§ The Minister for Aerospace and Shipping (Mr. Michael Heseltine)
The House will wish to know that the report of the public inquiry into the crash of the BEA Trident G-ARPI which occurred near Staines on 18th June shortly after taking off from London (Heathrow) is to be published today. The inquiry was a long and complicated one and I wish to pay tribute to the Commissioner, Mr. Justice Lane, and his two Assessors, Sir Morien Morgan and Captain Jessop, for the thoroughness of their inquiry and the valuable report which they have produced.
The court found that there were five immediate causes of the accident, namely—
and seven underlying causes which with one exception are all concerned with human factors, including the medical conditions of Captain Key, the experience of Second Officer Keighley and the distraction of Second Officer Ticehurst, rather than mechanical deficiencies. The House will be glad to know that the inquiry found no fault with the Trident aircraft and indeed commented favourably on its safety record and reputation. The court acknowledges that the parties concerned have already taken steps to implement much of what is contained in its recommendations, many of which are matters for the Civil Aviation Authority. The House will, I am sure, wish to know what action is being taken in respect of these matters, and I am setting out these recommendations and the action already in hand to meet them in the OFFICIAL REPORT.
- (a) a failure by the handling pilot to achieve and maintain adequate speed after noise-abatement procedures;
- (b) retraction of the droops at some 60 knots below the proper speed caus-
490 ing the aircraft to enter the stall régime;
- (c) failure by the crew to monitor the speed error and to observe the movement of the droop lever;
- (d) failure by the crew to diagnose the reason for the stick-pusher operation and the concomitant warnings;
- (e) operation of the stall recovery override lever;
§ Mr. Mason
I echo the tribute which the Minister paid to the Commissioner and his Assessors. I think we are all pleased to learn that this excellent aircraft was not proved to be faulty.
There was some unfortunate and perhaps upsetting publicity during the public inquiry. I think it is best in the long term interests of all who are concerned with safe air travel that public inquiries should be held, especially after a major accident. I have one cautionary note. Perhaps the Minister will consider the possibility of improving the system, especially when technical examinations are necessary.
I wish to ask four specific questions. First, the uncovery of the droop baulk early in the flight was done partially to follow the noise abatement procedures. Since the accident, more power has been allowed so that the flap can be kept down for a longer period of time. The uncovery of the droop is therefore delayed and the stalling position avoided. In this 491 connection a more detailed study is required of the technical and environmental problems so that the right balance may be struck between flight safety and social considerations.
Secondly, will the Minister enlighten the House on the extent to which training procedures have changed?
Thirdly, in liaison with the CAA, cockpit voice recorders are being introduced specifically for accident purposes. The British Airline Pilots Association may have had some complaint in the past about privacy in the cockpit, but the association is not worried about voice recorders being used for accident purposes.
My fourth question is about pilot stress. Is it not possible to introduce a system of examination of pilots under physical stress for the purpose of achieving higher reliability in the detection of heart weakness?
§ Mr. Heseltine
The right hon. Gentleman has a serious point about the publicity surrounding public inquiries. I fully share his conclusion that it would be intolerable not to permit the holding of public inquiries. Until the report was published I did not think it right to discuss with Mr. Justice Lane his conclusions and observations. I have it in mind to hold such a conversation with him to discuss any peripheral changes he might have in mind but not a change in the basic system.
As to the uncovery of the droop baulk and the relevance of noise abatement procedures, the inquiry considered this point and came to the conclusion that the crew should have been able to carry out the noise abatement procedures perfectly satisfactorily. Hawker Siddeley Aviation has developed a baulk which is now being fitted to the BEA Trident, and that work will be completed as soon as possible.
The training procedures have been looked at both at the training establishments and within BEA by the CAA to alert pilots and crews to the specific problems thrown up by this accident.
The report deals with cockpit recorders and suggests that they should be made a mandatory requirement for all civil passenger aircraft of more than 27,000 kg. 492 all-up weight. The Air Navigation Order has been amended recently to require cockpit recorders to be installed by 1st January 1975 in many of the aircraft types used by British operators. We are considering whether it is possible to bring this matter any further forward, but it is a difficult and expensive operation and I am not over-optimistic that the date can be changed appreciably.
The report says that electrocardiac testing should be reviewed and that when the tests are more reliable consideration should be given to their introduction. At the moment they are not considered to be sufficiently reliable and the CAA accepts the recommendation to keep them under review. We do not intend to move over to such tests at the moment.
§ Mr. Michael McNair-Wilson
My hon. Friend will be aware that many people were concerned that the captain of the aircraft was nearly 30 years older than his second and third pilots. Has my hon. Friend had discussions with the BAB on the possibility of flight crews in future being more equally matched in age?
§ Mr. Heseltine
BEA has introduced a modification to the "brown line" system which provides that in addition to the captain one of the second officers shall have at least two years' experience as opposed to the one year which was the custom when this accident occurred.
§ Mr. David Steel
Does the Minister accept that the carrying out of noise abatement procedures involves extra complications for pilots in the critical period after taking off, and is any study being made of these procedures? Is the Minister satisfied that the incidents which pilots are required to report to their airlines ever go beyond the particular airline concerned?
§ Mr. Heseltine
The noise abatement procedures are, as I have said, dealt with in the report, and are considered to be within the reasonable capabilities of the crew. The CAA is to carry out an urgent review of the noise abatement procedures at Heathrow, Gatwick and Manchester for the purpose of considering the procedures in the context of the report. Before the accident occurred a change took place in the CAA general 493 set-up. A controller of safety was appointed to co-ordinate the two sides of the CAA—operating and airworthiness— and to ensure that information available to one side is translated to the other. BEA has appointed a responsible person who has the opportunity and the power to investigate all incidents. Since the accident, BEA has reviewed the procedures involved within the airline to be sure that they are working effectively.
§ Mr. Warren
I fear from my hon. Friend's statement that the real tragedy of the Trident accident is that it was predictable. Will my hon. Friend institute an immediate survey of all flight deck equipment and procedures on British registered civil aircraft to ensure that there is nothing else on the flight deck with built-in catastrophic failure characteristics, as we have witnessed with this accident? Secondly, will he institute immediately the mandatory public incident reporting procedures which are accepted in Australia and the United Slates as a major contribution to the high safety record of civil aircraft in those countries and about which there have been many years of discussion here and on which action should now be taken?
§ Mr. Heseltine
Certainly it appears from the report that the specific incidents which had a part to play in this accident were matters on which work was being done in the airlines and on which advice was about to be issued to pilots. To that extent, my hon. Friend's opening remarks are valuable. A very detailed review is constantly undertaken by the CAA into the two matters about which my hon. Friend has asked me. In the context of the authority's responsibilities I have no doubt that it keeps these matters before it continually.
§ Mr. Churchill
Will my hon. Friend see to it that the noise abatement procedures are speedily reconsidered in view of the fact that it is clear in this case that the aircraft in question would have been higher, faster and carrying more power had it not been for these procedures, which are very stringent at Heathrow? Will my hon. Friend also comment on the change in the climbout profiles from Heathrow of the Trident recently effected, and can he say whether it will be extended to other aircraft?
§ Mr. Heseltine
The noise abatement procedures were covered by the report. It was the view of the report that they were well within the capability of the existing crew, although an urgent review is being carried out by the CAA at the three airports most affected—Heathrow, Gatwick and Manchester. As for the new procedures which are being adopted for Tridents on the climb out of London Airport, this is being done because it enables wing-flaps not to be withdrawn, so allowing the baulk on the front droop to remain in position, and therefore giving total protection against this sort of situation up to speeds of 190 knots, after which the risks do not remain. But this is a phenomenon applicable only to the Trident. It would not have the same relevance to other aircraft types.
§ Mr. Dalyell
As a weekly user of Gatwick, may I ask the Minister what exactly the noise abatement study there is? Is it simply a matter of engine power? How soon will it be done?
§ Mr. Heseltine
The noise abatement procedures are a form of power reduction at certain heights to reduce noise. Obviously the safest and most simple way to get an aircraft off the ground is to give it full power and let it go straight up. But in order to balance that requirement with the environmental amelioration which one can get by reducing power at certain heights, there are noise abatement procedures. These are considered perfectly satisfactory within the framework of the examination conducted on them, but they are being looked at again by the CAA.
§ Mr. Tebbit
Does not my hon. Friend agree that this question and answer session could have been much more useful if hon. Members had had the opportunity to read the report before starting to question my hon. Friend about it? Will he assure me, as I understand from what he said, that one recommendation of the report was that cockpit voice recorders should be carried and that the date for their carriage should be brought forward? My hon. Friend will be aware that this is a matter that I have been urging on him for some time. I hope that my hon. Friend will not take too much notice of those who say that it cannot be done in time. It is done already in the United States. Finally, in order that there may 495 be a balance of comment about the report, can my hon. Friend say whether there is any recommendation about the conduct of the airline which one could reasonably have expected by now to have been acted upon but which has not yet been acted upon?
§ Mr. Heseltine
The normal procedures for making information of this kind available to hon. Members have been followed in this case. It would be very difficult to publish a report in advance which was then not widely available to the public at large at a time when the Minister responsible was not available to comment on it. That is the normal procedure. We have taken steps to publish the report as quickly as possible in the circumstances.
As for cockpit voice recorders, I accept the urgency which my hon. Friend gives to this matter, as do the airline and the CAA. They are doing what they can to bring forward the date already agreed upon, which is 1st January 1975. The fact that the practice has been adopted already in the United States is not a factor. It is not the equipment which is difficult. It is the time that it takes to fit it and the economic penalty of withdrawing aircraft from service while it is done. It is expensive and time consuming.
My hon. Friend asks whether anything could have been done earlier than has already been done. This is a subjective matter, and hon. Members will want to consider that when the report is before them. I do not take a dogmatic view about it. Along with the CAA and the airlines, I shall keep the matter constantly under review, and I shall respond to any advice, especially that of my hon. Friend the Member for Epping (Mr. Tebbit), where it appears that we are being dilatory. But I hope that that will not be necessary.
Following is the information:
The first recommendation relates to "the need" for a baulk to prevent premature retraction of the leading edge droops or slats. Hawker Siddeley has developed and the Authority has approved an air speed sensitive baulk. Manufacture of the equipment is well advanced, its installation in the BEA Trident fleet is expected to start next month, and their whole Trident fleet should be equipped within a year. In addition, a mandatory procedure has been introduced to prevent premature retraction of the droops.
The second recommendation deals with the need for instruction and training for pilots on the causes and results of "change of configuration" stalls; on the circumsances in which a stick-pusher and stick-shaker may operate almost simultaneously; and on the difference in design concept between stick-shaker and stick-pusher mechanisms.
The CAA accepts the importance of giving additional emphasis to these items during basic and conversion training and is taking action with the flying schools and airlines concerned. It is also investigating what is done in Australia, France, Germany and the USA about stall training.
The third recommendation proposes that the carriage of cockpit voice recorders should as soon as possible be made a mandatory requirement for all civil passenger-carrying aircraft of more than 27,000 kg all-up weight.
The CAA accepts this recommendation in principle and will immediately consult the airline industry about the practicability of an early date for the supply of the equipment and its installation in all the aircraft involved. BEA plans to meet this requirement are well advanced. The Air Navigation Order was recently amended to require cockpit voice recorders to be installed by January 1st 1975 in many of the aircraft types used by British operators.
The fourth recommendation deals with the need for pilots to be aware of the dangers of subtle as well as obvious pilot incapacitation. In the light of the evidence given during the Inquiry the Authority has already instructed its Flight Operations Inspectors to ensure that crew training and flight procedures take full account of the point now made in the recommendation.
The fifth recommendation proposes that young trainee pilots should be given additional experience, possibly as observers on the flight deck, before operating as P2 on passenger-carrying flights. The Authority is about to discuss this with the airlines.
The sixth recommendation which proposes that should the "stress test" electrocardiogram in future become significantly more reliable, it should be substituted for the present "resting" ECG, is accepted by the Authority. Meanwhile the Authority implemented on 1 March the ICAO requirement for more frequent ECGs for professional pilots. This is 2 years in advance of the date set by ICAO.
The seventh recommendation questions the desirability of allowing the P4 seat to be occupied during critical stages of flight by anyone except a person having a flight function to perform or under training. Occupation of a spare flight deck seat is already regulated by the airlines, but the Authority will consider further whether this, coupled with the complete discretion of aircraft commanders to refuse access to the flight deck, provides adequate safeguards.
The eighth recommendation concerns the stowing of the pilots' folding arm-rests on the Trident during the take-off, initial climb, approach and landing. As the report indicates, BEA have already introduced an appropriate
rule. The CAA's Flight Operations Inspectorate are examining other airline aircraft to see whether a similar change is needed.
The ninth recommendation suggests that BEA should consider giving their Air Safety Officer greater authority to investigate potentially dangerous incidents. I understand from BEA that there is no limit on his authority to investigate such incidents. Since the Inquiry BEA has carefully reviewed the whole system including the organisation, staffing and procedures of its Air Safety Branch.
The final recommendation suggests that the CAA should encourage closer co-operation between its operational and airworthiness branches. I understand that in the past year the Authority has brought about close cooperation between these two complementary Divisions, under the Controller Safety, to whom both Divisions report.
Although the report makes no recommendation in respect of noise abatement procedures, and there appears to the CAA to be no evidence to cause doubt about the adequacy of safety margins, the Authority is nevertheless instituting a review of all safety aspects of noise abatement procedures.