Chinook - Still Hitting Back 3 (Merged)
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The BoI and Airworthiness
Dervish,
Can I add a bit of background to Tucumseh's response to your post earlier today. You say that the BoI report raised airworthiness issues and that is true - but they did not raise them in their own minds - they left unused evidence and unanswered questions that certainly raised airworthiness as an issue in the minds of others such as myself. A word search of the BoI and Reviewing Officers' comments will not give you one "hit" on the word "airworthiness".
In October 2002, at Michael Tapper's request, I did a full analysis of the airworthiness and engineering aspects of the BoI which was placed on the campaign website at the time -http://chinook-justice.org/ - it seems to have been deleted but I will be happy to send you a copy if you are interested - please PM me with the address I can send them to. At the same time a single page "Airworthiness" summary was written and both the full report and the summary were given to MoD - by C4 News and Lord Chalfont if I remember correctly. Both were dimissed by MoD as "no new evidence" even though they started from the premise of "unused" evidence, and made no claims to have "new" evidence. Since then of course we have seen many further documents such as the BD letters and the CHART report which appear to have "by-passed" the BoI, and real airworthiness experts such as Tucumseh have taken up the cause - not least because we can now see how long-dated and systemic the failures had become, and we can see how many further lives have been lost as a result of airworthiness and the related "fitness for purpose" issues.
As you point out in your last paragraph an aircraft being unairworthy does not necessarily cause it to crash, and I am not aware that any of the airworthiness campaigners have ever gone down the road of speculation that this was the cause (unlike the speculation that leads to the Gross Negligence verdict). What the airworthiness issues do though is to further reinforce the doubts - doubts that should anyway never have allowed such a verdict to be seen as fair and just even under the RAF's own rules. The reversing of this verdict and the clearing of the pilots' names remains my own priority, and I believe is the priority for all the "airworthiness" campaigners in what is now though a much wider area for concern.
The irony of course is that as a result of this verdict MoD and the RAF have dug an even bigger hole for themselves, and they continue to do so as we have learnt more about both the introduction to service of the Mk2 and the widespread "airworthiness" malaise which has existed for so long - culminating in the loss of Nimrod XV230, and leading to Haddon-Cave's Inquiry, the formation of the MAA and even, I would argue, the "loss" of the MRA4s. About as spectacular an "own goal" as would have been possible, and a tragedy for all those families who have lost loved ones as a direct result of these failings - this is where I suggest some quite justified considerations of gross negligence would be more appropriate!
JB
Can I add a bit of background to Tucumseh's response to your post earlier today. You say that the BoI report raised airworthiness issues and that is true - but they did not raise them in their own minds - they left unused evidence and unanswered questions that certainly raised airworthiness as an issue in the minds of others such as myself. A word search of the BoI and Reviewing Officers' comments will not give you one "hit" on the word "airworthiness".
In October 2002, at Michael Tapper's request, I did a full analysis of the airworthiness and engineering aspects of the BoI which was placed on the campaign website at the time -http://chinook-justice.org/ - it seems to have been deleted but I will be happy to send you a copy if you are interested - please PM me with the address I can send them to. At the same time a single page "Airworthiness" summary was written and both the full report and the summary were given to MoD - by C4 News and Lord Chalfont if I remember correctly. Both were dimissed by MoD as "no new evidence" even though they started from the premise of "unused" evidence, and made no claims to have "new" evidence. Since then of course we have seen many further documents such as the BD letters and the CHART report which appear to have "by-passed" the BoI, and real airworthiness experts such as Tucumseh have taken up the cause - not least because we can now see how long-dated and systemic the failures had become, and we can see how many further lives have been lost as a result of airworthiness and the related "fitness for purpose" issues.
As you point out in your last paragraph an aircraft being unairworthy does not necessarily cause it to crash, and I am not aware that any of the airworthiness campaigners have ever gone down the road of speculation that this was the cause (unlike the speculation that leads to the Gross Negligence verdict). What the airworthiness issues do though is to further reinforce the doubts - doubts that should anyway never have allowed such a verdict to be seen as fair and just even under the RAF's own rules. The reversing of this verdict and the clearing of the pilots' names remains my own priority, and I believe is the priority for all the "airworthiness" campaigners in what is now though a much wider area for concern.
The irony of course is that as a result of this verdict MoD and the RAF have dug an even bigger hole for themselves, and they continue to do so as we have learnt more about both the introduction to service of the Mk2 and the widespread "airworthiness" malaise which has existed for so long - culminating in the loss of Nimrod XV230, and leading to Haddon-Cave's Inquiry, the formation of the MAA and even, I would argue, the "loss" of the MRA4s. About as spectacular an "own goal" as would have been possible, and a tragedy for all those families who have lost loved ones as a direct result of these failings - this is where I suggest some quite justified considerations of gross negligence would be more appropriate!
JB
Dervish, excellent posts, Sir! You get to the very nub of a general malaise not only in airworthiness provision but also in airworthiness appreciation. The lack of interest and awareness by pilots in particular of this vital protection and safeguard, not only of their backsides, but also of those that they take with them into the wide blue yonder, is only too apparent in many posts on this forum. I can only assume that this seeming contempt for something that should be central to the professional pilot philosophy has been spread almost deliberately by the Forces of Evil that prevailed over the destruction of UK Military Airworthiness. As tuc points out, remove the follow up action to Flight Safety related reporting and the need and effectiveness of doing so is soon replaced in peoples minds with the feeling that it is a waste of time. Move one stage on and Flight Safety itself is a waste of time. Rufty, tufty members have posted as much in this Military Forum. Those who champion airworthiness reform here are seen to be riding a Hobby Horse, pushing their own agenda, and deflecting from the single declared intent of simply reversing the Finding of Pilot Gross Negligence.
Time perhaps we confront this issue square on. No-one knows for sure why Chinook HC2 ZD576 crashed on the Mull slopes in 1994. Not Wratten, not Day, not the BoI, the FAI, the HoL, the HoC, nor the Coroner, nor will we ever know for sure. The only thing we now know for sure is that ZD576 was Grossly Unairworthy, along with all its sister HC2's.
Those three preceding sentences, if accepted, mean that the Air Marshals' Finding is untenable and should be reversed by the Royal Air Force. It promulgated it in the first place, it alone can reverse it. Not to put to fine a point on it, its honour has been sullied ever since.
The real reason why Mull is so important to modern military aviation is that it then signalled the reckless criminal cost of the deliberate destruction of UK Military Airworthiness. That signal was not heeded then and has only been partially heeded since. More than 60 lives have been lost and still all we have is the typically British fudge of an "independent" MAA but within the MOD! More lives still will be lost if this isn't properly and professionally resolved. Nothing short of a completely separate and independent Regulator and Accident Investigator will suffice, ie a truly independent MAA and MAAIB. It's your backside, and even more important than yours are the other backsides that are strapped into your aircraft.
Hobby Horse? Maybe, but I for one don't intend climbing down from this one until it is properly stabled and the door bolted!
Time perhaps we confront this issue square on. No-one knows for sure why Chinook HC2 ZD576 crashed on the Mull slopes in 1994. Not Wratten, not Day, not the BoI, the FAI, the HoL, the HoC, nor the Coroner, nor will we ever know for sure. The only thing we now know for sure is that ZD576 was Grossly Unairworthy, along with all its sister HC2's.
Those three preceding sentences, if accepted, mean that the Air Marshals' Finding is untenable and should be reversed by the Royal Air Force. It promulgated it in the first place, it alone can reverse it. Not to put to fine a point on it, its honour has been sullied ever since.
The real reason why Mull is so important to modern military aviation is that it then signalled the reckless criminal cost of the deliberate destruction of UK Military Airworthiness. That signal was not heeded then and has only been partially heeded since. More than 60 lives have been lost and still all we have is the typically British fudge of an "independent" MAA but within the MOD! More lives still will be lost if this isn't properly and professionally resolved. Nothing short of a completely separate and independent Regulator and Accident Investigator will suffice, ie a truly independent MAA and MAAIB. It's your backside, and even more important than yours are the other backsides that are strapped into your aircraft.
Hobby Horse? Maybe, but I for one don't intend climbing down from this one until it is properly stabled and the door bolted!
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Tuc
Just a thought.
If you have the name of the person who buried the CHART report and fatal accidents can be directly attributed to this burial.
Shouldn't this information be in the hands of DPP instead / as well as Lord Philip?
Just a thought.
If you have the name of the person who buried the CHART report and fatal accidents can be directly attributed to this burial.
Shouldn't this information be in the hands of DPP instead / as well as Lord Philip?
Per Ardua ad Astraeus
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Out of interest is anyone aware of any (subsequent) comment from members of the BoI?
- absolutely.
Originally Posted by chugs
Time perhaps we confront this issue square on. No-one knows for sure why Chinook HC2 ZD576 crashed on the Mull slopes in 1994. Not Wratten, not Day, not the BoI, the FAI, the HoL, the HoC, nor the Coroner, nor will we ever know for sure. The only thing we now know for sure is that ZD576 was Grossly Unairworthy, along with all its sister HC2's.
Those three preceding sentences, if accepted, mean that the Air Marshals' Finding is untenable and should be reversed by the Royal Air Force. It promulgated it in the first place, it alone can reverse it. Not to put to fine a point on it, its honour has been sullied ever since.
Those three preceding sentences, if accepted, mean that the Air Marshals' Finding is untenable and should be reversed by the Royal Air Force. It promulgated it in the first place, it alone can reverse it. Not to put to fine a point on it, its honour has been sullied ever since.
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cazatou
No caz, it is not sub judice. That applies only when a matter is before a court of law or is being considered by a judge as part of a judicial process. However eminent a judge Lord Philip may have been, he is now a retired judge conducting an Inquiry. A very different status and not sub judice.
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John Purdey
You are alive and well and still monitoring this thread. I saw your last reply which you quickly thought the better of and removed.
I have a question for you.
If someone chooses to to suppress documents and that suppression can be shown to have contributed to later fatal accidents, should that person be held responsible for those accidents.
As you have said to me in the past. Cut out the waffle. A simple yes or no will suffice.
You are alive and well and still monitoring this thread. I saw your last reply which you quickly thought the better of and removed.
I have a question for you.
If someone chooses to to suppress documents and that suppression can be shown to have contributed to later fatal accidents, should that person be held responsible for those accidents.
As you have said to me in the past. Cut out the waffle. A simple yes or no will suffice.
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JP:
Dalek said:
You responded:
Were you always that slippery?
I'm also interested in your response to Dalek's question. Whether documents had been swept under a rug or not for the fatal Falklands crash I lost a few people I called friends in that. It horrified me when we were subsequently ordered not to discuss the potential cause with the bereaved "in case it embarrassed Boeing"...
Dalek said:
If someone chooses to to suppress documents and that suppression can be shown to have contributed to later fatal accidents, should that person be held responsible for those accidents.
Dalek. I did not remove my last post, and I am left wondering who did. For those interested, I pointed out that a Review is not the same as an Inquiry. JP
I'm also interested in your response to Dalek's question. Whether documents had been swept under a rug or not for the fatal Falklands crash I lost a few people I called friends in that. It horrified me when we were subsequently ordered not to discuss the potential cause with the bereaved "in case it embarrassed Boeing"...
AA
ZD576 Fatal Accident Inquiry – Witness J
Boeing Vertol have a vested interest in deterring any report which leaves them liable. This company is well funded and has shown a determination in the past to influence the outcome of inquiries. When Wg Cdr M Pledger took command of 78 Sqn in the Falkland Islands in Feb 88 I asked him to brief the Chinook Flight on the findings of the BOI for the fatal crash which killed Flt Lts Moffat, Newman, Sgt Johns and a number of engineering personnel, as this had not then been published. As Chairman of the board of inquiry he briefed 2 findings: the first his own most probable cause (failure of a hydraulic jack due to poor quality control at Boeing Vertol) and then that which would actually be published due to the failure of MOD to face pressure brought to bear by Boeing Vertol (cause unknown).
Haddon-Cave Report
Criticisms of Sir Malcolm Pledger
In my view, however, Sir Malcolm Pledger, did have a number of options and duties on taking up his appointment as the new CDL which he did not avail himself of or fulfil.......
Please tell me .......
It horrified me when we were subsequently ordered not to discuss the potential cause with the bereaved "in case it embarrassed Boeing"...
ZD576 Fatal Accident Inquiry – Witness J
Boeing Vertol have a vested interest in deterring any report which leaves them liable. This company is well funded and has shown a determination in the past to influence the outcome of inquiries. When Wg Cdr M Pledger took command of 78 Sqn in the Falkland Islands in Feb 88 I asked him to brief the Chinook Flight on the findings of the BOI for the fatal crash which killed Flt Lts Moffat, Newman, Sgt Johns and a number of engineering personnel, as this had not then been published. As Chairman of the board of inquiry he briefed 2 findings: the first his own most probable cause (failure of a hydraulic jack due to poor quality control at Boeing Vertol) and then that which would actually be published due to the failure of MOD to face pressure brought to bear by Boeing Vertol (cause unknown).
Haddon-Cave Report
Criticisms of Sir Malcolm Pledger
In my view, however, Sir Malcolm Pledger, did have a number of options and duties on taking up his appointment as the new CDL which he did not avail himself of or fulfil.......
Please tell me .......
Anyone got a reference to the Falklands accident; and who the Reviewing Officers were ?
The reference to Flt Lt Moffat brings back memories - was at his wedding when he married a fellow IOT flt cdr (what WAS her name?), and I had flown as pax in that aircraft only a couple of weeks earlier.
RIP
RIP
Anyone got a reference to the Falklands accident; and who the Reviewing Officers were ?
Part 4 - Remarks of Air Officer Commanding - AVM R J Honey Deputy Commander RAF Germany
Part 5 - Remarks by the Air Officer Commanding-in-Chief Strike Command - ACM P R Harding.
"...discounts malfunction of ..... DASH..."
And yet, Boscombe Down, in their Mk2 CAR recommendations.
22.10.93 “The DASH (Differential Airspeed Hold) Low Rate caption was not consistent with the DASH feedback signal, and was not an indication of any rate of actuator movement. The title of the caption was inaccurate”.
26.10.93 "There remains a requirement for a Differential Airspeed Hold (DASH) actuator runaway warning device. This requirement, often stated by (Boscombe Down) and most recently justified at Reference C (Letter APF/246/13 dated 11th April 1990) was considered Essential for CA Release for the Chinook HC Mk1, and remains so for the HC Mk2. This matter will be covered in detail in the definitive CA Release recommendations, but it is considered relevant to restate the Establishment’s position once again at this stage”.
No action taken. 13 days later the CA Release was signed, swiftly followed by the Release to Service. (As ever, I acknowledge MoD completely denies the existence of an RTS in Nov 1993. My copy, dated Nov 1993, is very clear).
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Witness J 7754
I am amazed that this witness was allowed to make the statement that Boeing Vertol had a vested interest in deterring any report that leaves them liable.
Surely someone from either the Company or MOD must have attempted to refute this statement later in the report.
If not, why were Boeing Vertol allowed to be the sole arbiters of the interpretation of events leading to the Mull crash.
They were always going to find any interpretation which freed the company from liability.
Good man Witness J. If he was allowed to make the statement without challenge, there must have been no possible defence.
Surely someone from either the Company or MOD must have attempted to refute this statement later in the report.
If not, why were Boeing Vertol allowed to be the sole arbiters of the interpretation of events leading to the Mull crash.
They were always going to find any interpretation which freed the company from liability.
Good man Witness J. If he was allowed to make the statement without challenge, there must have been no possible defence.
A good man indeed, Dalek, and one that reminds us yet again that for evil to happen it merely requires good men to do nothing. This one though stood up to be counted, but unfortunately was the exception rather than the rule. There comes a point when, whether one is "allowed" to or not, it is necessary to emulate Witness J's example.
Being ordered to accept the "DS solution" cause of an accident and to ignore the real one constitutes an illegal order in my book. Just because the SS ones concerned grenades, POW's and barns doesn't mean that other ones, concerning airworthiness, known faults, and a subsequent illegal RTS, aren't.
It's a simple enough concept, know what is right and what is wrong. Always do what you know to be right. All the rest is rhetoric.
Being ordered to accept the "DS solution" cause of an accident and to ignore the real one constitutes an illegal order in my book. Just because the SS ones concerned grenades, POW's and barns doesn't mean that other ones, concerning airworthiness, known faults, and a subsequent illegal RTS, aren't.
It's a simple enough concept, know what is right and what is wrong. Always do what you know to be right. All the rest is rhetoric.
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CHART and NART
Five years after the CHART report was published in 1992, in which many of the recommendations relate to the "integrity of the overall airworthiness management system" a similar review was carried out for the Nimrod aircraft. This airworthiness review (NART) was only undertaken, after the departure of ACM Alcock as Chief Engineer (RAF) and ACM Squires as ACAS. The NART report suggests that there was “neglect” during the 90’s culminating in low manning levels, declining experience, failing moral, overstretched tasking and reduced resources. The report calls for “highly attentive management” which needs to be “closely attuned”; clearly airworthiness ingredients that had been missing for several years. This period also saw a marked decline in airworthiness spending.
How then, was it possible for Haddon-Cave to state in paragraph 13.124 of his report that this was the “golden period” for airworthiness and that was “due in no small measure to the high calibre and leadership to those who held the post [CE]”? Haddon-Cave conveniently uses 1998 as the starting point for his detailed airworthiness analysis and attributes blame to those who followed, when in fact the true starting point for the airworthiness “meltdown” started some eight years earlier. Of course using the 1990 starting point brings up a different batch of names and guilty parties; so instead of Cowan and Pledger, one has to read Alcock and Squires. The question that needs to be answered is, was Haddon-Cave encouraged to adopt the 1998 start point, or did he simply get too engrossed in 136 pages of a safety case and missed the bigger picture?
DV
How then, was it possible for Haddon-Cave to state in paragraph 13.124 of his report that this was the “golden period” for airworthiness and that was “due in no small measure to the high calibre and leadership to those who held the post [CE]”? Haddon-Cave conveniently uses 1998 as the starting point for his detailed airworthiness analysis and attributes blame to those who followed, when in fact the true starting point for the airworthiness “meltdown” started some eight years earlier. Of course using the 1990 starting point brings up a different batch of names and guilty parties; so instead of Cowan and Pledger, one has to read Alcock and Squires. The question that needs to be answered is, was Haddon-Cave encouraged to adopt the 1998 start point, or did he simply get too engrossed in 136 pages of a safety case and missed the bigger picture?
DV
DV
In other words, NART came to the same conclusions as Inspectorate of Flight Safety in Aug 1992, and MoD(PE) staffs who advised senior AMSO staffs of this in January 1988 and and DGSM(RAF) throughout 1991/92.
DGSM's response, in December 1992, was to threaten civilian staffs with dismissal for revealing these facts and complaining that funding to maintain airworthiness had been slashed.
This Dec 1992 date is significant as it demonstrates AMSO's reaction to CHART (which reported Chinook, Puma and Wessex airworthiness was in tatters). Instead of implementing the many CHART recommendations they buried it and threatened staff whose sole function was maintaining airworthiness.
Does anyone think a mere 2 Star would take such action without the support of his seniors?
At the time, the solution to every technical problem listed in CHART was to implement mandated regulations. It is no co-incidence the relevant procedural Def Stan was last updated in 1991 and, after nearly 20 years of not being used, finally canceled 2 years ago. Says it all really.
Good post DV. Spot on.
In other words, NART came to the same conclusions as Inspectorate of Flight Safety in Aug 1992, and MoD(PE) staffs who advised senior AMSO staffs of this in January 1988 and and DGSM(RAF) throughout 1991/92.
DGSM's response, in December 1992, was to threaten civilian staffs with dismissal for revealing these facts and complaining that funding to maintain airworthiness had been slashed.
This Dec 1992 date is significant as it demonstrates AMSO's reaction to CHART (which reported Chinook, Puma and Wessex airworthiness was in tatters). Instead of implementing the many CHART recommendations they buried it and threatened staff whose sole function was maintaining airworthiness.
Does anyone think a mere 2 Star would take such action without the support of his seniors?
At the time, the solution to every technical problem listed in CHART was to implement mandated regulations. It is no co-incidence the relevant procedural Def Stan was last updated in 1991 and, after nearly 20 years of not being used, finally canceled 2 years ago. Says it all really.
Good post DV. Spot on.