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Sea King Accident 22 March 2003; Collision between XV650 and XV704
Having had one thread pulled by the OP and a further one enquiring after it locked by the Mods in the past week or so, I hope that this is third time lucky. I do not intend to pull this one so it will whither only from lack of interest or Mod action.
The following is a piece in the Sunday Times 15 Nov 09 by their Defence Correspondent Mick Smith: Sea Kings incident: Military aircraft accident summary, Board of Inquiry report and letters - Times Online Sea Kings incident: Military aircraft accident summary, Board of Inquiry report and letters The Board of Inquiry report into the loss of the two Sea Kings is heavily redacted throughout. The redactions include the references to the problems with the high intensity strobe lights (HISL), even though this is not a secret piece of equipment. The references to the lights being unfit for purpose as fitted on the helicopter and the breach of airworthiness regulations are at paragraphs 100-102, and the conclusion with regard to that problem is at paragraph 141, with a recommendation to replace the forward strobe light with an anti-collision light immediately at paragraph 146. The Military Aircraft Accident Summary, which is undated and is not redacted, notes in paragraph 14 that the strobe lights were switched off making it difficult to see the other helicopter and assess the distance between them. The first letter is from the former civil servant to his MP and was passed to Bob Ainsworth, now defence secretary, but then armed forces minister, in September last year. Headed "Military Airworthiness", it repeatedly points out the problems with airworthiness on both the Nimrod and Sea King fleets and the implications for military airworthiness as a whole. It also shows that Ainsworth has been misled by his officials over the board of inquiry into the loss of the two Sea Kings. It is dated 9 September 2008, more than a year before last month's publication of the Haddon-Cave review of the loss of an RAF Nimrod which condemned military airworthiness as a whole The second letter from the civil servant to his MP, dated 15 March this year, and also passed to Ainsworth, refers to the attempt to force the former civil servant to make a false declaration that the Sea Kings with the forward strobe light as fitted was airworthy. It also refers to the way in which the breach of airworthiness regulations and the correspondence and reports referring to it, were not revealed to either the board of inquiry or the inquest. |
Having had one thread pulled by the OP and a further one enquiring after it locked by the Mods in the past week or so, I hope that this is third time lucky A "further one enquiring after it" was "locked by the mods" because the question had been answered and no other questions had been asked! Incidentally, this thread was started by flipster. I can find no record back over the past week or so of a thread started by you about the Sea King accident. Can you give me more information on it? |
Here's the article that goes with those interesting docs, Chugalug
The mother of a Royal Navy officer killed when two Sea King helicopters collided during the invasion of Iraq has called for an inquest to be reopened after it emerged the Ministry of Defence withheld vital evidence from the original hearing. Ann Lawrence, whose son Marc, 26, was one of seven men killed in the mid-air crash, said the inquest in January had been told the helicopters were safe, but it was now clear that they had serious problems with their lights. "If the risk of similar accidents is to be reduced, the truth must be heard and the record put straight,” said Lawrence, 60, from Westgate, Kent. “The reputations of our boys must not be damaged in order for others to protect their own.” The two Sea King Mk 7 helicopters collided over the northern Persian Gulf in the early hours of March 22, 2003. The helicopters’ anti-collision lights had been replaced by high-intensity strobe lights (HISL), but these were switched off because they reflected off the surface of the sea, interfering with the pilots’ vision. A former civil servant at the MoD told The Sunday Times earlier this month that he repeatedly attempted to prevent the lights being fitted without proper testing or trials, but was overruled by his superiors. Documents withheld from the inquest and the victims' families relate to breaches of airworthiness regulations before, during and after the fitting of the strobe lights in place of the anti-collision lights. Both the board of inquiry report into the collision and the military air accident summary cited the fact that the lights were switched off as a factor in the pilots’ apparent failure to see each other. The board of inquiry said the strobe light installation was “not fit for purpose” and did not comply with the MoD's airworthiness regulations. Correspondence between Bob Ainsworth, the defence secretary, and the former civil servant - via his MP - suggest the minister was also misled by his own officials over the issue. Ainsworth told the whistleblower's MP in June 2008 that “no reference to any system being ‘unfit for purpose’ can be found" in the board of inquiry report. The documents that were not passed to the coroner include details of how the former civil servant, then working on the Sea King Mk 7 programme, tried to ensure the lights were safe. The strobe lights were fitted to predecessor aircraft but there was no evidence that they had been tested or trialled in accordance with MoD regulations. When the former civil servant discovered this in May 2000, he demanded that the lights should not be fitted until fully checked by Westland, the helicopter manufacturer, and any problems corrected. The whistleblower, however, was overruled. Six months later he pointed out that Westland still had concerns over the way in which the lights were being fitted and called for a full test schedule, but he was ignored again. The former civil servant subsequently moved to another MoD programme but following the board of inquiry into the crash he wrote a full report detailing his efforts to prevent the lights being fitted without trials. Neither this nor any of the other documents relating to the failure to observe airworthiness regulations were passed to lawyers representing the Sea King crash families. In a letter sent to Ainsworth via his MP in March this year, the whistleblower said: “These are very serious issues. Failure to pass on key evidence, especially when directly related to board of inquiry criticisms, is, I believe, a failure of duty of care amounting to gross negligence." Shawn Williams, a solicitor representing several victims' families, said: "They believe that significant evidence was not placed before the coroner. “We need to establish why and how this occurred so appropriate action can be taken. The purpose is to establish a legal basis for reopening the inquest. We will leave no stone unturned in doing so." Lawrence said: “They said the aircraft was airworthy but at no time was the question of the lights raised. Indeed, it was said the aircraft had been shown to be safe. “The obvious intention was to make clear that no further discussion about the aircraft’s safety was necessary. It is now all too clear this was not the case." The MoD declined to comment. |
Mick, thanks for that. I'm off to get the Sunday Times now to get the real McCoy (hint and plug there, did you see?).
Wholigan: I can find no record back over the past week or so of a thread started by you about the Sea King accident. Can you give me more information on it? |
Reconvene the Inquest? Perhaps they should also reconvene the BOI as there are a few unanswered questions thrown up by the RNFSAIC report that could do with answering and clarification?
Anyway, how come the BOI completed before the RNFSAIC had done their stuff? Seems a bit odd to me! Perhaps that is way it was done in 2003? I'm not sure, however, that is what the present regs (those pertaining to SIs) indicate. Furthermore, HQ Fleet should look hard at the FACT that the concept of use and operation of HISL on the Mk7 did not, categorically, comply with the airworthness regs - (the BoI was spot-on in that respect) - ie if you have to switch HISL off because it distracts the pilots, then it is not 'fit for purpose' - because your 'last line of defence' is now compromised. MoD were being disingenuous at the Inquest, when they implied that HISL was 'airworthy'. Of course, as a stand-alone piece of kit, HISL probably meets the airwothiness regs but it is the actual concept of use within a specific environment that renders the HISL 'non-compliant' - the original Mk7 Service Deviation proves that conclusively. I am afraid to disappoint some posters, this is a fact and is written in black and white. Yes, you may have for years, 'got away' with switching off HISL quite safely - that doesn't make that a correct action but you probably weren't to know. The engineers did but, sadly, they were over-ruled. For sure, there were other factors involved in this accident that may have saved them but ultimately, the loss of the crews of XV704 and 650 are testimony to that fact their last lines of defence did not defend them when they needed them. Now, I don't think anyone will benefit from a 'blame and shame game'. however, the MoD must come clean, apologise to the families and the engineers at MoD and Westlands who were ignored......and fix the system, so that this is not repeated. Add to this, the fact that many marks now use HISL and NVG - perhaps this needs proper assessment and trialling in representative environments - as proposed many years ago by the same experienced airworthiness engineers? Has this been done, I wonder? |
Am I missing something here?
Both aircraft and ship using serviceable radars - and still they collide? Where do the anti-cols/strobes come into the equation? Please enlighten me. I have read all the threads and am still mysified. |
Baston,
Neither ac nor ship radars would have given a complete picture and ATCers were out of the loop as both pilots had called a positive 'visual' while at LL over sea. Quite why they remained on a collision course, no-one will ever know but the BoI highlighted the confusing and disorientating lighting configuration produced by an ac with its fwd HISL 'off', the tail HISL 'on' (but dimmer and partly occluded by sets of rotors) and the nav lights flashing bright. If both crews were 'visual' and yet took evasive action only at the last minute then it is highly likely that they may have been disorientated and confused as to the relative movement, closure and speed of eachother. |
This is what the BoI said:
It is considered by the Board that the [forward HISL] is not fit for purpose and non-compliant with the requirement in DEF STAN 00970 Vol 2 para 2.1 (Enc. 42), in that the [redaction] it should be located so that the emitted light shall not be detrimental to the crew's vision. 102. However, this situation raises a dilemma. The conspicuity of each aircraft was significantly degraded from some angles without a [redaction] Thus, in trying to maximize their ability to see out of their cockpit each crew was at the same time ensuring that their own aircraft was more difficult to see from the most dangerous direction - directly ahead. I wonder what the BoI would have said if they had seen the paperwork that shows that an engineer fought hard to have it properly trialled and tested - trials and tests that would have presumably shown up a problem highlighted by both the BoI and the subsequent MAAS as a factor in the collision - but was overruled by people who did not have the qualifications to make that judgement? How on earth can anyone defend the fact that neither the BoI nor the Inquest saw that paperwork? |
Flipster
and the nav lights flashing bright I still seem to be missing something..................... Help please. |
Bast
Read para 103 of the BoI. In sum, as I see it, both ac had declared themselves visual (and therefore denied themselves ship-provided or self-provided radar avoidance) but the dark, the wx and the poor exterior lighting of BOTH ac conspired to impair the crews' ability to assess their visual picture and spatial orientation (as shown in the BoI trial) and, therefore, to keep clear. What is not mentioned is that the crews may well have been unaware of the degraded nature of their own lighting - this ac was a new mark on its first deployment, with new lights and it may be that they had not often met head on before, if at all. Of course, acceptance of radar separation, a height split, different routings or delayed arrival/deps etc would have kept them apart and then, the fact the HISL arrangement was poor would have been irrelevant. Unfortunately, nature is not like that and it will, at sometime, expose any of our weaknesses; it did so on this occasion. Have a read, if you will. BTW - I would also say that a helo's nav lights are much closer together (on the side of the ac, or on the wheel sponons - as on SK) and so can't give the same head-on aspect and cues as an FW ac with nav lights on the wing-tips. The wooded, occluded and dim nature of the rear HISL could only have added to the confusion about distance/closure. Baston, you have a point though; perhaps they would have been better off with both HISLs off? Unfortunately, a trial that would have discovered this was denied to the engineering project office (by a non-engineer), so we just don't know. |
Don't let me put words in bast0n's mouth, but there appear to be two seperate but linked events here:
(1) The undue haste with which the HISL mod was released to service. (2) The collision between the two aircraft at night. Our current propensity to line up the "holes in the cheese" seems to conveniently overlook some fundamental principles of airmanship that have been taught since (night) flying began. If these two aircraft had been oblivious of each other's presence and had the mid-air, then the HISL condition would obviously be a significant factor. Given the mutual awareness of the respective aircraft, the need to formate at night and the near head-on closure angles, then the HISL's condition is contributory but not necessarily causative. Vertical separation, radar assist, pre-briefed joining patterns and use of nav lights were all tools and techniques that would or could have prevented this tragic accident. To focus on the HISL mod to the exclusion of questioning the execution of basic airmanship skills is not likely to reveal all the lessons that could be (re)learned here. |
Two's in
You have said it in one and I am grateful for the "words in my mouth". The blindingly obvious seems to be being pushed out of the way in favour of blaming someone for introducing HISLs in a dodgy fashion. Thanks. |
Oh no, not again!
Oh no, not again! I thought that we had buried this subject, but no, it is once more resurrected so that the "mind's made up" brigade can, once more, get on on their soap-boxes and spout on.
I won't spoil your fun with facts this time guys; enjoy yourselves! |
Mick
I won't spoil your fun with facts this time guys; enjoy yourselves! Mid air collisions are an interest of mine having attended one betwen two Seakings south of the Isle of White in the 70's and having had one myself - Wessex/SeaHarrier - and no it wasn't my fault.............:ok: |
Oh no, not again! I thought that we had buried this subject, but no, it is once more resurrected so that the "mind's made up" brigade can, once more, get on on their soap-boxes and spout on. I won't spoil your fun with facts this time guys; enjoy yourselves! You were asked for the facts on the last thread but either didn't have time or couldnt be bothered to give them before the thread was removed by the originator and the subject in your terms "buried". So let me specify again what I would like to know. I appreciate you might not have answers to all these questions but if that is the case, I have to wonder why you can take the attitude quoted above. The BoI said the problems with HISL were a factor in the collision, particularly pointing to the fact that switching it off limited the crews' ability to see the other aircraft "from the most dangerous direction - directly ahead". It also said that "the ASaC Mk 7 radar was unable to paint primary radar return of another aircraft when in the mode employed for recovery to and departure from the ship". You and others used the last thread to dismiss this as an issue, also dismissing the BoI's assessment that it was to all intents and purposes a head-on collision. 1) Was this because - as you seem to suggest - the BoI's assessment had been overturned by another body, and did that body make a written report to that effect? 2) Since that report would have been overturning a key assessment of a document of public record, was it also made a public record? Two's In. The HISL as fitted was not released "with undue haste", it was released without the proper checks to see if it passed the military's own airworthiness regulations. It was found not to do so after a mid-air collision in which seven people died. 3) Was the BoI told that, in May 2000, the engineer managing the Sea King Mk7 programme had refused to agree "read across" of HISL from a previous mark because there was no evidence of any trials or tests. But was overruled by a senior official without the necessary qualifications to make that judgement. 4) Was the BoI told that the design authority had declined to back the replacement of the anti-collision lights with HISL? 5) Why was the inquest not told about the fully documented "facts" in questions 3 and 4? |
Mike Smith
4) Was the BoI told that the design authority had declined to back the replacement of the anti-collision lights with HISL? 5) Why was the inquest not told about the fully documented "facts" in questions 3 and 4?. I would not want to second guess these above questions of yours, so can I ask if you are asking whether the BOI had info withheld from it, or rather did not ask the questions (but should have)? I am merely trying to understand whether certain posters are alluding to a cover up of facts, or merely an incompetent BOI. Neither are the ideal situation, but one of them is a more sinister situation |
Baston
I am sure that your collision wasn't your fault....but even it was, you are around to argue your case. Sadly, as I am sure you are well aware, that is not the position of the crews of XV704 and 650. What would have happened if you had not survived? The chances are that someone, somewhere would have held you to blame, even partly, in absentia? In this case, as there was no real CVR/ADR, we are all mystified as to why the 2 ac did not avoid eachother - both having called 'visual'. Yes, there is a possibility of a c0ck-up but since the crews can't defend themselves, you cannot say that for certain - just like the Mull Chinook. What you can do, however, is to discover the probable contributory factors and fully address them so as to prevent recurrence - this is the whole idea of accident investigation, is it not? Or have I missed something? So, in this case, you would need to address all the contributory issues recommended by the BoI and RNFSAIC - there were a few! That is what MoD and Fleet have done....mainly - except that they decided, for reasons best known unto themselves, that the SK7 HISL was airworthy - however, they DID rescind the Service Deviation - mea culpa? Sadly, as I said, the light itself is probably ok but its concept of use is plainly not compliant with the def stan - this is in black and white and the BoI were quite right to say so. Why this was not followed up in the Inquest (and by the BoI) owes more to disingenuity and side-stepping by MoD; perhaps HM Coroner and the families may even have been purposefully misled? What is obvious here, to someone with an ounce of common-sense, is that the procedure around the introduction and fitment of this system was done poorly - and against engineering advice, for no other reason than cost or incompetence. Furthermore, this is an issue that has cropped up in a number of other accidents - inter alia - Nimrod and Herc (both admitted by MoD). The Haddon-Cave Report backs this up still further to include some big industry names. I agree that the Sea King HISL is probably not the sole cause of this accident but the disorientation caused by 'one-on, one-off' lighting system, is certainly a key element but a better lighting system could have prevented the accident. Also, if nothing else, this highlights some really poor management in MoD - which remains uncorrected and unaddressed. How many other latent failures like this are waiting out there? Also, this accident shows that the engineers who recommended the proper processes and trailling (and who were initially hounded by certain parts of MoD procurement system) should recieve a full, written and public apology. Anyway, to correct some of the less-considered comments - we are NOT trying to blame anyone - there is little mileage in the blame game, as prevention of recurrence is not helped in any way by that approach - why can't some posters grasp that? (Its all rather sad, really). The only caveat I would add to that is that, should there be any evidence of unmitigated willful neglect and/or criminal incompetence, higher-authorities are bound to consider taking matters further. That is not my preferred choice as it happens but, sometimes, this is only way that big organisations take note of the safety ethos and processes. Perhaps that is why the Haddon-Cave Report has it sights set on the wider military airworthiness system but I am convinced that some people in the MoD and industry are still in denial. That needs to change and the whole mil airworthiness system needs a complete overhaul. Whether the MoD riposte to the H-C report will acheive that remains to be seen - whether UK PLC (Mil) can afford to do so is also in question. One thing that is 'a given' is that we can no longer send our sons and daughters into a distant 'peace-keeping' conflict with equipment that does the enemy's job for him. I hope you might at least agree with that final statement? Kind regards flipster |
Barnstormer
I don't have any reason to think the BoI was incompetent. What I can say is that the facts - and they are documented facts - that I was alluding to were definitely not passed to the inquest. This was clearly illegal if done deliberately and the fact that they are not mentioned in the BoI report tends to support other evidence that the full facts surrounding this issue were also withheld from the BoI. Separately, I have tried twice now to get the ppruners who dismiss the relevance of the BoI report assessments I referred to in my last post to say if this is a result of a subsequent report that overruled the BoI - in which case their arguments would of course be perfectly reasonable - or just considered opinion within the wardroom or the IPT. I'm hoping for greater success this time round. |
Mick
As I understand it, the RNFSAIC report is not 'senior' to the BOI. Depending on who you ask, either the RNFSAIC support the BOI to come to their conclusions or that the RNFSAIC report directly to Fleet. But either way, it should not be possible for the reports to conflict greatly with eachother - at least not without the reconvening of the BOI and/or written clarification by Fleet. Interestingly, the quote I see on the Sea King BOI is that they believe that RNFSAIC were there to help them para 5 " The RNFSAIC was tasked to conduct an accident investigation in support (my emphasis) of the BOI....." This equates with the current regs regarding accident investigations and Service Inquiries (what were BOIs), JSP832, where it states "Service Inquiries for aviation occurrences are supported (my emphasis again) by specialist investigations conducted by RNFSAIC for RN aircraft and in-theatre RAF aircraft, AIEFSO for Army aircraft and the AAIB for MAFTR and out-of-theatre RAF aircraft." Therefore, if there are discrepancies between BOI and the later RNFSAIC (eg the discussion about 'playmates' and also autokinesis wrt disorientation by the HISLs), then perhaps it is only right to ask for clarification by the BOI and or Fleet. flipster |
Two's in - :ok::ok::ok: I tried to get the same points across on the previous threads but the 'HISLs were to blame' camp won't see that argument.
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