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Haddon-Cave, Airworthiness, Sea King et al (merged)

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Old 2nd Sep 2011, 13:07
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Jimmy Jones article

But Stirrup and other officers responsible for the safety of RAF aircraft at the time of the secret 1998 report escaped censure in the 2009 Haddon-Cave report.
Hmm. Now remind me who was in charge when this inquiry was set up and when it reported?
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Old 3rd Sep 2011, 07:25
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Mick, I asume you mean the Haddon-Cave Inquiry. If that is the case, then the answer is either,

(a) Air Chief Marshal Stirrup, or
(b) "Jock" Stirrup, or
(c) Lord Stirrup

Also, Stirrup was ACAS in 1998, and received a copy of NART

Other main players, according to the Jimmy Jones article, were,

(a) Air Chief Marshal Alcock, RAF (CE) from 1991 to 1996
(b) Air Marshal Terry, RAF (CE) from 1997 to 1999. Commissioned NART and received a copy of the final report.

Terry retired in 1999 and became President of the Royal Aeronautical Society. Haddon-Cave was Chairman of the Air Law Group Committee of the Royal Aeronautical Society.

With Darren Beck (see above) as Secretary to the H-C Review, one has to ask, "How independent was this independent review"?

DV

Last edited by Distant Voice; 3rd Sep 2011 at 07:37.
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Old 3rd Sep 2011, 09:53
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DV:
Chug; Who, with clout, will take the airworthiness case forward, and challenge the findings of H-C?
The $64,000 question indeed Distant Voice, and an indictment of the Profession, the Media (especially the Aviation Media), the present RAF High Command, The Government, Haddon-Cave, Lord Philip, and Parliament, that you have to ask such a question. That the rogues responsible will get off Scot Free I have no doubt. That is how the British establishment works, so I'm not holding my breath. Our concern must be that reform be implemented without delay, so that further airworthiness related fatal accidents might be avoided. It will take one good man, admittedly with clout as you say, but just one good man to start this happening. All such revolutions begin with one such man (or woman of course). That is the "who" of which you speak, and the one we have to find.
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Old 3rd Sep 2011, 10:21
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Of course Stirrup, Alcock and Terry were not interviewed by Haddon-Cave.(Well there is no record in the report itself). WHY NOT?

The more I read the Haddon-Cave report, the more it becomes like Tony Blair's "Dodgy Dossier".

DV
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Old 3rd Sep 2011, 10:51
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MAA

Just noticed that Air Marshal Terry was recently appointed as the Chairman of MSAC (MAA Safety Advisory Commitee).

DV
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Old 3rd Sep 2011, 17:55
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You lot are getting more tinfoil helmet all the time
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Old 3rd Sep 2011, 18:03
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Does anyone have a link to the NART report? I thought I read somewhere that an FoI request had been made in respect of it.
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Old 3rd Sep 2011, 18:44
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Those that need it have it. There is no link.

DV
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Old 11th Sep 2011, 20:06
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Online news can have a habit of changing, so for the sake of PPRuNe archives, I cut & paste:-


Caledonian Mercury Aug 30th 2011

Nimrod safety problems revealed in reluctantly released MoD report

By James Jones

A secret report reveals that senior RAF officers knew of serious safety problems with the Nimrod spy plane long before one caught fire and broke up over Afghanistan in 2006, killing the 14-man crew.
The Ministry of Defence (MoD) attempted to block the release of the Nimrod Airworthiness Review Team (NART) report which was obtained under freedom of information (FoI) rules. Within days of the FoI request, officials claimed it could not be found, even though it was referred to in the 2009 Haddon-Cave report. The claim that it could not be found was then backed up by other officials on appeal.
Eventually, the NART report was found, but officials said it was too expensive to copy. They finally agreed to release it after an offer was made to pay the costs.
But the MoD then held back the distribution list. When they did release the list, it showed that the most senior RAF officer who was sent the report – which warned that numerous serious “airworthiness hazards” could lead to disaster – was Air Chief Marshal Sir Jock Stirrup.
Stirrup was chief of defence staff at the time of the 2006 loss of Nimrod XV230, and when the inquiry by lawyer Charles Haddon-Cave into RAF airworthiness problems published its damning conclusions. But Stirrup and other officers responsible for the safety of RAF aircraft at the time of the secret 1998 report escaped censure in the 2009 Haddon-Cave report.
It is now clear that MPs were misled by certain aspects of the Haddon-Cave report, as presented by the secretary of state for defence on 28 November 2009. The report paints a glowing picture of airworthiness in the 1990s and claims that “Airworthiness in the MOD became a casualty of the process of cuts, change, dilution and distraction commenced by the 1998 Strategic Defence Review“.
In fact, Haddon-Cave went out of his way to praise the chief engineers of the period – Air Chief Marshal Sir Michael Alcock and Air Marshal Sir Colin Terry – referring to “high calibre, leadership and the long screw-driver approach”, and calling their tenure the “golden period” in airworthiness. He then reprimanded two senior officers, General Sir Sam Cowan and Air Chief Marshal Sir Malcolm Pledger, for allowing the situation to deteriorate on their watch from 2000 to 2006.
This state of affairs was far from the truth. Having read, in full, two reports drawn up by the Chinook and Nimrod Airworthiness Review (CHART and NART) teams in 1992 and 1998 respectively, it is clear that the period of decline started in the 1990s, during Alcock and Terry’s watch.
For example, the Nimrod report talks of inadequate supervision of aircrew and ground crews, an imbalance between tasking and available resources, depletion on manpower and equipment, ineffective simulator training, poor servicing manuals, outdated zonal inspection procedures, unknown safety margins for wing structure due to corrosion, poor control of tools and loose articles on aircraft, totally inadequate manning levels for key airworthiness positions at staff level, cost before safety with board of inquiry recommendations, dangerous operating conditions for the back-end crew of the Nimrod R Mk1 and problems with approach aid equipments on the MR Mk2 fleet which constituted a major threat to flight safety.
Many of the issues were repeats of those raised by CHART, clearly indicating (a) the systemic nature of the failings and (b) that little or nothing was done. In total, the NART report lists some 120 airworthiness recommendations, of which 47 were regarded as “Airworthiness Concerns” and 11 as “Airworthiness Hazards”.
One of those “Airworthiness Hazards” referred to recommendations made by boards of inquiry into previous accidents were not being carried out due to budget cuts. “Some recommendations with significant financial implications were not taken forward on those grounds alone, rather than after due consideration of the ongoing operational risks,” the report said.
One of the board of inquiry recommendations not implemented because of cost was the replacement of alloy hydraulic couplings with a stainless steel version. This recommendation was made after a fire on board a Nimrod R1 aircraft in 1995 melted the alloy hydraulic couplings leading to loss of control. The crew of Nimrod XV230 lost control of their aircraft 12 miles from Kandahar after the fire on board melted the alloy hydraulic couplings. The aircraft then broke up after an explosion on board.
The unavoidable question is this: had action been taken in 1992, would the Chinook have crashed on the Mull of Kintyre, the Nimrod in Afghanistan or, indeed, any of the other accidents occurred that were attributed to airworthiness failings?
In view of this enlightening information, it is considered that Cowan and Pledger could do little to reverse the decline in the airworthiness regime and culture that had been in existence for over a decade – and as such should be cleared of all “charges” that they were responsible for the decline. A question that needs to be answered is: what actions did the RAF chief engineers and assistant chiefs of air staff take once the CHART and NART reports were submitted to them?
In addition, the structural integrity/corrosion problems outlined in the NART report call into question the decision taken in 1996 to go ahead and use the Mk2 fuselage for the Nimrod MRA Mk4. How was it possible to know the state of the fuselage if “Both past and present procedures for the recording of all corrosion related repairs have been/are inadequate, to the extent that no comprehensive record for each aircraft is available to either the Design Authority (DA) or aircraft Support Authority (SA)”?
In 2006, “lap joints” on the fuselage were found to be cracking and a fleet-wide inspection of all lap joints on the fuselage skin was called for under a Special Technical Instruction. What is more concerning is that following the comments made by NART, relating to the possible erosion of reserve strength factors due to wings and fuselage corrosion, the Nimrod force continued flying because “it would seem that, regrettably, the aircraft SA did not think it necessary at the time to pursue the reasons behind, and implications of, the incomplete recording of corrosion repairs in service”. In short, should the MR2 fleet have been grounded in 1996?
Did corrosion problems eventually catch up with the MRA Mk4 programme? Was this the real reason for the cancellation (they were quick to cut up the aircraft)? Did we waste Ł4bn on something that should never have been started?
Perhaps, at a fraction of the cost, viable alternatives would have been money better spent, protecting the livelihoods of many people living in the Kinloss area and, vitally, maintaining a maritime capability crucial to an island nation.
Baroness Cohen of Pimlico, who was a non-executive member of the board of the Defence Logistics Organisation and who has campaigned on behalf of Cowan and Pledger, welcomed the report’s release. “It demonstrates that the organisational and other problems behind the Nimrod tragedy were far deeper and of longer standing than revealed in Mr Haddon Cave’s report,” she said. “I hope that the MoD can now concentrate on making the changes needed to avoid this sort of disaster for the future.”

James Jones worked as a Nimrod engineering officer and was responsible for carrying out flight trials prior to the aircraft entering service in 1968. Since the 2006 Nimrod XV230 crash in Afghanistan, he has acted as a technical advisor to the families who lost loved ones and has advised their legal counsel during the subsequent inquest.
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Old 11th Sep 2011, 20:09
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Independant on Sunday - Sept 11th 2011

Revealed: The secret report that could have saved 14 lives - Home News, UK - The Independent

Revealed: The secret report that could have saved 14 lives

Concerns over Nimrod airworthiness dismissed as 'emotive' eight years before fatal 2006 crash
By Brian Brady, Whitehall Editor

RAF chiefs were warned that the force's Nimrod spy planes were stricken with 60 problems that threatened their fitness to fly almost a decade before one plunged out of the sky in Afghanistan, killing all 14 servicemen on board.

The father of one of the victims of the crash in 2006 pledged yesterday to take action over the RAF's "neglect" after this newspaper unearthed damning concerns over the condition and maintenance of the aircraft from nearly a decade before his son died.
The confidential Nimrod Airworthiness Review Team (Nart) report, presented to senior RAF officers in 1998, detailed almost 60 "airworthiness concerns" and "airworthiness hazards", including a failure to learn the lessons of previous accidents.

In a stark assessment of safety standards among the RAF's 25 Nimrods, the review declared that "low manning levels, declining experience, failing morale and perceived overstretch" had compromised the fleet's "ability to meet its operational task safely".
It added: "Overall, the Maritime Patrol Aircraft Force is attempting to sustain historical levels of activity with far fewer personnel and a smaller proportion of serviceable ac [aircraft]; ie, there is a large element of continuously trying to get 'a quart out of a pint pot', with all the attendant hazards that such a scenario presents to state ac operations."
However, it has emerged that RAF chiefs at the time dismissed the report's warnings as "uninformed, crew-room level, emotive comment lacking substantive evidence and focus".
Eight years after the warning signs were first raised, Nimrod XV230 exploded in mid-air near Kandahar in September 2006, as the pilot tried to land after reporting a fire in the bomb bay. Subsequent inquiries concluded that the fire was sparked after leaking fuel made contact with a hot air pipe. Crews and engineers reported problems with a number of the planes, which were tasked with flying in Afghanistan and Iraq while fast approaching their out-of-service date.
Graham Knight, whose 25-year-old son Ben died in the XV230 disaster, said the findings would bolster his attempts to bring legal action against the Ministry of Defence (MoD) over its failure to meet its "duty of care" towards the lost service personnel.
He said: "I was aware of the failings of the Nimrods, but I did not know that they had been put so clearly in a report eight years before the XV230 went down. I am shocked and disgusted that the RAF knew about these problems but did nothing about them. Ben always used to tell me that the RAF would not allow its personnel to go up in an unsafe aircraft but he was wrong and I was right."
The official report into the Kandahar disaster referenced the Nart report, saying its concerns "proved to be very prescient" and insisted that they "should not have been dismissed so easily" in 1998. Charles Haddon-Cave QC, who wrote the 2006 inquiry report, said: "It should be noted that many of the same concerns were echoed to me by rank-and-file during my visits to RAF Kinloss 10 years later in 2008. In my view, the Nart concerns and warnings were not sufficiently heeded in the... years leading up to the XV230 accident."
However, the MoD has consistently declined to publish the full details of the Nart report, at one time claiming it had been lost. Following concerted pressure, the document was eventually slipped out into the House of Commons library in the summer recess.
The report, obtained by The Independent on Sunday, itemises 11 airworthiness hazards – "representing current threats to safety and, therefore, requiring urgent attention" – and 47 airworthiness concerns, "of a less serious nature that, nevertheless, merit remedial action as soon as possible". It listed 120 separate recommendations for action by RAF bosses.
The review team raised critical concerns over the inadequate supervision of crews, a reduction in manpower due to cuts, poor servicing manuals and outdated inspection procedures. Their report also warned of the damaging effect of corrosion on the fleet. Among the airworthiness hazards cited was the failure to carry out the recommendations of boards of inquiry into previous accidents.
Mr Haddon-Cave said the failure to heed the Nart team's warnings had had an impact on subsequent failings.
An MoD spokesman said the department had been addressing failings identified by Mr Haddon-Cave, although he could not confirm that the Nart conclusions had been acted on after they were presented in 1998. He said: "The Haddon-Cave review examined the Nimrods' airworthiness and did consider the Nart report. His final report highlighted failings which are being addressed."
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Old 12th Sep 2011, 05:53
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However, it has emerged that RAF chiefs at the time dismissed the report's warnings as "uninformed, crew-room level, emotive comment lacking substantive evidence and focus".

Systemic airworthiness failings were formally advised to;

RAF Chief Engineer, ACAS and CAS in Aug 1992 (CHART)

Director General Support Management (RAF) in Dec 1992 (by MoD(PE), when he threatened staffs with dismissal for voicing the same concerns)

PUS, the above, and all MoD aircraft Directorates in June 1996 (Director Internal Audit report, commissioned to provide evidence to protect those under threat of dismissal)


...and so on, every year since; including, tragically, the year before XV230 crashed. Nothing was done.



Point being, at a systemic level NART is simply a repeat of numerous previous reports, in addition to articulating details specific to Nimrod. Whoever dismissed NART as "crew room level, emotive comment" is disrespectful to those who inhabit crew rooms and criminally negligent in their failure to act upon previous warnings. It is the clearest possible evidence that MoD misled when claiming the CHART recommendations were implemented.
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Old 12th Sep 2011, 07:57
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The point indeed tucumseh is that there is and was a Systemic Failure in Airworthiness Provision by the MOD going back some three decades. The mechanics of how this suborning of the Regulations occurred you have described on this and other threads previously. The reason why it was allowed to happen can be summed up in the phrase; Lack of Moral Courage, or Lack of Moral Fibre (LMF) as it was termed in WWII. Those people who resisted these illegal orders, to the detriment or even the ending of their own careers, should earn our greatest respect and hopefully in time will do so. Those who did as they were bid, no doubt with a rhetorical "What can one person do?", and subverted the airworthiness regulations or helped cover it up, failed in their duty and will have to live with the consequences of the known death toll of Military Airworthiness Related Fatal Accidents.
General Dannatt has said that the Army's Moral Courage is key, following the finding of the inquiry into the death of Baha Mousa at the hands of 1st Battalion The Queens Lancashire Regiment in 2003:
BBC News - Today - Dannatt: 'Army's moral courage is key'
Exactly the same comment applies to the Royal Air Force following at least 62 deaths in airworthiness related fatal accidents. Time we heard just that from one of its Generals!
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Old 12th Sep 2011, 08:40
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A very thought provoking interview with the General.

It raises a number of points, the 2 most obvious are:

1. By blaming a few individual 'bad apples' one misses the key point that these individuals are products of the 'system' and that the organisation needs putting back on track rather than just removing the bad apples.

2. If however, you blame 'society' for the quality of the raw recruit's ethos (that led to them becoming bad apples), then surely you will need to provide even more training and give constant guidance throughout the individual's service career to correct this?

Interestingly, the General himself raised this last point but this is seen not to happen because, regrettably, the depth of and the time allocated for training is an easy target for the bean-counters. During my time, ALL useful training was forever being cutback - death by a million cuts!

Furthermore, what does one do about the middle and senior 'management' who, even though promoted, are likewise afflicted by this low societal ethos and are yet to be corrected?

You need your commanders to display the highest levels of integrity and principles at all times in all things - especially if it means confronting the bosses' poor decisions (i.e. cost v safety).

Unfortunately, in the RAF at least, this has been shown by the various airworthiness concerns listed in the CHART and NART to be well short of the mark and these senior officers set incredibly bad examples for their subordinates.

So what is the answer?

I suggest that the MAA must monitor more carefully the process that attains and maintains airworthiness and fitness for purpose. They must be seen to be ruthless with any bad decisions and seek out the senior commanders who have displayed a poor safety ethos at any time in their careers - and remove them from the chain of airworthiness provision. The MAA must correct and re-train the middle-management that may have similar ideas - that safety can be easily ignored on the grounds of cost.

Whilst I believe the MAA have made inroads already in providing a new, readily-understandable regulatory-framework that can be logically implemented, they must now go even further and ensure the regulations ARE steadfastly implemented - that is the real challenge facing Timo Anderson et al.

Ultimately, I believe that this would be made a much easier task if the MAA (and MAAIB) were outwith the insidious tentacles of the MoD Chain of Command and were given 'true independence'. But whatever their position in Services' architecture, failure by the MAA to change the ethos of safety within the military airworthiness process will only lead to even more unnecessary deaths in the future, mark my words.

Good luck to all involved therein - remember, an individual CAN make a difference!

Also remember that for evil flourish, all it takes is for good men (and women) to do nothing.

Last edited by flipster; 12th Sep 2011 at 09:16.
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Old 12th Sep 2011, 19:29
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"Whilst I believe the MAA have made inroads already in providing a new, readily-understandable regulatory-framework that can be logically implemented, they must now go even further and ensure the regulations ARE steadfastly implemented - that is the real challenge facing Timo Anderson et al."

Having read these new regulations (sad, I know - but that's wot gets me paid) I agree that the first test of the MAA's mettle is when some squadron or station commander thinks he/they/it has better "traditions" than those regulated and he/they/it request to do something other than the AMC calls for (normally wot they always did before).

If the MAA allows stations, squadrons, individuals the ability to chose as they please; the use of any regulation becomes quickly ineffective and the MAA looses reputation, and it's employees soon leave (unless they are holding on for a big CS pension?)

As an aside: The enforcement of the use of AMCs, by EASA and the CAA for instance, makes their own task of REGULATION much easier as they don't have to try to understand how that particular unit "works" before assessing their compliance with regulations, and the "airworthiness" of the unit and its staff.

"Airworthiness" is not just about the mechanics of flying.
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Old 12th Sep 2011, 19:50
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What worries me about this drivel is that somebody reading might believe that the majority of us agree with your crusade to make military aviation safely unaffordable.


We don't want it.
Stop.

When we lose the next war due to pencil pushing remfs then I hope you all go to the wall.
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Old 12th Sep 2011, 22:19
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"We don't want it.
Stop."

That phrase is probably the same argument for not checking the aircraft Prop and tyres before take-off and not checking the Met forecast when that was introduced...and likely to be almost the same against carrying radios too.

I'd just like to remind you that these are NOT civil Regs but the MOD's, written by your officer bretheren for the safety of most of your brother crews. But probably not for the one's that travel with you.
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Old 13th Sep 2011, 05:35
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If Tourist were on a wind-up it wouldn't even be funny. But he has been consistent in his belief that military aircraft needn't be safe and is apparently quite content his colleagues have died needlessly.

He is entitled to that opinion and who am I to argue with anyone who thinks he is a complete ****.
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Old 13th Sep 2011, 07:48
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Tourist

I don't think that making Military aviation safer is going to cost a lot of money, it is just going to take a major attitude change within the upper ranks of the service.

Recently I have seen a flight safety incident were the officers involved just circled the wagons and got nasty with someone who is unlikely to be at fault, this attitude (not the incident it's self) would get you fired from a civil airline.

Until the service accepts that people make unintentional errors and these errors should not punished, all that results from this is that valuable flight safety information being kept under wraps for fear of being put in a career altering situation. This is valid in both the hangar and in the air.

I can see how some people think that an open attitude to errors is at odds with military discipline but I can't help feel that this attitude is largely held by those who use other people's errors to advance their own careers.
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Old 13th Sep 2011, 08:35
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Until the service accepts that people make unintentional errors and these errors should not punished...
By and large, this has already happened; numerous examples spring to mind where someone has, rightly, not been crucified for an honest mistake. In fact, there have been occasions where the "just culture" (cf "just in time" culture) has gone too far, resulting in a culpable individual getting away with his or her acts because the hierarchy is too spineless to take appropriate action.

Not sure exactly what this has to do with the airworthiness debate, apart from the common theme of substandard top brass.
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Old 13th Sep 2011, 10:12
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Torque

Good point, and it has everything to do with the debate; as has A&C's excellent post.

We have gone from a "safety is everyone's business" culture to "if you notify seniors of safety concerns you can forget further promotion".

In 2000 a senior RN officer instructed me to wind it in or seek another job, because he was fed up with me insisting the airworthiness regulations should be implemented. A few years later, after a BoI report and Coroner's Inquest, he at least had the good grace to say I was right. F*** all use that, to the families.

But worse, almost to a man his IPT followed his ethos. He is now retired, but dozens of his former staffs now pass that ethos on to the next generation. It is endemic, witness a 2004 MoD briefing to Min(AF) that I was the only person in MoD who thought the airworthiness regs should be implemented. (Supplied to me under FoI). The MAA haven't a hope in hell unless truly independent of that system.
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