Chinook - Still Hitting Back 3 (Merged)
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Brian,
I hesitate to quibble with you, but surely it's not the case that "the pilots deserve the benefit of the doubt", but that anyone who seeks to condemn them must prove beyond a shadow of doubt that they were negligent?
Best regards in any case.
I hesitate to quibble with you, but surely it's not the case that "the pilots deserve the benefit of the doubt", but that anyone who seeks to condemn them must prove beyond a shadow of doubt that they were negligent?
Best regards in any case.
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Brian Dixon,
Thanks for the welcome, though I have little new to add to earlier posts. Just once more: at waypoint change, we all agree, the aircraft was under control. So why did the crew not turn away, which would have been the action of reasonable men? (the definition of negligence being that action was taken or not taken, which reasonable men would, or not, have taken)?
One or two posts have suggested that the crew could not turn away, ie there was a control failure. In that case you have to accept that at or about waypoint change, a failure occured virtually simultaneously in two discrete control systems (as I understand them), and then just a few seconds before impact the restrictions both freed themselves more or less simultaneusly, leaving absolutely no witness marks or other evidence of such failures. If you wish to believe that, then there is really no more to be said, at least not by me!
As to your question about height, speed and headings, I cannot believe that the precise figures (I repeat, precise figures) matter all that much. If the aircraft was not at low level and high speed heading for the Mull, then where was it and whar was it doing?
At a higher level of discussion, I think Chipp63 is quite right: there is an inconsistency in saying on the one hand that the crew'deserve the benefitof the doubt' but on the other hand saying that it must be proved beyond any doubt whatever that the crew were negligent.
Meanwhile, do read the book 'Chinook Crash', and do not, as one or two posts have already hinted, dismiss it because you might not agree with what it says when you get around to reading it. The author makes the interesting point, among others, that the crew mistook the fog signal building and the offshore rocks nearby at Rubha na Lice, for the lighthouse and the nearby offshore rocks at that point. I await views on that.
With all good wishes, as always. JP
Thanks for the welcome, though I have little new to add to earlier posts. Just once more: at waypoint change, we all agree, the aircraft was under control. So why did the crew not turn away, which would have been the action of reasonable men? (the definition of negligence being that action was taken or not taken, which reasonable men would, or not, have taken)?
One or two posts have suggested that the crew could not turn away, ie there was a control failure. In that case you have to accept that at or about waypoint change, a failure occured virtually simultaneously in two discrete control systems (as I understand them), and then just a few seconds before impact the restrictions both freed themselves more or less simultaneusly, leaving absolutely no witness marks or other evidence of such failures. If you wish to believe that, then there is really no more to be said, at least not by me!
As to your question about height, speed and headings, I cannot believe that the precise figures (I repeat, precise figures) matter all that much. If the aircraft was not at low level and high speed heading for the Mull, then where was it and whar was it doing?
At a higher level of discussion, I think Chipp63 is quite right: there is an inconsistency in saying on the one hand that the crew'deserve the benefitof the doubt' but on the other hand saying that it must be proved beyond any doubt whatever that the crew were negligent.
Meanwhile, do read the book 'Chinook Crash', and do not, as one or two posts have already hinted, dismiss it because you might not agree with what it says when you get around to reading it. The author makes the interesting point, among others, that the crew mistook the fog signal building and the offshore rocks nearby at Rubha na Lice, for the lighthouse and the nearby offshore rocks at that point. I await views on that.
With all good wishes, as always. JP
Last edited by John Purdey; 14th Sep 2004 at 15:42.
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Hi Mr Purdey,
I'm happy to agree that a waypoint change was made. That much is known as fact.
With regard to the aircraft turning away (or not as the case may be) I have to say that personally I don't know what happened between the waypoint change and the crash. I have ideas, beliefs and suggestions but I cannot say with absolutely no doubt whatsoever what happened. I also believe that no one else can either!
I take your point, to a degree, on precise figures, but would you agree that some of the questions are unanswerable due to ther being no recorded evidence (time of waypoint change, for example). Yet, some of these answers were presented as 'known facts' during the review of the Board process, ad subsequent reviews.
I agree with you about my 'benefit of the doubt' comment. Chippy63 and yourself are quite right, and I apologise for not getting my point across as meant. I was trying to say that the verdict of negligence was given after assumptions were made (purely to try to make sense of what little hard evidence there was to work with). Questions have been asked about safety of these assumptions and to that end, there are areas of doubt. The pilots should be given the benefit of that doubt, and not convicted outside of the parameters of the rules.
I hope that explains it ... or have I confused the issue further?
I have read the book by Mr Campbell, and whilst I admit it is an interesting read. Mr Campbell's conclusions are just as plausible as other views offered, as it is not backed up by hard evidence. This in itself negates the verdict as another possible solution may fit known facts. If Mr Campbell is right, would you say that the pilots were negligent, or is it an error of judgement?
However, the bottom line is that we will never know with absolutely no doubt whatsoever.
Hopefully, this answers your points. If not, please come back to me.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
I'm happy to agree that a waypoint change was made. That much is known as fact.
With regard to the aircraft turning away (or not as the case may be) I have to say that personally I don't know what happened between the waypoint change and the crash. I have ideas, beliefs and suggestions but I cannot say with absolutely no doubt whatsoever what happened. I also believe that no one else can either!
I take your point, to a degree, on precise figures, but would you agree that some of the questions are unanswerable due to ther being no recorded evidence (time of waypoint change, for example). Yet, some of these answers were presented as 'known facts' during the review of the Board process, ad subsequent reviews.
I agree with you about my 'benefit of the doubt' comment. Chippy63 and yourself are quite right, and I apologise for not getting my point across as meant. I was trying to say that the verdict of negligence was given after assumptions were made (purely to try to make sense of what little hard evidence there was to work with). Questions have been asked about safety of these assumptions and to that end, there are areas of doubt. The pilots should be given the benefit of that doubt, and not convicted outside of the parameters of the rules.
I hope that explains it ... or have I confused the issue further?
I have read the book by Mr Campbell, and whilst I admit it is an interesting read. Mr Campbell's conclusions are just as plausible as other views offered, as it is not backed up by hard evidence. This in itself negates the verdict as another possible solution may fit known facts. If Mr Campbell is right, would you say that the pilots were negligent, or is it an error of judgement?
However, the bottom line is that we will never know with absolutely no doubt whatsoever.
Hopefully, this answers your points. If not, please come back to me.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
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Greetings Brian Dixon,
If you are referring to details of time, speed etc, then yes I agree with you that some of the questions are unanswerable. My point was that high precision in those figures seems to me not to alter the basics of the picture
As you say, Campbell's book suggests an error of judgement as the cause of the crash (for those who have not seen the book, because in those poor weather conditions the crew misidentified the fog signal complex for the lighthouse complex). He seems to ignore the fact that in those conditions the aircraft should not have been where it was in the first place, which as you know is my own opinion.
But it is all about our different opinions. I know yours will not change, and I am not trying to change it; I have just been telling you what I think.
With all good wishes
JP
If you are referring to details of time, speed etc, then yes I agree with you that some of the questions are unanswerable. My point was that high precision in those figures seems to me not to alter the basics of the picture
As you say, Campbell's book suggests an error of judgement as the cause of the crash (for those who have not seen the book, because in those poor weather conditions the crew misidentified the fog signal complex for the lighthouse complex). He seems to ignore the fact that in those conditions the aircraft should not have been where it was in the first place, which as you know is my own opinion.
But it is all about our different opinions. I know yours will not change, and I am not trying to change it; I have just been telling you what I think.
With all good wishes
JP
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"He seems to ignore the fact that in those conditions the aircraft should not have been where it was in the first place, which as you know is my own opinion"
Your sentence is somewhat contradictory - if the above is your opinion it cannot be a "fact".
It would surely be more correct to write something along the lines of "He seems to ignore the possibility that in those conditions the aircraft should not have been where it was in the first place, which as you know is my own opinion". No-one can surely take issue with the latter statement, as it represents your opinion which is as valid as any other.
This may seem like arguing semantics, but it is, in my opinion, the root of the whole problem - we are where we are because sundry Air Marshals and politicians insist on representing opinions and suppositions as facts.
Your sentence is somewhat contradictory - if the above is your opinion it cannot be a "fact".
It would surely be more correct to write something along the lines of "He seems to ignore the possibility that in those conditions the aircraft should not have been where it was in the first place, which as you know is my own opinion". No-one can surely take issue with the latter statement, as it represents your opinion which is as valid as any other.
This may seem like arguing semantics, but it is, in my opinion, the root of the whole problem - we are where we are because sundry Air Marshals and politicians insist on representing opinions and suppositions as facts.
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Hi everyone,
I mentioned that a more comprehensive review of Mr Campbell's publication would be posted. It has been written by Air Cdr (Ret'd) John Blakeley, and has the full endorsement of Jon's father, Mike Tapper. It is very comprehensive. Apologies for the length of the post, but it would have lost much had it been shortened.
Introduction
I have now had the chance to look at Steuart Campbell's book "Chinook Crash", albeit on a speed reading basis. In parts it reads with the sort of detail of a Clancy techno-thriller, and this style will certainly appeal to some readers even though it generates a lot of page filling and irrelevant detail - but if it was a Clancy style work of fiction I would have suggested a happier ending. Sadly, of course, it isn't and we all know that the story ends in tragedy - but none of us, including Campbell, know with certainty why. Campbell's last sentence "The accident is now explained" must rate very high on the Jeremy Paxman scale of arrogant statements. By partial quotes from the BoI; by only using those "facts" that suit his theory and by failing to challenge the Board in so many areas where we know they were deficient, and I am looking very much at the engineering area and the evidence to the House of Lords Select Committee, I believe that Campbell has started from the answer and then "situated the appreciation". This is a pity, since he obviously put a lot of effort into his book but failed to analyse all potentially relevant causes of the accident, including such basics as the airworthiness of the Chinook fleet at the time. He also gives the impression of wanting to vilify the captain, Jonathan Tapper, at every opportunity, and one has to ask why? We have been here before as there was a serious attempt to vilify Jonathan Tapper at the FAI which drew the Sheriff's comment of " the universal plaudits of those witnesses who had actually flown with him before the accident and whose evidence I have outlined above".
Those readers familiar with the BoI and the inquiries will find little new in the summaries of all of these activities, and probably, like me, they will be constantly saying - did the Board really say that? As a few examples:
1. Board Conclusions
1.1 VFR versus IFR
At Chapter 4 Campbell notes that amongst the Board's incidental conclusions was a statement that " the weather was suitable for the flight, but would have required (my underlining) flight in accordance with IFR near the Mull of Kintyre". In fact this is one of the classic non sequiturs of the Board that one might have expected the detailed analysis that Campbell claims to have done to have picked up. I have, for example, seen Campbell's recent e-mail to Ralph Kohn criticising Tim Slessor's book in which Campbell claims "With no bias and thorough investigation, I was able to take a 'balanced' view, which I hope will be evident to you." I will not comment on the bias, but the thorough investigation claim has so far eluded me since at paragraph 42, discussing the weather, the Board says:
42. Weather - The Board considered that the weather information available to the crew at RAF Aldergrove prior to flight was comprehensive and adequate for the task, and the Board was content that the crew had considered the weather relevant to their flight. The Board then considered the suitability of the forecast and actual weather for the VFR flight planned by the crew. The weather documentation faxed to the crew indicated that conditions entirely suitable for helicopter low level VFR flight would prevail over the greater portion of their route, but that over coastal areas there would be an occasional risk of less favourable but acceptable conditions, and an isolated risk of conditions sufficiently poor to preclude VFR flight. These indications were reflected in the associated TAFs and METARs. Along the crews planned route, these occasional and isolated conditions would only have been expected in the area of the Mull of Kintyre, with a specific risk of a 30% probability of weather below VFR limits being forecast for Machrihanish. In the opinion of the Board, a forecast of a 30% probability of en-route weather below VFR limits was not sufficient to preclude an attempt at a VFR flight (my underlining). However, a suitable bad weather contingency plan would have been required. This might have been a VFR diversion around the bad weather, a VFR return to the point of departure, or a pre-planned climb and conversion to IFR flight (my underlining). The possibility of a lightning strike affecting the aircraft was also considered by the Board, but as there were no reports of lightning activity in the area, and no evidence of a lightning strike was found in the technical investigation, it was discounted. Similarly, the Board also considered the part that turbulence may have played in the accident and, as the aftercast indicates that the turbulence in the area was only moderate, the Board concluded that it could have provided no more than a distraction to the crew, particularly when flying in IMC. However, as the actual weather in the area of the crash site at the time of the accident was very poor, with very low cloud bases and low visibilities, the Board concluded that weather was a contributory factor in the accident.
Quite how the BoI and then Campbell take these statements as requiring IFR flight in the vicinity of the Mull I will leave others to work out.
1.2 Serviceability
1.2.1
Again Campbell is happy to accept the BoI's unfounded assertion that the aircraft was serviceable to undertake the flight. Leaving aside the fleet airworthiness issue which would have meant that the aircraft came nowhere near meeting the safety requirements for civilian passenger flight, neither the BoI nor Campbell recognise the fact that the BoI again ignores its own evidence and the technical history of the aircraft in making such an assertion. As a minimum we know that the aircraft was carrying at least one incipient electrical fault in the PTIT gauge or its DECU or the sensor or, even more likely in my experience in its wiring or connectors (and if Campbell knew anything about aircraft maintenance operations he would realise that the problem going away when the gauges were swapped round is a classic trait of any transient electrical fault. Sqn Ldr Burke said at the House of Lords Select Committee "The [DECU] Multi point connector was not of a good design, and again you had power interrupts on the system. The squadrons introduced a procedure, probably the OCU did as well, but I am not certain on that point, where the crewman every quarter of an hour would have to go up and check physically that this multi-point had not vibrated loose". HL Paper25(ii) para 677" Even in October 1995 the US Army Release to Service recognised the inherent "security" problems of the DECU connectors by requiring both a pre-fight and a 30 minute ramp check of the DECU connectors - ie they were still being inspected before every flight
1.2.2
In their opening remarks the Board decides to "eliminate [my bold] as possible causes: major technical malfunction or structural failure of the aircraft prior to impact; …… Therefore the Inquiry focused on the crew’s handling and operation of the aircraft.”
But at paragraph 35d the Board states:
“Nevertheless an unforeseen technical malfunction of the type being experienced on the Chinook HC2, which would not necessarily have left any physical evidence, remained a possibility, and could not be discounted.”
Perhaps I am missing something obvious, but it seems to me that this statement is at total odds with the Board's opening remarks, and this major discrepancy should have easily been picked up by the Review Process and indeed by Campbell's "unbiased and thorough investigation". Further evidence that Campbell was only too willing to believe the BoI in those areas that suited his appreciation of the situation - or perhaps better helped situate his appreciation!
1.2.3
In an amazing piece of logic under "Malfunction" Campbell makes the following statement:
"Much has been made of the fact that the AAIB admitted that it could not exclude the possibility of pre-impact damage or faults with some systems in ZD576. Those convinced that the accident was caused by some mechanical fault that somehow distracted the pilots at the moment when they should have been turning or made it impossible to turn the aircraft have seized on this admission as evidence that there was such a fault. However, absence of evidence is not evidence of absence (nor evidence of presence). If a mechanical component is found to be damaged from the impact, but it could have been faulty or damaged before the impact, and there is no way to distinguish between these two alternatives, it cannot be assumed that the damage was pre-impact. Claims that there was a pre-impact fault need to be based on direct evidence of such a fault. The complete absence of such evidence suggests that there was no such fault and that the aircraft was completely serviceable when it crashed. "
I was doing OK until the last two sentences, but then it goes very wrong. If you do not know whether the item was damaged before or after the accident (and bearing in mind that the "damage" may be a transient electrical or software fault) it goes without saying that there will be no direct evidence before the crash - that is where ADRs and CVRs are so useful as I know from personal involvement in my engineering officers using the Tornado ADR to investigate incidents where there were no symptoms by the time the aircraft landed - incidentally quite a few of which were uncommanded control movements and major aircraft departures from controlled flight. The use of this twisted logic to claim that "The complete absence of such evidence suggests that there was no such fault and that the aircraft was completely serviceable when it crashed." does not accord with any logical argument that I can see. Am I claiming the aircraft was unserviceable - no I am not - like everyone else, other than, it seems, Campbell, I do not know. I do know though that it could have been unserviceable and indeed there are at least as many "facts" pointing to this was as there are hypotheses, or worse hypotheses turned into facts, that point at an operational reason for the accident - had Campbell done the unbiased and thorough examination he claims he would see it too.
2. Crew Duty Time
In his evidence on the crew\'s intentions Campbell again mis-uses the BoI evidence by directly questioning how Tapper intended to get back to Belfast that evening without breaking Crew Duty Time CDT limitations and suggesting that whatever he did Tapper would have been "reprimanded". What an outrageous comment, again attacking Tapper\'s reputation to help support Campbell\'s story, which in my opinion shows just how low Campbell has had to sink to put his story together. Campbell could not have known anything of the sort. He repeats a similar comment in the conclusions where he claims as a contributory cause of the accident that "it may have been a mistake for Tapper to insist on taking the sortie near the end of his crew\'s shift, especially when he was bound to exceed the time limit and so break regulations". Again an unjustified and outrageous assertion by Campbell. Had the crew actually broken the rules and had the accident occurred on the homeward flight Campbell\'s comments might be relevant, but the fact is that the crew were perfectly "legal" in terms of CDT and it is mischief making to comment otherwise. If Campbell had read on to the comments of the Station Commander at Aldergrove (and also as SRAFONI responsible for authorising any CDT extension to the maximum allowable) he would have seen the following comments:
"Crew Duty Considerations- The crew of ZD 576 had flown a task within NI earlier on the 2 Jun. I concur with the Board\'s statement (para 66a), that the decision for the crew to carry out the Inverness sortie "Whilst not ideal, was not unreasonable". It was detachment practise, because of the extended day time in early June at Aldergrove\'s latitude, to preserve where possible, a "day-on day-off " routine between the 2 crews. Given the routine nature of the day\'s earlier tasking, it was reasonable, as a one off for a single crew to plan to complete the full day\'s tasking by extending flying hours within the Crew Duty Time (CDT).
Turning to possible further extensions of CDT, I do not believe that, in the absence of any firm evidence one way or the other, we can usefully speculate on TAPPER\'s further intentions after arrival at Inverness. At the time of the accident, the crew was operating within CDT extension which had been properly sought and granted (para 30b), and fatigue was unlikely to have contributed to the cause of the accident."
Not surprisingly, since it would have been a major criticism of flying supervision at RAF Aldergrove, neither of the Air Marshals disagrees with the Station Commander\'s statement. Campbell also implies that Tapper was acting alone by failing properly to take account of CDT on some sort of renegade mission - in fact nothing would have been further from the truth - both 230 Sqn and Aldergrove Operations would have been aware of the tasking and CDT issues (and if they were not they were failing in their duty) as would the JATOC. If supervisors had been unhappy with Tapper\'s plans they could have stopped them at any time, even allowing for the fact that Tapper was "self-authorising" - itself a carefully supervised delegation of authority from above.
3, FADEC
3.1 Although Campbell\'s book touches on the underlying airworthiness issues of the Chinook Mk 2 at the time of the accident, he does not seem to recognise their implications either as a potential cause of the accident or as a major issue that should have been considered by RAF command staffs, including RAF Odiham, before this aircraft was allocated for a passenger flight, where it might have been reasonable for the passengers to have expected to be flying in an aircraft that met at least basic CAA airworthiness standards. The FADEC is a particular example of Campbell\'s ability to ignore facts and draw his own (favourable) conclusions. The "Malfunction" section of his Conclusions is a classic example of muddled thinking and a lack of understanding of the equipment function. It is worth quoting, and then analysing, in full for those areas where he is discussing the FADEC:
"Malfunction
The accident in Wilmington in 1989 was to a Mkl Chinook that, for testing purposes, had been fitted with an experimental FADEC engine control system. The unit inquiry (not a Board) that investigated found that the accident was caused by an error in testing procedure, specifically the disconnection of a vital connector. It turned out that it was also due to a fault in the FADEC software that allowed a catastrophic engine runaway when the signal from that connector was lost. In effect, it was due to an unfortunate combination of these two factors. The aircraft was seriously damaged, but not beyond repair and the FADEC software was later substantially rewritten before Mk2s were introduced into service. Consequently, allegations that the incident showed that FADEC is dangerous and might have contributed to the Kintyre crash are misplaced and specious. It is invalid to argue that, because an engine runaway occurred five years earlier in a Chinook on test when a vital sensor was disconnected and the software was not able to cope, this happened on the fatal flight of ZD576. The problems that Boscombe Down experienced appear to have been self-inflicted, in taking FADEC beyond its limits. As a result, BD unnecessarily alarmed Chinook pilots. Nor, as it turned out, were the CA Release restrictions necessary.
FADEC has not featured in any of the other Chinook crashes, all to Mkls fitted with a hydro-mechanical fuel control system with a poor record for reliability. Although the particular FADEC system installed in the RAF Chinooks is unique to them, similar computerized fuel control systems are installed in US and Dutch Chinooks, all Airbuses, the Boeings 767 and 777, Concorde and aircraft of the Queen\'s Flight. Consequently, such an engine control system is not inherently unsafe and it has not been implicated in any aircraft accident. Nor, once the software was rewritten, has the RAF FADEC given further trouble. It is inherently unlikely therefore that the FADEC had anything to do with the accident. The House of Lords Select Committee accepted that neither the E5 code found in one of the FADEC\'s DECUs nor the faulty altimeter were relevant to the accident.
Excluding the Wilmington incident, of the eight other Chinook accidents (see list below and, reports in Appendix 1), only two were definitely attributed to a technical fault and in neither case were there any fatalities. In only one fatal case were mechanical faults discovered which could have caused the accident. However, in the case of ZD576, no mechanical fault was found. Crew error has been identified as the cause in all the fatal accidents except for one, the cause of which could not positively be determined."
3.2 I am not aware of any allegations that the FADEC itself was "dangerous", but there is no doubt that at the time of the accident it was not seen by Boscombe Down as being proven to be "fit for purpose" and in addition there was no doubt that even with the further re-written standard of software following the Wilmington incident FADEC was the cause of many in-service problems. Thus Witness 20 Sqn Ldr Morgan comments: "The unforeseen malfunctions on the Chinook HC2 of a flight critical nature [my bold] have mainly been associated with the engine system FADEC. They have resulted in undemanded engine shutdown, engine run-up, spurious engine failure captions and misleading and confusing cockpit indications.” This is a man who knew what he was talking about at the time even though the BoI themselves chose to omit the words "flight critical" when they quoted his evidence. Put this statement together with the BoI\'s major non sequitur on aircraft serviceability - see 1.2 above and is Campbell really so sure that FADEC could not have contributed to the accident even if only in the form of a major distraction at the critical moment of new waypoint selection? I am not saying this happened, but equally he does not know that it did not!
3.3 Campbell\'s comment that Boscombe Down\'s problems with the FADEC were self-inflicted is, in my view, total nonsense. Whilst we may not always like the time it takes and their sometimes pedantic approach (and certainly with his memo the Senior Reviewing Officer or one of his staff did not) it IS BD\'s job to both take the system to the limits and to fully understand the failure mechanisms and emergency/recovery procedures (which all too often in the past the manufacturer has failed fully to document, and which presumably showed in the state of the FRCs for the Chinook Mk 2). Campbell also comments, by implication as a criticism, that the CA Release restrictions were not necessary. This statement is unbelievably naive, and again shows a total lack of understanding of BD\'s role and methodology. The comment that the CA Release restrictions were not necessary is both incorrect, given the need to maintain flight on one engine in an aircraft subject to "flight critical" engine problems, and irrelevant. The fact is that the restriction was there, and the pilots had no choice but to obey it in all of their flight tasking and planning procedures - indeed the restrictions had been reinforced by comments from the flying supervisory chain.
3.4 Campbell comments that FADEC has not figured in any of the other Chinook crashes in his table of 8 accidents. Again he seems to be being somewhat disingenuous since even by his own admission they were all Chinook Mk 1s and did not have FADEC fitted! FADEC for the T55-L-712F engine only went into production in July 1991 for incorporation on the Chinook Mk 2 aircraft. His comment that the FADEC with the re-written and validated software has not been cited as the cause of any subsequent accident is more valid, but does he know how many flight incidents it has been cited in - we have consistently been refused this information by MOD.
3.5 There are so many more relevant comments questioning the FADEC that there is not room to cover them all. I have picked just two more:
3.5.1 Campbell claims that it is inherently unlikely that the FADEC had anything to do with the accident and then quotes the House of Lords saying that the E5 code ....etc. But the House of Lords conclusions also said the following: "Mr Cable accepted that it was possible that there had been an intermittent engine fault which had subsequently reverted to normal before the impact. The problems arising from the newly installed FADEC system had not all been resolved by June 1994". Are the House of Lords saying that FADEC caused the accident - no of course not, but they are not writing it out as a possible cause either - but Campbell does.
3.5.2 The Boscombe Down (EAS) memorandum reference AEN58/022/1 dated 3 June 1994, which I believe Campbell must have seen in any thorough examination states quite categorically "Notwithstanding the claims made by Textron\'s white paper, the problem remains that the product (FADEC at the software standard being tested at BD - assumed to be the same issue as on ZD 576) has been shown to be unverifiable and is therefore unsuitable (their bold) for its purpose". The Textron White Paper being referred to was, of course, only produced in March 1994 and was an attempt to answer major criticisms of their development programme for the FADEC software going back over many years, and made by independent system house assessments. As far as I can recall comments such as this, and indeed the Textron White Paper, were never shown to the BoI and if they were they were never investigated - this critical area from BD was not even asked to be a witness at the Inquiry, and no link was made to the BD decision to stop the flight trials. The EAS memorandum then goes on to make some 17 major comments (one of which has 7 sub-comments) on the content and testing of the software and notes that contrary to what was being said at the time (including I think to the investigations later) the software for FADEC was "safety critical" and hence should have been developed, tested and documented as such. Even against the lower JSP 188, level of documentation that had been contracted for BD had identified 34 category 1 and 48 category 2 anomalies in their Traceability Study (which was conducted against the system rather than the detailed requirement level). Since it would appear that the 8 RAF Chinook Mk3s that are sitting unused have had safety critical software procured with similar problems to the Chinook Mk2 (albeit, it is stated by MOD, in a different area) it is surprising that Campbell has not picked up this problem - which has already potentially "wasted" £200M of taxpayers\' money with a lot more to come to put them right. Given the BD position it was a major omission by the BoI not to investigate this area - did they know about it? Did they get warned off? These are the sort of areas a thorough investigation should have looked at.
4. Reporting of Defects
Campbell rightly picks up the problem of Tapper\'s failure to raise a defect report on the faulty PTIT gauge, using this as part of his contention that Tapper had a "relaxed" attitude to regulations and even going so far as to imply that this alleged attitude somehow contributed to the accident. The BoI actually notes the following failures to follow the regulations as far as the reporting of defects was concerned:
c. AP 100B-01, order 0703, para 16 in that Lt KINGSTON did not raise a maintenance work order log entry for the engine PTIT fault.
d. AP 100B-01, order 0701, para 5 in that Sgt MAY and Cpl POLLARD transposed the No 1 and No 2 engine PTIT gauges without raising a maintenance work order.
e. AP 100B-01, order 0703, para 16 in that Flt Lt TAPPER did not raise a maintenance work order log entry for the superTANS/GPS fault.
f. AP 100B-01, order 0701, para 5 in that Cpl GUEST and SAC CLARK carried out a functional test on the SuperTANS and GPS without raising a maintenance work order.
In their conclusions the Board then stated "that these failings were not factors in the accident".
As anyone who has been on an operational detachment or even a major training exercise knows this approach to the reporting of what are perceived as minor or nuisance defects is often taken, particularly when there is a shortage of aircraft. It is not correct, but it is a fact of life that it happens.
In fact Tapper also queried the PTIT gauge from the trip before the accident, but was assured that it was only a transient gauge problem. Hence he was carrying at least one unservicability in the engine system when he took off. Given the known defect history of ZD 576 and the issues with the security of DECU connectors (and the PTIT sensor routes its signal to the DECU where it is split one signal being used by the DECU in the engine control laws, and one signal going to the gauge) it was perhaps unfortunate with the benefit of hindsight (which the BoI of course had) that this area was not looked at further. It would be of particular interest to know how much Odiham knew as to what had gone on at Aldergrove, as it was there that the right information connection might have been made and questions asked as to the underlying serviceability of ZD 576. The Detachment was operating on the RAF Odiham EOB so both SEngO 7 Sqn and OC Eng Wg RAF Odiham were the responsible officers in the airworthiness chain for this aircraft, with SEngO 230 Sqn (and NOT Tapper as Detachment Commander who would normally have been responsible) being responsible for Chinook engineering supervision at Aldergrove. In fact the BoI did not call OC Eng Wg Odiham at all. SEngO 7 Sqn only appeared to present the servicing documentation to the BoI and SEngO 230 Sqn, who appeared to know something about the PTIT gauging problems and the "malpractices" claimed that he was “satisfied that Chinook HC2 ZD576 was serviceable for it’s (sic) final flight on 2 Jun 94". No-one asked how he was "satisfied" as to its serviceability (had he visited the detachment, had he reviewed the servicing records, had he discussed the defect history and the potential links to the PTIT problem, etc) or why he had done nothing to regularise the defect reporting omissions - he, not Tapper, appeared to be responsible for this, albeit both Kingston and Tapper would have to accept some of the initial blame for their failure to raise the work order log entry. Again Campbell ignores all of these issues in favour of the tiny bit of the story that fits his ideas.
5. Poor Research
As what would normally be a minor point, but in the light of Campbell\'s claims to have solved by his meticulous research and analysis what so many others more capable and skilled than him have failed to solve it is a pity that Campbell does not seem to know the difference between a Flight Lieutenant RAF and a Lieutenant Royal Navy, since Kingston was of course a naval pilot - and note 27 says this. A minor error, but an important one.
Summary and Conclusions
What must be of concern is that for those of Mr Campbell\'s readers who have not seen the BoI and the transcripts of the various other enquiries (presumably he hopes the majority if the book is to sell in large numbers) then his version, whilst not representing the correct facts in many areas and certainly having nothing in it to support his claim to have solved the mystery, is going to look very convincing to the lay reader.
Despite these reservations I would have to accept that along with many other people Campbell appears to have raised a valid possible cause for the accident - I say "appears" because I am not a helicopter pilot and I do not know the area of the Mull of Kintyre (although I sent many happy hours flying round the Falklands in helicopters, including Chinook Mk1s, in some very dodgy conditions - but then I have always had great faith in military pilots). Some more familiar with the helicopter and the area might wish to turn Campbell\'s "possibility" into a probability although I would not subscribe to this. What is clear is that his theories can never be the "certainty" that he claims. Whether possibility, probability or even the certainty that he would claim then Campbell\'s theory does, however, do the pilot\'s families one great favour for, as he rightly points out, a navigation error could not, by definition, be "Gross Negligence" not just in legal terms, but by the standards of judgement applied to other similar accidents of the time (remember AEW Mk Shackleton WR 965 - hit the Isle of Harris following a navigation error in a bad weather descent to low level on 30 April 1990 - 10 killed, but, as I recall no findings of negligence of any sort). So support Campbell\'s theory by all means, but remember that it is only one of the possibilities. Also remember that whilst Campbell\'s theory might still be an aircrew error, or one of the new equivalents, verdict, it will not be a gross negligence one - despite his publisher\'s flyer claiming their book "generally" supports the Gross Negligence verdict!
END
As I said in a previous post, I have no wish to turn the thread into a book critique thread, but I believe this to be a valid response to the publication. The only thing we can safely (and rightly) conclude is that we don\'t know what was the cause of the accident with absolutely no doubt whatsoever. The negligence verdict should, therefore be removed. Only then, will the campaign go away!
Apologies for the overall length of the post.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
I mentioned that a more comprehensive review of Mr Campbell's publication would be posted. It has been written by Air Cdr (Ret'd) John Blakeley, and has the full endorsement of Jon's father, Mike Tapper. It is very comprehensive. Apologies for the length of the post, but it would have lost much had it been shortened.
Introduction
I have now had the chance to look at Steuart Campbell's book "Chinook Crash", albeit on a speed reading basis. In parts it reads with the sort of detail of a Clancy techno-thriller, and this style will certainly appeal to some readers even though it generates a lot of page filling and irrelevant detail - but if it was a Clancy style work of fiction I would have suggested a happier ending. Sadly, of course, it isn't and we all know that the story ends in tragedy - but none of us, including Campbell, know with certainty why. Campbell's last sentence "The accident is now explained" must rate very high on the Jeremy Paxman scale of arrogant statements. By partial quotes from the BoI; by only using those "facts" that suit his theory and by failing to challenge the Board in so many areas where we know they were deficient, and I am looking very much at the engineering area and the evidence to the House of Lords Select Committee, I believe that Campbell has started from the answer and then "situated the appreciation". This is a pity, since he obviously put a lot of effort into his book but failed to analyse all potentially relevant causes of the accident, including such basics as the airworthiness of the Chinook fleet at the time. He also gives the impression of wanting to vilify the captain, Jonathan Tapper, at every opportunity, and one has to ask why? We have been here before as there was a serious attempt to vilify Jonathan Tapper at the FAI which drew the Sheriff's comment of " the universal plaudits of those witnesses who had actually flown with him before the accident and whose evidence I have outlined above".
Those readers familiar with the BoI and the inquiries will find little new in the summaries of all of these activities, and probably, like me, they will be constantly saying - did the Board really say that? As a few examples:
1. Board Conclusions
1.1 VFR versus IFR
At Chapter 4 Campbell notes that amongst the Board's incidental conclusions was a statement that " the weather was suitable for the flight, but would have required (my underlining) flight in accordance with IFR near the Mull of Kintyre". In fact this is one of the classic non sequiturs of the Board that one might have expected the detailed analysis that Campbell claims to have done to have picked up. I have, for example, seen Campbell's recent e-mail to Ralph Kohn criticising Tim Slessor's book in which Campbell claims "With no bias and thorough investigation, I was able to take a 'balanced' view, which I hope will be evident to you." I will not comment on the bias, but the thorough investigation claim has so far eluded me since at paragraph 42, discussing the weather, the Board says:
42. Weather - The Board considered that the weather information available to the crew at RAF Aldergrove prior to flight was comprehensive and adequate for the task, and the Board was content that the crew had considered the weather relevant to their flight. The Board then considered the suitability of the forecast and actual weather for the VFR flight planned by the crew. The weather documentation faxed to the crew indicated that conditions entirely suitable for helicopter low level VFR flight would prevail over the greater portion of their route, but that over coastal areas there would be an occasional risk of less favourable but acceptable conditions, and an isolated risk of conditions sufficiently poor to preclude VFR flight. These indications were reflected in the associated TAFs and METARs. Along the crews planned route, these occasional and isolated conditions would only have been expected in the area of the Mull of Kintyre, with a specific risk of a 30% probability of weather below VFR limits being forecast for Machrihanish. In the opinion of the Board, a forecast of a 30% probability of en-route weather below VFR limits was not sufficient to preclude an attempt at a VFR flight (my underlining). However, a suitable bad weather contingency plan would have been required. This might have been a VFR diversion around the bad weather, a VFR return to the point of departure, or a pre-planned climb and conversion to IFR flight (my underlining). The possibility of a lightning strike affecting the aircraft was also considered by the Board, but as there were no reports of lightning activity in the area, and no evidence of a lightning strike was found in the technical investigation, it was discounted. Similarly, the Board also considered the part that turbulence may have played in the accident and, as the aftercast indicates that the turbulence in the area was only moderate, the Board concluded that it could have provided no more than a distraction to the crew, particularly when flying in IMC. However, as the actual weather in the area of the crash site at the time of the accident was very poor, with very low cloud bases and low visibilities, the Board concluded that weather was a contributory factor in the accident.
Quite how the BoI and then Campbell take these statements as requiring IFR flight in the vicinity of the Mull I will leave others to work out.
1.2 Serviceability
1.2.1
Again Campbell is happy to accept the BoI's unfounded assertion that the aircraft was serviceable to undertake the flight. Leaving aside the fleet airworthiness issue which would have meant that the aircraft came nowhere near meeting the safety requirements for civilian passenger flight, neither the BoI nor Campbell recognise the fact that the BoI again ignores its own evidence and the technical history of the aircraft in making such an assertion. As a minimum we know that the aircraft was carrying at least one incipient electrical fault in the PTIT gauge or its DECU or the sensor or, even more likely in my experience in its wiring or connectors (and if Campbell knew anything about aircraft maintenance operations he would realise that the problem going away when the gauges were swapped round is a classic trait of any transient electrical fault. Sqn Ldr Burke said at the House of Lords Select Committee "The [DECU] Multi point connector was not of a good design, and again you had power interrupts on the system. The squadrons introduced a procedure, probably the OCU did as well, but I am not certain on that point, where the crewman every quarter of an hour would have to go up and check physically that this multi-point had not vibrated loose". HL Paper25(ii) para 677" Even in October 1995 the US Army Release to Service recognised the inherent "security" problems of the DECU connectors by requiring both a pre-fight and a 30 minute ramp check of the DECU connectors - ie they were still being inspected before every flight
1.2.2
In their opening remarks the Board decides to "eliminate [my bold] as possible causes: major technical malfunction or structural failure of the aircraft prior to impact; …… Therefore the Inquiry focused on the crew’s handling and operation of the aircraft.”
But at paragraph 35d the Board states:
“Nevertheless an unforeseen technical malfunction of the type being experienced on the Chinook HC2, which would not necessarily have left any physical evidence, remained a possibility, and could not be discounted.”
Perhaps I am missing something obvious, but it seems to me that this statement is at total odds with the Board's opening remarks, and this major discrepancy should have easily been picked up by the Review Process and indeed by Campbell's "unbiased and thorough investigation". Further evidence that Campbell was only too willing to believe the BoI in those areas that suited his appreciation of the situation - or perhaps better helped situate his appreciation!
1.2.3
In an amazing piece of logic under "Malfunction" Campbell makes the following statement:
"Much has been made of the fact that the AAIB admitted that it could not exclude the possibility of pre-impact damage or faults with some systems in ZD576. Those convinced that the accident was caused by some mechanical fault that somehow distracted the pilots at the moment when they should have been turning or made it impossible to turn the aircraft have seized on this admission as evidence that there was such a fault. However, absence of evidence is not evidence of absence (nor evidence of presence). If a mechanical component is found to be damaged from the impact, but it could have been faulty or damaged before the impact, and there is no way to distinguish between these two alternatives, it cannot be assumed that the damage was pre-impact. Claims that there was a pre-impact fault need to be based on direct evidence of such a fault. The complete absence of such evidence suggests that there was no such fault and that the aircraft was completely serviceable when it crashed. "
I was doing OK until the last two sentences, but then it goes very wrong. If you do not know whether the item was damaged before or after the accident (and bearing in mind that the "damage" may be a transient electrical or software fault) it goes without saying that there will be no direct evidence before the crash - that is where ADRs and CVRs are so useful as I know from personal involvement in my engineering officers using the Tornado ADR to investigate incidents where there were no symptoms by the time the aircraft landed - incidentally quite a few of which were uncommanded control movements and major aircraft departures from controlled flight. The use of this twisted logic to claim that "The complete absence of such evidence suggests that there was no such fault and that the aircraft was completely serviceable when it crashed." does not accord with any logical argument that I can see. Am I claiming the aircraft was unserviceable - no I am not - like everyone else, other than, it seems, Campbell, I do not know. I do know though that it could have been unserviceable and indeed there are at least as many "facts" pointing to this was as there are hypotheses, or worse hypotheses turned into facts, that point at an operational reason for the accident - had Campbell done the unbiased and thorough examination he claims he would see it too.
2. Crew Duty Time
In his evidence on the crew\'s intentions Campbell again mis-uses the BoI evidence by directly questioning how Tapper intended to get back to Belfast that evening without breaking Crew Duty Time CDT limitations and suggesting that whatever he did Tapper would have been "reprimanded". What an outrageous comment, again attacking Tapper\'s reputation to help support Campbell\'s story, which in my opinion shows just how low Campbell has had to sink to put his story together. Campbell could not have known anything of the sort. He repeats a similar comment in the conclusions where he claims as a contributory cause of the accident that "it may have been a mistake for Tapper to insist on taking the sortie near the end of his crew\'s shift, especially when he was bound to exceed the time limit and so break regulations". Again an unjustified and outrageous assertion by Campbell. Had the crew actually broken the rules and had the accident occurred on the homeward flight Campbell\'s comments might be relevant, but the fact is that the crew were perfectly "legal" in terms of CDT and it is mischief making to comment otherwise. If Campbell had read on to the comments of the Station Commander at Aldergrove (and also as SRAFONI responsible for authorising any CDT extension to the maximum allowable) he would have seen the following comments:
"Crew Duty Considerations- The crew of ZD 576 had flown a task within NI earlier on the 2 Jun. I concur with the Board\'s statement (para 66a), that the decision for the crew to carry out the Inverness sortie "Whilst not ideal, was not unreasonable". It was detachment practise, because of the extended day time in early June at Aldergrove\'s latitude, to preserve where possible, a "day-on day-off " routine between the 2 crews. Given the routine nature of the day\'s earlier tasking, it was reasonable, as a one off for a single crew to plan to complete the full day\'s tasking by extending flying hours within the Crew Duty Time (CDT).
Turning to possible further extensions of CDT, I do not believe that, in the absence of any firm evidence one way or the other, we can usefully speculate on TAPPER\'s further intentions after arrival at Inverness. At the time of the accident, the crew was operating within CDT extension which had been properly sought and granted (para 30b), and fatigue was unlikely to have contributed to the cause of the accident."
Not surprisingly, since it would have been a major criticism of flying supervision at RAF Aldergrove, neither of the Air Marshals disagrees with the Station Commander\'s statement. Campbell also implies that Tapper was acting alone by failing properly to take account of CDT on some sort of renegade mission - in fact nothing would have been further from the truth - both 230 Sqn and Aldergrove Operations would have been aware of the tasking and CDT issues (and if they were not they were failing in their duty) as would the JATOC. If supervisors had been unhappy with Tapper\'s plans they could have stopped them at any time, even allowing for the fact that Tapper was "self-authorising" - itself a carefully supervised delegation of authority from above.
3, FADEC
3.1 Although Campbell\'s book touches on the underlying airworthiness issues of the Chinook Mk 2 at the time of the accident, he does not seem to recognise their implications either as a potential cause of the accident or as a major issue that should have been considered by RAF command staffs, including RAF Odiham, before this aircraft was allocated for a passenger flight, where it might have been reasonable for the passengers to have expected to be flying in an aircraft that met at least basic CAA airworthiness standards. The FADEC is a particular example of Campbell\'s ability to ignore facts and draw his own (favourable) conclusions. The "Malfunction" section of his Conclusions is a classic example of muddled thinking and a lack of understanding of the equipment function. It is worth quoting, and then analysing, in full for those areas where he is discussing the FADEC:
"Malfunction
The accident in Wilmington in 1989 was to a Mkl Chinook that, for testing purposes, had been fitted with an experimental FADEC engine control system. The unit inquiry (not a Board) that investigated found that the accident was caused by an error in testing procedure, specifically the disconnection of a vital connector. It turned out that it was also due to a fault in the FADEC software that allowed a catastrophic engine runaway when the signal from that connector was lost. In effect, it was due to an unfortunate combination of these two factors. The aircraft was seriously damaged, but not beyond repair and the FADEC software was later substantially rewritten before Mk2s were introduced into service. Consequently, allegations that the incident showed that FADEC is dangerous and might have contributed to the Kintyre crash are misplaced and specious. It is invalid to argue that, because an engine runaway occurred five years earlier in a Chinook on test when a vital sensor was disconnected and the software was not able to cope, this happened on the fatal flight of ZD576. The problems that Boscombe Down experienced appear to have been self-inflicted, in taking FADEC beyond its limits. As a result, BD unnecessarily alarmed Chinook pilots. Nor, as it turned out, were the CA Release restrictions necessary.
FADEC has not featured in any of the other Chinook crashes, all to Mkls fitted with a hydro-mechanical fuel control system with a poor record for reliability. Although the particular FADEC system installed in the RAF Chinooks is unique to them, similar computerized fuel control systems are installed in US and Dutch Chinooks, all Airbuses, the Boeings 767 and 777, Concorde and aircraft of the Queen\'s Flight. Consequently, such an engine control system is not inherently unsafe and it has not been implicated in any aircraft accident. Nor, once the software was rewritten, has the RAF FADEC given further trouble. It is inherently unlikely therefore that the FADEC had anything to do with the accident. The House of Lords Select Committee accepted that neither the E5 code found in one of the FADEC\'s DECUs nor the faulty altimeter were relevant to the accident.
Excluding the Wilmington incident, of the eight other Chinook accidents (see list below and, reports in Appendix 1), only two were definitely attributed to a technical fault and in neither case were there any fatalities. In only one fatal case were mechanical faults discovered which could have caused the accident. However, in the case of ZD576, no mechanical fault was found. Crew error has been identified as the cause in all the fatal accidents except for one, the cause of which could not positively be determined."
3.2 I am not aware of any allegations that the FADEC itself was "dangerous", but there is no doubt that at the time of the accident it was not seen by Boscombe Down as being proven to be "fit for purpose" and in addition there was no doubt that even with the further re-written standard of software following the Wilmington incident FADEC was the cause of many in-service problems. Thus Witness 20 Sqn Ldr Morgan comments: "The unforeseen malfunctions on the Chinook HC2 of a flight critical nature [my bold] have mainly been associated with the engine system FADEC. They have resulted in undemanded engine shutdown, engine run-up, spurious engine failure captions and misleading and confusing cockpit indications.” This is a man who knew what he was talking about at the time even though the BoI themselves chose to omit the words "flight critical" when they quoted his evidence. Put this statement together with the BoI\'s major non sequitur on aircraft serviceability - see 1.2 above and is Campbell really so sure that FADEC could not have contributed to the accident even if only in the form of a major distraction at the critical moment of new waypoint selection? I am not saying this happened, but equally he does not know that it did not!
3.3 Campbell\'s comment that Boscombe Down\'s problems with the FADEC were self-inflicted is, in my view, total nonsense. Whilst we may not always like the time it takes and their sometimes pedantic approach (and certainly with his memo the Senior Reviewing Officer or one of his staff did not) it IS BD\'s job to both take the system to the limits and to fully understand the failure mechanisms and emergency/recovery procedures (which all too often in the past the manufacturer has failed fully to document, and which presumably showed in the state of the FRCs for the Chinook Mk 2). Campbell also comments, by implication as a criticism, that the CA Release restrictions were not necessary. This statement is unbelievably naive, and again shows a total lack of understanding of BD\'s role and methodology. The comment that the CA Release restrictions were not necessary is both incorrect, given the need to maintain flight on one engine in an aircraft subject to "flight critical" engine problems, and irrelevant. The fact is that the restriction was there, and the pilots had no choice but to obey it in all of their flight tasking and planning procedures - indeed the restrictions had been reinforced by comments from the flying supervisory chain.
3.4 Campbell comments that FADEC has not figured in any of the other Chinook crashes in his table of 8 accidents. Again he seems to be being somewhat disingenuous since even by his own admission they were all Chinook Mk 1s and did not have FADEC fitted! FADEC for the T55-L-712F engine only went into production in July 1991 for incorporation on the Chinook Mk 2 aircraft. His comment that the FADEC with the re-written and validated software has not been cited as the cause of any subsequent accident is more valid, but does he know how many flight incidents it has been cited in - we have consistently been refused this information by MOD.
3.5 There are so many more relevant comments questioning the FADEC that there is not room to cover them all. I have picked just two more:
3.5.1 Campbell claims that it is inherently unlikely that the FADEC had anything to do with the accident and then quotes the House of Lords saying that the E5 code ....etc. But the House of Lords conclusions also said the following: "Mr Cable accepted that it was possible that there had been an intermittent engine fault which had subsequently reverted to normal before the impact. The problems arising from the newly installed FADEC system had not all been resolved by June 1994". Are the House of Lords saying that FADEC caused the accident - no of course not, but they are not writing it out as a possible cause either - but Campbell does.
3.5.2 The Boscombe Down (EAS) memorandum reference AEN58/022/1 dated 3 June 1994, which I believe Campbell must have seen in any thorough examination states quite categorically "Notwithstanding the claims made by Textron\'s white paper, the problem remains that the product (FADEC at the software standard being tested at BD - assumed to be the same issue as on ZD 576) has been shown to be unverifiable and is therefore unsuitable (their bold) for its purpose". The Textron White Paper being referred to was, of course, only produced in March 1994 and was an attempt to answer major criticisms of their development programme for the FADEC software going back over many years, and made by independent system house assessments. As far as I can recall comments such as this, and indeed the Textron White Paper, were never shown to the BoI and if they were they were never investigated - this critical area from BD was not even asked to be a witness at the Inquiry, and no link was made to the BD decision to stop the flight trials. The EAS memorandum then goes on to make some 17 major comments (one of which has 7 sub-comments) on the content and testing of the software and notes that contrary to what was being said at the time (including I think to the investigations later) the software for FADEC was "safety critical" and hence should have been developed, tested and documented as such. Even against the lower JSP 188, level of documentation that had been contracted for BD had identified 34 category 1 and 48 category 2 anomalies in their Traceability Study (which was conducted against the system rather than the detailed requirement level). Since it would appear that the 8 RAF Chinook Mk3s that are sitting unused have had safety critical software procured with similar problems to the Chinook Mk2 (albeit, it is stated by MOD, in a different area) it is surprising that Campbell has not picked up this problem - which has already potentially "wasted" £200M of taxpayers\' money with a lot more to come to put them right. Given the BD position it was a major omission by the BoI not to investigate this area - did they know about it? Did they get warned off? These are the sort of areas a thorough investigation should have looked at.
4. Reporting of Defects
Campbell rightly picks up the problem of Tapper\'s failure to raise a defect report on the faulty PTIT gauge, using this as part of his contention that Tapper had a "relaxed" attitude to regulations and even going so far as to imply that this alleged attitude somehow contributed to the accident. The BoI actually notes the following failures to follow the regulations as far as the reporting of defects was concerned:
c. AP 100B-01, order 0703, para 16 in that Lt KINGSTON did not raise a maintenance work order log entry for the engine PTIT fault.
d. AP 100B-01, order 0701, para 5 in that Sgt MAY and Cpl POLLARD transposed the No 1 and No 2 engine PTIT gauges without raising a maintenance work order.
e. AP 100B-01, order 0703, para 16 in that Flt Lt TAPPER did not raise a maintenance work order log entry for the superTANS/GPS fault.
f. AP 100B-01, order 0701, para 5 in that Cpl GUEST and SAC CLARK carried out a functional test on the SuperTANS and GPS without raising a maintenance work order.
In their conclusions the Board then stated "that these failings were not factors in the accident".
As anyone who has been on an operational detachment or even a major training exercise knows this approach to the reporting of what are perceived as minor or nuisance defects is often taken, particularly when there is a shortage of aircraft. It is not correct, but it is a fact of life that it happens.
In fact Tapper also queried the PTIT gauge from the trip before the accident, but was assured that it was only a transient gauge problem. Hence he was carrying at least one unservicability in the engine system when he took off. Given the known defect history of ZD 576 and the issues with the security of DECU connectors (and the PTIT sensor routes its signal to the DECU where it is split one signal being used by the DECU in the engine control laws, and one signal going to the gauge) it was perhaps unfortunate with the benefit of hindsight (which the BoI of course had) that this area was not looked at further. It would be of particular interest to know how much Odiham knew as to what had gone on at Aldergrove, as it was there that the right information connection might have been made and questions asked as to the underlying serviceability of ZD 576. The Detachment was operating on the RAF Odiham EOB so both SEngO 7 Sqn and OC Eng Wg RAF Odiham were the responsible officers in the airworthiness chain for this aircraft, with SEngO 230 Sqn (and NOT Tapper as Detachment Commander who would normally have been responsible) being responsible for Chinook engineering supervision at Aldergrove. In fact the BoI did not call OC Eng Wg Odiham at all. SEngO 7 Sqn only appeared to present the servicing documentation to the BoI and SEngO 230 Sqn, who appeared to know something about the PTIT gauging problems and the "malpractices" claimed that he was “satisfied that Chinook HC2 ZD576 was serviceable for it’s (sic) final flight on 2 Jun 94". No-one asked how he was "satisfied" as to its serviceability (had he visited the detachment, had he reviewed the servicing records, had he discussed the defect history and the potential links to the PTIT problem, etc) or why he had done nothing to regularise the defect reporting omissions - he, not Tapper, appeared to be responsible for this, albeit both Kingston and Tapper would have to accept some of the initial blame for their failure to raise the work order log entry. Again Campbell ignores all of these issues in favour of the tiny bit of the story that fits his ideas.
5. Poor Research
As what would normally be a minor point, but in the light of Campbell\'s claims to have solved by his meticulous research and analysis what so many others more capable and skilled than him have failed to solve it is a pity that Campbell does not seem to know the difference between a Flight Lieutenant RAF and a Lieutenant Royal Navy, since Kingston was of course a naval pilot - and note 27 says this. A minor error, but an important one.
Summary and Conclusions
What must be of concern is that for those of Mr Campbell\'s readers who have not seen the BoI and the transcripts of the various other enquiries (presumably he hopes the majority if the book is to sell in large numbers) then his version, whilst not representing the correct facts in many areas and certainly having nothing in it to support his claim to have solved the mystery, is going to look very convincing to the lay reader.
Despite these reservations I would have to accept that along with many other people Campbell appears to have raised a valid possible cause for the accident - I say "appears" because I am not a helicopter pilot and I do not know the area of the Mull of Kintyre (although I sent many happy hours flying round the Falklands in helicopters, including Chinook Mk1s, in some very dodgy conditions - but then I have always had great faith in military pilots). Some more familiar with the helicopter and the area might wish to turn Campbell\'s "possibility" into a probability although I would not subscribe to this. What is clear is that his theories can never be the "certainty" that he claims. Whether possibility, probability or even the certainty that he would claim then Campbell\'s theory does, however, do the pilot\'s families one great favour for, as he rightly points out, a navigation error could not, by definition, be "Gross Negligence" not just in legal terms, but by the standards of judgement applied to other similar accidents of the time (remember AEW Mk Shackleton WR 965 - hit the Isle of Harris following a navigation error in a bad weather descent to low level on 30 April 1990 - 10 killed, but, as I recall no findings of negligence of any sort). So support Campbell\'s theory by all means, but remember that it is only one of the possibilities. Also remember that whilst Campbell\'s theory might still be an aircrew error, or one of the new equivalents, verdict, it will not be a gross negligence one - despite his publisher\'s flyer claiming their book "generally" supports the Gross Negligence verdict!
END
As I said in a previous post, I have no wish to turn the thread into a book critique thread, but I believe this to be a valid response to the publication. The only thing we can safely (and rightly) conclude is that we don\'t know what was the cause of the accident with absolutely no doubt whatsoever. The negligence verdict should, therefore be removed. Only then, will the campaign go away!
Apologies for the overall length of the post.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
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Long time since I added anything here but that absence does not mean I do not follow the case.
Strong response with respect to Campbell's speculation. Useful, engineer, and thanks.
I add only a point where I can - to the possible mindset of one pilot. Rick Cook packed an overnight bag. Crew time restrictions? If I was him I would have packed a bag too, happy to be off the bog.
Strong response with respect to Campbell's speculation. Useful, engineer, and thanks.
I add only a point where I can - to the possible mindset of one pilot. Rick Cook packed an overnight bag. Crew time restrictions? If I was him I would have packed a bag too, happy to be off the bog.
Avoid imitations
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Antenna,
I fly corporate stuff these days. I don't have a mindset about a return trip but usually have a bag with me to cater for a possible overnight away, even if not rostered to do so, if I personally think there's a possibility. We've all been caught out by an unexpected nightstop and anyone can be uncomfortable by not using their noddle. Don't forget the weather precluded an IFR option so it was always likely they might get one way only.
I fly corporate stuff these days. I don't have a mindset about a return trip but usually have a bag with me to cater for a possible overnight away, even if not rostered to do so, if I personally think there's a possibility. We've all been caught out by an unexpected nightstop and anyone can be uncomfortable by not using their noddle. Don't forget the weather precluded an IFR option so it was always likely they might get one way only.
A really irritating PPRuNer
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Hi again, everyone.
My final post on the subject of the book is the response from the author Tim Slessor:
I’ll go round that track again….! Even those of us who disagree with the official verdict of ‘gross negligence’ would, I think, have to agree that Steuart Campbell’s thesis of faulty navigation certainly represents a possibility. Who knows – maybe a probability? But he, of course, argues that possibility/probability up to the level of a cast-iron certainty. Therein lies the whole problem – which he just does not seem to recognise. It is simply not good enough to claim – no matter how well the claim is argued - that faulty navigation was, as a sure and certain fact, the cause of the crash. At best, it is a reasonable thesis. But we certainly don’t know ‘beyond absolutely all doubt whatsoever’. It is not enough to be 95% (or even 99.5%) certain; under the RAF’s own ‘rule’ one has to be 101% certain. It was/is the arrogance of the two Air Marshals in supposing that they know what happened that lies at the core of the whole dispute. They are now joined by Steuart Campbell. The fact is that any number of experts in the field feel that there are sufficient doubts that, at the least, the pilots must be given the benefit of those doubts.
A couple of quotes from the book….
The absence of any evidence for such a malfunction has not deterred many from assuming that such a malfunction existed. No, incorrect. It has not deterred many from assuming that the possibility of a malfunction existed. And if there was a possibility (nothing more) the official verdict cannot stand.
…the refusal of many to accept official explanations and/or their failure to understand the complex issues involved. That’s a bit rich – it means that Robert Burke and Malcolm Perks (to name but two of several dozen) don’t understand the complexity of the issues as well as Steuart Campbell. Actually, as I have already stated (twice -above) the basic issue is not complex at all: do enough Chinook experts hold enough doubts to make the Air Marshals unequivocal verdict ‘unsafe’?
Lastly, no one on the Air Marshals ‘side’ (least of all Mr Campbell) has ever explained why the three men in the cockpit, having just changed their GPS to give a heading for the next leg (to the Coran Wpt), should unanimously and within seconds change their minds and continue on their current heading into cloud. Why bother to change the GPS? It just doesn’t make sense.
Another ‘lastly’! He hardly touches on the backing, filling, dissembling and even lies with which the MoD have smoke-screened almost since the beginning. The fact that the MoD has found it ‘necessary’ to do so is, in itself, a persuasive reason why one should regard almost every statement coming out of that organisation with the deepest suspicion.
As I said, it is an impressive piece of work. What a pity that he doesn’t examine the basic (and rather simple) nub of the whole debate. Or does he truly think that all the doubters are totally ignorant?
END
As I say, I won't post any more on the subject of the book. If you are still unsure, read the book and reach your own conclusions.
I'm off to write another letter to the MoD
My best to you all, as always.
Brian
"Justice has no expiry date" - John Cook
My final post on the subject of the book is the response from the author Tim Slessor:
I’ll go round that track again….! Even those of us who disagree with the official verdict of ‘gross negligence’ would, I think, have to agree that Steuart Campbell’s thesis of faulty navigation certainly represents a possibility. Who knows – maybe a probability? But he, of course, argues that possibility/probability up to the level of a cast-iron certainty. Therein lies the whole problem – which he just does not seem to recognise. It is simply not good enough to claim – no matter how well the claim is argued - that faulty navigation was, as a sure and certain fact, the cause of the crash. At best, it is a reasonable thesis. But we certainly don’t know ‘beyond absolutely all doubt whatsoever’. It is not enough to be 95% (or even 99.5%) certain; under the RAF’s own ‘rule’ one has to be 101% certain. It was/is the arrogance of the two Air Marshals in supposing that they know what happened that lies at the core of the whole dispute. They are now joined by Steuart Campbell. The fact is that any number of experts in the field feel that there are sufficient doubts that, at the least, the pilots must be given the benefit of those doubts.
A couple of quotes from the book….
The absence of any evidence for such a malfunction has not deterred many from assuming that such a malfunction existed. No, incorrect. It has not deterred many from assuming that the possibility of a malfunction existed. And if there was a possibility (nothing more) the official verdict cannot stand.
…the refusal of many to accept official explanations and/or their failure to understand the complex issues involved. That’s a bit rich – it means that Robert Burke and Malcolm Perks (to name but two of several dozen) don’t understand the complexity of the issues as well as Steuart Campbell. Actually, as I have already stated (twice -above) the basic issue is not complex at all: do enough Chinook experts hold enough doubts to make the Air Marshals unequivocal verdict ‘unsafe’?
Lastly, no one on the Air Marshals ‘side’ (least of all Mr Campbell) has ever explained why the three men in the cockpit, having just changed their GPS to give a heading for the next leg (to the Coran Wpt), should unanimously and within seconds change their minds and continue on their current heading into cloud. Why bother to change the GPS? It just doesn’t make sense.
Another ‘lastly’! He hardly touches on the backing, filling, dissembling and even lies with which the MoD have smoke-screened almost since the beginning. The fact that the MoD has found it ‘necessary’ to do so is, in itself, a persuasive reason why one should regard almost every statement coming out of that organisation with the deepest suspicion.
As I said, it is an impressive piece of work. What a pity that he doesn’t examine the basic (and rather simple) nub of the whole debate. Or does he truly think that all the doubters are totally ignorant?
END
As I say, I won't post any more on the subject of the book. If you are still unsure, read the book and reach your own conclusions.
I'm off to write another letter to the MoD
My best to you all, as always.
Brian
"Justice has no expiry date" - John Cook
Just a numbered other
Thanks for those posts Brian, I think it has saved me from buying the book.
As Mr Slessor points out, the difference between the two 'sides' is mind set. WE are all quite willing to accept any reason, including gross negligence, for this crash.
THEY will not bend to accept that the evidence for the finding is simply not up to the required standard.
If ANYONE can post conclusive proof of negligence, we'd all pack up and p**s off.
Trouble is, that this question is normally answered along the lines of 'with no evidence of any other cause, it MUST have been negligence'. and there we go, full circle.
FDR and CVT would have it buttoned up. But.................................
As Mr Slessor points out, the difference between the two 'sides' is mind set. WE are all quite willing to accept any reason, including gross negligence, for this crash.
THEY will not bend to accept that the evidence for the finding is simply not up to the required standard.
If ANYONE can post conclusive proof of negligence, we'd all pack up and p**s off.
Trouble is, that this question is normally answered along the lines of 'with no evidence of any other cause, it MUST have been negligence'. and there we go, full circle.
FDR and CVT would have it buttoned up. But.................................
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Hi ShyTorque
I should clarify. I absolutely agree with you it is pure speculation what an overnight bag inside ZD576 means. I merely raised the point of Rick having an overnighter possibility to illustrate precisely that any discussion about crew time pressure is a red herring. We have absolutely no idea what the guys planned to do once safely in Scotland - stay or come back.
On another point, in supporting Slessor's position, I say that to dismiss Burke and Perks is foolhardy. The MoD tried it and that is poor company to be keeping on this matter.
I should clarify. I absolutely agree with you it is pure speculation what an overnight bag inside ZD576 means. I merely raised the point of Rick having an overnighter possibility to illustrate precisely that any discussion about crew time pressure is a red herring. We have absolutely no idea what the guys planned to do once safely in Scotland - stay or come back.
On another point, in supporting Slessor's position, I say that to dismiss Burke and Perks is foolhardy. The MoD tried it and that is poor company to be keeping on this matter.
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GENERAL NOTE
Printed in the “International Express”, just after the crash, as part of a big feature, a sub section entitled “Mull is Britain’s Bermuda Triangle” (but no journalist’s name given) included this little snippet: “Even the addition of sophisticated ground beacons which “speak” to instruments aboard aircraft has not removed the threat of the Kintyre Triangle”. Now, I wonder where the Express journalist got that from?
Arkroyal
You bring up points that I must address:
You wrote << the GPS and Doppler sides are separate. Poor doppler sea returns woulld have no effect on its sattelite accuracy >>
There appears to be some confusion as to the scope of the avionics upgrade – I believe that Mk 2 is on a par with 47D which means ZD576 had some changes that are significant to this debate.
The GPS and Doppler ARE combined in the upgraded HC2, in the AN/ASN-128B/C as fitted to 47Ds (as detailed below);
(BAE systems product info)
<<The AN/ASN-128B/C Doppler/GPS Navigation Set provides the advantages of a Global Positioning System (GPS) receiver and a self-contained Doppler navigation system. System installation and aircraft modifications have been minimized by embedding a Trimble one-card GPS receiver into the AN/ASN-128 Signal Data Converter (SDC) unit.
<<The AN/ASN-128B/C provides continuous velocities, navigation and guidance information. When both Doppler and GPS are available, the GPS accurately initializes and automatically updates Doppler present position. If the GPS is lost, the Doppler continues to provide accurate velocities for hover and navigation. If the Doppler is in Memory, the GPS continues to provide accurate present position; in each case navigation continues uninterrupted.>>
(Other sources)
<<The AN/ASN-128B DGNS provides a combined GPS/Doppler navigation capability through the embedding of a six channel GPS receiver into the signal data converter of the currently fielded AN/ASN-128 doppler navigation system. This system will reduce pilot workload and increase situational awareness by providing a precise navigation system. Considered a cost effective approach, the doppler with embedded GPS was recommended by a Draper Laboratory Study commisioned by PM-AEC. The 128B is the objective solution for the UH-60 & CH-47 fleet.>>
The problem of combined systems is when one is degraded (eg Doppler over water) because of how the two inputs are combined (mathematical algorithms) the net result can be worse than a single good input. This problem was well understood from the days when inertial navigation systems were complimented with Doppler radar systems – going over water was the thing for the radar return.
You wrote << IF they were that close to the high ground, and barrreling towards it relying on a piece of kit (which would have been less accurate than the on board TANS) >>
REGARDING THE ACCURACY OF THE SUPERTANS
Rather than argue technically further, I rather think this extract sums it up well:
Chinook ZD576: Select Committee Report
5 Nov 2002 : Column 661
<<… an incident that occurred on 13th July 1995, when a Chinook Mk2 helicopter was tasked to perform an over-flight of Flight Lieutenant Jonathan Tapper's memorial. The RNS 252 SuperTANS displayed an error of just 210 feet, yet the crew who were in visual contact with the ground, could see that the TANS was more than two nautical miles in error. The TANS system believed that it was some 12,000 feet away from its actual position. >>
Further, I believe that Flt Lt Tapper had warned the rest of the flight over his concerns regarding the accuracy of the TANS.
A distance measuring system is, on the other hand, very accurate – “pin point”.
PPRuNe Radar
You wrote: <<at the time of the accident, Aldergrove was not SSR equipped and therefore would not have observed any code>>
Well Belfast was – they were tracking it initially and in communication with it until 10mins before crash – I wonder what squawk code they saw? And I mean, what did they actually see – not what could have been selected/should have been selected/ etc etc..
AND further you wrote:<<… both of which would be very hard pushed to pick up a low level target in the accident area due to terrain shielding and line of sight restrictions. Otherwise the radar recordings would have been used to provide a lot more evidence of ground track and altitude in the accident enquiries.>>
– well how about this:
Circa 1st week July 1994 (reference detail lost - Author Owen Bowcott) – article titled “Radar recording ‘shows helicopter hit hillside due to navigation error’”
“Recordings of military radar tracking the RAF helicopter which crashed on the Mull of Kintyre last month show it flew straight into the hillside without altering course, writes Owen Bowcott.
“The flight path, revealed by air traffic control sources yesterday, reinforces suspicions that the accident was caused by a navigational error.
“… A controller who had seen the recordings, and requested his identity not be revealed, said: ‘The Chinook looks like it went more or less straight into the hillside. There was no distress signal. It all points toward some sort of navigational error. The pilot must have misjudged his position. He only needed to be half a mile to one side.’”
Surely, you could have replied the first time in a more positive manner (eg “try Belfast” or even better “I’ll find out for you”!) – I am only pushing for the truth, not for points.
Printed in the “International Express”, just after the crash, as part of a big feature, a sub section entitled “Mull is Britain’s Bermuda Triangle” (but no journalist’s name given) included this little snippet: “Even the addition of sophisticated ground beacons which “speak” to instruments aboard aircraft has not removed the threat of the Kintyre Triangle”. Now, I wonder where the Express journalist got that from?
Arkroyal
You bring up points that I must address:
You wrote << the GPS and Doppler sides are separate. Poor doppler sea returns woulld have no effect on its sattelite accuracy >>
There appears to be some confusion as to the scope of the avionics upgrade – I believe that Mk 2 is on a par with 47D which means ZD576 had some changes that are significant to this debate.
The GPS and Doppler ARE combined in the upgraded HC2, in the AN/ASN-128B/C as fitted to 47Ds (as detailed below);
(BAE systems product info)
<<The AN/ASN-128B/C Doppler/GPS Navigation Set provides the advantages of a Global Positioning System (GPS) receiver and a self-contained Doppler navigation system. System installation and aircraft modifications have been minimized by embedding a Trimble one-card GPS receiver into the AN/ASN-128 Signal Data Converter (SDC) unit.
<<The AN/ASN-128B/C provides continuous velocities, navigation and guidance information. When both Doppler and GPS are available, the GPS accurately initializes and automatically updates Doppler present position. If the GPS is lost, the Doppler continues to provide accurate velocities for hover and navigation. If the Doppler is in Memory, the GPS continues to provide accurate present position; in each case navigation continues uninterrupted.>>
(Other sources)
<<The AN/ASN-128B DGNS provides a combined GPS/Doppler navigation capability through the embedding of a six channel GPS receiver into the signal data converter of the currently fielded AN/ASN-128 doppler navigation system. This system will reduce pilot workload and increase situational awareness by providing a precise navigation system. Considered a cost effective approach, the doppler with embedded GPS was recommended by a Draper Laboratory Study commisioned by PM-AEC. The 128B is the objective solution for the UH-60 & CH-47 fleet.>>
The problem of combined systems is when one is degraded (eg Doppler over water) because of how the two inputs are combined (mathematical algorithms) the net result can be worse than a single good input. This problem was well understood from the days when inertial navigation systems were complimented with Doppler radar systems – going over water was the thing for the radar return.
You wrote << IF they were that close to the high ground, and barrreling towards it relying on a piece of kit (which would have been less accurate than the on board TANS) >>
REGARDING THE ACCURACY OF THE SUPERTANS
Rather than argue technically further, I rather think this extract sums it up well:
Chinook ZD576: Select Committee Report
5 Nov 2002 : Column 661
<<… an incident that occurred on 13th July 1995, when a Chinook Mk2 helicopter was tasked to perform an over-flight of Flight Lieutenant Jonathan Tapper's memorial. The RNS 252 SuperTANS displayed an error of just 210 feet, yet the crew who were in visual contact with the ground, could see that the TANS was more than two nautical miles in error. The TANS system believed that it was some 12,000 feet away from its actual position. >>
Further, I believe that Flt Lt Tapper had warned the rest of the flight over his concerns regarding the accuracy of the TANS.
A distance measuring system is, on the other hand, very accurate – “pin point”.
PPRuNe Radar
You wrote: <<at the time of the accident, Aldergrove was not SSR equipped and therefore would not have observed any code>>
Well Belfast was – they were tracking it initially and in communication with it until 10mins before crash – I wonder what squawk code they saw? And I mean, what did they actually see – not what could have been selected/should have been selected/ etc etc..
AND further you wrote:<<… both of which would be very hard pushed to pick up a low level target in the accident area due to terrain shielding and line of sight restrictions. Otherwise the radar recordings would have been used to provide a lot more evidence of ground track and altitude in the accident enquiries.>>
– well how about this:
Circa 1st week July 1994 (reference detail lost - Author Owen Bowcott) – article titled “Radar recording ‘shows helicopter hit hillside due to navigation error’”
“Recordings of military radar tracking the RAF helicopter which crashed on the Mull of Kintyre last month show it flew straight into the hillside without altering course, writes Owen Bowcott.
“The flight path, revealed by air traffic control sources yesterday, reinforces suspicions that the accident was caused by a navigational error.
“… A controller who had seen the recordings, and requested his identity not be revealed, said: ‘The Chinook looks like it went more or less straight into the hillside. There was no distress signal. It all points toward some sort of navigational error. The pilot must have misjudged his position. He only needed to be half a mile to one side.’”
Surely, you could have replied the first time in a more positive manner (eg “try Belfast” or even better “I’ll find out for you”!) – I am only pushing for the truth, not for points.
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Walter Kennedy
Your post included the following:
Circa 1st week July 1994 (reference detail lost - Author Owen Bowcott) – article titled “Radar recording ‘shows helicopter hit hillside due to navigation error’”
“Recordings of military radar tracking the RAF helicopter which crashed on the Mull of Kintyre last month show it flew straight into the hillside without altering course, writes Owen Bowcott.
“The flight path, revealed by air traffic control sources yesterday, reinforces suspicions that the accident was caused by a navigational error.
“… A controller who had seen the recordings, and requested his identity not be revealed, said: ‘The Chinook looks like it went more or less straight into the hillside. There was no distress signal. It all points toward some sort of navigational error. The pilot must have misjudged his position. He only needed to be half a mile to one side.’”
I wasn't aware of radar recordings but, be that as it may, it would be false to assume that, because the radar track continued in an apparently straight line, the aircraft was under control at the time. Indeed, the fact that it did not turn to the left towards the new turning point might indicate that it was not. One tends to think in terms of an aircraft being "out of control" as one that is in some sort of mad gyration, but the term really means that the aircraft is not in the control of the pilot. There is no certainty about what was going on in the cockpit (there being no ADR or CVR) and it is therefore not possible to show "beyond any doubt whatsoever" that the aircraft's apparent track was caused by the negligence of its pilots.
Your post included the following:
Circa 1st week July 1994 (reference detail lost - Author Owen Bowcott) – article titled “Radar recording ‘shows helicopter hit hillside due to navigation error’”
“Recordings of military radar tracking the RAF helicopter which crashed on the Mull of Kintyre last month show it flew straight into the hillside without altering course, writes Owen Bowcott.
“The flight path, revealed by air traffic control sources yesterday, reinforces suspicions that the accident was caused by a navigational error.
“… A controller who had seen the recordings, and requested his identity not be revealed, said: ‘The Chinook looks like it went more or less straight into the hillside. There was no distress signal. It all points toward some sort of navigational error. The pilot must have misjudged his position. He only needed to be half a mile to one side.’”
I wasn't aware of radar recordings but, be that as it may, it would be false to assume that, because the radar track continued in an apparently straight line, the aircraft was under control at the time. Indeed, the fact that it did not turn to the left towards the new turning point might indicate that it was not. One tends to think in terms of an aircraft being "out of control" as one that is in some sort of mad gyration, but the term really means that the aircraft is not in the control of the pilot. There is no certainty about what was going on in the cockpit (there being no ADR or CVR) and it is therefore not possible to show "beyond any doubt whatsoever" that the aircraft's apparent track was caused by the negligence of its pilots.
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The FaI in Paisley heard there was no confirmed final radar trace, adding to the whole jigsaw of confusion. I have not seen anything to change such a position though I know Bowcott's reporting is consistently strong on other issues. On this matter the authorities at Prestwick (who we should remember failed - even though they received it - to respond to Jon Tapper's introductory radio call as he was over the Irish Sea in transit) say no radar trace of the final moments was discovered. There was other activity spotted on radar in the moments before power down but none has been shown to be anything concrete.
With respect to Walter's somewhat earlier posting relating to US presence, I spoke to US Navy SEALS above the crash site at the time of the crash so can confirm their presence and their involvement in a recovery operation. I cannot confirm their precise role. They may not have had one beyond being asked to help in a general way. I mention this presence only as I know privately the issue of US presence has been a source of debate. The US was there the day after and on June 4 also. Why? No idea.
With respect to Walter's somewhat earlier posting relating to US presence, I spoke to US Navy SEALS above the crash site at the time of the crash so can confirm their presence and their involvement in a recovery operation. I cannot confirm their precise role. They may not have had one beyond being asked to help in a general way. I mention this presence only as I know privately the issue of US presence has been a source of debate. The US was there the day after and on June 4 also. Why? No idea.
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Meadowbank
They manually changed waypoint (thus not embroiled in an emergency, one could safely assume) at which time they altered course tp the RIGHT by 3deg - it was this track that they then held until the final evasive manouvre (which showed control).
They did not just plod on through waypoint change.
A simple explanation is that the last bit of the leg to the turn was being judged by reference to a transponder at the helipad - except that some b*****d had moved it to/substituted it with another half a mile inland.
Plot it on a chart - spot on - that 3deg turn to the right is a precious clue.
Antenna
Two points:
Unanswered radio call: on its own this anomaly on the calls could be regarded as insignificant (as regulars on this thread have insisted – I disagree) but together with a confused picture of the available radar track one has to wonder what is going on - perhaps there was more dialogue but the recordings were mislaid! Either it’s a circus or the powers that be are covering their embarrassment.
SEALS
I was told that the SEALS were there before UK personnel and were challenged.
OK, they could have been called by higher authority as they were stationed nearby – but surely the UK personnel would have been told to expect them at the site? And apart from medical help to casualties and cordoning off the area (to prevent unnecessary disturbance of the scene!!!!) how can they justify plodding about the crash site?
They manually changed waypoint (thus not embroiled in an emergency, one could safely assume) at which time they altered course tp the RIGHT by 3deg - it was this track that they then held until the final evasive manouvre (which showed control).
They did not just plod on through waypoint change.
A simple explanation is that the last bit of the leg to the turn was being judged by reference to a transponder at the helipad - except that some b*****d had moved it to/substituted it with another half a mile inland.
Plot it on a chart - spot on - that 3deg turn to the right is a precious clue.
Antenna
Two points:
Unanswered radio call: on its own this anomaly on the calls could be regarded as insignificant (as regulars on this thread have insisted – I disagree) but together with a confused picture of the available radar track one has to wonder what is going on - perhaps there was more dialogue but the recordings were mislaid! Either it’s a circus or the powers that be are covering their embarrassment.
SEALS
I was told that the SEALS were there before UK personnel and were challenged.
OK, they could have been called by higher authority as they were stationed nearby – but surely the UK personnel would have been told to expect them at the site? And apart from medical help to casualties and cordoning off the area (to prevent unnecessary disturbance of the scene!!!!) how can they justify plodding about the crash site?
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Walter
I agree that their change of waypoint tends to indicate that no emergency was ongoing. However, your assumption that a turn of 3 deg to the right shows control is incorrect. The aircraft may have been diverging in pitch and/or oscillating in roll. Incidentally, what are you using as your information source for the 3 deg right turn? There was no ADR and it seems that there is, indeed, no radar recording.
Your repeated reference to a transponder being used for a DME readout is wide of the mark and a number of correspondents (with Special Forces helo experience) have already explained this (look back at recent posts from, amongst others, Tandemrotor).
I agree that their change of waypoint tends to indicate that no emergency was ongoing. However, your assumption that a turn of 3 deg to the right shows control is incorrect. The aircraft may have been diverging in pitch and/or oscillating in roll. Incidentally, what are you using as your information source for the 3 deg right turn? There was no ADR and it seems that there is, indeed, no radar recording.
Your repeated reference to a transponder being used for a DME readout is wide of the mark and a number of correspondents (with Special Forces helo experience) have already explained this (look back at recent posts from, amongst others, Tandemrotor).
I enjoyed (if that is the right word) Air Cdre Blakeley's comments on the book. It seems the bottom line is a suggestion of "faulty navigation" which, to me, is different from "navigation error". The former suggests crew error, while the latter equipment. Maybe just my interpretation. As a sprog I was told, with the CAIP leaflet thrust under my nose, that if crew report a nav error, do a bonding check. Which prompts the question - does the Chinook have a history of poor (or lesser) bonding standards or implementation? No? - OK. Yes? - Reasonable doubt.
If I may add to a couple of subjects discussed by the Air Cdre.
Defect (sic) Reporting. Anyone (including industry) can raise a Fault Report and in bygone days it was more than your job was worth to avoid this obligation. But, it is not the initiator who approves the investigation – that is the role of the MoD’s Technical Agency, who is hamstrung by (a) lack of finance (b) failure of the Service customer to make financial provision to conduct such investigations (c) the increasing attitude within the MoD that the underpinning process (PDS) is a waste of money, which leads to (d) few left who understand. The turning point (around 1991) was when financiers took over and the cost of progressing a MF760 > 760A > 761 was deemed expensive compared to the number of “positive” results obtained. This was defined as the contractor acknowledging liability in the 761 for a design problem (at which points it becomes a “defect” and there follows a defect investigation). Clearly, this financial emphasis completely ignores the purpose of the Fault Reporting system but, when you think about it, it must cost a fortune and be awkward to manage when the aircraft Design Authority is in, for example, Philadelphia. Which is why, in my opinion, it is unfair to point the finger at operators or maintainers. Often, I would ask MoD engineers why they didn’t raise a 760. “Told not to – too expensive”. This may explain why the MoD have so far been unable (but not necessarily unwilling) to divulge certain historical information. There may be none to divulge, and it would be embarrassing to explain why not. Keeping and maintaining such records is part of the Airworthiness audit trail. Ask the right question.
Airworthiness. The Air Cdre clearly knows how Boscombe Down works. Additionally, it is worth noting what is often forgotten – BD make recommendations as to Airworthiness but the MoD Project Manager and the person granting MAR / Airworthiness / Type Approval (almost always different for aircraft, but often the same person for equipment) are under no obligation to accept these recommendations, although clearly mad and immoral if they don’t. This wider aspect never seems to be raised or looked in to, and may be relevant to this thread, and certainly to others. How many “accidents” can be traced to failure to act upon BD advice? Ask BD how often they are ignored and an aircraft or system certified with known safety or functional issues. This is exacerbated by the effective scrapping of the CDS process within MoD, the process for taking corrective action on "highly desirables" and "desirables" which remain post-MAR. But, what price safety?
Sorry, I don’t post often, but when I do it’s long. But, I often think, reading the postings, that there is little depth to technical and, especially, procedural/management discussion, sometimes in favour of an approach which is repetitive and has brought little progress.
T
If I may add to a couple of subjects discussed by the Air Cdre.
Defect (sic) Reporting. Anyone (including industry) can raise a Fault Report and in bygone days it was more than your job was worth to avoid this obligation. But, it is not the initiator who approves the investigation – that is the role of the MoD’s Technical Agency, who is hamstrung by (a) lack of finance (b) failure of the Service customer to make financial provision to conduct such investigations (c) the increasing attitude within the MoD that the underpinning process (PDS) is a waste of money, which leads to (d) few left who understand. The turning point (around 1991) was when financiers took over and the cost of progressing a MF760 > 760A > 761 was deemed expensive compared to the number of “positive” results obtained. This was defined as the contractor acknowledging liability in the 761 for a design problem (at which points it becomes a “defect” and there follows a defect investigation). Clearly, this financial emphasis completely ignores the purpose of the Fault Reporting system but, when you think about it, it must cost a fortune and be awkward to manage when the aircraft Design Authority is in, for example, Philadelphia. Which is why, in my opinion, it is unfair to point the finger at operators or maintainers. Often, I would ask MoD engineers why they didn’t raise a 760. “Told not to – too expensive”. This may explain why the MoD have so far been unable (but not necessarily unwilling) to divulge certain historical information. There may be none to divulge, and it would be embarrassing to explain why not. Keeping and maintaining such records is part of the Airworthiness audit trail. Ask the right question.
Airworthiness. The Air Cdre clearly knows how Boscombe Down works. Additionally, it is worth noting what is often forgotten – BD make recommendations as to Airworthiness but the MoD Project Manager and the person granting MAR / Airworthiness / Type Approval (almost always different for aircraft, but often the same person for equipment) are under no obligation to accept these recommendations, although clearly mad and immoral if they don’t. This wider aspect never seems to be raised or looked in to, and may be relevant to this thread, and certainly to others. How many “accidents” can be traced to failure to act upon BD advice? Ask BD how often they are ignored and an aircraft or system certified with known safety or functional issues. This is exacerbated by the effective scrapping of the CDS process within MoD, the process for taking corrective action on "highly desirables" and "desirables" which remain post-MAR. But, what price safety?
Sorry, I don’t post often, but when I do it’s long. But, I often think, reading the postings, that there is little depth to technical and, especially, procedural/management discussion, sometimes in favour of an approach which is repetitive and has brought little progress.
T
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Meadowbank
One of your questions (on radar recording) is answered in the following section – the others at the end.
SVFR
The crew were OK to use DME near the Mull if so agreed in Special VFR.
This flight was a classic for SVFR: because of the icing limitation, IMC was not on and the difficult part (for VFR) was localized (at the Mull) – conditions so prevalent that a routine SVFR practice would have been expected.
Special VFR is a concession granted by ATC not to go IMC in a planned VFR flight where VFR conditions cannot be met for the whole flight but, with suitable arrangements by ATC and the pilot, the pilot wishes to proceed VFR (very common for helicopters who do not wish to fly IMC in cloud).
I believe that in an SVFR flight, use of a local beacon would have been allowed if agreed with ATC; however, ATC would probably have monitored progress in the area of concern (yes, I have found a credible reference to the aircraft track on military radar right up to the point of impact) and would probably have allocated an appropriate squawk code to identify the SVFR aircraft and remind them of what it was doing nav wise in that area (the possible origin of 7760 on ZD576’s IFF).
DME transponders, in normal circumstances, give very accurate range and would have been a logical choice to use in navigating an isolated hazard – if there wasn’t one at the Mull helipad, then there should have been, such would have been the utility of it for a/c regularly doing that route (closing to handrail up the coast).
It is more common for helicopters to use SVFR – so perhaps you contributors with (much) fixed wing experience can be forgiven for not having brought this option up earlier.
It is amazing that this option was not discussed at any of the inquiries.
Meadowbank – you wrote:
<<I agree that their change of waypoint tends to indicate that no emergency was ongoing. However, your assumption that a turn of 3 deg to the right shows control is incorrect. The aircraft may have been diverging in pitch and/or oscillating in roll. Incidentally, what are you using as your information source for the 3 deg right turn? There was no ADR and it seems that there is, indeed, no radar recording.>>
If you work back from the impact, allowing a little for that last evasive turn, a straight line from waypoint change at the speed the a/c had been holding for the flight up to that point gets you there – put another way, if at waypoint change the a/c turned right 3 deg and maintained that heading (in a straight line) and speed it gets to the crash site at exactly the right time; if, as you suggest, the a/c could have been “diverging in pitch and/or oscillating in roll” – bearing in mind the nature of the beast – this would surely have resulted in a significant loss of velocity (along that line) and possibly a net divergence from track – this would have required the a/c to have done two things to get to the final position (at the exact time):
Make up the average speed exactly (unlikely as the a/c was already at the top end of its cruise speed);
Do a dog leg to get back on that line exactly (I suggest odds against this happening by chance – and I don’t think the pilots would have been too fussed about re-establishing that path (closing with high ground) if they had been experiencing any difficulty).
Further, an air traffic controller reported that it just went straight (and he specifically stated that he had seen the RECORDINGS).
So I say it is more likely that the a/c just stayed on the heading that it selected at waypoint change when it was under control.
That there is said to be no radar recording and it was not referred to in the inquiries is interesting as it certainly did exist immediately after the crash; together with the radio call anomaly (either the last call unanswered or the recordings after that point no longer available) this rather suggests censorship of some kind for whatever reason.
You wrote:
<<Your repeated reference to a transponder being used for a DME readout is wide of the mark and a number of correspondents (with Special Forces helo experience) have already explained this (look back at recent posts from, amongst others, Tandemrotor).>>
Well, many SAR as well as military helos had been so equipped at the time – I am not imagining the equipment, tens of thousands of PRC112 types had been manufactured for the US and other NATO countries by 1994 – check the manufacturers blurb – better, talk to SAR helo pilots or 7 Sqn.
I repeat, DME transponders, in normal circumstances, give very accurate range and would have been a logical choice to use in navigating an isolated hazard – if there wasn’t one at the Mull helipad, then there should have been, such would have been the utility of it for a/c regularly doing that route (closing to handrail up the coast).
HC2s were so equipped to get range AND (approximate) bearing to portable DME (embedded in PRC112 types) of which there were probably several on the Mull that day on the persons of the SEALS who were all over the crash site at the time (and who are equipped with PRC112s or equivalent).
That steer of 3 deg to the right at way point change was entirely consistent with ZD576 finishing off the approach to the coast referring to a portable DME inland of the lighthouse proper if they did not see the lighthouse itself (or were not that concerned as they trusted their readout).
Whether this system was used or not, its existence and possible availability should have been brought up at the inquiries so that its use could have been determined by specific questions in a formal setting – instead, we have had the sin of omission.
[B]
One of your questions (on radar recording) is answered in the following section – the others at the end.
SVFR
The crew were OK to use DME near the Mull if so agreed in Special VFR.
This flight was a classic for SVFR: because of the icing limitation, IMC was not on and the difficult part (for VFR) was localized (at the Mull) – conditions so prevalent that a routine SVFR practice would have been expected.
Special VFR is a concession granted by ATC not to go IMC in a planned VFR flight where VFR conditions cannot be met for the whole flight but, with suitable arrangements by ATC and the pilot, the pilot wishes to proceed VFR (very common for helicopters who do not wish to fly IMC in cloud).
I believe that in an SVFR flight, use of a local beacon would have been allowed if agreed with ATC; however, ATC would probably have monitored progress in the area of concern (yes, I have found a credible reference to the aircraft track on military radar right up to the point of impact) and would probably have allocated an appropriate squawk code to identify the SVFR aircraft and remind them of what it was doing nav wise in that area (the possible origin of 7760 on ZD576’s IFF).
DME transponders, in normal circumstances, give very accurate range and would have been a logical choice to use in navigating an isolated hazard – if there wasn’t one at the Mull helipad, then there should have been, such would have been the utility of it for a/c regularly doing that route (closing to handrail up the coast).
It is more common for helicopters to use SVFR – so perhaps you contributors with (much) fixed wing experience can be forgiven for not having brought this option up earlier.
It is amazing that this option was not discussed at any of the inquiries.
Meadowbank – you wrote:
<<I agree that their change of waypoint tends to indicate that no emergency was ongoing. However, your assumption that a turn of 3 deg to the right shows control is incorrect. The aircraft may have been diverging in pitch and/or oscillating in roll. Incidentally, what are you using as your information source for the 3 deg right turn? There was no ADR and it seems that there is, indeed, no radar recording.>>
If you work back from the impact, allowing a little for that last evasive turn, a straight line from waypoint change at the speed the a/c had been holding for the flight up to that point gets you there – put another way, if at waypoint change the a/c turned right 3 deg and maintained that heading (in a straight line) and speed it gets to the crash site at exactly the right time; if, as you suggest, the a/c could have been “diverging in pitch and/or oscillating in roll” – bearing in mind the nature of the beast – this would surely have resulted in a significant loss of velocity (along that line) and possibly a net divergence from track – this would have required the a/c to have done two things to get to the final position (at the exact time):
Make up the average speed exactly (unlikely as the a/c was already at the top end of its cruise speed);
Do a dog leg to get back on that line exactly (I suggest odds against this happening by chance – and I don’t think the pilots would have been too fussed about re-establishing that path (closing with high ground) if they had been experiencing any difficulty).
Further, an air traffic controller reported that it just went straight (and he specifically stated that he had seen the RECORDINGS).
So I say it is more likely that the a/c just stayed on the heading that it selected at waypoint change when it was under control.
That there is said to be no radar recording and it was not referred to in the inquiries is interesting as it certainly did exist immediately after the crash; together with the radio call anomaly (either the last call unanswered or the recordings after that point no longer available) this rather suggests censorship of some kind for whatever reason.
You wrote:
<<Your repeated reference to a transponder being used for a DME readout is wide of the mark and a number of correspondents (with Special Forces helo experience) have already explained this (look back at recent posts from, amongst others, Tandemrotor).>>
Well, many SAR as well as military helos had been so equipped at the time – I am not imagining the equipment, tens of thousands of PRC112 types had been manufactured for the US and other NATO countries by 1994 – check the manufacturers blurb – better, talk to SAR helo pilots or 7 Sqn.
I repeat, DME transponders, in normal circumstances, give very accurate range and would have been a logical choice to use in navigating an isolated hazard – if there wasn’t one at the Mull helipad, then there should have been, such would have been the utility of it for a/c regularly doing that route (closing to handrail up the coast).
HC2s were so equipped to get range AND (approximate) bearing to portable DME (embedded in PRC112 types) of which there were probably several on the Mull that day on the persons of the SEALS who were all over the crash site at the time (and who are equipped with PRC112s or equivalent).
That steer of 3 deg to the right at way point change was entirely consistent with ZD576 finishing off the approach to the coast referring to a portable DME inland of the lighthouse proper if they did not see the lighthouse itself (or were not that concerned as they trusted their readout).
Whether this system was used or not, its existence and possible availability should have been brought up at the inquiries so that its use could have been determined by specific questions in a formal setting – instead, we have had the sin of omission.
[B]
Just a numbered other
The crew were OK to use DME near the Mull if so agreed in Special VFR.
This flight was a classic for SVFR: because of the icing limitation, IMC was not on and the difficult part (for VFR) was localized (at the Mull) – conditions so prevalent that a routine SVFR practice would have been expected.
This flight was a classic for SVFR: because of the icing limitation, IMC was not on and the difficult part (for VFR) was localized (at the Mull) – conditions so prevalent that a routine SVFR practice would have been expected.
a straight line from waypoint change at the speed the a/c had been holding for the flight up to that point gets you there
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SVFR is nevertheless a practical compromise on otherwise rigid flight rules in particular situations, this flight seeming a classic candidate – of special relevance to this case is that for 10 years there have been a simplistic VFR vs IMC arguments with no mention of the SVFR option let alone any discussion. Yet again, an intuitively obvious line is being summarily dismissed rather than modest efforts being made to establish what exactly were the intentions (why not chase up an ATC contact?).
You say <<and in any case the Mull is not in such airspace>>; well, their intended path was at low level across the approach to the Macrihanish runway – and the critical turn not too far from it. I would have thought that ATC would want to know how the a/c knew where it was precisely if landmarks on the Mull were not clearly visible (which they were not) or SVFR conditions would have had to apply (eg. No other a/c in local area until ZD576 clear).
In answer to your question <<And what speed had the a/c been 'holding for the flight' then?>> I refer you to:
Mull of Kintyre -Analysis of Available Data
8-7D20-DS S-03 06, Enclosure 4
Dated: June 18,2002
By James Mitchell of the Boeing Company (available on the net).
Anyone interested in this case would be well advised to read this document (this is not the simulation).
You say <<and in any case the Mull is not in such airspace>>; well, their intended path was at low level across the approach to the Macrihanish runway – and the critical turn not too far from it. I would have thought that ATC would want to know how the a/c knew where it was precisely if landmarks on the Mull were not clearly visible (which they were not) or SVFR conditions would have had to apply (eg. No other a/c in local area until ZD576 clear).
In answer to your question <<And what speed had the a/c been 'holding for the flight' then?>> I refer you to:
Mull of Kintyre -Analysis of Available Data
8-7D20-DS S-03 06, Enclosure 4
Dated: June 18,2002
By James Mitchell of the Boeing Company (available on the net).
Anyone interested in this case would be well advised to read this document (this is not the simulation).