Helicopter down in Afghanistan
Join Date: Mar 2012
Location: Bristol
Posts: 16
Likes: 0
Received 0 Likes
on
0 Posts
It was reported in 2013 that, "Wire strike is Cdr JHC's (ODH)'s second highest Air Safety risk". Was this Puma fitted with Wire Strike Protection (first mentioned in PART report in 1995), or was the essential modification delayed in the same way as CWS for Tornado? Did the ODH sign off to say that the risk of Wire Strike was ALARP?
DV
DV
An excellent reply triboy.
My take on what Distant Voice is referring to, is the general process by which MoD decides a risk is ALARP, and continues to be so. My own experience of wire avoidance is of a very short period in 1986, when the laser based detection system was first offered in response to an RAF requirement (so far, so good - this shows a major part of the process was working). It was, rightly, not the solution at that time, mainly because the kit was quite large; but in terms of distance/wire thickness, it far exceeded the RAF spec. In project management terms, the basic technology was mature, but the system integration level lagged a little. That is normal, you need a customer to come along, thus firming up the direction the design takes. In this case, for example, the warning was on a PC in a lab, but in the aircraft it was to be on the HUD.
But, and this is what DV is (I think) getting at, the obvious next step in 1986 was to consider an R&D programme with an aim of getting the SIRL to the next level. (Wasn't called SIRL then, but there was an equivalent process set out by the Chief Scientific Advisor). But nothing was done and, I assume, the Risk Registers in DEC (!! discuss) show little or no progress (as suggested in 2013 - see DV's post); whereas the underlying technology has moved on in leaps and bounds. The Safety Management System demands continuous assessment (and improvement). MoD's failure to meet this obligation lies beneath many accidents. With MoD's withdrawal, the team just applied the science to another customer's requirement, which happened to be Air Traffic Control and missile launching. About 8 years ago they were all made redundant and MoD probably doesn't even realise it owns the Intellectual Property Rights. This is a recurring theme. In 2006, the Nimrod IPT issued an Invitation to Tender to undertake a 3 year R&D programme into mitigating a safety critical risk, not knowing the aircraft office next door had had the solution in service since 1996, to a far better spec than Nimrod sought; and had then improved it in 2001. The old 1996 kit could have just been handed to Nimrod, if that's all they wanted. These are Organisational failures which accident investigations are required to assess, but seldom do. In other words, we never learn, unless you ignore orders.
Wire avoidance is mainly based on mapping that has known telegraph/power cables.
But, and this is what DV is (I think) getting at, the obvious next step in 1986 was to consider an R&D programme with an aim of getting the SIRL to the next level. (Wasn't called SIRL then, but there was an equivalent process set out by the Chief Scientific Advisor). But nothing was done and, I assume, the Risk Registers in DEC (!! discuss) show little or no progress (as suggested in 2013 - see DV's post); whereas the underlying technology has moved on in leaps and bounds. The Safety Management System demands continuous assessment (and improvement). MoD's failure to meet this obligation lies beneath many accidents. With MoD's withdrawal, the team just applied the science to another customer's requirement, which happened to be Air Traffic Control and missile launching. About 8 years ago they were all made redundant and MoD probably doesn't even realise it owns the Intellectual Property Rights. This is a recurring theme. In 2006, the Nimrod IPT issued an Invitation to Tender to undertake a 3 year R&D programme into mitigating a safety critical risk, not knowing the aircraft office next door had had the solution in service since 1996, to a far better spec than Nimrod sought; and had then improved it in 2001. The old 1996 kit could have just been handed to Nimrod, if that's all they wanted. These are Organisational failures which accident investigations are required to assess, but seldom do. In other words, we never learn, unless you ignore orders.
Join Date: Mar 2007
Location: Bristol Temple Meads
Posts: 869
Likes: 0
Received 0 Likes
on
0 Posts
Puma Service Inquiry
The Service Inquiry report, published on 15th Dec 2016, cites the following as one of the main causes of the Puma accident in Afghanistan on 11th Oct 2015.
DV
The Panel assessed that a loss of situation awareness was caused by the discussion regarding ground features and resulted in the loss of visual contact with the formation leader. Subsequently, and in attempting to regain sight of the lead aircraft, there was a resultant reduction in awareness regarding the PTDS.
Loss of situation awareness was, according to the Coroner, one of the main causes of the loss of Lynx helicopter a year earlier. Puma and Lynx helicopters were not fitted with collision warning systems at the time of their respective accidents. In both cases pilots were on visual look out for the other aircraft they were flying with. Collision was the top risk according to the Duty Holder, Major General Felton, but still he signed off to say the risk was tolerable and ALARP. He needs to justify this at the inquest.'The safety statement in effect in May 2015 was that made at the 4th Puma 2 Puma Air System Safety Working Group on 4 February 2015, i.e. “Having reviewed the Equipment Safety Case, Hazard Log, Release to Service, Statement of Operating Intent and Usage, Air Safety Risk Registers and all governance issues, as Operating Duty Holder, I am content that all the Risks to Life on the Puma HC Mk2 are at least Tolerable and As Low As Reasonably Practicable' .
Also, Puma was not fitted with 'cable cutting' equipment at the time. Wire strike was another high risk according to the Duty Holder, but signed off as tolerable and ALARP.DV
Last edited by Distant Voice; 19th Dec 2016 at 18:06. Reason: Correction; Puma not Lynx in final paragraph
I've sat at many such events to hear the ALARP turned on its head - '...we are operating the platform so it must be ALARP'. Another one is '...it was ALARP at the last meeting and nothing has changed with the aircraft configuration so it must still be ALARP....'.
The comments reported on wrt the issues and perspective of ALARP appear to be centred around the current airframe. However, if technology, which is maturing, but not actively being explored or acknowledged by the MOD, then the statement itself would not stand scrutiny......?
With reference to the report itself, and looking at the devastation suffered in the cabin, it will be interesting to see what efforts are being put into improving the crash worthiness of seating for pax and the third member of the crew?
Moreover, considering that the 'bench style' seating used in the rear of 4-T trucks and other similar vehicles, was replaced post a number of RTAs in the 90's, I would now expect to see a similar change or at least an investigation into better seating as the ac has an OSD of beyond 2025!
Finally, I appreciate the forces incurred in the ac impact (15-30g) maybe significantly greater than a RTA, and the reduction in the 'survivable space' may not be fully mitigated by a redesign of the seating, but surely this is the opportunity to give those that travel in the rear of the ac something more effective for a heavy landing etc. Or will there be another slant on the use of ALARP and the SI's recommendations be ignored?
With reference to the report itself, and looking at the devastation suffered in the cabin, it will be interesting to see what efforts are being put into improving the crash worthiness of seating for pax and the third member of the crew?
Moreover, considering that the 'bench style' seating used in the rear of 4-T trucks and other similar vehicles, was replaced post a number of RTAs in the 90's, I would now expect to see a similar change or at least an investigation into better seating as the ac has an OSD of beyond 2025!
Finally, I appreciate the forces incurred in the ac impact (15-30g) maybe significantly greater than a RTA, and the reduction in the 'survivable space' may not be fully mitigated by a redesign of the seating, but surely this is the opportunity to give those that travel in the rear of the ac something more effective for a heavy landing etc. Or will there be another slant on the use of ALARP and the SI's recommendations be ignored?
Last edited by Could be the last?; 30th Dec 2016 at 10:11.
I'm not sure cutters would have helped here. Reading the report suggests the HP made a late, and instinctive, break to try to avoid the wire which placed the wire through the disc and, ultimately, over the boom where it fatally weakened the TRDS. WSPS are normally designed to cut horizontal wires you haven't seen. The key here is SA. The wirestrike risk was, likely, considered adequately mitigated by HLS maps,briefing, lookout and the obstructions tablet (which it seems the crews didn't use in congested areas....). The loss of SA degraded the lookout with aggravating factors (distraction, low arousal task, cockpit frames, Day HUD etc) leading to the holes lining up. It was not their day. The fact that anyone survived such an impact should be somewhat encouraging - but something better can always be found. There are plenty of active wire/obstacle warning systems out there, fully mature, in production and fitted to civ and mil aircraft - MoD considers an advisory only tablet (the database of which is out of date the moment 'save' is pressed...it doesn't take long to put up an aerial or string a wire...), route study, HLS books and lookout to be effective mitigation. Perhaps it's time to look at it again?
Join Date: Mar 2007
Location: Bristol Temple Meads
Posts: 869
Likes: 0
Received 0 Likes
on
0 Posts
Downsizer and TOTD; If you click on the thread title you will see that it was opened on 11th Oct 2015, and there are three pages of postings. Clearly not new.
DV
DV
I have compiled and published a number of books which list the RAFs aircraft losses between VE-Day and 2009 (9000+ aircraft/6000+ fatal casualties) and I try to keep the record up to date, in case there is ever a requirement to extend the coverage.
As regards the aircraft subject to this Thread, I know the names of the RAF crew and the two USAF personnel who were killed but have been unable to find the identity of the French civilian contractor, who was the fifth fatal casualty.
Please does anybody know and please will they PM me with the info?
Old Duffer
As regards the aircraft subject to this Thread, I know the names of the RAF crew and the two USAF personnel who were killed but have been unable to find the identity of the French civilian contractor, who was the fifth fatal casualty.
Please does anybody know and please will they PM me with the info?
Old Duffer
Thank you DV.
The next one which is proving more difficult are the two scientists involved in an RAE Puma in France several years ago but I'm still digging with that one.
Grateful for your prompt help.
Old Duffer
The next one which is proving more difficult are the two scientists involved in an RAE Puma in France several years ago but I'm still digging with that one.
Grateful for your prompt help.
Old Duffer
Join Date: Mar 2007
Location: Bristol Temple Meads
Posts: 869
Likes: 0
Received 0 Likes
on
0 Posts
Coroner's Narrative Verdict
The narrative verdict by the coroner is wrong, as it places most of the blame on the aircrew. On the balance of probability the evidence suggests that the crew were fixated on locating the other aircraft, not the football pitch.
Coroner Rules Afghan Helicopter Crash "Was An Avoidable Accident"
The Service Inquiry report, published on 15th Dec 2016, cites the following as one of the main causes of the Puma accident in Afghanistan on 11th Oct 2015.
"The Panel assessed that a loss of situation awareness was caused by the discussion regarding ground features and resulted in the loss of visual contact with the formation leader. Subsequently, and in attempting to regain sight of the lead aircraft, there was a resultant reduction in awareness regarding the PTDS."
Loss of situation awareness was, according to the Coroner, one of the main causes of the loss of Lynx helicopter a year earlier. Puma and Lynx helicopters were not fitted with collision warning systems at the time of their respective accidents. In both cases pilots were on visual look out for the other aircraft they were flying with. Collision was the top risk according to the Duty Holder, Major General Felton, but still he signed off to say the risk was tolerable and ALARP. Wire strike was the second highest risk.
In March 2016, MoD confirmed that the installation of a Wire Strike Protection System and a CWS were in the process of being installed in the Puma Mk2 helicopter. But these facts to not appear to get mentioned at the inquest.
DV
Coroner Rules Afghan Helicopter Crash "Was An Avoidable Accident"
The Service Inquiry report, published on 15th Dec 2016, cites the following as one of the main causes of the Puma accident in Afghanistan on 11th Oct 2015.
"The Panel assessed that a loss of situation awareness was caused by the discussion regarding ground features and resulted in the loss of visual contact with the formation leader. Subsequently, and in attempting to regain sight of the lead aircraft, there was a resultant reduction in awareness regarding the PTDS."
Loss of situation awareness was, according to the Coroner, one of the main causes of the loss of Lynx helicopter a year earlier. Puma and Lynx helicopters were not fitted with collision warning systems at the time of their respective accidents. In both cases pilots were on visual look out for the other aircraft they were flying with. Collision was the top risk according to the Duty Holder, Major General Felton, but still he signed off to say the risk was tolerable and ALARP. Wire strike was the second highest risk.
In March 2016, MoD confirmed that the installation of a Wire Strike Protection System and a CWS were in the process of being installed in the Puma Mk2 helicopter. But these facts to not appear to get mentioned at the inquest.
DV
Last edited by Distant Voice; 15th Sep 2017 at 11:02. Reason: Add Title
Collision was the top risk according to the Duty Holder, Major General Felton, but still he signed off to say the risk was tolerable and ALARP.
Join Date: Mar 2007
Location: Bristol Temple Meads
Posts: 869
Likes: 0
Received 0 Likes
on
0 Posts
Because with a program in place to fit a Traffic Awareness System to the Puma there was nothing more that could practicably be done.
Unfortunately, Duty Holders seen to thing that there is such a thing as ALARP (temporal), and there isn't.
DV
You could stop flying in pairs.
The HSE may say that, but they don't provide the regulation that aviation operates under, civilian or military. They were very clear on that when I asked them for some advice.
A difficulty certainly arises if the modification is considered "essential" to safety (e.g. to mitigate a Class A risk) as the regs say "to be embodied irrespective of delay, scrap or downtime involved". The fact that the risk of collision and death was predicted, and ultimately occurred, seals it. So, who above General Felton signed to say it would be borne?