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

[tucumseh]

Sorry, I'd just add that it is my opinion that "loss of aircraft" would be catastrophic. In this, I differ from a number of senior staffs who have ruled otherwise. Perhaps there is too much elasticity in a system which allows this view to prevail.

[JFZ90]

Thanks Tuc,

I think this is a difficult area as I tend to agree that surely "loss of aircraft" is catastrophic (not only due to risk to the pilot/aircrew, but also those near the smoking hole).

However, when you consider fast jet aircraft with only one engine the numbers game wrt loss rates starts to get a bit tricky - does this automatically mean single engine aircraft are likely to be "unsafe/unacceptable"? Theoretically this would mean F-16s and Harriers are fundamentally flawed designs, but its difficult to argue this given their basic success (despite their (especially early) loss rates).

"... when you map the various risks noted in BAeS and QQ reports, you'll find there are a number of Class As..."

Really? I'm getting a bit confused by this, I would have thought that all risks in Class A would need to be mitigated usually to a lower level (i.e. B or C) through system design or procedures? Otherwise how can you demonstrate you can meet the overall target? Surely a system with lots of real unmitigated Class As would be causing mayhem on a regular basis.


PS - there are some useful ALARP fallacies explained here.

http://www.hse.gov.uk/risk/theory/alarpglance.htm

[tucumseh]

(not only due to risk to the pilot, but also those near the smoking hole).

Nail on head. The concept of certain a/c losses not being catastrophic ignores the airworthinesses components dealing with ground crew, areas being overflown etc.

My comment on Class A risks existing on Nimrod was based on (a) my interpretation of, in particular, the BAeS report, and (b) loss of a Nimrod being deemed catastrophic. I hasten to add this is the report in which BAeS recommend urgent mitigation but were seemingly ignored.

[Da4orce]

DV wrote:

I understand the point you make about DEF STAN 00-56, but I would like to draw your attention to the first paragraph of that document.

"Under UK law, all employers have a duty of care to their employees, the general public and the wider environment. For the MOD, this includes an obligation to manage the safety risks associated with military systems and their operation. In addition safety is a vital characteristic of defence systems as it is often has a significant impact upon operational effectiveness. In accordance with the general guidance provided by the Health and Safety Executive, MOD will discharge this duty by ensuring that, in as so far as risks are not judged to be unacceptable, they are reduced to a level which is As Low As Reasonably Practicable (ALARP)"

The MoD have admitted that 230 was unsafe at the time of its loss and they have admitted that they failed in their

obligation to manage the safety risks associated

. They have clearly failed in their duty of care to crew 3, what then is the chance of HSE prosecution against the MoD?

[Safeware]

wrt HSE prosecution - it would be a Crown Censure, not a prosecution.

I wonder who would receive it - CAS or ACAS as the man who signs off on an RTS?

sw

[helgar33]

The quote which T D refers to which reads ‘was XV230 safe to fly’ was unfortunately inaccurately recorded in the minutes, which we have just recently received, from the BOI meeting in London on 4th December. What I actually asked was '' with the evidence you have seen; was XV 230 airworthy that day''. To which Sir Glenn Torpy replied ''in hindsight and under those circumstances I would have to say no''. Others in the room repeated this question with ''was XV 230 airworthy'' adding on ''yes or no'' to which Sir Glenn answered ''NO''.
I had just made several statements of fact, as I saw them, and had asked the following questions; which had prompted Sir Glenn to make the statement about ‘circumstances’. What I said and asked was as follows: -

1. That there was a major design flaw in the MK2 adaptation i.e. when the SCP was added.
2. That BAe designed the Nimrod and added on th SCP and did the safety case and didn’t realise that the SCP got hot!
Why wasn’t there a Nimrod specialist to accompany BAe to tell them what the SCP did i.e. that it got hot?
3. Who looks at and collates information which has been recorded; to help with identifying patterns e.g. with an increase in leaks?
Why was this not done before?
4. Why was the limiting of Tank 1 contents from 16,000 to 15,000 lbs accepted as a viable solution to a problem? Especially when it is difficult to judge levels (of fuel) accurately; due to pressures at that height.

This led straight on to my question ‘’ with the evidence you have seen; was XV 230 airworthy that day’’.

NB. most of the answers to the above questions were ‘’we will be looking in to that with the next inquiry’’ i.e. with the Hadden-Cave inquiry.

I have copied the above word for word from my notes and apologise for the grammar. I was pretty upset that day!

The inquest next month will probably reveal yet more unacceptable ‘circumstances’.
helgar33

[BEagle]

I think 8 top class engineers have a better idea what left on that fatefull day than anyone else

Although 8 experienced maintenance technicians (not 'engineers') might well have stated that there were no reported unserviceabilities within their trade area, that is most emphatically not the same thing as accepting an inherent design flaw. About which they probably had no knowledge.

As tucumseh has stated, the graphical relationship between probability and severity of harm is indeed straightforward enough. Whether it was properly complied with is another question.

[Tappers Dad]

Strongbowfan
"I know for dam fact that aircraft was Serviceable the day it left"

The a/c may have been serviceable that day however serviceable and airworthy are not the same. If you have been following this thread tucumseh has shown the differerence very clearly on a number of Occassions.

The MOD/Goverment/RAF have all admitted that XV230 wasn't airworthy because it failed to conform to airworthiness regulations eg: JSP 553-Def Stan 00-970 etc.

JSP 553

The formal definition of airworthiness is:

"The ability of an aircraft or other airbourne equipment or system to operate without significant hazard to aircrew, groundcrew, passengers (where relevant), or to the general public over which such airbourne systems are flown".

AAR has been stopped and the SCP switched off . Why ? Because they were/are a significant hazard to aircrew. As the loss of XV230 showed.

[tucumseh]

Strongbowfan

and im sorry i just have to add one thing , its taken over a year but finally we have a graph , a statistic bit of pish that officers use when they giving them briefs to all, somehow i knew within myself that one day we would get a graph here , with all shades of colours and looks great , many hours spent making one for what !!!

And I’m sorry you’re so anti-safety and airworthiness (although seemingly pro-serviceability, so on the right track), but you are in exalted company judging by the number of the senior staffs you allude to who have also told me I’m talking “pish” (or words to that effect, and normally followed by darker threats) when trying my best to impose some semblance of order on a fragmented and woefully inadequate airworthiness system. Certainly, I thought the 2 Star responsible for MRA4 was taking the “pish” when he told me I’d have received a better annual report had I not insisted on properly implementing the airworthiness regulations. In fact, I thought he’d been on the “pish”, so ludicrous and dangerous was his stance. But then his bosses “pished” on me by supporting him. I’m used to it and it’s water (or pish) off a duck’s back.

[Softie]

BEagle states:

8 experienced maintenance technicians (not 'engineers')

All RAF maintenance personnel are engineering technicians and mechanics and know their jobs and are not afraid get their hands dirty. There are too many who call themselves 'engineers' who don't know one of a spanner from the other. These experts are usually engineering managers or so far away from the front line that they have little or no knowledge for which they are responsible. Please be careful not to put down the few professionals we do have.

I do not, in any way, denigrate the dying breed of Air Engineers who are expert and professional system operators.

An Engineer.

[EdSet100]

TD:

AAR has been stopped and the SCP switched off . Why ? Because they were/are a significant hazard to aircrew. As the loss of XV230 showed.

I would like to amend that statement:

The SCP was definitely a significant hazard to the aircraft and crew in the years leading up to 2004, as demonstrated by the incident on XV227. Thereafter, it was made safe. It still is today.

AAR is safe. Nimrod is no more dangerous to refuel in the air than any other type.

AAR and SCP (or crossfeed pipe) operating simultaneously (or during the same flight): extremely dangerous. This is the circumstance that should been identified and prohibited under airworthiness requirements. It is irrelevant to serviceability and maintenance activities, which we know were carried out to the normal high standards.

Lets not get into a terminology bunfight over "engineers" (ground or air) and "technicians"

Ed Sett

[Safeware]

Strongbowfan,

I'm not sure what you're trying to get at in your post, esp

12 aircrew and 8 engineers that day accepted that aircraft as being serviceable , thats all that matters

??

sw

[OilCan]

EdSet100

The SCP was definitely a significant hazard to the aircraft and crew in the years leading up to 2004, as demonstrated by the incident on XV227. Thereafter, it was made safe. It still is today.

AAR is safe. Nimrod is no more dangerous to refuel in the air than any other type.

AAR and SCP (or crossfeed pipe) operating simultaneously (or during the same flight): extremely dangerous. This is the circumstance that should been identified and prohibited under airworthiness requirements. It is irrelevant to serviceability and maintenance activities, which we know were carried out to the normal high standards.

Spot on.

[helgar33]

I am greatly hoping that the comment about 'serviceability' of XV 230 that day are not levelled in any way at my post yesterday about ''was XV 230 airworthy that day'' (which I posted for factual accuracy reasons) I would be deeply hurt and horrified if that were the case. I am utterly convinced that my late husband, his crew, and the ground engineers who serviced XV 230 on September 2nd, were carrying out their jobs to the highest of standards; as was always the case. I am 100% certain that XV 230 would not have taken off that day if there were any doubts in any of their minds as to its safety. The problem arose directly after an AAR event; the risks of which, in my mind, were not properly assessed many years ago and could not have been known by the crew or ground crew.
I went to great pains to mention that the 'airworthy' question arose after many statements of fact that I made on 4th December e.g. that the design of the Nimrod, SCP add-on and the safety case were all done by BAE, I also mentionned that 'correlation of information' over many years was not carried out i.e. at an office some-where! None of this refers to 'serviceability' and I deliberately did not mention 'serviceability' on 4th December or in my post.
I also asked a question about tank 1 i.e. ''why the limiting of tank 1 from 16,000 to 15,000 lbs was accepted as a viable solution''? The reason I asked this was because it is widely assumed that the blow off valve from tank 1 blew off and that this fuel tracked down the outside of the Nimrod and entered the SCP housing. It was in no way said or meant as a stab at any one involved with the servicing of XV 230 that day. I was searching for reasons why the suspected 'blow-off' occured, as I was told that this event was thought to be a strong contender in the causes of the crash. The reason I mentionned what Sir Glenn said was because I wanted to accurately tell you i.e. 'word for word' what I said and what was said in reply; without emotion or slant on the facts. I am sad that I have felt the need to clarify what I said, when I had hoped that the original post spoke for itself, and can only hope that the post that appeared after my post did not actually refer to mine; though I feel deeply that it did which upsets me to the core.
helgar33

[betty swallox]

Helgar33,
Thank you for clarifying that in your first paragraph. I knew the aircraft captain very, very well. He would have not taken the jet were he not a million per cent happy.

[Safeware]

Strongbowfan,

Thanks, I don't think anyone (with any sense) has ever asserted here that those involved in the front line operation and maintenance of Nimrod knowingly acted in an unsafe manner and that what they were doing was "to the best of their knowledge and ability"

sw

[JFZ90]

wrt HSE prosecution - it would be a Crown Censure, not a prosecution.

I wonder who would receive it - CAS or ACAS as the man who signs off on an RTS?

sw

This is an interesting question, that will careful assessment of the facts. Technically, you would probably have to say (without being specific) that the key failings relate to both the original design and assumptions with respect to the addition of SCP & AAR capabilities etc. I'm not sure what safety analysis procedures were in place at the time these features were originally designed (e.g any zonal/hazard analysis type reviews during PDR, CDR etc., where they independant, etc.), but this may have some bearing on what went amiss re extant policy at the time. There was also alledgedly a more recent Safety Case produced which I assume should have followed best practice - hence it could be argued that some aspects were missed during this assessment, as this should have flagged up the design flaw if it had been done rigourously. It raises a question as to whether the MoD is responsible as it had the Safety Case commissioned, or whether the supplier of the Safety Case was in some way negligent. This will be a grey area as the supplier of the Safety Case may claim to have not known about x,y,z, (e.g. SCP operation in flight), hence its not their problem. This is a difficult one as you could argue that a competent Safety Case supplier should check assumptions and facts such as these - its part of the probing remit of Safety Case compilation to ensure the evidence is there to back up assertions of safe operation. Ultimately there is the argument the MoD is always responsible in such matters, hence is not able to discharge its reponsibilities to check the quality of externally produced Safety Cases. Was the Nimrod one reviewed by a 3rd party? Was this a fundamental part of the Safety Case process that was adopted anyway? It has admitted that there must have been a failure in the safety process, but there will be interesting lessons to be learnt as to exactly how the failure happened - it may prove quite hard to identify one action where you can definately say "that person should have spotted that issue".

Bottom line is it'll depend on what is found during the investigation, and speculation without all the facts is unlikely to reveal the true picture.

[Distant Voice]

Engineers are normally commissioned officers (Ground) with degrees, technicians are ground NCO's, and Flight Enginners are normally SNCO's who monitor Nimrod systems, in flight.

DV

[BEagle]

Engineers are normallly commisioned officers (Ground) with degrees

Correct

technicians are ground NCOs

Correct - although the branch was once known (correctly) as the Technical Branch, it was later re-named (wholly incorrectly) as the Engineering Branch

and Flight Enginneers are normally SNCOs who monitor Nimrod systems, in flight.

They are Air Engineers, commissioned or non-commissioned and they do considerably more than 'monitor' systems.

The common denominator is that all are skilled professionals who work together within their distinct fields of specialisation as a team with a common goal.

[Distant Voice]

EdSet 100, you said,

The SCP was definitely a significant hazard to aircraft and crew in the years leading up to 2004, as demonstrated by the incident on XV227. Thereafter it was made safe. It still is today

Sorry, must agree with TD. Following the XV227 incident the SCP was brought back into operation by RTI/NIMROD/119, dated 26th April 05, and was back to its "significant hazard" status at the time of XV230's accident.

DV