Nimrod crash in Afghanistan Tech/Info/Discussion (NOT condolences)
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Thanks Chappie I will pass on your thoughts and respect to the other families.
tucumseh at least someone knew what the Bath Tub curve was as well as Chirstmas tree and hangar Queen
tucumseh at least someone knew what the Bath Tub curve was as well as Chirstmas tree and hangar Queen
In fact, so many we can't see the trees for the forest.
How do control and limit Xmas Trees? Implement DGDQA Standing Instruction - 0136. MoD don't like this, as it's the one that gives lie to the fallacy that only Commercial can commit MoD to a contract. But it's the project manager's primary tool to control the standard and cost of repairs. Ignore it at your peril. That they do, places people in peril.
How do control and limit Xmas Trees? Implement DGDQA Standing Instruction - 0136. MoD don't like this, as it's the one that gives lie to the fallacy that only Commercial can commit MoD to a contract. But it's the project manager's primary tool to control the standard and cost of repairs. Ignore it at your peril. That they do, places people in peril.
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He had not been told in the months before the crash of a rise in fuel leaks on Nimrods, which he admitted was a “really serious failure”.
Something else intrigues me at the moment, unless I'm missing something. In the case of XV230, the MOD has admitted liability on the grounds of maintenance of an airworthy aircraft, yet in the case of XV179, where the MOD knew that the fitment of ESF was "reasonably practiable", they haven't admitted liability. Is there some element of "double standards" here?
sw
Something else intrigues me at the moment, unless I'm missing something. In the case of XV230, the MOD has admitted liability on the grounds of maintenance of an airworthy aircraft, yet in the case of XV179, where the MOD knew that the fitment of ESF was "reasonably practicable", they haven't admitted liability. Is there some element of "double standards" here?
Precisely. And add Tornado/Patriot and Sea King, where the BoIs stated the same thing, but using different terminology than ACM Loader. That is, procedures and regs were not implemented properly. One assumes this will be raised in due course on 179 - what the other two lack is a concerted campaign from a knowledgeable viewpoint. I know one set of families have been denied access to key documents, preventing them from doing what TD has achieved.
What makes you think he held QR640 responsibilities?
airsound
I wonder if those at the top nowadays know what a Christmas tree aircaft or hangar queen is, or understand what is involved in the rob (sorry cannabalisation) culture that is abound. The RAF Coningsby station Commander and his high ranking visitor (cannot remember his name nowadays) in 1996 did not know what I was talking about and yet the visitor seemed quite proud that he had slashed the Tornado spares budget by over a million pound and had seen no evidence that this had made any difference to the supply of spares, even the OIC supply was not aware of the scale of the problem.
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Inquest plane may have been switched
http://www.oxfordmail.net/display.va...n_switched.php
Relatives of 14 men killed when a spy plane crashed in Afghanistan may have been shown a replacement aircraft after the one they were meant to see developed a fuel leak, an Oxford coroner said today.
Coroner Andrew Walker, ordering inquiries into the matter, asked lawyers at the Oxford inquest this morning: "Was the aircraft the family was shown last week the aircraft they were meant to see, or was another one flown down from RAF Kinloss because the other had a fuel leak?"
Coroner Andrew Walker, ordering inquiries into the matter, asked lawyers at the Oxford inquest this morning: "Was the aircraft the family was shown last week the aircraft they were meant to see, or was another one flown down from RAF Kinloss because the other had a fuel leak?"
Inquest hears Nimrod recordings
http://news.bbc.co.uk/1/hi/uk/7396687.stm
A recording from the cockpit of an RAF Nimrod taken moments before it exploded has been played at an inquest to the families of the 14 men who died.
The aircraft exploded minutes after air-to-air refuelling near Kandahar, Afghanistan, on 2 September 2006.
A Harrier jet pilot who was flying nearby told the Oxford inquest he saw a "massive, catastrophic explosion".
Flt Lt Douglas McKay said the blast was spherical in shape and "about twice the diameter of the aircraft's wing span."
He said he initially saw two fires coming out from the rear of Nimrod XV230, some 90 seconds before the blast engulfed it.
The Nimrod was "totally destroyed before it hit the ground", Flt Lt McKay said.
Final moments
The blast was caused by fuel leaking and igniting on contact with a hot air pipe, the inquest has already heard.
The first part of the onboard audio recording, which ends about two minutes before Nimrod exploded, reveals the crew's communications about the refuelling procedure.
But moments later an engineer announces that there is a fire warning.
While more fire reports from his crew come across the radio the captain, Flt Lt Allan Squires, orders to steer towards Kandahar for an emergency landing.
However, at 3,000ft the aircraft exploded.
The Ministry of Defence has defended the Nimrod fleet's safety record.
The aircraft exploded minutes after air-to-air refuelling near Kandahar, Afghanistan, on 2 September 2006.
A Harrier jet pilot who was flying nearby told the Oxford inquest he saw a "massive, catastrophic explosion".
Flt Lt Douglas McKay said the blast was spherical in shape and "about twice the diameter of the aircraft's wing span."
He said he initially saw two fires coming out from the rear of Nimrod XV230, some 90 seconds before the blast engulfed it.
The Nimrod was "totally destroyed before it hit the ground", Flt Lt McKay said.
Final moments
The blast was caused by fuel leaking and igniting on contact with a hot air pipe, the inquest has already heard.
The first part of the onboard audio recording, which ends about two minutes before Nimrod exploded, reveals the crew's communications about the refuelling procedure.
But moments later an engineer announces that there is a fire warning.
While more fire reports from his crew come across the radio the captain, Flt Lt Allan Squires, orders to steer towards Kandahar for an emergency landing.
However, at 3,000ft the aircraft exploded.
The Ministry of Defence has defended the Nimrod fleet's safety record.
Nimrod downed by 'design flaw'
http://news.bbc.co.uk/1/hi/uk/7398039.stm
The explosion which downed a spy plane in Afghanistan killing 14 servicemen on board was due to a "fundamental design fault" an inquest has heard.
The coroner had before heard it was because fuel leaked into a dry bay and ignited on contact with a hot air pipe.
But on Tuesday, a senior RAF officer said a mistake was made during a hazard assessment of the Nimrod which could have identified that risk.
It exploded minutes after refuelling in Afghanistan in September 2006.
Hindsight on hazard
Air Commodore George Baber told the inquest at Oxford Coroners Court that had they known then what they knew now, the Nimrod would not have been passed as safe to fly.
He led an Integrated Project Team (IPT), who with BAE systems carried out a comprehensive hazard analysis of the plane.
When hazards were identified and categorised at a meeting in August 2004, he said, the possibility of an explosion in the dry bay was graded in as "improbable".
It should have been graded higher and warranted further action, he admitted.
The design flaw was to have fuel in the same compartment as a hot air pipe, he said.
He told the inquest: "At the heart of this was a fundamental design flaw. This hazard assessment process was an opportunity to catch any inherent design flaw.
"We failed to catch that design flaw. The consequences were catastrophic and that is why we are here today."
He described the categorising mistake as a "failure".
Buck stopped
Asked by Michael Rawlinson, the lawyer representing the families of the dead servicemen, whether the Nimrod was safe to fly, Air Commodore Baber answered: "I find it difficult to answer because the simple answer is 'no' because we had an accident.
"Any aircraft we fly carry hazards all the time. Clearly if we knew then what we know now we would not have flown the aircraft."
As head of the IPT, he said he was responsible for deciding whether the aircraft was airworthy and the buck stopped with him.
The men died when a 37-year-old Nimrod exploded after undergoing air-to-air refuelling near Kandahar on September 2, 2006.
The crew on Nimrod XV230 had no means of tackling the initial fire and were forced to attempt an emergency descent to the air base. But it exploded into flames at 3,000ft.
Plane grounded
Earlier, the coroner heard how a technical problem grounded an RAF Nimrod plane due to be shown as part of the inquest.
Relatives were to view the plane but a hydraulic problem meant a second plane had to be shown at RAF Brize Norton, Oxfordshire, last week.
The coroner had before heard it was because fuel leaked into a dry bay and ignited on contact with a hot air pipe.
But on Tuesday, a senior RAF officer said a mistake was made during a hazard assessment of the Nimrod which could have identified that risk.
It exploded minutes after refuelling in Afghanistan in September 2006.
Hindsight on hazard
Air Commodore George Baber told the inquest at Oxford Coroners Court that had they known then what they knew now, the Nimrod would not have been passed as safe to fly.
He led an Integrated Project Team (IPT), who with BAE systems carried out a comprehensive hazard analysis of the plane.
When hazards were identified and categorised at a meeting in August 2004, he said, the possibility of an explosion in the dry bay was graded in as "improbable".
It should have been graded higher and warranted further action, he admitted.
The design flaw was to have fuel in the same compartment as a hot air pipe, he said.
He told the inquest: "At the heart of this was a fundamental design flaw. This hazard assessment process was an opportunity to catch any inherent design flaw.
"We failed to catch that design flaw. The consequences were catastrophic and that is why we are here today."
He described the categorising mistake as a "failure".
Buck stopped
Asked by Michael Rawlinson, the lawyer representing the families of the dead servicemen, whether the Nimrod was safe to fly, Air Commodore Baber answered: "I find it difficult to answer because the simple answer is 'no' because we had an accident.
"Any aircraft we fly carry hazards all the time. Clearly if we knew then what we know now we would not have flown the aircraft."
As head of the IPT, he said he was responsible for deciding whether the aircraft was airworthy and the buck stopped with him.
The men died when a 37-year-old Nimrod exploded after undergoing air-to-air refuelling near Kandahar on September 2, 2006.
The crew on Nimrod XV230 had no means of tackling the initial fire and were forced to attempt an emergency descent to the air base. But it exploded into flames at 3,000ft.
Plane grounded
Earlier, the coroner heard how a technical problem grounded an RAF Nimrod plane due to be shown as part of the inquest.
Relatives were to view the plane but a hydraulic problem meant a second plane had to be shown at RAF Brize Norton, Oxfordshire, last week.
When hazards were identified and categorised at a meeting in August 2004, he said, the possibility of an explosion in the dry bay was graded in as "improbable".
http://www.dstan.mod.uk/dtd/data/5624.pdf
“Fibrous Polyester Material for use as a Flame and Fire Suppressant in Aircraft Dry Bays” dated March 1981.
Well, someone identified the hazard as it applied generally to aeroplanes and developed one method by which the risk could be brought ALARP, with MoD (much later) issuing a specification in 1981.
On Nimrod, MoD now acknowledge they recognised the hazard, but thought the probability of occurrence “improbable”. If one maps that to the Risk Classification Matrix (see earlier in the thread), and accepts that the Severity of Harm should the risk occur is “Catastrophic” (loss of aircraft and crew) then the risk is classified as “C” and is only Tolerable if ALARP. Therefore, the admission that it should have been “graded higher” is largely academic, as the requirement was to make it ALARP anyway. (Even if the probability had been assessed “incredible” it would still be a Class C).
So, if the report is accurate there is something missing from the evidence. Having agreed the risk was Tolerable, I’d be asking why the next mandated step of making it ALARP wasn’t taken. (And this is where you may get to the root cause, because embodiment costs money and reduces capability for a time, which would highlight the risk associated with cuts in the MRA4 programme numbers. It would also, of course, at the very least demand declaration of planning blight and a complete reassessment of MRA4 at a politically unacceptable time).
And I wouldn’t be talking about 2004, given the date of the specification for making such risks tolerable and ALARP. This is important. At that date, MoD could claim we were in “exceptional circumstances” and perhaps that they didn’t have a reasonable time to mitigate the risk. (Not that this holds water). The legal clock starts when you identify and classify.
There may indeed have been what MoD call a “design flaw” but using that phrase to explain why a properly identified risk was not mitigated to ALARP is disingenuous.
And just to show I'm fair-minded, the buck doesn't stop with the Air Cdre (who was presumably a Gp Capt as IPTL) if he can demonstrate that at any time he, or his stakeholders, were denied funding to maintain any component of Airworthiness.
I have been, numerous times on many aircraft types, including Nimrod.
I have been, numerous times on many aircraft types, including Nimrod.
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Much of what happened and perhaps is still happening in some cases, comes from a normalisation within an organisation.
The risks are identified and classified, and because of the nature of operational flying become accepted as 'normal'.
The same risks were accepted by NASA, with the solid rocket boosters on Challenger (despite numerous issues and problems arising with them over a number of years), and they were never revisited, because "we operate in a high risk environment".
Pressures associated with essential tasking of a 37 year old airframe become such, that even serious concerns are lost in noise.
Does that make any one part of that organisation culpable? Well probably not. But what it does serve to emphasize is that where the standard HM Forces culture of 'getting the job done' and 'old outdated equipment' are present at the sametime, there will be a high probability of tragic consequences.
The risks are identified and classified, and because of the nature of operational flying become accepted as 'normal'.
The same risks were accepted by NASA, with the solid rocket boosters on Challenger (despite numerous issues and problems arising with them over a number of years), and they were never revisited, because "we operate in a high risk environment".
Pressures associated with essential tasking of a 37 year old airframe become such, that even serious concerns are lost in noise.
Does that make any one part of that organisation culpable? Well probably not. But what it does serve to emphasize is that where the standard HM Forces culture of 'getting the job done' and 'old outdated equipment' are present at the sametime, there will be a high probability of tragic consequences.
Small Spinner (D1??)
While you are correct, it should be emphasised that the regs specifically don’t permit the argument “We’ve never had a crash, so it must be ok” or “The risk has never occurred so…..”. This doesn’t prevent the MoD from constantly trotting this line out (year after year on Mull for example), but they’ve now been well and truly hoisted.
Nor is the Duty Holder permitted to rest on the laurels of previous work – airworthiness and safety are through-life processes subject to constant review. If money isn’t provided for this, then the “requirement” fails scrutiny and MUST be reported up the chain. If one looks at the letters of delegation, this includes the RAF’s Chief Engineer (a 4 Star?). In fact, this delegation specifically excludes “key aspects of safety and airworthiness” which MUST be referred upwards. I won’t copy it verbatim, because not all letters are the same, but typically these exclusions include;
Of course, the real problem comes when someone is daft enough to actually delegate such a problem upwards. When I was a boy, you got a pat on the back. Now you’re constructively dismissed from post. You cannot imagine the odium someone in an IPT faces if they identify a risk that can only be mitigated at a higher level. You may as well start job hunting.
While you are correct, it should be emphasised that the regs specifically don’t permit the argument “We’ve never had a crash, so it must be ok” or “The risk has never occurred so…..”. This doesn’t prevent the MoD from constantly trotting this line out (year after year on Mull for example), but they’ve now been well and truly hoisted.
Nor is the Duty Holder permitted to rest on the laurels of previous work – airworthiness and safety are through-life processes subject to constant review. If money isn’t provided for this, then the “requirement” fails scrutiny and MUST be reported up the chain. If one looks at the letters of delegation, this includes the RAF’s Chief Engineer (a 4 Star?). In fact, this delegation specifically excludes “key aspects of safety and airworthiness” which MUST be referred upwards. I won’t copy it verbatim, because not all letters are the same, but typically these exclusions include;
- Advising the Air Force Board on engineering matters, in particular airworthiness of aircraft and performance of ground systems (assuming the GSE exists, which was an issue on Nimrod).
- Specifying RAF engineering policies and procedures, including standardisation of maintenance and repair methods, QA (!!), modifications, engineering documentation and tech pubs.
- Defining standards for, and methods for monitoring, structural integrity.
Of course, the real problem comes when someone is daft enough to actually delegate such a problem upwards. When I was a boy, you got a pat on the back. Now you’re constructively dismissed from post. You cannot imagine the odium someone in an IPT faces if they identify a risk that can only be mitigated at a higher level. You may as well start job hunting.
When hazards were identified and categorised at a meeting in August 2004, he said, the possibility of an explosion in the dry bay was graded in as "improbable".
Your conclusions above may prove correct, but the way I read the Air Cdre testimony is slightly different. It seems to me from what he says that they did infact incorrectly grade the hazard during the analysis (and indeed this must have happened also in the first place 20+ years ago when the SCP mod first went in under the prevailing safety analysis techniques). In this scenario the IPT would not have asked for more money etc. from above to fix it as you allude, but would have left the hazard there as they didn't pick up on it. Indeed, the IPTL would surely admit the latter if it were true as he could then pass the buck upwards as you say for lack of funds.
He did not however, and hence this was clearly therefore a key mistake. Ultimately he is correct as the IPTL to take responsibility for this mistake, though the error will have been 'made' or more properly not picked up by the various contributors/checkers of the Safety Case (a combination of IPT project officer(s) in his team, his contractor(s) (DA & safety case compiler / supplier), and his independant safety advisors who he contracted to review the Safety Case (probably Boscombe, maybe others)).
What is interesting here, and will surely form one of the key issues in the "procedural review" is that infact all/(most of?) the relevant extant safety processes and safety case procedures appear to have been followed*, and still a design flaw was left in the aircraft. Hence it is not so much a case here of "MoD not following its own procedures" that led to the loss (though I do not question whether this is potentially another valid issue that you Tuc raise regularly), but seemingly more a case of "MoD/suppliers followed procedures but despite this a design flaw still prevailed in the certified product".
For me the role of Boscombe (and other safety independants?) in this process failure will be interesting - after all are they not there to pick up on these kind of issues during Design/Safety Case reviews? Isn't this what they are contracted/paid for?
* this remains to be fully explored / understood.
Sorry JFZ90, I read it differently (and of course, unless you were there – I wasn’t – we don’t know exactly what was said).
The design “flaw” (I notice the imprecise use of terminology) and the subsequent management of the resultant hazard are two different things. The first was a one-off if you like; the second is the through-life bit.
The hazard may have been graded incorrectly (presumably he means it should have been remote, occasional, probable or frequent – not improbable). The point I made is that this is largely irrelevant. Whatever the probability of occurrence, the severity of harm was “catastrophic” (and so it proved) so the risk had to be reduced to ALARP. It clearly wasn’t and the existence of multiple references to the engineering solution in the airworthiness and safety regs compounds this. This is the long standing and presumably oft-repeated error (due to the requirement for constant review). As for the “design flaw” I deliberately don’t comment on the intricacies of the fuel and AAR systems, only to say that each, in isolation, may be physically safe, but when integrated the “system of systems” may not be functionally safe. (Which is presumably the justification for ceasing AAR and still flying). I confine myself to commenting that this is not unusual, especially when either or both are Service Engineered Modifications. I also state, from a position of personal knowledge (and from being in possession of relevant letters via FoI) that the 4 Star in MoD(PE) and DPA specifically ruled that it was acceptable for such a “system of systems” to be physically safe, but not functionally safe, thus rendering the aircraft not fit for purpose and placing the aircrew in danger. (And, again, so it proved in a separate accident in 2003). In doing so, he was upholding the rulings of various 1 and 2 Stars, some of whose responsibilities included Nimrod.
While I know for a certain fact MoD routinely don’t follow these regs, in this case I’m merely repeating what the BoI report says. The main point I make is that this was not a revelation, but a re-iteration of a long known problem. The MoD is trying to compartmentalise the Nimrod accident, but the same failures led to other fatal accidents – again I’m merely citing the BoI reports. I don’t agree MoD followed procedures. The risk was not reduced to ALARP. This is directed policy. It is not left to chance that someone spots these risks/hazards. The regs and Design and Airworthiness Requirements (00-970) are chock full of references to the basic risk and technical reports on the subject, and they are published by D/Stan on their site for all to see.
Good question. Were the Design Authorities (not just BAeS) under proper continuous contract to maintain the build standards? I can’t speak for BAeS, but I know the answer to many other DAs. No, they weren’t, and this is a matter of policy going back to 1991 which the IPT can do little about; in fact nothing if the funding and political will does not exist. It’s a case of crossing fingers and hoping. Again, this is a clear failure to implement regs. I am very careful not to condemn the IPT here. Many platform IPTs simply have no control whatsoever over much of the kit in their aircraft. I know what it’s like to assume management of both aircraft and equipment modification programmes only to discover that configuration control, tech pubs, drawings etc are 15 years out of date (something highlighted in the QQ report and which is a serious breach of airworthiness regs). This is not speaking out of turn – it is merely lending credence to a Public Accounts Committee report which, in 1999, said precisely the same thing. The MoD cannot pretend they haven’t been told the regs aren’t being implemented. Ingram signed a letter refuting it! Bet he wishes he hadn’t.
The design “flaw” (I notice the imprecise use of terminology) and the subsequent management of the resultant hazard are two different things. The first was a one-off if you like; the second is the through-life bit.
The hazard may have been graded incorrectly (presumably he means it should have been remote, occasional, probable or frequent – not improbable). The point I made is that this is largely irrelevant. Whatever the probability of occurrence, the severity of harm was “catastrophic” (and so it proved) so the risk had to be reduced to ALARP. It clearly wasn’t and the existence of multiple references to the engineering solution in the airworthiness and safety regs compounds this. This is the long standing and presumably oft-repeated error (due to the requirement for constant review). As for the “design flaw” I deliberately don’t comment on the intricacies of the fuel and AAR systems, only to say that each, in isolation, may be physically safe, but when integrated the “system of systems” may not be functionally safe. (Which is presumably the justification for ceasing AAR and still flying). I confine myself to commenting that this is not unusual, especially when either or both are Service Engineered Modifications. I also state, from a position of personal knowledge (and from being in possession of relevant letters via FoI) that the 4 Star in MoD(PE) and DPA specifically ruled that it was acceptable for such a “system of systems” to be physically safe, but not functionally safe, thus rendering the aircraft not fit for purpose and placing the aircrew in danger. (And, again, so it proved in a separate accident in 2003). In doing so, he was upholding the rulings of various 1 and 2 Stars, some of whose responsibilities included Nimrod.
Hence it is not so much a case here of "MoD not following its own procedures" that led to the loss (though I do not question whether this is potentially another valid issue that you Tuc raise regularly), but seemingly more a case of "MoD/suppliers followed procedures but despite this a design flaw still prevailed in the certified product".
While I know for a certain fact MoD routinely don’t follow these regs, in this case I’m merely repeating what the BoI report says. The main point I make is that this was not a revelation, but a re-iteration of a long known problem. The MoD is trying to compartmentalise the Nimrod accident, but the same failures led to other fatal accidents – again I’m merely citing the BoI reports. I don’t agree MoD followed procedures. The risk was not reduced to ALARP. This is directed policy. It is not left to chance that someone spots these risks/hazards. The regs and Design and Airworthiness Requirements (00-970) are chock full of references to the basic risk and technical reports on the subject, and they are published by D/Stan on their site for all to see.
For me the role of Boscombe (and other safety independants?) in this process failure will be interesting - after all are they not there to pick up on these kind of issues during Design/Safety Case reviews? Isn't this what they are contracted/paid for?
JFZ90, unlike you, tucumseh, and others who post here I am part of the great unwashed who don't understand many of the cryptic initials standing for processes, organisations, procedures and I know not what, that is your "Lingua Franca". Because of that I see your post not as the erudite reasoned logic as I am sure it really is but as symptomatic of the bureaucratic jobsworth world that is the MOD's Military Airworthiness Regulation and Enforcement System. Lots of huff, lots of puff but b****r all Regulation or Enforcement, in this case at least it would seem. You may see the solution as an in depth look at Boscombe Down's part in all this, you may be right, but I suspect that such an Inquiry would be as effective as all the other BoI's that are the subjects of various threads on this Forum. From where I stand, that is outside looking in, this is a Tower of Babel that is for whatever reasons past its sell by date. The result has been the needless loss of many precious lives. It does not, and cannot, do its job, to ensure the Airworthiness of the UK Military Air Fleets. That awesome responsibility must be placed in more capable and responsible hands, that is a separate and independent Military Airworthiness Authority to which the MOD would be subject and responsible just as Air Operators are in the civil world to the CAA who have made a far far better fist of their responsibilities in this field than the MOD.