Parliamentary Questions concerning Hercules Safety
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
SW, thanks, I was given the heads up on the contents of 00-56 esp the paras 10.4.1 and handed them across to Barrister and family and was subsequently entered as evidence. To be frank I simply couldn't believe what I was hearing. I do believe 00-56 also mentions duty of care, but the MoD soon put a stop to that line of questioning. Cooper managed to squeeze out an affirmative to the routine use of military risk when things get a bit sticky.
We came to the view that there must at least be a constraints document where hercules vulnerability to fuel tank explosion should have been recorded. It wasn't recorded, hence no record was kept for scrutiny and audit.
It still amazes me that an Air Force that has been at war since 2001 should have an IPT that isn't actively interested in FFP and vulnerability issues.
We came to the view that there must at least be a constraints document where hercules vulnerability to fuel tank explosion should have been recorded. It wasn't recorded, hence no record was kept for scrutiny and audit.
It still amazes me that an Air Force that has been at war since 2001 should have an IPT that isn't actively interested in FFP and vulnerability issues.
Last edited by nigegilb; 20th Oct 2008 at 21:21.
Join Date: Apr 2008
Location: UK
Posts: 49
Likes: 0
Received 0 Likes
on
0 Posts
Flipster wrote:
As much as MoD aviation safety in general is in a mess, I think the situation is worse for wartime safety, as opposed to peacetime safety. At least most air IPTs understand that it is their responsibility to assess and manage safety for peacetime flying (even if some may do it badly). For wartime safety, e.g. ESF, the impression I get is that nobody quite knows who should be assessing and managing safety. On the one hand, IPTs often say it should be the operator (and/or RTSA?) because only the operator can possibly understand all the factors that go into wartime risk assessment (their input is needed for peacetime safety assessment but perhaps less so and perhaps less exclusively). But, typically, the operators (2 Gp for Hercules) do not have the expertise or the resource to do the sort of detailed safety assessment that is normal practice for IPTs in the context of peacetime safety. As cash-strapped as IPTs are for safety management, I get the impression it is worse for the operators.
It doesn't help that vulnerability, defensive aids, etc. are obviously amongst the most security-sensitive issues, making informed, consensual safety management harder than for, say, engines, navigation, etc. But that just reinforces my opinion that there is a desperate need for clear policy and guidance from the "centre" to delineate wartime safety responsibilities. And then there's a need for proper resourcing to back up the policy.
In the light of the Herc and Nimrod Inquests, I sincerely hope all IPTs are reviewing their vulnerability assessments, hazard logs and safety cases to ensure FFP and AW, both now and in the future, against current defined threats (and maybe even those that our enemies are dreaming up for future use)?
It doesn't help that vulnerability, defensive aids, etc. are obviously amongst the most security-sensitive issues, making informed, consensual safety management harder than for, say, engines, navigation, etc. But that just reinforces my opinion that there is a desperate need for clear policy and guidance from the "centre" to delineate wartime safety responsibilities. And then there's a need for proper resourcing to back up the policy.
Join Date: Apr 2008
Location: UK
Posts: 49
Likes: 0
Received 0 Likes
on
0 Posts
Safeware wrote:
Is it possible that the IPTL was either:
1. Observing that such vulnerability information is much too sensitive to go in the Hazard Log without raising its security classification to such a level as to make it difficult to use in the open, collective way that it should be used?
2. Or just reflecting the uncertainty and confusion I mentioned in my last post, i.e. that he thought such vulnerability issues were for some other part of the MoD to deal with?
Of course, even if one or both of these options apply, they don't in any way excuse the MoD collectively from its responsibility to manage vulnerability or wartime safety in general.
Oh, and stepping on my soapbox again, just to be clear, 00-56 is NOT the relevant document here. The Hercules IPT is not mandated to follow 00-56; indeed it would be inappropriate for them to do so (it is a document that mandates safety management practices for contractors to the MoD - this is not well understood either within or without the MoD). The document that does tell IPTs what to do in respect of safety management is POSMS (Project-Oriented Safety Management System), available here:
http://www.mod.uk/DefenceInternet/Ab...osmsManual.htm
Having said that, POSMS will say much the same as 00-56 regarding the Hazard Log.
Nige,
Quote:
He stated that the hazard log was not the place to record the vulnerability to fuel tank explosion from specified threat effects, but did not add where it should have been recorded.
Actually, it is the prime place to record such info - 00-56 iss 4 Pt 1:
Quote:
He stated that the hazard log was not the place to record the vulnerability to fuel tank explosion from specified threat effects, but did not add where it should have been recorded.
Actually, it is the prime place to record such info - 00-56 iss 4 Pt 1:
1. Observing that such vulnerability information is much too sensitive to go in the Hazard Log without raising its security classification to such a level as to make it difficult to use in the open, collective way that it should be used?
2. Or just reflecting the uncertainty and confusion I mentioned in my last post, i.e. that he thought such vulnerability issues were for some other part of the MoD to deal with?
Of course, even if one or both of these options apply, they don't in any way excuse the MoD collectively from its responsibility to manage vulnerability or wartime safety in general.
Oh, and stepping on my soapbox again, just to be clear, 00-56 is NOT the relevant document here. The Hercules IPT is not mandated to follow 00-56; indeed it would be inappropriate for them to do so (it is a document that mandates safety management practices for contractors to the MoD - this is not well understood either within or without the MoD). The document that does tell IPTs what to do in respect of safety management is POSMS (Project-Oriented Safety Management System), available here:
http://www.mod.uk/DefenceInternet/Ab...osmsManual.htm
Having said that, POSMS will say much the same as 00-56 regarding the Hazard Log.
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
Squidlord, you and I share the same view of the situation. There is blurring at the heart of all this and Fitness For Purpose, if you get it wrong, is where people get killed.
The three core stakeholders, DEC, IPT and User have a shared interest but each tackle different priorities. At the now infamous AWC meeting there was no IPT rep, no DEC rep and relatively junior user group representation.
When the IPTL was asked if he should have been represented he answered negative. Not his responsibility.
Un surprisingly we are getting to the core of what went wrong over XV179. The IPTL faces outwards to Industry, ideally he should be an experienced engineer. If the TAT report had gone to him all He had to do was pick up the phone to Marshalls and ask about foam. He could also have pinged the report across to DEC who takes executive operational responsibility. Neither of these two, IPTL: or DEC were on the address list and yet they are both core stakeholders.
A shambles. 2Gp did its own thing and ignored the report, but its conclusions were not recorded anywhere.
I believe you have nailed the problem in one post.
SquidLord on a housekeeping point, only a few months ago the Nimrod IPT stated up front at a flight safety meeting that they regarded 00-56 as mandatory and it took priority over other source documents. Please state here if there are any great changes in the doc to which you refer. One thing that has been very obvious to me over the last few weeks is the perpetual state of change in the MoD and RAF.
The three core stakeholders, DEC, IPT and User have a shared interest but each tackle different priorities. At the now infamous AWC meeting there was no IPT rep, no DEC rep and relatively junior user group representation.
When the IPTL was asked if he should have been represented he answered negative. Not his responsibility.
Un surprisingly we are getting to the core of what went wrong over XV179. The IPTL faces outwards to Industry, ideally he should be an experienced engineer. If the TAT report had gone to him all He had to do was pick up the phone to Marshalls and ask about foam. He could also have pinged the report across to DEC who takes executive operational responsibility. Neither of these two, IPTL: or DEC were on the address list and yet they are both core stakeholders.
A shambles. 2Gp did its own thing and ignored the report, but its conclusions were not recorded anywhere.
I believe you have nailed the problem in one post.
SquidLord on a housekeeping point, only a few months ago the Nimrod IPT stated up front at a flight safety meeting that they regarded 00-56 as mandatory and it took priority over other source documents. Please state here if there are any great changes in the doc to which you refer. One thing that has been very obvious to me over the last few weeks is the perpetual state of change in the MoD and RAF.
Last edited by nigegilb; 20th Oct 2008 at 20:58.
Join Date: Jul 2002
Location: UK Sometimes
Posts: 1,062
Likes: 0
Received 0 Likes
on
0 Posts
Chug we are agreed! Thanks also to SW and squid - pertinent observations both. But are you really saying that no-one can define exactly whom should be running this show? Certainly, no-one has fessed up in court!
Is it too much to ask that, after the Herc and Nimrod Inquests, the MoD (in its broadest sense) agree as to whom the responsibility falls to make our ac safe for operations in war?
It certainly seems that they still cannot do so and as a result, perhaps it is now time to take the 'toys away from the children' and impose an independent and over-seeing MAA.
Personally, I'd like to nominate Tucumseh as the CEO of the new UK MAA.
Also, it would be fanastic to see the face of his previous boss - who sounds like 'a right one' who can't even spell the words 'safety'...... nor 'integrity'!
flipster
Is it too much to ask that, after the Herc and Nimrod Inquests, the MoD (in its broadest sense) agree as to whom the responsibility falls to make our ac safe for operations in war?
It certainly seems that they still cannot do so and as a result, perhaps it is now time to take the 'toys away from the children' and impose an independent and over-seeing MAA.
Personally, I'd like to nominate Tucumseh as the CEO of the new UK MAA.
Also, it would be fanastic to see the face of his previous boss - who sounds like 'a right one' who can't even spell the words 'safety'...... nor 'integrity'!flipster
Join Date: Mar 2005
Location: On the outside looking in
Posts: 542
Likes: 0
Received 0 Likes
on
0 Posts
Squidlord,
As regards POSMS / 00-56, you are correct, the words were just easier to find from 00-56 because it is bit more concise (IMHO), without the need to trawl through all the SMPs. For the linkage between the 2, I think that POSMS sums it up best itself:
but 00-56 is not a one-sided document:
Now, one can also get in arguments over applicable contractual standards etc, but I think the key issue is not what version of POSMS / 00-56 do we take the words from, but what principles do we follow? As is often the case it should be "common sense, written down"
sw
edit - ps, I don't take classification of the hazard log as an excuse not to address something. There are ways and means, even if it means that the content of one hazard entry is segregated.
As regards POSMS / 00-56, you are correct, the words were just easier to find from 00-56 because it is bit more concise (IMHO), without the need to trawl through all the SMPs. For the linkage between the 2, I think that POSMS sums it up best itself:
2.4 POSMS Alignment
2.4.1 The POSMS is intended to be consistent with the terminology and approach of
Def Stan 00-56 Issue 4.
2.4.1 The POSMS is intended to be consistent with the terminology and approach of
Def Stan 00-56 Issue 4.
Safety Management Requirements for Defence Systems
Part 1 : Requirements
a. This Part of the Defence Standard provides requirements for the management of
safety. It can be applied to any MOD project and can be applied in any phase of a project’s
life. This Standard shall be used by Defence Contractors as required by contract. The
effective application of this Standard requires close cooperation between all parties, as the
responsibility for the achievement of safety is shared.
.
.
f. This Standard has been devised solely for the use of the Ministry of Defence (MOD)
and its contractors in the execution of contracts for the MOD.
Part 1 : Requirements
a. This Part of the Defence Standard provides requirements for the management of
safety. It can be applied to any MOD project and can be applied in any phase of a project’s
life. This Standard shall be used by Defence Contractors as required by contract. The
effective application of this Standard requires close cooperation between all parties, as the
responsibility for the achievement of safety is shared.
.
.
f. This Standard has been devised solely for the use of the Ministry of Defence (MOD)
and its contractors in the execution of contracts for the MOD.
sw
edit - ps, I don't take classification of the hazard log as an excuse not to address something. There are ways and means, even if it means that the content of one hazard entry is segregated.
Join Date: Jul 2002
Location: UK Sometimes
Posts: 1,062
Likes: 0
Received 0 Likes
on
0 Posts
SW
Totally concur about 'common-sense written down'.
The sad fact of the matter is that 'common-sense' in the MoD doesn't seem to be very common!
Also, it no excuse to hide behind the security issue - this can be overcome, as you rightly say.
flipster
Totally concur about 'common-sense written down'.
The sad fact of the matter is that 'common-sense' in the MoD doesn't seem to be very common!
Also, it no excuse to hide behind the security issue - this can be overcome, as you rightly say.
flipster
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
Lyneham inquest: Verdict due today
7:46am Wednesday 22nd October 2008
Comments (0) Have your say »
By Gazette Reporter »
A coroner will record his verdicts today on the deaths of ten servicemen killed when their RAF Hercules was shot down in Iraq.
Wiltshire coroner David Masters is expected to make a series of recommendations at today's hearing at Trowbridge Town hall.
He has already pledged to write to Defence Secretary John Hutton.
The two-month inquest has heard how the men's C130k aircraft, 47 Squadron Special Forces flight XV179, was flying at low-level (about 150ft) in daylight from Baghdad to Balad to receive further tasking orders when it was felled by insurgents.
A medium-calibre anti-aircraft round hit a fuel tank in the right wing causing the ullage, a highly-flammable fuel vapour/air mix created as the tank empties, to explode and blow off the wing. All ten men on board - nine RAF serviceman and a soldier - died on January 30, 2005.
Had the craft's wing tanks been fitted with explosion suppressant foam (ESF), which stops ullage explosions, the men would be alive today, former Hercules pilot Nigel Gilbert told the inquest.
American Hercules have had ESF since the 1960s and evidence heard at the inquest indicated concerns about in-flight ullage explosion had been troubling military commanders since the Second World War.
RAF commanders were warned in 2002 in a research report about this exact vulnerability on Hercules and were advised to fit ESF - but nothing was done, the inquest heard.
Neither did they order ESF to be fitted, or even tell Hercules crews of the danger they were in, which would at least have enabled them to alter their flying tactics.
Wing Commander John Reid, president of the military Board of Inquiry which investigated the tragedy, said this failure to tell the crews made him even more "cross" than the decision not to fit ESF.
But Mr Reid said an even more important blunder in lead-up to the tragedy was that of the "failure of intelligence."
XV179 went down within hours of two US Blackhawk helicopter crews coming under fire from an insurgent ambush site on the ground in exactly the same area.
The inquest heard that an emailed incident report containing details which could have saved the ten men's lives was left unopened by a British intelligence officer.
He said he did not open it because he had no idea XV179 was even in that area at the time.
This is because 47 Squadron fly Special Forces missions, often without the knowledge of the rest of their military colleagues.
The intelligence officer agreed that the "left hand had not known what the right hand was doing."
Wing Commander Reid said: "This was a known ambush site and tragically XV179 flew into (it)."
The coroner has said he will record narrative verdicts.
The inquest at Trowbridge town hall began in April before breaking over the summer and resuming at the end of September.
Families, witnesses, even lawyers and journalists - all were moved to tears during the final day's evidence at the inquest.
The cause of such emotion in the usually-staid confines of Wiltshire Coroner's Court was the evidence of the RAF officer who led the investigation into the tragedy.
Wing Commander John Reid, president of the military Board of Inquiry (BoI) into the crash, criticised senior RAF commanders' failure to tell crews of a known vulnerability affecting the plane in question - detailed explicitly in a military research document three years beforehand.
He then apologised to the dead men's families, many of whom wept openly.
Bernard Collaery, lawyer for mother-of-three Kellie Merritt, widow of Australian airman Flight Lieutenant Paul Pardoel, thanked Mr Reid for his "thorough" investigation.
His voice cracked as he said: "My client's children will read it (the BoI) and you will become part of their history."
Mr Collaery - who later said this was the first time in his career he had cried in court - added: "Mr Reid, you have been a breath of fresh air as far as this matter has been concerned."
XV179 Master Engineer Gary Nicholson's mother Margaret, who attended throughout the two-month hearing, then stood to offer her thanks.
"Your son was my best friend," Mr Reid replied with tears in his eyes.
At this Mrs Nicholson broke down, causing a ripple of emotion to sweep the courtroom, visibly affecting lawyers and at least three journalists.
Hercules XV179 went down during a low-level daylight flight between Baghdad and Balad on January 30 2005 when a medium-calibre anti-aircraft round hit one of its wing-located fuel tanks, causing the ullage, highly-flammable fuel vapour/air mix created as fuel is used, to explode and blow off the right wing.
http://www.thisiswiltshire.co.uk/new...ict_due_today/
7:46am Wednesday 22nd October 2008
Comments (0) Have your say »
By Gazette Reporter »
A coroner will record his verdicts today on the deaths of ten servicemen killed when their RAF Hercules was shot down in Iraq.
Wiltshire coroner David Masters is expected to make a series of recommendations at today's hearing at Trowbridge Town hall.
He has already pledged to write to Defence Secretary John Hutton.
The two-month inquest has heard how the men's C130k aircraft, 47 Squadron Special Forces flight XV179, was flying at low-level (about 150ft) in daylight from Baghdad to Balad to receive further tasking orders when it was felled by insurgents.
A medium-calibre anti-aircraft round hit a fuel tank in the right wing causing the ullage, a highly-flammable fuel vapour/air mix created as the tank empties, to explode and blow off the wing. All ten men on board - nine RAF serviceman and a soldier - died on January 30, 2005.
Had the craft's wing tanks been fitted with explosion suppressant foam (ESF), which stops ullage explosions, the men would be alive today, former Hercules pilot Nigel Gilbert told the inquest.
American Hercules have had ESF since the 1960s and evidence heard at the inquest indicated concerns about in-flight ullage explosion had been troubling military commanders since the Second World War.
RAF commanders were warned in 2002 in a research report about this exact vulnerability on Hercules and were advised to fit ESF - but nothing was done, the inquest heard.
Neither did they order ESF to be fitted, or even tell Hercules crews of the danger they were in, which would at least have enabled them to alter their flying tactics.
Wing Commander John Reid, president of the military Board of Inquiry which investigated the tragedy, said this failure to tell the crews made him even more "cross" than the decision not to fit ESF.
But Mr Reid said an even more important blunder in lead-up to the tragedy was that of the "failure of intelligence."
XV179 went down within hours of two US Blackhawk helicopter crews coming under fire from an insurgent ambush site on the ground in exactly the same area.
The inquest heard that an emailed incident report containing details which could have saved the ten men's lives was left unopened by a British intelligence officer.
He said he did not open it because he had no idea XV179 was even in that area at the time.
This is because 47 Squadron fly Special Forces missions, often without the knowledge of the rest of their military colleagues.
The intelligence officer agreed that the "left hand had not known what the right hand was doing."
Wing Commander Reid said: "This was a known ambush site and tragically XV179 flew into (it)."
The coroner has said he will record narrative verdicts.
The inquest at Trowbridge town hall began in April before breaking over the summer and resuming at the end of September.
Families, witnesses, even lawyers and journalists - all were moved to tears during the final day's evidence at the inquest.
The cause of such emotion in the usually-staid confines of Wiltshire Coroner's Court was the evidence of the RAF officer who led the investigation into the tragedy.
Wing Commander John Reid, president of the military Board of Inquiry (BoI) into the crash, criticised senior RAF commanders' failure to tell crews of a known vulnerability affecting the plane in question - detailed explicitly in a military research document three years beforehand.
He then apologised to the dead men's families, many of whom wept openly.
Bernard Collaery, lawyer for mother-of-three Kellie Merritt, widow of Australian airman Flight Lieutenant Paul Pardoel, thanked Mr Reid for his "thorough" investigation.
His voice cracked as he said: "My client's children will read it (the BoI) and you will become part of their history."
Mr Collaery - who later said this was the first time in his career he had cried in court - added: "Mr Reid, you have been a breath of fresh air as far as this matter has been concerned."
XV179 Master Engineer Gary Nicholson's mother Margaret, who attended throughout the two-month hearing, then stood to offer her thanks.
"Your son was my best friend," Mr Reid replied with tears in his eyes.
At this Mrs Nicholson broke down, causing a ripple of emotion to sweep the courtroom, visibly affecting lawyers and at least three journalists.
Hercules XV179 went down during a low-level daylight flight between Baghdad and Balad on January 30 2005 when a medium-calibre anti-aircraft round hit one of its wing-located fuel tanks, causing the ullage, highly-flammable fuel vapour/air mix created as fuel is used, to explode and blow off the right wing.
http://www.thisiswiltshire.co.uk/new...ict_due_today/
Join Date: Jul 2002
Location: UK Sometimes
Posts: 1,062
Likes: 0
Received 0 Likes
on
0 Posts
Wg Cdr Reid,
I applaud your sincerity and honour. It must have been unbearably difficult for all of the BOI team when you knew the crew of XV179 so well.
Looking back, many of us wish we had done more, or done it better and we are profoundly sorry for that but it is great shame that so many of your superiors did not show the same emotional strength, integrity and humility when they had the chance to apologise themselves.
Flip
Im sure I speak for many when I say our thoughts are with the families today - I am distraught that I cannot be there. I hope that after today, you can see some light at the end of the tunnel and that it comes somewhere near to ending this desparately sad and difficult chapter, allowing you to complete the grieving process with a little more peace of mind. God bless you all and keep safe.
I applaud your sincerity and honour. It must have been unbearably difficult for all of the BOI team when you knew the crew of XV179 so well.
Looking back, many of us wish we had done more, or done it better and we are profoundly sorry for that but it is great shame that so many of your superiors did not show the same emotional strength, integrity and humility when they had the chance to apologise themselves.
Flip
Im sure I speak for many when I say our thoughts are with the families today - I am distraught that I cannot be there. I hope that after today, you can see some light at the end of the tunnel and that it comes somewhere near to ending this desparately sad and difficult chapter, allowing you to complete the grieving process with a little more peace of mind. God bless you all and keep safe.
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
Well said Flip, I cannot attend either, but the families have been well represented and John Reid's evidence will have helped enormously.
First comment from the Coroner concerns the lack of audit trail and the failure to record rationale behind safety decisions.
Audit trail, allowing the recording of rationale and scrutiny of decision making are;
KEY PLANKS OF AN EFFECTIVE SAFETY MANAGEMENT SYSTEM
In this case BLATANTLY IGNORED
Page last updated at 10:38 GMT, Wednesday, 22 October 2008 11:38 UK
E-mail this to a friend 
Printable version
Hercules inquest data criticised
The plane was flying at low level, through a known ambush zone
A coroner at the inquest into the deaths of 10 servicemen in a Hercules air crash says the hearing was "plagued by an inability to retrieve documents".
Wiltshire coroner David Masters said the two-month hearing was affected by access to data recording key RAF decisions before the incident in Iraq.
Nine RAF personnel and one soldier died when the RAF Hercules aircraft was shot down by enemy fire in 2005.
It was the largest RAF loss of life in a hostile act since World War II.
Summing up at Trowbridge town hall, Mr Masters said: "I believe that the ability to retrieve and view documents that record key decisions as not just important, but essential - equally important is the rationale behind them."
This criticism referred particularly to an apparently unrecorded decision taken by RAF commanders not to fit a key safety feature on Hercules aircraft after they were advised to do so in a military research document in 2002.
The inquest heard if explosion suppressant foam, or ESF, had been fitted to the Hercules, the crew may still be alive.
The 2002 document only came to light after a document trawl while the inquest was adjourned over the summer, the coroner said.
He also said a military policy of "shredding" documents was "difficult to come to terms with".
First comment from the Coroner concerns the lack of audit trail and the failure to record rationale behind safety decisions.
Audit trail, allowing the recording of rationale and scrutiny of decision making are;
KEY PLANKS OF AN EFFECTIVE SAFETY MANAGEMENT SYSTEM
In this case BLATANTLY IGNORED
Page last updated at 10:38 GMT, Wednesday, 22 October 2008 11:38 UK
E-mail this to a friend Printable version Hercules inquest data criticised
The plane was flying at low level, through a known ambush zoneA coroner at the inquest into the deaths of 10 servicemen in a Hercules air crash says the hearing was "plagued by an inability to retrieve documents".
Wiltshire coroner David Masters said the two-month hearing was affected by access to data recording key RAF decisions before the incident in Iraq.
Nine RAF personnel and one soldier died when the RAF Hercules aircraft was shot down by enemy fire in 2005.
It was the largest RAF loss of life in a hostile act since World War II.
Summing up at Trowbridge town hall, Mr Masters said: "I believe that the ability to retrieve and view documents that record key decisions as not just important, but essential - equally important is the rationale behind them."
This criticism referred particularly to an apparently unrecorded decision taken by RAF commanders not to fit a key safety feature on Hercules aircraft after they were advised to do so in a military research document in 2002.
The inquest heard if explosion suppressant foam, or ESF, had been fitted to the Hercules, the crew may still be alive.
The 2002 document only came to light after a document trawl while the inquest was adjourned over the summer, the coroner said.
He also said a military policy of "shredding" documents was "difficult to come to terms with".
Last edited by nigegilb; 22nd Oct 2008 at 11:04.
As flip says this is a day for our thoughts to be with the families who bear the unbearable, with the hope that it will bring some peace of mind at last. This is also a day to give thanks. Thanks to those who have persevered to unpeel and lay bare the intrigue and subversion that has sought to obscure the true story of why XV179 was lost. Many of them post here, whether under a nom de plume or in the clear. Others are known to us from reports of the inquest, The Coroner, Mr Masters, of course and certain witnesses, including the BoI president Mr Reid. Principally though the loved ones themselves, for whom this particular aspect is mercifully drawing to a close. Your steadfastness and courage throughout has been moving. To all of you I say well done, for there has been a greater service done here than the formality of an inquest into a terrible tragedy. It is now incumbent on us all to make certain that things change from now on so that such a known deficiency as was allowed, to render an entire fleet of military transport aircraft unfit to go to war, can never be allowed again.
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
Taken from page 3 of this thread on 16 March 2006;
"Flight International can, meanwhile, reveal that the UK is the only launch nation involved in the Airbus Military A400M programme not to have funded the installation of the safety equipment as part of its production order. “The [A400M] common standard aircraft does not come fitted with a fuel tank inerting system,” says the MoD. “Fuel tank inerting was not selected by the UK prior to, or after, contract signature.”
Airbus Military sources confirm that all other programme launch customers – Belgium, France, Germany, Luxembourg, Spain and Turkey – have selected the equipment for their 155 aircraft. The UK also previously removed defensive countermeasures equipment from all but nine of its 25 A400Ms, reducing procurement costs by around Ł240 million ($417 million)."
Keep an eye on that figure of NINE gentlemen. Reduced from 25 to 9 for one reason and one reason alone and that is COST.
I am not disputing the fact that 24 A400M now have the plumbing for PROBIGGS, but I am disputing if the plug-in kit is funded and that the DAS procurement figure could well be the same as stated in this "Flight" article.
Chug alludes to the fact that an entire Fleet should never again be sent to war unfit for purpose. Well, I am afraid I and very concerned about Hercules replacement A400M.
Are the MoD really that stupid?
"Flight International can, meanwhile, reveal that the UK is the only launch nation involved in the Airbus Military A400M programme not to have funded the installation of the safety equipment as part of its production order. “The [A400M] common standard aircraft does not come fitted with a fuel tank inerting system,” says the MoD. “Fuel tank inerting was not selected by the UK prior to, or after, contract signature.”
Airbus Military sources confirm that all other programme launch customers – Belgium, France, Germany, Luxembourg, Spain and Turkey – have selected the equipment for their 155 aircraft. The UK also previously removed defensive countermeasures equipment from all but nine of its 25 A400Ms, reducing procurement costs by around Ł240 million ($417 million)."
Keep an eye on that figure of NINE gentlemen. Reduced from 25 to 9 for one reason and one reason alone and that is COST.
I am not disputing the fact that 24 A400M now have the plumbing for PROBIGGS, but I am disputing if the plug-in kit is funded and that the DAS procurement figure could well be the same as stated in this "Flight" article.
Chug alludes to the fact that an entire Fleet should never again be sent to war unfit for purpose. Well, I am afraid I and very concerned about Hercules replacement A400M.
Are the MoD really that stupid?
Nigegilb:
Bad or Mad, it really makes little difference as they have to be made to change their ways. You are right to identify A400 as the next mad MOD decision to be put right, but these tactical threads, Hercules, Nimrod, Chinook and now A400, though in the end successful (to date), take that most precious commodity of all, time. Time is of the essence, as the lawyers would remind us, especially with Flight Safety as it is not only money at stake but, far more importantly, lives. The reform of your new ministry is pressing, Secretary of State, and the most pressing reform of all is the enforcement of Military Airworthiness, including fitness for purpose as Nigegilb reminds us. Your officials will tell you that it is already in hand and that you have no need to worry. You have every need to worry I'd say, and the solution is to remove such authority from the MOD entirely to a separate MAA. There the MOD's arrangements for the likes of A400's fitness for purpose, over and above basic airworthiness, will be found wanting. That entire fleet needs the full implementation of protection now restricted to a few, for that fleet's purpose is war and it must be made fit for that purpose.
Good TV interviews today, Nigel and Chappie, you both speak out so well on behalf of us all. Well done to both of you!
Are the MoD really that stupid?
Good TV interviews today, Nigel and Chappie, you both speak out so well on behalf of us all. Well done to both of you!
Join Date: Jan 2007
Location: GONE BY 2012
Age: 51
Posts: 151
Likes: 0
Received 0 Likes
on
0 Posts
If the A400M does not have a fuel-tank inerting system and a credible DAS I will refuse to fly it anywhere near an operational theatre. I will also recommend to my peers, senior multi-engine operators, that they do the same. I will not, repeat, not put any crew at risk in an unfit for purpose military aircraft.
My thoughts to the families of XV179 - may the truth be finally uncovered and some closure finally found.
My thoughts to the families of XV179 - may the truth be finally uncovered and some closure finally found.
A really irritating PPRuNer
Join Date: Jun 2000
Location: Just popping my head back up above the parapet
Posts: 903
Likes: 0
Received 0 Likes
on
0 Posts
My thoughts are with all involved in the tragic case of XV179. You have conducted your campaign with absolute resolution and the utmost dignity, through some incredibly difficult times. The pride you have for your loved ones, and those who continue to serve, is there for all to see. There are many who are proud of you all too – and I am one of those. Your campaign has highlighted, once again, the failings of those who should be protecting our service men and women and the lengths they will go to to protect themselves when those failings are exposed. Shredding documents, failing audit trails – I’ve heard, and seen, it all before.
Airworthiness and Flight Safety need to be priorities once again, and not the current penny pinching and ‘make-do’ attitudes. I hope that your determination will ensure that not only will you be watching the MoD, but many others will be too.
Your actions and determination will, undoubtedly, be responsible for saving the lives of people in the future and for that, I am sure that your loved ones will be just as proud of you, as you are of them.
With great respect to you all.
Brian
Airworthiness and Flight Safety need to be priorities once again, and not the current penny pinching and ‘make-do’ attitudes. I hope that your determination will ensure that not only will you be watching the MoD, but many others will be too.
Your actions and determination will, undoubtedly, be responsible for saving the lives of people in the future and for that, I am sure that your loved ones will be just as proud of you, as you are of them.
With great respect to you all.
Brian
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
Brian I would like to publically thank you for the support you have provided in the background, particularly when the MoD decided to get "heavy".
I have spoken with Chappie this afternoon and she made it clear that it doesn't stop here.
First stop is A400M and the issues over the lack of DASS on procurement. We will be seeking to resolve that issue over the next 56 days.
In respone to Trukkie, I understand that new Theatre Entry Standards (TES) have been established, I also understand that their robustness is already being questioned, an area that needs clarification.
Also, I have received a couple of particularly worrying PMs RE the current front line. I would urge all Users to use the system to flag up particular areas of concern with regard to fitness for purpose.
If necessary go to the Design Authority direct and miss out the IPT if it is a toothless one. Once contacted the design authority must act, Marshall's in the case of the Hercules.
I still have contacts on the Defence Committee and can raise points at Parliamentary level. But, a big BUT, we learned at the Inquest that the most important thing is to get your requests in writing. And you must keep a copy.
This is a very big day, it will have many repercussions. Coroner is even writing to other Air Forces who rejected foam he is asking that they think again.
Regarding the failure of the RAF and MoD to fit foam. The system is bust. The Herc IPTL wanted nothing to do with FFP and 2 Group failed in their duty to pass on the TAT report to DEC. I hope the new CAS realises that the system for sending crews to war is broken.
This must never happen again.
Total repsect to the Coroner, a stunning verdict.
I also would like to publically pass on my very best regards to the families.
Anyone who experienced the emotion of that Court will never forget it.
The boys would have hated the publicity but they would have been bloody proud of their loved ones.
I have spoken with Chappie this afternoon and she made it clear that it doesn't stop here.
First stop is A400M and the issues over the lack of DASS on procurement. We will be seeking to resolve that issue over the next 56 days.
In respone to Trukkie, I understand that new Theatre Entry Standards (TES) have been established, I also understand that their robustness is already being questioned, an area that needs clarification.
Also, I have received a couple of particularly worrying PMs RE the current front line. I would urge all Users to use the system to flag up particular areas of concern with regard to fitness for purpose.
If necessary go to the Design Authority direct and miss out the IPT if it is a toothless one. Once contacted the design authority must act, Marshall's in the case of the Hercules.
I still have contacts on the Defence Committee and can raise points at Parliamentary level. But, a big BUT, we learned at the Inquest that the most important thing is to get your requests in writing. And you must keep a copy.
This is a very big day, it will have many repercussions. Coroner is even writing to other Air Forces who rejected foam he is asking that they think again.
Regarding the failure of the RAF and MoD to fit foam. The system is bust. The Herc IPTL wanted nothing to do with FFP and 2 Group failed in their duty to pass on the TAT report to DEC. I hope the new CAS realises that the system for sending crews to war is broken.
This must never happen again.
Total repsect to the Coroner, a stunning verdict.
I also would like to publically pass on my very best regards to the families.
Anyone who experienced the emotion of that Court will never forget it.
The boys would have hated the publicity but they would have been bloody proud of their loved ones.
Join Date: Nov 2006
Location: West Yorkshire Zone
Posts: 976
Likes: 0
Received 0 Likes
on
0 Posts
Just watched John Snow 'grilling' someone on his program.
They said that it was not a priority at the time - To fit the foam.
What was the priority then
??
Give the Air marshall a pay inc??
The crew of 10 should have REFUSED to fly that Hercules.
A FIRM = NO
They said that it was not a priority at the time - To fit the foam.
What was the priority then
??Give the Air marshall a pay inc
??The crew of 10 should have REFUSED to fly that Hercules.
A FIRM = NO
Join Date: Jul 2001
Location: New Zealand
Posts: 254
Likes: 0
Received 0 Likes
on
0 Posts
Coroner's Findings released
Hercules inquest: MoD guilty of 'serious failure' over deaths of 10 servicemen
A coroner has accused the military of "serious systemic failure" which led to the deaths of 10 British servicemen killed when their RAF Hercules was shot down in Iraq.
by Stephen Adams
Last Updated: 9:50PM BST 22 Oct 2008
Ruling that the 10 men were unlawfully killed, Wiltshire coroner David Masters criticized the decision not to fit protective foam around the plane's fuel tanks that could have saved their lives.
In an unprecedented summing-up lasting almost four hours, Mr Masters made a string of technical recommendations to improve safety on RAF operations.
The Hercules C130k plane, 47 Squadron Special Forces flight XV179, was shot down by small arms fire as it flew at about 150ft between Baghdad and nearby Balad on 30 January 2005.
The rounds ruptured the fuel tank in its right wing, causing the tank to explode and blowing off the wing in the process.
Nine RAF servicemen and one soldier died.
During the two-month inquest it emerged that a military research document had recommended in 2002 that Hercules aircraft be fitted with 'explosive suppressant foam' (ESF), which could have saved the plane.
Concluding the inquest, Mr Masters said: "The failure to fit ESF was on the facts found a serious systemic failure and a contributory factor in the loss of the aircraft. There was a loss of opportunity for the survival of the crew by that failure."
He told the inquest at Trowbridge town hall he found it "difficult to find logic" in the decision not to fit the Hercules planes with the foam, and said it was "unbelievable" there was no record of that decision. He also criticized the military for a policy of "shredding" documents.
Insurgents had attacked two US Blackhawk helicopters in the same area earlier the same day, the inquest had heard.
But intelligence officers failed to pass the information on to air crews. Mr Masters said such a situation should "never be allowed to happen again" and recommended a review of coalition intelligence systems.
US military authorities refused to allow their servicemen who had witnessed the crash to give evidence. Mr Master said such a stance was "difficult to comprehend".
Using a 'narrative verdict', in which a coroner reads out the circumstances that lead to death, Mr Masters recorded verdicts of "unlawful killing by terrorist insurgents".
He then made a series of recommendations.
Under Rule 43 of the Coroners Rules he recommended that all RAF combat aircraft be fitted with 'fuel tank inerting systems', which do a similar job to ESF.
He recommended a review of weapon classification training, said all combat aircraft must have 'black box' flight data recorders, and said all suspected battle damage should be examined and reported.
Mr Masters also promised to press the Government for legal aid for family members of servicemen killed on operations so they could be represented at inquests, after the 10 Hercules families were originally denied it.
Family members gave short but emotional statements after the inquest.
Sarah Chapman, sister of Sergeant Robert O'Connor, one of the servicemen killed, said: "These failings have cost the lives of 10 fine men and as a result of that, lessons have been learned."
She warned the MoD: "I will put this out to you: the world is watching."
Pauline Stead, the mother of Hercules captain Flight Lieutenant David Stead, said: "We are truly disappointed that the RAF failed to protect our boys.
Research about the Hercules' vulnerability "went unheeded by many people over many years," she said.
She said the families were "very pleased" that all Hercules in theatre had been retro-fitted with ESF but added: "It is very sad that it took this tragedy to happen before anything was done."
Air Vice Marshal Stephen Hillier, commanding officer of Number 2 Group, said: "We were not able to provide the crew of the aircraft with all the up to date intelligence and tactical advice concerning potential vulnerabilities. MoD did not take all available information into account in developing equipment to protect against likely threats. For these shortcomings, I would like to apologize, on behalf of the RAF and the MoD."
Liberal Democrat defence spokesman Nick Harvey said: "Ministers must ensure that the views of experts and frontline personnel are never ignored again."
Bob Ainsworth, the armed forces minister, said ESF foam should have been fitted after the nature of the threat facing aircraft in Iraq changed.
"To that extent, we failed these people. There is no doubt about that whatsoever," he told BBC Radio 4.
But he denied the coroner's finding of "systemic failure", saying: "I don't accept that. The people in the MoD are doing a tremendously challenging job."
The dead:
Eight of the victims were based at RAF Lyneham in Wiltshire:
RAF 47 Squadron's Flt Lt David Stead, the pilot, 35;
Flt Lt Andrew Smith, 25, the co-pilot;
Master Engineer Gary Nicholson, 42;
Flt Sgt Mark Gibson, 34;
Australian airman Flt Lt Paul Pardoel, 35 a navigator;
Chief Technician Richard Brown, 40, an avionics specialist;
Sergeant Robert O'Connor, 38, an engineering technician;
Corporal David Williams, 37, a survival equipment fitter, a passenger.
Acting L/Cpl Steven Jones, 25, of Fareham, Hampshire, a Royal Signals soldier, was also part of the crew.
Sqn Ldr Patrick Marshall, 39, from Strike Command Headquarters, RAF High Wycombe, was another passenger on the Hercules.
Hercules inquest: MoD guilty of 'serious failure' over deaths of 10 servicemen - Telegraph
A coroner has accused the military of "serious systemic failure" which led to the deaths of 10 British servicemen killed when their RAF Hercules was shot down in Iraq.
by Stephen Adams
Last Updated: 9:50PM BST 22 Oct 2008
Ruling that the 10 men were unlawfully killed, Wiltshire coroner David Masters criticized the decision not to fit protective foam around the plane's fuel tanks that could have saved their lives.
In an unprecedented summing-up lasting almost four hours, Mr Masters made a string of technical recommendations to improve safety on RAF operations.
The Hercules C130k plane, 47 Squadron Special Forces flight XV179, was shot down by small arms fire as it flew at about 150ft between Baghdad and nearby Balad on 30 January 2005.
The rounds ruptured the fuel tank in its right wing, causing the tank to explode and blowing off the wing in the process.
Nine RAF servicemen and one soldier died.
During the two-month inquest it emerged that a military research document had recommended in 2002 that Hercules aircraft be fitted with 'explosive suppressant foam' (ESF), which could have saved the plane.
Concluding the inquest, Mr Masters said: "The failure to fit ESF was on the facts found a serious systemic failure and a contributory factor in the loss of the aircraft. There was a loss of opportunity for the survival of the crew by that failure."
He told the inquest at Trowbridge town hall he found it "difficult to find logic" in the decision not to fit the Hercules planes with the foam, and said it was "unbelievable" there was no record of that decision. He also criticized the military for a policy of "shredding" documents.
Insurgents had attacked two US Blackhawk helicopters in the same area earlier the same day, the inquest had heard.
But intelligence officers failed to pass the information on to air crews. Mr Masters said such a situation should "never be allowed to happen again" and recommended a review of coalition intelligence systems.
US military authorities refused to allow their servicemen who had witnessed the crash to give evidence. Mr Master said such a stance was "difficult to comprehend".
Using a 'narrative verdict', in which a coroner reads out the circumstances that lead to death, Mr Masters recorded verdicts of "unlawful killing by terrorist insurgents".
He then made a series of recommendations.
Under Rule 43 of the Coroners Rules he recommended that all RAF combat aircraft be fitted with 'fuel tank inerting systems', which do a similar job to ESF.
He recommended a review of weapon classification training, said all combat aircraft must have 'black box' flight data recorders, and said all suspected battle damage should be examined and reported.
Mr Masters also promised to press the Government for legal aid for family members of servicemen killed on operations so they could be represented at inquests, after the 10 Hercules families were originally denied it.
Family members gave short but emotional statements after the inquest.
Sarah Chapman, sister of Sergeant Robert O'Connor, one of the servicemen killed, said: "These failings have cost the lives of 10 fine men and as a result of that, lessons have been learned."
She warned the MoD: "I will put this out to you: the world is watching."
Pauline Stead, the mother of Hercules captain Flight Lieutenant David Stead, said: "We are truly disappointed that the RAF failed to protect our boys.
Research about the Hercules' vulnerability "went unheeded by many people over many years," she said.
She said the families were "very pleased" that all Hercules in theatre had been retro-fitted with ESF but added: "It is very sad that it took this tragedy to happen before anything was done."
Air Vice Marshal Stephen Hillier, commanding officer of Number 2 Group, said: "We were not able to provide the crew of the aircraft with all the up to date intelligence and tactical advice concerning potential vulnerabilities. MoD did not take all available information into account in developing equipment to protect against likely threats. For these shortcomings, I would like to apologize, on behalf of the RAF and the MoD."
Liberal Democrat defence spokesman Nick Harvey said: "Ministers must ensure that the views of experts and frontline personnel are never ignored again."
Bob Ainsworth, the armed forces minister, said ESF foam should have been fitted after the nature of the threat facing aircraft in Iraq changed.
"To that extent, we failed these people. There is no doubt about that whatsoever," he told BBC Radio 4.
But he denied the coroner's finding of "systemic failure", saying: "I don't accept that. The people in the MoD are doing a tremendously challenging job."
The dead:
Eight of the victims were based at RAF Lyneham in Wiltshire:
RAF 47 Squadron's Flt Lt David Stead, the pilot, 35;
Flt Lt Andrew Smith, 25, the co-pilot;
Master Engineer Gary Nicholson, 42;
Flt Sgt Mark Gibson, 34;
Australian airman Flt Lt Paul Pardoel, 35 a navigator;
Chief Technician Richard Brown, 40, an avionics specialist;
Sergeant Robert O'Connor, 38, an engineering technician;
Corporal David Williams, 37, a survival equipment fitter, a passenger.
Acting L/Cpl Steven Jones, 25, of Fareham, Hampshire, a Royal Signals soldier, was also part of the crew.
Sqn Ldr Patrick Marshall, 39, from Strike Command Headquarters, RAF High Wycombe, was another passenger on the Hercules.
Hercules inquest: MoD guilty of 'serious failure' over deaths of 10 servicemen - Telegraph
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
So, Bob Ainsworth rejects the finding that this was a "systemic failure".
The next 56 days should prove to be quite interesting, because from what I saw of the Wiltshire Coroner he is absolutely furious.
I wonder if Bob Ainsworth is basing his view on the evidence presented at the Inquest, because there was hardly any documentary evodence at all. The MoD had destroyed it all. Flip's UOR was found on.....well let's not go there, suffice to say that the MoDs copies had been detsroyed, along with all the requests for foam going back to the early 1980's.
The MoD fielded very few witnesses in post at the time. The only copy of the TAT report yielded nothing but a black hole. Several witnesses suffered corporate amnesia at key moments. It was all pretty obvious and I think many people saw through it.
I am unsighted of C4 Interview with Ainsworth, rather than reject the Coroner's verdict Ainsworth should accept it gracefully and start by ensuring that every one of the aircraft due to replace Hercules "K" is fitted with Flight Deck Armour, Fuel Tank Inerting and the very latest Defensive Aids Suite.
Anything less and we can all conclude that the MoD has learnt absolutely nothing.
If the Australian Government can guarantee this minimum equipment list for its aircrew, why can't the British Government?
The next 56 days should prove to be quite interesting, because from what I saw of the Wiltshire Coroner he is absolutely furious.
I wonder if Bob Ainsworth is basing his view on the evidence presented at the Inquest, because there was hardly any documentary evodence at all. The MoD had destroyed it all. Flip's UOR was found on.....well let's not go there, suffice to say that the MoDs copies had been detsroyed, along with all the requests for foam going back to the early 1980's.
The MoD fielded very few witnesses in post at the time. The only copy of the TAT report yielded nothing but a black hole. Several witnesses suffered corporate amnesia at key moments. It was all pretty obvious and I think many people saw through it.
I am unsighted of C4 Interview with Ainsworth, rather than reject the Coroner's verdict Ainsworth should accept it gracefully and start by ensuring that every one of the aircraft due to replace Hercules "K" is fitted with Flight Deck Armour, Fuel Tank Inerting and the very latest Defensive Aids Suite.
Anything less and we can all conclude that the MoD has learnt absolutely nothing.
If the Australian Government can guarantee this minimum equipment list for its aircrew, why can't the British Government?
Thread Starter
Join Date: Mar 2006
Location: wilts
Posts: 1,667
Likes: 0
Received 0 Likes
on
0 Posts
Bob Ainsworth if thi is not Systemic Failure what is?
Thanks to Air Sound for following list, not word for word but hopefully Ainsworth will get the MoD approved account before it is destroyed.
Below are his Rule 43 recommendations. (Notes taken verbatim - may not be 100%)
1. ‘Disconnect’ issue. Joined up comms and discussion cd well have prevented the risk of these deaths, and similar cd be prevented in future.
2. Never again shd a scientifically justified recommendation on safety not be acted on.
3. LIMS sytemm shd be enhanced so that all such future recommendations fm whatever source shd be included. (from BoIs, DSTL, TAT PORs PXRs etc.)
4. All wgs of RAF shd actively engage with that system
5. All TAT mtgs to be clearly minuted and shd show those present.
6. Effective audit trial to be introduced so record is made of all recommendations for safety enhancement, and their rationale.
7. Current storage retrieval and file destruction to be reviewed and documented.
8. Fuel tank inerting or other comparable system to be fitted to all combat ac in theatre.
9. Reassurance be given that all A-400M be fitted with fuel tank protection prior to op use in theatre, and preferrably before trg starts.
10. All op ac in theatre shd be vis at all times to ACHQ or such a crew shd inform ACHQ of the route before t/o, or in flt if it changes.
11. Staffing of int posts to be monitored. and 24 hr cover maintained.
12. OLF - can no longer be done without formal auth.... But AWC guidance shd be reviewed, so there is clear definition of class of wpns and guidance appropriate to those wpns.
13. Tac Memos shd be issued to clearly set out that guidance.
14. All combat ac, operating in and and tasked to theatre to have black box or ADI and or CVR. That cd have provided info about what happened in what order, and perhaps prevent future such events
15. SURVIAC MOU shd be pursued without delay.
16. ALll suspected battle damage to be assessed and rptd upon so as to warn others. Not just repaired with sticky tape.
17. My views on involvement of US personnel are that - lives cd be saved, so it might be a rule 43 matter. I want to see this pursued.
Below are his Rule 43 recommendations. (Notes taken verbatim - may not be 100%)
1. ‘Disconnect’ issue. Joined up comms and discussion cd well have prevented the risk of these deaths, and similar cd be prevented in future.
2. Never again shd a scientifically justified recommendation on safety not be acted on.
3. LIMS sytemm shd be enhanced so that all such future recommendations fm whatever source shd be included. (from BoIs, DSTL, TAT PORs PXRs etc.)
4. All wgs of RAF shd actively engage with that system
5. All TAT mtgs to be clearly minuted and shd show those present.
6. Effective audit trial to be introduced so record is made of all recommendations for safety enhancement, and their rationale.
7. Current storage retrieval and file destruction to be reviewed and documented.
8. Fuel tank inerting or other comparable system to be fitted to all combat ac in theatre.
9. Reassurance be given that all A-400M be fitted with fuel tank protection prior to op use in theatre, and preferrably before trg starts.
10. All op ac in theatre shd be vis at all times to ACHQ or such a crew shd inform ACHQ of the route before t/o, or in flt if it changes.
11. Staffing of int posts to be monitored. and 24 hr cover maintained.
12. OLF - can no longer be done without formal auth.... But AWC guidance shd be reviewed, so there is clear definition of class of wpns and guidance appropriate to those wpns.
13. Tac Memos shd be issued to clearly set out that guidance.
14. All combat ac, operating in and and tasked to theatre to have black box or ADI and or CVR. That cd have provided info about what happened in what order, and perhaps prevent future such events
15. SURVIAC MOU shd be pursued without delay.
16. ALll suspected battle damage to be assessed and rptd upon so as to warn others. Not just repaired with sticky tape.
17. My views on involvement of US personnel are that - lives cd be saved, so it might be a rule 43 matter. I want to see this pursued.