Philips noted that “prior to the crash, the aircraft was experiencing a number of malfunctions, the causes of which were not fully understood.
“We were told that, at the same time, and to some extent as a result, the flight manuals available to pilots were incomplete and in some respects misleading. Against that background, the possibility of the occurrence of a malfunction or malfunctions with which the crew were not fully equipped to cope could not be eliminated.”
FADEC was finally updated within four years of the accident, and the weight restriction was lifted so that the 24.5 tonne design limit could be carried, instead of the 18 tonne limit imposed following the software problems.
After the crash, a number of parliamentary inquiries were held into the accident, including the FADEC system and other technical issues. A 1998 report by the Defence Select Committee said that while performance had improved they were concerned that the software had not yet received full approval.
Two years later, a Public Accounts Committee report raised significant concerns over the lack of independent verification for the system and questioned the MoD’s testing and procurement. The PAC also said it found MoD assurances over the software’s safety “unconvincing”.
The PAC honed in on FADEC and said that technical malfunction on the helicopter had been a “potential” or “contributory” cause of the accident. This was an explicit rejection of the MoD’s official finding that the pilots had been grossly negligent.
In 2002, the House of Lords Select Committee closely examined the introduction of FADEC, and concluded that due to possible technical problems on the helicopter, the pilots were not necessarily in control of the aircraft.
The Royal Air Force and subsequently the Ministry of Defence continued to maintain that the gross negligence of the pilots was the cause the crash and argued this position to Lord Philip, who clearly rejected the argument.
In Wednesday’s report, Lord Philip in some way sided with previous Ministry of Defence reviews that said no definitive technical reason for the crash could be assigned. But this was in part because the report sought to concentrate on the legal basis for the Royal Air Force and Ministry of Defence verdict that the sole cause of the accident was the pilots’ alleged negligence, an argument Philip says was totally “flawed” and “unfair”.
Tony Cable, the Air Accidents Investigation Branch inspector who in 1994 produced a detailed report on the disaster, had said that the pre-impact serviceability of the helicopter could not be positively verified – a reference to various technical concerns including, but not only, IT.
Cable, who had not been able to access all documents or personnel, said that he found no evidence of a technical malfunction. But the report by Lord Philip notes that given the extensive damage to the helicopter and the problems this caused with the investigations, this “did not mean that the absence of such evidence conclusively proved that there had been no malfunction”.
Lord Philip branded as “extremely regrettable” the MoD’s decision to turn a “deaf ear” and continually rebuff all of the concerns raised around blaming the pilots, especially given that they had an impeccable record of service and that there remained serious technological and legal questions.
“Since 1995 the Ministry of Defence has continued resolutely to defend the finding of gross negligence and to rebuff all public and private representations that the finding should be reconsidered even when the representations included cogent arguments based on a sound understanding of the effect of the relevant Regulations,” said Lord Philip, regarding the requirement that deceased pilots only be blamed when there was no doubt whatsoever as to their failings.
“We find it extremely regrettable that the Department should have taken such an intransigent stance on the basis of an inadequate understanding of the RAF’s own Regulations in a matter which involved the reputation of men who died on active service.”