Accident Investigators and Boards of Inquiry - Terms of Reference
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Accident Investigators and Boards of Inquiry - Terms of Reference
Does anyone out there know what are the Terms of Reference (TORs) for military DAS/DARS Accident Investigators ?
For example, once they have investigated the local direct-efffect causes of the accident, are the investigators mandated to consider the organisational influences that may have predisposed those involved towards having the accident? How deep are the investigators allowed/required to go once they have been briefed by the AOC (therein lies a tale or two, I suspect)?
An example of 'organisational factors' could be squadron/fleet ethos or budget constraints impacting on crewing levels, manning policy, poor training opportunities, a lack of supervision, contradictory documentation or even inappropriate equipment or procedures etc. Whereas, the 'local factors' could be crew mishandling, incorrect procedures, lapses, errors, violations, inappropriate cockpit gradient, distractions or even poor awareness of enemy actions and int etc?
It would be interesting to know the current mil procedures, as it has taken years for aviation experts to get commerce (eg airlines), the govt and hence or the military to accept that such organisational influences could be important in major accidents (eg Chernobyl, Piper Alpha, Zeebrugge, Dryden etc). As a result of this, however, have the TORs actually been changed for accident investigators?
flipster
For example, once they have investigated the local direct-efffect causes of the accident, are the investigators mandated to consider the organisational influences that may have predisposed those involved towards having the accident? How deep are the investigators allowed/required to go once they have been briefed by the AOC (therein lies a tale or two, I suspect)?
An example of 'organisational factors' could be squadron/fleet ethos or budget constraints impacting on crewing levels, manning policy, poor training opportunities, a lack of supervision, contradictory documentation or even inappropriate equipment or procedures etc. Whereas, the 'local factors' could be crew mishandling, incorrect procedures, lapses, errors, violations, inappropriate cockpit gradient, distractions or even poor awareness of enemy actions and int etc?
It would be interesting to know the current mil procedures, as it has taken years for aviation experts to get commerce (eg airlines), the govt and hence or the military to accept that such organisational influences could be important in major accidents (eg Chernobyl, Piper Alpha, Zeebrugge, Dryden etc). As a result of this, however, have the TORs actually been changed for accident investigators?
flipster
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Flip,
As a guideline, they should go along the ICAO annex 13 route rather than the stuff you are alludeing to.
For wording that a pi§§ poor CMR (aka 2 Gp AT Sqns) was a "cause" of an accident - then good luck because I don't think that a) you could prove it and b) it would survive the past the initial draft stage.
As for having the millitary investigate their own accidents in the first place
C130JB
As a guideline, they should go along the ICAO annex 13 route rather than the stuff you are alludeing to.
For wording that a pi§§ poor CMR (aka 2 Gp AT Sqns) was a "cause" of an accident - then good luck because I don't think that a) you could prove it and b) it would survive the past the initial draft stage.
As for having the millitary investigate their own accidents in the first place
C130JB
How would you check if info has been presented to a BOI,SO or CC?
What happens if information comes to light post a BOI,SI, or CC?
How would you present it?
Just curious...............
What happens if information comes to light post a BOI,SI, or CC?
How would you present it?
Just curious...............
Each BOI's TORs are quoted in their reports. See Ministry of Defence | About Defence | Corporate Publications | Boards of Inquiry and look at Part 1.
These are usually standard TORs supplemented by additional items as deemed applicable by the Convening Officer (ie. AOC).
These are usually standard TORs supplemented by additional items as deemed applicable by the Convening Officer (ie. AOC).
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Thanks for your pointers chaps.
The link to TORs (above) does seem to allow the BOI president the lattitude to go as deep as he wants and if these TORs are indicative of a 'standard issue' from JSP551, then it is possible to interpret them to mean the BOI can cover any influencing factors.
It would be interesting is to see the TORs for the board advisors - DASC/DARS experts and AAIB?
However, it doesn't take the 'brains of an archbishop' to appreciate that, in these days of a fast-reducing pool of experienced personnel, the BOI convener is likely to be directly in the chain of command of the BOI president and the board members - they may even come from the same unit. As a result, it is possible that there may be an totally understandable reluctance on the part of the BOI to 'point the finger upwards' or even to dig that deep in the first place - (I'm not saying that this is the case in this, or any other, recent instance).
From the AOCs point of view, however, from where else is he to get the expertise required to form a BOI that has correct level of knowledge to make a sensible judgment of the causes of the accident? But one could counter that argument by saying that, in other fields, the investigators do not have to have fleet nor type specific knowledge - they just tap into the appropriate experience pools for the detailed answers to awkward questions.
Very much a double edged sword? I think, however, that BOIs, through not fault of their own, have become open to the criticism that the system has become too incestuous - irrespective of the integrity of the BOI presidents and members. Perhaps it is now time to let the AAIB expand into the military world and do away with BOIs? At least the AAIB is not constrained by the politics of the organisation in question.
Remember the aim of any investigation is NOT to apportion blame but identify lessons from which to learn and prevent recurence.
Would anyone with recent exprience of AAIB/BOIs care to comment?
The link to TORs (above) does seem to allow the BOI president the lattitude to go as deep as he wants and if these TORs are indicative of a 'standard issue' from JSP551, then it is possible to interpret them to mean the BOI can cover any influencing factors.
It would be interesting is to see the TORs for the board advisors - DASC/DARS experts and AAIB?
However, it doesn't take the 'brains of an archbishop' to appreciate that, in these days of a fast-reducing pool of experienced personnel, the BOI convener is likely to be directly in the chain of command of the BOI president and the board members - they may even come from the same unit. As a result, it is possible that there may be an totally understandable reluctance on the part of the BOI to 'point the finger upwards' or even to dig that deep in the first place - (I'm not saying that this is the case in this, or any other, recent instance).
From the AOCs point of view, however, from where else is he to get the expertise required to form a BOI that has correct level of knowledge to make a sensible judgment of the causes of the accident? But one could counter that argument by saying that, in other fields, the investigators do not have to have fleet nor type specific knowledge - they just tap into the appropriate experience pools for the detailed answers to awkward questions.
Very much a double edged sword? I think, however, that BOIs, through not fault of their own, have become open to the criticism that the system has become too incestuous - irrespective of the integrity of the BOI presidents and members. Perhaps it is now time to let the AAIB expand into the military world and do away with BOIs? At least the AAIB is not constrained by the politics of the organisation in question.
Remember the aim of any investigation is NOT to apportion blame but identify lessons from which to learn and prevent recurence.
Would anyone with recent exprience of AAIB/BOIs care to comment?
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Can tell you that since late last year the term BoI is dead. They are all now Service Investigations (SI) regardless of whether its a plane a tank or a ship. Those BoIs that were convened prior to the change will report as a BoI.
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Thanks Chris
Thats news to me - any change in TORs or JSP551 to reflect this?
Does this mean we will have 'Joint' Services' Investigation Agency - Naval Officers of the Watch investigating RAF aircraft accidents and Army tank commanders investigating why Grey Funnel Liners run aground or why their little green boats fall into Iranian hands?
Actually, such a system may just be an improvement!!!!?
Thats news to me - any change in TORs or JSP551 to reflect this?
Does this mean we will have 'Joint' Services' Investigation Agency - Naval Officers of the Watch investigating RAF aircraft accidents and Army tank commanders investigating why Grey Funnel Liners run aground or why their little green boats fall into Iranian hands?
Actually, such a system may just be an improvement!!!!?
Any evidence gathered as part of a SI can also be used to carryout 'Admin Action' against an individual. I've been assured that this is not the same as 'Discip Action' but is still career ending stuff, quite literally.
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If anyone has been flouting the regs big-time, then they will incur displeasure or sanction from above - whether they be civvie or military.
However, if someone makes a genuine, slip, lapse or error of judgement etc then this is not to be used for 'admin action'. I believe that is the case outside - I would be dismayed to hear it was different in the Services - it goes against the very raison d'etre of flight safety and against ICAO 'best practice':
I say again, the aim of such investigations is to learn from any mistakes; to prevent recurrence - NOT to apportion blame.
However, if someone makes a genuine, slip, lapse or error of judgement etc then this is not to be used for 'admin action'. I believe that is the case outside - I would be dismayed to hear it was different in the Services - it goes against the very raison d'etre of flight safety and against ICAO 'best practice':
I say again, the aim of such investigations is to learn from any mistakes; to prevent recurrence - NOT to apportion blame.
Flipster,
I would be very reluctant, having heard the way several colleagues have been treated recently, to give anything other than the minimum to an SI. The system is flawed, and if the cmd chain has an agenda then you are stuffed. The whole process needs some form of assurance or scrutiny from an external org to ensure objectivity: One fleet sitting in judgement of another is no way to conduct an inquiry!
But hey, that's just my opinion.
I would be very reluctant, having heard the way several colleagues have been treated recently, to give anything other than the minimum to an SI. The system is flawed, and if the cmd chain has an agenda then you are stuffed. The whole process needs some form of assurance or scrutiny from an external org to ensure objectivity: One fleet sitting in judgement of another is no way to conduct an inquiry!
But hey, that's just my opinion.
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Sounds like we are not as far away from 'the bad old days' as I'd hoped! AOCs with agendas? Surely not!
BTW anyone got a link to the AP3207/manual of flight safety - or JSP 551 I think it is called now?
Flip
BTW anyone got a link to the AP3207/manual of flight safety - or JSP 551 I think it is called now?
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Flipster
Re. TOR's for BoI/SI's I suggest that you look at the RAN Sea King investigation into the loss of Shark 07. That board also looked at the appropriateness or otherwise of the defense force also being the airworthiness authority of military ac.
This was when (as now) the RAN was suffering operational tempo, spares shortages, canabalisation of "hangar queens", skill shortages in engineering, increasing dilution of experience in senior NCO's and high turn-over of personnel in post. The real issue was that the engineering authority had a conflict of interest. To ground the fleet because of known engineering short-comings (with no replacement available) or keep the Sea King operational with the risk that something might go wrong.
Looks very familiar now in the context of XV206....
The real crunch will come when the aircrew refuse to take the ac alleging that it's C of A (or military equivalent) is in doubt or when they no longer have faith in the engineering decision-making so the paperwork is meaningless........C130 outer wings?? Trishaws?? VC10's?? GR4 wing pivots??
It also begs the question how will the RAF air transport assets handle a "surge" of 2,000 extra troops to Afganistan? They are at breaking-point now
.
MB
This was when (as now) the RAN was suffering operational tempo, spares shortages, canabalisation of "hangar queens", skill shortages in engineering, increasing dilution of experience in senior NCO's and high turn-over of personnel in post. The real issue was that the engineering authority had a conflict of interest. To ground the fleet because of known engineering short-comings (with no replacement available) or keep the Sea King operational with the risk that something might go wrong.
Looks very familiar now in the context of XV206....
The real crunch will come when the aircrew refuse to take the ac alleging that it's C of A (or military equivalent) is in doubt or when they no longer have faith in the engineering decision-making so the paperwork is meaningless........C130 outer wings?? Trishaws?? VC10's?? GR4 wing pivots??
It also begs the question how will the RAF air transport assets handle a "surge" of 2,000 extra troops to Afganistan? They are at breaking-point now
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Tucumseh
The real issue was that the engineering authority had a conflict of interest.
This rendered it impossible for those with relevant delegation to comply with the procedures, rules and regulations that are meant to underpin these activities. The resultant problems prompted a series of adverse, and very critical, reports in the 90s. One can see the predictable and predicted outcome in the various Coroner's rulings (e.g. "systemic airworthiness failings").
It is also one of the main reasons why the associated Def Stans, JSPs etc cannot be properly updated. If they were to reflect current practice and internal MoD policy, the Secretary of State could not be seen to approve their issue as they would contradict, for example, the rules laid down by the Chief Accounting Officer, PUS. Try asking D/Stan how difficult it is to find a sponsor for some of them - no-one wants the job as you'd immediately hit this stone wall.
The main Def Stan covering the vital area of maintaining airworthiness (as mandated by JSP 553) was last amended in 1991. (It's available on the D/Stan site, but what you get is less than half the standard, as they can't find the rest). If any current IPT member read it they would topple. The tried and tested procedures it describes are unrecognisable to them, yet if they were honest they'd recognise it contains the solution to almost every problem they face. 20 years ago, anyone with airworthiness delegation had to know it backwards!
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XV206, XV179, XV230, XV604, ZD576 etc etc etc etc......which one next?
I am coming to believe that, like a few others, the military are no longer suitably experienced nor manned sufficiently to be trusted with their own airworthiness nor their own accident investigation. Is it time there was an independent Mil AAIB and AW authority? There are arguments both ways but I am now in the camp of 'external oversight'; it is not rocket science and the principles are fundamentally the same as when Pontius was in groundschool, yet the military seem to have lost their way a tad.
I am coming to believe that, like a few others, the military are no longer suitably experienced nor manned sufficiently to be trusted with their own airworthiness nor their own accident investigation. Is it time there was an independent Mil AAIB and AW authority? There are arguments both ways but I am now in the camp of 'external oversight'; it is not rocket science and the principles are fundamentally the same as when Pontius was in groundschool, yet the military seem to have lost their way a tad.
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I'm baffled by Madbob's "Looks very familiar now in the context of XV206....
" and Flipster's inclusion of XV206 in his list.
XV206 was destroyed when it hit a land mine whilst landing at a TLZ and no engineering or operational tempo factors were mentioned as causal or contibutory factors.
Furthermore, I'm not aware of any controversy surrounding the BoI's findings (with the possible exception of a tenuous link to the discussion regarding ESF).
What am I missing?
N Joe
" and Flipster's inclusion of XV206 in his list.XV206 was destroyed when it hit a land mine whilst landing at a TLZ and no engineering or operational tempo factors were mentioned as causal or contibutory factors.
Furthermore, I'm not aware of any controversy surrounding the BoI's findings (with the possible exception of a tenuous link to the discussion regarding ESF).
What am I missing?
N Joe
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njoe,
Nothing sinister mate but there are some 'latent' conditions in this one - albeit not from an airworthiness point of view. eg - why daylight; were there any insiduous op pressures due diplomat on board; how did the bombs and their planters not get spotted; what was the force protection like, was the use of the strip predictable, if so, why; would foam or cargo bay armour have helped etc? Now before you all jump on me, I know that the BOI said foam would not have prevented the eventual destruction of the ac but it may have slowed the fire/explosion - we were very lucky that the crew were on their toes and got everyone off in time - so it may be still a matter for debate? However, apart from foam, the links with any underlying airworthiness probs in xv206 are tenuous as best, so perhaps I was wrong to include that in my list (bob might disagree); I am sorry for that but substitute the other Sea King mk7 and the GR1 in the list instead.
It is arguable that 'latent' conditions are quite often not that well dealt with by BOIs - eg Chinook - not because the BOI members don't want to do it but because these latent errors could reflect badly on the AOC and the hierarchy - or even another command/arm. I am convinced that if BOIs went to the depths of ICAO Annex 13 and related guidelines (what is commonly known as 'best practice') then a significant number of recent military accidents could have been prevented. Furthermore, despite their integrity and professionalism, many BOIs presidents and members do not have the time nor resources to do so, never mind the fact that the AOC (who is likely to be in their chain of command) is looking over their shoulder and having the final say. Therefore, it is not unreasonable that BOIs/SIs concentrate their efforts on the local 'active' conditions that led to the accident....but is that right? Answers on a postcard please.
ps I'm after a copy of JSP551 - or at least the bits relating to TORs for the BOI - anyone help?
flipster
Nothing sinister mate but there are some 'latent' conditions in this one - albeit not from an airworthiness point of view. eg - why daylight; were there any insiduous op pressures due diplomat on board; how did the bombs and their planters not get spotted; what was the force protection like, was the use of the strip predictable, if so, why; would foam or cargo bay armour have helped etc? Now before you all jump on me, I know that the BOI said foam would not have prevented the eventual destruction of the ac but it may have slowed the fire/explosion - we were very lucky that the crew were on their toes and got everyone off in time - so it may be still a matter for debate? However, apart from foam, the links with any underlying airworthiness probs in xv206 are tenuous as best, so perhaps I was wrong to include that in my list (bob might disagree); I am sorry for that but substitute the other Sea King mk7 and the GR1 in the list instead.
It is arguable that 'latent' conditions are quite often not that well dealt with by BOIs - eg Chinook - not because the BOI members don't want to do it but because these latent errors could reflect badly on the AOC and the hierarchy - or even another command/arm. I am convinced that if BOIs went to the depths of ICAO Annex 13 and related guidelines (what is commonly known as 'best practice') then a significant number of recent military accidents could have been prevented. Furthermore, despite their integrity and professionalism, many BOIs presidents and members do not have the time nor resources to do so, never mind the fact that the AOC (who is likely to be in their chain of command) is looking over their shoulder and having the final say. Therefore, it is not unreasonable that BOIs/SIs concentrate their efforts on the local 'active' conditions that led to the accident....but is that right? Answers on a postcard please.
ps I'm after a copy of JSP551 - or at least the bits relating to TORs for the BOI - anyone help?
flipster
Hi
JSP 551 Section 200 and Section 205 spring to mind - Should be at Change 6 (major revision). Man at DARS and ASG can be very helpful.
JSP 551 Section 200 and Section 205 spring to mind - Should be at Change 6 (major revision). Man at DARS and ASG can be very helpful.
Last edited by reds & greens; 28th Mar 2009 at 17:47.