We are all human and make mistakes. Why on earth can this not be acknowledged in this case?
While it is entirely possible the pilot(s) made an error of judgment, that does not excuse the actions of their seniors, who had a Duty of Care obligation.
As a great man once said “An error does not become a mistake until you refuse to fix it”. Assuming, of course, you have time to fix it. That luxury may not have been available in the final moments of ZD576; the most obvious reason being the statistical probability of a fault occurring. I base this statement on the long history of faults (and defects, a quite different thing indicating deeper Quality of Design issues) in the 57 hour life of the aircraft as a Mk2, the recommendation from Boscombe that it should not be flying and, finally, the ludicrously caveated Release To Service which clearly demonstrates even the most basic Airworthiness procedures were not implemented in this aircraft. That is, the Build Standard was not maintained.
For good reasons, very few here understand this last bit. The Safety Case or Safety Argument MUST reflect the in-use Build Standard, so by definition that Standard MUST be maintained. ANYONE remotely experienced in this highly specialised function would take one look at the Mk2 RTS and say “Build Standard not maintained”. (They wouldn't even have to be shown the admission from 2 years later, which resulted in a contract to correct this on certain systems). Ergo, you have possibly the single most serious breach in the airworthiness audit trail, as the Authority cannot validate or verify the evidence he has used to support their signing of both the MAR and RTS.
That this ability to demonstrate, validate and verify was being compromised by huge and successive cuts in the funding and was notified almost daily throughout 1991, 92 and 93. Despite these warnings, a quite deliberate decision was taken to compromise airworthiness. The warnings specifically said that the nature of the process meant problems would emerge gradually and accumulate, but by the time they manifested themselves it would be very costly and almost impossible to regress and take corrective action. In 1991, the prediction was it would take up to 3 years for the practical effect to bleed through the system, by which time the safety argument on most aircraft related kit would be invalid.
The warning also reminded the 2 Star (in our case) of the first rule of Maintaining the Build Standard. It is not volume related. That is why it was managed and funded separately – the funding cannot be cut proportionately when fleet numbers reduce or the Treasury demands a 25% chop in support costs. Since 1991, this activity, such as it is, has been lumped with “support”, so takes a financial hit with everything else.
In direct contrast, the staffs responsible for;
- Maintaining the Airworthiness of the Mk1,
- Attaining Airworthiness in the converted Mk2, and,
- Maintaining Airworthiness in the Mk2
made a series of errors which, despite being given ample opportunity and time to correct, they did not. They knew exactly what effect their decisions would have. They made a deliberate decision to state (falsely) that the Build Standard had been maintained, yet issued an MAR and RTS which clearly shows it had not. This is implicit in any MAR or RTS, but in my experience those responsible can rarely explain what I’ve said here. They don’t know the detail, so can’t understand where the Devil is lurking.
Their mistakes were compounded by serial breaches of the airworthiness regulations they were bound by, all of which adds up to, in my opinion, Gross Negligence.
The only possible thing I can say in their defence is that, at the time, the Project Management Guidelines were in the process of being replaced by the ludicrous and ill-fated Chief of Defence Procurement Instructions (CDPIs). The CDPI intended to instruct project managers on how to maintain Build Standards made the cardinal error so common on this thread (and, notably, by the Reviewing Officers) – it confused Serviceability with Airworthiness. A lengthy tome, it was completely and utterly without relevance to the subject. It did not even mention the relevant Def Stan, which had been updated the previous year. (All the CDPI had to do was say "Comply with the Def Stan and permanent LTC Instructions"). Ah, compliance. MoD don't do compliance. That was December 1993.