Culture of rule breaking led to Iroquois crash

MICHAEL FORBES
Last updated 16:08 16/12/2011

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The father of an airman killed in the Anzac Day Iroquois crash has rejected official findings his son and other crew were partly at fault.

The long-awaited findings into the crash that killed Flight Lieutenant Hayden Madsen, 33, Flying Officer Dan Gregory, 28, and Corporal Ben Carson, 25, were released this morning.

The fourth crewman on board, Sergeant Stevin Creeggan, was the only survivor when their Iroquois went down in rugged terrain east of Pukerua Bay while en route to perform a dawn service flypast in Wellington.

The report found sub-standard protocols and a culture of “rule breaking” among 3 Squadron was partly blame for the fatal crash.

Peter Madsen, father of pilot Flight Lieutenant Hayden Madsen, 33, said he still believed bad weather was to blame, despite the Court of Inquiry identifying a rage of other factors.

"The weather was obviously 100 per cent of the problem. If there was no low cloud, there would be no accident. It's as simple as that,'' he said.

He felt any suggestion his son was unqualified to be flying that day was unfair.

"The [Iroquois] aircraft is not designed to fly in those conditions, so therefore he [Hayden] was not trained to fly in those conditions. That really is the beginning and the end of it as far as I'm concerned."

Mr Madsen said he had no issues with how long the investigation had taken, because getting it right was the main priority.

The report had not brought him complete closure but it had helped, he said.

"It [the crash] is something that we'll live with until we die. But, in one way, this could possibly be the beginning of the end, so to speak.''

Dan Gregory's father Steve said the report was a ``tough read''.

But his view from the outset was that the crash was a tragic accident and the contents of the report had done nothing to change his mind, he said.

"It's upsetting to know how close this accident was to being avoided. It's also tempting to know think we could go back and alter just one minor detail and change the outcome.''

"No one ever thought that a ceremonial flight to honour the fallen would end this way, and no one intended it. I know and accept that.”

Andrew Carson, father of crewman Corporal Ben Carson, 25, said he found it difficult to understand why the air force were allowed to investigate themselves.

"Maybe OSH [Occupational Health and Safety] or the police should have investigated as well.''

Mr Carson said he had not personally delved far enough into the findings, but he believed there could be just cause to hold someone criminally responsible.

CULTURE OF RULE BREAKING

Sub-standard protocols and a culture of “rule breaking” among 3 Squadron was partly blame for the Anzac Day Iroquois crash that killed three servicemen.

The report found the crew lost situational awareness when then inadvertently flew into heavy cloud in the early-morning darkness, and did not recover in time to take evasive escape action.

Their night vision goggles were rendered useless by a lack of moonlight, and they were not properly prepared to fly using only their instruments.

The court of inquiry made 20 recommendations in total. Half of those directly addressed what it deemed to be the six causes of the crash.

There were no eye witnesses to the crash. Sgt. Creeggan has no memory of it or the ten days after.
 
HOW IT HAPPENED
 
A 5.13am, three Iroquois left Ohakea Air Base, near Bulls, flying in a staggered line. Madsen, Gregory, Carson and Creeggan were in the second of the three helicopters.

To avoid the forecast low cloud on the direct route, the formation headed west until they reached the ocean and then followed the coastline south.

At 5.48am, the formation reached Pukerua Bay, where they moved into a straight line in preparation for a left turn back towards the north.

The first two Iroquois made the turn and disappeared into low cloud, robbing them of their visual reference – a condition known as Instrument Meteorological Conditions (IMC).

The formation immediately lost cohesion and mutual awareness. Each initiated their own escape plans.

The first Iroquois switched to instruments and began to climb. It unknowingly crossed the coastline and flew over high terrain, but its rate of climb carried it clear.

Seconds after entering the cloud, the second Iroquois turned on its searchlight, which confirmed the crew could not see anything.

Madsen also made a radio call to say they had entered IMC and were climbing north.

“The absence of apparent distress in his voice over the radio is inconclusive but indicates that the crew were probably not aware of the imminent danger of terrain,” the report said.

The second Iroquois crashed into a hill about 30 seconds after entering the cloud. Madsen, Gregory and Carson were all killed, while Creeggan suffered severe head, chest and leg injuries.

He was able to activate a search beacon and managed to survive at the crash site for about 90 minutes before being rescued.

Upon seeing the first two Iroquois disappear into the cloud, the third opted to descend below cloud base and perform the turn. It continued north and landed at Paraparaumu.

CAUSES
 
The court of inquiry identified several significant factors that contributed to the crash. Some related to the actions of the Iroquois crew prior to the crash, others related to wider defence force protocol, which was found to be inadequate.
Those that relate to the Iroquois crews included:
 
•    The formation continued south, past Paraparaumu, despite encountering a cloud base below 600ft – the minimum for using night vision goggles.
•    Flying in a straight line increased the workload on the second Iroquois crew, reducing their capacity to judge the cloud and terrain.
•    After entering cloud, the second Iroquois did not immediately begin an effective rate of climb to avoid the terrain or turn onto a safe heading.
•    Its radar warning system was set to 50ft, when it should have been set to 200ft. It is likely to have activated only seconds before the crash.
•    No one on board the second Iroquois was current in relevant flying competencies for the task they were performing.
•    There is no evidence that Madsen was qualified to fly at low levels over water at night.
 
Factors that related to wider defence force protocols and procedures included:
 
•    Air force processes, at both an operational and tactical level were not effective at identifying and mitigating the risks associated with the night vision flights.
•    The air force did not ensure the three Iroquois crews were fully qualified, competent and up-to-date with training. Madsen and Gregory had little recent flight experience leading up to the crash and were the least experienced of all the pilots flying that day.
•    At the time, there was a culture of “rule breaking” among members of 3 Squadron, if they felt comfortable doing so.
•    Air Force audits were also to slow when it came to addressing and preventing unsafe flying practises.

Air Vice-Marshal Peter Stockwell, Chief of the Air Force, said most of the recommendations had been put in place, including a re-write of air force protocols and crating new positions at Ohakea to oversee flight operations.

More flight safety staff were being added to the base and the “can-do” culture was being addressed, he said.

- The Dominion Post

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