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Chinook - Still Hitting Back 3 (Merged)

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Chinook - Still Hitting Back 3 (Merged)

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Old 12th Apr 2009, 19:45
  #4201 (permalink)  
 
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I simply wish to understand, on whose evidence the crew were guilty of negligence at waypoint change? That's all
Only one witness had a useful perspective of that point in space. That being Holbrook, who has stated that the weather was relatively clear below the cloud which presumably is what enveloped all other witnesses?
In his statement to the Board Mr Holbrook said that the aircraft was well below cloud level and visibility was about a mile limited by haze
These were the facts at the time of the BOI.
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Old 12th Apr 2009, 20:15
  #4202 (permalink)  

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But the one thing we do know (without any doubt whatever) is that at waypoint change the crew had already broken the airmanship rules governing flight either in VMC or in IMC. This was the negligence.
JP could you please explain why this is so? What was the alleged negligence "at" (or before) the waypoint change?
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Old 14th Apr 2009, 13:33
  #4203 (permalink)  
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JP:
have you studied Annexes J and K to the MOD Response to the Mull Group submission, showing the intended track and the actual track
I don't have the ref to hand, but question your (and Caz's) claim to have any idea of the intended track.

The waypoint and the lines to it and away from it are not used in SH to indicate the intended track, simply a guide to give the TANS information to assist in steering guidance to the vicinity of the W/P.

The flight was VFR, the weather was VMC (Holbrook's testimony confirms).

Why the chinook continued more or less straight into the Mull, instead of turning left to follow the coast below the cloud will never be known without doubt.

That's the crux. How many times does it need to be spelled out!

And for those new to the thread, who wonder why a climb to MSA was not initiated: Chinook Mk2 icing clearance 4Deg C. MSA 2800ft (from memory) 0 Deg isotherm about 2500ft.
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Old 14th Apr 2009, 17:52
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It baffles me why so many (obviously) intelligent people can't seem to see the wood from the trees. However, there is a glimmer of hope....

I may be wrong but there seems to be a consensus that we all agree that:

no-one will ever know what occurrred on the flight-deck that day, nor the crew's decision-making process that led them to fly into the hill.


If someone disagrees, I would welcome their comment.

Most of the rest of our debate on a lack of airworthiness, transient engine/control malfunctions, strange control positions, VMC or not, viz, cloud base, MSA, navigation techniques, eating habits, VIP passengers or even landing at an LZ are all important but they are side-issues. They are secondary to the sad but ultimate truth that we just don't know the true sequence of events....at all.

The lack of a CVR/ADR in the HC2 is the reason why we don't know and why so many mil accidents to old, legacy ac recommend their fitment. In 2 other accidents in RAFSTC, that happened about the same time, (one of which was FJ and another Multi), this fact was enough to ensure that there was insufficient data to assess "with no doubt whatsoever". Those crews did not get labelled with the tag of gross negligence - in other words, manslaughter. Why was it different for ZD576?

Lastly, I believe that some would say that the reviewing officers made their decisions based on what was presented to them by the BOI and so, it must stand. Frankly, that is a cop-out for 2 reasons:

a. If the BOI had done more 'digging' in 1994, then many of those important side-issues might have been more fully addressed - perhaps they didn't because the chain of command wouldn't have let them/liked it/overruled it or because there was not time. All of which undermine the conclusion of the reviewing officers which, anyway, overruled the BOI findings.

b. BOIs and their reviewers are inherently compromrised by their own chain of command and are at best introverted and parochial.

Even if all those issues were discarded, then the sheer weight of argument and the fact that , would allow today's generation of accident investigators to assess the BOI process and compare it to modern 'best-practice'. As someone said, 'there were too many holes in the cheese' to allow the crew to take all the flak. I suspect that a modern investigator would come to a very different conclusion to that reached by the reviewing officers in question. I would also like to think that a modern perspective would result in an apology to the crew's families and a removal of the stain on their character.

Last edited by flipster; 14th Apr 2009 at 20:20.
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Old 14th Apr 2009, 19:48
  #4205 (permalink)  
 
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Go and watch the video taken moments before the crash.
Read the witness statements fromt the individuals on the Mull including the lighthouse keeper.
It was in cloud you idiots.
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Old 14th Apr 2009, 20:02
  #4206 (permalink)  
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Atlantic Cowboy,
I have a copy of the video. It clearly shows that you can see the breakers on the Mull coast and that the cloud cover did not go as low or as far out from the coast as the MoD says it does.

I have also read the statements from those on the Mull and you are right, they were stood in cloud. What none of them can say is what the view was like when looking towards the Mull.

Insults add nothing to the debate.

Chinook 240,
you say that "They were the facts at the time of the BoI". That may well be so, but since that time more information has become available that, perhaps, was not available at the time of the BoI. That does not invalidate the work that they did, but it certainly makes their finding unsustainable.

My best, as always,
Brian

"Justice has no expiry date" - John Cook
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Old 14th Apr 2009, 20:02
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What was in cloud?
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Old 14th Apr 2009, 20:19
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AC,

Please keep your insults to yourself.
BD is totally correct in all he says in reply - we now know that there were far too many unknowns to justify the verdict.
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Old 15th Apr 2009, 05:51
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Please keep your insults to yourself.
But on the other hand, when reasoned argument is abandoned, you know you're on to something. (Not that MoD has ever had a reasonable argument on this one). Good post flip.
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Old 15th Apr 2009, 10:34
  #4210 (permalink)  
 
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Chinook

Ark Royal. Entirely agree your "Why the chinook continued more or less straight into the Mull, instead of turning left to follow the coast below the cloud will never be known without doubt." Forget about assumed tracks and so on, but can we also agree that if the a/c had been about 500 yds to the left, (confusion between lighthouse compound and fog signal compound?- just a theory) it would have cleared the hill ahead with around 200 ft to spare, and no-one would then ever have known about this most greivous breach of airmanship ie flying blind over hills. With all good wishes JP
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Old 15th Apr 2009, 12:33
  #4211 (permalink)  
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Mr Purdey,

I would agree that had the Chinook been further to the left, then the crash probably would not have occurred. The possibility that (as concluded in Mr Campbell's book) the lighthouse compound and fog-horn compound were mis-identified is, just that - a possibility, and a remote one at that as the crew regularly flew that area and knew it very well.

Had, of course, the Chinook missed the landmass, the crew would be alive to make representation against any allegation of a breach of airmanship, or provide testimony that the aircraft was unfit for service. Sadly they, nor their families, have been given that opportunity.

Whilst we are looking to agree certain points, can I ask if we can agree the following:
a) The witnesses on the Mull were in cloud and had no way of knowing how far out it extended.

b) No one alive knows what could be seen from the cockpit.

c) No one alive knows what was said in the cockpit.

d) No one knows where, exactly, the waypoint change was made.

e) No one knows whether a flight control pallet became detached prior to, or as a result of impact.

f) No one knows, with absolutely no doubt whatsoever, the actual sequence of events which led to the tragic accident on the Mull of Kintyre.

I could go on, but you get the idea.

My best, as always.
Brian

"Justice has no expiry date" - John Cook
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Old 15th Apr 2009, 13:01
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Mr Purdey,

Your first sentence

Entirely agree your "Why the chinook continued more or less straight into the Mull, instead of turning left to follow the coast below the cloud will never be known without doubt."
We do seem to be gathering consensus!

Strangely, your next sentence that concludes with

this most greivous breach of airmanship ie flying blind over hills
and is totally at odds with the previous one. It is also conjecture (by your own admission) and really, it has limited value in reasoned discussion.

Despite this, I will rise to the bait.

Let us assume that your (and others') conjecture actually is the truth and the crew were negligent in flying IMC, below MSA without carrying out an emergency climb to above safety alt. If this is your position, then you must also accept the RTS limitation on the HC2 not to fly in icing conditions (0 deg isotherm was some way below MSA) would have been a major contributory factor that may have influenced the crew's decsision making prior to the mull - they would have been most reluctant to climb into icing conditions and may have pushed the limits of VMC...maybe.

That, I suggest, is a rather big hole in any slice of cheese and it almost instantaneously removes the 'absolutely no doubt whatsoever' option for any objective observer and places a heavy burden on those who insisted on operating the HC2 in an operational environment against expert advice. It is arguable that the mice may have eaten the airworthiness slice of cheese altogether!

However, I do not believe your assessment is correct. Sadly, I cannot disprove it but, likewise, neither can you prove it was the case - once again, not meeting the binding requirement to prove 'with absolutely no doubt whatsoever'.

So, if you are siding with Mssrs Day and Wratten, then I feel you have backed a tiring horse. I can understand how they may have made their decision at that time, with only the BOIs report and their limited recent operational experience to go on (Sen Staff Offs are are a long way from the frontline). In 1994/5 the reviewing offs may have produced their verdict with either a heavy heart or dispassionate objectivity (or there may have been undue pressure from above) but since then, it is plain to see that there are far too many holes in too few slices of cheese.

Therefore, I fail to understand people's reluctance to accept the possibility that, with hindsight, Mssrs Day and Wratten may have been wrong in their judgement. We are all only human and their conclusions could be forgiven as they did not have all the pieces of the jigsaw. Neither did they use modern reconstructive processes. If they had, then I believe they would have concluded that they did not know for sure what happened that day.

It is no use saying 'that was then and this is now'.... just because that was accepted practice back then, does not make it acceptable now, especailly in view of recent knowledge. For example, as a nation, the UK has apologised for its actions during the times of the Slave Trade and Germany continues to apologise for the actions of the Nazis during WWII. No-one thinks any less of the present countries' governments. Now, I am not comparing such atrocities with the judgment of the BOI Reviewing Officers, merely highlighting that it does one no harm to accept that the past may need re-appraisal in the light of recent knowledge and also to accept that we may have to view history in a different perspective.

One day, we will all be own our own death-beds, looking back at our acheivements and failures. I think that this episode, one way or another, will feature highly in the minds of those reviewing officers; what they make of it will be the mark of their contributions to society. I believe that Gp capt Crawford has already had the courage to accept that he might have been mistaken. Here's hoping that others may do the same.
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Old 15th Apr 2009, 14:05
  #4213 (permalink)  
 
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flipster

From the findings of the BOI as forwarded to the Stn Cdrs at Aldergrove and Odiham for their comments prior to submission to AOC 1Gp.

para 16e

"The weather was suitable for the flight but would have required flight in accordance with IFR in the vicinity of the Mull of Kintyre."

para 32c

"in the forecast conditions, the icing clearance would have allowed an IMC pull-up from low level flight to Safety Altitude over the Mull of Kintyre."

para 45b

"the Rad Alt setting procedures used by the crew were a contributory factor in the accident."

para 51

" any visual contact with the Mull or Lighthouse in the prevailing weather conditions should have prompted a reduction in height and speed well below those at impact."

para 56

" The positioning of the Rad Alt bugs would have limited the crew to either a visual or a visual and audio warning at 69ft, depending on selection of the audio selector switch would could not be determined. This warning would have been too late, in the circumstances, to prevent impact with the ground."
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Old 15th Apr 2009, 15:06
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See post #4202.

In layman’s terms “We knowingly compromised the airworthiness of the aircraft and, over a long period of time, didn’t to do anything about it” - which is a failure of Duty of Care amounting to Gross Negligence.


Try reading the proceedings of the Committees, then ask MoD if the promises made by CDP were kept. Promises relating to one of the key components of Airworthiness, which is directly linked to the Safety Case or Safety Argument. Or, if you like, just accept my word that, not only were they not kept, but instructions were issued NOT to make any attempt to keep them. (I was one of those who raised eyebrows at the promise, but duly asked – again - for the necessary funding to ensure the Committee was not being misled. You know the rest).


Funny how MoD apologists don’t comment on this, despite it being simple verifiable fact, and acknowledged by MoD who continue to be happy placing these rulings in writing.
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Old 15th Apr 2009, 15:41
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Cazatou:
<<para 32c
"in the forecast conditions, the icing clearance would have allowed an IMC pull-up from low level flight to Safety Altitude over the Mull of Kintyre.">>

An important point that should have been noted by anyone in discussing the options and should have stopped the repeated waffle about the a/c not being able to climb to safe altitude.
<<para 56
" The positioning of the Rad Alt bugs would have limited the crew to either a visual or a visual and audio warning at 69ft, depending on selection of the audio selector switch would could not be determined. This warning would have been too late, in the circumstances, to prevent impact with the ground." >>

And was it not you, yourself who first pointed out the most obvious meaning of such settings as found, that the RADALT alarm being set on 69ft (the minimum?) was consistent with an imminent landing in marginal conditions?
<<para 51
" any visual contact with the Mull or Lighthouse in the prevailing weather conditions should have prompted a reduction in height and speed well below those at impact.">>

At what perceived distance? - they surely had sight of the (fuzzy) Mull for many miles; the question is, what was the stopping distance for a Chinook at cruising speed? If you are, say, intending a high speed approach to an LZ, at what perceived distance from it do you have to start pulling up in one of those (very agile) beasts? Would being mistaken by ˝ a mile or so stuff you up?
Which of the following seems more likely for this experienced crew:
a. they discarded their nav computer (by changing waypoint) when apparently unaware of how close they were to a hazard which they had no need to be anywhere near;
b. they misjudged the closing range when approaching an LZ in difficult conditions.
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Old 15th Apr 2009, 15:56
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Walter Kennedy

Please stop raising questions of the "which is more likely?" type. The only question which is relevant to the present situation is "Does anyone have any information (not speculation or opinion) which shows that without any doubt whatsoever the pilots were grossly negligent?".

Time to put up or shut up.
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Old 15th Apr 2009, 15:57
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Tecumse
However unairworthy the beast may have been, if you do the chartwork you would surely agree that it had carried them to a point closer to a hazard in the prevailing conditions than was prudent unless they had business to do so – a point where by their actions in changing the waypoint strongly suggested that there was no problem with the a/c. The only merit in the continuance of the airworthiness debate in this instance is if you think a better performing Chinook could have helped them in a desperate evasive manouevre – perhaps you may be right but if you want to clear the pilots' names you'd better be looking at what reasons they could possibly have had for going in there because if their sole objective was to transport the passengers safely to Inverness they were indeed negligent.
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Old 15th Apr 2009, 16:19
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Walter

The "merit" in the airworthiness debate is to illustrate, beyond any doubt, that the MoD failed in its Duty of Care to the aircrew and pax.

Along with, primarily, the appalling history of ZD576 in the weeks before the crash, that constitutes reasonable doubt.

These are verifiable facts, unlike the MoD's conjecture. I submit this thread needs a regular dose of these facts, if only to counter the Anti-Airworthiness and Safety stance. Especially so today, as another group of bereaved families enter a new phase of their fight against MoD's systemic failings. The similarities are lost on many, but when you get down to it Mull, Nimrod, C130 and others are very similar indeed. Just different paragraphs of the same chapter of the regulations that haven't been applied properly (to paraphrase ACM Sir Clive Loader's statement in the Nimrod report).
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Old 15th Apr 2009, 16:32
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Vertico
Over many posts, I believe that I have pointed out sufficient parameters in what is known that indicate a possible intention to land at or approach closely a known LZ on the Mull – you as experienced pilots should have at least recognised their potential relevence. If known settings and procedures are recognised by experienced pilots as being consistent with a particular activity, then such parameters are evidence of that activity.
I believe that the strategy of saying that nothing can be proven has wasted many years.
I believe that if the interested parties could identify and argue with reason and experience any extra activity that the crew was engaged in that has not been declared by the authorities then the verdict would be blown away.
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Old 15th Apr 2009, 16:37
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Thanks for that Caz and Walt,

However, from the House of Lords Inquiry

After obtaining weather reports Flight Lieutenant Tapper decided that the flight to Fort George would be a low-level sortie flying under visual flight rules (VFR) and intimated that he was not intending to fly under instrument flight rules (IFR). Indeed flying under IFR in the vicinity of the mountains to the east of Ballachulish and Fort William would not have been permitted by the icing restrictions.
and then referenced to

Instrument flight must be conducted at or above a height ("safety altitude") 1000 ft above each of the high obstacles on the intended route (Q 280). Flt Lt Tapper had calculated the safety altitudes for the latter part of the sortie as 5900 ft Mull-Corran and 5800 ft Corran-Inverness. The CA Release precluded flight in an indicated temperature below +4° C. A weather aftercast shows that this temperature would have been reached at 5000 ft; and the Sheriff calculated that the crew may well have expected to reach it much lower, at 2500 ft (determination p 120 of HL Paper 25)

so its not as simple as it sounds, is it!? In my view, because of the CA RTS, the crew would have been pre-disposed to remaining VMC below. A large piece of Gruyere....but not containing much cheese!

Certainly, the BOI report may have influenced the Reviewing Officers but since 1994/5, this fact (and more about the FADEC/DECU) have surfaced than the BOI had time to consider - which renders the BOI report and the subsequent verdict incomplete, illogical and unsafe - admittedly with hindsight.

flipster

ps Perhaps the Rad Alt settings that Walter mentions are worthy of consideration. Would anyone who operated Chinnys care to comment?

BTW Walter, Tuc is right to point out the underlying failiure of the airworthiness system as a major contributory issue. By that I mean that if the crew had indeed been flying an aircraft that did not have the icing limitation, then maybe they might have have 'punched out' of low-level prior to the turning point (or LZ if you like). However, as BD points out we don't know what the crew could see from the cockpit, nor what was said, discussed or actioned.....almost everything else is guesswork and does not form the legal basis for 'with no doubt whatsoever'.

Last edited by flipster; 15th Apr 2009 at 17:03.
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