humans are fallible, and the duty of the second pilot - or executive vice president as he is sometimes called, is to act as the safety checker and alert the captain to dangerous situations, or in extremis, to take control to ensure the safety of the aircraft. This did not happen. Two major errors of judgement by experienced pilots.
There are many other matters, secondary causes, which can be almost anything ... lack of supervision, inadequate briefing, faulty weather data, technical problems, medical, difficulties at home, even as we have heard lately - gambling debts, but none in themselves cause the aircraft to fly into the ground. This is something that people who have not spent a life flying, or indeed investigating accidents as I have, seem to fail to grasp.
There have been many CFIT accidents in the past, in fact I think a Vulcan was lost in similar circumstances on the Scottish Low Flying route many years before this incident. Sadly, CFIT accidents continue in both military and civil flying.
Final point. I remember that in the early days of the Lightning, a pilot was lost when he became disorientated over the North Sea. It emerged he had not had breakfast or lunch, and it was determined that this was possible secondary cause of the accident. A result was that the Flight Safety organisation produced a series of large posters proclaiming "High Performance needs Energy" (I think - or maybe Food!). Subsequently, the V Force Aircrew Buffets spread to other stations, and finance was made available for the crew room snacks that have been mentioned earlier.
Yes lets get back to basics. 100% of aircraft accidents have a root cause, in this case the aircraft entered IMC below safety height and flew under control into the ground - now termed a CFIT accident. RAF pilots are trained from day one of the dangers of flight in IMC, and the action to be taken in the event that one enters IMC below safety height - climb to safety height. In this case there was no evidence that the aircraft was climbing when it hit the ground - the contrary - the Captain had failed in his primary duty. But humans are fallible, and the duty of the second pilot - or executive vice president as he is sometimes called, is to act as the safety checker and alert the captain to dangerous situations, or in extremis, to take control to ensure the safety of the aircraft. This did not happen. Two major errors of judgement by experienced pilots.
There are many other matters, secondary causes, which can be almost anything ... lack of supervision, inadequate briefing, faulty weather data, technical problems, medical, difficulties at home, even as we have heard lately - gambling debts, but none in themselves cause the aircraft to fly into the ground. This is something that people who have not spent a life flying, or indeed investigating accidents as I have, seem to fail to grasp.
There have been many CFIT accidents in the past, in fact I think a Vulcan was lost in similar circumstances on the Scottish Low Flying route many years before this incident. Sadly, CFIT accidents continue in both military and civil flying.
Final point. I remember that in the early days of the Lightning, a pilot was lost when he became disorientated over the North Sea. It emerged he had not had breakfast or lunch, and it was determined that this was possible secondary cause of the accident. A result was that the Flight Safety organisation produced a series of large posters proclaiming "High Performance needs Energy" (I think - or maybe Food!). Subsequently, the V Force Aircrew Buffets spread to other stations, and finance was made available for the crew room snacks that have been mentioned earlier.
Join Date: Feb 2007
Location: Oxon
Age: 66
Posts: 1,942
Likes: 0
Received 0 Likes
on
0 Posts
VictorPilot,
Welcome to the debate, not sure quite how you arrive at
"in this case the aircraft entered IMC below safety height and flew under control into the ground - now termed a CFIT accident" without resorting to a little bit of supposition however just a quick question,
Is there anyone alive today who actually knows exactly what happened on that fateful day?
Welcome to the debate, not sure quite how you arrive at
"in this case the aircraft entered IMC below safety height and flew under control into the ground - now termed a CFIT accident" without resorting to a little bit of supposition however just a quick question,
Is there anyone alive today who actually knows exactly what happened on that fateful day?
Join Date: Apr 2005
Location: France 46
Age: 77
Posts: 1,743
Likes: 0
Received 0 Likes
on
0 Posts
VictorPilot
Welcome to the thread - I trust you have a thick skin.
flipster & meadowbank
jayteeto stated:
"The crew sat & ate those rations before the very flight. At the same table I sat on, so I can confirm that they did eat."
As the "Computer Weekly" article revealed exactly what Flt Lt Cook and the ALM's had for breakfast in their respective Messes that morning (whilst Flt Lt Tapper was at Met) and that jayteeto uses the phrase "before the very flight"; I put it to you that he is referring to what happened in the Afternoon before the fatal sortie.
Perhaps jayteeto could clarify so as enlighten us as to what they ate and at what time of day?
Welcome to the thread - I trust you have a thick skin.
flipster & meadowbank
jayteeto stated:
"The crew sat & ate those rations before the very flight. At the same table I sat on, so I can confirm that they did eat."
As the "Computer Weekly" article revealed exactly what Flt Lt Cook and the ALM's had for breakfast in their respective Messes that morning (whilst Flt Lt Tapper was at Met) and that jayteeto uses the phrase "before the very flight"; I put it to you that he is referring to what happened in the Afternoon before the fatal sortie.
Perhaps jayteeto could clarify so as enlighten us as to what they ate and at what time of day?
Join Date: May 2002
Location: On the keyboard
Posts: 73
Likes: 0
Received 0 Likes
on
0 Posts
VMC or IMC
VictorPilot,
As a newcomer to this intensely active thread, may I suggest that before you make any further comments besmirching the memories of dead aircrew, you at least take the trouble to read all of the previous posts? If you do, you will see that there are clear reasons to suspect that this aircraft may (I put it no more strongly) not have been under control either at, or even for some time before, the point of impact.
Without firm EVIDENCE (not mere supposition) that it was indeed under control, there is not the slightest justification for the damning finding of gross negligence.
Considered comments will, I'm sure, always be welcomed by readers of this thread. Shooting from the hip by a newcomer is not.
As a newcomer to this intensely active thread, may I suggest that before you make any further comments besmirching the memories of dead aircrew, you at least take the trouble to read all of the previous posts? If you do, you will see that there are clear reasons to suspect that this aircraft may (I put it no more strongly) not have been under control either at, or even for some time before, the point of impact.
Without firm EVIDENCE (not mere supposition) that it was indeed under control, there is not the slightest justification for the damning finding of gross negligence.
Considered comments will, I'm sure, always be welcomed by readers of this thread. Shooting from the hip by a newcomer is not.
Join Date: Feb 2007
Location: Oxon
Age: 66
Posts: 1,942
Likes: 0
Received 0 Likes
on
0 Posts
Caz,
I take that ,in light of Jayteeto's rather revealing post, when you posted this on the 9th March in post # 4038 you had used assumption rather that actual hard evidence and were therefore factually incorrect.
"I was merely quoting the BOI regarding catering. They concluded that the crew would have eaten only a few biscuits during the first sortie. There was no record of Flt Lt Tapper having breakfast and no crew meals were ordered for either sortie.
Thus, when they departed on that final sortie, the Co pilot and ALM's had not had a meal for some 10 hours and the Captain for some 22 hours."
In light of that rather glaring and obviously ill informed error do you now not wonder if maybe your interpretation of the BOI might well suffer from other similar basic flaws?
I take that ,in light of Jayteeto's rather revealing post, when you posted this on the 9th March in post # 4038 you had used assumption rather that actual hard evidence and were therefore factually incorrect.
"I was merely quoting the BOI regarding catering. They concluded that the crew would have eaten only a few biscuits during the first sortie. There was no record of Flt Lt Tapper having breakfast and no crew meals were ordered for either sortie.
Thus, when they departed on that final sortie, the Co pilot and ALM's had not had a meal for some 10 hours and the Captain for some 22 hours."
In light of that rather glaring and obviously ill informed error do you now not wonder if maybe your interpretation of the BOI might well suffer from other similar basic flaws?
Join Date: Dec 2007
Location: england
Posts: 613
Likes: 0
Received 0 Likes
on
0 Posts
Victor P, welcome. As you say, CFIT is one of those things that has happened since the dawn of aviation. Can you recollect any other UK military CFIT where the pilot(s) were found to be grossly negligent?
Join Date: Aug 2006
Location: BATH
Posts: 375
Likes: 0
Received 0 Likes
on
0 Posts
Chinook
VictorPilot. Well said. There are too many folk on this thread who are determined to divert attention from the basic fact that this crew flew at high speed and low level, well below any safety altitude, towards and then into hills that were clearly IMC, and failed to turn away. For example, a recent Post suggested that perhaps a fly in the cockpit, or that the crew (both pilots?) suffered an itch, and that this might have caused /contibuted to the crash.
Perhaps it would help if experieced pilots (and I am one), rather than general S***-stirrers, made their background clear?
Do come off it some of you!! With all best wishes to those who look objectively at the facts, JP.
Perhaps it would help if experieced pilots (and I am one), rather than general S***-stirrers, made their background clear?
Do come off it some of you!! With all best wishes to those who look objectively at the facts, JP.
Join Date: Dec 2007
Location: england
Posts: 613
Likes: 0
Received 0 Likes
on
0 Posts
JP, you may well be right. My personal problem is trying to reconcile how other CFIT incidents, with far more credible and indisputable evidence, were not categorised as grossly negligent.
VictorPilot:
I'll give you your due VP. Most maiden/low posters who give us the benefit of their certain knowledge of the answer to your rhetorical question do not identify themselves as MOD staff/air officers at the time, leaving us to deduce that for ourselves. You man up from the outset and own up to that dubious qualification. Why dubious? As SFFP reminds us NO-ONE knows for sure what happened or why, not you, nor me nor even Messrs Wratten and Day. What we do know now though is that a deliberate and sustained policy of neglect (not even benign) of the mandated duty to enforce the UK Military Airworthiness Regulations was being enforced from 4* level downwards, affecting every military airfleet including the RAF Chinook HC-Mk2's. That an institution that so flagrantly reneged on its own responsibilities has the effrontery to so unjustly enforce the arbitrary findings of two Air Marshals with no real proof and contrary to other more respected national institutions' own findings is par for the course for this discredited organisation that so cries out for reform. That reform must start with the removal of airworthiness regulation to a seperate and independent MAA.
why did the aircraft crash?
Join Date: Apr 2005
Location: France 46
Age: 77
Posts: 1,743
Likes: 0
Received 0 Likes
on
0 Posts
Shy Torque
The answer is in the post that you attempt to denigrate - a trait that is more apparent with each of your posts.
The Flight Deck crew of ZD576 (as opposed to the cabin crew who were engaged in ensuring the safety and comfort of the passengers) had the prime duty of ensuring the safe conduct of the flight.
The BOI concluded that the Captain had failed in that duty - the Reviewing Officers agreed and extended that failure to the Co-Pilot (and incoming Detatchment Commander). Those Reviewing Officers were AOC 1 Gp; AOC in C STC and (Exceptionally - because of the media interest) CAS.
I accept that you disagree with that decision in regard of the 2 Pilots BUT we have now had (I believe) some 5 different Chiefs of the Air Staff who have reviewed this tragedy and all have reached the same conclusion.
You have highlighted several areas where you believe shortcomings were evident - may I ask how many incident reports you raised in this respect and whether you raised or reported your concerns throuh Official Channels. We all have (in my case had) a duty to notify our superiors of unsafe or dangerous procedures and practices.
Equally - we all had a duty to abide by the rules and regulations promulgated by those in authority over us.
Perhaps you may wish to consider whether early action by yourself, and your compatriots who agreed with you, may have prevented such a tragedy. You were, after all, the people who were operating the aircraft.
The answer is in the post that you attempt to denigrate - a trait that is more apparent with each of your posts.
The Flight Deck crew of ZD576 (as opposed to the cabin crew who were engaged in ensuring the safety and comfort of the passengers) had the prime duty of ensuring the safe conduct of the flight.
The BOI concluded that the Captain had failed in that duty - the Reviewing Officers agreed and extended that failure to the Co-Pilot (and incoming Detatchment Commander). Those Reviewing Officers were AOC 1 Gp; AOC in C STC and (Exceptionally - because of the media interest) CAS.
I accept that you disagree with that decision in regard of the 2 Pilots BUT we have now had (I believe) some 5 different Chiefs of the Air Staff who have reviewed this tragedy and all have reached the same conclusion.
You have highlighted several areas where you believe shortcomings were evident - may I ask how many incident reports you raised in this respect and whether you raised or reported your concerns throuh Official Channels. We all have (in my case had) a duty to notify our superiors of unsafe or dangerous procedures and practices.
Equally - we all had a duty to abide by the rules and regulations promulgated by those in authority over us.
Perhaps you may wish to consider whether early action by yourself, and your compatriots who agreed with you, may have prevented such a tragedy. You were, after all, the people who were operating the aircraft.
We all have (in my case had) a duty to notify our superiors of unsafe or dangerous procedures and practices.
Equally - we all had a duty to abide by the rules and regulations promulgated by those in authority over us.
Equally - we all had a duty to abide by the rules and regulations promulgated by those in authority over us.
As someone who held airworthiness delegation at the time, I can demonstrate beyond any doubt whatsoever that I fulfilled my duty by notifying my superiors (e.g. in the years immediately preceding Mull, an RAF 2 Star) of unsafe AND dangerous practices that compromised my/our ability to comply with the regulatory requirement to maintain airworthiness. Primarily, the ruling that anyone disobeying an order to ignore airworthiness was guilty of an offence. You must ask these senior staffs, who to this day stand by their rulings (not unlike Wratten and Day), why they disagree so violently with the regulations they are bound by. I just wish they would read the accompanying regulations which state they must resign if they cannot bring themselves to abide by their employer’s policy.
I chose to meet my duty to abide by the rules and regulations, in doing so disobeying direct orders. I know others chose to obey the order when they saw what would happen to them. That is why some aircraft and equipment have a more robust airworthiness audit trail than others. The Chinook Mk2 is one of least robust (along with Nimrod MR2 and C130, as ruled by two Coroners and agreed by SoS). As the same regs apply to all aircraft and equipment, and all form part of the same chain of delegation, it is impossible for anyone to ignore the statement of ACM Sir Clive Loader that MoD failed to implement their own regs, over a long period of time. 39 years according to the Oxford Coroner in he case of Nimrod – again accepted by Min(AF). Must I point out, again, that Nimrod and Chinook came under the same 2 Star, so it is not unreasonable to assume each were subjected to the same management (mal)practices? As confirmed by the NAO and HCDC.
What I describe is a failure of duty of care amounting to gross negligence; negligence that had already occurred long before ZD576 took off that day.
Seldomfit....
I have said it before on this thread, and I will say it again. there are only two beings on this planet that know "without any doubt whatsoever" what occurred in the final stages of that fateful flight: Day and Wratten.
The rest of us, less arrogant, mere mortals may only surmise!
I have said it before on this thread, and I will say it again. there are only two beings on this planet that know "without any doubt whatsoever" what occurred in the final stages of that fateful flight: Day and Wratten.
The rest of us, less arrogant, mere mortals may only surmise!
Join Date: Oct 2001
Location: Berkshire
Posts: 51
Likes: 0
Received 0 Likes
on
0 Posts
VictorPilot. Well said. There are too many folk on this thread who are determined to divert attention from the basic fact that this crew flew at high speed and low level, well below any safety altitude, towards and then into hills that were clearly IMC, and failed to turn away.
Apologies, but trying to look objectively, I see no factual evidence to suggest that they were flying at anything other than a normal cruising speed (rather than high speed) up to waypoint change nor any evidence that they were heading toward the hills at this point i.e that they had not turned away.
There's a lot to wade through so maybe I have missed something, in which case please could you clarify? Thanks.
The Aerosco
Avoid imitations
Join Date: Nov 2000
Location: Wandering the FIR and cyberspace often at highly unsociable times
Posts: 14,573
Received 419 Likes
on
221 Posts
Cazatou,
The answer to what? Is it a reply to something I posted? My last contribution was almost two weeks ago and it wasn't a question, but a reply.
Have you eaten breakfast today?
The answer is in the post that you attempt to denigrate - a trait that is more apparent with each of your posts.
Have you eaten breakfast today?
Join Date: Feb 2007
Location: Oxon
Age: 66
Posts: 1,942
Likes: 0
Received 0 Likes
on
0 Posts
Shy,
I am certain that the ludicrous rations suggestion is now well and truly dead and buried, never to raise it's silly billy head again.
As for you getting an answer, well I guess you are going to have to stop asking difficult questions of the chap in question
I am certain that the ludicrous rations suggestion is now well and truly dead and buried, never to raise it's silly billy head again.
As for you getting an answer, well I guess you are going to have to stop asking difficult questions of the chap in question
Join Date: Jul 2002
Location: UK Sometimes
Posts: 1,062
Likes: 0
Received 0 Likes
on
0 Posts
Lurking123 is correct to point out that other CFIT accidents did not draw the same responses by staff officers as those produced by Wratten and Day after the Mull crash. For example, Hercules XV193, also from Strike Command, crashed in Scotland in 1993. The BOI could not be sure of the cause as there was no CVR/ADR, nor witnesses to crash itself; any findings were 'conjecture' (MoD's words, not mine). This was a similar scenario to that of ZD576 but the crew of the Herc were, quite rightly, not found to be grossly negligent. However, Tapper and Cook were treated differently....why was this? Why was precedent ignored?
VP
You are quite correct to point out that the immediate root cause of the crash of ZD576 was that they crashed into a hill. However, I think you'll find that the concept of a single 'root cause analysis' is an outdated one.
In many accidents, there are local 'active' failures but also organisational 'latent' errors; this is called the Reason Model and is widely used and forms part of ICAO Annex 13.
Tuc rightly draws our attention to the possible 'latent' failures in the defences and safeguards of the organisation (ie the holes in the layers of swiss cheese). It is certainly possible (Tuc would say probable) that the MoD failed to maintain Airworthiness in the Chinook at this time (local engineering instructions to be performed in the air). This has been shown and admitted to by the MoD in the Nimrod XV230 enquiry - the same Senior Officer that looked after Chinook and the Hercules. One could even argue that airworthiness and possible FADEC failure/glitches are only one of a number other possible latent failures, which were not fully investigated at the time - because the AOC said so and because it was common practice). Instead, the BOI directed their attention to the local 'active' failings by the crew on that day (ie they unintentionally flew into cumulo-granite.... for some reason, which will forever remain unknown).
In 1994, blame was apportioned only if the facts were absolutely incontravertable. Even if that was the case (and I don't believe it was), have we not evolved from the bad old days of 'blame and shame'? Accident investigations in this more enlightened age should consider the Reason Model's 'latent' errors, as well as the unsafe acts that lead, more directly, to an accident. I am not sure that the MoD followed best practice - then in 1994 - nor perhaps, even now.
Sadly, it is understandable why the RAF hierarchy did what they did, especially considering the emotive loss of most of NI's counter-terrorism experts. Inherently, it is more 'psychologically satisfying' (and easier) for the organisation to blame an individual for the last error in the chain but I would argue that to continue doing so shows a lack of clarity in one's logic and reason and also a blinkered approach to the true aim of the investigation - to prevent recurrence.
If the BOI of ZD576 had been allowed/instructed to delve a little deeper than the obvious root cause of the crash, perhaps the crews of Hercules XV179, Nimrod XV230 and Sea Kings XV650 and XV704 would be alive today?
Numerous accidents and incidents such as the Herald of Free Enterprise, Clapham, Chernobyl, Dryden, Erebus et al have cited the pre-disposing conditions of organisational error (eg lack of training, supervision and/or poor risk/resource-management etc) as having made major contributions to the accidents. This modern approach is 'best practice'. Is it not time for the MoD to join the 21st century? Regrettably, they cannot (or will not) because, after an accident, the very people commanding the investigators will themselves come under scrutiny - yet I live in hope that things will change.
JP - I didn't mean to 'stir your sh!t'! I may have hit a nerve but I'm afraid that your answer leaves doesn't really make things any clearer to me. Try asking yourself why would an experienced and most capable pilot fly into a hill? One thing is for sure; it was not on purpose!
Also, your appreciation of low-level and safety altitude confuses me - if an ac is at LL then, by definition, it is below safety altitude - all of the time. There may well be cloud obscuring the high ground; that does not make it illegal (clear of cloud, in sight of the surface = VMC for helos, I think it was then) - in fact, it is 'situation normal' for most LL ops in the UK, as I'm sure you are aware. 150kts (not confirmed) is NOT high speed - it may have been quick for a Chinook, mind you but it is not fast. But if an ac then goes into cloud, the pilot should always try to climb as expeditiously as possible, in a safe direction, up to safety altitude - every single bit of training I ever received or gave in the RAF reinforced this and we have NO reason to believe that the crew of ZD576, nor anyone in the Chinook fleet, would have done differently. (Here, I assume that this was also SOP for the Chinook fleet - if not, then why not?)
If they had flown into cloud that day, it would be reasonable to assume that they would have followed their training - but, if they were in cloud, why didn't they do so? That question is as unfathomable now as it was then but it doesn't necesarily mean they were grossly negligent.
You talk about 'facts', well these are the facts:
The fact is that no-one really knew what the weather was actually like in the area at the time nor when or if ZD576 entered cloud (with due deference to the sailor, his view of the weather and the ac speed is, at best, a guess).
The fact is that no-one can be sure of the goings-on in the cockpit - visual illusions, distractions and a loss of SA come in many shapes and sizes (even fly-shaped!).
The fact is no-one can be totally sure of the integrity and performance of the ac, its systems, nor its powerplant - despite what the manufacturers say.
The fact is that no-one really knows what were the thought-processes of the crew, nor their plan, nor their actions.
The fact is that most of the BOI 'findings', everything talked about in the H of L and almost everything written on this site is conjecture because there was no ADR/CVR.
The fact is that no-one will ever really know what happened that fateful day.
With this as a backdrop, I argue that it was wholly inappropriate for the crew to be found grossly negligent and it is now time to change that ruling.
Please let the crew, the passengers and their families rest in peace.
VP
You are quite correct to point out that the immediate root cause of the crash of ZD576 was that they crashed into a hill. However, I think you'll find that the concept of a single 'root cause analysis' is an outdated one.
In many accidents, there are local 'active' failures but also organisational 'latent' errors; this is called the Reason Model and is widely used and forms part of ICAO Annex 13.
Tuc rightly draws our attention to the possible 'latent' failures in the defences and safeguards of the organisation (ie the holes in the layers of swiss cheese). It is certainly possible (Tuc would say probable) that the MoD failed to maintain Airworthiness in the Chinook at this time (local engineering instructions to be performed in the air). This has been shown and admitted to by the MoD in the Nimrod XV230 enquiry - the same Senior Officer that looked after Chinook and the Hercules. One could even argue that airworthiness and possible FADEC failure/glitches are only one of a number other possible latent failures, which were not fully investigated at the time - because the AOC said so and because it was common practice). Instead, the BOI directed their attention to the local 'active' failings by the crew on that day (ie they unintentionally flew into cumulo-granite.... for some reason, which will forever remain unknown).
In 1994, blame was apportioned only if the facts were absolutely incontravertable. Even if that was the case (and I don't believe it was), have we not evolved from the bad old days of 'blame and shame'? Accident investigations in this more enlightened age should consider the Reason Model's 'latent' errors, as well as the unsafe acts that lead, more directly, to an accident. I am not sure that the MoD followed best practice - then in 1994 - nor perhaps, even now.
Sadly, it is understandable why the RAF hierarchy did what they did, especially considering the emotive loss of most of NI's counter-terrorism experts. Inherently, it is more 'psychologically satisfying' (and easier) for the organisation to blame an individual for the last error in the chain but I would argue that to continue doing so shows a lack of clarity in one's logic and reason and also a blinkered approach to the true aim of the investigation - to prevent recurrence.
If the BOI of ZD576 had been allowed/instructed to delve a little deeper than the obvious root cause of the crash, perhaps the crews of Hercules XV179, Nimrod XV230 and Sea Kings XV650 and XV704 would be alive today?
Numerous accidents and incidents such as the Herald of Free Enterprise, Clapham, Chernobyl, Dryden, Erebus et al have cited the pre-disposing conditions of organisational error (eg lack of training, supervision and/or poor risk/resource-management etc) as having made major contributions to the accidents. This modern approach is 'best practice'. Is it not time for the MoD to join the 21st century? Regrettably, they cannot (or will not) because, after an accident, the very people commanding the investigators will themselves come under scrutiny - yet I live in hope that things will change.
JP - I didn't mean to 'stir your sh!t'! I may have hit a nerve but I'm afraid that your answer leaves doesn't really make things any clearer to me. Try asking yourself why would an experienced and most capable pilot fly into a hill? One thing is for sure; it was not on purpose!
Also, your appreciation of low-level and safety altitude confuses me - if an ac is at LL then, by definition, it is below safety altitude - all of the time. There may well be cloud obscuring the high ground; that does not make it illegal (clear of cloud, in sight of the surface = VMC for helos, I think it was then) - in fact, it is 'situation normal' for most LL ops in the UK, as I'm sure you are aware. 150kts (not confirmed) is NOT high speed - it may have been quick for a Chinook, mind you but it is not fast. But if an ac then goes into cloud, the pilot should always try to climb as expeditiously as possible, in a safe direction, up to safety altitude - every single bit of training I ever received or gave in the RAF reinforced this and we have NO reason to believe that the crew of ZD576, nor anyone in the Chinook fleet, would have done differently. (Here, I assume that this was also SOP for the Chinook fleet - if not, then why not?)
If they had flown into cloud that day, it would be reasonable to assume that they would have followed their training - but, if they were in cloud, why didn't they do so? That question is as unfathomable now as it was then but it doesn't necesarily mean they were grossly negligent.
You talk about 'facts', well these are the facts:
The fact is that no-one really knew what the weather was actually like in the area at the time nor when or if ZD576 entered cloud (with due deference to the sailor, his view of the weather and the ac speed is, at best, a guess).
The fact is that no-one can be sure of the goings-on in the cockpit - visual illusions, distractions and a loss of SA come in many shapes and sizes (even fly-shaped!).
The fact is no-one can be totally sure of the integrity and performance of the ac, its systems, nor its powerplant - despite what the manufacturers say.
The fact is that no-one really knows what were the thought-processes of the crew, nor their plan, nor their actions.
The fact is that most of the BOI 'findings', everything talked about in the H of L and almost everything written on this site is conjecture because there was no ADR/CVR.
The fact is that no-one will ever really know what happened that fateful day.
With this as a backdrop, I argue that it was wholly inappropriate for the crew to be found grossly negligent and it is now time to change that ruling.
Please let the crew, the passengers and their families rest in peace.
Last edited by flipster; 26th Mar 2009 at 09:04.