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'No blame' Over RAF Tornado Crash

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'No blame' Over RAF Tornado Crash

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Old 7th Apr 2010, 16:18
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Airworthiness

Chug, Tuc & S/W

I have sat and read your posts, finding myself nodding in agreement with you all. For me, JSP553 details the hurdle which has to be jumped to demonstrate that the platform is fit for purpose. I have never seen the safety case revisited post MAR to a significant level of scrutiny unless driven by a significant formal design change. Consider the changes made when aircraft are being operated under theatre pressures. Since GW1, the pressure from operations has been sustained on various aircraft types that are carrying out roles and profiles that were not considered at the outset of the aircrafts life.

The safety case of a design is often underpinned by various assumptions that change or may prove to be invalid in service, again I have never seen the assumptions re-visited or even considered in light of significant support cuts. You can achieve airworthiness but I feel that the through life maintenance of the safety case is a nettle that has never been firmly grasped, not through any lack of competence but purely due to complexity, cost and manning.

regards

retard
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Old 7th Apr 2010, 18:00
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Eng

Quite right.

A maintained Build Standard is a pre-requisite to a valid Safety Case.

It has not been MoD policy to routinely fund the maintenance of Build Standards since 1991. Today, it not uncommon for a BS to be more than two decades out of date.

As this thread is about Tornado, I suggest a quick glance at the recommendation at para 19b in the Patriot shootdown report of 2003. There is something very wrong when a reviewing officer has to recommend basic, mandated safety pre-requisites and engineering disciplines should be implemented. Given this very recommendation was made twice, on Tornado, to different 2 Stars in 1998 and 2001, it is doubly wrong that the BoI or ROs didn't seem to know that the problem was identified, notified and completely ignored 5 years earlier by the officers directly responsible for ensuring SofS's regulations are implemented. People again. Always people.
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Old 7th Apr 2010, 19:15
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Airworthiness is a sub element of System Safety

As has been intimated the theoretical airworthy aircraft is nought but a (un)controlled ballistic missile if the crew are not competent for task and that definition must include a measure of currency. Some of the more gifted and talented may be able to maintain competency with ease and others need much more stick time.

The overall safety case, that raises the questions that need to be answered to assure system safety, should have considered the possible outcomes and attendant risks arising from reducing flying hours. It would appear that it did not.

It is the appetite to address and manage this risk especially the frequent updates that are required to the safety case, including the career moments that may come with raising objections/observations, that need to be reasserted.

Not a pilot so can only trust opinions that 10 hrs per month is woeful but I know that as a motorbiker I need to get my eye in after some time out of the saddle, anything else is inviting disaster.
SJ
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Old 8th Apr 2010, 07:27
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Tucumseh,

You're tending to assume a level of background knowledge amongst the readership here that I for one don't have.

What recommendations from the reviewing officer re the Tornado/Patriot BOI? In what context was the recommendation previously twice made? To whom? Why was it not acted upon?

I follow the thrust of your main argument, but a bit more supporting info would be welcome (without impacting libel and National Security laws of course!)
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Old 8th Apr 2010, 07:58
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What recommendations from the reviewing officer re the Tornado/Patriot BOI? In what context was the recommendation previously twice made? To whom? Why was it not acted upon?
As I said before, there were other factors in that crash, but a Reviewing Officer recommended that IFF failure warnings be integrated into the cockpit. He doesn't say which ones were missing (or not integrated properly) but the report confirms modification action is in hand. If such safety related warnings are not presented to the crew, the functional safety of the aircraft has not been assured. It is a feature of Safety Management in MoD that physical safety is usually addressed reasonably well, but functional safety is often ignored.

As for context, Boscombe identified the general problem (failure, and subsequent flat refusal to integrate failure warnings) in 1998 (perhaps before, not sure) and specifically on another platform. Under the same programme the same IFF was being fitted to a Tornado variant and a recommendation was made to have all other aircraft installations, but especially Tornado, inspected for correct installation. This was made at the time, and later in 2001 to, inter alai, two Directors General / Executive Directors in PE/DPA as well as the project offices involved.

I'm afraid you'll have to ask them why they did not act. One reason given to me was "It worked on the bench, so it'll work in the aircraft" - which is a typical response to why system integration obligations are waived. The failure to act was the subject of a complaint to CDP (4 Star) who, in 1998, twice ruled that it was perfectly acceptable to deliver the aircraft in this state, and pay off the contract in the full knowledge that it was not fit for purpose. I say twice, because he was asked to reconsider as it was suspected he'd just had a lackey write the first reply.

I am but a pleb in the great machine and they must have had good reason. But, whatever that may be, it perfectly illustrates the complete ambivalence toward the subjects of safety, airworthiness and fitness for purpose. The point I make is that this, and many other examples, meant that the Haddon-Cave report and the vast majority of his recommendations came as no surprise whatsoever. This multitude of warnings throughout the 90s should have served to highlight, at the highest level, a systemic failing which has brought parts of the MoD to its knees in the last few years.

The above example is but a single step away from the main topic on this thread - lack of currency, training etc. On that subject, the BoI did not address whether or not the simulator was at the same build standard as the aircraft; but the programme I mentioned certainly did NOT modify the simulators. That is also a common safety failing.

Hope this helps.
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Old 8th Apr 2010, 10:18
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I have my doubts, but can't see how we could establish the requirement for the Typhoon, when there are Hawks available much cheaper.
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Old 8th Apr 2010, 10:41
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I agree with Safeware (& soddim) on the airworthiness vs. safety thing.

I have to admit I don't feel that confident that I understand airworthiness particularly well (unlike safety) but I reckon that's largely because it's so badly defined and documented. Whatever, most of what follows is imo ...

Chugalug2 gave us the (MoD) definition of airworthiness (from JSP 553 - others bits of 553 support Safeware's interpretation as he pointed out):

The ability of an aircraft or other airborne equipment or system to operate without significant hazard to aircrew, ground-crew, passengers (where relevant), or to the general public over which such airborne systems are flown.
The key word, to me, is "ability". If you have an airworthy aircraft then you have an aircraft that is safe if:

1. It is operated in a safe manor
2. It is maintained in a manner that enables safe operation
3. Other stuff, e.g. ATM

And competence of aircrew is clearly essential to safe operation, so aircrew competence is not part of airworthiness but is obviously part of safety.

To be safe, an aircraft must be airworthy. The converse is not true.

So when Chugalug2 writes:

You could have the most gold plated airworthy aircraft in the inventory, put an untrained pilot in the driving seat and it immediately falls foul of the definition of airworthy

I disagree. The fact that you've chosen to fly the aircraft (unsafely) with untrained crew does not affect the "ability of an aircraft or other airborne equipment or system to operate without significant hazard [...]". It's gold-plated so it still has that ability if you operate and maintain it properly.

Chugalug2 again:

Safeware makes the very valid point that it is the Military Airworthiness Authority

I don't think he did. In any case, it's not. It's a Military Aviation Authority (despite the letter of Haddon-Cave's recommendation). And if you look at its web page, you'll see it is concerned with safety as well as airworthiness. Admittedly, it's a bit buried but that, to me, is just a reflection of a general MoD unwarranted focus, possibly unintentional, on airworthiness rather than safety. Hopefully, we can get this changed.

Part of the reason I don't like the concept of "airworthiness" much, besides the fact that it's vaguely defined and there's lots of disagreement about what it means, is that, imo, it tends to detract from really counts ... safety. And that is Chugalug2's main concern, I think, and there we do agree.

On a slightly different subject, engineer(retard) writes:


I have never seen the safety case revisited post MAR to a significant level of scrutiny unless driven by a significant formal design change. [...]
The safety case of a design is often underpinned by various assumptions that change or may prove to be invalid in service, again I have never seen the assumptions re-visited or even considered ...

Totally agree with this. In my experience, MoD aircraft Safety Cases (SCs) do tend to get thrown in the filing cabinet and forgotten. Aircraft mods tend to be dealt with piecemeal rather than as part of a coherent whole aircraft Safety Case update. And even worse, imo, updating the SC in response to in-service experience invalidating assumptions ... well, it just doesn't happen on the platforms I know of. This includes the Nimrod where in-service experience totally and massively invalidated the estimates of (effectively assumptions about) fuel leak probabilities. From The Nimrod Review, 3.11.1 ...


The [Nimrod Safety Case] quoted the potential for fuel system leakage as ‘Improbable’, which is defined as ‘Remote likelihood of occurrence to just 1 or 2 aircraft during the operational life of a particular fleet’. The BOI’s analysis of fault data, however, indicated an average of 40 fuel leaks per annum for the Nimrod MR2 fleet between 2000 and 2005



I know the MoD are trying to address some of this, specifically the validation of assumptions, with Operational Safety Cases but progress seems painfully slow to me.
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Old 8th Apr 2010, 15:36
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To be safe, an aircraft must be airworthy. The converse is not true.
As we are talking about legacy aircraft, we must consider the Military Aircraft Release and Release to Service documents. I’ve therefore quoted some older policy documents while assuming the current equivalents are available to anyone who is interested. The newer GARP process differs, primarily in that there is no MAR, but the fundamentals remain the same. That is, the Safety Case is based on a build standard, which must be maintained for the SC to be valid. The SC is the primary evidence supporting airworthiness. Lacking this audit trail, the MAR and RTS cannot be issued. (The Mull failings in a nutshell!).

The MAR was based on the build standard presented at MAR trials, which was not necessarily the “as flown” standard “and is, inter alia, the statement that an acceptable Safety Case has been prepared for the aircraft. (AP 3456, CA Instructions etc).

The RTS includes the MAR as Part 1, but reflects the “as flown” standard by, for example, including Service Deviations. The RTS is the Master Airworthiness Reference, and it can be seen, by definition, it also requires a maintained build standard and a valid Safety Case. The Secretary of State mandates all this but, demonstrably, this has not been funded policy since 1991. Hence, the “systemic failures” noted in many reports, most recently by Mr Haddon-Cave.

Also, from AP3456 and CA Instructions.....

"Airworthiness is defined as the ability of an aircraft, or other airborne equipment or system, to operate without significant hazard to aircrew, ground crew, passengers (where relevant) or to the general public over which such airborne systems are flown. Airworthiness is not only concerned with engineering aspects, but also with the way an aircraft is flown and how its systems are operated".
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Old 8th Apr 2010, 16:57
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Devil Old practice

Long, long ago in a "ready-to-go" Air Force, there was an all-pervading general, but quite simple, Flight Safety campaign. (I think "they" were trying to hammer home the fact that "Flight Safety" is more than just Accident Prevention, as well as being more positive).
The most visible part was the appearance of large posters with different picture, but all bearing the message, in big, aircrew-friendly letters -

Flight Safety is YOUR business

Pix of be-ringed sleeves as well as rolled-up sleeves in every Station Office as well ..;

Too expensive, Mr/Mrs/Ms. Treasury ??? Have a few hundred yourselves !

Just a thought, but a Real campaign would seem to be needed .. innit?
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Old 8th Apr 2010, 17:01
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Squidlord:
It's a Military Aviation Authority (despite the letter of Haddon-Cave's recommendation). And if you look at its web page, you'll see it is concerned with safety as well as airworthiness.
Well I'm banged to rights and no mistake, guv'nor! I dunnit, I dunnit, I dunnit, it's a fair cop and no mistake! Don't think I can get away with a "Well done, I wondered who'd spot that first, but it might be worth a try...in the meantime thanks for the correction, Squidlord.
While we're discussing this organisation's title, perhaps we can now consider the word "Authority". So here we go again:
"authority, n; The power or right to control, judge or prohibit the actions of others"
So the MAA could indeed have dealt with this accident, whether or not it involved the airworthiness of the aircraft. Suppose it decided that a prime cause was the lack of flying continuity of the crew? Could it insist that this be subject to, say, a minimum of 15 hours a month? Could it enforce that? What would it do if, despite its ruling, 15 hours a month were not flown subsequently? In other words, how much authority has this Authority?
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Old 8th Apr 2010, 18:13
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From your resident 14 year old idiot TA cadet bizjet driver

I have just got back to this thread after a trip to Moscow on my employer's bizjet. That was preceded by a weekend spent training with our troop for deployment on Herrick XIV. As a private-sector taxpayer, having been made redundant recently and now working freelance, but contributing to our defence voluntarily at weekends, I admittedly have a different perspective to some contributors here.

However, I am left wondering what planet some of the supposedly well informed people on this thread live on? Have you actually been to Russia recently? When was the last time any of you actually visited Argentina? These are not countries filled with one-eyed monsters intent on starting unnecessary wars. These are countries filled with citizens who just want to do their best for their families like anybody else. The notion that we need to maintain hugely expensive QRA forces against the non-existent threat from these thriving and increasingly stable democracies is absurd!

I completely accept that we need a core QRA force - but nowhere near the level that we currently have.

There are far higher priorities - especially the threat of airborne terrorist attack on the UK, for which our vaunted QRA assets are no defence. Indeed, I would like Jackonicko to explain what possible scenario our QRA could actually save "thousands of lives"? Presumably he is talking about fighting "yesterday's war" against a 9/11 type attack, the risk of which a repeat has been thwarted by profoundly increased airport security and intelligence activity. Do you think terrorists are not aware of these changes? Do you think they don't read the internet? I can easily provide a scenario by which a terrorist, working as an indvidual (rather than requiring a large team with attendent risk of compromise) could, at a cost of a few thousand euros, evade all security, and destroy any target in central London. Our QRA could do nothing about it. I am obviously not going to provide details of the scenario here.

And Jackonicko, I don't support cutting the RN to levels of other comparably sized countries to the UK. Indeed, the RN nuclear deterrent and diplomatic/humanitarian contribution should be augmented.

All I am arguing against is the disproportionate RAF expenditure on air defence, which can far better be spend elsewhere at the moment. QRA air-defence has been "talked up" since the end of the cold war for job protection, not for genuine strategic necessity.

And while I am on the subject of wasting taxpayers' money, let's bin the RAFAT - they should be ashamed of themselves posing about wasting taxpayers' money crashing jets when there are young men risking their lives and limbs on the front line against a real threat, who have the where-withall and means to carry out the scenario I allude to above.

Last edited by Trim Stab; 8th Apr 2010 at 18:42.
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Old 8th Apr 2010, 20:04
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Trim Stab

they should be ashamed of themselves posing about wasting taxpayers' money crashing jets when there are young men risking their lives and limbs on the front line against a real threat
Are you CirrusF reborn.....?

Banter over, you say we should have QRA but not at the level know. So lets just have UK QRA and ignore any of our NATO commitments we have. How many jets on alert do you think we should have and how many crews will it take to man these 365/24/7. I know what the current answer is based on the current QRA commitment but curious to know what the TA view is. May even be able to turn this into a RN v RAF SAR force discussion as well

I also take it that given we are not fighting yesterdays war (9/11 ....!) that you would advocate the immediate scrapping of all heavy armour (cold war shock army blah) and its associated engineering support vehicles. And the Kings Horse Troop (when were horse and guns last used in anger). And all the Armys ceremonial duties (who needs horses, shiny breastplates and swords these days). Just curious.
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Old 8th Apr 2010, 20:21
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Not from a FJ background or a driver, but....

From what I have read about this tragic event, it is not too dissimilar from other fleets issues. Our currency was X hours per quarter, then the hours were reduced, then dropped all together and replaced by flights (profile not important). Then people started to use the term keeping current, unthinkable and not an issue a few years ago!
Luckily most of us recognised that it wasn't X hours or X flights which would keep us alive but a healthy mix of competency, experience and supervision, and we made sure we squeezed every training opportunity out of every sortie.
Also the message came down loud and clear from the top that safety was the absolute priority regardless of any perceived pressures.

What I'm getting at is that currency is just a number, it is the absolute minimum (from what I have seen) and not a target to achieve, if you are regularly just achieving it then alarm bells should be going off.
Content is also very important, 5 hours of quality training is better than 50 hours of transits.
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Old 8th Apr 2010, 20:36
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Wrath Monk

Neither you, nor I, nor Jackonicko, nor CAS, can possibly decide what absolute "minimum levels" of QRA are required. It is a pure judgement call, balancing risk against resource.

All that it is possible to speculate upon is the best use of the resource that the democratically elected government can afford to give to the MOD. The entire reason that I entered this thread is that some of you decided that Gordon Brown was responsible for the crash that ended the lives of the F3 crew.

There seems to be a general assumption by (presumably) serving members of the RAF on this forum that the general public owes them a living, and that the RAF should be allowed to spend public money ad nausea for the thinly justified existence of QRA and RAFAT.

I fully admit that I have a very different perspective from many of you on this forum. When I fly as a civilian pilot, every minute of our flights we are trying to save fuel by negotiating with controllers for short cuts, juggling winds and flight levels for best efficiency, taking visual approaches whenever possible to save a few minutes, and constantly calculating where it is cheapest to upload fuel. All that is motivated by trying to keep our jobs, to keep the company afloat, because of the taxes we pay! And where do those taxes go? I don't mind paying tax to support the old, the sick, the weak, and the defence of our country, particularly the latter as I am a TA volunteer.

I would just like to see the RAF take the same cuts as the RN and Army. RAFAT and air-defence (which are loosely linked) are disproportionately expensive. RAFAT in particular gives the impression that the RAF are not taking the current political and economical situation seriously - they write off £5m of my taxes attempting pointless stunts, burning more fuel in 20 mins than I save in a year of parsimonious flying (not to mention the raw diesel they into the atmosphere at the same time).

I fully support the RAF - but just give the funds to the hard-core front line guys - SH, RAF Reg, Medics, AT etc - and relegate the AD FJ and RAFAT to REMF status that they deserve.

PS The BBMF rocks - they represent all that is best of the RAF when up against the real front line - just like the ceremonial parts of the Army, or HMS Victory.

Last edited by Trim Stab; 8th Apr 2010 at 20:58.
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Old 8th Apr 2010, 21:41
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What a clown!
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Old 8th Apr 2010, 21:48
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It is a pure judgement call, balancing risk against resource.
And that, Sir, is the nub of it! The Defence Board (for it is they who sign off the Military Tasks for all the Services) have directed the level of QRA required. This has forced CAS to make the judgement and balance the perceived risk of real-QRA usage against the resources available across the board - he has, IMHO, cut the hours required to undertake QRA safely too far already (and that is the whole thrust of this thread - nothing to do with RAFAT, or poseurs or anything like that). He is also being forced to cut the GR4 force (currently on ops) and the GR7 (the best thing since sliced bread). Cut the Typhoon any further and not only will you not have QRA or fast air available for the FI but you won't have a CAS platform to support LAND in AFG / Iran / wherever.

Doesn't SH come under the LAND budget .....?

RAF Regt are being expanded. Guess they must already have got funds from the QRA pot .....

Medics is a purple organisation - the RAF can't be held to account for the shambles which was DCS 15.

AT - if the RAF/MODs hands weren't tied by the A400M saga ....

And finally - the 9/11 scenario is still a very real threat. IMHO.

You're right about one thing. You do have a very different view to most people on this board. But to call AD and RAFAT REMFs is a bit rich coming from a weekend volunteer. About 6.2% of the TA deploy on ops each year (figures taken from this article - and thats probably the same ones over and over again). And thats from an annual budget of £143,000,000 (same article). So how about we reduce the TA budget by 93.8% [approx £134M] (to plug all those gaps we desperately need to ..... (and I know there was talk of cutting back TA training but did it ever happen)

Anyway - back to thread. Apologies. If they (the government) want the MOD to do everything required of it then they need to fully fund it. Regardless of what GB says - they don't.
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Old 8th Apr 2010, 23:33
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Trim Stab,

Did OASC turn you down? Is that why you’re quite so anti-RAF?

You really should have tried harder at school.

“I would just like to see the RAF take the same cuts as the RN and Army.”

They have done, and then some.

By most metrics (numbers of personnel, number of frontline squadrons, etc.) the RAF has actually been cut back more than the Army or the Navy since the Cold War. Despite being a more relevant post Cold War service…..

“I completely accept that we need a core QRA force - but nowhere near the level that we currently have.”

A core QRA force, eh? What do you think? Sufficient to maintain two jets on alert, 24/7 at each of two airfields, one North, one South?

That’s what NATO expect us to do.

That’s what we do. That is a core QRA force. It’s quite easy to determine what absolute "minimum levels" of QRA are required – two interceptors ready to go 24/7 (with reserves) at each QRA station – each of those stations needing at least two squadrons to sustain the commitment and retain currency more broadly.

Don’t forget: QRA is f*cking meaningless if you only do it two days per week.

But you do want to ‘augment’ the Strategic nuclear deterrent?

What, six Trident subs instead of four? What on earth for?

And your remarks about the Red Arrows are a disgrace. They “should be ashamed of themselves posing about wasting taxpayers' money crashing jets when there are young men risking their lives and limbs on the front line against a real threat…?” They, and FJ AD are ‘REMFs’?

Anyone who comes out with that sort of crap is either a troll, or a clueless chimp.
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Old 8th Apr 2010, 23:39
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Jacko - I prefer chimps. Who let Trim Stab out?
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Old 9th Apr 2010, 00:04
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REMF status
Yep, says it all.

Why the **** has this clown drawn the thread down to this level??

GR
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Old 9th Apr 2010, 08:53
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Tuc,
I agree with you again there.

wrt your last 2 statements in bold, and particularly
Airworthiness is not only concerned with engineering aspects, but also with the way an aircraft is flown and how its systems are operated
this still shouldn't be construed as meaning that currency and competence form part of the airworthiness of an aircraft. As you know, issues about the way the aircraft is flown form one part of the RTS, defining the flight envelope for the varying configurations of an aircraft, and limitations on how the systems are to be operated form another. The fitness and suitability of the operator doesn't form part of the RTS.

sw
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