The three elements that contributed most to the tragic loss of a Leuchars-based RAF Tornado crew who ran out of turning room in a Scottish glen were pilot experience, hazard recognition and aircraft handling, a panel of inquiry has reported.
There is also a suggestion that a lack of training might have played a part and at the time of the accident flying hours had been cut back.
In addition, it was revealed that the 43 Squadron Tornado on the tail of the heavily laden jet only “narrowly avoided a similar fate” at Glen Kinglas in Argyll but recovered after witnessing the crash fireball.
The accident, in July 2009 just 14 minutes after take-off for a routine training flight from the Fife base, resulted in the deaths of the relatively inexperienced pilot Flt Lt Kenneth Thompson (27), who did not have extensive low-level flying time, and long-serving navigator Flt Lt Nigel Morton (43).
At the time the crews had only 10 hours a month flying time as Tornado numbers were reduced and the base undertook only quick reaction alert (QRA) work.
In relation to the “competency and currency” of the crews, the panel said it could not rule out some issues as contributory factors, either individually or collectively, in undermining the pilot’s competency to undertake the task.ExperienceThese were lack of refresher training, the paucity of dual checks, light aircraft flying, lack of low level currency and lack of competency checks at low level.
Of the navigator, the panel said he was competent to undertake the task, though this was as a result of “the likelihood of a lesser degree of skill fade in the low level environment” due to his experience level.
The panel also touched on the more human side of the situation — the well-being of crews. The accident happened after the squadron had gone through a significant amount of change in the year preceding the accident and was due to disband.
The panel stated that, despite having a posting to stay on the F3 force, the pilot had aired his concerns over his immediate and long-term future in the RAF.
“The panel concluded that the sudden change and insecurity in both immediate and long-term careers influenced the personal well-being of the crew.
“While the panel concluded that the well-being of the crew was likely to be affected, it was not able to determine whether this contributed to the accident,” stated their report.
On a technical point, the panel found the record for the crashed jet showed a history of two suspect “loose articles”. There had also been an incorrect removal from the records of an actuator pin that had been found to be missing in the cockpit just over a year before the accident.
“Although unlikely to be a factor, the panel could not positively rule out that a loose article prevented the wing sweep selection lever moving fully forward.”
Every single detail of the crews, their preparation and the flight itself were delved into during the intensive inquiry.
The whole incident has been summed up by the Commander in Chief of Air Command, Air Chief Marshall Sir Chris Moran, who supports the recommendations made by the inquiry.
He said that, notwithstanding a serviceable ground proximity warning system — which can produce false alarms during manoeuvres close to mountainside terrain — the crew failed to recognise the hazardous situation in time to take effective recovery action.
He said that he agreed that the pilot’s experience level was a factor, but the RAF had long experience in managing this known risk and a controlled flight into terrain (CFIT) is very rare.
Sir Chris said in failing to recognise the hazard, visual illusion seems to have played a part, and he had instructed RAF flight safety staff to refresh training material and institute a campaign to cover all crew required to fly at low level.
“The attempted flight path was marginal at best, but the weight and configuration of the aircraft made it even more challenging.”
He said the aircraft was heavy and throttle handling caused a loss of energy which was aggravated by wing sweep position.
“It is most likely that this configuration was simply a mistake. Therefore the aircraft handling at low level was also a factor, aggravating a false assessment about the turning capability of a heavy Tornado F3.
“An additional, unproven factor is the pilot’s familiarity with the area, that may have led him into starting a turn into a valley that someone less familiar with the geography might have attempted with more caution.”
Even with an accident data recorder, and the testimony of the other Tornado, it could not be said for certain why the crew lost awareness of hazardous terrain in their flight path.
The service inquiry panel made 26 recommendations, largely relating to aircrew training and check and assurance processes.
Every single detail of the crews, their preparation and the flight itself were delved into during the intensive inquiry.
The whole incident has been summed up by the Commander in Chief of Air Command, Air Chief Marshall Sir Chris Moran, who supports the recommendations made by the inquiry.
He said that, notwithstanding a serviceable ground proximity warning system — which can produce false alarms during manoeuvres close to mountainside terrain — the crew failed to recognise the hazardous situation in time to take effective recovery action.
He said that he agreed that the pilot’s experience level was a factor, but the RAF had long experience in managing this known risk and a controlled flight into terrain (CFIT) is very rare.
Sir Chris said in failing to recognise the hazard, visual illusion seems to have played a part, and he had instructed RAF flight safety staff to refresh training material and institute a campaign to cover all crew required to fly at low level.
“The attempted flight path was marginal at best, but the weight and configuration of the aircraft made it even more challenging.”
He said the aircraft was heavy and throttle handling caused a loss of energy which was aggravated by wing sweep position.
“It is most likely that this configuration was simply a mistake. Therefore the aircraft handling at low level was also a factor, aggravating a false assessment about the turning capability of a heavy Tornado F3.
“An additional, unproven factor is the pilot’s familiarity with the area, that may have led him into starting a turn into a valley that someone less familiar with the geography might have attempted with more caution.”
Even with an accident data recorder, and the testimony of the other Tornado, it could not be said for certain why the crew lost awareness of hazardous terrain in their flight path.
The service inquiry panel made 26 recommendations, largely relating to aircrew training and check and assurance processes.
Every single detail of the crews, their preparation and the flight itself were delved into during the intensive inquiry.
The whole incident has been summed up by the Commander in Chief of Air Command, Air Chief Marshall Sir Chris Moran, who supports the recommendations made by the inquiry.
He said that, notwithstanding a serviceable ground proximity warning system — which can produce false alarms during manoeuvres close to mountainside terrain — the crew failed to recognise the hazardous situation in time to take effective recovery action.
He said that he agreed that the pilot’s experience level was a factor, but the RAF had long experience in managing this known risk and a controlled flight into terrain (CFIT) is very rare.
Sir Chris said in failing to recognise the hazard, visual illusion seems to have played a part, and he had instructed RAF flight safety staff to refresh training material and institute a campaign to cover all crew required to fly at low level.
“The attempted flight path was marginal at best, but the weight and configuration of the aircraft made it even more challenging.”
He said the aircraft was heavy and throttle handling caused a loss of energy which was aggravated by wing sweep position.
“It is most likely that this configuration was simply a mistake. Therefore the aircraft handling at low level was also a factor, aggravating a false assessment about the turning capability of a heavy Tornado F3.
“An additional, unproven factor is the pilot’s familiarity with the area, that may have led him into starting a turn into a valley that someone less familiar with the geography might have attempted with more caution.”
Even with an accident data recorder, and the testimony of the other Tornado, it could not be said for certain why the crew lost awareness of hazardous terrain in their flight path.
The service inquiry panel made 26 recommendations, largely relating to aircrew training and check and assurance processes.