Pilot error 'led to Puma crash' in Iraq
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Pilot error 'led to Puma crash' in Iraq
BBC News - Pilot error 'led to Puma crash'
A helicopter crash in Iraq which killed two SAS soldiers in 2007 was primarily caused by pilot error, a coroner has ruled at an inquest into their deaths.
However Herefordshire coroner David Halpern also criticised the Ministry of Defence for "indefensible procedural and maintenance errors".
Sgt John Battersby, 31, of Lancashire, and Cpl Lee Fitzsimmons, 26, from Peterborough, died in the crash.
Two other servicemen were seriously injured in the incident in Baghdad.
Mr Halpern also said a lack of equipment contributed to the men's deaths.
Cpl Fitzsimmons' mother, Jacqui Auty, told the hearing: "When our sons lay their lives on the line for the greater good, I think they deserve better than this."
The crash happened during a mission to find and capture insurgents believed to be responsible for a bombing campaign.
A helicopter crash in Iraq which killed two SAS soldiers in 2007 was primarily caused by pilot error, a coroner has ruled at an inquest into their deaths.
However Herefordshire coroner David Halpern also criticised the Ministry of Defence for "indefensible procedural and maintenance errors".
Sgt John Battersby, 31, of Lancashire, and Cpl Lee Fitzsimmons, 26, from Peterborough, died in the crash.
Two other servicemen were seriously injured in the incident in Baghdad.
Mr Halpern also said a lack of equipment contributed to the men's deaths.
Cpl Fitzsimmons' mother, Jacqui Auty, told the hearing: "When our sons lay their lives on the line for the greater good, I think they deserve better than this."
The crash happened during a mission to find and capture insurgents believed to be responsible for a bombing campaign.
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Oh no! Not that term "Pilot Error" again?
How can he say that? The Coroner is not allowed to apportion blame and pointing out that an error was made by the pilot clearly points the finger at him! Furthermore, what Human Factors lead the pilot to make the error?
The Barristers at this inquest need shooting for allowing the Coroner to say this in his verdict.
How can he say that? The Coroner is not allowed to apportion blame and pointing out that an error was made by the pilot clearly points the finger at him! Furthermore, what Human Factors lead the pilot to make the error?
The Barristers at this inquest need shooting for allowing the Coroner to say this in his verdict.
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Coroner ruled pilot error in an air crash investigation?
makes me remember last audit where the lady cleaner was asked how she found our IT network infrastructure.
'good... good, as long as i dont have to clean them'
makes me remember last audit where the lady cleaner was asked how she found our IT network infrastructure.
'good... good, as long as i dont have to clean them'
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downsizer
Yes there is an airworthiness issue here:
The inquest heard that the anti-spill valves, which are operated by gravity, had not been checked or maintained for decades and were not listed on the aircraft's maintenance checklist.
Summing up the evidence, the coroner said: "They should have been part of a risk assessment and appropriate maintenance schedule.
"It was said by the pilot of the Puma that he would have considered the craft to be un-airworthy if he had known that it had an inoperative anti-spill valve.
In order to mitigate the risk of fire and explosion I would imagine that the MOD/RAF quoted the anti-spill valve, so the fact it was inoperative and hadn't been checked for 30 yrs would mean it was not airworthy.IMHO
Yes there is an airworthiness issue here:
The inquest heard that the anti-spill valves, which are operated by gravity, had not been checked or maintained for decades and were not listed on the aircraft's maintenance checklist.
Summing up the evidence, the coroner said: "They should have been part of a risk assessment and appropriate maintenance schedule.
"It was said by the pilot of the Puma that he would have considered the craft to be un-airworthy if he had known that it had an inoperative anti-spill valve.
In order to mitigate the risk of fire and explosion I would imagine that the MOD/RAF quoted the anti-spill valve, so the fact it was inoperative and hadn't been checked for 30 yrs would mean it was not airworthy.IMHO
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Sorry, but I'm not entirely convinced by
Given the operational imperative and the pressure on crews to deliver in this environment, I don't think this statement can be anything other thna speculation at best, and clutching at straws at worst.
Clearly this was not a causal factor in the crash, but a contributory factor to the consequences. Yes, it is wrong that the documentation did not reflect the state of the aircraft and that the chacks hadn't been done - but I think these are probably indicators of problems rather than problems themselves. I feel very sorry for these crews, who are doing their utmost to deliver but on a shoestring in terms of both equipment and training - and that probably goes for the engineers too. I would be looking not at the pilots but at the hierarchy that put so much pressure on the force.
It was said by the pilot of the Puma that he would have considered the craft to be un-airworthy if he had known that it had an inoperative anti-spill valve.
Clearly this was not a causal factor in the crash, but a contributory factor to the consequences. Yes, it is wrong that the documentation did not reflect the state of the aircraft and that the chacks hadn't been done - but I think these are probably indicators of problems rather than problems themselves. I feel very sorry for these crews, who are doing their utmost to deliver but on a shoestring in terms of both equipment and training - and that probably goes for the engineers too. I would be looking not at the pilots but at the hierarchy that put so much pressure on the force.
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Chaps,
Please have a think before posting, as usual the media has given a headline to explain an investigation that has went on for 2 years. It isn't that clear cut and hindsight is always 20/20 vision.
I know the circumstances and why things happened as they did I also know the deep and lasting effect it has had on the individuals concerned.
The media need to sell newspapers, mundane and boring stories dont sell its that simple.
HG
Please have a think before posting, as usual the media has given a headline to explain an investigation that has went on for 2 years. It isn't that clear cut and hindsight is always 20/20 vision.
I know the circumstances and why things happened as they did I also know the deep and lasting effect it has had on the individuals concerned.
The media need to sell newspapers, mundane and boring stories dont sell its that simple.
HG
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Having flown the Puma for three tours, I would say that this was an accident that could have happened in any type of helicopter.
"Brownout" i.e. loss of visual references due to the downwash lifting the dust is a known hazard when operating in a dry environment like this but operational risks do have to be taken.
It's easy for the coroner to criticise the pilot from a non-expert point of view, but even a successful desert landing is only a couple of seconds from brownout, as the downwash catches up with the airframe. If the aircraft can't immediately be landed at zero speed, e.g due to uneven ground, it's all too easy for this to occur.
"Brownout" i.e. loss of visual references due to the downwash lifting the dust is a known hazard when operating in a dry environment like this but operational risks do have to be taken.
It's easy for the coroner to criticise the pilot from a non-expert point of view, but even a successful desert landing is only a couple of seconds from brownout, as the downwash catches up with the airframe. If the aircraft can't immediately be landed at zero speed, e.g due to uneven ground, it's all too easy for this to occur.
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spill valve.....??
Having completed lots of Puma tours I know not or should I say, I remember not where the spill valves are. Are these in the fuel jettison lines from the collective fuel tanks?
Last edited by Dundiggin'; 9th Dec 2009 at 18:36.
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No, I think they are the valves in the fuel vent lines.
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2 experienced Puma Pilots at posts 10 & 11 have difficulty recalling where the valves are.
What experience has the Coroner had of operating a Military Aircraft in a War Zone with the added pressures placed on the crews operating in such an environment? Has the Coroner ever even flown an aircraft of any sort?
If he has not, then how can the Coroner (without any experience of aviation -let alone the Puma Helicopter) decide what was (or was not) a contributory factor in the crash under combat conditions?
Mind you - he has got his name in the Papers.
What experience has the Coroner had of operating a Military Aircraft in a War Zone with the added pressures placed on the crews operating in such an environment? Has the Coroner ever even flown an aircraft of any sort?
If he has not, then how can the Coroner (without any experience of aviation -let alone the Puma Helicopter) decide what was (or was not) a contributory factor in the crash under combat conditions?
Mind you - he has got his name in the Papers.
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Cazatou, One reason I can't be sure is that I never heard the precise term "anti-spill valves" before, that's why I can't be certain where they are.
However, I do recall that the fuel tank vent lines are plumbed to cross over to the opposite side of the airframe, so that if the aircraft rolls onto its side, fuel shouldn't drain out directly from the vents. The vent outlets are visible on the airframe.
Also, it's nearly sixteen years since I flew the type and the aircraft underwent an update after I moved on. Valves may have been fitted during that update; I don't know.
However, I do recall that the fuel tank vent lines are plumbed to cross over to the opposite side of the airframe, so that if the aircraft rolls onto its side, fuel shouldn't drain out directly from the vents. The vent outlets are visible on the airframe.
Also, it's nearly sixteen years since I flew the type and the aircraft underwent an update after I moved on. Valves may have been fitted during that update; I don't know.
Last edited by ShyTorque; 9th Dec 2009 at 23:02. Reason: spelling error corrected
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Just as a reminder, modern accident investigation organisations only come up with contributory factors. They are not listed in any order of importance as this is only misleading.
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The tank vent lines do route over the cabin roof to the opposite side of the airframe and are fitted with "NRVs". In addition the tank compartments are vented. If the fuel tanks are ruptured (highly likely in a crash where the aircraft ends up on its side) then fuel will probably end up out of the bag and in the tank bay and then overboard. With a high C of G and a narrow undercarriage, most Puma accidents end up on their side. Most Chinook accidents stay the right way up and generally just rip the wheels off, hence it's good safety record.
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Cheese Holes 101:
1. The crash was probably caused by adverse environmental/operating conditions exceeding the pilots ability to maintain effective control of the aircraft.
2. The incapacitation of the pax was caused by an inadequate/inappropriate restraint system during operations.
3. The fire was caused by the failure of a device only intended for use following a rollover and hence never used or apparently tested.
4. The deaths of the pax was a combination of 2 and 3.
Pax restraint on Ops is always a bone of contention, nobody expects to be fully strapped in when they are expecting to be leaping out at any moment. A fully functional restraint system for fully fitted troops has yet to be devised. This is an operational risk.
The spill valve check was either a scheduled maint check or not - if it had been checked previously and been found serviceable it was an equipment failure, if it hadn't been checked, but should have been according to the servicing schedule, it was a failure of the maintenance organisation.
This appears to be a classic case where operational pressures conspired to place the crew and pax in a situation that ended tragically. The aircraft handling in the operating conditions, the pax restraints, the spill valve and the fire all taken as single events probably would not have been fatal, but on the day where the professional ethos of getting the job done placed these events into an inescapable series of disasters, a tragedy ensued.
So once again, a layman with a bully pulpit thinks its his duty to publicly "name and shame" those whose professionalism and committment to public duty is beyond compare. On the day it all went wrong, but nobody conspired to set those events in motion, neither the pilot, the engineers, the designers, or the RAF. By all means let's learn from this but get off the "conspiracy of incompetence" hobby horse.
1. The crash was probably caused by adverse environmental/operating conditions exceeding the pilots ability to maintain effective control of the aircraft.
2. The incapacitation of the pax was caused by an inadequate/inappropriate restraint system during operations.
3. The fire was caused by the failure of a device only intended for use following a rollover and hence never used or apparently tested.
4. The deaths of the pax was a combination of 2 and 3.
Pax restraint on Ops is always a bone of contention, nobody expects to be fully strapped in when they are expecting to be leaping out at any moment. A fully functional restraint system for fully fitted troops has yet to be devised. This is an operational risk.
The spill valve check was either a scheduled maint check or not - if it had been checked previously and been found serviceable it was an equipment failure, if it hadn't been checked, but should have been according to the servicing schedule, it was a failure of the maintenance organisation.
This appears to be a classic case where operational pressures conspired to place the crew and pax in a situation that ended tragically. The aircraft handling in the operating conditions, the pax restraints, the spill valve and the fire all taken as single events probably would not have been fatal, but on the day where the professional ethos of getting the job done placed these events into an inescapable series of disasters, a tragedy ensued.
So once again, a layman with a bully pulpit thinks its his duty to publicly "name and shame" those whose professionalism and committment to public duty is beyond compare. On the day it all went wrong, but nobody conspired to set those events in motion, neither the pilot, the engineers, the designers, or the RAF. By all means let's learn from this but get off the "conspiracy of incompetence" hobby horse.
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Could it be that the fuel in question is from an onboard auxilary tank? That might account for the term 'non spill', whereas I am only familiar with Non-Return Valve (Eu) or Check Valve (US) for such things. I thought that the accident in which 2 troops were killed also killed the Crewman, or am I getting more than one accident confused.
It is a bit unfair to impose 'responsibility' of an engineering aspect onto the aircrew for an accident that appears to be covered by 'Normal Operating Hazard' and therefore considered risk by the service. Are we alone these days when things end up in a Coroners Court? Should we be covered by individual insurance for Legal Liability? I would not like to see my family go through the treadmill should I be involved in such an occurance and not live to defend myself.
It is a bit unfair to impose 'responsibility' of an engineering aspect onto the aircrew for an accident that appears to be covered by 'Normal Operating Hazard' and therefore considered risk by the service. Are we alone these days when things end up in a Coroners Court? Should we be covered by individual insurance for Legal Liability? I would not like to see my family go through the treadmill should I be involved in such an occurance and not live to defend myself.
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I am pretty sure that the crashworty fuel system modifications were incorporated in the late 80s, having been a JT on the MU team that did the modifications. The systems have never been fitted for 30 years..
The system itself was very simple as been stated, but there is no satisfactory way of testing such systems without ripping all the components out. I cannot see why the cornoner can make the statement that he has on maintenance errors like he has. He says that a valve might not have worked. I think it was more likely that the tanks or anti spill lines were damaged being the source of the fuel IMHO.
TD, this accident bears little relation to XV230, so please don't speculate that it does.
The system itself was very simple as been stated, but there is no satisfactory way of testing such systems without ripping all the components out. I cannot see why the cornoner can make the statement that he has on maintenance errors like he has. He says that a valve might not have worked. I think it was more likely that the tanks or anti spill lines were damaged being the source of the fuel IMHO.
TD, this accident bears little relation to XV230, so please don't speculate that it does.
Last edited by Alber Ratman; 9th Dec 2009 at 23:05.
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Could it be that the fuel in question is from an onboard auxilary tank?
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Shy-Tq The ones to which you refer are history. Were they ex-Andover? I have seen a black box shaped thing which appears quite large compared to the old ones. No idea if they were ever fitted in Iraq as there must be a significant weight penalty with them, but it could be the answer. That there was never an accident / major spillage or fire at least with the old ones is luck not judgement.
Of course this could be a complete Red Herring and may have nothing at all to do with this sad incident. But thats rumour for you.
Of course this could be a complete Red Herring and may have nothing at all to do with this sad incident. But thats rumour for you.