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Chinook - Still Hitting Back 3 (Merged)

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Chinook - Still Hitting Back 3 (Merged)

Old 24th Mar 2009, 16:32
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I agree with Flipster, there are too many unknowns to find the guys negligent in any way. The west coast of Scotland is littered with aircraft that did not mean to fly into the ground. There are lots of contributory factors but no one will know exactly what happened on that fateful day.

I can add to what I perceive as contributory factors and describe how I tried to break the chain of possible events.

For me speed was definitely a contributory factor but groundspeed rather than airspeed; apparently there was a strong westerly that day that would have amplified other factors (next point).

Having spent a lot of time flying around the coast (SAR Boy) I know that it is sometimes difficult to judge how far away from land you are - if you see a sheep it is easy to judge because you know how big sheep are but quite often it is difficult to judge the size of rocks as they vary in size and they are quite big around the Mull. A similar effect can be found over the boulder fields in the Falklands - they vary in size making it difficult to judge height at low level. The rate of closure with the coast and the poor viz and low cloud would have amplified this effect and could have led to misjudgement by the crew.
A year before the accident I got a lift on a Wokka to Stanley from MPA for a function (p**** up). The weather was poor and we followed the road at low level. The Chinooks rarely went to Stanley at that time but the SAR Boys went to the hospital frequently. I was listening in the back but couldn't speak as I didn't have an interrupter and had disconnected my boom mic. I became uneasy as we approached the LS as I knew there were some large masts between us and it and the co-pilot (a Nav) had not mentioned them. I was trying to reconnect my mic to warn them when the aircraft turned 90 degrees right in quick time to avoid the masts. That was my first experience of GPS, reletively new at that time and not yet fitted to the SK. That crew had put so much reliance on the accuracy of the GPS without reference to a map that the aircraft almost crashed. I spoke with the crew about it and we all went away a little wiser but the bottom line is always navigate with reference to a map.

You may have read these points and thought they were negative but they are not meant that way - the bottom line is that the aircraft crashed into the ground and no one knows why but we can all discuss factors that may have contributed so that it hopefully will not happen again. I've had some near misses in my time and feel lucky to be still here to learn from those experiences but those guys were not so lucky and do not deserve to be blamed for something that they may or may not have contributed too.
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Old 24th Mar 2009, 16:43
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Flipster, I agree with everything you say in your post. Unfortunately there has long been a philosophy in the RAF to 'blame the pilot' in the event of an accident. I am reminded of an accident to an F4 on an instrument approach to Leuchars one night from over the North Sea. An engine fire indication illuminated and the engine was shut down. The approach was continued on one engine until the 'good engine' lost thrust. The crew ejected and were rescued but the aircraft wreckage was never recovered.

A fleet check was carried out and it was discovered that several aircraft were cross-wired so a fire in one engine would indicate on the other engine. The Board of Inquiry deduced this was probably what had happened on this occasion. The pilot had shut down the good engine because the warning was for that engine. The engine that was on fire had eventually failed and that was the cause of the loss of thrust. The accident was the result of a technical problem. However, the Reviewing Officer decided that this was not the case; the pilot had misidentified the engine which had been on fire and had closed down the wrong engine. The cause was therefore Pilot Error.

Aircraft accidents can have many causes that may never be identified, particularly if evidence were to be destroyed in a post-crash fire. Even a cause such as the wrong length of a piece of string. A Dragon biplane was being displayed at an air show when it did a wing-over from which it never recovered, just diving into the ground. The pilot was killed. From a bystander's point of view it could have seemed like a simple case of pilot error. However the aircraft did not catch fire and evidence of the cause was recovered from the wreckage.

The pilot's seat was fitted with a Sutton Harness. When in use, the seat straps are secured onto a central spigot by a split pin. To prevent losing the split pin when it is not in use it is tied onto the harness with a piece of cord. At some time in the past the cord had become worn and been replaced. Unfortunately the new piece of cord was longer than the one it had replaced. During the display, when the pilot manoeuvered into the wing-over he pulled back the control yoke, applied aileron, and tragically the cord on the harness slipped over the parking brake lever on the right hand side of the yoke. Had the cord been the correct length this would not have happened. The pilot could not now roll the wings level nor move the control yoke forward and the aircraft spiralled into the ground.

I note that all the civil Air Accident Investigation Branch Accident Reports that I have read are written to simply state the known facts and do not indulge in speculation. They go into considerable technical detail but do not attempt to allocate blame. Perhaps the RAF should adopt a similar approach.
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Old 24th Mar 2009, 19:36
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Supplementary

Wow this thread can move fast! Firstly, I was in the MOD at that time, and in case someone thinks it relevant, I was of the same rank as the President of the Board of Inquiry, and was concerned with aircrew training. I have not read the full BOI, but I know from the data gathered a huge effort had gone into determining the speed and flight vector of the aircraft at the time of impact, and it was not up. Equally, I know a great deal of work was done to establish the state of the aircraft systems at impact, and everything was working. Correct me if I am wrong.

As stated elsewhere, no pilot would deliberately fly into the ground, and it is quite reasonable to assume that they did not think they were about to hit land. So what were they doing? Were they distracted? Did they enter cloud without adequate warning? So many questions and no answers. As in so many cases like this, and many military accidents, the benefit of a FDR and CVR would perhaps give clues, one thing is for sure - there were errors of judgement by both pilots.

The question was asked about the crew of aircraft involved in CFIT accidents being found culpably or gossly negligent. Personally, I cannot remember such an occurence except when it was patently obvious and demonstrably proven, that such was the case. My personal view is that whilst errors of judgement were made, it cannot be shown that the crew deliberately ignored orders and SOPs relevant to the stage of flight when it crashed. I am also mindful of the rearch on perception done by an RAF IAM aviation specialist. He could demonstrate that aircraw had tendencies based on "trust" to "perceive" what they wanted or expected to see. Based on my 12 years of FJ, ME and RW instruction, I have observed dozens of instances of this happening. Usually, the perception is corrected quickly, but not always, and I have had on several occasions to rescue the situation. My theory would be that the pilots were perceiving what they expected to see based on the "trust" they held based on their extensive experience, and did not have time to correct their spatial awareness to reality.

Military pilots who complete lengthy flying careers all have stories of "There but for the grace of God" ... or "Action not As Planned", I certainly have. This tragic accident could easily have fallen into the former category, but sadly did not.
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Old 25th Mar 2009, 13:50
  #4124 (permalink)  
 
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jayteeto

Still waiting.

1. Before which sortie that day did you sit down at the same table in the crewroom and eat a meal with the crew of ZD576?

2. Was that information given to the BOI?
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Old 25th Mar 2009, 14:04
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Caz

Still waiting

Post #4137

Any chance of an answer?
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Old 25th Mar 2009, 18:06
  #4126 (permalink)  
 
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We walked out to the aircraft together, were in the flight planning room together and sat in the crewroom together. Go back ten years to my early posts about JT showing me the blank page in the aircrew manual for handling advice/the crew briefing FADEC emergencies an hour before the flight and stating publicly they were doing it because they had no idea what the FADEC might do that day/ I sat three feet away while they scoffed lunch/breakfast/elevenses/god knows what it was called. Do we really have to repeat this information every few years because someone can't be bothered to read back?? The BOI were not interested in who sat with them in the crewroom, plus more importantly, everyone knew the facts then. These theories only came up years later when others got 'involved'. If we had operated the AT way, nothing would have got done!! Do you know that after the Bessbrook crash where 4 were killed, they were going to start a manifest system for picking troops up in South Armagh Bandit Country!! Lunatics who had no idea of how it works when the threat is real. The mess didn't serve breakfast for those on early starts.
PS. Didn't answer due to being in Gibraltar, got a great hangover today........ I am flying tomorrow, does that mean I am negligent because i didn't have breakfast 2 days ago? Even though I have eaten since??
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Old 25th Mar 2009, 21:40
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If we had operated the AT way, nothing would have got done!!
I agree, JT2.

Some, even RAF crews with no relevant SH role experience, have absolutely NO idea of the conditions under which SH operated in NI. For us it was a real, operational theatre, effectively a war role.

Many was the time I stood in the mist and pouring rain in the dark outside the station armoury (no breakfast taken, because no mess staff were ever available that early), loading live rounds into the magazines of my 9mm pistol and my SA-80, wondering if today was the day I was going to get shot down and have to try fight my way out of a ground ambush. The job had to get done, people were getting killed, crews were getting shot at (and sometimes shot down) by small arms fire, HLSs were being mortared, large IEDs were common place, and in a few cases, GA missiles were used against helicopters. Our weather limits were "go and see". We flew in weather and at heights that would make most fixed wing pilots have nightmares, often in the dark. We seldom had radar cover because we operated 24/7 and ATC didn't; in any event we operated at well below the coverage of any radar head. We only ever flew at extremely low level because the job required it (ask Cazatou if he is aware of PK factors for small arms fire). This meant routinely flying at 100ft agl or below.

For someone to claims to have been the Group FSO to try to tie the thread into knots by claiming the crew were negligent by not taking breakfast in the officers' mess, is crass, absurd, a red herring.
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Old 25th Mar 2009, 22:22
  #4128 (permalink)  
 
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Shy,

Now that brought back some rather unpleasant memories but at least you only had 2 weapons to pick up, the enlisted filth also had the joy of the GPMG and it's box of bullets

What I find most disturbing about the Group FSO you refer to, is his complete and utter lack of awareness with regard to what was going on right under his own nose. He freely admits that prior to this tragedy his own station had no facilities in place to provide crews with food first thing in the morning and that it took direct action at AOC level to address his FSO's serious professional failings.

It's rather ironic that the same individual who has done his utmost to smear the crew of ZD576 with these completely unsubstantiated claims was in fact a serial transgressor himself.
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Old 26th Mar 2009, 00:36
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JT2, SFFP, ShyT and VP

Thank you for reminding me that NI was a truly 'operational theatre' for SH; I'd rather forgotten that (being FW AT). However, this then adds to the mix a concept of which even FW AT is now more aware.

That is; sometimes, when flying on operations one needs to bend the peacetime rules just a little - this is not recklessness just pragmatism, especially when lives of the PBI are on the line.

Of course, the real down-side to this concept is that when you get back home, you then need to 'retrain' yourself to do things by the book. This can be difficult if you have been on ops for a long time, as the boundaries can get blurred.

Failing to adjust is not negligence; it is just another 'human-factor' that needs strong and sympathetic leadership, supervision and understanding. It is certainly possible that the crew ZD576 may have been suffering from such a blurred picture when they left the operational theatre and ventured into the 'peacetime' Low-Level Flying System in western Scotland - if, indeed, they were 'pushing' the limits of VMC - however, that has never been proven.

As for the ac being perfectly sound, VP - I think you'll find that it is not that simple. There are enough well-qualified people who have voiced concerns about the FADEC and its handling to make any sane person have doubts about the integrity thereof - not least because of the in-flight checking of connections. Nonetheless, I think you may well have a valid point that illusions, perceptions and expectations go hand in hand. Lord knows I've had a few of those moments myself.

We still come back to the crux of the matter - no-one knows for sure and we never will. So why 'grossly negligent'?
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Old 26th Mar 2009, 08:27
  #4130 (permalink)  
 
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Flipster, I will now slip back into my voluntary thread retirement, I keep lapsing when I read untruths!! You are right, we did get 'war happy' in our style of flying and it did take effort to remember to fly safer on the mainland.
One point that is vital here..... We are not slagging off the AT guys who do a fabulous job and operate in war zones with bravery and guts. We are only saying that WE had to do a DIFFERENT job to them at the time. Not better, just different. The current aircrew workforce (in my opinion) do a better job than I ever could have. Fly safe!!
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Old 26th Mar 2009, 08:59
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JT2
No probs m8 - I don't for a minute think you were slagging off anyone - actually, I was agreeing with you. I had the same concerns more recently after returning from 'hot and dusty' places. Rather than get on one's high horse about following 'peacetime trg' rules, instead, we tried to make our training 'back here' more closely resemble what was expected 'out there'.

I agree with your assessment of current aircrew; they do a lot more 'interesting' things than did their predecessors, in an even more intense combat environment, often with less support, less training, far from home and, on occasion, with old or defective kit! Hats off!

Last edited by flipster; 26th Mar 2009 at 11:51.
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Old 26th Mar 2009, 09:42
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VictorPilot:
Equally, I know a great deal of work was done to establish the state of the aircraft systems at impact, and everything was working. Correct me if I am wrong.
Well if you insist VP! No one knows for sure if "everything was working". Equally no one knows for sure if it wasn't. What we do know is that the Chinook HC2 had more than its fair share of things not working at the time. A FADEC notorious for not working properly, a DECU connector that often didn't, software that could not be justified and a restricted RTS that BD wanted rescinding that would have grounded the entire fleet. Now it could be that all those items along with everything else that day were just tickety-boo on that aircraft, but we just don't know. That is the message that needs to be grasped here by those who now inhabit the corridors of power that you used to roam. We just don't know! Those who "do know" are I'm afraid greatly in error, to my mind obsessively so. Why should that be?
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Old 26th Mar 2009, 10:09
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I know a great deal of work was done to establish the state of the aircraft systems at impact,
It was indeed. Almost in it's entirety by an independent group of World leading experts. The Air Accident Investigation Branch.

If you will allow me to summarise their findings, they stated that the pre-impact serviceability of ZD576 could not be positively determined.

You invite us to correct you if you are wrong in your assertion that:
everything was working
All I can say is. After the 'great deal of work' you correctly mentioned, the AAIB were unable to agree with you.

It really is that simple!
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Old 26th Mar 2009, 12:16
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Yep, it is that simple - in the light of more recent work, it is possible that something untoward was going on the cockpit.

VP - the ac attitude was NOT level but it was also not as one would expect if the ac was climbing in a incorrectly selected attempt to avoid the hill (eg shallow climb, as asserted by Day Wratten). Instead the ac probably had about 30 deg nose-up attitude, above 100kts, with 10 deg AOB and with an extra large bootful of rudder....why?

Yet, rather than climb into icing conditions above SA, everything else points to the crew having decided to staying VMC below, following the coast (an assessment that is widely accepted in hindsight). The crew would have been perfectly entitled to do this if VMC - visability possibly ok (if you believe the yachtsman), sea shore/lighthouse in view, next waypoint selected etc. But it is assessed that the crew didn't turn and slow down in time but we don't know why. As I've said before, either viewpoint is mostly conjecture. In the case of Hercules XV193, this element of uncertainty was enough for the BOI and the Reviewing Officers to stop short of apportioning blame, so why was ZD576 treated differently by the reviewing officers from the same Command?

Arthur (post 4151),
In those days the RAF could apportion blame after an accident if it was found to be in no doubt whatsoever. You will be glad to know that these days that option is no longer available to BOI or their Reveiwing Officers - but administrative action can be taken against someone deemed to willfully crass/negligent - ie an impromptu, unauthorised airshow or flying under bridges.

Nonetheless, it is arguable that now, as then, BOIs are not given the enough authority (arguably, TORs for BOIs can be quite limiting) to dig as deep as they would like, or are able - given their resources. That is, BOIs were normally limited to the local, 'active' "unsafe acts" and proximal conditions (flying into the hill) not the 'latent' organisational conditions (FADEC/DECU/UCFM and airworthiness conditions). Furthermore, it is often that new evidence, knowledge or opinions come to light (eg JT2, Boscombe's or S/L Burke's evidence) after the accident and which can put a whole different slant on the BOI findings (also the limitations of the Boeing simulation and Day/Wratten assumptions which were then taken as facts).

Looking back at some the HoL findings, I find it strange that, despite acknowledgement that the Day/Wratten 'facts' were shown to be 'less than wholesome', Messrs Day and Wratten STILL maintain their position; quite bizarre?! Now that they have retired (wasn't Day was still serving at time of HoL enquiry?), perhaps they can ease themselves away from whatever motivational pressures that drove their 'pig-headed stubborness to look facts in the face' (apologies to Gen Melchett)? How the MoD could respond to the HoL findings, as they did, beggars belief - but it is what we have come to expect of Hoon/Hutton/Ingram/Ainswort and the like!

Ultimately, if Lord Rifkind (Def Min at the time), can appreciate the fragility of the verdicts of the Reviewing Officers, why cannot they (and the MoD) do so themselves? I would wager that we would hold these gentlemen in a much higher regard as a result as it takes a truly brave and honourable man to admit his errors, especially in public and after such a long time bound by his own pride and perhaps, his obstinacy. These traits we could forgive - we are only human.
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Old 26th Mar 2009, 12:58
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Yet another balanced post from flipster should surely be the last word in this long and repetitive debate.
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Old 26th Mar 2009, 18:21
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Final Input

I agree with that and after reading so many messages now, I think my personal verdict is clearer. Thanks for the technical corrections too .... not what I recall, but if those are facts, they are facts!!
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Old 28th Mar 2009, 16:34
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flipster states at post #4163

"in the light of more recent work it is possible that something untoward was going on in the cockpit."

Therefore it is probable that nothing untoward was going on in the cockpit.

Please enlighten us "flipster" - what was the percentage "possibility" in respect of the work you refer to?
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Old 28th Mar 2009, 16:41
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Does "probable = absolutely no doubt whatsoever"?

PS. I would like to see one other example of UK Military CFIT where the same conclusion was made.
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Old 28th Mar 2009, 16:53
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lurking

I was merely pointing out the fallacy of his argument.

How often have you been in the position where you have to act in judgement on someone else; either in assessing someones ability or as a member of a BOI or a Jury?
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Old 28th Mar 2009, 17:30
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Three times in a legal sense; almost daily as an RAF officer.

Moving away from rations and the distinction between possible, probable and absolutely no doubt, I'm still trying to reconcile why this particular CFIT attracted a gross negligence judgement whereas I cannot recall any other time where this conclusion has been reached. For example, look at the report on the Shackleton crash on 30 April 1990. To quote:

The BOI concluded that the accident was caused because the aircraft was flown below a safe altitude in unsuitable weather conditions; the Board were unable to determine the reason for this.

and for the Mul of Kintyre accident

.... continued to fly towards the high ground of the Mull of Kintyre below a safe altitude in unsuitable weather conditions.
Reads rather similar, doesn't it?

Please correct me if I am wrong (and if I am I will retract my argument), but I don't think any of the Shackleton crew were found to be negligent. If that is the case, why the discrepancy in determination of proof?

Last edited by Lurking123; 28th Mar 2009 at 17:43.
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