PPRuNe Forums - View Single Post - BOI into the 2012 Tornado Collision over the Moray Firth
Old 5th Jul 2014, 05:58
  #252 (permalink)  
tucumseh
 
Join Date: Feb 2003
Location: uk
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But as I pointed out, the people of today are not responsible for the failings of their predecessors.
But now they know of the details of the failings (evidence to Haddon-Cave, Lord Philip etc). If they do nothing they are are equally guilty. Remember, it is a legal obligation to report such failings and illegal acts. MoD policy is to discipline those who do. The MAA are party to this ruling. As such, anyone who doesn't speak out perpetuates the problem and places lives at unnecessary risk.



They can only look to the future and do their best.
But their best demonstrably isn't good enough if they don't understand and accept history. Witness, the same recommendations being made. Fine, they made the recommendations. But very rarely in an SI/BoI report do we see the simple and honest acknowledgement that it is the umpteenth time a recommendation has been made. There has to be a register of recommendations and an action plan to clear them. And the SI report must cross reference to previous reports. Only then will the true systemic nature of the failings be exposed. At the moment, MoD compartmentalises everything.


The continued inference that the current incumbents of every position in military aviation safety are all are either incompetent or liars does a large number of very decent people a huge disservice.
Not sure who made this accusation, but you shouldn't draw inference that any such implication is true. But, that despicable lies have been told, and continue to be told, is a simple, demonstrable fact. I have said before; the lies come from the highest ranks. And pointed out a number of times that junior officers refused to lie during the MoK Review, and that honesty was a significant factor in (a) exposing the lies of their seniors and (b) forcing a Ministerial apology; all of which influenced Lord Philip.




In many ways, misleading by omission is even worse than lying. May I offer a simple example in this case? The SI Panel recommends better management of MF760 (Narrative Fault Reports). (The report is poorly worded, making me uncertain if they understand). The progression, to a satisfactory conclusion, of MF760s is a CORE component of Maintaining the Build Standard, which is a mandatory pre-requisite to a valid Safety Case and, hence, Release to Service. Not having such an audit trail, which MUST be a quite deliberate and conscious act of "savings at the expense of safety", would be your top risk.

As I said above, the MAA have studiously avoided mentioning this direct link. Why?

Very few in the past 20 years understood this simple process, because it was effectively cancelled under Chief Engineer Alcock. But that loss of Corporate Knowledge is no longer an excuse following the evidence to Lord Philip and Haddon-Cave. What the SI report should do is put a simple footnote to this effect against this recommendation, to demonstrate they actually appreciate the full impact of what, at the moment, looks like a throw-away statement. In fact, it is in many ways the most serious of them all, because it clearly reveals no lessons have been learned from the host of other accidents that shared this systemic failing. (See the Rivet Joint and Spry threads - MoD get the basic definitions worng, proving my point better than I ever could).


As I said above - compartmentalisation. What will happen in this Tornado case? Tornado will change their MF760 procedures slightly (yet still ignore mandated policy, or more likely continue in total ignorance of it), but what is needed is a policy decision to rid us of Alcock's legacy. That is, properly fund the subject (valid Safety Cases) pan-MoD. You'd be surprised at how little it costs compared to lives lost; as well as equipment. So, SI recommendations should also carry a statement of applicability. Is it isolated, or systemic? Having to answer this simple question would improve competences immeasurably. And it would almost certainly reveal holes in the education of the Panel's engineer!
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