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Old 2nd Sep 2009, 08:26
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I also heard the piece this morning. Despite being 22 years old the report probably still has some truth in it, but it is also somewhat overtaken by events in that the BOI system has been replaced by more independent Service Inquiries. I know that the previous system could (and did) suffer from intervention by convening authorities, but I think that problem is largely removed under the new regime.

As for the need for specialist investigators, AAIB support is available for all air accidents, but there will always be a need for investigators who understand the operating environment sufficiently to reach a properly informed judgement - for example, an ATPL(H) who has spent his career on North Sea rig-support might not be best-placed to investigate an accident that occurred in brown-out and under fire in the sandpit.

Do we need better trained investigators? Probably, but that is where the specialist external support should come in. However, the BBC assertion that the Nimrod airworthiness issue wasn't uncovered until the Inquest is plain wrong - the BOI came squarely and correctly to that conclusion and it was acknowledged in those terms by the CINC at the time, who stated that the loss resulted from quote "shortcomings in the application of the processes for assuring airworthiness and safe operation of the Nimrod." (check out published BOI on the MOD website).

Don't get me wrong here - I am not trying to defend what went on in the past, especially where it concerned senior intervention, and I do not want to get swept up in the Nimrod or Chinook debates. We just need to remember that the investigatory environment has already changed for the better. I would still prefer to be judged by my peers if ever I am on the wrong side of an accident, provided that those peers are suitably guided by experts in the investigation itself. And if I find myself on the end of an intervention by Air Mshl X based on something he heard down the pub, I will be the first to protest.
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Old 2nd Sep 2009, 08:36
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As for the need for specialist investigators, AAIB support is available for all air accidents, but there will always be a need for investigators who understand the operating environment sufficiently to reach a properly informed judgement
Which is why the RN FAA has always had professional, but serving, AIs trained to the same level as the AAIB but able to add that element of technical and aircrew knowledge to the peculiar environment of operating at and from the sea.

With respect to BOIs the FAA system allowed no avenue for "seniors" to interfere with the BOI process....the report stood on its own merits, signed off by the Board President (normally a Commander).
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Old 2nd Sep 2009, 09:31
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Firstly XV230 crew 3, killed 3 yrs ago today we will remember you. RIP

As for the BOI system the Nimrod BOI had no-one on it that had investigated an air crash before, and it wasn't the BOI that said
shortcomings in the application of the processes for assuring airworthiness and safe operation of the Nimrod
it was Sir Clive Loader Air Chief Marshall. The BOI didn't find the flaw in the design which meant it had never been airworthy. They asked the AAIB to look a a small piece of evidence, let me remind you of the AAIB at the inquest.

MALE SPEAKER: Just one quick one. You did mention that you
would not carry out the investigation on behalf of the
military aircraft because and you quoted lack of expertise in
the military operation. Who carries out the investigation
when military collides with a civil (several inaudible words)?

MR SLEIGHT: I am trying to recall the regulations now and I
might have to refer to my colleague, Steve Ross. Are you able
to answer that? Is that okay? My colleague Steve Ross is a
senior inspector.
THE CORONER: Yes, from where you are.

MR ROSS: To answer your question, where there is a military
civil interaction as you say in a collision what happens is
that an AIB investigation is launched and an RAF Board of
Inquiry is convened, and the two operate in parallel and share
their functions. So quite clearly we do not have the
authority to go into the Royal Air Force to take statements
(several inaudible words) the RAF cannot come into the civil
world and (several inaudible words). So we share information
and the two parallel investigations are carried out.

MALE SPEAKER: And who is responsible for finding decisions?

MR ROSS: If it affects the civil operation of aircraft it is
us. If it is the military then them, so if they want to
change military procedures the Board of Inquiry will be
(several inaudible words) that. If we need to change civilian
procedures or recommend any change then that would be down to
us.
THE CORONER: Do you think it is time for one standard to be
used for the investigation of any aircraft that is lost
regardless of whether it is civil or military?

MR ROSS: I have to remind the court of what Mr Sleight said,
that is not our decision. That is for the Chief Inspector of
Air Accidents. Certainly it would have huge resource
implications (several inaudible words).


So any change in investigating Air Accidents will cost money. So I guess we can forget that whilst this government is in power.
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Old 2nd Sep 2009, 12:28
  #24 (permalink)  
 
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Tench Report

Tapper's Dad - can I first join you in remembering the victims of an accident that was caused by so many failures in the RAF's airworthiness system and in learning the lessons from the investigation of previous incidents and accidents.

I am reluctant to cross thread boundaries and raise other accidents that took place before the so-called improvements in the BoI system (the main one being, as I understand it, that they no longer formally allocate blame, but then deal with this “out of sight” as a disciplinary/administrative issue – but I am happy to be corrected if I am wrong). However, the fact that the investigation of Air Accidents, and indeed the overall regulation and application of airworthiness standards, remains within the Command Chain, and hence potentially subject to interference, not least from the lack of money, still seems to me to be a basic weakness of the system - albeit I acknowledge that the RN (and I think the Army) has had a more professionally qualified and experienced approach to the investigation of accidents for some considerable time. The quote that the BBC used this morning from me on R4 was not given in the context of this news item (it was part of an interview for the recent File on 4 programme), and I am disappointed that in terms of using the Tench Report as an example of how MOD (I guess with every encouragement from the higher echelons of the RAF at the time) “buries” recommendations it does not like, the reporter took no notice of either my concerns at to the use of my comments, even though they are totally correct, in a different context, or of my suggested examples of why the Tench Report was so important.
When Angus Stickler contacted me to say he was doing this piece I suggested that a comparison of the BoI outcome of two accidents that took place within just a few weeks of each other, namely the Chinook on the Mull and the Tornado in Glen Ogle would provide a perfect example of why Tench was so important in terms of fairness and justice – as well as in terms of learning the right lessons from every accident. This, in summary, is what I suggested to Angus:
.... that a comparison of the final verdicts between the BoI for the Chinook (crashed Jun 94 ) and Glen Ogle Tornado (crashed Sep 94) verdicts by the same Senior Reviewing Officers (SROs) (made within a few days of each other) offered a classic example of the "failings" of the BoI system. In the case of the Chinook the SROs despite having no ADR or CVR data available, and ignoring the comments from the AAIB and the airworthiness doubts of their own flight test organisation at Boscombe Down, find "Gross Negligence". In the case of the Tornado there is “no doubt whatsoever” that the actions of the pilot (for indeterminate reasons) caused the crash with loss of crew and aircraft - yet in the extracts from the BoI in the public domain, the SROs find that any consideration of human failings would be "academic and fruitless". Why this major inconsistency of approach except perhaps to "protect" the system and RAF command chain from criticism in both cases. This is a classic example of why the BoI and indeed the military airworthiness authority should be removed from the Command chain and its potential self-serving influence! We did point this out some years ago with one of the members of the Mull Group sending a comparison letter to the S of S - without a response as far as I am aware.
I understand that the BBC producer was reluctant to use these examples, as they took place so long ago – I can only say that the basis of the item, the Tench Report, was even earlier, and I am sad that what was a generally good piece of journalism did not, in my view, really get down to the wider issues and left itself open to be fairly easily rebuffed by an “economical with the truth” MOD, especially on a day when this was a long way down the news agenda as far the public would be concerned.

JB
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Old 2nd Sep 2009, 13:11
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To pinpoint the extracts, the item is at 01.35.45 and Def Min (Kevin Jones) response is at 02.46.35 on: BBC iPlayer - Today: 02/09/2009
John Blakeley's post is very pertinent. With the media's wish to run a "good story" and the MOD's wish to confuse, it is very important to keep one's eye on the ball. The biggest omission from this item though were the 29 deaths on the Mull of Kintyre, IMOH. That would bring the headline figure in Angus Stickler's piece, of 31 lives lost in airworthiness related deaths since this 1986 report, to at least 60. I fear it is probably far far more. No matter what revisions to UK Military Air Accident Investigation have been made in the meantime, the original findings of mediocre standards achieved by complete novices (sic) still strike me as being close to the mark. Rather than importing qualified AAIB investigators to advise BoI's it would surely be more effective to import qualified service operators/maintainers etc to advise a fully professional Military Air Accident Investigation (by a joint civil/military AAIB?)
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Old 2nd Sep 2009, 13:58
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I have yet to listen to Kevan Jones, but if he really said that staffs have withheld their concerns while serving then he is a liar.

I have an extensive archive of such notifications stretching back to 1991. I have placed these concerns in writing to 1, 2, 3 and 4 Stars, four Mins(AF) and PUS.

At least 4 fatal Board of Inquiry reports have made recommendations reflecting word for word what I recommended years before, some on the same aircraft.

With the exception of the 3 Star (DCE of DPA) and PUS (as they didn't bother replying) I retain all their replies. They clearly demonstrate MoD's consistent stance - that the implementation of the airworthiness regulations is optional, to be ignored if they inconveniently delay a programme, add cost or embarrass more senior staffs.

But, far more importantly, each of the above has ruled, in writing, that an officer holding such delegation can be instructed to make a false written declaration to the effect he has complied with the regulations, when he has been instructed not to. That is fraud, abrogation of duty of care and gross negligence. When deaths result, add manslaughter.

(And, JP, to answer your question on the Mull thread, YES!!).
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Old 2nd Sep 2009, 14:19
  #27 (permalink)  
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John Blakely,
I hope, as always, this finds you well.

The written comparison between the Mull accident and the Tornado at Glen Ogle did receive a reply from Adam Ingram. He stated:
"I do not propose to answer your comparative analysis on a point to point basis. Although undoubtedly attractive to those who seek to use selected examples to illustrate a particular argument, it is not necessarily helpful to draw comparisons between individual cases. There may be differences in the cases that fall beyond those that your carful analysis has revealed. It may, for instance, be considered that the flight crew of the Chinook owed a "duty of care" to the passengers for whom they were responsible. The crew of the Tornado, with a joint responsibility for the operation of the aircraft, shared a duty of care to each other. Clearly the buden in the former case, and the need to exercise that care, is greater, leading, perhaps, to a greater need to consider whether negligence had occurred.

So it looks like the number of passengers influences the duty of care placed upon aircrew and not the actions of said crew.

For the record, the comparative document did not compare the two accidents, it compared the decision making processes of the same Reviewing Officers who made comment on the two Boards of Inquiry, some fourteen days apart.

Kind regards,
Brian
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Old 2nd Sep 2009, 14:49
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Duty of Care and Negligence

Brian,

Nice to hear from you - particularly as I no longer seem to be involved on the Chinook side. You are quite right - I was trying to compare the review process and not the complete BoI process, although I am sure that many of my concerns about the BoI process for the Chinook may read across to the Tornado - but I have only seen extracts from the latter BoI, and some of the more interesting looking bits of these were redacted (a great new (well 15th Century anyway) word for us all to use).

I am sorry, I had forgotten that Ingram had given a response - albeit with none of the questions answered. However, as I think I pointed out some time ago the decision on Gross Negligence is not related to the number of deaths - although given that the Minister incorrectly suggests that this is the case, as well as implying that the navigator somehow had a role in his own death through the crews joint "responsibility" for operation of the aircraft (and with single seat flight controls!), I can see that the SROs might have been tempted down this route at the time, if only to get other parts of the system "off the hook" - especially given the very high profile of this accident. I can remember one very senior officer proudly saying to me that the RAF had taken full responsibility for the accident (ie two flight lieutenants in an aircraft that was not seen as airworthy by many were to blame), and that the families had received compensation "in a record short time" - that alone would make most MOD watchers very suspicious!

All the best - keep the fight for justice alive.

JB
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Old 2nd Sep 2009, 18:14
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Listened to Kevan Jones. Yep, he lied.

He also claimed a full audit trail of events was maintained, the results of BoIs were made public, and the reasoning behind decisions was open to public scrutiny.

Wrong. He should speak to his boss, Aintworth, who earlier this year placed in writing that he was content that an audit trail was NOT kept and that vital evidence had been withheld from BoIs (and the Coroner and families), meaning that no proper investigation or scrutiny was possible. He was also content that staffs lied to investigators on airworthiness issues.
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Old 2nd Sep 2009, 23:57
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Looks Like its being going on for years

I heard this mornings Today broadcast The crash in 1960 of Valiant XD864 is a classic case of a cover up, but even the AAIB were complicit in this one..... XD864 5 dead and all for some dumb propaganda war
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Old 3rd Sep 2009, 16:50
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Over the years, many of us have heard people talk about AOCs convening the BoI and 'briefing' the board about 'the cause' what to report - allegations repeated on every FS course I attended and there is no smoke without fire.

One that comes to mind is the accident involving 2 x F3s, who came so close to a mid-air - not sure whether it was the 'NVG formation' incident or the 'fin-scrape' during ACM. Either way, it has been said that when the AOC (11 Gp?) convened the enquiry, he had briefed the BoI to come to a specific conclusion but BEFORE any evidence had been taken. Would anyone care to add fuel to the fire on this or any others by PM if necc?

TVM
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Old 19th Sep 2009, 17:34
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Continuing Airworthiness Management

Fascinating thread, but I am surprised at the lack of comment on the potential changes that should result from the forthcoming QC's report on his review of management of military airworthiness (following the Nimrod crash). Any views?
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Old 19th Sep 2009, 18:41
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Woodbine - why not just wait for the QC's report to be published? You've waited this long, not much longer to wait (allegedly!)....
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Old 25th Oct 2009, 09:22
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Sunday Times: Nimrod safety flaws identified

An independent review into an explosion on board an RAF Nimrod spy plane that killed all 14 on board will this week criticise air safety procedures in the armed forces.

Experts who advised the review blamed a series of accidents, including the Nimrod crash in Afghanistan, on cost-saving measures that removed the requirement for middle-ranking officers to undergo extensive training in safety compliance.

The chairman of the review, Charles Haddon-Cave QC, has written to the families of those killed, saying he will name individuals and companies or organisations responsible for safety failings.

The review was set up by Des Browne, then defence secretary, in December 2007 after a board of inquiry found fuel leaking on to hot air pipes had caused an explosion and the loss of the Nimrod in September 2006.
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Old 25th Oct 2009, 10:27
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Experts who advised the review blamed a series of accidents, including the Nimrod crash in Afghanistan, on cost-saving measures that removed the requirement for middle-ranking officers to undergo extensive training in safety compliance.

I sincerely hope he’s come up with more than this after 22 months.

In addition to said cost savings measures (dating from around 1991-onwards), MoD is now awash with grossly inexperienced staffs who simply don’t see the need in the first place. At least in the past someone saw the need, made provision for it, but was knocked back by BCs or suppliers.

As with the Gray report (last week) the answer is to implement the mandated regulations. Funny, that’s what ACM Loader reiterated in the BoI report. I hope someone in MoD sees the commonality between the two reports. I can just see the official responses in a few months time, from different areas, contradicting each other on the same subjects.
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Old 31st Oct 2009, 21:53
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Charles Haddon-Cave QC’s report is both hard-hitting and far-reaching. The report highlights failures in both the application and the design of the current UK military airworthiness management system. I do not envy Kevin Leeson (the new Defence Chief Airworthiness Engineer) and Charles Ness their considerable change management task. No-one should under-estimate the time and effort that will be needed to regenerate a robust UK military airworthiness management system (including an equally robust system for ensuring rigorous application of that airworthiness management system). Charles Haddon-Cave QC has given a vision. Hopefully the top-level plan published before the Parliamentary Christmas recess will address the highest risks first.
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Old 31st Oct 2009, 23:44
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SK 7 - Sunday Times article

As it says -
MoD sent men to die in ‘unsafe’ helicopter - Times Online
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Old 1st Nov 2009, 14:05
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It comes as no suprise that the lack of joined-up airworthiness implementation is not solely confined to the Nimrod - that is the unwritten basic message of the H-C Report and why his recommendations are so massively 'across the piste'.

Similar failings in airworthiness implementation can be easily seen in the case of the Sea King HISL but also, in Hercules ESF, Tornado IFF, Chinook (HC2 RTS, FADEC and HC3 procurement) and possibly even in the lack of Puma anticipators (made worse by reducing the opportunities for crew-training).

What really worries me is that, for sure, there are many other slices of cheese with gaping holes that are waiting to undermine the safety the ac that our crews are flying today (perhaps some of the crews will be blissfully unaware).

Which is why the H-C recommendations must be implemented PDQ. Perhaps the MoD should go even further ...but what chance of that?

But if you know of a hole in your particular slice of cheese - then point it out, in writing, to your chain of command and copy the FS chain -now!

Failure to address these holes in the cheese is only doing the enemy's job for him.

Good Luck AM Ness Sir!
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Old 1st Nov 2009, 15:03
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Flipster,

Agreed - I would've thought to apply the H-C Review to the whole of the RAF fleets.

I believe none of them are classed as "Ageing Aircraft" that would/should require full electrical and fuel system surveys in civvy street. This in itself is an airworthiness failing as the reliability of electrical systems is widely known to decrease with age and the same with fuel and hyd seals.

I don't believe the MOD has even considered ageing aircraft maintenance.

Other than Typhoon and Astor - name a RAF fleet less than 15 years old?

Consideration should also be given to structural/corrosion needs and requirements.

As we all know - Nothing in aviation is cheap or simple.
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Old 1st Nov 2009, 16:29
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Rigga - C17 is < 15 years old. In RAF since 17 May 2001.

MB
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