Hawk XX204 Service Inquiry
Another SI riddled with instances of non compliance with the services own regulations and procedures, some relevant to the incident, some not, but indicative of institutionalised lack of operational discipline.
The section regarding electronic authoriSations ( rather than the American authoriZations as used throughout the document) is frankly comical, with individuals able to use electronic copies of others' signatures to approve critical documentation. This, as does much in the report, illustrates a fundamental inability to understand what controls are for. The comments regarding the difficulties and delays in obtaining documentation from other parts of the RAF are more than a little concerning too.
The report goes to great pains to explain how the onset of the stall could well have been barely perceptible to the pilot without exploring what looks like being the unfortunate reality that he could not have escaped from the position he was in even if he hadn't stalled. The manoeuvre was botched from an early stage and should have been aborted long before it was. The background to why the pilot felt the need to press on as far as he did would be relevant, and I cant help thinking there might be some clues in the redacted comments. There seems to be something inferred regarding his sense of how he was perceived within The Arrows.
The Human Factors comments about fatigue from being overworked from, inter alia, collecting the packed lunches, tidying the kitchen, and making sure the IT works do not inspire confidence, or build credibility in a supposedly elite echelon of a 21st century air force.
The section regarding electronic authoriSations ( rather than the American authoriZations as used throughout the document) is frankly comical, with individuals able to use electronic copies of others' signatures to approve critical documentation. This, as does much in the report, illustrates a fundamental inability to understand what controls are for. The comments regarding the difficulties and delays in obtaining documentation from other parts of the RAF are more than a little concerning too.
The report goes to great pains to explain how the onset of the stall could well have been barely perceptible to the pilot without exploring what looks like being the unfortunate reality that he could not have escaped from the position he was in even if he hadn't stalled. The manoeuvre was botched from an early stage and should have been aborted long before it was. The background to why the pilot felt the need to press on as far as he did would be relevant, and I cant help thinking there might be some clues in the redacted comments. There seems to be something inferred regarding his sense of how he was perceived within The Arrows.
The Human Factors comments about fatigue from being overworked from, inter alia, collecting the packed lunches, tidying the kitchen, and making sure the IT works do not inspire confidence, or build credibility in a supposedly elite echelon of a 21st century air force.
I am reminded of all the times when as a well-paid professional I was drafted in to pick up litter and so on. They saved paying for litter-pickers, but were paying me several times as much to do the job in an untrained manner. My time not spent on my professional job did not appear on the bottom line, but the money they saved from employing people to do less-skilled job did.
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still worth trying
Let us consider the para 1.4.201 HSTF analysis.What a difference it would make if the text was NOT “while landings were achieved on a few occasions” BUT “more than one landing was achieved” - and if the text was NOT “On almost every occasion the HSTF showed indications of stall” BUT “occasionally there were no indications of stall”.
The panel seems to regard the “contract” parameters as critical to their investigation. It is however clear that the “contract” is only incidental to the exercise that R3 was conducting. It should be appreciated that the “Contract” is for the instruction of students and for the guidance of experienced Hawk pilots.
The panel might have examined the possibility that the “contract” actually interfered with R3’s safe execution of the exercise. Have the simulations discussed in para 1.4.201 and the successful landings achieved been fully reported to, at least, the Red Arrows ?
The new rule of 1400ft at the final turn, deemed essential to meeting the “contract” terms, could not be met by R3 and might almost never be met by the Arrows. The Arrows presumably risk an EFATO on every launch and still brief for it, on the clear understanding that the “contract” cannot apply. I expect that even to land on the launch runway would still be briefed, if there was no alternative and since the simulations have shown it can be done.
The panel seems to regard the “contract” parameters as critical to their investigation. It is however clear that the “contract” is only incidental to the exercise that R3 was conducting. It should be appreciated that the “Contract” is for the instruction of students and for the guidance of experienced Hawk pilots.
The panel might have examined the possibility that the “contract” actually interfered with R3’s safe execution of the exercise. Have the simulations discussed in para 1.4.201 and the successful landings achieved been fully reported to, at least, the Red Arrows ?
The new rule of 1400ft at the final turn, deemed essential to meeting the “contract” terms, could not be met by R3 and might almost never be met by the Arrows. The Arrows presumably risk an EFATO on every launch and still brief for it, on the clear understanding that the “contract” cannot apply. I expect that even to land on the launch runway would still be briefed, if there was no alternative and since the simulations have shown it can be done.
Last edited by rlsbutler; 12th Oct 2019 at 14:12. Reason: quote marks disappeared from the first paragraph
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Originally Posted by rlsbutler
Let us consider the para 1.4.201 HSTF analysis.What a difference it would make if the text was not “while landings were achieved on a few occasions” but “more than one landing was achieved” and if the text was not “On almost every occasion the HSTF showed indications of stall” but “occasionally there were no indications of stall”.
The panel seems to regard the “contract” parameters as critical to their investigation. It is however clear that the “contract” is only incidental to the exercise that R3 was conducting. It should be appreciated that the “Contract” is for the instruction of students and for the guidance of experienced Hawk pilots.
The panel seems to regard the “contract” parameters as critical to their investigation. It is however clear that the “contract” is only incidental to the exercise that R3 was conducting. It should be appreciated that the “Contract” is for the instruction of students and for the guidance of experienced Hawk pilots.
The panel might have examined the possibility that the “contract” actually interfered with R3’s safe execution of the exercise. Have the simulations discussed in para 1.4.201 and the successful landings achieved been fully reported to, at least, the Red Arrows ?
The new rule of 1400ft at the final turn, deemed essential to meeting the “contract” terms, could not be met by R3 and might almost never be met by the Arrows. The Arrows presumably risk an EFATO on every launch and still brief for it, on the clear understanding that the “contract” cannot apply. I expect that even to land on the launch runway would still be briefed, if there was no alternative and since the simulations have shown it can be done.
If you'd like to phrase your questions as questions I'd be more than inclined to answer or ignore them. Unfortunately you're making statements and those statements are incorrect.
There’s an obsession with the outcome instead of dealing with the “Gorilla in the room”....Distraction and Tiredness (the word Fatigue is incorrectly used in the Report). These are the things we need to mitigate.
This is simply about Risk Management and Good Decision-Making; however, the system is, and never will be, perfect as long as we have humans involved in it.
This is simply about Risk Management and Good Decision-Making; however, the system is, and never will be, perfect as long as we have humans involved in it.
A very long and detailed report, however, no mention that had the Hawk been retro fitted with an AoA system there would not need to be discussion about IAS, g, weight and configuration. Would be far safer and more relevant to the aircraft of today. I do accept that it would give the QFIs far less to talk about
I totally agree with the findings concerning the Command Eject system. Fundamentally flawed to cater for all different front/rear seat combinations. BAEs was naive to say the least and should have learnt from other 2 seat fast jets.
I totally agree with the findings concerning the Command Eject system. Fundamentally flawed to cater for all different front/rear seat combinations. BAEs was naive to say the least and should have learnt from other 2 seat fast jets.
On your second point regarding command ejection systems, when the Hawk T1 entered service (1977), none of the other RAF/RN ejection seat equipped two-seat aircraft had a command ejection system (Phantom, Buccaneer, Jaguar T2, Harrier T4, Lightning, Hunter, Jet Provost). Therefore, British Aerospace (as it was then) were not naďve but were taking a positive step forwards with what they installed, and it was to satisfy the required mission of the aircraft. The fact that better systems now exist and the Hawk T1 has not been modified is not down to the OEM per se but to customers not requesting a modification.
There are two items that were not discussed in the report that I felt should have been. First, the 150 KIAS minimum speed during PFLs. I consider this to be only applicable once you are wings level on the runway centreline and is dictated by the minimum speed at which you can commence the first stage flare without the risk of stalling. I have always practiced and taught that the gear down glide speed of 170/165 KIAS was a minimum as well as a target until rolled out wings level. The Aircrew Manual is not clear on this point and I believe clarification is needed on this. I cannot recall whether this was taught to me formally when I started flying the Hawk in 1978, whether it was just 'sage advice' or whether I worked it out for myself but I do apply this rigidly. Secondly, one aspect that was not considered when analysing what R3 did with the stick during the finals turn is the strong nose up trim change that occurs when the flaps are lowered. This would have occurred at a high bank angle when a significant aft stick force would be required prior to flap selection. When the flaps were lowered a push force would then have been required to maintain the g/turn rate, and applying nose down trim*would have been the normal response when flaps are lowered wings level but would probably have seemed counter-intuitive when turning. This would have resulted in further workload and distraction and a degradation in flight path control. This may not have been a significant contributory factor but I would have expected it to be discussed.
Or, stop doing PEFETOs and just mandate a height/speed criteria below which one flies straight ahead only and above which low key is a certainty?
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LOMCEVAK
My point about displayed AoA is that if used correctly on finals one should never get into the position R3 found himself. Yes, I agree there were many other "gates" and clues that were ignored that fateful day. Obviously height loss in a banked go-around at high weights can be significantly increased. In my day the first time that this was taught was at TWU for A/G dive recoveries. There was no mention (as far as I recall) at 4FTS. I do recall, however, "If its not right- throw it away and try again (having analysed errors made and corrections required "
As for Command Eject, my memory may be fading but I'm sure it was fitted at ALL models of F4. The implementation in the K/M was different to the D/E/F/G, however, they all had a Command Selector Valve?
I am afraid that I have to disagree with your first point. Whilst AOA indications could/should have given cues to avoid stalling, the height loss during the go-around is strongly a function of IAS, bank angle, weight and configuration (ie. rate of descent, angle to roll through and pitch attitude change). Therefore, they are all very relevant.
On your second point regarding command ejection systems, when the Hawk T1 entered service (1977), none of the other RAF/RN ejection seat equipped two-seat aircraft had a command ejection system (Phantom, Buccaneer, Jaguar T2, Harrier T4, Lightning, Hunter, Jet Provost).
On your second point regarding command ejection systems, when the Hawk T1 entered service (1977), none of the other RAF/RN ejection seat equipped two-seat aircraft had a command ejection system (Phantom, Buccaneer, Jaguar T2, Harrier T4, Lightning, Hunter, Jet Provost).
As for Command Eject, my memory may be fading but I'm sure it was fitted at ALL models of F4. The implementation in the K/M was different to the D/E/F/G, however, they all had a Command Selector Valve?
As for Command Eject, my memory may be fading but I'm sure it was fitted at ALL models of F4.
The first truly universal command eject was not until the Harrier T10 which had universal front-to-back, back-to-front, both and off selection options.
Only just started reading the SI report but already I feel compelled to note that para 1.3.3 footnote 5 uses vatsim.com (an online multiplayer ATC simulation game) as its reference for the description of the "Lichfield Radar Visual Corridor". Maybe if the panel had used (say) the UK Mil AIP as their reference, they would have found that it is a "Radar Corridor". Tantamount to citing Wikipedia, I find this astonishingly unprofessional in a document of public record.
I sincerely hope that this trivial example isn't indicative of the quality of investigation and research to come. But it does make one wonder.
I sincerely hope that this trivial example isn't indicative of the quality of investigation and research to come. But it does make one wonder.
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No command selector valve in the FG.1 or FGR.2...
FG.1
FGR.2
And the tragic loss of XT908, which H Peacock referred to...
XT908 accident summary
-RP
FG.1
FGR.2
And the tragic loss of XT908, which H Peacock referred to...
XT908 accident summary
-RP
Below the Glidepath - not correcting
The Terms of Reference for this Service Inquiry are pretty much verbatim as they have been for many others:
It's the "...in order to prevent a recurrence..." bit that drives the board down every rabbit hole that presents itself, with nary a thought for the context or prevalence of the factor being presented. This confused smorgasbord of factors, facts, policies and regulations almost deliberately avoids stating the obvious. On the day, circumstances conspired to put an experienced aviator into a deadly trap as old as flying itself, and him being part of the RAFAT didn't make a blind bit of difference to the tragic outcome. Of course all the other organizational issues amplified the consequences, specifically carrying out the manoeuvre with a passenger (he clearly was NOT supernumerary crew, despite some convenient and disingenuous institutionalized attempts to redefine that role) but there was no mystery as to the root cause. There may be a huge corporate reluctance to admit it, but it is a salutary lesson indeed to demonstrate that even with the level of experience and and skill available in the cockpit, he was not immune from the terrible consequences of getting it wrong on the day. You're only ever as good as your last flight.
The purpose of this SI is to investigate the circumstances surrounding the incident and to make recommendations in order to prevent recurrence.
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I don’t disagree with your point Two’s In but would add that you really only address the first of three criteria present that make this an accident; that of the lost aeroplane (neither here nor there really IMHO for the reason you state and with which I agree). The second would be the pilot’s unfortunate broken leg (possible learning point for ejecting in time but at the end of the day he ejected in time). The third is the tragic fatality - and I know we all know that - but that puts the board in the position of having to look at why the deceased was where he was/ doing what he was - and whether either or both were a bright idea etc.
Reserving my opinion on the above - I always feel that HF likes to ‘talk a good game’ in lectures and courses but stay on safe middle ground when it comes to reports. Hence you get ‘fatigue and distraction’ in reports but not the variety of biases that may have occurred - which spawns the inevitable ‘why didn’t the board look at’ questions. The answer is probably that they did but weren’t allowed to publish anything likely to be challenged even if only put forward as a possibility.
Reserving my opinion on the above - I always feel that HF likes to ‘talk a good game’ in lectures and courses but stay on safe middle ground when it comes to reports. Hence you get ‘fatigue and distraction’ in reports but not the variety of biases that may have occurred - which spawns the inevitable ‘why didn’t the board look at’ questions. The answer is probably that they did but weren’t allowed to publish anything likely to be challenged even if only put forward as a possibility.
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LOMCEVAK, and Rhino power, First apologies and second thanks. My memory clearly is failing. After your pictures and further investigation the EJECT LIGHT bought it back to me. No Command Eject on the F4K/M.
The first time that I flew with Command Eject was on the D/E models in the USA.
Remember well that the Wild Weasel Wing sent a detachment to Jever. At the end of the long transit from California the General decided to descend through cloud as a 6 ship for a flypast!! Two of the aircraft had a mid air and were lost. One of the WSOs initiated the Ejection and ejected himself and pilot from the ac. At the subsequent BOI the pilot stated that he thought that his aircraft MAY have been flyable. The General retired soon after as a Colonel!!
Our Wing Commander immediately sparked a near mutiny be trying to ban the use of Command Eject with WSOs in the rear seat as they were (in his opinion) unable to make the correct decision. After a heated Wing Meeting he was forced to rescind his decision. For the majority of flights in the USAF and GAF the Command Eject was set to Both.
The first time that I flew with Command Eject was on the D/E models in the USA.
Remember well that the Wild Weasel Wing sent a detachment to Jever. At the end of the long transit from California the General decided to descend through cloud as a 6 ship for a flypast!! Two of the aircraft had a mid air and were lost. One of the WSOs initiated the Ejection and ejected himself and pilot from the ac. At the subsequent BOI the pilot stated that he thought that his aircraft MAY have been flyable. The General retired soon after as a Colonel!!
Our Wing Commander immediately sparked a near mutiny be trying to ban the use of Command Eject with WSOs in the rear seat as they were (in his opinion) unable to make the correct decision. After a heated Wing Meeting he was forced to rescind his decision. For the majority of flights in the USAF and GAF the Command Eject was set to Both.
Have to agree. My experience of PFLs, albeit in a piston engine aircraft, is of picking the field and executing a safe approach with the fear that when the instructor says "that's a goodun" and opens up the throttle....The engine splutters and dies. Result would be one aircraft sans undercart in a field, or worse, for no good reason.
Althouth this is thread drift, following on regarding F4 Commam Ejection systems, I have just had a reliable source tell me that the F4J(UK) had a command ejection system. However, it’s entry into service post-dated the Hawk T1 by quite a few years.
The thing that strikes me about this is that an experienced and above average Hawk QFI screwed up an exercise he was patently capable of completing safely. Why? The report seems to hint at him being under self induced pressure but also under pressure from a multitude of trivial administrative tasks. If that is what it is like for a RED ARROWS pilot, what must it be like on a bog standard squadron?
The first film I saw called “ Distractions “ featured a Javelin crew! When will the lesson be learned?
The first film I saw called “ Distractions “ featured a Javelin crew! When will the lesson be learned?
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