The Mull of Kintyre Accident

 

On 2nd June 1994, a low-flying RAF Chinook helicopter hit the cloud-covered Mull of Kintyre, a steep-sided promontory on the west coast of Scotland. I am familiar with those impressive slopes, having approached them in military helicopters flying low-level from the sea many times. This accident, in which the four crew and 25 passengers died, would have been tragic by any standard; but the fact that the passengers were all members of the Northern Ireland intelligence services meant that it was a body-blow to the intelligence-lead security operations in the Province. The story was always going to have legs, but what made it run for over sixteen years is that this is also a story about governance.
This Chinook was a new variant – an HC2. It incorporated a number of new design features that gave it war-fighting advantages over its predecessors. With British Forces committed in Iraq, and a high danger of escalation to other areas that did in fact materialise, the machine was needed.
Its introduction had not gone well. At one point it was reported that the test pilots at Boscombe Down, who were conducting the programme, had refused to fly it because they regarded it as dangerous in its present state. The full authority digital engine control system (FADEC) was known for misbehaviour. There were also un-commanded flight control movement issues. From a pilot’s point of view, there are few things that will spoil your trip faster than an aircraft that does something you didn’t ask it to do. Notwithstanding, the HC2 varient was released to squadron service. The accident occurred against this backdrop of tension between operational need, and safety.
The Board of Inquiry was convened, and carried out its duties according to the book. The book said “Only in cases in which there is absolutely no doubt whatsoever should deceased aircrew be found negligent.” This is both common sense and common justice. Dead men cannot defend themselves against the convenient conclusions of others. When the aircraft struck the ground, the impact was huge, spreading wreckage over a wide area. Some wreckage had been beyond recovery, and there had been a fireball. In the absence of a Cockpit Voice Recorder or a Flight Data Recorder it proved impossible to establish “with absolutely no doubt whatsoever” exactly what had happened on that day. The Board recorded that while there were several possibilities, they were unable to determine a definite cause. In such cases, under the RAF’s own regulations, it was not permissible to reach a finding that the accident had been caused by aircrew negligence; nor did the Board of Inquiry do so. But it is also RAF procedure that Inquiry findings be reviewed up the chain of command. In this process, which involved the commanders of two stations where the squadron was based, and two Air Marshals, that rule of evidence did not receive due regard, and the pilots were pronounced to have been grossly negligent.
This seemed to be the outcome of choice by the agents of ‘governance’, both at the time, and subsequently until September 2010. This includes governance of the RAF, governance of the Ministry of Defence, and the political governance of the day. Yet, whatever had caused the crash, the passage of time seemed to confirm that there had been a breach of procedure. There were no less than four further inquiries into the accident. In 2000 for instance, the House of Commons Public Accounts Committee confirmed that the introduction into squadron service of the Chinook HC2 had been flawed, and concluded that the standard of proof for gross negligence on the part of the pilots had not been met. Later on, a House of Lords Select Committee also concluded that the various reviewing officers had not been justified in attributing gross negligence to the pilots who died.
The agonised families of the pilots had never given up their struggle to clear their names, and in 2010 Dr Liam Fox, then Secretary of State for Defence, appointed a retired judge to review the evidence. The judge reached the conclusion that the original RAF Board of Inquiry had been correct in their conclusion that there was insufficient evidence to be certain as to the cause, and that, subsequently, the reviewing officers had allocated blame without taking the RAFs rules as to standards of proof in such cases properly into account. The findings of the judge were, at last, accepted by the government.
But why had this happened in the first place, and why had it taken so long to reverse? In the face of such a clear, unambiguous and stringent evidential requirement, it is hard to credit that no less than four senior RAF officers did not understand that a conclusion of gross negligence would not be permissible. It is even harder to credit that the Ministry of Defence in all its various forms, peopled over time by all those different officials, politicians and civil servants, could support a flawed judgement with such dogged persistence. But those involved, at the time and subsequently, refused review or re-consideration for nearly sixteen years, despite the anguish this caused the families through the destruction of the pilots’ reputations, not to mention the increasing damage this did to their own reputations.
What is credible is that the introduction of the Chinook HC2 would have been seen as an indispensible stiffening of the sinews of war. It may be that the larger significance of destroying the reputation of two pilots was that it preserved the reputation of a machine that was flawed. Other conclusions might have resulted in the aircraft’s introduction being indefinitely delayed, with a consequent diminution of operational capability.
If, indeed, this is the nub of it, the warning is that executives can find themselves under irresistible pressure to choose the expedient thing, rather than the right thing. If the quality of governance under which they serve is not compelling, expect expediency rather than rectitude when the pressure comes on. The passage of time may confirm that this tragedy was not about gross negligence, but about gross expediency.
On 2nd June 1994, a low-flying RAF Chinook helicopter hit the cloud-covered Mull of Kintyre, a steep-sided promontory on the west coast of Scotland. I am familiar with those impressive slopes, having approached them in military helicopters flying low-level from the sea many times. This accident, in which the four crew and 25 passengers died, would have been tragic by any standard; but the fact that the passengers were all members of the Northern Ireland intelligence services meant that it was a body-blow to the intelligence-lead security operations in the Province. The story was always going to have legs, but what made it run for over sixteen years is that this is also a story about governance.

This Chinook was a new variant – an HC2. It incorporated a number of new design features that gave it war-fighting advantages over its predecessors. With British Forces committed in Iraq, and a high danger of escalation to other areas that did in fact materialise, the machine was needed.

Its introduction had not gone well. At one point it was reported that the test pilots at Boscombe Down, who were conducting the programme, had refused to fly it because they regarded it as dangerous in its present state. The full authority digital engine control system (FADEC) was known for misbehaviour. There were also un-commanded flight control movement issues. From a pilot’s point of view, there are few things that will spoil your trip faster than an aircraft that does something you didn’t ask it to do. Notwithstanding, the HC2 varient was released to squadron service. The accident occurred against this backdrop of tension between operational need, and safety.

The Board of Inquiry was convened, and carried out its duties according to the book. The book said “Only in cases in which there is absolutely no doubt whatsoever should deceased aircrew be found negligent.” This is both common sense and common justice. Dead men cannot defend themselves against the convenient conclusions of others. When the aircraft struck the ground, the impact was huge, spreading wreckage over a wide area. Some wreckage had been beyond recovery, and there had been a fireball. In the absence of a Cockpit Voice Recorder or a Flight Data Recorder it proved impossible to establish “with absolutely no doubt whatsoever” exactly what had happened on that day. The Board recorded that while there were several possibilities, they were unable to determine a definite cause. In such cases, under the RAF’s own regulations, it was not permissible to reach a finding that the accident had been caused by aircrew negligence; nor did the Board of Inquiry do so. But it is also RAF procedure that Inquiry findings be reviewed up the chain of command. In this process, which involved the commanders of two stations where the squadron was based, and two Air Marshals, that rule of evidence did not receive due regard, and the pilots were pronounced to have been grossly negligent.

This seemed to be the outcome of choice by the agents of ‘governance’, both at the time, and subsequently until September 2010. This includes governance of the RAF, governance of the Ministry of Defence, and the political governance of the day. Yet, whatever had caused the crash, the passage of time seemed to confirm that there had been a breach of procedure. There were no less than four further inquiries into the accident. In 2000 for instance, the House of Commons Public Accounts Committee confirmed that the introduction into squadron service of the Chinook HC2 had been flawed, and concluded that the standard of proof for gross negligence on the part of the pilots had not been met. Later on, a House of Lords Select Committee also concluded that the various reviewing officers had not been justified in attributing gross negligence to the pilots who died.

The agonised families of the pilots had never given up their struggle to clear their names, and in 2010 Dr Liam Fox, then Secretary of State for Defence, appointed a retired judge to review the evidence. The judge reached the conclusion that the original RAF Board of Inquiry had been correct in their conclusion that there was insufficient evidence to be certain as to the cause, and that, subsequently, the reviewing officers had allocated blame without taking the RAFs rules as to standards of proof in such cases properly into account. The findings of the judge were, at last, accepted by the government.

But why had this happened in the first place, and why had it taken so long to reverse? In the face of such a clear, unambiguous and stringent evidential requirement, it is hard to credit that no less than four senior RAF officers did not understand that a conclusion of gross negligence would not be permissible. It is even harder to credit that the Ministry of Defence in all its various forms, peopled over time by all those different officials, politicians and civil servants, could support a flawed judgement with such dogged persistence. But those involved, at the time and subsequently, refused review or re-consideration for nearly sixteen years, despite the anguish this caused the families through the destruction of the pilots’ reputations, not to mention the increasing damage this did to their own reputations.

What is credible is that the introduction of the Chinook HC2 would have been seen as an indispensible stiffening of the sinews of war. It may be that the larger significance of destroying the reputation of two pilots was that it preserved the reputation of a machine that was flawed. Other conclusions might have resulted in the aircraft’s introduction being indefinitely delayed, with a consequent diminution of operational capability.

If, indeed, this is the nub of it, the warning is that executives can find themselves under irresistible pressure to choose the expedient thing, rather than the right thing. If the quality of governance under which they serve is not compelling, expect expediency rather than rectitude when the pressure comes on. The passage of time may confirm that this tragedy was not about gross negligence, but about gross expediency.

Peter Saxton
November 2011
©Capstick Saxton Associates