UK HELICOPTER DOWN IN AFGHANISTAN
Avoid imitations
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My sincere condolences to all affected by the tragedy.
Another sobering reminder of the fraility of human life in the face of adversity.
Another sobering reminder of the fraility of human life in the face of adversity.
Not sure if this doesn't warrant a new thread, since this one doesn't really include much other than condolences and media-bashing.
But anyway, the Beeb has reported on the conclusion of the coroner's inquest into the five deaths.
Afghanistan helicopter crash inquest: Coroner calls for safety improvements - BBC News
I don't recall seeing any reports of the Service Inquiry.
airsound
But anyway, the Beeb has reported on the conclusion of the coroner's inquest into the five deaths.
Afghanistan helicopter crash inquest: Coroner calls for safety improvements - BBC News
I don't recall seeing any reports of the Service Inquiry.
airsound
There was one.
Strange how our latest top 5 Risks to Life for mil crews doesn't include CFIT!
Strange how our latest top 5 Risks to Life for mil crews doesn't include CFIT!
In this case, and within MAA imposed restrictions, the SI did a very good job; obviously helped by having a CVR, despite the installation design being poor. But what is lacking is a knowledgeable overview, perhaps helped by a simple relational database, which produces a comment of "FFS, NOT AGAIN". There are whole sections of this SI report that could have been lifted from ZD576 in 1994. Nobody asks "Why have previous recommendations not been implemented?" Yet again, defences in depth have been weakened or eliminated through not implementing mandated regs.
The most obvious similarity, and picked up by the media, was the RadAlt. The same one is fitted to both aircraft. Therefore, the same systemic failures apply. Like ZD576, there are lots of comments and implied criticism of crew, but there is no technical investigation of the background to see what could cause such failures. One simple example - has the modification been embodied to eliminate false tracking at 100-200 feet, which results in the indicators lurching through steps and false LLW warnings? I'd like to see the engineering report. In the list of avionics does it note the mod state? It's a simple thing to do. Then, the person employed to know about this can take one look and say "Well, you wouldn't expect it to work properly" - or whatever. On the other hand, I wonder if MoD realises this Lynx report actually contains the explanation that, had it been acknowledged on ZD576, would have prevented criticisms of that crew. (LLW bug procedures).
There is another thread running about how the MAA is getting on, after 6 years. Judging by this case, one step forward, two back.
The most obvious similarity, and picked up by the media, was the RadAlt. The same one is fitted to both aircraft. Therefore, the same systemic failures apply. Like ZD576, there are lots of comments and implied criticism of crew, but there is no technical investigation of the background to see what could cause such failures. One simple example - has the modification been embodied to eliminate false tracking at 100-200 feet, which results in the indicators lurching through steps and false LLW warnings? I'd like to see the engineering report. In the list of avionics does it note the mod state? It's a simple thing to do. Then, the person employed to know about this can take one look and say "Well, you wouldn't expect it to work properly" - or whatever. On the other hand, I wonder if MoD realises this Lynx report actually contains the explanation that, had it been acknowledged on ZD576, would have prevented criticisms of that crew. (LLW bug procedures).
There is another thread running about how the MAA is getting on, after 6 years. Judging by this case, one step forward, two back.
Thanks Mil-26 - missed that!
tuc - I'm sure most people will realise that when you say ZD576, you're referring to the Mull of Kintyre Chinook. But perhaps not everyone....
airsound
tuc - I'm sure most people will realise that when you say ZD576, you're referring to the Mull of Kintyre Chinook. But perhaps not everyone....
airsound
Here's the full text of the narrative conclusion of HM Senior Coroner for Oxfordshire, published with his permission
airsound
Lynx Inquest - Oxford Coroners Court 15 March 2016 - Narrative Conclusion
On Saturday 26 April 2014 at approximately 10:30 local Afghan time, Lynx Helicopter ZF540 crashed approximately 20 kilometres south of Kandahar Airfield in the Chaghray Ghar Valley, Afghanistan. All 5 on board (3 crew and 2 passengers) died from multiple injuries and the effects of fire. The aircraft was the lead aircraft in a formation of two Lynx helicopters conducting a live fire exercise in an area known as the Bowling Alley which is part of the Texas Helo Range. The incident occurred on the 6th serial of a race track pattern when the aircraft commander instructed the handling pilot to conduct an earlier left descending turn into the valley which required a higher rate of descent than the previous serials. The other Lynx helicopter was ahead in the valley range and it was necessary for the crew to locate it and maintain separation whilst descending. There was a loss of situational awareness with respect to height and rate of closure with the ground resulting in a misjudgement of height over the featureless desert surface leading to an impact with the ridge of a dried up riverbed not seen by crew until too late, about 1 second prior to impact with the ground. The radar altimeter which provides a warning to the crew of proximity to the ground was set below the authorised minimum at only 25ft and did not alarm in time to enable the crew to prevent the aircraft being accidently flown in to the ground. The accident was contributed to by under manning and an unsatisfactory system of training on the squadron resulting in the potential for cumulative fatigue and skill fade.
Mr D. M. Salter HM Senior Coroner for Oxfordshire
On Saturday 26 April 2014 at approximately 10:30 local Afghan time, Lynx Helicopter ZF540 crashed approximately 20 kilometres south of Kandahar Airfield in the Chaghray Ghar Valley, Afghanistan. All 5 on board (3 crew and 2 passengers) died from multiple injuries and the effects of fire. The aircraft was the lead aircraft in a formation of two Lynx helicopters conducting a live fire exercise in an area known as the Bowling Alley which is part of the Texas Helo Range. The incident occurred on the 6th serial of a race track pattern when the aircraft commander instructed the handling pilot to conduct an earlier left descending turn into the valley which required a higher rate of descent than the previous serials. The other Lynx helicopter was ahead in the valley range and it was necessary for the crew to locate it and maintain separation whilst descending. There was a loss of situational awareness with respect to height and rate of closure with the ground resulting in a misjudgement of height over the featureless desert surface leading to an impact with the ridge of a dried up riverbed not seen by crew until too late, about 1 second prior to impact with the ground. The radar altimeter which provides a warning to the crew of proximity to the ground was set below the authorised minimum at only 25ft and did not alarm in time to enable the crew to prevent the aircraft being accidently flown in to the ground. The accident was contributed to by under manning and an unsatisfactory system of training on the squadron resulting in the potential for cumulative fatigue and skill fade.
Mr D. M. Salter HM Senior Coroner for Oxfordshire
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I note that in para 1.4.235 we get back to the old subject of Duty Holders and ALARP. The ODH (2*) is legally responsible and accountable for the airworthiness, maintenance and safe use of the air systems in their defined area of responsibility. According to MAA RA1210 he is required to make an argument (written statement)that all risks are tolerable and ALARP, which must include CFIT. The validity of the argument can only be decided definitively by the courts, if an accident occurs; which it has. So will we see the Comd JHC (2*) in court, and who will initiate the move? If he goes to court then AOC No 1 Group must go to justify his tolerable and ALARP statement for Tornado.
I also note that, once again (page 1.4-67), the meaningless figure of 1 in 1000 per year is used as the acceptable level of tolerability. For Army Lynx the level was 0/1000 before the accident, and 6/1000 after the accident, which means that the CFIT risk is no longer tolerable and therefore not safe. The figure of 0/1000 is also used for Typhoon CWS, and suggests to me that MoD/MAA use actual death rates as the means of determining what is tolerable and what is not. No deaths means a risk is tolerable, this is worse than the approach used for Nimrod fire risk.
DV
I also note that, once again (page 1.4-67), the meaningless figure of 1 in 1000 per year is used as the acceptable level of tolerability. For Army Lynx the level was 0/1000 before the accident, and 6/1000 after the accident, which means that the CFIT risk is no longer tolerable and therefore not safe. The figure of 0/1000 is also used for Typhoon CWS, and suggests to me that MoD/MAA use actual death rates as the means of determining what is tolerable and what is not. No deaths means a risk is tolerable, this is worse than the approach used for Nimrod fire risk.
DV
A simple question. How does a typical ODH exercise his obligation to ensure airworthiness is attained and maintained? I wonder if the engineers who actually do it are now in his direct management chain. Interesting concept if they are. If he does not have absolute control, how can he be liable? There are lots of similar examples in MoD, and the CPS has ruled a number of times that this prevents accountability. We saw at the Nimrod and C130 inquests that the respective IPT leaders, 2 ranks below the ODH, had very little input over this in any way, as there were numerous and complex dependencies wholly outwith their knowledge, never mind control. At the latter, the IPTL admitted he hadn't a clue how fitness for purpose was attained or maintained, denying his team had anything to do with it, which any of his staff could have told him is nonsense. Bu**ers muddle if you ask me.
I suspect serious questions have now been asked of the MAA. They've existed for 6 years. It was predicted here at the time (late 2009) that they would be given a period of grace to get up and running. Someone will have asked why the same old failings remain. Hence, I suspect, the original question on the other thread discussing the MAA.
I suspect serious questions have now been asked of the MAA. They've existed for 6 years. It was predicted here at the time (late 2009) that they would be given a period of grace to get up and running. Someone will have asked why the same old failings remain. Hence, I suspect, the original question on the other thread discussing the MAA.
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The other Lynx helicopter was ahead in the valley range and it was necessary for the crew to locate it and maintain separation whilst descending. There was a loss of situational awareness with respect to height and rate of closure with the ground resulting in a misjudgement of height over the featureless desert surface
"There is no doubt that the TCAS II display rapidly becomes one of the more important instruments in the cockpit. The enhanced situational awareness provided by TCASII allows the pilots to concentrate on flying and operating the aircraft with higher levels of confidence and safety than would be possible with other systems"
DV
Last edited by Distant Voice; 17th Mar 2016 at 19:28. Reason: word spacing
