Hawk Risk Register abandoned ?
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Hawk (Red Arrows) Risk Register - PEFATO - Turnbacks
'Exhibit No 67 - Risk Register' - from the Scampton XX177 accident in 2011, includes some sixty separate risks and where necessary, the required mitigation.
Although the spreadsheet style register is not specifically titled, it seems reasonable to presume it is specific to the Red Arrows, because every one of the risk file names begins with 'RED/.' Each risk is required to be reviewed periodically - six months or a year, though a few are conditional.
One of the identified risks - Risk No. RED/LOCI-HAN/04 - refers to 'turnbacks.'
This risk was described as -
.... "Effect - Loss of Control during the manoeuvre ..."
.... "Worst credible outcome - loss of pilot and supervising pilot"
.... "Liklihood - remote."
.... "Severity - critical.
... "Risk level - Medium."
.... "Risk owner - DDH. .... Risk Manager - OC RAFAT.
The required mitigation to reduce the risk to 'Low and Tolerable and ALARP was in three parts -
.... i) "Bespoke turnback training by HQ CFS Exam Wing."
.... ii) "60 day currency" ... [That's one practice every two months.]
.... iii) "Requal by QFI if ... [60 day currency] ... lapsed."
I can find no mention of a Hawk or RAFAT Risk Register, nor of the specific risk, nor of the mandated mitigation, anywhere in the XX204 SI. ...... A lot of contradictory mishmash, like for instance, the table on Page 1.4 - 7. - PEFATO recency - 30 days for 100 Sqn, 60 days for 736 NAS and, unbelievably, 'Not mandated' for RAFAT.
You'd think that issue alone would have invited comment from the XX204 Board, if only to deplore the change from the mandated '60 days' only six years earlier, and given the record of accidents resulting from practicing EFATOs and Turnbacks, and including the presumption that passengers should not be carried while practicing 'dodgy' manoeuvres.
Nothing in Part 1 to say if the Risk Register was included as an exhibit or had been considered. The closest I got was this cryptic comment -
..... Page 1.4.105 Observations
...... j. ... "The DDH's Air Safety register appeared to be more of a personal record rather than a formal decision register."
Four specific problem areas listed in the Risk Register at the time of XX177 at Scampton were discussed in great detail in the XX204 SI (only six years later) but without any reference to the Risk Register or to the Risk Codes or to the required mitigations.
The specific risk codes are -
RED/OTHR-1/05 - Command Ejection. ... RED/STFBS/01 - Fatigue
RED/CFIT-PILINC/02 - Cumulative Fatigue and ... RED/LOCI-HAN/04 - Turnbacks
Was the XX204 Board unaware of the Risk Register or of the importance of (ignoring) the mandated mitigations that referred specifically to Red Arrows, whose fatal crash they were investigating ? .... Or were they told 'not to go there' ?
Or has the entire Hawk Risk Register been abandoned ?
Someone must know.
LFH
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