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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 10th Apr 2010, 18:53
  #121 (permalink)  
 
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Tuc

I'm in violent agreement with you as usual. Having previously been an ILSM I have been exposed to the mantra that doctrine that support will always maintain pace with the project. However, I've yet to see that realised on any programme. The support agreement has always been slipped and the budget plundered to pick up procurement shortfalls. Moreover, with simulators going the PFI route, it is nigh on impossible to build a simulator on time bacuase you are reliant on flight test data to design it. Consequently, you cannot fix the simulator spec and price until the design is very mature.

Back to the question I was trying to get to the bottom of, and I was hoping S/W might answer. What assumptions are the human error stat used in the fault trees based upon. It seems logical that it is based upon an average level of training and competence rather than the average number of keystroke errors a secretary makes. When I have looked at fault trees, the human error case is considered in many accident chains. If this assumption is invalidated because of lack of flying hours then the safety case also becomes unravelled.

regards

retard
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Old 11th Apr 2010, 16:56
  #122 (permalink)  
 
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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.

Just a thought, but if the Authorising Officer themselves only has experience of the current 'low hours' system, perhaps this would be the default normal ops to them and hence this is what we do, we've 'always' (in their experience), done it this way. Therefore it'd be ok to authorise the trip, its no different to any in their experience.

But ten hours a month!
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Old 11th Apr 2010, 17:18
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10hrs was a good flying month on the F3 a year or so ago. The whole attitude of the force was about producing results with the less than ideal equipment provided, I suspect that "can do" mentality transferred across to training hours as well.

I'm still curious as to how many hours the accident pilot had flown in the couple of months prior to the accident - not much in the report about that.....
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Old 11th Apr 2010, 20:21
  #124 (permalink)  
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Just a thought, but if the Authorising Officer themselves only has experience of the current 'low hours' system, perhaps this would be the default normal ops to them and hence this is what we do, we've 'always' (in their experience), done it this way. Therefore it'd be ok to authorise the trip, its no different to any in their experience.
Jumpseater - exactly the point. When the supervisors begin to view 10 hours a month as "normal" (BlindWingy), the very act of supervision becomes diluted by the pervasive inexperience of the operating community. Eventually those who truly understand the relationship between currency and competency begin to form the minority (or end up posting on PPRuNE) and the corporate or tribal knowledge is lost until a tragedy such as this brings it sharply back into focus.

Chugalug - that relates to your point, it's not a question of being silent, it's simply that the more experienced crew crew becomes almost an anochronism in a crew room full of bright new shiny people eager to get any flying, never mind a whole 10 hours a month.

The checks and balances we have in place to prevent the erosion of skill levels and maintain flying standards, be it at Unit or CFS level all fall victim to the reduced flying rates and the ever present "Op Tempo" where training hours are always at a premium. All driven by the cheerless scotsman in Number 10 of course, but an awful lot of people in the chain of command have to play ball before these failings become as institutionalised as in this case.

And finally I would agree completely that Airworthiness and Release to Service are all predicated on an assumed operator skill level and maintenance of that skill level. When that assumption is incorrect, the RTS by default is effectively invalid.
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Old 12th Apr 2010, 11:07
  #125 (permalink)  
 
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TI, thanks for coming back to me re "the silence of the lambs". Not directed at you personally of course but to the collective of those still serving and in particular, serving military aircrew. That there has been a failure of leadership here is plain, but it is too easy to simply blame "them" and see oneself as victim rather than perpetrator. The old Flight Safety slogan:
Flight Safety is YOUR business
means just that. If you are a very junior pilot and feel, together with your colleagues, that the level of continuity is just insufficient then say so loud and clear. It may not be well received, you may be seen as a trouble maker, tough! It is your professional duty to know when "Can do" becomes "Shouldn't do". Pressonitis is as deadly as it ever was in aviation. Of the 64 deaths including this one that I ascribe to airworthiness, fitness for purpose or currency shortcomings, the total enemy presence was AFAIK one AK47 round that killed 10 of them. That is just unacceptable and is down to you to prevent in the future. It is not all down to "them"!

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Old 15th Apr 2010, 10:00
  #126 (permalink)  
 
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In response to my claim that:

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.


tucumseh wrote:

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".
On the face of it, this clearly contradicts my claim. Except that I think it's just another example of poorly written documentation (that should be authoratatively error-free - there are many examples relevant to safety, e.g. Def Stan 00-56). The two sentences tucumseh quotes from AP3456 contradict each other, imo. So why is it written the way it is? Well, given that I have never read a jot of the documents tucumseh refers to you might, er, take my words with a pinch of salt. Anyway, I think the author of the documents in question probably knew that they had to cover wider (than airworthiness) safety issues such as, "the way an aircraft is flown and how its systems are operated". Rather than realising the subject they wanted to address was safety, and not just airworthiness, and rephrasing accordingly, they just tacked on the extra bits they wanted to cover as best (and as clumsily) as they could. Like I say, supposedly authoritative documents are riddled with such errors throughout MoD safety but also safety in other industries (e.g., the new drafts of IEC 61508 suffer similarly).

I understand (I think) the rest of what tucumseh writes about MAR, RTS, build standard, SC, etc. in the post I quote from above but don't understand its relevance to the airworthiness vs. safety issue. In particular I don't see that it contradicts my claim at the top of this post.

To me, the RTS is very clearly a safety document, not just an airworthiness document (even if it is the "Master Airworthiness Reference"). So, of course it follows that the RTS is based on the Safety Case (which subsumes an "Airworthiness Case", if you like).
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Old 15th Apr 2010, 10:10
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engineer(retard):

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?
For any (safety-related) system where humans perform a control function, the Safety Case is likely to include consideration of human error (erroneous control of the system!). Even if humans don't control the system, they surely designed and built it, so many Safety Cases for systems that are autonomous of humans will also consider (a different class of) human error.

All MoD aircraft Safety Cases should consider human error. They tend to do so in quite different ways and to quite different levels of rigour. I am aware of some that tend to use the same 1E-3ish figure no matter the error or context concerned and that is just poor. Def Stan 00-56, Issue 2, Part 2 (Guidance) did contain a handfull of ballpark probabilities for human error in different contexts. The lowest figure, 3E-3, was supposedly for "Errors of omission when the actions are embedded in a well-rehearsed procedure" or "General error of commission". The figures really are very broad-brush. For example, UK train drivers achieve much better than 3E-3 for stopping at red train signals (thank goodness).

There are techniques for analysing and quantifying human error, e.g. HEART, THERP, etc., but I always wonder whether, in their complexity, they just add a false patina of accuracy to what must inevitably be a very inexact science.

As for the derivation of the figures in 00-56, Issue 2, I forget. But whatever it was, it can't be that authorative. It's just not possible to make accurate broadbrush statements about the likelihood of human error (of all different kinds in all different contexts).

Generally speaking, most of the MoD aircraft Safety Cases I've come across tend to make a broadbrush assumption that the aircrew (and indeed maintainers) are appropriately trained and competent (this is not to say that the SCs don't consider human error in their risk assessments but for the most part, they only consider it in response to hazards arising, e.g. a failure to safely recover from a hazard, rather than as causes of the hazards in the first place). To be fair, there's not much else a BAE or Westlands, for example, can necessarily do. It's up to the MoD, or suitably delegated organization, to ensure that the assumption is valid. I suspect this will be part of the new MoD Operational Safety Cases but as I said in a previous post, progress on these is very slow.

engineer(retard) again:

What assumptions are the human error stat used in the fault trees based upon. It seems logical that it is based upon an average level of training and competence rather than the average number of keystroke errors a secretary makes. When I have looked at fault trees, the human error case is considered in many accident chains. If this assumption is invalidated because of lack of flying hours then the safety case also becomes unravelled.
I would suggest the aircrew human error probabilities used in quantitative risk assessment, e.g. in FTAs, should be based on the least experienced and capable aircrew reasonably forseeable. If you base your risk assessments and your risk acceptance on some sort of average experience and capability then you could be unacceptably endangering aircrew (and others) of below average experience, capability, etc. So, if you know you have a defined requirements for training, competence, etc., you assume a minimal level of experience, capability, etc. consistent with meeting the training, competence, etc. requirements.

This bites for me when I am involved in risk assessments that incorporate aircrew error because I often seem to end up talking to test pilots. As we all know, test pilots are supermen ... or they think they are . So I often have to remind them that just because they estimate there is an 80% chance that they could safety land the aircraft that has lost a wing, I need to know the chances of the minimally qualified, experienced, etc. pilot doing the same thing.

But engineer(retard) is absolutely right that "If this assumption [about competence of aircrew] is invalidated because of lack of flying hours then the safety case also becomes unravelled". This is not well-addressed in most aircraft Safety Cases I am familiar with but, again, Operational Safety Cases should, hopefully, address it thoroughly.
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Old 15th Apr 2010, 17:28
  #128 (permalink)  
 
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Squidlord

Thanks for the update. I have been out of that field for a while now and anticipate having to pick the books up again if I do. The typist retort was not meant to be derogatory, as I have seen a safety achievement level that was based on the probabiltiy of being struck by lightning whilst stood in a field. These figures seem to gain a life of their own without ever coming into question.

regards

retard
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Old 19th Apr 2010, 12:00
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The Sun have an article on this today

RAF pilots’ flight hours axed in MOD cutbacks | The Sun |News|Campaigns|Our Boys

RAF Top Guns are furious after MoD bean-counters slashed their flying time to save money, it was revealed yesterday.

Sixteen crews of the illustrious 111 Squadron were told to cut their 15 hours a month to ten.
The Ministry of Defence aims to save £80,000 a month in fuel and other costs.
But members of 111 Squadron, whose 14 F3 Tornado fighter jets protect Scotland and the north of England, say they are being left "dangerously short" of practice.
One said: "The cutback to ten hours is just enough to make you dangerous. It almost guarantees an accident if the jet is taken near its limits in the role."
The squadron, formed in 1917 and nicknamed the Tremblers, are based at RAF Leuchars in Fife, Scotland.
Following high-level protests, the hours have been "slightly" increased - but pilots are still angry, saying their allocation is worse than Soviet pilots were allowed at the end of the Cold War.
A crewman said: "I saw the results of low flying hours amongst the junior pilots on my last tour.
Knowledge of your own limitations and capabilities - and that of the aircraft - comes from time in the jet. No substitute."
Last night an RAF spokesman told The Sun: "Tornado F3 flying hours were reduced in line with the reduction in its operational role during 2009.
"Following a careful review, it was decided to increase the number of flying hours to a slightly higher level to make absolutely certain that the F3 is both safe and sustainable."
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Old 19th Apr 2010, 15:18
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to make absolutely certain that the F3 is both safe and sustainable

I was once told on a flying supervisors' course that the only certain way to do this was to fit bigger padlocks to all hangar doors.
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Old 19th Apr 2010, 15:56
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Proud of The Sun - using comments taken directly from PPRune too. Shame that our senior officers need this sort of reminder to increase flying hours.
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Old 19th Apr 2010, 17:45
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To chuck in a slightly different angle; what do the Flight Safety Officers have to say about this? I was an SFSO for a bit, and understood that part of my job was to say what everyone else was thinking. One had the option to phone up Harry Staish or even the Air Force Board about this sort of thing. A quick flick through the log book shows 220 hrs per year on my first tour (around 1990). And yes, decreasing hours and likely consequences thereof was on my PVR form. It's very hard to criticise the JP or his authoriser directly, as the frontline has been trying to keep going the proud RAF tradition of doing everything with nothing. A senior USAF Officer once told me "If you guys had our airplanes, we'd still be a colony." I think the responsibility for Nige & Kenny (RIP) has to lie with the Senior RAF types who accepted the loss of hours.
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Old 19th Apr 2010, 18:46
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F3WMB:
I think the responsibility for Nige & Kenny (RIP) has to lie with the Senior RAF types who accepted the loss of hours.
Amen to that Fox3, but responsibility is a very eroded concept these days. "Senior RAF types" had the responsibility for adhering to the UK Military Airworthiness Regulations and yet issued a Release to Service to a type so grossly unairworthy that Boscombe Down grounded theirs and begged the RAF to do the same. It didn't, with fatal results. Despite a current SIB investigation into airworthiness enforcement irregularities, I'm not holding my breath waiting for such "Senior RAF types" to assist them with their enquiries let alone face charges. All are equal under Military Law in the RAF, but "Senior RAF types" are more equal than others it seems. Meanwhile other squadron commanders operating other types face similar cutbacks to the minimum monthly training allocations and have to try anything and everything to keep their guys current. Responsibility just stops with them these days it would seem.
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Old 22nd Apr 2010, 22:32
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Sorry BGG, been away on holiday. Nice to know you're hanging on for me tho

Anyway,
Back to the question I was trying to get to the bottom of, and I was hoping S/W might answer. What assumptions are the human error stat used in the fault trees based upon. It seems logical that it is based upon an average level of training and competence rather than the average number of keystroke errors a secretary makes. When I have looked at fault trees, the human error case is considered in many accident chains. If this assumption is invalidated because of lack of flying hours then the safety case also becomes unravelled.
Specifically, I don't know about "the fault trees" you talk about however, as has been pointed out, Def Stan 00-56 used to give figures that have commonly been used. They're not there now, and Def Stan 00-250 (used to be 00-25) is the HF def stan. An issue I have often had to argue about was how people had used such figures, particularly when it was to mitigate a piece of kit with poor reliability to achieve the technical airworthiness target.

eg lets say in the case of the 43 Sqn Tornado there was a piece of kit that could provide a warning that CFIT was an increasing risk. Lets say it provided warnings to both crew, but had a probability of failure of 1E-3.

It would not be uncommon to see safety arguments that said that this was ok as it required the kit to fail, AND the nav to fail to notice AND the pilot to take notice and take appropriate action. Hence the prob of CFIT would be shown as of the order of 1E-9. The risk of CFIT would therefore be within the airworthiness limit. Right?

Wrong, see my #72:
The cumulative probability of the loss of an aircraft due to a technical fault and the cumulative probability of a technical failure of the aircraft (inclusive of its systems, structure and stores) which could result in the death of any air crew or passengers, should both be assessed to be of the order of one in a million per flying hour (probability of occurrence 1x10-6 per flying hour) when operated within the conditions used for the airworthiness demonstration.
Deals with technical failures.

Too often, fault trees use the aspect of simply ANDing human failure into the argument to shore up a weak technical argument.

Yes a safety case needs to consider the HF aspects of accidents, and the numbers cited have merit, but people need to be careful how they use them.

As regards the assertion that arguments are also based on average training and competence, yes I agree with what you say. When assessing aircraft tps are considering the ability of the average sqn pilot to handle the aircraft. Being controversial, given the info presented in the accident report, one could ask if that average standard has dropped such that the assessment by tps needs to be adjusted to accomodate for this?

sw
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Old 23rd Apr 2010, 15:50
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BGG

What assumptions are the human error stat used in the fault trees based upon. It seems logical that it is based upon an average level of training and competence rather than the average number of keystroke errors a secretary makes. When I have looked at fault trees, the human error case is considered in many accident chains. If this assumption is invalidated because of lack of flying hours then the safety case also becomes unravelled.

I agree with Safeware, and the above. It may help if you were to seek out the "Safety Case Policy" manuals from various Aircraft Design Authorities e.g. Westland, BAeS. They are prepared for and used by the DA but, obviously, they meet MoD and CAA requirements and MoD call them up in contracts (or did, in the days when Safety Cases were routinely maintained). Regarding your specific question, the version I have to hand, covering both MoD and CAA, uses this phrase;

".....using emergency procedures but without requiring exceptional pilot skill or strength"

which, I think, tends to confirm your assessment of what skills are assumed. It also confirms the assumption of adequate training is a fundamental component of the Safety Case and, hence, the RTS. If training / currency is compromised, so too is the Safety Case and the Master Airworthiness Reference.

I'm afraid I don't know where it is laid down what the flying hours per pilot are, for any given aircraft; someone like me would be more concerned with Fleet Flying Rate, which is stated in the annual EP Assumptions. (Or not, as the case may be. MoD stopped doing this a couple of years after introducing the policy not to routinely maintain airworthiness - 1991. As the funding was denied for the latter, there was no longer any point providing the annual data used to work out how much funding was needed!). Pilot hours is not quite as simple as dividing the Fleet hours by number of pilots, but it would be a rough guide.
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Old 23rd Apr 2010, 22:13
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Not sure what point you are making here BGG. Retard asks a question of Safeware who answers it following hellish return journey from ash ridden holiday in a far off country of which we know little. Well, I though I'd put a bit of topical spin on things while we're at it. Tuc adds his bit, endorsing Safeware's post and you go off on one. So what's your point? If it is that we very soft carbon units do not perform predictably to 10-3, or whatever, I think that was what Safeware was saying wasn't it? Or is that is what is just blindingly obvious? What seems blindingly obvious to me is that a whole clutch of professional pilot trainers (don't know about the WSOps) seem to have obsequiously submitted to the bean counters and accepted monthly hours being slashed to a dangerously low level, if comment on this thread is anything to go by. Sh*t happens when good men and women do nothing. All this talk of no experienced pilots and no-one knows any better these days is hogwash. The pity and the shame of the RAF is that a whole lot of what was done over the years, and so concisely described by tuc, was done by very senior and very experienced pilots. Far too many of their juniors have died as a result. Time that people faced up to their duty and responsibility and said No! "Can do" is often the easy way out in such a situation.

Last edited by Chugalug2; 23rd Apr 2010 at 22:26.
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Old 23rd Apr 2010, 22:47
  #137 (permalink)  
 
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BGG:
That said, I don't disagree with you.
Lol, your ringing endorsements are grudgingly given BGG, if you don't mind me saying so! I may be re-arranging the words in my posts sunshine, though not necessarily in the right order, but they all add up to the same thing. Flight Safety in the Royal Air Force is at a very dangerous low, deliberately driven there by its own senior commanders. Far too many have died as a result, possibly including those in the subject accident of this thread. Your advice to me is calm down? My strong advice to you and anyone else for that matter is get agitated and agitate!
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Old 24th Apr 2010, 01:15
  #138 (permalink)  
 
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BGG, cheers
I'll have you know i've upgraded - a number of times since. Now on an 09 :P and a nice new fast pc :P

You're right it didn't take rocket science to spot the ANDing, it's just sad that people who believe themselves to be safety engineers come up with such crap.

So, if I tried to answer it, why don't you give us the breadth of your knowledge

sw
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Old 24th Apr 2010, 04:44
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BGG

Having tried to help, you suddenly have a pop.

You say I am "stating the obvious". Well, what is obvious to me, and probably Safeware, certainly isn't obvious to, or even remotely understood by, those in MoD whose job it is to maintain airworthiness. Until it is, and they take the next step and demonstrate a willingness to do the job properly, then it is perhaps worth repeating.
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Old 24th Apr 2010, 10:33
  #140 (permalink)  
 
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Thanks S/W, I knew you would get back. Unfortunatley, I have seen the "AND" argument used a lot.

When did the human numbers drop out of 00-56, as I have seen them used recently?

regards

retard
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