Again, we have the words serviceable and airworthy bandied about and, as Chug says, they are not interchangeable. Not by a long way.
But in a sense the aircraft WAS serviceable and airworthy, because the respective Authorities said it was. There are bits of paper with signatures on them, and MoD takes great delight in offering them as “proof”.
But, a casual glance at the facts (which few bother with, and why should you – the ROs didn’t) shows that the MoD failed miserably to meet a fundamental obligation placed upon them; to be able to demonstrate and verify serviceability and airworthiness. In this it was (and remains) grossly negligent.
While someone signed to say the aircraft was serviceable, what he really meant was “within the constraints placed upon me by persons over whom I have no control, who knowingly refuse to provide me with the necessary resources to make a full assessment”. (But try entering that in the log!). Some of these constraints were noted during the various investigations, but conveniently ignored. Of course, we now know the aircraft was NOT serviceable - much worse, it carried design defects. I have discussed before a defect reported by the AAIB which 1st or 2nd Line couldn’t rectify even if they knew it existed. Likewise, the DECU connector, the control pallets and so on. Like every such operator and maintainer, they relied on those further “up” the chain to do their job, but many were constrained themselves. However, there were identifiable individuals at the “top” who knowingly made these rulings – recorded in a 1996 report to PUS, which was quickly dismissed by the MoD(PE) Chinook 2 Star as “of no concern to PE”.
As for airworthiness, again a casual glance at the Release to Service (the Master Airworthiness Reference) clearly illustrates the document is a farce. A simple example…..
Much is said of the Icing limitation (+4 Deg C). In the Initial Issue dated October 1993, as provided by MoD, the relevant section is ambiguous in that it omits the paragraph included in later versions headed “Icing Conditions”.
Amendment 1 was issued in March 1994 – MoD disingenuously claim this was the standard at the time of the accident, conveniently (and very suspiciously) omitting to mention a raft of Service Deviations. Now, you all know how any such document is amended. There is an pack issued by the RTSA, with an Instruction Sheet (“Remove and destroy pages….., Insert pages…..”). This task is given to the most junior clerk. Very often it is a consolidated task involving rafts of APs, Orders and so on. (In fact, it MUST be a consolidated task, as the RTS must be reflected in concurrent amendments to APs – but routinely isn’t). It’s mind-numbing, and they just follow the monkey sheet. Rip out, stick in, ditch the rubbish that’s left. In this case, there is no instruction to add the intended page R2, which provides “Icing Conditions”.
So, if amended in accordance with the instructions, at the time of the accident the RTS omits the following;
Pending resolution of the effect of the engine inlet screen blockage on engine surge margins, operations in cloud or fog (visibility less than 1000 metres) or rain are prohibited in ambient temperatures COLDER than +4 Deg C (indicated).
The accuracy of the OAT gauge is noted elsewhere as +/- 1 Deg C.
Therefore, there is no guarantee that any given copy of the Master Airworthiness Reference was accurate or complete at the time of the accident. Note, MASTER Reference. All other documents quoting or expanding on its contents must reflect the MASTER. (Part of the audit trail, which MoD don’t bother about either; and a good example of Configuration Control, which was not maintained on Chinook).
This may seem minor (but not, I suspect, to aircrew who should be horrified at such a howler) and it may be that the Aldergrove copy was correct (i.e. the instructions were not followed!), but it is indicative of a system under extreme strain, toward the end of a 3 year period of savage cuts in the airworthiness budget.
MoD freely admits all this, but dismisses any suggestion that the BoI should have investigated the deeper issues; simply saying, with supreme arrogance, that it was not in their remit. Ok, it wasn’t in the BoI’s remit, but BoIs are simply a small part of the Safety Management System. The SMS reflects the MoD’s legal obligations, mandating that the root cause is investigated to identify lessons to be learnt. It also requires these lessons ARE learnt and for this to be demonstrated. Simply put, the law does not permit MoD to place an artificial boundary round the BoI / RO reports. There is a wider legal obligation, which has been ignored. Put another way, the investigation is not yet complete.
So, if the BoI didn’t do this, who did? It was clearly the responsibility of the ROs and/or those who convened the BoI, acting for the SoS. They failed in this duty and systemic failures were left unattended. Their own failings are what have protected the ROs for so long. Time for the investigation to be completed, and then see how the verdict stands up.