BOI into the 2012 Tornado Collision over the Moray Firth

[Distant Voice]

What is Tolerable

Forgetting about ALARP, for the moment, when the MoD/MAA and Duty Holders refer to the risk of collision as being "Tolerable" they are basing their judgement on the MAA document RA 1210. That fact is clear from the SI report.

However, RA 1201 does not give any guide lines on risk classification in the form identified by Haddon-Cave (and the CAA), but merely presents a HSE table relating to death rates. This table defines the boundary between Tolerable and Intolerable as being 1 in 1000 for the population at risk per year. No guide lines are given on how this figure should be arrived at in practice, but given that during 2012/13 we had 7 Class A near misses (each with a potential for 2 fatalities), plus 3 actual fatalities, the potential death rate must be significantly worse than the 1 in 1000 per year. In other words "Intolerable". RA 1201 advises DHs to include "near misses"

N.B. Using the H-C approach (BP 1201) and that of the CAA the collision risk is also classed as being "Intolerable"

Moving on to a term that is used in all versions of the risk matrix, that of "Remote", or the frequency of the risk. Both H-C (BP 1201) and the CAA define "remote" as being "unlikely to occur during the operational life of the fleet (1.0 E-5 to 1.0 E-6 flying hours). RA 1210 simply defines "remote" as being "Likely to occur one or more times in 10 years" no mention of flying hours. The over all collision risk is defined in the current Risk Register as Remote/Catastrophic and from a matrix places the risk at AOC 1 Gp level. However, when we consider that over the last ten years we have had 25 Class A near misses, plus one collision, the frequency should be set at the "Occasional" level (Likely to occur one or more times a year). This puts it at the door of CAS.

As it stands RA 1210 appears to be "Unfit for purpose", and the MoD/MAA and all Duty Holders (risk owners) should have a big rethink regarding their interpretation of this document. RA 1210 should be rewritten and brought into line with the real world, as failure to do so could result in future accidents and legal implication.

DV