JFZ90
The IPT is pretty clear that they didn't know (but should have known) about the safety shortfall
The testimony (as reported) makes it clear they DID know, in that the hazard was identified and probability of occurrence graded “improbable”. That grading may in hindsight be an error of judgement (although not necessarily so, despite the Air Cdre’s admission) but that doesn’t detract from the inescapable fact that every Risk Matrix in various MoD publications says that “improbable” coupled with a Severity of Harm of “catastrophic” or “critical” equals a safety risk which MUST be reduced to ALARP.
If the Severity of Harm wasn’t classified “catastrophic” or “critical”, but “marginal”, this would produce a Class D and “broadly acceptable” risk. Given the outcome of the hazard was fire and/or explosion, who on earth would classify a fire and/or explosion as “marginal” severity? That’s insane. (Just as CDP’s ruling that airworthiness and safety were optional was insane).
Now, given we’re talking about “improbable” + “catastrophic” or “critical” = Class C risk, is it not interesting that BAeS reported SIX “HRI Classification B scenarios” which they referred to the MoD for a decision on mitigation; two of which related to “Fuel Tank explosion”? Bizarrely, the report then concludes the aircraft is “acceptably safe to operate” BUT only in a peacetime environment. I have seen reports like this before where the narrative, written by a safety engineer, is explicit about the risks; yet the conclusions are so obviously diluted at a higher level to suit a customer imperative (political or otherwise). I’m sure this evidence has been presented to the Coroner and no doubt he’ll take a view, but I wonder how many here have seen it?
As to money being the root, one has to ask what any IPT is required to do upon receipt of such a report, or identification of a risk which MUST be reduced to ALARP. They’d launch an IMMEDIATE task on the Design Authority to produce, as a minimum, a Development Cost Proposal (DCP) to mitigate the risk. That assumes they have the funding to pay for the task, and a contract in place. (Both widely ignored airworthiness requirements). Upon receipt of the report (and it looks like the factors had been carefully thought out anyway in the above BAeS report), accompanied perhaps by a MF714 modification proposal, the IPT would have to raise (a) Cost and Brief Sheet supporting the 714 submission to HQMC and (b) a Business Case if they wanted to proceed. (At this point Chug will perk up, as this is where PUS’ mandated requirement for independent scrutiny is ignored, a contradiction which prevents many key airworthiness documents being updated as one is forced to take sides – you agree with either PUS or your 4 Star, but not both). Regardless of the complexity of the modification, this is a very simple process with the procedures spelt out in great detail in two Def Stans. In fact, the practical problem most IPTs face is finding someone sufficiently junior to do this as both are core competences one attains before promotion into an IPT. I’m afraid my experience is that, more often than not, the decision comes down to money. Success or failure of the submission largely depends on the willingness of an individual to make a nuisance of himself with those vying for the same funding. And MoD doesn’t want the Coroner to go there.