BOI into the 2012 Tornado Collision over the Moray Firth
A small point but may help understanding. I was always told that rather than think of a 'bubble' around an aircraft, think of a long pointer expanding into a cone ahead of the aircraft. That is the 'tickling stick' that will cause the possible confliction warnings due to closing flight paths. Hence the problem where a/c in the circuit at Kinloss may 'tickle' the TCAS on a/c approaching Inverness even though the circuit a/c is in a turn onto downwind. Unfortunately, we never got the chance to worry about such issues on the MRA4 in the end.
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Just as with RA 1210 a couple of pages ago, I've pointed him in the right direction for some corrective reading. Let's see where that takes us.
DV
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"A fatal accident inquiry is needed" ...to what possible benefit? It will cost millions, probably more than fitting TCAS would cost, zero chance of anyone who deserves it receiving any meaningful sanction. In the highly unlikely event the MOD were found guilty of anything they'd be fined which would come out of the defence budget, i.e. we'd have to pay it.
Dervish:-
Shotone:-
So that people realise that Air Safety is not safe in the hands of the MOD. It took a Coroner to tell the RAF that there is something wrong with their bloody aircraft because they didn't want to admit it themselves. Nothing's changed and it never will, unless and until Regulation and Investigation are independent of the user (MOD/RAF/RN/Army) and of each other. If that
then that is part of the cost that is still being paid in blood and treasure just because certain VSOs once had a 'good idea'. If you think that the cost of an FAI is high then what about the cost of the avoidable predictable accidents that are still to come?
Guys died and MoD told porkies about when the kit that may have prevented it could have been in the aircraft. A fatal accident inquiry is needed.
...to what possible benefit?
will cost millions, probably more than fitting TCAS would cost,
DV,
Be that as it may, RA 1210 is the regulation in force, and it is pointless to say things like 'Catastrophic / Remote = Intolerable' just because it says so in an ancestor of that regulation, or in a recommendation that was not adopted. You may well have a justified objection to the MAA or the MOD over that state of regulatory affairs, but unless the RA is overturned, it will continue to define the acceptable levels of risk for duty holders, who are the people taking the decisions to keep aircraft flying.
At recommendation 22.5 Haddon-Cave calls for the "redrafting" of BP 1210, not for a replacement (RA 1210) with lower standards.
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Be that as it may, RA 1210 is the regulation in force, and it is pointless to say things like 'Catastrophic / Remote = Intolerable' just because it says so in an ancestor of that regulation, or in a recommendation that was not adopted.
Having said all that, it makes a nonsense of MAA/MOD's approach to risk assessment, if they think that by generating a new document (RA 1210) they can make a risk, that was once considered to be Intolerable, Tolerable.
DV
Easy street:-
Well, be that as it may, Easy Street, but if the BMA announced that henceforth it would be using the Boys Bumper Book of DIY Brain Surgery as its defining reference for overseeing the performance of surgeons, would you be inclined to put yourself under their knife?
The MAA is trying to do Air Safety Lite and failing spectacularly in the attempt. RA 1210 is symptomatic of that failure. It was written by people who need to learn airworthiness rather than trying to define it for others. In short, it is as potentially dangerous as the BBBODIYBS
RA 1210 is the regulation in force,... unless the RA is overturned, it will continue to define the acceptable levels of risk for duty holders
The MAA is trying to do Air Safety Lite and failing spectacularly in the attempt. RA 1210 is symptomatic of that failure. It was written by people who need to learn airworthiness rather than trying to define it for others. In short, it is as potentially dangerous as the BBBODIYBS
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RA 1210 is symptomatic of that failure. It was written by people who need to learn airworthiness rather than trying to define it for others
So who wrote RA 1210 (and the other RAs)? What were their qualifications? Who approved the end product? Was it Air Marshal (Retired) Sir Colin Terry, Chairman of the MAA Safety Advisory Committee? For those of you who may have forgotten Sir Colin Terry was Chief Engineer (RAF) from1997 to 99 and must have been aware of all the airworthiness issues outlined in NART and CHART that lead up to the Nimrod and Chinook accidents. He was also aware of the requirement to install CWS in Tornado GR4s, as this was specified in the 1998 SDR. As the previous MAA DG put it "a former RAF engineer of some repute"
DV
I must admit I'm glad I no longer have to do this on a daily basis, because if RA1210 was imposed upon me I'd raise a blanket MF765 (Unsatisfactory Feature Report) on it. Pending an answer (which would never arrive, as no-one in the MAA would know what to do) I'd ignore it and use regulations which remain consistent and make sense. I'd like to see the MAA arguing against that. Duty Holders must read RA1210 and ask "How on earth........." You all have my sympathy.
I ask myself what is better - this "new" MAA system or what went before.
Pre-MAA you were told not to implement perfectly good regs if time or cost was in peril. The choice was simple, you did as you were told or you met your legal obligation. Most accidents we discuss here can be traced to the former. Tornado/Patriot and MoK are obvious examples. DE&S still adhere to this policy/practice, which I suggest is what the MAA should be concentrating on. The proof, if any were needed, is contained in the audit reports the MAA commissioned.
Today, you have an extra choice. The "new" MAA regs, which contradict both the DE&S policy and "old" regs, despite many of these "old" regs still being mandated (mainly because the MAA don't actually know they exist).
Some have been cancelled without replacement - for example, it is patently obvious the author(s) of RA1210 have never heard of Def Stan 05-125/2, yet it is THE bible and adherence to it avoids or provides the solution to 99% of all problems you will ever encounter. Think about it. A mandated Air/Land/Sea Standard has been cancelled by the Air domain without replacement. What arrogance and ignorance. Does the MAA realise that it is still invoked in, for example, the Army's flagship Infantry programme?
Look at what worked in the past, not what didn't work. You'll learn more.
I ask myself what is better - this "new" MAA system or what went before.
Pre-MAA you were told not to implement perfectly good regs if time or cost was in peril. The choice was simple, you did as you were told or you met your legal obligation. Most accidents we discuss here can be traced to the former. Tornado/Patriot and MoK are obvious examples. DE&S still adhere to this policy/practice, which I suggest is what the MAA should be concentrating on. The proof, if any were needed, is contained in the audit reports the MAA commissioned.
Today, you have an extra choice. The "new" MAA regs, which contradict both the DE&S policy and "old" regs, despite many of these "old" regs still being mandated (mainly because the MAA don't actually know they exist).
Some have been cancelled without replacement - for example, it is patently obvious the author(s) of RA1210 have never heard of Def Stan 05-125/2, yet it is THE bible and adherence to it avoids or provides the solution to 99% of all problems you will ever encounter. Think about it. A mandated Air/Land/Sea Standard has been cancelled by the Air domain without replacement. What arrogance and ignorance. Does the MAA realise that it is still invoked in, for example, the Army's flagship Infantry programme?
Look at what worked in the past, not what didn't work. You'll learn more.
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Does Mr Dunne really believe in what he says? I would have thought that any risk associated with aviation would be based on flying hours, or flights, and not man-years, as presented in RA 1210.
Anyway, both CAA and BP 1201 documents refer to Equipment and Operational risks. EASA was never mentioned in the question put by Angus Robertson.
House of Commons Hansard Written Answers for 15 July 2014 (pt 0002)
DV
Anyway, both CAA and BP 1201 documents refer to Equipment and Operational risks. EASA was never mentioned in the question put by Angus Robertson.
House of Commons Hansard Written Answers for 15 July 2014 (pt 0002)
DV
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Does Mr Dunne really believe in what he says? I would have thought that any risk associated with aviation would be based on flying hours, or flights, and not man-years, as presented in RA 1210.
S-D
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I would expect the risk to be understood in terms of flying hours, or whatever other scaling factor is relevant to the industry or field concerned, e.g. controlled flying hours for ATM. In the case of the MAA/MoD it then also chooses to 'normalise' this to risk to the individual per annum. All quite normal and allows comparison and measurement against HSE guidance and the MoD's legal obligations.
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DV. The risk should be worked out for the individual's exposure, so one would need to take into account factors such as fleet size, flying hours for the fleet and possibly squadrons (depending on differences) and crews, types of flying/roles as they may carry differing risks and exposures. The risk is also calculated for 1st, 2nd and 3rd parties, broadly speaking you could probably think of that respectively as aircrew, ground crew and the public. I'm not familiar with the Tornado, but that breakdown won't be far off.
All of this would then be used to calibrate the risk classification matrix, especially the boundaries between intolerable and tolerable/ALARP.
S-D
All of this would then be used to calibrate the risk classification matrix, especially the boundaries between intolerable and tolerable/ALARP.
S-D
Regardless of the finer points of Risk Management the real problem here is that the MAA in its present form is not the answer.
Primarily because it simply will not acknowledge what the question is.
People didn't die because the regs were wrong. They died because senior staffs issued wasteful policies and then, to generate funding to conceal the waste, issued orders not to implement perfectly good regs (savings at the expense of safety). And to make sure they could not be implemented, withdrew funding. And too many obeyed.
None of this is in doubt. Original papers commencing June 1987 were submitted to Lord Philip. MoD's own auditors confirmed it in reports dated January 1989 and June 1996. Haddon-Cave ignored these reports and claimed the problem commenced in 1998. More recently, the MAA has been claiming 2002. (Allegedly the year Safety Cases were mandated. Contradicted somewhat by the 1992 policy mandating them for modification programmes, like Chinook and Nimrod. The Nimrod Safety Case task was conducted poorly in the early 2000s, but the real problem is that work on it commenced 10 years after it was first directed. And even then, prior to 1992 MoD required industry to have robust "safety arguments" - the only real difference was MoD management was vested in a different department). Sorry to repeat this, but the MAA continue to distort the truth by making these false claims in every presentation they give.
Until MoD/MAA acknowledges the truth, it cannot possibly proceed in the right direction. It has issued rafts of new or updated regs, but how to ensure staff will meet the legal obligation to implement them? This basic problem remains, and the upper echelons of DE&S is choc full of people brought up on the "safety is a waste of money" policy of the 90s/00s.
Primarily because it simply will not acknowledge what the question is.
People didn't die because the regs were wrong. They died because senior staffs issued wasteful policies and then, to generate funding to conceal the waste, issued orders not to implement perfectly good regs (savings at the expense of safety). And to make sure they could not be implemented, withdrew funding. And too many obeyed.
None of this is in doubt. Original papers commencing June 1987 were submitted to Lord Philip. MoD's own auditors confirmed it in reports dated January 1989 and June 1996. Haddon-Cave ignored these reports and claimed the problem commenced in 1998. More recently, the MAA has been claiming 2002. (Allegedly the year Safety Cases were mandated. Contradicted somewhat by the 1992 policy mandating them for modification programmes, like Chinook and Nimrod. The Nimrod Safety Case task was conducted poorly in the early 2000s, but the real problem is that work on it commenced 10 years after it was first directed. And even then, prior to 1992 MoD required industry to have robust "safety arguments" - the only real difference was MoD management was vested in a different department). Sorry to repeat this, but the MAA continue to distort the truth by making these false claims in every presentation they give.
Until MoD/MAA acknowledges the truth, it cannot possibly proceed in the right direction. It has issued rafts of new or updated regs, but how to ensure staff will meet the legal obligation to implement them? This basic problem remains, and the upper echelons of DE&S is choc full of people brought up on the "safety is a waste of money" policy of the 90s/00s.
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The risk should be worked out for the individual's exposure, so one would need to take into account factors such as fleet size, flying hours for the fleet and possibly squadrons (depending on differences) and crews, types of flying/roles as they may carry differing risks and exposures. The risk is also calculated for 1st, 2nd and 3rd parties, broadly speaking you could probably think of that respectively as aircrew, ground crew and the public.
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S-D
To assess risk in the way you suggest i.e. to relate it to an individual's exposure just ain't going to happen, commendable as it might be as a yard-stick of risk.
I'm long out of the RAF and my experience was in the 1980's.....back then the RAF lost close to 15 aircrew KILLED every year, that doesn't include those that were able to eject and survive, some of whom were badly injured in the process......
Losses were sometimes down to pure aircrew handling/operating error but many were partly down to poor risk management, others were due to structural failures (Buccaneer x2 and F4 x1) and the two biggest "gotcha's" were mid-air collisions and target fixation on a range or when doing a SAP.
The Jag Squadrons had it bad for a number of years particularly and reasons for this were many. Single seat, low level, marginal power excess (even on 2
), small wing, poor nav kit (NAVWASS) and a demanding role, particularly for the recce boys who also had a massive recce pod to lug around. Count the sqns..... 1 at Laarbruch, 4 at Bruggen, 2 at Coltishall and a big OCU at Lossie - say 8 squadrons with 200 pilots regularly flying them at any one time. Big if here, if you were on a three year tour (so were one of those 200) and 5 crew were killed every year from the Jag world you'd be looking at 7.5% as being the probability that you might be DEAD in 3 years.......similar stats could be found in the Harrier world too I suspect.
I could put names and faces to a number of those killed in accident then and I am only glad that in spite of this accident, they are far less frequent than they were 30 years ago. Other similar accidents that spring to mind are the Harrier mid-airs over Wisbeach and Otterburn, a Jag/Tornado mid-air and a Jag/Jag mid-air in Cumbria, a Jag/Cessna in Wales, a Tornado/JetRanger mid-air in Lancashire and various range-related accidents from Holbeach/Wainfleet/Tain, Capa Frasca and Nordhorn.
None of this excuses the behaviour of the MAA/MAIB/MoD but I think sometime it is best to have a certain amount of perspective. Flight safety was far from perfect 35 years ago. Did accident rates deter me from wanting to be a pilot or from flying a particular aircraft type? Answer NO. Would today's flight safety regime deter me from flying in the RAF today? Again NO. Could the RAF/MoD do more to improve flight safety? Answer... an emphatic YES.
But just as many aircrew in WW2 had to make do with going to war in obsolescent equipment with aircraft such as Fairy Battles and Bristol Blenheims, even biplanes such as the Gloster Gladiator years after they had been superceeded by aircraft such as the Mosquito and Spitfire it is not reasonable for every platform in service to be the latest model.
The chance of a fatal accident if flying SLF in a civil airliner is something like 1.6 x 10( - power 6). It will never get anywhere near that in military aircraft ops (even in peacetime) and if the goal is to do so the only way that to be achieved would be to ground all mil a/c now.
The lesson here is surely, learn from this accident, try an mitigate future risks (within reason), remember with affection those killed, and carry on with what aircrew do best - FLY.
MB
To assess risk in the way you suggest i.e. to relate it to an individual's exposure just ain't going to happen, commendable as it might be as a yard-stick of risk.
I'm long out of the RAF and my experience was in the 1980's.....back then the RAF lost close to 15 aircrew KILLED every year, that doesn't include those that were able to eject and survive, some of whom were badly injured in the process......
Losses were sometimes down to pure aircrew handling/operating error but many were partly down to poor risk management, others were due to structural failures (Buccaneer x2 and F4 x1) and the two biggest "gotcha's" were mid-air collisions and target fixation on a range or when doing a SAP.
The Jag Squadrons had it bad for a number of years particularly and reasons for this were many. Single seat, low level, marginal power excess (even on 2
), small wing, poor nav kit (NAVWASS) and a demanding role, particularly for the recce boys who also had a massive recce pod to lug around. Count the sqns..... 1 at Laarbruch, 4 at Bruggen, 2 at Coltishall and a big OCU at Lossie - say 8 squadrons with 200 pilots regularly flying them at any one time. Big if here, if you were on a three year tour (so were one of those 200) and 5 crew were killed every year from the Jag world you'd be looking at 7.5% as being the probability that you might be DEAD in 3 years.......similar stats could be found in the Harrier world too I suspect.I could put names and faces to a number of those killed in accident then
and I am only glad that in spite of this accident, they are far less frequent than they were 30 years ago. Other similar accidents that spring to mind are the Harrier mid-airs over Wisbeach and Otterburn, a Jag/Tornado mid-air and a Jag/Jag mid-air in Cumbria, a Jag/Cessna in Wales, a Tornado/JetRanger mid-air in Lancashire and various range-related accidents from Holbeach/Wainfleet/Tain, Capa Frasca and Nordhorn. None of this excuses the behaviour of the MAA/MAIB/MoD but I think sometime it is best to have a certain amount of perspective. Flight safety was far from perfect 35 years ago. Did accident rates deter me from wanting to be a pilot or from flying a particular aircraft type? Answer NO. Would today's flight safety regime deter me from flying in the RAF today? Again NO. Could the RAF/MoD do more to improve flight safety? Answer... an emphatic YES.
But just as many aircrew in WW2 had to make do with going to war in obsolescent equipment with aircraft such as Fairy Battles and Bristol Blenheims, even biplanes such as the Gloster Gladiator years after they had been superceeded by aircraft such as the Mosquito and Spitfire it is not reasonable for every platform in service to be the latest model.
The chance of a fatal accident if flying SLF in a civil airliner is something like 1.6 x 10( - power 6). It will never get anywhere near that in military aircraft ops (even in peacetime) and if the goal is to do so the only way that to be achieved would be to ground all mil a/c now.
The lesson here is surely, learn from this accident, try an mitigate future risks (within reason), remember with affection those killed, and carry on with what aircrew do best - FLY.
MB
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You are wrong, this is the approach that is already being taken. It might not be perfect yet, it might not be pan-MoD, but it is happening.
By the way when I say individual, I mean per person or type of operator, not Flt Lt X or Sgt Y.
S-D
You are wrong, this is the approach that is already being taken. It might not be perfect yet, it might not be pan-MoD, but it is happening.
By the way when I say individual, I mean per person or type of operator, not Flt Lt X or Sgt Y.
S-D
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So, this is something that AOC 1 Group would be required to calculate, and defend at a FAI.
I will leave you to decide who should prepare the risk assessment and have to defend at any FAI.
I don't think you need the links below DV, but they may be of benefit to others:
http://www.hse.gov.uk/risk/theory/r2p2.pdf
and
http://www.hse.gov.uk/pubns/indg163.pdf
These are the UK HSE's interpretations of the law and how to comply. Clearly the examples used are much simpler than military aviation, but the basic principles are the same and the law applies equally to simple and complex systems.
Of course the other major problem the MoD has is applying this to different scenarios, e.g. combat or combat support versus routine training etc. The crew of XV230 would have been exposed to pretty much the same (AAR related) risks on a training mission as they were flying over Afghanistan. The main difference is the benefit that is being delivered by taking the risk. That is very hard to measure and why that decision sits with the DH. Of course, if your safety assessment and safety case is so badly flawed that you don't even know or understand the risk, then..................
S-D
salad-dodger
You are not my target audience because you understand. I repeat myself because the turn-over in a 250+ strong MAA, and the wider MoD, must mean a great many at any one time do not understand and/or are not told the truth.
Please carry on discussing the finer points. It is interesting to see how often MoD has changed its approach to risk analysis, risk evaluation and risk management. With the passage of time, MoD policy and practice has become ever more contradictory. My approach was, when in doubt, adhere to the Chief Scientific Advisor's Guidelines for Technical Scrutiny. (Called "Guidelines", but mandated upon all Air Systems Controllerate staff).
You are not my target audience because you understand. I repeat myself because the turn-over in a 250+ strong MAA, and the wider MoD, must mean a great many at any one time do not understand and/or are not told the truth.
Please carry on discussing the finer points. It is interesting to see how often MoD has changed its approach to risk analysis, risk evaluation and risk management. With the passage of time, MoD policy and practice has become ever more contradictory. My approach was, when in doubt, adhere to the Chief Scientific Advisor's Guidelines for Technical Scrutiny. (Called "Guidelines", but mandated upon all Air Systems Controllerate staff).
There is a blurring of responsibilities in the MoD between DE&S and the DH that causes problems in this area. The MRP tries to make it clear, but it doesn't work all that well in practice. The DH will say that only they can truly control the risk to life, i.e. the individuals exposure, and they would be right. But it is often DE&S, in combination with the supplier, who really (should) understand the equipment and how it contributes to the risk. So in reality, they need to work together.
Excellent.
Now read Wg Cdr Spry thread and the comments on the new definition of Functional Safety. It then becomes obvious why there is blurring and confusion.
A key question is, for EQUIPMENT fitted to an AIRCRAFT, who owns the Equipment Safety Case? And what happens when the Equipment Safety Case is valid for one aircraft, but not for another?
The answer and how to manage the risk has always been well known. But not resourced and no longer taught. To such a degree you now get Wg Cdr Spry's safety organisation getting the definition completely wrong. That means DE&S and RqMs no longer have a policy basis for financial bids to do the job properly.
This failure contributed significantly to the Tornado/Patriot and Sea King ASaC accidents in 2003 and, of course, Nimrod XV230.