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'Placing Blame At Any Cost' (article relating to 52nd FW F-15 crash, 30th May 1995)

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'Placing Blame At Any Cost' (article relating to 52nd FW F-15 crash, 30th May 1995)

Old 1st Mar 2015, 10:23
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'Placing Blame At Any Cost' (article relating to 52nd FW F-15 crash, 30th May 1995)

Came across this article and found it interesting reading...

PLACING BLAME AT ANY COST - TIME

-RP
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Old 1st Mar 2015, 11:25
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It was called Murphy's Law, in my day.

Still doesn't excuse it, but it should be minimised.
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Old 1st Mar 2015, 13:42
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The article tries to politicize an incident that only required the application of basic engineering practices to avoid. An independent sense and movement check following work on a control system would have been mandatory within the MoD (or at least the one I remember), and the error would have been uncovered.

The fact that it wasn't done and the pilot died was almost certainly a failure of policy and practice within the USAF, so to hound the mechanics was simply a political ploy, but they did have the ultimate reponsibility for completing the task safely, hence were not blameless as the article insinuated.
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Old 1st Mar 2015, 15:48
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If true the hounding of the individuals is absolutely diabolical. Unfortunately I saw enough examples of a higher authority putting the blame on an individual lower down the food chain to cover up for their own mistakes. On one occasion I was "ordered" to charge one of my Sgt's by a MOD civil servant (B2) in an attempt to shift the blame away from his department. Of course I refused and suddenly all went quiet and the equipment concerned (which was under trial) scrapped and not brought into service.
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Old 1st Mar 2015, 16:05
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"Placing" blame is probably the wrong phrase since clearly there was blame to be placed in this instance. What is out of order here is that senior people appear to have been allowed to (ab)use their positions to make sure "little guys" took the hit while their wider systemic failures went unexamined.
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Old 1st Mar 2015, 16:49
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Two's in - XX164, Valley 13 Feb 1996.
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Old 1st Mar 2015, 18:22
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Simon Burgess, truly tragic. To make it back home after his 'incident' with Bob Ankerson, and then to lose him that way. Truly bloody awful.
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Old 1st Mar 2015, 18:50
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Indeed.
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Old 1st Mar 2015, 21:15
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I do not know how the U.S. Military operate but with civil aircraft any flight control rectification requires a duplicate inspection.This is carried out independently by two qualified personnel which would include a check that the control surface moved in the correct sense - that is what the check is for,to ensure that there is no crossed control. A civilian engineer or mechanic in Europe or the USA would have been held responsible.
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Old 2nd Mar 2015, 05:16
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In days long gone by, this problem was well known. The simple solution (for control wires) was to close junctions with turnbuckles of different diameters.

No reason why a similar idea should not be adopted for control rods. Then you can't assemble them incorrectly.

And it those halcyon days, you wiggled your rudder bar and stick when you climbed in, looked over your shoulder to see what the rudder and elevator were doing, and out along the wing to check ailerons. Everybody did that every time.

I suppose by "flaps" (in the original sad story), the writer means "elevators".

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Old 2nd Mar 2015, 08:35
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Agreed, gallacher; a civil aircraft engineer in this situation would probably find themselves in court too. And while I'm no expert on F15 preflight checks, isn't there a control check by the pilot which should have caught this?

None of this lets those in an oversight situation off the hook if, as seems the case, this tragedy was preceded by several near-identical accidents.
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Old 2nd Mar 2015, 09:30
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ShotOne wrote:
And while I'm no expert on F15 preflight checks, isn't there a control check by the pilot which should have caught this?
That was my thought too, particularly remembering the extensive check we used to do in the F-4 with the starter crew before taxying.

This shows an F-15 control check:


However, Courtney Mil will probably be able to say whether such a check is routine.
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Old 2nd Mar 2015, 09:51
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The Jaguar liney dance will be remembered by many, i assumed that other military fighters including the Hawk carried out similar checks, obviously not.
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Old 2nd Mar 2015, 14:15
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Interesting article. I knew Col Young (The Prosecutor in the case) he worked downstairs from me. Seemed a civil chap and ex-aircrew, he'd flown 'Igloo White' Missions over Vietnam. It shows the fairly unpleasant side of military 'Justice'.

ABS
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Old 2nd Mar 2015, 15:32
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Originally Posted by bcgallacher View Post
I do not know how the U.S. Military operate
No surprise, but I'd be careful about not using a grain of salt on this article. Given the narrative the author is promoting ... I'd be skeptical.
If the Air Force really wanted someone to blame for Lowry's crash, it could have gone back and figured out why no one had done anything following the earlier, identical mistakes. "Cross-connecting the rods is an easy mistake to make," an Air Force report warned after the 1986 foul-up. "We ought to fix it so they can't be connected wrong," a second said. The Air Force ignored that recommendation and even failed to warn its mechanics of the danger.
Depending on what maintenance manual one is working from, there are "CAUTION" and "WARNING" flags for certain maintenance procedures which, if gotten wrong, can cause damage, injury or death.
Typically, when one breaks a flight control linkage and has to put it back together to complete a repair, a QAR or CDQAR has to inspect the work. That was true in the Navy before I got into aviation in the early 80's, and I suspect the Air Force is/was at least as critical of flight control linkage repairs.

What this article asserts is that the maintenance manual and / or maintenance training didn't address a known nuance in a flight control assembly and disassembly. How many people are on the job isn't the issue.

I would presume that once a repair was done, the aircraft would have hydraulic power put on it and the flight controls moved through the range of motion to check for proper response before it was ever issued for flight. If that functional check was not part of the maintenance procedure at the time, in light of previous accidents, then one can easily argue that a "system error" was a major contributing cause of this accident.
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Old 2nd Mar 2015, 21:31
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I retired from the USAF in 1994. This article seem credible to me. I know of other instances where the lowest ranking person was court martialed for what were clearly accidents in which the root causes were management issues.

The Blackhawk shootdown mentioned in the article is the most egregious example, but I know of others.
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Old 3rd Mar 2015, 13:11
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Good point, Jim, in terms of USAF cultural influence on the incident.
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Old 3rd Mar 2015, 19:52
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"Cross connecting the rods is an easy mistake to make." - that is why a full control check is done after flight controls are disturbed. Over the years I have performed and certified innumerable flight control inspections under both European and FAA regulation - it is a check taken very seriously,not to be treated casually. Another point is that easily made mistakes on individual aircraft types is usually known about and the information disseminated by the 'mechanics Mafia'. Much information not in the maintenance manuals becomes known this way. Whoever signed the certification screwed up in no uncertain terms so I really do not think that it was a case of punishing the weakest.
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