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Vietnam
Air Accident Inquiry Organisation |
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Vietnamese Reports on the Loss of VN 474. November 14. 1992. A crash report was issued to the British Embassy in Hanoi on the 25th December 1993. The British family received it on the 14th January 1994. It was dated 11th January 1993 and was the finding of a "Provisional Committee of Investigation". It contained little information, covered half a page of A4 and stated that there were cumulonimbus clouds in the area, that the aircraft was already low, was caught in a down draft, then struck by trees. There was no substantiating evidence. On the 18th January 1994 it was requested that a full and credible report be obtained, and after many more reminders throughout the years the complete accident report was received on the 4th September 1999. This is a fuller account of 19 pages and includes the fragment obtained earlier in 1994, in the conclusion. It is vague, incomplete and contains unsupported assumptions, contradictions and anomalies, yet ignores the fact that the crew’s last wish was to descend further, with only intermittent ground contact, and already at the safety height for the sector. With a view to clarifying some of the discrepancies, further information was requested. After four months a reply was received. The Civil Aviation Authority of Vietnam considered that all of the questions asked were clarified in the report. Which is clearly untrue, none of them were. In view of the unwillingness of the CAAV to justify their conclusions with hard evidence and explanations, maintaining an evasive and defensive attitude suggesting extreme guilt, the following comments on some of the unsupported assumptions, contradictions and anomalies of the accident report are made. It is not intended to reproduce the whole of the Vietnamese Accident Report in these pages, but just to give an account of those items discussed. It is suggested that anyone requiring the full document, perhaps seeking further discrepancies, requests a copy from:- Mr Nguyen Tien Sam, Director General, Civil Aviation Authority Vietnam, Gialam Airport, Hanoi, Vietnam. tel 84 4 827 3384. fax 84 4 827 1933. E-mail iad_caav@hn.vnn.vn Observations on the Aircraft Accident Investigation Report VN 474, 14 November 1992 The Synopsis states that the investigation was to be in line with International Civil Aviation Organization recommendations. These include that States having casualties in an accident should be notified of the facts. A delay of 6 1/2 years before passing on the information is possibly not quite what the ICAO intended. There are many other deviations, as follow. The Executive Summary does not take into account that accident investigation recognises that in the majority of accidents there is no single cause. A combination of factors, with many factors contributing is considered usual. The crash report for this accident concentrates on finding one cause, and that a normal natural occurrence, to the exclusion of all others. The Provisional Committee for Aircraft Accident Investigation met for the final time on January 11 1993; "reviewed the whole scene of the accident (by model) and agreed upon the conclusions of the causes of the accident to be reported to the Government." Five possible causes
were considered. Factual Information. 1.1. History of the Flight. Times UTC. (Local VN Time is + 7) The report’s
account of radio transmissions between Nha Trang Tower (NGT) and VN474
differs from the transcription given on a diagram of the flight descent
profile released in May 1993. On neither account is there use
of the standard practice of a One to Five indication of readability.
At 00.00. reception is unsatisfactory, and two minutes later a call
of "Nghe tot", "Hear ok" is sustained throughout the transmissions.
Just how discernible the transmissions are, is not indicated. Nor is
there a ‘read back’ of the QFE, (altimeter setting to give
a 0 reading on landing at the airfield) an essential item, mentioned,
nor is this picked up elsewhere. There are many anomalies in the detail
of timing and content between the two accounts:
In the light of the discrepancies between the report and the text of the descent profile, and the lack of standard ICAO phraseology and procedure, it is likely that there was some confusion. Neither of the accounts is of a precise format that would be expected from a factual accident report. A true and legible verbatim transcript of the recorded tape has been requested, and has been refused. The crew were allegedly being subjected to extreme turbulence, struggling to control the aircraft and latterly being harassed by the Tower, which though asking VN474 to call on reaching Flight Level 070 anticipated this call twice. Or did the controller suspect that the aircraft was vertically further advanced in descent than the crew appeared to realise? At this time VN474, according to the Descent Profile provided by Vietnam, made a navigational error, estimating 20km to the coast, when it appears to have been 43km from Nha Trang and approximately 35km from the nearest point on the coast.
It would be expected from the inferred accuracy of the, to the nearest second, presumably true timing, that the descent profile was the definitive one of the two radio traffic accounts. But closer analysis reveals that the accuracy of the physical positions given for the various contacts are haphazard. There was no radar cover admitted after 00.02, so how were they arrived at? Given a start time of 00.00. at Dalat, 105 km to Nha Trang and an ETA of 00.17. suggests a ground speed of around 370 km/hr, an average advance of 6.17 km/minute. The advance illustrated is erratic and lagging, compared to that expected. The time of the final conversation, based on the crew’s estimation of ETA corresponds in distance to the location of the impact at 75 km from Dalat, 30 km from Nha Trang. Is this casually plotted descent profile the "model" mentioned in the Executive Summary ? By which the Provisional Committee "reviewed the whole scene of the accident and agreed upon the conclusions of the causes to the accident to be reported to the Government."? Factual Information should also have given the location of the accident, in latitude and longitude, and the elevation, the latter is mentioned in Accident Site 1.15., but there is no definitive geographic position given anywhere in the report. The Vietnamese Director of Air Safety has stated that this was because they had no "GSP"? GPS? (Global Positioning System). Nor had many other people at that time, but a position would have been expected. 1.7.4. Sigmet report. This is confused. It gives information that the edge of Typhoon "Forrest" was in the Khanh Son - Khanh Hoa area, the centre was 400 km to the south and the maximum wind speed at the centre was 25 m/s. (approx. 44 Nautical miles/hr) Then without pause, discusses cloud and air turbulence over mountains, and a wind (no strength given) from the sea. Confusing conditions in the centre of the Typhoon with those outside the periphery. Possibly there is some omission here, some text missing? 1.7.5. Weather conditions in South-central Vietnam. This indicates that
the typhoon only extended as far as Vung Tau, 300 kilometres to the
south-west. That in an undefined area to the south of Da Nang, (450
kilometres to the north of the accident site) there was 4-9? Cu (Cumulus)
300-500m, Sc (Stratocumulus) & As (Altostratus) with rain, visibility
5-8km and that the wind was north-north-west. (again no strength given)
The actual weather at Nha Trang gave a negligible wind speed of 1m/s,
at 310 "Nha Trang Airport was equipped with one NDB, NG 368, at 12.13.36N 109.11.05E." The only navigational aid at Nha Trang was a simple non directional beacon, broadcasting on a frequency susceptible to weather interference, especially from Cumulonimbus Clouds. For an airfield so hemmed in by high mountains, and with hilly islands on the sea approaches, this is not ideal. From information received December 1999, this is still the only aid. 1.11. Flight Data Recorder. (FDR) There is no mention of where the flight data recorder was installed in the aircraft. The distressed condition of the recorder tape is graphically described, yet there is no detail of the actual data obtained. The extensive damage to the relevant part of the tape and difficulty in reading the timing and zero co-ordinates, would make interpretation very difficult, compounded by the parameters being only "fairly readable". The parameters on the portion of tape applicable, "deformed, twisted, curved, shrunk and scratched, rumpled with some holes.", could only be "calculated approximately." Yet paragraphs 1.11.4. to 7. give an account of extreme forces that the aircraft was allegedly being subjected to over its last 15 minutes. Access to the alleged substantiating data has been denied. For at least 12 of these last 15 minutes, during which "there were up to seven times of sudden changes of the H, (altitude) V,(speed) and Ny", ("vertical overload") the crew were in contact with Nha Trang. Yet there was no mention of "violent turbulence" at any time during the descent when, according to the FDR, they must have been experiencing great difficulty in controlling the aircraft. In the absence of any comment on the alleged extreme conditions by the crew, the interpretation of a damaged tape, the parameters of which could only "be calculated approximately" can only be treated with extreme caution. There is no mention of a Cockpit Voice Recorder, (CVR) or data from one. Or of any Ground Proximity Warning System. 1.12. Wreckage and Impact Information. This is quite complex and very confusing. A Yak 40 has only one rudder, on the centreline, yet there is mention of a left rudder. 1.12.1.6. All landing gear assemblies were found at the same place. There is no mention of whether the gear was extended, as could be expected if all snapped off at the same spot. The flaps were also out of their housing, and could have been extended. The passenger step was 170m East of the rudder, an indication of the direction of travel. "The FDR was 150m away from the area where the tail caught fire." The FDR was found 150m away from other wreckage. 1.12.2.2. Possibly moved by looters, opened and then discarded as useless. There is no mention of where any of the three engines were found. A diagram would help in understanding the layout. Requests for further information have been denied. 1.13. Medical and Pathological Information. A survivor was found in the afternoon of 21st November. Carried down & into Khan Son Hospital in the morning of the 22nd. Taken to Nha Trang in the morning of the 23rd and on to Saigon. "The other passengers and all the crew members were found dead because of bad injuries and violent collisions." From this it is
deduced that first impact was made at the very top of a ridge, and that
the aircraft may have cleared this ridge, but for the trees. There was
then a short hop of 350m before the final impact, and a total length
of 600m. The height is given as 970m. Previous enquiry as to location
placed the site at 12° 03'
N. 108°
59' 30"E. This does correspond on maps of the area to a slope of 20°
-25 1.15.5. States "Most of the bodies were found undamaged." 1.13. Above says "found dead because of bad injuries and violent collisions." These statements are hardly compatible, and raise the question. How did the undamaged die? 1.15. under ICAO format would have been headed Survival Aspects and would have included search, evacuation and rescue, location of crew and passengers in relation to injuries sustained, failure of structures such as seats and seat-belt attachments. There is no complete coherent account of these details in the report. 1.16. Interviews. Witnesses statements from Mrs Mau Thi Nam, and Mr Mau Quoc Tan. Considered later. 1.16. Under ICAO format would have dealt with Tests and Research. Personal statements would not be included under ICAO Recommended Practices, nor the other individuals identified. Annex 13 Chapter 5.12 Disclosure of records. 1.17. Application and Efficiency of the Investigation Techniques. This would appear to be another deviation from the ICAO format, but following its line of enquiry other possibilities arise. There is no mention anywhere of the configuration of the aircraft, as to position of undercarriage and flaps, or indication of what power the engines were developing at the time of impact. Either from subsequent examination of the engines, study of trajectory between impacts, and the location of the engines. (Not mentioned in 1.12 above) There is no mention of any attempt to estimate the aircraft speed on impact. The configuration would be quite important in the event of meeting strong down drafts, the ability to recover altitude would be restricted if the undercarriage and flaps were deployed, and should the engines have been throttled back for descent the poor acceleration time of pure gas turbines would give a slow response in an emergency. An aircraft of this type, in a clean configuration, and on a cruise power setting, would be little affected by wind shear. The Vietnamese Director of Air Safety has also stated that Vietnam did not have the technology or expertise to perform some of the post accident checks asked about. Specifically they did not know if the undercarriage was down or the flaps extended. This is an amazing admission by a Director of Air Safety, and in the presence of the Chief Inspector of Air Safety. In the investigation of an accident concerning an aircraft on the approach and thought to have been subject to weather interference, the configuration of that aircraft would have been of prime importance, as outlined above. To say that they did not have the technology admits to complete ignorance of aircraft and their systems. There would have been many indications; the extent and direction of damage, hydraulic jack extensions, uplock and downlock positions, for three separate undercarriage assemblies. The flaps may have had less indicators, but examination of the damage to surfaces and again jack extensions should have provided sufficient evidence as to deployment. Similarly, the cockpit, though "smashed into smithereens" should have yielded some relevant information, altimeters showing pressure settings are very robust and other instruments can be examined to indicate readings on impact. The position of Undercarriage and Flap selectors and indicators may have been verifiable. There is very little evidence that did not come from the Flight Data Recorder tape which was "deformed, twisted, curved, shrunk and scratched, rumpled with some holes.", and could only be "calculated approximately." Access to the alleged FDR data has been denied. Earlier requests for information in 1992/3 revealed that VN474 was monitored by the national radar system until contact was lost at 00.02. UTC. The national radar system may have had relevant information on the weather and have been in a position to warn of severe weather. Yak 40 aircraft are equipped with weather warning radar for crew use. 2.2. This gives information that on checking the aircraft logbook, the FDR tape, comments from the Manufacturer the technical authorities and the actual scene showed that the aircraft was in a serviceable condition. What were the comments of the manufacturer? Surely the invited Russian engineers would have known if the undercarriage was up or down, or did they not visit the accident site, or see any parts of the aircraft that would enable them to determine its technical condition? The Director of Air Safety has admitted the Vietnamese technical authorities lack of competence. The FDR tape only recorded H, V, and Ny, not aircraft serviceability, unless the alleged FDR data was due to a violently fluctuating horizontal stabiliser, not the weather. (The Yak 40 has an electrically controlled hydraulically actuated tailplane, aircraft of similar design are known to have had accidents from pitch trim malfunction.) Was there any check of the tailplane mechanism? Unlikely if the Vietnamese could not even determine the position of the undercarriage. They have also admitted to not knowing if the engines were delivering power or not. 2.3 "The FDR clearly recorded that the aircraft was repeatedly overloaded vertically, drifted up and down many times by the static pressure, the speed of was (sic) changed with dynamic pressure. It was clear that the aircraft was seriously affected by weather in the last phase of the flight." Without access to the data from the damaged tape, guarded with great secrecy by the CAAV, it is difficult to comment on this, "clearly recorded" is at odds with "fairly readable" and "calculated approximately" 1.11.2/3, but as mentioned above. A malfunctioning tailplane could give sudden changes in pitch, producing similar results. This turbulent behaviour is said to have continued through the final 15 minutes. Why was there no mention of it on the crew's air traffic voice recording? 2.4. States that the crew were "qualified to fly the aircraft in all weather conditions during the day." Implying that they were not qualified for night operations, but clouds were no problem. Similar conditions to night could be experienced in the heart of the cumulonimbus clouds (Cbs) described. There is no mention of crew Instrument Ratings in 1.5. Personnel Information. Previous requests for information on the pilots Instrument Qualifications met replies such as: "The flight crew was fully capable of flying the flight in conformity with the existing regulations of Vietnam" (Note, October 30 1993) How these compared with international regulations is not known. 2.5. States. "The tape which recorded voice communications between Nha Trang Control Tower and VN474 showed that the aircraft had been in good condition". This tape showed that the radio worked until 00.12.15, nothing more. The crew had failed to report the alleged "violent air turbulence", "drifting them up and down many times". Making "it clear that the aircraft was seriously affected by weather". 2.2.&3. Similarly they may not have bothered to relay any technical difficulties. CAAV Conclusions Findings 3.1. 3.1.1 "According to the witnesses, it rained heavily with violent windshear." 3.1.2. "The witnesses also confirmed to have seen the aircraft over passing low trees at about 100m (700-800m above the sea level) with the red lights flashing." This implies that there were witnesses to the accident other than Mrs Mau Thi Nam. Also they were all observing violent wind shear. 3.1.1. Wind shear is not a term used by laymen or a condition generally known to them. There is no mention of how this "windshear" was manifest to them, or of them investigating the crash and/or informing the authorities. 3.1.4. "The aircraft
crashed in an area within the corridor of W-13 - heading 059° , 6,000m away from it’s centre line, which showed that the aircraft
had been flying as cleared by Nha Trang Control Tower for procedural
approach." 6km off track only 30km from the beacon would indicate a considerable
deviation from the correct track, A correction of 10°
3.1.5 Analysis of Kanh Hoa Weather. This alleges that satellite information of the cloud tops indicated the vertical instability clearly. Independent analysis indicates that though Typhoon 9229 would not play a specific role in the incident, the upper cloud associated with it made identifying individual cumulonimbus cells very difficult. Access to the Vietnamese data has been denied. The Director of Flight Safety now admits that this was drawn by hand? But what original source gave the artist inspiration? Visual and infrared images captured at 23.41 on the 13th November 1992 give no such clear information.
Causes. 3.2. (See Executive Summary above) The process of elimination is flawed by there being no factual evidence in the report to substantiate that there were no technical problems, or violations of flight procedure. The cause given, "Weather Conditions", (all of which the flight deck crew were qualified to fly the aircraft in) ( 2.4) are a normal flight hazard that current aviation practices are designed to overcome. If weather conditions did indeed lead to the accident then the Safety Recommendations in Part 4 are reflections of the true causes, the lack of previous installation of adequate navigation aids and procedures. The Safety Recommendations in the Report are:- "4.1 The Ministry of Defence, the Civil Aviation Administration of Vietnam should take into consideration with a view to increase the minimum obstacle clearance altitudes for routes over mountainous areas along the coast. All airports should be equipped with approach radars. 4.2 Aviation meteorology industry should in close collaboration with the General Directorate of Hydrometeorology pay more attention to the characteristics of the meteorological forecasts for Aviation industry, inform timely of thunderstorms, low pressure and climate changes in order to take precaution against windshears and vortex which cause violent downdraft and updraft. 4.3 Control towers at airports near the coast should have adequate meteorological equipment, and the controllers should improve their skills in controlling aircraft during approach. 4.4 Regarding Nha Trang Airport, if there appears a typhoon 250-400 km away, that typhoon should be watched and kept trace. If the typhoon is within a radius of 200 km or the airport is within the typhoon area, an alert should be initiated and the airport should be closed. Aircraft should be flown at the level of at least 2,000 metres above the highest obstacle along the route W-13 (Da Lat - Nha Trang). 4.5 The Government should promulgate a decision as soon as possible to form a National Committee for Search and Rescue, and there should be a decree for its operation from central to grassroots levels." The basic reasons for the accident therefore are:- (a) Failure to supply an adequate weather report or interpret the report correctly. 4.2,3&4. (b) Failure to appreciate the severity of the weather encountered on route and to take appropriate evasive action. 4.1,2,3&4. (c) Failure to provide adequate airfield approach aids to support the all weather operations required. 4.1,3.&4. (d) Failure to maintain adequate terrain clearance. 4.1,3&4. (e) Poor Air Traffic Control. 4.3. A sad history of cumulative negligence. Item 4.5. reflects the need to have acted urgently, to liaise with local populations and to have trained staff with adequate communications facilities available; if unnecessary, post accident, loss of life is to be prevented. There are two glaring omissions from the Safety Recommendations:- (1) The training of flight crews to be aware of the hazards of bad weather operations in mountainous regions. (2) Training of crews to make full use of the Grossa-40 Weather Radar, carried by Yak 40’s, expressly to avoid such dangerous weather. It is appreciated that the crew were of modest experience and, with the exception of the engineer, only recently qualified on type. 1.5.1,2&3. But to carry on through "15 minutes" of "violent turbulence", 1.11.4/7. "drifted up and down many times". Making "it clear that the aircraft was seriously affected by weather", 2.3. and at the same time continuing descent into mountainous terrain until being smashed into a hillside beggars belief. That action was required to alleviate the situation by regaining altitude and seeking to avoid the weather, must have been apparent long before reaching FL 070. In drawing their conclusion the committee must have also concluded that the crew were lacking in basic airmanship, and completely devoid of situational awareness, not to have realised their predicament. The adoption of weather conditions as the sole reason for the crash, whilst making the Part 4 Safety Recommendations is a reflection of the defensive nature of the report, sacrificing objectivity, but then casting doubt on the crew’s professionalism and common-sense in a fatalistic descent into danger. The assertion in the conclusion that "the aircraft was struck by the trees" is characteristic of this report’s bias. Not surprisingly, the members of the Committee are not named, and the report is not signed. Despite the ‘Safety Recommendations’ there would appear to have been no improvement in the navigational aids at Nha Trang up to 25 December 1999. One wonders, what is the state of progress at other airports, and on the other recommendations? Recent information is that Nha Trang is not a target airport for redevelopment. Despite the committee's recommendations navigation aids at Nha Trang are apparently not scheduled for improvement. Notwithstanding the above, without confirmation provided by the release of substantiating FDR data, definitive satellite cloud data, and a factual verbatim typescript of the RT tape. All of which have been refused, other possibilities should be considered. The most probable is:- The early descent from altitude that would have enabled VN474 to make a visual approach to Nha Trang indicates that this was the original intention. Descent to 2100m at the NDB for an instrument approach need not have been commenced before 00.10. (Optimum Descent Profile ) Giving a ride of greater comfort and a substantial terrain clearance buffer. The absence of comment, by the crew, on turbulence over the hills indicates that this was not excessive, despite imaginative interpretation of the damaged FDR tape. The request for further descent from 2100m, 20km from the coast and reference to ground contact indicates that a visual approach was the preferred intention of the crew. A definitive declaration of changing to visual flight rules? They gave a distance, not to the airfield, which if intending to carry out an instrument approach was their next objective, but to the coast. Which would have had no significance, unless a visual approach was intended. It is also difficult to believe that momentary views of the ground, at the perigee of violent vertical turbulence, induced the crew of VN474 to request further descent. The
pilot, having decided to carry out a visual let down, because of a cloud
base below the break off height of the NDB approach, ( Close study of the descent profile and the Descent Chart however indicate that the crew may have been correct and only 20km from the coast, though well right of track. The only problem being that they were not at 2100m, but well below, and only seconds away from impact. Was the "request" for further descent retrospective, almost posthumous? Was the Nha Trang controller not unduly harassing the crew as suggested earlier? He could have been a minute early if expecting a reply of "Level at FL 070" to his call of 07.09.05, but 3 minutes later his "wake up" call at 07.12.15 may have been long overdue? A later Vietnam Airline Flight, No HVN 815 on the Third of September 1997 on approach to Phnom Penh Airport was the subject of an accident report by the Secretariat of Civil Aviation for the Kingdom of Cambodia. This found that a principal factor in the accident was the Captains "psychological unreadiness" to deviate from his intention to land. Resulting in yet another CFIT accident, despite the first officer’s and engineer’s recorded warnings and entreaties to overshoot. Whatever other causes there may be, this could also be a principal factor in the case of VN474, for which there is no mention of a Cockpit Voice Recorder. Statistically; controlled flight into terrain accidents represent the greatest single risk to aircraft, crews and passengers, and are the leading cause of fatalities in commercial accidents. CFIT occurs when a serviceable aircraft, under the control of the flight crew is flown unintentionally into terrain. These accidents are common during the approach and landing phases of flight, and were responsible for almost half of the deaths in commercial aviation between 1988 and 1997. Human error was responsible for over 70% of accidents in the same period. Weather was attributed with 5%, and no doubt human failings to appreciate, anticipate and take appropriate action played a major part in these. The Search and Rescue Operation and it's Aftermath. A SAR team was assembled and departed by air within 2 hours of the alert. From where to where is not recorded. Another team left Tan Son Nhat for Khan Hoa by road later on the same day. Accident Report Page 4. Account of the actual finding of the crash is left to eye witness interviews. 1.16. Interviews. Mrs Mau Thi Nam. Mr Mau Quoc Tan. 1.16. under ICAO format would have been headed Tests and Research. 14.11.92. The aircraft was seen in flight, and heard to crash by Mrs Mau Thi Nam, of Mo O, Son Trung Commune, Khan Son, Khanh Hoa. 1.16.2., and other witnesses 3.1.2. 15. Day 2. Mr Mau Quoc Tan, Head of Village Militia, Son Trung Commune, Khan Son, was informed of a suspected crash in Khanh Hoa District and ordered to start searching. That afternoon the CAAV. SAR. team led by Mr Le Hai arrived. 16, 17&18. Day 3 4&5. Two teams from the Commune searched, finding a sick bag and foreign papers on one of the three days. 19. Day 6. The SAR team observed a burnt tree, near to where the bag and papers had been found. The SAR team and district militia ordered the village militia to search this area. 20. Day 7. Mr Mau Quoc Tan and five others left early, found wreckage at around 10.00. and stopped for lunch. Then Mr Mau Quoc Tan and one other ran back, reporting to the District Militia Unit, and SAR team at 16.30. Whether they were specifically ordered not to disturb the site, or were acting on their own initiative not to search for survivors at this stage, is not stated. 21. Day 8. Mr Mau Quoc Tan led the SAR team to the site, arriving at 14.00. They found one survivor. 1.16.1. According to the reports of the Criminology Institute it was not until 16.15., that on hearing a groaning, the survivor was found. 30 hours 15 minutes after the site was first reached. 3 to 5 days after the near location had been positively identified. 8 1/2 days after the witnessed crash. Information From Other Sources 22. Day 9. The survivor was carried down to Khan Son Hospital. 23. Day 10. The survivor was taken to Nha Trang for airlift to Cho Ray Hospital and Singapore. 24. Day 11. Criminology Institute Autopsies on bodies nos 21, 28 & 29. 25. Day 12. Bodies carried down. 26. Day 13. Bodies to Nha Trang. 27. Day 14. Bodies to HCMC, & Cho Ray Hospital. Second Autopsies carried out. After reported immediate action the rescue operation appears to have suffered from inertia. Local searching was not started until the third day, this then led to information that could have localised the search on that day, or it could have been two days later! The report is as vague as the search appears to have been. This information was not acted upon for a further two or five days when other evidence was seen. Even then there was the inadequate response of sending the local militia on recognisance. What the SAR team was doing is not recorded. Neither is why they took so long to reach the site on the following day. There would appear to have been little co-operation between the inhabitants of Khan Son and the authorities. The aircraft was observed, and heard to crash. It is inconceivable that the location was not known throughout the valley within hours. There were several witnesses (3.1.2) to the aircraft being in the valley, which is totally surrounded by high ground. ( Descent Chart ) Yet SAR facilities were being squandered on a widespread search, and a small number of ill-equipped militia left to cover the most likely area. One Safety Recommendation in the Report states:- 4.5 "The Government should promulgate a decision as soon as possible to form a National Committee for Search and Rescue, and there should be a decree for its operation from central to grassroots levels." Has there been any positive result? A communication from Vietnam on the 30 November 1992 reported that "According to the French Consulate-General all effects were looted by hill-tribes. According to MFA (Vietnam Ministry of Foreign Affairs) the effects will be repatriated later." No effects were received in the UK. Repatriation of the Three European Males Autopsies were carried out at the crash site on the 24th November and again at Cho Ray Hospital, Ho Chi Minh City on the 27th. The results of these varied and though individuals were identified at both venues, there were very few corresponding findings in the reports. Comparison of six reports on three individuals would give an impression that there were six individuals. It is perhaps significant that the crash site autopsy reports were not compiled/dated until 31 December, 37 days after the autopsies were alleged to have taken place. Where had the notes been for all of that time, how mixed up, and through what laundry? Identification was confirmed in Vietnam and the remains flown to the respective countries on the 29th. On receipt of the certified British remains in Cumbria, a further post-mortem showed no correlation with that in the documentation accompanying the body, and doubts were raised as to the identification. DNA testing was carried out, but inconclusive, it was not until the 22 March 1993 that dental records confirmed the remains to be those of the Swede who's supposed remains had been cremated. On the 7th April it was confirmed that no identification on arrival had been carried out on the body sent to Holland, and exhumation of the Dutch grave was requested. On the 9th July this body was found not to be the Dutchman. After further delay, the body was released from Holland on 14th September 1993. The second Cumbrian post-mortem report revealed only fractures of the right tibia and fibula, the left fibula, and undisplaced fractures of ribs:- Right 3-7, left 5-7. The first body had:- "advanced putrefying changes consistent with several days elapsing prior to discovery, examination and embalming. By contrast the embalming of the head and torso of (the Briton) clearly took place before such putrefying changes occurred." (Carlisle pathologist’s report). Indicating that he would have had a prolonged period of survival after the crash, and not necessarily have died as a direct result of injury. Given the expected ambient temperatures, humidity and delay in recovering the remains it is not inconceivable that he died after the discovery of the aircraft, or even during evacuation. Requests for information as to the ambient conditions and the date of embalming have not been answered. Other Information on the Distribution of the Remains. Efforts have been made to discover the events leading to the complete chaos in the misdirection of remains. A report of April 1993 states that the British Vice Consul visited Cho Ray Hospital, Ho Chi Minh City, and was assured by the staff that all procedures had been correct. The Swedes had checked their body into the coffin, adding an authenticating detail that the Swedish widow had personally changed the miss spelt label. That the coffin had been handed over at 08.00 and the family had accompanied the body to the airport. Information from Sweden is that the Swedish widow was not in Vietnam at that time, and that the son who was, did not travel with the body. The hand over was "about noon" and take off at "about 2 pm". The British body was not surrendered by Cho Ray until 14.00? Very little time for take off at 14.30? Information from a British official suggests that after being released at disputed times the coffins finished up together at the airport. It appears that little was done in the way of checking and sealing the bodies into the various coffins, and that there was ample opportunity for switching labels. There is now available a copy of the certificate of the contents of the British coffin signed by a Dr Tran Minh Thong, this presumably accompanied the Swedish body to Cumbria. It would appear that Dr Thong was responsible for the mix up. Or possibly he could provide an explanation? Did the Taiwanese and Vietnamese families have similar difficulties? Despite information that the Prime Minister’s Office had ordered Vietnam Airlines and the Health Ministry to resolve the problems of the repatriation, the only communication on the matter was Note 223 NG/LS dated September 16th 1993. Which only restated the information given to Vietnam by the bereaved. It did admit that there had been wrong identification and that they "expected a spirit of understanding and forgiveness on the part of the bereaved family." This is difficult to obtain given the continuing procrastination, denial of facts and the withholding of the Accident Investigation Report, such as it is, for so long. The family have studied this, and found it lacking in objectivity, content and conviction. The conduct of the investigation is remarkable, in that, within 5 weeks of reaching the site all of the research and evaluation required of the wreckage had been completed sufficiently for the manufacturers to comment on the aircraft's condition, yet not even know if the wheels were up, down, or transiting. In just a further 2 weeks the investigation was totally completed. This does not suggest an inquiry of any depth, and makes the delay of 6 1/2 years before presenting the results to enquiring relatives even more deplorable. It is known that in totalitarian states, aviation administrators are political appointees, even heads of village militia are. Similarly, air accident investigators, if any, would be not be independent. The collapse of the Eastern block at this time, though encouraging glasnost (Which the CAAV would not recognise) could increase the problems of the Russian manufacturers and raise questions regarding the independence of the invited Yakovlev engineers, who were not recorded as having access to anything other than documentation and damaged FDR data. There is no mention of any experienced investigators being consulted. Comment in "Flight International" recently, [11-17 January 2000] refers to flight safety in developing countries and makes a point about air safety improving: "when airlines and governments stop worrying about loss of face or loss of national prestige and start caring about loss of lives". In mitigation it may be said that Vietnamese officials have recently admitted they did not have the facilities to conduct a conclusive investigation, and alluded to the state of turmoil in Vietnam, but then illogically continue to insist that conclusions reached from incomplete and corrupt information are correct. The report on the more recent Vietnam Airlines Accident to HVN 815, in Cambodia September 3 1997 killing 64, mentioned earlier, would serve as a model for Vietnamese accident investigators and committees to follow. It is a factual account, giving precise information, and detailed appendices supporting the conclusions. The FDR data was supplied by Russia. The Vietnamese have been asked to provide such data on VN 474 and their refusal to comply can only arouse suspicion that none exists, or that it would be detrimental to their conclusions. It is of interest that the pilot in command of HVN 815, was reported to be the airline’s "Director of Safety Security", and as such may have been party to the accident report on VN 474, or even the person who qualified "the crew members to fly the aircraft in all weather conditions". (Report 2.4.) The loss of yet another Vietnamese aircraft in a similar CFIT situation on approach to Bangkok in September 1988 when the crew failed to execute a missed approach procedure on reaching decision height, suggests that there may be an endemic culture of recklessness in Vietnam Airlines. Being "qualified to fly the aircraft in all weather conditions" probably induces misplaced feelings of superiority, infallibility, and immortality. Not even suppressed by the assertion that weather conditions were the sole reason for the accident in November 1992. The CAAV in its reply to one request for information seeks to justify refusal in that neither the ICAO, or the other concerned countries have complained. The ICAO has confirmed that it is not mandated to comment upon accident investigations. Such powers are under consideration for the future, dependent upon the approval of the contracting states. All responsible states are requested to approve the extension of the ICAO Audit Programme, including Annex 13 without delay, to ensure that all investigations are conducted with skill and diligence, for true and transparent reports, whatever country has responsibility. The ICAO at the moment, by reason of its own constitution is by default a protector for the ineptitude of contracting states, rather than a guardian of flight safety. The French family now have a copy of the report, are appalled by its inadequacy and fully support the VAAIO quest for truth. The bereaved families of Sweden and the Netherlands are still so deep in grief and trauma that they do not wish to be reminded of the event, though they do not appear to be satisfied. It is sad that families can not yet come to terms with their losses, but prefer to nurse their grief in silence, allowing the CAAV to think that they are content, and that the travesty of an accident report is sufficient to whitewash over apparent deficiencies within Vietnamese aviation. Reaction from relatives of Taiwanese victims is invited. Also those of any independently minded Vietnamese. This was a relentless succession of events, beginning with the descent of the aircraft into terrain, whatever was the cause. Followed by the failure of the authorities to locate the wreck for seven days, although the crash was witnessed. Culminating in inept recovery, conflicting autopsies, incorrect identification and what appears to be a mismanaged attempt to cover up the extended survival of some victims. None of this creates confidence in air travel linked to Vietnam or Vietnam’s ability to conduct air operations. The infrastructure and skills to search and care for the injured, and even carry out correct autopsies on the dead seem also sadly lacking. The conduct of all the Vietnamese authorities concerned appears to have been negligent in the extreme and the policies which have been followed in this case appear to have prevented the full truth from emerging. A note from the Vietnamese, MFA 556 LS/QH dated September 11th 2000, in reply to the last request for information, refers to the admission of September 1993 that there had been mistakes in identification, also admitting inexperience, poor communications and inadequate rescue facilities, but still insisting in allocating certain injuries to the wrong victim, in support of continuing deception. They still expect "a spirit of understanding and forgiveness", after a further 7 years of deceit. The note refers to the problems in Vietnam at that time and all the difficulties facing the involved organisations, and wishes that the case be soon closed. That is the wish of all concerned, the case could have been closed seven years ago if Vietnam had enlisted the aid of professional and unbiased accident investigators, and co-operated in an unfettered investigation. Then published a proper and authentic report, making all relevant data available for scrutiny by the bereaved without delay. The callous withholding of the pathetic report for so long does not demonstrate the humanitarian concern that the MFA professes to have. The MFA is probably right in thinking that the problems of Vietnam were contributory factors in the accident and its report, they should put these points to the CAAV. Then impress upon the CAAV the need for a reappraisal of the report’s conclusions, bearing in mind "the then situation and all the difficulties" that obviously clouded the judgement of the Provisional Committee. It is hoped that the U.K. Air Accident Investigation Branch would be invited to assist in such a reappraisal. The CAAV report is a damning document, condemning Vietnamese aviation by its incompetence, confirmed now by the confessions from the Director of Air Safety, who also admits to being a member of the Provisional Accident Committee of 1992/3. Perhaps the Government of Vietnam could supply the data requested, and explain fully the unsupported assumptions, contradictions and anomalies of the accident report and make a reappraisal of the conclusions? Or in view of the new and significant information now available, they may wish to reopen the investigation in accordance with International Civil Aviation Organisation Recommended Practices Annex 13 Chapter 5 Item 13. Enlisting the aid of the UK. AAIB, thus removing the need for further inquiry, and fulfilling the wishes of Note MFA 556 "For the benefits of the existing good relations between the two countries". Pending this; any information concerning the crash and air operations into Nha Trang, or elsewhere on Vietnamese aircraft, if relevant is sought, and may be sent to:- quester@vietnamairaccidentinquiry.org.uk
Note: Vietnam Airlines alliances include:- Air France, Cathay Pacific, China Airlines, Japan Airlines, Korean Air, Malaysia Airlines, Quantas Airways & Swissair. "Flight International " 4-10 April 2000. Belgian City Bird, wet-lease agreement, Paris-Hanoi route. "Flight International" 5-11 December 2000.
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