I wish to inform the House today of the findings of the service inquiry into the incident involving Puma ZA934 on 8 August 2007 at Catterick in which three service personnel tragically lost their lives and others on board were injured.
A service inquiry was convened to examine the cause of this incident and to make recommendations to prevent recurrence and this is now complete. The purpose of the service inquiry is to establish the circumstances of the loss and to learn lessons from it; it does not seek to apportion blame.
Puma ZA934 from 33 Squadron RAF Benson was conducting training at the Catterick training area. The Puma was carrying 12 personnel: three RAF crew, an Army officer and eight recruits undergoing basic training at the infantry training centre, Catterick.
The service inquiry found that at approximately 20.50 local time during the day’s final sortie, the Puma failed to recover from a tight turn and crashed into land to the west of the Catterick training area. Detailed analysis by the Royal Navy Flight Safety Incident and Investigation Centre suggests that the aircraft’s tail rotor guard that protrudes below the tail hit the ground first as the pilot attempted to regain height. This initial impact resulted in the tail being severed. The aircraft then lost rotational stability as the rotor blades made ground contact, causing the fuselage to rotate and flip several times, finally coming to rest having broken up considerably.
Following extensive investigation, the service inquiry concluded that the cause of the incident was an incorrectly executed manoeuvre which caused the aircraft to crash. Contributory factors that led to the incident included: the crew’s combined relative inexperience; the lack of robust crew supervision; human factors; manning shortfalls; the high operational task load placed upon 33 Squadron; and the reduced opportunity, because of this task load, for supervised consolidation and reinforcement training.
In addition to these findings, the then Commander Joint Helicopter Command (Rear Admiral Johnstone-Burt) also identified three additional contributory factors: the crew’s lack of adherence to checks; operating procedures; and their flight at below the authorised minimum level. In total, 29 recommendations were made covering aircraft handling, training, supervision, manning, organisation and equipment. Of these, 25 have already been implemented and the residual recommendations are in hand.
A copy of the service inquiry, redacted in accordance with the provisions of the Freedom of Information Act, is being placed in the Library of the House and on the Ministry of Defence website.