Fatal Accident Inquiries and Inquest
JTO, I'm not sure what part of my post is not what happened. Could you elucidate, please?
It was not lobbied for by the sharp end and ESF was not offered as part of the C130K original build. The MoD did not select who reported to the coroner either; he had a free hand and exercised it.
Well, that's a lot of what didn't happens for sure.
As to wasn't offered that is contrary to my understanding. We purchased the K's via the USAF who were already fitting ESF from new as standard (and no doubt retro fitting their existing fleet). The account that I recall was that it was not only offered but recommended (given USAF experience in Vietnam), but if my impression is wrong then of course I withdraw that claim. Not only did we not get ESF, we didn't even get FSII, a pennies per gallon fuel additive, that led to the first of many Herc related windfalls for Marshalls by replanking the entire fleet. The same desire not to spend more dollars than the $60,000 that the fleet cost us led to MOD raising its own spec for ESF. They didn't spend the £'s that would have cost either, of course.
As to wasn't called for from the sharp end, that I do dispute. Some posters on nigegilb's "Parliamentary Questions" thread testified to exactly that, notably including flipster. The thread is long buried but can be exhumed here:-
http://www.pprune.org/military-aviat...es-safety.html
there is more likely evidence towards the end of the thread I suspect.
As to MOD witnesses, a coroner may call for them, but that doesn't mean that anything of consequence will result. Famously at this inquest, the officer responsible then for RAF C-130 airworthiness claimed that fitness for purpose was not his concern. It is of course a major component of military airworthiness and XV179 was both not fit for purpose but also unairworthy as a result.
As to wasn't offered that is contrary to my understanding. We purchased the K's via the USAF who were already fitting ESF from new as standard (and no doubt retro fitting their existing fleet). The account that I recall was that it was not only offered but recommended (given USAF experience in Vietnam), but if my impression is wrong then of course I withdraw that claim. Not only did we not get ESF, we didn't even get FSII, a pennies per gallon fuel additive, that led to the first of many Herc related windfalls for Marshalls by replanking the entire fleet. The same desire not to spend more dollars than the $60,000 that the fleet cost us led to MOD raising its own spec for ESF. They didn't spend the £'s that would have cost either, of course.
As to wasn't called for from the sharp end, that I do dispute. Some posters on nigegilb's "Parliamentary Questions" thread testified to exactly that, notably including flipster. The thread is long buried but can be exhumed here:-
http://www.pprune.org/military-aviat...es-safety.html
there is more likely evidence towards the end of the thread I suspect.
As to MOD witnesses, a coroner may call for them, but that doesn't mean that anything of consequence will result. Famously at this inquest, the officer responsible then for RAF C-130 airworthiness claimed that fitness for purpose was not his concern. It is of course a major component of military airworthiness and XV179 was both not fit for purpose but also unairworthy as a result.
Last edited by Chugalug2; 20th Jul 2015 at 12:57. Reason: Right letters, though not necessarily in the right order...
I don't think flipster claimed that and we have had many a conversation on the subject.
By the time the Vietnam lessons were being learned the C130Ks had been delivered. If you wind back the clock to the late '60s it was the UK leading on ESF and had fitted it to the first trial installation aircraft at Lyneham.
Anyway, we digress and probably goes to show the importance of well-documented inquests and enquiries to avoid the facts being clouded.
By the time the Vietnam lessons were being learned the C130Ks had been delivered. If you wind back the clock to the late '60s it was the UK leading on ESF and had fitted it to the first trial installation aircraft at Lyneham.
Anyway, we digress and probably goes to show the importance of well-documented inquests and enquiries to avoid the facts being clouded.
"At 14:50 hours on 27 June 1990, the crew of Canberra WH972 from RAF Wyton took off from RAF Kinloss to participate in a maritime training exercise.
"The operational aspects of the sortie was completed uneventfully, and the crew commenced recovery for an Instrument Landing System (ILS) approach to runway 26 of RAF Kinloss.
"At around 600 feet above ground level (AGL) the navigator noticed that the aircraft was diverging from the ILS localiser course and advised the pilot accordingly.
"At first, the pilot attempted corrective measures, but then decided to overshoot the runway. He applied power to both engines. However, the port engine appeared to surge, resulting in a loss of power. The pilot attempted to throttle back and re-apply power, but this failed to clear the engine surge and consequent loss of power. At this point, the aircraft-- which was still in cloud - yawed and rolled rapidly to the left before striking the ground, almost inverted and nose down. The aircraft caught fire on impact with the ground.
"Very soon after the aircraft started rolling rapidly, the navigator ejected. Although he survived, he suffered major injuries.
"The pilot ejected shortly after the navigator; but by this time the aircraft was too close to the ground. Tragically, the pilot died on impact with the ground.
"The accident occurred in a field about 1nm mile E of RAF Kinloss."
It's now near enough 25 years since we lost my old friend from ULAS days, Flt Lt Cameron Maxwell Locke. I still remember him with great fondness, but I don't know anything about FAIs, etc.
"The operational aspects of the sortie was completed uneventfully, and the crew commenced recovery for an Instrument Landing System (ILS) approach to runway 26 of RAF Kinloss.
"At around 600 feet above ground level (AGL) the navigator noticed that the aircraft was diverging from the ILS localiser course and advised the pilot accordingly.
"At first, the pilot attempted corrective measures, but then decided to overshoot the runway. He applied power to both engines. However, the port engine appeared to surge, resulting in a loss of power. The pilot attempted to throttle back and re-apply power, but this failed to clear the engine surge and consequent loss of power. At this point, the aircraft-- which was still in cloud - yawed and rolled rapidly to the left before striking the ground, almost inverted and nose down. The aircraft caught fire on impact with the ground.
"Very soon after the aircraft started rolling rapidly, the navigator ejected. Although he survived, he suffered major injuries.
"The pilot ejected shortly after the navigator; but by this time the aircraft was too close to the ground. Tragically, the pilot died on impact with the ground.
"The accident occurred in a field about 1nm mile E of RAF Kinloss."
It's now near enough 25 years since we lost my old friend from ULAS days, Flt Lt Cameron Maxwell Locke. I still remember him with great fondness, but I don't know anything about FAIs, etc.
JTO
JTO, we have corresponded privately many times and I respect your position.
My perspective is from having spoken at length to the QC representing a widow, who called me from the Coroner's Court after MoD claimed not to know about ESF. I e-mailed him the ESF specifications I mentioned by return, and he submitted them to the Court. I did not, for example, breach the OSA, as they were freely available on-line; which made the MoD denial all the worse.
You probably know why I could not attend in person, but a respected contributor and aviation journalist made sure I had notes of, especially, the evidence of the IPTL. I would not say he lied over Fitness for Purpose, but his errors were gross and misled the Court. But very many in MoD, including anyone with airworthiness delegation, would/should have known he misled, and it was incumbent upon MoD to tell the Court this as soon as possible. They did not.
These errors, and his apparent total lack of understanding of what FFP is, how to achieve it and his role in this was utterly appalling. Appointing people to critical posts who are totally unsuited and untrained is an organisational failing in MoD. Again, any technical staff in his IPT should have known the team's precise role in FFP, yet none stepped forward.
On the subject of Vulnerability Assessment, he claimed the IPT and DPA/DE&S in general had nothing whatsoever to do with it. That it was correct the IPT was not even invited to meetings. If he'd read the regulations, he'd have known he and the Design Authority are actually the lead. I simply pointed the Court to the mandated regulations which, again, he and his staffs were required to know backwards.....
“The Chief Designer SHALL (i.e. mandatory) consult with the Integrated Project Team Leader (IPTL) and establish whether, and how, the vulnerability of the aeroplane Defined and Specified Threat Effects will be assessed and consider how subsequent design changes, if any, will be introduced.”
Key to this is "defined and specified threats". The regulations actually list a series of threats; #1 is inert projectiles, #2 is incendiary, and so on. That is, the DA and MoD don't have to think of the threat that brought the aircraft down, they are required to consider it and, if it is deemed a threat, implement the regulations (which call up ESF). And, if they don’t consider it a threat, record their reasoning why. And, by definition, if the threat is subsequently present, the mitigation is well known and can be implemented immediately.
As for when ESF was offered to MoD, our mandated regulations, if implemented, would require it to be notified by Lockheed to (a) the MoD Technical Agency (named individual responsible for the build standard), and (b) the Design Custodian (Marshall). (They were later appointed Design Authority for the UK standard in 1988). It is utterly deranged for anyone to suggest MoD did not know of ESF. It was in Lockheed's base build standard and their contract with MoD would, buried in the detail, include the cost of deviating from that standard by not having ESF fitted; even if the only action was a call-up in the GA drawing. Nor is it remotely conceivable that Marshall, upon realising there was an opportunity to modify C130 up to the base US standard, would not submit a costed proposal. There are just so many ways of MoD knowing of this. I still have my submission to the Court listing six.
When interviewed on 22.10.08 (BBC Radio 5, 1730 hrs), Bob Ainsworth MP admitted MoD knew of ESF in the 60s, but the "RAF didn't consider this the top priority". Referring to threats/vulnerabilities he said "We should have had the procedures in place to deal with this failure". He deliberately missed the point, as he'd been told beforehand the procedures were in place, they just weren't implemented. He also said the Coroner exposed the failures. Well, it was actually a series of very critical internal audits and ART reports between 1988 and 1998.
This is a litany of incompetence and deceit. Given the sheer number of people who knew the truth and let the IPTL's evidence stand, it is conscious misleading, by omission and commission. That is in many ways worse than simple lying, because it almost always requires collusion.
It is a distortion to say that the MoD lied over ESF. Whilst it exposed a massive gap in corporate knowledge it would be unfair to compare this to a deliberate lie - those that were asked simply did not know.
My perspective is from having spoken at length to the QC representing a widow, who called me from the Coroner's Court after MoD claimed not to know about ESF. I e-mailed him the ESF specifications I mentioned by return, and he submitted them to the Court. I did not, for example, breach the OSA, as they were freely available on-line; which made the MoD denial all the worse.
You probably know why I could not attend in person, but a respected contributor and aviation journalist made sure I had notes of, especially, the evidence of the IPTL. I would not say he lied over Fitness for Purpose, but his errors were gross and misled the Court. But very many in MoD, including anyone with airworthiness delegation, would/should have known he misled, and it was incumbent upon MoD to tell the Court this as soon as possible. They did not.
These errors, and his apparent total lack of understanding of what FFP is, how to achieve it and his role in this was utterly appalling. Appointing people to critical posts who are totally unsuited and untrained is an organisational failing in MoD. Again, any technical staff in his IPT should have known the team's precise role in FFP, yet none stepped forward.
On the subject of Vulnerability Assessment, he claimed the IPT and DPA/DE&S in general had nothing whatsoever to do with it. That it was correct the IPT was not even invited to meetings. If he'd read the regulations, he'd have known he and the Design Authority are actually the lead. I simply pointed the Court to the mandated regulations which, again, he and his staffs were required to know backwards.....
“The Chief Designer SHALL (i.e. mandatory) consult with the Integrated Project Team Leader (IPTL) and establish whether, and how, the vulnerability of the aeroplane Defined and Specified Threat Effects will be assessed and consider how subsequent design changes, if any, will be introduced.”
Key to this is "defined and specified threats". The regulations actually list a series of threats; #1 is inert projectiles, #2 is incendiary, and so on. That is, the DA and MoD don't have to think of the threat that brought the aircraft down, they are required to consider it and, if it is deemed a threat, implement the regulations (which call up ESF). And, if they don’t consider it a threat, record their reasoning why. And, by definition, if the threat is subsequently present, the mitigation is well known and can be implemented immediately.
As for when ESF was offered to MoD, our mandated regulations, if implemented, would require it to be notified by Lockheed to (a) the MoD Technical Agency (named individual responsible for the build standard), and (b) the Design Custodian (Marshall). (They were later appointed Design Authority for the UK standard in 1988). It is utterly deranged for anyone to suggest MoD did not know of ESF. It was in Lockheed's base build standard and their contract with MoD would, buried in the detail, include the cost of deviating from that standard by not having ESF fitted; even if the only action was a call-up in the GA drawing. Nor is it remotely conceivable that Marshall, upon realising there was an opportunity to modify C130 up to the base US standard, would not submit a costed proposal. There are just so many ways of MoD knowing of this. I still have my submission to the Court listing six.
When interviewed on 22.10.08 (BBC Radio 5, 1730 hrs), Bob Ainsworth MP admitted MoD knew of ESF in the 60s, but the "RAF didn't consider this the top priority". Referring to threats/vulnerabilities he said "We should have had the procedures in place to deal with this failure". He deliberately missed the point, as he'd been told beforehand the procedures were in place, they just weren't implemented. He also said the Coroner exposed the failures. Well, it was actually a series of very critical internal audits and ART reports between 1988 and 1998.
This is a litany of incompetence and deceit. Given the sheer number of people who knew the truth and let the IPTL's evidence stand, it is conscious misleading, by omission and commission. That is in many ways worse than simple lying, because it almost always requires collusion.
Tuc,
I don't disagree with any of your points. But I still content that the failures in corporate memory and the lack of value we place in experience, qualifications and good old fashioned filing left future generations at MoD poorly equipped to do their jobs. Add in the continual lack of cash to fund research meant that were very few opportunities to plug the gap. But there were opportunities and these were squandered with little or no accountability.
The unfortunate sqn ldr who spent over a year stitching together six decades of fuel tank research from archives all over the UK did it as an untasked, unfunded personal effort to put the 8000 pages of evidence over what we knew and when into the coroners hands. The house of cards that was the MoD's position simply collapsed. Very painful times for the sqn ldr, but the truth had to come out. I've no idea why the BoI president sat on this evidence for so long.
You are correct that a number of senior officers appeared to lie on oath. I also believe that these officers had a very poor appreciation of the facts and lied more to cover their inadequacy and poor performance in their previous roles rather than any directed conspiracy. Quite simply some of them did not give a sh*t and openly expressed their lack of concern for the crews ahead of the shoot down. The 'cannot remember anything' excuse became commonplace when the special investigator started his interviews.
Still, some very good men told the truth and that is what mattered in the end.
I don't disagree with any of your points. But I still content that the failures in corporate memory and the lack of value we place in experience, qualifications and good old fashioned filing left future generations at MoD poorly equipped to do their jobs. Add in the continual lack of cash to fund research meant that were very few opportunities to plug the gap. But there were opportunities and these were squandered with little or no accountability.
The unfortunate sqn ldr who spent over a year stitching together six decades of fuel tank research from archives all over the UK did it as an untasked, unfunded personal effort to put the 8000 pages of evidence over what we knew and when into the coroners hands. The house of cards that was the MoD's position simply collapsed. Very painful times for the sqn ldr, but the truth had to come out. I've no idea why the BoI president sat on this evidence for so long.
You are correct that a number of senior officers appeared to lie on oath. I also believe that these officers had a very poor appreciation of the facts and lied more to cover their inadequacy and poor performance in their previous roles rather than any directed conspiracy. Quite simply some of them did not give a sh*t and openly expressed their lack of concern for the crews ahead of the shoot down. The 'cannot remember anything' excuse became commonplace when the special investigator started his interviews.
Still, some very good men told the truth and that is what mattered in the end.
JTO
Thank you. Fully concur, although I still say there was a conspiracy of silence. It is subtle but everyone in MoD knows the consequences of speaking the truth.
At least everyone admits there was an investigation! On Sea King ASaC, MoD now denies one of the three investigations took place. Which is why you keep records. And why I say that one is the worst of all. The other cases were won by knowing what questions to ask and what info to ask for. You eventually find someone who, often inadvertently, tells the truth. But on ASaC the lies have been consistent on this one aspect, from all sides of MoD, which implies collusion. The investigation of January/February 2004 did not take place, despite the written submissions and e-mails being presented to MoD and the BoI President. You always ask why and who benefits! It is why pprune is so valuable.
Thank you. Fully concur, although I still say there was a conspiracy of silence. It is subtle but everyone in MoD knows the consequences of speaking the truth.
At least everyone admits there was an investigation! On Sea King ASaC, MoD now denies one of the three investigations took place. Which is why you keep records. And why I say that one is the worst of all. The other cases were won by knowing what questions to ask and what info to ask for. You eventually find someone who, often inadvertently, tells the truth. But on ASaC the lies have been consistent on this one aspect, from all sides of MoD, which implies collusion. The investigation of January/February 2004 did not take place, despite the written submissions and e-mails being presented to MoD and the BoI President. You always ask why and who benefits! It is why pprune is so valuable.
Thank you tuc and JTO for dotting and crossing the i's and t's for us. I would merely add that an Airworthiness Authority that suffers from "a loss of corporate memory" is an Air Safety hazard in itself. That is why Coroners' Inquests and FAI's are so vital to the UK Military Air Safety process, and will be into the foreseeable future. That is why DV's probing into why that doesn't happen is an important Air Safety contribution and should be seen as such by those who want UK Military Aviation avoidable accidents to be avoided in future.
[MOAN ON]Whether those who called for ESF protection to the Hercules fleet over the decades were lobbying, pleading, or merely moaning, a system that had investigated, specified, and even trialled such protection could not only ignore those calls but then forget the very protection system itself speaks volumes about the dysfunctional state of UK Military Air Safety.[/MOAN OFF]
[MOAN ON]Whether those who called for ESF protection to the Hercules fleet over the decades were lobbying, pleading, or merely moaning, a system that had investigated, specified, and even trialled such protection could not only ignore those calls but then forget the very protection system itself speaks volumes about the dysfunctional state of UK Military Air Safety.[/MOAN OFF]
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Jackonicko
This is the sort of information we are looking for, relating to a military fatality in Scotland after the introduction of the 1976 Act. It is pointless asking the Crown Office as they claim their records do not go back that far; they had problems recovering data for the 2009 Glen Kinglass accident for the Justice Committee. The only hope is contact friends and families in oreder to find out what happened.
DV
It's now near enough 25 years since we lost my old friend from ULAS days, Flt Lt Cameron Maxwell Locke. I still remember him with great fondness, but I don't know anything about FAIs, etc.
DV
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ALTAM
I believe you are correct. Now the Crown Office has to go along with the errors of the past for fear of having to admit that their judgement was flawed. Following the release of the SI report into the Moray Firth accident, several meetings took place between the Crown Office and the MAA, but nothing between the Crown Office and families.
DV
I think that is more the influence that MoD had in those days. The trust us, we will investigate and let you know what happened was alive and well and was trusted by civil authorities.
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thanks for the input Tuc and others.
It still seems crystal clear to me however, that it is the Scottish Legal System in the dock (pun intended). If there was hegemonic influence from third parties, frankly that makes it even worse.
Having seen a number of threads by DV on this subject, it seems to me that if he (or she, idk) wishes to get useful information, it would be best that the threads are kept firmly on track and not drift off into MOD/RAF bashing or rumour/innuendo about specific accidents - neither of which are pertinent to DV's specific task. Which, unless I am mistaken, is to database all military aircraft fatalities, in Scotland, in recent history and find out which, if any, had a Scottish FAI.
It still seems crystal clear to me however, that it is the Scottish Legal System in the dock (pun intended). If there was hegemonic influence from third parties, frankly that makes it even worse.
Having seen a number of threads by DV on this subject, it seems to me that if he (or she, idk) wishes to get useful information, it would be best that the threads are kept firmly on track and not drift off into MOD/RAF bashing or rumour/innuendo about specific accidents - neither of which are pertinent to DV's specific task. Which, unless I am mistaken, is to database all military aircraft fatalities, in Scotland, in recent history and find out which, if any, had a Scottish FAI.
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Which, unless I am mistaken, is to database all military aircraft fatalities, in Scotland, in recent history and find out which, if any, had a Scottish FAI.
DV
TOFO, you are spot on. I would only add, "or UK Coroner's Inquest". Its important to see how consistant the Crown Offiice has been over the years with their interpretation of the 1976 ACT.
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I note that the Lord Advocate (Mr Ronald King Murray) stated in the House of Commons on 30th March 1976, prior to the introduction on the 1976 FAI Act, that "it is in the public interest to ascertain what is wrong with the system irrespective of the status of the of the person killed".
As stated earlier, the spirit/intent of the 1976 Act has been ignored. Who gains?
DV
As stated earlier, the spirit/intent of the 1976 Act has been ignored. Who gains?
DV
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1976 Act
The question DV, is why wait near on 40 years to rail against vagaries in Scottish Law in a Rumour Website when you should be organising petitions and rallies to argue your case in Holyrood.
Last edited by Dougie M; 28th Jul 2015 at 06:41.
The question DV, is why wait near on 40 years to rail against vagaries in Scottish Law in a Rumour Website when you should be organising petitions and rallies to argue your case in Holyrood.
dervish
I concur
I concur