Select Committee on Public Accounts Minutes of Evidence


Annex 1

A chronology of the FADEC problems from the start of the development in the early 1980s to the position today may help the Committee. Documents to support any of the facts reported in the chronology can be made available to the Committee.

1984-87

  Delivery of the FADEC was promised by the main contractor, [Textron] Lycoming, within 23 months of the date of contract which was signed in January 1986. Flight test validation was due to start by the end of September 1987. In fact the first flight tests of a FADEC started in 1989 and were abandoned when an MoD Chinook was badly damaged by a sudden and unexpected FADEC-induced acceleration of the engines [see 1989] The First FADEC-equipped Chinooks were not approved for operations until November 1993, and then without reservations that were expressed by the Ministry's own airworthiness assessors at Boscombe Down and by the MoD's Chinook Project Manager in the Procurement Executive.

  Problems in the relationship between the MoD/RAF and the software suppliers date back to the early days of software development. In 1984, the RAF's Chinook Liaison Office wrote that it considered [Textron] Lycoming was being secretive. The RAF noted that it was unable to deal directly with the FADEC's software contractor. On all queries about FADEC, the RAF had to contact the FADEC's prime contractor [Textron] Lycoming in the USA—althought he software was being written in Britain by Textron's subcontractor Hawker Siddeley Dynamics Engineering.

1988

  RAF-monitored tests on the FADEC highlighted "numerous discrepancies".

1989

  The first major series of "flight" tests on a FADEC, as installed on a Chinook, ended in a serious accident at Boeing's Flight Test Facility at Wilmington, Delaware, then an MoD Chinook was almost destroyed on the ground by an engine overspeed. The accident led to the MoD taking legal action against the manufacturer over what it called a "fundamental flaw" in the design of the FADEC. In the accident, the FADEC allowed the engines and the rotors (which cannot be disengaged from the engines) to accelerate out of control of the pilots—a so-called engine runaway. At the MoD's request, the FADEC was modified but there was not a rewrite of the software and flaws remained at the time of the crash on the Mull of Kintyre in June 1994 (see 1994).

1990

  The British Defence Staff Washington (based at the British Embassy in Massachusetts Avenue) wrote a letter to the Vice president Military Engine Programs at Textron Lycoming in Stratford, CT, claiming $5,815,350 related to losses on the MoD Chinook that was "severely damaged" in an engine overspeed on 20 January 1989. "Following a careful investigation of the overrun incident and its causes, we have concluded that the overrun and ensuring financial losses were the direct result of Textron's failure to meet the Contract's requirements, and the failure of Textron (and its subcontractors for whose work Textron is responsible) to use due care in the design and testing of FADEC".

1993

  The British Government, having, asserted a claim against Boeing, released Boeing from all claims related to the overspeed incident on 3 September for the consideration of $500,000. The MoD said that it was "entirely Textron's fault that the damage was done". Boeing was not asked to accept liability nor did it offer to accept such liability.

  Also in 1993, the disagreements between Textron Lycoming and the A&AEE at Boscombe Down over the quality of the FADEC software, were one reason that EDS-Scicon, an independent defence contractor, was brought in to comment on the software. EDS-Scicon agreed with the A&AEE. EDS-Scicon abandoned a review of the code after examining 18 per cent of the code and finding 485 anomalies. EDS-Scicon suggested a re-write of the software. Textron Lycoming rejected this suggestion as unnecessary. EDS-Scicon had found 56 "category one" anomalies in the software. EDS-Scicon said that safety-critical code should ideally have no anomalies in this category. There were a further 193 anomalies in category two, when there should have been very few indeed, according to EDS-Scicon. These 249 category one and two anomalies were found in only 18 per cent of the code. EDS-Scicon had abandoned its review at this stage because of the density of anomalies it found.

  At this time operational commanders had to meet a high demand for Chinooks but the number of the helicopters available was, at one point, down to 40 per cent.

  The MoD and RAF took advice other than Boscombe Down's and put the Chinook into service. The official justification for over-ruling A&AEE was given to the Defence Committee in 1998. The MoD said it took into account the fact that there had no safety-critical FADEC incidents in the US Army. It also took into account the fact that the FADEC was not safety critical because not even the engines were safety critical. Without its engines the Chinook could glide safely to earth. Indeed the Defence Committee was told in 1998 that Boeing and the MoD did not consider the FADEC to be safety critical. "Boeing did not consider the FADEC to be flight safety critical because the engines on the Chinook are not considered to be safety critical," said an MoD report to the Defence Committee (page 33—fourth report dated 13 May 1998).

  However, Boeing did classify the FADEC as safety critical, and the engines too. The MoD also regarded the FADEC as safety critical. An MoD document prepared for the arbitration proceedings against Textron Lycoming said: "The FADEC as designed by Lycoming . . . had few safety features that did not depend on the software. The software was truly critical in maintaining safe flight".

  And although it was true that the US Army had not had any FADEC incidents, not a single operational Chinook was flying in the US with an RAF version of the FADEC at this time. So it was true that there had not been a safety-critical FADEC incident in the US Army. But there had been a safety-critical FADEC incident involving an MoD Chinook—in 1989 at the Boeing Flight Test Facility.

  So the MoD was approving the Chinook partly on the basis that there had been no serious FADEC problems in the US—yet there had been serious FADEC problems with an MoD Chinook.

  Aware that they were putting into operational service a helicopter which had a FADEC with known deficiencies, the MoD and the RAF approved the Chinook for release in November 1993. Partly because of the A&AEE's concerns about FADEC, a weight restriction was imposed in case FADEC caused one engine to fail. This restriction did not, however, take account of a more serious risk—a sudden acceleration of the engines that was not commanded by the pilots. It was an uncommanded acceleration of the engines that caused the accident in 1989.

7 March 1994

  The unexpected flameout of an engine on a FADEC-equipped Chinook Mk2 led to the A&AEE at Boscombe Down suspending trials flying. The suspension was lifted on 20 April but resumed again on 1 June 1994.

April 1994 onwards

  Pilots on Chinooks fitted with FADEC discovered that the Chinook's engines sometimes accelerated or decelerated suddenly and without warning. A Squadron Leader at the main UK Chinook depot, RAF Odiham, later told an RAF Board of Inquiry: "The unforeseen malfunctions on the Chinook HC2 of a flight critical nature have mainly been associated with the engines control system FADEC. They have resulted in undemanded engine shutdown, engine run-up, spurious engine failure captions, [warnings in the cockpit and misleading and confusing cockpit engine indications".

  The two pilots of the Chinook HC2 who died in the crash on the Mull were among the pilots who had expressed concern about flying the upgraded aircraft. The RAF Board of Inquiry was told that the two pilots were "worried" about the "uncertainty of how the aircraft's Fully Automatic Digital Engine Control system would perform during operational sorties in Northern Ireland and what sort of emergencies or situations the present amount of spurious and unexplained incidents would lead to".

  On 21 April 1994, the advice of the MoD Procurement Executive was that it was "important to understand and take full account of A&AEE's views".

26 May 1994

  In the latest of a series of incidents involving FADEC, the pilots of Chinook ZD576 (the aircraft that crashed on the Mull of Kintyre) reported more FADEC-related problems. During a flight, it was found that various warnings were given in the cockpit, including a "master" warning, indicating a possible engine overspeed, and a No 2 engine failure notification. The pilots diverted to Luton. The pilots reported that the engine failure warning took 10 seconds to extinguish.

1 June 1994 (a day before the crash on the Mull of Kintyre)

  The A&AEE, for the second time in 1994, ceased trials flying of the Chinook fitted with FADEC because Textron Lycoming had not given satisfactory answers to questions raised by the A&AEE about the system.

  The official dispensation to trials pilots not fly Chinooks fitted with FADEC did not apply to operational pilots.

  Flt Lt Jonathon Tapper, one of the pilots of the Chinook HC2 that crashed on the Mull requested permission from Squadron Leader David Prowse for the use of a Chinook HC1 (not fitted with FADEC). This was because of the icing and other restrictions that were imposed on the Chinook HC2 as a result of the FADEC problems. The request was refused. Flt Lt Tapper and his co-pilot Flt Lt Rick Cook could have refused to fly Chinook ZD576, but this could have been seen as insubordination.

2 June 1994 (the day of the crash on the Mull of Kintyre)

  Chinook ZD576 flown by Flt Lts Tapper and Cook who were sufficiently highly regarded and experienced to be given the status of Special Forces pilots, took off from Northern Ireland for Scotland and crashed on the Mull of Kintyre. Everything appears to have been normal until the last half-minute or so before impact. What happened then is the subject of dispute. Critics of the decision to blame the pilots contend that, as there is no confirmed evidence of what happened in the last moments of flight, nobody will ever know if the aircraft was under control. The MoD contends that as there is no evidence of a malfunction, the aircraft was undoubtedly under control. The MoD also contends that the pilots saw the bad weather on the top of the Mull, and should have transferred to instrument flights rules, climbed to a safe altitude, slowed down, turned away or turned back. As they did none of these things, they were grossly negligent.

  Dozens of aviation specialists, including RAF officers, former and serving, have contended that the issue is not whether the pilots flew at speed into the Mull, the top of which was covered in cloud—it is obvious that they did—but whether the pilots flew voluntarily or compulsorily into the Mull. Computer Weekly does not believe that the answer to this question will ever be known.

December 1994

  The MoD completed its reports for the American Arbitration Association Commercial Arbitration Tribunal, in the case against Textron Lycoming. The reports said that:

    —  Faulty logic in the design of the FADEC software was the immediate cause of the accident in 1989.

    —  The FADEC was not airworthy.

    —  The software was not adequately documented.

    —  The Failure Modes Effects and Criticality Analysis was seriously incomplete.

    —  The Subsystem Hazard Analysis failed to cover possible failures that were critically important.

    —  Development tests on the FADEC hardware were inadequate.

    —  The software was not adequately verified.

    —  [Textron] Lycoming failed to comply with DO-178A (an international avionics standard).

    —  [Textron] Lycoming failed to meet the comparable design documentation requirements of JSP188 (an international documentation standard).

    —  [Textron] Lycoming did not adequately respond to warnings of design flaws.

    —  [Textron] Lycoming failed to supervise work adequately.

    —  Lycoming adopted an unnecessarily high-risk design strategy.

    —  Lycoming's failure to maintain schedule may have caused it to take short cuts with safety.

  As these reports were never published or shown to the RAF Board of Inquiry or the Scottish Fatal Accident Inquiry, it was not realised that FADEC was capable of causing a potentially fatal accident and indeed had caused a serious accident in 1989.

1995

  The RAF Board of Inquiry report into the crash on the Mull of Kintyre was published. Quotes from the report are as follows:

    —  In considering the cause of the accident the Board were severely hampered by the lack of a Cockpit Voice Recorder and an Accident Data Recorder

    —  Operationally both pilots [of ZD576] had a very stable and constructive attitude towards their flying. The concerns they had with reference to the Chinook HC . . . did worry both pilots in two ways. First was the uncertainty of how the aircraft's Fully Automatic Digital Engine Control System would perform during operational sorties in Northern Ireland and what sort of emergencies or situations the present amount of spurious and unexplained incidents would lead to".

    —  The Board considered engine control system malfunctions and it is particularly relevant to note that at this stage of the Chinook Mk2's service, spurious Engine Failure captions [warnings], lasting on average seven-eight seconds, were an increasingly frequent occurrence. These are now well understood but at the time they were not. Had such an indication occurred it would have caused the crew considerable concern particularly as they were over water with no obvious for an emergency landing. Such a warning would also have required an urgent and very careful check of engine instruments and Flight Reference Cards (the engineering manuals).

    —  The Board could find no evidence that Flt Lt Tapper had not approached and prepared for the sortie in anything other than a thorough and professional manner. The Board was unable to determine the sequence of events leading up to the accident...it would be incorrect to criticise him (Tapper) for human failings based on the available evidence".

    —  The Board reviewed the technical malfunctions and air incidents which had occurred with the Chinook HC2 in RAF service and considered whether they could have played a part in the accident. The Chinook HC2 had experienced a number of unforeseen malfunctions, mainly associated with the engine control system, including undemanded engine shutdown, engine run-up, spurious engine failure captions, and misleading and confusing cockpit indications. The board found no evidence that any of these malfunctions had occurred on Chinook ZD576's final flight. Nevertheless an unforeseen technical malfunction of the type being experienced on the Chinook HC2, which would not necessarily have left any physical evidence, remained a possibility and could not be discounted.

    —  In considering the available technical information, the Board concluded that technical failure was unlikely to have been a direct cause of the accident. However, given the large number of unexplained technical occurrences on the Chinook HC2 since its introduction, the Board considered it possible that a technical malfunction could have provided a distraction to the crew".

    —  The Board concluded that distraction by a technical malfunction could have been a contributory cause of the accident."

  The inquiry report said that although the pilots may have chosen an inappropriate rate of climb to fly over the Mull, there was insufficient evidence to blame them. A different view was taken, however, by two air marshals who reviewed the Board's findings: They judged the pilots to have been negligent to a gross degree. One of the air marshals said:

    "In my judgement none of the possible factors and scenarios are so strong that they would have been likely to prevent such an experienced crew from maintaining safe flight. Therefore, unlike the Board and the Officer Commanding RAF Odiham, I reluctantly conclude that the actions of the crew were the direct cause of the accident."

  The view of the air marshals assumed that no evidence of technical malfunction meant pilot error.

  In the years since the crash, more information has come to light regarding the criticality of the "FADEC" engine control software". Various statements issued by the MoD show that officials appear not to have been aware of the extent to which the near destruction of a Chinook in 1989 was caused by a design flaw in the FADEC software.

  Indeed the Defence Committee was told repeatedly that the accident in 1989 was caused by negligent testing procedures and was nothing to do with the software. Computer Weekly has MoD documents showing that the Ministry believed that the opposite is the case. In its litigation over the 1989 accident, the Ministry's case exonerated the testing procedures and found that the cause of the accident was a faulty design of the software.

Autumn 1995

  The MoD won its case against Textron Lycoming and was awarded about $3 million in damages.

1996

  A three-week Fatal Accident Inquiry in Scotland found that there was insufficient evidence to blame the pilots. The inquiry was not told about the litigation over FADEC, the EDS-Scicon report, or any of the memos or reports from A&AEE and the MoD Procurement Executive regarding the FADEC.

1997

  At 1,100 feet, during a normal cruise stage of flight, a US Army Chinook suffered a jam of the controls and turned upside down. With the pilots trying to free the controls, there was no time to make an emergency call. At 250ft about the ground the controls inexplicably freed themselves and the helicopter landed safety. No evidence of technical malfunction was found and the technology of computer simulations was not sufficiently advanced enough to replicate the circumstances of the incident.

  Had the crew died in a crash they may have been blamed, as there was no evidence of a serious technical malfunction.

1998

  The Defence Committee was told that:

    —  The A&AEE's concerns did not relate to safety but only to the fact that they could not read the FADEC software and therefore could not verify it. The Committee was not told that Boscombe Down had read the software and had found it unacceptable.

    —  The software was not safety critical. Some months after the hearing officials confirmed in writing that Boeing had considered the software to be safety critical.

    —  That the litigation against Textron was "nothing to do with software" only negligent testing procedures.

    —  That FADEC problems prior to the crash on the Mull were "trivial" and related only to "soft" faults.

    —  That the A&AEE's concern about the software was because it was trying to test the code using a method of testing software—static code analysis—that was not widely used, apart from in the nuclear industry (although the MoD's own standard for safety related software 00-55, dated 1994, recommended static code analysis).

    —  That the US Army was happy with its Chinook fleet (although the US Army did not have the same FADEC version)

    —  That there had never been a FADEC-caused accident (although the accident in 1989 was caused by a faulty design of FADEC).

  The Defence Committee concluded that "although the FADEC system has received much attention in the media and elsewhere it is far from being the main source of reported faults. Indeed engine problems more generally were only 25th on the MoD's list and of the 11,000 faults reported across all of the aircraft's systems, FADEC failures represented less than 0.2 per cent".

  The Committee was persuaded that the "failure of Boscombe Down to give final approval to the FADEC software . . . is a management failure".

1998-99

  In defending the decision of the two air marshals, the MoD went well beyond what was said at the RAF Board of Inquiry. For example, officials have made three factually disparate statements on how, when and at what point on the approach to the Mull the pilots were negligent.

2000

  A report for the national Transportation Safety Board in the US confirms that no evidence of technical malfunction does not mean no technical malfunction.


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2000
Prepared 30 November 2000