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MAA MILITARY AIR SAFETY CONFERENCE

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Old 19th Sep 2012, 20:05
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Awesome post! Thank you.
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Old 19th Sep 2012, 20:15
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Nice Castle,

What you describe is how I have seen things develop post-HC as well; those that should be concentrating their time on matters of Standards, Training and Supervision are battered with the maelstrom of questions and comfort-blanket answers required by those in the DDH chain that very little actual supervision happens.

Any chance of moving forwards in capability is wrapped up by the mass of staff work required to alter Safety Cases and the like to bring forward absolutely clear-cut advances that would improve safety & op effectiveness - the process has become a negative link in the safety chain due to the inertia of the whole thing.
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Old 20th Sep 2012, 00:31
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Nice Castle, the syndrome that you describe is both depressing and familiar, for others too have complained of the bureaucratic morass that "safety" has now become in HM aviation. The irony is of course, as you and others so rightly point out, that as well as being a pain in the proverbial, it actively reduces operational effectiveness and.... well, safety! The apparatchiks setting about rebuilding UK Military Airworthiness from Year Zero will have much the same effect as Pol Pot did.
As tuc repeatedly reminds us, it was not the existing Regulations that were the problem, but simply that they were deliberately suborned in accordance with orders from the highest levels! Better to get back to enforcing them, you would have thought, before completely and continuously revising them. Unbelievably the dilemma is that many of the Regulations were pulped even as those who were experienced in their implementation were sacked. So the MAA finds itself with a barren wasteland but, like many an RAF Board of Inquiry before them, under strict orders not to ask why.
If this were but a case of blundering staffing bogged down in endless paperwork one could sympathise but shrug it off with a "Well, what can you do?". But this is aviation and it doesn't tolerate such fatalism. 62 people have died in UK Military Air Accidents featured in this forum alone. The real total is almost certainly very much higher, but we shall never know because they were investigated by the very operator that suffered them.
Airworthiness related Military Air Accidents will go on happening, and the death-toll will go on rising, because the Regulator, the Operator, and the Investigator, are one and the same. Both Regulation and Investigation are as prone to unwarranted interference as ever, no matter what the sign says at the gate.
If that isn't the case why doesn't the MAA state unequivocally that Haddon-Cave's "Golden Age" of Airworthiness provision was in reality one of corruption, gross negligence, and deceit? It was in that "Golden Age" that illegal RTS's were issued to knowingly unairworthy types and the ARTs, that desperate attempt by DFS to air the scandal, were buried without ceremony.
The longer this scandal grinds on the longer the RAF's honour is sullied and the longer its aircraft will lack airworthiness. It has to bite the bullet, come clean, and face up to the gross betrayal by its leadership. Meanwhile the MAA and MAAIB must be released from the thrall of the MOD and be given real independence to get on with their vital work of avoiding avoidable accidents.

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Old 20th Sep 2012, 07:53
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Any chance of moving forwards in capability is wrapped up by the mass of staff work required to alter Safety Cases and the like to bring forward absolutely clear-cut advances that would improve safety & op effectiveness - the process has become a negative link in the safety chain due to the inertia of the whole thing.
Correct.


The very fact realisation has dawned that Safety Cases must (a) exist and (b) be maintained is a step forward. 20 years ago, under the then RAF Chief Engineer (Alcock) instructions were issued NOT to, under any circumstances, maintain Safety Cases.

The natural outcome was that the only Def Stan dedicated to this task was no longer maintained. At the time, those of us who no longer had a job (as airworthiness was no longer to be maintained and the posts were chopped) railed against this. D/Stan themselves agreed with us and made many attempts to update the Def Stan in line with legislation, the last in 2002 when I was asked to chair the proposed committee. My bosses refused this temporary secondment, on the grounds safety was a “waste of money”. It was finally cancelled, without replacement, 3 or 4 years ago.

All the above was presented to Haddon-Cave. He praised Alcock and others.

Some here will note that 1992 is precisely the year the Chinook ART was published (Aug 1992) which advised Alcock and Bagnall that the aircraft was not airworthy. CHART was what would have proved us right, but it was withheld from MoD(PE) staffs, including Controller Aircraft. So, in the certain knowledge our concerns were valid, what did Alcock’s organisation do? In December 1992 we were threatened with dismissal by his 2* 2i/c if we continued our complaints. THAT was the Chief Engineer’s reaction to being told his airworthiness system was shambolic. This threat was repeated, in my case, in 1998; I now know the Nimrod ART had just been published. Again, it was withheld from those who could have corrected the failures, even though the specialist department had been closed in 1993. When the Chief of Defence Procurement advised the Public Accounts Committee in 1999 that the CHART criticisms remained valid, a report to CDP’s Deputy went unanswered and was ignored. My point here is there exists a long, unbroken chain of evidence, much of which is outwith the MAA’s terms of reference.

Today, it is highly unlikely MoD has more than a handful who are even aware of this Def Stan and its accompanying 20 Specifications. The REAL problem is that many who are sit in senior positions, having gained advancement by virtue of the part they played in the rundown of the airworthiness system. That is, they actively supported the Nimrod and Chinook 2* in the late 90s when he, too, disciplined staffs for refusing an order to ignore airworthiness and financial probity. Today, that remains an offence in MoD.

If aircraft offices had people trained in the application of this Def Stan, and the general process, then they wouldn’t need to ask the MAA any questions. MAA’s task should be simple. Manage routine updates to these Standards, ensure correct training (which was stopped in 1992) and fight the cases for proper funding. The very fact they are being asked questions means they are not directing their efforts properly.

The question is always this. Would MAA’s current focus and output have prevented the Nimrod, Chinook, Sea King, Tornado or Hercules crashes? No. They would have been prevented by simple application of mandated, regulations; which were no longer in widespread use because staffs were instructed to ignore that mandate. That lack of focus is entirely down to the Nimrod Review actively protecting retired senior officers and the MAA being staffed by senior, serving officers, whose careers in part depend on their ability to protect the same officers, and their successors who still serve.

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Old 20th Sep 2012, 10:42
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Tuc,

Just a thought, but has the written evidence you refer to ever been brought to the attention of the Crown Prsoecution Service?

1.3V
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Old 20th Sep 2012, 10:50
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...or the Service Prosecution Authority. Incorrect, inaccurate or certification of airworthiness without having ensured its accuracy is now a specific service offence. No need for a crash anymore to earn a 2 year prison sentence; signing a bolloxs certificate linked to airworthiness is all you need.

The legal brief we had made quite a few go pale and I can name one PTL who changed his certificate at the front of an RTS as a direct result!
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Old 20th Sep 2012, 12:23
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1.3vStall

CPS - no, not directly.


RAF Provost Marshall, House of Commons Defence Select Committee, Thames Valley Police Chief Constable, Public Accounts Committee, various MPs, Prime Minister, 5 successive Ministers for the Armed Forces (the last time with the MAA present), MoD's PUS - Yes. None took any action and they continue to condone all that I describe. Now and again we "win" a case, such as Nimrod, Chinook, Hercules; but they don't seem to want to understand that the act of "winning" should lead to them overturning their previous rulings. Again, the compartmentalisation problem so typical of MoD.


JTO - As you say, what it needs is a prosecution. Making a false declaration has always been an offence - it is stated in letters of delegation; however, this was challenged by the senior officers I mention and Ministers have upheld their right to issue orders to make a false declaration, and confirmed it is an offence to refuse. This basic contradiction is the problem. I believe the specific offence regarding airworthiness is actually unnecessary, but does serve to emphasis the point. Now there is a new Min(AF) I'll be asking if he agrees with his 5 predecessors. The people who will prepare his reply will be the same old names and will no doubt advise him, yet again, to reject my submission.


Thanks for your interest. I'll let you know how I get on.
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Old 20th Sep 2012, 17:39
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What you will get for your money (or just your time) is AM (Retd.) Terry, the outgoing MAA DG, the outgoing Ops Director, the new Technical Director, AOC 2 Gp, the incoming CoM - Air and the Head of the MAAIB, all in the same room, potentially at the same time...
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Old 20th Sep 2012, 19:37
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In my experience of similar corporate ignorance:

A company used to (they don’t now) evaluate air accident insurance pay-outs against the cost of reviewing system effectiveness for modification…it took several accidents with fatalities (totalling hundreds) to motivate the national authority to mandate the changes required to stop the accidents. The company had not yet reached its internal mandate…but, for fear of imposed fleet-wide actions, felt encouraged to comply with the NAA’s instruction and changed the errant system.


A friend of mine theorises the MOD’s corporate responsibility thus:

It took many cases over many years and several dozen millions in compensation payments, in increasing amounts of money to more and more personnel, for the illegal ejection from the Armed Services of pregnant girls and of those wearing comfortable shoes, to gain some sort of recognition in the higher echelons and some action to review what was causing those cases and the loss of money…

Just think of how much longer, how much money and how many other cases to challenge the institutionalised arrogance/ignorance it will take to change the current attitudes to airworthiness?
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Old 20th Sep 2012, 21:17
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Tuc,

If officialdom is blocking your attempts to get politicians to take action, why not go to the press? It is a very dry, technical scandal for sure- but so was LIBOR and look at the fall-out from that (Alexi Mostrous at The Times was the journalist). You can be sure that ministers' private researchers will read your documents once their bosses' reputation is under question in the papers...
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Old 21st Sep 2012, 05:37
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Easy Street

Not an easy task. As you say, a dry and complex subject. Let's face it, about 3 people in MoD understand it, so the attention span of Joe Public is 2 seconds at most. Editors are aware of this. They don't understand that the same basic failures are responsible for the higher profile cases, like body armour, "armoured" vehicles, batteries exploding etc. That is not a criticism, because MoD don't understand it either. Individuals do, but policy militates against being able to correct it at a corporate level.


MoD play on this; in fact their policies rely on it. The classic example is: the year before XV230 crashed, Adam Ingram (Minister for Armed Forces) was formally
advised, in writing, that the airworthiness regs were not being implemented and there were systemic failures. At first he refused to reply, but an MP (now a Minister) pressed. (Kudos).


AFTER XV230 crashed, Ingram sent the MP a holding reply, stating the issues raised (by me) were "too complex" for anyone in MoD to answer, so a formal reply would take time. Eventually, 9 months after XV230 crashed, when it was already well known the crash was caused by airworthiness failures, Ingram replied to that MP, asserting there were no airworthiness failures, the regs were implemented correctly, and he had personally satisfied himself this was the truth.


Clearly, someone in MoD lied to him. In fact, quite a few people. Two years before (April 2004) the same MoD people had advised his predecessor that I was the only person in MoD who thought the airworthiness and financial probity regulations should be implemented! (I know this, because the Minister's office accidentally provided the MoD briefing paper to me under FoI).


Despite the Haddon-Cave and Lord Philip reports revealing the truth (up to a point), Ingram's successors have placed in writing that they remain content at the quality and accuracy of advice from MoD. Sir Malcolm Rifkind was the only past Minister to publicly breach protocol by stating he was grossly misled by Wratten and Graydon when briefed on Mull of Kintyre. (Kudos again; I believe this influenced Lord Philip). But no-one takes the next logical step - prosecution of this offence. THAT would switch the press on.


That is what we are up against. If the press want to publish anything they invite MoD comment. They get the same crap as the MP did. When they spoke to Alcock and Graydon during the Philip Inquiry, both blatantly lied; and those lies became official MoD policy and were included in Liam Fox's speeches. If they push MoD, the reply is (and remains) that XV230 was a single event, Haddon-Cave's report solved all problems while it remained in service, and now it's gone there can be no further problems. The compartmentalisation I speak of.


They completely ignore the "systemic" nature of the failings - the fact that much of airworthiness is (was, should be) a core MoD function, so if there was a failure on Nimrod (no valid Safety Case), it followed that the same failures existed on other aircraft. That was true for Chinook in June 1994, as it was for the other accidents mentioned here.


What I've written above makes senior people in MoD topple. You know what it's like. People who understand detail are frowned upon. If you do succeed in getting your point across, you're rocking the boat. Junior MoD staffs are today taught that understanding such detail is a career killer. I've known very highly qualified staff doctor their CVs by removing all evidence of such experience, as it helps them advance. And the VSOs prefer to sail in calm waters, ignoring the turbulence above and below.
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Old 21st Sep 2012, 09:57
  #32 (permalink)  
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Tuc,

I find all this utterly depressing. Surely there is a journo out there with enought nouse to pick this up and run with it?
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Old 21st Sep 2012, 10:02
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Or perhaps a TV producer; Panorama, Dispatches etc.
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Old 21st Sep 2012, 10:37
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A couple have tried. The last time, because there was irrefutable evidence, MoD's strategy was simply not to comment. If MoD doesn't comment, one way or another, the story goes away as far as the editor is concerned.

The same evidence was presented to H-C and Lord Philip. As you know, both noted the respective aircraft were not airworthy. The former spelled it out, the latter made a more oblique reference. But the press don't report that this calls into question the entire MoD process, over the past 20+ years. And MoD/MAA hide behind the H-C claim the problems only started in 1998.

However, it must be said that various Coroners are supportive and one has recently arranged for the audio tapes of a 2007 inquest to be handed to a family. This is one of the cases where MoD flatly refused to reveal ANY information, unlike Nimrod and, eventually, Chinook, where they handed over the evidence of unairworthiness. This is deeply suspicious and makes me wonder what they have to hide about this 2003 crash. (Same case as the one in my first paragraph).

The reason there is no record of the inquest is because the Coroner's stenographer posts had been chopped as a savings. So, if the families want a record, they have to arrange for forensic analysis of very poor recordings (in hand) and the acquisition of bespoke audio codecs owned by the Corner's Service (they quoted £600). This beggars belief, but luckily it is being carried out free of charge with the software provided by a well known professional mastering house. I submit that families should not have to go to such lengths to discover the truth. BTW, the first two days have been completed and the constant misleading of the Court, by omission and commission, is appalling. It will be up to the families what happens with the evidence. But as one bereaved father shouted out in Court, "What a fix!"
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Old 21st Sep 2012, 11:50
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tuc

Is that the one where the IPT blamed the civvy programme manager for making the aircraft unsafe, but he produced the evidence to show he'd directed it be made safe and was overruled? IIRC MoD withheld that evidence from the BOI and the coroner.
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Old 21st Sep 2012, 11:55
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Tuc/dervish,

I am finding this more and more disturbing. The information to which you refer must be brought to public awareness!

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Old 21st Sep 2012, 15:35
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Dervish

That's the one. The reason why the family sought the transcript was because MoD wrote to her a couple of years ago still blaming the PM; effectively denying the existence of the evidence and reports he'd submitted to investigators. They and their MP asked the BoI President (still serving as a 1*) to consider recommending re-convening. At first he was sympathetic, then suddenly changed his tone when (presumably) the implications became clear (senior officers and officials lying and withholding evidence).

However, the episode did serve to force MoD's hand and they revealed the aircraft were not serviceable, contrary to what was claimed by the BoI and in court. And, that the RTS was deeply flawed due to unverified "read across". In fact, very similar failures to Mull of Kintyre many years earlier, illustrating lessons had not been learned. These failures, and this evidence, would have explained all the unanswered questions posed by the BoI.

What I found particularly disappointing, as an ardent supporter of Boscombe Down, was the evidence given in Court by one of their former (but still serving) test aircrew. When asked by the Coroner if he had "anything relevant to add", he omitted to mention his MAR recommendations report which snagged an installation as unsafe, and the pressure he'd been put under to withdraw the report (i.e. leave the aircraft unsafe). I know he reads this forum and probably realises his failure to stand firm at the time led directly to 2 other deaths (although I think the greater blame lies with our 2* of the day who ruled it was acceptable to leave aircraft functionally unsafe, while making a false declaration it was safe).

Yes, 1.3VStall, it gets infinitely worse. But it needs good men to come forward, otherwise the likes of me are dismissed as liars. As I was in 2005 when Ingram was told of "systemic airworthiness failures". Despite the Nimrod Review and formation of the MAA, MoD still maintain I was wrong; which is utterly bizarre. BTW, the MAA are fully aware of this case and, like me, are waiting to see what the families decide to do. Unfortunately, legal action costs lots.
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Old 21st Sep 2012, 18:07
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Was there a reason he failed to mention it? I mean, that would only been an admission of having fulfilled his role at BDN. Did he simply forget, or was he cogniscent of the fact that it would end his career?
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Old 21st Sep 2012, 22:15
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I don't know. I last spoke to him 3 years before the crash. But he clearly knew what he was saying, as at the inquest he totally contradicted what he'd said in his initial MAR report, adopting the line Boscombe had been pressurised to take. It was the same issue that MoD and Ministers had lied about on Mull of Kintyre in the mid-90s - that of the definition of Safety Critical. He knew the problem rendered the aircraft functionally unsafe (as he'd clearly stated it in the MAR report), but never mentioned this to the court, saying it was not Safety Critical. MoD used this evidence to claim the aircraft were serviceable and fit for purpose, when they were clearly neither. Sorry, but if your primary sensors are designated "No Go" systems, but are unserviceable, then the aircraft is not fit for purpose (in this case, war fighting). Under extreme circumstances you may choose to take the risk and "Go", but to what end?
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Old 22nd Sep 2012, 08:49
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nice castle:
...or was he cogniscent of the fact that it would end his career?
In the more general arena that is, of course, the dilemma of everyone who is prevailed upon to lie, steal, and cheat by their superiors. No matter how it is dressed up that is the ultimate decision one has to make, and when the result of doing so is often to leave whole fleets unairworthy or fatal accidents improperly investigated then the cost can later be measured in lives lost. That is why the default reaction of doing what you are told and keeping quiet is not only morally wrong but criminally so as well. It should not be left to the MAA to spell out the personal consequences of improperly signing off work known to be not in compliance with the Regulations, it should be anathema to anyone declaring themselves to be aviation professionals. That latter term would appear to exclude the MOD, the RAF High Command, the RAeS, and quite possibly the MAA itself.
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