Nimrod crash in Afghanistan Tech/Info/Discussion (NOT condolences)

[JFZ90]

Tuc,

I see your point re ALARP - but this would perhaps depend on the "risk categorisation table" being used at the time on the project - & hence their defined categories of risk and when action had to be taken. Some guidance suggests that "broadly acceptable" risks don't necessarily have to be shown to be ALARP, though I think this can always be debated.

It is possible in this scenario that this risk being categorised as "improbable", could have been placed in a "broadly acceptable" area and hence no ALARP action was deemed necessary. From the comment:

It should have been graded higher and warranted further action, he admitted.


it sounds like something along these lines happened. Perhaps they also failed to categorise the impact correctly as "catastrophic" at the time too, only as e.g. "critical", compounding the issue. I don't think either of us have access to the tables being used at the time so not possible to comment further - it would be interesting to know what these were though.

Chug - I try (but perhaps fail) to keep my contributions related to the engineering processes surrounding design, airworthiness & safety management of complex systems - and understanding how & why these have failed with respect to the loss of 230. These processes are basically the same for civilian and military projects and driven by (safety) engineering best practice. I note that the safety targets themselves and the implementation of specific regulatory processes maybe different between the domains, but this does not detract from the fact that the basic engineering principles are the same when it comes down to e.g. hazard analysis & risk assessment. I don't seek to single out Boscombe themselves - just their (potential) key role as the "independant reviewer" (or whoever else undertook this role if it wasn't Boscombe) - this role is key in both civil and military safety engineering best practice and along with many other factors needs to be looked at in the review.

[blogger]

Lies, Lies and more lies the crew room was well aware of the problems. But the flying program required more AC.

Simple fact come on guys some one put their dirty paw up and admit it.

As per the norm sooner it goes away the better............... life in the RAF ...tut tut.

[Dave Angel]

Blogger,

WTF are you talking about?

Which crew rooms, cause it certainly wasn't at ISK.

Yes, we've had serviceability problems but none of us was aware of the underlying issue as identified by the BOI.

[Mad_Mark]

Agree with Dave - blogger you are talking out of your ar$e.

MadMark!!! :mad:

[MightyHunter AGE]

Blogger you want to watch what sh**e you spout off.

Lies lies and lies seems to be what you are telling.

MHAGE

[Biggus]

Air Commodore Baber says that 'the buck stopped with him', and that the IPT got it wrong.......

What are the implications of that?

Should he resign?

Has he opened himself up to a civil prosecution by relatives?

Is he the only person so far (in this or the Hercules inquest) to admit to any error/responsibility? If so should he be applauded?

What are the implications for subsequent witnesses?

Don't get me wrong, I'm not on a witch hunt. He seems to be the first person in recent times to admit to any responsibility in any way, as opposed to the 'lack of recollection' approach - which is actually very refreshing. I was just wondering if this opens up a new aspect on how proceedings may develop?

[Chugalug2]

JVZ90 "Chug - I try (but perhaps fail) to keep my contributions related to the engineering processes surrounding design, airworthiness & safety management of complex systems - and understanding how & why these have failed with respect to the loss of 230. These processes are basically the same for civilian and military projects and driven by (safety) engineering best practice."


I think there comes a time when one has to peer out from the confines of one's own little world, where all the i's are dotted, the t's crossed, and see the "big picture". Little purpose to the exercise if the technical feedback/ implementation loop has responded as intended, if some 2* has placed a giant spanner in the works and brought it to a grinding halt. With respect the difference between the civil and military worlds is that the operators in the one are obliged to implement safety related procedures ordered by an independent regulator, whereas in the other they are not, because there isn't one!

[JFZ90]

I think there comes a time when one has to peer out from the confines of one's own little world, where all the i's are dotted, the t's crossed, and see the "big picture". Little purpose to the exercise if the technical feedback/ implementation loop has responded as intended, if some 2* has placed a giant spanner in the works and brought it to a grinding halt. With respect the difference between the civil and military worlds is that the operators in the one are obliged to implement safety related procedures ordered by an independent regulator, whereas in the other they are not, because there isn't one!

Don't you feel your tone is a bit patronising Chug? You appear to infer some process or technique is missing in the defence approach, present in a civilian system, that would have had a bearing on the hazard analysis mistake identified above? What safety related procedures that a civil independant regulator would have insisted upon are relevant to this mistake?

I am part of the great unwashed who don't understand many of the cryptic initials

So why do you claim to know the answer and see the big picture? I fear you're only proving you don't really know what you are talking about.

[Mick Smith]

Air Cdre Baber is due respect for the way in which he admitted his part in this whole affair but Tuc is surely right. The ultimate blame should not be laid at his door. Money is at the root of all this and he had no control over that. The limited budget is initially down to the bean counters but they are only working on a budget shared out by the services having been dictated by the Treasury to policies dictated by the politicians that we vote in. As someone pointed out here a long time back and was wrongly shouted down for saying, we the taxpayers and more accurately the voters are ultimately responsible. We, not all of us for sure, but the majority, vote for the party that promises the least tax and give our priorities as ensuring that crime, education and health are dealt with first. The truth is that the forces are being asked to do more than anyone is prepared to budget for. I'm not saying the IPT is innocent, ultimately it could and should have spotted the problems and sounded the alarm, but even if it had, do you truly believe anyone would have been listening?

[tucumseh]

MS

Agreed. I firmly believe the Air Cdre's admission is a cynical attempt at damage limitation, thought by MoD to be the minimum necessary to (a) complement Browne's previous acceptance of liability while (b) trying to prevent the Coroner digging deeper and going higher to where, demonstrably, the real problems lie. This is so transparent it's laughably naive and illustrates, again, the arrogance of power.

If the latter were to occur, the attempt at compartmentalisation will fail as it will become increasingly obvious (to those who don't already know) that the problems are not confined to Nimrod. This is a simple fact, as the airworthiness regulations are standardised. Mr Walker isn't daft.

I should add, in fairness, that my opinion doesn't necessarily mean I think the Air Cdre cynical. I don't know him, but I have in the past witnessed the appalling pressures placed on staffs to lie or deceive in order to protect more senior staffs and hide their maladministration. To those who are really to blame, he's "only" an Air Cdre. I've also witnessed, first hand, attempts to hang someone out to dry for a fatal accident, knowing very well that he was innocent. There are many here who know exactly what I'm talking about.

[JFZ90]

Money is at the root of all this and he had no control over that.

While the forces are no doubt underfunded, I think to conclude that this was a key factor in this case maybe misleading. If the IPT was aware of a safety problem, and had gone back for more money to fix it and been rebuked (as some seem to imply) - why on earth wouldn't the IPTL have said so? The IPT is pretty clear that they didn't know (but should have known) about the safety shortfall - so where does lack of money come into play here?

Compare to the Chinook 3, which has sat grounded for years over what seems to be a far more minor (perhaps only a technicality?) safety shortfall in IMC operations for the want of a few bob to correct it. In this case, no money to fix it, no flying = safety not compromised at a time when the services are crying out for more helicopters.

[tucumseh]

JFZ90

The IPT is pretty clear that they didn't know (but should have known) about the safety shortfall


The testimony (as reported) makes it clear they DID know, in that the hazard was identified and probability of occurrence graded “improbable”. That grading may in hindsight be an error of judgement (although not necessarily so, despite the Air Cdre’s admission) but that doesn’t detract from the inescapable fact that every Risk Matrix in various MoD publications says that “improbable” coupled with a Severity of Harm of “catastrophic” or “critical” equals a safety risk which MUST be reduced to ALARP.

If the Severity of Harm wasn’t classified “catastrophic” or “critical”, but “marginal”, this would produce a Class D and “broadly acceptable” risk. Given the outcome of the hazard was fire and/or explosion, who on earth would classify a fire and/or explosion as “marginal” severity? That’s insane. (Just as CDP’s ruling that airworthiness and safety were optional was insane).

Now, given we’re talking about “improbable” + “catastrophic” or “critical” = Class C risk, is it not interesting that BAeS reported SIX “HRI Classification B scenarios” which they referred to the MoD for a decision on mitigation; two of which related to “Fuel Tank explosion”? Bizarrely, the report then concludes the aircraft is “acceptably safe to operate” BUT only in a peacetime environment. I have seen reports like this before where the narrative, written by a safety engineer, is explicit about the risks; yet the conclusions are so obviously diluted at a higher level to suit a customer imperative (political or otherwise). I’m sure this evidence has been presented to the Coroner and no doubt he’ll take a view, but I wonder how many here have seen it?

As to money being the root, one has to ask what any IPT is required to do upon receipt of such a report, or identification of a risk which MUST be reduced to ALARP. They’d launch an IMMEDIATE task on the Design Authority to produce, as a minimum, a Development Cost Proposal (DCP) to mitigate the risk. That assumes they have the funding to pay for the task, and a contract in place. (Both widely ignored airworthiness requirements). Upon receipt of the report (and it looks like the factors had been carefully thought out anyway in the above BAeS report), accompanied perhaps by a MF714 modification proposal, the IPT would have to raise (a) Cost and Brief Sheet supporting the 714 submission to HQMC and (b) a Business Case if they wanted to proceed. (At this point Chug will perk up, as this is where PUS’ mandated requirement for independent scrutiny is ignored, a contradiction which prevents many key airworthiness documents being updated as one is forced to take sides – you agree with either PUS or your 4 Star, but not both). Regardless of the complexity of the modification, this is a very simple process with the procedures spelt out in great detail in two Def Stans. In fact, the practical problem most IPTs face is finding someone sufficiently junior to do this as both are core competences one attains before promotion into an IPT. I’m afraid my experience is that, more often than not, the decision comes down to money. Success or failure of the submission largely depends on the willingness of an individual to make a nuisance of himself with those vying for the same funding. And MoD doesn’t want the Coroner to go there.

[JFZ90]

Given the outcome of the hazard was fire and/or explosion, who on earth would classify a fire and/or explosion as “marginal” severity? That’s insane.

Another possible issue that springs to mind is that I read somewhere that those undertaking the safety case were unaware that the SCP was operated in flight - hence this misunderstanding could have had a bearing on their (mis)assessment of the risk. As such they would have incorrectly assumed there was no credible source of ignition in flight in that area.

Alternatively even if they thought the SCP was on, they may have incorrectly assumed the SCP piping was not infact a significant ignition risk.

[Chugalug2]

JFZ90: “Don't you feel your tone is a bit patronising Chug?”
Well it wasn’t intended to be, and if it appeared so I apologise. Because I don’t follow the minutiae of the MOD’s labyrinthine system of Airworthiness Regulation and Enforcement, it doesn’t disbar me from being concerned with its efficacy, or lack thereof. Indeed the very complexity of the arrangements seems to me to be at the heart of its weakness. A system charged with such important life critical responsibility should be simple and robust, not complex and prone to interference. You ask what is the difference between the Civilian and Military systems. Just consider the terrible 737 fire at Manchester. Within months of the publication of the report, Floor Track Emergency Lighting, Fire Retardant Seat Cushions and Crew Smoke Hoods were fitted throughout the UK Civil Airfleet. Why? Because it was a mandatory CAA requirement, whatever the financial cost to the airlines, endex. That same objectivity has yet to be extended to the military airfleet, I fear. As to the particular issues here, you have the advantage on me. How would I know of them? But perhaps they are the trees and we should be looking at the entire wood.

[tucumseh]

Biggus

Sorry, I meant to comment on this…..


Air Commodore Baber says that 'the buck stopped with him', and that the IPT got it wrong.......

What are the implications of that?

Should he resign?

Has he opened himself up to a civil prosecution by relatives?
Responsibility for the Airworthiness of all UK Military aircraft rests with the Secretary of State. He discharges that responsibility by means of a system of delegation of authority. Therefore, it was proper for Des Browne to accept liability in his December speech.

I’d say the buck stops with SoS, if only because Air Cdre Baber was IPTL for a very short time whereas the failure to implement airworthiness regs has been endemic for almost two decades. This was not a single failure of process or procedure – it is a daily occurrence. The many who have, over the years, benignly accepted the dumbing down of MoD and continual financial cutbacks are equally guilty. But I reserve my utmost contempt for those at the top who, knowing they were abrogating their duty of care, did nothing except bully those who satisfied their obligation by raising the issues.


If I may, an unclassified extract from the lecture given at the likes of Cranwell and AbbeyWood on “The Application of Technical procedures for Airworthiness and MA Release”.

Airworthiness – The RAF perspective

……a number of factors have put the management of safety within MoD, and airworthiness in particular, under the spotlight.

Repeal of Section 10 of the Crown Proceedings Act, which now permits crown servants or their dependants to sue the Crown (doesn’t mention an individual) in cases of alleged negligence
The implication for the RAF is that litigation could now be initiated by people who know what questions to ask and where to point the finger, for example, the wife of a pilot killed in an air crash or tradesman injured in a ground accident. As someone who held airworthiness delegation before and after the repeal of Section 10, I know we were well warned and the above extract is taken from refresher course notes. That is, ADRP recognised the implications and did their bit. However, for our part (I and my colleagues) we immediately asked if there was to be a commensurate repeal of the decision to slash funding to maintain airworthiness and then bolster it further to fund retrospective action to close the gaps in the audit trails caused by the cuts. You know the answer. You see the result every day. If you look at what was happening concurrently, this is when the seriously critical reports on MoD’s application of airworthiness regs started emanating from auditors.

The MoD’s attitude towards people with such delegated authority was bizarre. I recall our Director ranting at a Directorate meeting (my only experience of an entire Directorate being gathered together) and shouting at us that we were the “rump end of MoD(PE)” and good riddance, we were being transferred to the RAF. Then the new boss, an Air Cdre, visited us and made it clear he would not tolerate our insubordination and henceforth all technical grades would be subservient to admin grades. That would sort us out. Meet the new boss, same as the old boss (as Pete would say). But we weren’t fooled again and when we didn’t comply, he bitched to the AVM who promptly threatened the “worst” offenders with the sack. Note – “Worst” in the sense that these were the people prepared to fight for airworthiness and safety.

Given all that, no I don’t think the Air Cdre should be sacked or resign. Just my opinion.

[Softie]

Published transcript from aircraft recorders.

http://www.eveningexpress.co.uk/Article.aspx/636681

[Da4orce]

ITV West Country News Report from lunchtime (http://www.itvlocal.com/westcountry/) (Video)

Air crash investigator tells inquest.... "Nimrod had more fuel lines and heat sources close together than any other aircraft he had seen".

[EdSet100]

I've been receiving accurate info from the inquest and there have been some quite interesting facts come to light this week:

Air Cdre Beber laid out the existing mechanism that provides the airworthiness requirements under BCARs. Regardless of individual opinion regarding a conceived need for a military aviation authority, that mechanism is robust. The mechanism and tools comprised the design, testing and limitations in the Release to Service and all supporting documents. These alone met the BCARs and the Nimrod was certified using the Comet and the Nimrod MR1 as the baseline design to meet the BCARs for certification of the MR2, as a modification of the original model.

The Nimrod Safety Case (NSC), which is not required for legacy systems before the HSAW Act, was carried out because the MOD's JSP indicated that, in general, it would be sensible to gather as much data as possible in order to provide an argument that the legacy aircraft also met the principles required under the HSAW Act. So, in essence, the safety case was an MOD generated requirement thus, again, demonstrating that there is no need for an MAA, Chug. There is more than sufficient self-regulation. The NSC was carried out in 2 phases: phase one was hazard identification, to be completed by a contractor through physical examination, (BAe in this case) and phase 2, which was to examine, among other things, what mitigation was in place to safequard against any hazard established in Phase 1. Phase 2 was carried out jointly, by discussion only, by staff of the IPT and employees of BAe.

Evidence was given to the Coroner, by Air Cdre Beber, that a member of the IPT had entered into the database incorrect mitigation against a remote hazard that could have catestrophic consequences. That database, as part of the NSC, was produced by both parties and formally accepted at a minuted meeting attended by a a senior member of the IPT (not the IPTL). (my thoughts here: although a staff member of the IPT entered the incorrect data, it could be reasonable to assume that he did so following a discussion with someone else - RAF or BAe). However, to quote Air Cdre Beber, "The buck stops with the IPTL".

Tuc, you say the SoS has responsibilty. Beber stated, quite clearly, that the IPTL is the Type Airworthiness Authority, insofar as what he says, goes. Therefore, he recognised that no-one above him can take reponsibility for actions that he alone can authorise without reference to those above him. He makes the decisions, he takes responsibility. Those staff below him have no authority so they cannot be held responsible for airworthiness.

Air Cdre Beber was, quite correctly (IMHO, and that of the AAIB), very critical in hindsight of the design of the 7 Tank Dry Bay and indicated that BAe produced a flawed design and that the IPT has missed an opportunity (the NSC) to identify that flaw. BAe's counsel refuted the suggestion that his client was solely involved in putting the flawed design into the air by producing a document outlining the acceptance, by the RAF, of the SCP design. I'm sure that the Coroner has heard this type of discussion many times before and he will have a case book to guide him. It is intriguing that BAe did not contest the assertion that they produced a flawed design.

Apparently, one or two press reporters have been in the gallery every day, taking notes. I recommend a search through the Sunday papers tomorrow to hopefully see some accurate reporting of this week's evidence.

Portsmouth for the cup !

Ed Sett

[JFZ90]

Apparently, one or two press reporters have been in the gallery every day, taking notes. I recommend a search through the Sunday papers tomorrow to hopefully see some accurate reporting of this week's evidence.

Edset - lets hope so, however,

Mick Smith (Sunday Times)
Air Cdre Baber is due respect for the way in which he admitted his part in this whole affair but ...... the ultimate blame should not be laid at his door. Money is at the root of all this and he had no control over that.

On the basis of this opinion, we'll see. I hope he (& others) reads your piece above and doesn't rush to potentially erroneous conclusions. You could argue that any excuse for bashing the Govt to better fund the Armed Forces is never a bad idea; however as its not really at the heart of the some of the issues currently coming out of the Nimrod enquiry it could just end up being misleading.

BAe's counsel refuted the suggestion that his client was solely involved in putting the flawed design into the air by producing a document outlining the acceptance, by the RAF, of the SCP design.


This is interesting - perhaps equivalent to saying, "will sold you the car with loose wheel nuts, but you did have a good look around it before we gave you the keys, so you're also partly liable for the fact they came off and it crashed.", though its not quite as simple as this of course.

Tangential rant - I'm no apologist for this govt btw, I just want to see the correct facts emerge so they can be learned from. I'd rather the papers bashed the Govt over the cynical changes to 2009/2010 Car Tax VED; it will be next years 10p tax issue when families face an almost £500/year hike in what it costs to tax their People Carrier and 2nd car - all supposedly in the name of the reducing CO2 when infact an opposite effect is likely with the premature scrapping of cars which are not past their service life, but will have plummeted in value (further hitting the poor who can't then trade them in for low CO2 cars) and are too expensive to tax. Now there is a Govt scandal.

[tucumseh]

EdSett

Air Cdre Beber laid out the existing mechanism that provides the airworthiness requirements under BCARs. Regardless of individual opinion regarding a conceived need for a military aviation authority, that mechanism is robust. This is the argument trotted out time after time by MoD, on this and other cases. To repeat – the regs are quite robust, but MoD doesn’t IMPLEMENT them properly. Two completely different things, and at the heart of this case. As I said, when challenged on this specific point, Ingram thought it wise to launch into print and claim the regs were robustly implemented. An unwise move, given the evidence and previous rulings of his predecessors, senior MoD staffs and, wait for it, himself.


So, in essence, the safety case was an MOD generated requirement thus, again, demonstrating that there is no need for an MAA, Chug. There is more than sufficient self-regulation. See above. I think the point Chug makes is self-regulation is fine so long as one implements the regs properly. MoD has admitted it doesn't, a simple verifiable fact.



Evidence was given to the Coroner, by Air Cdre Beber, that a member of the IPT had entered into the database incorrect mitigation against a remote hazard that could have catestrophic consequences. That database, as part of the NSC, was produced by both parties and formally accepted at a minuted meeting attended by a a senior member of the IPT (not the IPTL). (my thoughts here: although a staff member of the IPT entered the incorrect data, it could be reasonable to assume that he did so following a discussion with someone else - RAF or BAe). However, to quote Air Cdre Beber, "The buck stops with the IPTL". Without knowing precisely what was entered wrongly, one cannot comment. I’ve already said that what was reported doesn’t make sense – there is more to it. However, I agree with you – this is not a one-man job. It is likely BAeS have a very large team dedicated to the Safety Case, always assuming they are suitably contracted by MoD. We already know they are denied funding for routine airworthiness tasks.



Tuc, you say the SoS has responsibilty. Beber stated, quite clearly, that the IPTL is the Type Airworthiness Authority, insofar as what he says, goes. Therefore, he recognised that no-one above him can take reponsibility for actions that he alone can authorise without reference to those above him. He makes the decisions, he takes responsibility. Those staff below him have no authority so they cannot be held responsible for airworthiness. I am correct in saying responsibility rests with SoS. Authority is delegated downwards. Is he saying that no letters of delegation have been issued to ANY of his staff, or those staff of stakeholders IPTs who are responsible for “vendor” equipment? Not possible. He delegates. His level should enter the frame when his staffs delegate upwards to him the impact statements arising from funding cuts. And I’ve already said what typically happens when you do that. I also posted to the effect that the IPTL seldom, if ever, has complete delegation – he is required to report upwards on certain critical components of airworthiness. It is not clear to what extent the problems on Nimrod were delegated or reported upwards (but, as I said, the general problem of MoD NOT implementing the regs HAS been reported, many times). This is important, because components of airworthiness are shared across aircraft fleets. The Nimrod carries a host of kit which is common to other types. Conversely, I wonder how many times the IPTL was notified or reminded by his stakeholders that the build standard of their kit was not being maintained, therefore compromising his airworthiness audit trail? The last time I tried to notify someone of this I was told “of no concern”. (He was a member of the Defence Airworthiness Group). And if this sounds complicated, the management of the process is described adequately in one paragraph in the Def Stan.



Air Cdre Beber was, quite correctly (IMHO, and that of the AAIB), very critical in hindsight of the design of the 7 Tank Dry Bay and indicated that BAe produced a flawed design and that the IPT has missed an opportunity (the NSC) to identify that flaw. BAe's counsel refuted the suggestion that his client was solely involved in putting the flawed design into the air by producing a document outlining the acceptance, by the RAF, of the SCP design. I'm sure that the Coroner has heard this type of discussion many times before and he will have a case book to guide him. It is intriguing that BAe did not contest the assertion that they produced a flawed design. Yet, MoD accepted liability. Why? The Design Authority is responsible for the design, but it remains Under Ministry Control (UMC). As I said, the MoD has an obligation to maintain the build standard of the whole aircraft, including its equipment, through a series of suitable and continuous contracts. The Aircraft Design Authority (ADA) is NOT responsible for this; in simple terms because he is not the DA for everything in the aircraft.

You highlight an interesting line taken by BAeS’s counsel. The regulations state, quite clearly, that when MoD accepts the Declaration of Design or equivalent (which I assume is what Counsel was waving) this does not imply approval of the design nor acceptance of any responsibility for the design; that still rests with the contractor. But, MoD is responsible for contracting control of the design through all changes to the aircraft design. In this case, it is important to ask the question what exceptions or limitations were included in the Certificate of Design? It will also state what configuration the device was in at delivery and what configuration (including use) of the aircraft it was intended for – again, controlling that configuration is MoD’s responsibility. It has to be said here, that if the original manufacture and/or designer has gone out of business, then this complicates matters. It is often difficult to obtain the master drawings (and there are some of us who have stood at factory gates arguing with liquidators!) so it is often left to MoD to accept responsibility for the design. Or another DA can be appointed, but the contract is so heavily caveated that MoD are still responsible. I suspect very few here have any practical experience of this but it a fundamental part of what I refer to as “maintaining the build standard”, which in turn is one of the pillars of airworthiness; and the older the kit the more often these problems arise. But all the beancounters see is that it produces nothing tangible in terms of delivered kit, so they chop funding.

My view is that, while BAeS are rightly nervous over the flawed design, it is likely they are largely off the hook because MoD cannot demonstrate it has complied with its own airworthiness regs. Which brings us back to (a) Loader’s re-affirmation of this in the BoI report, and (b) Des Browne’s statement.

[Safety_Helmut]

The Nimrod Safety Case (NSC), which is not required for legacy systems before the HSAW Act, was carried out because the MOD's JSP indicated that, in general, it would be sensible to gather as much data as possible in order to provide an argument that the legacy aircraft also met the principles required under the HSAW Act.

EdSett, you have produced some of the more informative posts on this thread, but this is Twaddle !

Let's get something straight, THERE IS NO LEGAL REQUIREMENT FOR A SAFETY CASE. However, many regulated industries require a Safety Case to be produced and submitted for regulatory approval. The MoD has chosen this approach and has been using it for some time for new equipments, it has been well documented in successive issues of Def Stan 00-56. For legacy in-service aircraft, the MoD mandated the production of a Safety Case in (then ES(Air)) Business Procedure 1201.

S_H

[Chugalug2]

I think the point Chug makes is self-regulation is fine so long as one implements the regs properly. MoD has admitted it doesn't, a simple verifiable fact.


Thanks for covering for me tuc, but in all honesty I must nail my colours to the mast. It is my belief that self-regulation is never fine. It is a very British tradition practised by the Legal and Medical Professions among others, the purpose of which is to protect the professions rather than those seeking redress, IMHO. I see similarities in the MOD's process of self regulation regarding Airworthiness Provision to the military airfleets. The point isn't the discharge of responsibilities by particular organisations or individuals, the point surely is the actual quality of Airworthiness Provision by the MOD. Given the three threads running concurrently on this Forum concerning the Nimrod, Hercules and Chinook fleets and the serious Airworthiness shortcomings revealed therein, it seems to me that, for whatever reasons, the system is plainly dysfunctional and unfit for purpose, as are many of the aircraft it purports to protect. Put bluntly the proof is in the pudding, and I find this one well beyond its sell by date and a definite health hazard!

[tucumseh]

Apologies Chug. I spoke out of turn. It's just that self regulation is what I've been used to, and have seen it work on Military Airworthiness. However, in the last 17 years it has not, and I agree with you that it is now almost impossible to resurrect. I certainly wouldn't relish the task. MoD would argue there is provision in the regs for independent assessment, although it is debatable exactly how independent some are. Worse, the regs don't actually require MoD to accept this independent advice or give reasons why they are rejecting it. It will be interesting to read what the Coroner recommends.

Best wishes

[JFZ90]

I think the point Chug makes is self-regulation is fine so long as one implements the regs properly. MoD has admitted it doesn't, a simple verifiable fact.

As Tuc says, whether you've implemented the regs or not is the key issue, hence:


The point isn't the discharge of responsibilities by particular organisations or individuals

...well, you could argue it is really. That is the whole point, and furthermore you need to question whether the regs you did/did not follow were adequate to have caught the underlying problem in any case or whether a new facet of regulation is needed (e.g. years ago failure to properly consider Human Factors during design & risk analysis).

You cite problems
concerning the Nimrod, Hercules and Chinook fleets and the serious Airworthiness shortcomings revealed

Nimrod, potentially yes, but why Hercules & Chinook? The Hercules was shot down - a military risk/threat decision was made long ago not to bother with some technologies which may or may not have had any effect in any case. This is not really an airworthiness issue in the traditional sense, as bad guys firing bullets/rockets at you is always going to be a dangerous situation with risks that cannot be fully mitigated. The Chinook was regrettably, but almost certainly (but not perhaps beyond all doubt due to lack of much evidence) flown into the Mull by its pilots. The MAR/FADEC issue was a red herring.

Be careful not to lump together and confuse different complex issues.

[EdSet100]

Safety Helmut,
EdSett, you have produced some of the more informative posts on this thread, but this is Twaddle !

Let's get something straight, THERE IS NO LEGAL REQUIREMENT FOR A SAFETY CASE.

I didn't say there was a legal requirement to do so, neither did the Air Cdre, so far as I know. He simply said (so I'm told) that, in accordance with the principles of the HSAW Act, the JSP required him to provide an argument that the Nimrod was safe. Its not worth debating this particular point anyway. In a nutshell, the MOD shot itself in the foot when it mandated a safety case that was not required by law, which then turned out to be erroneous. Apologies if I gave anyone a wrong impression of what was said.

[Safety_Helmut]

In a nutshell, the MOD shot itself in the foot when it mandated a safety case that was not required by law, which then turned out to be erroneous.
No Ed, it did not. Assurance of safety under a safety case regime is widely regarded as best practice in this country. Power Generation, Nuclear, Chemical, Rail, ATM, Offshore to name a few, all take this approach.

S_H

[Chugalug2]

JFZ90:
Be careful not to lump together and confuse different complex issues.

Well I am lumping them together, or rather they lump themselves together in my view, and the thing that lumps them together is their shortfall in airworthiness. The Nimrod you tacitly concede I think, so perhaps therein we agree. The Hercules was bereft of a technology, ie ESF, adopted by our closest ally from whom we obtained the fleet. You say:

a military risk/threat decision was made long ago not to bother with some technologies which may or may not have had any effect in any case. This is not really an airworthiness issue in the traditional sense, as bad guys firing bullets/rockets at you is always going to be a dangerous situation with risks that cannot be fully mitigated.

Well quite, and that decision adversely affected the military airworthiness of the fleet, ie its fitness for purpose. It is possible that the hostile action that brought down XV179 might have been survivable with ESF. We don't know, but without it there wasn't a chance. Mitigation of risks is surely what Airworthiness is all about isn't it?
You say regarding Chinook:
The MAR/FADEC issue was a red herring.

Really? I'm afraid I would disagree. As I understand it Boscombe Down disagreed also. Note, I do not say that problem was a factor in the Mull accident, as you say we don't know (well other than Messrs Wratten and Day). I do say that the type was being operated with less than proper Airworthiness protection. Another MOD decision?
My point about who said or did what etc, is not that it is unimportant, of course it is and must be revealed. It is rather that the urgent need is not for investigation or introspection, but total reform of the Provision of Military Airworthiness in the UK. I take note of tuc's conclusion that it is probably beyond resurrection in its present form. In order to mitigate (that word again!) future needless loss of life it must be speedily removed from the MOD and placed in an Independent MAA.

[JFZ90]

Chug,

We'll have to differ on this one, but I can only reiterate that lumping them together as having 'common failures' is too simplistic.

I do not say that problem was a factor in the Mull accident

It is really a red herring though - the status of the MAR was an on-going issue which would have been very damning if it had had a bearing on the incident - but it didn't. I propose not to get into the debate here though - its too emotive - but by the same token that you can argue with me that it could be an issue, it is possible (& easier) for me to argue it wasn't. Suffice to say you can't draw parallels to what happened on Nimrod, and on balance of probabilities, Mull was 99.9% not a airworthiness issue.

For Nimrod it is clear that a design flaw which had a direct bearing on its safety during normal operations persisted in the in-service aircraft - no matter how you dress this up it is 100% an airworthiness issue. The MoD conducted a Safety Case exercise (which as discussed above was not even legally required, but did/does represent best practice) but which still failed to flag up the problem - the flaw goes back along way, probably to the days before the term Safety Case was even dreamt up (anyone know for sure when this term became common, late 80s/early 90s?). There are lessons to learn here, I've never questioned that - but from what I can see they are not necessarily obvious ones.

Hercules is a bit different in that its a capability/threat thing. To draw a simplistic extreme, you could find yourself shot down in combat by a Sukhoi Su-27 while flying your Tornado F-3, or even a Typhoon. In this case you could argue the MoD had been negligent by not sufficiently reducing the mission/combat risk to ALARP - it could have equipped the RAF with F-22s which is a bit of technology that is (perhaps only slightly) more likely to have shot down the Su-27 before being shot down itself. Should ALARP/fitness for purpose/airworthiness apply here to these type of risks? Training and tactics probably play a bigger part than the technology in the outcomes here anyway so where best to invest? You could debate this all day but I hope you can see this is not the same thing at all as an aircraft that may catch fire/expode all on its on during normal operation.

[tucumseh]

The common denominator here is the failure to implement the airworthiness regs.

The recent cases where this failure is absolutely clear cut, if only because it is spelt out in the BoI reports (so not just my own opinion), are Nimrod, Tornado/Patriot and Sea King ASaC. I won’t pre-judge C130, but suspect that one is more a fitness for purpose issue, which shares the same processes, procedures and Duty of Care obligation.

It is certainly a factor in the Chinook Mk2, because the evidence clearly shows the regs were not implemented properly. Whether or not this had a direct bearing on the crash nobody will ever know – which is the whole point of trying to have the verdict overturned. But it should not detract from the fact.

I’d say the above is a pretty damning body of evidence, all of it in the public domain. Of the five I’ve mentioned, at least 3 were predictable, predicted and ignored; with the MoD’s own airworthiness advisors having critical concerns about a 4th (Chinook). Yes, you very quickly get to the real problem. Lack of management oversight and leadership, and abrogation of responsibility. Start at 2 Star and work upwards.

[Safeware]

EdSett,

I think since your post others have re-iterated the MAA / Safety Case / airworthiness issues well enough, but I'd like to pick up on a contradiction in what you have posted:Air Cdre Beber laid out the existing mechanism that provides the airworthiness requirements under BCARs. Regardless of individual opinion regarding a conceived need for a military aviation authority, that mechanism is robust. The mechanism and tools comprised the design, testing and limitations in the Release to Service and all supporting documents. These alone met the BCARs and the Nimrod was certified using the Comet and the Nimrod MR1 as the baseline design to meet the BCARs for certification of the MR2, as a modification of the original model.vsvery critical in hindsight of the design of the 7 Tank Dry Bay and indicated that BAe produced a flawed design and that the IPT has missed an opportunity (the NSC) to identify that flaw.
If the mechanism was robust, a flawed design would not have been certified; or if the orginal design was robust, subsequent modifications would also be safe.

sw

[EdSet100]

The common denominator here is the failure to implement the airworthiness regs.


Absolutely.

It only remains for Mr Haddon Cave to find out who failed.

There was clearly a failure to accurately describe the risk controls in that dry bay.

S_H

Quote:
In a nutshell, the MOD shot itself in the foot when it mandated a safety case that was not required by law, which then turned out to be erroneous. Ed Set
unquote

No Ed, it did not. Assurance of safety under a safety case regime is widely regarded as best practice in this country. Power Generation, Nuclear, Chemical, Rail, ATM, Offshore to name a few, all take this approach. S_H


Thats true. But those working in/for the MOD failed to do the job properly, so they let down the MOD/RAF and the crews; one in particular). The irony of all this is that if the IPT had not carried out the NSC, the accident would still have happened and the Nimrod design and its operation would be subject to greater scrutiny. Maybe it will be, next week.

[Safeware]

JFZ90, as regarding lumping things together, the definition of airworthiness is:The ability of an aircraft or other airborne equipment or system to operate
without significant hazard to aircrew, ground crew, passengers (where relevant) or to the
general public over which such airborne systems are flown.
Seems to lump them together nicely.

sw

[EdSet100]

Safeware,
Thats a good point. However, If you accept that a system is deemed robust if it meets BCARs, then we have to accept that BCARs is/was not robust in its requirements. It seems that the MR2 was accepted as airworthy because the manufacturer was able to maintain certification under a modified MR1 design, because BCARs allowed them to do it. So, on that basis, not even the BCARs were able to prevent the flawed system within the MR2.

[Safeware]

Edsett,

What you can then come back to is that the mechanism was flawed in its implementation not its principle, something that tucumseh and I have long espoused.

sw

[Safety_Helmut]

SW, I tend to agree with you and Tuc. However, I would also argue that a system that vests responsibilities of ownership, operation and regulation in the same body will lead to conflict of interest and will fail. I would agree with Chugalug and call for an independent authority.

S_H

[Safeware]

S_H,

But then we get back to the issue I covered a while ago of civil regulation of a military operation that, inevitably, involves risk beyond that which would normally be taken in the civil world. How would a civil regulator view strapping a number of soldiers onto the outside of an Apache and flying them into an enemy fort?

Or should such a civil regulator only concern themselves with the "civil" elements of an aircraft and leave the military stuff to the military?

But then how does one consider military equipment such as AAR, which become a core part of the aircraft?

In an ideal world, it may work. But realistically, would it?

sw

[Chugalug2]

Safeware, I don't call for a civilian authority per se, rather I call for an independent one, ie independent of the MOD. While it would seem sensible to "nest" such an authority with the CAA, its remit would be to manage and enforce Military Airworthiness. Given the consensus building here that the regulatory system itself is sound, I would propose that it be exported to an MAA manned by a similar mix of those who manage the in house MOD system, ie military (presumably ex in this case to avoid divided loyalty) and civilian. Hopefully the former would develop a more professional application to their work than a single posting presently allows, and both they and the latter would merely encounter support from above in their aim to make for aircraft and systems fit for the work they are put to. As regards the military aspect of their airworthiness, it is entirely fundamental to that fitness. AT aircraft having to fly low, land and take off in enemy infested areas need the basic protection of the likes of ESF. That may or may not be appropriate for their civilian counterparts, it is essential for them. It is an example of where the MAA would have a differing agenda to the CAA and would be complementary to it, not part of it. At the end of the day the task of a military aircraft and its crew is to successfully carry out the task allotted it, if necessary to its own destruction. The MAA would merely attempt to make that success more certain and the survivability of the crew more likely.

[Safeware]

Chug,

But how would it be independent of the MOD? If a SoS is still to have responsibility, then even if the deckchairs were shuffled round within the government, true independence isn't achieved, merely another smokescreen. Civil regulation is demonstrably independent of the manufacturers, owners, operators and customers - that's why it works.

sw

[Chugalug2]

I don't envisage the SoS for Defence being responsible, independence makes that impossible. Nesting the MAA with the CAA, to share expertise and facilities, would imply sharing the same SoS as them surely?

[Safety_Helmut]

Sorry SW, I don't see the word 'civil' in my post.

I have to say that your reply smacks of a 'it's all too hard to sort out attitude' that seems so prevalent. Are you really suggesting that a system involving some level of independent oversight and assurance could not be established ?

But then how does one consider military equipment such as AAR, which become a core part of the aircraft?

As for the question above, to be honest, for someone with your background, I am very surprised. Read some of the more recent posts and have another think about it !


S_H

[tucumseh]

I know this may sound a bit simplistic, but I’ve always advocated adhering to the mandated processes, procedures and regulations. They were written by people who were very good indeed at doing this.

From the ridicule and odium aimed at me, I know I’m almost a lone voice – in fact I have it in writing from MoD that I am. But given their alternative, and the resultant accidents and deaths, perhaps you’ll forgive me for thinking various 1 Star, 2 Star, 3 Star (although he didn’t actually respond to my suggestion), 4 Star and Min(AF) wrong.

[EdSet100]

Edsett,

What you can then come back to is that the mechanism was flawed in its implementation not its principle, something that tucumseh and I have long espoused.

sw


Indeed. So, when a group of qualified people (IPT and BAe engineers) are entrusted to implement the mechanism, it must be wrong to blame the executive body for the failure of the staff to correctly implement the process. I would blame the executive if they entrusted unqualified people or failed to resource them properly, because it is the executive's responsibility to ensure that the right people and adequate resources are in place to implement the policy.

If it was the case that the implementation process would cause problems (funding and resources) and the IPTL (and higher) ordered either a quick broad review of the aircraft or simply didn't order one at all, then, yes, we can blame them.

As I understand it, the clear fact given to the Coroner by the, then, IPTL is that, "there was a genuine human error" during phase 2 of the NSC. I believe that fact and IMHO no amount of policy structuring, resource management and executive teeth grinding will ever obviate human errors at the coalface.

[Safeware]

S_H,

Maybe I'm trying to be too simplistic in my explanation. Yes I believe that a system of independent oversight and assurance could be established. But I'd also taken the the fact that you said "responsibilities of ownership, operation and regulation in the same body" to mean the MOD.

But if you mean that Director Air Systems, with DMSD, CASD and TESD, should be able to fulfil an effective role of independent oversight and assurance, then I'd agree.

Not sure what you mean by questioning my question on military systems. A challenge for the MOD wil be management of systems such as A400M and FSTA.

sw

[Safeware]

Edsett,I would blame the executive if they entrusted unqualified people or failed to resource them properly, because it is the executive's responsibility to ensure that the right people and adequate resources are in place to implement the policy.
There are just so many people who will be saying "yep, that's exactly the case"!!!

sw

[Chugalug2]

Safeware:
Civil regulation is demonstrably independent of the manufacturers, owners, operators and customers - that's why it works.


This is the very nub of the matter. It would be very nice if a little bit of tweaking here, reallocation there, reorganisation elsewhere could keep the whole package in house, ie within the MOD. Unfortunately that flies in the face of experience and logic. Independent means independent. The CAA has a difficult enough time ensuring that itself. If it were dependent on manufacturers or operators it couldn't function, neither could an MAA. It has to be outside the MOD or it can be nobbled to put it bluntly!

[JFZ90]

As I understand it, the clear fact given to the Coroner by the, then, IPTL is that, "there was a genuine human error" during phase 2 of the NSC. I believe that fact and IMHO no amount of policy structuring, resource management and executive teeth grinding will ever obviate human errors at the coalface.

This is a very important, well crucial, point that I think is being missed by those demanding sweeping MAA type changes. This mistake would still have been made even if such a "magical truely independant airworthiness body" was in place.

Chug - you mentioned earlier about the Manchester BA737 tradgedy as a positive reflection on the CAA. The other perspective is that 55(?) people died in an aircraft on the ground, in a design already under the "airworthiness control" of the CAA - why didn't your magical CAA spot the safety shortfalls before it happened and regulate/enforce a safer solution?

[tucumseh]

This is a very important, well crucial, point that I think is being missed by those demanding sweeping MAA type changes. This mistake would still have been made even if such a "magical truely independant airworthiness body" was in place.


Human errors happen. One aims to minimize them – the regs demand that one method, employing properly trained, competent and funded staff is used. The policy remains extant; the practice has been somewhat different for many years.

The question is not so much who made the error and why (although that is important, because human factors such as long hours and stress caused by under resource can be a contributory factor – again the regs cover this but are broadly ignored - a situation openly condoned by the "executive"), but rather what processes and procedures exist to validate and verify the work and whether or not they were resourced and implemented properly.

I’m not sure one can say for certain that the mistake would have been made anyway. From what little I know of the case, the MoD regs, if implemented properly, would have been sufficient. ACM Loader admitted as much.


Nor am I comfortable with this focusing on one “error”. If you read the main QQ report discussed here, there is a lengthy catalogue of failures of process and procedure, any one of which could have caused an accident. Like many accidents, a combination of factors conspired against the aircraft and crew on that day. Often, MoD focus on cause, but cumulative effect is often ignored, never more so when MoD try to compartmentalise the issue, thus deflecting attention away from the wider problem. The "error" by one person in the Nimrod IPT is a very minor issue here. Don't let it hide the big one.

[Chugalug2]

JFZ90: why didn't your magical CAA spot the safety shortfalls before it happened and regulate/enforce a safer solution?
Irony I know, but there is nothing magical about the proper application of Flight Safety. The real lessons learned from Manchester were the absolute importance of crew co-operation and integration, coupled with a review and overhaul of Abandoned Take Off procedures. All this was not just visited on the operator concerned, but on every other one as well. The philosophy is that however much you strive, accidents will still happen. The trick is to learn and apply every possible lesson from such tragedies to avoid or mitigate future ones. On the whole I think that the CAA is reasonably adept at this, on the whole I think that the MOD is not.

[JFZ90]

Nor am I comfortable with this focusing on one “error”.

True, there is always more to these cases than a single mistake.

I’m not sure one can say for certain that the mistake would have been made anyway. From what little I know of the case, the MoD regs, if implemented properly, would have been sufficient.

I only refer to the safety case error here. You can't say or imply this error would be removed if e.g. you had a MAA etc. Some here seem to be doing just that.


The "error" by one person in the Nimrod IPT is a very minor issue here.

As you say above, its only one of several issues - lets not forget that the safety case issue was only a review of the design, the 'flaw' was put in the design many years earlier.

I don't think you could lay this mistake at the door of one person in the IPT anyway - the review process would involve many, and I'd have expected at least one BAES engineer, + someone from BAES QA, + one Independant Safety engineer to have been involved all areas, i.e. including assessing the area under debate. Having an operator involved may have helped pick up the issue - this could be a lesson learned. Not sure how you'll get an operator interested in wading through pages of fault trees etc., but thats another issue....

[JFZ90]

The philosophy is that however much you strive, accidents will still happen. The trick is to learn and apply every possible lesson from such tragedies to avoid or mitigate future ones.


Every possible lesson? 'Lessons' like adopting smoke hoods for PAX across all fleets post Manchaster? The airlines effectively told the CAA to poke off on that one didn't they? Lessons like fitting tail cameras to all civil aircraft in the aftermath of Kegworth. Etc. I'm not saying the right decisions weren't taken in these cases, but lets keep some perspective.

On the whole I think that the CAA is reasonably adept at this, on the whole I think that the MOD is not.

I'm not seeing any evidence that you can back this up - its subjective, and dare I say comes across as emotive twaddle. Where's your audit trail to back up your assertions?

[Mad (Flt) Scientist]

Gents

As one who lives in the civil regulatory world and deals with safety assesments regularly I've been following this thread with some interest; it's illuminating to see the differences, and similarities, in approaches to risk management.

(Incidentally, if any of the DefStans and similar procedures which some have referred to earlier are non-Restricted, I'd be curious to look into them further; does MoD publish such things electronically where the unwashed could get access to them?)

However, I feel I should comment on this statement, because there may be an element of thinking the grass to be greener creeping in...

Civil regulation is demonstrably independent of the manufacturers, owners, operators and customers - that's why it works.

I don't think that's been true anywhere in the civil world for a long time. There's a great deal of day-to-day regulation delegated, in practice, to the manufacturers etc.

For example, in my OEM we are what Transport Canada calls a "DAO" - a Design Approval Organisation. Specific people within the company act as "Design Approval Designees", and act on behalf of TC to approve design changes. Depending on the scope of the design change, TC themselves may know little more than that it has occurred. The DADs are, of course, company employees, and while are selected for a supposed ability to be independent and objective, human nature means that not everyone sees that in the same light....

Prior to this incarnation, the "DAD" role was undertaken by Design Approval Representatives (DARs) who, although acting in a p[ersonal capacity rather than as part of a DAO were still wearing both a company and regulatory hat. In the near future, we're expected to move to a model where the company is an "Approved Design Organisation" - ADO - and the approvals will be made by the company itself on behalf of TC, not by individuals.

All of these models create conflicts of interest, yet its unavoidable, because there's no way a regulatory organisation can 'police' an OEM at the design approval level - I would estimate that on a typical certification programme there could be up to 50 DADs working some 3 years each involved - 150 man-years - compared to maybe ten authority people working a few months each - perhaps 5 man years total? For the authroities to man-up to replace the DADs would be a major issue. Never mind that an OEM could still 'hide' the facts if the model were adverserial anyway.

My understanding is that the OEMs in other jurisdictions are working in similar ways (The US equivalent of the DAR/DAD is called a DER for example). So while the MoD model may not be ideal, there's no magic solution in the civil world I fear...

[tucumseh]

Mad Scientist


Go here:

http://www.dstan.mod.uk/


Not all the relevant standards are there yet but start with JSP553, 00-970, 05-123, 00-55, 00-56, 00-57.


What you describe is similar to what we have here. If you search for DAOS (Design Approved Organisation Scheme).

[JFZ90]

Interesting post Mad Scientist,

Had a dig around for more info on Kegworth as it was so long ago.

http://en.wikipedia.org/wiki/Kegworth_air_disaster

Aside from the rather alarming pilot training issues which had a significant bearing on the mistake(s) they made during the emergency...


The pilots had received no simulator training on the new model as no simulator for the 737-400 existed in the UK at that time.

....the way the root cause of the incident escaped detection really surprised me:

the uprated CFM56 engine used on the 737-400 were subject to abnormal amounts of vibration when operating at high power settings above 25,000 ft. As it was an upgrade to an existing engine, in-flight testing was not mandatory, and the engine had only been tested in the laboratory.

Surprised the CAA etc. were ever talked into this (and not surprisingly recommendations were made not to allow this again). Flight test with paying passengers.

[Chugalug2]

JFZ90: I'm not seeing any evidence that you can back this up - its subjective, and dare I say comes across as emotive twaddle. Where's your audit trail to back up your assertions?

Oh, now we have to produce evidence to back up assertions on this thread? Well the only audit trails I have access to are the same ones every PPRuNer has, this Forum! Now you may be in the comfortable position of having all the evidence to satisfy your conclusions, and all the audit trails to confirm the correctness of those conclusions. Personally I take note of what others have written here and on other threads, based on their personal experience and apparent professional expertise, and I come to the conclusion that it is dare I say such complacency that lies at the heart of this discussion. Some are saying that the Emperor has no clothes, others that he is well dressed and on top of the situation. Personally I have a high incidence of suspicion that the latter assertion is a tautological inexactitude, but lacking the evidence and not having access to audit trails....

[OilCan]

......the 'accident' might still have happened. :hmm:

[buoy15]

Jeez
Why can't you lot put this to bed
This was a tragic accident
The ac was serviceable, declared and signed for by the captain who was also 1st pilot
What happened later was a failure that could not have been forecast or predicted by the best Crew chief, CFI, CDS, or God!
The profile was one of thousands that had already been completed successfuly - and then something failed - try and fix it - call for help - oh bugger, we are in trouble
You wankers that drive around at 70 every day in your 4x4's on the phone, have no idea about failure and how to react to it - your in the outside lane doing 80 and your engine packs up or the brakes fail - what do you do? Yeh!
call the dealer or manufacturer and complain in the middle of a pile up:D
Get Real!

[BEagle]

Whilst the aircraft may not have had any snags of which the aircrew or groundcrew were aware, it might still have had an inherent design fault sufficient to cause its destruction.

I'm sure that the BOAC crews who operated the first Comets thought that their aircraft were fully serviceable. But a design flaw (nothing to do with the Nimrod accident) caused the structural failures and inevitable consequence for the 60 people on board the 3 Comet 1s which fell out of the sky in the early 1950s.

buoy15, all 'accidents' have some primary cause. Which must be clearly established if the aircraft is to be operated with adequate safety in future.

Incidentally, construction and use regulations mean that car (or 4x4) brakes are unlikely to suffer a total failure these days; similarly, a total engine failure is unlikely unless the vehicle runs out of fuel. But there again, how many modern cars have design features inherited from the early 1950s?

[Winco]

I too am fairly certain that buoy 15 is just getting a bit frustrated with the whole saga, and he like many others want it putting to bed. The problem is that accidents 'don't just happen' there is always a reason, and in many cases, as you say, it could not have been forseen or predicted.

The problem here is that it WAS forseen and it WAS predicted.

I have stopped posting on here about what might or might not have gone wrong. I now leave it to those who are far more current on the aircraft, however, it is clear to me that your comment of:
'What happened later was a failure that could not have been forecast or predicted by the best Crew chief, CFI, CDS, or God!' is simply incorrect - apart from the bit about God maybe.

Regarding your comparison with the car, could I just say that if your car manufacturer wrote to you saying that your brakes needed checking because there might be a problem, and your local garage/dealership said 'Oh it's nothing Mr b15, it will be ok' and ignored the warning and you then crashed with no brakes, would you just say 'oh it was a tragic accident?' I think not.

[nigegilb]

I would agree that we should wait until Mr Walker gives his view. The input from the likes of Tuc has been invaluable in providing insight to the workings or otherwise in the higher reaches of MoD. Ed Set as ever provides a balance.

One thing bothers me. The risks associated with the design fault were not appreciated until the crash, but the day after the crash the SCP as a source of fire was removed. AAR continued until the MAYDAY last November. No AAR sorties have been carried out since. CAS told the world that Nimrod was as safe as it needed to be.

Doesn't square does it?

Not sure how wide the remit of the Inquest is, but I would hope, fuel leaks and events post crash have also been analysed by Mr Walker.

[Mick Smith]

Let's hope the conclusion of the Mr H-C's inquest can offer some genuine closure and allow us to move on

Mr H-C's report - which is of course not the ongoing inquest - is going to be a while coming sadly, but it would certainly be good to see someone give a report that allows closure. Given the evidence at the inquest and the discrepancies with the conclusions of the BoI, I doubt the inquest is going to give any closure at all. The sooner Mr H-C's report comes out the better.

[Softie]

Winco states:
The problem here is that it WAS forseen and it WAS predicted.I don't know whether Winco can be so definitive in his statement. If the designers, policy makers, operators, maintainers and hazard experts had know what each other had know, then the problem should have been seen and would have been predicted.

Looking at the history behind the design flaw, hightlighted by the IPTL, would suggest that there were plenty of opportunities for the catastrophic implications of that flaw to have come to light. However, no one did. I draw on the BOI report for the facts.

Early 1950s - First post-war jet airliner designed with fuel system intended only for ground refuelling, including blow-off valves to protect tank structure from over-pressurisation.

Late 1960s - MR1 designed with Spey engines and insulated hot bleed air crossfeed pipe for ground and air starting of engines. Also, fuel tanks (No 7) added to wing root trailing edge to extend range. Both sets of pipes passing through same area (No 7 tank dry bay). Not a great issue as hot air only present at idle temperatures on ground or briefly for air starting.

1970s - RAF operating world's most successful anti-submarine patrol aircraft at height of cold war. Range extended by routine shutting down of engines - a fact widely known certainly within the RAF, if not the public. This led to the crossfeed pipe being left open during flight (for quick restarts) with much higher bleed air temperatures - a fact probably not know to engineers or BAES.

Late-1970s - MR1 upgraded to MR2 with new mission system equipment necessitating additional cooling provided by new Supplementary Cooling Pack (SCP) in tail with connecting ducting passing through bottom of No 7 tank dry bay. The SCP, when in use, constantly draws air from the crossfeed air pipe at higher engine rpms and temperatures.

1982 - Urgent modification to add AAR capability for the Falklands conflict. This mod was very Heath Robinson and bears no resemblance to the current installation (except probe).

1980s - Aborted development of AEW3 looked at formal embodiment of AAR and identified blow-off implications. Some work taken forward to MR2
designs but much of information was archived or binned when AEW3 was cancelled.

late-1980s - AAR formally incorporated on MR2 and R1 with fuel feed into main refuelling gallery. Blow-off values removed from No 5 (front low fuselage tank) because of possible fuel ingestion into engines, if operated.

Date unknown - Introduction of Tristar tanker with higher output than Victors or VC10s.

Throughout - Groundcrew were aware of blow-off during ground refuel if flow rate too high as tanks reach full. Fact not known to aircrew. Any blow-off was seen as a safety device operating correctly.

2004 - IPT/BAES Hazard Analysis identifies hazards of co-located hot air and fuel pipes. Risk assessment under-rated risk and missed opportunity to catch previous oversights (from above).

As the BOI concluded "the formal incorporation of AAR ... did not identify the full implications of successive changes to the fuel system".

Nigglib states:
The risks associated with the design fault were not appreciated until the crash, but the day after the crash the SCP as a source of fire was removed.The location of the fire was reported by the Harrier pilot on the day. The IPT carried out a immediate review and removed/isolated all possible ignition sources (the SCP was just one of them). AAR was also barred, except for operationally essential sorties: those after the crash were at the time deemed to be.

For those contributors with knowledge of high level policy and safety knowledge within DLO and/or DPA (like Tucs and SH), have you made yourselves know to the QC doing the Nimrod Review? If not your views will not have any relevance or impact.

As a personal view, I do not see any possibility of a MAA being established outside the MOD. Who would pay for it, except the MOD budget. I believe the problem lies with the loss of RAF control when the support organization charged with airworthiness was subsumed into DLO under one budget fighting with all the other demands from Land and Sea.

The MOD and RAF tend to work in its own little areas (ie. IPT, airstaff, aircrew, maintainers) with some and necessary same-level communication but little up-and-down outside specializations. As a result, some important things are not recognised or acted upon until the worst happens as in this case. I agree with other contributors that the level of corporate knowledge in all areas has diminished over the past 20 years.

Finally, can anyone explain why the has been no press coverage on the Coroner's Inquest for most of last week?

Softie

[Mick Smith]

Finally, can anyone explain why the has been no press coverage on the Coroner's Inquest for most of last week?

It is common with inquests and court cases, even relatively high-profile ones, for the opening day's events - when the respective parties put their initial case - and the final day's summing up and judgement to be the only thing that makes it into the papers. In this case, I think there was coverage for a couple of days at the beginning but once the questions began to deal with highly technical detail it became of less interest for the general reader and even the press association withdrew its reporter. The main dailies will only have attended on the first day and their reporters then have to move on to other stories. There is I think one agency reporter there every day. If, as was expected, QinetiQ are there today, that might make it into the papers but they will now be waiting for Friday's summing up and verdict.

[EdSet100]

Softie's outline of Nimrod development is spot on. However, there was one development that interests me and I would be grateful if anyone can confirm it; its the bit in bold print:

1970s - RAF operating world's most successful anti-submarine patrol aircraft at height of cold war. Range extended by routine shutting down of engines - a fact widely known certainly within the RAF, if not the public. This led to the crossfeed pipe being left open during flight (for quick restarts) with much higher bleed air temperatures - a fact probably not known to engineers or BAES.


On a technical matter, its my opinion that the pipe probably didn't get very hot due to a lack of significant air flow through it, due to balanced pressure from the opposing engines. And, just for accuracy, the pipe was only open while one or more engines was shut down; assuming that the Routine Engine shut down checks existed then. Would any pilots or engs from that era care to comment?

Ed

PS. Buoy 15, this subject lay dormant for a few months after the BOI report. It is only to be expected that the Inquest will re-generate interest as information, not published in the BOI report (intercom tape, etc), comes into the public (and the RAF in general) domain. I miss the guys, too, and there is absolutely no enjoyment in discussing the subject. But, we have a responsibility to the bereaved families to learn from the deaths of their loved ones and do our individual best to ensure that it never happens again. I don't believe that PPrune is influential in the corridors of power, but sensible and sensitive facts that appear here can be useful to the front line air and ground crews who do not receive the information in their normal work routines. You would not have known that Air Cdre George Beber stated that the buck stopped with him. We can debate whether or not he is right, but the fact is, he said it on oath, in front of the families, to their faces. Its worth reporting that we have an honourable man among our leaders.

[Softie]

http://news.bbc.co.uk/1/hi/uk/7410544.stm

Safety recommendations made after 14 servicemen died when a Nimrod aircraft crashed in Afghanistan have not been fully implemented, the MoD has said.
Thirty recommendations were made after the 2006 crash. Inquests into the 14 deaths are currently taking place.
Defence secretary Des Browne said 21 of the 30 were being implemented and three considered, while six were "on hold".
But Westminster SNP leader Angus Robertson said it was "unacceptable" they had not all been fully introduced.
Mr Robertson, who represents the Nimrod home base of RAF Kinloss, said under the MoD's own rules, for an aircraft to be considered safe, any risk must be reduced to a level that is as low as reasonably practical.
But he said the announcement by Mr Browne, which he made in a letter to the Moray MP, showed this had not happened.
The MoD said the report and recommendations were part of a more comprehensive safety review of the Nimrod air system, which was continuing.

[airsound]

Excellent - and useful - potted history, Softie, thank you very much.

On a small point
routine shutting down of engines - a fact widely known certainly within the RAF, if not the public.
I’ve been rabitting on to the public at airshows for 30 years, and whenever I covered Nimrod in the days when its main job was Kipper Fleet-ing. I always used to mention the shutting down of two engines while on task. It was one of the significant arguments about the world’s only maritime 4-jet versus the turboprop remainder.

On the question of why no press coverage, perhaps I can add a little to what Mick says. I’ve probably been at the inquest more often than most of HM 4th Estate. But I’m a broadcast hack, and I don’t have the contacts in the written press to sell regularly to them. When I was at the Hercules inquest in Trowbridge, I did two weekly upsums for BBC News Online - but when I offered them something similar last Friday (after a week with little other coverage) they declined, saying they were happy to await the verdict. I expressed my unhappiness at their lack of interest (which I suppose I may live to regret....).

But I believe it was especially unfortunate, because, as I told them, last thing on Friday, Robert Dicketts, father of Corporal Oliver Dicketts, put this question to Philip Sleight, Senior AAIB Inspector:
“You said in your evidence that Nimrod would not have qualified for a (civil) airworthiness certificate. When you link that to the Coroner’s (rhetorical) question earlier in the week about whether it wasn’t time to ground the whole fleet, doesn’t that give you pause for thought?”

The Coroner intervened to say that this question was not one Mr Sleight could reasonably answer, but he did add another rhetorical question about whether it wasn’t time for accident inquiries to be standardised across the military and civil fields.

But anyway, the Beeb wasn’t interested. or maybe they just don’t like my reporting........

Things are a bit better this week - with Olly Hemans of INS News Agency there most of the week, and Simon Evans of PA filing today.

And the Coroner does plan to deliver his verdict on Friday.

Btw, a bit surprised no one’s mentioned the hero status that Mr Coroner Walker achieved on last Sunday’s Bremner Bird & Fortune on Channel 4. The George Parr interview was fantastic, pitting Andrew Walker’s earlier inquest sallies against the feeble replies of the MoD. You can see it again (till next Sat, I think) at
http://www.channel4.com/video/bremner-bird-and-fortune/catchup.html?intcmp=watchpage_box4#popover
although if you have a Mac, Channel 4 is having some ridiculous spat with Apple and it won’t work. Harrumph. (Fortunately I do have an audio recording :})

airsound

[Mick Smith]

And here is the PA copy

DOOMED NIMROD 'HAD SERIOUS DESIGN FLAW'
An RAF Nimrod spy plane which crashed in Afghanistan, killing four servicemen from the region and 10 others, had a serious design flaw, an inquest has heard.
A senior engineer from BAE Systems, the British defence and aerospace firm, said his predecessors who made the Nimrod some 40 years ago also failed to fit a fire protection system on a key area of risk on the aircraft.
Nimrod XV230, a 37-year-old craft, exploded in mid-air near Kandahar on September 2 2006 shortly after undergoing air-to-air refuelling.
Sgt John Langton, 29, Flt Lt Steven Swarbrick, 28, both of Liverpool, Sgt Gary Quilliam, 42, of Manchester, and Flt Lt Allan Squires, 39, of Clatterbridge on the Wirrall, were killed in the crash alongside 10 of their colleagues.
The tragedy is believed to have been caused by fuel leaking in one of the craft's dry bays, then igniting on contact with a hot air pipe, the men's inquest has heard.
The hearing in Oxford was told on Tuesday that a section of hot air pipe in XV230's Dry Bay 7 was not lagged to protect it from igniting fuel in the event of a leak from a fuel pipe below it.
Although the hot air pipe, which can reach temperatures of up to 500C, is insulated in most parts of the aircraft, it remains uncovered in Dry Bay 7, the inquest heard.
Andrew Walker, the coroner, said: "What we have here amounts to a serious design flaw, because we could have a single point failure (where just one fault could cause a serious problem)."
Martin Breakell, BAE's chief Nimrod engineer, agreed although he stressed this scenario would be very unlikely.
Mr Breakell, asked by the coroner if he considered the lack of a fire suppressant system to be a serious failure, said: "It is a serious failure."
Tom McMichael, head of airworthiness at BAE's Military Air Solutions, said that if the evidence heard today was correct, the Nimrod planes had, at the time of the tragedy, been flying in an unairworthy state for 37 years.
Mr McMichael said because Dry Bay 7 was potentially a single-point failure area, it should have been fitted with a fire-suppressant system. That it was not meant it should never have been passed fit to fly, he said.
Mr Walker, pondering on the decisions of those who passed the Nimrod airworthy four decades ago, asked: "Was it not a serious possibility that no one really recognised the risks associated with this aircraft?"
"It is a possibility," replied Mr McMichael.
An "acceptance conference", to decide the Nimrod's airworthiness, took place in August 1968 and it was declared fit to fly.
The coroner, reacting to today's evidence, said: "So, at the end of the acceptance conference, on the evidence as it stands, this aircraft was not airworthy."
The inquest was adjourned until tomorrow.

[nigegilb]

This is a copy of part of my post on 2nd Dec 2007,

"Large ac self-protection has simply been ignored until very recently.

Ignored by people who have never been to war, or whose only experience is life in a fast jet. Tuc you are suggesting that combat survivability and ac self-protection should be at the core of the design. I could not agree more. We lost XV230 even though we learnt the hard way on the Herc fleet that fuel tanks explode. We await the BoI for the Herc that was destroyed on a strip in Iraq. I believe that too was a fuel tank explosion.

So to the future. The word from military officers in MoD is that MRA4 is an old design, procured a long time ago. Well, the design was only frozen last December. I have been told that large aircraft safety and combat survivability is now taken very seriously. So seriously that A400M OBIGGS has not been funded yet. The plan for MRA4 is to introduce it into service without FDA, OBIGGS, BBay Fire protection, under floor fire protection, probe inerting protection, dual skin AAR pipework.

I am sorry, but that is simply not good enough."

[Mick Smith]

Nige
You must have been somewhere hot and sunny when the BOI into the Herc blown up at Amarah was published last week.


http://www.mod.uk/DefenceInternet/AboutDefence/CorporatePublications/BoardsOfInquiry/BoardOfInquiryIntoAccidentInvolvingHerculesC130Mk4Zh876.htm

[tucumseh]

I sincerely hope this doesn’t mean the MoD will claim that this all happened in the past and we now have “a robust airworthiness regulatory framework”. As has been said many times in the past (years before ACM Loader re-iterated it in the BoI report) the framework may be robust but implementation is not.

What did or didn’t happen in 1968 may have been an oversight or error but, in the words of a famous man, “an error does not become a mistake unless you refuse to fix it”. Not only did MoD refuse to fix it, but in the late 90s they ruled that delivering aircraft safety is optional and implementing mandated components of airworthiness is a disciplinary offence. This was upheld as recently as last year. End of, as far as I’m concerned.

[nigegilb]

Tuc, I wonder if Nimrod has suffered from its status as a maritime aircraft? We already know that the crews have to fly without TCAS, a fact I find astonishing. Nimrod comes under the recent control of AOC 2 Gp, but it is not certificated as an Air Transport aircraft, managing to avoid AT regulations aimed at improving aircraft safety. Procurement of MRA4 is something of a one off.
RAF AT assets meanwhile, are steadily improving in terms of DAS, fuel tank protection. In fact the Herc fleet must have one of the best systems in the world.

I think the plan for MRA4 is to introduce it and improve combat safety with the use of UORs, but the aircraft will be needed on the front line immediately. The RAF (at war), appears to have failed to insist on combat survivability being at the core design. There is no way on earth an American military aircraft would be procured in such a fashion-why do we? Lack of money? Or a lack of coherency?

[tucumseh]

I think the plan for MRA4 is to introduce it and improve combat safety with the use of UORs, but the aircraft will be needed on the front line immediately. The RAF (at war), appears to have failed to insist on combat survivability being at the core design. There is no way on earth an American military aircraft would be procured in such a fashion-why do we? Lack of money? Or a lack of coherency?


There is an old, but true, saying. One man’s Urgent Operational Requirement is another man’s total incompetence and lack of foresight. It may be about money now, but if you don’t ask in the first place………. Coherent? MoD? Not only does the left hand not know what the right is doing, it’s debatable if either knows the other exists.

[nigegilb]

An RAF Nimrod which exploded in mid-air, killing 14 British servicemen, was not airworthy at the time, its own manufacturer admitted today/yesterday (Thurs).

Hushed gasps from bereaved relatives of the men could be heard as BAE Systems’ chief engineer for the Nimrod conceded the point at an inquest into the deaths.

Martin Breakell said that based on what he had learned during the 12-day hearing, the ageing plane should not have left the ground.

Yesterday/on Wednesday Group Captain Colin Hickman admitted that the Nimrod was only “tolerably safe” because of faults identified since the crash.

BAE Systems Ltd is the successor to British Aerospace, which designed and built the Nimrod in the 1960s, modelling it on the De Havilland Comet airliner.

Mr Breakell’s comments today/yesterday (Thurs) came in response to a direct question from a family member as to whether he believed the aircraft was safe to fly.

After initially arguing that he was not qualified to decide on certain parts of the Nimrod, he was pressed by the crew’s relatives and the coroner.

He responded: “I concur that in regards to the evidence on the incident, then no, it wasn’t (airworthy).”

On September 2, 2006, Nimrod XV230, at the age of 37 the oldest plane in the fleet, caught fire and exploded while on NATO operations against the Taliban in Afghanistan.

The inquest, in Oxford’s County Hall, has heard evidence from numerous witnesses from the RAF, BAE Systems and other maintenance and fuelling contractors, as well as a parts manufacturer.

Andrew Walker, the assistant deputy coroner for Oxfordshire, has examined different theories as to what caused the devastating fire, which led to the greatest loss of life among the British Armed Forces in a single incident since the Falklands War.

Theories put forward by investigators, including the RAF’s own Board of Inquiry, have focussed on a possible fuel leak onto a hot air pipe in a compartment next to one of the fuel tanks.

However, Mr Walker remains apparently unconvinced of the validity of the RAF’s conclusion and instructed Mr Breakell to examine whether a leak on the high pressure system on one of the Rolls Royce Spey engines could have been to blame.

The witness concluded, after consulting engineers at the Nimrod’s base at RAF Kinloss, in Scotland, that it was possible the fault lay with the engine system.

He added that he was “staggered” to learn from Rolls Royce that an engine could continue to function normally with a leak of up to 1,000 gallons per hour.

Group Captain Nicholas Sharpe, the president of the Board of Inquiry, discounted the new information and said he stood by the board’s findings, as he said they were, on the balance of probabilities, the most compelling reasons for the fire.

While clearly struggling to accept Gp Capt Sharpe’s stance,the coroner said: “I have to say it is not my intention to criticise, directly or indirectly, the Board of Inquiry’s findings.

“One must not forget that without the BoI, what is described as a serious design fault on this aircraft would continue to go unnoticed, and that is no small achievement.”

Michael Rawlinson, the lawyer for 13 of the 14 families, together with Mick Bell, whose brother Gerard died in the crash, paid tribute to the BoI team for their work.

The inquest, which began on Tuesday, May 6 with a visit by a Nimrod to RAF Brize Norton, Oxon., for families to view, is expected to end tomorrow/today (Fri) when the coroner will record his verdicts.
ends

[Winco]

What sticks in my throat more than anything was listening to that useless CAS we have at the moment, Torpey, when he claimed that the aircraft were 'as safe as necessary' (or something like that)

Clearly Gp Capt Hickman felt slightly differently, with his statement of 'the Nimrod was only “tolerably safe” '

It just shows how ignorant of the facts the CAS was, and probably still is.

Go now Torpey, you are well past your sell-by date, just like the aircraft. Instead of being hell-bent on getting more Typhoons and getting rid of the Arrows and closing Scampton, concentrate on the things that are of importance to the RAF at the moment, little things such as Airworthiness of aircraft, aircraft fire protection and Flight Safety.

[chappie]

there is not alot that i can offer or be of any use but i want to take this opportunity to say that my heart goes out to all the families and colleagues and friends affected by this tragic, unecessary loss. i will have you in my thoughts tomorrow as the verdict is delivered and i pray that you all find some peace in this sad journey we are left to walk through.

hold your head up high and be proud in your boys.

with love
chappie

[nigegilb]

Torpy said it was as safe as it needs to be, without specifying what risks he wanted his men to continue to run.

Baber appears to be saying that if it is not tolerably safe, with a risk as low as reasonably practicable (ALARP), it is not airworthy.

Hickman appears to be saying tolerably safe, but not ALARP is OK, so long as one is working towards ALARP.

How long has that taken so far, 37 years?

A coherent airworthiness system? Would help if the men in uniform could get their ducks in a row.

Hickman appears to be saying he does not agree with some regs in JSP553 as Tuc has said, he is NOT allowed to set the standards, he is required to meet them. Rule number 1.

Confused? I am. Does the RAF comply with JSP553 or not? Does the RAF comply with Def Stan, or not?

Is this aircraft about to be grounded? And what about MRA4?

I would also like to extend my thoughts to the families for tomorrow's verdict. I am shocked by what has been revealed at this Inquest.

Systemic failure? I hope Mr Walker feels able to express an opinion on the implementation of military airworthiness, I have heard enough MoD spin to last a lifetime.

It is my understanding that Baber is correct here, but how can two IPTLs appear to be interpreting airworthiness regulations in two different ways?

[Mick Smith]

Winco
You have very understandably misinterpreted what the IPTL said. His belief stated in the witness box and mirroring what the SoS said in the House of Commons, citing CAS, was that although the aircraft was only "tolerably safe" and not ALARP it was nevertheless safe. Since the aircraft was "tolerably safe" it was OK to work towards being ALARP while still flying and they were aiming towards being ALARP by the end of the year.

[andgo]

Mick,
Not according to JSP553, or health and safety.....

[airsound]

Would you care to elucidate, andgo? I've been at the inquest, and I find the JSP references fairly confusing......

airsound

[Mick Smith]

Mick,
Not according to JSP553, or health and safety

Absolutely Andgo. I'm not saying it's true only that this is what he claimed to be the case.

[JFZ90]

Winco
You have very understandably misinterpreted what the IPTL said. His belief stated in the witness box and mirroring what the SoS said in the House of Commons, citing CAS, was that although the aircraft was only "tolerably safe" and not ALARP it was nevertheless safe. Since the aircraft was "tolerably safe" it was OK to work towards being ALARP while still flying and they were aiming towards being ALARP by the end of the year.

Mick - do your (in my view correct) observations above mean you now believe the SoS was infact not misleading/lying to the House when he told them the aircraft was now safe?

[nigegilb]

Mr Walker is the man in charge and he will be announcing his verdict tomorrow.

Hickman appears to have rejected JSP553, difficult to see how he can come back from that, "mitigating circumstances" or otherwise.

He has gone on to make further comments today, perhaps Mick will elucidate perhaps he won't.

SoS's comments appear in my view to be risible, but it really doesn't matter does it?

Let's be patient for one more day.

[JFZ90]

From some weeks back...

From today's (13th April) The Sunday Times:

Des Browne, the defence secretary, appears to have misled MPs when he told them an independent report had ruled that the RAF’s Nimrod aircraft were safe to fly.


When Mick wrote the above article, and in his follow up posts, he seemed sure SoS was definately misleading the house; I'm interested to know if he still holds that view as his quote above implies he acknowledges that the statement "although the aircraft was only "tolerably safe" and not ALARP it was nevertheless safe" could actually be a valid and reasonable one.

[tucumseh]

From Def Stan 00-56 Part 2/4. Pretty clear.

http://i214.photobucket.com/albums/cc291/exploringtheblue/alarp.jpg

[The Real Slim Shady]

Guys, I'm coming to this very,very late but as an ex mil, now civilian pilot, may I express my indignation that a front line aircraft was / is 37 yrs old. In Pakistan the limit on the age of an aircraft in airline service is 18 yrs: in India they have a similar limit.

Nuff said?

[Mick Smith]

Quote:
Winco
You have very understandably misinterpreted what the IPTL said. His belief stated in the witness box and mirroring what the SoS said in the House of Commons, citing CAS, was that although the aircraft was only "tolerably safe" and not ALARP it was nevertheless safe. Since the aircraft was "tolerably safe" it was OK to work towards being ALARP while still flying and they were aiming towards being ALARP by the end of the year.

Mick - do your (in my view correct) observations above mean you now believe the SoS was infact not misleading/lying to the House when he told them the aircraft was now safe?


My observations to Winco are correct but only because I am making clear that the IPTL was saying that he thought the aircraft was safe. If you read Winco's original post, you will see that he understandably assumed that when the IPTL said the aircraft was "only tolerably safe" he meant that it wasnt really safe. He didnt. To him, as apparently to you, this meant it was safe.

No of course I dont believe that the aircraft can be described as "tolerably safe" and actually be safe without the risk being ALARP. I apologise for misunderstanding you previously JFZ90. I thought that even you, with your indefatigable determination to insist that everything is fine and dandy, had accepted the facts as laid out by numerous posters here.

For the record, I don't hold the same views as when I wrote that article, because, as you pointed out, I said he appeared to have misled the House. It is now very clear that he did mislead the house. I have never suggested he lied. I don't believe he did lie. He was told something that wasnt true and simply repeated it and as we have seen at least one of the people in that chain of senior officers through whom he obtained his "expert" advice, a key figure, actually believed it was true.

It ought to be a matter of deep concern that anyone at any senior level believed this to be true and yet the SoS was assured by senior officers that it was. (Of course you could be one of those senior officers for all I know. You certainly talk as if you are.)

I might add that it is also of some concern that the initial QQ draft report to the IPT cannot be found by anyone within the RAF or the MoD (lost apparently) and the witness from QinetiQ who was supposed to give evidence on it, and any differences between what the original draft and the final version said about safety, and in particular that very odd "tolerably safe" phrase the IPTL and you like so much, didnt turn up to the inquest. Perhaps you have some wonderfully reassuring comments to make on that.

[andgo]

The Nimrod aircrew that appeared earlier in the week did not seem too convinced by the current IPTL either.

[JFZ90]

Mick

Apologies if I have given the impression that I have an "indefatigable determination to insist that everything is fine and dandy".

On the contrary it is clear that there has been a failure (or series of issues leading to a failure) in the airworthiness of Nimrod as I think most people, including SoS, have stated - this directly led to the tragedy. The reasons and mistakes behind this must be understood, learned from and action taken to avoid such failures in the future. I don't question this - sorry if I've given the impression I do.

[Tappers Dad]

Mr Hickman also told the court that NO battle damage assessment, as required by Def Stan 00-970, was done. He said it was not needed because the ac flys too high. I had to point out to him that on take off and landing the height it flys at is quite low.

I will post more tommorow night.

[nigegilb]

When SoS Defence reconsiders his comments perhaps the first thing he should consider is whether the Nimrod fleet should now be grounded.

Credit to the Nimrod crews who were ordered to resume AAR days after their colleagues perished. The routine operational AAR sorties only terminated after a highly publicised MAYDAY following a serious fuel leak, at the back end of last year. It now appears that post crash the fleet should never have been signed off.

One thing is clear, the buck does not stop with Hickman regardless of how he has come across in all this, this goes right to the very top.

"Tolerable" is not acceptable unless ALARP.

[EdSet100]

The Inquest has caused some confusion because some questions in court have referred to pre-crash risk analysis and some have referred to post crash analysis. Some discussions on oath have been in reference to AAR, some not.

Nigegilb, you said:Hickman appears to be saying tolerably safe, but not ALARP is OK, so long as one is working towards ALARP.
which we all know is not a legal policy. So, either he is wrong or you are.

Can you, or anyone else here, tell me in what zone or system is the risk, now, not as low as reasonably practical?

I am concerned that you might be misunderstanding his position. We have had strict restrictions in place, since 4 Sep 06, that make the aircraft ALARP, or better, IMHO. The restrictions are effectively temporary in nature (maintenance log entries with expiry dates), thus it arguable that we are "working towards" permanence in ALARP, ie currently giving consideration to either modifying the design or pemanently changing our procedures, thus enabling removal of the temporary restrictions.

Ed

[kam]

My thoughts are with you today and beyond. I hope, in the memory of your loved ones and the future of others, that some constructive outcomes result from what has been a uniquely intense and emotionally demanding 2 weeks. To Tappers dad and Helgar33 thankyou for your kind words and support.
Warmest regards, a widow from XV 179

[chappie]

hi kam, love and thoughts to you and yours. email winging it's way to you as we/i type! this may sound so very odd but today, when the verdict is delivered, we will share your grief and the hardness of the situation as we still await completion of the inquest into our lost loved ones. i want to re iterate all that i said the other day but i forgot to add something very important. a huge thankyou for those who have helped us, the families left behind, with all your explanations, support and expertise. without you we would not be able to find out the answers to the questions we ask and we would not be able to help ensure that ultimately this kind of travesty comes to an end. i know i will be forever indebted.

please can someone tell me what ALARP/AAS/JSP553 is, as it gets very difficult to follow!many thanks.

keep the faith

[harrogate]

Radio 5Live just reported that the Assistant Deputy Coroner has just said that the "entire RAF Nimrod fleet has never been airworthy".

That's quite a statement.

[Roland Pulfrew]

On the BBC News website here (http://news.bbc.co.uk/1/hi/uk/7416627.stm)

That's quite a statement.

Quite an over the top statement. I never worried about the jet's airworthiness in my small number of hours flying it!

[On_The_Top_Bunk]

On the BBC News website here (http://news.bbc.co.uk/1/hi/uk/7416627.stm)



Quite an over the top statement. I never worried about the jet's airworthiness in my small number of hours flying it!

It may well be over the top but will no doubt have implications for the future of the fleet.

[spheroid]

He said the crew and passengers on that day could not have known that their plane was not fit to fly.
In his view the entire Nimrod fleet had "never been airworthy from the first time it was released to service" nearly 40 years ago, he added


Big statement. It is going to be interesting to hear the MODs response to that.

[Donna K Babbs]

Sky News is reporting that the Coroner has recommended that the whole Nimrod fleet is grounded immediately. It will be a brave call if the MOD turns down the recommendations and there is a further incident.

[GasFitter]

This statement just shows that the Coroner is way outside of his professional knowledge. This is a military aircraft not a 737 going from Luton to Edinburgh. The risk of NOT having these aircraft operating would put more troops on the ground at risk, and at any future Coroners Court, they will say "why isn't there any air support?".

Can't win!

A little less 'headline grabbibg' statement and a little more considered thought would have been taken more seriously and had a better impact in support of the RAF and equipment support for the MOD.

It's a case of "Thanks for your comments, Judge" ..... let's carry on.

[JessTheDog]

Following the ruling of Mr Justice Collins on the human rights of personnel (albeit subject to appeal) the MoD would be placing themselves in a very awkward position (to say the least) if they continue operating the fleet.

Stand-down at Kinloss until further notice?

[GasFitter]

Guys, I'm coming to this very,very late but as an ex mil, now civilian pilot, may I express my indignation that a front line aircraft was / is 37 yrs old. In Pakistan the limit on the age of an aircraft in airline service is 18 yrs: in India they have a similar limit.

Nuff said?

Like all the Puma guff that spouted about the aircraft being too old. It's a case of 'Triggers Broom', mate.

Nuff said.

[Avitor]

Gas Fitter.

"A little less 'headline grabbibg' statement and a little more considered thought would have been taken more seriously and had a better impact in support of the RAF and equipment support for the MOD".
======================================================

So the Coroner's findings are nonsense? Admitted, I TOO have not heard the full story but I do not raise children only to have them fly rusty, ageing old crates in the name of expediency and cost cutting.

[GasFitter]

Following the ruling of Mr Justice Collins ......

... Might as well be Justin Lee Collins!

[JessTheDog]

The risk of NOT having these aircraft operating would put more troops on the ground at risk, and at any future Coroners Court, they will say "why isn't there any air support?".

Would the response not be "why were the troops on the ground" if air support - and other support - could not be provided. This question is at the very heart of our overstretched expeditionary adventures.

[slip and turn]

Seems to be some very unusual televised post-hearing audience free for all / Question Time kind of thing going on in the Coroner's Court right now?

What's occurring?

[phil gollin]

MOD/Government has been having an "issue" with the Oxfordshire coroner for a long time as he has been imposing "civilian" ideas on the examination of Iraqi/Afghanistan deaths.

MOD/Government have been trying to bully him and have been doing devious things to delay inquests. The latest may OR MAY NOT BE the fact that the area of inquests will be transferred because flights will be diverted to another county due to runway works.

------------

As far as his comments - they should be based purely on what evidence was presented to him. If he comes up with a controversial judgement it is PROBABLY because the MOD case was crap.

.

[Chugalug2]

This is surely a day for the families. Their courage, tenacity and resolve to discover the circumstances of the deaths of their loved ones has at last culminated in this verdict passed by the inestimable Mr Walker. He is to be commended for his professional and thorough findings. They may be uncomfortable even unacceptable to some, but if any good is to come out of this tragedy it is surely to utterly reform the provision of Military Airworthiness in the UK. This was not an isolated case, but symptomatic of a broken system. Hopefully this inquest will be seen in retrospect as the turning point in that downward spiral. A particular mention for NoK that have posted here, in particular Tapper's Dad who despite considerable opposition and even hostility has in my view been vindicated; Kam whose quiet courage and resolve has never wavered, and of course Chappie another stalwart of the XV270 thread, following the loss of her beloved brother, the both of them bringing love and support to those who have suffered from this tragedy. Let them all be an inspiration for the rest of us that a positive outcome results from this terrible loss.

[Doha_lad]

Lead article on the MODs website


Minister of State for the Armed Forces Bob Ainsworth MP and the RAF's most senior engineer, Air Marshal Sir Barry Thornton, have made statements following the conclusion of the Inquest into the crash of RAF Nimrod XV230 on 2 September 2006 in which 14 servicemen lost their lives.


http://www.mod.uk/DefenceInternet/Templates/GenerateThumbnail.aspx?imageURL=/NR/rdonlyres/EDB6283D-37E9-412A-B30D-335DA15019AA/0/KIN0049G6599.jpg&maxSize=210 (http://www.mod.uk/DefenceInternet/Templates/LargeImageTemplate.aspx?img=/NR/rdonlyres/EDB6283D-37E9-412A-B30D-335DA15019AA/0/KIN0049G6599.jpg&alt=Nimrod%20MR2) Nimrod MR2

Air Marshal Sir Barry Thornton, Chief of Materiel (Air), said:
"My thoughts today are first and foremost with the families and friends of those who died, and with the men and women of the Armed Forces, who I know feel the loss of their colleagues very deeply.
"From the evidence heard at the Inquest, and from the findings of the Board of Inquiry, it is clear that the crew of XV230 acted with the utmost professionalism in the face of a complex and demanding emergency situation. I pay tribute to their courage and dedication.
"With respect to the airworthiness of the aircraft today, we have stopped air-to-air refuelling and no longer use the very hot air systems in flight. This eradicates any dangers from the serious design failures noted by the Coroner that have been present in this aircraft since the 1980s. These measures have been supplemented with enhanced aircraft maintenance and inspection procedures to ensure the aircraft, as it is today, is safe to fly.
"In addition, to ensure we can operate the aircraft safely until its planned retirement from service, we have in place an effective package of more permanent measures which are being progressed as quickly as practicable. All of this work and our safety assessment are based on advice from both inside and outside the Department.
"I can assure you that the Ministry of Defence and the Royal Air Force place the highest priority on airworthiness and the safety of our personnel in the air and those we support in operations in the ground. We would not ask our personnel to fly in aircraft we did not believe were safe."
Bob Ainsworth said:
"My thoughts are with the families, friends and colleagues of those who died in XV230. On behalf of the MOD and the Royal Air Force, I would like to apologise again to the families of those who died for our failings which led to this tragic incident.
"I would like to reassure all those concerned that the Chief of the Air Staff has reaffirmed to me that the Nimrod is airworthy, and that we are dealing with all the issues raised by this incident. The independent review of the airworthiness and safety of the Nimrod is ongoing.
"I have noted the coroner's comments and I will consider them carefully. The Nimrod is saving lives in operational theatres every day. However, if it was not safe we would not be flying it; it is safe with the measures we have taken and that is why we will not be grounding the fleet.
"Finally, in remembering the crew of V230, we must not forget that that they acted with the utmost professionalism throughout and I pay tribute to them."

[Doha_lad]

Do you think that senior officers and government MPs hav autocorrect enabled on MS office so that any press release starts with the phrase:

"My thoughts today are first and foremost with the families and friends of those who died, and with the men and women of the Armed Forces, who I know feel the loss of their colleagues very deeply."

or similar.

I don't know about everyone else, but it's starting to sound a bit hollow.

[taxydual]

Air Marshal Sir Barry Thornton, Chief of Materiel (Air)

....."This eradicates any dangers from the serious design failures noted by the Coroner that have been present in this aircraft since the 1980s........

......We would not ask our personnel to fly in aircraft we did not believe were safe."

Surely the AM is contradicting his own statement!!!

[GasFitter]

This question is at the very heart of our overstretched expeditionary adventures.

Combat is an inherently risky activity!

In Korea, the UK lost over 1100 military personnel in 3 years. No Coroners inquests, no Health & Safety prosecutions, no calls for ac grounding etc. We are all proud and thankful for their sacrifice.

War involves painful sacrifices which is part of the risk we understand. I do not believe that anyone goes to work in the morning with a deliberate aim of killing their comrades.

It seems to me that the Coroners want a 'risk-free' combat operations. The whole point of war is that people get killed and we should think long and hard about commiting to such action .... that's the point!

[Bring_back_Buck]

Just a quick thought, maybe if there had been a few coroners inquests, then, just maybe less than 1100 people would have died.......

[Doha_lad]

Combat is an inherently risky activity!

GF I agree with what you say - to an extent.

Surely the Powers That Be have a "duty of care" (their words, not mine) to minimise said risks.

DL

[VinRouge]

And maybe if those tight fisted bastards in government stumped up the cash for the right kit for our armed forces, we wouldnt have people die needlessly.

About time Gordon and this socialist government put its money where its priorities lie... and I am not talking about propping up banks that have strong links with the Labour government, such as Northern Rock...

Its one thing to die for the cause and your country if your number is up, its another thing all together to die as a result of the government not investing the cash to give you the best fighting chance in theatre. Disgraceful.

[betty swallox]

Doha Lad.
Inappropriate. Take a look at your post again. Shameful. Thoughless. Get back in your box. Or grow up.

[blogger]

How much longer is the RAF going to put up with Cr@P kit?

Put a sticking plaster on it and get it out............as per the norm.

[Just a spotter]

From InTheNews.co.uk

A coroner presiding over the inquest into the death of 14 UK servicemen has said the Nimrod plane they died in has "never been airworthy". (http://www.inthenews.co.uk/news/autocodes/countries/afghanistan/nimrod-fleet-not-airworthy-and-should-be-grounded-$1224180.htm)

JAS

[cornish-stormrider]

Gas Fitter, the can do attitude is commendable. After all the engineers can fix anything, the crews could fly anything........My question to you is this..?

Do you think there is a comprehensive and robust system of ensuring airworthiness and "reasonable" safety in the RAF for aircraft?

If not then people have been flying in unsafe aircraft. Aircraft can only be demonstrated to be safe if the man has signed on the line saying so, no signature = not safe.

TD, Kam, Chappie and all the others. I think the coroner has vindicated you all. This saga is the latest in a long line of hemmoragings against the men and women who sign their lives onto the line......

Time it ends

[Winco]

Gas Fitter,

What the hell are you on about? This isn't Korea is it? This is 2008 and whatever you say about the coroner, these guys didn't need to die and the aircraft should not have crashed frankly.

We have had a whole bunch of experts on this thread giving us their expert opinion, but at the end of the day,someone has finally had the balls to stand up and say that the aircraft are NOW unairworthy and should be grounded. I for one applaud the guy for having the courage to say that.

Of course, we've now got the AirShips and the government 'experts' such as Ainsworth saying that the coroner was wrong, and that he doesn't know what he's talking about. Well clearly he doesn't know what he's talking about does he? He is speaking up against those in power, therefore he MUST be wrong! Yeh right.

As Blogger says, how much longer will the RAF have to put up with out-of-date and obsolete kit?

It's time for this so-called head of the RAF, Torpey, to be a true leader, stand up and say 'I'm sorry' and then hold his head in shame and resign. A leader? He couldn't lead a dog frankly. A total waste of space and oxygen IMHO.

Glenn, for Christs sake do the honourable thing, lead from the front and call it a day.

'tis a sad day for the RAF

[Double Zero]

Winco,

I generally agree with you - though I don't know the individuals you mention.

What has really got our forces in this position - and that means ALL our forces - is the 'Can Do' attitude has been taken for granted by polticians of all flavours and now we have crap aircraft, ships & vehicles.

The forces need a true ballsy person to stand up for them ! I'm not suggesting a military coup, just someone looking beyond their own pension.

DZ

[Doha_lad]

Betty

Check you PMs

DL

[Rigger1]

Surely there has to come a time when enough is enough, how much longer is CDS and CAS etc just going to roll over and tow the party line. The forces as a whole are broke and broken. Someone needs to tell this uncaring, self serving, bunch of left wing lunatics that we cannot carry on like this.
As usual, it is the brave men and women in uniform that pay the ultimate sacrifice, I hope that at the going down of the sun and in the morning the politicians will remember them … I know I do.

[John Blakeley]

Gas Fitter,

Whilst I actually agree with the underlying implications of your comments, namely that MOD has little option but to carry on flying the Nimrods, you are very wrong to criticise the Coroner in the way you have - a similar criticism was made by very senior RAF officers about results of the Mull of Kintyre FAI when the Sheriff did not agree with the RAF's position and unjustified verdict.

An airworthy aircraft is just that airworthy! A RAF aircraft should indeed be as airworthy as a 737 flying from Luton - the MOD definition of airwothiness in JSP 318 used to be "the ability of an aircraft or other airborne equipment or system to operate without significant hazard to aircrew, groundcrew, passengers (where relevant) or to the general public over which the airborne systems are flown.” I doubt it has been relaxed since the JSP 553 came in. Where the difference and hence the risks come is what you do with this airworthy aircraft, and there the risks of military aviation are inevitably significantly higher in many cases. As one of the parents said to me "if my son had been shot down I would still have grieved", but to know that he has been killed because of lack of money and, as has now been revealed at the Inquest, a lack of professional standards and failure to follow procedures by the very people who were supposed to be giving him an aircraft that was "fit for purpose" is probably more than the families can bear - and that came over if you saw their post verdict press conference.

Given how few resources we have there is, I suggest, nothing either operational or professional, if the RAF is to lose these scarce resources because they have failed, whether for lack of money or poor engineering judgement or any other reason, to provide equipment that is fit for purpose and meets their legal obligations for a duty of care - obligations that rightly, in my view, apply to MOD as to any other walk of life. The Coroner was right!

JB

[Winco]

Gas Fitter,

Would you have felt the same if the jet had fallen out of the sky onto say..........your house? or a loved one??

Would you still feel the same?

I fear that CAS will do nothing. He has shown himself to be utterly spineless and I suspect that he is quietly lining himself up for the next CDS job (after all, he is clearly on this shambolic governments' side)

CDS will do nothing because he is awaiing an invite to join the board of some big defence co'

[Len Ganley]

From the BBC article


This week a senior engineer from defence and aerospace firm BAE Systems told the inquest that his predecessors, who made the Nimrod some 40 years ago, failed to fit a fire protection system on a key area of risk on the aircraft. And the firm's head of airworthiness Tom McMichael said that if the evidence heard was correct, the Nimrod planes had, at the time of the tragedy, been flying in an unairworthy state for 37 years.


If this has been reported correctly, does it mean that even BWOS (sorry, BAe Systems) have doubts about the state of the Nimrod fleet???

[JessTheDog]

Are these aircraft fit to fly in UK airspace? What view would the CAA take?

[betty swallox]

Doha Lad,
Thanx for the pm. I now understand what you were trying to say. No offence meant!

[Secretsooty]

If I can just add in my thoughts here please.

It's rather unfair and also unproffesional (in my opinion) to claim that the aircraft is un-airwirthy now and never was airwirthy. Of course it was airworthy once, but the current decision making process is being based on current technology and design - the Nimrod is not current in either, it is a very old design.
Now, when it was designed from the Comet, it is reasonable to assume that the then-current aviation designers, working to the standards and guidelines of the day, weren't to know that passing a main refuel duct through an engine bay or passing a hot air duct through a dry-bay fairly adjacent to a fuel line would be an issue - because the hot air duct was lagged and the fuel line was leak-free. That was the current thinking at that time and as such it was airworthy.
Move on to current times and it's pretty obvious with hindsight that maybe it wasn't such a good idea (and probably wouldn't be declared airwirthy if it was a new design today), but it isn't practical to try and redesign something that doesn't lend itself to such process due to the very nature of the design and technology used - i.e. there is no other space through which to pass these components.
It is relatively rare to have such an age of design still in-use actively, hence the current situation. The easy answer of course is to say "replace it with something better".... well, that's happening but an awful lot slower than we would all like in an ideal world. (Oh, and the MRA4 has a TOTALLY different design of fuel system, before anyone starts trying to tell me it hasn't changed! I've had access to the maintenance manuals and seen it for myself!!)
Let's not forget that the MOD started the process to replace the MR2 in, what, 1994/5? It isn't the MOD's fault that things are running so late, but that does not excuse a perceived lack of attention towards maintenance on the "old" model. I say perceived as a lot of people just don't know what work is going on behind the scenes engineering-wise, that much is obvious when I read down this thread and see some of the comments made - comments based more than likely on how things were a long time ago, and comments made from people who are obviously not engineers or technicians but seem to think they are because they maybe once flew on it. There are currently active programmes being undertaken at ISK to check and/or replace on spec. various component parts of the aircraft, and certain systems have been isolated from use and operating procedures changed. I will not add anything else to that or enter into any deeper detail so don't ask please. These measures make the aircraft safe to fly in my personal opinion and if asked to, I'd fly on one tomorrow without any doubts or concerns.

Going back to what happened and why, IF the engineers were left to get on with what they do best and were given the funding for the parts that THEY say are required WHEN they say it, then things would be very different indeed but we all know that'll never ever happen.:ugh:
Two things must change...
1 - The officers who do a university course and think they know all about engineering when they don't know how to use a spanner MUST start to listen to their experienced tradesmen/women.
2 - IF a problem is encountered, funding MUST be made available to resolve it.

As for current ops, well, that is the big issue.
Fact - The aircraft is needed to do a job as long as the troops are there.
Fact - There is NO other platform that can step in and take over the same roles, a lot of which aren't talked about!
Fact - The replacement won't be ready for another few years.
Fact - The government aren't about to pull the troops out!
This leaves only one realistic option - make it safe to remain in-use....
Fact - This IS being done.

None of this detracts from the fact that this was a terrible accident that we all wish had never happened and hope to God that legislative measures will prevent from ever happening again on ANY piece of equipment.

[ANAPROP]

My sympathies also to the bereaved; you have shown great courage...

I know this is a sensitive issue but I think it needs raising.

My concern is this, would an insurance company now honor the insurance policy of a person injured or killed in/by a Nimrod crash, given the Coroners verdict?

[nigegilb]

I was present during the press conference today, when Paul Adams informed the assembled families that Ainsworth had stated during a simultaneous interview that Nimrod was airworthy and would continue to fly. The anger in the room was palpable. Ainsworth had responded to the Coroner's verdict before the ink had dried on the report.

Just one more clumsy, thoughtless, I would even say heartless reaction from a discredited ministry.

Justifiably, family members who I spoke to, were appalled by the evidence and the manner in which the evidence was given by Gp Capt Hickman IPTL. If Ainsworth has based his statement on advice given by the IPTL, then he could be open to a criminal charge of gross negligence for authorising the Nimrod fleet to continue flying.

It is absolutely clear in my view, that there is a systemic failure in the implementation of airworthiness regulations in the RAF and MoD.

[Kitsune]

If this happened in a civilian firm then there would be charges of corporate manslaughter at the very least for the officers in charge of the station, engineering, and operations. Is the MOD and the RAF completely devoid of all morality in this or what?

[nigegilb]

Kitsune they may be devoid of morality but they are not devoid of culpability.

[Green Flash]

As someone has allready said, I wonder what the CAA think? If there is doubt about an aircrafts serviceability can the CAA prevent it's use in UK airspace? What about using civvy airports as divs? What about other aviation regulators around the world? Will they ban the Nimrod in their airspace?:confused:

[Biggus]

Gas Fitter

Reference your comments along the lines of....'war is war, get on with it, risks must be taken, etc'...... XV230 was not lost due to enemy action. It happened to be lost while taking part in a conflict, but it was as a result of AAR which is routinely carried out. The aircraft could just have well been lost after AAR on the way to the Falklands, or some other more mundane AAR tasking.


As for the line taken by politicians and senior RAF officers to the effect....'if we considered the aircraft unsafe we wouldn't let it fly....', what about the fact that AAR sorties over Afghanistan carried on in the days immediately following the loss of XV230? That fact gets convienently forgotten!

[GOLF_BRAVO_ZULU]

It’s interesting that many of you chaps are baying for the blood of ACMs Glenn and Jock but breath not a word about Gen Kevin. Remember him? He’s the 4 * head shed for kit who undertook to provide (sorry, we call it "deliver" now, don’t we) the FLCs with safe, capable and available platforms and equipment. Mission statement: "To equip and support our Armed Forces for operations now and in the future." http://www.mod.uk/DefenceInternet/MicroSite/DES/OurPublications/DefenceEquipmentAndSupportBusinessStrategy200812.htm

Perhaps it's a good thing the "V" Force entered service when it did. The Coroner would have had a field day with H Broadhurst's early touchdown at Heathrow with just the 2 bang seats.

[OilCan]

I'd like to read the coroners report had there been any fatalities in the recent BA 777 drop short at Heathrow. :eek:

[buoy15]

Ok then air expert Mr Coroner Walker - if XV230 "has never been airworthy" - how did I manage to complete 306 hrs and 5 minutes in that frame, flying from 1973 as a Mk1 and converting in the 80's to a Mk2, and be here today writing this thread?
A BOI is far more in depth than any Coroners inquest (viz, 12 months vs 2 weeks) and should be accepted in good faith, not dismissed in the pursuit of compensation - particularly from an alleged 'MoD hostile Coroner'
I have flown in every Nimrod in the fleet and have had more than my fair share of in-flight heart stoppers, but was lucky to sort them and walk away
This was a unique, tragic accident due to an in-flight system failure rather than systemic engineering ignorance that some of this audience would imply
As this drags on, it starts to insult the memory of Al Squires, his crew and the groundcrew who honestly signed for, and produced, a serviceable ac for that sortie, that day

[gijoe]

Agreed.

And if you look at some of the other inquests that Mr Walker has conducted that is exactly the opinion he is trying to convey - do it properly or don't do it at all.

Defence on the cheap has been acceptable for too long and MOD, it is about time that you stop trying to punch above your weight.

.

G

[flipster]

Kam/Chappie

Check yr pms pse.

Flip

[tucumseh]

A BOI is far more in depth than any Coroners inquest (viz, 12 months vs 2 weeks) and should be accepted in good faith, not dismissed in the pursuit of compensation - particularly from an alleged 'MoD hostile Coroner'



Please do not forget that Mr Walker has simply agreed with the statement made in the BoI report by ACM Sir Clive Loader – that the mandated airworthiness regulations have NOT been implemented properly. Mr Walker could reach no other conclusion. He did not dismiss the BoI – but he did dig deeper. I’m sure the BoI did, but their findings weren’t published. I’m not surprised, given the conflict of interests which exists.

In also accepting the BoI report, Des Browne admitted liability. Underpinning this decision was a QinetiQ report which listed 30 recommendations. It is not clear if these are the same 30 recommendations one hears MoD speak of, where 20 or so are either in hand or implemented and half a dozen not. But, speaking as someone who has both been on the tools and held airworthiness delegation for a very long time, I’ll tell one certain, irrefutable fact. Of these 30 recommendations, some 29 refer DIRECTLY to MANDATED airworthiness regulations which have not been implemented. The 30th (recommending introduction of a Master Minimum Equipment List) is probably not actually mandated but if one doesn’t exist it casts doubt on the currency (or otherwise) of other mandated documents, like Appendix A of the Aircraft Specification.

And this is just one of many such reports. The main “QQ report” referred to in this thread is, quite frankly, the single most damning piece of evidence I’ve ever read. It is utterly shocking. It discusses causes, whereas I believe the MoD have successfully managed to compartmentalize the issues (as I feared) and what is reported today discusses the effect – and not in any great depth. Notably, the report refers back to previous reports on the SAME SUBJECT from 1995 and 1997. The tone of the report throughout is one of “here we go again”. Nothing came as a surprise.

I sincerely hope in due course what Tapper’s Dad, and others, have achieved today will be seen as one huge step forward in military aviation safety. Judging by the two planks who spoke on behalf of MoD today, I have my doubts.

[Tappers Dad]

Group Captain Hickman IPT leader for the Nimrod told the coroner on Wednesday that the ac was not ALARP . If you read JSP 553 Chapter 2 Page 13- The justification for the airworthiness of the aircraft, sys em or equipment is the safety Case.The health and safety commission defines a safety case as" A suite of documents providing a written demonstration that risks have been reduced as low as reasonably practicable (ALARP).

This is why it is NOT AIRWORTHY

ian176 (http://www.pprune.org/forums/member.php?u=203243) If you can get better witnesses than Rolls Royce The head Engineer of BAe systems and the AAIB then tell me were they are. The head Engineer of BAe systems told Mr Walker this ac is not airworthy.

[Robby NL]

Whilst not being an engineer or aircrew a question which keeps coming to mind is that if the RAF have outsourced all 2nd -3rd and 4th line maintenance to the latest reincarnation of the OEM, who by all accounts are contracted on an availability basis, shouldn’t they be the worried organisation as they are fully liable to the full force of the lawyers?

[davejb]

Ok then air expert Mr Coroner Walker - if XV230 "has never been airworthy" - how did I manage to complete 306 hrs and 5 minutes in that frame, flying from 1973 as a Mk1 and converting in the 80's to a Mk2, and be here today writing this thread?

The same way lots of others - including myself - did...by never, thank goodness, encountering the set of circumstances that led to the flaw in the aircraft manifesting itself as tragically as it eventually did.
Are you saying that if AAR resumed, behind the same tankers, with the cross feed operating, that this tragedy would not be repeated?

The airworthiness remarks are simply pointing out that the aircraft was flown for its entire service life with a bay that was devoid of fire protection, when a fire in that bay would invariably lead to a catastrophic loss of the aircraft. Some of the fallout reflects the fact that nobody seems to have spotted this in almost 40 years, except one chap in the early days who incorrectly figured it wasn't a problem.

I don't believe for a single moment that this is detracting from the memory of any of the guys, they're untainted by the argument and I think it would have been far more of a dishonour to their memory to do anything but dig right down to the core of what happened, so it could be prevented from ever happening again.

[blogger]

Old kit worn out kit.........why does the RAF do it?

Because its all they have.


Full stop.


Deaths will occurr more and more whats new? not the aircraft.


More will die............full stop.


Full stop.



Full stop.



Full stop.

[blogger]

Sorry only way to get the message across.

[buoy15]

Yes, agreed
The Capt signs the F700 for the serviceability of the ac, not for the Appendix A of the ac Specification
Des Browne was forced to admit liability and was wrong to do so - hitherto, Nimrod performed safely prior to this event, and still does
Spitfires and Hurricanes in WW2 were not fitted with foam/fire depressant, but we don't see those pilots widows trying to wring money out of the MoD
There was a war on then, as there is now - Churchill must have had some sort or ALARP to get the job done otherwise we would have lost - as we have done under New Labour anyway :sad:
You hand wringing, bleeding heart, health and safety, ambulance chasing brigade need to get real and go and spend 2 months in the sand with the lads - then we might get some sensible debate on this thread

Davejb - The ac design and build is based on safety in every compartment and the life expectancy of components including seals, valves and pipes, which are lifed - even the best engineer cannot predict a failure at the wrong moment in the wrong place at the wrong time

[grousehunter]

Its fine cause according to the 'stiash everything is ok and the jet is fully serviceable. HEEEEEELLLLLLOOOOOOOOOOOO??????????!!!!!!!!
Beggers belief.

RIP dudes. Every morning i drive to work i think of you, and every time i fly you are in my mind and yet I still fly.

GH

[airsound]

ian76, mileandahalf, buoy15, GasFitter,

I have been at the inquest for eight long, back-crunching days. I have closely observed Mr Coroner Walker at work.

As someone who has aviation fuel flowing in his veins, I have been deeply, but deeply, impressed with the Coroner’s ability to get to grips with some amazingly complicated stuff. He has sifted his way through masses of documentation, and, even more impressively, through hours of obfuscation, bureaucratic bull**** and downright buck-passing by some witnesses. (Btw, I don't mean any of the RAF techies here)

He has come out of this with an enviably clear view of what actually happened some years ago, and which, sad to say, is still happening today. He has pointed out some deeply important stuff that, perhaps, those of us closer to the action might have missed.

I, for one, am grateful that this society, which seems to be descending in a rapidly tightening spiral of government abuse and micromanagement, does still have people of the calibre of Andrew Walker to look after the interests of us ordinary people.

Btw, Len Ganley, you say
If this has been reported correctly, does it mean that even BWOS have doubts about the state of the Nimrod fleet???
This is what happened on Thursday:
BAE Systems’ chief engineer for the Nimrod, Martin Breakell, admitted that the Nimrod was not airworthy at the time of the crash.
His admission produced an audible reaction of astonishment from the families.
He said that, based on what he had learned during the 12 days of the inquest, Nimrod should not have been flying.
Mr Breakell’s comments came in response to a direct question from a family member as to whether he believed the aircraft was safe to fly.
After initially arguing that he was not qualified to decide on certain parts of the Nimrod, he was pressed by the crew’s relatives and the coroner.
He replied: “I concur that in regards to the evidence on the incident, then no, it wasn’t (airworthy).”

airsound

[Tappers Dad]

By the way no Battle Damage assesment has been done on the Nimrod as requiired by Def Stan 00-970.
So if one gets hit taking off or landing in a sandy place its because of the MODs cavalier attitude to safety ( Andrew Walker QC)

[tucumseh]

Airworthiness is far more than the aircraft’s ability to take off and land. Crucially, the regs don’t actually tell you how to implement them in practice – they are written for an audience who are assumed to be experienced and competent, the implementation of which QQ recommended (see my previous post). One assumes they had a reason for this! Implementation is (or was) taught both on the job and by ADRP-run courses. In the simplest terms, to clear an aircraft for flight one assesses airworthiness thus;

1. Build Standard
2. Proven Limitations
3. Operational Usage
4. Maintenance

A "serviceable" aircraft is not necessarily airworthy. MoD's definition, not mine.




I can’t speak for 2 and 3 on Nimrod, but it is a simple, verifiable fact that MoD habitually does NOT maintain the Build Standard or most aspects of Maintenance. (There is overlap between these two, the most obvious being Tech Pubs, which MoD accepted were not kept up to date). I won’t bother listing the times these deficiencies have been notified formally to 2 Star and above. Suffice to say I didn’t agree with CDP’s rulings that safety and fitness for purpose were optional, and I didn’t agree with Min(AF)’s decision to uphold this. It is rulings like these which are at the root of this accident. The “error” that was admitted was low level stuff and quite obviously an MoD device to deflect from the real issues.


Others will no doubt inform us of more detail from the inquest, but what is absolutely certain is that what you have seen on tonight’s news is the bare minimum. It is NOTHING compared to what will emerge.

Oh, and the BAeS Chief Engineer's statement (see airsound) presumably means they cannot and will not accept any more Mk2s for conversion.

[BillHicksRules]

Airsound,

Bravo sir. 10 out of 10.

I agree with your last post 100%.

If it was left to the likes of Buoy15 we would have all the safety equipment removed from our aircraft and if you come back count yourself lucky. If you do not then your family should pay for the cost of replacement of the lost aircraft, after all their is a war on and we all need to shoulder the burden.

Cheers

BHR

[buoy15]

airworthy
Martin Breakwells asumption was stating the bleeding obvious - "the ac was not airworthy at the time of the crash" - Wow!
No wonder - it was a ball of flame, had lost most of it's systems, was out of control and hit the ground as a result of a unique and tragic post AAR accident? How revealing!
However, it was airworthy at launch and prior to AAR and had been flying for at least 3 hours because it had been deemed safe to fly and had been signed for by the Crew Chief and the Capt
When pressed by clever QC's and Coroners to answer simply Yes or No to a question, the answer never comes out - the man is a pratt

[davejb]

Davejb - The ac design and build is based on safety in every compartment and the life expectancy of components including seals, valves and pipes, which are lifed - even the best engineer cannot predict a failure at the wrong moment in the wrong place at the wrong time
Yes, which is why seals etc are lifed - so you can replace them before they fail. Unfortunately the problem was more one of failing to spot that potential fuel source and source of ignition were colocated in a bay where there was no possibility of extinguishing any fire.

However, as I understand it, BAe's rep himself has agreed that the lack of fire suppression in that bay made the aircraft non-airworthy. To quote from earlier in the thread:-

Tom McMichael said that if the evidence heard was correct, the Nimrod planes had, at the time of the tragedy, been flying in an unairworthy state for 37 years.

As far as I can see a number of people are blaming the coroner for repeating what the aircraft company and a variety of senior RAF officers (IPTL, AM Loader) have said. The RAF stance is 'it's safe NOW' whilst accepting that it actually wasn't prior to XV230, I'm surprised that you appear to be arguing that the jet was okay 20 years ago when even the RAF and BAe are saying "it wasn't but we didn't know that at the time".

To conclude, I have to take exception to this comment, which I sincerely hope reflects a momentary reduction in judgement rather than a seriously held opinion -

Spitfires and Hurricanes in WW2 were not fitted with foam/fire depressant, but we don't see those pilots widows trying to wring money out of the MoD

Those relatives that I know are not treating this as an opportunity to make a few quid, I think they deserve better than the implications in this statement.

[nigegilb]

I completely agree with Airsound. There are people posting here who would appear to be suggesting that they would prefer the judgement of Bob Ainsworth, "... if it was not safe [Nimrod] we would not be flying it; it is safe with the measures we have taken and that is why we will not be grounding the fleet.".."we are convinced this aircraft is safe to fly." (BBC interview tonight). Anyone who prefers the judgement of this man over Mr Andrew Walker must be stark raving mad. (Check out the infamous Paxman interview http://www.youtube.com/watch?v=ziTrlKAkn94 ).

Where was Des Browne today? Oh, on a visit overseas. Where was CAS today? He is the man who told us that Nimrod was as safe as it needs to be.

"Def Stan 00-56 contains numerous references to the point of repeating many times that "tolerable" is NOT acceptable unless ALARP. I'd argue that what MoD call "tolerable" on Nimrod is actually "Unacceptable" but the bottom line is the same - the risk is NOT to be signed off until ALARP."

De facto, NOT AIRWORTHY.

[buoy15]

BillHicksRules

Don't spoil my day by telling me you are serving aircrew - please?

[tucumseh]

However, it was airworthy at launch and prior to AAR and had been flying for at least 3 hours because it had been deemed safe to fly and had been signed for by the Crew Chief and the Capt


Sorry Buoy15, but I recommend you read JSP553 and the Standards called up therein. "Deemed safe to fly" and two signatures doesn't remotely cover it.

[JPA-HATER]

THIS SUMS IT ALL UP


Joseph Windall, whose 22-year-old son Joe died in the Nimrod accident, said: 'This shows an appalling lack of care for our fighting men - to send them to war with ancient, inadequate equipment services.'
Coroner Andrew Walker has called for the entire RAF Nimrod fleet to be grounded
'The Nimrods are a relic from a bygone age. They belong in the air museum at Duxford. It is a dreadful indictment of the Government's cost- cutting policy.'

[Safeware]

buoy15

You really don't understand the concepts of airworthiness and safety do you?



sw

[Winco]

buoy 15

Your comment 'we don't see those pilots widows trying to wring money out of the MoD' is utterly shameful and I hope that the moderator removes it immediately. How dare you suggest, even remotely, that the families of XV230 are doing this for finacial gain, you are a real sh1t, and that is a terrible thing to say.

How is it that you are so right, and the real experts from RR, QQ, and even BAe themselves are so wrong?

Get a life and accept that the aircraft should be grounded and just thank God that, like me and lots of others, you were never faced with the sequence of events that struck XV230, and accept with humility that it was more by luck than judgement, that we are left and able to talk about it.

To TD and all the families, let me be the first to apologise on behalf of all PPruners for buoy 15's outrageous comment.

[nigegilb]

further to B15s, good advert for aircrew, comments. Might I suggest you should have gotten off your arrse and turned up at the Inquest?

Seeing the families assembled together, in great dignity, is very humbling. You might have learned something, even by simply counting how many are directly affected by this tragedy.

Humility is something you do not appear to possess.

Please remove your post forthwith and show a modicum of sense.

[sumps]

Just fill me in here - as a service man and registered engineer, what exactly is the defining point as “Never been AIRWORTHY”?

[Donna K Babbs]

Buoy 15: (With reference to his own Nimrod close-calls)but was lucky to sort them and walk away

I though the cavalier attitude towards Nimrod safety was reserved for the Nimrod IPT. I just hope I never have to fly with you.

[Ivan Rogov]

Is the coroner saying that the MR2 is not airworthy until proved ALRAP? The MOD have incorrectly classed it to be airworthy before the accident, it would be understandable that the coroner is asking for proof if they now state it is airworthy.



RIP CXX/3

[The Gorilla]

Boy 15 is a numpty, he could be admin guru in disguise for all we know. Or of course an Air Rank Officer, he has the same lack of honour and integrity!
:mad:

[nigegilb]

Sumps the words of Mr Walker;

The crew and passengers were not to know that this aircraft like every other aircraft within Nimrod fleet was not airworthy. What is more the aircraft was in my judgement never airworthy from the first release to service in 1969 following its conversion from the Comet 4C Civil Aircraft to the Nimrod MR1-through modification to the Nimrod MR2 completed in 1979 - to the point where the Nimrod MR2 XV 230 was lost.

I am satisfied on the balance of probability that the design modifications for the MR1 contained a serious design flaw that made the MR1 unsafe to fly. I am similarly satisfied that the design modifications to the MR2 made the aircraft unsafe to fly and that this serious flaw in the design was not discovered despite a baseline safety case study undertaken by the IPT and the manufacturer.

If this were not enough an incident involving the potential ignition of fuel that had been drawn into lagging on a hot duct on a different aircraft with the consequent loss of that aircraft passed without any follow up investigation despite a recommendation by the board of inquiry.

THIS CAVALIER APPROACH TO SAFETY MUST COME TO AN END.

This in my view was the very source of ignition that on balance of probability caused the loss of XV230 with all souls on board.

There were failures within the operation of the Cassandra hazard log that should if the information had been correctly recorded and acted upon have led to the discovery of this design flaw within the Nimrod fleet. I simply do not understand why it was not noticed that according to that hazard log a fire detection and suppression system existed within the dry bay 7 when there was clearly no such system within dry bay 7 and never had been.

If the A s Low As Reasonably Practicable standard is the standard accepted it is not airworthy today.

[Papa Whisky Alpha]

Airsound

A first class post, I agree with everything you said about Andrew Walker, a remarkable man.

I was however less than impressed wqith some of the evidence given by, and about the Nimrod IPT.

The much vaunted "Nimrod Safety Case", discussed previously on this thread, was produced by a contractor, no doubt at great expense, on behalf of the IPT. This resulted in a number of hazards and subsequent risks being identified where, if they occurred, would have"catastrophic"
consequences (ie loss of aircraft and crew). The risk was assessed as "Remote" but did require remedial action. IPT had the category re-assessed as "Improbable" so that action was no longer required.

The requirement to manage risk so that it was ALARP is a requirement of the MOD's own system of regulation, so it would not be unreasonable to expect compliance from the MOD, however when questioned by the Coroner the IPTL kept insisting the aircraft was tolerably safe, and did not appear to understand the concept of ALARP, but said they "were working towards ALARP compliance". He refused however to acknowledge the requirement for risk to be ALARP.

Bouy 15
Bob Ainsworth stated on the BBC today that the fleet had "not been airworthy for many years prior to the accident" !

Andrew Walker recommended that the fleet should be grounded until the ALARP condition could be achieved, whilst I do not expect this to happen it may speed up the process to make Nimrod a safer aircraft

[helgar33]

pm sent to me by :confused: - can't reply/ need to. Where r u? pm again. helgar33.

[cooheed]

Rigger1

"Someone needs to tell this uncaring, self serving, bunch of left wing lunatics that we cannot carry on like this.
As usual, it is the brave men and women in uniform that pay the ultimate sacrifice, I hope that at the going down of the sun and in the morning the politicians will remember them … I know I do."

They will not remember them past the first line of their speech 'offering' their 'condolences'. :mad:

[bondo]

Gorilla - you assume much!

[OilCan]

Can somebody help me too please? :confused:

Setting aside the legal definitions argument and systemic failures for a moment, the accident was initiated by the unfortunate interaction of the SCP/X feed pipe and the AAR system. The ‘design flaw’ did not cause the accident, but clearly failed to mitigate that interaction with disastrous results.

Given that neither system is currently in use, what exactly are the remaining risks that justify the grounding of the fleet?

[nigegilb]

Oil can, an engineer should really answer your question and I do not claim to be an engineer, but these are some of the outstanding issues.

FRS Couplings, seals checked every 30 days but dry out in 5,(plus annual check), misaligned pipes, chief source of continuing leaks, checked by eye(only gross misalignment can be found), couplings that can't be checked,fuel leaks over hot and electrical sources, even more important as Coroner challenged BoI version of fuel leak source, this risk to hot and electrical sources exists at low level, but was discounted by IPTL.

Hickman confirmed Nimrod was not ALARP, HSWA requires aircraft to be ALARP, it is not!

Tolerable not safe unless ALARP, only other option exceptional circumstances. Due process for this clearly not being carried out, exceptional circumstances claim has been rightly (in my view), rejected.
"Their weakness is, I think, their inability to show they complied with this rigorous process which requires constant review. Elsewhere I noted the frequency with which the IPTL must carry out certain reviews, and if he has a hazard which would result in explosion/fire/loss of aircraft then, frankly, his Safety Manager, the Safety Committee and the Contractor should be employed full time."

I do not understand the response from Torpy and his ilk. I believe he is wrong.

I believe Mr Walker has accurately described the airworthiness of Nimrod.

[tucumseh]

Further to Nige’s post, and in addition to my previous comments on the recent (2007) QQ report containing 30 recommendations, may I offer some detail from a previous QQ report dated 17th March 2006 entitled ”Nimrod Fuel Leak Study” (which itself refers back to reports from 1995 and 1997).

It is in 3 sections, plus a summary, addressing;

1. Repair and Maintenance Issues
2. Materials and Processes
3. Structural Integrity

Section 1 contains 8 recommendations, 7 of which are directly related to airworthiness.

Section 2 contains a table of 12 Deficiencies, their consequences and recommended corrective action. All relate directly to airworthiness. Section 2 also contains 12 recommendations, all relating to airworthiness.

Section 3 is less well presented and contains 5 conclusions each of which affect airworthiness.

The report correctly states many of the above are interrelated and so approaches issues from different viewpoints. It therefore summarises the 3 sections with 17 recommendations, all related to airworthiness.

It is unclear what action has been taken on these but, of those I’m familiar with (generic problems common across MoD), I can assure you they are long term and need an awful lot of investment as there is up to 20 years regression work required. Others could have been implemented immediately, the remainder following a major recruitment drive in RAF and MoD to claw back the experience and expertise that was ditched. This last is a specific criticism in the report.

I understand there are further QQ reports in a similar vein which have not been released, presumably because they are even more shocking.

[general all rounder]

I have no knowledge of the Nimrod's fuel system so I pass no comment. What is of interest is the risk that CAS and SofS have just taken; if there were another crash, they would have few options other than suicide or long jail terms.

If I were them I would consider one half of the monkey tree syndrome - the half which says that all the monkeys at the top of the tree can see is happy faces looking up. All the monkeys at the bottom of the tree can see is a***holes at the top.

Everybody knows the pressure to deliver effective support to the troops on the ground in Afghanistan, what does that pressure do to self-censor the honest views of those who advise the men at the top? I don't know but I hope the men at the top have thought about it.

[EdSet100]

If Gp Capt Hickman, as the Delegated Airworthiness Authority, has stated that the Nimrod currently IS NOT ALARP, we are in trouble. I wasn't there to hear his words on oath, but if he used those words, or similar, he is contradicting virtually everyone (from SoS down to NLS liney) involved with the aircraft. Given his appointment, there should be no way that he would be contradicted by his superiors. I believe he has been mis-represented here.

Buoy 15, I don't known what caused your outbursts yesterday, but you should study JSP 553 (its on every sqn) and have a rethink. I think you are confusing serviceability with airworthiness, which is a subject not normally on the minds of aircrew. We have a right to expect that our aircraft have been designed to meet the definition of airworthiness. The definition is in the JSP. Read it and then try to reconcile the JSP with a design that has a collection of very hot pipes and fuel pipes in the same small bay, such that a small fuel leak (single failure) will have catestrophic consequences.

I miss my mates on that crew and, furthermore, I consider that all of us here today are fortunate to be still alive.

Ed

[Tappers Dad]

Deputy Coroner Andrew Walker’s Verdict

I should like to begin by offering my deepest sympathies to members of the fourteen families.

I realise that there is nothing that I could ever say that would be enough to comfort them in their grief and if this were not enough to bear by itself they have had to wait far too long for this inquest to be heard and like so many families should not have had to fight for access to documents to help understand this tragedy.

Of one thing there can be no doubt, the crew and passengers on that aircraft were highly trained, highly professional, brave and courageous and it is clear to me as I have sat here over the last three weeks I can see in the families sitting in court that same determination and courage reflected in their drive to uncover the truth and in their concern for those who have still to fly this aircraft.

I will never forget the crew's last words as they calmly dealt with the fire on their aircraft with every intention that they should land safely having diverted to Kandahar airport.

I have no doubt that these fine men will never be forgotten and their loss will be keenly felt by their families their friends and our armed forces.

The weather was fine and there was nothing unusual as the crew and passengers of the Nimrod XV230 took off for their mission over Afghanistan from their deployment base at 09.13 in the morning.

The crew and passengers were not to know that this aircraft like- every other aircraft within the Nimrod fleet-was not airworthy. What is more the aircraft was in my judgment never airworthy from the first release to service in 1969 following its conversion from the Comet 4C Civil Aircraft to the Nimrod MR1- through the modification to the Nimrod MR2 completed in 1979- to the point where the Nimrod MR2 XV 230 was lost.

I am satisfied on the balance of probability that the design modifications for the MR I contained a serious design flaw that made the MR1 unsafe to fly. I am similarly satisfied that the design modifications to the MR2 made the aircraft unsafe to fly and that this serious flaw in the design was not discovered despite a baseline safety case study undertaken by the IPT and the Manufacture.

If this were not enough an incident involving the potential ignition of fuel that had been drawn into lagging on a hot duct on a different aircraft with the consequent loss of that aircraft passed without any follow up investigation despite a recommendation by the board on inquiry.

This cavalier approach to safety must come to an end.

This in my view was the very source of ignition that on the balance of probability caused the loss of the XV230 with all souls on board.
There were failures within the operation of the Cassandra hazard log that should if the information had been correctly recorded and acted upon have led to the discovery of this design flaw within the Nimrod fleet. I simply do not understand why it was not noticed that according to that hazard log a fire detection and suppression system existed within dry bay 7 when there was clearly no such system within dry bay 7 and never had been.

If the As Low As Reasonably Practicable standard is the standard accepted it is not airworthy today.

For each of the service personnel who lost their lives I record the following narrative verdict.

The fourteen members of crew and passengers of the XV 230 Nimrod mark 2 aircraft which left from an operational base to fly a mission into Afghanistan on the 2nd September 2006 at 9 13 were lost when shortly after air to air refuelling when fuel from a fuel leak, most likely from a fuel feed pipe, was ignited by a hot duct within or closely associated with dry bay 7 on the starboard side of the aircraft. As there was no fire detection and suppression system within dry bay 7 the crew could do nothing to prevent the fire and the aircraft broke up in the air following an explosive ignition of fuel from fuel tank 7 as the crew were preparing for an emergency landing at Kandahar airport.

Their deaths were in part the result of failures, some of them serious, that resulted in the dangers inherent within dry bay 7 of the aircraft, created by the introduction of a hot air engine cross feed system and subsequently a bleed from that system, on the part of the aircraft manufacturer and the those responsible for the safety of the aircraft, going un noticed.

The creation of a baseline safety case and Cassandra hazard log that contained serious errors failed to deal adequately with the dangers posed by dry bay 7 and the danger remained until its discovery after the loss of the aircraft, crew and passengers.

The different aircraft reffered to was a Tornado that had a fuel leak onto a hot Air duct the Nimrod IPT were told about in 2004 .The Tornado was lost but the crew ejected hence no BOI or Inquest.The Nimrod IPT took no action to look at the Nimrod to see if it could have a similar acident.

[kevmusic]

Interview on R4's 'Today' with Jimmy Jones, a Nimrod engineer & AM Sir Barry Thornton available here:
http://www.bbc.co.uk/radio4/today/index.shtml?survey=no&url=www.bbc.co.uk/radio4/today/index.shtml&site=today&js=yes

[Softie]

Nigeglib

Thank you for your informative posts yesterday.

Might I suggest you should have gotten off your arrse and turned up at the Inquest?Not all had the opportunity or the proximity to do this. I think we were greatly let down by the media who stopped reporting the inquest when it became "too technical" for them to follow.

If this were not enough an incident involving the potential ignition of fuel that had been drawn into lagging on a hot duct on a different aircraft with the consequent loss of that aircraft passed without any follow up investigation despite a recommendation by the board of inquiry.Can you clarify what incident and timescale Mr Walker is referring too?

TD has just answered my question:

The different aircraft reffered to was a Tornado that had a fuel leak onto a hot Air duct the Nimrod IPT were told about in 2004 .The Tornado was lost but the crew ejected hence no BOI or Inquest.The Nimrod IPT took no action to look at the Nimrod to see if it could have a similar acident.Oilcan

The ‘design flaw’ did not cause the accident, but clearly failed to mitigate that interaction with disastrous results.

Given that neither system is currently in use, what exactly are the remaining risks that justify the grounding of the fleet?As correctly highlighted, if the 'design flaw' had been identified and ignition source removed this accident would not have happened. I agree that with the ignition source removed, one side of the fire triangle (oxygen/fuel/ignition) has been removed. However, the risk of fuel leaking has not been addressed and as stated by Jimmy Jones on TV it will be years before a seal replacement programme could be carried out on all aircraft. What has never been discussed here is how difficult jet fuel is to ignite. Even at the 400C temperature, it can take 'minutes' for fuel to ignite, if it has not evaporated first. This does not excuse the mistakes and oversights that lead to this tragedy, but might explain some people's thinking up to this point.

[ORAC]

What are the implications of this for the MRA4 contract, if any? I presume the wing change and refurbishment has rigorously identified and covered all these issues, right?

[chappie]

firstly and most importantly i absolutely echo the words of andrew walker, this cavalier approach to safety must come to an end.
there needs to be no more said on this matter.
for those of you who disagree, you are of course entitled to do so. this would not be a discussion forum if we all agreed, but there are those of you who's views belong to an era, nay a culture which no longer has any place in the 21st century. it is also to be noted, and no doubt ignored that the way in which the opposing views are communicated in the most ignorant and offensive way. of course i am making reference to buoy 15 and his disgusting reference to the widows and wringing of compensation etc, blah blah. this is all about keeping the lives of serving aircrew safe protected and MAINTAINED! HOW DARE YOU TRY AND ATTACH THAT KIND OF REFERENCE TO US. the RAF is one of the finest in the world. we are keen to maintain that.
to tappers dad and others :D :D :D :D

KEEP THE FAITH:ok:

[JessTheDog]

Des Browne was forced to admit liability and was wrong to do so - hitherto, Nimrod performed safely prior to this event, and still does
Spitfires and Hurricanes in WW2 were not fitted with foam/fire depressant, but we don't see those pilots widows trying to wring money out of the MoD
There was a war on then, as there is now - Churchill must have had some sort or ALARP to get the job done otherwise we would have lost - as we have done under New Labour anyway
You hand wringing, bleeding heart, health and safety, ambulance chasing brigade need to get real and go and spend 2 months in the sand with the lads - then we might get some sensible debate on this thread


What utter rubbish. I hope you are no-one's boss.

[tucumseh]

What are the implications of this for the MRA4 contract, if any? I presume the wing change and refurbishment has rigorously identified and covered all these issues, right?
By default, but probably not by design, many problems will be negated.

However, I cannot see how the problems could have been rigorously identified by the MRA4 team, yet not advised to the MR2 team and corrective action taken. What will (should) have happened is that the issues arising from the raft of reports (and I mentioned the QQ/DERA ones go back to 1995 at least and the same fuel problems were identified concurrently on VC10 and corrected) will have been advised to the RMPA/Nimrod 2000/MRA4 team by MR2 and, I would hope, VC10. As mutual stakeholders (they were dependent on each other when separate entities) they would agree an action plan. Judging by the QQ report, the action plan was fix VC10 but not Nimrod.

Furthermore, it is a fundamental up front requirement of any modification programme (MRA4) to establish the Induction Build Standard of the aircraft to be modified. Given the programme timescales, this would be bottomed out in the period 1997-99 and kept up to date through 10 or so years of slippage(!!). If it was not, this is a grave oversight and alone would force years of delay in the MRA4 programme, even without the major design issues that were known at the time. Note – not yesterday as a result of the Coroner’s verdict, or last year with the issue of the BoI report, but over a decade ago for specific fuel related problems and nearly two decades ago for generic Build Standard deficiencies. As it is, we know the Build Standard has not been maintained and one should be asking the MRA4 team what they did about it and were they climbing all over the MR2 team, and their stakeholders, to resurrect the Build Standard?

Given this, see here;

http://www.globalsecurity.org/military/world/europe/nimrod_mra4.htm

Under the Smart Procurement Initiative, the Nimrod MRA4 was identified as one of the pilot (http://www.globalsecurity.org/military/world/europe/nimrod_mra4.htm) Integrated Project Teams (IPTs) in November 1998, led by Air Commodore Barry Thornton. Although the project was established around an integrated team concept from the outset, both at Abbey Wood and in industry, the latest initiative enabled the Nimrod Integrated Project Team to re-focus and embrace other personnel who work full time on Nimrod MRA4 from other areas which were previously outside the IPT.


My opinion is that there is a conflict of interest here which may explain why MRA4 is seldom mentioned. But the two are inextricably linked and I imagine there will be much to discuss in the coming months. Perhaps the past IPTL (and contributor to the BoI report) will be asked to comment.

[Basil]

What has never been discussed here is how difficult jet fuel is to ignite.
True if just pooled but, if subjected to the 'wicking' effect of, say, lagging then much more likely to ignite.

[Da4orce]

Given that neither system is currently in use, what exactly are the remaining risks that justify the grounding of the fleet?

Well there are the seals for a start; the manufacturer stated on oath that they are not suitable for the purpose that they are being used on the Nimrod. When Grp Captain Hickman describes how the seals on the blow-offs are tested by passing air through them (that’s right seals that degrade after 5 days dry have air blown over them to test them!) oh then everybody has to be quite while the engineer listens for a whistling sound!

He was almost laughed out of the court room. I repeat what I said in the press conference yesterday Hickman as head of the IPT is arrogant and has a casual attitude towards safety, if my life was in that comedians hands I would get a seriously good life insurance policy, although that may be difficult for serving air crew now as it has been proven that they are flying in an aircraft that is not airworthy!

If Gp Capt Hickman, as the Delegated Airworthiness Authority, has stated that the Nimrod currently IS NOT ALARP, we are in trouble. I wasn't there to hear his words on oath, but if he used those words, or similar, he is contradicting virtually everyone (from SoS down to NLS liney) involved with the aircraft. Given his appointment, there should be no way that he would be contradicted by his superiors. I believe he has been mis-represented here.

I was in court and Group Captain Hickman stated that the “Nimrod is tolerably safe but not ALARP” he went on to describe that they hope to be ALARP by the end of 2008. Only took them 40 years to achieve!!!


Buey15 – you’re a disgrace to your service, your comments are an insult to crew 3 and their families, and you should be ashamed. :mad:

[Biggus]

Buoy 15

You say...."Spitfires and Hurricanes in WW2 were not fitted with foam/fire depressant, but we don't see those pilots widows trying to wring money out of the MoD"......

Well, Spitfires and Hurricanes in WW2 did have self sealing fuel tanks,

http://en.wikipedia.org/wiki/Self-sealing_fuel_tank

which was the equivalent of foam at the time (and is more than the RAF Nimrod/Herc/etc fleet had until very recently, and is now only going onto Hercs, but not MRA4) - once again your ignorance shines through. As has already been stated, none of the relatives are in this for the money, and for you to suggest so ............ frankly your suggestion leaves me speechless, and once again speaks volumes about you.

You give me the impression of someone who has the same attitude as RFC/RAF senior officers in WW1. That attitude being one of, ....'we won't give the pilots parachutes as they may bail out at the first sign of a fight'.... How many unneccesary deaths did that approach cause???

[TOPBUNKER]

The coroner was right.
Buoy 15 is a knob.
Any questions?

[zedder]

I would get a seriously good life insurance policy, although that may be difficult for serving air crew now as it has been proven that they are flying in an aircraft that is not airworthy!

More importantly Da4orce, where do people stand with existing Life Insurance policies? God forbid there were to be another crash, but should it happen, that would conclusively prove that the MOD and the Government should not have continued to risk flying an aircraft that is only Tolerably Safe.

At the individual level, your Life Insurance company might then decide that while you personally accepted the risk of flying in such an aircraft, they did not. Worst case, that could result in a refusal to pay out. Any Financial Advisors out there that could offer a view on this?

[Woodbine]

I find the whole debate on this thread over Nimrod airworthiness confused and unclear.
My understanding is that the original Comet design was extensively modified to generate a military aircraft type called Nimrod. To permit self-start, the Nimrod MR1 had an auxiliary power unit and a hot air cross-feed system installed. In the installation of the cross-feed system, the hot air ducts come close to fuel pipes, particularly in the vicinity of the starboard 7 tank (another addition to Nimrod). The airworthiness requirement for the interaction of the hot air system and the fuel system was defined in Design and Airworthiness Standards within AvP 970 (now extensively amended and published as Def Stan 00-970). The records of the clearance of the original design between the MOD and Hawker Siddley are not all available and the evidence available does not cover proximity of hot air and fuel systems. Thus, the situation is that either the proximity of the hot air system and the fuel system was not recognised or it was recognised and accepted by the MOD as an exception to AvP 970. In either case, the failing happened in the late 1960s. The aircraft then flew in a state where it was not compliant with the airworthiness standards in AvP 970 for many years.
The subsequent introduction of air-to-air refuelling in Nimrod may have increased the peak fuel pressures experienced by the aircraft refuel system.
When the Nimrod MR1 was converted into the Nimrod MR2, the situation was exacerbated when a Secondary Cooling Pack was added in the rear fuselage powered from the cross-feed ducts. This meant that whenever the Secondary Cooling Pack was in use, the Cross-Feed Ducts had to be pressurised by hot air. This extended the period when the fuel system was exposed to air ducts containing hot air. Again, the records of the clearance of the original design between the MOD and the manufacturer are not all available. The conversion of Nimrod MR1 to MR2 was an opportunity to identify the airworthiness issue and resolve it. The aircraft continued to fly in a state where it was not compliant with the airworthiness standards in AvP 970.
Much later, the Nimrod IPT had a safety case produced to document the justification of the airworthiness of Nimrod. During this exercise, a failing of the risk assessment occurred within the Nimrod IPT. This inadequate risk assessment resulted in a missed opportunity to recognise that adequate measures were not in place to cater for the close proximity of the fuel system and the hot air system. The aircraft continued to fly in a state where it was not compliant with the airworthiness standards in Def Stan 00-970.
The accident to XV230 was caused by an explosion resulting from a fuel fire most probably in the area where the fuel system and hot air systems are in close proximity near the 7 tank. There was not enough evidence to either the Board of Inquiry or the Inquest to define precisely where the fuel leaked or the ignition source. Thus, the accident sequence will never be known for certain.
After the accident a number of actions have been taken. Air-to-air refuelling is no longer carried out by Nimrods. The Secondary Cooling Pack is no longer used. The cross-feed system is only pressurised and used for engine start on the ground. The fuel system has an increased 30-day maintenance inspection regime. In addition on scheduled maintenance, there is a fuel system inspection and targeted fuel seal replacement programme under way. There is a plan to replace all hot air ducts as soon as reasonably practicable after they are available.
So where is the Nimrod force now. The immediate actions regarding the use of the hot air system where taken to remove the risks of proximity of hot air system and fuel system in flight. There is a programme to make further improvements. Does that make the Nimrod airworthy? Airworthiness is a risk management process. The aim is to manage the risk to a level that is both tolerable and as low as reasonably practicable. Should time for embodiment of safety enhancements be a factor in “reasonably practicable”? On a military aircraft, should the acceptability of risk be balanced against the potential operational benefit? These are big questions that must be answered as soon as possible. I have opinions as will many other individuals; our opinions are only that! I do not envy Charles Haddon-Cave QC his task.

[VinRouge]

Thats a pretty detailed first post Woodbine. Sure you arent in main building and not in Lossiemouth?

I suppose the main question should be were there concerns about the system expressed by individuals prior to the accident? If so, the MOD should be hung, drwan and quartered if they got round it by justifying "operational risk".:hmm:

[SirPercyWare-Armitag]

TB - you will never reach senior rank with clear, concise and pertinent judgements like that.

[The Real Slim Shady]

Airworthiness is a risk management process. The aim is to manage the risk to a level that is both tolerable and as low as reasonably practicable.

Perhaps a more simple test would answer your unspoken, and unanswered questions: was the airframe and engine combination fit for the purpose for which it was it intended?

Patently not.

Modified and altered from the original Comet airframe and engine combination, additional components added and finally made AAR capable, yet without any apparent stringent examination of potential problems or technical competence.

Years of make do and mend for the RAF may finally have reached their peak: the " press on regardless attitude" of Their Airships, "Of course we can do it" WW2 machismo is not, and has not been, valid for many, many years.

[Tourist]

Some on here are missing an important point.
Whether or not the aircraft meets some definition of safe is unimportant in my view compared to whether not having it flying makes the guys on the ground safer.
They are the ones who are facing by far the biggest risk of death or injury.
If, by flying the Nimrod we accept a higher risk than we would like, but lower their frankly horrendous risk levels, we should do it.
I find it a little uncomfortable that members of the armed forces are unwilling to accept risk of death just down to bloody ALARP or whatever. The soldiers don't get to discuss alarp before they go on patrol, or they would never go. Why should we of the flying fraternity be any different? Half the military aircraft and mission roles in history would never meet the modern definition of safe.
Anyone who calls for the grounding of the fleet whilst we have no replacement needs to take a look at themselves. There are plenty of unsuitable/unsafe a/c types in theatre (SK4 for one) but they are required. If you don't want to fly them then PVR.
I was recently informed that the soldiers death or severe injury chance is currently 11% during their time in sandy places.
Until our risk level hits theirs, then fly the Nimrod.

[Softie]

Basil states:
True if just pooled but, if subjected to the 'wicking' effect of, say, lagging then much more likely to ignite.Even with a wicking effect, there the fuel will spontaneously ignite after a certain elapse time depending on temperature. Over 550C, this time less than a second, at 400C it is several minutes and below 300C it is 10s of minutes.

[JPA-HATER]

I understand the view put forward by Tourist who raises a good point. That said, just because one set of people are operating in a high-risk area does not mean that we should risk others. The Nimrod was placed in theatre to mitigate risk to ground troops. In doing that, the risk to others has increased alarmingly. I am not saying don't operate Nimrods at all, only that taskers should specifically identify the benefit of each mission. We currently operate approximately 18 Nimrods....2 on a good day !!! Should we not start to think about drastically cutting the fleet to say 6-8 aircraft and provide the engineers with the time and resources to keep the airframe in the best of conditions until the MRA4 enters service (and it will enter service). The current state of the MR2 fleet, at present, is a quite simply unfit for mission.

[Biggus]

Tourist,

You quote....'The soldiers don't get to discuss alarp before they go on patrol'...which is correct, but only up to a point. Airman don't get to discuss ALARP before they go flying either, those decisions/actions are taken by MOD/IPT, etc.

As to the MODs/Governments/Armys approach to something akin to ALARP for the troops, well they are doing it!! It is the reason why Bulldogs/Mastiffs (spelling?)/improved body armour/reduction in use of Landrovers, etc have all occurred - to reduce the risk to the troops on the ground. In the same way DAS systems on aircraft have been updated/added/improved, Hercs are now getting foam, etc.

But how many of these risk reduction measures for troops on the ground are directly/partly the result of inquests, press comments, statements by relatives, and even, dare I say it, internet forums!!

[Biggus]

Regarding the investigation by the QC, I thought that it had started in mid Jan and was supposed to take 3 months (finish mid Apr).

Well, according to my calender we are in the back end of May!?

[tucumseh]

Woodbine

There is a programme to make further improvements. Does that make the Nimrod airworthy? Airworthiness is a risk management process. The aim is to manage the risk to a level that is both tolerable and as low as reasonably practicable. Should time for embodiment of safety enhancements be a factor in “reasonably practicable”? On a military aircraft, should the acceptability of risk be balanced against the potential operational benefit?

I have touched on this before and I can offer what I have done when faced with similar situations. The general principle is that you are given a “reasonable time” to comply. Yes, cost and operational benefit are allowable considerations, but there is an overarching Duty of Care. This becomes emotive, as people are asked to place a price on a man’s life. DECs, understandably, don’t like having to justify requirements in this context but it is unavoidable and much effort goes into quantifying the benefits. But there are many scenarios to consider so I’ll just give a few;

a. Complying with new legislation. That is, the aircraft is airworthy/safe/fit for purpose in that it complies with the “standards of the day”. Then new legislation makes it non-compliant. Good examples were the Montreal Protocol (CFCs) and use of Cadmium. Most effort is concentrated on updating standards for future contracts and, if you’re lucky, changing ongoing contracts. Design Authorities were tasked to compile a list of non-compliant kit and a case by case view was taken on what to do. In short, little retrospective action was taken (correctly in my view).

b. Long standing legislation or requirements that have been deemed impossible to implement in aircraft because, typically, there is no engineering solution. Then one comes along and risk mitigation is suddenly viable. A good example is miniaturisation of electronics. What took up a room 50 years ago can be fitted in a matchbox these days. Related to this are limitations imposed by available electrical power. In these cases, you are given a reasonable time (depending on the class of risk of course, which may indicate no action required). A useful tool is to make the modification classification system work for you by applying a classification such as “embody at next major”, thus maintaining operational capability while being seen to comply. Typically, an EP bid would be made in the next planning round > funding approved > development > production etc. It would not be unusual for a “reasonable time” to be some years as the engineering solution may be novel and ground breaking. For litigation purposes, the clock starts running after a “reasonable time” has expired.

c. A genuinely unforeseen event happens resulting in, for example, a Serious Incident Signal. Much the same as b.

d. A design error has been admitted, compounding a known risk. It is belatedly recognised and mitigation commences. This one applies to Nimrod, as far as I can see. Implementation is the same as b. but for litigation purposes the clock started running when the error was made and the MoD’s positioned is weakened by every days delay.


The common denominator here is that each requires immediate access to the relevant Design Authorities or Design Custodians. This does NOT mean having to initiate a contract, which can take many months. It REQUIRES a contract which can be invoked IMMEDIATELY. I don’t just mean by MoD making a phone call, convening meetings and faffing about negotiating a price, but calling up the correct Standards and Specifications in a suitable contract which permits the Design Authority to self task and commit resources in the certain knowledge he will be paid. The relevant Specification (Spec 5) covers just this and sets a financial limit which equates to an amount of man-hours, giving MoD time to get its act together. The SOLE purpose of this contract is to Maintain the Build Standard and I live in hope that the Nimrod accident will somehow prompt MoD to overturn the RAF’s 1991 decision to slash funding and progressively run down this fundamental and mandated airworthiness process. Note – the DA representative with this unique delegated authority to commit MoD funding (assuming the correct contract is in place) is an MoD appointment, of a Company employee. MoD hold the power of God over him/her and can revoke his authority at any time – far more authority to “hire and fire” than MoD has over its own staff. Ironic, given the criminal acts it routinely condones.

[davejb]

Tofo:
Did a 3 engine ferry from Leuchars once, 25 minutes apparently. I always thought it sad when the survival flyoff turned into the survival fast taxy... It was hard to look cool on a Nimrod (imo) but there was something impressive about a whole bunch getting airborne in rapid succession.

As for those who belong to an older, darker age, when clipping on a parachute was akin to sticking an 'I'm a big puff' badge above your brevet....and apologies if I misquote these annual report gems....

'I would not breed from this officer'

and

'His men would follow him anywhere, but only out of a morbid sense of curiosity'.

Dave
(edited to add a missing word)

[JFZ90]

I'm confused as to the status of the aircraft & ALARP at the moment.

Are the "30 recs to get to ALARP" known? If the only outstanding ones relate to AAR (which I've read somewhere), then as if the aircraft doesn't do AAR then it would then be ALARP and can continue safe operation - is this the thrust of the MoD position relating to continued operations?

If this is not the case, what are the outstanding ones, and what is their impact on the safety of current operations? Are they really "ALARP" issues in the true sense?

[tucumseh]

JFZ90

The important point is that the "30 requirements" cited by MoD relate, I believe, to one part of the problem. QinetiQ could just have easily added a 31st - "Comply with all our previous recommendations in the following reports.......". And if certain people in MoD had seen it, they would have said "As advised to 2 and 4 Stars yonks ago".

Most of the 30 relate to airworthiness process implementation and are therefore generic (not specific to Nimrod). In a previous post I cited a further raft of recommendations relating to the Nimrod Fuel System - listed under 3 headings each of which are fundamental airworthiness components. This report References previous reports covering the same subject (including reference to another aircraft - VC10) which presumably contain more recommendations. It is these which I understand have not been released under FoI, inferring they are even more damning (which, I admit, is hard to imagine, but then I would have said that about the 2006 report before I read it).

[Mick Smith]

Only six of them relate to AAR and as you say those six are not really important any more. The other 24 all relate to other elements of the fuel system and I think Tuc pointed out that all but one of the 30 relate to a failure to implement mandated airworthiness regulations. I can't tell you whether the one that isnt is AAR related or not but I'm sure he could.

[Posted while Tuc was making his post!]

[airsound]

Thanks for the kind words, folks

This thread is moving on at such a pace it’s a bit hard to keep up. But before we leave the inquest altogether, there is something else I would like to share from my days there. It’s actually the second time this has happened to me this year.

There’s a word that’s much overused by politicians and celebs, and when they use it, they usually mean exactly the opposite. But in this case, it’s the only appropriate word. I felt totally humbled by the courage, dignity and strength of the families.

As with the Hercules inquest at Trowbridge, I watched in awe as the Nimrod families coped with everything that was thrown at them. I noted their tears after they had heard the audio recording from the mission tape, their utter derision at some of the less impressive witnesses, their steely determination to get at any truths that might have slipped past the coroner, and also, of course, their humour - aided by the fine, understated sense of humour of the coroner himself. There was even laughter after the verdict.

Two events in particular stay in my mind. One was just before the verdict was announced. One by one, the family members laid big, long-stemmed roses on the steps of the courthouse, the Old Oxford Assizes - one red rose for each of the 14 men who died, and one white rose for each of the 18 children now fatherless. It was..... well, it was deeply touching.

But perhaps best of all was the day before the verdict, when counsel were making their final submissions. There had been divided opinions amongst those who know about these things as to whether Mr Walker was going to go for an ‘unlawful killing’ verdict. But the families let it be known, through their barrister Michael Rawlinson, that they did not want any individuals punished, and they especially did not want ‘unlawful killing’. They did, however, want it to be made loud and clear that there had been, and still were, deep systemic failings in the RAF and MoD system. I would like to think that their gracious but just plea figured highly in the coroner’s deliberations.

It was a privilege to be associated with those families, however peripherally. They made me proud to be British.

airsound

[Tourist]

Biggus.
My point exactly. The new kit has been arriving for the troops, but they certainly did not leave the country whilst waiting for it to arrive, and it is not as if they would have been leaving others in the lurch if they had.
Don't get me wrong, I would be first in line for firing party duties if the cretins who have got Nimrod and the like into the current parlous state ever stand trial, I just think grounding the fleet is a very short sighted view.

[Laboratoryqueen]

As one of the many who sat through the entire three weeks, heard many painful things and cried many tears but also had a few laughs.

Mr Walker came by his verdict not because of his own personal views or because he's a wannabe engineer but based solely on the comments of witnesses and the full evidence presented before him. The respect he showed to all of us families was clear.

To have anyone state that a payout is important in this is deeply wrong, the important factors here is that we finally learnt what happened to our boys, no matter how hurtful that was to hear and to view, we know without doubt and so do others that they died in the most professional manner and I, as well as every single family member, is extremely proud of them and to have hope that this may be prevented from happening again. My wish, my hope, is that all those who work on and those who fly on the Nimrod can do so without fear and with the knowledge that everything which can be done to ensure their safety is being done.

From my family to the 13 others, our thoughts, love and wishes remain always with you.

From me to TD, :ok:

[davejb]

Tourist,
with respect - supporting the other servicemen in theatre is going to be very dear to all other servicemen, including Nimrod aircrew.
The problem is that the government repeatedly (and I am not referring solely to the current incumbents) absolutely rely on this sense of duty while they callously skimp on the resources provided to the MOD to carry out the policies they themselves have dictated. Now, finally, in the 21st century, it is becoming more common to haul the politicians who make these crass decisions over the coals instead of simply covering up needless casualty figures.

Stop for one tiny moment and ponder what the MOD could do with the money used to prop up Nothern Rock - a bank that should have collapsed due to gross mismanagement, having followed a policy that an O level economics student would have considered unsustainable...why? Well, turn the cash over, regardless of risk, because the turnover dictates your bonus size. That the government can spare whatever it takes to provide N Rock with a lifeboat, whilst fighting wars in two countries on sub-peacetime budget levels, is a scathing indictment of our political leadership.

It does nobody, ESPECIALLY those on the ground in Afghanistan, any favours to prop up a mismanaged system - the ground troops would be infinitely better supported if the government provided ALL in theatre forces with the level of support they provide as a matter of course to greedy financial mismanagers. The big difference is that the banks carry more weight in discussions than soldiers lives.

The aim here is really to make the government provide the cash needed to produce whatever the troops need - 'candoitis' is playing right into the hands of those who we have entrusted to do better, but would rather cement votes from the city.

[JessTheDog]

Some on here are missing an important point.
Whether or not the aircraft meets some definition of safe is unimportant in my view compared to whether not having it flying makes the guys on the ground safer.
They are the ones who are facing by far the biggest risk of death or injury.
If, by flying the Nimrod we accept a higher risk than we would like, but lower their frankly horrendous risk levels, we should do it.


A reasonable and understandable point - I doubt if anyone in light blue uniform would shirk from supporting their dark green comrades. However, the argument misses an important point itself:

The Nimrods are supporting ground troops because their resourcing and mission require this. There are not enough troops and, as usual, the UK is picking up the tab and getting sucked into Enduring Freedom (certainly is enduring - seems like a long time ago since I heard the op name!). The question is not as simple as "we are where we are, we need the Nimrod". This is a coalition operation, why is the Nimrod the only solution? Most of us armchair commentators think that the Afghanistan situation is irrecoverable, certainly with the limited numbers of troops in theatre. Why throw more lives onto the bonfire? That argument stands for the soldiers as much as for the aircrew and we all share the anger about equipment shortages that have led to deaths amongst soldiers. Resource the operation properly, get coalition and alliance partner support, or get the hell out. This is not 1940 and Dunkirk.

[nigegilb]

Wouldn't normally quote The Sun, but what the hell,

Blood on Government's hands

By TOM NEWTON DUNN
Defence Editor





THE Government has the blood of 14 servicemen on its hands this morning.
Yesterday’s kicking over ageing Nimrod spy planes from campaigning coroner Andrew Walker was no surprise to top brass.
Privately, they told me weeks ago it was coming. They know how many corners have been cut in aircraft funding over the past ten years. It is a national embarrassment that airmen should fly a 1960s plane in today’s wars.
But that’s all the once-proud RAF can afford. As Chancellor for a decade, Gordon Brown is responsible.
It would have cost a few hundred thousand to fit fire extinguishers on doomed jet XV230.
Yesterday a senior air marshall insisted the Nimrod fleet is safe. They have to say that – because the truth is that entire offensives could be lost without them.
Yet again this morning, our incredibly brave crews will take to the skies despite the risks.
So, Mr Brown – how many heroes must die before you pay for the wars you want to fight?

[Oldlae]

It is obvious to me that the Nimrod has to be kept flying as top cover and the apparent steps taken, no AAR and making the SCP redundant, should make the aircraft that much safer to operate even ALARP. But no AAR must severely restrict operations in the war zones, as sorties must be that much shorter than ideal and we must use more aircraft to provide the necessary cover which is quite possibly unobtainable, thus making our gallant troops more vulnerable.
JessTD mentioned the lack of available troops, I saw a post which said the we had 22,500 troops in Germany, surely 90% of these could be released from NATO duties in this day and age and utilised wherever they are more needed, when I served in Germany it was the Cold War, but I do not think that we should maintain such high levels of troops in 2008.
I saw one post that suggested that the army could not operate if their risk on patrol was ALARP, but they would not expect that their most dangerous risk would come from their Land Rover et al.

[Laboratoryqueen]

From the evidence given in court with regards to the FRS couplings, they were never designed to be used in a system which allowed the seals to come in contact for periods of time with air. They were only designed with the assumption they would be used in a constant fuel supply system. In only five days of contact with air the seals begin to degrade and will be more prone to leaks. This fact is one of the main factors in the process of them not being safe.

The fact that Hickmann stated one of the tests on if there were leaks was to blow air through the pipes and listen for a whistle caused a great deal of concern, as this would aid degredation of the seal, seemed to be totally lost on him. His arrogance was an insult. While I still hold my view of respect to the ground and air crews of the Nimrod fleet, I also hold my view of him.

It's not just the SCP pipe or the engine cross feed, it's not just AAR being a factor, it's more now to do with the FRS couplings being used in areas which do not have constant fuel submersion.

[EdSet100]

We shouldn't get too worked up about the seals drying out. The same seals are used throughout the aviation industry and the Nimrod is certainly not the only aircraft that goes into a hanger for weeks on end and dries out the seals. However, it is the post dry-period test that is crucial. The company recommends that the seals are ground-tested to normal working system pressure when re-wetted. Coroner suggested that a test to max working pressure would be better. Company engineer agreed. Nimrod is currently tested to 50psi, although spikes up 90 psi during AAR have been observed. But we do not do AAR now, so we are OK.

Also, for those interested in pressure spikes: the seal company has no problems with spikes up to 120 psi. None has been witnessed at that pressure, so that issue is now irrelevant.

Temperature profile limits given by the company: -45C to +70C. Seal and pipe have similar co-efficient of thermal expansion. So, temp limits are not exceeded, unless an adjacent hot air pipe leaks onto it or warms it up due to radiation. Possible scenario pre-Sep 06. Not possible now.

Fuel pipes must align within one degree of each other for the coupling to guarantee no leakage. hmmm

As TD pointed out, to the seal company's chief engineer, the only difference in the use of the seals between Nimrod and the rest of the customers is that we do AAR. However, it is/was carried out within the temp and pressure limits set by the company.

The seal company has decided, as a result of the accident, to change the life of their seals from unlimited (with 5 years inspection) to 25 years, with 5 years inspection. This forces the airline industry to change seals as well. Before the accident the company had not received any significant reports of seal failure on the unlimited life policy, so the change of life policy might not be soundly based. Obviously this policy change means that 300 seals on most Nimrods will have to be changed.

Changing 300 seals on a Nimrod will create more leaks. This is why we, and other operators have a corrective maintenance policy. It is inherent in this policy that we accept that occasional leaks might occur (though seal company says that they will not leak). However, it is a fact that in the long term there will be less leaks than those that will ocur if the system is disturbed under a replacement policy, due to human factors. Therefore, due to the inherent expectation of fuel leaks it is vital that the fuel system is not co-located with ignition sources, such as hot pipes, outside fire zones. This has now been satisfied.

300 seal changes per aircraft....this is going to cause us more problems. I guess the VC10 (more than 25 years old) is in the same can of worms.

The first Nimrod to have all its seals changed will leak on test. Those leaks will be identified and cured. Then, the first flight (post major air test?) will suffer leaks due to flexing and, despite a safe flight and landing, that will be the last flight of the Nimrod fleet. All under the guise of working towards ALARP. This is a complete mess.

Ed

[OilCan]

Nige, tuc, labqueen and others, thank you for your informed replies, I think I’m beginning to understand the concerns a little better.

However, as I do have fairly intimate knowledge of the systems I’d like a little more specifics if possible. Which pipes are misaligned? Which couplings can’t be checked? Where are the remaining hot/electrical sources? Which FRS couplings do not have constant fuel submersion? Are there any Nimrod specifics in the QQ report other than policy and generic issues?

Also, I note that the Coroner challenged the BoI version of the fuel leak source. Is he therefore discounting the AAR as a red herring and merely coincidental to another problem in the fuel feed gallery? :confused:

Neppie
The Mk1 did have an APU. The Aircrew Bk1 used to state “An APU is provided for starting engines when away from base or if there is no external air source available”

I believe in those early days there was an abundance of small, man portable (ish) air start trolleys around and they were perceived as the normal method of starting. Didn’t last long! – or - of course, your APU could have been U/s.
As for starting engines in the taxi – possible & probable - with the early converted ex ‘Shac’ crews and before the proper establishment of ‘standards’. :=

[Winco]

Woodbine

You have really confused me with your posting. You appear to be quite knowledgeable about the Nimrod, yet you make such a blatant and stupid statement about the APU. How did you manage that?
You know all about future programs and intricate details, yet the simplest of things, like the APU, you get 100% wrong!

How strange also, that such an 'expert' is at Lossie, and not ISK??

I just wonder who you really are??

[Laboratoryqueen]

However, as I do have fairly intimate knowledge of the systems I’d like a little more specifics if possible. Which pipes are misaligned? Which couplings can’t be checked? Where are the remaining hot/electrical sources? Which FRS couplings do not have constant fuel submersion? Are there any Nimrod specifics in the QQ report other than policy and generic issues?

Also, I note that the Coroner challenged the BoI version of the fuel leak source. Is he therefore discounting the AAR as a red herring and merely coincidental to another problem in the fuel feed gallery?

It was not specified which pipes are misaligned, rather stated that Eaton would list misalignment of pipes as being a most probable cause of leaks and that on checks two pipes had been found misaligned. Taking into account the magnitude of pipes involved, I'd say that was a very low number.

The FRS couplings which do not have a constant fuel submersion are in the vent system and the AAR system. The AAR system is not used now so to a point may be ruled out, unless it comes back into play. There are FRS couplings in the feed system, which again isn't a constant submersion.

Yes the Coroner challenged the BoI version of events, that is his job to do so. He is required to take any possible cause and to investigate with the intention of acceptance or to disregard. He praised the BoI on their findings but he must not simply accept what is presented to him, he has to challenge every angle on every aspect.

[On_The_Top_Bunk]

In my Lightning days we had big problems with FRS couplings going through hot areas. (No fire suppressant aft of the Turbines)

Every time we disturbed the fuel system the couplings were X-rayed to check for alignment and the image was clipped to the paperwork.

Any Nimrod techies confirm if this is the case at ISK?

[Da4orce]

Oilcan

Also, I note that the Coroner challenged the BoI version of the fuel leak source. Is he therefore discounting the AAR as a red herring and merely coincidental to another problem in the fuel feed gallery?

My recollection is that the Coroner believed on the evidence presented to him that the fuel leak occurred in the fuel feed system forward of dry bay 7 and tracked back to dry bay 7 where it came into contact with the heat source.

Anyone who has the transcript of his verdict please correct me if I am mistaken.

On The Top Bunker

Every time we disturbed the fuel system the couplings were X-rayed to check for alignment and the image was clipped to the paperwork.

Any Nimrod techies confirm if this is the case at ISK?

Group Captain Hickman described the maintenance procedure in court, the alignment is done by eye. The manufacturer said that it was almost impossible to achieve the degree of alignment required to prevent leaks using naked eye alignment.

[Winco]

Woodbine,

Forgive my misunderstanding here, I am sorry. MY comments should have been addressed to Nep Rex, I do apologise.

[Mad_Mark]

Da4orce ,
Anyone who has the transcript of his verdict please correct me if I am mistaken.
From the copy of the verdict posted by TD...

The fourteen members of crew and passengers of the XV 230 Nimrod mark 2 aircraft which left from an operational base to fly a mission into Afghanistan on the 2nd September 2006 at 9 13 were lost when shortly after air to air refuelling when fuel from a fuel leak, most likely from a fuel feed pipe, was ignited by a hot duct within or closely associated with dry bay 7 on the starboard side of the aircraft.

MadMark!!! :mad:

[Da4orce]

Thanks Mark. I believe that the Coroner actually went into more detail earlier in his summing up, he also made mention of a similar incident on XV230 just 2 weeks earlier. I will endeavour to find the full transcript of his summing up.

[Ray Dahvectac]

The MK1 and MK2 used an APU as the primary method of starting engines.

This whole APU argument is a red herring in this thread, and to treat it as a points-scoring or name-calling exercise it is even less worthy, but the APU in the MR1 (and, IIRC, THE MR2 also) did not provide a reliable method of starting an engine. The much preferred method was to use the GPU electrical output or a Palouste (if a serviceable one cold be found) to provide an air start.

The APU was very much a last resort and, from memory, often unsuccessful.

(No, I am not a pilot/flight engineer either but we were all on Crew intercom at that point.)

[Dave Angel]

This whole APU argument is a red herring in this thread, and to treat it as a points-scoring or name-calling exercise it is even less worthy, but the APU in the MR1 (and, IIRC, THE MR2 also) did not provide a reliable method of starting an engine. The much preferred method was to use the GPU electrical output or a Palouste (if a serviceable one cold be found) to provide an air start.

The APU was very much a last resort and, from memory, often unsuccessful.

(No, I am not a pilot/flight engineer either but we were all on Crew intercom at that point.)

No Ray, The APU is started using the GPU electrical input, then one engine (usually No3) is started using the APU. Once this engine is stable the APU is switched off and the running engine is used to start the remaining engines.
I can't speak for MR1 but that has been the case on the MR2 since I joined the fleet nearly 20 years ago.

Regards,
DA.

[On_The_Top_Bunk]

Oilcan

On The Top Bunker

Group Captain Hickman described the maintenance procedure in court, the alignment is done by eye. The manufacturer said that it was almost impossible to achieve the degree of alignment required to prevent leaks using naked eye alignment.

I would have thought that the X-Ray procedures we were using up to 1988 at Binbrook on FRS couplings would have been the same across all aircraft types.
Especially as it involves routing pipes through "hot" areas with a similar risk level due to lack of extinguishant.

[Duncan D'Sorderlee]

Ray,

I agree with your sentiment regarding the APU as a red herring - other than using the same pipework.

You state above 'THE MR2' when suggesting that a LPAS was the preferred method of start. Unless you are talking about a very long time ago (os a specific ac) then, I'm afraid that you are incorrect; the preferred method of engine start is APU, then No3 from the APU, then the rest using bleed air from No3 at 75% HPRPM. The LPAS is only used if the APU is u/s.

Duncs:ok:

[Mick Smith]

As Lab Queen points out, the coroner certainly did not criticise the board of inquiry. He in fact commended the board for finding the design fault, the co-location of hot air pipes and fuel pipes in the No7 tank dry bay with no fire detection or suppression system present.

That said, one of the possible causes of the leaking fuel put forward by the board of inquiry, the idea that fuel blowing off from the No 1 tank travelled along the side of the aircraft and into the No 7 tank dry bay, was disproved by the evidence to the inquest. BAE Systems experts showed conclusively that this could not have happened.

But anyone who has read the board’s report will know that this was only one of two possibilities it put forward for the source of the fuel that led to the fire, albeit what it saw as the most likely. The other, a leak from fuel pipes inside the aircraft, was assessed by the experts as the most likely source which is why the misalignment and seals issues have been raised.

One thing the coroner did say with regard to the board of inquiry was that there ought to be an independent inquiry system, not because the BoI in this case did anything wrong. But it was clear that in practice if not in theory there were limitations on what it could do, particularly when relying for some of its evidence on the IPT. Just one example: as Tuc has pointed out a number of times, the QinetiQ report on the wing tank leaks was not read by the BoI because the wing tank leaks were irrelevant to the XV230 incident. But the report actually looked much wider than the wing tanks and in particular noted that some leaks inside the aircraft were not being followed up because they could not be replicated on the ground.

When the fuel leak occurred inside the bomb bay of another Nimrod last November and it made an emergency landing at Kandahar, Glenn Torpy said that the fleet was grounded because the leak could not be replicated on the ground. He looked very surprised when I pointed out that this was precisely what QinetiQ had said of previous leaks in its 2006 report. Why was he of all people not briefed on this before he faced the press.

As for the ALARP issue, which is the reason the coroner called for the fleet to be grounded, EdSet said:

If Gp Capt Hickman, as the Delegated Airworthiness Authority, has stated that the Nimrod currently IS NOT ALARP, we are in trouble. I wasn't there to hear his words on oath, but if he used those words, or similar, he is contradicting virtually everyone (from SoS down to NLS liney) involved with the aircraft. Given his appointment, there should be no way that he would be contradicted by his superiors. I believe he has been mis-represented here.


Not misrepresented and certainly not contradicting SoS, who wrote to Angus Robertson, MP for Kinloss and deputy chairman of the all-party RAF group, last week to say:

During defence questions in the House on 28 April 2008 I undertook to write to you about a QinetiQ safety report concerning the RAF’s Nimrod aircraft. You asked how many of the 30 recommendations made in the report had been complied with (Official Report: Column 4)

You did not specify which QinetiQ report you were referring to but I believe it to be the Nimrod Fuel System Safety Review Report dated October 2007 which was recently released under the Freedom of Information Act. This report is an interim report and is part of a more comprehensive safety review of the Nimrod Fuel System being carried out by the Department in accordance with recommendation four of the Board of Inquiry Report into the loss of Nimrod XV230.

Of the 30 recommendations contained in the QinetiQ report: 21 have been accepted and are being implemented; 3 are being considered for implementation and a further 6 are on hold as they relate to Air-to-Air Refuelling. Following the leak incident on Nimrod XV235 on 5 November 2007, all Air-to-Air Refuelling on the Nimrod fleet was suspended. This suspension remains in force.


(my italics)

[airsound]

Da4orce, you say
I believe that the Coroner actually went into more detail earlier in his summing up, he also made mention of a similar incident on XV230 just 2 weeks earlier.
I do have contemporaneous notes of this, but at some stages in his very lengthy narrative verdict, Mr Walker was going through his stuff at a great rate of knots, and in considerable detail. I’m afraid my record-keeping was not always up to snuff! However, here’s what I think happened.

The coroner said he believed the fire came from fuel leaks. He said there was no evidence to support the BoI theory of fuel from a blow-off getting into dry bay 7. He referred to the video, that we all saw many times, of a big fuel leak (on the ground) which could pass into dry bay 7. But it was clear that such leaks, which may occur when airborne, are not always able to be reproduced on the ground.

He did indeed mention that XV230 had had a transient leak two weeks before the crash, and could have been lost then.

So he believes that the fuel for the fire came from leaks in couplings. He accepted evidence that refuel/defuel system leaks came from misaligned couplings rather than seal failure.

Over the last two or three days of the inquest, he had been pursuing a theory that the fatal leaks may have occurred within No 3 engine. This idea came about because there should, in theory, have been no pressure left in the refuel/defuel system to produce enough fuel to sustain the fire. But fuel in the high pressure system of the engine would be at 1200psi, and any leak there would supply more than enough fuel to sustain the fire.

The coroner commended Mick Bell, who was representing himself over the death of his brother, FS Gerard Bell, for his work on this aspect in particular. That research had shown that an engine could lose as much as 15 gallons a minute without a loss of power of more than 7%, and other research showed that this fuel could indeed have migrated into dry bay 7 via the airflow on the underside of the wing.

Despite his dismissal of the BoI finding on the blow-off theory, the coroner did, as Laboratoryqueen and Mick Smith say, go out of his way to commend the BoI team.

For anyone who has not yet discovered it, Mick Smith has another coruscating and scathing article in today’s Sunday Times, which should be mandatory reading for all concerned.

http://www.timesonline.co.uk/tol/news/politics/article3998966.ece


airsound

[JFZ90]

the idea that fuel blowing off from the No 1 tank travelled along the side of the aircraft and into the No 7 tank dry bay, was disproved by the evidence to the inquest. BAE Systems experts showed conclusively that this could not have happened.

Interesting. How did they show this? This then puts more focus on leaks, though as I think has been said leaks will always be impossible to entirely remove so you must have a design that can tolerant some degree of leakage (mtn errors, battle damage etc.). Anecdotes suggest the old Lightning design was very unforgiving in this respect.

Ed

300 seal changes per aircraft....this is going to cause us more problems. I guess the VC10 (more than 25 years old) is in the same can of worms.

The first Nimrod to have all its seals changed will leak on test. Those leaks will be identified and cured. Then, the first flight (post major air test?) will suffer leaks due to flexing and, despite a safe flight and landing, that will be the last flight of the Nimrod fleet. All under the guise of working towards ALARP. This is a complete mess.

A mess it certainly it is. I think your choice of the word guise is telling. Its all too political now though isn't it - the seals must be seen to be changed, irrespective of a balanced risk assessment of the impact of such a decision.

Having said that, did the seals really have no lifing data prior to this incident? Is the science behind their degradation known, or is the 25yrs limit just a liability limiting exercise be the OEM as it is infact unknown?

[nigegilb]

From Mick's article and this is for Ed Sett,

Group Captain Colin Hickman, who is in charge of the safety of the Nimrod fleet, admitted to the coroner that the remaining Nimrods were not Alarp and would not be so until the end of this year. Asked if this process could be speeded up, Hickman replied: “No, it is driven by resources.”

Once again this Fleet cannot be described as airworthy. If anyone get's info on life assurance validity please post it here and send a copy to Des Browne.

"Oh my goodness! A secretary of state has misled us. Shock horror. Seriously, is there anyone in this nation who would not prefer to believe the word of a coroner than that of a politician - especially a minister?"

Well aside from a fair few people here.....

[Laboratoryqueen]

The issue of ALARP does raise concern, and as others who have been posting on here who were there to hear the statement made by Group Captain Hickman, he stated the fleet is not ALARP at present, the situation is being managed by offline conversations between the IPT and BAe and the aim is to have a standard of ALARP by the end of this year. When asked if the resources would be made available to perform this, bearing in mind the fleet is at the end of it's service life, he stated that yes it would be done.

He stated that while the fleet is not ALARP it is still airworthy and it is still safe to fly as they are working towards that standard.

The coroner then asked some aircrew who were in attendance how that knowledge made them feel, which produced a wry laugh.

I am still somewhat confused as to how one previous IPTL can state the fleet is not airworthy and never has been and yet a different claims it is.

I do very much agree with the coroners view that those who are the "managers of people" know nothing of what is really going on, those who should be talked to and whose opinions are the most important are those on the "coalface".

[JFZ90]

Labqueen - I agree the situation has become very confused.

I think it would help to understand what the remaining issues to get to "ALARP" are, then perhaps we could grasp what risks are being taken until the end of the year.

Until that happens I think it will be impossible for anyone to accept this statement:

while the fleet is not ALARP it is still airworthy and it is still safe to fly as they are working towards that standard.

though as Tuc has posted this is not necessarily inconsistent with normal practice.

Did the coroner ask what these outstanding issues/measure were?

[tucumseh]

He stated that while the fleet is not ALARP it is still airworthy and it is still safe to fly as they are working towards that standard.

The way I see it is that those who say the aircraft is NOT airworthy can DEMONSTRATE it is not by comparing and applying expert opinion and known facts to the REGULATIONS.

Those who opine it IS airworthy CANNOT demonstrate it, and have arrogantly ignored both the experts (whom they pay for) and their own MANDATED regulations (which they clearly have never read or don’t understand).

As it is extremely difficult to demonstrate airworthiness in finite terms (especially when the records show that the funding necessary to maintain the necessary evidence has been slashed and the whole process is regarded as optional) then it is a very foolish man who asks the experts and then ignores them. (The regs also require the reason why independent advice is ignored to be recorded in the Safety Case, which I’m sure is being duly amended as I type).:rolleyes: I’m sure Mr Walker recognised this and, while the rules prevent him making public all his thoughts I assume the QC’s Review will be informed. One then has to hope that is not tainted by MoD interference.


I’ve read all this before – on the Mull thread.

[KeepItTidy]

Have to agree with the Old Fat One there

The APU is very reliable and rarely fails.

I think its made by Rover , if thats the case then why does it not rust :E

[Mick Smith]

Just as the rest of us were moving towards some sort of unanimity, the APU comes in from left field to spark a bit of controversy. I'm not sure what the relevance is to be honest Old Fat One. The APU issue went right across the top of my radar and I think, although I might be wrong, that the first time I had heard of the term was this morning on this thread. Certainly it has not been a part of any of my reporting on the issue so I am prepared to believe it is indeed a red herring and as for the accuracy of those posting on it, I am not in a position to judge. You can keep me out of that debate TVM!

[tucumseh]

Earlier, I said that 29 of the 30 recommendations in the QQ report of October 2007 referred directly to airworthiness regulations. The one I hedged about was the Master Minimum Equipment List (MMEL).

The precise wording of the recommendation is “Consideration should be given to the introduction of a Master Minimum Equipment List”.

The reason I hesitated was because, clearly, an MMEL is mandated as it “relates to the fundamental airworthiness of the air vehicle” (JSP553). However, it is a manufacturer’s document for an aircraft type (Nimrod in this case, perhaps traceable back to Comet – I don’t know enough history) and I assumed BAeS have one. The aircraft operator (MoD) may choose to have a Minimum Equipment List (specific to aircraft and operating environment) but it must not contradict the MMEL and the Safety Case must demonstrate traceability. Again I hesitated because I’m unsure what’s in the Nimrod MR2 or R1 Aircrew Manuals.

If taken literally, the QQ report infers an MMEL doesn’t exist, meaning all 30 recommendations refer directly to airworthiness. Also, given the aircraft’s operating environment would seem to have changed recently (not much use for Sonics over AFG) it follows that the MEL would have been at least re-assessed. Anyway, thought I’d just clarify this.


Much is made of the 6 recommendations relating to AAR, and MoD deeming implementation unnecessary. However, of these 6, I consider 4 to be generic problems relating to application of airworthiness regs. (That sounds rather grand – I’m not an authority, just my opinion). For example, 3 relate to the failure to apply the principles of “System of Systems” integration, where each system is “safe” in isolation, but not when integrated. Put another way, physical safety is addressed in isolation but not functional safety. Two of the recommendations say;


Additional activities should be undertaken to better understand the behaviour and operation of the Nimrod / Tri-Star and Nimrod / VC10 mated system, and,
Hazard identification, assessment and management activities should be undertaken once the behaviour and operation of the mated systems is more clearly understood.
Do I need to spell this out? It’s absolutely appalling. Importantly, you have to view this also as “Tri-Star / VC10 plus any aircraft it mates with”. If the Nimrod (team) has not complied then it rather follows, as core stakeholders, neither have Tri-Star or VC10. I apologise to the both if I am wrong and they have banged on about this to Nimrod every day for the last umpteen years. This is really basic engineering stuff and bottomed out at Design Reviews, Functional Configuration Audits etc before they ever come near each other. And if a high profile aircraft like Nimrod can omit the basics, then if I were SoS I’d be demanding a review of these recommendations as they applied across the MoD.

The inference is that CA Release and Release to Service were granted without fully understanding the behaviour of (a) an aircraft laden with fuel pumping it out at high pressure and (b) and aircraft it was physically integrated with which was known to disgorge said fuel at a rate of knots through leaking fuel lines. Am I being unfair?

[Laboratoryqueen]

JFZ90

The coroner did not ask outright what issues where outstanding, instead he questioned the fact that QinetiQ had produced a report which stated the FRS couplings were cause for concern due to the fact of degradation in the seal and that when not held in a constant fuel supply they would be more prone to leaks. They advised tests be completed on the seals and an inspection performed more often than which is in place and that the tests performed at present are not suitable.

Group Captain Hickman said he did not agree with that report and so had disregarded it, instead he was taking advice from BAe. The manufacturer of the couplings, Eaton Aerospace, also stated the couplings were not suitable for some of the systems in which they are in place and that they are not designed for systems which do not have constant fuel submersion, he was concerned at the fact they are being used in this way, again Hickman said he disagreed with this and instead of taking advice from the couplings manufacturer he would discuss with BAe.

[Da4orce]

Surely the question of why the Nimrod is not airworthy is one that should be answered by Grp Captain Hickman and his superiors as it is Hickman who by implication of saying that they are not ALARP is saying that they are not airworthy.


(BBC) The Politics Show Scotland - 25/05/2008 (go to 43.55 min into the programme)

http://www.bbc.co.uk/iplayer/page/item/b00bxlqq.shtml?filter=category%3AletterP&scope=iplayercategories&start=1&version_pid=b00bxl3m

BBC Online - Nimrod crew 'leaving over safety' - http://news.bbc.co.uk/1/hi/scotland/north_east/7419096.stm

[Mick Smith]

I should add one thing to my previous post on Des Browne admitting that the QQ recommendations to make the risk to the MR2 ALARP are still being implemented.

When EdSet said Hickman was contradicting Browne, he of course meant Browne's claim in December that QQ had designated the aircraft safe.

In fact both Hickman and Browne are, quite bizarrely in the latter case, contradicting that claim. Given that Browne's admission came in a letter to the SNP leader in the Commons, perhaps the Scottish Secretary was simply contradicting the Defence Secretary!

[mary_hinge]

Additional activities should be undertaken to better understand the behaviour and operation of the Nimrod / Tri-Star and Nimrod / VC10 mated system, and,
Hazard identification, assessment and management activities should be undertaken once the behaviour and operation of the mated systems is more clearly understood. Do I need to spell this out? It’s absolutely appalling. Importantly, you have to view this also as “Tri-Star / VC10 plus any aircraft it mates with”.

The "mated system," does this relate to the 2 aircraft types when AAR taking place or is it the modified systems within each airframe type?

[Da4orce]

The MoD said it would not comment, but in a statement, Air Marshal Sir Barry Thornton, the RAF's most senior engineer, said: "We have stopped air-to-air refuelling and no longer use the very hot air systems in flight.

"This eradicates any dangers from the serious design failures noted by the coroner that have been present in this aircraft since the 1980s.

"These measures have been supplemented with enhanced aircraft maintenance and inspection procedures to ensure the aircraft, as it is today, is safe to fly."
He added: "We would not ask our personnel to fly in aircraft we did not believe were safe."


Can anyone confirm or deny the suggestion that Air Marshal Sir Barry Thornton was in fact the first head of the Nimrod IPT?

If correct he clearly has a slight conflict of interest in this situation as it could be argued that he forms a long line of senior RAF staff that missed the serious design flaw within the Nimrod!

[airsound]

Mick and The Old Fat One

Before we leave the APU issue altogether, I've consulted my notes of the coroner's words on Friday. I find that, even if some ex Nimrod crew don't seem to be able to remember how it all worked, the coroner was perfectly clear.

He said that No 3 engine was started using the APU in the tail, which provided air via 4-way ducts to the engine's air-start mechanism. The APU was then shut down, and No 4 engine started using another air connection from the No 3 engine. I and 2 were then started using air from 3 via the crossfeed duct.

airsound

[Softie]

DaForce

AM Thornton was first IPTL for the Nimrod MRA4 in DPA under "Smart" (sic) Procurement. See biog at http://192.5.30.122/ptc/index.html. (http://192.5.30.122/ptc/index.html)

[Da4orce]

Thank you Softie (I understood it was MR2 IPT but I was mistaken).

His wife is a barrister, interesting!

[Softie]

Daforce
You also see from the biog that he was also DG Equipment Support (Air)/DG Logistics (Strike) from 2003, the 2* with oversight of all IPTs at Wyton.

[tucumseh]

DaForce

It would appear he was the first IPTL of the RMPA/MRA4 IPT, appointed in 1999. Not responsible for in-service Nimrods, but a stakeholder (as the input to his contract was the MR2 fleet) and therefore had a vested interest in (and a requirement to have a finger on the pulse of) the airworthiness of the aircraft his team had to modify. Put another way, he would have a Service Level Agreement in place between his IPT and the Support IPT (at Wyton) whereby the latter agreed to provide xx serviceable and airworthy aircraft at yy build standard, and would have staff to continually monitor this at it would almost certainly be one of his top risks. (As the agreed build standard would be enshrined in his contract with BAeS, and any deviation would mean programme slippage and extra cost). I believe this to accurate but please correct me anyone if I'm wrong.

I should add that, at the time, it was a standing risk in any such modification programme that you would be poorly served by such SLAs as senior management in DPA did not enforce them. That is, DLO (and AML and AMSO before them) could, and often did, ignore them, leaving DPA in the clag. As I said, DPA management were entirely comfortable with this - a prime example of the "lack of management oversight" they were accused of on the Chinook Mk3 debacle (same 2 Star BTW). This was one of the many drawbacks when support was split from MoD(PE) as dependencies increased over which the PM had no control. This has been corrected (again) by the formation of DE&S and the creation (again) of a single Nimrod office. See here for a wider discussion of the problems;

http://www.publications.parliament.uk/pa/cm199899/cmselect/cmpubacc/300/30005.htm



Mary - "mated" in the context of the two aircraft, although the principle applies equally to AAR modification integrated into the aircraft.

[Tappers Dad]

I would just like to thank all those PRuNers who have helped me collect information over the last year.

A special thanks goes out to tucumseh and his expert knowledge of the regulations on Airworthiness of Military Aircraft. I only wish you could have been there but I know why you couldn't.

It will be left to Politicians or Nimrod Aircrew's now to take forward the fight.
I can only hope that Charles Hadden-Cave QC having had two of his staff there throughout the Inquest will come to the same conclusion . And those responsible are found.

Thank you all :D

[nonemmet]

When a civilian Aircraft Captain signs the tech log, he takes responsibility for the safety of the aircraft and crew (amongst other things).

If the a Nimrod Captain takes similar responsibilities on signing the military equivalent of the tech log, how does he do this in the knowledge that the aircraft is not safe to fly (not ALARP) ?

[TheSmiter]

TD - permit me to give you a starter for ten

http://www.orange.co.uk/images/editorial/brown_case_mar07_emp_300.jpg

[nigegilb]

I have quoted an editorial from The Sun and now I am going to quote from another newspaper I don't habitually read.

This was the view from Michael White (I think) from The Guardian, by way of reply to TD's gracious post.

....That said, Mr Walker is not alone in pointing out these problems; a separate RAF inquiry that reported last year heard from other critics, including air chief marshals - and even a senior engineer from BAE Systems, the Nimrod's manufacturer. The public might not have known about these expert reservations had it not been for pressure put on the Ministry of Defence by the families of the 14 servicemen killed in the crash. What stands out from the inquest is not so much the technical arguments about using a particular aircraft but the fight involved in bringing such details into the open. Since the explosion in September 2006, the servicemen's relatives have campaigned for these safety issues to be made public. One spent over a year making his own investigations; it was only by lodging a freedom of information request that he learned that BAE's recommendations of safety improvements to Nimrod craft had not been implemented by the MoD. Had the advice been followed, the explosion in Afghanistan might well have been prevented.
British forces put their lives at risk on the command of their country. In return they are due a reasonable level of protection. This inquest shows that the MoD failed terribly. Defence officials should now make public all the various safety recommendations made about the Nimrod fleet - and explain how and when they will follow them. That might provide some satisfaction for the relatives of the lost servicemen - and some reassurance for those aircrew asked to fly in these old, dangerous planes.

Well done TD and everyone else. Tuc I was there on the last day, really wished you could have been alongside, would have been a privilege.

Nige

[airsound]

Here's the next step.

23rd May 2008


CONCLUSION OF THE INQUEST INTO THE DEATHS OF THE FOURTEEN
SERVICEMEN WHO DIED AS A RESULT OF THE LOSS OF XV230 IN
AFGHANISTAN ON 2 SEPTEMBER 2006


• The Inquest into the loss of those on board the Nimrod XV230 before HM
Deputy Assistant Coroner for Oxfordshire, Mr Andrew Walker, has now
concluded after 3 weeks.

• Mr Haddon-Cave QC has taken a close interest in the hearing and the
evidence presented. He has had counsel present throughout the
proceedings, Mr Peter Ferrer. Much of the evidence has also been observed
by Counsel to the Review, Mr Luke Parsons QC and Miss Caroline Pounds.

• Mr Haddon-Cave QC and his team with be carefully studying the transcript of
the hearing and the documents and statements in evidence, together with the
narrative verdict of the Coroner.

• It is likely that Mr Haddon-Cave QC will want to see, and further question, a
number of the key witnesses who gave evidence at the Inquest.

• Mr Haddon-Cave QC has noted the Coroner’s Rule 43 recommendation that
the Nimrod fleet be grounded, pending demonstration that airworthiness risks
have been reduced to ALARP. Mr Haddon-Cave QC will be closely
examining all the currently available evidence, including that relied upon by
the Coroner, before reaching his own conclusion.

• As he has previously indicated, Mr Haddon-Cave QC will issue an interim
report if he decides any matter requires urgent action.


Notice to Editors


The Terms of Reference for the Nimrod Review were announced by the Secretary of
State for Defence on 13th December 2007.

Further information on the Nimrod Review can be found at
www.nimrod-review.org.uk.

[OilCan]

Lab queen, thanks once again, but more clarification please. :confused:

To state that a misaligned pipe can cause seals to leak is rather stating the obvious. Of the two misaligned pipes that were found, did either of them leak and where are they fitted?

The fuel ‘vent’ system is primarily to allow the inflow/outflow of air. It is also deliberately pressurised with air to allow for jettison from the main tanks. Fuel submersion of ‘vent’ system seals would only occur in abnormal circumstances. I note that the seal manufacturer appears to say they shouldn’t have been used in the first place, nevertheless, which ones currently pose a threat?

The AAR system simply taps into the normal ground refuelling system pipework. A procedure known as ‘suck back’ was used to ensure that gallery was emptied of residual fuel after every ground refuel. Interesting to note this procedure was stopped a number of years ago, ironically to prevent damage to part of the AAR section. So constant submersion of some of the AAR/refuel system couplings is more likely today than it ever was. Again, which ones currently pose a threat?

Which couplings in the feed system are not constant submersion?? If any were ‘dry’, would my engines not also be dry and stop??

Mick/Da4orce
Ref the 1Tk blow off tracking back. Could you describe in detail how the BAe experts showed conclusively that this could not happen. Is this the video referred to by airsound?

Finally, can anybody enlighten/remind me of the incident on XV230 two weeks prior. What exactly was the source?

[Unsworth]

The Terms of Reference are particularly weak. I'd like to have seen some legal force behind this too, with the ability to compel witnesses to attend and/or provide testimony.

[airsound]

Oilcan, I can partly answer two of your queries, from evidence at the inquest.
constant submersion of some of the AAR/refuel system couplings is more likely today than it ever was
Couplings can dry out after 5 days with no fuel contact. This is most likely during long periods of maintenance when engines are not run.
Is this the video referred to by airsound?
No, the video was on the ground, made by techies who discovered the leak and decided to video it. It shows a panel off in the dry bay 7 area, and fuel is pouring out from a coupling onto the ground. It was used to show how bad a leak on the ground could be. There was no video shown at the inquest (as far as I know) of airborne leaks.

airsound

[Da4orce]

Oilcan

Mick/Da4orce
Ref the 1Tk blow off tracking back. Could you describe in detail how the BAe experts showed conclusively that this could not happen. Is this the video referred to by airsound?

Finally, can anybody enlighten/remind me of the incident on XV230 two weeks prior. What exactly was the source?

I don't recall how they showed that 1 tank blow off tracking back could not happen, forgive me but there was so much evidence heard, just the Coroners summing up ran to 40 pages.

Regarding the incident 2 weeks earlier again I cannot recall the detail with enough certainty to post here at present, suffice to say that the Coroner made reference to the incident in his extensive summing up. I believe and that it related to a similar fuel feed system leak that had occurred 2 weeks earlier but which had clearly not resulted in a fire. I am seeking to source a copy of the Coroners full summing up, at which point more detail will be available.

[buoy15]

Just checked in
Seems you lot intend to milk this accident till the MK2 goes out of Service in 2012 - not to worry, youv'e got your experts, Jimmy James and Deputy Coroner Walker to help you - Have Fun
By the way - the present Mk2 will fly safely until 2012, because I know the genuine people who service and fly it; they are more familiar with things that you lot could not even guess at and have something called moral fibre!
How about changing thread and trashing the RN for crashing a Nuc T boat into the seabed through negligence at a cost of £5m rather than demoralising ISK personnel with your vendetta about compensation which the MoD have already agreed to
Please tell me in man readable English what this saga is about and what your narrow minded objectives are - because if you can't see them, I can

Compensation
Compensation
Compensation

Ah Yes! Lets ground the MR2 and close Kinloss?

And before you know-alls get on your high horses - I played golf today with one of the 2 best Air Engineers in the fleet who attended the inquest - what he doesn't know about Nimrod systems you can write on the back of a stamp, and he is happy to keep flying

Can we now put this to rest, and let ISK get on with the job of fighting a war in Afgan and Iraq, plus SAR, JMC, OPS CT, Spec Ops, OCU, whilst still finding time to raise money for charities in their 'spare' time and wish them well