Chinook - Still Hitting Back 3 (Merged)
Avoid imitations
Join Date: Nov 2000
Location: Wandering the FIR and cyberspace often at highly unsociable times
Posts: 14,573
Received 422 Likes
on
222 Posts
I wrote to my local MP, John Mann, asking him to consider signing the new EDM as he DID sign the previous one.
Mr Mann responded by writing to John Reid. I received his actual reply on MOD headed note paper signed by Adam Ingram on 11 Nov 05, which states the following:
[Quote]
"The crash of Chinook ZD576 is the most extensively examined accident in the history of UK military aviation. The Ministry of Defence is very aware that many have found it difficult to accept the findings of the RAF Board of Inquiry, but in the 11 years since this tragic accident, the Ministry of Defence has examined all the complex technical, legal and airmanship issues raised by those opposed to the finding, but has found nothing that undermines it. The Government retains every confidence in the judgement of the reviewing officers but remains prepared to review it's position should any compelling new factual evidence be brought forward."
[Unquote]
The same old reply. I think this means Mr Mann won't be signing the EDM. Disappointing to say the least.
Mr Mann responded by writing to John Reid. I received his actual reply on MOD headed note paper signed by Adam Ingram on 11 Nov 05, which states the following:
[Quote]
"The crash of Chinook ZD576 is the most extensively examined accident in the history of UK military aviation. The Ministry of Defence is very aware that many have found it difficult to accept the findings of the RAF Board of Inquiry, but in the 11 years since this tragic accident, the Ministry of Defence has examined all the complex technical, legal and airmanship issues raised by those opposed to the finding, but has found nothing that undermines it. The Government retains every confidence in the judgement of the reviewing officers but remains prepared to review it's position should any compelling new factual evidence be brought forward."
[Unquote]
The same old reply. I think this means Mr Mann won't be signing the EDM. Disappointing to say the least.
A really irritating PPRuNer
Thread Starter
Join Date: Jun 2000
Location: Just popping my head back up above the parapet
Posts: 903
Likes: 0
Received 0 Likes
on
0 Posts
Hi Shy Torque,
write back to Mr Mann and ask what convinced him to sign last time, and what has subsequently changed.
It will be easy for you to dismantle the generic Ingram letter. This may then make Mr Mann change his mind and add his signature.
The EDM currently stands at 159 signatures. Thank you everyone.
Brian
"Justice has no expiry date" - John Cook
write back to Mr Mann and ask what convinced him to sign last time, and what has subsequently changed.
It will be easy for you to dismantle the generic Ingram letter. This may then make Mr Mann change his mind and add his signature.
The EDM currently stands at 159 signatures. Thank you everyone.
Brian
"Justice has no expiry date" - John Cook
Join Date: Mar 2003
Location: England
Posts: 286
Likes: 0
Received 0 Likes
on
0 Posts
I noticed my MP has not signed, so I have written to him (ruthlessly plagiarising John Blakeley's letter - with apologies):
Dear EG's MP,
I write, as a constituent, to ask you to sign the above Early Day Motion.
At the time I was serving in the Army in Northern Ireland and several of my friends and colleagues were on board. When the Board of Inquiry reported, I assumed their finding of the aircrew to be grossly negligent to be correct.
Since then, as a result of the investigations of the Defence Select Committee, the Public Accounts Committee and the House of Lords Select Committee, I have been convinced that the verdict of the Board of Inquiry is unsafe and the position of the reviewing Air Marshals is untenable.
Detailled evidence from the Board of Inquiry shows quite clearly that, at the time, the Chinook HC2 fleet was suffering a continuing series of problems, any one of which could have caused the pilots of ZD 576 to have been either unable, or so distracted that they failed, to make the turn up the west coast of the Mull. For example a senior RAF instructor in evidence to the Board of Inquiry commented:
“The unforeseen malfunctions on the Chinook HC2 of a flight critical nature 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.”
The problems were so severe that, just prior to the accident, the RAF's safety evaluation branch at RAF Boscombe Down had grounded the Chinook HC2 that they were evaluating due to concerns about flight safety.
Would you climb onto an airliner you knew was suffering from a wide range of "flight safety critical" false and real transient problems, and which had just been grounded by the test and certification organisation of the same "airline"?
Because they pick and choose the facts that suit them the MoD has been able to ignore all criticisms of the judgement – even that of the HoL Select Committee. The MoD’s need to keep this as a pilot error accident is clearly paramount because if it were to be found that it was not then Pandora's Box is opened on the whole process of getting the Chinook HC2 into service and the decision to use it for such a passenger flight.
The result is that MoD steadfastly sticks by this unjust and outrageous verdict, which not only broke the RAF’s rules of the time on finding deceased aircrew negligent but did so without any chance of the “guilty” pilots being able to defend themselves.
Therefore I ask that you sign the above EDM.
Yours Sincerely
EG
I await his response.
EG
Dear EG's MP,
I write, as a constituent, to ask you to sign the above Early Day Motion.
At the time I was serving in the Army in Northern Ireland and several of my friends and colleagues were on board. When the Board of Inquiry reported, I assumed their finding of the aircrew to be grossly negligent to be correct.
Since then, as a result of the investigations of the Defence Select Committee, the Public Accounts Committee and the House of Lords Select Committee, I have been convinced that the verdict of the Board of Inquiry is unsafe and the position of the reviewing Air Marshals is untenable.
Detailled evidence from the Board of Inquiry shows quite clearly that, at the time, the Chinook HC2 fleet was suffering a continuing series of problems, any one of which could have caused the pilots of ZD 576 to have been either unable, or so distracted that they failed, to make the turn up the west coast of the Mull. For example a senior RAF instructor in evidence to the Board of Inquiry commented:
“The unforeseen malfunctions on the Chinook HC2 of a flight critical nature 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.”
The problems were so severe that, just prior to the accident, the RAF's safety evaluation branch at RAF Boscombe Down had grounded the Chinook HC2 that they were evaluating due to concerns about flight safety.
Would you climb onto an airliner you knew was suffering from a wide range of "flight safety critical" false and real transient problems, and which had just been grounded by the test and certification organisation of the same "airline"?
Because they pick and choose the facts that suit them the MoD has been able to ignore all criticisms of the judgement – even that of the HoL Select Committee. The MoD’s need to keep this as a pilot error accident is clearly paramount because if it were to be found that it was not then Pandora's Box is opened on the whole process of getting the Chinook HC2 into service and the decision to use it for such a passenger flight.
The result is that MoD steadfastly sticks by this unjust and outrageous verdict, which not only broke the RAF’s rules of the time on finding deceased aircrew negligent but did so without any chance of the “guilty” pilots being able to defend themselves.
Therefore I ask that you sign the above EDM.
Yours Sincerely
EG
EG
A really irritating PPRuNer
Thread Starter
Join Date: Jun 2000
Location: Just popping my head back up above the parapet
Posts: 903
Likes: 0
Received 0 Likes
on
0 Posts
Hi everyone,
I have just been advised that a further Early Day Motion (EDM) has been tabled by Mr Douglas Hogg MP.
His EDM states: That this House calls on the Government to appoint a Judge of the High Court or some other person who has held high judicial office to review all the evidence that has been gathered in all the hearings and inquiries that have been held regarding the crash of the Chinook helicopter on the Mull of Kintyre on 2nd June 1994 and for that person to advise whether, having regard to the appropriate burden and standard of proof, such evidence is sufficient to support the conclusion that the pilots were guilty of gross negligence.
Link to EDM
As this was an unprompted EDM, might I please ask that you, again, contact your MP and ask that they lend their support to Mr Hogg's EDM. The current signature total stands at 15.
A letter has gone to Mr Hogg, expressing my sincere thanks. If anyone else would like to do so, you may contact him on the following:
The Rt. Hon. Douglas Hogg, QC, MP, The Viscount Hailsham
House of Commons
London SW1A 0AA
Let's see if we can get this EDM over the 100 mark too!!
My best, as always.
Brian
"Justice has no expiry date" - John Cook
I have just been advised that a further Early Day Motion (EDM) has been tabled by Mr Douglas Hogg MP.
His EDM states: That this House calls on the Government to appoint a Judge of the High Court or some other person who has held high judicial office to review all the evidence that has been gathered in all the hearings and inquiries that have been held regarding the crash of the Chinook helicopter on the Mull of Kintyre on 2nd June 1994 and for that person to advise whether, having regard to the appropriate burden and standard of proof, such evidence is sufficient to support the conclusion that the pilots were guilty of gross negligence.
Link to EDM
As this was an unprompted EDM, might I please ask that you, again, contact your MP and ask that they lend their support to Mr Hogg's EDM. The current signature total stands at 15.
A letter has gone to Mr Hogg, expressing my sincere thanks. If anyone else would like to do so, you may contact him on the following:
The Rt. Hon. Douglas Hogg, QC, MP, The Viscount Hailsham
House of Commons
London SW1A 0AA
Let's see if we can get this EDM over the 100 mark too!!
My best, as always.
Brian
"Justice has no expiry date" - John Cook
A really irritating PPRuNer
Thread Starter
Join Date: Jun 2000
Location: Just popping my head back up above the parapet
Posts: 903
Likes: 0
Received 0 Likes
on
0 Posts
Thank you, as always BOAC.
Good idea. Fax your MP from your computer
As always, the Campaign is very grateful for all the support we receive.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
Good idea. Fax your MP from your computer
As always, the Campaign is very grateful for all the support we receive.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
Join Date: Oct 2005
Location: Sadland
Posts: 14
Likes: 0
Received 0 Likes
on
0 Posts
Brian
I am humbled by your tenacity, compassion and honour. We knew each other well many years ago, were, and still are I guess, good friends, but I never saw the man you truly are.
It is so easy to run around in the modern world and be too busy to reflect on what’s important. Whenever I grab a quick look at PPRuNe it is this thread that makes me pause and think.
I had the pleasure of calling these two honourable men my friends. I know the fact that they were honourable does not mean they weren’t capable of CFIT, but I also know that there is not a single aircrew member reading this that isn’t as well. Those same readers will expect their service to treat them as you do John and Rick, to consider the mitigating circumstances, whatever they are.
Well done mate
Whooper 5
Ps Faxed MP.
Pps.If you need some more plague I’ve got the needles!
I am humbled by your tenacity, compassion and honour. We knew each other well many years ago, were, and still are I guess, good friends, but I never saw the man you truly are.
It is so easy to run around in the modern world and be too busy to reflect on what’s important. Whenever I grab a quick look at PPRuNe it is this thread that makes me pause and think.
I had the pleasure of calling these two honourable men my friends. I know the fact that they were honourable does not mean they weren’t capable of CFIT, but I also know that there is not a single aircrew member reading this that isn’t as well. Those same readers will expect their service to treat them as you do John and Rick, to consider the mitigating circumstances, whatever they are.
Well done mate
Whooper 5
Ps Faxed MP.
Pps.If you need some more plague I’ve got the needles!
Avoid imitations
Join Date: Nov 2000
Location: Wandering the FIR and cyberspace often at highly unsociable times
Posts: 14,573
Received 422 Likes
on
222 Posts
Brian, Please empty your PM intray - it's full.
A really irritating PPRuNer
Thread Starter
Join Date: Jun 2000
Location: Just popping my head back up above the parapet
Posts: 903
Likes: 0
Received 0 Likes
on
0 Posts
Shy,
apologies, please try again.
Whooper,
Great to hear from you and for your kind words. Have no fear, friendship is something that continues - unless, of course, you've got a needle in your hand! Drop me a line. Thanks for faxing your MP.
As always, my thanks to all our supporters. EDM 1111 has now jumped to 31 signatures. Great work everyone.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
apologies, please try again.
Whooper,
Great to hear from you and for your kind words. Have no fear, friendship is something that continues - unless, of course, you've got a needle in your hand! Drop me a line. Thanks for faxing your MP.
As always, my thanks to all our supporters. EDM 1111 has now jumped to 31 signatures. Great work everyone.
My best, as always.
Brian
"Justice has no expiry date" - John Cook
Brian sent to my local MP - will keep you posted.
Dear Christopher Huhne,
Could I please request that you sign 2 EDMs that are currently active. Both concern the Chinook crash over 10 years ago now at the Mull of Kintyre. As a former colleague of both pilots I remain convinced that no-one can say for sure what happened that day and for a verdict of Gross Negligence to have been levied against them is absolutely unjust.
At the time the RAF's own rules stated that, if a pilot had died and was therefore unable to present his side of the story, a verdict of Gross Negligence could only be valid if "there was no doubt whatsoever". I am not so blinkered that I cannot consider the fact that Jon and Rick did NOT make a grave mistake which led to this terrible accident but theories/supposition have been presented as facts to produce a possible scenario which is being delivered as a "no doubt whatsoever" situation
Over the years a number of august bodies have found that the verdict is not sustainable, in fact the original Board of Inquiry did not feel able to claim Gross Negligence; this was raised later by the reviewing officers.
Despite constant approaches to the MoD the constant refrain is "no new evidence therefore no change of decision". This flys in the face of a number of other reports and there is an active campaign out there to try and get this verdict put aside or changed; this campaign has the support, not only of the families of the 2 crewman, but crucially families of some of the passenger victims also.
I apologise for the long-winded letter but I am aware that this is your first term as an MP and wished to provide some background to the situation. I hope you are able to sign the EDMs concerned, 651 and 1111. I would add finally that both EDMs are attracting cross-party support and indeed both the PM and Defence Minister at the time of the incident have since reversed their view and now support the removal of the Gross Negligence verdict.
Yours sincerely,
S&S
Dear Christopher Huhne,
Could I please request that you sign 2 EDMs that are currently active. Both concern the Chinook crash over 10 years ago now at the Mull of Kintyre. As a former colleague of both pilots I remain convinced that no-one can say for sure what happened that day and for a verdict of Gross Negligence to have been levied against them is absolutely unjust.
At the time the RAF's own rules stated that, if a pilot had died and was therefore unable to present his side of the story, a verdict of Gross Negligence could only be valid if "there was no doubt whatsoever". I am not so blinkered that I cannot consider the fact that Jon and Rick did NOT make a grave mistake which led to this terrible accident but theories/supposition have been presented as facts to produce a possible scenario which is being delivered as a "no doubt whatsoever" situation
Over the years a number of august bodies have found that the verdict is not sustainable, in fact the original Board of Inquiry did not feel able to claim Gross Negligence; this was raised later by the reviewing officers.
Despite constant approaches to the MoD the constant refrain is "no new evidence therefore no change of decision". This flys in the face of a number of other reports and there is an active campaign out there to try and get this verdict put aside or changed; this campaign has the support, not only of the families of the 2 crewman, but crucially families of some of the passenger victims also.
I apologise for the long-winded letter but I am aware that this is your first term as an MP and wished to provide some background to the situation. I hope you are able to sign the EDMs concerned, 651 and 1111. I would add finally that both EDMs are attracting cross-party support and indeed both the PM and Defence Minister at the time of the incident have since reversed their view and now support the removal of the Gross Negligence verdict.
Yours sincerely,
S&S
Just a numbered other
I have had a singular lack of success so far in enlisting my MP's support, and indeed fell out with him a while back over this matter.
Brian's tenacity has encouraged me to try again. I have today written to him again, asking him to sign.
Brian's tenacity has encouraged me to try again. I have today written to him again, asking him to sign.
Join Date: Mar 2003
Location: England
Posts: 286
Likes: 0
Received 0 Likes
on
0 Posts
MPs response
Received the following reply from my MP David Ruffley
So I await my MoD form letter.
EG
Dear EG,
Thank you for your e-mail regarding your concerns over the Early Day Motion (EDM) 651 - Mull of Kintyre Chinook Helicopter Crash.
You ask if I will sign this EDM. I very rarely sign EDMs because in practice they have little effect. What I prefer to do is to raise matters directly with the relevant Government Minister on behalf of individual constituents. I have, therefore, today written to The Rt Hon Dr John Reid MP, Secretary of State for Defence, to raise this matter on your behalf. I will send his reply to you as soon as I receive it.
With kind regards,
David Ruffley
Thank you for your e-mail regarding your concerns over the Early Day Motion (EDM) 651 - Mull of Kintyre Chinook Helicopter Crash.
You ask if I will sign this EDM. I very rarely sign EDMs because in practice they have little effect. What I prefer to do is to raise matters directly with the relevant Government Minister on behalf of individual constituents. I have, therefore, today written to The Rt Hon Dr John Reid MP, Secretary of State for Defence, to raise this matter on your behalf. I will send his reply to you as soon as I receive it.
With kind regards,
David Ruffley
EG
Avoid imitations
Join Date: Nov 2000
Location: Wandering the FIR and cyberspace often at highly unsociable times
Posts: 14,573
Received 422 Likes
on
222 Posts
ExGrunt,
I'm afraid that you will probably get the same standard letter on MOD notepaper that I received recently after my MP wrote to John Reid (see my post of 20th November).
MOD will only consider "new" evidence. Tell your MP that the best "new" evidence is that they (MOD) were suing Boeing over the FADEC software issues at the time whilst they claimed that there was no problem with it, btw.
This is all about liability. They will do everything not to change their viewpoint.
Best of luck.
I'm afraid that you will probably get the same standard letter on MOD notepaper that I received recently after my MP wrote to John Reid (see my post of 20th November).
MOD will only consider "new" evidence. Tell your MP that the best "new" evidence is that they (MOD) were suing Boeing over the FADEC software issues at the time whilst they claimed that there was no problem with it, btw.
This is all about liability. They will do everything not to change their viewpoint.
Best of luck.
Join Date: Nov 2005
Location: Norfolk England
Posts: 247
Likes: 0
Received 0 Likes
on
0 Posts
New Evidence
Can I again point out that it is not a question of new evidence it is a question of the MOD (and the BoI process) failing to make use of the evidence they have, not asking the obvious questions and not considering major areas such as airworthiness and fitness for purpose. They also happily allow the Reviewing Officers to ignore the requirements of AP3207 and even the "requirements" of the Senior Reviewing Officer's own flight safety directive issued just weeks before the findings of Gross Negligence. I suggest that these are the areas that need to be "attacked" so that MOD cannot keep sheltering behind the "new" evidence response.
John Blakeley,
My MP seems to be quite supportive at the moment and I would love to give him some ammunition to throw at John Reid.
For those of us who are not familiar with BoI procedures, can you give us a bit more information on "these areas". It sound like they might be the trigger for some awkward questions. I am finding that my MP sometimes gets a better response than the rest of us.
My MP seems to be quite supportive at the moment and I would love to give him some ammunition to throw at John Reid.
For those of us who are not familiar with BoI procedures, can you give us a bit more information on "these areas". It sound like they might be the trigger for some awkward questions. I am finding that my MP sometimes gets a better response than the rest of us.
Join Date: Nov 2005
Location: Norfolk England
Posts: 247
Likes: 0
Received 0 Likes
on
0 Posts
MP Letter
Pulse 1 - I would be very happy to provide you with as much information as I can to help you write to your MP, but you need to see the examples in context. If you have time could I suggest that you go to the main web site at http://chinook-justice.org/ and select the "Reports" link. The original ctirtique I did of the BoI for the Tapper family can be picked up there. It has been submitted to MOD and the only response we got was the usual "no new evidence" even though I had pointed out in advance that I had nothing new, and that I was seeking to get them to look at the evidence they already had.
I have recently done some more analysis relating to the "join" where the BoI was sent back for re-work and also to the Senior Reviewing Officer's Fllight Safety Directive (issued just before the finding of Gross Negligence). These are probably too long to put on PPRuNE but I will try to get them to you via the PM system if I can work it out.
Hope this helps.
Keep fighting.
John Blakeley
I have recently done some more analysis relating to the "join" where the BoI was sent back for re-work and also to the Senior Reviewing Officer's Fllight Safety Directive (issued just before the finding of Gross Negligence). These are probably too long to put on PPRuNE but I will try to get them to you via the PM system if I can work it out.
Hope this helps.
Keep fighting.
John Blakeley
John Blakeley,
All information gratefully received, thank you. I will try to prepare a suitable letter.
One of the problems you highlight in your report is one which is of particular interest to me. This is the problem with the DECU connector and I understand that, because of previous problems, it was normal procedure to check this connector every 15 minutes during flight.
Having spent a significant part of my working life investigating electric contact problems I am horrified that any one should put an aircraft into service without full confidence in such a critical part and in an environment where vibration could seriously degrade light duty contacts in a very short time. You would be amazed how quickly a precious metal contact surface can be destroyed even with electrical loads as small as 50 mA at 10 mV.
That an aircraft with this problem should be used to carry passengers is beyond belief.
Surely it is now time to start pestering our MP's to ask MoD why this aircraft was used for this purpose. If I thought that my son was flying equipment in this condition I would get very cross indeed.
I will let you know how I get on.
p1
All information gratefully received, thank you. I will try to prepare a suitable letter.
One of the problems you highlight in your report is one which is of particular interest to me. This is the problem with the DECU connector and I understand that, because of previous problems, it was normal procedure to check this connector every 15 minutes during flight.
Having spent a significant part of my working life investigating electric contact problems I am horrified that any one should put an aircraft into service without full confidence in such a critical part and in an environment where vibration could seriously degrade light duty contacts in a very short time. You would be amazed how quickly a precious metal contact surface can be destroyed even with electrical loads as small as 50 mA at 10 mV.
That an aircraft with this problem should be used to carry passengers is beyond belief.
Surely it is now time to start pestering our MP's to ask MoD why this aircraft was used for this purpose. If I thought that my son was flying equipment in this condition I would get very cross indeed.
I will let you know how I get on.
p1
Join Date: Mar 2003
Location: England
Posts: 286
Likes: 0
Received 0 Likes
on
0 Posts
Committee of Public Accounts
Published today:
Achieving value for money in the delivery of public services HC 742
At Para 27:
Achieving value for money in the delivery of public services HC 742
At Para 27:
In 2000, our predecessors criticised the procurement by the Ministry of Defence of the Chinook Mark 2 helicopter in a contract worth £143 million. There were significant technical problems with accepting the Chinook into service, which may have contributed to the tragic crash of Chinook ZD-576 in June 1994.
Join Date: Jan 2004
Location: Hampshire
Posts: 112
Likes: 0
Received 0 Likes
on
0 Posts
There were significant technical problems with accepting the Chinook into service, which may have contributed to the tragic crash of Chinook ZD-576 in June 1994.
Earlier this year I posted on this thread:
What was wrong with the aircraft? How have they fixed them. People are still flying them, do they need to be grounded?
Join Date: Nov 2005
Location: Norfolk England
Posts: 247
Likes: 0
Received 0 Likes
on
0 Posts
PAC Report
Ex Grunt
I would certainly support the PAC statement - if you want the airworthiness issues in detail please find time to read the engineering critique on the BoI (see link above to pulse1) where you will find full details to back up their opinion. Sadly the PAC has already made such a strong statement before, but with no obvious effect on MOD's position. Still it is nice to see that they still believe it and that by saying so they again reject the Gross Negligence verdict.
Twin Act
I assume that such things as uncommanded engine run-ups etc have been fixed, but a current operator needs to confirm this. However it took some time as more than a year after the Mull accident the US Army Release to Service for their "new" Chinook still contained warnings on DECU connector security and false FADEC fault codes etc.
In October 2003 I attempted to encapsulate my enginnering investigation into a single A4 page - as shown below. This was given to Hoon at a meeting with senior members of the Mull Group and was rejected, unread, as "no new evidence". This is one of the reasons why I hope that PPRuNe contributors can change direction from considering some of the very low chance operational reasons to what I consider (but like everybody else I still do NOT KNOW) to be the very high chance that a technical issue, possibly only a transient one, was a direct and major contributor to the accident.
UNUSED AND NEW EVIDENCE RELATING TO THE AIRWORTHINESS OF CHINOOK HC2 ZD 576
In making its early decision to “eliminate as possible causes: major technical malfunction or structural failure of the aircraft prior to impact” and to focus “on the crew’s handling and operation of the aircraft” the BoI, including the Review process not only ignored taking potentially significant evidence but also failed to follow up evidence showing potential airworthiness, engineering and maintenance issues that was placed before it. As such, either by direction or of its own volition, the BoI behaved in a partial manner and the findings were heavily biased in favour of a verdict that ensured that the RAF themselves were not questioned on their decisions and shortfalls in their processes. The finding of a balance of probabilities of aircrew error, changed to Gross Negligence by the Senior Reviewing Officer, could not have been justified if the available evidence had been correctly analysed and followed up. Such actions would have shown that the airworthiness status of the Chinook HC2 fleet at that time, potentially coupled with a major technical defect on ZD 576 itself, was a plausible alternative cause for the accident.
JSP 318 (Regulation of Ministry of Defence Aircraft) defines “Airworthiness” as “the ability of an aircraft or other airborne equipment or system to operate without significant hazard to aircrew, groundcrew, passengers (where relevant) or to the general public over which the airborne systems are flown”.
The Airworthiness Chain
The BoI Terms of reference do not specifically task the Board to look at whether the aircraft was “airworthy” in terms of MOD’s own definition of airworthiness, despite the fact that the “problems” of the Chinook HC2 fleet at that time were well known to supervisors and commanders. However the Board is specifically tasked to assess the equivalent “Human Failings”. The Board, including the Reviewing Officers, does not mention “airworthiness” at any point.
Witness 20 ably sums up the fleet airworthiness problems of the Chinook HC2 with his evidence: The unforeseen malfunctions on the Chinook HC2 of a flight critical nature 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.” In their findings the BoI use this evidence but omit the words “flight critical nature”. ZD 576 had experienced all of these problems in the short period since its acceptance off the conversion programme. No confirmation of the cause of these defects had been established when it was decided to transfer the aircraft to the Aldergrove detachment. In addition to these “accepted” engine problems ZD 576 had suffered a major control problem leading to the need for fleet checks and a serious defect report – the results of which were still outstanding at the time of the accident.
To justify its action in ignoring engine problems or a control malfunction as potential causes of the accident the BoI “interprets" AAIB evidence in a way that the much more experienced AAIB inspector does not support. The latest Boeing simulation analysis shows that a control malfunction cannot be ruled out and that the engine power settings would have to have been at full or emergency power – in direct conflict with the BoI/MOD cruise/climb theory.
The links in the airworthiness chain include maintenance standards. The BoI found clear evidence of a major lapse of maintenance standards at Aldergrove, but takes no action to follow this up. Key witnesses such as OC Engineering Wing RAF Odiham who would have been responsible for the airworthiness of ZD 576 and for the engineering standards of the Aldergrove detachment (which was still operating to the Odiham EOB) were not called at all.
The Board does ascertain (witness 4) that the Senior Engineering Officer 230 Squadron and not the Chinook Detachment Commander, was responsible for the engineering supervision of the attached Chinook aircraft and personnel. However, despite the clear lapse in this supervision, no attempt is made to find out how this responsibility was being discharged, how such a major breach of engineering regulations was ignored and most importantly how, as the front line link in the airworthiness chain, he was “satisfied that Chinook HC2 ZD576 was serviceable for it’s (sic) final flight on 2 Jun 94”.
Summary
In summary, the Board, including the Review process, does not consider the central question of whether, either as a result of the Release to Service process and/or the defect history of the aircraft, the “airworthiness chain” was still intact for ZD 576. There is clear, and unused, evidence that it was not, and that there is at least one more plausible explanation for the accident. It is also clear that the RAF’s decision to operate the HC2 at all with the introduction to service problems it had at the time, as well as the choice of the HC2, and ZD 576 in particular, for a high profile but non-operational, passenger flight could be called into question.
Again please check the link to the engineering report for a fuller picture.
I would certainly support the PAC statement - if you want the airworthiness issues in detail please find time to read the engineering critique on the BoI (see link above to pulse1) where you will find full details to back up their opinion. Sadly the PAC has already made such a strong statement before, but with no obvious effect on MOD's position. Still it is nice to see that they still believe it and that by saying so they again reject the Gross Negligence verdict.
Twin Act
I assume that such things as uncommanded engine run-ups etc have been fixed, but a current operator needs to confirm this. However it took some time as more than a year after the Mull accident the US Army Release to Service for their "new" Chinook still contained warnings on DECU connector security and false FADEC fault codes etc.
In October 2003 I attempted to encapsulate my enginnering investigation into a single A4 page - as shown below. This was given to Hoon at a meeting with senior members of the Mull Group and was rejected, unread, as "no new evidence". This is one of the reasons why I hope that PPRuNe contributors can change direction from considering some of the very low chance operational reasons to what I consider (but like everybody else I still do NOT KNOW) to be the very high chance that a technical issue, possibly only a transient one, was a direct and major contributor to the accident.
UNUSED AND NEW EVIDENCE RELATING TO THE AIRWORTHINESS OF CHINOOK HC2 ZD 576
In making its early decision to “eliminate as possible causes: major technical malfunction or structural failure of the aircraft prior to impact” and to focus “on the crew’s handling and operation of the aircraft” the BoI, including the Review process not only ignored taking potentially significant evidence but also failed to follow up evidence showing potential airworthiness, engineering and maintenance issues that was placed before it. As such, either by direction or of its own volition, the BoI behaved in a partial manner and the findings were heavily biased in favour of a verdict that ensured that the RAF themselves were not questioned on their decisions and shortfalls in their processes. The finding of a balance of probabilities of aircrew error, changed to Gross Negligence by the Senior Reviewing Officer, could not have been justified if the available evidence had been correctly analysed and followed up. Such actions would have shown that the airworthiness status of the Chinook HC2 fleet at that time, potentially coupled with a major technical defect on ZD 576 itself, was a plausible alternative cause for the accident.
JSP 318 (Regulation of Ministry of Defence Aircraft) defines “Airworthiness” as “the ability of an aircraft or other airborne equipment or system to operate without significant hazard to aircrew, groundcrew, passengers (where relevant) or to the general public over which the airborne systems are flown”.
The Airworthiness Chain
The BoI Terms of reference do not specifically task the Board to look at whether the aircraft was “airworthy” in terms of MOD’s own definition of airworthiness, despite the fact that the “problems” of the Chinook HC2 fleet at that time were well known to supervisors and commanders. However the Board is specifically tasked to assess the equivalent “Human Failings”. The Board, including the Reviewing Officers, does not mention “airworthiness” at any point.
Witness 20 ably sums up the fleet airworthiness problems of the Chinook HC2 with his evidence: The unforeseen malfunctions on the Chinook HC2 of a flight critical nature 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.” In their findings the BoI use this evidence but omit the words “flight critical nature”. ZD 576 had experienced all of these problems in the short period since its acceptance off the conversion programme. No confirmation of the cause of these defects had been established when it was decided to transfer the aircraft to the Aldergrove detachment. In addition to these “accepted” engine problems ZD 576 had suffered a major control problem leading to the need for fleet checks and a serious defect report – the results of which were still outstanding at the time of the accident.
To justify its action in ignoring engine problems or a control malfunction as potential causes of the accident the BoI “interprets" AAIB evidence in a way that the much more experienced AAIB inspector does not support. The latest Boeing simulation analysis shows that a control malfunction cannot be ruled out and that the engine power settings would have to have been at full or emergency power – in direct conflict with the BoI/MOD cruise/climb theory.
The links in the airworthiness chain include maintenance standards. The BoI found clear evidence of a major lapse of maintenance standards at Aldergrove, but takes no action to follow this up. Key witnesses such as OC Engineering Wing RAF Odiham who would have been responsible for the airworthiness of ZD 576 and for the engineering standards of the Aldergrove detachment (which was still operating to the Odiham EOB) were not called at all.
The Board does ascertain (witness 4) that the Senior Engineering Officer 230 Squadron and not the Chinook Detachment Commander, was responsible for the engineering supervision of the attached Chinook aircraft and personnel. However, despite the clear lapse in this supervision, no attempt is made to find out how this responsibility was being discharged, how such a major breach of engineering regulations was ignored and most importantly how, as the front line link in the airworthiness chain, he was “satisfied that Chinook HC2 ZD576 was serviceable for it’s (sic) final flight on 2 Jun 94”.
Summary
In summary, the Board, including the Review process, does not consider the central question of whether, either as a result of the Release to Service process and/or the defect history of the aircraft, the “airworthiness chain” was still intact for ZD 576. There is clear, and unused, evidence that it was not, and that there is at least one more plausible explanation for the accident. It is also clear that the RAF’s decision to operate the HC2 at all with the introduction to service problems it had at the time, as well as the choice of the HC2, and ZD 576 in particular, for a high profile but non-operational, passenger flight could be called into question.
Again please check the link to the engineering report for a fuller picture.