Haddon-Cave, Airworthiness, Sea King et al (merged)
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But I knew about most of them and thus informed I was able to make a rational, risk based, decision on whether I wished to fly in such an aircraft.
I'm not one for the notion of a "Flight Prevention Branch" - safety engineers who try to stop operators for the sake of it are not doing their job. We don't need an overly prescriptive culture such as exists in some places that won't let you do the simplest of things because "Health and Safety Says so". It doesn't say so, it says to make realistic risk assessments.
In relation to airworthiness and safety, I once said to a BAES safety engineer who challenged my approach (probably because of company policy rather than of real conviction), that his approach was purely commercial, my approach was based on the fact that I didn't want to go to a mate's funeral and tell his wife that "I'm sorry, but if I'd done my job a bit better....." Made him think!
sw
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If you don't mind, stop embarking on a crusade based mostly on hearsay and conspiracy theories.
Thanks Chaps
As I dress for this evenings Taranto Night, it occurs to me to wonder:
If you bunch were around back then, how many reasons would you have found to ground the stringbag?
Old.
Slow.
Unsafe.
No armour.
No Nav equipment.
Obsolete.
(probably had sh1t strobes, too)
No Comms
Without The Attack on Taranto, who knows what would have happened in the Med?
Sometimes you just gotta fly it.
Thanks Chaps
As I dress for this evenings Taranto Night, it occurs to me to wonder:
If you bunch were around back then, how many reasons would you have found to ground the stringbag?
Old.
Slow.
Unsafe.
No armour.
No Nav equipment.
Obsolete.
(probably had sh1t strobes, too)
No Comms
Without The Attack on Taranto, who knows what would have happened in the Med?
Sometimes you just gotta fly it.
Last edited by Tourist; 12th Nov 2009 at 17:44.
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If you don't mind, stop embarking on a crusade based mostly on hearsay and conspiracy theories.
One day, in a meeting which included an RM, you could see the penny drop when, in his own words, he figured out that we were only applying the MOD's own standards and doing what we were contracted to do. We weren't being "difficult" for the sake of it.
sw
Tourist and OFO - I think you both want to grow up a bit - we are not flying Swordfish any more than we send the 20 minuters in Sopwith Camels to do battle with the hun. The 'we will fly it and get the job done no matter how shi8e it is' belongs firmly in the volumes of Boy's Own annuals and Commando war comics.
Your statements conflict with your assertion that you are professional aircrew who are supposed to be responsible for the safety of the aircraft and crew first and foremost.
Your statements conflict with your assertion that you are professional aircrew who are supposed to be responsible for the safety of the aircraft and crew first and foremost.
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Tourist
Thank you for replying with a modicum of politeness; that is progress at least. However, I cannot understand from where you get the impression that a number of Coroners' Inquests, a review carried out by a member of Queen's Council, uncontested High Court actions against the MoD, along with a number of Boards of Inquiry and even a couple Air Ranking Officers could possibly constitute 'hearsay and conspiracy' theories. Perhaps you could elucidate your reasoning?
I am also at a loss why any 'aircrew mate' would seem disinterested in the functional safety of their aircraft - they may not understand the dark world of safety engineers (I didn't) but it should make them think hard about the verity of the promises and premises that underpin the ac document set that directly relates to the safe and effective operation of their chosen steed (it did).
Even armed with the knowledge that your ac may have some shortcomings, I respect your decision to go out and do your job and duty - perhaps that is brave and the ethos of the military (I did too)? But the point is that if you are fully informed you are able to mitigate the snags - as pointed out by Pheasant. The problem is that the CoC has for some time, begun to assume that we will risk our necks 'for the greater good' but they will not provide you with the knowledge to asses the risks you are taking. If you wish to continue to play russian roulette, that's you choice (perhaps not so brave as foolish). However, how do you fully inform your crew/pax if you are not fully in the picture yourself?
Or are you a protagonist and adherent of the BIFWSS principle?
Thank you for replying with a modicum of politeness; that is progress at least. However, I cannot understand from where you get the impression that a number of Coroners' Inquests, a review carried out by a member of Queen's Council, uncontested High Court actions against the MoD, along with a number of Boards of Inquiry and even a couple Air Ranking Officers could possibly constitute 'hearsay and conspiracy' theories. Perhaps you could elucidate your reasoning?
I am also at a loss why any 'aircrew mate' would seem disinterested in the functional safety of their aircraft - they may not understand the dark world of safety engineers (I didn't) but it should make them think hard about the verity of the promises and premises that underpin the ac document set that directly relates to the safe and effective operation of their chosen steed (it did).
Even armed with the knowledge that your ac may have some shortcomings, I respect your decision to go out and do your job and duty - perhaps that is brave and the ethos of the military (I did too)? But the point is that if you are fully informed you are able to mitigate the snags - as pointed out by Pheasant. The problem is that the CoC has for some time, begun to assume that we will risk our necks 'for the greater good' but they will not provide you with the knowledge to asses the risks you are taking. If you wish to continue to play russian roulette, that's you choice (perhaps not so brave as foolish). However, how do you fully inform your crew/pax if you are not fully in the picture yourself?
Or are you a protagonist and adherent of the BIFWSS principle?
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What we could do here is to start a new thread entitled...
"Who gives a ***** about airworthiness? That's for Engineers to worry about"
Oh no.....We've already done that
"Who gives a ***** about airworthiness? That's for Engineers to worry about"
Oh no.....We've already done that
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I think 'crusade' (without the implicit religious connotations) is the essence that taints these threads. I read many posts and wonder if the author wants to save the operators from themselves, or actually has a huge bone to pick with those up the chain and feels able to do so now that they no longer have to continue in the life of and on the aircraft of their vocation. The Old Fat One is right, we are pilots, we fly aeroplanes. Pheasant sums up how we live with aeroplanes (and justify them to our dearest who question us). We do our best, we love it. We are in charge and we prepare for each flight to the best of our ability to succeed. Fortunately and sadly, we are also lucky. We are the 99,999,999:1,000,000,000 (made up probability) for whom it all works. Many of us could have been the one (or one of 14). I now know that the aircraft I loved, trusted and thoroughly enjoyed hasn't been fit since it came into service. Am I stupid, no. Do I want to blame anybody, no. It doesn't take away anything that I did with the aircraft and I'm sure I don't want it to.
BUT, I hope the Review can do some good. I want it to and I believe it is starting to.
BUT, I hope the Review can do some good. I want it to and I believe it is starting to.
?
Flip
Because you started with the conspiracy theories in your first post??
However, I cannot understand from where you get the impression that a number of Coroners' Inquests, a review carried out by a member of Queen's Council, uncontested High Court actions against the MoD, along with a number of Boards of Inquiry and even a couple Air Ranking Officers could possibly constitute 'hearsay and conspiracy' theories. Perhaps you could elucidate your reasoning?
Because you started with the conspiracy theories in your first post??
Why - did the MoD limit his TORs on purpose?
Why is there a delay in the MoD response?
Why is there a delay in the MoD response?
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"I think 'crusade' (without the implicit religious connotations) is the essence that taints these threads."
I think you should contact the author and get to know him rather than attack his motivation. I can vouch for the purity of what he is trying to achieve and I have seen the enormous amount of work he has done (in his own time), in a tireless effort to improve safety. What the hell were your highly paid representatives in the CofC doing all this time? Looking after their careers? You can call it what you like, it is bl**dy effective and I for one, don't give a stuff if it offends your "sensibilities".
Moving on, this was a constructive and welcome addition to the debate. An AVM moved to write to The Times a couple of days ago;
November 10, 0009
Reinstate qualified RAF engineers
The public should demand the restoration of military airworthiness responsibility to those who are qualified and trained to handle it
Sir, Having spent most of my working life involved with the airworthiness of many types of military aircraft, I read the detailed and forensic report into the loss of Nimrod XV230 with great interest and deep concern (report, Oct 29). There are serious aspects of the report that should concern the public who ought to demand thoroughgoing changes to restore faith in the airworthiness of our military aircraft.
The age of our Nimrod fleet is not unusual for a military aircraft. Our defence budget only allows us to replace aircraft fleets every 30 years or so, and usually heavier aircraft remain in service for longer. During these extended lifetimes aircraft normally change roles and have many different operating procedures. Standard design and maintenance safety regulations are frequently challenged by these changes and new methods of achieving the required levels of safety have to be worked out. All such changes have to be tracked throughout the remaining life of the fleet and new generations of maintenance personnel trained to understand their implications for the long-term battle against the inevitable consequences of metal fatigue, corrosion and the like. The resulting programmes require the reservation of funds and facilities for many years ahead. However, day-to-day problems and crisis arising from training and operations are urgent and never ending. Inevitably, there is a temptation to neglect the longer term with potential disastrous consequences.
From the formation of RAF Strike Command in the early Sixties the engineering branch of the RAF met these challenges by co-locating all the specialist engineering staff for each aircraft in a single office — the Role Office — and required each office to prepare an annual review of its long-term airworthiness plans. By the late 1990s these reviews were heard by the Chief Engineer himself so that he could satisfy the responsibility that all RAF aircraft were airworthy.
The XV230 report details that early this century the post of Chief Engineer was discontinued, that the chain of delegation now no longer passes through the hands of properly qualified and experienced engineers. Instead, it seems to follow the chain of command, which could and did include not just non-engineers but also personnel who had no experience of military aircraft operation. In addition, a whole management layer was removed and with it the capability to supervise the Role Offices — now expanded and retitled integrated project teams. This was a recipe for disaster. It was akin to giving a GP responsibility for the quality and extent of cancer care — or even giving the task to a non-medical person.
The report into XV230 rightly takes to task personnel who failed to meet the standards required of them, but it does not address the larger problem of allowing airworthiness responsibility to be held by untrained personnel. Nor does it sufficiently criticise the convoluted dissipation of airworthiness responsibility in the new tri-service logistic organisation so that the heavy weight of this task is not clearly laid on specific individuals. The public should demand the immediate restoration of airworthiness responsibility to those who are qualified and trained to handle it.
Air Vice-Marshal K. A. Campbell RAF (Ret’d)
I think you should contact the author and get to know him rather than attack his motivation. I can vouch for the purity of what he is trying to achieve and I have seen the enormous amount of work he has done (in his own time), in a tireless effort to improve safety. What the hell were your highly paid representatives in the CofC doing all this time? Looking after their careers? You can call it what you like, it is bl**dy effective and I for one, don't give a stuff if it offends your "sensibilities".
Moving on, this was a constructive and welcome addition to the debate. An AVM moved to write to The Times a couple of days ago;
November 10, 0009
Reinstate qualified RAF engineers
The public should demand the restoration of military airworthiness responsibility to those who are qualified and trained to handle it
Sir, Having spent most of my working life involved with the airworthiness of many types of military aircraft, I read the detailed and forensic report into the loss of Nimrod XV230 with great interest and deep concern (report, Oct 29). There are serious aspects of the report that should concern the public who ought to demand thoroughgoing changes to restore faith in the airworthiness of our military aircraft.
The age of our Nimrod fleet is not unusual for a military aircraft. Our defence budget only allows us to replace aircraft fleets every 30 years or so, and usually heavier aircraft remain in service for longer. During these extended lifetimes aircraft normally change roles and have many different operating procedures. Standard design and maintenance safety regulations are frequently challenged by these changes and new methods of achieving the required levels of safety have to be worked out. All such changes have to be tracked throughout the remaining life of the fleet and new generations of maintenance personnel trained to understand their implications for the long-term battle against the inevitable consequences of metal fatigue, corrosion and the like. The resulting programmes require the reservation of funds and facilities for many years ahead. However, day-to-day problems and crisis arising from training and operations are urgent and never ending. Inevitably, there is a temptation to neglect the longer term with potential disastrous consequences.
From the formation of RAF Strike Command in the early Sixties the engineering branch of the RAF met these challenges by co-locating all the specialist engineering staff for each aircraft in a single office — the Role Office — and required each office to prepare an annual review of its long-term airworthiness plans. By the late 1990s these reviews were heard by the Chief Engineer himself so that he could satisfy the responsibility that all RAF aircraft were airworthy.
The XV230 report details that early this century the post of Chief Engineer was discontinued, that the chain of delegation now no longer passes through the hands of properly qualified and experienced engineers. Instead, it seems to follow the chain of command, which could and did include not just non-engineers but also personnel who had no experience of military aircraft operation. In addition, a whole management layer was removed and with it the capability to supervise the Role Offices — now expanded and retitled integrated project teams. This was a recipe for disaster. It was akin to giving a GP responsibility for the quality and extent of cancer care — or even giving the task to a non-medical person.
The report into XV230 rightly takes to task personnel who failed to meet the standards required of them, but it does not address the larger problem of allowing airworthiness responsibility to be held by untrained personnel. Nor does it sufficiently criticise the convoluted dissipation of airworthiness responsibility in the new tri-service logistic organisation so that the heavy weight of this task is not clearly laid on specific individuals. The public should demand the immediate restoration of airworthiness responsibility to those who are qualified and trained to handle it.
Air Vice-Marshal K. A. Campbell RAF (Ret’d)
Last edited by nigegilb; 12th Nov 2009 at 18:46.
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"Who gives a ***** about airworthiness? That's for Engineers to worry about"
If you're not interested / don't care, fine, leave the threads to those that are and do.
sw
Wow! what a start to a thread that could be of value to a lot of people.
To follow the form of previous intro's:
I'm not a pilot. I did used to be a crew-chief for some years, but I don't consider myself as aircrew in any way. I was in the mob 1975-1999.
I am now a QA manager in a company that you might know. For the past eleven years I have been involved in commercial aviation QA and continued airworthiness - as it is now known.
I know something of EASA and MAOS parts 145 and M (and a few others too). I know that MAOS is certainly the poor relation of EASA. I believe I now understand why the Mil regulation has sections omitted and what a 'full' regulation would do to the MOD Fleets if implemented.
Although I had discussed anomalies in the RAF, I was stunned by H-C's review. However, the voices of denial recorded in these threads is absolutely, gobsmackingly, astounding.
Although I read it on-line, I have purchased a copy and re-read it as I believe it will be used in "Human Factors" courses for a very long while indeed. It is a historic document of bullying, mis-management and blundering.
Nigegilb said:
"...He said Haddon-Cave's report is having an effect across the board, he said from the moment we get up, even when we are brushing our teeth we are thinking about H-C."
I think they bl00dy well should too! To say "Thats the way it was when we got here!" just shows feeble and limp weaknesses for those in-post - the Peter Principle comes to mind.
The findings of H-C need to be read across the whole of the MOD fleets and management processes should be completely re-vamped.
In the meantime we should wait quietly to see what MOD's response is - on December 13th, I believe - and see which way "they" jump.
To follow the form of previous intro's:
I'm not a pilot. I did used to be a crew-chief for some years, but I don't consider myself as aircrew in any way. I was in the mob 1975-1999.
I am now a QA manager in a company that you might know. For the past eleven years I have been involved in commercial aviation QA and continued airworthiness - as it is now known.
I know something of EASA and MAOS parts 145 and M (and a few others too). I know that MAOS is certainly the poor relation of EASA. I believe I now understand why the Mil regulation has sections omitted and what a 'full' regulation would do to the MOD Fleets if implemented.
Although I had discussed anomalies in the RAF, I was stunned by H-C's review. However, the voices of denial recorded in these threads is absolutely, gobsmackingly, astounding.
Although I read it on-line, I have purchased a copy and re-read it as I believe it will be used in "Human Factors" courses for a very long while indeed. It is a historic document of bullying, mis-management and blundering.
Nigegilb said:
"...He said Haddon-Cave's report is having an effect across the board, he said from the moment we get up, even when we are brushing our teeth we are thinking about H-C."
I think they bl00dy well should too! To say "Thats the way it was when we got here!" just shows feeble and limp weaknesses for those in-post - the Peter Principle comes to mind.
The findings of H-C need to be read across the whole of the MOD fleets and management processes should be completely re-vamped.
In the meantime we should wait quietly to see what MOD's response is - on December 13th, I believe - and see which way "they" jump.
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Flip,
The basis for the figures, as per JSP 553, is rooted in civil aviation standards, so there is pedigree in what "should" happen.
As regards Feyman, I haven't heard the quote from him (his Appendix to the Roger's Commission is here: http://www.ralentz.com/old/space/feynman-report.html, but suspect he may be mis-quoted / mis-understood (although he is very critical of the probabilities used). But I have heard something similar said of software safety from a Prof Bev Littlewood, along the lines of "If you try to tell me that the probability of your software failing in a hazardous way is 1 :1 000 000, I won't believe you, but if you tell me that it will never fail in a hazardous way, I'm much more likely to believe you" This first bit is on the basis that testing software to that degree is not feasible, but if someone presents an argument that the software will never fail in a hazardous way, they must have a very good case for saying so.
As regards 1:100 000 being crap, here's an example of why I think he's been misquoted. Take a function, with the potential for catstrophic failure, and the system has a p(F) of 1:1000. If the function has a parallel system, providing the same function, but independently ie no common mode failures, and with the same p(F), such that the probability of a catastophic failure depends on both systems failing then the probability of this is p(F) system A x p(F) system B. ie 1:1 000 000. Building 2 systems to 1:1000 is far easier to demonstrate than 1 system to 1:1 000 000.
sw
The basis for the figures, as per JSP 553, is rooted in civil aviation standards, so there is pedigree in what "should" happen.
As regards Feyman, I haven't heard the quote from him (his Appendix to the Roger's Commission is here: http://www.ralentz.com/old/space/feynman-report.html, but suspect he may be mis-quoted / mis-understood (although he is very critical of the probabilities used). But I have heard something similar said of software safety from a Prof Bev Littlewood, along the lines of "If you try to tell me that the probability of your software failing in a hazardous way is 1 :1 000 000, I won't believe you, but if you tell me that it will never fail in a hazardous way, I'm much more likely to believe you" This first bit is on the basis that testing software to that degree is not feasible, but if someone presents an argument that the software will never fail in a hazardous way, they must have a very good case for saying so.
As regards 1:100 000 being crap, here's an example of why I think he's been misquoted. Take a function, with the potential for catstrophic failure, and the system has a p(F) of 1:1000. If the function has a parallel system, providing the same function, but independently ie no common mode failures, and with the same p(F), such that the probability of a catastophic failure depends on both systems failing then the probability of this is p(F) system A x p(F) system B. ie 1:1 000 000. Building 2 systems to 1:1000 is far easier to demonstrate than 1 system to 1:1 000 000.
sw
How many other instances are there of a lack of implementation of the airworthiness regulations? Sea King HISL? Tornado IFF? Chinook FADEC? Puma Anticipators?
While we should embrace the progress which one hopes will result from the shocking loss of XV230, we shouldn't use it to shield ourselves from the fact that, in many cases, the aircraft is perfectly airworthy - whether 3 years old or 30 - and it may simply be down to the crew that the accident happened. And if, one day, I make a mistake and end up in a crash of my own making, I would want people to learn from my mistake rather than have the episode hijacked by talk of airworthiness which MIGHT be totally irrelevant.
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Conspiracy Theories?
Before anyone jumps to conclusions about conspiracies, I asked the Mods to merge my thread on H-C's issues with Flip's, so that the report's issues can be discussed in one place.
Flip - hope you don't mind - it still get's your title!
sw
Flip - hope you don't mind - it still get's your title!
sw
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TOTD,
I wouldn't want airworthiness to be the scapegoat every time either. If there is a "technical failure" aspect which comes within JSP553 requirements then fine. Everyone needs to remember that the greater risk is from human factors (70 - 80%??) rather than technical failure, so lets put efforts there as well.
sw
I wouldn't want airworthiness to be the scapegoat every time either. If there is a "technical failure" aspect which comes within JSP553 requirements then fine. Everyone needs to remember that the greater risk is from human factors (70 - 80%??) rather than technical failure, so lets put efforts there as well.
sw
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SW, just so long as you don't pull the thread!!
There will, no doubt, be more reporting of airworthiness issues in the coming days.
I understand the worries of attributing everything to airworthiness failures. To be fair, there is nothing new in those fatal accidents listed above, we have been banging the drum for some time, it appears we are gaining a wider audience, at last. And Haddon-Cave referred to systemic problems at the MoD, so it would appear the argument is largely won.
The focus in the coming days will most likely fall on the Sea King collision. I am hoping that evidence will be sufficiently strong to cause either the investigation or the inquest to be re-opened.
WRT Puma fatal accidents on ops. I understand that the SF role given to the Puma in Iraq, is no longer applicable, so the operational pressures have now been removed. Agree with SW though, human factors do appear to have significantly affected these crashes. That said, aircrew training is an aspect of airworthiness, I do wonder if the crews had been properly trained for the SF role.
There will, no doubt, be more reporting of airworthiness issues in the coming days.
I understand the worries of attributing everything to airworthiness failures. To be fair, there is nothing new in those fatal accidents listed above, we have been banging the drum for some time, it appears we are gaining a wider audience, at last. And Haddon-Cave referred to systemic problems at the MoD, so it would appear the argument is largely won.
The focus in the coming days will most likely fall on the Sea King collision. I am hoping that evidence will be sufficiently strong to cause either the investigation or the inquest to be re-opened.
WRT Puma fatal accidents on ops. I understand that the SF role given to the Puma in Iraq, is no longer applicable, so the operational pressures have now been removed. Agree with SW though, human factors do appear to have significantly affected these crashes. That said, aircrew training is an aspect of airworthiness, I do wonder if the crews had been properly trained for the SF role.
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I am seeing Bill Rammel on Monday and part of one of my questions(Sent in advance) is:
In the light of the Nimrod Review, does the MOD intend to revisit with some urgency, all the work on Airworthiness and Safety undertaken for the MOD/RAF by those people named in the review from the MOD.RAF,BAE and QinetiQ.
I will post his answer on here on Tuesday morning.
In the light of the Nimrod Review, does the MOD intend to revisit with some urgency, all the work on Airworthiness and Safety undertaken for the MOD/RAF by those people named in the review from the MOD.RAF,BAE and QinetiQ.
I will post his answer on here on Tuesday morning.
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Maybe you should quote the witness below Graham. This is precisely why H-C was right to name and shame. Don't worry about Rammell, let's just get them in court.
QinetiQ’s representative ‘booed’
I turn now to consider the role of QinetiQ’s representative, Witness O [QinetiQ], during the Customer Acceptance Conference. At the beginning of the meeting, Witness O [QinetiQ] introduced himself and explained that was standing in for Martyn Mahy at short notice. He was seated beside Frank Walsh. He had not previously been involved in the NSC and was not familiar with the project or the detail. Accordingly, he was for the most part a passive observer during the meeting. He said that everyone else seemed to know each other and that he felt like “a fish out of water”. He did, however, raise the question of the level of risk mitigation controls in place during the demonstration of CASSANDRA. He was told that the risk mitigation was only 85-90% completed but would be before the Phase 2 was completed.
When, at the end of the second day, all present were asked to state in turn whether they supported the completion of Phase 2 of the NSC by BAE Systems, Witness O [QinetiQ] said that, because he was only standing in for Martyn Mahy and had not seen any of the key deliverable documents, he felt that he could not validate BAE Systems’ claim that these documents satisfied the contractual requirements. His account in his statement to the Review of what then happened is striking:
“I have a strong memory that upon stating this, various meeting attendees booed me and muttered things along the lines ‘bloody safety engineers always have to caveat their statements’. I can remember this clearly because I have never been booed in a meeting before (and have not been at any time since).”
He said that, although the booing was not intentionally aggressive, he found it intimidating and was surprised and embarrassed at being heckled in this manner. BAE Systems’ representatives were questioned about this matter in interview, but said they had had no recollection of such an incident. I have no reason, however, to doubt Witness O [QinetiQ]’s recollection of being subject to this sort of treatment at the meeting. It has the ring of truth about it.
QinetiQ’s representative ‘booed’
I turn now to consider the role of QinetiQ’s representative, Witness O [QinetiQ], during the Customer Acceptance Conference. At the beginning of the meeting, Witness O [QinetiQ] introduced himself and explained that was standing in for Martyn Mahy at short notice. He was seated beside Frank Walsh. He had not previously been involved in the NSC and was not familiar with the project or the detail. Accordingly, he was for the most part a passive observer during the meeting. He said that everyone else seemed to know each other and that he felt like “a fish out of water”. He did, however, raise the question of the level of risk mitigation controls in place during the demonstration of CASSANDRA. He was told that the risk mitigation was only 85-90% completed but would be before the Phase 2 was completed.
When, at the end of the second day, all present were asked to state in turn whether they supported the completion of Phase 2 of the NSC by BAE Systems, Witness O [QinetiQ] said that, because he was only standing in for Martyn Mahy and had not seen any of the key deliverable documents, he felt that he could not validate BAE Systems’ claim that these documents satisfied the contractual requirements. His account in his statement to the Review of what then happened is striking:
“I have a strong memory that upon stating this, various meeting attendees booed me and muttered things along the lines ‘bloody safety engineers always have to caveat their statements’. I can remember this clearly because I have never been booed in a meeting before (and have not been at any time since).”
He said that, although the booing was not intentionally aggressive, he found it intimidating and was surprised and embarrassed at being heckled in this manner. BAE Systems’ representatives were questioned about this matter in interview, but said they had had no recollection of such an incident. I have no reason, however, to doubt Witness O [QinetiQ]’s recollection of being subject to this sort of treatment at the meeting. It has the ring of truth about it.
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An example of how the MoD do airworthiness
20 January 2005: E-mail from Frank Walsh to George Baber
On 20 January 2005, Frank Walsh e-mailed George Baber as follows:
“George,
All the hazards in CASSANDRA, with the exception of H2 .... have controls
and references in place to show that they are at ALARP. I am awaiting a copy of the Unit snow and ice plan to include as mitigation for H2. I believe that the hazards, except H2, should be set to MANAGED on CASSANDRA now and H2 when the last piece of mitigation is in place. If you agree I will instruct BAE Systems to amend CASSANDRA. Frank”
Frank Walsh’s e-mail does not appear to have contained any detail or supporting material or referenced any input from the Nimrod IPT Specialist Desks or Heads of Branch or Michael Eagles. Nevertheless, it appears
that George Baber was prepared to approve his request, because subsequently, on 1 February 2005, Frank Walsh wrote to BAE Systems authorising them to set the post control status of the hazards in CASSANDRA
in accordance with an attached annex (Annex A) which he had prepared (see further below). I discuss in Chapter 11 the significance of this and other steps taken in relation to the sentencing of the remaining risks.
The above e-mail shows an informality of approach to the sentencing of risks by both George Baber as IPTL and Frank Walsh as Safety Manager. George Baber’s explanation in interview was “I trusted him and I took
what he said at face value”. It remained, however, George Baber’s personal responsibility as IPTL, Project Engineer and Letter of Delegation holder, to ensure that the risks were properly sentenced.
1 February 2005: Frank Walsh’s memo to BAE Systems
On 1 February 2005, Frank Walsh drafted a memo to BAE Systems which he signed and sent out under his own name. It stated that the Nimrod IPT had reviewed the BLSC produced by BAE Systems, agreed with the status of the hazards set by BAE Systems, and had considered the evidence to set the rest. Attached to the memo was an annex (Annex A) entitled “Evidence for Mitigation of Hazards” (Annex A) which he had prepared, and which was described as “the evidence that should be entered into the hazard log as controls and the post control status as decided by the IPT”. Frank Walsh said that his Annex A was based on a template which he had been sent by Witness C [BAE Systems]. It was not clear when, but probably shortly before.
Annex A
Frank Walsh’s Annex A purported to show the mitigating Controls and Post Control Status of 33 hazards. 32 of these hazards were those which BAE Systems had left “Open” and “Unclassified” in Annex B to the BLSC.6
A total of 21 of these were referred to as “Interacting Systems” hazards and contained identical entries.
It is clear, therefore, that by 1 February 2005, Frank Walsh had had a look at Annexes B and C of the BLSC
Reports and discovered that there were, in fact, a large number of “Open” and “Unclassified” hazards which remained to be sentenced. This contrasted starkly with the picture which he had presented to the Sixth PSWG when he had highlighted only a handful of hazards as requiring action.
Frank Walsh’s realisation
It is not clear precisely when, and how, Frank Walsh, came by this realisation or revelation. He was unable or unwilling to give a clear or satisfactory explanation to the Review in interview. It is likely that, sometime after the Sixth PSWG meeting had tasked him to produce a document to ‘sign-off’ the NSC, he turned to the BLSC Reports and discovered that there were in fact a large number of hazards which had been left “Open” and “Unclassified”. Upon making this discovery, it appears that he did not (as one might expect) immediately draw it to the attention of Michael Eagles or George Baber. The question arises, why not? The likelihood is that it was a combination of the fact that he was simply too embarrassed at this point in time because he should have spotted it earlier, and a sense that it did not really matter because the task had been formally signed-off and the Nimrod was safe anyway, and a belief that he could quietly find mitigating evidence to sentence all the remaining hazards without difficulty. This is, in any event, what he proceeded to do. Unfortunately, Frank Walsh’s attempt to sentence these hazards (including Hazard H73) {The critical catastrophic fire hazard relating to the Cross-Feed/SCP duct had not been properly assessed and, in fact, was one of those left “Open” and “Unclassified”} was woefully inadequate. There exists no documentary trail, however, of precisely how he went about it.
On 20 January 2005, Frank Walsh e-mailed George Baber as follows:
“George,
All the hazards in CASSANDRA, with the exception of H2 .... have controls
and references in place to show that they are at ALARP. I am awaiting a copy of the Unit snow and ice plan to include as mitigation for H2. I believe that the hazards, except H2, should be set to MANAGED on CASSANDRA now and H2 when the last piece of mitigation is in place. If you agree I will instruct BAE Systems to amend CASSANDRA. Frank”
Frank Walsh’s e-mail does not appear to have contained any detail or supporting material or referenced any input from the Nimrod IPT Specialist Desks or Heads of Branch or Michael Eagles. Nevertheless, it appears
that George Baber was prepared to approve his request, because subsequently, on 1 February 2005, Frank Walsh wrote to BAE Systems authorising them to set the post control status of the hazards in CASSANDRA
in accordance with an attached annex (Annex A) which he had prepared (see further below). I discuss in Chapter 11 the significance of this and other steps taken in relation to the sentencing of the remaining risks.
The above e-mail shows an informality of approach to the sentencing of risks by both George Baber as IPTL and Frank Walsh as Safety Manager. George Baber’s explanation in interview was “I trusted him and I took
what he said at face value”. It remained, however, George Baber’s personal responsibility as IPTL, Project Engineer and Letter of Delegation holder, to ensure that the risks were properly sentenced.
1 February 2005: Frank Walsh’s memo to BAE Systems
On 1 February 2005, Frank Walsh drafted a memo to BAE Systems which he signed and sent out under his own name. It stated that the Nimrod IPT had reviewed the BLSC produced by BAE Systems, agreed with the status of the hazards set by BAE Systems, and had considered the evidence to set the rest. Attached to the memo was an annex (Annex A) entitled “Evidence for Mitigation of Hazards” (Annex A) which he had prepared, and which was described as “the evidence that should be entered into the hazard log as controls and the post control status as decided by the IPT”. Frank Walsh said that his Annex A was based on a template which he had been sent by Witness C [BAE Systems]. It was not clear when, but probably shortly before.
Annex A
Frank Walsh’s Annex A purported to show the mitigating Controls and Post Control Status of 33 hazards. 32 of these hazards were those which BAE Systems had left “Open” and “Unclassified” in Annex B to the BLSC.6
A total of 21 of these were referred to as “Interacting Systems” hazards and contained identical entries.
It is clear, therefore, that by 1 February 2005, Frank Walsh had had a look at Annexes B and C of the BLSC
Reports and discovered that there were, in fact, a large number of “Open” and “Unclassified” hazards which remained to be sentenced. This contrasted starkly with the picture which he had presented to the Sixth PSWG when he had highlighted only a handful of hazards as requiring action.
Frank Walsh’s realisation
It is not clear precisely when, and how, Frank Walsh, came by this realisation or revelation. He was unable or unwilling to give a clear or satisfactory explanation to the Review in interview. It is likely that, sometime after the Sixth PSWG meeting had tasked him to produce a document to ‘sign-off’ the NSC, he turned to the BLSC Reports and discovered that there were in fact a large number of hazards which had been left “Open” and “Unclassified”. Upon making this discovery, it appears that he did not (as one might expect) immediately draw it to the attention of Michael Eagles or George Baber. The question arises, why not? The likelihood is that it was a combination of the fact that he was simply too embarrassed at this point in time because he should have spotted it earlier, and a sense that it did not really matter because the task had been formally signed-off and the Nimrod was safe anyway, and a belief that he could quietly find mitigating evidence to sentence all the remaining hazards without difficulty. This is, in any event, what he proceeded to do. Unfortunately, Frank Walsh’s attempt to sentence these hazards (including Hazard H73) {The critical catastrophic fire hazard relating to the Cross-Feed/SCP duct had not been properly assessed and, in fact, was one of those left “Open” and “Unclassified”} was woefully inadequate. There exists no documentary trail, however, of precisely how he went about it.
Last edited by nigegilb; 13th Nov 2009 at 10:08.
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safeware
no probs - thanks don't fullly appreciate the nuances of thread ownership but I would like this one to run. Thanks also for link. On what objective data are the values applied to the probabilities in the cases I mentioned? Who collates these stats? What about the widely acclamied Perrow Normal Accident Theory - surely a military ac and its supporting systems are both 'tightly coupled' and 'complex'? The less funding we have and the leaner we are, then it follows that the more 'complex' and 'tight' we get? Accidents are therefore assured, if not a certainty.
Mods
Please don't let the ill-considered and personal attacks by some minority posters prompt you to pull the thread - that would only play into their hands, the more they squeal, the warmer we are getting.
Roland P
Sorry, I think you may have misunderstood - I posted questions not statements - conspiracy theories I am not willing to believe (yet) - more likely, its is because of govt/MoD incompetence and/or perhaps a lack of integrity; it wouldn't be first time, would it? However, the MoD/CS/Sen Ofs are only human and I am quite happy to forgive and foget most errors and lapses, as long as
a. They were not willful violations or self-serving abbrogations of duty.
b. The lapses and faults are acknowledged and put right PDQ.
Everyone else
This is no crusade but the fact remains that a number of accidents have implicated a lack of airworthiness compliance as a cause. Of course, this was not the only cause but as it has become a common occurence, I think it should be of grave concern to ALL operators. Accidents are often system failures and rarely, is the final act of the operator the SOLE cause, though he/she might be the last one able to prevent the completion of the chain of events. 'Operator error' is often a smokescreen behind which management can hide.
And....
Yes, to a certain degree, airworthiness is the domain of safety engineers and designers - but they can't be expected to forsee everything (and an operator who is completely unaware of this is missing a part of his own defences). Nonethless, on the basis of previous experience, the engineers are directed to consider certain 'givens' by the regulations (eg fire protection of certain ac parts, lighting considerations and training systems). It is obvious that this 'dark world' has lost its capability to comply with those regs and the operators aren't being told. This, I would argue, is unaccaeptable. If you disagree, please add your tuppence worth but I suspect that the crews and the families of XV179, 230, 704 and 650 might not agree with you.
To all operators out there - it is your choice - do you trust the airworthiness system any more? Do you know the weaknesses of your systems? If you take an active interest in the functional safety of your platform and try to identify and gaps or lapses, only then can you make informed decisions about how you operate. Increasingly, it is up to you to ask those questions - but your crew and pax might also like to know.
sincerely,
flipster
no probs - thanks don't fullly appreciate the nuances of thread ownership but I would like this one to run. Thanks also for link. On what objective data are the values applied to the probabilities in the cases I mentioned? Who collates these stats? What about the widely acclamied Perrow Normal Accident Theory - surely a military ac and its supporting systems are both 'tightly coupled' and 'complex'? The less funding we have and the leaner we are, then it follows that the more 'complex' and 'tight' we get? Accidents are therefore assured, if not a certainty.
Mods
Please don't let the ill-considered and personal attacks by some minority posters prompt you to pull the thread - that would only play into their hands, the more they squeal, the warmer we are getting.
Roland P
Sorry, I think you may have misunderstood - I posted questions not statements - conspiracy theories I am not willing to believe (yet) - more likely, its is because of govt/MoD incompetence and/or perhaps a lack of integrity; it wouldn't be first time, would it? However, the MoD/CS/Sen Ofs are only human and I am quite happy to forgive and foget most errors and lapses, as long as
a. They were not willful violations or self-serving abbrogations of duty.
b. The lapses and faults are acknowledged and put right PDQ.
Everyone else
This is no crusade but the fact remains that a number of accidents have implicated a lack of airworthiness compliance as a cause. Of course, this was not the only cause but as it has become a common occurence, I think it should be of grave concern to ALL operators. Accidents are often system failures and rarely, is the final act of the operator the SOLE cause, though he/she might be the last one able to prevent the completion of the chain of events. 'Operator error' is often a smokescreen behind which management can hide.
And....
Yes, to a certain degree, airworthiness is the domain of safety engineers and designers - but they can't be expected to forsee everything (and an operator who is completely unaware of this is missing a part of his own defences). Nonethless, on the basis of previous experience, the engineers are directed to consider certain 'givens' by the regulations (eg fire protection of certain ac parts, lighting considerations and training systems). It is obvious that this 'dark world' has lost its capability to comply with those regs and the operators aren't being told. This, I would argue, is unaccaeptable. If you disagree, please add your tuppence worth but I suspect that the crews and the families of XV179, 230, 704 and 650 might not agree with you.
To all operators out there - it is your choice - do you trust the airworthiness system any more? Do you know the weaknesses of your systems? If you take an active interest in the functional safety of your platform and try to identify and gaps or lapses, only then can you make informed decisions about how you operate. Increasingly, it is up to you to ask those questions - but your crew and pax might also like to know.
sincerely,
flipster