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

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

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Old 13th May 2008, 22:21
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Tuc,

I see your point re ALARP - but this would perhaps depend on the "risk categorisation table" being used at the time on the project - & hence their defined categories of risk and when action had to be taken. Some guidance suggests that "broadly acceptable" risks don't necessarily have to be shown to be ALARP, though I think this can always be debated.

It is possible in this scenario that this risk being categorised as "improbable", could have been placed in a "broadly acceptable" area and hence no ALARP action was deemed necessary. From the comment:

It should have been graded higher and warranted further action, he admitted.
it sounds like something along these lines happened. Perhaps they also failed to categorise the impact correctly as "catastrophic" at the time too, only as e.g. "critical", compounding the issue. I don't think either of us have access to the tables being used at the time so not possible to comment further - it would be interesting to know what these were though.

Chug - I try (but perhaps fail) to keep my contributions related to the engineering processes surrounding design, airworthiness & safety management of complex systems - and understanding how & why these have failed with respect to the loss of 230. These processes are basically the same for civilian and military projects and driven by (safety) engineering best practice. I note that the safety targets themselves and the implementation of specific regulatory processes maybe different between the domains, but this does not detract from the fact that the basic engineering principles are the same when it comes down to e.g. hazard analysis & risk assessment. I don't seek to single out Boscombe themselves - just their (potential) key role as the "independant reviewer" (or whoever else undertook this role if it wasn't Boscombe) - this role is key in both civil and military safety engineering best practice and along with many other factors needs to be looked at in the review.
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Old 13th May 2008, 22:47
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Lies, Lies and more lies the crew room was well aware of the problems. But the flying program required more AC.

Simple fact come on guys some one put their dirty paw up and admit it.

As per the norm sooner it goes away the better............... life in the RAF ...tut tut.
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Old 14th May 2008, 07:07
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Question WTF

Blogger,

WTF are you talking about?

Which crew rooms, cause it certainly wasn't at ISK.

Yes, we've had serviceability problems but none of us was aware of the underlying issue as identified by the BOI.
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Old 14th May 2008, 08:19
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Agree with Dave - blogger you are talking out of your ar$e.

MadMark!!!
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Old 14th May 2008, 08:25
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Blogger you want to watch what sh**e you spout off.

Lies lies and lies seems to be what you are telling.

MHAGE
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Old 14th May 2008, 16:42
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Air Commodore Baber says that 'the buck stopped with him', and that the IPT got it wrong.......

What are the implications of that?

Should he resign?

Has he opened himself up to a civil prosecution by relatives?

Is he the only person so far (in this or the Hercules inquest) to admit to any error/responsibility? If so should he be applauded?

What are the implications for subsequent witnesses?

Don't get me wrong, I'm not on a witch hunt. He seems to be the first person in recent times to admit to any responsibility in any way, as opposed to the 'lack of recollection' approach - which is actually very refreshing. I was just wondering if this opens up a new aspect on how proceedings may develop?
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Old 14th May 2008, 18:42
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JVZ90 "Chug - I try (but perhaps fail) to keep my contributions related to the engineering processes surrounding design, airworthiness & safety management of complex systems - and understanding how & why these have failed with respect to the loss of 230. These processes are basically the same for civilian and military projects and driven by (safety) engineering best practice."
I think there comes a time when one has to peer out from the confines of one's own little world, where all the i's are dotted, the t's crossed, and see the "big picture". Little purpose to the exercise if the technical feedback/ implementation loop has responded as intended, if some 2* has placed a giant spanner in the works and brought it to a grinding halt. With respect the difference between the civil and military worlds is that the operators in the one are obliged to implement safety related procedures ordered by an independent regulator, whereas in the other they are not, because there isn't one!
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Old 14th May 2008, 19:24
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I think there comes a time when one has to peer out from the confines of one's own little world, where all the i's are dotted, the t's crossed, and see the "big picture". Little purpose to the exercise if the technical feedback/ implementation loop has responded as intended, if some 2* has placed a giant spanner in the works and brought it to a grinding halt. With respect the difference between the civil and military worlds is that the operators in the one are obliged to implement safety related procedures ordered by an independent regulator, whereas in the other they are not, because there isn't one!
Don't you feel your tone is a bit patronising Chug? You appear to infer some process or technique is missing in the defence approach, present in a civilian system, that would have had a bearing on the hazard analysis mistake identified above? What safety related procedures that a civil independant regulator would have insisted upon are relevant to this mistake?

I am part of the great unwashed who don't understand many of the cryptic initials
So why do you claim to know the answer and see the big picture? I fear you're only proving you don't really know what you are talking about.
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Old 14th May 2008, 19:26
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Air Cdre Baber is due respect for the way in which he admitted his part in this whole affair but Tuc is surely right. The ultimate blame should not be laid at his door. Money is at the root of all this and he had no control over that. The limited budget is initially down to the bean counters but they are only working on a budget shared out by the services having been dictated by the Treasury to policies dictated by the politicians that we vote in. As someone pointed out here a long time back and was wrongly shouted down for saying, we the taxpayers and more accurately the voters are ultimately responsible. We, not all of us for sure, but the majority, vote for the party that promises the least tax and give our priorities as ensuring that crime, education and health are dealt with first. The truth is that the forces are being asked to do more than anyone is prepared to budget for. I'm not saying the IPT is innocent, ultimately it could and should have spotted the problems and sounded the alarm, but even if it had, do you truly believe anyone would have been listening?
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Old 14th May 2008, 19:48
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MS

Agreed. I firmly believe the Air Cdre's admission is a cynical attempt at damage limitation, thought by MoD to be the minimum necessary to (a) complement Browne's previous acceptance of liability while (b) trying to prevent the Coroner digging deeper and going higher to where, demonstrably, the real problems lie. This is so transparent it's laughably naive and illustrates, again, the arrogance of power.

If the latter were to occur, the attempt at compartmentalisation will fail as it will become increasingly obvious (to those who don't already know) that the problems are not confined to Nimrod. This is a simple fact, as the airworthiness regulations are standardised. Mr Walker isn't daft.

I should add, in fairness, that my opinion doesn't necessarily mean I think the Air Cdre cynical. I don't know him, but I have in the past witnessed the appalling pressures placed on staffs to lie or deceive in order to protect more senior staffs and hide their maladministration. To those who are really to blame, he's "only" an Air Cdre. I've also witnessed, first hand, attempts to hang someone out to dry for a fatal accident, knowing very well that he was innocent. There are many here who know exactly what I'm talking about.
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Old 14th May 2008, 19:55
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Money is at the root of all this and he had no control over that.
While the forces are no doubt underfunded, I think to conclude that this was a key factor in this case maybe misleading. If the IPT was aware of a safety problem, and had gone back for more money to fix it and been rebuked (as some seem to imply) - why on earth wouldn't the IPTL have said so? The IPT is pretty clear that they didn't know (but should have known) about the safety shortfall - so where does lack of money come into play here?

Compare to the Chinook 3, which has sat grounded for years over what seems to be a far more minor (perhaps only a technicality?) safety shortfall in IMC operations for the want of a few bob to correct it. In this case, no money to fix it, no flying = safety not compromised at a time when the services are crying out for more helicopters.
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Old 14th May 2008, 21:42
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JFZ90

The IPT is pretty clear that they didn't know (but should have known) about the safety shortfall

The testimony (as reported) makes it clear they DID know, in that the hazard was identified and probability of occurrence graded “improbable”. That grading may in hindsight be an error of judgement (although not necessarily so, despite the Air Cdre’s admission) but that doesn’t detract from the inescapable fact that every Risk Matrix in various MoD publications says that “improbable” coupled with a Severity of Harm of “catastrophic” or “critical” equals a safety risk which MUST be reduced to ALARP.

If the Severity of Harm wasn’t classified “catastrophic” or “critical”, but “marginal”, this would produce a Class D and “broadly acceptable” risk. Given the outcome of the hazard was fire and/or explosion, who on earth would classify a fire and/or explosion as “marginal” severity? That’s insane. (Just as CDP’s ruling that airworthiness and safety were optional was insane).

Now, given we’re talking about “improbable” + “catastrophic” or “critical” = Class C risk, is it not interesting that BAeS reported SIX “HRI Classification B scenarios” which they referred to the MoD for a decision on mitigation; two of which related to “Fuel Tank explosion”? Bizarrely, the report then concludes the aircraft is “acceptably safe to operate” BUT only in a peacetime environment. I have seen reports like this before where the narrative, written by a safety engineer, is explicit about the risks; yet the conclusions are so obviously diluted at a higher level to suit a customer imperative (political or otherwise). I’m sure this evidence has been presented to the Coroner and no doubt he’ll take a view, but I wonder how many here have seen it?

As to money being the root, one has to ask what any IPT is required to do upon receipt of such a report, or identification of a risk which MUST be reduced to ALARP. They’d launch an IMMEDIATE task on the Design Authority to produce, as a minimum, a Development Cost Proposal (DCP) to mitigate the risk. That assumes they have the funding to pay for the task, and a contract in place. (Both widely ignored airworthiness requirements). Upon receipt of the report (and it looks like the factors had been carefully thought out anyway in the above BAeS report), accompanied perhaps by a MF714 modification proposal, the IPT would have to raise (a) Cost and Brief Sheet supporting the 714 submission to HQMC and (b) a Business Case if they wanted to proceed. (At this point Chug will perk up, as this is where PUS’ mandated requirement for independent scrutiny is ignored, a contradiction which prevents many key airworthiness documents being updated as one is forced to take sides – you agree with either PUS or your 4 Star, but not both). Regardless of the complexity of the modification, this is a very simple process with the procedures spelt out in great detail in two Def Stans. In fact, the practical problem most IPTs face is finding someone sufficiently junior to do this as both are core competences one attains before promotion into an IPT. I’m afraid my experience is that, more often than not, the decision comes down to money. Success or failure of the submission largely depends on the willingness of an individual to make a nuisance of himself with those vying for the same funding. And MoD doesn’t want the Coroner to go there.
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Old 14th May 2008, 22:25
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Given the outcome of the hazard was fire and/or explosion, who on earth would classify a fire and/or explosion as “marginal” severity? That’s insane.
Another possible issue that springs to mind is that I read somewhere that those undertaking the safety case were unaware that the SCP was operated in flight - hence this misunderstanding could have had a bearing on their (mis)assessment of the risk. As such they would have incorrectly assumed there was no credible source of ignition in flight in that area.

Alternatively even if they thought the SCP was on, they may have incorrectly assumed the SCP piping was not infact a significant ignition risk.
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Old 14th May 2008, 22:26
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JFZ90: “Don't you feel your tone is a bit patronising Chug?”
Well it wasn’t intended to be, and if it appeared so I apologise. Because I don’t follow the minutiae of the MOD’s labyrinthine system of Airworthiness Regulation and Enforcement, it doesn’t disbar me from being concerned with its efficacy, or lack thereof. Indeed the very complexity of the arrangements seems to me to be at the heart of its weakness. A system charged with such important life critical responsibility should be simple and robust, not complex and prone to interference. You ask what is the difference between the Civilian and Military systems. Just consider the terrible 737 fire at Manchester. Within months of the publication of the report, Floor Track Emergency Lighting, Fire Retardant Seat Cushions and Crew Smoke Hoods were fitted throughout the UK Civil Airfleet. Why? Because it was a mandatory CAA requirement, whatever the financial cost to the airlines, endex. That same objectivity has yet to be extended to the military airfleet, I fear. As to the particular issues here, you have the advantage on me. How would I know of them? But perhaps they are the trees and we should be looking at the entire wood.
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Old 15th May 2008, 06:40
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Biggus

Sorry, I meant to comment on this…..


Air Commodore Baber says that 'the buck stopped with him', and that the IPT got it wrong.......

What are the implications of that?

Should he resign?

Has he opened himself up to a civil prosecution by relatives?
Responsibility for the Airworthiness of all UK Military aircraft rests with the Secretary of State. He discharges that responsibility by means of a system of delegation of authority. Therefore, it was proper for Des Browne to accept liability in his December speech.

I’d say the buck stops with SoS, if only because Air Cdre Baber was IPTL for a very short time whereas the failure to implement airworthiness regs has been endemic for almost two decades. This was not a single failure of process or procedure – it is a daily occurrence. The many who have, over the years, benignly accepted the dumbing down of MoD and continual financial cutbacks are equally guilty. But I reserve my utmost contempt for those at the top who, knowing they were abrogating their duty of care, did nothing except bully those who satisfied their obligation by raising the issues.


If I may, an unclassified extract from the lecture given at the likes of Cranwell and AbbeyWood on “The Application of Technical procedures for Airworthiness and MA Release”.

Airworthiness – The RAF perspective

……a number of factors have put the management of safety within MoD, and airworthiness in particular, under the spotlight.
  • Repeal of Section 10 of the Crown Proceedings Act, which now permits crown servants or their dependants to sue the Crown (doesn’t mention an individual) in cases of alleged negligence
  • The implication for the RAF is that litigation could now be initiated by people who know what questions to ask and where to point the finger, for example, the wife of a pilot killed in an air crash or tradesman injured in a ground accident.
As someone who held airworthiness delegation before and after the repeal of Section 10, I know we were well warned and the above extract is taken from refresher course notes. That is, ADRP recognised the implications and did their bit. However, for our part (I and my colleagues) we immediately asked if there was to be a commensurate repeal of the decision to slash funding to maintain airworthiness and then bolster it further to fund retrospective action to close the gaps in the audit trails caused by the cuts. You know the answer. You see the result every day. If you look at what was happening concurrently, this is when the seriously critical reports on MoD’s application of airworthiness regs started emanating from auditors.

The MoD’s attitude towards people with such delegated authority was bizarre. I recall our Director ranting at a Directorate meeting (my only experience of an entire Directorate being gathered together) and shouting at us that we were the “rump end of MoD(PE)” and good riddance, we were being transferred to the RAF. Then the new boss, an Air Cdre, visited us and made it clear he would not tolerate our insubordination and henceforth all technical grades would be subservient to admin grades. That would sort us out. Meet the new boss, same as the old boss (as Pete would say). But we weren’t fooled again and when we didn’t comply, he bitched to the AVM who promptly threatened the “worst” offenders with the sack. Note – “Worst” in the sense that these were the people prepared to fight for airworthiness and safety.

Given all that, no I don’t think the Air Cdre should be sacked or resign. Just my opinion.
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Old 15th May 2008, 14:45
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Transcript of Nimrod conversation

Published transcript from aircraft recorders.

http://www.eveningexpress.co.uk/Article.aspx/636681
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Old 16th May 2008, 19:38
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ITV West Country News Report from lunchtime (Video)

Air crash investigator tells inquest.... "Nimrod had more fuel lines and heat sources close together than any other aircraft he had seen".
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Old 17th May 2008, 10:09
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I've been receiving accurate info from the inquest and there have been some quite interesting facts come to light this week:

Air Cdre Beber laid out the existing mechanism that provides the airworthiness requirements under BCARs. Regardless of individual opinion regarding a conceived need for a military aviation authority, that mechanism is robust. The mechanism and tools comprised the design, testing and limitations in the Release to Service and all supporting documents. These alone met the BCARs and the Nimrod was certified using the Comet and the Nimrod MR1 as the baseline design to meet the BCARs for certification of the MR2, as a modification of the original model.

The Nimrod Safety Case (NSC), which is not required for legacy systems before the HSAW Act, was carried out because the MOD's JSP indicated that, in general, it would be sensible to gather as much data as possible in order to provide an argument that the legacy aircraft also met the principles required under the HSAW Act. So, in essence, the safety case was an MOD generated requirement thus, again, demonstrating that there is no need for an MAA, Chug. There is more than sufficient self-regulation. The NSC was carried out in 2 phases: phase one was hazard identification, to be completed by a contractor through physical examination, (BAe in this case) and phase 2, which was to examine, among other things, what mitigation was in place to safequard against any hazard established in Phase 1. Phase 2 was carried out jointly, by discussion only, by staff of the IPT and employees of BAe.

Evidence was given to the Coroner, by Air Cdre Beber, that a member of the IPT had entered into the database incorrect mitigation against a remote hazard that could have catestrophic consequences. That database, as part of the NSC, was produced by both parties and formally accepted at a minuted meeting attended by a a senior member of the IPT (not the IPTL). (my thoughts here: although a staff member of the IPT entered the incorrect data, it could be reasonable to assume that he did so following a discussion with someone else - RAF or BAe). However, to quote Air Cdre Beber, "The buck stops with the IPTL".

Tuc, you say the SoS has responsibilty. Beber stated, quite clearly, that the IPTL is the Type Airworthiness Authority, insofar as what he says, goes. Therefore, he recognised that no-one above him can take reponsibility for actions that he alone can authorise without reference to those above him. He makes the decisions, he takes responsibility. Those staff below him have no authority so they cannot be held responsible for airworthiness.

Air Cdre Beber was, quite correctly (IMHO, and that of the AAIB), very critical in hindsight of the design of the 7 Tank Dry Bay and indicated that BAe produced a flawed design and that the IPT has missed an opportunity (the NSC) to identify that flaw. BAe's counsel refuted the suggestion that his client was solely involved in putting the flawed design into the air by producing a document outlining the acceptance, by the RAF, of the SCP design. I'm sure that the Coroner has heard this type of discussion many times before and he will have a case book to guide him. It is intriguing that BAe did not contest the assertion that they produced a flawed design.

Apparently, one or two press reporters have been in the gallery every day, taking notes. I recommend a search through the Sunday papers tomorrow to hopefully see some accurate reporting of this week's evidence.

Portsmouth for the cup !

Ed Sett
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Old 17th May 2008, 11:05
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Apparently, one or two press reporters have been in the gallery every day, taking notes. I recommend a search through the Sunday papers tomorrow to hopefully see some accurate reporting of this week's evidence.
Edset - lets hope so, however,

Mick Smith (Sunday Times)
Air Cdre Baber is due respect for the way in which he admitted his part in this whole affair but ...... the ultimate blame should not be laid at his door. Money is at the root of all this and he had no control over that.
On the basis of this opinion, we'll see. I hope he (& others) reads your piece above and doesn't rush to potentially erroneous conclusions. You could argue that any excuse for bashing the Govt to better fund the Armed Forces is never a bad idea; however as its not really at the heart of the some of the issues currently coming out of the Nimrod enquiry it could just end up being misleading.

BAe's counsel refuted the suggestion that his client was solely involved in putting the flawed design into the air by producing a document outlining the acceptance, by the RAF, of the SCP design.
This is interesting - perhaps equivalent to saying, "will sold you the car with loose wheel nuts, but you did have a good look around it before we gave you the keys, so you're also partly liable for the fact they came off and it crashed.", though its not quite as simple as this of course.

Tangential rant - I'm no apologist for this govt btw, I just want to see the correct facts emerge so they can be learned from. I'd rather the papers bashed the Govt over the cynical changes to 2009/2010 Car Tax VED; it will be next years 10p tax issue when families face an almost £500/year hike in what it costs to tax their People Carrier and 2nd car - all supposedly in the name of the reducing CO2 when infact an opposite effect is likely with the premature scrapping of cars which are not past their service life, but will have plummeted in value (further hitting the poor who can't then trade them in for low CO2 cars) and are too expensive to tax. Now there is a Govt scandal.
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Old 17th May 2008, 11:56
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Air Cdre Beber laid out the existing mechanism that provides the airworthiness requirements under BCARs. Regardless of individual opinion regarding a conceived need for a military aviation authority, that mechanism is robust.
This is the argument trotted out time after time by MoD, on this and other cases. To repeat – the regs are quite robust, but MoD doesn’t IMPLEMENT them properly. Two completely different things, and at the heart of this case. As I said, when challenged on this specific point, Ingram thought it wise to launch into print and claim the regs were robustly implemented. An unwise move, given the evidence and previous rulings of his predecessors, senior MoD staffs and, wait for it, himself.


So, in essence, the safety case was an MOD generated requirement thus, again, demonstrating that there is no need for an MAA, Chug. There is more than sufficient self-regulation.
See above. I think the point Chug makes is self-regulation is fine so long as one implements the regs properly. MoD has admitted it doesn't, a simple verifiable fact.



Evidence was given to the Coroner, by Air Cdre Beber, that a member of the IPT had entered into the database incorrect mitigation against a remote hazard that could have catestrophic consequences. That database, as part of the NSC, was produced by both parties and formally accepted at a minuted meeting attended by a a senior member of the IPT (not the IPTL). (my thoughts here: although a staff member of the IPT entered the incorrect data, it could be reasonable to assume that he did so following a discussion with someone else - RAF or BAe). However, to quote Air Cdre Beber, "The buck stops with the IPTL".
Without knowing precisely what was entered wrongly, one cannot comment. I’ve already said that what was reported doesn’t make sense – there is more to it. However, I agree with you – this is not a one-man job. It is likely BAeS have a very large team dedicated to the Safety Case, always assuming they are suitably contracted by MoD. We already know they are denied funding for routine airworthiness tasks.



Tuc, you say the SoS has responsibilty. Beber stated, quite clearly, that the IPTL is the Type Airworthiness Authority, insofar as what he says, goes. Therefore, he recognised that no-one above him can take reponsibility for actions that he alone can authorise without reference to those above him. He makes the decisions, he takes responsibility. Those staff below him have no authority so they cannot be held responsible for airworthiness.
I am correct in saying responsibility rests with SoS. Authority is delegated downwards. Is he saying that no letters of delegation have been issued to ANY of his staff, or those staff of stakeholders IPTs who are responsible for “vendor” equipment? Not possible. He delegates. His level should enter the frame when his staffs delegate upwards to him the impact statements arising from funding cuts. And I’ve already said what typically happens when you do that. I also posted to the effect that the IPTL seldom, if ever, has complete delegation – he is required to report upwards on certain critical components of airworthiness. It is not clear to what extent the problems on Nimrod were delegated or reported upwards (but, as I said, the general problem of MoD NOT implementing the regs HAS been reported, many times). This is important, because components of airworthiness are shared across aircraft fleets. The Nimrod carries a host of kit which is common to other types. Conversely, I wonder how many times the IPTL was notified or reminded by his stakeholders that the build standard of their kit was not being maintained, therefore compromising his airworthiness audit trail? The last time I tried to notify someone of this I was told “of no concern”. (He was a member of the Defence Airworthiness Group). And if this sounds complicated, the management of the process is described adequately in one paragraph in the Def Stan.



Air Cdre Beber was, quite correctly (IMHO, and that of the AAIB), very critical in hindsight of the design of the 7 Tank Dry Bay and indicated that BAe produced a flawed design and that the IPT has missed an opportunity (the NSC) to identify that flaw. BAe's counsel refuted the suggestion that his client was solely involved in putting the flawed design into the air by producing a document outlining the acceptance, by the RAF, of the SCP design. I'm sure that the Coroner has heard this type of discussion many times before and he will have a case book to guide him. It is intriguing that BAe did not contest the assertion that they produced a flawed design.
Yet, MoD accepted liability. Why? The Design Authority is responsible for the design, but it remains Under Ministry Control (UMC). As I said, the MoD has an obligation to maintain the build standard of the whole aircraft, including its equipment, through a series of suitable and continuous contracts. The Aircraft Design Authority (ADA) is NOT responsible for this; in simple terms because he is not the DA for everything in the aircraft.

You highlight an interesting line taken by BAeS’s counsel. The regulations state, quite clearly, that when MoD accepts the Declaration of Design or equivalent (which I assume is what Counsel was waving) this does not imply approval of the design nor acceptance of any responsibility for the design; that still rests with the contractor. But, MoD is responsible for contracting control of the design through all changes to the aircraft design. In this case, it is important to ask the question what exceptions or limitations were included in the Certificate of Design? It will also state what configuration the device was in at delivery and what configuration (including use) of the aircraft it was intended for – again, controlling that configuration is MoD’s responsibility. It has to be said here, that if the original manufacture and/or designer has gone out of business, then this complicates matters. It is often difficult to obtain the master drawings (and there are some of us who have stood at factory gates arguing with liquidators!) so it is often left to MoD to accept responsibility for the design. Or another DA can be appointed, but the contract is so heavily caveated that MoD are still responsible. I suspect very few here have any practical experience of this but it a fundamental part of what I refer to as “maintaining the build standard”, which in turn is one of the pillars of airworthiness; and the older the kit the more often these problems arise. But all the beancounters see is that it produces nothing tangible in terms of delivered kit, so they chop funding.

My view is that, while BAeS are rightly nervous over the flawed design, it is likely they are largely off the hook because MoD cannot demonstrate it has complied with its own airworthiness regs. Which brings us back to (a) Loader’s re-affirmation of this in the BoI report, and (b) Des Browne’s statement.
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