The crash looks very different from the cockpit

 

From Boyd Munro of  www.airsafety.com.au

e-mail: bmunro@airsafety.com.au Phone: 018 22 0047 Fax: 02 9225 9127 Mail: PO Box 172, Balmain, Australia 2041

The following copyright article appears in today's London Sunday Times at

 http://www.sunday-times.co.uk/news/pages/sti/2000/06/25/stirevnws01008.html

 It refers to the official investigation of a helicopter accident in Scotland.  However the main point which the author makes could be made of any transport accident investigation conducted by the Australian Transportation Safety Board (ATSB).

 The author says of the two dead pilots

 "They were allowed no legal representation at what was tantamount to a trial, held in secrecy and presided over by the very people who had most to lose in the case."

 
Sadly, all too often that also describes ATSB investigations here in Australia.  This is because the ATSB is directly answerable to the Minister for Transport.  It is most improbable, therefore, that the ATSB will ever find that the cause of an Australian accident is due to any failing of the Minister himself or those under his command.  An investigating bureaucrat will always be tempted to see a dead pilot as a much easier target than his or her own Minister.

 

Australia's ATSB should be headed by a Board appointed by the Prime Minister, with each member serving a fixed non-renewable term and being removable only for serious cause.  As long as the ATSB remains answerable to the Minister for Transport it can never do the job which the public expects it to do.  As John Nichol says, "If an airline suffered a fatal crash, would it be allowed to investigate its own culpability?.  Of course not."  Every transport accident has the potential to be the responsibility of the Minister for Transport, whether for poor legislation, poor enforcement of that legislation, or inadequate transport infrastructure. Yet, in Australia, the Minister is in command of every ATSB investigation and therefore investigates his own culpability in relation to that accident.


 

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June 25 2000

NEWS REVIEW

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The Gulf war pilot John Nichol finds plenty of room for error in the RAF's account of the Chinook disaster

The crash looks very different from the cockpit

On a windswept Scottish hillside on June 2, 1994, an RAF Chinook helicopter crashed, killing all 29 people on board. In last week's News Review Sir William Wratten, who led the crash inquiry, defended his finding that the pilots were guilty of gross negligence. As an experienced pilot Sir William is, of course, entitled to an opinion but what he is offering us is theory, not fact.

He dismisses the idea of an unidentified emergency out of hand; sadly this shows a lack of understanding about today's computerised aircraft; things do go wrong and the unexplained does happen. A few years ago I was taking off in a Tornado when it refused to do what the pilot asked. Seconds away from disaster, the aircraft responded and, after much brow mopping, we landed the jet and handed it over to the engineers.

They spent days examining the flying controls but not only could they find no fault, they found no evidence that anything had gone wrong in the first place. Imagine driving down the motorway at 70mph when your car inexplicably applies its own brakes or puts the steering to full left lock.

Though it might be difficult to believe, incidents such as this are legion in the RAF and are called "uncommanded flying control movements", or UFCMs.

Since 1994 there have been more than 160 UFCMs reported on helicopters alone. I am not saying that a UFCM was responsible for the crash, but if I had not been so fortunate on the day my aircraft did something it shouldn't, I wonder who would be defending my reputation now.

The pilot chatrooms on the internet have been glowing red hot over the past week as a result of last week's article. I could almost agree with Sir William's conclusions if that was all I knew. But if you read all the details of the case - rather than selecting bits to help an argument - you realise that a grave injustice was perpetrated against the pilots.

When crash investigators arrived at the smouldering wreckage on the Mull of Kintyre all 29 people on board were dead. There were no witnesses, no radio calls, no radar traces and, as they had not been fitted, no information from either a cockpit voice or accident data recorder (so-called black boxes). Much can be gleaned from wreckage, but it is not a precise science.

Seven months later the inquiry report was delivered. The president concluded that "there were many potential causes of the accident . . . but . . . the board was unable to determine a definite cause".

To avoid the sin of cherry picking myself, I should say that the president also concluded that the "most probable" cause was that the pilots selected an inappropriate rate of climb over the Mull. The crew simply failed to avoid the hillside. This theory was subject to "speculation" and "it would be incorrect to criticise [the pilot] for human failings based on the available evidence". The Ministry of Defence - and Wratten - read the report and came to a different conclusion; that the pilots were guilty of gross negligence. Is an opinion, based on limited evidence, good enough grounds to destroy the reputations of two good men? Sir William believes that it is. In their absence Flight Lieutenant Jonathan Tapper and Flight Lieutenant Richard Cook were found guilty of gross negligence, in effect, guilty of manslaughter. They were allowed no legal representation at what was tantamount to a trial, held in secrecy and presided over by the very people who had most to lose in the case.

If an airline suffered a fatal crash, would it be allowed to investigate its own culpability, produce its own report and exonerate the company from any responsibility? Would it be allowed to cast aside independent scrutiny of its findings; calling them, as Sir William did, "a seriously misleading public campaign . . . wilful ignorance"? Probably not, but sadly that is the ethos of the military hierarchy.

To set the record straight, the "wilful ignorance" has been contributed by a senior aircraft accident investigator, a Chinook unit test pilot and a Chinook software engineer.

As for the "misleading public campaign"; the families of the dead pilots believe that, as there is doubt surrounding the crash, the verdict of gross negligence was unjust. The Ministry of Defence insists it has a "full and accurate picture" of the final seconds of the flight. This, quite simply, is untrue.

Sir William insists that because a navigation button was pressed the crew was in full control. That is rather like saying because a car driver used his indicator it proved that there was nothing wrong with the steering and that the tyres could not subsequently have burst.

Flying a complex military aircraft is not like flying a desk. All that is left of flight ZD 576 are gravestones, wreckage and theories. The fact that a senior officer holds a theory does not necessarily make it right.

John Nichol, whose Tornado was shot down during the Gulf war, served in the RAF for 15 years