Saturday, December 22, 2012

AN 'ACCIDENT' WAITING TO HAPPEN

There is a lot of comment floating around concerning the crash of Iroquois Black – the ANZAC Day flight where Black 2 (the No. 2 aircraft) crashed with only one survivor. Some of this is from politicians who should know better and some from members of the media interviewing their own word processors from a limited knowledge base. 
 
So, I have decided to give you my two-penny worth. I agree my aviation knowledge is limited; my log book records less than 1,000 hours as pilot-in-command in fixed wing aircraft (not helicopters). I am instrument rated qualified.    I have only limited night flying experience and virtually nil formation flying experience. But given all that there are some basic truths that most aviators can identify with no matter what their experience.

The first and most simple is that rarely it is a single error alone that causes an aircraft to crash. There will be a matrix of errors, each one taken taken in isolation and no big deal but collectively they spell disaster. The second is the truism that 'there are old pilots and bold pilots but there are very few old bold pilots'.

It is clear to me that both these apply in this case.

The Court of Inquiry (CoI) into the crash is a comprehensive document. It was peer reviewed by members of the Royal Australian Air Force Aviation Air Safety Directorate who reported that “the methodology used in the investigation is both thorough and systematic” and that the “CoI is adequately resourced in terms of both the numbers and competency of its members”. The Report identifies a large number of contributing factors to the crash. To my mind three stand out.

But before discussing those I want to highlight some matters in relation to Iroquois operations as these are important to understanding what happened. The CoI records in para 39 that “Iroquois pilots interviewed all stated a clear preference to avoid Instrument Flying (IF) in the Iroquois. The inherent instability of the aircraft, limited fuel capacity, lack of de-icing/anti-icing equipment and limited navigation equipment all add up to make flight under Instrument Flight Rules (IFR) very difficult to achieve safely. Consequently, most Squadron Operating Procedures (SOP) are designed to remain under Visual Flight Rules (VFR) and to avoid flight into Instrument Meteorological Conditions (IMC)”.

Coupled with this the Report in para 230 highlights the differing views concerning Night Vision Goggles (NVG) viz a viz IMC as seen by 3 Squadron (parent squadron of the Iroquois) in their training documentation and the United States Air Force in theirs ... I quote

  • 3 Squadron ... ‘Although not strictly an emergency, inadvertent IMC with NVGs is worth a mention. There are only a couple of points to stress as the procedure remains the same as for unaided inadvertent IMC recoveries.’
  • USAF ... ‘One of the most dangerous situations that can be experienced during NVG operations, and one with which students should be thoroughly familiar, is flight into undetected meteorological conditions. This has been and continues to be a real threat in all rotary wing communities, and has been implicated in several NVG related mishaps.’
Iroquois Black was a low level VFR, close formation transit, using NVG, flown by crews, some with only limited experience (see para 66), in marginal weather conditions.     It can be argued this task was pushing the envelope and deserving of close and detailed scrutiny.   The CoI records this was not the case.

I will now focus on what I consider to be the three main causes of the crash.

The failure to Pre-Position the Aircraft in Wellington

Para 47 of the CoI records that the ANZAC Day flypast was tasked by Headquarters Joint Force New Zealand (the organisation tasked with the control of all land, sea and air operations in New Zealand and o’seas) on 13 April and included the specific directive that the aircraft were to be pre-positioned in Wellington on 24 April.   For whatever reason or combination of reasons (and there were three advanced) 3 Squadron took it upon themselves to ignore the directive and instead opt for a night transit.
 
I find it disturbing that a junior headquarters felt it could override a directive of a senior headquarters. Others I have spoken to and whose opinions I respect immensely have commented on the breakdown of the principle of ‘Unity of Command’ i.e. a headquarters only answers to a single headquarters. The CoI comments on this in Para 284 which highlights the problems caused following the introduction of Project Refocus in 2001.   

Under Refocus 3 Squadron answered to two separate headquarters dependent on the task. The CoI records “Frustration in the system was apparent with witnesses describing the situation in 3 Squadron as like working under divorced parents, Mum is in Auckland and Dad is in Upper Hutt’.  

If the aircraft had been pre-positioned the night before as directed the ‘accident’ would not have occurred.
 

Route Planning and Authorisation

The CoI identifies many deficiencies the the planning and execution of the flight up until the moment the decision was made by the flight commander to turn back.   It highlights that at no stage was any consideration given to a high level transit which might have involved going IFR, presumably for the reasons advanced earlier, although it is worth noting in para 20 that Black 1 (the lead aircraft), after executing the so called escape turn, climbed back above cloud at 5,000 feet and was vectored onto a safe approach into Wellington airport by Air Traffic Control.   

Perhaps the decision to go low level is reflected in the ‘can do’ culture prevalent in 3 Squadron discussed at length in the CoI.  
   

But to my mind the main issue highlighted in para 100 was the disregard of DFFO 2.196 © which requires that “before authorising cross-country helicopter operations using night vision systems, the Flight Authorising Officer is to ensure that routes have been surveyed by day. An unsurveyed route must be flown above 500 feet MSD” i.e. above the highest point of ground.  

A route survey was not conducted and the route was authorised to be flown Not Inside (NI) 250 feet MSD.

The “Escape’ Turn

Iroquois Black tracked south along the Kapiti coastline with SH1 on their port (left) side.   Abeam Paekakariki the formation leader (Black 1), facing poor weather conditions, called the aircraft into tail formation (they had been flying Vic), in preparation for a return to Paraparaumu. He then ordered 180 degree port turn i.e. towards land.

There is a very good three-dimensional view of the flight path followed by the three aircraft at para 143 of the Report. Where I have a major difficulty is that drilled into me at flying birth (and all pilots) when flying a coastline route at low level and you need to execute a reverse turn you ALWAYS turn away from ground i.e. towards the sea.   

If Iroquois Black had done this there would have been no crash.

This is my take on the ‘accident’ with all the caveats that apply to a lay commentator.    Some of you will disagree, that is your privilege. It was a difficult post to write. I am a graduate of the RNZAF Command and Staff College. The airforce that I knew took pride in its professionalism.  I have many friends ex airforce. I know this incident has caused them great distress.   The RNZAF will learn from this.   They need to.
 

But I want to end with this.  The CoI comments on the ‘can do’ culture in 3 Squadron at the time. The military is steeped in a can do culture.   It part of the Westminster tradition.   When successive governments of all political persuasions cut defence spending (and cut it yet again) they inevitably trumpet that this will not impact on front end capability and the Chief of Defence and the Service Chiefs say yes sir and get on with it .... but it does in a myriad of ways    

Oh for the day when we have a military leader prepared to front up to the Prime Minister in full dress uniform and say this is all bullshit, enough is enough.   Order me to implement this and I will resign and tell the county why I am resigning. Now that is REAL leadership, not of the ersatz type ... but I doubt very much we will ever see a Service Chief with the balls to so act.
















3 comments:

LesterPK said...

Regarding your third point, the turn was made into the high ground because it gave a light source and outside reference point. NVGs dont work in no light, they still need some light source to amplify.

The Veteran said...

Lester ... I'm aware that was the rationale. My comment stands. You never turn into ground lest what happened, happens.

Anonymous said...

Veteran,
Your point about senior military officers not fronting up to politicians is very valid. I remember entertaining Lt General in the British Army visiting NZ. A distinguished soldier, he said all he wanted to do was not to rock the boat so that he could retire on the pension full General.
Richard