Thursday, 14 July 2011

Chinook Accident.

We Shall Never Know.

I well remember how easily airborne accidents in both military and civilian scenarios are more easily able to lay blame on an operating crew than any underlying causes. This terrible tragedy appears to be such a case. However, if we look hard at the evidence, I, as a long time aviator am unable to square the latest findings that completely exonerate the pilots. A good source of material is  here together with substantial references.
Question marks over the serviceability of the machine, crew fatigue and navigational issues, all combine to form a picture of  a sequence of events coming together rather than any single major factor. However I argue that in the prevailing weather conditions the speed and altitude of the aircraft were significant. Why a safe altitude was not sought baffles me. A pure aviation mantra is that if in doubt climb and was always a good one.
I guess we really shall never know but I have little faith in Dr Liam Fox's expertise to comment as he has. I suspect a greater desire to look noble and gracious in the public eye is more likely than hours in a simulator to grasp the nature of the conditions prevailing on that rainy, foggy day in Scotland. It is also another opportune moment to have a go at the top brass. In some cases they deserve it, not in this.


petem130 said...

The IT press has covered this accident many times. The prevailing view is that this was a software related fault. The fault was known prior to the accident.

As is the case with these things we will neve really know although there may be some people who know exactly what happened.

Blaming the pilots was an easy option. Nasty.

Brian said...

Air accidents are seldom the result of a single cause but the accumulation of several. If would appear that pilot fatigue, adverse weather and mechanical/avionics failure were possible causes. The main cause was the RAF's attititude to airworthiness which led to the Nimrod mid-air explosion. Just because brave men and women are prepared to risk their lives doesn't release their employers from ensuring the machines they fly are as airworthy as their civil counterparts.

Oldrightie said...

"The main cause was the RAF's attititude to airworthiness which led to the Nimrod mid-air explosion."
Indeed that same attitude prevails in all "commercial" thinking, Brian.
"Blaming the pilots was an easy option." To a certain extent, Petem but training and attitudes are part of the picture, surely.

Jo G said...

I have no technical knowledge but I have followed developments in this tragedy over the years. I thought the swiftness with which senior military figures laid all responsibility at the feet of two dead pilots was obscene. The Chinook had its own issues even then, and since, and these are well documented. I am very happy that, finally, the families of the deceased pilots have had their apology and seen the names of their loved ones cleared.

RMcGeddon said...

If you had watched last night's report on Newsnight Scotland you would be none the wiser as to the cause of the crash. It highlighted how poorly we are served in Scotland.
They showed a picture of 'the Chinook crew' which anyone who had a slight interest in defence matters would have known was actually the crew from the Nimrod crash in Afghanistan. Complete with the young Royal Marine in full No1 uniform who died on the Nimrod.
There was no expert to discuss matters. The link to Lord Gilbert still sullying the reputation of the pilots ( original report author) froze as he was in his stride in the House of Lords. Cue 'interview' with Malcolm Bruce who mysteriously sat in front of 'Big Ben' with the clock at 9.20pm We then jumped to the hackgate story and the clock jumped to 1120pm and then the link to the story froze again. It was dire and I think they should bin the show and give us the full English version which is slightly more informative.
With reference to the Chinook crash it looks like a nav computing error due to a software fault. Or engine surge problems. The rad alt was no good as it can't look ahead. There was no forward looking radar as far as I know so heading and height were essential. Especially with drifting fog where the mark one eyeball was useless.
Good news for the families but sad for the relatives who died not seeing justice finally done.

Weekend Yachtsman said...

"Especially with drifting fog where the mark one eyeball was useless."

I have some knowledge of this incident, and the fact is that five minutes before the impact the aircraft was flying in clear air, in sunshine actually.

The fog was extremely localised around the hill where the crash happened.

Using the Mark 1 eyeball, they would have been perfectly capable of avoiding the problem; this makes it overwhelmingly likely that the immediate cause was a malfunction, probably of the software which as stated was known to be full of errors - so much so that a review of it was terminated incomplete, as so many faults were evident.

Another point is that where gross negligence is proved, the compensation paid to service families is much lower. Just sayin' .

Time Traveller said...

I'd just like to say that Joe G is spot on - the rush to judgement was obscene. So much so that I believe it was meant to mask a serious known fault with the Chinook.

English Pensioner said...

I tend to agree. It is easy to blame the pilot in any aircraft accident where there is no other real evidence. And of course it invariably in the interests of people, who might otherwise be in the firing line, to blame the pilot.
But, however you look at it, most accidents are invariably an unfortunate combination of circumstances, none of which, in themselves, would have caused any harm.
One thing that does surprise me is that, if there was a serious problem with the Chinocks, RAF Chinock pilots were apparently not aware of this, as word of such problems would normally spread through a relatively small group such as this like wildfire. I know RAF pilots can't strike like civilians, but if they were unhappy about the safety, I'm sure word would have got out.

JRB said...

We should rejoice in the fact that after seventeen long years a dreadful wrong has at last been put right.

Let us hope that the families of Flt Lt Tapper, Flt Lt Cook, the other two crew members and the twenty-five passengers can at long last put the past behind them.

That original finding of ‘Gross Negligence’ was a total miscarriage of justice and should never have been put on record.

Readers, I now beg your indulgence for this somewhat lengthy post -

It is worth reminding ourselves of some of the factual and salient points surrounding the crash of ZD576

The RAF Manual of Flight Safety, Chapter 8, Appendix G, page 9 states that -

The night before the crash Flt Lt Tapper expressed his concerns about being asked to fly a Mk2 Chinook because some time had passed since his conversion training.
In addition he requested that his superiors spread the passenger load between more than one aircraft. (This has now been adopted as standard RAF protocol.)
…His requests were refused.

ZD576 had only recently returned from maintenance having been upgraded to Mk2 specification. Shortly thereafter and only weeks prior to the crash one of the engines on ZD576 required to be replaced due to a fault.
… This was not revealed to the crash investigators at the time.

ZD576 was fitted with two FADEC units (Full Authority Digital Engine Control). These were notoriously temperamental.
… It was stated at the inquest that there had been several “flight critical incidents” associated with FADEC.
… What was not stated at the inquest was that, at the same time as the crash, the Ministry of Defence was suing the manufacturers of FADEC because of faults in the system.

Flt Lt Tapper had previously requested that a Chinook Mk1 be kept in Northern Ireland simply because the Mk1 was not fitted with the temperamental FADEC.
… His request was refused.

The RAF Board of Inquiry in April 1995 concluded that human failings were not the cause of the fatal accident.
… However the Reviewing Officers, one of whom had no operational helicopter experience, chose to disregard the verdict of the Board and without examining any further evidence, imposed a verdict of ‘Gross Negligence’

We may never know what actually happened to ZD576, but what is certain is that -
"Those who ordered that finding of Gross Negligence have now been shown to have acted wrongly."

I would refer you to –
Campaign for Justice =
PPRuNe =

Oldrightie said...

Excellent comments and I hope my post is seen as fair. The "gross negligence" verdict was stupid, when who would be so negligent as to kill themselves? I still must offer some responsibility to the crew, however. I speak of a lifetime in aviation and not in a condemnatory manner.

DougtheDug said...

Around the time of the crash there were reports in the Private Eye that British intelligence from various services in Northern Ireland were meeting with American intelligence in Machrihanish in order to minimise the chances of the meetings becoming known in Northern Ireland. Machrihanish is closer to Prestwick international airport than it is to Belfast and is just a short flight away for both Northern Ireland security personnel coming from Belfast and Americans flying in from the States.

If the chinook was flying to Machrihanish from Belfast everything makes sense. Look at a map and you'll see the Kintyre peninsula points almost directly at Belfast where the flight originated. The questioning and uncertainty about why they flew so so low and why they made no contact about aircraft problems only applies if they were heading for Inverness not Machrihanish. If they were heading for Machrihanish then there is no reason to question their height or lack of distress calls. The problem everyone has is trying to explain why experienced pilots with valuable passengers were flying so low on the way to Inverness.

If the pilots were flying in poor visibility with no radar trusting their navigation systems the obvious and safe route was to fly up the west coast of Kintyre keeping in visual contact with the sea surface and then make a dog leg east and come in low and slow over the low-lying west facing beach in front of Machrihanish. That part of the coast is flat and level and leads directly to the Machrihanish airfield. In poor visibility the pilots would have kept low to keep visual contact with the sea surface and to identify the coast when they came in over the beach.

What I am almost sure happened is that the navigation system failed and placed the pilots too far east and they hit the Mull of Kintyre instead of flying to the west of it. It was equipment failure not pilot error.

Flying at less than 5,000 feet across Scotland in bad visibility with no radar is suicidal when many of Scotland's mountains rise well above 4,000 feet. The only reason that has been offered is that they had engine problems but this is complicated by the fact they made no distress calls.

The only explanations for the low height of the aircraft are:

1. The pilots were playing silly buggers by flying at a low level as they approached the Scottish coast and playing a game of dodge the mountain which they lost.

2. They were on their way to Machrihanish in poor visibility which explains why they were so low and in visual contact with the sea surface and also explains why they made no distress calls because they had no engine problems. A failure in their navigation system flew them into the Mull.

The whole mess has been caused by the MOD claiming the helicopter was flying to Inverness. Once they'd made the initial lie they couldn't change it. No-one flies low in a helicopter through mountains in poor visibility and with no radar with a cargo of extremely valuable passengers. The reason the helicopter was low was that it was on the way to the airbase in Machrihanish.

Gordon the Fence Post Tortoise said...

Odd that I should comment the other day on the Chinook FADEC and this post turns up...

The incident reeked of cover up from day 1. The aircraft was loaded with senior army, MI5 and the principal NI Special Branch officers who under ordinary circumstances would have been forbidden absolutely from travelling together on the same bus let alone helicopter.

Although the military are well known for bending flight rules 'pon occasion, I find it difficult to credit that carrying such an ostensibly high value cargo of brass that the crew didn't toe the line and plug in an altitude well above the tallest obstacle on the route.

General Zia comes to mind.

Gordon the Fence Post Tortoise said...

I find it odd that folk should describe the RAF Chinook Textron Lycoming FADEC as "temperamental" - given that civvy test pilots at Boscombe Down eventually flatly refused to even sit in one and press "Start" let alone fly the damned things.

These are highly experienced people who take calculated risks every day...

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