BOI into the 2012 Tornado Collision over the Moray Firth
DV,
Round numbers only: if the normal annual activity rate of a Tornado crew is 200 flying hours per year then the tolerable (according to RA1210) incidence of fatal mid-air collision, based on first-party casualties only, is one fatal collision per 100,000 flying hours (on the assumption that both crew are killed). This is 500 crew-years' worth of activity. If there are 50 Tornado crews at any one time, this is one fatal collision every 10 years.
Even though I've picked deliberately round numbers, you can see that these are much more 'in-the-ballpark' than the millions of hours you quoted. Another point is that Cat A airproxes are not fatal. Not even all mid-air collisions are fatal (I can think of at least 5 off-hand in which all survived, whether through ejection or safely landing the damaged aircraft). So airprox and collision rates don't provide as straightforward an input into the risk calculations as might be expected.
Round numbers only: if the normal annual activity rate of a Tornado crew is 200 flying hours per year then the tolerable (according to RA1210) incidence of fatal mid-air collision, based on first-party casualties only, is one fatal collision per 100,000 flying hours (on the assumption that both crew are killed). This is 500 crew-years' worth of activity. If there are 50 Tornado crews at any one time, this is one fatal collision every 10 years.
Even though I've picked deliberately round numbers, you can see that these are much more 'in-the-ballpark' than the millions of hours you quoted. Another point is that Cat A airproxes are not fatal. Not even all mid-air collisions are fatal (I can think of at least 5 off-hand in which all survived, whether through ejection or safely landing the damaged aircraft). So airprox and collision rates don't provide as straightforward an input into the risk calculations as might be expected.
Round numbers only: if the normal annual activity rate of a Tornado crew is 200 flying hours per year then the tolerable (according to RA1210) incidence of fatal mid-air collision, based on first-party casualties only, is one fatal collision per 100,000 flying hours (on the assumption that both crew are killed). This is 500 crew-years' worth of activity. If there are 50 Tornado crews at any one time, this is one fatal collision every 10 years.
Serious question.
Having abandoned such numerical assessments on legal advice (issued by DLS(RAF) in 1992), when did MoD start doing it again, and why?
RAF Cranwell and Controller Aircraft started including this in their training at the same time as the repeal of Section 10 of the Crown Proceedings Act (1947). The CAA the same year.
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If there are 50 Tornado crews at any one time, this is one fatal collision every 10 years.
Another point is that Cat A airproxes are not fatal. Not even all mid-air collisions are fatal (I can think of at least 5 off-hand in which all survived, whether through ejection or safely landing the damaged aircraft). So airprox and collision rates don't provide as straightforward an input into the risk calculations as might be expected.
Do not follow your figures. How do you arrive at 100,000 flying hours based on the 1 in 1000 rate?
DV
DV
I sat on the UK AIRPROX Board for 3 years. Your analysis of Cat A is flawed in my opinion; if you look at risk of collision and RTL then you could argue that every time 2 seperate aircraft get airborne there is a RTL and risk of collision!
Even a Cat A doesn't tell the full story as in most cases the assessment is purely subjective - don't forget the definition of an AIRPROX...
I've added my bold for reference.
Sometimes a Cat A AIRPROX was not a unanimous vote - so that could also blur the overall picture when a panel of a dozen or so Board members could all have differing opinions.
All said, the UK AIRPROX Board data is useful for an indicator of risk, but needs to be done carefully if it is to support any safety case. In my humble opinion of course.
LJ
PS. Here are the categories (note not classes or classifications):
I sat on the UK AIRPROX Board for 3 years. Your analysis of Cat A is flawed in my opinion; if you look at risk of collision and RTL then you could argue that every time 2 seperate aircraft get airborne there is a RTL and risk of collision!
Even a Cat A doesn't tell the full story as in most cases the assessment is purely subjective - don't forget the definition of an AIRPROX...
An AIRPROX is a situation in which, in the opinion of a pilot or air traffic services personnel, the distance between aircraft as well as their relative positions and speed have been such that the safety of the aircraft involved may have been compromised. (ICAO Doc 4444: PANS-ATM).
Sometimes a Cat A AIRPROX was not a unanimous vote - so that could also blur the overall picture when a panel of a dozen or so Board members could all have differing opinions.
All said, the UK AIRPROX Board data is useful for an indicator of risk, but needs to be done carefully if it is to support any safety case. In my humble opinion of course.
LJ
PS. Here are the categories (note not classes or classifications):
Risk Ratings
Risk level assessments are made on the basis of what actually took place and not on what may or may not have happened. There are four categories, A - D agreed at international level, and one UK category, E, as follows:
A Risk of Collision: aircraft proximity in which serious risk of collision has existed.
B Safety not assured: aircraft proximity in which the safety of the aircraft may have been compromised.
C No risk of collision: aircraft proximity in which no risk of collision has existed.
D Risk not determined: aircraft proximity in which insufficient information was available to determine the risk involved, or inconclusive or conflicting evidence precluded such determination.
E Met the criteria for reporting but, by analysis, it was determined that normal procedures, safety standards and parameters pertained.
Risk level assessments are made on the basis of what actually took place and not on what may or may not have happened. There are four categories, A - D agreed at international level, and one UK category, E, as follows:
A Risk of Collision: aircraft proximity in which serious risk of collision has existed.
B Safety not assured: aircraft proximity in which the safety of the aircraft may have been compromised.
C No risk of collision: aircraft proximity in which no risk of collision has existed.
D Risk not determined: aircraft proximity in which insufficient information was available to determine the risk involved, or inconclusive or conflicting evidence precluded such determination.
E Met the criteria for reporting but, by analysis, it was determined that normal procedures, safety standards and parameters pertained.
IMHO the last 2 posts emphasize the confusion that reigns. What Leon says sounds sensible, but DV was just quoting what the MAA DG said. And DV is right saying it is risk of collision that's at issue, not an outcome of collision.
And then further confusion raised by the legal services advice issued 22 years ago. I think that's a quite important question because if no-one knows why MoD changed back again to using numbers, how do we know if the legal advice itself was changed? That would be another reason to question the validity of RA1210.
And then further confusion raised by the legal services advice issued 22 years ago. I think that's a quite important question because if no-one knows why MoD changed back again to using numbers, how do we know if the legal advice itself was changed? That would be another reason to question the validity of RA1210.
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if you look at risk of collision and RTL then you could argue that every time 2 seperate aircraft get airborne there is a RTL and risk of collision!
So it could be argued that there is a RtL for every Airprox, but I limited it to Class A.
By the way, RA 1210 states that "near misses" should be taken into consideration when assessing risk.
DV
Last edited by Distant Voice; 19th Jul 2014 at 11:37.
Originally Posted by Distant Voice
Do not follow your figures. How do you arrive at 100,000 flying hours based on the 1 in 1000 rate?
Tolerable first-party fatality rate = 1 per 1000 population at risk per year (RA1210)
therefore
Tolerable number of first-party fatalities per year = Population at risk / 1000
which equals
(Number of crews * 2) / 1000
which equals
Number of crews / 500
If there are 50 crews then the tolerable first-party fatality rate is 0.1 crew per year, or one crew per 10 years.
The amount of flying that would be conducted in that period is:
(200 hours per crew per year)*(50 crews)*(10 years) = 100,000 hours
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Tolerable and ALARP
I understand that AVM Atha (ODH) did not sign off on the No 1 Group Tolerable and ALARP statement until 31st Oct 2013, which is about the time the SI board concluded their investigation. The question has to be asked, "Who was responsible at the time of the accidient?"
DV
DV
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Mathematician Wanted
Just read that the probabilty of a collision event per flight hour between GR4 and another military aircraft is 4.30E-07 (1 in 2,325,581). The statement goes on to say that assuming 212 hrs of flying per crew per annum, this calculates as a per annum risk of collision with military aircraft of 1 in 10969.
But there are 94 crews, each flying 212 hrs, which gives a annual flying rate for the fleet of around 20,000 hrs. Isn't this the figure that should used, which gives a annual risk of collision for the fleet as 1 in 116?
DV
But there are 94 crews, each flying 212 hrs, which gives a annual flying rate for the fleet of around 20,000 hrs. Isn't this the figure that should used, which gives a annual risk of collision for the fleet as 1 in 116?
DV
DV
I can see what you are trying to show but in my non-mathematicians mind I would say the first paragraph is correct because it is pertinent to one crew at a time and only when they fly (and because all 94 crews could never be airborne at the same time). There will be an element of "fudge" for the number of military aircraft airborne at any one time (which may be higher or lower at any particular time of day or location). If the figures in para 2 were correct most RAF aircrew would have at least one midair per year (based on an average sortie length of 1.5hrs)!
I can see what you are trying to show but in my non-mathematicians mind I would say the first paragraph is correct because it is pertinent to one crew at a time and only when they fly (and because all 94 crews could never be airborne at the same time). There will be an element of "fudge" for the number of military aircraft airborne at any one time (which may be higher or lower at any particular time of day or location). If the figures in para 2 were correct most RAF aircrew would have at least one midair per year (based on an average sortie length of 1.5hrs)!
Last edited by Wrathmonk; 25th Sep 2014 at 16:51.
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Watched several Tornado aircraft head north yesterday from Lossiemouth to the Tain range. I sincerely hope that all colision warning mitigations are in place and that the aircraft are not operatiing with the sort of limitations that were in place at the time of the accident over two years ago. No word yet on the Warton CWS trials.
DV
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Delay in CWS Installation
This is the latest from MOD on the CWS (TCAS II) fit. It has always been my belief that the TCAS programme was part of a stalling game so that the risk could be declared ALARP. It will never be fitted to Tornado, but remain as an ALARP programme.
http://www.theyworkforyou.com/wrans/?id=2014-10-15.210783.h&s=speaker%3A11189+section%3Awrans#g210783.q0
DV
http://www.theyworkforyou.com/wrans/?id=2014-10-15.210783.h&s=speaker%3A11189+section%3Awrans#g210783.q0
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I read these threads with a combination of dread and hope. This one has headed in the dread direction unfortunately.
If the MOD are genuinely using Bowtie type methodologies without a proper numeric or quantified assessment they are being deliberately casual and legally non-compliant (suitable and sufficient risk assessment!).
The risk which the previous posts have struggled with have confused posters. With a fleet the risks which must be assessed are the fleet risks - not the individual crew risks. If you have 40 aircraft then the 40 aircraft need to be protected. Protecting one aircraft makes for a 'lucky' crew or two but does not address the fleet issues.
If potential collisions are occurring - and I'll accept that the category or assessment does make a real difference then this is a pretty poor situation where there is an obvious technical 'fix'. Simple cost benefit takes the cost of the modification versus the cost of life saved - severely modified by the ready availability of a technical solution which could easily be incorporated into standard operations.
For training operations to subject aircraft crew to a real collision risk seems to me utterly appalling. Simple procedures could eliminate it. If you decide to operated aircraft in close proximity under high stress situations as a matter of training realism or something similar then sensible engineered barriers become essential - apart it would seem in the MOD .
If the MOD are genuinely using Bowtie type methodologies without a proper numeric or quantified assessment they are being deliberately casual and legally non-compliant (suitable and sufficient risk assessment!).
The risk which the previous posts have struggled with have confused posters. With a fleet the risks which must be assessed are the fleet risks - not the individual crew risks. If you have 40 aircraft then the 40 aircraft need to be protected. Protecting one aircraft makes for a 'lucky' crew or two but does not address the fleet issues.
If potential collisions are occurring - and I'll accept that the category or assessment does make a real difference then this is a pretty poor situation where there is an obvious technical 'fix'. Simple cost benefit takes the cost of the modification versus the cost of life saved - severely modified by the ready availability of a technical solution which could easily be incorporated into standard operations.
For training operations to subject aircraft crew to a real collision risk seems to me utterly appalling. Simple procedures could eliminate it. If you decide to operated aircraft in close proximity under high stress situations as a matter of training realism or something similar then sensible engineered barriers become essential - apart it would seem in the MOD .
If the MOD are genuinely using Bowtie type methodologies without a proper numeric or quantified assessment they are being deliberately casual and legally non-compliant (suitable and sufficient risk assessment!).
1. Numerical risk assessments were outlawed by the CAA in the early 90s and MoD immediately fell in to line. They have never explained why they have (apparently) changed back. It must be very confusing to those FEW in MoD who actually do Risk Management.
2. Throughout the 90s and 00s, MoD's stated policy on Risk Management was - "Wait to see if the Risk materialises, then do something". In furtherance of this poilcy, programmes were denied the mandated resources to appoint a Risk Manager. The inevitable happened - MoD lost its corporate knowledge. (Read the Wg Cdr Spry thread!) When something happened, it often involved loss of life. Accidents that fall in to this category include Sea King ASaC, Tornado/Patriot, Nimrod, C130, Chinook and this one under discussion. That is, the Cause(s) and Contributory Factors were all known and notified years in advance, and conscious decisions made to wait to see if they materialised.
3. Allied to this, and your own comment, in this period MoD policy was to ignore altogether the concept of trend failures and the need to apply mitigation to the WHOLE fleet. In particular, Adam Ingram when Min(AF) stated a number of times in the mid-00s that it was completely irrelevant if a serious safety fault was known to exist in one tail number; that could not be used as evidence of the POSSIBILITY of the same fault existing in any other in the same fleet. This was utterly deranged but a natural progression from the Chief Engineer's policy of 1991 to cease all trend failure analysis, as part of his policy of running down the management of airworthiness.
There are exceptions to the above, but only because some decided to ignore these policies. In April 2005 MoD claimed in a briefing to PUS that, as of September 2004, none were left in MoD; but I'd disagree. Perhaps a handful do. It is those few who aircrew rely upon. Everyone needs to understand that for well over 20 years they have been the subject of outright hatred from senior staffs.
But latterly, in particular this last year and coinciding with the appointment of the new CAS, it has been very noticeable that MoD's approach has changed, at long last. Why? It is tempting to speculate he has read the evidence withheld from him in 1994. And to address your point; their answers in this case may claim they use Bowtie, but the detail they contain reveals many don't understand it or find it difficult articulating an answer when they know fine well the rules they operate under are so contradictory. The above explains why.
tuc:-
Then time is of the essence and cannot be wasted with yet more new initiatives and yet more sign writing within the MOD. Too many people have died, and too many lives are still at risk. UK Military Airworthiness Provision must come under an external and independent Regulator, headed by a civilian DG (though still call it the MAA by all means).
Ditto all that for the MilAAIB, which must also be independent of the MAA.
Then and only then can the long and weary business begin of making the CAS's fleets airworthy again.
Self Regulation Doesn't Work and in Aviation It Kills!
with the appointment of the new CAS, it has been very noticeable that MoD's approach has changed, at long last.
Ditto all that for the MilAAIB, which must also be independent of the MAA.
Then and only then can the long and weary business begin of making the CAS's fleets airworthy again.
Self Regulation Doesn't Work and in Aviation It Kills!
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Thank you both for the explanation and background. My risk management is around what people like to call 'high integrity' organisations - which is often something of an oxymoron!
Self regulation can and does work - but the organisation has to have some decent values and ethics, and sanctions. In the MOD the only sanction appears to have been promotion! Haddon Cave did at least ruffle some feathers but...
Most of my work is with the HSE - HID and peripherally the CAA. neither organisation can bee said to be a shining light. The HSE do have some good people, CAA oversight has been casual at best.
There is no magic bullet but I read there are further delays in equipment fit to address this issue - politically I suspect they hope the Tornado will be out of service before the kit has to be fitted.
Perhaps it is naïve to expect the military to have much of a conscience and so at least an 'arms length' regulator would be better.
Self regulation can and does work - but the organisation has to have some decent values and ethics, and sanctions. In the MOD the only sanction appears to have been promotion! Haddon Cave did at least ruffle some feathers but...
Most of my work is with the HSE - HID and peripherally the CAA. neither organisation can bee said to be a shining light. The HSE do have some good people, CAA oversight has been casual at best.
There is no magic bullet but I read there are further delays in equipment fit to address this issue - politically I suspect they hope the Tornado will be out of service before the kit has to be fitted.
Perhaps it is naïve to expect the military to have much of a conscience and so at least an 'arms length' regulator would be better.
gasax:-
We'll have to agree to disagree over that one. My belief is that Self Regulation is the British Disease, whether it be by the Police, Doctors, Lawyers, or the MOD. Of course those who come under those headings will be outraged at such a suggestion and angrily testify to the dedicated and honourable people that regulate their particular patch. Well they would, wouldn't they?
The particular problem with aviation is that it is trying to kill you all the time and only professional and expert input at every stage from start to finish will lend itself to obviating such malevolent intent. The particular problem of the UK Military's particular problem is that professional expertise was arbitrarily dispensed with by the RAF Chief Engineer and replaced by those prepared to sign off the Regs as complied with, even though they hadn't been. A few years of that and there is an irredeemable gap in the continuous auditing process that is the very lifeblood of Airworthiness Provision.
That such suborning can be occasioned by a few VSOs is the reason that UK Military Airworthiness must be vested in an independent Regulator which it isn't right now. Ditto the MilAAIB.
More disagreement. It isn't the UK Military that lacks a conscience. I would suggest that there are generally higher moral standards and empathy in the UK Armed Forces than in the UK Civil Population. It wasn't they that set out recklessly and malevolently to sabotage the very aircraft and equipment on which their lives depended, but those who inhabited the murky MOD corridors of power. They are not "the military", though I confess that many wore the uniforms of RAF VSOs. They had ceased to be "the military" the moment they set out to betray their juniors.
Self regulation can and does work - but the organisation has to have some decent values and ethics, and sanctions.
The particular problem with aviation is that it is trying to kill you all the time and only professional and expert input at every stage from start to finish will lend itself to obviating such malevolent intent. The particular problem of the UK Military's particular problem is that professional expertise was arbitrarily dispensed with by the RAF Chief Engineer and replaced by those prepared to sign off the Regs as complied with, even though they hadn't been. A few years of that and there is an irredeemable gap in the continuous auditing process that is the very lifeblood of Airworthiness Provision.
That such suborning can be occasioned by a few VSOs is the reason that UK Military Airworthiness must be vested in an independent Regulator which it isn't right now. Ditto the MilAAIB.
it is naïve to expect the military to have much of a conscience and so at least an 'arms length' regulator would be better.
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Just noticed a note at the bottom of the "Hazard Data Criteria" page associated with Nimrod. The information comes from BP1201, which was the document used prior to the new MAA regs, and referred to in a letter, dated 11th Feb 2011, by AVM Bagwell (AOC No.1 Group). The note reads "The Baseline Safety Case generally employs only qualitative probabilities in risk assessment". Unfortunety, AVMs Bagwell and Atha appear to have gone down the "numbers" route in order to justify their Tolerable and ALARP statements. Numbers that were provide in a report by QinetiQ, and a report that MoD is having problems locating.
In addition they, with the aid of the new MAA regs, have been able to downgrade the frequency of the risk from OCCASIONAL to REMOTE. The original definition for OCCASIONAL was, "Likely to occur during the operational life of a particular fleet", and for REMOTE, "Unlikely to occur at all during the operational life of a particular fleet". We now have in the new regs, OCCASIONAL - "Likely to occur one or more times per year", and REMOTE - "Likely to occur one or more times in 10 years". So what was OCCASIONAL (or even PROBABLE) is now REMOTE. However, what is important is what was the true risk on the lead-up to the accident, and at the time that Bagwell and Atha signed off in 2011, it was OCCASIONAL (and CATASTROPHIC) which makes it an INTOLERABLE risk. I put the frequenct as being OCCASIONAL because between 1984 and 2009 the fleet was involved in a total of 9 mid-air collision accidents.
Normally, a combination of risk frequecy and severity determines the risk index; Broadly Acceptable, Tolerable, Undesirable or Intolerable, but this is no longer applied. Instead we compare the mathematial probabilty of a risk of death with a 1 in 1000 figure from an HSE document. A figure which is based on industry where people are exposed to a risk for some 2000 hours per year not 212 hours (Tornado aircrew), and a figure which the HSE have stated does not cover a flying environment.
If this is an example of self regulation then it is time to think again.
DV
In addition they, with the aid of the new MAA regs, have been able to downgrade the frequency of the risk from OCCASIONAL to REMOTE. The original definition for OCCASIONAL was, "Likely to occur during the operational life of a particular fleet", and for REMOTE, "Unlikely to occur at all during the operational life of a particular fleet". We now have in the new regs, OCCASIONAL - "Likely to occur one or more times per year", and REMOTE - "Likely to occur one or more times in 10 years". So what was OCCASIONAL (or even PROBABLE) is now REMOTE. However, what is important is what was the true risk on the lead-up to the accident, and at the time that Bagwell and Atha signed off in 2011, it was OCCASIONAL (and CATASTROPHIC) which makes it an INTOLERABLE risk. I put the frequenct as being OCCASIONAL because between 1984 and 2009 the fleet was involved in a total of 9 mid-air collision accidents.
Normally, a combination of risk frequecy and severity determines the risk index; Broadly Acceptable, Tolerable, Undesirable or Intolerable, but this is no longer applied. Instead we compare the mathematial probabilty of a risk of death with a 1 in 1000 figure from an HSE document. A figure which is based on industry where people are exposed to a risk for some 2000 hours per year not 212 hours (Tornado aircrew), and a figure which the HSE have stated does not cover a flying environment.
If this is an example of self regulation then it is time to think again.
DV
Last edited by Distant Voice; 30th Oct 2014 at 20:10. Reason: spelling
Self regulation...........
MoD has this week advised Sir Jeremy Heywood KCB, CVO, Secretary of the Cabinet and Head of the Civil Service, that it should remain an offence to refuse to obey a direct order to make a false declaration regarding airworthiness and financial probity. To issue such an order is not an offence.
To obey such an order is to commit fraud and constitutes misconduct in public office.
Sir Jeremy accepted this advice and personally signed the letter containing his ruling on 28th October.
At least they're consistent. As far as I know, this ruling was first made in December 1992 by Director General Support Management (RAF), the immediate subordinate of the Chief Engineer. As you say, no values or ethics.
Count the dead......
MoD has this week advised Sir Jeremy Heywood KCB, CVO, Secretary of the Cabinet and Head of the Civil Service, that it should remain an offence to refuse to obey a direct order to make a false declaration regarding airworthiness and financial probity. To issue such an order is not an offence.
To obey such an order is to commit fraud and constitutes misconduct in public office.
Sir Jeremy accepted this advice and personally signed the letter containing his ruling on 28th October.
At least they're consistent. As far as I know, this ruling was first made in December 1992 by Director General Support Management (RAF), the immediate subordinate of the Chief Engineer. As you say, no values or ethics.
Count the dead......