Haddon-Cave, Airworthiness, Sea King et al (merged)
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Flipster; "However, the MoD/CS/Sen Ofs are only human and I am quite happy to forgive and forget 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."
FRANK WALSH;
"Frank Walsh, who worked as safety manager for the Nimrod review and was the MoD's primary point of contact with the BAE Systems team carrying out the work, is said to have assessed hazards himself in a "slapdash" manner and failed to alert his superiors when he realised he had overlooked important issues.(Of greatest concern here is Hazard 73).
The report states: "Frank Walsh's failure to put his hand up and admit to his superiors that he had overlooked matters, and then effectively to cover over his mistakes, is his most serious failing. In doing so, he failed to act honourably.
"In matters of safety, there can be no compromise on openness and honesty."
However, the report's author noted that he should not have been placed in the position of having to manage the project with little, or no, supervision or guidance.
Mr Walsh no longer works at the Ministry of Defence."
So Frank Walsh is alleged to have failed to have acted honourably or honestly. Category A case Flip?
I wonder if he received an MoD bonus? Let's hope John Cooper is taking an interest.....
a. They were not willful violations or self-serving abbrogations of duty.
b. The lapses and faults are acknowledged and put right PDQ."
FRANK WALSH;
"Frank Walsh, who worked as safety manager for the Nimrod review and was the MoD's primary point of contact with the BAE Systems team carrying out the work, is said to have assessed hazards himself in a "slapdash" manner and failed to alert his superiors when he realised he had overlooked important issues.(Of greatest concern here is Hazard 73).
The report states: "Frank Walsh's failure to put his hand up and admit to his superiors that he had overlooked matters, and then effectively to cover over his mistakes, is his most serious failing. In doing so, he failed to act honourably.
"In matters of safety, there can be no compromise on openness and honesty."
However, the report's author noted that he should not have been placed in the position of having to manage the project with little, or no, supervision or guidance.
Mr Walsh no longer works at the Ministry of Defence."
So Frank Walsh is alleged to have failed to have acted honourably or honestly. Category A case Flip?
I wonder if he received an MoD bonus? Let's hope John Cooper is taking an interest.....
Last edited by nigegilb; 13th Nov 2009 at 10:21.
I spent the most miserable seven years of my life as a Quality Manager of an 05/21 registered company supplying parts and services to the Defence industry. In that time I went thorough a variety of audits by the MoD (PE) and some of them were corrupt, slapdash and slovenly. The first one was a new experience for me as, before lunch, the auditor did about 20 minutes work and, after lunch, he was drunk and argumentative. I passed the audit with three minor defects which, I was later told, he always found. I was both relieved and disgusted.
Haddon-Cave has effectively carried out a representative Quality Audit on the MoD and it's supply chain (look at the supply chain for rubber seals). It has been found seriously wanting and, if this had happened to one of it's suppliers, the supplier would have lost any approvals it had. He has named some names but, just as a defect in a quality sample rejects the whole batch, the whole of the MoD should be considered to be below par until it proves otherwise. It cannot heal itself, the only answer would seem to be the urgent setting up of an independent MAA. Where you will find enough suitably qualified engineers who have not already been corrupted by the MoD system I do not know.
Haddon-Cave has effectively carried out a representative Quality Audit on the MoD and it's supply chain (look at the supply chain for rubber seals). It has been found seriously wanting and, if this had happened to one of it's suppliers, the supplier would have lost any approvals it had. He has named some names but, just as a defect in a quality sample rejects the whole batch, the whole of the MoD should be considered to be below par until it proves otherwise. It cannot heal itself, the only answer would seem to be the urgent setting up of an independent MAA. Where you will find enough suitably qualified engineers who have not already been corrupted by the MoD system I do not know.
I have now read the H-C report, which I found very disturbing, but not really surprising. With a masters degree in aircraft design, over 25 years service in the RAF as an engineering officer and having been an airline CAA nominated post holder on two occasions since retirement from the Service I hope I can add informed comment to this thread.
The responsibility for airworthiness in the civilian world is clear cut. The industry is heavily regulated, all key personnel are licensed/approved by the relevant Authority and there are formal checks and balances. Despite the inevitable commercial pressures of running an airline, if an engineering director holds up his "airworthiness card" the bean counters can be effectively kept at bay.
The RAF does not have such a formal system (please don't bring up MAOS, it is nowhere near yet fit for purpose). Nevertheless, until the mid 1990s the RAF's airworthiness chain was pretty well defined; this is referred to in Archie Campbell's recent letter to the Times. Moreover, we had the post of Chief Engineer (CE), which carried with it the ultimate authority for airworthiness. This post was successively filled by men of stature, who engendered admiration, respect and, dare I say it, affection within the Engineering Branch. (The last of these was Bill Richardson, who was dined out by his Branch at RAF Abingdon). This ethos was particularly important in maintaining the professionalism of the Branch.
Three things happened to change this. First, the CE post became Chief of Logistic Support (CLS) and the Engineering and Supply Branches moved closer together, blurring the edges. Second, we had a number of occupants of the CLS post, who most certainly did not earn the admiration, respect and affection of their subordinates. Third, we embarked on a series of Defence Reviews, which put budgets as the principal focus. These three issues combined to start and continue the rot.
Fifeen years on we have reached the unacceptable level so starkly highlighted by the H-C report. There is no clear leadership (all the leaders and commanders have been replaced by managers and executives). There is no clearly defined airworthiness chain. There are no adequate checks and balances within the MoD. There are people in positions with responsibility for airworthiness who are not competent to do the job. Perhaps most significantly, the increased use of outsourcing, the pressure on budgets and the focus on logistics rather than engineering has emasculated the Engineering Branch. This has driven many talented engineering officers to leave, rather than pursue a full career in the RAF, further diluting the expertise within the Engineering Branch.
In all of this I ask myself whether an old fashioned CE would have, well before now, held up his "airworthiness card". The answer is most probably yes!
What can be done? The MoD clearly needs to digest the thrusts of the H-C report and make a prompt and measured response. The airworthiness chain needs to be quickly re-established, with clear-cut responsibilities and, most importantly, effective leadership. Existing safety cases must be critically re-examined - and quickly. In my view some form of independent military airworthiness authority is now inevitable; I do not believe the MoD is now capable of setting up and maintaining and audit system that will provide adequate assurance of ongoing airworthiness across all fleets. (Perhaps I'll even offer my services!).
The responsibility for airworthiness in the civilian world is clear cut. The industry is heavily regulated, all key personnel are licensed/approved by the relevant Authority and there are formal checks and balances. Despite the inevitable commercial pressures of running an airline, if an engineering director holds up his "airworthiness card" the bean counters can be effectively kept at bay.
The RAF does not have such a formal system (please don't bring up MAOS, it is nowhere near yet fit for purpose). Nevertheless, until the mid 1990s the RAF's airworthiness chain was pretty well defined; this is referred to in Archie Campbell's recent letter to the Times. Moreover, we had the post of Chief Engineer (CE), which carried with it the ultimate authority for airworthiness. This post was successively filled by men of stature, who engendered admiration, respect and, dare I say it, affection within the Engineering Branch. (The last of these was Bill Richardson, who was dined out by his Branch at RAF Abingdon). This ethos was particularly important in maintaining the professionalism of the Branch.
Three things happened to change this. First, the CE post became Chief of Logistic Support (CLS) and the Engineering and Supply Branches moved closer together, blurring the edges. Second, we had a number of occupants of the CLS post, who most certainly did not earn the admiration, respect and affection of their subordinates. Third, we embarked on a series of Defence Reviews, which put budgets as the principal focus. These three issues combined to start and continue the rot.
Fifeen years on we have reached the unacceptable level so starkly highlighted by the H-C report. There is no clear leadership (all the leaders and commanders have been replaced by managers and executives). There is no clearly defined airworthiness chain. There are no adequate checks and balances within the MoD. There are people in positions with responsibility for airworthiness who are not competent to do the job. Perhaps most significantly, the increased use of outsourcing, the pressure on budgets and the focus on logistics rather than engineering has emasculated the Engineering Branch. This has driven many talented engineering officers to leave, rather than pursue a full career in the RAF, further diluting the expertise within the Engineering Branch.
In all of this I ask myself whether an old fashioned CE would have, well before now, held up his "airworthiness card". The answer is most probably yes!
What can be done? The MoD clearly needs to digest the thrusts of the H-C report and make a prompt and measured response. The airworthiness chain needs to be quickly re-established, with clear-cut responsibilities and, most importantly, effective leadership. Existing safety cases must be critically re-examined - and quickly. In my view some form of independent military airworthiness authority is now inevitable; I do not believe the MoD is now capable of setting up and maintaining and audit system that will provide adequate assurance of ongoing airworthiness across all fleets. (Perhaps I'll even offer my services!).
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One small observation:- Is it not correct that there were flaws in the No 7 bay design that go back all the way to the late 60s and also a failure to act on information from the AEW3 programme in the 80's? Why was the 'airworthiness card' not held up then?
Is it not a little simplistic to think that every problem was created in the last 15 years and all that went before that must have been perfect?
Fatal airworthiness failures that needed the 'airworthiness card' are not just limited to the military world:-
http://www.pprune.org/rotorheads/365...aboard-26.html
http://www.pprune.org/rotorheads/365...aboard-27.html
So replicating a CAA is not an automatic answer.
Is it not a little simplistic to think that every problem was created in the last 15 years and all that went before that must have been perfect?
Fatal airworthiness failures that needed the 'airworthiness card' are not just limited to the military world:-
http://www.pprune.org/rotorheads/365...aboard-26.html
http://www.pprune.org/rotorheads/365...aboard-27.html
So replicating a CAA is not an automatic answer.
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1.3 vstall,
I can understand why H-C implies the breakdown/erosion of safety regulation in the MoD was a top down process. Certainly I agree with his assertion that MoD need to re-establish the post of Chief Engineer, (pity the blinkered MoD couldn't see the damage being done for themselves). Nobody would appear to be arguing against this recommendation and I doubt the MoD will resist when they eventually get round to replying to the report. However, those who have considerable experience in trying to maintain military airworthiness argue that the erosion started years before, from the bottom up.
Just wondered if you had any experience of this bottom up erosion.
Latest News;
The head of the multinational arms company BAE Systems, has provoked criticism with a dismissive comment about the Haddon-Cave Report into the deaths of 14 members of the UK armed forces in a Nimrod aircraft.
The report attributed a heavy portion of the blame for the deaths to BAE, but when questioned about it in London yesterday evening (12 November), BAE's chair Dick Olver rejected the report's findings because Haddon-Cave had interviewed "only" 19 BAE officials. Olver said that he would not “be blown off course by comments about 19 people”.
The remarks followed Olver's delivery of the Mountbatten Memorial Lecture, a public event, at the Institute for Engineering and Technology. He focused on the theme of “ethical leadership”.
During his lecture, Olver insisted that BAE was thoroughly implementing a set of ethical guidelines which it had accepted in 2008. When questioned from the floor by Symon Hill, associate director of the thinktank Ekklesia, Olver described the Nimrod incident as a “tragedy” and said that his company would look very carefully at Haddon-Cave's comments.
When it was pointed out that Haddon-Cave had declared that BAE was not following its own ethical guidelines, Olver became flustered, saying “I reject that absolutely”, and adding “I will not be blown off course by comments about 19 people or anything else”.
The Haddon-Cave Report declared that “BAE Systems has failed to implement its expressed ethical business culture company-wide. The responsibility for this must lie with the leadership”.
Haddon-Cave insisted that “Throughout my review BAE Systems has been a company in denial”.
The report found that BAE shared responsibility for Nimrod's failings with Qinetiq, another arms company, as well as with the Ministry of Defence.
Olver faced several challenging questions after his lecture, some of which focused on the ethics of selling arms to dictators.
He said that all BAE employees are bound by a “clear and consistent code of conduct” wherever they operate. He insisted that his company was not corrupt and argued that the arms trade was not unethical.
Although the IET said that it was “delighted” to welcome Olver, there has been widespread derision at the concept of a leading arms dealer lecturing on ethics. Kaye Stearman of the Campaign Against Arms Trade (CAAT) has compared it to “Nick Griffin lecturing on multi-racial harmony or Bernard Madoff on financial probity”.
BAE has long been criticised by churches, faith groups, charities and NGOs for arming oppressive regimes such as Saudi Arabia and Indonesia. The company is facing allegations of corruption in five continents and is thought to be on the brink of prosecution in British courts.
I can understand why H-C implies the breakdown/erosion of safety regulation in the MoD was a top down process. Certainly I agree with his assertion that MoD need to re-establish the post of Chief Engineer, (pity the blinkered MoD couldn't see the damage being done for themselves). Nobody would appear to be arguing against this recommendation and I doubt the MoD will resist when they eventually get round to replying to the report. However, those who have considerable experience in trying to maintain military airworthiness argue that the erosion started years before, from the bottom up.
Just wondered if you had any experience of this bottom up erosion.
Latest News;
The head of the multinational arms company BAE Systems, has provoked criticism with a dismissive comment about the Haddon-Cave Report into the deaths of 14 members of the UK armed forces in a Nimrod aircraft.
The report attributed a heavy portion of the blame for the deaths to BAE, but when questioned about it in London yesterday evening (12 November), BAE's chair Dick Olver rejected the report's findings because Haddon-Cave had interviewed "only" 19 BAE officials. Olver said that he would not “be blown off course by comments about 19 people”.
The remarks followed Olver's delivery of the Mountbatten Memorial Lecture, a public event, at the Institute for Engineering and Technology. He focused on the theme of “ethical leadership”.
During his lecture, Olver insisted that BAE was thoroughly implementing a set of ethical guidelines which it had accepted in 2008. When questioned from the floor by Symon Hill, associate director of the thinktank Ekklesia, Olver described the Nimrod incident as a “tragedy” and said that his company would look very carefully at Haddon-Cave's comments.
When it was pointed out that Haddon-Cave had declared that BAE was not following its own ethical guidelines, Olver became flustered, saying “I reject that absolutely”, and adding “I will not be blown off course by comments about 19 people or anything else”.
The Haddon-Cave Report declared that “BAE Systems has failed to implement its expressed ethical business culture company-wide. The responsibility for this must lie with the leadership”.
Haddon-Cave insisted that “Throughout my review BAE Systems has been a company in denial”.
The report found that BAE shared responsibility for Nimrod's failings with Qinetiq, another arms company, as well as with the Ministry of Defence.
Olver faced several challenging questions after his lecture, some of which focused on the ethics of selling arms to dictators.
He said that all BAE employees are bound by a “clear and consistent code of conduct” wherever they operate. He insisted that his company was not corrupt and argued that the arms trade was not unethical.
Although the IET said that it was “delighted” to welcome Olver, there has been widespread derision at the concept of a leading arms dealer lecturing on ethics. Kaye Stearman of the Campaign Against Arms Trade (CAAT) has compared it to “Nick Griffin lecturing on multi-racial harmony or Bernard Madoff on financial probity”.
BAE has long been criticised by churches, faith groups, charities and NGOs for arming oppressive regimes such as Saudi Arabia and Indonesia. The company is facing allegations of corruption in five continents and is thought to be on the brink of prosecution in British courts.
Last edited by nigegilb; 13th Nov 2009 at 15:22.
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Right at the beginning of this thread, Safeware quoted the Haddon-Cave report (HC):
and then asked:
I don't think so. At least not in the sense that Safeware is enquiring (for risks that are just a little higher than "broadly acceptable").
I think I criticised Qinetiq's (QQ) use of the term "tolerably safe" in one of my posts on the Nimrod thread, mostly because they didn't define it (and it isn't defined in any authoritative document that I know of). Even if Safeware has a point (though see below) and QQ intended a similar usage to that he intends, they should have defined the term. They're not the only offenders - many air IPTs have done the same.
As it goes, I have been told that the term "tolerably safe" was introduced to military air safety as "weasel words" to help justify continued operation when you have tolerable risks that have not been demonstarted ALARP. I.e., not to cover the situation that Safeware describes when your risk is just a little higher than "broadly acceptable" but any situation when your risks are tolerable but not necessarily ALARP.
Of course, there is intuitively something intrinsically more acceptable about a risk that is only a little higher than "broadly acceptable" as opposed to one that is just short of "intolerable". But that is factored into the difficulties of demonstrating the two risks ALARP. Basically, the first will very likely be easy to demonstrate ALARP (unless it really is risk without any benefit) but the second will be virtually impossible to demonstrate ALARP.
Flipster wrote:
In principle, whenever a target like this is allocated, it should be justified. In practice (in my experience), the justification is often missing. Def Stan 00-56, Issue 2 (we're now at Issue 4) contained an example risk matrix. The intention was that IPTs would select and justify their own risk matrix, with agreement from stakeholders, but because so many were clueless about how or why, they just adopted the example risk matrix ... even if it was inappropriate for their circumstances.
It is possible to use sound criteria to "design" project-specific risk targets, e.g. in a risk matrix. You can use risk matrices already used for similar equipments in similar contexts (e.g., consider using the Typhoon risk matrix for JSF), design one from scratch according to higher-level criteria (e.g., the HSE annual risk of individual death criteria that Safeware mentions in his first post on this thread, the JSP 553 1E-6 cumulative risk target or the civil aviation targets that Safeware also mentioned - all of these have something of a higher level justification sitting behind them too), design one that implies safety performance no worse (or preferably better) than the equipment currently exhibits, etc.
nigegilbert:
There's a Defence Chief Airworthiness Engineer already in place - Air Marshal Kevin Leeson.
http://www.blogs.mod.uk/defence_news...er-2009-1.html
There is no such thing as ‘tolerably safe but not ALARP. Risks are either ‘tolerable and ALARP’ or intolerable
does
Quote: ‘tolerably safe but not ALARP’
then make sense in the real world beyond Def Stan definitions?
Quote: ‘tolerably safe but not ALARP’
then make sense in the real world beyond Def Stan definitions?
I think I criticised Qinetiq's (QQ) use of the term "tolerably safe" in one of my posts on the Nimrod thread, mostly because they didn't define it (and it isn't defined in any authoritative document that I know of). Even if Safeware has a point (though see below) and QQ intended a similar usage to that he intends, they should have defined the term. They're not the only offenders - many air IPTs have done the same.
As it goes, I have been told that the term "tolerably safe" was introduced to military air safety as "weasel words" to help justify continued operation when you have tolerable risks that have not been demonstarted ALARP. I.e., not to cover the situation that Safeware describes when your risk is just a little higher than "broadly acceptable" but any situation when your risks are tolerable but not necessarily ALARP.
Of course, there is intuitively something intrinsically more acceptable about a risk that is only a little higher than "broadly acceptable" as opposed to one that is just short of "intolerable". But that is factored into the difficulties of demonstrating the two risks ALARP. Basically, the first will very likely be easy to demonstrate ALARP (unless it really is risk without any benefit) but the second will be virtually impossible to demonstrate ALARP.
Flipster wrote:
What worries me is who apportions the 10p-6 or 10p-5 etc for the MoD airworthiness processes involving catestrophic failures eg Herc Fuel Tanks, Nimrod Dry Bays, Sea King HISLS, Chinook FADECS etc?
Where do these probabilities come from?
Where do these probabilities come from?
It is possible to use sound criteria to "design" project-specific risk targets, e.g. in a risk matrix. You can use risk matrices already used for similar equipments in similar contexts (e.g., consider using the Typhoon risk matrix for JSF), design one from scratch according to higher-level criteria (e.g., the HSE annual risk of individual death criteria that Safeware mentions in his first post on this thread, the JSP 553 1E-6 cumulative risk target or the civil aviation targets that Safeware also mentioned - all of these have something of a higher level justification sitting behind them too), design one that implies safety performance no worse (or preferably better) than the equipment currently exhibits, etc.
nigegilbert:
I agree with [HC's] assertion that MoD need to re-establish the post of Chief Engineer
http://www.blogs.mod.uk/defence_news...er-2009-1.html
rarely, is the final act of the operator the SOLE cause
As stated before, I am well aware of my own potential fallibility - I'm not seeking to pretend that this is just someone else's problem.
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Torque, the most topical fatal accident is the Sea King collision, given your comments above, how would you categorize that mid-air in terms of pilot error or otherwise?
You seem so certain that pilot error alone is a main factor, it is only fair to ask for a few examples.
You seem so certain that pilot error alone is a main factor, it is only fair to ask for a few examples.
Last edited by nigegilb; 14th Nov 2009 at 10:03.
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TotD
As I mentioned, the operator is often the one left 'holding the baby' ie their actions, or inactions, could have prevented the accident - but are they the sole cause? No way!
In many cases, the last 'unsafe act' is product of the circumstances in which the operator is placed - poor design, supervision, fatigue, data overload etc. Other than in crashes where a pilot has been wilfully stupid, so many cases have been shown to involve a number of mitigating circumstances outwith the control of the operators. You may wish to cogitate upon the fact that this often suits the management - who are gulity of risk transfer...... 'they make it, we take it' - wittingly or unwittingly (in the case of Nimrod, Herc, Sea King, Chinook).
If you fancy, have a read of 'The Limits of Expertise' by Berman (NTSB), Dismukes (NASA) and Loukopoulos (NASA). ISBN 978-0-7546-4965-6. I would recommend this book to all aircrew and supervisors.
KR
flipster
As I mentioned, the operator is often the one left 'holding the baby' ie their actions, or inactions, could have prevented the accident - but are they the sole cause? No way!
In many cases, the last 'unsafe act' is product of the circumstances in which the operator is placed - poor design, supervision, fatigue, data overload etc. Other than in crashes where a pilot has been wilfully stupid, so many cases have been shown to involve a number of mitigating circumstances outwith the control of the operators. You may wish to cogitate upon the fact that this often suits the management - who are gulity of risk transfer...... 'they make it, we take it' - wittingly or unwittingly (in the case of Nimrod, Herc, Sea King, Chinook).
If you fancy, have a read of 'The Limits of Expertise' by Berman (NTSB), Dismukes (NASA) and Loukopoulos (NASA). ISBN 978-0-7546-4965-6. I would recommend this book to all aircrew and supervisors.
KR
flipster
As CH-C mentioned in his report the RAF 'can do' has masked many fissures & failings.It's been the RAF's glory & partly the cause of its undoing.
The men & women have worked within a culture which has gradually shifted (certainly within maintenance) where violation has become the tacitly accepted norm.People's attitude is that without this norm the RAF could not operate.
The challenge is to change the culture which has gradually arisen,for all the right reasonsie to maintain our dwindling capability.
The post H-C landscape will be very different, unfortunately (through no fault of their own) our people have become an obstacle.
Some of H-C's reccommendations regarding error management & Just Culture are already in train.This should create a framework for all to play the 'Airworthiness Card'. To enable a cultural shift to take place the most senoir levels of command must not only play their rightful part,they must be seen to do so.
The men & women have worked within a culture which has gradually shifted (certainly within maintenance) where violation has become the tacitly accepted norm.People's attitude is that without this norm the RAF could not operate.
The challenge is to change the culture which has gradually arisen,for all the right reasonsie to maintain our dwindling capability.
The post H-C landscape will be very different, unfortunately (through no fault of their own) our people have become an obstacle.
Some of H-C's reccommendations regarding error management & Just Culture are already in train.This should create a framework for all to play the 'Airworthiness Card'. To enable a cultural shift to take place the most senoir levels of command must not only play their rightful part,they must be seen to do so.
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My big concern is that the system wil swing wildly in the opposite direction in the post H-C world. I now work in civil aviation we carry snags in the same way as we used to do in the military. Someone mentioned to me the other day that following H-C report, reds and greens might disappear and people will be reluctant to put their name to paperwork, effectively grounding aircraft unnecessarily.
The big picture here is that H-C named 10 people who failed to implement airworthiness regulations within the existing framework.
I hope that fact is not lost in the melee following the report.
I see the two biggest problems as the legacy fleets at Brize Norton, namely VC10 and Tri Star. I suspect airworthiness concerns may well swing in their direction when the response to H-C is worked through.
The tear down of the Nimrod frame and the XV230 explosion has led to the virtual grounding of the fleet. One wonders what the tear down of the VC10 and TriStar might reveal........
The capability gap of going without Nimrod is a calculated but understandable gamble. However, the capability gap caused by the grounding of VC10 or TriStar would be a game changer. Never know, this report might yet lead to a considerable investment in the transport fleet. Lord knows it is overdue.
The big picture here is that H-C named 10 people who failed to implement airworthiness regulations within the existing framework.
I hope that fact is not lost in the melee following the report.
I see the two biggest problems as the legacy fleets at Brize Norton, namely VC10 and Tri Star. I suspect airworthiness concerns may well swing in their direction when the response to H-C is worked through.
The tear down of the Nimrod frame and the XV230 explosion has led to the virtual grounding of the fleet. One wonders what the tear down of the VC10 and TriStar might reveal........
The capability gap of going without Nimrod is a calculated but understandable gamble. However, the capability gap caused by the grounding of VC10 or TriStar would be a game changer. Never know, this report might yet lead to a considerable investment in the transport fleet. Lord knows it is overdue.
Last edited by nigegilb; 14th Nov 2009 at 14:24.
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Shift in the culture of maintenance - Violations?? me thick sootie but when I went through Cosford I was taught that there was no such thing as a sign off servicing. You did it, you signed it. and vice versa. How is it that when I got to my first sqn (as a wet behing the ears LAC mech tech ******) I was rapidly indoctrinated into the culture of laxity??
Poor leadership, lack of checks on the mech doing the servicing? lack of manpower and spares? Flypro pressure??
I'll confess to not doing all the zonals I might possibly have signed for as well as I would have with a trainer watching me but when you get told by the sqn training cell we do it this way and not the book way who do you go to for advice??
I'm not going to lie and say all my servicings were perfect but I never did one from the crewroom. (I don't think)
My point is (long winded I know) that if the culture on the sqn engineers can be so different from what I expect then surely the culture at MOD and BWOS can be more so.
Oh, sign it off - this aircraft will never be in those circumstances. it will cost XYZ millions to fix, thats an awful lot of pay rise we will lose........
Looking back I'd say I was a much better and more thorough engineer now than then, but the training I was given and the inegrity and attention to detail I was taught about still stays the same.
Airwothiness is a part of flight safety Yes/No?
If no then who cares, if yes then it is Everybodys Business
Point of order Mr moderator - The filter has banned a word I used. I call foul. This word was a derogatory name pinned on me and many others - we wear it with pride. I want my ****** back
Poor leadership, lack of checks on the mech doing the servicing? lack of manpower and spares? Flypro pressure??
I'll confess to not doing all the zonals I might possibly have signed for as well as I would have with a trainer watching me but when you get told by the sqn training cell we do it this way and not the book way who do you go to for advice??
I'm not going to lie and say all my servicings were perfect but I never did one from the crewroom. (I don't think)
My point is (long winded I know) that if the culture on the sqn engineers can be so different from what I expect then surely the culture at MOD and BWOS can be more so.
Oh, sign it off - this aircraft will never be in those circumstances. it will cost XYZ millions to fix, thats an awful lot of pay rise we will lose........
Looking back I'd say I was a much better and more thorough engineer now than then, but the training I was given and the inegrity and attention to detail I was taught about still stays the same.
Airwothiness is a part of flight safety Yes/No?
If no then who cares, if yes then it is Everybodys Business
Point of order Mr moderator - The filter has banned a word I used. I call foul. This word was a derogatory name pinned on me and many others - we wear it with pride. I want my ****** back
nigegilb:
Strikes me you are touching on my other great soapbox item, the Powers of Subordinate Commanders! So gather round and I'll tell you tales of long long ago , when even Pontious was a Driver of Aerial Perambulators....
Most of my RAF Career was spent in total ignorance of AOC's, C-in-C's, CAS's, etc etc. The only brass you were accountable to, and who in turn were expected to mind you in turn, were the boss (ie Sqn Cdr, etc) and the Station Commander. Occasionally a charming elderly gentleman with loads of medals, rank and a sword would come to visit but then the boss and Stn Cdr were the ones who had you charging round in circles for his visit anyway. In the meantime everything started and stopped with the boss or Staish. That would include a policy about Captain's discretion, ie a good boss (as mine were) would back up his captains' decisions as to what fuel, what mel, what diversion, decisions etc they took, unless of course they were simply unjustified. Thus the boss exercised his discretion over his subordinates' discretion. They also took on and won battles with NAAFI, MPBW etc with the support of their commander, ie the Staish who used his discretion. As I understand it these same Subordinate Commanders have lost a lot of their powers and hence discretion. They have to get it back and start commanding again. The day to day cost may well rise as a consequence. All that I might say is that the MOD is about to hit by costs as a result of H-C that will greatly outweigh the bean-counters' savings in slashing Airworthiness, and of course the price in lives lost has been terrible. I have railed about all this before and been told that the clock cannot be put back. It must be!
Someone mentioned to me the other day that following H-C report, reds and greens might disappear and people will be reluctant to put their name to paperwork, effectively grounding aircraft unnecessarily.
Most of my RAF Career was spent in total ignorance of AOC's, C-in-C's, CAS's, etc etc. The only brass you were accountable to, and who in turn were expected to mind you in turn, were the boss (ie Sqn Cdr, etc) and the Station Commander. Occasionally a charming elderly gentleman with loads of medals, rank and a sword would come to visit but then the boss and Stn Cdr were the ones who had you charging round in circles for his visit anyway. In the meantime everything started and stopped with the boss or Staish. That would include a policy about Captain's discretion, ie a good boss (as mine were) would back up his captains' decisions as to what fuel, what mel, what diversion, decisions etc they took, unless of course they were simply unjustified. Thus the boss exercised his discretion over his subordinates' discretion. They also took on and won battles with NAAFI, MPBW etc with the support of their commander, ie the Staish who used his discretion. As I understand it these same Subordinate Commanders have lost a lot of their powers and hence discretion. They have to get it back and start commanding again. The day to day cost may well rise as a consequence. All that I might say is that the MOD is about to hit by costs as a result of H-C that will greatly outweigh the bean-counters' savings in slashing Airworthiness, and of course the price in lives lost has been terrible. I have railed about all this before and been told that the clock cannot be put back. It must be!
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There seems to be a wee bit of confusion here.
Risks are either Intolerable, tolerable or broadly acceptable. All risks should have the ALARP principal applied - even those that are broadly acceptable (according to Def Stan 00-56 Issue 4). However, if you have an intolerable risk you would be mad to spend all your time and effort addressing the 'ALARPness' of a broadly acceptable one prior to the intolerable one - it is all about criticality. This is a defensible position but not an excuse for not applying the ALARP principal to all your risks.
A quick analogy. You need your brakes on a car to be to a certain standard to operate effectively. Similarly, you need the rear seatbelts to function effectively (both 'risks' - I won't get into the risk/hazard debate here!). You need them both functioning to pass an MOT (~similar to the ALARP principal). If you drive the car, with a current MOT, and you don't generally use the rear seatbelt which risk do you address first? The brakes!
Secondly, we can all harp on about the golden age of Qualified Engineers (arguably equated to Chartered Engineer). With the new 'fast track' CEng open to RAF Eng Officers I would be worried at some of the SO2's who are eligible for this track to CEng - BTW not scare-mongering I feel that CEng has been devalued. I am a mentor for one of the Institutes and (hopefully) an interviewer. So a 'whinge' in perspective.
What also amazes me is the amount of people running around quoting H-C when they really don't have a clue (not talking about this forum btw). Remember ALARP is a verb not a noun as most people have been intimating.
Also, the eng v operators discussion has raised it head. It is a combined effort and no-one has the right to overrule anyone else. I remember an SAC ringing ATC to stop a jet leaving. The rest of the sorties were cancelled. Aircrew were not happy. Who was right? One of the most junior people. Don't judge this by rank/trade/branch. Remember there is no 'i' in Team (but there is a 'me')!
Risks are either Intolerable, tolerable or broadly acceptable. All risks should have the ALARP principal applied - even those that are broadly acceptable (according to Def Stan 00-56 Issue 4). However, if you have an intolerable risk you would be mad to spend all your time and effort addressing the 'ALARPness' of a broadly acceptable one prior to the intolerable one - it is all about criticality. This is a defensible position but not an excuse for not applying the ALARP principal to all your risks.
A quick analogy. You need your brakes on a car to be to a certain standard to operate effectively. Similarly, you need the rear seatbelts to function effectively (both 'risks' - I won't get into the risk/hazard debate here!). You need them both functioning to pass an MOT (~similar to the ALARP principal). If you drive the car, with a current MOT, and you don't generally use the rear seatbelt which risk do you address first? The brakes!
Secondly, we can all harp on about the golden age of Qualified Engineers (arguably equated to Chartered Engineer). With the new 'fast track' CEng open to RAF Eng Officers I would be worried at some of the SO2's who are eligible for this track to CEng - BTW not scare-mongering I feel that CEng has been devalued. I am a mentor for one of the Institutes and (hopefully) an interviewer. So a 'whinge' in perspective.
What also amazes me is the amount of people running around quoting H-C when they really don't have a clue (not talking about this forum btw). Remember ALARP is a verb not a noun as most people have been intimating.
Also, the eng v operators discussion has raised it head. It is a combined effort and no-one has the right to overrule anyone else. I remember an SAC ringing ATC to stop a jet leaving. The rest of the sorties were cancelled. Aircrew were not happy. Who was right? One of the most junior people. Don't judge this by rank/trade/branch. Remember there is no 'i' in Team (but there is a 'me')!
Nige,
I'm not disputing the role of airworthiness (or lack of it) in accidents such as XV230, XV179, or the Sea King 7s - my point is more general and relates to all aircraft accidents.
Off the top of my head:
All three Squirrel losses at DHFS since 2004
Puma at Catterick 2007, Basrah 2004, Abingdon 2003 and perhaps others
Several Jungly Sea Kings in Iraq, Lynx over Indian Ocean
Hawks all over the place, notably Mona '95, Portugal '96, Shap '99, Mona '01
Harrier avoiding Tucano over Northumberland
Nimrod in Canada, various Jaguar crashes etc etc
I should make clear that I'm not criticising the crews for their actions in all of these cases - far from it - but merely using them as examples of occasions when the actions of aircrew alone led to an accident/incident. If I have my facts wrong on any of these, I apologize profusely, but I'm reasonably confident in the list above.
Flipster
You're absolutely right - most accidents have several contributory factors. I just took exception to what appeared to be people seeing airworthiness as a bandwagon to jump on, when I think it's important to bear in mind that - more often than 'rarely' IMHO - the accident/incident is largely or solely due to the actions of the crew. Thanks for the recommend of the book - I look forward to reading it.
I'm not disputing the role of airworthiness (or lack of it) in accidents such as XV230, XV179, or the Sea King 7s - my point is more general and relates to all aircraft accidents.
a few examples
All three Squirrel losses at DHFS since 2004
Puma at Catterick 2007, Basrah 2004, Abingdon 2003 and perhaps others
Several Jungly Sea Kings in Iraq, Lynx over Indian Ocean
Hawks all over the place, notably Mona '95, Portugal '96, Shap '99, Mona '01
Harrier avoiding Tucano over Northumberland
Nimrod in Canada, various Jaguar crashes etc etc
I should make clear that I'm not criticising the crews for their actions in all of these cases - far from it - but merely using them as examples of occasions when the actions of aircrew alone led to an accident/incident. If I have my facts wrong on any of these, I apologize profusely, but I'm reasonably confident in the list above.
Flipster
You're absolutely right - most accidents have several contributory factors. I just took exception to what appeared to be people seeing airworthiness as a bandwagon to jump on, when I think it's important to bear in mind that - more often than 'rarely' IMHO - the accident/incident is largely or solely due to the actions of the crew. Thanks for the recommend of the book - I look forward to reading it.
Last edited by TorqueOfTheDevil; 15th Nov 2009 at 09:44.
My big concern is that the system will swing wildly in the opposite direction in the post H-C world.
people will be reluctant to put their name to paperwork, effectively grounding aircraft unnecessarily.
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TotD
Thanks - Certainly in the military arena, where the operations can be 'closer to the edge' than in the civil world, there is more chance of the act of the final operator having a big say in the outcome. One could argue that the op tempo and level of tasking vs the lack of crews and frames is certainly a systemic factor (not to mention the ALQ/Taliban having a go).
Unfortunately, I don't think you can include ac and crews involved in earlier stages of trg- although goodness knows the bean-counters have constantly shaved away valuble experience and solo sorties out of most, if not all, trg syllabi; so perhaps some of these accidents could be construed as having systemic shortcomings. Even ones with an engineering input - Budgies' sad loss at Valley - have systemic influences. Sadly, I can't comment on all the examples you gave, sorry.
BTW Another good read is 'The Grown-Ups Book of Risk - or Why Sh!t Happens' by Omar Malik (available through that well-known, on-line book company with links to the sub-equatorial rainforests of Brazil!). You may or may not agree with Omar's politics (I do) but his assessment of the "science' of risk-managment, is spot-on, amusing and slightly worrying. He uses many good examples (including the MoK) of where a system's 'risk appraisal' has been hopelessly optimistic (against the advice of the coal-face, I might add).
flipster
Thanks - Certainly in the military arena, where the operations can be 'closer to the edge' than in the civil world, there is more chance of the act of the final operator having a big say in the outcome. One could argue that the op tempo and level of tasking vs the lack of crews and frames is certainly a systemic factor (not to mention the ALQ/Taliban having a go).
Unfortunately, I don't think you can include ac and crews involved in earlier stages of trg- although goodness knows the bean-counters have constantly shaved away valuble experience and solo sorties out of most, if not all, trg syllabi; so perhaps some of these accidents could be construed as having systemic shortcomings. Even ones with an engineering input - Budgies' sad loss at Valley - have systemic influences. Sadly, I can't comment on all the examples you gave, sorry.
BTW Another good read is 'The Grown-Ups Book of Risk - or Why Sh!t Happens' by Omar Malik (available through that well-known, on-line book company with links to the sub-equatorial rainforests of Brazil!). You may or may not agree with Omar's politics (I do) but his assessment of the "science' of risk-managment, is spot-on, amusing and slightly worrying. He uses many good examples (including the MoK) of where a system's 'risk appraisal' has been hopelessly optimistic (against the advice of the coal-face, I might add).
flipster
Last edited by flipster; 16th Nov 2009 at 20:25.
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If Flipster's suggestions have not cured your insomnia, then also read:
The Field Guide to Understanding Human Error by Sidney Dekker
The Human Contribution by James Reason ( the better of the 2 )
Both available here http://www.ashgate.com/default.aspx?page=0
Prof Reason's book is a must IMHO
The Field Guide to Understanding Human Error by Sidney Dekker
The Human Contribution by James Reason ( the better of the 2 )
Both available here http://www.ashgate.com/default.aspx?page=0
Prof Reason's book is a must IMHO