Flipster
<<It is also apparent that there is some confusion as to the speed and ROC of the ac as the crew penetrated cloud, as they eventually did do - even Boeing's best guess seems like a stab in the dark. Helos do not zoom climb like jets, as you well know - but this is a fact that may have been lost on some? >>


I should wait until someone else qualifies this but what the hell.
While a helo does not have that combination of momentum and aerofoils that can, with a pull on the stick, execute a “zoom climb” regardless of power (eg as a glider can), it has two sources of “energy” that can indeed allow a zoom climb:
the stored energy in the rotors;
the thrust in excess of that for holding it up in the air (lift = weight) that is used for propelling it along at its cruising speed that is balanced by the drag.
You only have to look at air displays by Chinooks to realise how agile they can be when their payload is not excessive (and ZD576 that day was not heavily loaded with respect to two engines operating).
If you go through Boeing's “Analysis of Available Data”, by Mitchel, you would appreciate that it was a fair effort of rational analysis attending to speed/distance calculations in great detail; for a start contrary to the picture of excessive speed that seemed to be presented by many, they had simply covered their route at thecruising speed for an HC2 Chinook;
further, and I suggest of great significance to understanding this crash, after the turn at waypoint change their airspeed on that final leg had dropped significantly (this being masked by the increase in wind speed as the landmass was approached), the Boeing analyst concluding that they were slowing down; that the engine powers were found matched suggests that this was a steady state for a while in turn suggesting a planned slow down.
If the a/c had been continuing at its cruise speed, it would have had the thrust component used for pushing it along through the air available, at a pull on the cyclic, to push it up.
Indeed this does cause unwanted ballooning when not complimented carefully with the requisite working on the thrust lever when you want to do a fast approach/landing, does it not? That they had not zoomed up significantly despite having cranked her back (nose up 30 deg from memory? - path 20 deg up?) suggests that this extra thrust was not available reinforcing Boeing's conclusion that they were slowing down. The bit that they had climbed seems due to the stored rotor energy alone (reduced to about 90%?). The thrust lever, having been pulled fully up, had acted as collective but the engine system had not had time to respond as the power was still matched. They had been taken by surprise.
So how could they have been surprised by entering the ground mist when they had turned towards ground that was higher than them and they had started to slow down? Only that they had got there sooner than they expected is surely the only logical explanation.
They had turned onto a heading, reflected in the HP's course selector, that was the optimum approach for a known landing area, for which waypoint A would have been an obvious inner marker, with a RADALT warning set appropriately for an imminent landing, with the HP's baro alt subscale setting appropriate as a QFE for the elevation of that landing area, and they had started slowing down. And they were using a call sign appropriate for an exercise.
Looks like it is at least worth some consideration that, for whatever reason, they were doing a fast approach to that landing area but, for whatever reason, misjudged their closing rate.
Because of the nature of the ground there (topography, lack of features, nature of vegetation, etc) a fast approach to that landing area on that track is difficult to judge in the best of conditions – in the conditions of the day, it would have been folly to approach at speed without some other trusted reference other than the mk1 eyeball or the SuperTANS – and had that other reference been for whatever reason been misguiding them, it would have been hard to pick up on the error from visual cues until it was too late.

Flipster

Thank you for a well thought-out, thorough and reasoned post, which must have taken a significant time to write.

I agree.

John Purdey

Thank you for carefully reading my last post. I recommend that you also read flipster's posting above. Unfortunately, even if I accept that you and I will never agree, it is unseemly and impolite for you to ignore my question to you:
I'll take your failure to answer as a 'Yes'!

It is also impolite that, having carefully tried to answer your points, and at some length, you answer in such a cursory and arrogant manner.

With all good wishes,
Meadowbank

flipster,

My apologies for a tardy reply but I can only plead the vagaries of "appointments" with Estate Agents and other interested parties regarding the sale of 2 of our houses.

You state that I am "persistant with the notion that not having breakfast indicates that Flt Lt Tapper was a persistant breaker of GASO's, ASI's etc."
I do no such thing - I merely point out that there is no record of him having breakfast that morning; a requirement for all Aircrew in the Orders and Instructions regulating the operation of STC Aircraft within the United Kingdom

That point assumes significance when you consider that ALL the other crew members complied with the laid down requirements in respect of having breakfast before embarking on flying duties.

Before we go on from here and I have to keep repeating myself in respect of other claims you have made - can you at least acknowledge that you agree with the above synopsis?

Caz,

But there is also no proof that he did not have breakfast in the crewroom, a practice that was common place at that time, so a bit of an impasse I would suggest, but I doubt you will concede that point.

I'm confused .. (not difficult I know) ... but just what difference does the fact that he did, or did not, or might, or might not, have eaten, or not, be it ham and eggs or a mars bar ... actually have to do with the right or wrong of the findings against the crew ??

The eventual findings broke the rules, in force at that time, and I thought that was the point ??

Methinks there is more smoke here than a WWII destroyer produced.

OmegaV6
 

Very well said. There is far too much of a smokescreen on this thread, from people who (whatever their motives) want to distract us from the primary purpose of the thread. That is, of course, to overturn the verdict of gross negligence - for which there is no justification whatsoever.

Cazatou (K52)

On page 123 of this thread, in Jul 2006, I said to you:
You attempted to imply you HAD knowledge of the contents of Flt Lt Tapper's stomach.

Please clear this up for me, once and for all:

When, and what, had he eaten on the 2nd June 1994?

Thank you.

The importance of food - a cautionary tale
 

A little tale. In 1998 the MoD(PE) Directors General started what was termed “coffee with the DG”, whereby ones DG (2 Star) would invite about half a dozen staff, of different ranks/grades, to sit with him, have a coffee and, without fear of retribution, speak openly about issues which concerned them. (But only one issue each).

When it was my turn, a few colleagues became tongue-tied in the presence of greatness, so there were 3 issues.

First, a Sqn Ldr expressed concern that experienced staffs were being ignored on Nimrod RMPA and the long-predicted, and yet only recently announced, 4 year slip was nothing compared to what was to come.

Secondly, I got on my hobby horse and noted that senior staffs continued to condone the deliberate waste of money, while I was being denied funds to attain and maintain airworthiness; while waving the audit report which backed me up.

Lastly, a young lady took her life in her hands by complaining that our staff canteen charged more for a banana than Sainsburys across the road.

The good Sqn Ldr and I were dismissed out of hand. “What slip?” and “Of no concern to MoD(PE)”, I clearly recall. But the case of a banana which cost 2p more received the full weight of his 2 stars, whereas we would have preferred him to concentrate on little things like Nimrod and Chinook Mk3 which, while simple enough jobs, were turning to rats in precisely the manner predicted a few years before.

There are some who are fixated about food (who end up too fat to pass their emergency egress drills), and there are those whose limitations are exposed by an inability to grasp what is important.

I entirely agree. Particularly so in this case.

However, I think it important for cazatou (K52) to respond, since it is he who is trying to smear the captain.

As the jackels are gathering again I would merely point out that immediately after the first formal briefing of the AOC by the BOI (as opposed to the initial signal) Stn Cdrs were instructed to ensure that crews partook of breakfast before flying. At Northolt, where Government Ministers always wanted to depart at 0800 hrs to impress the PM, a system was instigated whereby crews were served breakfast by In-Flight Catering after Met Brief & Flt Planning. Coincidence? Non!!

PS
Has anyone asked Lt K what the turning point was on the Mull? The old adage "Don't assume - CHECK" could perhaps have averted the tragedy.

Thankfully RAF Aldergrove already had a perfectly suitable system in place with the provision of in flight rations, available 24/7 in the always well stocked crewrooms of 72 and 230 Sqn's :ok:

cazatou (K52)

Jackels (sic)?

Non!!

Simply highlighting the fact that you do not know whether Flt Lt Tapper had breakfast or not. His only misfortune was that nobody could say for certain that they witnessed it!

You simply use this innuendo to smear his reputation. Are you really that desperate?

We also shouldn't overlook the fact that two and a half years ago you made a claim which you now are unable to support!

Kind regards.

Chinook
 

Meadowbank. I'm afraid the arrogance is all yours, in supposing that people are obliged to answer your ill-informed questions. With all good wishes, JP

Tandemrotor

1.The evidence was compelling enough for the AOC to instigate measures to ensure that personnel had breakfast prior to flying.

2. If Flt Lt Tapper had partaken of breakfast in the Mess then both he and Flt Lt Cook could have gone to Met Brief together - standard practice for Flight Deck Crew in all my flying appointments.

3. There was also no record of any in-flight meals being ordered - hence the comment in the BOI that they were unlikely to have had anything to eat "other than a few biscuits" during the first sortie.

4. Nobody has yet explained (in the light of all the posts on this thread regarding Flt Lts Tapper & Cook "taking over" the VIP task from Lt K and Flt Lt T) why the 2 experienced Chinook Pilots flew the routine in -theatre Army support tasks with the inexperienced (on type) Lt K and his Nav programmed to fly the "VIP Task".

5. Finally, nobody has explained (again in the light of the posts on this and previous threads) how it came about that the BOI concluded that Tapper & Cook flew the fatal sortie because detatchment crews preferred to operate on a "day on - day off" basis. I wonder where that misleading information came from?

Caz

"As the jackels are gathering again I would merely point out that immediately after the first formal briefing of the AOC by the BOI (as opposed to the initial signal) Stn Cdrs were instructed to ensure that crews partook of breakfast before flying. At Northolt, where Government Ministers always wanted to depart at 0800 hrs to impress the PM, a system was instigated whereby crews were served breakfast by In-Flight Catering after Met Brief & Flt Planning. Coincidence? Non!!"

It does rather seem to me from the above that prior to this unfortunate incident you and the rest of the aircrew at RAF Northholt were all guilty of

"knowingly flouted HQ STC Air Staff Instructions and Group Air Staff Orders whilst on Active Service." your words Sir, not mine.

The difference between Northolt and Aldergrove is that prior to that fateful day on both 72 and 230 Sqn's in flight rations were in plentiful supply and available 24/7. To me it suggests that adherence to the relevant orders with regards to catering was common place in Ireland but was, by your own admission woefully inadequate at Northolt, shame on you for your hypocrisy.

cazatou (K52)

Just so we can put this one completely to bed then:

In Jul 06 (on p123 of this thread) When you said you had seen evidence of Flt Lt Tapper's stomach contents, you were in fact 'mistaken'?

Is that correct?

In fact you do not know what he had eaten, nor when?

Is that also correct?

Very many thanks.

TR

Just a point of order, they would have struggled to go to met brief together. There wasn't a met brief to go to, you self briefed because everyone had a different reporting time. For longer flights, it was normal that 1 crew member went over for a face to face brief with the met man. Usually but not always the captain.
In flight meals?? You are having a laugh of course. The squadron claimed money and bought flying rations that were kept in the crewroom. The crew sat and ate those very rations before the very flight. At the same table I was sat on, so I can confirm they did eat. If you need that under oath, I can comply if required.

Caz,

"In flight meals?? You are having a laugh of course. The squadron claimed money and bought flying rations that were kept in the crewroom. The crew sat and ate those very rations before the very flight. At the same table I was sat on, so I can confirm they did eat. If you need that under oath, I can comply if required."

Care to comment?

It seems Northolt aircrew, who were charged with carrying the most important people in the UK including the very person I declared my allegiance to in 1974, serially flouted the requirement to eat breakfast, hence the introduction of "a system was instigated whereby crews were served breakfast by In-Flight Catering"

By comparison the system that had been in place for as long as I can remember at RAF Aldergrove not only more than satisfied the rules and regs you are attempting to hang this crew out to dry with but JT's post above completely shreds any hint of credibility you may have had with regards to this subject and I look forward to your response.

cazatou (K52) ? :rolleyes:

Standing by for obfuscation!

(Or silence!)

It will be one or the other for sure!

Come on, gentlemen, this is getting silly. We should remain above petty point-scoring if we wish the thread and the campaign to continue to be taken seriously. When we branch out into semi-private feuds about meal arrangements and the like we start to sound like more like schoolboys in the playground than professional aviators.

Boslandew

And to maintain this thread in the complete nonsense it has degenerated into over recent posts; Please do not forget prawn voluvents were served in flight (true) but did both pilots eat the same thing at the same time;? and did this contribute to the incident? For goodness sake please get this thread back onto line and away from this complete rubbish being posted at present!:ugh:

Caz,

In the light of Jayteeto's comments, I really think you should drop the alledged lack of crew breakfast argument - once and for all; to persist would do you no credit.

I note that few 'cognoscenti' seem to have any views on the other points I rasied in post 4109. I freely admit that I may have the wrong end of stick but the stony silence, in itself, speaks volumes. Please enlighten me.

flipster

Boslandew

Far from petty points scoring, we now have positive evidence (from Jayteeto) that breakfast was eaten by the crew, thus putting to bed the rather lame notion that the crew was already negligent by having not eaten it.

Perhaps we could now fast forward to the issue of whether or not the crew was negligent to have continued towards the cloud-covered Mull, despite, according to the yachtsman, being in perfectly acceptable VMC over the Sea. JP seems unwilling to discuss this but it is something central to the argument of Messrs Wratten and Day that the crew was grossly negiligent.
Of course, 1 nm would be a bit too close for a fast jet pilot (like AM Wratten) to make a decision to turn up the coast at 420 kts+, but what about in a Chinook at 150 kts G/S?

VMC or IMC
 

This is my first day and just registered! Looking round the site I was surprised to see this thread running at full speed after all this time. That said, I was in MOD at the time of the BOI and met the President on several occasions. Most of what we discussed must remain priviledged, but I recall several points that have subsequently been blurred by press and political comment - albeit well intentioned. Equally, several external issues have become involved in the search for the Holy Grail - why did the aircraft crash?

Yes lets get back to basics. 100% of aircraft accidents have a root cause, in this case the aircraft entered IMC below safety height and flew under control into the ground - now termed a CFIT accident. RAF pilots are trained from day one of the dangers of flight in IMC, and the action to be taken in the event that one enters IMC below safety height - climb to safety height. In this case there was no evidence that the aircraft was climbing when it hit the ground - the contrary - the Captain had failed in his primary duty. But humans are fallible, and the duty of the second pilot - or executive vice president as he is sometimes called, is to act as the safety checker and alert the captain to dangerous situations, or in extremis, to take control to ensure the safety of the aircraft. This did not happen. Two major errors of judgement by experienced pilots.

There are many other matters, secondary causes, which can be almost anything ... lack of supervision, inadequate briefing, faulty weather data, technical problems, medical, difficulties at home, even as we have heard lately - gambling debts, but none in themselves cause the aircraft to fly into the ground. This is something that people who have not spent a life flying, or indeed investigating accidents as I have, seem to fail to grasp.

There have been many CFIT accidents in the past, in fact I think a Vulcan was lost in similar circumstances on the Scottish Low Flying route many years before this incident. Sadly, CFIT accidents continue in both military and civil flying.

Final point. I remember that in the early days of the Lightning, a pilot was lost when he became disorientated over the North Sea. It emerged he had not had breakfast or lunch, and it was determined that this was possible secondary cause of the accident. A result was that the Flight Safety organisation produced a series of large posters proclaiming "High Performance needs Energy" (I think - or maybe Food!). Subsequently, the V Force Aircrew Buffets spread to other stations, and finance was made available for the crew room snacks that have been mentioned earlier.

VictorPilot,

Welcome to the debate, not sure quite how you arrive at

"in this case the aircraft entered IMC below safety height and flew under control into the ground - now termed a CFIT accident" without resorting to a little bit of supposition however just a quick question,

Is there anyone alive today who actually knows exactly what happened on that fateful day?

VictorPilot

Welcome to the thread - I trust you have a thick skin.

flipster & meadowbank

jayteeto stated:

"The crew sat & ate those rations before the very flight. At the same table I sat on, so I can confirm that they did eat."

As the "Computer Weekly" article revealed exactly what Flt Lt Cook and the ALM's had for breakfast in their respective Messes that morning (whilst Flt Lt Tapper was at Met) and that jayteeto uses the phrase "before the very flight"; I put it to you that he is referring to what happened in the Afternoon before the fatal sortie.

Perhaps jayteeto could clarify so as enlighten us as to what they ate and at what time of day?

VMC or IMC
 

VictorPilot,

As a newcomer to this intensely active thread, may I suggest that before you make any further comments besmirching the memories of dead aircrew, you at least take the trouble to read all of the previous posts? If you do, you will see that there are clear reasons to suspect that this aircraft may (I put it no more strongly) not have been under control either at, or even for some time before, the point of impact.

Without firm EVIDENCE (not mere supposition) that it was indeed under control, there is not the slightest justification for the damning finding of gross negligence.

Considered comments will, I'm sure, always be welcomed by readers of this thread. Shooting from the hip by a newcomer is not.

Caz,

I take that ,in light of Jayteeto's rather revealing post, when you posted this on the 9th March in post # 4038 you had used assumption rather that actual hard evidence and were therefore factually incorrect.

"I was merely quoting the BOI regarding catering. They concluded that the crew would have eaten only a few biscuits during the first sortie. There was no record of Flt Lt Tapper having breakfast and no crew meals were ordered for either sortie.

Thus, when they departed on that final sortie, the Co pilot and ALM's had not had a meal for some 10 hours and the Captain for some 22 hours."

In light of that rather glaring and obviously ill informed error do you now not wonder if maybe your interpretation of the BOI might well suffer from other similar basic flaws?

Victor P, welcome. As you say, CFIT is one of those things that has happened since the dawn of aviation. Can you recollect any other UK military CFIT where the pilot(s) were found to be grossly negligent?

Chinook
 

VictorPilot. Well said. There are too many folk on this thread who are determined to divert attention from the basic fact that this crew flew at high speed and low level, well below any safety altitude, towards and then into hills that were clearly IMC, and failed to turn away. For example, a recent Post suggested that perhaps a fly in the cockpit, or that the crew (both pilots?) suffered an itch, and that this might have caused /contibuted to the crash.
Perhaps it would help if experieced pilots (and I am one), rather than general S***-stirrers, made their background clear?
Do come off it some of you!! With all best wishes to those who look objectively at the facts, JP.

JP,

Is there anyone alive today who actually knows exactly what happened on that fateful day?

Easy question for you :ok:

JP, you may well be right. My personal problem is trying to reconcile how other CFIT incidents, with far more credible and indisputable evidence, were not categorised as grossly negligent.

VictorPilot:
I'll give you your due VP. Most maiden/low posters who give us the benefit of their certain knowledge of the answer to your rhetorical question do not identify themselves as MOD staff/air officers at the time, leaving us to deduce that for ourselves. You man up from the outset and own up to that dubious qualification. Why dubious? As SFFP reminds us NO-ONE knows for sure what happened or why, not you, nor me nor even Messrs Wratten and Day. What we do know now though is that a deliberate and sustained policy of neglect (not even benign) of the mandated duty to enforce the UK Military Airworthiness Regulations was being enforced from 4* level downwards, affecting every military airfleet including the RAF Chinook HC-Mk2's. That an institution that so flagrantly reneged on its own responsibilities has the effrontery to so unjustly enforce the arbitrary findings of two Air Marshals with no real proof and contrary to other more respected national institutions' own findings is par for the course for this discredited organisation that so cries out for reform. That reform must start with the removal of airworthiness regulation to a seperate and independent MAA.

Shy Torque

The answer is in the post that you attempt to denigrate - a trait that is more apparent with each of your posts.

The Flight Deck crew of ZD576 (as opposed to the cabin crew who were engaged in ensuring the safety and comfort of the passengers) had the prime duty of ensuring the safe conduct of the flight.

The BOI concluded that the Captain had failed in that duty - the Reviewing Officers agreed and extended that failure to the Co-Pilot (and incoming Detatchment Commander). Those Reviewing Officers were AOC 1 Gp; AOC in C STC and (Exceptionally - because of the media interest) CAS.

I accept that you disagree with that decision in regard of the 2 Pilots BUT we have now had (I believe) some 5 different Chiefs of the Air Staff who have reviewed this tragedy and all have reached the same conclusion.

You have highlighted several areas where you believe shortcomings were evident - may I ask how many incident reports you raised in this respect and whether you raised or reported your concerns throuh Official Channels. We all have (in my case had) a duty to notify our superiors of unsafe or dangerous procedures and practices.

Equally - we all had a duty to abide by the rules and regulations promulgated by those in authority over us.

Perhaps you may wish to consider whether early action by yourself, and your compatriots who agreed with you, may have prevented such a tragedy. You were, after all, the people who were operating the aircraft.

Absolutely right.

As someone who held airworthiness delegation at the time, I can demonstrate beyond any doubt whatsoever that I fulfilled my duty by notifying my superiors (e.g. in the years immediately preceding Mull, an RAF 2 Star) of unsafe AND dangerous practices that compromised my/our ability to comply with the regulatory requirement to maintain airworthiness. Primarily, the ruling that anyone disobeying an order to ignore airworthiness was guilty of an offence. You must ask these senior staffs, who to this day stand by their rulings (not unlike Wratten and Day), why they disagree so violently with the regulations they are bound by. I just wish they would read the accompanying regulations which state they must resign if they cannot bring themselves to abide by their employer’s policy.

I chose to meet my duty to abide by the rules and regulations, in doing so disobeying direct orders. I know others chose to obey the order when they saw what would happen to them. That is why some aircraft and equipment have a more robust airworthiness audit trail than others. The Chinook Mk2 is one of least robust (along with Nimrod MR2 and C130, as ruled by two Coroners and agreed by SoS). As the same regs apply to all aircraft and equipment, and all form part of the same chain of delegation, it is impossible for anyone to ignore the statement of ACM Sir Clive Loader that MoD failed to implement their own regs, over a long period of time. 39 years according to the Oxford Coroner in he case of Nimrod – again accepted by Min(AF). Must I point out, again, that Nimrod and Chinook came under the same 2 Star, so it is not unreasonable to assume each were subjected to the same management (mal)practices? As confirmed by the NAO and HCDC.


What I describe is a failure of duty of care amounting to gross negligence; negligence that had already occurred long before ZD576 took off that day.

Seldomfit....

I have said it before on this thread, and I will say it again. there are only two beings on this planet that know "without any doubt whatsoever" what occurred in the final stages of that fateful flight: Day and Wratten.

The rest of us, less arrogant, mere mortals may only surmise!

JP
Apologies, but trying to look objectively, I see no factual evidence to suggest that they were flying at anything other than a normal cruising speed (rather than high speed) up to waypoint change nor any evidence that they were heading toward the hills at this point i.e that they had not turned away.

There's a lot to wade through so maybe I have missed something, in which case please could you clarify? Thanks.

The Aerosco

Cazatou,

The answer to what? Is it a reply to something I posted? My last contribution was almost two weeks ago and it wasn't a question, but a reply.

Have you eaten breakfast today?

Shy,

I am certain that the ludicrous rations suggestion is now well and truly dead and buried, never to raise it's silly billy head again.

As for you getting an answer, well I guess you are going to have to stop asking difficult questions of the chap in question :ok:

Lurking123 is correct to point out that other CFIT accidents did not draw the same responses by staff officers as those produced by Wratten and Day after the Mull crash. For example, Hercules XV193, also from Strike Command, crashed in Scotland in 1993. The BOI could not be sure of the cause as there was no CVR/ADR, nor witnesses to crash itself; any findings were 'conjecture' (MoD's words, not mine). This was a similar scenario to that of ZD576 but the crew of the Herc were, quite rightly, not found to be grossly negligent. However, Tapper and Cook were treated differently....why was this? Why was precedent ignored?

VP
You are quite correct to point out that the immediate root cause of the crash of ZD576 was that they crashed into a hill. However, I think you'll find that the concept of a single 'root cause analysis' is an outdated one.

In many accidents, there are local 'active' failures but also organisational 'latent' errors; this is called the Reason Model and is widely used and forms part of ICAO Annex 13.

Tuc rightly draws our attention to the possible 'latent' failures in the defences and safeguards of the organisation (ie the holes in the layers of swiss cheese). It is certainly possible (Tuc would say probable) that the MoD failed to maintain Airworthiness in the Chinook at this time (local engineering instructions to be performed in the air). This has been shown and admitted to by the MoD in the Nimrod XV230 enquiry - the same Senior Officer that looked after Chinook and the Hercules. One could even argue that airworthiness and possible FADEC failure/glitches are only one of a number other possible latent failures, which were not fully investigated at the time - because the AOC said so and because it was common practice). Instead, the BOI directed their attention to the local 'active' failings by the crew on that day (ie they unintentionally flew into cumulo-granite.... for some reason, which will forever remain unknown).

In 1994, blame was apportioned only if the facts were absolutely incontravertable. Even if that was the case (and I don't believe it was), have we not evolved from the bad old days of 'blame and shame'? Accident investigations in this more enlightened age should consider the Reason Model's 'latent' errors, as well as the unsafe acts that lead, more directly, to an accident. I am not sure that the MoD followed best practice - then in 1994 - nor perhaps, even now.

Sadly, it is understandable why the RAF hierarchy did what they did, especially considering the emotive loss of most of NI's counter-terrorism experts. Inherently, it is more 'psychologically satisfying' (and easier) for the organisation to blame an individual for the last error in the chain but I would argue that to continue doing so shows a lack of clarity in one's logic and reason and also a blinkered approach to the true aim of the investigation - to prevent recurrence.

If the BOI of ZD576 had been allowed/instructed to delve a little deeper than the obvious root cause of the crash, perhaps the crews of Hercules XV179, Nimrod XV230 and Sea Kings XV650 and XV704 would be alive today?

Numerous accidents and incidents such as the Herald of Free Enterprise, Clapham, Chernobyl, Dryden, Erebus et al have cited the pre-disposing conditions of organisational error (eg lack of training, supervision and/or poor risk/resource-management etc) as having made major contributions to the accidents. This modern approach is 'best practice'. Is it not time for the MoD to join the 21st century? Regrettably, they cannot (or will not) because, after an accident, the very people commanding the investigators will themselves come under scrutiny - yet I live in hope that things will change.


JP - I didn't mean to 'stir your sh!t'! I may have hit a nerve but I'm afraid that your answer leaves doesn't really make things any clearer to me. Try asking yourself why would an experienced and most capable pilot fly into a hill? One thing is for sure; it was not on purpose!
Also, your appreciation of low-level and safety altitude confuses me - if an ac is at LL then, by definition, it is below safety altitude - all of the time. There may well be cloud obscuring the high ground; that does not make it illegal (clear of cloud, in sight of the surface = VMC for helos, I think it was then) - in fact, it is 'situation normal' for most LL ops in the UK, as I'm sure you are aware. 150kts (not confirmed) is NOT high speed - it may have been quick for a Chinook, mind you but it is not fast. But if an ac then goes into cloud, the pilot should always try to climb as expeditiously as possible, in a safe direction, up to safety altitude - every single bit of training I ever received or gave in the RAF reinforced this and we have NO reason to believe that the crew of ZD576, nor anyone in the Chinook fleet, would have done differently. (Here, I assume that this was also SOP for the Chinook fleet - if not, then why not?)

If they had flown into cloud that day, it would be reasonable to assume that they would have followed their training - but, if they were in cloud, why didn't they do so? That question is as unfathomable now as it was then but it doesn't necesarily mean they were grossly negligent.

You talk about 'facts', well these are the facts:

The fact is that no-one really knew what the weather was actually like in the area at the time nor when or if ZD576 entered cloud (with due deference to the sailor, his view of the weather and the ac speed is, at best, a guess).

The fact is that no-one can be sure of the goings-on in the cockpit - visual illusions, distractions and a loss of SA come in many shapes and sizes (even fly-shaped!).

The fact is no-one can be totally sure of the integrity and performance of the ac, its systems, nor its powerplant - despite what the manufacturers say.

The fact is that no-one really knows what were the thought-processes of the crew, nor their plan, nor their actions.

The fact is that most of the BOI 'findings', everything talked about in the H of L and almost everything written on this site is conjecture because there was no ADR/CVR.

The fact is that no-one will ever really know what happened that fateful day.

With this as a backdrop, I argue that it was wholly inappropriate for the crew to be found grossly negligent and it is now time to change that ruling.

Please let the crew, the passengers and their families rest in peace.