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Service Inquiry Puma XW229, 11 October 2015

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Service Inquiry Puma XW229, 11 October 2015 OFFICIAL SENSITIVE PART 1.4- ANALYSIS AND FINDINGS Introduction 5 Methodology Accident Factors...... ...... ... ..... ... .... .... ..... .... .. .... ... ... ..... .. ..... ..... ...... ...... ... 5 Human Factors modelling ................................. ....... .. .. ............ ...... ... .. ... .. 6 Available evidence.. ... .......... .. ... ............................. .. ........................... .... 6 Services..... .... ... ... ... ..... .. .. ... ..... .... .. ................................. ... ...... .. ...... ..... 7 Factors considered by the Panel. ... ... .................... .. ............... .. ... ........... .... 8 Background Op TORAL Aviation Detachment . 8 Puma HC Mk2 Life Extension Programme . .. 8 Puma Force development. ........................ .. .... ....... ..................... ... .... ....... 9 Fight-by-Flight. ... ... ... ................. ..... ......... ..... .. ....... ............. ...... ....... 10 Puma Force Op TORAL deployment. .... .... ..... ... .... ... .... ..... .. ............. ... 10 X Flight.... ..... ... ... ...................... ................... ..... ...... .. ..... ... ..... ... ... 10 Environmental Training and Environmental Qualifications . .. 11 Pre-Deployment Training . 11 Reporting.. ..... .. ... .. ........ .... ....................... .... ...... ... .. ...... ..... ...... ... .. 12 Theatre Qualification . 12 Conclusion - Environmental Qualifications, pre-Deployment Training and Theatre Qualifications.. ........................... ... ... ... ...... .. ...... ... .......... 14 Air operations..... .... .. .... .. .... ..... .. .... .. .... ... .............. .... ... ... ... .. ............... .. 14 Tasking process. ... ... ... ... ....... ....... .... ... ... .... ... .. ......... .. ..... ..... .... ... .... 14 TAD operations.. .... ... ... .. ...... ...... ........... ... ... ...... ........ .... ... ... ...... ...... 14 Operating tempo... ... .. .... .. ................. ..... ... ..... .... ...... .... .... .. ... .... ... ... 14 Fatigue.... .... .... ..... .. .. ... ... ... .... .. ... .... .. ........... ...... .... .. ...... ....................... 15 Individual fatigue............ ................................. ...... .. .. ............ ...... .... 15 Cumulative fatigue..... .. ... .. ..... ......... ........ ... .... ... .. .... ...... ......... ..... ... .. 15 Aviation activity over Kabul. ..... ...... .............. .... .... ... ....... ....... .... .... .... ........ 15 Rotary Wing coordination............................. .. .... .... .... ... ...... ..... ......... 16 Background summary.. ....................... .. ....... ..... ... .... ... ....... ..... .... .. .. .. ..... .. 17 Pre-flight Planning, briefing and authorisation ... ... .. .................... ...... ......... .......... .. .. .... 17 Formation briefing.. ... ... ... ..... ..... .... .... ...... ... .. .... ...... ............ .. ............. ....... 18 Flying currency and proficiency................................................ ... ........... ... 18 Simulator emergency training ........... ............. .. ... .. ..... ........................ 19 Crew composition........ .. .. ...... ........ .. ........ ....... ... ..... .......... ... .... .. ... ....... .... 19 A21's Crew..... .... ... .. .. ...... .. .. .... ............................ .... .. .... ...... ........... 19 A22's Crew.... .. ............. ............. ..... .. ... ....... .... .. .... .......................... 20 Recent crew composition ..... ... .... ..... .................. ............. ..... .......... .. .. ..... 21 Aircraft serviceability.. .... ................. .. ... ... ... .......................... ... .. .. ... ..... ..... 21 Task.. ..... .... .... .. .... ..... ............ .... ... .......... ... .......... ... .. .. ..... ..... .. .. ... .. ... ... .. 22 Pre-flight considerations - summary.. ... .... ... ........... .. ... ... .... .... .... .. .. .. ... ... ... ... 23 1.4- 1 OFFICIAL SENSITIVE Defence Safety 'Author ity ©Crown Copyright 2016 OFFICIAL SENSITIVE Accident sortie- pre-tether strike Passenger embarkation ............................................................. .. .. ............ 24 Aircraft loading ...... .................................. .... .... ...................... .. .. ..... ... ..... 24 Loading guidance........................................ ... ........ .................. ....... 24 A22 loading ...................... ..... ... ........ ............... ..... ............. .... ......... 25 Safety briefing. ... ............ ......... ..... .. ............................... ..... ................ .... 26 Ammunition container used as Crewman rest.. .. ..... ... ..... .......................... ..... 28 Aircraft weight.. .................. .. .... ... ..... .. ....... ... .. .. ... ..... ....... ....... .. ... ... ......... 28 Centre of Gravity.................................................. ..... ............................ .. 29 Departure from HKIA(N).. .. ... .. .. .. ... .... ... .. ... .. ... ... ...... .. .. ... ... .. ... .. .... ... ... 30 Transit to SOC........................................... ..... ... .. .. ... ........... ........... 30 Aviation activity... .. ...... .... ....................... .................. ...... ...... .. .. .. ...... ... .... 32 Radio communications with SOC OPS ............. ............ .. ... .... .................... .. 33 Meteorological cond itions at SOC ..... .............................. .. ...... .. ........ ... .. .. ... 34 SOC .. .................... ..... .. ....................... ...... ... .......... ... ... ... ... ... 34 HLS management. ... ..... ... ...... ..... ..................... ...... ... ... .. ... .... ..... .............. 35 Go around to tether strike. .. .... ................... ... .. .. .. .......... ............... .. ........ .. 36 SOC clearance........ .. ......... .......... .... .... ........................ .................. .. .. .. .. 36 Crew perceptions after go around ...................................... ........... ....... ....... ..... .... 37 Notification of intent to orbit. ......................... ... ..... .. .... ............ .... ..... ... ....... 37 A22 aircrew focus..... .. ..................................... .. .. .. ........................ ..... ...... 38 MOD as an avoid ............................... ..... .... ................... ............ .. .. ... 43 A22 loss of visual contact with A21 . 43 A22 crew reactions............. ........... .... ...... ..... .. ..... ... .... ....... ..... ...... .. .... ...... 46 Captain .............................. ..... ... .... ... .... ... .... ..................... ............. 46 Co-pilot. .............. ..... ... ..... .... ............. .... ...... .. ... .... ... ....................... 46 Crewman ......................... ...... ..... .... .. .. ....... .... ... ... .. ......................... 46 Intra-Formation communication....... ...... .. .. ... ................ .. ..... .... ...... .. .... 47 Loss of Situation Awareness... ........ .. ...... .. .... ... .. ... .. ...... .... .. .. ............ .. 47 Lack of search for the Persistent Threat Detection System ... .... ..................... .... 48 Potential equipment distraction. .... ........ ... .... ... ..... .... ...... .. ....... .. ..... ... .... .. .... 48 Armoured seat. .. .... .... .. ... .... ... .. ... .......... .... .. ... ... .. .. ....... ... ....... .. ... ..... 48 IECD. .............. .. .... ..................... ..... .. .... ..................... ...... .... .. .. ..... 49 Mk 10 Aircrew helmet.. .. ... .... .... .... ... ... ... .. ...... .. .. ... ... ... .. .. .... .. .. .. .. ....... 49 Conclusion ..... ... ... .. ................... ...... .. ... .... .. ............... ...... ..... ....... .. .. 49 Initiation of Avoiding Action ...... .. .. ...... .... ... ... .. ..... ... .. .. ... .. ... .. ..... ..... ..... .. ... ... 49 Persistent Threat Detection System . 49 Conspicuity.......................... .. .. ..... .. ..... .. .. ..... ...... ..... .... .. .... ..... ........ ... .... 51 Previous detachment near miss................... ........... ...... .... .. .. .. ... ... ...... 54 Familiarity....... ................ ... ... ........ .. ... ... ..... ..... .. .. .. .. ..... ............ ..... ..... .... 54 Hazard mitigation. .. .. ............ .... ............. .................... .. .... .... ..... ........ 55 Tether visibility prior to impact...... .. ........... ...... .. ........ .... ..... .. ... .. ...... ... .. .. .... 55 Accident sortie, pre-tether strike summary. ... ... ... .. .. ... .. ...... ... .... ................. .. 57 Tether strike Avoiding action and tether strike.... ... .. ... ................... ........ .. .... .... .. .. ... .... ... .. 58 Damage to right side of aircraft... .. ... ... ..................... ... .... .... ....... .... ... ... ....... 60 Damage to left side of aircraft............. .... .. .... .... ... .... .. .... ...... .... .. .. .... ... .... .... 61 Interaction with TRDS ... .. .. ... .. .. .. ... .. ... .. ... .... ... ... ... .. ... ... ... .... ... .... ... .. .. 62 Effect on TRDS .. .................................. ........... .. .. .... ........ ... .... .. ..... ... ....... 63 1.4 - 2 6 OFFICIAL SENSITIVE Defence Safety Authority ©Crown Copyright 2016 OFFICIAL SENSITIVE Aircraft systems....... ...... ..... ...................... ..... .. ..... .. ...... ... .. .... .... .. ......... ... 64 Auto-Pilot related cautions................. .. .... .. ... .... .... ... .........
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