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

[tucumseh]

Regulating Military Airworthiness

I know this may sound a bit simplistic, but I’ve always advocated adhering to the mandated processes, procedures and regulations. They were written by people who were very good indeed at doing this.

From the ridicule and odium aimed at me, I know I’m almost a lone voice – in fact I have it in writing from MoD that I am. But given their alternative, and the resultant accidents and deaths, perhaps you’ll forgive me for thinking various 1 Star, 2 Star, 3 Star (although he didn’t actually respond to my suggestion), 4 Star and Min(AF) wrong.

[EdSet100]

Edsett,

What you can then come back to is that the mechanism was flawed in its implementation not its principle, something that tucumseh and I have long espoused.

sw

Indeed. So, when a group of qualified people (IPT and BAe engineers) are entrusted to implement the mechanism, it must be wrong to blame the executive body for the failure of the staff to correctly implement the process. I would blame the executive if they entrusted unqualified people or failed to resource them properly, because it is the executive's responsibility to ensure that the right people and adequate resources are in place to implement the policy.

If it was the case that the implementation process would cause problems (funding and resources) and the IPTL (and higher) ordered either a quick broad review of the aircraft or simply didn't order one at all, then, yes, we can blame them.

As I understand it, the clear fact given to the Coroner by the, then, IPTL is that, "there was a genuine human error" during phase 2 of the NSC. I believe that fact and IMHO no amount of policy structuring, resource management and executive teeth grinding will ever obviate human errors at the coalface.

[Safeware]

S_H,

Maybe I'm trying to be too simplistic in my explanation. Yes I believe that a system of independent oversight and assurance could be established. But I'd also taken the the fact that you said "responsibilities of ownership, operation and regulation in the same body" to mean the MOD.

But if you mean that Director Air Systems, with DMSD, CASD and TESD, should be able to fulfil an effective role of independent oversight and assurance, then I'd agree.

Not sure what you mean by questioning my question on military systems. A challenge for the MOD wil be management of systems such as A400M and FSTA.

sw

[Safeware]

Edsett,

I would blame the executive if they entrusted unqualified people or failed to resource them properly, because it is the executive's responsibility to ensure that the right people and adequate resources are in place to implement the policy.

There are just so many people who will be saying "yep, that's exactly the case"!!!

sw

[Chugalug2]

Safeware:
Civil regulation is demonstrably independent of the manufacturers, owners, operators and customers - that's why it works.

This is the very nub of the matter. It would be very nice if a little bit of tweaking here, reallocation there, reorganisation elsewhere could keep the whole package in house, ie within the MOD. Unfortunately that flies in the face of experience and logic. Independent means independent. The CAA has a difficult enough time ensuring that itself. If it were dependent on manufacturers or operators it couldn't function, neither could an MAA. It has to be outside the MOD or it can be nobbled to put it bluntly!

[JFZ90]

As I understand it, the clear fact given to the Coroner by the, then, IPTL is that, "there was a genuine human error" during phase 2 of the NSC. I believe that fact and IMHO no amount of policy structuring, resource management and executive teeth grinding will ever obviate human errors at the coalface.

This is a very important, well crucial, point that I think is being missed by those demanding sweeping MAA type changes. This mistake would still have been made even if such a "magical truely independant airworthiness body" was in place.

Chug - you mentioned earlier about the Manchester BA737 tradgedy as a positive reflection on the CAA. The other perspective is that 55(?) people died in an aircraft on the ground, in a design already under the "airworthiness control" of the CAA - why didn't your magical CAA spot the safety shortfalls before it happened and regulate/enforce a safer solution?

[tucumseh]

This is a very important, well crucial, point that I think is being missed by those demanding sweeping MAA type changes. This mistake would still have been made even if such a "magical truely independant airworthiness body" was in place.

Human errors happen. One aims to minimize them – the regs demand that one method, employing properly trained, competent and funded staff is used. The policy remains extant; the practice has been somewhat different for many years.

The question is not so much who made the error and why (although that is important, because human factors such as long hours and stress caused by under resource can be a contributory factor – again the regs cover this but are broadly ignored - a situation openly condoned by the "executive"), but rather what processes and procedures exist to validate and verify the work and whether or not they were resourced and implemented properly.

I’m not sure one can say for certain that the mistake would have been made anyway. From what little I know of the case, the MoD regs, if implemented properly, would have been sufficient. ACM Loader admitted as much.


Nor am I comfortable with this focusing on one “error”. If you read the main QQ report discussed here, there is a lengthy catalogue of failures of process and procedure, any one of which could have caused an accident. Like many accidents, a combination of factors conspired against the aircraft and crew on that day. Often, MoD focus on cause, but cumulative effect is often ignored, never more so when MoD try to compartmentalise the issue, thus deflecting attention away from the wider problem. The "error" by one person in the Nimrod IPT is a very minor issue here. Don't let it hide the big one.

[Chugalug2]

JFZ90: why didn't your magical CAA spot the safety shortfalls before it happened and regulate/enforce a safer solution?

Irony I know, but there is nothing magical about the proper application of Flight Safety. The real lessons learned from Manchester were the absolute importance of crew co-operation and integration, coupled with a review and overhaul of Abandoned Take Off procedures. All this was not just visited on the operator concerned, but on every other one as well. The philosophy is that however much you strive, accidents will still happen. The trick is to learn and apply every possible lesson from such tragedies to avoid or mitigate future ones. On the whole I think that the CAA is reasonably adept at this, on the whole I think that the MOD is not.

[JFZ90]

Nor am I comfortable with this focusing on one “error”.

True, there is always more to these cases than a single mistake.

I’m not sure one can say for certain that the mistake would have been made anyway. From what little I know of the case, the MoD regs, if implemented properly, would have been sufficient.

I only refer to the safety case error here. You can't say or imply this error would be removed if e.g. you had a MAA etc. Some here seem to be doing just that.

The "error" by one person in the Nimrod IPT is a very minor issue here.

As you say above, its only one of several issues - lets not forget that the safety case issue was only a review of the design, the 'flaw' was put in the design many years earlier.

I don't think you could lay this mistake at the door of one person in the IPT anyway - the review process would involve many, and I'd have expected at least one BAES engineer, + someone from BAES QA, + one Independant Safety engineer to have been involved all areas, i.e. including assessing the area under debate. Having an operator involved may have helped pick up the issue - this could be a lesson learned. Not sure how you'll get an operator interested in wading through pages of fault trees etc., but thats another issue....

[JFZ90]

The philosophy is that however much you strive, accidents will still happen. The trick is to learn and apply every possible lesson from such tragedies to avoid or mitigate future ones.

Every possible lesson? 'Lessons' like adopting smoke hoods for PAX across all fleets post Manchaster? The airlines effectively told the CAA to poke off on that one didn't they? Lessons like fitting tail cameras to all civil aircraft in the aftermath of Kegworth. Etc. I'm not saying the right decisions weren't taken in these cases, but lets keep some perspective.

On the whole I think that the CAA is reasonably adept at this, on the whole I think that the MOD is not.

I'm not seeing any evidence that you can back this up - its subjective, and dare I say comes across as emotive twaddle. Where's your audit trail to back up your assertions?

[Mad (Flt) Scientist]

Gents

As one who lives in the civil regulatory world and deals with safety assesments regularly I've been following this thread with some interest; it's illuminating to see the differences, and similarities, in approaches to risk management.

(Incidentally, if any of the DefStans and similar procedures which some have referred to earlier are non-Restricted, I'd be curious to look into them further; does MoD publish such things electronically where the unwashed could get access to them?)

However, I feel I should comment on this statement, because there may be an element of thinking the grass to be greener creeping in...

Civil regulation is demonstrably independent of the manufacturers, owners, operators and customers - that's why it works.

I don't think that's been true anywhere in the civil world for a long time. There's a great deal of day-to-day regulation delegated, in practice, to the manufacturers etc.

For example, in my OEM we are what Transport Canada calls a "DAO" - a Design Approval Organisation. Specific people within the company act as "Design Approval Designees", and act on behalf of TC to approve design changes. Depending on the scope of the design change, TC themselves may know little more than that it has occurred. The DADs are, of course, company employees, and while are selected for a supposed ability to be independent and objective, human nature means that not everyone sees that in the same light....

Prior to this incarnation, the "DAD" role was undertaken by Design Approval Representatives (DARs) who, although acting in a p[ersonal capacity rather than as part of a DAO were still wearing both a company and regulatory hat. In the near future, we're expected to move to a model where the company is an "Approved Design Organisation" - ADO - and the approvals will be made by the company itself on behalf of TC, not by individuals.

All of these models create conflicts of interest, yet its unavoidable, because there's no way a regulatory organisation can 'police' an OEM at the design approval level - I would estimate that on a typical certification programme there could be up to 50 DADs working some 3 years each involved - 150 man-years - compared to maybe ten authority people working a few months each - perhaps 5 man years total? For the authroities to man-up to replace the DADs would be a major issue. Never mind that an OEM could still 'hide' the facts if the model were adverserial anyway.

My understanding is that the OEMs in other jurisdictions are working in similar ways (The US equivalent of the DAR/DAD is called a DER for example). So while the MoD model may not be ideal, there's no magic solution in the civil world I fear...

[tucumseh]

Mad Scientist


Go here:

http://www.dstan.mod.uk/


Not all the relevant standards are there yet but start with JSP553, 00-970, 05-123, 00-55, 00-56, 00-57.


What you describe is similar to what we have here. If you search for DAOS (Design Approved Organisation Scheme).

[JFZ90]

Interesting post Mad Scientist,

Had a dig around for more info on Kegworth as it was so long ago.

http://en.wikipedia.org/wiki/Kegworth_air_disaster

Aside from the rather alarming pilot training issues which had a significant bearing on the mistake(s) they made during the emergency...

The pilots had received no simulator training on the new model as no simulator for the 737-400 existed in the UK at that time.

....the way the root cause of the incident escaped detection really surprised me:

the uprated CFM56 engine used on the 737-400 were subject to abnormal amounts of vibration when operating at high power settings above 25,000 ft. As it was an upgrade to an existing engine, in-flight testing was not mandatory, and the engine had only been tested in the laboratory.

Surprised the CAA etc. were ever talked into this (and not surprisingly recommendations were made not to allow this again). Flight test with paying passengers.

[Chugalug2]

JFZ90: I'm not seeing any evidence that you can back this up - its subjective, and dare I say comes across as emotive twaddle. Where's your audit trail to back up your assertions?

Oh, now we have to produce evidence to back up assertions on this thread? Well the only audit trails I have access to are the same ones every PPRuNer has, this Forum! Now you may be in the comfortable position of having all the evidence to satisfy your conclusions, and all the audit trails to confirm the correctness of those conclusions. Personally I take note of what others have written here and on other threads, based on their personal experience and apparent professional expertise, and I come to the conclusion that it is dare I say such complacency that lies at the heart of this discussion. Some are saying that the Emperor has no clothes, others that he is well dressed and on top of the situation. Personally I have a high incidence of suspicion that the latter assertion is a tautological inexactitude, but lacking the evidence and not having access to audit trails....

[OilCan]

......the 'accident' might still have happened.

[buoy15]

Jeez
Why can't you lot put this to bed
This was a tragic accident
The ac was serviceable, declared and signed for by the captain who was also 1st pilot
What happened later was a failure that could not have been forecast or predicted by the best Crew chief, CFI, CDS, or God!
The profile was one of thousands that had already been completed successfuly - and then something failed - try and fix it - call for help - oh bugger, we are in trouble
You wankers that drive around at 70 every day in your 4x4's on the phone, have no idea about failure and how to react to it - your in the outside lane doing 80 and your engine packs up or the brakes fail - what do you do? Yeh!
call the dealer or manufacturer and complain in the middle of a pile up
Get Real!

[BEagle]

Whilst the aircraft may not have had any snags of which the aircrew or groundcrew were aware, it might still have had an inherent design fault sufficient to cause its destruction.

I'm sure that the BOAC crews who operated the first Comets thought that their aircraft were fully serviceable. But a design flaw (nothing to do with the Nimrod accident) caused the structural failures and inevitable consequence for the 60 people on board the 3 Comet 1s which fell out of the sky in the early 1950s.

buoy15, all 'accidents' have some primary cause. Which must be clearly established if the aircraft is to be operated with adequate safety in future.

Incidentally, construction and use regulations mean that car (or 4x4) brakes are unlikely to suffer a total failure these days; similarly, a total engine failure is unlikely unless the vehicle runs out of fuel. But there again, how many modern cars have design features inherited from the early 1950s?

[Winco]

I too am fairly certain that buoy 15 is just getting a bit frustrated with the whole saga, and he like many others want it putting to bed. The problem is that accidents 'don't just happen' there is always a reason, and in many cases, as you say, it could not have been forseen or predicted.

The problem here is that it WAS forseen and it WAS predicted.

I have stopped posting on here about what might or might not have gone wrong. I now leave it to those who are far more current on the aircraft, however, it is clear to me that your comment of:
'What happened later was a failure that could not have been forecast or predicted by the best Crew chief, CFI, CDS, or God!' is simply incorrect - apart from the bit about God maybe.

Regarding your comparison with the car, could I just say that if your car manufacturer wrote to you saying that your brakes needed checking because there might be a problem, and your local garage/dealership said 'Oh it's nothing Mr b15, it will be ok' and ignored the warning and you then crashed with no brakes, would you just say 'oh it was a tragic accident?' I think not.

[nigegilb]

I would agree that we should wait until Mr Walker gives his view. The input from the likes of Tuc has been invaluable in providing insight to the workings or otherwise in the higher reaches of MoD. Ed Set as ever provides a balance.

One thing bothers me. The risks associated with the design fault were not appreciated until the crash, but the day after the crash the SCP as a source of fire was removed. AAR continued until the MAYDAY last November. No AAR sorties have been carried out since. CAS told the world that Nimrod was as safe as it needed to be.

Doesn't square does it?

Not sure how wide the remit of the Inquest is, but I would hope, fuel leaks and events post crash have also been analysed by Mr Walker.

[Mick Smith]

Let's hope the conclusion of the Mr H-C's inquest can offer some genuine closure and allow us to move on

Mr H-C's report - which is of course not the ongoing inquest - is going to be a while coming sadly, but it would certainly be good to see someone give a report that allows closure. Given the evidence at the inquest and the discrepancies with the conclusions of the BoI, I doubt the inquest is going to give any closure at all. The sooner Mr H-C's report comes out the better.