Air Safety Implications?

[woptb]

A lot of sense being talked. It must be top down,for a number years people talked the talk,but ahaven't accomplished the walk element. I wasn't slating the FAA,its a sound organisation in many respects,but the RAF is leading the way in the process and the FAA is behind the curve.
The RAF was only shaken out of its complacency by the loss of all souls onboard XV230, other elements of Mil aviation do suffer from a sort of pre Haddon Cave torpor.
In some quarters the FAA & Army aviation believe they have nothing to learn,I've experienced this first hand.
One of the biggest issues is a certain level of political resistance between and within each of the services; along the lines of we do it our way because its best.This blinkered approach is devisive/counterproductive.
Ideally the MAA & MAAIB would be completely independant,but there must be a certain level of evolution,if people see it as revolution you won't carry the majority. I've seen this with the introduction of Just Culture & the evolved investigation & reporting process. Many believe they must put their 'own' stamp on it .These political actions dilute & make the systems more difficult to implement,for instance at a basic level the RAF reporting system has undergone three name changes in two & a half years!

[tucumseh]

Zyder

Thank you. I entirely agree.

I was trying to interpret Graydon's misleading letter to Sir John Grandy. He made no effort to distinguish between the excellent organisations you mention, but in the context of what he was discussing I believe he meant the AAIB; because the RAF always cited the AAIB report as evidence of absence of technical failure, when of course it said no such thing. Tony Cable made it his business to clarify this to Lord Philip when giving evidence.

The main point is that his (Graydon's) words were intended to deceive Sir John into thinking there was independent support for the gross negligence verdict against the pilots, when there was none. The only question in my mind is how many years such an offence warrants.

[tucumseh]

The RAF was only shaken out of its complacency by the loss of all souls onboard XV230

I’m sorry, I beg to differ. I know what you mean but in this context it is important to get this exactly right.


MoD (the RAF Chief Engineer and the MoD(PE)/DPA Nimrod 2 Star, DGAS2 in particular) and Ministers were given formal written warnings for many years BEFORE AND AFTER XV230 crashed; and did absolutely nothing.

The year AFTER the crash, Adam Ingram signed a letter stating he was satisfied the airworthiness regulations WERE being implemented correctly. The MoD staffs who drafted it knew this to be a lie.


Even after Haddon-Cave reported, the RAF’s Directorate of Air Staffs’ formal position (in writing) was there were no systemic failings; that they disagreed with Haddon-Cave. The timing of this letter was unfortunate; while in the post Des Browne issued a statement accepting the Nimrod Review. DAS did not reply when asked if they still disagreed with the Secretary of State, but it is clear from numerous subsequent MoD letters to various MPs that there remains stiff opposition. It only needs one senior officer thinking this way to compromise anything the MAA is trying to achieve.

Despite MoD denials, one only has to compare these briefings with the utterances in the media of retired officers such as Graydon and Alcock to see these people continue to influence the thinking of their successors. Precisely the same happened in the run up to the Mull of Kintyre announcement; with both dissembling in the media and in correspondence, clearly trying to influence the outcome. They didn’t succeed in that Dr Fox overturned (something Graydon claimed impossible) but they did succeed in the sense the official MoD line was exactly what they’d said on radio, and remains so. You must always study the lie to find out the truth. What both consistently lied about was the 1992 CHART report, which warned of far worse systemic failings than Haddon-Cave did 17 years later. Top down is fine, but when this is the standard at the top, the tone they set is difficult to overcome when promotions are at stake.

[woptb]

Tucumseh,
I concur,my view was simplistic. Political macchinations have had a huge effect on upper echelons Safety Culture.
There has been every appearance of love of self (agrandisement?) over service and safety

[oldgrubber]

woptb,
I kept silent after your original "opinion" in this thread but I'll bite this time. I have 33 years man and boy in the Navy as my credential, and as you can see from my "handle" I'm an engineer.
I have seen the FAA move from an organisation that got the job done by any means, to one that as has been stated, actually came out of Hadden Cave without too many bruises. This is due in no small part to the systems of quality assurance, adherance to procedures and authorisations that the FAA has FULLY embraced.
I see that the "blinkered and devisive" approach that you talk of may actually be your own. "but the RAF is leading the way in the process and the FAA is behind the curve".
I too have experienced working with RAF and Army in situations both ashore and afloat and I can tell you that for the most part I was happy that our processes and procedures were more than equal to, if not better in most areas than some of those I witnessed being used by the other forces. I made no judgement because I did not work on Lynx, Chinook or Harrier and who am I to tell them how to do business. The RAF personnel at Culdrose for instance are more than happy to work under "our" rules, which incidentally means ALL of our "joint" rules; enforced by our regular QA checks and very robust reporting system, so enough "us and them"!The discussion here as I see it is about the "Just Culture" and as an old engineer I can catergorically state that it is embraced, developed and practiced at FAA stations. As an old engineer I also think that losing a days pay for a minor crime of stupidity was no bad thing, but that didn't encourage openess and honesty.

Cheers now

[Chugalug2]

og:-

The discussion here as I see it is about the "Just Culture" and as an old engineer I can catergorically state that it is embraced, developed and practiced at FAA stations.

Well in part, og, in part. The real elephant in the room is UK Military Airworthiness, or rather the lack of it, and that affects Army, Navy and Air Force Aviation. Every fleet and every aircraft. That is the real problem, and it cannot be resolved by grounding fleet after fleet, though that seems to be the MAA default solution at present. It can only be resolved by having an independent MAA and an independent MAAIB, both of the MOD and of each other. You cannot evolve to that but must get there ASAP, for delay simply means more avoidable accidents and deaths.

Sorry WOPTB but I fundamentally disagree when you say:-

Ideally the MAA & MAAIB would be completely independant,but there must be a certain level of evolution,if people see it as revolution you won't carry the majority.

It isn't a matter of carrying the majority. This isn't a referendum it's airworthiness, and aviation doesn't give a damn about opinions. Get it wrong and you pay with your life or, far far worse, someone else's.

Self Regulation Doesn't Work and in Aviation It Kills!

[tucumseh]

I wouldn’t like to see this become a pissing contest between Services. At the practical, working level at Air Stations (1st/2nd Line) I have nothing but respect for those who maintain our aircraft. (Well, I’ve got to say that, because at the end of the day I’m just a bum aircraft fitter).

I’ve never come across anyone at 1st/2nd who deliberately and knowingly rendered an aircraft unsafe, or signed to say one was safe, knowing it was not. Unlike the instructions doled out in MoD(PE), DPA, AMSO, AML, DLO throughout the 90s/00s.

Studying the various reports Haddon-Cave drew on, yes there are a few criticisms of 1st/2nd Line but he carefully avoided going into the detail of why, for example, training, tech pubs, tooling, spares and support in general had deteriorated over a long period. They can only work with what they are given. He criticised General Cowan for 20% cuts over 4 years (in line with a general fleet reduction) while failing to mention Alcock oversaw two 28% cuts directly targeting airworthiness, at a time regulatory changes required an increase.

Here, you must say what the output of “support” is in two key areas of the airworthiness chain. Broadly speaking, at front line the output is “fit for purpose” (and preferably serviceable) aircraft. But to the likes of me, working earlier in the process (but having done the former as well), the output is a valid Safety Case; a prerequisite to ACAS (in the RAF) signing the RTS, or a signed RTS remaining valid. That is, my work facilitated that of front line. How many at front line, in the period from 1990-on, knew we were being ordered not to do our job, that the vital output (the Safety Case) was deemed a complete waste of time, and funding was systematically slashed, year on year? And, because this work ground to a halt (by June 1993), all our posts were cut and the department disbanded. By the Chief Engineer. Haddon-Cave was given this evidence, and all the supporting papers, but he didn’t mention it. Why? Because it blew his criticism of General Cowan out of the water, concentrating focus on the people he intended praising (and eventually did).

MoD don’t like this being pointed out, because it draws the attention to where the real systemic failings lie, and where the MAA, even now, simply doesn’t want to go. Practical implementation of the airworthiness regulations BEFORE the aircraft is even released to service and provision of the services to, and resources for, 1st /2nd Line after ISD.
If you study each of the cases discussed here, Nimrod, C130, Tornado, Chinook etc, the accidents would have been prevented by AMSO/AML/RAF**Chief Engineer;

1. Heeding warnings of staffs in the years from 1987
2. Directing staffs in the airworthiness delegation chain to implement mandated regulations

Instead, the formal warnings were ignored to the point the messengers were threatened with dismissal, the same juniors being instructed to ignore their legal obligation to implement regulations.

The Nimrod Review did not contain a single surprise. This should never be forgotten. It was merely a rather simplistic compilation of what was well known and reported many times previously, in greater and more accurate detail. It completely lost direction as soon as it adopted the MoD party line, muddying the waters between serviceability and airworthiness. It lost all credibility when praising named Chief Engineers and the Nimrod MRA4 IPTL whose job it was to be satisfied MR2 was airworthy. Yes, he talked a good fight, and made some good points; but the very fact he said nothing new, and most in MoD didn’t realise this, is actually the biggest indictment. The result is hundreds running around thinking “Gotta implement Haddon-Cave” when the actual solution is “Speak to those who know how to do it in their sleep, but have been prevented from doing so for 20 years”.

Today, the MAA is re-writing these regulations (so far, not very well) while Ministers continue to rule it is acceptable to ignore them. Given this cultural stagnation, how far forward have we actually moved since Haddon-Cave reported? Have all the practical problems at 1st/2nd line been solved? Has funding been resurrected to enable DE&S to do their bit?


** I know I bang on about the RAF Chief Engineer, but from the late 80s most aviation support funding came under AMSO (as opposed to the proper RAF), with the other two Services having no real say in what their money was spent on. (Or, in practice, which drain it was poured down). When AMSO was restructured in this way, it was meant to become a “purple” organisation. It didn’t.

Haddon-Cave kept going on about “the RAF”, which the RN and Army have chosen to interpret as meaning they are ok. In fact, Haddon-Cave was (perhaps unwittingly) merely reflecting the reality of what I describe; for a long time the RAF has controlled aviation support funding. The RN and Army shouldn’t get complacent.

[exMudmover]

Surely the real ‘elephant in the room’ with any modern Safety Investigation is the iniquitous Compensation Culture, offering vast payouts to anyone who can convince a court of the slightest error on the part of any service body?

While I have utmost sympathy with any relative of a serviceman killed or injured on duty ( I lost a good few colleagues myself), I believe that when you take the Queen’s shilling you contract in for a certain measure of danger. If you don’t want that then join an airline instead.

In my early flying days RAF Boards of Inquiry were required to produce a 48 hour signal for all to see, giving the Board’s best guess of the likely sequence of events and - most important - any changes of procedure necessary by air and ground crew to avoid similar accidents. These would be implemented immediately if necessary.

Naturally enough this produced a fair share of false alarms but I believe it saved many lives. If the Board believed the pilot had screwed up they would say so, without fear of Civil Court action to follow.

I gave evidence to and was occasionally subject of quite a few Inquiries, and I was always impressed with the effort made to get at the truth and prevent similar accidents, regardless of whose feathers were ruffled. Are these still the priorities nowadays?

[tucumseh]

Surely the real ‘elephant in the room’ with any modern Safety Investigation is the iniquitous Compensation Culture, offering vast payouts to anyone who can convince a court of the slightest error on the part of any service body?

I think it is too simplistic to say this but not mention what lies beneath.


I can only speak from my experience of speaking to some of the bereaved (e.g. Nimrod, C130, Chinook) and, without exception, all accepted the inherent risks associated with serving.


What got to them was it became obvious that each accident was avoidable. In fact, some had been predicted in fine detail. That is, the system you describe (aim - preventing recurrence) had worked up to a point, as very experienced people had formally notified those with the authority to correct the failings. THAT is where the breakdown occurred – they didn’t do anything.


MoD don’t like this link being made, insisting each accident be considered in isolation; but the fact remains Nimrod and C130 (e.g.) would have been avoided by implementing different paragraphs of the same chapter in the regs.
The families’ views were further strengthened by MoD systematically lying. Examples.



· C130 – “We’d never heard of ESF until after the crash”. (Called up in 00-970, which invokes 1970s MoD ESF specifications).
· Nimrod – “Airworthiness regs are irrelevant”. (The all time howler).
· Chinook – “There was no such thing as an RTS in June 1994”. (Another MoD department handed over an unredacted copy).
· Sea King – “We’ve never heard of HISL”. (Despite photographs of aircraft with HISL fitted hanging the IPTL’s office wall).



And so on. In a way, it matters not if the subject of the lie was a causal factor (e.g. Sea King is debatable). It is the fact they lied which is important and, more importantly, continued to lie in briefings to Ministers after they were caught out.

When you’re lied to on such a scale, you tend to suspect MoD have something to hide. You seek the truth. This requires legal intervention. The natural outcome of the legal process is often compensation, but that is seldom what the families sought. Most, rightly, take the view nothing can compensate for the loss of a son in an avoidable and predicted accident.

[VinRouge]

Exmudmover,

When I fly in Afghan, I and my family accept there is a risk of loss due to enemy action. I can fully understand this.

What I dont accept is being expected to fly an aircraft that due to budgetary constraints and service politics, is not airworthy, or for the same reasons (budgetary constraints on manning levels) am so ball bagged that I cannot stay awake on an approach. Things HAVE changed for the better and those 2 scenarios above are less likely these days, however, we still have a way to go. I dont accept that service risk due to penny pinching is something that any service member should ever have to accept whilst at the same time being put in harms way.

[exMudmover]

Vinrouge

“I don’t accept that service risk due to penny pinching is something that any service member should ever have to accept whilst at the same time being put in harms way. “

You should have seen the kind of problems we had in the 60s, 70s and 80s with some of the inadequate equipment we had. Compromises were made to get the new generation of fast jets (Harrier, Jaguar, Phantom etc.) into service and there was never enough money to fix every design fault straight away. Aircrew knew this and made allowances in their flying – expecting things to go wrong.

As I’ve stated before in this forum, Cold War Fast Jet flying was very much more hazardous than present day operations anyway: flying a jet that was likely to go wrong was just part of the deal you had bought into.

As I said before – if you want totally safe flying at all times then either quadruple the defence budget, or join an airline. As usual, in the end it’s all about money.

Tucumseh.

“each accident is avoidable”

Er, no. Accidents are inevitable. Incidents may be avoidable (if enough money is spent).

[Chugalug2]

exMudMover:

RAF Boards of Inquiry were required to produce a 48 hour signal for all to see, giving the Board’s best guess of the likely sequence of events and - most important - any changes of procedure necessary by air and ground crew to avoid similar accidents. These would be implemented immediately if necessary.

... and what chance that any such signal would highlight deliberate suborning of the Airworthiness Regulations as a result of direct illegal orders from RAF Air Rank Officers to do just that? You highlight the very Achilles Heel of this dysfunctional system, that it cannot be trusted to provide for airworthiness or objectively investigate its own accidents. Nothing to do with compensation, more to do with corruption.

[tucumseh]

exMudmover

I didn’t say “each accident is avoidable”, which you then interpreted as every accident. What I said was specific accidents were avoidable, as their root cause was identified beforehand and, had the regulations been followed, preventative action would have followed.

As usual, in the end it’s all about money.

Agree with this sentiment up to a point. But it also about what you do with the money. My posts here seek to get across the point that the deliberate rundown of airworthiness is directly linked to the deliberate waste of money; especially following an AMSO policy promulgated in June 1987. The resultant waste was truly astronomical. It wasn’t that we didn’t have the money; it was just poured down the nearest drain.
On top of that, and as part of the same policy, perfectly serviceable kit was scrapped overnight and funding immediately (and I mean the same day) approved to buy it again, even before the existing kit had been carted off to the nearest skip. This criminal waste swiftly resulted in AMSO not having funding to buy what was required. To generate funding, the airworthiness budget (hitherto ring fenced) was robbed to the point of extinction.



This was the subject of an internal audit report in January 1988. AMSO took no action, except to threaten civilian staffs with dismissal (in December 1992) for complaining about being required to maintain airworthiness without funding and make false declarations the regulations were being implemented correctly. This 5 year gap between the audit and threats illustrates just how long this was going on, and how big the gaps are in audit trails. This continued throughout the 90s and 00s; to this day it remains an offence to refuse to make the same false declaration.



Thus, at a certain level, MoD will quite rightly say airworthiness was properly funded in this early period. And, quite rightly, they did not approve replacement funding for that poured down the drain. But, equally, they took no action against those who committed the waste (aka fraud). That is, senior staffs took no action against themselves. Funny old thing, that.

[woptb]

Grubber, sorry if I touched a nerve,it wasn't my intention to belittle the FAA. I was talking about the introduction of the Defence Aviation Error Management System (DAEMS) & it associated components (reporting,investigation & just culture etc.). The RAF was the first,doesn't make it the best. As an ex maintainer I didn't always follow procedures,I over signed work I hadn't seen & tended to keep errors 'in house'.
The DAEMs process (to have any hope of brining about change) has to (and does) recognise that our people are imperfect & sometimes make bad choices. Unfortunately this has become the cultural norm,we make decisions & take on risks we shouldn't.
Can do & initiative are valued & will be still. we have to work on the whole of military aviations culture top to bottom. Willing horses are great but (mixing my metaphors here!) in being part of a culture where we always achieve (no matter what) we create a rod for our own back. One of the things about military aviations just culture is once you move outside (death,serious injury loss of platform) you move to civil law & it isn't just & it isn't fair.
Precursors of serious accidents are generally known before you get the bad outcome, but people don't flag up issues or if they do they aren't listened.
DAEMs is trying to adress this,it by no means perfect & our people (because of the way the've been treated) are jaded & become cynical,but its moving in the right direction. Its already startuing to bare some fruit.

[oldgrubber]

woptb,
No worries just little old sensative me, I think this thread is interesting in many ways and was worried it was doing the "usual", which would have been a shame.
The best way to sum up the attitude that I was taught and hopefully have passed on to all my trainees and young mechanics (and even supervisors) over the years is, "Think once, think twice, think board of inquiry". It's a good way to focus a guy who's about to sign "off", rather than "up".
I think we are more alike than I thought!

Cheers now

[JFZ90]

I think it's a bit of a shame that there has not been more discussion - or outrage - at what appears to have happened to the Greece engineer.

There is surely nothing for the MAA etc. to learn from the Greece incident, other than of course being sure that any such (seemingly) unjust outcome ever creeps into uk airworthiness. I always understood the basic principle that making a mistake itself was not necessarily a crime - the real airworthiness value is to ensure such mistakes are reported, recognised and the implications and appropriate mitigations are it in place.

What is wrong on the Greece incident is that too much emphasis is put on a single factor (switch position), rather than wider issues.

Haddon Cave did the same over the safety case IMO - the bigger mistakes were much earlier. Just my opinion.

[Chugalug2]

JFZ90, this is a direct quote from the OP's link:

Once again we are witnessing a judicial process that offered an opportunity to improve aviation safety failing to meet that challenge preferring instead to allocate blame on an uninformed and irrational basis and with a mindset that someone must pay because an accident sadly causing deaths has occurred and society demands a scapegoat.

If you think that:

There is surely nothing for the MAA etc. to learn from the Greece incident, other than of course being sure that any such (seemingly) unjust outcome ever creeps into uk airworthiness.

then I should read the OP quote again, reflect on Mull and the unjust finding that besmirched the reputations of 2 deceased JOs taking over 16 years to quash, on the RTS that was issued despite known severe airworthiness shortcomings then of the Chinook HC2, and finally on nothing of that emerging from the RAF BoI. Nothing to learn, or won't learn?

[woptb]

JFZ90 Greece isn't alone in its way of responding to the loss of the Helios 73.

The Tuninter ATR 72 that ditched off the coast of Italy was another case in point,a string of errors,a litany of systemic problems coupled with some imperfect decision making led to the ditching & the death of 16 people.

9 people in court,7 convicted, receiving sentences of between 8-10 years.
The Italian judicial system took the results of the accident investigation (which the ICAO says is all about preventing & learning) & used it to prosecute those involved. This was a travesty,but unfortunately (in the majority of cases) civil law is about blame & not justice.

[Exrigger]

I watched a TV programme about the Greek crash with a UK investigator who found there is a known electrical short circuit possible in the cabin outflow circuit that causes the valve at the back of the aircraft to open and dumps cabin pressure.

It apparently was what was found on a couple of other aircraft of the same type, the pilots on those flights descended when they got the same indications found from the Greek aircraft flight recorder and landed at the nearest airport instead of continuing to climb to cruise altitude which the Greek crew did.

There was some interesting info from two fighters scrambled to intercept as there was no answer from the plane they thought it was highjacked, it turned out it was two cabin crew members trying to fly the plane as one pilot was seen slumped over the controls and the other was in the cabin.

Also the checklists require that switch to be checked at various stages during start up, taxy and take off and it should of been in Auto.

[tucumseh]

JFZ90

I always understood the basic principle that making a mistake itself was not necessarily a crime - the real airworthiness value is to ensure such mistakes are reported, recognised and the implications and appropriate mitigations are it in place.

"An error does not become a mistake unless you refuse to fix it".

Those who erred not only made mistakes, but rejected the notion they should meet their duty of care by meeting their legal obligations. Thus, the transition from error to mistake was consciously followed by committing serious offences.

Haddon Cave did the same over the safety case IMO - the bigger mistakes were much earlier. Just my opinion.

Demonstrable Fact!



What rang alarm bells was that the same "MoD advisor" to Haddon-Cave was placed in charge of the implementation team, and posted to the MAA. I'd like to know what advice he gave to Haddon-Cave regarding the unpalatable, but factual, evidence that was not published. This failure is what allowed him to lay blame on named individuals. Both were complicit.

That was bad enough, but as a legal eagle Haddon-Cave would have known it was wrong to;

a. Withhold vital evidence that "the bigger mistakes were much earlier".

b. Then name and praise those who made these "bigger mistakes".

There is something fundamentally corrupt about this whole process. MoD will call it continuity, but the only visible continuity is MoD's denial of problems before 1998, and compartmentalisation of them after 1998. The common thread here is not only scapegoating junior staff, but protecting the guilty.


The only question that need be asked of the Nimrod IPTL (Gp Capt Baber) is - Why did you need to let a Safety Case task on BAeS? The answer reveals the directions handed down not to waste money on Safety Cases. If Baber was guilty of anything, it was disobeying this order that money shouldn't be wasted on safety. Until the MAA openly accept this simple fact, they will never be able to convince anyone of their "independence". And a "Just Culture" can never prevail.