Brian Dixon said;
are you aware that the CAS described the BoI as being "barely adequate"? I wonder whether his concerns were raised with either the BoI President or the reviewing Officers, and why there was no request for a more thorough job?
Brian has raised this before, but good points are worth repeating.
The MoD’s Safety Management Systems (in fact any SMS) requires that ”Knowledgeable people should investigate the incident (sic) and determine the causes, both immediate and
underlying”.
Examples of “underlying” causes are given, such as safety culture, how work is controlled, co-ordinated & supervised, adequacy of safety planning & risk assessment, how competency is achieved & tested and adequacy of safety review & audits.
The simple reason why MoD doesn’t “go there” is because it fails every count, except perhaps the last (as numerous audits, safety and otherwise, have highlighted the failings I speak of). If you recall, the Chinook 2 Star in MoD(PE) dismissed one as “Of no concern to PE”.
Which brings us to the next paragraph in the book – “There should be follow-up…..”. As far as I can see, MoD’s follow-up resources are expended making sure there is no follow-up.
It would seem this higher, over-riding requirement is not reflected in what BoI’s or (especially, in this case) ROs do in practice. I have a feeling Mr Haddon-Cave’s report is going to dwell at length on the fact the regulations are not implemented, which we all know anyway.