Chinook - Still Hitting Back 3 (Merged)
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Ark. Your...."If you are suggesting that the crew were actually intending to rely on TANS to take them in IMC to an accuracy of 500 yds within 200ft of terrain then you are indeed suggesting reckless folly and gross negligence" I did not suggest that, you did. Regards By the way, you still have not answered my question!!! JP
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What almost everyone ignores is the fact that negligence was found by OC RAF Odiham in his capacity as one of the first Reviewing Officers.
He found that Flt Lt Tapper (as Aircraft Captain) "had a duty of care" in respect of his Passengers and Crew and that Flt Lt Tapper had failed in that duty.
Chambers Dictionary - Negligence
"Omission of duty, especially such care for the interests of others as the law may require"
AOC 1Gp concurred and extended that finding to Flt Lt Cook.
He found that Flt Lt Tapper (as Aircraft Captain) "had a duty of care" in respect of his Passengers and Crew and that Flt Lt Tapper had failed in that duty.
Chambers Dictionary - Negligence
"Omission of duty, especially such care for the interests of others as the law may require"
AOC 1Gp concurred and extended that finding to Flt Lt Cook.
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Hi Cazatou,
It is also a fact that the same Commanding Officer stated that "the crew faced with the expected deteriorating weather, consciously elected to make a climb on track over high ground and in doing so used a speed and power combination that is unrecognisable as a Chinook technique. I find this difficult to believe; such actions would go against all the crew's instincs and training."
Now, as we all accept, every aircraft Captain has a duty of care to their crew and passengers. The Chinook crashed and all on board were killed. As an isolated statement, OC Odiham is correct. The Captain failed in that duty. What OC Odiham does not claim is that the crew were grossly negligent or that he knows why the Chinook crashed.
He further goes on to state that the Board were unable to discount the following factors:
Now let us look at the President, and Board members conclusion -
In respect of Jonathan Tapper, they wrote:
"The Board was unable to positively determine the sequence of events leading up to the accident, and therefore concluded that although it is likely that Flt Lt Tapper made an Error of Judgement in the conduct of the attempted climb over the Mull of Kintyre, it would be incorrect to criticise him for human failings based on the available evidence."
In respect of Flt Lt Cook, they wrote:
"The Board concluded that there were no human failings with respect to Flt Lt Cook."
So, there it is. The first time Gross Negligence is mentioned is in the conclusion of the first Reviewing Officer, who read a report and took legal advice.
Fact
My best, as always,
Brian
"Justice has no expiry date" - John Cook
It is also a fact that the same Commanding Officer stated that "the crew faced with the expected deteriorating weather, consciously elected to make a climb on track over high ground and in doing so used a speed and power combination that is unrecognisable as a Chinook technique. I find this difficult to believe; such actions would go against all the crew's instincs and training."
Now, as we all accept, every aircraft Captain has a duty of care to their crew and passengers. The Chinook crashed and all on board were killed. As an isolated statement, OC Odiham is correct. The Captain failed in that duty. What OC Odiham does not claim is that the crew were grossly negligent or that he knows why the Chinook crashed.
He further goes on to state that the Board were unable to discount the following factors:
- An unregistered technical malfunction
- Human factors
Now let us look at the President, and Board members conclusion -
In respect of Jonathan Tapper, they wrote:
"The Board was unable to positively determine the sequence of events leading up to the accident, and therefore concluded that although it is likely that Flt Lt Tapper made an Error of Judgement in the conduct of the attempted climb over the Mull of Kintyre, it would be incorrect to criticise him for human failings based on the available evidence."
In respect of Flt Lt Cook, they wrote:
"The Board concluded that there were no human failings with respect to Flt Lt Cook."
So, there it is. The first time Gross Negligence is mentioned is in the conclusion of the first Reviewing Officer, who read a report and took legal advice.
Fact
My best, as always,
Brian
"Justice has no expiry date" - John Cook
Brian
Thank you for placing these facts in true context, but may I ask if the officer's statement / opinion was revised after he learned of the evidence that was withheld.
I refer, in the main, to the lengthy catalogue of engineering problems experienced by ZD576, Boscombe's recommendation that the fleet be grounded, their grounding of the PE Fleet and the (apparently) unrecorded decision why all this could be ignored.
Thank you for placing these facts in true context, but may I ask if the officer's statement / opinion was revised after he learned of the evidence that was withheld.
I refer, in the main, to the lengthy catalogue of engineering problems experienced by ZD576, Boscombe's recommendation that the fleet be grounded, their grounding of the PE Fleet and the (apparently) unrecorded decision why all this could be ignored.
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Tuc,
the simple answer is no he didn't. However, having just read through his testimony to the Select Committee, in order for me to answer your question, I found some of his answers quite interesting (again).
Follow the link below for the full transcript of his evidence:
House of Lords - Committee to review Chinook ZD 576 crash - Minutes of Evidence
Paragraph 128 is Mr Pulford's response to a similar question to yours.
I hope this helps,
Kind regards,
Brian
"Justice has no expiry date" - John Cook
the simple answer is no he didn't. However, having just read through his testimony to the Select Committee, in order for me to answer your question, I found some of his answers quite interesting (again).
Follow the link below for the full transcript of his evidence:
House of Lords - Committee to review Chinook ZD 576 crash - Minutes of Evidence
Paragraph 128 is Mr Pulford's response to a similar question to yours.
I hope this helps,
Kind regards,
Brian
"Justice has no expiry date" - John Cook
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Arkroyal
When you wrote
<<If you are suggesting that the crew were actually intending to rely on TANS to take them in IMC to an accuracy of 500 yds within 200ft of terrain then you are indeed suggesting reckless folly and gross negligence.
I find such a plan quite incredible. Ludicrous. >>
you were not just making an important, indeed fundamental point – your phraseology described it so well.
Reinforcing what you wrote, let us not forget that Flt Lt Tapper (acknowledged as a nav systems expert) had misgivings about the accuracy of the SuperTANS and had given his opinion to others in his flight, had he not?
I would like to extend it by saying that, with the slight angle (20 deg or so) at which they were closing with the shoreline, they were already within a few hundred yards of that coast by the position where they changed the waypoint; this waypoint change dumped the only useful reference in the SuperTANS for their immediate situation; it left them with a heading to Corran that gave a track over even higher ground than they crashed into.
Given the conditions ahead, to the right, and (probably) above, their conduct would appear extraordinary – ludicrous, as you so rightly say – and their having the luxury of changing that waypoint suggests surely that they had no desperate problems at that point (the matched power of the engines reinforces the picture of no control problems).
Having some confidence in the abilities and intelligence of the pilots, I personally cannot imagine them having got into that situation without having some other external reference that they believed reliable – it would have had to have been something in the immediate vicinity and intrinsically accurate. That's why I have suggested what I did.
KG86
<<The conspiracy theorists speculate on the fact that this was the top echelon of the Province's counter terrorist officers being flown by a Chinook SF crew. I can tell you that it was purely coincidental that a SF crew was on duty that day. The very same task was flown by a Chinook the year before with an 'ordinary' crew. >>
It was only the expedite and “absolutely no doubt whatsoever” blame on the pilots that prevented a large number of people becoming “conspiracy theorists”.
To me, it did not matter who was flying it – the concern to me was that they were all bundled into a single aircraft which crashed. When the same task was flown a year earlier, the team on board at that time would not have been seen as an obstacle to the peace process as this team was by those who had been holding secret talks with the IRA in the months leading up to the crash.
By the way, you and the other poster who are so adamant that there was no plan to land on the Mull – I thought there was a shortage of people that had intimate knowledge of their actual flight plan? This came out clearly in the FAI during the duty hours deliberations. Did you realise that even a momentory touch down on the mainland released them from the constraints of duty hours in the operational area? - and the Mull was just within their allowed time remaining.
When you wrote
<<If you are suggesting that the crew were actually intending to rely on TANS to take them in IMC to an accuracy of 500 yds within 200ft of terrain then you are indeed suggesting reckless folly and gross negligence.
I find such a plan quite incredible. Ludicrous. >>
you were not just making an important, indeed fundamental point – your phraseology described it so well.
Reinforcing what you wrote, let us not forget that Flt Lt Tapper (acknowledged as a nav systems expert) had misgivings about the accuracy of the SuperTANS and had given his opinion to others in his flight, had he not?
I would like to extend it by saying that, with the slight angle (20 deg or so) at which they were closing with the shoreline, they were already within a few hundred yards of that coast by the position where they changed the waypoint; this waypoint change dumped the only useful reference in the SuperTANS for their immediate situation; it left them with a heading to Corran that gave a track over even higher ground than they crashed into.
Given the conditions ahead, to the right, and (probably) above, their conduct would appear extraordinary – ludicrous, as you so rightly say – and their having the luxury of changing that waypoint suggests surely that they had no desperate problems at that point (the matched power of the engines reinforces the picture of no control problems).
Having some confidence in the abilities and intelligence of the pilots, I personally cannot imagine them having got into that situation without having some other external reference that they believed reliable – it would have had to have been something in the immediate vicinity and intrinsically accurate. That's why I have suggested what I did.
KG86
<<The conspiracy theorists speculate on the fact that this was the top echelon of the Province's counter terrorist officers being flown by a Chinook SF crew. I can tell you that it was purely coincidental that a SF crew was on duty that day. The very same task was flown by a Chinook the year before with an 'ordinary' crew. >>
It was only the expedite and “absolutely no doubt whatsoever” blame on the pilots that prevented a large number of people becoming “conspiracy theorists”.
To me, it did not matter who was flying it – the concern to me was that they were all bundled into a single aircraft which crashed. When the same task was flown a year earlier, the team on board at that time would not have been seen as an obstacle to the peace process as this team was by those who had been holding secret talks with the IRA in the months leading up to the crash.
By the way, you and the other poster who are so adamant that there was no plan to land on the Mull – I thought there was a shortage of people that had intimate knowledge of their actual flight plan? This came out clearly in the FAI during the duty hours deliberations. Did you realise that even a momentory touch down on the mainland released them from the constraints of duty hours in the operational area? - and the Mull was just within their allowed time remaining.
Caz
As ever I bow to your experience, but what if a distraction prevented the aircraft being flown, even temporarily, due to, for example, a dodgy and functionally unsafe connector coming loose during in-flight servicing? As in SI/CHK/57.
Surely there are some distractions which are more distracting than others, like the apparent loss of an engine control unit? What did the FRCs say about the DECU recovery time if the connector was disconnected, then reconnected? Or its ability, or that of the power supplies, to cope with a single or multiple temporary interrupts?
If, as the evidence suggests, the connector was to be checked every 15 mins, statistically there is a reasonable chance that a check was being conducted in the timeframe under consideration.
As ever I bow to your experience, but what if a distraction prevented the aircraft being flown, even temporarily, due to, for example, a dodgy and functionally unsafe connector coming loose during in-flight servicing? As in SI/CHK/57.
Surely there are some distractions which are more distracting than others, like the apparent loss of an engine control unit? What did the FRCs say about the DECU recovery time if the connector was disconnected, then reconnected? Or its ability, or that of the power supplies, to cope with a single or multiple temporary interrupts?
If, as the evidence suggests, the connector was to be checked every 15 mins, statistically there is a reasonable chance that a check was being conducted in the timeframe under consideration.
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Tandemrotor
There was a record of the engine state, a/c orientation, and track all of which more strongly suggested steady flight until the last minute evasive manoeuvre when proximity to the ground must have been suddenly apparent rather than any kind of erratic demands one would have expected had there been any kind of control difficulties when desperately (as it would surely have been in this scenario) trying to avoid the known imminent contact with the ground.
You really do not need to have had a voice recording to judge which was the more likely - even if there had been a recorder, the way this case has unfolded, it would have likely been declared blank or missing or something.
There was a record of the engine state, a/c orientation, and track all of which more strongly suggested steady flight until the last minute evasive manoeuvre when proximity to the ground must have been suddenly apparent rather than any kind of erratic demands one would have expected had there been any kind of control difficulties when desperately (as it would surely have been in this scenario) trying to avoid the known imminent contact with the ground.
You really do not need to have had a voice recording to judge which was the more likely - even if there had been a recorder, the way this case has unfolded, it would have likely been declared blank or missing or something.
Last edited by walter kennedy; 18th Apr 2009 at 22:41. Reason: addition
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all of which more strongly suggested
You have a right to your opinion, as does everyone else and we can all argue our points. Unfortunately, for the crew, they cannot and they have never had the opportunity to do so; therein lies the injustice.
Walter Kennedy:
You've lost me there Walter. What record? I thought that the whole problem with this accident is that there was no record (ie ADR or CVR) and no witnesses to it. What record do you mean? If you are referring to the SuperTANS "postmortem" that was surely no record, more the absence of anything showing out of the ordinary in the very limited evidence available from it. If you refer to the engine remains as showing stable paired power output, again not a record other than the state at the moment of impact.
There was a record of the engine state, a/c orientation, and track all of which more strongly suggested steady flight until the last minute evasive manoeuvre
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<<If you refer to the engine remains as showing stable paired power output, again not a record other than the state at the moment of impact.>>
If you check it out, there was more to it - some historical data was obtained from one of the engine computers (whatever they're called) and no emergency power demands had been recorded - and the engines were closely matched to a degree which is normally arrived at by a steady state for a period in which either the pilot via his beep trim or the FADEC trims them. The final manoeuvre included a full pull up of the thrust lever/collective - the obvious conclusion from the engine data and this control position is that the time between the start of this manoeuvre and impact was so short that the engine system had not had time to react and so disturb the balanced state - they were taken by surprise - they had not been struggling with controls before this final, urgent action which would almost certainly have left the engine records and state rather different to what they were.
Why is it so many of you try so hard to argue against any and every piece of data having any value or relevance to the crash - some data is surely good? Still the old mantra of nothing can be known? Take your blinkers off just for an exercise - while you argue each point severally, you are missing the point that so many parameters correlate to a particular result very strongly. I would go so far as to say that everything that is known about this crash points to an intentional approach to that LZ with a misjudged closing range resulting in an overshoot.
Why they were going there is unknown and likely causes for that causal misjudgement are pure speculation - but the evidence for that failed approach is strong.
If you check it out, there was more to it - some historical data was obtained from one of the engine computers (whatever they're called) and no emergency power demands had been recorded - and the engines were closely matched to a degree which is normally arrived at by a steady state for a period in which either the pilot via his beep trim or the FADEC trims them. The final manoeuvre included a full pull up of the thrust lever/collective - the obvious conclusion from the engine data and this control position is that the time between the start of this manoeuvre and impact was so short that the engine system had not had time to react and so disturb the balanced state - they were taken by surprise - they had not been struggling with controls before this final, urgent action which would almost certainly have left the engine records and state rather different to what they were.
Why is it so many of you try so hard to argue against any and every piece of data having any value or relevance to the crash - some data is surely good? Still the old mantra of nothing can be known? Take your blinkers off just for an exercise - while you argue each point severally, you are missing the point that so many parameters correlate to a particular result very strongly. I would go so far as to say that everything that is known about this crash points to an intentional approach to that LZ with a misjudged closing range resulting in an overshoot.
Why they were going there is unknown and likely causes for that causal misjudgement are pure speculation - but the evidence for that failed approach is strong.
I'm not sure who the "so many of you" are, Walter. Personally my interest here started merely because it seemed such an outrageous travesty of justice. I still think that but my belief now is that injustice is a cover for a much greater scandal, that the Chinook HC2 was awarded its CAR though it was known to be unairworthy, mainly because of the FADEC design and software problems. The MOD wanted it in service and BD weren't going to prevent that. As soon as the accident happened the word was being put out that this was a human rather than technical error. Those who cast doubt on that, such as Sqn Ldr Burke were marginalised (ie told not to speak to the AAIB) and ridiculed (by no less than the SoS). That is why I think that the airworthiness of ZD576 is the key to this accident. As regards the post accident analysis of the engines, the main evidence came from the DECUs. One was badly damaged, the other less so and revealed no faults logged on itself for that flight. On that specious basis Reid said that both FADECs were found to have performed normally. Rubbish! Even if that were true they would be only as good as the software driving them, ie GIGO. It was a bone of contention that BD wanted it rewritten, but it wasn't and was found riddled with anomalies. That's conspiracy enough for me Walter without having to look for more spooks when there were more than enough in Main Building!
Chugalug2,
Can you say what has happened to the FADEC software that was "riddled with anomolies"? Should the current Chinook fleet be grounded if the same code is still in use and wasn't rewritten as BD wanted?
Rubbish! Even if that were true they would be only as good as the software driving them, ie GIGO. It was a bone of contention that BD wanted it rewritten, but it wasn't and was found riddled with anomalies
Well you tell me C240 (as I suspect you are about to anyway). Are the uncommanded power excursions and run downs still present? No? What made them go away? After 15 years I would imagine that even in a safety critical component such as this (ie if it ain't bust don't fix it) there would be redesign, revision and update. You know stuff like ensuring that the reversionary channel to the primary digital one wasn't itself digital?
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Chinook 240, the only FADEC I am interested in is the one fitted to ZD576 at the time of the accident. What the RAF/MoD have done since then is, with respect, a matter for them (although you might wish to search for the Chinook Mk3 threads).
At the time of the accident, EDS Scicon, were requested to analyse the FADEC code fitted to the Mk2. Their findings are below.
After reading 17.4% of the primary lane of FADEC software and 19% of the FADEC's reversionary, or back up, lane, they identified the following faults:
A category one anomaly indicates an actual coding error or non-compliance with the documentation. However this does not mean that it necessarily has any safety implications, it may not even affect the overall operation of the system. Each category one anomaly has to be investigated in this case ultimately by Hawker Siddeley to determine its impact on the system behaviour.
When a response from Hawker Siddeley indicates that an error does not have
any safety impact or does not significantly affect the operation of the system,it should be emphasised that latent errors in the code may still have serious implications for future maintenance of the system.”
So, chinook 240, what, if anything, has happened to the FADEC software?
Kind regards,
Brian
"Justice has no expiry date" - John Cook
At the time of the accident, EDS Scicon, were requested to analyse the FADEC code fitted to the Mk2. Their findings are below.
After reading 17.4% of the primary lane of FADEC software and 19% of the FADEC's reversionary, or back up, lane, they identified the following faults:
- 56 anomalies graded Category 1
- 193 anomalies graded Category 2
- 132 anomalies graded Category 3
- 104 anomalies graded Category 4
A category one anomaly indicates an actual coding error or non-compliance with the documentation. However this does not mean that it necessarily has any safety implications, it may not even affect the overall operation of the system. Each category one anomaly has to be investigated in this case ultimately by Hawker Siddeley to determine its impact on the system behaviour.
When a response from Hawker Siddeley indicates that an error does not have
any safety impact or does not significantly affect the operation of the system,it should be emphasised that latent errors in the code may still have serious implications for future maintenance of the system.”
So, chinook 240, what, if anything, has happened to the FADEC software?
Kind regards,
Brian
"Justice has no expiry date" - John Cook
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The code was rewritten...for the fadec software. Everyone flying the ch47 knows that....At the same time Decu problems were....removed...any loadie will tell u that.
Brian will I'm sure answer any questions posted towards him....GH
Brian will I'm sure answer any questions posted towards him....GH
Winchcontrol:
Thanks for the straight from the horse's mouth info, WC. As for your invitation above, well here goes for nothing as they say:
Brian, what is the aim of the Mull Group now? Do you merely want to see the unjust and outrageous findings of Wratten and Day struck from the record of Rick and Jon, or do you want to leave a more lasting legacy in their name? It seems to me that this thread has shown, perhaps even more strikingly than the Hercules or Nimrod ones, that the UK Military Airworthiness Authority (the MOD) deliberately flouted its own Regulations by pushing the Chinook HC2 into service despite specialist advice that it was unairworthy and should be grounded. This was not an aberration but par for the course, indeed I suspect many more accidents to those and other fleets will merely confirm that tragic reality if, like in this case, one dug deep enough. What the solution is will be the preoccupation of much worthier souls than we, no doubt. My two penneth of course is to take airworthiness provision out of the MOD entirely into a separate and independent MAA. Others may differ. The important thing is to start the ball rolling now. It must succeed and when it does it would be a fitting epitaph to the crew of ZD576. Do you agree?
Brian will I'm sure answer any questions posted towards him....
Brian, what is the aim of the Mull Group now? Do you merely want to see the unjust and outrageous findings of Wratten and Day struck from the record of Rick and Jon, or do you want to leave a more lasting legacy in their name? It seems to me that this thread has shown, perhaps even more strikingly than the Hercules or Nimrod ones, that the UK Military Airworthiness Authority (the MOD) deliberately flouted its own Regulations by pushing the Chinook HC2 into service despite specialist advice that it was unairworthy and should be grounded. This was not an aberration but par for the course, indeed I suspect many more accidents to those and other fleets will merely confirm that tragic reality if, like in this case, one dug deep enough. What the solution is will be the preoccupation of much worthier souls than we, no doubt. My two penneth of course is to take airworthiness provision out of the MOD entirely into a separate and independent MAA. Others may differ. The important thing is to start the ball rolling now. It must succeed and when it does it would be a fitting epitaph to the crew of ZD576. Do you agree?