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RAF Puma ZA938 (Board of Inquiry)

Volume 485: debated on Monday 15 December 2008

I wish to inform the House today of the findings of the Royal Air Force Board Of Inquiry into the accident involving RAF Puma ZA938 in Iraq on 20 November 2007, which sadly resulted in the deaths of two servicemen, Sergeant John Battersby, Queen’s Lancashire Regiment, and Corporal Lee Fitzsimmons, Royal Marines. Our deepest sympathies remain with their families and friends. Two other servicemen were seriously injured in the incident.

The purpose of a board of inquiry is to establish the circumstances of the loss and to learn lessons from it: it does not seek to apportion blame.

The board of inquiry was convened on 21 November 2007. It considered a large amount of evidence. On 20 November 2007, ZA938 was supporting UK operations in Iraq as part of a formation of helicopters to deliver troops to an identified landing site. Due to the tactical situation, ZA938 made a steeper than normal approach to its landing site. It made a heavy landing, with a small amount of forward movement, after which it rapidly became unstable. Fearing that the aircraft might topple over, the pilot elected to take off again. During this manoeuvre the Puma struck the ground and rolled over onto its right side. The aircraft quickly caught fire and was destroyed.

The board concluded that the main cause of the accident was controlled flight into terrain, brought about by the handling pilot’s disorientation due to the use of an incorrect technique for a dust take off. A number of contributory and aggravating factors were also identified.

A redacted version of the BOI findings is being placed in the Library of the House and in addition, a redacted version will be available on the MOD internet site:

The safety of our people is a principal consideration and we have therefore removed from the report information that might endanger the security or capability of UK and Coalition personnel. We have, however, tried to be as open as possible and have carefully considered the public interest arguments for and against disclosure of the information in the Report. We have ensured that each redaction is fully justified by an appropriate exemption in the Freedom of Information Act.

I remind the House that the purpose of the inquiry, in identifying those factors which contributed to the loss, is to identify lessons to be taken forward to minimise the risk of a similar incident happening again. The board President and the Chain of Command made a number of recommendations regarding supervision; cabin security; adherence to standard operating procedures; post-crash management; aircrew qualifications; engineering issues; brown-out; and Aircrew Equipment Assembly issues that are now being studied closely. It made recommendations in 10 areas, which resulted in over 20 separate actions of which two thirds have been implemented and urgent work is underway on the rest.

The board of inquiry into the accident involving Puma ZA938 is now complete. I express my gratitude to the President of the board and his team for their painstaking work.

The Ministry of Defence is co-operating fully with the Herefordshire Coroner who will hold an inquest in due course.