BOI into the 2012 Tornado Collision over the Moray Firth

[Distant Voice]

The SI panel concludes at para 1.4.6.605. a. (5) that the MAC risk mitigations fell short of what is considered Reasonably Practicable, and therefore not ALARP.

The DG of the "independent" MAA tries to play down the SI panel's conclusion by remarking, in the Convening Authorities Comments, that,

However, I am not persuaded that HQ 1 Group risk management process did not reduce the risk of Mid-air collision to the position of As Low As Reasonably Practicable (ALARP), bearing in mind the activity over the years to reduce the Mid-air risk and the significant work predating the accident in HQ 1 Group (and Air Command) into this risk, including that generated by the Senior Duty Holder following a spike in Air Proximity (near-miss) reporting. Moreover, a fully funded programme for the fitment of CWS to Tornado existed and was being pursued by DE&S with full haste and thus satisfying the 'R' in Reasonable in the ALARP mnemonic

I take this as a statement by the DG to protect a SDH from having to justify his management system and ALARP statement in court; as require by RA1210. There is no evidence shown in the No 1 Group Tolerable and ALARP statement, in force at the time of the accident, that near-misses had been included in the risk assessment process, the statement only talks about actual deaths from past collisions.

Clearly, the DG had his head in the clouds when he wrote that statement. The panel makes it clear in para 1.4.6.601 that, "there were several mitigations in place to avoid MAC, nearly all either did not work, were not applicable or were not adhered to". Furthermore there was no "fully funded programme to fit CWS" at the time of the accident, that did not happen until around November 2012.

Finally, the biggest misunderstanding within the MAA and MoD is that regarding the "R" in Reasonable. The temporal element of "Reasonable" has got nothing to do with the time permitted to reduce a risk to ALARP, it is time in terms of a cost; manhours to cover the necessary modifications. The idea that there is such a thing as ALARP (Temporal) was dismissed recently by Lord Cullen when the idea was put to him.

The sad thing is is that the DG of the MAA has been advising the Crown Office of Scotland that there is no need for an FAI, because all is covered by his SI report.

DV

[Distant Voice]

Just tracked my grandson's flight from London to Edinburgh using a £2.99 app know as Flight Radar 24. This app tracks all civilian flights IN THE WORLD, giving height, position, ground speed, and vertical speed. I find it inconceivable that we can not provide our Typhoon/Tornado aircraft with a similar system for civil and military aircraft.

DV

[Courtney Mil]

FR24 is impressive, yes? But it's only a website using secondary radar, partly from amateur spotters, using ADS-B. You may notice that a lot of mil ac are missing from the picture. You may not have noticed that the system is neither authenticated nor secure. It is an up and coming system and it has the potential to use satellite receivers.

But for the purposes you are implying, we already have systems to do collision avoidance; they just haven't paid for it to go into the entire RAF fleet.

[Skeleton]

DV it is a good point but replicating FR24 in the Military environment would be problematical to say the least. The coverage in Europe is ok provided the aircraft has the right radar (A lot do not) but the data from the US is lousy and a lot is subject to a time delay, with no info on type or destination etc. Here in Oz I can assure you where FR24 thinks my jets are is not even close to where they actually are at many points across the globe. It is not the golden app it is made out to be.

[Easy Street]

I think it's a damn good job that most military aircraft don't appear on FR24. It would be like offering a seat at the ACMI debrief to every single intelligence agency in the world. Changes of heading after simulated missile shots would be quite obvious and repeated observation would allow our tactics to be analysed and countered.

Before anyone suggests that Mode S could be disabled inside segregated airspace like the MDAs to prevent such analysis, I'd point out firstly that collisions are most likely to occur between aircraft operating as part of the same package, so by the logic of combat aircraft needing a collision avoidance system Mode S should always be on, and secondly that we conduct much tactical activity outside of segregated airspace.

[Distant Voice]

Two issues that do not appear to have been adressed by anyone are;

(a) As both aircraft waited to join the range why were they orbiting in opposite directions?

(b) Knowing that the normal SSR radar system was out of action why wasn't a feed taken from the SSR radar at Inverness airport? It is understood that positional data was taken from this system during the Service Iquiry.

DV

[airsound]

There's some wonderful MoD-speak in a piece on Forces TV - where the ministry is trying to defend a lack of action on the TCAS/CWS front.

But Forces TV also mentions reports of CAS warning Sec Def about the risk of Typhoon/passenger aircraft collision.

Worth a look
MoD Defends Fast Jet Collision Avoidance Policy | Forces TV

airsound

[Distant Voice]

This MoD spokesperson is talking out of the wrong end of his body. The majority of civilian aircraft CAN operate with TCAS. This is an MoD attempt to justify over 20 years lack of progress. If we all follow their logic we would not bother fitting headlight to cars because they could not "remove the threat of collision" at night.

DV

[Chugalug2]

Forces TV:-

Under half of British Tornado GR4s have a traffic collision avoidance system (TCas) despite a government pledge to install them nearly 20 years ago, according to the Independent newspaper.

Harumph! Bloody mistake giving the Twenty-Minuters a parachute. Undermines a proud tradition of pointless sacrifice!

[MAINJAFAD]

(b) Knowing that the normal SSR radar system was out of action why wasn't a feed taken from the SSR radar at Inverness airport? It is understood that positional data was taken from this system during the Service Inquiry.

.


The data taken from Inverness SSR came off their own data recorder, not an MoD one as the Inverness SSR data was not feed into the RAF ATC tower for a whole host of reasons:


1. The Radar at Inverness does not belong to NATS or the MOD, therefore it will cost the MOD money to rent its use and for the Airport to run it at times that suit the MoD and not the Airport.


2. The Civil radar will need data link equipment that will provide a data signal that is compatible with the MoD system which is around 30 years old. If not compatible some form of data conversion equipment will be required at the MoD end, plus the data link equipment compatible with the civil radar. Equipment has to be procured, installed and a service support contract for the system has to be funded.


3. Communication link costs. This is the big one. The Radar has to be linked to tower by a dedicated continuous telecommunications link for the life of the system. The only reliable way of doing it is by land line. In this case you are tied to a single provider as it is they who own all of the telecommunications infrastructure on the MoD estate. Imagine what the cost of a five year long telephone call would be, because if the contract for the service is that long that is how long that single line would have a running call on it (plus line rental at commercial rates).


To give you a clue on how much it costs the MoD to rent the use of a civil radar, some of the contract costs are on the internet (I've no idea if this cost includes the rental and usage cost of the land lines).


https://data.gov.uk/data/contracts-f...tract/1125982/
https://data.gov.uk/data/contracts-f...tract/1193802/


In simple terms, its not cheap and not easy.

[tucumseh]

Mainjafad

Very interesting. £391k for a 6 year contract in the example quoted. Making a case for such an Inverness facility would be easy. Finding £391k is a 5-minute job. The Services routinely "forget" to include much larger requirements and any DE&S project officer should be well versed in delivering it. On one of my last programmes before retiring, the RN said they didn't need a mission trainer so there was no funding granted. They did, it cost £22M and finding that that was off-loaded to the office junior as a half day job. Money isn't the issue I'm afraid. More likely some VSO not wanting to admit the need (probably related to DV's underlying concern). That's the way MoD works - you wait until he's gone, then re-submit and get it approved retrospectively. (On the same programme, an entire new comms system was approved to enter development, 3 years after embodiment). I'm not up to date by any means, but Crowsnest is a good current example. That whole FOAEW/MASC thing stalled for many years for similar reasons. The FOAEW "requirement" was years behind its predecessor, but the PM only found out when conducting interviews to fill posts. He'd spent an entire tour not realising the link between AEW Mk2 > ASaC Mk7 > his upgrade. When something like that happens to an anointed one, the system quietly closes ranks and the front line requirement is forgotten. Sorry, a little cynical but true!

[Distant Voice]

In simple terms, its not cheap and not easy

On 3rd July 2012 we lost three lives and two Tornado aircraft, how cheap does it have to be?

Also, in view of the importance of having height information I would have thought that a simple call from Lossie ATC to Inverness informing them of the lack of Kinloss SSR information, with a request to keep a watching brief between certain times. On the other hand, perhaps pride got in the way.

DV

[MSOCS]

Perhaps pride got in the way?

Seriously DV?! You seem hell bent on pointing the the finger here with your clear armchair theorems. Nobody wanted to die that day. Nobody. Unless you've cast iron proof to back up such a distasteful comment I politely invite you to keep such disrespectful theories in your suspicious mind, Poirot!

How about we mourn lost friends, understand the nature of military flying, learn the lessons, invoke change that makes a difference (not just for change's sake) and try to be better at what we do?

That approach is fundamentally human and more wholesome than your finger-wagging clap trap.

Rant over.

[Chugalug2]

MSOCS:-

How about we mourn lost friends, understand the nature of military flying, learn the lessons, invoke change that makes a difference (not just for change's sake) and try to be better at what we do?

I mourn the loss of the 3 that died on 3 Jul 2012, not because they were friends, I didn't have the honour of knowing any of them, but because they were fellow aviators whose deaths were unnecessary and avoidable. If they had died in combat then it would indeed be in

the nature of military flying

They didn't though, they were simply holding clear of the Tain Air Weapons Range awaiting clearance to enter. Neither knew the other was there because they were not told, and their aircraft were not fitted with TCAS. As to

learn the lessons

You will forgive me if I curl a churlish lip, having been assured of that by just about everybody after every tragedy that should not have happened. So,"Yeah, right!". Similarly with

invoke change that makes a difference (not just for change's sake)

Let me guess. Compulsory FAIs for Military Air Accidents in Scotland, fitting TCAS to all RAF FJs as an urgent priority, ensuring that the MAA and the MilAAIB be made independent of the MOD and of each other, would all be change for changes sake, right?

try to be better at what we do?

No! Try to be the best! We were once the world leader in Military Air Safety. What went wrong?

[Distant Voice]

I politely invite you to keep such disrespectful theories in your suspicious mind

This is not a theory, it is fact. The lack of SSR was a contributing factor to the accident, and the question I am asking is why wasn't Inverness considered as a back-up. What was the back-up? These are the type of questions that would have been asked at an FAI, had one taken place.

On the subject of FAIs, my armchair finger-wagging clap trap has ensured that during the course of this year it will become mandatory for all military fatal accidents in Scotland to result in an FAI. Something that has been avoided for over 40 years.

DV

[MSOCS]

DV, your inflammatory opinion that it was, "perhaps pride that got in the way" is what is finger-wagging clap trap.

Anything people do to make things better is great, but don't guess at motives or pride causing such things when you clearly don't have the evidence to back up such claims. It ruins your otherwise noble intentions.

Chugalug, you are splitting hairs chap. Trying to be better is reality. Being the best is, well, frankly, not. I'd argue no death is necessary. There are duties of care in war and in peacetime. We train as we fight, but it does not absolve us to be as safe as we can. That's the point of "the nature of military flying" comment - to be better at our jobs we subject ourselves to risks that are, where possible, bounded. Goal posts shift with time and as lessons are learned about what we do. To discuss hindsight is valuable only if lessons are learned. To use it as an "I told you so" isn't.

Both aircraft were at low level; a tactic fundamentally designed to defeat radar, which is exactly the things you are arguing weren't used effectively - probably because they wouldn't have been. I don't know your background but I suspect only a few here have much experience at 100-250ft and 8 miles per minute.

[Chugalug2]

The BoI reported the collision at or about 900' AMSL over the sea and, as they were both holding, 8 miles a minute would seem to be a bit OTT wouldn't it?

So they couldn't be seen not because of radar avoidance practice, but because of the shortcomings that DV has raised, and hence weren't warned of one another's presence by R/T. If they had been fitted with TCAS then they would have been warned of one another's presence by TCAS, but they weren't, so they weren't!

You may think all that is splitting hairs, the UK Military Regulator thinks all that is splitting hairs. Others, like me, disagree.