Chinook - Still Hitting Back 3 (Merged)

[tucumseh]

TR

Sent by e-mail.

T

[Chugalug2]

Squidlord:

(Oh, and strictly, I disagree with Chugalug2 when (s)he suggests that if regulation is not followed, it necessarily means the software is unairworthy. However, I do believe that if regulation is not followed then it is very unlikely that the software could be satsifactorily demonstrated airworthy (as required) - a subtle distinction.)

A subtle distinction indeed, Squidlord, and one no doubt eagerly seized upon by those who have so assiduously managed to undermine UK military airworthiness, thus leading to the Regulations being totally flouted over the past few decades. Better by far that such temptation be removed entirely from the CoC by moving responsibility for enforcement to a separate and independent MAA, and likewise an MAAIB, who would ensure that the Regulations are indeed followed, and demonstrated to have been so. The bread and butter of the CAA and AAIB of course!

[walter kennedy]

Dervish
<<It really does take a special kind of imbecile to come on an aviation forum and openly state he doesn't agree with the need to have airworthy aircraft. >>
I'm not sure that your spin is justified – I am saying that it was demonstrably not the cause of this crash - but no matter, let's press on.
Wow! - then what would you call those who input to a forum on a possible CFIT who do not understand the localised nature of the WX on the Mull on that day?
At the risk of inducing RSI amongst the flock, I'd like to make a suggestion: as you are well placed (location “W. Scotland”?) to be familiar with the WX, would you please be so kind as to describe how such headlands appear from sea with a strong on-shore wind late in the day? (The time of year is right for you to go and have a look.)
You could expect to make out the Mull from some way off but judgement of distance off is difficult, right?
Avoiding it would not be a problem but judging your approach to a spot right on the cliffs would be tricky, wouldn't it?
But if a trusted crewman was relaying distance to go through your head phones, you wouldn't need to creep in over the water, would you?
And if his info was wrong, the HP could so easily be misled.
So please do us all a favour, Dervish, by explaining the problem of visual illusion that the crew most probably had that day caused by that (all too common) localised weather.

[Seldomfitforpurpose]

[QUOTE=walter kennedy;6512055]Dervish
<<It really does take a special kind of imbecile to come on an aviation forum and openly state he doesn't agree with the need to have airworthy aircraft. >>
I'm not sure that your spin is justified – I am saying that it was demonstrably not the cause of this crash - but no matter, let's press on.

Perhaps Dervish has a valid point. When you consider all that has been revealed with regards to equipment clearances etc to say that was "demonstrably not the cause of the crash" without one single shred of concrete evidence to back that statement up is plain daft

[dervish]

Walter Kennedy

I have no problem with most of what you say about the weather. I have stood on the Mull of Kintyre many times in the localised mist you describe. I've also walked a few yards and suddenly been able to see Northern Ireland. What I cannot describe is the view the pilots had from the cockpit on that day. As that is the important factor then I make a hopeless witness.

I still don't think you understand the "airworthiness" argument. Nobody has claimed it caused the accident. From what I've read, there was a history of accidents being directly caused by this so the possibility of it being the cause has a plausible basis. Your theory is less plausible.

[The Old Fat One]

Your theory is less plausible.

I find anybody using the font of a four year old somewhat plausibly challenged.

[Fitter2]

Possibly Walter has read the notes WS Churchill used to add to his speches - 'argument weak here, shout louder'.

[tucumseh]

Walter

I think you need to actually read what has been said on the airworthiness subject; not by me or anyone else here, but the Inspector of Flight Safety himself.

One need only recall Flt Lt Tapper took the extraordinary step of visiting a Design Authority to discuss RNS252 because the information he had wasn't good enough. That immaturity of the Aircraft Data Set should have been sufficient to raise red flags. He didn't trust the information he had, which is a serious Human Factors hazard. While the bare facts were reported by the BoI, they didn't take the next obvious step of asking why, and who had decided that Aircraft Publications should not be kept up to date.

The above is bad enough, but one must go further and ask what IFS said about the subject (APs) in his report. He confirmed not only were they not good enough, but the RAF used captured Argentinian APs to help maintain the aircraft. What an embarrassment and an indictment of the savings AMSO was ordering at the expense of safety. (Again, something notified by IFS, 17 years before Haddon-Cave said the same thing).

Quite a little gem that one, and for some reason not made public or, one assumes, known to the BoI, FAI, HCDC or HoL. (Or the Sun for that matter, who would have had a field day).

The scale of their use is irrelevant and IFS quite rightly doesn't expand on this aspect. The failure is so profound one need say no more in such a report except recommend investigation and corrective action - which IFS does.

At a higher level, it is a basic regulation that the APs authorised for use must be listed in the RTS. Neither the Mk1 or Mk2 RTS mentions these Argie pubs. At the very least, when notified of this by IFS, the Chief Engineer (Alcock) should have ordered a fleet inspection of the relevant components (IFS doesn't list them) and an urgent update of APs and maintenance procedures. If he did, it took years to achieve, and still wasn't correct on the day of the crash. But I'm sure he's explained all this to Lord Philip. And this is what Haddon-Cave called the Golden Period! I hope he's asked for a revised opinion on the evidence he was given by these senior staffs.

[Distant Voice]

Tuc;

Nothing changed. I read the QinetiQ report of 2006 into Nimrod fuel leak's;

(1) The AP in use by RAMS was out-of-date in terms of tooling requirements.

(2) The AP documents concerned with fuel tank test are of limited, if any, value to NSG.

(3) NSG have adopted their own up-to-date procedures to replace redundant techniques from APs.

DV.

[tucumseh]

DV

NSG have adopted their own up-to-date procedures to replace redundant techniques from APs.

This is the laughable bit. Who is the common denominator? ACAS, as he must sign an RTS stating what APs are authorised. In making this declaration, he is saying he’s satisfied there is an audit trail back through validation and verification.

But, instead of demanding the regulations be followed (existing APs made good) he apparently allows NSG to make their own documents up. I wonder if they were validated and verified properly? If not, this compounds the problem. Better, simpler, cheaper and quicker to implement the regs in the first place.

But, throughout the late 80s and 90s (at least) ACAS was in the position that if he insisted on his aircraft being airworthy, then he was challenging stated policies (e.g. that safety should be sacrificed to save money). But that’s what 2 Stars are paid for. Isn’t it? No chance. It was left to civilian project managers to make these challenges. The Chief Engineer’s immediate subordinate promptly ruled this a disciplinary offence (3 months after publication of CHART). That’s the kind of response we came to expect from these people. I don’t imagine IFS was impressed either.





For anyone wondering why we're mentioning other aircraft, this is one component of airworthiness that was centralised at the time. That is, if one aircraft was affected, almost certainly all were, to a greater or lesser extent. Hence, systemic failings.

[walter kennedy]

dervish
At least you have some knowledge of that weather; may I recommend you try and recall the wind, time of day, etc that gave rise to it? Further, find out just how prevalent it is. Then borrow a boat (cheaper than an a/c) and view it from off-shore on a summer evening with similar conditions forecast. Compare what you see to the accounts from witnesses on the day. Then perhaps you may understand that the view they most likely had presented the problem of range judgement I described – they would have been aware of the immediate presence of the Mull but would have had a problem approaching a particular point on the shoreline at speed.
Tuc
<<One need only recall Flt Lt Tapper took the extraordinary step of visiting a Design Authority to discuss RNS252 because the information he had wasn't good enough.>>
Flt Lt Tapper's concerns were not limited to documentation, were they? Did he not express concerns to others in his flight as to the accuracy of the system? I have made the point many times that he would not have trusted it as close in as waypoint change to keep them from bumping into the Mull at speed – he would not have entrusted the steer data (the system using combined Doppler and GPS data) to guide the HP to waypoint A closely enough for the start of their swing around the light house – he would not have been alarmed at a discrepancy between this steer data and data from a local reference (such as CPLS data to a PRC112 at the LZ at waypoint A) and would surely have preferred the latter.


dervish et al
The whole of the available data is consistent with a planned approach to a particular point;
the LZ (with which this crew was familiar) was a good point to start a swing around the light house, given the practical range of turning radii of a Chinook at cruise speed;
from a distance, this LZ was represented by waypoint A in the STANS and, had they continued to use this system, they would have crossed the shoreline at waypoint A/the LZ, having kept on a track of 027;
close in, they changed waypoints in the STANS consistent with the NHP's course selector so as to define the route H-B, the 028 track that handrailed along the coast of Islay/Jura – a logical route to head for after turning at the Mull given that that coast was clear weatherwise but that north on the Mull was not;
the nearest shore to this point (waypoint change) was only about 600 metres away;
the a/c then followed a track of 035 to the area of the crash – that the turn onto this track was deliberate is evidenced by the HP's course selector being found set on this (without a clear visual cue ahead, it would have helped him stick to his course) and that the engines were found to have been matched at an intermediate level (a steady state consistent with coasting along and not indicating any manoeuvring);
the above suggests a change in reference from the STANS to a local reference at this point;
their right turn at waypoint change took them towards higher ground with no safe wave-off option;
the data preserved by the impact (controls and engine state, etc) pointed to a sudden awareness at their immediate proximity to the ground – they must have been misled as to their distance to go;
their actions are fully explained by that local reference being out of the position that they were expecting it to be at (waypoint A/LZ) – whether this was due to an error in an exercise or due to a wilful act needs to be investigated – the latter cannot be lightly discounted because of the security team on board who were effectively an obstacle to the peace process.
I trust that you may find this explanation more plausible than an a/c fault (for which there is no evidence and in an a/c type that has completed so many hours successfully) coming into play just as they were approaching a spot where my suggested scenario fits so well.

[tucumseh]

I trust that you may find this explanation more plausible than an a/c fault (for which there is no evidence and in an a/c type that has completed so many hours successfully)

Remind us how many Chinook losses the Inspector of Flight Safety stated had been attributed solely to airworthiness failings. That doesn’t mean ZD576 was lost to such failings, but it introduces doubt where MoD says absolutely no doubt exists.

As I’ve said before, I don’t doubt your scenario is feasible; but I’ve also pointed out SFI(RAF)/Chinook 12, Issue 1 (Restrictive) – Chinook HC Mk2 Undemanded Flight Control Movement, dated 28th February 1994.

There have been a number of incidents…. during flight trials. The characteristic is manifested by very sharp uncommanded inputs to the yaw axis which result in a rapid 3-4 degree change in aircraft heading, in both hover and when in forward flight, when the aircraft is subject to high levels of vibration. …The Aircraft is to be landed as soon as practicable.

The Odiham test pilot has stated this SFI was not promulgated and he never saw it while serving; although of course he had reported the problem. You will recall MoD dismissed his evidence. He also confirms that, when this occurred to the Aldergrove aircraft shortly after the crash, and he flew across to conduct a check flight, the pilots involved had never seen the SFI.

Doubt again. And very serious systemic failures.

[Seldomfitforpurpose]

Walter,

Your theory and speculation, have you got any concrete evidence to support it, any witness statements to back it up, any documentation showing what actually happened, have you got anything from anyone that backs up what you say

[Squidlord]

walter kennedy:

To that enormous number of hours I add that not only was there no evidence of a FADEC problem in this crash but, as I have described previously, that snapshot state preserved by the impact showed definitively that the engine management system had been performing normally.

No problem with the lack of evidence of a FADEC problem but I am very sceptical that for an extremely complex piece of software such as a FADEC it would be possible that a "snapshot state preserved by the impact showed definitively that the engine management system had been performing normally". It is entirely plausible for such complex software to fail and to mask its own failure from any monitoring devices. Indeed, the "masking" can be an essential ingredient of the accident (if it wasn't masked something would have noticed and raised an alarm, which/or someone would have noticed and recovered to a safe state).

Of course, none of what I write above is any kind of evidence that the FADEC caused the crash. But, imo, it is evidence that it can't be ruled out.


tucumseh, quoting from policy:

If validation procedures are to be carried out by an independent agency (in this case, Boscombe) MoD should secure adequate rights of access and use to design information and code for itself and its agents, while protecting the rights of the originators.

Presumably tucumseh hasn't quoted everything here because this doesn't fully substantiate what he wrote in #7861. In a way, the quoted paragraph is nugatory because if you're going to carry out "validation procedures" then you need "adequate rights of access and use to design information and code". What's more interesting, I think, is the extent to which MoD was (or even is) required to facilitate that independent validation. For a time in the 90s it seemed to be a de facto policy for safety-critical avionics software but I wouldn't know whether it was ever formally required.

[dalek]

CRM

I am surprised nobody got back to Olive oil on his question in 7849.
I asked it many years ago. I knew a few pilots at Odiham at the time. They told me that the working relationship between the two pilots and the crewmen involved was very good. Anybody know anything different?

Mind you, that doesn't mean that the working relationship between the crew members didn't break down on this particular sortie. That is why every organisation other than the Royal Air Force insists on CVR.

Cazatou 7851

I have no idea why the Det Cdr chose the crews the way he did. But I can hazard a guess.
Flt Lt Tapper was flying an extended crew duty day in marginal conditions. He put his most experienced crew on the Mull sortie and left his less experienced RN Officer and Navigator to tackle something (he considered) less challenging.
You have done daily programmes. You know as well as I do that the previous and next days programmes, medical appointments, leave etc etc all have to be factored into the decision.
There was only one person who knew the answer to your question. I'm sorry he can't tell us

[tucumseh]

Presumably tucumseh hasn't quoted everything here because this doesn't fully substantiate what he wrote in #7861. In a way, the quoted paragraph is nugatory because if you're going to carry out "validation procedures" then you need "adequate rights of access and use to design information and code".

squidlord

Not sure what you're getting at here. If you aren't are familiar with the policy document, it is 49 pages long. If you are familiar with it, what part do you want me to quote?

As I said, it is the policy issued by DUS(DP) which D/Stan were required to reflect in their standards and Project Managers were required to implement. I didn't write it and can't help the way it is written. To me, it is clear enough; although, as you imply, it does spell out some rather obvious aspects.

However, that is infinitely better than many other standards, which assume competence and detailed prior knowledge, which was fine at time of writing. This has not been an MoD requirement in this field for over 20 years (when suppliers in AMSO assumed command of procurement process) which is a major reason behind many acquisition and airworthiness failures.

Surely the question you must be asking it whether or not these regulations were complied with. When you discover the answer is "No", ask if that constitutes doubt (as well as a major risk). Then I think we'll both agree.

[Chugalug2]

Squidlord:

For a time in the 90s it seemed to be a de facto policy for safety-critical avionics software but I wouldn't know whether it was ever formally required.

Curious to know when in the 90s you are referring to here. We have been told that those years were the "Golden Age" of Military Airworthiness Provision by someone, who was told that by someone else....Given that this was the decade that produced this code that was declared positively dangerous by BD, an MAR fuel system that was equally so, an IFF system that did not fail safe, and the continual pleas for a tactical transport's fuel tanks to be given minimal battle protection at least ignored, oh, as well as the replacing of acl's with strobe lights in contravention to regulatory procedures that should have been followed, I wouldn't want to be around when it wasn't a Golden Age! BTW all those airworthiness shortcomings were involved in Airworthiness Related Fatal Military Air Accidents that claimed a total of 62 lives. It seems to me that de facto policy did not lead to de facto observance of the Regulations, but that is something that you have said is not strictly necessary, isn't it?

I disagree with Chugalug2 when (s)he suggests that if regulation is not followed, it necessarily means the software is unairworthy.

[walter kennedy]

Such was the requirement for routine NAVEXs that one should not have been surprised if one of the first questions asked had been “What was the NAVEX planned?”
Yet so many of you will not even consider one that fits with the available data.
How could a long flight in that area be wasted in a new a/c fitted with a useful locating aid?
We know that Flt Lt Tapper won over the duty officer for his crew to do this sortie on the grounds that they had been planning extensively for it.
Think about it.

[Seldomfitforpurpose]

Evidence Walter, evidence, have you actually got any or is what you suggest simply supposition. You berate one and all on here but never answer questions directed at you

What evidence do you ave to back up your theory

[dalek]

Walter

1. The map used by the crew was lost in the fire, so we don't know the finalised plan. Once the Navigator, who started the planning, handed over to the operating crew, we don't know what changes were made.
2. All C130's were capable of receiving portable TACANS. On the couple of hundred LL sorties I did on that aircraft, we used the facility twice for DZ / LZ marking. Equipment fitted does not mean equipment used.
a. Can you tell us who on the Mull switched the beacon on?
b. Can you show there was any Malicious Intent with the switch on.
3. I thought that JT was the Det Cdr? He didn't need to "win over" anyone to select his crew?