'No blame' Over RAF Tornado Crash
But should it? You talk about a system safety case - the human is part of that system. If you treat them as 2 separate entities then problems start to creep in. I think that we're almost all agreed that the level of flying time available to maintain currency is an issue, but it's an issue across a lot of aircraft fleets and ATC and WCs. Does it come back to trying to do too much across the board with too little?
safeware
We speak from same page.
As has been noted, the regs, rules and instructions have been for many years contradictory and sometimes downright confusing.
Who does what part of airworthiness/safety/fitness for purpose? The MoD were embarrassed into not being able to answer the question at the C130 inquest - and I could sympathise (up to a point!).
In system integration terms this is a boundary definition and control issue. What often happens in MoD is that a rule or organisational change will shift the boundary of responsibility to remove a responsibilty from one person, but there is no complementary shift (or financial provision) to make sure the gap is closed. These gaps are numerous, and each constitutes a risk. If you are lucky, this simply manifests it self as a delay - but increasingly the result is more serious. Very often it doesn't matter who does the job, as long as it is done properly, on time and efficiently. The problem arises when no-one polices this from on high to ensure the gaps don't exist. They used to liken this to a roof of interlocking tiles. For 20 years the MoD have systematically removed the tiles, the rain has got in and rotted the foundations.
We speak from same page.
As has been noted, the regs, rules and instructions have been for many years contradictory and sometimes downright confusing.
Who does what part of airworthiness/safety/fitness for purpose? The MoD were embarrassed into not being able to answer the question at the C130 inquest - and I could sympathise (up to a point!).
In system integration terms this is a boundary definition and control issue. What often happens in MoD is that a rule or organisational change will shift the boundary of responsibility to remove a responsibilty from one person, but there is no complementary shift (or financial provision) to make sure the gap is closed. These gaps are numerous, and each constitutes a risk. If you are lucky, this simply manifests it self as a delay - but increasingly the result is more serious. Very often it doesn't matter who does the job, as long as it is done properly, on time and efficiently. The problem arises when no-one polices this from on high to ensure the gaps don't exist. They used to liken this to a roof of interlocking tiles. For 20 years the MoD have systematically removed the tiles, the rain has got in and rotted the foundations.
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Human Interaction
Tuc & S/W
I stand to be corrected but I recall many cases where human error forms part of the safety case and a figure of 1x10(-3) operation comes to mind. I have a feeling that it used to be derived from Def Stan guidance.
Where is this figure derived from, there must be some basis on having an operator trained to a defined level?
regards
retard
I stand to be corrected but I recall many cases where human error forms part of the safety case and a figure of 1x10(-3) operation comes to mind. I have a feeling that it used to be derived from Def Stan guidance.
Where is this figure derived from, there must be some basis on having an operator trained to a defined level?
regards
retard
Eng
Sorry if I don’t answer your question directly, but I think the issue of training, and its undoubted link to airworthiness, is important, but the actual problem is organisational and failure or misunderstanding of process.
The regs (and mandated instructions to officers charged with implementing the regs) say the RTS is a pre-requisite to the commencement of aircrew training; and we already know the Safety Case (which must consider Human Factors as you say), FRCs, ACM and ODM are pre-requisites to the RTS. (Thus, they are all inextricably linked). However, I don’t think it should expressed as simply as this; I have managed many programmes where the training commences, and progresses incrementally, long before the RTS is issued. One has to be more flexible and “tailor” the introduction to service according to the nature of the programme.
Historically, as long as all were seen to be controlled by the same person (say, the Project Director), then I’d be satisfied. But then along came Integrated Logistic Support (v. 2.0, not the original concept ditched when AMSO was formed around 1990) and training came under the ILS Manager. This created two main problems. First, the ILSM was seldom part of the project team delivering airworthiness so control and oversight was lost – he was part of the Service HQ and increasingly untrained for the job. Secondly, ILSMs were (and probably remain) fixated on the “LS Date”, usually set in concrete at 3 months before In Service Date.
Any pilot can see the problem. If you deliver training at the LS Date, you only have 3 months to train sufficient aircrew and ground crew (and, for example, deck crew on ships etc). This seldom computes if the ISD is defined as “10 operational aircraft” and a pilot takes 6 months to train. I think Apache is a good example here. The training requirement is more likely to be scheduled properly, and integrated into the overall programme, if under the control of the programme manager who will understand the RTS may be issued, but it is of no practical use, without training. Thus, ACAS should not sign the RTS until he is satisfied it can be put to its intended use; rather like the obligation on me not to sign the Critical Design Review until satisfied it meets the spec (including safety). Again, the close dependency between airworthiness and training. In this sense, it is both, or none.
But to the problem here, lack of flying hours. That is an aviation safety matter. It is directly related to the Master Airworthiness Reference (RTS) as the RTS is based on a Safety Case which assumes a given level of currency and competence; in turn linked to the TNA and Training Plan. If that currency is lost, the Safety Case validity is compromised, and so too RTS.
The aircraft is but one part of a system (“a combination of physical components, procedures and human resources organised to achieve a function”). This last introduces the concept of functional safety. The aircraft may be physically safe, but the overall system is functionally unsafe if the operator is not trained. Therefore, to declare airworthiness, one must first train an aircrew to demonstrate functional safety in the system, and this process must then continue and be maintained through-life. Therefore, and this is where my views originate from, the RTS is a statement that the training plan has been verified, and a properly trained pilot can operate the system safely, within defined limits.
I believe in this case, if currency was lost or compromised, then the RTS should have been amended to impose limitations or restrictions on crews who were not current. This is where I have to stop as I don’t know what aircrew think of this, but it would seem from the discussion that the final manoeuvre was made “difficult” by a combination of the aircraft configuration and lack of currency. The former is quite definitely a fundamental component of the RTS so there is a clear overlap. To a Risk Manager, lack of currency is a risk (was it notified as such by Tornado bosses?). It would seem reasonable that mitigation would include restrictions until currency was achieved. It works the other way round when the RTS is first issued. One builds up to flying within the complete envelope through progressive issues of the RTS, as the aircraft and its behaviour are understood. I’d be interested in aircrew opinion.
Sorry if I don’t answer your question directly, but I think the issue of training, and its undoubted link to airworthiness, is important, but the actual problem is organisational and failure or misunderstanding of process.
The regs (and mandated instructions to officers charged with implementing the regs) say the RTS is a pre-requisite to the commencement of aircrew training; and we already know the Safety Case (which must consider Human Factors as you say), FRCs, ACM and ODM are pre-requisites to the RTS. (Thus, they are all inextricably linked). However, I don’t think it should expressed as simply as this; I have managed many programmes where the training commences, and progresses incrementally, long before the RTS is issued. One has to be more flexible and “tailor” the introduction to service according to the nature of the programme.
Historically, as long as all were seen to be controlled by the same person (say, the Project Director), then I’d be satisfied. But then along came Integrated Logistic Support (v. 2.0, not the original concept ditched when AMSO was formed around 1990) and training came under the ILS Manager. This created two main problems. First, the ILSM was seldom part of the project team delivering airworthiness so control and oversight was lost – he was part of the Service HQ and increasingly untrained for the job. Secondly, ILSMs were (and probably remain) fixated on the “LS Date”, usually set in concrete at 3 months before In Service Date.
Any pilot can see the problem. If you deliver training at the LS Date, you only have 3 months to train sufficient aircrew and ground crew (and, for example, deck crew on ships etc). This seldom computes if the ISD is defined as “10 operational aircraft” and a pilot takes 6 months to train. I think Apache is a good example here. The training requirement is more likely to be scheduled properly, and integrated into the overall programme, if under the control of the programme manager who will understand the RTS may be issued, but it is of no practical use, without training. Thus, ACAS should not sign the RTS until he is satisfied it can be put to its intended use; rather like the obligation on me not to sign the Critical Design Review until satisfied it meets the spec (including safety). Again, the close dependency between airworthiness and training. In this sense, it is both, or none.
But to the problem here, lack of flying hours. That is an aviation safety matter. It is directly related to the Master Airworthiness Reference (RTS) as the RTS is based on a Safety Case which assumes a given level of currency and competence; in turn linked to the TNA and Training Plan. If that currency is lost, the Safety Case validity is compromised, and so too RTS.
The aircraft is but one part of a system (“a combination of physical components, procedures and human resources organised to achieve a function”). This last introduces the concept of functional safety. The aircraft may be physically safe, but the overall system is functionally unsafe if the operator is not trained. Therefore, to declare airworthiness, one must first train an aircrew to demonstrate functional safety in the system, and this process must then continue and be maintained through-life. Therefore, and this is where my views originate from, the RTS is a statement that the training plan has been verified, and a properly trained pilot can operate the system safely, within defined limits.
I believe in this case, if currency was lost or compromised, then the RTS should have been amended to impose limitations or restrictions on crews who were not current. This is where I have to stop as I don’t know what aircrew think of this, but it would seem from the discussion that the final manoeuvre was made “difficult” by a combination of the aircraft configuration and lack of currency. The former is quite definitely a fundamental component of the RTS so there is a clear overlap. To a Risk Manager, lack of currency is a risk (was it notified as such by Tornado bosses?). It would seem reasonable that mitigation would include restrictions until currency was achieved. It works the other way round when the RTS is first issued. One builds up to flying within the complete envelope through progressive issues of the RTS, as the aircraft and its behaviour are understood. I’d be interested in aircrew opinion.
I too would be interested in aircrew opinion, not only to the questions you pose tuc, but to the larger safety/airworthiness/MAA questions that have been raised in this thread, mainly by engineers past or present I suspect. There seems to be a bit of a one sided discussion going on here, to the effect that airworthiness is to do with aircraft and hence engineers, and currency is to do with policy implemented by aircrew commanders. So none of it is to do with PBI aircrew? Of course not, for as Jig Peter reminds us:
Flight Safety is YOUR business
So let's hear from you! Personally I am not so concerned about the demarcation between these various aspects of safety, for the very goal post moving by the MOD that so bedevilled things in the past will now come under the control of the MAA, or should do! Just as BA cannot chop and change the duties and responsibilities of its engineers or aircrew without the sanction of the CAA, so will it be with the MAA, or should be! So the real bottom line to all this is the MAA, and once again I pose the question:
Flight Safety is YOUR business
So let's hear from you! Personally I am not so concerned about the demarcation between these various aspects of safety, for the very goal post moving by the MOD that so bedevilled things in the past will now come under the control of the MAA, or should do! Just as BA cannot chop and change the duties and responsibilities of its engineers or aircrew without the sanction of the CAA, so will it be with the MAA, or should be! So the real bottom line to all this is the MAA, and once again I pose the question:
how much authority has this Authority?
Recommendation 1 d. of this report states:
This is an utter red herring. They may as well 'recommend' that you don't drive a car or ride a bicycle if you have to fly a fast jet. Many RAF aircrew fly both Brenda-jets and light aeroplanes with no difficulty whatsoever in switching brain cells between the disciplines. Along with many others, I've gone straight from instructing on the VC10 to instructing in a Cherokee on the same day - there really is no problem. The only occasion when flying light aircraft should perhaps be avoided is when the pilot is undergoing military helicopter flying training - although I don't actually subscribe to this view personally.
The real issue is the scandalously low allocation of flying hours to each fast-jet pilot per month. This horse$hit about the effect light aircraft flying might or might not have played in this fatal accident is smoke and mirrors and is complete and utter bolleaux.
The supervisory measures for aircrew that (sic) fly multiple ac types are reviewed, including General Aviation.
The real issue is the scandalously low allocation of flying hours to each fast-jet pilot per month. This horse$hit about the effect light aircraft flying might or might not have played in this fatal accident is smoke and mirrors and is complete and utter bolleaux.
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Trimstab.
Good luck on Herrick XIV; as a reservist myself, I understand the special kind of passion required to do this as well as possible. Be safe out there, and look after your team.
When you get back, feel free to PM me; we should be able to arrange a visit for you to QRA and you can tell the REMFs sitting around with nothing to do exactly what you think of them sitting in the shed waiting for the call. In fact, please do let them know that about 3 Hawks would be sufficient and do let's discuss exactly what you know about the force structure and the job; don't worry, it's already clear that it won't take long.....
A little knowledge and all of that!
S41
Good luck on Herrick XIV; as a reservist myself, I understand the special kind of passion required to do this as well as possible. Be safe out there, and look after your team.
When you get back, feel free to PM me; we should be able to arrange a visit for you to QRA and you can tell the REMFs sitting around with nothing to do exactly what you think of them sitting in the shed waiting for the call. In fact, please do let them know that about 3 Hawks would be sufficient and do let's discuss exactly what you know about the force structure and the job; don't worry, it's already clear that it won't take long.....
A little knowledge and all of that!
S41
BEagle,
Agree totally. The rubbish about light aircraft flying is clearly heading towards a new GASO that would show that "lessons have been learned" from this tragedy, and allow the chain of command to show that they've discharged their supervisory responsibilities. An increase in flying hours, needless to say, will only come from cutting crew numbers.
The real issue is the scandalously low allocation of flying hours to each fast-jet pilot per month.
BEagle,
Regarding FJ flying at the same time as light aircraft flying; it's in the BOI report that the pilot stuck in a bootful of rudder not long before impact. Do you think that this was a total red herring and nothing to do with his light aircraft experience, or was it related to his GA experience but would have been mitigated if he had a more appropriate number of hours in the F3?
Regarding FJ flying at the same time as light aircraft flying; it's in the BOI report that the pilot stuck in a bootful of rudder not long before impact. Do you think that this was a total red herring and nothing to do with his light aircraft experience, or was it related to his GA experience but would have been mitigated if he had a more appropriate number of hours in the F3?
Do you think that this was a total red herring and nothing to do with his light aircraft experience.....
Easy Street, I thought that these days the hierarchy only refers to 'lessons identified' rather than 'lessons learned'?
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The 'bootful of rudder' is not anything that a pilot has learned to help in this situation but it is an example of why it is necessary to supervise adequately an inexperienced pilot on type and to provide continuity in training.
Whatever the symantics of 'airworthiness' definitions, this is a simple case of failure to provide both supervision and continuity of training.
The buck stops well above those who perished in this tragic accident.
Whatever the symantics of 'airworthiness' definitions, this is a simple case of failure to provide both supervision and continuity of training.
The buck stops well above those who perished in this tragic accident.
I agree with BEagle on light aircraft flying having little to do with this. According to the registration earlier the aircraft the pilot flew was a Jabiru 400 - this aircraft has a small amount of adverse yaw to deal with using a bit of rudder. However, when you compare this to the Spitfire, Hurricane and even Chippie that BBMF fly the rudder required on the Jabiru is tiny. Don't forget that the majority of BBMF pilots are all current FJ pilots and I don't see them spearing in every 5 minutes. So I disagree with the Board's finding on this - the President, I understand, is a Navigator with little PPL type experience, so it would be interesting to see where he got his advice from! Everyone, knows that the rudder pedals are foot rests in the Tornado unless there is a crosswind on landing! Even the CSAS removes most of the rudder input for single engine work.
However, the rest of the Board looks about right IMHO as the currency and competency from 10hrs a month is definately the biggest root cause.
LJ
PS. I believe that airworthiness is about aircraft engineering and nothing to do with competency, currency and regulations. Furthermore, if we did as some suggested and only released the RTS when all the crews are trained and competent - how would we train them in the first place without an aircraft RTS
However, the rest of the Board looks about right IMHO as the currency and competency from 10hrs a month is definately the biggest root cause.
LJ
PS. I believe that airworthiness is about aircraft engineering and nothing to do with competency, currency and regulations. Furthermore, if we did as some suggested and only released the RTS when all the crews are trained and competent - how would we train them in the first place without an aircraft RTS
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This is not the only FJ accident where a bootfull of rudder was applied by a relatively inexperienced pilot.
I believe that BoI took the advice of a psychologist who suggested it was a reflex action when faced with an impending impact.
Now I don't know when Kenny applied the rudder with regard to the impact time, but I wonder if this BoI sought advice, rather than assuming it was a learned response from light aircraft flying?
I believe that BoI took the advice of a psychologist who suggested it was a reflex action when faced with an impending impact.
Now I don't know when Kenny applied the rudder with regard to the impact time, but I wonder if this BoI sought advice, rather than assuming it was a learned response from light aircraft flying?
This is not the only FJ accident where a bootfull of rudder was applied by a relatively inexperienced pilot.
Remnants of ingrained Tucano experience perhaps?
Nope, I suspect the core reason for the accident was lack of recency. When the hirearchy kept cutting away at flying hours, the old wise heads said it would all end in tears. Others quit whilst the going was good...
Another issue which will bite one day is the experience levels of pilot coming out of training - particularly their PIC (Captain) time.
OK, I know it's a bit 'swing the lantern and pull up a sandbag', but back in the early 1970s I arrived at RAFC with 55 hrs PIC from the UAS, plus the PPL from my RAF Scholarship. On the JP course I amassed another 37 hours PIC and a further 20 during my Gnat course. Add TWU, a few holds and refreshers and I arrived at my first (
) OCU with 185 hrs PIC.....I met someone recently who told me that ME pilots are arriving at their OCUs these days with only 30 hours PIC. To those who say that the dual training would more than compensate I say "Bolleaux! Quantity has a quality of its own! Learning to save your neck when there's no-one to turn to is a very useful lesson".
Below the Glidepath - not correcting
Having read all the preceding posts, in which most people seem to be in violent agreement that this "organisational" failing was both systematic and preventable, I have not seen anything about the final link of the chain before the crew strapped in and took off - the Authorisation. It certainly used to be a function of the Authorising Oficer to ensure the crew and the task were successfully mapped to the aircraft fit/role and the flying conditions, but in this case the experience and currency of the pilot seem somewhat at odds with the sortie - MSD specifically.
This is in no way intended to cast aspersions about the final Auth, just to indicate that those organisational failings led to low hours and experience levels combined with a taxing role fit and weight, being viewed as a normal occurrence within the unit. Alarm bells that may have rung only a few years ago were silenced by repeated exposure to institutionalised shortcomings in training and currency and as a result the Authorisation, the last safecheck in the system, was effectively negated.
This is in no way intended to cast aspersions about the final Auth, just to indicate that those organisational failings led to low hours and experience levels combined with a taxing role fit and weight, being viewed as a normal occurrence within the unit. Alarm bells that may have rung only a few years ago were silenced by repeated exposure to institutionalised shortcomings in training and currency and as a result the Authorisation, the last safecheck in the system, was effectively negated.
Two's in:
Silenced TI? I think that is a rather easy out for every one who is now wise after the event! This is not about some esoteric "not me Chief, I'm airframes" feature of aircraft operation. It's the one thing that we are all aware of from the time we seek to drive aeroplanes- hours! They dominate our life, get logged to the minute in our log books and describe our experience. Of course ignorance of the extent of this parsimony is some excuse, and one which I would claim, but those who keep their ears to the ground, let alone those who suffered it, were surely aware. Nothing said though, or was it? If this were solely about FJ flying then I would leave it to those far more informed than I (right! I heard that!), but this is very very basic business indeed. We are all agreed that currency is all important, so why no outcry before the event? ESF was pursued for decades by those who cared. Did anyone care about this?
Alarm bells that may have rung only a few years ago were silenced by repeated exposure to institutionalised shortcomings in training and currency and as a result the Authorisation, the last safecheck in the system, was effectively negated.