Thor

I did not know I had! It probably fell off when I was correcting something else!

Any way - I have always been against the "Gross" negligence and for pilot error.

To you but not to me........

My post 6046
Quite - but many accidents have come up with verdicts in pre data recording aircraft without that knowledge. Balance of probability and all that.........and there is a lot of probability hanging around here.

Now that does look like pilot error.

but does not excuse the fact that the aircraft must continue to be flown by whatever means available by one of the crew. (see airline accidents ad infinitum)


All the best, D

Bertie

Are you saying that they should not have accepted the aircraft for that flight given the knowledge that you state they had?

bastOn

While I respect your right to an opinion, I am uncomfortable with such a stance from any aircrew.


The irrefutable evidence is that the airworthiness regulations were ignored to such a degree that both the CA Release and Release to Service were laughably non-compliant. That was so in November 1993 (initial issue of a fabricated CAR, which had no audit trail whatsoever to any formal Boscombe recommendation; or any other independent advisor) and remained the case at time of accident. That is not my opinion – it is a simple fact and the MoD correspondence proving it was published a week or so ago. As the aircraft did not remotely meet the mandated airworthiness regulations, in particular the appallingly immature status of various clearances (i.e. many completely missing), then I submit this had an impact on the flight safety; ultimately demonstrated by Flt Lt Tapper’s request for a Mk1. He knew.


The sudden denigration of such a respected organisation as Boscombe Down is incomprehensible. You can only be talking about Rotary Wing Test Squadron, as it was they who flagged the major issues preventing CAR/RTS. (And safety critical software being “positively dangerous” is MAJOR). In my experience, RWTS is/was largely staffed by your fellow Servicemen who, by definition, had to have front line experience. (And those I came to know very well had bags of it, not just with the UK but on exchange with Allies in-theatre). The first thing they are taught on taking up post is – here are the regulations. They are not guidelines, lab notes or rumour; but regulations to be followed to ensure the safety of both yourself and your fellow aviators. I have never met one who didn’t understand this and all were keenly aware they would probably be back flying the aircraft in their next tour. It is not their fault that, in 1993, it had been MoD policy for 2 years not to maintain airworthiness.


On Chinook, they did their job. DHP was advised the CAR should NOT be signed. He would have taken this to his boss, DGA2 (an RAF AVM). In turn, they would advise CA to sign (there would be little point walking the document into his office and advising him not to sign). Critically, at every stage ACAS and his staffs had to be involved. Part of the evidence required by CA (a requirement stated in his own CA Instructions) is that, before he signs, ACAS must state in writing he is content and will incorporate the CAR in his RTS. That letter forms a crucial part of the audit trail, confirming he has not been taken unawares by being offered something he cannot Release. This is were gross negligence took place, and only a comprehensive investigation and assessment of documents not made available to any inquiry will reveal who made the decision to ignore Boscombe, and their reasoning. I wonder who the PE > ACAS linkman was? And what reply/instructions was he receiving from his other master?

Tucumseh

I bow to your far greater knowledge than mine regarding Boscombe Down. I based my view solely on a couple of personal experiences and I apologise to all those brave chaps who clearly have done a great job over the years in areas that I have not wot of!

Sorry.

David

BastOn

Thank you.

Bast0n,

I don't want to drag this out - we'll probably go around in circles :)

Coming back to a previous question

Flipster suggested the alternative findings would be: Pilot Error, Engineering Error, Normal Operating Hazard, Cause Not Positively Determined.

I would still expect that for Pilot Error to be an applicable verdict, you'd have to know what they did. I.e. taking a clue from the verdicts, you would have to Positively Determine that they made an error.

Surely, you either have to take the view that either

A) There was nothing wrong with the aircraft and they just carelessly flew it into the Mull - therefore Gross Negligence

or

B) There is not enough evidence to positively determine why they crashed - therefore CNPD.

You're to a certain degree correct in saying we shouldn't mix up the cause of the crash with the Airworthiness issues. The aircraft was there, and they did fly it.

However, it is clear to me now (and apologies for being so slow on the uptake), that the Airworthiness issues should be investigated fully, and the appropriate changes made.

TN

THOR

Hullo again!

I just don't take that view point. I think that there degrees of error and carelessness and gross negligence is the top of the tree. Take a personal incident of mine - I hit a dead tree whilst flying low over the jungle. Now dead trees are notoriously difficult to see against the backdrop and I dinged a tip. No doubt about it - pilot error - too low - not a good enough lookout.
Gross negligence? - no. If I had been beating up the Gurkhas in a clearing - hit a bigger tree - crashed - killed a few people - gross negligence. Court marshall had I survived but what if I had died and there were no credible witnesses left? Bees in the cockpit or on the balance of probability I had ****** it up in spades? What would Hine say?

In this instance I think we are in the "Nibbled to death by ducks" syndrome - but the final act, in all probability on the evidence available was "Pilot error". Not a huge damnation of the crew but a gentle reminder to us all that simple mistakes can have consequences far beyond the simple error, especially as in this case the VVIP load in the back moved the whole disaster up the scale. Had the aircraft been empty would be here now?

Hit a tree in Borneo - no problem - Windsor Great Park whilst the Queen was out riding, man with camera phone, Daily Mirror...........?

See where I am coming from?

David

Let's make the hypothetical scenario more akin to the one under dispute.

Everyone killed, no witnesses - ok.
Let's add a little to that...
No data recordings either present or retrievable.
A history of technical problems with that particular aircraft
Serious concerns over the safety and airworthiness of the type.
The tree you hit was the biggest one in the forest and visible for miles around - in fact, so big it had its own weather system surrounding it.

I'd hope your family would hear a CNPD verdict being read out.

Maybe there wouldn't have been the neccessity to produce such a "case closing" verdict in that case.

Personally, I find it unacceptable that the pilots are being blamed for the accident, and I would feel the same had they been on their own.

Not really - in the Windsor case there would be credible witnesses and more information available. Hopefully that would lead to a fair verdict.

Or did you mean a more high profile incident should lead to a harsher verdict, regardless of the evidence? ;)

TN

bast0n,

I am genuinely not wishing to sound offensive here but I have never really got my head around where you are trying to come from, I know I am but a simple soul but I am as flummoxed now as I ever was :confused:

Like you I suspect the guys quite probably got it horribly wrong on the day but where we depart is that I accept that "I suspect" simply does not cut the mustard with regards to the verdict.

Without clear, concise and fully substantiated evidence how can anyone possibly KNOW exactly what happened that day.

If we do not know EXACTLY what happened we can all surmise till the cows come home, and you and I seem to have a similar mindset, but surely in that case the only possible VERDICT is CNPD and not what the two AM's surmised.

SFFP - correct!

Bottom Line:


"Balance of probabilities" does not meet the burden of proof of "with no doubt whatsoever" .......end!

Well, I have several times re-read Dalton's letter and can see no evidence there that he is actually playing a (dangerous) political game as suggested here. I think we are giving him undue credit.

If, as is likely, the letter was (written?) cleared by MOD advisors, it opens an interesting insight into 'positions' being assembled in Lemming House. If the Lemmings are in fact jostling away from the cliff edge, may we hope that we are near a watershed (if there are not too many analogies there:)) for Brian and all?

Thor

No - the higher profile frightens their Lordships into knee jerk reactions!

As I asked before does this also cover Pilot error? I always thought that negligence was considerably higher up the scale. Genuine mistake - Pilot error. Being a prat et all - negligence.

Seldom

This is not an argument but a discussion, and of course you do not offend. I am of the mindset that thinks on the balance of probabilities on the day these poor chaps could be accused of Pilot Error. That's all.

Intelligent experts can, and have in the past, come to conclusions in the circumstances you quote above. "Exactly" maybe not - but 99% sure based on the evidence available maybe.

I do not put myself in that bracket, but I have a point of view........

Out of interest, whatever happened to a finding of 'error of judgement - excusable/culpable' which was around in my day?

BOAC

Sounds reasonable and looks a bit like my view of Pilot Error.

Good evening all.

I understand that there will be another feature on BBC radio 4 Today programme tomorrow morning. :ok:

Regards,
Brian

"Justice has no expiry date" - John Cook

Excellent - I will be listening!

Before 'some' get too excited with my post - I wish it to be clear that I am not suggesting this as a 'verdict' - it is just that it has not been mentioned in any posts here.

CNPD for me.

At the time of the Chinook accident, an 'Error of Judgement' was defined as 'an honest mistake, accompanied by no lack of zeal', if memory serves. Only rarely applied in HF accidents where the crew survived, perhaps because of the special care required in aircraft operations. Incidentally, you could not be found merely negligent; the board were required to assess the degree (minor/major/gross). The next level of blameworthiness I think was 'reckless'.

Link to report of the 3 Fellows
 

Permalink 5976 refers - Page 299 @ 13:16
On 9 Jan 10, the Guardian published this agreed abridged version of our letter which may be found with others on
http://www.guardian.co.uk/uk/2010/jan/09/chinook-crash-1993-evidence-software

It reads:

In his reply to recent coverage of the “positively dangerous” software implementation in Chinook fuel computers (Letters, 6 January), Air Chief Marshal Stephen Dalton makes three main claims and admissions.

1. The “positively dangerous” status of the software was well known at the time. That being so, perhaps the MoD would say what corrective action was taken, and why it wasn’t corrected before the assistant chief of air staff signed the release to service (RTS) in November 1993?

2. That the above status was “factored into the operating instructions”. These instructions are, primarily, the aircrew manual and the flight reference cards. Successive inquiries, including the MoD’s own board of inquiry, heard irrefutable evidence of the immaturity of these documents. Indeed, the evidence of one Chinook flight commander at the time described them as “incomprehensible to aircrew operating the aircraft”. Again, why did assistant chief of the air staff sign the RTS, given such a fundamental breach of the airworthiness regulations?

3. That the software issue was discounted after the Air Accident Investigation Branch report. This is quite wrong. A search of the report shows no mention of “positively dangerous”, or even the word “software”. However, it does state that the (fuel computer) “operating program” was “not altered from delivery”. That is, it remained in the “positively dangerous” state advised by the MoD’s own experts at Boscombe Down.

ACM Dalton’s letter, far from protecting the MoD’s position, actually admits they knew ofthe problems and adds weight to our submission that the aircraft was demonstrably not airworthy. It is now time for the MoD to say why this decision was made. Who, we ask, would sign to say an aircraft was safe in the face of world-leading, expert advice that the fuel computer software implementation was “positively dangerous”? And why would they do this before taking corrective action?

Finally, as ACM Graydon was the superior of the assistant chief of the air staff, was he aware of his signing the RTS/air force department release (RTS/AFDR) and why he (and controller of aircraft) disregarded the advice of Boscombe Down?

Captain Ralph Kohn, Captain Ron Macdonald and Captain Richard KJ Hadlow
Compiler and co-authors of the Macdonald Report (April 2000)


To refresh memories, I understand that the on-line Guardian copy of the published letter now has a link to our original Macdonald Report of the Year 2000, as now updated by a new Jan 2010 Addendum 4, captioned "HC2 - RAF Acceptance Airworthiness Connotations".

The Macdonald Report may be found on
http://www.scribd.com/share/upload/20816348/2ecf7hocouvm9wc81n

In the context of military accident investigations, may I draw attention to the "Report of Study of Accident Investigation Procedures in the Armed Services" by W H Tench CBE CEng FRAeS, published in January 1987 with recommendations that make interesting reading?

Mr Tench was the former Head of the UK Air Accidents Investigation Board.

On 19 May 1986, he was appointed by the then Minister of Defence Support, to conduct a study with the following terms of reference:

“To examine the reports and investigate the methods of conducting inquiries into military aircraft accidents in all three Services and MoD(PE) in order to establish whether alternative procedures, or any other features, would be more efficient or effective in determining the cause of accidents.”

Here is hoping that someone may find something of interest in our report, but in particular Addendum 4 which was written at the end of last year as a letter to MoD and copied to others in Westminster. The Tench report may be found ‘on line’ (55 pages).

For the "3 Fellows" who prepared the Macdonald report.

Without a copy of AP3207 that was in-use at the time, we are all groping for the correct terminology 'like blind men in dark room'.
I seem to remember that the MoD/Govt could not provide such a copy of AP3207 in the HoL Inq era, as no-one had ever thought to keep one!

Did Mull get featured on Today as Brian predicted? Has anyone an idea of when that was if so? We could then get a link onto the thread. Re discussion about possible findings I feel strongly that there is only one that in all honesty can be arrived at, ie that which Brian calls for. Their airships will have far more immediate and personal preoccupations to dwell on rather than stringing out a tawdry and inappropriate haggle to arrive at a "compromise". For those tempted to do so I repeat that this is a case of right and wrong. Those who know the difference should ensure that they are on the side of right now!

Angus Stickler had a 4.5 min piece on at about 0845. Not available yet on the Today site, but a recording should appear soon at
BBC News - Today - Today: Wednesday 13th January

airsound

BOAC,

As I recall from my time in the Service, an "Error of Judgement" was classified as a genuine mistake and therefore was non culpable. On the other hand an "Error of Skill" was classified as culpable - i.e. the guy(s) had been equipped with the skills to get out of the particular situation, but porked it.

I don't know whether there were formal definitions of these for BoIs to consider, but BoIs made the call as appropriate.

Of course in this case, as no-one (with the exception of W & D!) actually knows what happened with absolutely no doubt whatsoever, the only sustainable verdict is CNPD.

Thanks Airsound, first as always with the news! :ok: I must admit for a story that I was told the public would have no interest in, as it happened so long ago, the coverage is constant and high profile; Today, all the National Papers, Flight Editorial, TV News. It just won't go away will it? How annoying is that? :D

I wish, chugs. But thanks.

I do believe the current coverage is a reflection that you can, with perseverance and contacts in the right places, get support from the media, and, once rolling, the story can go all over the place. Trouble is, you can only do that on the right day, and you never know what 'the right day' is until afterwards.

So we don't know how long our time in the spotlight will be. We need to make the most of it while we can - because it does seem, perhaps, (fingers etc crossed, touching wood and all those other things) that some sort of critical mass may be near.....

airsound

hear here at approx 0850 (2:50 into the prog)

BBC iPlayer - Today: 13/01/2010


Sadly, what MoD and Baroness T have failed to spot that the s/w c0ck-up is only indicative of a complete failure of the airworthiness process. That process failed to ensure the ac was legally airworthy. Spiers said nothing of note, other than to point the finger at ACAS, the RAF and MoD. They can bluff as much as they like but they will have to answer one day.....probably in court. Keep it going journos!

At the end of the report he says "the hierarchy protecting its own".

Precisely! That is why the momentum of this campaign must not be allowed to slacken. Justice is being prevented by the arrogance of air marshals.

Can someone with a sharp, interpretive and 'legal' eye summarise where we are please?

Do we in fact now have a formal admission from Lemming House (various) that the Chinook MkII was released to service in what was technically an unairworthy state?

Where does that leave the bereaved in law? Is a case now developing for an action against the Lemmings? Has anyone heard from/asked of ACAS of the time as to what judgement he had made of the aircraft before allowing it to pass into operation?

I believe it is now 'admitted' (certainly what I heard this am anyway) that the parlous state of the Chinook MkII's equipment was NOT placed in sight of the B of I. Is this alone grounds for a re-hearing? Can anyone confirm (to save me re-ploughing here) whether the board were informed of the request from B Down to cease operations?

The whole affair becomes more ridiculous as every news item is delivered.

BOAC There was a time when I went through hundreds of pages of documents and memos. I don't recall the BOI or AAIB referencing any of the Boscombe Down memos including the ones about ceasing flying. The MoD now says the documents were "available" but not in practice - the BOI had to know what to ask for.

It may also be worth pointing out that the BOI did not reference - and there's no evidence they knew of - the Wilmington incident in which a Chinook on test was damaged by a Fadec-related overspeed. The MoD was suing Textron Lycoming at the time of the Mull crash. This wasn't known about until years later.

As to what the BoI had access to (from BD or elsewhere) and, in keeping with the Kafkaesque nature of the MoD's position thus far, I am reminded of the famous Rumsfeld quote which could easily have come from the mouth of Sir Humphrey Appleby:

Memory is fading now, but I think as far as the BoI was concerned, "positively dangerous" Fadec inadequacies and the MoD's response to them would fall into the 'Unknown Unknowns' category.

Given the next postings of the BoI, they most certainly became aware of these Boscombe issues shortly after the event. :E

Latest Closing of Ranks
 

From todays Telegraph:-

"Sir,
We understand that in the event of a Conservative administration coming to power it will revisit the Mull of Kintyre Chinook accident and consider the negligence finding.
Each one of us has reviewed separately the findings of the Board of Inquiry and reached the same conclusion, namely that basic airmanship failings caused this tragic accident.
If yet another review is to take place then we would welcome an opportunity to brief ministers and discuss in necessary detail why this finding remains unescapable. in particular, it will be explained precisely why it cannot be overturned by recourse to a hypothesis for which there is no evidence and which is revealed as wholly implausible when tested against the known facts."

The letter is signed by Sir Michael Graydon, SIr Richard Johns,Sir Peter Squire,Sir Glenn Torpy and Sir Michael Alcock.

Their reference to "a hypothesis for which there is no evidence" begs the question " where is the evidence for gross negligence " ?

Their continued arrogance astounds me. Do they really believe that by recruiting additional airships to their cause, and by writing letters to the press, that this campaign will go away? Are they getting increasingly frightened that a properly constituted (legal?) review of this whole case will show that the verdict delivered by W & D is supported only by opinion, rather than fact?

Methinks they protesteth too much!

Note that they still try to compartmentalise to the final act, when recent coverage has been entirely based on the events of October/November 1993 and the fabricated CAR/RTS.

Interestingly, by concentrating on June 1994, they have a convenient getout if CA and ACAS cannot justify their decision to ignore the regulations.

I can see buckpassing in this letter, and perhaps a rift developing between those who prepared and signed the CAR/RTS and those who operate against the RTS. Shades of Nimrod and C130 - the difference between attaining and maintaining airworthiness.

Collars tightening gentlemen?

I read that the story of the mass suicide of Lemmings is just a myth. I believe the myth says that they gather together in a group before they jump.

These gentlemen convince me that the BoI should be reopened. They indicate that they have evidence relating to this tragedy. If that is so it should be heard and evaluated by the BoI alongside, inter alia, that relating to the airworthiness of ZD576 and its sister Mk2's and given the credence it warrants. The result should be a finding somewhat sounder than the infamous hypothesis that it replaces.

In a letter to the Glasgow Herald on 7th January, the Convener of the Church of Scotland quoted the reply received to a letter to Gordon Brown;
Yet again MoD moves the goalposts. From the long-stated “new evidence”, why the move to evidence relating only to failure of airframe, avionics or engine?

For years they have claimed (wrongly) to have investigated all airmanship, technical and legal issues. Now, it appears, they only need to consider a small part of the technical aspect. Sorry, I must have missed this retrospective change to the regulations.

A clear attempt, yet again, to exclude evidence of systemic failings in the application of the airworthiness regulations in 1993.

It won’t wash this time, as the cat is out of the bag. Their actions are laughably transparent. This time, unlike before, questions will be asked of key participants.



Here’s a good question – which category does the DECU sit in? Engine or avionics? Therein lies the answer to why the safety critical software was mismanaged, until Boscombe applied the correct procedures. You’d think an electronics unit, containing safety critical software, would be overseen by a specialist electronics HQ Modifications Committee. Oh, the committee was disbanded in early1993, leaving no independent scrutiny; as demanded by the airworthiness regulations.

Who made this decision? The RAF. Oh dear. As I used to say on the Nimrod thread, this is the reason why the only Def Stan setting out the procedures for maintaining airworthiness has not been updated since 1990 – there is a fundamental contradiction whereby the structure of MoD no longer aligns with the Secretary of State’s requirement for independent expert scrutiny. Nobody will take on the task as they will immediately be in conflict with their management.

MoD were crucified by their own Director of Internal Audit in 1996 over this, and refused to do anything; the Chinook 2 Star in MoD(PE) saying it was “of no concern to PE”. He was later supported by CDP, and Ministers Ingram, Ainsworth and now Rammell. Safety. No concern. And yes, all evidence with Haddon-Cave.

At least they got that part right.

Did they ? How do we know ?

I wonder to what hypothesis they are referring? As far as I'm aware, the campaign has not officially propounded any alternative hypothesis. As the "known facts" do not amount to a hill of beans, the only hypotheses I can imagine being rendered "wholly implausible" by said sparse "known facts" would be some of Walter Kennedy's more exotic Tin Foil Hattery.

Of course, it is the absolute acme of plausibility that the highly experienced and highly qualified aircrew just took the notion to fly themselves, their aircraft and their passengers into Beinn na Lice.

X767


Time for your head to come out from under the sand...............