Before turning to consider the events immediately preceding the initial impact, it is I think important to examine in some detail the background to these events as it was disclosed during the inquiry. I propose to do this under four headings, namely (1) the qualifications and experience of the members of the crew, (2) the crew's working relationships, (3) the procedure upon encountering Instrument Meteorological Conditions, and (4) the preparation for the sortie.

(1)  The qualifications and experience of the crew

  It was very plain from the evidence of a number of witnesses that all four members of the crew of ZD576 were very experienced and capable at their work. The first witness to speak of this was A who said of MALM Forbes that "he was the most experienced Special Forces crewman at that time, and had been carrying out his duties for many years, and was very highly regarded as a very professional operator". B, who was the captain of the alternate crew of ZD576 at the material time, had known Flt Lt Tapper and Flt Lt Cook for 18 months and two years respectively before the accident. He explained that he had flown with both Flt Lt Tapper and Flt Lt Cook "quite regularly" and that the crew on the fatal sortie "were probably one of the best crews in the RAF if we are talking about crews, which is why they were on that particular flight on 7 Squadron". Earlier he had been asked a number of questions about the crew as follows: "Q.—| can you give us your view of his capabilities as a pilot? A.—John Tapper was an extremely capable pilot. Q.—Was he professional in his approach to things? A.—Extremely professional. He was very honest, he was very friendly and a very likeable person but above all he was very professional. Q.—Was he a conscientious pilot? A.—Extremely. Q.—Similarly, I think by the time of his death you had known Flt Lt Cook for about two years I think, is that right? A.—That is about right, yes. Q.—Again, can you help the inquiry or give your view of his competence and practice as a pilot? A.—Again, he was a very professional pilot. Very safe, very conscientious. Q.—In short, is it fair to say that they were both very professional pilots? A.—Extremely, yes. Q.—Were they safety conscious pilots? A.—I would have said they were more safety conscious than most pilots. Both of them. Q.—Is that your view of them? A.—Yes. Q.—Not the sort of men who would have taken unnecessary risks? A.—Absolutely none. Q.—Are you quite sure about that? A.—Quite sure. Q.—You also knew I think Mr Forbes and Sgt Hardie, is that right? A.—That is correct, yes. Q.—What was your view of their capability as aircrew? A.—They were probably among the top in their profession, they were very, very professional, very experienced and very safe and at the time that I flew with them I came to regard them very highly. Q.—Top in their profession is the way you put it, is that right? A.—That is correct. Q.—Would either of them be the sort of men who, in your view, would have taken unnecessary risks if they could have avoided it? A.—Again, no".

  C, who was the navigator of B's crew, spoke similarly of the abilities of MALM Forbes and Sgt Hardie, and when he was asked for his opinion of Flt Lt Tapper and Flt Lt Cook he replied: "From my experience, primarily with Mr Tapper, I had no doubts as to his capabilities. Certainly on the flights I flew with him at Aldergrove nothing had occurred to make me doubt that I was in safe hands, so to speak. The same goes for Mr Cook, although my experience with him was less".

  D was the captain of the crew which flew ZD576 to Northern Ireland from RAF Odiham on 31 May 1994. He was a very experienced helicopter pilot and at that time had had about 2,100 flying hours in Chinooks, mainly in the MkI models but also in the MkII models. He had been a Qualified Helicopter Instructor since 1988. As Flt Lt Tapper was out of currency for flying the MkII Chinook D was responsible for conducting the necessary check on him. Asked how he performed, D replied: "Flt Lt Tapper performed very well, and displayed a good knowledge of the aircraft". At the time Flt Lt Tapper was the officer in charge of the Chinook detachment based at RAF Aldergrove and D was asked: "Q.—Was there any indication you got the impression he had been particularly preparing himself again for the MkII? A.—Yes. We had telephone calls, myself and Flt Lt Tapper, since he had gone out to Northern Ireland, talking about technical aspects, or questions he had on the MkII. I gained the impression from that that he was preparing his detachment very well for the new aircraft coming out. Q.—Was that borne out when you conducted this currency check on him? A.—Yes." Later he was asked for his personal assessment of Flt Lt Tapper and Flt Lt Cook. Of Flt Lt Tapper he said "I would say from what I recall he was above the average". Of Flt Lt Cook he said: "I would probably have assessed him as a high average pilot".

  D's co-pilot on 31 May 1994 was E. He too was a very experienced helicopter pilot and had had 1,800 flying hours in Wessex helicopters, 1,600 hours in MkI Chinooks, 400 hours in MkII Chinooks and, as he put it, a few hundred hours in Gazelle helicopters. When he was asked about Flt Lt Tapper and Flt Lt Cook he stated: "Both Flt Lts Tapper and Cook in my opinion were high calibre, capable and mature pilots and I know that they had practised aborts from low level and numerous flight stages or stages of flight". F was one of the aircrew on the flight on 31 May 1994 and he conducted out of currency checks on MALM Forbes and Sgt Hardie. Asked about how they had responded to the simulated emergencies which he had posed for them, he replied: "I flew with them for just over an hour and there was minor confusion over one of the simulated emergencies because it was in an obscure document and there was some confusion on the intercom but apart from that everything else was satisfactory". Later he was asked: "Q.—What was your opinion of them (ie MALM Forbes and Sgt Hardie) in general terms as crew members in their attitude to their work? A.—They were both very good. Q.—Were they experienced? A.—Yes."

  At the beginning of June 1994 G was the Duty Flight Commander at RAF Aldergrove. He explained that he had known both Flt Lt Tapper and Flt Lt Cook professionally for quite some time. He was asked: "Q.—Dealing with them separately, first of all Mr Tapper: What was your view of his professional competence in general? A.—In my experience of dealing with Flt Lt Tapper I considered him to be a well qualified, experienced, safe, sensible operator, not given to shall we say flights of unnecessary enjoyment. He was quite a serious pilot, who took things sensibly and safely.| Q.—And in relation to Flt Lt Cook? A.—I have no variance of opinion. They were both what I considered to be very competent professional officers, who undertook their duties quite seriously". Later, explaining the position of self-authorising officers (of whom Flt Lt Tapper was one), G said: "The self-authorising officers are only self-authorising officers because of their level of experience, trust and ability. They have an implicit trust in them to be doing the necessary organisational and planning functions for the sortie". He was subsequently asked: "Q.—Do you know what training pilots get in flying over mountainous country such as we have in the West of Scotland and in the North? A.—We do basic training flying over mountainous terrain, and in normal training, while serving in that squadron particularly, the squadron both pilots were attached to, we routinely fly in the mountainous areas of Germany to refresh our techniques. I have no doubt in my mind they had the qualifications and the experience to know the techniques and to apply the techniques in these particular instances".

  Early on in his evidence H was asked to speak to the official RAF records in relation to Flt Lt Tapper and Flt Lt Cook which were incorporated in Annexe C to the Board of Inquiry's report. According to these records T had most recently been assessed as High Average and Combat Ready. He had had a total of 3,062 flying hours in helicopters of which 683 had been in Chinook helicopters. Flt Lt Cook had most recently been assessed as Above Average and Combat Ready. He had had a total of 2,789 flying hours in helicopters of which 2,492 had been in Chinook helicopters. At the conclusion of this chapter of his evidence H was asked: "Q.—But in relation to both of these Flight Lieutenants, they were obviously very experienced, but not only that, very experienced in relation to this type of aircraft? A.—I would agree with that". He then spoke to the flying experience of MALM Forbes and Sgt Hardie as 2,418 and 2,064 flying hours respectively and agreed that they were both "very experienced aircrew". H was also able to confirm that Flt Lt Tapper had on a previous occasion landed a helicopter at the Mull of Kintyre lighthouse.

  J was one of those responsible for the conversion of Chinook pilots to Special Forces work. He explained that: "Any pilot who came to us would be initially above average, both on the ground and in the air, particularly as a Chinook pilot". He said that he had regularly flown with, and assessed, all of the crew members of ZD576 and was asked: "Q.—And how would you assess Flt Lt Tapper's abilities? A.—He was extremely good". Then he was asked: "Q.—Do you know from your own knowledge whether Flt Lt Tapper had previously flown an aircraft either as handling or non-handling pilot at or around the Mull of Kintyre lighthouse? A.—He certainly had, yes. Q.—Do you happen to know if he had any experience of flying Chinooks at low level say in the Scottish Highlands? A.—Yes, we train them in that area extensively. Q.—Had you ever flown with any of this crew in this particular aircraft in which there was a need to abort from Visual Flight Rules to Instrument Flight Rules? A.—Yes, it is safe to say I will have done with all of them and certainly with Flt Lt Cook about a week before he went to Northern Ireland, we did exactly that". Later he was asked how he found Flt Lt Cook as a pilot to which he replied: "He was a very good pilot".

  K was also asked about the crew of ZD576 as follows: "Q.—First of all, we have heard various assessments of the individual crew members. From your own experience of them, how would you assess their abilities and competence of each of the crew in this flight? A.—My assessment of their abilities wouldn't disagree in any way with anything that we have heard previously. They were all extremely capable, confident and competent operators and meticulous to a fault sometimes. Q.—In particular, how would you describe Flt Lt Tapper? A.—An extremely likeable character. He was very academically inclined.| spending a lot of time developing his capabilities along academic lines, both in terms of electronic warfare and helicopter tactics, but in addition to that he was also a very competent aviator". Later he too confirmed that Flt Lt Tapper had flown in the area of the Mull of Kintyre lighthouse, that he had himself flown in that area with all of the crew apart from Flt Lt Tapper, and that Flt Lt Tapper "with his regard for the regulations" would not have broken the aircraft's icing clearance.

  In the course of his submissions, counsel for the Ministry of Defence posed the question whether Flt Lt Tapper was indeed the paragon of virtue in his professional abilities that might have been inferred from the evidence which I have just rehearsed. He mentioned in this context the fact that Flt Lt Tapper had not raised a maintenance work order in respect of an apparent fault in the SuperTANS which he had had investigated by engineering staff during the afternoon of 2 June 1994 before departure of ZD576 for Inverness. Strictly, it appears that this was a breach of the relevant RAF regulations, but it is to be noted that when the engineers investigated the matter they found nothing wrong with the SuperTANS and that Flt Lt Tapper was not alone in having been in breach of this particular regulation since B had similarly not raised a maintenance work order the day before when the aircraft's PTIT gauges had been checked by engineering staff. Counsel also referred to the fact that the safety altitude for the third leg (from Corran to Inverness) of the fatal flight had been entered as 5,800 feet on the copy of the 1:500000 map which had been left behind by Flt Lt Tapper with an operations clerk before departure of the flight. It appeared that the figure should have been 6,500, or even 6,700, feet if all the heights within a 10 mile corridor either side of the proposed track from Corran to Inverness were taken into account. But it was not at all clear from the evidence of B and C whether there was a rule that this should be done or whether it was merely common practice. Besides, in the context of the planning for the flight on 2 June 1994 the point was clearly academic since it was plain from the weather forecasts that the aircraft's icing clearance would not permit an IFR flight at such heights. Counsel also suggests that on the leg between RAF Aldergrove and the Mull of Kintyre there had been a breach of the visibility requirements for VFR flights in excess of 140 knots airspeed. But since Carnlough was in sunshine when the aircraft passed overhead and since it is by no means clear that the aircraft was in fact flown at an airspeed in excess of 140 knots except during the last few seconds of flight before the final cyclic flare, I do not consider that it has been demonstrated that these visibility requirements were broken except during those few seconds (when arguably the flight had in any event ceased to be a VFR flight).

  Counsel rightly did not seek to attach much importance to these three details. Nor do I. But counsel did place rather more emphasis in this context on the fact that Flt Lt Tapper had departed for Inverness without having obtained the necessary authorisation for an extension of the crew's duty flying hours or, in the alternative, for the aircraft to be kept out of Northern Ireland overnight. This particular issue was canvassed initially by the advocate depute in the course of his submissions, and he invited me to consider whether or not the absence of the required authorisations had put pressure on the crew of the aircraft to complete the sortie to Inverness and back as quickly as possible. Counsel for the remaining families submitted that the absence of either of these authorisations had indeed given an incentive to the crew to minimise the flying time to Inverness, and he further submitted that, unpalatable although it might be to conclude this, the conduct of Flt Lt Tapper in this regard could not be categorised as careful, competent and professional.

  The background to these questions was that at the material time Chinook helicopter crews in Northern Ireland were not normally permitted to fly for more than seven hours a day. But these hours could be extended if need be up to eight or 10 hours upon an application being made to, and granted by, the Duty Flight Commander at RAF Aldergrove or the Senior RAF Officer Northern Ireland (SRAFONI) respectively. Some time before 9.00am on 2 June 1994 Flt Lt Tapper had a meeting with the Duty Flight Commander, G, to discuss the possibility of an extension of the crew's flying hours that day to eight hours. During the early part of 2 June 1994 ZD576 had been allocated the task of completing various troop movements within Northern Ireland with the sortie to Inverness and back being scheduled to depart around 5.30pm that day. On paper it had been estimated by JATOC (Joint Air Tasking Operations Centre) that nine and a half flying hours would be required to complete these tasks. But Flt Lt Tapper was evidently of the opinion (as apparently was B) that the troop movements could be completed in less than the estimated times and that the sortie to Inverness could therefore be completed within eight flying hours provided that G was willing to authorise an extension for that purpose. This G agreed to do, but only on the understanding that the sortie to Inverness could indeed be completed within eight flying hours that day. The question of an extension to 10 hours was discussed but G indicated to Flt Lt Tapper that he would be reluctant to approach SRAFONI for this purpose since there was no operational imperative which required that the sortie to Inverness should be flown by Flt Lt Tapper's crew rather than the alternate crew. The possibility that Flt Lt Tapper's crew might spend the night at Inverness with ZD576 returning to Northern Ireland the following day was also discussed. G instructed Flt Lt Tapper that, "in the event he had to divert or the time of arrival overran (by which he evidently meant that ZD576 was delayed en route to Inverness) in insufficient time to come back, my briefing to him was that he was to ring and remain at Inverness. Q.—Was that an instruction? A.—Yes. Q.—Assuming he had complied with that instruction, what would have been required to keep the aircraft out of Northern Ireland? A.—Notification to the Senior RAF Officer in Northern Ireland would have been required. It would have been his decision whether he wished to grant an extension to the final operating limit of 10 hours for that crew to recover that aircraft or leave it in Inverness.| Q.—Would you like to have been in the position of asking the Senior Officer for authority in these circumstances? A.—I would have been uncomfortable with it, Sir."

  In the event the time taken to complete the troop movements was five hours forty minutes, leaving only two hours twenty minutes for the sortie to Inverness and back. When he came to complete the appropriate flight authorisation sheet sometime during the afternoon of 2 June 1994 Flt Lt Tapper entered the approximate duration of the flight to Inverness and back as four hours so that on the face of the authorisation sheet his crew would have spent nine hours forty minutes flying by the time they had returned from Inverness. Whether he seriously thought that the sortie would take as much as four hours is not clear, but he cannot in my opinion have been in any doubt before he and his crew left that they could not hope to fly to Inverness, disembark the passengers, re-fuel the aircraft and return to RAF Aldergrove within two hours twenty minutes. Yet before departure he did not approach G again, nor did he obtain authorisation either for an extension of his crew's flying hours to 10 or for the aircraft to be kept out of Northern Ireland overnight. Counsel for the remaining families submitted that authorisation for the latter would have been required before departure, and that submission was presumably based on G's evidence to that effect. In that I think G was mistaken since it appeared from what H said that an application to keep the aircraft out of Northern Ireland had to be made, not to SRAFONI, but to JATOC and it was not clear that that organisation required such an application to be made before departure. Besides, as is evident from G's instruction to Flt Lt Tapper to telephone from Inverness in the event of a delay, there clearly were circumstances in which it would have been permissible to seek authorisation for an extension of flying hours or for an aircraft to be kept out of Northern Ireland after a sortie had been commenced.

  When asked whether he had been available during the afternoon of 2 June 1994, G replied: "I had manifold duties but I was around the building, yes". Later he was asked about the possibility of Flt Lt Tapper telephoning him from Inverness asking for authority for the aircraft to be kept out of Northern Ireland (the aircraft not having been delayed en route) and he said that he "would have been very disappointed. I would have felt a loss of trust in the individual concerned". And then he said that, had the aircraft been flown back to RAF Aldergrove outwith the eight hours flying time which he had previously authorised and in the absence of the necessary authorisation from SRAFONI, "there would probably have been no alternative but to have recourse to disciplinary action against him (ie Flt Lt Tapper)".

  Both J and K sought to suggest in short that there would have been nothing very remarkable in Flt Lt Tapper telephoning from Inverness for the necessary authorisation either for an extension of the crew's flying hours or to keep the aircraft out of Northern Ireland. But without going into detail, I think that it is fair to say that they would normally only have envisaged this being done in the event of some unforeseen development arising rather than in a situation similar to that in which Flt Lt Tapper found himself of knowing that he would need to seek the necessary authorisation even before ZD576 had departed for Inverness. On the other hand, K did give an insight into what Flt Lt Tapper would have been doing between the completion of the troop movements and the departure of the sortie to Inverness when he said ".|and just on the chance that anybody thinks that preparing for one of these flights is like preparing for the Shuttle to London, the delay between him landing at 1525 and signing the aircraft in and departing again at 1720 would not be spent sitting in a departure lounge, so to speak. He would have numerous distractions and tasks to complete within that time. Say he found himself unable to track down (G) for any reason, then I would not consider it to be completely unusual that he would continue with the flight and attempt to seek approval either to stay or to bring the aircraft back when he got to Inverness". Counsel suggested that it must be a matter for speculation whether Flt Lt Tapper would have been distracted in this way, but I am bound to say that I saw no reason to doubt what K said in this respect. It seems to me that it is perfectly intelligible that Flt Lt Tapper would have been busy during the afternoon of 2 June 1994 preparing for the Inverness sortie and that if G was then engaged, as he said he was, in "manifold duties" then the two men might not have had the opportunity to meet to discuss the question of extending the crew's flying hours or leaving the aircraft at Inverness overnight.

  I have dwelt on this aspect of the case at some length in deference to counsels' submissions. I agree with the submission of counsel for the remaining relatives that it is likely on the evidence that Flt Lt Tapper's intention was to return immediately from Inverness rather than stay overnight there. What more he intended to do about the difficulty into which he had apparently got himself is not known. But it is important to notice that, when G gave his assessment of Flt Lt Tapper which I have already rehearsed, he did not think it necessary at the same time to qualify what he had to say by reference to this episode which, so far as Flt Lt Tapper was concerned, was apparently isolated and wholly out of character. For my part, it seems to me that the matter should be regarded at worst as raising a minor question mark about Flt Lt Tapper's attitude to RAF regulations and procedures which has no bearing on his competence as a pilot and which should be kept firmly in perspective against the background of the universal plaudits of those witnesses who had actually flown with him in the months and years before the accident and whose evidence I have outlined above.

  The question whether this incident may have put pressure on the aircraft's crew to complete the sortie to Inverness as quickly as possible is clearly an important one. G agreed that the incident could have had this effect. And so too did H, albeit that the latter appeared to qualify his opinion later on in his evidence. But in reality I doubt whether it would have done. In the first place, so long as the aircraft reached Inverness within the eight flying hours for which authorisation had been granted by G (which it should easily have done) there was nothing to be gained by Flt Lt Tapper flying there at excessive speeds in order to save perhaps 10 or 15 minutes. Whatever happened, on arrival at Inverness Flt Lt Tapper knew that he would have to seek an extension to 10 flying hours for his crew or authorisation to keep the aircraft out of Northern Ireland overnight and it would have scarcely have made any difference whether he telephoned back to RAF Aldergrove for this purpose at, say, 7.15pm that evening rather than 7.30pm. In the second place, he would have known that, as G pointed out, to operate the aircraft at high speed at low level would not be practicable since the risk of hitting an obstruction would rise considerably. And even if he had been so indifferent to his own personal safety, let alone that of his passengers and crew, as to ignore this risk, it is not credible that the other three members of his crew (who would have known about the limits on crew duty flying hours) would have been prepared to run this risk in order to save Flt Lt Tapper from subsequent embarrassment or disciplinary action at the hands of his superiors. They would in my opinion have been likely to have made this perfectly plain to him either during the pre-flight briefing or, if need be, during the flight itself. Besides, it does not in any event appear that the aircraft was flown at excessive speeds from Belfast to the Mull of Kintyre. A member of the crew reported that it was lifting and departing from RAF Aldergrove sometime between 1642 and 1643GMT, and its arrival at the zone boundary (about 9nm from the airfield) was reported at 1646:14.06. According to the SuperTANS the times given for powerdown were 1659:10.4 and 1659:36.0. If the time of departure is taken to have been 1642:30 and the time of the initial impact 1659:30, that gives an overall time for the flight of 17 minutes and times for the section from take-off to the zone boundary and from the zone boundary to the initial impact point of almost exactly three minutes 45 seconds and 13 minutes 15 seconds respectively. The overall distance travelled was 42nm, that is 9nm to the zone boundary and 33nm thence to the initial impact point. On the basis of these figures the average groundspeed for the whole journey was 148 knots, for the leg from the airport to the zone boundary 144 knots and for the leg from the zone boundary to the initial impact point 149 knots. Clearly these are average speeds and it is not possible to say at what speed the aircraft might have been going at any stage along the route (except during the last few seconds of flight). But paragraph 2.4.3.5 of the Racal report states: "The accuracy of the Doppler position over the flight suggests that there had been little change of heading throughout the flight", and Mrs Tylor's sighting of the aircraft put it more or less exactly on its planned track. So it appears unlikely that the aircraft had to deviate much, if at all, from that track (and hence increase speed to maintain the average over the whole journey). According to the meteorological area forecast issued at 1030 on 2 June 1994, the surface wind was forecast as 160º 12-15 knots, locally 20 knots over the North Channel. It is known that by the time the aircraft reached the yachtsman, Mr Holbrook, the wind was blowing in the order of 20-30 knots. And in the Boeing simulation the tailwind component was taken to be 24 knots. B reported that a MkII Chinook could be cruised at an airspeed of 140 knots, and in particular that on 1 June 1994 he had flown ZD576 "generally round about 135 to 140 knots". Likewise, during the morning of 2 June 1994 A reported that the maximum speed quoted as having been achieved by the aircraft was 135 knots. Accordingly, while it is impossible to work out the aircraft's airspeed at any particular point during the flight to the Mull of Kintyre (apart from during the last few seconds), it does not appear to me that there is any basis in the evidence for holding that, at least until the last few seconds of flight, the aircraft was flown at excessive speeds such as might have been expected had the crew felt under pressure of time to reach Inverness. And in any event, even if I am wrong in this conclusion, I do not consider that the fact that the crew might have felt themselves under pressure of time would have contributed to the accident since the time taken to pull back the aircraft's speed to minimum power speed and then climb at the maximum rate permissible (3,000 feet per second) to safety altitude above the Mull of Kintyre would have scarcely added more than a minute or so to the overall journey time.

(2)  The crew's working relationships

  I turn now to consider the evidence as to the relationships that are likely to have existed between the four members of the crew of ZD576 (and I should emphasise that I do not intend to suggest that I consider that either MALM Forbes or Sgt Hardie might have been in any way to blame for the accident).

  All four members of the crew were members of the RAF Special Forces Flight. The significance of this became clear when J was asked: "Q.—You mentioned part of your responsibility was to convert pilots from ordinary crew pilots to Special Forces pilots. Is there any specific level of co-operation that you might expect to exist within a Special Forces trained crew? A.—One of the key features we see in conventional aircrew when they come to us is that pilots tend to be egocentric. They fly aircraft and the crew sit in the back. In our environment this simply would be an untenable position. We therefore accentuate the fact that a four-man crew works together in co-operation far more than they do in conventional flying. For example, one of the crewmen at all times navigates and acts as a second navigator. The other crewman, whilst looking after the serviceability of the aircraft, will also be monitoring the performance of the pilot and at any stage any member of that four-man crew can call for a change of flight condition, flight status, ask that an exercise be aborted and the captain of the aircraft or the pilot handling the aircraft will immediately respond to that. We stress they are a four-man crew, not a pilot and three assistants". He emphasised these considerations later on when he was asked: "Q.—Is it your position that a pilot by virtue of being a pilot is completely free from the risk of error? A.—There is no such thing as a person who might act consistently without error, which is why we have four people in the crew, not one".

  The practical implications of what J said were explained by a number of other witnesses. Thus A was asked: "Q.—Does the fact that the crew on 2 June 1994 were members of Special Forces have any bearing on the types of levels of co-operation and integration of that crew? A.—Yes. The crews who are selected for those types of duties have to be a minimum of above average standard as compared to the rest of the helicopter pilots. They then undertake a long and extensive period of specialist training, during which crew members fly together on a regular basis and develop high levels of crew co-operation and integration with each other, and a bond of trust grows out of that. Q.—So there is a particular esprit de corps within that four-man crew, which would grow up because of the training? A.—It is a very small unit, and yes, all the individuals fly together on a regular basis and would know each other very well. Q.—What would be the duties of non-pilot aircrew, the No 1 and No 2 aircrew, in a Special Forces Task Group, in particular regarding navigation of the aircraft? A.—The non-flying personnel in a Special Forces duty would be responsible for more of the navigation of the aircraft, assisting the pilot who is doing that duty, and is expected to have a higher degree of navigational ability than the standard crews of normal helicopters. Q.—So the crewmen also would take an active role in the navigation of the aircraft? A.—Yes. The No 2 crewman, who sits nearest to the pilot, takes a greater role in the cockpit activity, including navigation, monitoring and checks and making sure the pilots are doing what they are supposed to do, and he is effectively a third pair of eyes in the cockpit". Later A was asked: "Q.—Did you yourself see any of the non-flying aircrew, Messrs Forbes or Hardie, making any navigational preparations in relation to this flight and navigation? A.—Yes, MALM Forbes was preparing a 1:500000 scale map of the route, which was a copy of the pilot's.| Q.—So you say MALM Forbes had an exact copy of the route map for the Inverness flight, and was appending further information on that map? A.—Yes. Q.—Why would he be doing that? A.—As a back-up to the navigator pilot. If for instance the non-handling pilot was required to make a radio call in circumstances which required navigational assistance, he would then hand on responsibility to the crewman with a map who would take over for a short period the navigation of the aircraft. Q.—Would he also be assisting in the navigation when the non-handling pilot was available for navigation as well? Would there be two navigators? A.—Yes, he would continuously monitor the progress of the aircraft along the track line.| Q.—On a flight such as the flight to Inverness would the crewmen's primary responsibility, in particular MALM Forbes, have been particularly with regard to this back-up navigation or occupying himself with the passengers? A.—Due to the fact there are two crewmen carried within the cabin it is easy for the No 2 to allow the other crewman to concentrate on looking after the passengers while he takes more interest in the navigation and the operation in the cockpit of the aircraft". Later A was asked: "Q.—In a helicopter heading towards cloud apparently covering land at cruising speed and there is no apparent avoiding action being taken by the pilots, what would you expect the crewmen to do? A.—As a crewman myself I would have questioned the captain or the handling pilot as to their intentions, certainly making reference to the fact that if there was a known point of land approaching covering cloud, certainly what they intended to do about that. Q.—So you would seek clarification from the pilot as to what was the intention? A.—Yes. Q.—And in so doing would you be bringing the matter to the attention of the pilot? A.—Yes, it is entirely possible that the pilots might be doing something and had not noticed for a split second the fact that that situation was occurring and I would bring it to their attention immediately."

  F was also asked about the crewmen's involvement with the passengers on a flight such as the sortie to Inverness. First he was asked: "Q.—Can you help me with this; just so that the court understands this, in normal flight conditions what are essentially the duties of the other members of the crew other than the pilot and the navigator? What are the two loadmaster members of the crew doing basically during the flight? A.—It would be dependent upon the type of flight that they are on but they are responsible for any load situation on the aircraft, be it freight, passengers or vehicles, anything that is carried under-slung on the aircraft, assist with the navigation, assist with the servicing and general aircraftsmen duties, look-out, listening to radio calls and making radio calls.| Q.—If the sortie is in fact carrying a full number of passengers, shall we say as we know on the last journey, 25 passengers, what are the loadmasters actually doing in relation to these passengers, assuming we have actually commenced the journey with all passengers properly located in the aircraft and properly strapped in? A.—Just generally looking out for their general concern, passing on any information that is relayed from the cockpit back, if there is going to be a delay or anything like that. They are in no other way responsible for their wellbeing". Later F was asked: "Q.—To understand the situation from the loadmaster's point of view where the aircraft is navigating over water, planning to come to a waypoint on land at some point in the journey, would it normally be part of their duties to look out for that waypoint or would that not be necessary given that the pilots have the ability to check the waypoint? A.—No, the crewmen would confirm that for their own peace of mind and also make sure they had identified the correct point".

  The navigator's view of the involvement of the crewmen in the navigation of the aircraft was touched upon briefly by C who confirmed that during the over-sea leg of a sortie there would be no features in relation to which the aircraft's position could be verified. Then he was asked: "Q.—During the over-sea phase of the leg therefore what navigational assistance can the loadmaster crew give to the flight deck crew? A.—Over the sea —very little. Q.—Well in practical terms none I would think; is that right? A.—The only thing they can do is supervise the basics are unchanged by reference to the track.| He would know the wind direction off the Doppler indicator and by applying drift to the track he would know which heading the pilot should be holding to maintain that track. Q.—I will have to ask you a little bit more about that as you have raised it. Really what you are saying is you can't help by reference to anything on the surface below you, the best he can do is monitor, to see that the crew are flying the correct heading to get to the next turning point? A.—He can monitor the heading and he can monitor the 252 as well".

  The likely involvement of the various members of the crew was explained in rather more detail by B. He explained how Flt Lt Tapper as the navigator on the sortie to Inverness would have prepared maps for the sortie and he was asked to what extent Flt Lt Cook would have been involved in that. He answered: "A.—They would both have gone over the details normally, looked at the map, both gone over the map and agree the route was feasible, the details were correct, and just confirm the details. Q.—And then do they make notes or do they have some form of aide memoire? What do they physically do to keep all this information before them when they set off? A.—There are several ways to do it. You can put all your navigational information on a piece of paper or a log card or you can put all that navigational information on the map so instead of having lots of pieces of paper in the cockpit you have that information in the one place. Again that depends on who is flying. Of course, they would also have conferred with the two loadmasters because they would have their own maps and they would be following the route in the back of the aircraft and watching and checking details back to front, especially over the sea. Q.—I will come back to the loadmasters in a minute because I'm interested in that too. Do I take it from what you are saying that both of the men in the cockpit on that flight must have had a crystal-clear idea in their minds before they set out about what was going to happen, what they were going to find on the flight, what obstructions there were going to be and so on and so forth? A.—Yes Sir". Later with reference to the first stage of the flight from RAF Aldergrove to the Mull of Kintyre B was asked: "Q.—What would have been happening in the cockpit of this helicopter during that period? A.—Flt Lt Tapper would almost certainly have been giving details to Flt Lt Cook and the rest of the crew about the heading and obstructions that you are looking for in front, wires, masts, that sort of thing, and giving a countdown of distances both to the coast and the next turning point. For example, as they left Aldergrove or as they leave the coast they would have started the clock and given the bearings to the loadmasters down the back so they could then put these details on their own maps in case the Automatic Air Navigation System fails, the TANS. Q.—That is the TANS? A.—If that failed you are then left to do dead reckoning navigation. Almost certainly if you started the clock at a known point you can then get details of airspeed, groundspeed, and also drift because of wind, and you can then work back from the time you left to where you would actually be with these details en route. What they would have been doing is they would have started the clock, they would have been giving these details to the other members of the crew, and they would have been doing, at a specific point along that route, checked with the dead reckoning navigation, confirming the information that was coming from the satellites through the computer". Subsequently, after confirming that the responsibility of the pilot (as opposed to the navigator) would have been chiefly to fly the heading he had been told to by the navigator and to keep a look-out ahead, B was asked: Q.—Now, that would be the pilots. I hadn't appreciated the loadmasters would have been involved in this. Just tell me a bit about what they would have been doing and what was going on? A.—They would have been getting the information from both pilots at the front, ie the information about what they could see, because down the back they have got rather restricted forward visibility.| Q.—Would the loadmasters have a rough idea of where they were? A.—Yes, because they would have been asking the pilots at specific points along that leg for the navigational information. Q.—But they perhaps wouldn't have quite such up-to-date information as the two men in the cockpit? A.—No." Later B added some colour to these last observations when he remarked: "|.both loadmasters were extremely competent in everything they did, asking for information. I have had occasions when they were continually trying to drag information out of me navigation-wise, and they were extremely safe and competent navigators as well".

  E was similarly asked about the involvement of the various members of the crew during the planning and execution of a sortie. He confirmed that on coasting out he would ask his No 2 crewman to call out the coasting out checks and then he was asked: "Q.—|.can I just try and identify the respective roles of the handling pilot and the non-handling pilot. Am I right in thinking that before ever a flight takes off there will be a degree of planning which involves both pilots? A.—That is correct, and members of the crew. Q.—And members of the crew. And the sort of information that will be taken into account will be the route to be flown? A.—Yes, Sir. Q.—The distances covered? A.—Yes, Sir. Q.—The headings or track which is to be flown in terms of position on the compass? A.—That is correct. Q.—And perhaps most importantly the safety altitude that has to be observed at any particular stage of that route? A.—And indeed fuel consideration, diversions and the meteorological situation. Q.—And am I right in thinking that this is an exercise into which all members of the crew at least have a part to play? A.—Yes, they do. Q.—If nothing more than to have an awareness of what is going to happen at any particular stage on the route? A.—That is correct. Q.—So far as the handling pilot is concerned, what navigational responsibilities does the handling pilot have? A.—The captain of the aircraft, depending on whether he is the handling pilot or the non-handling pilot, will have the ultimate responsibility for the conduct of the sortie, therefore to ensure that he is happy with the plan and following the navigation. If one assumes that the non-captain first pilot is the handling pilot, his responsibility would be to follow directions given to him by the non-handling pilot who is navigating the aircraft. He would also have a mental picture but would not have the detail immediately available. He would, because of the briefing, be aware of the stage of flight and the conduct of the sortie both in the event of a malfunction of any sort or a change of plan. He would have an instinct of where to turn and would be able to help the non-handling pilot in the decision making process and summing up the options available. Q.—So he would require to have a spatial awareness as handling pilot, is that correct? A.—I would expect him to have spatial awareness. Q.—That is to say an awareness of where he was at any particular time? A.—Within a certain..... Obviously he will not know down to the nearest 30 seconds where he is. However, I would expect over a five minute period and within 10 or 12 miles he would have a feel for where indeed the aircraft was. Q.—And what the terrain ahead of him is likely to be? A.—I think so, yes."

  The importance of the whole crew being involved in decisions about the progress of a sortie was emphasised too by H. He was asked whether Flt Lt Tapper as the captain of the aircraft and seated in the left hand seat in the cockpit would have been doing the navigation: "A.—Yes, I would expect in the left hand seat would be the non-handler and effectively the mission manager. He would have been running the sortie from the left hand side. Q.—In discussing decisions which are taken in relation to the progress of the aircraft such as a decision to change a waypoint or a decision to gain altitude, is that essentially a collective decision or is it properly viewed as the decision of the navigator or captain? A.—I would expect that to be the decision of the mission manager. I would also expect an experienced crew, including the two crew down the back, if they became uncomfortable at what was being organised by the mission manager, then questions would be asked". Later H was asked a series of questions by the solicitor for the Cook family about the precise relationship between the handling and the non-handling pilots. It is I think unnecessary to rehearse this chapter of the evidence in detail. In essence H confirmed that in conditions of poor visibility the handling pilot would have a general picture in his own mind of the flight plan and the aircraft's current position and would be able to see the display on the SuperTANS, but would otherwise be largely dependent upon the navigator for precise details of the aircraft's position and the course to be steered. But H emphasised once again the involvement of all the crew when the aircraft was approaching IMC conditions and a decision to abort to IFR was under consideration. He was asked: "Q.—Such a change of plan is one which the captain would authorise or certainly approve? A.—Correct. I would have expected there would have been discussions on the flight deck as they were approaching conditions such as that, but at the end of the day it is the captain's responsibility. Q.—And the general responsibility borne by the other members of the crew to raise concerns is something that we would only know if, for example, we had a voice recorder on board? A.—That is correct. Q.—The duty would be to voice it, but at the end of the day the decision is of course the captain's? A.—Yes. Q.—Would it be fair to say in general terms the handling pilot would reasonably expect the navigator of the aircraft to keep him clear of high ground whilst he flew under his direction? A.—Correct. I would have expected there to have been continual dialogue within the flight deck and within the crew in that scenario". And H gave further evidence to broadly similar effect the following day when he was asked: "Q.—You were asked some questions about the respective responsibilities of the flight crew and I am only concerned for present purposes with the flight crew. You described the overall responsibility as the captain's but am I right in thinking that it would be entirely to be expected that at least the flight crew would be participating in the decision making processes, in the sense of discussing what was to be done and what the options were? A.—That is what I would expect, yes."

3.  The procedure upon encountering IMC

  In the course of the inquiry there was a great deal of evidence about the procedures to be followed by the crew of a helicopter and in particular a Chinook helicopter, upon encountering Instrument Meteorological Conditions. Much of this evidence was of a very general kind (and in the case of B appeared to be based as much on his experience in other types of helicopter as in Chinook helicopters) and was not focussed upon the particular question which arose in this case, namely what would have been expected of a competent crew finding themselves in the position in which the crew of ZD576 found themselves as the aircraft approached the land mass of the Mull of Kintyre. Accordingly, I do not propose to rehearse here all that was said on this subject by the various witnesses. Instead I shall concentrate on those parts of the evidence which seem to me to have a bearing on the particular question which I have identified.

  E was asked about the training of pilots such as Flt Lt Tapper and Flt Lt Cook as follows: "Q.—Well, I am not going to ask you specifically whether you trained any of the crew on this particular flight. I am simply trying to ascertain the preparedness with which crews go into a flight on any particular occasion and what I am anxious to know is whether there is routine training which deals with a variety of scenarios that might arise. A.—Yes, there is routine training. We prepare crews for flying at low level, flying under IFR, for transition from one to the other, flying by day and flying by night with similar scenarios. Q.—So for example it would not be a new technique for any pilot to have to convert from Visual Meteorological Conditions to Instrument Meteorological Conditions? A.—For a pilot of track record standing in 7 Squadron, that is the case. It is not new to him. It might well be to somebody of lesser standing who has not the experience. Q.—But that is something that would be covered in training and you would expect a crew of the calibre that you have just referred to, to be perfectly familiar with that sort of thing? A.—Yes. Q.—Just to be clear, were Flt Lts Tapper and Cook in that category? A.—Both Flt Lts Tapper and Cook in my opinion were high calibre, capable and mature pilots and I know that they had practised aborts from low level and numerous flight stages or stages of flight. Q.—So flying towards cloud they should have known the appropriate procedure to have followed? A.—Flying towards cloud, they would be faced with quite a few options. Q.—I will come to deal with those options in a moment? A.—They were correctly equipped to be able to make a decision on what action to take." Then in a long passage E was asked about these procedures as follows: "Q.—In a situation in which one is in or is entering Instrument Meteorological Conditions what would you expect as a matter of normal procedure the crews to do in that situation? A.—Wishing to remain in Visual Flight Rules, I would not enter. I would slow down, descend, and maintain clear sight of the surface for visual clues. If it was not possible . . . Q.—Can we just pause there? It is just that you are about to embark on a number of options and I want to be careful to make sure we have got all these options. That last answer pre-supposes the flight has been continued according to Visual Flight Rules? A.—Yes, Sir. Q.—The first option when confronting Instrument Meteorological Conditions would be to slow down? A.—If I wished to maintain Visual Flight Rules I would slow down, descend, maintain visual references. If I made a positive decision to abort the Visual Flight Rules then presumably . . . Q.—Can you tell us what is the procedure for that? A.—It would be from my point of view as handling pilot an immediate cyclic climb and power to effect a rate of climb to a safety altitude and from there to get a radar service and climb to a flight level or altitude on directions of that radar if I was still in cloud at that height. Q.—What is a cyclic climb? A.—A cyclic climb is when pulling back the cyclic it has the effect of flaring the aircraft and transferring the forward airspeed and slowing the aircraft down because it is going up, and without changing the collective. There is a trade-off, speed to rate of climb. Q.—Just to be clear about that: if you are travelling at cruising speed the effect of that would be to bring back the speed to what sort of speed? A.—If I was in the middle of the Atlantic Ocean and there was no obstruction then I would generally first bring the airspeed back to 80 knots. Q.—We have heard at that speed you obtain the maximum rate of climb? A.—Yes Sir, that is correct. Q.—Or are capable of maintaining the maximum rate of climb? A.—If you pull the power provided for. Q.—I am much obliged for that last comment. Can you come to the third possibility: if you have inadvertently entered Instrument Meteorological Conditions, what would be the procedure in that situation? A.—I didn't quite finish the answer to the last question, because power is also—to initiate a cyclic climb you use a degree of power comfortably to make the altitude, once the speed is steady at 80 knots. When you come to the second scenario . . . Q.—Before we come to that, just follow up your last answer to that last one. The answer you gave pre-supposes that you know what rate of climb is appropriate to reach your safety altitude before the obstruction arises? A.—My scenario was in the middle of the Atlantic with no obstructions. If we know that the scenario is in the middle of the Atlantic you start the climb, initiate with the cyclic, back to 80 knots, trim the aircraft, and adjust the power as necessary to make a comfortable climb to an altitude which you wish to climb to. The second scenario I presented, one is wishing to abort low level, you are close to an obstruction, is an immediate cyclic flare, depending upon how close you are to either 80 to 60 knots and the application of maximum power, and once a positive rate of climb has been achieved and the aircraft is under control, then you turn away from the obstruction. Q.—Before we go any further, just for the benefit of the notes, you have talked several times about the application of power and maximum power and each time you have done that you have indicated an upward pulling movement with your left hand? A.—That is correct. Q.—That presumably means you are adjusting the collective lever? A.—The thrust lever—it is commonly called in England the collective—you raised that to increase the power from the engine to give you extra lift . . . Q.—Correct me if I am wrong, but a common feature of these procedures that you have just described is to slow the aircraft down? Or speed the aircraft up. If you had wished to remain Visual Flight Rules and slowed down, you might select say 40 knots and then you would have to increase speed. Q.—I apologise, I forgot the first option was to maintain the visual references? A.—If you wish to do so. Q.—In all the other options a common feature is that you slow down? A.—That is correct, yes."

  D gave evidence substantially to the same effect. But at one point he was asked about the distinction between the procedure to be adopted following, on the one hand, an inadvertent entry into IMC and, on the other hand, a pre-planned entry into IMC as follows: "Q.—To make a distinction between the situation of, if I can put it this way, inadvertent transition from Visual Meteorological Conditions into Instrument Meteorological Conditions. In that situation you would pull back the speed and resort to maximum rate of climb and if you were approaching high ground, turn away from that high ground? A.—Yes. Q.—Is that what you would do? A.—Yes. Q.—That would be standard procedure? A.—Yes. Q.—If, on the other hand, you did not pass inadvertently from Visual Meteorological Conditions but deliberately passed into Instrument Meteorological Conditions what would be the situation there? A.—If it was pre-planned then there could be any number of ways of gaining that altitude. You could do it over several miles or you could circle in your present position. It depends on the knowledge of what is ahead. Q.—You could circle, is that what you said? A.—Yes, you could circle. Q.—You said something else? A.—It depends on the situation. This is a pre-planned climb, and then perhaps you know there are obstructions ahead or perhaps you are surrounded by obstructions and high ground, so you can actually do a spiralling climb. Q.—Whatever be the particular circumstances at the time, the essential requirement is to get up to the safety altitude? A.—Yes. Q.—And if the course of action that you select is to continue to travel towards high ground, presumably you require to select a rate of climb that will get you to a safety altitude before that high ground is reached; is that right? A.—Yes." Earlier D had also been asked about the training of Chinook pilots as follows: "Q . . . exactly what would you do to switch from visual flying to instrument flying? Was there any set procedure? A.—I can't recall that order being written down but I recall it being taught to me sometime. Q.—You do recall it being taught to you. A.—Yes. Q.—And would you expect that to have been taught to any qualified pilot of Chinooks? A.—Yes. Q.—I mean, has it been written down since then or not, since this accident? A.—I don't think so. I can't think of where it is written down. Q.—You are not aware of any change since the accident in 1994? A.—No."

  H also spoke about the procedures to be followed upon entering IMC. In particular, he was asked about how a handling pilot would react upon entering IMC: "Q.—Indeed in the event of inadvertent transition at least into IMC, you told us yesterday that you would expect the handling pilot to take action without being told what to do by the captain? A.—That is correct. Q.—And what action would you expect the handling pilot to take in those circumstances? A.—As I said yesterday, I would expect the handling pilot to reduce speed, start the climb and turn away from the high ground. Q.—Just to make the position clear; in a situation where there is a planned abort to IFR and you are aware of high ground ahead of you, even in that situation if you are unable to get to your safety altitude before you reach that obstruction, you should turn away? A.—That is correct." Later H was asked some questions by counsel for Boeing Helicopters about the adoption of a cruise climb as follows: "Q.—Do I take it from the use of this phrase "cruise climb" and from the way that you have explained it that that would be a recognised operating procedure in appropriate circumstances? A.—That is correct. Q.—So from what you have told us, if this crew had determined that they could climb up to IFR, again leaving everything else out of consideration, that would not in itself be regarded as an inappropriate procedure and they were adopting a cruise climb which, again if you leave the circumstances out, is a procedure which in appropriate circumstances would be unexceptional? A.—That is correct. Q.—And clearly the crew, knowing that there was a land mass in front of them, did not intend to collide with it? A.—That is correct. Q.—And what you then here are suggesting is the crew may have been deceived by a combination of factors into believing that a cruise climb would have provided them with adequate terrain clearance and that is what you then go on to discuss? A.—That is correct". The emphasis on the qualifications expressed in the first two questions in this short passage is mine, and it is I think significant that it was not suggested to H by counsel that the circumstances of the approach of ZD576 to the Mull of Kintyre were such as to make a cruise climb over the land mass appropriate, and nothing was said by H to suggest that he believed that such a procedure would have been appropriate in the circumstances.

  In the course of his evidence J was asked: "Q.—Had you ever flown with any of this crew in this particular aircraft in which there was a need to abort from Visual Flight Rules to Instrument Flight Rules? A.—Yes, it is safe to say I will have done with all of them and certainly with Flt Lt Cook about a week before he went to Northern Ireland, we did exactly that. Q.—Is there a particular procedure or manoeuvre which one would expect for going from Visual Flight Rules into Instrument Flight Rules? A.—Yes, the first point is one of awareness. It is to make a firm decision that the weather is becoming unacceptable. As the weather deteriorates the crew will slow down and descend to maintain visual references with the ground. As soon as this position becomes untenable then a firm decision has to be made to abort and then the aircraft is climbed using the cyclic to bring the nose up, reduce the speed, one hundred per cent power is selected to get the best climb you can and then you turn onto what is deemed to be a safe heading, away from any obvious high ground or obstructions and then the climb is continued until above safety altitude". J touched briefly upon the possibility of climbing at cruising speed when he was asked: "Q.—So there may come a point in time when the decision is taken to convert from VMC to IMC; is that right? A.—Yes. Q.—But the like is that one would expect them to have slowed down before making that decision? A.—It is a possibility. If it was patently obvious that there was cloud ahead or impossible weather ahead you would initiate the abort early (my emphasis) in order to avoid that problem, therefore there would be high speed initiation". Then J emphasised the role of all the members of the crew, and not just the captain, when he was asked: "Q.—And then going through the IMC abort or pull-up procedure it is nevertheless necessary to slow down to do that; is that correct? A.—If you are at high speed it would be necessary to slow down, yes Sir. Q.—Then you select your maximum speed of climb? A.—Yes, you bring in power to climb. Q.—And turn away from any obvious obstacle in front of you until you have reached safety altitude? A.—If there is an obvious clear ahead, yes, you would turn on to that. Q.—And no doubt Mr Cook—because you told us you had personal experience of doing this with him—would be well aware of the procedure which would require to be followed? A.—Yes. Q.—And if some different procedure were to be followed, presumably Mr Cook would be interested to know why that different procedure should be followed? A.—As would Mr Forbes and Mr Hardie". Then J was asked some questions about the rate of climb selected by the crew of ZD576: "Q.—And if the crew were aware that for this particular leg of the journey the immediate concern, if I can put it that way, was simply to reach a safe altitude of 2,800 feet, is it possible that what happened was that they simply chose the wrong rate of climb? A—If they had been unable to see the mountain that they knew was there, as they did, it was on the map, then they would have initiated a climb I suggest at least say about five miles before reaching that point. Particularly if you can't see an obstruction you have to be extremely cautious and climb much earlier than you do if you can see it for the obvious reason . . . Q.—What would that involve in practice? To deal with speed first of all, they are flying on this hypothesis at low level and cruising speed. What would you expect in that regard were they to confront that situation? A.—The aircraft to be brought back to around 80 knots for a good climb speed. Q.—Because for the obvious reason to continue ahead towards an area of cloud where you know there is a mountain just does not make any sense at high speed? A.—With two crew members navigating and two crew members at least pointing out there is a mountain ahead you would certainly climb and bring the speed back to effect that climb. Q.—Because obviously in this it is not only the selected rate of climb but it is the angle of climb that you are concerned about? A.—Yes, ultimately." J was asked too about the possibility that the crew might have felt under pressure of time to complete the sortie to Inverness as follows: "Q.—In any event, you maintain that any concerns about the timing of the flight in relation to crew duty hours or anything of that sort should not have been sufficient to have diverted the crew from normal practice in the event of them losing Visual Flight Rules contact? A.—Certainly not. Q.—It would not have justified continuing at cruising speed? A.—No. Q.—Is that right? A.—If they could safely initiate the climb on coasting out from Northern Ireland they could probably climb at cruising speed but I don't believe they would attempt that with a flight profile with close obstruction because there is no way that aircraft could climb, initiate a climb, as late as it did at cruise speed. Q.—Just on that point, there is no doubt it was a, if not fully laden, pretty nearly fully laden aircraft, is that right? A.—It was within the 18 tonne constraint rather than the 22,700 I believe, yes. Q.—I take it that the crew would have been aware of the limited rate of climb that could be obtained by such an aircraft at cruising speed? A.—Yes, very much so."

  K was asked about the training of Special Forces crews as follows: "Q.—Were there procedures specific to the training of flight crew, Special Forces flight crew perhaps even, over what to do when inadvertently entering Instrument Meteorological Conditions from VFR? A.—There is certainly taught procedures which were general to the helicopter community. The only difference with Special Forces Flight is we practice them on a very regular basis. Q.—What were those procedures? A.—If you inadvertently entered IMC as a single aircraft you immediately initiated a cyclic flare and climbed, back to 80 knots, which was the minimum power speed, simultaneously pulling on 100 per cent power or maximum available power for that particular airframe on the collective, and then when safely established in the climb, turn the aircraft away from any obstruction or high ground if that was pertinent. Q.—And that kind of procedure or reaction, is that standard? A.—Instinctive. Q.—If you had to inadvertently enter IMC? A.—Correct." Later K was asked about the possibility of ZD576 having got as close as it did to the Mull of Kintyre without climbing to safety altitude: "Q.—The scenario of the Board of Inquiry is that, as I understand it, the waypoint change to Corran 1.7 kilometres before the lighthouse was made in the absence of visual contact with the first waypoint and as part of a pre-planned change into Instrument Flight Rules? A.—Yes. Q.—Is that explicable to you? A.—The distances that we are talking about here were very small. I think we worked it out at 1.75 kilometres, equal to 0.81 of a nautical mile, which is the normal distance units we think in, and to be that close to land and not to be visual with it and not be above safety altitude is just inconceivable. Q.—We can do the calculations in nautical miles. Say it had been one nautical mile? A.—If it had been five nautical miles it was still too close. A crew of that experience, electing to go over the top of the Mull of Kintyre, would have made sure they were on safety altitude a considerable distance before they got anywhere near the land mass". K was also asked about the technique of a cruise climb: "Q.— . . . You are familiar with the term "cruise climb"? A.—I am. Q.—Do I understand that that involves simply a lifting up of the collective lever without actually increasing the forward speed? A.—In general terms, yes. More specifically, a cruise climb is a climb at the speed at which the aircraft is normally proceeding through the air. However, because extremely high forward speeds produce extremely low rates of climb, even using maximum available rates of power, you will generally find that pilots do not cruise climb at speeds in excess of about 120 knots. Even if an aircraft is proceeding though the air at 150 knots airspeed, the pilot will generally reduce speeds slightly to enable them to obtain a higher rate of ascent." But again it was not suggested to K that it would have been appropriate or in accordance with accepted procedures to adopt such a technique to overfly the Mull of Kintyre form a starting point of less than one nautical mile from the land mass and a height of some 400 to 500 feet above sea level.

(4)  The preparation for the sortie

  Apart from the question mark about Flt Lt Tapper's not having obtained an extension to 10 of his crew's duty flying hours or authorisation for the aircraft to be kept out of Northern Ireland overnight, the planning of, and preparation for, the flight to Inverness appears to have been unexceptional. During the evening of 1 June 1994 Flt Lt Tapper conferred with B about the flight and they agreed that it would have to be flown under VFR conditions in light of the forecast meteorological conditions and the aircraft's icing clearance and fuel limitations. B offered to fly the sortie to Inverness with his crew but Flt Lt Tapper said that he would do it and would apply for the necessary extension of his crew's duty flying hours. He duly prepared details of the flight on a 1:500,000 map and later that evening was seen by C in his room transferring the details to the appropriate 1:250,000 maps. At some stage too MALM Forbes was seen by A preparing a 1:500,000 map of the route taking the details off the map previously prepared by Flt Lt Tapper.

  The following morning Flt Lt Tapper had the meeting with G to which reference has already been made. In the course of that meeting there was a discussion in light of the weather forecast about what should be done if the aircraft was unable to proceed under VFR conditions or inadvertently entered cloud and it appears to have been agreed that in the event Flt Lt Tapper should attempt to regain VFR conditions as quickly as possible or else return to RAF Aldergrove or divert to an airport with radar facilities such as Glasgow or Prestwick. There was also a flight crew briefing that morning which was attended by A, but nothing of any particular significance to the present inquiry appears to have been said during that meeting. A was also a passenger on two of the short sorties undertaken by ZD576 in the earlier part of 2 June 1994. These sorties were, as he put it, "nothing out of the ordinary" and during them, as already noted, the aircraft was flown at airspeeds of up to 135 knots which were not unexpected, and indeed were commented upon by Flt Lt Tapper and Flt Lt Cook, since, at least to begin with, the MkII Chinooks tended to vibrate less at speed than the MkIs had done. In the course of these sorties there was a recurrence of a problem with one of the PTIT gauges which had occurred the previous day and which was duly investigated by engineering staff. In the afternoon Flt Lt Tapper also asked the latter to investigate the SuperTANS since it appeared to be tracking more satellites than it could see. But no fault was found.

  Sometime before departure of the flight for Inverness the members of the crew held a briefing. At some stage too, presumably in anticipation of this briefing, up-to-date meteorological information was obtained by the crew from the Met Office at Belfast International Airport. This information consisted of three sheets. The first comprised Terminal Area Forecasts (TAFS) and Meteorological Actual Reports (METARS or Actuals) for a variety of airports in and around the aircraft's planned track to Inverness, a United Kingdom Low Level forecast for 1500GMT on 2 June 1994 and a fixed time chart showing wind directions and speeds and air temperatures at specified heights about sea level. Among the TAFS was a forecast for Machrihanish issued at 1100GMT on 2 June 1994 and valid between 1400 and 2100GMT that day. The forecast wind direction was 130 degrees with a speed of 15 knots gusting up to 25 knots. The forecast visibility was 7,000 metres in haze with scattered cloud down to 1,200 feet and broken cloud down to 3,000 feet and temporarily throughout the forecast period visibility of 4,000 metres and broken cloud down to 500 feet. In addition it was said that there was a 30 per cent probability that temporarily during the forecast period there would be fog with visibility down to 500 metres and broken cloud down to 100 feet. Among the Actuals was a report from Machrihanish timed at 1416GMT on 2 June 1994. This indicated that the wind direction and speed at that time were 150 degrees and 15 knots respectively, the visibility was 4,800 metres in haze, there was scattered cloud down to 200 feet and broken cloud down to 800 feet, the outside air temperature was plus 11º and the dewpoint was plus 10º. This would have confirmed to the crew that there was a prospect of the weather being poor for periods in the area of Machrihanish and they would have noticed in particular the report of the scattered cloud base at 200 feet. The other TAFS and Actuals for the proposed route to Inverness in short indicated rather better weather conditions on either side of the area around Machrihanish. H was asked about these forecasts as follows: "Q.—Before I go on to look at other aspects of this document which was apparently sent to the aircrew, can you give us an insight as to how an experienced aircrew looking at this picture on these two documents would have seen the weather for this particular flight? A.—Indeed. The weather for the vast majority of the route is absolutely fine and there would be no weather problems whatsoever. However, obviously there is an area of concern or an area of reduced both visibility and cloud base in the Machrihanish area. I would probably term those conditions as marginal. However, with a 30 per cent probability of conditions below those required for VFR flight, I would consider them suitable to attempt the route . . . Q.—would they be expected to be aware, because of this forecast, of the possibility that they are going to have to come out of Visual Flight Rules? A.—That is correct. The way I would put it is they would have had to have planned and thought about what they are going to do if they occasioned upon weather below that that they required to remain visual and the options . . . would be to turn round and go home, to turn away from the area of poor weather and try and find a way through or to remain in good weather and still find a way through to rejoin their route later or indeed climb into Instrument Flight Conditions and fly high".

  The UK Low Level forecast was divided into zones, one of which covered the whole mainland of Britain and most of Northern Ireland. In this zone it was forecast, inter alia, that the temperature at 7,000 feet above sea level would be zero degrees and that in isolated sea and coastal areas there would be fog, visibility of 500 metres and seven eighths stratus cloud down to 100 feet with tops at 1,500 feet. And finally the fixed time chart indicated, inter alia, that at 1,000 feet above sea level the direction and speed of the wind would be 180 degrees and 20 knots respectively and the air temperature plus 10º. There was also available in the Operations Room at RAF Aldergrove an area forecast issued at 1030 GMT on 2 June 1994 for Northern Ireland and coastal waters within a 40 kilometre radius (thus including the waters around the southern end of the Mull of Kintyre). This forecast was for the use of all the aircraft crews engaged in operations that day. The details on this forecast largely coincided with the details shown in the TAFS and Actuals sent to the crew of ZD576. In particular it forecast that the direction and speed of the surface wind would be respectively 160 degrees and 12 to 15 knots, locally 20 knots over the North Channel, the temperature at 2,000 feet would be plus 8o and at 5,000 feet plus 3o and that over the sea in the east of the area the visibility would be 4,000 metres and locally 500 metres in mist and fog.

  In the ordinary course of events Flt Lt Tapper would have been expected to outbrief the Duty Authorising Officer (DAO) at RAF Aldergrove before departing for Inverness. But the DAO was not available at the material time since he was engaged in a briefing of some other helicopter crews. Instead Flt Lt Tapper left copies of sections of the 1:500,000 map which he had prepared for the flight with an operations clerk. He also completed the appropriate flight authorisation sheet in respect of the sortie to Inverness indicating that he would be in the left hand seat in the cockpit of ZD576 and that the estimated duration of the sortie was four hours. In addition he made a low flying booking for Low Flying Area 14 (which included the Scottish section of the proposed route). The booking covered the period between 1645 and 1925 GMT and was for flying at heights down to 50 feet above ground or sea level.