2007 Puma Crash, Enquiry and Inquest (Merged)
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Chug me old china, you still haven't got your ducks in a row 
. The RNFSAIC carries out and reports its accident investigations iaw ICAO Annex 13 principles and is independent from the RN Service Inquiry. In effect, the RNFSAIC is a 'fire and regret' missile that goes away and turns over as many stones as it feels are necessary to establish the cause(s) of an accident and then makes appropriate recommendations to prevent re-occurence. The convening authority will receive two reports, one from the SI and one from the RNFSAIC. Whilst the SI is standing, they will advised and guided by a dedicated SI advisor from the RNFSAIC who is a trained Accident Investigator in their own right. Logically, the RNFSAIC investigators will also share their findings with the SI as appropriate and flag up any safety critical issues as soon as they find them. The SI can conclude its work and report whilst the RNFSAIC investigation is still ongoing. The RNFSAIC will then report independently to the convening authority and anybody up, down or sideways who needs to know. Simples 
. The RNFSAIC carries out and reports its accident investigations iaw ICAO Annex 13 principles and is independent from the RN Service Inquiry. In effect, the RNFSAIC is a 'fire and regret' missile that goes away and turns over as many stones as it feels are necessary to establish the cause(s) of an accident and then makes appropriate recommendations to prevent re-occurence. The convening authority will receive two reports, one from the SI and one from the RNFSAIC. Whilst the SI is standing, they will advised and guided by a dedicated SI advisor from the RNFSAIC who is a trained Accident Investigator in their own right. Logically, the RNFSAIC investigators will also share their findings with the SI as appropriate and flag up any safety critical issues as soon as they find them. The SI can conclude its work and report whilst the RNFSAIC investigation is still ongoing. The RNFSAIC will then report independently to the convening authority and anybody up, down or sideways who needs to know. Simples
Zyder, thanks for the heads up on the RN system. Simples for you perhaps, but me and my ducks are more confused than ever! OK, for General read Admiral Melchett. He receives SI report from President who has taken the little chat he had previously to heart, and his finding while cognisant of the advice from RNFSAIC is that the Scruggs BB can indeed continue to fly subject to newly increased operating limits on AUW, speed and manoeuvring. He also has an urgent recommendation from RNFSAIC that the type be grounded wie and a complete rebuild of the tail assembly initiated, as he first suspected would be called for. He is still disinclined to do so. What happens next?
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Chug,
You really won't give up on this but you will just have to accept that in the RN it just would not happen the way you describe it. The SI team leader in ANY SI (aviation or not) is given complete freedom to get on with his SI without interference. Heavens knows the RN has had some good ones to look at - NOTTINGHAM grounding, ENDURANCE flooding, BRAZEN on the rocks etc. The RN interest it to get at the facts and the truth so that all can learn and move on - they are not interested in a fudge.
You really won't give up on this but you will just have to accept that in the RN it just would not happen the way you describe it. The SI team leader in ANY SI (aviation or not) is given complete freedom to get on with his SI without interference. Heavens knows the RN has had some good ones to look at - NOTTINGHAM grounding, ENDURANCE flooding, BRAZEN on the rocks etc. The RN interest it to get at the facts and the truth so that all can learn and move on - they are not interested in a fudge.
Bismark:
Well I'm sure that the RAF (let us keep the AAC on their pedestal for the moment) would say the same thing but events dear boy have proved otherwise in their case I'm afraid. So the essential difference between the two systems are the people within them? Naval officers are moral high-minded Ladies and Gentlemen whereas Royal Air Force ones, particularly in the higher echelons, are not? There was a time when I would have confidently described the RAF Flight Safety system including AI in much the same way that you describe the RN's. You are clearly proud of it, I was similarly proud of the RAF's. Times have changed! At the very least surely it would be wise to take note of the morass that the RAF's Accident Investigation system has sunk into and ensure that the RN and AAC does not follow suit, as well as setting out to salvage the RAF's before it goes down with all hands (to borrow your terminology)? I've said before that we are all essentially in the same backyard and faced with Treasury parsimony. The RN and AAC seem to have made a better fist of protecting their AI process from that than the RAF, so muchos kudos, but where to from here? It is either up or down. I suggest that this is very much a case of divided we all fall, albeit at different rates, and united we stand. A tri-service Accident Investigation Service answerable directly to the SoS for Defence might avoid the career threatening interference of the Services CoC's, and possibly give access to a civilian career path in the same organisation or the AAIB for those wishing to dedicate their lives to such a worthy and fulfilling cause. Or are my ducks now wandering around in drunken stupor?
The RN interest it to get at the facts and the truth so that all can learn and move on - they are not interested in a fudge.
Last edited by Chugalug2; 25th Oct 2009 at 10:43.
I agree with all that is said about RNFSAIC. They have a superb reputation, world wide. As a benchmark, they are ideal, so the suggestion of a Tri-Service organisation based on this model has merit.
But I do think it wrong to suggest they can and do investigate wherever they like to uncover the underlying causes. I think, like BoIs / SIs, they are influenced too much from above, and boundaries set which they shall not cross. In the RAF domain, the classic example is the Mull BoI, which barely touched airworthiness and, indeed, MoD have always admitted it was not in their remit. In other words, they were told not to go there, as it exposed too many embarrassing truths. Independence from higher influence is needed.
If one was to read the BoI and RNFSAIC reports on, for example, the Sea King ASaC collision, written 2 years apart, there are a ludicrous number of contradictions between them (and within). One, the interpretation of a tape recording, was misinterpreted so badly by the BoI (for entirely understandable reasons) that it clearly influenced their recommendations and the tone of the report.
In such cases, would it not be proper for either the BoI to reconvene, even if only to issue a clarifying statement or acknowledgment; or is it for the Convening Authority to reconcile the differences and issue a statement? After all, their common goal is to prevent recurrence. If you don’t get to the root cause(s), then this basic pillar of Safety Management cannot be satisfied. But, there again, in many cases the Convening Authority / Reviewing Officers have too much to hide. Which brings us back to independence.
But I do think it wrong to suggest they can and do investigate wherever they like to uncover the underlying causes. I think, like BoIs / SIs, they are influenced too much from above, and boundaries set which they shall not cross. In the RAF domain, the classic example is the Mull BoI, which barely touched airworthiness and, indeed, MoD have always admitted it was not in their remit. In other words, they were told not to go there, as it exposed too many embarrassing truths. Independence from higher influence is needed.
If one was to read the BoI and RNFSAIC reports on, for example, the Sea King ASaC collision, written 2 years apart, there are a ludicrous number of contradictions between them (and within). One, the interpretation of a tape recording, was misinterpreted so badly by the BoI (for entirely understandable reasons) that it clearly influenced their recommendations and the tone of the report.
In such cases, would it not be proper for either the BoI to reconvene, even if only to issue a clarifying statement or acknowledgment; or is it for the Convening Authority to reconcile the differences and issue a statement? After all, their common goal is to prevent recurrence. If you don’t get to the root cause(s), then this basic pillar of Safety Management cannot be satisfied. But, there again, in many cases the Convening Authority / Reviewing Officers have too much to hide. Which brings us back to independence.
Below the Glidepath - not correcting
let us keep the AAC on their pedestal for the moment
In 30 years of crashes, not a single jot or iota has been done to effect this.
This, however, comes back to Tucumseh's territory rather than the AAC per se. The Support Authority (MoD) and the Design Authority (Yeovil's finest) can never quite find the funding, motivation or time to do any of this, so the Lynx still remains as "Most Imflammable Light Utility Helicopter in its Class." despite numerous BOI recommendations to the contrary.
My point? An effective BOI means doing something about the problem, not just neatly and accurately identifying it.
Two's in:
And point taken TI, which is where the Regulatory Authority comes in or, as you so rightly point out, invariably doesn't in the case of the MOD. That is why I'm prepared to accept as possible that a sufficiently robust inter service arrangement for Air Accident Investigations might be possible, but am adamant in my belief that UK Military Airworthiness Regulatory enforcement must be entirely separate from and independent of the Ministry of Defence. Leaving the operator to voluntarily pick up the tab for such upgrading as you describe is simply asking too much of it whether it be Civil or Military. We know a slogan about all of that, don't we Boys and Girls? Yes, that's right:
Self Regulation does not work and in Aviation it Kills!
My point? An effective BOI means doing something about the problem, not just neatly and accurately identifying it.
Self Regulation does not work and in Aviation it Kills!
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My point? An effective BOI means doing something about the problem, not just neatly and accurately identifying it.
Bismark:
Er, not if it can help it it doesn't! That is why Reviewing Officers such as Messrs Wratten and Day are so useful. They can blissfully ignore a BoI (even one as pliable as the Mull one), come up with their own creative "take" and usefully bury the very idea that the totally dysfunctional Digital Engine Control system or even a history of control jamming in one two or even all three axis might have any bearing whatsoever. As to the "Military Acceptable Risk" aspects of Airworthiness, that would include fuel couplings that leak under pressure, fuel lines routed through bays containing ignition sources, Anti Collision Lights swapped in situ for High Intensity Strobe Lights that can dazzle the pilots in low level haze to the extent that they switch them off, IFF sets with no failure warning and unprotected fuel tanks on a Tactical Transport aircraft? All of these airworthiness deficiencies have occurred in fatal crashes. Where was the "Military" advantage to that? Seems to me there would be a "Military" advantage in breaking up this self serving incestuous arrangement!
the MoD places itself on record as to why it does or does not agree and why it has or has not implemented a change to equipment/regulation
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Anti Collision Lights swapped in situ for High Intensity Strobe Lights that can dazzle the pilots in low level haze to the extent that they switch them off,
Chug,
I seem to recall from an earlier post that the assertion above was false and the act of switching them off was a local one and not widespread practice.
I am also beginning to wonder at your deep persistence i wishing to break up the current system...perhaps you have a vested interest in a new organisation?
Well the assertion is based on the fact that this fit on this particular Mk of Seaking was never properly trialled and tested in accordance with UK Military Airworthiness Regulations, but that HISL's were merely swapped for the old anti-collision lights. As to "local", I assume you mean those units alone that operated that particular Mk. If so, why do you think that those who operated that type which had not been properly trialled would find it necessary to switch off their forward HISL's in those conditions while other units that operated other Mks did not? I also understand that the BoI conducted its own ad hoc trials to check out these same HISLs and found them to be deficient. Top marks for them, null points for the MOD!
I could make some smart alec remark about your insinuation as to my motives and supposed vested interests but I'll simply say that my sole vested interest is simply to stop the needless waste of avoidable accidents and hence tragic loss of life. It seems to me that the vested interests are to be found in those that defend the existing patently deficient system.
I could make some smart alec remark about your insinuation as to my motives and supposed vested interests but I'll simply say that my sole vested interest is simply to stop the needless waste of avoidable accidents and hence tragic loss of life. It seems to me that the vested interests are to be found in those that defend the existing patently deficient system.
Bismark
Not so, according to official reports, which mention a Service Deviation applicable to all Sea Kings which, post-crash, was revised and re-issued; in line with the BoI recommendations. In short, something was wrong and MoD acknowledged it.
I seem to recall from an earlier post that the assertion above was false and the act of switching them off was a local one and not widespread practice.
Not so, according to official reports, which mention a Service Deviation applicable to all Sea Kings which, post-crash, was revised and re-issued; in line with the BoI recommendations. In short, something was wrong and MoD acknowledged it.
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"Both the Army and the Navy have Cranfield trained AI teams, being trained on the same course as the AAIB."
The current military system with the Navy and the AAC, has guys doing 1 maybe 2 tours, then moving on.
If a MAAIB was to be the chosen way forward, then it would need to consider Investigators continuity
Thanks for that input, SiClick. If the services were to retain AI then I would expect their Accident Inspectors to be professional ones to the same degree and expertise as those in the AAIB. Otherwise you have the same process as bedevils MOD Airworthiness where people are posted in for a tour and just about getting into their stride when they move on. In (old) RAF terms AI would be a branch, like GD/P, ATC etc where you would spend the bulk, if not all, of an entire career. If that's a no no, then the Tri-Service AI unit would be also and the solution would have to be like the MAA, ie a separate independent and professional MAAIB. Those inspectors would then presumably be civilian though ideally ex-service. That will rankle but anything less than fully professional and objective Air Accident Investigations are pointless and dangerous.
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Si,
I am not sure you are right. The techs tend to stay there for a long period.
Re the HISLs - believe it was isolated to one unit and not the others that operated the same type. The SD was updated to clarify better the earlier SD iaw BOI recommendations.
I am not sure you are right. The techs tend to stay there for a long period.
Re the HISLs - believe it was isolated to one unit and not the others that operated the same type. The SD was updated to clarify better the earlier SD iaw BOI recommendations.
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As a large percentage of the AAIB are ex-military, would it not be easier alround just to require the AAIB to deploy in theatre. They only don't at the moment because they don't have to!
Ah, if only life were that simple, SiClick. Quite apart from the contractual problems that might stand in the way of your suggestion, what we are talking of here is an Air Accident Investigation conducted entirely by Air Accident Inspectors. Their findings would be the basis of any necessary remedial action required by the MAA, ie a process parallel to the existing Civilian one. The Services of course could and most probably would continue with their own SI's etc but would have to conform to the MAA's strictures. Thus the MAAIB would have to be able to access all facets of a Military Accident. Immediately one can see security aspects to this and at the very least their Inspectors would have to subject to the OSA. Whether that is the case of the AAIB I do not know but suspect not, hence the need for a specialist MAAIB.