Nimrod crash in Afghanistan Tech/Info/Discussion (NOT condolences)
mile and a half, OK so I'm hypocritical, out of touch and pompous in your book. Add to that I'm probably one of the "many arrogant, self-appointed know it alls", as well. As Homer would say: "Yeah? Well what can you do?". I certainly was not querying your professionalism, or for that matter any of your colleagues. I'm sure that the high standards of engineering professionalism in the RAF are as sound as ever. What I was criticising was the professionalism of the comments you made that I quoted. But as you say, I'm an OAP and don't do banter, which seems to be boorishness by a different name to me. You tell Mike Smith that:
Well, guilty again as charged! I feel strongly that "Nimrod issues" are directly related to the "MOD and its failings in the area of Flight Safety". Are we to not comment on the latter because a thread is seemingly about Nimrod, Hercules, Chinook, etc? At least we are agreed about our regard for tucumseh. He has illustrated repeatedly the pattern of cause and effect leading to the parlous state of UK Military Airworthiness. I'm afraid I intend to go on about relieving the MOD of its airworthiness responsibilities. If that is self appointed and arrogant so be it.
the thread has been adopted by a niche group who are using it as a campaign against the MoD and it's failings in the area of flight safety, rather than a discussion of Nimrod issues.
Davejb,
Re your points...
I've raised it a number of times, but there can be a time factor involved in airworthiness (ALARP) assessments. I don't know whether this applies to Nimrod, or any of the QQ recs, but its important to recognise that it could, and furthermore it is not unusual to do so in civil or military airworthiness circles.
The link below takes you to a mandatory civil airworthiness directive. It stems from the TWA800 accident in 1996, and this particular one (there will be lots of others) requires some mandatory changes to A330 & A340 aircraft to reduce the risk of fuel tank explosions, for instance by changing some of the clips used on wiring harnesses etc. This one came into force in 2007, but the A330/A340 aircraft involved must only comply by 2009. They do not need to be grounded in the meantime.
http://ad.easa.europa.eu/ad/2007-0278 *
I think your point 3 is valid - MoD could probably benefit from clarifying the situation and avoiding this speculation.
You can probably see from the above that your point 5 is not necessarily black and white. Note that you wouldn't expect the QinetiQ report to comment on timescales for embodiment - they probably wouldn't have had the complete picture to advise on this, though they could have been consulted since then - this is probably likely.
* I should add that if you have a fear of flying I wouldn't recommend browsing all the ADs on this site. As crimewatch used to say, "don't have nightmares".
Re your points...
I've raised it a number of times, but there can be a time factor involved in airworthiness (ALARP) assessments. I don't know whether this applies to Nimrod, or any of the QQ recs, but its important to recognise that it could, and furthermore it is not unusual to do so in civil or military airworthiness circles.
The link below takes you to a mandatory civil airworthiness directive. It stems from the TWA800 accident in 1996, and this particular one (there will be lots of others) requires some mandatory changes to A330 & A340 aircraft to reduce the risk of fuel tank explosions, for instance by changing some of the clips used on wiring harnesses etc. This one came into force in 2007, but the A330/A340 aircraft involved must only comply by 2009. They do not need to be grounded in the meantime.
http://ad.easa.europa.eu/ad/2007-0278 *
I think your point 3 is valid - MoD could probably benefit from clarifying the situation and avoiding this speculation.
You can probably see from the above that your point 5 is not necessarily black and white. Note that you wouldn't expect the QinetiQ report to comment on timescales for embodiment - they probably wouldn't have had the complete picture to advise on this, though they could have been consulted since then - this is probably likely.
* I should add that if you have a fear of flying I wouldn't recommend browsing all the ADs on this site. As crimewatch used to say, "don't have nightmares".
Last edited by JFZ90; 21st Jun 2008 at 20:56.
The quote was merely edited for brevity, not misrepresentation, maah. But while we comment on the missing part in my post let me make my position clear. I do not criticise the current maintainers, I do criticise the current operators. Let me emphasise by that I mean, in the civil sense, the "AOC" holder, ie the MOD. I am delighted that we find common cause in our wish to have the Operator and the Regulatory Authority to be separate and apart from one another. It seems that we are in violent agreement. Let us stop there and give thanks!
Well said davejb, a pressure check must imply that a pressure guage is used, I forget to mention it in my earlier post but I assumed that a guage must be employed. I am very surprised that they aren't on the Nimrod. If they aren't used I am not surprised that the pipe system is checked by listening for whistles which implies that compressed air is merely blown into the piping system which would not apply any pressure to the seals. They should, ideally be pressurised to 150% of the safe working pressure, if the manufacturers do not recommend this test they may well be afraid that the system cannot meet this test.
I well remember RAF posters in my day quoting "Don't assume, check", and I am guilty of that.
I well remember RAF posters in my day quoting "Don't assume, check", and I am guilty of that.
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I dont think any of the APs call for a pressure check , there is a few guages that are fitted on certain checks but I cant off my heart tell you what systems they are as they require guages to be fitted to overwing points on the tanks (think its jettison but dont quote)
Anyway we are not referring to pressure checks , I thought this was about leak checks. to pressurize a large aircrafts fuel system to 150% above standard operating pressure is not very practicle indeed.
May be prudent to ask others that work on different types how they go about leak checks , you may find people have very similar answers.
Anyway we are not referring to pressure checks , I thought this was about leak checks. to pressurize a large aircrafts fuel system to 150% above standard operating pressure is not very practicle indeed.
May be prudent to ask others that work on different types how they go about leak checks , you may find people have very similar answers.
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JFZ90 -
yes, if there is a caveat to the ALARP requirement that gives a timeframe for carrying out the necessary fixes, then I can see how the aircraft could still be operated "while attaining full airworthiness" so to speak... I'm unaware of any such grace period though, and if one exists then I'd have thought it would have been mentioned by now?
Oldlae - how the plumbing might be done I wouldn't dream of guessing, my 'expertise' amounts to the simple side of it... pressurise the pipe(s) and monitor the pressure, provided the temperature and pipe volume remain constant then so should the pressure. It may be that it would be difficult/impossible to do this in practise, but I would have thought it a more sensible approach than trying to eyeball a tolerance of one degree.
(No aspersions on the groundies there, by the way, who are doubtless working their c***s off with all this).
yes, if there is a caveat to the ALARP requirement that gives a timeframe for carrying out the necessary fixes, then I can see how the aircraft could still be operated "while attaining full airworthiness" so to speak... I'm unaware of any such grace period though, and if one exists then I'd have thought it would have been mentioned by now?
Oldlae - how the plumbing might be done I wouldn't dream of guessing, my 'expertise' amounts to the simple side of it... pressurise the pipe(s) and monitor the pressure, provided the temperature and pipe volume remain constant then so should the pressure. It may be that it would be difficult/impossible to do this in practise, but I would have thought it a more sensible approach than trying to eyeball a tolerance of one degree.
(No aspersions on the groundies there, by the way, who are doubtless working their c***s off with all this).
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I am not so sure we can safely ignore the 6 recommendations concerning AAR, just because AAR is not currently being carried out.
"The important point about the more recent report - the one with the 30 recommendations - is that is it NOT acceptable for the MoD to say "We don't need to address those relating to AAR as it has been stopped".
There is an underlying problem that concerns ALL safety management - that they don't assess both physical and functional safety. If they can ignore this on high profile aircraft, how do they address it on routine work??"
Remember AAR was being carried out until November last year, the reasoning given here that all forms of ignition had been removed therefor it was OK.
"Partly correct, but it’s a valid engineering decision to stop AAR because, as QQ say, nobody fully understands the behaviour of the AAR systems. If you don’t, then how can you sign it off as safe? Only a fool would. Again, a basic process failure.
.......they’re using the argument that it’s never happened before (in that configuration) so won’t happen. This argument is specifically excluded by the regs when assessing risk. As before, invite him to read the March 06 report and see the wider picture. He may then say, on balance of probability I’m happy to fly, but I bet he twitches. And that makes for nervous aircrew whose confidence is eroded. Which is a human factors risk! You’re a pilot – do I make a valid point? This is one reason why aircrew are deliberately isolated to a certain degree – for example, not having direct access to the Hazard Log. It can be alarming. Confidence in the product is vital. Safety doesn’t necessarily improve with the passage of time – it needs human input. And we’ve seen the humans responsible in action. Put another way, if you plotted safety over the last 40 years, you’d see a few peaks and troughs. They would directly correspond to the availability of experience, competence, corporate knowledge and funding. We’ve been in one huge trough for some years now. "
I am afraid I do not share the confidence in engineering practice at Kinloss, in my view the endless practice of cutting costs, civilianisation and contracting out engineering support has caused great damage in the RAF in general.
The full quote from a snippet I posted previously.
"Perhaps the most damning was the FRA statement that they don't inspect holes and threads when they change a wing bolt (holding sections together) because "it's not in the contract". That single line demands deep investigation. It's simply criminal. Did they ask for it to be in the contract? Was it in their bid? Did the IPT remove it or omit it? But, the overarching principle, which should over-ride all these arguments, is "good engineering practice". Worse, if you're removing an aluminium bolt and replacing it with a steel one - itself a howler, explained very clearly by QQ. Think of something simple like the expansion bolts that hold your cylinder head and engine block together in your car. The manufacturer puts a matched set in, made from the same material, at the same torque setting for very good reason. What would happen if you took out half the bolts at random and replaced them with bolts of a dissimilar metal. The "expansion" characteristics change and you'd probably blow a gasket. You wouldn't do it in your car, so why do it in an aircraft in an area where the whole point is to seal fuel tanks. I am quite confident that if I saw this in an aircraft I was repairing, I'd raise an query on the Eng Dept, at least; and they'd raise a MF765 (UFR) on the IPT. perhasp it WAS spotted and concern raised? perhaps the plethora of organisations now at Kinloss obscured the boundaries of responsibility (although everyone concerned has a duty to report such things). I feel there is an element of blindly following the Tech Pubs, which we already know are out of date. As someone who has managed a number of workshops, I know this is the practical difference you find between fitters/technicians. Some are head down and don't say a word, read the book, do what it says. If you ask them if they doing what they were taught as apprentices, they'll smile and say "No, but not my problem". Many haven't a clue what they are repairing actually does or how it works in a system. They don't understand context and don't want to. Others actually pay attention to what they're doing and try to understand the processes before and after what they are doing. I suspect the problem is FRA, not RAF, if only because of commercial pressures to hit deadlines and make profit."
"The important point about the more recent report - the one with the 30 recommendations - is that is it NOT acceptable for the MoD to say "We don't need to address those relating to AAR as it has been stopped".
There is an underlying problem that concerns ALL safety management - that they don't assess both physical and functional safety. If they can ignore this on high profile aircraft, how do they address it on routine work??"
Remember AAR was being carried out until November last year, the reasoning given here that all forms of ignition had been removed therefor it was OK.
"Partly correct, but it’s a valid engineering decision to stop AAR because, as QQ say, nobody fully understands the behaviour of the AAR systems. If you don’t, then how can you sign it off as safe? Only a fool would. Again, a basic process failure.
.......they’re using the argument that it’s never happened before (in that configuration) so won’t happen. This argument is specifically excluded by the regs when assessing risk. As before, invite him to read the March 06 report and see the wider picture. He may then say, on balance of probability I’m happy to fly, but I bet he twitches. And that makes for nervous aircrew whose confidence is eroded. Which is a human factors risk! You’re a pilot – do I make a valid point? This is one reason why aircrew are deliberately isolated to a certain degree – for example, not having direct access to the Hazard Log. It can be alarming. Confidence in the product is vital. Safety doesn’t necessarily improve with the passage of time – it needs human input. And we’ve seen the humans responsible in action. Put another way, if you plotted safety over the last 40 years, you’d see a few peaks and troughs. They would directly correspond to the availability of experience, competence, corporate knowledge and funding. We’ve been in one huge trough for some years now. "
I am afraid I do not share the confidence in engineering practice at Kinloss, in my view the endless practice of cutting costs, civilianisation and contracting out engineering support has caused great damage in the RAF in general.
The full quote from a snippet I posted previously.
"Perhaps the most damning was the FRA statement that they don't inspect holes and threads when they change a wing bolt (holding sections together) because "it's not in the contract". That single line demands deep investigation. It's simply criminal. Did they ask for it to be in the contract? Was it in their bid? Did the IPT remove it or omit it? But, the overarching principle, which should over-ride all these arguments, is "good engineering practice". Worse, if you're removing an aluminium bolt and replacing it with a steel one - itself a howler, explained very clearly by QQ. Think of something simple like the expansion bolts that hold your cylinder head and engine block together in your car. The manufacturer puts a matched set in, made from the same material, at the same torque setting for very good reason. What would happen if you took out half the bolts at random and replaced them with bolts of a dissimilar metal. The "expansion" characteristics change and you'd probably blow a gasket. You wouldn't do it in your car, so why do it in an aircraft in an area where the whole point is to seal fuel tanks. I am quite confident that if I saw this in an aircraft I was repairing, I'd raise an query on the Eng Dept, at least; and they'd raise a MF765 (UFR) on the IPT. perhasp it WAS spotted and concern raised? perhaps the plethora of organisations now at Kinloss obscured the boundaries of responsibility (although everyone concerned has a duty to report such things). I feel there is an element of blindly following the Tech Pubs, which we already know are out of date. As someone who has managed a number of workshops, I know this is the practical difference you find between fitters/technicians. Some are head down and don't say a word, read the book, do what it says. If you ask them if they doing what they were taught as apprentices, they'll smile and say "No, but not my problem". Many haven't a clue what they are repairing actually does or how it works in a system. They don't understand context and don't want to. Others actually pay attention to what they're doing and try to understand the processes before and after what they are doing. I suspect the problem is FRA, not RAF, if only because of commercial pressures to hit deadlines and make profit."
Last edited by nigegilb; 22nd Jun 2008 at 10:42.
Nige - to be honest I don't really follow what point your post is trying to make - who are you qouting? Whats this stuff about alu bolts and steel bolts, have I missed something? Are you saying mistakes have been made fitting incorrect parts during maintenance?
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Nigegilb I think you have hit the nail on the head.
The RAF is trying to run itself like a business and is sadly failing miserably. Constant cost cutting is taking its toll and contracturalisation of many parts of core RAF servicing is showing itself to be the wrong way to go.
I would say something in the defense of the technicians though by giving you a two wee stories I have been involved in on Nimrods whilst on Operational deployment in the Gulf.
Firstly:
A bolt holding a hot air clamp on the SCP ducting was sheared when removed due to corrosion wastage of the threads (a common problem on Nimrod). As there were no stock I informed the Engineering Officer who will remain nameless (he came from second line for a stint OOA to give the other EngOs a break).
He then disappeared for an hour and came back with a similar shape and size of bolt and said 'fit this'. I inspected said bolt and said point blank 'NO' as it was not of original spec and was in-fact a bolt that was used on ground equipment. He proceeded to 'order' me to fit the bolt to which I said 'charge me for disobeying an order. I am not putting my signature or sending an aircraft flying with that fitted as that bolt is not fit to be fitted to an aircraft and I am advising you not to do so'.
He then proceeded to go out himself and fit said bolt against my and sign off an ADF for that bolt.
Secondly:
A UTI came out to check a fuel pipe in the no7 dry bay going into 7 tanks. I informed Engops that due to the nature of the UTI I would carry it out at the next landing (it was flying at the time).
Upon inspection one side failed and I informed Eng Ops of the failure and that the jet was grounded until it was fixed.
I was then confronted by an non-Nimrod Engo from the base and told in no uncertain terms to ignore the UTI as it had a window of 28 days to be carried out (this in itself was wrong as a UTI only has 7 days validity) and I was to ignore the fact that the pipe was leaking until then!!!!!!!!!!!
I then told him to quote '**** off' un-quote. He took offense at this naturally and contacted the Nimdet XO who also told him the same.
Now if this is the kind of engineering officers we are getting who obviously doesn't have a clue and over-rides someone of immensely more knowledge and experience than him.
Now imagine what it is like being at Kinloss and having worse than this directed to NLS engineering personnel from upon high with supposed superior engineering knowledge than OC Eng and Sengo.
This is the reason why I left ISK and why I have put my papers in and am on my way out.
The lunatics are in charge of the asylum.
The RAF is trying to run itself like a business and is sadly failing miserably. Constant cost cutting is taking its toll and contracturalisation of many parts of core RAF servicing is showing itself to be the wrong way to go.
I would say something in the defense of the technicians though by giving you a two wee stories I have been involved in on Nimrods whilst on Operational deployment in the Gulf.
Firstly:
A bolt holding a hot air clamp on the SCP ducting was sheared when removed due to corrosion wastage of the threads (a common problem on Nimrod). As there were no stock I informed the Engineering Officer who will remain nameless (he came from second line for a stint OOA to give the other EngOs a break).
He then disappeared for an hour and came back with a similar shape and size of bolt and said 'fit this'. I inspected said bolt and said point blank 'NO' as it was not of original spec and was in-fact a bolt that was used on ground equipment. He proceeded to 'order' me to fit the bolt to which I said 'charge me for disobeying an order. I am not putting my signature or sending an aircraft flying with that fitted as that bolt is not fit to be fitted to an aircraft and I am advising you not to do so'.
He then proceeded to go out himself and fit said bolt against my and sign off an ADF for that bolt.
Secondly:
A UTI came out to check a fuel pipe in the no7 dry bay going into 7 tanks. I informed Engops that due to the nature of the UTI I would carry it out at the next landing (it was flying at the time).
Upon inspection one side failed and I informed Eng Ops of the failure and that the jet was grounded until it was fixed.
I was then confronted by an non-Nimrod Engo from the base and told in no uncertain terms to ignore the UTI as it had a window of 28 days to be carried out (this in itself was wrong as a UTI only has 7 days validity) and I was to ignore the fact that the pipe was leaking until then!!!!!!!!!!!
I then told him to quote '**** off' un-quote. He took offense at this naturally and contacted the Nimdet XO who also told him the same.
Now if this is the kind of engineering officers we are getting who obviously doesn't have a clue and over-rides someone of immensely more knowledge and experience than him.
Now imagine what it is like being at Kinloss and having worse than this directed to NLS engineering personnel from upon high with supposed superior engineering knowledge than OC Eng and Sengo.
This is the reason why I left ISK and why I have put my papers in and am on my way out.
The lunatics are in charge of the asylum.
Last edited by MightyHunter AGE; 22nd Jun 2008 at 17:27.
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Nige,
I'm similarly confused (to a point)...for the Kinloss engineering side I believe the general trend has been to acknowledge that the lineys are doing their best, but for a long time now thw workload has been increasing, whilst the manpower and experience are decreasing - it's an acknowledgement that whilst this inevitably leads to a reduction in service (so to speak) it's not something the groundcrew have control over. The steel v ally bolt stuff - not familiar with the story at all, but if it - and other similar bodges - occurred then clearly the experience level was insufficient for the job...I and others are simply blaming those on high who make the decisions on manning rather than the poor devils who do ever more with ever less, when somebody at the base of the food chain says 'just doing what I'm told' I blame the guy at the top of the chain - what do you expect an SAC to do, when even Harry Staish's are expected to bend over and grin while the bat is inserted?
Have you posted the 30 recs here at all? Perhaps they're buried somewhere in this thread? If the 6 AAR recs are completely fixed by not AARing I don't see the problem, provided it is accepted that AAR will not happen, ie operational need or not.
Dave
I'm similarly confused (to a point)...for the Kinloss engineering side I believe the general trend has been to acknowledge that the lineys are doing their best, but for a long time now thw workload has been increasing, whilst the manpower and experience are decreasing - it's an acknowledgement that whilst this inevitably leads to a reduction in service (so to speak) it's not something the groundcrew have control over. The steel v ally bolt stuff - not familiar with the story at all, but if it - and other similar bodges - occurred then clearly the experience level was insufficient for the job...I and others are simply blaming those on high who make the decisions on manning rather than the poor devils who do ever more with ever less, when somebody at the base of the food chain says 'just doing what I'm told' I blame the guy at the top of the chain - what do you expect an SAC to do, when even Harry Staish's are expected to bend over and grin while the bat is inserted?
Have you posted the 30 recs here at all? Perhaps they're buried somewhere in this thread? If the 6 AAR recs are completely fixed by not AARing I don't see the problem, provided it is accepted that AAR will not happen, ie operational need or not.
Dave
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"The lunatics are in charge of the asylum."
Remember your incident well MHA, and well done you for sticking to your guns.
Sadly mate, your reasons for leaving ring a sad bell with myself. Feel bad about leaving the lads/lasses to carry on grafting, but my mind has been made up since the days following the Tragedy, not an hour goes by without me thinking of that day, and since the inquest, the knowledge that this tragedy could of been avoided, just makes it an extremely bitter pill to swallow. "the lunatics in charge of the asylum" and they know who they are, should be charged with manslaughter.. The Bast**ds.
RIP CXX/3
Take care Bud.
DS
Remember your incident well MHA, and well done you for sticking to your guns.
Sadly mate, your reasons for leaving ring a sad bell with myself. Feel bad about leaving the lads/lasses to carry on grafting, but my mind has been made up since the days following the Tragedy, not an hour goes by without me thinking of that day, and since the inquest, the knowledge that this tragedy could of been avoided, just makes it an extremely bitter pill to swallow. "the lunatics in charge of the asylum" and they know who they are, should be charged with manslaughter.. The Bast**ds.
RIP CXX/3
Take care Bud.
DS
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JFZ90
With regards to "bolts and holes", nigegilb is quoting from a highly critical report produced by QinetiQ in March 2006.
I am afraid that there are so many of these IPT tasked reports that do not filter down to people like yourself.
DV
With regards to "bolts and holes", nigegilb is quoting from a highly critical report produced by QinetiQ in March 2006.
I am afraid that there are so many of these IPT tasked reports that do not filter down to people like yourself.
DV
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Blimey MHA I never knew that story and good on you for sticking to your guns.
There is many stories like that that can be told but I dont think it would be appropriate to tell them here but all Fleets have some scary stories im sure. 100% agree and things like this maybe need to be said for changes to happen, nothing has made a difference so far.
Its just sad when so many good lads are quitting when we really need them people back , Its a ship that has been sinking for so long and I like a few are clinging onto hope that things may change.
To have some more men with good engineering skills would be a good start.
There is many stories like that that can be told but I dont think it would be appropriate to tell them here but all Fleets have some scary stories im sure. 100% agree and things like this maybe need to be said for changes to happen, nothing has made a difference so far.
Its just sad when so many good lads are quitting when we really need them people back , Its a ship that has been sinking for so long and I like a few are clinging onto hope that things may change.
To have some more men with good engineering skills would be a good start.
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Cheers DS keep up the good work!
Keep it Tidy don't even get me started on the Wng Cmdr EngO at Al Udied who told me to send the Nimrod up for an inverted flight for a small piece of plastic (loose article). When I said that Nimrods don't do inverted flight he got shirty and said I was to get the crew to do a 'near rotate' aborted take-off to shake the offending loose article 'loose' to aid recovery.
When I again pointed out that wasn't a good idea as it could cause all sorts of problems he got even shirtier and shouted at me 'What do YOU suggest then Chief?!'. I said 'I suggest you sign the ADF off as the QR640 holder and then go to bed and let me do the engineering he scrawled his name and stormed off.
INVERTED FLIGHT, NEAR ROTATE ABORTS?
An engineering degree does not maketh an engineer......................
Keep it Tidy don't even get me started on the Wng Cmdr EngO at Al Udied who told me to send the Nimrod up for an inverted flight for a small piece of plastic (loose article). When I said that Nimrods don't do inverted flight he got shirty and said I was to get the crew to do a 'near rotate' aborted take-off to shake the offending loose article 'loose' to aid recovery.
When I again pointed out that wasn't a good idea as it could cause all sorts of problems he got even shirtier and shouted at me 'What do YOU suggest then Chief?!'. I said 'I suggest you sign the ADF off as the QR640 holder and then go to bed and let me do the engineering he scrawled his name and stormed off.
INVERTED FLIGHT, NEAR ROTATE ABORTS?
An engineering degree does not maketh an engineer......................
Last edited by MightyHunter AGE; 26th Jun 2008 at 12:21.
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Dodgy S
Not sure how widely known it is, but it was in the remit of the Coroner to consider a verdict of unlawful killing in the case of XV230. It is possible that senior officers could have been named and and action could presumably have followed.
I will leave it to one of the families to fill in the blanks about the possibility of an unlawful killing verdict and what their response was. I can tell you that the MoD allegedly threatened to appeal the unlawful killing verdict, which would have extended the process by another two years.
Again it is only fair for a family member to describe their reaction to an appeal.
I think the families showed remarkable restraint and did not appear to want one or two people to be singled out.
That there was clear evidence of unbelievable lapses in procedure and dire engineering decision making is something that few people would dispute.
The idea of hiving off whole tracts of engineering resource is, for me morally bankrupt. The last major round of redundancies involved hundreds of trained engineers being shown the door.
Again, for me, morally bankrupt in time of war and overstretch.
Very little had been done in the way of implementing QQ recs Hickman had the opportunity to show what work had been done and how much urgency had been applied.
I include the folowing quote for people who are arguing that more time should be given to allow ALARP to be reached.
Needless to say I reject the argument.
"The regs require tolerable and ALARP. The only "out" is "exceptional circumstances" which are usually held to be operational necessity of the highest order - for example a SAR mission which itself is designed to save lives. The ubiquitous Apache rescue is a case in point.
The general principle is that in matters of safety/regulatory compliance one is given a "reasonable period" in which to mitigate the risk after it is identified. Clearly, the impact is assessed and priority is determined by a combination of what is required and operational necessity. In cases of flight safety cost shouldn't really be a factor, but this changed in 1991 when funding was cut, and instructions issued not to even address safety problems (on equipment). that is the period when MoD started losing configuration control big time, and never recovered. What is certain is that, the moment the risk or error is recognised, one kicks off mitigation, if only by phoning the ADA and notifying God (as required by airworthiness letters of delegation). The regs actually permit the DA to immediately commit MoD funding without approval - a unique delegation of authority and the reason why the DA's named representative is approved by MoD. The delegation isn't much, amounting to a few man days work, but is designed to get things moving and give commercial a few days to issue formal contract docs. That is, the regs are implicit that MoD action WILL follow in such cases. The litigation clock runs from identifying the risk and takes into account reasonable period. This is where there is confusion over the evidence. The Air Cdre said they wrongly "graded" the hazard. This can only mean probability of occurrence or severity of harm. But, crucially (and this needs bottomed out) it was later claimed that they were graded correctly and the risk known, but someone wrongly entered in the database that the mitigation (fire suppressant) was installed. Either way there was an error, and the Air Cdre, quite properly, made no attempt to claim exceptional circumstances for the period *BEFORE *the accident.
However, the rules rather assume that all reasonable steps are taken through life to make risks ALARP. The concept of deliberately ignoring risks and hazards isn't even contemplated, or the cumulative effects of such actions - nor would anyone dare include this in the regs. This is where I sympathise, as the Gp Capt clearly inherited a situation not of his own making - and is why I believe IPTL is far too low to be stood up in court to explain MoD's actions. But, he has made a rod for his back by saying he disagrees with the JSP - he has effectively lost the protection of "reasonable period" and "exceptional circumstances" by inferring a deliberate decision to ignore the regs. He could have stated that his responsibility lay *AFTER* the accident (given the above error remained unrecognised) and he was doing something about it. If he had said this, then a higher authority would have to answer the question as to what discussions had taken place on what "reasonable" period he (IPTL) had been given to implement mitigation.
This is were the baseline (clock start) is important to establish. *HIS* baseline may be the post-crash investigation. But *MoD's* baseline is much farther back in time, evidenced by QQ and BAeS reports in the 00s, the VC10 conversions in the 90s and the specs prepared in the 80s. There is ample evidence that the basic problem (poor or incorrect risk assessment and mitigation) was evident long before the crash. I was right to be concerned that MoD would claim "we've identified the problem, we're fixing it". They are being reactive, whereas the book requires them to be proactive."
Not sure how widely known it is, but it was in the remit of the Coroner to consider a verdict of unlawful killing in the case of XV230. It is possible that senior officers could have been named and and action could presumably have followed.
I will leave it to one of the families to fill in the blanks about the possibility of an unlawful killing verdict and what their response was. I can tell you that the MoD allegedly threatened to appeal the unlawful killing verdict, which would have extended the process by another two years.
Again it is only fair for a family member to describe their reaction to an appeal.
I think the families showed remarkable restraint and did not appear to want one or two people to be singled out.
That there was clear evidence of unbelievable lapses in procedure and dire engineering decision making is something that few people would dispute.
The idea of hiving off whole tracts of engineering resource is, for me morally bankrupt. The last major round of redundancies involved hundreds of trained engineers being shown the door.
Again, for me, morally bankrupt in time of war and overstretch.
Very little had been done in the way of implementing QQ recs Hickman had the opportunity to show what work had been done and how much urgency had been applied.
I include the folowing quote for people who are arguing that more time should be given to allow ALARP to be reached.
Needless to say I reject the argument.
"The regs require tolerable and ALARP. The only "out" is "exceptional circumstances" which are usually held to be operational necessity of the highest order - for example a SAR mission which itself is designed to save lives. The ubiquitous Apache rescue is a case in point.
The general principle is that in matters of safety/regulatory compliance one is given a "reasonable period" in which to mitigate the risk after it is identified. Clearly, the impact is assessed and priority is determined by a combination of what is required and operational necessity. In cases of flight safety cost shouldn't really be a factor, but this changed in 1991 when funding was cut, and instructions issued not to even address safety problems (on equipment). that is the period when MoD started losing configuration control big time, and never recovered. What is certain is that, the moment the risk or error is recognised, one kicks off mitigation, if only by phoning the ADA and notifying God (as required by airworthiness letters of delegation). The regs actually permit the DA to immediately commit MoD funding without approval - a unique delegation of authority and the reason why the DA's named representative is approved by MoD. The delegation isn't much, amounting to a few man days work, but is designed to get things moving and give commercial a few days to issue formal contract docs. That is, the regs are implicit that MoD action WILL follow in such cases. The litigation clock runs from identifying the risk and takes into account reasonable period. This is where there is confusion over the evidence. The Air Cdre said they wrongly "graded" the hazard. This can only mean probability of occurrence or severity of harm. But, crucially (and this needs bottomed out) it was later claimed that they were graded correctly and the risk known, but someone wrongly entered in the database that the mitigation (fire suppressant) was installed. Either way there was an error, and the Air Cdre, quite properly, made no attempt to claim exceptional circumstances for the period *BEFORE *the accident.
However, the rules rather assume that all reasonable steps are taken through life to make risks ALARP. The concept of deliberately ignoring risks and hazards isn't even contemplated, or the cumulative effects of such actions - nor would anyone dare include this in the regs. This is where I sympathise, as the Gp Capt clearly inherited a situation not of his own making - and is why I believe IPTL is far too low to be stood up in court to explain MoD's actions. But, he has made a rod for his back by saying he disagrees with the JSP - he has effectively lost the protection of "reasonable period" and "exceptional circumstances" by inferring a deliberate decision to ignore the regs. He could have stated that his responsibility lay *AFTER* the accident (given the above error remained unrecognised) and he was doing something about it. If he had said this, then a higher authority would have to answer the question as to what discussions had taken place on what "reasonable" period he (IPTL) had been given to implement mitigation.
This is were the baseline (clock start) is important to establish. *HIS* baseline may be the post-crash investigation. But *MoD's* baseline is much farther back in time, evidenced by QQ and BAeS reports in the 00s, the VC10 conversions in the 90s and the specs prepared in the 80s. There is ample evidence that the basic problem (poor or incorrect risk assessment and mitigation) was evident long before the crash. I was right to be concerned that MoD would claim "we've identified the problem, we're fixing it". They are being reactive, whereas the book requires them to be proactive."
Last edited by nigegilb; 23rd Jun 2008 at 20:55.
Nige,
Who are you qouting above? Sounds a bit like Tuc, but presented up to seem like its something formal from the inquiry. I assume its not infact formal with phrases like "MoD started losing configuration control big time" included.
There is a risk here that some may mix up the resourcing issues at Kinloss servicing / maintaining the aircraft day to day with the overall control of the aircraft design standard and safety case etc. Whilst there are interactions, some maybe misled into thinking that the recent reduction in engineering knowledge in Kinloss had a bearing on the design error under debate here. Indeed, it should be noted that while the safety case missed the issue only a few years ago, the real mistakes were made 10-20 years ago. Note I'm NOT saying the skills loss is a good thing - it clearly is not a good thing at all - just that be careful not to get the causal analysis of the mistakes wrong.
To be clear, I'm not arguing for more time for ALARP to be met - just that the issue of "time to fix" should be recognised as not an outrageous approach - it is sometimes portrayed here as such.
The TWA800 accident happened in 1996 - current airworthiness directives stemming from that apply to say an Airbus/Boeing aircraft built in e.g. 1999 that have features that are not ALARP with respect to Fuel Tank Explosions are still flying today and have been declared as not needing to comply until 2009. Now I'm sure the risk to the Airbus/Boeing here is tolerable in that period, but technically you'd have to say they are not ALARP under the definitions being touted here that make no allowance for time and seek immediate grounding. The example planes above will have been flying with non ALARP explosion risks with 300+ passengers a day for 10 years - double standards?
Do you think the Airbus/Boeings should be grounded - if so why? If not, then by the same token why should the Nimrod?
Who are you qouting above? Sounds a bit like Tuc, but presented up to seem like its something formal from the inquiry. I assume its not infact formal with phrases like "MoD started losing configuration control big time" included.
There is a risk here that some may mix up the resourcing issues at Kinloss servicing / maintaining the aircraft day to day with the overall control of the aircraft design standard and safety case etc. Whilst there are interactions, some maybe misled into thinking that the recent reduction in engineering knowledge in Kinloss had a bearing on the design error under debate here. Indeed, it should be noted that while the safety case missed the issue only a few years ago, the real mistakes were made 10-20 years ago. Note I'm NOT saying the skills loss is a good thing - it clearly is not a good thing at all - just that be careful not to get the causal analysis of the mistakes wrong.
To be clear, I'm not arguing for more time for ALARP to be met - just that the issue of "time to fix" should be recognised as not an outrageous approach - it is sometimes portrayed here as such.
The TWA800 accident happened in 1996 - current airworthiness directives stemming from that apply to say an Airbus/Boeing aircraft built in e.g. 1999 that have features that are not ALARP with respect to Fuel Tank Explosions are still flying today and have been declared as not needing to comply until 2009. Now I'm sure the risk to the Airbus/Boeing here is tolerable in that period, but technically you'd have to say they are not ALARP under the definitions being touted here that make no allowance for time and seek immediate grounding. The example planes above will have been flying with non ALARP explosion risks with 300+ passengers a day for 10 years - double standards?
Do you think the Airbus/Boeings should be grounded - if so why? If not, then by the same token why should the Nimrod?
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JFZ90, I should make it clear that I have a number of engineering sources each with varying levels of expertise. I sometimes find it easier to quote word for word because I am not an engineer and there is little room on this thread for error.
The whole subject is confusing for contributors interested in what happened to XV230 but not really sure who to believe. The passage in my last post was an informal comment as you quite rightly pointed out. In an effort to understand the situation I have been asking a lot of questions, some people at Kinloss have kindly helped as well.
With regard to TWA800, I can't really comment except to say that design engineers are now approaching the problems of fuel tank explosions in airliners in two very different ways. Witness the incredible amount of engineering that has gone into Airbus A380 and Boeing 787 Dreamliner, two markedly different engineering solutions.
I favour the Boeing approach which is to still provide a version of OBIGGS just in case. It is worth noting that the spec for dry bay protection in Nimrod can be traced back to 1981/2.
I don't buy the idea that Nimrod is safe just because obvious forms of ignition have been removed. There are many remaining issues Angus Robertson has asked for a detailed account of where we are in each of the QQ recs. There is a real need for the MoD to explain where it is right now, otherwise confidence will continue to ebb. One of my aims which I stated a long time ago is that military aircraft are routinely given fuel tank protection. A no brainer. I am deeply saddened that there is still no protection on MRA4.
There are big arguments to be won here, They might have to be won in Court. But when you witness the two fingered approach from Bob Ainsworth in reaction to the Coroner's verdict, and from RAF Chiefs of Staff RE the Nimrod flypast I have little sympathy and little confidence that the MoD is capable of being taken seriously as an airworthiness enforcer.
I will look into TWA 800 recs. I am aware of FAA proposed legislation I am also aware of the very simple fix that is now used on 747 400 to mitigate the threat of centre wing tank explosion. I will post back anything here of note.
With regards to the risk to passengers `I can tell you that I doubt if any airline in the land would fly passengers around in an aircraft deemed non-airworthy. As a result, Bob Ainsworth has placed himself in a very exposed position.
Eventually I believe that all airliners in the States will have fuel tank protection. The modern systems are very light-weight and efficient. There is obviously a balance to reach. And I have some sympathy with the argument that Nimrod is much safer now. That said I have no faith in the implementation of airworthiness regulations. Witness the fact that AAR continued til Nov 2007 long after QQ reports had been posted.
It is important to understand the relationship between, and roles of, the RAF maintainers, FRA and the IPT in the context of Nimrod line servicing. I would welcome a post from someone who understands the relationship. I confess my own knowledge is weak in this area. I do understand that merely placing 2 organizations side by side will not solve anything if there is an inherent lack of skills, experience, training etc.
Edited to add, JFZ90,If you've not looked already, the following might be of interest:
SFAR 88
Airworthiness Notice 55 issued by the CAA and EASA
Google those lines and a lot of information comes up: bottom line (one
of them)is that on modified fuel systems a lot of work / rework needs to
be carried out with regards to reducing risk of fire / explosion. This
is not only on old Aircraft, but also on more modern ac, eg BBJ (based on the B737-700). Operators that do not comply will have to have the Aux fuel system made inoperable.
Part of this mod is to install "dual wall" fuel pipes. At present, it is allowable to shroud a standard rigid pipe with a larger flexible hose type assembly, with a gland drain that can indentify the source of a leak to within a certain distance. The hose will go.
The MRA4 should be built now to Civil Standard, but of course, it does not even have dual wall fuel pipes. It also does not have probe inerting, fuel tank inerting systems, under floor fire protection, bomb bay fire protection, FDA, etc etc. This argument is as much about MRA4 as it is about MR2, but again nothing but deafening silence from MoD...........
The whole subject is confusing for contributors interested in what happened to XV230 but not really sure who to believe. The passage in my last post was an informal comment as you quite rightly pointed out. In an effort to understand the situation I have been asking a lot of questions, some people at Kinloss have kindly helped as well.
With regard to TWA800, I can't really comment except to say that design engineers are now approaching the problems of fuel tank explosions in airliners in two very different ways. Witness the incredible amount of engineering that has gone into Airbus A380 and Boeing 787 Dreamliner, two markedly different engineering solutions.
I favour the Boeing approach which is to still provide a version of OBIGGS just in case. It is worth noting that the spec for dry bay protection in Nimrod can be traced back to 1981/2.
I don't buy the idea that Nimrod is safe just because obvious forms of ignition have been removed. There are many remaining issues Angus Robertson has asked for a detailed account of where we are in each of the QQ recs. There is a real need for the MoD to explain where it is right now, otherwise confidence will continue to ebb. One of my aims which I stated a long time ago is that military aircraft are routinely given fuel tank protection. A no brainer. I am deeply saddened that there is still no protection on MRA4.
There are big arguments to be won here, They might have to be won in Court. But when you witness the two fingered approach from Bob Ainsworth in reaction to the Coroner's verdict, and from RAF Chiefs of Staff RE the Nimrod flypast I have little sympathy and little confidence that the MoD is capable of being taken seriously as an airworthiness enforcer.
I will look into TWA 800 recs. I am aware of FAA proposed legislation I am also aware of the very simple fix that is now used on 747 400 to mitigate the threat of centre wing tank explosion. I will post back anything here of note.
With regards to the risk to passengers `I can tell you that I doubt if any airline in the land would fly passengers around in an aircraft deemed non-airworthy. As a result, Bob Ainsworth has placed himself in a very exposed position.
Eventually I believe that all airliners in the States will have fuel tank protection. The modern systems are very light-weight and efficient. There is obviously a balance to reach. And I have some sympathy with the argument that Nimrod is much safer now. That said I have no faith in the implementation of airworthiness regulations. Witness the fact that AAR continued til Nov 2007 long after QQ reports had been posted.
It is important to understand the relationship between, and roles of, the RAF maintainers, FRA and the IPT in the context of Nimrod line servicing. I would welcome a post from someone who understands the relationship. I confess my own knowledge is weak in this area. I do understand that merely placing 2 organizations side by side will not solve anything if there is an inherent lack of skills, experience, training etc.
Edited to add, JFZ90,If you've not looked already, the following might be of interest:
SFAR 88
Airworthiness Notice 55 issued by the CAA and EASA
Google those lines and a lot of information comes up: bottom line (one
of them)is that on modified fuel systems a lot of work / rework needs to
be carried out with regards to reducing risk of fire / explosion. This
is not only on old Aircraft, but also on more modern ac, eg BBJ (based on the B737-700). Operators that do not comply will have to have the Aux fuel system made inoperable.
Part of this mod is to install "dual wall" fuel pipes. At present, it is allowable to shroud a standard rigid pipe with a larger flexible hose type assembly, with a gland drain that can indentify the source of a leak to within a certain distance. The hose will go.
The MRA4 should be built now to Civil Standard, but of course, it does not even have dual wall fuel pipes. It also does not have probe inerting, fuel tank inerting systems, under floor fire protection, bomb bay fire protection, FDA, etc etc. This argument is as much about MRA4 as it is about MR2, but again nothing but deafening silence from MoD...........
Last edited by nigegilb; 22nd Jun 2008 at 23:52.
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Re post 1137
I have been reading the numerous posts on this thread with interest, but I also feel that anyone who did not hear what was said at the inquest and the statements made (under oath) by those giving evidence must be totally confused, I am, and I was present throughout the three weeks.
May I take up some space to give my understanding of what was said by various people during the inquest:
Firstly, at no stage was there any statement or inference that those servicing XV230 were not being thorough in the way in which they carried out their tasks. It was accepted that the work was being done in accordance with the instructions and procedures laid down in the relevant documents.
On the subject of airworthiness. The MoD requires that for an aircraft to be considered "airworthy" the risk to the aircraft and crew must be ALARP.
The MoD employed a competent contractor to undertake a Safety Case for the MR2 which identified several areas where a significant risk was identified and stated that if the risk was realised there was the likelyhood of the aircraft and the crew would be lost. The effect of the risk was graded as "catastrophic", but the likelyhood was downgraded to "undesirable" when the report was received, thus reducing the need for immediate action. Thus the MoD failed to reach their own standard for airworthiness and admitted this in court. The Coroner had no option but to state the aircraft had been unairworthy with the recommendation that they be grounded until they meet the MoD's own standard.
British legislation requires every employer to provide SFARP a "package of work" that is safe. To achieve this every employer is required undertake a risk assessment of his undertaking to identify risk and determine what remedial measures need to be put in place. This is the reason for carrying out a safety case on complex operations. Where the necessary expertise is not available "in house" then the employer is required to engage "competent" assistance. When the IPTL was asked if he was aware of the employers responsibilities in this respect he said he was not.
It was acknowledged that the BOI had done a thorough and professional job and they were thanked by the coroner for this, this was echoed by the counsel for the families.
My own feelings are mixed following the inquest. I feel a certain loyalty towards the RAF having served for many years, as did my surviving son, but I feel the crew of XV230 were let down, not at station level but by the MoD and those who make policy and control funding. To take an ageing design and keep asking it to carry out different tasks which in turn requires more equipment to be installed is short sighted. The MR2 is after all a development of the Comet IVc design, but they are as dissimilar as chalk and cheese.
The decision to downgrade the findings of the case study made by a competent contractor, presumably for financial reasons, was in my view nothing short of criminal.
With the suspension of AAR and the taking out of use of the SCP it is likely that the MR2 is now ALARP and therefore airworthy.
Sorry for the length of this, I promise not to write any more on this thread!
I have been reading the numerous posts on this thread with interest, but I also feel that anyone who did not hear what was said at the inquest and the statements made (under oath) by those giving evidence must be totally confused, I am, and I was present throughout the three weeks.
May I take up some space to give my understanding of what was said by various people during the inquest:
Firstly, at no stage was there any statement or inference that those servicing XV230 were not being thorough in the way in which they carried out their tasks. It was accepted that the work was being done in accordance with the instructions and procedures laid down in the relevant documents.
On the subject of airworthiness. The MoD requires that for an aircraft to be considered "airworthy" the risk to the aircraft and crew must be ALARP.
The MoD employed a competent contractor to undertake a Safety Case for the MR2 which identified several areas where a significant risk was identified and stated that if the risk was realised there was the likelyhood of the aircraft and the crew would be lost. The effect of the risk was graded as "catastrophic", but the likelyhood was downgraded to "undesirable" when the report was received, thus reducing the need for immediate action. Thus the MoD failed to reach their own standard for airworthiness and admitted this in court. The Coroner had no option but to state the aircraft had been unairworthy with the recommendation that they be grounded until they meet the MoD's own standard.
British legislation requires every employer to provide SFARP a "package of work" that is safe. To achieve this every employer is required undertake a risk assessment of his undertaking to identify risk and determine what remedial measures need to be put in place. This is the reason for carrying out a safety case on complex operations. Where the necessary expertise is not available "in house" then the employer is required to engage "competent" assistance. When the IPTL was asked if he was aware of the employers responsibilities in this respect he said he was not.
It was acknowledged that the BOI had done a thorough and professional job and they were thanked by the coroner for this, this was echoed by the counsel for the families.
My own feelings are mixed following the inquest. I feel a certain loyalty towards the RAF having served for many years, as did my surviving son, but I feel the crew of XV230 were let down, not at station level but by the MoD and those who make policy and control funding. To take an ageing design and keep asking it to carry out different tasks which in turn requires more equipment to be installed is short sighted. The MR2 is after all a development of the Comet IVc design, but they are as dissimilar as chalk and cheese.
The decision to downgrade the findings of the case study made by a competent contractor, presumably for financial reasons, was in my view nothing short of criminal.
With the suspension of AAR and the taking out of use of the SCP it is likely that the MR2 is now ALARP and therefore airworthy.
Sorry for the length of this, I promise not to write any more on this thread!
Last edited by Papa Whisky Alpha; 22nd Jun 2008 at 23:34. Reason: additional line crept in
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PWA, you said,
I am afraid this is not the case. These restrictions were already in place when the coroner gave his verdict, and when Gp Capt Hickman confirmed that the aircraft was not ALARP.
DV
With the suspension of AAR and taking out of use the SCP it's likely that the MK2 is now ALARP and is therefore airworthy
DV
Last edited by Distant Voice; 23rd Jun 2008 at 07:31.