Nimrod crash in Afghanistan Tech/Info/Discussion (NOT condolences)
Do a Hover - it avoids G
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An issue that I don't think has been raised is properly using the expertise of the men and women on the hangar floor who prepare aircraft for flight.
In my experience these people can often see airworthiness weaknesses in a design or mod but expressing their views upwards in a meaningful way is not easy whether they are in the services or in industry.
I hope that the Foremen, Chiefies and JEngos of this world will in future find it much easier to pass such wisdom upwards. Indeed I would hope that at unit level management sets up procedures to actively encourage such inputs.
In my experience these people can often see airworthiness weaknesses in a design or mod but expressing their views upwards in a meaningful way is not easy whether they are in the services or in industry.
I hope that the Foremen, Chiefies and JEngos of this world will in future find it much easier to pass such wisdom upwards. Indeed I would hope that at unit level management sets up procedures to actively encourage such inputs.
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jOHN fARLEY
MR HADDON-CAVES REPORT page 570:
5. In my view, there are five elements required for building an Engaged Organisation and SafetyCulture:
A Reporting Culture: an organisational climate where people readily report problems, errors and near misses.
A Just Culture: an atmosphere of trust where people are encouraged and even rewarded for providing safety-related information; and it is clear to everyone what is acceptable and unacceptable behaviour.
A Flexible Culture: a culture that can adapt to changing circumstances and demands while maintaining its focus on safety.
A Learning Culture: the willingness and competence to draw the right conclusions from its safety information and the will to implement major safety reforms.
A Questioning Culture:1 It is vital to ask “What if?” and “Why?” questions. Questions are the antidote to assumptions, which so often incubate mistakes.
6. The role of Leadership is critical in Safety Culture.
7. I make appropriate Recommendations with a view to building an Engaged Organisation and Safety Culture for the Future.
I hope you can see he has covered this but it has to be implimented .
MR HADDON-CAVES REPORT page 570:
5. In my view, there are five elements required for building an Engaged Organisation and SafetyCulture:
A Reporting Culture: an organisational climate where people readily report problems, errors and near misses.
A Just Culture: an atmosphere of trust where people are encouraged and even rewarded for providing safety-related information; and it is clear to everyone what is acceptable and unacceptable behaviour.
A Flexible Culture: a culture that can adapt to changing circumstances and demands while maintaining its focus on safety.
A Learning Culture: the willingness and competence to draw the right conclusions from its safety information and the will to implement major safety reforms.
A Questioning Culture:1 It is vital to ask “What if?” and “Why?” questions. Questions are the antidote to assumptions, which so often incubate mistakes.
6. The role of Leadership is critical in Safety Culture.
7. I make appropriate Recommendations with a view to building an Engaged Organisation and Safety Culture for the Future.
I hope you can see he has covered this but it has to be implimented .
Hopefully the report will be compulsory reading for everyone on Staff Course, Command Course or the equivelant. The lessons identified can almost certainly read across to other aspects of the Military, not just those in aviation.
Perhaps we should view this excellent report as the opportunity for the MoD to draw a line under the "leadership" principles of the past few years, and to dismantle the ethos of "advancement via savings/efficiencies/budget cuts whilst increasing output, smiling, and saying that everything is fine".
Now, more than ever, we need officers at the top of the military with moral courage and plainspeaking agendas. We need a new generation of leaders that are genuinely experienced (and professionally qualified) to hold senior posts in the acquisition/airworthiness fields. We need to inculcate and nurture a proper acquisition stream, where those with competance can continue to exploit their knowledge whilst having fulfilling and full careers. We cannot afford the "revolving door" policy (which, ironically, I believe is one reason why IPTs were first established) as it just encourages the "hope it won't happen on my watch" attitude as career-hungry individuals dip in and out of the ECC/DE&S as quickly as possible.
What will this take? A fundmental shift in the tenets of career management policy by manning, the generation of a new specialisation and, yes, more money as so many projects are currently compromised by gapped posts and the dreaded manpower control totals. It will take an admission that things have been done wrong in the past.
I'm all too aware though that the rule of "like promotes like" is in force here, and thus am pessimistic that, this close to an election, anything more than some window-dressing and deckchair re-arranging will actually happen.
Now, more than ever, we need officers at the top of the military with moral courage and plainspeaking agendas. We need a new generation of leaders that are genuinely experienced (and professionally qualified) to hold senior posts in the acquisition/airworthiness fields. We need to inculcate and nurture a proper acquisition stream, where those with competance can continue to exploit their knowledge whilst having fulfilling and full careers. We cannot afford the "revolving door" policy (which, ironically, I believe is one reason why IPTs were first established) as it just encourages the "hope it won't happen on my watch" attitude as career-hungry individuals dip in and out of the ECC/DE&S as quickly as possible.
What will this take? A fundmental shift in the tenets of career management policy by manning, the generation of a new specialisation and, yes, more money as so many projects are currently compromised by gapped posts and the dreaded manpower control totals. It will take an admission that things have been done wrong in the past.
I'm all too aware though that the rule of "like promotes like" is in force here, and thus am pessimistic that, this close to an election, anything more than some window-dressing and deckchair re-arranging will actually happen.
In my recent past life I have helped "bid" support service projects in to the MoD and several times, when bidding for contractors to take over MoD functions, we were asked to explain "who goes to jail" if it all goes wrong, contractor or IPTL? ie who has ultimate responsibility. This expression came from Civil Service concern following the Hatfield rail disaster when the subsequent enquiry could not find anyone to blame. Responsibility for the outcomes that occurred could not be laid at any one person or one organisations door. One of the outcomes of that enquiry was that management & contract structures were supposed to be put in place so that it is clear where the responsibility lies. Plainly that has not been achieved yet but the "Hatfield question" was certainly one that exercised minds within many parts of the wider Civil Service in all sorts of contexts. (sadly perhaps not in this bit of the MoD). Perhaps the "Hatfield question" & now the "Nimrod question" are legacies that will hopefully now be imprinted on every ones mind when they take decisons affecting the lives of others.
Do a Hover - it avoids G
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Tappers Dad
Sure the points are covered in the top level down sense (H-C's role) but that is not quite the same thing as positively enabling (yea encouraging) the wisdom of the people at the bottom of the organisation to be accepted upwards.
I have had a convenor say to me "that is not the fitters job and if they do that they will be victimised by the hangar boss who just wants the thing out of the door"
The real world....
JF
Sure the points are covered in the top level down sense (H-C's role) but that is not quite the same thing as positively enabling (yea encouraging) the wisdom of the people at the bottom of the organisation to be accepted upwards.
I have had a convenor say to me "that is not the fitters job and if they do that they will be victimised by the hangar boss who just wants the thing out of the door"
The real world....
JF
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Helen I agree with your statement fully, if people are not identified in such a wide, well researched nimrod review like this then, the attitude and lack of accountability will prevail, and this culture that has got to change. However we shall have to wait to see if it is implemented and how long it will take.
We can only hope that the review is fully implemented and my husband Steve and the other 13 members of the crew have not died in vain, but have enabled a safety platform to be produced, to make the armed forces safer.
We can only hope that the review is fully implemented and my husband Steve and the other 13 members of the crew have not died in vain, but have enabled a safety platform to be produced, to make the armed forces safer.
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As a civilian who has been reading these posts with interest i'd like to take this opportunity to say to Tappers Dad sir you are a credit to your son and the other crewmembers who lost their lives for your patience and determination in pursueing this against the powers that be.
To all those who lost their lives in XV230 RIP.
To all those who lost their lives in XV230 RIP.
Tappers Dad
Sure the points are covered in the top level down sense (H-C's role) but that is not quite the same thing as positively enabling (yea encouraging) the wisdom of the people at the bottom of the organisation to be accepted upwards.
I have had a convenor say to me "that is not the fitters job and if they do that they will be victimised by the hangar boss who just wants the thing out of the door"
The real world....
JF
Sure the points are covered in the top level down sense (H-C's role) but that is not quite the same thing as positively enabling (yea encouraging) the wisdom of the people at the bottom of the organisation to be accepted upwards.
I have had a convenor say to me "that is not the fitters job and if they do that they will be victimised by the hangar boss who just wants the thing out of the door"
The real world....
JF
John
If I may expand on what Graham has said.
You are correct about the top-down approach. Be assured the precise detail of what you are talking about was conveyed to Mr Haddon-Cave.
Feedback is a mandated obligation of the MoD Safety Management System, without which the Safety Case cannot be said to be robust.
Evidence was provided that senior MoD staffs (2 and 4 Stars) had encouraged an ethos whereby such feedback was frowned upon and openly denigrated. Related to this, evidence was also provided that the formal routes, for example Narrative Fault Reports or Unsatisfactory Feature Reports, had funding withdrawn over a period of years, culminating in an instruction that not even safety tasks were to be undertaken. (The example cited to Mr H-C was smoke in cockpits, causing heavy landings and injuries, with funding to investigate and correct refused by the budget holder, a supplier).
Successive Ministers supported these actions, in writing (although I accept they simply sign what is put in front of them, but Mr H-C rightly condemns this practice).
So, one weakness of the report is that such detail is not included; rather a top level statement is made that regulations have not been followed and funding cut, rather assuming MoD retains the corporate knowledge (a mandated airworthiness component) to understand all the detailed implications. They do not, at least not on the scale to implement this report.
It is almost as if a huge Appendix is missing which fleshes out this detail. I can foresee MoD desperately employing a raft of consultants to work out WTF Mr H-C means! Of course, this may be a deliberate ploy to prove his report accurate!
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Graham,
Well done. You richly deserve that, as all on here (I believe) agree. If you can't find any other reason to stay on, then start posting entries to the caption competition, you are a welcome mess guest any time you feel like dropping in.
Well done also to those other family members who have joined in demanding this review be conducted, and also for 'simply' getting on with life and holding it all together over the last few years. I am positive that this view is shared by everyone on here. I wish you the very best for the future.
I hope all family members take some comfort from this report, which really does, in my view, drag the RAF (and MoD) into the 20th (maybe even the 21st) century after what has been a 19th century approach to date. There is still a feeling prevalent in society that when servicemen lose their lives 'that is what they are paid for' but I hope this report goes some way to changing that stupid attitude.
If the redoubtable Haddon - Cave reads this, then I'll buy you any number of drinks all night long any time you like*, it was a triumph. You have every right to be extremely proud of your efforts.
Dave
* All drinks to be consumed in the Beastie, Mosset, Ramnee or - in extremis - LaichMoray... I have to get to work in the morning.
Well done. You richly deserve that, as all on here (I believe) agree. If you can't find any other reason to stay on, then start posting entries to the caption competition, you are a welcome mess guest any time you feel like dropping in.
Well done also to those other family members who have joined in demanding this review be conducted, and also for 'simply' getting on with life and holding it all together over the last few years. I am positive that this view is shared by everyone on here. I wish you the very best for the future.
I hope all family members take some comfort from this report, which really does, in my view, drag the RAF (and MoD) into the 20th (maybe even the 21st) century after what has been a 19th century approach to date. There is still a feeling prevalent in society that when servicemen lose their lives 'that is what they are paid for' but I hope this report goes some way to changing that stupid attitude.
If the redoubtable Haddon - Cave reads this, then I'll buy you any number of drinks all night long any time you like*, it was a triumph. You have every right to be extremely proud of your efforts.
Dave
* All drinks to be consumed in the Beastie, Mosset, Ramnee or - in extremis - LaichMoray... I have to get to work in the morning.
A Reporting Culture: an organisational climate where people readily report problems, errors and near misses. We do have this, but what is needed is the will of management to actually do something.
A Just Culture: an atmosphere of trust where people are encouraged and even rewarded for providing safety-related information; and it is clear to everyone what is acceptable and unacceptable behaviour. We have this, but management, but rewards are virtually non-existant and the acceptable/unacceptable behaviour is only made clear when things go wrong.
A Flexible Culture: a culture that can adapt to changing circumstances and demands while maintaining its focus on safety. We have this, but the management have not the will, money, empowerment to allow the changes to happen.
A Learning Culture: the willingness and competence to draw the right conclusions from its safety information and the will to implement major safety reforms. Well now we get down to the crux of the matter, as can probably be seen from my responses above.
A Questioning Culture: It is vital to ask “What if?” and “Why?” questions. Questions are the antidote to assumptions, which so often incubate mistakes. We do this, but the management don't answer or do anything about as it will cost in money, schedule, risk of non advancement or in some cases just cause work they do not want or can cope with.
Now the 'we' is most people on the 'shop floor' of most work places, the paragraphs TD quoted from the report are included in most companies code of conduct/ethics policy, but as above the only people who are the ones expected to comply to these policies are the guys on the shop floor and they are hamstrung by all the things that have been highlighted in the report/above and elsewhere in this thread.
The problem is endemic throughout the industry and it is going to to take a lot off money, willpower and commitment from those at the top to sort this out for the future, but with self serving government officials and management it is not going to happen anytime soon in my opinion.
A Just Culture: an atmosphere of trust where people are encouraged and even rewarded for providing safety-related information; and it is clear to everyone what is acceptable and unacceptable behaviour. We have this, but management, but rewards are virtually non-existant and the acceptable/unacceptable behaviour is only made clear when things go wrong.
A Flexible Culture: a culture that can adapt to changing circumstances and demands while maintaining its focus on safety. We have this, but the management have not the will, money, empowerment to allow the changes to happen.
A Learning Culture: the willingness and competence to draw the right conclusions from its safety information and the will to implement major safety reforms. Well now we get down to the crux of the matter, as can probably be seen from my responses above.
A Questioning Culture: It is vital to ask “What if?” and “Why?” questions. Questions are the antidote to assumptions, which so often incubate mistakes. We do this, but the management don't answer or do anything about as it will cost in money, schedule, risk of non advancement or in some cases just cause work they do not want or can cope with.
Now the 'we' is most people on the 'shop floor' of most work places, the paragraphs TD quoted from the report are included in most companies code of conduct/ethics policy, but as above the only people who are the ones expected to comply to these policies are the guys on the shop floor and they are hamstrung by all the things that have been highlighted in the report/above and elsewhere in this thread.
The problem is endemic throughout the industry and it is going to to take a lot off money, willpower and commitment from those at the top to sort this out for the future, but with self serving government officials and management it is not going to happen anytime soon in my opinion.
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andyy / shona - agree totally, accountability is the key.
If I worked in a faceless organisation where there had historically been no accountability then what is the disincentive for me not to think 'oh well if I screw up it doesn't matter'.
This report has changed that, no more hiding in the shadows, you screw up and you will be exposed.
Accountability, it's a wonderful thing for focussing the mind!
As for the 10 named, well it should have been at least 13 (Blair, Brown(G), Ainsworth), if not more. I have not one ounce of sympathy for them, they had the chance to do the right thing, they failed.
I hope they now get as little sleep as I do thinking of my little brother being blown out of the sky over a hostile country in a plane that I wouldn't send my worst enemy up in!
R.I.P Tapper
If I worked in a faceless organisation where there had historically been no accountability then what is the disincentive for me not to think 'oh well if I screw up it doesn't matter'.
This report has changed that, no more hiding in the shadows, you screw up and you will be exposed.
Accountability, it's a wonderful thing for focussing the mind!
As for the 10 named, well it should have been at least 13 (Blair, Brown(G), Ainsworth), if not more. I have not one ounce of sympathy for them, they had the chance to do the right thing, they failed.
I hope they now get as little sleep as I do thinking of my little brother being blown out of the sky over a hostile country in a plane that I wouldn't send my worst enemy up in!
R.I.P Tapper
Do a Hover - it avoids G
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tucumseh
Thanks.
We oiled the wheels where I worked by calling the feedback upwards a "Suggestion Scheme" and handing out small amounts of money for good suggestions.
However for obvious reasons military organisations are not normally geared to having unsolicited comments going up the rank structure. Technical based comments clearly must be an exception and indeed (in my view) should be seen by senior people as welcome advice aimed aimed at saving them from receiving top down criticism following accidents.
John
Thanks.
We oiled the wheels where I worked by calling the feedback upwards a "Suggestion Scheme" and handing out small amounts of money for good suggestions.
However for obvious reasons military organisations are not normally geared to having unsolicited comments going up the rank structure. Technical based comments clearly must be an exception and indeed (in my view) should be seen by senior people as welcome advice aimed aimed at saving them from receiving top down criticism following accidents.
John
John
Yes, the MoD suggestions schemes. MIDAS and then GEMS.
A feature of them was that suggestions to change policy were not allowed.
As it was stated and fully implemented policy to reduce airworthiness funding and knowingly compromise safety (a small part of which was the 20% “savings” General Cowan was slated for introducing), any suggestions to rescind were not even acknowledged. I submitted one such suggestion in 2001 (still got it), citing various audit reports which, if you read them, would remind you of the Haddon-Cave report. No reply. I later spoke directly to the 3 Star. Turned his back on me.
His failure to act was far worse than those named in the report, as he was in a position to change this policy. Those named were not.
Yes, the MoD suggestions schemes. MIDAS and then GEMS.
A feature of them was that suggestions to change policy were not allowed.
As it was stated and fully implemented policy to reduce airworthiness funding and knowingly compromise safety (a small part of which was the 20% “savings” General Cowan was slated for introducing), any suggestions to rescind were not even acknowledged. I submitted one such suggestion in 2001 (still got it), citing various audit reports which, if you read them, would remind you of the Haddon-Cave report. No reply. I later spoke directly to the 3 Star. Turned his back on me.
His failure to act was far worse than those named in the report, as he was in a position to change this policy. Those named were not.
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I've no direct experience of MIDAS, but have benefited personally from GEMS. ISTR one of the difficulties with it was assessing the magnitude of the award, and working out whether the suggestion was part of someone's core role (which effectively made the individual ineligible). GEMS awards were most likely to be made where any work had been done in one's own time, the idea could be proved not to be part of someone's job and easy to assess in terms of benefit.
Thus if a medic came up with an idea to link the switching on of airfield lighting to when the light levels fell to a certain level, and she had done some work (in her own time) to research equipment that could automate the process, and that this would save £10,000 per year, she might well get £2,000 and a nice letter from the Stn Cdr for her efforts.
On the other hand, a line technician looking at the implementation of a UOR on an ac and wishing to point out that the system was fundamentally dangerous for whatever reason would not qualify for an award. That's not to say that the suggestion wouldn't merit consideration (or even be implemented), but that was not (if memory serves) what GEMS was intended for.
RIP Q.
STH
Thus if a medic came up with an idea to link the switching on of airfield lighting to when the light levels fell to a certain level, and she had done some work (in her own time) to research equipment that could automate the process, and that this would save £10,000 per year, she might well get £2,000 and a nice letter from the Stn Cdr for her efforts.
On the other hand, a line technician looking at the implementation of a UOR on an ac and wishing to point out that the system was fundamentally dangerous for whatever reason would not qualify for an award. That's not to say that the suggestion wouldn't merit consideration (or even be implemented), but that was not (if memory serves) what GEMS was intended for.
RIP Q.
STH
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Thanks for your words Winco and Shona.
I would also like to add my thanks to all the other people who were acknowledged at the end of the H-C report including Jimmy Jones, Tappers dad and Mike Bell and to all the other family members who, like my father who suggested the tearing down of a nimrod (which was not a MoD initiative as suggested), pushed this report forward. Hopefully things will now, finally, change for the better. That is all that I wanted and means that they didn't die for nothing.
Helen.
I would also like to add my thanks to all the other people who were acknowledged at the end of the H-C report including Jimmy Jones, Tappers dad and Mike Bell and to all the other family members who, like my father who suggested the tearing down of a nimrod (which was not a MoD initiative as suggested), pushed this report forward. Hopefully things will now, finally, change for the better. That is all that I wanted and means that they didn't die for nothing.
Helen.
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Tuc,
Go ahead and name him, Baber has already taken complete responsibility for this disaster. Lord only knows why, for he has surely opened himself up to criminal charges for gross negligence manslaughter? I don't see why he should go down alone, this obliteration of safety culture was cynically manipulated by much higher-ups and resulted in a systemic breakdown of safety standards. A morally bankrupt leadership, that only seemed to care about the rise of one's own career. Difficult to see how that culture is going to change overnight, but you can do us all a favour by naming the guy who turned his back on safety because he didn't think he was accountable (and probably still doesn't)..
Go ahead and name him, Baber has already taken complete responsibility for this disaster. Lord only knows why, for he has surely opened himself up to criminal charges for gross negligence manslaughter? I don't see why he should go down alone, this obliteration of safety culture was cynically manipulated by much higher-ups and resulted in a systemic breakdown of safety standards. A morally bankrupt leadership, that only seemed to care about the rise of one's own career. Difficult to see how that culture is going to change overnight, but you can do us all a favour by naming the guy who turned his back on safety because he didn't think he was accountable (and probably still doesn't)..
Last edited by nigegilb; 30th Oct 2009 at 20:28.
H-C's report was everything everyone on this forum had hoped and prayed for. In the media it has been a one-day wonder. Who will monitor the impact and the implemenation of it's recommendations on the MoD and BWoS etc? How will the necessary sea-change in attitudes be forced through? Will they stick or wither on the vine?
The cynic in me says that should there be (God forbid) a need for a similar inquiry, the Government will be very careful to appoint someone compliant and with very carefully limited terms of reference. Once bitten, twice shy and all that.
The cynic in me says that should there be (God forbid) a need for a similar inquiry, the Government will be very careful to appoint someone compliant and with very carefully limited terms of reference. Once bitten, twice shy and all that.
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After finally getting through the report all i can say is i am amazed how thorough and comprehensive it is. I know colleagues who spoke to H-C are well chuffed he took on board their views. Here is to the future, hoping for big changes on the shop floor.
RIP Finally CXX crew 3
RIP Finally CXX crew 3