PPRuNe Forums - View Single Post - BOI into the 2012 Tornado Collision over the Moray Firth
Old 10th Jul 2014, 17:43
  #295 (permalink)  
tucumseh
 
Join Date: Feb 2003
Location: uk
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"Another issue is that concerning the meaning of "Remote", which is an important parameter when classifying a risk. Have you any idea how the MAA came up with "Likely to occur one or more times in 10 years", an interpretation which is completely out of step with the general definition. Who in their right mind can believe that 120 Class A's an 18 collisions since the aircraft entered service is Remote."
Absolutely right.

Also, one needs to understand inter-relationships and dependencies. My concern here is the recurring nature of risks and failures, and "stove-piping". An example;

Tornado ZG710 (Patriot shootdown) and the Sea King mid-air (same day in 2003) had a common factor - the same individuals refused to direct that the known and notified risks be mitigated. Their ethos and behaviour were major risks to MoD's Air Systems, not just individual platforms. The 2 Star involved also had management oversight responsibility for ensuring Nimrod MR2 was airworthy. Also, the MRA4 programme. And Chinook Mk3. (That's some track record and he was duly made CB).

Similarly, the same risk that came to fruition on ZG710 (increasing likelihood of friendly fire, caused by refusal to properly integrate failure warnings) was only mitigated on AEW Mk2 by ignoring direct orders to leave it unsafe. The IFF project office refused to make their system safe, making false declarations that it was. The AEW programme manager fixed his aircraft during the Mk7 programme, but the recommendation for a fleet inspection of Tornado was rejected by two 2 Stars; in 1998 and 2002. ZG710 proved they did nothing. Even after the senior Reviewing Officer DIRECTED it be made safe, they took no action for over 6 years. Yet a more complex fix in AEW took days.

So, the same risk was mitigated on one platform, but not on others. Was it in all applicable Risk Registers? No, only one. At higher levels, no action was taken, so the risk associated with their refusal to meet legal obligations remained - and remains, because the MAA/MoD know about it and continue to maintain nothing untoward occurred. In turn, THIS risk has been at the root of numerous other fatalities. Associated with this risk is that the senior ranks are permitted to judge their own case. These risks are enduring, and the probability of occurrence increases daily because the ethos is taught to all new generations.


Clearly, at some level, commonality exists between ZG710 and the Moray Forth mid-air, because the risks associated with this Corporate abrogation of responsibility, both on Tornado and in the wider MoD, still exist.


Please don't interpret this as the entire MAA/MoD being bad. Drawing up a simple family tree of all the accidents we discuss here quickly illustrates just a few common names. (And, by MoD's own admission, the same person notifying the risk!). It only needs one, especially if it is the one charged with oversight. Worse, if he happens to be mentor and patron of the dolt who regards functional safety as optional. Oh God, I'm back on the Wg Cdr Spry thread. Never mind six degrees of separation. Here there are three at most, between every accident.


Not one of the above issues has ever been acknowledged or investigated by MAA/MoD.
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