How can this happen - controller partly blamed (merged)
 

http://news.bbc.co.uk/1/hi/scotland/4686602.stm

Surely if your not guilty at a court martial, then you arent to blame !!

The right way around
 

Surely this is a case of the horse going before the cart The Courts Mashall shouldn't have taken place until after the RAF Enquiry was complete. That way all the information would have been available.

The BBC report also seems to imply that the Courts Marshall cleared him of total blame; in other words that he wasn't solely to blame, but leaving the door open for the official RAF enquiry to find him partially to blame for giving an unsafe clearance.

Seems he had a 'lucky' escape at the CM, if it had come after the official enquiry he might now be facing very serious charges. Or does double jeopardy not come into play here?

Beagle

I try hard to bite my tongue at the drivel you normally spout. However on this occasion...

This is worthy of nothing like the level of disgust felt around the service at the dreadful Mull of Kintyre saga.

Read some information on the case, read some information on the BoI and then see if your opinions are still the same.

Lots of people at fault, lots of issues raised. Blame? Not on any single person. And rightly so.

Sad facts: Two dead aircrew. RIP.

The purpose, surely is to estsablish facts and prevent it happening again?
Sadly the crews can't comment. Do F15s carry FDRs?

Please don't lambast me for lack of knowledge, I'm merely an interested civilian.

If the RAF enquiry is in the standard format of an accident report, then it would not lay the blame with any one, it would instead list the various contributory factors which lead to the accident. This has been the case I believe ever since after the Mull of Kintyre accident report. This would tie in with the quote in the report:-

"A spokesman for the Ministry of Defence said it was not the role of a Board of Inquiry to apportion blame, and it marked the closure of an unfortunate incident for the RAF."

It would therefore seem that this is another piece of badly written reporting by the BBC, reopening wounds best left alone.

Edited because my grammar is appalling.

Crash controller 'partly blamed'
 

http://news.bbc.co.uk/1/hi/scotland/4686602.stm

A crash which killed two fighter pilots in the Cairngorms has been partly blamed on a military air traffic controller, BBC Scotland has learned.
The official RAF inquiry reached its conclusion even though the controller was cleared of causing the deaths by an earlier RAF court martial.

Two US pilots from Suffolk died when their F-15 jets crashed into Ben Macdui on a low flying exercise in 2001.

The report concludes they accepted an unsafe air traffic control instruction.

The deaths of Lieutenant Colonel Kenneth Hyvonen and Captain Kirk Jones, who were based at RAF Lakenheath, have been scrutinised several times.

The original RAF Board of Inquiry was suspended pending the court martial of Malcolm Williams, the air traffic controller at RAF Leuchars who gave flight descent information to the two US planes shortly before they crashed.

The RAF court martial cleared Flt Lt Williams of causing the deaths of the two pilots.



A US Air Force inquiry then concluded the American pilots made the first mistake, following confusion about terminology with the RAF controller.

Now the findings of the reconvened RAF Board of Inquiry conclude the crash happened partly because the pilots accepted an air traffic control instruction that was clearly unsafe.

A spokesman for the Ministry of Defence said it was not the role of a Board of Inquiry to apportion blame, and it marked the closure of an unfortunate incident for the RAF.

The F-15 pilots were flying in variable cloud on a low altitude training mission and were lost from radar during an air traffic control handover on 26 March, 2001.

Lieutenant Colonel Hyvonen, 40, and Captain Jones, 27, were killed instantly when their aircraft crashed while on a low flying exercise from RAF Lakenheath.

Is this bad reporting, or do the BoI really believe that he gave an INSTRUCTION when providiing RIS?

A detailed account of the Courts Martial is at: http://www.pprune.org/forums/showthr...ight=F15+Court

The whole sad and sorry story seems to whiff of the foulest sort of politics. I wonder if the BoI ignored eyewitness accounts etc. in the same way as the Prosecution appeared to have done!

Reporting
 

JTIDS are you suggesting that this shouldn't have been reported? Or are you suggesting that the report didn't say that the pilots accepted an unsafe clearance and that the media have got that wrong? There seems to be the suggestion of both, in your last posting.

Any of us who have been around avaiation for a while know that most accidents are caused by a catalogue of events. It seems that this is the case here. If the board state that the clearance was unsafe, then that is the conclusion of the board. The board isn't apportioning blame just stating the facts. This fact, was a contributary factor to the accident and must be recognised by all concerned.

In the interest of safety and to ensure that another tragic event like this does not happen again, it is necessary for all concerned to be aware, take this on board and ensure that any clearnce given and received is clearly understood by all parties.

In no way shape or form can this be equated with the Mull of Kintyre travesty!
:mad:

Gorilla,

I repect your right to an opinion. I just disagree with it.

PAMACC, I am agreeing with pretty much what you say. What I was trying to say that the BBC report seemed to be trying to create controversy where there was none. However I have just re-read my posting and realised the possible area of confusion.

Some have questioned this choice of words? From what I recall of the accident (not first-hand, but read on this forum and in other more "official" sources)... On request from the formation leader for descent, the Controller allocated a level that did not provide terrain clearance... the fact that the pilots, under RIS, had responsible for terrain clearance and that the allocated level was above the mountain top so could not have directly caused the death of the pilots... even the not guilty decision (which incidently I do support) does not diminish from the fact IMHO it was still an unsafe instruction?

What phraseology was used?
 

JTIDS, the media always have a habit of trying to create controversy. Thank you for your reply though :)

I hope, that sensible people will think that the Board's report raises interesting saftey issues. I am curious to know why they say that the phraseology used by the ATCO was constributary to the accident. If, it was indeed, contributary, then we should all be asking this question and a resolution made to ensure that better phraseology is used in the future. This has got to be worthy of discussion on this thread.

Can anyone tell me what the exact phraseology was? Is there a transcript available anywhere?

Had he "issued a clearance" (under a RIS i understand) to descend to an altitude below MSA for the area?

Presumably this is why we are now constantly reminded that we are responsible for our own terrain clearance when in reciept of such a service now...

Beags....has an RAF crew smacked rock since you were first trained on Boxkites in the RAF? Seems to me we have had a long ongoing discussion about at least one crew in a Chinook.

Try to answer your own question....why did the two pilots find themselves flying lower than the rock? Reckon they may have had some help in making that mistake? It does not have to be intentional help....it does not have to be direct help....but two good men died for some bad reason.

It seems very odd to hold a court martial while a BOI is on-going. They are two indepenent inquiries and have completely different purposes, however they are about the very same set of facts and thus cannot be separated.

My view would be the court martial was hurried up and the BOI was suspended so that political face could be saved. No one on the RAF side wanted to confronted with any responsibliity for two USAF aircraft and pilots being lost.....no matter how tangentially involved.

I see it as being a very transparant method of shielding the home team while leaving the visitors out on the limb.

That the USAF pilots made a mistake....or a series of mistakes but the bottom line....any vector given by radar to an aircraft has to take into account the minimum safe altitude for the area being flown. The terminology difference should not have rendered that mandate invalid.

The controller if confused...and aware of being confused...should have announced his uncertainty and suggested a climb to altitude while things got sorted out. I would suggest if the pilots had sensed any uncertainty, in all liklihood they would have asked for the climb clearance or one would hope anyway.

The thrust of the BOI should be to accurately layout the facts....assess them for factors that led to the disaster and fairly descibed what those factors were without regard to who winds up with egg on their face.

The inclusion of the court martial smacks of some self serving interest by the Airships in this matter and not a seeking of justice for either the pilots or the controller.

The Chinook thread is yet another indicator of how good men can be let down by the system.

It is indeed SixDelta,

although I have to say that it took me a while to get used to!

"You are identified RIS blah blah. You are responsible for terrain avoidance."

No Sh*t..!

Confusion and correct phraseology
 

Issues as to the ATCO being confused with respect to the terminology used, are, in my opinion exactly why the safety issues from the BoI should be being addressed. An ATCO of his apparent long standing and capability (and I'm going on what all his friends and collegues wrote on this forum leading up to the CM) should not have been confused. So why did this happen and why did he feel unable to advise the pilot that this was the case?

The results of the CM are known and unarguable.

However there are lessons to be learnt here. I have not had any replies as to the exact phraseology used. What happened to the good old phrase "at your discretion' or "unable to give descent below Minimum safe Altitude"? Were these phrases used or weren't they? If they were then how could the BoI have considered the phraseology used to be unsafe?

It also seems that the ATCO was well aware that the aircraft intended to descend to 4000ft and that the aircarft disappeared from radar, but that this was not due to the crash. I read from this, that this descent took the aircraft out of known radar coverage. Is that correct? If so what happened to that good old phrase "you are (going) out of radar coverage, Radar Information Service Terminated".

All of the above are little alert messages to the pilot that he is now doing entirely his own thing and if they had been used, would have absolutely and fully exonerated the ATCO.

So someone out there please tell me. Are military controllers no longer taught the above phraseology? Has it changed? Did they ever use it? Was it used in this case? From what we are learning from the BoI, it seems the latter is unlikely.

So I say once again. We all have a lot to learn on the issue of safety here. What is likely to be done about it? Has any of it already been addressed?

Rule One in aviation = Don't crash
Rule two = see rule one.

I wholeheartedly recommend that you read the referenced thread. If you believe in the conditions of "reasonable doubt" then this whole event is nothing more than a very sad accident. I was an expert witness in this case, I too thought when I first encountered the evidence that it was a straight descent into terrain, but having studied all (and I do mean all) the evidence that there is another possible scenario. Especially when one of the highlights of my 4 days in the witness stand was the Gp Capt prosecutor asking me:
"well Mr X if it wasn't for the eye witnesses, nobody actually saw the aircraft".

Brilliant, abso-fkin-lutely brilliant.

Maybe its a sign of the times, but when I was learning to be a pilot I was always taught to look after myself, trust no one, never assume, check and be well prepared. Why is someone else always responsible these days???

Tarnished

Clear to whom....the controller...the pilots? Or some fecker who had naught to do but spend weeks mulling over things in the quiet of an office with lots of tea and biscuits?

If it is that "clear"....what happened?

The F15 accident
 

In support of Tarnished:

The full findings of the Board of Inquiry can be found on the MOD UK website. I have only had a very brief read and will reply more thoroughly after a proper look at the full report.
In essence, it would appear that the full reporting chain still believe the F15s followed a straight line descent in IMC into the ground. To support their theory, they believe that the eyewitnesses saw Tornados (AXIS formation) and not the F15s. This despite the leader of AXIS formation stating at the Court Martial that the flight was flying in loose trail and not in close formation as the eyewitnesses reported the F15s. The F15s crashed in very close formation. Further to that, AXIS formation landed 30 minutes before the estimated time of the crash.

If the new BoI has persuaded the leader of AXIS formation to change his recollection of their route on the day to coincide with eye witness positions then surely perjury will have been committed? The original verbal testimony of the route was given under oath at the GCM and a map of the route was presented as an exhibit (I have a copy of that map). The only other aircraft in the area that day were the F15s. The eyewitnesses could not have seen the Tornados on the route given in evidence.

One of the crassest questions asked by the chief prosecutor (and there were quite a few) at the GCM was : " If you take away the eyewitnesses, there is no evidence that the aircraft were seen to the east of Ben McDui, isn't that true?"

The original BoI was accused of fudging evidence to fit their theory of the cause of the accident; I hope this latest saga is not a repeat performance. The RAF seems to find eyewitnesses very inconvenient !! The subject aircraft overflew 2 of the eyewitnesses at something like 250' in close formation, they then overflew another eyewitness in a matter of seconds having altered heading. I would suggest that fast jets in loose trail almost constitute 2 sightings, not one.


DICK DOLEMAN is online now Edit/Delete Message

Another thread on this
 

There is another thread on this called 'How Can This Happen' (perhaps the moderators can put these together). I have posted quite a few questions on the other site and now that there are people reading this one, who know more about what happened, perhaps they can read those questions and answer them.

It seems to me that the BoI are questioning the phraseology used. If there is a fault in the phraseology, then in the interests of safety, this has to be addressed. If Mr Doleman can get off his train of thought that we are all trying to sling mud at his friend (which I, for one, am not) and get onto the subject of safety, we might all learn something useful.

A few more quetsions for DD
 

[quote=DICK DOLEMAN] >The original BoI was accused of fudging evidence to fit their theory of the cause of the accident; <

Who accused them? Was this and official accusation? Were any charges brought? Was the accusation proved (legally) justified? How come we didn't hear the fallout of such an event?

I thought that the original BoI was halted because the CM was convened. You're now implying something different. Were the members of this BoI the same as the original board?

Dick Doleman please read this thread
 

DD I'd be interested in your answers to the questions that I've posed on this thead.

BEagle
 

This comment by the board is most surprising:
None of the eye-witnesses were anywhere near the last radar plot. They were between 6km and 8km to the east and south east of the crash site. This evidence was crucial in supporting the defence theory that the F15s were already engaged in low flying prior to the accident and were last seen on a westerly heading towards the area of the crash site.

PAMCC
 

Check your PMs

Thread merge would be good.

To answer Speedpigs question, only one in 10 of all F-15s (all USAF fast jets??) is/was fitted with an FDR, if it has a serial number ending in a zero, it has a FDR.

Not a lot of people know that.

Sadly neither of these aircraft had one fitted.

Tarnished

PAMCC,

I believe the ATC world has learnt a lot from this already. Certainly now you would never be let down anywhere dodgy under RIS without the obligatory reminder that "you are responsible for terrain clearance" or whatever the phrase is. I believe that a number of guidelines were brought in pretty quickly after the accident.

Phraseology + altimeters
 

That's good to know. Is RIS also terminated when A/c go low level? Surely these a/c would have decended out of radar cover. So I couldn't figure why the RIS wasn't terminated.

Something else that puzzles me.
In the original thread about the CM there was information about the pressure setting for the area and it seemed that if the a/c were on regional and at 4,000ft indicated, they would not have hit the mountain due to the difference between the regional and the actual.

Many words have been written about the theory that these a/c had descended below 4,000ft. So...........was there no readable/useable information recovered from the wreckage to confirm what was on the altimeters? Was it too badly damaged?

A thought provoking thread! However, a few misconceptions about RIS. Terrain clearance remains the responsibility of the aircrew under both RIS and RAS. Furthermore under a RIS you can be cleared to a height/altitude below the radar vector chart, under a RAS you can't. I've never managed to understand why that is. Surely the only difference between a RIS and a RAS is the avoiding action given from other traffic, but I digress.

The time consuming blah about '...resposible for terrain avoidance ..' has, I believe, thankfully been removed from the book. Certainly I've not heard ATC use it for a few months.

As regards the low-level abort, it is still taught during flying training. If a student is unable to fly a safe abort he will not pass his Instrument Rating. The BIG proplem is knowing when to initiate it, not how!

H Peacock

H Peacock. Just wanted to clarify a few points!
Radar Advisory Service is where the aircraft recieve warnings and avoiding action information from other aircraft. The pilot is not obliged to take that action. They certainly cannot be cleared to below a radar vector chart. To do so would relegate them to FIS.
Radar Information Service is where the pilot recieves information only on other aircraft and takes his own avoiding action. Again, they cannot be cleared under the RVC as this would take them down to a FIS.

and no, '...responsible for own terrain clearance...' has most certainly not been taken out of the book and should be given everytime by ATC especially in Class G airspace.

hope that clarifies that!

The BOI Report is at http://www.mod.uk/DefenceInternet/AboutDefence/CorporatePublications/Reports/OtherPublications/BOI/BoiReportIntoF15AccidentMarch2001.htm

I've followed this tragic accident, and its aftermath, with more than passing interest.

This is not the first time military aircraft have descended into high ground in northern Scotland while in receipt of some form of ATC service.

There was a similar accident in January 1966, when a Canberra from 2TAF crashed into high ground west of Inverness, on descent to become "VMC below', to enter Tain Range.

If memory serves me correctly, in the Canberra accident, the aircraft was in receipt of what used to be called 'Limited Radar Advisory Service' (LRAS); and was cleared by ATC to an altitude below that of the local safety height, while heading west along the Moray Firth towards high ground.

In those days, ATC was provided via Moray Radar/Approach based at Lossie using the S264 and CPN4 radars; the former for area/approach and director, the latter for GCA finals. The S264 incorporated both primary and secondary radars, had a max range, I think of 160 nm, and a very good anti clutter/weather filter. If one deselected the MTI, Ben Macdui, Ben Nevis and various other peaks stood out like canine testicles. In the idiom of the day, the term ‘cumuli granites’ comes to mind.

As in the F15 accident, both Canberra crew members were killed instantly. Similarly, it took some days to locate the wreckage and bodies due to adverse weather.

The RN controller involved was court martialled. I understand he was “dismissed his ship” and never controlled aircraft again.

I believe that disciplinary proceedings were also taken against Squadron staff at RAF Bruggen. I'm not sure what the outcome was but involvement in same isn't likely to be career enhancing.

One of the procedural changes adopted by RN ATC (Moray Radar/Approach) at Lossie after this accident was to tell pilots on VFR descent into LFAs 14 & 15 under LRAS that they were responsible for terrain clearance, they were descending towards high ground; that if they became IMC, they were to climb immediately to FL .... ( a quadrantal level based on the lowest safe altitude within 100nm of Lossie, calculated on the current Regional Pressure Setting and displayed in bold font on the tote board above the controller's display); and to contact Moray Radar/Approach ASAP on … (freq).

And all 2TAF descents into Tain Range from VMC on top were via a GCA into Lossie with overshoot across the Moray Firth.

"Plus ca change, plus c'est la meme chose"!

In the BOI Report, there’s some reference to what, on any version of the facts, must be a Heath Robinson means of communication between Leuchars and Lossie ATC. Even in the 1960s, there was direct ATC land line comms between controllers (and to Highland Radar at Buchan, too) to facilitate ATC/ADIZ/QRA/MDA responsibilities and radar handovers via GEOREF i.a.w a SOP. The vision of using an ordinary telephone in 2001 to effect a radar handover via an assistant simply beggars belief.

And there’s the hoary old chestnut about the permissive nature of the drafting of orders. Is the RAF using public servants to draft orders these days? As Grampaw Pettibone used to say: “Holy snapping ducks*hit, it don’t take no Einstein to know that an order that’s capable of more than one interpretation ain’t worth the paper it’s printed on”.

Also in the Report, both the AOCIC and the AOC note that while responsibility for terrain clearance must remain with aircrew, air traffic controllers "must be responsible for the accuracy and the safety of their instructions". If so, is this responsibility made clear to controllers from ab initio days?

And if the AOCIC is correct in saying that this is a duty of care issue (and I think he is), then, in the absence of any Crown immunity, the question arises as to what civil liability is imposed on both the controller and his employer, vicariously, if that duty is breached. Or is the controller solely liable if he is on a frolic of his own? Never mind the "it's not in my duty statement" cry (whatever that might mean), did he know, or ought to have known, that the altitude that he approved descent to (4000ft), was below the height of high ground in the vicinity of the aircrafts' track?

Which in turn leads to the questions (relevantly in the F15 matter) of what duty of care supervisors have towards ATC staff, and staff to supervisors, where an individual is not completely fit for duty due to circumstances beyond their control.


On reading the BOI Report, it’s not clear to me if these issues are to be addressed. IMHO, they should; and all concerned need to know what their responsibilities are.

Succinctly put: a SNAFU with unnecessary loss of life, career/reputation and aircraft that shouldn't have happened if the lessons of history had been applied.

This seems to be another case of finding a verdict for the verdict's sake without adressing the issues. For example, how 'au fait' were the US pilots with UK procedures and terminology. I know they were based in the UK, but from my experience of the US use of the UKLFS I'm not convinced in this case they had a full understanding of their own terrain clearance responsibilies. Under US procedures there isn't a Radar Information Service as such - so did the pilots understand what they were getting? There has been more than one incident in the past where confusion between systems has been a factor.

I did not read the entire thing yet but what I did read makes me think going IMC under RAF radar control might be a dodgy thing.

From what I read, discounting how much was blacked out, I see an image of a guy who had suffered some sort of personal tragedy prior to the day in question. His co-workers asked him how he felt...for some good reason. His supervisor had not gotten around to verifying that he was fit. He admittedly had not signed off or read all of the memo's as required. He lost situational awareness (at best) and gave a clearance that placed the aircraft below the height of the mountain they hit while using it as a checkpoint in discussing handover to the next controller. The changeover was effected by a speed dial setup and not a direct line....required the assignment of the trade off to be decided before the handoff could occur. He had been asked for a descent clearance to by a non-standard terminology. He knew the aircraft were above or in cloud thus could not see terrain. He mishandled the radar by offsetting it vice extending the range setting. He was handling one other aircraft was it or was it a second aircraft was on the frequency. Anyway...he was not exactly swamped with business.

There is a lot of discussion about the whys and wherefores that deal with the very limited effect each variance from established procedure had on the fatal crash that killed two pilots but it does not consider the perception that can be formed by assessing the cumulative effect of so many deviations from procedure and plain old commonsense. I see a sloppy operation that failed to accomplish their mission, that being the safe control of air traffic.

The emphasis on the request for Minimum Vector Altitude is misplaced. The emphasis should be simply on why the aircraft were cleared towards the mountain whose height exceeded the altitude they were cleared down to by the controller....all the time he knew they were headed for that location as evidenced by the discussion he had requesting the handover.

One can say the pilots are responsible for terrain clearance....and they are. One cannot evade responsiblity for a controller giving a descent clearance that is lower than the terrain along which the aircraft will be flying. Pilots must be able to rely upon ATC to ensure terrain clearance is considered anytime an ATC clearance is given. Why else is it called a "Clearance".

Seems to me this was a case of aircrew not aware of MSA, loss of situational awareness. It's a planning issue. As I understand it, they were not in controlled airspace and should not have put themselves in a position where they relied solely on ATC.

Angrel.
Having spoken to a competent 'air tafffickker' yesterday on the subject of radar-to-visuals (nothing to do with the F15 CFIT), he assured me that an aircraft could be cleared to a lower height on a RIS than a RAS. This was because on a RIS we can be cleared below the radar vector chart. Surely this is why you can get a RIS as soon as getting airborne but before you are high enough for a RAS? I'll double check with my contact, but this does concur with my understanding that you'll always get lower on a RIS!

As regards the 'blah' about terrain clearance, this has gone from ATC phraseology where I work, maybe a local procedure. Do I really need constantly telling something that is SOP? I think not.

H Peacock.

Cleared? I think not
 

You cannot be 'Cleared' to do anything on a RIS. It stands for Radar INFORMATION service. If you have an ATCO telling you this they ought to be sent back to training !!! Equally any pilot who doesn't understand ATSORA.

I hope ATCOs are still using the phraseology about terrain clearance. It could save them their licence/a long CM, if, God forbid, something else like the tragic F15 accident happens.