Haddon-Cave, Airworthiness, Sea King et al (merged)
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Other "Ignorant and Naive" statements
The following represent other "ignorant and naive" statements made by the QC in his report, which threaten the credibility of the whole review, and in doing so present opportunties to the guilty parties to get off the hook.
Page 129
This limitation [restriction to 15k in No.1 tank] was not formally recorded in the aircraft documentation but I have no doubt that it was put into operation by crews, and was relayed to FS Davies when he was briefed prior to his first AAR sortie in theatre and carried out by him.
I (DV) have no doubt that this was a serious error. The QC can not reprimand IPT, QinetiQ and BAe for bad practices, and at the same time condone this action. You can not operate an aircraft safely when crew members rely on word of mouth to pass on defects. There was a problem that was in need of investigation. In the end this investigation should have resulted in a recorded ADD or Limitation.
Page 119
At the inquest much was made of the fact that the 'fuel witness trail' (described by Witness 22 and 28 to the BOI) observed following a sortie around 9/10 August 2006 was a 'crescent' shape, descending from the No1 blow-valve exit and crossing the bomb door hinges.
This is not true. At the inquest, Witness 28 pointed out that his statement, attached to the BOI report, was incorrect and this fact had been pointed out to the BOI at the time he received the first draft. In the corrected version, which was presented to the court, the Witness states "It was like a tea pot stain. Starting just aft of No1 tank blow-off it was six-nine inches wide and a foot below the bomb bay hinge line"
My A&AEE boss once told me; "If anyone finds one mistake in any officail report that you produce, I may as well rip it up and hang it in the toilet"
DV
Page 129
This limitation [restriction to 15k in No.1 tank] was not formally recorded in the aircraft documentation but I have no doubt that it was put into operation by crews, and was relayed to FS Davies when he was briefed prior to his first AAR sortie in theatre and carried out by him.
I (DV) have no doubt that this was a serious error. The QC can not reprimand IPT, QinetiQ and BAe for bad practices, and at the same time condone this action. You can not operate an aircraft safely when crew members rely on word of mouth to pass on defects. There was a problem that was in need of investigation. In the end this investigation should have resulted in a recorded ADD or Limitation.
Page 119
At the inquest much was made of the fact that the 'fuel witness trail' (described by Witness 22 and 28 to the BOI) observed following a sortie around 9/10 August 2006 was a 'crescent' shape, descending from the No1 blow-valve exit and crossing the bomb door hinges.
This is not true. At the inquest, Witness 28 pointed out that his statement, attached to the BOI report, was incorrect and this fact had been pointed out to the BOI at the time he received the first draft. In the corrected version, which was presented to the court, the Witness states "It was like a tea pot stain. Starting just aft of No1 tank blow-off it was six-nine inches wide and a foot below the bomb bay hinge line"
My A&AEE boss once told me; "If anyone finds one mistake in any officail report that you produce, I may as well rip it up and hang it in the toilet"
DV
Raewald said,
"Incidentally, I was hoping that someone might comment on my possibly contradictory suggestion that you can be tolerable and not ALARP and still acceptable during the period when it is reasonable to allow newly determined ALARP measures to be introduced."
That's what I was eluding to in post 95 - In some circumstances, on discovering an acceptably tolerable fault, the movement towards ALARP can be via a managed recovery process. Subject of course to reliability and safety management processes.
Reading these latest posts:
How often can important documents be ignored/deleted because of unimportant mistakes?
I know I'm no Legal beagle, I tend to read the words and not between the lines, but you guys now seem to be pointing out the "spelling mistakes" and missing the whole point of the H-C Review?
"Incidentally, I was hoping that someone might comment on my possibly contradictory suggestion that you can be tolerable and not ALARP and still acceptable during the period when it is reasonable to allow newly determined ALARP measures to be introduced."
That's what I was eluding to in post 95 - In some circumstances, on discovering an acceptably tolerable fault, the movement towards ALARP can be via a managed recovery process. Subject of course to reliability and safety management processes.
Reading these latest posts:
How often can important documents be ignored/deleted because of unimportant mistakes?
I know I'm no Legal beagle, I tend to read the words and not between the lines, but you guys now seem to be pointing out the "spelling mistakes" and missing the whole point of the H-C Review?
Rigga
The Review arose from two statements made by ACM Sir Clive Loader in the XV230 BoI report;
I think people will agree he was pretty thorough in the period 1999 to 2006, although missing a few important engineering points outlined by DV.
He got part of the bigger picture just about right – as it applied to the Nimrod Safety Case. But, what happened to the period 1979-1999? He pointedly baselined most of the report at the SDR which, given the evidence presented to him of deliberate dilution of safety in previous years, can only have been an attempt at damage limitation. Who made this baselining decision? It completely ignores the remit.
For example, he criticises General Cowan for introducing a 20% cut over a 5 year period from about 1998, across all support domains, yet fails to mentions 28% each year for 3 years in the early 90s, which DIRECTLY targeted JSP553 Chapter 5 (maintaining airworthiness). Why not mention this single most important factor in the run down of aviation Safety Management in the last 20 years? It falls squarely in the middle of his timeframe remit, and occurred at just the time when extra funding was required as Safety Cases were being mandated.
What General Cowan did was nothing compared to this, and I doubt if any of the 3 IPT staff even knew this was the root cause of them not having sufficient funding to implement JSP553; so were in no position to defend themselves. (The fact they allegedly acted incompetently is another issue).
Perhaps I’m too cynical, but the 2 Star (AVM) who oversaw this is the same man who threatened staffs with the sack for complaining about the effect of the policy - an attitide that remained throughout the 90s and beyond.
General Cowan certainly didn’t do this – in fact, in my experience he understood precisely where money should be spent and believe the thrust of his 20% was to reduce inefficiencies so freeing up funding for more important things, like functional safety. I only spoke to him once, but this was the general subject under discussion. I know 4% a year sounds a lot, but at the time he had dual-accountable IPTs (who were in DPA but spending some of "his" DLO money) and was newly exposed to how efficiently some projects were run, compared to others who were following management guidlelines. It is the age old question - why are some projects run with effortless competence, yet other far less complex ones are disasters? The potential for true savings (which don't impact time, performance or OC) is obvious and, given the odium he will face, it takes a brave man to set higher benchmarks.
And so on. H-C's remit is applied very narrowly and ACM Loader’s second statement is simply not addressed. In fact, Ainsworth betrayed the fact he had prior notice by immediately making a statement that no other aircraft were affected. The report doesn’t say this; it just doesn’t address it properly, so Ainsworth’s view is based on an omission, not a positive, factual based statement. So, that 2nd recommendation is still outstanding. Who is addressing it?
But, at the end of the day, this is the biggest reaming MoD has had since the Chinook Mk3 inquiry said of precisely the same people – “failure of management oversight”. And there’s the rub. It’s the same names who crop up time and time again in all these cases, yet none are mentioned. The protected species – until Air Cdre Baber has his say in court!
the whole point of the H-C Review?
(a)“I conclude that the loss of XV230 and, far more importantly, of the 14 Service personnel who were aboard, resulted in shortcomings in the application of the processes for assuring airworthiness and safe operation of the Nimrod”
(b)“I am clear that further activity must be undertaken for our other aircraft types to check whether any read-across of lessons we have learned from this accident at such enormous (and immensely sad) cost”.
Mr Haddon-Cave’s remit was;(b)“I am clear that further activity must be undertaken for our other aircraft types to check whether any read-across of lessons we have learned from this accident at such enormous (and immensely sad) cost”.
- ·To examine the arrangements for assuring the airworthiness and safe operation of the Nimrod MR2 in the period from its introduction in 1979 to the accident on 2 September 2006, including hazard analysis, the safety case compiled in 2005, maintenance arrangements, and responses to any earlier incidents which might have highlighted the risk and led to corrective action;
- ·To assess where responsibility lies for any failures and what lessons are to be learned;
- ·To assess more broadly the process for compiling safety cases, taking account of best practice in the civilian and military world;
- ·And to make recommendations to the Secretary of State as soon as practicable, if necessary by way of interim report.
I think people will agree he was pretty thorough in the period 1999 to 2006, although missing a few important engineering points outlined by DV.
He got part of the bigger picture just about right – as it applied to the Nimrod Safety Case. But, what happened to the period 1979-1999? He pointedly baselined most of the report at the SDR which, given the evidence presented to him of deliberate dilution of safety in previous years, can only have been an attempt at damage limitation. Who made this baselining decision? It completely ignores the remit.
For example, he criticises General Cowan for introducing a 20% cut over a 5 year period from about 1998, across all support domains, yet fails to mentions 28% each year for 3 years in the early 90s, which DIRECTLY targeted JSP553 Chapter 5 (maintaining airworthiness). Why not mention this single most important factor in the run down of aviation Safety Management in the last 20 years? It falls squarely in the middle of his timeframe remit, and occurred at just the time when extra funding was required as Safety Cases were being mandated.
What General Cowan did was nothing compared to this, and I doubt if any of the 3 IPT staff even knew this was the root cause of them not having sufficient funding to implement JSP553; so were in no position to defend themselves. (The fact they allegedly acted incompetently is another issue).
Perhaps I’m too cynical, but the 2 Star (AVM) who oversaw this is the same man who threatened staffs with the sack for complaining about the effect of the policy - an attitide that remained throughout the 90s and beyond.
General Cowan certainly didn’t do this – in fact, in my experience he understood precisely where money should be spent and believe the thrust of his 20% was to reduce inefficiencies so freeing up funding for more important things, like functional safety. I only spoke to him once, but this was the general subject under discussion. I know 4% a year sounds a lot, but at the time he had dual-accountable IPTs (who were in DPA but spending some of "his" DLO money) and was newly exposed to how efficiently some projects were run, compared to others who were following management guidlelines. It is the age old question - why are some projects run with effortless competence, yet other far less complex ones are disasters? The potential for true savings (which don't impact time, performance or OC) is obvious and, given the odium he will face, it takes a brave man to set higher benchmarks.
And so on. H-C's remit is applied very narrowly and ACM Loader’s second statement is simply not addressed. In fact, Ainsworth betrayed the fact he had prior notice by immediately making a statement that no other aircraft were affected. The report doesn’t say this; it just doesn’t address it properly, so Ainsworth’s view is based on an omission, not a positive, factual based statement. So, that 2nd recommendation is still outstanding. Who is addressing it?
But, at the end of the day, this is the biggest reaming MoD has had since the Chinook Mk3 inquiry said of precisely the same people – “failure of management oversight”. And there’s the rub. It’s the same names who crop up time and time again in all these cases, yet none are mentioned. The protected species – until Air Cdre Baber has his say in court!
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Nimrod Safety Case (H-C Report)
The H-C report devotes some 161 pages to the Nimrod safety case. It condemns it in many ways, and criticizes eight people. The irony of it all is that there was no requirement to produce a safety case for a legacy aircraft with an imminent OSD, such as Nimrod. This is made clear in Baber's inquest statement and is confirmed by DE&S. Furthermore, Baber goes on to state that the exercise was carried out in an "economic manner", and "clearly if we made it far too complicated the whole aircraft would be out of service by the time we finished".
Also, on page 235, H-C claims that the three BAES people involved in the August meeting took a "deliberate and conscious decision" (H-C opinion)not to mention the "open and unclassified" hazards. Yet in Baber's inquest statement he says "at that point there were a range of still open hazards". So he knew about them. Surely, if he thought he had been deceived he would have reveled that to the coroner.
The Nimrod safety case became an issue because Baber's predecessor "decided to take a far more rigorous approach and decided to go for a better safety case than just assuming the the release to service [which was the required level] would be adequate"
In order to present a "balanced" review, I believe issues such as these should have been mentioned in the report. The IPTL was guilty of many things, but to be damned for doing something, that need not have been done in the first place does give the impression that a "hit list" was drawn up very early on, and evidence and the QC's personal opinion made to fit. Once again, these are the sort of things that any competent legal defence team will latch onto.
DV
Also, on page 235, H-C claims that the three BAES people involved in the August meeting took a "deliberate and conscious decision" (H-C opinion)not to mention the "open and unclassified" hazards. Yet in Baber's inquest statement he says "at that point there were a range of still open hazards". So he knew about them. Surely, if he thought he had been deceived he would have reveled that to the coroner.
The Nimrod safety case became an issue because Baber's predecessor "decided to take a far more rigorous approach and decided to go for a better safety case than just assuming the the release to service [which was the required level] would be adequate"
In order to present a "balanced" review, I believe issues such as these should have been mentioned in the report. The IPTL was guilty of many things, but to be damned for doing something, that need not have been done in the first place does give the impression that a "hit list" was drawn up very early on, and evidence and the QC's personal opinion made to fit. Once again, these are the sort of things that any competent legal defence team will latch onto.
DV
Thanks for that Tuc and DV,
Although I know my version of airworthiness, I obviously don't know of the bubbles in MOD during those periods and the political rigours of those encumbents. I was unaware of particular funding issues in the mid 90's - at my level there was always funding issues.
My own thoughts were simply of a more politicised leadership giving unwritten directives to MOD.
I know the MOD is thick-skinned and skint beyond belief, but surely it can't think that it could get away with just plugging one small hole in this rather large Swiss cheese? MOD has an over indulgence of officers doing far less important jobs that could do most of this research at virtually no cost. (I await the bleatings of perceived importance against cost)
I don't think the buck has stopped yet. Unfortunately, if only the small hole is plugged, we will have to wait for another one to open up and start quoting H-C again.
Although I know my version of airworthiness, I obviously don't know of the bubbles in MOD during those periods and the political rigours of those encumbents. I was unaware of particular funding issues in the mid 90's - at my level there was always funding issues.
My own thoughts were simply of a more politicised leadership giving unwritten directives to MOD.
I know the MOD is thick-skinned and skint beyond belief, but surely it can't think that it could get away with just plugging one small hole in this rather large Swiss cheese? MOD has an over indulgence of officers doing far less important jobs that could do most of this research at virtually no cost. (I await the bleatings of perceived importance against cost)
I don't think the buck has stopped yet. Unfortunately, if only the small hole is plugged, we will have to wait for another one to open up and start quoting H-C again.
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It is my belief that taking the evidence in the Inquest and Review together it appears there was:
1.. Gross breach of duty of care creating very high risk of death
2.. Action or lack of action due to financial or other inappropriate motive(s).
3.. Marked or endemic corporate culture encouraging or producing tolerance of breach of duty of care.
4.. Exposing vulnerable employees to unsafe practices.
5.. Breaches of the duties under sections 2 and 3 HSWA involve failure to take all ‘reasonably practicable steps to ensure the safety of employees and/or the public'.
6.. There was a disregard of the duty of care, and that disregard amounted to recklessness.
Anyone agree/disagree ?
1.. Gross breach of duty of care creating very high risk of death
2.. Action or lack of action due to financial or other inappropriate motive(s).
3.. Marked or endemic corporate culture encouraging or producing tolerance of breach of duty of care.
4.. Exposing vulnerable employees to unsafe practices.
5.. Breaches of the duties under sections 2 and 3 HSWA involve failure to take all ‘reasonably practicable steps to ensure the safety of employees and/or the public'.
6.. There was a disregard of the duty of care, and that disregard amounted to recklessness.
Anyone agree/disagree ?
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TD, that'll do it! (I agree) Nicely done.
But I see a split in the road ahead.
If this is a claim for compensation then the MoD will admit liability and settle out of court.
If this is to be a prosecution by the HSE or the CPS then it could be very interesting, but is more likely to be a massive fudge.
When is the MoD/Gov't reaction the the H-C report due?
Good Luck, SPHLC
But I see a split in the road ahead.
If this is a claim for compensation then the MoD will admit liability and settle out of court.
If this is to be a prosecution by the HSE or the CPS then it could be very interesting, but is more likely to be a massive fudge.
When is the MoD/Gov't reaction the the H-C report due?
Good Luck, SPHLC
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SPHLC
Bill Rammell will be making a statement in the House of Commons before the House rises for the Christmas recess on 16th December, so we have been informed.
As far as the legal side of it goes, I think we may see that all the authorities will work together on this.
It is up to those relevant authorities to investigate the information put before them.
For the time being I have done as much as I can for Ben.
Bill Rammell will be making a statement in the House of Commons before the House rises for the Christmas recess on 16th December, so we have been informed.
As far as the legal side of it goes, I think we may see that all the authorities will work together on this.
It is up to those relevant authorities to investigate the information put before them.
For the time being I have done as much as I can for Ben.
Tappers Dad:
TD, what you have done has been remarkable. You have overcome the disbelief that your son and his colleagues could have been failed so grossly by those who owed them a duty of care. You have overcome a Secretary of State's incorrect assertion that the remainder of the fleet was fit to fly. You have ensured that the fleet was made safe for Ben's fellow aircrew. You have caused a review of not only the way in which the airworthiness of that fleet was so badly neglected, but other fleets as well. Now, as you say, it is for the MOD to put its house in order. If it chooses not to then there will be more avoidable accidents, more needless deaths. This is not a time for cleverness, this is a time for doing the right thing. History will decide on that.
Let Right Be Done!
For the time being I have done as much as I can for Ben.
Let Right Be Done!
For the time being I have done as much as I can for Ben.
No son could have wished for more from his Dad (and Mum).
Deep respect.
airsound
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If this is a claim for compensation then the MoD will admit liability and settle out of court.
I don’t know the legal ins and outs Acoustic, but from time to time, and despite the seriousness of what has happened, I find myself having a little smile to myself when I think of the briefings Ministers must be getting.
Can you imagine it? Ainsworth - “What idiot dropped us in it by agreeing that airworthiness was irrelevant?” “Eh, never mind that Minister, what’s more important is that you, and your predecessors, have all stated in writing you agree with him. Minister, you should be more worried that if this gets to court these letters will be Exhibit A.”.
Even if he gets an answer, our Bob must surely possess the mental agility to realise the same 4 or 5 names crop up with monotonous regularity. Tornado, Nimrod, Hercules, Sea King…….. That will severely test MoD’s policy of not involving retired staffs. I’m pretty sure the current lot will have noted what happened to Air Cdre Baber when he took the rap for others (at the inquest), and won’t be so keen to hold their own hands up.
Can you imagine it? Ainsworth - “What idiot dropped us in it by agreeing that airworthiness was irrelevant?” “Eh, never mind that Minister, what’s more important is that you, and your predecessors, have all stated in writing you agree with him. Minister, you should be more worried that if this gets to court these letters will be Exhibit A.”.
Even if he gets an answer, our Bob must surely possess the mental agility to realise the same 4 or 5 names crop up with monotonous regularity. Tornado, Nimrod, Hercules, Sea King…….. That will severely test MoD’s policy of not involving retired staffs. I’m pretty sure the current lot will have noted what happened to Air Cdre Baber when he took the rap for others (at the inquest), and won’t be so keen to hold their own hands up.
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tecumseh, I have to agree with your last point . I doubt any of them will have the courage to stick their heads above the parapet.
As to Acoustic's question, apologies for the length of this but I'll try to be as brief as possible.
The Civil Procedure Rules 1999, introduced a mechanism for settling cases - Part 36 offers. This allowed one party to make a "without prejudice" offer to settle a claim. If the offer is not accepted and the offeror does better than his offer when the case goes to court, the recipient of the offer will suffer from a reduction of the costs awarded by the court. If the recipient of the offer is a defendant there may also be an adverse effect in the interest awarded.
So you don't have to accept, but it could affect the award of costs by a court should the settlement awarded in court differ from the offer out of it.
As to Acoustic's question, apologies for the length of this but I'll try to be as brief as possible.
The Civil Procedure Rules 1999, introduced a mechanism for settling cases - Part 36 offers. This allowed one party to make a "without prejudice" offer to settle a claim. If the offer is not accepted and the offeror does better than his offer when the case goes to court, the recipient of the offer will suffer from a reduction of the costs awarded by the court. If the recipient of the offer is a defendant there may also be an adverse effect in the interest awarded.
So you don't have to accept, but it could affect the award of costs by a court should the settlement awarded in court differ from the offer out of it.
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Your Defence News - BAE Systems appoints Dr. Chris Elliott to support safety review
In a press release BAE said today 'After careful consideration of Charles Haddon-Cave QC’s Nimrod Review, BAE Systems has appointed Dr. Chris Elliott FREng, a leading systems engineer and barrister, to support and advise Nigel Whitehead FREng, Group Managing Director Programmes & Support who will undertake a review of the Company's approach to product safety across all its sectors in the UK'.
I see that both Qinetic and BAE Systems have now employed legal experts to look into their processes, I wonder why?
In a press release BAE said today 'After careful consideration of Charles Haddon-Cave QC’s Nimrod Review, BAE Systems has appointed Dr. Chris Elliott FREng, a leading systems engineer and barrister, to support and advise Nigel Whitehead FREng, Group Managing Director Programmes & Support who will undertake a review of the Company's approach to product safety across all its sectors in the UK'.
I see that both Qinetic and BAE Systems have now employed legal experts to look into their processes, I wonder why?
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I thought the MoD were also supposed to have published the reply to the HC report by now.
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JFZ90:
The term "ALARP" is well-defined already. See POSMS, Def Stan 00-56, etc. There is no need for Qinetiq (QQ) reports of the kind under discussion to define ALARP since there is an authoratative definition in place already.
Having claimed more than once that "tolerably safe" isn't defined anywhere (unlike "ALARP"), Haddon-Cave told me it once was. It's in BP 1201, Issue 2 (September 2002):
(The term "tolerably safe" was gone by Issue 3, Sep 2005 - I don't know if it was ever in Issue 1.) What interests me about this is that the clear intent of BP 1201, Issue 2 is that you should only claim something is "tolerably safe" if you've demonstrated the associated risks are ALARP. This is not how the term came to be used by the half-dozen or so air IPTs that I've had exposure to and it doesn't appear to be how QQ use it in the report JFZ90 discusses. They all use(d) the term "tolerably safe" to mean that the associated risks were "tolerable" (but not necessarily ALARP).
JFZ90 goes on to debate what the QQ report in question was trying to say about safety. I can't remember what the report says or was trying to say about safety so I can't comment particularly authoritatively. But when JFZ90 writes:
You don't necessarily need "access to the costs involved in mitigating risks" to determine that those risks are not ALARP. It is generally held (i.e., it's HSE guidance) that risks can not be ALARP unless relevant good practice is followed (e.g. relevant design or process standards encapsulating good practice). My very hazy recollection is that the QQ report in question made some recommendations that would be very much considered relevant good practice.
JFZ 90 again:
Willing to be be proved wrong, but I think it is you, not HC, who has this wrong. Give us an example of such a risk? It doesn't make sense.
I think I can do that by appeal to definitions. But I have to admit the situation is murkier than I thought before JFZ90 made me look at it in more detail. The basic problem is that we are stuck with a stupid set of terms for safety engineering (this is not the MoD's fault necessarily - it's a much wider problem than that). Basically, within safety engineering, there are relatively well-defined terms like "tolerable" and "unacceptable" that, very unfortunately, have meanings that are quite distinct from their generic dictionary definitions. The problems flow when the safety engineering terms are mixed with generic English usage.
There are two primary definitions of "tolerable" relevant to MoD safety. First , POSMS:
Secondly Def Stan 00-56:
The precise right one for the QQ report depends on the context of the report. But you can see the definitions are very similar (and neither is particularly well-worded). Crucially, both admit that a risk can be tolerable but not ALARP (despite HC, para 11.322). And if you read 00-56 and POSMS in any detail, it is clear from the use of the terms "tolerable" and "ALARP" that it is possible for risks to be tolerable but not ALARP.
It's an unfortunate situation because the generic meaning of "tolerable" is not that similar to the safety engineering meaning of the word (as captured in the definitions above). Risks can be "tolerable", in the safety engineering sense, but "intolerable" or "unacceptable", in the generic English sense (i.e., when those risks are not ALARP). A better term for the safety engineering specific use would be "potentially tolerable".
In para 11.322 of his report, HC quotes BP 1201:
I don't know whether HC is:
1. genuinely confused.
2. is using "tolerable" in the safety engineering sense, and "intolerable" in the generic English sense (which is not the same as "not tolerable" in the safety engineering sense).
raedwald:
In MoD safety circles, "intolerable" is usually referred to as "unacceptable". The definition of "unacceptable" from POSMS (& 00-56):
It's unfortunate that the term "unacceptable" is used in this way since it means there are risks that are "unacceptable" in the generic sense that are not "unacceptable" in the safety-engineering specific sense (i.e., risks that are tolerable but not ALARP). Again, a clash between safety engineering English and generic English!
Distant Voice:
I agree with Distant Voice's analysis of the two different sorts of "time" above and I think it is plausible that Haddon-Cave (HC) mixed them up in his report.
But I maintain that "we have got time to reduce the risk to ALARP [while still operating]" can be a valid claim (though not necessarily for the reasons HC advances). I.e., it is possible to:
1. identify that a risk is not ALARP in the long-term,
2. identify a "reasonably practicable" risk reduction that is necessary to reduce the risk ALARP in the long term, that will take a lengthy time to implement,
3. continue operating pending implementation of the risk reduction
4. claim that the risk of operation in that interim period is ALARP.
See the end of my post #96 in this thread. Specifically:
The crucial thing, to me, is that you must do an ALARP assessment of the risk in question pending implementation of the long-term risk reduction. This will tell you whether you can continue to operate or not.
Having said the above, I agree with raedwald:
(except it will be a jury, not a judge).
A few people are being highly critical of the HC report. Yes, it does contain significant errors and it's a shame its scope is limited. But, imo and depending on MoD response, it could still be a force for significant improvement in safety. In that light, the criticisms are relatively minor, in my opinion.
I agree with your point that "tolerably safe" should be defined [in Qinetiq reports about the Nimrod] if it is to be used in any meaningful way. The same of course applies to using the term ALARP.
Having claimed more than once that "tolerably safe" isn't defined anywhere (unlike "ALARP"), Haddon-Cave told me it once was. It's in BP 1201, Issue 2 (September 2002):
A safety case is to be maintained throughout the life of the equipment in order to continue to provide the justification that the equipment remains tolerably safe (targets achieved and ALARP demonstrated)
JFZ90 goes on to debate what the QQ report in question was trying to say about safety. I can't remember what the report says or was trying to say about safety so I can't comment particularly authoritatively. But when JFZ90 writes:
it is not necessarily the case that QQ in writing the report have access to the costs involved in mitigating risks - for this reason alone it is unclear on what basis they were making an ALARP assessment
JFZ 90 again:
Squidlord Risks can be "tolerable" but not ALARP
There are two primary definitions of "tolerable" relevant to MoD safety. First , POSMS:
A level of risk that may be tolerated when it has been demonstrated that the risk is ALARP and is not unacceptable.
A level of risk between broadly acceptable and unacceptable that may be tolerated when it has been demonstrated to be ALARP.
It's an unfortunate situation because the generic meaning of "tolerable" is not that similar to the safety engineering meaning of the word (as captured in the definitions above). Risks can be "tolerable", in the safety engineering sense, but "intolerable" or "unacceptable", in the generic English sense (i.e., when those risks are not ALARP). A better term for the safety engineering specific use would be "potentially tolerable".
In para 11.322 of his report, HC quotes BP 1201:
Tolerable - The residual risk is tolerable only if further risk reduction is impracticable or requires action that is grossly disproportionate in time, trouble and effort to the reduction in risk achieved.
This definition is at odds with the definitions in 00-56and POSMS. If MoD can't even get it right in their own standards and regulation (POSMS also abuses terminology and much too freely mixes the safety engineering and generic English uses of terms like "tolerable" and "unacceptable"), what chance have the rest of us! And it's no wonder that HC appears confused in para 11.322 when he states:
There is no such thing as ‘tolerably safe but not ALARP’. Risks are either ‘tolerable and ALARP’ or intolerable
I don't know whether HC is:
1. genuinely confused.
2. is using "tolerable" in the safety engineering sense, and "intolerable" in the generic English sense (which is not the same as "not tolerable" in the safety engineering sense).
raedwald:
There are 3 levels of tolerability: intolerable, tolerable and broadly acceptable.
A level of risk that is tolerated only under exceptional circumstances.
Distant Voice:
In his report [Haddon-Cave] stressed the point that the "R" in ALARP has a temporal element, and criticize the Coroner for calling for the grounding of the Nimrod, because in his opinion "a reasonable time is allowed" to mitigate identified risks.
[...]
Now, having read Lord Cullen's findings, and the Health and Safety guidelines, I believe that "time" in [the context of the judge's (not Cullen's!) summation of Edwards v The National Coal Board] means downtime (lost time) of the plant or equipment and its associated costs and trouble. It does not mean, as Group Capt. Hickman (inquest witness) and the QC claim that "we have got time to reduce the risk to ALARP".
[...]
Now, having read Lord Cullen's findings, and the Health and Safety guidelines, I believe that "time" in [the context of the judge's (not Cullen's!) summation of Edwards v The National Coal Board] means downtime (lost time) of the plant or equipment and its associated costs and trouble. It does not mean, as Group Capt. Hickman (inquest witness) and the QC claim that "we have got time to reduce the risk to ALARP".
But I maintain that "we have got time to reduce the risk to ALARP [while still operating]" can be a valid claim (though not necessarily for the reasons HC advances). I.e., it is possible to:
1. identify that a risk is not ALARP in the long-term,
2. identify a "reasonably practicable" risk reduction that is necessary to reduce the risk ALARP in the long term, that will take a lengthy time to implement,
3. continue operating pending implementation of the risk reduction
4. claim that the risk of operation in that interim period is ALARP.
See the end of my post #96 in this thread. Specifically:
You must show that the risk of operation pending implementation of risk reduction is ALARP. It might seem obvious that you can't do this. After all, that is why you are implementing the long-term risk reduction. But this ignores the exposure aspect of ALARP. In essence, the longer your exposure to a risk, the less likely it is to be ALARP (because that risk is more likely to precipitate an accident(s)). So it is possible, in principle, to demonstrate that the risk of operation pending implementation of the long-term risk reduction is ALARP.
Having said the above, I agree with raedwald:
since everyone has their own ideas I don't think that there is a right and wrong - the only way you find our is if a Judge decides that your argument is not reasonable, I guess!
A few people are being highly critical of the HC report. Yes, it does contain significant errors and it's a shame its scope is limited. But, imo and depending on MoD response, it could still be a force for significant improvement in safety. In that light, the criticisms are relatively minor, in my opinion.