Safe 'Aware' or 'Risk' Averse- Where are we?

[advocatusDIABOLI]

I've had the lucky chance, over the last few months, to review new Release To Service documents (RTSs). I may be getting old, but they are getting ever more 'Legal' in their language. To the point, in my view, that they stop being a 'Limitations' document, and start being a 'Litigation' document, in some cases, almost unreadable!.

Personally, I'd a like a single book that tells me the: A, B, C, limits of an A/C, including, as required, warnings, as what might happen beyond. Easy really.

How does the current flying mob, feel about their respective RTS?

Advo

Feel Free to PM, for specifics (if I can).


Advo

[Pontius Navigator]

The boss of my organisation has just realised he has too many able administrators but not enough decision makers. Now there's a thing.

I was asked today if I had permission to do something. I countered and asked if he was going to tell me not to do something. He shut up PDQ when he realised that he might have to make a decision rather than just offer advice.

[advocatusDIABOLI]

'Advice' The great recent 'Cop Out' for 'Direction' ie an Order.

Like:

"You should try to lose some weight, you'll feel better"

or

'Go to the GYM, or be dismissed.' (And I will assess you in 2 weeks.......mate)

Hmmmmmmmmm, which works?

Advo

[Mr C Hinecap]

advo - I think there has to be a little more substance to an order - I'd certainly tell you to poke off if you directed your second effort at me.

[tucumseh]

I've had the lucky chance, over the last few months, to review new Release To Service documents (RTSs). I may be getting old, but they are getting ever more 'Legal' in their language. To the point, in my view, that they stop being a 'Limitations' document, and start being a 'Litigation' document, in some cases, almost unreadable!.




Excellent question.


I don’t know how far back your RTS’ go but in MoD(PE) we expected such changes to commence around 1993, following the repeal of Section 10 of the Crown Proceedings Act of 1947, which had effectively prevented the possibility of a court case against Crown Servants and the MoD.

Although those with airworthiness delegation had been given the heads up long before (letters of delegation were first issued in October 1991, and we were all briefed as to how to inform and direct Design Authorities and Custodians), I say 1993 because the new Defence Airworthiness Group (est. February 1992) issued its first amendment to JSP318B and CA Instructions in January that year, swiftly promulgated to the plebs by DCI GEN 89, in March 1993.

The general principle is that those affected (i.e. MoD) are given a reasonable period in which to comply with new legislation. After that “period of grace” the clock runs on litigation. This was hammered into us.


Without going into too much detail, the resultant changes in how we managed airworthiness would clearly cost more. The senior management (2 Star in so far as it affected my projects) response was to promptly CUT funding, so what changes took place were negative. That is, airworthiness, instead of being given a higher profile and bolstered, was severely compromised and treated as an even greater waste of money (by beancounters, administrators and especially – as they controlled funding at this point – Suppliers) but not by those with delegation who were now under threat of legal action.

The issue of how delegation is managed remains important, given its contribution to recent fatal accidents. As ever, the regulations are pretty robust, but poorly implemented. For example, while a non-engineer cannot be given airworthiness or type approval delegation, he/she is permitted to over-rule/make engineering design decisions; which in an aircraft almost by definition affects safety and airworthiness. This, of course, is ludicrous (and demonstrably fatal), but is universally condoned. In my own experience this became common in the late 90s, and Ministerial support has been expressed as recently as this year.


In answer to your question, and against this background, it is no surprise that these legal concerns are reflected in RTS’. If I were a Release To Service Authority (RTSA), and knowing the above, I’d engage legal counsel on a daily basis. The problem RTSA’s face is that they have little or no control over the process that leads to MAR. (The system requires them to, but in practice they don't have the resources so leave it to the IPT). Similarly, the IPTs do not have control over everything in their aircraft, and such is the dearth of experience most don't know how to implement the regs now, even if they have the money. The system relies on adequate funding, experience, competence and trust. When Stars and Ministers do not insist on any of these airworthiness components, and are quite happy to state this, the RTSA becomes a lonely man.

[obnoxio f*ckwit]

Everything that Tecumseh said.

It's been a few years since I had anything to do with it, but the amount of advice/recommendations that came with a new clearance/piece of equipment was, at times, almost unmanageable.

It was usually from Qinetiq, but make recommendations and give advice was what they were paid to do, but as a private-ish company they of course had to make sure that they didn't miss anything out as well, in case it backfired on them. Most of it was good, occasionally wrong, but sometimes irrelevant.

The first two are fairly straightforward, but it could be a juggling job trying to decide what to put in a new RTS clearance, but as importantly, what to leave out. The RTSA is ultimately responsible, but he has to rely on what the DRTSAs tell him, and so on down the line until it reaches the desk officers who actually do the work. Should an investigation result in a court case or lawsuit, it seemed most likely that it would be one of us that ended up on the witness stand after an accident, so I used to try and use the rule of thumb that if I could stand in a court of law and justify why not including a piece of advice or a recommendation in the clearance submission was "reasonable" (a wonderful word!), then it was probably OK to leave out.

A lot depended on the diligence of the particular DRTSA, whether he properly read all the submissions and made up his own mind, or whether he was just too busy with his real job and took what we said pretty much at face value.

Sometimes it was just easier to include everything, which is why they often got a bit long.

[flipster]

OF

Do you get the impression that those who have airworthiness delgation are being well suported by their non-technical bosses? Are they producing equipment that is safe and fit-for-purpose, or does the RTS documentation cover the bosses' backsides, knowing that the kit is cr@p!?

[advocatusDIABOLI]

Excellent Responses, thank you all.

However, Mr C- I would of course phrase my order differently, and in writing. My point was the theme rather than the detail. Telling me to 'Poke Off' would certainly illicit a different, but equally decisive result!

My main question is really not about the detailed history of 'why' these documents as they are, but more 'should' they be as they are?

My view (being a driver-1st class), is that the complex lexicon of legal jargon should be left out of these documents, and I say that for 3 reasons:

1- The books are intended predominately for aircrew, not legal experts. As such they should be easily understood by their intended audience.
2- The nature of millitary aviation in itself contains great risk, this is universally understood, and no amount of fancy word mitigation will change that fact. Consequently, the 'ultra-safe' document, actually adds nothing.
3- Quite the reverse of 2 is actually true (in my view). A complex and difficult to digest document of legalese / contractural clap trap is so tedious to read, that a proportion of the intended audience will either fail to read, misunderstand or ignore the content. That in itself will make the 'whole system' less, rather than 'more' safe. Rather ironic, don't you think?

So, rather than only proposing the problem, I would appreciate your comments on a solution.

2 Documents.

1- As I described- By aircrew for aircrew in aircrew speak. The do this- don't do that book.

2- A limitations / Liability / Litigatory framework document, for Geeks, by geeks and to be used in court. This book would contain as much fancy English as the comercial folks could muster, and obviously would link and be totally configured with the aircrew 'noddy guide'.

I think the result would be rather pleasing to everyone. However, someone will say 'Hey Advo, that's the Aircrew Manual you just described?' well in the day, it would have been. But, now, such things don't really exist (in any usable or meaningful fashion). As an example, TrilogyView for Typhoon is a piece of 'Art'....... great to look at, but overall Fecking Useless!

Advo

[chumzpilla]

Hey Advo, that's the Aircrew Manual you just described?

[advocatusDIABOLI]

Chumpzilla... Hmmm well named methinks! I guess someone had to, I've only myself to blame!

Advo

[Rigga]

Military aviation may be a risky business - but are the drivers really aware of what risks they are taking by merely operating their flying machines?

Do the drivers need to be aware of those particular risks if the "Airworthiness" bigwigs have said its "Okay to go!" in whatever state that is?

However, I do agree with the need for a "Fisher-Price" type of Flight Manual that keeps the plaything instructions direct and brief. But I don't think anyone will write one in this litigious period of our history.

[Hubstrasse]

can think of some interesting answers.. but that's another thread.
When MARDS (military aircraft documentary reulation set) was introduced I was joed by the boss to give a brief but now I've forgotten it all. I think the precedence of orders was : QRs, RTS, ASOs/GASOs, FOB, SOPs. I am quite probably wrong but the gist is that I recall one of the most senior documents having a preface which said somthing like "these orders should not preclude good judgement, airmanship and common sense" On more than one ocaision saussage side I have certainly used this mantra to protect the large yellow streak on my back. The RTS must remain an easy to read ultimate limitations book so that when Johnny foreigner is chucking lead you know when the wings are going to fall off!

[tucumseh]

I recommend JSP 553 (Military Airworthiness Regulations), Chapter 5 (Management of Airworthiness In Service) as interesting reading.

It clearly illustrates the linkages between all the documents mentioned, the scope of each and who is responsible for maintaining them.

Particularly interesting is the role of the Delegated RTSA, outlined in para 5.3. He is appointed by the RTSA and is responsible for the In Service Safety Management System.

In all my time in MoD, if such a postholder had made themselves known to me (!) I'd have asked him where he was to get the resources to implement these regulations, or persuade others (e.g. IPTs) to do it for him. Perhaps that's why I've never met one.

Of the 9 MANDATED task elements in 5.3, I could provide written evidence instructing or ruling that 8 can be ignored or treated as optional. For example, Item 2 requires him to ensure "The Safety Case for the aircraft/system is maintained". Invariably, if one seeks funding to do this you expect a severe bollocking. It's something you quietly do without telling the boss. Last time a boss of mine caught me trying to comply I was disciplined and the contract item cancelled. In a letter explaining their actions (which I obviously retain), MoD stated I was the only one who thought what I did was right, so I must be wrong.

As I said, the regs are fine, practical implementation is a different matter.

[StopStart]

I have to agree with advo's original suggestion. As a simple driver with little or no interest in the legalese that protects the originator's ass, I would dearly love to see the ridiculous myriad of documents we have reduced to a single Aircrew Manual set. The RTS should not be a document I should have to refer to on a regular basis; that which is relevant to me as a driver should have been distilled out and presented in the ACM. I should have a working knowledge of the RTS but it should not be a primary reference doc for a Sqn shag.

As to your original question I'd have to say that we, as a Service, are now so Risk Averse (note "averse" and not "aware" or any other jargon) that it affects our ability to do our jobs as a military force.

[endplay]

On the point of orders v advice/suggestions. IIRC it states in QRs that "A request from a superior is to be treated as an order." Or to paraphrase, be nice!

[Safeware]

Without knowledge of the RTS in question, and without knowledge of which point the legalese has crept in, I must say I'm surprised. When involved in writing RTS recs, one of the key aspects I had to look for (and I had to look across all the lims, warnings, cautions and notes) was that they were not only observable, but easy to understand because as Advo says, if it is too complicated, it stands a greater chance of being mis-understood or ignored as too cumbersome.

As regards DES desk officers, and kinda following on from Tuc's theme, I heard recently that a number of desk officers are turning down letters of delegation because they feel that they can't effectively discharge their safety responsibilities without the finances, and financial authority, to back them up.

:(

sw

[Herc-u-lease]

the idea that desk officers are "turning down" LoDs seems a bit strange to me. the whole point of having a LoD is that you only sign what are comfortable with. there will be some elements of risk in the decision, but if the risk is perceived as too great then don't sign the document and consult your boss, IPTL if necessary.

To reiterate a point made earlier - the litmus test is asking yourself "if i authorise this and it goes horribly wrong can i reasonably justify my decision in court?" the decision should be including decision factors such as risk, operational imperitive and most importantly safety. If the desk officers are uncomfortable in signing because of wider concerns then the whole system will come to a halt pretty quickly. I'm sure willingness to accept risk is part of the OJAR/SJAR grading guide for Officers.

I've worked with two RTSAs embedded in IPTs (i know they cover multiple fleets) and they were outstanding.:ok:

[tucumseh]

Herc-u-lease

While I agree with what you say…..

One point I was making is that the Delegation rules are robust, but there are many examples of more senior staffs who do not have the necessary experience, qualifications, competence, background etc and therefore cannot be granted delegation, who seem to resent the fact that their juniors carry delegation and far greater responsibility and authority on the project.

Clearly, this places them in an awkward position. They become spare, redundant parts in their own team. They may be the line manager and 1st / 2nd Reporting Officer, but at regular intervals in the project, primarily Configuration Milestones when the design is reviewed, these seniors have little or no work to do, and are seen to be completely bypassed as they play no part.

I have known many “managers” in this position, but 15 years ago they were few and far between because people were selected for posts according to suitability, not who they played tennis with. Some have handled their situation well, found a role within their team (!) and let the proper project managers get on with the job. Without exception (in my experience), these projects have been successful and the aircraft/kit safe.

However, unfortunately, I’ve seen the other side. Managers reacting badly to juniors making all the decisions, so they try to impose their incompetence by making or over-ruling engineering design decisions. Without exception, these projects have hit problems. Sometimes it is just having to regress, quietly over-rule your boss and correct his error. This costs time and money (and box markings in your report), but performance (including safety) is safeguarded. But as lack of leadership kicks in, and HIS boss condones what he is doing, he feels encouraged and no longer tells his staff what he is doing. Often, this is accompanied by him “going native”, by acceding to Contractor “suggestions” which are invariably aimed at increasing profit. Tragically, you find out when sifting through the audit trail post-accident.

That is when audit trails start to erode, disappear into file 13. I’m glad Safeware joined this discussion – he will understand the implications when I say my 2 and 4 Stars even condoned the creation of a 2nd and then 3rd Risk Register by one of the staff I mention, the sole aim being to hide / dilute the main Register, which showed that risks had materialised that had been predictable, predicted and ignored. Mitigation contracts had been cancelled. Design reviews waived as an unnecessary hindrance. Expensive and unnecessary designs “approved” which sucked up precious funding, milestones paid off without the work being done; while we, Boscombe and DEC seethed that crucial Capability was salami sliced and safety compromised. The Board of Inquiry wasn’t told this, nor was the Coroner. And onwards and upwards.

Under these circumstances, is it little wonder people are declining LoDs? In a similar vein, I know very good, highly qualified engineers, who don’t admit to being engineers as it is a career limiting vocation. I know others who, to progress, have transferred to “Admin” as such posts attract authority and better prospects without the degree of responsibility. Why should I condemn them? Why expose yourself to disciplinary action by continually trying to implement the regs, only to be over-ruled?

One should ask why they are placed in charge of aircraft/equipment projects! In effect, such project teams are upside down, with the most junior staffs making all the decisions, while desperately trying to hide from their bosses that they’re trying to make the aircraft airworthy. You correctly mention “willingness to accept risk is part of the OJAR/SJAR grading guide for Officers”, but a great deal of staffs with delegation are Civil Servants. It is now some years since the willingness to accept responsibility and ability to make good decisions was removed from our Staff Reporting system. These are no longer required competencies, in that one is not tested or marked on them – you only find out AFTER they have been promoted/appointed, often when things have turned to rats.

[advocatusDIABOLI]

Some more excellent responses.

However, we're not really anserwing the fundamental question. Is the present system, of document production and maintainence too legalese, ungainly and unuseable for 'average' aircrews?

As has been noted, the 'litmus' test would be a captain standing in court and plainly stating that it would be unreasonable for him/her to understand all this gobble-a-duke without specific legal training..... now, there's a can of worms.

My view is still, that at present, the system serves no one adequately.

Personal 'arse-protection' should not drive the system.

Just my view.

Advo

[Rigga]

In the non-military world of large transport aircraft, that don't do punching holes in the sky but instead plod from one runway's end to another runway's end: The size of the "Aircrew Manual Set" seems to be directly proportional to the aircraft size especially when compared to your two-seat playthings and assuming the larger ones don't have all the variable toy possibilities that you may have.

I am also quite sure that the words and style of writing are probably quite similar to those in your manuals, even given that the nationalities of the authors are different! I believe that both manual sets possess an Emergency Procedures section that may contain some of the more pertinant articles of interest - when you may need it - and there are, of course, the old FRC's when you 'need' them.

In legalese short...

It has become apparent to this thread contributor that the wishes of the majority of participants subscribing to this thread (hereby known as the article), and the majority of those viewing said article, may not, within their assumed normal life cycle, or alternatively, assuming the positive possession of a Human Systems combined single-access valve-type device and orifice, observe the wishes of the above mentioned manual changes.


Hope this helps...

[Herc-u-lease]

Tucumseh,

really enlightening post; many things i can relate to and others which are interesting.

H-u-L

[Occasional Aviator]

I have had direct experience of this area; I sympathise with a-d, and recognise every one of tucumseh's points and thoroughly agree with them all save one: I don't think airworthiness is restricted solely to engineers - operator input is required too (not to over-rule engineering advice, but to complete the picture).

However, to answer the original question:

The PURPOSE of the RTS is to control and track the limitations applying to an aircraft arising from the safety case. I therefore think that it should not be an everyday reference for aircrew, but more a library document where you can go to clarify or get more detail on the limitations contained in the rest of the aircraft document set.

You should, however, be able to fly the aircraft safely and effectively solely by reference to the aircrew manual and FRCs (you might, on occasion, need to refer to the RTS t clear up the more esoteric points). Where I think the system has fallen down is the loss of a robust system to validate and verify the content of the ACM/FRCs - Handling Sqn are only mandated to do one of these things. Over the years our concerns over litigation combined with the underfunding and emasculation of organisations like Han Sqn has meant that the ACM no longer provides what is required and people are referring more and more to the RTS.

[Safeware]

tuc: I’m glad Safeware joined this discussion – he will understand the implications

Oh yes.

Particularly the risks being taken by one IPT when the the advice from Boscombe was "translated" up the chain. At least there was one desk officer in the IPT who was prepared to put in writing that he didn't agree with what was being done - not that it made much difference.

sw

[tucumseh]

O-A

Thanks. You are of course correct and I apologise if I seemed to disregard aircrew input. This is mandated and only a fool would ignore it.

My main concern it where non-engineers with no aviation, or even MoD, background whatsoever, are parachuted into projects in a relatively senior post and immediately assume they can make or over-rule engineering design decisions. One may (just about) excuse this once, and hope it only affects one project momentarily, but it is when more senior staffs, whose rulings affect all aircraft projects, condone this that things get out of hand.

Like CDP's rulings (late 90s and supported to this day by Min(AF)) that functional safety can be ignored, as long as the system is physically safe. To correct that, as Safeware says, you need someone in each IPT to stick their head above the parapet. This happens rarely. Lack of functional safety was noted or later discovered to be contributory factors in Nimrod, C130, Sea King and other recent accidents.

Couldn't agree more about Handling Sqn. From a project management viewpoint, I'd ask to see the Publications Management Plan on any project causing concern. Full tasking of HS went from being automatic, to sporadic, to "Who they?" in the space of a few years, after the ruling that pubs could be ignored if it meant meeting time and cost. In my own experience, this was reported formally to 3 Star in January 2000. (Nil response). As you say, PMPs are often valid, but the output is seldom fully verified. This subject crops up in most accidents, but is never investigated properly so is often a throw away line. Mull comes to mind.

[ShyTorque]

Put the following advice inside the front cover:

"Military aviation involves a level of risk. Other jobs are available."

[tucumseh]

Put the following advice inside the front cover:

"Military aviation involves a level of risk. Other jobs are available."


Here’s a quite serious suggestion, which has been booted into touch in the past……

Include a section in the RTS and MAR detailing Project Office, Boscombe and Design Authority recommendations directly affecting flight safety which have been ignored or rejected; giving the reasons why. This is not a big deal, as the information MUST be recorded in the Project History, Risk Register and Safety Case. (That it isn’t is another serious failing, as it helps prevent MoD learning from its mistakes).

That way, aircrew who routinely accept a degree of risk (which is what ST is referring to), can make an informed decision about what other people regard as unacceptable risks.

And the halfwits who think safety is an irritating inconvenience to be ditched at the first opportunity would think twice.

[flipster]

Include a section in the RTS and MAR detailing Project Office, Boscombe and Design Authority recommendations directly affecting flight safety which have been ignored or rejected; giving the reasons why.

Tuc

Do you mean to say that these august people can be over-ruled by non-engineering/non-airworthiness/non-aviation 'politicians' in MoD PE/DE&S....just to hide the politician's own incompetent management?
In doing so, you intimate that some of the aircraft that our crews fly are not actually airworthy? Surely not?

If so, I would think it a very good idea that aircraft commanders and their crews should be made aware of these limitations, constraints and know the real risks that they are taking!!!

[tucumseh]

Flip

Correct.


The thrust of my argument is aimed at forcing those involved in attaining and maintaining airworthiness to meet their legal obligations. It’s really quite simple. The regulations mandate it; in practice they are treated as mere guidelines, which can be ignored if Time, Cost or career progression are at risk.

The name of the game is “Avoid the avoidable, manage the unavoidable”. Far too often I have found myself managing the avoidable.



Much is written about the Mull accident, and the aircrew asking to use a Mk1, as they harboured concerns over the Mk2. Request denied.

I wonder if the request would be been treated differently if the Mk2 RTS or ACM had included an Annex, as per my suggestion above, listing Boscombe’s recommendations which had been ignored or rejected? At the very least the aircrew would have supporting evidence, and the request would have been elevated. Just a thought.