Fatal Crash on ANZAC day avoidable says Inquiry

[flyinkiwi]

www.stuff.co.nz/national/6151607/Deadly-Anzac-Day-helicopter-crash-was-avoidable

The fatal crash of an Iroquois helicopter was avoidable, the Defence Force has conceded.

The crash, on Anzac Day last year, killed three of the four crew onboard: Pilot Flight Lieutenant Hayden Madsen, 33, co-pilot Flying Officer Daniel Gregory, 28, and crewman Corporal Ben Carson, 25.

Sergeant Stevin Creeggan, 37, survived but suffered serious injuries.

The Defence Force's court of inquiry, released today, into to the accident found sub-standard protocols and a culture of "rule breaking" among 3 Squadron was partly to blame.

The report found the crew lost situational awareness when then inadvertently flew into heavy cloud in the early-morning darkness, and did not recover in time to take evasive escape action.

Their night vision goggles were rendered useless by a lack of moonlight, and they were not properly prepared to fly using only their instruments.

The court of inquiry made 20 recommendations in total. Half of those directly addressed what it deemed to be the six causes of the crash.
There were no eye-witnesses to the crash.

Sgt. Creeggan has no memory of it or the 10 days after.

[luke6745]

The reporter on ONE News said something about budget cuts and chains of command being removed back in 2001 having something to do with it? Any truth to that? Does Helen have blood on her hands yet again?

[skyhawkdon]

That is a pretty long bow to draw but an expert in root cause analysis would (and probably has in this inquiry) looked at what structures and supervision were in place at Ohakea when 3 Sqn arrived in late 2001 and how that influenced the "culture" of the unit over the next 9 years. But 3 Sqn had been a law unto themselves for a long time from my observations, even before they arrived at Ohakea. I'm not criticising them for that, it was just the "culture" that was allowed (and encouraged) to develop. I also saw it in the Air Combat Force Squadrons in the late 90s.

3 Sqn operated for many years in isolation, without adequate supervision from the wider RNZAF, including even at their home base at Hobsonville. The many 3 Sqn detachments and operations in the likes of East Timor, etc. further contributed to this culture.

Sadly the lessons from Muz Neilson's Skyhawk accident in 2001 around risk taking, "can-do", supervision and training were not learned by the RNZAF. You could blame HC for that but I think it has more to do with the failings of senior leadership in the RNZAF at the time, who failed to act on the recommendations of the COI into that accident.

The Airtrainer crash had very similar root causes and if you look at what they have done as a result of this and the Airtrainer crash they have put in a whole new structure above the flying units to provide better supervision and monitoring. Something they should have done after Muz Neilson's accident...

Finally, military aviation is different to civil and commercial flying. Risk is part of BAU for the RNZAF. We are the best at what we do because of our can-do culture. We don't want to stiffle this with bureaucracy and rules. I think we have seen one extreme and the consequences of it, now we are about to see the other! There needs to be a balance and I'm sure the RNZAF will find it in the years to come.

[mumbles]

Dec 17, 2011 8:15:19 GMT 12 skyhawkdon said:

3 Sqn had been a law unto themselves for a long time from my observations, even before they arrived at Ohakea. I'm not criticising them for that, it was just the "culture" that was allowed (and encouraged) to develop. I also saw it in the Air Combat Force Squadrons in the late 90s.

3 Sqn operated for many years in isolation, without adequate supervision from the wider RNZAF, including even at their home base at Hobsonville. The many 3 Sqn detachments and operations in the likes of East Timor, etc. further contributed to this culture.

I know someone intimately involved with both the ACF and 3 Sqn (who has asked not to be named here), and remember quite vividly his impressions of seeing firsthand how 3 operated when they arrived at Ohakea. They weren't complimentary.

[horicle]

During the inquiry one of the panel gave a group of us a 'heads up' on the proceedings, limited of course by sensitivity, and made the statement. We have to decide if we are investigating a survivable event that killed three or an un-serviveable event that someone survived. My immediate gut feeling was that the survivor, who was supercrew, was facing aft with his back to the cabin bulkhead. So far no statement about this has emerged. All I have got so far is that the task was aborted and they about turned to port - towards the problem - rather than a stbd turn towards open sea. There must be more to come out of this.

[BATLDR]

They made the left-hand turn back towards land for the fact that the land (and the lights of Pukerua Bay) was where their only visual reference as out to the west was extremely dark. Under night vision goggles you need a source of light for the goggles to amplify. As it was very dark (no moon and thick, low cloud cover obscuring the starlight) the goggles only pick up artificial light. So the logical way to turn back was towards the land which they could see, as opposed to out to sea where they could not.

[Dave Homewood]

Welcome to the forum BATLDR. Thanks for that explanation, that makes a lot of sense.

[aileronroll]

has the full report been made public, if possible could someone please direct me to a copy, thank you!

[corsair67]

Would be interesting to see the full report, but I assume there is not much chance of that happening?

It's not a good look for the RNZAF when there are at least two fatal accidents where supervision (or lack of) and training standards come to the fore in both incidents. As Don says, the loss of Murray Nielson in 2001 should have lead to changes being made way back then - not 10 years later, after another four personnel have been killed in two separate accidents.

I am also not sure if the Air Force handled some elements of their dealings with the victim's families post-accident very well either, going by what has appeared in the media over the past 12 months. Even taking much of what Cpl. Carson's family have said with a grain of salt, some of the mud they have flung seems to have stuck at a very high level in the RNZAF, including the current Chief of Air Force. There also doesn't seem to be much of an attempt made by the RNZAF to deny some of the allegations, which in my opinion only adds fuel to the fire.

I personally think that Cpl. Carson's family are 'media tarts', who have used whatever means to air their grievences in whichever media outlets will let them do so. They finally lost my sympathy when they appeared in a newspaper in the week before the accident report was issued, stating that they believed it was unfair that the report should be issued at this time because they were still grieving for their son and brother; and post report release, Andrew Carson was quoted as saying to TVNZ "Personally, I think the Air Force should be shut down and given to the Navy or the Army to look after".

I too think blaming Clark for any of this is drawing a very long bow indeed - but I do honestly believe budget cuts and the loss of some very experienced personnel over the past 10 years has seriously had an impact on the previously very high standards held by the RNZAF.

[Dave Homewood]

I have not read the reports so have no opinion of the circumstances of the crashes. But I do recall around five years ago an audit of the RNZAF practices found that there was just sufficient budget for either training or operational flying and not both at a safe level and the gist that it predicted if changes were not made we'd start seeing more operational accidents due to failings in training standards. I wonder what was done as a follow up to that audit?

[corsair67]

Dec 29, 2011 14:41:50 GMT 12 Dave Homewood said:

......I wonder what was done as a follow up to that audit?

I'm guessing the follow-up was to bury the audit report as deeply as possible in the basement of the Beehive!

[Dave Homewood]

Yes, it was reported on National Radio at the time and I think there was a very brief discussion here, and that is all I heard of it.

[classicman]

Sorry - this is all rubbish about supervision and oversight. We go through this same hand-wringing exercise after every crash. We could just dust off the last report and use it again. Military aviation operates at the dangerous edge of flying - it always has and always will. Dick, Carter, Tanner, Beats, Neilson, Cree, the ANZAC 3...
We have always lost flyers and sadly always will due to the nature of the job we do. We can only try to improve on the way we do things, but this is not an airline or an aero club.
I have served under the present CAF - remember, unlike the deceased parents, his hands are tied as to what he can say to the media.
While I sympathise with them for their loss, they are trying to ease their pain with a witch hunt.

[Dave Homewood]

I quite agree with you about how those in the RNZAF are completely restricted from speaking out in the media and answering allegations. I thought that as soon as the news began to break. In today's viscious and sensationalist media climate in such cases the RNZAF doesn't stand a chance.

[phil]

Hence you'll note the lack of any of the usual vigorous input from current serving members.

[Dave Homewood]

Sadly I doubt the public at large do has any idea that the military laws prohibit serving personnel from speaking to the media without higher up authorty and carefully prepared messages. This is why usually it's the Minisiter of Defence that faces the media, or the PRO or Chief of Air Force. The only time I think this law was ever relaxed by the RNZAF was whe they allowed currently serving personnel to speak out in the media about the Govt decision to cull the Air Combat Force.

[corsair67]

Dec 29, 2011 20:27:05 GMT 12 classicman said:

Sorry - this is all rubbish about supervision and oversight. We go through this same hand-wringing exercise after every crash. We could just dust off the last report and use it again. Military aviation operates at the dangerous edge of flying - it always has and always will. Dick, Carter, Tanner, Beats, Neilson, Cree, the ANZAC 3...

We have always lost flyers and sadly always will due to the nature of the job we do. We can only try to improve on the way we do things, but this is not an airline or an aero club........

I agree: military flying IS a dangerous business, and crews and aircraft are often operating very close to the edge of the envelope.

However, what concerns me is that two the most recent accidents were not in the strict sense of the word purely operational flying - one occurred during practice for an aerobatic display while the other occurred during transit to a flypast - which would seem to me to be two examples of military flying that shouldn't involve a greater amount of risk than any other military flying?

With the ANZAC Day crash one the saddest thing that seems to have come out of this report is that it appears the limitations of night-vision googles either weren't understood properly and/or weren't taken into account - and in my opinion this falls into the area of lack of adequate training and supervision. The other factor that I wonder about is whether there was there an element of push-on-itis involved in this accident, due to it being an ANZAC Day flypast?

The elephant in the room in all of this is why weren't the crews trained and/or supervised properly - and I think we all know the answer to this one. You cannot cut the soul out of an organisation and restrict spending on core functions without there being a trade-off somewhere along the line - which in a military context unfortunately often means injuries occur, or worse still, the loss of life.

As to Cpl. Carson's family having a go at the CAF and the Air Force, as I see it the biggest issue is that they appear to have documents in their possession which seem to show that things were not handled as well as they should be, in so far as the RNZAF's dealings with them post-accident were concerned (and they are not the only family that have made mention of this either, as I believe Sgt Creegan's parents also raised concerns about this as well). Part of this seems to have stemmed from the fact that Cpl Carson's next-of-kin was listed as his girlfriend, and not his parents - which is not the Air Force's problem, but rather a personal issue between the partner and family - which they need to sort out amongst themselves.

[htbrst]

Dec 30, 2011 10:52:27 GMT 12 corsair67 said:

Dec 29, 2011 20:27:05 GMT 12 classicman said:

Part of this seems to have stemmed from the fact that Cpl Carson's next-of-kin was listed as his girlfriend, and not his parents - which is not the Air Force's problem, but rather a personal issue between the partner and family - which they need to sort out amongst themselves.

Other way around I think- his parents were listed as next-of-kin, but were shut out and repeatedly excluded from proceedings in favour of the girlfriend (reading between the lines the relationship may not have been going on particularly long.)

This would be pretty bad form, and would certainly cloud their judgement as to the all round performance of the air-force

[corsair67]

Dec 30, 2011 18:07:56 GMT 12 htbrst said:

Dec 30, 2011 10:52:27 GMT 12 corsair67 said:

Dec 29, 2011 20:27:05 GMT 12 classicman said:

Part of this seems to have stemmed from the fact that Cpl Carson's next-of-kin was listed as his girlfriend, and not his parents - which is not the Air Force's problem, but rather a personal issue between the partner and family - which they need to sort out amongst themselves.

Other way around I think- his parents were listed as next-of-kin, but were shut out and repeatedly excluded from proceedings in favour of the girlfriend (reading between the lines the relationship may not have been going on particularly long.)

This would be pretty bad form, and would certainly cloud their judgement as to the all round performance of the air-force

Oh dear - that makes things even worse then!

[nat]

I can assure you all that Ben and his partner had been together for over 3 years. Owning bank accouts, property etc together.......I can also assure you that the Carson family have been treated with more respect than they deserve.......it is a shame that instead of enjoying the time that they could have been spending with the woman that he loved, his friends, work mates and nephews they are spending all of their energy trying to blame someone and throwing around stupid comments like 'hand the airforce over to the army' when the problem is that they didn't actually fully understand what thier son did for a job and they didn't understand as they didn't take the time with their son to learn!!!
It is a shame that the media only report half a story and NEVER check that the information that they are putting out in the public is actually correct.