Lightning Down At FAOB

[DucatiST4]

Its likely that whoever wrote the report probably doesn't have English as their first language.

[DucatiST4]

Thunder City ceased trading nearly two years ago now. That article relates to the interim CAA report released in 2010.

[Hammer Head Too]

I would be difficult to imagine that there is still a "Thunder City Management" in any meaningful form and whilst the way the report is presented is poor the underlying failings seem very apparent... only time will tell

[Agaricus bisporus]

Well, having read that incredible report I have to say its a damn good thing Thunder City have closed down. A ,more incompetent, irresponsible cowboy outfit is hard to imagine. In 30 years of aviation I don't recall seeing a report even five percent as damning as that one. Simply beyond belief that multiple criminal cases haven't resulted, so probably equally damning on the "regulating" authority.

As the French say, "Quel bordel!"

[Rigga]

I never learned RAf writing and decorum in letters and memo's and I have often been frustrated over the problem of many 'people' reading something of potentially massive importance and then completely disregarding the points made to make petty remarks on grammar and spelling?

Believe it or not, more than 99.999% of the world does not know what is in the RAF/MOD manual of writing stuff and has not passed a UK based GCSE A level in English - but still manage to get into jobs where report writing is needed.

[Waddo Plumber]

I'm sorry you feel that way, Rigga, but it's not the use of language, but the lack of a coherent arguement that is the problem with the report. Don't get me wrong, I think TC comes out very badly, but the report is a string of separate issues, mentioned, but not drawn together in a coherent facts, conclusions, recommendations fashion. Here's the nub, what specific issue caused the accident: ejection seat, canopy, fuel leak, double hyd failure, pilot?

[Tableview]

what specific issue caused the accident: ejection seat, canopy, fuel leak, double hyd failure, pilot?

We all know that there is rarely, if ever, one specific 'issue' (I hate the misuse of that word) that causes an accident, it's a combination of circumstances.

Ejection seat : That might have caused the tragic death of the pilot but it wouldn't have caused the accident.

[flipflopman RB199]

I find myself squarely behind Waddo Plumber.

I'm not one either for the 'grammar police' and freely admit to the odd use of the unwanted comma or extra dots in an ellipsis, however, there is no shame whatsoever in wishing for an official report to be written clearly, and in plain unambiguous English.

I too found the accident report to be a little odd in the way it didn't actually try to identify the physical root cause of the accident, merely picking up on all of the other, admittedly shocking, failures along the way. Do we actually know what failed, or was likely to have failed in order to cause this crash? It appears to have been lost along the way.

I personally think that in this instance, you're having a whine rather than making a point Rigga...


Flipflopman

[Waddo Plumber]

According to the report, the cause was hyd failure. That's my point, not the lack of literacy, but the lack of rigour. it's like saying someone died because their heart stopped. The primary cause was a fuel fire. There was an organisational failure which didn't recognise the serious fuel leak problems which are well documented elsewhere. When we had to put a diverted Lightning in my (Phantom) ASF hangar, my Lightning experienced WO rightly grabbed every available drip tray to put under it. The report does not pull these strands together.

All the ancillary points about lifex carts seats etc, are well made, but don't form part of the determination of the cause of the accident. However, they do indicate the organisation was inadequate.

[flipflopman RB199]

I suppose that in a way, that's made my point too, Waddo Plumber.

My initial intention was to say that in your average AAIB or RAF accident report, the physical root cause is always sought, as in..

"The nozzle lever was inadvertently moved to ...."

Or...

"At which time the main fuel feed to the engine fractured.."

As opposed to the meandering ramble that took place in this instance. We know that a double hyd failure caused the aircraft to crash, and we can all see how that might have taken place, but the report goes nowhere near HOW it may have taken place as regards which component was likely to have failed, and how that failure led to the other sequences involved

[Al R]

Waddo Plumber,

In light of XV230 (especially) and of your WO's actions, why did we allow them to fly at all if we were aware of the risks and even joked about them (if its not leaking, it must be empty, etc) - different risk culture?

[John Farley]

different risk culture?

In the 20th century when it came to military capabilities I believe there was an overiding need culture that determined whether aircraft were used. I would suggest that risk only comes into the mix when you doubt the real need.

[Agaricus bisporus]

Agree completely with the incomplete logic of the report, leaving aside its tortured english which serves to call into question the competence of the investigation. How can you imagine an investigation was carried out properly if the report was written in an inaccurate and incoherent manner? It may not be an accurate assumption, but like posts here with greengrocers apostrophes, bad spelling and random capitalisation it gives the impression of illiteracy and therefore lack of authority or worse. And that isn't suitable in an official report.

As to the content, I too wondered when the conclusions were to appear and they never did. The repeated tales of substantial fuel leaks was never quantified and unless I missed it - I only skimmed the report - I never saw any indication of where these severe leaks were emanating from which seemed bizarre.

The ultimate "cause" may well have been "hydraulic failure" but the intense fire that caused that seemed glossed over to me, and the causes of that barely mentioned let alone investigated. Surely that was the real cause of the accident? There seemed to me to be a possible connection between the missing drag chute and its mechanical problems in the afterburner bay where it is located that were passed by too.

If I were writing a report for the "authority" that had overseen Thunder City's operation I'd have fudged the report to the point of incomprehensibility too...out of sheer self-preservation.

[Tableview]

but like posts here with greengrocers apostrophes,

ahem, or with missing apostrophes!

Back to topic, one has to bear in mind that the standard of English literacy in SA has dropped since 1994 and the report may well have been drafted by engineers and then given to others to edit and produce the final copy. Any of those people might not have been native English speakers (SA has 11 official languages although only 3 are significant in the Western Cape).

I read the report and whilst I'm not an engineer I do have some technical knowledge and this seems a classic case of multiple factors, or 'holes in the cheese lining up.'

[John Farley]

I have another view about the report.

While I accept all the comments about the English I was extremely impressed with an organistion that went into so much technical detail during the investigation. Given that there was a great deal of RAF 'history' about fires in Lightning backends (as well as canopy issues preventing ejection), the investigators could almost have been excused if they had done a few paragraphs referring to the similarity with the past and left it at that.

Apart from the English I don't think the content can really be criticised. Mind you perhaps one does need to study the very lengthy and detailed report to hold that view.

[Waddo Plumber]

The link at post #61 is to the full report. I have no knowledge or view on how good or bad the SA CAA's investigation ability is, and the fluency of English is probably a red herring. I'm certain you've read many more accident reports than I have, John, but I've read quite a few as an interested party, and helped write one or two. I feel fairly sure this one would not have passed muster in the RAF. As for the investigation, I was privileged to work with the AAIB on a Tornado GR3 crash at Mamby, and in my opinion, their analysis was far superior to this, which seems to be an assembly of information without any real attempt at synthesis into a coherent explanation. Perhaps the following statement near the front of the report explains this:

"In terms of Regulation 12.03.1 of the Civil Aviation Regulations (1997) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability."

[John Farley]

Waddo

I do take your points.

However my view is this was not a typical accident where at first we all wondered what happened (and why) in order that we all learn from it. In other words an accident that required analysis for the benefit of aviation.

I feel this was history repeating itself and a very type related event that needed no explanation. Importantly there are no more of the type operating - so no lessons to pass on. Not all accidents are like that. That is why I would not compare it with other reports from the past that were written about some very puzzling accidents.

I guess all I am saying is nothing more profound than I don't see any need for all accident reports to meet a common standard.

[Chugalug2]

JF:

I guess all I am saying is nothing more profound than I don't see any need for all accident reports to meet a common standard.

Your point is well made and I would agree that the standard of the report is less important than its honest search for the truth. In that regard those decrying this report, as not meeting the standards of RAF BoI's, should remember the advice given to those who live in glasshouses.
In this forum alone certain RAF fatal accident inquiries have been shown to have been at best partial in their search for causes and at worst guilty of blatantly ignoring known type deficiencies in favour of once again finding the crew responsible, even to the point of labelling them negligent with no evidence to support that finding. I know that I am about to be brought to task by being reminded that with Mull it was the RO's rather than the BoI that found thus. That's a bit like being told by Tesco customer services that they would happily refund you the money but Head Office won't allow it!
The RAF had the accident. The RAF held the Inquiry. The RAF found the pilots Grossly Negligent. The stain on its honour will persist while it still sits on the evidence of Gross Unairworthiness that its BoI would not consider 17 years ago.
Self Regulation doesn't Work and in Aviation it Kills!
(enough grocers and capitals in that lot for you Agaricus?)

[M609]

Re:

Perhaps the following statement near the front of the report explains this:

"In terms of Regulation 12.03.1 of the Civil Aviation Regulations (1997) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability."

I think you will find that it is normal for investigation branches performing ICAO Annex 13 investigations all over the world.

Norway:

The Accident Investigation Board has compiled this report for the sole purpose of improving flight safety. The object of any investigation is to identify faults or discrepancies which may endanger flight safety, whether or not these are causal factors in the accident, and to make safety recommendations. It is not the Board’s task to apportion blame or liability. Use of this report for any other purpose than for flight safety should be avoided.

UK:

The sole objective of the investigation of an accident or incident under these Regulations
shall be the prevention of accidents and incidents. It shall not be the purpose of such an
investigation to apportion blame or liability

Sweden (Both Civ and MIL)

SHK investigates accidents and incidents with regard to safety. The
sole objective of the investigations is the prevention of similar occurrences in the future. It is not the purpose of this activity to apportion blame or liability.

[Waddo Plumber]

John, you're probably right, in that the technical investigation wouldn't assist those running a fleet of aircraft - the normal outcome, and the "legal liability" exclusion (I didn't think it was a SA only concept, M609) as I said, probably explains the presentation of a catalogue of organisational failures, rather than a discussion. Chugalug, I meant accident investigations, and specifically AAIB ones, not RAF boards of enquiry, but if I remember, the Kintyre board produced a report which was reasonable and competent, it was what happened to it afterwards that caused the furore.