Chinook - Still Hitting Back 3 (Merged)
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CHINOOK
Arkroyal.
But Mr Arbuthnot did not only make a written submission, he had a golden opportunity to actually argue the case personally, face to face as it were, with the PM.
JP
Tandemrotor,
......and the evidence from the lighthouse keeper as to the visibility.
JP
But Mr Arbuthnot did not only make a written submission, he had a golden opportunity to actually argue the case personally, face to face as it were, with the PM.
JP
Tandemrotor,
......and the evidence from the lighthouse keeper as to the visibility.
JP
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Looking at Blair's letter, the interesting point to me is in line 2 of para 3:
"..Day..discounted through lack of evidence any possibility of technical failure.."
Seems to me to be an admission that Day was on the hunt for a scapegoat, since his approach is the reciprocal to what is required under the RAF's burden of proof. That there was no evidence against something is not to be taken as positive proof for it. If you get my drift.
A bit of an own goal, I would say. I don't think Blair can have been a very impressive barrister. Email sent to No 10 on this point of Day's conclusion.
"..Day..discounted through lack of evidence any possibility of technical failure.."
Seems to me to be an admission that Day was on the hunt for a scapegoat, since his approach is the reciprocal to what is required under the RAF's burden of proof. That there was no evidence against something is not to be taken as positive proof for it. If you get my drift.
A bit of an own goal, I would say. I don't think Blair can have been a very impressive barrister. Email sent to No 10 on this point of Day's conclusion.
Last edited by chippy63; 14th Aug 2004 at 19:34.
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Hi again everyone.
Quite a few interesting points made, following my last post.
Tandemrotor,
Kind words, thank you. As you are well aware, there are very few actual 'facts' that are known about the whole flight. I agree we should, perhaps, isolate them, thereby exposing all else for what it is. Merely speculation or assumption.
Mr Purdey,
Mr Arbuthnot did argue the case with Mr Blair. I can tell you that Mr Hoon was also there at the time of the meeting, and he was totally negative throughout. Hardly an open mind! Also, the only factual thing you can take from the lighthouse keeper is that he was stood in dense (not thick) cloud/fog/mist. No disrespect to him, but what else is there he can say about it?
Chippy,
what I find interesting in the letter is the complete absence of Mr Wratten's name. Seems most of the 'influence' (my word) came from Mr Day - the very same person that Mr Blair very recently personally intervened for, so that he may work in the aviation industry.
Maybe I'm just a natural cynic!
I can assure you all that the campaign will continue.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
Quite a few interesting points made, following my last post.
Tandemrotor,
Kind words, thank you. As you are well aware, there are very few actual 'facts' that are known about the whole flight. I agree we should, perhaps, isolate them, thereby exposing all else for what it is. Merely speculation or assumption.
Mr Purdey,
Mr Arbuthnot did argue the case with Mr Blair. I can tell you that Mr Hoon was also there at the time of the meeting, and he was totally negative throughout. Hardly an open mind! Also, the only factual thing you can take from the lighthouse keeper is that he was stood in dense (not thick) cloud/fog/mist. No disrespect to him, but what else is there he can say about it?
Chippy,
what I find interesting in the letter is the complete absence of Mr Wratten's name. Seems most of the 'influence' (my word) came from Mr Day - the very same person that Mr Blair very recently personally intervened for, so that he may work in the aviation industry.
Maybe I'm just a natural cynic!
I can assure you all that the campaign will continue.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
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JP
I have little doubt that the evidence of the lighthouse keepers (in fact 2 gave evidence, Mr Murchie and Mr Lamont) was a reasonably accurate description of weather conditions at ground level in the immediate vicinity of the lighthouse. This lighthouse is of course charted on a hillside, at 91m (shall we say 300'?) above sea level.
Notwithstanding the fact that a holidaymaker's video, filmed at the lighthouse, and within minutes of the accident, suggested significantly better visibility, perhaps tying in with statements to the effect that the visibility was patchy, or 'coming and going'
Is it your OPINION that these weather conditions (whatever they were) also prevailed out to sea?
Or would you perhaps prefer the evidence of a yachtsman, and last eyewitness (Mr Holbrook). In his statement to the BOI, he describes visibility as about 1 mile in haze (presumably difficult to judge at sea) and says that the aircraft was at a height of about 200-400', apparently in sunlight proceeding towards the cloud localisation covering the Mull land mass. It was well below cloud level, cloud cover being around 80%, very structured with the lower clouds grey and heavy, with higher lighter coloured clouds above. At no time in the 5 secs or so he observed it, did the helicopter move into cloud. He estimated the time of his observation as 1800 hours, which along with his approximate geographical position, MAY put this within 60secs of impact.
He did of course during his sworn evidence to the Fatal Accident Inquiry, state categorically, that he believed the pilots could have seen the Mull of Kintyre lighthouse, or at least it's wall, as they approached the Mull.
There is other meteorological evidence, for example metars from Machrihanish, but non of these speak to what was being seen from the cockpit AS THE CREW APPROACHED THE MULL.
I suggest that weather MAY have been a factor in this accident, but since we DO NOT KNOW, it most certainly is not 'cut and dried' There is a perfectly plausible scenario to suggest that the crew were legally entitled to continue VFR without climbing above 250', indeed the Station Commander RAF Odiham (Gp Capt Crawford) concluded this was highly probable! It also is entirely compatible with the change of waypoint on RNS252 Supertans.
We are all then faced with the same problem of how the aircraft came to crash around 810' above sea level at high speed! APPARENTLY using a speed and power combination that is "unrecognisable as a chinook technique!"
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
b. An unregistered technical malfunction
(Which were common on this aircraft at this time!) - My comment
c. Human factors
Any of these are plausible explanations!
The meteorological evidence alone is inconclusive! We need to better understand the flight path of the aircraft. But it had no data recorder did it!
I have little doubt that the evidence of the lighthouse keepers (in fact 2 gave evidence, Mr Murchie and Mr Lamont) was a reasonably accurate description of weather conditions at ground level in the immediate vicinity of the lighthouse. This lighthouse is of course charted on a hillside, at 91m (shall we say 300'?) above sea level.
Notwithstanding the fact that a holidaymaker's video, filmed at the lighthouse, and within minutes of the accident, suggested significantly better visibility, perhaps tying in with statements to the effect that the visibility was patchy, or 'coming and going'
Is it your OPINION that these weather conditions (whatever they were) also prevailed out to sea?
Or would you perhaps prefer the evidence of a yachtsman, and last eyewitness (Mr Holbrook). In his statement to the BOI, he describes visibility as about 1 mile in haze (presumably difficult to judge at sea) and says that the aircraft was at a height of about 200-400', apparently in sunlight proceeding towards the cloud localisation covering the Mull land mass. It was well below cloud level, cloud cover being around 80%, very structured with the lower clouds grey and heavy, with higher lighter coloured clouds above. At no time in the 5 secs or so he observed it, did the helicopter move into cloud. He estimated the time of his observation as 1800 hours, which along with his approximate geographical position, MAY put this within 60secs of impact.
He did of course during his sworn evidence to the Fatal Accident Inquiry, state categorically, that he believed the pilots could have seen the Mull of Kintyre lighthouse, or at least it's wall, as they approached the Mull.
There is other meteorological evidence, for example metars from Machrihanish, but non of these speak to what was being seen from the cockpit AS THE CREW APPROACHED THE MULL.
I suggest that weather MAY have been a factor in this accident, but since we DO NOT KNOW, it most certainly is not 'cut and dried' There is a perfectly plausible scenario to suggest that the crew were legally entitled to continue VFR without climbing above 250', indeed the Station Commander RAF Odiham (Gp Capt Crawford) concluded this was highly probable! It also is entirely compatible with the change of waypoint on RNS252 Supertans.
We are all then faced with the same problem of how the aircraft came to crash around 810' above sea level at high speed! APPARENTLY using a speed and power combination that is "unrecognisable as a chinook technique!"
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
b. An unregistered technical malfunction
(Which were common on this aircraft at this time!) - My comment
c. Human factors
Any of these are plausible explanations!
The meteorological evidence alone is inconclusive! We need to better understand the flight path of the aircraft. But it had no data recorder did it!
Last edited by Tandemrotor; 14th Aug 2004 at 22:24.
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One witness who was on the NI coast at the time of the flight told me that he could see the Mull clear across the sea but the landmass was grey with mist. These are common conditions, the localized mist being formed as the air rises AT the landmass.
The crew would have been able to see the landmass but not any detail on the ground – this would have been a common situation for any low level crossing there.
Being very much an “end on” approach to the Mull, there would not have been any other topography to either side to give spatial orientation.
It is very difficult to judge accurately one’s distance off a single feature without seeing a familiar object for scale.
If they were intending to come in so very close (as they did even to the waypoint change) they may have become spatially disorientated in the one dimension (ie. How close or not they were) – and what is it that experienced airmen do when they are temporarily spatially disorientated (even in VFR flight)? – they look at their instruments.
Let me emphasize, this would have been while they were still in clear air (to either side, behind, and below to the sea, and for an undeterminable distance ahead of them) – once they were IN mist they should have taken immediate action and should not have relied upon instruments – but the mist was localized on the landmass and it would have been too late by then.
Now what instrument could reassure them that they had not gotten too close?
Well, the IFF system was set to interrogate a ground beacon (see post 13th Aug) – the mobile type.
At the very least, we should be asking why this was not mentioned at the inquiries – especially when pertinent questions as to the squwark code were asked – indeed, the answers appear to have been misleading or at least not fully open.
Perhaps a new arrangement was being tried whereby a (112 type) unit had been placed, say, near the lighthouse pad – it would have been a cheap solution to the common localised mist problem that otherwise complicated regular simple low level VFR flights. I do not know this, but the squwark code suggests it as does common sense. Someone out there knows.
One witness who was on the NI coast at the time of the flight told me that he could see the Mull clear across the sea but the landmass was grey with mist. These are common conditions, the localized mist being formed as the air rises AT the landmass.
The crew would have been able to see the landmass but not any detail on the ground – this would have been a common situation for any low level crossing there.
Being very much an “end on” approach to the Mull, there would not have been any other topography to either side to give spatial orientation.
It is very difficult to judge accurately one’s distance off a single feature without seeing a familiar object for scale.
If they were intending to come in so very close (as they did even to the waypoint change) they may have become spatially disorientated in the one dimension (ie. How close or not they were) – and what is it that experienced airmen do when they are temporarily spatially disorientated (even in VFR flight)? – they look at their instruments.
Let me emphasize, this would have been while they were still in clear air (to either side, behind, and below to the sea, and for an undeterminable distance ahead of them) – once they were IN mist they should have taken immediate action and should not have relied upon instruments – but the mist was localized on the landmass and it would have been too late by then.
Now what instrument could reassure them that they had not gotten too close?
Well, the IFF system was set to interrogate a ground beacon (see post 13th Aug) – the mobile type.
At the very least, we should be asking why this was not mentioned at the inquiries – especially when pertinent questions as to the squwark code were asked – indeed, the answers appear to have been misleading or at least not fully open.
Perhaps a new arrangement was being tried whereby a (112 type) unit had been placed, say, near the lighthouse pad – it would have been a cheap solution to the common localised mist problem that otherwise complicated regular simple low level VFR flights. I do not know this, but the squwark code suggests it as does common sense. Someone out there knows.
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Tony Blairs letter requires some consideration of the House of Lords and others stance on negligence
"Only in cases in which there is absolutely no doubt whatsoever, should deceased aircrew be found negligent"
It seems to me that in the approach of the House of Lords Select Committee and others gross negligence could only be found if it were established beyond all doubt that the pilots had done something to cause that action and it was provable.
Blair’s approach
“I recognise that the standard of proof required for Reviewing Officers to arrive at such a decision is necessarily high. Before reaching such a judgement the Air Marshals were required to consider the evidence as a whole, and then use their own experience of military flying. If after this they were left with no honest or genuine doubt that the air crew had been negligent, it was their duty to find accordingly”
Note the use of the words honest and genuine doubt. Nothing about proving negligence which is the usual way of doing things. Even if we accept the view of Blair the House of Lords Select Committee showed there were a number of areas of doubt.
The House of Lords conclusion shows there were a number of instances where there was question as to doubt and also at paras 147, 148 and 165 it is shown that the Air Marshall’s were nowhere near “in no doubt” as Blair seems to think. In addition we have the comment at para 148 that Sir John Day confused facts with hypotheses or assumptions.
Some extracts from Conclusions of House of Lords Select Committee
"146. Negligence, as a concern of the board, was not an abstract concept but could only be inferred from facts relevant to causation. Paragraph 1 of Annex G to Chapter 8 of AP3207 stated that causes of accidents broadly speaking fell into three categories: technical faults, natural operating or medical hazards and human failings. Paragraph 2 provided among other things:
"Before making a detailed assessment of human failings the board must distinguish between those irregularities which had no direct connection with the cause of the accident and those which had. This can be resolved by the answers to two questions:
a. Was the person's act which is under consideration an essential link without which the final event would not have happened?
b. Ought the person to have foreseen that their action or their failure to take action would in all probability occasion the final event?"
147. In the context of the Air Marshals' conclusion that the pilots were grossly negligent in placing the aircraft in the position in which it was at or before the way point change was made, regardless of what happened thereafter, the question to be answered is whether there is absolutely no doubt whatsoever that they ought to have foreseen that their action would in all probability occasion the final event. It must be borne in mind that it is not known at what height or speed the aircraft was flying at the way point change, nor its position in relation to cloud. However Sir William accepted the possibility that they could have seen the coastline under cloud cover (Q 364). Furthermore the Air Marshals' views as to the danger of the aircraft being at or in the vicinity of the way point change position even if the crew had intended to alter course at that point were much influenced by the high speed at which they assumed the aircraft then to be travelling - an assumption which, having regard to the deficiencies in the simulation which have now emerged, may no longer be justified.
148 We consider that Sir John's conclusions on this matter must be weakened by his reliance on matters which he treated as facts but which have been demonstrated to our satisfaction to be not facts but merely hypotheses or assumptions. It must be a matter of speculation what would have been the Air Marshals' conclusion if the Boeing simulation had not been available, or if its deficiencies had been identified.
165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their negligence in reaching that position was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71).
166 However the finding of negligence at or before the way point change has not been established to the required standard of proof, as we consider to be the case, this proposition does not stand up. The evidence before us was entirely consistent with an intention to alter course and fly VFR to Corran and equally inconsistent with an intention to continue on the same course over the Mull under IFR.
168 AAIB were not able to exclude the possibility of a control jam given the level of system damage…
174. In carrying out our terms of reference, we have considered the justification for the Air Marshals' finding of negligence against the pilots of ZD 576 against the applicable standard of proof, which required "absolutely no doubt whatsoever". In the light of all the evidence before us, and having regard to that standard, we unanimously conclude that the reviewing officers were not justified in finding that negligence on the part of the pilots caused the aircraft to crash.
175. We consider it appropriate to identify those matters to which we have had regard which were not before the Air Marshals when they considered the investigating board's report:
(a) the more detailed evidence of Mr Holbrook as to the weather conditions at sea, and the probability that the crew would have seen the land mass from some distance offshore;
(b) the evidence of Mr Perks, Witness A and Squadron Leader Burke;
(c) the deficiencies in the Boeing simulation with particular reference to the facts that
(i) it did not take account of FADEC and
(ii) it used a postulated speed and ROC which have been shown to be incompatible; and
(d) the possible effect of contamination in the hydraulic fluid in the integrated lower control actuators, as referred to in the US Army report of June 1997.
176. How could it be that a very experienced crew, having planned to fly VFR, having taken when probably visual with the Mull the appropriate steps to alter course, when there was nothing to prevent them flying northwards within sight of the coast, flew into the Mull? It is as Sir John and Sir William speculatively described "incomprehensible" (Q 342) and "astonishing" (Q 377). We shall never know".
The final four words of the House of Lords Select Committee “We shall never know” are so important.
The only ones who know are dead.
Tony Blair\'s letter deserves some consideration of the aproach to neligence and the words "Only in cases in which there is absolutely no doubt whatsoever, should deceased aircrew be found negligent"
It seems to me that in the approach of the House of Lords Select Committee and others gross negligence could only be found if it were established beyond all doubt that the pilots had done something to cause that action and it was provable.
Blair’s approach
“I recognise that the standard of proof required for Reviewing Officers to arrive at such a decision is necessarily high. Before reaching such a judgement the Air Marshals were required to consider the evidence as a whole, and then use their own experience of military flying. If after this they were left with no honest or genuine doubt that the air crew had been negligent, it was their duty to find accordingly”
Note the use of the words honest and genuine doubt. Nothing about proving negligence which is the usual way of doing things. Even if we accept the view of Blair the House of Lords Select Committee showed there were a number of areas of doubt.
The House of Lords conclusion shows there were a number of instances where there was question as to doubt and also at paras 147, 148 and 165 it is shown that the Air Marshall’s were nowhere near “in no doubt” as Blair seems to think. In addition we have the comment at para 148 that Sir John Day confused facts with hypotheses or assumptions.
Some extracts from Conclusions of House of Lords Select Committee
"146. Negligence, as a concern of the board, was not an abstract concept but could only be inferred from facts relevant to causation. Paragraph 1 of Annex G to Chapter 8 of AP3207 stated that causes of accidents broadly speaking fell into three categories: technical faults, natural operating or medical hazards and human failings. Paragraph 2 provided among other things:
"Before making a detailed assessment of human failings the board must distinguish between those irregularities which had no direct connection with the cause of the accident and those which had. This can be resolved by the answers to two questions:
a. Was the person\'s act which is under consideration an essential link without which the final event would not have happened?
b. Ought the person to have foreseen that their action or their failure to take action would in all probability occasion the final event?"
147. In the context of the Air Marshals\' conclusion that the pilots were grossly negligent in placing the aircraft in the position in which it was at or before the way point change was made, regardless of what happened thereafter, the question to be answered is whether there is absolutely no doubt whatsoever that they ought to have foreseen that their action would in all probability occasion the final event. It must be borne in mind that it is not known at what height or speed the aircraft was flying at the way point change, nor its position in relation to cloud. However Sir William accepted the possibility that they could have seen the coastline under cloud cover (Q 364). Furthermore the Air Marshals\' views as to the danger of the aircraft being at or in the vicinity of the way point change position even if the crew had intended to alter course at that point were much influenced by the high speed at which they assumed the aircraft then to be travelling - an assumption which, having regard to the deficiencies in the simulation which have now emerged, may no longer be justified.
148 We consider that Sir John\'s conclusions on this matter must be weakened by his reliance on matters which he treated as facts but which have been demonstrated to our satisfaction to be not facts but merely hypotheses or assumptions. It must be a matter of speculation what would have been the Air Marshals\' conclusion if the Boeing simulation had not been available, or if its deficiencies had been identified.
165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their negligence in reaching that position was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71).
166 However the finding of negligence at or before the way point change has not been established to the required standard of proof, as we consider to be the case, this proposition does not stand up. The evidence before us was entirely consistent with an intention to alter course and fly VFR to Corran and equally inconsistent with an intention to continue on the same course over the Mull under IFR.
168 AAIB were not able to exclude the possibility of a control jam given the level of system damage…
174. In carrying out our terms of reference, we have considered the justification for the Air Marshals\' finding of negligence against the pilots of ZD 576 against the applicable standard of proof, which required "absolutely no doubt whatsoever". In the light of all the evidence before us, and having regard to that standard, we unanimously conclude that the reviewing officers were not justified in finding that negligence on the part of the pilots caused the aircraft to crash.
175. We consider it appropriate to identify those matters to which we have had regard which were not before the Air Marshals when they considered the investigating board\'s report:
(a) the more detailed evidence of Mr Holbrook as to the weather conditions at sea, and the probability that the crew would have seen the land mass from some distance offshore;
(b) the evidence of Mr Perks, Witness A and Squadron Leader Burke;
(c) the deficiencies in the Boeing simulation with particular reference to the facts that
(i) it did not take account of FADEC and
(ii) it used a postulated speed and ROC which have been shown to be incompatible; and
(d) the possible effect of contamination in the hydraulic fluid in the integrated lower control actuators, as referred to in the US Army report of June 1997.
176. How could it be that a very experienced crew, having planned to fly VFR, having taken when probably visual with the Mull the appropriate steps to alter course, when there was nothing to prevent them flying northwards within sight of the coast, flew into the Mull? It is as Sir John and Sir William speculatively described "incomprehensible" (Q 342) and "astonishing" (Q 377). We shall never know".
The final four words of the House of Lords Select Committee “We shall never know” are so important.
Sadly, the only ones who know what happene that night are dead.
"Only in cases in which there is absolutely no doubt whatsoever, should deceased aircrew be found negligent"
It seems to me that in the approach of the House of Lords Select Committee and others gross negligence could only be found if it were established beyond all doubt that the pilots had done something to cause that action and it was provable.
Blair’s approach
“I recognise that the standard of proof required for Reviewing Officers to arrive at such a decision is necessarily high. Before reaching such a judgement the Air Marshals were required to consider the evidence as a whole, and then use their own experience of military flying. If after this they were left with no honest or genuine doubt that the air crew had been negligent, it was their duty to find accordingly”
Note the use of the words honest and genuine doubt. Nothing about proving negligence which is the usual way of doing things. Even if we accept the view of Blair the House of Lords Select Committee showed there were a number of areas of doubt.
The House of Lords conclusion shows there were a number of instances where there was question as to doubt and also at paras 147, 148 and 165 it is shown that the Air Marshall’s were nowhere near “in no doubt” as Blair seems to think. In addition we have the comment at para 148 that Sir John Day confused facts with hypotheses or assumptions.
Some extracts from Conclusions of House of Lords Select Committee
"146. Negligence, as a concern of the board, was not an abstract concept but could only be inferred from facts relevant to causation. Paragraph 1 of Annex G to Chapter 8 of AP3207 stated that causes of accidents broadly speaking fell into three categories: technical faults, natural operating or medical hazards and human failings. Paragraph 2 provided among other things:
"Before making a detailed assessment of human failings the board must distinguish between those irregularities which had no direct connection with the cause of the accident and those which had. This can be resolved by the answers to two questions:
a. Was the person's act which is under consideration an essential link without which the final event would not have happened?
b. Ought the person to have foreseen that their action or their failure to take action would in all probability occasion the final event?"
147. In the context of the Air Marshals' conclusion that the pilots were grossly negligent in placing the aircraft in the position in which it was at or before the way point change was made, regardless of what happened thereafter, the question to be answered is whether there is absolutely no doubt whatsoever that they ought to have foreseen that their action would in all probability occasion the final event. It must be borne in mind that it is not known at what height or speed the aircraft was flying at the way point change, nor its position in relation to cloud. However Sir William accepted the possibility that they could have seen the coastline under cloud cover (Q 364). Furthermore the Air Marshals' views as to the danger of the aircraft being at or in the vicinity of the way point change position even if the crew had intended to alter course at that point were much influenced by the high speed at which they assumed the aircraft then to be travelling - an assumption which, having regard to the deficiencies in the simulation which have now emerged, may no longer be justified.
148 We consider that Sir John's conclusions on this matter must be weakened by his reliance on matters which he treated as facts but which have been demonstrated to our satisfaction to be not facts but merely hypotheses or assumptions. It must be a matter of speculation what would have been the Air Marshals' conclusion if the Boeing simulation had not been available, or if its deficiencies had been identified.
165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their negligence in reaching that position was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71).
166 However the finding of negligence at or before the way point change has not been established to the required standard of proof, as we consider to be the case, this proposition does not stand up. The evidence before us was entirely consistent with an intention to alter course and fly VFR to Corran and equally inconsistent with an intention to continue on the same course over the Mull under IFR.
168 AAIB were not able to exclude the possibility of a control jam given the level of system damage…
174. In carrying out our terms of reference, we have considered the justification for the Air Marshals' finding of negligence against the pilots of ZD 576 against the applicable standard of proof, which required "absolutely no doubt whatsoever". In the light of all the evidence before us, and having regard to that standard, we unanimously conclude that the reviewing officers were not justified in finding that negligence on the part of the pilots caused the aircraft to crash.
175. We consider it appropriate to identify those matters to which we have had regard which were not before the Air Marshals when they considered the investigating board's report:
(a) the more detailed evidence of Mr Holbrook as to the weather conditions at sea, and the probability that the crew would have seen the land mass from some distance offshore;
(b) the evidence of Mr Perks, Witness A and Squadron Leader Burke;
(c) the deficiencies in the Boeing simulation with particular reference to the facts that
(i) it did not take account of FADEC and
(ii) it used a postulated speed and ROC which have been shown to be incompatible; and
(d) the possible effect of contamination in the hydraulic fluid in the integrated lower control actuators, as referred to in the US Army report of June 1997.
176. How could it be that a very experienced crew, having planned to fly VFR, having taken when probably visual with the Mull the appropriate steps to alter course, when there was nothing to prevent them flying northwards within sight of the coast, flew into the Mull? It is as Sir John and Sir William speculatively described "incomprehensible" (Q 342) and "astonishing" (Q 377). We shall never know".
The final four words of the House of Lords Select Committee “We shall never know” are so important.
The only ones who know are dead.
Tony Blair\'s letter deserves some consideration of the aproach to neligence and the words "Only in cases in which there is absolutely no doubt whatsoever, should deceased aircrew be found negligent"
It seems to me that in the approach of the House of Lords Select Committee and others gross negligence could only be found if it were established beyond all doubt that the pilots had done something to cause that action and it was provable.
Blair’s approach
“I recognise that the standard of proof required for Reviewing Officers to arrive at such a decision is necessarily high. Before reaching such a judgement the Air Marshals were required to consider the evidence as a whole, and then use their own experience of military flying. If after this they were left with no honest or genuine doubt that the air crew had been negligent, it was their duty to find accordingly”
Note the use of the words honest and genuine doubt. Nothing about proving negligence which is the usual way of doing things. Even if we accept the view of Blair the House of Lords Select Committee showed there were a number of areas of doubt.
The House of Lords conclusion shows there were a number of instances where there was question as to doubt and also at paras 147, 148 and 165 it is shown that the Air Marshall’s were nowhere near “in no doubt” as Blair seems to think. In addition we have the comment at para 148 that Sir John Day confused facts with hypotheses or assumptions.
Some extracts from Conclusions of House of Lords Select Committee
"146. Negligence, as a concern of the board, was not an abstract concept but could only be inferred from facts relevant to causation. Paragraph 1 of Annex G to Chapter 8 of AP3207 stated that causes of accidents broadly speaking fell into three categories: technical faults, natural operating or medical hazards and human failings. Paragraph 2 provided among other things:
"Before making a detailed assessment of human failings the board must distinguish between those irregularities which had no direct connection with the cause of the accident and those which had. This can be resolved by the answers to two questions:
a. Was the person\'s act which is under consideration an essential link without which the final event would not have happened?
b. Ought the person to have foreseen that their action or their failure to take action would in all probability occasion the final event?"
147. In the context of the Air Marshals\' conclusion that the pilots were grossly negligent in placing the aircraft in the position in which it was at or before the way point change was made, regardless of what happened thereafter, the question to be answered is whether there is absolutely no doubt whatsoever that they ought to have foreseen that their action would in all probability occasion the final event. It must be borne in mind that it is not known at what height or speed the aircraft was flying at the way point change, nor its position in relation to cloud. However Sir William accepted the possibility that they could have seen the coastline under cloud cover (Q 364). Furthermore the Air Marshals\' views as to the danger of the aircraft being at or in the vicinity of the way point change position even if the crew had intended to alter course at that point were much influenced by the high speed at which they assumed the aircraft then to be travelling - an assumption which, having regard to the deficiencies in the simulation which have now emerged, may no longer be justified.
148 We consider that Sir John\'s conclusions on this matter must be weakened by his reliance on matters which he treated as facts but which have been demonstrated to our satisfaction to be not facts but merely hypotheses or assumptions. It must be a matter of speculation what would have been the Air Marshals\' conclusion if the Boeing simulation had not been available, or if its deficiencies had been identified.
165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their negligence in reaching that position was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71).
166 However the finding of negligence at or before the way point change has not been established to the required standard of proof, as we consider to be the case, this proposition does not stand up. The evidence before us was entirely consistent with an intention to alter course and fly VFR to Corran and equally inconsistent with an intention to continue on the same course over the Mull under IFR.
168 AAIB were not able to exclude the possibility of a control jam given the level of system damage…
174. In carrying out our terms of reference, we have considered the justification for the Air Marshals\' finding of negligence against the pilots of ZD 576 against the applicable standard of proof, which required "absolutely no doubt whatsoever". In the light of all the evidence before us, and having regard to that standard, we unanimously conclude that the reviewing officers were not justified in finding that negligence on the part of the pilots caused the aircraft to crash.
175. We consider it appropriate to identify those matters to which we have had regard which were not before the Air Marshals when they considered the investigating board\'s report:
(a) the more detailed evidence of Mr Holbrook as to the weather conditions at sea, and the probability that the crew would have seen the land mass from some distance offshore;
(b) the evidence of Mr Perks, Witness A and Squadron Leader Burke;
(c) the deficiencies in the Boeing simulation with particular reference to the facts that
(i) it did not take account of FADEC and
(ii) it used a postulated speed and ROC which have been shown to be incompatible; and
(d) the possible effect of contamination in the hydraulic fluid in the integrated lower control actuators, as referred to in the US Army report of June 1997.
176. How could it be that a very experienced crew, having planned to fly VFR, having taken when probably visual with the Mull the appropriate steps to alter course, when there was nothing to prevent them flying northwards within sight of the coast, flew into the Mull? It is as Sir John and Sir William speculatively described "incomprehensible" (Q 342) and "astonishing" (Q 377). We shall never know".
The final four words of the House of Lords Select Committee “We shall never know” are so important.
Sadly, the only ones who know what happene that night are dead.
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So JP, K52, WOrkER
The question seems to be a little more simplified!
It is the Air Marshalls position that:
"165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their NEGLIGENCE IN REACHING THAT POSITION was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71)."
In other words, it did not matter whether the crew were IMC or VMC (co-incidentally, we CANNOT know!) at waypoint change. Since their negligence PRECEDED this moment!
I believe this is precisely the point implied in WOrkER's and JP's 'exam questions'
Yet how CAN this premise be correct, when it can be simply demonstrated, that the crew were very possibly flying perfectly legally at this time?
If only they had a data recorder, but they didn't, did they?
Any comment WOrkER, JP, K52?
Pulse 1
In my humble opinion, you showed considerable insight when you said;
"For me, there is still too much extrapolation going on here. i.e. it’s like drawing the graph you want with too few measurements."
How are you seeing things now?
The question seems to be a little more simplified!
It is the Air Marshalls position that:
"165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their NEGLIGENCE IN REACHING THAT POSITION was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71)."
In other words, it did not matter whether the crew were IMC or VMC (co-incidentally, we CANNOT know!) at waypoint change. Since their negligence PRECEDED this moment!
I believe this is precisely the point implied in WOrkER's and JP's 'exam questions'
Yet how CAN this premise be correct, when it can be simply demonstrated, that the crew were very possibly flying perfectly legally at this time?
If only they had a data recorder, but they didn't, did they?
Any comment WOrkER, JP, K52?
Pulse 1
In my humble opinion, you showed considerable insight when you said;
"For me, there is still too much extrapolation going on here. i.e. it’s like drawing the graph you want with too few measurements."
How are you seeing things now?
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Tandemrotor
Did my notes posted 13th & 15th Fall on deaf ears? I thought that the squark code set may have told us that they were using a ground transponder - which I would have thought was relevent - comments on this would be gratefully received.
Regards all
Walter
Did my notes posted 13th & 15th Fall on deaf ears? I thought that the squark code set may have told us that they were using a ground transponder - which I would have thought was relevent - comments on this would be gratefully received.
Regards all
Walter
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WOrkER, in a previous post, you stated the following:
"The pilots must have been in control until at least WP change. It is inconceivable that they would have made the three cockpit selections to change WP if out of control. We can also be in no doubt whatsoever that they were at low level and at high cruising speed, heading directly towards the Mull. This is not hypothesis. It is fact."
If the 'official' hypothesis is to be believed, these are PRECISELY the kind of 'FACTS' that should be scrutinised!!
I accept that what you have stated, may be your OPINION, and that YOU have 'no doubt whatsoever', but I imagine you are aware, that these are EXACTLY the kind of statements which were described by the PAC as patently NOT 'factual' at all!
This is your opportunity to correct the PAC, by stating, from where this 'FACTUAL' evidence, regarding altitude, speed, and heading at WP change, was retrieved. We could then move the debate on somewhat.
If only they had a data recorder - but they didn't did they!
Walter:
Sending you a PM
"The pilots must have been in control until at least WP change. It is inconceivable that they would have made the three cockpit selections to change WP if out of control. We can also be in no doubt whatsoever that they were at low level and at high cruising speed, heading directly towards the Mull. This is not hypothesis. It is fact."
If the 'official' hypothesis is to be believed, these are PRECISELY the kind of 'FACTS' that should be scrutinised!!
I accept that what you have stated, may be your OPINION, and that YOU have 'no doubt whatsoever', but I imagine you are aware, that these are EXACTLY the kind of statements which were described by the PAC as patently NOT 'factual' at all!
This is your opportunity to correct the PAC, by stating, from where this 'FACTUAL' evidence, regarding altitude, speed, and heading at WP change, was retrieved. We could then move the debate on somewhat.
If only they had a data recorder - but they didn't did they!
Walter:
Sending you a PM
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JP
Thank you. I am sure some of us will indeed refer to the publication you mention, and look forward to it moving the debate on.
In the meantime, shall we take it that you accept, that the concept of 'negligence' PRECEDING waypoint change is (at the very least) problematic, to defend, since, at your invitation, we have demonstrated the crew may well, at this point, have been flying perfectly legally in VMC?
Is this author to which you refer, the same Steuart Campbell, who has conducted 'investigations' into the Loch Ness Monster, and the existence of UFOs?
Thank you. I am sure some of us will indeed refer to the publication you mention, and look forward to it moving the debate on.
In the meantime, shall we take it that you accept, that the concept of 'negligence' PRECEDING waypoint change is (at the very least) problematic, to defend, since, at your invitation, we have demonstrated the crew may well, at this point, have been flying perfectly legally in VMC?
Is this author to which you refer, the same Steuart Campbell, who has conducted 'investigations' into the Loch Ness Monster, and the existence of UFOs?
Last edited by Tandemrotor; 17th Aug 2004 at 13:09.
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And was he able to prove whether or not the Loch Ness Monster, or UFOs actually do exist?
I may not like what he says about that either.
In the meant time, I am pleased we are making progress. You clearly are unable to defend the concept of negligence prior to way point change.
Thank you
If I may say, your postings seem to be more brief than usual.
I may not like what he says about that either.
In the meant time, I am pleased we are making progress. You clearly are unable to defend the concept of negligence prior to way point change.
Thank you
If I may say, your postings seem to be more brief than usual.
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John Purdy, You are quite right to criticize when people rubbish statements they have not seen. How do you feel about Worker's complete dismissal of the Blakely findings simply because he had only partially quoted ACM Wratten?
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Now that we seem to be making progress, let me state the case for the defence, if I may.
It has been demonstrated, and accepted by ALL, that it is NOT POSSIBLE to state that the crew had been negligent PRIOR to waypoint change. (If IFR they quite possibly were negligent, if VFR, they may well NOT have been!) But we all agree, we don't know whether they were IFR, or VFR.
The evidence simply DOES NOT EXIST!
The crew may very well have been flying in VMC, and complying with the Visual Flight Rules (VFR) at that moment. This idea is confirmed by Stn Cdr RAF Odiham, who thought it quite likely.
We are then compelled to consider far more closely the period SUBSEQUENT to waypoint change, in order to assess the competence, or negligence of the crew.
This sadly, is rather problematic, since this period provides us with NO RECORDED INFORMATION WHATSOEVER!
We (and the BOI!) are left with ONLY a computer simulation (now largely discredited since the input data was so dissimilar to the accident aircraft!) to provide us with a POSSIBLE profile flown by ZD576!
I now remind you of the position of the Air Marshalls:
165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their negligence in reaching that position was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71).
I emphasise:
1) "THEIR NEGLIGENCE IN REACHING THAT POSITION WAS NOT MITIGATED BY ANYTHING THAT MIGHT HAVE HAPPENED THEREAFTER."
2) "BOTH SIR JOHN AND SIR WILLIAM ACCEPTED THAT THE POSSIBILITY OF A CONTROL JAM OR ENGINE MALFUNCTION COULD NOT BE DISPROVED "
Not to mention a previous quote from the BOI:
"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
b. An unregistered technical malfunction
(Which were common on this aircraft at this time!) - My comment
c. Human factors
Any of these are plausible explanations!"
"Absolutely no doubt whatsoever"??
If only they had a data recorder - But they didn't, did they!
Very many thanks to Brian, slj, Arkroyal, Walter, Pulse 1, and many others with an interest in justice.
Any response from JP, WOrkER, K52, flatiron?
It has been demonstrated, and accepted by ALL, that it is NOT POSSIBLE to state that the crew had been negligent PRIOR to waypoint change. (If IFR they quite possibly were negligent, if VFR, they may well NOT have been!) But we all agree, we don't know whether they were IFR, or VFR.
The evidence simply DOES NOT EXIST!
The crew may very well have been flying in VMC, and complying with the Visual Flight Rules (VFR) at that moment. This idea is confirmed by Stn Cdr RAF Odiham, who thought it quite likely.
We are then compelled to consider far more closely the period SUBSEQUENT to waypoint change, in order to assess the competence, or negligence of the crew.
This sadly, is rather problematic, since this period provides us with NO RECORDED INFORMATION WHATSOEVER!
We (and the BOI!) are left with ONLY a computer simulation (now largely discredited since the input data was so dissimilar to the accident aircraft!) to provide us with a POSSIBLE profile flown by ZD576!
I now remind you of the position of the Air Marshalls:
165. Both Sir John and Sir William accepted that the possibility of a control jam or engine malfunction could not be disproved. They were adamant however that the pilots were faced with no problem prior to the way point change and that their negligence in reaching that position was not mitigated by anything that might have happened thereafter (QQ 339, 1069-71).
I emphasise:
1) "THEIR NEGLIGENCE IN REACHING THAT POSITION WAS NOT MITIGATED BY ANYTHING THAT MIGHT HAVE HAPPENED THEREAFTER."
2) "BOTH SIR JOHN AND SIR WILLIAM ACCEPTED THAT THE POSSIBILITY OF A CONTROL JAM OR ENGINE MALFUNCTION COULD NOT BE DISPROVED "
Not to mention a previous quote from the BOI:
"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
b. An unregistered technical malfunction
(Which were common on this aircraft at this time!) - My comment
c. Human factors
Any of these are plausible explanations!"
"Absolutely no doubt whatsoever"??
If only they had a data recorder - But they didn't, did they!
Very many thanks to Brian, slj, Arkroyal, Walter, Pulse 1, and many others with an interest in justice.
Any response from JP, WOrkER, K52, flatiron?
Last edited by Tandemrotor; 20th Aug 2004 at 20:25.
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Following on from Tandemrotor's post.
The Air Marshals, and several of their supporters, state that the point of negligence occurs when the pilots make the waypoint change too close to the Mull to turn away, or overfly the ground.
How can anyone know how close they were to the Mull, when there is no recorded time of that change being made? The whole basis of their argument is completely undermined by this lack of vital information.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
The Air Marshals, and several of their supporters, state that the point of negligence occurs when the pilots make the waypoint change too close to the Mull to turn away, or overfly the ground.
How can anyone know how close they were to the Mull, when there is no recorded time of that change being made? The whole basis of their argument is completely undermined by this lack of vital information.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
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Mr Purdey and friends
One of the problems in this unfortunate matter is that you use what I would refer to as operating mistakes or possible operating mistakes as being negligence when they are not that in law.
The making of a mistake(s) only become negligence in law if a number of demanding legal tests are met. One of these is beyond all doubt and another, and critical one is that the maker of the mistake should have forseen the consequences of his action and still continued with that course(s) of action. The forseeability test is a critical and demading one based on facts not hypotheses or assumptions, in proving negligence and is mentioned in the House of Lords Select Committee Conclusions.
One of the problems in this discussion is the massive difference in everyday understanding of negligence and the legal definition. As the reputation of the two pilots has been tarnished by the inferences drawn on assumptions and hunches rather than fact it is quickly appreciated why many of us feel that the reputations of the two pilots be restored. We simply do not know for certain what happened. There might well have been human error, there might well have been mechanical or other failure. We do not know and will never know. All the evidence is full of suggestion but precious little fact.
If the approach of the Air Marshall’s and Blair is correct it would lead to legal chaos. Someone would just have to look at the outcome of an event and because there was no factual or logical explanation conclude that there must have been negligence. The law is much more sensitive and equitable. It requires factual evidence of negligence and stringent tests such as forseeability and beyond all doubt before we tarnish reputations, especially reputations of those who are unable speak for and defend themselves.
It is sad to see the Prime Minister perpetuate a clear miscarriage of justice when he had the opportunity to do what is right and just.
Mr Purdey. You will never prove legal negligence. You are entitled with your experience and unquestioned integrity to believe that mistake(s) were made. There might have been mistakes made. But that does not go anywhere near proving the two pilots were legally negligent for the reasons put forward in the House of Lords Select Committee Conclusions.
One of the problems in this unfortunate matter is that you use what I would refer to as operating mistakes or possible operating mistakes as being negligence when they are not that in law.
The making of a mistake(s) only become negligence in law if a number of demanding legal tests are met. One of these is beyond all doubt and another, and critical one is that the maker of the mistake should have forseen the consequences of his action and still continued with that course(s) of action. The forseeability test is a critical and demading one based on facts not hypotheses or assumptions, in proving negligence and is mentioned in the House of Lords Select Committee Conclusions.
One of the problems in this discussion is the massive difference in everyday understanding of negligence and the legal definition. As the reputation of the two pilots has been tarnished by the inferences drawn on assumptions and hunches rather than fact it is quickly appreciated why many of us feel that the reputations of the two pilots be restored. We simply do not know for certain what happened. There might well have been human error, there might well have been mechanical or other failure. We do not know and will never know. All the evidence is full of suggestion but precious little fact.
If the approach of the Air Marshall’s and Blair is correct it would lead to legal chaos. Someone would just have to look at the outcome of an event and because there was no factual or logical explanation conclude that there must have been negligence. The law is much more sensitive and equitable. It requires factual evidence of negligence and stringent tests such as forseeability and beyond all doubt before we tarnish reputations, especially reputations of those who are unable speak for and defend themselves.
It is sad to see the Prime Minister perpetuate a clear miscarriage of justice when he had the opportunity to do what is right and just.
Mr Purdey. You will never prove legal negligence. You are entitled with your experience and unquestioned integrity to believe that mistake(s) were made. There might have been mistakes made. But that does not go anywhere near proving the two pilots were legally negligent for the reasons put forward in the House of Lords Select Committee Conclusions.
John Purdey, WOrker,
JP says "Yes, brief because we have been over this ground too often before".
I hope that you will agree that we are on new ground as we wait for you to tell us what the crew could see, and what they could'nt see at the point at which you are convinced beyond any doubt that they should have turned away or climbed.
Please note that the weather information referred to 10 Km visibility in patches. Except for the top of the Mull itself are you certain that they were not in one of these patches at the time?
Holbrook's evidence suggests that they might have been.
JP says "Yes, brief because we have been over this ground too often before".
I hope that you will agree that we are on new ground as we wait for you to tell us what the crew could see, and what they could'nt see at the point at which you are convinced beyond any doubt that they should have turned away or climbed.
Please note that the weather information referred to 10 Km visibility in patches. Except for the top of the Mull itself are you certain that they were not in one of these patches at the time?
Holbrook's evidence suggests that they might have been.