MAA MILITARY AIR SAFETY CONFERENCE
JTO
I posted above that MoD staffs were under Instruction to mandate certain Def Stans in contracts. Included was 00-970, Design and Airworthiness Requirements for Service Aircraft (previously, Design Requirements for Service Aircraft).
The point I make in my various posts is that there came a time when, to save money, orders were issued that this Instruction, and others, could and should be ignored. (In practice, implementation funding was withdrawn). But, what we weren't told was, what Standards should we now invoke.
In about 1993 these Controller Aircraft Instructions were to be replaced with Chief of Defence Procurement Instructions (CDPIs). The CAIs were duly withdrawn, but the CDPIs never issued. A few appeared in draft form, but their content would embarrass a five year old. At precisely the same time the Chief Engineer was running down airworthiness with even more draconian cuts (~28% per year, as stated in CHART in 1992).
Bearing in mind that in one sense, a "generation" of MoD staff is the length of a 2-3 year tour, many generations have now been taught that "Def Stans are not mandatory" and "Safety is a waste of money".
I retain full records of an instance in 1998 when I was instructed not to invoke JSP553, 00-970 and 05-123 for this very reason. When I pointed out my legal obligation was to produce an airworthy Military aircraft, so what Standards should I use in their stead, my boss (non-engineer, with self appointed airworthiness delegation
) completely toppled. He hadn't been taught that bit at his half day seminar. I ignored him, as did my contractors, but a few years later, after I moved posts, he over-ruled me and amended the contract. This explained the three main contributory causes in a subsequent BoI, but the evidence was actively withheld from the BoI and Coroner by the IPT.
Personally, I never invoked one of these CDPIs, and can't recall ever seeing one at formal Issue 1. The sensible among us continued to adhere to the "old" rules, if only because there were no "new" ones to implement. You can appreciate that, if you are a contractor and an aircraft related contract is being negotiated, you want to know what Terms and Conditions MoD, your customer, is seeking to apply. Industry were not part of this ill-fated CDPI fiasco (itself a huge waste of money) and in negotiations rightly assumed the only relevant Def Stans would be applied. To the likes of Westland, MoD were a laughing stock. It was rightly pointed out above that, for example, 05-123 is in the new MAA document set, but what the MAA don't tell you is we were told not to use it for over a decade. Question - Why does the MAA not just come out and acknowledge this? In fact, how many of their staff actually know this background? And if they don't, then what makes them suitable and who is training them? I think this pretty important in an organisation whose job is to correct past failures. If you don't know what the failures were, then how can your work be validated? That is not a criticism of MAA staff, per se, but of the system and culture. And part of that culture is an overly cosy relationship with, for example, those who are meant to be independent auditors of the MAA. Witness, the speakers at the forthcoming conference. For example, what are the two audit panel members going to say in their presentations? One of them is talking about "Safety Culture". Does she realise that MoD's approach to the subject was draconian disciplinary action against those who sought to make aircraft safe? The Chair of the audit panel is talking about "Implementing the Nimrod Review". Is he going to start with "The Nimrod Review is deeply flawed, and therefore so too is the MAA's terms of Reference"? I doubt it, because MoD hasn't told him this.
In the case of Hercules ESF, the relevant Def Stan requires a vulnerability analysis to be carried out. You do not have to dream up threats in the first instance - they are listed. The very first is "inert projectiles", which all agree is what brought the aircraft down. The second is "incendiary projectiles", and so on. In the last column of the table is the required mitigation. ESF. It calls up two MoD specifications for ESF, in Fuel Tanks and Dry Bays. It is true that one can choose not to fit it, for whatever reason, but then the Build Standard, the RTS and Statement of Operating Use and Intent must be reconciled, with the Use and Intent parts excluding the possibility of being in a position whereby these threats exist. And if circumstances dictate there is an operational imperative, then in parallel mitigation must be put in hand, accompanied by formal acceptance of this risk. I suggest that 35+ years after delivery is far too long. But that is entirely in line with MoD's stated Risk Management policy of the 90s/00s - Do not mitigate, wait until something happens and then deal with it. Trouble is, when "something happened" people died. That applies equally to Chinook, Nimrod, Sea King ASaC and Tornado, where the record shows the failures were well known, yet ignored for this very reason. Savings at the expense of safety.
At the inquest, and I'm sure Flip will provide the precise words as he was there, MoD denied knowledge of ESF prior to the accident. Can you imagine how ludicrous this lie looked to the Coroner in the face of two MoD specifications that can be downloaded from the internet? As I always say, to get to the truth, follow the lie.
Which gets us back to the forthcoming conference, at which Marshall Aerospace is represented with a guest speaker. (Mr Steve Fitz-Gerald, their CEO and Accountable Manager). I hope someone asks him at what point ESF was offered to MoD, and when MoD declined it. At the time of the inquest, I opined it was inconceivable that the Design Authority would abrogate their legal obligation to point out the UK build standard was (a) at variance with what was considered safe in the US and (b) non complaint with MoD's own regulations; resulting in a Safety Case that could not be reconciled with the SOUI. From MoD's viewpoint, they are required to retain the signed declaration that the regs have been waived, and for what reason. Lack of ESF would have been a major risk, especially given the content of 00-970. At the very least, one would have to annotate the risk register to say why the risk was not mitigated, even if that were "not enough money".
I posted above that MoD staffs were under Instruction to mandate certain Def Stans in contracts. Included was 00-970, Design and Airworthiness Requirements for Service Aircraft (previously, Design Requirements for Service Aircraft).
The point I make in my various posts is that there came a time when, to save money, orders were issued that this Instruction, and others, could and should be ignored. (In practice, implementation funding was withdrawn). But, what we weren't told was, what Standards should we now invoke.
In about 1993 these Controller Aircraft Instructions were to be replaced with Chief of Defence Procurement Instructions (CDPIs). The CAIs were duly withdrawn, but the CDPIs never issued. A few appeared in draft form, but their content would embarrass a five year old. At precisely the same time the Chief Engineer was running down airworthiness with even more draconian cuts (~28% per year, as stated in CHART in 1992).
Bearing in mind that in one sense, a "generation" of MoD staff is the length of a 2-3 year tour, many generations have now been taught that "Def Stans are not mandatory" and "Safety is a waste of money".
I retain full records of an instance in 1998 when I was instructed not to invoke JSP553, 00-970 and 05-123 for this very reason. When I pointed out my legal obligation was to produce an airworthy Military aircraft, so what Standards should I use in their stead, my boss (non-engineer, with self appointed airworthiness delegation
) completely toppled. He hadn't been taught that bit at his half day seminar. I ignored him, as did my contractors, but a few years later, after I moved posts, he over-ruled me and amended the contract. This explained the three main contributory causes in a subsequent BoI, but the evidence was actively withheld from the BoI and Coroner by the IPT. Personally, I never invoked one of these CDPIs, and can't recall ever seeing one at formal Issue 1. The sensible among us continued to adhere to the "old" rules, if only because there were no "new" ones to implement. You can appreciate that, if you are a contractor and an aircraft related contract is being negotiated, you want to know what Terms and Conditions MoD, your customer, is seeking to apply. Industry were not part of this ill-fated CDPI fiasco (itself a huge waste of money) and in negotiations rightly assumed the only relevant Def Stans would be applied. To the likes of Westland, MoD were a laughing stock. It was rightly pointed out above that, for example, 05-123 is in the new MAA document set, but what the MAA don't tell you is we were told not to use it for over a decade. Question - Why does the MAA not just come out and acknowledge this? In fact, how many of their staff actually know this background? And if they don't, then what makes them suitable and who is training them? I think this pretty important in an organisation whose job is to correct past failures. If you don't know what the failures were, then how can your work be validated? That is not a criticism of MAA staff, per se, but of the system and culture. And part of that culture is an overly cosy relationship with, for example, those who are meant to be independent auditors of the MAA. Witness, the speakers at the forthcoming conference. For example, what are the two audit panel members going to say in their presentations? One of them is talking about "Safety Culture". Does she realise that MoD's approach to the subject was draconian disciplinary action against those who sought to make aircraft safe? The Chair of the audit panel is talking about "Implementing the Nimrod Review". Is he going to start with "The Nimrod Review is deeply flawed, and therefore so too is the MAA's terms of Reference"? I doubt it, because MoD hasn't told him this.
In the case of Hercules ESF, the relevant Def Stan requires a vulnerability analysis to be carried out. You do not have to dream up threats in the first instance - they are listed. The very first is "inert projectiles", which all agree is what brought the aircraft down. The second is "incendiary projectiles", and so on. In the last column of the table is the required mitigation. ESF. It calls up two MoD specifications for ESF, in Fuel Tanks and Dry Bays. It is true that one can choose not to fit it, for whatever reason, but then the Build Standard, the RTS and Statement of Operating Use and Intent must be reconciled, with the Use and Intent parts excluding the possibility of being in a position whereby these threats exist. And if circumstances dictate there is an operational imperative, then in parallel mitigation must be put in hand, accompanied by formal acceptance of this risk. I suggest that 35+ years after delivery is far too long. But that is entirely in line with MoD's stated Risk Management policy of the 90s/00s - Do not mitigate, wait until something happens and then deal with it. Trouble is, when "something happened" people died. That applies equally to Chinook, Nimrod, Sea King ASaC and Tornado, where the record shows the failures were well known, yet ignored for this very reason. Savings at the expense of safety.
At the inquest, and I'm sure Flip will provide the precise words as he was there, MoD denied knowledge of ESF prior to the accident. Can you imagine how ludicrous this lie looked to the Coroner in the face of two MoD specifications that can be downloaded from the internet? As I always say, to get to the truth, follow the lie.
Which gets us back to the forthcoming conference, at which Marshall Aerospace is represented with a guest speaker. (Mr Steve Fitz-Gerald, their CEO and Accountable Manager). I hope someone asks him at what point ESF was offered to MoD, and when MoD declined it. At the time of the inquest, I opined it was inconceivable that the Design Authority would abrogate their legal obligation to point out the UK build standard was (a) at variance with what was considered safe in the US and (b) non complaint with MoD's own regulations; resulting in a Safety Case that could not be reconciled with the SOUI. From MoD's viewpoint, they are required to retain the signed declaration that the regs have been waived, and for what reason. Lack of ESF would have been a major risk, especially given the content of 00-970. At the very least, one would have to annotate the risk register to say why the risk was not mitigated, even if that were "not enough money".
Last edited by tucumseh; 8th Oct 2012 at 06:12.
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I think Tuc has said that far more eloquently than ever I could have done.
The question I was asked in the Coroner's Court by, I think, Mr Stead was:
"Is the Hercules airworthy and fit for purpose?"
I don't think I was wrong to say
"No, it is not."
That this was so was the culmination of many years of degraded MoD airworthiness provision - in turn, caused by a 'skewed safety-culture' at the highest levels of MoD PE, DPA/DLO, DE&S and various IPTLs.
When the leaders take a dim view of safety vs cost, what chance do their subordinates have?
It is because many of those 'leaders' are still about, spreading their poison, that I fear the gargantuan task facing the MAA will be too great for their resources. But although the MAA has made many great strides, I feel that its task would be much easier if it were truly independent from the MoD, had sharper teeth and was prepared to use the latter to maul the architects of this skewed culture. Some of these culture-criminals have many stars and/or a whopping pension - while our friends and comrades take unnecessary and unknown risks with their own lives - and with those of their crews and passengers. Any of these could be your sons and daughters and I know that troubles many here.
Is there any evidence out there that the MAA is being thwarted in its efforts by unwarranted high-level interference or indifference - is the skewed culture extant despite the MAA's efforts?
Are the lower levels still saying
"This is not (functionally) safe!" but the hierarchy then ignores their pleas?
If so, the MAA conference might be the time to stand up and be counted, if it is not to become a back-slapping, self-licking lollipop event.
The question I was asked in the Coroner's Court by, I think, Mr Stead was:
"Is the Hercules airworthy and fit for purpose?"
I don't think I was wrong to say
"No, it is not."
That this was so was the culmination of many years of degraded MoD airworthiness provision - in turn, caused by a 'skewed safety-culture' at the highest levels of MoD PE, DPA/DLO, DE&S and various IPTLs.
When the leaders take a dim view of safety vs cost, what chance do their subordinates have?
It is because many of those 'leaders' are still about, spreading their poison, that I fear the gargantuan task facing the MAA will be too great for their resources. But although the MAA has made many great strides, I feel that its task would be much easier if it were truly independent from the MoD, had sharper teeth and was prepared to use the latter to maul the architects of this skewed culture. Some of these culture-criminals have many stars and/or a whopping pension - while our friends and comrades take unnecessary and unknown risks with their own lives - and with those of their crews and passengers. Any of these could be your sons and daughters and I know that troubles many here.
Is there any evidence out there that the MAA is being thwarted in its efforts by unwarranted high-level interference or indifference - is the skewed culture extant despite the MAA's efforts?
Are the lower levels still saying
"This is not (functionally) safe!" but the hierarchy then ignores their pleas?
If so, the MAA conference might be the time to stand up and be counted, if it is not to become a back-slapping, self-licking lollipop event.
Last edited by flipster; 8th Oct 2012 at 08:56.
Well said, tuc and flip! 
What we have here is an MAA that is built on sand. We repeatedly hear that its foundations are set in the Haddon-Cave Nimrod Report, but that was deeply flawed as we have since learnt. By taking the Report as its gospel, the MAA is preaching a false doctrine. That may work in the ecclesiastical sense but it can't work in Aviation. People have died already and more will die unless and until it speaks the truth, that Haddon-Cave's Golden Period of Airworthiness was anything but and culminated in the issuing of an illegal Release to Service to a knowingly Grossly Unairworthy aircraft type. 29 people died in one within months.
With all due respect for Vin Rouge, and indeed for all who are now serving, I must respectfully disagree with your sentiments. Of course people are disheartened, clinging on, hoping for the best. The same could be said for the people of the newly occupied nations of Europe under the Naziis in WWII. Some though knew what to do and at great personal risk joined the resistance. They did what was right. This conference gives that same opportunity, as flip says. The liberation of Flight Safety that would follow the removal of the MAA and the MAAIB from the thrall of the MOD is an outcome that will save lives and is well worth the fight.
What we have here is an MAA that is built on sand. We repeatedly hear that its foundations are set in the Haddon-Cave Nimrod Report, but that was deeply flawed as we have since learnt. By taking the Report as its gospel, the MAA is preaching a false doctrine. That may work in the ecclesiastical sense but it can't work in Aviation. People have died already and more will die unless and until it speaks the truth, that Haddon-Cave's Golden Period of Airworthiness was anything but and culminated in the issuing of an illegal Release to Service to a knowingly Grossly Unairworthy aircraft type. 29 people died in one within months.
With all due respect for Vin Rouge, and indeed for all who are now serving, I must respectfully disagree with your sentiments. Of course people are disheartened, clinging on, hoping for the best. The same could be said for the people of the newly occupied nations of Europe under the Naziis in WWII. Some though knew what to do and at great personal risk joined the resistance. They did what was right. This conference gives that same opportunity, as flip says. The liberation of Flight Safety that would follow the removal of the MAA and the MAAIB from the thrall of the MOD is an outcome that will save lives and is well worth the fight.
Wow.
It's not often that I get to read something like this brilliant reasoning behind potentially important happenings.
All I can say is...Hear Hear!
Just a shame that these arguments are not in the right place to be read by the right people.
It's not often that I get to read something like this brilliant reasoning behind potentially important happenings.
All I can say is...Hear Hear!
Just a shame that these arguments are not in the right place to be read by the right people.
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So why did C130K go so long without ESF?
Tucumseh
You regularly appear on this forum whenever a thread touches on Air Safety (term deliberately chosen). You repeatedly state that the problems stem from the early 90s or thereabouts and were a deliberate act of policy by certain very senior individuals who also instigated severe budgetary cuts. This contrasts starkly with Haddon-Cave's view of the 90s as the "golden age". So assuming that the" golden age" in your view was prior to the early 90s, how come the system of the day didn't sort out Hercules ESF after its entry in service in the mid 60s in the nearly 30 years until the early 90s.
PS As an aside I was an EA with letter of delegation in the Aero engine MDG in AMSO's area which became AML's in the early to mid '90s. My experience of how airworthiness was managed was distinctly different to how you experienced it.
You regularly appear on this forum whenever a thread touches on Air Safety (term deliberately chosen). You repeatedly state that the problems stem from the early 90s or thereabouts and were a deliberate act of policy by certain very senior individuals who also instigated severe budgetary cuts. This contrasts starkly with Haddon-Cave's view of the 90s as the "golden age". So assuming that the" golden age" in your view was prior to the early 90s, how come the system of the day didn't sort out Hercules ESF after its entry in service in the mid 60s in the nearly 30 years until the early 90s.
PS As an aside I was an EA with letter of delegation in the Aero engine MDG in AMSO's area which became AML's in the early to mid '90s. My experience of how airworthiness was managed was distinctly different to how you experienced it.
Tuc & Flip,
I'm not denying the DefStan, nor the ridiculous statement from the MoD regarding the knowledge of ESF (and the position it put me in, given my evidence) but the DefStan did not explicitly mandate it.
As Tuc has covered already the DefStans did (and still do) require quite a path to get there (eg threat assessment). Unfortunately, as Tuc has described elsewhere, the route to the DefStan in question was via a path that a number in the MoD believed was optional. I am not sure we have eradicated such tendencies.
If you give people wriggle-room and don't enforce standards then these events will repeat themselves. The MAA need to get this sorted before it becomes a self-licking lollipop. As it is, people are declaring ALARP & Tolerable having failed to achieve the minimum standards prescribed by the regulations. ALARP is becoming shorthand for 'doing the best we can right now with no money or people to fix the issue at hand', this is not what H-C had in mind.
I'm not denying the DefStan, nor the ridiculous statement from the MoD regarding the knowledge of ESF (and the position it put me in, given my evidence) but the DefStan did not explicitly mandate it.
As Tuc has covered already the DefStans did (and still do) require quite a path to get there (eg threat assessment). Unfortunately, as Tuc has described elsewhere, the route to the DefStan in question was via a path that a number in the MoD believed was optional. I am not sure we have eradicated such tendencies.
If you give people wriggle-room and don't enforce standards then these events will repeat themselves. The MAA need to get this sorted before it becomes a self-licking lollipop. As it is, people are declaring ALARP & Tolerable having failed to achieve the minimum standards prescribed by the regulations. ALARP is becoming shorthand for 'doing the best we can right now with no money or people to fix the issue at hand', this is not what H-C had in mind.
Mr Bollo
Thank you.
First, I have always said the implementation was variable. I have mentioned a paper submitted to DPA’s 3 Star DCE in January 2000, which specifically praises certain parts of DLO, but notes their competence and adherence is largely down to the background of the staffs they had. That is, they were taught properly.
I stand by my statements regarding my own experiences, in MoD(PE), AMSO (when we were forced to move there) and DPA. When I was handed my first letter of delegation in MoD(PE) in the 80s I was given one piece of advice. Always retain a copy of anything you put your name to when exercising your delegation. Apart from anything else, you are required to be able to justify decisions for all time. Many years after leaving a particular job, I have been asked to give evidence to BoIs, Coroners, MPs and others. My files are voluminous and have come in very handy! Later, in 1990, I was given a second piece of advice – If someone lies to you, record all subsequent conversations. That was after a meeting in Harrogate at which AMSO supply staffs passed on their bosses’ directions – I was not to maintain airworthiness on my programmes. That specific example was smoke in RN Lynx cockpits. AMSO’s view was – let the RN ground their fleet and come a-begging next year for funding. Not sure the aircrew in sickbay agreed. I didn’t.
To further support what you say, the Director Internal Audit report of June 1996 only praised one section across the entirety of MoD(PE) and AMSO/AML – Aero Engines. That reprot was submitted directly to PUS, the Chief Accounting Officer. It was initiated in January 1993 (I know, 3.5 years, but that’s MoD for you) with the sole aim of protecting the jobs of civilians who had been threatened with dismissal by AMSO’s DGSM in December 1992, for refusing to obey orders (above) to make false declarations about airworthiness and financial probity. That is a simple matter of record, and DIA reaffirmed this when they sent me my own copy. Under FoI, a few years ago MoD confirmed the original no longer exists, as it was destroyed after being marked “No Further Action”. Of 19 recommendations, #13 stands out as implementing it would have nipped the airworthiness failings in the bud. Most of the rest relate to (lack of) financial probity, a euphemism for staffs being instructed to commit fraud.
You make an excellent point about C130. First, I’d say I’ve never claimed any age was “golden”. That was a phrase coined by Haddon-Cave after permitting a retired Chief Engineer to judge his own case. Haddon-Cave offered no evidence to support his claim, but completely ignored evidence to the contrary; not just in written submissions, but from MoD’s own hand. The 1992 CHART report is the best example. At a stroke, it clears General Sam Cowan of the appalling accusations levelled at him by Haddon-Cave.
I can only offer an opinion what happened in the days of the C130K, and then J, buys. MoD will not, or cannot say, because they haven’t kept the records. I do know, however, that a long time C130 project manager from the early 80s still works in Air Systems on DE&S, so no doubt he’d be able to cast some light, but has obviously decided not to. In my opinion it was a financial decision. I would not go so far as to claim it was “savings at the expense of safety” of a deliberate nature reported to Haddon-Cave, but the fact remains MoD would have known of ESF very soon after the C130K was delivered, if not sooner, because the US build standard of the day included it and the Lockheed patent is dated 1968. Also, the retrofit was costed. Not long after this, in the early 70s, MoD issued the two DTD specs I mentioned above, which they claimed to know nothing about, despite being called up in Def Stan 00-970.
As I said, I have no problem with a decision not to fit it if the reasoning was sound, and recorded, but what MUST go hand in hand with such a decision is a root and branch review of the Statement of Operating Intent and Use (not called that in those days, but there was an equivalent), against which the Constraints Working Group would assess Operational Constraints and Limitations. It would be absolutely clear to the CWG that not having ESF meant one would be at risk of, in this case, fire if hit by inert projectiles.
Again, in my opinion, this is such a huge Operational Constraint (i.e. a C130 not being allowed to fly at low level) that it would automatically be afforded “Critical” status (not Major or Minor). Additionally, it would be annotated “Safety” and/or “Airworthiness”. This is how OR Branches (DEC) are prodded into initiating programmes. Their priority is set by the CWG decisions. It is the answer to the age old question project managers get from front line - “How do we influence procurement?” You attend CWG, try to reconcile the SOUI against what you actually do, and fight your corner and prioritise what you need to reconcile the build standard and SOUI.
In parallel with all this, lack of ESF should have been more or less the top risk in the C130 Risk Register for nigh on 35 years; also reflected in the Safety Case. If there came a time when MoD’s corporate knowledge reduced so far they lost sight of this (which, as I’ve said, was a dead cert from the early 90s-on), the fall back was the obligation Marshalls were under to advise MoD. They would certainly appreciate that the Safety Case, Build Standard and SOUI could not be reconciled. Of course, this assumes they were under proper contract to maintain the Safety Case; and we know from the various ARTs that this was not the case.
I hope this helps. I strongly recommend you read the HEART (Hercules Airworthiness Review Team) report of 1997. You will be appalled at how variable the approach to airworthiness was, even within AML, at this time. I know many here don’t quite believe all that I say, but every word is supported by the various ARTs (1992-98), plus the audit reports I mention.
Thank you.
First, I have always said the implementation was variable. I have mentioned a paper submitted to DPA’s 3 Star DCE in January 2000, which specifically praises certain parts of DLO, but notes their competence and adherence is largely down to the background of the staffs they had. That is, they were taught properly.
I stand by my statements regarding my own experiences, in MoD(PE), AMSO (when we were forced to move there) and DPA. When I was handed my first letter of delegation in MoD(PE) in the 80s I was given one piece of advice. Always retain a copy of anything you put your name to when exercising your delegation. Apart from anything else, you are required to be able to justify decisions for all time. Many years after leaving a particular job, I have been asked to give evidence to BoIs, Coroners, MPs and others. My files are voluminous and have come in very handy! Later, in 1990, I was given a second piece of advice – If someone lies to you, record all subsequent conversations. That was after a meeting in Harrogate at which AMSO supply staffs passed on their bosses’ directions – I was not to maintain airworthiness on my programmes. That specific example was smoke in RN Lynx cockpits. AMSO’s view was – let the RN ground their fleet and come a-begging next year for funding. Not sure the aircrew in sickbay agreed. I didn’t.
To further support what you say, the Director Internal Audit report of June 1996 only praised one section across the entirety of MoD(PE) and AMSO/AML – Aero Engines. That reprot was submitted directly to PUS, the Chief Accounting Officer. It was initiated in January 1993 (I know, 3.5 years, but that’s MoD for you) with the sole aim of protecting the jobs of civilians who had been threatened with dismissal by AMSO’s DGSM in December 1992, for refusing to obey orders (above) to make false declarations about airworthiness and financial probity. That is a simple matter of record, and DIA reaffirmed this when they sent me my own copy. Under FoI, a few years ago MoD confirmed the original no longer exists, as it was destroyed after being marked “No Further Action”. Of 19 recommendations, #13 stands out as implementing it would have nipped the airworthiness failings in the bud. Most of the rest relate to (lack of) financial probity, a euphemism for staffs being instructed to commit fraud.
You make an excellent point about C130. First, I’d say I’ve never claimed any age was “golden”. That was a phrase coined by Haddon-Cave after permitting a retired Chief Engineer to judge his own case. Haddon-Cave offered no evidence to support his claim, but completely ignored evidence to the contrary; not just in written submissions, but from MoD’s own hand. The 1992 CHART report is the best example. At a stroke, it clears General Sam Cowan of the appalling accusations levelled at him by Haddon-Cave.
I can only offer an opinion what happened in the days of the C130K, and then J, buys. MoD will not, or cannot say, because they haven’t kept the records. I do know, however, that a long time C130 project manager from the early 80s still works in Air Systems on DE&S, so no doubt he’d be able to cast some light, but has obviously decided not to. In my opinion it was a financial decision. I would not go so far as to claim it was “savings at the expense of safety” of a deliberate nature reported to Haddon-Cave, but the fact remains MoD would have known of ESF very soon after the C130K was delivered, if not sooner, because the US build standard of the day included it and the Lockheed patent is dated 1968. Also, the retrofit was costed. Not long after this, in the early 70s, MoD issued the two DTD specs I mentioned above, which they claimed to know nothing about, despite being called up in Def Stan 00-970.
As I said, I have no problem with a decision not to fit it if the reasoning was sound, and recorded, but what MUST go hand in hand with such a decision is a root and branch review of the Statement of Operating Intent and Use (not called that in those days, but there was an equivalent), against which the Constraints Working Group would assess Operational Constraints and Limitations. It would be absolutely clear to the CWG that not having ESF meant one would be at risk of, in this case, fire if hit by inert projectiles.
Again, in my opinion, this is such a huge Operational Constraint (i.e. a C130 not being allowed to fly at low level) that it would automatically be afforded “Critical” status (not Major or Minor). Additionally, it would be annotated “Safety” and/or “Airworthiness”. This is how OR Branches (DEC) are prodded into initiating programmes. Their priority is set by the CWG decisions. It is the answer to the age old question project managers get from front line - “How do we influence procurement?” You attend CWG, try to reconcile the SOUI against what you actually do, and fight your corner and prioritise what you need to reconcile the build standard and SOUI.
In parallel with all this, lack of ESF should have been more or less the top risk in the C130 Risk Register for nigh on 35 years; also reflected in the Safety Case. If there came a time when MoD’s corporate knowledge reduced so far they lost sight of this (which, as I’ve said, was a dead cert from the early 90s-on), the fall back was the obligation Marshalls were under to advise MoD. They would certainly appreciate that the Safety Case, Build Standard and SOUI could not be reconciled. Of course, this assumes they were under proper contract to maintain the Safety Case; and we know from the various ARTs that this was not the case.
I hope this helps. I strongly recommend you read the HEART (Hercules Airworthiness Review Team) report of 1997. You will be appalled at how variable the approach to airworthiness was, even within AML, at this time. I know many here don’t quite believe all that I say, but every word is supported by the various ARTs (1992-98), plus the audit reports I mention.
Last edited by tucumseh; 8th Oct 2012 at 19:38.
I'll never understand why MoD denied knowledge of ESF especially as they part funded the development of it, as well as other methods of fuel tank inerting. Indeed, one of the first aircraft ever fitted with reticulated foam was a Lyneham aircraft decades before the loss.
Why the BoI missed these facts is also one of the XV179 mysteries, but at least the BoI president passed all the (unread?) information to the coroner; he relished reading 40 years of MoD-owned research on a topic that they 'knew nothing about…'.
Why the BoI missed these facts is also one of the XV179 mysteries, but at least the BoI president passed all the (unread?) information to the coroner; he relished reading 40 years of MoD-owned research on a topic that they 'knew nothing about…'.
JTO
Yes, kudos to the BoI president and those who gave evidence. My opinion is one should always ask who the lie is designed to protect. The field then narrows considerably.
HEART report (1997) Download 7.2 Hercules Airworthiness Review Team Report 30.9.97.pdf from Sendspace.com - send big files the easy way
A Discussion of the "Principle Airworthiness Hazard to the Operation of the Aircraft"
Download 7.1 Hercules Airworthiness Review Team - Discussion Paper.pdf from Sendspace.com - send big files the easy way
One really has to read the ARTs in sequence, commencing with CHART (Aug 1992). Only then can you appreciate the sheer frustration evident in the Inspector of Flight Safety's words, as each report simply repeats the systemic failings of the previous ones. In 1999, CDP gave evidence to the Public Accounts Committee that the main criticism in CHART remained extant. So, in Haddon-Cave's "golden period", nowt was done.
The second paper may seem at first glance to be criticism of the HEART, but please remember that the ARTs' terms of reference were set by the Chief Engineer, who instructed them NOT to speak to anyone outside a narrow range of RAF offices; thus excluding Design Authorities and MoD's own specialists. Therefore, some of the conclusions in the report are very wrong, but they got close.
Yes, kudos to the BoI president and those who gave evidence. My opinion is one should always ask who the lie is designed to protect. The field then narrows considerably.
HEART report (1997) Download 7.2 Hercules Airworthiness Review Team Report 30.9.97.pdf from Sendspace.com - send big files the easy way
A Discussion of the "Principle Airworthiness Hazard to the Operation of the Aircraft"
Download 7.1 Hercules Airworthiness Review Team - Discussion Paper.pdf from Sendspace.com - send big files the easy way
One really has to read the ARTs in sequence, commencing with CHART (Aug 1992). Only then can you appreciate the sheer frustration evident in the Inspector of Flight Safety's words, as each report simply repeats the systemic failings of the previous ones. In 1999, CDP gave evidence to the Public Accounts Committee that the main criticism in CHART remained extant. So, in Haddon-Cave's "golden period", nowt was done.
The second paper may seem at first glance to be criticism of the HEART, but please remember that the ARTs' terms of reference were set by the Chief Engineer, who instructed them NOT to speak to anyone outside a narrow range of RAF offices; thus excluding Design Authorities and MoD's own specialists. Therefore, some of the conclusions in the report are very wrong, but they got close.
Last edited by tucumseh; 9th Oct 2012 at 06:17.
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The fact that HEART missed the ESF issue was partly down to its narrow TORs (as you say, constrained by CE and ACAS). One other reason why perhaps ESF was not fitted at initial buy (early-mid 1960s) was perhaps that it wasn't offered, or that it was too 'immature' (ESF fitted to USAF ac in 1968 IIRC). But I think it could have been because, in Transport Command, the Herc was initially used mainly in the 'strategic-lift' role. I might be wrong but it was only in the early 1970s that it started regularly going 'sausage-side' in Africa etc - an opportunity missed? But the fact the IRA were becoming increasingly well-armed in the mid 1970s should have brought the fitting of ESF to go with IRCM. Why it didn't, Lord only knows - perhaps even then the experience in PE, OR and on the Sqns had already disappated? For sure, too many 'shiney-types' at Group HQ has always been a hindrance to the TacAT fleet (I recall it still was in 2003/5 when SASO and AOC were super-shineys). JTO will confirm this I'm sure.
However, JTO makes a hugely valid point if he is correct that some officers are saying a risk/threat is deemed ALARP when all they have done is identified the problem but not actually mitigated/addressed it (ie no funding). If so, this is criminal and I think it is morally indefensible - these should become constraints and passed onward/upward and the responsibility taken at a much higher level. Certainly, this needs to brought out at MAA Conference because DG MAA cannot allow the MoD to get away with it - otherwise he is undermining everything the MAA has acheived so far and it risks being seen a lap-dog of MoD..... if it is not too late already? More independence is the only way, I fear.
However, JTO makes a hugely valid point if he is correct that some officers are saying a risk/threat is deemed ALARP when all they have done is identified the problem but not actually mitigated/addressed it (ie no funding). If so, this is criminal and I think it is morally indefensible - these should become constraints and passed onward/upward and the responsibility taken at a much higher level. Certainly, this needs to brought out at MAA Conference because DG MAA cannot allow the MoD to get away with it - otherwise he is undermining everything the MAA has acheived so far and it risks being seen a lap-dog of MoD..... if it is not too late already? More independence is the only way, I fear.
Last edited by flipster; 9th Oct 2012 at 06:59.
However, JTO makes a hugely valid point if he is correct that some officers are saying a risk/threat is deemed ALARP when all they have done is identified the problem but not actually mitigated/addressed it (ie no funding).
I recall one Shrivenham type who, when the subject came up, always shouted out "What software do you use?" Post 1996, the answer was "Pandora" as that was MoD's own tool. His reply was always "Pandora's rubbish". That was all he'd been taught on a Defence Administration MBA - to fill in the boxes in Pandora. But of course filling in the boxes doesn't actually create a mitigation plan or implement it. The concept of mitigation was completely alien to him (an otherwise quite intelligent young man). To us dinosaurs, it merely confirmed our thoughts on people who are given huge responsibility while being allowed to skip 5 or 6 grades. Flip's super-shineys!
This culture was widespread in MoD(PE) and then DPA, largely because our 2/4 Stars (2 Star was the same one as Nimrod and Chinook) refused to allocate resources to mitigation. If you insisted on mitigating risk, you had to do so in your own time, at home and with no funding. Not much has changed and I'm not sure the MAA has the authority to force change.
Thread Starter
I refer back to my post no 68. Is anyone with an in-depth knowledge of the MoD's historic failings going to be at the conference to ask awkward questions of the MAA?
Oh dear. I do know how horrible that feels.
My "session" with a rent-a-crowd / mob-handed PT ended in me backing out of the building and raising a "risk" from my home turf against him/them. Very slow, but more positive/productive than a one-sided argument.
Still, I won't have to do that anymore.
My "session" with a rent-a-crowd / mob-handed PT ended in me backing out of the building and raising a "risk" from my home turf against him/them. Very slow, but more positive/productive than a one-sided argument.
Still, I won't have to do that anymore.
Last edited by Rigga; 9th Oct 2012 at 22:35.
'tuc'' is correct when he says the TORs of the HEART were very narrow and as I recollect it via my fading memory they were narrowed even further once we had started. This I think was a reaction to the previous reports especially the 'in house' Canberra report.
I had left the service by the time the report had been staffed and printed so had no way at that time of knowing what had been 'staffed' out or altered.
Part of the HEART remit was a 'glance' at the incoming C130J. We were told very firmly that there would not be any upgrades to this a/c to enhance any aspects.
So for example the well know fact that the insulation blanket in the cargo compartment gave off phosgene gas when heated above a certain temperature was not deemed worthy of action. So I assume the risk still exists on the 'J' unless the lessons of the Belgian AF C130 crash at Eindhoven were eventually taken on board. The system showed no signs of doing so when I left.
I had left the service by the time the report had been staffed and printed so had no way at that time of knowing what had been 'staffed' out or altered.
Part of the HEART remit was a 'glance' at the incoming C130J. We were told very firmly that there would not be any upgrades to this a/c to enhance any aspects.
So for example the well know fact that the insulation blanket in the cargo compartment gave off phosgene gas when heated above a certain temperature was not deemed worthy of action. So I assume the risk still exists on the 'J' unless the lessons of the Belgian AF C130 crash at Eindhoven were eventually taken on board. The system showed no signs of doing so when I left.
Ancient
Thank you for those comments. In general terms we knew the ARTs had very narrow remits, but the only one we had firsthand knowledge of was CHART in 1992 (which also covered Puma and Wessex). The RAF Chief Engineer delayed their start, spending 2 months “adjusting” the TORs to stop CHART speaking to anyone outside the RAF; specifically excluding anyone in MoD who managed attaining or maintaining airworthiness. But he kept their target delivery date the same – August 1992. (i.e. 3 months instead of 5). This meant they were spread very thinly with a fixed number of Air Stations and departments to visit, so for example a non-engineer would have to conduct interviews with Engineering/Maintenance staffs (and engineers with aircrew).
Nevertheless, the CHART team did an excellent job and, had the ZD576 BoI been shown, for example, the Annex discussing RAF Aldergrove, then I imagine things would have been very different. Also, given the criticism of aircraft documentation by witnesses, I’m sure the BoI would have mentioned the use of captured Argentinean pubs, used because ours weren’t up to scratch. (By definition, this alone renders the RTS invalid).
If I were to criticise the ARTs, they made the common error of confusing airworthiness and serviceability, although given their narrow remit this was perhaps understandable. The result is they identify a subject (typically a systemic failure) and get so far, but then stop. They seldom dig deep enough to reveal the root cause (but maybe didn't have the time, and their interviewees wouldn't understand that detail anyway). For example, the use of Argentinean pubs draws a simple criticism of Guttersloh (from memory) for using them (which was a good spot by the team), but doesn’t take the next step of asking why the UK versions are crap. The answer was that the Chief Engineer’s department had directed that AP updates should cease. However, I may be doing them a disservice because I know there were a number of draft CHARTs which were diluted. I only have one of them, and it is obvious word came down not to criticise senior staffs.
What I found interesting was the Executive Summary and Covering Letter (to CE and ACAS – Alcock and Bagnall respectively) was taken out of the hands of the Team Leader and written personally by IFS. Clearly, this was to send the message that the report raised very serious concerns about BOTH Mk1 and Mk2. Graydon, Alcock and, ultimately, Fox, lied about this aspect, claiming CHART only addressed Mk1. The TORs make it very clear they were instructed to assess Mk2. Graydon, Alcock and MoD claimed CHART didn’t mention Mk2; it did, 363 times!! Lord Philip wasn’t impressed by that lie either.
Rigga
I had the same experience. Asked to present to an IPT at AbbeyWood some years ago (2002 I think), when I told them they were required to have a continuous contract with their Design Authorities to maintain the Build Standard and Safety Case (essentially, the Nimrod failing), almost to a man they jumped up shouting “Waste of money”. Much the same at Shrivenham the same year, although to be fair a couple of DEC Brigadiers told their Colonels to shut up, I had a point (even though they didn’t understand it!) But then they were over-ruled!
Thank you for those comments. In general terms we knew the ARTs had very narrow remits, but the only one we had firsthand knowledge of was CHART in 1992 (which also covered Puma and Wessex). The RAF Chief Engineer delayed their start, spending 2 months “adjusting” the TORs to stop CHART speaking to anyone outside the RAF; specifically excluding anyone in MoD who managed attaining or maintaining airworthiness. But he kept their target delivery date the same – August 1992. (i.e. 3 months instead of 5). This meant they were spread very thinly with a fixed number of Air Stations and departments to visit, so for example a non-engineer would have to conduct interviews with Engineering/Maintenance staffs (and engineers with aircrew).
Nevertheless, the CHART team did an excellent job and, had the ZD576 BoI been shown, for example, the Annex discussing RAF Aldergrove, then I imagine things would have been very different. Also, given the criticism of aircraft documentation by witnesses, I’m sure the BoI would have mentioned the use of captured Argentinean pubs, used because ours weren’t up to scratch. (By definition, this alone renders the RTS invalid).
If I were to criticise the ARTs, they made the common error of confusing airworthiness and serviceability, although given their narrow remit this was perhaps understandable. The result is they identify a subject (typically a systemic failure) and get so far, but then stop. They seldom dig deep enough to reveal the root cause (but maybe didn't have the time, and their interviewees wouldn't understand that detail anyway). For example, the use of Argentinean pubs draws a simple criticism of Guttersloh (from memory) for using them (which was a good spot by the team), but doesn’t take the next step of asking why the UK versions are crap. The answer was that the Chief Engineer’s department had directed that AP updates should cease. However, I may be doing them a disservice because I know there were a number of draft CHARTs which were diluted. I only have one of them, and it is obvious word came down not to criticise senior staffs.
What I found interesting was the Executive Summary and Covering Letter (to CE and ACAS – Alcock and Bagnall respectively) was taken out of the hands of the Team Leader and written personally by IFS. Clearly, this was to send the message that the report raised very serious concerns about BOTH Mk1 and Mk2. Graydon, Alcock and, ultimately, Fox, lied about this aspect, claiming CHART only addressed Mk1. The TORs make it very clear they were instructed to assess Mk2. Graydon, Alcock and MoD claimed CHART didn’t mention Mk2; it did, 363 times!! Lord Philip wasn’t impressed by that lie either.
Rigga
My "session" with a rent-a-crowd / mob-handed PT ended in me backing out of the building and raising a "risk" from my home turf against him/them. Very slow, but more positive/productive than a one-sided argument.
Last edited by tucumseh; 10th Oct 2012 at 06:16.
Tuc,
spot on again ref the serviceability/airworthiness confusion at least with the other aircrew member and myself. I think it is fair to say that our knowledge of the airworthiness chain was restricted to the chap who signed the F700 and the line chief ! The two engineering members of the team were much better qualified than we to assess the 'snakes and ladders' of the RAF airworthiness structure. We were given the Chinook report to read as a template and tried to follow that as far as possible. I recall that a great emphasis was placed on the concern that counterfeit parts may be infiltrating the system. I do not think we found much evidence of that. What did astound me despite my almost 30 years with the Hercules was the number of people with their fingers in the Hercules 'pie'. Many seemed to be duplicating work already in hand. Not very many had seen the a/c 'in the flesh' and even less seemed to want to.
spot on again ref the serviceability/airworthiness confusion at least with the other aircrew member and myself. I think it is fair to say that our knowledge of the airworthiness chain was restricted to the chap who signed the F700 and the line chief ! The two engineering members of the team were much better qualified than we to assess the 'snakes and ladders' of the RAF airworthiness structure. We were given the Chinook report to read as a template and tried to follow that as far as possible. I recall that a great emphasis was placed on the concern that counterfeit parts may be infiltrating the system. I do not think we found much evidence of that. What did astound me despite my almost 30 years with the Hercules was the number of people with their fingers in the Hercules 'pie'. Many seemed to be duplicating work already in hand. Not very many had seen the a/c 'in the flesh' and even less seemed to want to.
Ancient
The CHART consisted of 2 engineers and a pilot. Not a big “team” for such a task! I looked through my records and was reminded they were instructed not to look at engineering aspects, but tended to ignore this when so many issues were revealed. But, given the lack of staff and time constraints, they couldn’t dig deeper. Now, why would a Chief Engineer instruct an airworthiness team not to look at engineering?
Your comment about counterfeit parts is interesting. I can’t recall ever coming across a case, but lack of Quality Control was rife, especially when MoD ran down their Quality Assurance Directorate General (DGDQA). Once the Chief Engineer stopped proper training, a typical problem was mismanagement of Production Permits and Concessions, which allowed sub-standard (but not counterfeit) components into the system. (That is, the paper trail would be complete and valid, but too few realised what “MF77” meant in the small print, so the aircraft documents wouldn’t record a sub-standard component was fitted and, for example, had to be checked more regularly until replaced with a proper one). That mismanagement would hide the problem from you (the ARTs), and because (e.g. CHART) was not permitted to speak to the staffs who were responsible, the problem was effectively hidden from everyone. More so because CE had slashed the budget that undertook the mandatory follow-up action.
The CHART consisted of 2 engineers and a pilot. Not a big “team” for such a task! I looked through my records and was reminded they were instructed not to look at engineering aspects, but tended to ignore this when so many issues were revealed. But, given the lack of staff and time constraints, they couldn’t dig deeper. Now, why would a Chief Engineer instruct an airworthiness team not to look at engineering?
Your comment about counterfeit parts is interesting. I can’t recall ever coming across a case, but lack of Quality Control was rife, especially when MoD ran down their Quality Assurance Directorate General (DGDQA). Once the Chief Engineer stopped proper training, a typical problem was mismanagement of Production Permits and Concessions, which allowed sub-standard (but not counterfeit) components into the system. (That is, the paper trail would be complete and valid, but too few realised what “MF77” meant in the small print, so the aircraft documents wouldn’t record a sub-standard component was fitted and, for example, had to be checked more regularly until replaced with a proper one). That mismanagement would hide the problem from you (the ARTs), and because (e.g. CHART) was not permitted to speak to the staffs who were responsible, the problem was effectively hidden from everyone. More so because CE had slashed the budget that undertook the mandatory follow-up action.