Haddon-Cave - RAeS Lecture

[Mandator]

The man himself is lecturing about XV230 at the RAeS next week:

http://aerosociety.com/Assets/Docs/Events/NamedLectures/NL84/Beaumont_Flyer_2014.pdf?utm_source=The+Royal+Aeronautical+So ciety+e-communications&utm_campaign=d3d5e5d907-&utm_medium=email&utm_term=0_01701ea34d-d3d5e5d907-291994905

[Sandy Parts]

Will he receive a payment for this lecture? If so, I'd hope a donation to a suitable charity is made, given the subject is entirely related to a recent tragedy. I appreciate spreading the knowledge may help prevent a future event, but his profiting personally would leave a sour note to my mind.
On the other hand, hats off to him if he is doing it 'gratis' as a way of highlighting the errors uncovered. After all, he was no doubt adequately rewarded for his work on the inquiry in the first instance. Just my opinion - only ever met the bloke once.

[Raikum]

As a current High Court Judge I would be absolutely certain he's doing it gratis.

[skua]

If anyone is going, please could they post a precis here afterwards?

ta

[Pittsextra]

Following an editorial comment in Aerospace (the RAeS monthly publication) in the Sept edition a letter by Tony Blackman followed a month later.

Tony Blackman FRAeS letter as it was published here provides a useful insight :-

MAA and Nimrod Ref the article on the MAA(2) there can be little
doubt that military air safety has been improved by the Haddon-Cave Report
but, unfortunately, it was done unnecessarily at the expense of the Nimrod by misidentifying the source of the fi re. Sadly nothing can bring the aircraft and the crew back but the fact remains that the Nimrod crashed not by having a fundamentally bad fuel system as suggested in the Report but by lack of flight testing and not understanding the prophetic warning given by BAe in 1985: ‘There may be some cause for concern with regard to the wetted surfaces caused by a discharge of fuel and it is suggested that tests are made in flight using a coloured dye to study the behaviour of liquid in relation to the various ports and intakes, particularly the tail-pack pre-cooler in the bottom of the rear fairing. If the liquid is found to enter this intake, it may be necessary either to switch off the tail pack before commencing air-to-air refuel, or to carry out a modification on the blow-off valve outlets of
tanks 1 and 6 to prevent the fuel running down the skin.’ It is remarkable that the BAe warning was ignored not only by the firm itself but also by the
MoD. The Haddon-Cave Inquiry found this report but did not understand
its implication which warned that blow-off fuel might be going into the pre-cooler intake where the temperature was 400°C and any fuel would immediately be set alight. From the accident investigation evidence which showed that the tail-pack warning occurred first followed much later
by the bomb bay fire warning it is clear that that is exactly what happened
to Nimrod XV230. Had the cooling pack been switched off the accident
would never have happened. There seems to be universal acclaim for
the Haddon-Cave Report but it is interesting that no attempt was made by the Inquiry to find out where the blow-off fuel from the tanks actually went by carrying out simple tests. It could be argued that had the real reason for the tragic loss of the Nimrod been appreciated the pressure to cancel the project and leave the UK without a maritime military aircraft might not
have been so great.


Given his prior comments on this could make for an interesting night:-


http://www.blackmanbooks.co.uk/fpdb/nimrod%20XV230.doc

[tucumseh]

There seems to be universal acclaim for the Haddon-Cave Report

Not in this quarter. Many of his conclusions are not evidence based. Some of his claims are arrant nonsense. Some are quite deliberate deceits, because he used them to knowingly name and blame people who were desperately trying to deal with a situation they, and their predecessors, inherited. He knew these people were completely innocent, especially General Sir Sam Cowan.

Notably, he claimed implementation of the airworthiness system was fine before 1998. He completely ignored written evidence from the MoD's own auditors (EAC Liverpool and DIA Bath) that a 1987 policy issued by AMSO led directly to the Chief Engineer beginning a 3 year rundown of the system in 1991. (The "savings at the expense of safety" he repeated, but without mentioning no savings were necessary in the first place if the regulations had been followed by those he protected).

He also completely ignored almost all the ART reports, which independently confirmed the EAC and DIA reports. He did mention the Nimrod ART, but didn't say that, in 1996-98 it repeated the failings noted in the 1992 Chinook ART report. Why did he omit this? Because to include it would mean he would have to push back his 1998 date to, at least, 1990.

But hey, why pay any attention to something the RAeS host? As their main man said in an e-mail to me, he considers Air Safety to be "none of my or the Society's business" (5th October 2012).

[Pittsextra]

.....but then if you attend you could put all those points directly to the man himself?? Or am I missing something!?? Pop corn sales should be through the roof!

[Chugalug2]

Pittsextra, the 'man himself' had all the points put to him in the form of evidence for his review. He chose to cherry pick from it in the manner that tuc describes. Whether or not Haddon-Cave is minded to take heed of any such testimony doesn't change the fundamental principles of aviation. If you put unairworthy aircraft into the air then sooner rather than later you will get bitten. The RAF has been doing that for decades and the MAA won't stop it happening anytime soon. Only if it becomes fully independent of the MOD can the massive job of regaining UK Military Airworthiness begin in partnership with the MilAAIB, providing it is independent of both the MOD and the MAA.

Self Regulation Doesn't Work and in Aviation It Kills!

[Pittsextra]

I'm not sure we necessarily disagree I guess my points in this thread are that it's surprising how Haddon continues to ignore the fact the cause of the fire was incorrectly identified. I guess if nothing else it shows the measure of the man.

it would seem incredible to me that a man giving a lecture on topics of leadership, culture, professionalism etc if he can employ the rigour in his own process to accurately identify the cause of the accident..

[tucumseh]

What many, including MoD, choose to ignore is that Haddon-Cave was proved utterly wrong on the points I made above by Lord Philip's Mull of Kintyre Review.

Despite Haddon-Cave's nonsense about 1998 and a "golden period" under Alcock from 1991-96, Lord Philip had the common decency to acknowledge the Chinook was not airworthy and should not have been released to service by ACAS (Bagnall) in Nov 1993. In signing this release, Bagnall made a false declaration. If you care to read the evidence to both Haddon-Cave and Lord Philip, you can only be struck by the similarity throughout. Again, you don't need to beleive me; just read the MoD's own reports from the 80s and early 90s. If the Nimrod Review were a criminal trial, there would be a retrial ordered!

By the way, I have a lot of time for Tony Blackman. Like the late Ralph Kohn, he is not afraid to ignore the RAeS party line.

[Distant Voice]

In Tony Blackman's amplification note, mentioned in Pittsextra's posting, he states that,


"Significantly, just over a year after the XV230 accident on 5th November 2007 and before the Review was finalised, Nimrod XV235 made an emergency landing due to fuel in the bomb bay after flight refuelling but the Review looked for a leak and didn’t appreciate that the fuel almost certainly had come from the same place as XV230, namely the No 1 tank blow-off valve;"

This is incorrect. The fuel was observed by the crew of XV235, with the aid of the under floor periscope, coming from a coupling in the refuelling line, in the forward bomb bay. It was spraying, "like a garden hose, with your finger over the end" on to the bomb bay heating mixing chamber. The hot air inlet temp of the mixing chamber was above the auto ignition temp, and the mixing chamber is in line with leading edge of the fire, according to a drawing produced by the Harrier pilot immediately after he landed on 2nd Sept 2006.

DV

[kevnurse]

DV, you wrote: "The hot air inlet temp of the mixing chamber was above the auto ignition temp, and the mixing chamber is in line with leading edge of the fire"


2 points: use of the mixing chamber (bomb bay heating) was prohibited after the crash. The inlet temp of the chamber would normally have been no more than 100 degrees, as it was sourced from the LP compressor. Although your stated location of the chamber relative to the location of the fire as observed, is correct, the chamber could not have been the source of the fire.


I agree with you that the blow-off valve was not involved in the XV235 incident.


I have written to Tony Blackman explaining where he has made many factual errors in his postulations. He has since replied and stated that he no longer wishes to debate the cause of the accident.


One (last) matter in Tony's postulation that I wish to address concerns the SCP Pre-cooler overheat warning received shortly before the bomb bay warning was activated. Yes, it certainly appears to be a factor in the accident, but it was not. While researching my comments to Tony, I read the transcript of the other in-theatre flight engineer's evidence to the Coroner in which he stated that the SCP Pre-cooler was overheating during the later stages of the AAR. He correctly judged that it was due to a combination of turbulence and high engine power, as outlined within the aircrew manual.


Tony very kindly wrote to me this evening, telling me that H-C's lecture was excellent and that the Nimrod accident was barely mentioned.


Time to let this sad subject go.

[Eminence Gris]

The lecture on Wednesday was extremely well attended, about 200 people, I would guess. The lecture itself was somewhat self congratulatory and the whole event a bit of a lawyers mutual admiration society, but good all the same.

The lecture steered clear of any controversial detail concentrating mainly on the classic cultural failures that can be found in most disasters of this nature: complex and constantly changing organisations, lack of accountability, the normalisation of deviance, increased pressure of operations combined with cost cutting, lack of challenge, the belittling of engineering knowledge, success engendered optimism and unmanaged outsourcing. Sir Charles advocated a return to core values, the establishment of accountability, and the simplifying of procedures.

In describing the MAA Sir Charles described it as being "well on the way to becoming a world class organisation, a model being adopted by the other services and other nations".

Question time was very carefully managed and only two were allowed (there being an "urgent" post-lecture drinks reception) from two named individuals who were probably known to be unlikely to say anything too controversial. If Tony Blackman was planning to say anything, he wasn't given the opportunity.

EG