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

[tucumseh]

The MAA's first tranche of new regs can be found here:

Ministry of Defence | About Defence | Corporate Publications | Air Safety and Aviation Publications | Military Aviation Authority

Lots to read...

I've read a few selected documents. Absolutely gobsmacked that, for example, they got the definition of the process that maintains the Safety Case 100% wrong, not even mentioning "Safety Case". As that was the headline failure noted by Haddon-Cave, you'd think they'd make the effort to get that one right. They compound matters by omitting the safety net whereby the necessary funding is (was) ring-fenced; but now it can just be used by anyone at the expense of safety (again, as reported by Haddon-Cave). That is like leaving Orville and Wilbur out of the history of aviation. I just gave up.

[Chugalug2]

tucumseh:

I just gave up.

So should the MAA as presently constituted. It makes the Press Complaints Commission look like a powerfully effective and objective enforcer of journalistic principle by comparison. Both are of course part of the beloved British love affair with Self-Regulation. Both are useless. The latter merely ruining peoples lives by its ineffectiveness, the former costing them.
It seem likely that the PCC is destined for the big news room in the Sky (no pun intended, though it is rather good, all things considered, wouldn't you say?). Time that the MAA was similarly sent off to its regulatory Valhalla and a truly independent one, entirely separate from the MOD, put in its place, together also with an independent MAAIB.

[Squidlord]

EAP86:

The MAA's first tranche of new regs can be found here:

Ministry of Defence | About Defence | Corporate Publications | Air Safety and Aviation Publications | Military Aviation Authority

If folks are interested to take a look, the risk management Regulatory Instruction that was discussed here

http://www.pprune.org/military-aircr...-set-up-3.html

is essentially Regulatory Article 1210 in

http://www.mod.uk/NR/rdonlyres/A85B2...riesPrints.pdf

[ORAC]

Independent: Revealed: The secret report that could have saved 14 lives

Concerns over Nimrod airworthiness dismissed as 'emotive' eight years before fatal 2006 crash

[SirPeterHardingsLovechild]

It's getting interesting. When might we see the actual report?

Even though it duplicates the post, I'm going to put this on the Haddon Cave thread for the sake of the archives.

[Rigga]

Following SPHLC's post on the Airworthiness Thread I thought I'd stick my oar in here ....

Reading these MAA regulations - I can see where "EASA Part 145" is starting to form, but there are still large bits missing - and there is no mention of any aircraft "management" (EASA Part M) in there at all?

I suppose mandating the ownership of "management" accountability and responsibility is not yet the MAA's thing. - Probably not even teething yet?

In this instance I credit Groupies and Sengo's as line co-ordinators and not 'Managers' - At this level, Managers hold the REAL Purse Strings and are not just given some annual dosh to worry about and stir some local stuff with.

Forgot to mention.....
I hear that three European countries (including France!) have now signed up to the next regulation set to hit MOD - the European Military Airworthiness Regulations (EMAR's)

We'll have to wait and see who's the Boss....

[Nimbus265]

Reading these MAA regulations - I can see where "EASA Part 145" is starting to form, but there are still large bits missing - and there is no mention of any aircraft "management" (EASA Part M) in there at all?

In fact the pilot CAMO scheme being introduced does not even make reference to EASA Part M, which I find rather daft, as Continuing Airworthiness Magement has it roots in EASA Basic Regulation. Perhaps the MOD have a better way

Having said that, if the quality of the Manual of Air Safty is anything to go on, then I shouldn't be that surprised. A 1/3rd of it contains a description of the rest of the MRP, a bit is borrowed from the second edition of the ICAO Safety Manual, and the rest describes the ASMS policies to be inplemented.

It does seem to have been rather cobbled together. As a Manual, it lacks any real "why" or "how" information that you would expect a 'manual' to contain and is is written in such a way that is more in keeping with a reactive safety management system, rather than a proactive or predictive system.

... jumps off of soap box....

[Nimbus265]

I hear that three European countries (including France!) have now signed up to the next regulation set to hit MOD - the European Military Airworthiness Regulations (EMAR's)

The initial issue of EMARS is a more like an abridged version of Part 145, and is focused on Reqts for Maintenance Organisations; ergo a MAOS type scheme.

It is certainly more far more aligned to EASA regulations than to UK MRPs.

[tucumseh]

As a Manual, it lacks any real "why" or "how" information

With respect to the basic requirements of being able to demonstrate airworthiness (i.e. a maintained Build Standard and, hence, Safety Case);


"Why" used to be taught to MoD staff from Day 1. Direct Entrant staff now arrive, apparently fully trained but having skipped 5 grades. That would be ok(ish) if they realised they had skipped 5 grades and were required to retrospectively attain key competencies, but....


"How" was in a procedural Def Stan which was last amended in May 1991 (at AL1) and finally scrapped, without replacement, 2 years ago. The reason it was last amended in 1991 was shortly thereafter AMSO promulgated the policy that airworthiness was no longer to be maintained in accordance with the regulations. Again, that would be ok(ish) if there was a proven replacement process, but there wasn't. The "framework" was simply torn down, with funding chopped 28% in 3 successive years. (CHART specifically mentions the FY1991/92 cut, although says it was 25%).

Hence, Haddon-Cave's 1998 baseline is palpable nonsense.

[EAP86]

EMARs

There was more about this initiative (MAWA) on the EDA's website some time ago but I'm not sure whether its still there; try searching for "MAWA". There are 26 participating Member States involved and have been for some time – the initial moves started in 2008 under an Air Cdre who shall not be named. EMAR 145 was the first one finished probably because it is the simplest to adapt. Its been ratified by several pMS but I'm not sure how many. EMAR 66, 147 and M are also in prep will follow.

Another task force have prepared an EMAR 21 and its getting close to ratification. An EMAR version of MIL HDBK 516 has been started. Lots of the other building blocks are being put together, in fact, allegedly good progress continues to be made despite the numbers of nations involved. Maybe someone who is better informed (MAA?) could say more?

[Distant Voice]

If a closed bomb bay is effectively pressurised by the "injection" of bomb bay heating air, would you expect hot gasses to flow into it, or out of it?

DV

[cornish-stormrider]

depends on the relative pressure from where the hot gases are as to the pressure in the bomb bay.

[Distant Voice]

I am talking about gasses from a fire.

In the case of ruptured hot air pipe on XV227, photographic evidence shows that the gasses from the pipe (located at bottom of dry bay No.7) did not find their way into the bomb bay. As a consequence the bomb bay alarm was not activated. Which tends to suggest that XV230 bomb bay alarm was activated by a fire in the bomb bay, not the dry bay.

DV

[FATTER GATOR]

My friend, I fear you are in danger of wrapping yourself up in an ever decreasing spiral of trying to make information fit whatever it is you want to prove.

Why don't you go public and state here exactly what your hypothesis (plural) are, exactly which people you want to prove are at fault, what punishment you want them to undergo and anything else you want the powers-that-be to do. Justice is a subjective matter, but bear in mind that our armed forces will still need to fly aeroplanes.

Also, try this.
Go and get formal training in Aeronautical Engineering and 'major' in something along the lines of air-accident investigation. Then, with technical credibility established, start from the beginning and see where you end up.

FG

[Distant Voice]

My friend, I fear you are in danger of wrapping yourself up in an ever decreasing spiral of trying to make information fit whatever it is you want to prove.

My concern is that is what the BoI and H-C appear to have done. By the way I did spend several years involved in investigative aeronautical engineering, and in my book, the "Blow-off" and gasses coming into the bomb bay theory does not fit. I can not speak for the experience of the BoI members and H-C in that field.

The photgraphic evidence, not mentioned by BoI or H-C, clearly indicates that in the case of XV227 the hot gasses did not flow from Dry Bay No.7 to the bomb bay, therefore, on the balance of probability it is unlikely to have happened with XV230. The "blow-off" was not seen by the tanker crew, and the theory rejected by the coroner, not just me.

Finally, an Air Incident report, involving AAR of XV260 on 8th Nov 2006, provides the evidence that the tanker crew could see venting and "blow-off" (if they took place). This report gets no mention by the BoI or H-C, probably because it does not fit "what they wanted to prove"

DV

[Chugalug2]

FG:

Go and get formal training in Aeronautical Engineering and 'major' in something along the lines of air-accident investigation.

Wouldn't that advice be better put to the BoI's that have consistently and wantonly failed to identify the systemic failures of the UK Military Airworthiness Authority (aka the MOD) to ensure the airworthiness of UK Military Aircraft?
Would not the first lesson of such formal training be the requirement that all such investigation be separate and independent of the Airworthiness Authority?
Would not the second lesson of such formal training be the requirement that all such investigation be separate of and independent of the Operator?
Would not the third lesson of such formal training be that the MAA is none of these things? That unless and until there be an independent Military Airworthiness Authority and a Military Air Accident Investigation Board, separate from each other and from the MOD, the death toll of avoidable Military Airworthiness Related Air Accidents will simply go on rising?

[JFZ90]

Can you say a bit more about this 'investigative aeronautical engineering' you've been involved in DV?

[Distant Voice]

Dear JFZ 90, happy to do so. Nimrod trials officer at A&AEE Boscombe Down and Nimrod CEDIT.

Now, what are the BoI and H-C's claim to fame, in this area?

DV

[Distant Voice]

H-C and the Missing Information.

What I find difficult to understand is that H-C spends some 174 pages dealing with the Nimrod safety case, and how people like Baber and Eagles failed to recognise the fact that Dry Bay No.7 did not have fire detection and suppression, and yet the abuse of the STF procedure and in particular this witnesses important statement, gets no mention. In fact H-C has the impertinence to state, "The Inquest produced little factual evidence of value to the Review" This statement indicates a clear violation of the Nimrod safety case; unofficial amendments to RTS document, equipment installed on the galley table, circuit breakers being used as switches etc.


THE CORONER: Did you have any problems with Special Trials Fit in the equipment?

SQN LDR ******: To put it in context, I am a qualified trials officers at the General Duties Air Assistance Course in 1992 and then spent three years from 1992 to 1995 at Boscombe Down as a trials officer doing special trials fix on the Comet aircraft, the laboratory aircraft. So I did have a bit of knowledge of the system and how it should be used and I just wanted to sort of point out as part of this that I thought you were abusing it slightly.

THE CORONER: And why would you [think] it was being abused?

SQN LDR ******: From what I remember of my training, the definition of a special trials fit is a fit that has gone onto the aircraft for the duration of the trial which, in exception
circumstances, could be taken into operational use.

THE CORONER: So, your criticism here is that the special trials fits just stay?

SQN LDR ******: Exactly. I mean, yes, my interpretation would be you had an urgent operation requirement, special trials fit onto an aircraft, take it to theatre, get the job done, bring it back, take the equipment off. Whereas, we were doing go to theatre, take it back, onto a different aircraft, that goes out. So, yes, there were ... and there are reasons behind that why I think it is not quite the way to play business.

THE CORONER: And why do you think it is not quite the way.

SQN LDR ******: Okay, one of the reasons I have a degree in electrical and electronic engineering, so to my mind moving cable harnesses regularly is not good practice.

THE CORONER: Why?

SQN LDR ******: Just potential damage.

THE CORONER: To the harnesses?

SQN LDR ******: To the actual cable harnesses when they are moved from one aircraft to stored, moved back to another aircraft.

THE CORONER: So potential damage to the cabling and constant shorting?

SQN LDR ******: Potentially.

THE CORONER: With a fire?

SQN LDR ******: Potentially.

THE CORONER: Potentially, yes.

MALE SPEAKER: Right, you say specifically, and this was the reason I wished to ask you this question, “we will (inaudible) in writing but before the accident there were three circuit breakers we were meant to pull before taking it and we didn’t”. What did you mean by that?

SQN LDR ******: Okay, what had happened was when we first arrived in theatre, the problem is you do not have ready access to this equipment in the UK. So you often arrive out in theatre to an aircraft that has got, in this case I believe it was four or five separate special trials fits fitted to it and that is the first time you have really got, to get to grips with it again. Somebody at Kinross had tried to be helpful when they produced like a local briefing package where they had in the back of the release to service document for each special trials fit they made, sort of make a waiver of, if you are going to do air to air refuelling you need to pull the circuit breaker or not use this particular item.

THE CORONER: Why do you think that was? Why did they say pull those circuit breakers?

SQN LDR ******: Because of the way it is being fitted to the aircraft, it is another safety break, if you like, just in case. Because they had not had the opportunity to fully embody the equipment onto the aircraft and perhaps test it as thoroughly as it should have been.

THE CORONER: So, (inaudible) if the system is switched off during air to air refuel then chances of any problems associated with electrical shorting or failure in that period are removed?

SQN LDR ******: They should be zero.

THE CORONER: Yes.

MALE SPEAKER: What was it about air to air refuelling in particular that meant that the special trials fit had to be switched off during that process?

SQN LDR ******: Well, as if have just explained, it was because of ... when you have not properly embodied something onto the aeroplane, the big issue for us as the operating crew is that the air to air refuelling checks when you have not embodied it will not reflect what you need to do. Until a piece of equipment is serviced embodiment modification that will include changing all the paperwork that goes with it. So as part of your air to air refuelling checks you would have then been told pull this circuit breaker, pull that circuit breaker, do not use that. What had happened was that was not in the formal checklist so crews had ... as I say, somebody had tried to develop a local checklist that had an error in it and as a result of the accident we had a quick look back to make sure we were doing things properly, and that is when we discovered that error.

THE CORONER: Do you think that error might have had anything to do with what happened to this aircraft?

SQN LDR ******: In reality I do not, but at the time I made this statement obviously, you know, it was fresh after the event and –

THE CORONER: So, fresh out of the event, what made the connection in your mind?

SQN LDR ******: Purely because with my background I was aware of how we were using special trails fits and I wondered if the way we had used them might have been significant.

THE CORONER: So it was just in your mind that there might have been some electrical failure that might have been responsible for the ignition of fuel?

SQN LDR ******: Possibly that. The other aspect was were trying to sort of, you know, put ourselves into that crew’s position in terms of the time line as it was described to us. And one of the things post having done your air to air refuelling is obviously putting circuit breakers back in to get this equipment working again, and potentially that might have been significant.

THE CORONER: Potentially, yes, thank you.


The abuse of the STF system is covered in the CHART report (1992), the HEART report (1997) and the NART report (1998), and yet all follow up documents and MoMs appear to have got lost. I strongly recommened that if anyone from the MAA reads Pprune they should demand that these documents be made available to the new organisation. If we do not know where we have gone wrong in the past (or hide the past), how can the future be any better. Perhaps, one day, H-C will explain why this vital evidence was ignored.


DV.

[Chugalug2]

DV:

Perhaps, one day, H-C will explain why this vital evidence was ignored.

Now you are getting to the very nub of the case, for in truth we both know that he will not. Perhaps even more important we both know that the MAA will not take on the MOD as the responsible authority that shaped this farrago as it cannot, no matter how much it declares itself to be independent. Even if that were not so the British desire not to make waves will decide that what is past is past, there's no point crying over spilt milk etc etc. Let's get real, the important thing from now on is to prevent another Mull, Iraq, or Afghanistan, etc, avoidable airworthiness related fatal military air accident. That can only start to happen if there be a truly independent MAA and MAAIB, separated from each other and from the MOD. No doubt there are insurmountable difficulties to doing that, but surmounted they must be, or the needless death toll will simply go on rising inexorably.