Haddon-Cave, Airworthiness, Sea King et al (merged) [Archive]

flipster

12th Nov 2009, 13:51

The Haddon Cave Report has been described as

"The biggest condemnation of the MoD and the Govt - IN LIVING MEMORY."

It underlines the failings surrounding the tragic losses of the Nimrod and Hercules. However, I find it strange that this has been only mentioned 'en passant' in other threads. The likelihood is that further failings of the system will be unearthed by a re-examination of other ac losses.

Now that the Sea King thread was prematurely closed and despite the likelihood of me upsetting the non-believers who may be in denial about the lack of effective airworthiness processes in the MoD, I believe there may be significant mileage in continuing the discussions relating to assertions that there be significant substance in Mr Haddon-Cave's Report and its further ramifications.

Such questions might include:

Could the H-C report have gone even further, wider and deeper?

Why - did the MoD limit his TORs on purpose?

Why is there a delay in the MoD response?

How many other instances are there of a lack of implementation of the airworthiness regulations? Sea King HISL? Tornado IFF? Chinook FADEC? Puma Anticipators?

When? By Whom? Going Back how far? Why? Do they have a common denominator?

What relevance is this to current aircraft and systems?

Why would some crews ignore the inherent lack of functional safety of their steeds?

Why would the high-paid help at MoD seek to suppress this - safety is everyone's concern and functional safety = better operational effectiveness = less chance of someone's son or daughter coming home to Lyneham in a coffin on a C-17?

If the HC recs are implemented in full will that correct the obvious deficiencies in the system - or do even more peope have to go to the high court before the MoD accept their responsibilities and their duty to prevent recurrence?

How can the MoD dither any more - especially if there are further suspicions about other losses?

Bottom-line in my opinion:

The MoD has accepted there was a lack of airwothiness in the Nimrod and the Hercules. It just cannot wait any longer. If any other cases rear their heads, the MoD will look even more ridiculous. It is patently obvious that the MoD have no wriggle-room on the HC recommendations and should implement them forthwith. God forbid there should be any more instances and losses.

Tourist

12th Nov 2009, 14:20

Please just stop it.

Rigger1

12th Nov 2009, 14:59

Please just stop it. Why?

We need to learn and change, it's the least we can do. If we bury our heads in the sand there will be more needless deaths. So don't just stop it, the system is not fit for purpose.

tucumseh

12th Nov 2009, 15:17

Tourist, I'm afraid you sound like the IPT Leader who told me, if I didn't like being told to ignore the regulations, I should find another job.

However, I don't think you ARE him, because he later acknowledged the error of his ways, expressing regret he encouraged a staff member to issue these orders.

Unfortunately, that was after the funerals.

nigegilb

12th Nov 2009, 15:56

A few encouraging noises Flip. A person in the CofC told me the other day, that Haddon-Cave has changed everything. He said Haddon-Cave's report is having an effect across the board, he said from the moment we get up, even when we are brushing our teeth we are thinking about H-C.

If you want to be totally astonished, search the name "Frank Walsh" in the report.

I suggest to that foul-mouthed contributor Tourist, that he reads some of Frank Walsh's specials, he might realise then, how dangerous the total disregard for airworthiness appears to have become.

For example, at one meeting, the QQ rep was actually booed.

Lets, flesh out choice bits of the report on this thread. Most people don't have the time to read hundreds of pages of a report of this nature.

Might surprise a few of the idiots lurking here.

The Old Fat One

12th Nov 2009, 15:57

Tourist, I'm afraid you sound like the IPT Leader who told me, if I didn't like being told to ignore the regulations, I should find another job.

Know he doesn't, he sounds like an aircrew mate that is sick to the back teeth of being patronised on his own forum by a bunch of people who think they have all the answers and who fundamentally don't know squat about the philosophy and professional judgement of people who fly combat aircraft for a living.

Don't bother replying because as with all the other threads that have gone down this road... the aircrew (or in my case ex aircrew) have already left the building.

Bye Bye

Snow Dog

12th Nov 2009, 16:00

The Nimrod Review was made public from the date of release. It hit everyone's desk at the same time. In my view, this is good; a report like this usually goes first to those implicated, who then get a finite time to get their story straight before the document is made public.

The MoD, and others involved, have had as much time as we have to read and digest. A response has been promised.

No Review can answer all your questions. I'm not even going to try and assess whether or not they are relevant. I do know that the Review has stated what many felt, but couldn't put a finger on. I suggest that we give the Review a chance before all response, answers, fact finding committees and implementation groups are rubbished here. It is a step on the correct, open and honest path and I sincerely hope the path is long.

nigegilb

12th Nov 2009, 16:02

Fat One, come back when you have read the report and have something to contribute. More than happy for the likes of you and Tourist to disappear from the thread.

Maybe we should tag it, grown ups only....

You are so twisted you are probably saddened by how seriously MoD are taking this report and how much change it is going to create.

Some of the main players are now being listened to and taken seriously at politically high levels. We aim to influence the decision makers of the future, so tough s**t, I suggest you go and twiddle with something else, so as to not raise your blood pressure unduly.......

The Old Fat One

12th Nov 2009, 16:18

NigeGlib

Sorry, since you posted on top of me allow me a couple of bites before I clear off.

Comparing Tourists post to yours (and speaking as an idiot with a Masters Degree in English), I find yours to be a more "foul mouthed" post than his.

And you don't need to "flesh out" the HC report - I've read it. Four very good mates of mine were in the aircraft and I wanted to know the facts as presented by the QC - not through the filter of Pprune. It was an interesting report but it did not tell me anything about the aircraft I flew in for 27 years that I had not long since worked out myself. I could bang on about many things to do with HC, Nimrods and military aviation, but to do so would be to tread on my point. Which is simply this...

Try and get your head round the thinking and personality of military avaitors, and why they are willing to take risks, without insulting them.

HC wrote a chapter on the shuttle accidents. If NASA hadn't fixed a single thing and and Del Trotter had taken over as head of flight safety, do you not think there would not still be queue of aviators a mile long waiting to fly it?

Finally, if you can't get your head round any of that, at least acknowledge that this is supposed to be a pilot's forum in the first instance, so you might show the opinions of the fly boys and girls just a tiny bit more respect.

And now I'm outta here.

Pheasant

12th Nov 2009, 16:39

This thread has got off to a really bad start! Can we try and be constructive rather than destroy each others entries.

We do need to learn the lessons of HC as there is clearly something quite wrong with elements of the airworthiness regime. The buzzes that I hear are that such a process is well in hand. But that does not mean that errors will not occur in the future, especially when finance is tight and that ""must do" mod is not affordable.

I spent much of my career flying an aircraft that would not pass the H-C test - it sank on impact with the water for a start - but had many other shortcomings as well. But I knew about most of them and thus informed I was able to make a rational, risk based, decision on whether I wished to fly in such an aircraft. I accepted the risks and compensated for the majority in the the way I planned and executed missions, many in hostile situations. But at the end of the day I knew that if I ditched I had a less than 50/50 chance of survival, if I had a fire the risk was similar (no diversions at sea), the fuel tanks were not self sealing and the spare tank was effectively a single skinned jerry can in the back. Oh yes, if the hydraulics failed there was no connection between my flying controls and the rotor head. So what! it was great fun and a privilege to fly such a great machine.

Learn lessons but please stop moaning, know your aircraft and remember that the vast majority of military accidents are due to aircrew error, not the airframe - I suspect that includes the Mull Chinook as well (God rest their souls).

nigegilb

12th Nov 2009, 17:08

Thanks for the balancer pheasant, please allow me to give my own perspective.

Flip and myself cut our teeth on ops in Afghanistan. We flew Hercules aircraft with hardly any protection bar the assist of flying at night, against regular ground fire in the early days of the op.

Did we accept the risks and crack on with the job? Of course, because we were military aviators and it was our job. I can understand where others are coming from, one thing you learn very quickly in the military is that nothing is EVER perfect.

Did our chain of command at the highest level (including defence ministers), ackowledge the risks we were taking and confront the situation with honesty? No it didn't. This lack of honesty led, in my opinion to the crew of XV179 taking risks beyond their knowledge and understanding. A simple tweak of tactics would have kept them safe, whilst FTP was installed. The recommend was sat on and so was the desperately important risk assessment.

Did the Nimrod crew have the knowledge that their aircraft was safe? No, due to outrageous, deliberate ignorance of airworthiness regulations they were led to believe their aircraft was safe.

I am in this for the long run. I want to see the culture changed in MOD, where people today have blood on their hands. The signs are good, a new generation of senior officers are taking over, but there is still work to be done. I won't be sitting on the sidelines, hoping it is going to happen.
I make no apology for my forthright approach, this is not a popularity contest.

flipster

12th Nov 2009, 17:24

OFO and Tourist
If you don't mind; polite, rational, considered posts only - pretty please. :):)
Thanks chaps

Safeware

12th Nov 2009, 17:27

But I knew about most of them and thus informed I was able to make a rational, risk based, decision on whether I wished to fly in such an aircraft.
For those of us that are safety engineers, that's what we want to do, provide you with the information to allow you to make rationale decisions on the risks that YOU are prepared to take.

I'm not one for the notion of a "Flight Prevention Branch" - safety engineers who try to stop operators for the sake of it are not doing their job. We don't need an overly prescriptive culture such as exists in some places that won't let you do the simplest of things because "Health and Safety Says so". It doesn't say so, it says to make realistic risk assessments.

In relation to airworthiness and safety, I once said to a BAES safety engineer who challenged my approach (probably because of company policy rather than of real conviction), that his approach was purely commercial, my approach was based on the fact that I didn't want to go to a mate's funeral and tell his wife that "I'm sorry, but if I'd done my job a bit better....." Made him think!

sw

Tourist

12th Nov 2009, 17:33

If you don't mind, stop embarking on a crusade based mostly on hearsay and conspiracy theories.:):)
Thanks Chaps

As I dress for this evenings Taranto Night, it occurs to me to wonder:
If you bunch were around back then, how many reasons would you have found to ground the stringbag?
Old.
Slow.
Unsafe.
No armour.
No Nav equipment.
Obsolete.
(probably had sh1t strobes, too)
No Comms

Without The Attack on Taranto, who knows what would have happened in the Med?

Sometimes you just gotta fly it.

Safeware

12th Nov 2009, 17:49

If you don't mind, stop embarking on a crusade based mostly on hearsay and conspiracy theories.

Sorry Tourist, I have to base my work on evidence, not hearsay or conspiracy theories. And I'll bet the Stringbag met the requirements of the day.

One day, in a meeting which included an RM, you could see the penny drop when, in his own words, he figured out that we were only applying the MOD's own standards and doing what we were contracted to do. We weren't being "difficult" for the sake of it.

sw

[email protected]

12th Nov 2009, 17:53

Tourist and OFO - I think you both want to grow up a bit - we are not flying Swordfish any more than we send the 20 minuters in Sopwith Camels to do battle with the hun. The 'we will fly it and get the job done no matter how shi8e it is' belongs firmly in the volumes of Boy's Own annuals and Commando war comics.

Your statements conflict with your assertion that you are professional aircrew who are supposed to be responsible for the safety of the aircraft and crew first and foremost.

flipster

12th Nov 2009, 18:01

Tourist

Thank you for replying with a modicum of politeness; that is progress at least. However, I cannot understand from where you get the impression that a number of Coroners' Inquests, a review carried out by a member of Queen's Council, uncontested High Court actions against the MoD, along with a number of Boards of Inquiry and even a couple Air Ranking Officers could possibly constitute 'hearsay and conspiracy' theories. Perhaps you could elucidate your reasoning?

I am also at a loss why any 'aircrew mate' would seem disinterested in the functional safety of their aircraft - they may not understand the dark world of safety engineers (I didn't) but it should make them think hard about the verity of the promises and premises that underpin the ac document set that directly relates to the safe and effective operation of their chosen steed (it did).

Even armed with the knowledge that your ac may have some shortcomings, I respect your decision to go out and do your job and duty - perhaps that is brave and the ethos of the military (I did too)? But the point is that if you are fully informed you are able to mitigate the snags - as pointed out by Pheasant. The problem is that the CoC has for some time, begun to assume that we will risk our necks 'for the greater good' but they will not provide you with the knowledge to asses the risks you are taking. If you wish to continue to play russian roulette, that's you choice (perhaps not so brave as foolish). However, how do you fully inform your crew/pax if you are not fully in the picture yourself?

Or are you a protagonist and adherent of the BIFWSS principle?

vecvechookattack

12th Nov 2009, 18:04

What we could do here is to start a new thread entitled...

"Who gives a ***** about airworthiness? That's for Engineers to worry about"

Oh no.....We've already done that

Snow Dog

12th Nov 2009, 18:12

I think 'crusade' (without the implicit religious connotations) is the essence that taints these threads. I read many posts and wonder if the author wants to save the operators from themselves, or actually has a huge bone to pick with those up the chain and feels able to do so now that they no longer have to continue in the life of and on the aircraft of their vocation. The Old Fat One is right, we are pilots, we fly aeroplanes. Pheasant sums up how we live with aeroplanes (and justify them to our dearest who question us). We do our best, we love it. We are in charge and we prepare for each flight to the best of our ability to succeed. Fortunately and sadly, we are also lucky. We are the 99,999,999:1,000,000,000 (made up probability) for whom it all works. Many of us could have been the one (or one of 14). I now know that the aircraft I loved, trusted and thoroughly enjoyed hasn't been fit since it came into service. Am I stupid, no. Do I want to blame anybody, no. It doesn't take away anything that I did with the aircraft and I'm sure I don't want it to.
BUT, I hope the Review can do some good. I want it to and I believe it is starting to.

Roland Pulfrew

12th Nov 2009, 18:17

?However, I cannot understand from where you get the impression that a number of Coroners' Inquests, a review carried out by a member of Queen's Council, uncontested High Court actions against the MoD, along with a number of Boards of Inquiry and even a couple Air Ranking Officers could possibly constitute 'hearsay and conspiracy' theories. Perhaps you could elucidate your reasoning?

Flip

Because you started with the conspiracy theories in your first post??

Why - did the MoD limit his TORs on purpose?

Why is there a delay in the MoD response?

nigegilb

12th Nov 2009, 18:20

"I think 'crusade' (without the implicit religious connotations) is the essence that taints these threads."

I think you should contact the author and get to know him rather than attack his motivation. I can vouch for the purity of what he is trying to achieve and I have seen the enormous amount of work he has done (in his own time), in a tireless effort to improve safety. What the hell were your highly paid representatives in the CofC doing all this time? Looking after their careers? You can call it what you like, it is bl**dy effective and I for one, don't give a stuff if it offends your "sensibilities".

Moving on, this was a constructive and welcome addition to the debate. An AVM moved to write to The Times a couple of days ago;

November 10, 0009
Reinstate qualified RAF engineers

The public should demand the restoration of military airworthiness responsibility to those who are qualified and trained to handle it

Sir, Having spent most of my working life involved with the airworthiness of many types of military aircraft, I read the detailed and forensic report into the loss of Nimrod XV230 with great interest and deep concern (report, Oct 29). There are serious aspects of the report that should concern the public who ought to demand thoroughgoing changes to restore faith in the airworthiness of our military aircraft.

The age of our Nimrod fleet is not unusual for a military aircraft. Our defence budget only allows us to replace aircraft fleets every 30 years or so, and usually heavier aircraft remain in service for longer. During these extended lifetimes aircraft normally change roles and have many different operating procedures. Standard design and maintenance safety regulations are frequently challenged by these changes and new methods of achieving the required levels of safety have to be worked out. All such changes have to be tracked throughout the remaining life of the fleet and new generations of maintenance personnel trained to understand their implications for the long-term battle against the inevitable consequences of metal fatigue, corrosion and the like. The resulting programmes require the reservation of funds and facilities for many years ahead. However, day-to-day problems and crisis arising from training and operations are urgent and never ending. Inevitably, there is a temptation to neglect the longer term with potential disastrous consequences.

From the formation of RAF Strike Command in the early Sixties the engineering branch of the RAF met these challenges by co-locating all the specialist engineering staff for each aircraft in a single office — the Role Office — and required each office to prepare an annual review of its long-term airworthiness plans. By the late 1990s these reviews were heard by the Chief Engineer himself so that he could satisfy the responsibility that all RAF aircraft were airworthy.

The XV230 report details that early this century the post of Chief Engineer was discontinued, that the chain of delegation now no longer passes through the hands of properly qualified and experienced engineers. Instead, it seems to follow the chain of command, which could and did include not just non-engineers but also personnel who had no experience of military aircraft operation. In addition, a whole management layer was removed and with it the capability to supervise the Role Offices — now expanded and retitled integrated project teams. This was a recipe for disaster. It was akin to giving a GP responsibility for the quality and extent of cancer care — or even giving the task to a non-medical person.

The report into XV230 rightly takes to task personnel who failed to meet the standards required of them, but it does not address the larger problem of allowing airworthiness responsibility to be held by untrained personnel. Nor does it sufficiently criticise the convoluted dissipation of airworthiness responsibility in the new tri-service logistic organisation so that the heavy weight of this task is not clearly laid on specific individuals. The public should demand the immediate restoration of airworthiness responsibility to those who are qualified and trained to handle it.

Air Vice-Marshal K. A. Campbell RAF (Ret’d)

Safeware

12th Nov 2009, 18:21

"Who gives a ***** about airworthiness? That's for Engineers to worry about"

vec, even in that simple, self-centred statement you miss a huge point that H-C made about operators being involved in airworthiness.

If you're not interested / don't care, fine, leave the threads to those that are and do.

sw

Rigga

12th Nov 2009, 20:45

Wow! what a start to a thread that could be of value to a lot of people.

To follow the form of previous intro's:

I'm not a pilot. I did used to be a crew-chief for some years, but I don't consider myself as aircrew in any way. I was in the mob 1975-1999.

I am now a QA manager in a company that you might know. For the past eleven years I have been involved in commercial aviation QA and continued airworthiness - as it is now known.

I know something of EASA and MAOS parts 145 and M (and a few others too). I know that MAOS is certainly the poor relation of EASA. I believe I now understand why the Mil regulation has sections omitted and what a 'full' regulation would do to the MOD Fleets if implemented.

Although I had discussed anomalies in the RAF, I was stunned by H-C's review. However, the voices of denial recorded in these threads is absolutely, gobsmackingly, astounding.

Although I read it on-line, I have purchased a copy and re-read it as I believe it will be used in "Human Factors" courses for a very long while indeed. It is a historic document of bullying, mis-management and blundering.

Nigegilb said:
"...He said Haddon-Cave's report is having an effect across the board, he said from the moment we get up, even when we are brushing our teeth we are thinking about H-C."

I think they bl00dy well should too! To say "Thats the way it was when we got here!" just shows feeble and limp weaknesses for those in-post - the Peter Principle comes to mind.

The findings of H-C need to be read across the whole of the MOD fleets and management processes should be completely re-vamped.

In the meantime we should wait quietly to see what MOD's response is - on December 13th, I believe - and see which way "they" jump.

Safeware

12th Nov 2009, 21:20

Flip,

The basis for the figures, as per JSP 553, is rooted in civil aviation standards, so there is pedigree in what "should" happen.

As regards Feyman, I haven't heard the quote from him (his Appendix to the Roger's Commission is here: http://www.ralentz.com/old/space/feynman-report.html, but suspect he may be mis-quoted / mis-understood (although he is very critical of the probabilities used). But I have heard something similar said of software safety from a Prof Bev Littlewood, along the lines of "If you try to tell me that the probability of your software failing in a hazardous way is 1 :1 000 000, I won't believe you, but if you tell me that it will never fail in a hazardous way, I'm much more likely to believe you" This first bit is on the basis that testing software to that degree is not feasible, but if someone presents an argument that the software will never fail in a hazardous way, they must have a very good case for saying so.

As regards 1:100 000 being crap, here's an example of why I think he's been misquoted. Take a function, with the potential for catstrophic failure, and the system has a p(F) of 1:1000. If the function has a parallel system, providing the same function, but independently ie no common mode failures, and with the same p(F), such that the probability of a catastophic failure depends on both systems failing then the probability of this is p(F) system A x p(F) system B. ie 1:1 000 000. Building 2 systems to 1:1000 is far easier to demonstrate than 1 system to 1:1 000 000.

sw

TorqueOfTheDevil

12th Nov 2009, 21:25

How many other instances are there of a lack of implementation of the airworthiness regulations? Sea King HISL? Tornado IFF? Chinook FADEC? Puma Anticipators?

There is a risk here that every accident, past and future, is now going to be attributed to airworthiness issues - for instance, pick any FJ CFIT from the early days of TCAS. If one FJ type had TCAS and another didn't, it doesn't automatically follow that the latter type is therefore not airworthy and that the airframe is fully or even partly to blame. Likewise, the numerous Puma crashes in the last 10 years blamed on lack of anticipators don't mean the aircraft is fundamentally at fault - the Puma flew for several decades without the number of losses which have been seen recently (those on ops are clearly not included in my argument).

While we should embrace the progress which one hopes will result from the shocking loss of XV230, we shouldn't use it to shield ourselves from the fact that, in many cases, the aircraft is perfectly airworthy - whether 3 years old or 30 - and it may simply be down to the crew that the accident happened. And if, one day, I make a mistake and end up in a crash of my own making, I would want people to learn from my mistake rather than have the episode hijacked by talk of airworthiness which MIGHT be totally irrelevant.

Safeware

12th Nov 2009, 21:26

Before anyone jumps to conclusions about conspiracies, I asked the Mods to merge my thread on H-C's issues with Flip's, so that the report's issues can be discussed in one place.

Flip - hope you don't mind - it still get's your title!

sw

Safeware

12th Nov 2009, 21:37

TOTD,

I wouldn't want airworthiness to be the scapegoat every time either. If there is a "technical failure" aspect which comes within JSP553 requirements then fine. Everyone needs to remember that the greater risk is from human factors (70 - 80%??) rather than technical failure, so lets put efforts there as well.

sw

nigegilb

12th Nov 2009, 21:44

SW, just so long as you don't pull the thread!!

There will, no doubt, be more reporting of airworthiness issues in the coming days.

I understand the worries of attributing everything to airworthiness failures. To be fair, there is nothing new in those fatal accidents listed above, we have been banging the drum for some time, it appears we are gaining a wider audience, at last. And Haddon-Cave referred to systemic problems at the MoD, so it would appear the argument is largely won.

The focus in the coming days will most likely fall on the Sea King collision. I am hoping that evidence will be sufficiently strong to cause either the investigation or the inquest to be re-opened.

WRT Puma fatal accidents on ops. I understand that the SF role given to the Puma in Iraq, is no longer applicable, so the operational pressures have now been removed. Agree with SW though, human factors do appear to have significantly affected these crashes. That said, aircrew training is an aspect of airworthiness, I do wonder if the crews had been properly trained for the SF role.

Tappers Dad

12th Nov 2009, 21:57

I am seeing Bill Rammel on Monday and part of one of my questions(Sent in advance) is:

In the light of the Nimrod Review, does the MOD intend to revisit with some urgency, all the work on Airworthiness and Safety undertaken for the MOD/RAF by those people named in the review from the MOD.RAF,BAE and QinetiQ.

I will post his answer on here on Tuesday morning.

nigegilb

12th Nov 2009, 22:13

Maybe you should quote the witness below Graham. This is precisely why H-C was right to name and shame. Don't worry about Rammell, let's just get them in court.

QinetiQ’s representative ‘booed’
I turn now to consider the role of QinetiQ’s representative, Witness O [QinetiQ], during the Customer Acceptance Conference. At the beginning of the meeting, Witness O [QinetiQ] introduced himself and explained that was standing in for Martyn Mahy at short notice. He was seated beside Frank Walsh. He had not previously been involved in the NSC and was not familiar with the project or the detail. Accordingly, he was for the most part a passive observer during the meeting. He said that everyone else seemed to know each other and that he felt like “a ﬁsh out of water”. He did, however, raise the question of the level of risk mitigation controls in place during the demonstration of CASSANDRA. He was told that the risk mitigation was only 85-90% completed but would be before the Phase 2 was completed.

When, at the end of the second day, all present were asked to state in turn whether they supported the completion of Phase 2 of the NSC by BAE Systems, Witness O [QinetiQ] said that, because he was only standing in for Martyn Mahy and had not seen any of the key deliverable documents, he felt that he could not validate BAE Systems’ claim that these documents satisﬁed the contractual requirements. His account in his statement to the Review of what then happened is striking:

“I have a strong memory that upon stating this, various meeting attendees booed me and muttered things along the lines ‘bloody safety engineers always have to caveat their statements’. I can remember this clearly because I have never been booed in a meeting before (and have not been at any time since).”

He said that, although the booing was not intentionally aggressive, he found it intimidating and was surprised and embarrassed at being heckled in this manner. BAE Systems’ representatives were questioned about this matter in interview, but said they had had no recollection of such an incident. I have no reason, however, to doubt Witness O [QinetiQ]’s recollection of being subject to this sort of treatment at the meeting. It has the ring of truth about it.

nigegilb

12th Nov 2009, 22:28

20 January 2005: E-mail from Frank Walsh to George Baber
On 20 January 2005, Frank Walsh e-mailed George Baber as follows:

“George,
All the hazards in CASSANDRA, with the exception of H2 .... have controls
and references in place to show that they are at ALARP. I am awaiting a copy of the Unit snow and ice plan to include as mitigation for H2. I believe that the hazards, except H2, should be set to MANAGED on CASSANDRA now and H2 when the last piece of mitigation is in place. If you agree I will instruct BAE Systems to amend CASSANDRA. Frank”

Frank Walsh’s e-mail does not appear to have contained any detail or supporting material or referenced any input from the Nimrod IPT Specialist Desks or Heads of Branch or Michael Eagles. Nevertheless, it appears
that George Baber was prepared to approve his request, because subsequently, on 1 February 2005, Frank Walsh wrote to BAE Systems authorising them to set the post control status of the hazards in CASSANDRA
in accordance with an attached annex (Annex A) which he had prepared (see further below). I discuss in Chapter 11 the signiﬁcance of this and other steps taken in relation to the sentencing of the remaining risks.

The above e-mail shows an informality of approach to the sentencing of risks by both George Baber as IPTL and Frank Walsh as Safety Manager. George Baber’s explanation in interview was “I trusted him and I took
what he said at face value”. It remained, however, George Baber’s personal responsibility as IPTL, Project Engineer and Letter of Delegation holder, to ensure that the risks were properly sentenced.

1 February 2005: Frank Walsh’s memo to BAE Systems

On 1 February 2005, Frank Walsh drafted a memo to BAE Systems which he signed and sent out under his own name. It stated that the Nimrod IPT had reviewed the BLSC produced by BAE Systems, agreed with the status of the hazards set by BAE Systems, and had considered the evidence to set the rest. Attached to the memo was an annex (Annex A) entitled “Evidence for Mitigation of Hazards” (Annex A) which he had prepared, and which was described as “the evidence that should be entered into the hazard log as controls and the post control status as decided by the IPT”. Frank Walsh said that his Annex A was based on a template which he had been sent by Witness C . It was not clear when, but probably shortly before.

Annex A
Frank Walsh’s Annex A purported to show the mitigating Controls and Post Control Status of 33 hazards. 32 of these hazards were those which BAE Systems had left “Open” and “Unclassiﬁed” in Annex B to the BLSC.6
A total of 21 of these were referred to as “Interacting Systems” hazards and contained identical entries.

It is clear, therefore, that by 1 February 2005, Frank Walsh had had a look at Annexes B and C of the BLSC

Reports and discovered that there were, in fact, a large number of “Open” and “Unclassiﬁed” hazards which remained to be sentenced. This contrasted starkly with the picture which he had presented to the Sixth PSWG when he had highlighted only a handful of hazards as requiring action.

[B]Frank Walsh’s realisation
It is not clear precisely when, and how, Frank Walsh, came by this realisation or revelation. He was unable or unwilling to give a clear or satisfactory explanation to the Review in interview. It is likely that, sometime after the Sixth PSWG meeting had tasked him to produce a document to ‘sign-off’ the NSC, he turned to the BLSC Reports and discovered that there were in fact a large number of hazards which had been left “Open” and “Unclassiﬁed”. Upon making this discovery, it appears that he did not (as one might expect) immediately draw it to the attention of Michael Eagles or George Baber. The question arises, why not? The likelihood is that it was a combination of the fact that he was simply too embarrassed at this point in time because he should have spotted it earlier, and a sense that it did not really matter because the task had been formally signed-off and the Nimrod was safe anyway, and a belief that he could quietly ﬁnd mitigating evidence to sentence all the remaining hazards without difﬁculty. This is, in any event, what he proceeded to do. Unfortunately, Frank Walsh’s attempt to sentence these hazards (including Hazard H73) {The critical catastrophic ﬁre hazard relating to the Cross-Feed/SCP duct had not been properly assessed and, in fact, was one of those left “Open” and “Unclassiﬁed”} was woefully inadequate. There exists no documentary trail, however, of precisely how he went about it.

flipster

13th Nov 2009, 07:44

safeware

no probs - thanks don't fullly appreciate the nuances of thread ownership but I would like this one to run. Thanks also for link. On what objective data are the values applied to the probabilities in the cases I mentioned? Who collates these stats? What about the widely acclamied Perrow Normal Accident Theory - surely a military ac and its supporting systems are both 'tightly coupled' and 'complex'? The less funding we have and the leaner we are, then it follows that the more 'complex' and 'tight' we get? Accidents are therefore assured, if not a certainty.

Mods

Please don't let the ill-considered and personal attacks by some minority posters prompt you to pull the thread - that would only play into their hands, the more they squeal, the warmer we are getting.

Roland P

Sorry, I think you may have misunderstood - I posted questions not statements - conspiracy theories I am not willing to believe (yet) - more likely, its is because of govt/MoD incompetence and/or perhaps a lack of integrity; it wouldn't be first time, would it? However, the MoD/CS/Sen Ofs are only human and I am quite happy to forgive and foget most errors and lapses, as long as

a. They were not willful violations or self-serving abbrogations of duty.
b. The lapses and faults are acknowledged and put right PDQ.

Everyone else

This is no crusade but the fact remains that a number of accidents have implicated a lack of airworthiness compliance as a cause. Of course, this was not the only cause but as it has become a common occurence, I think it should be of grave concern to ALL operators. Accidents are often system failures and rarely, is the final act of the operator the SOLE cause, though he/she might be the last one able to prevent the completion of the chain of events. 'Operator error' is often a smokescreen behind which management can hide.

And....

Yes, to a certain degree, airworthiness is the domain of safety engineers and designers - but they can't be expected to forsee everything (and an operator who is completely unaware of this is missing a part of his own defences). Nonethless, on the basis of previous experience, the engineers are directed to consider certain 'givens' by the regulations (eg fire protection of certain ac parts, lighting considerations and training systems). It is obvious that this 'dark world' has lost its capability to comply with those regs and the operators aren't being told. This, I would argue, is unaccaeptable. If you disagree, please add your tuppence worth but I suspect that the crews and the families of XV179, 230, 704 and 650 might not agree with you.

To all operators out there - it is your choice - do you trust the airworthiness system any more? Do you know the weaknesses of your systems? If you take an active interest in the functional safety of your platform and try to identify and gaps or lapses, only then can you make informed decisions about how you operate. Increasingly, it is up to you to ask those questions - but your crew and pax might also like to know.

sincerely,

flipster

nigegilb

13th Nov 2009, 09:04

Flipster; "However, the MoD/CS/Sen Ofs are only human and I am quite happy to forgive and forget most errors and lapses, as long as

a. They were not willful violations or self-serving abbrogations of duty.
b. The lapses and faults are acknowledged and put right PDQ."

FRANK WALSH;

"Frank Walsh, who worked as safety manager for the Nimrod review and was the MoD's primary point of contact with the BAE Systems team carrying out the work, is said to have assessed hazards himself in a "slapdash" manner and failed to alert his superiors when he realised he had overlooked important issues.(Of greatest concern here is Hazard 73).
The report states: "Frank Walsh's failure to put his hand up and admit to his superiors that he had overlooked matters, and then effectively to cover over his mistakes, is his most serious failing. In doing so, he failed to act honourably.
"In matters of safety, there can be no compromise on openness and honesty."
However, the report's author noted that he should not have been placed in the position of having to manage the project with little, or no, supervision or guidance.
Mr Walsh no longer works at the Ministry of Defence."

So Frank Walsh is alleged to have failed to have acted honourably or honestly. Category A case Flip?

I wonder if he received an MoD bonus? Let's hope John Cooper is taking an interest.....

pulse1

13th Nov 2009, 11:32

I spent the most miserable seven years of my life as a Quality Manager of an 05/21 registered company supplying parts and services to the Defence industry. In that time I went thorough a variety of audits by the MoD (PE) and some of them were corrupt, slapdash and slovenly. The first one was a new experience for me as, before lunch, the auditor did about 20 minutes work and, after lunch, he was drunk and argumentative. I passed the audit with three minor defects which, I was later told, he always found. I was both relieved and disgusted.

Haddon-Cave has effectively carried out a representative Quality Audit on the MoD and it's supply chain (look at the supply chain for rubber seals). It has been found seriously wanting and, if this had happened to one of it's suppliers, the supplier would have lost any approvals it had. He has named some names but, just as a defect in a quality sample rejects the whole batch, the whole of the MoD should be considered to be below par until it proves otherwise. It cannot heal itself, the only answer would seem to be the urgent setting up of an independent MAA. Where you will find enough suitably qualified engineers who have not already been corrupted by the MoD system I do not know.

1.3VStall

13th Nov 2009, 12:12

I have now read the H-C report, which I found very disturbing, but not really surprising. With a masters degree in aircraft design, over 25 years service in the RAF as an engineering officer and having been an airline CAA nominated post holder on two occasions since retirement from the Service I hope I can add informed comment to this thread.

The responsibility for airworthiness in the civilian world is clear cut. The industry is heavily regulated, all key personnel are licensed/approved by the relevant Authority and there are formal checks and balances. Despite the inevitable commercial pressures of running an airline, if an engineering director holds up his "airworthiness card" the bean counters can be effectively kept at bay.

The RAF does not have such a formal system (please don't bring up MAOS, it is nowhere near yet fit for purpose). Nevertheless, until the mid 1990s the RAF's airworthiness chain was pretty well defined; this is referred to in Archie Campbell's recent letter to the Times. Moreover, we had the post of Chief Engineer (CE), which carried with it the ultimate authority for airworthiness. This post was successively filled by men of stature, who engendered admiration, respect and, dare I say it, affection within the Engineering Branch. (The last of these was Bill Richardson, who was dined out by his Branch at RAF Abingdon). This ethos was particularly important in maintaining the professionalism of the Branch.

Three things happened to change this. First, the CE post became Chief of Logistic Support (CLS) and the Engineering and Supply Branches moved closer together, blurring the edges. Second, we had a number of occupants of the CLS post, who most certainly did not earn the admiration, respect and affection of their subordinates. Third, we embarked on a series of Defence Reviews, which put budgets as the principal focus. These three issues combined to start and continue the rot.

Fifeen years on we have reached the unacceptable level so starkly highlighted by the H-C report. There is no clear leadership (all the leaders and commanders have been replaced by managers and executives). There is no clearly defined airworthiness chain. There are no adequate checks and balances within the MoD. There are people in positions with responsibility for airworthiness who are not competent to do the job. Perhaps most significantly, the increased use of outsourcing, the pressure on budgets and the focus on logistics rather than engineering has emasculated the Engineering Branch. This has driven many talented engineering officers to leave, rather than pursue a full career in the RAF, further diluting the expertise within the Engineering Branch.

In all of this I ask myself whether an old fashioned CE would have, well before now, held up his "airworthiness card". The answer is most probably yes!

What can be done? The MoD clearly needs to digest the thrusts of the H-C report and make a prompt and measured response. The airworthiness chain needs to be quickly re-established, with clear-cut responsibilities and, most importantly, effective leadership. Existing safety cases must be critically re-examined - and quickly. In my view some form of independent military airworthiness authority is now inevitable; I do not believe the MoD is now capable of setting up and maintaining and audit system that will provide adequate assurance of ongoing airworthiness across all fleets. (Perhaps I'll even offer my services!).

squib66

13th Nov 2009, 12:45

One small observation:- Is it not correct that there were flaws in the No 7 bay design that go back all the way to the late 60s and also a failure to act on information from the AEW3 programme in the 80's? Why was the 'airworthiness card' not held up then?

Is it not a little simplistic to think that every problem was created in the last 15 years and all that went before that must have been perfect?

Fatal airworthiness failures that needed the 'airworthiness card' are not just limited to the military world:-

http://www.pprune.org/rotorheads/365720-helicopter-crash-off-coast-newfoundland-18-aboard-26.html
http://www.pprune.org/rotorheads/365720-helicopter-crash-off-coast-newfoundland-18-aboard-27.html

So replicating a CAA is not an automatic answer.

nigegilb

13th Nov 2009, 13:50

1.3 vstall,

I can understand why H-C implies the breakdown/erosion of safety regulation in the MoD was a top down process. Certainly I agree with his assertion that MoD need to re-establish the post of Chief Engineer, (pity the blinkered MoD couldn't see the damage being done for themselves). Nobody would appear to be arguing against this recommendation and I doubt the MoD will resist when they eventually get round to replying to the report. However, those who have considerable experience in trying to maintain military airworthiness argue that the erosion started years before, from the bottom up.

Just wondered if you had any experience of this bottom up erosion.

Latest News;

The head of the multinational arms company BAE Systems, has provoked criticism with a dismissive comment about the Haddon-Cave Report into the deaths of 14 members of the UK armed forces in a Nimrod aircraft.

The report attributed a heavy portion of the blame for the deaths to BAE, but when questioned about it in London yesterday evening (12 November), BAE's chair Dick Olver rejected the report's findings because Haddon-Cave had interviewed "only" 19 BAE officials. Olver said that he would not “be blown off course by comments about 19 people”.

The remarks followed Olver's delivery of the Mountbatten Memorial Lecture, a public event, at the Institute for Engineering and Technology. He focused on the theme of “ethical leadership”.

During his lecture, Olver insisted that BAE was thoroughly implementing a set of ethical guidelines which it had accepted in 2008. When questioned from the floor by Symon Hill, associate director of the thinktank Ekklesia, Olver described the Nimrod incident as a “tragedy” and said that his company would look very carefully at Haddon-Cave's comments.

When it was pointed out that Haddon-Cave had declared that BAE was not following its own ethical guidelines, Olver became flustered, saying “I reject that absolutely”, and adding “I will not be blown off course by comments about 19 people or anything else”.

The Haddon-Cave Report declared that “BAE Systems has failed to implement its expressed ethical business culture company-wide. The responsibility for this must lie with the leadership”.

Haddon-Cave insisted that “Throughout my review BAE Systems has been a company in denial”.

The report found that BAE shared responsibility for Nimrod's failings with Qinetiq, another arms company, as well as with the Ministry of Defence.

Olver faced several challenging questions after his lecture, some of which focused on the ethics of selling arms to dictators.

He said that all BAE employees are bound by a “clear and consistent code of conduct” wherever they operate. He insisted that his company was not corrupt and argued that the arms trade was not unethical.

Although the IET said that it was “delighted” to welcome Olver, there has been widespread derision at the concept of a leading arms dealer lecturing on ethics. Kaye Stearman of the Campaign Against Arms Trade (CAAT) has compared it to “Nick Griffin lecturing on multi-racial harmony or Bernard Madoff on financial probity”.

BAE has long been criticised by churches, faith groups, charities and NGOs for arming oppressive regimes such as Saudi Arabia and Indonesia. The company is facing allegations of corruption in five continents and is thought to be on the brink of prosecution in British courts.

Squidlord

13th Nov 2009, 16:35

Right at the beginning of this thread, Safeware quoted the Haddon-Cave report (HC):

There is no such thing as ‘tolerably safe but not ALARP. Risks are either ‘tolerable and ALARP’ or intolerable

and then asked:

does
Quote: ‘tolerably safe but not ALARP’
then make sense in the real world beyond Def Stan definitions?

I don't think so. At least not in the sense that Safeware is enquiring (for risks that are just a little higher than "broadly acceptable").
I think I criticised Qinetiq's (QQ) use of the term "tolerably safe" in one of my posts on the Nimrod thread, mostly because they didn't define it (and it isn't defined in any authoritative document that I know of). Even if Safeware has a point (though see below) and QQ intended a similar usage to that he intends, they should have defined the term. They're not the only offenders - many air IPTs have done the same.

As it goes, I have been told that the term "tolerably safe" was introduced to military air safety as "weasel words" to help justify continued operation when you have tolerable risks that have not been demonstarted ALARP. I.e., not to cover the situation that Safeware describes when your risk is just a little higher than "broadly acceptable" but any situation when your risks are tolerable but not necessarily ALARP.

Of course, there is intuitively something intrinsically more acceptable about a risk that is only a little higher than "broadly acceptable" as opposed to one that is just short of "intolerable". But that is factored into the difficulties of demonstrating the two risks ALARP. Basically, the first will very likely be easy to demonstrate ALARP (unless it really is risk without any benefit) but the second will be virtually impossible to demonstrate ALARP.

Flipster wrote:

What worries me is who apportions the 10p-6 or 10p-5 etc for the MoD airworthiness processes involving catestrophic failures eg Herc Fuel Tanks, Nimrod Dry Bays, Sea King HISLS, Chinook FADECS etc?
Where do these probabilities come from?

In principle, whenever a target like this is allocated, it should be justified. In practice (in my experience), the justification is often missing. Def Stan 00-56, Issue 2 (we're now at Issue 4) contained an example risk matrix. The intention was that IPTs would select and justify their own risk matrix, with agreement from stakeholders, but because so many were clueless about how or why, they just adopted the example risk matrix ... even if it was inappropriate for their circumstances.

It is possible to use sound criteria to "design" project-specific risk targets, e.g. in a risk matrix. You can use risk matrices already used for similar equipments in similar contexts (e.g., consider using the Typhoon risk matrix for JSF), design one from scratch according to higher-level criteria (e.g., the HSE annual risk of individual death criteria that Safeware mentions in his first post on this thread, the JSP 553 1E-6 cumulative risk target or the civil aviation targets that Safeware also mentioned - all of these have something of a higher level justification sitting behind them too), design one that implies safety performance no worse (or preferably better) than the equipment currently exhibits, etc.

nigegilbert:

I agree with [HC's] assertion that MoD need to re-establish the post of Chief Engineer

There's a Defence Chief Airworthiness Engineer already in place - Air Marshal Kevin Leeson.

http://www.blogs.mod.uk/defence_news/2009/10/defence-in-the-media-29-october-2009-1.html

TorqueOfTheDevil

13th Nov 2009, 23:19

rarely, is the final act of the operator the SOLE cause

Disagree. I accept the main thrust of your argument, but aircrew error alone is to blame more often than rarely.

As stated before, I am well aware of my own potential fallibility - I'm not seeking to pretend that this is just someone else's problem.

nigegilb

14th Nov 2009, 08:27

Torque, the most topical fatal accident is the Sea King collision, given your comments above, how would you categorize that mid-air in terms of pilot error or otherwise?

You seem so certain that pilot error alone is a main factor, it is only fair to ask for a few examples.

flipster

14th Nov 2009, 09:44

TotD

As I mentioned, the operator is often the one left 'holding the baby' ie their actions, or inactions, could have prevented the accident - but are they the sole cause? No way!

In many cases, the last 'unsafe act' is product of the circumstances in which the operator is placed - poor design, supervision, fatigue, data overload etc. Other than in crashes where a pilot has been wilfully stupid, so many cases have been shown to involve a number of mitigating circumstances outwith the control of the operators. You may wish to cogitate upon the fact that this often suits the management - who are gulity of risk transfer...... 'they make it, we take it' - wittingly or unwittingly (in the case of Nimrod, Herc, Sea King, Chinook).

If you fancy, have a read of 'The Limits of Expertise' by Berman (NTSB), Dismukes (NASA) and Loukopoulos (NASA). ISBN 978-0-7546-4965-6. I would recommend this book to all aircrew and supervisors.

KR

flipster

woptb

14th Nov 2009, 12:01

As CH-C mentioned in his report the RAF 'can do' has masked many fissures & failings.It's been the RAF's glory & partly the cause of its undoing.
The men & women have worked within a culture which has gradually shifted (certainly within maintenance) where violation has become the tacitly accepted norm.People's attitude is that without this norm the RAF could not operate.
The challenge is to change the culture which has gradually arisen,for all the right reasonsie to maintain our dwindling capability.
The post H-C landscape will be very different, unfortunately (through no fault of their own) our people have become an obstacle.
Some of H-C's reccommendations regarding error management & Just Culture are already in train.This should create a framework for all to play the 'Airworthiness Card'. To enable a cultural shift to take place the most senoir levels of command must not only play their rightful part,they must be seen to do so.

nigegilb

14th Nov 2009, 13:12

My big concern is that the system wil swing wildly in the opposite direction in the post H-C world. I now work in civil aviation we carry snags in the same way as we used to do in the military. Someone mentioned to me the other day that following H-C report, reds and greens might disappear and people will be reluctant to put their name to paperwork, effectively grounding aircraft unnecessarily.

The big picture here is that H-C named 10 people who failed to implement airworthiness regulations within the existing framework.

I hope that fact is not lost in the melee following the report.

I see the two biggest problems as the legacy fleets at Brize Norton, namely VC10 and Tri Star. I suspect airworthiness concerns may well swing in their direction when the response to H-C is worked through.

The tear down of the Nimrod frame and the XV230 explosion has led to the virtual grounding of the fleet. One wonders what the tear down of the VC10 and TriStar might reveal........

The capability gap of going without Nimrod is a calculated but understandable gamble. However, the capability gap caused by the grounding of VC10 or TriStar would be a game changer. Never know, this report might yet lead to a considerable investment in the transport fleet. Lord knows it is overdue.

cornish-stormrider

14th Nov 2009, 15:23

Shift in the culture of maintenance - Violations?? me thick sootie but when I went through Cosford I was taught that there was no such thing as a sign off servicing. You did it, you signed it. and vice versa. How is it that when I got to my first sqn (as a wet behing the ears LAC mech tech ******) I was rapidly indoctrinated into the culture of laxity??

Poor leadership, lack of checks on the mech doing the servicing? lack of manpower and spares? Flypro pressure??

I'll confess to not doing all the zonals I might possibly have signed for as well as I would have with a trainer watching me but when you get told by the sqn training cell we do it this way and not the book way who do you go to for advice??

I'm not going to lie and say all my servicings were perfect but I never did one from the crewroom. (I don't think)

My point is (long winded I know) that if the culture on the sqn engineers can be so different from what I expect then surely the culture at MOD and BWOS can be more so.

Oh, sign it off - this aircraft will never be in those circumstances. it will cost XYZ millions to fix, thats an awful lot of pay rise we will lose........

Looking back I'd say I was a much better and more thorough engineer now than then, but the training I was given and the inegrity and attention to detail I was taught about still stays the same.

Airwothiness is a part of flight safety Yes/No?
If no then who cares, if yes then it is Everybodys Business

Point of order Mr moderator - The filter has banned a word I used. I call foul. This word was a derogatory name pinned on me and many others - we wear it with pride. I want my ****** back:E

Chugalug2

14th Nov 2009, 16:51

nigegilb:Someone mentioned to me the other day that following H-C report, reds and greens might disappear and people will be reluctant to put their name to paperwork, effectively grounding aircraft unnecessarily.
Strikes me you are touching on my other great soapbox item, the Powers of Subordinate Commanders! So gather round and I'll tell you tales of long long ago , when even Pontious was a Driver of Aerial Perambulators....
Most of my RAF Career was spent in total ignorance of AOC's, C-in-C's, CAS's, etc etc. The only brass you were accountable to, and who in turn were expected to mind you in turn, were the boss (ie Sqn Cdr, etc) and the Station Commander. Occasionally a charming elderly gentleman with loads of medals, rank and a sword would come to visit but then the boss and Stn Cdr were the ones who had you charging round in circles for his visit anyway. In the meantime everything started and stopped with the boss or Staish. That would include a policy about Captain's discretion, ie a good boss (as mine were) would back up his captains' decisions as to what fuel, what mel, what diversion, decisions etc they took, unless of course they were simply unjustified. Thus the boss exercised his discretion over his subordinates' discretion. They also took on and won battles with NAAFI, MPBW etc with the support of their commander, ie the Staish who used his discretion. As I understand it these same Subordinate Commanders have lost a lot of their powers and hence discretion. They have to get it back and start commanding again. The day to day cost may well rise as a consequence. All that I might say is that the MOD is about to hit by costs as a result of H-C that will greatly outweigh the bean-counters' savings in slashing Airworthiness, and of course the price in lives lost has been terrible. I have railed about all this before and been told that the clock cannot be put back. It must be!

themightyimp

14th Nov 2009, 18:42

There seems to be a wee bit of confusion here.

Risks are either Intolerable, tolerable or broadly acceptable. All risks should have the ALARP principal applied - even those that are broadly acceptable (according to Def Stan 00-56 Issue 4). However, if you have an intolerable risk you would be mad to spend all your time and effort addressing the 'ALARPness' of a broadly acceptable one prior to the intolerable one - it is all about criticality. This is a defensible position but not an excuse for not applying the ALARP principal to all your risks.

A quick analogy. You need your brakes on a car to be to a certain standard to operate effectively. Similarly, you need the rear seatbelts to function effectively (both 'risks' - I won't get into the risk/hazard debate here!). You need them both functioning to pass an MOT (~similar to the ALARP principal). If you drive the car, with a current MOT, and you don't generally use the rear seatbelt which risk do you address first? The brakes!

Secondly, we can all harp on about the golden age of Qualified Engineers (arguably equated to Chartered Engineer). With the new 'fast track' CEng open to RAF Eng Officers I would be worried at some of the SO2's who are eligible for this track to CEng - BTW not scare-mongering I feel that CEng has been devalued. I am a mentor for one of the Institutes and (hopefully) an interviewer. So a 'whinge' in perspective.

What also amazes me is the amount of people running around quoting H-C when they really don't have a clue (not talking about this forum btw). Remember ALARP is a verb not a noun as most people have been intimating.

Also, the eng v operators discussion has raised it head. It is a combined effort and no-one has the right to overrule anyone else. I remember an SAC ringing ATC to stop a jet leaving. The rest of the sorties were cancelled. Aircrew were not happy. Who was right? One of the most junior people. Don't judge this by rank/trade/branch. Remember there is no 'i' in Team (but there is a 'me')! :ouch:

TorqueOfTheDevil

14th Nov 2009, 20:27

Nige,

I'm not disputing the role of airworthiness (or lack of it) in accidents such as XV230, XV179, or the Sea King 7s - my point is more general and relates to all aircraft accidents.

a few examples

Off the top of my head:

All three Squirrel losses at DHFS since 2004
Puma at Catterick 2007, Basrah 2004, Abingdon 2003 and perhaps others
Several Jungly Sea Kings in Iraq, Lynx over Indian Ocean
Hawks all over the place, notably Mona '95, Portugal '96, Shap '99, Mona '01
Harrier avoiding Tucano over Northumberland
Nimrod in Canada, various Jaguar crashes etc etc

I should make clear that I'm not criticising the crews for their actions in all of these cases - far from it - but merely using them as examples of occasions when the actions of aircrew alone led to an accident/incident. If I have my facts wrong on any of these, I apologize profusely, but I'm reasonably confident in the list above.

Flipster

You're absolutely right - most accidents have several contributory factors. I just took exception to what appeared to be people seeing airworthiness as a bandwagon to jump on, when I think it's important to bear in mind that - more often than 'rarely' IMHO - the accident/incident is largely or solely due to the actions of the crew. Thanks for the recommend of the book - I look forward to reading it.

Roland Pulfrew

14th Nov 2009, 21:13

My big concern is that the system will swing wildly in the opposite direction in the post H-C world.

people will be reluctant to put their name to paperwork, effectively grounding aircraft unnecessarily.

Too late nige, too late. Law of unintended consequences I guess!! :hmm:

flipster

15th Nov 2009, 16:16

TotD

Thanks - Certainly in the military arena, where the operations can be 'closer to the edge' than in the civil world, there is more chance of the act of the final operator having a big say in the outcome. One could argue that the op tempo and level of tasking vs the lack of crews and frames is certainly a systemic factor (not to mention the ALQ/Taliban having a go).

Unfortunately, I don't think you can include ac and crews involved in earlier stages of trg- although goodness knows the bean-counters have constantly shaved away valuble experience and solo sorties out of most, if not all, trg syllabi; so perhaps some of these accidents could be construed as having systemic shortcomings. Even ones with an engineering input - Budgies' sad loss at Valley - have systemic influences. Sadly, I can't comment on all the examples you gave, sorry.

BTW Another good read is 'The Grown-Ups Book of Risk - or Why Sh!t Happens' by Omar Malik (available through that well-known, on-line book company with links to the sub-equatorial rainforests of Brazil!). You may or may not agree with Omar's politics (I do) but his assessment of the "science' of risk-managment, is spot-on, amusing and slightly worrying. He uses many good examples (including the MoK) of where a system's 'risk appraisal' has been hopelessly optimistic (against the advice of the coal-face, I might add).

flipster

c130jbloke

16th Nov 2009, 19:32

If Flipster's suggestions have not cured your insomnia, then also read:

The Field Guide to Understanding Human Error by Sidney Dekker

The Human Contribution by James Reason ( the better of the 2 )

Both available here http://www.ashgate.com/default.aspx?page=0

Prof Reason's book is a must IMHO :ok:

flipster

16th Nov 2009, 20:21

c130jb

Read both and agree with you - Reason's latest is very good.

f

Rigga

16th Nov 2009, 20:39

Beware of Prof Reasons' "Culpability Flow Chart" - it doesn't quite work!

deeceethree

17th Nov 2009, 18:14

Tappers Dad,

On 12 Nov you posted: "I am seeing Bill Rammel on Monday ....." and "I will post his answer on here on Tuesday morning."

Looking forward to any info you may have to share with us. Thanks.

Tappers Dad

17th Nov 2009, 19:50

Sorry guys too busy today ,I will put something on here tomorrow.

phutbang

17th Nov 2009, 19:52

Looking at the Scotsman, it suggests that those outside the MoD could be up in court HERE (http://news.scotsman.com/latestnews/Nimrod-crash-chiefs-may-.5829261.jp)...I thought the days of crown immunity and the likes of General Sir Sam Cowan, Air Chief Marshal Sir Malcolm Pledger, Group Captain George Baber, Wing Commander Michael Eagles and Frank Walsh could face the courts as well as those not in the MoD might...or should I stand corrected?

nigegilb

17th Nov 2009, 20:07

This was looked into a few months ago when charges were being considered against a former Govt Minister. As I recall, the charge of gross negligence manslaughter can be made against MoD, Ministers etc. For private companies I believe the charge is corporate manslaughter. Interested in the views of any legal eagles, there may have been some changes to the law since.

BTW all that is required is 5K to kick off a case against the former Minister. If anyone has a spare 5K lying around please PM me!

The interesting aspect of Haddon Cave's report is its status. It cannot be challenged. I wouldn't like to comment on the specifics of the news story in the above link, but it must be very worrying for those named individuals because the evidence is so damning and so clear.

Tappers Dad

18th Nov 2009, 21:40

Take a look at this from the Health and Safety Executive website http://www.hse.gov.uk/foi/internalops/fod/oc/300-399/335_1.pdf

I couldn't believe what I was reading on page 21 135:

Measuring performance

135 Absence of routine monitoring of health and safety objectives set appears to be an MOD weakness. The phrase ‘management by exception’ is used, indicating that if nothing is evidently wrong nobody checks whether it is actually right.

:ugh::mad:

Safeware

18th Nov 2009, 23:03

TD, while this may seem to "fit", I'd be cautious in considering it "evidence" - a) because it is so old b) because it is an "Operational Circular" for HSE Inspectors who may have to go to MOD establishments on shall I say "traditional H&S" work and c) it says "However, HSE’s policy is not to seek to investigate issues relating to airworthiness or aircraft crashes."

sw

Tappers Dad

19th Nov 2009, 09:02

Safeware
Worry not, this is not evidence as such, however it does however fit in with Haddon-Caves findings Re The Safety Case. Also with regard to the age of the document, it was written in August 2000 not to be reviewed until 2010 therefore it is current. Remember also that the Safety Case was compiled during the period 2001-2005.

The Secretary of State requires: “that the airworthiness arrangements for military aircraft should be at least as effective as those for civil aircraft contained in the [Air Navigation Orders], and should comply with the [Health
& Safety at Work Act 1974] where relevant.

Also
The Health & Safety at Work Act 1974 (H&SWA) lays down duties which employers owe to employees.
Section 2 provides:
“2. (1) It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.

http://www.mod.uk/NR/rdonlyres/CC4F4816-D663-42AA-959F-3022003A5D7B/0/leaf_47.pdf

HEALTH AND SAFETY RESPONSIBILITIES AND DUTIES OF MOD EMPLOYEES

In general, however, the HSE have made it clear that they have no intention of prosecuting an individual Crown servant in substitution for his Department. There is moreover no question of the HS prosecuting individuals because of defects in management organisation. Prosecutions of individual Crown servants would only be pursued in circumstances where the HSE would normally prosecute an individual employee or manager outside the Civil Service or Armed Services, e.g. if there were a wilful or reckless disregard of H&S requirements and a consequential contravention of the HSWA. As a rule,
though, the HSE have tended to regard the criminal law as a weapon of last resort.

But the bottom line is it is up to the HSE to investigate and decide if they failed to comply with The Health & Safety at Work Act 1974 and the subordinate regulations.

tucumseh

19th Nov 2009, 11:10

e.g. if there were a wilful or reckless disregard of H&S requirements and a consequential contravention of the HSWA.

While not a legal eagle, I'd say this just about covers it, given the number of times MoD officials and Ministers were told about this reckless disregard BEFORE the accident. Having been told and carried on regardless, that is willful.

Safeware

19th Nov 2009, 19:02

TD,

I have no issue with the MOD's requirements re duty of care and H&SWA, and that it has been lacking in this (airworthiness) and other areas - look at the various crown censures that have been issued over even the last few years.

My concern with this is that the HSE have divorced themselves from airworthiness in particular and functional safety in general. Therefore, wrt to the circular, the information therein is not in the same context. Also, while it says that it is valid until 2010, is that reasonable? Would a 10 yr old "audit report" be considered valid in any other context? Next year will the HSE consider that they need to change their policy? - I bet not.

Don't get me wrong, I'm not saying that the H&SWA and duty of care isn't a valid line of approach, just that whereas the HSE are there to police industry, they don't police the MOD in the same way.

sw

deeceethree

19th Nov 2009, 21:42

Tappers Dad,

Anything you can give us on the meeting with Bill Rammel? Thanks.

SirPeterHardingsLovechild

19th Nov 2009, 22:51

This was reported a couple of days ago -

BBC NEWS | UK | England | Somerset | Nimrod family seeking prosecution (http://news.bbc.co.uk/1/hi/england/somerset/8362939.stm)

The family of a man who was killed when an RAF Nimrod exploded over Afghanistan are calling for lawyers to consider a criminal prosecution......

.....Sgt Knight's parents have written to the Crown Prosecution Service (CPS) urging lawyers to take up the case.....

....Graham and Trish Knight have also written to the Health and Safety Executive (HSE) calling for an investigation into whether the Ministry of Defence (MoD) should be prosecuted for failing to ensure the airworthiness of the Nimrod.

Tappers Dad

20th Nov 2009, 08:32

deeceethree

The Bill Rammell meeting was something and nothing, something because he answered some questions we had. Nothing because we had to submit our questions in writing prior to the meeting and he will reply to those in writing . He is going to make a statement to the 'House' before Christmas on progress Re Haddon-Cave Review and what action if any is being taken on serving officers.

MrBernoulli

20th Nov 2009, 12:06

Thats interesting, Tappers Dad, thankyou.

tucumseh

20th Nov 2009, 12:11

Sir Robert Nelson to head independent review for QinetiQ (http://www.qinetiq.com/home/newsroom/news_releases_homepage/2009/4th_quarter/sir_robert_nelson.html)

The Board of QinetiQ Group plc today announces that it has appointed Sir Robert Nelson, a former High Court Judge, to oversee the company’s formal investigation that is underway into the conclusions and recommendations made in the Haddon-Cave report into the loss of Nimrod XV230.

Sir Robert will address the conclusions and recommendations made by Charles Haddon-Cave QC in the Nimrod Review. He will also assess the processes, structure and reporting requirements covering QinetiQ's advisory work in the UK and will propose the actions he thinks QinetiQ should take in response to the Haddon-Cave report.

He will provide an interim report to the Board of QinetiQ Group plc before the end of 2009. In the meantime all airworthiness advisory projects have been given an additional reporting line and the two QinetiQ employees named in the Haddon-Cave report have been suspended on full pay while the investigation is underway.

Sir John Chisholm, Chairman of QinetiQ said: “The QinetiQ Board has received a detailed briefing on the Haddon-Cave report and is determined the company learns from all that the report says. To ensure that this happens, we have appointed Sir Robert Nelson, recently retired as a High Court Judge, to oversee an independent investigation, proposing any actions he thinks are appropriate."

He added: "The Board believes that input from an independent third party will provide important impetus to our analysis of the lessons to be learned from the Haddon-Cave report. Sir Robert has the experience and expertise to oversee this process and the Board looks forward to reviewing his preliminary recommendations before the end of the year.”

Caustic Comments:

1. "In the meantime all airworthiness advisory projects have been given an additional reporting line" = We're resubmitting our quotes to MoD to increase the price for this advice, especially given they now want good advice.

2. "The Board believes that input from an independent third party will provide important impetus to our analysis of the lessons to be learned from the Haddon-Cave report" = Like MoD, we've systematically rid ourselves of the very people who told us all along we were doing the wrong thing, so haven't a clue which way to turn.

Safeware

20th Nov 2009, 16:57

"In the meantime all airworthiness advisory projects have been given an additional reporting line"

Not sure what that will do in reality - is it spin to make it look like they are adding an additional level of oversight? And what does it entail - lawyers?

Or is it because something is wrong with the current process?

Things may have changed recently, QQ having done the "lean" thing, but at the time in question:

Stage 1 - author(s) would review the available evidence, whether from industry, 3rd parties or QQ testing and write their report on this basis, making their RTS argument based on this evidence, cross-referenced as required for traceability. (JSP 553 requirement to be able to trace back from the RTS to the supporting evidence)

Stage 2 - Technical Assurance - those with such responsibility - Technical Leader / OC Test Sqn review the reports, giving due consideration to the recommendations being made, the rationale for such recommendations and the evidence supporting them.

Stage 3 - Release - the Technical Assurance Manager, having reviewed the report (as signed off as SATIS by Stage 2, attended review meetings, giving due consideration to the recommendations being made, the rationale for such recommendations and the evidence supporting them, signs off the report.

So, if done effectively (ie not as described by H-C), this is a robust system IMHO. Or are they now going to have the Technical Director sign off all reports. :*

sw

Mick Smith

20th Nov 2009, 19:38

I think it will be interesting. I think there may be a more nuanced view of QQ's role and it would be nice to have the precise detail of the genesis of that useful little phrase, which minister's and the MoD were so happy to have to fob off any critics, that the system was "tolerably safe". Odd no-one was prepared to accept until H-C came along that it was rubbish, including it has to be said some ppruners. That little phrase definitely wasnt in the first QQ report, which was pretty much a blanket condemnation without it. So who told them to put it there? Not that they should have agreed to, of course, but nevertheless.

Roland Pulfrew

20th Nov 2009, 22:13

Mick

Have you spent a bit too much time in The Angel tonight?? Care to translate that into English?:confused:

Mick Smith

20th Nov 2009, 23:10

I've read it through and it still reads as English to me but then I havent had any time to sober up yet!

Haddon-Cave criticised QinetiQ for the use of the term "tolerably safe but not ALARP" (p334). He says: "There is no such thing as 'tolerably safe but not ALARP'. Risks are either 'tolerable and ALARP' or intolerable.

But the QinetiQ report which used the words "tolerably safe" did not originally use those words. They appear to have been put into a second version of the report at the request of the IPT.

The claim that the aircraft was "tolerably safe" was then used by ministers (http://www.timesonline.co.uk/tol/news/politics/article3998966.ece) and the MoD press office to insist that it meant there were no problems when there were a number.

I am simply saying that the review ordered by QinetiQ seems likely to get to the bottom of who actually persuaded their engineers to insert words "tolerably safe" into their conclusions.

tucumseh

21st Nov 2009, 06:53

I am simply saying that the review ordered by QinetiQ seems likely to get to the bottom of who actually persuaded their engineers to insert words "tolerably safe" into their conclusions.

I hope you are right Mick. I confess I haven't seen it often, but I recall Boscombe (RWTS) being pressurised into downgrading recommendations and 4 years later a BoI report using precisely the same words as the original. 2 dead.

SirPeterHardingsLovechild

21st Nov 2009, 07:42

Mick, Safeware, Tuc, Flip, Nige

Have you considered writing direct to Sir Robert Nelson about this specific issue?

[Insert conspiracy theory:-
'Re-write your independant report or you won't get paid']

Having attended Human Factors training last week, I will not be content with the two names that this will throw up (probably already named)

I would like to know what factors caused them to act the way they did. If the individuals have any sense of self preservation, they will implicate the higher-ups who got us into this mess.

Not holding my breath, shades of the Dodgy Dossier

nigegilb

21st Nov 2009, 08:40

SPH, I know some of those mentioned, well at least one to my knowledge, is regarded as a good guy. Problem is, for far too long MoD culture has gotten away with decision making that has resulted in loss of life. In recent years it has been relatively low risk regarding the possibility of being accounted for. H-C has blown that wide open. As I stated before, his devastating critique has given prosecution lawyers something of a slam dunk case. My sympathy for the individuals is limited. They knew they were playing musical chairs, the music stopped and they happen to be in the firing line. They are also alive, which is more that can be said for the 14 crewmen sent to their deaths.

I welcome the idea of court cases. You touched on the fact that they might sing like canaries when the pressure is on and the very real possibility of a stretch inside is staring them in the face. We need the full story. Certainly one very senior person probably couldn't believe his luck when he didn't get a mention by H-C. I suspect the reluctance of some of those mentioned to fully cooperate/recall will change when they are placed in the dock.

Perhaps someone else can help me out? The recently announced QQ inquiry. Will it be published? Or will the results be covered up?

Tappers Dad

21st Nov 2009, 09:14

This may help or confuse the situation :

The ALARP (As Low As Reasonably Practicable) principle provides a means for assessing the tolerability of risk. In essence, it says that if the cost of reducing a risk outweighs the benefit, then the risk may be considered tolerable.

Ergo.a risk is ALARP if the cost of any reduction in that risk is grossly disproportionate to the benefit obtained from the reduction.

However if the risk to the aircraft is explosion or fire, then the benefit of reducing the risk is great. It follows that the cost of reducing the risk would have to be very high in order to say it was tolerable.

This is where I think the term tolerably safe stems from, I didn't see anywhere either in the BOI or Safety Case where the cost of reducing a risk was discussed or assessed.

I believe therefore that the XV230 was neither 'tolerably safe' nor ALARP as the risk in Dry Bay 7 was never assessed correctly and the mitigation put forward was erroneous.

To use a simple analogy, if the brakes need doing on your car because they won't stop the car, the risk to those on board is high and the cost is £300 say they have to be fixed to make it ALARP.
If there is danger to life or limb then even if the cost was £3000 it would not outweigh the risk. It can only be tolerable if the car is never driven or moved.

HSE guidance is that risks should be reduced unless the cost is “grossly disproportionate” to the benefit.

What cost would be “grossly disproportionate” to save the lives of 14 men and one Nimrod Mk2?

Having read most of Haddon-Caves report it is clear that certain companies wished to appear in a good light in order to 'please' the customer. This may explain the apparent anomaly between the first and second version.

Chapter 19 of thee HC review says:
(3) The meaning of “Airworthiness” is not sufficiently understood;
(4) The meaning of ALARP is not sufficiently understood;

Which says it all really.

He went on to say.
(10) QinetiQ failed to understand the meaning of ALARP

11.320 In my view, it is also a matter of concern that leading experts such as QinetiQ do not seem to understand basic concepts such as the meaning of ALARP (As Low As Reasonably Practicable).

11.321 The Executive Summary to QinetiQ’s Nimrod Fuel System Safety Review Report (QINETIQ/EMEA/IX/ SCR0702915,
October 2007, Issue 1) stated:
“Having considered the evidence referred to within this safety case report, noting that there are outstanding recommendations and the level of risk present to the fuel system is not ALARP, the operation of the fuel system is tolerably safe given the mitigation currently in place.” (emphasis added)

11.322 This report sowed much confusion. There is no such thing as ‘tolerably safe but not ALARP’. Risks are either ‘tolerable and ALARP’ or intolerable:

SirPeterHardingsLovechild

21st Nov 2009, 10:13

I would expect people involved in Airworthiness to have a definition of it framed on the office wall, but I'm a picture framer.

I think you are now barking up the wrong tree, this stage of your battle has been won. (Congratulations, Sir, and good luck for the future)

These guys knew exacly what they were doing. They fudged the issue and will now be held to account.

Why did they do it?

We already know the answer.

JFZ90

21st Nov 2009, 11:00

I could be mistaken, but I think there still remains much confusion over ALARP.

My opinion is as follows:

When HC talks about no such thing as "tolerably safe but not ALARP" he mentions the fact that the time aspect of the R has been misunderstood. This is consistent with many comments at the time made on here, e.g. in relation to TWA800.

My theory (only guessing here but seems to me the best fit):

It has been suggested that the original QinetiQ report did not mention tolerably safe and only said it was not (yet) ALARP. They probably stated this on the basis that the you could spend relatively little money to address some further residual safety risk (i.e. replacing seals). The report did not make it clear however that from a risk perspective it was reasonable to take x months to conduct this further risk reduction and continue flying - i.e. they thought it was tolerably safe. Hence it was flawed to state that it wasn't ALARP - it should have stated it was tolerably safe but a timely seal replacement programme should be implemented to address residual risk. This would be more consistent with established procedure - i.e. similar to post TWA800 Airworthiness directives where airlines were given years to rectify safety risks over a "reasonable" timeframe (hence this was ALARP decision making).

Hence, if the IPT asked for "tolerably safe" to be included* (i.e. properly reflected) then they were in fact just trying to get QinetiQ to write their report properly. It appears that they didn't do this right as when they added "tolerably safe" they didn't properly use the word ALARP or put it in the right context which has created no end of problems and misunderstandings.

I seem to recall Mick Smith used the QQ report wording of ALARP to imply SofS had lied to the house many months ago - looking now at the likelihood that the report should have said "tolerably safe" and not mentioned "not ALARP" (which was false as stated by HC), it can be seen that he wasn't actually lying. It can be seen however why the HC report criticises QQ for not understanding the term, and he mentions how this has created much confusion (I suspect this is a direct reference to Micks article).

PS I am not defending MoD here (I found HC gripping and alarming in equal measure) - just trying to put what is in my opinion the correct interpretation on the ALARP issue.

*don't know if this is true, just assuming that the accusation that they did is true for a minute which I know is dangerous!

nigegilb

21st Nov 2009, 11:27

If Nimrod [safety risk] is ALARP why is it (largely) grounded?

PPRuNeUser0139

21st Nov 2009, 11:30

Nige,
Your PM inbox overfloweth.. Just emailed you.
sv

Mick Smith

21st Nov 2009, 12:45

I seem to recall Mick Smith used the QQ report wording of ALARP to imply SofS had lied to the house many months ago - looking now at the likelihood that the report should have said "tolerably safe" and not mentioned not "not ALARP" (which was false as stated by HC), it can be seen that he wasn't actually lying.

Mick Smith didn't. He quoted Angus Robertson as saying Browne misled the house (http://www.timesonline.co.uk/tol/news/politics/article3998966.ece), and explained the evidence for this which hasn't changed as far as I'm concerned.

JFZ90

21st Nov 2009, 13:08

Mick, I see your point, but my main memory was just the headline:

Des Browne ‘misled’ MPs on Nimrod spy plane safety

Michael Smith

but to quote your own blog....

Defence consultants QinetiQ ruled in a report last year that the aircraft was “tolerably safe” but not ALARP. It gave the MoD a list of 30 issues that had to be sorted out before the aircraft could be safe. Under the MoD’s own safety rules, if the risk to the aircraft is only “tolerable” it must also be ALARP.

...you are making the case that there is something misleading going on by quoting specifically the QQ report "tolerably safe but not ALARP". Now that HC has now said that this phrase and therefore the wording of the report is contradictory and misleading, it follows that any argument based on them is potentially invalid. He also raises how the temporal aspects of ALARP were not correctly understood / ignored (and even stated as irrelevant by some).

The HC report has shed useful light on what the QQ report should have said. That is what has changed.

If you accept for a moment that the report should have said "the system is tolerably safe" and not erroneously mentioned ALARP - then surely you can see how the whole "its not ALARP, ground them" red herring would not have started - and the coroner could have been spared some blushes!

Like I said, I'm not defending MoD here - just safety engineering practice and logic which I fear is taking a real hammering here and clouding the real issues!

Mick Smith

21st Nov 2009, 14:11

I can see where you're coming from JFZ90 BUT the nub of the report concerned the 30 issues that had to be sorted to make it ALARP. QQ was originally saying it was "tolerable but not ALARP", so the 30 problems had to be eradicated to make it ALARP, (although I accept that there were a few that were no longer relevant because of the ban on air-to-air refuelling.)

QQ was then persuaded to make it read 'tolerably safe', one suspects because it as easier to play down the importance of a critical report. So on that basis I stick by that quote from my blog.

I'm not playing down QQ's blame here, or imagining some conspiracy theory in which H-C somehow used them as a patsy for the IPTL - which could scarcely be the case! - only saying that the situation was more nuanced than it appears in the black and white of H-C's report, and that the QQ review, since it will focus on the QQ side of things, and question the person responsible for agreeing the change in a more protected atmosphere, is therefore likely to elicit greater detail, and is bound to get to the bottom of what actually happened there.

On the headline, the quotes around the misled means it is someone alleging it, not absoluted hammered down fact. I absolutely concede it is itself misleading but I don't make the rules on headlines - or even write the headlines - and with all its flaws, that usage is an industry standard. I suspect it is pretty much the best that can be done with the space the headline writers get.

I certainly would not accuse a minister of lying over something like this because he just gets the advice from civil servants and service officers and while he may well question it, will be easily reassured that it is correct, whatever the facts. This is actually, incidentally given the thread we are on, even more of the case with ministers' responses on the Sea King issue.

Not that I have much sympathy with the ministers here. It has to be said that they created the situation in which bad news - often arising from their own decisions on budgets - was unwelcome however unavoidable and therefore have some responsibility for the way in which the civil servants and service officers advising them seem increasingly to act more like courtiers reassuring an emperor than professionals making professional decisions and telling the minister the way it is.

nigegilb

21st Nov 2009, 15:41

I understand it has so far cost 30 million to rectify the scp and fuel pipes/seals.

JFZ90

22nd Nov 2009, 14:09

If Nimrod [safety risk] is ALARP why is it (largely) grounded?

I understood that the ALARP consideration gave the nimrod fleet until date X to rectifiy the seals. It looks like a decision was taken not to take the operational impact of doing all the seals by this date (i.e. you'd have to tie up so many airframes in depth / out of the flypro that it would impact ops). This was probably on the basis it still gave time to get a mitigating op capability in place. Once this was decided, it was clear that once the date was reached the ac that hadn't had the work done would be grounded until they were fixed.

In any other circumstances an extension to the timeframe may have been considered/granted on the basis of risk, but I suspect this was not sought on the basis of political grounds (i.e. whilst potentially OK from an engineering risk perspective, it might look "bad" from a presentational perspective to be extending the deadline - given the fact that there is still media confusion over ALARP anyway, I think its true that there would have been an media uproar if they had tried to do that).

I understand it has so far cost 30 million to rectify the scp and fuel pipes/seals.

Not sure what your point is - either the cost is so high a judgement could have been made to say it was ALARP anyway without doing the seals? Per ac it seems to me a lower ££ than the cost of losing a crew, even though it seems the contribution of the seal issue to such a event seems very very low (given any ac design must cope with fuel leaks in any case). Is your cost correct just for seals, or mixed up with routine servicing?

Or is the seal issue much more of an issue that I'm led to believe above?

nigegilb

22nd Nov 2009, 17:59

Maybe I misunderstand something now. How could Nimrod be ALARP with a time line? Surely it is either ALARP or it isn't? I remember a conversation with someone involved at the time. He was keen to tell me that the new standard was being allegedly described by Vsenior officers as ALARP plus. IE the aircraft ALREADY met the requirements for ALARP, nut once the peripheral work was completed the aircraft surpassed the requirements for ALARP.

I suspect the political involvement became obvious at this stage. Furthermore, your argument about seals and the fact that all aircraft suffer fuel leaks was dealt with by H-C, he was unimpressed.

Surprised you are still using the same line.

Regards,

Nige

JFZ90

22nd Nov 2009, 19:34

Maybe I misunderstand something now. How could Nimrod be ALARP with a time line? Surely it is either ALARP or it isn't?

HC makes reference to how the temporal (time) aspect of R (i.e. reasonable) in ALARP is widely misunderstood (but highlights how QinetiQ should know better). I.e. it is reasonable for it to take time to embody safety design changes, depending on the residual risk. TWA800 is a case in point where airworthiness directives gave Airlines years to modify their aircraft - on the basis that to ground all the worlds airliners until they were all modified was unreasonable in proportion to the risk. Obviously if the residual risk is such that another loss is not remote, then you do ground the fleet (e.g. Buccaneer - 1980 - most of the fleet 6 months on ground).

Furthermore, your argument about seals and the fact that all aircraft suffer fuel leaks was dealt with by H-C, he was unimpressed.

Doing all you can to avoid leaks is the design aim - but from an engineering perspective you can't make the probability of a fuel leak so remote that you don't have to mitigate (i.e. design) against their occurance. You can't be sure an aircraft won't leak - but you need to be confident as you can be that such a single failure won't cause the loss of the aircraft. HC does comment (p66) that this is a common philosophy across civil and mil. His main criticism is that he feels that (perhaps due to this this philosophy) there had been complacency in the management of fuel leak trends etc. - i.e. more could have been done to understand & reduce fuel leak risks. I wouldn't dispute this. I don't think he says you can eliminate fuel leaks altogether.

nigegilb

22nd Nov 2009, 20:01

Fair answer, I have 747 experience, we adopted procedures approved by Boeing to reduce the chance of a CWT pump issue whilst the aircraft were modded, true enough.

I am just curious about ALARP Plus. I don't hear it used anymore, funny that!

Rigga

22nd Nov 2009, 21:23

JFZ90 - Spot-On!

There is no leakproof or defect-proof system - only more leak resistant or more reliable systems.

Modifications come out all the time, due to the findings/reports of analysts and end-users, and each Airline vets whether the Mod is suitable or not for them - unless it is mandated.

Even before the Mandatory Mods are published, plans are (or should be) made, by the mandating authority and the OEM, to ensure the right parts are available for the affected fleets and the dates to comply with mandated mods are also mandated because they KNOW the availability of said parts. The risks in NOT embodying the Mods may involve the grounding of the fleets.

Some Mandated Mods are subjected to fleet planning and implementation times that may, in some way, risk an incident that is considered acceptable during that implementation time.

I (rather naively, I suppose) assume these risk values are very similar to those published in the CAA/ICAO SMS risk value charts and are, I suspect, "your" ALARP Plus items - on their way to being ALARP.

However; should I assume MOD would not be using CAA/ICAO values?

Squidlord

27th Nov 2009, 09:59

Tapper's Dad:

The ALARP (As Low As Reasonably Practicable) principle provides a means for assessing the tolerability of risk. In essence, it says that if the cost of reducing a risk outweighs the benefit, then the risk may be considered tolerable.

Replace "tolerability" by "acceptability", and "tolerable" by "acceptable" in the above and it would be more correct. "Tolerability" and, especially, "tolerable" are loaded words with specific meanings in the context of risk assessment so it would be more correct to use "acceptable" and "acceptability" (with generic meanings).

However if the risk to the aircraft is explosion or fire, then the benefit of reducing the risk is great. It follows that the cost of reducing the risk would have to be very high in order to say it was tolerable.

(Substitute "acceptable" for "tolerable" again.) This ignores the probability component of risk. If the probability of explosion or fire is very small then the risk is also small and so the cost of risk reduction would not need to be so high to sustain a claim that the risk was ALARP and *acceptable*.

So when Tapper's Dad writes,

What cost would be “grossly disproportionate” to save the lives of 14 men and one Nimrod Mk2?

the answer depends on what associated probability is. If it could be shown that this probability was *correctly* assessed as being very very low, then the answer would be not much money at all. I.e., the risk could have been correctly considered ALARP. I emphasise the word "correctly" because, of course, this was the fundamental failing of the Nimrod risk assessment prior to the disaster. They very badly (negligently in my opinion, and that of Haddon-Cave, I think) underestimated the risk.

This is where I think the term tolerably safe stems from

I doubt it very much. (JFZ90 and Mick Smith as well,) see my post #46 in this thread.

I didn't see anywhere either in the BOI or Safety Case where the cost of reducing a risk was discussed or assessed

I don't know/can't remember whether Nimrod IPT even assessed the ALARP status of the risks associated with the XV230 disaster. But the fundamental point was that they completely mis-assessed that risk. ALARP determination is secondary to risk estimation. If you severely underestimate the risk, as Nimrod IPT did, whether or not you do an ALARP assessment (correctly) tends to be irrelevant.

As you say ...

I believe therefore that the XV230 was neither 'tolerably safe' nor ALARP as the risk in Dry Bay 7 was never assessed correctly and the mitigation put forward was erroneous.

(Best not to use the term "tolerably safe".) Possibly the risk of operating XV230 was "tolerable" (in the specific meaning of that word in the risk assessment context). But this is not enough. It needs to be tolerable and ALARP. It was certainly never demonstrated ALARP (correctly) and it seems extremely unlikely that it was ALARP.

Tapper's Dad quotes Haddon-Cave

Chapter 19 of thee HC review says:
(3) The meaning of “Airworthiness” is not sufficiently understood;
(4) The meaning of ALARP is not sufficiently understood;

I agree entirely. I could write an essay on the term "airworthy" (personally, I would like to see the term scrapped because it is so ill-defined - we should just use the term "safe" instead). I have written essays on the meaning of "ALARP". It's a contentious principle for determining the acceptability of risk and, in my opinion, one of the best reasons for dumping it is its complexity and difficulty.

Having said all that, Haddon-Cave betrays a possible lack of understanding himself:

11.322 This report sowed much confusion. There is no such thing as ‘tolerably safe but not ALARP’. Risks are either ‘tolerable and ALARP’ or intolerable

I don't think this is true. Risks can be "tolerable" but not ALARP. The language of risk assessment ("tolerable", "broadly acceptable", etc.) is unfortunately pretty badly put together but we are stuck with it now (like "airworthiness"?). So it doesn't surprise me that Haddon-Cave doesn't seem to have quite got it right (or his understanding of ALARP and Safety Cases) but it does suggest to me that it would have been better had he retained someone who could authoratatively advise him on risk and safety technical issues, e.g. Professor John McDermid (who is acknowledged in the report but didn't actually fulfill that role) or a senior HSE person.

SirPeterHardingsLovechild:

I would expect people involved in Airworthiness to have a definition of it framed on the office wall, but I'm a picture framer.

In my experience, most people involved in MoD safety don't actually know what the MoD definition of "safe" is. Ok, you might say, they could always look it up if they needed it. But they don't! I have seen so many MoD Safety Cases and safety assessments and the majority (yes - the majority!) use the wrong definition of "safe". It is pitiful.

So I'm not surprised if the same people don't know the definition of "airworthiness" or "ALARP".

JFZ90:

The report did not make it clear however that from a risk perspective it was reasonable to take x months to conduct this further risk reduction and continue flying - i.e. they thought it was tolerably safe. Hence it was flawed to state that it wasn't ALARP - it should have stated it was tolerably safe but a timely seal replacement programme should be implemented to address residual risk. This would be more consistent with established procedure - i.e. similar to post TWA800 Airworthiness directives where airlines were given years to rectify safety risks over a "reasonable" timeframe (hence this was ALARP decision making).

Hence, if the IPT asked for "tolerably safe" to be included* (i.e. properly reflected) then they were in fact just trying to get QinetiQ to write their report properly.

[...]

the report should have said "tolerably safe"

and in a later post:

If you accept for a moment that the report should have said "the system is tolerably safe" and not erroneously mentioned ALARP

This second quote manages to get the situation completely wrong. See my post #46 in this thread. The report was absolutely not erroneous in mentioning ALARP. It was erroneous in mentioning "tolerably safe". This is precisely the point Haddon-Cave makes (and I agree completely with the first two paras of Mick Smith's post #89). Firstly, the term "tolerably safe" should not be used without definition (and preferably not at all). Further, you do not write a report "properly" by using ill-defined terminology and it is definitely not the case that "they were in fact just trying to get QinetiQ to write their report properly". If the inclusion of the words was at the behest of the Nimrod IPT, I would be very surprised if it was anything other than an attempt to make the situation sound less bad that it was, i.e. "weasel words".

Secondly, my recollection of the QQ recommendations to address ALARP is hazy but I do recall they included some that would be considered fundamental good practice. It is generally considered (i.e., it is HSE guidance) that to demonstrate a risk is ALARP, it is necessary to apply all relevant good practice. Ergo, the non-ALARP status was nothing to do with timely implementation of risk reduction.

At the end of this post, I write more on the temporal aspects of ALARP.

JFZ90 quoted Mick Smith's blog:

Under the MoD’s own safety rules, if the risk to the aircraft is only “tolerable” it must also be ALARP.

This is potentially misleading as it suggests that "tolerable" risks are automatically ALARP, which is not the case. It would be correct to say, "if the risk to the aircraft is “tolerable” it must also be shown to be ALARP".

JFZ90 in another post:

In any other circumstances an extension to the timeframe may have been considered/granted on the basis of risk, but I suspect this was not sought on the basis of political grounds

Although I don't know precisely why the Nimrods are grounded, I agree with the principle of this. The ALARP principle is only one means of deciding whether a risk is acceptable (it just happens to be a necessary one).

Some more words about the temporal nature of ALARP.

Nigegilb wrote:

Maybe I misunderstand something now. How could Nimrod be ALARP with a time line? Surely it is either ALARP or it isn't?

It is much much more complex than this. Leaving aside the fact that ALARP is a property of the risk of the way an aircraft (or other equipment) is operated, not just a property of the aircraft itself, e.g. see

http://www.pprune.org/military-aircrew/242005-nimrod-crash-afghanistan-tech-info-discussion-not-condolences-post4214180.html?highlight=car#post4214180

there is, as Haddon-Cave alludes to, a temporal aspect to ALARP ...

Within MoD safety circles, there a is principle doing the rounds that is often referred to as "temporal ALARP", though use of this precise term is discouraged. The idea is roughly as follows. If you identify a (single) risk reduction that is necessary to reduce a risk ALARP and if that risk reduction would necessarily take some time to implement (e.g., a significant design change to a fuel system) then you may claim the risk is ALARP pending implementation of the design change as soon as practicable (and afterwards as well). There are (at least) three flaws with this.

1. You must show that the risk of operation pending implementation of risk reduction is ALARP. It might seem obvious that you can't do this. After all, that is why you are implementing the long-term risk reduction. But this ignores the exposure aspect of ALARP. In essence, the longer your exposure to a risk, the less likely it is to be ALARP (because that risk is more likely to precipitate an accident(s)). So it is possible, in principle, to demonstrate that the risk of operation pending implementation of the long-term risk reduction is ALARP. However, the "temporal ALARP" principle, as I've always seen it stated, does not require an explicit consideration of ALARP status pending risk reduction. And it is always possible to reduce that risk, e.g. by taking the equipment out of service (grounding an aircraft). There is, effectively, an assumption that the operational imperative makes removal from service impracticable but this assumption does not always hold.

2. So you decide to implement long-term risk reduction, e.g. a design change, as soon as practicable. What's to stop you from constantly delaying that design change, letting it slip to the right, etc? (not a problem with the principle itself but a problem with its application). I have seen this happening already.

3. The principle is already being abused. It was intended to be applied, where ALARP status has been assessed, to justify continued operation pending long-term risk reduction. It is also being used to justify continued operation where ALARP status hasn't even been assessed ("we've plans to do the ALARP assessment in the future so under "temporal ALARP", pending that assessment, our risk of continued operation is ALARP"). Arrrrghhhh!

Haddon-Cave supports some kind of "temporal ALARP" principle (as do I) and, as JFZ90 suggests and Rigga confirms, similar ideas are enshrined in, e.g., civil aviation. But such civil aviation ideas are much more closely bounded to address the three flaws above.

tucumseh

27th Nov 2009, 16:17

SPHLC

I will not be content with the two names that this will throw up (probably already named). I would like to know what factors caused them to act the way they did. If the individuals have any sense of self preservation, they will implicate the higher-ups who got us into this mess.

Squidlord

In my experience, most people involved in MoD safety don't actually know what the MoD definition of "safe" is. Ok, you might say, they could always look it up if they needed it. But they don't! I have seen so many MoD Safety Cases and safety assessments and the majority (yes - the majority!) use the wrong definition of "safe". It is pitiful.

I am uneasy about the 3 IPT staffs being named. As SPHLC says, they knew what they were doing, fudged it, and must now stand to account. However, H-C makes much of the need for a “just” system. It is unjust to name 3 juniors (a Gp Capt is very junior in this context) yet disregard the management chain above them. Where was the management oversight and leadership? I do not think either H-C or MoD wanted to go there, because one would immediately see the links to other accidents.

Squidlord is right about the lack of understanding in MoD, and one significant reason is the above senior staffs (2 Star and above) have consistently ruled over many years that the safety and airworthiness regs can be waived. In particular, that physical safety is sufficient, functional safety can be ignored. When staffs see what happens to those who press for the regs to be implemented, is it any wonder they tend to switch off a little?

While no comfort to those who lost loved ones, at a certain level at least the Nimrod IPT understood they had to implement the regs and tried to do so; albeit incompetently. What is the greater offence; that incompetence by the Nimrod IPT, or the abrogation of duty of care by their seniors and other IPTs who don’t bother in the first place? I’ve asked that before and have written replies from two 2 Stars and a 4 Star, who state those who ignore the regs are in the right. The Nimrod IPT problem can be corrected relatively easily. The real problems lie elsewhere. I suspect MoD will be trying to fix the former while shoving the latter under a carpet. But, as someone said, the H-C report was Day 1.

Tappers Dad

27th Nov 2009, 17:45

I received this from the top(well near the top)

Haddon-Cave Review Implementation Team (HCRIT)
HCRIT is an independent organisation that has been directed by the Second Permanent Under-Secretary (2ndPUS) to set specific requirements on the key airworthiness organisations to ensure they deliver the required outcomes, as agreed by the Secretary of State. Thereafter, the Team will be responsible for the coherent management of the requirements and for policing the implementation across Defence against agreed outputs and timelines, with the appropriate organisations managing any changes that are called for within their respective areas of responsibility. Specifically:

a. Inform 2ndPUS and the Nimrod Review Analysis Sub Group
(NRASG) on the impact and implications of the recommendations made by the Review.
b. Produce an implementation plan for the required work to be agreed by NRASG.
c. Deliver clear understanding throughout the implementation
across all air domain stakeholders of the impact of the Haddon-Cave Review recommendations.
d. Lead and champion implementation across the air environment, negotiating as necessary the reprioritisation of activity to meet the Department's commitment to the delivery of Haddon-Cave findings.
e. Orchestrate any follow on work that is required to facilitate or understand the recommendations.
f. Provide periodic updates to 2ndPUS on progress, identifying barriers to implementation that cannot be resolved.
g. Liaise with external agencies where recommendations have
implications to both the non-air environment and agencies outside of the Ministry of Defence.

I am not sure about f. identifying barriers to implementation that cannot be resolved.But it sounds like a good start.

JFZ90

27th Nov 2009, 18:21

This second quote manages to get the situation completely wrong. See my post #46 in this thread. The report was absolutely not erroneous in mentioning ALARP.

I'm not sure you're right - actually for the reasons that you outline in post #46 - i.e. I agree with your point that "tolerably safe" should be defined if it is to be used in any meaningful way. The same of course applies to using the term ALARP.

I think the view on whether my quote is correct depends on what you think the meaning/conclusion of the report should have been. Given this report was post the accident, post the steps taken to remove the ignition source etc., I believe its intention was to report on whether the fuel system within the new context was actually "safe" (or not).

Hence - you either think:

A) the report concludes that it was "not safe enough", in which case this should be reflected in the conclusion. This could make reference to risks remaining are so high that they are e.g. intolerable and require fixing before flight ops continue - this could have resulted in the fleet being grounded. The risk would have to have been quantified to substantiate such a conclusion.

or

B) the report concludes that it was "safe enough", in which case this should also be reflected in the conclusion. This would then require a conclusion that outlines that the remaining risks were defined to be tolerable. The risks would have to have been quantified to substantiate such a conclusion.

I agree the terminology can be confusing - but given that I don't believe that the Nimrod fleet was grounded following this report I can only conclude that the report message was intended to be B). In this context it was therefore misleadingly for the report to mention it was not ALARP - to do so would have ignored the temporal aspect.

Also - it is not necessarily the case that QQ in writing the report have access to the costs involved in mitigating risks - for this reason alone it is unclear on what basis they were making an ALARP assessment - is it quantified in the report? By the same token they don't quantify tolerably safe. I think the intention was to give the B) conclusion - in which case any assertion the it was tolerably safe should have been quantified and hence justified more clearly.

In either case A) or B) the risks are not quantified so it could be argued the report is fundamentally flawed in any case.

On this basis it is also true that you can't actually use the report as the basis to say some minister/RAF officer/civil servant has lied.

Squidlord Risks can be "tolerable" but not ALARP

Willing to be be proved wrong, but I think it is you, not HC, who has this wrong. Give us an example of such a risk? It doesn't make sense.

Lyneham Lad

27th Nov 2009, 18:43

I have just been catching up on this thread and read the in-depth discussions re QQ and MoD failings. However, I see no mention of BAE. The last time I read comment on them, it appeared that they were covering-up par excellence (or head in the sand). Surely they and their failings should still be centre-stage?

Rigga

27th Nov 2009, 19:38

LL - Although the RAF and QQ have made some forms of acceptance and adjustment statements I dont think BAE have (yet). So it is difficult to remark on any change in their stance to date.

Example of Tolerable: - Mainwheel tyre rapid deflation on landing.
Likelyhood is high - Consequence is Potentially Fatal.

CURE is to build a totally damage resistant tyre (of approx 1 ton(ne) weight). and having to redesign the whole aircraft to pick the landing gear up!

Within my understanding of "As Low As Reasonably Practicable". The practicality aspect has passed the 'reasonable' point.

...unless you know a better example?

JFZ90

28th Nov 2009, 10:08

Rigga

That is a bad example for a number of reasons - are you pulling legs?

If it was high prob & likely to be fatal - then it clearly is never ever going to be a tolerable risk.

PlasticCabDriver

29th Nov 2009, 17:20

Rigga, you seem to have fallen into a common trap, which is to take the probability of something happening and then apply the worst severity to it to generate a risk.

If this was an aircraft with a large number of mainwheels (B52 or similar?), then the probability of a single tyre failing on landing may indeed be high, but the probable severity of that is unlikely to be a fatal accident. Of course you should consider the situation where a failing tyre does somehow result in a fatal accident, but the likelihood of that occurring will be much more remote. You will then have 2 risk factors, both of which would be closer to the real risk. IIRC, a fatal accident is always classed Catastrophic (happy to be corrected though), so anything higher than a Remote probability in this case would lead to the risk classification of A – Unacceptable. This would seem to rather overstate the actual risk of a single tyre failing on something like B-52 causing a fatal accident. That’s not to say it can’t happen (Concorde?), but that it is very unlikely.

Rigga

29th Nov 2009, 20:21

Perhaps I should have said "Hypothetical..." and my assessment was swayed by ### Police risk assessment training - where everything ends in a death or a potential death! (no, I don't work there now)

...Adjust the risk constituents to your own values - my point was to get the 'practicability' to exceed 'reasonable'-ness.

IMO The complete elimination of blow-outs can only be achieved by the removal of the gas element from tyres.

Apply this to any (wheeled landing gear) type you wish and discuss the changes required.

...and like I said - Unless you know of a better example?

nigegilb

30th Nov 2009, 07:58

Got airborne off the grass at Valley on one occasion, after a main tyre burst. Half an hour later landed safely and a nice fireman helped me out still on the runway.

Transfer your scenario to an airliner and you wouldn't even abort the take off at high speed for a tyre failure.

Not a good example at all. Landing an airliner with a tyre failure is straightforward. Concorde is interesting, but don't get me started on fuel tank protection!

Problem is that v senior officers did not appear to understand safety management systems. Was chatting to a middle ranking officer the other day, he was explaining that at his level the understanding of what they are trying to achieve is improving all the time. I was reassured that in response to H-C the military will not swing violently in the opposite direction. There are a lot of bright minds out there, just a question of pointing them in the right direction.

Signs are encouraging from what I can see, simplistic arguments put forward by Rigga do not reflect the current thinking IMHO.

raedwald

1st Dec 2009, 10:14

I have just been shown the Nimrod report - isn't it amazing how someone can be so wrong and so self-satisfied about it. Perhaps the QC should have listened to the York safety folk or gone to the local library rather than jetting off to the States at Taxpayers' expense.

There are 3 main elements in an ALARPassessment and a couple of influencing elements. First there is the tolerability measurement. There are 3 levels of tolerability: intolerable, tolerable and broadly acceptable. These are set with one of the influencing elements in mind - the industry sector or the environment (ie what is tolerable in the aviaition industry may be acceptable in a coal mine). Second there is the ALARP judgement. Third there is the acceptability of the risk. These are influenced by the passage of time.

The QC is quite wrong to say that a tolerable risk that is not ALARP is intolerable. It is generally unacceptable - but in principle any risk can be accepted in dire circunmstances - but once it is determined it fits into the tolerable basket there it stays unless the measurment of tolerability changes.

ALARP is more difficult. The 'temporal' bit has 3 ways of interpretation - all valid. The obvious one is that risks change with time and you should re-evaluate then regularly. The second is that just because your competitor has brought in a safer piece of equipment than the one you are using does not mean that you have to retrospectively apply a higher standard to your old kit - relevant to the old Nimrod. The third is that once you have determined that there is a reasonably practicable measure that you could take you are no longer ALARP but clearly there is no reason why your kit suddenly becomes unacceptable - there is a reasonable amount of time allowed to become ALARP again.

As for tyre burst - that is why you have a clear area around a runway as an ALARP measure. Just take care when you put in your runway monitoring radar to allow enough space!

Distant Voice

1st Dec 2009, 11:39

In his report he stressed the point that the "R" in ALARP has a temporal element, and criticize the Coroner for calling for the grounding of the Nimrod, because in his opinion "a reasonable time is allowed" to mitigate identified risks. He makes constant reference to Lord Cullen's guidance in the Edwards v The National Coal Board in which Cullen states:

"'Resaonably practicable' is a narrow term than 'physically posible' and seems to imply that a computation must be made by the owner in which the quantum of risk is placed on one scale and the sacrifice involved in the measures necessary for averting the risk (whether in money, time OR trouble) is placed in the other, and that, if it is shown that there is gross disproportion between them - the risk being insignificant in relation to the sacrifice - the defendants discharge the onus on them"

Now, having read Lord Cullen's findings, and the Health and Safety guidelines, I believe that "time" in this context means downtime (lost time) of the plant or equipment and its associated costs and trouble. It does not mean, as Group Capt. Hickman (inquest witness) and the QC claim that "we have got time to reduce the risk to ALARP". In the case of the current hot air duct replacement programme "time" means the downtime of the aircraft and/or the trouble of not having them operational. It does not mean, as Group Capt Hickman suggested at the inquest, that he had until mid 2009 to complete the modification, and that aircraft were "tolerably safe but not ALARP".

In Lord Cullen's findings "time or trouble" are linked and viewed as a "sacrifice", or cost to be borne by a company or organisation in order to achieve ALARP. To view "time" in the manner in which the QC described in his report can only be seen as a let out, not a sacrifice.

DV

SirPeterHardingsLovechild

1st Dec 2009, 18:42

I'm not quite sure why you chaps are debating definitions to this depth.

It's plain & simple, to me.

JFZ90

1st Dec 2009, 23:12

Radweld The QC is quite wrong to say that a tolerable risk that is not ALARP is intolerable.

Does he say this? I don't recall him saying this - can you point to the page in the report? I thought he was saying quite the opposite.

DV Now, having read Lord Cullen's findings, and the Health and Safety guidelines, I believe that "time" in this context means downtime (lost time) of the plant or equipment and its associated costs and trouble. It does not mean, as Group Capt. Hickman (inquest witness) and the QC claim that "we have got time to reduce the risk to ALARP".

By the same token, would you therefore argue airlines should not be given several years to implement ADs and minimise their downtime? They are certainly given it. The "sacrifice" to MoD is not necessarily different in terms of down time - if anything the loss of assets in theatre that maybe saving lives on the ground is a greater sacrifice than that of a civil airliner being on the ground when it is just making money for its shareholders.

tucumseh

2nd Dec 2009, 06:33

The concept of time (urgency) to embody a safety modification is dealt with in Def Stans 05-123, 125 and elsewhere. The decision manifests itself in the Class of modification.

For example, a Class 1 (Service) or A (Contractor) mod is “essential for safety, the absence of which would involve, or may have already involved, the grounding of aircraft, the imposition on the use of aircraft, vehicles or ground equipment, or the shutdown of ground radio installations. They MUST be embodied, irrespective of the scrap or equipment downtime involved”.

In practice, the problem is failure to apply the mandated regulations. These regs require complete independence in that the decision must not be made by the proposer of the modification (normally the IPT or the Design Authority).

The regs still state that the proposer shall submit a “Cost and Brief Sheet” to the relevant HQ Mods Committee, the chairman of which holds a key person in the airworthiness chain. Such is the independence required that, should the Chairman be a MoD Technical Agency (the named individual responsible for maintaining the Build Standard) in his own right and his name appears on a modification proposal, then he must hand over the decision to the Deputy Chair.

It follows that if a mod is deemed Class A or 1 (when safety is involved, this decision is normally made within hours, before work commences to develop a mod) then the RTSA is automatically informed so that the question of grounding can be addressed.

Of course, this system was effectively scrapped in 1992 with the disbandment of most HQMCs. The mandated requirement for independent scrutiny was lost as the proposer was given authority to decide. That meant other factors (financial mainly) could cloud their judgment.

In practice, this immediately resulted in a raft of mods being hastily “approved”, many falling into the “nice to have” or complete bollox category. Then, a safety mod requirement would come along and there was no in-year money left, so you would get urgent mods deferred (by financiers, who were given the authority to over-rule engineering/safety decisions). Also, the HQMC would always ensure provision was made for support, training, embodiment etc. Not any more – the rush to buy the mod sets would be followed by a hiatus lasting years as squadrons, workshops and contractors were overloaded with unplanned work. Anyone at 2nd line sees the result on a daily basis.

If you read the criticisms in the Haddon-Cave report, very often the solution is to simply follow these regulations.

The above raises a few questions, including;

Why, if the current practice does not reflect the regulations, have the latter not been changed? Answer – because formally changing them would bring senior staffs into conflict with PUS, whose mandated regs they ignore. D/Stan can’t bring themselves to amend the books because they would be forced to take sides, so just leave them. For example, the key Def Stan, quoted above, has not been amended since January 1990, yet every MoD Technical Agency should know it off by heart. Today, few have heard of it. It calls up 20 specifications instructing Technical Agencies on how to maintain, inter alia, safety, but try asking D/Stan for a copy of them. Why is it ignored? Because funding has been cut so far that IPTs very often simply cannot afford to maintain safety, so you get to the stage where new entrants are simply not taught what they are meant to do. They lose sight of the need for safety to the point, nowadays, where people are shouted down (or booed, as happened on Nimrod) and told not to waste money maintaining airworthiness.

Has senior MoD management been informed of this critical safety issue? YES. The last time I did so was January 2000, to a 3 Star (DCE of DPA). He didn’t reply. Perhaps if he did the IPTs would have been directed to comply with the regs and this thread wouldn’t exist. However, I do realise that if he had done something he, in turn, would have had to choose between the regs and his boss (CDP) who had already ruled that functional safety was optional. But, a 3 Star gets paid a lot of money to make hard decisions and have quiet words in the boss’s ear. A mere project manager is paid peanuts to make decisions within his remit, and seek decisions outwith his own remit. Any breakdown in this process leads to …… Haddon-Cave.

Finally, and no apologies for labouring this point, but the H-C report contains absolutely NOTHING new that has not been notified to senior staffs and Ministers numerous times over the last 18 years. To quote MoD’s own Directorate of Internal Audit (June 1996) when reporting to PUS… “We are unable to provide an assurance to PUS that (the above regulations are) operating efficiently in all Service PAO areas”. There followed 19 recommendations. Read them, then Haddon-Cave’s, and weep at the commonality.

My MoD(PE) 2 Star dismissed the report as “of no concern to MoD(PE)”.

nigegilb

2nd Dec 2009, 10:00

Don't know why the MoD doesn't just bite the bullet and employ you again Tuc!

Even in your retirement your knowledge and understanding of airworthiness regulations continue to impress. God, they must be regretting the way they [MoD] responded to your insistence on maintaining safety standards.

Guess the mandarins have been well and truly found out for the slap dash approach that followed in the brave new world of "command" of budgets.

Idiots..

Safeware

2nd Dec 2009, 11:45

JFZ90,

See #1 on this thread.

sw

Rigga

2nd Dec 2009, 19:13

Tuc:
"...but try asking D/Stan for a copy of them."

I know mr Google wasn't around 18 years ago, but if you typed "05-123 Part" or "dstan" you might find them quite easily.

tucumseh

2nd Dec 2009, 19:19

Rigga

No you won't!

Rigga

2nd Dec 2009, 19:57

...I just did!
That's why I wrote it.

Edited bit:
I've just downloaded 05-123 parts 0-5 and 05-130 parts 1-3

Rigga

2nd Dec 2009, 22:17

Thanks BGG - LOL'd your comment on the Weird Chinook thread.
Rigga

raedwald

3rd Dec 2009, 11:48

Lovechild, it's a culture thing - just keep your head in the clouds and you won't know what is likely to hit you. I am glad I was ignorant about the underlying (lack of) rigorous safety thinking when filling out my logbooks!

DV - You are right, downtime is one of the costs that you need to consider if you are arguing ALARP with a cost benefit analysis. The 'temporal' thing is usually considered outside that, but since everyone has their own ideas I don't think that there is a right and wrong - the only way you find our is if a Judge decides that your argument is not reasonable, I guess!

Incidentally, I was hoping that someone might comment on my possibly contradictory suggestion that you can be tolerable and not ALARP and still acceptable during the period when it is reasonable to allow newly determined ALARP measures to be introduced.

Also, apologies to the coal miners. Two counts: first I should have compared 'tolerable' to 'broadly acceptable' (not just 'acceptable'); second with the modern miners' approach to safety you might suggest that a risk that was tolerable in aviation would be intolerable in mining - if you could think of equivalent risks in the 2 contrasting industries that is. Oh well - at least my high horse is not as high as the QC's.

I have continued to read the QC's report - despite flashes of common sense it is remarkable in its ignorance and naivety. Shame - because I guess the MOD will use this as an excuse to bury it quietly and carry on much as before.

MrBernoulli

3rd Dec 2009, 12:20

I have continued to read the QC's report - despite flashes of common sense it is remarkable in its ignorance and naivety. Ignorance and naivety? Really? I am ploughing through the HC report at the mo (I purchased the expensive paper copy - reading lengthy PDF documents is just too darn tiring) and I am finding it very illuminating, as I used to fly one of the mentioned 'legacy aircraft' (but not the Nimrod).

I would never have used terms such as 'ignorance' and 'naivety' in describing the review itself, but might be tempted to ascribe them to the MoD chumps involved in not doing their jobs. As for Qinetic and BAE Systems - well, 'greed' and 'laziness' would probably be my chosen terms.

Distant Voice

3rd Dec 2009, 14:15

I have continued to read the QC's report - despite flashes of common sense it is remarkable in its ignorance and naivety. Shame - because I guess the MOD will use this as an excuse to bury it quietly and carry on much as before..

I agree. As I have already indicated on another thread, his attack on the Coroner is based on a misunderstanding of what was said. As an example, on page 105, Under "The coroner's Source of Fuel", the QC states that following:

The Oxfordshire Assistant Deputy Coroner, Mr Andrew Walker, found the most likely source for the fuel was a leak from the fuel feed system to engines Nos. 3 and 4. Such a leak, he said would have provided a "continuous source of fuel" which would "travel along the aircraft into dry bay 7" to the seat of the fire. In my view this is highly unlikely.

This is not the the "Coroner's Source of the Fuel". The extracts come from his statement (page 25 of his summing up) where he is in fact challenging Mr Bell's engine based theory . The full statement is as follows:

The flow from a leak in the fuel feed systems to engine 3 or 4 would have had to increase up to 15 gallons a minute before the engine performance would be affected, and this leak would not be determined in terms of engine warnings to the crew. The flow rate of such a leak would supply a continuous source of fuel. Interestingly, the supply of fuel would travel along the aircraft into dry bay 7 where the seat of the fire was believed to have started.

There are several other serious mistakes in the report which distort the actual evidence.

DV

tucumseh

3rd Dec 2009, 15:03

remarkable in its ignorance and naivety
I know what you mean. When I read it my immediate thought was, there must be a supplementary paper providing the deeper detail, as the main report is very often abbreviated so much that meaning is lost. No sign of such a supplementary yet but perhaps it is “MoD-Eyes Only”. Or maybe he’s waiting for the MoD to reply, this month.

However, I am reasonably satisfied from statements and correspondence that he actually understood, or came to understand, the importance of this detail as applied to the regulations and the failure to implement them (which was the basic criticism in the Nimrod BoI report). But, like Distant Voice, I am concerned at the factual distortions in the report, and wonder if he simply accepted the advice of his MoD “advisors” who, very clearly, had an agenda - ensure criticism of MoD is contained to a few scapegoats. And the wider Government, including MoD, would have loved the criticism of Mr Walker and the general muddying of waters.

I still think there are quite a few MoD staff, past and present, who are nervous in case this gets to a court, where those named would be mad not to cite higher rulings and precedent.

Distant Voice

3rd Dec 2009, 15:07

The following represent other "ignorant and naive" statements made by the QC in his report, which threaten the credibility of the whole review, and in doing so present opportunties to the guilty parties to get off the hook.

Page 129
This limitation [restriction to 15k in No.1 tank] was not formally recorded in the aircraft documentation but I have no doubt that it was put into operation by crews, and was relayed to FS Davies when he was briefed prior to his first AAR sortie in theatre and carried out by him.

I (DV) have no doubt that this was a serious error. The QC can not reprimand IPT, QinetiQ and BAe for bad practices, and at the same time condone this action. You can not operate an aircraft safely when crew members rely on word of mouth to pass on defects. There was a problem that was in need of investigation. In the end this investigation should have resulted in a recorded ADD or Limitation.

Page 119
At the inquest much was made of the fact that the 'fuel witness trail' (described by Witness 22 and 28 to the BOI) observed following a sortie around 9/10 August 2006 was a 'crescent' shape, descending from the No1 blow-valve exit and crossing the bomb door hinges.

This is not true. At the inquest, Witness 28 pointed out that his statement, attached to the BOI report, was incorrect and this fact had been pointed out to the BOI at the time he received the first draft. In the corrected version, which was presented to the court, the Witness states "It was like a tea pot stain. Starting just aft of No1 tank blow-off it was six-nine inches wide and a foot below the bomb bay hinge line"

My A&AEE boss once told me; "If anyone finds one mistake in any officail report that you produce, I may as well rip it up and hang it in the toilet"

DV

Rigga

3rd Dec 2009, 20:53

Raewald said,
"Incidentally, I was hoping that someone might comment on my possibly contradictory suggestion that you can be tolerable and not ALARP and still acceptable during the period when it is reasonable to allow newly determined ALARP measures to be introduced."

That's what I was eluding to in post 95 - In some circumstances, on discovering an acceptably tolerable fault, the movement towards ALARP can be via a managed recovery process. Subject of course to reliability and safety management processes.

Reading these latest posts:
How often can important documents be ignored/deleted because of unimportant mistakes?

I know I'm no Legal beagle, I tend to read the words and not between the lines, but you guys now seem to be pointing out the "spelling mistakes" and missing the whole point of the H-C Review?

tucumseh

4th Dec 2009, 08:05

Rigga

the whole point of the H-C Review?The Review arose from two statements made by ACM Sir Clive Loader in the XV230 BoI report;(a)“I conclude that the loss of XV230 and, far more importantly, of the 14 Service personnel who were aboard, resulted in shortcomings in the application of the processes for assuring airworthiness and safe operation of the Nimrod”

(b)“I am clear that further activity must be undertaken for our other aircraft types to check whether any read-across of lessons we have learned from this accident at such enormous (and immensely sad) cost”.Mr Haddon-Cave’s remit was;

·To examine the arrangements for assuring the airworthiness and safe operation of the Nimrod MR2 in the period from its introduction in 1979 to the accident on 2 September 2006, including hazard analysis, the safety case compiled in 2005, maintenance arrangements, and responses to any earlier incidents which might have highlighted the risk and led to corrective action;
·To assess where responsibility lies for any failures and what lessons are to be learned;
·To assess more broadly the process for compiling safety cases, taking account of best practice in the civilian and military world;
·And to make recommendations to the Secretary of State as soon as practicable, if necessary by way of interim report.

I think people will agree he was pretty thorough in the period 1999 to 2006, although missing a few important engineering points outlined by DV.

He got part of the bigger picture just about right – as it applied to the Nimrod Safety Case. But, what happened to the period 1979-1999? He pointedly baselined most of the report at the SDR which, given the evidence presented to him of deliberate dilution of safety in previous years, can only have been an attempt at damage limitation. Who made this baselining decision? It completely ignores the remit.

For example, he criticises General Cowan for introducing a 20% cut over a 5 year period from about 1998, across all support domains, yet fails to mentions 28% each year for 3 years in the early 90s, which DIRECTLY targeted JSP553 Chapter 5 (maintaining airworthiness). Why not mention this single most important factor in the run down of aviation Safety Management in the last 20 years? It falls squarely in the middle of his timeframe remit, and occurred at just the time when extra funding was required as Safety Cases were being mandated.

What General Cowan did was nothing compared to this, and I doubt if any of the 3 IPT staff even knew this was the root cause of them not having sufficient funding to implement JSP553; so were in no position to defend themselves. (The fact they allegedly acted incompetently is another issue).

Perhaps I’m too cynical, but the 2 Star (AVM) who oversaw this is the same man who threatened staffs with the sack for complaining about the effect of the policy - an attitide that remained throughout the 90s and beyond.

General Cowan certainly didn’t do this – in fact, in my experience he understood precisely where money should be spent and believe the thrust of his 20% was to reduce inefficiencies so freeing up funding for more important things, like functional safety. I only spoke to him once, but this was the general subject under discussion. I know 4% a year sounds a lot, but at the time he had dual-accountable IPTs (who were in DPA but spending some of "his" DLO money) and was newly exposed to how efficiently some projects were run, compared to others who were following management guidlelines. It is the age old question - why are some projects run with effortless competence, yet other far less complex ones are disasters? The potential for true savings (which don't impact time, performance or OC) is obvious and, given the odium he will face, it takes a brave man to set higher benchmarks.

And so on. H-C's remit is applied very narrowly and ACM Loader’s second statement is simply not addressed. In fact, Ainsworth betrayed the fact he had prior notice by immediately making a statement that no other aircraft were affected. The report doesn’t say this; it just doesn’t address it properly, so Ainsworth’s view is based on an omission, not a positive, factual based statement. So, that 2nd recommendation is still outstanding. Who is addressing it?

But, at the end of the day, this is the biggest reaming MoD has had since the Chinook Mk3 inquiry said of precisely the same people – “failure of management oversight”. And there’s the rub. It’s the same names who crop up time and time again in all these cases, yet none are mentioned. The protected species – until Air Cdre Baber has his say in court!

Distant Voice

4th Dec 2009, 11:14

The H-C report devotes some 161 pages to the Nimrod safety case. It condemns it in many ways, and criticizes eight people. The irony of it all is that there was no requirement to produce a safety case for a legacy aircraft with an imminent OSD, such as Nimrod. This is made clear in Baber's inquest statement and is confirmed by DE&S. Furthermore, Baber goes on to state that the exercise was carried out in an "economic manner", and "clearly if we made it far too complicated the whole aircraft would be out of service by the time we finished".

Also, on page 235, H-C claims that the three BAES people involved in the August meeting took a "deliberate and conscious decision" (H-C opinion)not to mention the "open and unclassified" hazards. Yet in Baber's inquest statement he says "at that point there were a range of still open hazards". So he knew about them. Surely, if he thought he had been deceived he would have reveled that to the coroner.

The Nimrod safety case became an issue because Baber's predecessor "decided to take a far more rigorous approach and decided to go for a better safety case than just assuming the the release to service [which was the required level] would be adequate"

In order to present a "balanced" review, I believe issues such as these should have been mentioned in the report. The IPTL was guilty of many things, but to be damned for doing something, that need not have been done in the first place does give the impression that a "hit list" was drawn up very early on, and evidence and the QC's personal opinion made to fit. Once again, these are the sort of things that any competent legal defence team will latch onto.

DV

Rigga

4th Dec 2009, 20:41

Thanks for that Tuc and DV,

Although I know my version of airworthiness, I obviously don't know of the bubbles in MOD during those periods and the political rigours of those encumbents. I was unaware of particular funding issues in the mid 90's - at my level there was always funding issues.
My own thoughts were simply of a more politicised leadership giving unwritten directives to MOD.

I know the MOD is thick-skinned and skint beyond belief, but surely it can't think that it could get away with just plugging one small hole in this rather large Swiss cheese? MOD has an over indulgence of officers doing far less important jobs that could do most of this research at virtually no cost. (I await the bleatings of perceived importance against cost)

I don't think the buck has stopped yet. Unfortunately, if only the small hole is plugged, we will have to wait for another one to open up and start quoting H-C again.

Tappers Dad

4th Dec 2009, 21:42

It is my belief that taking the evidence in the Inquest and Review together it appears there was:

1.. Gross breach of duty of care creating very high risk of death
2.. Action or lack of action due to financial or other inappropriate motive(s).
3.. Marked or endemic corporate culture encouraging or producing tolerance of breach of duty of care.
4.. Exposing vulnerable employees to unsafe practices.
5.. Breaches of the duties under sections 2 and 3 HSWA involve failure to take all ‘reasonably practicable steps to ensure the safety of employees and/or the public'.
6.. There was a disregard of the duty of care, and that disregard amounted to recklessness.

Anyone agree/disagree ?

Mick Smith

4th Dec 2009, 23:10

Difficult to argue against any of those TD!

SirPeterHardingsLovechild

6th Dec 2009, 12:12

TD, that'll do it! (I agree) Nicely done.

But I see a split in the road ahead.

If this is a claim for compensation then the MoD will admit liability and settle out of court.

If this is to be a prosecution by the HSE or the CPS then it could be very interesting, but is more likely to be a massive fudge.

When is the MoD/Gov't reaction the the H-C report due?

Good Luck, SPHLC

Tappers Dad

6th Dec 2009, 19:41

SPHLC

Bill Rammell will be making a statement in the House of Commons before the House rises for the Christmas recess on 16th December, so we have been informed.
As far as the legal side of it goes, I think we may see that all the authorities will work together on this.
It is up to those relevant authorities to investigate the information put before them.
For the time being I have done as much as I can for Ben.

Chugalug2

6th Dec 2009, 23:10

Tappers Dad:
For the time being I have done as much as I can for Ben.
TD, what you have done has been remarkable. You have overcome the disbelief that your son and his colleagues could have been failed so grossly by those who owed them a duty of care. You have overcome a Secretary of State's incorrect assertion that the remainder of the fleet was fit to fly. You have ensured that the fleet was made safe for Ben's fellow aircrew. You have caused a review of not only the way in which the airworthiness of that fleet was so badly neglected, but other fleets as well. Now, as you say, it is for the MOD to put its house in order. If it chooses not to then there will be more avoidable accidents, more needless deaths. This is not a time for cleverness, this is a time for doing the right thing. History will decide on that.
Let Right Be Done!

airsound

7th Dec 2009, 08:54

For the time being I have done as much as I can for Ben.
Wth that sentence, you brought about the welling of a very large tear in these sometimes jaundiced old eyes, TD.

No son could have wished for more from his Dad (and Mum).

Deep respect.

airsound

Acoustic

8th Dec 2009, 09:51

If this is a claim for compensation then the MoD will admit liability and settle out of court.

If they offer to settle out of court, thereby trying to avoid legal proceedings, does such an offer have to be accepted?

tucumseh

8th Dec 2009, 15:02

I don’t know the legal ins and outs Acoustic, but from time to time, and despite the seriousness of what has happened, I find myself having a little smile to myself when I think of the briefings Ministers must be getting.

Can you imagine it? Ainsworth - “What idiot dropped us in it by agreeing that airworthiness was irrelevant?” “Eh, never mind that Minister, what’s more important is that you, and your predecessors, have all stated in writing you agree with him. Minister, you should be more worried that if this gets to court these letters will be Exhibit A.”.

Even if he gets an answer, our Bob must surely possess the mental agility to realise the same 4 or 5 names crop up with monotonous regularity. Tornado, Nimrod, Hercules, Sea King…….. That will severely test MoD’s policy of not involving retired staffs. I’m pretty sure the current lot will have noted what happened to Air Cdre Baber when he took the rap for others (at the inquest), and won’t be so keen to hold their own hands up.

Len Ganley

8th Dec 2009, 16:22

tecumseh, I have to agree with your last point . I doubt any of them will have the courage to stick their heads above the parapet.

As to Acoustic's question, apologies for the length of this but I'll try to be as brief as possible.
The Civil Procedure Rules 1999, introduced a mechanism for settling cases - Part 36 offers. This allowed one party to make a "without prejudice" offer to settle a claim. If the offer is not accepted and the offeror does better than his offer when the case goes to court, the recipient of the offer will suffer from a reduction of the costs awarded by the court. If the recipient of the offer is a defendant there may also be an adverse effect in the interest awarded.
So you don't have to accept, but it could affect the award of costs by a court should the settlement awarded in court differ from the offer out of it.

Acoustic

9th Dec 2009, 08:55

Thanks for that. I had the dubious pleasure of meeting Bob Ainsworth once and I'm not sure he is overly blessed with mental agility but we shall see.

Tappers Dad

14th Dec 2009, 12:58

Your Defence News - BAE Systems appoints Dr. Chris Elliott to support safety review (http://www.yourdefencenews.com/bae+systems+appoints+dr.+chris+elliott+to+support+safety+rev iew_43352.html)

In a press release BAE said today 'After careful consideration of Charles Haddon-Cave QC’s Nimrod Review, BAE Systems has appointed Dr. Chris Elliott FREng, a leading systems engineer and barrister, to support and advise Nigel Whitehead FREng, Group Managing Director Programmes & Support who will undertake a review of the Company's approach to product safety across all its sectors in the UK'.

I see that both Qinetic and BAE Systems have now employed legal experts to look into their processes, I wonder why? :rolleyes:

bit-twiddler

14th Dec 2009, 19:41

I thought the MoD were also supposed to have published the reply to the HC report by now.

Wonder what's keeping it back?

Tappers Dad

14th Dec 2009, 20:08

I thought the MoD were also supposed to have published the reply to the HC report by now.

A statement is being made in the House of Commons on Wednesday 12.30pm, I understand it will be Bob Ainsworth making it.

Papa Whisky Alpha

14th Dec 2009, 20:53

It will be interesting to see how many Honourable Members are present on the day The House rises for the Christmas Recess.

Squidlord

16th Dec 2009, 12:27

JFZ90:

I agree with your point that "tolerably safe" should be defined [in Qinetiq reports about the Nimrod] if it is to be used in any meaningful way. The same of course applies to using the term ALARP.

The term "ALARP" is well-defined already. See POSMS, Def Stan 00-56, etc. There is no need for Qinetiq (QQ) reports of the kind under discussion to define ALARP since there is an authoratative definition in place already.

Having claimed more than once that "tolerably safe" isn't defined anywhere (unlike "ALARP"), Haddon-Cave told me it once was. It's in BP 1201, Issue 2 (September 2002):

A safety case is to be maintained throughout the life of the equipment in order to continue to provide the justification that the equipment remains tolerably safe (targets achieved and ALARP demonstrated)

(The term "tolerably safe" was gone by Issue 3, Sep 2005 - I don't know if it was ever in Issue 1.) What interests me about this is that the clear intent of BP 1201, Issue 2 is that you should only claim something is "tolerably safe" if you've demonstrated the associated risks are ALARP. This is not how the term came to be used by the half-dozen or so air IPTs that I've had exposure to and it doesn't appear to be how QQ use it in the report JFZ90 discusses. They all use(d) the term "tolerably safe" to mean that the associated risks were "tolerable" (but not necessarily ALARP).

JFZ90 goes on to debate what the QQ report in question was trying to say about safety. I can't remember what the report says or was trying to say about safety so I can't comment particularly authoritatively. But when JFZ90 writes:

it is not necessarily the case that QQ in writing the report have access to the costs involved in mitigating risks - for this reason alone it is unclear on what basis they were making an ALARP assessment

You don't necessarily need "access to the costs involved in mitigating risks" to determine that those risks are not ALARP. It is generally held (i.e., it's HSE guidance) that risks can not be ALARP unless relevant good practice is followed (e.g. relevant design or process standards encapsulating good practice). My very hazy recollection is that the QQ report in question made some recommendations that would be very much considered relevant good practice.

JFZ 90 again:

Squidlord Risks can be "tolerable" but not ALARP
Willing to be be proved wrong, but I think it is you, not HC, who has this wrong. Give us an example of such a risk? It doesn't make sense.

I think I can do that by appeal to definitions. But I have to admit the situation is murkier than I thought before JFZ90 made me look at it in more detail. The basic problem is that we are stuck with a stupid set of terms for safety engineering (this is not the MoD's fault necessarily - it's a much wider problem than that). Basically, within safety engineering, there are relatively well-defined terms like "tolerable" and "unacceptable" that, very unfortunately, have meanings that are quite distinct from their generic dictionary definitions. The problems flow when the safety engineering terms are mixed with generic English usage.

There are two primary definitions of "tolerable" relevant to MoD safety. First , POSMS:

A level of risk that may be tolerated when it has been demonstrated that the risk is ALARP and is not unacceptable.

Secondly Def Stan 00-56:

A level of risk between broadly acceptable and unacceptable that may be tolerated when it has been demonstrated to be ALARP.

The precise right one for the QQ report depends on the context of the report. But you can see the definitions are very similar (and neither is particularly well-worded). Crucially, both admit that a risk can be tolerable but not ALARP (despite HC, para 11.322). And if you read 00-56 and POSMS in any detail, it is clear from the use of the terms "tolerable" and "ALARP" that it is possible for risks to be tolerable but not ALARP.

It's an unfortunate situation because the generic meaning of "tolerable" is not that similar to the safety engineering meaning of the word (as captured in the definitions above). Risks can be "tolerable", in the safety engineering sense, but "intolerable" or "unacceptable", in the generic English sense (i.e., when those risks are not ALARP). A better term for the safety engineering specific use would be "potentially tolerable".

In para 11.322 of his report, HC quotes BP 1201:

Tolerable - The residual risk is tolerable only if further risk reduction is impracticable or requires action that is grossly disproportionate in time, trouble and effort to the reduction in risk achieved.

This definition is at odds with the definitions in 00-56and POSMS. If MoD can't even get it right in their own standards and regulation (POSMS also abuses terminology and much too freely mixes the safety engineering and generic English uses of terms like "tolerable" and "unacceptable"), what chance have the rest of us! And it's no wonder that HC appears confused in para 11.322 when he states:

There is no such thing as ‘tolerably safe but not ALARP’. Risks are either ‘tolerable and ALARP’ or intolerable

I don't know whether HC is:

1. genuinely confused.
2. is using "tolerable" in the safety engineering sense, and "intolerable" in the generic English sense (which is not the same as "not tolerable" in the safety engineering sense).

raedwald:

There are 3 levels of tolerability: intolerable, tolerable and broadly acceptable.

In MoD safety circles, "intolerable" is usually referred to as "unacceptable". The definition of "unacceptable" from POSMS (& 00-56):

A level of risk that is tolerated only under exceptional circumstances.

It's unfortunate that the term "unacceptable" is used in this way since it means there are risks that are "unacceptable" in the generic sense that are not "unacceptable" in the safety-engineering specific sense (i.e., risks that are tolerable but not ALARP). Again, a clash between safety engineering English and generic English!

Distant Voice:

In his report [Haddon-Cave] stressed the point that the "R" in ALARP has a temporal element, and criticize the Coroner for calling for the grounding of the Nimrod, because in his opinion "a reasonable time is allowed" to mitigate identified risks.

[...]

Now, having read Lord Cullen's findings, and the Health and Safety guidelines, I believe that "time" in [the context of the judge's (not Cullen's!) summation of Edwards v The National Coal Board] means downtime (lost time) of the plant or equipment and its associated costs and trouble. It does not mean, as Group Capt. Hickman (inquest witness) and the QC claim that "we have got time to reduce the risk to ALARP".

I agree with Distant Voice's analysis of the two different sorts of "time" above and I think it is plausible that Haddon-Cave (HC) mixed them up in his report.

But I maintain that "we have got time to reduce the risk to ALARP [while still operating]" can be a valid claim (though not necessarily for the reasons HC advances). I.e., it is possible to:

1. identify that a risk is not ALARP in the long-term,
2. identify a "reasonably practicable" risk reduction that is necessary to reduce the risk ALARP in the long term, that will take a lengthy time to implement,
3. continue operating pending implementation of the risk reduction
4. claim that the risk of operation in that interim period is ALARP.

See the end of my post #96 in this thread. Specifically:

You must show that the risk of operation pending implementation of risk reduction is ALARP. It might seem obvious that you can't do this. After all, that is why you are implementing the long-term risk reduction. But this ignores the exposure aspect of ALARP. In essence, the longer your exposure to a risk, the less likely it is to be ALARP (because that risk is more likely to precipitate an accident(s)). So it is possible, in principle, to demonstrate that the risk of operation pending implementation of the long-term risk reduction is ALARP.

The crucial thing, to me, is that you must do an ALARP assessment of the risk in question pending implementation of the long-term risk reduction. This will tell you whether you can continue to operate or not.

Having said the above, I agree with raedwald:

since everyone has their own ideas I don't think that there is a right and wrong - the only way you find our is if a Judge decides that your argument is not reasonable, I guess!

(except it will be a jury, not a judge).

A few people are being highly critical of the HC report. Yes, it does contain significant errors and it's a shame its scope is limited. But, imo and depending on MoD response, it could still be a force for significant improvement in safety. In that light, the criticisms are relatively minor, in my opinion.

airsound

16th Dec 2009, 12:50

Secretary of State for Defence has announced, in a Commons Statement, the formation, by next April, of a Military Aviation Authority, to be headed by a 3-star.

airsound

I see we've now got another thread
New military aviation 'body' to set up.

The Old Fat One

16th Dec 2009, 15:49

PWA,

Approximately 70.

20 odd labour and about 50 on the opposition benches.

Papa Whisky Alpha

16th Dec 2009, 20:31

I think you must have been watching during PM's Questions, at the end of which many left the Chamber. I counted 7 on the Govt. benches and about 18-20 on the other side during Ainsworth's statement, many of whom had questions to ask regarding their constituences.

PWA

edited for spelling error

raedwald

17th Dec 2009, 13:08

Sqidlord,

You are right, of course. It is many moons since I read 00-56. It needs a rewrite.

As for unacceptable - it seems to me that advising the Secretary of State that it is safe to fly an aircraft that you have determined has a flawed design and that you have stated has been maintained and supported by a failed organisation is unacceptable. The Nimrod should be grounded immediately.

So should a number of other aircraft and if that means that we cannot impress the world with our contribution to the Afghanistan adventure with as much capability as we would like - tough. Ground the aircraft, hire some civil aircraft to supply the troops or bring them home and then sort out the air power bit - in that order.

Pegasus#

17th Dec 2009, 16:40

The Nimrod should be grounded immediately

As you may have noticed from Tuesday's announcement, it pretty much has been.

nigegilb said on 14 November:
I see the two biggest problems as the legacy fleets at Brize Norton, namely VC10 and Tri Star. I suspect airworthiness concerns may well swing in their direction when the response to H-C is worked through.

The tear down of the Nimrod frame and the XV230 explosion has led to the virtual grounding of the fleet. One wonders what the tear down of the VC10 and TriStar might reveal........

It seems to me that the broader issue arising from H-C is whether many/most "old aircraft" (we could start by defining that as any airframe over 40 years old but, ultimately, it will probably become a definition for the lawyers) have not now become potentially politically toxic and therefore uneconomic for us to operate. Simply, politicians and senior leadership (uniformed or other) are starting to see the deep, and in many cases unquantifiable, liabilities attached to these, and the potentially high financial costs of reducing these to which ever of the many excellent definitions of ALARP you care to use from this thread. Very noticeable that in the recent appearance of CDM and his lackeys at the HofC Defence Committee, the words “safety case” poured from their mouths at an astonishing rate.

To my mind I can now understand how easy it may have become to decide to retire the Sea King fleet. Two questions arise, though:
1) would the Puma upgrade contract have actually been awarded if H-C had come out earlier?
2) What chance that a purchase of 40-something year old Rivet Joints looks a considerably higher risk for a Minister and PUS today than a couple of months ago?

Rigga

17th Dec 2009, 20:41

Hmmm..

By my reckoning there are many Tornadoes that are fast approaching 40. And certainly the Frame design and technology is based in that of the deep 1960's.
On the plus side; they're mostly very low hours and cycles for their years and only have small pressure cabins with relatively low stresses. I would assume they are more likely to have electrical/loom issues rather than structural issues.
But who proves they're all okay?

Rigga

17th Dec 2009, 23:16

OOPS! too much red vine again! Fancy - them only being 30 an' all.

Still, Ageing aircraft are at 15 years plus - so they qualify anyway for typical old aeroplane faults and issues.

tucumseh

18th Dec 2009, 05:45

Still, Ageing aircraft are at 15 years plus - so they qualify anyway for typical old aeroplane faults and issues.

I agree. But I know a great many who don’t, the immortal statement being “This is old equipment and reliability improves with age, so we’re not approving funding to investigate (safety related) faults”. Made by RAF at Harrogate in 1992 (part of AMSO, who controlled funding to maintain airworthiness). Subject – C130 equipment exhibiting cracks propagating at an alarming rate. Believe me, you keep those letters when its your signature on the PE(CA) 6/7 or DDP.

North Front

18th Dec 2009, 11:32

I believe an aging ac systems audit is under way, or imminent on Tornado.

Tappers Dad

18th Dec 2009, 14:39

http://www.timesonline.co.uk/tol/news/politics/article6960975.ece

'Don’t blame us for Nimrod crash, says general '

No Comment!

Chugalug2

18th Dec 2009, 15:44

Perhaps those, including the General, mentioned by Mr Haddon-Cave QC in his Nimrod Report do have a grievance, TD. That grievance being that no mention was made in the Report of other very senior officers who are conspicuous by their absence. Perhaps the General and the Air Chief Marshal might feel so aggrieved as to mention those names to Investigating Officers already detailed to interview two comparatively junior Royal Air Force officers. Their inquiry needs to range far wider than that. The newly announced MAA cannot begin to put right the mischief that has been done to UK Military Airworthiness if the depth and extent of that mischief is not discovered. That knowledge lies with many more senior officers than have so far been identified.

tucumseh

18th Dec 2009, 18:03

Air Chief Marshal Pledger said the cuts had nothing to do with the failure to spot the design flaw in the Nimrod which was a matter for a different organisation, not defence logistics.

I like to be fair and have previously posted in defence of General Cowan, whose 20% cuts (now seen to have Hoon’s hand behind them) were trifling compared to the damage done by those before him (e.g. 33%, 28%, 28%, 28%; the last 3 specifically targeting airworthiness).

But if the above quote attributed to ACM Pledger is accurate (and I concede it is entirely possible it is not, given the source) then this is precisely the simplistic attitude that has led to this and other accidents. In fact, it betrays a complete ignorance of the very basics of Safety Management. It smacks of “It was deemed safe, so we don’t have to ensure it remains safe”. This leads to the erosion of functional safety and, to varying degrees, was blamed in Hercules, Sea King, Tornado and others.

To quote the Secretary of State’s Policy on Safety….

“…in the acquisition of materiel and equipment of all kinds, safety and environmental management begins at the requirement definition stage and is carried forward through service to disposal. This includes all aspects of maintenance and operation”.

Who would be a SofS when his “junior” staffs so openly disagree with him? But when the SofS compounds the issue by disagreeing with himself……….

Also, please note the structure of MoD at the time. The above are 3 Stars. There was still a 4 Star above them to whom they reported, even though he was in charge of the “other” organisation. Ain’t it funny how he’s never mentioned, yet is on record as agreeing that functional safety is unnecessary? This is getting interesting!

Finally, do these statements mean that these two officers are not being investigated? (See Nimrod thread).

flipster

19th Dec 2009, 07:09

Whoever is being investigated, might it not pay their defence counsel to be aware of the above 'machinations'???

While 'the brown stuff' flows downhill, responsibility goes the other way!

Daysleeper

19th Dec 2009, 08:06

The Secretary of State for Defence statement was an abbreviated response dealing with only a couple of the key recommendations. The full response to the H-C report was to be placed in the "Library of the House of Commons"...does anyone know how to get hold of that as it does not seem to be online or if it is I can't find it.....:confused:

flipster

19th Dec 2009, 09:14

Try the Nimrod Review Website or better still, write to them.
Failing that, email your MP.

raedwald

19th Dec 2009, 10:22

BGG

Its a bit snooty of you - I guess you are well qualified in these matters. Even so - your quaint use of the old ad-hominem line doesn't wash. Please explain what is drivel and why?

Incidentally, I am quite well acquainted with all 4 issues of Defence Standard 00-56 and the various related standards that have been withdrawn - even though it is a while since I needed to review them. The Standard at Issue 4 needs a rewrite because it does not fully reflect HSE guidance. Let me explain: young Ainsworth has stated publicly that the MOD meets HSE guidance - so you might expect Defence Standard 00-56 to use exactly the same terms as used by the HSE.

Perhaps you ought to read more widely on the subject of risk management and safety management. You might then appreciate that the brief comments posted here are addressing complex issues. One of the points to note is that the QC has reinforced the introduction of a blame culture into military aviation safety. What is interesting is that there are many people more to blame than the poor scapegoats he picked on. Tucumseh has shown that there is plenty of mud to sling. And it won't be sling at at dead men.

Ciao.

Distant Voice

19th Dec 2009, 16:38

Don't blame us for the Nimrod crash

TD. I have heard the same story from friends of General Gowan, and whilst it is easy to think that it is just another senior officer trying to wriggle off the hook, I begin to doubt the reliability of H-C "evidence". I know for a fact that in attacking the coroner he has been " selective" and at times has misquoted what was said. It is just a question of establishing how wide spread this is in his report.

DV

tucumseh

20th Dec 2009, 08:24

BGG

Of course the problem comes when you have an organisation (the MoD) with such an obvious lack of training, knowledge, experience and ability in this area. Go to any Project Team and look.
Spot on. And within those teams you’ll hear an ethos “Maintaining safety is a waste of money”.

That doesn’t necessarily mean those in the team actually ignore safety, but it makes it difficult for those who recognise the implications, as straight away they are fighting against the “system”.

Haddon-Cave made many recommendations and comments on this general subject, but didn't go into the detail of how this situation came about. The reason, to me, is very clear.

Coroner Walker opined that the Nimrod had not been airworthy since 1969. To what degree this was accurate was the only real debate, given the clear evidence presented to H-C that it was true for a large part of that period.

However, H-C launched into an astonishing attack on Mr Walker (as noted by DV). In isolation one could almost ignore this, as the bottom line was criticism of MoD far greater than Mr Walker’s. When reading it, I thought the two must have had a private spat in the past. Whatever, it was unprofessional and uncalled for.

But, it served a purpose because, as noted many times on the Nimrod thread, the clear agenda was for MoD to take a hit on airworthiness, but compartmentalise the damage. H-C baselined his report at 1999 and concentrated on the Nimrod Safety Case, completely ignoring an obligation to assess the wider impact of the systemic failure to apply airworthiness regulations – notably ignoring ACM Sir Clive Loader’s 2nd recommendation in the Nimrod BoI.

Why baseline at 1999, not 1969? That is the key question. In part, the answer can be seen in Ainsworth’s immediate statement that no other aircraft were affected. That illustrates the compartmentalisation policy. He didn’t want to spend money on 30 years regression work, across all fleets.

Yet, a few weeks later and very clearly the higher level committees in MoD have reported back to Ainsworth that yes, indeed, they and their predecessors had taken their eye off the ball for a long period. The result? A Military Airworthiness Authority. Note – not a Nimrod Airworthiness Authority, but pan-MoD. At least THEY have been honest and recognised the truth (or read pprune!) – that MoD simply no longer has the “training, experience, knowledge and ability” to perform their most basic task – exercise their Duty of Care over staff.

So, where are we now? We have (effectively) an admission from Ainsworth that he was wrong to claim the problems were confined to Nimrod (although I doubt if he realises or remotely understands what he’s said). By definition, the H-C report is seen to be at best incomplete, as it does not address the years to 1999. Yet, it is so damning and demonstrably accurate about 1999-onwards I’d say he was honest in his approach. But, crucially, I sincerely believe there was influence brought to bear to draw a line at 1999. H-C could be seen to meet his very restrictive terms of reference and still accede to MoD’s wishes. A compromise from his viewpoint, if you like. He can be proud that he made 80+ recommendations (many of which have been made before anyway) and MoD have accepted all but a few.

And there’s the rub – they have been made before and the same people who have most to lose by looking pre-1999 rejected them, time and again.

Who has most to gain or lose from not going back beyond 1999?

I’ve mentioned General Cowan. He would have been “in the clear” if the huge cuts of 87-93 had been considered, or even the 5% per annum from about 96-99. His 20% over 4 or 5 years would have been seen for what it was – quite insignificant and the continuation of long standing policy directives, from both main parties. Who was responsible for the really damaging, long term cuts that targeted airworthiness? Not Cowan.

Gp Capt (as was) Baber. His, and therefore his staffs’ task, was made very difficult by the prevailing management / leadership practices and policies of the preceding 10 or so years. What was his task? In a nutshell, to provide a Nimrod capable of meeting the Operational Capability required of it, safely. What resources did he need? Back to “training, experience, knowledge and ability”. Plus funding. Whose policies denied him (and most IPTLs) all of that? Not Baber’s. He was denied the “training, experience, knowledge and ability” (and funding), which of course has not been MoD policy to provide since 1996 when CDP decided all he needed was administrators. Crucially, this was against a background of 10 years or more deliberate neglect of airworthiness.

Now that Ainsworth has been forced to backtrack and accept that the failures are pan-MoD, it is surely incumbent upon MoD to now fill in the gaps in the H-C report. It doesn’t require much work, as all the evidence was presented to him. Then we can truly see how many past cases this applies to, including the big one, Mull of Kintyre.

THAT is where MoD didn’t want this to go. Throughout the H-C report, you so often come to the end of a sentence and think “Go on, the next logical link brings you to Mull”. But he stops (or MoD stopped him). I think he’s been very clever (notwithstanding the spat with Walker). His recommendations have left MoD with nowhere to go. Who among us truly though they would accept 80 of them? But I think the classic passage is his swipe at submariners being in charge of aircraft. Which gets us back to those who denuded MoD of “training, experience, knowledge and ability” and ruled that ignoring functional safety was acceptable………. Yes, in that one sentence he demonstrated he had indeed read the evidence submitted, and I think it may have been a subliminal nod in the right direction, from behind the barrier erected by MoD.

Distant Voice

20th Dec 2009, 09:44

Who carried out the release to service trials for the Mk2 in 1982 (?); was it A&AEE Boscombe Down? And who issued the RTS document; was the Controller of Aircraft?

Does anyone know?

DV

Chugalug2

20th Dec 2009, 09:52

Bravo, tuc! You describe this malevolent countdown to doom with persuasive and authoratative skill. We can now see more clearly the significance of the successive cutbacks that you enumerate in post #155:
(e.g. 33%, 28%, 28%, 28%; the last 3 specifically targeting airworthiness).
Not so much Salami slices as brutal butchery of a magnificent but doomed beast. As you say Mull is the key, and Mull is where the MOD just will not go, not for the Next of Kin, not for the Fatal Accident Inquiry, not for the House of Lords, not for the House of Commons, not for the Mull Campaign, and not for Mr Haddon-Cave QC. 29 deaths still not properly accounted for. 2 deceased junior officers reputations destroyed. A Board of Inquiry that was a disgrace. The honour of the Royal Air Force sullied. For what? Or rather for whom?

Tappers Dad

20th Dec 2009, 15:16

tucumseh
training, experience, knowledge and ability

Sir Malcolm Pledger told the Review, candidly, that he did not believe that he was fully qualified for the job of CDL. He said this was one of the reasons why he attended a two-week course at the IMD Business School in Switzerland.
He was not a logistician or an engineer; he was a career helicopter pilot who had only brief hands-on logistics experience and no business experience.

If the RAF/MOD was a commercial business he would never have been considered for the job.

woptb

20th Dec 2009, 17:33

The RAF has become an organisation populated by careerist individuals to concerned with promotion to always do the right thing.
Having been involved with an initiative in maintenance flight safety, I have been astonished by the response. This has varied between cynicism and distrust to a complete inability to comprehend how big a cultural change is required to improve. The 'learned helplessness' engendered by successive failures in leadership makes what is a difficult task, even harder.
Leaders of men with some bottle & the ability to say we ‘Can’t do it’ are required.

Rigga

21st Dec 2009, 21:03

Tuc said:
"And there’s the rub – they have been made before and the same people who have most to lose by looking pre-1999 rejected them, time and again."

Welcome to my world!

TD said:
"If the RAF/MOD was a commercial business he would never have been considered for the job."

That's a consideration that should ensure the RIGHT person for the job rather than just the next in line. Some might think the same of the unassailable need to place a pilot at the top. Why?

And finally, woptb said:
"....a complete inability to comprehend how big a cultural change is required to improve."

Gents,
That thin white line, currently just visible on your horizon, is a Tsunami coming your way.
Having brought all these issues very publicly to yours and everyone's attention, H-C has raised the expectations of lots of military personnel, in all strata, that may soon see what's missing from their "superiors" and their so-called military "contract".

Distant Voice

28th Dec 2009, 17:18

Further to my posting #163, it is now clear that Nimrod Mk2 flight trials were carried out at Woodford, but A&AEE Boscombe Down were responsible for the clearance of all systems. A&AEE issued the Release to Service recommendations, not BEA Systems. Does this fact get mentioned in any report/review?

DV

Tappers Dad

1st Apr 2010, 14:34

QinetiQ to create new role of Group Safety Director following independent review (http://www.qinetiq.com/home/newsroom/news_releases_homepage/2010/1st_quarter/qinetiq_to_create.html)

QinetiQ to create new role of Group Safety Director following independent review by Sir Robert Nelson QC

Rigga

1st Apr 2010, 18:31

Unfortunately, nowadays it is the norm for big or (for Qinetiq) rich companies to pay other people to collate information readily available and within their own grasp.

As you say...stunning

...and me and my mate would have done it for just 250K!

matkat

1st Apr 2010, 18:36

K. hope I was the mate you were refering to:ok:

tucumseh

1st Apr 2010, 20:20

While I agree with the recent posts, it should be remembered that most of the damage was done when "QinetiQ" were part of MoD and subject to the rulings of MoD(PE); in particular those senior staffs in PE who sat above the boss of, for example, Boscombe Down.

I have questioned before why Mr Haddon-Cave baselined his report at 1999 when all the evidence submitted to him clearly showed the systemic failings went back many years before this.

For example, what rulings were made by CDP (4 Star) the previous year (1998)? Here's one - a project or programme manager in PE can declare his project complete and make full an final payment despite Boscombe advising him that the aircraft is not functionally safe. And that the same company can be contracted and paid again to "finish" the job, and receive full payment despite failing to do so. And a 3rd and 4th contract.........

Then go back to September 1993 when Boscombe advised PE (same 2 Star as Nimrod) that the Chinook HC Mk2 was "positively dangerous" and recommended that it NOT be released to service. What happened? Boscombe were completely ignored and senior staffs in PE falsely misrepresented this recommendation by issuing a CA Release purporting to be a statement by Boscombe that she WAS fit for release.

Against that background, is it any wonder those in DERA/DRA/QinetiQ simply didn't know where they stood with their "customer"? The two men directly responsible for oversight of aircraft safety management in PE routinely ruled safety could be ignored.

None of this emerged in the report due to the simple deceit of implying the problem only started in 1999. I do hope these verifiable facts are aired during the ongoing investigation into the 2 RAF officers from the Nimrod IPT.

Sun Who

2nd Apr 2010, 07:35

Given the scope and remit of the Haddon Cave report, it should have gone back to at least Feb 1997 (when work began on refurbishing the first 3 MR2 airframes) or, ideally, if the real systemic issues were to explored, 25 July 1996, when the contract was awarded to BAES.

Sun.

tucumseh

2nd Apr 2010, 11:09

Sun

His remit was slightly vague but I know assurances were sought in Parliament (as I've seen the Ministerial replies) that BOTH ACM Sir Clive Loader's recommendations would be addressed. That is (a) the systemic failings on Nimrod and (b) other aircraft should be assessed (as the regulations apply equally to them, and the same individuals were involved - and I don't mean junior officers like Gp Capt Baber).

Also, Coroner Walker had stated, rightly or wrongly, that these problems had existed on Nimrod since 1969. This should have been verified.

My own opinion is that, because the safety management regulations apply in all domains (Air, Land and Sea), only diverging late in the day when airworthiness must be considered on Air platforms, it was patently obvious the systemic failings applied elsewhere as well.

So, it should be asked why, given the above, H-C didn't go back further than 1999 - especially as the evidence presented to him was irrefutable. One answer - it protected certain current serving staffs.

The most obvious outcome was him naming and shaming individuals connected with Nimrod, while failing to name those more senior who had actually issued orders that safety could be ignored; who, notoriously, took disciplinary action against those who disobeyed. I don't want to seem flippant but, if anything, Baber's "offence" was to disobey this stated policy and let a (very badly managed) Safety Case task. Many others considered this a complete waste of money and didn't bother.

I have said before that anyone reading the H-C report is left thinking there must be a classifed version with a broader scope which is even more damning. Having managed to compartmentalise the report, in doing so protecting the usual suspects, it is telling that we now have a Military Airworthiness Authority, not a Nimrod Airworthiness Authority or a dose of salts run through the Nimrod IPTs. Also, across all domains, we are seeing a resurrection of Quality Control and Assurance not seen since the disbanding of DGDQA. What remains unclear is if MoD are implementing the recommendations of previous reports which I can assure you were infinitely more damning that Haddon-Cave. (Something else H-C didn't mention).

Chugalug2

2nd Apr 2010, 18:21

tucumseh:
So, it should be asked why, given the above, H-C didn't go back further than 1999 - especially as the evidence presented to him was irrefutable. One answer - it protected certain current serving staffs.

I think we all know the answer to your, no doubt rhetorical, question, tuc. Now, as you have mentioned in a previous post, the challenge to reveal the real truth behind this scandal has passed to the RAF Provost Marshal. It is he who has been tasked to investigate matters arising from the Nimrod Review. In particular he, or a subordinate, will be interviewing the two officers named in the report. Let us hope that what the MOD has done, to limit the extent of the suborning of the UK Military Airworthiness Regulations being revealed, will be discovered by the RAF Provost Branch as a result of their enquiries. A good copper follows the evidence wherever, or to whoever, it leads. Let us all pray for good coppers!

Rigga

2nd Apr 2010, 18:55

"Let us all pray for good coppers!"

...Amen.

Sun Who

2nd Apr 2010, 21:41

I know very little about the RAF provo branch but I do know this is a complicated and specialist area of endeavor. I don't see how the Provo Marshall can be properly equipped to investigate it.

Sun.

Could be the last?

2nd Apr 2010, 21:47

Maybe that is why he has been tasked to carry out the investigation......

Chugalug2

2nd Apr 2010, 22:19

Sun Who:
this is a complicated and specialist area of endeavor. I don't see how the Provo Marshall can be properly equipped to investigate it.
There is nothing very complicated in knowing if you've been ordered to disregard the Airworthiness Regulations which you are responsible for implementing, but to sign them off as being complied with, Sun. You either have or you haven't. As for the matter of UK Military Aircraft being airworthy or not, it seems these days that it takes HM Coroners to know better than the Royal Air Force the answer to that one. So much for complication and specialism!

Tappers Dad

3rd Apr 2010, 11:37

I would think given serious nature of the offences,that the Special Investigation Branch would investigate. Then submit their findings to the CO and to the single service Legal Services branch. They then decide if to refer it to the The Service Prosecuting Authority who manage the prosecution of all serious crime within the Services. IMHO

Chugalug2

4th Apr 2010, 13:44

The formalities of the investigation of serious crime within the Services no doubt are clearly laid down TD. What is not clearly laid down is the ability of those formations mentioned in your post and mine to conduct their enquiries and carry out their duties unhindered from above. I seem to recall that the evidence collected in a previous investigation into allegations of serious offences against Military Law was lost overboard on a cross-channel ferry while being conducted to the UK!

5206

23rd May 2010, 20:14

I know it was announced on April Fool's Day, but has anything come of QinetiQ appointing a Group Safety Director?

Internal or External appointment?

5206

Safeware

25th May 2010, 15:14

5206,

No idea, QQ and recruitment aren't 2 words to put together at the moment, expect they'll have to look internally, but I'm not sure who they'd pick.

sw

5206

29th Jun 2010, 19:31

Thanks

I've heard they are now going to an external agency, and looking for a H&S Director :ugh:

5206

themightyimp

4th Jul 2010, 20:20

A few people are being highly critical of the HC report. Yes, it does contain significant errors and it's a shame its scope is limited. But, imo and depending on MoD response, it could still be a force for significant improvement in safety. In that light, the criticisms are relatively minor, in my opinion.

Could being the operative word. If the current MAA work is anything to go by it is just another audit process (and thus another 'hoop' - again the operative word) and IMHO does not have the staff with the required competencies to provide advice on best practice or, indeed, actually qualified auditors. Of course, it is early days and hopefully this will change................

tucumseh

5th Jul 2010, 05:36

the mightyimp

If the current MAA work is anything to go by it is just another audit process (and thus another 'hoop' - again the operative word) and IMHO does not have the staff with the required competencies to provide advice on best practice or, indeed, actually qualified auditors.Well said. I think you are spot on. The point being that having staff with the required competencies is a fundamental requirement of JSP553.

Haddon-Cave's report is superb given the resistance he met from within MoD, but he missed a number of vital points including the fact that getting rid of these staff was a quite deliberate act. It commenced in about 1990 and peaked in 1996 when the then CDP (Walmsley) announced he didn't want or need engineers as engineering project managers. As airworthiness is primarily an engineering discipline..........

In omitting this fact (it wasn't that he didn't know), H-C baselined his report at 1998, implying there were no problems before that date. I have struggled to understand why and can only conclude there was a malignant MoD influence at hand to limit the damage. MoD did not want H-C looking into ACM Loader's second recommendation, that because the regulations apply to every aircraft then it is logical that other fleets have suffered. (A simple proven fact).

Crucially, and unforgivably, H-C omitted the written evidence that showed senior staffs in MoD(PE), AMSO, AML, DLO and DPA had, for nearly 20 years, received a series of formal warnings as to the inevitable outcome of their policies.

Nor did he mention the letter to Adam Ingram, Minister for the Armed Forces, written some months BEFORE XV230 crashed, which stated that the airworthiness regulations were not being implemented properly - PRECISELY the wording used by ACM Loader in the BoI report. THAT is scandalous, and the staffs who advised Ingram to say they were implemented properly 9 months AFTER the crash, should, quite simply, be sacked.

matkat

5th Jul 2010, 05:59

I sent a question to the MAA it was answered by a Wing Commander, says it all really:ugh:

Chugalug2

5th Jul 2010, 08:09

In the MAA we have all that is wrong in 21st Century Britain. It cannot do its job because it is not competent enough to do so, but even if it could it can't because it is part of the MOD, the very organisation guilty of flouting its very own UK Military Airworthiness Regulations. It did so in the mistaken belief that such flouting would save money. It has not, it has cost money, lives and operational capability. The MOD needs protecting from itself by an independent professional regulator, indeed we all do. Time is of the essence for until that be done the then unforeseen consequences (one has to presume) of such Gross Negligence will continue in a plainly predictable fashion. That is more lives, money and operational capability lost unnecessarily.

Tallsar

5th Jul 2010, 19:33

I have some difficulty with those who continuously repeat the popular mantra that "if it is part of the MoD it then it cannot take an independent view"...it is too much of a 21st Century get out phrase...there was time when proper airworthiness management was more than possible - with the right organisation, the right competencies and the right minded acceptance of such by those in authority - and the rules to ensure it was so. Having been part of such a system I can vouch that it can work. That said, as Tucumseh has regularly highlighted, the gradual erosion of the right organisation and competencies over more than 20 years has lead to present parlous situation. In part, IMO, this has been driven fundamentally by us continually trying to achieve world player status with the "best" technology ...and a joke of budget to underpin it (or not). The large erosions in competent personnel at every level, the blurring of responsibilities (particularly with the introduction of the IPT system amongst other issues), the ignorance of many about the issues and what drives them at AFB level (and at 1* level below) , the constant pressure to provide working operational capability - always in tension against proper airworthiness testing, analysis and deliverance - and the ripping apart of the independent organisations that used to deliver such so effectively and honestly ---- all have lead to this deplorable situation we now live in and with.
Couple that with the appalling decline in simple but essential qualities such as integrity and honesty...and loyalty by those in power down to those who are at risk...and we have a fatal combination which will need more than H-C to rescue us.

Cheers!! :ugh::ouch:

Rigga

5th Jul 2010, 20:59

Tallsar:
"...there was time when proper airworthiness management was more than possible - with the right organisation, the right competencies and the right minded acceptance of such by those in authority - and the rules to ensure it was so. Having been part of such a system I can vouch that it can work."...

In 20:20 Hindsight - Ahh, them was the days!

Those standards are still achieveable - but alas, in this environment, not with the same old rules. It seems we have gone beyond trusting officers and gentlement to do their jobs - we must assure the tasks are now properly done by them - whether they like it or not!

Like Chug, I don't have a ha'porth of faith in the "old crowd", wearing their "new hats", doing anything other than what they did before (but with a new letterhead).

Rigga

flipster

6th Jul 2010, 09:29

Tallsar has a point - independence of the MAA should be possible in its present position within the MoD. But its not!

I believe that the times have changed and that history has shown that many officers lack the moral fibre to fight for what is right. In the past, that sort of behaviour was encouraged by similarly-minded bosses. Unfortunately, those days are gone and all that appears to matter is office politics, budgets and promotion. The buck is passed......but sideways and not upwards.

As I have said elsewhere, perhaps all the recent loss of life on operations has bred more leaders ready to stand up and be counted on behalf of the troops? I sincerely hope so and that, one day, those people will be very senior; the wheel will have turned full circle. Only then will we have the personnel to effectively populate the MAA to give it proper independence but that could take a long, long time.

Therefore, it would be better if the MAA was made truly independent of the whole MoD and not just be 'independent of the front-line'. Far better for the MAA to be grouped together with the CAA (and the MAAIB with the AAIB). An option might be for the MAA to be staffed by current MoD personnel but who were 'seconded to' and working with the civil service, retired officers and experienced (and trained) engineers for the duration of their time with the MAA. Why would that be so difficult?

Sadly, however, I do not think that will happen, so until the MAA is innoculated with personnel with 'the right stuff', I suspect that the MAA will be anything but 'truly independent' and those within the MAA who do have sufficient moral courage will be in the minority. But if you are one of those people, don't give up hope and keep up the good fight. If you do have to make a stand, don't be afraid to do so - promotion ain't everything and you have to be able to look yourself in the eye in the bathroom mirror of a morning.

In the meantime, IPTs must not use the MAA as a 'buffer' and the MAA must be rigorous in forcing IPTs to comply with the regulations that make aircraft airworthy and fit for purpose. Otherwise the MAA is a white elephant and all that has happened is that the old DASC/DARS officers have changed offices and hats but without doing anything different.

Who watches the watchers???

Chugalug2

6th Jul 2010, 20:35

Tallsar:
Having been part of such a system I can vouch that it can work.
And having been part of a fleet of some 80+ aircraft that were simultaneously grounded around the world very soon after one of them crashed, I can vouch that "such a system" worked well... then! But that was a long long time ago when subordinate commanders commanded, ie demanded loyalty from their subordinates who got it in return. Those days are long past, and the present is ably portrayed above by flip. Airworthiness is vital in aviation. It's not just a wish list item but a must have, or people will needlessly die . The renegade Air Officers that suborned it showed just how vulnerable "such a system" is in the wrong hands. It would be unthinkable that the airlines be given control over Civil Airworthiness Regulatory Control. It should be equally unthinkable that any other operator be given similar control. At least 62 people have died in Military Airworthiness related accidents featured in this forum recently. The true overall total is bound to be magnitudes higher. That is an unacceptable cost and why, with respect, I have to disagree with flip when he says:
it would be better if the MAA was made truly independent of the whole MoD and not just be 'independent of the front-line'......Sadly, however, I do not think that will happen
It has to happen. No matter how dedicated and professional its staff are they can be simply over-ruled and bypassed by the Higher Command and the MOD. It's happened before so it can happen again. So let us all now recite the mantra together after 3,...3!
Self Regulation never works and in Aviation it kills!

Rigga

6th Jul 2010, 21:02

Well said Flip and Chug.

"Who watches the watchers??? "

As part of the H-C review and report - good 'ole H-C said that there would be a further review of the new MAA's progress in two years time - Due in November/December 2012 I believe.

I think he'll find a whole bunch of confused middle ranking personnel with no real idea of what is required, leading a lesser ranking group of personnel who are likely to know what they are supposed to be doing, but unable to do it due to a huge amount of MOD beaurocracy. Thus, following the Marham mantra..."Comfortable with Complication" ????

flipster

7th Jul 2010, 07:27

Chug

While I do not think it will happen, it won't stop me pressing for it and I agree wholeheartedly that it should indeed happen. I was only trying to be realistic to help understand the perspective of those good guys and girls actually in the MAA.

One of the problems maybe that that there are not enough engineers that have the 'historical norms' of airworthiness experience or the training req'd to lead the MAA back to reality. They must also have the courage to fight off IPTs that try to use the MAA as a whipping boy for blame and excuses, as surely they will when the inevitable delays and budget over-runs occur.

There must be a percentage of engineers in the MAA asking themselves "what the f**k are people like tucumseh and safeware etc talking about - I've never been taught/learnt that?" When they check the regs, they find tuc et al are spot-on!

But we have to remember that it is not the fault of these good people in MAA - they have been put in this position by years of under-funding, bleeding of experience and incredibly poor leadership, so much so that there were people who, until recently (and maybe still), held airworthiness authority who would fit easily the descriptor of 'tumbleweed' (loss of awareness and position).

Furthermore, many of those who caused the demise of the pre-existing AW system (or who stood idly by while the system was dismantled) are still in post - at high-level or in a highly-paid consultative role - and it is they, not some 'low-level' Gp Capts or Wg Cdrs, who are the one who should be charged with negligence, dereliction of duty or even prosecuted by the Provost Marshal (or the Thames Valley Police)!

It is not until all the bad wood is gone will things really change.

Chugalug2

7th Jul 2010, 10:54

flip, we are it seems in violent agreement with each other and in particular with your final paragraph. In which case might I propose that pursuing those very senior officers involved through the courts, civil or military as you suggest, is what is needed for the full extent of this scandal to be realised at large. Then perhaps it will be accepted that Military Aviation is as much in need of independent regulation as is Civil Aviation. It is not only the lives of members of the Armed Forces at stake here, important as they are, but those over whom they fly. I wouldn't be allowed to launch an unairworthy aircraft into the UK skies, so why should an Air Marshal?

Tallsar

7th Jul 2010, 11:25

I have no difficulty with the clear authority of the CAA and its like (as well as the operators) to ensure the safety of pax and crew and those on the ground below them in civil aviation where there is a clear cut need to maximise safety and minimise risk. This is not so in military aviation - and we must not forget this. Wars are not won by staying safe at all times and minimising the risk at all times. Therefore, any MAA has to account for this as I'm sure you would agree. Its processes must ensure that military judgement and assessment of those risks are accounted for, in the right circumstances. Will a totally independent MAA enable this? Of course I am not suggesting that the MoD has carte blanche to ride roughshod on safety concerns at every opportunity and wave the "war" flag - an issue which perhaps has had to much leeway in recent times. In the understandable hiatus resulting from the recent Inquiries, it is all too easy to forget that constant attention to safety and airworthiness at the expense of operational and war winning capability is not always the best approach - ALARP must play its part as well as flight envelope management. To undertsand this better, we must also constantly recognise that airworthiness is not only a structural, maintainance and design issue, but also an operational spectrum issue - as I know many understand already. As some have already said, getting the modern generation to change their ways at any rank level after several decades of "other" thinking is important and vital work that need start now (if it already has not done!)

Cheers
:ugh::)

Chugalug2

7th Jul 2010, 17:59

Tallsar:
constant attention to safety and airworthiness at the expense of operational and war winning capability is not always the best approach
What was the war winning capability of a constantly leaking fuel system running through bays containing an ignition source, or a tactical transport with no fuel tank protection, or a support helicopter with a FADEC arbitrarily causing power excursions from max to zero? The whole point of military Flight Safety used to be that of preserving Force levels and capability with which to go and win wars. Not sure what its point is these days, something to do with career development perhaps?

tucumseh

7th Jul 2010, 18:21

Tallsar

Your point is well made but what you are discussing is (a) airworthiness and (b) fitness for purpose. The latter is an operational term in this context. They are related, but not the same.

The regulations require MoD to first attain airworthiness. The Release to Service is the statement this has been achieved. Only then can they address FFP. Very often, attaining FFP involves a lot more than attaining or maintaining airworthiness. But over the years MoD has increasingly used the FFP concept to degrade safety to save money. That misses the point of FFP entirely.

The important point here is that MoD, when asked in a Coroner’s Court, could not explain who was responsible for FFP. It is a pity the Coroner did not pursue this and demand an answer.

Rigga

7th Jul 2010, 20:19

"The regulations require MoD to first attain airworthiness. The Release to Service is the statement this has been achieved. Only then can they address FFP. Very often, attaining FFP involves a lot more than attaining or maintaining airworthiness. But over the years MoD has increasingly used the FFP concept to degrade safety to save money. That misses the point of FFP entirely. "

Tuc, As you say - The RTS is the statement of the attainment of an Airworthiness Status.

From that RTS point onwards there is a need to maintain "Continued Airworthiness" which is not just 'airworthiness' but the full and proper enactment of ALL the processes required to maintain the designed purpose of the aircraft - and not just Fitness For Purpose

This means that even if the aircraft has a role change it should still meet (or exceed) its new designed purpose.

Tallsar

7th Jul 2010, 21:06

T.... couldn't agree more....FFP and its association and differentiation with airworthiness are so fuzzy in many people's mind. I raised the point as it appears that all too often this intimate relationship is ignored, blurred or as you say, FFP is used to overide the association. Some others have a tendency to focus too much on airworthiness at the expense of other matters needing consideration too to produce the optimum safe and effective "system"
You may laugh (in sadness), but some of it may have its roots in such stupid cultural nonsense associated with engineering trying to keep servicable ac in the hangar whilst aircrew want to get them out and get on with the job...seems silly ...but life can sometimes be as stupid as that - particualry if chips on shoulders are invovled.
I really do despair as I have watched the need for urgent capability generation overide best practice - the latter has often been scoffed at by some very senior people in the past (I point to 1982 as the watershed here). Often it was the very same individuals' inability to approve and provide airframe resources to ensure the correct processes were carried out as efficiently as possible in the first place. I recall only too well a meeting in MoD where a certain senior staff officer fought hard to minimise the time and hours available from only one airframe to be used for full RTS trials at Boscombe, based on ignorant prejudice of what was actually happening there, and no understandfing of the detailed engineering involved to permit the trials to happen at all. And more ....the 1971 Puma RTS recomendation that said the ac was unacceptable for service due to its poor engine/rotor governing design (The tp was awarded an AFC for the testing risks taken to prove it!).....and how many have died and been injured as a result of the MoD's decison to overide this and get the ac into service anyway. In these sort of things are rooted the very issues you (and others) have spoken so elequently on in this thread.

Cheers
:ugh::)

Tallsar

7th Jul 2010, 21:38

Hi Chug.. Do not misunderstand me....I have no truck with failure to sort the very issues you remind us of - the Puma engine governing issue has long been a hobby horse of mine. But my point stands - and every issue has its moment critique where action should have been taken. Airworthiness must always be paramount along with all the issues that attempt to ensure optimum safety and capability in a platform or operational system.
Similarly, all operational risks that are taken to pursue victory need to be fully understood by all those involved, and when at an extreme, provide enough leeway for dissent and volunteering. Most don't appreciate for example, that all RAF SAR winchmen are volunteers, however airworthy the platform and winch system and its associated kit. No, any operational risks taken should and must be confined to their specific context and then not run on (in ignorance or due to financial stringency) when the neccessity to take such risks is gone. Many of us have been part of an organisation that has avoided doing precisely that over the last 3 decades. How many of us for example have been part of debates about UOR mod continuance post their prime operational use, and then seen it take years for the proper integration of such mods to be funded, never mind properly engineered, and seen the airframes continue on in use during that period in some form or another. Indeed I would argue in some cases that a generation passes and the signifcance of the issue then fades as important, particualry if chance has not lead to any major problems. The situation has always been complex, and at the heart of it there was has needed some good and well educated and experienced staff and leaders prepared to act in the best interests of the very flight safety and airworthiness of which we speak. Quite clearly, not enough of it has been happening.

tucumseh

8th Jul 2010, 06:21

Tallsar

Well said. Excellent.

flipster

8th Jul 2010, 06:38

Well said all.

For those who think that maintaining AW and FFP will inhibit our operational efficiency, I say this:

We have so few assets these days, that the loss of one ac (Herc, Nimrod or Sea King Mk7) due a lack of AW/FFP often represents a huge reduction of in-theatre capability - NOT ensuring our ac are safe and airworthy is doing the enemy's job for him.

However, as a former military, operational, in-theatre commander, I am very cognisant of the fact that sometimes, when lives on the ground are at risk, we need to say occasionally 'just go and do it'. However, this should be the exception and not the rule and those who do 'go sausage side with their fingers crossed' must do so armed with all the reasons why and all their ac's limitations known. Sadly, what has become the norm is that no-one knows that the ac have serious limitations and risks because no-one has done a rigorous threat assessment of them. Senior commanders who fail explain the whys and wherefores or accept the risks people take on their behalf are the lowest of the low.

ps Tallsar - When I last mentioned that the Puma engine/RPM droop probs could be construed as not meeting the Def Stans and so were unairworthy, I was shot down by Puma pilots who said they got taught how to prevent this. What they seemed to miss was the fact, rightly or wrongly, was that the MoD's risk mitigation was 'loads of trg and flying experience' that allowed pilots to be aware of the risks. Pilots don't get the hours and extensive trg these days (so I'm told) which thereby undermines the mitigations and so the AW of the Puma is in question (if it wasn't already).
F

tucumseh

8th Jul 2010, 07:35

Sorry Rigga, I missed your post.

From that RTS point onwards there is a need to maintain "Continued Airworthiness" which is not just 'airworthiness' but the full and proper enactment of ALL the processes required to maintain the designed purpose of the aircraft - and not just Fitness For Purpose

This means that even if the aircraft has a role change it should still meet (or exceed) its new designed purpose.Fully agree. What I have consistently said is that MoD do the "attaining airworthiness" reasonably well - but have largely ignored the "maintaining airworthiness". So important is it to understand the two they have different chapters in JSP553. When I say funding has been slashed over the years, it is primarily in the "maintaining" of airworthiness. But, as 80% of through life costs fall in this area, it is rather important.

To add to your second statement, there is a requirement to upissue the Safety Case at every such change in use or design, but this is almost totally ignored - for the same reasons, funding cuts. In the beginning, people complained, but in time this became the norm and most are no longer taught this basic discipline so don't know to ask the question.

I know what some will think- that sod Tuc bangs on about Chinook HC Mk2 and he's just said we attain airworthiness very well. But, the Mk2, like Nimrod MRA4, was in configuration control terms a simple modification to the Mk1. It is not a new aircraft in that sense, with a new Safety Case and RTS to be developed. It is a legacy aircraft with an extant Safety Case and RTS, which must be valid and verifiable at the Induction Build Standard. They form the contractual baseline. That is where MoD fell down on both programmes (and, conversely, why other similar programmes succeed effortlessly). And it is why Haddon-Cave was wrong to praise the Nimrod 2000/RMPA/MRA4 IPT leader, as a crucial part of his job was to be continually satisfied that the aircraft being inducted into his programme, the MR2, was airworthy. It wasn't, and one wonders what he said about this, or if he even knew. (His 2 Star did - he was happy for configuration control to be ignored).

Chugalug2

8th Jul 2010, 09:05

Tallsar:
Many of us have been part of an organisation that has avoided doing precisely that over the last 3 decades.
Include me out there, for I left the RAF in 1973! Hence my angry old man tendency to hold each and everyone younger than I to be personally responsible for what's happened to my baby - RAF Flight Safety! Out of order, totally unjustified and uncalled for, I have to admit. The guilty parties are relatively few, even over such a long time frame, but their effect has been devastating and deadly, literally. Nonetheless let me quickly add that I fully agree with you that the business of the Armed Forces is war and the winning of it. Flip reminds us of his personal experience as a tactical commander in that respect. If he or his ilk requires three engined take offs, people clinging to the outside of an aircraft in flight, overload operation or whatever to achieve the tactical goal so be it. The MAA should not in anyway inhibit that choice, other than to be advised of such operation outside of the RTS envelope in such circumstances no doubt. What such commanders don't want is that their aircraft are unfit for the purpose, are likely to fly out of control or spontaneously explode with no help from the enemy! That used to be a given, but not any more it would seem. What have you lot done to my baby? Oh, there I go again, sorry!

Squidlord

8th Jul 2010, 10:30

themightyimp:

If the current MAA work is anything to go by it is just another audit process (and thus another 'hoop' - again the operative word) and IMHO does not have the staff with the required competencies to provide advice on best practice or, indeed, actually qualified auditors. Of course, it is early days and hopefully this will change...

I think that's an incorrectly narrow view of "current MAA work" though I would always expect much of the MAA's work to be based on audit and review. And I agree that one of the MAA's biggest challenges is to build up a large competent staff (imo, it does already have many competent staff but not enough). Perhaps (either as a short-term or permanent feature), the MAA will contract out where it is lacking in competence and/or resource, just as the CAA does.

What I am keen to know is what are the MAA's teeth like? Does it have any? The closest I can find is in:

http://www.mod.uk/NR/rdonlyres/92B4352A-6AB0-4033-B21D-1A0EB8481EFB/0/MAA_high_level_statement.pdf

"The Authority will employ a system of approvals, permissions and, if necessary, sanctions to ensure compliance with laid-down regulations, rules and procedures ..."

Personally, I think it should be a relatively urgent requirement for the MAA to define those "sanctions". Specifically (and simplistically):under what circumstances will the MAA stop or limit aircraft operation?The last thing we need is another "hoop", as themightyimp describes it, that has no teeth.

Changing subject, tucumseh wrote:

there is a requirement to upissue the Safety Case at every such change in use or design, but this is almost totally ignored

Just for the record, my reasonably extensive experience is very different to tucumseh's For the aircraft I am familiar with, very large amounts of work are done (quite properly) to assess the impact of and, if necessary, update the Safety Case in response to every change in design. It's also done in response to every "abrupt" change in use. However, it's not always done as coherently as it should be and I do have a concern over "slow" changes in use. I think the latter ought to be captured by regular review of the SOIU but those regular reviews don't happen as often as they should.

Rigga

8th Jul 2010, 21:03

Tallsar said:
"...No, any operational risks taken should and must be confined to their specific context and then not run on (in ignorance or due to financial stringency) when the neccessity to take such risks is gone. "

Agreed - But should you add to that 'operational' risk by going to war in an aircraft that doesn't meet the spec for the mission?

I believe you confuse "operations" with "maintenance" and the two are very different beasts when we talk of aircraft.

I have never seen any Fixed Wing "maintenance" done in a combat area... Combat 'Zones' - yes, but 'Areas'? (and I have done rotary wing maintenance in combat areas where no plank dared stop)

I wholeheartily agree that every 'operational' necessity should indeed be taken to defeat an enemy. But that this is best done in an operationally fit aircraft and not one of a "near enough" nature.

The military do not hold the monopoly of "Live Ops", nor are they the only ones in danger of being shot at - though they are more exposed to that.

I have recent experience of civil maintenance (perceived as rigid and unwavering by most military personnel) standards for state aircraft operations at a constant 5 minutes readiness, 24/7/365 (yes, 5 minutes.) It can be done - and relatively easlily, with very few aircraft.

The use of 'normal' and 'proper' maintenance practices increases the reliability of most aircraft by a factor of five or six and reduces the risk of mission cancellations due to airborne system failures by an enormous amount.

There are almost no circumstances where proper and correct maintenance practices cannot be conducted. Being somewhere hot, dry and remote with a threat of incoming munitions isn't one of them.

What I describe above is known as "Continued Airworthiness". Some of which can be found in Def-Stan 05-130 (MAOS) - or - if you want the full story, read EASA 2042/2003.

Believe it or not - even in the civil world it is possible to move away from the required maintenance and 'go wild' (Contingency Maintenance?) - but you have to say when you do it and do a formal recovery afterwards.

Rigga

8th Jul 2010, 22:02

Squidlord said:
"I think that's an incorrectly narrow view of "current MAA work" though I would always expect much of the MAA's work to be based on audit and review. And I agree that one of the MAA's biggest challenges is to build up a large competent staff (imo, it does already have many competent staff but not enough). Perhaps (either as a short-term or permanent feature), the MAA will contract out where it is lacking in competence and/or resource, just as the CAA does."

In my personal view the former MAR had little or no real control over their remit. They either misinterpreted the values they promulgated in manuals or didn’t understand that many were interpreting them in other ways – or just not following them. All a sign of not monitoring the effectiveness of regulation at ground level and enforcing a change of behaviour to the required pattern.

It is a classic mistake to assume that the processes written are actually being performed. Still, it’s much cheaper to just sit back and assume…

The MAOS rules, apparently written by the old MAR incumbents, plainly don’t make any real sense and even include forms that just don’t exist, and never have done (another classic assumption). But they expect people (well, civvies) to work to them anyway – and possibly, they wonder why there’s some questioning of what is required.

That the old rule makers have moved to new positions within the new MAA organisation doesn’t put much faith into that organisation’s future successes!

As for the competence of MAA personnel…if 80% are military - they will almost all move away from the fires they start when in office.

I would rudely assume that most will not want to go into the Abbeywood blocks as a matter of choice - So an individual's morale may be at a low when incumbents start - and may continue through their tour!

It will take approx 12 to 18 months to become properly familiar with the rules and regulations involved in initial and continued airworthiness matters. Given that a Tour can be screened for up to four to five years, only two or three years of meaningful duty time can be expected before an incumbent begins to wind down for his next move. Inefficient at least, but mainly disjointed and inconsistent.

There are some very capable, proficient and able people who are good at regulation and at steering errant organisations in the correct direction for compliance with a single interpretation of a specific rule – but they are not as cheap as existing civil servants or servicemen.

..awaiting the incoming :-}

Tallsar

8th Jul 2010, 22:34

Hi Flip. There are so many good messages running here now its difficult to know which to respond to. That said, you have by accident or design rasied the one of the other major issues (in talking of the Puma training/awareness issue) that has undermined our RTS process in my time.
One of the significant tensions in the RTS process has been the perception that tps at Boscombe are bereft of operational understanding and really don't get the operational "get arounds" associated with front line ops. Of course they did, having been chosen as above average operators in the first place! - but it was their job as part of the RTS process to provide impartial advice to underpin the operational spectrum and ensure it was safe - not to make amends for poor specification (by MoD) or inadequate design by the maker. Thus MoD air staff have long had the tendency to countermand what they see as very clinical and scientific assessments on such issues as the acceptability or otherwise of poor rotor governing in the Puma etc. IMO this is often driven by the very financial pressures I spoke of earlier - no one likes to be caught out as a desk officer with a problem to be sorted and no budget with which to do it! While there is no doubt that many issues can have their risk impact reduced by good training, awareness and smaller modifications (such as low RRPM audio warning), there comes a point when a qualitative and quantative assessment has to be made (often through trials) of whether there are times when the problem becomes unavoidable, or indeed cannot be recovered from, once enterred (the cliff-edge effect). Professional pride has to be put in the box if risk is to be minimised for a real problem. Of course this also involves understanding the role the ac is used in (often very customer specific) and then being able to relate it to the problem. This was what tps and their boffins used to do at Boscombe - often to the professional atagonism of well worn "operational experts" occupying MoD staff positions - particularly CFS qualified aircrew who believed there was always a training solution for every problem. Puma rotor governing is indeed a case in point..when the Puma was enterring service in 1971, its major deficiency could not be put in the right context by those senior staff officers used to (what was then world class very high tech) accurate analogue computer rotor governing available on the Wessex and Whirlwind, and for an ac type that already had design freeze due to the "anglo-french" helo deal politics of the time. Despite the accidents, the extra training and the incorporation of audio rotor warning, there have still been accidents associated with the rotor governing problem. Why, because in the heat of the operational/tactical moment where situational awareness is at the limit, the very training is (in some cases) of insufficent value to overide the getting into the flight envelope red area(in a single pilot ac in particular), and the rotor warning is too late, close to the ground, to prevent the inevitable accident. Goodness knows thats why even the next variant of the Puma made in the mid 1970s had better rotor governing fitted and its been there for over 30 years in many other operators cabs!!! it will appear at last in the Puma Mk2 upgrade programme emerging now (40 years on!!!!!:{)
My apologies - I have pontificated for too long
Cheers :ugh::)

tucumseh

9th Jul 2010, 05:58

Squidlord

Just for the record, my reasonably extensive experience is very different to tucumseh's For the aircraft I am familiar with, very large amounts of work are done (quite properly) to assess the impact of and, if necessary, update the Safety Case in response to every change in design. It's also done in response to every "abrupt" change in use. However, it's not always done as coherently as it should be and I do have a concern over "slow" changes in use. I think the latter ought to be captured by regular review of the SOIU but those regular reviews don't happen as often as they should.

Fully agree. Excellent. This variation in the application of the regulations started when the necessary funding and the posts whose sole role was maintaning airworthiness were cut, in 1990/91. We were posted to various sections in MoD(PE) and AMSO and, depending on the ethos of our new bosses, our experience/expertise (such as it was!) was either used or abused. Overnight, some aircraft and equipment stopped the work altogether, but others continue to do it properly to this day (but often with a fight and by underhand means to hide what we're spending the money on). This fragmentation, the underlying reason and the solution was reported to DPA's Deputy Chief Executive (3 Star) in 2000 (at least - I only mention this example because I was the author). He didn't reply. This paper formed the basis of two submissions to Haddon-Cave.

I'm afraid this is the bit that makes me angry; the fact that many people have died since this negligence was first reported. Haddon-Cave wasn't a revelation - it was a simple collation of known and reported facts.

flipster

9th Jul 2010, 08:49

Tuc/SL

I would be suprised if many front-line crews had ever seen the SOUI and appreciated its worth. However, on both of my last ac, the SOUI was so out of date to be worthless, thereby proving your point. I remember asking an engineer about the overwieght landings of the Herc in AFG/IRQ and being told it was being noted and taken care of. Subsequently, I think the engineers reaslised that the crews had been beating the sh!t out of the frame on altar of operational necessity. I wonder if that's why we have so few left??

Tallsar,

Quite right! Please could you just clarify this last bit of your post.

Goodness knows thats why even the next variant of the Puma made in the mid 1970s had better rotor governing fitted and its been there for over 30 years in many other operators cabs!!! it will appear at last in the Puma Mk2 upgrade programme emerging now (40 years on!!!!!)

What was the improvement in the 1970s and did the RAF ac get it?
Or are you saying that the improvement was available in the 1970s but that the RAF ac are only getting it now (or at least soon)? I suspect the latter?

Tappers Dad

9th Jul 2010, 10:16

One wonders what the recent court ruling that British Service men and women have no human rights once they have left their base will have on the MAA. It could be argued that basically once you have taken off the RAF has no "Duty of Care". So if things drop off or stop working on the aircraft whilst in flight rendering it "Un-airworthy"the RAF can turn round and say "Tough" get on with it.

Am I wrong in this?

Tallsar

9th Jul 2010, 14:31

Hi Flip
The improvement in the Puma design resulted from upgrades to the engines and later re-engining. Although similar variants to the RAF one continued to be sold in that decade, once the North Sea got hold of it for use out there, the re-engined version had a much changed/improved engine rotor governing system. Such "Super Puma" variants included the new Makila engines and associated rotor governing system. The RAF has seen none of this, despite several aborted attempts over the decades to fund either upgraded engines or replace the fleet with the latest "super puma" variants. The Mk2 upgrade programme is on-going as we speak, and includes the new engines and associated rotor governing system - so at last the system will be where it should have been circa 1980.

Cheers
:ugh::)

[email protected]

9th Jul 2010, 16:40

The Puma may have its governing faults but all the RAF Puma aircraft crashes in the last 10 years have been as a result of pilot error!

Had a brief on MAA the other day and despite all their best laid plans, they will still be hamstrung by the fact that the senior officers in charge will move jobs every 2 years and never face the repercussions of their decisions.

Tallsar

9th Jul 2010, 18:02

You and I may have some further discussopn on that sometime Crab.....:)

Rigga

9th Jul 2010, 20:25

Crab,
See post 209.

flipster

10th Jul 2010, 08:16

Crab and Rigga - check PMs
flipster

Shell Management

13th Jul 2010, 11:35

The leaders in the oil industry now believes that the Super Puma is obselete. Which shows how far behind the RAF are!

Tallsar

13th Jul 2010, 11:43

A reasonable point SM ....although EC would no doubt argue that the 322 has much to commend it beyond the old SP design and seems to be finding favour with all the main NS operators and others still.
More to the point ...as others have said...its is diffcult to accept that taking 40 year old airframes and spending hundreds of millions of squids on them is a cost-effective way forward for the UK's LSH fleet (and perhaps creating other airworthiness management problems that are not mainstream 322 or SP)....I suspect the new goverment will agree...but will they spend the cash on something more modern....Mmmm sadly don't think so.
Cheers
:ugh::)

Tallsar

13th Jul 2010, 20:43

Unfortunatley we (the UK Mod) are not good at doing "second hand" either.....look at the joke of a programme to bring into service some ex SAAF Pumas. To be fairer, any purchase like that would entail further modification to ensure some key systems compatibilty for UK tac ops at the very least, and no doubt some refurbishment work to establish their basic lifeing and airworthiness baselines under mil registration. Probably meaning it wouldn't be cost-effective. No a better way forward has to be new, to the right spec but with a cost-effective procurement process .....mmm tricky!!
Cheers
:ugh::O

tucumseh

14th Jul 2010, 05:32

No a better way forward has to be new, to the right spec but with a cost-effective procurment process .....mmm tricky!!

Back in the days when MoD trained people to "do" airworthiness, one of the basic rules of thumb was "Never modify a modification". It wasn't a hard and fast rule; more designed to make you stop and think before giving approval to proceed with developing the mod in the first place. Good advice.

Chugalug2

14th Jul 2010, 09:21

tuc:
"Never modify a modification"
Seems to me that many pilots who find all this airworthiness stuff boring and best left to the engineers should at least relate to tuc's old saws as above. Imagine if CFS were denuded of all those expensive and fussy pilots how much money could then be saved in replacing them with scribblies and blanket stackers as happened with the airworthiness engineers. Only problem is that much of ever that we learned about flying was from similar old saws from similar wise heads. No wise heads = no wise words = much reduced pilot life expectancy. Same result as the removal of the airworthiness engineers of course.

Squidlord

16th Jul 2010, 05:24

Tappers Dad:

One wonders what the recent court ruling that British Service men and women have no human rights once they have left their base will have on the MAA. It could be argued that basically once you have taken off the RAF has no "Duty of Care". So if things drop off or stop working on the aircraft whilst in flight rendering it "Un-airworthy"the RAF can turn round and say "Tough" get on with it.

I guess you'd have to ask a lawyer but my understanding is that this is only about the scope of one piece of legislation - the Human Rights Act. I think the Supreme Court have decided it does not apply abroad outside of UK bases. But I see no reason why other relevant legislation wouldn't apply (in general).

Rigga

16th Jul 2010, 18:37

Tappers Dad said:
"One wonders what the recent court ruling that British Service men and women have no human rights once they have left their base will have on the MAA. It could be argued that basically once you have taken off the RAF has no "Duty of Care". So if things drop off or stop working on the aircraft whilst in flight rendering it "Un-airworthy"the RAF can turn round and say "Tough" get on with it.

Am I wrong in this?"

TD,
No, You're not wrong - but only for personnel and aircraft in a war zone.

My understanding of the ruling is that Human Rights would apply in a (my phrase) "non-combat zone".

Now, the next interesting point is what constitutes a "Non-combat zone"?

flipster

17th Jul 2010, 08:37

Is there a correct legal definiton of Operations, Combat or Battle?

Even Rigga's 'Combat Zone', as a definition, may be clouding things a bit, as admin moves/support work can be done in a combat zone by people not under direct military threat - without the urgency or immediacy of battle conditions - in this case, their ac must be fit for the job they are doing.

This is a very grey area for sure and one that will tax the legal lot a tad! However, might it not be better to define 'combat operations' as

'Under direct attack by the enemy, IN BATTLE'.

In any other situation, to lose an ac because of a lack of airworthiness is doing our enemies' job for them...surely?:eek:

As an example, an Apache/Tornado providing covering fire for our own troops would, of course, be 'in combat' - as would be an SH or AT 'Medevac' in a firefight. Whereas an adminstrative/logistical move of personnel/equipment in SH or AT, even in the 'badlands', would not necessarily be 'in combat'.

In my opinion, I do not consider our flying in and out of AFG in Hercs, Tristars and C-17s etc as 'combat' per se. Dangerous, risky and perhaps stupid, yes - but not combat. And as such, the crews (and, most importantly, their passengers) should be able to trust that 'the system' would ensure that the aircraft was both airworthy and fit for purpose before ordering, authorising and conducting such ops - without infringing one's human right to life.

Interestingly enough, although the Human Rights Act may not apply in combat, the Health & Safety at Work Act may do - as MoD policy has makes no distinction between ops or not! Perhaps someone could explain that one?

SirPeterHardingsLovechild

2nd Aug 2010, 11:25

I've recently seen some post-Haddon Cave AP Amendments

The documents have 'to the best of my knowledge' and 'as far as I am aware' inserted above the signature block.

That's progress for you. Legal get-outs on airwothiness documents.

Maybe we should employ people who know what they're doing.

tucumseh

2nd Aug 2010, 15:19

SPHLC

That's progress for you. Legal get-outs on airworthiness documents.In a perverse way, this IS progress. Those who sign these documents (and for other components of airworthiness) are now acutely aware the baseline is so untrustworthy, so dated, they cannot be sure that what they are adding is valid.

Companies have been doing this on MoD contracts for decades - prefacing the contract with a caveat that the design is Under Ministry Control and, because MoD acknowledge they have not maintained the design (although Adam Ingram denied this when advised of the problems before the Nimrod crash), there is an assumption the design is safe - but if it turns out it isn't, it is MoD's liability.

"All" Haddon-Cave did was recognise this simple fact and bring it to the fore.

As you imply, how MoD copes with this legacy of negligence is the big question. From what you say, it would seem they haven't been funded to retrospectively update the publications. They never are - for example, there is a 3 year gap in many AP amendments from 1990-93. In another simple example, Merlin entered service in the 90s with over 50 modifications missing from the Topic 2 of a single LRU, making it impossible to repair said unit to specification. It is a huge task and I don't think the MAA have the will to fix it - flagging the problem up would merely implicate staffs who have simply changed post title and are in the MAA, and past senior officers.

Chugalug2

2nd Aug 2010, 16:59

SPHL:
'to the best of my knowledge' and 'as far as I am aware'
Even if those weasel words had been included in the RTS of the Chinook HC2 or the Nimrod Mk2 they would still have been lies. Now it would seem that the legal position for those who sign for one of Her Majesty's aircraft pre-flight is on the basis of "Caveat Emptor", as it will only be airworthy "as far as I am aware". Feeling lucky? The more the "system" tries to accommodate itself to the consequences of its very own actions, the more it will be seen as a mass of hopeless contradictions. No magic wand will make the UK Military Fleet airworthy again. The very least the crews that fly them are owed is that Airworthiness be in independent and competent hands with the power and will to ground aircraft when necessary. The MAA, as presently constituted, does not meet that very least requirement.
Self Regulation never works and in Aviation it Kills!

Gnd

2nd Aug 2010, 17:24

ALARP - use it wisely and we will all be military pilots again, not cowering bureaucrats!!
Never be airworthy again – pish!

tucumseh

2nd Aug 2010, 18:07

Never be airworthy again – pish!

Try as I may I can't find anyone saying aircraft will never be airworthy again. Those that aren't - and I'm sure the MAA have already worked that one out - can be made so by following a few simple rules. What we need is people who are willing to stick their heads above the parapet and tell it like it is; and then be given the resources to fix it. Of course, being able to recite the regulations and having the skill to implement them are two entirely different things. MoD stopped training people in the latter in the early 90s when the "maintaining" airworthiness system was largely disbanded.

For instance, a key submission was made in 2000 to DPA's Deputy Chief Executive (3 Star) making some detailed recommendations. DCE did not reply.

What is inescapable is that if one read H-C first, you are left asking "How do we implement these recommendations". But if one read the old submission first, and implemented the recommendations, H-C would have been unnecessary. Some may sneer at this, but the fact remains Adam Ingram was warned, in writing, of the failures reiterated by H-C - many months BEFORE XV230 crashed. He was advised by MoD to reject this warning, which he did 9 months AFTER the crash. That very simple, irrefutable fact, is the most damning thing about this tragedy.

Rigga

2nd Aug 2010, 21:42

Tuc said:
"No magic wand will make the UK Military Fleet airworthy again."

Neither is there a fairy godmother to do it.

Almost ALL the RAFs aircraft can be made airworthy - but they will need willpower and some funding (groan)

To make something as "small" as one Tornado airworthy will take approx two years to plan, act, check and issue an Airworthiness Certificate (and its first ARC if thats your aim)

First, you have to identify and plan the maintenance of major and even some minor components and get them all overhauled to a point when you can reliably state their known condition.
Second, the chosen aircraft is taken into Base maintenance for a Major Check. All components are stripped and sent for overhaul (for the next aircraft in), all repairs are checked for correct rivets, metal specs and Drawing compliance. A full structural integrity survey is carried out and defects repaired iaw OEM standards. An Ageing Aircraft survey is conducted alongside and elecrical integrity check, etc, etc.
Finally, all known-condition components are installed and all systems tested iaw OEM instructions including Check Flights.

All the aircraft and components documentation is retained for future reference/audit/investigation - for at least the In-Service-Life of the aircraft plus two years.
Once you have a full aircraft with known components and confirmed history start points (because all the previous historic documents are likely to have been thrown away iaw MOD rules!) a kind CAA surveyor MAY issue an Airworthiness Certificate...

And then, of course, after all that hard work, the aircraft returns to the Line for their "care and attention to accurate documentary detail"... Oh well...You can take a Horse to water...

Maybe the MAA do have the right attitude to Military maintenance standards?

Anyone got some really thin Paste for this cheap wallpaper?

Chugalug2

2nd Aug 2010, 22:23

Rigga:
Tuc said:
"No magic wand will make the UK Military Fleet airworthy again."

Actually I said it Rigga, but thank you for at least showing that I never used the word never! Neither do you I notice, but nevertheless you give your list of requirements for a CAA CofA. Fair enough and point taken, but as you will know and as no doubt others are about to remind you in short order, this thread is about Military Airworthiness, not Civil. That still means that the UK Military Airworthiness Regulations need to be fully applied again! Easy to say but not so easy to do, but stage one must be that application be truly independent. As I have posted before, if BA (or any other airline) were in charge of enforcing its own airworthiness regulations rather than complying with those of an independent regulator as now, I doubt if they'd attract many, if any, pax. Gnd tells us to put our faith in ALARP as we're (or in my case, were?) rough tough military, not numpty softy civvies (well OK he didn't, please excuse the artistic license). This has got nothing to do with military mores, but with avoiding needless waste of people and planes, so that there are more of both available to do the rough tough stuff. However, some very senior officers decided that was all too costly and took far too long. They have been shown to have been very very wrong, and it's time they were made to account for that.

Rigga

2nd Aug 2010, 23:30

"So you're talking about assessing each aircraft against................?"

...The designed standards required by the Maintenance Manuals and the OEM to assure that the aircraft actually works as designed/expected.

There is nothing to stop the MAA (and the OEM) at any time recalculating the original and additional stresses and strains imposed by heavy modification programmes to produce revised Type Certificate Data Sheets (Possibly what you refer to as the Release To Service) Isn't that what happened to the Bucc?

However, to clarify things, Role/Mission Equipment includes items that may only affect "airworthiness" through changes to flying/handling properties, electrical load shifts or major structural changes affecting strength or airflow.

And yes, BBG, civil or military - the principles for airworthiness achievement are the same.

and again, it is nice to see some signs of "considered" responsibility at the top appearing in Manuals - Maybe the mist is clearing? - and they can now see the Tsunami coming their way.

G'Nite

Mandator

2nd Aug 2010, 23:44

I have watched this debate with great interest because my day job involves sustaining the continued airworthiness of a worldwide civil fleet of over 1000 aircraft of various types.

Rigga is right about the maintenance actions that might be needed to re-establish the airworthiness of an individual aircraft if its integrity is in doubt. However, before that work can be carried out there must be a design audit of the type, which is where BGG is coming from.

It is all very well pulling off all the bits from the aircraft and replacing them with overhauled items, but before that can be done the integrity of the overhaul procedures must be established. So must the sources of spare parts, especially so-called alternatives, many of which seem to get approved by a storeman and not by a design assessment process carried out by engineers.

It is only after some form of design audit has been carried out that Rigga's checks can start. I'm not sure that I can get my head around doing a design audit on a modern military aircraft type - even the prospect of doing that on one of my little civvy puddle jumpers is daunting.

If there is any doubt that the integrity of an aircraft type has been compromised then that design audit must be carried out. The question remains - can the type be allowed to continue flying until that work is completed? An external regulator like a CAA will make sure that the right decisions are taken. I fear that a self-regulator may not be remote enough from the command chain to have the bottle to do that.

Edit: have just seen Rigga's most recent post:
A key outcome of a design audit will, of course, be any required revision of the aircraft data set so that those in the field are working with correct, up-to-date and accurate data. Moreover, it is so important for the staff in the field to feed back to the designers what they find when they carry out thie work, be it unapproved repairs, unapproved modifications, new faults or errors in the aircraft data set. Without this whole loop working as one, continued airworthiness cannot be assured.

tucumseh

3rd Aug 2010, 06:05

Good, considered posts.

A key outcome of a design audit will, of course, be any required revision of the aircraft data set so that those in the field are working with correct, up-to-date and accurate data. Moreover, it is so important for the staff in the field to feed back to the designers what they find when they carry out the work, be it unapproved repairs, unapproved modifications, new faults or errors in the aircraft data set. Without this whole loop working as one, continued airworthiness cannot be assured.This was one of the recommendations I spoke of from 2000 (it is all mandated anyway), which repeated those from 91, 92 ......... In 2002 I was asked to present on this to a certain IPT. I was shouted down by the entire IPT, bar one old hand who had worked in D/Air Arm. "We don't do this. A complete waste of money". You've got to get past this ingrained ethos. Some of those who sat in front of me are now quite senior in DE&S (but, hopefully, not in the MAA which would be catastrophic).

To the issues raised by Rigga and BGG. They are complementary. I look at it this way (because I was taught to). There are core airworthiness components that are not volume related - they cost the same whether you have one or one thousand aircraft. Then there are volume related issues, like serviceability of a fleet. The former is a pre-requisite to the latter. A simple example is an accurate and maintained Aircraft Publication (the cost of printing isn't in the core - that delivers Camera Ready Copy, which is the boundary for output regardless of quantity).

It is vital that the monies are kept separate so that, if there is a fleet reduction, then proportionate cuts are not applied to the core.

A simple little concept but absolutely fundamental. The separate pot of money always makes you think - What is this for? Why is it so special that it is kept separate? The questions make you stop and think, daily, about airworthiness.

The basic problem stems from a FY 1990/91 decision to lump the two together, so that the fixed core took a hit every time there was an "efficiency" saving or fleet reduction - of which there have been many. In fact, what happened was the ability to maintain and sustain airworthiness was eroded in a series of large chunks over the next three years.

The MAA needs people who understand these real basics otherwise the "sustainability" is forfeited for short term gains (like caveats in APs). I sincerely doubt if they have anyone remotely junior enough to know all this. Their senior staffs will regard such detail as beneath them. That only washes if you have someone properly trained to delegate the detail to - a concept almost entirely lost on today's managers and leaders, because most of them haven't attained that experience themselves. Unfortunately, you can now count on one hand those in MoD who have direct experience of having done this properly.

Chugalug2

3rd Aug 2010, 07:17

BGG:
Chug, the points that Rigga made are still valid even though he refers to a civil model.
Absolutely accepted, but this situation is peculiar to the entire Military Air Fleet. I cannot believe that the CAA would ever have caused such a massive problem with the Civilian one. In practical terms there is no way that the entire Military Fleet can be grounded whilst Rigga's process is carried out. This will take decades to put behind us even if we start right now. Some fleets will be compromised right up to withdrawal (indeed one already has been). So huge decisions will be needed about what flies and what doesn't and why, and where, and when. Those decisions must be made by the very best airworthiness professionals available, albeit in close consultation with the MOD. Bottom line is though they can say no to the MOD and mean it. This is plain chicken and egg, I cannot see how you can have the one without already ensuring the other, so when you say:
I can't disagree with your sentiments, but it does tend to distract from any other sensible discussion.
I would simply reply that you won't have a sensible discussion if it is not predicated with the vital need for a seperate and independent MAA.

Rigga

3rd Aug 2010, 21:06

First, Many thanks to Mandator for clarifying BBGs points so well - even I understand it now! (Do I know you?)

In the civil world we have ETOPS aircraft and non-ETOPS aircraft.
Often worked on by the same (Ground and Flight) staff but the work is conducted using a separate ethos in the care of ETOPS with specific regard to certain checks and standards, all of which are to maintain levels of redundancy within specific systems and components using timely and accurate process adherances in actions and documentation.

These methods, developed to improve Twin Engined aircraft reliability for flights over large distances without suitable support, are so effective that many multi-engined aircraft types have also now adopted the rules and also improved their reliability.

I don't see any reason for not applying these types of practice changes to military maintenance while fleets go through their programmes of certification conversions - indeed to practice the new policies for all the fleets would help with subsequent Airworthiness Reviews and certifications.

If there is a "real" reason to fly (such as in a war for instance) then this would be DECLARED as an "Uncontrolled Environment" and any missing maintenance could be performed or re-checked on re-entry to a "Controlled Environment". It also requires honesty and willingness by all to operate with all the books open (no secret-squirrel domains)

Trouble is - this "dream" means that ALL the maintenance staff (IPT, EngO, SNCOs, Lineys and even Contractors) sticking to the rules and waiting for queries to be answered before allowing crews to punch holes in clouds.

The details quoted are civil but the practices can easily be adopted with a bit of willpower and some decent leadership. They cost nothing but training sessions, supervision and the enforcement of intended standards by REGULATORS, who know what is needed and what tricks are used to get around it, not short-term career climbers or long-term pension seekers.

As I stated before, there is no reason to cut short any maintenance checks - except for REAL reasons (and excercises at home or abroad aren't one of them)

...Rant over.

Gnd

4th Aug 2010, 20:43

If there is a "real" reason to fly (such as in a war for instance) then this would be DECLARED as an "Uncontrolled Environment" and any missing maintenance could be performed or re-checked on re-entry to a "Controlled Environment". It also requires honesty and willingness by all to operate with all the books open (no secret-squirrel domains)This to me is ALARP and the way forward - even Mr H-C seems to think so? Does that revoke the AW or MAR cert?

tucumseh

5th Aug 2010, 05:46

This to me is ALARP and the way forward - even Mr H-C seems to think so? Does that revoke the AW or MAR cert?

No, because the Release is based on a defined Build Standard. What "revokes" (or progressively invalidates) the Safety Case, and hence the Release, is failing to maintain that Build Standard. This is the part MoD doesn't do well, following policy directives from nearly 20 years ago. I think the Services do manage Operational deviations from this very well (broadly, assuring Fitness for Purpose), but Rigga's point...

any missing maintenance could be performed or re-checked on re-entry to a "Controlled Environment".

is rendered very difficult by lack of funding and experience in the domain which is meant to "catch up". Such retrospective work was largely cancelled in the aforesaid cuts of the early 90s. ("Maintenance" being in the broader sense, not spanner wielding). Coupled with the refusal to fund the mandated "continuous review" of safety what this does is create gaps in the audit trail which are never filled. You get away with it for a while, perhaps even a lifetime, but somewhere the lack of defences in depth catches up with you.

Rigga

The details quoted are civil but the practices can easily be adopted with a bit of willpower and some decent leadership. They cost nothing but training sessions, supervision and the enforcement of intended standards by REGULATORS, who know what is needed and what tricks are used to get around it, not short-term career climbers or long-term pension seekers.Agreed. So, given the composition of MoD, you're advocating a totally independent MAA? :}

Rigga

5th Aug 2010, 21:24

Tuc:
"Agreed. So, given the composition of MoD, you're advocating a totally independent MAA?"

Abso-Bloody-Lutely!

The minimum requirement for an effective "Competent Authority" is one with Teeth to enforce the standards required right from the start; to avoid individual and spurious interpretation of the rules; and to prevent independant officers (or contractors) from imposing their own standards for fleets of aircraft operations and maintenance.

Only this sort of direct and positive intervention can avoid the poor standards of today continuing into the new "regime". Evenso, the bleed of present standards into the future will take years to get corrected.

The only reason for not installing a fully independant authority is the ability of MOD to quietly corrupt it as time goes on and the reason for doing the right things becomes lost in budget arguments again.

The present proposition, of a breast-fed authority, can only result in yet more Chinooks, Sea Kings, Hercs, Nimrods, Torpedoes, Typhoons or F35s producing more unhappy relatives...

An independant authority will produce more hassle, but less accidents.

Chugalug2

5th Aug 2010, 22:18

Rigga:
An independant authority will produce more hassle, but less accidents.
Nail, hammer; hammer, nail; just like that! :D:D:D

Tappers Dad

16th Aug 2010, 15:05

Yes I am still here, I may have some news in the next few weeks to share with you so watch this space.

MrBernoulli

16th Aug 2010, 17:38

Tappers Dad,

So unfair! You dangle that carrot in front of us, and it is only a "may have some news in the next few weeks to share with you", so we might not learn anything! Harsh! :ok:

I sincerely hope you will have some gems for us!

tucumseh

26th Aug 2010, 14:00

Short Interview with Director General of Military Aviation Authority.

First briefing for authority set up after fatal Nimrod crash | British Forces News (http://www.bfbs.com/news/uk/first-briefing-authority-set-after-fatal-nimrod-crash-38539.html)

He doesn't say much, but omits something very important. In stating that MoD were not "joined up" and didn't manage from "cradle to grave" (implying they now do), he conveniently omits that MoD used to do precisely that until, for example, the specialist airworthiness sections and committees mandated by Secy of State, and which comprised the bulk of MoD's expertise and held most of their corporate knowledge (both important airworthiness components) were disbanded in 1993 by the RAF. Nor does he say that numerous recommendations to resurrect such a system were ignored throughout the 90s/early 00s, and it took this tragedy to drag MoD screaming into the 80s.

Nevertheless, the MAA now exists and they need our support. But without acknowledging the above, how do we know they are not simply reinventing the wheel?

Rigga

26th Aug 2010, 21:52

...you should read his speech made to the ADS Air Interest Group at the RAF Club in June.
Promising words, worthy of a good cause.

flipster

27th Aug 2010, 08:22

does anyone have a transcript or even a resumee?

Tappers Dad

27th Aug 2010, 15:28

flipster
Here is the link to transcript:
Ministry of Defence | About Defence | What we do | Air Safety and Aviation | Military Aviation Authority | Director General Military Aviation Authority (MAA) speech to ADS Air Interest Group (http://www.mod.uk/DefenceInternet/AboutDefence/WhatWeDo/AirSafetyandAviation/MAA/DirectorGeneralMilitaryAviationAuthoritymaaSpeechToAdsAirInt erestGroup.htm)

tucumseh

27th Aug 2010, 16:17

Tapper's Dad

Many thanks. I hadn't read it.

He talks of “elephants”.

Well, the biggest bloody elephant in his room is the fact that MoD’s “experts” briefed Adam Ingram, both before and after XV230 crashed, that the airworthiness regulations were being implemented correctly. Time after time Ministers were told this was wrong and actual examples given.

If I were Director General MAA, the very first thing I’d do is make sure those staffs, and those who support(ed) them, play no part whatsoever in my organisation. And if that denudes DE&S and the rest of MoD of much of their hierarchy, so much the better.

In the very next paragraph he says we do have established Defence Standards. News Flash. While Mr Haddon-Cave was deliberating, MoD declared obsolete the only procedural airworthiness Defence Standard. Take a look at many of his recommendations and ask where the answer is. That Def Stan.

Oh how I’d hate being in the MAA. This paragraph is a cracker.

Another aspect of better specification of requirements lies in the area of data capture and management. I mentioned previously fault trend monitoring and, whilst the Department must take a more active role in such monitoring across the support and operating spectrum, clearly some, perhaps the majority in the case of partnered support, of the relevant data will be generated and captured in Industry activities and reside on Industry systems. As a first order requirement, the understanding of what data is available, or required; where and how it is accessed; what use it is put to, by whom; and how it is safeguarded, must be explicit. Moreover, adequate and effective contractual cover must be in place to protect mission critical data and mitigate the risk of broken logic/evidence chains, or inappropriate commercial leverage being a temptation downstream during a system's potentially long life.

For those in DE&S reading this, dig out the obsolete Def Stan. This is stuff you need to know and have done a thousand times before being promoted to the grade 3 steps below the DE&S minima.

I’m afraid I really am utterly appalled. Not one single person in any DE&S Project Team should have to be told any of this. One assumes the DG assessed his target audience while preparing this speech; as one is taught to. His conclusion, and the basic level at which he aimed, tells me this is going to take years.

flipster

27th Aug 2010, 18:15

TD thanks
Tucs reply is a bit worrying - it looks like the MoD airworthiness process is in even worse shape than I thought!!! MAA are between a rock and a hard place!
F

Rigga

27th Aug 2010, 21:10

Whilst Tuc's reply might appear a little worrying - I think its spot-on!

Many of the current incumbents are most likely to be the same weak-willed drongoes that allowed the degradation of the specific services they were supposed to supply for budgetry reasons alone. And then they allowed these issues to worsten using "creative reporting" (smoke and mirrors) to cover it all until opened up by public inquiry.

It will probably take 5-10 years to build a new safety culture within the MAA itself and possibly further to reach into all Line operations and be accepted as the new "norm" for the shop floor - Thats where your safety culture is maintained.

IMO the new safety culture would be better served using newly inducted and untainted staff who are keen to do the "proper" job in a sustainable way - like their new Boss suggests he would like too.

flipster

27th Aug 2010, 23:51

Either that or trawling the retirement homes for engineers (over 50 yo at least) who gave a sh!t about the aircraft for which they were given charge!

tucumseh

28th Aug 2010, 07:31

IMO the new safety culture would be better served using newly inducted and untainted staff who are keen to do the "proper" job in a sustainable way - like their new Boss suggests he would like too.I agree, but the entire MoD personnel structure has to change. If the MAA is to provide continuity, who is going to join for 10 years while their contemporaries do a succession of less responsible jobs and get promoted each time? The willingness to accept responsibility, be accountable and an ability to do the job properly, must be rewarded somehow. We used to have “scarce discipline” allowance in MoD(PE). But many recipients wouldn’t accept airworthiness delegation and were little more than minutes secretaries. What MoD needs is to recognise this and those who don’t accept responsibility or delegation are effectively held back. This is nothing new. There used to be a system whereby it was recognised certain posts required seniority for line management purposes, but they couldn’t be promoted until serving 2 years in a post with wider responsibility, like having airworthiness delegation. “Restricted opportunity” posts I think they were called. They were rare, but they need to become the norm.

Either that or trawling the retirement homes for engineers (over 50 yo at least) who gave a sh!t about the aircraft for which they were given charge!And that is what industry does successfully whenever they hit a problem the younger staff have never seen before. The pinnacle for their engineers is Chief Designer. He is God+1. It may take 30 years to achieve that level of experience and competence, and then he retires after a few years. That doesn’t suddenly make him incompetent and very often they are held on a retainer. That doesn’t mean the younger staffs are lacking. It is simply a pragmatic recognition that you get different problems every day and some don’t reoccur for decades. It is the nature of safety and risk management. It prevents reinvention of the wheel. MoD don’t do that. When their older staffs advise them something is going very wrong and aircrew are at risk, they simply get one of Rigga’s drongoes to trash him in a Ministerial brief. (One day, I shall frame the Ministerial brief from AbbeyWood saying I am the only person in MoD who says there is an airworthiness problem, therefore I am wrong. Dated 2 years before XV230).

I will never stop saying this until MoD acknowledge it. The record will show, for all time, that Ministers were advised in writing, long before XV230 crashed, of systemic airworthiness failings. ACM Loader’s words, which led directly to Haddon-Cave, were simply a reiteration if known facts, as was the H-C report.