Sea King Accident 22 March 2003; Collision between XV650 and XV704

[Mick Strigg]

Crab,

Perhaps the "Minds made up" brigade live in the "HISLs were to blame" camp!

[bast0n]

Flipster

Your posts have been very enlightening - thank you.

I agree with the view that apportioning blame achieves almost nothing. The desire to find out what happened - as far as is possible - is so much more productive, specially if we can all learn from the evidence, and dare I say it, conjecture.

PS Flipster - the Wessex FAW 1 did a good job, and over a pub as well..........

[Mick Smith]

Crab

Two's in - I tried to get the same points across on the previous threads but the 'HISLs were to blame' camp won't see that argument.

Mick Strigg

Crab,
Perhaps the "Minds made up" brigade live in the "HISLs were to blame" camp!

I am not aware of a "HISLs were to blame camp".

Any chance that either of you might answer the questions, rather than throwing pathetic little darts at the board?

[nigegilb]

Mick Sm, no chance of that, you are p****ing in the wind.

Interestingly I was chatting with an ex RN Sea King pilot the other day, he was saying that in his time the RNFSAIC had "allegedly", on occasion, been known to protect the careers of high flying officers with their "helpful" contributions to BoIs when, how can one say it, when one had clearly fcuked up somewhat.

I guess it has always gone on to some extent, but I wouldn't be in a rush to place the findings of RNSAIC, or members of the Admiralty above those from a BoI.

What interested me from yesterday's article was the complete lack of comment from the MoD. Most unusual, I suggest we keep pushing on a half open door.

Until the children answer your excellent questions Mick Sm, I also suggest we ignore them.

[Pheasant]

in his time the RNFSAIC had "allegedly", on occasion, been known to protect the careers of high flying officers with their "helpful" contributions to BoIs when, how can one say it, when one had clearly fcuked up somewhat.

Under the RN system of BOIs/Tech Investigations I simply cannot see this sort of thing happening. In the case of the current discussion if the evidence of "covered up" HISLs issues had been available to the BOI/AI guys it would have been included in their reports. The FAA has absolutely no interest in anything but the facts and truth so that accidents can be understood and lessons identified and learned.

[nigegilb]

Pheasant, perhaps you can cast some light as to why neither BoI or RNFSAIC appeared to have read any of the reports concerning the Safety Engineer's refusal to grant read across for the HISL's to be installed on SK MK7?

And his resolute position to insist on functional safety trials?

Or the refusal of Westland to have anything to do with the outrageous breach of airworthiness regulations?

We are all ears?

[Mick Smith]

Nige,
if the RNFSAIC appears not to have read the documentation re the engineer's refusal to read across, isnt it more likely that it simply wasnt told about it either? Or am I missing something?

[Mick Smith]

This is a message to all the members of what might be called the "you dont care about the facts" camp. Pprune is full of attacks on hacks for not caring about the facts. I have asked repeatedly about the facts. You havent answered the questions. You insist these facts exist and are confirmed facts without ever explaining the authority for gainsaying the BoI. So I am going to give you yet another chance to answer the following questions:

You and others used the last thread to dismiss this as an issue, also dismissing the BoI's assessment that it was to all intents and purposes a head-on collision.

1) Was this because - as you seem to suggest - the BoI's assessment had been overturned by another body, and did that body make a written report to that effect?

2) Since that report would have been overturning a key assessment of a document of public record, was it also made a public record?

3) Was the BoI told that, in May 2000, the engineer managing the Sea King Mk7 programme had refused to agree "read across" of the HISL installation from a previous mark because there was no evidence of any trials or tests, but was overruled by a senior official without the necessary qualifications to make that judgement?

4) Was the BoI told that the design authority had declined to back the replacement of the anti-collision lights with HISL?

5) Why was the inquest not told about the fully documented "facts" in questions 3 and 4?

It would be really good if someone had the balls to actually answer the questions.

[dervish]

I posted to the old thread that it was well known at the time the IPT denied any knowledge of HISL when an investigation was launched into the Board’s statement that the installation was unfit for purpose.


This Parliamentary answer was also posted;

Mr. Bob Ainsworth [holding answer 26 March 2008]: High Intensity Strobe Lighting (HISL) was progressively fitted to all Marks of the UK MOD Sea King fleet between 1983 and 2001:

Mark 3—Rear Light introduced in 1983; Forward Light introduced in 1985.
Mark 3a—1996 (fitted when the aircraft was introduced to service).
Mark 2—1997 (all Mark 2 aircraft have subsequently been converted to the Mark 7 standard).
Mark 4—2001
Mark 5—1998
Mark 6—1998
Mark 7—2000

Could someone explain the MoD system which permits seven marks of Seaking to be fitted with a system since 1983, yet the IPT can claim ignorance 21 years later? Is this related to the Gray and Nimrod reports which both emphasize the MoD airworthiness system is in disarray?

[nigegilb]

Thanks Dervish, most useful. This is being looked into at a legal level at the moment.

[nunquamparatus]

WTFO?

Guys,

Whilst I am aware that for some (namely the families of the aviators who perished) this is still and will ever remain an incredibly painful subject. I knew all of the 849 Sqdn guys (standfast Lt Adams USN) and their death hit me, and many other that knew them, extremely hard. Before people start using Haddon-Cave as a drum to beat and resurrect this incident and attack UK MoD to, in some cathartic way, find someone to blame, let's re-cap:

1. The accident occured at night, at Low Level (due to Airspace Control Measures - ie hard-ceiling above) in an extremely pressurised environment.

2. The ATCO made the correct call, in sufficient time to both aircraft - on an unbeliveably busy circuit. The two SKs collided despite this call.

Would NVG and/or different lighting have made a difference? Perhaps, maybe probably. Would the ATCO have done something made more calls if he knew the aircraft were going to collide? OF COURSE - WOULDN'T WE ALL. But there were no NVG for the ASAC community, they were not trained. It was not deemed to be a requirement at the time. We can all find reasons why this should not have happened - but it comes down to this. It was a tragic accident - utterly awful and the loss of life was and will always be unbearable to those who mourn them. Everything that happened after the moment of impact can now be questioned in hindsight - up to the moment the two aircraft collided, the pilots were in charge of their destiny (to a degree I accept).

Before I am criticised for, in some way, defending the UK MoD policy of ill-equipping our forces - don't go there. I lost friends - people I lived with, spent quality time with, flew with. DO NOT think I wouldn't change anything to have them all back. Aviation, especially military aviation, is a dangerous business. Aircrew operate near and sometimes beyond the edge of the envelope of safety, dependent upon operational necessity. When we lose people through accidents it is only right that we look inwards and try to ensure that it never happens again, for whatever reason. But you cannot change what has happened and to argue that HISL or NVG would have stopped this happening is an exercise in futility and an insult to the seven men who perished on that night, going out to do their job - a job they all signed up for - despite knowing the inherent risks.

[flipster]

Nunc

An emotive post and many here respect and sympathise with you and, of course, the families.

Having said that, would it be possible for you to clarify your position wrt

Would NVG and/or different lighting have made a difference? Perhaps, maybe probably.

and

to argue that HISL or NVG would have stopped this happening is an exercise in futility and an insult....

Of course nothing is guaranteed, but to me, the 2 phrases are not mutally compatible, I'm afraid.

For the record, I do happen to believe that effective ACL/HISLs would have prevented this accident - along with a number of other actions, of course (eg Radar Vectors/Alt split etc) and HISLs are not the b-all and end-all - but they do highlight failings in MoD that remain uncorrected to this day.

Nonetheless, I fully agree that this was 'an accident' and a very sad one indeed. However, it can be argued that there is no such thing a 'just an accident' - just unfoseen and unpredicted events - either through things such as lack of information, use of that information or even complacency (and not necessarily by the final operators).

Unfortunately, the fact that there are laid down regulations in the Defence Standards and JSPs indicates that such accidents may have happened before - hence why switching off lights was/is frowned upon by the Def Stans. So, this accident could be construed as a 'predictable outcome' of not having good enough external lighting.

However, the intent of most people here to is prevent recurrence (I would hope) - in my case, to help ensure the airworthiness system (that was meant to prevent such 'predictable' accidents) is, once again, robustly enforced. Indoubtedly, doing this will go some way to preventing recurrence. Having lost a number of colleagues to 'preventable' accidents, I don't believe that aiming to stop any replay of those losses, is in way an insult to the fallen. The less greiving families, the better, I hope you would agree?

sympathetically,

flipster

[Mick Smith]

Nunc
Thanks for your very moving post. As someone else out there has already said, there are two issues here, one of which you deal with.

I certainly dont blame anyone out there that night for what happened, nor would I ever seek to.

The issue that is driving my questions is not ambiguous or difficult to understand fully, as the moments that led up to the collision will inevitably remain. The issue is very clear.

It is the process in which one man sought to ensure that the regulations applying to airworthiness with regard to the fitting of HISL to the Mk7 were properly followed, and was repeatedly overruled by someone who did not have the qualifications to do so.

The documentation relating to that was not given to the board of inquiry and it was not given to the inquest. That first act breached service rules. The second was illegal. All the evidence suggests the information was withheld deliberately, and not just by one person, by a number of people acting in concert.

I'm not trying to blame anyone for the collision. I am blaming someone for forcing through a piece of equipment that was not properly tested and trialled, and a number of people for illegally seeking to prevent evidence of that action being made available to the bodies trying to work out what happened that night.

It is of course true that this raises legitimate questions over the effect on the collision. If an official body, working on expert testimony decides that the failure to carry out the proper airworthiness procedures could not have had any impact, so be it.

But both the board of inquiry and the inquest should have been given that information so they could make that judgement and if they had been given the information, and used it in coming to their decisions, whatever they decided, I suspect this thread would not exist.

I'm sorry if it inevitably brings back bad memories for those relatives who do not want to revisit the situation or the colleagues of the crews.

[nigegilb]

Nunc, I too am sorry for your loss.

Mick Smith's post and Flip's highlight what went so badly wrong regarding airworthiness and what is hoped to be achieved in the bigger picture by highlighting Sea King mid-air collision now.

If I was the Coroner I would be hopping mad if there was evidence from a prime witness of;

a. Collusion

b. Willful failure to implement airworthiness regulations.

At the very least, I would move to ensure that I heard the new evidence from the witness. The only way this can happen is to re-convene either the BoI then the Inquest, or simply re-convene the Inquest.

Many of us have conflicting views on this collision. The most important views are those of the Coroner and the BoI. If they are going to be prevented from seeing this this evidence then one can state categorically that justice will not have seen to have been done. And the families might be condemned to live with the element of blame lingering in the air unnecessarily.

I fully expect to see some developments in the coming days and weeks.

[tucumseh]

Flipster #17

That is what MoD and Fleet have done....mainly - except that they decided, for reasons best known unto themselves, that the SK7 HISL was airworthy - however, they DID rescind the Service Deviation - mea culpa? Sadly, as I said, the light itself is probably ok but its concept of use is plainly not compliant with the def stan - this is in black and white and the BoI were quite right to say so. Why this was not followed up in the Inquest (and by the BoI) owes more to disingenuity and side-stepping by MoD; perhaps HM Coroner and the families may even have been purposefully misled?

I think this is a significant area given the similarities it highlights with the Mull of Kintyre accident; that staffs at a certain level are allowed to stand as judge and jury in their own case.

To summarise the above posts;

The BoI criticised the HISL installation design (a Naval Service Modification, not an Aircraft Design Authority Modification) and the way crews were instructed in its use (the Service Deviation).

2 years later the RNFSAIC contradicted parts of the BoI report, partly in disagreement and partly because they used forensic tools to properly analyse the mission tape. This last is critical because it completely alters the tone of the BoI report which, we now know, wrongly infers mild panic in the cockpits.

Both reports went up to FLEET who, along with the IPT, decided the HISL design was ok (note, HISL units, not the HISL installation design and use). The significance here, in addition to Flip’s “side-stepping”, is that the BoI criticised functional safety (although didn’t use those words), but FLEET and the IPT only commented on the physical safety of the discrete HISL unit.

It seems clear the trial conducted by the BoI (whose actions I suggest were exemplary) was almost certainly the only comprehensive trial conducted thus far to assess the functional safety of a HISL installation.


Whether or not this was deliberately disingenuous is not for me to say, but it is clearly in the interests of both that the confusion be perpetuated and the real issues hidden – as it seems they were from both the BoI and Coroner. Why? Possibly because (a) the IPT is responsible for tasking and approving the HISL installation design, and (b) FLEET are the signatory to Category 1 Service Deviations?

This conflict of interests should be declared, although I confess I don’t know enough to say who would resolve the conflict. But it does seem odd that the BoI did not reconvene to assess the RNFSAIC report. Anyone reading just their report gets entirely the wrong picture.

[Chugalug2]

Nunquamparatus, I too am sorry for your loss and the pain that revisiting it causes you. Like others have said the doing of it is not simply gratuitous. The purpose of Airworthiness Regulation and Accident Investigation is to avoid future avoidable accidents and the needless loss of life. Your sentiments, or similar, were expressed by ex colleagues of those who perished in the Hercules, the Nimrod and the Chinook tragedies. The Military Aviation world is a surprisingly close knit one, and like any family it resents intrusions into its private grief. Like other ex-serving members I have experienced that and can empathise with your feelings. But serving or retired we are or were all professionals and it is as professionals that we post here for a purpose, that is to avoid future avoidable accidents. We cannot do that if Airworthiness Regulations are not properly enforced or Aircraft Accidents are not effectively Investigated.
You posted:

The ATCO made the correct call, in sufficient time to both aircraft - on an unbeliveably busy circuit. The two SKs collided despite this call.

I had not realised that the frequency being used was incredibly busy. Does this not make the claim that it was not being recorded on Ark Royal all the more strange, indeed as a mere ex light blue I might say incredible? If you had told me that a major fleet unit did not routinely record and preserve as a matter of course all transmissions made in the launching and recovery of its aircraft I would find it unbelievable. Upon reflection I still do. Am I wrong? By the way, when you say that the ATCO "made the correct call" how do you know? How does anyone know if the recording does not exist? I'm not saying he didn't but simply asking; how do we know?

[scottishbeefer]

Sandy?

My chats with the other 849 boys who were there that night led me to believe the air was carrying a lot of sand that night. In those conditions (like being in cloud) it don't matter none if you're on anti-cols/HISLs or whatever, the reflection from the sand caused by the lower light is at best distracting, at worst blinding - so you're likely to turn 'em off. Hence the possibility of bumping into your oppo increases a lot. I'd have done the same I hasten to add.

At night I routinely turn off my lower strobe (especially on NVG) if it's wet/cloudy, as the risk/benefit of distraction/collision vs easier flying usually weighs up in favour of selecting "OFF".

You can argue about which lighting set-up is better/airworthy until the cows come home to roost, but the simple fact is, most of us in that position would have had a light off. As eluded to in earlier posts, this was one of those tragic accidents - but no more than that. I'm certain the RN have examined how to launch/recover cabs with slightly more coordination (although I'm not aware of the actual outcome there) but the bottom line is that looking at lighting is a hiding to nothing here.

SB

[tucumseh]

You can argue about which lighting set-up is better/airworthy until the cows come home to roost, but the simple fact is, most of us in that position would have had a light off. As eluded to in earlier posts, this was one of those tragic accidents - but no more than that.

As you say, it seems obvious there are occasions when the light(s) must be off. The point made by the BoI was that, because other defences in depth (against the risk of collision) were missing, the final defence (lights) became even more crucial. This was exacerbated by the remaining light being "dim" and "wooded", leading to disorientation. These are the BoI's words, not mine.


If the BoI are to be criticised it is that they don't spell out all these issues, or explore the background. They came to the logical conclusion that the HISL installation, as fitted and used within that aircraft and system of systems, was unfit for purpose. Compare their trials results with the requirements of Def Stan 00-970 (which they quoted verbatim), and they could come to no other conclsuion. Perhaps, if the other defences had been available, they would not have been so hard on HISL, but the fact remains they were missing and that should have flagged serious problems in the Safety Case (which one assumes was updated when HISL was introduced into the AEW Mk2 in 1997?).

I see this problem all the time in procurement. In the same way the report is written with a target audience in mind, whom the Board assume understand implicitly the background detail, so too are airworthiness standards written for the use of staff who understand each nuance from long experience. But, that experience, competence and corporate knowledge (all crucial components of airworthiness) are missing (see Gray and Haddon-Cave), the position today being inexperienced staffs are taught Def Stans are not mandatory; so they routinely ignore them. The problem is, they are not taught the next sentence; that if you ignore one standard you MUST invoke another.

So, when you say;

I'm certain the RN have examined how to launch/recover cabs with slightly more coordination.

is this not an implicit acknowledgment that the regulations governing interoperability and systems of systems integration were, it appears, not followed? (I'm sure you are correct!). It is an obvious area to investigate on a programme that changed the designation to ASaC Mk7. One obvious reason for doing that is change of use and function, so it would make sense to investigate the impact of that change with those who use it. For example, ships, to ensure their procedures are still suitable for the new aircraft and the way it must operate. The regulations demand it. The BoI does explore this, but much is redacted. But their conclusions make it clear that there were serious failings in this area.


So, in answer to a previous question, yes, in my opinion this case is entirely linked to the Gray and Haddon-Cave reports.

[nigegilb]

"Incidentally there is also a dimmer unit for the Dual Colour Strobe Light which allows it to run at lower intensity for exactly this type of scenario but I am not aware that the MOD ever bought any except for air to air refueling aircraft so that the lower strobe did not blind the inbound pilot."

[Mick Smith]

I'm not clear who that's a quote from Nige?