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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 25th May 2008, 10:14
  #721 (permalink)  
 
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As Lab Queen points out, the coroner certainly did not criticise the board of inquiry. He in fact commended the board for finding the design fault, the co-location of hot air pipes and fuel pipes in the No7 tank dry bay with no fire detection or suppression system present.

That said, one of the possible causes of the leaking fuel put forward by the board of inquiry, the idea that fuel blowing off from the No 1 tank travelled along the side of the aircraft and into the No 7 tank dry bay, was disproved by the evidence to the inquest. BAE Systems experts showed conclusively that this could not have happened.

But anyone who has read the board’s report will know that this was only one of two possibilities it put forward for the source of the fuel that led to the fire, albeit what it saw as the most likely. The other, a leak from fuel pipes inside the aircraft, was assessed by the experts as the most likely source which is why the misalignment and seals issues have been raised.

One thing the coroner did say with regard to the board of inquiry was that there ought to be an independent inquiry system, not because the BoI in this case did anything wrong. But it was clear that in practice if not in theory there were limitations on what it could do, particularly when relying for some of its evidence on the IPT. Just one example: as Tuc has pointed out a number of times, the QinetiQ report on the wing tank leaks was not read by the BoI because the wing tank leaks were irrelevant to the XV230 incident. But the report actually looked much wider than the wing tanks and in particular noted that some leaks inside the aircraft were not being followed up because they could not be replicated on the ground.

When the fuel leak occurred inside the bomb bay of another Nimrod last November and it made an emergency landing at Kandahar, Glenn Torpy said that the fleet was grounded because the leak could not be replicated on the ground. He looked very surprised when I pointed out that this was precisely what QinetiQ had said of previous leaks in its 2006 report. Why was he of all people not briefed on this before he faced the press.

As for the ALARP issue, which is the reason the coroner called for the fleet to be grounded, EdSet said:

If Gp Capt Hickman, as the Delegated Airworthiness Authority, has stated that the Nimrod currently IS NOT ALARP, we are in trouble. I wasn't there to hear his words on oath, but if he used those words, or similar, he is contradicting virtually everyone (from SoS down to NLS liney) involved with the aircraft. Given his appointment, there should be no way that he would be contradicted by his superiors. I believe he has been mis-represented here.
Not misrepresented and certainly not contradicting SoS, who wrote to Angus Robertson, MP for Kinloss and deputy chairman of the all-party RAF group, last week to say:

During defence questions in the House on 28 April 2008 I undertook to write to you about a QinetiQ safety report concerning the RAF’s Nimrod aircraft. You asked how many of the 30 recommendations made in the report had been complied with (Official Report: Column 4)

You did not specify which QinetiQ report you were referring to but I believe it to be the Nimrod Fuel System Safety Review Report dated October 2007 which was recently released under the Freedom of Information Act. This report is an interim report and is part of a more comprehensive safety review of the Nimrod Fuel System being carried out by the Department in accordance with recommendation four of the Board of Inquiry Report into the loss of Nimrod XV230.

Of the 30 recommendations contained in the QinetiQ report: 21 have been accepted and are being implemented; 3 are being considered for implementation and a further 6 are on hold as they relate to Air-to-Air Refuelling. Following the leak incident on Nimrod XV235 on 5 November 2007, all Air-to-Air Refuelling on the Nimrod fleet was suspended. This suspension remains in force.
(my italics)
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Old 25th May 2008, 10:50
  #722 (permalink)  

 
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Da4orce, you say
I believe that the Coroner actually went into more detail earlier in his summing up, he also made mention of a similar incident on XV230 just 2 weeks earlier.
I do have contemporaneous notes of this, but at some stages in his very lengthy narrative verdict, Mr Walker was going through his stuff at a great rate of knots, and in considerable detail. I’m afraid my record-keeping was not always up to snuff! However, here’s what I think happened.

The coroner said he believed the fire came from fuel leaks. He said there was no evidence to support the BoI theory of fuel from a blow-off getting into dry bay 7. He referred to the video, that we all saw many times, of a big fuel leak (on the ground) which could pass into dry bay 7. But it was clear that such leaks, which may occur when airborne, are not always able to be reproduced on the ground.

He did indeed mention that XV230 had had a transient leak two weeks before the crash, and could have been lost then.

So he believes that the fuel for the fire came from leaks in couplings. He accepted evidence that refuel/defuel system leaks came from misaligned couplings rather than seal failure.

Over the last two or three days of the inquest, he had been pursuing a theory that the fatal leaks may have occurred within No 3 engine. This idea came about because there should, in theory, have been no pressure left in the refuel/defuel system to produce enough fuel to sustain the fire. But fuel in the high pressure system of the engine would be at 1200psi, and any leak there would supply more than enough fuel to sustain the fire.

The coroner commended Mick Bell, who was representing himself over the death of his brother, FS Gerard Bell, for his work on this aspect in particular. That research had shown that an engine could lose as much as 15 gallons a minute without a loss of power of more than 7%, and other research showed that this fuel could indeed have migrated into dry bay 7 via the airflow on the underside of the wing.

Despite his dismissal of the BoI finding on the blow-off theory, the coroner did, as Laboratoryqueen and Mick Smith say, go out of his way to commend the BoI team.

For anyone who has not yet discovered it, Mick Smith has another coruscating and scathing article in today’s Sunday Times, which should be mandatory reading for all concerned.

http://www.timesonline.co.uk/tol/new...cle3998966.ece


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Old 25th May 2008, 11:23
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the idea that fuel blowing off from the No 1 tank travelled along the side of the aircraft and into the No 7 tank dry bay, was disproved by the evidence to the inquest. BAE Systems experts showed conclusively that this could not have happened.
Interesting. How did they show this? This then puts more focus on leaks, though as I think has been said leaks will always be impossible to entirely remove so you must have a design that can tolerant some degree of leakage (mtn errors, battle damage etc.). Anecdotes suggest the old Lightning design was very unforgiving in this respect.

Ed

300 seal changes per aircraft....this is going to cause us more problems. I guess the VC10 (more than 25 years old) is in the same can of worms.

The first Nimrod to have all its seals changed will leak on test. Those leaks will be identified and cured. Then, the first flight (post major air test?) will suffer leaks due to flexing and, despite a safe flight and landing, that will be the last flight of the Nimrod fleet. All under the guise of working towards ALARP. This is a complete mess.
A mess it certainly it is. I think your choice of the word guise is telling. Its all too political now though isn't it - the seals must be seen to be changed, irrespective of a balanced risk assessment of the impact of such a decision.

Having said that, did the seals really have no lifing data prior to this incident? Is the science behind their degradation known, or is the 25yrs limit just a liability limiting exercise be the OEM as it is infact unknown?
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Old 25th May 2008, 11:23
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From Mick's article and this is for Ed Sett,

Group Captain Colin Hickman, who is in charge of the safety of the Nimrod fleet, admitted to the coroner that the remaining Nimrods were not Alarp and would not be so until the end of this year. Asked if this process could be speeded up, Hickman replied: “No, it is driven by resources.”

Once again this Fleet cannot be described as airworthy. If anyone get's info on life assurance validity please post it here and send a copy to Des Browne.

"Oh my goodness! A secretary of state has misled us. Shock horror. Seriously, is there anyone in this nation who would not prefer to believe the word of a coroner than that of a politician - especially a minister?"

Well aside from a fair few people here.....
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Old 25th May 2008, 11:43
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The issue of ALARP does raise concern, and as others who have been posting on here who were there to hear the statement made by Group Captain Hickman, he stated the fleet is not ALARP at present, the situation is being managed by offline conversations between the IPT and BAe and the aim is to have a standard of ALARP by the end of this year. When asked if the resources would be made available to perform this, bearing in mind the fleet is at the end of it's service life, he stated that yes it would be done.

He stated that while the fleet is not ALARP it is still airworthy and it is still safe to fly as they are working towards that standard.

The coroner then asked some aircrew who were in attendance how that knowledge made them feel, which produced a wry laugh.

I am still somewhat confused as to how one previous IPTL can state the fleet is not airworthy and never has been and yet a different claims it is.

I do very much agree with the coroners view that those who are the "managers of people" know nothing of what is really going on, those who should be talked to and whose opinions are the most important are those on the "coalface".
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Old 25th May 2008, 11:59
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Labqueen - I agree the situation has become very confused.

I think it would help to understand what the remaining issues to get to "ALARP" are, then perhaps we could grasp what risks are being taken until the end of the year.

Until that happens I think it will be impossible for anyone to accept this statement:

while the fleet is not ALARP it is still airworthy and it is still safe to fly as they are working towards that standard.
though as Tuc has posted this is not necessarily inconsistent with normal practice.

Did the coroner ask what these outstanding issues/measure were?
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Old 25th May 2008, 12:01
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He stated that while the fleet is not ALARP it is still airworthy and it is still safe to fly as they are working towards that standard.
The way I see it is that those who say the aircraft is NOT airworthy can DEMONSTRATE it is not by comparing and applying expert opinion and known facts to the REGULATIONS.

Those who opine it IS airworthy CANNOT demonstrate it, and have arrogantly ignored both the experts (whom they pay for) and their own MANDATED regulations (which they clearly have never read or don’t understand).

As it is extremely difficult to demonstrate airworthiness in finite terms (especially when the records show that the funding necessary to maintain the necessary evidence has been slashed and the whole process is regarded as optional) then it is a very foolish man who asks the experts and then ignores them. (The regs also require the reason why independent advice is ignored to be recorded in the Safety Case, which I’m sure is being duly amended as I type). I’m sure Mr Walker recognised this and, while the rules prevent him making public all his thoughts I assume the QC’s Review will be informed. One then has to hope that is not tainted by MoD interference.


I’ve read all this before – on the Mull thread.
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Old 25th May 2008, 13:09
  #728 (permalink)  
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Have to agree with the Old Fat One there

The APU is very reliable and rarely fails.

I think its made by Rover , if thats the case then why does it not rust
 
Old 25th May 2008, 13:18
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Just as the rest of us were moving towards some sort of unanimity, the APU comes in from left field to spark a bit of controversy. I'm not sure what the relevance is to be honest Old Fat One. The APU issue went right across the top of my radar and I think, although I might be wrong, that the first time I had heard of the term was this morning on this thread. Certainly it has not been a part of any of my reporting on the issue so I am prepared to believe it is indeed a red herring and as for the accuracy of those posting on it, I am not in a position to judge. You can keep me out of that debate TVM!
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Old 25th May 2008, 13:49
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The "30 Recommendations"

Earlier, I said that 29 of the 30 recommendations in the QQ report of October 2007 referred directly to airworthiness regulations. The one I hedged about was the Master Minimum Equipment List (MMEL).

The precise wording of the recommendation is “Consideration should be given to the introduction of a Master Minimum Equipment List”.

The reason I hesitated was because, clearly, an MMEL is mandated as it “relates to the fundamental airworthiness of the air vehicle” (JSP553). However, it is a manufacturer’s document for an aircraft type (Nimrod in this case, perhaps traceable back to Comet – I don’t know enough history) and I assumed BAeS have one. The aircraft operator (MoD) may choose to have a Minimum Equipment List (specific to aircraft and operating environment) but it must not contradict the MMEL and the Safety Case must demonstrate traceability. Again I hesitated because I’m unsure what’s in the Nimrod MR2 or R1 Aircrew Manuals.

If taken literally, the QQ report infers an MMEL doesn’t exist, meaning all 30 recommendations refer directly to airworthiness. Also, given the aircraft’s operating environment would seem to have changed recently (not much use for Sonics over AFG) it follows that the MEL would have been at least re-assessed. Anyway, thought I’d just clarify this.


Much is made of the 6 recommendations relating to AAR, and MoD deeming implementation unnecessary. However, of these 6, I consider 4 to be generic problems relating to application of airworthiness regs. (That sounds rather grand – I’m not an authority, just my opinion). For example, 3 relate to the failure to apply the principles of “System of Systems” integration, where each system is “safe” in isolation, but not when integrated. Put another way, physical safety is addressed in isolation but not functional safety. Two of the recommendations say;
  • Additional activities should be undertaken to better understand the behaviour and operation of the Nimrod / Tri-Star and Nimrod / VC10 mated system, and,
  • Hazard identification, assessment and management activities should be undertaken once the behaviour and operation of the mated systems is more clearly understood.
Do I need to spell this out? It’s absolutely appalling. Importantly, you have to view this also as “Tri-Star / VC10 plus any aircraft it mates with”. If the Nimrod (team) has not complied then it rather follows, as core stakeholders, neither have Tri-Star or VC10. I apologise to the both if I am wrong and they have banged on about this to Nimrod every day for the last umpteen years. This is really basic engineering stuff and bottomed out at Design Reviews, Functional Configuration Audits etc before they ever come near each other. And if a high profile aircraft like Nimrod can omit the basics, then if I were SoS I’d be demanding a review of these recommendations as they applied across the MoD.

The inference is that CA Release and Release to Service were granted without fully understanding the behaviour of (a) an aircraft laden with fuel pumping it out at high pressure and (b) and aircraft it was physically integrated with which was known to disgorge said fuel at a rate of knots through leaking fuel lines. Am I being unfair?
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Old 25th May 2008, 13:50
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JFZ90

The coroner did not ask outright what issues where outstanding, instead he questioned the fact that QinetiQ had produced a report which stated the FRS couplings were cause for concern due to the fact of degradation in the seal and that when not held in a constant fuel supply they would be more prone to leaks. They advised tests be completed on the seals and an inspection performed more often than which is in place and that the tests performed at present are not suitable.

Group Captain Hickman said he did not agree with that report and so had disregarded it, instead he was taking advice from BAe. The manufacturer of the couplings, Eaton Aerospace, also stated the couplings were not suitable for some of the systems in which they are in place and that they are not designed for systems which do not have constant fuel submersion, he was concerned at the fact they are being used in this way, again Hickman said he disagreed with this and instead of taking advice from the couplings manufacturer he would discuss with BAe.
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Old 25th May 2008, 14:46
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Surely the question of why the Nimrod is not airworthy is one that should be answered by Grp Captain Hickman and his superiors as it is Hickman who by implication of saying that they are not ALARP is saying that they are not airworthy.


(BBC) The Politics Show Scotland - 25/05/2008 (go to 43.55 min into the programme)

http://www.bbc.co.uk/iplayer/page/it...n_pid=b00bxl3m

BBC Online - Nimrod crew 'leaving over safety' - http://news.bbc.co.uk/1/hi/scotland/...st/7419096.stm

Last edited by Da4orce; 25th May 2008 at 15:11. Reason: To add link
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Old 25th May 2008, 14:46
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I should add one thing to my previous post on Des Browne admitting that the QQ recommendations to make the risk to the MR2 ALARP are still being implemented.

When EdSet said Hickman was contradicting Browne, he of course meant Browne's claim in December that QQ had designated the aircraft safe.

In fact both Hickman and Browne are, quite bizarrely in the latter case, contradicting that claim. Given that Browne's admission came in a letter to the SNP leader in the Commons, perhaps the Scottish Secretary was simply contradicting the Defence Secretary!
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Old 25th May 2008, 14:59
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  • Additional activities should be undertaken to better understand the behaviour and operation of the Nimrod / Tri-Star and Nimrod / VC10 mated system, and,
  • Hazard identification, assessment and management activities should be undertaken once the behaviour and operation of the mated systems is more clearly understood.
Do I need to spell this out? It’s absolutely appalling. Importantly, you have to view this also as “Tri-Star / VC10 plus any aircraft it mates with”.

The "mated system," does this relate to the 2 aircraft types when AAR taking place or is it the modified systems within each airframe type?
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Old 25th May 2008, 15:16
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The MoD said it would not comment, but in a statement, Air Marshal Sir Barry Thornton, the RAF's most senior engineer, said: "We have stopped air-to-air refuelling and no longer use the very hot air systems in flight.

"This eradicates any dangers from the serious design failures noted by the coroner that have been present in this aircraft since the 1980s.

"These measures have been supplemented with enhanced aircraft maintenance and inspection procedures to ensure the aircraft, as it is today, is safe to fly."
He added: "We would not ask our personnel to fly in aircraft we did not believe were safe."
Can anyone confirm or deny the suggestion that Air Marshal Sir Barry Thornton was in fact the first head of the Nimrod IPT?

If correct he clearly has a slight conflict of interest in this situation as it could be argued that he forms a long line of senior RAF staff that missed the serious design flaw within the Nimrod!
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Old 25th May 2008, 15:26
  #736 (permalink)  

 
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Mick and The Old Fat One

Before we leave the APU issue altogether, I've consulted my notes of the coroner's words on Friday. I find that, even if some ex Nimrod crew don't seem to be able to remember how it all worked, the coroner was perfectly clear.

He said that No 3 engine was started using the APU in the tail, which provided air via 4-way ducts to the engine's air-start mechanism. The APU was then shut down, and No 4 engine started using another air connection from the No 3 engine. I and 2 were then started using air from 3 via the crossfeed duct.

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Old 25th May 2008, 15:26
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AM Thornton

DaForce

AM Thornton was first IPTL for the Nimrod MRA4 in DPA under "Smart" (sic) Procurement. See biog at http://192.5.30.122/ptc/index.html.
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Old 25th May 2008, 15:34
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Thank you Softie (I understood it was MR2 IPT but I was mistaken).

His wife is a barrister, interesting!
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Old 25th May 2008, 15:41
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Re- AM Thornton

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You also see from the biog that he was also DG Equipment Support (Air)/DG Logistics (Strike) from 2003, the 2* with oversight of all IPTs at Wyton.
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Old 25th May 2008, 15:46
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DaForce

It would appear he was the first IPTL of the RMPA/MRA4 IPT, appointed in 1999. Not responsible for in-service Nimrods, but a stakeholder (as the input to his contract was the MR2 fleet) and therefore had a vested interest in (and a requirement to have a finger on the pulse of) the airworthiness of the aircraft his team had to modify. Put another way, he would have a Service Level Agreement in place between his IPT and the Support IPT (at Wyton) whereby the latter agreed to provide xx serviceable and airworthy aircraft at yy build standard, and would have staff to continually monitor this at it would almost certainly be one of his top risks. (As the agreed build standard would be enshrined in his contract with BAeS, and any deviation would mean programme slippage and extra cost). I believe this to accurate but please correct me anyone if I'm wrong.

I should add that, at the time, it was a standing risk in any such modification programme that you would be poorly served by such SLAs as senior management in DPA did not enforce them. That is, DLO (and AML and AMSO before them) could, and often did, ignore them, leaving DPA in the clag. As I said, DPA management were entirely comfortable with this - a prime example of the "lack of management oversight" they were accused of on the Chinook Mk3 debacle (same 2 Star BTW). This was one of the many drawbacks when support was split from MoD(PE) as dependencies increased over which the PM had no control. This has been corrected (again) by the formation of DE&S and the creation (again) of a single Nimrod office. See here for a wider discussion of the problems;

http://www.publications.parliament.u.../300/30005.htm



Mary - "mated" in the context of the two aircraft, although the principle applies equally to AAR modification integrated into the aircraft.
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