Lightning Down At FAOB

[Chugalug2]

Waddo:

..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.

Well it causes me furore! The type was very recently in RAF service and had already acquired an unfavourable reputation within Squadron crewrooms.
The Aldergrove detachment commander earnestly requested that an HC1 be substituted for the ill-fated VIP pax task. He was turned down.
Boscombe Down were so perturbed by the uncommanded power ups/ downs and shut-downs caused by the FADEC's bad code that they stopped flying their aircraft and requested the RAF do the same. They didn't.
The Odiham Station Test Pilot had many similar alarming experiences with the FADECs and also UFCMs in 1,2 or all 3 axis. None of this came out in the BoI, and when Sqn Ldr Burke (The RAF Odiham TP) asked that he might present himself to the BoI as a witness he was told to keep quiet and wait to be called. He wasn't.
Competent? Whatever you say.

[Waddo Plumber]

Chugalug, I understand your frustration. However, as I said, I wasn't talking about RAF BoIs. Can I suggest that we don't derail this thread into another Kintyre discussion.

[Chugalug2]

On one thing we seem to be in agreement at least, Waddo. Your differentiation between Air Accident Investigations and RAF BoI's is well made and one that I fully concur with.
As to turning this thread into a Kintyre discussion, that was never my intention. It was being proposed that RAF BoIs were/are inherently superior compared to the SA one under discussion. I have attempted to propose otherwise. Indeed other threads on this forum have not been solely "Kintyre discussions" but have revealed that there is something fundamentally corrupt in the UK Military Air Accident Investigation system, even under the supposedly "independent" MAAIB. Until the MAAIB is truly independent of the MOD and the MAA, the investigation of military air accidents remains unreliable to say the least. Hence the inappropriateness of slagging off other nations' accident reports, I would contend.

[Rigga]

Thank you for your responses - and yes, I was griping about the apostrophe police. But maybe thats because I did not not realise that the report was "inconclusive".

I had apparently missed that gem because I clearly saw the root cause of the incident: The lack of capable, qualified and competent management and staff exacerbated by the lack of adequate NAA oversight.

What you guys are now alluding to are the symptoms from that cause - why did the plane stop working.

[Milo Minderbinder]

Surely this report has achieved what it set out to do: ensured that those involved in the company are unlikely to be allowed to work in a similar venture again.
What it hasn't done is explain the circumstances by which the regulatory authorities failed to notice the shortcomings and shut them down, Or even why the South African authorities felt they knew better than the CAA, and approved the operation. Was this due to naivety, incompetence, or some kind of financial inducement?
While the report has thoroughly explained the shortcomings of the company, the shortcomings of the authorities are not even considered

[Navaleye]

I'm not qualified to discuss either of these reports and will not do so. I have seen several BoI's in action, mostly Navy. I'm reminded of the line from "Yes Prime Minister" which is "you naver have an an inquiry until you know what the outcome is going to be." I think there is a lot of truth in that.

[jumpseater]

Or even why the South African authorities felt they knew better than the CAA, and approved the operation. Was this die to naivety, incompetence, or some kind of financial inducement?

Its sort of covered in 1.6.5.p12 of the report. The NDOT determined the technology was 'relatively simple technology' and they appear to be refering to aircraft systems rather than the military weapons/avionics/radar. No doubt a good argument was made by the operator that because the 'military' sytems were removed that the aircraft systems could be maintained adequately. What doesn't seem to have been appreciated, or made apparent was the difficulty of maintaining these systems.

At section 2.8 the report covers the change in the South African regulatory authorities which as it was concurrent with the registration and initial set up of TC lightning operations, could have aligned more than a few more holes in the cheese.

[Waddo Plumber]

Just to be clear, the TC Lightning was a civil aircraft and a civil enquiry produced a civil report. Intoducing any connection to RAF BoIs is inappropriate. As for the technical enquiry, can anyone tell me from the report what was the root, not consequential, cause of the ejection sequence failing?

[porch monkey]

My reading was a failure of the ferrule connecting the left canopy release actuator to the canopy jettison system (piping), thereby not releasing the canopy. If the canopy does not release, the seats can't fire, by design. I stand to be corrected. The reason for the ferrule failure tho, was not determined.

[tucumseh]

but the report is a string of separate issues, mentioned, but not drawn together in a coherent facts, conclusions, recommendations fashion.

Not unlike Haddon-Cave’s, except he deliberately omitted key, verifiable facts.




Navaleye - you got it right. The Haddon-Cave report was, I believe, pre-determined. I said so (here) long before he reported and I have not change my mind. He omitted the Organisational Faults and blamed the wrong people; thus misdirecting the efforts of the MAA for ever more.





John Farley

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.

I think this may be the first time I disagree with you. MoD UK regulations require the possibility of “Organisational Fault” to be addressed (as alluded to above). That makes the fact the type is no longer in service irrelevant.

What is wrong with the UK system is that the same “organisation” that may be at “fault” is the same one allowed to judge its own case. That is an even higher level Organisational Fault.





Chug is right to cite Mull of Kintyre. There can be no greater organisational fault than the officer responsible for signing the Master Airworthiness Reference doing so, while omitting the rather important facts that (a) the new fuel computers were functionally unsafe (in fact, "positively dangerous") and (b) operational flight was not authorised because there was no clearance whatsoever to use any Nav or Comms equipment. There are calls above for legal action - why not start with MoK?





There is much justified criticism here about this Lightning case, but the great irony is that for 25 years the MoD have deserved far worse. There is no evidence presented that orders were issued in SA to completely ignore their airworthiness regulations and make false declarations that they had been adhered to. Yet that is precisely what MoD staffs were ordered to do from 1988 to 2009 (in my experience). That is a awful lot of people who have been "trained" under such a regime.

[Waddo Plumber]

Porch Monkey, that's as far as I got too. Tecumseh, whilst it might be "right" to mention the Mull because both have roots in serious mismanagement, I think it would be a shame to divert a perfectly good discussion about a civil SA accident into yet another thread about MoD/RAF shortcomings since 1988. Nothing about the latter affected the former.

[John Farley]

tucumseh

I think this may be the first time I disagree with you. MoD UK regulations require the possibility of “Organisational Fault” to be addressed

I did not mention MOD and I don't see how they can be connected to a discussion about this accident or its report. If my post gave such an impression I am sorry.

[tucumseh]

Waddo

I stayed out of this one until MoD was mentioned. I posted in reply to other comments about MoD's rather tainted past. I won't bother reading the thread again, but did you challenge everyone else?



John

No apologies necessary. I was making a point that is too often overlooked - the obligation on BoI's to address Organisational Fault. Someone praised the MoK BoI but, as published, it is an appalling abrogation of this responsibility. This Organisational Fault served to hide the systemic failings (deliberately so, given how often it has happened and been pointed out). MoD like to compartmentalise such reports and simply do not address the fact that many airworthiness components are centralised functions; so if there is a problem on one aircraft, there will be a pan-MoD problem. It is a general point applicable world-wide, especially as very many countries follow our regulatory lead.



Regards

[PPRuNe Pop]

I am not supposed to have an opinion - or to participate. However, on this occasion, having read this dreadful report I feel justified in making the following point - it is relevant.

I was told, many years ago when one of my aircraft (C404) crashed, the CAA were quick to tell me after the incident that this was yet another example of 'accidents never just happen, they are caused.'

I think this is probably a classic example and a very bad and sad one.

PPP

[Waddo Plumber]

Sorry, Tecumseh, you've lost me there. I ddn't think I was challenging anyone- you or Chugalug, just pointing out that I didn't think a divergence into an MoD debate added anything to a story about a South African civil matter. I recognise others may feel differently.

What is true is that I've come round to John Farley's point. They investigated the engineering cause of the crash reasonably well, but only catalogued the organisational issues, because their ToRs required them not to get involved in legal liability - which precluded a discussion on management.

[walbut]

I do not know the date on which the final accident report was published, nor do I know if any subsequent limitations or corrective actions were placed on Thunder City or the remnants of their operation. However it is not long since they flew one of their Buccaneers for the first time since the Lightning accident. I do not know any great detail of the Lightning systems but I am quite familiar with the Buccaneer's and I would have thought it would be considered of comparable complexity and risk. While it did not have the Lightning's propensity to catch fire, I would not have expected the operators to be allowed to continue their flight operations with such an aircraft, even if they are not in a passenger carrying role. Does anyone know if the South African authorities are still allowing this particular 'warbird' operation to continue in some shape or form despite the findings of the Lightning investigation?

[Chugalug2]

Waddo:

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.

Waddo, you were one of the first to draw comparisons with RAF BoI reports, before tuc or I had even posted. It was very much with the supposed superiority of their reports versus this one that prompted me to post to the contrary. Now you say that this is a civilian accident thread alone (posted on a Military forum!). Pots and kettles?
Oh, in case it would appear that I am by implication criticising the AAIB, I included your reference to them merely to point out that when they are allowed by a BoI to investigate a military accident fully, they do indeed do as you state. The problem is that often they are not so allowed, then of course they cannot do so. I have one particular military fatal accident in mind, but better not mention it, given your sensitivity to it above.

[tucumseh]

Waddo, sorry my turn to be lost.

You said the MoK BoI was reasonable and competent. The published report was grossly incompetent (how on earth do you miss the fact the aircraft was not airworthy, a fact even admitted by Wratten a few weeks after the crash?), but the detail I don't know is whether or not the 3-man BoI criticised the "organisation" in an early draft. We know the ROs sent it back to them a number of times. Given what we know, my opinion is the "organisation" protected itself (that is, Wratten and Day protected Graydon, Bagnall and Alcock) by not allowing criticism of itself, so blamed the crew. By no means the only time.

I'm afraid I cannot agree with the concept of failing to address Organisational Fault just because there is no other aircraft of that type in the fleet. If you study the systemic failures on nearly every accident discussed here (e.g. Chinook, Hercules, Nimrod, Sea King, Tornado) the majority of contributory causes could have been avoided by application of core, centralised functions in the organisation. In each case, all failures were notified well in advance - the failure to correct them is an Organisational Fault if ever there was. This principle applies regardless of the operator's country of origin.


I notice the operator has called the Lightning report a pack of lies. If true, another time honoured tradition that characterises the five UK examples above! There is a lot of harsh criticism here of what happened in this case; on the face of it, entirely justified. What was perpetrated by MoD was infinitely worse and I find it puzzling (but entirely consistent) that so few make the same observations about events closer to home.

[Waddo Plumber]

Tecumseh, I didn't introduce the topic of the Mull of Kintyre, Chugalug did that, but to help this thread get back on track, I'll take back any comment I made about that BoI's competence or otherwise, which obviously derailed the discussion about TC, while not adding anything. I'm not going to edit my post, otherwise it makes subsequent posts look odd.

So, back to TC. While I agree with your second point about the failure to address organisational fault, because that reads across to all TCs aircraft types, the SA CAA ToRs said ""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." and, as M609 pointed out yesterday, this is normal for investigation branches performing ICAO Annex 13 investigations all over the world.

[Easy Street]

In this specific Lightning report, clear failings are identified in the regulation and inspection of the TC operation by the South African aviation authorities. To that end, the report should be making recommendations along the lines of "the certification requirements for ex-military aircraft should be reviewed", etc etc, which would be helping to prevent future accidents.

The fact that the Lightnings are no longer flying is irrelevant to this aspect of the inquiry, and to that end I disagree with JF as well.