Unsolved Mysteries

Hugh Pennington

A police helicopter crashed into the Clutha Vaults Bar in Glasgow on 29 November 2013. The pilot, two police officer passengers and seven in the bar were killed. The Air Accidents Investigation Branch published its final report last week. Relatives of those who died had been briefed in advance. They said that they were doubly disappointed.

First, because the AAIB Inquiry report concluded that:

the investigation could not establish why a pilot with over 5500 hours flying experience in military and civilian helicopters, who had been a Qualified Helicopter Instructor and an Instrument Rating Examiner, with previous assessments as an above average pilot, did not complete the actions detailed in the Pilot’s Checklist Emergency and Malfunction Procedures for the Low Fuel 1 and Low Fuel 2 warnings.

The low fuel warnings came from the tanks that directly supplied the two engines. The pilot acknowledged them five times, but did not turn on the transfer pump from the main tank, which contained fuel, or land within ten minutes. He should have done both. The warnings started sounding twenty minutes before the crash. One of the engines flamed out because of fuel starvation forty seconds before the crash, the other eight seconds before.

Second, the relatives were unhappy because the main recommendations of the investigation, that flight data recorders should be installed on small police and medical helicopters, do not carry the immediate force of law. But the AAIB does not make the rules. They come from the Civil Aviation Authority and the European Aviation Safety Authority. And there are political tensions. The Scottish government is putting pressure on the recipient of the AAIB report, the UK Secretary of State for Transport, regarding the implementation of the recommendations.

The public has a touching faith in the ability of inquiries to answer questions, learn lessons and prevent disasters being repeated. But sometimes they can’t do the first because the evidence is missing. The Clutha helicopter crash may well join the 1906 Grantham railway accident as an exhaustively investigated but unresolved – and unresolvable – mystery.

The night mail from London to Edinburgh was due to stop at Grantham at 11 p.m. on 19 September 1906. The points north of the station were set to divert another train to the Nottingham line. The signals were red. But the train roared through, derailed and caught fire. The driver and fireman, eleven passengers and a postal worker died. The driver had 18 years driving experience and had been in sole charge of the two-year-old engine since its construction. There were plenty of rumours: he was drunk, or had gone mad, or had collapsed, or had started a fight with the fireman. But the signalman in the box that the train passed just before the crash had seen them standing motionless on either side of the footplate, looking ahead. As L.T.C. Rolt said in his classic 1955 book about rail disasters, Red for Danger, ‘what precisely took place on the footplate of Number 276... is a question that Sherlock Holmes himself could not answer.’ It will probably be the same regarding events in the police helicopter on 29 November 2013. Even a flight data recorder (FDR) might not have provided the necessary information.

The BEA Trident that crashed 120 seconds after taking off from Heathrow on 18 June 1972 (the deadliest civil aircraft disaster in the UK, with 118 deaths) had an FDR. It showed that the plane was stalling, that the warning system had operated three times, but was turned off 22 seconds before the aircraft dived into the ground. The reason why remains a mystery. There were four pilots in the cockpit. The Trident FDR did not record images or audio. Even if it had, the only words might well have been ‘oh shit!’ just before the crash. It could have been the same over the Clutha.

As for learning lessons, we do that well, but we’re good at forgetting them too. I investigated the 1996 E. Coli O157 outbreak in central Scotland. The bacterium killed 17. The rules for butchers were changed. But in 2005 another butcher was ignoring them. There was another outbreak. A little boy died. I chaired another inquiry, and concluded: ‘I had hoped that the lessons of the shocking event in 1996 would stay in people’s minds. But comparison of the failures that led to this outbreak in South Wales with those in the outbreak in Scotland showed that this has not been the case.’


  • 27 October 2015 at 7:20pm
    killiegradge says:
    I often wonder how much these so called experts really know?I do recall one "expert" predicting that "bird flu" could kill 2 million Britains.

    • 31 October 2015 at 3:15pm
      Joe Morison says: @ killiegradge
      An unusual strain of influenza, very possibly mutated from avian influenza, could easily kill 2 million Brits. The Spanish flu that emerged after WWI not only killed more people than the conflict, but in particular it killed young healthy people because it had the knack of turning our immune systems against us - the stronger the immune system, the more potent the virus.

      Of all the threats we know of that might seriously devastate humanity in the next few decades, flu is easily the most likely. (On the up side, if you do survive, for a brief period property in London will be affordable.)

  • 28 October 2015 at 8:58am
    cufflink says:
    This raises searching and profound questions as to just what 'years of experience' means in connection with prudent safety under operational conditions. I drove for two years as a security cash delivery agent for a sizeable firm and was utterly flabbergasted at the phlegmatic approach to immediate problems in order to keep the ship going. In many ways it was admirable as a test of nerve and manliness and I was complicit in its insouciance. The fact is improvisation and disregard of warning indicators was taken on the basis that nothing was seriously wrong but that it was only the indicator playing up; after all we were still motoring; and a test of the brakes, a rev of the engine was all the reassurance needed. We used foil cigarette wrappings to mend a fuse. My wife was for many years a Head of a Primary School and took the safety of the children as paramount to anything else. One morning the outing coach was not showing one brake light and she requested that it be put right but the carrier said there was no one to do it within the hour, and in any case the problem was not critical, so the trip after much agonising was cancelled with great disappoihntment to the children.
    These are small matters compared with Hugh Pennington's dire recounting of the tragedies. But how many times has one when ordinarily driving on our roads missed tragedy by a wisker?
    This is no indictment of the good people who were titually involved in the mentioned disasters. Hugh does not prescribe a remedy but does imply that opportune reiteration of the known facts to the general public will instil the necessary wise caution to prevent such disasters. However a dull world is not necessarily a safe one either. I'm coming in on a wing and a prayer!

  • 28 October 2015 at 5:06pm
    kadinsky says:
    For several days after the police helicopter crashed on the Glasgow pub two years ago there was breathless round-the-clock reportage by BBC and Sky - with endless expert interviews and speculation. It was instructive, then, that when dramatic new revelations about the crash emerged last week they were deemed to be worthy of no more than cursory mention by the media. Another small reminder of how utterly bogus our news culture and news gatherers are.