IX Cockpit Voice Recorder and
Accident Data Recorder
The evidence as to the value of fitting a Cockpit
Voice Recorder (CVR) and/or an Accident Data Recorder (ADR) in
an aircraft was spoken to chiefly by Mr Cable. In his report he
expressed the matter thus:-
"The absence of either an ADR or CVR resulted
in considerable hindrance and protraction of the technical investigation.
Both facilities commonly provide major benefit to the investigation
of both fixed and rotary wing aircraft accidents and hence to
the identification of measures aimed at preventing subsequent
similar accidents. The availability of information from either
source almost invariably expedites the investigation to a considerable
degree and enhances the level of confidence in the final conclusions
reached as to the causal factors, at times crucially. While it
is preferable to have both data and sound recordings available
a CVR alone can provide a considerable quantity of information,
not only on crew and ATC communications but also on other sounds
reflecting features of aircraft operation such as cockpit control
selections, explosions, structural failure and characteristics
of rotating machinery. Although typical CVR recordings are of
relatively short duration and low fidelity, spectral analysis
can provide detailed information on such parameters as the rotational
speed of engines and rotors and on malfunctions such as impending
transmission gearwheel failure and these facilities have been
utilised to major effect in a number of AAIB investigations. For
example, in the case of Chinook BV234 G-BWFC that crashed in the
North Sea on 6 November 1986 with 45 fatalities (AAIB Report 2/88)
CVR recording analysis had, within 48 hours of impact, pinpointed
the component whose failure caused the loss of the aircraft together
with data on the progression of the failure. Such analysis can
also provide a high level of confidence as to the satisfactory
operation of engines, transmission and rotors in the absence of
malfunction. The AAIB Recorder Section estimates that a CVR typically
costs around US$10,000-15,000 per aircraft, including both the
unit and its installation".
In the course of cross-examination Mr Cable
was asked by counsel for the Tapper family: "Q.....given
that you don't have data from an Accident Data Recorder or a Cockpit
Voice Recorder, there must be less confidence in your final conclusions
than there would have been if you had all that extra data... that
might otherwise have been available? A.Yes, I think conclusions
like this, like safety, are not absolute terms. There are levels
of safety and levels of confidence. I have no doubts in the overall
conclusions that I have drawn from my examination of the wreckage
and accident site....Q.But if an Accident Data Recorder
had been installed and if you had found it functioning you would
have a much greater degree of confidence in your conclusions.
A.I would have reached the point that I have reached much
quicker. I would have more confidence in the quantitative value
of the parameters, the impact parameters, the possible tolerances
of those would be much lower. In general terms, at the end of
the day, I don't believe it would have added greatly to the confidence
in the conclusions I had reached. I have qualified my conclusions
where I consider the evidence requires it".
Later Mr Cable was asked by the solicitor for
the Cook family: "Q.Now, I am right, am I not, in
understanding that you are confident in the conclusions which
you have reached in your report...? A.Yes, I am, with the
qualifications that I have included there. Q.What I think
would be fair to say is with the appropriate recording equipment
which we have heard about you may have been able to go further
in your conclusions. A.Oh, yes certainly. Q.To take
a simple example: If a pilot had been recorded as saying something
about what was happening at the aircraft at the time of the crash
you would have perhaps been able to conclude with further investigation
that was at least a possibility? A.Depends what it was.
I am splitting hairs, but it depends if it related to an operational
matter or an engineering matter. I mean it would clearly add quite
a lot on the operational side to have heard a defined flight path
leading to the accident. Q.Would it be fair to say certainly
in a civilian context that pilots can often have a measure of
protection from such recording equipment when crashes take place
in that such recording equipment may point to causes for accidents
which in the absence of that recording equipment might leave the
pilots being inappropriately blamed? A.Yes, we have commonly
found this".
This last observation found an echo in a passage
in a report (Annexe V) which was prepared for the Board of Inquiry
by a principal psychologist of what I take to be the Institute
of Aviation Medicine. After considering a possible scenario of
events the author of the report wrote: "But the only possible
source of evidence that could have cast some light on the crew's
intentions and thoughts, a recording of their communications,
was not available. At one stage in the investigation, because
the RNS252 system was found in the wreckage switched off, evidence
was sought to explain why a crew might choose to do without this
essential equipment. Fortuitously data stored in the system survived
the crash and only its recovery showed this line of inquiry to
be a red herring. This fact provides a benchmark against which
speculative explanations should be judged. The lack of CVR on
the Chinook has two major consequences: The competence and skill
of the crew are unavoidably but invidiously called into question
in a speculative manner. And, if they did fail, the lessons that
could have been learned from their tragic error are denied to
their colleagues". H was asked: "Q....would you
agree the lack of a Cockpit Voice Recorder had the consequences
described here? A.Yes".
It was submitted by counsel for the Ministry
of Defence that it was not easy to see how the issue of fitting
either a CVR or an ADR could be dealt with within the parameters
of section 6 of the 1976 Act and that in any event it would not
be possible for the court to say that it would have been a reasonable
precaution to have fitted either of these without more evidence,
for example about their cost and whether other items of equipment
might require to be omitted to make way for them. Counsel for
the remaining families on the other hand invited me under reference
to section 6(1)(e) of the Act to support the recommendation made
by the Board of Inquiry to the effect that such recorders should
be fitted in all RAF Chinook aircraft at the earliest opportunity
and by Mr Cable that fitment of such recorders should be considered.
He drew attention to the benefits of such recorders as disclosed
by the evidence and submitted that anything which assisted in
providing an explanation for what had happened would in generality
almost always be of some benefit to the relatives of victims of
tragedies such as this who quite naturally craved an understanding
and explanation for what had occurred. Similarly, it might provide
some consolation in supporting the hope that lessons would be
learned which might prevent a repetition. Counsel also commented
that no explanation had been tendered to the inquiry by the Ministry
of Defence for the failure to implement previous recommendations
to the same effect made by RAF Boards of Inquiry into two earlier
accidents involving Chinook helicopters.
A not dissimilar approach to that of counsel
for the remaining families was taken by the advocate depute, counsel
for the Tapper family and the solicitor for the Cook family. For
my part, I think that the absence of either or both of a CVR and
ADR is clearly relevant to the circumstances of the deaths in
this case inasmuch as that absence has prevented those circumstances
being investigated as fully as they might otherwise have been.
On the other hand, notwithstanding certain comments which I have
read in the press, I have no power to make recommendations in
this respect which would be binding on anyone, least of all the
Royal Air Force. But I would certainly endorse the view that it
would be highly desirable to fit Cockpit Voice Recorders and Accident
Data Recorders in all RAF Chinook helicopters as soon as possible
unless there are overriding military or operational reasons to
the contrary (and there was no evidence to that effect before
the inquiry).
|