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Will Other Controversial BOI's Be Reviewed?

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Old 5th Jan 2012, 09:32
  #41 (permalink)  
 
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In 1960 I think BoI reports were 'Secret' and not released to the public for thirty years. Perhaps snippets were published in newspapers - I don't know.The Valiant Spanhoe crash (XD864) warranted only four column inches of basic information in next day's Telegraph - I don't know which page - and less in The Times.

Today we expect all the information to be available to us.

For these reasons, I can't help thinking that the older reports are more likely to be free of outside interference because they were in house - only those that need to know would see them. Today I would have thought the writers of these reports have to keep one eye on public opinion/political implications etc..

I also get the impression that earlier we were acceptiong of blame being placed on the foot soldiers (pilots, train drivers etc.) whereas today we are more likely to look at them as victims of a weak system and put blame on leaders, directors and so on.
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Old 5th Jan 2012, 09:56
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Thanks for the kind words and PMs, guys. I have to say, I've been increasingly shocked by the things being revealed here. It was always my impression that some of the BoI outcomes were wrong (putting it mildly), but really didn't realise how corrupt and rotten so many findings were (alledgedly, obviously).


Tuc,

Nicely put!


MG,

Thank you for your impression of the quote from my journal. Actually, it wasn't my intention to imply that the boys were partying every night so I'm very glad you brought that to my attention. I've added a note to it accordingly. Of course the boys always have a few beers in Cyprus, but I'm glad to say it's much more restrained than it was two or three decades ago.


Both of Stu's accident summaries, if anyone was still looking:

ZE858 BoI summary

ZH558 BoI summary


Courtney
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Old 4th Aug 2012, 21:57
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My Mother

It is with great, great sadness I write this post. My mother Jeanette Hyde passed away on Tuesday 31st July 2012. She was married to my father Roy Harvey Johsnon who died in the Valiant crash in 1960. I have spent the recent few years finding out about my dad and grieving and came through that. The sadness of very painful loss is now back. My mother suffered so much after that crash and I now realise that my brother and I shared some of that pain throughout our lives so far. Even though it was a long time ago it has always been with us. I hope with all my heart that life goes on in some way and that my mother is at peace with those she loved and with those who loved her.

Last edited by Carol Johnson; 4th Aug 2012 at 22:09.
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Old 4th Aug 2012, 23:53
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Carol,

Very sad news - sincere condolences to you and your family.
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Old 5th Aug 2012, 07:21
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Carol, I am very sorry to hear of your sad loss. Your story is very pertinent to this thread, for it reminds us all of the real cost of fatal aircraft accidents, which is to the loved ones left behind to grieve for what amounts to a life sentence.
If it is of any consolation at all, you should know that there are many here who firmly want to see UK Military Airworthiness and Air Accident Investigation reformed, so that avoidable aircraft accidents are properly investigated to ensure that they are then avoided thereafter. While the MAA and the MAAIB are neither independent of the MOD nor of each other that cannot be relied upon.
It has only been with the help and support of devastated families that we have been encouraged to keep persevering. Our creed is simple and self explanatory:-
Self Regulation Doesn't Work and in Aviation it Kills.
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Old 5th Aug 2012, 16:14
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I know, and respect, many of the guys (M & F) who were drafted into the UK MOD, MAA and the MAAIB.

They are good operators, engineers and other branches - they believe in the supremacy of flight safety and they are trying their best.

But I'm not sure they have complete buy-in from the very top.

It's de-rigeur to blame politicians; sometimes I wonder about our Air Marshals, Generals and Admirals.

Carol, I'm sorry if my post doesn't give you much comfort.

Rgds SOS
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Old 5th Aug 2012, 18:02
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First of all, my sincere condolences. I may be a civvy, but I knew some who died unnecessarily in airworthiness related accidents. It is very sad.



The failures that led to the MAA being formed could not be influenced by (Service) maintainers or operators. Few, if any, have the necessary training to simply step into the MAA and understand, never mind correct, what went wrong.


Few have any experience of working in a system where VSOs dictate, under threat of disciplinary action, that ATTAINING and MAINTAINING airworthiness should be IGNORED. Their experience is primarily in one small part of the latter (1st/2nd Line). The failures that caused or contributed to Nimrod, Tornado/Patriot, Chinook, Sea King and C130 were all made in the attaining domain; primarily during major upgrades. What would have prevented these failures? Adherence to mandated regulations. From what I read the MAA are focusing almost entirely on one small part of maintaining.

In each case, the recommendations made by the Boards of Inquiry came as no surprise whatsoever to staffs taught how to attain airworthiness. In many cases, the proof is here on pprune, in the posts preceding the BoI reports. In each case there is a written record of senior staffs being advised to implement mandated regulations directly related to subsequent recommendations. In each case the BoI (and Haddon-Cave and Philip reports) can be summarised as "Implement your mandated regulations".

Until that simple truth is acknowledged, little will improve. MoD will not acknowledge it, because doing so directly implicates retired VSOs and senior Civil Servants. They will continue to lie to Ministers (not that Ministers bother about such things). This is where pprune plays a vital role, by naming those who Haddon-Cave refused to, despite being given irrefutable evidence. In this sense, he is part of the problem, not the solution.

It only needs one BoI to be reconvened. I believe, for example, this would require the President / ROs to state they were misled, by omission or commission. I know of two such Presidents / Senior ROs who have been approached recently and presented with such evidence. Disgracefully, each declined to comment, although one expressed himself satisfied that the direct cause of one accident (a Tornado crash) had been mitigated - but only after 20 years had passed since the original mistake. He was content that the systemic failure remained unaddressed in that period, despite VSOs being formally notified on numerous occasions. At first he was up for it. But when he saw the evidence proving his senior colleagues had condoned the aircraft being functionally unsafe, he closed ranks again.

A personal note, which is worth considering. The formal Ministerial and MoD position, conveyed to my MP, is that I remain the only person (in MoD) who believes the airworthiness regulations should be implemented properly. They refuse to withdraw this (written) claim, first made in 2003, even post Haddon-Cave/Philip and the formation of the MAA. I dare say the head of MAA disagrees, but he won't say so; each time I seek a retraction Ministers are advised the ruling should stand (and questions on airworthiness are now directed at the MAA). But this is the point I'm making. Keeping this opinion private to avoid conflict with VSOs and Ministers goes against everything the MAA is meant to stand for. If the MAA were truly independent, he wouldn't have to worry about this.

(Edited to clarify a point. The 2003 statement was made to justify a ruling that the Chief of Defence Procurement was right to uphold disciplinary action against me when I refused to obey an order to make a false declaration that the airworthiness regs had been implemented, when the person issuing the order (and myself, who had the signature) knew they had not. CDP also ruled that it was not an offence to issue such an order. This remains MoD's official position. I issued directions that the aircraft be made safe. The officer issuing the (il)legal order countermanded me, and the resulting lack of functional safety was cited in a subsequent Board of Inquiry report. Hence my "attitude" on here!).

Last edited by tucumseh; 5th Aug 2012 at 18:15.
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Old 5th Aug 2012, 18:28
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My condolences to Carol and her family for their loss.

I admit to not knowing how the previous MOD airworthiness systems did or did not work. But the new MAA have a real dilemma in picking which end of their huge problem to sort out first - the chicken or the egg.

Unfortunately it appears that the egg is the easiest to correct first and (doubly unfortunately) they have laid another egg in trying to correct the first.

In their attempt to take charge of their situation they have merely set some new rules in place...no training, familiarisation visits, guidance or enforcement - just new rules.

Oh well. At least someone is enjoying debating them and writing them - cos no-one appears to be reading them!
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Old 5th Aug 2012, 19:20
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tucumseh,

Perhaps the answer to your point is that the MAA is independent but those who work in and lead it are not.
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Old 5th Aug 2012, 22:22
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Regarding the Vulcan loss at Heathrow on talkdown refered to much earlier, I recall reading that aside from a talkdown issue it was also partly attributed to the lack of a Pressure Error Correction (correct FW terminology? I use a Helicopter Type Allowance) for the Vulcan's Bar Alt - although hardly the certain truth, pprune supplies the following:

http://www.pprune.org/aviation-histo...merged-59.html

Thanks AvroLincoln. According to the BoI report, about 7sec before the Vulcan hit the ground,the GCA controller told Podge Howard that he was 80ft above the glidepath. Even after XA 897 struck the ground, the talkdown continued as if the approach had been normal. The BoI concluded that 'the failure to warn the captain that he was going below the glidepath was the principal cause of the accident.' A subsequent Boscombe study of Vulcan altimerer errors revealed that the large delta wing area, plus friction with the altimeter, amounted to a total possible error of 200ft. As Heathrow 10 Left was 80ft above sea leave, even with 300ft indicated on his altimeter Podge Howard was already among the weeds.

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Old 6th Aug 2012, 05:56
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tucumseh,

Perhaps the answer to your point is that the MAA is independent but those who work in and lead it are not.
I think I know what you're getting at, but the fact is that if the MAA is headed by senior officers whose career path is determined by the very people who are hostile to what the MAA is trying to achieve, then that degree of influence means there is no independence.

As Rigga says, they have chosen the path of least resistance. As there has been robust resistance to airworthiness since it was run down by (primarily) the RAF Chief Engineer in the early 90s, then it cannot possibly be addressing the failures.

The basic problem is, I believe, the MAA was established to clear the Haddon-Cave recommendations, thinking this would resolve "airworthiness". But H-C's report is fatally flawed, because he declined to publish the historical evidence detailing the depth and breadth of the problems. He blamed the wrong people, while protecting, in fact praising, those who were on record as disagreeing with the concept of airworthiness.

When asked to distil this down to one point, I always say this. H-C blamed Gp Capt Baber (Nimrod ITPL) for the poor management of the Safety Case task he let on BAeS. While partly true, he completely, and quite deliberately, missed the point that the regulations require continuous tasking on BAeS, and Baber should have inherited a valid Safety Case. The very fact he had to let a task on BAeS reveals long term systemic failures. That would have been Baber's defence; and MoD, the Provost Marshall, Thames Valley Police, the H&SE and CPS all played a blinder in conspiring to not bring charges. Thus protecting the guilty.

Allied to this, General Cowan was criticised for implementing 20% cuts over a 4 year period. A five year old can tell you that 28% per year, for 3 successive years (1991-94), is infinitely worse. Especially when it targets airworthiness, whereas Cowan's 5% p/a barely touched it. Why did H-C not mention this? (All the evidence was provided to him). Again, to protect the same guilty people.

The two are related because, when ordering the 28% cuts, the RAF Chief Engineer's department specifically directed that Safety Cases should not be maintained.

The MAA should be acknowledging these facts and addressing them. But to do so would upset the cadre of retired VSOs, who very obviously still dictate matters to their successors; especially the Directorate of Air Staffs. Instead, by re-writing the regs they are implying they were wrong and the cause of the failures. Wrong. Demonstrably, if implemented they would have prevented (at least) Nimrod, Chinook, Tornado, Sea King and C130.

What is the tangible output of the process of "attaining airworthiness"? The Master Airworthiness Reference, the Release to Service, which reflects the Build Standard of the aircraft; and aircraft built and maintainable to that BS. The RTSs of all the above cases exhibit multiple failures to implement regs. The Chinook HC Mk2 RTS of Nov 1993 - June 1994 is typical. There are over 50 major non-compliances with mandated regs, any one of which should have prevented it being signed. So why did ACAS sign it? It is THE BIG QUESTION which has never been asked of him, in the same way Haddon-Cave avoided the big issues.
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Old 6th Aug 2012, 09:31
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Carol, I hope that you can see here some of the determination to expose the corrupt morass that now envelops UK Military Flight Safety. In this one thread alone we have those, like yourself that have witnessed the devastating effects that fatal aircraft accidents leave behind them. We have those, like tucumseh, that have been directly persecuted for simply trying to do their job, which was to carry out the mandated airworthiness regulations to ensure that UK Military Aircraft can carry out their most basic function, to stay in the sky! We have many others who have come to realise that those set in command above them far from leading have reneged on their duty of care over those that they command, have issued illegal orders to subvert the Airworthiness Regulations, and have directly suborned them themselves by issuing Release to Service to knowingly unairworthy aircraft.
As tuc says, no-one in authority wishes to heed the evidence laid before them. Because that is the case no reform can take place. Because that is the case avoidable aircraft accidents will go on happening. Because that is the case Servicemen and women will die needlessly. That is a stupid and senseless situation. Every Air Marshal acquainted with this stupidity who does not seek to end it becomes part of the problem, part of the cover-up. Somewhere there is the man or woman who will finally seek to end it. High time they stepped forward!
Self Regulation Doesn't Work, and in Aviation it Kills!
Set the MAA and MAAIB free of the MOD and of each other.
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Old 6th Aug 2012, 10:37
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Carol, although we have spoken privately I wanted to post my sincere condolences to you and you family for the loss of your Mum. She was so very kind to me at the memorial service for the crew of XD864. Be brave, she would be extremely proud of you.

Chugalug2 - we have suspected a cover up for many years and the points made in your posts simply confirm that this is still the case. Tragically there will be many more families condemned to serve what you very rightly call a life sentence before someone somewhere stands up and puts an end to the current shameful situation.
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Old 6th Aug 2012, 18:26
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LyndaV, welcome to the thread (and indeed to PPRuNe!). Would that it were in happier circumstances. No doubt you are familiar with this site:-
XD864
but others such as I will be struck with the similarities revealed between the BoIs of Chinook HC2 ZD576 and Valiant BK1 XD864. Technical evidence at the crash site (a fractured centre plane spar in the case of XD864) and previously known problems experienced in operation ignored in favour of a case against Captain and Crew produced by insinuation and sweeping statements. It's deja-vu all over again, Brian!
Of all the places that this allegedly overconfident Captain elects to crash his allegedly airworthy aircraft, he chooses a disused airfield finishing up just off its runway 14! Black eye or feather in cap? I know what looks more appropriate to me.

Last edited by Chugalug2; 6th Aug 2012 at 19:23.
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Old 8th Aug 2012, 17:42
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Chugalug2 - I am indeed familiar with the XD864 website, the BOI and every piece of information I could find about the incident.

Whilst I remember punching the air in a most unladylike manner when the Chinook result came through I had not appreciated the similarities between the two BOIs. Frankly one BOI report was enough sad reading for me.

I wholeheartedly agree with your final 3 sentences and having stood at the crash site on more than one occasion it seems obvious that the captain was trying to get down on Spanhoe. I know what I believe.

Good luck with your campaign.
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Old 9th Aug 2012, 20:42
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LyndaV, thank you for your encouragement. As I said above, it is the support of the families that is the essential ingredient if we are ever going to get UK Military Airworthiness Provision and Air Accident Investigation reformed. To be honest with you the similarities between the Valiant and Chinook BoIs was as much a revelation to me as they were to you, but they merely reflect the pattern of many UK Military Fatal Air Accidents reviewed in this Forum. Poor investigation, interference from above, suppression of vital evidence, and downright lying from the highest levels, characterises most of them in full or in part. It is axiomatic in Aviation that the Operator, the Regulator, and the Investigator be independent and separate of each other. What happened with XD864 from initial Release to Service to the smouldering wreckage at Spanhoe and the subsequent BoI report is a classic example of what happens when they are but one and the same.
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Old 10th Aug 2012, 11:06
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Chugalug2 I have PM'd you.
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Old 11th Aug 2012, 05:40
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Chugalug2, that was a bloody good effort even if it didn’t pan out. Well spotted. I don’t think it thread drift as that ASaC collision is crying out for the BoI to be reconvened. If a BoI starts with the premise that the aircraft were serviceable, but it emerges they were not (especially in areas the BoI cited as contributory factors), then the BoI itself should be asking for a review. The evidence withheld from it was significant. Not least the IPT immediately blaming a civil servant, but withholding this when the CS produced evidence he’d been told to leave the aircraft unsafe. MoD reverted to this argument after the Inquest, when the CS was no longer in a position to defend himself, and still maintains it. This background detail of organizational faults may not change the conclusions pertaining to the final moments (which I think are pretty well accurate except for the confusion caused by HMS Liverpool’s Lynx, which MoD lied about) but it should make interesting reading for the MAA who are trying to avoid recurrence in the MoD as a whole. But from what I read here they don't want to know.


Does anyone know if the MAA has, for want of a better term, a “cold case” section which reviews old BoIs? It would be an easy way to quickly learn from past mistakes. It also strikes me there is a lot of expertise here on pprune that has immediately spotted the underlying causes on the likes of Nimrod, C130 and Chinook. Why have MoD’s investigators seemingly missed all this? This can’t be coincidence surely? In each case the BoI dwelt on the final moments but didn’t look at underlying causes. In each case the true cause was revealed on pprune. MoD’s role seems to be to denigrate that expertise, but at the cost of human life. So MoD become part of the problem, while doing its best to avoid the solution. Which I guess is what most of your posts are saying!

Keep up the good work.
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Old 11th Aug 2012, 07:56
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It took years for the Commercial sector to get around to investigating air incidents properly (and even now you get accusations of hidden/altered evidence)

The military SO's hate the idea that any decision they make /made will be questioned - they see it as the slippery slope to non-obedience. Combine this with the UK Civil Service mania for secrecy and never attributing blame for any past decision and we are left with a poisonous mix

Regrettably I think a constant series of re-visited BOI's will be a running sore for everyone - better to have some outside agency to have the power to revisit old accidents and publish the historic facts
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Old 11th Aug 2012, 08:44
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Heathrow Harry

I agree. Your final point is what Chugalug2 has been pressing for and seems the only way to get round the entrenched views and behavior of the senior officers and politicians.
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