The SI panel concludes at para 1.4.6.605. a. (5) that the MAC risk mitigations fell short of what is considered Reasonably Practicable, and therefore not ALARP.
The DG of the "independent" MAA tries to play down the SI panel's conclusion by remarking, in the Convening Authorities Comments, that,
However, I am not persuaded that HQ 1 Group risk management process did not reduce the risk of Mid-air collision to the position of As Low As Reasonably Practicable (ALARP), bearing in mind the activity over the years to reduce the Mid-air risk and the significant work predating the accident in HQ 1 Group (and Air Command) into this risk, including that generated by the Senior Duty Holder following a spike in Air Proximity (near-miss) reporting. Moreover, a fully funded programme for the fitment of CWS to Tornado existed and was being pursued by DE&S with full haste and thus satisfying the 'R' in Reasonable in the ALARP mnemonic
I take this as a statement by the DG to protect a SDH from having to justify his management system and ALARP statement in court; as require by RA1210. There is no evidence shown in the No 1 Group Tolerable and ALARP statement, in force at the time of the accident, that near-misses had been included in the risk assessment process, the statement only talks about actual deaths from past collisions.
Clearly, the DG had his head in the clouds when he wrote that statement. The panel makes it clear in para 1.4.6.601 that,
"there were several mitigations in place to avoid MAC, nearly all either did not work, were not applicable or were not adhered to". Furthermore there was no "fully funded programme to fit CWS" at the time of the accident, that did not happen until around November 2012.
Finally, the biggest misunderstanding within the MAA and MoD is that regarding the "R" in Reasonable. The temporal element of "Reasonable" has got nothing to do with the time permitted to reduce a risk to ALARP, it is time in terms of a cost; manhours to cover the necessary modifications. The idea that there is such a thing as ALARP (Temporal) was dismissed recently by Lord Cullen when the idea was put to him.
The sad thing is is that the DG of the MAA has been advising the Crown Office of Scotland that there is no need for an FAI, because all is covered by his SI report.
DV