PPRuNe Forums - View Single Post - BOI into the 2012 Tornado Collision over the Moray Firth
Old 11th Jul 2014, 05:57
  #298 (permalink)  
tucumseh
 
Join Date: Feb 2003
Location: uk
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I've deliberately compartmentalised my arguments to the present day because the subject of my posts has been limited to the continued operation of the aircraft while integration and installation of the current incarnation of CWS is completed. I have not addressed the question of whether the risk was tolerable and ALARP from 1996-2012; indeed your evidence strongly suggests that it wasn't. As I've made clear, though, I consider it to have been tolerable and ALARP since the decision to reinstate the CWS programme. Whether or not the risk was ALARP during the 2000s is not relevant to its status today, given that we can't turn back the clock and retro-fit the system. The current duty holders can only play the cards they've been dealt.


Thank you Easy Street. But while I understand what you say, the danger is of being sucked in to the MAA/MoD dogma I mentioned, that Haddon-Cave handed them a huge “RESET” button which permits them to ignore everything that happened in the past. This would be an insult on so many levels, not least to those who perished.




I accept that, strictly speaking, the status of this specific risk has changed, and the Risk Register (if manipulated in a certain way) may cough out “Tolerable and ALARP”. But, as Distant Voice says, what criteria are used? Common sense (and mandated procedures in my day) says, given the history of repeated refusal to mitigate, one simply cannot reset to zero and say the same old risk mitigation plan WILL be effective. History shows the same plan was NOT effective (not least because of the MoD ethos that safety is optional and can be waived to save time and money). This ethos persists today, and MoD is quite happy to state this in writing (DE&S policy branch, to be precise). You cannot reset the probabilities of occurrence to the original figures. They MUST reflect history, trends and reality. Bluntly, they must reflect the fact that many senior staffs are hostile to what the project is trying to achieve. That alone would prevent Tolerable and ALARP. It is not As Low As Reasonably Practicable, because the same individuals are fighting against you, and they have a long and successful track record of winning and enjoying top level support. This may be in secondary or inter-related risks, but it MUST be there and linked to the main risk. All this would combine to push up the Risk Score. Also, the Project History Sheets (do they even exist?) must be referenced in the Risk Register. Not just the current "project", but the entire requirement. And not just referenced, but read and understood by all concerned. Perhaps more importantly, also understand how others have successfully fought your enemy off (e.g. the AEW example I quoted). And why they failed as well (e.g. Tornado/Patriot). The paper on that one case should be required reading for ALL in DE&S and MAA.




The elephant in the room is that MAA/MoD conveniently ignores that the causes and/or contributory factors in each of the many accidents we discuss here were predicted, predictable, notified and ignored. Ignored by the predecessors, mentors and tutors of those in charge today, who continue to protect them. This approach arises from the fact the MAA is built on two lies – that everything was fine until 1998 (Haddon-Cave) and the regulations are rubbish (MAA/MoD). To admit either is wrong would be a major step forward. At the moment, the MAA is seen to tread water at best, because much of its effort concentrates on the regulations, not implementation. Yet again, we have in CWS an example disproving the first lie; and MAA seen to gloss over it.

So, I do not believe this long standing risk that is neither Tolerable nor ALARP, and has come to fruition (causing deaths), can be reset to Tolerable and ALARP just because MoD has been (reluctantly) forced to think about it by these deaths.


This is the worst kind of management artifice.



Again, a history lesson, which few in MoD know about. Distant Voice and Angus Robertson MP were lied to by MoD when seeking papers on this crash; as they have lied to everyone I know who asks such questions. (ASaC, Patriot, Chinook, Nimrod, C130 and so on). It should not take the persistence of a few retired old lags to force MoD in to accepting legal obligations, yet demonstrably that is what has happened. MoD would quite happily have done absolutely nothing in each case if they could have got away with it.
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