Category Archives: Chinook campaign

The best reason to remember the coalition government?

By Tony Collins

A day before people go to the polls to elect a new government is, perhaps, a good time to remember a momentous achievement of the old one.

It’s rare in any government for politicians to override the settled wishes and views of senior public officials.

In “Yes Minister” Sir Humphrey usually gets his way over his minister – which many politicians say reflects reality.

liam foxBut in 2011 the defence secretary Liam Fox did something remarkable: he went against the fervent wishes of an officialdom that had, since 1996, persuaded prime ministers and successive defence ministers that two pilots, beyond any doubt, had caused the deaths of 25 top intelligence and security officers who were on board a Chinook helicopter, ZD576, that crashed on the Mull of Kintyre on 2 June 1994.

All 29 were killed in the crash including two pilots Flight Lieutenants Rick Cook and Jonathan Tapper and senior crewmen, Malm Graham Forbes, and Sgt Kevin Hardie.

It was under a Conservative government that two RAF air marshals found that Cook and Tapper caused the crash and were grossly negligent. The defence secretary at the time, Malcolm Rifkind, agreed with the decision to blame the pilots.

Later he changed his mind and said officials had given him incomplete information. He was unaware of the history of problems with a new “Fadec” fuel-control system fitted to the Chinook Mark 2 – the helicopter type that crashed on the Mull of Kintyre.

The safety-critical Fadec [full authority digital engine control] system was controlled entirely by error-ridden software that controlled the flow of fuel to the Chinook’s two jet engines.

The system was so unreliable that a day before the crash, test pilots had stopped flying Chinooks fitted with the new Fadec.  The system caused engines to behave unpredictably – at times surging or running down without leaving a trace of any fault.

At the time of the crash there were internal disagreements within the RAF over the seriousness of the Fadec-related problems.  A senior RAF software engineering specialist wrote in 1993 that the Fadec had an undocumented feature in the processor that was “positively dangerous”.

When Chinook ZD576 crashed there were no black boxes, no eyewitnesses, and no survivors to say what happened in the last minutes and seconds.  It is not known for certain whether the pilots were in control.

One of the air marshals who found the pilots grossly negligent drew his conclusions, in part, from data obtained from the crashed Chinook by the manufacturer of an RNS252 navigation system. The air marshal described the RNS252 as a “black box”.

RNS 252 chinookData obtained from the RNS252 was not independently verified; it’s unusual in any civil air accident investigation to draw conclusions on the cause of a crash from a system that has not been independently proven to be accurate.

None of this was known to the Conservative government when it announced to Parliament in 1994 that the gross negligence of the two pilots caused the crash.

The then prime minister John Major later changed his mind about the pilots being to blame. He wrote in The Times in May 2004:

“We may never know what truly caused this tragedy. It follows, therefore, that there is no justification for blaming pilot error… We owe justice to the dead. I am not persuaded that they have had it.”

RAF rules at the time of the crash were that dead pilots could not be found grossly negligent unless there was “absolutely no doubt whatsoever” about the cause of an accident.

The doubts of Major, Rifkind and James Arbuthnot , a Conservative defence minister, deepened as the years went by and more evidence of the Chinook Mark 2’s technical problems  came to light.

Arbuthnot, in particular, campaigned vigorously for the pilots’ names to be cleared, as did many other MPs and peers.

But nobody could persuade a succession of Labour defence ministers that the pilots might not have been to blame. Tony Blair, when prime minister, wrote twice to the families of the dead pilots repeating the MoD and RAF line that there was no new evidence to justify a reopening of the inquiry into the crash.  Defence secretaries John Reid, Geoff Hoon, George Robertson, Bob Ainsworth, John Hutton and Des Browne took the same position.

The MoD even set up a small team to answer many questions from MPs and peers – and the families of the pilots – about the crash investigation, the Fadec system, and other technical shortcomings that raised questions about the airworthiness of the Chinook Mark 2.  The team’s official retort was that there was no new evidence to justify a new inquiry.

But it was the MoD, RAF and their ministers who were judge and jury on what represented new evidence – and they dismissed as irrelevant every leaked internal RAF software engineering memo on the poor state of the Chinook Mark 2.

In opposition some conservatives said they would hold a new inquiry into the crash if they came to power. Cameron was among them. Liberal-Democrats wanted also wanted a new inquiry, particularly the ardent campaigner Menzies Campbell.

Labour MPs and peers also campaigned for a new inquiry particularly the peer Martin O’Neill. Crossbench peer Lord Chalfont led a Parliamentary group that campaigned on behalf of the Cook and Tapper families.

Families of some of the VIPs who died in the crash supported the campaign.

When the coalition was formed, Cameron and Clegg did what they’d promised and set up a new inquiry, led by a retired judge Lord Philip

His report recommended that the finding of gross negligence be set aside; and he and his privy counsellors had strong criticisms, not of the air marshals who had made their finding in good faith, but of officialdom. Lord Philip’s report said:

 “Since 1995 the Ministry of Defence has continued resolutely to defend the finding of gross negligence and to rebuff all public and private representations that the finding should be reconsidered even when the representations included cogent arguments based on a sound understanding of the effect of the relevant Regulations.

“We find it extremely regrettable that the Department [MoD] should have taken such an intransigent stance on the basis of an inadequate understanding of the RAF’s own Regulations in a matter which involved the reputation of men who died on active service.”

The Philips report did not, and could not, set aside the finding of the air marshals. Whether right or wrong, the finding had a firm legal status. There was no right of appeal.  How could the finding be set aside?

Then came the coalition’s arguably most important machinery-of-government decision:  Liam Fox convened a special meeting of the Defence Council.  Chaired by the defence secretary, the Defence Council provides the formal legal basis for the conduct of defence in the UK through a range of powers.

It comprises the chief of defence staff and senior service officers and senior officials who head the armed services and the MoD’s major corporate functions.

How the Defence Council came to its vote to set aside the finding of the air marshals is not known. There are rumours one or two of its members were replaced before the vote.

John Cook, the father of Rick, did not live to see his son’s reputation restored. John Cook died in 2005. A former British Airways Concorde pilot, he had been concerned about the lack of black boxes on the crashed Chinook. He was also concerned about the air marshals’ partial reliance, in drawing their conclusions, on the manufacturer’s data derived from the RNS252.   On John Cook’s death, the campaign for justice was taken up by his other son Chris.

Mike Tapper, the father of Jonathan, began the campaign to his the pilots’ names a few days after the crash  when it appeared that some officials were suggesting to the media that the likely cause was pilot error.

In fact the cause – or causes – of the crash will never be known. Much of the helicopter was destroyed in the fire that followed impact.  It might have been caused by pilot error. It might have been the result of technical malfunctions, or combination of human and technical factors. What’s certain is that there is doubt over the cause.

Liam Fox and his coalition colleagues have proved that when public officials are wrong – and even when, in their misconceptions, they have persuaded two prime ministers and successive defence secretaries to adopt their arguments – that those misconceptions can be overturned if the political will is strong enough.

Many political decisions of the coalition government will soon be forgotten. But correcting a grievous and long-standing miscarriage of justice against two Special Forces pilots who could not speak for themselves will never be forgotten.

It will never be forgotten by the campaigners who are too numerous to mention; and it will never not be forgotten by the children of the two pilots.

Advertisements

A major change in departmental policy

The quashing of the findings of gross negligence against the pilots of Chinook ZD576 shows, among other things, that independently-minded ministers can make decisions that countermand the wishes of their senior officials.

Chinook ZD576 crashed on the Mull of Kintyre on 2 June 1994 killing all 29 on board including 25 senior police and intelligence officials. RAF air marshals blamed the two pilots but the Government set aside the finding last week after an independent review by Lord Philip said the air marshals were wrong.

Nobody knows the cause of the crash but it transpired that the helicopter type that crashed had unreliable safety-critical software which had hundreds of bugs. The MoD’s purchase of the Chinook Mk2’s Full Authority Digital Control [Fadec]  proved to be one of the worst IT-related procurements in Whitehall: the RAF’s software engineers had little control or say over the developing or final Fadec product. In the end the RAF could not verify the software as safe.

Separately a senior RAF engineer categorised the Fadec system as “positively dangerous” nine months before the crash on the Mull of Kintyre.

Successive defence secretaries in the last administration, including government spokespeople in the House of Lords, were unwilling to upset officials and air marshals. They rejected all well-argued calls for a review of the decision of two air marshals to find the pilots of ZD576, Flight Lieutenants Jonathan Tapper and Rick Cook, grossly negligent.

But the coalition’s defence secretary Liam Fox has proved to be much less susceptible to the influence of his officials.

The quashing of a decision by the air marshals could not be set aside by the defence secretary or even a prime minister acting alone. It required a decision of the Defence Council which is the MoD’s most senior departmental committee.

The Defence Council is chaired by the defence secretary, and includes other ministers, the Chief of Defence Staff, senior officers and officials who head the armed services and the department’s major corporate functions. It has a range of powers vested in it by statute.

At a specially-convened meeting of the Defence Council on Monday last week, Liam Fox drove its decision not simply to accept the report of the Lord Philip panel, which said that the MoD should consider apologising to the families of Cook and Tapper, but to quash the finding of a properly-constituted RAF Board of Inquiry.

The Defence Council decided that the finding of two air marshals that Tapper and Cook were grossly negligent was “no longer sustainable and must therefore be set aside”, said Fox in the House of Commons on Wednesday this week. The Council ordered that “those findings shall be set aside”.

And to his further credit Fox, after his announcement to Parliament, had the grace to meet the families of Cook and Tapper in a room near the main debating chamber of the Commons.

As Fox told the Commons:

“It shows the House of Commons at its best when pressure from the House of Commons can cause an injustice to be overturned.”

If a minister can achieve what Fox has achieved – a fundamental change of thinking within a major department of state – coalition ministers can achieve anything within reason.

Labour MP Frank Field, in congratulating Fox for driving the decision to clear the pilots’ names, put it succinctly in his short speech in the House of Commons on 13 July 2011:

“May I congratulate the Secretary of State on showing the guts to get his Department’s public stance to where justice demanded it should have been for many a year?”

All the defence ministers in the last administration will soon be forgotten. If for nothing else Liam Fox will be long remembered for overturning a miscarriage of justice, one of the most grievous in the past 100 years.

Chinook campaign – the 16-year campaign for justice.

Chinook crash – the 16-year campaign to right an injustice

By Tony Collins

Chinook ZD576

The day after the fatal crash of Chinook ZD576 on the Mull of Kintyre an RAF Board of Inquiry convened.

There was little to go on: what could be retrieved from the fire at the crash site, and records of recent trouble with the aircraft type, including difficulties with the Chinook Mk2’s software-controlled “Fadec” system.

There had been so much trouble with the Fadec, in fact, that test pilots had ceased flying the Mk2 the previous day. But operational flights continued.

The crash of ZD576 left no survivors: all 29 on board were killed. There was no cockpit voice recorder. No flight data recorder. Particularly for John Cook, the father of one of the pilots, the absence of black boxes compounded his grief.

While a Concorde pilot for British Airways, John Cook led successful negotiations with the Air Accidents Investigation Branch for the installation of cockpit voice recorders on large passenger aircraft.

He recognised the importance of flight data and cockpit voice recorders to investigators and the families of dead pilots because they could show how an aircraft was performing in the moments before it crashed. A cockpit voice recorder could record audible warnings, pilots expressing concern about a possible malfunction and any unusual noises.

Without black boxes it would be easy to blame dead pilots for a major, fatal accident.

Said John Cook in 1999: “I fought to have the recorders installed and then I lost a son in an aircraft which didn’t have one.”

The campaign begins

In crashes of civil airliners the data from the black boxes often gives the best clues as to the likely cause or causes. Even when the black box data is fully recovered the likely causes of an accident can elude investigators.

So how could anyone know what happened in the moments before the crash of ZD576? In 1995, nearly a year after the accident, the RAF Board of Inquiry produced its findings.

The campaign to restore the reputations of the two pilots of ZD576, Flight Lieutenants Jonathan Tapper and Rick Cook, began.

MoD  and RAF attack their own software experts

In some ways the investigation into the crash was exhaustive. In other ways it was limited. It reflected the mindset of the RAF at the time, which was that Chinooks were needed desperately, and, if possible, in greater numbers. The last thing the RAF hierarchy needed was credibility being given to the internal concerns about the helicopter’s Fadec system, in which software controlled fuel to the Chinook’s two jet engines.

Days after the crash on the Mull of Kintyre in June 1994, a senior RAF officer expressed his frustration at the internal concerns over the Fadec.

In a signed, draft memo, the RAF officer attacked the MoD’s own software experts at Boscombe Down. He said their “ongoing stance towards the Mk2 contrasts sharply with the considerable efforts being made by the front line to bring the aircraft into service and maintain a capability”.

Boscombe Down’s attitude, he said, “does nothing to engender aircrew confidence in the aircraft”.

It was beginning to look as if the RAF would not tolerate an investigation that concentrated too much on the integrity of the helicopter and its software. But, to its credit, the RAF brought in the civil Air Accidents Investigation Branch.

The AAIB did not have a free hand, however. The limits of its investigation were agreed with the RAF. The AAIB could not simply require all relevant documents. It was up to the MoD and RAF what documents it showed the AAIB.

And the MoD supplied the bare minimum.

Documents not shown to investigators

Many potentially-relevant documents were to emerge years later, long after the RAF Board of Inquiry had been disbanded. The documents came to light, in part, because of leaks by well-intentioned insiders who were concerned that possible flaws in the airworthiness of the Mk2 were being overlooked.

Back in 1994, the AAIB’s chief investigator Tony Cable knew there had been problems with the Fadec, none of which the RAF hierarchy regarded as serious. Among the many things Cable wasn’t told was that the Superintendent of Engineering Systems at the MoD, Boscombe Down had, nine months before the crash, found flaws in the Fadec that he said in an internal memo were “positively dangerous”.

And Cable didn’t know at the time of his investigation that the MoD was suing the Fadec suppliers because of faults in the system’s software that were exposed by a ground test of a Chinook at Wilmington in the US, Boeing’s “Center of Excellence”.

When the Fadec was working properly, which was most of the time, it made the job of Chinook pilots easier: they could fly the helicopter without controlling power to the engines. When the Fadec systems were not working properly they were apt to leave no trace of a fault, and could endanger the lives of all on board, said Squadron Leader Robert Burke who, at the time of the crash, was one of the most experienced Chinook Mk2 unit test pilots.

A near-catastrophe that left no trace

Four years after the crash of ZD576, Bric Lewis, the pilot of a US Chinook, exclaimed involuntarily “Oh God” into the microphone of his headset. His words were transmitted to all on board. His Chinook was falling out of the sky … upside down.

The displays in the cockpit showed no warning lights… no evidence of any technical malfunction. Then, as inexplicably as the Chinook had turned over, it flipped back again, into a normal, wheels-down position. After it landed safely no serious fault was found.

Bric Lewis and his crew lived to provide evidence that their Chinook had turned over. If they had died in the incident, would they have been blamed on the basis that no serious malfunction capable of causing the crash had been found?

An extraordinary campaign

That the campaign to clear the names of Cook and Tapper has succeeded is extraordinary, and yet it’s not in the least extraordinary. It has been a campaign characterised by its intensity, perseverance, and the status and number of those involved.

It has been a campaign that pivoted on the tenacity of the families of the two pilots and their pro bono advisers. Some of the campaigners cannot be named.

MoD spin

The campaign has also been marked by the determination of the MoD and RAF hierarchy not to attach any credibility or relevance to newly-disclosed information.

In the words of then independent MP Martin Bell in 2001: “The MoD is being anything but straightforward… clearly civil servants are trying to spin the facts to suit the air marshals’ agenda.”

With a manipulative use of language, and an evasive but self-confident way of answering of difficult questions – sophistry exemplified – the MoD was a decisive influence on defence ministers of the last administration.

Every defence minister in the last government was persuaded that there could be only one cause of the accident, and that was pilot error. Tony Blair wrote in his own hand that the pilots were to blame.

So how did one of most grievous military miscarriages of justice in the last 100 years come to be corrected? It was thanks, in part, to the injustice’s enduring visibility in Parliament and in the media, such that David Cameron, when in opposition, promised, if elected, to launch a formal review of the decision to blame the pilots.

And only a prime minister or his defence secretary could, in effect, take the steps necessary to overturn the judgement of a properly-constituted RAF Board of Inquiry. In ordering the Philip review, Cameron proved as good his word.

Liam Fox, too, unlike defence secretaries in the last government, has shown by his actions that he is not prepared to be putty in the hands of his civil servants and RAF air marshals. All credit also to Nick Clegg for his support of the Philip review.

Did the RAF try to dissuade Cameron from holding a review?

It’s unclear whether the RAF tried to discourage Cameron from setting up a review. What is not in doubt is that, in January 2010, a few months before the general election, four former chiefs of the air staff, and a former RAF Chief Engineer, wrote to the Daily Telegraph saying they would wish to brief ministers if there were to be “yet another” review of the RAF’s decision to blame the pilots for the crash of Chinook ZD576.

In their letter, Sir Michael Graydon, Sir Richard Johns, Sir Peter Squire, Sir Glenn Torpy, and Sir Michael Alcock said the finding of gross negligence against the pilots of ZD576 was “inescapable”.

“We understand that in the event of a Conservative administration coming to power it will revisit the Mull of Kintyre Chinook accident and consider the negligence finding,” said the letter of the five knights. “Each one of us has reviewed separately the findings of the Board of Inquiry and reached the same conclusion, namely that basic airmanship failings caused this tragic accident.

“If yet another review is to take place then we would welcome an opportunity to brief ministers and discuss in necessary detail why this finding remains inescapable. In particular, it will be explained precisely why it cannot be overturned by recourse to a hypothesis for which there is no evidence and which is revealed as wholly implausible when tested against the known facts.”

Sir Michael Graydon
Chief of the Air Staff 1992-1997
Sir Richard Johns
Chief of the Air Staff 1997-2000
Sir Peter Squire
Chief of the Air Staff 2000-2003
Sir Glenn Torpy
Chief of the Air Staff 2006-2009
Sir Michael Alcock
Chief Engineer (RAF) 1994-1999
London W1

It is likely that the Philip review came under pressure from the MoD and the RAF not to question the finding of gross negligence. The fact remains, though, that nobody knows the cause of the crash. It could have been pilot error. It could have been a chain of events that had little or nothing to do with pilot error. Indeed the AAIB investigation of equipment recovered from the wreckage revealed several anomalies that were never explained.

That said Tony Cable noted that there was little evidence to be gleaned from the investigation. Cable told a House of Lords select committee on 7 November 2001: “Throughout this investigation the evidence was remarkably thin, from my point of view, I must say”.

What could have caused the crash?

There were many potential causes of the loss of ZD576. What can be said with certainty is that we don’t know why it happened, or the events that preceded it.

One of the lessons is that “evidence” from aircraft manufacturers and their subcontractors should be treated with the same scepticism as speculation about the actions of the pilots. After the crash of ZD576, the main attention of the RAF and the MoD was on the possible actions of the pilots, not on the possible behaviour of the aircraft.

Nobody in the RAF hierarchy questioned the fact that most of the allegations against the pilots were made on the basis of manufacturers’ “evidence”. If that evidence is set aside as lacking impartiality, and indeed the AAIB does not confirm the accuracy of that evidence, there is no basis even for speculation about the actions of the pilots.

One of the things the campaign for justice has shown is that the RAF hierarchy took a circumscribed investigation of equipment found in the wreckage as the basis for a case against the pilots.

Black boxes found in the debris of civil airliners are sometimes transported under armed guard to independent investigators. Manufacturers are not always allowed to look at their equipment until it has been studied independently. Yet in the case of ZD576 manufacturers’ evidence has been taken as the whole truth. An Mod lawyer at the ZD576 Fatal Accident Inquiry in Scotland in 1996 sought to persuade the Sheriff that the manufacturer’s evidence was “hard fact”.

To my knowledge there has never been an investigation by the National Transportation Safety Board, the US equivalent of the AAIB, in which uncorroborated, unchecked evidence from aircraft manufacturers been taken as hard fact.

Today, the lack of understanding at the top of the RAF over how much information is needed after crashes of civil airliners to establish the likely chain of events may help to explain why air marshals still blame the pilots of ZD576.

In their eyes, the lack of evidence of serious technical malfunction appears to mean that the pilots were in control of the aircraft. Such a simplistic assumption would not be made in a full civil aircraft crash investigation.

Justice has now prevailed thanks to the Cameron government, supported by Sir Menzies “Ming” Campbell, Martin O’Neill, and numerous other parliamentarians including Lord ChalfontJames ArbuthnotDavid Davis and Frank Field . There are too many other campaigners to name, though I make exceptions with Hooman Bassirian, Karl Schneider and Mike Simons who, at Computer Weekly, were willing to shape and publish innumerable stories in support of the Chinook campaign. David Harrison, a freelance producer  at Channel 4  News, which has covered developments since the day of the crash, first alerted me to the flaws in the Chinook Mk2’s Fadec.  Most of the documents relevant to the crash came to me from the Tapper family.

Air marshals will never accept that the pilots were not to blame. But that’s a hallmark of institutional disasters: once a decision is taken on the main cause that decision will be supported and stuck to whatever the facts. Thank goodness the Philip review, when it came to its investigation, had an open mind.

**

The campaign for justice for the pilots of Chinook ZD576 – Brian Dixon’s website

PPrune – hundreds of online pages of thoughtful discussion on the crash.

RAF Justice – how the RAF covered up problems with the Chinook Mk2’s Fadec.

Chinook ZD576 – report by Michael Powers QC.

Macdonald report on the crash of ZD576 – by three fellows of the Royal Aeronautical Society.

Flawed Chinook software updated after crash of ZD576.

The Chinook Fadec in-depth – by Malcolm Perks, another of the campaigners