MPs slam MoD over 1994 crash whitewash. Software, not pilot error,
could have killed 29
Tony Collins
Parliament's most powerful committee of MPs said today
(Thursday) that faulty software could have been a factor in the
RAF's worst peacetime air accident.
The Public Accounts Committee (PAC) accused the Ministry of
Defence (MoD) of "unwarrantable arrogance" in defending the
"unsustainable finding" of pilot error in the 1994 Chinook
helicopter crash, which killed 29 people.
The committee's report contradicts more than four years of
denials by ministers in both administrations who, briefed by the
MoD, have insisted that the Chinook's Full Authority Digital Engine
Control (Fadec) software could not have played a part in the
crash.
The PAC called on the MoD to set aside the verdict of gross
negligence on pilots Rick Cook and Jonathan Tapper. "The evidence
provided to the committee points quite clearly to a major
miscarriage of natural justice," said PAC chairman David Davis.
The report said, "The faults with the Fadec led to doubts as to
the reliability and safety of the aircraft at the time and make it
very difficult to rule out categorically a technical fault as at
least a contributory cause of [Chinook] ZD576's crash."
MPs said the MoD's acceptance process for the Chinook Mk2 was
flawed, as was its outcome.
And MPs warned that engine software on helicopter - the troop
transport workhorse of the armed forces - could still not be
guaranteed. "The committee does not believe that there was in 1994,
or is now, sufficient independent assurance on the performance of
the Fadec software.
"The committee simply cannot understand why the department
continues to defend the unsustainable finding of gross negligence
and recommends it should be set aside," said the report.
In a finding that has implications for all IT procurement, the
PAC said reliance on equipment manufacturers to investigate faults
in their own systems "undermines the department's ability to act as
a truly intelligent customer".
The committee challenged the decision by two air marshals who
found the pilots grossly negligent. It said the RAF Board of
Inquiry did not satisfy the burden of proof required. At the time
of the crash, RAF rules said that deceased aircrew could be found
negligent only when there was "absolutely no doubt whatsoever".
Earlier this year prime minister Tony Blair concurred with at
least six other ministers when he rejected calls for a new inquiry.
He said the Board of Inquiry had found that the Chinook was flown
below safety altitude, at speed, in unsuitable weather conditions.
"Accordingly the pilots were judged to have been negligent," said
Blair.
But the PAC said the Board of Inquiry process was
"unsatisfactory", with officers sitting in judgement on the causes
of the crash also reporting to those tasked with getting the
helicopter quickly into operation.
"At present, the position of reviewing officers on Boards of
Inquiry opens the way to allegations of conflicts of interest."
The report contains 11 pages of evidence from Computer
Weekly showing that the Chinook's engine software system had
been plagued with flight critical problems at the time of the crash
- despite assertions by ministers that the software was "not
flight-critical".
Main points of the PAC report
- The gross negligence finding against the Chinook's pilots is a
breach of natural justice that should be set aside
- The MoD's reliance on its own procedures over the Scottish
courts constituted "unwarrantable arrogance"
- There is still not sufficient assurance of the performance of
engine software in the UK armed forces' front-line troop
helicopter
- Reliance on software manufacturers to investigate faults in
their own software "undermines MoD's ability to act as an
intelligent customer"
- RAF Board of Inquiry process is unsatisfactory and opens the
way to charges of conflict of interest between operational
imperatives and justice
- RAF's acceptance process was flawed, with software problems not
detected until rear end of procurement process.
Computer Weekly comment
The PAC report vindicates Computer Weekly's three-year
campaign to clear the names of flight lieutenants Rick Cook and
Jonathan Tapper. It shows that software or mechanical error cannot
be ruled out as a cause of the Chinook crash. The gross negligence
finding against the dead pilots should be set aside now.
All users of safety-critical IT systems need to ask whether they
too would be reliant on the manufacturers to investigate in the
case of a catastrophic failure.
And ministers need to ask why the Ministy of Defence continued
for five years after the crash to defend its own flawed procurement
and safety practice in the face of mounting evidence.
Exclusive: Excerpts from the 1993 EDS-Scicon Report the
Defence Select Committee did not see in 1998. Click here
The Computer Weekly
evidence to the Public Accounts Committee
Fatal flaws in defence procurement process
Did Tony Blair mislead MP over Chinook?
Leader
Background: Milestones in the Computer Weekly campaign
for truth about the causes of the Chinook crash
RAF Justice
Report
(You will require Adobe's Acrobat Reader to view this - download it
here)
MoD kept RAF chief in the dark
MPs misled over Chinook system
Parliament push to clear Chinook pilots
MoD slated for unresolved Chinook testing issues
MoD in Chinook report cover-up