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Chinook - Still Hitting Back 3 (Merged)

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Old 30th Mar 2009, 19:21
  #4161 (permalink)  
 
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The two experienced Chinook Pilots were allocated to the in-theatre support tasks and the inexperienced (on Chinook) RN Pilot was allocated (with an RAF Navigator) to the VIP task.
This was not a VIP task. The most senior rank was planned to be a 2 Star general, whose status would not qualify as a VIP, but he could not make the flight on the day.

Furthermore, no one at Aldergrove knew who the pax were as the pax manifest was retained elsewhere to protect the identities of some of them.

Compared to day-to-day ops in the Province, this was a benign pax run, and the only challenge was the weather.
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Old 30th Mar 2009, 19:30
  #4162 (permalink)  
 
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you do not allocate a Pilot straight out of the OCU to fly HM the Queen

Couldn't imagine the Queen being allowed, by senior officers, in any aircraft where the DECU fault codes had to be checked (by the Loadmaster, looking behind a little panel in the cabin wall) every 15 minutes, in case everything was about to go pear shaped.

Pity senior officers didn't think that other very special and irreplaceable persons weren't as important.
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Old 30th Mar 2009, 20:48
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Cazatou's points are relevant.
This sortie was late in the day: it would be nice to know that the crew was refreshed and ready for it;
it would be nice to know that the most able crew was doing it in view of the importance of the passengers (yes they were VIPs to the people of NI and the service personnel involved in the conflict – they were indeed irreplaceable and their loss ended any practical alternative to capitulation to the peace process negotiated between MI6 and the IRA);
it should not have been thought to have been less vulnerable to the usual operational threats because it was going out of “theatre” - it had, after all, to cross 10+ miles of Antrim countryside before getting its feet wet and the Mull should have been such an obvious spot to bushwack a mil helo crossing from NI (as I have suggested recently) that extra awareness should have been in order – and one would have hoped that the crew was in 100% condition to react to the unexpected;
add to this the slip in a post some years back from one of you who appeared to be knowledgeable of operations at the time that it had been the intention several weeks earlier to use an HC2 Chinook for this flight;
seems to an outsider that there had been some higher influence that disrupted the usual detachment decision making processes, preparations, and routines.
Or was planning and preparation at the detachment level as chaotic and unsatifactory as you all seem to accept as the norm? - or at least as you portray it to the public? Do you think that a request for a flight for such VIPs would have just plopped on someone's desk at detachment level with no further dialogue with a higher level of command?
Is it not time for you who know to come forward with all you know about the planning for this flight and who specifically put it together and ultimately gave the go-ahead given the worries of the aircrew re the HC2 Chinook, the weather, the unknowns re the flightplan, etc, etc, etc...? A more deserving fall-guy than the captain perhaps ...
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Old 30th Mar 2009, 20:50
  #4164 (permalink)  

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Bertie, I totally agree with your sentiments.

I've said it before more than once (first in 1995), but these passengers (or any others) should have been re-scheduled to fly either with 32 Sqn, one of the C-130 squadrons or by civvie air transport. Or postponed until another SH was available.

Not in an experimental aircraft that was deemed unsafe to fly by the very department tasked with bringing it into service.

The Chinook Mk2, (as a type), should NOT have been flying at all. If those running the show at Command and MOD level had any morals or common sense, instead of an insistance and a spiteful indignance to put this type prematurely into service, they would have agreed and grounded it until the airworthiness concerns had been met.

I wonder what input the RAF's Flight Safety organisation had at this time.
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Old 30th Mar 2009, 21:23
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Couldn't imagine the Queen being allowed, by senior officers, in any aircraft where the DECU fault codes had to be checked (by the Loadmaster, looking behind a little panel in the cabin wall) every 15 minutes, in case everything was about to go pear shaped
The DECU Display is not active in flight unless the ECLs are moved past a 5 degree gate; therefore, the crewman cannot check it every 15 minutes.
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Old 30th Mar 2009, 21:44
  #4166 (permalink)  
 
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Ah the memory fades. What the hell were the Loadmasters checking?

Soon I'll forget that every time the cab had a DECU fault indication the fault was 'cleared' at base by simply swopping the DECU to the other engine. No spares you see. And no maintainance manual for the DECU's.

Bet the F700's have disappeared now!
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Old 31st Mar 2009, 06:48
  #4167 (permalink)  
 
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Compared to day-to-day ops in the Province, this was a benign pax run, and the only challenge was the weather.
I recall from the Flying Supervisors' Course, that 'benign transits' feature quite disproportionally often amongst accident statistics.....

Not that anyone actually knows what happened in this accident, of course.
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Old 31st Mar 2009, 07:54
  #4168 (permalink)  
 
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DECU Connector

I feel the DECU connector saga gets to the heart of the airworthiness issue, exposing the obvious political imperative that the “new” Mk2 must be seen to be flying which, I believe, led to shortcuts and poor engineering practice. If I may, the following is from the House of Lords Committee minutes; House of Lords - Chinook ZD 576 - Report. See Section 5 – Evidence.

109. Squadron Leader Burke spoke to having experienced two engine run ups on the ground at the Boeing factory in Philadelphia while flying with an American Army test pilot (Q 655) and similar run ups when testing the overspeed limiter on the ground at Odiham (Q 680). He also spoke to problems with the multi-point connectors which went from the engines into the DECU. These were of bad design and liable to be displaced by vibration which then produced a power interruption. Although there was a back-up system this did not always work and on two or three occasions pilots had lost control of the engine condition lever. As a result squadrons introduced a procedure whereby crewmen every quarter of an hour checked that the connections had not been displaced in flight (QQ 677-9).
110. At the time of the accident DECUs still presented recurring problems. They were removed from the aircraft when something had gone wrong and returned to the makers who on many occasions could find no fault (QQ 698-9).

And from the Board of Inquiry:

“There were two entries in the Supplementary Flight Servicing Register that had potential relevance to the accident: Serial 2, SI/CHK/57 on the security of the DECU connectors…….”



I do not have a copy of the SI (Servicing Instruction) but it would seem to relate to a pre-flight check to be carried out on the ground. The “supplementary” in-flight 15 minute check was, it appears, introduced by the “Squadrons”. If I’m wrong about this, sorry, but I’ve asked the question many times without reply. It changes little of what I am about to say.

SIs are issued by MoD(PE) (as was). The Def Stan is very clear on this. The User or Design Authority can be tasked to develop / trial the SI, but it is seen to be issued by PE (that is, the Technical Agency – the named person in the mandated contract whose sole purpose is to maintain the build standard). Therefore, straight away one knows who approved it, as he/she is NAMED in the contract. I won’t comment on the fact the SI was controlled by the very people who have, for 15 years, been allowed to sit in judgement of themselves and prepare Ministerial replies. The independent scrutiny argument.

The reason why PE controls the SI is because it represents a change to the build standard, and should be a fully documented. If it is not, the airworthiness audit trail is broken.

Nowhere does the Def Stan address the concept of in-flight SIs.

It is my opinion that such a design problem should not have been managed by an SI. There are some parts of an aircraft design that you just don’t mess with, and fuel computers are one. For example, you can accept an EMC problem almost anywhere, but if a fuel system is affected, the aircraft doesn’t fly. Simple. Users and maintainers tend not to see such problems in-service – precisely because they MUST be designed out. I accept I have limited knowledge of this particular problem, but even the basic information screams “Class A modification” (“essential for safety, to be embodied irrespective of delay, scrap or downtime involved”). A Class A does not necessarily mean grounding, but in this case I’d have said yes, especially given Boscombe’s concern with the associated software.

I’d go further. If the problem was known about before CA Release was granted, a Class AA modification should have been issued (“essential for initial approval, for Service Use or a new type of equipment” e.g. FADEC/DECU). “To be embodied prior to delivery, irrespective of cost, scrap or delay involved”. All quotes are from the Def Stan.


But, checking in-flight is a new level of lunacy altogether. Why was this extraordinary action necessary? There must be a recorded reason, but it seems no deeper investigation took place post-crash. Some of the more obvious questions are - Did the Users report concerns about the DECU or the SI? Was a request for a proper engineering solution refused, or was it “in hand”? Who authorised this in-flight servicing? What tests/tools/test equipment were to be used to verify the check/repair (as servicing is not complete until verified)? What was the test - a simple wiggle? (See previous posts about degradation). An electrical continuity check? An insulation check? Was electrical bonding compromised by constant wiggling? (Poor bonding is the first thing to check if one suspects nav problems). What was the maintainer (Loadmaster/Maintainer??) meant to do if the connector came loose in his hand? Get on the intercom to the pilot and say “I think I may know why we’re in the clag”?

Frankly, this stinks. Yet, the systemic failings I describe were becoming common practice at the time, due mainly to the RAF (in particular) not requiring the build standard to be maintained. A waste of money you see.

The Safety Case (or Safety argument, whatever) MUST reflect the current in use build standard (which is why one maintains it). Therefore, what safety and risk related documentation exists to support the SI? Read the Nimrod thread and see the discussion of impact and probability. Someone in the Sqn apparently disagreed with the probability of occurrence and, probably, the impact. For example, a pre-flight check may be a temporary risk mitigation, but it is not the engineering solution. An SI is not a permanent device; it is temporary pending superseding modification.

What mod superseded the SI to replace/improve the design? Crucially, what on earth do Fields 6 and 7 of the 714 say? This is a serious question, because the 714 (the modification proposal) demands a multitude of answers, and would reveal prior knowledge and understanding of the problems, which could not be hidden given the extant SI/CHK/57.

And what was the impact if the connector came loose or detached? Catastrophic? Critical? When combined with an increasing probability of occurrence (witnessed by the 15min check), the risk is definitely Class A - in other words, unacceptable and to be tolerated only under exceptional circumstances. May I suggest a VVIP transit to FG is not exceptional circumstances?

There - down to precisely the same argument as Nimrod. Sorry, I've been there before with this on Mull, but few reply. Is it apathy?
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Old 31st Mar 2009, 08:43
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Nail..... Head......SMACK!


Doubtless, there will be lots of scurrying along the corridors of power and files being 'lost'?
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Old 31st Mar 2009, 10:21
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Strikes me you've pointed to a known known, in the midst of all the known unknowns and unknown knowns that obfuscate this thread, tuc. As always all roads lead to the MOD. As always we discover gross negligence there. Why should we wonder that they are so determined to pin it on anyone other than themselves?
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Old 31st Mar 2009, 11:00
  #4171 (permalink)  
 
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Here’s another relevant question. Given SI/CHK/57 by definition accepts the possibility that the connector can become detached or loose, is the system design (not just the male and female connectors) designed for “hot-swapping”? That is, does it facilitate safe removal/insertion when powered up through, for example, offset contacts which ensure certain pins mate before others? I’ve chaired meetings which went on for hours debating this very point. It’s really quite important as getting it wrong tends to trip CBs and make lights flash. The Chief Test Pilot, Chief Designer and his Chief Safety Officer always attended!! One of those occasions when you need lots of Chiefs.

And, while slightly facetious, can the test pilot who flew the trials aircraft when the SI was validated and verified, please step forward?
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Old 31st Mar 2009, 14:39
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Its not facetious, I believe he has already stepped forward...S/L Burke. He has given his opinion at the highest possible level to him. And he was also the one to require the grounding post accident, tho that didn;t happen
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Old 3rd Apr 2009, 19:20
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MoD (including Ministers) have always denied that the safety management system was not implemented properly on Chinook.

As any engineer, and everything ever written on the subject, will tell you, configuration management is a crucial component of airworthiness and safety management.

From Public Accounts Committee report, July 1999........


33. Looking at the Sea King helicopters, paragraph 3.6, those were Sea King Mark 2 which were introduced quite quickly in 1982, and it seems your management information systems have not been able to establish their design status or keep up with the modifications to Chinook helicopters. Is that right? That is what that paragraph seems to say. I am not an expert on defence equipment so I hope I have understood it correctly.


(Sir Robert Walmsley) I think you have understood it absolutely correctly. That is true.


So, even after everything that had happened 5 years previously.......................
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Old 3rd Apr 2009, 22:41
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Tuc, it seems that you only have to lift any MOD airworthiness rock to find something very unpleasant slithering desperately to avoid being seen. From a position of proposing that there may be specific problems with specific aircraft types, the MOD's record shows that the whole system of UK Military Airworthiness under the MOD is broken. No fleet is unaffected, as the rot is endemic throughout. Blame and consequences are secondary to urgent remedial action. Notice I do not say "swift", for the system may be broken simply by a two star ordering his subordinates to flagrantly ignore their mandated duty to enforce the airworthiness regulations; that's the swift part, as breaking the system merely requires "good men" to do nothing. Restoring airworthiness to the military airfleets will take much longer, decades perhaps, and some fleets will never attain the status of airworthiness before they are scrapped. All the more reason to initiate reform ASAP, and that reform begins only when the MOD is no longer responsible for UK Military Airworthiness Regulation enforcement.
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Old 6th Apr 2009, 12:13
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Not had a chance to read as yet, but an article in today's Daily Telegraph on the crash.
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Old 6th Apr 2009, 14:11
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Unable to post a link to the DT article. Gist of it is "Those in charge of helicopter safety warned that the upgraded HC2 model was not fit for service and that flying operations should cease immediately". This statement was made on the day that the crash occurred.

The well known aviation and legal expert John Hutton (Who he?) states that "No new arguments have been advanced to warrant the overturning of the findings" Another name to add to the list of incompetent top men who are shamed by their approach to this matter.

Dr Michael Powers QC, speaking for those fighting the finding, said "This Chinook was so unreliable that the very people charged with its safety had reached the conclusion that they would not let their test pilots fly it"
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Old 6th Apr 2009, 23:30
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The DT seems to have sorted itself out and the link is a bit easier to find now:

DT article - 'Chinook that crashed into Mull of Kintyre should have been grounded'
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Old 7th Apr 2009, 15:30
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Chinook that crashed into Mull of Kintyre 'should have been grounded'

A Chinook helicopter crashed killing 29 servicemen on the very day that RAF safety experts requested it should be grounded because of serious mechanical flaws, new evidence has shown.



By Thomas Harding, Defence Correspondent
Last Updated: 3:00PM BST 06 Apr 2009

Previous
of Images
Next



The wreckage of the Chinook Helicopter which crashed on the Mull of Kintyre Photo: PA

A Royal Airforce Chinook HC2


The loss of the aircraft, which was carrying 25 of the top MI5, Army and RUC Special Branch officers combating terrorism in Northern Ireland, has been blamed on the "gross negligence" of the pilots.
But a document obtained by The Daily Telegraph indicates that those in charge of RAF helicopter safety gave warning that the upgraded HC2 model of the Chinook was not fit for service and that flying operations should "cease immediately".

Related Articles
The Chinook crashed into the Mull of Kintyre on June 2 1994 after it hit a hillside in thick fog while flown by Flt Lts Jonathan Tapper and Richard Cook.
In the hitherto unseen document, coincidentally written on the same day as the crash, the commanding officer of the Rotary Wing Test Squadron (RWTS) recommended in the "strongest possible terms" that the Air Force should "cease Chinook HC2 operations" until mechanical problems over digital flight systems had been addressed.
Campaigners, who have fought for years to clear the names of the pilots following a questionable RAF board of inquiry, have now demanded that John Hutton, the Defence Secretary, should annul the inquiry findings of two senior officers.
While the report said it appreciated that delays in an overhaul would have an impact upon operations the RWTS would be "failing in its primary role of providing the front line with equipment which can not only efficiently carry out the task but to do this safely".
However, suggested improvements had been "ignored" and until there was "clear, unequivocal and realistic explanation of the faults" further Chinook HC2 flying "shall not be authorized".
The document, uncovered by the Mull of Kintyre Group, was made public at a time when the RAF has grounded its Nimrod reconnaissance fleet because of safety fears following a crash over Afghanistan that killed 14 servicemen.
Despite the new evidence the Mr Hutton has refused to either open a new inquiry or even annul the "gross negligence" findings because there are "no arguments advanced to warrant overturning" the original findings he wrote in the letter to the group.
Dr Michael Powers, QC, spokesman for the Mull of Kintyre group, said the Ministry of Defence's (MoD's) position was "unsustainable" because there was "stacks of evidence" which showed mechanical failure could not be ruled out.
"This Chinook was so unreliable that the very people charged with its safety had reached the conclusion that it was so unsafe that they would not let their test pilots fly it. That is a critical piece of evidence."
He said the families and the group would be "perfectly happy" with an annulment of the "gross negligence" findings in a move that would avoid the cost of another inquiry.
The former RAF pilot Omar Malik, representing the group, said it was astonishing that "even this damning document" was not considered as new evidence.
"The MoD is well aware that the families of the pilots have been well nigh destroyed by their fight for justice for their sons."
Mr Malik, author of The Grown-Ups' Book of Risk, added that there were "serious questions" over Air Force boards of inquiry where senior officers could "influence findings".
He said the original verdict was the "equivalent to manslaughter" and if the pilots were living "they would have the right of representation" that would have "rapidly demolished as risible" the reviewing officers' verdict.
In the original investigation evidence was remarkably scarce because 80 per cent of the aircraft was destroyed. There was no flight data recorder and no cockpit voice recorder.
The cause of the accident can never be ascertained but at least six technical failures have been identified. In the weeks before the accident the Chinook suffered three mechanical failures.
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Old 7th Apr 2009, 16:16
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If I may, I’d like to add to my previous two posts regarding Configuration Control. But first, to recap, if an aircraft or equipment is not under CC, then the Safety Case or Safety argument cannot be validated or verified, a pre-requisite for an aircraft to be deemed “airworthy” or fit for purpose. But, as we have seen, it can be offered to the Release to Service Authority knowing that it is unsafe, and subsequently Released to Service. Furthermore, the contract can be paid off in full, in the knowledge that the contractual requirement to make the aircraft safe has not been met. Similarly, this contractual requirement may be waived, with full payment made. This has been ruled on many times, and is still the case; although MoD is somewhat reluctant to advise Boards of Inquiry or Coroners’ Inquests of this little gem. I wonder why.

As I noted, in July 1999 CDP acknowledged CC of the Chinook Mk2 was somewhat lacking (in 1999).

In the few years leading up to the accident, the MoD slashed funding to maintain the Build Standard (what the PAC refer to as “design status”, a crucial component of which is CC), so the Mk1 suffered along with most aircraft and their equipment. You don’t have to take my word for this; it’s noted in a number of subsequent HCDC, PAC and NAO reports.

However, in November 2005, in a written reply, the then Min(AF) Adam Ingram stated that the Mk1 WAS under CC as of November 1993; and the Mk2 CC was maintained from that date until the accident. This resurrection, worthy of Lazarus, would have been a major programme, involving most of the Directorates in the little family tree I posted a few weeks ago. Anyone involved would surely remember it.

As someone whose job it was to try to maintain build standards (without funding) at this time, I can assure you that, far from being resurrected, the RAF (especially, as they controlled funds) were actively running down this process. In fact, the 2 Star responsible threatened anyone who voiced an opinion that, inter alia, we should try to make kit safe, with disciplinary action. (A threat which still hangs over staffs today, again confirmed in writing by Ingram, Ainsworth et al).

So, in addition to the usual lies, we have a situation whereby the MoD (a) knowingly compromised safety in the years before the accident (b) in the days immediately preceding the accident refused to take Boscombe advice that the aircraft should be made airworthy, and (c) in the following years, to at least July 1999, apparently did nothing to correct matters.

Perhaps the most damning confirmation is this. The procedures for maintaining CC are laid down in Def Stan 05-57. But there is another Def Stan laying down the wider procedures for maintaining the Build Standard, of which CC is but one part. Try asking D/Stan for this Def Stan, and all the specifications it calls up. They topple.
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Old 7th Apr 2009, 19:27
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UK Military Airworthiness

tucumseh, your perceptive post illustrating the Gross Negligence of the UK Military Airworthiness Authority (AKA the MOD) is timely. Reading the Telegraph piece one might well think that the story is of two Chinook HC2 pilots sacrificed to protect those who presided over the operation of this flawed type, leading to the loss of not only an RAF crew but also the cream of British Intelligence on the slopes of the Mull of Kintyre. Of course that is part of the story, but only part of a much bigger and even more damning one. This is a story of the intentional dismemberment of the airworthiness protection of the UK Military Airfleet. It has cost many tens of lives already and sadly will probably cost many more before it can be put right. To my mind it is a story of dereliction of duty far graver than that perpetrated by the banks. They lost merely treasure and jobs, the MOD's Gross Negligence lost lives. It must be replaced forthwith in this vital responsibility, having reneged on it totally.
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