§ 2.5 p.m.
§ Lord Chalfont rose to ask Her Majesty's Government whether they will review the findings of the RAF Board of Inquiry into the accident involving Chinook helicopter ZD576 in June 1994.543
§ The noble Lord said: My Lords, I rise to ask the Question standing in my name on the Order Paper. Before explaining the background, perhaps I may offer a warm welcome to the noble Lord on his first appearance at this Dispatch Box as Minister of State. This is, of course, not his first tour of duty as a Minister, and he brings to this House a formidable fund of knowledge of defence matters.
§ More than 30 years ago I made my own maiden speech in your Lordships' House from the same Dispatch Box as a Minister of State but then without the political experience of the noble Lord. I welcome his appointment in the confidence that we shall receive from him the same consideration and courtesy as we were accustomed to receive from his predecessor, the noble Earl, as a Minister in the previous Government.
§ In that context perhaps I may say at once that I ask this question in no confrontational or contentious spirit. It is an attempt to clarify a matter which has been a mystery to me for some time, and, as it became clear from a recent, and quite remarkable television programme on the subject, has been a mystery to many other people as well.
§ The story which lies behind this question begins on 2nd June 1994, when a Chinook helicopter of the Royal Air Force crashed on the Mull of Kintyre in Scotland on a flight from Northern Ireland. It was carrying 25 passengers, most of them senior members of the British Intelligence Services, and it was manned by a crew of four—two pilots and two loadmasters, all from the Royal Air Force Special Forces. All 29 people on board were killed in that accident.
§ After a year of investigations into the crash, a Royal Air Force board of inquiry concluded that the two pilots—Flight Lieutenant Tapper, the captain, and Flight Lieutenant Cook, the co-pilot—had been guilty of gross negligence and that that negligence was to blame for the disaster. My purpose in raising this issue now is to suggest that to the families of the two pilots, and to many knowledgeable people both inside and outside the Royal Air Force, that verdict constituted a grave injustice to the two young pilots.
The important point of departure in this analysis, and one that one must keep in the front of one's mind throughout any consideration of it, is the apparently unambiguous guidance issued by the Royal Air Force relevant to accident investigations of this kind. With the leave of the House I shall quote it verbatim, because it is important. It states:
only in cases in which there is absolutely no doubt whatsoever should deceased air crew he found negligent".
§ The simple and fundamental question is: was there in this case absolutely no doubt whatsoever about the cause of the accident?
§ For me it is the only question. Speculation about aircraft serviceability, inadequate equipment, even the dark possibility of intelligence-related cover-ups and sabotage is entirely unsubstantiated. But it can also be argued that negligence on the part of the pilots is equally unsubstantiated and the history of this episode 544 demonstrates clearly why there is a widespread belief that this was not a case in which there was "absolutely no doubt whatsoever".
Let me go briefly through the sequence of events. In the first place the initial findings of the president of the very thorough and comprehensive Royal Air Force board of inquiry contained the following conclusions:
There were many potential causes of the accident and, despite detailed and in depth analysis, the Board was unable to determine a definite cause".
With regard to Flight Lieutenant Tapper, the board's findings were:
it would be incorrect to criticise him for human failings based on the available evidence":
and on Flight Lieutenant Cook,
The board concluded that there were no human failings with respect to Flight Lieutenant Cook".
The officer commanding Royal Air Force Odiham, the parent station in this case, reviewing these findings, referred to a possible failure to ensure the safety of the aircraft, but observed:
In assessing human failings, the evidence is insufficient to he specific".
And the station commander RAF Aldergrove, the station from which the flight originated, noted:
I am impressed by the meticulous and detailed examination of events which the Board has provided. However, I believe that the exact train of events can never be determined with absolute certainty".
§ So far, so good—all the opinions and evidence indicating that up to this point the Royal Air Force view, the view of the board of inquiry and two station commanders, was that this was certainly not a case of "absolutely no doubt whatsoever".
However, in reviewing the proceedings of the board of inquiry, Air Vice-Marshal Day, the air officer commanding No. 1 Group, interpreted the same evidence differently, coming to the conclusion that Flight Lieutenant Tapper and Flight Lieutenant Cook were both,
negligent to a gross degree";
and Air Chief Marshal Sir William Wratten, at that time the Air Officer Commanding-in-Chief Strike Command, although conceding in his review—this is a very important qualification made by the air chief marshal—that:
there is inevitably a degree of speculation as to the precise detail of the sequence of events in the minutes and seconds immediately prior to impact",
nevertheless concluded that:
the actions of the two pilots were the direct cause of this crash. I also conclude that this amounted to gross negligence".
§ It is important to be clear that these two senior and experienced reviewing officers had every right to disagree with the opinion of the president of the board of inquiry, as they are an integral part of the whole inquiry procedure. It is not over until they have concluded their review.
§ I have been able to discuss this issue with both these senior officers. They are clearly both men of great experience and total professional integrity, who would not do anything which they did not believe to be fair 545 and in the interests of the service. However, the families of the two pilots, among many others, find it difficult to understand, in the light of the opinion of the president of the board of inquiry and the other officers concerned, how they could possibly have come to a conclusion that there was "absolutely no doubt whatsoever" about the cause of the accident.
Their judgment was delivered in April 1995. But they were not the last words on the subject. Because the accident took place in Scotland, early in 1996 a fatal accident inquiry was held under a civil judge, Sheriff Sir Stephen Young who is a distinguished legal figure. After hearing all the evidence, including that of the president of the Royal Air Force board of inquiry, the sheriff came to the conclusion that there was no proof that the pilots were to blame. I quote a crucial passage from the judge's determination:
I have found myself unable to accept the conclusion reached by …the [RAF] board of inquiry…It may then be asked what was the cause of the accident. For my part, I can only say that I do not know …in the absence of any evidence from eyewitnesses aboard the aircraft or of information that might have been recorded from a cockpit voice recorder or an accident data recorder, I do not think any useful purpose would he served by my speculating further on the matter".
§ It seems to me that in the light of all that it must be a matter for grave concern that two young officers of the Royal Air Force Special Forces, officers with exemplary records and considerable flying experience, should be found guilty of gross negligence and held entirely responsible for a disaster of this magnitude when two thorough and comprehensive inquiries—one military and one civilian—have clearly been unable to identify beyond doubt the cause of the accident. It is impossible to imagine a more terrible indictment of two professional service officers than that they have brought about by gross negligence their own deaths and the deaths of 27 other people, not to mention the total destruction of the aircraft which was under their command.
§ Apart from the appalling impact of that on the families of the young men, the episode must inevitably involve the jealously guarded honour of the Armed Forces. It seems to me that there would be nothing dishonourable in now conceding that the verdict of gross negligence was severe and unjust, however honestly and sincerely it might have been reached.
§ When the television film was made—and it was a quite remarkable documentary film—the Ministry of Defence complained subsequently to the programme makers that the Royal Air Force side of the case had not been adequately represented. In concluding, I express the hope that if the Question today does nothing else, it will provide the Minister with an opportunity to repair that alleged omission and to explain precisely why, in the absence of evidence and in the absence of a situation where there was no doubt whatsoever, these young men were found guilty of gross negligence. I hope too that the Minister will be able to go further and agree to review the whole matter in the expectation that it might be possible to restore the reputations of two young officers and bring at least some comfort to their families.546
§ 2.17 p.m.
§ Lord Craig of Radley
My Lords, let me say at the outset that I warmly welcome the Minister to his new position in this House and hope that his past considerable experience in the Ministry of Defence will make it easy for him to hit the ground running.
I speak to this Question with a great deal of reluctance. I am not aware that there is any new evidence or information which is relevant to the cause of the tragedy. Of course, if there were, then it could be a reason to re-open the inquiry. I assume that there is not and that the Minister will confirm it when he speaks.
My reluctance arises because to discuss this tragic event yet again may be distressing for relatives of many of the 29 who were killed three years ago on 2nd June 1994. I hope most sincerely that what I say will not add to that distress. However, as noble Lords will appreciate, I know a great deal about Royal Air Force boards of inquiry, their importance and the way in which they are carried out.
The two senior officers and others involved with the inquiry are well known to me. I have not read the full report of the board but I have on a number of occasions discussed the contents and findings with Air Chief Marshal Wratten, Air Marshal Day and others. I have absolute confidence in the integrity of those officers, but what I say is entirely my own view.
The noble Lord, Lord Chalfont, has spoken to the Question in his admirably lucid and cogent way. I listened to his speech with the closest attention, which it fully deserves. The nub of his call for a review is where he asks whether there is absolutely no doubt whatsoever about the cause of the accident.
The civil Air Accident Investigation Branch—the same organisation which established the cause of the Lockerbie accident and many others of extreme complexity—was able to rule out categorically any structural or technical malfunction. Sabotage and terrorism were also ruled out. The Chinook was climbing close to its maximum forward speed and the navigational equipment was functioning up to the point of impact. That the Air Accident Investigation Branch, with help from the manufacturers, could establish so much factual evidence from the wreckage not only points to their expertise; it has an important bearing on the findings.
To my mind, the key question is not: what may have happened on board the Chinook in the remaining seconds before it crashed? The question to ask is: why was it advancing in poor visibility below a safe altitude? Why was the Chinook being flown in that way? Noble Lords will note that I refer to "the Chinook" and not to "the aircraft". A Chinook, any helicopter, has much greater freedom of manoeuvre in the air than a fixed wing aircraft, which must keep moving forward to remain airborne.
Until shortly before it reached the cloud covered Mull, the Chinook was flying in clear conditions. The pilots were in visual contact with the sea, a few hundred feet below them. If the Mull had been clear of cloud and they could have flown over or around it while relying on visual references to fly safely, they could have 547 maintained their planned route at low level to Scotland. If, however, cloud or poor visibility on their planned route precluded reliance on visual references, there were two options to ensure the safety of the Chinook and its passengers. Both would be covered by flying orders well known to the pilots.
One option would be to alter course, even to retrace their route, to maintain that visual contact with the surface and separation from poor weather. The other would be to put the Chinook into a maximum rate climb, to attain a safe height. But the evidence is that the flying pilot and the other, whose responsibility it was to monitor the actions of his colleague, did neither. The Chinook hit the side of the Mull below 1,000 feet.
If they had been inexperienced air crew, unfamiliar with the route that they were flying, perhaps misled by a more favourable weather forecast than the actual conditions, their action might be classed as an error of judgment. But the pilots were both highly experienced on Chinooks. They had more than a normal responsibility of care because they were carrying passengers. They were qualified and trusted to adhere to the highest professional standards of flight safety and airmanship at all times. The safety of their Chinook and passengers was their top priority.
For the purpose of a board of inquiry finding, negligence is defined as:The doing of something which in the circumstances a reasonable person would not do or do differently".It is not reasonable to put at risk your aircraft and the lives of all on board. It must be dreadfully distressing to some of the many concerned with this tragedy that the view the senior officers recorded was that the two pilots displayed, perhaps even for a short moment of time, such negligence of their responsibilities.
Noble Lords will appreciate that these views are reached only after considerable work and study of all the evidence by experts at headquarters. The views recorded will have been guided by that painstaking study. In other words, we see the result of many minds and experts in the operation of aircraft being brought to hear in reaching these findings.
I fear that it is a feature of aviation, both Service and civil, and throughout the world, that pilots, being human, can make mistakes. One of the most insidious is to be tempted to continue in deteriorating conditions, believing that they may be transitory, or that there is no danger, even though one is in cloud. Too many aviators have found to their cost that not all clouds have soft centres. The temptation to behave unreasonably in poor weather is not confined to aviators. Winter after winter there are motorists driving too fast in fog who meet untimely deaths.
I learnt a terrifying lesson about that hazard early in my own flying career. I was on my third or fourth solo flight; I was drug-high on excitement; on a sense of achievement; on the freedom of flying by myself. What could be more exhilarating for a young man, 10 to 15 minutes after takeoff, than to be skimming just along the tops of the clouds, weaving in and out of the hills and valleys that they made with the sun streaming down 548 on this brilliantly white, cotton wool world? As I clipped the top of one of the higher cloud hills I was confronted by the crown of a large tree sticking out from the top of my cloud. I pulled up hard to safety from a height which I afterwards realised could have been less than 50 feet from the ground. My rolling cloud-land was the top of a fog bank over the Lincolnshire fens.
Flying is a seductive mistress. Constant training, strict professionalism and obedience to flight safety rules must never be relaxed if aircraft and their occupants are not to feature in yet another accident. We learn not only from our own mistakes, but also from the behaviour of others. Boards of inquiry are expected to identify actions to minimise the risk of recurrence. If the lessons sink in, maybe another death, another accident will be avoided.
Adverse board of inquiry findings, so sad, even tough when key individuals are not there to explain or account for their actions, play a part in flight safety. Others will learn about the ever-present danger in the air if, even for a moment, awareness and anticipation lapse. I hope that the lessons from the tragic event on the Mull of Kintyre will serve to save the lives of others.
§ 2.27 p.m.
§ Baroness Park of Monmouth
My Lords, I warmly support the action of the noble Lord, Lord Chalfont, in raising this very serious Question in this House. At a time when the services are threatened by yet another defence review and the cuts that reviews have so far inevitably brought, service morale must be at a low ebb. I am sure therefore that the new Minister—I warmly welcome him to the House, though he has a hard act to follow; we have been admirably served, as have the services, by his predecessor—will recognise the importance of reviewing the matter.
I have two concerns. The first is that there was no cockpit voice recorder or accident data recorder on the aircraft. I believe that plans are in hand to install those in the future and that the reason they were not there was because of expense. I hope it will be recognised by the MoD that such an expense is more than justified when it comes to establishing the true cause of this and possibly other accidents.
My other concern is: what did cause the accident? I speak with some diffidence after the noble and gallant Lord's cogent speech, but I shall persevere. We do not know that there was inadequate equipment or maintenance; we do not know that there was not. I believe that in pursuit of market testing and the overriding objective of saving money, too much contractorisation, coupled perhaps with understaffed and possibly inadequately trained and experienced quality control and maintenance staff, are putting the lives of pilots as well as their valuable aircraft at risk. I believe that that could be an underlying cause of what happened.
In 1993 16 Tornado aircraft had to be withdrawn from service because of serious damage they had sustained when they were being modified by a private firm, Airwork, which won the contract against British Aerospace (which had the proper skills) because the Airwork bid was the lowest. Those aircraft cost, I believe, roughly £25 million each. The loss of the 549 highly trained pilot in any accident sustained by such aircraft must carry a heavy financial loss also, if we are to speak, as we are constantly required to do, in terms of money alone. Yet Airwork was allowed to certify its own work as properly done, and was paid for it. Only a routine inspection of undercarriages at RAF Leeming before a Tornado squadron flew to Bosnia revealed the very serious damage done, damage that undoubtedly constituted a threat of several fatal accidents. I cannot forget that, to quote from co1.183 of Hansard of another place of 20th July 1993:Huge quantities of aircraft polyfilla, known as thyokol, had been used to cover up the damage".The defence committee subsequently established that accidents would have occurred and lives would have been lost if those aircraft had flown. Indeed, one of them, even after the damage had presumably been corrected, crashed into the sea on a test flight. It seems unbelievable that, after its performance with the Tornados, Airwork was given the contract to modify the almost equally valuable Hercules aircraft and managed to damage 11 of these before quality inspectors discovered what was happening. According to page 21 of the report on market testing,Airwork had underestimated the complexity of the task, failed to provide adequate staffing in terms of numbers and skills, and finally failed to highlight technical problems when they arose".Even after that, a full rectification programme was initiated by Airwork. It had another go at those 11 aircraft and then was sent some more. In both the Tornado and Hercules contracts the MoD expected, we are told, to get financially recompensed eventually, and,no long term airworthiness implications for the Hercules fleet as a result of the damage were expected".I share the amazement of the defence committee that the MoD accepted back the eight Tornado aircraft which Airwork returned, and paid for the work without any inspection, so that the very serious damage was discovered only because an RAF technician was alert.
The reason I have spoken at some length about these two cases—my noble friend Lord Howe will know that I have raised the subject of Airwork before but I make no apology for that—is that I believe that the MoD's commitment, in pursuit of previous government policy laid down for it, to saving money and contractorising has very dangerous long-term implications both for the safety of the aircraft and the crews. Are too many corners being cut in the sacred name of value for money?
One would have thought, incidentally, that the Tornado and the Hercules experiences should have demonstrated that money is not being saved, since 18 Tornados costing £25 million each, and 11 Hercules which can scarcely be cheap, were out of action for years. Could the cause of this accident, therefore, have indeed been in some way the result of poor maintenance, inadequate training, pressure on inadequate staff, the financial pressures of the budget and the competing-for-quality programme, and too severe cuts in service manpower at the support end? All these things are not only dangerous but deeply destructive of morale. Is the remorseless reduction of skilled in-house 550 manpower leading to a failure to communicate at an inter-service level, moreover, between under-staffed, overworked maintenance teams?
One of the private contractors working in the military field said in written evidence to the defence committee:We believe that a range and depth of what are broadly classified as the Services support functions must remain in uniformed hands, under the direct control of the military. Too extensive a transfer of such tasks to the private sector would inevitably impact adversely on the ability of the Armed Forces to react in a timely and effective manner to the challenges of the post-Cold War world. It must he recognised that if, through the excessive pursuit of contractor-isation in the interests of cost-saving, the size and capability of the uniformed support services are less than is required for the effective support of front line forces, not only will it adversely affect their capability hut it could and probably would also be prejudicial to the very concept of contractor-isation of military support services".It would be difficult to improve on that very prescient statement.
I am sure the RAF will have made the most exhaustive inquiry into the previous history of the Chinook—whether, when and by whom it was modified and serviced, and whether the pilots would have been fully aware of any modification. Yet only one failure to check a piece of equipment with the proper rigour, somewhere along the line, could surely have been enough to explain this accident.
I cannot but feel that somewhere along the line a weak link developed, for I share the view of the noble Lord, Lord Chalfont, and that of the RAF Board of Inquiry, and the civil inquiry, that not one but two experienced pilots surely could not have been guilty of the "gross" negligence which has been attributed to them. I believe that we should be concerned not only, and rightly, for the good name of two young men now dead, but that we should pursue this matter in the interests of those pilots who are still flying in what may be unacceptably dangerous conditions. I hope very much that the Minister will be able to pursue this matter effectively.
§ 2.35 p.m.
§ Viscount Simon
My Lords, I am somewhat daunted at the prospect of following the noble and gallant Lord, Lord Craig of Radley, and the noble Baroness, Lady Park. In contrast to them I shall seem somewhat lightweight. However, having listened to them, does not alter that which I wish to say, nor does it alter my belief that what might have been a questionable decision should be looked at again. I promise to be brief.
Before proceeding further I should mention that I used to work with Flight Lieutenant Tapper's father some 25 or so years ago and, I suppose, this could possibly be construed as a form of declarable interest.
On the basis of the information which I have been given and elicited following the crash, it seems to me that the finding of gross negligence against the pilots is, to say the least, suspect. However, without having access to all of the papers, it is difficult to be specific about the finding of the RAF's board of inquiry being unjust. I do, however, have a two-page summary published by the Ministry of Defence. It is not very helpful, but it does indicate that most possible causes of 551 the accident were eliminated. Notwithstanding that, its sole observation on the weather is that conditions were bad with poor visibility and low cloud. Did the inquiry exclude the possibility of katabatic winds being present? Whilst this is not very likely, if they were present, could not the handling characteristics of a Chinook aircraft have been affected? I have no way of knowing as I have no access to papers other than the summary. The Minister, whom I welcome to your Lordships' House and congratulate on his appointment, will no doubt make appropriate observations.
Not all aircraft of the RAF contain voice and data recorders. In the case of Chinooks, however, much data can be extracted from alternative sources in accidents. But we will never know what words passed between the pilots, which would, in all probability, have been helpful to the inquiry. Both accident and voice data recorders are being fitted to Chinooks before the end of 1998. It would be interesting to know whether this was planned before or after ZD576 crashed.
I make no apology for repeating part of that previously mentioned by the noble Lord, Lord Chalfont. There is doubt written in large letters, underlined and highlighted in those extracts of reports which I have received. And that includes an extract from the review of the RAF board of inquiry by Air Vice-Marshal Day where he used the words, "a degree of speculation". Part of the dictionary definition of the word "speculation" is "theory or conjecture about". I wonder if Air Vice-Marshal Day in using those words, really had doubts as to the actual cause of this crash. His use of these words leads me to speculate that this is possible, but I only speculate because I do not really know. If he did have doubts and thereby joins the throng of those who also have doubts, then the finding of gross negligence against these two experienced aviators must be reviewed. Such a finding can only be given when there is no doubt whatsoever.
§ 2.39 p.m.
§ Lord Quirk
My Lords, I am sadly lacking in the expert knowledge of previous speakers such as in particular the noble and gallant Lord who has such a noble and gallant record of service in the RAF. But I am distressed precisely by how very much is unknown and unknowable about this disaster.
So for the past three years the family and friends of two RAF officers have endured a double burden: the grief of their personal loss and their grievous inability to understand the posthumous conviction of their loved ones. In calling for a review, the noble Lord, Lord Chalfont, deserves the gratitude of everyone concerned with air accident investigation where—so often—crucial and convincing evidence is inevitably lacking.
I served with RAF Bomber Command for five years and witnessed some terrible disasters at close quarters. It was not unusual for a court of inquiry to conclude that the cause was pilot error. But I do not recall a single instance in which that error was damned as so culpable as to call for the verdict of "gross negligence".
552 Of one such crash, I have especially vivid, cruelly indelible memories, nightmare-inducing even after more than half a century. A bomber returned to base from a mission over Germany, badly disabled by enemy fire. After circling for some time in obvious difficulty, the aircraft landed with undercarriage incompletely lowered. It burst into flames, with the screaming aircrew unable to escape the inferno, except for one who was thrown out as the fuselage split open. He died within minutes of quite horrendous injuries, but not before being heard to say, "The skipper panicked". I am glad to say that the court of inquiry disallowed the recording of that claim, because the witness was unhappily beyond giving evidence and because, even if the court had been satisfied with the authenticity of those dying words, his judgment on the pilot's state of mind might well have been affected by his own hideous injuries.
By contrast, in the case of the crash on the Mull of Kintyre, senior officers have been able to convince themselves that there was culpable negligence on the part of two officers. On the evidence that I for one have read—and even the additional evidence that I have heard today—the source of their certainty remains entirely unclear. I quote the passage already quoted by the noble Lord, Lord Chalfont:Only in cases in which there is absolutely no doubt whatsoever, should deceased air crew he found negligent".So reads the relevant RAF regulation. On what grounds was doubt removed so absolutely in this instance?
§ 2.42 p.m.
§ Lord Ackner
My Lords, your Lordships may have observed from the unamended list of speakers that I was down to speak in the debate on the report of the Science and Technology Committee. That was an error—no doubt due to gross negligence on my part. As far as your Lordships' House is concerned, it operates as a blessing in very small disguise because whereas noble Lords who are down to speak are limited to 12 minutes each, as I now fall within the gap I am limited to four minutes. I am obliged. Having to be brief will no doubt be a very good self-discipline.
I put down my name to speak to discover what was the material available for the finding which was ultimately made. I was devoid of any real specialised knowledge on this, save that I appeared for the Crown when I was at the Bar in the inquiry into the Vanguard air crash at Heathrow some 30-odd years ago. I am concerned about the onus of proof: "absolutely no doubt whatsoever" is apparently the test.
Via the Library, I managed to achieve a summary of what was in the full report. I was told that I could not see the full report because it was not available to the public. I noted that in the full report the very heavy onus is not referred to at all. The summary states:The Inquiry therefore concluded that the cause of the accident was that the two pilots had wrongly continued to fly towards the high ground",in a situation which it concluded was negligent.
That could probably have been the cause, and that might have been the basis of that decision. Perhaps it was "very probably" the cause, and that might have been 553 the basis of the decision, but in either of those two cases the onus has not been satisfied, and the conclusion reached would not be sustainable.
The criminal obligation of proving beyond reasonable doubt is involved in the phrase "absolutely no doubt whatsoever". In fact, it could be argued by the purist that that was an even higher level, because "no doubt whatsoever" must include an unreasonable doubt. But I do not put the matter as high as that, because I can see that there can be arguments to the contrary if you once let in a reasonable doubt. But the high degree of certainty should be reflected in the judgment which was given. If it was not reflected in the judgment that was given—I have only the summary to go on—then one is entitled to say that the board of inquiry did not apply the appropriate test.
I hope that when replying the Minister will devote some time to demonstrate to us to what extent the very high test in regard to the onus of proof is reflected in the decisions and is reflected, in particular, in the views of the two very senior officers who, on review, appear to have departed quite clearly from what was the initial finding.
§ 2.47 p.m.
My Lords, I apologise for speaking in the gap. I had considered speaking on this Unstarred Question but decided not to. However an issue has been raised which I felt that I could not ignore. We are discussing a depressing matter. I have a high regard for my noble friend Lady Park of Monmouth. We worked together on the all-party defence study group, but I must take issue with her views on the use of defence contractors.
When carrying out its own maintenance of equipment, whether aircraft, tanks or wheeled vehicles, the MoD has its own technical problems, but when the work is carried out in-house those technical problems are hushed up; they are kept quiet. When you use a commercial contractor, those problems become all too evident. My noble friend referred to the difficulties of obtaining recompense from a contractor. At least you can get recompense from a contractor, whereas when you do it yourself and make a mistake you cannot obtain any recompense from yourself.
Commercial airlines, especially the smaller ones, use third party maintenance facilities for necessary servicing and even major repairs on their aircraft. There may be maintenance problems in that situation, and there is commercial recompense when things go wrong. So I would caution against damning the use of contractors for maintaining MoD equipment. I hope that the Minister will say that the MoD will continue to use contractors where it is appropriate and where it gives best value for money and maximum safety for the users of the equipment.
§ 2.50 p.m.
§ Lord Fitt
My Lords, I rise for only a few moments to associate myself with the plea made by the noble Lord, Lord Chalfont, for a review of the Royal Air Force inquiry.
554 I come from Northern Ireland and I know many of the people involved. I knew the policemen. Since the event, I have been in almost daily or weekly contact with the widows of those who lost their lives. Whatever the clinical assessment which was made by the Royal Air Force inquiry, people in Northern Ireland, and particularly the widows and descendants, feel particularly bitter and aggrieved that the two young Air Force pilots are now being charged with responsibility for the deaths.
The tragedy had a devastating effect on the community in Northern Ireland. The whole security situation was called into question. But knowing the policemen who were killed in the crash, and knowing the widows and children of those who lost their lives, I am absolutely certain that it was not as a result of any act or overt mistake made by those pilots or the people on the plane.
I wish to put on record that whatever the clinical assessment from the point of view of the Royal Air Force, people in Northern Ireland will not believe that the two young pilots were guilty of negligence and of causing the deaths of their comrades.
§ 2.52 p.m.
My Lords, first, perhaps I may add my congratulations to the noble Lord, Lord Gilbert, and welcome him most warmly to his place on the Government Front Bench. He brings with him a wealth of experience from another place, including an in-depth knowledge of defence matters. It would therefore he difficult to imagine a more appropriate appointment. We wish him well in it during the months and years ahead.
We heard from the noble Lord, Lord Chalfont, the background to the Question that he has brought before the House. I am well aware that this tragic matter has occupied the noble Lord, others of your Lordships and, indeed, the wider public for a good many months. As someone who went into the facts of the case in a good deal of depth during my time at the Ministry of Defence, I feel qualified to offer a number of observations on it. However, naturally, it is the response of the Minister which must merit our chief attention.
I must say at the outset that I find myself in some difficulty with the decision of the noble Lord, Lord Chalfont, to bring this Question to the Floor of your Lordships' House. With all respect to him, I do not agree with that decision because I believe that there are ways of satisfying his concerns which do not risk further public hurt to the feelings of the families of the dead pilots and of the RAF. Furthermore, I am far from convinced that this kind of formal debate enables the Minister to place on the record all the necessary facts and arguments. However, I shall be happy to reconsider that view once I have heard what the Minister has to say.
I turn briefly to the substance of the Question. All along, the noble Lord's concern has been with the board's finding of gross negligence. With the evidence available to it, how could the board have been in absolutely no doubt that the accident was not attributable to other factors? If it is true that extraneous causes can be ruled out, how can the board have said with total confidence that this was not a case of pilot error?
555 In my experience, many people who ask those questions are under the impression that the board of inquiry was obliged to base its conclusions on an extremely thin body of evidence. The reality is very different. The evidence available to the board was not only clear but, in my view, it also pointed unambiguously to the conclusion which was reached. What the board had to do in the first instance was to examine thoroughly all possible causes of the accident. Through the Air Accidents Investigations Branch, it was able to confirm that both engines were functioning normally up to the point of impact and, I emphasise to my noble friend Lady Park, it was able to rule out categorically any structural or technical malfunction. Sabotage and hostile action were also eliminated as possible causes. In addition, the inquiry had the benefit of data downloaded from the aircraft's tactical air navigation system. From that information, it could derive an accurate picture of the Chinook's flight path. It was able to establish the fact that the aircraft was climbing; that it was travelling at a certain speed; and that the navigation equipment was functioning properly up to the point of impact. Having ruled out any mechanical or extraneous cause, the inquiry was left with only two possible conclusions: pilot error or pilot negligence.
Why did the inquiry reach the latter conclusion and not the former? To answer that, it is necessary to understand one thing and one thing above all; namely, the nature of the rules which governed that particular flight. Because of forecast weather conditions, the flight was carried out under visual flight rules, or VFR. Those rules state that a flight should be undertaken only within closely defined conditions of visibility and cloud clearance and at a safe height and speed.
Under VFR, it is the air crew who have prime responsibility for terrain avoidance so that, at low level, they must rely on actually seeing the ground and other external reference points to fly the aircraft. Nevertheless, the rules provide for a huge margin of error. They stipulate that an aircraft operating in limited visibility, which the Chinook was, must be at least 1,000 feet above the height of the highest obstacle. The highest point of the Mull is 1,463 feet. Therefore, the aircraft should have been flying at around 2,500 feet as it completed its transit of the Irish Sea. In fact, we know that 40 seconds before impact its height was between 200 and 400 feet. At 15 to 18 seconds before impact its height was approximately 460 feet. It crashed at a height of 812 feet. It is clear that, until the crew's emergency manoeuvre in the last few seconds of flight, the Chinook was at least 2,000 feet below the height at which it should have been flying. Incidentally, there were no atmospheric conditions or icing restrictions preventing it from flying at the correct altitude.
The VFR rules insist also that, as well as the minimum height requirement, the crew should also have not less than five kilometres of visibility. As the Chinook approached the Mull those conditions no longer obtained. The Mull was covered in cloud.
556 The crew should also have been flying at a safe speed. We know that the aircraft proceeded directly towards the Mull at a very high speed, slowing down only in the final few seconds, as it attempted its avoiding manoeuvre. On impact, the speed was 151 knots.
The board of inquiry, including the senior officers who reached the finding of gross negligence, asked themselves how it could have been that two experienced pilots could have broken the fundamental rules of VFR—safe height, safe speed in safe weather conditions. The members of the board were at a total loss to understand that. What the pilots did ran contrary to all the training they had received. It belied completely the professional standards of airmanship which they had attained.
As the noble and gallant Lord, Lord Craig, said, BOI regulations define negligence as:The doing of something which, in the circumstances, a reasonable person would not do or would do differently".The actions taken by the pilots led directly to the crash. The senior officers were in absolutely no doubt that this was not a case of excusable error; it was gross negligence.
There is a great deal which could be added to that inevitably brief summary. A lot of misleading, tendentious and erroneous things have been said about the matter in the press and on television. I should like to add only one thing. The integrity and the diligence of both senior officers whose duty it was to reach the board's finding—Air Vice-Marshal Day and Air Chief Marshal Wratten—are beyond question. They had expert evidence before them and they reached their verdict with scrupulous care and total honesty.
The sympathies of this House must go out to the families of the pilots and all those killed on that terrible day, nearly three years ago. However, in my opinion, there are absolutely no grounds on which a reopening of the investigation or of the inquiry would be justified.
§ 3 p.m.
§ The Minister of State, Ministry of Defence (Lord Gilbert)
My Lords, I understand that it is a very sensible tradition of your Lordships' House that maiden speeches should be non-controversial. It is my lugubrious fate today to have to break that tradition, although I am very glad to say, following on from the extremely helpful and lucid remarks of the noble Earl, Lord Howe, that the controversy does not exist between the two Front Benches with respect to this very sorry matter.
Before going into the speech that I had prepared for me today, I think it might be helpful if I were to address one or two points that other noble Lords have mentioned during the debate so that I can make quite sure that I have covered them. I believe that the noble Viscount, Lord Simon—and perhaps noble Lords will forgive me if I do not get everyone's name right to start with—raised the question of katabatic winds. The fact is that, at the time of the accident, the aircraft was flying with a 30-knot tailwind behind it and, when approaching 557 higher ground, that tailwind would actually have had the effect of lifting the aircraft rather than causing it to go into a precipitate descent.
The noble Baroness, Lady Park, asked whether or not there were cockpit voice recorders; there were not. However, I am happy to confirm that they are being installed in all Chinooks. I am not sure whether the programme is yet finished—indeed, I do not believe that it is—because the process is an on-going one. The noble Baroness, quite understandably, took the debate far wider than the Unstarred Question tabled in the name of the noble Lord, Lord Chalfont, and took us into the sphere of maintenance questions.
I am fully seized of the importance of the questions that the noble Baroness raised. It may be helpful for her to know that one of the very first instructions that I gave to officials when re-entering the Ministry of Defence was that I was unhappy that we had the balance between the acquisition of weapons systems and platforms on the one hand, and spares and maintenance, on the other, correct and that I wanted to give that the single highest priority during my time of office however long or short that may be. I hope that that gives some reassurance to the noble Baroness.
The noble Baroness asked about the possibility of there being an equipment failure. All the evidence is that there was not an equipment failure. But even if we were to assume that the people who in good faith undertook the investigations—and I shall deal with them in some detail in a moment—made an error and there was such a failure, the fact remains that that aircraft should not have been where it was. That is why I turn for support to the admirably eloquent speech of the noble and gallant Lord, Lord Craig, who, to my mind and distinction, if the noble Lord, Lord Chalfont, will forgive, did ask the crucial question. That question is not: was there no doubt whatsoever as to why the pilots were there? The question is: why was the aircraft being flown in that way at that time? Because there seems to be no doubt whatsoever as to where it was and the weather conditions at the time, the verdict of negligence is one which, very sadly, it is impossible to resist.
The tragic accident that we have been discussing today saw the loss of 29 lives of very loyal servants of the Crown who died suddenly and without warning in the course of their duties. As we have heard, not only did the events of that evening cast a very long shadow, they also brutally disrupted the lives of the many families that lost a loved one and seriously affected all those who had to try to deal with the consequences.
Perhaps I may say at the outset that I personally have the greatest sympathy with the families of the two pilots. I fully understand their desire to overturn in some way or other the apparently harsh verdict of the Board of Inquiry of the Royal Air Force. I also fully understand the incomprehension expressed by the noble Lord, Lord Fitt, which is felt by many that these two brave young men, trained and competent as they were to fly the most hazardous of helicopter missions for the RAF, could have been responsible for the deaths of so many people on what was, after all, a routine transport flight. I understand therefore the incredulity of all those who, 558 knowing these two men, believed that there must be some other explanation of the events of that day. However, I must say to noble Lords that the facts must be allowed to speak for themselves. These are the facts that were available to Air Vice-Marshal Day and Air Chief Marshal Wratten who, in the proper exercise of their discretion, reached their considered conclusions.
I wish to emphasise that the Royal Air Force's investigation into this accident was carried out not only by RAF experts but also by civilian specialists from the Air Accidents Investigation Branch. They had unstinting assistance from the manufacturers both of the aircraft and of its systems. The investigation was scrupulously thorough and exhaustive. It found no evidence whatever of structural or technical malfunction, nor of any hostile action and concluded that the accident had been caused by the action of the two pilots who had continued to fly their aircraft towards the Mull of Kintyre at high speed at an unsafe altitude in extremely bad weather. I pray in aid here the remarks of the noble and gallant Lord, Lord Craig, as to how seductive it can often be to fly an aircraft into conditions of danger. That unfortunately is something that one sees all too frequently in the civilian as well as the military field.
It was the view of the senior officers responsible for this inquiry, and consequently it was the overall finding of the inquiry, that the pilots in handling their aircraft in this way had not exercised the skill, care or judgment that they were known to possess, and that their actions regrettably but unmistakably constituted a breach in their duty of care to a degree that amounted to gross negligence. Negligence is not a word which the Royal Air Force uses lightly. But it is important that whenever possible the causes of accidents are clearly established so that the necessary lessons are learnt and the risks of such accidents happening again are minimised.
Much has been made in the media—and mention has been made today—of the so-called difference of opinion between the president of the board of inquiry and his senior officers and that aspect of this sad affair, as I say, has been touched on this afternoon. I think therefore it is necessary that I make it clear to the House that the assessments by the convening officer and his commander in chief are an integral part of the inquiry and are a way of bringing to bear not only the wide range of skills and expertise of their specialist staffs, but also their own considerable personal experience of the service and of flying standards. In the case of this crash the president of the board concluded that the accident was caused by the pilots selecting an inappropriate rate of climb.
Some may feel—and I would agree—that this was not an illuminating conclusion. The station commander at RAF Odiham went further, concluding with regret that the pilots had failed in their duty. It was left to Air Marshals Day and Wratten as the most senior officers involved in the inquiry to assess what that failure amounted to. They concluded sadly and with great reluctance that it amounted to gross negligence. Both these senior officers are men of the highest integrity. They would clearly have very much preferred to have found some other explanation as to what caused this accident. However, all the evidence, and not just some 559 of it, pointed in the same direction. It was the Air Marshals' duty to reach an honest conclusion upon the evidence and that is what they did.
I shall now turn to the evidence. It is well known that the weather in the vicinity of the Mull is often foggy and affected by low cloud. On the day in question the crew received an accurate weather forecast indicating suitable conditions for the flight which was intended to run from RAF Aldergrove to Inverness. However, the forecast included a warning that there would be a risk of poor conditions affecting the area of the Mull of Kintyre. This would have required a bad weather contingency plan. The pilots, in their proper discretion, elected to carry out the flight under visual flight rules which stipulate that a flight should only be undertaken within clearly defined weather conditions, as set out by the noble Earl. I shall not repeat them in detail. They are defined in terms of visibility and cloud clearance, at a safe height and speed. At low level, air crew rely upon seeing the ground and other external references to fly the aircraft. Electronic navigation aids can be and are used but these are secondary. At all times the pilot flying under visual flight rules must remain in visual contact with the ground. The highest point of the Mull of Kintyre is 1,463 feet above sea level. Instrument flight rules stipulate that an aircraft must be at least 1,000 feet above the height of the highest obstacle along the intended track if the crew is not in visual contact with the ground.
On this particular day the transit across the Irish Sea was uneventful and conducted in clear conditions. But, as forecast, there was a very low cloud base and poor visibility over the Mull. We know from an eye witness that at a distance of about two nautical miles from the Mull or approximately 40 seconds from impact, the aircraft was flying at a height estimated at between 200 feet and 400 feet.
From this your Lordships will understand that the aircraft was approaching the Mull of Kintyre at least 2,000 feet below the height at which it should have been in order to clear the Mull under instrument flight rules. It was travelling at a high speed, climbing only gently until the final few seconds. The question is, why? There were two alternative courses that the crew could have taken. About 20 seconds before impact, the crew selected a way point change, releasing the on-board computer from its fix on the Mull of Kintyre and locking on to Corran, 87 miles to the north. At this way point change, or preferably earlier, the crew could have turned to the left, away from the Mull, and gradually started to climb. Alternatively, the crew could have slowed down and devoted full engine power to a rapid climb. The latter manoeuvre, known as a "low level abort" is a procedure which the handling pilot had recently practised. The crew could then have diverted or climbed and requested an air traffic service under instrument meterological conditions. Either of those courses of action would have been the proper response.
At 15 to 18 seconds before impact the helicopter's height was 468 feet; at 4½ seconds before impact the crew exercised an emergency manoeuvre and the 560 aircraft climbed about 150 feet in those final 4½ seconds. The aircraft crashed at a height of 812 feet at a ground speed of 151 knots.
Unfortunately, there was no cockpit voice recorder or accident data recorder to let us know precisely what happened in the cockpit in those final seconds of flight. So we turn to the aircraft's tactical air navigation system. This is a computer which continually updates the aircraft's position using two independent sources. Those are satellite transmissions from the global positioning system and a Doppler velocity sensor linked with the aircraft compass. I should explain that the tactical air navigation system, for navigational and system operating reasons, stores masses of data which are retained in its memory each time the computer powers down. The board of inquiry invited the manufacturer to extract all the data from the system and analyse it. The resultant report formed one of the many pieces of evidence considered by the inquiry.
While the manufacturer stated in this report that.The equipment is not designed to store historical data".the report also stated that,The analysis reveals that the tactical air navigation system and the navigation sensors to which it interfaces appear to have been performing perfectly at the time of loss of power".The inquiry used that, together with other statements in the report, to assist with its determination of the likely final flight path of the aircraft. The inquiry also used the Air Accident Investigation Board's technical reports and the Boeing flight path simulation, supported by the findings of a second flight path simulation carried out by the Defence Research Agency. From that mass of data the board of inquiry was able to derive an accurate picture of the Chinook's flight path.
Some have suggested that because there were restrictions on the MK2 Chinook relating to icing conditions the pilots had little freedom of manoeuvre. That was not so. Although the icing restriction would have been relevant for that part of the flight which took them over the Scottish Highlands, there was nothing that would have prevented the aircraft from climbing to a comfortable safety height over the Mull itself. The weather report known as the aftercast showed that at the time of the accident the MK2 Chinook icing limit occurred at a height of 5,000 feet above sea level.
Another theory in circulation has had it that the Chinook MK2 was rushed into service and that some technical fault might have caused the crash, or at least distracted the pilots from their safe operation of the aircraft. There is no evidence for that whatsoever. The aircraft conversion programme began in 1992 and the first aircraft was delivered to Boscombe Down in April 1993; the resulting Chinook MK2 release to service was signed on 22nd November 1993. At the time of the accident in the following June 1994 the aircraft was properly cleared for routine squadron flying and the transport task on the evening in question was well within its capabilities.
There have been reports that the aircraft had been grounded by test pilots at the Defence Test and Evaluation Organisation at Boscombe Down. Those reports should be seen in the context of the role of the 561 Defence Test and Evaluation Organisation. Test pilots fly an aircraft in order to extend its cleared envelope, beyond that which has already been cleared for use by Royal Air Force aircrew for routine squadron flying. Such testing to extend the cleared envelope stopped in April 1994 for a short period to allow a review of trials safety precautions. No change to procedures was needed. That is regarded as normal practice in trials planning. Test flying was stopped again in early June 1994 when specific information was requested from the aircraft and engine manufacturers on the engine control system. The trial then being planned was the icing trial for which partial blockage of the engine air inlet would be used to simulate the formation of ice. In such a situation a full understanding of any possible control malfunctions was vital. Once the information was received, trials continued with no changes to the aircraft and no additional operating limitations.
These suspensions of trials to extend the cleared flight envelope had no bearing whatsoever on the use of the aircraft by the Royal Air Force, which continued to operate it within the already cleared flight envelope. The transport task undertaken by Chinook ZD576 on the evening in question was well within its capabilities.
It has also been said that the pilots did not have a complete handbook for the aircraft. Again, that is not the case. In order that aircrew shall have the most up-to-date information it is normal practice to issue loose-leaf amendments, as they arise. All the limitations, including any amendments, were part of the release to service document, which was available to all aircrew. Both pilots were fully briefed and had signed as having read and understood the latest amendments to the release to service document. All the evidence is that ZD576 was fully serviceable when it crashed.
I turn now to the subject of the fatal accident inquiry. I must stress that this and the Royal Air Force board of inquiry were carried out for entirely different purposes. The Royal Air Force board of inquiry was carried out to ascertain the cause of the accident and identify what action was necessary to minimise the possibility of recurrence. The fatal accident inquiry, on the other hand, which took place some nine months after the findings of the Royal Air Force board of inquiry had been published, was convened to determine the cause of death, a much more restrictive term of reference. It is an essential part of the board of inquiry process that, where any human failings have been identified, they are clearly stated so that any necessary lessons can be passed on to personnel throughout the RAF. In the case of the fatal accident inquiry, the sheriff was not under such a remit and that he did not feel able to reach a verdict should not detract from the fact that a very thorough RAF investigation, carried out by experts with first-hand experience of flying Chinooks, concluded that the pilots were responsible.
The RAF inquiry has looked with scrupulous thoroughness at all the possible causes of this sad accident. The conclusion, from all the evidence, is that 562 the aircraft was flown at high speed, well below safety altitude in cloud, in instrument meteorological conditions, in direct contravention of the rules for flight under either visual flight rules or instrument flight rules. Various factors and scenarios have been postulated, including whether the pilots were distracted or disorientated, in attempts to explain why the crew might have failed to make a safe transition to instrument flight rules. The inquiry concluded that none of those hypotheses was so compelling that it would have been likely to prevent an experienced crew from maintaining safe flight. As the commander in chief himself commented, why the crew elected to ignore the safe options open to them and pursue the one imposing the ultimate danger, we shall never know.
In conclusion, I can only add once again my sympathy to all those who lost family or friends in the tragic crash of ZD576. I recognise very clearly the particular anguish felt by the families of the dead pilots but I am confident that the House will accept that the Royal Air Force has approached this case with honesty, frankness and great experience. It has provided and tested the facts as we know them, however unpalatable they sadly may be.
§ 3.23 p.m.
§ Lord Chalfont
My Lords, before the Minister sits down, perhaps I may claim the indulgence of the House to do one thing which might otherwise go by default. It is to congratulate the Minister on his maiden speech. It is rare that a maiden speech is made from the Front Bench in reply to an Unstarred Question and it would be sad if we allowed such a distinguished performance to go by without comment.
I cannot pretend that everything the Minister said has satisfied me nor that it will satisfy others concerned. I might also in passing remark with a sense of wonder on the total identity of view between the two Front Benches. I wonder whether it will continue for long.
I conclude by saying that I thought it was a remarkable performance which demonstrates the noble Lord's ability not only to master a complicated brief at enormous speed, but also the depth of his background knowledge of defence matters. I welcome his speech, I congratulate him on it and hope that we shall hear many similar performances from him.
§ Lord Gilbert
My Lords, by leave of the House—if that is the correct formula—I am grateful to the noble Lord, an old friend of mine, for saying that. I am happy at the coincidence of view between the two Front Benches on this sad matter, not because it relieves the Government of some potential embarrassment but because it has always been my view that defence questions in this country should be treated on a far less partisan basis than they often are in other places.
§ House adjourned for the Spring Bank Holiday Recess at twenty-four minutes past three o'clock.