Air Cadets grounded?
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Skeletons in the cupboard ?
Yes, agreed, he did hold valid rating and medical.
However the point you overlook ( but the report didn't !) is whether he should have held a valid medical.
In this sad case, there were three occasions when the causal chain could have, and should have, been broken to prevent the fatal accident. One medical, one operational, and the final one, a negligent omission by the pilot himself. Any one of the three would have prevented the accident.
His FMed4 was held as is normal on Station, but the examining MO failed to read all the relevant reports in the file, for reasons not explained or accounted for. (p 42 of report).
Had he done so, he stated, that he may have carried out cockpit checks himself. He didn't read all the relevant history, so he didn't do the checks as a clinician, and the result was self evident.
Thus in accident terms, the first opportunity to "break the causal chain" was missed. Should we expect a clinician to read your file where you have a complex and serious history ? Same applies in Hospital before any surgical procedure is undertaken. The GMC would not look kindly upon a clinician who failed to read the file before treating you with a complex history!
Another lost opportunity was that when the pilot was being trained at 115 Sqn, when no less than 4 instructors commented that "the pilot could not do the full range of lookout i.a.w. CFS standard"
Another link in the casual chain missed.
On the fateful day, as the report states "...immediately before entering any manoeuvre, it is normal practice for a pilot to ensure that the area is clear of other aircraft".
How basic is that routine to those of us who have been instructors?
The report concluded that "on the basis of the medical evidence, it is highly unlikely that he would have been able to do this."
He failed to do so, and thus his omission brought about the fatal accident.
No matter what technology of an advanced nature is introduced, human failure cannot be eliminated. Despite all the other technology improvements suggested and discussed in the report, none of them would have prevented this fatal accident.
No medical granted would have totally removed the pilot from any RAF flying duty ( and possibly any CAA activity on private Class 3 medical) and prevented this unnecessary accident.
However the point you overlook ( but the report didn't !) is whether he should have held a valid medical.
In this sad case, there were three occasions when the causal chain could have, and should have, been broken to prevent the fatal accident. One medical, one operational, and the final one, a negligent omission by the pilot himself. Any one of the three would have prevented the accident.
His FMed4 was held as is normal on Station, but the examining MO failed to read all the relevant reports in the file, for reasons not explained or accounted for. (p 42 of report).
Had he done so, he stated, that he may have carried out cockpit checks himself. He didn't read all the relevant history, so he didn't do the checks as a clinician, and the result was self evident.
Thus in accident terms, the first opportunity to "break the causal chain" was missed. Should we expect a clinician to read your file where you have a complex and serious history ? Same applies in Hospital before any surgical procedure is undertaken. The GMC would not look kindly upon a clinician who failed to read the file before treating you with a complex history!
Another lost opportunity was that when the pilot was being trained at 115 Sqn, when no less than 4 instructors commented that "the pilot could not do the full range of lookout i.a.w. CFS standard"
Another link in the casual chain missed.
On the fateful day, as the report states "...immediately before entering any manoeuvre, it is normal practice for a pilot to ensure that the area is clear of other aircraft".
How basic is that routine to those of us who have been instructors?
The report concluded that "on the basis of the medical evidence, it is highly unlikely that he would have been able to do this."
He failed to do so, and thus his omission brought about the fatal accident.
No matter what technology of an advanced nature is introduced, human failure cannot be eliminated. Despite all the other technology improvements suggested and discussed in the report, none of them would have prevented this fatal accident.
No medical granted would have totally removed the pilot from any RAF flying duty ( and possibly any CAA activity on private Class 3 medical) and prevented this unnecessary accident.
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@EnigmAviation thank you for pointing these issues out. As you rightly say, although he had a medical, should he? My personal view and that of any other glider pilot I've discussed it with is an emphatic no.
Chaps,
I'm pretty sure we've been around the buoy several times on the two Tutor accidents. In addition, a huge number of lessons have been learnt by the RAF as a whole from them.
Let's just leave it a that shall we and stick to discussing getting the glider fleet back to flying, given that the AEF organisation is now pretty much up to speed on the tutor it seems.
I'm pretty sure we've been around the buoy several times on the two Tutor accidents. In addition, a huge number of lessons have been learnt by the RAF as a whole from them.
Let's just leave it a that shall we and stick to discussing getting the glider fleet back to flying, given that the AEF organisation is now pretty much up to speed on the tutor it seems.
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Unfortunately the two Tutor accidents have made the AC far more risk-averse in the wrong area - AFAIK there were no airworthiness issues contributing to the incidents occurring.
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Careful there EnigmA, the report concluded that it was highly unlikely that he was able to look out properly, not that he failed to do so. The board could not conclude that he failed to do so because the evidence could not be conclusive. That may be your own conclusion, but stating that as fact in public may leave you exposed.
Anyway, as has been said already this is not germane to the issue.
Anyway, as has been said already this is not germane to the issue.
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Random Bloke and Skeleton, it is of course very sad that the Pilot flying the Tutor when it collided with a glider in busy airspace had been flying with a condition known as Ankylosing Spondylitis. If you care to read up on this condition, you would be horrified and astonished that he may have been permitted to fly children, and it was a mistake by the authorising medics that he was permitted to fly at all. It is your duty and indeed anyone who is aware that a pilot to your knowlege is not physically fit to fly passengers, to express your concern to the person in charge. If you neglect to do this and an accident happens, you must share the blame. That is why this must concern all of us. It is not to be forgotten or swept under the rug.
There were two reports on this incident, one by the RAF, one by the AAIB. I have read both of them long ago, and the lessons that officialdom MUST LEARN is not to repeat these mistakes. The people supervising any program that flies children must take care that instructors are fit and of good character.
If you have indeed read both of these reports, you will realise that the pilot's colleagues should certainly have flagged up his condition; no way they would not have been aware. It is your friends who first begin to notice you are starting to loose it. Officialdom is the last to find out.
And flying in airspace that is very very busy on a good soaring day, and performing aerobatics in such airspace, is unwise to say the least.
Why was not airspace over say Brize Norton or Benson made available to the Tutor?
In any event, it is unnecessary to throw kids around the sky to give them a taste of flight. Just letting them have a go on the controls is enough of a thrill. Aerobatics should be saved for later, or at least reserved for consenting adults.
There were two reports on this incident, one by the RAF, one by the AAIB. I have read both of them long ago, and the lessons that officialdom MUST LEARN is not to repeat these mistakes. The people supervising any program that flies children must take care that instructors are fit and of good character.
If you have indeed read both of these reports, you will realise that the pilot's colleagues should certainly have flagged up his condition; no way they would not have been aware. It is your friends who first begin to notice you are starting to loose it. Officialdom is the last to find out.
And flying in airspace that is very very busy on a good soaring day, and performing aerobatics in such airspace, is unwise to say the least.
Why was not airspace over say Brize Norton or Benson made available to the Tutor?
In any event, it is unnecessary to throw kids around the sky to give them a taste of flight. Just letting them have a go on the controls is enough of a thrill. Aerobatics should be saved for later, or at least reserved for consenting adults.
mary meagher, the last time I met the pilot in question was some 25 years before the fatal accident. I was surprised even then that he was still flying as his condition was clearly acute - but I was astonished to learn about his later accident as I assumed he would have given up flying years earlier.
Certainly in the late 1970s, the word was:
1. NO aerobatics on a cadet's first ever flight.
2. Subsequent flights could include aeros if the cadet asked.
However, since when did AEF pilots ever obey the rules?
Certainly in the late 1970s, the word was:
1. NO aerobatics on a cadet's first ever flight.
2. Subsequent flights could include aeros if the cadet asked.
However, since when did AEF pilots ever obey the rules?
A&C,
I am not questionig the Tutor Contractor's capability, I am saying that the RAF seem to have given up on certain areas of technical expertise. Whilst these have no-doubt been assessed as not affecting thier 'real job' of keeping front-line aircraft airworthy, it does seem that this is the root-cause of the present grounding of two aircraft types.
I am sure this is an outcome of the usual Cost/Benefit analysis (a process I have no real beef with since it is virtually essential when dealing with the reality of a limited budget). However the same process should have revealed the lack of oversight expertise as a 'risk'.
Bearing in mind that that risk was realised, it should also follow that you don't want to make the same misstake twice. Ergo they should be identifying this failure as a definite item that needs to be corrected if they are not to end up in the same situation again, rather than try pot-luck with another contractor who hasn't already screwed up.
You mention Part-145, and who approves and oversees that standard? an independent organisation that has the expertise to say that the do or don't meet the standard!
Please don't take this as a personal criticism, I am really just trying to say that in all these situations you do need a source of expertise that can spot when an organisation is not doing work that is up to the agreed standards.
Flug
I am not questionig the Tutor Contractor's capability, I am saying that the RAF seem to have given up on certain areas of technical expertise. Whilst these have no-doubt been assessed as not affecting thier 'real job' of keeping front-line aircraft airworthy, it does seem that this is the root-cause of the present grounding of two aircraft types.
I am sure this is an outcome of the usual Cost/Benefit analysis (a process I have no real beef with since it is virtually essential when dealing with the reality of a limited budget). However the same process should have revealed the lack of oversight expertise as a 'risk'.
Bearing in mind that that risk was realised, it should also follow that you don't want to make the same misstake twice. Ergo they should be identifying this failure as a definite item that needs to be corrected if they are not to end up in the same situation again, rather than try pot-luck with another contractor who hasn't already screwed up.
You mention Part-145, and who approves and oversees that standard? an independent organisation that has the expertise to say that the do or don't meet the standard!
Please don't take this as a personal criticism, I am really just trying to say that in all these situations you do need a source of expertise that can spot when an organisation is not doing work that is up to the agreed standards.
Flug
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Flugplatz
I agree with you about the need for the RAF to have a more robust oversight of the contractors product delivery, In the case of the gliding contract the RAF unit responsible was woefully understaffed and stretched to breaking point with front line work, this is an example of short term cost cutting that costs more in the long run.
The lack of knowlage of glider technology and industry cuts both ways, while the RAF might get shortchanged by some contractors other contractors yet have gliding industry best practice questioned and hindered by those who have yet to grasp that the technology is totally different from a pressurised metal airframe.
The very close investigation of the gliders has also uncovered holes in the technical data that had not been questioned since the aircraft was built, twenty years back these small items would have been ignored or fixed by using common sence and industry coustom and practice, these days the lawyers will take to task anyone who fails to comply with the official technical data.
EASA 145 approval is overseen by EASA who audit the company on a regular basis, normally this is by a formal annual inspection ( in the UK by the CAA) however due to the nature of the business CAA surveyors will visit these company's on other business ( inspections of individual aircraft, MOR investigation, approval upgrade or change etc) and these visits often paint a picture for the formal annual inspection.
The lack of knowlage of glider technology and industry cuts both ways, while the RAF might get shortchanged by some contractors other contractors yet have gliding industry best practice questioned and hindered by those who have yet to grasp that the technology is totally different from a pressurised metal airframe.
The very close investigation of the gliders has also uncovered holes in the technical data that had not been questioned since the aircraft was built, twenty years back these small items would have been ignored or fixed by using common sence and industry coustom and practice, these days the lawyers will take to task anyone who fails to comply with the official technical data.
EASA 145 approval is overseen by EASA who audit the company on a regular basis, normally this is by a formal annual inspection ( in the UK by the CAA) however due to the nature of the business CAA surveyors will visit these company's on other business ( inspections of individual aircraft, MOR investigation, approval upgrade or change etc) and these visits often paint a picture for the formal annual inspection.
Last edited by A and C; 29th Nov 2015 at 11:57.
All the talk focussing on one Tutor pilot's limited neck movement deflects from the real 'elephant in the the room', namely that to open the canopy and bail out of this aircraft is nearly impossible after a mid-air collision. Two other Tutors collided with each other, also resulting in the loss of all on board, yet it seems to be accepted as 'one of those things'.
The RAF's focus is on air combat with experienced crew and the need to get out of a burning aircraft is paramount. In the case of the Tutor, 50% of those on board are likely to be on their first flight in one, and possibly their first flight in any aircraft. As in-flight fires are pretty rare, isn't it time the AEFs recognise which the most likely hazards and either modify their Tutors to accept an airframe parachute, or change to a type which can be so equipped?
The RAF's focus is on air combat with experienced crew and the need to get out of a burning aircraft is paramount. In the case of the Tutor, 50% of those on board are likely to be on their first flight in one, and possibly their first flight in any aircraft. As in-flight fires are pretty rare, isn't it time the AEFs recognise which the most likely hazards and either modify their Tutors to accept an airframe parachute, or change to a type which can be so equipped?
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Mechta
Airframe parachutes are not realistic retrofit, the Kevlar straps that support the aircraft have to be laid into channels in the structure.
Cirrus aircraft have these channels built into the aircraft at manufacture and I can't see any reasonably priced option to do this on an airframe that has not been designed from the outset to have this system fitted.
The only improvement that I could be made at reasonable cost would be something to assist canopy opening.
The Grob 120 that looks like it will be the next RAF primary trainer can be fitted with a M-B light weight ejection seat but I have my reservations about putting the younger cadets in a bang seat.
Cirrus aircraft have these channels built into the aircraft at manufacture and I can't see any reasonably priced option to do this on an airframe that has not been designed from the outset to have this system fitted.
The only improvement that I could be made at reasonable cost would be something to assist canopy opening.
The Grob 120 that looks like it will be the next RAF primary trainer can be fitted with a M-B light weight ejection seat but I have my reservations about putting the younger cadets in a bang seat.
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From what I've heard the new G120TPs are only for EFT (which would make sense) whilst the excess Tutors are getting thrown into the AEF/UAS system so more cadets can get airborne as more airframes should be available when others are out for maintenance etc, though I stand to be corrected if someone knows more than I do
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A minor correction to "Random Bloke"
Random Bloke - with the greatest of respect, no, the report didn't specifically say he failed to carry out either an eyeball check/scan or eyeball check/scan + clearing turn, BUT by the evidence of the facts, there could be no other rational explanation for the evidence of collision. In legal terms "Res Ipsa Loquitur" the facts speak for themselves.
A qualified pilot who had just immediately before contact occurred, carried out the normal pre-manoeuvre checks expected of this grade of pilot, and then knowingly pulled up into traffic in his overhead that he had just "eyeballed" would have been knowingly negligent at best, and suicidal at worst, especially since the aircraft overhead was a glider - and Rules of the air.........power gives way to.......etc. By deed of the evidence he cannot have done so otherwise the accident would never have taken place.
Agreed it's not totally relevant to the current lack of ACO VGS aircraft but it has some relevance insofar as there have been some suggestions in this thread, that all future ACO aerial activity should be led by the professionals, if not flown by professionals.
The current limiting qualifications for the AEF Pilots on the Grob 115 Tutor would ordinarily preclude most if not all VGS Instructors, despite the remarkable similarity between that and the Grob 109B Vigilant T Mk1 aircraft operating systems, and despite the fact that the role in VGS aircraft is of a higher skill level - i.e., instructional sorties rather than Air EX.
All that I aimed to show was that human errors cut across the whole of the RAF, and are not confined to the VR(T) guys. 100% flight safety can only be assured by welding up the hangar doors - something not entirely miles away from where we've been since April 2014 !
A qualified pilot who had just immediately before contact occurred, carried out the normal pre-manoeuvre checks expected of this grade of pilot, and then knowingly pulled up into traffic in his overhead that he had just "eyeballed" would have been knowingly negligent at best, and suicidal at worst, especially since the aircraft overhead was a glider - and Rules of the air.........power gives way to.......etc. By deed of the evidence he cannot have done so otherwise the accident would never have taken place.
Agreed it's not totally relevant to the current lack of ACO VGS aircraft but it has some relevance insofar as there have been some suggestions in this thread, that all future ACO aerial activity should be led by the professionals, if not flown by professionals.
The current limiting qualifications for the AEF Pilots on the Grob 115 Tutor would ordinarily preclude most if not all VGS Instructors, despite the remarkable similarity between that and the Grob 109B Vigilant T Mk1 aircraft operating systems, and despite the fact that the role in VGS aircraft is of a higher skill level - i.e., instructional sorties rather than Air EX.
All that I aimed to show was that human errors cut across the whole of the RAF, and are not confined to the VR(T) guys. 100% flight safety can only be assured by welding up the hangar doors - something not entirely miles away from where we've been since April 2014 !
A and C
"Airframe parachutes are not a realistic retrofit" - What rot. There is a kit to modify the Cessna 172/182 with a BRS - probably one of the most ubiqitous training aircraft out there.
BRS Parachutes | Cessna 182 Systems FAQ
Anything can be modified, it just depends on whether you are prepared to pay for the engineering design costs, the flight testing and the certification. I suspect that there aren't enough G-115E owners out there to make the upfront costs worth it. Indeed it would probably be cheaper to bin the G-115s and buy Sportstars or alike...
The B Word
"Airframe parachutes are not a realistic retrofit" - What rot. There is a kit to modify the Cessna 172/182 with a BRS - probably one of the most ubiqitous training aircraft out there.
BRS Parachutes | Cessna 182 Systems FAQ
Anything can be modified, it just depends on whether you are prepared to pay for the engineering design costs, the flight testing and the certification. I suspect that there aren't enough G-115E owners out there to make the upfront costs worth it. Indeed it would probably be cheaper to bin the G-115s and buy Sportstars or alike...
The B Word
Oh good grief. 'Airframe parachutes' or 'lightweight ejection seats'. While no doubt well meaning you are rather demonstrating why the RAF has such trouble with all this.
If the darn thing is so hard to get out of, make it easier. Why was that not part of the original assessment - or was it?
So - sort its exit procedures. Improve the canopy jettison if required. Add air bags under the seat squab - becoming common practice in heavily reclined position racing sailplanes. Use a time expired airframe or simple mock-up to allow passengers to practice exit before flight if you are really paranoid. There are relatively cheap effective solutions.
The AEFs and others used Chipmunks for years, with standard parachutes for cadets. That was viewed as satisfactory, with adequate briefing. What has changed - the attitude to risk ?I flew a Grob 109B occasionally. Really hard to get out of quickly, but it can be done. We carried parachutes. Handy to practice exits, just in case, if high enough.
But there will always be risk.
This is not directly part of the Air Cadets thread it seems to me, though the OTT thinking at time sounds rather familiar!
If the darn thing is so hard to get out of, make it easier. Why was that not part of the original assessment - or was it?
So - sort its exit procedures. Improve the canopy jettison if required. Add air bags under the seat squab - becoming common practice in heavily reclined position racing sailplanes. Use a time expired airframe or simple mock-up to allow passengers to practice exit before flight if you are really paranoid. There are relatively cheap effective solutions.
The AEFs and others used Chipmunks for years, with standard parachutes for cadets. That was viewed as satisfactory, with adequate briefing. What has changed - the attitude to risk ?I flew a Grob 109B occasionally. Really hard to get out of quickly, but it can be done. We carried parachutes. Handy to practice exits, just in case, if high enough.
But there will always be risk.
This is not directly part of the Air Cadets thread it seems to me, though the OTT thinking at time sounds rather familiar!
In days gone by UK military aircraft were tested for canopy jettison / abandonment / ejection seat function at the Blower Tunnel facility at Boscombe Down using both dummies and live subjects. None of the Grobs ever went through the process, if they had maybe the difficulties with canopy jettison that led to the fatalities could have been discovered before rather than after the event. It'll never happen now as the Blower Tunnel is no longer in service and is due for removal.
''Skylaunch has completed the order to replace the Air Cadet's ageing winch fleet, with the delivery of the 25th Skylaunch Evo twin drum (6.6 litre turbo diesel engine).''
From 'Sailplane and Gliding', - the British Gliding Association's magazine, Dec 15/ Jan 16 edition.
Hopefully, the MOD got a good deal for a bulk buy of these top-of-the-range winches. Let's hope they get used before too long.
From 'Sailplane and Gliding', - the British Gliding Association's magazine, Dec 15/ Jan 16 edition.
Hopefully, the MOD got a good deal for a bulk buy of these top-of-the-range winches. Let's hope they get used before too long.
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B word "what rot"
So Mr B word I am guessing that you are are a licensed engineer who has extensive experience of composite aircraft maintenance and repair especially Grob 115 and Cirrus types ?
The BRS retrofit for the Cessna is particularly easy as the main structural members that the Kevlar strops attach to are on top of the aircraft ( main spar webs & rear spar frame ) can be reached by one central channel along the top of the cabin.
To retrofit a low wing aircraft the strops would have to be routed along the outside of the fuselage to the engine frame mount structure aft of the firewall and to a hard point in the aft fuselage. For C of G equipment reasons and to attach to the rear spar carry through structure the parachute/rocket pack would have to be mounted in the rear baggage area of the Grob. This means that the strops to the forward hard points would have to go under the sliding canopy and the canopy and the canopy rails would have to be jettisoned during deployment, this would require some sort of explosive canopy ( and mounting rail ) jettison system that would sequence ahead of the parachute rocket deployment.
Unlike the Cessna or Cirrus that have the crew & pax in an enclosed cabin the need to jettison the canopy the crew of a Grob would be very close to the canopy as it is explosively jettisoned and then be exposed to the rocket motor as it fires.
As Mr B word you have clearly considered these issues I would be very interested to know how your engineering expertees would resolve these problems with the Grob and what your estimated cost would be ?
The BRS retrofit for the Cessna is particularly easy as the main structural members that the Kevlar strops attach to are on top of the aircraft ( main spar webs & rear spar frame ) can be reached by one central channel along the top of the cabin.
To retrofit a low wing aircraft the strops would have to be routed along the outside of the fuselage to the engine frame mount structure aft of the firewall and to a hard point in the aft fuselage. For C of G equipment reasons and to attach to the rear spar carry through structure the parachute/rocket pack would have to be mounted in the rear baggage area of the Grob. This means that the strops to the forward hard points would have to go under the sliding canopy and the canopy and the canopy rails would have to be jettisoned during deployment, this would require some sort of explosive canopy ( and mounting rail ) jettison system that would sequence ahead of the parachute rocket deployment.
Unlike the Cessna or Cirrus that have the crew & pax in an enclosed cabin the need to jettison the canopy the crew of a Grob would be very close to the canopy as it is explosively jettisoned and then be exposed to the rocket motor as it fires.
As Mr B word you have clearly considered these issues I would be very interested to know how your engineering expertees would resolve these problems with the Grob and what your estimated cost would be ?
A and C, Grob themselves evidently considered a Ballistic Recovery System (airframe parachute) as seen in this G115/120TP marketing presentation of theirs, on page 10:
http://www.grob-aircraft.eu/tl_files...t-10-02-19.pdf
Figures for the Cirrus and Cessna 182 BRS systems indicate a weight between 79 and 85lbs.
Looking at the cutaway of the Tutor http://www.eaachapter837.org/pages/m...15-cutaway.jpg suggests that connecting a strop to each spar/main leg would be possible, with a third line going under a frangible fairing to the top of the firewall. Frangible fairings covering external strops would be the easiest way of achieving this without the trenches in the structure used by Cirrus.
If firing the parachute out the top is impractical for the reasons you describe, then firing it out one side or the other has to be the next best solution.
If there was a will to fit an airframe parachute to the Tutor it could be done.
Biscuit74 wrote
Recollections from ex-cadets who flew their AEFs in Chipmunks, include sitting on piles of folded up RAF greatcoats between their bottom and the parachute, to take up the slack in the parachute straps and to get them high enough to see out. Successful egress in an emergency clearly wasn't a priority then! 
http://www.grob-aircraft.eu/tl_files...t-10-02-19.pdf
Figures for the Cirrus and Cessna 182 BRS systems indicate a weight between 79 and 85lbs.
Looking at the cutaway of the Tutor http://www.eaachapter837.org/pages/m...15-cutaway.jpg suggests that connecting a strop to each spar/main leg would be possible, with a third line going under a frangible fairing to the top of the firewall. Frangible fairings covering external strops would be the easiest way of achieving this without the trenches in the structure used by Cirrus.
If firing the parachute out the top is impractical for the reasons you describe, then firing it out one side or the other has to be the next best solution.
If there was a will to fit an airframe parachute to the Tutor it could be done.
Biscuit74 wrote
The AEFs and others used Chipmunks for years, with standard parachutes for cadets. That was viewed as satisfactory, with adequate briefing. What has changed - the attitude to risk ?