§ 3.50 p.m.
§ THE MINISTER WITHOUT PORTFOLIO (LORD DRUMALBYN)
My Lords, it may be for the convenience of your Lordships if I repeat a Statement which has just been made by the Minister for Aerospace and Shipping in another place. It is as follows:
"The House will wish to know that the report of the public Inquiry into the crash of the B.E.A. Trident G-ARPI which occurred near Staines on June 18 shortly after taking off 429 from London (Heathrow) is to be published to-day.
"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 condition 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 their 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 causing 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,
My Lords, that is the end of the Statement. I would only add that the recommendations and the action taken 430 to implement them will, with your Lordships' permission, be printed in the OFFICIAL REPORT of this House.
The following is the information referred to:
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 B.E.A. 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 circumstances 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 C.A.A. 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 U.S.A. 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 C.A.A. 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. B.E.A. 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 1, 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 traineee 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' E.C.G., is accepted by the Authority. Meanwhile the Authority imple-
mented on March 1 the ICAO requirement more frequent E.C.G.s for professional pilots. This is two 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, B.E.A. have already introduced an appropriate rule. The C.A.A.'s Flight Operations Inspectorate are examining other airline aircraft to see whether a similar change is needed.
The ninth recommendation suggests that B.E.A. should consider giving their air safety officer greater authority to investigate potentially dangerous incidents. I understand from B.E.A. that there is no limit on his authority to investigate such incidents. Since the inquiry B.E.A. has carefully reviewed the whole system including the organisation, staffing and procedures of its Air Safety Branch.
The final recommendation suggests that the C.A.A. should encourage closer co-operation between its operational and airworthiness branches. I understand that in the past year the Authority has brought about close co-operation 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 C.A.A. 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.
§ 3.53 p.m.
§ LORD BESWICK
My Lords, we are grateful to the noble Lord for repeating the Statement. May we take it that the action to which he refers, and which he said will become available, is that issued by the Civil Aviation Authority last night? If that is so, may I say that the prompt and thorough reaction of the Authority, and indeed the manufacturers, to the issues which emerged from this inquiry are wholly commendable and one must say that one admires the thorough and conscientious way in which they have taken that action. I have one reservation, however, about the British European Airways Corporation, to which I will refer later.
432 Whilst agreeing with the noble Lord in the tributes which he has paid to the Tribunal, may I ask whether he is aware that many of us have very serious doubts about the procedures under which the inquiry was conducted? Would he not agree that it should be possible to ensure that the public interest is adequately protected without these premature public allegations of guilt which were made by various counsel during the course of the public proceedings and which can cause such unnecessary grief to those who have lost relatives in an accident?
On the causes of the crash, does it not seem that the shortcomings listed in the report appear to be associated with, or arise out of, the noise abatement procedures and is any reconsideration being given to the possibility that under present regulations these procedures are called for too early after take-off? Would the noble Lord also say what happened to the inquiries or action which was taken following the other two cases of premature selection of the droop lever? Is it not strange that apparently no action was taken after these two incidents were reported—if indeed they were reported—and can he say whether the report deals adequately with that aspect of the case?
§ EARL AMHERST
My Lords, from these Benches we too would wish to thank the noble Lord for reading the Statement and also to add to the congratulations to the people who undertook this investigation and made this report. I should particularly like to follow the noble Lord, Lord Beswick, in his question about the procedures that took place and the unfortunate remarks made by certain people during the inquiry which implied guilt and which were then, unfortunately, printed in some newspapers. Can the Government take steps to see that this does not happen again? We on these Benches should like to have time to consider and study this long and very complicated report before deciding whether we want to make further comment on it. But in the meantime can the noble Lord say how many of the recommendations—I think there are nine in all—have so far been fully implemented, and if some have not already been implemented, when they will be implemented; and can this information be made very much public so as to restore any loss of confidence in the 433 type of aircraft? I would also ask when the recommendations for modifications, both technical and in the handling of the aircraft and the flight training, will be made known to all users of Tridents throughout the world.
§ LORD DRUMALBYN
My Lords, I thank both noble Lords for the tone of their comments on this Statement. The noble Lord, Lord Beswick, said that there were serious doubts about procedures. My Lords, my right honourable friend the Minister for Aerospace is considering whether any improvement can be made to the procedures for public inquiries and has said he is willing to consider any constructive proposals. At the moment I am bound to say that he is not contemplating any changes in the regulations. After all, public inquiries are a fact of the way of British life and it would be difficult to justify singling out civil aircraft disasters for immunity from investigation in public if the Secretary of State considered that this would not be in the public interest. However, I take note of what the noble Earl, Lord Amherst, has said, and of his serious misgivings on this point.
On the question of noise abatement procedures, this is something which is certainly being looked at. I take it that the noble Lord, Lord Beswick, will read the report, and I am sure he will see what is said on this subject. A review is being carried out by the Civil Aviation Authority and will include discussions with the airlines on operations at Heathrow, Gatwick and Manchester.
My Lords, as to the point about the inquiry into the two previous cases of premature retraction, the Report comments on these fairly fully and I hope that the noble Lord will be satisfied with the comments there. The noble Earl, Lord Amherst, asked whether all the recommendations had been fully implemented. As I am circulating a summary of those recommendations, together with comments on them, in the OFFICIAL REPORT. perhaps he will be good enough to read those first. I shall of course be glad to give him any further information that he may like.
LORD HARVEY or PRESTBURY
My Lords, while in no way suggesting that this type of inquiry should be behind 434 closed doors, I would ask my noble friend whether he is aware that it has caused considerable distress to relatives and to other bodies concerned? Could we at some future date have a debate in this House or another place, or both, on aircraft inquiries in general? After all, the maritime organisations have long experience and the cost of this inquiry has been enormous. I am not saying or suggesting that the money has not been well spent, but to professional bodies it has been quite a hardship. May I have an assurance from my noble friend that B.E.A. have taken effective action where criticism has been directed towards them.
THE EARL OF SELKIRK
My Lords, before my noble friend replies to that question, may I refer to the situation in divorce actions, in which reports of an action as proceeding are not given but the results are? Could not something similar be done in this type of investigation, so that it would be held in public but would not be reported until the official report is published? May I also ask my noble friend whether he is aware that there are nearly always secondary causes behind a disaster, so it is very important to see that a pilot—who can so easily be blamed when he is dead—is not led by them into making mistakes which would otherwise not occur.
§ 4.0 p.m.
§ LORD ORR-EWING
My Lords, while associating myself with the comments on the thoroughness of this examination and of this tribunal, may I ask my noble friend to consider whether, without sacrificing any of this thoroughness, a speeding-up could take place? It is now nearly 11 months since this crash took place and one wonders, when he reports on the action that has been taken on each of the faults found, when that action was taken. Was it put in hand straight away when it was revealed in confidential reports to the Corporations, or have they had to await a final draft report before taking action? Lastly, can my noble friend make known to the House whether the training procedures of the Corporations have been in any way changed and improved as a result of this report?
§ LORD DRUMALBYN
My Lords, I shall try to deal with those questions. I can assure your Lordships that I well understand the misgivings that are felt 435 about the procedures of these investigations, and also about the time they take, but I am quite certain that this is not the appropriate time for me to comment on those aspects. I take note of the suggestion of my noble friend Lord Harvey that we should have a debate on this matter, and I certainly think that it would be a very suitable subject for a short debate. Whether the time is yet right, I am not sure. I am grateful to my noble friend Lord Selkirk for his comments and suggestions. I am sure he will agree, when he has read the report, that it is not always easy to sort out what are the primary causes and what are the secondary causes, when both physical controls and human controls are involved. If my noble friend Lord Orr-Ewing will read the summary of the recommendations and of the action taken, I think he will find that action was taken very promptly. It was not necessary to wait until the report was published before action began to be taken, as is very clear from the paper which I shall be circulating.
§ LORD TREFGARNE
My Lords, while accepting what my noble friend Lord Harvey has said about the need to keep these inquiries public, I would suggest that there is some need to modify the procedure, particularly the rules about who may appear before an inquiry. I gather from the newspapers, and from my rapid reading of the report, that a small number of American lawyers appeared before the inquiry on behalf of a number of people who were killed in the accident, and, although I do not suggest that they wasted the time of the inquiry, certainly they extended the period which it took for Mr. Lane to reach his conclusions. Also, may I ask my noble friend whether the C.A.A. will reconsider the present arrangements whereby senior professional pilots are required to retire at the age of 60, particularly in the light of the fact that Captain Key's heart condition was apparently not easily detectable.
§ LORD DRUMALBYN
My Lords, I take note of my noble friend's comments on the procedures and I am sure that they will be taken into account. As regards the retirement of senior professional pilots and the medical examination of 436 pilots, action is being taken at the present time. One of the recommendations is that stress electrocardiogram tests should be carried out when they can be done more satisfactorily. At the moment they are, of course, done in a rest situation which is said not to give fully satisfactory conclusions. But the frequency of E.C.G. tests for professional pilots has been changed with effect from March 1, 1973, and pilots over 50 years of age will be subjected to six-monthly medical examinations.
§ LORD BESWICK
My Lords, while offering unqualified thanks to the noble Lord for the answers which he has given to me—and I think I can probably say to other noble Lords as well—may I ask him whether, when he informs his right honourable friend of what has been said from all parts of the House about the procedure followed in this inquiry, he will be careful not to tell him that a public inquiry of this kind is part of the British way of life, since this is the first major inquiry that has been held under the 1968 Act? Also, may I ask the noble Lord one other question? As there was considerable delay, right up to the last moment, in finding the courtesy copies of this Statement for the Opposition Front Benches, can he say why this should have been, in view of the fact that the report itself was issued to the Press certainly 24 hours ago, and probably two or three days ago.
§ LORD DRUMALBYN
My Lords, on the last point, I understand that the numbers of the report in the Printed Paper Office were extremely small, and I apologise to the House for this. There were only two copies available, but as soon as I found that out I immediately took steps to try to have more put into the Printed Paper Office. I take note of what the noble Lord has said on the other point and I will convey it to my honourable friend.
§ LORD O'NEILL OF THE MAINE
My Lords, is the noble Lord aware that there is one good piece of news which appears to emerge from this tragedy, and that is that the Trident aircraft has been given a clean bill of health. This, I think, is extremely important, both from the point of view of our export sales of the plane and from the point of view of those who, like myself, fly in a Trident at least 437 twice a week. I think this is something which we should bear in mind. I am sure the Minister will also bear in mind the fact that, in effect, this crash—which, if I recall rightly, was an Anglo-Irish tragedy, as I think that nearly all Dublin's leading businessmen were on that plane going to Brussels—need never have occurred. Therefore I feel sure the Minister will take due notice of all the remarks that have been made by noble Lords in this House with regard to making certain that if any of the recommendations have not already been implemented they will be implemented as soon as possible.
§ LORD DRUMALBYN
My Lords, I am grateful to my noble friend. One can never take steps to ensure that no accident ever happens, but the recommendations that have been made as a result of this accident will, I think, go a long way to reduce the chances of human conditions influencing an accident in this way in the future. As to what my noble friend said about the Trident, it is extremely valuable that the Trident has been given a clean bill of health. One of the recommendations relates to the addition of one more fail/safe device, and that is one extra safeguard.