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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 27th May 2008, 15:27
  #821 (permalink)  
 
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Instead of discussing discrete issues, try thinking about risk / safety management this way. When we talk about probability of occurrence, we say the chances of an event happening must be at least one in, say, 1000. Fine, analysis of the initial design, coupled with the mandated processes for maintaining this figure, shows one in 1500. Go for it, the risk is “broadly acceptable”.

We have infant failures etc and re-assessment shows 1:1400. OK. Now, consider this scenario. Call it hypothetical if you will (at your own peril);


This bottoms out and stability is achieved, then some clown says “OK, that’s enough; we’re mot monitoring reliability any more – we moving from proactive to reactive”. 1:1250 now.

Then he says, no problems last year, so this year we stop amending tech pubs. 1:1150.

Then, no more obsolescence tasks. 1:1050.

Then, no more single Fault Investigations (MF760s), you must save them up and when you have (x) you raise an omnibus request. 1:950.

Now, no configuration control, you will only address safety tasks. 1 -in-800.

Now, NO SAFETY TASKS. 1:650.


Above funding cuts force Service Users to expand the boundaries of Service Engineered Modifications into complex system design, without access to a maintained build standard, skills, expertise etc. 1:550.

Are you beginning to appreciate the cumulative effect?

But, even worse (because they should know better), MoD(PE) 4 Star “I don’t want experienced engineers”. 1:400

Then, his 2 Star “System integration is optional”. 1:300

Then, “Achieving fitness for purpose is optional – it is ok to pay off a contract knowing the aircraft is unsafe”. 1:200.


Question – At what point did the risk that mandated airworthiness regs were not being implemented properly move from “Broadly Acceptable” to “Tolerable, if ALARP” and then to “Unacceptable”? (And yes, the risk was notified and recognised; there are numerous public domain reports proving this). Was the Senior Officer in charge managing this situation, was he merely monitoring it, or was his head buried up his a##?

Then, tragically;

Tornado/Patriot (BoI - IFF failure warnings not integrated properly)

Sea King ASaC (BoI- Anti-collision light system not fit for purpose)

Hercules (Failure to implement airworthiness regs, as witnessed by post crash agreement to retro-fit ESF).

Nimrod XV230.

MoD, May 2008 - “It’s ok if we’re moving toward ALARP”. Really? WTF did you move away from it in the first place?





RIP each and everyone of you. CBs and knighthoods to the ####wits who oversaw all this. My utmost contempt for those who stood back. Best of luck to those who still serve. The above indicates you need it.
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Old 27th May 2008, 17:00
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We would not ask our personnel to fly in aircraft we did not believe were safe
Air Marshal Sir Barry Thornton, Chief of Materiel (Air),
Bob Ainsworth
Secretary of State for Defence, Des Browne MP

We had the same assurances in the immediate aftermath of the crash, this is what some of the people at the sharp end thought then...

“It’s not a nice place to work just now,” one Nimrod crew member said. “Confidence in both the aircraft and the hierarchy are at an all time low. Ground crew are leaving in droves and a number of aircrew, pilots, engineers and back end [surveillance operators], are jumping ship. More worrying are the six major leaks we have had since the accident and the hurry to resume air-to-air refueling after each one.”
“We've not heard a dicky bird then suddenly the ACC [the then Air Component Commander] in the Gulf wants us airborne and tanker capable again. So, we had a jet air-to-air refueling over Kandahar four days after the accident!! Unbelievable. I can't see how that could ever possibly be considered to be good risk management.”
http://timesonline.typepad.com/mick_...andal_of_.html

Why would anyone believe a word that Ainsworth et al say?
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Old 27th May 2008, 17:06
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Quote.
MoD, May 2008 - “It’s ok if we’re moving toward ALARP”. Really? WTF did you move away from it in the first place?

Never moved away, we were never there, now we're moving toward this 'new' requirement. (One that we should always have had, but we didn't)

No-one mentioned this when it was all accepted into service, including the so-called expert Jimmy Jones.

Deepest sympathy to the families, I knew most of the crew. It was a privilage to serve along side them.

Last edited by andgo; 27th May 2008 at 17:21.
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Old 27th May 2008, 17:17
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tuc, agreed 100% what a mess.

Whats the chances of an event on a post major air test as aposed to an in service aircraft?

How are those odds affected if such major work is carried out by inexperienced, unsupervised or contract labour with questionable type certification and suitable authorisations?

The devils in the small print.
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Old 27th May 2008, 17:24
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Helgar33

Bouy15 is very much in a minority in airing that view. We know we are not running after compensation and as you say, any payout will effect benefits already received and would not equate to the amount of a full working life. No amount of money will ever compensate for our loss, and will never lessen that loss.

Stay strong xx
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Old 27th May 2008, 17:36
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LabQueen SoS Defence has the power to waive the reduction in existing benefit. The widows I have had contact with regarding XV179, signed legal contracts without even knowing why or how they lost loved ones. The legality of signing these contracts without legal advice and whilst grieving will probably not stand up to scrutiny. PM me if you need more detail.

SoS Defence has already agreed to pay compensation, there is no ambulance chasing going on here. In my opinion legal advice should be provided to loved ones caught up in all of this. As it is in Australia. Don't listen to the likes of B15 he is what people call an "oxygen thief" in the military.

You are right to ignore everything Ainsworth says, the ministry of defence did not even allow the families a 30 minute press conference without interfering with a ridiculously pre-emptive assessment of a 3 week process.

Last edited by nigegilb; 27th May 2008 at 22:48.
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Old 27th May 2008, 17:40
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Tuc

SK ASAC anti colls work perfectly well as do the same anti colls on all the other fleets. Total red herring.
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Old 27th May 2008, 18:16
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Tourist

Thank you. I read the BoI report. It clearly states the strobe light installation was not "fit for purpose" and specifically cited Def Stan 00-970 (Design and Airworthiness Requirements), chapter and verse. (The bit about interfering with crews' vision). Which is more than the Nimrod report did. I haven't heard anyone say the members were wrong. I'm not aircrew so can't comment on what the practical effect would be of switching off the lights in darkness, without NVG; which is what was concerning the BoI. My point was that it was one of a series of BoI reports which criticised the implementation of the regs - Nimrod was by no means the first.
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Old 27th May 2008, 18:29
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The lower anti Coll is routinely turned of at low level or in cloud because the reflection of the bright light is distracting to the pilots. To say that it is not fit for purpose because it is a bright flashing light is imbecility. Its job is to be a bright flashing light. It performs in this role admirably. Unfortunately light has this pesky habit of reflecting. You might as well say that the atmosphere is not fit for purpose due to its effect on light.
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Old 27th May 2008, 18:50
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Edited to add, the Sea King BoI made its recommendations in order to improve safety, after a very thorough investigation and after test flights in the Sea King. I find your attitude to BoIs difficult to understand, but frankly, you are entitled to your opinion.

Problems with the HISL were known about before the crash and you are fully aware who fought tooth and nail on this subject. You have also had the BoI reasoning explained to you, with regard to the criticism concerning the turning off of the lower strobe.

You will be horrified to know that R4 are covering this tragic accident in a program to be aired shortly.

I am fully aware of the functions and settings of the Sea King HISL, I agree that IR strobes had nothing to do with this accident, I may have misled you by not explaining my comment.

You state that Nimrod should be flown even if the risk is higher than ideal. Fine, let's just hear some honesty from senior levels of command on this subject.

Last edited by nigegilb; 27th May 2008 at 22:57.
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Old 27th May 2008, 20:22
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Nige,
Stick your drivel up your sanctimonious @rse.
I am a Seaking pilot. Are you? I knew the aircrew. Did you?
It is not an IR strobe as anybody who knew anything about the aircaft would know if they hadn't got all their knowledge about a subject from reading frankly b@llox BOI's and Coroners inquiry's (unairworthy for 30 odd years, what c@ck!)

Drivel is in my opinion what this thread is full of anyway
I don't subscribe to Bouy 15's view that the families of the nimrod crew are after compensation, however, I honestly believe that that whilst their motives are good, their campaign is detrimental to current serving members of the armed forces.

The military must always fight with what it has, not what it would like to have, and our leaders chose to use Nimrod safe or not. It is part of being in the military that your leaders may knowingly send you on missions that you may not return from. Sometimes the mission is important enough to risk the aircraft and crew.
I do not understand why you all seem tobelieve that aircrew should not be subjected to the same risks as the troops on the ground.
Leaders must have the right to make tough decisions involving others lives, and even more importantly must be safe from legal action even if wrong in their decision. Could you imagine winning the second world war if every death caused an inquiry?
A leader who is watching his back will win nothing, and the legal costs of this and numerous other actions will all come out of our small budget.
Everyone involved was in the military. It comes with the territory.
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Old 27th May 2008, 20:22
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....so we need a light that only the good guys can see...

..Speechless one, report level passing!
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Old 27th May 2008, 21:10
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The military must always fight with what it has, not what it would like to have, and our leaders chose to use Nimrod safe or not. It is part of being in the military that your leaders may knowingly send you on missions that you may not return from. Sometimes the mission is important enough to risk the aircraft and crew.
I do not understand why you all seem tobelieve that aircrew should not be subjected to the same risks as the troops on the ground.
Leaders must have the right to make tough decisions involving others lives, and even more importantly must be safe from legal action even if wrong in their decision. Could you imagine winning the second world war if every death caused an inquiry?
A leader who is watching his back will win nothing, and the legal costs of this and numerous other actions will all come out of our small budget.
Everyone involved was in the military. It comes with the territory.
Yes the military do fight with what they have. The military have accomodation which is, in some cases, not fit to live in, they have inadequate kit, they have defective equipment, they have a shortage of man power, they have a lack of funding, they have a lack of resources, they have a government which happily screws them over day after day, watching news reports of brave men and women dying or injured, while they relax in their second home having dinner cooked in their brand new kitchen, all at the expense of the tax payer and at the expense of what could provide the funding required for the forces.

Casualties of war are expected, but generally by enemy fire, not killed by the very equipment which is meant to save lives.

The guys on the ground rely on having eyes in the sky, like the Nimrod but when they are relying on one platform to provide that support and to lose it in such a way, what then? How effective would the support be to those on the ground when their support has to make emergency landings due to technical faults or in this worst case, when it crashes.

We were told after this event that all would be done to prevent this ever happening again, we were told funding would be put in place to prevent this. One week later, the very man who made those promises then announced a further armed forces budget cut. Short promises from this government.

The leaders chose to use Nimrod but those same leaders can't seem to agree on what is safe or not.
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Old 27th May 2008, 21:28
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The reasosn why Assistant deputy coroner for Oxfordshire Andrew Walker told the inquest “The aircraft was never airworthy from the first release to service in 1969." Was because he had in front of him the drawings supplied by BAE Systems of the Nimrod conversion from a Comet and the R1 to Mr2 conversion. In his questioning of the Senior Engineer from BAE Systems the engineer agreed that a section of the cross feed pipe where there were bellows were never lagged and was only inches from a fuel pipe. He also agreed it should have been as it was a fire hazard.

PS;
http://www.manxradio.com/readNEwsItem.aspx?id=20890
The Celtic League is asking the Manx government to restrict the use of Ronaldsway Isle of Man Airport by RAF Nimrod aircraft.
The call comes in the wake of comments by an English coroner investigating the deaths of the crew of a Nimrod, which exploded in mid-air over Afghanistan in September 2006.
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Old 27th May 2008, 22:35
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Tuc

By your estimation then, anyone with more than 300 hundred hours should have been subject to a significant flight safety incident...

Now I'm sure that's not what you mean, but goes a long way towards demonstrating that all statistics can be forced to demonstrate whatever facts or arguments are desired. Or indeed that this sort of safety factoring has little significance to the layman, but a differing albeit confusing significance to engineers.

Interesting to note that the compensation issue has raised a couple of hackles. Then it's suggested by a frequent poster that the MOD should be taken to the cleaners for millions; I'm assuming this money would be used altruistically for implementation of Nimrod safety recommendations?

I don't agree with the tone of Buoy15 and his posts, however I also have difficulty in understanding what the end game is here?

RAF BOI sits over a long period, utilising Nimrod SMEs, civil aviation safety investigators and submits detailed report. This report seemingly widely accepted, but discredited in some quarters as being 'in house'.

MOD admits major safety/system errors. Probably/possibly influenced by impressive campaign orchestrated by relative of deceased.

Sqn Cdr is awarded national recognition, which results in undignified public slanging between relatives of deceased and 'serving' RAF incensed by criticisms of one of their own.

MOD offers compensation to relatives, who don't want any compensation.

Short, non-expert coroners inquiry results in various legal opinion aiming off in different directions?

Coroner states Nimrod has never been airworthy, following three weeks of confusing testimony from various expert and some dubious witnesses with varying degrees of interest in the case.

Ex-RAF types with no obvious interest in the case jump on bandwagon of MOD failings. Feathering own nest for future in politics?

So, following an apology, compensation and an independent inquiry by a MOD appointed QC, what does the barrack room want?

Nimrod grounded?

Corporate manslaughter charges?

More money for families?

More money for Nimrod?

Anyone got a clue?



Also interesting to see the selective ratification of quotations; an emotive quote from a presumably serving Nimrod Sqn mate is taken at face value, demonstrating the MOD approach to be devoid of safety reasoning. This is Daily Mail reporting at the very best.

On a lighter note...

If we ever need to go to war in the Irish Sea, we will have lost a major force multiplier and staging post to Barrow in Furness due to the Manx governments potential ban for Nimrod on Ronaldsway. A UN security council meeting has been convened...
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Old 27th May 2008, 23:04
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Nimrod grounded?

Corporate manslaughter charges?

More money for families?

More money for Nimrod?

Anyone got a clue?
!) I don't want the Nimrod grounded, I do to know all has been done to ensure she is safe, and to ensure those who fly in her are safe.

2) Corporate manslaughter would not achieve anything apart from an attempt at laying blame, that will not bring change anything saftey wise, it would just defer from the fact.

3 and 4) Personally I'd prefer to see the money put into the fleet and into providing better facilities and equipment for the forces. Enough have died through failings and lack of equipment.

While there is a need to understand why this happened I do feel more and more that the lives of those lost are being over looked, almost as an afterthought by some. What I want at the end of all this is to know no more lives will be lost in this way, that means more than anything to me.

I do believe a lot can be learnt from listening to the groundcrew and the aircrew, not just talking to them but listening to them and taking note instead of just discussion with those in ivory towers.
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Old 28th May 2008, 07:47
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Tuc

By your estimation then, anyone with more than 300 hundred hours should have been subject to a significant flight safety incident...


I think you know I was illustrating the concept of cumulative risk, and the figures I chose were deliberately ridiculous such that no-one would think them real.

I wanted to show that a broadly acceptable risk could change in classification through time due to external factors, and simply point out that there must be a management process to identify this and determine when it moves into a higher risk class (Tolerable, if ALARP or Unacceptable).

Everyone talks about the risks/hazards associated with couplings and seal and leaks, which is fine. Perfectly valid. But the actual criticism in the BoI report, which led to Browne accepting liability, is that MoD didn't implement the regs. Failure to implement them MUST have an associated risk (cause and effect). One may start out with good intent, and the probability of occurrence is remote, but the events I listed are very real and, in my opinion, changed the nature of this risk significantly over a long period. That is why the regs require experience and retention of corporate knowledge. If you lack either, a new Risk or Safety Manager coming into the IPT for a 2 year tour (and these roles are very often minor tasks among many others) will think his inheritance is a long term stable position; but in fact he has a very unstable foundation for one of the pillars of airworthiness.

If you mitigate THAT risk, the benefits flow down and automatically help to mitigate other risks.




Best wishes
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Old 28th May 2008, 09:14
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Mod As Self Regulator Of Airworthiness

At the risk of thread creep what is the view of the MOD being both the end user and arbiter of whether its aircraft are airworthy or not.

I am not an expert here but surely in Civvy Street it is not allowed, nor would it be considered good practice, for an airline to set airworthiness standards for its ac. The airworthiness standards are set by the FAA, CAA, JAA or whoever and policed accordingly in a way that seperates the responsibilities between the operator and the enforcer.

It would seem that the MOD has the final say whether an ac, be it Nimrod, Herc, VC10 or whatever (all now getting very, very long-in-the-tooth) is still safe to fly or not. Surely this is a conflict of interest that can't continue. I think that this was also an issue in the RAN Shark 02 BOI where the RAN had run-down spares and support for their Sea King fleet anticipating a withdrawal from service that never happened. Result was old ac, shortage of spares, canibalisation, over-stretch in maintenance departments leading to short-cuts on the job to keep the cabs flying....sounds all too familiar.

Maybe there needs to be an independent body (perhaps QinetiQ) to oversee the airworthiness standards and remove the MOD's conflict of interest before there are more Coroner's inquests. There must be others on PPRuNe who could expand on this thought....it might even be worthy of becoming a new thread.

MB

MB
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Old 28th May 2008, 09:37
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Just in case anyone thinks that Andrew Walker spoke to the wrong people
Here is a list of the witnesses that gave the evidence he based his verdict on.

Redacted for this forum--Coroner's Officer
Redacted for this forum--The medical evidence, causes of death.
Redacted for this forum--Executive Officer, Nimrod Detachment
Redacted for this forum--Engineering Officer
Redacted for this forum--Aircraft Ground Engineer
Redacted for this forum--Propulsion Tradesman
Redacted for this forum--Electrical Tradesman
Redacted for this forum--Armour Tradesman
Redacted for this forum--Airframe Tradesman
Redacted for this forum--Aircraft Ground Engineer
Redacted for this forum--Propulsion Tradesman
Redacted for this forum--Engineering Officer
Redacted for this forum--Air Engineer
Redacted for this forum--AAR Pilot
Redacted for this forum--AAR Air Engineer
Redacted for this forum--Pilot
BAE Witness--Design history of aircraft including the introduction of the engine cross feed pipe
BAE Witness--Hazard analysis following above
BAE Witness--Design and operation of the fuel system including the seals
Qinetic --Combustion Analysis of Nimrod MR2 XV230 Accident
Qinetic--Nimrod Fuel Leak Study (Part)
Qinetic--Nimrod Fuel Leak Study (Part)
Redacted for this forum --Integrated Project Team Leader--Nimrod maintenance policy, including pressure testing of fuel lines, disturbance of seals, the hot air bleed system - Pre the loss of XV230

Redacted for this forum --Integrated Project Team Leader--Nimrod maintenance policy, including pressure testing of fuel lines, disturbance of seals, the hot air bleed system - After the loss of XV230
Eaton Airospace--Designer's Recommendations -The Declaration of Design and Performance issued in 1968
Gp Capt Redacted for this forum --Fuel leak trends (video)
Sqn Ldr Redacted for this forum--Air Engineer
Sqn Ldr Redacted for this forum--OC Nimrod Line Squadron
Wg Cdr Redacted for this forum--OC Logistics Support Wing
Chief Tech SCO Redacted for this forum--Senior Aircraft Ground engineer
Chief Tech Redacted for this forum--SNCO Propulsion
Rolls Royce Engineer-Spey Engines
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Old 28th May 2008, 10:38
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Equiv "Coroner states Nimrod has never been airworthy, following three weeks of confusing testimony from various expert and some dubious witnesses with varying degrees of interest in the case."

Right, would you please state from TD's list who provided confusing testimony and who were the dubious witnesses?

Equiv "Short, non-expert coroners inquiry results in various legal opinion aiming off in different directions? "

Please explain where the legal opinion goes off in different directions.

Did you mean the Coroner was non expert or the Coroner's Inquiry was non expert?
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