Chinook - Still Hitting Back 3 (Merged)
Olive Oil:
I am very reluctant to disagree with Brian, but disagree I must. Given that the evidence that has emerged since the BoI points to severe airworthiness problems with the Chinook Mk2, that this was only too well known at the time, and the obvious witness to all its many manifestations, Sqn Ldr Burke, was never called; I would suggest that the BoI is proved to be totally inadequate. Therefore its finding should be simply put aside as any other finding would be similarly compromised. If the RAF is interested in Accident Prevention, which seems doubtful, I have already proposed that the BoI be reconvened and the new evidence taken from witnesses that were not previously called upon. Hopefully then the state of the aircraft's airworthiness may be found to have been a probable (without ADR or CVR the best you can get) cause of this accident. That of course would be down to the BoI, but you know and I know it ain't going to happen. Too many other reputations at stake. Hence the urgent need for an MAA and MAAIB to prevent future avoidable accidents which the present arrangements do not.
Just suppose that in the great scheme of revisionist history the gross negligence finding were to be dropped/rescinded/whatever.....
What finding would you have it replaced with?
What finding would you have it replaced with?
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JP:
That's quite telling... You had the time to come in and snipe at SFFP but, apparently, answering my question requires more consideration. Does this mean there is a question in your mind about the possibility of the scenario I presented?
That's quite telling... You had the time to come in and snipe at SFFP but, apparently, answering my question requires more consideration. Does this mean there is a question in your mind about the possibility of the scenario I presented?
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Chinook
Airborne Aircrew. You post the possibility that .... "The pilots approach the waypoint. The lighthouse is in fog but the "somewhat similar looking fog station site" is visible and they make the mistake of identifying it as the lighthouse. Now, the land ahead is 300' higher than it would have been but, that day, the optical illusion shrouded the actual higher ground and cloud to the left would appear to be shrouding what would be the higher ground... The picture "fits" so the two pilots fly on into what appears to be clear, though grey, sky ahead with Strato-Granite to their left under the cloud - the picture both pilots are "expecting" to see".
I entirely agree that that this may well have been the case!!!*. But that such confusion was possible, WAS the negligence. In other words, they should have turned away before exposing themselves to such dangerous and ultimately fatal possibilities. (*In order to accommodate your thesis, I am of course ignoring for the moment the ten witnesses on the hillside who testified to a visibility of 10/ 25 meters).
I am sorry that someone who claims to be 'Airborne Aircrew' cannot see that.
As to the 'Burmuda Triangle' you mention, should we add that possibility to the some of thes others on this thread, eg distracting flies in the cockpit, a false IRA beacon etc? With all good wishes, JP
I entirely agree that that this may well have been the case!!!*. But that such confusion was possible, WAS the negligence. In other words, they should have turned away before exposing themselves to such dangerous and ultimately fatal possibilities. (*In order to accommodate your thesis, I am of course ignoring for the moment the ten witnesses on the hillside who testified to a visibility of 10/ 25 meters).
I am sorry that someone who claims to be 'Airborne Aircrew' cannot see that.
As to the 'Burmuda Triangle' you mention, should we add that possibility to the some of thes others on this thread, eg distracting flies in the cockpit, a false IRA beacon etc? With all good wishes, JP
Last edited by John Purdey; 8th Jun 2009 at 16:06.
Don't see how succumbing to an optical illusion while flying VMC can count as "gross negligence".
Rather like the RAF Wessex that crashed a few years earlier, hovering in the Highlands, when the blades were too close to the hillside. That was caused by an optical illusion. A civilian passenger was killed.
No recriminations from 'on high' on that one.
Rather like the RAF Wessex that crashed a few years earlier, hovering in the Highlands, when the blades were too close to the hillside. That was caused by an optical illusion. A civilian passenger was killed.
No recriminations from 'on high' on that one.
Avoid imitations
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Similarly, the fatal Wessex night crash at Forkhill, where the pilot became disorientated and the aircraft drifted into the radio mast and rolled down the hill.
Or the Puma in Rhodesia which fatally crashed after hitting a low slung power cable (18 feet agl estimated by the BOI) with the rotor mast, which sits 16 feet up.
Both also in operational theatres.
Or the Puma in Rhodesia which fatally crashed after hitting a low slung power cable (18 feet agl estimated by the BOI) with the rotor mast, which sits 16 feet up.
Both also in operational theatres.
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In other words, they should have turned away before exposing themselves to such dangerous and ultimately fatal possibilities.
I'll ask again, are you stating categorically that this did not happen?
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Chinook
AA It seems from what you say that it is not just this crew who suffered from illusions of one kind or another. How can you possibly postulate clear skies over the hills when there were so many witnesse, scattered on the hillside, who all agreed that the visibility was absolutely minimal? With that kind of weather ahead, would you - as an airborne aviator , which I take you to be - have flown straight on?
I really thought this thread had finished discussing the weather over the hills some time ago, because of all those on-the-spot witnesses. That was why we got into 'flies in the cockpit' theories and so on.
And now we have your Bermuda Triangle to think about.
By the way, what happened to the possibility mentioned a few weeks back that it was all a government sponsored murder?
If we are to have a discussion, may we please have a more rational one?
Regards. JP
I really thought this thread had finished discussing the weather over the hills some time ago, because of all those on-the-spot witnesses. That was why we got into 'flies in the cockpit' theories and so on.
And now we have your Bermuda Triangle to think about.
By the way, what happened to the possibility mentioned a few weeks back that it was all a government sponsored murder?
If we are to have a discussion, may we please have a more rational one?
Regards. JP
JP,
We may have finished discussing the weather over the hills but your theory depends on the weather seen from the cockpit. You have consistently refused to remove the doubt about this. All you seem to be able to do now is ridicule all other theories by putting them in the "flies in the cockpit" category. That really is an act of desperation.
So tell us, in what category do you put the evidence given to the HoL by Sq Ldr Burke? I realise that you think it is not relevant because, in your view, negligence occurred at waypoint change when they appeared to be under control. But, unless you can have no doubt about the view from the cockpit, you cannot ignore other possibilities.
I really thought this thread had finished discussing the weather over the hills some time ago, because of all those on-the-spot witnesses.
So tell us, in what category do you put the evidence given to the HoL by Sq Ldr Burke? I realise that you think it is not relevant because, in your view, negligence occurred at waypoint change when they appeared to be under control. But, unless you can have no doubt about the view from the cockpit, you cannot ignore other possibilities.
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John,
You're obviously too bright to be this dense so I have to assume you are being deliberately obtuse.
I accept the fact that the hill was in cloud but, as other people here have referenced, there seems to be certain situations where a cloud that obscures a hillside blends in with the distant sky such that it appears to be open sky ahead.
Link
My emphasis...
Link
I hope that helps you visualize the scenario and allows you no other way to be evasive...
You're obviously too bright to be this dense so I have to assume you are being deliberately obtuse.
I accept the fact that the hill was in cloud but, as other people here have referenced, there seems to be certain situations where a cloud that obscures a hillside blends in with the distant sky such that it appears to be open sky ahead.
" In light winds and high relative humidity, layers of fog and low cloud form adjacent to the Mull to obscure the high ground completely. There are occasions when a relatively calm sea and a grey sky of similar hue merge, so that in otherwise good visibility a pilot flying in accordance with Visual Flight Rules may be unaware that he is about to enter a fog/cloud bank."
My emphasis...
There are issues which the Board were unable to totally discount (though apparently the Air Marshalls could!)
They were:
a. Spatial disorientation or visual illusion
They were:
a. Spatial disorientation or visual illusion
I hope that helps you visualize the scenario and allows you no other way to be evasive...
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JP
We spoke about the matter of weather in Feb 08 and it became clear to me that we would never agree and that you would never understand. The conditions mentioned above very well cover what I experienced that evening. False horizon, cloud and hill merging to give deceptive aspect etc etc, but still in sight of surface and clear of cloud. I have never been able to understand why so much emphasis was put on the eye witness reports on the ground..er ..they were on the ground. I accept that the lighthouse keepers may have been trained met observers, but their experience was not in aviation meteorology.
At Carradale visibility in one direction on the ground was very poor in certain directions but good in others, by the same token an observer in the air (ie me) looking in the same direction could find himself with a completely different view.
Unless you can clear the matter up without doubt I do not see how it can be "put to bed"
rgds
DL
At Carradale visibility in one direction on the ground was very poor in certain directions but good in others, by the same token an observer in the air (ie me) looking in the same direction could find himself with a completely different view.
Unless you can clear the matter up without doubt I do not see how it can be "put to bed"
rgds
DL
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so that in otherwise good visibility a pilot flying in accordance with Visual Flight Rules may be unaware that he is about to enter a fog/cloud bank."
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But they knew that they were close to land...they knew that they were flying near to the Mull....and you are suggesting that they couldn't see it...?
As JP stated had they come ashore closer to the lighthouse, (where they expected to), then they would have had 300' more leeway with regard to height on their track. In my scenario I accept JP's proposition that they came ashore alongside the fog station and therefore no longer had that 300' of airspace ahead.
Place yourself in their position. You think you just came ashore at the lighthouse and looking at the map and your track you see that, (were you actually on that track), the higher ground would be to your left as you proceed, (Per JP's own writing). While looking in that direction you see obvious cloud that you don't turn towards because you don't want to enter IMC and you "know", (erroneously because the high ground you expect to be there is dead ahead), there to be a hill hidden in it.
At this time, on this day, the weather factors combine to create the illusion directly ahead of the aircraft, (where the pilots believe the lower ground to be - and it would be if they had come ashore at the lighthouse not the fog station), that there was clear sky similar to the illusion mentioned in my last post. So, looking slightly down the pilots can see the ground and it appears to reach a ridge that will be below them should they continue on the same heading and at the same level or rate of climb, (I'm unsure if they initiated a climb but in this scenario it matters not because they think they are VMC with clear sky on their intended path). Turning their heads towards the left they could see cloud that they believe is shrouding the higher ground.
At this point, looking out of the cockpit they are traversing medium high ground be it in a climb or in level flight with cloud to their left. This would be a totally acceptable visual picture upon checking a map of the area.
Unfortunately the ridge was not a ridge, it was the lower portion of the higher ground they thought were traversing to the right of while the upper portion, due to the meteorological anomoly, was hidden from them directly on their track and they flew straight into it.
I really find it difficult to believe that my writing has been so unclear that I have to write this in such detail and for the third or fourth time for gentlemen that were never shy about informing me in the past how quick, bright and intelligent they were.
My only remaining resort will be to draw a picture, (which I can do but you will, forever, label yourself as an idiot if you force me to draw it for you).
So, would anyone who has stated that there is no doubt whatsoever that the finding of Gross Negligence like to address the probability of the scenario outlined in this post?
AA,
Annexes J & K of the linked document would save you the bother of drawing a picture and thus avoiding labeling someone.
http://www.mod.uk/NR/rdonlyres/B4E75...t_response.pdf
Annexes J & K of the linked document would save you the bother of drawing a picture and thus avoiding labeling someone.
http://www.mod.uk/NR/rdonlyres/B4E75...t_response.pdf
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John Purdey,
Wessex, Puma, other visual illusion accidents.
How many "Gross Negligence" verdicts?
Am I saying this was a visual illusion accident?
No. I have no idea, but it is as good a hypothesis as any.
Wessex, Puma, other visual illusion accidents.
How many "Gross Negligence" verdicts?
Am I saying this was a visual illusion accident?
No. I have no idea, but it is as good a hypothesis as any.
One of the best documents I've read on this accident was the Computer Weekly report.
Some may say its biased (in that it tells the truth, concluding that the verdict is unsustainable because the burden of proof was not met) but anyone remotely connected with the MoD will recognise many of the author's source(s) were clearly within MoD.
I think it is time to update this report in the light of facts that have emerged in the last 9 years. (Facts that were available to the BoI etc but withheld, so do not constitute “new evidence” according to MoD). I'd particularly like to see a deeper discussion of the long list of MoD lies and deceit (Chapter 7). The only reason for lying is to hide the truth.
Also, the many subsequent lies should be added, as they help one see the wider picture. One of the real howlers is Adam Ingram's claim in 2005 that ZD576 was a new aircraft, so any accumulation of legacy problems from before October 1993 is a non-issue. (The point being that the conversion to Mk2 may just have been the straw which broke the camel’s back). Such a claim neatly avoids discussion of problems arising from one of the most common shortcuts taken on such programmes - unverified read across. This is always dangerous, especially when the thrust of the upgrade is introducing a new device such as FADEC, which is Safety Critical (although MoD deny this, saying the aircraft will always auto-rotate to a safe landing) and susceptible to Electro-Magnetic Interference.
Have a read of, for example, Def Stan 00-970 - Part 1/5, Section 6.10 - "EMC of Safety Critical Systems", and related chapters. If MoD do not regard FADEC as “Safety Critical”, one wonders if they applied Ch. 6.10? And then read the Master Airworthiness Reference. The two cannot be reconciled.
Sorry for the bit of techy stuff, but the manifestation of all this was the pilots’ lack of confidence in the Mk2. If the end-user isn’t confident in the product you’ve given him, you’ve failed. This failure MUST be a significant factor to consider in any subsequent investigation. That’s why the regs mandate it.
Some may say its biased (in that it tells the truth, concluding that the verdict is unsustainable because the burden of proof was not met) but anyone remotely connected with the MoD will recognise many of the author's source(s) were clearly within MoD.
I think it is time to update this report in the light of facts that have emerged in the last 9 years. (Facts that were available to the BoI etc but withheld, so do not constitute “new evidence” according to MoD). I'd particularly like to see a deeper discussion of the long list of MoD lies and deceit (Chapter 7). The only reason for lying is to hide the truth.
Also, the many subsequent lies should be added, as they help one see the wider picture. One of the real howlers is Adam Ingram's claim in 2005 that ZD576 was a new aircraft, so any accumulation of legacy problems from before October 1993 is a non-issue. (The point being that the conversion to Mk2 may just have been the straw which broke the camel’s back). Such a claim neatly avoids discussion of problems arising from one of the most common shortcuts taken on such programmes - unverified read across. This is always dangerous, especially when the thrust of the upgrade is introducing a new device such as FADEC, which is Safety Critical (although MoD deny this, saying the aircraft will always auto-rotate to a safe landing) and susceptible to Electro-Magnetic Interference.
Have a read of, for example, Def Stan 00-970 - Part 1/5, Section 6.10 - "EMC of Safety Critical Systems", and related chapters. If MoD do not regard FADEC as “Safety Critical”, one wonders if they applied Ch. 6.10? And then read the Master Airworthiness Reference. The two cannot be reconciled.
Sorry for the bit of techy stuff, but the manifestation of all this was the pilots’ lack of confidence in the Mk2. If the end-user isn’t confident in the product you’ve given him, you’ve failed. This failure MUST be a significant factor to consider in any subsequent investigation. That’s why the regs mandate it.
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A play on words.....
The ROs were fully aware of the standard of proof required iaw the guidance contained within AP3207, and in consultation with the incumbent Director of Legal Services (RAF). However, the guidelines were not worded to state that Day/Wratten had to establish causal facts to find Jon and Rich grossly negligent. All the ROs had to satisfy was that they had to be in no doubt whatsoever regarding the finding of gross negligence.
i.e. (in Jon's case) Day concluded that Jon was negligent to a gross degree at or before the waypoint change - he didn't have to prove it, he just had to believe it.
AA
i.e. (in Jon's case) Day concluded that Jon was negligent to a gross degree at or before the waypoint change - he didn't have to prove it, he just had to believe it.
AP3207 – RAF Manual of Flight Safety, Chapter 8, Appendix G, page 9 states "ONLY IN CASES IN WHICH THERE IS ABSOLUTELY NO DOUBT WHATSOEVER SHOULD DECEASED AIRCREW BE FOUND NEGLIGENT
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Of course the RO's beliefs were based on an incomplete picture - provided by the RO's own interpretation of the incomplete BOI; a self-induced 'mental illusion' if you like!
The BOI had concluded that nothing was certain but somehow the ROs managed to twist the fact the ac crashed into a hill that was IMC as definite proof that the crew were flying in IMC at low-level in the vicinity of the Mull 20 secs before. The two are not directly linked and cannot be proven with the requisite burden of proof.
This is because Holbrook said that he physically saw the ac below cloud approaching the Mull, close to the waypoint change - perhaps the most relevant piece of evidence in the whole BOI because if Mr Holbrook could see the ac, the crew could see him, so they were not in cloud.
Furthermore, there exists an element of doubt as to how far and how low the cloud extended - somehow, the ROs did not fully appreciate that those 9 witnesses on land (above approx 3-400 ft amsl) were in cloud and they could in no way describe the weather as seen from the cockpit of an ac that was below cloud. Also, the ROs missed the point that there were no witnesses below the cloud, near the shore, who could confirm (or deny) the extent of the cloud over the sea. Instead, the ROs based their findings/beliefs on the BOIs 'probable cause' - in itself the word 'probable' does not meet the burden of proof. Frankly, if RAF justice is only about some Staff Officer's 'beliefs' then the system really is FUBAH! Of course he would need proof and hard facts on which to base his findings - but there weren't any - just a belief!
Now, if the ac had purposefully entered cloud at 300ft, so close to the Mull that they could neither turn away onto a northerly heading to avoid land, slow down, nor immediately conduct an LL abort to safety altitude for the selected leg, then yes, the crew would have got it wrong. Even then, as there were possible outside effects (disorientaion/distraction/tightening wind etc), this is more an 'error of judgment' but not 'gross negligence'.
Despite not fully considering the impact of the lack of airworthiness (not serviceability) of the ac, which would have been a pre-disposing 'latent pathogen', the BOI stated that they could not positively dismiss distraction from an (over-common) transient engine fault, visual illusion, disorientation nor UFCM as contributory factors as to why they entered cloud. These further undermine the plausibility of the eventual 'probable cause' which itself was based on a somewhat-dubious Boeing simulation and the assumption that the ac was under control when it entered cloud. (If you assume you make an 'ass' out of 'u' and 'me'!)
Basically, there were few hard facts other than: a hillside strewn with debris, a sighting of the ac clear of cloud a few seconds before and the fact the hill above approx 300ft was in cloud. Without an ADR/CVR, everything about how they got from overhead Mr Holbrook's yacht to the hillside is supposition.
Nonetheless, I can understand how the ROs came to their conclusions - they are only human but they did get it wrong. However, I am not attaching blame to them (unless this was a wilful cover-up). But now with the benefit of hindsight, to blindly repeat their assertions makes the ROs look very foolish, stubborn and intransigent; as someone said - a little like the 'flat-earth society'! We would have greater respect for them if they could take off their blinkers and accept the considered opinions of the wider world, including their former Def Sec and PM, who would expect the ROs to be more flexible and mature in their thinking. I wonder, if Her Majesty agreed with her previous Prime Minister and his Def Sec, whether the ROs would remain so unmoved?.....Probably!
The BOI had concluded that nothing was certain but somehow the ROs managed to twist the fact the ac crashed into a hill that was IMC as definite proof that the crew were flying in IMC at low-level in the vicinity of the Mull 20 secs before. The two are not directly linked and cannot be proven with the requisite burden of proof.
This is because Holbrook said that he physically saw the ac below cloud approaching the Mull, close to the waypoint change - perhaps the most relevant piece of evidence in the whole BOI because if Mr Holbrook could see the ac, the crew could see him, so they were not in cloud.
Furthermore, there exists an element of doubt as to how far and how low the cloud extended - somehow, the ROs did not fully appreciate that those 9 witnesses on land (above approx 3-400 ft amsl) were in cloud and they could in no way describe the weather as seen from the cockpit of an ac that was below cloud. Also, the ROs missed the point that there were no witnesses below the cloud, near the shore, who could confirm (or deny) the extent of the cloud over the sea. Instead, the ROs based their findings/beliefs on the BOIs 'probable cause' - in itself the word 'probable' does not meet the burden of proof. Frankly, if RAF justice is only about some Staff Officer's 'beliefs' then the system really is FUBAH! Of course he would need proof and hard facts on which to base his findings - but there weren't any - just a belief!
Now, if the ac had purposefully entered cloud at 300ft, so close to the Mull that they could neither turn away onto a northerly heading to avoid land, slow down, nor immediately conduct an LL abort to safety altitude for the selected leg, then yes, the crew would have got it wrong. Even then, as there were possible outside effects (disorientaion/distraction/tightening wind etc), this is more an 'error of judgment' but not 'gross negligence'.
Despite not fully considering the impact of the lack of airworthiness (not serviceability) of the ac, which would have been a pre-disposing 'latent pathogen', the BOI stated that they could not positively dismiss distraction from an (over-common) transient engine fault, visual illusion, disorientation nor UFCM as contributory factors as to why they entered cloud. These further undermine the plausibility of the eventual 'probable cause' which itself was based on a somewhat-dubious Boeing simulation and the assumption that the ac was under control when it entered cloud. (If you assume you make an 'ass' out of 'u' and 'me'!)
Basically, there were few hard facts other than: a hillside strewn with debris, a sighting of the ac clear of cloud a few seconds before and the fact the hill above approx 300ft was in cloud. Without an ADR/CVR, everything about how they got from overhead Mr Holbrook's yacht to the hillside is supposition.
Nonetheless, I can understand how the ROs came to their conclusions - they are only human but they did get it wrong. However, I am not attaching blame to them (unless this was a wilful cover-up). But now with the benefit of hindsight, to blindly repeat their assertions makes the ROs look very foolish, stubborn and intransigent; as someone said - a little like the 'flat-earth society'! We would have greater respect for them if they could take off their blinkers and accept the considered opinions of the wider world, including their former Def Sec and PM, who would expect the ROs to be more flexible and mature in their thinking. I wonder, if Her Majesty agreed with her previous Prime Minister and his Def Sec, whether the ROs would remain so unmoved?.....Probably!
Last edited by flipster; 9th Jun 2009 at 17:14.
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I really find it difficult to believe that my writing has been so unclear
However, I don't believe that they were negligent.... just foolish.