Deliverance
You make perfectly fair points which deserve discussion.
I think we must accept that very few accidents have a single cause. The “Reason Model”, which MoD teaches, characterises it as many slices of cheese, with many holes, whose size is constantly changing. The “accident trajectory” occurs when they momentarily line up.
Problems ARE always present (i.e. as you say, nothing is ever perfect) but the number of slices and fewer/smaller holes are defences in depth. Correct implementation of mandated regulations is one of the biggest and most important defences. In doing so, you avoid the avoidable, leaving time and resources to manage the unavoidable. In Tornado, CWS is one defence, which as you and others say we have done without until now.
But the problem Chug speaks of is that MoD has quite deliberately stripped away the defences. MoD staffs are now spending time and money on retrospectively managing the avoidable. Not just avoidable; but quite deliberate decisions taken to render aircraft unsafe, despite many warnings. For example, the un-ring fencing of airworthiness funding in 1991 and 3 successive years of 28% cuts. I accept that, to today’s staffs, they are faced with this frustration. But I also believe there to be very few in MoD who can articulate cause and effect, which makes it very difficult to make a case for resource.
The ASaC mid-air was a perfect example and the BoI, uniquely in my experience, talked about the defences being stripped so much that crews were only left with one; their own eyesight, at 0400, in pitch darkness, after a recent sand storm. Systems which many pilots had barely thought of (because, unwittingly, they had other defences) became critical. In that case, the BoI did very well given they were serially lied to and deceived, with crucial files “missing”. This Tornado mid-air isn’t too different in most respects.
But sometimes the defences you build just cannot prevent recurrence. Especially when the legal obligation to try to avoid recurrence is deliberately ignored and the oversight process suborned. (Chinook ZD576 is a good example). In this case, as Distant Voice said, there were far too many Tornado mid-airs and near misses and OR(RAF) correctly ran a requirement for a CWS. Sometimes you must temporarily accept the risk (and try to bolster other defences) because the technology simply isn’t available or, commonly, is too heavy and bulky for a small aeroplane like Tornado. For example, wire-strike warning technology has always been needed, but it wasn’t until 1986 it was miniaturised to an acceptable degree. Not sure when that Tornado requirement is going to be resurrected, or if it has been embodied in Typhoon and F35. (The designer sits patiently awaiting MoD – I’m off to see him shortly and perhaps waste a good walk!) It may be that the RAF decided not to proceed in 1986 because other defences were deemed sufficient, but I mention it because it has resonance with this CWS case.
One crucial piece of evidence Haddon-Cave used (but presented as his own) was the relative inexperience of the MoD staffs who manage all this. The last major aircraft programme I managed saw the prime contractor appoint the company’s most senior programme manager as Risk Manager. In purely grade terms he was more senior to the programme manager. By 1996 he knew all about MoD’s run down of its airworthiness system and exploited it mercilessly. (H-C studiously avoided this bit). By contrast, my 2 Star flatly refused to approve me having a Risk Manager at all. I did it myself, but senior management issued orders that no-one was to engage in Risk Management, or submit Risk Notifications. In 7 years, only one notification was submitted. Yet the biggest risk was inability to achieve airworthiness certification, RTS or enter Service, because the same management had directed that, for example, the Mission Trainer (among other airworthiness pre-requisites) should not be procured. Ever. The same management who ignored the recommendation to conduct fleet checks on Tornado IFF functional safety. Mitigation was to completely ignore our 2 Star, and treat him as if he didn’t exist. Which was actually pretty easy, as he made no effort to do his job anyway. Too busy making sure his ethos was embedded in his pet projects, Nimrod MRA4 and Chinook Mk3. Successfully, to be fair, as the predicted came to pass.
Therein lies the root of our problems. It only takes one or two to undermine the whole shebang. I often wonder what steps the MAA would take if that happened today. That 2 Star, and his bosses, may be retired, but he has been replaced by those he taught. Do they have their SQEP status withdrawn for example? If a procurement 1 or 2 Star isn’t a SQEP in his field, surely they must go? I hear whispers the MAA is quite robust in this area, which if true is good news. They’re learning to implement mandated regulations, and avoid the avoidable!