Nimrod crash in Afghanistan Tech/Info/Discussion (NOT condolences)
Chapter 21 Para 21.1
"The purpose of the Recommendations in this Chapter is to provide a blueprint to enable the MOD to develop a clear, coherent, comprehensive and comprehensible pan-MOD Military Airworthiness Regime to which everyone in the organisation can subscribe, which adopts elements of the Civil Model where there is self-evident benefit, and which demonstrably addresses Risk to Life without compromising capability, and which drives new attitudes, behaviours and a new Safety Culture. In both peacetime and in military
operations, the military need to operate, in a safe manner, aircraft which are available, capable and safe. An effective Airworthiness Regime which demonstrably assures and ensures this will take several years to
mature. I recognise that implementation will be a major undertaking. The structural, substantive, cultural and behavioural changes required are significant. A sea-change in attitudes will be required. I am confident that
the effort will be worthwhile in terms of Availability, Capability and Risk to Life."
I feel that this could raise the Game to the level of independance of the MAA by using (non-ex military) civil airworthiness surveyors as the regulatory body - This should (if the civil model is adopted properly) give a means of appeal against real or perceived incorrect decisions made by aircraft type IPT's/AOA's.
Unfortunately - that rules me out!
"The purpose of the Recommendations in this Chapter is to provide a blueprint to enable the MOD to develop a clear, coherent, comprehensive and comprehensible pan-MOD Military Airworthiness Regime to which everyone in the organisation can subscribe, which adopts elements of the Civil Model where there is self-evident benefit, and which demonstrably addresses Risk to Life without compromising capability, and which drives new attitudes, behaviours and a new Safety Culture. In both peacetime and in military
operations, the military need to operate, in a safe manner, aircraft which are available, capable and safe. An effective Airworthiness Regime which demonstrably assures and ensures this will take several years to
mature. I recognise that implementation will be a major undertaking. The structural, substantive, cultural and behavioural changes required are significant. A sea-change in attitudes will be required. I am confident that
the effort will be worthwhile in terms of Availability, Capability and Risk to Life."
I feel that this could raise the Game to the level of independance of the MAA by using (non-ex military) civil airworthiness surveyors as the regulatory body - This should (if the civil model is adopted properly) give a means of appeal against real or perceived incorrect decisions made by aircraft type IPT's/AOA's.
Unfortunately - that rules me out!
Chug,
I think you might be encouraged by the fact that MOD is taking H-C seriously and that the degree of independence that H-C recommends is not something that he will have done lightly, especially given that he has not exactly been shy in the naming and shaming game. The key point is the cultural change required to make sure this never happens again. The other factor that will hold MOD to account will be the legal action from the families - this is going to cost MOD millions, and rightly so. This has a level of visibility that is unprecedented; H-C's report is arguably the most comprehensive investigation into the real causes of an accident that this country has conducted and it will be exceedingly difficult for MOD to try to water down his conclusions. I think we need to give it a month or two before condemning any follow-up action as doomed to failure - the Airworthiness empire now has more clout than at any time in recent memory, and there is nothing like the prospect of ending up in clink (as some of those named have been warned is a possibility) to keep people in line.
I think you might be encouraged by the fact that MOD is taking H-C seriously and that the degree of independence that H-C recommends is not something that he will have done lightly, especially given that he has not exactly been shy in the naming and shaming game. The key point is the cultural change required to make sure this never happens again. The other factor that will hold MOD to account will be the legal action from the families - this is going to cost MOD millions, and rightly so. This has a level of visibility that is unprecedented; H-C's report is arguably the most comprehensive investigation into the real causes of an accident that this country has conducted and it will be exceedingly difficult for MOD to try to water down his conclusions. I think we need to give it a month or two before condemning any follow-up action as doomed to failure - the Airworthiness empire now has more clout than at any time in recent memory, and there is nothing like the prospect of ending up in clink (as some of those named have been warned is a possibility) to keep people in line.
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Firstly, from prelim page 6:
because I share that hope.
However,
Should not be underestimated. Despite the 2 years work that Bob A harped on about on C4 news, I think that there is a long way still to go to really start making headway on this. I bet there is more than one aircraft out there with the management hoping it doesn't crash, exposing financially driven risk management. Not that VPF isn't an issue to be considered, but "too difficult" shouldn't be the answer either.
I also don't want to see a draconian "Can't do that because of H&S" attitude either. I was at an airworthiness seminar a few months ago, and one of the speakers (not from the world of military aviation) highlighted the fact that the more successful organisations in his experience (oil being one) were more successful where they had a better understanding, safety culture and management of the risks involved.
sw
DEDICATION
This report is dedicated to
Gary Wayne Andrews
Stephen Beattie
Gerard Martin Bell
Adrian Davies
Oliver Simon Dicketts
Steven Johnson
Benjamin James Knight
Leigh Anthony Mitchelmore
Gareth Rodney Nicholas
John Joseph Langton
Gary Paul Quilliam
Allan James Squires
Steven Swarbrick
Joseph David Windall
and their families and loved ones
in the hope and expectation that lessons will be
learned from their sacrifice.
This report is dedicated to
Gary Wayne Andrews
Stephen Beattie
Gerard Martin Bell
Adrian Davies
Oliver Simon Dicketts
Steven Johnson
Benjamin James Knight
Leigh Anthony Mitchelmore
Gareth Rodney Nicholas
John Joseph Langton
Gary Paul Quilliam
Allan James Squires
Steven Swarbrick
Joseph David Windall
and their families and loved ones
in the hope and expectation that lessons will be
learned from their sacrifice.
because I share that hope.
However,
An effective Airworthiness Regime which demonstrably assures and ensures this will take several years to mature. I recognise that implementation will be a major undertaking. The structural, substantive, cultural and behavioural changes required are significant.
I also don't want to see a draconian "Can't do that because of H&S" attitude either. I was at an airworthiness seminar a few months ago, and one of the speakers (not from the world of military aviation) highlighted the fact that the more successful organisations in his experience (oil being one) were more successful where they had a better understanding, safety culture and management of the risks involved.
sw
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Chug,
I think H-C is talking (really) about an ideal - his description works really well IF you can accept the idea that a subsidiary organisation within a larger whole can be truly independent (ie the boss says what he and his minions think, not what they know their boss wants them to think), therefore you gain the advantages of your truly independent MAA whilst retaining the huge amount of real life operational experience that is still present in the RAF/MoD (although ever more diluted). Integrity is the word, unfortunately it is sometimes seen as being bloody minded and dismissed. On the other hand, sometimes it IS bloody mindedness of course...
Where I tend to agree with you is in the realisation that, in practical terms, nobody will ever really buck the trend when the higher organisation has a different priority. So his idea has merit, but would probably prove susceptible to the Sir Humphreys - on the downside a truly independent MAA will lose a lot of hands on, realtime, sharp end understanding.... which, in the long run, can you afford to lose? (The answer is neither, and it would take a much sharper knife than me to figure out how to achieve that).
Baber - how to put this politely... err, several old mates of mine were on 230, so I appreciate that it's old fashioned but kindly **** off and don't stop to collect the richly unearned pension enroute - and the same goes for every other named individual in that report. Mahy, from what I read, gradually gave up but started out okay - I can understand that, and sympathise to a degree, but the rest should now be drafting resignation letters and applying for self funded posts with Christian Aid in the Yemen.... let's face it, it won't last as long as the alternative, burning in hell, will it?
I could write pages of even more vitriolic stuff, but what's the point? H-C has put it all so much more eloquently more than I can, let's see what happens... oh yeah, sack Ainsworth as well, he's a useless git*.**
Dave
* sorry, but I felt obliged to note down what I'm sure we've all felt for a good while now... bit like shooting fish in a barrel I know, but I just felt compelled to say it...
** Legal disclaimer - re 'Useless Git' is a term of endearment intended solely to imply that the personage so described should not be provided with sharp implements, explosives, corrosives, or poisons due to the possibility of unintentional self harm or other unwarranted side effects resulting from the subjects unfortunately low IQ. On no account should the individual be placed in a position of responsibility, if accidentally ingested seek medical assistance immediately. Product may contain nuts.
I think H-C is talking (really) about an ideal - his description works really well IF you can accept the idea that a subsidiary organisation within a larger whole can be truly independent (ie the boss says what he and his minions think, not what they know their boss wants them to think), therefore you gain the advantages of your truly independent MAA whilst retaining the huge amount of real life operational experience that is still present in the RAF/MoD (although ever more diluted). Integrity is the word, unfortunately it is sometimes seen as being bloody minded and dismissed. On the other hand, sometimes it IS bloody mindedness of course...
Where I tend to agree with you is in the realisation that, in practical terms, nobody will ever really buck the trend when the higher organisation has a different priority. So his idea has merit, but would probably prove susceptible to the Sir Humphreys - on the downside a truly independent MAA will lose a lot of hands on, realtime, sharp end understanding.... which, in the long run, can you afford to lose? (The answer is neither, and it would take a much sharper knife than me to figure out how to achieve that).
Baber - how to put this politely... err, several old mates of mine were on 230, so I appreciate that it's old fashioned but kindly **** off and don't stop to collect the richly unearned pension enroute - and the same goes for every other named individual in that report. Mahy, from what I read, gradually gave up but started out okay - I can understand that, and sympathise to a degree, but the rest should now be drafting resignation letters and applying for self funded posts with Christian Aid in the Yemen.... let's face it, it won't last as long as the alternative, burning in hell, will it?
I could write pages of even more vitriolic stuff, but what's the point? H-C has put it all so much more eloquently more than I can, let's see what happens... oh yeah, sack Ainsworth as well, he's a useless git*.**
Dave
* sorry, but I felt obliged to note down what I'm sure we've all felt for a good while now... bit like shooting fish in a barrel I know, but I just felt compelled to say it...
** Legal disclaimer - re 'Useless Git' is a term of endearment intended solely to imply that the personage so described should not be provided with sharp implements, explosives, corrosives, or poisons due to the possibility of unintentional self harm or other unwarranted side effects resulting from the subjects unfortunately low IQ. On no account should the individual be placed in a position of responsibility, if accidentally ingested seek medical assistance immediately. Product may contain nuts.
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The MOD will respond by Christmas...
Parliament in recess for Christmas and New Year...
New aircraft arrives...
Convenient timing eh?
By the way who was the chancellor when all the cost cutting was being forced upon the MOD?
Parliament in recess for Christmas and New Year...
New aircraft arrives...
Convenient timing eh?
By the way who was the chancellor when all the cost cutting was being forced upon the MOD?
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Praise for Nimrod "Community"
As someone has previously noted, Mr H-C has very eloquently stated much of what has previously been said (and undoubtedly will be said again) on this thread, but I was v. pleased by his inclusion, at para 15.58, of this:
"The fact that the Nimrod fleet has continued to fly successfully
in support of Coalition Forces, in the face of all these challenges, is a tribute to the cool professionalism and dedication of the RAF Nimrod community at RAF Kinloss and RAF Waddington and the strong leadership shown by the Station Commanders and Senior Executives. Both stations have, I know, received particular support over many trying and turbulent months from the three senior officers who have held the position of Air Officer Commanding No. 2 Group" [all individuals were named in the report, but I've omitted them here]
in support of Coalition Forces, in the face of all these challenges, is a tribute to the cool professionalism and dedication of the RAF Nimrod community at RAF Kinloss and RAF Waddington and the strong leadership shown by the Station Commanders and Senior Executives. Both stations have, I know, received particular support over many trying and turbulent months from the three senior officers who have held the position of Air Officer Commanding No. 2 Group" [all individuals were named in the report, but I've omitted them here]
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Of all the named individuals receiving criticism this one sticks in the throat the most....
From: 10 named and shamed over Nimrod crash - Home News, UK - The Independent
Group Captain (now Air Commodore) George Baber
He was the leader of the Ministry of Defence integrated project team (IPT) responsible for a safety review of the RAF's Nimrods that took place between 2001 and 2005.
Mr Haddon-Cave accused Group Capt Baber of a "fundamental failure of leadership" in drawing up the "safety case" into potential dangers in the fleet.
He allowed himself to be distracted by other matters, failed to follow processes he himself introduced and did not take reasonable care in signing off the project, the report said.
Mr Haddon-Cave noted he appeared to have been more interested in "trumpeting" the fact that it was the first safety review of an old aircraft than ensuring its contents were correct.
He wrote: "He failed to give the NSC (Nimrod safety case) the priority it deserved. In doing so, he failed, in truth, to make safety his first priority."
Group Capt Baber has since been promoted and is still serving with the RAF.
He was the leader of the Ministry of Defence integrated project team (IPT) responsible for a safety review of the RAF's Nimrods that took place between 2001 and 2005.
Mr Haddon-Cave accused Group Capt Baber of a "fundamental failure of leadership" in drawing up the "safety case" into potential dangers in the fleet.
He allowed himself to be distracted by other matters, failed to follow processes he himself introduced and did not take reasonable care in signing off the project, the report said.
Mr Haddon-Cave noted he appeared to have been more interested in "trumpeting" the fact that it was the first safety review of an old aircraft than ensuring its contents were correct.
He wrote: "He failed to give the NSC (Nimrod safety case) the priority it deserved. In doing so, he failed, in truth, to make safety his first priority."
Group Capt Baber has since been promoted and is still serving with the RAF.
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Culture
16. The regrettable conduct of some of BAE Systems’ managers suggests that BAE Systems has failed to implement an adequate or effective culture, committed to safety and ethical conduct. The responsibility for this must lie with the leadership of the Company.
17. BAE Systems formalised its UK ethics policy in 2002, setting out five key principles of ethical business conduct: “accountability, integrity, honesty, openness and respect”. In my judgment, all five principles were breached in the present case.
16. The regrettable conduct of some of BAE Systems’ managers suggests that BAE Systems has failed to implement an adequate or effective culture, committed to safety and ethical conduct. The responsibility for this must lie with the leadership of the Company.
17. BAE Systems formalised its UK ethics policy in 2002, setting out five key principles of ethical business conduct: “accountability, integrity, honesty, openness and respect”. In my judgment, all five principles were breached in the present case.
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Just read 10 and 11 and I agree with Zedder.
Nice to see someone who recognises an iceberg as an iceberg and not a frozen water opportunity - well done H-C!
regards
LM
Nice to see someone who recognises an iceberg as an iceberg and not a frozen water opportunity - well done H-C!
regards
LM
Last edited by Gp Capt L Mandrake; 28th Oct 2009 at 21:33.
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The failures of BAE Systems in relation to the Nimrod Safety Case are legion: the project planning
was poor; the personnel involved were insufficiently trained and inexperienced; the general
approach was flawed from the outset, the task was wrongly regarded as essentially a documentary
exercise; there was no sensible priority given to the high risks; there was no continuity of personnel;
there was little operator input; the project management was inadequate; there was insufficient
guidance for staff; the man-hours estimate was inadequate; the task was inadequately resourced;
there was disagreement, confusion, and dissent between those involved as to how to proceed
was poor; the personnel involved were insufficiently trained and inexperienced; the general
approach was flawed from the outset, the task was wrongly regarded as essentially a documentary
exercise; there was no sensible priority given to the high risks; there was no continuity of personnel;
there was little operator input; the project management was inadequate; there was insufficient
guidance for staff; the man-hours estimate was inadequate; the task was inadequately resourced;
there was disagreement, confusion, and dissent between those involved as to how to proceed
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And my personal favourite:
I think that it is fair to say that this is not the only part of the company in such a state. BAE, in my experience, talks a good fight wrt Safety and Process, but when it comes down to it they don't deliver much more than hot air.
In my judgment, BAE Systems is a company in denial. Denial has been the hallmark of BAE Systems’ response,
both to the Nimrod Review and in respect of the XV230 incident itself. Denial of design defects; denial of fault
in respect of the NSC, other than minor errors; denial of mistakes, save with the benefit of ‘hindsight’; denial of
any real responsibility, causal or otherwise. This has been troubling and a cause of real concern for the Review.
both to the Nimrod Review and in respect of the XV230 incident itself. Denial of design defects; denial of fault
in respect of the NSC, other than minor errors; denial of mistakes, save with the benefit of ‘hindsight’; denial of
any real responsibility, causal or otherwise. This has been troubling and a cause of real concern for the Review.
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I was reading Section IV on the airworthiness under DLO/DPA and D&ES. Unbelievable. What a bunch of self-serving incompetent pusillanimous imbeciles - if you are drawing a pension, I hope we withdraw it, and if you've a shred of honour, you'd be writing a letter to HMTQ to remove your names from the list of Commissioned Officers.
Well done C H-C QC for putting faces to the faceless. Bravo!
Shame on those named and on those not named who must have contributed.
RIP to the 14 men of XV230 who were left to contend with the failures, lies and cover-ups of others. I'll be raising a glass to you and your families tonight, and as has already been pointed out by Safeware, may your sacrifice not be in vain.
S41
Well done C H-C QC for putting faces to the faceless. Bravo!
Shame on those named and on those not named who must have contributed.
RIP to the 14 men of XV230 who were left to contend with the failures, lies and cover-ups of others. I'll be raising a glass to you and your families tonight, and as has already been pointed out by Safeware, may your sacrifice not be in vain.
S41
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Whilst BAE SYSTEMS (or BAe as Jon Snow seemed to liek calling them earlier) don't come out across well, isn't it worrying that the company that provides the independent advice to the MoD doesn't even read the reports and just signs them? And even more worrying, (as discussed on another thread - think it was on the flight test forum) who is independent for QQ projects - oh yes themselves.....
I don't know many of the individuals named, but both Malcolm Pledger and George Baber are good men, who have done good things, and I am profoundly uncomfortable at seeing them labelled in this way.
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Does anyone know if the Corporate Manslaughter Act applies in this case? From my reading of the act it may just apply.
http://www.opsi.gov.uk/ACTS/acts2007...0070019_en.pdf
(I highlighted the text in red - Adminblunty)
I hope it does, it might concentrate a few minds in the future.
http://www.opsi.gov.uk/ACTS/acts2007...0070019_en.pdf
4 Military activities
(1) Any duty of care owed by the Ministry of Defence in respect of—
(a) operations within subsection (2),
(b) activities carried on in preparation for, or directly in support of, such
operations, or
(c) training of a hazardous nature, or training carried out in a hazardous
way, which it is considered needs to be carried out, or carried out in
that way, in order to improve or maintain the effectiveness of the armed
forces with respect to such operations,
is not a “relevant duty of care”.
(2) The operations within this subsection are operations, including peacekeeping
operations and operations for dealing with terrorism, civil unrest or serious
public disorder, in the course of which members of the armed forces come
under attack or face the threat of attack or violent resistance.
(3) Any duty of care owed by the Ministry of Defence in respect of activities
carried on by members of the special forces is not a “relevant duty of care”.
(4) In this section “the special forces” means those units of the armed forces the
maintenance of whose capabilities is the responsibility of the Director of
Special Forces or which are for the time being subject to the operational
command of that Director.(a) operations within subsection (2),
(b) activities carried on in preparation for, or directly in support of, such
operations, or
(c) training of a hazardous nature, or training carried out in a hazardous
way, which it is considered needs to be carried out, or carried out in
that way, in order to improve or maintain the effectiveness of the armed
forces with respect to such operations,
is not a “relevant duty of care”.
(2) The operations within this subsection are operations, including peacekeeping
operations and operations for dealing with terrorism, civil unrest or serious
public disorder, in the course of which members of the armed forces come
under attack or face the threat of attack or violent resistance.
(3) Any duty of care owed by the Ministry of Defence in respect of activities
carried on by members of the special forces is not a “relevant duty of care”.
(4) In this section “the special forces” means those units of the armed forces the
maintenance of whose capabilities is the responsibility of the Director of
Special Forces or which are for the time being subject to the operational
(I highlighted the text in red - Adminblunty)
I hope it does, it might concentrate a few minds in the future.
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Still reading through, up to p390 odd right now. To me the most fascinating thing about this report is the sheer depth and breadth of what Mr Haddon-Cave has looked at. He is linking directly decisions made after the SDR in 98,99 on reductions in budgets to the fate of XV230. He names names, and rightly so. Taking those names up to 4 star level.
But what he hasn't done clearly (yet, p390 etc..) has also served it up to the politicians and perm under secs in MoD and Treasury who are responsible for the culture of change change change and savings savings savings. As ACM Pledger states, he was posted into the job and told to get on with it, that doesn't absolve him of his responsibilities as a leader and an officer, but we, as officers, are servants of the state and it is the state (in the form of the politicians) that must take responsibility for the tasks that we are given.
Obviously in the interim the poor buggers in uniform are fighting a couple of wars so that one day Tone can be 'El Presidente' of the New Labour Republic of Europe. I worked in EC in MoD for less than 2 years and the number of eye catching initiatives to save money and restructuring for efficiency made everyone dizzy, we shouldn't be totally surprised (without condoning) that some in the DLO and sister organisations dropped the ball. Often there is just some spilt milk, no harm done just money wasted; horrifically in this case 14 priceless lives were taken away forever unecessarily. The answer is simple - if you want us to fight then fund us properly. If you don't want to fund us because of other budgetry pressures then don't ask us to fight. On the other hand, BAE and QQ have no bloody excuses whatsoever.
But what he hasn't done clearly (yet, p390 etc..) has also served it up to the politicians and perm under secs in MoD and Treasury who are responsible for the culture of change change change and savings savings savings. As ACM Pledger states, he was posted into the job and told to get on with it, that doesn't absolve him of his responsibilities as a leader and an officer, but we, as officers, are servants of the state and it is the state (in the form of the politicians) that must take responsibility for the tasks that we are given.
Obviously in the interim the poor buggers in uniform are fighting a couple of wars so that one day Tone can be 'El Presidente' of the New Labour Republic of Europe. I worked in EC in MoD for less than 2 years and the number of eye catching initiatives to save money and restructuring for efficiency made everyone dizzy, we shouldn't be totally surprised (without condoning) that some in the DLO and sister organisations dropped the ball. Often there is just some spilt milk, no harm done just money wasted; horrifically in this case 14 priceless lives were taken away forever unecessarily. The answer is simple - if you want us to fight then fund us properly. If you don't want to fund us because of other budgetry pressures then don't ask us to fight. On the other hand, BAE and QQ have no bloody excuses whatsoever.
This is all serious stuff, but just to show the MOD etc aren't the only incompetent organisations, the BBC 10 o'clock news had a huge placard below pictures of the 14 who died, which read "DAMMING REPORT" (sic).
Gawd save us
Gawd save us
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Admin blunty:
.
.
.
edited.... However....
... may apply to BAES, but then I'd ask a lawyer.
sw
1 The offence
(1) An organisation to which this section applies is guilty of an offence if the way
in which its activities are managed or organised—
(a) causes a person’s death, and
(b) amounts to a gross breach of a relevant duty of care owed by the
organisation to the deceased.
(1) An organisation to which this section applies is guilty of an offence if the way
in which its activities are managed or organised—
(a) causes a person’s death, and
(b) amounts to a gross breach of a relevant duty of care owed by the
organisation to the deceased.
.
.
4 Military activities
(1) Any duty of care owed by the Ministry of Defence in respect of—
(a) operations within subsection (2),
.....
is not a “relevant duty of care”.
(1) Any duty of care owed by the Ministry of Defence in respect of—
(a) operations within subsection (2),
.....
is not a “relevant duty of care”.
2 Meaning of “relevant duty of care”
(1) A “relevant duty of care”, in relation to an organisation, means any of the
following duties owed by it under the law of negligence—
(a) a duty owed to its employees or to other persons working for the
organisation or performing services for it;
(b) a duty owed as occupier of premises;
(c) a duty owed in connection with—
(i) the supply by the organisation of goods or services (whether for
consideration or not),
(1) A “relevant duty of care”, in relation to an organisation, means any of the
following duties owed by it under the law of negligence—
(a) a duty owed to its employees or to other persons working for the
organisation or performing services for it;
(b) a duty owed as occupier of premises;
(c) a duty owed in connection with—
(i) the supply by the organisation of goods or services (whether for
consideration or not),
sw
Last edited by Safeware; 28th Oct 2009 at 22:47.