BOI into the 2012 Tornado Collision over the Moray Firth
I think the comment from AOC 1 Gp in 2011 as ODH gives a fair impression of the mentality:
Given the amount of letters the DG MAA wrote at the time articulating his belief that it was not Tolerable & ALARP I am not even sure the AOC's comments were even accurate.
'Our calculation of a Tolerable and ALARP [situation] without CWS was audited by the MAA recently without adverse comment. So assuming the SofS is happy to hold Societal risk we can save some money!'
[Ref:Page 263]
[Ref:Page 263]
Fox3 wrote:
Fox, do you regard it as a coincidence that his e-record was erased before being available to the BOI? Implicit in that statement, is that the other 3 crews' reports were not erased?
Accepted that this did not contribute to the collision, but after the way the Reds were mangled for poor record keeping, I'm surprised it only got one line.
CG
He was under treatment, all supervisors were well aware, and he was cleared to fly. With the withdrawal of specialist RAF mental health services, the Panel criticised the lack of an organised system to return him to full operations, which seems perfectly valid.
Accepted that this did not contribute to the collision, but after the way the Reds were mangled for poor record keeping, I'm surprised it only got one line.
CG
CG - I have no info on which to comment. I left a long time ago.
Personally I think it was an extremely bad move getting rid of in-house mental illness treatment, and the WSO (and the RAF) were extremely lucky to get such an experienced nurse. In 10 years time, all the legacy people will have retired, the Service will be a very long way up sh!t creek, and there will be a massive hunt for non-existent paddles. The same applies to a lot of the civilianised contracts. I gave this as one of my reasons for PVR'ing. I said it would take 20-25 years, and I was just about right.
Personally I think it was an extremely bad move getting rid of in-house mental illness treatment, and the WSO (and the RAF) were extremely lucky to get such an experienced nurse. In 10 years time, all the legacy people will have retired, the Service will be a very long way up sh!t creek, and there will be a massive hunt for non-existent paddles. The same applies to a lot of the civilianised contracts. I gave this as one of my reasons for PVR'ing. I said it would take 20-25 years, and I was just about right.
Quote:
If a 3 phase TDP was completed in 1996, why does the convening authority say the CWS issue only began in 1998? Am I correct in saying this is exactly what Hadden-Cave did, saying nothing was wrong before 1998 despite evidence to the contrary?
Simple answer is that neither he nor the SI team reviewed the pre-1998 documentation.
DV
If a 3 phase TDP was completed in 1996, why does the convening authority say the CWS issue only began in 1998? Am I correct in saying this is exactly what Hadden-Cave did, saying nothing was wrong before 1998 despite evidence to the contrary?
Simple answer is that neither he nor the SI team reviewed the pre-1998 documentation.
DV
Thanks DV. So, important information withheld from yet another BoI. I think they did a decent job under the circumstances but if the president reads pprune I wonder if he'll ask to be reconvened as it would change a number of his recommendations.
In the past you've often mentioned the TART report. Did they see that?
Worth re-reading recent posts on the Rivet Joint thread which explain the background to a few of the recommendations a lot better than the report does. Its pretty obvious there is no safety case because the report admits important work wasn't carried out. And its pretty obvious the MAA still doesn't understand some basic concepts, confirming the views in the RJ thread.
JTO, -re tolerable and ALARP, I think you're right. Lots of contradictions that need explaining. Any word on a FAI?
The Moray MP is demanding an FAI, based on the BoI report.
With my near mid-air, I spotted and called one of the other formation, then my wingie (who is now DG MAA !) yelled "PAIR!" as he saw the other on a collision with me. I ducked under (at 250', but luckily we'd just crossed a ridge); the other formation didn't see us.
So DG MAA has saved at least one life - me!
With my near mid-air, I spotted and called one of the other formation, then my wingie (who is now DG MAA !) yelled "PAIR!" as he saw the other on a collision with me. I ducked under (at 250', but luckily we'd just crossed a ridge); the other formation didn't see us.
So DG MAA has saved at least one life - me!
BOI into the 2012 Tornado Collision over the Moray Firth
I've been away from Valley for a couple of years now but operated with TCAS in the Hawk for a while. Despite my previous criticism of the system as currently installed it would almost certainly have prevented this accident. It's far from perfect but better than nothing.
May I just add that we may all think this would never happen to us but this report really brings home to me how it is the benign, thumb-up-butt moments that seem to have the greatest ability to bite us in the arse.
RIP chaps and may we never have to read a similar report again.
BV
May I just add that we may all think this would never happen to us but this report really brings home to me how it is the benign, thumb-up-butt moments that seem to have the greatest ability to bite us in the arse.
RIP chaps and may we never have to read a similar report again.
BV
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Deliverance, I agree. Whilst this is probably the most thorough military accident report I have ever seen, I can't help thinking that the key messages are somewhat diluted by some of the noise. Sure, someone needs to pick up how air traffickers are authorised but does this really need to be commented on in the SI? At times, I thought the report read like an MAA shopping list, having been passed round all the desks within the organisation, each feeling obliged to make an observation.
That said, it is heartening to see that this accident has warranted far more than the traditional "pilots failed to see each other" and it does seem to reinforce weaknesses spotted after other relatively recent high profile accidents.
That said, it is heartening to see that this accident has warranted far more than the traditional "pilots failed to see each other" and it does seem to reinforce weaknesses spotted after other relatively recent high profile accidents.
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This is all so very sad. 3 good guys dead and two valuable aircraft destroyed. Previous warnings missed and lessons not learned - again.
Apart from the lack of a CWS the other thing that screams at me is the lack of an effective, automatic PLB that works on 406Mhz.
As 121.5/243.0 are no longer monitored (and DF capabilities are limited anyway) SARBE 7 is a bit obsolete IMHO. Also, reductions of SAR capability are not good either, so taken together rescue times could become a lot longer that most airecrew are led to believe, especially if there is also a shortage of rear crew - no winching possible - or aircraft un-serviceability means that a more distant SAR asset needs to be tasked.
I believe that individual crews could legitimately say that some sorties would be too risky to carry out in peacetime training. I shudder to think if there had been a QRA mid-air say just 100 miles further to the north-east involving a 1.30 transit. The one survivor, no immersion suit, water at 12 degrees, and not in a dingy spent 75 minutes in the sea and only just survived.
I don't envy future F-35B crews, with their single engine, if they ever got tasked with doing low level maritime attack profiles in the same vein as the Bucc or Tonka if SAR capabilities are stretched so thinly. All it would take is a big fat herring gull down the intake.........
MB
Apart from the lack of a CWS the other thing that screams at me is the lack of an effective, automatic PLB that works on 406Mhz.
As 121.5/243.0 are no longer monitored (and DF capabilities are limited anyway) SARBE 7 is a bit obsolete IMHO. Also, reductions of SAR capability are not good either, so taken together rescue times could become a lot longer that most airecrew are led to believe, especially if there is also a shortage of rear crew - no winching possible - or aircraft un-serviceability means that a more distant SAR asset needs to be tasked.
I believe that individual crews could legitimately say that some sorties would be too risky to carry out in peacetime training. I shudder to think if there had been a QRA mid-air say just 100 miles further to the north-east involving a 1.30 transit. The one survivor, no immersion suit, water at 12 degrees, and not in a dingy spent 75 minutes in the sea and only just survived.
I don't envy future F-35B crews, with their single engine, if they ever got tasked with doing low level maritime attack profiles in the same vein as the Bucc or Tonka if SAR capabilities are stretched so thinly. All it would take is a big fat herring gull down the intake.........
MB
Last edited by Madbob; 1st Jul 2014 at 10:34. Reason: spelling correction
QRA always used to wear immersion suits all year; silly not to.
I think there was a comment somewhere in the BoI about making sea drills more realistic so aircrew would be prompted to make sensible decisions themselves. Gets my vote. We used to alternate one 'easy' sea drill (say, off the beach in Cyprus) with one 'hard' one (Off Hartlepool in Febrrrrrruary). I recommend one night drill also.
I think there was a comment somewhere in the BoI about making sea drills more realistic so aircrew would be prompted to make sensible decisions themselves. Gets my vote. We used to alternate one 'easy' sea drill (say, off the beach in Cyprus) with one 'hard' one (Off Hartlepool in Febrrrrrruary). I recommend one night drill also.
Madbob
I agree. It is worth noting that many (most?) civi pilots cough up to pay for a 406mhz PLB. I doubt you would find many 121.5 versions in puddle jumpers these days.
I agree. It is worth noting that many (most?) civi pilots cough up to pay for a 406mhz PLB. I doubt you would find many 121.5 versions in puddle jumpers these days.
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Don't make them too realistic (night drill.. please not at sea!), fox or you might find a greater likelihood of losing someone in a drill than a real accident. There are a number of pools which offer top notch training, waves, spray, darkness.
Madbob it's not entirely true to say 121.5 isn't monitored. Airline pilots listen out most of the time so there's still a good chance of a signal being picked up in most areas. But I'm shocked to hear this is the best that's being issued when for a couple of hundred quid you can buy a fag-packet sized 406 MHz PLB
Madbob it's not entirely true to say 121.5 isn't monitored. Airline pilots listen out most of the time so there's still a good chance of a signal being picked up in most areas. But I'm shocked to hear this is the best that's being issued when for a couple of hundred quid you can buy a fag-packet sized 406 MHz PLB
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ShotOne - just because civil air traffic (CAT) listen out on 121.5 doesn't really help much to speed up the likely SAR scramble. As here there was confusion between ELT/PLB reports by a Speedbird near Stornoway and a Loganair near Wick.
What is so hugely depressing it that the MOD has not addressed this effectively by a suitable off-the-shelf procurement plan. I no longer fly so I am not up to date here but I'd be interested to see what other air forces do. I can't imagine RCAF or USAF aircrew being happy to operate in northern Canada/Alaska with the same kit the RAF use.
MB
What is so hugely depressing it that the MOD has not addressed this effectively by a suitable off-the-shelf procurement plan. I no longer fly so I am not up to date here but I'd be interested to see what other air forces do. I can't imagine RCAF or USAF aircrew being happy to operate in northern Canada/Alaska with the same kit the RAF use.
MB
USAF AN/URT-44 PLBs
The USAF bought 17,000 URT-44 for $30M in 2009 and they were in service from 2011 - there was 8 years notice of the change to 406 MHz:
https://timeswampland.files.wordpres...n_urt44-ds.pdf
However, there have been a lot of failures and there are already plans to replace the URT-44:
Locator Beacons For Us Air Force Ejection Seats Failing At 'Unacceptable' Rate | Defense News | defensenews.com
http://www.af.mil/News/ArticleDispla...r-beacons.aspx
https://timeswampland.files.wordpres...n_urt44-ds.pdf
However, there have been a lot of failures and there are already plans to replace the URT-44:
Locator Beacons For Us Air Force Ejection Seats Failing At 'Unacceptable' Rate | Defense News | defensenews.com
http://www.af.mil/News/ArticleDispla...r-beacons.aspx
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When tested on the shelves, the URT-44 has a 24 percent failure rate, according to Air Force documents.
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Madbob, I can see why you'd be depressed. I certainly wasn't endorsing 121.5. On the contrary I'm appalled to hear this is still relied upon! Rather than a muti-million £ procurement programme if only someone would pop down to an outdoor shop.
BOI into the 2012 Tornado Collision over the Moray Firth
MadBob
Don't get me started on the survival equipment and beacons that the RCAF issue. It's not as great as you may think!
Deliverance
The Hawk T2s will have TCAS on all the time apart from a few notable times which are specifically briefed. For example BFM sorties to avoid nuisance warnings but will usually only happen in segregated airspace.
In this scenario (if both aircraft had been T2s) they would both have had TCAS on. They would probably turn it off once they had entered the range pattern. They would have been well aware of the position of the other aircraft using the TCAS screen. It is actually very well integrated in the Hawk T2. I'm not sure how it would be displayed in a GR4.
The nuisance warnings and constant trips and resets (the TCAS doesn't handle any kind of dynamic manouvering very well) are the downside of the system. It does at least auto reset nowadays but still leads to constant AVBIT warnings especially in range type sorties.
I hope that makes sense.
BV
Don't get me started on the survival equipment and beacons that the RCAF issue. It's not as great as you may think!
Deliverance
The Hawk T2s will have TCAS on all the time apart from a few notable times which are specifically briefed. For example BFM sorties to avoid nuisance warnings but will usually only happen in segregated airspace.
In this scenario (if both aircraft had been T2s) they would both have had TCAS on. They would probably turn it off once they had entered the range pattern. They would have been well aware of the position of the other aircraft using the TCAS screen. It is actually very well integrated in the Hawk T2. I'm not sure how it would be displayed in a GR4.
The nuisance warnings and constant trips and resets (the TCAS doesn't handle any kind of dynamic manouvering very well) are the downside of the system. It does at least auto reset nowadays but still leads to constant AVBIT warnings especially in range type sorties.
I hope that makes sense.
BV
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It does sound like it, OAP and that seems to be the view of the BOI too.
But does the blame really lie with the procurement process? The quoted price figure for TCAS fit seemed enormously high. Why? Presumably because someone has insisted on a gold plated specification. Surely an off the shelf system could have been fitted for a fraction? It wouldn't offer protection during air combat or formation but would anything?
Ditto for the PLB. The RAF could have gps-enabled 406 MHz ones in life jacket pockets tomorrow for £199.95 a pop. How many years before that does get sorted and at what cost?
But does the blame really lie with the procurement process? The quoted price figure for TCAS fit seemed enormously high. Why? Presumably because someone has insisted on a gold plated specification. Surely an off the shelf system could have been fitted for a fraction? It wouldn't offer protection during air combat or formation but would anything?
Ditto for the PLB. The RAF could have gps-enabled 406 MHz ones in life jacket pockets tomorrow for £199.95 a pop. How many years before that does get sorted and at what cost?
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I thought 121.5 was still monitored as I work on a station where we look after ground to air comms on the emergancy freqs. If we do any radio servicing or testing we have to get permission from Scampton or boulmer (cant remember of top of my head)