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T-45C Crash Report

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Old 15th Apr 2018, 05:00
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T-45C Crash Report

Pretty savage indictment of the system.

Leadership failures in Navy pilot training squadrons led to Tennessee T-45 crash

The Navy’s official investigation into the Oct. 1 crash in rural Tennessee of a T-45C Goshawk from Training Squadron 7 concluded the crash was the fault of the instructor pilot, even though at the time of impact, he wasn’t at the controls.

Investigators said that the instructor pilot was “flat-hatting” by flying and directing his student to fly too close and too fast to ground, which is against the Navy’s procedure for such training of student pilots, the Navy’s investigation into the crash concluded. The report also said that the investigation shows that such out-of-bounds flights and unauthorized training had become part of culture in the VT-7, but also throughout all the Navy’s tactical jet training, which investigators called a “failure of leadership.”.....

“The investigation further demonstrated [Ruth] was overly confident, nonchalant and aggressive at low altitude training, with limited awareness of the performance capabilities of the T-45C in the [low altitude awareness training] environment,” Bynum wrote. “This attitude influenced [Ruth’s} instructional style and conditioned [Burch] to fly the aircraft in an aggressive manner, without correction from [Ruth].”.....

Bynum also said it was questionable that Ruth was even qualified to fly the T-45C or teach the low-level maneuvers, because there was no record he’d completed the requisite training in the T-45C himself and in the end formally concluded: “It was their actions flying the aircraft in violation of the [chief of naval air training] syllabus and training objectives that resulted in the mishap.”.....
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Old 15th Apr 2018, 06:11
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As a famous Naval Aviator would say, "Jumpin' Jehosaphat!"
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Old 15th Apr 2018, 07:43
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Not again...

I wrote something similar on a thread only a few days ago. If you’re not going to do low level training properly don’t do it at all.

I don’t like LLAT for reasons I have already discussed. This does nothing to change my mind.

I don’t like sitting in judgment on cases like this but I hate it when history repeats itself.

BV
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Old 15th Apr 2018, 08:43
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Remarkable that a USN pilot can join, train, fly orbits on the E-2C for his first 3-year tour, get posted as a fast jet instructor before wiping himself and his student out. Only now do they wonder if the instructor was even qualified on the T-45C.
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Old 15th Apr 2018, 12:26
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I would say it is more criminal than remarkable. I mean, WTF?!!!
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Old 15th Apr 2018, 17:33
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The report also said that the investigation shows that such out-of-bounds flights and unauthorized training had become part of culture in the VT-7, but also throughout all the Navy’s tactical jet training, which investigators called a “failure of leadership.
Bynum also said it was questionable that Ruth was even qualified to fly the T-45C or teach the low-level maneuvers, because there was no record he’d completed the requisite training in the T-45C
The former VT-7 skipper has retired. Will CNATRA (Rear Adm. Bynum) step down as well?

I'd be hard pressed to think of a case, civilian or military in the big leagues, where an instructor was never trained on an aircraft (s)he instructed on. There have been cases of missing signatures in a file and the like.

Was the instructor training done but not properly documented? Or, were things 'pencil-whipped' to expedite Lt. Ruth's qualification as a T-45C instructor?

I believe the Navy fires more skippers than the rest of the services combined. I would think some heads should roll if the facts are as presented in the article.

Anybody find a link to the actual accident report? Often these are published on an obscure military air safety database with a media release at happy hour on Friday afternoon.
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Old 15th Apr 2018, 20:35
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Salute!

A sad finding, but not one I dismissed back last year.

The debris field and the "witness" that saw the plane very low a minute before gave me the clue.

I was in the system when USAF decided that we had to make our stateside low altitude nav "legal". So we let down to lower than 500 feet AGL and practiced. Being in the VietNam group, we flew as low as required to get the job done whether a CSAR or CAS or interdiction mission. Then we came home and had restrictions. That all changed about 1974, and we trained to fly lower and lower. It worked.
++++++++

I have a hard time with a "nugget" IP that does not have a lotta hours in tactical planes serving as an instructor.

RIP.
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Old 16th Apr 2018, 08:40
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Gums - out of interest - roughly what's the lowest you'd estimate you've flown in a fast jet `stateside when training?
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Old 16th Apr 2018, 13:09
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Salute!

Before it was legal to go lower than 500 feet I got down one or two times low enough to experience ground effect! I was stoopid and very young.. Never did it again after realizing how stoopid it was.

In combat I would routinely get down to about 200 to 300 feet but that was for weapon delivery and not nav. Escorting a Jolly for a CSAR we would usually be about 500 or 600 feet in a race track about the Jolly. Ditto when escorting the Ranch Hand spray birds, you know the guys....
" Only we can pervent forests!"

After we changed things circa 1974, I was cleared to 200 feet legally, although sometimes you would have to get closer to the rocks when clearing a ridge or such.

At Red Flag when our flight defeated the SA-6, they showed the tape from the missile site at mission debrief for all to see and we never got lower than 200 feet but used the intervening hills and "beaming" maneuvers to break missile lock.

Coming out one day we spotted a Canadian F-5 that was so low his shadow was almost his size. Trouble with being that low is you can't fly a formation and you can't look around. So wingie and I joined above him and escorted him out. He was startled, and we saw a sudden wing dip, then an obvious wing rock and he came up a bit.

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Old 16th Apr 2018, 20:30
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Originally Posted by Airbubba View Post
The former VT-7 skipper has retired. Will CNATRA (Rear Adm. Bynum) step down as well?
For what?
I'd be hard pressed to think of a case, civilian or military in the big leagues, where an instructor was never trained on an aircraft (s)he instructed on.
Good thinking, why have you changed your mind now?
There have been cases of missing signatures in a file and the like.
Yes, or an expired qual, or someone flying a maneuver in a stage/phase they are not qualified to instruct in.
Was the instructor training done but not properly documented? Or, were things 'pencil-whipped' to expedite Lt. Ruth's qualification as a T-45C instructor?
The latter is unlikely; TW-1 has an ITU, and you don't get to sign for the bird and take any student up until you pass through the IUT syllabus. If you think that TW-1 pencil whips the IUT's, you better be able to back that up.
I believe the Navy fires more skippers than the rest of the services combined.
Heh, that is a fine old Naval Tradition.
Anybody find a link to the actual accident report?
Mishap reports are not for public release.
Often these are published on an obscure military air safety database with a media release at happy hour on Friday afternoon.
Do you mean the FOIA requests for the results of the JAG investigation? Any mishap that results in a fatality, or that has pilot error as a contributory cause, will typically have a JAG investigation as well. I've seen the JAG investigations take more time than the mishap investigations before.

Or do you think that, maybe, the journo is full of crap? I do. That has happened before.


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Remarkable that a USN pilot can join, train, fly orbits on the E-2C for his first 3-year tour, get posted as a fast jet instructor before wiping himself and his student out. Only now do they wonder if the instructor was even qualified on the T-45C.
Given that they can't, it is really remarkable that you made that up. two questions for you:
Did you actually serve in the armed forces as a pilot?
Did you, as I have sometimes done, Post Whilst Pissed?

Here are a few facts for you:
Fact 1. E-2 pilots go through strike training pipeline. That includes T-45 and carrier qual.
Fact 2. E-2 pilots are some of the IPs sent to Meridian and Kingsville to instruct, since all communities have to offer people up for IP duty.
Fact 3. All T-45 instructors at TW-1 and TW-2 have to complete the IUT before flying a single student "X."
Fact 4. I actually know something about how this works. PM me if you are interested in other facts.
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Old 16th Apr 2018, 21:14
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I’m a bit confused by this Lonewolf. You post a blow by blow rebuttal yet there seems to have been catastrophic errors made. Indeed even the Admiral says

Bynum also said it was questionable that Ruth was even qualified to fly the T-45C or teach the low-level maneuvers, because there was no record he’d completed the requisite training in the T-45C himself
Am I missing something?
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Old 16th Apr 2018, 21:58
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questionable that Ruth was even qualified to fly the T-45C or teach the low-level maneuvers
That bolded part I addressed, and is possibly what the journo was talking about. I do not find it credible that this person walked into the hangar in Mississippi, and was given a T-45 for an instructional hop without having ever gone through the ITU.

Not credible; that looks to me like a reporter putting the words into an Admiral's mouth ... or an Admiral speaking without precision. (It Happens! How many admirals and generals have you worked for? I've worked for a few ...)

So here are the question that is germane to the points I have addressed:

Was the IP's NATOPS qual out of date? If out of date, then technically the IP is no longer NATOPS qualified until the annual NATOPS check is flown and passed.
Was the IP's Instrument qual out of date? If out of date, then technically the IP would be no longer NATOPS qualified until instrument check is flown and passed.
If scheduled for a hop, and either of the above is true, then the skipper ought to resign. That stuff is boiler plate.

Was the IP assigned a hop when he wasn't current in that stage/phase of instruction? This is where the Standards Officer and the Ops Officer, and the Scheduling Officer, earn there pay. This question also gets into 30, 60, 90 day quals on various stages of instruction. If this IP was qualified in, for example, the Carrier Landing and Instrument stages, but was not current in the TacForm stage (not enough flights in last X days/months) then technically "not qualled" for a TacForm hop. (see also low level nav, weapons, ACM, etc. Each differing training stages for the students. )

An example from my dim and distant past, when I was an IP.
When I was teaching formation flights, I got sick and was grounded for six weeks. When I came back up, I was not allowed to be assigned instructional flights before 1) a warmup was flown and 2) a formation warm up was flown (me in the back for a form flight, usually as a sand bag for a IUT flight) before I could fly a student flight for formation .. staying sharp, etc.

Lots of questions that are germane to qualifications not being up to date; If this IP wasn't current (foul! OpsO).
If this IP was doing stuff not current in, or a stage not yet checked out to teach in by the Standardication department, Foul! (on the IP)
Nothing to do with "not qualified to fly the T-45C on instructional hops."

The other question in the back of my mind is this; did the IP go out on an instrument or ONAV hop and start doing maneuvers for a different stage of training? (Foul! Four Minute Major!) I know a guy who lost his IP qual for doing exactly that, some years ago. Got into a real crap storm, and got to go and see the Wing Commander (Commodore) for "tea and biscuits with no tea and no biscuits" ...

That kind of thing by the IP might also lead to a "not-authorized" or "not-qualified" comment, since that aint' how it's supposed to be done and every IP and CO knows that.

You buying the journo's BS?
Go ahead. Ignorance is bliss.

I don't buy it, because I know the details of how CNATRA and its subordinate units work.
A few of the posters here, and for sure the Journo in question, do not seem to understand that.

(I am pretty sure that Airbubba knows how CNATRA works well enough, some things haven't changed ... ).

Last edited by Lonewolf_50; 16th Apr 2018 at 22:12.
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Old 16th Apr 2018, 23:07
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Salute!

I am not all that hyper about the IP filling all the training and currency squares as I am about "personality", "reputation" and such of the IP.

I infer that the "board" had clues about the style and record of the IP. Maybe testimony from students? Check rides by other IP folks?

If the IP was "loose" and maybe very agressive, then that could lead to letting the student fly a bit lower than most of us would wish. But the debris field seems more like simply trying to fly 5 feet lower than the dirt. I cannot find the original thread, but seems I recall it was a Sunday and the folks had gone someplace and spent the night or two before returning to Meridian. A common scenario, and one that many of us experienced to get the nuggets trained to see strange fields and various ATC procedures and so forth.

Regardless of all of the above opinions, I lean toward lack of supervision and folks not telling the IP to 'back off' as contributing factors.

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Old 17th Apr 2018, 00:12
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I got down one or two times low enough to experience ground effect
One FJ who had a low flying penchant said that once you got down onto the ground cushion you could push forward, attitude would change, but that's all. Degree of attitude change or degree of push not quoted. Did see gun camera of going under power lines.
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Old 17th Apr 2018, 01:46
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Originally Posted by Lonewolf_50 View Post
:Mishap reports are not for public release.

Do you mean the FOIA requests for the results of the JAG investigation? Any mishap that results in a fatality, or that has pilot error as a contributory cause, will typically have a JAG investigation as well. I've seen the JAG investigations take more time than the mishap investigations before.
Maybe they are not for public release but here's 81 pages of the command investigation report into the mishap with endorsements:

https://news.usni.org/2018/04/16/fin...-goshawk-crash

As you suggest, the missing qual seems to be a paperwork error. I don't see anywhere that the instructor wasn't qualified to fly the T-45.

Originally Posted by Airbubba View Post
The former VT-7 skipper has retired. Will CNATRA (Rear Adm. Bynum) step down as well?
Originally Posted by Lonewolf_50 View Post
For what?
Since the admiral cites a culture at CNATRA at large to go beyond the curriculum and a failure of leadership to oversee training operations as contributors to the cause of the accident it almost sounds like he's falling on his own sword. But, maybe not.

Both the skipper and the commodore have already retired. The commodore had already put in his papers before the mishap. Oddly enough, I met both of these men at a TW-1 ceremony at Navy Meridian a couple of years ago. The field is named after Senator John Mc Cain III's grandfather, Admiral John S. Mc Cain, Sr. (John Junior was an admiral as well).

Rather, this mishap resulted from individual pilot error, a culture within VT-7, and Chief of Naval Air Training (CNATRA) at large, which fostered IPs and SNAS flying their aircraft beyond the bounds of approved Naval Air Training Command (NATRACOM) curriculum, and a failure of leadership to oversee training operations to ensure strict adherence to all approved publications.
From the admiral's endorsement of the command mishap report in the link above:

Executive Summary

a. On Sunday, 1 October 2Ol7, at approximately 1600 local (EDT), a T-45C jet aircraft assigned to Training Squadron SEVEN (VT-7) and piloted by LT Patrick Ruth (Instructor Pilot (IP)) and LTJG Wallace Burch (Student Naval Aviator (SNA)), impacted an isolated area of the mountainous National Forest near Tellico Plains, Tennessee. Tragically, neither the IP nor the SNA survived the crash.

b. The cause of the mishap was not due to mechanical, maintenance, or weather related issues. The cause of the mishap is not related to a physiological episode on the part of either the IP or the SNA nor due to inadequate written training procedures or directions. Rather, this mishap resulted from individual pilot error, a culture within VT-7, and Chief of Naval Air Training (CNATRA) at large, which fostered IPs and SNAS flying their aircraft beyond the bounds of approved Naval Air Training Command (NATRACOM) curriculum, and a failure of leadership to oversee training operations to ensure strict adherence to all approved publications.

c. The mishap flight was the second leg of a properly scheduled Operational Navigation (ONAV) Low Altitude Awareness Training (LAAT) flight on an approved military training route (MTR). The aircrew was returning to their home base of Naval Air Station Meridian, as the final event in an approved weekend cross-country mission during which several ONAV LAAT training events were conducted.

d. As documented in the Second Endorsement, the IP was “flat hatting” (flight conducted at low altitude and/or a high rate of speed for thrill purposes) during various parts of this particular cross-country training event, and actively encouraged/instructed his SNA to follow his example.
The investigation further demonstrated that this IP was overly confident, nonchalant, and aggressive at low altitude training, with limited awareness of the performance capabilities of the T-45C in the LAAT environment. This attitude influenced the IP’s instructional style, and conditioned the SNA to fly the aircraft in an aggressive manner, without correction from the IP.
e. At the time of the mishap, events were being flown at the direction of the IP that exceeded approved training curriculum, specifically tactical type maneuvers. This included aggressive ridgeline crossings and descending tums that took them below the minimum altitude of 500 feet above ground level (AGL) many times, to include potentially as low as 210 feet AGL. Per the written syllabus they should not have been operating so close to the limits of the aircraft’s performance. Such advanced skills and abilities are the responsibility of the Fleet Replacement Squadrons (FRSS) to train and are not part of the NATRACOM curriculum.

f. Approximately 35 seconds before the mishap, the IP told the SNA that they would deviate from the direct line of the MTR in order to follow terrain. The IP assumed control of the aircraft 26 seconds before mishap, and commenced a descending tum to demonstrate terrain following techniques. The IP nonchalantly returned the aircraft to the SNA I0 seconds before the mishap, and then instructed the SNA to make a hard right tum. What neither the IP nor SNA knew was that they were too slow and too low relative to the rising terrain in front of them and that the attempted control input to recover was beyond the limitations of the aircraft. In response to their maneuvers the aircraft entered into a stall. By the time the aircrew realized they were in extremis, it was too late to eject safely.
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Old 17th Apr 2018, 03:11
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@Airbubba

Thanks, I was of course right, and the journo and the know-nothings who I responded to were as I depicted them: both ignorant and wrong. What got me to respond at all was the foolish commentary on qualifications.
I don't see anywhere that the instructor wasn't qualified to fly the T-45.
Of course not.

The previous CNATRA got fired over the OBOGS thing (among others). Trying to lay this all on current CNATRA is (IMO) absurd. Aside: he ought to have had fair warning when the JO's felt empowered to make what looked like "going on strike" was their attitude. The culture he feel in on was already sick. (I have spoken to two senior O-6's whose root cause analysis of cultural problems reach to the sequester issue ... but that's a different topic).

When you and I were nuggets, the number of deaths like those described in the report were "not uncommon" in terms of occurrence rates. Flat-hatting has been a bogey chased by CO's of squadrons since before you and I were born. We in the aviation community attract Type A personalities. A side effect off that is the risk of the above: sure, I can do that! It's been in the NATOPS(OPNAVISNT 3710 series) for a very long time: rules covering flathatting, and how wrong it is, predate me earning my wings nearly 40 years ago. I suspect that Orville and Wilbur had a few heated conversations over who was doing what with their one plane, way back when.

a failure of leadership to oversee training operations to ensure strict adherence to all approved publications
I have written flag officer endorsements on both JAG investigations and mishap reports for fatal accidents. (That's part of why I drink). I am fully aware of what goes into the kind of document you provided excerpts from. (Thanks). The critical leadership failures are the usual suspects: CO's and Wing Commanders who do not do a thing called "deck plate leadership" (Also a a fine old Navy tradition.) and Ops O's who don't ride herd on a bucket full of Type A personalities, or, and this is another recent problem, whose hands are tied by the current Navy culture from putting a boot in the right arse at the right time. (I've seen both ...)

When I was an IP the Ops O's freedom to stuff in the boot was not so constrained.

FWIW, if you want to read a few pages of "it makes me sick" accident summary, go to the late 90' and a mid air collision in a VT squadron. A few lives lost... and part of that problem was an unbriefed formation flight, sort of an ad hoc formation that ended in tears.

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Old 17th Apr 2018, 07:30
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Sorry Lonewolf.

Still don’t get it. You, very aggressively, rail against the journo and know-nothings for inaccuracies(if you include me in the know-nothings then you are too kind but I’ve done a fair bit of this stuff cheers). I’ve read and re-read the article and can’t see anything where he doesn’t directly wuote from the report or the Admiral. A dangerous, poor instructor existed in an atmosphere of poor leadership and supervision, with ill disciplined flying practices. That ultimately led to the death of two pilots. I really struggle to see what you are so vehemently defending.
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Old 17th Apr 2018, 07:48
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After finishing my Gnat course, I held for a while waiting for the pre-TWU Hunter refresher course. One day I went flying with a new QFI who had come from a non-FJ background. His flying was aggressive and not that good, to my inexperienced eyes. After a session of aeros, he had no idea how to fly the normal TAC dive procedure to Point Alfa, so I had to talk him through it....

Once back in the visual circuit, he exhorted me to pull to the buffet when turning downwind "otherwise you're not really trying hard enough" I didn't go flying with him again and it didn't surprise me when he had a landing incident a few weeks later, badly damaging the aircraft.

Another non-FJ QFI killed himself and his student after mishandling the Gnat at Shawbury.

But a third pilot (ex-Victor), going through CFS to the Gnat, had the good sense to ask for a posting change as he felt that the little jet was too much for him.

It strikes me that it's those who feel they have something to prove, having never flown a FJ beforehand, who need to be watched the most when instructing on fast jet trainers. Maybe the ex-FJ pilots have a stronger sense of self-preservation?
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Old 17th Apr 2018, 12:56
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Originally Posted by Flap62 View Post
Sorry Lonewolf.

I really struggle to see what you are so vehemently defending.
I am not defending anything; I began by attacking the foolish statement (see the post by Just This Once) about an E-2C pilot not being qualified to be an IP in a T-45 (pure horsecrap), and followed up with attacking the assertions that the person was unqualified to fly the T-45. Also horsecrap. If the assessment was that this IP was flathatting, it's another tragic case of "the system learns, but individuals sometimes don't believe" that's killed people over the years.

Beyond that, this is sadly not the first time ever that an IP did something outside the box. (See my note about the tea and biscuits episode ). The midair I referred to (ad hoc formation, it's been almost 20 years since that one) IIRC did not, even though there were lives lost, lead to as many heads rolling as I would have expected.

If the command climate at the squadron, and in Trawing One, was indeed too loose then an episode like this was one of those things that was going to happen sooner or later. As stated, have been on the investigator/report writing side of that more than once.

As to firing training command CO's, and training wing commanders: it's a bit harder than you might think, but it happens now and again.
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Old 17th Apr 2018, 14:02
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Originally Posted by Flap62 View Post
Sorry Lonewolf. Still don’t get it. You, very aggressively, rail against the journo and know-nothings for inaccuracies(if you include me in the know-nothings then you are too kind but I’ve done a fair bit of this stuff cheers). I’ve read and re-read the article and can’t see anything where he doesn’t directly wuote from the report or the Admiral. A dangerous, poor instructor existed in an atmosphere of poor leadership and supervision, with ill disciplined flying practices. That ultimately led to the death of two pilots. I really struggle to see what you are so vehemently defending.
I thought Lonewolf was very clear and quite detailed in his rebuttal. I suggest you re-read what Lonewolf wrote rather than re-reading the article. There's a lot you appear to have missed.
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