Remarks of senior officers on
the investigating board's findings
80. In his brief remarks the Station Commander at RAF Aldergrove,
Group Captain R E Wedge, stated among other things,
"I am impressed with the meticulous
and detailed examination of events which the Board has provided.
However, I believe that the exact train of events can never be
determined with absolute certainty".
81. The Station Commander at RAF Odiham, Group Captain (now
Air Commodore, retired) Peter Crawford, rejected the investigating
board's conclusion that the most probable cause of the accident
was selection of an inappropriate rate of climb. He explained
that when approaching high ground in bad weather the appropriate
action was ingrained in helicopter crews. They should (1) slow
down and if necessary stop, (2) turn away from high ground and
if necessary turn back, and (3) if a climb was required do so
on a safe heading at full power at the maximum rate of climb to
at least safety altitude.
82. He went on to express the belief that the
crew had seen the Mull, which prompted them to make the way point
change, and had intended to follow the western coast of the Mull.
His cogent argument for that belief was stated in these terms:
"This WP change is crucial in trying
to understand what the crew intended to do. If they had intended
to abort at this stage and climb over the Mull despite the difficulty,
which would have been so obvious to them, of clearing the high
ground they would not have selected the Corran WP. Firstly, it
removed from them the only easily interpretable information about
the location of the high ground. Secondly, it was of little practical
value; the crew would not have been able to climb to SA on track
to Corran, in the hope of reverting to low level VFR, because
of the forecast level of the 4°C isotherm. If they intended
to climb over the Mull the only sensible option would have been
to keep the lighthouse WP on until well clear of it and then to
select the chosen diversion airfield. On the other hand, selection
of the Corran WP was entirely appropriate if the intention was
to follow the western coast of the Mull Peninsula and regain the
planned track at the first convenient opportunity. In arriving
at this alternative scenario I am now faced with the same problem
that faced the Board - how did the aircraft get to around 500
ft, at 150 kts IAS with a ROC of approximately 1,000 ft per minute,
which are the computed starting parameters of the final 18 seconds
of flight?"
83. The Group Captain later in his remarks referred to the
fact that at the time of the accident spurious engine fail captions
lasting an average of 7-8 seconds were an increasingly frequent
occurrence and were not well understood. In his conclusions he
stated that the reason why the crew flew the aircraft into the
ground was "open to conjecture" and that in the absence
of firm evidence there was not much to be gained by "speculating
on the actions that led to the last few seconds of flight",
although he expressed the opinion that the aircraft was under
control when it was flared shortly before impact - an opinion
based apparently on the Boeing simulation. He stated that "there
is sufficient evidence to conclude that … there was no major
technical failure that would have an implication for the Chinook
fleet". In evidence before us he accepted that this was a
matter of judgment on his part (Q 884). He expressed the view
that, while there might arguably be some mitigating circumstances,
Flight Lieutenant Tapper as captain of the aircraft had failed
in "his overriding duty to ensure the safety of the aircraft".
This did not amount to a finding of negligence (Q 902).
84. The Air Officer Commanding No.1 Group, Air
Vice Marshal J R Day (now Air Chief Marshal Sir John Day), remarked
that "when the aircraft crashed, it was flying at high speed,
well below Safety Altitude in cloud (in Instrument Meteorological
Conditions) in direct contravention of the rules for flight under
either Visual Flight Rules [VFR] or Instrument Flight Rules [IFR]".
He further stated,
"On approaching the deteriorating
weather near the Mull, they had two choices. If they intended
and were able to maintain flight under Visual Flight Rules, they
should have slowed down, turned away or turned back. If they planned
to continue their flight under Instrument Flight Rules, they should
have climbed to above Safety Altitude well before they approached
the Mull. If they were forced to transition to Instrument Flight
Rules because they inadvertently entered cloud when close to the
Mull, they should have made a rapid climb to at least Safety Altitude
at maximum power and best climbing speed, while also turning away
from the Mull."
85. The Air Vice Marshal concluded that both pilots were "negligent
to a gross degree". He commented that it was "incomprehensible
why two trusted, experienced and skilled pilots should …
have flown a serviceable aircraft into cloud covered high ground".
86. The Air Officer Commanding in Chief Strike
Command, Air Chief Marshal Sir William Wratten, remarked,
"Lamentably, all the evidence points
towards them having ignored one of the most basic tenets of airmanship,
which is never to attempt to fly visually below safety altitude
unless the weather conditions are unambiguously suitable for operating
under Visual Flight Rules."
87. Therefore he agreed with the summary and verdict of the
Air Vice Marshal. Neither of the Air Marshals referred to the
change of way point shortly before the accident, nor commented
on Group Captain Crawford's reasoning in relation to it. Both
Air Marshals at this stage appear to have proceeded on the basis
that
(a) the pilots never saw the Mull,
(b) no technical failure or malfunction occurred
which deprived the pilots of control up to the point of impact,
and
(c) the Boeing simulation provided a reasonably
accurate demonstration of the aircraft's movements for a period
prior to impact.
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