Self Regulation Does Not Work, and in Aviation it Kills!

[Lima Juliet]

Self Regulation Does Not Work, and in Aviation it Kills! (c) Chugalug2

This is an intent that Chug/Tuc always press with and so I thought I would do some Sunday morning research:

UK MILITARY SAFETY
The Ministry of Defence (a Govt Dept) uses the following to safely regulate its activities:
Defence Accident Investigation Branch (Defence AIB)
Defence Fire Safety Regulator (DFSR)
Defence Land Safety Regulator (DLSR)
Defence Maritime Regulator (DMR)
Defence Nuclear Safety Regulator (DNSR)
Defence Ordnance, Munitions and Explosives (OME) Safety Regulator (DOSR)
Military Aviation Authority (MAA)
Headquarters Policy (HQ-Pol)

UK CIVILIAN TRANSPORT SAFETY
The Department for Transport uses the following to safely regulate its activities:
Office of Rail and Road
Driver Vehicle and Licencing Agency (DVLA)
Driver and Vehicle Standards Agency (DVSA)
Maritime and Coastguard Agency (MCA)
British Transport Police Authority
National Lighthouse Board
Transport Commissioners
Civil Aviation Authority (CAA)
Highways England
Air Accident Investigation Branch (AAIB)
Rail Accident Investigation Branch (RAIB)
Maritime Accident Investigation Branch (MAIB)

HIGH LEVEL REGULATORY OVERSIGHT OF BOTH DEPARTMENTS
Both of these are overseen by the Government Legal Department (GLD) to ensure that UK Law is upheld. The GLD are a part of the Treasury and is headed by a Senior Civil Servant. The Health and Safety Executive (HSE) have UK Legal jurisdiction over all Govt Depts and have enacted their right of Crown Censure in recent times on the MOD - Brecon Beacons deaths and the crushing of driver at MOD Kineton. Moreover they were given primacy on the Red Arrows ejection seat accident. Then, when there is a death or serious injury, there is the Coroner to answer to. So the only 'Self Regulation' I can see is that the Government effectively regulates its own activity. But then who would check the Government? Well the electorate every 5 years or so.

So, this leads me to think that there is no sense in the 'self regulation' comment and that this is misleading? If it is meant that regulation should not be within that particular Govt Dept then we would need to deconstruct all Govt Depts as they all regulate within but with a level of cross-Dept oversight. Is that a fair assessment given the facts above, or am I missing something?

LJ :confused:

[ancientaviator62]

Leon,
seems to be a variant of the Roman conundrum ' Quis custodiet ipsos custodes ?' !

[tucumseh]

Leon

Having headed the thread “...Aviation”, you list a number of entities who are mostly unconcerned. But your point is taken.

Irrefutable facts:



Many Government Ministers of all persuasions, Senior Officers/Officials and Cabinet Secretaries, have formally ruled that it is an offence to disobey an order to make a false declaration on airworthiness (and financial probity). The MAA has existed for seven years and has not sought to overturn these rulings – in fact, DE&S actually named a senior MAA officer in its last briefing to Minister, when it advised him to continue upholding the ruling. Which he did. In the past, some have queried this statement, but I assume that my having published the References, and MoD approved their publication, means it is now accepted.
On 17 January 2011, Minister for the Armed Forces Nick Harvey confirmed that, under SDSR 2010, various MoD departments had demanded a substantial cut in airworthinesss funding. This, shortly after publication of the Nimrod Review and formation of the MAA. Clearly, MoD still retains a culture whereby such “savings at the expense of safety” are still acceptable, even after the Nimrod Review. As of that date, this was being fought by other parts of MoD (well done). Subsequent events, such as (but not restricted to) (a) the MAA condoning no safety case for the Hawk ejection seat, and an invalid one for the aircraft itself, and, similarly, (b) the Air Cadet saga, again involving unairworthy aircraft and no valid safety case, means that these demands were, at least in part, met. Or, perhaps, the “good” part of MoD succeeded in maintaining the status quo, which would actually be a huge setback, given the regression need to fix the failings noted by so many since the late 80s, and simply repeated by Haddon-Cave.


This, and natural justice, makes it unsafe for MoD to sit in judgement of itself. The fact that MoD continues to make – in fact actively demands, under threat of sanction – the same old mistakes, means, I believe, that it is time to try something different. And legal.

Of those you list involved in aviation, the Air Accidents Investigation Branch are the full-time professionals. The MoD departments are, at best, enthusiastic amateurs, most there on a 2 year desk job they see as a route to advancement. A possible solution emerges.

You cite the HSE having primacy on the Red Arrows XX177 accident, but they only got seriously involved after the CPS conducted a disgracefully narrow “investigation”, limiting its investigation to servicing of the equipment. The CPS has form here, including lying about lack of witnesses coming forward on Nimrod XV230. The case is sub judice, and it is to be hoped that the Crown Court, unlike the CPS and HSE, actually pays attention to the evidence. Perhaps, if justice is served and the MoD replaces Martin Baker in the dock, your question may receive more attention!

[Just This Once...]

LJ, I see it much the same way as yourself. Where I do tip my hat to Tuc & Chug is that the MAA and MilAAIB draw all of their uniformed staff from the area under investigation and then return said staff to the area of investigation either at tourex or end of temporary detachment. In this regard the MoD aviation safety organisation is unique and it probably has a deleterious effect.

Could it be better - I believe so and have raised this point with 2 different MAA heads. The alternative structure I offered is to more closely mirror the AAIB who draw permanent staff from civil aviation. The MilAAIB should similarly draw permanent staff from military aviation (ideally FTRS) and (given the airspace is inherently a civilian/military mix) should report jointly to both Secretaries of State.

Unfortunately nobody made me Emperor so the status quo remains.

[tucumseh]

JTO

In other words, you agree with me!

MoD is long past the stage where it can appoint its own permanent staff in sufficient numbers. By definition, the vast majority were civilians, but the decision to close most workshops meant it no longer had a recruiting ground. I was speaking to an airworthiness certification engineer yesterday, and he wouldn’t get out of bed for what MoD offers the inexperienced staff who have replaced highly trained engineers. This is not to the MAA’s fault – they inherited this situation. Like you, I’ve made representations - our 3 Star (Mr Gould) didn’t bother to reply in January 2000. Perhaps because his immediate subordinate, the Nimrod/Chinook 2 Star, had just ruled that safety was optional, and one could sign to say the regs had been met, knowing they hadn’t. (Which is what prompted my submission to him).

The MAA cannot make inroads into this culture, and I’m not sure it wants to or even understands. Remember, MoD continues to confirm that not a single person in the MAA reported the systemic failings. That means; if they were trained, they avoided a legal obligation; if untrained, they aren’t suitably qualified or experienced. Some in the MAA might choose to challenge this; if so, take it up with your Air Policy branch and DE&S Secretariat, who wrote the letters with the agreement of your bosses. (Not too far from your own experiences, JTO).

As ever, I acknowledge the vast majority in MoD loathe this culture. Some years ago we speculated here that a high profile court case might do the business. We got the timid Nimrod Review, which MoD now rejects. Perhaps the XX177 case might be the catalyst. Come on Mr Campbell, tell the truth on behalf of your client.

[Lima Juliet]

Ancient Aviator

"Quis custodiet ipsos custodes?", indeed, who does watch the watchmen. It is ever thus and a difficult conundrum to solve.

Tuc/JTO, yup, I agree. But as AA62 has pointed out, who would you use? If the CPS and HSE can't be trusted then I guess we are kind of stuck with it? Whomever pays for any independent regulator is always at risk of accusations of bias or narrowing down the scope of their investigation. FTRS seems like a neat solition but still involves post sponsors and lines of funding - also, when it comes to renewal, then if the individual has been a difficult SOB then renewal may be unlikely. As for career inspectors like the AAIB then again this has pros and cons - yes you may get consistency, but you may also get staleness after 5-10 years in the same role; plus also, if you get a twonk in the post you may be stuck with them for aome time!

I think we should accept the current slight imperfections as it may be 'better the devil you know'?

LJ

[tucumseh]

Leon

Again, points taken, but I can think of over 70 families who would prefer the "devil we know" to be in gaol. A "devil" may be just about acceptable if it could be guaranteed that he would not systematically breach his own mandated regulations, and then lie in court about it. MoD has proven itself, time and again, incapable. That is not a slight imperfection. That is a direct attack.

[Brian W May]

Whilst this discussion is a little 'above' me, my personal experience of both military and civil flying anecdotally supports the original statement.

Certain companies actually falsified documentation in order to satisfy regulations (on several occasions).

Airlines that use 'Standard Weights' when we all knew they were wrong. I asked for a check weigh at Manchester once . . . - guess what.

When I flew with Biman Bangladesh there were appalling levels of incompetence, once more 'covered up' and even though I reported officially, it was still covered up.

I would love to believe 'Safety is our Prime Concern', my own experience doesn't support the assertion.

[Lima Juliet]

but I can think of over 70 families who would prefer the "devil we know" to be in gaol. A "devil" may be just about acceptable if it could be guaranteed that he would not systematically breach his own mandated regulations, and then lie in court about it. MoD has proven itself, time and again, incapable. That is not a slight imperfection. That is a direct attack

Tuc, I hear what you say but what I can't understand is that all of those 70 families' losses were subject to a Coroner's Court. That is an 'independent' Coroner and most definately not an MOD employee. So why were these people, that had been so obviously neglegent, prosecuted?

Brian, I agree. There are some dreadful cover ups at all levels of civil aviation from General Aviation to Commercial Air Transport. Often the commercial edge is what instigates such bad behaviour especially if profit margins are low.

LJ

[Chugalug2]

Leon, thank you for publicising my catch phrase. No charges levied and all are welcome to use it to spread the word! :ok:

As tuc wisely says, best we stick to aviation without straying into yet other worlds such as those of the BMA or the Law Society. The main difference between the DfT and the MOD is that whereas the former is not an operator of any substance, the latter most certainly is via its Service subsidiaries. Thus the CAA can and does require every operator to conform to whatever it deems necessary, witness the extensive and costly list of kit and training following the 737 fire tragedy at Manchester. In contrast the MAA can't even accept that the chalice it was handed on its formation was a poisoned one, in that UK Military Airworthiness had been dealt a savage blow by the MOD in the "Golden Period" from which it is still reeling. Before it can begin to put it right it has to face up to that truth. Before it can do that it has to be free of the RAF High Command's continuing cover up of the actions of its VSOs in that Golden Period. To do that it has to be independent of the MOD. Ditto all of the above for the MilAAIB.

As to cost, the poor suffering British Taxpayer will have to bear it. He/she always does. As to the arrangements, keep it simple and sister the MAA with the CAA, likewise the MilAAIB with the AAIB. Both must be civilian led, both can be staffed by military personnel, preferably in new branches created for the purpose, as well as civilians. Expensive? Yes. Difficult? Certainly. But less expensive than the dysfunctional morass that we have today. There is a limit to how many fleets we can afford to ground or even pause. The rest must stay flying and the chronic and systemic unairworthiness purged from them. It will be a long job, hence the sooner we get started the better. Rather that than yet more heart breaking Airworthiness Related Fatal Air Accident threads started in this forum.

PS Apologies for the delay in posting. Mothers Day at Chug Towers!

[Lima Juliet]

Hi Chug, yes I had a short diversion in the middle of the day as well. :ok:

As to the arrangements, keep it simple and sister the MAA with the CAA, likewise the MilAAIB with the AAIB. Both must be civilian led, both can be staffed by military personnel, preferably in new branches created for the purpose, as well as civilians.

Now I really like the first bit but less the second bit. The problem with making the leadership all civvy is that personal agendas always come to bear when humans are involved. So I would suggest a 2-3 year rotational post between the CAA and MAA with the deputy always being cut from the other side's cloth. That would see independence. The UK AIRPROX Board kind of does what you suggest on a far smaller scale and I think that it would benefit from having a mix of CAA staff and uniformed MAA staff, possibly FTRS. If nothing else having the civvies investigate the military and the military investigating the civvies would see some neet cross-pollenation of ideas and best practice. Also, both sides could demonstrate further independence that seems to be required.

When you look at the Air Navigation Order, SERA and MAA Regulatory Publications then you see that they are pretty closely aligned. So to see a merger may not be that very difficult - as ever waivers and derogations will be needed for niche capabilities on both sides. Since the Shoreham accident the drafts of CAP403 and RA2335 have become very closely aligned and that shows what could be done. Maybe if the CAA leaves EASA due to BREXIT then a golden opportunity may present itself? (I know they have stated they do not intend to leave EASA but depending on where BREXIT takes us then we have no choice!).

LJ

[Chugalug2]

Leon, I do not think that the two would knit naturally together anyway at first. For a start the CAA is funded by the operators and licensees while the MAA would be funded by the government. On the other hand, a cross fertilisation of personnel and good practice between the two would ensure the return of much of the expertise and knowledge to Military Regulation so ruthlessly driven out of military airworthiness maintenance and provision.

As to who would be the DG, I'm afraid that the RAF has rather shot itself in the foot in that regard. Once its VSOs had targeted the Air Safety budgets, subverted the regs, and ordered subordinates to suborn them into the bargain, they have rather forfeited any expectation of being allowed the opportunity to repeat such pillage. You might respond that it was all some thirty odd years ago and times change, but as tuc reminds us it is still policy that such orders were acceptable and that disobeying them is still an offence. The cover up continues and hence perpetuates the crime.

Maybe in years to come an arrangement such as you propose might emerge after the reform we seek has changed hearts and minds. An important factor would be that the personnel should be semi permanent. A lot of the problems at the MOD seem to stem from the constant comings and goings into posts that require far more than 2-3 years experience. That is why I suggest the formation of a new Air Safety Branch so that whether you are civilian or Service, you understand the system intimately and thus would be aware of its fragility and the importance of preventing its subversion again.

Re the Regs, they never were the problem. All that was necessary was to implement them. That they weren't has cost some 70 lives accounted for in airworthiness related fatal air accident threads in this forum alone.

Finally, it's a bit rich to try to pin any blame on the Coroners for not bringing the MOD to heel. Other than telling the RAF that "There's something wrong with your bloody aircraft" or words to that effect, as famously stated by the Oxford Coroner, it is for the UK Military Air Regulator to ensure that it is not so. That it chose instead to mislead and dissemble to them instead is a comment on the MOD and not the Coroners!

[EESDL]

After yet another crash of a perfectly serviceable helicopter being mishandled due to incorrect and illogical (negligent?) use of the autopilot, the CAA were embarrassingly forced to 'step-in' and mandate changes which were previously regarded as 'optional' by the operators.
Lest not forget the abuse of FDM data to allow flights and deterioration of MRGBs to continue.
Follow that with the political pressure applied by Hairbrush to get their grounded choppers flying again; until a repeat event exposed the shenanigans and spin for what it was.
Government/revenue collector and Oil companies' unhealthy relationship re slack use of 'best practice' and the number of 'blind eyes' present in authority, or at least where the Accountable Manager was meant to be seated......automation and performance 20-years behind fixed-wing despite operating to the same regulations.
Industry being asked if 'commercial pressure' had any affect upon 'safety' and the enquirer accepting the first answer they got as they didn't have the wherewithal to 'turn the stone over' and to have a good look.
The result:
Yet another Industry-quango was formed, employees paid by the oil operators and OEMs with the inevitable glossy brochures and proclamations quickly following on how everything was great again.
Next thing you read is industry media mis-reporting that everything is indeed 'safe' again - so get back in the chopper, sit down, strap-in and shut-up!

That's what happens in Civvy Street.

[Chugalug2]

EESDL, I am under no illusions that all will become a panacea under the reforms I call for. I well remember resenting the Dane Geld forever having to be forked out into the ever ravenous maw of the CAA, but as far as I know it has never set out to subvert its own mandated regulations. Of course the operators are always on its back to alleviate the financial and operational burden of conforming with those regulations. It is its job to insist that they be complied with. If it isn't doing that then start a campaign to force it to do so!

Civil Aviation does though have one great advantage over Military Aviation; the regulator, investigator and operators are separate and independent. In Military Aviation they are all one and the same.

[EESDL]

Then Military Aviation must be dire straits!
I left 11-years ago, not due to safety concerns but due to financial concerns and the fact that it was becoming obvious that there were not the funds to both fight a war and to and to provide the manpower and brainpower for such 'niceties'.
We were very much 'second-class citizens'

[Just This Once...]

JTO

In other words, you agree with me!

MoD is long past the stage where it can appoint its own permanent staff in sufficient numbers.

The MAA cannot make inroads into this culture, and I’m not sure it wants to or even understands.

I'm not sure I do, at least in part. I am comfortable with the MAA doing its thing and in its reporting chain. Where I am not comfortable with is the attitude of the MAA by which it pushes issues back onto the Duty Holder chain whilst washing their hands. They don't even appear to have a moral compass let alone a duty of care to ensure that issues are resolved at the earliest practical level.

The DH staff are frequently exposed to intolerable issues that should have never been accepted by the PTs. The MAA expend their horsepower critiquing how quickly the DH staff can uncover the buried truth and the speed of the DH reaction to the seemingly endless crisis points. The PTLs and those with airworthiness responsibility appear to be flameproof and carry on photocopying their errors or misdeeds, typically with the MAA rep in the room who says nothing.

So why do I support the MAA - well with the one distinct exception it does have a structure and capability capable of ensuring airworthiness in a military environment. If the performance and actions of the MAA were critiqued as part of an independent MilAAIB investigation I am convinced that its emphasis would shift from ensuring that the DH or operators get the blame, to assuring that the MoD (including the MAA) is actually abiding to the standards that the SofS thinks he has set.

If and when major systemic failures are found during an incident or accident investigation the MAA staff, who through indifference, inaction or undue professional deference have failed in their duty, should be having sleepless nights. Authority without responsibility or accountability is having a deleterious effect on military airworthiness.

[[email protected]]

Perhaps the MAA would be more effective if it wasn't obsessed by trivia - every tiny problem seems to require a DASOR, especially the sort of thing that should just be an entry in a tech log or F700.

They must be drowning in useless and pointless data - none of which makes anything any safer - far from it, anyone who has been the 'victim' of an OSI or even lower level investigation will know that the 'just culture' turns into a witch-hunt and erodes trust between the 'four worlds' (God I hate that expression).

Eventually people stop reporting the sorts of things that do need to be reported and real problems get covered up in order to save face or avoid another pointless witch-hunt.

The MAA has turned into the manic cousin of HSE and it provides a horrible outlet for those career-types who revel in bringing others down or those that love spreadsheets, pie-charts and tick-boxes to show just how much safer they are than the 'other-guys'.

Add in all the other barriers to getting airborne - computer-based auths, on-line regulatory and planning documents and and endless stream of QCCs that HAVE to be met (and all of this stops working when Dii is upgraded) plus an ever increasing removal of trust in anyone to just do their job properly and you get a real Flight Safety problem since no-one is in their 'mission-bubble' any more when they walk for the aircraft.

[tucumseh]

JTO, I disagree, as I still think we agree! The failings you (and crab) list are sufficient to warrant disbanding the MAA. It is unfit for purpose. I would be very much kinder if just one of its senior staff would speak out and admit why it exists. Instead, they lie.


So why do I support the MAA - well with the one distinct exception it does have a structure and capability capable of ensuring airworthiness in a military environment.

A viable structure and capability has always existed. In most of the accidents we discuss, the system worked perfectly well until a few identifiable individuals broke the law. The system identified these breaches, but other identifiable individuals dismissed complaints with malice, and knowingly placed aircrew in danger. They did not intend to harm aircrew, but that was the predicted outcome. Some notifications were in general terms (e.g. Chinook - it isn't airworthy, you're prohibited from flying it); others very specific and deadly accurate (C130 XV179, Tornado ZG710, Nimrod XV230). Therefore, the knowledge that harm would be caused must have played a part in their decision making. In each case, it was cheaper, quicker and better to simply meet legal obligations.

None of that is in doubt. So why does the MAA continue to denigrate and deny?

[Engines]

Leon,

Thanks for starting what will be a really interesting thread for discussion and opinion. Here’s my attempt to help things along. When we talk about ‘self-regulation’, perhaps it might help to try to define what activities we think an ‘airworthiness regulator’ should do, and who should (or should not) be doing it.

1. First one’s obvious – to be the authority for all regulations, covering both operating and technical airworthiness. I think a high level MoD department should be doing this. Next is the job of setting up and running systems for reporting occurrences and events that bear on airworthiness. That includes providing independent oversight of the outputs. Again, I don’t think that having a two star led MoD Centre organisation doing that is a bad thing

2. Now a contentious one – assurance. Who audits the operation of the system to make sure that people are doing what they’re supposed to be doing? Again, I think that a two star led MoD centre department should be sufficiently separate from the DE&S and the Operating Commands to do be able to do this. Note that this aspect doesn’t include the next one:

3. Accident Investigation. I think this is one Haddon-Cave got it wrong. Conducting inquiries into accidents should be taken out of the MAA’s control and moved to a separate Government Agency, possibly reporting directly to the Secretary of State for Defence. This would allow inquiries to properly examine whether the MAA’s actions had a bearing. The MAAIB should be moved to the same location, but reporting separately to the SofS.

4. I’ve kept the contentious one until last. Haddon-Cave was clear that the role of RTSA should not be carried out by Service Commanders. He devoted a lot of space to arguing that the new MAA ‘Operating Airworthiness’ department should carry out the RTSA role. I agree that RTSA should be taken away from Service Commands – it’s here that some of the most egregious airworthiness failings (and cover ups) have taken place, with wholly inadequate and plain incorrect documents being used to put unsafe aircraft into service. The MoK Chinook was an example.

5. However I(and here I’m probably going to upset the pilots) I think it should go to the Technical area of the MAA, not the ‘Operating’ area as Haddon-Cave recommended. Preparation of an RTS is, in my view (a stand by for incoming) a systems engineering task. It uses the evidence developed by the technical processes of procurement to develop a safe and auditable set of limitations inside which the aircraft can be operated. It’s inextricably linked to the configuration of the aircraft. It’s a technical document, and should be owned and authorised by a technically competent person. At that stage, aircrew can take it for use.

6. Which brings me to my last point. Why didn’t the RTSA role go to the MAA as Haddon-Cave recommended? As I remember, there was a gap of around two years before the RA (1021) on RTSA came out, which confirmed that the role remained with ACAS for the RAF, ACNS(Pol) for the RN and ACGS for the Army. My guess – the RAF VSOs decided that this was the ditch they were going to die in. Looking at the RA, having the RTSA role held by the Service command chain makes little or no sense. The RA actually says that the RTSA is supposed to provide ‘Independent Air Safety assurance’ – some hope.

This is a direct contravention of the MoD’s undertaking to implement Haddon-Cave ‘in full’, and should be corrected.

So, that’s my put – comments? Best Regards as ever to all those who want the system to be better,

Engines

[tucumseh]

Engines

MoD’s undertaking to implement Haddon-Cave ‘in full’

Interestingly, on 28 November 2012 MoD’s Defence Equipment and Support Policy Secretariat distanced itself from the (previous) Government's acceptance of the Nimrod Review. This was after an MP pointed out to MoD that the MAA was not implementing Haddon-Cave's recommendations in full.

I think your item 5 important. You are of course correct. The "Operating" input should be limited to non-technical Service Deviations. (Technical ones already need to be written by engineering staff in the project team - a largely ignored reg). I think the VSOs' stance comes from the widespread failure to understand the difference between airworthiness and fitness for purpose. (And last time I spoke to a senior officers in the MAA, they didn't understand either). If you don't understand, you should not be involved.

[Lynxman]

Leon,

Thanks for starting what will be a really interesting thread for discussion and opinion. Here’s my attempt to help things along. When we talk about ‘self-regulation’, perhaps it might help to try to define what activities we think an ‘airworthiness regulator’ should do, and who should (or should not) be doing it.

1. First one’s obvious – to be the authority for all regulations, covering both operating and technical airworthiness. I think a high level MoD department should be doing this. Next is the job of setting up and running systems for reporting occurrences and events that bear on airworthiness. That includes providing independent oversight of the outputs. Again, I don’t think that having a two star led MoD Centre organisation doing that is a bad thing

2. Now a contentious one – assurance. Who audits the operation of the system to make sure that people are doing what they’re supposed to be doing? Again, I think that a two star led MoD centre department should be sufficiently separate from the DE&S and the Operating Commands to do be able to do this. Note that this aspect doesn’t include the next one:

3. Accident Investigation. I think this is one Haddon-Cave got it wrong. Conducting inquiries into accidents should be taken out of the MAA’s control and moved to a separate Government Agency, possibly reporting directly to the Secretary of State for Defence. This would allow inquiries to properly examine whether the MAA’s actions had a bearing. The MAAIB should be moved to the same location, but reporting separately to the SofS.

4. I’ve kept the contentious one until last. Haddon-Cave was clear that the role of RTSA should not be carried out by Service Commanders. He devoted a lot of space to arguing that the new MAA ‘Operating Airworthiness’ department should carry out the RTSA role. I agree that RTSA should be taken away from Service Commands – it’s here that some of the most egregious airworthiness failings (and cover ups) have taken place, with wholly inadequate and plain incorrect documents being used to put unsafe aircraft into service. The MoK Chinook was an example.

5. However I(and here I’m probably going to upset the pilots) I think it should go to the Technical area of the MAA, not the ‘Operating’ area as Haddon-Cave recommended. Preparation of an RTS is, in my view (a stand by for incoming) a systems engineering task. It uses the evidence developed by the technical processes of procurement to develop a safe and auditable set of limitations inside which the aircraft can be operated. It’s inextricably linked to the configuration of the aircraft. It’s a technical document, and should be owned and authorised by a technically competent person. At that stage, aircrew can take it for use.

6. Which brings me to my last point. Why didn’t the RTSA role go to the MAA as Haddon-Cave recommended? As I remember, there was a gap of around two years before the RA (1021) on RTSA came out, which confirmed that the role remained with ACAS for the RAF, ACNS(Pol) for the RN and ACGS for the Army. My guess – the RAF VSOs decided that this was the ditch they were going to die in. Looking at the RA, having the RTSA role held by the Service command chain makes little or no sense. The RA actually says that the RTSA is supposed to provide ‘Independent Air Safety assurance’ – some hope.

This is a direct contravention of the MoD’s undertaking to implement Haddon-Cave ‘in full’, and should be corrected.

So, that’s my put – comments? Best Regards as ever to all those who want the system to be better,

Engines

As Leon initially said, the Defence Accident Investgation Branch does not report to the MAA, it is an independent organization under DG DSA that can report directly to the SofS via DG DSA. Item 3 on your list, check!

[Chugalug2]

Lynxman:-
the Defence Accident Investigation Branch does not report to the MAA, it is an independent organization under DG DSA that can report directly to the SofS via DG DSA

Just because the sign on the door (next to the one warning of Wet Paint!) includes the word "independent" doesn't mean it is. The Regulator and the Investigator do indeed come under the same DG and all are part of the MOD (ie the Operator). How is anything/anybody independent in that arrangement?

[Engines]

Lynxman,

Thanks for coming back. I'm afraid I think I may have to gently disagree with you here.

While the MilAAIB may now be under the direct line management of the DSA (a fairly recent development that corrected the utter nonsense of having an accident investigation team under an airworthiness regulator), it is the MAA who convenes an SI and appoints the President. During that investigation, the MilAAIB is an integral part of the "team" (SI + MilAAIB), which is headed by the President, who reports direct to D/ MAA. Therefore, the MAA potentially acquires control of MilAAIB activities during an investigation, which is the important part of their work. This functional link is not made entirely clear by MoD in its various websites.

There's also the fact that MilAAIB findings are incorporated into the MAA published report. This is an important point - the original RNAIU arrangements (which Haddon-Cave praised and recommended as a model) involved the President of a BoI requesting an AIU investigation. This investigation led to a separate AIU report, with findings and recommendations, which was submitted to the BoI president. The BoI then referred to the AIU report as it wished - but it couldn't edit the findings.

So, sorry, but I don't think the current arrangements provide a 'check' for item 3. In my view, accident inquiries need to be carried out by a department outside the MoD. I'd go further - the number of senior officers in the MilAAIB needs to be reduced. Certainly, the Head needs to be a suitably experienced and respected civilian.

But thanks again for coming back - and please feel free to continue to disagree - discussion and exchange of views is the only way to progress.

Best regards as ever to all those doing the investigations,

Engines

[EAP86]

JTO: "Where I am not comfortable with is the attitude of the MAA by which it pushes issues back onto the Duty Holder chain whilst washing their hands. They don't even appear to have a moral compass let alone a duty of care to ensure that issues are resolved at the earliest practical level." I believe they do this because the legal duty of care for safety is mainly owned by the operators, hence the "Duty Holder" term (as an aside I think the term actually causes far more confusion than its worth). The MAA have expended considerable efforts trying to ensure that the operators understand their obligations.

Engines, point 3. At the time there was general surprise that CHC made recommendations around accident investigation at all since it wasn't seen as a particularly problematic area. The management chain aspect was always going to be a contentious issue but pragmatically speaking, I don't think its been a real issue (apart from one DG's obsession with a/c scaring horses being ridden by the public, allegedly :-))

Engines, points about the RTSA. I think the MAA had a few difficulties with how to fit the RTSA role into their proposed scheme of things at all. If the RTSA had moved into the MAA, I think the role would have disappeared within a few years purely because the complexity of modern in-service types tends to interfere with the more technical aspects of the RTSA role. Nevertheless the MAA probably could envisage that technical deviations have become necessary in some operational contexts, so the possibility remains. I might not be explaining this very well but I'm trying to avoid an essay on the subject. Its worth noting that it is very much in the operators' interests to own their own safety assurance function since they hold the duties so the RTSA role isn't a regulatory dead end.

I believe that when the new arrangements were becoming clearer, the MAA did take CHC through the differences from his recommendations to assure he was comfortable with them. I believe he refused to adopt a more formal role as this would have been in conflict with the independence demanded of his role as a Judge.

EAP

[[email protected]]

Engines - whilst it may be the way of the modern world to have RTSA exclusively manned by engineers - that stops working when they make decisions about piloty things because they think they know better and won't ask an operator. That goes for aircraft configuration, role equipment, avionics and general ergonomic layouts of cockpits.

In order to free up aircrew, many aircrew posts within PTs and the like were gapped or removed so the aircrew input to many areas of airworthiness was lost.

As for the Duty Holder chain, we are constantly told that they are 'managing the risk' - this is nonsense, the people managing and dealing with the risk on a day to day basis are the crews but it gives upper management a warm and fuzzy feeling that they have taken responsibility.

As another example of how mad the world has become - colleagues and I who have been QHIs for many, many years now have to do the DTTT (defence train the trainers) course before we are deemed compliant with regulations. Accreditation was only provided in 2011 for the CFSH course and all of those who passed it - and instructed on it - before that time now have to lose a week of productive flying training to learn classroom skills that are wholly irrelevant to that flying training - just to keep the educators empire happy and tick some more 'safety' boxes. How did we ever manage to produce good quality aircrew without the extended INTROSH course?????

[tucumseh]

Whilst it may be the way of the modern world to have RTSA exclusively manned by engineers - that stops working when they make decisions about piloty things because they think they know better and won't ask an operator. That goes for aircraft configuration, role equipment, avionics and general ergonomic layouts of cockpits. Crab, I recall a few years ago replying to the same issues by simply quoting the regs. RN types agreed with me, RAF didn't recognise anything I was talking about! So, there are many answers. (Essentially, the RTSA has little or no input to the elements you mention, and MoD has recently stated that he has no responsibility for matters relating to actually flying the aircraft. Some might disagree, but there you are). I thought a different approach might help......

In 1999, the National Audit Office, and then Public Accounts Committee, published reports “Modifying Defence Equipment”. The NAO took on 7 test cases, two of which were programmes of mine. One of the questions it posed (it didn’t know the answer, so made no recommendation) was - why, when presented with precisely the same problem (relating to the issues you raise) do some projects crack them with effortless competence, and others (e.g. Nimrod, Chinook Mk3) immediately grind to a halt and waste billions? (By the way, this is the evidence that MoD and Government knew in 1999 these programmes were dying on their feet).

I was tasked with replying, initially to our 3 Star, Deputy Chief Executive of the Defence Procurement Agency, one David Gould. It was in 3 parts.



I took a hypothetical test case, a proposed major modification/upgrade. I set out the process and procedures, and who was meant to what, and when. That’s simple, it’s a direct lift from a mandated Defence Standard, basic training notes, internal instructions, etc; all of which you must know backwards long before becoming a project manager.
I then explained why and when all but one of the posts (and, hence the people) no longer existed. The only remaining one was the project manager. It followed that we no longer recruited project managers who knew the answer, which did not bode well.
It was therefore a matter of luck if the project manager had done any of these jobs before, and was able to simply do his old job to maintain progress. I demonstrated that the successful projects among the 7 had such managers, the unsuccessful ones didn’t.


All very simple, but the 3 Star didn’t reply, and DPA’s official response was “We cocked up and it’ll never happen again”. A ludicrous response, when PE/DPA could not be held responsible for (e.g.) (a) the RN shutting down these posts, and (b) the RAF never having them in the first place (at least, not in living memory). That situation will, of course, be familiar to the few left in MoD who are familiar with this policy. (Which, because it is not resourced, is now only an aspiration).

Related to the general subject (airworthiness), this was the audit at which the Chief of Defence Procurement, in his evidence to the PAC in March 1999, admitted that the Chinook HC Mk2 was still not airworthy, almost 7 years after the Director of Flight Safety had warned the Chief Engineer and ACAS (who signs the RTS) of precisely the same thing. Had the Committees had their thinking hats on, they would have realised this immediately cleared the ZD576 pilots – as it did, 10 years later. Nothing in CDP's background suggested he knew anything about the subject. At the time, we thought it a subtle move by a sympathetic RAF or Army officer to slip that into his briefing, but nobody took the bait.

[Engines]

EAP, Crab,

Thanks for coming back - you've raised some really useful points. I'd like to clarify a couple of things - my apologies for not being clearer in the first place.

First, accident investigation - Haddon-Cave's recommendations were a surprise. My guess is that he noted the differences between the RN and the RAF and thought that the RAF could do better. He may also have seen accident investigation as part of the safety management cycle, and this led him to recommend incorporating the new MilAAIB within the MAA. I thought this was an utter nonsense. It’s still not been properly fixed.

RTS and RTSA – this is an important area, and I’m honestly concerned at some of the comments here. Perhaps I can help.

In my view, the primary role of military aircraft engineer is to provide crews with available and effective aircraft and weapons. Safety and risk management are important, but are secondary. (Crab, I’m truly sorry to hear that this appears to have been forgotten in your area). It’s the engineers that ensure that aircraft are designed, built, modified and maintained so that the risk of them exploding, falling apart or otherwise catastrophically failing while carrying out their mission is acceptably low. They also ensure that the systems within it are working and are ‘fit for purpose’ – that is, they can be operated and used in a safe and effective way. All this can be rolled up into the term 'airworthy'.

The RTS is a key document and It’s absolutely vital that it’s supported by a thoroughly prepared Safety Case, and is 100% accurate. It's the key 'Certificate of Airworthiness' for the user to put the aircraft and crews into harm's way. It underpins documents such as the Aircrew manuals, FRCs and ODMs. It also authorises the use of service modifications, as it sets out the Service Deviations clearing those mods.

Building an RTS is the responsibility of engineers. But it has to be built with and for the user. For example, if a system doesn’t properly or reliably show its status, the RTS must contain limitations or warnings that allow the crew to manage that risk in the air. Those have to be developed with pilots at every stage. The process starts with test pilots, goes on with OEU crew and completes with aircrew working in the RTSA. It finishes with accurate and complete aircrew manuals, FRCs, ODMs, etc. I’ve built a few RTS, for fixed and rotary wing aircraft, dark and light blue. In every case, I made damn sure that anything ‘piloty’ in nature was built with and for ‘pilots’. Especially anything to do with ergonomics and system operation. Crab, any engineer who doesn’t do this needs a good kicking. Have at it. I certainly didn’t think I ‘knew better’ than aircrew.

One of the problems in the 90s was that the role and responsibilities of the RTSA had become diluted and confused during the many changes in the relevant publications. JSP553’s definition, which tried to fudge the differences between the RAF and the RN, was an utter disgrace. I think Haddon-Cave recognised this, and made an honest effort to put the system right by giving the job of preparing the RTS Request (RTSR) to the engineers in the PT, but leaving the job of issuing it to a separate and independent RTSA function in the ‘Operating’ area within the MAA.

I remain of the opinion that giving up the RTSA function was culturally unacceptable to RAF aircrew VSOs. To them, the job of issuing an aircraft ‘release’ could only be undertaken by senior aircrew. I’m sorry if this offends, but in my 25 odd years I saw many examples of RTS documents that were just poor. Poor beyond imagining. Poor to the point where they presented an obvious hazard to crews. All of these had been signed off by aircrew VSOs.

The argument presented in the MAA RA that the RTSAs “… shall provide the Duty Holder (DH) chain with independent Air Safety assurance…’ is, in my view, risible. They cannot be, in any normal sense of the word, considered independent. They’ve failed to do it for too many years at too high a cost in lives.

Best regards as ever to all those trying to do the right thing,

Engines

[BossEyed]

At the risk of being accused of blowing smoke...

Engines, if I may:

I think your last post is the best sub-1 page summary I have ever seen on the fundamental reasons behind the need for a proper role-relatable design process.

In particular, what "airworthiness" means in context. Also, the essential symbiotic relationship between pilots and engineers within the design & airworthiness domain is superbly well described.

When I am King, I'll put the contents of that post on the walls of every room and corridor in ABW (and, if truth be told, in a few Test Squadron and T&E engineers' offices as well.)

Smoke off, smoke off, GO!

[NutLoose]

I would like to point out while you all think the CAA and EASA system Is impressive, it is far from it, it has become a overburdened bloatware driven by beurocrats whose main task appears to be to to generate legislation and paperwork which at the end of the day does nothing to increase safety nor productivity, increasing the legislative burden does not increase safety, it simply means those that play by the rules are penalised, while those that don't will not change simply because someone has stuck another layer of regulation on them.
The whole idea of EASA was to make a single playing field, however EASA of late on several issues have pushed it out to individual authorities to decide their course of actions, defeating the prime objective behind its existence, 8.33 radios being one of them.

As for the military conforming to airworthiness standards, well that has to be a none starter by their very operational requirements, I would love to see an airworthiness standard that covers BDR.

[Evalu8ter]

Crab et al,
Unless things have changed, the role of the RTSA is equivocally not to mandate what goes on the aircraft. The platform Requirements Manager (aircrew type) is the custodian of what capability the aircraft has, and is responsible for corralling the relevant stakeholders to draft and endorse the URD/SRD. When the "trading" has happened and the kit purchased and mounted, the RTSA take the output of the ITEAP (V&V output, Safety Case and Boscombe flight test reports etc) and ensure the evidence points to the award of an RTS clearance. The role of the OEU is then to assure fitness for purpose. My increasing concern over the past decade has been the atrophy of such skills in the aircrew world, placing increased burden on others in the acquisition world. A career option for SQEP aircrew in acquisition / airworthiness would go an awful long way to solving our problems IMHO.....

[EAP86]

There's a lot of detail in previous postings so I hope you won't mind if I generalise a little in response.

Any aerospace regulatory system, military or civil, exists to assure fitness for flight which is a property of the platform. Almost all definitions of 'airworthiness' are concerned with safety (fitness for flight) and they recognise that airworthiness is a property of the platform. The only western nation I'm aware of which brings fitness for purpose into its definition of airworthiness is Italy. I am not trying to say that fitness for purpose is not important or operationally essential, it's just that airworthiness (using my definition) has to come first. I have no problem with any relevant area of expertise having a contribution into the determination of airworthiness and I certainly include aircrew in this.

I do however have reservations with the current MAA approach to RTS regulation in that it is over-complex, suffers from a fair degree of duplication and seeks to involve all parties that have ever been involved historically with the production of the RTS irrespective of their competence or usefulness of contribution. Too much of the RTS process is driven by the organisational topology of the MOD and Service Operating Branches. To be fair to the MAA, they probably appreciated they were compromising matters but it was deemed necessary to obtain the buy-in of VSOs. My comments about RTSAs were in the context of how the contribution is made, not in the principle of taking aircrew inputs into account.

Much as Nutloose charges, I do admire the EASA regulatory system (the CAA's is hardly worth a mention as it is barely used) in that it seeks to place decision making in the hands of those competent to do so. Note that EASA didn't make the mistake of taking all powers to itself, something upon which the MAA is also to be congratuated. Nutloose seems to have issues with the implementation of the EASA system but without knowing more about the particulars, its hard to comment. I will say that regulation is a thankless task at the best of times as shown by the old term for the CAA, the Campaign Against Aviation.

I'm aware that under the pre-MAA regulatory regime George Baber actually tried to sort out a regulatory approach modelled on the authority structure of the EASA approach, working from first principles but adapted to the needs of the MOD. As you might imagine, that work probably wasn't given too much attention by the MAA; a pity as it could well have avoided some of the complexities of the current system.

EAP

[tucumseh]

EAP86

I'm glad you said that about Gp Capt Baber. I've said all along that Haddon-Cave was an idiot for naming and shaming him. Baber actually deserved praise for recognising the safety case was poor (inevitable, given the 1993 policy to no longer fund their upkeep) and for letting a contract. That it was poorly managed is a separate matter.

Try telling the MAA that airworthiness precedes FFP! I did, and they told me I was wrong. If you get that wrong, it more or less follows that your entire approach and management structure will be wrong, leading to a misunderstanding about who does what, and who is responsible for the various parts of the Aircraft Document Set. I'd like to think they've changed their minds, but they haven't got round to changing the structure back.

[Chugalug2]

Nutloose:-
As for the military conforming to airworthiness standards, well that has to be a none starter by their very operational requirements, I would love to see an airworthiness standard that covers BDR.
Of the 70 deaths in airworthiness related fatal accidents discussed in this forum, only 10 were as a result of enemy action (Iraq Hercules), and it might be said that if the aircraft had been fit for purpose with ESF fitted even those could have been avoided. The real point of Military Airworthiness is force preservation, ie the aircraft and crews survive the peace so that they can get to war.

Of course war means that peacetime practice and regulation go out the window if the situation calls for it. I always instance Royal Marines clinging to the outside of two Apache's on a rescue mission. It's war, get over it! Eventually the paper work will follow, eventually the MAA will issue an exemption, or maybe not...

We've had the "military aviation is dangerous, you can't wrap it up in cotton wool" spiel in every airworthiness related thread on this forum. We never said you should. Just give the guys and girls a decent chance to get to the bloody war!

[NutLoose]

I understand that, and I heartily agree, what I was trying to get across is no matter how much you like to lessen the impact on crews from poor design and airworthiness failings, in a war situation the only way you can ensure zero deaths in the air due to failings in the aircraft or its defensive / offensive capability, is to stay on the ground.

The Jag used to have a BDR if I remember correctly that was a pre-drilled slab of ally that was screwed to the damaged wing, control rods were repaired with broom handles and jubilee clips, these are the things done in wartime to ensure it was a goer, ( Mind you, desperation came to mind ) hence the " I would love to see an airworthiness standard that covers BDR." in wartime you play by a different set of rules, you have too.

[Chugalug2]

It seems that we are in violent agreement then Nutty. All the airworthiness campaign is trying to do is to provide airworthy aircraft to aircrews that are kept airworthy and fit for purpose until first contact. After that it's mayhem of course, as you so rightly highlight.

[EAP86]

TUC

It was actually Air Commodore Baber by the time he was leading the MAA's predecessor. CHC had started his review exercise with a promise to name names if he found blame. I think he felt bound by that position when push came to shove.

I'm not sure which part of the MAA you were dealing with. I well remember sitting in a meeting around 3 years ago which was chaired by a MAA person where everyone (representing 10 or so european MAAs) was telling the Italian MAA equivalent that they had got it wrong. To be fair, during the first few years of the MAA's existence, I found most members had a reasonable appreciation of airworthiness principles.

As regards BDR, most military aviation takes place during peacetime so the emphasis on airworthiness is reasonable and cogent. I'm far from convinced that you can apply an airworthiness standard to BDR because its a discipline which only comes into play when the only meaningful standard is balancing operational necessity against the likelihood of fatality. For me the MAA have got this right; its not an area for regulation but it makes sense that the operators understand risk assessment and management so that their judgements can be defended if questions are asked.

EAP

[Chugalug2]

EAP86:-
CHC had started his review exercise with a promise to name names if he found blame. I think he felt bound by that position when push came to shove.

And did so by naming officers of 1* and below, ie the usual MOD scapegoats. Strangely he didn't feel bound enough by his position to name the VSOs above those ranks who were really responsible for the UK Military Airworthiness scandal, and whose identities and actions he was very well aware of. Another MOD tradition...

[TorqueOfTheDevil]

So why were these people, that had been so obviously neglegent, prosecuted?


Is there a word missing from this sentence?


whilst it may be the way of the modern world to have RTSA exclusively manned by engineers - that stops working when they make decisions about piloty things because they think they know better and won't ask an operator. That goes for aircraft configuration, role equipment, avionics and general ergonomic layouts of cockpits.


This situation is nothing new - see the constant battles between Bill Waterton and the engineers at Gloster. I accept that Gloster were the OEM rather than RTSA equivalent, but it's a similar idea.

[tucumseh]

CHC had started his review exercise with a promise to name names if he found blame. I think he felt bound by that position when push came to shove.

The point is, he was told the names and given the evidence in MoD's own hand. He changed the date to 11 years later, ignored MoD's own audit reports, praised the culprits and blamed Baber and others. There's a reason why they were not prosecuted. The CPS accepted the original evidence. But when asked why they didn't then prosecute the culprits, the CPS claimed (to families) that no witnesses would come forward. Yet they were sitting on formal witness statements. Hence, the decision not to prosecute was based on rank - a recurring theme.

To be fair, during the first few years of the MAA's existence, I found most members had a reasonable appreciation of airworthiness principles.

I find 1st year apprentices have a reasonable appreciation after about a week! The failure was implementation. Worse, issuing orders not to implement.

[Engines]

Perhaps it would help things along if I focussed more on what could be done to improve the UK's military airworthiness. Alert - these are my opinions only, dissent is positively welcomed.

It struck me that we could take a look at how aircrew do their business - how do they achieve and maintain good standards of 'airmanship'? From my experience, it certainly included good clear rules. But far more important were good supervision and oversight. Plus really excellent training and a clear system for building experience. What they didn't do was rely on obeying their rules. I never met a pilot (or observer or aircrewman) whose proud boast was that they had submitted a 50 page document that proved that they were compliant with the latest set of rules. Nor did I ever encounter aircrew who said that they knew that they were safe because they always 'obeyed the rules'. God help me, I never heard aircrew justify a decision they'd made because 'you always have to think about how it would look in a Coroner's Court'.

We need to build a system that develops our young engineers in such a way that they get the information they need and build the experience they need, while getting the right level of supervision to stop them doing dumb stuff. We also need a better system of oversight (an engineers' equivalent of QFIs) to monitor what they are doing. How to do that? Well, my first stab would be to take some of the old Def Stand and recast them as 'Handbooks' - clearly setting out the key principles of airworthiness, and providing worked examples of how to achieve the right standards.

Next, I'd reinstate (in a modern form) the Modifications Committees, along with a recast version of the MF714/715 system (modification approval and progression forms) to help the PTs and other areas properly manage mods. I'd also make a rule that any acceptance of an aircraft, system, or modification would have to have a proper acceptance conference (along the lines of the old '555' system).

I'd also introduce a proper system of project reviews that brought in external reviewers to really 'scrub' the key stages, such as requirements approvals, V&V plans, and design reviews. (Incidentally, almost all aerospace companies already do these). In case you think I'm being overly bureaucratic about this, and just adding more layers of paperwork, here's what I saw happen over the past few years - this is happening on an aircraft near you right now....

1. Installing highly vulnerable civilian standard GPS systems in direct contravention of MoD policy
2. Deliberately disconnecting electrically operated weapon system from mandated safety switches
3. Failing to incorporate safety critical DA modifications for over three years (should have been done within 6 months). Then failing to record this failure on the Hazard Log
4. Failing to get expert advice from Dstl before specifying an all new INGPS primary navigation and flight control system. Result was an accuracy requirement less demanding than for an iPhone.
5. Installing a new radalt system with no (repeat, no) accuracy requirement
6. Letting the prime contractor decide what went in the SRD, and ignoring the warnings from the Requirements Manager

I'd help people get there by dismantling the runaway 'SQEP' empire that chews up man-hours, and restrict the MAA to one major update of each main RA series every 6 months.

Ok, I've doubtless bored enough people silly - any other suggestions?

Best Regards as ever to all those taking the time to get it right,

Engines